Anwar E Owais

Review article: permissive underfeeding in short-term nutritional support.

Aliment Pharmacol Ther 2010; 32: 628–636

Whose appendicectomy?--Do laparoscopic appendicectomies impair SHO training?

INTRODUCTION Open appendicectomy is an ideal procedure for junior surgical trainees to develop operative skills. However, in recent years, we have noticed a decline in the number of appendicectomies performed by basic surgical trainees and a shift towards increasing use of laparoscopic appendicectomy. The aim of this study was to determine whether the growing popularity of laparoscopic appendicectomy is having a detrimental impact on the training experience of SHOs. PATIENTS AND METHODS We undertook a retrospective review of all cases of appendicectomies performed in one district hospital over a 7-year period (August 1999 to August 2006.) A standard performa was used to extract data from the original case notes of these patients relating to the operating surgeon and technique. RESULTS Data were obtained for 857 appendicectomies. Between February 2002 and July 2003, there was a significant decline in the proportion of appendicectomies performed by SHOs from 78.7% to 29.3% (P < 0.001). Either side of this decline there were no significant changes in the proportion of SHO appendicectomies. The number of appendicectomies performed laparoscopically only began to rise after February 2004, with a year-on-year increase. The number of appendicectomies performed by SHOs remained stable during this time. No laparoscopic appendicectomy was performed by an SHO. CONCLUSIONS We found no evidence that the popularisation of laparoscopic appendicectomy has contributed to the decline of appendicectomies performed by SHOs. Nevertheless, with the continual rise in popularity of this procedure, it is important to balance training opportunities for both junior and higher surgical trainees.

Could pre-mortem computerised tomography scans reduce the need for coroner's post-mortem examinations?

INTRODUCTION Post-mortem examinations may result in considerable distress to the bereaved family. This audit was undertaken to examine whether computerised tomography (CT) scanning prior to death might reduce the need for post-mortems without compromising the accuracy of recording the cause of death. SUBJECTS AND METHODS The case notes of 100 consecutive patients who had a coroners post-mortem, because the cause of death was unknown, were reviewed by four senior clinicians. Along with the likely cause of death, the clinicians gave their opinion as to whether a CT scan would have enabled certification of death without the need for a post-mortem. Concordance between the post-mortem findings and the clinical events surrounding death was explored. RESULTS It would have been possible to perform a pre-mortem CT scan on 90 of the 100 patients. A pre-mortem CT scan would have given the cause of death in 59 (66%) of these. In 30 patients, the cause of death established by the post-mortem was at variance with the clinical events surrounding death and clinically relevant information, such as recent surgery, was not recorded on the death certificates of 26 patients. CONCLUSIONS The use of a pre-mortem CT scan and involvement of senior clinicians in the process of establishing cause of death will improve the accuracy and may obviate the need for a post-mortem in some patients. However, if a post-mortem is needed, the clinical notes should always be available for the pathologists and a senior member of the patients team should attend the post-mortem to help accurate death certification.

Aortoduodenal fistula and streptococcal myonecrosis.

Pyomyositis is a rare primary bacterial infection of the skeletal muscles. Pyomyonecrosis is the most severe manifestation of this disease and is associated with a potentially devastating outcome. Patients with peripheral vascular disease presenting with pyomyositis may be difficult to distinguish from those with critical ischemia or synthetic graft sepsis. This article reports on a patient with aortobifemoral bypass graft and severe vitamin B12 deficiency who developed pyomyonecrosis and aortoduodenal fistula. This article highlights the etiologic dilemma, diagnostic difficulties, and management challenges inherent in such cases. Pitfalls in our management of this patient are discussed.

Authors's Response 1.

We agree with Laughlan and colleagues that the proportion of laparoscopic appendicectomies performed in our district general hospital is considerably less than those performed in a teaching hospital, and that this could explain why our study did not demonstrate the reduction in SHO operative experience we expected to find. Nevertheless, we believe that our data are likely to reflect the situation in many district general hospitals, with the change in working patterns having a far greater influence on SHO training experiences over the last 10 years. Despite this, the data provided by Laughlan and co-workers suggest that the further popularisation of laparoscopic appendicectomy is likely to contribute to the depletion of SHO training opportunities. This serves to highlight the pressing need to re-examine the way in which junior surgeons are trained.

Authors' Response 3

The suggestion by Khan and colleagues that senior trainees should be formally required to train juniors as part of their own training requirements is an interesting one. This would certainly help to balance the training opportunities between junior and senior trainees, but more detail would be required as to how this would work in practice. With the increasing pressures placed on junior trainees by hospital-at-night, we believe that ring-fenced training opportunities should be identified. Moreover, there should be a formal recognition of contractual time for consultants to train junior surgeons. These aims could be addressed by having dedicated training lists for juniors on a weekly basis.