Non-centralised service for palliative stenting of malignant gastric outlet obstruction

INTRODUCTION

Malignant gastric outlet obstruction (GOO) is a common, debilitating and frequently pre-terminal symptom of intra-abdominal malignancies. Traditional 'gold standard' treatment has been palliative surgical gastro-enterostomy. Over the past two decades, use of self-expanding metallic stents (SEMSs) to relieve malignant GOO has become first-line treatment. We present the results from a single district general hospital in the UK in which malignant GOO was treated with SEMSs over a six-year period.

METHODS

All patients who underwent palliative stenting for malignant gastro-duodenal tumours in our centre for six years up to January 2013 were assessed retrospectively. Outcomes were assessed with regard to: technical and clinical success; return to oral nutrition; prevalence of complications and re-intervention; and overall survival.

RESULTS

Thirty-two stents were implanted in 29 patients. Technical success was 100%. Clinical success and return to oral nutrition were both 91%. The prevalence of complications was 16%. The prevalence of re-intervention was 13%. Mean survival was 91 (range, 5-392) days. Median wait from decision to implant a stent to stent implantation was 1 (range, 0-14) day. Overall, 25 covered and nine uncovered stents were implanted.

CONCLUSION

Stent implantation for GOO in this patient group is an established and preferable alternative to surgical intervention. Much of the treatment for malignancies of the upper gastrointestinal tract has now been centralised. Our data showed comparable results with published data for these procedures, with a high prevalence of success and low prevalence of major complications. It is of considerable benefit to these patients not to have to travel to a regional centre for stent implantation.

Ten-year experience of esophageal self-expanding metal stent insertion at a single institution

Palliation of malignant dysphagia can be achieved using self-expanding metal stents (SEMS). This study was conceived to confirm that the insertion of SEMS improved patient symptoms without serious complications and to allow comparison with recent national data. Retrospective case note review of all patients receiving SEMS over a 10-year period between March 1999 and February 2009 was used in this study. There were 138 consecutive patients (50 female), median age of 75 (range 46-90) years, 122 (88.5%) had primary malignant disease of the esophagus or gastroesophageal junction. In total, 250 endoscopic examinations were carried out, with 200 interventional procedures, including the insertion of 156 SEMS. Before stenting, 74.2% of patients had a dysphagia score of 2-3. Following stent insertion, dysphagia scores improved to 0-1 in 90.3% of patients (P < 0.0001, Wilcoxon signed ranks). No complications were encountered in 61 (44%) patients. Chest pain was the most frequent difficulty, encountered in 50 (36%) patients. Tumor overgrowth occurred in 17 (12.3%) patients and food bolus obstruction was seen in 7% of patients. There were no esophageal perforations attributable to SEMS insertion. Overall 30-day mortality for those with esophago-gastric malignancy was 11.6% (16 patients), although the SEMS-related mortality was 2.2% (3 patients). Median survival from SEMS insertion was 3 (IQR 1.5-7) months. Patients requiring re-intervention for tumor overgrowth had a significantly longer median survival of 9.2 months (P= 0.001, log rank). SEMS were well tolerated with overall mortality and complication rates comparable to national data. For the longer survivors, re-intervention for recurrent dysphagia was not unusual.

Use of the internet by patients undergoing elective hernia repair or cholecystectomy

INTRODUCTION

Patient-directed information available on the internet is not always regulated; it may be confusing and sometimes just overwhelming. We aimed to establish the proportion of patients undergoing two common surgical procedures, who searched the internet for information about their operations and to assess the usefulness of the information they received.

PATIENTS AND METHODS

A total of 105 consecutive patients undergoing elective abdominal wall hernia repair (n = 54) or laparoscopic cholecystectomy (n = 51) in a single surgical firm were included in the study. Patients were counselled about their operation in pre-operative assessment clinics and standard trust information leaflets were provided without any mention of this study. Patients were then asked to complete a questionnaire on the morning of their operation.

RESULTS

All patients completed the questionnaire. Of the patients, 59% stated that they had access to the internet and 77% of these accessed the internet over 2 h a week. Of the patients with internet access, 31% used it to acquire additional information about their operations and 58% used internet search engines. Of the patients who searched the internet regarding their operations, 26% were confused and/or worried by the information they received.

CONCLUSIONS

A significant proportion of patients undergoing common surgical procedures used the internet and about one-third of them specifically sought information about their operation on the internet. Such information can cause worry and confusion in patients. Our study highlights the need for regulated, comprehensible, patient information on hospital websites to which patients should be directed.

Ultrasonic investigation of the effect of topical glyceryl trinitrate on peripheral arm vein diameter: implications for intravenous nutrition

BACKGROUND

It has been suggested that topical glyceryl trinitrate (GTN) ointment may cause venodilatation and hence deter thrombophlebitis. However, objective evidence of an increase in vein diameter has not been demonstrated.

METHODS

B mode ultrasonography was used to measure arm vein diameter. In a prospective study, measurements were taken before and after 24 hours of exposure to topical GTN.

RESULTS

Reproducibility of vein diameter measurement was demonstrated. Basilic veins were larger than cephalic veins, but exposure to GTN ointment for 24 hours was not associated with measurable venodilatation.

CONCLUSIONS

Ultrasonography enabled noninvasive measurement of intraluminal vein diameter. It is unlikely that GTN prevents thrombophlebitis in superficial arm veins by causing venodilatation.

Effect of prolonged infusion on vein calibre: a prospective study

Infusion thrombophlebitis is common and is the principal limitation to intravenous nutrition (IVN) via a peripheral vein, yet its precise pathogenesis is unclear. Prospective observations were performed on patients in whom a hypertonic, acidic, nutritional emulsion was infused via fine-bore polyurethane catheters placed in peripheral veins. B mode ultrasound was used to determine vein calibre and proved to be a useful means for serial examination during intravenous infusion. Contrary to previous reports, no evidence of venospasm was observed. It is suggested that previous evidence of venoconstriction is erroneous and that other mechanisms are responsible for thrombophlebitis.

An alternative database for the computerised surgical logbook

A computerised surgical logbook has many advantages, but some may find the prospect of database design daunting. In this paper the author hopes, by description of his own logbook, to encourage the computer-wary. Jargon is explained, and the fundamental steps necessary to create a computerised logbook are outlined. Consideration is given to coding of operative procedure, and to the future of computerised logbooks in training.

Ultrasonographic investigation of the pathogenesis of infusion thrombophlebitis

BACKGROUND

Thrombophlebitis frequently complicates intravenous infusion, but its precise pathogenesis remains unclear.

METHODS

Serial B mode ultrasonographic imaging was used to detect intraluminal thrombosis when intravenous nutrition was delivered via fine-bore catheters inserted into peripheral veins.

RESULTS

Thrombus was detected in 14 of 22 catheterized veins. There were nine episodes of clinical phlebitis; each was associated with intravenous thrombosis. Venospasm was not observed. The time at which thrombus was first detected varied from within 24 h to more than 15 days after catheterization. Detection of intravenous thrombosis within 24 h of catheter insertion was associated with early catheter complications. Early thrombus tended to be found close to the site of venepuncture, whereas late thrombus was found at the catheter tip, where the hypertonic feed was delivered.

DISCUSSION

Ultrasonographic imaging was a useful technique for investigation of infusion thrombophlebitis. Two patterns of thrombosis were observed: distal early thrombosis and proximal late thrombosis. Information acquired may help in the design of novel catheters and strategies to reduce the incidence of thrombophlebitis.

Influence of fine-bore catheter length on infusion thrombophlebitis in peripheral intravenous nutrition: a randomised controlled trial

Previous studies indicated that the risk of thrombophlebitis associated with continuous infusion of intravenous nutrition (IVN) via peripheral veins was reduced when fine-bore catheters, inserted to 15 cm, were used in place of standard intravenous cannulas. An explanation has not been identified, but may be owing to the greater length of the catheters. A randomised controlled study was performed in which a standard nutritional solution was infused via 22G polyurethane catheters inserted to a length of either 5 cm or 15 cm. Catheters were reviewed twice each day and removed when complications occurred, or when IVN was no longer required. There was no significant difference in median time to thrombophlebitis or extravasation, or in daily risk of thrombophlebitis, between insertion lengths. Survival proportions were similar for each length at all times. Catheters inserted into cephalic veins were more prone to thrombophlebitis or extravasation (nine episodes, 14 catheters) than catheters inserted into basilic veins (five episodes, 24 catheters, P = 0.009). The survival proportion was at all times greater when catheter tips lay in basilic veins. Thus, the risk of thrombophlebitis or extravasation was not influenced by the length of catheter within the vein. However, the vein in which the catheter tip lay appeared to influence the development of morbidity.

Peripheral infusion as the route of choice for intravenous nutrition: a prospective two year study

A central venous catheter (CVC) is widely regarded as the standard route for delivery of intravenous nutrition (IVN). Peripheral venous infusion avoids the morbidity of a CVC, but may require regular resiting of standard intravenous cannulae, or compromise of the nutritional quality of the feed, to avoid thrombophlebitis. Fine-bore catheters, designed for use in neonates, have been associated with a much lower incidence of phlebitis when used for peripheral IVN in adults, but reports have been limited to selected groups of patients. A prospective study of 302 courses of IVN is presented in which a peripheral vein was the route of first choice. The composition of the feed was determined by the patient's metabolic requirement, and was not compromised to facilitate peripheral venous infusion. In 51% of all courses of IVN the peripheral route alone was used; 76% of patients who received peripheral IVN required only one fine-bore catheter.

Psychiatric consequences of radical curative surgery for gastric cancer

Radical resection of gastric cancer offers the best hope of cure, but carries the risk of significant psychological morbidity in addition to the well-documented physical complications. In the case presented, recognition of clinical depression after thoracoabdominal gastrectomy enabled successful psychological intervention.

Influence of laparoscopic and conventional cholecystectomy upon cell-mediated immunity

Surgery, trauma and anaesthesia induce a state of transient immunosuppression. Laparoscopic cholecystectomy has several well documented clinical advantages over traditional cholecystectomy and provokes a lower acute phase response, thought to be a result of the smaller wound size. The influence of laparoscopic cholecystectomy (21 patients) and conventional open cholecystectomy (13 patients) upon components of the cell-mediated immune system was investigated. Cell-mediated immunity was studied by in vitro assays of T lymphocyte proliferation to different mitogens, and by natural killer cell cytotoxicity using a standard 51Cr release assay. Blood samples were taken before and 24 h after the start of the operation. In the sample taken after operation there was significant depression of T lymphocyte proliferation to phytohaemagglutinin (stimulation index 149.4 versus 33.3, P < 0.002), staphylococcal enterotoxin B (85.2 versus 52.6, P = 0.01) and toxic shock syndrome toxin (48.4 versus 14.8, P = 0.08) in the group of patients who underwent open surgery, but not in the group treated by laparoscopic surgery. There was a small but statistically insignificant decrease of natural killer cell cytotoxicity in both groups of patients. These findings suggest that laparoscopic cholecystectomy causes less depression of cell-mediated immunity than open cholecystectomy.

Fine bore silicone rubber and polyurethane catheters for the delivery of complete intravenous nutrition via a peripheral vein

The aim of the study was to evaluate two fine bore catheters for the delivery of complete intravenous nutrition (IVN), of osmolality 1250 mosm/kg, via a peripheral vein. 50 patients were randomised to receive either a 23G silicone rubber catheter or 22G polyurethane catheter. The median duration of feeding was 9 days for silicone rubber catheters and 10 days for polyurethane catheters. Silicone rubber catheters developed complications significantly more frequently (44%) than polyurethane catheters (22%, p < 0.05). There was no significant difference in the median life span of the catheters removed because of complications, nor in the daily risk of thrombophlebitis. 92% of patients who were fed through a polyurethane catheter required only a single catheter for the duration of IVN. The peripheral venous route should be the first choice when the administration of IVN is considered for a period of less than 2 weeks.

Evaluation of current practices in routine preoperative crossmatching for transurethral resection of the prostate

Increasing demand for blood during elective surgery has led to attempts to rationalize routine preoperative crossmatching to those operations when there is a reasonable (greater than 30%) chance of it being required. Results of a questionnaire returned by 86% of the urology units in Great Britain show that 41% continue to crossmatch 2 units of blood before transurethral prostatectomy. A review of 301 transurethral prostatectomies performed with preoperative grouping and saving of blood showed that only 11% of the patients required transfusion. The need for transfusion was significantly associated with presentation in chronic or acute on chronic retention (p < 0.01), and the operative factors of weight of resection (p < 0.0001) and degree of hemostasis (p < 0.001). Therefore, a policy of routine preoperative blood grouping and saving is safe, and could be widely adopted, leading to financial saving and a decrease in wastage of blood that becomes too old to use.