Yasser Al Omran

The Brain-Gut Axis in Health and Disease

The interaction between the brain and the gut has been recognized for many centuries. This bidirectional interaction occurs via neural, immunological and hormonal routes, and is important not only in normal gastrointestinal function but also plays a significant role in shaping higher cognitive function such as our feelings and our subconscious decision-making. Therefore, it remains unsurprising that perturbations in normal signalling have been associated with a multitude of disorders, including inflammatory and functional gastrointestinal disorders, and eating disorders.

Functional brain imaging in gastroenterology: to new beginnings

With more than 100 studies published over the past two decades, functional brain imaging research in gastroenterology has become an established field; one that has enabled improved insight into the supraspinal responses evoked by gastrointestinal stimulation both in health and disease. However, there remains considerable inter-study variation in the published results, largely owing to methodological differences in stimulation and recording techniques, heterogeneous patient selection, lack of control for psychological factors and so on. These issues with reproducibility, although not unique to studies of the gastrointestinal tract, can lead to unjustified inferences. To obtain consistent and more clinically relevant results, there is a need to optimize and standardize brain imaging studies across different centres. In addition, the use of complementary and more novel brain imaging modalities and analyses, which are now being used in other fields of research, might help unravel the factors at play in functional gastrointestinal disorders. This Review highlights the areas in which functional brain imaging has been useful and what it has revealed, the areas that are in need of improvement, and finally suggestions for future directions.

Anastomosis Lapse Index (ALI): A Validated End Product Assessment Tool for Simulation Microsurgery Training.

BACKGROUND Over the last decade, simulation has become a principal training method in microsurgery. With an increasing move toward the use of nonliving models, there is a need to develop methods for assessment of microvascular anastomosis skill acquisition substituting traditional patency rate. The authors present and validate a novel method of microvascular anastomosis assessment tool for formative and summative skills competency assessment. METHODS In this study, 29 trainees with varying levels of experience in microsurgery undertook a 5-day microsurgery course. Two consecutive end-to-end microvascular anastomoses of cryopreserved rat aortas performed on day 3 and day 5 of the course were longitudinally split and photographed for randomized blinded qualitative evaluation. Four consecutive anastomoses by two experienced microsurgeons were analyzed as expert controls. Errors potentially leading to anastomotic leak or thrombosis were identified and logged. Statistical analysis using the Kruskal-Wallis analysis of variance (ANOVA) and a two-way repeated measure ANOVA was used to measure construct and concurrent validity, respectively. RESULTS A total of 128 microvascular anastomoses were analyzed for both student and control groups. Ten errors were identified and indexed. There was a statistically significant difference detected between average errors per anastomosis performed between groups (p < 0.05). Average errors per anastomosis was statistically decreased on day 5 of the course compared with day 3 (p < 0.001). CONCLUSION Evaluation of anastomosis structural patency and quality in nonliving models is possible. The proposed error list showed construct and predictive validity. The anastomosis lapse index can serve as a formative and summative assessment tool during microvascular training.

The impact of medical student surgical conferences

Recent reports have shown that in the UK there has been a decrease in interest towards pursuing a surgical career, whereas early exposure to surgery may increase interest. We aimed to assess the effect of a 1‐day medical school surgical conference in encouraging attendees to pursue a surgical career.

Against all odds. Conservative management of Boerhaave’s syndrome

Spontaneous oesophageal perforation or Boerhaaves syndrome is a life-threatening condition that usually requires early diagnosis and early surgical management. A 79-year-old man presented to the accident and emergency department with an ischaemic left big toe. He reported a 2-week history of worsening symptoms and a claudication distance in his left leg of 20–30 m. Three days post-revascularisation of the leg, the patient reported chest pain radiating to the back. CT angiography of the aorta indicated Boerhaave’s syndrome. Following 35 days of conservative management in the intensive care unit and high dependency unit, the patient was stepped down to a surgical ward. A water-soluble contrast study demonstrated minimal leak through the perforated oesophagus. The patient was started on oral intake, which was well tolerated. This case highlights that conservative management may be appropriate.

The importance of timely detection and management in neonatal appendicitis.

The clinical presentation of cute appendicitis is rarely encountered in neonatology. When it does occur, it is thought to be due to prematurity or develops secondary to coexisting diseases. We present a case of appendicitis in a 10-day-old Middle-Eastern girl, who was born at term and who had no underlying conditions that are typically associated with neonatal appendicitis. This case highlights that certain causes and clinical signs are unreliable when coming to a working diagnosis of neonatal appendicitis, and that regardless of the cause, timely detection and management are necessary in achieving surgical success.

Stercoral perforation in a child: a rare complication of NSAID use

The adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs) on the gastrointestinal (GI) tract are well known. However, NSAID use rarely leads to a stercoral perforation, an extremely rare but life-threatening cause of acute abdomen. We present a case of stercoral sigmoid colon perforation in a 2-year-old girl, secondary to unintentional NSAID overdose, developing as a result of miscommunication between the general practitioner (GP) and the mother. To the best of our knowledge, stercoral perforation has never before been reported in a child.

Meckel's diverticulum with intussusception in a 5-year-old patient with Down's syndrome

Meckels diverticulum is understood to be the commonest congenital malformation within the gastrointestinal tract with a prevalence of 2%, as found on autopsy studies. Although many cases are asymptomatic, complications can occur including haemorrhage, diverticulitis, chronic ulceration and intestinal obstruction. Intussusception is also a complication, but extremely rare. We present a rare case of Meckels diverticulum causing intussusception, which was surgically resolved, in a 5-year-old girl. Our aim through this case report is to generate greater awareness of this complication and to provide some potential guidance towards its treatment.

Effects of habitual physical activity on microsurgical performance

We investigated the effect of physical activity on microsurgical performance. Forty novice candidates and 6 expert controls did a series of consecutive end-to-end microvascular anastomoses. To assess performance, we did a hand motion analysis and correlated the results with levels of habitual physical activity. Higher levels of activity in the novice candidates correlated with slower completion of anastomosis for medical students on day 1 (p=0.0035) and day 5 (p=0.0003). The same pattern was seen for postgraduate trainees on day 1 (p=0.024) and day 5 (p=0.0063). Higher level of activity also correlated with an increase in path length (total distance travelled and direction of travel) and in total movements on day 1 for medical students (p=0.016 and p=0.0021, respectively), and in total path length on day 1 for postgraduate trainees (p=0.0305).

Vascular hamartoma of the parotid gland

Hamartomas of the parotid gland are highly unusual. We present a case of a vascular hamartoma of the parotid gland arising as a 1.5 cm mass in a 5-year-old girl. As far as we are aware, no other case with the same features has been reported. We present this case to generate greater consideration of hamartomas as part of the differential diagnosis of parotid lesions, and to reflect over the criteria used to identify a hamartoma from other parotid lesions, as there appears to be some confusion in the literature.