Gastric perforation secondary to ingestion of a plastic bag.

Foreign body ingestion is a common presentation in clinical practice, seen predominantly in children. Most foreign bodies pass through the gastrointestinal tract without any additional morbidity. We present a case of gastric perforation secondary to the ingestion of a small plastic bag. We discuss the likely pathophysiological process underlying perforation secondary to plastic bag ingestion, which is most commonly associated with the concealment of narcotics.

Non-steroidal anti-inflammatory drugs and antibiotics prescription trends at a central west bank hospital.

OBJECTIVES: We aimed to reliably describe the pattern of outpatient prescription of non-steroidal anti-inflammatory drugs (NSAIDs) and antibiotics (ATBs) at a central hospital in the West Bank, Palestine. METHODS: This was a retrospective, cross-sectional study investigating a cohort of 2,208 prescriptions ordered by outpatient clinics and the emergency room over one year in Beit Jala Hospital in Bethlehem, West Bank. The orders were analysed for the rate and types of NSAIDs and ATBs utilised, and the appropriateness of these drugs to the diagnosis. RESULTS: Of the total prescriptions, 410 contained NSAIDs (18.6%), including diclofenac (40.2%), low dose aspirin (23.9%), ibuprofen (17.8%) and indomethacin (15.1%). A minority of these prescriptions contained a combination of these agents (2.5%). Only one prescription contained cyclooxyeganse-2 inhibitors (0.2%). The appropriateness of NSAID use to the diagnosis was as follows: appropriate (58.3%), inappropriate (14.4%) and difficult to tell (27.3%). The rate of ATB use was 30.3% (669 prescriptions). The ATBs prescribed were amoxicillin (23.3%), augmentin (14.3%), quinolones (12.7%), first and second generation cephalosporins (9.4% and 12.7%, respectively) and macrolides (7.2%). ATB combinations were identified in 9.4%, with the most common being second-generation cephalopsorins and metronidazole (4.3%). Regarding the appropriateness of prescribing ATBs according to the diagnosis, it was appropriate in 44.8%, inappropriate in 20.6% and difficult to tell in 34.6% of the prescriptions. CONCLUSION: These findings revealed a relatively large number and inappropriate utilisation of ATBs and NSAIDs. An interventional programme needs to be adopted to reinforce physicians' knowledge of the rational prescription of these agents.

Carcinoma arising within an anal gland.

Anal gland carcinoma (AGC) is rare, and its innocuous presentation and developing immunohistochemical profile make the diagnosis of it challenging. Predominant presenting symptoms include anal pain, rectal bleeding and the presence of a perianal mass in advanced stages of the disease. Histological profile commonly reveals an intramural adenocarcinoma with normal unaffected overlying anorectal mucosa. Immunohistochemical analysis shows positive staining for cytokeratin (CK) 7 and negative staining for CK20. MUC5AC expression with CK5/6 and p53 negativity has been reported. The authors report a case of a 68-year-old woman with a rapidly advancing AGC and review the current literature with respect to diagnosis and current consensus on therapeutic management.

Competency in laparoscopic colorectal surgery is achievable with appropriate training but takes time: a comparison of 300 elective resections with anastomosis.

AIM: The aim of this retrospective cohort study was to compare outcomes in patients who underwent elective laparoscopic colorectal resection with anastomosis performed by a single surgeon or his training fellow. METHOD: A prospective electronic database of all laparoscopic procedures between January 2005 and September 2008 was used. Two groups were compared; those patients operated upon by the Consultant trainer (C) and those by seven supervised Fellows (F). Fellows were either post CCT or in their last year of training. Three hundred consecutive patients undergoing laparoscopic colorectal resection with anastomosis were examined, 150 in each group. Groups were matched for indication, age, American Society of Anesthesiology (ASA) grade, cancer T stage and resection performed. Preoperative work-up, operative surgery and anaesthesia were identical between groups. RESULTS: No significant difference was demonstrated in age, mean 67 (26-91) or ASA grade. Indications for surgery were; cancer (C) 120, (F) 126, diverticular disease (C) 22, (F) 20, Crohn's disease (C) 8, (F) 7. Fellow's mean operative time was significantly longer at 123 min (95%CI 117-134) compared to the consultant trainer -105 min. (95%CI 98-111): P < 0.01). No significant differences in the complication or conversion rates were demonstrated. Length of stay and the 30-day readmission rates were similar. CONCLUSION: In this retrospective cohort study we have demonstrate that when matched patients are compared, supervised trainee operating time is significantly longer than that of the consultant trainer but without any significant increase in length of stay, complication or readmission rates. Training to a level of competency takes time but not at the expense of patient care.

The role of (99m)technetium-labelled hepato imino diacetic acid (HIDA) scan in the management of biliary pain.

OBJECTIVE: To assess the outcome of laparoscopic cholecystectomy on the basis of an abnormal provocative (99m)technetium-labelled hepato imino diacetic acid (HIDA) scan for patients with typical biliary pain and normal trans-abdominal ultrasound (TUS) scan. PATIENTS AND METHODS: Prospective data were collected for 1201 consecutive patients with typical biliary symptoms. Patients who were found to have a normal TUS and upper GI endoscopy subsequently underwent cholescintigraphy (HIDA scan). Patients with an abnormal HIDA scan, i.e.<40% ejection fraction with Sincalide (cholecystokinin octapeptide)--were offered cholecystectomy. Symptoms and histology were reviewed postoperatively. RESULTS: In all, 48/1201 (4%) patients with typical biliary symptoms had a normal ultrasound and endoscopy; 35/48 patients had an abnormal provocative HIDA scan and all underwent laparoscopic cholecystectomy. Histology in all cases revealed chronic cholecystitis and 18 patients had sludge or microlithiasis within the gallbladder. At 6-week follow-up, 31 of the 35 patients were completely asymptomatic or improved. Furthermore, 79% of patients remained symptom-free or improved at a median follow-up of 28.5 months (range 4-70). CONCLUSIONS: HIDA scan is a useful clinical tool as an adjunct to the diagnosis and management of patients who present with typical biliary pain and a normal TUS scan.