• Laparoscopic Roux en-Y Gastric Bypass Using a Modified Retrocolic-Supracolic Approach: Outcomes from 300 Patients.

      Bull, Charles; Awad, Sherif; Ahmed, Javed; Al-Khyatt, Waleed (2016-03)
      BACKGROUND: Laparoscopic Roux en-Y gastric bypass (LRYGB) achieves sustained long-term weight loss and reduced mortality in morbidly obese patients. It is routinely performed using an ante- or retrocolic approach with the jejuno-jejunostomy constructed in the infracolic compartment. We have modified the standard technique of performing LRYGB by constructing both anastomoses in the supracolic compartment. This study describes the outcomes of consecutive primary LRYGB performed using this novel retrocolic-supracolic approach. METHODS: Data were prospectively collected on consecutive primary LRYGB performed in a tertiary-referral Bariatric Centre in the United Kingdom from September 2009 to March 2013. Data included demographics, operative outcomes (duration of surgery, postoperative anastomotic leak/bleeding/reoperations), development of strictures, length of stay, excess weight loss (EWL) and resolution of diabetes mellitus. RESULTS: Hand-sewn LRYGB was successfully performed using the retrocolic-supracolic approach in 300 of 307 (98 %) consecutive patients (72 % female). Median (IQR) age, weight and baseline body mass index were 49 (41-56) years, 146 (134-163) kg and 52.9 (48.8-57.2) kg/m(2), respectively. There were 4 (1.3 %) anastomotic leaks and 8 (2.6 %) postoperative bleeds. The 30-day reoperation rate was 1.6 %. Median (IQR) hospital stay was 2 (2-2) days. Postoperative dysphagia requiring endoscopic balloon dilatation occurred in 19 (6.3 %) patients. Mean ± SD 12-month EWL was 69.9 ± 19.0 %. Within the follow-up period, 81 % of patients with type II diabetes mellitus achieved remission and 19 % reduced dosage of diabetes medication. CONCLUSIONS: LRYGB performed using the retrocolic-supracolic approach was safe, feasible, technically advantageous and resulted in clinical outcomes akin to the standard infracolic approach.
    • Legacy of COVID-19 - the opportunity to enhance surgical services for patients with colorectal disease.

      Tierney, Gillian (2020-08)
      After wide consultation with trainees, trainers, employers and other stakeholders, the new General Surgical Curriculum was approved earlier this year and will be implemented from 4 August 2021. It will be outcome based and will be the biggest change in surgical training since 2007. Trainees can progress at their own rate and complete when they have acquired the capabilities of a Day-1 consultant in general surgery with a special interest. The Multiple Consultant Report (MCR) is new and has been developed as the main assessment tool for this outcomes-based curriculum. Assessment in the MCR will be on progress from the ability to only observe at the start of training, to performance at the level of Day-1 consultant in the complex, integrated skills needed for the day-to-day performance of the role in each of the areas of the job (the Capabilities in Practice). The MCR and trainee self assessment will improve feedback and allow specific and bespoke agreed learning objectives to be more easily developed and delivered, and faster but safe training for many. New training pathways have been developed, emphasizing the commonality of emergency general surgery, but also developing special interests reflecting the needs of patients and the service.
    • Less is more: re-evaluating systematic reviews.

      Schlichtemeier, S; Tou, Samson; Parks, R (2018-08)
    • 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.
    • A literature review: The role of plakoglobin as a biomarker to determine the invasive potential of ductal carcinoma in situ

      Carmichael, Amtul (2018-01)
      DCIS is a heterogeneous disease exhibiting varying degrees of aggressiveness; approximately 40% of DCIS will progress into invasive cancer. Currently, no molecular marker is identified that can reliably predict the invasive potential of DCIS in an individual patient. Additionally, DCIS carries a recurrence rate of 3-17% within 10 years, and half of these recurrences could be invasive cancers. A biomarker that can reliably predict which DCIS lesions have a high likelihood of developing into invasive cancers can potentially prevent over- or undertreating patients. Method: A search of electronic databases 'MEDLINE' and 'PUBMED' for relevant published articles was undertaken in February 2015. Publications deemed sufficiently relevant to the topic and published between January 1990 and February 2015 were included in the review. Results: Desmosomes are molecular complexes that attach adjacent epithelial cells together by means of linking proteins together. Any disruption in desmosomal proteins can lead to certain diseases-such as cardiomyopathy and pemphigus and cancer progression. Plakoglobin (PG) is a desmosomal protein that has been implicated in malignant transformation associated with phenotypic features of reduced cell-cell adhesion, increased invasiveness, migration and cell proliferation. PG can be a potential biomarker for cancer progression, differentiating between chronic pancreatitis and pancreatic ductal adenocarcinoma (PDAC) cancer. Ellis et al. have reported reduced PG expression in invasive Paget's disease of the vulva, when compared to intraepidermal Paget's disease of the vulva. Conclusions: The loss of PG can serve as a potential biomarker to predict the invasive potential of DCIS. If PG is a reliable predictor of the invasive potential of DCIS lesions, this will help to tailor treatment for patients with DCIS according to its invasive potential. For example, patients with low-grade DCIS with a low invasive potential will not have to undergo disfiguring surgical treatment of mastectomy.
    • 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.
    • The management of acute fracture dislocations of proximal interphalangeal joints: a systematic review.

      Arrowsmith, J; Lindau, Tommy (2020-07)
      A systematic review was conducted to identify the best management for acute proximal interphalangeal joint fracture-dislocations. A study protocol was designed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Due to limited data in the primary assessment, the hypothesis was tested in a secondary analysis of articles that marginally met the inclusion criteria (i.e. studies that included patients under 18 years of age). A further tertiary analysis was conducted by dividing the studies into closed reduction techniques, open reduction internal fixation and 'other studies' and a narrative synthesis was performed. The study found a higher rate of complications and arthritis in the closed reduction group compared to open reduction internal fixation, suggesting that operative management should be considered for acute PIP joint fracture-dislocations. Level of evidence: III
    • The management of adult appendicitis during the COVID-19 pandemic: an interim analysis of a UK cohort study.

      Boyd-Carson, H (2020-07)
      BACKGROUND: Acute appendicitis (AA) is the most common general surgical emergency. Early laparoscopic appendicectomy is the gold-standard management. SARS-CoV-2 (COVID-19) brought concerns of increased perioperative mortality and spread of infection during aerosol generating procedures: as a consequence, conservative management was advised, and open appendicectomy recommended when surgery was unavoidable. This study describes the impact of the first weeks of the pandemic on the management of AA in the United Kingdom (UK). METHODS: Patients 18 years or older, diagnosed clinically and/or radiologically with AA were eligible for inclusion in this prospective, multicentre cohort study. Data was collected from 23rd March 2020 (beginning of the UK Government lockdown) to 1st May 2020 and included: patient demographics, COVID status; initial management (operative and conservative); length of stay; and 30-day complications. Analysis was performed on the first 500 cases with 30-day follow-up. RESULTS: The patient cohort consisted of 500 patients from 48 sites. The median age of this cohort was 35 [26-49.75] years and 233 (47%) of patients were female. Two hundred and seventy-one (54%) patients were initially treated conservatively; with only 26 (10%) cases progressing to an operation. Operative interventions were performed laparoscopically in 44% (93/211). Median length of hospital stay was significantly reduced in the conservatively managed group (2 [IQR 1-4] days vs. 3 [2-4], p < 0.001). At 30 days, complications were significantly higher in the operative group (p < 0.001), with no deaths in any group. Of the 159 (32%) patients tested for COVID-19 on admission, only 6 (4%) were positive. CONCLUSION: COVID-19 has changed the management of acute appendicitis in the UK, with non-operative management shown to be safe and effective in the short-term. Antibiotics should be considered as the first line during the pandemic and perhaps beyond.
    • Managing the Quality of Ward Based Training in Surgery in UK- A Critical Review.

      Athar, Sajjad; Ashwood, Neil; Karagkevrekis, Babis; Knight, Victoria (2017-11)
      Junior doctors alerted the Director of Medical Education (D.M.E.) to a lack of training by senior colleagues on ward rounds in surgery. At the same time surgical training was rated poorly on the General Medical Council (G.M.C.) Trainees Survey. The West Midlands Deanery threatened to withdraw posts recommending that at least 40% of trainee time be dedicated to training. Trainers reported a lack of time to train and poor engagement by trainees. This review examines the merits of different quality improvement initiatives to patient care through programmed ward round training. Poor feedback from trainees within the trust at the ‘Junior Doctors Forum (J.D.F.)’ had suggested a lack of ward based training opportunities due to unstructured ward rounds poorly led by the senior doctors within surgery. The Medical Director (M.D.) tasked the Royal College of Surgeons Tutor for the trust with changing the learning environment on ward rounds to improve care and training. To identify factors within the educational and management literature that would enable training within the workplace. To consider the values, mind-sets and barriers to managing changes to training within varied clinical environments. To consider the quality improvement strategy that would enable doctors to develop and maintain robust reproducible training on the surgical ward round.
    • Mature ganglioneuroma of the adrenal gland as a new rare cause of visible haematuria: A case report & literature review.

      Williams, Simon; Jaulim, A; Nkwam, N (2015-07)
      INTRODUCTION: Ganglioneuromas are benign tumours of the sympathetic ganglia and the adrenal glands medulla. We describe a case of a fit and well 18 year old Caucasian male patient who initially presented to primary care with intermittent episodes of painless frank haematuria as well as some non-specific right-sided loin pain. PRESENTATION OF CASE: In this 18 year old man, initial ultrasound investigations at a 'one stop haematuria' clinic revealed the presence of an echogenic solid mass of 120×110×90mm around the upper pole of the right kidney. A CT scan of the abdomen proved inconclusive to further determine the aetiology of the mass. Following a local multidisciplinary meeting (MDT) an MRI of the abdomen was undertaken which confirmed the presence of a large right adrenal mass. A biopsy was taken to determine the histology of the mass confirming a mature ganglioneuroma. The patient subsequently underwent surgery within 6 weeks of having presented to his general practitioner. CONCLUSION AND DISCUSSION: The surgery was uncomplicated and excision of the mass was made via a thoraco-abdominal approach. The patient recovered well post operatively and was discharged home within 8 days with outpatient follow-ups organised.
    • A Method to Evaluate Trainee Progression During Simulation Training at the Urology Simulation Boot Camp (USBC) Course.

      Kailavasan, Mithun (2018-08)
      OBJECTIVES: To evaluate skills progression at the Urology Simulation Boot Camp (USBC), a course intended to provide urology trainees with 32 hours of 1:1 training on low and high-fidelity simulators. DESIGN: In this single-group cohort study, trainees rotated through modules based on aspects of the United Kingdom urology residency curriculum and undertook a pre and postcourse MCQ. Specific procedural skill was evaluated by an expert and graded as either: "A"-Good (≥4 on a 5-point Likert Scale) or "B"-Poor (Likert scale of 1-3). Competence progression was calculated as the change in score between baseline and final assessments. SETTING: The USBC was held at St James' University Hospital, Leeds, U.K. PARTICIPANTS: Of the 34 trainees attended the second USBC, 33 trainees participated in all the pre and postcourse assessments. The mean duration of urology training prior to undertaking the USBC was 15 months. RESULTS: Competence progression was assessed in 33 urology trainees. Mean MCQ scores improved by 16.7% (p < 0.001) between pre and postcourse assessment. At final assessment, 87.9% of trainees scored "A" in instrument knowledge and assembly compared to 44.4% at baseline (p < 0.001). There was a mean improvement of 439s (p < 0.001) in the time taken to complete the European-Basic Laparoscopic skills assessment. CONCLUSIONS: The USBC has shown to aid trainees in competence progression during the simulation on a variety of urological skills; however, retention of skill in the long-term was undetermined. The use of our grading system is simple to understand and may be used in other simulation courses to guide participants with their future training needs.
    • 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.
    • Mid term functional results following surgical treatment of recto-urinary fistulas postprostate cancer treatment.

      Zafar, Narisa (2018-09)
      INTRODUCTION: To evaluate the mid term functional results of patients treated for RUF and to determine an optimal treatment strategy to improve their quality of life. Recto-urinary Fistula (RUF) is a rare complication following prostate cancer treatment, and can have a major impact on patients' quality of life. There is a lack of consensus concerning the best approach and different techniques have been proposed: endoscopic, transrectal, perineal and transperitoneal (open, laparoscopic or robotic). MATERIALS AND METHODS: We retrospectively reviewed the charts of patients who underwent RUF repair from January 2001 to December 2010 at our Institute. 16 patients who developed RUF following prostate cancer treatment were included in the study. The fistula had to be confirmed both clinically and by imaging. All patients had follow up consultation every 3 month for the first year and then annually. They were asked to fill questionnaires evaluating functional outcomes. The International Continence Society (ICS) score was used to assess the postoperative urinary continence. Fecal continence was evaluated with the Wexner score and sexual function was assessed with the International Index for erectile function (IIEF-5) score. RESULTS: Eighty-seven percent patients (14/16) in our series developed RUF as a consequence of prostate cancer surgery and 13% (2/16) postbrachytherapy (BT). All patients initially had a diversion colostomy and a supra pubic catheter. 69% (11/16) underwent primary YM repair and 73% (8/11) were successful. 2/3 primary failures were successfully retreated with graciloplasty. Primary gracilis flap interposition (GFI), on 3 non-irradiated patients were successful (100%). Primary GFI postbrachytherapy, no patient had recover urinary and digestive continuity. In total primary GIF was successful in 60% (3/5). Over all long term, success rate with a urinary and digestive continuity and without recurrence of the fistula was 81% (13/16). Mid term functional results were evaluated at mean follow up of 40 months (14-92). 13% (2/16) achieved complete urinary continence, 48% (7/16) required single pad, 25% (4/16) developed major incontinence, 7% (1/16) required urinary diversion and 13% (2/16) developed complete urethral closure post BT requiring permanent suprapubic catheterization. Colostomy was reversed in 93% (15/16) cases. 75% (12/16) achieved complete faecal continence, minor incontinence (wexner score 3-4) was seen in 13% (2/16) and major incontinence (wexner score 14) in 7% (1/16) and 7% (1/16) required a long term colostomy. 19% (3/16) developed colostomy related complications. Only 13% (2/16) achieved adequate erections with the use of intra cavernosal prostaglandin injections. CONCLUSIONS: RUF following prostate cancer treatment is a serious complication with severe repercussion on patients' quality of life. Surgical repair with the York Mason technique or Gracilis Flap interposition is associated with good success rates. If available pediculed gracilis muscle should be used as it offers better success rates. LEVEL OF EVIDENCE: 3.
    • Minimally Invasive Circumferential Hiatal Dissection for the Treatment of Adenocarcinoma of the Distal Esophagus and Esophago-gastric Junction: Technical Considerations Combined With Histopathological Outcomes.

      Fareed, K; Barter, C (2019-06)
      BACKGROUND/AIM: Circumferential resection margin involvement is an independent prognostic factor in patients with adenocarcinoma of the distal esophagus and esophago-gastric junction. However, there is currently no consensus on the extent and the technique of hiatal dissection. We describe a minimally invasive technique of circumferential hiatal dissection for adenocarcinoma of the distal esophagus and esophago-gastric junction with its related histopathological results. PATIENTS AND METHODS: A prospective study of 40 consecutive patients undergoing hybrid (laparoscopic/thoracotomic) or totally minimally invasive Ivor-Lewis esophagogastrectomy over a period of 21 months was conducted. Dissection of the hiatus included peri-esophageal surrounding tissues in a cylindrical fashion maximizing the distance from the oesophageal wall. Crural muscle fibers and pleura bilaterally, pericardial fat anteriorly and pre-aortic tissue posteriorly were excised en bloc. Histopathological results particularly focused on involvement of the circumferential resection margin. Neoadjuvant chemotherapy wasgiven to 24 (60%) patients. RESULTS: Complete histological clearance (R0) was achieved in 92.5% (n=37) according to the criteria of the College of American Pathologists and in 87.5% (n=35) according to those of the Royal College of Pathologists. In pT3 tumors (n=22), the circumferential resection margin was negative in 20 patients (91%) according to the College of American Pathologists, and in 17 (77%) according to the Royal College of Pathologists. CONCLUSION: Adoption of this safe and reproducible technique might reduce the incidence of circumferential resection margin involvement and improve pathological outcomes. In addition, there may be positive implications for training and quality control.
    • Molecular mechanisms of urolithiasis.

      Green, William; Ratan, Hari (2013-04)
    • Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

      Iftikhar, Syed (2020-12)
      Background: No evidence currently exists characterising global outcomes following major cancersurgery, including esophageal cancer. Therefore, this study aimed to characteriseimpact of high income countries (HIC) versus low and middle income countries (LMIC)on the outcomes following esophagectomy for esophageal cancer. Method: This international multi-center prospective study across 137 hospitals in 41 countriesincluded patients who underwent an esophagectomy for esophageal cancer, with 90-dayfollow-up. The main explanatory variable was country income, defined according tothe World Bank Data classification. The primary outcome was 90-day postoperative mortality,and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis)and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimatingequation models were used to produce adjusted odds ratios (ORs) and 95% confidenceintervals (CI 95%). Results: Between April 2018 to December 2018, 2247 patients were included. Patients from HICwere more significantly older, with higher ASA grade, and more advanced tumors. Patientsfrom LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4%vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated withhigher 90-day mortality (OR: 2.31, CI 95%: 1.17–4.55, p = 0.015). However, LMIC were not independently associated with higherrates of anastomotic leaks (OR: 1.06, CI 95%: 0.57–1.99, p = 0.9) or major complications (OR: 0.85, CI 95%: 0.54–1.32, p = 0.5), compared to HIC. Conclusion: Resections in LMIC were independently associated with higher 90-day postoperativemortality, likely reflecting a failure to rescue of these patients following esophagectomy,despite similar composite anastomotic leaks and major complication rates to HIC. Thesefindings warrant further research, to identify potential issues and solutions to improveglobal outcomes following esophagectomy for cancer.
    • A multicentre prospective feasibility study of carbon dye tattooing of biopsied axillary node and surgical localisation in breast cancer patients

      Goyal, Amit; Puri, Shama; Carmichael, Amtul; Erdelyi, Gabriella; York, Joanne (2020-10)
      Background: The primary aim of this prospective, multicentre feasibility study was to determine whether the biopsied axillary node can be marked using black carbon dye and successfully identified at the time of surgery. Methods: We included breast cancer patients undergoing needle biopsy of the axillary node. The biopsied node was tattooed at the time of needle biopsy (fine needle aspiration or core biopsy) or at a separate visit with black carbon dye (Spot® or Black Eye™). Participants underwent primary surgery or neoadjuvant chemotherapy (NACT) and axillary surgery (SNB or ALND) as per routine care. Results: 110 patients were included. Median age of the women was 59 (range 31-88) years. 48 (44%) underwent SNB and 62 (56%) ALND. Median volume of dye injected was 2.0 ml (range 0.2-4.2). Tattooed node was identified intra-operatively in 90 (82%) patients. The identification rate was higher (76 of 88, 86%) in the primary surgery group compared with NACT (14 of 22, 64%) (p = 0.03). Of those undergoing NACT, the identification rate was better in the patients undergoing SNB (3 of 4, 75%) compared with ALND (11 of 18, 61%) (p > 0.99). The tattooed node was the sentinel node in 78% (28 of 36) patients in the primary surgery group and 100% (3 of 3) in the NACT group. There was no learning curve for surgeons or radiologists. The identification rate did not vary with timing between dye injection and surgery (p = 0.56), body mass index (p = 0.62) or volume of dye injected (p = 0.25). Conclusion: It is feasible to mark the axillary node with carbon dye and identify it intra-operatively. ClinicalTrials.gov: NCT03640819.
    • Multifocal necrotising fasciitis: a rarer presentation of a rare disease.

      Boghossian, Shahe; Herrod, Philip (2014-11)
      Necrotising fasciitis is a rare life-threatening surgical emergency in which timely diagnosis and treatment are key. We present a case in which a patient rapidly succumbed to synchronous multifocal necrotising fasciitis from a likely intra-abdominal source. The ability for the disease to present in the unusual fashion described in this case must be highlighted to all clinicians.
    • Multipathogenic necrotising supraglottitis in an immunocompetent patient

      Ahmed, Jacob; Constable, James; Kamani, Tawakir; De, Mriganka (2017-06)
      Supraglottitis is a potentially life-threatening condition. It is now uncommon due to the Haemophilus influenza type B vaccination and is more recently caused by Streptococcus pneumoniae, S. pyogenes, H. influenza non-type B, H. parainfluenzae, Staphylococcus aureus and Pasteurella multocida. Very rarely, it can cause necrotising supraglottitis/epiglottitis, and this has been reported in immunocompromised individuals. We present a unique case of multipathogenic supraglottitis causing laryngeal fibrinoid necrosis in an immunocompetent patient. During his admission, the patient was critically unwell and required surgical intervention and tracheostomy. However, he made a full recovery with no persisting morbidity. We believe that this was owed to the aggressive antimicrobial therapy, timely surgical management of the disease process and the patients immunocompetency.