A gastrointestinal stromal tumour presenting incidentally with haemorrhage and perforation associated with a Meckel's diverticulum: a case report

<p>Abstract</p> <p>Introduction</p> <p>This is the first reported case of perforation and haemorrhage of a Meckel's diverticulum leading to the incidental finding of a gastrointestinal stromal tumour within the diverticulum. Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract, however, when symptomatic, it is often misdiagnosed at presentation. Common complications presenting in adults include bleeding, obstruction, diverticulitis and perforation. Tumours within a Meckel's diverticulum are a rare but recognised complication. We discuss the management of a gastrointestinal tumour within the diverticulum.</p> <p>Case presentation</p> <p>A 59-year-old Caucasian man presented with acute right iliac fossa pain with localized peritonism. At surgery, he was found to have a perforated and haemorrhagic Meckel's diverticulum, associated with a gastrointestinal stromal tumour within the apex of the diverticulum. The absence of necrosis and a low mitotic rate indicated primary resection with subsequent computed tomography surveillance to be the most appropriate management strategy.</p> <p>Conclusion</p> <p>We report a unique triad of complications associated with the presentation of a Meckel's diverticulum. This article reviews this common congenital abnormality and discusses the management of a gastrointestinal tumour. Meckel's diverticulum will mimic other intra-abdominal pathologies in presentation and should therefore often be considered as a differential diagnosis.</p

Surgical practices in emergency umbilical hernia repair and implications for trial design

Introduction: There is variation in the investigation, management, and surgical technique of acutely symptomatic umbilical hernias and optimal strategies remain to be established. This survey aimed to identify key variables influencing decision-making and preferred surgical techniques in emergency umbilical hernia care to help inform trial design and understand potential challenges to trial delivery. Methods: A survey was distributed to surgeons through social media, personal contacts, and ASGBI lists. It comprised five sections: (i) performer of repair, (ii) repair preferences, (iii) important outcomes, (iv) perioperative antibiotic use, and (v) potential future trial design. Results: There were 105 respondents, of which 49 (46.6%) were consultants. The median largest defect surgeons would attempt to repair with sutures alone was 2 cm (IQR 2–4 cm). In the acute setting, the most common mesh preferences are preperitoneal plane placement (n = 61, 58.1%), with synthetic non-absorbable mesh (n = 72, 68.6%), in clean (n = 41, 39.0%) or clean-contaminated (n = 52, 49.5%) wounds. Respondents believed suture repair to be associated with better short-term outcomes, and mesh repair with better long-term outcomes. Pre-/intra-operative antibiotics were very frequently given (n = 48, 45.7%) whilst post-operative antibiotics were rarely (n = 41, 39%) or very rarely (n = 28, 26.7%) given. The trial design felt to most likely influence practice is comparing mesh and suture repair, and post-operative antibiotics versus no post-operative antibiotics. Respondents indicated that to change their practice, the median difference in surgical site infection rate and recurrence rate would both need to be 5%. Conclusion: This survey provides insight into surgical preferences in emergency umbilical hernia management, offering guidance for the design of future trials.</p

Women’s experiences of the Odon Device to assist vaginal birth and participation in intrapartum research:a qualitative study in a maternity unit in the Southwest of England

OBJECTIVE: To investigate women’s experiences of having a birth assisted by the Odon Device (an innovative device for assisted vaginal birth) and participation in intrapartum research. DESIGN: Qualitative semistructured interviews and observations undertaken in the context of case study work embedded in the ASSIST feasibility study. SETTING: A tertiary referral National Health Service (NHS) maternity unit in the Southwest of England, between 8 October 2018 and 26 January 2019. PARTICIPANTS: Eight women, four operators and 11 midwives participated with eight observations of the assisted vaginal birth, eight interviews with women in the postnatal period, 39 interviews/reflections with operators and 19 interviews with midwives. Women in the case study research were recruited from participants in the main ASSIST Study. INTERVENTION: The Odon Device, an innovative device for assisted vaginal birth. RESULTS: Thirty-nine case studies were undertaken. Triangulation of data sources (participant observation, interviews with women, operators and midwives) enabled the exploration of women’s experiences of the Odon Device and recruitment in the intrapartum trial. Experiences were overwhelmingly positive. Women were motivated to take part by a wish for a kinder birth, and because they perceived both the recruitment and research processes (including observation) to be highly acceptable, regardless of whether the Odon-assisted birth was successful or not. CONCLUSIONS: Interviews and observations from multiple stakeholders enabled insight into women’s experiences of an innovative device for assisted vaginal birth. Applying these qualitative methods more broadly may illuminate perspectives of key stakeholders in future intrapartum intervention research and beyond. TRIAL REGISTRATION NUMBER: ISRCTN10203171; ASSIST Study registration; https://doi.org/10.1186/ISRCTN10203171

Delivering successful randomized controlled trials in surgery:methods to optimize collaboration and study design

Randomized controlled trials in surgery are notoriously difficult to design and conduct due to numerous methodological and cultural challenges. Over the last 5 years, several UK-based surgical trial-related initiatives have been funded to address these issues. These include the development of Surgical Trials Centers and Surgical Specialty Leads (individual surgeons responsible for championing randomized controlled trials in their specialist fields), both funded by the Royal College of Surgeons of England; networks of research-active surgeons in training; and investment in methodological research relating to surgical randomized controlled trials (to address issues such as recruitment, blinding, and the selection and standardization of interventions). This article discusses these initiatives more in detail and provides exemplar cases to illustrate how the methodological challenges have been tackled. The initiatives have surpassed expectations, resulting in a renaissance in surgical research throughout the United Kingdom, such that the number of patients entering surgical randomized controlled trials has doubled