Defunctioning stomas in patients with locally advanced rectal cancer prior to preoperative chemoradiotherapy.

OBJECTIVE: A literature search did not produce any evidence-based objective criteria to determine which patients with locally advanced rectal cancer would benefit from a defunctioning stoma prior to neoadjuvant chemoradiotherapy. Our criteria for formation of a defunctioning stoma are: faecal incontinence and inability to cannulate the tumour at colonoscopy. The aim of this study was to examine whether these current criteria are appropriate. METHOD: Forty-nine consecutive locally advanced rectal cancer patients treated from February 2003 to November 2006 were identified from our colorectal database. All received long-course chemoradiotherapy (Bossett regimen) and definitive surgery was performed 6-8 weeks later. RESULTS: Of the 49 patients, 31 presented with diarrhoea and two with faecal incontinence; nine patients were defunctioned by trephine stoma prior to treatment [cannulation impossible at colonoscopy (n = 8); faecal incontinence (n = 1)]. One patient with faecal incontinence refused early defunctioning stoma. Median hospital stay was 12 days (interquartile range: 7-30), and complications included pneumonia (n = 1) and peristomal cellulitis (n = 2). Of the 40 patients who went directly to neoadjuvant chemoradiotherapy, two subsequently required a defunctioning stoma for severe diarrhoeal symptoms during therapy. Eight patients had worsening diarrhoeal symptoms but tolerated treatment. Three patients, who had stoma formation, did not proceed to definitive surgery following neoadjuvant therapy: poor operative fitness (n = 2) and disease progression (n = 1). CONCLUSION: Stenosis causing inability to cannulate the tumour at colonoscopy and faecal incontinence were the only objective indications for an early defunctioning stoma. Worsening diarrhoea during therapy (unless severe) did not appear to be a good indication for a defunctioning stoma.

A preliminary evaluation of an innovative synthetic soft tissue simulation module ('Skilltray') for use in basic surgical skills workshops.

The results of a preliminary evaluation comparing the relative merits of biological (freshly-prepared animal offal tissue) and synthetic (Skilltray) simulation modalities are presented, subsequent to their use during two basic surgical skills courses organised by The Royal College of Surgeons of England and The Royal College of Physicians and Surgeons of Glasgow in September 1995, and at which 18 SHO grade surgical trainees attended. Each trainee completed a questionnaire at the end of the first session on the second day of the course to assist the evaluation. Our conclusions were as follows: 1. The synthetic tissues evaluated provided a useful and functionally reproducible means for learning the basic exercises included in the mandatory skills course. 2. Freshly-prepared animal tissues undoubtedly provided a more "realistic' medium for rehearsing the basic surgical techniques taught. Trainees preferred to use the synthetic tissues initially and then to progress to the fresh equivalents subsequently. 3. The Skilltray provided all the requisite elements for rehearsing basic tissue handling, suturing, and anastomotic techniques in a self-contained, easily transportable module. We would suggest that such a unit be given to each participant to take away at the end of the basic skills course, to enable consolidation of the skills learned. 4. Where the use of fresh tissues is not possible the highly functional nature of the synthetic simulators evaluated make it acceptable then to use them as the only training modality.

Early outcome after open versus extraperitoneal endoscopic tension-free hernioplasty: a randomized clinical trial.

BACKGROUND: The use of minimal access surgery for repair of groin hernias is controversial. The aim of this study was to compare endoscopic tension-free hernia repair with open tension-free hernia repair within a randomized clinical trial. METHODS: One hundred twenty patients were randomized by four surgeons during a 1-year period. Early outcome measures were then analyzed by intention to treat. RESULTS: Median postoperative pain scores (63 [interquartile range (IQR), 23 to 81] versus 35 [IQR, 17 to 62]; p = 0.004) and analgesia requirements (2.5 [IQR, 2 to 4] doses verus 2.0 [IQR, 1 to 3] doses; p = 0.0008) were significantly less for patients undergoing endoscopic hernia repair. Hospital stay (1 [IQR, 0 to 1] day versus 2 [IQR, 1 to 2] days; p < 0.0001) was also significantly reduced for the endoscopic group. Wound complications occurred significantly more frequently in the open group. No difference in pulmonary function or metabolic response to trauma (interleukin-6, C-reactive protein, glucose, albumin) was observed between the groups. CONCLUSIONS: This study shows significant short-term advantages for endoscopic tension-free repair over open tension-free repair. However, larger studies with a longer follow-up period are required to establish the relative merits of both procedures in the management of patients with groin hernias.

Symptomatic outcome 1 year after laparoscopic and minilaparotomy cholecystectomy: a randomized trial.

In a randomized controlled trial, 299 patients were sent a symptoms questionnaire 1 year after laparoscopic (n = 151) or minilaparotomy (n = 148) cholecystectomy for symptomatic cholelithiasis. The response rate to the questionnaire from contactable patients was 86 per cent. In both groups, at least 90 per cent of patients reported that their symptoms were improved, and at least 93 per cent rated the success of their operation as 'excellent', 'good', or 'fair'. However, over half the patients reported abdominal pain, a quarter reported flatulence, and a quarter dyspepsia. The only difference between treatment groups was that a higher proportion of patients who underwent minilaparotomy reported heartburn (35 per cent versus 19 per cent, P = 0.005). Patients who reported a 'poor' outcome were more likely to have suffered a postoperative complication, had lower quality of life scores, and higher anxiety and depression scores. Both laparoscopic and minilaparotomy cholecystectomy result in symptomatic benefit in at least 90 per cent of patients with symptomatic cholelithiasis.

Videoproctography in selecting patients with constipation for colectomy.

The results of colectomy for constipation based only on evidence of delayed colonic markers have been disappointing. The operation may fail because these patients are unable to evacuate the rectum owing to outlet obstruction. In the present study, we have used a combination of videoproctography and transit marker studies in an attempt to predict patients who will have a favorable outcome after colectomy by excluding patients with outlet obstruction. Videoproctography was performed in 228 patients referred for consideration of surgery for constipation. Only 111 (38 percent) had a normal proctogram with complete evacuation of liquid barium. Of these 111 patients, 21 (19 percent) had delayed colonic marker studies. Colectomy and ileorectal anastomosis were performed in 18 of these 21 patients; two years later, 16 were symptom free, with a median daily bowel frequency of four (range, two to six). The remaining two patients failed to respond to surgery. These data suggest that true idiopathic, slow-transit constipation is uncommon, but, when identified on the basis of delayed markers and the ability to expel liquid on proctography, an excellent result can be anticipated from colectomy and ileorectal anastomosis.

Alcohol injection: a treatment for ruptured hepatocellular carcinoma.

Nine patients with bleeding from a ruptured hepatocellular carcinoma had absolute alcohol injection. Laparotomy and alcohol injection stopped the bleeding in seven patients. Injection under laparoscopic visualization was attempted in two patients and in one patient haemostatis was achieved initially. He rebled, however, 4 h later and laparotomy failed to control the bleeding. He died 2 days later because of coagulopathy and renal failure. In the second patient, bleeding was not controlled laparoscopically and immediate laparotomy and alcohol injection stopped the bleeding. The eight patients who survived left hospital between 8 and 21 days after surgery (median 10 days). In our experience, laparotomy and alcohol injection achieved good results in bleeding hepatocellular carcinoma.

Pancreatic and biliary pressure changes during ERCP.

Injection of contrast is a prerequisite for endoscopic retrograde cholangiopancreatography. Such injection into the biliary and pancreatic duct systems may require considerable force. This paper reports the changes in pressure that result within the duct systems and highlights the significant pressure rise that occurs within the pancreatic duct.

Clinical application of the cholecystokinin provocation test.

This paper reviews the value of administration of cholecystokinin (CCK) in the assessment of patients thought to have acalculous biliary pain. The literature contains conflicting reports and there is no unequivocal evidence to support the use of CCK provocation tests as a basis for deciding the need for cholecystectomy.

A double blind randomised placebo controlled trial of hexopal in primary Raynaud's disease.

The peripheral vasospastic symptoms associated with Raynaud's disease continue to be an unsolved clinical problem. Hexopal (Hexanicotinate inositol) has shown promise in uncontrolled studies and its use in patients with Raynaud's disease may reduce such vasospasm. This study examines the effects of 4 g/day of Hexopal or placebo, during cold weather, in 23 patients with primary Raynaud's disease. The Hexopal group felt subjectively better and had demonstrably shorter and fewer attacks of vasospasm during the trial period. Serum biochemistry and rheology was not significantly different between the two groups. Although the mechanism of action remains unclear Hexopal is safe and is effective in reducing the vasospasm of primary Raynaud's disease during the winter months.

Using word processor text files as an active bibliography.

Data base systems for microcomputers are generally available. Most are reasonable priced and easy to use. Their disadvantages are restrictions placed on the amount of data stored in a single field, and the output format--usually tabular or label in style. This article describes the use of word processor text files as a data base allowing search and retrieval, with special reference to abstracting and storage of literature citations. Size of text entry and ultimate output format are extremely flexible using this method.

Blood transfusion and survival following nephrectomy for carcinoma of kidney.

Blood transfusion has been reported adversely to affect survival following surgery for a number of malignancies. We have examined retrospectively the records of 126 patients undergoing nephrectomy for renal carcinoma and established that 80 (63%) were transfused. Comparison of the two groups of patients, after controlling for differences in age, sex, tumour stage and haemoglobin level, showed that the transfused patients did not necessarily have poorer survival. In this study, peri-operative transfusion did not appear to have an adverse effect on long-term survival following surgery for renal cancer.