Ann R Coll Surg Engl 2010; 92: 548-554 548The incidence of acute gastrointestinal bleeding ranges from 50-150 per 100,000 of the population each year. It is caused by peptic ulcers and oesophageal or gastroduodenal erosions in almost 80% of patients.1 Obscure gastrointestinal bleeding is reported to account for up to 5% of all gastrointestinal (GI) haemorrhages. It is defined as overt or occult bleeding from a source that cannot be readily determined by standard investigations, such as barium studies and endoscopic investigation. The source is often difficult to locate because the pathology is anatomically inaccessible, small, or subtle. Dieulafoy's lesion is one of the causes of obscure gastrointestinal bleeding that could result in treacherous and life-threatening gastrointestinal haemorrhage. 2,3A Dieulafoy's lesion, also termed 'calibre persistent artery', 2 is a relatively rare, but potentially life-threatening, cause of haemorrhage from the gastrointestinal tract. It is difficult to determine its true incidence in the general population accurately as they are silent until presentation and, even then, it can pose a diagnostic challenge. They are believed to account for only 1-2% of acute GI bleeding, [3][4][5] but are arguably under-recognised rather than being truly rare. The lack of awareness about the Dieulafoy's lesion contributes to its 'rarity', increase in morbidity, and also the previously reported mortality of up to 80% associated with this lesion.6 Rare or not, the precarious nature of the presentation make it necessary to include them in differential diagnosis of any acute GI haemorrhage. The aim of this article is to present an up-to-date review of literature on Dieulafoy's lesion and the recent trends in its diagnosis, treatment and prognosis. Materials and MethodsUsing Medline, a literature search was performed for papers published in English, using the text words 'Dieulafoy'(s)' and 'gastrointestinal bleeding'. All retrieved papers which were relevant to the study were analysed and the findings are summarised in this review. Overall, 159 Dieulafoy's lesion: current trends in diagnosis and management M Baxter, EH AlyLaparoscopic Colorectal Surgery and Training Unit, Aberdeen Royal Infirmary, Aberdeen, UK ABSTRACT BACKGROUND Dieulafoy's lesion is a relatively rare, but potentially life-threatening, condition. It accounts for 1-2% of acute gastrointestinal (GI) bleeding, but arguably is under-recognised rather than rare. Its serious nature makes it necessary to include it in the differential diagnosis of obscure GI bleeding. The aim of this study was to review the current trends in the diagnosis and management of Dieulafoy's lesion. MATERIALS AND METHODS Using Medline, a literature search was performed for articles published in English, using the search words 'Dieulafoy'(s)' and 'gastrointestinal bleeding'. All retrieved papers were analysed and the findings are summarised in this review. RESULTS There is no consensus on the treatment of Dieulafoy's lesions. Therapeutic endoscopy can control t...

Colonic SILS should be restricted to highly selected patients; operations should be performed by experienced laparoscopic surgeons, with critical appraisal of clinical outcomes.

Overall, our analysis found that IEN decreases wound infection rates and reduces length of stay. It should be recommended as routine nutritional support as part of the Enhanced Recovery after Surgery (ERAS) programmes for upper GI Surgery.

Background: Deficiencies and lack of standardisation of the management of acute pancreatitis in the UK have been reported. National UK guidelines for the management of acute pancreatitis were published in 1998. However, implementation of national guidelines in other areas has been patchy, suggesting that evaluation of the uptake of the pancreatitis guidelines would be appropriate. Aim: Identification of current practice in the management of acute pancreatitis as reported by consultant surgeons, in order to determine how effectively the UK guidelines have been introduced into practice. Methods: A questionnaire was posted to 1,072 full members of the Association of Surgeons of Great Britain and Ireland. It consisted of 13 questions that aimed to identify the surgeon’s practice in the management of patients with acute pancreatitis in relation to key points in the UK guidelines. We compared the practice of hepatobiliary and pancreatic (HBP) vs. non-HBP specialists, and teaching vs. non-teaching hospital surgeons using the χ² test. Results: Of 538 responses (50%), 519 were from consultant surgeons. 59 did not look after patients with acute pancreatitis and 89 (17%) had a HBP interest. There were differences between the recommendations in the guidelines and reported practice, particularly in the use of critical care resources and referral to specialist units. Of consultants looking after acute pancreatitis 371 (72%) were non-HBP specialists. There were significant overall differences between the practice of HBP specialists and non-specialists: in severity assessment (Glasgow and C-reactive protein vs. Ranson criteria); indication and timing of requesting computed tomography (routinely at 7–10 days vs. when clinically indicated); nutritional support (enteral feeding vs. no support), and in common bile duct assessment prior to cholecystectomy (intra-operative cholangiography vs. endoscopic retrograde cholangiopancreatography). There was no significant difference between practice in teaching and non-teaching hospitals. Conclusion: Implementation of national guidelines for the management of acute pancreatitis was greater in the practice of HBP specialists than non-specialists. This has implications for the rationale of creating guidelines, and for the strategies associated with their introduction.

The current evidence suggests that robotic rectal surgery could potentially offer better short-term outcomes especially when applied in selected patients. Obesity, male sex, preoperative radiotherapy, and tumors in the lower two-thirds of the rectum may represent selection criteria for robotic surgery to justify its increased cost.

The use of robotic approach seems to be capable of addressing most of the shortcomings of the standard laparoscopic surgery. The technique has proved its safety profile in both colonic and rectal surgery. However, the cost involved may restrict its use to patients with challenging rectal cancer and in specialist centres.

The present evidence on robotic colonic surgery has shown both feasibility and a safety profile comparable to standard laparoscopic colonic surgery. However, operative time and cost were greater in robotic colonic surgery, with no difference in the length of postoperative stay in comparison with standard laparoscopic colonic surgery. Whether the general surgical community should embark on a new learning curve for robotic colonic surgery can only be answered in the light of future studies.

The addition of oral antibiotics to systemic antibiotics could potentially reduce the risk of SSIs in elective colorectal surgery. Additionally, MBP does not seem to provide a clear benefit with regard to SSI prevention.