Ileal Pouch Excision: A Contemporary Observational Cohort.

BACKGROUND: Pouch excision is required for many of those patients experiencing pouch failure in whom ileostomy alone is inadequate and revision surgery is not appropriate. The published rate of pouch failure is approximately 10% at 10 years, resulting in a growing cohort of patients requiring excision. OBJECTIVE: In this article, we aim to describe the indications for excision and postoperative outcomes at our center since 2004. DESIGN: This is a retrospective observational study. SETTINGS: This study was conducted at a tertiary referral center for ileal pouch dysfunction. Cases were documented from 2004 to 2017. PATIENTS: The cohort comprised 92 patients; 83% were diagnosed with ulcerative colitis, 15% with familial adenomatous polyposis, and 2% with indeterminate colitis. INTERVENTIONS: Patients underwent excision of pelvic ileal pouches. MAIN OUTCOME MEASURES: The primary outcomes measured were the time to perineal wound healing and healing at 6 months. Thirty- and 90-day morbidity and mortality were evaluated. RESULTS: Postoperative histology was consistent with Crohn's disease in 1 patient. The median time from pouch creation to excision was 7 years. The rate of perineal wound healing at 6 months was 78%, and regression analysis demonstrated significantly improved chances of healing for noninfective indications for excision (p = 0.023; OR, 15.22; 95% CI, 1.45-160.27) and for more recent procedures (p = 0.032; OR, 12.00; 95% CI, 1.87-76.87). LIMITATIONS: This study was limited because it was retrospective in nature, and it was a single-center experience. CONCLUSIONS: This study represents the most contemporary cohort of patients undergoing pouch excision surgery. The procedure retains a relatively high postoperative morbidity, but this study demonstrates a learning curve with improving perineal healing over time associated with a high institutional volume. Defunctioning ileostomy may improve perineal wound healing in patients with infective indications for excision. Further investigation is required to establish the quality-of-life benefits of pouch excision in this modern cohort. See Video Abstract at http://links.lww.com/DCR/A804.

Incidental finding - the discovery of a bronchopulmonary foregut malformation through investigations for Crohn's disease.

Pulmonary sequestration (PMS) is a rare bronchopulmonary malformation. It has an incidence of between 0.15% to 1.7%. Likewise, cystic adenomatoid malformation (CCAM) is another relatively rare category of a bronchopulmonary malformation with a reported incidence of between 1 in 25,000 to 1 in 35,000. Moreover, a bronchopulmonary malformation with features allied to both of these forms is considered an even rarer entity. In general, bronchopulmonary malformations present with a range of non-specific symptoms. Radiological features can be non-specific yet distinctive when related to clinical features. Ultimately, definitive diagnosis depends upon histological assessment of lung tissue. We present an adult female with radiological features of both pulmonary sequestration and cystic adenomatoid malformation. This was an incidental finding unrelated to the patients presenting complaint. This case highlights the importance of using a structured and systematic approach when interpreting medical imagery.

Robotic partial nephrectomy for duplex kidney with ectopic ureter draining in the vagina in an adult patient with urinary incontinence.

A duplex kidney system with an ectopic ureter draining into the vagina is a congenital malformation that typically presents as refractory urinary incontinence. Diagnosis is often difficult to establish and delayed due to a low incidence. We present the case of a patient aged 26 years with a life-long history of persistent urinary incontinence. Initial presentation was at childhood; however, the diagnosis went undetermined for 22 years. CT urography revealed a duplex kidney with an atrophic upper pole associated with an ectopic ureter that drained into the vaginal vault. This is the first description of such a case being managed successfully via a robot-assisted partial nephrectomy approach. Ectopic ureteral duplication should be considered in the differential diagnosis for young women with refractory urinary incontinence. Robotic partial nephrectomy is a safe and effective technique to manage such cases.

Near Peer Group training on 'How to be a Foundation doctor' Course.

This article was migrated. The article was marked as recommended. Introduction After graduating from medical school, all UK based doctors enter the Foundation Programme. There is on-going evidence, both anecdotally and published, that final year medical students continue to feel unprepared about starting work. We thus designed a one-day course aiming to improve these students' preparedness and anxiety levels. Methods Pre-course material was provided to the students with information on the skills that were going to be explored in the course. After an initial introduction, there was an interactive demonstration to refresh the students' knowledge on assessment of an unwell patient using the recognised ABCDE approach- Airway; Breathing; Circulation; Disability; Exposure . Thereafter, the students were split into 10 groups of 3 and 4 and rotated around 10 different stations. Each station was 40 minutes long and breaks were interspersed amongst the teaching to ensure that concentration was maintained. The emphasis was on near-peer teaching with guidance from a recently qualified doctor. Feedback was requested immediately post-course and three months afterwards. Results and Feedback The immediate feedback was very positive with the overall quality rated at 3.93/4. Regarding the 3 month feedback, there was an average reduction in anxiety levels by 18.3% (p<0.0001) and improvement in perceived preparedness levels by 24.7% (p<0.0001). All students agreed that the course will help them in preparing to become a foundation doctor and that similar courses should be offered to all final year students. Conclusions Practical courses focusing on preparedness can provide a unique opportunity for collaborative training by universities and foundation trusts. These courses are well evaluated and are perceived to improve anxiety and preparedness levels.

Discontinuation and non-publication of surgical randomised controlled trials: observational study.

OBJECTIVE: To determine the rate of early discontinuation and non-publication of randomised controlled trials involving patients undergoing surgery. DESIGN: Cross sectional observational study of registered and published trials. SETTING: Randomised controlled trials of interventions in patients undergoing a surgical procedure. DATA SOURCES: The ClinicalTrials.gov database was searched for interventional trials registered between January 2008 and December 2009 using the keyword "surgery". Recruitment status was extracted from the ClinicalTrials.gov database. A systematic search for studies published in peer reviewed journals was performed; if they were not found, results posted on the ClinicalTrials.gov results database were sought. Email queries were sent to trial investigators of discontinued and unpublished completed trials if no reason for the respective status was disclosed. MAIN OUTCOME MEASURES: Trial discontinuation before completion and non-publication after completion. Logistic regression was used to determine the effect of funding source on publication status, with adjustment for intervention type and trial size. RESULTS: Of 818 registered trials found using the keyword "surgery", 395 met the inclusion criteria. Of these, 21% (81/395) were discontinued early, most commonly owing to poor recruitment (44%, 36/81). The remaining 314 (79%) trials proceeded to completion, with a publication rate of 66% (208/314) at a median time of 4.9 (interquartile range 4.0-6.0) years from study completion to publication search. A further 6% (20/314) of studies presented results on ClinicalTrials.gov without a corresponding peer reviewed publication. Industry funding did not affect the rate of discontinuation (adjusted odds ratio 0.91, 95% confidence interval 0.54 to 1.55) but was associated with a lower odds of publication for completed trials (0.43, 0.26 to 0.72). Investigators' email addresses for trials with an uncertain fate were identified for 71.4% (10/14) of discontinued trials and 83% (101/122) of unpublished studies. Only 43% (6/14) and 20% (25/122) replies were received. Email responses for completed trials indicated 11 trials in press, five published studies (four in non-indexed peer reviewed journals), and nine trials remaining unpublished. CONCLUSIONS: One in five surgical randomised controlled trials are discontinued early, one in three completed trials remain unpublished, and investigators of unpublished studies are frequently not contactable. This represents a waste of research resources and raises ethical concerns regarding hidden clinical data and futile participation by patients with its attendant risks. To promote future efficiency and transparency, changes are proposed to research governance frameworks to overcome these concerns.

Enterobiasis-related inflammatory caecal polyp masquerading as a malignancy.

A 55 -year-old Asian man was seen in the emergency department with bleeding per rectum. He was a teetotaller and had no previous abdominal surgery. He did, however, report a change in bowel habit towards constipation. He underwent colonoscopy which revealed a lesion, highly suspicious of malignancy, in the caecum. On review by two consultants, a decision to completely resect this lesion was made. Histological analysis of the polypoidal growth showed it to be a consequence of chronic infection with the helminth Enterobius vermicularis. Importantly, there was no evidence of dysplastic or malignant cells. The patient was subsequently discharged with a 3-day course of antihelminthic mebendazole and reassured that his per rectal bleeding was most likely due to haemorrhoids discovered at rectal examination.