When the bowel meets the bladder: Optimal management of colorectal pathology with urological involvement.

Fistulae between the gastrointestinal and urinary systems are rare but becoming increasingly more common in current surgical practice. They are a heterogeneous group of pathological entities that are uncommon complications of both benign and malignant processes. As the incidence of complicated diverticular disease and colorectal malignancy increases, so too does the extent of fistulous connections between the gastrointestinal and urinary systems. These complex problems will be more common as a factor of an aging population with increased life expectancy. Diverticular disease is the most commonly encountered aetiology, accounting for up to 80% of cases, followed by colorectal malignancy in up to 20%. A high index of suspicion is required in order to make the diagnosis, with ever improving imaging techniques playing an important role in the diagnostic algorithm. Management strategies vary, with most surgeons now advocating for a single-stage approach to enterovesical fistulae, particularly in the elective setting. Concomitant bladder management techniques are also disputed. Traditionally, open techniques were the standard; however, increased experience and advances in surgical technology have contributed to refined and improved laparoscopic management. Unfortunately, due to the relative rarity of these entities, no randomised studies have been performed to ascertain the most appropriate management strategy. Rectourinary fistulae have dramatically increased in incidence with advances in the non-operative management of prostate cancer. With radiotherapy being a major contributing factor in the development of these complex fistulae, optimum surgical approach and exposure has changed accordingly to optimise their management. Conservative management in the form of diversion therapy is effective in temporising the situation and allowing for the diversion of faecal contents if there is associated soiling, macerated tissues or associated co-morbidities. One may plan for definitive surgical intervention at a later stage. Less contaminated cases with no fibrosis may proceed directly to definitive surgery if the appropriate expertise is available. An abdominal approach with direct repair and omentum interposition between the repaired tissues has been well described. In low lying fistulae, a transperineal approach with the patient in a prone-jack knife position provides optimum exposure and allows for the use of interposition muscle grafts. According to recent literature, it offers a high success rate in complex cases.

Thermal Osteonecrosis Caused by Bone Drilling in Orthopedic Surgery: A Literature Review.

Thermal osteonecrosis is the in situ death of bone tissue as a result of excessively high temperatures. While the exact temperature at which thermal osteonecrosis occurs has not yet been determined, 50°C is the accepted critical value, as bone regeneration is almost completely impaired from this point on. Thermal osteonecrosis is a significant concern in orthopedic surgery, as it can compromise the bone-implant interface in fracture fixation, which, by definition, is a complication. A literature review was undertaken of the pertinent literature concerning heat generation from bone drilling and how this heat affects bone tissue. The Pubmed, ScienceDirect, and secondary (Cochrane Library) databases were searched up to December 2017 using keywords with the appropriate use of Boolean operators. Both simple text word searching and thesaurus searching were used to maximize the number of relevant articles retrieved. Reference tracking was performed via the retrieved articles to further extend the boundaries of the search. The level of evidence was Level V. It was identified that factors affecting heat generation during bone drilling were multifactorial and did not act independently of each other. Good quality evidence exists that both bone drilling parameters and the drill itself affect heat generation in bone during bone drilling. However, external irrigation is the most important variable and should always be used to keep the bone temperature below the critical value of 50°C. Future studies should focus on how the parameters of bone drilling interact with each other and how this influences heat generation in bone drilling. There is also a lack of in vivo studies on the human bone; this too should be further investigated.

Preoperative Patient Preparation Audit: Completed Loop Cycle.

Introduction Nurses usually check patients scheduled for surgery while the patients are still in the ward. A lack of complete preoperative patient preparation can cause delayed care and disastrous outcomes. The objective of this study was to assess the number of patients en route to surgery who had been fully preoperatively prepared and evaluate any change in that number once a proforma was introduced as part of the preparation protocol. Methods We conducted a two-part audit of preoperative preparedness to assess factors such as up-to-date blood work, group and save, cross-match, and surgical site marking, among others. We then devised a proforma to be signed and checked by the ward doctor (e.g., intern or senior house officer). We compared the number of patients marked completely ready for surgery in the six weeks prior to use of the proforma with the number of patients marked completely ready for surgery for six weeks after implementation of the proforma. Results The study included the preoperative audit of 35 patients prior to the use of the proforma and 30 patients after the implementation of the proforma. Use of the proforma improved preoperative patient preparation by 50% compared to the level of preparedness when no proforma was used. Conclusion Health care facilities may benefit from a similar proforma for supplementing standardized, widely accepted preoperative protocols as an additional safety measure.