• Mortality in perforated duodenal ulcer depends upon pre-operative risk: a retrospective 10-year study.

      Larkin, J O; Bourke, M G; Muhammed, A; Waldron, R; Barry, K; Eustace, P W; Department of Surgery, Mayo General Hospital, Castlebar, Co., Mayo, Ireland., larkin.dundalk@gmail.com (2012-01-31)
      INTRODUCTION: Most patients presenting with acutely perforated duodenal ulcer undergo operation, but conservative treatment may be indicated when an ulcer has spontaneously sealed with minimal/localised peritoneal irritation or when the patient's premorbid performance status is poor. We retrospectively reviewed our experience with operative and conservative management of perforated duodenal ulcers over a 10-year period and analysed outcome according to American Society of Anesthesiologists (ASA) score. METHODS: The records of all patients presenting with perforated duodenal ulcer to the Department of Surgery, Mayo General Hospital, between January 1998 and December 2007 were reviewed. Age, gender, co-morbidity, ASA-score, clinical presentation, mode of management, operative procedures, morbidity and mortality were considered. RESULTS: Of 76 patients included, 48 (44 operative, 4 conservative) were ASA I-III, with no mortality irrespective of treatment. Amongst 28 patients with ASA-score IV/V, mortality was 54.5% (6/11) following operative management and 52.9% (9/17) with conservative management. CONCLUSION: In patients with a perforated duodenal ulcer and ASA-score I-III, postoperative outcome is uniformly favourable. We recommend these patients have repair with peritoneal lavage performed, routinely followed postoperatively by empirical triple therapy. Given that mortality is equivalent between ASA IV/V patients whether managed operatively or conservatively, we suggest that both management options are equally justifiable.
    • Modern management of pyogenic hepatic abscess: a case series and review of the literature.

      Heneghan, Helen M; Healy, Nuala A; Martin, Sean T; Ryan, Ronan S; Nolan, Niamh; Traynor, Oscar; Waldron, Ronan; Department of Surgery, Mayo General Hospital, Castlebar, Mayo, Ireland., helenheneghan@hotmail.com. (2012-01-31)
      BACKGROUND: Pyogenic hepatic abscesses are relatively rare, though untreated are uniformly fatal. A recent paradigm shift in the management of liver abscesses, facilitated by advances in diagnostic and interventional radiology, has decreased mortality rates. The aim of this study was to review our experience in managing pyogenic liver abscess, review the literature in this field, and propose guidelines to aid in the current management of this complex disease. METHODS: Demographic and clinical details of all patients admitted to a single institution with liver abscess over a 5 year period were reviewed. Clinical presentation, aetiology, diagnostic work-up, treatment, morbidity and mortality data were collated. RESULTS: Over a 5 year period 11 patients presented to a single institution with pyogenic hepatic abscess (55% males, mean age 60.3 years). Common clinical features at presentation were non-specific constitutional symptoms and signs. Aetiology was predominantly gallstones (45%) or diverticular disease (27%). In addition to empiric antimicrobial therapy, all patients underwent radiologically guided percutaneous drainage of the liver abscess at diagnosis and only 2 patients required surgical intervention, including one 16-year old female who underwent hemi-hepatectomy for a complex and rare Actinomycotic abscess. There were no mortalities after minimum follow-up of one year. CONCLUSIONS: Pyogenic liver abscesses are uncommon, and mortality has decreased over the last two decades. Antimicrobial therapy and radiological intervention form the mainstay of modern treatment. Surgical intervention should be considered for patients with large, complex, septated or multiple abscesses, underlying disease or in whom percutaneous drainage has failed.
    • The effectiveness of methicillin-resistant Staphylococcus aureus colonisation screening in asymptomatic healthcare workers in an Irish orthopaedic unit.

      Edmundson, S P; Hirpara, K M; Bennett, D; Department of Trauma and Orthopaedics, Mayo General Hospital, Castlebar, County, Mayo, Ireland. stevenedmundson@yahoo.co.uk (2012-01-31)
      Methicillin-resistant Staphylococcus aureus (MRSA) infections are associated with increased mortality, costs and length of stay compared to non-MRSA infections. This observational 4-year study analyses the impact of screening and treating orthopaedic healthcare workers for MRSA colonisation. A total of 1,011 swabs were taken from 566 healthcare workers. Positive healthcare workers were treated with topical mupirocin to both anterior nares. The prevalence of MRSA colonisation on initial testing was 4.77%. The rate of positive MRSA colonisation of those tested on more than one occasion fell from 5.88% to 2.71% (p = 0.055) on subsequent screening. All healthcare workers receiving treatment were successfully cleared of colonisation; however, some required more than one course of treatment. These results show that there could be a role for screening and treating orthopaedic staff for MRSA colonisation as part of a strategy to reduce the prevalence of MRSA infections in orthopaedic units.
    • Isolated pancreatic metastases from a bronchogenic small cell carcinoma.

      Walshe, T; Martin, S T; Khan, M F; Egan, A; Ryan, R S; Tobbia, I; Waldron, R; Department of Surgery, Mayo General Hospital, Castlebar, Co Mayo., walshetriona@hotmail.com (2012-01-31)
      We describe the case of a 60 year old female smoker who presented with a three month history of weight loss (14 Kg), generalized abdominal discomfort and malaise. Chest radiography demonstrated a mass projected inferior to the hilum of the right lung. Computed Tomography of thorax confirmed a lobulated lesion in the right infrahilar region and subsequent staging abdominal CT demonstrated a low density lesion in the neck of the pancreas. Percutaneous Ultrasound guided pancreatic biopsy was performed, histology of which demonstrated pancreatic tissue containing a highly necrotic small cell undifferentiated carcinoma consistent with metastatic small cell carcinoma of the bronchus.
    • Mesenteric venous thrombosis secondary to an unsuspected JAK2 V617F-positive myeloproliferative disorder.

      Department of Surgery, Mayo General Hospital, Mayo, Ireland,, mikebourkecork@yahoo.co.uk. (2012-01-31)
      BACKGROUND: Mesenteric venous thrombosis (MVT) is a rare but potentially fatal cause of mesenteric ischaemia. It presents insidiously and often diagnosis is made at emergency surgery. In half of the cases MVT develops without a causative factor, while in cases in which a pro-thrombotic state is found to exist MVT may be the first clinically detected consequence of that state. The myeloproliferative disorders (MPD) are known to contribute to the development of pro-thrombotic states. Recently, the JAK2 V617F mutation has been associated with the MPDs. CONCLUSION: We describe a case of MVT occurring secondary to an unsuspected MPD, in which the patient was subsequently found to carry this mutation. We highlight the necessity to screen for this mutation in cases of intra-abdominal thromboses so that appropriate systemic anticoagulation may be instituted, and the patient may be followed so as to detect the development of an overt MPD.
    • Screening for developmental dysplasia of the hip: current practices in Ireland.

      O'Grady, M J; Mujtaba, G; Hanaghan, J; Gallagher, D; Department of Paediatrics, Mayo General Hospital, Castlebar, Co, Mayo, Republic, of Ireland. michael_ogrady2001@hotmail.com (2012-01-31)
      OBJECTIVE: To ascertain the current approach to screen for developmental dysplasia of the hip in the Republic of Ireland. METHODS: Two-pronged prospective and retrospective study. (1) Postal questionnaire to consultant paediatricians responsible for the routine neonatal care of infants in the Irish Republic in June 2006. (2) Retrospective database review to identify infants undergoing radiological follow-up and their outcome. RESULTS: All maternity units surveyed responded. Most units (84%) were dependent on radiographs at 4-6 months for imaging hips, only two units primarily used ultrasound (10.5%). We estimate that neonatal hip examination is performed by an experienced examiner in less than 30% of routine newborn examinations. On retrospective analysis, 94% of radiographs performed were normal. CONCLUSIONS: The most effective interventions, selective ultrasound and examination by an experienced clinician are not widely practiced. There is a need for the development of national guidelines based on available resources.
    • Management of the acute scrotum in a district general hospital: 10-year experience.

      Tajchner, Lukas; Larkin, John O; Bourke, Michael G; Waldron, Ronan; Barry, Kevin; Eustace, Paul W; Department of Surgery, Mayo General Hospital, Castlebar, Co. Mayo, Republic of, Ireland. (2012-01-31)
      The acutely painful scrotum is a common urologic emergency. The primary objective of management is to avoid testicular loss. This requires a high index of clinical suspicion and prompt surgical intervention. In our series conducted between January 1996 and December 2005, 119 patients (age range: 4-62 years) underwent emergency operative exploration for acute scrotal pain. The most common finding was torted cyst of Morgagni (63/119, 52.9%), followed by testicular torsion (41/119, 34.4%). The majority of testicular torsions occurred in the pubertal group (22/41, 53.6%). Only one patient in this group had an unsalvageable testis necessitating orchidectomy, a testicular loss rate in torsion of 2.4%. There were no postoperative wound infections or scrotal haematomas. Testicular salvage depends critically on early surgical intervention, so the delay incurred in diagnostic imaging may extend the period of ischaemia. Furthermore, all radiological investigations have a certain false-negative rate. We advocate immediate surgical exploration of the acute scrotum. We report a low orchidectomy rate (2.4%) in testicular torsion.
    • Squamous cell carcinoma of the anal canal.

      Martin, F T; Kavanagh, D; Waldron, R; Department of Colorectal Surgery, Mayo General Hospital, Castlebar, Co. Mayo,, Ireland. fiachra1978@yahoo.com (2012-01-31)
      Squamous cell carcinoma ofthe anal canal represents 1.5% of all malignancies affectingthe gastrointestinal tract. Over the past 20 years dramatic changes have been seen in both the epidemiological distribution of the disease and in the therapeutic modalities utilised to manage it. CLINICAL MANAGEMENT: Historically abdominoperineal resection had been the treatment of choice with local resection reserved for early stage disease. Work by Nigro et al. has revolutionised how we currently manage carcinoma of the anal canal, demonstrating combined modality chemoradiotherapy as an appropriate alternative to surgical resection with the benefit of preserving sphincter function. Surgery is then reserved for recurrent disease with salvage abdominoperineal resection. This article reviews current literature and highlights the changing therapeutic modalities with selected clinical cases
    • Withholding truth from patients.

      O'Sullivan, Elizabeth; Mayo General Hospital, Castlebar, Co Mayo. lizosul@eircom.net (2012-01-31)
      The issue of whether patients should always be told the truth regarding their diagnosis and prognosis has afforded much debate in healthcare literature. This article examines telling the truth from an ethical perspective. It puts forward arguments for and against being honest with patients, using a clinical example to illustrate each point.
    • Recurrent sigmoid volvulus - early resection may obviate later emergency surgery and reduce morbidity and mortality.

      Larkin, J O; Thekiso, T B; Waldron, R; Barry, K; Eustace, P W; Department of Surgery, Mayo General Hospital, Castlebar, Co. Mayo, Ireland., larkin.dundalk@gmail.com (2012-01-31)
      INTRODUCTION: Acute sigmoid volvulus is a well recognised cause of acute large bowel obstruction. PATIENTS AND METHODS: We reviewed our unit's experience with non-operative and operative management of this condition. A total of 27 patients were treated for acute sigmoid volvulus between 1996 and 2006. In total, there were 62 separate hospital admissions. RESULTS: Eleven patients were managed with colonoscopic decompression alone. The overall mortality rate for non-operative management was 36.4% (4 of 11 patients). Fifteen patients had operative management (five semi-elective following decompression, 10 emergency). There was no mortality in the semi-elective cohort and one in the emergency surgery group. The overall mortality for surgery was 6% (1 of 15). Five of the seven patients managed with colonoscopic decompression alone who survived were subsequently re-admitted with sigmoid volvulus (a 71.4% recurrence rate). The six deaths in our overall series each occurred in patients with established gangrene of the bowel. With early surgical intervention before the onset of gangrene, however, good outcomes may be achieved, even in patients apparently unsuitable for elective surgery. Eight of the 15 operatively managed patients were considered to be ASA (American Society of Anesthesiologists) grade 4. There was no postoperative mortality in this group. CONCLUSIONS: Given the high rate of recurrence of sigmoid volvulus after initial successful non-operative management and the attendant risks of mortality from gangrenous bowel developing with a subsequent volvulus, it is our contention that all patients should be considered for definitive surgery after initial colonoscopic decompression, irrespective of the ASA score.
    • Delayed presentation of carotid artery dissection following major orthopaedic trauma resulting in dense hemiparesis.

      Edmundson, S P; Hirpara, K M; Ryan, R S; O'Malley, T; O'Grady, P; Department of Trauma and Orthopaedics, Mayo General Hospital, Westport Road,, Castlebar, County Mayo, Ireland. stevenedmundson@yahoo.co.uk (2012-01-31)
      We report a 30-year-old patient who was involved in a high-velocity road traffic accident and developed a left-sided hemiparesis, which was noted in the post-operative period following bilateral femoral intramedullary nailing. CT scanning of the brain revealed infarcts in the right frontal and parietal lobes in the distribution of the right middle cerebral artery. CT angiography showed occlusion of the right internal carotid artery consistent with internal carotid artery dissection. He was anticoagulated and nine months later was able to walk independently. An awareness of this injury is needed to diagnose blunt trauma to the internal carotid artery. Even in the absence of obvious neck trauma, carotid artery dissection should be suspected in patients with a neurological deficit in the peri-operative period.
    • Measuring emergency department nurses' attitudes towards deliberate self-harm using the Self-Harm Antipathy Scale.

      Conlon, Mary; O'Tuathail, Claire; Mayo Mental Health Services, Mayo General Hospital, Castlebar, Co. Mayo, Ireland. (2012-01-31)
      The emergency department is an important gateway for the treatment of self-harm patients. Nurses' attitudes towards patients who self-harm can be negative and often nurses experience frustration, helplessness, ambivalence and antipathy. Patients are often dissatisfied with the care provided, and meeting with positive or negative attitudes greatly influences whether they seek additional help. A quantitative design was utilised to measure emergency department nurses' attitudes towards deliberate self-harm. The 'Self-Harm Antipathy Scale', a validated questionnaire, was administered to a random sample of nurses in four emergency departments in the Republic of Ireland. A total of 87 questionnaires were returned (87% response rate). Results reveal that nurses show slightly negative antipathy overall, indicating positive attitudes towards self-harming patients. Attitudes were significantly different in accordance with a nurse's age. Education and social judgment also contribute to the way nurses view, interact and make moral decisions regarding self-harm patients. Evidence indicates there is need to improve the training, supervision and support of nurses caring for patients who self-harm, and that practical strategies should be implemented to manage the alienation process and inform practice.
    • Is overexpression of HER-2 a predictor of prognosis in colorectal cancer?

      Kavanagh, Dara O; Chambers, Gillian; O'Grady, Liam; Barry, Kevin M; Waldron, Ronan P; Bennani, Fadel; Eustace, Paul W; Tobbia, Iqdam; Department of Surgery, Mayo General Hospital, Castlebar, Co Mayo, Ireland., dara_kav@hotmail.com (2012-01-31)
      BACKGROUND: The development of novel chemotherapeutic agents in colorectal cancer has improved survival. Following initial response to chemotherapeutic strategies many patients develop refractory disease. This poses a significant challenge common to many cancer subtypes. Newer agents such as Bevacizumab have successfully targeted the tyrosine kinase receptor epidermal growth factor receptor in metastatic colorectal cancer. Human epidermal growth factor receptor-2 is another member of the tyrosine kinase receptor family which has been successfully targeted in breast cancer. This may play a role in colorectal cancer. We conducted a clinicopathological study to determine if overexpression of human epidermal growth factor receptor-2 is a predictor of outcome in a cohort of patients with colorectal cancer. METHODS: Clinicopathological data and paraffin-embedded specimens were collected on 132 consecutive patients who underwent colorectal resections over a 24-month period at Mayo General Hospital. Twenty-six contained non-malignant disease. Her-2/neu protein overexpression was detected using immunohistochemistry (IHC). The HER-2 4B5 Ventana monoclonal antibody was used. Fluorescent insitu hybridisation (FISH) was performed using INFORM HER-2/Neu Plus. Results were correlated with established clinical and pathological predictors of outcome including TNM stage. Statistical analysis was performed using SPSS version 11.5. RESULTS: 114 were HER-2/Neu negative using IHC, 7 showed barely perceptible positivity (1+), 9 showed moderate staining (2+) and 2 were strongly positive (3+). There was no correlation with gender, age, grade, Dukes' stage, TNM stage, time to recurrence and 5-year survival (p > 0.05). FISH was applied to all 2+ and 3+ cases as well as some negative cases selected at random. Three were amplified (2 were 3+ and 1 was 2+). Similarly, HER-2 gene overexpression did not correlate with established prognostic indicators. CONCLUSION: HER-2 protein is over expressed in 11% of colorectal cancer patients. The gene encoding HER-2 is amplified in 3% of cases. Overexpression of HER-2 is not a predictor of outcome. However, patients who over express HER-2 may respond to Herceptin therapy.
    • Scrotal metastases from colorectal carcinoma: a case report.

      McWeeney, Doireann M; Martin, Sean T; Ryan, Ronan S; Tobbia, Iqdam N; Donnellan, Paul P; Barry, Kevin M; Department of Surgery, Mayo General Hospital, Castlebar, Co, Mayo, Ireland., doireannmcweeney@gmail.com. (2012-01-31)
      ABSTRACT: A 72-year-old man presented with a two month history of rectal bleeding. Colonoscopy demonstrated synchronous lesions at 3 cm and 40 cm with histological analysis confirming synchronous adenocarcinomata. He developed bilobar hepatic metastases while undergoing neoadjuvant chemoradiotherapy. Treatment was complicated by Fournier's gangrene of the right hemiscrotum which required surgical debridement. Eight months later he re-presented with an ulcerating lesion on the right hemiscrotum. An en-bloc resection of the ulcerating scrotal lesion and underlying testis was performed. Immunohistological analysis revealed metastatic adenocarcinoma of large bowel origin. Colorectal metastasis to the urogenital tract is rare and here we report a case of rectal carcinoma metastasizing to scrotal skin.
    • Seatbelt injury causing small bowel devascularisation: case series and review of the literature.

      O'Dowd, Vincent; Kiernan, Christine; Lowery, Aoife; Khan, Waqar; Barry, Kevin; Department of Surgery, Mayo General Hospital, Castlebar, Mayo, Ireland. (2012-01-31)
      The use of seatbelts has increased significantly in the last twenty years, leading to a decrease in mortality from road traffic accidents (RTA). However, this increase in seatbelt use has also led to a change in the spectrum of injuries from RTA; abdominal injuries, particularly intestinal injuries have dramatically increased with the routine use of seatbelts. Such intestinal injuries frequently result from improper placement of the "lap belt". We present 3 cases in which passengers wearing a seatbelt sustained significant devascularisation injuries to the small bowel requiring emergency surgical intervention. A high index of suspicion is crucial in such cases to prevent delays in diagnosis that can lead to severe complications and adverse outcomes. It is evident that while advocating seatbelt use, the importance of education in correct seatbelt placement should also be a focus of public health strategies to reduce RTA morbidity and mortality.