Internal hernia and small bowel obstruction following open ileoanal pouch formation: A case report.

INTRODUCTION: Internal herniae, although rare, can give rise to potentially serious morbidity and mortality. The protrusion and entrapment of the small bowel through an embryological or iatrogenic mesenteric aperture within the confines of the peritoneal cavity can be difficult to diagnose, and delay treatment (operative). Timely intervention must be achieved to minimize small bowel ischemia and infarction. CASE PRESENTATION: In this case, a young lady who had a previous laparoscopic total colectomy and ileostomy developed an unusual internal hernia. Small bowel was passing behind the lesser curvature of the stomach causing the stomach to be rotated to form of a tight "band" trapping bowel. The herniated small bowel was reduced, hence, avoiding resection; the defect closed by interupted 4-0 PDS. "Prompt" surgery avoided small bowel length resection and sacrifice of the ileoanal pouch reconstruction. DISCUSSION: It is theorized that a laparoscopic approach results in a more advanced mobilization of the mesentery right up to the small bowel origin, and with less adhesion formation may in fact promote unusual internal hernia and volvulus. CONCLUSION: The case presented highlights the difficulty in making the diagnosis, and the pictures clearly indicate an unusual hernia passing directly behind the stomach and involving a large section of the small bowel. The lead up history of several admissions with sub acute small bowel obstruction suggested the underlying problem was adhesional but quite clearly there was a well defined internal hernia. Without timely surgery she would have been at high risk of losing her pouch.

Chicken or the leg: Sigmoid colon perforation by ingested poultry fibula proximal to an occult malignancy.

INTRODUCTION: Colonic perforation by ingested foreign bodies is exceedingly rare, with the diagnosis made more challenging by patients infrequently recalling any inadvertent ingestion and the poor sensitivity of plain radiography. PRESENTATION OF CASE: The presented case demonstrates that bony perforation of the large bowel might occur immediately proximal to an otherwise occult colonic malignancy. DISCUSSION: Ingestion of foreign bodies is common and rarely results in colonic perforation. However, bony ingestion is not usually remembered and can be missed even with cross-sectional imaging. If present, consideration should be given to the presence of an adjacent concealed colon cancer. CONCLUSION: The co-existence of separate pathology should be carefully assessed in these patients, since this has important implications for relevant investigations and appropriate surgical management.

New data on some species of Monogenea and Digenea parasites of marine fish from the coast of the State of Rio de Janeiro, Brazil.

Fifty four specimens of marine fish belonging to seven species collected from the coast of the State of Rio de Janeiro, Brazil were examined for helminths, and results relating to Monogenea and Digenea are presented. The monogeneans Metamicrocotyla macracantha, Microcotyle pomatomi and Gotocotyla acanthura are reported in new hosts. The digeneans Parahemiurus merus, Lecithochirium microstomum, Gonocercella pacifica, Aponurus laguncula, Gonocerca trematomi and Lampritrema miescheri are reported in new hosts, and the latter two species are also reported for the first time in Brazil.

New data on some species of Monogenea and Digenea parasites of marine fish from the coast of the State of Rio de Janeiro, Brazil / Novos dados sobre algumas especies de Monogenea e Digenea parasitas de peixes marinhos da costa do estado do Rio de Janeiro, Brasil

Fifty four specimens of marine fish belonging to seven species collected from the coast of the State of Rio de Janeiro, Brazil were examined for helminths, and results relating to Monogenea and Digenea are presented. The monogeneans Metamicrocotyla macracantha, Microcotyle pomatomi and Gotocotyla acanthura are reported in new hosts. The digeneans Parahemiurus merus, Lecithochirium microstomum, Gonocercella pacifica, Aponurus laguncula, Gonocerca trematomi and Lampritrema miescheri are reported in new hosts, and the latter two species are also reported for the first time in Brazil.

Cinquenta e quatro espécimens de peixes marinhos pertencentes a sete espécies coletados do litoral do estado do Rio de Janeiro, Brasil foram examinados para helmintos, os resultados referentes a Monogenea e Digenea são apresentados. Os monogenéticos Metamicrocotyla macracantha, Microcotyle pomatomi e Gotocotyla acanthura são apresentados em novos hospedeiros. Os digenéticos Parahemiurus merus, Lecithochirium microstomum, Gonocercella pacifica, Aponurus laguncula, Gonocerca trematomi e Lampritrema miescheri são registrados em novos hospedeiros, as duas últimas espécies são também registradas pela primeira vez no Brasil.

Basic surgical training in the era of the European Working Time Directive: what are the problems and solutions?

BACKGROUND AND AIMS: Imposed reductions in working hours will impact significantly on the ability of surgical trainees to achieve competency. The objective of this study was to obtain the opinions of Scottish surgical trainees concerning the training they receive, in order to inform and guide the development of future, high-standard training programmes. METHODS: An anonymous questionnaire was sent to basic surgical trainees on the Edinburgh, Aberdeen and Dundee Basic Surgical Rotations commencing after August 2002. RESULTS: Thirty six questionnaire responses were analysed. Very few of the returned comments were complimentary to the existing training structure; indeed, most comments demonstrated significant trainee disappointment. Despite "regular" exposure to operative sessions, training tutorials and named consultant trainers, the most common concern was a perceived lack of high-quality, structured, operative exposure and responsibility. Textbooks and journals remain the most frequently utilised learning tools, with high-tech systems such as teleconferencing, videos, CD-ROMS, and DVDs being poorly exploited. CONCLUSIONS: Current surgical training is not meeting the expectation of the majority of its trainees. To solve this problem will require extensive revision of attitudes and current educational format. A greater emphasis on the integration of 21st century learning tools in the training programme may help bridge this gap.

Preoperative conditioning with oral carbohydrate loading and oral nutritional supplements can be combined with mechanical bowel preparation prior to elective colorectal resection.

OBJECTIVE: Preoperative conditioning with oral fluid and carbohydrate (CHO) loading allows the patient to undergo surgery in the fed state and is associated with reduced postoperative insulin resistance. Further benefit may accrue from oral nutritional supplements (ONS) to counteract the fasting associated with mechanical bowel preparation (MBP). In this study we assess the ability to prescribe, dispense and have patients comply with a protocol combining preoperative ONS and CHO/fluid loading during MBP. METHOD: One hundred and forty-seven patients undergoing elective left colonic or rectal resection were recruited to an Enhanced Recovery after Surgery (ERAS) programme. All patients were prescribed MBP (2 sachets Picolax). On the daytime prior to surgery, eligible patients were prescribed 2 x 200 ml of ONS (Fortijuice, Nutricia) and in the evening 800 ml oral CHO/fluid loading (Preop(R), Nutricia,). Patients were prescribed a further 400 ml of oral/CHO/fluid on the morning of surgery 2 h prior to induction of anaesthesia. Protocol compliance was audited prospectively. RESULTS: One hundred and forty-seven patients received MBP. Twenty-three patients were ineligible for oral CHO/fluid loading [diabetes (n = 22), allergy to lemon flavoured drinks (n = 1)]. Fourteen patients did not receive the preoperative CHO drinks due to failure to prescribe (n = 8) or dispense (n = 6). One hundred and ten patients were dispensed the combined ONS and CHO/fluid loading regimen, compliance rates were 83% with ONS, 80% with CHO/fluid loading and 74% with both. CONCLUSION: Approximately 74% of patients undergoing MBP can comply with preoperative conditioning with ONS and CHO/fluid loading. Prescription and dispensing requires close attention to detail.

Paraileostomy recontouring by collagen sealant injection: a novel approach to one aspect of ileostomy morbidity. Report of a case.

INTRODUCTION: Poorly fitting stoma appliances, resulting in stomal leakage and subsequent skin excoriation, remain a significant cause of ileostomy-related morbidity. One cause of ill-fitting stoma bags is the presence of parastomal dermal contour defects/irregularities. These may occur after surgical complications or change in patient weight and body habitus. METHODS: We report the case of a 29-year-old man who, after panproctocolectomy and formation of ileostomy for ulcerative colitis, experienced significant problems with stoma bag application because of dermal contour defects. As a result, he suffered from significant stomal leakage and skin excoriation. After a single treatment of cutaneous parastomal infiltration of porcine collagen (Permacol Injection), applied stoma bags achieved a watertight seal, and the patient experienced complete and sustained resolution of his symptoms. CONCLUSIONS: Porcine collagen is a safe, versatile, and relatively easy method of restoring irregular skin defects surrounding abdominal stomas, thus resolving the significant patient morbidity associated with ill-fitting stomal appliances. Such a technique avoids the need for surgical stoma refashioning, which may be associated with significant morbidity and unsatisfactory outcomes.

Secondary perineal hernia following open abdominoperineal excision of the rectum: report of a case and review of the literature.

This is a case report of a 46-year-old man who presented with a painful perineal lump four months after abdominoperineal excision of the rectum (APER) with pre-operative radiotherapy and adjuvant chemotherapy. Perineal hernia (suspected clinically) was confirmed by magnetic resonance imaging, and the patient underwent open Permacol mesh repair via a perineal approach. Symptomatic perineal herniation after surgical resection is a rare phenomenon, and the approach to management remains challenging. Several different surgical approaches and techniques of repair have been described. In this report, we review the literature surrounding the presentation, aetiology and repair of this unusual post-operative complication. Furthermore, our case confirms that closure of the hernial orifice with mesh via a perineal approach is a satisfactory technique.

Red herring: a rare cause of small bowel obstruction.

This is a case report of a 73-year-old man with a small bowel obstruction secondary to an incarcerated paracaecal hernia. His large right inguinal hernia, initially suspected as a potential source of obstruction, turned out to be a red herring. Congenital internal hernias are a very rare cause of bowel obstruction. In this report we review the literature and embryology behind these uncommon occurrences.

Duodenal webs--no age limit.

BACKGROUND: Duodenal webs usually give rise to symptoms of gastric outlet obstruction in infancy, but they occasionally present in adulthood. CASE OUTLINE: We report an 82-year-old woman with an unusual cause of gastric outlet obstruction. Peptic ulcer stricture or carcinoma were suspected, but a CT scan and upper gastrointestinal endoscopy revealed that her symptoms were the result of duodenal webs. The webs were successfully dilated at endoscopy. DISCUSSION: Duodenal webs may rarely account for gastric outlet obstruction in adults. Failure to visualise the second and third parts of the duodenum at endoscopy means that the diagnosis may be missed. Diclofenac and slow-release potassium tablets may have played an aetiological role in the formation of the webs in this patient.

Domiciliary clinics I: effects on non-attendance.

OBJECTIVE: To compare the rate of non-attendance for new referrals to a hospital based clinic versus home assessment. SETTING: Two old age psychiatry services in an urban area. METHOD: A four year prospective study comparing rates of non-attendance for new referrals to a hospital based clinic versus assessment at home in two parallel old age psychiatry services. RESULTS: The rate of non-attendance for new referrals seen at home was considerably lower (1.7%) than the hospital based clinic (21.2%). CONCLUSIONS: Assessing new outpatient referrals to old age psychiatry services at home reduces non-attendance. This improves efficient use of medical time in a small geographical catchment area but may not apply to rural or larger areas.

Treating depression in old age: the reasons to be positive.

Depression affects 10-15% of people over 65 living at home in the United Kingdom. It is the commonest and the most reversible mental health problem in old age. Depression is associated with physical illness and disability, life events, social isolation and loneliness. Depression in old age carries an increased risk of suicide and natural mortality. Recognition and simple intervention can reduce morbidity, demand on health and social services and the cost of community care. Despite a favourable response to treatment, depression remains largely undetected and untreated.

Onycholysis as a complication of systemic chemotherapy: report of five cases associated with prolonged weekly paclitaxel therapy and review of the literature.

BACKGROUND: Onycholysis has been reported in association with the use of several noncytotoxic drugs and with chemotherapy in 135 patients. Onycholysis may be precipitated by exposure to ultraviolet radiation. METHODS: The authors studied 91 patients who received paclitaxel and 187 patients who received doxorubicin. RESULTS: Onycholysis occurred in 5 of 21 patients who received > 6 courses of weekly paclitaxel, developing in the summer months in all 5 patients. It did not occur in patients who received fewer weekly paclitaxel courses or those who were treated every 3 weeks. Onycholysis did not occur in 187 patients who received doxorubicin. Review of the literature revealed that onycholysis is nearly exclusively associated with anthracycline and taxane therapy. CONCLUSIONS: Prolonged weekly paclitaxel, other taxanes, and anthracyclines cause onycholysis in some patients, which may be precipitated by exposure to sunlight. Patients receiving these drugs should protect their nails from sunlight.

Colonic perforation following prolonged hypovolaemia in a major burns injury.

Perforation of the lower gastrointestinal tract is rare in burns patients. A 41-year-old male, who sustained 40% total body surface area burns and subsequently developed an acute abdomen on day 15 postburn, is presented. Emergency management included a subtotal colectomy and ileostomy formation performed to repair a perforated transverse colon found at laparotomy. The burns were debrided and grafted and the patient required cardiac, renal and respiratory support initially in the ITU setting before making a complete recovery. It is suggested that ischaemia caused the perforated transverse colon due to a prolonged low flow state. This was not detected until invasive cardiovascular catheterisation was performed and revealed a hypovolaemic state, which was corrected by fluids and noradrenaline. Both the previous cardiac history of the patient (Fallot's Tetralogy repair) and the noradrenaline may have exacerbated the low flow state within the mesenteric circulation leading to ultimate perforation. This case highlights the difficulties that may arise in resuscitating a patient who has previously had a cardiac defect repaired. Despite repair, abnormal physiology may persist resulting in misleading observations that produce undetected hypovolaemia with subsequent adverse events, as in this case. In such patients, early invasive cardiovascular monitoring should be considered.

The role of pterins and related factors in the biology of early postpartum depression.

Plasma tryptophan and other putative amino acids, cortisol, folate and vitamin B12 and urinary biopterin (B) and neopterins (N) were measured in three groups of women: 62 women in the early postpartum period, 23 pregnant and 38 non-gravid controls. Sixty-two postpartum women were screened for depression by the Edinburgh postnatal depression scale (EPDS) on day 7 after delivery. Postpartum women had significantly lower tryptophan, vitamin B12 and significantly greater levels of cortisol, folate, neopterins and biopterins than controls. Comparisons between women who were classified on the EPDS as cases and non-cases revealed only a statistically significant difference for lower N:B (P<0.01) and lower folate (P<0.01) ratio in cases than non-cases. Multiple regression analysis showed a significant contribution for low tryptophan to increased EPDS which also showed significant correlations with low methionine, low tyrosine, low N:B ratio and high vitamin B12.

Vesico-colic fistulae in the Grampian region: presentation, assessment, management and outcome.

Over a 12-year period, 67 patients presented with a vesico-colic fistula. The mean age was 69 years (range 19-96 years), with symptoms predominantly referred to the urinary tract. Cystoscopy and barium enema confirmed the presence of a fistula in 60 and 44% of patients respectively. A computerized tomography (CT) scan, used in only seven patients, revealed the fistula in each case. The underlying pathology included diverticular disease (62%), carcinoma (27%) and inflammatory bowel disease (6%). Fifty-one patients proceeded to surgery, of whom 32 (63%) had a sigmoid/recto sigmoid resection with primary anastomosis, and 13 (25%) a Hartmann's procedure. A diverting colostomy alone was employed to palliate cases of widespread carcinoma. No patient subsequently had the Hartmann's reversed. In addition to colonic resection, 48 (92%) patients had a simultaneous bladder procedure, varying from simple oversew in 32 (70%) patients to cystectomy and ileal conduit in three (6%). Wedge excision with primary bladder closure was practised in 12 (24%). Fistula recurrence occurred in seven (14%) patients, and the 30-day mortality was 10%. Surgery for vesico-colic fistula has an appreciable morbidity and mortality, yet if offers the only hope of achieving permanent symptomatic control.

Diverticular disease in patients under 50 years of age.

Sigmoid diverticular disease, when it occurs in a young age group, may follow a more aggressive course with a higher incidence of complications than in elderly. The mode of presentation and management in 77 patients under 50 years of age presenting with sigmoid diverticular disease over a 6-year period is described. Surgery for complications (peritonitis, abscess, bowel obstruction, fistula and haemorrhage) was performed in 18 (23%) individuals. Colonic resection was carried out in 14 (78%) of the operated group with primary anastomosis in six patients and Hartmann's procedure in eight patients. The mortality (30 day) was zero. Nineteen (25%) of the entire group, and 12 (67%) of those undergoing surgery had been previously hospitalized with a complication of diverticular disease. The recurrent nature and frequency of serious complications in this group, suggests that elective surgery should be considered if an acute infective episode is successfully managed conservatively.

Maintenance electroconvulsive therapy and cognitive function.

BACKGROUND: ECT is rarely used as a prophylactic treatment. A 74-year-old woman with unstable bipolar affective disorder receiving maintenance ECT presented a unique opportunity to measure the cognitive effects of continuing ECT. METHOD: A single case report with serial psychometric testing during over 400 ECT treatments as a single maintenance treatment. RESULTS: Serial testing did not demonstrate progressive cognitive deterioration, but consistent cognitive deficits typical of acute treatment were evident. The degree of cognitive difficulty may be related to the frequency of treatment. CONCLUSIONS: Maintenance ECT can be an effective prophylactic treatment for selected patients. Cognitive effects would appear to be no greater than with acute treatment and seem to be non-progressive.