The yield of colorectal cancer among fast track patients with normocytic and microcytic anaemia.

INTRODUCTION: We receive fast track referrals on the basis of iron deficiency anaemia (IDA) for patients with normocytic anaemia or for patients with no iron studies. This study examined the yield of colorectal cancer (CRC) among fast track patients to ascertain whether awaiting confirmation of IDA is necessary prior to performing bowel investigations. METHODS: A review was undertaken of 321 and 930 consecutive fast track referrals from Centre A and Centre B respectively. Contingency tables were analysed using Fisher's exact test. Logistic regression analyses were performed to investigate significant predictors of CRC. RESULTS: Overall, 229 patients were included from Centre A and 689 from Centre B. The odds ratio for microcytic anaemia versus normocytic anaemia in the outcome of CRC was 1.3 (95% confidence interval [CI]: 0.5-3.9) for Centre A and 1.6 (95% CI: 0.8-3.3) for Centre B. In a logistic regression analysis (Centre B only), no significant difference in CRC rates was seen between microcytic and normocytic anaemia (adjusted odds ratio: 1.9, 95% CI: 0.9-3.9). There was no statistically significant difference in the yield of CRC between microcytic and normocytic anaemia (p=0.515, Fisher's exact test) in patients with anaemia only and no colorectal symptoms. Finally, CRC cases were seen in both microcytic and normocytic groups with or without low ferritin. CONCLUSIONS: There is no significant difference in the yield of CRC between fast track patients with microcytic and normocytic anaemia. This study provides insufficient evidence to support awaiting confirmation of IDA in fast track patients with normocytic anaemia prior to requesting bowel investigations.

The diagnostic value of white cell count, C-reactive protein and bilirubin in acute appendicitis and its complications.

INTRODUCTION: Inflammatory markers such as white cell count (WCC) and C-reactive protein (CRP) and, more recently, bilirubin have been used as adjuncts in the diagnosis of appendicitis. The aim of this study was to determine the diagnostic accuracy of the above markers in acute and perforated appendicitis as well as their value in excluding the condition. METHODS: A retrospective analysis of 1,169 appendicectomies was performed. Patients were grouped according to histological examination of appendicectomy specimens (normal appendix = NA, acute appendicitis = AA, perforated appendicitis = PA) and preoperative laboratory test results were correlated. Receiver operating characteristic (ROC) curve area analysis (area under the curve [AUC]) was performed to examine diagnostic accuracy. RESULTS: ROC analysis of all laboratory variables showed that no independent variable was diagnostic for AA. Good diagnostic accuracy was seen for AA when all variables were combined (WCC/CRP/bilirubin combined AUC: 0.8173). In PA, the median CRP level was significantly higher than that of AA (158mg/l vs 30mg, p<0.0001). CRP also showed the highest sensitivity (100%) and negative predictive value (100%) for PA. CRP had the highest diagnostic accuracy in PA (AUC: 0.9322) and this was increased when it was combined with WCC (AUC: 0.9388). Bilirubin added no diagnostic value in PA. Normal levels of WCC, CRP and bilirubin could not rule out appendicitis. CONCLUSIONS: CRP provides the highest diagnostic accuracy for PA. Bilirubin did not provide any discriminatory value for AA and its complications. Normal inflammatory markers cannot exclude appendicitis, which remains a clinical diagnosis.

Laparoscopic repair of perforated duodenal ulcers with a falciform ligament patch.

Six patients are reported who presented with perforated duodenal ulcers. These were repaired laparoscopically by suturing the falciform ligament over the perforated ulcer. There were no complications and patients were discharged between 3 and 5 days after surgery. This technique is simpler to perform than a laparoscopic omental patch repair.

Vasovasostomy: 10 years' experience in a district general hospital showing improved results with luminal dilatation.

We report a simple and effective technique for vasovasostomy. Over 105 procedures have been performed over a 10-year period by a single consultant and his registrars with results comparable to those obtained with more time-consuming formal microsurgical techniques when routine luminal dilatation of the vas was adopted. Additionally, the chances of success were found to be greater the shorter the interval between vasectomy and vasovasostomy.

PIP: Various vasectomy reversal techniques have been reported, but no single technique has proven to be clearly better. In this article, the authors report on a simple, lower-cost vasectomy reversal technique. A retrospective study of 105 men, who had had a vasectomy performed between 2 and 14 years earlier, was carried out. 33 of these patients had received luminal dilatation, while 72 had not; these two groups were used for operative comparison. The operative technique involved opening the scrotum and locating the vas. The vas was incised next to the testicular side and then dilated. A prolene stent was passed into each end of the cut vas; then sutures were applied. In the second group, an identical procedure was performed except for the dilatation of the lumen. 77 of the 105 men (73%) showed a reversal in the vasectomy. Dilatation of the lumen improved reversal rate success over those without dilatation (26/33 [79%] vs. 51/72 [71%]). Also shown was that, as time between original vasectomy and reversal increased, the success rate decreased. Complications from these procedures were uncommon.