ISRN Surgery

Learning Curve for D2 Lymphadenectomy in Gastric Cancer

Alexis Luna, Pere Rebasa, Sandra Montmany, and Salvador Navarro — Sun, 16 Jun 2013 13:03:53 +0000

Background. D2 lymphadenectomy is a demanding technique which is associated with high morbidity in the West. We report our experience with D2 lymphadenectomy after a training period in Japan. Methods. Prospective, descriptive study in 133 consecutive patients undergoing radical gastrectomy for gastric adenocarcinoma from 2005 to 2011. We analysed the number of lymph nodes removed, observed morbidity/mortality compared with the predictions of POSSUM and O-POSSUM, survival, and disease-free interval for patients with D1 and D2 lymphadenectomy. Results. The morbidity rate in patients with D1 lymphadenectomy was 59.4%. For D2 it was 47.7%. The mortality rate in patients with D1 was 6.7%. In the D2 group it was 6.8%. Median survival was 42.9 months in D1 and 55 months in D2. The disease-free interval was 49 months for D1 and 58 months for D2. Conclusion. The learning curve for D2 lymphadenectomy presents acceptable rates of morbidity and mortality, providing that the technique is learnt at a center with extensive experience.

Control of Bleeding in Endoscopic Skull Base Surgery: Current Concepts to Improve Hemostasis

Cattleya Thongrong, Pornthep Kasemsiri, Ricardo L. Carrau, and Sergio D. Bergese — Thu, 13 Jun 2013 10:28:59 +0000

Hemostasis is critical for adequate anatomical visualization during endoscopic endonasal skull base surgery. Reduction of intraoperative bleeding should be considered during the treatment planning and continued throughout the perioperative period. Preoperative preparations include the optimization of comorbidities and cessation of drugs that may inhibit coagulation. Intraoperative considerations comprise anesthetic and surgical aspects. Controlled hypotension is the main anesthetic technique to reduce bleeding; however, there is controversy regarding its effectiveness; what the appropriate mean arterial pressure is and how to maintain it. In extradural cases, we advocate a mean arterial pressure of 65–70 mm Hg to reduce bleeding while preventing ischemic complications. For dealing intradural lesion, controlled hypotension should be cautious. We do not advocate a marked blood pressure reduction, as this often affects the perfusion of neural structures. Further reduction could lead to stroke or loss of cranial nerve function. From the surgical perspective, there are novel technologies and techniques that reduce bleeding, thus, improving the visualization of the surgical field.

The Effects of Bile Duct Obstruction on Liver Volume: An Experimental Study

Wed, 05 Jun 2013 08:35:42 +0000

Objectives. This study is aimed at investigating alterations in liver volume during obstructive jaundice in rat liver. Materials and Methods. Thirty-six rats were divided into four groups. Abdominal tomography was performed for baseline volumetric analyses. The main bile ducts were ligated (BDL). Volumetric analyses were repeated 3 days after BDL in group 1, 7 days after BDL in group 2, 15 days after BDL in group 3, and 25 days after BDL in group 4, and total hepatectomy was performed in all animals. Control group () was created with the rats that died before bile duct ligation. Results. There was no difference found in liver volume in group 1 compared to control animals. The liver volume was increased 7 days after BDL (). It was increased up to 60% of baseline values 25 days after BDL (). Wet liver weights of animals were also increased compared to control group. Liver weights were increased up to 40% percent of baseline values in group 4 (). Conclusions. Liver volume and weight were increased after BDL. Liver surgery in patients with huge liver mass is generally associated with significant difficulty. The surgeon should be aware of the time-dependent alteration in liver volume after obstructive jaundice.

Characterization of the Mechanical Strength, Resorption Properties, and Histologic Characteristics of a Fully Absorbable Material (Poly-4-hydroxybutyrate—PHASIX Mesh) in a Porcine Model of Hernia Repair

Corey R. Deeken and Brent D. Matthews — Tue, 28 May 2013 10:44:23 +0000

Purpose. Poly-4-hydroxybutyrate (P4HB) is a naturally derived, absorbable polymer. P4HB has been manufactured into PHASIX Mesh and P4HB Plug designs for soft tissue repair. The objective of this study was to evaluate mechanical strength, resorption properties, and histologic characteristics in a porcine model. Methods. Bilateral defects were created in the abdominal wall of Yucatan minipigs and repaired in a bridged fashion with PHASIX Mesh or P4HB Plug fixated with SorbaFix or permanent suture, respectively. Mechanical strength, resorption properties, and histologic characteristics were evaluated at 6, 12, 26, and 52 weeks ( each). Results. PHASIX Mesh and P4HB Plug repairs exhibited similar burst strength, stiffness, and molecular weight at all time points, with no significant differences detected between the two devices (). PHASIX Mesh and P4HB Plug repairs also demonstrated significantly greater burst strength and stiffness than native abdominal wall at all time points (), and material resorption increased significantly over time (). Inflammatory infiltrates were mononuclear, and both devices exhibited mild to moderate granulation tissue/vascularization. Conclusions. PHASIX Mesh and P4HB Plug demonstrated significant mechanical strength compared to native abdominal wall, despite significant material resorption over time. Histological assessment revealed a comparable mild inflammatory response and mild to moderate granulation tissue/vascularization.

Recurrent Pyogenic Cholangitis: Disease Characteristics and Patterns of Recurrence

Sat, 25 May 2013 13:04:56 +0000

Recurrent pyogenic cholangitis (RPC) is characterized by repeated infections of the biliary system with the formation of stones and strictures. The management aims are to treat acute cholangitis, clear the biliary ductal debris and calculi, and eliminate predisposing factors of bile stasis. Operative options include hepatectomy and biliary drainage procedures or a combination of both; nonoperative options include endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC) guided procedures. This current study compares the operative and the nonoperative management outcomes in patients with RPC in 80 consecutive patients. In addition, we aim to evaluate our approach to the management of RPC over the past decade, according to the various degrees of severity and extent of the disease, and identify the patterns of recurrence in this complex clinical condition. Initial failure rate in terms of residual stone of operative compared with nonoperative treatment was 10.2% versus 32.3% (). Long-term failure rate for operative compared with non-operative treatment was 20.4% versus 61.3% (). Based on multivariate logistic regression, the only significant factors associated with failure were bilaterality of disease (OR: 8.101, ) and nonoperative treatment (OR: 26.843, ). The median time to failure of the operative group was 48 months as compared to 20 months in the nonoperative group (). Thus operative treatment is a durable option in long-term resolution of disease. Hepatectomy is the preferred option to prevent recurrent disease. However, biliary drainage procedures are also an effective treatment option. The utility of nonoperative treatment can achieve a reasonable duration of disease free interval with minimal complications, albeit inferior to operative management.

Evaluation of ECHO PS Positioning System in a Porcine Model of Simulated Laparoscopic Ventral Hernia Repair

Thu, 23 May 2013 15:22:29 +0000

Purpose. Operative efficiency improvements for laparoscopic ventral hernia repair (LVHR) have focused on reducing operative time while maintaining overall repair efficacy. Our objective was to evaluate procedure time and positioning accuracy of an inflatable mesh positioning device (ECHO PS Positioning System), as compared to a standard transfascial suture technique, using a porcine model of simulated LVHR. Methods. The study population consisted of seventeen general surgeons () that performed simulated LVHR on seventeen () female Yorkshire pigs using two implantation techniques: (1) VENTRALIGHT ST Mesh + ECHO PS Positioning System (ECHO PS) and (2) VENTRALIGHT ST Mesh + transfascial sutures (TSs). Procedure time and mesh centering accuracy overtop of a simulated surgical defect were evaluated. Results. ECHO PS demonstrated a 38.9% reduction in the overall procedure time, as compared to TS. During mesh preparation and positioning, ECHO PS demonstrated a 60.5% reduction in procedure time (). Although a trend toward improved centering accuracy was observed for ECHO PS (16.2%), this was not significantly different than TS. Conclusions. ECHO PS demonstrated a significant reduction in overall simulated LVHR procedure time, particularly during mesh preparation/positioning. These operative time savings may translate into reduced operating room costs and improved surgeon/operating room efficiency.

Morbidity Assessment in Surgery: Refinement Proposal Based on a Concept of Perioperative Adverse Events

Airazat M. Kazaryan, Bård I. Røsok, and Bjørn Edwin — Thu, 16 May 2013 17:57:48 +0000

Background. Morbidity is a cornerstone assessing surgical treatment; nevertheless surgeons have not reached extensive consensus on this problem. Methods and Findings. Clavien, Dindo, and Strasberg with coauthors (1992, 2004, 2009, and 2010) made significant efforts to the standardization of surgical morbidity (Clavien-Dindo-Strasberg classification, last revision, the Accordion classification). However, this classification includes only postoperative complications and has two principal shortcomings: disregard of intraoperative events and confusing terminology. Postoperative events have a major impact on patient well-being. However, intraoperative events should also be recorded and reported even if they do not evidently affect the patient’s postoperative well-being. The term surgical complication applied in the Clavien-Dindo-Strasberg classification may be regarded as an incident resulting in a complication caused by technical failure of surgery, in contrast to the so-called medical complications. Therefore, the term surgical complication contributes to misinterpretation of perioperative morbidity. The term perioperative adverse events comprising both intraoperative unfavourable incidents and postoperative complications could be regarded as better alternative. In 2005, Satava suggested a simple grading to evaluate intraoperative surgical errors. Based on that approach, we have elaborated a 3-grade classification of intraoperative incidents so that it can be used to grade intraoperative events of any type of surgery. Refinements have been made to the Accordion classification of postoperative complications. Interpretation. The proposed systematization of perioperative adverse events utilizing the combined application of two appraisal tools, that is, the elaborated classification of intraoperative incidents on the basis of the Satava approach to surgical error evaluation together with the modified Accordion classification of postoperative complication, appears to be an effective tool for comprehensive assessment of surgical outcomes. This concept was validated in regard to various surgical procedures. Broad implementation of this approach will promote the development of surgical science and practice.

A Modified Method in Laparoscopic Peritoneal Catheter Implantation: The Combination of Preperitoneal Tunneling and Pelvic Fixation

Wed, 15 May 2013 13:35:32 +0000

Introduction. Continuous ambulatory peritoneal dialysis (CAPD) is widely accepted for the management of end-stage renal disease (ESRD). Although not as widely used as hemodialysis, CAPD has clear advantages, especially those related to patient satisfaction and simplicity. Peritoneal dialysis (PD) catheter insertion can be accomplished by several different techniques. In this study, we aimed to evaluate our results obtained with peritoneal dialysis catheter placement by combination of pelvic fixation plus preperitoneal tunneling. Material and Methods. Laparoscopic peritoneal catheter implantation by combining preperitoneal tunneling and pelvic fixation methods was performed in 82 consecutive patients with end-stage renal disease. Sex, age, primary disease etiology, complications, mean duration of surgery, mean duration of hospital stay, morbidity, mortality, and catheter survival rates and surgical technique used were assessed. Analysis of catheter survival was performed using the Kaplan-Meier method. Results. Mean follow-up period was 28.35 ± 14.5 months (range of 13–44 months). Mean operative time was 28 ± 6 minutes, and mean duration of hospital stay was 3 ± 1 days. There were no conversions from laparoscopy to other insertion methods. None of the patients developed serious complications during surgery or the postoperative period. No infections of the exit site or subcutaneous tunnel, hemorrhagic complications, abdominal wall hernias, or extrusion of the superficial catheter cuff was detected. No mortality occurred in this series of patients. Catheter survival was found to be 92% at 3 years followup. Conclusions. During one-year followup, we had seven patients of migrated catheters due to separation of pelvic fixation suture from peritoneal surface, but they were reimplanted and fixated again laparoscopically with success. Over a three-year followup period, catheter survival was found to be 92%. In the literature, similar catheter survival rates without combination of the two techniques are reported. As a conclusion, although laparoscopic placement of PD catheters avoids many perioperative and early complications, as well as increasing catheter free survival period and quality of life, our results comparing to other studies in the literature indicate that different laparoscopic placement methods are still in debate, and further studies are necessary to make a more accurate decision.

A Review of the Clinical Outcomes for Patients Diagnosed with Brainstem Metastasis and Treated with Stereotactic Radiosurgery

Thu, 11 Apr 2013 11:48:10 +0000

Only 3%–5% of all brain metastases are located in the brainstem. We present a comprehensive review of the clinical outcomes from modern studies that treated patients with brainstem metastasis using either a Gamma Knife or a linear accelerator-based stereotactic radiosurgery. The median survival time of patients was compared to better understand what clinical or treatment factors are predictive of improved survival. This information can then be utilized to optimize patient care. The data suggests that higher prescribed marginal dose and the associated greater local control of brainstem lesions are associated with longer patient survival. Further research is necessary to better describe the most effective dose for individual brainstem lesions and to tailor optimum therapy to specific patient subgroups.

Nephron-Sparing Surgery for Renal Masses Measuring Larger Than on Preoperative Imaging: A Single Surgeon, Single Center Experience

Thu, 04 Apr 2013 14:24:24 +0000

Objectives. To document the feasibility of nephron-sparing surgery (NSS) for the surgical treatment of renal masses measuring larger than 7 cm (cT2) on preoperative imaging. Methods. A total of 139 patients have undergone NSS between 2001 and 2012 by a single surgeon in our clinic. Of these, we identified 17 patients whose tumors were measuring greater than 7 cm on preoperative imaging studies and were limited to the kidney. Their charts were retrospectively reviewed. Results. Mean age of the study population was years. Thirteen patients were managed by open NSS, while 4 patients have undergone robot-assisted NSS. Mean diameter and mean R.E.N.A.L. score of the tumors that were enucleoresected were 8.2 cm and 8.5, respectively. A total of 5 Clavien grade 2 and higher complications were recorded within 30 days of surgery. Histopathologic examination revealed benign histology in almost 1/4 of the cases. After a median followup of 33 months, all of our patients were alive. Only one patient (5.8%) experienced local recurrence. Conclusions. NSS is a feasible and safe option for large (>7 cm) renal masses. It may be considered not only for imperative conditions but also for highly selected cases with a normal contralateral kidney.

Gross Hematuria in Patients with Prostate Cancer: Etiology and Management

Sun, 24 Mar 2013 14:06:49 +0000

The objective of the study is to assess the etiology and prognosis of gross hematuria (GH) in patients with carcinoma of the prostate (CAP). From 1991 to 2011, 81 men (mean age 74.3 years, SD 6.5) with CAP were hospitalized with GH. Primary treatment of CAP was radical surgery in 13 patients (group 1) and nonsurgical therapy in 68 (group 2), mostly radiotherapy (35 cases) and hormonal treatment (25 cases). The common etiologies of GH in group 1 were bladder cancer (38.5%) and urinary infection (23%). In contrast, CAP itself caused GH in 60% of the patients in group 2. Thirty-nine patients (48%) required transurethral surgery to manage GH which was effective in all cases; nevertheless, the prognosis of group 2 patients was dismal with median overall survival of 13 months after sustaining hematuria, compared to 50 months in group 1 (). We conclude that the etiology of GH in patients with CAP varies according to primary treatment. After radical prostatectomy, it is habitually caused by bladder cancer or infection. When the primary treatment is not surgical, GH is most commonly due to CAP itself. Although surgical intervention is effective in alleviating hematuria of these patients, their prognosis is dismal.

The Exploratory Burr Hole: Indication and Results at One Departmental Hospital of Benin

Thu, 21 Mar 2013 10:58:52 +0000

Objective. The aim of this study was to describe the indications and results of exploratory burr hole performed at the Departmental Teaching Hospital of Borgou (Benin). Methods. It was a retrospective study performed from January 2008 to February 2011. It concerned patients with a closed traumatic brain injury (TBI) in which an exploratory burr hole was performed. The selection criteria were unilateral mydriasis associated with neurological deficits on the opposite side or the occurrence of a decreased consciousness associated with the appearance of a motor deficit after a lucid interval. Results. Amongst the 74 patients operated, 23 (31%) underwent an exploratory burr hole for which the average age was 24.8 ± 17.3 years. Sex ratio male/female was 3.6. TBI was due to road traffic accident (56.5%), a fall (26.1%), and an assault (17.4%). It was severe (47.8%), moderate (39.1%), and mild (13.1%). Mydriasis was observed in 69.6% of cases as well as neurological deficit in all patients. A lesion was observed in 15 (65.2%) cases. Conclusion. The exploratory burr hole seemed as an old practice, still no longer performed in full practice in Benin, and is a diagnosis and therapeutic approach. Better technical conditions would allow more relevant therapeutic options.

Phyllodes Tumor of Breast: A Review Article

Wed, 20 Mar 2013 08:57:00 +0000

Introduction. Phyllodes tumours are rare fibroepithelial lesions. Accurate preoperative pathological diagnosis allows correct surgical planning and avoidance of reoperation. Treatment can be either wide local excision or mastectomy to achieve histologically clear margins. Discussion. The exact aetiology of phyllodes tumour and its relationship with fibroadenoma are unclear. Women aged between 35 and 55 years are commonly involved. The median tumour size is 4 cm but can grow even larger having dilated veins and a blue discoloration over skin. Palpable axillary lymphadenopathy can be identified in up to 10–15% of patients but <1% had pathological positive nodes. Mammography and ultrasonography are main imaging modalities. Cytologically the presence of both epithelial and stromal elements supports the diagnosis. The value of FNAC in diagnosis of phyllodes tumour remains controversial, but core needle biopsy has high sensitivity and negative predictive value. Surgical management is the mainstay and local recurrence in phyllodes tumours has been associated with inadequate local excision. The role of adjuvant radiotherapy and chemotherapy remains uncertain and use of hormonal therapy has not been fully investigated. Conclusion. The preoperative diagnosis and proper management are crucial in phyllodes tumours because of their tendency to recur and malignant potential in some of these tumours.

Postoperative Complications following Nodal Dissection and Their Association with Melanoma Recurrence

Tue, 26 Feb 2013 09:45:19 +0000

Background. Although postoperative complications are common after lymph node dissection, its association with disease recurrence has not yet been fully investigated. Methods. A retrospective review of a prospectively maintained database was conducted, looking at all malignant melanoma patients with sentinel nodes positive disease requiring axillary or inguinal dissection between 2002 and 2011. Results. A total of 124 patients required nodal clearance from 317 patients with stage I/II malignant melanoma who had undergone sentinel lymph node biopsy. Of these, 104 patients met the inclusion criteria and were divided into inguinal lymph node dissections (ILND; ) or axillary lymph node dissections (ALND; ). Immunohistochemical deposits had higher detection rate in ALND (). The ILND patients had a higher recurrence rate (84.1% versus 63.4%; ) and mortality (68.3% versus 48.8%; ) without a significant difference in complications. In patients whom complications developed, 75% of the ILND group and 71.4% of the ALND group had disease recurrence, but without reaching a statistical value as an independent predictor of melanoma recurrence. Conclusion. Complications are common following ILND and ALND; however there is no significant difference in complications rates between the groups with some associations with recurrence without reaching a significant difference.

A Practical Update of Surgical Management of Merkel Cell Carcinoma of the Skin

Patricia Tai — Wed, 30 Jan 2013 07:44:29 +0000

The role of surgeons in the treatment of Merkel cell carcinoma (MCC) of the skin is reviewed, with respect to diagnosis and treatment. Most of the data in the literature are case reports. Surgery is the mainstay of treatment. A wide local excision, with sentinel node (SLN) biopsy, is the recommended treatment of choice. If SLN is involved, nodal dissection should be performed; unless patient is unfit, then regional radiotherapy can be given. Surgeons should always refer patients for assessment of the need for adjuvant treatments. Adjuvant radiotherapy is well tolerated and effective to minimize recurrence. Adjuvant chemotherapy may be considered for selected node-positive patients, as per National Comprehensive Cancer Network guideline. Data are insufficient to assess whether adjuvant chemotherapy improves survival. Recurrent disease should be treated by complete surgical resection if possible, followed by radiotherapy and possibly chemotherapy. Generally results of multimodality treatment for recurrent disease are better than lesser treatments. Future research should focus on newer chemotherapy and molecular targeted agents in the adjuvant setting and for gross disease.

The Role of Open Necrosectomy in the Current Management of Acute Necrotizing Pancreatitis: A Review Article

K. Vasiliadis, C. Papavasiliou, A. Al Nimer, N. Lamprou, and C. Makridis — Mon, 28 Jan 2013 18:55:48 +0000

The optimal management of necrotizing pancreatitis continues to evolve. Currently, conservative intensive care treatment represents the primary therapy of acute severe necrotizing pancreatitis, aiming at prevention of organ failure. Following this mode of treatment most patients with sterile necroses can be managed successfully. Surgery might be considered as an option in the late phase of the disease for patients with proven infected pancreatic necroses and organ failure. For these patients surgical debridement is still considered the treatment of choice. However, even for this subgroup of patients, the concept of operative strategy has been recently challenged. Nowadays, it is generally accepted that necrotizing pancreatitis with proven infected necroses as well as septic complications directly caused by pancreatic infection are strong indications for surgical management. However, the question of the most appropriate surgical technique for the treatment of pancreatic necroses remains unsettled. At the same time, recent advances in radiological imaging, new developments in interventional radiology, and other minimal access interventions have revolutionised the management of necrotizing pancreatitis. In light of these controversies, the present paper will focus on the current role of surgery in terms of open necrosectomy in the management of severe acute necrotizing pancreatitis.

The Effect of Fibrin Glue on the Intensity of Colonic Anastomosis in the Presence and Absence of Peritonitis: An Experimental Randomized Controlled Trial on Rats

Mon, 21 Jan 2013 09:13:41 +0000

Aim. Anastomotic leakage after colon anastomosis is the most frequent and most feared complication with its highest mortality rate. In this study, we aimed to expose the impact of performing fibrin glue on sutured colocolic anastomosis, in the presence of experimental peritonitis, on anastomosis safety. Method. In this experimental study, the rats were divided into two groups as control group (Groups 1 and 3) and experimental group (Groups 2 and 4). They were also divided as clean abdomen (Groups 1 and 2) and infected abdomen (3 and 4) groups. Full-thickness incisions were made on the proximal colon of both groups of rats. The control group’s anastomoses were conducted only with sutures, whereas in experimental group, fibrin glue was applied over the sutures. The samples were taken on the 10th day. Results. Highest values for average levels of hydroxyproline in the tissues and anastomotic bursting pressures were detected when fibrin glue was applied on sutured anastomosis in clean abdomen. In the histopathological staging performed in line with Ehrlich-Hunt model, lowest values were detected during the presence of peritonitis. Conclusion. As a result, it has been established that the use of fibrin glue over sutured colocolic anastomosis, both in clean abdomen and in the presence of peritonitis, had increased anastomosis safety.

Skull Base Inverted Papilloma: A Comprehensive Review

Shafik N. Wassef, Pete S. Batra, and Samuel Barnett — Mon, 31 Dec 2012 09:53:40 +0000

Skull base inverted papilloma (IP) is an unusual entity for many neurosurgeons. IP is renowned for its high rate of recurrence, its ability to cause local destruction, and its association with malignancy. This paper is a comprehensive review of the reports, studies, and reviews published in the current biomedical literature from 1947 to September 2010 and synthesize this information to focus on its potential invasion to the base of the skull and possible intradural extension. The objective is to familiarize the clinician with the different aspects of this unusual disease. The role of modern diagnostic tools in medical imaging in order to assess clearly the limits of the tumors and to enhance the efficiency and the safety in the choice of a surgical approach is pointed out. The treatment guidelines for IP have undergone a complex evolution that continues today. Radical excision of the tumour is technically difficult and often incomplete. Successful management of IP requires resection of the affected mucosa which could be achieved with open surgery, endoscopic, or combined approach. Radio and chemotherapy were used for certain indications. More optimally research would be a multicenter randomized trials with large size cohorts.

Fast-Track Surgery in Gynaecology and Gynaecologic Oncology: A Review of a Rolling Clinical Audit

Jonathan Carter — Mon, 24 Dec 2012 17:31:27 +0000

Clinical audit is the process by which clinicians are able to demonstrate to themselves, their patients, hospital administrators, and healthcare financial providers the outcome and safety of their clinical practice. It is a process by which the public can be assured of safety and outcomes. A fast-track surgery program was initiated in January 2008, and this paper represents a rolling clinical audit of the outcomes of that program until the end of June 2012. Three hundred and eighty-nine patients underwent fast track surgical management after having a laparotomy for suspected or confirmed gynaecological cancer. There were no exclusions and the data presented represents the practice and outcomes of all patients referred to a single gynaecological oncologist. The majority of patients were deemed to have complex surgical procedures performed usually through a vertical midline incision. One third of patients had a nonzero performance status, median weight was 68 kilograms, and median BMI was 26.5 with 31% being classified as obese. Median operating time was 2.25 hours, and the median estimated blood loss was 175 mL. Overall the median length of stay (LOS) was 3 days with 95% of patients tolerating early oral feeding. Four percent of patients required readmission, and 0.5% were required to return to the operating room. Whilst the wound infection rate was 2.6%, there were no ureteric, bowel or neurovascular injuries. Overall there were 2 bladder injuries (0.5%), and the incidence of venous thromboembolism was 1%. Subset analysis was also undertaken. Whilst a number of variables were associated with reduced LOS, on multivariate analysis, benign pathology, shorter operating time, and the ability to tolerate early oral feeding were found to be significant. The data and experience presented is the largest and most extensive reported in the literature relating to fast-track surgery in gynaecology and gynaecologic oncology. The public can be reassured of the safety and improved outcomes that can be achieved after the introduction of such a program.

Comparison between Tube Ileostomy and Loop Ileostomy as a Diversion Procedure

Vijayraj Patil, Abhishek Vijayakumar, M. B. Ajitha, and Sharath Kumar L — Tue, 18 Dec 2012 17:42:36 +0000

Aim. Loop ileostomy has high complication rates and causes much patient inconvenience. This study was performed to compare the outcome of tube versus loop ileostomy in management of ileal perforations. Patients and Methods. From July 2008 to July 2011, all patients with ileal perforation on laparotomy where a defunctioning proximal protective loop ileostomy was considered advisable were chosen for study. Patients were randomly assigned to undergo either tube ileostomy or classical loop ileostomy as the diversion procedure. Tube ileostomy was constructed in the fashion of feeding jejunostomy, with postoperative saline irrigation. Results. A total of 60 diversion procedures were performed over the period with 30 for each of tube and loop ileostomy. Typhoid and tuberculosis formed the most common etiology for ileal perforation. The complication rate of tube ileostomy was 33%. Main complications related to tube ileostomy were peritubal leak, tube blockage. In patients with loop, overall complications in 53% majority were peristomal skin irritation and wound infection following ileostomy closure. Two patients developed obstruction following ileostomy closure which needed reoperation. Conclusions. Tube ileostomy is effective and feasible as a diversion procedure and has reduced morbidity. It can be used as an alternative to loop ileostomy.

Biliary Atresia: 50 Years after the First Kasai

Barbara E. Wildhaber — Thu, 06 Dec 2012 10:38:53 +0000

Biliary atresia is a rare neonatal disease of unknown etiology, where obstruction of the biliary tree causes severe cholestasis, leading to biliary cirrhosis and death in the first years of life, if the condition is left untreated. Biliary atresia is the most frequent surgical cause of cholestatic jaundice in neonates and should be evoked whenever this clinical sign is associated with pale stools and hepatomegaly. The treatment of biliary atresia is surgical and currently recommended as a sequence of, eventually, two interventions. During the first months of life a hepatoportoenterostomy (a “Kasai,” modifications of which are discussed in this paper) should be performed, in order to restore the biliary flow to the intestine and lessen further damage to the liver. If this fails and/or the disease progresses towards biliary cirrhosis and life-threatening complications, then liver transplantation is indicated, for which biliary atresia represents the most frequent pediatric indication. Of importance, the earlier the Kasai is performed, the later a liver transplantation is usually needed. This warrants a great degree of awareness of biliary atresia, and the implementation of systematic screening for this life-threatening pathology.

Fournier’s Gangrene: Current Practices

M. N. Mallikarjuna, Abhishek Vijayakumar, Vijayraj S. Patil, and B. S. Shivswamy — Mon, 03 Dec 2012 15:43:01 +0000

Fournier’s gangrene is an acute, rapidly progressive, and potentially fatal, infective necrotizing fasciitis affecting the external genitalia, perineal or perianal regions, which commonly affects men, but can also occur in women and children. There has been an increase in number of cases in recent times. Despite advanced management mortality is still high and averages 20–30%. Early diagnosis using Laboratory Risk Indicator for Necrotizing Fasciitis score and stratification of patients into high risk category using Fournier's Gangrene Severity Index score help in early initiation of treatment. Triple antibiotic combined with radical debridement is the mainstay of treatment. There have been many advances in management of Fournier gangrene including use of vaccum assisted closure and hyperbaric oxygen therapy. With introduction of newer devices like Flexi-Seal, fecal diversion can be done, avoiding colostomy. Reconstruction of perineal defects using skin grafts, flaps, and urethral reconstruction using gracilis flaps can reduce the morbidity associated with FG and provide acceptable functional and aesthetic outcomes.

Computerized Decision Support System for Intraoperative Analysis of Margin Status in Breast Conservation Therapy

Wed, 14 Nov 2012 10:51:27 +0000

Background. Breast conservation therapy (BCT) is the standard treatment for breast cancer; however, 32–63% of procedures have a positive margin leading to secondary procedures. The standard of care to evaluate surgical margins is based on permanent section. Imprint cytology (IC) has been used to evaluate surgical samples but is limited by excessive cauterization thus requiring experienced cytopathologist for interpretation. An automated image screening process has been developed to detect cancerous cells from IC on cauterized margins. Methods. IC was prospectively performed on margins during lumpectomy operations for breast cancer in addition to permanent section on 127 patients. An 8-slide training subset and 8-slide testing subset were culled. H&E IC automated analysis, based on linear discriminant analysis, was compared to manual pathologist interpretation. Results. The most important descriptors, from highest to lowest performance, are nucleus color (23%), cytoplasm color (15%), shape (12%), grey intensity (9%), and local area (5%). There was 100% agreement between automated and manual interpretation of IC slides. Conclusion. Although limited by IC sampling variability, an automated system for accurate IC cancer cell identification system is demonstrated, with high correlation to manual analysis, even in the face of cauterization effects which supplement permanent section analysis.

Surgery for Gynecomastia in the Islamic Golden Age: Al-Tasrif of Al-Zahrawi (936–1013 AD)

Thu, 20 Sep 2012 09:43:04 +0000

The rise of European science during the Renaissance is greatly indebted to the flourishing of the sciences during the Islamic Golden Age. However, some believe that medieval Islamic physicians and in particular surgeons had been merely a medium for Greco-Roman ideas. Contrarily, in some medieval Islamic medical books, such as Al-Tasrif of Al-Zahrawi (936–1013), the surgical instructions represent a change in the usual techniques or are accompanied by a case history, implying that the procedure was actually undertaken. Along with the hundreds of chapters on different diseases and related medical and surgical treatments, Al-Tasrif includes a chapter on surgical techniques for gynecomastia. The present paper is a review of the description of the surgical management of gynecomastia by Al-Zahrawi as well as that of the ancient Greek, medieval, and modern medicine. Although Al-Zahrawi seemed to base his descriptions of surgery for gynecomastia upon those of Paulus of Aegina, his modification of the procedure and application of the medicinal substances might be indicative of Al-Zahrawi’s own practice of the procedure. Al-Zahrawi’s surgical procedures remained unchanged for many centuries thenceforward until the technological evolution in the recent centuries.

Hemostatic Agents in Hepatobiliary and Pancreas Surgery: A Review of the Literature and Critical Evaluation of a Novel Carrier-Bound Fibrin Sealant (TachoSil)

K. A. Simo, E. M. Hanna, D. K. Imagawa, and D. A. Iannitti — Thu, 13 Sep 2012 11:46:16 +0000

Background. Despite progress in surgical techniques applied during hepatobiliary and pancreas (HPB) surgery, bleeding and bile leak remain significant contributors to postoperative mortality and morbidity. Topical hemostatics have been developed and utilized across surgical specialties, but data regarding effectiveness remains inconsistent and sparse in HPB surgery. Methods. A comprehensive search for studies and reviews on hemostatics in HPB surgery was performed via an October 2011 query of Medline, EMBASE, and Cochrane Library. In-depth evaluation of a novel carrier-bound fibrin sealant (TachoSil) was also performed. Results. The literature review illustrates multiple attempts have been made at developing different topical hemostatics and sealants to aid in surgical procedures. In HPB surgery, efforts have been directed at decreasing bleeding, biliary leakage, and pancreatic fistula. Conflicting scientific evidence exists regarding the effectiveness of these agents. Critical evaluation of the literature demonstrates TachoSil is a valuable tool in achieving hemostasis, and possibly biliostasis and pancreatic fistula prevention. Conclusion. While progress has been made in topical hemostatics for HPB surgery, an ideal agent has not yet been identified. TachoSil is promising, but larger randomized, controlled clinical trials are required to more fully evaluate its efficacy in reducing bleeding, biliary leakage, and pancreatic fistulas in HPB surgery.

Incidence and Surgical Importance of Zuckerkandl’s Tubercle of the Thyroid and Its Relations with Recurrent Laryngeal Nerve

Emin Gurleyik and Gunay Gurleyik — Thu, 16 Aug 2012 12:20:24 +0000

Background. Variations of recurrent laryngeal nerve (RLN) and Zuckerkandl’s tubercle (ZT), which is posterior extension of lateral lobes, may affect safety of thyroidectomy. Methods. Total and hemithyroidectomy were surgical procedures in 60 and 40 patients, respectively. Surgical anatomy was studied in 87 right and 73 left lobes. Presence of ZT was noted and its incidence was determined. RLNs were identified and fully isolated. Relationship between ZT and RLN was established. Results. ZTs were identified in 66 (66%) patients and in 81 (51%) lobes. ZT was present in 53 (61%) right and in 28 (38%) left lobes. ZTs were bilateral in 15 (25%) of 60 total thyroidectomy cases. Smaller tubercles show the neurovascular crossing point. RLN was posterior (medial) to ZT in 76 (94%) occurrences. RLN was laying on anterior surface of ZT only in 5 (6%) instances. Conclusions. RLN is unusually laying lateral to ZT which is common structure in the thyroid. Lateral RLN may be more vulnerable to injury. Total thyroidectomy requires dissection of ZT adjacent to RLN. Based on unusual relations and variations, RLN should be fully isolated before excision of adjacent structures.

To Sleeve or NOT to Sleeve in Bariatric Surgery?

P. W. J. van Rutte, M. D. P. Luyer, I. H. J. T. de Hingh, and S. W. Nienhuijs — Thu, 16 Aug 2012 11:14:27 +0000

Morbid obesity has become a global epidemic during the 20th century. Until now bariatric surgery is the only effective treatment for this disease leading to sustained weight loss and improvement of comorbidities. The sleeve gastrectomy is becoming a promising alternative for the gold standard the gastric bypass and it is gaining popularity as a stand-alone procedure. The effect of the laparoscopic sleeve gastrectomy is based on a restrictive mechanism, but a hormonal effect also seems to play an important role. Similar results are achieved in terms of excess weight loss and resolution of comorbidities compared to the gastric bypass. Inadequate weight loss or weight regain can be treated by revisional surgery. Complication rates after LSG appear to be lower compared with gastric bypass. General guidelines recommend bariatric surgery between the age of 18 and 65. However bariatric surgery in the elderly seems safe with respect to weight loss and resolution of comorbidities. At the same time weight loss surgery is more often performed in adolescent patients failing weight loss attempts. Even though more studies are needed describing long-term effects, there is already enough evidence that this technique is an effective single procedure for a considerable proportion of obese patients.

What Is the Place of Intersphincteric Resection When Operating on Low Rectal Cancer?

Satoshi Nagayama, Waheeb Al-Kubati, and Yoshiharu Sakai — Wed, 01 Aug 2012 11:13:50 +0000

Operating on low rectal cancer by performing an intersphincteric resection (ISR) with coloanal anastomosis has been adopted as an alternative to abdominoperineal excision (APE) following Schiessel et al. report in 1994, as it preserves the sphincter and avoids the need for a permanent stoma. We undertook a review of the recent literature specifically focusing on long-term oncologic and functional outcomes of ISR to evaluate whether this operation is a valid alternative to an APE. In conclusion, younger patients with T1 or T2 rectal cancers who require no preoperative therapy are ideal candidates for ISR, given that preoperative chemoradiotherapy may cause long-term severe anal dysfunction after ISR.

Mortality and Survival Rates after Elective Hepatic Surgery in a Low-Volume Centre Are Comparable to Those of High-Volume Centres

I. E. Nygård, K. Lassen, J. Kjæve, and A. Revhaug — Tue, 31 Jul 2012 11:46:23 +0000

Background. Over the last decades, liver resection has become a frequently performed procedure in western countries because of its acceptance as the most effective treatment for patients with selected cases of metastatic tumours. The purpose of this study was to evaluate the results after hepatic resections performed electively in our centre since 1979 and compare the results to those of larger high-volume centres. Methods. Medical records of all patients who underwent liver resection from January 1979 to December 2011 were reviewed. Disease-free survival and overall survival were determined by Kaplan-Meier analysis. Risk factors for complications were tested with the log-rank test and the Cox proportional hazard model. Complications were classified according to the modified Clavien classification system. Results. 290 elective liver resections were performed between January 1979 and December 2011. There were 171 males (59.0%) and 119 females (41.0%). Median age was 63 years, range 1–87. Overall survival ranged from 0 to 383 months, with a median of 31 months. Five-year survival rate for patients who underwent liver resection for colorectal metastases was 35.8% (34/95). Discussion. Hepatic resections are safely performed at a low-volume centre, with regard to perioperative- and in-house mortality and 5-year survival rates.

Relative Prognostic Value of Human Epidermal Growth Factor Receptor 2 (HER2) Expression in Operable Oesophagogastric Cancer

Thu, 26 Jul 2012 14:13:12 +0000

Aims. The aim of this study was to determine the prognostic significance of HER2 receptor expression in operable oesophagogastric adenocarcinoma. Methods. Eighty-five consecutive patients diagnosed with oesophagogastric adenocarcinoma [18 oesophageal (OC), 32 junctional (JC) and 35 gastric (GC)] undergoing potentially curative resection were studied retrospectively. Immunohistochemistry was used to determine HER2 status at endoscopic biopsy and resection specimen. The primary outcome measure was survival. Results. Twenty (24%) patients had HER2 positive tumours which was commoner in JC (14/32, 44% versus 2/18, 11% in OC and 4/35, 11% in GC, 𝑃=0.003). The sensitivity, specificity, positive and negative predictive values of HER2 status at endoscopic biopsy were 56%, 93%, 63%, 91% respectively (weighted Kappa=0.504, 𝑃<0.0001). Five-year survival in OC HER2 positive negative was 100% and 36% (𝑃=0.167) compared with 14% and 44% (𝑃=0.0726) in JC and 50% and 46% (𝑃=0.942) in GC respectively. Conclusions. Endoscopic biopsy had a high specificity and negative predictive value in determining HER2 status. Patients with JC had a significantly higher rate of HER2 overexpression and this was associated with a nonsignificant poorer survival trend. A larger study is needed to confirm these findings because of the implications for neoadjuvant and adjuvant chemotherapy regimens.