An improved technique for Soave trans-anal pull-through.

AIM: To describe a new technique for the Soave trans-anal pull-through. METHOD: After the mucosectomy during a Soave's procedure, a laparoscopic wound retractor was used to line the distal rectal segment to facilitate delivery of the proximal bowel through a narrow scarred pelvis. RESULTS: The technique greatly assisted delivery of the proximal bowel and helped prevent mesenteric injury. CONCLUSION: Soave trans-anal pull-through is a difficult operation that is largely confined to specialist centres. We describe an improvement to the technique that greatly facilitates the procedure.

National UK audit of procedure for prolapsing haemorrhoids on behalf of the Association of Coloproctology of Great Britain and Ireland.

OBJECTIVE: To assess the safety and short term outcomes of the procedure for prolapsing haemorrhoids (PPH), a relatively new procedure for the treatment of symptomatic haemorrhoids. METHOD: In 2005, the Association of Coloproctology of Great Britain and Ireland set up an online electronic database to audit the indications and outcomes for patients undergoing a PPH procedure. RESULTS: During the audit period, 695 patients were entered onto the database by 61 surgeons (range 1-50 patients per surgeon). The main indications for surgery were bleeding (90.5%) and prolapse (83.9%). Three hundred and ninety-seven (57.1%) patients had grade III or IV haemorrhoids. PPH was performed under general anaesthetic in 602 (86.6%) cases and a consultant surgeon performed the procedure in 572 (82.3%) cases. The median length of stay was 1 day (range 0-6 days). Two hundred and eighty-nine (41.6%) procedures were performed as a day case. Immediate complications were recorded in 75 (10.8%) patients, the commonest being bleeding (21) and urinary retention (24). At 6-week follow-up, 626 (90.1%) patients were pain free. Five patients required hospital re-admission for secondary haemorrhage (3), peri-anal abscess (1) and pain (1). The commonest problems were minor bleeding (48), urgency (22), pain (14), continued prolapse (12) and pruritus (11). Four patients required an open haemorrhoidectomy for persistent symptomatic haemorrhoids. CONCLUSION: Procedure for PPH is a safe and effective procedure for symptomatic haemorrhoids with good short-term outcomes. Long-term follow-up is required perhaps through a compulsory national register.

Acute Abdominal Pain for the General Physician - who, when and how to refer to the on-call surgeon.

Patients with abdominal pain are most frequently referred to the on-call surgical team, but there are occasions when physicians may be required to assess, investigate or treat such patients. This article aims to equip non-surgeons with the skills to undertake an appropriate initial assessment and consider the most appropriate selection, timing and mode of referral to the surgical team.

A prospective evaluation of the combined use of the modified Alvarado score with selective laparoscopy in adult females in the management of suspected appendicitis.

BACKGROUND: A diagnostic scoring system such as the modified Alvarado score, combined with selective laparoscopy in adult females, can be used in the assessment of acute abdominal pain suggestive of appendicitis. METHOD: A total of 84 consecutive patients presenting to our surgical team with suspected appendicitis were assessed prospectively using the modified Alvarado score. The definitive management of this study group was instigated according to a set algorithm based on the score. The algorithm included the use of diagnostic laparoscopy in adult female patients with scores suggestive of appendicitis. A negative appendicectomy rate was obtained from those undergoing appendicectomy using this approach and compared to that obtained from the 97 patients that had undergone appendicectomy under the care of the other surgical teams in our unit during the study period. RESULTS: The rate of negative appendicectomy in the study group was 0% compared to 18% in the control group (P < 0.05); 10% of adult female women had negative diagnostic laparoscopies for appendicitis thus saving this group an unnecessary appendicectomy. This was achieved without an increase in total in-patient stay. CONCLUSION: An algorithm combining the modified Alvarado score with selective laparoscopy is recommended for widespread use in the management of suspected acute appendicitis.

A 14-year experience with 6 cm as a criterion for surgical treatment of abdominal aortic aneurysm.

BACKGROUND: It remains unclear when to recommend operation for an asymptomatic abdominal aortic aneurysm (AAA). This study examined a prospective series of patients for whom standard criteria were applied. METHODS: Some 584 consecutive patients with an AAA of diameter 3 cm or greater detected by ultrasonographic screening have been observed for up to 14 years. Repeat ultrasonographic examinations have been performed at intervals. Surgery was not considered unless the aneurysm measured 6 cm in diameter, expanded at a rate equivalent to at least 1 cm per year, caused the patient symptoms, or an iliac aneurysm was present that required treatment. RESULTS: Operation was performed on 127 patients; the majority (80; 63 per cent) had an aneurysm that reached 6 cm in diameter. Use of the above criteria prevented rupture in all but 24 (4 per cent) of the 584 patients over the 14-year interval. Of these 24 patients, 11 were unfit for planned surgery and eight declined operation or follow-up. Rupture in the five remaining patients (1 per cent) who were available for treatment compared favourably with the reported 30-day mortality rate for elective surgical treatment of 1.4-12 per cent. CONCLUSION: Repeated observation is preferable to surgical intervention until an aortic aneurysm measures 6 cm in diameter, expands by 1 cm per annum or causes symptoms. Presented as a poster to the 52nd Annual Meeting of the Society for Vascular Surgery, San Diego, California, USA, June 1998

Traumatic avulsion of the ulnar collateral ligament of the IP joint of the thumb.

We present a previously undescribed injury of avulsion of the ulnar collateral ligament of the thumb IP joint. Stress radiographs may be used to confirm the diagnosis in cases of clinical suspicion.