Stoma complications: a literature overview.

Stoma formation is a commonly performed procedure in colorectal surgery as a part of operations performed for malignant- and inflammatory bowel disease. Stoma formation is a simple, but not trivial, undertaking. When performed badly, it can leave the patients with a legacy of complications such as leakage, prolapse, parastomal hernia and retraction. Various studies have reported a complication rate of 21-70%. We performed a literature search using the Medline, Ovid and Google scholar database for all the articles published between January 1980 and December 2008. The search terms used were colostomy, ileostomy, stoma, parastomal hernia, stenosis, prolapse, necrosis and complications. The following article summarizes the common complications associated with stomas.

Spotlight on a distant mirror - colorectal cancer surgery in a 20-year period at a general hospital.

BACKGROUND: A published audit of the management of colorectal cancer at a general hospital in the 1970s was available for comparison with a later audit at the same hospital in the 1990s. METHODS: Case note analysis. RESULTS: In the later audit, more cases were treated annually by an unchanged surgical team. The incidence of synchronous combined excision of the rectum, for rectal cancers suitable for resection, was halved, and that of anterior resection of the rectum (sphincter sparing, without a permanent stoma) increased almost threefold. The incidence of local recurrence in cases suitable for rectal surgery dropped from 17% to 9%, in spite of the change in the principal operation undertaken for this population. Outcomes associated with critical care improved as resources in this discipline became available. Overall survival figures were only improved by 6% in the20-year period, reflecting a diagnosis of Dukes C tumours or worse in at least 45% of the stable population studied in both audits. CONCLUSION: More resources are necessary in Great Britain to increase survival figures in this common cancer. Earlier diagnosis and more specialist management of the disease may allow us to emulate American and Swedish survival figures.

Emergency surgery: atavistic refuge of the general surgeon?

A prospective audit of emergency soft-tissue surgery for an eight-week period revealed that general surgical emergency operations were more than twice as common as those undertaken in other soft-tissue specialties. The audit reveals that emergency general surgery needs an increase in resources, an increase in available staff and an increase in the role of the consultant general surgeon on call. An alternative solution would be to admit soft-tissue emergencies by specialty and develop specialist emergency services.

The benefit of geriatric intervention in surgery-increased throughput does not necessarily need more beds.

OBJECTIVE: Three years ago a consultant geriatrician began regular visits to the coloproctology and general surgery wards of an acute Trust every weekday, to assist staff with the medical management, rehabilitation and discharge planning of patients aged 65 years and above. The length of stay of these patients in the first 10 months of the appointment was compared with younger concurrent controls and with historical controls in the preceding 10 months. RESULTS: The mean length of stay for the 4146 patients aged 16 years and above in a 10-month intervention period was 1.3 days shorter (95% confidence interval (CI) 0.86-1.74 days) than for the 4002 patients in the 10-month control period. This pattern was consistent across all ages and types of surgery, including major colorectal resection. CONCLUSION: There was an important benefit to the availability of coloproctology and general surgical beds in this acute Trust. More efficient rehabilitation of elderly patients reduces 'bed blockage' post-operatively, and allows more effective use of available resources. Co-ordination of the geriatric service with the specialized stoma support service allows earlier discharge of the elderly, and their relocation to appropriate premises where long-term changes in bowel habit and problems with stoma care can be managed away from the acute surgical unit.

An audit of hospital mortality after urgent and emergency surgery in the elderly.

An audit was carried out of 102 patients aged over 75 years undergoing urgent or emergency surgery in a district general hospital. The risk of death in hospital after general surgery (13 deaths in 49 patients) was greater than after orthopaedic surgery (two deaths in 53 patients) (P < 0.05). In particular, laparotomy carried a high in-hospital mortality: 12 of 25 patients undergoing laparotomy died. Risk of death after general surgery increased with increasing preoperative ASA class, increasing medical risk factors and duration of operation. Orthopaedic cases were fitter than the general surgical cases as determined by ASA class and the number of medical risk factors. NCEPOD has recommended increased involvement of senior medical staff in operations, reduced night-time operating and avoidance of futile surgery. A high proportion of cases were operated on and anaesthetised by higher specialist trainees and consultants. Death rate was not affected by the seniority of doctors involved, nor by the time of day the operation took place. General surgical deaths were predictable postoperatively in most cases, but preoperative prediction of outcome was not specific enough to alter management.

An audit of the effect of a 24-hour emergency operating theatre in a district general hospital.

The recent introduction of a 24-hour emergency theatre for General Surgery provided an opportunity to audit its effect on emergency operating in a District General Hospital. Prior to its introduction much of the emergency operating was determined by theatre availability rather than clinical need. Half of the emergency operations were carried out between 10 pm and 8 am. This proportion was reduced to a third when a theatre was continually available. This had benefits for the patients in reducing their waiting time and also for the junior surgeons by increasing their sleep. A survey of the Region indicated that very few hospitals provided adequate emergency theatre facilities.

Abdominocervical (transhiatal) oesophagectomy in the management of oesophageal carcinoma.

Fifty-four patients have undergone abdominocervical oesophagectomy for oesophageal carcinoma as an alternative to a conventional transthoracic approach. Their median age was 69 years, with a range of 38-90 years, and 39 per cent of patients had chronic cardiorespiratory disease. Lymph node metastases were found in 80 per cent of patients and transmural tumour spread in 91 per cent. Median duration of operation was 2.2 h (range 1.75-6.0 h), and median transfusion requirement was 2.5 units (range 0-8 units). Respiratory complications were common (41 per cent) and caused all six postoperative deaths (11 per cent). Other complications were atrial fibrillation (26 per cent), transient recurrent laryngeal nerve palsy (11 per cent), cardiac failure (2 per cent), stroke (2 per cent), subphrenic abscess (2 per cent) and empyema (2 per cent). There were two anastomotic leaks (4 per cent), clinically manifest as temporary salivary fistulae. There have been 32 deaths from recurrent carcinoma, with a median duration of survival of 14 months (range 4-53 months). Fifteen patients are still alive, with a median survival of 16.5 months (range 3-49 months); the current 3-year survival rate is 10 per cent. All patients resumed normal swallowing after operation, but 11 of them developed anastomotic strictures requiring a median of three dilatations. Avoidance of formal thoracotomy by the abdominocervical approach may allow more rapid oesophagectomy without increasing the risk of postoperative death and gives a quality of palliation at least equivalent to that of conventional transthoracic oesophageal excision.

Value of a centralised approach in the management of haematemesis and melaena: experience in a district general hospital.

All patients presenting with acute upper gastrointestinal bleeding between November 1986 and April 1988 were admitted to a centralised joint medical/surgical unit, with a policy of early clinical and endoscopic assessment and rapid surgical intervention in those at high risk. Of the 430 patients admitted 69.5% were over the age of 60 and 30% had significant additional medical conditions. 50.4% were bleeding from peptic ulcers and one third had been taking non-steroidal anti-inflammatory agents. Fifty five patients underwent surgery, which in two thirds was carried out within 24 hours of admission, usually for continued bleeding. In patients with peptic ulcer the operation rate was 21.6%. Overall mortality was 3.7%, and in those with bleeding gastric or duodenal ulcers 5.5%; surgical mortality in the later group was 15.2%. All patients who died had serious concomitant pathology and 87% were over 70 years of age. Adoption of a centralised approach to management of haematemasis and melaena is feasible in a District General Hospital and associated with an improved survival.

Surgical palliation for pancreatic cancer: will biliary bypass alone suffice?

Because a number of options are available to relieve the obstructed bile duct, stomach or both in patients with irresectable carcinoma of the pancreatic head, palliative surgery for this condition was reviewed retrospectively between 1971 and 1981 at the Royal United Hospital, Bath. One hundred and sixty-five patients underwent a biliary bypass procedure with (n = 37), or without (n = 128) gastric drainage. Thirty patients had a prophylactic gastroenterostomy to avoid gastric outlet obstruction: tumour encroachment made gastroenterostomy essential in seven others. After biliary bypass alone, operative mortality was 14%. After a concomitant gastroenterostomy, mortality was 27% (P less than 0.04). Within a year of biliary bypass alone, there was a 9% incidence of gastric outlet obstruction requiring gastric drainage, with an associated mortality rate of 18%. Survival after biliary bypass or biliary bypass with gastroenterostomy was equal (7-8 months). Except where gastric outlet obstruction is imminent, palliation for irresectable pancreatic head carcinomas should be by biliary bypass alone, because the addition of a gastroenterostomy almost doubles the mortality without any advantage in survival time.

Experimental pancreatic cancer in the Syrian hamster: effect of cholecystectomy.

Because cholecystectomy stimulates hypertrophy and hyperplasia in the hamster pancreas, its effect on experimental pancreatic carcinogenesis was studied in this animal model. Forty female Syrian hamsters underwent cholecystectomy, while 40 others underwent sham operations. Two weeks later, 30 hamsters undergoing cholecystectomy and 30 hamsters undergoing sham operations received 4 weekly subcutaneous injections of N-nitroso-bis (2-oxopropyl) amine (BOP) (10 mg/kg). Remaining hamsters (n = 20) received equal volumes of 0.9% saline solution. A further 10 hamsters (controls) underwent no surgery and received no injections. Thirty weeks after the first BOP or saline injection the pancreas of hamsters that had undergone cholecystectomy was only 3% heavier than that of sham-operated animals, and there was no difference in the incidence of pancreatic cancer between BOP-treated hamsters that had undergone cholecystectomy and those that had undergone sham operations. In this study, cholecystectomy had no influence on BOP-induced pancreatic carcinogenesis in the Syrian hamster.

Secondary arterio-enteric fistulae: a surgical challenge.

Ten cases of secondary arterio-enteric fistulae are described. There were nine graft enteric fistulae and one fistula involving the aortic suture line following elective resection of an infected graft. Only four of the patients initially received prophylactic antibiotics (single dose) at the original aortic reconstruction, and the vascular suture line had only been protected in two. Eight patients presented with bleeding and two with groin abscesses. One patient died before operation. Graft resection was undertaken in all patients and organisms were grown from six of eight grafts cultured. No patient died during operation but one died after 3 days. Axillofemoral bypass grafts were constructed in seven patients (four immediately after resection of prosthetic grafts and three within 4 days of operation). Only three of the eight patients who survived operation are still alive; two died of a ruptured aorta and one from a recurrent fistula. Two patients died of other causes. Four of five axillofemoral grafts in surviving patients subsequently occluded.

Method of one-way surgical drainage for the inexpensive accurate measurement of abdominal secretions.

A simple, inexpensive method for one-way collection and measurement of secretions is described. This method has been used successfully in surgical practice in Bath for more than 20 years (1).

The organisation and evaluation of an open-access dysphagia clinic.

We describe our experience in organising an open access dysphagia clinic. Any patient with dysphagia for solids of at least one week's duration can be seen within one week of referral. One hundred and nine 'new' patients were referred in the first year. Fifty-five (50.4%) had peptic or malignant strictures. The majority of these received definitive treatment within ten days of the date of referral. This system of referral and treatment improves the speed of detection and treatment of patients with oesophageal stenosis.

Morphological study of antigen-sampling structures in the rat large intestine.

Organized lymphoid tissue in the rat colon exists as clusters (colonic lymphoid patches) of intramucosal and submucosal follicles in the proximal, mid, and distal colon, interspersed by solitary follicles. The follicular lymphoid cells of colonic lymphoid patches are separated from the gut lumen by a highly specialized lymphoepithelium which lacks mature goblet cells. Cells of this epithelium are of two types: those characterized by an electron-dense cytoplasm, large numbers of apical vesicles and lysosomes, and prolonged extensions of the apical cytoplasm forming thin partitions between the gut lumen and underlying intercellular spaces; and cells with a less electron-dense cytoplasm, distorted mitochondria, and little endoplasmic reticulum. Both cell types bear normal microvilli and have numerous lateral membrane processes which penetrate large intercellular spaces. A ferritin-India ink label infused into the colonic lumen was preferentially adsorbed onto the surface of this follicle-associated epithelium. Indigenous colonic bacteria were observed penetrating the superficial cytoplasm of the electron-dense cells where they were enclosed in lysosomes and digested. An antigen-sampling role is proposed for the colonic lymphoid patch epithelium.

Intervention in large bowel carcinogenesis--does screening improve prognosis?

Cancer of the large bowel is the second most common malignant tumour in the western world, with approximately 20,000 new cases registered each year in England and Wales. No improvement in the survival figures has occurred in the past 30 years, and since 1970 the number of deaths per annum in Great Britain has been rising. The prognosis of the disease is related directly to the degree of centrifugal spread of the tumour. Patients with cancer limited to the bowel wall have a corrected 5-year survival of about 90%, whereas those with tumours with lymphatic spread have a 5-year survival of about 30%. The prognosis for early colorectal tumours is therefore good, but a method of identifying such lesions is required. If early tumours bleed, the detection of occult blood in the faeces may be a valuable screening test for colorectal cancer. In one town, 8,925 asymptomatic people over the age of 40 were invited to be screened for faecal occult bleeding using Haemoccult slides. The invitation was accepted by 2,439 patients, a compliance rate of 27%. On Haemoccult screening 121 patients were positive initially, but 39 of these were found to be false-positive after further investigation. Haemoccult therefore gives a false-positive incidence of 30%. Twelve tumours of the bowel were identified, eight polyps and four cancers. Another patient who had been negative in the screening survey was identified within 2 months of the end of the experiment as having large-bowel cancer. This means that Haemoccult gives a false negative rate, in our hands, of 20%. The ability of a cancer screening procedure to identify and cure early tumours depends upon the compliance of the population, the sensitivity of the test and the availability of effective treatment. The poor compliance of our population and the disappointing sensitivity of Haemoccult mean that occult blood screening for early large bowel cancer remains theoretically possible but practically inefficient.