Apical lymph node dissection of the inferior mesenteric artery.

AIM: It is controversial whether a high or low ligation of the inferior mesenteric artery (IMA) is superior. The former allows an extended lymph node clearance whereas the latter preserves the distal vascular supply via the left colic artery (LCA). Apical lymph node dissection of the IMA (ALMA) harvests nodal tissue along the IMA proximal to the LCA whilst performing a low ligation. This anatomically replicates the oncological benefit of high ligation and the vascular preservation of low ligation. Our study evaluates the nodal yield of ALMA and the short-term outcome of this technique. METHOD: We retrospectively studied 19 patients with sigmoid or rectal cancer who underwent curative surgical resection with ALMA. All ALMAs were performed with a standard technique previously described (Kobayashi et al., Surg Endosc 2005, 20:563-9; Sekimoto et al. Surg Endosc 2010, 25:861-6) . The lymph node yield from the dissection (the ALMA specimen) was compared with the total lymph node yield. Data on the LCA anatomy, time required to perform ALMA, complications and postoperative recovery were evaluated. RESULTS: ALMA was successful in 18 patients. Median postoperative hospitalization was 5 (2-26) days without ALMA-related morbidity or mortality. The median lymph node yield was 20 (9-41) and a median of 14.3 (0-80)% were harvested with ALMA. Two patients not having neoadjuvant chemoradiotherapy had fewer than 12 lymph nodes, excluding nodes harvested from ALMA. The average time required for ALMA was 18 min. CONCLUSION: ALMA is a safe and feasible technique, allowing extended lymphadenectomy without sacrificing the LCA. In this small group of patients none were upstaged due to cancerous involvement of the proximal nodes.

Non-operative management of obturator hernia in an elderly female.

Obturator hernia is a rare surgical condition, with about 800 cases being reported in the literature. It can cause significant morbidity and mortality, especially in the elderly age group. Delayed treatment is associated with high rates of strangulation (25-100 %). The mainstay of management for obturator hernia has been surgical. Non-operative management can lead to significant morbidity and mortality, but may be an option in patients who decline surgery, as described in our case.

Recall of discharge advice given to patients with minor head injury presenting to a Singapore emergency department.

INTRODUCTION: Most patients presenting to the emergency department (ED) with minor head injury (HI) can be discharged, provided a caregiver is present and careful discharge instructions are given. The study ED uses an advice leaflet with verbal reinforcement to patients and caregivers detailing post-discharge instructions and warning symptoms of worsening HI. We aim to evaluate local patients' and caregivers' compliance to discharge instructions and their ability to recall HI advice. METHODS: A prospective study was conducted in an adult ED between April 10, 2006 and May 1, 2006. All patients with minor HI discharged from the ED or its 24-hour observation ward were included in the study. A telephone survey was conducted within 48 hours of discharge using a standardised questionnaire. RESULTS: During the study period, 292 patients had HI, of which 182 were eligible for the study. 71 were uncontactable and one refused to participate, leaving 110 patients in the study. Patients' age ranged between 7 and 109 years (median 41 years). 100 confirmed receiving HI advice (57 percent received by patients, 26 percent caregivers, 16 percent both patients and caregivers). 29 percent of respondents reported non-compliance to discharge advice. Mean HI-symptom recall score was 1.9 (SD 1.6) (total 9 symptoms). 30 percent cited other symptoms not part of the HI advice, which they believed necessitated a return to the ED. Recall scores were not statistically different, regardless of mode of instruction (verbal or printed) or the recipient (patient, caregiver or both). CONCLUSION: Our study raises concerns about the reliability of discharge advice for minor HI patients.

How much do diabetic patients know about diabetes mellitus and its complications?

INTRODUCTION: A Singapore study reported that 99% of diabetics had received some diabetes mellitus (DM) education. Another study reported that the Singapore public is generally well-informed about DM but whether diabetics are well-informed is not known. The objectives of this study were to determine DM knowledge of diabetics visiting the Emergency Department (ED) and to determine the diabetics' knowledge versus practice gap. MATERIALS AND METHODS: A pretested questionnaire was used to survey a convenient sample of ED patients and visitors. The respondents were required to answer 43 questions on areas including "Risk Factors", "Treatment and Management" and "Monitoring". A point was awarded for each correct response. Diabetics were asked if they practised the items described in "Treatment and Management" and "Monitoring" sections. RESULTS: There were 95 diabetics and 91 non-diabetics surveyed, with no difference in the mean age or the proportion of men. There was no difference (P = 0.51) between the diabetics' mean score of 29.2/43 (68.1%) and the non-diabetics' 28.3/43 (65.9%). The younger diabetics tended to score higher with those <54.99 years obtaining the highest score of 34.2/43 (79.5%) in the study. More than 50% of diabetics practised what they knew of self-care but 25% were ignorant of key aspects like need for home glucose monitoring and regular ophthalmic reviews. Only 21.2% diabetics performed home glucose monitoring though another 42.1% knew they should but were not doing it. CONCLUSION: In this study, knowledge of DM was similar between diabetics and non-diabetics even though younger diabetics obtained higher scores. Diabetes education resulted in better-informed diabetics and changed practices but 25% were ignorant of some key aspects. Among the informed diabetics, various issues need to be addressed to close the gaps between knowledge and practice.