Surgery Research and Practice The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Teamwork Assessment Tools in Modern Surgical Practice: A Systematic Review Thu, 03 Sep 2015 11:34:28 +0000 Introduction. Deficiencies in teamwork skills have been shown to contribute to the occurrence of adverse events during surgery. Consequently, several teamwork assessment tools have been developed to evaluate trainee nontechnical performance. This paper aims to provide an overview of these instruments and review the validity of each tool. Furthermore, the present paper aims to review the deficiencies surrounding training and propose several recommendations to address these issues. Methods. A systematic literature search was conducted to identify teamwork assessment tools using MEDLINE (1946 to August 2015), EMBASE (1974 to August 2015), and PsycINFO (1806 to August 2015) databases. Results. Eight assessment tools which encompass aspects of teamwork were identified. The Nontechnical Skills for Surgeons (NOTSS) assessment was found to possess the highest level of validity from a variety of sources; reliability and acceptability have also been established for this tool. Conclusions. Deficits in current surgical training pathways have prompted several recommendations to meet the evolving requirements of surgeons. Recommendations from the current paper include integration of teamwork training and assessment into medical school curricula, standardised formal training of assessors to ensure accurate evaluation of nontechnical skill acquisition, and integration of concurrent technical and nontechnical skills training throughout training. George Whittaker, Hamid Abboudi, Muhammed Shamim Khan, Prokar Dasgupta, and Kamran Ahmed Copyright © 2015 George Whittaker et al. All rights reserved. The Use of Tutomesh for a Tension-Free and Tridimensional Repair of Uterovaginal and Vaginal Vault Prolapse: Preliminary Report Wed, 02 Sep 2015 06:58:34 +0000 Objective. To evaluate efficacy in terms of vaginal capacity, coital function, and recurrence prevention of a new biological mesh of bovine pericardium (Tutomesh) in the repair of severe POP. Methods. Thirty cases of patients suffering from stage III uterine or apical prolapse undergone surgical repair by means of a modified sacrospinous ligament suspension combined with mesh attachment to both the cardinal ligaments, posterior and anterior colporrhaphy, and perineal body fixation. The mesh was replaced inside the pelvis with the goal of reconstructing the tridimensional fascial disposition of the structures sustaining the correct axis of vagina. Follow-up was done at 12 months with POPIQ analysis. Results. One total mesh failure occurred early after surgery due to marked deficiency of anatomy. Two cystoceles were observed at 12 months in two patients treated for apical prolapse where anterior repair was not performed. Two other patients developed a de novo SUI at 12 months. No reported abnormalities of coital function or dyspareunia were ever found after surgery. Conclusions. It is possible that the utilization of a tension-free and tridimensional placement of Tutomesh might favor a more physiologic reconstruction of the vaginal axis as compared with traditional sacrospinous ligament suspension. Danilo Dodero and Luca Bernardini Copyright © 2015 Danilo Dodero and Luca Bernardini. All rights reserved. Evaluation of Factor VIII as a Risk Factor in Indian Patients with DVT Tue, 01 Sep 2015 11:46:07 +0000 Introduction. Elevated factor VIII population in the Indian population has not been studied as a possible risk factor for deep vein thrombosis (DVT). High factor VIII level is considered a predisposing factor for DVT and its recurrence. However it is known to vary between populations and its exact role in the etiopathogenesis of thrombophilia remains unknown. Material and Methods. Factor VIII levels of patients with DVT who had undergone a prothrombotic workup as a part of their workup was compared to normal age matched controls in a 1 : 3 ratio. Results. There were 75 patients with DVT who had undergone a prothrombotic workup in the course of their treatment for lower limb DVT. In these, 64% had levels of factor VIII more than 150 as compared to 63% of normal controls (, not significant). Conclusion. Elevated factor VIII in the Indians may not be associated with the same thrombotic risk as seen in the West. We find a variation in the levels of factor VIII with a different “normal” than what is reported in other populations. This needs further study to elucidate the role of factor VIII in the evaluation and treatment of thrombophilia. Darpanarayan Hazra, Indrani Sen, Edwin Stephen, Sunil Agarwal, Sukesh Chandran Nair, and Joy Mammen Copyright © 2015 Darpanarayan Hazra et al. All rights reserved. An Assessment of the Clinical and Economic Impact of Establishing Ileocolic Anastomoses in Right-Colon Resection Surgeries Using Mechanical Staplers Compared to Hand-Sewn Technique Thu, 27 Aug 2015 12:51:29 +0000 Purpose. To estimate and compare clinical outcomes and costs associated with mechanical stapling versus hand-sewn sutured technique in creation of ileocolic anastomoses after right sided colon surgery. Methods. A previously conducted meta-analysis was updated for estimates of anastomotic leak rates and other clinical outcomes. A value analysis model was developed to estimate cost savings due to improved outcomes in a hypothetical cohort of 100 patients who underwent right colon surgery involving either mechanical stapling or hand-sewn anastomoses. Cost data were obtained from publicly available literature. Results. Findings from the updated meta-analysis reported that the mechanical stapling group had lower anastomotic leaks 2.4%   compared to the hand-sewn group 6.1% leaks . Utilizing this data, the value analysis model estimated total potential cost savings for a hospital to be around $1,130,656 for the 100-patient cohort using mechanical stapling instead of hand-sewn suturing, after accounting for incremental supplies cost of $49,400. These savings were attributed to lower index surgery costs, reduced OR time costs, and reduced reoperation costs driven by lower anastomotic leak rates associated with mechanical stapling. Conclusion. Mechanical stapling can be considered as a clinically and economically favorable option compared to suturing for establishing anastomoses in patients undergoing right colon surgery. S. Roy, S. Ghosh, and A. Yoo Copyright © 2015 S. Roy et al. All rights reserved. Comparison of Subcuticular Suture Materials in Cesarean Skin Closure Thu, 27 Aug 2015 09:46:24 +0000 Aim. Comparison of the rate of wound complications, pain, and patient satisfaction based on used subcuticular suture material. Methods. A total of 250 consecutive women undergoing primary and repeat cesarean section with low transverse incision were prospectively included. The primary outcome was wound complication rate including infection, dehiscence, hematoma, and hypertrophic scar formation within a 6-week period after operation. Secondary outcomes were skin closure time, the need for use of additional analgesic agent, pain score on numeric rating scale, cosmetic score, and patient scar satisfaction scale. Results. Absorbable polyglactin was used in 108 patients and nonabsorbable polypropylene was used in 142 patients. Wound complication rates were similar in primary and repeat cesarean groups based on the type of suture material. Skin closure time is longer in nonabsorbable suture material group in both primary and repeat cesarean groups. There was no difference between groups in terms of postoperative pain, need for additional analgesic use, late phase pain, and itching at the scar. Although the cosmetic results tended to be better in the nonabsorbable group in primary surgery patients, there was no significant difference in the visual satisfaction of the patients. Conclusions. Absorbable and nonabsorbable suture materials are comparable in cesarean section operation skin closure. Pınar Solmaz Hasdemir, Tevfik Guvenal, Hasan Tayfun Ozcakir, Faik Mumtaz Koyuncu, Gonul Dinc Horasan, Mustafa Erkan, and Semra Oruc Koltan Copyright © 2015 Pınar Solmaz Hasdemir et al. All rights reserved. Factors Associated with Perforated Appendicitis in Elderly Patients in a Tertiary Care Hospital Mon, 24 Aug 2015 12:40:30 +0000 Background. The incidence of perforated appendicitis in elderly patients is high and carries increased morbidity and mortality rates. The aim of this study was to identify risk factors of perforation in elderly patients who presented with clinical of acute appendicitis. Methods. This was a retrospective study, reviewing medical records of patients over the age of 60 years who had a confirmed diagnosis of acute appendicitis. Patients were classified into two groups: those with perforated appendicitis and those with nonperforated appendicitis. Demographic data, clinical presentations, and laboratory analysis were compared. Results. Of the 206 acute appendicitis patients over the age of 60 years, perforated appendicitis was found in 106 (50%) patients. The four factors which predicted appendiceal rupture were as follows: male; duration of pain in preadmission period; fever (>38°C); and anorexia. The overall complication rate was 34% in the perforation group and 12.6% in the nonperforation group. Conclusions. The incidence of perforated appendicitis in elderly patients was higher in males and those who had certain clinical features such as fever and anorexia. Duration of pain in the preadmission period was also an important factor in appendiceal rupture. Early diagnosis may decrease the incidence of perforated appendicitis in elderly patients. Siripong Sirikurnpiboon and Suparat Amornpornchareon Copyright © 2015 Siripong Sirikurnpiboon and Suparat Amornpornchareon. All rights reserved. Audit of Orthopaedic Surgical Documentation Wed, 19 Aug 2015 09:26:32 +0000 Introduction. The Royal College of Surgeons in England published guidelines in 2008 outlining the information that should be documented at each surgery. St. James’s Hospital uses a standard operation sheet for all surgical procedures and these were examined to assess documentation standards. Objectives. To retrospectively audit the hand written orthopaedic operative notes according to established guidelines. Methods. A total of 63 operation notes over seven months were audited in terms of date and time of surgery, surgeon, procedure, elective or emergency indication, operative diagnosis, incision details, signature, closure details, tourniquet time, postop instructions, complications, prosthesis, and serial numbers. Results. A consultant performed 71.4% of procedures; however, 85.7% of the operative notes were written by the registrar. The date and time of surgery, name of surgeon, procedure name, and signature were documented in all cases. The operative diagnosis and postoperative instructions were frequently not documented in the designated location. Incision details were included in 81.7% and prosthesis details in only 30% while the tourniquet time was not documented in any. Conclusion. Completion and documentation of operative procedures were excellent in some areas; improvement is needed in documenting tourniquet time, prosthesis and incision details, and the location of operative diagnosis and postoperative instructions. Fionn Coughlan, Prasad Ellanti, Cliodhna Ní Fhoghlu, Andrew Moriarity, and Niall Hogan Copyright © 2015 Fionn Coughlan et al. All rights reserved. Superior Mesenteric Artery Syndrome: Clinical and Radiological Considerations Wed, 12 Aug 2015 14:22:13 +0000 Background. Superior mesenteric artery (SMA) syndrome is a rare condition of duodenal obstruction, caused by the overlying SMA. Aim. To report on our experience with the management of SMA syndrome, drawing the attention to its existence. Material and Methods. We reviewed our records to identify cases diagnosed with SMA syndrome, in the period from October 1995 to January 2012. Results. Seven patients were identified, one male and six females. Their mean age was 17.1 years. Vomiting and abdominal pain were the presenting complaints in all patients and history of weight loss was present in six of them. In no patient was the diagnosis suspected initially on clinical grounds. Only after radiological investigations was the diagnosis declared. Radiology took the form of gastrografin/barium meal only in four patients and both gastrografin/barium meal and computerized tomography scan in the remaining three. Four patients responded to medical treatment and surgery was performed in the remaining three, with open duodenojejunostomy in two patients and laparoscopic dissection of the ligament of Treitz in the third. Long lasting improvement was sustained in all patients except one in the surgery group who, despite initial improvement, still has infrequent attacks of abdominal pain. Conclusion. Although the clinical manifestations of SMA syndrome are shared with many other disease entities, it has unique radiological as well as endoscopic features, which enables a confident diagnosis to be made. Once diagnosed, conservative treatment with nutritional support and positioning should be tried first. In case of unresponsiveness, surgery may give a lasting cure. M. Ezzedien Rabie, Olajide Ogunbiyi, Abdullah Saad Al Qahtani, Sherif B. M. Taha, Ahmad El Hadad, and Ismail El Hakeem Copyright © 2015 M. Ezzedien Rabie et al. All rights reserved. Pharyngoesophageal Suturing Technique May Decrease the Incidence of Pharyngocutaneous Fistula following Total Laryngectomy Wed, 05 Aug 2015 12:54:11 +0000 Objectives. A pharyngocutaneous fistula (PCF) following total laryngectomy is associated with increased morbidity and severe life threatening complications. We aimed to review our experience with the PCF following total laryngectomy and determine the impact of previously reported risk factors on the development of PCF in our patients. Methods. The medical records of 20 patients who had a total laryngectomy operation were retrospectively analyzed. The association between the proposed risk factors and the incidence of the PCF was investigated. Results. Comparison of the suture techniques used for the closure of the pharynx (either continuous Cushing type or interrupted) yielded that primary interrupted sutures had a significantly higher incidence of PCF formation . Although it was not statistically significant, diabetes mellitus was also associated with increased PCF formation . No significant difference was observed between the PCF and non-PCF groups in terms of other proposed risk factors .  Conclusions. The main risk factor associated with PCF was found to be the type of pharyngeal closure technique. A vertical closure with a Cushing type continuous suture may be more successful than interrupted sutures in preventing a PCF. Mahmut Deniz, Zafer Ciftci, and Erdogan Gultekin Copyright © 2015 Mahmut Deniz et al. All rights reserved. Surgical Management of Endometrial Polyps in Infertile Women: A Comprehensive Review Sun, 02 Aug 2015 13:01:25 +0000 Endometrial polyps are benign localized lesions of the endometrium, which are commonly seen in women of reproductive age. Observational studies have suggested a detrimental effect of endometrial polyps on fertility. The natural course of endometrial polyps remains unclear. Expectant management of small and asymptomatic polyps is reasonable in many cases. However, surgical resection of endometrial polyps is recommended in infertile patients prior to treatment in order to increase natural conception or assisted reproductive pregnancy rates. There is mixed evidence regarding the resection of newly diagnosed endometrial polyps during ovarian stimulation to improve the outcomes of fresh in vitro fertilization cycles. Hysteroscopy polypectomy remains the gold standard for surgical treatment. Evidence regarding the cost and efficacy of different methods for hysteroscopic resection of endometrial polyps in the office and outpatient surgical settings has begun to emerge. Nigel Pereira, Allison C. Petrini, Jovana P. Lekovich, Rony T. Elias, and Steven D. Spandorfer Copyright © 2015 Nigel Pereira et al. All rights reserved. Surgical Audit of Patients with Ileal Perforations Requiring Ileostomy in a Tertiary Care Hospital in India Mon, 13 Jul 2015 12:32:59 +0000 Introduction. Ileal perforation peritonitis is a frequently encountered surgical emergency in the developing countries. The choice of a procedure for source control depends on the patient condition as well as the surgeon preference. Material and Methods. This was a prospective observational study including 41 patients presenting with perforation peritonitis due to ileal perforation and managed with ileostomy. Demographic profile and operative findings in terms of number of perforations, site, and size of perforation along with histopathological findings of all the cases were recorded. Results. The majority of patients were male. Pain abdomen and fever were the most common presenting complaints. Body mass index of the patients was in the range of 15.4–25.3 while comorbidities were present in 43% cases. Mean duration of preoperative resuscitation was hours. Operative findings showed that 78% patients had a single perforation; most perforations were 0.6–1 cm in size and within 15 cm proximal to ileocecal junction. Mesenteric lymphadenopathy was seen in 29.2% patients. On histopathological examination, nonspecific perforations followed by typhoid and tubercular perforations respectively were the most common. Conclusion. Patients with ileal perforations are routinely seen in surgical emergencies and their demography, clinical profile, and intraoperative findings may guide the choice of procedure to be performed. Hemkant Verma, Siddharth Pandey, Kapil Dev Sheoran, and Sanjay Marwah Copyright © 2015 Hemkant Verma et al. All rights reserved. Guidelines for Perioperative Management of the Diabetic Patient Tue, 19 May 2015 07:22:09 +0000 Management of glycemic levels in the perioperative setting is critical, especially in diabetic patients. The effects of surgical stress and anesthesia have unique effects on blood glucose levels, which should be taken into consideration to maintain optimum glycemic control. Each stage of surgery presents unique challenges in keeping glucose levels within target range. Additionally, there are special operative conditions that require distinctive glucose management protocols. Interestingly, the literature still does not report a consensus perioperative glucose management strategy for diabetic patients. We hope to outline the most important factors required in formulating a perioperative diabetic regimen, while still allowing for specific adjustments using prudent clinical judgment. Overall, through careful glycemic management in perioperative patients, we may reduce morbidity and mortality and improve surgical outcomes. Sivakumar Sudhakaran and Salim R. Surani Copyright © 2015 Sivakumar Sudhakaran and Salim R. Surani. All rights reserved. Hiatus Hernia Repair with Bilateral Oesophageal Fixation Thu, 30 Apr 2015 07:24:04 +0000 Background. Despite advances in surgical repair of hiatus hernias, there remains a high radiological recurrence rate. We performed a novel technique incorporating bilateral oesophageal fixation and evaluated outcomes, principally symptom improvement and hernia recurrence. Methods. A retrospective study was performed on a prospective database of patients undergoing hiatus hernia repair with bilateral oesophageal fixation. Retrospective and prospective quality of life (QOL), PPI usage, and patient satisfaction data were obtained. Hernia recurrence was assessed by either barium swallow or gastroscopy. Results. 87 patients were identified in the database with a minimum of 3 months followup. There were significant improvements in QOL scores including GERD HRQL (29.13 to 4.38, ), Visick (3 to 1), and RSI (17.45 to 5, ). PPI usage decreased from a median of daily to none, and there was high patient satisfaction (94%). 57 patients were assessed for recurrence with either gastroscopy or barium swallow, and one patient had evidence of recurrence on barium swallow at 45 months postoperatively. There was an 8% complication rate and no mortality or oesophageal perforation. Conclusions. This study demonstrates that our technique is both safe and effective in symptom control, and our recurrence investigations demonstrate at least short term durability. Rajith Mendis, Caran Cheung, and David Martin Copyright © 2015 Rajith Mendis et al. All rights reserved. Evaluation of Early versus Delayed Laparoscopic Cholecystectomy in Acute Cholecystitis Tue, 03 Feb 2015 08:45:29 +0000 Background. The role of early laparoscopic cholecystectomy for acute cholecystitis with cholelithiasis is not yet established. The aim of our prospective randomized study was to evaluate the safety and feasibility of early LC for acute cholecystitis and to compare the results with delayed LC. Methods. Between March 2007 to December 2008, 50 patients with diagnosis of acute cholecystitis were assigned randomly to early group, (LC within 24 hrs of admission), and delayed group, (initial conservative treatment followed by delayed LC, 6–8 weeks later). Results. We found in our study that the conversion rate in early LC and delayed LC was 16% and 8%, respectively, Operation time for early LC was 69.4 min versus 66.4 min for delayed LC, postoperative complications for early LC were 24% versus 8% for delayed LC, and blood loss was 159.6 mL early group versus 146.8 mL for delayed group. However early LC had significantly shorter hospital stay (4.1 days versus 8.6 days). Conclusions. Early LC for acute cholecystitis with cholelithiasis is safe and feasible, offering the additional benefit of shorter hospital stay. It should be offered to the patients with acute cholecystitis, provided that the surgery is performed within 96 hrs of acute symptoms by an experienced surgeon. Rati Agrawal, K. C. Sood, and Bhupender Agarwal Copyright © 2015 Rati Agrawal et al. All rights reserved. Appendicitis in Children: Evaluation of the Pediatric Appendicitis Score in Younger and Older Children Wed, 10 Dec 2014 10:26:04 +0000 Background. This study aimed to evaluate Pediatric Appendicitis Score (PAS), diagnostic delay, and factors responsible for possible late diagnosis in children <4 years compared with older children who were operated on for suspected appendicitis. Method. 122 children, between 1 and 14 years, operated on with appendectomy for suspected appendicitis, were retrospectively analyzed. The cohort was divided into two age groups: ≥4 years () and <4 years (). Results. The mean PAS was lower among the younger compared with the older patients (5.3 and 6.6, resp.; ), despite the fact that younger children had more severe appendicitis (75.0% and 33.3%, resp.; ). PAS had low sensitivity in both groups, with a significantly lower sensitivity among the younger patients. Parent and doctor delay were confirmed in children <4 years of age with appendicitis. PAS did not aid in patients with doctor delay. Parameters in patient history, symptoms, and abdominal examination were more diffuse in younger children. Conclusion. PAS should be used with caution when examining children younger than 4 years of age. Diffuse symptoms in younger children with acute appendicitis lead to delay and to later diagnosis and more complicated appendicitis. Martin Salö, Gustav Friman, Pernilla Stenström, Bodil Ohlsson, and Einar Arnbjörnsson Copyright © 2014 Martin Salö et al. All rights reserved. Team Training (Training at Own Facility) versus Individual Surgeon’s Training (Training at Trainer’s Facility) When Implementing a New Surgical Technique: Example from the ONSTEP Inguinal Hernia Repair Wed, 19 Nov 2014 12:38:42 +0000 Background. When implementing a new surgical technique, the best method for didactic learning has not been settled. There are basically two scenarios: the trainee goes to the teacher’s clinic and learns the new technique hands-on, or the teacher goes to the trainee’s clinic and performs the teaching there. Methods. An informal literature review was conducted to provide a basis for discussing pros and cons. We also wanted to discuss how many surgeons can be trained in a day and the importance of the demand for a new surgical procedure to ensure a high adoption rate and finally to apply these issues on a discussion of barriers for adoption of the new ONSTEP technique for inguinal hernia repair after initial training. Results and Conclusions. The optimal training method would include moving the teacher to the trainee’s department to obtain team-training effects simultaneous with surgical technical training of the trainee surgeon. The training should also include a theoretical presentation and discussion along with the practical training. Importantly, the training visit should probably be followed by a scheduled visit to clear misunderstandings and fine-tune the technique after an initial self-learning period. Jacob Rosenberg, Kristoffer Andresen, and Jannie Laursen Copyright © 2014 Jacob Rosenberg et al. All rights reserved. A Surgeon’s Perspective of Abdominal Wall Endometriosis at a Caesarean Section Incision: Nine Cases in a Single Institution Mon, 22 Sep 2014 07:03:27 +0000 Abdominal wall endometriosis in a Caesarean section scar (AEC) is an infrequent type of extrapelvic endometriosis which rarely transforms into a malignant lesion. A painful mass located in the scar of a Caesarean section is a typical sign of AEC. This condition is diagnosed preoperatively using imaging modalities such as computed tomography and ultrasonography, as well as fine-needle aspiration. Although AEC has typical signs, general surgeons often misdiagnose it due to its rarity. Herein, we report our experience of AEC in a single institution. Eun Mee Oh, Won-Suk Lee, Jin Mo Kang, Sang Tae Choi, Keon Kuk Kim, and Woon Kee Lee Copyright © 2014 Eun Mee Oh et al. All rights reserved. Pre- and Postoperative Vomiting in Children Undergoing Video-Assisted Gastrostomy Tube Placement Tue, 12 Aug 2014 09:30:54 +0000 Background. The aim of this study was to determine the incidence of pre- and postoperative vomiting in children undergoing a Video-Assisted Gastrostomy (VAG) operation. Patients and Methods. 180 children underwent a VAG operation and were subdivided into groups based on their underlying diagnosis. An anamnesis with respect to vomiting was taken from each of the children’s parents before the operation. After the VAG operation, all patients were followed prospectively at one and six months after surgery. All complications including vomiting were documented according to a standardized protocol. Results. Vomiting occurred preoperatively in 51 children (28%). One month after surgery the incidence was 43 (24%) in the same group of children and six months after it was found in 40 (22%). There was a difference in vomiting frequency both pre- and postoperatively between the children in the groups with different diagnoses included in the study. No difference was noted in pre- and postoperative vomiting frequency within each specific diagnosis group. Conclusion. The preoperative vomiting symptoms persisted after the VAG operation. Neurologically impaired children had a higher incidence of vomiting than patients with other diagnoses, a well-known fact, probably due to their underlying diagnosis and not the VAG operation. This information is useful in preoperative counselling. Torbjörn Backman, Helén Sjövie, Malin Mellberg, Anna Börjesson, Magnus Anderberg, Carl-Magnus Kullendorff, and Einar Arnbjörnsson Copyright © 2014 Torbjörn Backman et al. All rights reserved. Residual Prolapse in Patients with III-IV Degree Haemorrhoids Undergoing Stapled Haemorrhoidopexy with CPH34 HV: Results of an Italian Multicentric Clinical Study Sun, 15 Jun 2014 10:16:54 +0000 CPH34 HV, a high volume stapler, was tested in order to assess its safety and efficacy in reducing residual/recurrent haemorrhoids. The clinical charts of 430 patients with third- to fourth-degree haemorrhoids undergoing SH in 2012-2013 were consecutively reviewed, excluding those with obstructed defecation (rectocele >2 cm; Wexner’s score >15). Follow-up was scheduled at six and 12 months. Rectal prolapse exceeding more than half of CAD was reported in 341 patients (79.3%); one technical failure was reported (0.2%) without any serious untoward effect; and 1.3 stitch/patient (SD, 1.7) was required to achieve complete haemostasis. Doughnuts volume was higher (13.8 mL; SD, 1.5) in patients with a large rectal prolapse than with smaller one (8.9 mL; SD, 0.7) ( value <0.05). Residual and recurrent haemorrhoids occurred in 8 of 430 patients (1.8%) and 5 of 254 patients (1.9%), respectively. A high index of patient satisfaction (visual analogue scale = 8.9; SD, 0.9) coupled with a persistent reduction of constipation scores (CSS = 5.0, SD, 2.2) was observed. The wider prolapse resection well correlated with a clear-cut reduction of haemorrhoidal relapse, a high index of patient satisfaction, and clinically relevant reduction of constipations scores coupled with satisfactory haemostatic properties of CPH34 HV. Giuliano Reboa, Marco Gipponi, Andrea Rattaro, Giovanni Ciotta, Marco Tarantello, Angelo Caviglia, Antonio Pagliazzo, Luigi Masoni, Giuseppe Caldarelli, Fabio Gaj, Bruno Masci, and Andrea Verdi Copyright © 2014 Giuliano Reboa et al. All rights reserved. Awareness and Attitude of Healthcare Workers to Cosmetic Surgery in Osogbo, Nigeria Wed, 11 Jun 2014 07:14:49 +0000 This study aimed at understanding the level of awareness and elucidates the attitude and disposition of healthcare workers to cosmetic surgery in Osogbo, Nigeria. A questionnaire-based survey was done at LAUTECH Teaching Hospital, Osogbo, in 2012. Questionnaires were administered to 213 workers and students in the hospital. These were then analysed using SPSS version 16.0 with frequencies, means, and so forth. Respondents were 33 doctors, 32 nurses, 79 medical students, 60 nursing students, 4 administrative staff, 1 pharmacist, and 4 ward maids. There is fair awareness about cosmetic surgery generally with 94.5% and its availability in Nigeria with 67.0%. A fewer proportion of the respondents (44.5%) were aware of the facility for cosmetic surgery in their locality. A large percentage (86.5%) favorably considers facilities outside Nigeria when making choice of facility to have cosmetic surgery done. 85.5% considered the information about cosmetic surgery reliable while 19.0% objected going for cosmetic surgery of their choice even if done free. Only 34.0% consider cosmetic surgery socially acceptable. Although the awareness of health workers about cosmetic surgery is high, their disposition to it is low. There is a need to increase the awareness in order to increase cosmetic surgery practice in Nigeria. Opeyemi Adeniyi Adedeji, Ganiyu Oladiran Oseni, and Peter Babatunde Olaitan Copyright © 2014 Opeyemi Adeniyi Adedeji et al. All rights reserved. Management of Superficial Abscesses: Scope for Day Case Surgery Mon, 26 May 2014 07:05:50 +0000 Background. Patients presenting with superficial abscesses are often regarded as low priority and given a less efficient service. Aim. The aim of this study was to investigate the efficiency of emergency treatment of superficial abscesses and to identify areas for service improvement. Method. A retrospective case review of patients admitted to Derriford Hospital, Plymouth, over a four-month period. Results. Ninety-seven patients were included in the study. Seventy two (74%) arrived between 08.00 and 16.00 hours. Overall, 75 patients (77%) were referred on weekdays with 22 patients (23%) during weekends. Seventy-two patients (74%) had treatment under a general anaesthetic. Sixty-three percent of operations occurred within the working day. The time interval between admission and surgery ranged from 52 minutes to 38 hours (mean ± SD 16 ± 9.15). The length of admission ranged from 5.3 hours to 11 days (mean 36 hours). Of the one hundred overnight beds used by the 97 patients, 30 nights were spent awaiting surgery and 70 following surgery and awaiting discharge. Conclusion. Eighty-nine percent of the patients would have been suitable for treatment as day cases. This review shows that a simple service redesign has the potential of reducing inpatient bed occupancy and improving the patient’s journey. Martha Nixon and Jacob A. Akoh Copyright © 2014 Martha Nixon and Jacob A. Akoh. All rights reserved. Six-Year Experience of a Nurse-Led Colorectal Cancer Follow-Up Clinic Tue, 20 May 2014 12:52:43 +0000 Aims and Objectives. To review the experience of a nurse-led colorectal cancer follow-up clinic in a tertiary referral colorectal cancer centre. Methodology. Data from the nurse-led colorectal cancer follow-up clinic in our unit was prospectively maintained in a colorectal cancer database. Data was analysed from January 1, 2006 until the December 31, 2011. Results. 1125 patients were diagnosed with colorectal cancer, and referred to our unit as a tertiary centre for specialised colorectal cancer. Nine hundred and four patients had surgical resection of their colorectal cancer. Four hundred and seven patients were referred to the nurse-led colorectal cancer clinic for surveillance. The mean age of the patient cohort was 67 years (range 32–88) and 56% of patients were male. One hundred and seventeen patients were discharged to their general practitioner having been disease free after 5 years of followup. Fifty-four patients were diagnosed with either local or distant recurrence. Conclusion. A nurse-led colorectal cancer follow-up clinic is running according to strict follow-up protocols. This type of clinic significantly reduces the number of routine follow-up patients that have to be seen by the colorectal surgical consultant. Hasan Al Chalabi, James M. O’Riordan, Alex Richardson, Delia Flannery, Katrina O'Connor, Charlotte Stuart, John Larkin, Paul McCormick, and Brian Mehigan Copyright © 2014 Hasan Al Chalabi et al. All rights reserved. PET/CT Is Complementary to Fine-Needle Aspiration Cytology in Assessment of Irradiated Neck in Head and Neck Cancers Sun, 18 May 2014 08:08:25 +0000 Background. Accurate assessment of irradiated neck in squamous cell carcinoma of the head and neck (HNSCC) is essential. Fine-needle aspiration cytology is often performed for suspicious lesions but it is limited by its low negative predictive value (NPV). We postulated that F-18 fluorodeoxyglucose (FDG) positron emission tomography combined with computed tomography (PET/CT) can overcome this limitation by its high NPV value and allow for a more accurate assessment of irradiated neck in HNSCC. Methods. Fifty-four HNSCC patients were included for the study. They all received previous irradiation to the neck. Clinical characteristics, details of radiotherapy, PET/CT results, follow-up findings, and final histological diagnosis were analyzed. Results. The sensitivity, specificity, positive predictive value (PPV), and NPV were 95.8%, 96.7%, 95.8%, and 96.7%, respectively. Age, sex, radiation dose, interval between PET/CT and radiotherapy completion, nature of radiotherapy, and use of second course of radiotherapy were not found to affect diagnostic accuracy of PET/CT. A new algorithm for investigation of masses in irradiated neck is proposed. Conclusions. PET/CT is an effective diagnostic tool and has a complementary role to FNAC in the management of irradiated neck in head and neck cancers, particularly in cases where suspicious lesions were identified but FNAC showed negative results. R. C. L. Chan and Y. W. Chan Copyright © 2014 R. C. L. Chan and Y. W. Chan. All rights reserved. Percutaneous Vertebral Body Augmentation: An Updated Review Mon, 28 Apr 2014 13:29:56 +0000 There are many medical conditions like osteoporosis, tumor, or osteonecrosis that weaken the structural strength of the vertebral body and prone it to fracture. Percutaneous vertebral augmentation that is usually applied by polymethylmethacrylate is a relatively safe, effective, and long lasting procedure commonly performed in these situations. In this paper, we updated a review of biomechanics, indications, contraindications, surgical techniques, complications, and overall prognosis of these minimally invasive spinal procedures. Farzad Omidi-Kashani Copyright © 2014 Farzad Omidi-Kashani. All rights reserved. Skin Staples: A Safe Technique for Securing Mesh in Lichtensteins Hernioplasty as Compared to Suture Thu, 03 Apr 2014 11:06:12 +0000 Background. Lichtenstein tension free repair is the most commonly used technique due to cost effectiveness, low recurrence rate, and better patient satisfaction. This study was done to compare the duration of surgery and postoperative outcome of securing mesh with skin staples versus polypropylene sutures in Lichtenstein hernia repair. Materials and Methods. A total of 96 patients with inguinal hernia undergoing Lichtenstein mesh repair were randomly assigned into two groups. The mesh was secured either by using skin staples (group I) or polypropylene sutures (group II). Results. The operation time was significantly reduced from mesh insertion to completion of skin closure in group I (mean 20.7 min) as compared to group II (mean 32.7 min) with significant value and less complication rate in group I as compared to group II. Conclusion. Mesh fixation with skin staples is as effective as conventional sutures with added advantage of significant reduction in the operating time and complications or recurrence. The staples can be applied much more quickly than sutures for fixing the mesh, thus saving the operating time. Infection rate is significantly decreased with staples. Anand Munghate, Sushil Mittal, Harnam Singh, Gurpreet Singh, and Manish Yadav Copyright © 2014 Anand Munghate et al. All rights reserved. Resection Leads to Less Recurrence Than Strictureplasty in a Paediatric Population with Obstructive Crohn’s Disease Tue, 01 Apr 2014 08:17:45 +0000 Introduction. Resection and strictureplasty are used to treat patients with obstructive Crohn’s disease. Strictureplasty is preferable in adults as it retains bowel length. This study aims to identify differences in outcomes of children undergoing strictureplasty and resection for obstructive Crohn’s disease. Method. Patients under 20 years undergoing surgery over a nine-year period were included. Data was collected on procedures for stenotic Crohn’s disease. Patients were divided into 2 groups: Group 1 treated with strictureplasties and Group 2 resections. Postoperative complications and recurrence rates were recorded. Kaplan-Meier method was used to analyze the data. Results. Twenty-six patients and 40 operations were identified. Mean age was 15.6 years (7.2–19.4) with equal numbers of males and females. Mean follow-up was 45.9 months (0.1–149.9). 20/40 procedures involved the terminal ileum; 9/40, the ileocolic junction; 8/40, the upper GI tract; and 3/40, the colon. Group 1 consisted of 19 strictureplasties and Group 2 consisted of 13 resections and 8 combined procedures. Significantly more patients in Group 1 required further surgery (11/19 versus 3/21; ). Conclusion. Allowing for variations in disease duration, severity, and previous medical management, these data suggest that resection is preferable to strictureplasty in treating obstructive Crohn’s disease in children and adolescents. Richard Bamford, Ashley Hay, and Devinder Kumar Copyright © 2014 Richard Bamford et al. All rights reserved. A Comparative Study between the Outcome of Primary Repair versus Loop Ileostomy in Ileal Perforation Thu, 27 Mar 2014 09:57:01 +0000 Introduction. Ileal perforation peritonitis is a common surgical emergency in the Indian subcontinent and in tropical countries. It is reported to constitute the fifth common cause of abdominal emergencies due to high incidence of enteric fever and tuberculosis in these regions. Methods. Sixty proven cases of ileal perforation patients admitted to Surgical Emergency were taken up for emergency surgery. Randomisation was done by senior surgeons by picking up card from both the groups. The surgical management was done as primary repair (group A) and loop ileostomy (group B). Results. An increased rate of postoperative complications was seen in group A when compared with group B with 6 (20%) patients landed up in peritonitis secondary to leakage from primary repair requiring reoperation as compared to 2 (6.67%) in ileostomy closure. A ratio of 1 : 1.51 days was observed between hospital stay of group A to group B. Conclusion. In cases of ileal perforation temporary defunctioning loop ileostomy plays an important role. We recommend that defunctioning ileostomy should be preferred over other surgical options in cases of ileal perforations. It should be recommended that ileostomy in these cases is only temporary and the extra cost and cost of management are not more than the price of life. Sushil Mittal, Harnam Singh, Anand Munghate, Gurpreet Singh, Anjna Garg, and Jyoti Sharma Copyright © 2014 Sushil Mittal et al. All rights reserved. Treatment of Sternoclavicular Joint Osteomyelitis with Debridement and Delayed Resection with Muscle Flap Coverage Improves Outcomes Wed, 12 Mar 2014 08:07:32 +0000 The objective of this study was to evaluate the efficacy of various treatment options for sternoclavicular joint osteomyelitis. We evaluated patients with a diagnosis of sternoclavicular joint osteomyelitis, treated at our hospital from 2002 to 2012. Four treatment options were compared. Three out of twelve patients were successfully cured with antibiotics alone (25%). Debridement with or without negative pressure therapy was successful for one of three patients (33%). Simultaneous debridement, bone resection, and muscle flap coverage of the acquired defect successfully treated one of two patients (50%). Debridement with delayed bone resection and muscle flap coverage was successful in five of five patients (100%). Osteomyelitis of the sternoclavicular joint is a rare disease that has become more prevalent in recent years and can be associated with increasing use of long-term indwelling catheters. Initial debridement with delayed bone resection and pectoralis major muscle flap coverage can effectively treat sternoclavicular joint osteomyelitis. Jason L. Muesse, Shanda H. Blackmon, Warren A. Ellsworth IV, and Min P. Kim Copyright © 2014 Jason L. Muesse et al. All rights reserved. What Is the Role of Hysteroscopic Surgery in the Management of Female Infertility? A Review of the Literature Mon, 03 Mar 2014 12:55:43 +0000 The position of hysteroscopy in current fertility practice is under debate. There are many randomized controlled trials on technical feasibility and patient compliance demonstrating that the procedure is well tolerated and effective in the treatment of intrauterine pathologies. However, no consensus on the effectiveness of hysteroscopic surgery in improving the prognosis of subfertile women is available. A literature review was performed to explore the available information regarding the role of hysteroscopy in the evaluation and management of female infertility as well as to ascertain evidence that treatment of these uterine abnormalities improves fertility. The debate regarding the role of hysteroscopic surgery in the management of female infertility remains as the published studies did not reach a consensus on the benefit of such an intervention in this setting. The randomized trials do not clearly demonstrate that surgical correction of all intrauterine abnormalities improves IVF outcome. However, published observational studies suggest a benefit for resection of submucosal leiomyomas, adhesions, and endometrial polyps in increasing pregnancy rates. More randomised controlled studies are needed to substantiate the effectiveness of the hysteroscopic removal of suspected intrauterine pathology in women with unexplained subfertility or prior to assisted reproductive technology. Márcia Mendonça Carneiro Copyright © 2014 Márcia Mendonça Carneiro. All rights reserved. Utility of Preoperative CA125 Assay in the Management Planning of Women Diagnosed with Uterine Cancer Thu, 27 Feb 2014 11:50:18 +0000 Objective. This study assesses the role of preoperative serum CA125 levels in the planning treatment options for women diagnosed with uterine cancer. Material and Method. Ninety five consecutive patients diagnosed with uterine cancer during a four-year period were identified. Age ranged from 35 to 89 years with a mean age of 69 years. The preoperative CA125 levels were dichotomised at 28 U/mL (using ROC analysis to identify the best discriminating threshold for 5-year survival). This level was then correlated with preoperative prognostic indicators: patient age, tumour grade, and histopathological tumour cell type. Survival data was plotted using Kaplan-Meier curves and analysed using the log-rank test. Univariate and multivariate analysis were performed to identify the predictors of overall survival. Results. The mean age of patients was 69 years (range: 35–89). On univariate analysis, the use of preoperative CA125 levels of greater or less than 28 U/mL correlated significantly with age , the grade of disease and unfavourable tissue type . This threshold CA125 level had a sensitivity of 75%, specificity of 76%, positive predictive value of 35% and negative predicative value of 96.25%, and a likelihood ratio of 3.12 for predicting nodal disease. Using a threshold of preoperative CA125 level of 28 U/mL (area under curve: 0.60) was also a significant predictor of 5-year survival (log-rank test, ). Using Cox multivariate survival analysis to identify predictive preoperative factors overall, unfavourable cell type was the strongest predictor of survival (Chi square = 36.5, df = 4, and ), followed by preoperative CA125 level (CA125 > 28 U/mL, ) and unfavourable preoperative grade (). Amongst patients with a favourable histological tissue type (endometrioid), preoperative CA125 levels predicted overall survival (Chi square = 6.039, df = 2, ); however unfavourable preoperative grade did not (). Overall, at five-year follow-up, while there were no deaths among the women with preoperative serum CA125 less than 12 U/mL, eleven of the twenty-three deaths (47.82%) in the study occurred in women with a preoperative CA125 more than 28 U/mL. Conclusions. A preoperative CA125 assay for women with uterine cancer is a relatively inexpensive, reproducible, and objective test which provides valuable information regarding the risk of metastatic disease and overall likelihood of long term survival. Patients with a low likelihood of metastatic/nodal disease (favourable tissue type and CA125 level < 28 U/mL) and significant comorbidities may benefit from avoiding an extended complete staging procedure. Alternatively, a high level of CA125 may prompt further imaging and multidisciplinary discussions to plan for individualised management and consideration for recruitment to clinical trials. N. Povolotskaya, N. Das, K. Dhar, D. Brinkmann, F. Gardner, and R. Woolas Copyright © 2014 N. Povolotskaya et al. All rights reserved.