Towards a 3-day hospital stay for right hemicolectomy.
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Aged↗
Biomedical subjects
Andrew G Hill
Publications and source records attributed to Andrew G Hill.
Minimal access colorectal surgery: is it truly minimally invasive?
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Clinical Trials as Topic↗
Comprehensive assessment of peri-operative fatigue: development of the Identity-Consequence Fatigue Scale.
OBJECTIVE: Fatigue is one of the complaints most widely reported during peri-operative periods. However, despite its prevalence, the aetiology of this fatigue remains poorly understood. Recent meta-analysis suggests that the limited applicability of existing fatigue measures is contributing to the current lack of understanding. This research therefore sought to use a rigorous analytic process to develop a comprehensive measure of fatigue suitable for use with recovering surgical patients. METHODS: Content analysis was undertaken to investigate the structure of 55 items initially generated. Self-report questionnaires were then distributed to surgical out-patients, and the 177 responses analysed using principal components analysis. Once item selection was finalized, the convergent and discriminant validity of the new measure was assessed. RESULTS: The new measure, the Identity-Consequence Fatigue Scale (ICFS), has 28 items and five subscales. All subscales show high internal reliability, and reentry of deleted items showed that the finalized items form a robust component structure. Discriminant validity analysis confirmed that all ICFS subscales are distinctive from depression and anxiety. Convergent validity analysis confirmed the extent to which the ICFS assesses Fatigue-Consequences is a unique feature of the new measure. CONCLUSION: The ICFS has a clear and stable structure that offers more comprehensive assessment of fatigue than provided by the measures most widely used in postsurgical fatigue (PSF) literature to date.
Adult↗
Minimal access colonic surgery: is it truly minimally invasive?
Laparoscopic colonic surgery has an established role in the management of both benign and malignant conditions. Proposed benefits from laparoscopic surgery include decreased pain, decreased metabolic disturbance to the patient and faster recovery. It is now generally accepted that pro-inflammatory mediators, including cytokines, are to a great extent responsible for the metabolic changes associated with injury and surgery, and that these metabolic changes are related to postoperative recovery. Cytokine levels in the serum are decreased after major laparoscopic colorectal surgery compared with open surgery. However, the cytokine concentration in abdominal drain fluid is the same independent of the size of the incision and these concentrations are far higher than those found in the serum suggesting that the peritoneal would from the surgery itself is more important to metabolic events than the skin wound used to access the abdominal cavity to perform the operation. When looked at critically in programmes where patients are optimally managed perioperatively, there appears to be minimal metabolic benefit from performing a major colonic resection using minimal access surgery. Thus, it appears that the wound is critical when the operation involves only minor peritoneal disruption, such as in laparoscopic cholecystectomy, but when large peritoneal defects are created, such as in major colorectal surgery, then the skin wound becomes irrelevant to metabolism and hence recovery. Thus, minimal access does not necessarily equate to minimal invasion and the terms should not be used interchangeably in the context of laparoscopic colorectal surgery.
Abdominal Cavity↗
Comparison of the possum, P-POSSUM and Cr-POSSUM scoring systems as predictors of postoperative mortality in patients undergoing major colorectal surgery.
BACKGROUND: Physiologic and operative severity score for the enumeration of mortality and morbidity (POSSUM), 'Portsmouth'-physiologic and operative severity score for the enumeration of mortality and morbidity (P-POSSUM) and 'Colorectal'-physiologic and operative severity score for the enumeration of mortality and morbidity (Cr-POSSUM) are three related scoring systems, which uses individual patient parameters to predict postoperative mortality. POSSUM overpredicts mortality in low-risk patients and underpredicts mortality in elderly and emergency patients. P-POSSUM was developed to compensate for these weaknesses. Cr-POSSUM was developed specifically for colorectal surgery. We aim to establish which of these scoring systems would be most useful in an Australasian context. METHODS: Data were collected for 308 patients and predicted mortality risk values were generated using each of the three systems. The Mann-Whitney U-test was then carried out on the scores for each system. Receiver-operator characteristic curves were designed to determine the relative accuracy of each approach at discriminating between death and survival. RESULTS: All three POSSUM scoring systems showed a statistically significant ability to predict postoperative mortality. Additionally, in each system there was a significant difference in the raw physiologic and operative severity scores between survivors and those who died. A risk-stratification model was applied to each set of data, showing a correlation between an increase in risk and an increase in mortality rate. Finally, the receiver-operator characteristic curves generated showed that in this study group POSSUM, P-POSSUM and Cr-POSSUM were all satisfactory predictive tools although the latter tended to be relatively less accurate. CONCLUSION: Physiologic and operative severity score for the enumeration of mortality and morbidity, P-POSSUM and Cr-POSSUM are all reliable predictors of postoperative mortality in the Australasian context; although there was a trend towards POSSUM and P-POSSUM being better predictors than Cr-POSSUM. However, Cr-POSSUM requires fewer individual patient parameters to be calculated and is thus easier to generate. An ideal preoperative scoring system remains to be developed for predicting mortality in patients undergoing colorectal surgery.
Adolescent↗
Differential production of cytokines following colorectal surgery.
BACKGROUND: Colorectal surgery is associated with a number of postoperative complications, including anastomotic leak and local recurrence. These complications are more common after rectal surgery than after colon surgery. Cytokines are secreted into the peritoneal cavity after colorectal surgery and have a number of metabolic and immunological effects. Hence we suggested that differential secretion of these may contribute to the differences in complications between colon and rectal surgeries. METHODS: Patients undergoing either elective rectal excision or colectomy for benign or malignant disease were recruited into the study. The region in relation to the anastomosis was drained with a silastic drain for 12-18 h. Drain fluid was collected on the morning following surgery. The drain fluid was assayed for interleukin (IL)-1beta, tumour necrosis factor-alpha, IL-6, IL-8, IL-10 and IL-13 using multiplexed biomarker immunoassays. RESULTS: Interleukin-8 concentrations were significantly higher in the region of the anastomosis after rectal excision compared with colectomy. Also, IL-6 levels were very high in both groups, but there was no significant difference between the groups. Although the concentrations of IL-10 were higher in the rectal group relative to the colectomy group, only low levels of this cytokine were present in the drain fluids. No other cytokines were consistently detected in significant concentrations. CONCLUSION: This study has shown that the concentration of IL-8 in the region of the anastomosis of patients who have undergone rectal surgery is much higher than those who have undergone colonic surgery. The increased level of IL-8 may provide a milieu conducive to local recurrence and anastomotic leak.
Adult↗
Stapled hemorrhoidectomy.
The procedure of stapled hemorrhoidectomy has been established as a safe and effective method for treating symptomatic hemorrhoids not responsive to more conservative measures. This chapter discusses the issues of safety, efficacy, durability, and cost of this procedure. In addition, we outline techniques for performing the procedure safely and effectively.
Digestive System Surgical Procedures↗
Investigation for iron deficiency anaemia.
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Aged↗
Ileostomy closure without contrast study is safe in selected patients.
BACKGROUND: Following anterior resection of the rectum it is common to defunction the anastomosis with an ileostomy. Prior to closure of this, a contrast study is usually performed to check for healing. Several patients at our institution have not undergone a contrast study prior to closure. The present study aimed to compare outcome in this group with patients who had undergone contrast radiology. METHODS: A retrospective review of patients undergoing anterior resection with an ileostomy was performed. We only included those patients who had a straight colorectal/coloanal anastomosis that could be examined clinically and had a smooth postoperative course with no evidence of pelvic sepsis. RESULTS: Fifty-nine patients fulfilled the criteria for the study. Thirty-five patients had a contrast study. These showed two leaks and five strictures. The anastomosis was 0-7 cm from the anal verge in 31 patients (16 contrast studies). It was above 7 cm in 28 patients (19 contrast studies). No patient had pelvic sepsis after ileostomy reversal. CONCLUSIONS: In patients with an ileostomy following anterior resection, with a clinically examinable anastomosis and a smooth postoperative course, a radiological examination of the anastomosis prior to ileostomy closure appears unnecessary.
Aged↗
Randomized controlled trial of Gastrografin in adhesive small bowel obstruction.
BACKGROUND: Several previous studies have shown that Gastrografin can be utilized to triage patients with adhesive small bowel obstruction (ASBO) to an operative or a non-operative course. Previous studies assessing the therapeutic effect of Gastrografin have been confounded by post-administration radiology alerting the physician to the treatment group of the patient. Therefore the aim of the present paper was to test the hypothesis that Gastrografin hastens the non-operative resolution of (ASBO). METHODS: Patients, diagnosed with ASBO on clinical and radiological grounds, were randomized to receive Gastrografin or placebo in a double-blinded fashion. Patients did not undergo further radiological investigation. If the patient required subsequent radiological intervention or surgical intervention they were excluded from the study. End-points were passage of time to resolution of ASBO (flatus and bowel motion), length of hospital stay and complications. RESULTS: Forty-five patients with ASBO were randomized to receive either Gastrografin or placebo. Two patients were excluded due to protocol violations. Four patients in each group required surgery. Eighteen of the remaining patients received Gastrografin and 17 received placebo. Patients who received Gastrografin had complete resolution of their ASBO significantly earlier than placebo patients (12 vs 21 h, P = 0.009) and this translated into a median of a 1-day saving in time in hospital (3 vs 4 days, P = 0.03). CONCLUSIONS: Gastrografin accelerates resolution of ASBO by a specific therapeutic effect.
Adult↗
Central nervous system interleukin-8 production following neck of femur fracture.
AIM: To establish a proinflammatory cytokine profile of the cerebrospinal fluid (CSF) following trauma. BACKGROUND: Trauma is associated with a postinjury syndrome consisting of loss of weight and nitrogen, pyrexia, anorexia and fatigue. It has been proposed that cytokines are pathophysiologically involved in this syndrome but the site of action of these is unclear. Previous work in head injury models, supported by animal work, has suggested that one important site of action is the central nervous system (CNS). METHODS: Women who had sustained neck of femur fractures were enrolled (trauma group). CSF was collected at the time of spinal anaesthetic. Women undergoing elective lower limb surgery were recruited as controls. CSF and serum were assayed for Interleukin (IL) 1, 2, 4, 6, 8, 10, 12, interferon gamma, and tumour necrosis factor by cytometric bead array. RESULTS: In the trauma group, IL-8 was elevated in the CSF but not in the serum, while IL-6 was elevated in the serum but not in the CSF. IL-1beta, associated with elevated IL-12, was also detected in the serum of three of 11 trauma patients but none of the nine controls. No other cytokines were consistently detected. CONCLUSIONS: This study raises the possibility that IL-8, acting in the CNS, plays a role in the postinjury syndrome. It is unclear as to the mechanism by which CNS IL-8 is produced in trauma but a physiological role is supported by the known ability of the CNS to produce IL-8 and the presence of receptors for its action in the CNS.
Central Nervous System↗
Trauma in rural Kenya.
BACKGROUND: Trauma in Africa is an increasingly significant problem. The aims of this study were to document the epidemiology and clinical management of trauma in a rural Kenyan hospital and from this to highlight important areas for the medical training of doctors managing trauma in similar situations. METHODS: Prospective audit of 202 consecutive trauma patients admitted to Kijabe Hospital. RESULTS: The mean patient age was 31, 77% were males. The median Injury Severity Score (ISS) was nine. The median distance to hospital was 60 km, with a 9 h delay in presentation. Injury mechanisms included road traffic accidents 52%, fall 22%, assaults 13% and burns 6%. The main injuries were limb fractures, soft tissue injuries, head injury and haemo/pneumothorax. Common interventions included fracture management, wound debridement, chest drain insertion, blood transfusion and skin grafting. The overall mortality rate was 3.5%. CONCLUSION: With appropriate resources and training, good trauma outcomes are possible. The importance of access to hospital care and orthopaedic training are highlighted.
Accidents, Traffic↗
Role of Gastrografin in assigning patients to a non-operative course in adhesive small bowel obstruction.
BACKGROUND: Adhesive small bowel obstruction (SBO) is a common surgical emergency. Water soluble contrast agents have been used to identify patients who might be treated non-operatively rather than operatively. The present study was designed to audit the introduction of such use of Gastrografin contrast into clinical practice. METHOD: Patients presenting acutely to hospital with clinically suspected and radiologically proven SBO were entered in the study. As soon as practicable, 100 mL of undiluted Gastrografin was given either orally or by the nasogastric tube (which was then spigotted). After 4 h, a plain supine abdominal X-ray (AXR) was taken. If the contrast was seen in the large bowel, and there had been no deterioration in the patient's condition, then non-operative treatment was continued. If the contrast remained in the small bowel, a clinical judgement was made as to whether to proceed with operative intervention. A group of historical controls were obtained by a retrospective review of the hospital medical records through data obtained from the Department of General Surgery Audit System. RESULTS: Twenty-five patients were entered into the study. In 20 of these patients the contrast was seen to arrive in the large bowel at 4 h. All of these patients completed a non-operative course to full recovery. In another two patients a successful decision was made to pursue a non-operative management strategy. These 22 patients had a mean hospital stay of 3.9 days. Eighty historical controls had successfully completed a non-operative course for SBO. They had a mean hospital stay of 5.6 days. This was significantly longer than that of the Gastrografin group (P < 0.016, t-test). CONCLUSION: This paper has demonstrated that undiluted Gastrografin may be safely used to assign patients to a non-operative management plan and this results in a decreased hospital stay.
Contrast Media↗
Training outside of the box.
BACKGROUND: Developments in surgical training in Australasia allow for individualization of training to suit individual requirements. One uncommon career track is medical aid or missionary surgery in the developing world. It is difficult to receive appropriate training for this type of surgical practice in Australasia. The present paper describes a novel approach to preparing for this kind of work by spending a 6 month rotation in a mission hospital in rural East Africa. METHODS: The surgical trainee spent 5 months working at Kijabe Hospital in Kenya. This is a large mission hospital with a busy general surgical workload and adequate staffing for training. RESULTS: The trainee performed 214 major cases, in a broad range of general surgery, under appropriate supervision. He also took part in regular educational sessions, surgical audit, and helped to develop one of East Africa's pioneering laparoscopic surgical -programmes. CONCLUSIONS: The present paper demonstrates that it is possible for Australasian trainees to gain useful experience in the rural African environment, in hospitals where appropriate surgical supervision is available.
Australasia↗
Boerhaave's syndrome: 10 years experience and review of the literature.
BACKGROUND: Spontaneous oesophageal rupture, also known as Boerhaave's syndrome, is a rare condition. It has a high mortality and its management is clouded with controversy. METHODS: A retrospective review of cases presenting to Middlemore Hospital over a period of 10 years was performed. RESULTS: A total of eight patients were found to have spontaneous oesophageal perforation. Six were managed operatively and two were managed non-operatively. There were seven men and one woman, whose ages ranged from 37 to 80 years (median: 64 years) at presentation. Six patients underwent thoracotomy. Five patients had primary closure of oesophageal perforation, two of these with tissue reinforcement. One patient underwent lavage alone without primary closure because there was widespread inflammation from the perforation. Two of the patients were managed non-operatively. Both subsequently died. The median postoperative stay was 36 days (range: 12-60 days). There was no postoperative mortality. CONCLUSION: Boerhaave's syndrome is rare and its management is not uniform. A review of the literature demonstrates wide disparity in management due to the rarity of the condition. Primary repair is appropriate for ruptures diagnosed early. Many are diagnosed late and T-tube drainage may be the simplest way to manage this difficult condition in this situation.
Adult↗
Necrotizing fasciitis: analysis of 48 cases in South Auckland, New Zealand.
BACKGROUND: To assess the presentation, management and risk factors for mortality in necrotizing fasciitis at Middlemore Hospital in South Auckland, New Zealand. METHODS: A retrospective review of the medical records of patients presenting to Middlemore Hospital over a 6-year period (1997-2002) with a diagnosis of necrotizing fasciitis. RESULTS: Forty eight patients were identified. There were 27 men and 21 women whose age ranged from 19 to 80 years (median 51 years) at presentation. Maori and Pacific Islanders accounted for 64% of total admissions despite making up only 31% of the referral population. Streptococcus Pyogenes was the most common bacterial isolate (54%). 31% of patients had polymicrobial infections. Sixty-two per cent of cases involved extremities. The median number of operations and length of stay were 4 and 31 days, respectively. Overall mortality was 29%. In multivariate analysis, delay in surgical intervention (P = 0.015) and diabetes mellitus (P = 0.023) were found to be associated with increased mortality. Ethnicity, sex, type of pathogen, site of infection and increasing age did not affect mortality. CONCLUSION: Necrotizing fasciitis remains a significant problem in our community especially in the Maori and Pacific population. Early surgical debridement decreases mortality rates.
Adult↗