ISRN Surgery The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Perforation Peritonitis and the Developing World Wed, 02 Apr 2014 06:46:07 +0000 Background. Perforation peritonitis is the one of the commonest emergency encountered by surgeons. The aim of this paper is to provide an overview of the spectrum of perforation peritonitis managed in a single unit of a tertiary care hospital in Delhi. Methods. A retrospective study was carried out between May 2010 and June 2013 in a single unit of the department of Surgery, Lok Nayak Hospital, Delhi. It included 400 patients of perforation peritonitis (diffuse or localized) who were studied retrospectively in terms of cause, site of perforation, surgical treatment, complications, and mortality. Only those patients who underwent exploratory laparotomy for management of perforation peritonitis were included. Results. The commonest cause of perforation peritonitis included 179 cases of peptic ulcer disease (150 duodenal ulcers and 29 gastric ulcers) followed by appendicitis (74 cases), typhoid fever (48 cases), tuberculosis (40 cases), and trauma (31). The overall mortality was 7%. Conclusions. Perforation peritonitis in India has a different spectrum as compared to the western countries. Peptic ulcer perforation, perforating appendicitis, typhoid, and tubercular perforations are the major causes of gastrointestinal perforations. Early surgical intervention under the cover of broad spectrum antibiotics preceded by adequate aggressive resuscitation and correction of electrolyte imbalances is imperative for good outcomes minimizing morbidity and mortality. Rajandeep Singh Bali, Sushant Verma, P. N. Agarwal, Rajdeep Singh, and Nikhil Talwar Copyright © 2014 Rajandeep Singh Bali et al. All rights reserved. Pathology Slide Review in Vulvar Cancer Does Not Change Patient Management Tue, 25 Mar 2014 08:43:53 +0000 Hypothesis. Pathology slide review in vulvar cancer is only necessary in a restricted number of cases. Methods. A retrospective chart review of all cases of vulvar cancer treated in a tertiary centre between January 1, 2000, and April 1, 2006. Histopathology reports from the referring and tertiary centre were compared. Results. 121 pathology reports from 112 patients were reviewed. Of the original reports, 56% were deemed adequate, commenting on tumor type and depth of infiltration; of the reviews, 83% were adequate. Conclusion. There were no discrepancies that influenced patient management. We suggest that vulvar cancer biopsies need to be reviewed only when the tumor is less than 10 mm in linear extension, when the infiltration is 1 mm or less, when there is no residual tumor on inspection, and in any nonsquamous cancer. Maaike Beugeling, Patricia C. Ewing-Graham, Zineb Mzallassi, and Helena C. van Doorn Copyright © 2014 Maaike Beugeling et al. All rights reserved. An Audit of Operating Room Time Utilization in a Teaching Hospital: Is There a Place for Improvement? Thu, 13 Mar 2014 13:23:59 +0000 Aim. To perform a thorough and step-by-step assessment of operating room (OR) time utilization, with a view to assess the efficacy of our practice and to identify areas of further improvement. Materials and Methods. We retrospectively analyzed the most ordinary general surgery procedures, in terms of five intervals of OR time utilization: anaesthesia induction, surgery preparation, duration of operation, recovery from anaesthesia, and transfer to postanaesthesia care unit (PACU) or intensive care unit (ICU). According to their surgical impact, the procedures were defined as minor, moderate, and major. Results. A total of 548 operations were analyzed. The mean (SD) time in minutes for anaesthesia induction was 19 (9), for surgery preparation 13 (8), for surgery 115 (64), for recovery from anaesthesia 12 (8), and for transfer to PACU/ICU 12 (9). The time spent in each step presented an ascending escalation pattern proportional to the surgical impact , which was less pronounced in the transfer to PACU/ICU . Conclusions. Albeit, our study was conducted in a teaching hospital, the recorded time estimates ranged within acceptable limits. Efficient OR time usage and outliers elimination could be accomplished by a better organized transfer personnel service, greater availability of anaesthesia providers, and interdisciplinary collaboration. George Stavrou, Stavros Panidis, John Tsouskas, Georgia Tsaousi, and Katerina Kotzampassi Copyright © 2014 George Stavrou et al. All rights reserved. Three Ports Laparoscopic Resection for Colorectal Cancer: A Step on Refining of Reduced Port Surgery Wed, 12 Mar 2014 13:51:58 +0000 Background. Reduced port surgery (RPS) is becoming increasingly popular for some surgeries. However, the application of RPS to the field of colectomy is still underdeveloped. Patients and Methods. In this series, we evaluated the outcome of laparoscopic colorectal resection using 3 ports technique (10 mm umbilical port plus another two ports of either 5 or 10 mm) for twenty-four cases of colorectal cancer as a step for refining of RPS. Results. The mean estimated blood loss was 70 mL (40–90 mL). No major intraoperative complications have been encountered. The mean time for passing flatus after surgery was 36 hours (12–48 hrs). The mean time for oral fluid intake was 36 hours and for semisolid food was 48 hours. The mean hospital stay was 5 days (4–7 days). The perioperative period passed without events. All cases had free surgical margins. The mean number of retrieved lymph nodes was 14 lymph nodes (5–23). Conclusion. Three ports laparoscopy assisted colorectal surgeries looks to be safe, effective and has cosmetic advantages. The procedure could maintain the oncologic principles of cancer surgery. It’s a step on the way of refining of reduced port surgery. Anwar Tawfik Amin, Tarek M. Elsaba, and Gamal Amira Copyright © 2014 Anwar Tawfik Amin et al. All rights reserved. Quantification of Protoporphyrin IX Accumulation in Glioblastoma Cells: A New Technique Tue, 04 Mar 2014 14:19:48 +0000 Introduction. 5-Aminolevulinic Acid (5-ALA) is a precursor of heme synthesis. A metabolite, protoporphyrin IX (PpIX), selectively accumulates in neoplastic tissue including glioblastoma. Presurgical administration of 5-ALA forms the basis of fluorescence-guided resection (FGR) of glioblastoma (GBM) tumors. However, not all gliomas accumulate sufficient quantities of PpIX to fluoresce, thus limiting the utility of FGR. We therefore developed an assay to determine cellular and pharmacological factors that impact PpIX fluorescence in GBM. This assay takes advantage of a GBM cell line engineered to express yellow fluorescent protein. Methods. The human GBM cell line U87MG was transfected with a YFP expression vector. After treatment with a series of 5-ALA doses, both PpIX and YFP fluorescence were measured. The ratio of PpIX to YFP fluorescence was calculated. Results. YFP fluorescence permitted the quantification of cell numbers and did not interfere with 5-ALA metabolism. The PpIX/YFP fluorescence ratio provided accurate relative PpIX levels, allowing for the assessment of PpIX accumulation in tissue. Conclusion. Constitutive YFP expression strongly correlates with cell number and permits PpIX quantification. Absolute PpIX fluorescence alone does not provide information regarding PpIX accumulation within the cells. Our research indicates that our PpIX/YFP ratio assay may be a promising model for in vitro 5-ALA testing and its interactions with other compounds during FGR surgery. Johnathan E. Lawrence, Ashish S. Patel, Richard A. Rovin, Robert J. Belton Jr., Catherine E. Bammert, Christopher J. Steele, and Robert J. Winn Copyright © 2014 Johnathan E. Lawrence et al. All rights reserved. Fibrin Sealant: The Only Approved Hemostat, Sealant, and Adhesive—a Laboratory and Clinical Perspective Tue, 04 Mar 2014 13:01:56 +0000 Background. Fibrin sealant became the first modern era material approved as a hemostat in the United States in 1998. It is the only agent presently approved as a hemostat, sealant, and adhesive by the Food and Drug Administration (FDA). The product is now supplied as patches in addition to the original liquid formulations. Both laboratory and clinical uses of fibrin sealant continue to grow. The new literature on this material also continues to proliferate rapidly (approximately 200 papers/year). Methods. An overview of current fibrin sealant products and their approved uses and a comprehensive PubMed based review of the recent literature (February 2012, through March 2013) on the laboratory and clinical use of fibrin sealant are provided. Product information is organized into sections based on a classification system for commercially available materials. Publications are presented in sections based on both laboratory research and clinical topics are listed in order of decreasing frequency. Results. Fibrin sealant remains useful hemostat, sealant, and adhesive. New formulations and applications continue to be developed. Conclusions. This agent remains clinically important with the recent introduction of new commercially available products. Fibrin sealant has multiple new uses that should result in further improvements in patient care. William D. Spotnitz Copyright © 2014 William D. Spotnitz. All rights reserved. Prognostic Value of Mandard and Dworak Tumor Regression Grading in Rectal Cancer: Study of a Single Tertiary Center Tue, 04 Mar 2014 12:02:51 +0000 Goal. To evaluate the prognostic value of Mandard and Dworak grading systems regarding neoadjuvant chemoradiotherapy (CRT) response on rectal cancer. Materials and Methods. We queried our center’s database for patients with colo rectal cancer with locally advanced rectal cancer (LARC) who received neoadjuvant CRT followed by total mesorectum excision (TME) between 2003 and 2011. After excluding 18 patients from the initial query the remaining 139 were reassessed for disease recurrence and survival; the specimens’ slides were reviewed and classified according to two tumor regression grading (TRG) systems: Mandard and Dworak. Based on these TRG scores, two patient groups were created: patients with good response versus patients with bad response (Mandard TRG1+2 versus Mandard TRG3+4+5 and Dworak TRG4+3 versus Dworak TRG2+1+0). Overall survival (OS), disease-free survival (DFS), and disease recurrence were then evaluated. Results. Mean age was 64.2 years and median follow up was 56 months. No significant survival difference was found when comparing patients with Dworak TRG 4+3 versus Dworak TRG2+1+0 (). Mandard TRG1+2 presented with significantly better OS and DFS than Mandard TRG3+4+5 (OS ; DFS ). Conclusions. Mandard system provides higher accuracy over Dworak system in predicting rectal cancer prognosis when neoadjuvant CRT is applied for tumor regression. Marisa D. Santos, Cristina Silva, Anabela Rocha, Eduarda Matos, Carlos Nogueira, and Carlos Lopes Copyright © 2014 Marisa D. Santos et al. All rights reserved. Randomized, Controlled Comparison of Advanced Hemostatic Pads in Hepatic Surgical Models Tue, 04 Mar 2014 08:56:00 +0000 Blood loss during hepatic surgery leads to poor patient outcomes. This study investigates the hemostatic efficacy of a novel sealing hemostatic pad (polyethylene glycol-coated collagen, PCC) and a fibrin sealant pad (fibrin-thrombin coated collagen, FTC) in a leporine hepatic segmentectomy and a porcine hepatic abrasion model. A segmentectomy was used to compare hemostatic success and hematoma incidence in 20 rabbits (10/group). Hepatic abrasions were used to compare hemostatic success up to 10 min after application in six pigs (42 lesions/group). In the segmentectomy model, PCC achieved 100% hemostatic success within 2 min (95% CI: 72.3% to 100%) and FTC achieved 80% hemostatic success within 3 min (49.0% to 94.3%). PCC had lower hematoma incidence at 15 min (0.0 versus 11.1%) and 24 h (20.0 versus 66.7%). In the abrasion model, PCC provided superior hemostatic success at 3 (odds ratio: 24.8, 95% CI: 8.86 to 69.2, ), 5 (66.3, 28.5 to 153.9, ), 7 (177.5, 64.4 to 489.1, ), and 10 min (777.6, 148.2 to 4078, ) leading to statistically significant less blood loss. The novel sealing hemostat provides faster and more sustained hemostasis than a fibrin sealant pad in a leporine hepatic segmentectomy and a porcine hepatic abrasion model of hepatic surgery. Kevin M. Lewis, Jeff McKee, Alexandra Schiviz, Alexander Bauer, Martin Wolfsegger, and Andreas Goppelt Copyright © 2014 Kevin M. Lewis et al. All rights reserved. Consenting Operative Orthopaedic Trauma Patients: Challenges and Solutions Thu, 06 Feb 2014 00:00:00 +0000 Guidelines exist to obtain informed consent before any operative procedure. We completed an audit cycle starting with retrospective review of 50 orthopaedic trauma procedures (Phase 1 over three months to determine the quality of consenting documentation). The results were conveyed and adequate training of the staff was arranged according to guidelines from BOA, DoH, and GMC. Compliance in filling consent forms was then prospectively assessed on 50 consecutive trauma surgeries over further three months (Phase 2). Use of abbreviations was significantly reduced () in Phase 2 (none) compared to 10 (20%) in Phase 1 with odds ratio of 0.04. Initially, allocation of patient’s copy was dispensed in three (6% in Phase 1) cases compared to 100% in Phase 2, when appropriate. Senior doctors (registrars or consultant) filled most consent forms. However, 7 (14%) consent forms in Phase 1 and eleven (22%) in Phase 2 were signed by Core Surgical Trainees year 2, which reflects the difference in seniority amongst junior doctors. The requirement for blood transfusion was addressed in 40% of cases where relevant and 100% cases in Phase 2. Consenting patients for trauma surgery improved in Phase 2. Regular audit is essential to maintain expected national standards. Amin Kheiran, Purnajyoti Banerjee, and Philip Stott Copyright © 2014 Amin Kheiran et al. All rights reserved. The Presence of Mutations in the K-RAS Gene Does Not Affect Survival after Resection of Pulmonary Metastases from Colorectal Cancer Tue, 04 Feb 2014 06:23:49 +0000 Introduction. Our objective was to identify mutations in the K-RAS gene in cases of pulmonary metastases from colorectal cancer (CRC) and determine whether their presence was a prognostic factor for survival. Methods. We included all patients with pulmonary metastases from CRC operated on between 1998 and 2010. K-RAS mutations were investigated by direct sequencing of DNA. Differences in survival were explored with the Kaplan-Meier method log-rank tests and multivariate Cox regression analysis. Results. 110 surgical interventions were performed on 90 patients. Factors significantly associated with survival were disease-free interval , age , number of metastases , lymph node involvement , size of the metastases , and previous liver metastasis . Searching in 79 patients, K-RAS mutations were found in 30 cases. We did not find statistically significant differences in survival comparing native and mutated K-RAS. We found a higher rate of lung recurrence and shorter time to recurrence in patients with K-RAS mutations. Gly12Asp mutation was associated with higher recurrence and lower survival . Conclusions. The presence of K-RAS mutations in pulmonary metastases does not affect overall survival but is associated with higher rates of pulmonary recurrence. Jon Zabaleta, Borja Aguinagalde, José M. Izquierdo, Nerea Bazterargui, Stephany M. Laguna, Maialen Martin-Arruti, Carmen Lobo, and José I. Emparanza Copyright © 2014 Jon Zabaleta et al. All rights reserved. Surgical Management of Malignant Pleural Mesothelioma: Impact of Surgery on Survival and Quality of Life—Relation to Chemotherapy, Radiotherapy, and Alternative Therapies Mon, 03 Feb 2014 00:00:00 +0000 Introduction. Malignant pleural mesothelioma (MPM) is an aggressive cancer arising from pleural mesothelium. Surgery aims to either cure the disease or control the symptoms. Two surgical procedures exist: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). In this systematic review we assess current evidence on safety and efficacy of surgery. Methods. Five electronic databases were reviewed from January 1990 to January 2013. Studies were selected according to a predefined protocol. Primary endpoint was overall survival. Secondary endpoints included quality of life, disease-free survival, disease recurrence, morbidity, and length of hospital stay. Results. Sixteen studies were included. Median survival ranged from 8.1 to 32 months for P/D and from 6.9 to 46.9 months for EPP. Perioperative mortality was 0%–9.8% and 3.2%–12.5%, respectively. Perioperative morbidity was 5.9%–55% for P/D and 10%–82.6% for EPP. Average length of stay was 7 days for P/D and 9 days for EPP. Conclusion. Current evidence cannot definitively answer which procedure (EPP or P/D) is more beneficial in terms of survival and operative risks. This systematic review suggests that surgery in the context of trimodality therapy offers acceptable perioperative outcomes and long-term survival. Centres specialising in MPM management have better results. Sotiris Papaspyros and Sayonara Papaspyros Copyright © 2014 Sotiris Papaspyros and Sayonara Papaspyros. All rights reserved. Coloplasty Neorectum versus Straight Anastomosis in Low Rectal Cancers Thu, 30 Jan 2014 08:28:39 +0000 Introduction. Patients with the diagnosis of carcinoma rectum after random allocation were assigned to 2 groups. One group was subjected to total mesorectal excision with coloplasty neorectum reconstruction and another group to total mesorectal excision with straight anastomosis. This randomization was done by odds and even method by the sister in charge of the ward to avoid bias in randomization. The study included 42 patients with diagnosis of carcinoma rectum from 4 to 12 centimeters from anal verge. Composite incontinence score, bladder function, and sexual function were considered as the main outcome measures. Results. All patients of transverse coloplasty group had mild or moderate composite incontinence score while 7 (36.8%) patients of straight anastomosis group had a severe score at 7th POD (). At 6 months, 100% patients in transverse coloplasty group had a nil score which was not achieved by any of the patients in the other group. An intragroup comparison showed an improvement in score with time in both groups more marked in transverse coloplasty group. Conclusion. Transverse coloplasty group showed a better QOL so far as anal incontinence is considered. However, no statistically significant difference was achieved when comparing bladder and sexual dysfunction between the two groups. Fazl Q. Parray, Javaid A. Magray, Manzoor Ahmad Dar, Nisar A. Chowdri, Rauf A. Wani, and Natasha Thakur Copyright © 2014 Fazl Q. Parray et al. All rights reserved. Sentinel Lymph Node Biopsy in Uterine Cervical Cancer Patients: Ready for Clinical Use? A Review of the Literature Thu, 16 Jan 2014 09:19:32 +0000 Sentinel lymph node biopsy has been widely studied in a number of cancer types. As far as cervical cancer is concerned, this technique has already been used, revealing both positive results and several issues to be solved. The debate on the role of sentinel lymph node biopsy in cervical cancer is still open although most of the studies have already revealed its superiority over complete lymphadenectomy and the best handling possible of the emerging practical problems. Further research should be made in order to standardize this method and include it in the clinical routine. Viktoria-Varvara Palla, Georgios Karaolanis, Demetrios Moris, and Aristides Antsaklis Copyright © 2014 Viktoria-Varvara Palla et al. All rights reserved. Outcomes of Diabetic and Nondiabetic Patients Undergoing General and Vascular Surgery Thu, 26 Dec 2013 10:45:25 +0000 Aims. Preoperative diabetic and glycemic screening may or may not be cost effective. Although hyperglycemia is known to compromise surgical outcomes, the effect of a diabetic diagnosis on outcomes is poorly known. We examine the effect of diabetes on outcomes for general and vascular surgery patients. Methods. Data were collected from the Michigan Surgical Quality Collaborative for general or vascular surgery patients who had diabetes. Primary and secondary outcomes were 30-day mortality and 30-day overall morbidity, respectively. Binary logistic regression analysis was used to identify risk factors. Results. We identified 177,430 (89.9%) general surgery and 34,006 (16.1%) vascular surgery patients. Insulin and noninsulin diabetics accounted for 7.1% and 9.8%, respectively. Insulin and noninsulin dependent diabetics were not at increased risk for mortality. Diabetics are at a slight increased odds than non-diabetics for overall morbidity, and insulin dependent diabetics more so than non-insulin dependent. Ventilator dependence, 10% weight loss, emergent case, and ASA class were most predictive. Conclusions. Diabetics were not at increased risk for postoperative mortality. Insulin-dependent diabetics undergoing general or vascular surgery were at increased risk of overall 30-day morbidity. These data provide insight towards mitigating poor surgical outcomes in diabetic patients and the cost effectiveness of preoperative diabetic screening. Stephen Serio, John M. Clements, Dawn Grauf, and Aziz M. Merchant Copyright © 2013 Stephen Serio et al. All rights reserved. The Effect of Autologous Platelet-Rich Plasma on Bronchial Stump Tissue Granulation after Pneumonectomy: Experimental Study Mon, 16 Dec 2013 14:41:29 +0000 Objectives. Recent advances in perioperative management, antibiotics, and surgical materials, including mechanical staplers, have decreased the operative risk of pulmonary resection. However, bronchopleural fistula can still occur in some instances, the occurrence often being lethal. This study investigated whether platelet-rich plasma (PRP) promotes granulation of the bronchial stump after pneumonectomy. Methods. Ten pigs were randomized into two groups: (A) control or non-PRP group (pneumonectomy) and (B) PRP group (pneumonectomy and PRP application). PRP was obtained by spinning down the animal’s own blood and collecting the buffy coat containing platelets and white blood cells. Results. Increased platelet concentration triggered the healing process. The percentage of granulation tissue formed at the stumps was significantly higher in the PRP group of animals. This observation was confirmed when statistical analysis using Mann-Whitney U test was performed (). Conclusions. PRP is easily produced with minimal basic equipment and is useful in accelerating granulation of the bronchial stump, although the timing and optimum number of applications in humans require further study. Autologous PRP is a safe, feasible, and reliable new healing promoter with potential therapeutic effects. Eleftherios Spartalis, Periklis Tomos, Petros Konofaos, Grigorios Karagkiouzis, Georgia Levidou, Nikolaos Kavantzas, Alkistis Pantopoulou, Othon Michail, Despina Perrea, and Gregory Kouraklis Copyright © 2013 Eleftherios Spartalis et al. All rights reserved. Quality of Scar after Total Thyroidectomy: A Single Blinded Randomized Trial Comparing Octyl-Cyanoacrylate and Subcuticular Absorbable Suture Tue, 12 Nov 2013 13:49:15 +0000 Objective. To compare the quality of resulting scar at 6 weeks after total thyroidectomy with the use of the tissue adhesive octyl-cyanoacrylate or subcuticular absorbable suture for the closure of cervicotomy. Material and Methods. There are 50 patients undergoing a cervicotomy for total thyroidectomy. Twenty-five patients were randomly assigned to closure with tissue adhesive and 25 with subcuticular absorbable suture. At week 6 the scar was evaluated by blinded assessors with the Italian version of POSAS questionnaire, a validated wound scale composed of an observer’s and a patient’s subscale. Results. Assessment of scar appearance showed a statistically significant difference () in favor of subcuticular suture with respect to tissue adhesive on observer’s assessment. The difference on patients’ self-assessment was not significant. A multivariate analysis of six qualitative features of scars showed a significant influence on assessment for hyperpigmentation and relief of scar. The Italian version of POSAS proved to be reliable. Conclusion. Though tissue adhesive represents a valid method of skin closure, subcuticular absorbable suture provides a better aesthetic outcome in small cervical incisions in the early phase after thyroid surgery. Fabrizio Consorti, Rosaria Mancuso, Annalisa Piccolo, Eugenio Pretore, and Alfredo Antonaci Copyright © 2013 Fabrizio Consorti et al. All rights reserved. Is Surgery in the Elderly for Oesophageal Cancer Justifiable? Results from a Single Centre Tue, 24 Sep 2013 15:51:34 +0000 Aims. Advanced age is an identified risk factor for patients undergoing oncological surgical resection. The surgery for oesophageal cancer is associated with significant morbidity and mortality. Our aim was to study the operative management of elderly patients (≥70 years) at a single institute. Methods. The data was collected from 206 patients who have undergone operative resection of oesophageal cancer. The demographic, operative, histological, and postoperative follow-up of all patients were analysed. Results. A total of 46 patients of ≥70 years who had surgical resection for oesophageal cancer were identified. Patients ≥70 years had poor overall survival (). Also elderly patients with nodal involvement had poor survival (). Age at the time of surgery had no impact on the incidence of postoperative complication and inpatient mortality. Both the univariate and multivariate analyses showed age, nodal stage, and positive resection margins as independent prognostic factors for patients undergoing surgery for oesophageal cancer. Conclusions. Advanced age is associated with poor outcome following oesophageal resection. However, the optimisation of both preoperative and postoperative care can significantly improve outcomes. The decision of operative management should be individualised. Age should be considered as one of the factors in surgical resection of oesophageal cancer in the elderly patients. A. Mirza, S. Pritchard, and I. Welch Copyright © 2013 A. Mirza et al. All rights reserved. Operative Treatment of Hepatic Hydatid Cysts: A Single Center Experience in Israel, a Nonendemic Country Mon, 23 Sep 2013 15:11:49 +0000 Background. Hydatid cyst disease is a zoonosis caused by Echinococcus genera. The disease is endemic to certain rural areas in the world. Operative treatment is the main component in curing hydatid cysts of the liver. Objective. Describing the unique characteristics of the hydatid cyst patients in Israel, a nonendemic country. Methods. Data was collected form 29 patients treated operatively in Rabin Medical Center from 1994 to 2007. Results. The study included 18 females and 11 males with an average age of 54.9 years. Fifty-two% of the patients immigrated as children from Arab countries to Israel, 21% were Arab-Israelis leaving in the north and center of Israel, and 24% immigrated from the former Communist Bloc. Pericystectomy was performed in 20/29, and cyst unroofing was performed in 9/29. Hydatid cysts average size was 10.7 cm, and the cysts were located in the right or left or involved both lobes in 62%, 28%, and 10% of the lesions, respectively. Postoperative mortality occurred in one case, and severe morbidity occurred in 4 patients. Conclusions. Hydatid cyst disease in Israel is uncommon and is mostly seen in distinct 3 demographic groups. Despite the relatively low patient volume, good results in terms of morbidity, mortality, and recurrence were achieved. Daniel Maoz, Franklin Greif, and Jacob Chen Copyright © 2013 Daniel Maoz et al. All rights reserved. Postmastectomy Radiation Therapy: An Overview for the Practicing Surgeon Wed, 11 Sep 2013 11:25:02 +0000 Locoregional control of breast cancer is the shared domain and responsibility of surgeons and radiation oncologists. Because surgeons are often the first providers to discuss locoregional control and recurrence risks with patients and because they serve in a key gatekeeping role as referring providers for radiation therapy, a sophisticated understanding of the evidence regarding radiotherapy in breast cancer management is essential for the practicing surgeon. This paper synthesizes the complex and evolving evidence regarding the role of radiation therapy after mastectomy. Although substantial evidence indicates that radiation therapy can reduce the risk of locoregional failure after mastectomy (with a relative reduction of risk of approximately two-thirds), debate persists regarding the specific subgroups who have sufficient risks of residual microscopic locoregional disease after mastectomy to warrant treatment with radiation. This paper reviews the evidence available to guide appropriate referral and patient decision making, with special attention to areas of controversy, including patients with limited nodal disease, those with large tumors but negative nodes, node-negative patients with high risk features, patients who have received systemic chemotherapy in the neoadjuvant setting, and patients who may wish to integrate radiation therapy with breast reconstruction surgery. Reshma Jagsi Copyright © 2013 Reshma Jagsi. All rights reserved. Completely Resected N0 Non-Small Cell Lung Cancer: Prognostic Factors Affecting Long-Term Survival Thu, 29 Aug 2013 15:40:09 +0000 Background. Although early stage non-small cell lung cancer (NSCLC) has an excellent outcome and correlated with good long-term survival, up to 15 percent of patients still relapse postoperatively and die. This study is conducted to identify prognostic factors that may affect the long-term survival in completely resected N0 NSCLC. Methods. Medical records of 124 patients with completely resected N0 NSCLC were retrospectively reviewed. Prognostic factors affecting long-term survival were analyzed by the Kaplan-Meier method and Cox proportional hazards analysis. Results. Overall five-year survival rate was 48 percent. Multivariable analysis revealed stage of disease, tumor necrosis, tumor recurrence, brain metastasis, adrenal metastases, and skin metastases as significant prognostic factors affecting long-term survival. The hazard ratio (HR) of tumor necrosis, tumor recurrence, brain metastasis, adrenal metastases, and skin metastases was 2.0, 2.3, 7.6, 4.1, and 8.3, respectively, and all P values were less than 0.001. Conclusions. Our study shows stage of disease, tumor necrosis, tumor recurrence, brain metastasis, adrenal metastasis, and skin metastasis as the independent prognostic factors of long-term survival in pathological N0 NSCLC. Early stage NSCLC patients without nodal involvement or presented with tumor necrosis should benefit from adjuvant chemotherapy, and sites of metastasis could predict the long-term survival as described. Apichat Tantraworasin, Somcharoen Saeteng, Nirush Lertprasertsuke, Nuttapon Arayawudhikule, Choosak Kasemsarn, and Jayanton Patumanond Copyright © 2013 Apichat Tantraworasin et al. All rights reserved. Pancreatic Remnant Occlusion after Whipple's Procedure: An Alternative Oncologically Safe Method Mon, 05 Aug 2013 08:17:29 +0000 Introduction. To present our experience regarding the use of pancreatic stump occlusion technique as an alternative management of the pancreatic remnant after pancreatoduodenectomy (PD). Methods. Between 2002 and 2009, hospital records of 93 patients who had undergone a Whipple's procedure for either pancreatic-periampullary cancer or chronic pancreatitis were retrospectively studied. In 37 patients the pancreatic duct was occluded by stapling and running suture without anastomosis of the pancreatic remnant, whereas in 56 patients a pancreaticojejunostomy was performed. Operative data, postoperative complications, oncological parameters, and survival rates were recorded. Results. 2/37 patients of the occlusion group and 9/56 patients of the anastomosis group were treated for chronic pancreatitis, whereas 35/37 and 47/56 patients for periampullary malignancies. The duration of surgery for the anastomosis group was significantly longer (mean time 220 versus 180 minutes). Mean hospitalization time was 6 days for both groups. The occlusion group had a lower morbidity rate (24% versus 32%). With regard to postoperative complications, a slightly higher incidence of pancreatic fistulas was observed in the anastomosis group. Conclusions. Pancreatic remnant occlusion is a safe, technically feasible, and reducing postoperative complications alternative approach of the pancreatic stump during Whipple's procedure. Theodosios Theodosopoulos, Dionysios Dellaportas, Anneza I. Yiallourou, George Gkiokas, George Polymeneas, and Alexios Fotopoulos Copyright © 2013 Theodosios Theodosopoulos et al. All rights reserved. Learning Curve for D2 Lymphadenectomy in Gastric Cancer 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. Alexis Luna, Pere Rebasa, Sandra Montmany, and Salvador Navarro Copyright © 2013 Alexis Luna et al. All rights reserved. Control of Bleeding in Endoscopic Skull Base Surgery: Current Concepts to Improve Hemostasis 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. Cattleya Thongrong, Pornthep Kasemsiri, Ricardo L. Carrau, and Sergio D. Bergese Copyright © 2013 Cattleya Thongrong et al. All rights reserved. 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. Bahtiyar Ertor, Serdar Topaloglu, Adnan Calik, Umit Cobanoglu, Ali Ahmetoglu, Huseyin Ak, Erdem Karabulut, and Mithat Kerim Arslan Copyright © 2013 Bahtiyar Ertor et al. All rights reserved. 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 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. Corey R. Deeken and Brent D. Matthews Copyright © 2013 Corey R. Deeken and Brent D. Matthews. All rights reserved. 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. Ye Xin Koh, Adrian Kah Heng Chiow, Aik Yong Chok, Lip Seng Lee, Siong San Tan, and Salleh Ibrahim Copyright © 2013 Ye Xin Koh et al. All rights reserved. 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. Erin M. Hanna, Guy R. Voeller, J. Scott Roth, Jeffrey R. Scott, Darcy H. Gagne, and David A. Iannitti Copyright © 2013 Erin M. Hanna et al. All rights reserved. Morbidity Assessment in Surgery: Refinement Proposal Based on a Concept of Perioperative Adverse Events 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. Airazat M. Kazaryan, Bård I. Røsok, and Bjørn Edwin Copyright © 2013 Airazat M. Kazaryan et al. All rights reserved. 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. Mehmet Emin Gunes, Gungor Uzum, Oguz Koc, Yiğit Duzkoylu, Meltem Kucukyilmaz, Yavuz Selim Sari, Vahit Tunalı, and Sennur Kose Copyright © 2013 Mehmet Emin Gunes et al. All rights reserved. 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. Andrew F. Lamm, Ameer L. Elaimy, Wayne T. Lamoreaux, Alexander R. Mackay, Robert K. Fairbanks, John J. Demakas, Barton S. Cooke, and Christopher M. Lee Copyright © 2013 Andrew F. Lamm et al. All rights reserved.