Transurethral electroresection--an alternative to the indwelling catheter of old patients with prostatic hypertrophy]

The people become elder in this time, everywhere. The number of patients with adenoma of the prostate is increasing. Most of them have other diseases, too. A retrospective study (2646 cases in 8 years, exactly specially analysed 469 cases from 1975/1976) was done, comparing the results of TUR and open surgery. Well known is the lower risk of TUR, the lower blood loss, the lower discomfort, the lower nursing in the postoperative period ect. There are not news in this study. But it is important, to recall some things, because it's more and more difficult, to classify an old man as an "inoperable case". Nobody knows, where he should stay. The family does not like him at home (his "dripping", his incontinence etc.) In the veterans house it's the same problem, and from the hospital he is removed, because he is an "inoperable case". The situation of this old man is very bad, because he feels there isn't a place for him and nobody likes him. Each man, also if it's the strongest one, will be broken psychically and physically after a short time. Concerning these aspects, must be enlarged the indication of removal the bladder neck obstruction per transurethral resection, more and more.     

Goya's Lost Hearing: A Twenty-First Century Perspective on Its Cause,Effects and Possible Treatment

Francisco Goya produced over 1,800 works during his long career, which earned him a reputation as one of the greatest artists of modern times. When he was 47, he developed a mysterious illness that destroyed his hearing, and for the next 35 years left him “deaf as a stump.” Of the diagnoses proposed to date, Susac syndrome is the one most consistent with what little we do know of the character of that illness. If he were alive today, given the severity of his hearing loss, Goya would be treated with a cochlear implant, which might restore his ability to communicate in spoken language, though probably not to the level preceding his 1793 illness.     

Learning on the Web. Case 6: aortic valve replacement in the elderly

A 90 year old man was found at home by his daughter, slumped at the bottom of his stairs. He recalled quite severe tight central chest pain associated with breathlessness and sweating while going up stairs which was not relieved by taking a spray of sublingual glyceryl trinitrate (GTN). He sensed that he was "about to die" before collapsing with loss of consciousness. He was sent to the accident and emergency department (emergency room) of his local hospital by ambulance. The patient had a five year history of angina pectoris that limited him to one flight of stairs within the house and light housework only. Over the two weeks preceding his admission to hospital he had experienced increasing frequency of these symptoms and used his GTN spray more often than usual. He had not smoked for over 50 years and there were no other risk factors for cardiovascular disease. There was no other notable past medical history and he was otherwise fit, living completely independently. The significance of these signs and symptoms, the diagnosis, and the short and long term treatment of these problems are discussed in an interactive case presentation.     

Sandostatin as a "hormonal" temporary protective ileostomy in patients with total or subtotal colectomy

BACKGROUND/AIMS: We describe our experience with the use of a new method of so-called "hormonal" ileostomy by using Octreotide, a long-acting analog of the inhibitory peptide Somatostatin (Sandostatin Novartis), aiming to advocate protective ileostomy or colostomy, in patients who underwent total or subtotal colectomy for ulcerative colitis or obstruction of left colon, due to carcinoma or diverticulitis. METHODOLOGY: "Hormonal" protective ileostomy by using Sandostatin (Novartis) was performed in 10 patients after subtotal colectomy for ulcerative or left colon obstruction without a protective ileostomy or colostomy. Sandostatin 0.5 mg/mL was given from the day of operation to the 10th postoperative day, in a dose of 2 x 3 per day subcutaneously. The time of return of peristalsis, number of bouts of diarrhea and postoperative complications were evaluated. RESULTS: The patients were classified in two groups: First group (40% of all patients) with bowel obstruction and second group (60% of all patients) with ulcerative colitis. In the first group the mean time of return of peristalsis was 4.5 days and the mean number of bouts of diarrhea was 4.2 per day. One patient was reoperated for intraabdominal abscess and the morbidity was 50% with minor postoperative complications. In the second group the mean time of peristalsis return was 5 days and the mean number of bouts of diarrhea was 5.4 per day. One patient was reoperated for intestinal bleeding and the morbidity was 60% with minor postoperative complications. CONCLUSIONS: The use of Octreotide appears to serve as a useful adjunctive and important role in controlling intestinal output, so that it is an available method of "hormonal" protective ileostomy in very low rectal or anal anastomosis, by avoiding a second operation for ileostomy or colostomy closure and reducing the median hospital stay and total socioeconomic cost.     

Henry Drysdale Dakin 1880–1952

H.D. Dakin was born in London on March 12, 1880, the son of a Leeds iron and steel merchant. In 1898 he entered Yorkshire College, now the University of Leeds, to study under a famous organic chemist, Julius Cohen. Because of Dakin's particular interest in enzyme chemistry, Cohen gave him the nickname “zyme” which became his mode of address by his friends for the rest of his life. Indeed, Dakin became one of the founding leaders in the emerging field of biochemistry. In 1902 he was awarded a scholarship to study in other laboratories —the Jenner Institute in London, and with Kossel in Heidelberg. While in Heidelberg, he shared in the discovery of arginase. In 1905 he was invited to work in the private laboratory of Dr. Christian A. Herter in New York City. The opportunity permitted him to devote his entire time to investigations of his own choice. Although he worked primarily in the United States, for the remainder of his life he maintained his British citizenship, and when World War I broke out in 1914 he went to England to offer his services. He was asked to cooperate with Alexis Carrel in a research effort in the treatment of injuries suffered by the French wounded at Compiegne. It was there that he developed the buffered-hypochlorite solution that bears his name. Later, in the Dardenelles, the shipAquitania was fitted with a special tank for the electrolysis of sea water, by which an unlimited supply of hypochlorite disinfectant solution was made available. An immediate reduction in the incidence of infection was noted on this converted hospital ship. Among his other notable scientific achievements were the synthesis of adrenaline, the discovery of glyoxalase, and the oxidation of fatty acids. He wrote over 80 papers published in theJournal of Biological Chemistry. Dakin received many honors and recognitions—the University of Leeds granted him a Ph.D. in 1907, and honorary Doctorate of Laws in 1936. Yale and Heidelberg also granted him honorary degrees. The French government made him a chevalier of the Legion d'Honneur. His pioneering works profoundly affected the though and progress of medicine. He died on February 10, 1952, at the age of 71.     

Frank Howard Lahey

Frank H. Lahey, the descendant of Irish grandparents, was born June 1, 1880, in Haverhill, Massachusetts, the only child of a successful bridge building contracior. He was an outstanding athlete in the schools in Haverhill, and went on to Harvard University for his undergraduate study. In the fall of 1900 he entered Harvard Medical School, and did graduate training at the Boston City Hospital. He had joined the Staffs of Harvard and Tufts Medical Schools when World War I interrupted. He became a major in the Medical Corps and went to France to be Chief of Surgery in an evacuation hospital. Following the war he opened an office and shortly thereafter was joined by a surgeon and an anesthesiologist. It was at this time that he conceived the idea of developing a multiple specialty clinic a practice which had been successful in the mid-west, but not in New England. With the clinic established he developed a Fellowship Program for training surgeons from all over the world. He was a master technician and his surgical interest encompassed a wide range, but he was particularly well known for his operative approaches to the thyroid, the biliary tract, and the gastrointestinal tract. The concept of staged operations was vigorously applied at the Lahey Clinic for many diseases-thyrotoxicosis, esophageal diverticulum, subphrenic abscess, hepatic abscess, pancreatic cancer, diverticular disease, and cancer of the rectum. By staging the operation, Lahey and other surgeons were able to keep operative mortality extremely low. Of all the operations that Lahey did the one that is eponymously associated with him is the two-stage operation for cancer of the rectum, the subject of this Classics presentation. It was not until the early 1940s that one stage abdominoperineal resection had replaced this procedure as the primary treatment for cancer of the rectum at the Lahey Clinic. Lahey was a master surgeon; he was consistent and thorough. He often cautioned, “Be not the first to adopt a new technique nor the last to discard an old one.” It has been said that through all his honors and awards the one that meant the most to him was the Bigelow medal of the Boston Surgical Society, which stated in part “... superlative surgeon, doctor who teaches doctors, redoubtable administrator, advisor of Presidents in war and peace and, above all, a man who has the courage to be honest with himself...” Lahey died June 27, 1953 at the age of 73, after having been stricken in the operating room of a myocardial infarction. The editor is grateful to Cornelius E. Sedgwick, M.D., for his reminiscences of Doctor Lahey.     

Cases from the Osler Medical Service at Johns Hopkins University. Pseudoachalasia due to esophageal adenocarcinoma

Presenting features

A 69-year-old man presented with nausea and vomiting. He was in good health until 2 years before presentation, when he first noted occasional difficulty eating solid foods. He could chew food without difficulty, but sometimes he had the sensation that the food was lodged in his chest. This sensation would persist for several hours; occasionally, he would need to induce emesis for relief.These episodes of chest discomfort became more frequent over time. Two weeks before presentation, he had to induce emesis after every meal and began having difficulty ingesting both liquids and solids. On the day of his presentation, he awoke at 3:00 am feeling hungry. He drank some juice, after which he had emesis and chest pain, which led him to believe that he was having a myocardial infarction.His past medical history included hypercholesterolemia and gastroesophageal reflux disease attributed to a hiatal hernia. His only medication was simvastatin, which he stopped taking 1 month before presentation because he thought that it was con-tributing to his difficulty in swallowing. He had not smoked for more than 30 years. He previously drank one beer a day but recently stopped drinking as well. A review of systems was notable for an unintentional weight loss of 20 lbs during the past 6 months.On admission, his vital signs were normal. His chest, cardiac, and abdominal examinations were unremarkable. His electrocardiogram and laboratory tests were normal. A barium swallow (Figure 1 and Figure 2) demonstrated tapering of the distal esophagus.What is the diagnosis?     

Successful treatment for pouchitis with rebamipide refractory to a combination of metronidazole (MNZ) and ciprofloxacin (CFX)

A 35-year-old male who had undergone proctocolectomy and ileo-anal pouch surgery (IPAA) because of ulcerative colitis presented with worsening diarrhea and hematochezia. Pouchitis was diagnosed, and he was prescribed with metronidazole (MNZ) and a betamethasone enema. However, his condition did not remarkably improve despite these strategies. Endoscopy revealed ulceration and inflammation in the ileal pouch together with contact bleeding and mucous discharge. He underwent granulocytapheresis (G-CAP) and was prescribed anal 5-aminosalicylic acid (5-ASA) and oral prednisolone. Oral azathioprine (AZA) and a combination of MNZ and ciprofloxacin (CFX) did not result in any improvement. He was then treated with rebamipide enemas twice daily for 8 weeks without additional drug therapy. Two weeks thereafter, stool frequency started to decrease, fecal hemoglobin became negative, and his symptoms gradually improved. Endoscopic findings after the rebamipide therapy showed that the ulcers in the ileal pouch had mostly healed without obvious inflammation and bleeding. Rebamipide was thus maintained throughout the therapeutic period and for 13 months of follow-up. Rebamipide effectively treated severe pouchitis that was refractory to intensive conventional medication including antibiotics and corticosteroids.     

The Montreal Heart Institute: the idea and the man behind it

The Montreal Heart Institute (MHI) opened on January 11, 1954. It was the work of a single individual, a young cardiologist with a vision. Paul David (1919-1999) trained in the late 1940s -- first, in Boston with Paul Dudley White and, second, in Paris with Jean Lenègre, two of the well-known cardiologists of the times. In the early 1950s, the only heart institute in the world was the one that Ignacio Chavez had founded in Mexico in 1944. Montreal had a medical institute of its own, the Montreal Neurological Institute, which Wilder Penfield had established in 1934. David probably got his inspiration from these two institutions. Two events also coincided somewhat at the time. In 1950, David attended the first meeting of the International Society of Cardiology in Paris where Alfred Blalock presented his experience with his operation for blue babies and Charles Bailey discussed valvular commissurotomy for mitral stenosis. Shortly after he returned from France, David was approached by the Sisters of Charity to lead the cardiology division of a new hospital under construction in Montreal. The young man, barely out of residency, insisted on having a full floor of the hospital to himself with complete administrative independence from the main hospital. He also indicated that he would call the place a Heart Institute, no less. The nuns took him seriously and, after two or three encounters, agreed with his requests, perhaps much to his surprise. The rest, as they say, is history.     

Indiana pouch stone formation caused by a long-forgotten metallic ball bearing

The presence of a foreign body in the urinary tract may serve as a nidus for stone formation. A 40-year-old male was found on CT scan to have a 2.4 cm stone in his Indiana pouch urinary diversion. As the stone was fragmented during endoscopic lithotripsy, a metallic round object was visualized, which was subsequently established to be a metallic ball bearing. Upon questioning after the procedure, the patient reported that 4 years earlier he had been accidentally shot with a blow dart gun and the "miraculous hit" went directly into his Indiana pouch stoma.     

Rapidly progressed secondary amyloidosis in a patient with Still's disease with gamma-allele in his SAA 1 gene]

A fifteen-year-old boy was admitted to our hospital because of lower abdominal pain, watery diarrhea and mucobloody stool. Two years before admission, he was diagnosed to have Still's disease presenting with polyarthritis, sore throat, remittent fever and typical skin rash. He had been treated with non-steroidal anti-inflammatory agents, oral prednisolone and low-dose methotrexate. Although he was almost free of symptoms during the next two years, serum C-reactive protein (CRP) levels continued to be elevated moderately. He began to complain of lower abdominal pain and loose stool in May 1997 and came down with mucous-bloody diarrhea in June. Laboratory data on admission showed an elevated level of serum CRP (13.9 mg/dl). The biopsy of the stomach, ileum, sigmoid colon and rectum revealed the deposition of amyloid protein of AA type, which confirmed the diagnosis of secondary amyloidosis. The dose of prednisolone was increased and dimethyl sulfoxide per os or rectum was instituted, which improved his gastro-intestinal symptoms to some extent. However, fever, arthritis and diarrhea recurred along with tapered prednisolone dosage. In addition to gastro-intestinal symptoms, arrhythmia and proteinuria appeared. These symptoms were considered to reflect general deposition of amyloid in his body. He is now on immunosuppressive agent and high-dose prednisolone. Several studies report the higher frequency of gamma-allele of SAA 1 gene in the cases of rheumatoid arthritis with AA-amyloidosis than in those without. In the patient presented here, molecular biological analysis revealed that his SAA 1 gene was composed of beta- and gamma-allele. The presence of gamma-allele in his SAA 1 gene might be one of the factors that predisposed him for generalized deposition of amyloid protein in such a short period of time.     

David Henry Goodsall 1843–1906

David Goodsall was born in Gravesend, England, January 4, 1843. His father, rather late in life, decided on medicine as a career, and he matriculated at St. Bartholomew's Hospital. While doing a post-mortem examination as a student, the elder Goodsall injured his hand and subsequently died. In 1865, David Goodsall entered St. Bartholomew's, having his fees waived because of his father's tragic death. In 1870 Goodsall was appointed house surgeon to St. Mark's Hospital, becoming full surgeon in 1888. It was there that he developed his life-long interest in rectal surgery. He contributed many articles to the surgical literature, especially in his chosen field, including reports onforeign bodies of the rectum, pilonidal sinus disease, colostomy and anal fissure. But his most significant work, a book entitledDiseases of the Anus and Rectum, was done in concert with Mr. W. Ernest Miles. It was in his chapter on “Anal Fistula” that he espoused the rule that has become eponymously associated with him. In addition to Goodsall's medical prowess he was a skilled businessman, directing a waterworks company and the Western Telegraph Company. He died, presumably of a myocardial infarction, September 14, 1906. He had married late in life and was survived by his widow and seven-year-old son. Because of space limitations, the following chapter on “Anal Fistula” has been slightly abridged by deleting the discussion on the operative approaches to treatment. Senior Surgeon (late House Surgeon) to St. Mark's Hospital for Fistula and other Diseases of the Rectum; Senior Surgeon to the Metropolitan Hospital. Surgeon (out-patients) to the Gordon Hospital for Diseases of the Rectum; Assistant Surgeon to the Cancer Hospital, Brompton; late Senior Assistant Demonstrator of Anatomy at St. Bartholomew's Hospital Medical School, and House Surgeon to St. Mark's Hospital for Fistula and other Diseases of the Rectum, etc.     

Staphylococcus warneri endocarditis after implantation of a lumbar disc prosthesis in an immunocompetent patient

We report our findings and results on treating a patient with Fournier's gangrene by using colostomy along with open drainage. A 39-year-old male had noticed a swelling and experienced pain in the scrotal sac approximately 1 week before his admission. On admission, his symptoms aggravated and he experienced constipation and difficulty in urination. Local examination of the scrotum circumference revealed a remarkable swelling, and redness and sloughing that had extended to the perianal area. In an emergency operation, incision and drainage of the scrotum, double-barrelled colostomy at the transverse colon, and reconstruction of the percutaneous cystotomy were performed. Postoperative open wound was cleaned twice a day and intravenous infusions of 1g imipenem/cilastatin sodium and 1.2g clindamycin phosphate were administered daily. The patient was discharged 61 days after the operation. Fournier's gangrene has a high mortality rate, and in severe cases that are complicated with infection protracted from defecation, dyschezia and difficulty in urination, we believe that it would be most effective to perform an open drainage and a colostomy simultaneously.     

Use of honorifics in all situations by a patient with semantic dementia

We report the case of a 72-year-old man who had been given a diagnosis of semantic dementia (SD) at 64 years of age, and who began to use honorifics in all situations during the later clinical course. His initial clinical features were problems in word comprehension and naming, and some behavioural changes, including clockwatching and aberrant eating behaviours. The most prominent feature in this case was the use of honorifics in all situations, while other aspects of his language ability deteriorated. He even used honorifics with members of his family, including young grandchildren. Although it is difficult to explain the reason why the patient used honorifics in all situations, we considered 2 possibilities. The first is that although he remains able to use honorifics, he is unable to distinguish when the use of honorifics is not required. The second is that a change in emotional state, such as the "taming effect" or "placidity" that has been suggested to accompany frontotemporal lobar degeneration, might have affected his use of honorifics. The regular schedule of daycare services provides him with emotional stability because he does not have to constantly be aware of the time. Since no standard treatment has been established for SD, our experience with this case might be beneficial in caring for patients with SD.     

Ipilimumab and Nivolumab induced steroid-refractory colitis treated with infliximab: A case report

BACKGROUND A variety of immune-modulating drugs are becoming increasingly used for various cancers. Despite increasing indications and improved efficacy, they are often associated with a wide variety of immune mediated adverse events including colitis that may be refractory to conventional therapy. Although these drugs are being more commonly used by Hematologists and Oncologists, there are still many gastroenterologists who are not familiar with the incidence and natural history of gastrointestinal immune-mediated side effects, as well as the role of infliximab in the management of this condition.CASE SUMMARY We report a case of a 63-year-old male with a history of metastatic renal cell carcinoma who presented to our hospital with severe diarrhea. The patient had received his third combination infusion of the anti-CTLA-4 monoclonal antibody Ipilimumab and the immune checkpoint inhibitor Nivolumab and developed severe watery non-bloody diarrhea the same day. He presented to the hospital where he was found to be severely dehydrated and in acute renal failure. An extensive workup was negative for infectious etiologies and he was initiated on high dose intravenous steroids. However, he continued to worsen. A colonoscopy was performed and revealed no endoscopic evidence of inflammation. Random biopsies for histology were obtained which showed mild colitis, and were negative for Cytomegalovirus and Herpes Simplex Virus. He was diagnosed with severe steroid-refractory colitis induced by Ipilimumab and Nivolumab and was initiated on Infliximab. He responded promptly to it and his diarrhea resolved the next day with progressive resolution of his renal impairment. On follow up his gastrointestinal side symptoms did not recur.CONCLUSION Given the increasing use of immune therapy in a variety of cancers, it is important for gastroenterologists to be familiar with their gastrointestinal side effects and comfortable with their management, including prescribing infliximab.     

William Heneage Ogilvie

Heneage Ogilvie was born in Valparaiso, Chile, July 14, 1887. His father was an engineer from Dundee who had been in Chile for business reasons. Ogilvie was educated at Clifton College and New College, Oxford, where he gained first class honors in physiology. He then entered Guy's Hospital for his medical training and obtained his FRCS in 1920. Ogilvie was recognized as a technically great surgeon. His primary interests were surgery of the gastrointestinal tract and orthopedics. He was one of the very few medical men of his generation to serve in three wars: the Balkan War of 1902–1903 and the two world wars. He rose to the rank of Major General and was the Consultant Surgeon to the East Africa Force in 1941. One of his most remembered admonitions was to require the performance of a colostomy for all wounds of the colon (Abdominal wounds in the western desert. Surg Gynecol Obstet 1944;78:225–238). It was for his military service that he was appointed Knight of the British Empire in 1946. He was considered a brilliant essayist and authored several books which provided some of the finest medical writing. He was also responsible for the first two editions ofRecent Advances in Surgery. Ogilvie had an international reputation, and many visiting surgeons attended his theatre sessions. Travel and yachting occupied his leisure time. He founded the Surgical Travelers' Club and was Commodore of the Oxford University Sailing Club and the United Hospitals Sailing Club. The condition for which Ogilvie's name is eponymously associated is the article selected for this “Classics” presentation. The author describes two cases of colonic ileus that he attributes to sympathetic deprivation caused by invasion by tumor. Since the publication of this article, numerous predisposing causes for the development of colonic ileus have been suggested. In his obituary notice from theBritish Medical Journal, Ogilvie was described as “a curious mixture of shrewdness and ingenuousness. There was always something of the innocence and wonder of a child about him, and it was this trait in his character that made him so sensitive to the inevitable blows of life.” Among his many distinctions were honorary fellowships of the Royal College of Surgeons of Canada, the Royal Australasian College of Surgeons, and the American College of Surgeons. Ogilvie died on April 15, 1971, at the age of 83.     

A case of shigellosis due to Shigella dysenteriae 1 which was thought to be infected in domestic area

A 43-year-old man was admitted to our hospital because of bloody diarrhea and abdominal pain on January 10, 1989. On laboratory examination S. dysenteriae 1 was isolated from his stool, therefore he was diagnosed as shigellosis. After the administration of ofloxacin was started, S. dysenteriae 1 was immediately eradicated. But his diarrhea persisted until the 19th day from the onset of the illness and his abdominal pain persisted until the 21st day. He had never been overseas and he had never eaten any imported uncooked food recently. Only 14 cases of shigellosis due to S. dysenteriae 1 were found in the last ten years in Japan. All of them were overseas travellers. Although we were not able to determine the source of infection in our case, we inferred that he was primarily infected with S. dysenteriae 1 in Japan.     

Rescue therapy with tacrolimus for a patient with severe ulcerative colitis refractory to combination leukocytapheresis and high-dose corticosteroid therapy

A19-year-old man complaining of severe diarrhea and hematochezia was admitted to our hospital. Endoscopic findings and laboratory data revealed that he had ulcerative colitis (UC). Despite combination therapy with high-dose corticosteroids and intensive granulocytapheresis, his condition did not improve. Therefore, we initiated tacrolimus therapy. Intravenous administration of tacrolimus with a trough level of 10 to 15 ng/ml relieved his abdominal symptoms within 1 week. The patient experienced no UC relapse 1 year after treatment with oral tacrolimus. Tacrolimus is a promising therapy for patients with UC refractory to the combination of high-dose corticosteroids and leukocytapheresis.     

Thomas Bowdler: censor, philanthropist, and doctor

A recent biography of the physician William Osler credits him with having generated a verb, to "oslerize", as a synonym for euthanasia. Actually, Osler had been mocking his own impending senescent uselessness at the time of his move from Baltimore to Oxford. That neologism did not last. Two earlier doctors who did make it to the dictionaries in a verbally eponymous way were F A Mesmer and Thomas Bowdler, and Bowdler, at least, would not have liked the recognition. The first use of the verb to "bowdlerise" seems to have been in 1836, with a reference to "names in the writings of the apostles which modern ultrachristians would probably have Bowdlerized". However, Bowdler is better remembered for his cleaning up of the plays of Shakespeare.     

Raising a colostomy — results of a prospective surgical audit

A prospective surgical audit of all colostomies fashioned over a 1-year period in one hospital was conducted. Of one hundred and ten colostomies there were 56 loop and 52 end stomas. Following the formation of the colostomy a proforma was completed and the surgeon interviewed to document the precise surgical technique employed. Whilst in hospital the patients were regularly reviewed and the colostomies assessed by a surgeon and stomatherapist using a scoring system. Follow up was continued until closure of the colostomy or for a minimum period of 1 year. Only 53 (48%) of patients saw a stomatherapist preoperatively. This rate was higher in elective (86%) than in urgent cases (15%). The surgial technique used did not appear to influence the outcome of any given colostomy. However, failure to cruciate the posterior rectus sheath may predispose to stomal stenosis and the use of a subcutaneous polyethylene rod to support a loop colostomy often led to infection. Tension of the colostomy led to complications in 29 cases (26%), this was often the precipitating event to other complications and led to the only colostomy-related death. Registrars with experience of fewer than 5 colostomies received their training largely from other registrars rather than consultants. This prospective surgical audit has disclosed that fashioning a colostomy carries significant stoma related morbidity, most of which is potentially avoidable. Appropriate audit can contribute to the maintenance and improvement of surgical standards.