Susan Shedda

Preoperative immunonutrition and its effect on postoperative outcomes in well-nourished and malnourished gastrointestinal surgery patients: a randomised controlled trial

Background/Objectives:Invasive procedures such as surgery cause immunosuppression, leading to increased risk of complications, infections and extended hospital stay. Emerging research around immune-enhancing nutrition supplements and their ability to reduce postoperative complications and reduce treatment costs is promising. This randomised controlled trial aims to examine the effect of preoperative immunonutrition supplementation on length of hospital stay (LOS), complications and treatment costs in both well-nourished and malnourished gastrointestinal surgery patients.Subjects/Methods:Ninety-five patients undergoing elective upper and lower gastrointestinal surgery were recruited. The treatment group (n=46) received a commercial immuno-enhancing supplement 5 days preoperatively. The control group (n=49) received no supplements. The primary outcome measure was LOS, and secondary outcome measures included complications and cost.Results:A nonsignificant trend towards a shorter LOS within the treatment group was observed (7.1±4.1 compared with 8.8±6.5 days; P=0.11). For malnourished patients, this trend was greater with hospital stay reduced by 4 days (8.3±3.5 vs 12.3±9.5 days; P=0.21). Complications and unplanned intensive care admission rates were very low in both the groups. The average admission cost was reduced by AUD1576 in the treatment group compared with the control group (P=0.37).Conclusions:Preoperative immunonutrition therapy in gastrointestinal surgery has the potential to reduce the LOS and cost, with greater treatment benefit seen in malnourished patients; however, there is a need for additional research with greater patient numbers.

Sacral nerve stimulation for fecal incontinence: long-term outcomes.

BACKGROUND: Numerous studies advocate the short-term benefits of sacral nerve stimulation for fecal incontinence, but there has been a paucity of studies on longer-term outcomes. OBJECTIVE: The objective of this study was to report the long-term outcome of sacral nerve stimulation performed for fecal incontinence at a single institution. PATIENTS AND DESIGN: Between January 2004 and May 2007, 53 patients underwent definitive sacral nerve stimulation for fecal incontinence at our institution. Prospectively recorded baseline information, including Wexner incontinence scores and standard short-form (SF-12) health survey scores, were compared with scores at follow-up. RESULTS: Forty-one patients were available for long-term follow-up with a mean duration of 51 months. The median Wexner score decreased from a baseline of 11.5 (range, 3.0–18.0) to 8.0 (range, 0.0–18.0) at follow-up. The mean difference in Wexner score was 2.7 (P < .001). There was no statistically significant change in SF-12 physical scores, but a small but highly significant change occurred in SF-12 mental scores. The median SF-12 mental domain score was 49.5 (range, 15.0–62.1) at baseline, and 57.0 (range, 20.0–64.0) at follow-up, with a mean difference of 4.5 (P = .006). Subgroup analysis performed comparing patients with or without prior intersphincteric silicon biomaterial implants demonstrated a mean difference in Wexner score of −3.5 (no implant) vs 0.0 (previous implant), with P < .09 (not statistically significant). CONCLUSIONS: Sacral nerve stimulation results in a statistically significant improvement in fecal incontinence scores in the long term.

Effect of the introduction of an emergency general surgery service on outcomes from appendicectomy

Appendicectomy is a common general surgical emergency procedure and may be used as a surrogate marker to evaluate quality in surgical management. The aim of this study was to assess the outcomes of appendicectomy before and after the introduction of a consultant‐led emergency general surgery (EGS) service at a large metropolitan tertiary referral centre.

CAROLI’S SYNDROME AND ADULT POLYCYSTIC KIDNEY DISEASE

Caroli’s disease is a cystic disease of the liver, which has been rarely associated with adult onset polycystic kidney disease. Three cases have been reported in the English Medline search. The presentation of this fourth case discusses the issues surrounding the treatment of Caroli’s disease in the setting of a renal transplant.

Comparing oncological outcomes of laparoscopic versus open surgery for colon cancer: Analysis of a large prospective clinical database.

Oncological outcomes of laparoscopic colon cancer surgery have been shown to be equivalent to those of open surgery, but only in the setting of randomized controlled trials on highly selected patients. The aim of this study is to investigate whether this finding is generalizable to real world practice.

Predictors of clinic non‐attendance: opportunities to improve patient outcomes in colorectal cancer

Aim: Colorectal cancer is one of the few tumour types, where routine patient follow up has been demonstrated to impact significantly on survival. Patients who fail to attend regular clinic reviews may compromise their outcome, but the frequency at which this occurs is unknown. Identifying the extent of this problem, and the factors that predict non‐attendance, may provide opportunities to improve patient outcomes.

Gunsight skin incision and closure technique for stoma reversal.

BACKGROUND: Several techniques have been described in the literature for skin closure following stoma reversal. We describe the “gunsight skin closure” technique and highlight its potential advantages. METHOD: Four triangles of skin are excised to enlarge the skin incision. This increases exposure for mobilization of the bowel. The resulting skin wound is approximated with a pursestring suture to give a small, neat scar that allows some central drainage. The final wound resembles a gunsight. CONCLUSION: This method of skin closure allows increased surgical exposure, facilitates creation of a subsequent stoma at the same site, simplifies wound care, and gives a neat cosmetic result.

Recurrence of acute colonic pseudo-obstruction post-caesarean section: a case report

imaging (MRI) was performed on day 5 to aid diagnosis. The MRI confirmed primary myositis involving the short head of biceps femoris with extensive surrounding oedema (Fig. 1). At this time, the formal histology report of the deep fascia sampled during exploratory surgery revealed patchy chronic inflammatory infiltrates with no necrosis, and microbiology confirmed β-haemolytic streptococcus Group-A infection. Subsequently, the patient was returned to theatre on multiple occasions for deeper exploration and debridement of the posterior thigh compartment musculature. The short head of biceps alone was found to be necrotic, in close proximity to the sciatic nerve and popliteal vessels. She began to improve and was discharged home on oral clindamycin on day 27. Staphylococcus aureus accounts for over 90% of bacterial pyomyositis, a condition usually diagnosed late, followed by increased morbidity and significant mortality rate. Clinical diagnosis of pyomyositis may be difficult; MRI is an important adjunct to exploratory surgery in making an early diagnosis.

Impact of bowel endometriosis surgery on bowel and bladder function, pain symptoms and quality of life

Purpose To evaluate the impact of bowel endometriosis surgery on obstructive defecation syndrome symptoms, bladder dysfunction, pain symptoms and quality of life (QOL). Methods This was a retrospective cohort study of patients who underwent surgery for endometriosis where bowel was involved between 2005 and 2013. Patients were grouped according to extent of bowel endometriosis treatment: Group 1 - no treatment of bowel endometriosis, Group 2 - “shaving” of endometriosis, Group 3 - wedge resection, or Group 4 - segmental bowel resection. Data were collected via chart review and a mail-out survey consisting of six validated questionnaires designed to evaluate the study aims. Results Of 337 eligible patients, completed survey responses were returned by 99. There were 22 patients in Group 1, 61 in Group 2, 5 in Group 3 and 11 in Group 4. Patient demographic data were similar across the groups. There was no difference in disease severity between Groups 1-4, nor between respondents and non-respondents. Patients in Group 4 were more likely to have open surgery (p<0.001) and to have a stoma placed (p = 0.001). Patients in Group 3 were more likely to have dysmenorrhoea post-operatively (p = 0.02). Otherwise, bowel and bladder symptoms, pain, and health status were comparable between the groups, with a low incidence of bladder symptoms, generally low pain scores, and high QOL for all patients. Conclusions Deciding the extent of surgical aggressiveness based on symptom severity has resulted in similar long-term post-operative bowel and bladder symptoms, pain scores, quality of life and overall health across the groups.

Triradiate caecal fold: Is it a useful landmark for caecal intubation in colonoscopy?

AIM To determine the frequency of identification of the triradiate fold during colonoscopy and evaluate its reliability as a marker of caecal intubation. METHODS One hundred consecutive patients undergoing colonoscopy in a tertiary hospital colorectal unit from May to September 2013 were studied. Video documentation of the caecum was recorded and shown to consultant colorectal surgeons on the unit. Each reviewer was asked through a series of questions to independently identify the triradiate fold. The main outcome was the frequency of visualisation of the triradiate fold in the caecum. RESULTS The triradiate fold was seen on average in 18% of cases, but inter-observer agreement was poor. There were only four patients (4%) in which all reviewers agreed on the presence of a triradiate fold. In patients who had undergone previous appendicectomy, the appendiceal orifice was less frequently seen compared with patients who had not undergone appendicectomy. CONCLUSION The triradiate fold is infrequently seen during colonoscopy and is therefore an unreliable landmark of caecal intubation.