A 3 day old girl presented with lobulated mass protruding from her mouth. The mass was clinically diagnosed as a congenital epulis. The child had no airway obstruction and was able to feed well. A conservative treatment was proposed with monthly follow up appointments to monitor the lesion. After 10 months the lesion completely regressed and the eruption of maxillary anterior teeth remained unaffected.

C omplications associated with long-term steroid use in ulcerative colitis are well known. High output ileostomy of unknown aetiology has been reported in all published series of pouch surgery for ulcerative colitis. 1,2We report a patient with ulcerative colitis who, in the period following surgery, developed recurrent episodes of acute adrenal insufficiency presenting clinically as a high output ileostomy. Case reportA 31-year-old man with histologically proven ulcerative colitis since 1992 underwent a restorative proctocolectomy with pouch-anal anastomosis and a defunctioning ileostomy in April 1997. He was given the standard peri-operative cover with intravenous hydrocortisone having stopped his regular steroids (prednisolone) 1 month prior to surgery.He recovered well from surgery, but from the 10th day developed a high-output stoma producing more than 5 l/day along with general lethargy and fever with serum biochemistry showing sodium levels of 117 mmol/l, potassium 5.5 mmol/l, urea 16.2 mmol/l and creatinine 129 mmol/l. On examination, he was hypotensive, the abdomen was soft with normal bowel sounds, a rectal examination revealed an intact anastomosis, a CT scan of the abdomen showed no intra-abdominal collections and stool cultures proved negative. In view of the clinical findings of lethargy, diarrhoea presenting as high-output stoma and abnormal biochemistry, a possibility of acute adrenal insufficiency was considered in spite of high blood cortisol levels (night-time level of 534 nmol/l and day-time level of more than 1380 nmol/l). The patient showed immediate clinical response to intravenous hydrocortisone (100 mg) and stomal output reduced to less than 1 l/day within 24 h. He was subsequently discharged on a reducing dose of oral steroids.The patient was re-admitted within a few days with generalized lethargy, poor appetite, sore throat and a highoutput stoma. He was found to be hypotensive. Investigations revealed hyponatraemia, hyperkalaemia and a raised white cell count. Again, there was no evidence of intra-abdominal sepsis and stool cultures proved negative. A diagnosis of acute adrenal insufficiency precipitated by infection was made. An endocrinologist's opinion concurred with the diagnosis of secondary adrenal suppression. No other clinical features of Addison's disease or hypopituitarism were identified. The 'normal' serum cortisol levels in the initial postoperative period were thought to be less than required/expected for the degree of the patient's illness. The standard replacement doses of hydrocortisone were probably inadequate in his case. The high salt and fluid loss from the ileostomy may have caused the need for Acute adrenal insufficiency presenting as high output ileostomy S Rai, D Hemingway Department of Surgery, Leicester Royal Infirmary, Leicester, UKWe report a patient with ulcerative colitis who, in the period following surgery, developed recurrent episodes of acute adrenal insufficiency presenting clinically as a high output ileostomy.

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Background: Meta-analysis has shown the effectiveness of various training methods for the acquisition of laparoscopic skills in surgical training. However, there is very limited literature focusing on the translation of skill acquisition on training models into improved operating room (OR) performance. This study was conducted to evaluate the effectiveness of the Tuebingen trainer with integrated Porcine tissue in improving OR the performance of surgical trainees using standard assessment tools. Materials and Methods:The study was a single-blinded doublearmed randomized control study conducted between July 2016 and March 2018. Eighteen, fourth, and fifth semesters of surgery residents were included in the study. The baseline performance was assessed in OR by performing laparoscopic cholecystectomy using validated scores, that is, Global Operative Assessment of Laparoscopic Skills (GOALS), Additional Five Criteria, Task-specific Checklist, Error Checklist, Visual Analogue Scale. The residents were then randomized into trainee and nontrainee groups. The training group received 5 days of short-term-focused training on the Tuebingen trainer, and the improvement was reassessed in OR. Results:The demographic profile of residents was similar. The baseline scores were comparable. The training group showed statistically significant improvement in GOALS (9.88 ± 1.76 to 12 ± 0.66, P = 0.05 vs. 10.33 ± 1.5 to 11.4 ± 2.24, P = 0.28), taskspecific checklist (42.22 ± 10.92 to 53.33 ± 14.14, P = 0.027 vs. 45.55 ± 10.13 to 50 ± 17.32, P = 0.51), and error checklist. The operating time significantly reduced (36.0 ± 4.03 vs. 50.44 ± 11.39, P = 0.0025) following training.Conclusions: Our study concludes that the training on the Tuebingen trainer with integrated porcine organs results in a statistically significant improvement in the OR performance of surgical residents as compared with the nontrained residents, thereby indicating a transfer of skills from training to OR.

Conclusion:Perioperative nutritional management appears to contribute to early induction and increase of completion rate of adjuvant chemotherapy. Combining nutritional management with adjuvant chemotherapy may enable to improve the treatment outcome in pancreatic cancer.