PET-CT in the diagnosis of recurrent rectal cancer complicated by left thigh abscess

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Torsion of an omental lipoma presenting as an emergency

Primary omental pathology is rare. A case of torsion of an omental lipoma is reported in a 77-year-old women presenting as an emergency with lower abdominal pain. Abdominal and pelvic CT scan was of value in the pre-operative investigation.

Improvement in quality of colorectal cancer pathology reporting with a standardized proforma--a comparative study

BACKGROUND

Histopathological evaluation is a critical component in the management of patients with colorectal cancer (CRC). It is the single most powerful prognostic indicator in CRC and determines if adjuvant chemotherapy is indicated. The aim of this study was to assess if the introduction of a comprehensive standardized pathology proforma improved the quality of histopathology reporting.

METHODS

A standardized pathology proforma, based on the 1996 minimum dataset for colorectal histopathology reporting, was introduced in our pathology department in 1998. Pathology reports for all colonic resection specimens for 1996 (n = 85) and 2000 (n = 86) were identified, retrieved and entered on to database. Comparison was made with the minimum dataset published in the 1996 guidelines for the management of colorectal cancer.

RESULTS

Demographic details were complete in all cases. Clinical data was incomplete in 57 (67%) patients in 1996 and 63 (73%) in 2000 (ns; chi2). There were 24 (28%) (7 Abdomino-perineal resections (APER)) and 40 (47%) (17 APER's) rectal specimens for 1996 and 2000, respectively. The presence or absence of pathological background abnormalities were commented on in 18 (21%) reports in 1996 and 80 (93%) reports in 2000 (P < 0.01; Fishers exact test (Fisher)). Histological differentiation was commented on in 73 (86%) and 86 (100%) in 1996 and 2000, respectively (P < 0.01; Fisher). Dukes' stage was stated in 33 (39%) reports in 1996 and 86 (100%) in 2000 (P < 0.01; Fisher) but Dukes' stage was calculable in 84 (99%) in 1996 and 86 reports (100%) for 2000 (ns; Fisher). The apical node was commented on in 34 (40%) reports in 1996 and 85 (99%) reports in 2000 (P < 0.01; Fisher). The median (IQR) number of nodes assessed in 1996 was 8 (5-12) compared to 12 (8-17) in 2000 (P < 0.001; Mann-Whitney (MW)). Complete resection was mentioned in 74 (87%) reports in 1996 and 86 (100%) in 2000 (P < 0.01; Fisher). Regarding rectal specimens, the circumferential resection margin (CRM) was commented on in 19 of 24 specimens in 1996 and 38 of 40 specimens in 2000 (ns; Fisher). Relationship to the peritoneal reflection was commented on in 1 (1%) rectal specimen in 1996 and 30 (35%) in 2000 (P < 0.001; Fisher).

CONCLUSION

The introduction of a standardized proforma for reporting CRC resection specimens improves the quality of histopathological reporting. This aids decision-making regarding adjuvant chemotherapy or radiotherapy and further surveillance.

Vacuum assisted closure system in the management of enterocutaneous fistulae

BACKGROUND

A very important yet often troublesome element in the conservative management of enterocutaneous fistulae is the protection of the surrounding skin from contact with the effluent. This report describes the successful use of a vacuum assisted closure (VAC) system in dealing with this problem.

METHODS

The results of using the VAC system were studied in three patients with moderate or high volume output enterocutaneous fistulae where conventional treatment had failed to prevent skin excoriation.

RESULTS

The VAC system was found to be highly effective in controlling fistula effluent and in promoting healing of excoriated skin in all three patients. Complete healing of the fistula was also achieved in two of the three patients.

CONCLUSION

The VAC system can be an effective and economically viable method of containing fistula effluent and protecting the skin of patients with enterocutaneous fistulae. Contrary to conventional thought, the VAC system may also actually promote healing of the fistula.

Cronkhite-Canada syndrome

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Hartmann procedure revisited

OBJECTIVE

To assess the complications and results of Hartmann's procedure and secondary restoration of continuity for left-sided colonic disease.

DESIGN

Retrospective study.

SETTING

University hospitals, Northern Ireland.

SUBJECTS

72 Patients who required a Hartmann's procedure over a 13 year period (1985-1998).

INTERVENTION

Of these 45 (63%) were done as emergencies and 27 (38%) as elective procedures. The indications for an emergency procedure were obstruction and perforation.

MAIN OUTCOME MEASURES

Mortality, morbidity, reversal of stoma rate.

RESULTS

The overall postoperative mortality was 7/72 (10%), with no significant difference between the emergency (4/45, 9%) and the elective (3/27, 11%) groups. Postoperative complications occurred in 31 patients (43%), and 8 developed wound infections (11%). Of the 43 surviving patients who where deemed suitable for re-establishment of continuity, 30 (70%) have had it done. There were no postoperative deaths or anastomotic dehiscences after the restoration of continuity.

CONCLUSION

Hartmann's procedure remains a safe and suitable option in patients with left sided colonic emergencies.

Massive abdominal and pelvic myxoma in Carney's syndrome

This report describes a massive abdominal and pelvic myxoma in a patient with Carney's syndrome. A 38 year old woman presented with abdominal distension and a palpable mass, and at operation a large pelvic and abdominal tumour was identified and resected. The surgical specimen consisted of a lobulated mass, which on cut section had a uniform gelatinous consistency. The mass surrounded both ovaries, the appendix, and the upper part of the uterus, but macroscopically did not appear to involve these organs. Histological examination showed plump stellate and spindle shaped cells set in an abundant myxoid stroma, in keeping with a myxoma. Immunohistochemical staining revealed positivity of tumour cells for vimentin, but no reactivity to desmin, alpha-smooth muscle actin, S-100 protein, CD34, or AE1/AE3. This is the first documented case of massive adominal and pelvic myxoma in a patient with Carney's syndrome. Clinicians and pathologists should be aware that myxomas in Carney's syndrome can rarely involve unusual sites other than the skin and heart.

Rectus sheath haematoma

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A prospective randomised study comparing polyethylene glycol and sodium phosphate bowel cleansing solutions for colonoscopy

Polyethylene glycol (Klean-Prep, Norgine) is widely used for bowel cleansing in the United Kingdom. This study compares the efficacy, acceptability and adverse effects of a polyethylene glycol (PEG) solution with sodium phosphate (Fleet Phospho-soda, De Witt) for bowel preparation prior to colonoscopy. Two hundred and nine consecutive patients were prospectively randomised to either PEG or sodium phosphate (SP) preparation. The endoscopist was blinded to the randomisation process. Fifty patients were excluded from the study because of previous colectomies or incomplete data. Of the remaining 159 patients, 88 had been randomised to the PEG group and 71 to the SP group. There was no difference in sex distribution between the groups. There were no significant differences between groups in terms of patient acceptability, side effects (nausea/vomiting and abdominal cramps), adequacy of bowel preparation and colonoscopy completion rates. 74% of the PEG and 70.4% of the SP group were rated by the endoscopist as having good or excellent bowel preparation. Sodium phosphate is well tolerated without additional side effects when compared with PEG solution. Both solutions were found to be equally effective in bowel cleansing.

Pathology of rectal adenocarcinoma following preoperative adjuvant radiotherapy and chemotherapy

The study group comprised 13 patients (mean age 68 years) with clinically fixed and biopsy proven moderately differentiated rectal adenocarcinoma (8 high rectal, 5 low-mid rectal) who received synchronous courses of preoperative combination chemotherapy and pelvic radiotherapy (radiotherapy alone in 3 cases) over a period of 8-20 weeks prior to surgical resection. All cases showed varying degrees of mural and mesorectal fibrosis. Three cases did not differ otherwise from usual rectal adenocarcinoma while 4 had a 20-30% diminution in expected tumour area. In 6 cases tumour could not be definitely identified grossly--1 showed a 50% reduction in tumour bulk while 5 had only residual microscopic foci from 0.6-4 mm in maximum dimensions. Only 3 cases had involvement of the mesorectal circumferential radial margin. Four involved lymph nodes in 2 cases were partially hyalinised and calcified. Preoperative combination adjuvant therapy can produce marked regressive morphological changes in rectal adenocarcinoma. The implications of this are discussed.

Small intestinal ulceration secondary to carcinoid tumour arising in a Meckel's diverticulum

A solitary small intestinal ulcer associated with a carcinoid tumour in a nearby Meckel's diverticulum was found in a 77 year old man presenting with massive rectal bleeding. Angiography and a radioisotope study localised the bleeding to the ileum. At operation, the Meckel's diverticulum was identified, with bleeding from an ulcer just distal to it. Pathological examination revealed a small carcinoid tumour confined to the Meckel's diverticulum. Close to the opening of the diverticulum, within the ileum, a well demarcated ulcer was present. Histology showed a non-specific ulcer which eroded a large blood vessel. This is the first documented occurrence of solitary small intestinal ulceration in association with a carcinoid tumour. Carcinoid tumour should be added to the list of possible causes of small intestinal ulceration. The ulceration may be secondary to release of cytokines by the tumour.

Fine needle aspiration cytology of gastric carcinoma

Four patients between 58 and 81 years of age undergoing investigation and endoscopic biopsy for gastric carcinoma also were subjected to direct-vision fine needle aspiration cytology of their mucosal lesions which yielded malignant cells. The relevance of this technique is discussed regarding both intrinsic and extrinsic lesions of the gastrointestinal tract.

Experience with schistosomiasis in Northern Ireland

Five cases of schistosomiasis have been recorded in the Belfast City Hospital Histopathology Laboratory over the last three years. The sites of infection have included the colon, bladder, uterus and seminal vesicles. All the infected individuals had visited Africa. Three of them were health care workers. The clinician must maintain a high index of suspicion when treating those with a history of travel and risk of exposure to this infection. Diagnosis is made even more critical as the condition is treatable, and serological markers can identify those with occult infection.

A prospective study of adult inguinal hernia repairs using absorbable sutures

A prospective study was conducted over a 5-year period to determine whether inguinal hernia repair could be safely performed with absorbable suture material (polydioxanone) with reference to recurrence rates, wound pain, haematoma formation and wound infection. Analysis is available for 111 operations involving 111 patients. Mean follow-up was 36 (range 21-66) months, with 81 procedures monitored for more than 2 years. Two-layered hernia repair was used in all cases with polydioxanone as the chosen suture material. Mean post-operative stay was 2.1 days, with no hospital wound infections and three haematomas. Review identified 1 wound infection. There have been two recurrences. Preliminary results suggest that hernia repair with absorbable suture materials is comparable to traditional non-absorbable repair in terms of recurrence and associated wound complications. The additional benefit is the absence of foreign material in the wound region following degradation of the absorbable material. This does not appear to compromise the integrity of the hernia repair. Mesh repairs are increasingly preferred to Shouldice-style repairs in elective inguinal hernias. However, we believe that polydioxanone should be the suture material of choice in obstructed or strangulated hernia. A larger study is required to verify this, as well as a longer follow-up period. The use of absorbable material warrants further investigation.

Unnecessary delays in accident and emergency departments: do medical and surgical senior house officers need to vet admissions?

Work was carried out to determine whether patients requiring emergency medical or surgical admission to hospital via accident and emergency (A&E) departments benefit from initial assessment by the ward senior house officer (SHO) as well as the A&E SHO. Two comparable consultant-led A&E departments sharing the same catchment population and receiving similar numbers of new patients each year were studied. A panel of four consultants audited the A&E notes and in-patient records of consecutive emergency medical and surgical patients admitted to two hospitals over the same 6 month period. In one hospital patients were seen and admitted by the A&E SHO alone. In the other hospital patients were seen by the A&E SHO and the medical or surgical SHO from the admitting unit. Diagnostic errors, inappropriate admissions to hospital and admission of patients to inappropriate wards were used as outcome measures. There was no significant difference in the rates of diagnostic error or inappropriate admissions between those patients seen by an A&E SHO only, and those seen in A&E by the A&E and ward SHOs. Detaining emergency medical and surgical patients in the A&E department for further assessment by ward SHOs does not alter inappropriate admission rate or improve diagnostic accuracy.

Linear IgA disease (LAD): immunoglobulin deposition in oral and colonic lesions

Two cases of adult linear IgA disease (LAD) with oral and colonic involvement are presented. Oral findings, for both patients, were of widespread painful ulceration present for two to three months and diagnosis was confirmed by biopsy and direct immunofluorescence. Colonic symptoms preceded oral symptoms in both cases and a number of investigations were undertaken, including routine histological examination, which suggested either lymphocytic colitis or Crohn's disease. Immunofluorescence studies showed linear IgA deposition confined to the distal colon. These cases highlight that large bowel involvement can be a feature of linear IgA disease and for the first time demonstrate IgA deposition at that site.

Irradiated polyglactin 910: a new synthetic absorbable suture

Two hundred and thirty-six patients had a variety of skin and mucosal wounds sutured with a new rapidly absorbed suture material (irradiated polyglactin 910). No wound complications could be attributed to the material. These included 62 patients with scalp wounds, taking part in a comparative trial with traditional interrupted, monofilament, non-absorbable suturing. No difference in the cosmetic result could be detected three months later. The irradiated polyglactin disappeared from the wound surface spontaneously and suture removal was not normally required. Irradiated polyglactin 910 is suitable for closure of wounds where rapid suture absorption is desirable, particularly for wounds in the scalp, scrotum, and perineum and is an ideal material for mucocutaneous anastomosis at stoma surgery. Loss of suture strength is so rapid that suture removal is unnecessary, eliminating the need for further medical or paramedical care. As absorption is by hydrolysis rather than enzymatic digestion, stitch abscesses are not seen.

Herniography for occult hernia and groin pain

In a prospective 3-year study herniography was used to assess patients with unexplained groin pain in whom clinical signs were inconclusive. Fifty-two patients were studied. No serious complications were observed. Twenty-two hernias were identified in 18 patients. The positive herniographic findings were confirmed at operation in 12 patients. Of 34 patients with a negative herniogram, none has developed a hernia. Pain settled spontaneously in 29 patients and five were referred to a pain clinic for further management.

Malignant obstruction of the left colon

The management of malignant obstruction of the colon distal to the splenic flexure is controversial. The 'traditional' three-stage procedure is marred by frequent failure to complete the planned sequence of operations and a resulting high permanent stoma rate. At each stage the mortality rate (7 per cent) and morbidity rate (30 per cent) are significant. The mortality rate following primary resection with delayed anastomosis (Hartmann's procedure) is 10 per cent. However, many patients experience complications and only 60 per cent have the stoma reversed. Primary anastomosis may be performed after subtotal or segmental colonic resection. The reported mortality rate is about 10 per cent with anastomotic leakage in 4-6 per cent, but cases are often carefully selected. It is difficult to suggest clear guidelines based on existing data. Although there are strong arguments in favour of a single-stage procedure, surgeons must decide whether available resources and local circumstances permit this. The alternative is Hartmann's procedure or referral to a surgeon with an interest in emergency colorectal surgery.

Benign lymphangioma of the jejunal mesentery: an unusual cause of small bowel obstruction

Lymphangiomas are rare tumours of lymphatic vessels, most commonly found in children. We present the unusual case of small bowel obstruction caused by benign lymphangioma in a middle aged woman.

The surgical management of familial adenomatous polyposis in Northern Ireland

Sixty-eight patients from 18 families have been identified as having familial adenomatous polyposis during the past 30 years in Northern Ireland (population 1.5 million). Six of the 18 probands (33%) had developed colonic carcinoma when first seen at mean age 34 years. Ten of the 44 patients identified by surgical screening (21%) at a significantly lower mean age of 23 years had colonic carcinoma. Surgical management has generally been by subtotal colectomy with ileorectal anastomosis, or by panproctocolectomy and ileostomy.

Surgical training posts in Northern Ireland: assessment by surgeons in training

Northern Ireland has one of the largest surgical training programmes in the United Kingdom. The surgical trainees' assessment of the quality of training provided has been collated prospectively since 1983, and provides a useful insight into the strengths and weaknesses of the programme, as well as the training value of individual posts. The overall quality of clinical training in surgery was considered to be well above average, but some registrars felt that supervision of operative surgery could be improved. Clinical research was considered to be of average quality in the teaching hospitals but below average in district general hospitals. In the current climate of restriction of the number of training posts in general surgery, the views of the trainees should not be neglected in assessing which posts are best suited for training.

Single layer anastomosis in the upper gastrointestinal tract

A total of 466 single layer upper gastrointestinal anastomoses were made in 349 patients during an 11-year period. Six (1.3 per cent) anastomoses leaked. Radiological leakage was seen in one of 24 (4.2 per cent) oesophagogastric/jejunal anastomoses. There were no leaks after 66 gastrojejunal anastomoses; one of 84 (1.2 per cent) gastroduodenal anastomoses leaked and was converted to a gastrojejunal anastomosis. Two of 121 (1.7 per cent) biliary-enteric anastomoses leaked and both were successfully managed without reoperation. Two of 171 (1.2 per cent) enteroenteric anastomoses leaked, both in patients with established intraperitoneal sepsis which proved fatal. Of the 349 patients, 13 (3.7 per cent) died in hospital or within 30 days of operation but in only two was anastomotic leakage implicated. Single layer appositional upper gastrointestinal anastomoses are simple, safe and economic.

Post-operative sputum retention treated by minitracheostomy--a ward procedure?

Cricothyroidotomy, using the percutaneous 'minitracheotomy' technique, was performed in 67 patients (55 for sputum retention, two for endobronchial rupture of an empyema, 10 prophylactically). In two patients the cricothyroid membrane was penetrated with considerable difficulty, and in one further patient insertion was not possible due to calcification of the cricothyroid membrane. One patient required exploration of the insertion site because of bleeding. Two patients inhaled the 'Mark 1 Minitrach' device and required urgent bronchoscopic removal. In those patients undergoing successful cricothyroidotomy, there was a dramatic improvement in respiratory distress. There were no deaths related to the insertion of the minitracheotomy device in this series.

Clinical and pathological variability of infection by enterohaemorrhagic (Vero cytotoxin producing) Escherichia coli

The clinical and pathological features of five sporadic cases of enteric infection caused by Escherichia coli O157 (enterohaemorrhagic or Vero cytotoxin-producing E coli showed a range of features. These included one case with pseudomembranous colitis, one with an acute exacerbation of ulcerative colitis, and three with enterocolitis. Diagnostic difficulties encountered initially in four of the five cases were finally resolved by correlating the results of microbiological with histopathological investigations. In view of the heterogeneity of clinical and histological signs and symptoms, it is concluded that all patients with abdominal pain and diarrhoea or rectal bleeding should have early microbiological investigation.

Blood flow in diabetics with foot lesions due to 'small vessel disease'

Blood flow was measured in the feet and toes of 23 diabetics, 7 controls and 6 non-diabetic neuropathic controls, using venous occlusion plethysmography. All of the diabetics showed a characteristic flow abnormality with mild hyperperfusion of the foot at rest but impaired peak flow following arterial occlusion. When the diabetics were subdivided into those with 'small vessel disease', those with neuropathic ulceration and those with neuropathy but no ulceration, the groups had remarkably comparable blood flows, except that peak great toe blood flow was rather lower in small vessel disease. In small vessel disease, the combination of high resting blood flow and elevated foot venous oxygen saturation suggests that the hyperperfusion is due to arteriovenous shunting. It seems likely that the toe lesions ascribed to small vessel disease were in fact manifestations of severe diabetic neuropathy. The term small vessel disease should be avoided in the context of diabetic foot lesions.

Preventing wound infection after appendicectomy: a review

An exponential increase in the number of published prospective studies reflects both a continuing interest in, and a lack of consensus on, the optimal prophylaxis of wound sepsis after appendicectomy. Review of the literature over the last 25 years leads us to emphasize both the importance of adequate study size and of stratification of the severity of the sepsis found at operation. For critical comparison of prophylactic regimens the high percentage of wound infections disclosed after discharge from hospital must be taken into account. Antibiotics reduce the frequency of wound sepsis and although low wound sepsis rates have been reported with systemic antibiotics active against only anaerobes, the cumulative evidence favours a spectrum of antibacterial activity against both aerobic and anaerobic organisms. Topical antiseptics have no significant effect but topical antibiotics are beneficial. Wide variations in outcome for similar antibiotic regimens reflect the importance of technical factors in determining the frequency of wound sepsis.

Major arteriovenous fistula complicating aorto-iliac aneurysms

Seven cases of fistula developing between aortic or iliac aneurysms and adjacent major venous trunks are presented. The clinical diagnosis and principles of management of this exceptionally rare complication are discussed in the light of the literature on the subject.

A plethysmograph for the measurement of digital blood flow

Venous occlusion plethysmography using a water-filled plethysmograph is an accurate and reliable method for the measurement of limb flow which has been used for many years. The technique has been adapted to produce a plethysmograph for the measurement of digital blood flow. The device is small, light, cheap, simple to use, and can be calibrated directly with the digit 'in situ'. It is especially suitable for the assessment of digital blood flow, since flow through a large portion of the whole digit is measured and the local temperature of the digit is accurately controlled.

Effect of reconstructive vascular surgery on red cell deformability--preliminary results

Using a simple filtration method, red cell deformability was measured in healthy control subjects and in patients with peripheral vascular disease. Impaired red cell deformability was demonstrated in patients with rest pain or gangrene and in patients with intermittent claudication. An improvement in red cell deformability was demonstrated after successful reconstructive vascular surgery in both patient groups. An improvement in red cell deformability was demonstrated in patients undergoing major limb amputation.