Aisling Maria Hogan

Xanthogranulomatous inflammation (XGI) is a rare process. Colonic XGI is extremely rare. We present a case report of XGI arising within an intra-abdominal cyst involving the transverse colon. A 28-year-old man presented with abdominal discomfort. He underwent a computed tomography abdomen–pelvis, which found three subcutaneous collections and a large cystic intra-abdominal structure. The decision was made for resection. Intraoperatively, the cyst originated from the pelvis and was adherent to the surrounding tissues. Histology from the lesion revealed XGI extending into the surrounding tissue. XGI is a rare inflammatory condition. Clinically, it can be difficult to distinguish XGI from an infiltrative malignancy. Therefore, it is usually necessary to obtain a pathological diagnosis of XGI. This case describes an atypical cystic lesion with XGI involving the transverse colon. Although rare, it should be considered in the potential differential diagnosis of an infective or malignant mesenteric cyst.

Background: Pudendal nerve entrapment (PNE) is a disabling condition which is notoriously difficult to diagnose and treat. A 5-point Nantes Criteria including a diagnostic pudendal nerve block is widely used to allow identification of patients likely to benefit from the definitive but invasive pudendal nerve release. The aim of this study was to determine the role of pudendal nerve block in diagnosis and management of PNE. Methods: Retrospective analysis was performed of a prospectively maintained database examining outcomes of recipients of diagnostic pudendal nerve block in a quaternary referral centre over a 5-year period [2012–2017]. Primary outcome was relief of chronic intractable pain. Secondary outcomes were referral patterns for nerve release, demographics and complication rates. Statistical analysis was performed using SPSS v 24. Results: A total of 77 patients were included. Mean age was 57.27±13.55 years. A majority were female (n=62, 80.5%). Pain was experienced by 47/76 (68.1%). Of 37 patients (52.9%) referred for surgery, 20 underwent surgical decompression with 60% success rate (n=12). Complication rate was 3.9% (All Clavien Dindo 1). Conclusions: Pudendal nerve injection is a safe procedure that can provide diagnosis of and transient relief from this debilitating problem. This technique helps isolate patients suitable for referral for pudendal nerve decompression.

Iatrogenic bile duct injury (BDI) is the most significant associated complication to laparoscopic cholecystectomy (LC). Little is known about the evolution of the pattern of BDI in the era of laparoscopy. The aim of the study is to assess the pattern of post-LC BDIs managed in a tertiary referral centre. Post-LC BDI referred over two decades were studied. Demographic data, type of BDI (classified using the Strasberg System), clinical symptoms, diagnostic investigations, timing of referral, post-referral management and morbidity were analysed. The pattern of injury, associated vascular injuries rate and their management were compared over two time periods (1992-2004,2005-2014). 78 BDIs were referred. During the second time period Strasberg A injuries decreased from 14% to 0 and Strasberg E1increased from 4% to 23%, the rate of associated vascular injury was six time higher (3.6% versus 22.7%), more patients had an attempted repair at the index hospital (16% versus 35%) sand fewer patients could be managed without surgical intervention at the referral hospital (28% versus 4%). Complexity of referred BDIs and rate of associated vascular injuries have increased over time. These findings led to more patients managed requiring surgical intervention at the referral hospital.

Background. One-fifth of people who develop colorectal cancer (CRC) have a first-degree relative (FDR) also affected. There is a large disparity in guidelines for screening of relatives of patients with CRC. Herein we address awareness and uptake of family screening amongst patients diagnosed with CRC under age 60 and compare guidelines for screening.Study Design. Patients under age 60 who received surgical management for CRC between June 2009 and May 2012 were identified using pathology records and theatre logbooks. A telephone questionnaire was carried out to investigate family history and screening uptake among FDRs.Results. Of 317 patients surgically managed for CRC over the study period, 65 were under age 60 at diagnosis (8 deceased). The mean age was 51 (30–59). 66% had node positive disease. 25% had a family history of colorectal cancer in a FDR. While American and Canadian guidelines identified 100% of these patients as requiring screening, British guidelines advocated screening for only 40%. Of 324 FDRs, only 40.9% had been screened as a result of patient’s diagnosis.Conclusions. Uptake of screening in FDRs of young patients with CRC is low. Increased education and uniformity of guidelines may improve screening uptake in this high-risk population.

A significant amount of valuable undergraduate medical teaching may be informal, unscheduled and delivered by non-consultant hospital doctors (NCHDs). 800 Questionnaires were distributed to consultants, NCHDs and medical students in Irish teaching hospitals. The aim was to quantify the level of unscheduled teaching carried out in these hospitals and the manner in which it was performed. The response rate was 46% (364/800). 71% of doctors who replied are independently teaching undergraduate medical students (77/109), including 71% of interns and senior house officers (48/68). Students tend to prefer small group teaching. Fifty-six percent of students suggest they would benefit from more surgical teaching time (144/255). No interns surveyed were scheduled to teach as part of a formal curriculum. A significant amount of unscheduled teaching by interns and senior house officers takes place in Irish hospitals. It may prove beneficial to incorporate interns into scheduled surgical teaching curricula.

Ring-fencing of elective orthopaedic beds has been shown to significantly reduce surgical site infection (SSI) rates. There are fewer studies in general surgical practice. Comparison of overall surgical workload in 2007 and 2011 was performed. Data pertaining to SSI were collected and analysis of this prospectively maintained database was performed on all SSI diagnosed in 2007 and 2011. There was a significant reduction in the crude SSI rate from 117 cases in 2007 (8%) to 42 cases in 2011 (3.5%). A statistically significant reduction in SSI rate for elective surgery was observed, 7.6% vs. 2.5% (p<0.001 Chi-square test). Apart from the introduction of ring fencing, all other contributory variables remained unchanged. Ring-fencing of inpatient general surgical beds has been associated with a significant reduction in SSI rates. These data provide timely supportive evidence that ring-fencing of inpatient beds is an appropriate patient-orientated strategy.

Concerns have been voiced regarding the impact of the European Working Time Directive (EWTD) on surgical training. Following its introduction (August 2009) in Wexford General Hospital, Ireland Surgical Senior House Officers (SSHOs) are required to leave the hospital at 10 a.m. the morning after on-call duty. This study investigates the consequences of this practice on operative experience gained by six SSHOs in comparison to their predecessors.

INTRODUCTION: Acute appendicitis is a common surgical emergency. The presence of an inflamed appendix in an incisional hernia is rare. Incisional hernias complicate both open and laparoscopic surgery. PRESENTATION OF CASE: We describe two unique cases of acute appendicitis within incisional hernias following an open cholecystectomy and a diagnostic laparoscopy. Acute appendicitis was diagnosed intraoperatively and a formal appendicectomy was performed with subsequent primary repair of the hernial defect in each case. DISCUSSION: The method chosen for primary repair of an incisional hernia containing an acutely inflamed appendix depends on a number of factors including size of hernial defect and degree of contamination. Closure of 5 mm port sites is not routine in current surgical practice. Herniation of intra-abdominal contents through such defects can occur rarely. The repair of an incisional hernia using mesh in a contaminated surgical field is controversial. There may be advantages in the use of biological meshes. CONCLUSION: Surgical awareness of potential complications relating to the management of incisional hernia appendicitis is of primary importance in determining intraoperative strategy.

INTRODUCTION: Ischiorectal abscesses have been shown to form sinuses with various deep structures but continuity with the spinal canal is extremely rare. PRESENTATION OF CASE: A previously healthy sixty-five year old man presented emergently with rectal pain, weight loss and recurrent severe tension headaches. He had systemic sepsis and resultant coagulapathy (INR 3.4) which precluded investigation of neurological symptoms by lumbar puncture. MRI rectum demonstrated a well circumscribed fluid collection with direct connection to the spinal canal and containing meningeal tissue. It extended inferiorly to the right ischiorectal fossa and abutted the natal cleft. A radiological diagnosis of ischiorectal abscess which had become continuous with a previously existing anterior sacral myelomeningocoele (ASM) was made. He was treated with broad spectrum antibiotics and a neurosurgical opinion was sought. He remained clinically unwell (septic and coagulopathic) until the abscess fistulated through the perianal skin, draining pus mixed with clear fluid (likely CSF) at which point he improved systemically. DISCUSSION: Few general surgeons would be faced with acute management of complicated ASM. Paucity of literature made application of evidence based medicine difficult. In fit healthy patients surgery is the mainstay of treatment as myelomengingoceles do not regress spontaneously. Conservative management is associated with up to 30% mortality (largely due to bacterial meningitis). The patient in this case was adamant that he did not consent to definitive surgical intervention. CONCLUSION: This case highlights challenges encountered in the management of complicated ASM in a general hospital.