ERUS is an accurate method for staging rectal cancer pre-operatively. Accurate assessment of tumour stage can be achieved immediately by an experienced radiologist without specific training in ERUS. Nodal staging accuracy tends to improve with experience but reaches a plateau after 30 cases.
Traditionally, patients have fasted from midnight before elective surgery. This ensures an empty stomach, thereby helping protective laryngeal reflexes and reducing complications such as aspiration pneumonia. Enhanced recovery for elective colorectal surgery permits clear fluids and solids two and six hours respectively prior to surgery. Nutritional supplements pre-operatively are safe and alter the immune and catabolic response to surgery, enhancing post-operative recovery. [1][2][3][4] Fasting depletes glycogen stores, increasing the demand for amino acids. The endocrine response of insulin resistance to fasting is central to the catabolic surgical response, resulting in reduced insulin stimulated glucose uptake in skeletal muscle and adipose tissue, increased glucose release and hyperglycaemia. Hyperglycaemia is associated with more post-operative complications. Pre-operative carbohydrate (CHO) drinks may reduce insulin resistance by maintaining and improving whole-body protein balance and muscle function.This review aimed critically to appraise the evidence available regarding the use of pre-operative CHO supplements for elective colorectal surgery. MethodsA literature search was undertaken using PubMed, MEDLINE ® , Athens and Google Scholar. The following keywords were used: 'pre-operative', 'carbohydrate supplements', 'enhanced recovery' and 'colorectal surgery', singly or in combination. Twenty papers were found but only eleven were reviewed. Nine were excluded as they described studies involving nutritional supplements rather than carbohydrates specifically. The search was limited to English language papers but not restricted according to study type. To ensure an up-to-date literature search, it was restricted to the last ten years, with backward chaining of reference lists from retrieved papers. Discussion Safety of pre-operative nutritional supplementsEnhanced recovery has revolutionised colorectal surgery. Initially, concern was expressed regarding the safety of CHO supplements, which Yagci et al evaluated. 5 This was a randomised controlled trial (RCT) of 70 patients either undergoing a cholecystectomy or thyroidectomy. Pre-oper-
Flexible sigmoidoscopy is an effective method for assessing low-risk patients.
A 52-year-old man presented with a 3-day history of left shoulder-tip pain and shortness of breath, in the background of abdominal pain for 3 weeks. The patient had been admitted 4 months previously following a fall onto his left posterior chest wall, when he sustained a left-sided pneumothorax and fractures of the left 6th, 7th and 8th ribs posteriorly. At that time a computed tomography scan showed a left-sided pneumothorax with associated basal atelectasis and consolidation. On this, the second admission, initial observations were stable, apart from a mild tachypnoea. Abdominal examination was normal, but respiratory auscultation revealed bowel sounds in the left hemithorax. The chest radiograph showed a new left-sided pneumothorax and large bowel in the left chest (Figure 1). Abdominal radiography confirmed this, with some mildly dilated loops of bowel. A computed tomography scan demonstrated a left diaphragmatic rupture with associated intra-thoracic incarcerated large bowel, a left hydropneumothorax and mediastinal shift to the right (Figures 2 and 3). Subsequently, the patient underwent a transverse colectomy with colostomy formation, along with diaphragmatic repair through a left thoraco-abdominal approach. Gastrointestinal continuity was later restored electively.
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