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Preface This is the third article in the series ‘Fundamentals of good medical practice’. In this paper I will discuss the definitions of ‘Competence’ and ‘Performance’, the distinction and relationship between the two areas, and the possible/suggested different aspects of their assessment for the purpose of assuring the competence of current and future doctors, in particularly surgeons in practice.

MANAGEMENT OF COLORECTAL CANCER DURING PREGNANCY Majeed H Alwan MBChB, FRCSEd, FRACS, FACS, Gastrointestinal and General Surgeon, Tauranga Hospital, Tauranga, New Zealand. E-mail: majeedalwan@xtra.co.nz Abstract Although cancer in pregnancy is uncommon, several types of cancer were encountered. These include malignant melanoma, breast cancer, carcinoma of the cervix, bladder cancer, renal cancer, lymphomas, thyroid cancer, brain tumours, ovarian cancer, gastric and pancreatic cancer and colorectal cancer. Due to the uncommon incidence of the disease and therefore the limited experience coupled with the complexity of the situation which could affect the wellbeing of the foetus and mother, then the management of the pregnant woman with cancer might result in achieving less than the expected optimum. However, from the experience of single case reports and short reviews a reasonable management approach could be reached through multidisciplinary speciality collaboration. The author had encountered two pregnant women with colon cancer, both of them were symptomatic, and one of them had bowel obstruction. Their clinical presentation, diagnosis and management are described followed by a concise review of the literature.

Delirium is a common complication after surgery, especially among critically ill patients. The etiology is multifactorial and the condition is frequently identified after major complicated surgery. It is associated with prolonged hospital stay and increased morbidity and mortality. This paper present a complex case which required intensive treatment and support as a result of several complications including delirium. The case also serves a good example in discussing the different aspects of the condition.

Despite important advances in surgical care and minimized surgical trauma, postoperative complications are still of great concern. Nutritional depletion has been demonstrated to be a major determinant in the development of postoperative complications. Nutritional status of gastrointestinal surgical patients is an important issue, which need to be attended in particularly during the perioperative period. Fears of postoperative ileus and the integrity of the newly constructed anastomosis have led to the adoption of starvation with administration of intravenous fluids until the return of normal bowel sounds and passage of flatus. However, it has been shown that early postoperative enteral feeding is both beneficial and well-tolerated. Meta-analysis has shown that enteral feeding compared with parenteral nutrition is associated with fewer complications, reduced costs and a shorter hospital stay. Therefore it should be the preferred option whenever possible. Evidence to support preoperative nutrition is limited, but malnourished individuals fed for 7-10 days preoperatively may have improved surgical outcome. Prolong preoperative starvation is not essential, and the administration of preoperative carbohydrates is safe without the fear of increasing the risk of aspiration. Initially nutritional support was aimed at meeting the energy needs and providing proteins and other essential micronutrients, while now it is more directed at modulation of the immune functions, the so called immunonutrition. Multimodal strategies including minimal invasive surgery, adequate postoperative analgesia, nutritional care, and enforced mobilization resulted in reduction in postoperative complications and length of hospital stay.

Majeed H Alwan FRCS, FRACS, FACS, Gastrointestinal and General Surgeon, New Zealand 5 Tamworth Place, Gate Pa, TAURANGA, NEW ZEALAND. malwan@paradise.net.nz Abstract The traditional treatment of patients with adenocarcinoma of the rectum involved some form of radical surgery in fit patients followed by radiotherapy, or chemotherapy, or both depending on the stage of the disease and the general condition of the patient. More recently the emergence of neoadjuvant chemoradiotherapy (CRT) has fundamentally changed the management of these patients. Although initially it was recommended for locally advanced disease in an attempt of downstaging the tumour to make it resectable, the indication in using this modality had been widened. In clinical trials, up to 30% complete pathological response (pCR) of tumours have raised the question as to whether surgery, especially radical could be avoided in certain group of patients. A trial of omission of surgery in this group of patients has shown favourable long-term results. This article is an outline of the emerging factors for achieving complete pathological response; the non-operative or the minimal surgery strategies, methods of predicting response to chemoradiotherapy, and means of judging the complete pathological response.

The field of minimally invasive surgery has seen tremendous development and refinement since the first laparoscopic cholecystectomy was performed in 1987. Laparoscopic surgery has several advantages over traditional surgery. The next logical step in the evolution of minimally invasive surgery may be to eliminate all abdominal incisions. The terms being used in the literature include �incisionless�, �endoluminal�, �transluminal�, and �Natural Orifice Transluminal Endoscopic Surgery� (NOTES). This article aims to summarize the background and current status of NOTES.

Postoperative ileus (POI) is an inevitable adverse consequence of abdominal and other surgical procedures. Prolonged POI can lead to slow postoperative recovery, add to the patients discomfort and ultimately prolonged hospitalization and increased costs. It is believed that POI occurs as a result of inhibitory neural reflexes and inflammatory processes. The potential influence of endogenous opioids, in addition to exogenous opioids on the pathogenesis of POI has become more evident. The traditional routine use of nasogastric suction and the effects of prokinetic agents has been studied more and either challenged or refuted. Current treatment modalities, which are well studied includes the use of epidural long-acting local anaesthetics, early enteral feeding, multimodal postoperative care pathway, and less invasive surgical procedures. Recent research showed the usefulness of the newly introduced medications among the most promising is the peripherally acting �-opioid antagonist.

PATIENTS WITH METASTATIC CANCER OF UNKNOWN PRIMARY SITE: DIAGNOSTIC WORKUP AND THERAPEUTIC MANAGEMENT Majeed H Alwan FRCS, FACS, Gastrointestinal and General Surgeon, Wellington Hospital, Wellington, New Zealand Abstract Metastatic Cancer of Unknown Primary site (CUP) accounts for about 4% of all cancer patients and is therefore one of the 10 most frequent cancer diagnoses in man. It is defined as biopsy-confirmed malignancy for which the site of origin is not identified by routine workup. It is believed that CUP represents a heterogeneous group of malignancies that have a presumably, specific biology with clinical characteristics of rapid progression and random atypical metastases. The diagnostic work-up could be variable. Certain clinicopathological CUP entities are considered as favorable subsets responding to systemic platinum-based chemotherapy or managed by locoregional treatment. These subsets have a better prognosis than the average median survival time of four months in patients who belong to the non-favorable subsets.

The spleen is not considered any more to be dispensable1. By the end of the last century, virtually ‎none of the dogma believed to be unequivocally true 25 years earlier in the management of the ‎injured spleen was practiced. In this review several changes in the management of injuries to the ‎spleen, in particularly blunt injuries are presented. These includes: diagnosis, attempts of operative ‎splenic salvage, nonoperative management, and emphasis of preventing postsplenectomy ‎infection versus controlling bleeding.‎ ‎ Recently and during a period of less than two months, six patients with injury to the spleen (five ‎with blunt trauma and one atraumatic spontaneous rupture) were admitted under the care of the ‎present author. They are briefly presented before the rest of the review. As these cases have had ‎different presentation and management, it was thought that the discussion will give a further ‎account of the diversity of the management of injuries to this solid abdominal organ.‎

Pregnancy is the only physiologic condition that is treated in the hospital environment. All other medical conditions that are treated in such a setting are pathologic. When a pregnant patient develops a pathologic condition that requires surgical intervention, it is imperative to remember that the lives of two individuals are involved, the mother and the foetus. In such settings it is essential that the treating surgeon understand the physiologic states of these two individuals as an interdependent symbiotic relationship. Not only must appropriate maternal care be rendered, prevention of foetal complications is also desirable. Changing physiology and anatomical landmarks frequently cause confusion and delay in dealing with surgical problems in the pregnant patient. Both symptoms and signs could be modified, contributing to delay in seeking medical attention, timely referral for surgical evaluation, or the initiation of appropriate diagnostic procedures. Surgery during pregnancy is an uncommon event, but one that creates a great deal of anxiety for both patients and medical practitioners. Delays in diagnosis and definitive treatment represent the most significant risk for untoward outcome in both the mother and the foetus. Laparoscopic surgery has rapidly and widely spread in the management of wide abdominal conditions, which resulted in several significant benefits to the non-gravid patients. Pregnant patients and their foetuses could drive the same benefits from minimally invasive surgery, which are received by the non-gravidas. However, due to the several physiological and anatomical factors encountered during pregnancy many issues need to be thought about and dealt with. Optimal surgical treatment of the pregnant patient will be realized when there is collaboration between the various subspecialties involved in her care.

Surgical operations have developed in the method which the surgeon’s hands and eyes are used to gain ‎experience and advance the skills. However, to realize a new surgical therapy in the 21st century, it is ‎necessary to use various advanced technologies. These include among many, three dimensional medical ‎images, computer simulation and virtual reality technology, and robots in surgery. This is an outline of ‎the various aspects of these technologies with some more details about robotics in surgery as it is the ‎most recent advancement in that technology arena.‎

Background: Acute colonic pseudo-obstruction is an acute non-mechanical colonic obstruction. Twenty patients with this condition presenting between 1988 and 1996 were retrospectively reviewed to identify the incidence and potential aetiologic factors, and to establish a uniform therapeutic approach. Methods: Patients who fulfilled the criteria of acute pseudo-obstruction of the colon were reviewed retrospectively from a computerized database, and from a study of the hospital notes. Results: There were 12 men and eight women with a median age of 71 years. Seventeen patients (85%) had various coexisting medical conditions, and none of the cases had a recent surgical operation or trauma. Four patients had previous similar attacks. Patients had a median duration of symptoms and a hospital stay of 3 and 7 days, respectively. Diagnosis was based on the clinical features coupled with the findings on plain abdominal X-rays and contrast enema. Sixteen patients were successfully treated conservatively over a median time of 5 days. Three patients had a laparotomy: two patients had tube caecostomy (followed by complications), and one patient had no further treatment. One patient had colonoscopy with an unsatisfactory result. Two patients (10%) died and three (15%) developed complications. Conclusions: Acute colonic pseudo-obstruction is an uncommon but serious condition. The majority of our patients (17/20) had associated significant medical problems. Most of the patients were successfully managed conservatively. This was the preferred initial line of treatment in this department during the study period.

Auger, a deepwater Gulf of Mexico (GOM) field, successfully implemented e-WellBook solution enabling its Wells Reservoirs Facilities Management (WRFM) program — providing integrated data visualization and easy access to reservoir, production, petrophysical and geological data. The data challenges commonly encountered in upstream are: 1) technical data is often hard to access all at once being scattered in non-standard data files and repositories, 2) data used in projects maybe unreliable, not current, sometimes lacking quality assurance which may impact decisions and 3) engineers and geoscientists may hold on to technical data, creating discipline data silos and orphan data difficult to gain access to or used sustainably by a multi-discipline WRFM team. Aiming to add additional barrels with efficiency gains and timely decisions, it was necessary to address the underpinning data challenges. Within Deepwater Gulf of Mexico, the Wells and Surveillance leaders collaborated with Technical Data Management Group (TDM) to drive forward the data integration efforts for past three years. Working with Production Technologists, Reservoir Engineers, Geologists and key stakeholders of WRFM teams, each key field within Gulf of Mexico now has access to integrated data with visualization using an e-WellBook (e-WB). The efforts were replicated and standardized as much possible across upstream Americas, also covering Heavy Oil and Onshore deployments. The business championship, steer from discipline experts, knowledge of holistic data management and data know-how coupled with needed application/ infrastructure support from IT made the e-WellBook deployments sustainable. Shell's focus on increased production and maximizing value from its existing assets warrants efficient means to support assets in their WRFM reviews. Integrated data within e-WellBooks offers value-add to the teams in gaining efficiencies and helping expedite their decision making. The data integration steps were standardized, and applied to all key fields within Gulf of Mexico within less than three year period. A 50% or more time reduction in data search itself is of great value to the teams actively involved in WRFM efforts. Other added benefits are efficient integrated review with access to "live" integrated multidiscipline data and the visualization of full spectrum of E&P disciplines' data in a single e-WB solution. It eliminates need for paper poster and charts that adorned the walls or slides in the past well reviews. Majority of critical WRFM data — well history, well schematic, production chemistry, cased hole logs and other valuable data, are readily available with a few clicks of e-WellBook on the desktop. With increased well activity within deepwater, unconventionals onshore, and heavy oil, in addition to heightened access to new tools/technologies, there is a significant increase in volume of data. Moreover, in comparison to a few decades ago, engineers, geoscientists and business leaders are hard pressed to make faster decisions and to manage increased responsibilities. In order to facilitate decision making that supports the industry's aspirations for additional barrels —produced with heightened focus on safety, proper management of technical data quality readability, integration and its ease of use are essential basic steps for success. The paper presents the technical data management functional excellence journey deploying e-WellBooks to support WRFM in Shell's Gulf-of-Mexico Deepwater assets and lessons learnt.

Introduction: Graduated compression stockings (GCS) are used for mechanical prophylaxis for VTE. The aim of our study was to compare the incidence of VTE with and without the use of compression stockings after total hip and knee arthroplasty. Methods: Data was collected retrospectively over 18 month’s duration, and included all consecutive primary total hip and knee replacements. Patients were divided into 2 groups; group І (patients in whom GCS were used) and group ІІ (patients in whom GCS were not used). Data was analyzed by excluding as well as including the patients with previous history of VTE. Results: 1875 patients underwent total hip and knee replacements, excluding the patients with previous history of VTE. Group І consisted of 982 patients (52.3%) and group ІІ consisted of 893 patients (47.7%). In total, 23 patients (1.22%) had a VTE diagnosed postoperatively (DVT: 8, PE: 15). In group І, 11 patients (1.12%) suffered from VTE (DVT: 4, PE: 7). In group ІІ, 12 patients (1.34%) had VTE (DVT: 4, PE: 8). Including the patients with previous VTE; in total, 2020 patients underwent hip and knee arthroplasty. Group I comprised of 1040 patients with 14 patients (1.34%) diagnosed with VTE (DVT: 5, PE: 9). Group II comprised of 984 patients with15 patients (1.52%) diagnosed with VTE (DVT: 5, PE: 10). Conclusion: We did not find any obvious benefit of compression stockings in the prevention of VTE after primary total hip and knee arthroplasty in the presence of enoxaparin prophylaxis.

Review Article RETROPERITONEAL SARCOMA Majeed H Alwan MBChB, FRCSEd, FRACS, FACS, Gastrointestinal and General Surgeon, Tauranga Hospital, Tauranga, New Zealand. E-mail: majeedalwan@xtra.co.nz Abstract Retroperitoneal sarcoma (RPS) is a rare tumour. Its management is challenging because of often late presentation when the tumour attain a significant size, and its close relationship to several vital organs and structures in the retroperitoneum. Although surgery remains the main hope in controlling the disease, the use of neoadjuvant or adjuvant radiotherapy and/or chemotherapy remains controversial. Local recurrence is high and there are reports of successful second and third resections after recurrence. In this report the author reports two cases recently he had managed and presents the unique CT scan findings of the first case. This is followed by a brief review of the important matters related to this tumour.

This is an overview of the various factors related to the substernal (retrosternal) goitre. The presentation and discussion include the terminology of the condition, its definition, type, the mechanism and way the goitre descends in the thorax, its incidence, clinical features, investigations, and possible challenges in anaesthesia and surgical exposures.

Quality assurance and performance evaluations, have become central issues in medicine. There are several studies which indicates that general patients care is suboptimal in many different medical conditions and clinical settings1,2. Delivering high-quality care is important to all clinicians, but this issue may be more relevant to certain subgroups, such as those with less specialised training and those who deal with smaller number of patients3. There is also a general believe that the longer clinicians are in practice the more experienced they will be, and therefore it is assumed that this group of medical doctors are able to provide a high quality of care. But there are some studies that found a consistently or partially negative association. The aim of this report is to discuss this subject further and reach some conclusions.

Background: Laparoscopic cholecystectomy is the standard treatment for symptomatic gallbladder disease. Preoperative prediction of a difficult laparoscopic cholecystectomy can help the surgeon to prepare better for intraoperative risk and the risk of conversion to open cholecystectomy.Objectives: Evaluation of the influence of gallbladder wall thickness, assessed by sonography preoperatively, on the outcome of laparoscopic cholecystectomy and to evaluate any intra- or postoperative complications in relation to them.Patients and Methods: This prospective clinical trial conducted in Department of Surgery, Al-yarmouk Teaching Hospital, between October 2010 and October 2012.Abdominal sonography performed in 122 consecutive patients before laparoscopic cholecystectomy. The surgeon re-verified sonographic findings in the operating room.Difficulty of laparoscopy was evaluated with multiple parameters related to the gall bladder wall thickness, so classified as easy or difficult laparoscopy or conversion.Results: Out of 122 patients with cholecystolithiasis on sonography, we encountered straight forward laparoscopic cholecystectomy in 87 patients (71.31%), difficult laparoscopic cholecystectomy in 27 (22.13%) and the procedure was converted to open cholecystectomy in 8 patients (6.55%). 47 patients(38.5%) had sonography revealing gallbladder wall thickness (>3 mm), and 75 patients (61.47%) had wall thickness < 3mm .Conclusions: Gallbladder wall thickening is the most sensitive indicator of technical difficulties during laparoscopic cholecystectomy. Such difficulties may require conversion to Laparotomy.

Summary Fast track surgery is a novel concept in perioperative care of patients undergoing elective surgical procedures that combines recent advances in anesthesia, new approaches to pain control, techniques that reduce the perioperative stress response and organ dysfunction, and the use of minimally invasive techniques. These measures aimed to rapid mobilization, early feeding, rapid recovery, minimize complications, and shorter in-hospital stay.

Background: Difficulty in sleeping under stressor due to various living style needs appears to be a great risk factor for physical and mental health status. Physicians are a population that appears to be at increased risk for sleep deprivation due to demanding academic and clinical duties. Aims & Objective: To estimate the prevalence of different forms of sleeping disturbance and determine its associated factors among family medicine and emergency medicine (ER) physicians at military hospital in Tabuk. Materials and Methods: A cross-sectional analytical study was adopted. All Family medicine (n=80) and ER (n=25) physician in Prince Salman Armed Forces hospital in Tabuk, KSA were invited to participate in the study. A validated questionnaire was used based on Pittsburgh Sleep Quality Index (PSQI) and Pittsburg Insomnia Symptoms questionnaire. It differentiates “poor” from “good” sleep by measuring seven areas: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction over the last month. Results: The study included 92 physicians out of 105 invited to participate in the study, giving a response rate of 87.6%. Their age ranged between 26 and 55 years with a mean of 34.3 years and standard deviation of 5.4 years. Males represent almost two-thirds of them (64.1%). Most of them (78.3%) were poor sleepers during the past month, based on Global PSQI Score. Sleep complaints were reported by 77.2% of the participants. Of them, 18.5% suffered from difficulty falling asleep. Difficulty staying asleep and frequent awakening from sleep were reported as frequent or always complaints by 10.9% and 18.5% of them, respectively. Felling that sleep is not sound and it is unrefreshing were mentioned frequently or always by 18.4% and 26.1% of them, respectively. Sleep complaints had extreme impact on concentration and caused extreme sleepy feeling during the day among 7% of physicians. Conclusion: Poor sleep quality is a common problem affecting most of physicians in Prince Salman Armed Forces hospital in Tabuk, KSA.

This paper presents an experience of thirty consecutive patients with hepatic colorectal metastases who were treated with hepatic cryotherapy and subsequent hepatic arterial infusion (HAI) chemotherapy using 5FU.Patients with colorectal metastases confined to the liver but not suitable for resection, and with liver involvement of less than 50% were offered the treatment. Prospective documentation of all patients was undertaken with data being recorded on a computerised database.Patients had a median of 6 (2–15) lesions with sizes ranging from 1–12 cm. There was no 30 day mortality. Postoperative complications developed in 8 patients but were followed by full recovery in all instances. Side effects from chemotherapy occured in 23% of cycles. Twenty seven patients have died. Median survival from the time of cryotherapy was 18.2 months (7–34), or 23months (9–44) from diagnosis of liver lesions.Hepatic cryotherapy with subsequent arterial chemotherapy is safe and well tolerated. The results suggest survival of patients with colorectal hepatic metastases can be improved by the use of this modality of treatment.

The dynamic responses of a railway bridge members due to vehicle‐track‐bridge interaction were investigated for the effects of vertical and lateral track irregularities, approach track quality, and bridge damping. In each case, a train consisting of three vehicles moving at constant speed was simulated traveling on the bridge. It was found that: (1) Greater approach irregularities produce higher impact factors and dynamic forces in bridge members; (2) impact factors in members with low static stress are high, but the dynamic stresses produced are low; (3) in general, impact factors reduce slightly due to bridge damping; and (4) the dynamic forces in lower lateral bracing members are small as compared to their allowable values.

A young male patient with schistosomiasis and sarcoma of the urinary bladder is presented. Total cystectomy followed by radiotherapy was performed. The gross appearance, microscopic findings of the tumor and an outline of the disease are discussed.