Best poster: Postoperative fluid prescribing practices in children by British Columbia Children's Hospital surgeons
N Lee*, S Whyte† and T Ripley†,‡
*Newcastle University Medical School, Newcastle-upon-Tyne, England, UK
†Department of Anaesthesia, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
‡British Columbia Children's Hospital, Vancouver, BC, Canada
Background: In the postoperative period, children often present with subclinical dehydration as the non-osmotic arginine vasopressin mechanism is enhanced, inducing water retention. Unless isotonic fluids are prescribed for volume resuscitation, the risk of hyponatraemia is increased, especially since children have larger brain-to-skull size ratios. Hence, the National Patient Safety Agency currently suggests the prescribing of postoperative hypotonic fluids be minimized unless there is a specific indication for its use. Methods: A total of 641 charts for elective surgeries occurring between January and July of 2010 at the British Columbia Children's Hospital in Canada were reviewed retrospectively. The postoperative fluid prescribed from 10 specialties upon discharge from the postanaesthesia care unit was recorded. Results: Data were obtained for 600 (93.6%) charts. Paediatric surgeons prescribed isotonic fluids in 89.7% of the cases. Conversely, hypotonic fluids were prescribed in 10.3% of the remaining cases. Conclusion: Postoperative prescribing practices at the British Columbia Children's Hospital currently stand to favour isotonic fluids for maintenance in children receiving intravenous fluids, yet those children who received hypotonic fluids may have been put at risk from iatrogenic hyponatraemia. As a result of this audit, all hypotonic fluids have been removed from the recovery area and prescriptions for non-isotonic fluids are questioned by recovery nursing.
DOI: 10.1258/smj.2012.012068
Quality-of-life assessment following adenotonsillectomy for obstructive sleep apnoea in children
R Mandavia*, V Dhar†, K Kapoor† and A Rachmanidou†
*King's College London School of Medicine, London, England, UK
†Department of Otolaryngology, University Hospital Lewisham, London, England, UK
Background: The major cause of obstructive sleep apnoea (OSA) in children is adenotonsillar hypertrophy and in such cases, the treatment of choice is adenotonsillectomy. Few studies have investigated the impact of adenotonsillectomy on the quality of life (QOL) of children with OSA. In particular, to our knowledge, no study has investigated the effects of adenotonsillectomy on QOL of children under three years of age with OSA. We aimed to investigate the effects of adenotonsillectomy on QOL of children under three years of age with OSA. Methods: Thirty-nine children, all under three years of age treated with adenotonsillectomy for OSA met the inclusion criteria. The QOL questionnaire was adapted from the validated 6-item instrument developed by de Serres et al. (2000). The questionnaire assessed the improvement of specific domains following adenotonsillectomy. Carers scored each domain on a point scale ranging from ‘none’ (0) to ‘couldn't be more’ (6). Results: The QOL of all children improved after surgery. The greatest average improvement scores were in: care-giver concern, physical suffering and sleep disturbance. The modal questionnaire score was 4 and the overall average questionnaire score was 4.2. Conclusion: Adenotonsillectomy provides measurable improvements in QOL of children under three years of age with OSA.
DOI: 10.1258/smj.2012.012069
Complications of ear cartilage piercing: how much do piercing parlours know?
R Mandavia*, K Kapoor† and H Osmani*
*King's College London School of Medicine, London, England, UK
†Department of Otolaryngology, University Hospital Lewisham, London, England, UK
Background: Ear cartilage piercing can lead to a range of severe complications. Clearly those undergoing such piercings should be informed of possible risks. To our knowledge no study has investigated practitioners’ awareness of complications of cartilage piercing. We aimed to evaluate current ear piercing practices in a sample of piercing parlours in London. Methods: Twenty-five London piercing parlours completed a telephone questionnaire. Questions assessed knowledge of cartilage piercing complications and pre- and postpiercing practices. Results: All parlours required completed consent forms prior to procedure. While 4% and 3% of parlours were aware of keloid scarring and hypertrophic scarring, respectively, no parlours were aware of the risk of cauliflower ear as a potential complication of cartilage piercing. Of all study participants, 16% advised customers to see their general practitioner following a complication and 12% recommended going to accident and emergency. Conclusion: All piercing parlours required customer consent prior to piercing. However, the majority of parlours showed considerable lack of awareness concerning the complications posed by cartilage piercing and thus did not fully inform their customers of the possible risks. Moreover, surprisingly only 28% of parlours advised customers to seek medical help following a complication and 40% did not provide any written postpiercing instructions.
DOI: 10.1258/smj.2012.012070
A case of carotico-cavernous fistula
S Martin*, M Teo†, J Bhattacharya‡, D Hadley‡ and L Alakandy†
*University of Glasgow, School of Medicine, Glasgow, Scotland, UK
†Department of Neurosurgery, Institute of Neurological Science, Glasgow, Scotland, UK
‡Department of Neuroradiology, Institute of Neurological Science, Glasgow, Scotland, UK
A 55-year-old man with a recent history of head trauma presented with one-week history of left eye discomfort, double-vision and pulsatile tinnitus. Examination of the left eye showed proptosis, chemosis, orbital bruit and sixth cranial nerve palsy. Visual acuity was 6/6 in both eyes, and there were no other neurological findings. Computerized tomography showed marked dilation of the left superior ophthalmic vein: a finding suggestive of carotico-cavernous fistula (CCF). Cerebral angiography confirmed the presence of a high-flow fistulous connection between the internal carotid artery and the cavernous sinus by demonstrating rapid filling of the cavernous sinus following internal carotid arterial injection. Treatment was effected successfully by transarterial embolization using several platinum coils. All symptoms fully resolved following treatment. CCF can be caused by trauma or occur spontaneously. Blunt head injury can cause shearing of the intracavernous arteries, while penetrating head injury can lead to direct laceration of the intracavernous arteries, causing the formation of a fistula. Dilation of the superior ophthalmic vein, a sign of venous hypertension, should be identified to avoid delay in diagnosis. The definitive management of obliterating the fistulous connection is most often achieved by endovascular strategy.
DOI: 10.1258/smj.2012.012071
Assessment of surgical voice restoration following laryngectomy
J D Bone*, L Gamberini† and A K Robson‡
*University of Glasgow, Glasgow, Scotland, UK
†North Cumbria University Hospitals NHS Trust, Cumbria, England, UK
‡Consultant ENT Surgeon, Cumberland Infirmary, Carlisle, England, UK
Background: Laryngectomy, is indicated as curative treatment for advanced laryngeal cancer. Patients should be offered surgical voice restoration, to achieve the use of a tracheo-oesophageal speech valve as the main method of communication. Return to functional voice reduces distress and negative psychological impact. Successful outcome should include a return to the best possible quality of life as well as cure. The audit aim was to assess success of surgical voice restoration in producing effective voice postlaryngectomy. Methods: A total of 40 laryngectomees were identified to assess the use of valved voice as the main form of communication and overall satisfaction with their voice and valve; 16 were excluded for unsuitability or non-response; 24 were surveyed using the validated Sunderland Surgical Voice Restoration Self Rating Scale, assessing voice production, quality, acceptability and satisfaction, valve issues and an overall rating of voice. Results: Five regarded their voice as ‘excellent’, 10 as ‘good’, six as ‘adequate’ and three as ‘poor'; 22 of 24 used valved voice as their main form of communication. Conclusion: Factors that make adaptation to valved voice difficult were identified. Improved understanding of the capabilities of valved voice before surgery could increase satisfaction scores and awareness of potential problems may allow counselling to ensure realistic expectations.
DOI: 10.1258/smj.2012.012072
Indications for circumcision
R Wollerton
Cardiff University, Cardiff, Wales, UK
Background: The only absolute medical indication for circumcision in boys is Balanitis Xerotica Obliterans (BXO). Yet the frequency of medically indicated circumcision far outweighs the reported incidence of BXO. The aim of this study was to establish the other diagnoses that lead to circumcision for medical reasons and correlation of clinical diagnoses with the histological findings. Methods: A two-year review of boys undergoing circumcision for medical indication at the University Hospital Wales (UHW) was undertaken. Medical records and the histopathology database were consulted for indication and foreskin histology, respectively. Results: A total of 109 boys were circumcised for medical indications at UHW over the two-year period. Of the boys circumcised for medical indications, 75 were circumcised for phimosis (21 symptomatic and 54 pathological). Other medical indications for circumcision included uropathy, congenital megaprepuce and scrotalized foreskin. Histopathology was available for 78% of suspected BXO cases and demonstrated a 76% correlation between clinical diagnosis and histopathological findings. Conclusion: The majority of medically indicated circumcisions are carried out for symptomatic physiological phimosis or pathological phimosis (BXO). There is not a significantly high correlation between clinical and histological diagnosis of BXO/early BXO. Therefore clinical diagnosis of BXO should be supported by histopathological findings after circumcision.
DOI: 10.1258/smj.2012.012073
Overview and evidence basis of Boerhaave's syndrome: a hole in the differential for chest pain?
A Allen
Brasenose College, Oxford University, Oxford, England, UK
A 39-year-old man presented to accident and emergency with central crushing chest pain. Fortunately, the doctor on call was astute enough to link this with the patient's previous history of food poisoning and subsequent vomiting, and arranged an erect chest X-ray and computerized tomography scan, successfully picking up the diagnosis of Boerhaave's syndrome. A primary repair involving a left thoracotomy was performed within 24 hours, leading to a complete recovery. Boerhaave's syndrome is a specific case of oesophageal rupture precipitated by effort, most commonly vomiting. Besides its rarity, one of the principal difficulties in its diagnosis is the symptoms can be vague and generalized, and easily attributed to other more common chest or abdominal pathologies. Boerhaave's syndrome left untreated has a mortality approaching 100%; treatment is almost always surgical, with longer delays resulting in worse prognosis. The difficulty in clinical diagnosis means Boerhaave's syndrome is easily overlooked, but its potentially high mortality rate makes the condition one for which a high index of suspicion should be held in the differential diagnosis for chest pain. If this patient had been a 68-year-old overweight smoker, would the diagnosis have been made so quickly?
DOI: 10.1258/smj.2012.012074
Role of regulatory T-cells in murine model of liver fibrosis
X Lim, P Ramachandran and J P Iredale
College of Medicine and Veterinary Medicine, University of Edinburgh, MRC Centre for Inflammation Research, Edinburgh, Scotland, UK
Background: Liver fibrosis is a chronic inflammatory condition that afflicts many people. Because regulatory T-cells (Tregs) are known to dampen the inflammatory responses, we hypothesize that Tregs mediate the switch from fibrosis to resolution of liver fibrosis by interacting with macrophages. Methods: Using various Tregs and macrophage depletion models, we aimed to elucidate the relationship between Tregs and proresolution macrophages. All micewere injected with carbon tetrachloride for four weeks and allowed to recover. The livers were harvested, fixed and stained for fibrillar collagen, hepatic stellate cells (HSCs), Tregs and macrophages. Mann-Whitney statistical test was used and values of P < 0.05 were considered significant. Results: We established that Foxp3-DT is a novel viable method of Treg depletion (P < 0.05). Treg depletion resulted in worse liver fibrosis (P < 0.05) but with no change in amount of collagen I and HSCs.CD11b-DT proresolution macrophage depletion caused an increase in number of Tregs during resolution of liver fibrosis (P < 0.05) while liposome-induced activation of proresolution macrophages caused decrease in Tregs during resolution of liver fibrosis (P < 0.05). Conclusion: We conclude that there is an inverse relationship between Tregs and proresolution macrophages. We propose that this is due to negative feedback signals from proresolution macrophages that resulted in accumulation of Tregs when they are depleted.
DOI: 10.1258/smj.2012.012075
A case report: oesophageal reconstruction using colonic interposition
S Ikidde* and C Cheruvu†
*Keele University School of Medicine, Staffordshire, England, UK
†University Hospital of North Staffordshire, Stoke-on-Trent, England, UK
Colonic interposition is rarely performed in adults. The most acceptable method of oesophageal reconstruction after an oesophagectomy is by using the stomach. The indications for colonic interposition are patients who have oesophageal cancer with a history of gastric surgery or patients with stomach and oesophageal tumours. This case report looks at a 70-year-old man with an incidental finding of oesophageal cancer. After an oesophagectomy, an anastomotic leak occurred from the oesophagogastric anastomosis, eventually necessitating the procedure of colonic interposition. Complications arose when the caecum within the thorax became grossly distended by adhesion obstructions, compressing the left lung and right ventricle. Efforts to avoid adhesions could have made complications of the surgery less severe or alternatively, reconstruction using a pedicled jejunum. Although it is a more demanding procedure, reconstruction using the jejunum has been found to have better patient outcomes.
DOI: 10.1258/smj.2012.012076
When two systems collide: an uncommon but important cause of melaena
D Thurtle
Norfolk and Norwich University Hospitals, NHS Trust, Norwich, England, UK
Background: When a patient presents with melaena it is tempting to focus on the gastrointestinal system. I report an unusual case of secondary aortoenteric fistula. Case description: An 80-year-old man presented shocked to accident and emergency following collapse at home; he had a three-day history of central abdominal pain and three recent episodes of melaena. He was resuscitated and sent for oesophagogastroduodenoscopy which was unremarkable. Computerized tomography showed necrotic tissue and free gas surrounding the graft site and closely adherent loops of small bowel without an active bleedingpoint. An emergency laparotomy found foul-smelling necrotic tissue around the Dacron graft and blood clots in the jejunum. Bilateral axillofemoral bypasses were inserted, the graft removed and abdominal aorta ligated. The patient recovered well. Discussion: This case was unique as a ‘para-prosthetic’ fistula, by communicating with the jejunum (<30%) not duodenum (60%); the duration of bleeding was two days as opposed to the mean of 25, and the patient survived surgery (77% mortality). While this specific condition was rare, the incidence of secondary aortoenteric fistulas is 4%. This patient survived because of the early suspicion and laparotomy. This case highlights the importance of taking a good surgical history and not confining your differential diagnosis to one bodily system.
DOI: 10.1258/smj.2012.012077
