Catheter balloon mimicking incarcerated femoral hernia and co-existing small bowel diverticular perforation: a case report

The majority of patients with small bowel diverticula are asymptomatic, however, associated complications include inflammation, intestinal obstruction, perforation and gastrointestinal haemorrhage. Bladder divertulae are uncommon and can herniate into the femoral or inguinal canal as well as the scrotum. We report the case of an elderly lady who underwent laparotomy for an incarcerated femoral hernia and was found to have the catheter balloon stuck into a bladder diverticulum in the femoral canal and coexisting small bowel diverticular perforation

A study into the prevention of parastomal herniation

PhDA hernia frequently complicates abdominal stoma formation. The aetiology of parastomal herniation is claimed to be multi-factorial but currently only age and trephine diameter have been shown to independently predict its development. Open or laparoscopic repair of a symptomatic parastomal hernia is frequently challenging and is associated with unsatisfactory recurrence rates. As a result, many affected patients are managed non-operatively. Prevention of parastomal herniation by prophylactic mesh reinforcement of the stoma site is a new strategy that may reduce its incidence. Manual mesh implantation, however, is thought to increase the operating time and is considered cumbersome, particularly in laparoscopic surgery. As a result, routine reinforcement of the stoma site is not currently standard practice within the National Health Service. Thus, there is a need for a simple and quick technique for stoma formation which avoids creating an oversized defect and simultaneously reinforces the trephine with mesh. The aims of this thesis included: (i) understanding the aetiopathogenesis of parastomal herniation, assessing its impact on patients’ quality of life and examining the outcomes associated with current therapeutic strategies in order to find novel therapies that may lead to its prevention; (ii) assessing the safety, reproducibility and efficacy of the Stapled Mesh stomA Reinforcement Technique (SMART) in preventing parastomal herniation and (iii) investigating the contribution of the rectus abdominis muscle to the development of herniation. A detailed literature review of PubMed and Medline databases confirmed that stoma formation through the rectus muscle is complicated by parastomal herniation in 50%-80% of 4 cases. Surgeons have underestimated its impact on patients’ quality of life. There is no conclusive evidence that alternative techniques (e.g. extraperitoneal, lateral rectus abdominis positioned stoma) are superior. Open and laparoscopic parastomal hernia repair have similar recurrence rates up to 50%. Prophylactic reinforcement of the stoma trephine with mesh in the sublay or subperitoneal position is safe and appears to reduce the herniation rate but it is difficult laparoscopically and does not address the issue of trephine size when a defect <25mm is associated with a reduced herniation risk. The Stapled Mesh stomA Reinforcement Technique (SMART) obviates the technical issues associated with routine stoma formation and reinforcement. In a pilot study with patients at high risk for herniation, SMART was found to be safe and reproducible and reduced the herniation rate to 18%. Preliminary results of the international multicentre randomised controlled trial in all patients undergoing permanent stoma formation show that SMART reduces the herniation rate compared to the standard technique, without added morbidity and minimal impact on the operating time. A radiological study assessing the contribution of the rectus abdominis muscle into the development of parastomal herniation showed that the abdominal musculature undergoes postoperative changes consistent with atrophy with postoperative muscle density being higher in patients without parastomal herniation. In conclusion, at this moment in time, prophylactic mesh reinforcement should be offered to all patients undergoing elective permanent stoma formation. The SMART procedure has the potential to change current surgical practice. The contribution of the rectus muscle to the development of herniation warrants further research since improving muscle repair and regeneration may result in therapeutic benefits

Gangrene due to axial torsion of a Giant Meckel's Diverticulum containing multiple stones in the lumen: a case report

Meckel's diverticulum is the most common congenital anomaly of the small intestine. Common complications related to a Meckel's diverticulum include haemorrhage, intestinal obstruction and inflammation. Gangrene due to axial torsion and enteroliths of a Meckel's diverticulum are the rarest complications that have been reported in the literature. We report a case of gangrene due to axial torsion of giant Meckel's diverticulum with multiple stones in its lumen

Perioperative outcomes and adverse events of robotic colorectal resections for inflammatory bowel disease: a systematic literature review

The purpose of this study was to assess outcome measures and cost-effectiveness of robotic colorectal resections in adult patients with inflammatory bowel disease. The Cochrane Library, PubMed/Medline and Embase databases were reviewed, using the text “robotic(s)” AND (“inflammatory bowel disease” OR “Crohn’s” OR “Ulcerative Colitis”). Two investigators screened abstracts for eligibility. All English language full-text articles were reviewed for specified outcomes. Data were pre - sented in a summarised and aggregate form, since the lack of higher-level evidence studies precluded meta-analysis. Primary outcomes included mortality and postoperative complications. Secondary outcomes included readmission rate, length of stay, conversion rate, procedure time, estimated blood loss and functional outcome. The tertiary outcome was cost-effectiveness. Eight studies (3 case-matched observational studies, 4 case series and 1 case report) met the inclusion criteria. There was no reported mortality. Overall, complications occurred in 81 patients (54%) including 30 (20%) Clavien-Dindo III–IV complica - tions. Mean length of stay was 8.6 days. Eleven cases (7.3%) were converted to open. The mean robotic operating time was 99 min out of a mean total operating time of 298.6 min. Thirty-two patients (24.7%) were readmitted. Functional outcomes were comparable among robotic, laparoscopic and open approaches. Case-matched observational studies comparing robotic to laparoscopic surgery revealed a significantly longer procedure time; however, conversion, complication, length of stay and readmission rates were similar. The case-matched observational study comparing robotic to open surgery also revealed a longer procedure time and a higher readmission rate; postoperative complication rates and length of stay were similar. No studies compared cost-effectiveness between robotic and traditional approaches. Although robotic resections for inflamma - tory bowel disease are technically feasible, outcomes must be interpreted with caution due to low-quality studies

Double-blind randomised controlled trial of percutaneous tibial nerve stimulation versus sham electrical stimulation in the treatment of faecal incontinence: CONtrol of Faecal Incontinence using Distal NeuromodulaTion (the CONFIDeNT trial)

Background: Faecal incontinence (FI) is a common condition which is often under-reported. It is distressing for those suffering from it, impacting heavily on their quality of life. When conservative strategies fail, treatment options are limited. Percutaneous tibial nerve stimulation (PTNS) is a minimally invasive outpatient treatment, shown in preliminary case series to have significant effectiveness; however, no randomised controlled trial has been conducted. Objectives: To assess the effectiveness of PTNS compared with sham electrical stimulation in the treatment of patients with FI in whom initial conservative strategies have failed. Design: Multicentre, parallel-arm, double-blind randomised (1 : 1) controlled trial. Setting: Eighteen UK centres providing specialist nurse-led (or equivalent) treatment for pelvic floor disorders. Participants: Participants aged > 18 years with FI who have failed conservative treatments and whose symptoms are sufficiently severe to merit further intervention. Interventions: PTNS was delivered via the Urgent® PC device (Uroplasty Limited, Manchester, UK), a hand-held pulse generator unit, with single-use leads and fine-needle electrodes. The needle was inserted near the tibial nerve on the right leg adhering to the manufacturer’s protocol (and specialist training). Treatment was for 30 minutes weekly for a duration of 12 treatments. Validated sham stimulation involved insertion of the Urgent PC needle subcutaneously at the same site with electrical stimulation delivered to the distal foot using transcutaneous electrical nerve stimulation. Main outcome measures: Outcome measures were assessed at baseline and 2 weeks following treatment. Clinical outcomes were derived from bowel diaries and validated, investigator-administered questionnaires. The primary outcome classified patients as responders or non-responders, with a responder defined as someone having achieved ≥ 50% reduction in weekly faecal incontinence episodes (FIEs). Results: In total, 227 patients were randomised from 373 screened: 115 received PTNS and 112 received sham stimulation. There were 12 trial withdrawals: seven from the PTNS arm and five from the sham arm. Missing data were multiply imputed. For the primary outcome, the proportion of patients achieving a ≥ 50% reduction in weekly FIEs was similar in both arms: 39 in the PTNS arm (38%) compared with 32 in the sham arm (31%) [odds ratio 1.28, 95% confidence interval (CI) 0.72 to 2.28; p = 0.396]. For the secondary outcomes, significantly greater decreases in weekly FIEs were observed in the PTNS arm than in the sham arm (beta –2.3, 95% CI –4.2 to –0.3; p = 0.02), comprising a reduction in urge FIEs (p = 0.02) rather than passive FIEs (p = 0.23). No significant differences were found in the St Mark’s Continence Score or any quality-of-life measures. No serious adverse events related to treatment were reported. Conclusions: PTNS did not show significant clinical benefit over sham electrical stimulation in the treatment of FI based on number of patients who received at least a 50% reduction in weekly FIE. It would be difficult to recommend this therapy for the patient population studied. Further research will concentrate on particular subgroups of patients, for example those with pure urge FI. Trial registration: Current Controlled Trials ISRCTN88559475. Funding: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 77. See the NIHR Journals Library website for further project information

Small bowel perforation by a piece of china with a synchronous asymptomatic sigmoid carcinoma: A case report

A 75 year old gentleman who presented with an incarcerated paraumibilical hernia was found intraoperatively to have small bowel perforation due to a piece of china with a synchronous asymptomatic sigmoid carcinoma

Radiological progression of end colostomy trephine diameter and area

Development of a parastomal hernia is common following abdominoperineal excision (APE). The true incidence is difficult to assess fully owing to differing lengths of follow-up and techniques used to assess herniation; radiological or clinical. The primary aim of this study was to evaluate colostomy diameter by studying the rate of change of axial and sagittal trephine diameters, trephine area, and the ratio of the trephine over time. A secondary aim was to investigate variation in trephine area and variables affecting parastomal hernia over time

Fluorescence lifetime spectroscopy of tissue autofluorescence in normal and diseased colon measured ex vivo using a fiber-optic probe

We present an ex vivo study of temporally and spectrally resolved autofluorescence in a total of 47 endoscopic excision biopsy/resection specimens from colon, using pulsed excitation laser sources operating at wavelengths of 375 nm and 435 nm. A paired analysis of normal and neoplastic (adenomatous polyp) tissue specimens obtained from the same patient yielded a significant difference in the mean spectrally averaged autofluorescence lifetime −570 ± 740 ps (p = 0.021, n = 12). We also investigated the fluorescence signature of non-neoplastic polyps (n = 6) and inflammatory bowel disease (n = 4) compared to normal tissue in a small number of specimens