A torted wandering spleen: a case report.

INTRODUCTION: A torted wandering spleen is a rare clinical occurrence with fewer than 500 cases reported and an incidence of less than 0.2%. It is brought about through laxity of the gastrosplenic and splenorenal ligaments; however, the precise aetiology remains unknown. It can prove to be a diagnostic challenge with high mortality if misdiagnosed. CASE PRESENTATION: We present the case of a 27-year-old woman of Arabic ethnicity, who complained of a short history of severe abdominal pain with the background of recurrent abdominal pain and vomiting. An abdominal computerized tomography scan revealed a torted wandering spleen. This required a splenectomy due to splenic infarction. CONCLUSION: This report highlights the investigations and management necessary for a patient who presents with an ischaemic torted wandering spleen.

Reduction in hospital reattendance due to improved preoperative patient education following hemorrhoidectomy.

INTRODUCTION: To improve quality of healthcare, patient information must be thorough and easy to understand. This is important in day surgery where patients are seen less often by health practitioners. We looked at the impact of improving patient information in the setting of day-case hemorrhoidectomy in terms of patient satisfaction and whether medical attention was sought after the operation. METHODS: A retrospective, comparative study was performed on 60 patients undergoing day-case hemorrhoidectomy and on 60 patients undergoing the same operation with improved patient information. Comparisons were made between the groups regarding patient satisfaction scores, those seeking medical attention, the numbers of patients requesting a 6-week outpatient follow-up and the reasons for seeking medical advice. RESULTS: There was a significant improvement in the patient satisfaction scores in the second study group who received the improved information. This group sought medical attention significantly less and they felt less need for a routine follow-up. CONCLUSIONS: This study has shown that by improving the quality of patient information for day-case hemorrhoidectomy, patient satisfaction was higher and fewer patients sought medical attention, which has beneficial financial indications for the NHS Trust and improvement of healthcare for the patient.

Focused preoperative patient stoma education, prior to ileostomy formation after anterior resection, contributes to a reduction in delayed discharge within the enhanced recovery programme.

PURPOSE: Stoma formation is a well-known cause for delayed discharge following colorectal surgery. This has been addressed by the enhanced recovery programme (ERP) preoperatively through stoma counselling sessions. These aim to promote independent stoma management post-operatively, thus expediting hospital discharge. We compared the numbers of patients with prolonged hospital stay secondary to delayed independent stoma management prior to and following the introduction of an enhanced recovery programme with preoperative stoma education. METHODS: Data collection on patients undergoing anterior resection with the formation of a loop ileostomy was carried out retrospectively prior to ERP (January 2006 to August 2008) and prospectively following the introduction of ERP (September 2008 to October 2010). Comparisons were made in patients with prolonged hospital stay (defined as hospital stay of more than 5 days) secondary to stoma management. RESULTS: Two hundred forty patients underwent elective anterior resection with the formation of a loop ileostomy, 120 prior ERP and 120 post-ERP. Average length of hospital stay was 14 days before ERP introduction, with a range of 7-25 days. The mean length of stay amongst the ERP patients was 8 days (p = 0.17), ranging from 3 to 17 days. Twenty-one patients in the pre-ERP group (17.5%) experienced postponed hospital discharge due to a delay in independent stoma management, compared to one patient experiencing such a delay after the introduction of ERP (0.8%, p < 0.0001). CONCLUSIONS: Delayed discharge secondary to independent stoma management can be significantly reduced with preoperative stoma management teaching as part of an enhanced recovery programme.

MRI predictive factors for long-term outcomes of low rectal tumours.

BACKGROUND: Low rectal cancers have poor outcomes. It has been suggested that low tumours are biologically more aggressive and tend to be more locally advanced at presentation. Pre-operative identification of prognostic factors will enable use of selective neoadjuvant therapies and possibly increase sphincter-sparing rates where oncologically safe. METHODS: A subset of 101 patients with low rectal cancer (within 5 cm of the anal verge) in a multicentre trial were studied. MRI images were reviewed by a senior radiologist, blinded to outcome. MRI-predicted tumour spread and MRI tumour regression grade (TRG) were analysed for 5-year recurrence and survival rates using a Cox regression model. RESULTS: On univariate analysis, advanced MRI low rectal tumour stage correlated with greater incidence of recurrence (p=0.013) and death (p=0.029) compared with earlier stage tumours. Good MRI TRG score (good response to pre-operative therapy) correlated with significantly reduced tumour recurrence rates (p=0.008) and increased survival (p=0.008) versus the poor MRI TRG score group. On multivariate analysis, good MRI TRG score was associated with reduced recurrence (p=0.003) but not survival rates. CONCLUSIONS: This study confirms that MRI can be used to predict patients at increased risk of recurrence following surgery in low rectal cancer. This information can be used to direct pre-operative therapies and plan operative strategies. This is the first study to confirm the association between MRI TRG and long-term outcome. Poor response to neoadjuvant therapy can be used to plan use of further therapies prior to surgery to attempt to improve outcome.

Magnetic resonance imaging prediction of an involved surgical resection margin in low rectal cancer.

PURPOSE: Low rectal cancers (<5 cm from the anal verge), compared with all others, have greater positive resection margin rates, attributed to mesorectal tapering and higher perforation risk. The aim of this study was to assess positive resection margin prediction by using magnetic resonance imaging staging. METHODS: The following features were analyzed by using preoperative magnetic resonance imaging from 101 consecutive patients with low rectal tumors: tumor location (posterior/anterior) and magnetic resonance stage (Stage 1-2, tumor within the intersphincteric plane; Stage 3-4 tumor extending into the intersphincteric plane). Magnetic resonance imaging tumor regression grade was measured where posttreatment magnetic resonance imaging was available and compared with histopathologic findings. RESULTS: Seventy of 101 patients had abdominoperineal excisions, and 31 of 101 had low anterior resections. Using logistic regression, positive resection margin odds were higher for magnetic resonance Stages 3 to 4 than Stages 1 to 2 by a factor of 17.7 (P < 0.001), and positive resection margin odds were higher by a factor of 2.8 for anterior vs. posterior tumors (P = 0.026). Magnetic resonance imaging tumor regression grade strongly predicted for positive resection margins; 11 of 15 patients with little treatment response had positive resection margins, compared with 2 of 15 with >50 percent complete treatment response on magnetic resonance imaging (P < 0.001). CONCLUSION: Significant magnetic resonance imaging positive resection margin predictors are tumor into or beyond the intersphincteric plane and magnetic resonance imaging tumor regression grade.

Management and imaging of low rectal carcinoma.

Large variations in recurrence rates have been reported with the best results following total mesorectal excision (TME) surgery for low and middle rectal cancers. However, the low rectal cancers still have higher rates of local recurrence (up to 30%) whether operated by low anterior resection or abdominoperineal excision (APE) due to high rates of circumferential margin involvement. The treatment of choice for low rectal cancers that encroach upon the potential circumferential resection margin is surgery combined with preoperative neoadjuvant treatment. Preoperative chemotherapy combined with long-term radiotherapy reduces recurrence rates and preoperative loco-regional staging can help to select the patients more likely to benefit from neo-adjuvant therapy. Surface coil MRI is the most promising modality for patient selection, which can provide good views of the circumferential resection margin especially the presence or absence of tumour encroaching the intersphincteric plane.