Charles Hendrickse

Appendicitis in children: a comparative study between a specialist paediatric centre and a district general hospital

PURPOSE The study aimed to compare paediatric appendicectomy practice in a specialist paediatric centre (SPC) with a district general hospital (DGH). METHODS This was a retrospective study of children younger than 16 years treated between January 1, 2005, and September 30, 2007. RESULTS Two hundred seven patients (SPC) and 264 (DGH) had an operation for suspected appendicitis. Thirty-one percent of SPC patients were female vs 41% in the DGH (P = .03). Median age (range) was 10.3 years (1.2-15.9 years) in the SPC and 11.8 (3.3-16.0 years) in the DGH (P < or = .0001). The negative appendicectomy rate was 4% at the SPC and 20% at the DGH (P < or = .0001). Perforated appendicitis was found in 37% of children at the SPC compared with only 18% at the DGH (P < or = .0001). Median (range) length of stay was 5 days at the SPC (1-21 days) compared with 2 days at the DGH (1-21 days) (P < or = .0001). CONCLUSION Our findings have important implications for local practice in our 2 centres but may also have wider implications for the national organisation of the surgical care of children and for the training of general surgeons.

Engaging with Faith Councils to Develop Stoma-specific Fatawās: A Novel Approach to the Healthcare Needs of Muslim Colorectal Patients.

Intestinal stomas are common. Muslims report significantly lower quality of life following stoma surgery compared to non-Muslims. A fatwā is a ruling on a point of Islamic law according to a recognised religious authority. The use of fatawās to guide health-related decision-making has becoming an increasingly popular practice amongst Muslims, regardless of geographic location. This project aimed to improve the quality of life of Muslim ostomates by addressing faith-specific stoma concerns. Through close collaboration with Muslim ostomates, a series of 10 faith-related questions were generated, which were posed to invited local faith leaders during a stoma educational event. Faith leaders received education concerning the realities of stoma care before generating their fatawās. The event lead to the formulation of a series of stoma-specific fatawās representing Hanafi and Salafi scholarship, providing faith-based guidance for Muslim ostomates and their carers. Enhanced communication between healthcare providers and Islamic faith leaders allows for the delivery of informed fatawās that directly benefit Muslim patients and may represent an efficient method of improving health outcomes in this faith group.

Cloacogenic polyps in an adolescent: a rare cause of rectal bleeding.

Cloacogenic polyps are rare inflammatory lesions occurring around the anal transitional zone and in the lower rectum which can mimic neoplasia. They should be given diagnostic consideration in patients presenting with symptoms of rectal bleeding, tenesmus, and altered bowel habits.

Trends in whole colonic imaging

In our experience, the change in imaging modality is purely due to a change in hospital physician requesting, as general practitioners ’ referral patterns have not changed over the past 7 years. In our unit in 2009, general practitioners accounted for only 4.6% (26/561) of CTC referrals, but 39% (126/326) of DCBE referrals ( P 0.0001). Although the survey did not specifi cally address this, we would expect that a similar pattern would be observed in Sweden. It will take time for community practitioners to learn of the availability and advantages of CTC, and hospital doctors should do more to educate their colleagues in primary care. Although DCBE continues to be performed routinely, its end appears to be in sight.

Extended Abdominoperineal Resection Is Oncologically Advantageous and when Undertaken in the Prone Position Offers an Optimal Position for Bilateral Inferior Gluteal Artery Perforator Reconstruction

We agree with Peter B Arnold and colleagues that primary losure of the perineal defect after abdominoperineal resecion (APR) is enhanced by bilateral inferior gluteal artery erforator (BIGAP) fasciocutaneous flaps. However, we isagree that the patient should be operated on in a ynchronous-combined manner and advocate that an exended APR should be undertaken in the prone position or patients with low rectal cancer. Conventional APR is associated with a high incidence f circumferential resection margin (CRM) involveent, with rates up to 40%. The CRM involvement in conventional APR specimens is thought to be related to removal of inadequate tissue volumes at the level of the tumor, as the mesorectum narrows to a bare muscle tube at the level of the anal sphincter complex. In 2005, Marr and associates examined local recurrence and patient survival after APR and anterior resection for rectal cancer. They analyzed 561 patients and found that patients undergoing APR had a higher local recurrence (22.3% vs 13.5%) and a lower 5-year survival (52.3% vs 65.8%). They noted that the total volume of surgically removed tissue outside the muscularis propria was less in the APR specimens and advocated a more radical approach to the surgical management of low rectal cancers. In 2007, Holm and coworkers from the Karolinska Institute in Stockholm reported a low risk of bowel perforation, CRM involvement, and perineal wound complications when implementing extended APR with flap reconstruction of the perineal defect. In this case series, the

Neutrophil Extracellular Trap Production in Patients with Colorectal Cancer In Vitro

Purpose Neutrophil Extracellular Traps (NETs) are extracellular neutrophil derived DNA webs which have been implicated in cancer progression and in the development of metastases. NETs production in patients with colorectal cancer was investigated to elucidate their role and prognostic significance. Methods Systemic neutrophils were isolated from consecutive patients with colorectal cancer and from age-matched healthy volunteers. Neutrophils were stimulated to produce NETs which were quantified by a measure of the fluorescence of the extracellular DNA. The impact of cancer location, tumour stage, and patient outcomes (complications, length of stay, and mortality) on NET production was investigated. Results Quantification of NET formation was performed in patients with colorectal cancer (n = 45) and in well-matched healthy individuals (n = 20). Significant increases in NETs production in response to no stimulant (9,735 AFU versus 11347 AFU, p = 0.0209), IL-8 (8,644 AFU versus 11,915 AFU, p = 0.0032), and LPS (10,576 AFU versus 12,473 AFU, p = 0.0428) were identified in patients with colorectal cancer. A significant increase in NETs production in response to fMLP was detected in patients who developed significant postoperative complications (11,760 AFU versus 18,340 AFU, p = 0.0242) and who had a prolonged hospital recovery (9,008 AFU versus 12,530 AFU, p = 0.0476). An increase in NETs production was also observed in patients who died, but this did not reach statistical significance. Cancer location and tumour stage did not appear to affect preoperative NETs production. Conclusions Patients with colorectal cancer have significantly increased NETs production in vitro when compared to healthy volunteers, possibly implicating them in cancer development. Adverse patient outcomes were associated with increased preoperative NETs production, which highlights them as potential therapeutic targets.

Internal Pudendal Artery Perforator Island Flap for Management of Recurrent Benign Rectovaginal Fistula.

Summary: The management of recurrent rectovaginal fistula after obstetric injury and cryptoglandular sepsis is considered a major surgical challenge. The fistula poses a significant negative psychosocial and sexual morbidity. In addition, the poor quality of local tissues due to previous attempts at surgical repair adds to this challenge. There are few data regarding the management of persistent or recurrent fistula in the literature; however, several studies reported high failure rates after 2 or more procedures. We present 4 cases managed successfully in a multidisciplinary approach involving fistulectomy and immediate reconstruction with an internal pudendal artery perforator island flap.

Heterogeneity in practice during negative scrotal exploration for clinically-suspected testicular torsion

Diagnostic uncertainty, inadequate training and inexperience could lead to surgeons performing unnecessary orchidopexy during negative scrotal exploration for suspected testicular torsion. In the present study, we aimed to examine current practice, in order to highlight areas for improvement and focused guideline recommendations.