The Effect of Interval From Completion of Short-Course Radiotherapy to Surgery on the Post-Operative Morbidity and Mortality of Patients with Rectal Cancer.

AIM: Surgery is the mainstay of treatment for invasive rectal cancer. Advances in surgical technique and radiotherapy over the past few decades have resulted in improved local control and survival.1-3 Some concern remains regarding the morbidity associated with performing surgery within a short window following radiotherapy. The current study assessed whether the interval between short-course radiotherapy and surgery influences all cause post-operative morbidity and mortality. METHODS: All patients who had undergone short-course radiotherapy for rectal cancer within the Belfast Health and Social Care Trust from 2005 to 2014 held on a prospective database were included (n=102). A retrospective review of patients' clinical records was performed and a comparison made of patients who had undergone surgery less than 4 days with those 4 or more days following completion of radiotherapy. Baseline patient and tumour characteristics, post-operative complications and readmission rates were compared. Statistical analysis was performed using SPSS ®, Version 22 (SPSS, Inc, Chicago, Illinois, USA). RESULTS: There was no significant difference in mortality or overall post-operative complications between groups, however, less serious complications were reduced in patients undergoing surgery less than 4 days following radiotherapy. Perineal wound complications were significantly more common in patients who had undergone surgery 4 or more days following radiotherapy. CONCLUSION: Our results support the existing data that post-operative complications may be more common with increasing interval to surgery from completion of radiotherapy. Perineal wound morbidity appears significantly more common in patients who undergo surgery 4 or more days following short-course radiotherapy. A larger study to look particularly at perineal wound morbidity and interval from completion of radiotherapy is warranted.

Torsion of an omental lipoma presenting as an emergency.

Primary omental pathology is rare. A case of torsion of an omental lipoma is reported in a 77-year-old women presenting as an emergency with lower abdominal pain. Abdominal and pelvic CT scan was of value in the pre-operative investigation.

Improvement in quality of colorectal cancer pathology reporting with a standardized proforma--a comparative study.

BACKGROUND: Histopathological evaluation is a critical component in the management of patients with colorectal cancer (CRC). It is the single most powerful prognostic indicator in CRC and determines if adjuvant chemotherapy is indicated. The aim of this study was to assess if the introduction of a comprehensive standardized pathology proforma improved the quality of histopathology reporting. METHODS: A standardized pathology proforma, based on the 1996 minimum dataset for colorectal histopathology reporting, was introduced in our pathology department in 1998. Pathology reports for all colonic resection specimens for 1996 (n = 85) and 2000 (n = 86) were identified, retrieved and entered on to database. Comparison was made with the minimum dataset published in the 1996 guidelines for the management of colorectal cancer. RESULTS: Demographic details were complete in all cases. Clinical data was incomplete in 57 (67%) patients in 1996 and 63 (73%) in 2000 (ns; chi2). There were 24 (28%) (7 Abdomino-perineal resections (APER)) and 40 (47%) (17 APER's) rectal specimens for 1996 and 2000, respectively. The presence or absence of pathological background abnormalities were commented on in 18 (21%) reports in 1996 and 80 (93%) reports in 2000 (P < 0.01; Fishers exact test (Fisher)). Histological differentiation was commented on in 73 (86%) and 86 (100%) in 1996 and 2000, respectively (P < 0.01; Fisher). Dukes' stage was stated in 33 (39%) reports in 1996 and 86 (100%) in 2000 (P < 0.01; Fisher) but Dukes' stage was calculable in 84 (99%) in 1996 and 86 reports (100%) for 2000 (ns; Fisher). The apical node was commented on in 34 (40%) reports in 1996 and 85 (99%) reports in 2000 (P < 0.01; Fisher). The median (IQR) number of nodes assessed in 1996 was 8 (5-12) compared to 12 (8-17) in 2000 (P < 0.001; Mann-Whitney (MW)). Complete resection was mentioned in 74 (87%) reports in 1996 and 86 (100%) in 2000 (P < 0.01; Fisher). Regarding rectal specimens, the circumferential resection margin (CRM) was commented on in 19 of 24 specimens in 1996 and 38 of 40 specimens in 2000 (ns; Fisher). Relationship to the peritoneal reflection was commented on in 1 (1%) rectal specimen in 1996 and 30 (35%) in 2000 (P < 0.001; Fisher). CONCLUSION: The introduction of a standardized proforma for reporting CRC resection specimens improves the quality of histopathological reporting. This aids decision-making regarding adjuvant chemotherapy or radiotherapy and further surveillance.

Vacuum assisted closure system in the management of enterocutaneous fistulae.

BACKGROUND: A very important yet often troublesome element in the conservative management of enterocutaneous fistulae is the protection of the surrounding skin from contact with the effluent. This report describes the successful use of a vacuum assisted closure (VAC) system in dealing with this problem. METHODS: The results of using the VAC system were studied in three patients with moderate or high volume output enterocutaneous fistulae where conventional treatment had failed to prevent skin excoriation. RESULTS: The VAC system was found to be highly effective in controlling fistula effluent and in promoting healing of excoriated skin in all three patients. Complete healing of the fistula was also achieved in two of the three patients. CONCLUSION: The VAC system can be an effective and economically viable method of containing fistula effluent and protecting the skin of patients with enterocutaneous fistulae. Contrary to conventional thought, the VAC system may also actually promote healing of the fistula.

Colonic malignancy arising in colitis - a single unit experience.

OBJECTIVES: Colorectal malignancy complicating inflammatory bowel disease constitutes 1% of all colorectal malignancies. Although its overall numbers are low it represents the greatest cause of colitis related mortality in these patients. This paper describes the management of 24 patients presenting to a single unit over a period of 10 years. METHODS: The names of patients were collected prospectively when they presented with malignancy. Clinical details were collected by retrospective review of charts. RESULTS: In all, 24 patients with 27 malignancies were identified. The median age of presentation with malignancy was 56 years. Most patients were treated with proctocolectomy. Other patients were treated with segmental colectomy. In these patients the surgical procedure was dictated by the stage of the cancer, the age and comorbid state of the patient and the severity of ongoing colitis. CONCLUSIONS: Malignancy arising in colitis will constitute only a small part of a colorectal practice. The optimum method for detecting early, and potentially curable, disease has not been defined. Surgery should be tailored to the individual needs of the patient.

Hartmann procedure revisited.

OBJECTIVE: To assess the complications and results of Hartmann's procedure and secondary restoration of continuity for left-sided colonic disease. DESIGN: Retrospective study. SETTING: University hospitals, Northern Ireland. SUBJECTS: 72 Patients who required a Hartmann's procedure over a 13 year period (1985-1998). INTERVENTION: Of these 45 (63%) were done as emergencies and 27 (38%) as elective procedures. The indications for an emergency procedure were obstruction and perforation. MAIN OUTCOME MEASURES: Mortality, morbidity, reversal of stoma rate. RESULTS: The overall postoperative mortality was 7/72 (10%), with no significant difference between the emergency (4/45, 9%) and the elective (3/27, 11%) groups. Postoperative complications occurred in 31 patients (43%), and 8 developed wound infections (11%). Of the 43 surviving patients who where deemed suitable for re-establishment of continuity, 30 (70%) have had it done. There were no postoperative deaths or anastomotic dehiscences after the restoration of continuity. CONCLUSION: Hartmann's procedure remains a safe and suitable option in patients with left sided colonic emergencies.

Massive abdominal and pelvic myxoma in Carney's syndrome.

This report describes a massive abdominal and pelvic myxoma in a patient with Carney's syndrome. A 38 year old woman presented with abdominal distension and a palpable mass, and at operation a large pelvic and abdominal tumour was identified and resected. The surgical specimen consisted of a lobulated mass, which on cut section had a uniform gelatinous consistency. The mass surrounded both ovaries, the appendix, and the upper part of the uterus, but macroscopically did not appear to involve these organs. Histological examination showed plump stellate and spindle shaped cells set in an abundant myxoid stroma, in keeping with a myxoma. Immunohistochemical staining revealed positivity of tumour cells for vimentin, but no reactivity to desmin, alpha-smooth muscle actin, S-100 protein, CD34, or AE1/AE3. This is the first documented case of massive adominal and pelvic myxoma in a patient with Carney's syndrome. Clinicians and pathologists should be aware that myxomas in Carney's syndrome can rarely involve unusual sites other than the skin and heart.

Pathology of rectal adenocarcinoma following preoperative adjuvant radiotherapy and chemotherapy.

The study group comprised 13 patients (mean age 68 years) with clinically fixed and biopsy proven moderately differentiated rectal adenocarcinoma (8 high rectal, 5 low-mid rectal) who received synchronous courses of preoperative combination chemotherapy and pelvic radiotherapy (radiotherapy alone in 3 cases) over a period of 8-20 weeks prior to surgical resection. All cases showed varying degrees of mural and mesorectal fibrosis. Three cases did not differ otherwise from usual rectal adenocarcinoma while 4 had a 20-30% diminution in expected tumour area. In 6 cases tumour could not be definitely identified grossly--1 showed a 50% reduction in tumour bulk while 5 had only residual microscopic foci from 0.6-4 mm in maximum dimensions. Only 3 cases had involvement of the mesorectal circumferential radial margin. Four involved lymph nodes in 2 cases were partially hyalinised and calcified. Preoperative combination adjuvant therapy can produce marked regressive morphological changes in rectal adenocarcinoma. The implications of this are discussed.

Small intestinal ulceration secondary to carcinoid tumour arising in a Meckel's diverticulum.

A solitary small intestinal ulcer associated with a carcinoid tumour in a nearby Meckel's diverticulum was found in a 77 year old man presenting with massive rectal bleeding. Angiography and a radioisotope study localised the bleeding to the ileum. At operation, the Meckel's diverticulum was identified, with bleeding from an ulcer just distal to it. Pathological examination revealed a small carcinoid tumour confined to the Meckel's diverticulum. Close to the opening of the diverticulum, within the ileum, a well demarcated ulcer was present. Histology showed a non-specific ulcer which eroded a large blood vessel. This is the first documented occurrence of solitary small intestinal ulceration in association with a carcinoid tumour. Carcinoid tumour should be added to the list of possible causes of small intestinal ulceration. The ulceration may be secondary to release of cytokines by the tumour.

A prospective randomised study comparing polyethylene glycol and sodium phosphate bowel cleansing solutions for colonoscopy.

Polyethylene glycol (Klean-Prep, Norgine) is widely used for bowel cleansing in the United Kingdom. This study compares the efficacy, acceptability and adverse effects of a polyethylene glycol (PEG) solution with sodium phosphate (Fleet Phospho-soda, De Witt) for bowel preparation prior to colonoscopy. Two hundred and nine consecutive patients were prospectively randomised to either PEG or sodium phosphate (SP) preparation. The endoscopist was blinded to the randomisation process. Fifty patients were excluded from the study because of previous colectomies or incomplete data. Of the remaining 159 patients, 88 had been randomised to the PEG group and 71 to the SP group. There was no difference in sex distribution between the groups. There were no significant differences between groups in terms of patient acceptability, side effects (nausea/vomiting and abdominal cramps), adequacy of bowel preparation and colonoscopy completion rates. 74% of the PEG and 70.4% of the SP group were rated by the endoscopist as having good or excellent bowel preparation. Sodium phosphate is well tolerated without additional side effects when compared with PEG solution. Both solutions were found to be equally effective in bowel cleansing.

Fine needle aspiration cytology of gastric carcinoma.

Four patients between 58 and 81 years of age undergoing investigation and endoscopic biopsy for gastric carcinoma also were subjected to direct-vision fine needle aspiration cytology of their mucosal lesions which yielded malignant cells. The relevance of this technique is discussed regarding both intrinsic and extrinsic lesions of the gastrointestinal tract.

Experience with schistosomiasis in Northern Ireland.

Five cases of schistosomiasis have been recorded in the Belfast City Hospital Histopathology Laboratory over the last three years. The sites of infection have included the colon, bladder, uterus and seminal vesicles. All the infected individuals had visited Africa. Three of them were health care workers. The clinician must maintain a high index of suspicion when treating those with a history of travel and risk of exposure to this infection. Diagnosis is made even more critical as the condition is treatable, and serological markers can identify those with occult infection.

A prospective study of adult inguinal hernia repairs using absorbable sutures.

A prospective study was conducted over a 5-year period to determine whether inguinal hernia repair could be safely performed with absorbable suture material (polydioxanone) with reference to recurrence rates, wound pain, haematoma formation and wound infection. Analysis is available for 111 operations involving 111 patients. Mean follow-up was 36 (range 21-66) months, with 81 procedures monitored for more than 2 years. Two-layered hernia repair was used in all cases with polydioxanone as the chosen suture material. Mean post-operative stay was 2.1 days, with no hospital wound infections and three haematomas. Review identified 1 wound infection. There have been two recurrences. Preliminary results suggest that hernia repair with absorbable suture materials is comparable to traditional non-absorbable repair in terms of recurrence and associated wound complications. The additional benefit is the absence of foreign material in the wound region following degradation of the absorbable material. This does not appear to compromise the integrity of the hernia repair. Mesh repairs are increasingly preferred to Shouldice-style repairs in elective inguinal hernias. However, we believe that polydioxanone should be the suture material of choice in obstructed or strangulated hernia. A larger study is required to verify this, as well as a longer follow-up period. The use of absorbable material warrants further investigation.

Unnecessary delays in accident and emergency departments: do medical and surgical senior house officers need to vet admissions?

Work was carried out to determine whether patients requiring emergency medical or surgical admission to hospital via accident and emergency (A&E) departments benefit from initial assessment by the ward senior house officer (SHO) as well as the A&E SHO. Two comparable consultant-led A&E departments sharing the same catchment population and receiving similar numbers of new patients each year were studied. A panel of four consultants audited the A&E notes and in-patient records of consecutive emergency medical and surgical patients admitted to two hospitals over the same 6 month period. In one hospital patients were seen and admitted by the A&E SHO alone. In the other hospital patients were seen by the A&E SHO and the medical or surgical SHO from the admitting unit. Diagnostic errors, inappropriate admissions to hospital and admission of patients to inappropriate wards were used as outcome measures. There was no significant difference in the rates of diagnostic error or inappropriate admissions between those patients seen by an A&E SHO only, and those seen in A&E by the A&E and ward SHOs. Detaining emergency medical and surgical patients in the A&E department for further assessment by ward SHOs does not alter inappropriate admission rate or improve diagnostic accuracy.