Nontraumatic Emergency Laparotomy: Surgical Principles Similar to Trauma Need to Be Adopted?

OBJECTIVES: In 2011, the Royal College of Surgeons published Emergency Surgery: Standards for Unscheduled Care in response to variable clinical outcomes for emergency surgery. The purpose of this study was to examine whether different treatment modalities would alter survival. METHODS: All patients who underwent emergency laparotomy between April 2011 and December 2012 at Warwick Hospital (Warwick, UK) were included retrospectively. Information relating to their demographics; preoperative score; primary pathology; timing of surgery; intraoperative details; and postoperative outcome, including 30-day mortality, were collated for statistical analysis. RESULTS: In total, 91 patients underwent 97 operations. The median age was 64 years (range 50-90, male:female 1:2). Sixty-five percent of cases were obstruction and perforation, and 66% of all operations were performed during office hours. The unadjusted 30-day mortality was 15.4%. Compared with nonsurvivors, survivors had a significantly higher Portsmouth-Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity score (P < 0.001), prolonged duration of hypotension and use of inotropes (P = 0.013), higher volume of colloid use (P = 0.04), and lower core body temperature (P < 0.05). Grades of surgeons did not influence mortality. CONCLUSIONS: The 30-day mortality rate is comparable to the national standard. Further studies are warranted to determine whether trauma management modalities may be adopted to target high-risk patients who exhibit the lethal triad of hypotension, coagulopathy, and hypothermia.

Endoscopic stenting of acutely obstructing colorectal cancer: a 10-year review from a tertiary referral centre.

BACKGROUND: Insertion of self-expanding metallic stents for obstructing colorectal cancer (CRC) is a potential alternative to emergency resection, but evidence regarding efficacy is inconclusive. We aim to assess local efficacy of stent insertion for obstructing CRC, and to establish whether the service could be offered regionally. METHOD: Retrospective patient data analysis using local paper notes and electronic records was performed. All patients underwent stent insertion for an obstructing CRC from April 2004 to March 2014. The main outcome measures were success of stent insertion, complications, further surgery and overall mortality. RESULTS: Eighty-nine stent insertions were performed. Twenty-five were performed as a bridge to surgery, 49 due to advanced disease, 11 due to patient co-morbidity and four due to patient choice. Time from referral to stent insertion for emergency referrals was 1-360 h (median 23). Eighty-seven stents were successfully deployed. Perforation occurred in three patients and migration in nine patients. Twenty-one patients underwent planned surgery (time to surgery was 2-208 days, median 24), 14 patients underwent emergency surgery (time to surgery was 0-277 days, median 11). Forty-six patients have died since stent insertion (time to death was 0-42 months, median 6.04). CONCLUSION: Stent insertion for obstructing CRC is a viable alternative to emergency resection, with a low complication rate. Stent insertion may allow a proportion of patients to later undergo planned surgery. Stent insertion carries a lower peri-procedure mortality than emergency resection. An acute stent insertion service for obstructing CRC could potentially be offered at regional level in our Trust.

The Two-Week Referral System for colorectal cancer--not fit for purpose.

PURPOSE: The UK government target expects all suspected colorectal cancer (CRC) patients to be seen within the Two-Week Referral (TWR) system made by general practitioners. These guidelines originally derived from only level 5 evidence. However, this has significant impact on the workload for colorectal surgeons. The aim of the study is to investigate the effectiveness of this colorectal service and whether the referral criteria are predictive of CRC. METHODS: A retrospective study of all patients referred under the TWR guidance in 2010 was assessed. The first 573 TWRs were piloted for analysis. Clinical information from each patient was collected regarding TWR criteria and additional colorectal symptoms or risk factors. Multiple regression analysis was performed to determine which symptoms independently correlated with CRC. RESULTS: One hundred twenty-six CRCs were diagnosed via all methods of referral in 2010. There were 940 patients referred under the TWR guidelines in that year, when 50 CRC patients were identified. Amongst the 573 patients, 32 CRCs were diagnosed. Multiple regression analysis revealed tenesmus to be independently associated with CRC (p = 0.003, Pearson's r = 0.09185). None of the individual TWR criteria confidently predicted CRC. CONCLUSION: Our preliminary results suggest that the current TWR guidelines cannot effectively predict CRC. There is an urgent need for an evidence-based approach to referral criteria for suspected CRC.

Preliminary results of sacral transcutaneous electrical nerve stimulation for fecal incontinence.

BACKGROUND: Fecal incontinence is a common debilitating condition. OBJECTIVE: The aim of this study is to investigate the feasibility of sacral transcutaneous electrical nerve stimulation as an alternative treatment modality for fecal incontinence. DESIGN: All consecutive patients who presented with fecal incontinence to the senior author's clinic were prospectively recruited between June 2009 and September 2010. The severity of their fecal incontinence was assessed by the Wexner and Vaizey scores and anal physiology. MAIN OUTCOME MEASURES: Any improvement following a period of sacral transcutaneous electrical nerve stimulation treatment was determined by repeating the scores. In addition, patient satisfaction with the procedure was assessed by using a patient impression score. RESULTS: Twenty female patients with a median age of 57.5 years (range, 30-86) were evaluated. The median follow-up was 10 months (range, 5-12 months). Two patients did not record a change in their Vaizey score. The overall mean Wexner score was 7.9 ± 4.2 before in comparison with 4.0 ± 3.1 after sacral transcutaneous electrical nerve stimulation treatment (p < 0.0001, CI = 2.2-5.7, SE = 0.832). The overall mean Vaizey score was 12.7 ± 5.7 before in comparison with 5.8 ± 5.6 after sacral transcutaneous electrical nerve stimulation treatment (p < 0.0001, CI = 4.5-9.4, SE = 1.162). The pretreatment patient impression score was set at a mean of 1 ± 0 in comparison with 2.8 ± 1.1 after sacral transcutaneous electrical nerve stimulation treatment (p < 0.0001, CI = 1.2-2.3, SE = 0.25). CONCLUSION: The preliminary results suggest sacral transcutaneous electrical nerve stimulation is a promising noninvasive alternative to existing modalities in the treatment of idiopathic fecal incontinence.

Isolated unilateral tongue oedema: the adverse effect of Angiotensin converting enzyme inhibitors.

Angiotensin converting enzyme inhibitors (ACEI) are widely used to treat benign hypertension. These drugs are generally well tolerated. Serious side effects such as angio-oedema are very rare. The authors report a 64-year-old Caucasian woman with a history of liver transplant on Mammalian Target Of Rapamycin (mTOR) inhibitor, who attended Emergency department with angio-oedema only on the left side of her tongue. Her airway was patent and she was haemodynamically stable. Trauma was denied. Her physician had 2 days earlier commenced her on Lisinopril for newly diagnosed benign hypertension. Intravenous steroids and anti-histamine were immediately administered. A good response of oedema subsidence was noted. In general, angio-oedema can present in a spectrum of severity. Precipitating factors are often difficult to pre-determine and avoid. Early recognition of risk factors for and diagnosis of angio-oedema can often be life-saving.

STAR procedure: stapled transanal resection of tumour.

This study assesses the practicality, mortality and morbidity of the STAR procedure for debulking of large rectal tumours prior to transanal endoscopic microsurgery.