With adequate supervision, the grade of the operating surgeon is not a determinant of outcome for patients undergoing urgent colorectal surgery.

INTRODUCTION: It is essential that higher surgical trainees (HSTs) obtain adequate emergency operative experience without compromising patient outcome. The aim of this study was to compare the outcomes of patients operated by HSTs with those operated by consultants and to look at the effect of consultant supervision. PATIENTS AND METHODS: A retrospective analysis of 362 patients who underwent urgent colorectal surgery was performed. The primary outcome was 30-day mortality. Secondary outcomes were intra-operative and postoperative surgery, specific and systemic complications, and delayed complications. RESULTS: Comparison of the patients operated by a consultant (n = 190) and a HST (n = 172) as the primary surgeon revealed no significant difference between the two groups for age, gender, ASA status or indication for surgery. There was a difference in the type of procedure performed (left-sided resections: consultants 122/190, HST 91/172; P = 0.050). There was no difference between the two groups for the primary and secondary outcomes. However, HSTs operating unsupervised performed significantly fewer primary anastomoses for left-sided resections (P = 0.019) and had more surgery specific complications (P = 0.028) than those supervised by a consultant. CONCLUSIONS: HSTs can perform emergency colorectal surgery with similar outcomes to their consultants, but adequate consultant supervision is vital to achieving these results.

The role of the microcirculation in the multi-organ dysfunction syndrome.

The systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS) are significant causes of morbidity and mortality in the intensive care unit. The pathogenesis of MODS is poorly understood; however, endotoxin (LPS) and cytokines (for example interleukins, tumor necrosis factor and platelet activating factor) are thought to play a major role by inducing microvascular injury. A crucial step in the normal functioning of the immune system is the adhesion of cells to each other and, via extravasation, penetration of the extracellular matrix. This is an essential process for normal host defence against injury and infection. In SIRS this process becomes uncontrolled, leading to extravasation of neutrophils causing tissue injury and inflammation. In addition there is increased capillary permeability. It is this disturbance of the microcirculation that is responsible, either wholly or in part, for the development of SIRS and MODS.

Silent myocardial ischemia during rehabilitation for cerebrovascular disease.

In asymptomatic patients the importance of silent ischemic ST-T wave changes on Holter monitoring is known to be a significant predictive variable for one-year mortality of postmyocardial infarction patients. This case report represents the uses of ambulatory ECG to detect ischemic ST changes in patients who have had recent strokes. The cases reported here of silent myocardiac ischemia in stroke patients reflect previous reports in which 70% of the ischemic episodes in patients with symptomatic coronary artery disease are not associated with angina and in which approximately 10% to 15% of acute myocardial infarctions are silent. We now believe that the incidence of "silent" ischemia may be precipitated in poststroke patients during their rehabilitation program. This belief is supported by two main factors. First, a high level of personally relevant mental stress exists which activates the sympathoadrenal system, which may lead to myocardial ischemia. Second, some stroke patients become aphasic and are unable to communicate adequately even if they experience angina symptoms. We have found that poststroke, most patients could not undergo exercise treadmill testing secondary to a variety of factors: inability to coordinate limbs, poor endurance, inability to follow directions, and/or lack of attention. We now propose that 24-hour monitoring for ST-T wave changes poststroke should be considered as part of a vigorous investigation for myocardial ischemia during the rehabilitation of these patients because they have an increased risk of cardiac morbidity.