A keyhole approach gives a sound repair for ileal conduit parastomal hernia

PURPOSE

The purpose of this study was to report and evaluate a laparoscopic surgical technique for the treatment of parastomal hernia (PSH) after ileal conduit urinary diversion aiming to minimize PSH recurrence and perioperative complications.

METHODS

We retrospectively evaluated all patients who underwent a PSH (after ileal conduit urinary diversion) repair at Addenbrookes Hospital, Cambridge. As a surgical approach, a laparoscopic repair with mesh was utilized in all cases. Subsequently, we performed a voluntary follow-up of the patients to evaluate long-term recurrence and complication rates. In addition, we conducted a reassessment of the cross-sectional imaging available.

RESULTS

Between November 2008 and December 2019, 27 patients underwent hernia repair due to a clinically significant hernia. Out of those patients, one suffered from a post-operative wound infection. In total 23 patients participated in the follow-up with a median follow-up period of 91 months. Follow-up examination revealed two cases of recurrent PSH (8.7% of patients followed up), four patients suffered from minor complications (14.8%).

CONCLUSION

Repair of PSH associated with ileal conduit is particularly scarce. Our surgical approach presents the only laparoscopic case series of an effective method for treating a PSH from an ileal conduit with a low complication and recurrence rate.

1611 Significant Epistaxis Secondary To COVID-19 Nasopharyngeal Swab

Aim

This case highlights the need for appropriate training when adopting new techniques, even for relatively simple procedures.

Method

we report a rare complication of the innovative COVID-19 nasopharyngeal swab which is a new skill for many healthcare professionals and frequently performed with little or no training.

Results

We describe a case of iatrogenic epistaxis after a diagnostic nasopharyngeal swab was taken during the COVID-19 pandemic. The epistaxis was significant, causing haemodynamic and respiratory compromise. In a frail patient who is susceptible to epistaxis, the potenial for further harm is significant. After initially presenting with shortness of breath, this patient (who had no previous nasal pathology) underwent routine naso- and oro- pharyngeal swabbing to test for COVID-19. He felt immediate discomfort in his nasopharynx and epistaxis ensued. The bleeding persisted for several hours; bilateral anterior and posterior nasal packing was required to eventually cease the bleed. He was compromised with a falling haemoglobin, and aspiration of blood compounded his shortness of breath.

Conclusions

Epistaxis is a potentially serious side effect of nasopharyngeal swabbing; a procedural skill dramatically increasing in prevalence during the COVID-19 pandemic. We advocate for formal training of this procedure for all healthcare staff required to undertake it. Presenting such a case report can help us in understanding the complications of this procedure, and better thus inform the patient consenting process.

Elderly patients have more infectious complications following laparoscopic colorectal cancer surgery

AIM

Elderly patients may be at higher risk of postoperative complications, particularly infective, than younger patients.

METHOD

We prospectively followed 163 consecutive patients undergoing elective laparoscopic resection for cancer. We compared patients < 65, 65-80 and > 80 years of age at the time of surgery.

RESULTS

Seventy (42.9%) patients had no complication; 93 (57.1%) had at least one complication following surgery and in 20 (12.3%) this was major. There was no difference in major complications between the groups (P = 0.47). Patients over 65 years of age were more likely to have a complication of any severity [< 65 years, 39.3%; 65-80 years, 69.3%; and > 80 years, 63.0% (P = 0.002)]. The frequency of gastrointestinal complications (30.1%) was similar in the groups (P = 0.29), as was wound infection (25.2%) (P = 0.65). There was an increase in the frequency of infectious complications, especially chest infection, with age, from 14.8% in patients < 65 years, to 22.7% in patients 65-80 years, to 44.4% in patients > 80 years (P = 0.01). Multivariate analysis showed no increase in overall complications in elderly patients, but Stage II or Stage III cancer (OR = 2.59, P = 0.04) and increasing body mass index (BMI) (OR = 1.07 for each unit increase in BMI, P = 0.04) were related to complications. Age remained the only predictor of an infective complication on multivariate analysis. Patients > 80 years of age had 4.21 times the OR of an infective complication (P = 0.03).

CONCLUSION

Older patients are more susceptible to infective complications postoperatively, particularly chest complications. Surgeons should alter their practice to reduce morbidity, such as adopting protocols requiring early physiotherapy.

Pelvic floor reeducation for stress incontinence: comparing three methods

Stress urinary incontinence is a common problem among women of all ages but may resolve with pelvic floor reeducation in many cases. Compliance to a regimen of pelvic floor muscle exercises is poor and many devices have been produced to make exercising these muscles more effective and interesting. This article describes a study in which two such devices -- vaginal cones and pressure biofeedback -- were compared with pelvic floor exercises alone. The results show that there is no statistically significant difference between the three modalities; all treatments produced significant improvement in symptoms and quality of life scores.

Circulating stress hormone and insulin concentrations in acute coronary syndromes: identification of insulin resistance on admission

We re-examined, in the context of modern practice, plasma insulin and stress hormone concentrations in patients admitted to hospital with acute coronary syndromes. Venous blood sampling was carried out prior to anti-thrombotic therapy in 148 patients with myocardial infarction (MI); 76 patients with unstable angina (UA) pectoris were also studied, together with 27 patients with non-cardiac chest pain (NCP). There were significant progressive increases in the concentrations of catecholamines, cortisol, glucose and insulin from NCP to UA to MI patients. Hyperglycaemia (glucose >8 mmol/l) was present in over 50% of MI patients. The plasma cortisol and insulin levels were both significantly positively correlated with the glucose concentration on admission. Only the cortisol concentration was correlated with peak cardiac enzyme levels. The glucose and insulin concentrations on admission in 141 MI and UA patients were related to insulin resistance, as judged from subsequent insulin and glucose concentrations measured while fasting and during a glucose tolerance test. The product of admission insulinxglucose (divided by 25; the admission insulin-resistance index, or AIRI) was significantly correlated with indices of insulin resistance, and was significantly higher (approximately double) in the MI group (7. 81+/-0.76) and the UA group (6.88+/-1.19) than in the control NCP group (3.59+/-0.06; Kuskul-Wallis: P=0.0001), implying that the insulin levels in the first two groups were approximately twice as high as is appropriate for the glucose levels. The ethnic origin of 20% of the patients was the Indian subcontinent; admission insulin and glucose levels in this subgroup were higher than in the non-Asians across all the groups with chest pain. Cortisol was the only stress hormone that was raised in proportion to the size of the infarct, and is a likely partial cause of the elevation in blood glucose. The high insulin levels were related to the prevalence of insulin resistance, and this was particularly important in the Asian subgroup presenting with MI and UA. Thus it appears feasible to identify acute coronary syndrome patients who are insulin-resistant at a time (on admission) when alternative early therapeutic strategies can be instituted.

Stability of the vasopressin V2 receptor-adenylyl cyclase system in rat kidney

In the Brattleboro rat with diabetes insipidus vasopressin V2 receptor mRNA and the mRNA of various adenylyl cyclase (AC) isoforms are moderately reduced compared with those of normal rats. In the present study renal vasopressin V2 receptor mRNA was modestly higher (by 34%), as was expression of AC 5, 6 and 9 mRNAs (up to 22% greater), in BDI rats treated with the vasopressin V2 receptor agonist desamino-[Arg8] vasopressin than in untreated controls. AC 4 mRNA was decreased by 17% following desamino-[Arg8s] vasopressin treatment. While the stimulatory Gsalpha mRNA was little affected by the desamino-[Arg8] vasopressin treatment, two of the inhibitory G proteins were raised (Galphai-2 by 54% and Galphai-3 by 57%). Treatment of Sprague-Dawley rats with a specific vasopressin V2 receptor antagonist (SR 121463A) was not associated with any marked changes in mRNA expression. These results indicate that the vasopressin V2 receptor adenylyl cyclase system mediating the antidiuretic response to vasopressin is relatively stable. The Gi proteins may be involved in the stabilizing mechanism.

Objective methods for evaluation of interferential therapy in the treatment of incontinence

Electrotherapy is a treatment for various conditions, and can be difficult to quantify in effect. This paper examines the form known as interferential therapy, with particular application in the management of urinary incontinence. Objective validation of the treatment is described, which allows optimal positioning of the electrodes for a particular patient.

Pure tone thresholds for the rhesus monkey

Auditory thresholds were measured for 18 ears from 13 rhesus monkeys using a simple reaction-time procedure. The threshold contour was a smooth W-shaped function with rises at the extreme frequencies and around 4 kHz and was comparable in shape with previously reported thresholds for this animal. Standard deviations averaged 5.3 dB.