Amit Sarkar

Aim: To quantify cost, waste, carbon emissions and early feasibility of source reduction in proctology. Method: Population‐based cost and carbon analysis of common proctology procedures in New South Wales public hospitals. Targeted recycling was compared with source reduction through drape avoidance, clean non‐sterile protective equipment, and selective opening of suction and diathermy. A focused audit assessed state‐level inputs against routine practice. Implementation outcomes followed adoption at one tertiary hospital. Results: Annual procedures totalled 6753 in New South Wales. The Australian denominator was 22,084 procedures. Suction and diathermy were unused in 54% and 46% of audited procedures respectively. Targeted recycling was projected to save AUD 0.84 (GBP 0.44, EUR 0.52) and 0.47 kg waste per procedure. Source reduction was projected to save AUD 40 (GBP 21.06, EUR 24.80), 1.36 kg waste and 7.9 kg CO ₂ e per procedure. For conservative national modelling using 20,000 cases, projected annual savings were AUD 776,857 (GBP 408,938, EUR 481,651), 27 tonnes waste and 158 tonnes CO ₂ e. During early implementation, no infective complications were recorded in 100 procedures. Drape omission avoided a median 3 min of set‐up time. Selective device opening introduced a 30‐s delay when required. Four of five surgeons adopted the practice, and 11 of 12 nurses strongly supported the source‐reduction initiative. Conclusion: Source reduction was feasible in early proctology implementation and projected to reduce cost, waste and carbon emissions. These proof‐of‐concept findings support multicentre evaluation but do not establish clinical equivalence.

Colonic Perforation and Transstomal Evisceration of Small Bowel

Gastric volvulus is a surgical emergency that requires prompt recognition and management. The acromegalic patient has a number of pathophysiological factors that predispose to gastric volvulus and slow gastrointestinal (GI) transit. Authors aimed to present a case of hiatus hernia and gastric volvulus in a patient with acromegaly and review the current literature on GI anomalies in this population. A 70-year-old female presented to our institute with epigastric pain and coffee-ground vomiting on the background of acromegaly secondary to pituitary adenoma (resected in 1997). She was found to have a gastric volvulus and hiatus hernia which was repaired laparoscopically. She was discharged home but re-presented six days later with abdominal distension and vomiting. Computed tomography (CT) scan of abdomen showed recurrent gastric volvulus with involvement of the transverse colon. She underwent a laparotomy but no evidence of gastric or colonic volvulus was seen intra-operatively. The CT findings were attributed to a large stomach and coiled redundant transverse colon which could be misinterpreted as volvulus on imaging. Gastroparesis and slow bowel transit were the likely aetiology of this second presentation. This is consistent with literature reporting slow bowel transit and dolichocolon in acromegalic patients. Gastric volvulus is a rare finding associated with acromegaly. Structural anomalies in the anatomy of the acromegalic patient can make CT diagnosis challenging. This case demonstrates the need for caution when interpreting imaging in this cohort, as well as the need for further research on GI pathology associated with acromegaly.

Surgical mesh infections from ventral hernia repairs are common in obese patients. Definitive management includes the surgical removal of mesh; however, obese patients are often poor surgical candidates with limited therapeutic options. We report the case of a 64-year-old male with an abdominal wall seroma secondary to an infected surgical mesh. This was on a background of multiple abdominal wall reconstructions for previous strangulated ventral hernias. A nonoperative novel approach utilizing bromelain percutaneously in conjunction with antibiotics successfully resolved the infected seroma. The purpose of this case is to detail the potential clinical application of bromelain in surgical site infections involving surgical prosthesis. We illustrate the successful use of bromelain as a nonoperative alternative for abdominal infections or when all other surgical and conservative therapies have been exhausted.