Small bowel perforation due to an adhesion ruptured by peritoneal insufflation

BACKGROUND

Despite the widespread use of laparoscopic cholecystectomy, technical complications unique to the laparoscopic approach may lead to significant postoperative morbidity and mortality. Case report: We report the first published case of small bowel fistula due to peritoneal insufflation that broke a thin string adhesion between the peritoneal wall and a jejunal segment, which lead to a focal perforation in a 75-year-old woman. Leakage of enteric fluid through the umbilical scar indicated this adverse event during the early postoperative period. The patient was immediately and successfully treated with a suture of the intestinal lesion. Conclusion: Peritoneal insufflation induced for laparoscopic procedures may break abdominal adhesions and lead to organs and vascular injuries, including small bowel perforation.

Systemic bias in peer review: suggested causes, potential remedies

OBJECTIVE

The aim of this study was to determine if peer review conducted under real-world conditions is systematically biased.

STUDY DESIGN

A repeated-measures design was effectively created when two board-certified obstetrician-gynecologists reviewed the same 26 medical records of patients treated by the same physician, and provided written evaluations of each case and a summary of their criticisms. The reviews were conducted independently for two different, unaffiliated hospitals. Neither reviewer was aware of the other's review, and neither was affiliated with either hospital or knew the physician under review. This study reports the degree of agreement between the two reviewers over the care rendered to these 26 patients.

RESULTS

Three of the 26 cases reviewed had complications. Both reviewers criticized these cases, but criticized 2 of them for different reasons. At least one of the reviewers criticized 14 (61%) of the 23 uncomplicated cases, about which no quality concerns had been raised prior to the review. With one exception, they criticized completely different cases and criticized this 1 case for different reasons. Thus, only 4 of the 17 cases criticized by at least one of the reviewers were criticized by both of them, and only 1 of the 4 cases were criticized for the same reason. The Kappa statistic was -0.024, indicating no agreement between the reviewers (P = 0.98).

CONCLUSIONS

As presently conducted, peer review can be systematically biased even when conducted independently by external reviewers. Dual-process theory of reasoning can account for the bias and predicts how the bias may potentially be eliminated or reduced.

Laparoscopic entry techniques and complications

OBJECTIVE

To identify laparoscopic entry techniques employed by gynecologists in the United Kingdom to determine if the consensus technique is adhered to, and to observe whether entry technique affects complication rate.

METHOD

An anonymous postal questionnaire was sent to gynecologists with an interest in laparoscopic surgery in the United Kingdom.

RESULTS

At total of 568 questionnaires were sent and 345 (60.7%) were returned. Of gynecologists who returned the questionnaire 194 (57%) reported occurrence of a major bowel or vascular complication. In terms of the key elements of the consensus document there was no significant difference in entry technique used between those that reported major injury (vascular, bowel, or both), and those that did not.

CONCLUSIONS

This survey demonstrates the variation in entry techniques used by gynecologists in the United Kingdom. Without a good evidence-base to the contrary no entry technique can be stated as safer than another.