Laparoscopic silastic ring mini-gastric bypass: a single centre experience.

BACKGROUND: Laparoscopic mini-gastric bypass (MGBP) represents a simpler alternative to Roux-en-Y gastric bypass. The placement of a silastic ring (SR) may enhance excess weight loss and minimize weight regain. This study reports on the results of a consecutive cohort of patients undergoing SR-MGBP in a single centre. METHODS: Short- and medium-term outcomes of 156 consecutive patients undergoing surgery between August 2005 and January 2008 were analysed. Weight loss, comorbidity resolution and morbidity/mortality were assessed. RESULTS: A total of 156 patients (78% female, 22% male) with a mean (range) age of 44 years (18-63), pre-operative weight of 129 kg (83-197) and body mass index of 46 kg/m(2) (35-64) underwent surgery. Eighty-seven percent had pre-operative comorbidities, and median (range) follow-up was 35 months (6-72). Mean (SD) % excess weight loss (EWL) at 6, 12, 24, 36 and 60 months was 74.6 (19.5), 93.4 (21.1), 98.8 (27.6), 93.5 (20.1) and 89 (16.1) respectively. Thirty-seven percent had complete resolution of comorbidities and 67.3% required vitamin/mineral supplementation. Overall, 10.3% patients suffered early complications, of which 7.7% were minor and 2.6% were major. A total of 45.5% patients suffered late complications, of which 34.6% were minor and 10.9% were major. Food intolerance/vomiting, bile reflux and stomal ulcer were seen in 18.6, 10.3 and 7.7% of patients, respectively. Surgical re-intervention was required in 12.8% of patients. There were no deaths. CONCLUSIONS: Whilst SR-MGBP achieves excellent EWL with low mortality, there is a high incidence of food intolerance/vomiting likely related to the silastic ring. The majority of complications were managed with pharmacological and endoscopic intervention, although 13% required reoperation within 5 years.

An Effective Approach to Improving Day-Case Rates following Laparoscopic Cholecystectomy.

Background. Day-case laparoscopic cholecystectomy (LC) is a safe and cost-effective treatment for gallstones. In 2006, our institution recorded an 86% laparoscopic, 10% day-case, and 5% readmission rate. A gallbladder pathway was therefore introduced in 2007 with the aim of increasing daycase rates. Methods. Patients with symptomatic gallstones, proven on ultrasound, were referred to a specialist-led clinic. Those suitable for surgery were consented, preassessed, and provided with a choice of dates. All defaulted to day case unless deemed unsuitable due to comorbidity or social factors. Results. The number of cholecystectomies increased from 464 in 2006 to 578 in 2008. Day-case rates in 2006, 2007, 2008, and June 2009 were 10%, 20%, 30%, and 61%, respectively. Laparoscopic and readmission rates remained unchanged. Conversion rates for elective cholecystectomy fell from 6% in 2006 to 3% in 2009. Conclusions. Development of a gallbladder pathway increased day-case rates sixfold without an associated increase in conversion or readmission rates.

Optimising methods for communicating survival data to patients undergoing cancer surgery.

BACKGROUND: Patients undergoing cancer surgery require outcome data to inform decisions, but communication of numerical risk is difficult. This study assessed patient understanding of survival data presented in different formats. METHODS: Semi-structured interviews in which patients interpreted four presentation formats of survival data (three graphical and one narrative) were audio-recorded. The interviewer and a blinded observer (listening to the audio-recordings) scored patients' understanding of each format. Logistic regression examined associations between understanding and clinical and socio-demographic details. RESULTS: Seventy participants with colorectal cancer were interviewed and 67 [95.7%, 95% confidence intervals (CIs) 90.9-100%] correctly interpreted a simplified Kaplan-Meier survival curve. A high proportion accurately understood data presented as a bar chart or pictograph (94.3%, 95% CIs 88.7-99.9% and 92.9%, 95% CIs 86.7-99.0% respectively). Standard narrative alone was least well understood (n = 53, 75.7%, 95% CIs 65.4-86.0%). Multivariable analyses demonstrated that older and female patients had poorer overall understanding (OR 0.93 per year, 95% CIs 0.87-0.98, p = 0.01 and OR 0.24, 95% CIs 0.07-0.86, p = 0.03). CONCLUSION: Patient understanding of survival data was higher when presented with graphs compared to narrative alone. Further work examining understanding in the clinical context and before surgery is recommended before this can be used routinely.

The surgical management of acute upper gastrointestinal bleeding: a 12-year experience.

INTRODUCTION: Acute upper gastrointestinal bleeding (AUGIB) is a common reason for admission to gastroenterologists, with only 2% of patients requiring surgical intervention. The aim of this study was to review the surgical management of patients with non-variceal AUGIB in a single institution over a 12-year period and compare practice with recognised regional and national standards. MATERIALS AND METHODS: Data was collected retrospectively for all patients undergoing surgery for AUGIB between September 1995 and September 2007. Audit standards included the local hospital protocol, British Society of Gastroenterology Endoscopy Committee guidelines and the UK Comparative Audit of AUGIB and the Use of Blood. RESULTS: 53 patients were identified, of which 41 case notes were available. Mean (range) age of the patients was 75.8 (45-92) years. 56% had pre-existing cardiorespiratory comorbidity and 63% were taking anti-inflammatory drugs. Pre-operative Rockall score was >or=7 in 46% and ASA score was >or=3 in 65% of patients. 56% of operations were performed by the registrar, compared with 20% reported nationally. All cases after 2004 were performed by the consultant. No operations were performed after midnight beyond 1999. 23 (56%) patients suffered post-operative complications compared with 55% reported nationally; cardiorespiratory (n = 16), wound infection (n = 7) and rebleed (n = 6). 37% required intensive care support and median length of hospital stay was 13 days. In-hospital mortality rate was 10%, compared with 30% reported nationally and this increased with rising Rockall, Blatchford, APACHE-2, P-POSSUM and Charlson scores. CONCLUSIONS: These findings highlight the high rate of morbidity and mortality associated with surgical treatment for AUGIB. The small volume of cases and reduction in registrar operating raises training issues. An integrated approach with greater use of interventional radiology is likely to play a greater role in the future.

The use of sterilised polyester mosquito net mesh for inguinal hernia repair in Ghana.

BACKGROUND: The use of alloplastic mesh is now commonplace in hernia repair. However, in developing countries, cheaper alternatives to commercial mesh are required due to the high associated cost. Whilst nylon mosquito net mesh has been trialled previously, this study aimed to assess the use of polyester mosquito net mesh in tension-free inguinal hernia repair in Ghana. METHODS: All patients undergoing inguinal hernia repair during the 5-day 'Operation Hernia' mission in 2007 were eligible for the study. A piece of sterilised 10 x 15-cm 100% polyester mosquito net mesh, manufactured and donated by Scotmas Limited, was implanted for all tension-free hernia repairs. The surgeons' ease of handling and incidence of complications at 6 weeks and 6 months were assessed. RESULTS: Ninety-five patients underwent inguinal hernia repair using a total of 106 polyester mosquito net meshes. The mean (range) age of patients was 44.3 (15-78) years. Seventy-two (76%) were repaired using local anaesthesia. At 6 weeks and 6 months, a total of seven (7%) patients suffered wound complications (five haematomas, two wound infections). Ease of practical handling improved after the first 2-5 cases. The cost of an individual 10 x 15-cm mesh was estimated at US$0.0072-0.014, and the cost of sterilisation and packaging was US$1.46 per mesh. CONCLUSIONS: Polyester mosquito net mesh represents a cost-effective alternative to commercial meshes in developing countries, with a relatively low rate of early complications and similar short-term recurrence rates. The use of local anaesthesia may enhance this further.

Development of a clinical prediction model to calculate patient life expectancy: the measure of actuarial life expectancy (MALE).

OBJECTIVES: To develop a clinical prediction model enabling the calculation of an individual patient's life expectancy (LE) and survival probability based on age, sex, and comorbidity for use in the joint decision-making process regarding medical treatment. METHODS: A computer software program was developed with a team of 3 clinicians, 2 professional actuaries, and 2 professional computer programmers. This incorporated statistical spreadsheet and database access design methods. Data sources included life insurance industry actuarial rating factor tables (public and private domain), Government Actuary Department UK life tables, professional actuarial sources, and evidence-based medical literature. The main outcome measures were numerical and graphical display of comorbidity-adjusted LE; 5-, 10-, and 15-year survival probability; in addition to generic UK population LE. RESULTS: Nineteen medical conditions, which impacted significantly on LE in actuarial terms and were commonly encountered in clinical practice, were incorporated in the final model. Numerical and graphical representations of statistical predictions of LE and survival probability were successfully generated for patients with either no comorbidity or a combination of the 19 medical conditions included. Validation and testing, including actuarial peer review, confirmed consistency with the data sources utilized. CONCLUSIONS: The evidence-based actuarial data utilized in this computer program design represent a valuable resource for use in the clinical decision-making process, where an accurate objective assessment of patient LE can so often make the difference between patients being offered or denied medical and surgical treatment. Ongoing development to incorporate additional comorbidities and enable Web-based access will enhance its use further.

MRSA-infected external iliac artery pseudoaneurysm treated with endovascular stenting.

A 48-year-old woman with severe juvenile-onset rheumatoid arthritis presented with a bleeding cutaneous sinus distal to her right total hip replacement scar. Methicillin resistant Staphylococcus aureus (MRSA) was isolated on culture. She had previously undergone bilateral total hip and knee replacements at aged 23 and six years later had the right knee prosthesis removed for infection, with subsequent osteomyelitis of the femoral shaft and right total hip prosthesis disruption. Peripheral arteriography was performed in view of persistent bleeding from the sinus, which revealed a 6 cm false aneurysm filling from and compressing the right external iliac artery (EIA). A PTFE-covered, balloon expandable JOSTENT was deployed in the right EIA, successfully excluding the false aneurysm and preventing further bleeding from the sinus. No graft infection was reported at 12 months. This case illustrates the potential use of endovascular stent-grafting in the treatment of an infected pseudoaneurysm.

Conservative treatment as an option in the management of pancreatic pseudocyst.

BACKGROUND: Management of pancreatic pseudocysts is associated with considerable morbidity (15-25%). Traditionally, pancreatic pseudocysts have been drained because of the perceived risks of complications including infection, rupture or haemorrhage. We have adopted a more conservative approach with drainage only for uncontrolled pain or gastric outlet obstruction. This study reports our experience. PATIENTS AND METHODS: A consecutive series of 36 patients with pancreatic pseudocysts were treated over an 11-year period in one district general hospital serving a population of 310,000. This study group comprised of 19 men and 17 women with a median age of 55 years (range, 10-88 years). Twenty-two patients had a preceding attack of acute pancreatitis whilst 12 patients had clinical and radiological evidence of chronic pancreatitis. The aetiology comprised of gallstones (16), alcohol (5), trauma (2), tumour (2), hyperlipidaemia (1) and idiopathic (10). RESULTS: All patients were initially managed conservatively and intervention, either by radiological-assisted external drainage or cyst-enteric drainage (by surgery or endoscopy), was only performed for persisting symptoms or complications. Patients treated conservatively had 6 monthly follow-up abdominal ultrasound scans (USS) for 1 year. Fourteen of the 36 patients (39%) were successfully managed conservatively, whilst 22 patients required intervention either by percutaneous radiological drainage (12), by endoscopic cystogastrostomy (1) or by open surgical cyst-enteric anastomosis (9). Median size of the pancreatic pseudocysts in the 14 patients managed conservatively (7 cm) was nearly similar to that of the 22 patients requiring intervention (8 cm). The most common indications for invasive intervention in the 22 patients were persistent pain (16), gastric outlet obstruction (4), jaundice (1) and dyspepsia with weight loss (1). Although one patient required surgery for persistent pain, no other patients required urgent or scheduled surgery for complications of untreated pancreatic pseudocysts. Two of the 12 patients treated by percutaneous radiological drainage had recurrence of pancreatic pseudocysts requiring surgery. Two patients developed an intra-abdominal abscess following cyst-enteric drainage of pancreatic pseudocysts and one patient had a pulmonary embolism. On the mean follow-up of 37.3 months, one patient with alcoholic pancreatitis died 5 months after surgical cyst-enteric bypass. CONCLUSIONS: These results suggest that many patients with pancreatic pseudocysts can be managed conservatively if presenting symptoms can be controlled.

Serious consequences of a sore throat.

Lemierre's syndrome, caused by Fusobacterium necrophorum, is a potentially fatal sequelae of a sore throat characterised by septicaemia, internal jugular vein thrombophlebitis and metastatic abscesses. The Chief Medical Officer reported in February 2001 that the incidence is increasing. Two cases seen in one year, with different presentations, are reported. The first patient presented with sepsis, jaundice, hepatic abscesses and portal vein/superior mesenteric vein thrombosis, whilst the second presented with sepsis, sore throat and internal jugular vein thrombophlebitis. Both patients were treated with antibiotics and anticoagulants with a favourable outcome.

Lexical comprehension and grammatical deficits in children with specific language impairment.

Several accounts of specific language impairment (SLI) in children have appeared in the recent literature. One of the most explicit is that of Locke. The purpose of the present investigation was to evaluate some of the details of Locke's proposal. In the first of two studies, it was found that children with SLI who were limited to single-word utterances showed deficits in their lexical comprehension. In the second study, a number of children with SLI who had reached the grammatical stage of development showed age-appropriate levels of lexical comprehension. Although the first of these findings was in keeping with Locke's account, the second was not. Additional provisions for this proposal are suggested.

Eating attitudes and neurotic symptoms in university students.

A postal survey of male and female university students is reported, using the Eating Attitude Test (EAT) and the Crown Crisp Experiential Index (CCEI). Eleven per cent of the 156 female respondents but none of 120 males scored above 30 on the EAT, thereby declaring eating attitudes comparable to anorexic subjects. Of those interviewed, none fulfilled diagnostic criteria for anorexia nervosa, but half showed eating disorder of clinical severity. There was a clear association between high EAT scores and higher scores on all the subscales of the CCEI except the phobic scale. The results are discussed in relation to ideas about the possible origins of clinical eating disorders.

Psychiatric consultations in clinical haematology.

A psychiatrist's role in the management of patients with malignant blood disorders being treated by clinical haematologists is described. Twenty-seven patients were seen, the majority (21) for an initial assessment only, and many (21) within three months of diagnosis or their death. Seventeen were referred for assessment of abnormal mood or behaviour and the others for a variety of problems which affected their management. A small group (4) had organic psychosyndromes; the majority (15) were suffering from understandable adjustment reactions, with another 5 having morbid neurotic or depressive reactions. Family and hospital factors were important and a description of these is included in an account of the consultation process.

A psychogeriatric survey of old people's homes.

An assessment of mental impairment and behavioral disabilities in 289 residents in six old people's homes indicated that 50.6% were probably demented and 54% needed considerable help in daily living, 74% were taking prescribed medication, and 11% were taking four or more prescribed drugs. There was a wide variation between homes in those rated as behaviourally disabled, and in the amount of medication prescribed. A follow-up of 60 mentally impaired residents showed few remediable psychiatric disorders or psychotoxic drug effects. A community psychiatric nurse working with the psychogeriatric team would provide a useful support service to old people's homes, particularly where there is a high proportion of disturbed residents and where the staff lack nursing experience.