Iain J.D. McCallum

Management of faecal incontinence in adults

#### Summary pointsnnFaecal incontinence is the involuntary loss of stool or flatus. It is a distressing condition that can have a substantially negative effect on quality of life.1 2 According to a systematic review it may affect 11-15% of the population.3 The estimated cost of absorbent products (such as pads) is around £94m (€112m;

Nutritional strategies in severe acute pancreatitis: A systematic review of the evidence

138m) per annum in the United Kingdom.4 Because faecal incontinence is a heterogeneous problem that ranges from minor faecal soiling to incapacitating urge or passive faecal incontinence and embarrassment may prevent patients from seeking help, estimates of prevalence may not be accurate. Incontinence is a common reason for admission to residential care even though in many cases simple measures are available in primary care that could enable people to remain at home. We review evidence on causes, diagnosis, and management of faecal incontinence in adults and summarise the findings of systematic reviews and guidelines where possible.nn#### Sources and selection criteriannWe searched PubMed, National Institute for Health and Clinical Excellence guidelines, Embase, and the Cochrane library using the search terms faecal/fecal incontinence. We retrieved potentially useful studies and critically evaluated them for inclusion.nnAn epidemiological survey showed a rising incidence with advancing age and the highest prevalence in elderly people in long term care, with no sex difference in adults aged over 40.5 The higher reported prevalence of faecal incontinence in younger women is probably the result of childbirth related injuries, and a prospective study showed that the greatest risk follows the first vaginal …

ENDOVENOUS THERAPY OF VARICOSE VEINS: A BETTER OUTCOME THAN STANDARD SURGERY?

Nutrition in severe acute pancreatitis is a critical aspect in the management of this condition. This review aims to systematically review the evidence available to inform the use of nutritional support in severe acute pancreatitis. High quality (level 1) evidence supports naso-jejunal enteral nutrition (NJ-EN) over parenteral nutrition (PN) reducing infectious morbidity and showing a trend towards reduced organ failure although there is no detectable difference in mortality. Trial data may underestimate benefit as patients are often recruited with predicted rather than proven severe disease. NJ-EN is safe when started immediately (level 3 evidence). NJ-EN is often impractical and naso-gastric (NG) feeding seems to be equivalent in terms of safety and outcomes whilst being more practical (level 2 evidence). Regarding feed supplementation, probiotic feed supplementation is not beneficial (level 1 evidence) the and may cause harm with excess mortality (level 2 evidence). No evidence exists to confirm benefit of the addition of prokinetics in severe acute pancreatitis (SAP) although their use is proven in other critically ill patients. Level 2 evidence does not currently support the use of combination immuno-nutrition though further work on individual agents may provide differing results. Level 2 evidence does not support intravenous supplementation of anti-oxidants and has demonstrated that these too may cause harm.

A 15-year retrospective analysis of the epidemiology and outcomes for elderly emergency general surgical admissions in the North East of England: A case for multidisciplinary geriatric input.

In the UK approximately one million people are affected with varicose veins. Nearly half a million patients seek advice from their GPs about lower limb varicose veins related symptoms every year. Therefore, they constitute an important part of the elective operations and waiting lists in NHS hospitals. About 40,000 operations for varicose veins were performed in the NHS in 2001. The majority (60-70%) of those patients had an incompetent saphenofemoral junction (SFJ) and great saphenous vein (GSV) reflux. The traditional and most common approach for treating SFJ incompetence and GSV reflux is saphenofemoral disconnection and GSV stripping to the knee. Despite being considered a minor surgical procedure, complications are not uncommon. The minimally invasive endovenous treatment of lower limbs varicose veins has been used over the last few years in many centres across the world. It would appear to be equal to, if not superior to, traditional surgery. It has also been proven to be safe with few serious complications. The most common treatments are endovenous laser ablation and endovenous radiofrequency ablation and chemical sclerotherapy. The case for minimally invasive strategies appears to have been accepted by many patients already and it would appear in trials that they are voting with their feet. Rigorous scientific evidence remains elusive and not yet conclusive. As in all other branches of surgery new technology should be embraced but cautiously, with all results collected and disseminated to finally prove the utility or otherwise of this technique.

Simulation and stress: acceptable to students and not confidence-busting.

INTRODUCTIONnLife expectancies in the UK are increasing and with this there is an increasing elderly population with more complex co-morbidity. Emergency surgery in the elderly is challenging in terms of decision making, managing co-morbidity and post-operative rehabilitation with high morbidity and mortality. To optimise service design and development, it is important to understand the changing pattern of emergency surgical care for this group.nnnMETHODSnAfter obtaining necessary approvals, we approached each hospital trust in the North of England for details of every emergency admission under a general surgeon from 2000 to 2014. Data for each admission included demographics, co-morbidities, diagnoses, procedures undertaken and outcomes.nnnRESULTSnThere were 105xa0002 elderly (≥70 years) emergency general surgical admissions, and mean age and co-morbidity (defined by Charlson index scores) increased (both pxa0<xa00.001). Operative intervention was undertaken in a similar proportion of patients in all age groups (13%), with more patients undergoing operations over time (pxa0<xa00.001), of which 50% were within 48xa0h of admission. Overall in-hospital mortality decreased significantly as did length of hospital stay (both pxa0<xa00.001). Factors associated with increased 30 day in-hospital mortality were increasing age and Charlson score, admissions directly from clinic, operations undertaken at the weekend and patients admitted earlier in the study period.nnnCONCLUSIONnThe workload of emergency general surgery in the elderly is becoming more complex. This challenge is already being addressed with improvements in outcomes. The data presented here reinforces the need for new models of care with increased multidisciplinary geriatric care input into elderly surgical patient care in the perioperative period.

Colorectal stents: Do we have enough evidence?

Background:u2002 Newly qualified doctors frequently feel unprepared for clinical practice. ‘Performing under stress’ has been cited as a particular barrier in this transitional period. Conventional views on training using simulation state that it must take place in a controlled environment to benefit learning; however, we attempted to create a high realism ‘high‐stress’ simulated scenario to try and prepare students for stressful situations in future practice.

Impact of a care pathway in acute pancreatitis

BACKGROUNDnThe use of colonic stents has significantly evolved over the last few years. Emergency surgery for colonic obstructions is usually associated with significant mortality, morbidity and often stoma formation. Colonic stents provide an alternative way to relieve colonic obstruction, and hence avoiding the risks associated with emergency surgery. This literature review aims to summarize the important current evidence regarding colorectal stenting and show whether further evaluation of the procedure is required.nnnRESULTSnThe available large number of non-randomized studies suggests that Self-Expandable-Metal-Stents (SEMS) placement for acute colonic obstruction could be considered as safe and effective alternative to surgery in experienced hands either as a bridge to surgery or as a palliative measure. This evidence has led to SEMS being widely adopted. However, randomized evidence has begun to show the defects that are inherent in the low level evidence that has so far supported SEMS use and it may be that reports of randomized controlled trials may clarify the patient population where SEMS placement is appropriate.nnnCONCLUSIONnWhile we are still waiting for the outcome of the multicentre randomized controlled trials in the UK and Europe, clinicians must be aware of the current evidence limitations and apply SEMS use pragmatically.

Longterm –ostomy as a quality marker: Comparison of outcomes from a six year series of laparoscopic surgery in MRI defined low rectal cancer

Background Previous studies have shown that accurate process of care predicts quality of care. Few examples currently exist for process of care for the acute surgical patient. A recent region wide audit had identified good outcomes for patients with acute pancreatitis at our institution but aspects of care that could be improved. Methods For this re-audit, a simple written care pathway for the management of those presenting with acute pancreatitis was introduced in our institution from February to July 2009. The audit standards were set against the British Society of Gastroenterology (BSG) guidelines for management of acute pancreatitis and were compared with the previous region wide audit. Results Marked improvements were noted in the rates of abdominal imaging achieved within 24 h of diagnosis (35.2% vs 47.7%), severity stratification within 48 h of diagnosis (28.7% vs 75%), critical care admission for those classified as severe (39.3% vs 63.6%) and definitive treatment during index admission (22.2% vs 38.5%). Survival rates were 100% for this audit cycle and 95% for all patients within the region wide audit. Despite these improvements, care still does not reach the standards set out by BSG. Conclusion Predefined processes of care may help to recognise those developing or likely to develop severe pancreatitis, ensure accurate documentation of severity, expedite critical care review and/or admission, and help to encourage the timely management of those with a treatable underlying cause of their pancreatitis.

The results of high-frequency duplex surveillance after iliac arterial stenting in a single center.

AIMnWe propose long-term -ostomy rate following laparoscopic rectal cancer resection must be included as an overall quality indicator of treatment in conjunction with frequently reported and readily available end points.nnnMETHODnA database was collated prospectively of consecutive rectal cancer resections over a 6-year period. Recorded data included pre-operative MRI (tumour stage and height from the anal-verge), as well as demographics, treatment, local recurrence rate, survival and -ostomy rate as the primary outcome measure.nnnRESULTSn65 patients were identified and classified as low-rectal cancer if the tumour on MRI was < 6 cm from the anal verge or middle/upper-rectal cancer if between 6 and 15 cm from the anal-verge and below the peritoneal reflection. Permanent stoma rates including colostomies and non-reversed ileostomies were 31.7% for middle/upper rectal cancer; 62.5% for low-rectal cancer and an overall rate of 42.1% for all rectal cancers. For upper-rectal cancer the rates of local recurrence, predicted mortality, R0 resection and conversion were: 0%, 1.9%, 97.6% and 0% respectively. Corresponding figures for low-rectal cancer were: 4.2%, 2.7%, 95.8% and 0%. There were no significant differences for age, sex, predicted morbidity/mortality, survival, recurrence or leak rates between the groups.nnnCONCLUSIONnLaparoscopic rectal cancer surgery has a comparable permanent -ostomy rate to open rectal cancer surgery. We benchmark 31.7% as the permanent -ostomy rate for upper-rectal cancer and 62.5% for low-rectal cancer following laparoscopic resection, in the context of 96.9% R0 resection and 0% conversion rate in a consecutive series of patients.

Seminal vesicle-rectal fistula: A review of an unusual complication following low anterior resection for rectal cancer

Frequent duplex surveillance after iliac arterial stenting is time-consuming and costly, so solid benefits of this approach must be available. Frequent duplex surveillance was performed at our center, this was reviewed retrospectively.A total of 117 stents were assessed. Duplex was done for 84 (71.8%) of 117 patients at 1 year and 25 (21.4%) of 117 at 5 years, mean follow-up 27.6 months. Totally, 456 scans were performed; 386 (84.6%) scans were normal, 43 (9.4%) showed an abnormality for which intervention was not necessary, 27 (5.9%) showed abnormalities which needed interventions. The maximum attendance of patients was 62%. In all, 18 patients had interventions unrelated to scheduled follow-up; 15 (83.3%) of 18 had no prior abnormalities on duplex, 3 (16.6%) of 18 had prior abnormalities which were not acted upon after clinical assessment. Our findings demonstrate a high nonattendance rate with frequent emergency presentations due to acute complications. We cannot, therefore, recommend frequent duplex surveillance program both in terms of results or resource allocation.