• A review article on gastric volvulus: a challenge to diagnosis and management.

      Rashid, Farhan (2010)
      Acute gastric volvulus is a life-threatening condition, but its intermittent nature and vague symptoms may make diagnosis difficult. Imaging is usually only diagnostic if carried out when patients are symptomatic. The population affected ranges from paediatric age group to elderly with multiple co-morbidities. Laparoscopic repair is advisable once a diagnosis is reached. This review on gastric volvulus focuses on the diagnostic and management challenges encountered, together with strategies for dealing with them. Lessons have emerged which may assist in dealing with such a rare presentation in future.
    • Preoperative hematologic markers as independent predictors of prognosis in resected pancreatic ductal adenocarcinoma: neutrophil-lymphocyte versus platelet-lymphocyte ratio.

      Peacock, Oliver (2010-08)
      BACKGROUND: The objective of this study was to investigate whether the preoperative hematologic markers, the platelet-lymphocyte ratio (PLR), or the neutrophil-lymphocyte ratio (NLR) ratio are significant prognostic indicators in resected pancreatic ductal adenocarcinoma. METHODS: A total of 84 patients undergoing pancreatoduodenectomy for pancreatic ductal adenocarcinoma over a 10-year period were identified from a retrospectively maintained database. RESULTS: The preoperative NLR was found to be a significant prognostic marker (P = .023), whereas PLR had no significant relationship with survival (P = .642) using univariate Cox survival analysis. The median overall survival in patients with an NLR of < or =3.0 (n = 55) was 13.7, 17.0 months in those with an NLR of 3.0 to 4.0 (n = 17) and 5.9 months in patients with a value of >4.0 (n = 12) (log rank, P = .016). The NLR retained its significance on multivariate analysis (P = .039) along with resection margin status (P = .001). CONCLUSION: The preoperative NLR represents a significant independent prognostic indicator in patients with resected pancreatic ductal adenocarcinoma, whereas PLR does not.
    • Vascular invasion is not a risk factor in oesophageal cancer recurrence.

      Waraich, Naseem; Rashid, Farhan; Deb, Rahul; Leeder, Paul; Iftikhar, Syed (2011-01)
      AIM: The outcome of the treatment of oesophageal cancer remains poor despite improved treatment modalities and recurrence remains a major problem despite improved staging and treatment. The aim was to identify the independent risk factors responsible in the recurrence of oesophageal cancer. METHODS: The patients who had elective oesophagectomy (n = 244) with curative intent were studied. One hundred and eighty four patients had surgery alone, 44 patients had neo-adjuvant chemotherapy and surgery while 16 patients had neo-adjuvant chemotherapy, surgery and adjuvant chemotherapy. We have analysed patients who had surgery alone (n = 184). Data was collected for demography, type of operation, histology, staging (TNM), vascular invasion (VI), differentiation of tumour, type of chemotherapy and recurrence of tumour. RESULTS: The median age was 67 years (IQR 60, 71). The T1, T2, T3 distribution was 10%, 24% and 66% respectively. Forty percent had no nodal involvement (N0) and 60% had N1 stage disease. Twenty three percent of patients had vascular invasion. Univariate analysis of histo-pathological factors identified lymph node yield (p = 0.06), curative resection R0 (p = 0.004) and vascular invasion (VI) (P = 0.69) as prognostic indicators of recurrence. Multivariate analysis showed that number of lymph nodes yielded (p = 0.01) and R0 resection remain independent indicators of recurrence of tumour. However, VI (p = 0.2) and age at disease onset (p = 0.8) were not indicators of recurrence in oesophageal cancer patients. CONCLUSION: R0 and lymph node yield may help to predict the recurrence of oesophageal cancer. However the presence of VI may not be a significant risk factor in disease recurrence.
    • Listeria monocytogenes: a rare cause for an infected abdominal aortic aneurysm.

      Haroon, Y; Bhalla, Ashish; El-Tahir, A (2011-11)
      Infected aneurysms associated with Listeria monocytogenes are rare. We describe a case of an infrarenal abdominal aortic aneurysm infected by Listeria monocytogenes. The aneurysm was diagnosed using a contrast-enhanced computed tomography (CT) scan and the infective organism identified within positive blood cultures. The patient underwent a successful urgent open aortic aneurysm repair and completed a 6-week course of antibiotics.
    • Closure of loop ileostomy: potentially a daycase procedure?

      Peacock, Oliver; Speake, WJ; Lund, Jonathan; Tierney, Gillian (2011-12)
      BACKGROUND: Four thousand four hundred and twenty-seven ileostomy closures were performed in the UK in 2008-2009, (35,432 bed days). None were recorded as being performed as a daycase procedure. Our aim is to evaluate the morbidity and mortality associated with this procedure and to investigate whether daycase surgery is feasible. METHOD: Patients having closure of loop ileostomy were identified retrospectively from May 2005 to July 2010. The primary surgery, method of ileostomy closure, length of hospital stay and early (≤30 days) or late (>30 days) complications were recorded. RESULTS: A total of 138 patients were evaluated. The median age was 63 (17-83) years and 64% were male patients. The primary surgery was predominantly anterior resection (74%). Median time from initial surgery to reversal was 37 (1-117) weeks. The median length of hospital stay was 4 (1-39) days. Applying a 23-h discharge protocol to our results excluded 18 patients categorised as ASA3. Ninety-six patients (80%) met the discharge criteria for a potential 23-h hospital stay. The expected readmission rate within 30 days of surgery was 12% (n = 14). 85 patients (71%) did not suffer an early complication. There were 35 early complications (30%), 10 general and 25 specific to the procedure, but serious only in 5%. There were no deaths in the eligible patients. CONCLUSION: Closure of loop ileostomy in our series is safe, with a low serious morbidity rate. It may be feasible to perform reversal of ileostomy as a daycase/23-h stay. We intend to implement a 23-h stay for reversal of ileostomy.
    • A review on gastric diverticulum.

      Iftikhar, Syed (2012-01)
      The gastric fundal diverticulae are rare. They can present with variable symptoms. We are enclosing a literature review on gastric fundal diverticulum. Lessons have emerged which may help in the management of this rare condition in future.
    • Basic opioid pharmacology: an update.

      Williams, John P (2012-02)
      Opioids are a group of analgesic agents commonly used in clinical practice. There are three classical opioid receptors (DOP, KOP and MOP), while the novel NOP receptor is considered to be a non-opioid branch of the opioid receptor family. Opioids can act at these receptors as agonists, antagonists or partial agonists. Opioid agonists bind to G-protein coupled receptors to cause cellular hyperpolarisation. Most clinically relevant opioid analgesics bind to MOP receptors in the central and peripheral nervous system in an agonist manner to elicit analgesia. Opioids may also be classified according to their mode of synthesis into alkaloids, semi-synthetic and synthetic compounds.
    • Lymph node ratio versus number of affected lymph nodes as predictors of survival for resected pancreatic adenocarcinoma.

      Peacock, Oliver; Awan, Altaf (2012-04)
      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.
    • Port-site metastasis after laparoscopic surgery for urological malignancy: forgotten or missed.

      Kadi, Nourdin; Isherwood, M; William, S (2012-04)
      Purpose. Port-site metastasis has been a concern with the common use of laparoscopy in urologic oncology. We conducted this study to provide a review of port-site metastases reported after the laparoscopy in managing urologic malignancies, possible contributing factors and preventative measures. Materials and Methods. An electronic search of MEDLINE using the combined MESH key words "port-site metastasis" and "Urology". Results. 51 articles addressing port-site metastasis after laparoscopic surgery for urolo¬gical malignancy were identified. Conclusion. Port-site metastasis after laparoscopic surgery for urolo¬gical malignancy is rare. The incidence is comparable to the rate for surgical wound metastases.
    • MicroRNAs: relevant tools for a colorectal surgeon?

      Peacock, Oliver; Lund, Jonathan (2012-04)
      Colorectal cancer is the third most common malignancy and cause of cancer-related deaths worldwide. Approximately half of the patients diagnosed with colorectal cancer ultimately die of the condition. Death from colorectal cancer can be prevented by early detection, but unfortunately presentation is often late, with a worse prognosis. Screening by fecal occult blood testing reduces disease-specific mortality, but there is a need for sensitive and specific non-invasive biomarkers to facilitate detecting the disease, staging it, and predicting the best therapeutic options. MicroRNAs (miRNAs) are short noncoding RNA sequences that have a crucial role in the regulation of gene expression. They have significant regulatory functions in basic cellular processes, such as cell differentiation, proliferation, and apoptosis. Evidence suggests that miRNAs may function as both tumor suppressors and oncogenes. The main mechanism for changes in the function of miRNAs in cancer cells is due to aberrant gene expression. Accurate discrimination of miRNA profiles between tumor and normal mucosa in colorectal cancer allows definition of specific expression patterns of miRNAs, giving good potential as diagnostic and therapeutic targets. MiRNAs expressed in colorectal cancers are also abundantly present and stable in stool and plasma samples. Their extraction from these three sources is feasible and reproducible. The ease and reliability of determining miRNA profiles in plasma or stool makes them potential molecular markers for colorectal cancer screening. This review summarizes the role miRNAs have in colorectal cancer, highlighting particularly the potential diagnostic, prognostic, and therapeutic implications in the future treatment of the disease.
    • Presentation skills amongst surgical trainees at a national conference: an observational study.

      Peacock, Oliver; Lund, Jonathan (2012-05)
      OBJECTIVES: The ability to deliver public presentations is important for doctors of all specialities. Despite this, there is little emphasis on training in presentation skills within medical curriculae. The aim of this paper was to establish the current standard of presentations being delivered by surgical trainees at a national conference and to confirm the need for further training. DESIGN: An observational study of 96 six-minute research presentations. SETTING: A national surgical conference in the United Kingdom. PARTICIPANTS: Four independent observers each appraised 24 six-minute presentations by surgical trainees against a pre-determined standard. MAIN OUTCOME MEASURES: A set of 19 audit criteria were established after a literature search to ascertain commonly accepted presentation standards. These outcome measures included keeping to time, number of slides used, the nature of slide content, methods of data representation, use of images and presentation style. RESULTS: A total of 61 (64%) presenters overran. The median number of slides used was 13 (range 6-28). Thirty-three (34%) presenters displayed slides with more than six bullet points on two or more occasions. Sixty-four (67%) presenters displayed whole paragraphs of text on two or more occasions. Sixty-eight (71%) presenters displayed raw numerical data in the course of their presentations. Seventy (73%) presenters used images. Thirty-one (32%) presenters repeatedly read out sentences word-for-word from their slides. Nineteen (20%) presenters appeared not to know their presentation content well. CONCLUSIONS: Presentation skills amongst surgical trainees are well below those that should be aspired to. Efforts to improve training, motivation and the examples set by senior surgeons should be instigated in order to improve this situation.
    • Practical management of diet and lifestyle interventions for people with diabetes or cardiovascular disease.

      Symes, Fiona (2012-05)
      Increased collaboration between the vascular specialities is clearly leading to increased understanding of the interrelationships between the different disease states and how each impacts and influences the other. This advantage will be reflected in improved patient care if the practical outputs of this growing knowledge are carefully implemented at service level. This article outlines how the aspects of diet and lifestyle associated with vascular-related disease complement, contrast and in some cases contradict each other. It gives information and guidelines as to how the expertise of dietitians working in the different specialist areas might usefully be shared to be of maximum advantage to all patients.
    • Focal urethral stricturing following intraurethral mitomycin-C gel and the use of a penile clamp.

      Stanford, Richard (2012-07)
      We present a case of a 51-year-old gentleman, previously diagnosed with high-grade superficial transitional cell carcinoma of the bladder and treated with intravesical mitomycin C and BCG, who developed serial recurrences in the prostatic urethra. This was resected and treated further with intraurethral mitomycin-C gel. He subsequently developed an almost impassable distal penile urethral stricture, corresponding to the site of penile clamp application which we hypothesise is secondary to a combination of the mitomycin-C gel and penile clamp pressure.
    • The 'cut and push' technique: is it really safe?

      Peacock, Oliver; Singh, Rajeev; Cole, Andrew; Speake, WJ (2012-07)
      Percutaneous endoscopic gastrostomy (PEG) feeding is routinely used as an endoscopic and effective method for providing enteral nutrition in those whose oral access has been diminished or lost. One technique for removal of the PEG is cutting the tube at the skin level and allowing the tube and internal flange to pass spontaneously. This is known as the 'cut and push' method. Several studies have concluded that the 'cut and push' method is a safe and cost-effective method. This case demonstrates a rare cause of small bowel obstruction following the 'cut and push' method for PEG replacement, with only a few other cases been reported. This method of removal should be avoided in patients with previous abdominal surgery. It is important that the PEG flange is retrieved endoscopically or an alternative PEG tube (designed to be completely removed through the skin) is used to prevent this complication occurring in such individuals.
    • Piriformis muscle metastasis from a rectal polyp.

      Salar, Omer; Flockton, Helen; Singh, Rajeev; Reynolds, Jonathan (2012-10)
      Rectal cancers constitute over a quarter of all colorectal cancers. Spread of rectal cancer is usually to liver, lung and brain from high risk rectal cancers. Cases have rarely been reported of spread to soft tissue structures. Here we present a case of metastatic spread of a previously excised, early invasive adenocarcinomatous polyp to piriformis.
    • The use of the Anaconda™ stent graft for abdominal aortic aneurysms.

      Bungay, Peter (2012-10)
      The Anaconda™ is a modular bifurcated stent-graft of woven polyester and nitinol ring stents that has been commercially available since 2005. It was the first truly repositionable stent-graft and features a magnet wire contralateral limb cannulation system. It has excellent fixation and sealing properties and its ring stent construction results in it being highly conformable and therefore applicable in angulated and tortuous anatomy.
    • Inappropriate use of the faecal occult blood test outside of the National Health Service colorectal cancer screening programme.

      Peacock, Oliver; Watts, E; Hanna, N; Kerr, K; Goddard, Andrew; Lund, Jonathan (2012-11)
      OBJECTIVE: The faecal occult blood test (FOBT) is the screening test validated for use in the National Health Service (NHS) Bowel Cancer Screening Programme (BCSP) after trials demonstrated a 16% reduction in colorectal cancer-specific mortality. FOBT is not validated for use outside the BCSP. The aim was to investigate the number of FOBTs performed outside of the NHS BCSP at a single centre. METHODS: All FOBTs performed over 1 year were identified. Basic patient demographics, requesting physician and FOBT results were obtained. Referrals and outcomes of the investigation following the FOBT were collected. RESULTS: A total of 758 FOBTs were requested in 701 patients (352 female; median age 69; range 16-99). The majority (91%) were requested by general practitioners. A total of 515 out of 758 tests (68%) were performed in patients outside the NHS BCSP age range. Thirty-seven out of 86 positive FOBTs were investigated, diagnosing four rectal cancers and two polyps. Forty-nine out of 87 patients with a positive FOBT were not investigated further by the requesting physician or the test repeated. Of the remaining 672 FOBTs, 615 were negative and 57 were either incomplete or unsuitable for analysis. A total of 111 patients (18%) were referred to hospital and 105 of these had FOBT performed as part of the referral process. CONCLUSION: Our study demonstrates significant misuse of the FOBT outside the NHS BCSP. Inappropriate use leads to false positives and exposes patients to unnecessary risk. False negatives provide reassurance to patients who may have symptoms that should be investigated. The FOBT should not be available to physicians in either primary or secondary care and be restricted to NHS BCSP.
    • Evaluation of teaching methods for students on hernias: an observational study.

      Watts, E; Foreman, D; Lund, Jonathan; Tierney, Gillian; Peacock, Oliver (2013-01)
      BACKGROUND: Teaching may be delivered through different media in different settings. We aimed to evaluate four teaching modalities for medical students on a common surgical topic. We compared learning, student preferences and experiences as outcome measures. METHODS: This is a prospective observational study of all medical students undertaking their first attachment in surgery. Students were randomly allocated into four groups: lecture, handout, website and patient-based tutorial, all on the management of an inguinal hernia. Baseline knowledge was assessed prior to group allocations through a questionnaire. Students completed a 24-h post-intervention questionnaire and satisfaction survey. RESULTS: One hundred fifty-four students participated. There was no difference in the pre-intervention knowledge scores between the groups. The post-intervention knowledge scores significantly improved in the lecture and website groups. However, the website was significantly less engaging and clinically relevant form of teaching compared with the lecture. Despite being engaging and relevant, the tutorial group failed to improve knowledge scores. The handout did not improve knowledge scores, nor was it considered engaging or relevant. CONCLUSION: Knowledge scores significantly improved with the lecture and website teaching methods. The lecture was more engaging, clinically relevant and instilled confidence. Students preferred the website/podcasts as additional information to facilitate their learning and increased their knowledge equivalent or superior to other standard media. However, despite being effective, the student experience was less positive than for non-reusable contact teaching. If student satisfaction is to be a factor in achievement of learning outcomes, a balance has to be struck between different media delivery.