Current practice in the United Kingdom for the use of diagnostic laparoscopy in suspected acute appendicitis.

OBJECTIVE: Diagnostic laparoscopy is advocated in the management of patients with acute right iliac fossa pain. We asked consultant surgeons in the UK about their current use of this technique. METHOD: A short anonymous questionnaire was sent to consultant surgeons from the ASGBI database. Information was sought on general surgical specialty, participation in the emergency surgical on-call rota, current practice regarding the use of diagnostic laparoscopy in patients with suspected acute appendicitis and on the management of an inflamed or noninflamed appendix. Statistical analysis was by means of chi(2) test. RESULTS: There were 161 eligible returns from 250 questionnaires (64%) and the proportion of consultants replying from each subspecialty was similar to membership numbers of subspecialty organizations. Most consultants (68%) performed diagnostic laparoscopy in patients with suspected acute appendicitis. The majority (69%) reserved its use for women of reproductive age and 14% of respondents laparoscoped all patients with suspected appendicitis. Compared to nongastrointestinal (GI), GI surgeons were significantly more likely to perform diagnostic laparoscopy (75 vs 52%, P = 0.008). In the case of an overtly inflamed appendix, 81% of respondents would remove it laparoscopically with significantly more GI surgeons following this course than nonGI surgeons (P = 0.04). CONCLUSION: Despite good evidence on the benefits of diagnostic laparoscopy in certain patients with suspected acute appendicitis, there is significant variation in its use. This difference appears to be based upon subspecialty and may be as a result of increasing subspecialization.

Day-case stoma surgery: is it feasible?

INTRODUCTION: The National Health Service (NHS) Modernisation Agency has identified ten high impact changes for health organisations to adopt in order to improve their service. Top of this list is increasing day-surgery rates. The basket of interventions offered as short-stay procedures will have to increase to achieve this target. The aim of this study was to investigate whether it is feasible to offer fashioning or reversal of loop stomas as a short-stay procedure. METHODS: Consecutive patients needing stoma fashioning or reversal were offered surgery as a day-case. All were recruited from a single colorectal consultant's caseload. Patients scheduled for stoma formation were taught how to manage the stoma by a specialist nurse prior to hospital admission. The stoma nurse then visited all patients at home one day after discharge. Laparoscopic-assisted techniques, opiate avoidance and early mobilisation were included in the management protocol. Data relating to patient demographics, length of stay and complications were collected prospectively. Results of continuous variables were presented as median and interquartile ranges (IQRs). RESULTS: All patients offered day-surgery accepted it readily. A total of twelve patients (M:F, 5:7) with a median (IQR) age of 70 (63-74) years were recruited. Seven had laparoscopically assisted loop ileostomy formation while five underwent loop stoma reversal (four loop ileostomies, one transverse colostomy). Four out of twelve patients were discharged the same day and 11/12 patients were home within 23 hours of admission. One patient needed admission for 72 hours for social reasons. None of the patients required readmission, and there were no observed complications associated with early discharge. CONCLUSIONS: With the appropriate supportive set up, 23-hour stoma surgery is indeed feasible. Day-case procedures are possible in some, however, as with all short-stay surgery, careful patient selection is required.

Dukes' staging is poorly understood by doctors managing colorectal cancer.

OBJECTIVE: This study set out to investigate the current understanding of Dukes' staging for colorectal cancer. DESIGN: A questionnaire was distributed to surgeons and general practitioners attending colorectal meetings asking for a definition of Dukes' stages A, B and C. Results were analysed blind by two authors jointly to assess accuracy as correct, within definition, or incorrect. Within definition was defined as a description fitting within but not covering all tumours within that stage. RESULTS: 128 answers were received from 48 GPs, 7 final year medical students, 38 house officers and SHOs, 19 higher surgical trainees and 16 consultants. Overall, 3.9% defined all three stages correctly and 13.3% got all three definitions incorrect. Correct stages were Dukes' A 7.8%, Dukes' B 16.4% and Dukes' C 29.7%. Two consultants (12.5%) achieved three correct definitions, as did two HSTs (10.5%). No GPs had all three stages correct and 10 (20.8%) were wrong in all three. If those said to be within definition were considered right, 35.1% were correct for all three stages with 76.6% getting Dukes' A correct, 46.9% Dukes' B and 56.6% Dukes' C. CONCLUSIONS: Dukes' staging is, therefore, still poorly understood by doctors managing patients with colorectal cancer. The introduction of proformas will reduce the reliability upon memory for this and more complex staging classifications.

Laparoscopic management of pseudoachalasia, esophageal diverticulum, and benign esophageal stromal tumor.

A case report is presented of a 59-year-old woman who was suspected of having a paraesophageal hernia, but at operation was found to have an epiphrenic diverticulum of the esophagus, a benign stromal tumor of the esophagus, and pseudoachalasia. The stromal tumor was resected laparoscopically together with a laparoscopic Heller's myotomy and partial posterior fundoplication.

Surgical management of polypoid lesions of the gallbladder.

BACKGROUND: With improvements in ultrasonography more polypoid lesions of the gallbladder (PLGs) are being detected. The management of these is controversial. METHODS: The demographic, radiological and pathological data of 38 patients with ultrasonographically detected PLGs were reviewed. A Medline search for such lesions was performed and a review of the literature is presented. RESULTS: Thirty-four patients underwent cholecystectomy and four were advised against or declined operation. Of the 34 who had cholecystectomy, 11 had macroscopic and histopathologically proven PLGs. Of these, seven had cholesterol polyps, two had adenomas, one had a carcinoid tumour and one had an adenocarcinoma of the gallbladder. One patient had a histopathologically normal gallbladder. The remainder had chronic cholecystitis with or without gallstones. All of the patients with neoplastic lesions of the gallbladder had solitary polyps greater than 1.0 cm in diameter. CONCLUSION: A protocol for the management of ultrasonographically detected PLGs is proposed. In this protocol it is suggested that patients with a PLG should undergo surgery if they are symptomatic, or if the PLG is 1.0 cm or more in diameter.

Early colorectal cancer: recognition, classification and treatment.

BACKGROUND: With the introduction of colorectal cancer screening and improvements in endoscopic technology, the recognition and management of early colorectal cancer assumes increasing importance. METHODS: A literature review was undertaken using Medline (National Library of Medicine, Washington DC, USA) searches of the headings early colonic, colorectal and rectal cancer, carcinoma and adenocarcinoma up to and including 1997. All relevant references were examined. RESULTS AND CONCLUSION: The diagnosis, classification and treatment options are described. Accurate diagnosis, preoperative and histopathological staging is crucial in the management of early colorectal cancer.

How many lymph nodes to stage colorectal carcinoma?

This study aimed to establish the number of cassettes that should be filled with lymph nodes to stage a colorectal carcinoma as Dukes's stage C. The records from the Oxford Colorectal Cancer database of all patients diagnosed with Dukes's stage C cancer from late 1988 to early 1993 were reviewed. Each slide of lymph nodes was examined to determine how many slides needed to be looked at to find the first positive lymph node. The resected specimens were not fat cleared but dissected manually in a routine fashion. One hundred and eight slides were retrieved. The mean total lymph node harvest was 8.44 for each patient. Ninety eight patients (90.7%) had positive lymph nodes on the first slide with an average of 3.42 lymph nodes on each slide, of which a mean of 1.82 were positive. For nine patients, two slides were required to make a diagnosis of lymph node involvement, and for one patient the first three slides needed inspection to establish Dukes's stage C. In conclusion, using a routine technique to obtain lymph nodes from colorectal cancer specimens 99% of Dukes's stage C colorectal carcinoma can be found by filling two cassettes with lymph nodes.