Survival following rectal cancer surgery: does the age matter?

Introduction: Information regarding rectal cancer surgery outcomes and survival benefits in the elderly is sparse. Radical rectal surgery can be associated with substantial morbidity and mortality. We investigated age-specific survival for patients undergoing radical rectal surgery to determine outcomes in elderly patients Methods: Over a 10-year period data on all patients who underwent rectal cancer surgery was performed. Patients were grouped according to age and eight other variables including cancer stage (Duke's/TNM). Data analysed using computer program R. Kaplan-Meier survival curves estimated for age groups and compared using a modified log-rank permutation test. Survival curves fitted using Cox proportional hazard models and hazard ratios obtained Results: About 374 patients underwent surgery. Survival percentages at 1 year by age group are 91.3% for age <50, and 75.5% for age >80. At 5 years these are 87.0% for age <50 and 57.1% for >80. Overall the variation among the survival curves for the age groups is significant (p < .001). The hazard ratio for over the 80+ with the age group <50 as the reference is 4.79 (95% CI: 1.44-15.92) and is significant (p = .011) Conclusion: Overall survival is significantly less in the elderly. There is a striking reduction in survival in >80 year olds in the first post-operative year. This study highlights that care must be taken in deciding whether radical surgery should be offered to those patients and careful consideration is given to allow the best overall survival and quality of life.

Chronic biliary colic associated with ketamine abuse.

INTRODUCTION: Biliary colic is a common clinical presentation, with the majority of cases being related to gallstone disease. However, rarely, patients may present with biliary symptoms without evidence of gallbladder stones - referred to as acalculous gallstone disease. This case report details a rare case of chronic biliary colic associated with ketamine abuse. CASE PRESENTATION: A 24-year-old Caucasian female presented to the emergency department with a history of intermittent right upper quadrant pain associated with nausea and malaise. She had experienced bouts of similar symptoms three times a year for the past 4 years. Various investigations had been conducted during her multiple admissions, which showed possible dilatation of the common bile duct, with no evidence of gallstones. CONCLUSION: Patients can present with a dilated common bile duct and an acalculous cholecystitis. This requires considerable investigation, with an emphasis on drug history, especially with the current rise of recreational hallucinogenic drug abuse.

Safety and Efficacy of Permacol Injection in the Treatment of Fecal Incontinence.

PURPOSE: Permacol has been gaining popularity in recent times for the treatment of fecal incontinence (FI). This study aims to evaluate the safety and efficacy of anal submucosal Permacol injection in the treatment of FI. METHODS: All consecutive patients who underwent Permacol injection for FI over a 3-year period were included. Patients' data relating to obstetric history, anorectal/pelvic operations, type of FI, preoperative anorectal physiology results and follow-up details for outcome measures were collected. Preoperative and postoperative Cleveland Clinic Florida Incontinence Scores (CCFISs) were noted. Patients were surveyed by using a telephone questionnaire to assess the quality of life and other outcome measures. Data were analysed using SPSS ver.19.0. RESULTS: Thirty patients (28 females and 2 males) with a median age of 67 years were included in the study. Of those patients, 37%, 50%, and 13% were noted to have passive, mixed and urge FI, respectively. Six of the patients (20%) had repeat Permacol injections, 5 of whom had sustained responses to the first Permacol injection for a mean of 11 months. There was a significant improvement in the CCFIS from a baseline median of 12.5, mean 12.8 interquartile range [IQR], 6-20), to a median of 3.5, mean 4.8 (IQR, 0-20), P < 0.001. Of the patients surveyed by telephone 89% were satisfied with their overall experience and the improvement in their symptoms following Permacol injections. CONCLUSION: This study has demonstrated that Permacol injection for the treatment of FI is safe and effective and has no associated major complications. However, the results are not permanent; consequently, a significant proportion of the patients with an initial response may require repeat injections.

Diagnostic markers in acute appendicitis.

BACKGROUND: An adequate medical history combined with clinical examination is usually enough to make the diagnosis of acute appendicitis. The aim of this study was to determine the value of elevated white cell count (WCC), C-reactive protein (CRP), and bilirubin as diagnostic markers of acute appendicitis. METHODS: A retrospective analysis was carried out on consecutive patients who underwent appendicectomy over a 3-year period. All data including patients' age, sex, blood test results, and appendix histology were summarized. Sensitivities, specificities, positive, and negative predictive values of WCC, CRP, and bilirubin were calculated separately or in combination for all patients. RESULTS: A total of 447 patients were included. There is a significant difference in the results between patients with negative and positive appendicitis with regards to CRP (32 vs. 73; P < .001), mean total WCC (10.9 vs. 14.0; P < .001), and the mean levels of bilirubin (10.9 vs. 17.2; P < .001). CONCLUSIONS: The diagnosis of appendicitis remains multifactorial and blood tests may help to guide the surgeon in the decision making.

Tight swimming trunks to prevent post scrotal surgery: an experimental justification.

PURPOSE: To conduct a study to measure the pressure effects of the different scrotal supports applied on a simulated expanding scrotal hematoma. MATERIALS AND METHODS: We created a model of an expanding hematoma with simultaneous pressure recording using a urodynamics system. Pressures were recorded independently first without application of any support. Then, three types of scrotal supports were tested, including Euron Net Knickers, scrotal suspensory bandage, and tight swimming trunks brand Speedo® brief and shorts. Subsequent pressures were recorded using the model created, which was applied inside the supports worn by two male volunteers A and B. RESULTS: Without any external compression, the pressure inside the simulated expanding hematoma "balloon" reached a maximum of 15 cmH2O. The pressures measured whilst wearing "Netelast knickers" in both subjects A and B reached a maximum of 15 cmH2O suggesting that this garment exerted no measurable compression. The suspensory scrotal support was then tested in both subjects. As the balloon started to fill with saline, the simulated hematoma pushed the scrotal support forward resulting in falling of the balloon outside the scrotal support. Subsequently, Speedo® briefs and shorts were tested. With Speedo® briefs, maximum filling pressures of 49 cmH2O and 40 cmH2O were reached in subjects A and B, respectively. When using Speedo® shorts, however, maximum pressures of 55 cmH2O in subject A and 54 cmH2O in subject B were reached at the end of the balloon filling to 300 mL of saline. CONCLUSION: The use of tight swimming trunks (Speedo®) has led to satisfactory results in the prevention of hematoma post scrotal surgery.

Tissue-conserving, yet radical surgery for extensive gas-forming soft tissue infections arising from perirectal abscess: report of a case.

BACKGROUND: Perirectal abscess is encountered commonly in surgical practice, and simple incision and drainage usually is sufficient. However, life-threatening sepsis may occur. In such instances, the high morbidity and mortality rates from the severe systemic inflammatory response syndrome (SIRS) associated with rapidly evolving necrotizing and gas-forming soft tissue infections are of major concern. METHODS: Case report and review of pertinent literature. RESULTS: A rare case of extensive necrotizing fasciitis of the torso arising from a perirectal abscess, in which the principles of radical surgical debridement were adhered to while minimizing disfigurement, is reported in a 19-year-old female. In some cases, despite the life-threatening nature of necrotizing fasciitis, it is possible to minimize tissue loss without compromising patient survival. CONCLUSION: Planning of the patient's site rehabilitation for maximum cosmetic outcome commences at the time of surgical debridement and is especially important for the young patient.

A simple technique for safe mesenteric defect closure following bowel resection.

The closure of the mesenteric defect following bowel resection remains controversial. Proponents of the intervention cite the risk of bowel herniation through an open mesenteric defect and subsequent bowel obstruction whereas supporters of the opposing view advocate that such practice may lead to inadvertent compromise of the bowel blood supply. We describe a novel technique that enables efficient mesenteric defect closure while minimizing the risk of blood vessel injury.

Simultaneous xanthogranulomatous cholecystitis and gallbladder cancer in a patient with a large abdominal aortic aneurysm.

There have been reports of the coexistence of abdominal aortic aneurysm (AAA) with intra-abdominal malignancy including gastric, colonic, pancreatic, and renal. We herein report a case of a previously undiagnosed AAA and a presenting complaint consistent with acute cholecystitis. Following cholecystectomy, this was noted to be a rare form of chronic cholecystitis: xanthogranulomatous cholecystitis. There is a known possible association of this uncommon condition with gallbladder cancer. The management of concomitant pathologies can present a real challenge to the multidisciplinary team, especially with large aneurysms.

The uses of the iPhone for surgeons.

Mobile technology is continuously improving and it is important that all physicians are aware of its new advances. Smartphones have the potential to improve diagnostic skills and education of a surgeon. The iPhone is a popular type of smartphone in the market. This article intends to educate surgeons about its uses, functions and medical applications. The phone is an invaluable tool for the modern day surgeon.

Outcomes of emergency colectomy for fulminant Clostridium difficile colitis.

INTRODUCTION: Clostridium difficile has become increasingly a common cause of nosocomial infection with increasing antibiotic usage. Recently there has been an increase in the incidence of patients undergoing colectomy for fulminant C. difficile colitis (FCDC). Early surgical consultation is necessary to avoid delay in diagnosis. We present a retrospective review of the outcomes of colectomies for FCDC at our large district general hospital. MATERIALS AND METHODS: Over a twenty one month period, from January 2007 to September 2009, a total number of 20 patients underwent exploratory laparotomy for FCDC. A retrospective analysis of patients' case notes, was carried out retrieving all relevant. Data on haematology, biochemistry and imaging were extracted from the trust's on-line clinical databases. RESULTS: A total number of 528 diagnosed cases with C. difficile infection were identified. Of these, twenty patients underwent colectomy for FCDC (3.7%). All patients had received antibiotics prior to symptoms development. 45% of patients had multiple antibiotics. 35% of patients developed FCDC after having three doses of prophylactic antibiotic (Cefuroxime) for a surgical procedure. Time from referral to having surgery varied. Seventeen patients received subtotal colectomy and end ileostomy in a single operation. Mortality rate was 40%. CONCLUSION: Emergency colectomy for FCDC is associated with high mortality rate. The majority of patients who have significant co-morbidities (75%) did not survive following emergency colectomy. Therefore, it is crucial to identify those patients early in their disease course before they progress into FCDC and organ failure.

A novel home laparoscopic simulator.

As laparoscopic surgery becomes increasingly accepted as the technique of choice for many procedures, changes in training structure and working practice limit opportunities for trainees to acquire these new skills. A solution to this problem is the development of simulators that help to develop and hone skills before exposure to the operating theater. Several excellent yet costly simulators exist that have been demonstrated to improve laparoscopic skills. Furthermore, several reports in the literature describe the development of "home simulators"; however, each of these has limitations. The development of a home laparoscopic simulator is reported here that is cheap and easy to build and incorporates an extra dimension of practical port insertion as well as a novel design for a mobile light and camera source.

Metastatic Hurthle Cell Carcinoma of the thyroid presenting as a Breast Lump: A Case Report.

BACKGROUND: Hurthle cell carcinoma of the thyroid is a rare form of thyroid cancer. It may present as a low grade tumour or can present as a more aggressive metastatic carcinoma. Hurthle cell carcinoma has the highest incidence of metastasis among all differentiated thyroid cancers. Most commonly haematogenous spread to lungs, bones and brain, however spread to regional lymph nodes is not uncommon. The breast is a rare site for metastasis from extramammary sources. We present the first case of breast metastasis from Hurthle cell carcinoma of the thyroid. CASE PRESENTATION: We report a 77 year old lady who had total thyroidectomy and bilateral neck dissection followed by radiotherapy for a high grade metastatic Hurthle cell carcinoma of the thyroid. Ten months later she presented to the breast clinic with left breast lump and a lump at the left axilla. Fine needle aspiration cytology of the lumps and histology after wide local excision of the breast lump confirmed metastatic Hurthle cell carcinoma. CONCLUSION: The presence of breast lumps in patients with history of extramammary cancer should raise the possibility of metastasis.