A 10-year serial, prospective study of laparoscopic cholecystectomy training in a single region.

AIM: To determine how surgical registrar training in laparoscopic cholecystectomy evolved in a single region in the 10 years since the introduction of this technique. METHODS: In 1993, 1996, and 2001, identical, standardised postal questionnaires were sent to all general surgical registrars in the Oxford region. The questionnaire enquired about the number of laparoscopic cholecystectomies performed, performed with supervision or simply assisted at within a set time period. RESULTS: There has been a significant increase in the number of procedures performed by trainees between 1993 and 2000, in comparison to the number purely assisted at. CONCLUSIONS: After an initial learning period for the consultant trainers, laparoscopic cholecystectomy has been rapidly adopted, and is now a major training operation, much as open cholecystectomy was in the past.

The incidence and causes of permanent stoma after anterior resection.

AIMS: Defunctioning stomas are used following anterior resection to guard against the serious consequences of anastomotic leak such as pelvic sepsis and generalized peritonitis. This study aims to determine what proportion of patients undergoing anterior resection have a defunctioning stoma, how many of these patients do not have their stoma closed, and the reasons for this. METHODS: All patients undergoing a resection for rectal cancer in our institution in a five year period (January 1995 to December 1999) are included in the study. Anterior resection was performed on 154 patients, divided into 76 anterior resections (AR) and 78 low anterior resections (defined as the anastomosis within 6 cm of the anal verge). The data from these patients were analysed retrospectively. RESULTS: Of the total of 154 patients undergoing anterior resection, 59 (38%) were defunctioned, divided into 33 with loop ileostomy and 26 with loop colostomy. Five of these patients had not had their stoma closed at a median follow up of four years (range 1.5-6.5 years). The reasons for non closure were anastomotic stricture (2), metastatic disease (2), and patient choice (1). When comparing AR and LAR, 16% of patients had a defunctioning stoma after AR, compared with 60% after LAR (P < 0.01). CONCLUSION: Anterior resection is being performed for very low rectal tumours in order to avoid a permanent stoma. However we have found that 8% of patients who are defunctioned with a stoma at anterior resection will not have their stoma closed, and conclude that patients should be warned of this pre-operatively.

A 1 year prospective study of management and outcome of patients presenting with critical lower limb ischaemia.

OBJECTIVES: to determine management of patients with critical lower limb ischaemia (CLI) from first presentation to investigation and treatment. DESIGN: prospective study of critical ischaemia patients. METHODS: one-year prospective survey (May 2000-May 2001). Follow-up 3-15 months. RESULTS: some 873 arterial cases presented, 134 patients had CLI. Of the latter 49% were men, 30% diabetic, the median age was 81 years. Only 15 (24%) of 62 cases were referred to outpatients as urgent. Patients waited a median of 25 days (range 1-100) to be seen in outpatients, and had symptoms for a median of 8 weeks. Treatment was conservative for 70 patients, and 11 primary amputations, six secondary amputations, and 62 revascularisation procedures (34 operative, 28 percutaneous transluminal angioplasty) were performed. At follow-up (3-15 months, median 9 months), rates of major amputation and death were 12 and 27% respectively. Significantly more diabetics underwent major amputation (p < 0.02) than non diabetics. Patients presenting with ulceration or gangrene were at greater risk of death than those with rest pain alone (p < 0.01). CONCLUSION: patients with CLI often have symptoms for many weeks before being seen by a specialist, and 76% are referred as non-urgent cases. This compares with patients with suspected malignant disease in the U.K. who are required to be seen within 2 weeks.

Avoiding inappropriate surgery for secondary rectal cancer.

AIMS: Secondary rectal carcinoma occurs by invasion of the rectum by local primaries or by metastatic spread from a distant primary. The principle management of primary rectal carcinoma is surgery, but this is not usually the case for secondary carcinoma. This study investigates how these two may be differentiated and inappropriate surgery, in particular inappropriate abdominoperineal excision, can be avoided. METHODS: There were six patients with secondary carcinoma of the rectum. The primary tumours were: prostate (three), endometrium (two), breast (one). RESULTS: All the patients presented with lower gastrointestinal symptoms and four had a palpable mass on rectal examination. The diagnosis was made on histology and immunohistochemistry. Treatment was with endocrine therapy, chemotherapy, radiotherapy, and surgery. Three patients had palliative surgical procedures, and one had a curative anterior resection. The median survival was 7.5 months. CONCLUSIONS: This study has found that the presentation of primary and secondary rectal carcinoma is similar, and the method for distinguishing between the two is histology and immunohistochemistry. Staining for prostate-specific antigen was 100% accurate in the diagnosis of secondary rectal carcinoma arising from a prostate primary. The treatment of secondary rectal carcinoma is with systemic therapy and surgery is usually palliative, and therefore abdominoperineal excision should be avoided.