The appendix-mucosal immunity and tolerance in the gut: consequences for the syndromes of appendicitis and its epidemiology

The cause of appendicitis is unknown. A review is presented across diverse sources relating to the biology of the appendix and its perturbations. A mechanistic model of the function of the appendix is presented, and its application to the syndromes and consequences of appendicitis is described

A sanctuary in the city

A brief description of an inner city wetland which has been successfully developed into a bird sanctuary in Colombo, Sri Lank

Predicting difficult cholecstectomy using a science based model

There has been considerable interest over the last decade in the development of models to predict conversion to open at laparoscopic cholecystectomy (CONV). This is of increasing relevance as trainees and younger surgeons have less exposure to Open Cholecystectomy. The Cairns Prediction Model (CBM), and the model produced by the West Midlands Research Collaborative using the CholeS dataset in the UK are described. They are both validated models and have a role to play. Analysis of the CholeS dataset suggests that it provides evidence to relate the notion of "difficulty" to conversion risk. It also shows that as the cases become more difficult (as judged against the Nassar grade) conversion rates and complications increase in the chole S dataset, but not in the Reference dataset of an expert surgeon. It is suggested that the models be used for ethical discussion with patients and the process of obtaining consent in the light of the notion of "material" risk. Further uses for the model are to arrange operation lists, to select day case procedures and those for registrar training. Importantly it allows selection of difficult cholecystectomy for referral to expert surgeons. The term Selective Cholecystectomy is introduced to describe this approach

How many facts make an "informed patient"? Practical challenges for junior doctors in acquiring surgical informed consent

Purpose: In addition to technical surgical skills, the complete surgeon requires skills in communication and consenting patients. This protects patients, hospitals, and doctors themselves, but also promotes best practice. However, surgical informed consent (SIC) is commonly acquired by junior doctors (defined as PGY1 until completion of specialist training). Little is known about the quality of SIC that doctors at this level may acquire. This study aimed to synthesize known evidence on challenges faced by junior doctors on this issue. Methodology:The authors conducted a systematic review of all English-language studies published from 1 January 2007 looking at junior doctors (considered to be from PGY1 to the end of specialist training) and any issues that arose around acquiring SIC. A qualitative synthesis was then conducted. Results: Junior doctors understanding of the legal standards of consent, including both capacity/competence and the concepts of material risk, varied considerably across studies. Documentation and discussion of possible complications in surgery was found to be highly variable within both trainees and consultants consenting practices. Few junior doctors discussed alternative treatment options, including the possibility of having no treatment; evidence on discussion of benefits and recovery were conflicting. Overall documentation of the SIC process was poor. Conclusions: While junior doctors are commonly responsible for acquir-ing SIC, this study shows that there are significant practical deficiencies in how they discharge this duty. As a result, SIC acquired by junior doctors may not always comply with required legal standards, which may open up this cohort, and their hospitals, to legal action

Closing the open abdomen

The baseline treatment of Abdominal Compartment Syndrome is lparostomy. While this is a life saving procedure, the resulting open abdomen (OA) introduces its own challenges, mainly enteric fistula and complex ventral hernia. We propose that the incidence of these complications is proportional tothe length of time the abdomen remains open. The corollary is that OA wounds should be closed as soon as practicable. We examine the different models of abdominal wound healing, and how they can be exploited and modified to obtain early closure of the open abdomen

The management of the open abdomen: 11 years experience in the tropics

Purpose: The management of the open abdomen (OA) has changed over the last 11 years with Topical Negative Pressure (TNP) systems now the first line of treatment in our institution. We share our experiences with the use of TNP systems in contrast to the previous Planned Ventral Hernia (PVH) approach. Methodology: 92 consecutive patients with OA were reviewed from operating theatre and intensive care unit (ICU) databases from 2001 to 2011 at the Cairns Base Hospital, Queensland, Australia. Mortality rates were compared in relation to APACHE III scores as well as the incidence of adverse outcomes such as entero-cutaneous fistulas (ECF), anastomotic leaks, and intra-abdominal abscesses within the two management systems. These results were analysed using chi-squared test for categorical variables, with statistical significance being identified as p value less than 0.05. Results: Peritonitis accounted for 58% of cases of an open abdomen. There was observed increased mortality associated with PVH (16% vs. 29%) when APACHE III scores ranged from 46–126. There was no statistical significance between the two management systems in relation to incidence of ECF rate, anastomotic leaks or intra-abdominal abscesses. Patients with TNP spent less time in ICU (24.3 days vs. 31.6 days). Conclusions: The TNP systems have replaced the previously used PVH systems in the management of the OA in our institution. Analysis suggests that TNP systems can be safely employed in the management of OA as com-pared to the PVH approach

Validation of the Cairns prediction model for conversion of laparoscopic to open cholecystectomy

Purpose: At present there are limited prediction models that are user friendly and simple to understand when considering conversion from laparoscopic to open cholecystectomy. Recently a prediction model has been developed at Cairns Hospital (QLD), which aims to identify patients who are at greater risk of conversion. The aim of this study was to externally validate the predictive model developed in Cairns using patients from Townsville Hospital. It is hypothesized that this model is feasible for use in current surgical practice. It was hoped that by early recognition of thee at risk patients, will lead to reduced operative times, diminished hospital length of stay and operative complications. Methodology: This study was a retrospective longitudinal study of all patients who underwent a laparoscopic cholecystectomy at The Townsville Hospital during the years 2013 and 2014. Two patient factors (previous upper abdominal surgery, obesity) and three ultrasonography findings (impacted gallstones, gallbladder wall thickness and visible choledocholithiasis) were evaluated for each case. The rate of conversion was also documented. This data was then analyzed and incorporated into the pre-developed Cairns predictive model to determine its external validity. Results: In total there were 451 patients who underwent laparoscopic cholecystectomies, seven of whom had conversions to open procedures (1.6%). 400 patients had complete data and could be included in the ROC analysis. Five of the included patients had conversions (1.3%). Conclusion: External validation provides some support for the Cairns prediction model (AUC 0.74, p=0.061). We aim to add 2015–2016 data and re-do the analysis

Evaluation of general surgical outreach on Thursday Island

Purpose: Surgical outreach is generally accepted as an effective method to overcome many of the barriers to effective healthcare in rural areas. The Cairns Hospital conducts outreach to a number of communities in North Queensland, the most significant of which being Thursday Island (TI). There is however a paucity of data describing the effectiveness of these programs. Methodology: A retrospective review of the General Surgical Outreach program spanning 03/2015 to 08/2016 was performed to identify factors associated with successful management in the outreach setting using Chi-square analysis. Markers for successful management included 1) whether the initial patient consultation was made within the nationally adopted maxi-mum time frame from referral, and 2) whether the patient was managed solely in the outreach setting. Results: 89 cases were evaluated, 72% of which were Aboriginal or Torres Strait Islander Peoples. The most common presenting complaints were cholelithiasis (26%) followed by abdominal hernias (17%). 54% of patients had completed their consultation within maximum time frame. 63%were managed entirely on TI, 37% of which were surgically managed in the local operating theatre. No demographical or clinical factors were associated with successful management. Conclusion: Surgical outreach on TI allows a significant proportion of patients to be managed locally, thereby breaking a barrier to accessing health care. This research has identified that it is common however for patients to be seen beyond the recommended time frame and for patients to have to travel regardless. Further research is needed to identify the patients that are most successfully managed in this setting in order to improve the effectiveness of the program

Does being indigenous make it complex general surgery?

Purpose: Evaluate if being indigenous increases the overall risk of conversion (CONV) from a laparoscopic to open cholecystectomy. No previous study evaluating risk of CONV has analysed an indigenous population. Methodology: In a cross sectional observational study, data was collected from any patient who underwent a laparoscopic cholecystectomy at the Cairns Hospital between 2010-2012. Risk factors relating to patient factors, radiological factors and laboratory factors were considered. Univariate and multivariate logistic regression with the construction of nomograms was performed (accepted in Am J Surg 2015) Results: Of 732 patients, 197 (26.9%) were indigenous. This study has the largest indigenous cohort to date. 40 preoperative risk factors were evaluated. The difference in CONV rate between patients who are indigenous (11%) and non-indigenous (4.7%) was statistically significant (P = 0.0033). However, ethnicity did not remain in the final multivariate model as a direct predictor of risk of CONV Conclusion: Patients who are indigenous had a significantly higher CONV rate compared to patients who are non-indigenous. This was better explained by an increased prevalence of other risk factors and adding as a risk factor does not increase the overall risk of CONV. The nomogram developed to predict CONV can be applied to any patient regardless of their ethnicity

The correlation between diverticulosis and redundant colon

Purpose: Diverticulosis and redundant colon are colonic conditions for which underlying pathophysiology, management and prevention are poorly understood. Historical papers suggest an inverse relationship of these two conditions. However, no further attempt has been made to validate this relationship. This study set out to assess the correlation between diverticulosis and colonic redundancy. Methodology: The presence of redundant colon and diverticulosis were noted during colonoscopy. Multivariate binary logistic regression was per-formed with the aim of developing a probability nomogram. Multivariate logistic regression was performed with redundant colon as the dependent variable and diverticulosis, age and gender as independent variables. Nagelkerke R2 and a receiver operator curve with area under curve were calculated to assess goodness off it and internally validate the multivariate model. Results: The probability of redundant colon was increased by female gender odds ratio (OR) 8.4 (95% CI 2.7-26, p=0.00020) and increasing age OR 1.7 (95% CI 1.1-2.6, p=0.017). Paradoxically, diverticulosis strongly reduced the probability of redundant colon with OR of 0.12 (95% CI 0.42-0.32, p=0.000039). The Nagelkerke R2 for the multivariate model was 0.29and area under the curve at ROC analysis was 0.81 (CI 95% 0.73-0.90 p-value 3.1x10-8). Conclusions: This study found an inverse correlation between redundant colon and diverticulosis, supporting the historical suggestion that the two conditions rarely occur concurrently. The underlying principle for this relationship remains to be found. However, it may contribute to the understanding of the aetiology and pathophysiology of these colonic condition