928 Current Practice in The Investigation and Management of Post-Operative Ileus

Introduction

Post-operative ileus is non-obstructive impairment of gastrointestinal motility after surgery. Treatment involves nil-by-mouth, correction of electrolytes and stopping aggravating medications. There is no current national/trust guideline for investigation and management of post-operative ileus.

Aim

To assess current practice in investigation and management of post-operative ileus on surgical wards at St Thomas’s Hospital.

Method

All patients with a diagnosis of post-operative ileus on surgical wards between November - December 2020 were identified. Their clinical notes were reviewed, and common themes explored.

Results

16 patients were diagnosed with post-operative ileus. 12 (75%) patients were male, with a median age of 60 (IQR: 28). 10 (63%) were open procedures, majority being colorectal (10; 63%), cardiothoracic (3; 19%), urological (2; 13%), vascular (1; 6%) operations. Average time between operation and diagnosis was 5.2 (range: 2-14) days. Bowel sounds were auscultated in only 2 (12.5%) patients at initial assessment. 8 (50%) patients had imaging to confirm diagnosis (AXR; 5, CT scan; 4). Majority (15; 94%) of patients had serum magnesium and potassium checked at diagnosis. All patients with serum potassium <4.0mmol/L (5) and magnesium <0.7mmol/L (2) had intravenous supplementation. 14 (88%) were administered Hartmann’s solution. 10 (63%) patients were made nil-by-mouth and 15 (94%) had a Ryles tube inserted. 2 (12.5%) patients were prescribed a prokinetic, and only 2 had either opioids or laxatives stopped. No patients were offered gum.

Conclusions

There is apparent clinical variation in investigation and management of post-operative ileus. We plan to develop an evidence-based trust guideline to reduce unwarranted clinical variation.

A rare case of heterotopic pancreatitis and intestinal malrotation in a COVID-19 positive patient. COVID-19, causative or coincidence?

Introduction and importance

Heterotopic pancreas (HP) is defined as the presence of pancreatic tissue without anatomical and vascular continuity with the main body of the pancreas. HP typically remains asymptomatic, however complications such as acute pancreatitis can arise. Gastrointestinal involvement with coronavirus disease 2019 (COVID-19) is not uncommon and there are reported cases of associated pancreatitis.

Case presentation

A 31-year-old male presented to the Emergency department (ED) with a 3-day history of right iliac fossa pain. The patient was found to have COVID-19 and a planned laparoscopic appendectomy was later converted to a midline laparotomy when a mass close to the duodeno-jejunal (DJ) flexure was identified. Following a hand-sewn anastomosis the patient made a good post-operative recovery. Histology illustrated the presence of heterotopic pancreatic tissue within the small bowel with underlying fat necrosis typical of acute pancreatitis. Follow-up radiology supported the intraoperative finding of intestinal malrotation.

Clinical discussion

Rarely the combined presence of intestinal malrotation and HP in patients has been noted. Heterotopic pancreatitis can present in a multitude of ways and it is a difficult diagnosis to make pre-operatively. Emerging literature documents the potential presentation of COVID-19 with acute pancreatitis. The expression of angiotensin-converting enzyme 2 (ACE2) receptors on the pancreas is believed to play a role.

Conclusion

This is the first documented case of heterotopic pancreatitis with intestinal malrotation in a COVID-19 positive patient. We hypothesise that the COVID-19 infection contributed to the heterotopic pancreatitis.

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Heterotopic pancreas can be present in up to 13.7% of patients.

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Heterotopic pancreatitis is a rare complication.

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Pre-operative diagnosis of heterotopic pancreatitis is difficult.

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COVID-19 can induce pancreatic injury and potentially acute pancreatitis.

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COVID-19 may have contributed to the heterotopic pancreatitis in our patient.

Telementoring and telerobotics in urological surgery

For more than 150 years, doctors have had the ability to transmit medical information to advise and assist their colleagues in remote locations via teleconsultation using a variety of communication modalities. In surgery this has evolved into the telementoring of minimally invasive procedures, particularly, robotic surgery, which have become relatively commonplace in urology. The ultimate progression to true telerobotic surgery, in which remote surgeons independently perform complex and fundamental parts of procedures at long range, is starting to occur. This article discusses the current state of telementoring and telerobotics in urology and examines the pros and cons of this technology at the present time.

Live Surgery: Essential Surgical Education or Putting Patients at Risk?

Surgical and anatomical demonstrations have been fundamental to medical education since the times of John Hunter and William Cheselden, when groups of students and junior surgeons learnt by observing the masters of their time. With the advent of minimally invasive surgery it has become possible to obtain as good a view of an individual procedure as the primary surgeon him or herself. With technological advances in telemedicine and the increasing bandwidth offered by internet links, surgical procedures can be easily observed remotely in high quality with no concern for distance.