My SHO recently took a man to theatrewith a clinical diagnosis of peri-analabscess. When no abscess could befound with a “white” needle, I was calledand, despite agreeing with the clinicaldiagnosis, could neither aspirate any pusnor identify an abscess on laying open thesuperficial layers of the wound. However,an MRI clearly showed a large peri-rectalabscess so the patient was returned totheatre. Again it proved impossible toaspirate pus at which point the SPRsuggested that I might be using a “filter”needle. On changing the needle to adifferent type, pus drained immediatelyand open drainage was achieved.

Reporter’s Comments:The prepared packs for incision anddrainage of ano-rectal sepsis contained a

filter needle as they were mainly used forelective work which required the drawingup of local anaesthetic. This has been add-ressed but it is easy to see how ithappened.

CORESS Expert’s Comments:The Advisory Committee were mostgrateful for this timely warning. Filterneedles are used to avoid aspiratingorganisms and foreign material whendrawing up fluids from glass vials. Theyare particularly used for intrathecalinjections. Although not in widespreaduse in operating theatres, the potentialfor misuse is clearly present. Aspirationis an acceptable diagnostic measureand/or treatment for ano-rectal sepsisbut the correct equipment must beused!

This edition of CORESS Feedback includes a lesson (35) learnt by every generation of surgeons.It reminds us that although learning from others can alter behaviour, errors tend to return andlessons must be repeated. Originality is not a necessary condition for reports and CORESS isgrateful to surgeons who give us the opportunity to repeat these important lessons. Manysurgeons are understandably preoccupied with the current disarray in the NHS, and may bereluctant to send reports to CORESS at this time. CORESS needs your input for a high qualityoutput. If you value this Feedback, please remember that the CORESS on-line reporting form isat www.coress.org.uk It does not take long to let other surgeons learn from your experience.

TRY, TRY, TRY AGAIN?

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July 2007

(Ref: 31)

An elderly man, with a past history ofabdominal aortic aneurysm repair, was referredto the gastroenterologists for investigation ofdyspepsia. Investigation showed him to haveiron deficiency anaemia but OGD andcolonoscopy were normal. A year later he wasadmitted as an emergency with haematemesisand melaena and was given a bloodtransfusion. Once more he was investigated bythe gastroenterologists with OGD andcolonoscopy without finding a source of thebleeding. A further year later he was admittedwith a further melaena and I was asked to seehim. Investigation showed an aorto-entericfistula which was repaired successfully.

Reporter’s Comments:I believe that this patient should have beenreferred to a vascular surgeon much

sooner. It is always necessary to excludeaorto-enteric fistula in an anaemic patientwith previous abdominal aortic aneurysmrepair and delay in treatment leads to avery high mortality.

CORESS Expert’s Comments:The Committee very much agree withreporter’s comments. This story is all toocommon and certainly not confined to therealm of gastroenterology. Managementmust include a thorough history andphysical examination and all surgicalscars should be accounted for.Substantial or occult blood loss in apatient who has undergone an abdominalaortic aneurism repair is always due to anaorto-enteric fistula until provedotherwise.

BACK TO BASICS (Ref: 32)

CONSTIPATION...OR PERFORATION? (Ref: 33)

A fit elderly man was admitted as anemergency with a short history ofobstructive symptoms from a smallcarcinoma of the sigmoid colon. He hadappropriate pre-operative preparation, butwithout mechanical bowel cleansing. Onthe following day he underwent sigmoidcolectomy with standard antibioticprophylaxis and post-operatively wastransferred to ITU. On the 3rd postoperative day he had not yet opened hisbowels and was prescribed a regularlaxative by the ITU SHO. This was notnoticed by the surgical team over theweekend and was given for 3 days, untilstopped by the consultant on Mondaymorning. On Monday afternoon hedeteriorated and CT scan confirmedanastomotic leakage. At laparotomy theanastomosis had completely dehisced. Hehad a Hartmann's procedure and made avery protracted recovery.

Reporter’s Comments:I do not think that laxatives should be usedimmediately following bowel anastomosiswithout Consultant approval. The surgicalteam should check drug charts daily.

CORESS Expert’s Comments:The Advisory Committee agreed with thereporter that there appeared to have beena failure of senior supervision in the ITU.Evidence of anastomotic leakage in theearly post-operative period may be verysubtle and not apparent to a relativelyinexperienced trainee. Drugs were writtenup by the ITU doctors without reference tothe surgical team who do not seem tohave checked the drug chart or electronicrecord on a regular basis. Surgeons do, ofcourse, rely heavily on the expertise ofcolleagues but responsibility for the post-operative patient remains with the surgicalteam, even in the most difficultcircumstances.

The BNF states that parasympathomimeticlaxatives should not be used after bowelanastomosis. Although there is noobjective evidence that laxatives causeleaks, their use can certainly complicatediagnosis. The Advisory Committeeagreed with the reporter that laxativesshould be avoided in these circumstancesexcept after careful consideration by anexperienced clinician.

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MINUTES COUNT!A young man came to our A&E with anhour’s history of acute pain in his singledescended testis. The surgical registrarmade a clinical diagnosis of acute testiculartorsion and asked the anaesthetic SHO tosee the patient in A&E with a view toimmediate surgery. The anaesthetist couldnot come immediately and the patient was,therefore, transferred to the ward. Theoriginal anaesthetist had by then gone offduty and there was further delay forhandover to another trainee anaesthetistwho was concerned that the patient was notfully starved. I was then contacted, spoke tothe duty anaesthetic consultant, after whichthe patient was immediately taken totheatre. At operation the single testis wasuntwisted but was only partly viable.

Reporter’s Comments:Acute testicular torsion is an acuteemergency and needs urgent surgery.Delays are not acceptable and aconsultant anaesthetist may be required ifanaesthetic problems are anticipated.

CORESS Expert’s Comments:The Committee strongly endorsed thereporter’s comments. The admitting doctorshould either assert his/her authority orcontact the appropriate consultantimmediately.

Minutes count. Both the MDU and the MPSare aware of this recurring problem andhave referred to it in their publications.Sadly, further reminders are clearly needed.

(Ref: 34)

COMMUNICATE, COMMUNICATE,..................An elderly man was admitted to a medicalward with pneumonia and a CT scan showedmultiple nodules throughout both lung fields.He then suddenly developed lowerabdominal pain and a provisional diagnosisof appendicitis was made. An ultrasoundscan showed multiple gall stones but theradiologist noted the marked tenderness andadvised a CT scan which was said to showan appendix abscess. He was then seen by

the duty Consultant Surgeon who wrote inthe notes that a perforated viscus, possibly acolonic primary, was the most likely diagnosisand despite his co-morbidity, he needed anurgent laparotomy which he asked hisRegistrar to arrange. However, due to achange of shifts, a different registrar exploredthe abdomen through a Lanz incision andfound what appeared to be a gangrenousappendix. The registrar had difficulty closing

(Ref: 35)

the appendix stump and post-operatively thepatient developed a faecal fistula. Threeweeks later, a CT scan and colonoscopyshowed a perforated hepatic flexurecarcinoma associated with an abscess cavitydraining through the fistula. In due course thiswas successfully resected.

Reporter’s Comments:There appear to be several things to learn,none of which, of course, are in any waynew. Firstly, there were communicationproblems at several levels especiallybetween the duty consultant and registrarand in the registrar’s handover. Secondly,when the clinical picture does not fit the X-rays, treat patients not X-rays. Thirdly, weshould have gone back to the beginningand re-thought the diagnosis rather thanpursuing the original diagnosis long after itceased being very likely.

CORESS Expert’s Comments:The Advisory Committee agreed withreporter’s comments. It is also difficult tounderstand why the operating registrarfailed to inform the duty consultant when,after an inappropriate incision, difficultywas experienced in theatre, particularlywhen the consultant’s diagnosis was notconfirmed. Handover between theregistrars appears to have beeninadequate - a feature of previousCORESS reports - and this subject hasrecently been addressed by thepublication of guidance by the RoyalCollege of Surgeons of England (Safehandover: Guidance from the Working TimeDirective Working Party; March 2007)http://www.rcseng.ac.ukMeanwhile, handover arrangementsremain a consultant responsibility - oftendifficult to fulfil.

SHOs: “THE LOST TRIBE” ORA LOST OPPORTUNITY?The recent debacle of MTAS has served to highlightthe ever-increasing disillusionment and deepunhappiness of the medical profession withGovernment micromanagement in a whole range ofmedical and health areas. Issues such as the GP andConsultant Contracts, Choose and Book, Connectingfor Health (CfH), privatisation, lack of strategy forspecialist services and an overwhelming, almostevangelical, desire for change at any cost have furtherfuelled this disenchantment. Despite these problems,the most pressing issue must be the future careers ofour medical and surgical trainees.

The principles behind the drive for change in medicaltraining are commendable and the development of thefoundation years have, in general, been received well,although the evidence base for tangible benefit is, todate, absent. The concept of (what is effectively) atwo-year internship is desirable, given the reductionin hours and the seemingly ever-increasing amount ofnon-clinical and clinical information that is pushedupon our students. The problem comes when a careerchoice in a speciality/General Practice has to bemade. This problem is particularly acute in surgeryand its specialities.

MTAS: Selection and short-listingThis was unquestionably a disaster. It was predictedby many but ignored by the few decision-makers whofelt they knew better. Some people have recentlysuggested that because the candidates in round 2 havenot been found to be as good as round 1, this

vindicates MTAS. It would be truly staggering if thesecond round candidates in MTAS were as good asthe first round. The point that many of us have madewas that there were some excellent candidates that didnot get short-listed when they should have been, notthat the majority of candidates left out were worthy.

MTAS is inherently a flawed system in terms ofselection, the IT system and process. Importantly,this point has been conceded by the DoH and MrsHewitt herself, rendering it vulnerable to successfullegal challenge even by candidates who we would allgenerally agree are not up to the mark.

Using MRCS type questions on surgery/medicine iseducationally unsound in those candidates who havealready demonstrated competence by passing theMRCS (SpR2/3). This is true even if we subscribe tothe notion that this exam has been 'dumbed-down' inrecent years; (you are asking one or two selectedquestions on candidates who have previously passedin a far more exacting and rigorous competenceexamination system already).

Using aspirational statements on "why I want to be asurgeon" to shortlist candidates is ridiculous. The onecertainty is that the candidate will not have writtenthe statement. If they have, then he/she will likelyrun the risk of non-selection (very similar to ACASselection of medical students!).

Participation in MTAS and appointing candidates fortraining under the new system means effectively thatthe deanery will be contractually obliged to provideseamless training for the candidate for six years. This isthe case even though MMC, as it is currently planned,

FINALLY...Failed to ClickInvestigations into loss of output duringdiathermy have revealed the use ofdiathermy electrodes that are incompatiblewith the generator. It is important to beaware that electro-surgical instruments

from one manufacturer are not alwayscompatible with the generator of a differentmanufacturer.Reprinted from “One Liners” (Issue 48, March2007) with the kind permission of the Medical andHealthcare Products Regulatory Agency.

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