General Surgery
Recent Submissions
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Is the increase in emergency colorectal cancer presentation directly related to the after effects of the pandemic?Poster abstract from the ESCP 17th Scientific & Annual Meeting, 21 - 23 September 2022, Dublin, Ireland.
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Multiple synchronous intestinal tumorsLetter to the Editor reporting the case of an 83-year-old woman with synchronous primary cancers of terminal ileum, sigmoid and upper rectum.
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Auditing the routine microbiological examination of pus swabs from uncomplicated perianal abscesses: clinical necessity or old habit?Background: Obtaining pus swabs from perianal abscesses after incision and drainage for subsequent microbiological analysis is traditionally performed by general surgeons. Our aim is to assess the current practice in our institution, emphasizing on whether pus swabs were sent or not, as well as to identify any associations between the revealed microbiology and the occurrence of immediate post-operative complications and re-admission rates with fistula-in-ano up to 12 months post the emergency drainage. Finally, we aimed to identify if the any members of the surgical team reviewed at any stage post-operatively the results of the microbiological examination of the obtained pus swabs and if that resulted in changes of the patient management. Methods: We reviewed the operative findings and perioperative antimicrobial management of all patients within our institution that required surgical treatment of perianal abscesses over a 6-week period and re-assessed them after 12 months from the performed drainage, with respect to re-admission and identification of occurred fistula-in-ano. Results: A total of 24 patients met our inclusion criteria. Pus swabs were sent in 66.7% of cases and only a third of the requested microbiology reports were reviewed by a part of the surgical team. All patients were discharged prior to the release of the microbiology results with no subsequent change in the management plan. We did not find any consistent association between the microbiology results and re-admission with perianal abscess, with or without fistula-in-ano. Conclusions: We do not recommend routine use of pus swabs when draining perianal abscesses unless clinical concerns arise, including recurrent perianal sepsis, immuno-compromised status or extensive soft tissue necrosis, especially when these features are associated with systemic sepsis.
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Benign multicystic peritoneal mesothelioma presenting as appendiceal abscess: a diagnostic and therapeutic challengePrimary peritoneal tumors are rarely encountered and their management is usually challenging for the clinicians. Especially when the patients with advanced peritoneal malignancy present as surgical emergencies, usually with symptoms of obstruction, perforation or gross space-occupying lesions, the on-call surgical team has to weigh the pros and cons of urgent versus delayed treatment and plans a safe and simultaneously oncologically beneficial therapeutic approach. Herein, we present a case of a Caucasian man who was referred as suspected complicated appendicitis by his primary care physician, with the final diagnosis being benign multicystic mesothelioma. We describe the challenges of the clinical decision making for the emergency general surgeon and relevant diagnostic and therapeutic pitfalls, which can be potentially minimized by early liaison with tertiary units specializing in the treatment of disseminated peritoneal malignancy.
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Low preoperative serum albumin levels are associated with impaired outcome after cytoreductive surgery and perioperative intraperitoneal chemotherapy for peritoneal surface malignanciesPreoperative hypoalbuminemia is known to be associated with postoperative morbidity and mortality, as well as with poor survival after gastrointestinal cancer surgery. However, limited data exist regarding the prognostic significance of hypoalbuminemia in patients with peritoneal metastases undergoing cytoreductive surgery, combined with perioperative intraperitoneal chemotherapy. We performed a systematic literature review of the previously published studies addressing the potential association between preoperative albumin levels and overall surgical outcomes after the performance of cytoreductive surgery and perioperative intraperitoneal chemotherapy for peritoneal surface malignancies. Our research yielded a total of nine retrospective studies which met our inclusion criteria, and despite their heterogeneity; and we can conclude that preoperatively low albumin levels are associated with greater likelihood of overall and major morbidity, as well as less favorable oncological outcome after the performance of cytoreductive surgery and perioperative intraperitoneal chemotherapy.
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Surveillance colonoscopy after appendicectomy in patients over the age of 40: targeted audit of outcomes and variability in practiceIntroduction: Recent evidence suggests the need to proceed with a surveillance colonoscopy in patients above the age of 40 years who undergo appendicectomy for acute appendicitis, given the higher risk of an underlying colonic tumor. After anecdotally observing a substantial variability in terms of adaptation of these recommendations by the on-call surgical teams, we performed a clinical audit regarding our relevant endoscopic follow-up compliance rates to identify areas for improvement of our practise. Materials Methods: We performed a retrospective review of the electronic records of all patients above 40 years who had appendicectomy for acute appendicitis within a 3-year period in our institution, assessing as primary outcome the actual performance of a follow-up colonoscopy and the detected endoscopic findings. Results: Our results demonstrated that more than 80% of our patients did not have an endoscopic follow-up, as suggested by the current evidence. In addition, with respect to the subspecialisation of the parent surgical team, it seems that non-colorectal teams had lower compliance regarding the arrangement of endoscopic surveillance, when compared to specialist colorectal team. Conclusions: Emergency surgical teams need to be further educated with respect to the current practise recommendations concerning the appropriate endoscopic follow-up after the performance of appendicectomy for acute appendicitis. Establishment of dedicated bundles of postoperative care, as well as clear relevant guidance from the gastrointestinal/emergency surgery societies would be of great value in this direction.
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Colonic obstruction secondary to incarcerated transiliac bone herniaTransiliac bone hernias are a rare cause of intestinal obstruction, and high clinical suspicion is required for their diagnosis.
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Single-centre experience of emergency hernia surgery during COVID-19 pandemic: a comparative study of the operative activity and outcomes before and after the outbreakAim The outbreak of COVID-19 pandemic in January 2020 affected largely the elective operating for non-urgent surgical pathologies, such as hernias, due to periodical cancellations of the operating lists on a worldwide scale. To the best of our knowledge, the long-term impact of the COVID-19 pandemic in relation to the emergency hernia surgery operative workload and postoperative outcomes remains largely unknown. Methods Retrospective research of admission, operation and inpatient records of all patients who underwent emergency surgery over a 2-year period (2019-2020) was done. Results An 18% increase in terms of emergency hernia surgery operating volume, with a 23% increase of visceral resections due to unsalvageable herniated content strangulation was found. Overall morbidity did not increase during the pandemic period and there was no postoperative mortality or occurrence of COVID-19 related complications. Conclusion Emergency operative management of acutely symptomatic hernias can be safely performed even during the COVID-19 infection peak waves; hernia taxis should be reserved only for patients unfit or unwilling to undergo upfront surgery.
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EGS P21 A review of emergency laparoscopic cholecystectomies during the COVID-19 pandemic compared to pre-pandemic. Is there a difference in patient and financial outcomes?A poster abstract from the AUGIS Annual Scientific Meeting, 21–23 September 2022, Aberdeen, reviewing emergency laparoscopic cholecystectomies during the COVID-19 pandemic.
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Routine extensive dissection of the cystic duct during laparoscopic cholecystectomy to reduce the risk of residual choledocholithiasis: an unnecessary step and a potentially hazardous conceptIntroduction: Post-cholecystectomy choledocholithiasis can occur from retained stones at the cystic duct stump remnant; however, most surgeons would not proceed with extensive dissection of the cystic duct during routine cholecystectomy, mainly in fear of inadvertent bile duct injuries, given the frequent anatomical variations of the extrahepatic biliary tree. Aim: To determine the need and feasibility of extensive dissection of the cystic duct during laparoscopic cholecystectomy, to reduce the risk of post-cholecystectomy choledocholithiasis. Material and methods: We performed a retrospective review of our institutional database of all patients who had magnetic resonance cholangiopancreatography (MRCP) prior to cholecystectomy over a 3-year period (03/2016-04/2019), assessing the anatomical variations of the cystic duct and the incidence of cystic duct stones. Results: During the study period, from a total of 763 patients who underwent cholecystectomy for symptomatic gallstones, 284 had undergone pre-operative MRCP and were all included in the final analysis. The typical right lateral insertion of the cystic duct in the midpoint between the confluence of the main hepatic ducts and the ampulla of Vater was identified in less than 50% of the patients. In our series, cystic duct stones were present only in 1.8% of our patients. Conclusions: The presence of significant anatomical variations and the low likelihood of incidental cystic duct stones render prophylactic extensive dissection of the cystic duct during standard laparoscopic cholecystectomy a rather unnecessary and probably hazardous step.
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Prevention of parastomal hernia using pre-peritoneal mesh - long term outcome of a prospective studyBackground: Parastomal hernia is a frequent complication after stoma formation. The objective of this prospective study was to find long-term outcome of prophylactic mesh placement in the pre-peritoneal space in order to prevent parastomal hernia. Methods: Patients undergoing elective formation of permanent stoma were included in the study. A polypropylene mesh was placed in the pre-peritoneal space without any anchoring stitches and bowel was taken out through a central circular hole made in the mesh. These patients were followed up for 5 years-by clinical examination and CT scan when needed. Results: A total of 42 patients were included in the study. These patients were followed up for a median period of 60 months (range 32-100 months). Twelve patients died before the 5-year follow up due to causes unrelated to stoma. As two patients were unable to be contacted, 28 patients remained in the long-term follow up. Three cases of parastomal hernia were detected after 5 years. None of these patients required repairing of the parastomal hernia. However, a previous study conducted 3 years ago found 4 cases of parastomal hernia that was treated by resiting the stomas. Therefore the total number of parastomal hernia detected in our series is 7 (incidence 25%). Conclusion: Putting a pre-peritoneal polypropylene mesh is an easy, quick and inexpensive method, and easy to learn. The outcome is better than creating stomas without mesh, but further studies are needed to explore potential benefits of different types of mesh and their methods of positioning and anchoring.
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Massive intra-abdominal massA Clinical Challenge to diagnose a massive intra-abdominal mass in a 60-year-old woman.
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Idiopathic spontaneous lesser sac haematoma : a perplexing case of abdominal apoplexyA 37-year-old woman presented with a 3-hour history of back pain, nausea and vomiting and an episode of syncope. A fluid collection in the lesser sac was detected on ultrasound and CT scan. Emergency laparoscopy and subsequent laparotomy were performed and a large blood clot was evacuated from the lesser sac. No identifiable source or predisposition to bleeding was found. She made a full recovery postoperatively. There are few reported cases of spontaneous intraperitoneal haemorrhage. In a third of cases, there is no identifiable source of bleeding. Unfortunately, patients present late with non-specific symptoms and a prompt diagnosis is difficult to make. The case reiterates the importance of awareness of lesser sac haematoma formation; an unusual clinical entity with a high morbidity and mortality rate. A high index of suspicion, radiological adjuncts and appropriate surgical intervention, especially in unstable patients, is essential for a good outcome.
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Acute appendicitis : are we over diagnosing it?Introduction: Appendicectomy is by far the commonest major emergency general surgical operation and laparoscopic appendicectomy is now becoming common. The question of whether a normal-looking appendix should be removed laparoscopically is more pertinent than ever before. Patients and methods: A retrospective study was undertaken to review the histopathology results and compare macroscopic with microscopic descriptions of all patients who underwent an appendicectomy, either by open surgery or laparoscopically, over a 1-year period from 1 September 2004 to 31 August 2005. Results: A total of 199 appendicectomies were carried out in the year of which histopathology results for 190 could be retrieved. Of the 190 who had an appendicectomy, 110 (57.9%) were female and 80 (42.1%) were male. While appendicitis was confirmed histologically in 65 of 80 (81.2%) male patients, it could only be confirmed histologically in 57 of 110 (51.8%) female patients. However, in a large number of female patients in whom macroscopically normal appendices had been removed, other findings were noted including fibro-obliterative changes in 10, luminal inflammation in 6, serositis in 5, lymphoid hyperplasia in 3, feacoliths in 2, and pinworm in 1, making another abdominal pathology a possibility. Conclusions: The number of macroscopically normal appendices removed was much larger in female patients. However in 27 of 49 normal looking appendices in females, findings such as serositis, luminal inflammation, lymphoid hyperplasia, etc. were noted on histology, suggesting that another abdominal pathology may have been missed or the appendix may still have been the cause for pain. On the basis of these findings, we suggest that diagnostic laparoscopy should be performed at least in all female patients before an appendicectomy; if no other findings are noted on laparoscopy, it is likely to be worthwhile to remove the appendix.
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Mammalian bite wounds : is primary repair safe?No abstract available.
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A Ten-Year Observational Study of The Use of Two-Way Catheters Post-Transurethral Resection of The Prostate Without the Use of Post-Op IrrigationOver 15,000 transurethral resections of the prostate (TURP) are performed yearly in the UK. It is therefore vital that peri-operative care is optimised. Our centre favours the use of two-way catheters post-operatively without continuous bladder irrigation (CBI). Aim To evaluate our practice of using two-way catheters without irrigation post-TURP and to determine impact on patient care compared to standard three-way catheterization. Our primary outcome was duration of admission, but multiple secondary outcomes were also analysed. Method This was a prospective observational study. Every patient undergoing TURP at our centre from 2009 to 2019 was included. Prospective patient data were collected pertaining to peri-operative factors. This data was then compared with data published in the NICE guidance pertaining to TURP. Results 687 patients underwent TURP at our centre between 2009-2019. The average age of patients was 71.42 (±7.89). 87.17% (n = 598) had two-way catheters placed post-operatively. Average duration of admission was 1.61 (±1.35) days. TWOC was successful in 93.74% (n = 644). Complication rate was 8.73% (n = 60), reduced in comparison to other units. Furthermore, when compared to other centres, our method reduced lengths of admission and transfusion rates (1.6 days vs. 3.1 days and 0.87% vs. 2.83% respectively). Conclusions Our method preserves patient safety and is associated with reduced length of admission. It also has cost-saving benefits and a reduced post-operative period of catheterisation. We recommend this practice to the wider urological community.