Satheesh Yalamarthi

Outcome of right‐ and left‐sided colonic and rectal cancer following surgical resection

Aim  To determine the outcome of surgery for colorectal cancer from a single region and to see whether location of the primary cancer influences prognosis.

Use of topical negative pressure in assisted abdominal closure does not lead to high incidence of enteric fistulae.

Aim  Reports suggested an increase in enterocutaneous fistulae with topical negative pressure (TNP) use in the open abdomen. The purpose of this study was to establish if our experience raises similar concerns.

Predictors of severity in ischaemic colitis

PurposeIschaemic colitis (IC) is an inadequate perfusion leading to potentially life-threatening colonic inflammation. The aim was to identify patient characteristics that predict severity in biopsy-confirmed IC.MethodsA retrospective study of consecutive patients admitted with a robust diagnosis of IC over a 5-year period was performed. As IC is often misdiagnosed, strict inclusion criteria including supporting histopathology, exclusion of inflammatory bowel disease, absence of recent antibiotics or negative stool sampling with testing for Clostridium difficile were adhered to. Due to differing pathophysiology involved, patients suffering IC due to injury to colonic perfusion from vascular procedures or tumours were also excluded. Patients were divided by outcomes into a severe IC group including those that needed surgery or suffered mortality and a non-severe IC group that included patients managed medically with good evolution during their index admission. Patient characteristics were analysed to identify statistically significant predictors of severity (p < 0.05).ResultsThirty-two patients (11 males, 21 females; mean age 72.5) met the inclusion criteria. Medical management was adopted in 23 patients with a single mortality (4.3%). Nine patients were managed surgically with two mortalities (22.2%), giving an overall mortality of 9.4% and a severe IC group consisting of ten patients. Significant prognostic predictors of severity included: right-sided IC (p = 0.0002), guarding (p = 0.001), lack of bleeding per rectum (p = 0.005) and chronic constipation (p = 0.02).ConclusionsThe majority of patients with IC can be managed conservatively. Right-sided IC, guarding, lack of bleeding per rectum and chronic constipation are associated with severe IC.

Microcoil Embolisation of Mycotic Cystic Artery Pseudoaneurysm: A Viable Option in High-Risk Patients

Mycotic cystic artery pseudoaneurysm is a rare complication of cholecystitis, of which the main treatment has been cholecystectomy plus ligation of the cystic artery. We highlight our experience with successful coil embolisation of this condition without the need for surgical intervention. This is followed by a comprehensive review of the literature regarding management of this unusual condition.

The clinical significance of radiologically detected indeterminate pulmonary nodules in colorectal cancer

Aim  Colorectal cancer patients identified with indeterminate pulmonary nodules (IPN) in the absence of other metastasis represent a clinical dilemma. This study aimed to identify characteristics that could predict which nodules truly represented a metastasis in an attempt to optimize therapy and to reduce the number of follow‐up chest CT scans performed.

The impact of specialist experience in the surgical management of perianal abscesses.

UNLABELLED Perianal abscesses are one of the most common general surgical emergencies and the management of this can be variable. The aim of our study was to assess the management strategy used by different grades of surgeons in the surgical management of an acute perianal abscess. MATERIAL AND METHODS A retrospective analysis was carried out of all patients presenting with an abscess in the perianal region over a two-year period from January 2006 to December 2007. Patient demographics and co-morbidities were noted. The management strategies of different grades of operating surgeon were analysed. RESULTS During the two-year period, 147 patients presented with a perianal abscess of whom 52 (28%) had recurrent abscess. Fistulae were identified in 30 patients, with more than half picked up by consultants (P = 0.00001). Consultants performed fistulotomy and Seton insertion in 50% and 17% of patients respectively, whilst registrars performed these procedures in only 4% and 8% of patients (p < 0.00001). CONCLUSION Whilst surgical management of the perianal abscess is one of the most common surgical emergency procedures performed by the surgical trainees, input from a senior clinician improves the identification and definitive management of an underlying fistula. This study reinforces the importance of involvement of senior surgeons in the management of this common condition.

MR imaging of fistula in ano: indications and contribution to surgical assessment.

Abstract Background : Magnetic Resonance Imaging (MRI) is the imaging modality of choice for fistula in ano. The purpose of this study was to analyse the use of MRI, and to assess its contribution towards the assessment of this sometimes difficult condition. Methods : A retrospective analysis of all patients with fistula in ano between January 2003 and December 2007 was performed, focussing on those who had MRI assessment. The primary pathology, indication for MRI and the contribution of this investigation to assessment of fistula in ano were analysed. Results : MRI was performed in 40 patients. The primary pathologies included: perianal sepsis in 20 (50%), Crohn’s disease in 11 (27.5%), primary fistula in ano in 6 (15%) and others in 3 (7.5%) patients. Indications for MRI were to assess the fistula anatomy in 17 (42.5%), to assess a clinically suspected fistula in 12 (30%), to assess a complex fistula found at Examination Under Anaesthesia (EUA) in 6 (15%) and to exclude a fistula in 5 (12.5%). MRI was considered helpful in 34 (85%) of all cases. MRI established the fistula anatomy and guided further surgery in 47.1%, correlated with EUA findings in 38.2% and excluded a suspected fistula in 14.7% of these. Conclusions : This study further supports the benefit of using MRI to assess fistula in ano. When used in selected patients, it was of benefit in 85% of cases, by establishing fistula anatomy and guiding further surgery, correlating EUA findings or excluding a clinically suspected fistula.

Volvulus of the sigmoid colon treated by percutaneous endoscopic colostomy.

Volvulus of the sigmoid colon is a condition that, in the Western world, predominately affects the elderly. In fit patients sigmoid colectomy, after a period of decompression, is the treatment of choice. However, this carries a high mortality in elderly high-risk patients. Percutaneous endoscopic colostomy (PEC) has been reported as a treatment for those who are considered high risk for surgery. We report the successful use of PEC in an 87-year-old lady, for the treatment of recurrent sigmoid volvulus, without complication. This procedure has also been used effectively for colonic pseudo-obstruction, constipation, and obstructed defecation. There are various complications associated with PEC, the most serious of which is tube migration and fecal peritonitis. Our experience supports the use of PEC to treat sigmoid volvulus in those too frail for colonic resection.

Are we performing enough emergency laparoscopic cholecystectomies? An experience from a district general hospital

Abstract Background Emergency Laparoscopic cholecystectomy (LC) is a well established procedure for acute cholecystitis. However a recent report suggested that about 15% were operated on during their emergency admission. The aim of this study was to evaluate our performance in a district general hospital (DGH). Methods Data of all cholecystectomies performed from 1st April 2003 to 31st March 2008 were analysed. Timing of surgery (Elective vs Emergency), conversion rate, hospital stay and complications were analysed. Results 2011 cholecystectomies were performed during this period. 740 patients had surgery following emergency admission. 488/740 (66%) had their operation at the time of emergency admission and the remaining 252/740 (34%) were admitted later for elective surgery. 8% of the emergency procedures were performed by open approach and the conversion rate was 14.5%. 1523 patients had elective surgery of which 3.7% patients were operated by open approach and the conversion rate was 6.9%. Conclusion In a DGH, consultants having a variety of subspecialty interests, who take part in emergency surgical rota, can safely undertake emergency cholecystectomy. We believe that LC can be done in acute gall stone disease during their index admission with acceptable conversion and complication rates.

Reply to Miss Clark

Dear Sir, I read this article with interest, but was surprised that the discussion regarding the variation of molecular genetics within this tumour group was limited to a brief paragraph with some rather limited and outdated references addressing differential gene expression. It is now accepted that there are at least three distinct molecular genetic pathways leading to the formation of colorectal cancer, and that these tumours can be distinguished by examining them for mismatch repair function (using microsatellite instability or mismatch repair immuno-histochemistry), the presence of DNA methylation and BRAF mutation and aneuploidy [1,2]. One of these pathways, characterized by mismatch repair deficiency due to HMLH1 promoter methylation, is associated with BRAF mutations and accounts for about 10–15% of sporadic colorectal cancers. These are found predominantly on the right side of the colon and in the elderly. They have a poor prognosis [3]. This may well explain the finding of poor prognosis in right-sided tumours by Suttie et al. The techniques used to identify these different tumour groups are relatively straightforward and can be applied to formalin-fixed, paraffin-embedded material. Indeed this sort of profiling has become a feature of regular clinical practice in some large centres particularly in the United States. It is time that an appreciation of the underlying molecular mechanisms should play a part in our day to day management of colorectal cancer and research into it. Profiling of tumours in this way should allow a much more sophisticated approach to research, acknowledging that there are biologically distinct forms of the disease. Ultimately this will lead towards individualized treatment [4].