Biomedical subjects
Publications and source records attributed to D Hemingway.
Loop colostomy formation commonly involves temporary support over a plastic bridge. We describe a technique of loop colostomy using a permanent skin bridge. By joining two inter-digitating skin flaps raised from the margins of the stoma, an adjustable bridge is formed that can accommodate colon loops of any diameter. In a series of twenty cases, our technique has been complication free and well tolerated by patients.
OBJECTIVES: The recently published ACPGBI colorectal cancer (ACPGBI CRC) scoring system for predicting operative mortality has been suggested as an instrument to improve patient consent procedures and to compare results between centres. This study compares the results of a surgical unit against the standards set by the ACPGBI colorectal cancer model and for emergency surgery, against the p-POSSUM instrument. METHODS: Data for the ACPGBI CRC model were collected prospectively through 2003 at the Leicester Royal Infirmary. Additional data needed for the p-POSSUM was retrospectively collected from case records. The actual mortality was compared with that predicted by the models. RESULTS: Seventy-two colorectal cancer operations were performed during the study period. The observed operative mortality in elective cases was lower, and in emergency cases higher, than predicted by the ACPGBI CRC model. With emergency cases the predicted mortality using P-POSSUM was significantly higher than that using the ACPGBI CRC model, particularly in the presence of faecal contamination. CONCLUSION: The ACPGBI CRC model may be accurate for elective cases, but appears to significantly underestimate predicted mortality in the emergency setting, both actual and predicted by p-POSSUM. This may be due to a failure to incorporate adequate weighting for faecal peritonitis and the associated systemic insult into the ACPGBI model.
OBJECTIVE: Diagnosis of right-sided colon cancers requires total colonic imaging. The decision as to when a symptomatic patient should undergo a complete colonic imaging is difficult. It has been suggested that the presence of iron deficiency anaemia in such patients can be a useful tool in making that decision, as the vast majority of proximal colon cancers are anaemic. Our study aimed to evaluate the relation between proximal colon cancers and anaemia. METHODS: A list of 194 patients who underwent a right hemicolectomy for colon cancer was extracted from our hospital cancer database. The haemoglobin levels of each of these patients at the time of their referral were identified. The proportion of these patients, who had anaemia as per locally agreed guidelines, was determined. RESULTS: Only 44% of the men and 57% of women with proximal colon cancer were found to be anaemic. Even after using higher cut-off levels for 'low' haemoglobin, a significant proportion of patients were not anaemic. CONCLUSIONS: Anaemia is a poor predictor of right-sided colon cancers and cannot be used as an effective investigative tool in symptomatic patients.
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We report a patient with ulcerative colitis who, in the period following surgery, developed recurrent episodes of acute adrenal insufficiency presenting clinically as a high output ileostomy.
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A technique is described to test the integrity of the anastomosis formed during reversal of ileostomy intra-operatively and the early clinical results obtained using the technique.
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BACKGROUND: Idiopathic slow-transit constipation may be a pangastrointestinal motility disorder. We have screened patients referred to surgery for constipation for the presence of biliary dyskinesia. METHOD: Patients had cholecystokinin-augmented trimethyl-3-bromo iminodiacetic acid scans to measure gallbladder ejection fraction. RESULTS: There is a significant difference in gallbladder ejection fraction between patients with idiopathic slow-transit constipation (median value, 28.5) compared with patients with other causes of constipation (median value, 71; Mann-Whitney, P = 0.0025). CONCLUSION: Idiopathic slow-transit constipation may be a pangastrointestinal motility disorder.
Many techniques are available for the identification of patients with hepatic colorectal metastases. The accuracy and clinical relevance of transabdominal ultrasound (US), computed tomography (CT), static scintigraphy, dynamic scintigraphy (HPI), intraoperative ultrasound (IOUS) and manual palpation, in the detection of intrahepatic colorectal metastases were assessed in 73 consecutive patients presenting with colorectal carcinoma; 39 were male and 34 female with a mean age of 68 years (range 43-90 years). In 33 patients either intraoperative ultrasound or palpation were omitted owing to emergency presentation (n = 14) or subsequent non-operative management (n = 19). All six investigations were completed in 40 patients. Computed tomography and hepatic perfusion scintigraphy (HPI) were the most sensitive, detecting over 90% of lesions, the others identifying approximately 80% of lesions, Specificity in all methods, apart from dynamic scintigraphy, was over 80%. Contrast-enhanced CT would appear to remain the most accurate method available. However, if the prognostic ability of HPI is confirmed on subsequent follow-up, the accuracy of HPI will rise with time, whereas that of CT will fall. Intraoperative ultrasonography took time to perform and did not alter the management of any patient within the study. We suggest that its use is limited to those patients in whom resection is contemplated, where the vascular anatomical detail provided may be invaluable.
Both biodegradable emboli and pharmacological agents can enhance regional therapy for hepatic targeting. Using a rat model with similar haemodynamic characteristics to human colorectal liver tumour and a radio-labelled marker of similar molecular weight to Adriamycin, we have combined the two approaches to see if the effect was addictive. Following induction of liver tumour in male hooded rats by intrahepatic injection of HSN sarcoma cells, the relative distribution of marker, 99mTc methylene diphosphonate (MDP), was studied in three groups given the following by injection into the hepatic artery. (1) Saline (Control) + MDP; (2) Degradable Starch Microspheres (DSM) + MDP; and (3) Angiotensin II + DSM + MDP. Both Degradable Starch Microspheres alone (P less than 0.001) and Degradable Starch Microspheres + Angiotensin II (P = 0.003) significantly increased the retention of marker in liver and tumour at 1 min following injection, with a 12-fold improvement over controls, but the tumour:liver ratio was unaltered. By 90 min the MDP levels in normal hepatic parenchyma had returned to control values. There was relatively less washout with significant retention in tumour tissue in both DSM (P = 0.03) and combination treated animals (P = 0.001), with a significantly improved (P = 0.001) tumour to liver ratio (5.22:1) in combination treated animal relative to those treated with DSM alone.
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Patients with bleeding disorders or who are anticoagulated may present with haematuria. Failure to investigate such patients when they first present may delay the diagnosis and treatment of a serious genito-urinary pathology.
In a four-year experience with selective nonoperative management of splenic trauma in adults and children, 24 (35%) of 68 patients with documented splenic trauma were initially treated nonoperatively. In only one patient was an operation and laparotomy ultimately required. There was no morbidity or mortality in the nonoperative group. In the operative group (44 patients), 4% died after operation, largely of multiple injuries. Confirmation of splenic injury and follow-up of patients were mostly performed by splenic scintiscans. There was no significant difference in length of hospitalization between operative and nonoperative groups. Operative splenic repair and preservation of the spleen to prevent postsplenectomy sepsis often requires considerable experience and may be a lengthy, tedious procedure. Nonoperative therapy in adults and children is an attractive alternative in a selective group of patients.