Are we jumping the gun with pharmaconutrition (immunonutrition) in gastrointestinal onoclogical surgery?

Over the last 20 years there has been considerable research into the use of immunonutrition, also referred to as pharmaconutrition, in the management of patients undergoing and recovering from elective gastrointestinal surgery for malignancy. In this group of patients, the use of pharmaconutrition seems to confer superior outcomes to standard nutrition formulations with regards to postoperative infective complications and length of hospital stay. It is therefore frequently recommended for use in elective gastrointestinal oncological surgical populations. However, it remains unclear whether the data supporting these recommendation is robust. Studies reporting improved outcomes with pharmaconutrition frequently compare this intervention with non-equivalent control groups, do not report on the actual nutritional provision received by study participants, overlook the potential impact of industry funding on the conduct of research and do not adopt a multi-disciplinary approach to the research undertaken. For these reasons, an urgent critical re-appraisal of the use and recommendations of pharmaconutrition in this group of patients is warranted to resolve some of the above mentioned issues.

Early versus traditional postoperative feeding in patients undergoing resectional gastrointestinal surgery: a meta-analysis

BACKGROUND

A meta-analysis evaluating surgical outcomes following nutritional provision provided proximal to the anastomosis within 24 hours of gastrointestinal surgery compared with traditional postoperative management was conducted.

METHODS

Databases were searched to identify randomized controlled trials comparing the outcomes of early and traditional postoperative feeding. Trials involving gastrointestinal tract resection followed by patients receiving nutritionally significant oral or enteral intake within 24 hours after surgery were included for analysis.

RESULTS

Fifteen studies involving a total of 1240 patients were analyzed. A statistically significant reduction (45%) in relative odds of total postoperative complications was seen in patients receiving early postoperative feeding (odds ratio [OR] 0.55; confidence interval [CI], 0.35 -0.87, P = .01). No effect of early feeding was seen with relation to anastomotic dehiscence (OR 0.75; CI, 0.39-1.4, P = .39), mortality (OR 0.71; CI, 0.32-1.56, P = .39), days to passage of flatus (weighted mean difference [WMD] -0.42; CI, -1.12 to 0.28, P = .23), first bowel motion (WMD -0.28; CI, -1.20 to 0.64, P = .55), or reduced length of stay (WMD -1.28; CI, -2.94 to 0.38, P = .13); however, the direction of clinical outcomes favored early feeding. Nasogastric tube reinsertion was less common in traditional feeding interventions (OR 1.48; CI, 0.93-2.35, P = .10).

CONCLUSIONS

Early postoperative nutrition is associated with significant reductions in total complications compared with traditional postoperative feeding practices and does not negatively affect outcomes such as mortality, anastomotic dehiscence, resumption of bowel function, or hospital length of stay.

Minimally invasive oesophagectomy: current status and future direction

BACKGROUND

Oesophagectomy is one of the most challenging surgeries. Potential for morbidity and mortality is high. Minimally invasive techniques have been introduced in an attempt to reduce postoperative complications and recovery times. Debate continues over whether these techniques are beneficial to morbidity and whether oncological resection is compromised. This review article will analyse the different techniques employed in minimally invasive oesophagectomy (MIO) and critically evaluate commonly reported outcome measures from the available literature.

METHODS

Medline, Embase, Science Citation Index, Current Contents, and PubMed databases were used to search English language articles published on MIO. Thirty-one articles underwent thorough analysis and the data were tabulated where appropriate. To date, only level III evidence exists. Where appropriate, comparisons are made with a meta-analysis on open oesophagectomy.

RESULTS

Positive aspects of MIO include at least comparable postoperative recovery data and oncological resection measures to open surgery. Intensive care unit requirements are lower, as is duration of inpatient stay. Respiratory morbidity varies. Negative aspects include increased technical skill of the surgeon and increased equipment requirements, increased operative time and limitation with respect to local advancement of cancer. With increasing individual experience, improvements in outcome measures and the amenability of this approach to increasing neoplastic advancement has been shown.

CONCLUSION

MIO has outcome measures at least as comparable to open oesophagectomy in the setting of benign and nonlocally advanced cancer. Transthoracic oesophagectomy provides superior exposure to the thoracic oesophagus compared to the transhiatal approach and is currently preferred. No multicentre randomised controlled trials exist or are likely to come into fruition. As with all surgery, careful patient selection is required for optimal results from MIO.

Mentoring and surgical training: a time for reflection!

Effective mentoring has an invaluable role in the development of surgeons at various levels and is frequently perceived vital in achieving career success. Its role therefore is only second to credentialing. However, the formal role of mentoring and learner support in surgical training remains non-existent. This is reflected in a paucity of empirical data on mentoring in graduate medical education which makes meaningful research even more difficult. This article reflects on these failings, explores the reasons for apathy towards mentoring in surgical training and why the attitudes toward mentoring remain casual and lukewarm. Furthermore the authors explore the literature on this subject to identify ways and methods of remedying the situation.

Emergency intraperitoneal onlay mesh repair of incarcerated spigelian hernia

BACKGROUND AND OBJECTIVES

Spigelian hernia is a rare cause of incarcerated ventral abdominal hernia that may pose a diagnostic dilemma. However, with the increasing utilization of double contrast computed tomography (CT) for undiagnosed small bowel obstruction in a virgin abdomen, more such cases are being diagnosed with increasing confidence. Furthermore, with the rapid expansion of the indications for minimal access surgery in emergency situations, these rare emergencies are increasingly tackled using a laparoscopic approach leading to swift patient recovery and discharge.

METHODS

We present the case of an emergency intraperitoneal onlay mesh (IPOM) repair of Spigelian hernia, causing acute small bowel obstruction in a 55-year-old man with liver disease and ascites that was diagnosed using a CT scan. We conducted a search of Medline, Embase, Science Citation Index, Current Contents, PubMed, and the Cochrane Database to review the history of laparoscopic repair of Spigelian hernia and its various advancements, which are briefly presented here.

RESULTS

The hernia was successfully reduced using laparoscopy, revealing a moderate-size defect in the linea semilunaris. The hernial defect was repaired with a composite mesh that was tacked into position. The patient was discharged from the hospital on the second postoperative day.

CONCLUSIONS

Spigelian hernia in an emergency setting can be easily and swiftly repaired using the IPOM method utilizing a composite mesh.

Oral assessment and postgraduate medical examinations: establishing conditions for validity, reliability and fairness

The purpose of this review was to examine the practice of oral assessment in postgraduate medical education in the context of the core assessment constructs of validity, reliability and fairness. Although oral assessment has a long history in the certification process of medical specialists and is a well-established part of such proceedings for a wide range of specialties in most countries, there remains concern regarding its use. Therefore, there has been some move away from oral assessment for postgraduate medical education in some countries. This review also highlights the complexity of oral assessment as an examination format, partly through a consideration of the six dimensions of oral assessment, and raises concerns about the validity, reliability and fairness of such an assessment procedure for the award of certification of completion of the specialist training. Supporting high quality published research into examination practices and outcomes and acting on the findings of such research is needed urgently to allay concerns about the transparency and fairness of these examinations, especially when assessing international medical graduates. The article concludes by proposing 15 conditions under which oral assessment is valid, reliable and fair.

Assessing the surgeon's technical skills: analysis of the available tools

The concept of assessing competency in surgical practice is not new and has taken on an added urgency in view of the recent high-profile inquiries into "botched cases" involving surgeons of various levels in different parts of the world. Until very recently, surgeons in the United Kingdom and other parts of the world, although required to undergo formal and compulsory examinations to test their factual knowledge and decision making, were not required to demonstrate technical ability. Therefore, there existed (and still exist) no objective assessment criteria to test trainees' surgical skill, especially during the exit examination, which, if passed, provides unrestricted license to surgeons to practice their specialties. However, with the introduction of a new curriculum by various surgical societies and a demand from the lay community for better standards, new assessment tools are emerging that focus on technical competency and that could objectively and reliably measure surgical skills. Furthermore, training authorities and hospitals are keen to embrace these changes for satisfactory accreditation and reaccreditation processes and to assure the public of the safety of the public and private health care systems. In the United Kingdom, two new surgical tools (Surgical Direct Observation of Procedural Skill, and Procedure Based Assessments) have been simultaneously introduced to assess surgical trainees. The authors describe these two assessment methods, provide an overview of other assessment tools currently or previously used to assess surgical skills, critically analyze the two new assessment tools, and reflect on the merit of simultaneously introducing them.

Early postoperative feeding in resectional gastrointestinal surgical cancer patients

Malnutrition is present in the majority of patients presenting for surgical management of gastrointestinal malignancies, due to the effects of the tumour and preoperative anti-neoplastic treatments. The traditional practice of fasting patients until the resumption of bowel function threatens to further contribute to the malnutrition experienced by these patients. Furthermore, the rationale behind this traditional practice has been rendered obsolete through developments in anaesthetic agents and changes to postoperative analgesia practices. Conversely, there is a growing body of literature that consistently demonstrates that providing oral or tube feeding proximal to the anastomosis within 24 h postoperatively, is not only safe, but might be associated with significant benefits to the postoperative course. Early post operative feeding should therefore be adopted as a standard of care in oncology patients undergoing gastrointestinal resections.

The issue of lymphadenectomy during laparoscopic gastrectomy for gastric carcinoma

Surgical resection remains the mainstay of treatment for gastric cancer. Laparoscopic assisted gastrectomy has failed to gain universal acceptance as an alternative to the open approach for a number of reasons, one of which includes the issue of oncological radicality in terms of lymph node dissection. Nodal status, which is one of the most crucial and independent predictors of patient survival, therefore has been examined both in single institutional trials and also in randomised controlled trials especially on early gastric cancer. The issue of oncological adequacy for laparoscopic lymph node harvesting for advanced gastric cancer remains a contentious issue because of the unique challenges it poses in terms of complexity, safety and time, and also the lack of randomised controlled trials in this area. It is thus imperative that good quality multicentre randomised controlled trials are designed to investigate the benefits of extended lymphadenectomy in the setting of laparoscopic surgery, especially for advanced gastric cancer and its impact on both short and long term survival.

Outcome of palliative esophageal stenting for malignant dysphagia: a retrospective analysis

Greater than 50% of patients with esophageal carcinoma are found to be incurable at the time of diagnosis, leaving only palliative options. Self-expanding metal stents (SEMs) are effective for relieving symptoms and complications associated with esophageal carcinoma and improving quality of life. We undertook a retrospective analysis to evaluate the experience of palliative esophageal stenting for symptomatic malignant dysphagia in our institution over a period of 7 years. Between January 1999 and January 2006, 126 patients who received SEMs for malignant dysphagia were identified using an upper gastrointestinal specialist nurse clinician database. Data were obtained from patient case notes, endoscopy, histopathology, radiology, and external agency databases. Of the 126 identified, 36 patients were excluded from the analysis. A number of variables including age, sex, presenting complaints, type of stent, indications of stenting, success or failure of stent insertion, survival rate, and complication rate were analyzed. Of the 90 patients, 55 (61%) were male and 35 (39%) were female. The mean age of patients was 70.79 (range 40-97) years. The predominant presenting complaints were dysphagia (n = 81) and weight loss (n = 48). The indication for stenting was worsening dysphagia in all patients. Tumors were confined to the distal esophagus and esophagogastric junction in 73 patients (81%), and the mid-esophagus in 17 (19%). Adenocarcinoma was identified in 61 patients (67.8%) and squamous cell carcinoma in 29 (32.2%). Stenting numbers were comparable in endoscopic and radiologic groups (47 vs. 43), with successful stent deployment in 89 patients. The 7- and 30-day mortality was 9% (n = 8) and 28% (n = 25), respectively. Comparable numbers of early deaths were seen in both radiologic (n = 13) and endoscopic (n = 12) groups. Causes of early inpatient death included hemorrhage (n = 5), pneumonia (n = 7), exhaustion (n = 2), cardiac causes (n = 3), perforation (n = 1), and sepsis (n = 1). The number of patients with complications was 41 (45.6%), 25 in the surgical group and 15 in the radiologic group; the difference was not significant (P = 0.13). The mean survival time was 92.5 (0-638) days and median survival time was 61 days. A subgroup of patients with complete dysphagia (score 4) gained a mean survival of 59 days. Those patients receiving adjuvant chemotherapy or radiotherapy survived significantly longer than those receiving stenting alone (152.8 days vs. 71.8 days). There is no significant difference in complications or survival when using endoscopic or radiologic methods to deploy SEMs in patients with inoperable esophageal cancer. Mortality is low; however, the morbidity rate is significant. Patients receiving adjuvant chemotherapy or radiotherapy, in addition to stenting, survived significantly longer than those with a stent only.

Time saving modified BCR sequential extraction procedure for the fraction of Cd, Cr, Cu, Ni, Pb and Zn in sediment samples of polluted lake

The mobility, availability and persistence of heavy metals (Cd, Cr, Cu, Ni, Pb and Zn) in contaminated lake sediment samples were evaluated by means of sequential extraction scheme, proposed by the Community Bureau of Reference protocol (BCR). The metal content in the extracts was measured by atomic absorption spectrometry. The precision and accuracy of the proposed procedure were evaluated by using a certified reference material BCR 701. The maximum recoveries for heavy metals (HMs) were observed for all three steps of BCR protocol at 32h total shaking period instead of previously reported 51h, with p>0.05. The lixiviation tests (DIN 38414-S4) were used to evaluate the leaching of HMs from sediment samples and it was observed that levels of water extractable HMs were low as compared to those values obtained by acid-soluble fraction of the BCR protocol.

Gallstone ileus: a difficult emergency diagnosis!

Gallstone ileus (GSI) is a rare cause of mechanical small bowel obstruction. It occurs when a fistula between the gallbladder and the small bowel facilitates the migration of gallstone(s) into the small bowel. The commonest site of impaction is in the terminal ileum. We report the case of a 71-year-old female presenting with GSI diagnosed on CT scan. She was surgically explored and gallstones extracted by a simple enterotomy leading to full recovery of the patient.

Unusual presentation of acute pancreatitis: an irreducible inguinoscrotal swelling mimicking a strangulated hernia

We report an unusual presentation of acute pancreatitis as a tender, irreducible, inguinoscrotal swelling mimicking a strangulated hernia. Lack of abdominal symptoms or signs can lead to misdiagnosis and unnecessary surgery.

Common causes of male dog infertility

A complete breeding soundness evaluation is essential for assessment of the infertile male dog. Cryptorchidism, a sex-limited autosomal recessive trait, is more common as a unilateral condition. Azoospermia is an ejaculate consisting of seminal plasma but lacking sperm; repeated semen collections in the presence of an estrual bitch will rule out inadequate experience and lack of sexual stimulation. Both carnitine and alkaline phosphatase (AP) are produced in the epididymis; seminal plasma AP concentrations>5000 U/L indicate a normal ejaculate, whereas <5000 U/L is associated with incomplete ejaculation. Benign prostatic hypertrophy (BPH), the most common age-related condition in intact male dogs, is characterized by a sanguineous urethral discharge, hematuria, or hemospermia; diagnosis is based on prostatic enlargement and confirmed by a transabdominal biopsy. Although castration is recommended, valuable breeding dogs can be given finasteride. Prostatitis is more common in older dogs with BPH. Culture of the third fraction of the ejaculate or urine obtained by cystocentesis is indicated. Bacterial prostatitis is treated with antibiotics with high lipid solubility. Some dogs with bacterial prostatitis may develop prostatic abscesses (a medical and surgical emergency). Prostatic cysts are often asymptomatic. Approximately, 5-7% of dogs with prostatic disease have prostatic neoplasia, most commonly adenocarcinoma (it occurs in both intact and castrated dogs), which often metastasizes and has a very poor prognosis. Although a specific diagnosis can be made in many cases of male dog infertility, not all causes are amenable to treatment.

Syndromic management training for non-formal care providers in Pakistan improves quality of care for sexually transmitted diseases STD care: a randomized clinical trial

We conducted a randomized, controlled, three-armed trial to assess whether training in syndromic management, with provision of packets, could improve the quality of STD services provided among non-formal care providers. The quality of STD case management service, observed by "incognito patients" in both intervention groups, improved substantially compared to the control group (p < 0.05). The training-and-packets group performed better in service delivery, HIV-testing referral, and condom provision when compared to the training-only group (all p < 0.05). The training-and-packets group also retained more knowledge and practiced more skillfully at six months post-intervention when compared to the training-only group (p < 0.05). Exit interviews of clients suggested that 81% of providers in the intervention groups offered advice on condom use when compared to none of those in the control group (p < 0.001). Syndromic management training and free syndrome packets for non-formal providers had a positive impact on the quality of STD care among the trained providers.

Current status of minimal access surgery for gastric cancer

BACKGROUND

The aim was to conduct a systematic review of the literature on the subject of laparoscopic gastrectomy (LG) and determine the relative merits of laparoscopic (LG) and open gastrectomy (OG) for gastric carcinoma.

MATERIAL AND METHODS

A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified individual retrospective and prospective series on LG (proximal, distal and total). Furthermore, all clinical trials that compared LG and OG published in the English language between January 1990 and the end of December 2006 were also identified. A large number of outcome variables were analysed for individual series and comparative trials between LG and OG and results discussed and tabulated.

RESULTS

The majority of the literature is published from Japan showing both oncological adequacy and safety of LG. The majority of early series and comparative studies have utilized laparoscopic resection for early and distal gastric cancer. However, with increasing advanced laparoscopic experience, advancement in digital technology and improvement in instrumentation, more advanced gastric cancers and more extensive procedures such as laparoscopic-assisted total gastrectomy and laparoscopy-assisted D2 dissection are becoming more common. To date lymph node harvesting, resection margins and complication rates seem to be equivalent to open procedures. Furthermore, the earlier fears of port-site metastases have not been borne out.

CONCLUSIONS

The available data suggests that LG seems to be associated with quicker return of gastrointestinal function, faster ambulation, earlier discharge from hospital, and comparable complications and recurrence rate to OG. However, the operating time for LG remains significantly longer compared to its open counterpart, although with experience it is achieving parity with OG. However, the majority of the comparative trials (if not all) probably do not have the power to detect differences in the outcome. As far as the RCT's (LG vs. OG) are concerned, the numbers of patients in such trials are small and the majority of patients were operated upon for early distal gastric cancer and, therefore, any meaningful conclusions regarding the advantages or disadvantages of LG for both the ECGs and extensive and advanced gastric tumours are difficult to justify.

Resolution of gallstone ileus with spontaneous evacuation of gallstone

Gallstone ileus (GSI) is a rare cause of small bowel obstruction (SBO). Even more extraordinary is the spontaneous evacuation of a gallstone, which has caused SBO. A 69-year-old gentleman presented with symptoms and signs of SBO. His plain abdominal X-ray revealed dilated loops of the small bowel and opacity in the region of the terminal ileum consistent with a diagnosis of GSI. Because of severe cardiorespiratory co-morbidities, the patient was treated conservatively and improved within 24 h. A CT scan revealed that the stone had passed into the rectum and was spontaneously evacuated. If the gallstone is <2.5 cm on CT scan, spontaneous evacuation is a real possibility and initial conservative treatment in a high-risk surgical patient is a consideration.

Rectus sheath haematoma: a rare presentation of non-contact strenuous exercises

Rectus sheath haematoma (RSH) is a well-documented but uncommon clinical condition. It is usually a self-limiting condition but can present as a life-threatening emergency. RSH after non-contact vigorous exercise is unknown. Two such cases secondary to yoga and laughter therapy sessions, respectively, are reported. One of them required surgical intervention, whereas the other was successfully treated conservatively.

De Garengeot hernia: an analysis of our experience

AIM

The presence of a vermiform appendix in a femoral hernia sac is termed De Garengeot hernia. It may present as a tender and/or erythematous groin swelling and is often misdiagnosed as an incarcerated or strangulated femoral hernia. The purpose of this study is to review the management of De Garengeot hernia at a single institution since 1991.

MATERIALS AND METHODS

A retrospective analysis of seven consecutive patients operated upon at our institution from 1991 to 2006 with De Garengeot hernia was undertaken. Patients' demographics, treatment performed and postoperative outcome were analysed.

RESULTS

There were three men and four women. The median age was 55 years. None of the patients were diagnosed preoperatively. The commonest presenting symptom was painful groin swelling. All patients therefore underwent emergency surgery with a presumptive diagnosis of either incarcerated or strangulated femoral hernia. Operative findings included four normal appendices, two inflamed appendices and one perforated appendix in the femoral hernial sac. Patients with normal appendix (n = 4) had mesh hernia repair without an appendicectomy. The rest of the patients (n = 3) with abnormal appendix underwent emergency open appendicectomy followed by sutured hernia repair. We had no deaths in this series and one minor wound infection. No recurrent hernia has been detected to date.

CONCLUSION

Inflammation of the appendix determines the type of hernia repair and surgical approach. Incidental appendicectomy in the case of a normal appendix is not preferred.

A novel technique for nonoperative removal of round rectal foreign bodies

Extraction of rectal foreign bodies is challenging. The medical literature confirms the diversity of the problem and equally some ingenious solutions, the majority of which requires either an anesthetic agent or a laparotomy to remove them. This case report presents a simple nonoperative technique to deal with one such situation.