The use of a composite synthetic mesh in the vicinity of bowel - For repair and prophylaxis of parastomal hernias. Does it increase the risk of short term infective complications?

AIMS: The use of synthetic meshes in potentially infected operative fields such as in the vicinity of large bowel, is controversial. This study describes our experience with the use of a synthetic composite mesh for prophylaxis and repair of parastomal hernias. METHODS: Data were collected retrospectively over a 7-year period from 2008 to 2015. An IPOM (DynaMesh™) was used either during the formation of the stoma to reinforce the abdominal wall around the stoma or during the surgical repair of existing parastomal hernias, using keyhole or sandwich technique. Majority of meshes were placed laparoscopically. Clinical data and outcomes any stoma wound complications were collected. RESULTS: Forty seven patients were included with a male to female ratio of 34:13. Median age was 66 years (38-91 years) with median follow-up of 17 months (3-73 months). Twenty seven patients had a prophylactic mesh placement (PMP) around colostomy after resection of colorectal cancer. None of these patients had any wound complications. Twenty patients had repair of parastomal hernias (RPH). One patient (1/20) in this group had a superficial wound infection around the stoma site and underwent an incision and drainage. One patient developed seroma and one had parastomal wound haematoma. CONCLUSIONS: The use of a composite synthetic mesh using a laparoscopic IPOM technique for the prophylaxis and treatment of parastomal hernias, even in a clean contaminated surgical field, is safe and feasible.

Acute pain management in symptomatic cholelithiasis.

AIM: To review the evidence for the use of different non-steroidal anti-inflammatory drugs (NSAIDs) in the treatment of biliary colic. METHODS: The strategies employed included an extensive literature review for articles and studies related to biliary colic from electronic databases including PubMed, Science Direct, Wiley Inter Science, Medline and Cochrane from last 15 years. Keywords: "Biliary colic", "management of biliary colic", "non-steroidal anti-inflammatory drugs", "cholelithiasis" and "biliary colic management". Six randomized control trials, 1 non-randomized trial and 1 meta-analysis were included in this review. The outcomes of these studies and their significance have been reviewed in this paper. RESULTS: Current evidence suggests there are no set protocols for biliary colic pain management. NSAIDs are potent in the management of biliary colic, not only in terms of symptom control but in disease progression as well. Apart from the studies on diclofenac and ketorolac, there are studies which have shown that intravenous tenoxicam and injectable flurbiprofen are equally effective in managing biliary colic. The efficacy of NSAIDs is superior in terms of lower number of doses and longer duration of action in comparison to other analgesic agents. CONCLUSION: This literature review has found that NSAIDs are safe and effective for pain control in biliary colic, and reduce the likelihood of further complications.

Outcomes Following Interval Debulking Surgery in Primary Peritoneal Carcinoma.

AIM: Primary peritoneal carcinoma (PPC) has a poor prognosis, with a median survival of 11-24 months. Unlike ovarian cancer, there exist no published data on the effectiveness of interval debulking surgery (IDS) in PPC and it is not routine practice. Our series compared outcomes in patients with PPC treated with IDS following chemotherapy versus patients treated with chemotherapy alone. PATIENTS AND METHODS: A retrospective case-note analysis was undertaken of all patients diagnosed with PPC in the Pan-Birmingham network between May 2000 and October 2008. Data were analysed for age, performance status, response to chemotherapy, surgical outcomes, subsequent treatments, site of relapse, median progression-free (PFS) and overall (OS) survival. Analysis for PFS and OS was undertaken using both Kaplan-Meier and log-rank analysis. RESULTS: A total of 44 patients with histologically-proven PPC were identified: 41 patients received chemotherapy with platinum combination or alone; 17/44 (39%) of patients underwent IDS following chemotherapy and 15 of these had optimal debulking; 3/15 (20%) had a complete pathological response. The recurrence rate for the surgical group was 11/17 (65%) including those with suboptimal debulking, whereas disease recurred in 25/27(93%) of the non-surgical group. The median PFS was 25 months (range=8-33 months) in the IDS group compared to 9 months (range=0-30 months) in the non-surgical group (p=0.001). The median OS was 48 months in the IDS group compared to 18 months in the non-surgical group (p=0.0016). The median OS for the whole patient cohort was 32 months. CONCLUSION: The median OS for the whole cohort compares favourably with previously published survival data of 11-24 months. IDS in selected cases of PPC appears to improve median OS and PFS in PPC and we would recommend that surgery is considered as a treatment option in all patients who have a good response to chemotherapy or entry into a clinical trial.

Meta-analysis of handsewn versus stapled reversal of loop ileostomy.

BACKGROUND: The morbidity associated with closure of loop ileostomy (LI) may be attributed to the various surgical techniques employed for the closure. The purpose of this review was to review the hand-sutured (HS) versus the stapled anastomosis (SA) techniques, used in the reversal of LI. METHODS: The MEDLINE, PubMed, CINHAL, Cochrane library and Web of Knowledge databases were searched for randomized controlled trials (RCTs) and case-control trials (CCTs), evaluating HS and SA in reversal of LI. Data extraction with risk of bias assessment was followed by subgroup and pooled data meta-analysis where applicable per outcome. RESULTS: Four RCTs (HS: 321, SA: 328) and 10 CCTs (HS: 2808, SA: 1044) were identified, with a total of 4508 patients. Regardless of subgroup analysis, no difference was seen between the two techniques with regard to anastomotic leaks (P = 0.24, odds ratio (OR): 1.37, 95% confidence interval (CI): 0.81-2.29) or re-operation. The stapled group showed a significantly lower rate of conservatively managed small bowel obstruction (SBO)/ ileus at 30 days (P < 0.001, OR: 2.27, 95% CI: 1.59-2.96) (P < 0.001) and SBO during combined short- and long-term follow-up (P < 0.001). The SA also showed significant shorter operative time (P = 0.02; WMD 11.52 min), time to first bowel opening (P < 0.001; WMD 0.52 days) and length of hospital stay (P = 0.03; WMD 0.70 days). CONCLUSION: The stapled technique offers an advantage in terms of lower post-operative subacute SBO rates, a faster operative technique and shorter hospitalization times. These perceived benefits make it potentially superior to HS for the reversal of LI.

Chemotherapy for advanced endometrial cancer with carboplatin and epirubicin.

UNLABELLED: Endometrial cancer is the most common gynecological cancer in the Western world. In early-stage disease, surgery remains the mainstay of treatment. Adjuvant pelvic radiotherapy reduces the risk of pelvic recurrence, however, without improvement in overall survival. The aim of the present study was to assess the efficacy and toxicity of carboplatin and epirubicin combination chemotherapy for patients with advanced and high-risk endometrial cancer. PATIENTS AND METHODS: Between 1999 and 2007, 43 patients with endometrial cancer were treated with carboplatin and epirubicin. Two groups were identified: Group 1 (n=34) included patients with stage III endometrial cancer receiving adjuvant chemotherapy; and group 2 included those with metastatic endometrial cancer (n=9). RESULTS: After a median follow-up of 37 months, disease in 19 patients had progressed/relapsed (12 patients from group 1; 7 from group 2) and 23 patients had died (15 from group 1; 8 from group 2). The median time-to-progression was 62 months and median overall survival was 64 months. The median survival for patients in group 1 was 69 months and for those in group 2 was 22 months. Ten patients (27.9%) experienced grade 3 or 4 toxicities. There were no cases of treatment-related cardiac failure or neuropathy. CONCLUSION: Cisplatin, carboplatin, anthracyclines and taxanes are the most active agents in endometrial cancer. Combination chemotherapy leads to better progression-free survival and overall survival, however, this is at the expense of increased toxicity. RESULTS from our study show that the combination of carboplatin and epirubicin is an effective alternative regimen for patients with advanced endometrial cancer. In addition, treatment-related toxicity is minimal when compared to anthracyclines and platinum agents. There is a particular advantage of this regimen over taxane-based regimens, including minimal neuropathy, less use of steroids and low risk of allergic reaction and alopecia.

Acalculous Phrygian cap cholecystitis.

We report a case of a 53-year-old Caucasian woman who presented with symptoms of cholecystitis; an ultrasound and CT scans showed a mass lesion associated with the gallbladder and no gallstones. Laparoscopic cholecystectomy and further histological analysis confirmed acalculous cholecystitis in a Phrygian cap gallbladder.

Surgical specialization and training - its relation to clinical outcome for colorectal cancer surgery.

RATIONALE, AIMS AND OBJECTIVES: Surgical sub-specialization has been considered to be a major factor in improving cancer surgery-related outcomes in terms of 5-year survival and disease-free intervals. In this article we have looked at the evidence supporting the improvement in colorectal cancer outcomes with 'colorectal specialists' performing colon and rectal surgery. METHODS: A literature review was carried out using search engines such as Pubmed, Ovid and Cochrane Databases. Only studies looking at colorectal cancer outcome related to surgery were included in our review. RESULTS: Specialist surgeons performing a high volume of colorectal cancer surgery demonstrated better 5-year survival rates in patients, with less local recurrence. This was most evident in surgery for rectal cancer, where an association with increased sphincter saving surgery was also seen. Total mesorectal excision is now the accepted treatment for rectal cancer and has markedly improved survival rates and decreased local recurrence. CONCLUSION: The outcomes in colorectal surgery continue to steadily improve. The training of specialized colorectal surgeons is a major contributing factor towards this improvement.

Improving the quality of general surgical operation notes in accordance with the Royal College of Surgeons guidelines: a prospective completed audit loop study.

AIMS AND OBJECTIVES: Accurate documentation of surgical operation notes is crucial as it facilitates the post-operative management of the patients. It also serves as an important medico-legal document for any discrepancies or disputes. The objectives of this study were twofold: to compare operation note documentation against guidelines published in Good Surgical Practice by the Royal College of Surgeons of England (RCS Eng), 2008, and to improve adherence to these guidelines, through educating surgeons and the introduction of theatre aide-memoires. METHOD: We prospectively identified 100 general surgical patients operated between February 2010 and July 2010. Equal numbers of upper gastroenterology, colorectal and vascular patients were selected. We audited operation note documentation against the RCS Eng guidelines. Our findings were presented at the trust clinical governance meeting. Areas with deficient documentation were highlighted. In addition to educating surgeons, aide-memoires were subsequently introduced in the operating theatres and our practice was re-audited. RESULTS: A total of 18 RCS Eng guidelines were identified and audited. The first audit cycle revealed poor areas in documentation of 'emergency/elective procedure' (36%), 'time of operation' (36%), 'date of operation' (87%), 'assistant' (87%) and 'post-operative management' (88%). After educating surgeons and introducing aide-memoires in theatres, the results were re-audited with an equal number of patients. The re-audit demonstrated a clear improvement in four out of five deficient areas with compliance reaching almost up to 100%. CONCLUSION: Operation note documentation is of paramount importance, it has medical and legal implications. Educating surgeons and providing aide-memoires in theatres clearly improved documentation of operation notes in compliance with the RCS Eng guidelines.

Gallbladder carcinoma: a retrospective analysis of twenty-two years experience of a single teaching hospital.

BACKGROUND: The purpose of this study was to retrospectively evaluate our experience with gallbladder cancer since the establishment of a tumour registry in our institute. METHODS: Between 1975 and 1998, 23 consecutive patients with gallbladder cancer were identified using the tumour registry database. There were 18 females (78%) and 5 (22%) males. The mean age at diagnosis was 70.6 (range 42-85) years. The diagnosis was achieved either intra-operatively or following the histological analysis of the gallbladder (n = 17), following gallbladder or liver biopsy (n = 4) or at autopsy (n = 2). Presenting symptoms included upper abdominal pain, weight loss, nausea, vomiting, fever, painless jaundice, hepatomegaly, upper abdominal mass, upper abdominal tenderness, and gastrointestinal haemorrhage. RESULTS: Histological examination revealed 20 adenocarcinomas (87%), 2 squamous cell carcinomas (9%) and one spindle cell sarcoma (4%). At presentation, 14 (61%) gallbladder cancers were stage IV, 5 (22%) were stage III and 4 (17%) were stage II. Kaplan Meier analysis revealed a mean survival of 3.2, 7.8 and 8.2 months for stage IV, III, and II disease respectively. Out of 14 patients with stage IV disease, 8 patients received adjuvant chemotherapy and survived for 4.6 months whereas six patients who did not receive adjuvant chemotherapy survived for 1.3 months. This difference was statistically significant (p = 0.04). CONCLUSION: The majority of patients with gallbladder cancer presented with advanced stage disease (stage IV) which carries a dismal prognosis. Patients who received chemotherapy with stage IV disease, however, did better than those who did not, but this is probably a reflection of patient selection.

The role of ERCP in management of retained bile duct stones after laparoscopic cholecystectomy.

BACKGROUND: Retained bile duct stones after cholecystectomy are an established entity. To find out the incidence of retained common bile duct (CBD) stones after laparoscopic cholecystectomy (LC) in our hospital, we conducted a retrospective study of patients who presented with symptomatic retained stones in the biliary system after a LC. METHODS: Between the period 1992-2000, 824 LCs were performed in our hospital. Twenty-five of these returned to the hospital with symptoms and signs suggestive of CBD stones. RESULTS: Prior to LC, ultrasound scans of all the patients showed gall stones. Alanine transaminase (ALT) was raised in 15 patients. All of these patients underwent LC. On readmission, ALT was raised in 20 patients, bilirubin was raised in 9 patients, and alkaline phosphatase (ALK) was raised in 16 patients. Ultrasound showed common bile duct dilatations in 16 patients, with 6 of these dilated bile ducts having stones. All 25 patients underwent endoscopic retrograde cholangiopancreatography (ERCP)--with successful removal of stones in 16 cases, failure in 5 cases, and no stones in 4 cases. A second ERCP was successful in removing stones in 4 of the 5 failed patients. CONCLUSIONS: In our hospital, the incidence of symptomatic retained stones after a LC is about 2.5%. Ultrasound is poor in visualising common bile duct stones although it detects CBD dilatations in majority of cases (76%). ERCP is an effective technique for diagnosis and treatment of retained post-LC stones, with minimum morbidity and no mortality in our small series.

Current practice for anticoagulation prophylaxis in inguinal hernia surgery: a questionnaire survey.

AIMS: The incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) is well documented in patients undergoing surgery involving general anaesthesia. A large number of trials have been conducted establishing the efficacy of prophylactic measures against deep vein thrombosis, yet there remains wide practice variation amongst surgeons regarding the use of anticoagulation measures. The main aims of our study were to survey the use of DVT prophylaxis for inguinal hernia repairs in the UK, and to establish any variations amongst British surgeons in their use of anticoagulation measures for repair of inguinal hernias. METHODS: We conducted a questionnaire survey amongst surgeons of the Association of Endoscopic Surgeons of Great Britain and Ireland (AESGBI). Two hundred and fifty questionnaires were sent with a response rate of 72%. RESULTS: Our results have shown wide variation amongst British surgeons in the use of anticoagulation measures. Furthermore, only 10% of the surgeons in the laparoscopic and 14% in the open group risk stratify their patients; 10% of the surgeons do not use any DVT prophylaxis at all. CONCLUSIONS: Although the incidence of DVT in inguinal hernia repair is very low this is a very commonly performed procedure. Both over and under treatment with thromboprophylaxis can have implications in terms of side effects and costs. One possible way to avoid problems is to risk stratify patients before thromboprophylaxis is instituted.