M. A. Loudon

Damage control resuscitation for patients with major trauma

#### Summary points Military conflict has always driven innovation and technical advances in medicine and surgery. Accepted concepts of trauma resuscitation and surgery have been challenged in the wars in Iraq and Afghanistan, and novel approaches have been developed to address the current complexity and severity of military trauma.1 A number of these new strategies have evolved into a single seamless approach that extends from the point of wounding to surgery, and on to critical care. Although the precise contribution of medical care is difficult to ascertain, better trauma management has almost certainly contributed to a remarkable reduction in the lethality of war wounds. Only 10% of United States servicemen wounded in Iraq and Afghanistan between 2003 and 2009 died, compared with 24% in the first Gulf War (1990-1991) and Vietnam War (1961-1973).w1 Initially derived from clinical experience, new concepts in caring for the injured have been refined with experiment and study and have been translated back to the battlefield in a dynamic process.2 Many of these advances are also relevant to trauma care in civilian practice. The aim of this article is to provide an overview of a new approach …

Outcomes after placement of colorectal stents

Background  Colonic stents are increasingly used to palliate or alleviate large bowel obstruction in patients with colon cancer and other obstructing lesions in whom a definitive surgical procedure is inappropriate. We report on the outcomes of a large group of patients who underwent deployment of a colon stent in a single institution by a single operator.

Investigation of blunt abdominal trauma

#### Summary points Concealed haemorrhage is the second most common cause of death after trauma,1 and missed abdominal injuries are a frequent cause of morbidity and late mortality in patients who survive the early period after injury. Appropriate and expeditious investigation facilitates definitive management and minimises the risk of complications, so it is crucially important. #### Sources and selection criteria We searched the Medline database for reviews and clinical trials using the terms “blunt abdominal trauma”, “blunt abdominal injury”, “investigation”, “computed tomography”, “ultrasound”, “FAST”, and “diagnostic peritoneal lavage”. Search results were individually reviewed and manually cross referenced. We also searched the Cochrane Library and Clinical Evidence databases, reviewed guidelines from the American College of Radiology and the Royal College of Radiologists, and used references from our personal collections. The literature is dominated by non-randomised studies, and few systematic reviews and meta-analyses are available. Most of the evidence is level II-IV. Several high quality prospective and retrospective studies have shown non-operative management of solid organ injury to be safe and effective, and this strategy is now accepted into mainstream practice.2 3 4 In parallel, a paradigm shift has occurred in imaging algorithms, with greater emphasis being put on the detection of specific findings, rather than the mere detection of intraperitoneal fluid, which does not predict the need for intervention.5 The greater availability of computed tomography and ultrasound in emergency departments has contributed to changes in practice, but it has also created new controversies—diagnostic peritoneal lavage is now rarely performed, but the diagnosis of hollow …

Systematic review of randomized trials comparing rubber band ligation with excisional haemorrhoidectomy

This review compares the two most popular treatments for haemorrhoids, namely rubber band ligation (RBL) and excisional haemorrhoidectomy. Randomized trials were identified from the major electronic databases. Symptom control, retreatment, postoperative pain, complications, time off work and patient satisfaction were assessed. Relative risk (RR) and weighted mean difference with 95 per cent confidence interval (c.i.) were estimated using a random‐effects model for dichotomous and continuous outcomes respectively.

Damage control surgery in a non-trauma setting.

Damage control surgery has become a firmly established concept in the management of abdominal trauma, with the recognition that severely injured patients undergoing prolonged operations often die from metabolic failure rather than the inability to complete organ repairs. This has resulted in a surgical strategy that sacrifices completeness of the immediate repair in order to address the combined physiological impact of injury and surgery, and prevent progression to a nonsalvageable metabolic state1. Damage control surgery encompasses procedures such as abdominal packing for haemorrhage control, temporary closure of gastrointestinal injuries without restoration of continuity, and temporary abdominal closure combined with planned relaparotomy to remove residual contamination and restore anatomical integrity and physiological function. Many of the problems encountered in trauma surgery, such as the need to obtain control of the source of contamination and interrupt the development of the deleterious and synergistic triad of metabolic acidosis, hypothermia and coagulopathy, also arise in non-trauma emergency abdominal surgery. The application of damage control techniques in this context, however, is contentious. Possible indications for damage control in the general surgical setting include haemodynamic instability from severe sepsis or massive haemorrhage, coagulopathy, abdominal compartment syndrome, acute mesenteric ischaemia, necrotizing infections, and a requirement for repeated peritoneal lavage to eradicate sepsis or reinspect problematic suture lines and anastomoses. There is no level I evidence to support damage control surgery in a non-trauma setting. Available studies are hampered by small sample size, lack of randomization, and heterogeneity of both study population and intervention. Two prospective studies and one retrospective case–control study comparing planned with on-demand relaparotomy for intra-abdominal sepsis found little difference in terms of mortality rate, but there was a higher incidence of multiple organ failure and infectious complications in the planned intervention group2–4. Another case–control study by Billing and colleagues5 also found no difference in overall mortality, but a subgroup analysis of patients in whom source control had not been achieved during the index operation suggested a lower mortality rate in those managed with planned relaparotomy. Two small, heterogeneous, uncontrolled series of general surgical patients managed with damage control techniques had low observed mortality compared with that predicted by the Portsmouth modification of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM)6,7. Schein8 also reported an unexpectedly low mortality rate in patients with diffuse faecal peritonitis managed with planned relaparotomy. As in trauma, there is evidence to support abdominal decompression and temporary closure in secondary abdominal compartment syndrome9. These conflicting results are to a large extent a reflection of the methodological difficulties encountered in evaluating a multifaceted management strategy (rather than an isolated intervention) that incorporates surgical technique, critical care and, above all, decision-making, in a complex and diverse group of patients. Even in the context of trauma, the damage control concept has never been evaluated in a formal trial, but the volume of other evidence in its favour is such that many trauma surgeons now consider a randomized trial unethical1. Although further verification of benefit in the general surgical setting is needed, the evidence that is currently available supports a cautious endorsement of the damage control strategy much as for trauma. Some recommendations may be made. The sine qua non of surgical treatment for intra-abdominal sepsis is control of the source of infection. The dilemma is whether outcome may be improved by a limited initial operation and subsequent relaparotomy. There is little doubt that planned reoperation is indicated when the source of contamination has not been adequately controlled during the index operation, either because of physiological instability or an inability to close, resect, exteriorize or exclude the source of infection. Limiting the impact of surgery by minimizing the duration of operation by means of temporizing techniques is conceptually attractive. Modern methods of temporary abdominal closure, such as the ‘Opsite (Smith & Nephew, Hull, UK) sandwich’, both simplify nursing care and facilitate relaparotomy7. On

Factors affecting anastomotic complications following anterior resection in rectal cancer

Objective  Anastomotic complications following sphincter saving rectal surgery remains a significant clinical problem in rectal cancer surgery. Preoperative combined modality therapy followed by anterior resection with total mesorectal excision (TME) has become the preferred treatment paradigm for locally advanced rectal cancer. However, its impact on anastomotic complications has not been adequately evaluated. This study aimed to assess the relationship between the response of the primary tumour to neo‐adjuvant therapy with anastomotic complications and to evaluate the effect of other clinico‐pathological factors previously implicated, in this patient cohort.

APRIL is a novel clinical chemo-resistance biomarker in colorectal adenocarcinoma identified by gene expression profiling

Background5-Fluorouracil(5FU) and oral analogues, such as capecitabine, remain one of the most useful agents for the treatment of colorectal adenocarcinoma. Low toxicity and convenience of administration facilitate use, however clinical resistance is a major limitation. Investigation has failed to fully explain the molecular mechanisms of resistance and no clinically useful predictive biomarkers for 5FU resistance have been identified. We investigated the molecular mechanisms of clinical 5FU resistance in colorectal adenocarcinoma patients in a prospective biomarker discovery project utilising gene expression profiling. The aim was to identify novel 5FU resistance mechanisms and qualify these as candidate biomarkers and therapeutic targets.MethodsPutative treatment specific gene expression changes were identified in a transcriptomics study of rectal adenocarcinomas, biopsied and profiled before and after pre-operative short-course radiotherapy or 5FU based chemo-radiotherapy, using microarrays. Tumour from untreated controls at diagnosis and resection identified treatment-independent gene expression changes. Candidate 5FU chemo-resistant genes were identified by comparison of gene expression data sets from these clinical specimens with gene expression signatures from our previous studies of colorectal cancer cell lines, where parental and daughter lines resistant to 5FU were compared. A colorectal adenocarcinoma tissue microarray (n = 234, resected tumours) was used as an independent set to qualify candidates thus identified.ResultsAPRIL/TNFSF13 mRNA was significantly upregulated following 5FU based concurrent chemo-radiotherapy and in 5FU resistant colorectal adenocarcinoma cell lines but not in radiotherapy alone treated colorectal adenocarcinomas. Consistent withAPRILs known function as an autocrine or paracrine secreted molecule, stromal but not tumour cell protein expression by immunohistochemistry was correlated with poor prognosis (p = 0.019) in the independent set. Stratified analysis revealed that protein expression of APRIL in the tumour stroma is associated with survival in adjuvant 5FU treated patients only (n = 103, p < 0.001), and is independently predictive of lack of clinical benefit from adjuvant 5FU [HR 6.25 (95%CI 1.48-26.32), p = 0.013].ConclusionsA combined investigative model, analysing the transcriptional response in clinical tumour specimens and cancers cell lines, has identified APRIL, a novel chemo-resistance biomarker with independent predictive impact in 5FU-treated CRC patients, that may represent a target for novel therapeutics.

The contemporary management of haemorrhoids

Background  New concepts in the management of haemorrhoidal disease have recently rekindled interest in this common pathology. General and subspecialist colorectal surgeons were surveyed to assess their impact on the current management of haemorrhoids.

Pathological audit of stapled haemorhoidopexy

Introduction  Stapled haemorrhoidopexy is increasingly used for the surgical management of prolapsing haemorrhoids. Accurate placement of the staple line is essential to avoid involvement of the internal anal sphincter (IAS) and the pain sensitive squamous epithelium. The aim of this study was to correlate histology with symptomatic outcome after stapled haemorrhoidopexy.

Nicorandil associated anal ulceration

Objective  Nicorandil is a vasodilator used to control angina. It has been associated with oral and anal ulceration that resolves upon withdrawal of the drug.