Kevin Sargen

The value of routine histopathological examination of appendicectomy specimens

BackgroundAppendicectomy specimens removed from patients with suspected acute appendicitis often appear macroscopically normal but histopathological analysis of these cases may reveal a more sinister underlying pathology. We evaluated histopathological reports of 1225 appendicectomy specimens at the Norfolk and Norwich University Hospital (NNUH) over the past three years.MethodsHistopathology reports for all appendices analysed at the NNUH between March 2003 and March 2006 were reviewed by examination of the case notes. The analysis focussed on the confirmation of acute appendicitis, incidental unexpected incidental findings other than inflammation, whether these abnormalities were suspected on gross examination at the time of surgery, and the effect on patient management and prognosis.ResultsThe histopathology reports disclosed a variety of abnormal incidental lesions. Of the 1225 specimens, 46 (3.75%) revealed abnormal diagnoses other than inflammatory changes. Twenty-four (1.96%) of these were clinically significant and affected further patient management. Only two of these (0.16%) were suspected on macroscopic examination intra-operatively.ConclusionTwenty-four of the 1225 specimens (1.96%) had an impact on patient management or outcome and were not suspected on macroscopic examination at the time of surgery. These would have been missed had the specimens not been examined microscopically. The intra-operative diagnosis of the surgeon is therefore unreliable in detecting abnormalities of the appendix. This study supports the sending of all appendicectomy specimens for routine histopathological examination.

Should the macroscopically normal appendix be removed during laparoscopy for acute right iliac fossa pain when no other explanatory pathology is found

Background Acute appendicitis remains the most common surgical emergency and although diagnosis should be made on clinical grounds, sometimes this can be difficult. Laparoscopy has gained increasing favour as a method of both investigating right iliac fossa pain and treating the finding of appendicitis. The aim of this study was to determine the accuracy of intraoperative diagnosis of appendicitis. Patients and Methods Records of all patients who underwent laparoscopy for possible appendicitis at the Norfolk and Norwich University Hospital over a 1-year period were reviewed. Notes of those patients who underwent an open appendicectomy were also reviewed for comparison. Intraoperative findings were recorded, as were the subsequent pathologic findings. Results Over the 1-year period from September 2005 to September 2006, 355 operations for suspected appendicitis were performed. In 277 (78%) cases, these were performed laparoscopically. Seventy-three out of 78 open appendectomies were confirmed as appendicitis. Only 1 of these was not macroscopically evident to the surgeon. The appendix was removed in 259 of the 277 laparoscopic procedures. Correct intraoperative diagnosis was made in 217 (84%) of removed appendices, 12 (29%) of the appendices thought to be macroscopically normal and removed were found to be appendicitis after histologic examination. Eighteen patients undergoing the laparoscopic procedure had their appendix left in situ due to normal appearance; none had represented at 6 months postsurgery. Conclusions Laparoscopy may aid in the diagnosis of acute right iliac fossa pain. However, intraoperative diagnosis is not easy with almost one-third of apparently normal appendices being inflamed histologically. We would therefore advocate the removal of a normal looking appendix in the absence of other explanatory pathology.

Randomized clinical trial of fluid and salt restriction compared with a controlled liberal regimen in elective gastrointestinal surgery

Excessive intravenous fluid prescription may play a causal role in postoperative complications following major gastrointestinal resectional surgery. The aim of this study was to investigate whether fluid and salt restriction would decrease postoperative complications compared with a more modern controlled liberal regimen.

Multidimensional collaboration: reflections on action research in a clinical context

This paper reflects on the challenges and benefits of multidimensional collaboration in an action research study to evaluate and improve preoperative education for patients awaiting colorectal surgery. Three cycles of planning, acting, observing and reflecting were designed to evaluate practice and implement change in this interactive setting, calling for specific and distinct collaborations. Data collection includes: observing educational interactions; administering patient evaluation questionnaires; interviewing healthcare staff, patients and carers; patient and carer focus groups; and examining written and audiovisual educational materials. The study revolves around and depends on multi-dimensional collaborations. Reflecting on these collaborations highlights the diversity of perspectives held by all those engaged in the study and enhances the action research lessons. Successfully maintaining the collaborations recognises the need for negotiation, inclusivity, comprehension, brokerage, and problem-solving. Managing the potential tensions is crucial to the successful implementation of changes introduced to practice and thus has important implications for patients’ well-being. This paper describes the experiences from an action research project involving new and specific collaborations, focusing on a particular healthcare setting. It exemplifies the challenges of the collaborative action research process and examines how both researchers and practitioners might reflect on the translation of theory into educational practices within a hospital colorectal department. Despite its context-specific features, the reflections on the types of challenges faced and lessons learned provide implications for action researchers in diverse healthcare settings across the world.

Developing patient education to enhance recovery after colorectal surgery through action research: a qualitative study

Objectives To understand the role of preoperative education for patients undergoing colorectal surgery by involving patients, carers and staff in: (1) identifying its perceived value and deficits for enhanced recovery; (2) modifying current education practices to address educational deficits; and (3) evaluating these changes for preparing patients to enhance their recovery. Design Qualitative study of three cycles of action research using mixed methods within a 24-month naturalistic enquiry to identify, implement and evaluate changes through observations, questionnaires, semistructured longitudinal interviews, focus groups and documentation review. Setting A UK 1200-bed National Health Service (NHS) hospital providing colorectal surgery in a small city in a rural county. Participants Ninety-sevenpatients having colorectal surgery, 19 carers and 22 clinical staff. Results Themes identified were: (1) knowledge and engagement; (2) situated understanding and confidence building; and (3) partnership and proactive involvement in enhancing recovery. All patients articulated needs to prepare mentally and physically to plan for colorectal surgery and rehabilitation. Patients and carers wanted to counter uncertainty about medical procedures: likely bodily changes, recovery timescales and future. They therefore sought as much personalised, relevant information as possible about their disease, planned surgery and recovery. Staff implemented preoperative education to more specifically inform and respond multimodally to individual needs. Conclusions Patients wanted to be proactively involved in managing their recovery to re-engage with their everyday lives. Preoperative education supported this through developing patients’ situated understanding of hospital and bodily processes related to colorectal surgery. Situated understanding was achieved through educational product to give knowledge and processes promoting engagement. Multimodal, comprehensive and timely preoperative education on the whole patient pathway facilitates active engagement. Situated understanding increased patients’ confidence to work in partnership with healthcare professionals and proactively self-manage recovery.

Addressing patients’ colorectal cancer needs in preoperative education

Purpose – The purpose of this paper is to understand and develop ways to enhance patients’ experiences of preoperative education received prior to surgery for colorectal cancer. Design/methodology/approach – Based in the UK, three-action research cycles were undertaken to evaluate preoperative education, identify changes seen by patients and staff as likely to improve the service and to re-evaluate such changes following implementation. Data in each cycle were collected from: observations of clinic interactions; patient questionnaires; individual semi-structured interviews with multidisciplinary colorectal unit staff; longitudinal semi-structured interviews with patients and carers pre-surgery, two weeks post-surgery and 12 weeks post-surgery; patient and carer focus groups post-surgery; and existing educational material. Findings – In total, 138 participants shared their experiences of either giving or receiving preoperative education. Findings were themed into why patients want preoperative education, a...

Cystogram use and outcomes in colorectal surgery involving bladder repair: A clinical audit

The role of routine cystograms after bladder repair during colorectal surgery is unclear so we aimed to evaluate this in our department.

Routine surgical pathology in general surgery (Br J Surg 2006 93 362–368)

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