An established abdominal wall multidisciplinary team improves patient care and aids surgical decision making with complex ventral hernia patients.

INTRODUCTION: Abdominal wall reconstruction (AWR) is an emerging subspecialty within general surgery. The practice of multidisciplinary team (MDT) meetings to aid decision making and improve patient care has been demonstrated, with widespread acceptance. This study presents our initial experience of over 150 cases of complex hernia patients discussed in a newly established MDT setting. METHODS: From February 2020 to July 2022 (30-month period), abdominal wall MDTs were held bimonthly. Key stakeholders included upper and lower gastrointestinal surgeons, a gastrointestinal specialist radiologist, a plastic surgeon, a high-risk anaesthetist and two junior doctors integrated into the AWR clinical team. Meetings were held online, where patient history, past medical and surgical history, hernia characteristics and up-to-date computed tomography scans were discussed. RESULTS: Some 156 patients were discussed over 18 meetings within the above period. Ninety-five (61%) patients were recommended for surgery, and 61 (39%) patients were recommended for conservative management or referred elsewhere. Seventy-eight (82%) patients were directly waitlisted, whereas seventeen (18%) required preoperative optimisation: three (18%) for smoking cessation, eleven (65%) for weight-loss management and three (18%) for specialist diabetic assessment and management. In total, 92 (59%) patients (including operative and nonoperative management) have been discharged to primary care. DISCUSSION: A multidisciplinary forum for complex abdominal wall patients is a safe process that facilitates decision making, promotes education and improves patient care. As the AWR subspecialty evolves, our view is that the "complex hernia MDT" will become commonplace. We present our experience and share advice for others planning to establish an AWR centre.

Intrinsic predictors of prolonged length of stay in a colorectal enhanced recovery pathway: a prospective cohort study and multivariate analysis.

AIM: This was a prospective cohort study to determine the intrinsic non-modifiable factors influencing length of stay (LOS) in unselected consecutive patients undergoing elective colorectal surgery within an enhanced recovery pathway. METHODS: This study interrogated a prospective database of consecutive elective procedures from October 2006 to April 2011 at a tertiary referral academic hospital in the UK to identify independent predictors of prolonged length of stay (pLOS). pLOS was defined as longer than median length of stay (mLOS). Differences in determinants were identified in three groups of increasing operative complexity. RESULTS: In all, 872 procedures were identified and ranged from a simple ileostomy reversal to complex total pelvic exenteration. Preoperative anaemia and American Society of Anesthesiologists (ASA) Grade III+ predicted pLOS in stoma reversal surgery patients (n = 191, mLOS 4 days). In colonic and small bowel surgery (n = 444, mLOS 8 days), an open procedure, new stoma formation, planned critical care admission and ASA III+ predicted pLOS. New stoma formation and planned critical care admission predicted pLOS in patients undergoing pelvic rectal surgery (n = 237, mLOS 11 days). pLOS was associated with significantly higher morbidity across Dindo-Clavien grades and a longer time to postoperative functional recovery and discharge. CONCLUSIONS: Operative complexity is associated with longer LOS even with an established enhanced recovery pathway in place. Intrinsic non-modifiable predictors of pLOS differ with operative complexity, and this should be taken into account when planning benchmarking and research across units.

Financial and clinical governance implications of clinical coding accuracy in neurosurgery: a multidisciplinary audit.

Clinical coding is the translation of documented clinical activities during an admission to a codified language. Healthcare Resource Groupings (HRGs) are derived from coding data and are used to calculate payment to hospitals in England, Wales and Scotland and to conduct national audit and benchmarking exercises. Coding is an error-prone process and an understanding of its accuracy within neurosurgery is critical for financial, organizational and clinical governance purposes. We undertook a multidisciplinary audit of neurosurgical clinical coding accuracy. Neurosurgeons trained in coding assessed the accuracy of 386 patient episodes. Where clinicians felt a coding error was present, the case was discussed with an experienced clinical coder. Concordance between the initial coder-only clinical coding and the final clinician-coder multidisciplinary coding was assessed. At least one coding error occurred in 71/386 patients (18.4%). There were 36 diagnosis and 93 procedure errors and in 40 cases, the initial HRG changed (10.4%). Financially, this translated to pound111 revenue-loss per patient episode and projected to pound171,452 of annual loss to the department. 85% of all coding errors were due to accumulation of coding changes that occurred only once in the whole data set. Neurosurgical clinical coding is error-prone. This is financially disadvantageous and with the coding data being the source of comparisons within and between departments, coding inaccuracies paint a distorted picture of departmental activity and subspecialism in audit and benchmarking. Clinical engagement improves accuracy and is encouraged within a clinical governance framework.

The uptake of laparoscopic colorectal surgery in Great Britain and Ireland: a questionnaire survey of consultant members of the ACPGBI.

OBJECTIVE: The National Institute for Clinical Excellence (NICE) has recommended laparoscopic resection as an alternative to open surgery for patients with colorectal cancer. The aim of this study was to evaluate the current uptake of laparoscopic colorectal surgery in Great Britain and Ireland. METHOD: A questionnaire was distributed to members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) regarding their current surgical practice. Results were analysed individually, by region, and nationwide. RESULTS: Information was received on 436 consultants (in 155 replies), of whom 233 (53%) perform laparoscopic colorectal procedures. During the previous year, 25% of colorectal resections were performed laparoscopically by the respondents. However, of those surgeons who were performing laparoscopic resections, only 30% performed more than half of all their resections laparoscopically. Right hemicolectomy, left-sided resections, and rectopexy were the most frequently performed laparoscopic resections. There was an even distribution throughout the country of consultants performing laparoscopic resections (regional IQR 48-60%). The main reason for consultants not performing laparoscopic procedures was a lack of training or funding. CONCLUSION: Laparoscopic colorectal surgery is being performed by more than half (53%) of colorectal consultants nationwide, although only a quarter of all procedures are being undertaken laparoscopically.

Unilateral avulsion fracture of the transverse atlantal ligament: successful treatment in a rigid cervical collar.

A 34-year-old male sustained a unilateral avulsion fracture through the origin of the transverse atlantal ligament following a road traffic accident. This was successfully treated in a rigid neck collar for 8 weeks. Injuries to the transverse atlantal ligament are often associated with significant bony injury and atlanto-axial instability. Isolated injuries to the transverse ligament are extremely rare and the present case suggests that a trial of conservative management may be worth pursuing.

The role of parenteral nutrition as a supplement to enteral nutrition in patients with severe brain injury.

Enteral nutrition (EN) is the preferred and safe route of feeding in surgical patients incapable of self-nutrition. We describe three patients with severe brain insult and recurrent sepsis, who despite the early introduction of EN, remained hypoalbuminaemic, hypoproteinaemic and developed peripheral oedema. This state persisted, despite increasing the caloric and protein intake via the enteral route. However, after a short course of supplemental parenteral nutrition (PN), albumin and total protein levels improved, with resolution of peripheral oedema. We hypothesize that, in certain critically ill neurosurgical patients on EN, gastrointestinal malabsorption may underlie a persistently low serum albumin, total protein and peripheral oedema. A short course of supplemental PN may help to reverse this and a normal regimen of EN can then be continued.

Delayed postoperative intracerebral abscess caused by Proprionibacterium acnes: case report and review of the literature.

A case of delayed intracerebral abscess due to Proprionibacterium acnes (P. acnes), 18 months after an uneventful excision of a parasagittal haemangiopericytoma in a 61-year-old female is reported. This is highly unusual as cerebral abscess by P. acnes is rare and it occurred so late postoperatively in the absence of known risk factors. We propose the inclusion of cerebral abscess by P. acnes in the differential diagnosis of lesions that mimic tumour recurrences, after clean craniotomies.

Genetic vulnerability following traumatic brain injury: the role of apolipoprotein E.

Apolipoprotein E (APOE) is thought to be responsible for the transportation of lipids within the brain, maintaining structural integrity of the microtubule within the neurone, and assisting with neural transmission. Possession of the APOE epsilon4 allele has also been shown to influence neuropathological findings in patients who die from traumatic brain injury, including the accumulation of amyloid beta protein. Previous clinical studies reporting varying outcome severities of traumatic brain injury, including cognitive and functional recovery, all support the notion that APOE epsilon4 allele possession is associated with an unfavourable outcome. Evidence from experimental and clinical brain injury studies confirms that APOE plays an important role in the response of the brain to injury.

Craniotomy improves outcomes for cranial subdural empyemas: computed tomography-era experience with 699 patients.

OBJECTIVE: Uncertainty regarding the best surgical management for subdural empyemas (SDEs) continues. Our unit has considered craniotomy the preferred method of surgical drainage for all cranial SDEs since 1988. We performed an analysis of our previously published, computed tomography-era, experience with 699 patients. METHODS: Two analyses of the database (1983-1997) were performed. First, analysis of the periods from 1983 to 1987 and from 1988 to 1997 was performed. Second, analysis of the composite database was performed. Outcomes were compared for possible outcome predictors by univariate analysis. Multivariate analysis was used to identify variables that contributed independently to outcomes, using stepwise discriminant analysis. RESULTS: Significant correlations between the analyzed periods with respect to outcome and type of surgery (P = 0.001) were noted. Analysis of the entire database (1983-1997) revealed a significant relationship between outcome and surgery type (P = 0.05). Pairwise comparison of limited procedures such as burr holes or craniectomies with wide-exposure surgical procedures such as primary craniotomies or procedures proceeding to full craniotomies indicated significant correlation with outcomes (P = 0.027). Reoperation and morbidity rates were increased with limited procedures. Stepwise discriminant analyses revealed that the type of surgery was correlated with outcomes (P = 0.0008, partial r(2) = 0.034). CONCLUSION: Craniotomy was determined to be the surgical procedure of choice for treatment of cranial SDEs, allowing complete evacuation of the pus and, more importantly, decompressing the underlying cerebral hemisphere. Limited procedures such as burr holes or craniectomies may be performed for patients in septic shock, for patients with parafalcine empyemas, or for children with SDEs secondary to meningitis.

Traumatic cranial empyemas: a review of 55 patients.

A 15-year (1983-1997) review of our unit's computed tomographic experience with traumatic cranial empyema (TCE) is reported. Fifty-five patients with documented history and clinical evidence of neurotrauma with secondary cranial empyema at surgery were identified. The clinical records and CT scans were analysed. TCE [four extradural and 51 subdural collections (SDE)] accounted for 7.86% of the total cranial empyemas seen during the study period. Most of the patients were young males (44 patients) and neurological deficits on admission were found only in the SDE group. Forty-one of 53 patients presented with septic compound skull fractures. Fifty-four patients had urgent surgical drainage. Eighty per cent of patients experienced a good outcome (GOS 4 or 5). A morbidity of 16.4% (including postoperative seizures) was noted and eight patients died (mortality rate 14.5%). Urgent surgical drainage, removal of osteitic bone, wound debridement and high dose intravenous antibiotic therapy form the mainstay of treatment.

Role of cerebrospinal fluid shunting for human immunodeficiency virus-positive patients with tuberculous meningitis and hydrocephalus.

OBJECTIVE: Tuberculous meningitis (TBM) and its complications continue to have devastating neurological consequences for patients. Budgetary constraints, especially in developing countries, have made it necessary to select patients for shunting who are likely to experience good recoveries. To date, the value of cerebrospinal fluid shunting for human immunodeficiency virus (HIV)-positive patients with TBM has not been clearly established. METHODS: Thirty patients with TBM and hydrocephalus were prospectively evaluated. Coincidentally, one-half of the patients were HIV-positive. All patients underwent uniform treatment, including ventriculoperitoneal shunt placement and antituberculosis treatment. CD4 counts were measured for all patients. Outcomes were assessed at 1 month. RESULTS: No complications related to shunt insertion were noted. The HIV-positive group fared poorly (death, 66.7%; poor outcome, 64.7%), compared with the HIV-negative group (death, 26.7%; poor outcome, 30.8%). Despite cerebrospinal fluid shunting, no patient in the HIV-positive group experienced a good recovery (Glasgow Outcome Scale score of 5). This is in contrast to the six patients (40%) in the HIV-negative group who, with the same treatment, experienced good recoveries (Glasgow Outcome Scale scores of 5) at discharge (P<0.14). No patient (either HIV-positive or HIV-negative) who presented in TBM Grade 4 survived, whereas no HIV-positive patient who presented in TBM Grade 3 survived. A significant relationship was noted between CD4 counts and patient outcomes (P<0.031). CONCLUSION: In the absence of obvious clinical benefit, HIV-positive patients with TBM should undergo a trial of ventricular or lumbar cerebrospinal fluid drainage, and only those who exhibit significant neurological improvement should proceed to shunt surgery.

Cerebral blood flow changes in rhinogenic subdural empyema and the role of hyperaemia in brain swelling.

BACKGROUND: Previous studies have demonstrated that rhinogenic subdural empyema (SDE) generally has a good prognosis. Most patients are admitted with an altered level of consciousness or significant neurological deficit, but eventually have a good outcome. It is well known that intra-operative brain swelling may occur with subdural empyema. OBJECTIVE: To define cerebral blood flow (CBF) dynamics and determine the role of cerebral hyperaemia, if any, in intracranial SDE. METHODS: CBF dynamics were assessed in five patients (mean age 13.2 +/- 2.2 years) with unilateral rhinogenic convexity SDE documented on computer tomography (CT). Regional cortical blood flow (rCBF) was measured using a thermo-coupled sensor placed on the cortex at the time of surgery. Dynamic CT scans were performed to assess cerebral blood volume (CBV) quantitatively, while transcranial Doppler ultrasonography (TCD) was used to measure cerebral blood flow velocities (CBF velocities) both pre- and post-operatively for 21 days. The opposite 'normal' hemisphere served as a control for each patient. RESULTS: Post-operative rCBF and CBF velocities in the pathological hemisphere progressively increased to plateau at 96 hours. Cerebral blood volume was increased bilaterally, but to a greater extent in the pathological hemisphere and more so in grey than white matter. These haemodynamic changes, though clinically significant did not reach statistical significance (p>0.05). CONCLUSION: Our results suggest that the accompanying brain swelling in rhinogenic SDE is a complex event, with reactive cerebral hyperaemia possibly playing neuroprotective role. Furthermore, unilateral convexity empyema causes bilateral cerebral haemodynamic changes. Future studies are necessary to define the aetiology of brain swelling in intracranial SDE.

Cranial extradural empyema in the era of computed tomography: a review of 82 cases.

OBJECTIVE: Intracranial suppurative disorders (abscesses and empyemas) continue to be common neurosurgical emergencies in South Africa. Cranial extradural empyema (EDE) occurs less frequently than its subdural counterpart but remains a potentially devastating disease process. We present our 15-year experience with this condition in the era of computed tomography. METHODS: Of the 4623 patients with intracranial sepsis who were admitted to the neurosurgical unit at Wentworth Hospital (Durban, South Africa) during a 15-year period (1983-1997), 76 patients with EDEs were identified. An additional six patients who were identified from our outpatient records were treated nonsurgically. Analyses were performed with respect to clinical, radiological, bacteriological, surgical, and outcome data. All information for this study was obtained from the computerized databank for the unit. Statistical analyses of the related pre- and postoperative clinical data were performed. RESULTS: The 76 patients with EDEs accounted for 1.6% of the total number of patients admitted for treatment of intracranial sepsis during the study period. Thirteen patients (15.8%) had infratentorial pus collections. Male patients predominated by a ratio of 2:1, and 66 patients were between the ages of 6 and 20 years (mean age, 16.56+/-9.87 yr). The origins of the sepsis were paranasal sinusitis for 53 patients (64.6%), mastoiditis for 16 patients, trauma for 5 patients, dental caries for 1 patient, and miscellaneous causes for 7 patients. The most common clinical presenting features were fever, neck stiffness, and periorbital edema. Surgery was performed in the form of burrholes for 21 patients, small craniectomies for 39 patients, and craniotomies for 5 patients. The additional five patients, while having drainage of their infected paranasal sinuses, had simultaneous drainage of their extradural pus collections by the ear, nose, and throat surgeon. The majority of patients (81 patients) experienced good outcomes (Glasgow Outcome Scale scores of 4 or 5). A single patient died after surgery (mortality rate, 1.22%). CONCLUSION: EDEs occur less frequently than subdural empyemas and are associated with better prognoses. Surgical drainage (burrholes), simultaneous eradication of the source of sepsis, and high-dose intravenous antibiotic therapy remain the mainstays of treatment. Selective nonsurgical management of small EDEs is possible, provided the source of sepsis is surgically eradicated. It is our opinion that EDE is a disease that should be managed without morbidity or death.

Intracranial subdural empyemas in the era of computed tomography: a review of 699 cases.

OBJECTIVE: Intracranial empyemas are the most common form of intracranial suppuration seen in our unit and, despite modern antibiotic therapy and advanced neurosurgical and imaging facilities, these pus collections remain a formidable challenge, often resulting in significant morbidity and death. We present an analysis of our 15-year experience with this condition in the era of computed tomography. METHODS: A retrospective analysis of 4623 patients admitted with intracranial sepsis during a 15-year period (1983-1997) identified 699 patients with intracranial subdural empyemas. The inpatient notes for these patients were analyzed with respect to clinical, radiological, bacteriological, surgical, and outcome data. Statistical analyses were performed. RESULTS: The 699 intracranial subdural empyemas accounted for 15% of all admissions for intracranial sepsis during the study period. Young male patients in the second or third decade of life were most commonly affected (62%), and the mean age was 14.65+/-12.2 years. Almost all patients (96%) underwent surgery. Eighty-two percent of patients experienced good outcomes (Glasgow Outcome Scale scores of 4 or 5). A morbidity rate of 25.9% (including postoperative seizures) was noted, and 85 patients died (mortality rate, 12.2%). CONCLUSION: Intracranial subdural empyema, which is a neurosurgical emergency, is rapidly fatal if not recognized early and managed promptly. Early surgical drainage, simultaneous eradication of the primary source of sepsis, and intravenous administration of high doses of appropriate antibiotic agents represent the mainstays of treatment.

Cytokine expression in patients with treated congenital hydrocephalus: a preliminary report of five patients.

BACKGROUND: Previous studies have described the elaboration of cytokines in experimental models of congenital hydrocephalus using rats or mice. However, there have been no reports of similar studies in humans. OBJECTIVE: To determine the cytokine expression pattern in the cerebrospinal fluid (CSF) of patients with treated congenital hydrocephalus. DESIGN: A prospective study. SETTING: Wentworth Hospital, Durban, South Africa. SUBJECTS: Five patients (three infants and two older patients) with congenital hydrocephalus treated by means of a ventriculoperitoneal shunt. INTERVENTIONS: Immunophenotyping of peripheral blood was performed on a flow cytometer. The isolation, in-vitro stimulation of peripheral blood and CSF mononuclear cells, and intracellular cytokine determination by flow cytometry were performed. MAIN OUTCOME MEASURES: Peripheral blood and CSF cytokine measurements. RESULTS: Although not statistically significant, all measured mean cytokine levels in the peripheral blood of the infant group were consistently higher than that of the adult group. CSF cytokine levels in both groups were similar and unremarkable. CONCLUSION: No clear pattern of CSF cytokine elaboration, either type-1 (T helper 1) (Th1) or Type-2 (T helper 2) (Th2), could be demonstrated in either of the groups. The significance of higher peripheral blood cytokine levels in the infants is unclear, but may be age-related, and is not apparent in the CSF.