Tropical Doctor, July 1990
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charge about which patients are discharged, which patients are having surgery and finding out if there are any problems or special requirements in the ward. The trolleys are available following the doctor's rounds, usually about 09.00-09.30 h. They are not needed on the ward again until 11.00 h when it is time to give medicines again. Figure 2 shows pre-labelled medicine bottles on the left and bottles of medicine on the right. On the bottom shelf on the left hand side are sterile bandages and on the right any bottles holding liquid medicines. At the nurse's station there are two cupboards. One contains the supply of injectable drugs and the other is the 'night cupboard'. The injectable medicines are used by the nursing staff and the empty bottles/vials are put in a box which is collected by the pharmacist when he takes the trolley to the pharmacy. The empties are thrown in a bucket filled with water which removes the labels. The empty bottles are used by the laboratory and other areas of the hospital. The pharmacy replaces the used injectables with new ones and puts them on the shelf. This gives us good control as it is done daily. The shelf is labelled and also has the proper number of ampoules/vials that should be there. The night nursing supervisor and the doctor on call have a key to the 'night cupboard', which contains drugs to take care of emergency needs during the night hours. The labels in this cupboard are coloured red so when the nurse gets medicine from this area and puts it in the trolley box in the morning it is noticeable and it is taken out, refilled and returned to the cupboard along with the trolley. In the cupboard is a small book in which the nurse writes the following information: bed number, medicine and her initials. This is checked and crossed off by the pharmacist. Some medicines are ordered PRN by the doctor. In this case the pharmacist usually supplies what he thinks the patient would need in one day and makes a note of that on the doctors orders. For example; Aspirin PRN receives six tablets. The pharmacy is staffed from 0800 to 1800 h daily except Saturday and Wednesday afternoons. During the two afternoons the outpatient area sometimes needs medicines for people who come on an emergency basis but are not sick enough to be admitted to hospital. The doctors have a list of 12 medicines available from the nursing supervisor. These are kept in a locked cupboard with a small book which lists the medicines available. The nurse writes the patients chart number, the medicine given and her initials. When the pharmacist restocks he
signs to indicate that the full number of packages has been replaced. This simple and effective system costs very little to start and only requires two work hours a day to fill the requirements of the wards. It reduces effectively the number of errors made on the wards. The quantity of drugs lost is reduced to nothing as even the PRN orders are counted accurately. The medicines are readily available for the nursing staff and the trolley is moved to the bedside very easily. The system has been readily accepted by all concerned.
Ileo ascending colon anastomosis after resection of terminal ileum and caecum for benign diseases Edwin N Elechi Department of Surgery, College of Health Sciences, University of Port Harcourt, PO Box 450, Choba, Port Harcourt, Nigeria TROPICAL DOCTOR,
1990, 20, 140-141
Between 1983 and 1988, 13 patients underwent ileo ascending colon anastomosis after resection of the terminal ileum and caecum for benign conditions. There was one immediate postoperative death due to sepsis and respiratory failure. There were no cases of anastomotic leak or diarrhoea. The 12 patients who survived have remained healthy after an average follow-up period of 3.4 years. METHODS
From January 1983 to December 1988, 13 patients were admitted requiring resection of the terminal ileum and caecum for obvious benign diseases. In all cases, ileo ascending colon anastomosis was carried out instead of right hemicolectomy and ileo transverse colon anastomosis. Each patient had a soft corrugated red rubber drain inserted near the anastomotic site and brought out through a separate stab wound to monitor drainage. Frequency of bowel motions and the consistency of the stools were monitored for the first 4 weeks after surgery.
141
Tropical Doctor, July 1990
All patients had emergency operations after adequate fluid and electrolyte resuscitation. Each was covered with preoperative antibiotics consisting of broad spectrum penicillinase-resistant penicillin (Ampiclox) and metronidazole 500mg intravenously at least one hour before surgery and continued for 48 h postoperatively at 6 and 8 hourly intervals respectively. There were no mechanical bowel preparations. RESULTS
Of the 13 patients (9 men, 4 women; average age 30 years, range 32-56) seven had strangulated right inguinal hernia with gangrenous caecum and terminal ileum, three had ruptured gangrenous appendicitis with phlegmon, while two had gangrenous ileo caecal volvulus and one had a strangulated terminal ileum and part of the caecal wall due to congenital bands. One patient (a 37-year-old man) who had strangulated hernia for more than 8 days before he was brought from a rural village to the Teaching Hospital died in the immediate postoperative period of septicaemia and respiratory failure. Another patient developed pelvic abscess which was drained on the 10th postoperative day. Two patients had minor wound infections. Five patients required bisacodyl suppositories before they opened their bowels between the 7th and 9th postoperative days. No patient in this study had clinical evidence of anastomotic leak and none had diarrhoea within 4 weeks after surgery. At an average follow-up of 3.4 years, none of the 12 surviving patients had history of persistent diarrhoea. DISCUSSION
Right hemicolectomy and ileo transverse colon anastomosis are the accepted curative surgical treatment for resectable malignant conditions of the ileocaecal region 1. However, some surgeons carry out similar extensive resections for benign conditions involving the terminal ileum and caecum. The reasons usually given include: (i) technical difficulties in anastomosing the ileum which is intraperitoneal to the ascending colon which is retroperitoneal; (ii) fear of increased incidence of anastomotic leak; (iii) possibility of postoperative intussusception;and (iv) training experience which this author believes was the most obvious reason.
Wolfe and Wilson- in their review of 22 cases of emergency operation for volvulus of the caecum employed ileo ascending colon anastomosis with good results. Surgeons practising in developed countries are most familiar with ileocaecal malignant conditions for which a right hemicolectomy and ileo transverse colon anastomosis are required. Occasionally when faced with an unusual ileocaecal lesion surgeons justifiably carry out a right hemicolectomy and ileo transverse colon anastomosis as if it were a malignant condition. Since benign conditions of ileocaecal region requiring bowel resection are uncommon in the Western world, little has been written in the English literature about the indications and benefits of ileo ascending colon anastomosis. Most of us who trained in the Western world came back to developing countries and adopted the policy of right hemicolectomy and ileo transverse colon anastomosis for all lesions of the ileo caecal region whether malignant or benign. In Port Harcourt, Nigeria, benign lesions of the ileocaecal region are much more common than malignant lesions", Technically, it is easier and faster to accomplish ileo ascending colon anastomosis than right hemicolectomy and ileo transverse colon anastomosis. Blood loss is also minimal. Since ileo ascending colon anastomosis conserves the ascending colon with its water absorbing capacity, it is not surprising that postoperative diarrhoea was not seen among the 12 surviving patients in the series described. Furthermore, there was no clinical evidence of any anastomotic leakage, a complication feared by some surgeons. I therefore recommend that ileo ascending colon anastomosis should be the method of choice to restore bowel continuity after resection of the caecum and the terminal ileum for benign conditions. The procedure is easy, quick and safe without increased incidence of immediate or long-term postoperative morbidity and mortality.
REFERENCES
I Elechi EN, Ali SO, Calhoun T, Kurtz LH. Extra-nodal reticulum cell sarcoma of the terminal ileum with intussusception. JNMA 1974;66:420-3 2 Wolfe RY, Wilson H. Emergency operation for volvulus of the cecum: review of twenty-two cases. Am Surg 1966;32:96-100 3 Elechi EN. External abdominal wall hernias: experiencewith elective and emergency repairs in Nigeria. Br J Surg 1987;74:834-5
140
charge about which patients are discharged, which patients are having surgery and finding out if there are any problems or special requirements in the ward. The trolleys are available following the doctor's rounds, usually about 09.00-09.30 h. They are not needed on the ward again until 11.00 h when it is time to give medicines again. Figure 2 shows pre-labelled medicine bottles on the left and bottles of medicine on the right. On the bottom shelf on the left hand side are sterile bandages and on the right any bottles holding liquid medicines. At the nurse's station there are two cupboards. One contains the supply of injectable drugs and the other is the 'night cupboard'. The injectable medicines are used by the nursing staff and the empty bottles/vials are put in a box which is collected by the pharmacist when he takes the trolley to the pharmacy. The empties are thrown in a bucket filled with water which removes the labels. The empty bottles are used by the laboratory and other areas of the hospital. The pharmacy replaces the used injectables with new ones and puts them on the shelf. This gives us good control as it is done daily. The shelf is labelled and also has the proper number of ampoules/vials that should be there. The night nursing supervisor and the doctor on call have a key to the 'night cupboard', which contains drugs to take care of emergency needs during the night hours. The labels in this cupboard are coloured red so when the nurse gets medicine from this area and puts it in the trolley box in the morning it is noticeable and it is taken out, refilled and returned to the cupboard along with the trolley. In the cupboard is a small book in which the nurse writes the following information: bed number, medicine and her initials. This is checked and crossed off by the pharmacist. Some medicines are ordered PRN by the doctor. In this case the pharmacist usually supplies what he thinks the patient would need in one day and makes a note of that on the doctors orders. For example; Aspirin PRN receives six tablets. The pharmacy is staffed from 0800 to 1800 h daily except Saturday and Wednesday afternoons. During the two afternoons the outpatient area sometimes needs medicines for people who come on an emergency basis but are not sick enough to be admitted to hospital. The doctors have a list of 12 medicines available from the nursing supervisor. These are kept in a locked cupboard with a small book which lists the medicines available. The nurse writes the patients chart number, the medicine given and her initials. When the pharmacist restocks he
signs to indicate that the full number of packages has been replaced. This simple and effective system costs very little to start and only requires two work hours a day to fill the requirements of the wards. It reduces effectively the number of errors made on the wards. The quantity of drugs lost is reduced to nothing as even the PRN orders are counted accurately. The medicines are readily available for the nursing staff and the trolley is moved to the bedside very easily. The system has been readily accepted by all concerned.
Ileo ascending colon anastomosis after resection of terminal ileum and caecum for benign diseases Edwin N Elechi Department of Surgery, College of Health Sciences, University of Port Harcourt, PO Box 450, Choba, Port Harcourt, Nigeria TROPICAL DOCTOR,
1990, 20, 140-141
Between 1983 and 1988, 13 patients underwent ileo ascending colon anastomosis after resection of the terminal ileum and caecum for benign conditions. There was one immediate postoperative death due to sepsis and respiratory failure. There were no cases of anastomotic leak or diarrhoea. The 12 patients who survived have remained healthy after an average follow-up period of 3.4 years. METHODS
From January 1983 to December 1988, 13 patients were admitted requiring resection of the terminal ileum and caecum for obvious benign diseases. In all cases, ileo ascending colon anastomosis was carried out instead of right hemicolectomy and ileo transverse colon anastomosis. Each patient had a soft corrugated red rubber drain inserted near the anastomotic site and brought out through a separate stab wound to monitor drainage. Frequency of bowel motions and the consistency of the stools were monitored for the first 4 weeks after surgery.
141
Tropical Doctor, July 1990
All patients had emergency operations after adequate fluid and electrolyte resuscitation. Each was covered with preoperative antibiotics consisting of broad spectrum penicillinase-resistant penicillin (Ampiclox) and metronidazole 500mg intravenously at least one hour before surgery and continued for 48 h postoperatively at 6 and 8 hourly intervals respectively. There were no mechanical bowel preparations. RESULTS
Of the 13 patients (9 men, 4 women; average age 30 years, range 32-56) seven had strangulated right inguinal hernia with gangrenous caecum and terminal ileum, three had ruptured gangrenous appendicitis with phlegmon, while two had gangrenous ileo caecal volvulus and one had a strangulated terminal ileum and part of the caecal wall due to congenital bands. One patient (a 37-year-old man) who had strangulated hernia for more than 8 days before he was brought from a rural village to the Teaching Hospital died in the immediate postoperative period of septicaemia and respiratory failure. Another patient developed pelvic abscess which was drained on the 10th postoperative day. Two patients had minor wound infections. Five patients required bisacodyl suppositories before they opened their bowels between the 7th and 9th postoperative days. No patient in this study had clinical evidence of anastomotic leak and none had diarrhoea within 4 weeks after surgery. At an average follow-up of 3.4 years, none of the 12 surviving patients had history of persistent diarrhoea. DISCUSSION
Right hemicolectomy and ileo transverse colon anastomosis are the accepted curative surgical treatment for resectable malignant conditions of the ileocaecal region 1. However, some surgeons carry out similar extensive resections for benign conditions involving the terminal ileum and caecum. The reasons usually given include: (i) technical difficulties in anastomosing the ileum which is intraperitoneal to the ascending colon which is retroperitoneal; (ii) fear of increased incidence of anastomotic leak; (iii) possibility of postoperative intussusception;and (iv) training experience which this author believes was the most obvious reason.
Wolfe and Wilson- in their review of 22 cases of emergency operation for volvulus of the caecum employed ileo ascending colon anastomosis with good results. Surgeons practising in developed countries are most familiar with ileocaecal malignant conditions for which a right hemicolectomy and ileo transverse colon anastomosis are required. Occasionally when faced with an unusual ileocaecal lesion surgeons justifiably carry out a right hemicolectomy and ileo transverse colon anastomosis as if it were a malignant condition. Since benign conditions of ileocaecal region requiring bowel resection are uncommon in the Western world, little has been written in the English literature about the indications and benefits of ileo ascending colon anastomosis. Most of us who trained in the Western world came back to developing countries and adopted the policy of right hemicolectomy and ileo transverse colon anastomosis for all lesions of the ileo caecal region whether malignant or benign. In Port Harcourt, Nigeria, benign lesions of the ileocaecal region are much more common than malignant lesions", Technically, it is easier and faster to accomplish ileo ascending colon anastomosis than right hemicolectomy and ileo transverse colon anastomosis. Blood loss is also minimal. Since ileo ascending colon anastomosis conserves the ascending colon with its water absorbing capacity, it is not surprising that postoperative diarrhoea was not seen among the 12 surviving patients in the series described. Furthermore, there was no clinical evidence of any anastomotic leakage, a complication feared by some surgeons. I therefore recommend that ileo ascending colon anastomosis should be the method of choice to restore bowel continuity after resection of the caecum and the terminal ileum for benign conditions. The procedure is easy, quick and safe without increased incidence of immediate or long-term postoperative morbidity and mortality.
REFERENCES
I Elechi EN, Ali SO, Calhoun T, Kurtz LH. Extra-nodal reticulum cell sarcoma of the terminal ileum with intussusception. JNMA 1974;66:420-3 2 Wolfe RY, Wilson H. Emergency operation for volvulus of the cecum: review of twenty-two cases. Am Surg 1966;32:96-100 3 Elechi EN. External abdominal wall hernias: experiencewith elective and emergency repairs in Nigeria. Br J Surg 1987;74:834-5
