Surgicalamerica by Surgical America

Surgical America 20TH MARCH 2014 PRO CONCEPT UK EDITION

MRI staging and hstopatholoical correlation in rectal tumours

Leiomyosarcoma of the scrotum, a full in depth analysis

Current review of VTE prophylaxis in lower limb replacements

Welcome friends to the first edition of SurgicalAmerica PreCONCEPT UK edition.

This journal differs from our mainstream journal by offering a showcase of new and exciting projects. As always all submissions are peer reviewed and thoroughly authenticated by our expert team.

Correlation between preoperative MRI staging and histological stage for carcinomas of the mid and lower thirds of rectum in a district general hospital Dr Osama Moussa

, Dr Jonathan Berry2 & Dr Frank L Hinson1

1. Department of Colorectal surgery, Cumberland Infirmary, North Cumbria Acute Hospital Trust, Carlisle 2. Department of Radiology, Cumberland Infirmary, North Cumbria Acute Hospital Trust, Carlisle

Abstract: Objectives: MRI

- resections or abdomino-perineal

staging of rectal cancer has been

resections for mid or low rectal

shown to correlate with final

adenocarcinoma were performed

histological stage and to predict

during the study period at our

surgical margin involvement in

hospital, only 88 were included

studies performed by radiologists

due to inaccessibility of reports.

pioneering these techniques in

M:F ratio was 2.2: 1 mean (SD)

large centres.

We sought after

67.6 (8.8) years. The median

whether the results were as good

distance from anal verge was 58

in our colorectal practice in a

mm with a range between 6 to 105

small district general hospital.

mm. There was 65% agreement

! Key Words: Rectal adenocarcinoma, MRI staging, operative histology

! *- Corresponding Author: Mr Osama Moussa, Cumberland Infirmary,

between pathology and

Patients and methods:

assessment of T stage by MRI (κ=

A retrospective comparison of

0.392, 95% confidence interval, CI

pre-operative magnetic

= 0.18 to 0.604, p<0.001).

resonance imaging (MRI) reports

Agreement between MRI and

and

post-operative

histological assessment of nodal

histopathological findings at our

status was 51% (κ= 0.113, 95% CI=

hospital between July 2007 and

0.0 to 0.329, p= 0.313).

February 2011. Correlation was

North Cumbria Acute Hospital Trust,

assessed by the kappa, κ statistic.

Carlisle, Cumbria, CA2 7HY, United

Correlation between histological

Kingdom, Tel: 01228 814364 Email:

and MRI measurements of the maximum depth of extramural

omoussa@nhs.net Manuscript category:

tumour infiltration was made

Retrospective overview of clinical outcome

using method analysis described

by Bland and Altman.19

! to

Results: 98 low anteriorresection

Conclusion: Compared with pioneering studies of MRI staging our data showed comparable prediction of final histological stage. The risk of understaging T status is small and comparable to earlier studies.

As previously

demonstrated, MRI is less accurate in predicting N stage.

Introduction

Objective

Rectal cancer is a common disease with a high rate of mortality in Western countries. The disease is more common after the age of 50 and shows a slight male predilection. Many improvements have been made over the past 20 years in the surgical, radiologic, and oncologic treatment of rectal cancer. However, this neoplasm remains associated with a poor prognosis owing to the high risk of metastases and local recurrence. With better radiological staging, better selection of patients for surgery and preoperative treatments, possibly leading to better cure rate.

Our aim was to retrospectively review the accuracy in agreement between pre-operative magnetic resonance imaging (MRI) staging with the definitive post-operative histopathological findings in a series of patients at a district general hospital.

Magnetic resonance (MR) imaging routinely being used to evaluate tumour resectability in patients with rectal cancer and to determine which patients can be treated with surgery alone and which will require preoperative radiation therapy to promote tumour regression. MRI is now central in pre-operative tumour assessment (1, 2). Current evidence suggests that MRI is the most accurate technique for predicting tumour stage (3) and can also provide measurements of the distance to the mesorectal fascia, which forms the potential resection margin in total mesorectal excision. (3)

The success of tumour excision depends largely upon accurate staging. Magnetic resonance (MR) imaging is increasingly used to evaluate tumour resectability of patients with rectal cancer in order to determine patients who can be treated with surgery alone and those who will require radiation therapy to promote tumour regression. It is well established that a positive CRM is associated with both local recurrence and poor survival (4). The pre-operative identification of this by MRI enables patients to benefit from therapy that causes tumour regression away from the potential CRM prior to surgery. (5)

MRI provides a reliable measurement of the extent of extramural tumour penetration, which potentially shows direct agreement with histopathological measurements. This has major implications for improving the management of the disease by virtue of accurate preoperative spatial depiction of the tumour.

Patients and Methods The study consisted of 88 low anterior resections or abdominoperineal resections for mid or low rectal adenocarcinoma that were performed at our local Hospital between July 2007 and February 2011. Of the 88 patients, 26 had received long-course preoperative radiotherapy that might have led to tumour regression causing difficulty in distinguishing tumour from radiation-induced fibration by MRI. Therefore the data was independently analysed to the subgroups of enduring short versus long course adjuvant therapy. Male: Female ratio was 2.2:1 with mean age (standard deviation, SD) 67.6 (8.8) years and range between 46 to 86 years. MRI was performed on all patients, including those who had undergone long-course radiotherapy; staging investigations were repeated before surgery in the last group.

Magnetic resonance images The variables analysed were the extent of tumour invasion (T component of the tumour node metastasis (TNM) classification), depth of extramural spread, lymph node involvement, and involvement of the mesorectal fascia (the potential CRM).For each patient, an overall T stage (TNM classification) was assigned using the criteria given in Table 1.

Lymph node involvement A lymph node was defined as involved by tumour if it returned either mixed signal intensity or had irregular or ill-defined borders (6).

Circumferential resection margin This was defined as tumour involvement of the painted nonperitonealized mesorectal surgical margins. A note was made of whether such involvement was by direct continuity with the main tumour, by tumour in veins, lymphatics or lymph nodes, or by tumour deposits discontinuous from the main growth. When.

Statistical analysis

Lymph node involvement

Agreement between radiological and histological assessment of T stage was assessed by the kappa, κ statistic. In addition, agreement for the MRI allocation of T stage for each tumour was assessed by the κ statistic. Assessment of agreement between histological and MRI measurements of the maximum depth of extramural tumour infiltration was made using method comparison analysis described by Bland and Altman7 and by κ statistic. Agreement between pathology and MRI assessment of nodal status and CRM status was calculated with the κ statistic, based on marginal homogenized data8. Confidence intervals were calculated by the method of Donner and Eliasziw9.

Nineteen (37.3%) of 51 patients of the short course radiotherapy had positive nodes on histological examination and 15 of these were correctly identified by MRI using signal intensity and border characteristics, Table 4. Conversely, 32 (62.7%) of 51 had negative nodes on histological examination and 11 of these were correctly identified by MRI. Agreement between MRI and histological assessment of nodal status was 51% (κ =0.113, 95% CI= 0.0 to 0.329, p=0.313). MRI failed to predict nodal deposits in 4 patients. Conversely, MRI overstaged 21 patients as node positive. Node-positive status was correctly predicted by MRI in each of the 2 patients with N2 nodal disease and 6 patients with N1 nodal disease.

! Results !

Table 2 shows the prognostic factors in the studied 62 patients who received short-course preoperative radiotherapy. Male gender constituted 50 (80.6%). The surgical procedure followed was anterior resection plus loop ileostomy in 23 (37.1%) patients, laparoscopic anterior resection in 11 (17.7%) patients, and abdominoperineal resection in 28 (45.2%) patients. The median distance from anal verge was 59 mm with a range between 6 to 105 mm.

! Circumferential margin involvement, (CRM) Prediction of CRM status by MRI was recorded for only 4 patients but the majority of other cases did not explicitly mention CRM status but the context of the overall whole report makes it clear that CRM was not involved. Histological assessment for 53 patients; hence it was not possible to compare them with Bland-Altman method comparison analysis.

T staging

Long-course preoperative radiotherapy

There were 3 pT1, 23 PT2, 24 pT3 and 2 pT4 tumours. Table 3 summarizes the correlation between MRI and histological assessment of T stage in the short course radiotherapy group. Two patients were understaged for the T component of the TNM classification and 12 patients were overstaged. Table 3 shows that nearly all disagreements in staging were between T1 and T2 tumours, and between T2 and T3 tumours. Two tumours that were pT3 on histological assessment were staged as T2 tumours on MRI. Similarly, 10 pT2 tumours were staged as T3 by MRI, and 2 pT3 tumours were staged as T4 by MRI. There was good agreement between pathology and assessment of T stage by MRI (κ= 0.392, 95% confidence interval, CI = 0.18 to 0.604, p<0.001).

Table 5 shows the prognostic factors in the studied 26 patients who received long-course preoperative radiotherapy. Male gender constituted 18 (69.2%). The surgical procedure followed was anterior resection plus loop ileostomy in 6 (23.1%) patients, laparoscopic anterior resection in 5(19.2%) patients, and abdominoperineal resection in 15 (57.7%) patients. These patients had initial pre- chemotherapy staging MRI and a second post-chemotherapy staging MRI. Prediction of CRM status by pre-chemotherapy MRI was available for 8 patients and for one patient by post-chemotherapy MRI, hence it was not possible to compare with histological assessment using BlandAltman method comparison analysis. In addition, there was no attempt to assess the agreement between MRI and histological findings of T stage or lymph node involvement since the long-course preoperative radiotherapy might have led to tumour regression causing difficulty in distinguishing tumour from radiation-induced fibration by MRI. This would make comparison of T stage or lymph node involvement by MRI and histological assessment incomparable.

Discussion

While there is growing evidence that preoperative radiotherapy and TME have an additive (Holm et al, 1997) effect on improvement of local recurrence rates, it is becoming clear that preoperative radiotherapy for ‘good’ prognosis patients is overtreatment that wastes resources and leads to significant morbidity. Thus, the advantages of preoperative high-resolution MRI in selecting appropriate patients for neoadjuvant therapy justify its routine use in the staging of rectal cancer patients.

This retrospective study, using histological validation, demonstrates that high-resolution MRI has good potential for staging rectal cancer preoperatively, for assessing operability, and for predicting pathological prognostic features that inform clinical decision making on the use of neoadjuvant therapy. Though being in significant agreement with respect to T staging.

The main goal of staging rectal tumours with MR imaging is to identify those patients with T3 and T4 lesions where immediate surgery would likely result in an involved circumferential resection margin. Such patients may benefit from neoadjuvant treatment (radiation therapy and chemotherapy). In recent studies, high spatial resolution MR imaging has been shown to be highly accurate in predicting CRM involvement, although it is less accurate and less consistent in predicting the correct T stage and so more with Nstaging. CRM involvement still remains the single most important factor in predicting the prognosis of rectal cancer. (12)

In recent studies, the overall accuracy of MR imaging for the T staging of rectal cancer has varied from 86% to 100% (1, 3, 10, and 11). This variability in clinical results reflects the difficulties in staging borderline lesions as either stage T2 or stage T3 tumours. Our study elaborates a significant agreement of T staging between preoperative radiological staging versus post-operative histological staging though this could not be further extended to patients undergoing long course radiotherapy. This was not true concerning the N staging, as well as other aspects of long course radiotherapy group due to incomplete documentation.

Our findings were similar to previously published data as shown above in the results section. The results might have been better if nodal deposits in the mesorectum had not been missed in four patients with low rectal tumours. Not only has it confirmed already established findings that MRI enables the extent of extramural spread to be assessed with high accuracy and reproducibility (13), allowing accurate prediction of a tumour-free CRM 2, but it has also established that MRI can ascertain, with considerable confidence, the existence of lymph node metastases, involvement of the serosa at or above the peritoneal reflection, and extramural vascular invasion, features that are of proven prognostic importance. Accordingly, MRI results in significant treatment cost benefits that are very likely to offset the costs of the procedure itself as well as being more clinically effective than the alternatives. (14)

!! !! !

In the analysis of long course radio/chemotherapy subgroup there was a smaller sample size in the long course group but there was overall poorer documentation in aspects of CRM, TN staging and inability to establish inter-observer significance in results. Sauer et al estimated the “neoadjuvant chemoradiotherapy overtreatment rate” (of pT1 and pT2 tumours) caused by MRI overstaging to be 15– 20%. (15, 16)

Taking into consideration the results and conclusions of our modest study, we were able to successfully introduce significant changes to practice. Initially our firm proposed to introduce a standardised proforma to the radiology department to be subsequently incorporated into the multidisciplinary meeting and patient clinical notes. Introduction of this change is essential in providing the optimal, evidence based treatment. As a medium sized district general hospital, we are a centre for bowel cancer screening programme which is known to identify early stage cancers in people without symptoms and hence it is crucial for our unit to adapt the best evidence.

This is a retrospective study, hence has inherent deficiencies but on a whole scale we believe to have identified and recognized how to improve our procedures and the vitality of MRI in pre-operative planning.

!! Conclusion !

At present, MR imaging accomplishes the clinical requirements for preoperative staging of rectal cancer. Preoperative staging with MRI is very sensitive in identifying CRM involvement, which is the main factor affecting the outcome of surgery. Our local hospital results compare to other larger scale studies. There is feasibility of departments to alter routine towards best evidence patient care through a multidisciplinary approach. We successfully attempt change our local protocol to enhance our outcome and hence potentially improve long term results.

Dr Osama Moussa SpR General Surgery Dr Jonathan Berry Cons Radiologist Dr Frank L Hinson Cons General Surgeon 1. Department of Colorectal surgery, Cumberland Infirmary, North Cumbria Acute Hospital Trust, Carlisle 2. Department of Radiology, Cumberland Infirmary, North Cumbria Acute Hospital Trust, Carlisle

!! ! Data tables available on request at SurigcalAmerica.com

Conflict of interest statement: None of the authors have any conflicting interests to declare.

References 1. Brown G, Richards CJ, Newcombe RG, et al. Rectal carcinoma: thin-section MR imaging for staging in 28 patients. Radiology 1999; 211:215–222

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2. Beets-Tan RG, Beets GL, Vliegen RF, et al. Accuracy of magnetic resonance imaging in prediction of tumour-free resection margin in rectal cancer surgery. Lancet 2001; 357:497–504 3. Beets-Tan RG, Beets GL. Rectal cancer: review with emphasis on MR imaging. Radiology 2004; 232:335–346

4. Hall NR, Finan PJ, al-Jaberi T, Tsang CS, Brown SR, Dixon MF, et al. Circumferential margin involvement after mesorectal excision of rectal cancer with curative intent. Predictor of survival but not local recurrence? Dis Colon Rectum 1998; 41:979-83.

5. Chau I, Brown G, Cunningham D, et al. Neoadjuvant capecitabine and oxaliplatin followed by synchronous chemoradiation and total mesorectal excision in magnetic resonance imaging-defined poor-risk rectal cancer. J Clin Oncol. 2006; 24:668–74. 6. Brown G, Richards CJ, Williams GT, Radcliffe A, Dallimore NS, Bourne MW. Morphological predictors of lymph node status in rectal cancer using high spatial resolution magnetic resonance imaging with histopathological comparison. Radiology 2003 7. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986; 3 2 7 : 307–3 10. 8. Scott WA. Reliability of content analysis: the case of nominal case coding. Public Opinion Quarterly 1955; 1 9 : 32 1–325.

9. Donner A, Eliasziw M. A goodness-of-fit approach to inference procedures for the kappa statistic: confidence interval construction, significance testing and sample size estimation. Stat Med 1992; 7 7 : 1511–1519.

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10. Gagliardi G, Bayar S, Smith R, Salem RR. Preoperative staging of rectal cancer using magnetic resonance imaging with external phase-arrayed coils. Arch Surg 2002;137:447–451. 11. Blomqvist L, Machado M, Rubio C, et al. Rectal tumor staging: MR imaging using pelvic phasedarray and endorectal coils vs endoscopic ultrasonography. Eur Radiol 2000;10:653–660. 12. Videhult P, Smedh K, Lundin P, Kraaz W. Magnetic resonance imaging for preoperative staging of rectal cancer in clinical practice: high accuracy in predicting circumferential margin with clinical benefit. Colorectal Dis 2007; 9:412-9. 13. Brown, G., Radcliffe, A. G., Newcombe, R. G., Dallimore, N. S., Bourne, M. W. and Williams, G. T. (2003), Preoperative assessment of prognostic factors in rectal cancer using high-resolution magnetic resonance imaging. British Journal of Surgery, 90: 355–364. doi: 10.1002/bjs 4034 14. G Brown, S Davies, G T Williams, M W Bourne, R G Newcombe, A G Radcliffe, J Blethyn, N S Dallimore, B I Rees, C J Phillips and T S Maughan Effectiveness of preoperative staging in rectal cancer: digital rectal examination, endoluminal ultrasound or magnetic resonance imaging; British Journal of Cancer (2004) 91, 23–29. doi:10.1038/sj.bjc 6601871 15. Sauer R, Fiekau R, Wittekind C. et al Adjuvant versus neoadjuvant radiochemotherapy for locally advanced rectal cancer. Strahlenther Onkol 2001. 4173–181. 16. Sauer R, Becker H, Hohenberger W. et al Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004. 3511731–1740.

Leiomyosarcoma of the scrotum, an analytical review

! Mr C Tait *1, Mr S Ahmad1 Dr C Simon2 & Mr DJ Byrne1

! ! Abstract

Case Report

L e i o myo s a rc o m a o f t h e scrotum is a urological rarity. We report the case of an 84 year old man who presented with a multinodular, rapidly growing mass over his right upper scrotal wall, subsequently treated with excision.

An 84 year old man presented to the urology outpatient clinic with a firm, multinodular, rapidly growing mass over his right upper scrotal wall (Figures 1-2). Th i s wa s c a u s i n g worsening discomfort, which was his only symptom. Clinical examination showed a 4 x 3 cm nodular swelling with relatively fixed overlying skin in upper scrotum on right side. This lesion was well above the right testis and was separate from the spermatic cord structures. There was no palpable inguinal lymphadenopathy. Additionally, his prostate felt benign on digital rectal examination and both testes were normal on palpation.

Histological features were consistent with a scrotal leiomyosarcoma. The patient made a full recovery and further imaging was negative for evidence of metastatic spread. This case report illustrates the presentation, management and histological features of this highly unusual scrotal tumour.

"a firm, multinodular, rapidly growing mass over his right upper scrotal wall"

! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !

The patient underwent ellipse excision of the mass which measured 5 cm in maximum diameter (Figure 4). Histological analysis revealed a well circumscribed, multinodular mass centred within dermis and composed of markedly pleomorphic spindle cells. The tumour cells exhibited bizarre nuclear morphology and readily identifiable atypical mitotic figures.

Figures 1

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! !

Figure 2

Figures 1 & 2 showing anterior and lateral views of the scrotal wall mass prior to excision.

Histologically, foci of coagulative tumour necrosis and mitotic figures were plentiful, yielding a Trojani (soft tissue sarcoma grading)1 score of 6 (2,1,3); grade 3 (Figures 4 & 5)

! !

Figure 3 – excision of subdermal scrotal lesion

Immunohistochemistry showed positive staining within the tumour cells for actin, caldesmon and focal strong positivity for desmin. Immunohistochemistry S100, CD31, CD34 and CD99 were negative.

The overall features were typical of a malignant spindle cell neoplasm and the immunophenotype favoured a diagnosis of high grade leiomyosarcoma.

After multidisciplinary team discussion, a CT scan of the thorax, abdomen and pelvis was performed. This was negative for any evidence of metastatic disease.

Figure 4 Alexander

! H

Matthews

Boerhaave Syndrome –

Figure 5

Spontaneous rupture of the oesophagus

Figures 4&5 representative histological sections of the lesion stained with haematoxylin and eosin

Our patient made a full recovery and did not show any clinical evidence of recurrence of his disease. He is being reviewed regularly in the outpatient setting.

! Discussion & Literature Review !

L e i o m yo s a r c o m a ( m a l i g n a n t tumour of smooth muscle)2 of the scrotum is very rare, with just over 30 cases reported in the literature. Historically, this tumour has been described as relatively indolent in its course of growth and subsequent delayed presentation, often mimicking a benign mass.

These tumours require wide surgical excision for complete clearance. The optimal extent of margins is not reported specifically for these rare tumours. However, for soft tissue sarcomas, local recurrence-free interval at 5 years was seen higher with a margin of >10 mm (84%) than margins of 1– 9 mm (58%) 4.

Hence, for leiomyosarcomas, a wide the excision is advisable for better oncological outcomes. Recurrence most commonly tends to be local but distant metastases in bones and lungs have been reported 5.

Given that this tumour is a u r o l o g i c a l r a r i t y, t h e r e i s understandably a lack of long term oncological evidence for suggested follow up and long term outcome. 6. The optimal duration of follow up is also not well known but distant metastases can occur years after the initial excision 6. It is therefore agreed that regular follow up should take place in a similar fashion to other sarcomas, under the auspices of oncologists with a specialist interest in sarcomas.

Acknowledgement: The patient provided written consent for his case to be reported, with the use of clinical photographs for publication.

Conflicts of Interest: None Declared

1. Coindre JM, Nguyen BB, Bonichon F, Trojani M. Histopathologic grading in spindle cell soft tissue sarcomas. Cancer. 1988 Jun 1;61(11):2305-9. 2. Underwood, JCE. Carcinogenesis and neoplasia. In: Underwood JCE, editor. General and Systematic Pathology. Fourth Edition. Edinburgh: Churchill Livingstone; 2005.

3. Quinlan M, D'Arcy F, Corcoran S, Casey M, Harding B, Hussey A, Durkan G. Case Reports: Scrotal Leiomyosarcoma. BJUI Online. Available from URL http:// www.bjui.org/ContentFullItem.aspx? id=745&SectionType=1&title=Scrotal-leiomyosarcoma Accessed October 2012

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4. McKeeMD, Dong Feng Liu, Brooks J, et al. The prognostic significance of margin width for extremity and trunk sarcoma. Journal of Surgical Oncology. 2004;85:68 5 Diz Rodríguez MR, Vírseda Chamorro M, Ramírez García JR, Merino Royo E, Moreno Reyes A, Paños Lozano P. Scrotal leiomyosarcoma with bone metastasis]. Actas Urol Esp. 2006 Jun;30(6):638-40. Review.

6. John T, Portenier D, Auster B, Mehregan D, Drelichman A, Telmos A. Leiomyosarcoma of scrotum - case report and review of literature. Urology. 2006 Feb;67(2): 424.e13-424.e15. Review.

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Critical appraisal of current guidelines for total joint VTE prophylaxis, a comprehensive review Dr Akmal Turaev*1 (principal author) 1. Department of Trauma and Orthopaedics, John Radcliffe Hospital, Oxford, OX3 9DU

Introduction In terms of validity and relevance this

Both being highly developed OECD

topic is very important as it focuses on

nations with well funded universal

an ongoing and widely prevalent

healthcare systems. The main

issue. Venous thromboembolic (VTE)

difference however between these two

disease (notably pulmonary embolus

studies and its relevance to our topic

[PE] and deep vein thrombosis

is simply that the South Korean study

[DVT]) relating to total knee

provided no thromboprophylaxis and

arthroplasty (TKA) is an undeniably

the

significant correlation. According to

Thromboprophylaxis was delivered by

Kim YH, et al in 'Factors leading to

means of LMWH which would be

decreased rates of deep vein

consistent with American College of

thrombosis and pulmonary embolism

Chest Physicians (ACCP) grade 1A or

after total knee arthroplasty', the

more recently grade 1B.

Swiss

study

did.

incidence of post operative PE can range between 11% to 20%. However according to Januel JM et al in 'Symptomatic in-hospital deep vein thrombosis and pulmonary embolism following hip and knee arthroplasty among patients receiving recommended prophylaxis: a systematic review' fewer than two patients in a cohort of one hundred were diagnosed with VTE.

Again methodologies varied greatly,

! Key Words: DVT, emergency and elective or t hopaedic surger y, war f ar in, low

where the former employed

molecular weight heparin

venography and the latter advocating

ultrasonography. It has to be noted that venography is no longer routinely

*- Corresponding Author:

recommended at Perth Royal Infirmary, Scotland and in fact

Dr Akmal Turaev, John Radcliffe Hospital,

throughout much of NHS Tayside in

Oxford, OX3 9DU

the diagnosis of DVT. Doppler ultrasonography is recommended as it is safer, requires no contrast, is non

It has to be noted that both studies

invasive, faster and considerably

were performed in different countries,

cheaper. It is however NOT as

the former being South Korea and the

sensitive as venography in the

latter being Switzerland respectively.

diagnosis of DVT.

Tel: 01865 741166 Email: akmal.turaev@ouh.nhs.uk

Continued / It is important to note that according to Ozbudak O et al in

This leads us to the next point of new AACP recommendations

'Doppler ultrasonography versus venography in the detection of

of homogenising all low VTE risk patients regardless of

deep vein thrombosis in patients with pulmonary embolism'

background into AACP grade 1B, whereby giving either a

patients who clinically present with DVT in whom PE has been

LMWH, fondaparinux, rivaroxaban or a vitamin K antagonist

confirmed or previously confirmed, venography should instead

(warfarin is not mentioned specifically).

be employed. According to the author this has both failed to appropriately Spiral CT pulmonary angiogram has largely superseded the

alleviate issues of VTE incidence and has rather dramatically

practice of ventilation/ perfusion scans in NHS Tayside. This

increased post operative complications relating to TKA in his

was in part due to logistical, cost and safety reasons. It is also in

hospital and at another neighbouring institution where a

accordance with British Thoracic Society (BTS) guidelines.

dramatic increase in post operative bleeding complications was

Relevance to current literature

observed.

The author has outlined again how his hospital used warfarin

An interesting collaborative by Barrack et al in article in its

and Doppler ultrasonography on discharge prior to the

introduction familiarises the reader to the degree of variation

implementation of AACP guidelines. During this time only one

and flexibility in prophylaxis and active treatment (or

patient out of 700 was diagnosed with PE.

proposed treatment) in post-operative TKA patients suspected of having VTE disease. This is important as it highlights the usage of multiple guidelines and sub-guidelines in from a multidisciplinary perspective, i.e. the ACCP initially attempting to standardise thromboprophylactic therapy followed by the American Academy of Orthopaedic Surgeons (AAOS) deriving another set of guidelines based on a different group of patients.

According to the previous ACCP guidelines, high dose

The author has mentioned that after rigorous introduction of AACP guidelines, which included universal LMWH therapy and discontinuation of warfarin postoperatively and Doppler ultrasonography on discharge, rates of post operative complications jumped to 9%. Unfortunately the author has not provided accurate numbers, as such a rise would need to be independently assessed for statistical significance.

Extrapolation of results

warfarin (INR 2 - 3) was recommended for grade 1A patients as a modality of prophylaxis, it has to be noted that warfarin

In addition to the above the author has rightly pointed out that

can take up to three to five days to take effect, and at the time

rather controversially the clinicians behind the AACP

there was much debate as to whether or not this would

guidelines failed to declare significant financial conflicts of

provide adequate VTE cover during the perioperative period,

interest. The reality unfortunately is such that forced corporate

this was explored very well by Lieberman JR in ' Warfarin

coercion or to put it euphemistically 'financial incentivisation'

prophylaxis after total knee arthroplasty'.

is observed universally, especially in newer drugs.

Interestingly, according to R. Chana et al in 'Warfarin management in patients on continuous anticoagulation therapy undergoing total knee replacement' warfarin should not be discontinued preoperatively, as there was 'no significant difference between the two groups (control and experimental groups respectively) in pre- or post-operative haemoglobin, incidence of transfusion or incidence of postoperative complications'.

Conflicts of Interest: None Declared

! ! !

Background

Boerhaave syndrome was first described in 1724 by a dutch physician called Hermann Boerhaave.1 His patient died following 18 hours of self vomiting which at autopsy revealed a ruptured distal oesophagus.2 For more than 200 years, the condition remained fatal and largely a post mortum diagnosis. However in the late1940s it was successfully managed by Frink and Barrett.2

Epidemiology Boerhaave syndrome is a rare condition and over 1000 cases have been reported in the literature.3 It has a low incidence in Denmark, a country with similar health demographics to the UK.4 It most commonly occurs after over-indulgence of food and alcohol, particularly in males aged 50-70 years old.1

Etiology This condition is characterised by a transmural ruptured oesophagus due to forceful vomiting against a closed glottis, leading to a rapid raise in intraluminal pressure and subsequent mediastinitis.5 The classic presentation is Mackler’s triad1, which comprises of thoraco-abdominal pain, vomiting and surgical emphysema. However this is present in only 10% of cases. The majority of cases present atypically, consequently a diagnosis is frequently missed or delayed.5 Investigations and diagnosis Boerhaave syndrome is a diagnostic challenge. Blood investigations are of limited diagnostic use but large study series of adult populations have shown that leucocytosis is a common laboratory finding.1 This evidence also suggests that as many as 50% of patients have polycythemia owing to the loss of fluid into the third space. An urgent water-soluble contrast swallow and/or CT scan with oral contrast are essential to confirm the diagnosis of Boerhaave syndrome.5 The use of contrast swallow may aid diagnosis, but this has a false-negative rate of 10% and in such cases computerised tomography (CT) provides a good diagnostic tool.6

Treatment In the majority of patients surgical repair is possible and if undertaken within 24 hours of the onset of symptoms it can be associated with excellent survival rates.5 Management of cases after the acute phase of presentation is less well defined. A conservative approach has been advocated for stable patients within this group.6 However there is evidence to suggest that these patients often deteriorate and require further surgery.5 With recent advances in endoscopy, successful management of perforations have been described using stenting and clipping techniques. Endoscopic clipping has recently shown favourable outcomes if used in the management of late cases.6 Following surgical intervention, the clinician must make sure there is adequate drainage, appropriate antibiotics and adequate feeding.

! !

Prognosis The condition carries a 20-40% mortality rate if not identified and treated early.4

References 1) Chikkappa M, Morrison C, Lowe A, Gorman S, Antrum R, Gokhale J. Paediatric Boerhaave's syndrome: a case report and review of the literature. Cases Journal 2009; 2:8302 2) Hecser L, Siklodi K, Csiki G, Lungu M, Jung H, Buda O. Boerhaave syndrome: a case report. Rom J Leg Med 2011; 19: 283-286 3) Lewis A, Dharmarajah R. Walked in with Boerhaave’s…Emerg Med J 2007; 24(4): 1-2 4) Veno S, Eckardt J. Boerhaave’s syndrome and tension pneumothorax secondary to Norovirus induced forceful emesis. J Thorac Dis 2013; 5(2): 38-40 5) Sutcliffe R, Forshaw M, Datta G, Rohatgi A, Strauss D, Mason R, Botha A. Surgical Management of Boerhaave's Syndrome in a Tertiary Oesophagogastric Centre. Ann R Coll Surg Engl 2009; 91(5): 374-380 6) Ramhamadany E, Mohamed S, Jaunoo S, Baker T, Mannath J, Harding J, Menon V. A delayed presentation of Boerhaave's syndrome with mediastinitis managed using the over-the-scope clip. J. surg. case rep 2013; 5:1-3

Management of Pancreatic Pseudocysts

Pancreatic pseudocysts are defined by the 1992 Atlanta symposium as a collection of pancreatic fluid that arises as a consequence of acute pancreatitis, pancreatic trauma or chronic pancreatitis and is enclosed by a non-epithelialised wall1. This review will primarily concern its self with the drainage strategies currently available.

Management of pseudocysts can be difficult and often requires the utilisation of a multi-disciplinary approach, especially if malignancy has not been ruled out2. The choice of which technique to use will partly depend on the anatomical location of the collection and local expertise.

There are only three indications for intervention3, which is namely drainage. These are: 1. Diagnostic ambiguity, i.e. is this a neoplasm? 2. Symptoms unacceptable to the patient. Related to the mass effect on surrounding structures and include pain, anorexia and early satiety. 3. Complications secondary to the pseudocyst. These include infection, pseudocyst rupture either into the bowel or into the peritoneum, which may cause peritonitis; obstruction (bowel or biliary) and erosion into a vessel leading to pseudoaneurysm formation and haemorrhage.

Expectant treatment Many patients with pancreatic pseudocysts are asymptomatic and, furthermore, up to 60% can expect their pseudocyst to resolve spontaneously over a period of 6 weeks4. For these reasons expectant treatment is a reasonable first-line treatment for most patients. Negative predictors of spontaneous resolution include: chronic pseudocysts (i.e. those persisting beyond 6 weeks), size greater than 6cm, thick wall and those that have arisen in the context of chronic pancreatitis4.

Percutaneous drainage Percutaneous drainage is often only considered for drainage of infected or immature pseudocysts. The advantage of a percutaneous drain is that it can quickly control sepsis and can be used before the granulomatous wall has fully mature. However, there is a higher recurrence rate and the patient risks developing a pancreatocutaneous fistula, especially if imaging has shown ongoing communication with the pancreatic ductal system3.

Internal drainage Endoscopic drainage of pseudocysts has achieved popularity due to low recurrence rates and low morbidity5. Endoscopic transmural drainage is possible when the pseudocyst abuts either the stomach or duodenum. A double pigtail stent can be placed through the stomach or the duodenum to create a cystogastrostomy or cystoduodenostomy, respectively2.

Another endoscopic method is transpapillary drainage, which is only possible when the pseudocyst communicates with the pancreatic duct. In this method the duct is first cannulated and a stent are passed into the pseudocyst3 along a guidewire. The complications are similar to those of ERCP.

Surgery Surgery drainage, either open or laparoscopic, tends to be reserved for patients with multiple, recurrent and pseudocysts associated unfavourable anatomy. Surgical drainage of pseudocysts involves the same principles as endoscopic internal drainage. Cystogastrostomy, cystoduodenostomy and cystojejunostomy are performed for cysts adjacent to the stomach, duodenum and distant cysts, respectively. An alternative to surgical drainage is resection, for example, if the patient also has haemorrhage from a pseudoanerysm2.

References 1.

Bradley EL. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992. Arch Surg 1993;128(5):586– 90.

Fischer’s Mastery of Surgery (Vol 1&2 Set 6E). Lippincott Williams & Wilkins; 2011

Aghdassi AA, Mayerle J, Kraft M, Sielenkämper AW, Heidecke C-D, Lerch MM. Pancreatic pseudocysts-when and how to treat? HPB 2006;8(6):432–41.

Yeo CJ, Bastidas JA, Lynch-Nyhan A, Fishman EK, Zinner MJ, Cameron JL. The natural history of pancreatic pseudocysts documented by computed tomography. Surg Gynecol Obstet 1990;170(5):411–7.

Baron TH, Harewood GC, Morgan DE, Yates MR. Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocysts. Gastrointest Endosc 2002;56(1):7–17.

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