Surgical consent during the COVID-19 pandemic.

BACKGROUND AND AIMS: During the COVID-19 pandemic, surgical practice may deviate with operative and non-operative management considered. Appropriate discussion of options with patients is paramount to quality surgical care. Intercollegiate and EAES guidelines recommend discussing and documenting risk of COVID-19 exposure in the consent process for patients undergoing surgery. MATERIALS AND METHODS: Closed-loop audit of consent forms for patients undergoing emergency and elective surgical procedures. Interventions implemented included education of wider surgical teams. Data was collected during a one-week period for each cycle and analysed using Chi-squared test. RESULTS: In cycle 1, 6/17 (35.3%) case notes documented discussion of COVID-19 risk. Following intervention, compliance improved to 23/29 (79.3%) cases in cycle 2 and 33/45 (73.3%) cases in cycle 3. CONCLUSION: Pre-intervention, our consenting practice was non-compliant. Our interventions led to significant and sustained improvements in practice. We recommend provision of wider surgical team education to facilitate good consenting practice.

Colonoscopy and flexible sigmoidoscopy for follow-up of patients with left-sided diverticulitis.

INTRODUCTION: The prevalence of diverticular disease has been increasing in the western world over the last few decades, causing a growing burden on health care systems. This study compared the uses of flexible sigmoidoscopy with colonoscopy as a follow-up investigation for patients diagnosed with acute left-sided diverticulitis and to evaluate the need for using either procedure. MATERIALS AND METHODS: A retrospective study of 327 patients diagnosed with acute diverticulitis was carried out. Of this total, 240 patients with left-sided diverticulitis diagnosed via computed tomography were included. These patients were categorised into two equal groups: the first 120 patients underwent colonoscopy and the second 120 patients underwent flexible sigmoidoscopy. RESULTS: All colonoscopes and flexible sigmoidoscopes confirmed the computed tomography diagnosis of sigmoid diverticular disease with no major new findings. All colonoscopes and flexible sigmoidoscopes were reported as having no complications, with nine colonoscopes reported as being difficult compared with only three flexible sigmoidoscopes. All biopsies were reported as no malignancy. Full bowel preparation was required in all colonoscopes, compared with no preparation required for flexible sigmoidoscopes. CONCLUSIONS: There is no evidence to support the routine use of endoscopic evaluation after an episode of left-sided diverticulitis diagnosed on computed tomography if no worrying radiological findings have been reported. This study supports similar findings from other studies and therefore we disagree with The Royal College of Surgeons of England (Association of Coloproctology of Great Britain and Ireland recommendations) commissioning guide, which advocates routine surveillance of the colon.

Local drug delivery for percutaneous coronary intervention.

Since the first successful coronary angioplasty by Andreas Grüntzig in 1977, the field of percutaneous coronary intervention (PCI) has expanded rapidly. Rapid technological refinement has seen equipment and complementary pharmacotherapy to improve the outcome of PCI evolve dramatically, driven by clinical need and enormous market forces. The ideal intervention should expand the vessel lumen without inflicting endothelial injury, and provide local drug delivery to prevent subsequent acute thrombosis and neointimal hyperplasia. Drug eluting stents, once regarded as the "gold standard" in PCI, and established as the treatment of choice for nearly a decade, remain limited in their performance by important risks of in-stent restenosis and late stent thrombosis. In this review, we discuss need for local drug therapy as an adjunct to angioplasty and present exciting new technological advances to deliver local pharmacotherapy to the coronary artery, which will hopefully overcome some of the limitations of DES and may represent the way forward in coronary intervention.

Sirolimus-eluting stents, bare metal stents or coronary artery bypass grafting for patients with multivessel disease including involvement of the proximal left anterior descending artery: analysis of the Arterial Revascularization Therapies study part 2 (ARTS-II).

OBJECTIVE: The The Arterial Revascularization Therapies Study (ARTS)-II trial found no differences in survival or overall adverse events between sirolimus-eluting stents (SES) and the surgical arm of ARTS-I. Nevertheless, existing data suggest that patients with disease of the proximal left anterior descending artery (LAD) may derive particular benefit from coronary artery bypass grafting (CABG). We therefore analysed the clinical outcome of patients in ARTS-I and ARTS-II with proximal LAD involvement. DESIGN: Multicentre observational study. SETTING: Forty-five European academic hospitals. PATIENTS: Patients with multivessel coronary artery disease. INTERVENTIONS: Patients in ARTS-II with proximal LAD disease treated with SES (289/607, 48%) were compared with 187/600 (31%) bare metal stent patients (ARTS-I BMS) and 206/605 (34%) surgical patients (ARTS-I CABG) with proximal LAD involvement from ARTS-I. MAIN OUTCOME MEASURES: Major adverse cardiac and cerebrovascular events after 3 years. RESULTS: The Arterial Revascularization Therapies study part 2 (ARTS-II) subgroup had better survival than both ARTS-I groups (ARTS-II 98.6% vs ARTS-I BMS 95.7%, p = 0.05 and vs ARTS-I CABG 94.7%, p = 0.01) and lower rates of the hard clinical composite endpoint of death or non-fatal myocardial infarction (ARTS-II 3.1% vs ARTS-I BMS 9.6%, p = 0.002 and vs ARTS-I CABG 9.7%, p = 0.002). Although the ARTS-I CABG patients had a lower need for repeat revascularisation than ARTS-II (5.3% vs 13.1%, p = 0.002), the overall composite adverse event rates (death, myocardial infarction, stroke or any repeat revascularisation) were not significantly different between the ARTS-I CABG and ARTS-II patients (15.0% vs 18.0%, p = 0.4). CONCLUSIONS: SES are not inferior to CABG or bare metal stents for the treatment of patients with multivessel coronary disease including involvement of the proximal LAD.

Effect of proteolytic activity of Epicoccum purpurascens major allergen, Epi p 1 in allergic inflammation.

Enzymes play an important role in inducing airway inflammation, but knowledge is limited to few proteins. This study was carried out to assess the role of Epi p 1, a serine protease of Epicoccum purpurascens, in inducing allergy and inflammation in a murine model. Balb/c mice were sensitized with Epi p 1 active protease (EAP) or Epicoccum extract. Subsequently, Epi p 1 sensitized mice were boosted on day 14 with EAP or inactivated protease (EIAP). Three intranasal challenges were given and mice were killed to obtain blood, bronchoalveolar lavage fluid (BALF), spleen and lung tissues. Cellular airways infiltration, immunoglobulin E (Ig)E titres and cytokine levels in BALF and splenocyte culture supernatant were compared. Mice immunized with EAP had higher Epi p 1-specific serum IgE and IgG1 than EIAP immunized mice (P < 0.01). There was a twofold difference in the number of eosinophils in BALF of EAP mice and EIAP mice (P < 0.01). A similar trend was recorded for eosinophil peroxidase activity (P < 0.05), indicating the role of proteolytic activity in inducing inflammation. Further, lung histology revealed increased leucocyte infiltration and airway narrowing, with higher inflammation scores in the EAP group than in the EIAP group. The lungs of EAP mice showed increased mucus and goblet cell metaplasia. Interleukin (IL)-4 and IL-5 levels were higher in BALF and splenocyte culture supernatant of EAP mice than in EIAP mice (P < 0.05), indicating a T helper 2 response. Proteolytic activity of Epi p 1 plays an important role in inducing allergic inflammation. The enzymatically inactive form may be investigated for immunotherapy.

Revascularization in the high-risk patient: multivessel disease.

The aim of this article is to review the treatment of patients with multi-vessel coronary artery disease. Percutaneous coronary intervention (PCI) has been challenging coronary artery bypass grafting (CABG) as the gold standard of care for patients with multi-vessel disease; however, the application of PCI to these patients has been mainly limited by restenosis. Up to the late 1990s, numerous large-scale, randomized trials addressed this issue comparing CABG to PCI with balloon angioplasty or bare-metal stents. These studies demonstrated similar rates of death and myocardial infarction in both groups, while the need for revascularization remained significantly lower in the CABG group. Drug-eluting stents (DES) have dramatically reduced restenosis and repeat revascularization rates. CABG has also progressed with improvements in perioperative management, a higher use of arterial grafting, and advanced techniques with the implementation of minimally invasive and off-pump surgery as options. Therefore, the results of previous trials in the pre-DES era can no longer be extrapolated into the ''real world''. As intermediate steps preceding a fully-fledged, randomized trial, several trials have compared PCI with DES and the historical control of CABG, but the results are still inconclusive. Several dedicated randomized trials are currently ongoing to compare PCI with DES and CABG using contemporary techniques. Until the results of these randomized trials are presented, the choice for each strategy should be based on the patients' individual risk and anatomy.

Invasive imaging techniques for the assessment of vulnerable plaque.

Coronary artery disease is the leading cause of mortality and morbidity in the Western world and an ever-increasing problem in developing countries. Unheralded acute coronary syndromes (ACS) are common initial manifestations of coronary atherosclerosis and are often caused by lesions which have previously not generated symptoms. Histopathological studies have identified several plaque morphologies associated with ACS. However, the natural history of these high-risk or vulnerable lesions remains unknown and the limited knowledge about their eventual prognosis is provided by retrospective histopathological studies. Detection of these vulnerable plaques in vivo is essential to study their natural history and to evaluate potential treatment modalities and, therefore, may ultimately have an important impact on the prevention of acute myocardial infarction and death. Currently, there are several diagnostic imaging tools capable of evaluating determinants of plaque vulnerability. These techniques can provide information on the vessel lumen and wall size, tissue composition and the status of inflammation. This article aims to review the current status of these imaging techniques.

Pancreatic cancer--is an aggressive approach justified?

INTRODUCTION: Surgery is the only curative treatment for carcinoma of the pancreas. Resection rates can be low (4.5%), figures of 30% have also been suggested as possible. The approach undertaken in this unit is to consider all patients as potentially resectable unless otherwise proven. PATIENTS & METHODS: 140 patients were studied over 6-year period; 113 underwent palliative treatment (48% distant metastases, 40% local spread, 11% high operative risk); 14 had a triple bypass (14/113 = 12%), 99 were managed conservatively, 43 received palliative chemotherapy. 23/140 (16%) underwent Whipple's procedure (n = 23; 12 females, 11 males; mean age, 60 years); 4/23 had chronic pancreatitis. Distal pancreatectomy was undertaken in 4 patients. RESULTS: Median survival time for patients undergoing a triple bypass was 5 months (range, 0.1-20 months), 3 months for patients treated conservatively (range, 0.1-30 months) and 5 months for patients undergoing palliative chemotherapy (range, 1-30 months). 30-day mortality for Whipple's procedure was 4% (1/23) with median survival rate for patients with carcinoma of 13 months (range, 5-66 months); 31 months for patients with clear resection margins and negative nodes (n = 5). CONCLUSION: This policy allows a resection rate of 19% with increased median survival rate for patients with cancer by 8 months more than those who where not resected. Aggressive staging and pancreatic biopsies allow patients to be entered into chemotherapy trials with improvement in survival and potential future benefits.

Is the MIC useful in deciding to treat endocarditis surgically?

The infecting pathogen and its susceptibility to antibiotics is used to suggest prognosis in endocarditis. A case study was performed in a tertiary referral cardiology centre to assess the contribution of the measurement of minimum inhibitory concentration (MIC) to the decision to treat endocarditis surgically. The records were examined of 125 patients admitted between 1981 and 1999 in whom the minimum inhibitory concentration for the pathogen had been measured. The measures of outcome were mortality at time of hospital discharge and at 6 months, surgical referral and cure by medical treatment. Endocarditis caused by Staphylococcus aureus with a raised MIC of flucloxacillin (methicillin) was associated with higher mortality even if glycopeptides were used in treatment (< or = 35 mg/l 0/7 versus MIC 1-2 mg/l 4/13, P = 0.01). Elevated MICs of flucloxacillin in S. aureus infection or of gentamicin in streptococcal disease were associated with surgical intervention. There were no significant differences between bacterial pathogens in mortality, surgical referral or cure by medical treatment. The measurement of MIC appears prognostically important in deciding the surgical management of endocarditis.