Angus Macdonald

Observational study of intra-abdominal pressure monitoring in acute pancreatitis

BACKGROUND Intra-abdominal hypertension (IAH) is predictive of adverse outcome in critically ill patients; however, its role in acute pancreatitis is unclear, and prospective studies are lacking. We aimed to determine the overall incidence and predictive value of IAH on mortality in acute pancreatitis. METHODS Transvesical IAP was measured on admission and every 4 hours within high-dependency unit/intensive care unit. Serum biochemistry and physiologic parameters permitted calculation of Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, Imrie, and Ranson scores. The primary end point was 30-day mortality. RESULTS A total of 218 patients with acute pancreatitis were recruited; 30-day mortality was greater in patients with IAH (IAP ≥12 mmHg; 37%) than no IAH (2%; P < .001). A total of 14% of patients had IAH on admission; another 3% developed IAH in hospital. Mortality was greater in the latter group (37% vs 50%; P < .01). In the majority of cases IAH developed in line with other organ failure; however, there were several patients in whom the development of IAH appeared to be the sentinel event before rapid clinical decline. An IAP threshold of 9 mmHg had best predictive value for mortality (sensitivity 86%, specificity 87%; area under the ROC curve 0.91). This finding was comparable with other validated markers of severe pancreatitis (Imrie ≥3: sensitivity 51%, specificity 70%; Acute Physiology and Chronic Health Evaluation II: sensitivity 67%, specificity 96%; C-reactive protein >150: sensitivity 89%, specificity 83%). CONCLUSION IAP is a good predictor of mortality and organ failure in acute pancreatitis and compares favorably with other validated prognostic scores. Whether IAH is a phenomenon causative of organ failure or an epiphenomenon, occurring in conjunction with other organ dysfunction, remains unclear.

What proportion of basic surgical trainees continue in a surgical career?: A survey of the factors which are important in influencing career decisions

INTRODUCTION Since the launch of Modernising Medical Careers, trainees are selected for a run-through training programme in a single surgical specialty. The surgical training bodies are currently considering the recommendations of the Tooke report as they review the policy for selection into surgical training in the UK. There is little information available on the factors involved in career choices amongst surgical trainees and this study aimed to address this issue. METHOD Trainees appointed to the Basic Surgical Training Programmes in the west and south-east of Scotland (1996-2006) were contacted by email and invited to participate in an online survey. RESULTS Of 467 trainees identified, valid email addresses were available for 299 of which 191 (64%) responded to the survey. One hundred and forty-nine (78%) trainees were still working in surgery but 38 (20%) had moved to a non-surgical specialty and 4 (2%) had left the medical profession. Of those who had obtained a NTN at the time of the survey (n = 138), 62 (45%) had a NTN in the specialty they chose at the start of the BST but 34 (25%) had changed to a different surgical specialty and 42 (30%) had left surgery altogether. For those still working in surgery, enjoyment of the specialty was the most important factor affecting career choice. Achieving an acceptable work/life balance was the most significant factor influencing trainees who left surgery. CONCLUSION The majority of trainees recruited to surgery at an early stage change specialty or leave surgery altogether. Both social and professional factors are important in career choices. The findings of this study support a period of core surgical training to provide flexibility prior to further training in a surgical specialty.

The Effect of Adjuvant Chemotherapy on Stoma-Related Complications After Surgery for Colorectal Cancer: A Retrospective Analysis.

PURPOSE: To assess stoma-related complications of colorectal cancer patients undergoing surgery with curative intent who received adjuvant chemotherapy compared to those who underwent surgery alone. DESIGN: A retrospective analysis of a prospectively maintained colorectal cancer clinical audit database was completed. SUBJECTS AND SETTINGS: Patients undergoing curative surgery for colorectal cancer with the formation of a stoma (end ileostomy, loop ileostomy, end colostomy) between 1999 and 2011 at a single hospital in Lanarkshire, United Kingdom. Patients who underwent neo-adjuvant chemotherapy were excluded. Two hundred twenty-two patients comprised the study sample; 130 (59%) were male. Seventy-five (34%) patients comprised the chemotherapy group and 147 (66%) made up the surgery-only group. Patients in the chemotherapy group were younger (61.6 vs 65.4 years; P = .001) and had higher stage colorectal cancer (P < .001). There was no difference in baseline (day 10) stoma scores between the chemotherapy or surgery-only groups. METHODS: Postoperative stoma-related complications were serially assessed using a stoma complication scoring tool; scores were calculated at 10 days and 3 months postoperatively. Scores of patients receiving adjuvant chemotherapy were compared to scores of participants who underwent surgery alone. INSTRUMENT: A composite stoma function score was calculated for each patient after assessment of stoma-related complications. The overall score included a global assessment of stoma quality (stoma retraction, prolapse, stenosis, parastomal hernia, skin changes) and patient-reported stoma function (leakage, soiling, nighttime emptying, odor). RESULTS: At 3 months, the mean loop ileostomy stoma function score was poorer among the chemotherapy group when compared to the surgery-only group (4.55 vs 1.53; P = .041). No differences were found when colostomy (2.00 vs 2.62; P = .411) or end ileostomy (1.00 vs 2.00; P = .170) function scores were compared at 3 months. CONCLUSION: Patients undergoing curative surgery for colorectal cancer resulting in a loop ileostomy who received adjuvant chemotherapy had higher stoma complication scores at 3 months compared to those who underwent surgery with no chemotherapy. This difference was not seen in patients with colostomies or end ileostomies. Patients, WOC nurses, and medical staff must be alert to the potential of increased loop ileostomy-related complications with adjuvant chemotherapy. Fully informed patient consent coupled with timely support and advice may reduce stoma-related morbidity and improve quality of life for such patients.

Neurovasculature of high and low tie ligation of the inferior mesenteric artery

PurposeControversy exists as to whether a high or low tie ligation of the inferior mesenteric artery (IMA) is the preferred technique in surgeries of the left colon and rectum. This study aims to contribute to the discussion as to which is the more beneficial technique by investigating the neurovasculature at each site.MethodsTen embalmed cadaveric donors underwent division of the inferior mesenteric artery at the level of the low tie. The artery was subsequently ligated at the root to render a section of tissue for histological analysis of the proximal (high tie), mid and distal (low tie) segments.ResultsGanglia observed in the proximal end of seven specimens in the sample imply that there would be disruption to the innervation in a high tie procedure.ConclusionThis study suggests that a high tie should be avoided if the low tie is oncologically viable.

Patient consent in the post-Montgomery era: A national multi-speciality prospective study

BACKGROUND The Montgomery ruling has had a wide-ranging impact on the consent process and has been the subject of new guidelines by bodies, including the Royal College of Surgeons (RCSEng). This is the first study to examine the current standard of consent for surgical procedures at a national level. METHOD A national collaborative research model was used, with prospective data collection performed across hospitals in Scotland. Variables associated with the consent process were audited across three surgical specialities (general surgery, urology and orthopaedics) and measured against standards set by RCSEng, the Scottish Public Services Ombudsman and medical defence organisations. RESULTS A total of 289 cases were identified from 12 hospitals. The majority of patients were reviewed by a consultant surgeon in clinic (79.9%) or on the day of surgery (55.4%). The clinic consent rate was 27.0%, while a copy of the documented discussion was only provided to 4.2% of patients. On the day of surgery, the benefits, risks and alternatives to the planned procedure were discussed in less than half of cases. This rate was similar across different clinician grades, while marked variation was seen across hospitals. CONCLUSION In this prospective multi-centre study we have demonstrated wide variation in the consent processes in many surgical specialities across Scotland. Following the Montgomery ruling, we have demonstrated the current consent process in elective surgery is likely to be substandard, and may require additional steps to be taken by clinicians to ensure patients are fully informed to make decisions regarding their treatment.

PTH-232 Retention of the ileocolic sphincter in a modified brooke ileostomy decreases the loss of key electrolytes in ileostomy fluid of patients who have undergone colectomy for ulcerative colitis

Introduction Previous published work has shown that modifying the traditional Brooke ileostomy (MBI) by retaining the ileocolic sphincter (ICS) preserves a functional high pressure zone which may improve the clinical function of the stoma. The effect of this modification (MBI) on ileal fluid biochemistry has not been reported previously by this group. This study reports the results of this modification on the electrolyte concentration in ileal fluid and also its influence on the reabsorption of urinary electrolytes by way of renal compensation. Method Ileostomy fluid specimens were collected from stoma bags in two groups of patients. Group 1 – ileocolic sphincter retained (MBI); controls – patients undergoing formation of a loop ileostomy (10 cm from the ileocolic junction) as part of an operation for rectal cancer. These samples were collected from patients and controls from stoma bags after an overnight fast. Additionally, 24hr urine collections were made from MBI patients and controls to measure the concentration of routine urinary electrolyes and, in addition, urinary magnesium and calcium. In order to compensate for the changes in urinary volume, which can be accounted for by varied water intake and different kidney efficiency, the urine results for each analyte measured were adjusted against the change in creatinine using a standard formula: adjusted concentration = mmol of analyte/mmol of urinary creatinine. Contemporaneously, routine serum electolytes were collected from patients and controls. This study was approved by the regional ethics committee and statistical analysis was performed using the Wilcoxon paired test where appropriate with p < 0.05 considered significant. Results 13 MBI patients (mean (SD) age - 52.5(17.8)yrs) were compared with 11 controls age −58.4 (10.9) yrs). Routine serum and urinary biochemistry (except sodium) in both groups was the same. Urinary sodium, calcium and magnesium were raised in patients with a modified Brooke Ileostomy (MBI), when compared to controls: urinary sodium, 8.2 ± 4.5 vs. 4.43 ± 2.19 mmols/mmol creatinine, p < 0.05, urinary calcium, 0.28 ± 0.15 vs. 0.15 ± 0.13 mmols/mmol creatinine, p < 0.03 and urinary magnesium, 0.21 ± 0.09 vs. 0.08 ± 0.04 mmols/mmol creatinine, p < 0.01. Electrolyte concentrations in ileal fluid in both patients (MBI and controls) was the same. Conclusion These results suggest that retention of the ICS in an ileostomy (MBI) has beneficial effects on the retention of ileal sodium, calcium and magnesium by virtue of the reduced reabsorption of these electrolytes from the MBI patients’ urine. Further work is required to confirm this initial finding. Disclosure of interest None Declared.