G. M. Tierney

E-learning vs lecture: which is the best approach to surgical teaching?

Aim  Most medical teaching is still delivered by traditional face‐to‐face interaction. E‐learning has the potential benefit of instilling deeper learning of topics by virtue of repeated and convenient access to content presented in a range of media. We aimed to evaluate objectively the benefit of educating medical students on a common surgical topic (haemorrhoids), through a website and podcast package vs a traditional lecture.

V-Y advancement flap for treatment of fistula-in-ano

AbstractPURPOSE: The management of high fistula-in-ano presents a difficult surgical challenge. Laying open of high transsphincteric, intersphincteric, and suprasphincteric fistulas is associated with incontinence. Mucosal advancement flap can be technically difficult and is associated with ectropion and incontinence. We report a new technique for the treatment of fistulas, which may eliminate these problems. PATIENTS AND METHODS: Between 1997 and 2002, 18 patients (13 males), median age 46 (range, 25–64) years with high fistula-in-ano were treated. There were ten transsphincteric, four intersphincteric, and four suprasphincteric fistulas. In all patients, perianal sepsis was allowed to resolve completely with a drainage seton before definitive surgery. The surgical technique used involved core fistulectomy, curettage of any cavity, closure of the defect in the internal anal sphincter, and a V-Y advancement buttock flap to cover the internal opening, leaving the site of the external opening for drainage while preserving both internal and external sphincters. Outcome was assessed in terms of healing and continence. RESULTS: Most patients were discharged from the hospital within 48 hours. Median follow-up was 19 (range, 3–60) months. There were three patients who failed to heal. Of these, two underwent repeat surgery and healed. Two further patients had recurrent fistulas, both of whom continued with conservative treatment. Overall, 15 of 18 (83 percent) patients experienced healing of their fistula. Continence was preserved in all patients. CONCLUSION: This procedure is easy to perform, healing is rapid, and it appears to be effective in curing fistula-in-ano while preserving both external and internal anal sphincters.

‘Be Clear on Cancer’: the impact of the UK National Bowel Cancer Awareness Campaign

The National Bowel Cancer Awareness Campaign (‘Be Clear on Cancer’) was launched by the UK government in January 2012, encouraging people with bowel symptoms to present to primary care. Our aim was to evaluate the impact of the campaign on colorectal services in secondary care.

Osseous metaplasia in an ulcerating tubular adenoma of the colon: a case report

IntroductionHeterotopic bone is rarely found in the gastrointestinal tract. Here we report a rare case of metaplastic ossification within a benign ulcerating adenoma and review the literature concerning the aetiology.Case presentationA 63-year-old woman, who presented with a history of melaena, was found at colonoscopy to have a pedunculated ulcerating polyp. Histological examination demonstrated multiple areas of osseous metaplasia within the polyp stroma.ConclusionHeterotopic ossification in colonic adenomas is a particularly rare phenomenon, with the majority of cases occurring within malignant lesions. The suggested mechanisms for its aetiology still remain unclear.

Large bowel obstruction and perforation secondary to endometriosis complicated by a ventriculoperitoneal shunt

A 36‐year‐old lady, with a past medical history of hydrocephalus requiring a ventriculoperitoneal (VP) shunt, was admitted with symptoms and signs of large bowel obstruction. Her condition worsened and she underwent laparotomy, where she had faecal peritonitis secondary to a perforated sigmoid colon. The shunt was contaminated with faeces leading to postoperative shunt infection and meningitis. Histology of the resected sigmoid colon revealed endometriosis at the site of perforation. Endometriosis is a rare cause of large bowel obstruction and literature review has found only two other cases of perforation because of endometriosis not associated with pregnancy. No case has been reported involving the concurrent surgical management of a contaminated VP shunt. We discuss the rarity of large bowel perforation and obstruction because of endometriosis, and the complications and management of VP shunts.

Day-case closure of ileostomy: feasible, safe and efficient

Over 5000 loop ileostomy closures were performed in the UK in 2013 with a median inpatient stay of 5 days. Previously we have successfully implemented a 23‐h protocol for loop ileostomy closure which was modified for same‐day discharge. We present our early experience of day‐case loop ileostomy closure.

Nicorandil‐induced foreskin ulceration

A 75-year-old gentleman presented to the colorectal clinic with perianal irritation and rectal discharge. He is known to be an arteriopath and was prescribed Aspirin, Nicorandil, Ramipril and Atorvastatin. Recently the cardiologist had altered his antianginal medication to treat episodes of early morning angina. An examination under anaesthesia (EUA) performed to find the cause of his symptoms revealed a perianal fistula, which was treated surgically by laying it open. Two weeks post treatment he represented to the ward with perianal pain and bleeding per rectum. On examining his perineum, a large perianal ulcer was discovered. Biopsy of the ulcer reported acute inflammation, appearance of granulation tissue with no evidence of neoplasia. Interestingly he also had developed an ulcer on his foreskin (Fig. 1). Syphilis was ruled out by confirming both a negative, microscopy and serum venereal disease research laboratory test (VDRL). The patient had been taking Nicorandil for a long period previous to the presentation of the ulcers. However, his recent change in medications to control his episodes of angina included an increase in the dose of Nicorandil. Since all the previous investigations had been negative, an association of the ulceration was made with escalation in the dose of Nicorandil. With the advice of the cardiologist we cautiously stopped his Nicorandil and replaced it with an alternative antianginal to prevent further episodes of angina. After 12 weeks, this resulted in complete resolution of both the perianal and foreskin ulcer.

Referral of patients with iron deficiency anaemia under the lower gastrointestinal two‐week wait rule

Objective  One of the 2‐week wait (2WW) criteria for suspected lower gastrointestinal cancer states that patients should be referred who have iron deficiency anaemia (IDA) without obvious cause [Haemoglobin (Hb) <11 g/dl men, <10 g/dl postmenopausal women].

Evaluation of teaching methods for students on hernias: an observational study.

Teaching may be delivered through different media in different settings. We aimed to evaluate four teaching modalities for medical students on a common surgical topic. We compared learning, student preferences and experiences as outcome measures.

Diagnostic yield and economic implications of endoscopic colonic biopsies in patients with chronic diarrhoea

Aims  Random colonic biopsies are recommended to exclude microscopic colitis in patients with chronic diarrhoea especially when mucosa is macroscopically normal at endoscopy. This study aimed to assess the clinical outcome and economic impact of such a policy in an unselected group of patients with macroscopically normal mucosa.