Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

BACKGROUND

Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.

METHODS

This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.

RESULTS

A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 per cent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 per cent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 per cent; however, it was 41 per cent in low-to-middle- compared with 19 per cent in very high-HDI countries.

CONCLUSION

Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761).

Towards improved outcome in children treated surgically for spontaneous intracranial suppuration in South Wales

INTRODUCTION

Spontaneous central nervous system (CNS) infections in children are rare. Treatment involves surgical intervention and antibiotic therapy. We describe a single centre experience of managing this condition in South Wales.

METHODS

We performed a retrospective review of surgically managed cases in our unit for patients under 18 years of age between 2008 and 2018. Data were collected regarding aetiology, location, microbiology examination, treatment and outcomes.

RESULTS

Twenty-six patients were identified of which 25 case notes were available. Fifteen were male and 10 were female. Median age was 12 years (age range 0.3-17 years). Seven patients (28%) had a burr-hole aspiration and 18 (72%) underwent craniotomy. A second procedure was performed in 10 (40%) and a third procedure in two (8%). Fourteen (56%) had a brain abscess, 10 (40%) had subdural empyema (one was bilateral) and one (4%) had an extradural empyema. Fifteen (60%) had a raised WCC (>11.5 × 10⁹/L) and 22 (88%) had a CRP of >10 mg/L at presentation. Three (12%) patients had a normal WCC and CRP at presentation. Overall, 12 (48%) were secondary to sinus infection, with the most common organism being Streptococcus. Seven (28%) were due to otitis media or mastoiditis, six (24%) had no cause identified. The mean number of CT/MRI scans was 6.7 (range 3-13). The mean follow-up period was 16.7 months (range 1-117 months). At last follow up, 19 (76%) had a GOS of 5, five (20%) had a GOS of 4 and one (12%) had GOS of 3. There were no deaths.

CONCLUSIONS

In Wales, outcomes have improved over time in keeping with other paediatric neurosurgical units in England. Increased availability of imaging resources in our hospital and use of neuro-navigation for all cases in our unit as well as earlier identification of sepsis, communication with microbiologists with dedicated ward rounds and, enhanced identification of causative organisms and contemporary anti-microbials have also contributed towards the improved management of this condition.

Presentation, management, and outcomes of cauda equina syndrome up to one year after surgery, using clinician and participant reporting: A multi-centre prospective cohort study

Background

Cauda equina syndrome (CES) results from nerve root compression in the lumbosacral spine, usually due to a prolapsed intervertebral disc. Evidence for management of CES is limited by its infrequent occurrence and lack of standardised clinical definitions and outcome measures.

Methods

This is a prospective multi-centre observational cohort study of adults with CES in the UK. We assessed presentation, investigation, management, and all Core Outcome Set domains up to one year post-operatively using clinician and participant reporting. Univariable and multivariable associations with the Oswestry Disability Index (ODI) and urinary outcomes were investigated.

Findings

In 621 participants with CES, catheterisation for urinary retention was required pre-operatively in 31% (191/615). At discharge, only 13% (78/616) required a catheter. Median time to surgery from symptom onset was 3 days (IQR:1–8) with 32% (175/545) undergoing surgery within 48 h. Earlier surgery was associated with catheterisation (OR:2.2, 95%CI:1.5–3.3) but not with admission ODI or radiological compression. In multivariable analyses catheter requirement at discharge was associated with pre-operative catheterisation (OR:10.6, 95%CI:5.8–20.4) and one-year ODI was associated with presentation ODI (r = 0.3, 95%CI:0.2–0.4), but neither outcome was associated with time to surgery or radiological compression. Additional healthcare services were required by 65% (320/490) during one year follow up.

Interpretation

Post-operative functional improvement occurred even in those presenting with urinary retention. There was no association between outcomes and time to surgery in this observational study. Significant healthcare needs remained post-operatively.

Funding

DCN Endowment Fund funded study administration. Castor EDC provided database use. No other study funding was received.

V-005 A CASE SERIES DEMONSTRATING APPLICABILITY OF LAPAROSCOPIC MANAGEMENT OF STRANGULATED OR INCARCERATED HERNIAS IN EMERGENCY GENERAL SURGERY

Aims

Acute small bowel obstruction secondary to strangulated hernias is a presentation often encountered during the acute surgical take. Despite the widespread use of a minimally invasive approach for elective hernia surgery, there is a significant reduction in use of laparoscopy in the emergency setting. We aim to describe a case series on the applicability of laparoscopy in the management of emergency strangulated or incarcerated hernias.

Materials

We describe 4 cases of patients who presented with acutely strangulated or incarcerated hernias as an emergency to a single centre in the United Kingdom. The cases demonstrated include inguinal, femoral, obturator and spigelian hernias, each presenting as an acute emergency with concomitant small bowel obstruction.

Results

The patients underwent emergency surgery using a laparoscopic approach for repair of strangulated or incarcerated hernias and assessment of obstructed small bowel. Where indicated, small bowel resection and primary anastomosis was undertaken when viability of affected segment of bowel was compromised. All procedures were completed laparoscopically, with no recurrence occurring in these patients during the follow-up period.

Conclusion

Minimally invasive surgery is an important tool in the armamentarium of the acute care surgeon. A laparoscopic approach will reduce the insult of intervention in already physiologically deplete patients. This case series demonstrates the feasibility of laparoscopy in the management of strangulated or incarcerated hernias in the emergent setting, requiring advanced laparoscopic skill as demonstrated in this video.

355 Comparison of Outcomes in Surgical and Endoscopic Transgastric Cystgastrostomy for Severe Acute Pancreatitis

Aim

The heterogeneous nature of severe acute pancreatitis (SAP) renders decisions related to complications challenging. A select group of patients may be suitable for surgical (S-CG), which can be performed open or laparoscopic, or endoscopic (E-CG) transgastric cystgastrostomy (TCG) of symptomatic or infected retrogastric pancreatic collections (walled-off pancreatic necrosis (WOPN) or pseudocyst). There is limited data comparing outcomes between these approaches.

Method

Retrospective analysis of all patients that underwent S-CG or E-CG was performed from a single, high-volume benign pancreatic centre between 2012 – 2021 inclusive. Patient demographics, clinical characteristics, and outcomes of these 3 groups was compared. One-way analysis of variance tests was used to compare categorical data.

Results

47 patients underwent TCG: 20 S-CG (12 open and 8 laparoscopic), and 27 E-CG. There was no statistical difference between S-CG and E-CG for age, body mass index (BMI), aetiology, organ failure and type or position of collection. S-CG patients had less burden of pre-existing co-morbidities (APACHE-II and Charlson-Co-morbidity-Index (CCI)) (p<0.05). S-CG patients had shorter length of stay, emergency readmission and reintervention (p<0.05). Those who underwent E-CG had higher burden of intervention due to persistent/recurrent pancreatic collections, with 33% mortality rate (p <0.05).

Conclusions

S-CG, in a select group of patients, provides a single-staged intervention for drainage of transgastric pancreatic collections, especially when they predominantly contain solid necrosis and patient is suitable for general anaesthetic. Outcomes are favourable for S-CG, but multidisciplinary approach is critical to delineate the most appropriate approach for each individual patient.

Complicated Severe Acute Pancreatitis: Open and Laparoscopic Infracolic Approach

INTRODUCTION

The heterogeneous nature of severe acute pancreatitis (SAP) renders decisions related to complications challenging. Central solid collections at the root of the mesentery are difficult to access with traditional techniques. Here we describe a case series of laparoscopic infracolic necrosectomy (ICN) and open or laparoscopic infracolic necrosectomy with Roux-en Y cystjejunostomy (ICN-RYCJ) for the management of complicated SAP.

MATERIALS AND METHODS

A retrospective analysis of a prospectively maintained database identified all patients treated with infracolic necrosectomy or drainage of pancreatic collections for complicated SAP between 2012 and 2021 inclusive at a single institution.

RESULTS

Forty patients were identified (median age 53 years)-ICN group 9 patients (median time to intervention-22 days) and ICN-RYCJ group 31 patients (median time to intervention-99 days). Two patients in ICN group underwent interval fistula-tract jejunostomy. Thirty-one patients had laparoscopic surgery and 9 patients underwent an open approach. Four patients required intervention post-operatively. Nineteen patients were discharged from follow-up at two years.

CONCLUSION

Infracolic approach with selective Roux-en Y cystjejunostomy, as a single or staged intervention, is an effective and safe operative option to add to the armamentarium of the pancreatic surgeon when dealing with complicated SAP not amenable to drainage/debridement by traditional techniques.

Laparoscopic Cholecystectomy Versus Percutaneous Cholecystostomy: Suitability of APACHE-II Score, ASA Grade, and Tokyo Guidelines 18 Grade as Predictors of Outcome in Patients With Acute Cholecystitis

INTRODUCTION

Intervention options in acute cholecystitis (AC) include drainage (percutaneous/endoscopic) or surgery. Several scoring systems have been used to risk stratify acute surgical patients, but few have been validated. This study investigated the suitability of Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, American Society of Anesthesiologist (ASA) grade, and Tokyo Guidelines 2018 (TG18) grade as predictors of outcome and assess laparoscopic cholecystectomy versus percutaneous cholecystostomy (PC) as treatment options in patients with AC.

MATERIALS AND METHODS

Retrospective data was collected from patients that underwent acute inpatient cholecystectomy (index admission), urgent interval cholecystectomy (2 to 4 wk) and PC between 2016 and 2018. Data included baseline demographics, co-morbidities, ASA grade, APACHE-II score, TG18 grade, morbidity, and mortality. A P-value of <0.05 was statistically significant. Area under the receiver operating characteristic curve was calculated to compare accuracy of APACHE-II, ASA and TG18 in predicting morbidity.

RESULTS

A total of 344 consecutive patients (266 cholecystectomies and 84 PC) were included in the study. Significant difference in co-morbidities [median Charlson Co-Morbidity Index (CCI) 1 surgery and 4 cholecystostomy (PC) (P<0.05)], median APACHE-II score (3 surgery and 9 PC), median TG18 grade (1 surgery and 2 PC) and mortality rate [0% surgery and 7% cholecystostomy (PC)]. TG18 grade alone predicted postoperative/postprocedure morbidity (receiver operating characteristic; AUC=0.884; 95% confidence interval: 0.845-0.923; odds ratio: 4.38, 96% confidence interval, P<0.05).

DISCUSSION

Utilization of the TG18 grade have shown to be more accurate in risk stratifying and predicting outcomes in patients with AC and therefore may appropriately guide biliary intervention.PC can be utilized in a select group of septic and co-morbid patients (myocardial infarction <6 weeks, chest infection and acute cerebrovascular accident) unable to withstand surgical intervention or in those with complex biliary disease (Mirizzi Syndrome). In a proportion, PC drains sepsis to improve critical state of the patient enough to consider an interval cholecystectomy with satisfactory outcomes.

OV13 LAPAROSCOPIC APPROACH IN EMERGENCY HERNIA SURGERY: MANAGEMENT OF ACUTE SMALL BOWEL OBSTRUCTION SECONDARY TO STRANGULATED OBTURATOR HERNIA

Aim

Acute small bowel obstruction secondary to strangulated obturator hernia is a rare condition, with high rates of morbidity and mortality in the absence of prompt diagnosis and intervention. We aim to describe a case with the above presentation, managed using a minimally-invasive approach with positive outcomes.

Material and Methods

We describe a case of an 82-year-old female who presented with acute small bowel obstruction secondary to strangulated obturator hernia on cross-sectional imaging.

Results

The patient underwent emergency surgery using laparoscopic approach for repair of obturator hernia and assessment of obstructed small bowel. Our approach involved identification and reduction of small bowel loop. A transabdominal preperitoneal approach was made to obturator hernia and ischaemic sac was reduced followed by closure of defect with a plug of biologic mesh. A linear segment of ischaemic small bowel was oversewn. Total operative time was 90 minutes.

Conclusions

Minimally-invasive surgery is an important tool in the armamentarium of the acute care surgeon. A laparoscopic approach will reduce the insult of intervention in already physiologically deplete patients. This case demonstrates the feasibility of laparoscopy for small bowel obstruction secondary to strangulated obturator hernia in the acute setting, requiring advanced laparoscopic skill as demonstrated in this video.

Development and evaluation of a brief educational cartoon on trainee clinicians' awareness of risks of ionising-radiation exposure: a feasibility pre-post intervention study of a novel educational tool to promote patient safety

Background

Over recent decades, CT scans have become routinely available and are used in both acute medical and outpatient environments. However, there is a small increase in the risk of adverse consequences, including an increase in the risk of both malignancy and cataracts. Clinicians are often unaware of these facts, and this represents a challenge for medical educators in England, where almost 5 million CT scans are done annually. New whiteboard methodologies permit development of innovative educational tools that are efficient and scalable in communicating simple educational messages that promote patient safety.

Methods

A short educational whiteboard cartoon was developed to explore the prior observation that adolescents under the care of paediatricians had a much lower risk of receiving a CT scan than those under the care of clinicians who care for adults. This explored the risks after receiving a CT scan and strategies that can be used to avoid them. The educational cartoon was piloted on new doctors who were attending induction training at a busy teaching hospital.

Results

The main output was the educational whiteboard cartoon itself. Before the new medical trainees’ induction, 56% (25/45) had received no formal training in radiation awareness, and this decreased to 26% (6/23) after the exposure to the educational cartoon (p=0.02). At baseline, 60% (27/45) of respondents considered that young females were at highest risk from exposure to ionising radiation, and this increased to 87% (20/23) after exposure to the educational cartoon (p=0.06).

Conclusions

This proof-of-concept feasibility study demonstrates that whiteboard cartoons provide a novel and feasible approach to efficiently promote patient safety issues, where a short succinct message is often appropriate.

The efficacy of endoscopic third ventriculostomy in children 1 year of age or younger: A systematic review and meta-analysis

PURPOSE

Hydrocephalus is a major cause of morbidity in the pediatric population, with potentially severe consequences if left untreated. Two viable strategies for management of non-communicating hydrocephalus are endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunting. However, there is uncertainty over the safety and efficacy of ETV in younger infants aged 1 year or below. In this systematic review, we aim to elucidate the success rate and procedural risks of ETV in this age group.

METHODS

A multi-database (PubMed, Embase, Web of Science) literature search between January 1990 and April 2018 was performed in accordance with PRISMA guidelines. Eligible studies were included if they (i) examined non-communicating hydrocephalus; (ii) quantified the success/failure rates of ETV; and (iii) assessed outcomes in children 1 year of age or younger.

RESULTS

A total of 19 articles with 399 patients were eligible for inclusion. Mean age at procedure was 4.2 months (range 34 weeks gestation to 12 months), with 116 females and 143 males. Commonest underlying aetiology was congenital aqueductal stenosis (AS) (60.4%). Remaining causes included post-haemorrhagic, post-infection, Chiari malformations, malignancies and others. Overall and AS mean success rates were 51.6% and 56.5% respectively. Overall complication rate was 10.0%, consisting mainly of CSF leak, infection, and haemorrhage. Younger age was significantly associated with poorer ETV success rate when divided into <6 months and 6-12 months of age (44.4 vs 66.7%; p = 0.0007). Underlying pathology had no significant association with ETV outcome when divided into AS and other pathologies (p = 0.53).

CONCLUSIONS

Age is significantly associated with ETV success rates. Pathology-dependent effects were not found in this age group. Despite a lower ETV success rate at younger ages (44.4 vs 66.7%), it offers a comparable safety profile that is independent of age. ETV remains a viable treatment option for non-communicating hydrocephalus for infants aged 1 year or younger.

Outcomes with respect to extent of surgical resection for pediatric atypical teratoid rhabdoid tumors

PURPOSE

To evaluate overall survival for atypical teratoid rhabdoid tumors (ATRTs) in relation to extent of surgical resection.

METHODS

The neurosurgical tumor databases from three UK Pediatric centers (University Hospital of Wales, Alder Hey and Royal Manchester Children's Hospital) were analyzed. Patients with a diagnosis of ATRT were identified between 2000 and 2018. Data was collected regarding demographics, extent of resection, complications, and overall survival.

RESULTS

Twenty-four patients diagnosed with ATRT underwent thirty-eight operations. The age range was 20 days to 147 months (median 17.5 months). The most common location for the tumor was the posterior fossa (nine patients; 38%). Six patients (25%) underwent a complete total resection (CTR), seven (29%) underwent a near total resection (NTR), eight (33.3%) underwent a subtotal resection (STR), and three patients (12.5%) had biopsy only. Two-thirds of patients who underwent a CTR are still alive, as of March 2019, compared to 29% in the NTR and 12.5% in the STR groups. Out of the thirty-eight operations, there were a total of twenty-two complications, of which the most common was pseudomeningocele (27%). The extent of surgical resection (p = 0.021), age at surgery (p = 0.00015), and the presence of metastases at diagnosis (0.015) significantly affected overall survival.

CONCLUSIONS

Although these patients are a highly vulnerable group, maximal resection is recommended where possible, for the best chance of long-term survival. However, near total resections are likely beneficial when compared with subtotal resections and biopsy alone. Maximal surgical resection should be combined with adjuvant therapies for the best long-term outcomes.

Surgical management of raised intracranial pressure secondary to otogenic infection and venous sinus thrombosis

PURPOSE

This study reviews paediatric patients with raised intracranial pressure as a result of venous sinus thrombosis secondary to otogenic mastoiditis, requiring admission to the paediatric neuroscience centre at the University Hospital Wales, Cardiff. The consensus regarding the management of otogenic hydrocephalus in the published literature is inconsistent, with a trend towards conservative over surgical management. We reviewed our management of this condition over a 9-year period especially with regard to ventriculo-peritoneal (VP) shunting.

METHODS

Analysis of a prospectively collected database of paediatric surgical patients was analysed and patients diagnosed with otogenic hydrocephalus from November 2010 to August 2018 were identified. Our data was compared with the published literature on this condition.

RESULTS

Eleven children, 7 males and 4 females, were diagnosed with otogenic hydrocephalus over the 9-year period. Five (45.5%) required VP shunt insertion to manage their intracranial pressure and protect their vision. The remaining six patients (54.5%) were managed medically.

CONCLUSIONS

When children with mastoiditis and venous sinus thrombosis progress to having symptoms or signs of raised intracranial pressure, they should ideally be managed within a neuroscience centre. Of those children, almost half will need permanent cerebrospinal fluid diversion to protect their sight.

P104 One year failure rates for de novo ventriculo-peritonealshunts in under 3- month-old children

Objectives

Historically VPS failure and infection rates are higher for neonates than for older children. We compared our one year VPS failure and infection rates in under 3-month-olds with those of older children.

Design

A retrospective, single centre study comparing 1 year survival and infection rates of VPS in under 3-month-olds verses older children.

Subjects

58 children under 3 months of age underwent VPS insertion between January 2007 and December 2016.

Methods

Data was collected by three independent reviewers from electronic files and case notes. Data was analysed using descriptive statistics and one year shunt survival curves were produced.

Results

For children under 3 months there was a 29.3% one-year shunt failure rate, of which 2 were shunt infections (3.4%). In patients greater than 3 months, the shunt malfunction rate was 23.4% and the infection rate was 4.3%. There were no shunt-related mortalities in either group.

Conclusions

Children under 3-months-old undergoing VPS insertion should not automatically expect an increased 1 year failure or infection rate compared with older children. Reasons for this may be increased sub-specialisation, improved neonatal care and use of antibiotic impregnated catheters.

One year failure rates for de-novo ventriculo-peritoneal shunts in under 3-month-old children

Introduction: Ventriculo-peritoneal shunts (VPS) are still the mainstay treatment for hydrocephalus in children. It is generally accepted that VPS failure and infection rates are higher for neonates than for older children. We compared our 1-year failure and infection rates in under 3-month-old children compared with older children in our department. Results: We identified 58 children under 3 months of age who underwent VPS insertion between January 2007 and December 2016. They had a 29.3% (17) shunt failure rate over the first year. There were two confirmed shunt infections (3.4%). Discussion: The 1-year shunt failure rate at our institution for VPS insertion in children over 3 months is 26.1% and the infection rate is 4.3% (9). The literature suggests that the outcome for VPS in younger children is worse than for older children. Our work shows similar outcomes for all children compared to those under 3 months at time of VPS insertion alone. Conclusion: Children under 3-months-old undergoing VPS insertion should not automatically expect an increased 1-year failure or infection rate compared with older children. The reasons for this may be as a result of increased subspecialisation, the more widespread use of antibiotic-impregnated catheters and improved neonatal care.

How much do plastic surgeons add to the closure of myelomeningoceles?

PURPOSE

This study reviews the outcomes of children undergoing myelomeningocele (MMC) repair in the paediatric neurosurgical department in Cardiff. These procedures are historically performed by paediatric neurosurgeons with occasional support from plastic surgeons for the larger lesions. We reviewed the postoperative outcomes over a 9-year period to assess the efficacy of having a plastic surgeon present at all MMC closures.

METHODS

Analysis of a prospectively collected database of all MMC closures performed at University Hospital Wales from April 2009 to August 2017 was used. Comparison was made with the published literature especially with regard to complications.

RESULTS

Thirty-one children, 13 males and 18 females, underwent MMC closure over the 9-year period. Twenty-four (77.4%) defects were closed by direct approximation. Seven patients (22.5%) required a more complex plastic procedure to obtain closure. Two patients (6.5%) had a wound complication, one wound infection and one flap edge necrosis both healing with dressings alone. Two patients had cerebrospinal fluid (CSF) leaks that responded to ventriculo-peritoneal shunting. Two patients died from unrelated conditions during the study period.

CONCLUSION

In our series, 7/31 (22.5%) cases involved a more complex closure in keeping with the literature. The authors feel that having the plastic surgeon at all closures has led to a low wound complication rate.

Outcomes of ventriculoperitoneal shunt insertion in the management of idiopathic intracranial hypertension in children

PURPOSE

The ventriculoperitoneal (VP) shunt has become the procedure of choice for treatment of idiopathic intracranial hypertension (IIH). We aimed to assess the efficacy of frameless stereotactic placement of VP shunts for the management of medically resistant IIH in children and to assess the role of gender and obesity in the aetiology of the condition.

METHODS

This is a retrospective analysis of the case notes of 10 patients treated surgically at the University Hospital of Wales in Cardiff, from May 2006 to September 2012.

RESULTS

VP shunts were successful in relieving headache, papilloedema and stabilising vision. No sex predilection was identified, and increased BMI was a feature throughout the population, regardless of age.

CONCLUSIONS

Neuronavigated VP shunt insertion is an effective mode of treatment for medically resistant IIH in children. The aetiological picture in children does not seem to be dominated by obesity, as in adults. Literature on childhood IIH is sparse, and larger scale, comparative studies would be of benefit to treating clinicians.

Ventriculo-peritoneal shunt independence following successful treatment of Gram negative (E. coli) ventriculitis: Case report and review of the literature

We report a case of tumour-related hydrocephalus in a child treated with a ventriculo-peritoneal shunt which subsequently became infected with gram negative bacteria (Escherichia coli). After successful treatment of the infection the patient became shunt independent and has remained so for over 2 years. Gram negative ventriculitis is associated with diminished cerebro-spinal fluid production and we discuss the literature to date regarding this phenomenon.

Utility of postoperative CEA for surveillance of recurrence after resection of primary colorectal cancer

INTRODUCTION

To evaluate the usefulness of postoperative CEA levels in the surveillance of colorectal cancer patients.

METHODS

Over a 56 month period a total of 569 patients with measured CEA levels underwent curative resection for colorectal cancer. The median follow up was 40 months, during which period recurrence occurred in 149. Serum CEA levels were measured at 6 monthly intervals starting from 3 months post resection. ROC was used to calculate the optimum cut-off of CEA (5 ng/ml).

RESULTS

Postoperative elevation of CEA levels were more frequent in patients with an aggressive primary colorectal cancer (grade, T stage and nodal disease; p < 0.05). In patients found to have colorectal recurrence, a significantly higher proportion of patients were resectable in the group with a non-elevated CEA (diagnosed by CT with PET imaging p < 0.05). The median interval between CEA elevation and diagnosis of recurrence (diagnostic interval) was 4 weeks. CEA elevation led to a change in the routine surveillance program by bringing imaging forward by 2 months. CEA levels were a significant predictor of survival following resection of colorectal primary (CEA ≤5-38 months, CEA >5-27 months; p < 0.05). CEA (p < 0.05) retained its significance on multivariate analysis along with the T stage (p < 0.05).

CONCLUSION

CEA is a predictor of recurrence, resectability and survival following resection of colorectal cancer. Furthermore, an elevated CEA has a short diagnostic interval (4 weeks) for detecting recurrent disease and therefore should mandate adjustment of the routine surveillance program with the next planned imaging being brought forward (2 months).

Acute appendicitis with unusual dual pathology

INTRODUCTION

Meckel's diverticulum is a rare congenital abnormality arising due to the persistence of the vitelline duct in 1-3% of the population. Clinical presentation is varied and includes rectal bleeding, intestinal obstruction, diverticulitis and ulceration; therefore diagnosis can be difficult.

PRESENTATION OF CASE

We report a case of acute appendicitis complicated by persistent post operative small bowel obstruction. Further surgical examination of the bowel revealed an non-inflamed, inverted Meckel's diverticulum causing intussusception.

DISCUSSION

Intestinal obstruction in patients with Meckel's diverticulum may be caused by volvulus, intussusception or incarceration of the diverticulum into a hernia. Obstruction secondary to intussusception is relatively uncommon and frequently leads to a confusing and complicated clinical picture.

CONCLUSION

Consideration of Meckel's diverticulum although a rare diagnosis is imperative and this case raises the question "should surgeons routinely examine the bowel for Meckel's diverticulum at laparoscopy?"

E-learning vs lecture: which is the best approach to surgical teaching?

AIM

Most medical teaching is still delivered by traditional face-to-face interaction. E-learning has the potential benefit of instilling deeper learning of topics by virtue of repeated and convenient access to content presented in a range of media. We aimed to evaluate objectively the benefit of educating medical students on a common surgical topic (haemorrhoids), through a website and podcast package vs a traditional lecture.

METHOD

Baseline knowledge was established by a questionnaire given to two different groups of third-year medical students starting their first clinical attachment. Group A (n = 73) was given a lecture and group B (n = 75) was asked to use a website containing text and pictures augmented by a podcast. Students were reassessed using the same preintervention questionnaire, and satisfaction was acquired from details given in a feedback form.

RESULTS

There was no difference in knowledge between the two groups at baseline. Both groups demonstrated significant gains in knowledge after intervention (P < 0.0001). Group B (Web/podcast) showed a significantly greater increase in knowledge (P < 0.05) than group A (lecture). Preintervention subjective assessment of knowledge rated by the students showed no difference between the groups. Both groups of students were equally satisfied with the educational method.

CONCLUSION

E-learning supplemented with a podcast results in greater knowledge acquisition when compared with a traditional lecture, without a loss of satisfaction with teaching. Using augmented Web-based educational tools reduces demands on teaching time with no decrease in quality for selected parts of the curriculum.

Lymph node ratio versus number of affected lymph nodes as predictors of survival for resected pancreatic adenocarcinoma

BACKGROUND

The objective of this study was to compare the prognostic significance of the lymph node ratio (LNR) with the absolute number of affected lymph nodes for resected pancreatic ductal adenocarcinoma.

METHODS

Data were collected from 84 patients who had undergone pancreatoduodenectomy for pancreatic ductal adenocarcinoma over a 10-year period. Patients were categorized into four groups according to the absolute LNR (0, 0-0.199, 0.2-0.299, > or =0.3). Kaplan-Meier and Cox proportional hazard models were used to evaluate the prognostic effect.

RESULTS

An LNR of > or =0.2 (median survival 8.1 vs. 35.7 months with LNR < 0.2; p < 0.001) and > or =0.3 (median survival 5.9 vs. 29.6 months with LNR < 0.3; p < 0.001), tumor size (p < 0.017), positive resection margin (p < 0.001), and nodal involvement (p < 0.001) were found to be significant prognostic markers following univariate analysis. Following multivariate analysis, only LNR at both levels [> or =0.2 (p = 0.05; HR 1.8) and LNR of > or =0.3 (p = 0.01; HR 2.7)] were independent predictors of a poor outcome. The number of lymph nodes examined had no effect on overall survival in either node-positive patients (p = 0.339) or node-negative patients (p = 0.473).

CONCLUSIONS

The LNR represents a stronger independent prognostic indicator than the absolute number of affected lymph nodes in patients with resected pancreatic ductal adenocarcinoma.

Otosclerosis 3: the surgical management of otosclerosis

The surgical management for otosclerosis has evolved from stapes mobilisation to total extraction of the footplate, the so called 'stapedectomy', to a small hole in the stapes footplate, the 'stapedotomy'. The aim of stapes surgery is to restore the vibration of fluids within the cochlear canal. Revision stapedectomy should be approached with caution. Stapedectomy can lead to some minor and other more serious complications.

A pre-operative elevated neutrophil: lymphocyte ratio does not predict survival from oesophageal cancer resection

Background

Elevated pre-operative neutrophil: lymphocyte ratio (NLR) has been identified as a predictor of survival in patients with hepatocellular and colorectal cancer. The aim of this study was to examine the prognostic value of an elevated preoperative NLR following resection for oesophageal cancer.

Methods

Patients who underwent resection for oesophageal carcinoma from June 1997 to September 2007 were identified from a local cancer database. Data on demographics, conventional prognostic markers, laboratory analyses including blood count results, and histopathology were collected and analysed.

Results

A total of 294 patients were identified with a median age at diagnosis of 65.2 (IQR 59-72) years. The median pre-operative time of blood sample collection was three days (IQR 1-8). The median neutrophil count was 64.2 × 10^-9/litre, median lymphocyte count 23.9 × 10^-9/litre, whilst the NLR was 2.69 (IQR 1.95-4.02). NLR did not prove to be a significant predictor of number of involved lymph nodes (Cox regression, p = 0.754), disease recurrence (p = 0.288) or death (Cox regression, p = 0.374). Furthermore, survival time was not significantly different between patients with high (≥ 3.5) or low (< 3.5) NLR (p = 0.49).

Conclusion

Preoperative NLR does not appear to offer useful predictive ability for outcome, disease-free and overall survival following oesophageal cancer resection.

Small RNA: a large contributor to carcinogenesis?

INTRODUCTION

Homeostasis in normal tissue includes balancing cell proliferation and apoptosis (programmed cell death). Mutations in proto-oncogenes or tumor suppressor genes may lead to disruption of normal cellular function, uncontrolled cell proliferation, and subsequent carcinogenesis.

DISCUSSION

Micro-RNAs (miRNAs) are short (19-24 nucleotide) noncoding RNA sequences that inhibit protein translation and can cause the degradation of subsequent messenger RNA, thus playing an important role in the regulation of gene expression. Aberrant expression of miRNAs has been shown to inhibit tumor suppressor genes or inappropriately activate oncogenes initiating the cancer process. Unique miRNA expression profiles have been found in different cancer types at different stages, suggesting a possible diagnostic application. This review summarizes the current evidence supporting a link between aberrant miRNA expression and carcinogenesis and its possible role in improving diagnosis and treatment of cancers, particularly of gastrointestinal origin.

Two-ion Coulomb crystals of Ca + in a Penning trap

Results demonstrating laser cooling and observation of individual calcium ions in a Penning trap are presented. We show that we are able to trap, cool, image and manipulate the shape of very small ensembles of ions sufficiently well to produce two-ion 'Coulomb crystals' aligned along the magnetic field of a Penning trap. Images are presented which show the individual ions to be resolved in a two-ion crystal. A distinct change in the configuration of such a crystal is observed as the experimental parameters are changed. These structures could eventually be used as building blocks in a Penning trap based quantum computer.

Clinical outcomes of total laryngectomy for laryngeal carcinoma

Background: Controversy exists as to the management of advanced laryngeal carcinoma. In general primary radical surgery is favoured. Objective: The aim of this study was to analyse the clinical outcome of patients having total laryngectomy for cancer of larynx. Materials and methods: This study was a retrospective case note review and questionnaires were used for evaluating voice handicap. These laryngectomies included in this study were performed by the senior author (CJW) from January 2001 till June 2007 at Leeds General Infirmary, Leeds. Some of the patients had partial or total pharyngectomy in addition to total laryngectomy. Results: In this study a total of 59 patients were included. Seventeen (28.8%) of these patients had preoperative radiotherapy and laryngectomy was performed for residual or recurrent disease. The initial TNM staging of the tumour ranged from T1N0 to T4N2C. Tracheoesophageal puncture for speech prosthesis was done in 48/59 (81.4%) patients. Post-operative complications were seen in 30.5% (18/59) patients. In this study group 9 patients (15.2%) developed pharyngocutaneous fistulas. For communication 31/51 (60.8%) patients were using speech valves. In this study 30.4% had minimal, 26.1% moderate and the rest 43.4% feeling severely handicapped with regards to voice use after total laryngectomy. Five year survival after laryngectomy in this study was 65.2%. Conclusion: Long term disease control and survival is achievable with total laryngectomy with or without postoperative radiotherapy with minimal risks in patients with advanced carcinoma of larynx. Key words: Laryngectomy; Larynx; Carcinoma DOI: 10.3126/kumj.v7i3.2734 Kathmandu University Medical Journal (2009) Vol.7, No.3 Issue 27, 258-262