Incise and lay open: an effective procedure for coccygeal pilonidal sinus disease.

AIM: This study aims to analyze the outcome of various procedures performed for coccygeal pilonidal disease. METHODS: Between January 1999 and February 2004, patients with coccygeal pilonidal disease were included. Data were analyzed for the nature of operation (elective/emergency), grade of surgeon, type of procedure and further definitive surgery. RESULTS: Two hundred and four patients underwent surgery for coccygeal pilonidal disease. One hundred and thirty-six patients had emergency surgery (abscess drainage: 61; abscess drainage + lay open: 75) and further definitive procedure was performed in 20 (33.3%) and 8 (11.1%) patients, respectively (P = 0.013, Fishers' exact test). Sixty-eight patients had elective surgery (incision and lay open: 34; excision and lay open: 24; excision and closure/Bascom's/other: 10) and further procedure for recurrence was noted among 3 (8.8%), 5 (20.8%) and 4 (40%) patients, respectively (P = 0.17, chi(2) test). CONCLUSION: In patients with coccygeal pilonidal sinus disease, a single-stage incision and lay open of the sinus tract is the most efficient operation, especially during emergency surgery.

A prospective randomized single blind trial of Fleet phosphate enema versus glycerin suppositories as preparation for flexible sigmoidoscopy.

AIM: This study compared the efficacy and patient acceptability of two methods of bowel preparation for flexible sigmoidoscopy. METHODS: Patients attending for outpatient flexible sigmoidoscopy were prospectively randomized to receive one Fleet ready-to-use enema or 2 x 4 g glycerin suppositories, 2 h preprocedure. Patient and endoscopist questionnaires were used to compare the outcomes. RESULTS: From November 2000 to August 2001, 203 (male = 95; female = 108) patients were randomized. Patient data available for 163 patients (enema = 93; suppository = 70) revealed: ease of use (enema = 52; suppository = 25; P < 0.02, Fisher's exact); assistance required (enema = 19; suppository = 3; P < 0.005, Fisher's exact); grade of effectiveness (enema = 83; suppository = 44; P < 0.0001, Fisher's exact), and whether patients wished to try another preparation in future (enema = 16; suppository = 24; P = 0.016, Fisher's exact). Endoscopist data available for 151 patients (enema = 76; suppository = 75) revealed: average depth of insertion (enema = 53.6 +/- 11.6 cm; suppository 46.3 +/- 13.7 cm; P < 0.001, Student's t test); acceptable (excellent + good) quality of preparation [enema = 60 (78.9%); suppository = 34 (45.3%); P < 0.0001, Fisher's exact]. CONCLUSION: Bowel preparation for flexible sigmoidoscopy using a single Fleet enema is acceptable to patients and more effective than glycerin suppositories.

Endoscopically assisted minimally invasive surgery for gallstones.

BACKGROUND: We present a case report of Bouveret syndrome followed by a review of the recent literature regarding the management of this condition. Bouveret syndrome is a form of gastric outlet obstruction secondary to a gallstone which has eroded through the gallbladder into the duodenum. It is an uncommon variant of gallstone ileus. Endoscopic methods have been described to extract the stone from the duodenum. METHODS: This is a case of an 85-year-old female patient who presented with a 1-week history of nausea, intermittent bilious vomiting and anorexia. Imaging confirmed the diagnosis of Bouveret syndrome caused by two large gallstones. Conventional endoscopic methods successfully extracted the impacted stones from the duodenum into the stomach but were unable to extract the stones from the stomach. A mini-transverse laparotomy and gastrotomy were performed to finally extract the stones.

Surgical experience with small bowel damage secondary to pelvic radiotherapy.

BACKGROUND: Patients undergoing pelvic radiotherapy are at risk of developing radiation enteritis. This study reviewed patients with radiation enteritis referred to a specialist colorectal unit. METHODS: Patients referred with radiation enteritis secondary to pelvic radiotherapy (July 2001 to July 2005) were analysed regarding: indication, duration, dosage/fractionation of radiotherapy, nutritional/biochemical assessment, investigation, surgery, histopathology, and hospital stay. RESULTS: Eleven patients underwent pelvic radiotherapy. The median interval between radiotherapy and referral was 17 months. The majority were nutritionally deficient at presentation (haemoglobin < 12 g/l: 91%; magnesium < 0.75 mmol/l: 64%; albumin < 35 g/l: 91%). Eight (73%) patients had either a BMI < 20 or weight loss of >10% within 3 months prior to referral. Radiation enteritis was diagnosed by preoperative radiology, laparotomy and at histopathology. All patients underwent surgery (resection/ilesotomy/bypass) and median post-operative stay was 24 days. CONCLUSIONS: Radiation enteritis is associated with prolonged symptoms. Majority of patients are undernourished and despite nutritional support a high morbidity is noted.

Four pathologies in one.

BACKGROUND: Acute appendicitis is a frequently encountered entity in emergency surgery. Incidental findings as Meckel's diverticulum or Crohn's disease during this operation are not uncommon. METHODS: Laparotomy revealed a perforated appendix with an incidental Meckel's diverticulum and thickened distal small bowel with fat encroaching the mesentery suggestive of active Crohn's disease. A routine appendicectomy was done and pathology revealed inflamed perforated appendix with an incidental carcinoid within the appendix. CONCLUSIONS: Presence of active Crohn's disease along with an incidental Meckel's diverticulum or acute appendicitis raises controversies in their surgical management. We discuss the issues in managing patients with two or more of these co-existent pathologies.

A prospective randomized single-blind comparison of three methods of bowel preparation for outpatient flexible sigmoidoscopy.

BACKGROUND: Preparation for outpatient flexible sigmoidoscopy using a self-administered phosphate enema is the standard practice in our unit, but it provides acceptable bowel preparation in only 80% of patients. This study compared two methods of bowel preparation with the current standard in an attempt to improve efficacy and acceptability. METHODS: From January to September 2003, patients scheduled for out-patient flexible sigmoidoscopy were prospectively randomized to 3 groups: group 1: one Fleet enema 2 h pre-procedure; group 2: two Fleet enemas, one on the evening prior to sigmoidoscopy and one 2 h pre-procedure; group 3: lactulose 30 ml orally 48 and 24 h prior to sigmoidoscopy, plus a single Fleet enema 2 h pre-procedure. A patient questionnaire was used to assess side effects and tolerance. The endoscopists questionnaire assessed the indication for the procedure, quality of preparation, depth of insertion, and pathological findings identified. Power calculations were based on the 80% acceptable preparation rate obtained using a single enema. RESULTS: For this study, 305 patients were randomized to the three groups. Patient data were available for 261 patients (group 1 = 105; group 2 = 81; group 3 = 75), and endoscopist data were available for 251 patients (group 1 = 97; group 2 = 79; group 3 = 75). No difference was noted between the groups with regard to age, gender, procedure indication, grade of endoscopist, or patient acceptability variables (ease of use: p = 0.09; assistance required: p = 0.11; cramps experienced: p = 0.84; alternative method: p = 0.25). There was no significant difference between the groups in terms of depth of insertion (p = 0.42-chi-squared test) or abnormalities noted (p = 0.34-chi-squared test). Nor was there any difference in the quality of preparation of patients in group 1 versus group 2 (p = 0.39-Fishers exact test) or group 1 versus group 3 (p = 0.13-Fishers exact). However, lactulose + Fleet resulted in significantly fewer patients with acceptable preparation compared with those who administered two Fleet enemas (p = 0.02- Fishers exact test). CONCLUSIONS: The addition of a Fleet enema or oral lactulose over and above a single Fleet enema gives no significant improvement in the acceptability or efficacy of bowel preparation.

Inflamed solitary caecal diverticulum - it is not appendicitis, what should I do?

We describe three cases that presented with symptoms suggestive of appendicitis but were found at operation to have an inflamed solitary caecal diverticulum. All were treated successfully with diverticulectomy or inversion of the diverticulum. We wish to highlight this diagnosis and its surgical management so that informed decisions can be made if this is first encountered in the operating theatre.

Solitary fibrous tumour of the falciform ligament containing multiple foci of malignant transformation.

Solitary fibrous tumour is an uncommon soft tissue tumour initially described in the pleural cavity. In the past decade, it has been described in various extrapleural sites, including the abdomen. Traditionally regarded as benign, cases of histologically or clinically malignant solitary fibrous tumours are rare. This report describes such a case, although the patient is still disease free five years after excisional surgery, without adjuvant treatment. The acute clinical presentation may be related to malignant transformation occurring in a long standing solitary fibrous tumour.

Fluorescence anisotropy measurements of lipid order in plasma membranes and lipid rafts from RBL-2H3 mast cells.

Specialized plasma membrane domains known as lipid rafts participate in signal transduction and other cellular processes, and their liquid ordered (L(o)) phase appears to be important for their function. To quantify ordered lipids in biological membranes, we investigated steady-state fluorescence anisotropy of two lipid probes, 2-[3-(diphenylhexatrienyl)propanoyl]-1-hexadecanoyl-sn-glycero-3-phosphocholine (DPH-PC) and N-(7-nitrobenz-2-oxa-1,3-diazol-4-yl)-1,2-dihexadecanoyl-sn-glycero-3-phosphoethanolamine (NBD-PE). We show using model membranes with varying amounts of cholesterol that steady-state fluorescence anisotropy is a sensitive measure of cholesterol-dependent ordering. The results suggest that DPH-PC is a more sensitive probe than NBD-PE. In the presence of cholesterol, ordering also depends on the degree of saturation of the phospholipid acyl chains. Using DPH-PC, we find that the plasma membrane of RBL-2H3 mast cells is substantially ordered, roughly 40%, as determined by comparison with anisotropy values for model membranes entirely in a liquid ordered (L(o)) phase and in a liquid disordered (L(alpha)) phase. This result is consistent with the finding that approximately 30% of plasma membrane phospholipids are insoluble in 0.5% Triton X-100. Furthermore, detergent-resistant membranes isolated by sucrose gradient fractionation of Triton X-100 cell lysates are more ordered than plasma membrane vesicles, suggesting that they represent a more ordered subset of the plasma membrane. Treatment of plasma membrane vesicles with methyl-beta-cyclodextrin resulting in 75% cholesterol depletion leads to commensurate decreases in lipid order as measured by anisotropy of DPH-PC and NBD-PE. These results demonstrate that steady-state fluorescence anisotropy of DPH-PC is a useful way to measure the amount of lipid order in biological membranes.