Surgery Research and Practice The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Local Anaesthetic Infiltration and Indwelling Postoperative Wound Catheters for Patients with Hip Fracture Reduce Death Rates and Length of Stay Mon, 16 Nov 2015 14:20:39 +0000 Background. An analgesic enhanced recovery (ER) protocol for patients with a hip fracture was introduced. It was hypothesised that the ER would reduce pain, length of stay and improve clinical outcomes. The protocol used intraoperative infiltration of levobupivacaine followed by ongoing wound infusions. Methods. Consecutive patients admitted to two hospitals were eligible for the ER protocol. Numerical Reporting Scale pain scores (0–10) were recorded alongside opiate requirements. 434 patients in the ER group (316 full ER, 90 partial ER, and 28 no ER) were compared to a control group (CG) of 100 consecutive patients managed with traditional opiate analgesia. Results. Mean opiate requirement was 49.2 mg (CG) versus 32.5 mg (ER). Pain scores were significantly reduced in the full ER group, . Direct discharge home and mean acute inpatient stay were significantly reduced ( and , resp.). 30-day mortality was 15% (CG) versus 5.5% (ER), . Conclusions. This analgesic ER protocol for patients with a hip fracture was safe and effective and was associated with reduced inpatient stay and mortality. William D. Harrison, Deborah Lees, Jamie A’Court, Thomas Ankers, Ian Harper, Dominic Inman, and Mike R. Reed Copyright © 2015 William D. Harrison et al. All rights reserved. Biomechanical Evaluation of a Mandibular Spanning Plate Technique Compared to Standard Plating Techniques to Treat Mandibular Symphyseal Fractures Mon, 16 Nov 2015 08:17:18 +0000 Purpose. The purpose of this study is to compare the biomechanical behavior of the spanning reconstruction plate compared to standard plating techniques for mandibular symphyseal fractures. Materials and Methods. Twenty-five human mandible replicas were used. Five unaltered synthetic mandibles were used as controls. Four experimental groups of different reconstruction techniques with five in each group were tested. Each synthetic mandible was subjected to a splaying force applied to the mandibular angle by a mechanical testing unit until the construct failed. Peak load and stiffness were recorded. The peak load and stiffness were analyzed using ANOVA and the Tukey test at a confidence level of 95% (). Results. The two parallel plates’ group showed statistically significant lower values for peak load and stiffness compared to all other groups. No statistically significant difference was found for peak load and stiffness between the control (C) group, lag screw (LS) group, and the spanning plate (SP1) group. Conclusions. The spanning reconstruction plate technique for fixation of mandibular symphyseal fractures showed similar mechanical behavior to the lag screw technique when subjected to splaying forces between the mandibular gonial angles and may be considered as an alternative technique when increased reconstructive strength is needed. Matthew Richardson, Jonathan Hayes, J. Randall Jordan, Aaron Puckett, and Matthew Fort Copyright © 2015 Matthew Richardson et al. All rights reserved. Patient Satisfaction and Quality of Life in DIEAP Flap versus Implant Breast Reconstruction Mon, 16 Nov 2015 07:46:55 +0000 The psychological impact of breast reconstruction has widely been described, and multiple studies show that reconstruction improves the well-being and quality of life of patients. In breast reconstruction, the goal is not only the morphological result, but mainly the patient’s perception of it. The objective of our study is to compare the physical and psychosocial well-being and satisfaction concerning the body image of patients who had reconstruction with breast implants to those of patients who had reconstruction with deep inferior epigastric artery perforator flaps. Our results demonstrated a similar quality of life between the two groups, but the satisfaction level was significantly higher in patients who had reconstruction with autologous tissue. Feedback from patients who have already received breast reconstruction may be useful in the decision-making process for future patients and plastic surgeons, enabling both to choose the reconstructive technique with the best long-term satisfaction. Rossella Sgarzani, Luca Negosanti, Paolo Giovanni Morselli, Veronica Vietti Michelina, Luigi Maria Lapalorcia, and Riccardo Cipriani Copyright © 2015 Rossella Sgarzani et al. All rights reserved. Panniculectomy Combined with Bariatric Surgery by Laparotomy: An Analysis of 325 Cases Sun, 15 Nov 2015 12:35:53 +0000 Surgical treatment of obese patients is much debated in the literature because of the significant intraoperative risks related to comorbidities presented by this type of patients. Recent literature suggests that panniculectomy should follow bariatric surgery after the patient’s weight loss has been stabilized. However, when performed by laparotomy, bariatric surgery can be combined with panniculectomy. This paper presents the analysis of 325 cases of patients undergoing abdominal panniculectomy combined with bariatric surgery. The study highlights the risks, complications, and benefits of the combined procedure and describes a standardized technique for excision of a large abdominal panniculus in a short operating time. Vincenzo Colabianchi, Giancarlo de Bernardinis, Matteo Giovannini, and Marika Langella Copyright © 2015 Vincenzo Colabianchi et al. All rights reserved. Leakage after Surgery for Rectum Cancer: Inconsistency in Reporting to the Danish Colorectal Cancer Group Mon, 09 Nov 2015 08:59:27 +0000 Purpose. Anastomotic leakage accounts for up to 1/3 of all fatalities after rectal cancer surgery. Evidence suggests that anastomotic leakage has a negative prognostic impact on local cancer recurrence and long-term cancer specific survival. The reported leakage rate in 2011 in Denmark varied from 7 to 45 percent. The objective was to clarify if the reporting of anastomotic leakage to the Danish Colorectal Cancer Group was rigorous and unequivocal. Methods. An Internet-based questionnaire was e-mailed to all Danish surgical departments, who reported to Danish Colorectal Cancer Group (DCCG) in 2011. There were 23 questions. Four core questions were whether pelvic collection, fecal appearance in a pelvic drain, rectovaginal fistula, and “watchfull” waiting patients were reported as anastomotic leakage. Results. Fourteen out of 17 departments, who in 2011 according to DDCG performed rectal cancer surgery, answered the questionnaire. This gave a response rate of 82%. In three of four core questions there was disagreement in what should be reported as anastomotic leakage. Conclusion. The reporting of anastomotic leakage to the Danish Colorectal Cancer Group was not rigorous and unequivocal. The reported anastomotic leakage rate in Danish Colorectal Cancer Group should be interpreted with caution. L. Borly, M. B. Ellebæk, and N. Qvist Copyright © 2015 L. Borly et al. All rights reserved. A EWTD Compliant Rotation Schedule Which Protects Elective Training Opportunities Is Safe and Provides Sufficient Exposure to Emergency General Surgery: A Prospective Study Mon, 02 Nov 2015 14:15:31 +0000 Introduction. Training opportunities have decreased dramatically since the introduction of the European Working Time Directive (EWTD). In order to maximise training we introduced a rotation schedule in which registrars do not work night shifts and elective training opportunities are protected. We aimed to determine the safety and effectiveness of this EWTD compliant rotation schedule in achieving exposure of trainees to acute general surgical admissions and operations. Methods. A prospective study of consecutive emergency surgical admissions over a 6-month period. Exposure to acute admissions and operative procedures and patient outcomes during day and night shifts was compared. Results. There were 1156 emergency admissions covering a broad range of acute conditions. Significantly more patients were admitted during the day shift and almost all emergency procedures were performed during the day shift (2.1 versus 0.3, p < 0.001). A registrar was the primary operating surgeon in 49% of cases and was directly involved in over 65%. There were no significant differences between patients admitted during the day and night shifts in mortality rate, length of stay, admission to ICU, requirement for surgery, or readmission rates. Conclusion. A EWTD compliant rotation schedule that protects elective training opportunities is safe for patients and provides adequate exposure to training opportunities in emergency surgery. Andrew Emmanuel, Ezzat Chohda, Carolyn Sands, Joseph Ellul, and Hamid Khawaja Copyright © 2015 Andrew Emmanuel et al. All rights reserved. Negative Pressure Incision Management System in the Prevention of Groin Wound Infection in Vascular Surgery Patients Sun, 01 Nov 2015 07:05:49 +0000 Objectives. Groin wounds following vascular surgery are highly susceptible to healing disturbances, with reported site infections reaching 30%. Negative pressure incision management systems (NPIMS) are believed to positively influence the prevention of surgical wound-healing disturbances (WHD) and surgical site infections (SSI). NPIMS placed directly after closure of the surgical wound is thought to result in fewer infections; we analysed its effect on postoperative wound infections in patients after vascular surgery via the groin. Methods. From May 2012 to March 2013 we included 90 surgical patients; 40 received a NPIMS. All patients with WHDs were labelled and subanalysed for surgical site infection in case of positive microbiological culture. These infections were graded according to Szilagyi. Number of WHDs and SSIs were compared across cohorts. Results. Patient and perioperative characteristics were equal, except for a significantly higher number of emergency procedures among non-NPIMS patients. We found no significant differences in number of WHDs, SSIs, or Szilagyi grades between the two cohorts. Conclusion. The equal number of SSIs across cohorts showed that NPIMS could not reduce the number of surgical site infections after vascular groin surgery. Jan H. Koetje, Karsten D. Ottink, Iris Feenstra, and Wilbert M. Fritschy Copyright © 2015 Jan H. Koetje et al. All rights reserved. Comparing Supervised Exercise Therapy to Invasive Measures in the Management of Symptomatic Peripheral Arterial Disease Tue, 27 Oct 2015 13:42:27 +0000 Peripheral arterial disease (PAD) is associated with considerable morbidity and mortality. Consensus rightly demands the incorporation of supervised exercise training (SET) into PAD treatment protocols. However, the exact role of SET particularly its relationship with intervention requires further clarification. While supervised exercise is undoubtedly an excellent tool in the conservative management of mild PAD its use in more advanced disease as an adjunct to open or endovascular intervention is not clearly defined. Indeed its use in isolation in this cohort is incompletely reported. The aim of this review is to clarify the exact role of SET in the management of symptomatic PAD and in particular to assess its role in comparison with or as an adjunct to invasive intervention. A systematic literature search revealed a total 11 randomised studies inclusive of 969 patients. All studies compared SET and intervention with monotherapy. Study results suggest that exercise is a complication-free treatment. Furthermore, it appears to offer significant improvements in patients walk distances with a combination of both SET and intervention offering a superior walking outcome to monotherapy in those requiring invasive measures. Thomas Aherne, Seamus McHugh, Elrasheid A. Kheirelseid, Michael J. Lee, Noel McCaffrey, Daragh Moneley, Austin L. Leahy, and Peter Naughton Copyright © 2015 Thomas Aherne et al. All rights reserved. Perioperative Evaluation of Patient Outcomes after Severe Acid Corrosive Injury Sun, 25 Oct 2015 12:51:12 +0000 We reviewed 64 patients with perforation or full-thickness injury of the alimentary tract after acid ingestion. Based on our classification of laparotomy findings, there were class I (); class II (); class III (); and class IV (). Study parameters were preoperative laboratory data, gastric perforation, associated visceral injury, and extension of the injury. End points of the study were the patients’ mortality and length of hospital stay. All these patients underwent esophagogastrectomy with () or without () concomitant resection, esophagogastroduodenojejunectomy with () or without () concomitant resection, and laparotomy only (). Concomitant resections were performed on the spleen (), colon (), pancreas (), gall bladder (), skipped areas of jejunum (), and the first portion of the duodenum (). The study demonstrates five preoperative risk factors, female gender, shock status, shock index, pH value, and base deficit, and four intraoperative risk factors, gastric perforation, associated visceral injury, injury beyond the pylorus, and continuous involvement of the jejunum over a length of 50 cm. The overall mortality rate was 45.3%, which increased significantly with advancing class of corrosive injury. Ming-Ho Wu and Han-Yun Wu Copyright © 2015 Ming-Ho Wu and Han-Yun Wu. All rights reserved. Long-Term Outcomes of Sacrococcygeal Germ Cell Tumors in Infancy and Childhood Sun, 04 Oct 2015 16:20:06 +0000 Purpose. The aim of this study was to evaluate long-term outcomes of sacrococcygeal germ cell tumors (SC-GCTs) over a 15-year period. Materials and Methods. A retrospective review was conducted of all pediatric patients treated for SC-GCTs at our hospital from 1998 to 2012. Results. Fifty-seven patients were treated for SC-GCTs with the most common in Altman’s classification type I. Age at surgery ranged from one day to 5.6 years. Tumor resection and coccygectomy were primarily performed in about 84% of the cases. Pathology revealed mature, immature, malignant sacrococcygeal teratomas (SCTs), and endodermal sinus tumors (ESTs) in 41 (72%), 4 (77%), 6 (10.5%), and 6 (10.5%), respectively. Recurrence of discase occurred in 3 of 41 patients with mature teratomas (7.3%); 2 recurrences with mature teratomas and one recurrence with EST. Five of 6 malignant SCTs and 3 of 6 ESTs responded well to the treatment. Alpha-fetoprotein (AFP) level was elevated in both malignant teratomas and ESTs. No immediate patient death was noted in any of the 57 cases, but 4 patients with malignant tumors and distant metastasis succumbed at home within 2 years of the initial treatment. Conclusion. Benign SCTs have a significant recurrence rate of approximately 7%. Close follow-up with serial AFP level monitoring should be done for 5 years after initial tumor resection and coccygectomy. The survival rate for malignant SC-GCTs with distant metastasis was unfavorable in the present study. Rangsan Niramis, Maitree Anuntkosol, Veera Buranakitjaroen, Achariya Tongsin, Varaporn Mahatharadol, Wannisa Poocharoen, Suranetr La-orwong, and Kulsiri Tiansri Copyright © 2015 Rangsan Niramis et al. All rights reserved. Will Septal Correction Surgery for Deviated Nasal Septum Improve the Sense of Smell? A Prospective Study Tue, 29 Sep 2015 11:47:28 +0000 Background and Objectives. Nasal obstruction due to deviated nasal septum is a common problem bringing a patient to an otorhinolaryngologist. Occasionally, these patients may also complain of olfactory impairment. We proposed to study the effect of septal deviation on the lateralised olfactory function and the change in olfaction after surgery of the septum (septoplasty). Methods. Forty-one patients with deviated nasal septum were evaluated for nasal airflow, olfactory score, and nasal symptomatology. Septoplasty was done under local anesthesia. Pre- and postoperative olfactory scores, airflow and olfactory scores, and nasal symptomatology and olfactory scores were compared and correlated. Results. The range of preoperative composite olfactory score (COS) on the side of septal deviation was 4–14 (mean ) and on the nonobstructed side was 9–18 (mean ). Severity of deviated nasal septum and preoperative COS of diseased side were correlated and the correlation was found to be significant (rho = −0.690, (<0.001)). The preoperative mean COS () was compared with the postoperative mean COS () and the improvement was found to be statistically significant ( (<0.001)). Conclusion. We found improvement in olfactory function in 70.6% patients after surgery, no change in 20.1%, and reduced function in 7.6%. With the limitation of a small sample size and a potential repeat testing bias, we would conclude that correction of nasal septal deviation may lead to improvement in sense of smell. Neelima Gupta, P. P. Singh, and Rahul Kumar Bagla Copyright © 2015 Neelima Gupta et al. All rights reserved. To Investigate the Effect of Colchicine in Prevention of Adhesions Caused by Serosal Damage in Rats Mon, 28 Sep 2015 13:36:52 +0000 Introduction and Aim. Adhesion formation is a process which starts with an inflammation caused by a number of factors and eventually results in fibrosis. Colchicine prevents adhesion formation which is antifibrous process. The effectivity of colchicine in the prevention of adhesions was investigated. Materials and Methods. A total of 36 rats were equally divided into three groups: (I) control group 1 (), (II) abrasion group 2 (), and (III) abrasion + colchicine group 3 (). Group 1 underwent laparotomy and was orally given physiological serum 2 cc/day for 10 days. In Group 2, injury was created in the cecum serosa following laparotomy and they were orally given physiological serum 2 cc/day for 10 days. In Group 3, injury was created in the cecum serosa following laparotomy and the rats were orally given colchicine 50 mcg kg/day mixed with physiological serum 2 cc/day for 10 days. Laparotomy was performed and adhesions were examined both macroscopically and microscopically. Both macroscopic and microscopic examinations were performed using Zühlke’s score. Results. A significant difference was observed among the adhesion scores of the groups both macroscopically and microscopically. Macroscopic score was lower in group 3 than group 2. Microscopic score was lower in group 3 than group 2. Conclusion. Oral administration of colchicine is effective in the prevention of adhesions. İhsan Yıldız and Yavuz Savas Koca Copyright © 2015 İhsan Yıldız and Yavuz Savas Koca. All rights reserved. Operative Exposure of a Surgical Trainee at a Tertiary Hospital in Kenya Sun, 13 Sep 2015 14:00:26 +0000 Background. Psychomotor domain training requires repetitive exposure in order to develop proficiency in skills. This depends on many training factors in any training institution. Objective. This study sought to look at the operative exposure of surgical trainees in a tertiary hospital in a developing country. Design and Setting. This was a six-month retrospective study performed in one surgical firm at Kenyatta National Hospital. Patients and Methods. The files of all patients admitted to the unit at that time were retrieved. The demographics, diagnosis at admission, need for surgery, and cadre of operating surgeon among others were recorded. Scientific Package for Social Sciences (SPSS) version 17.0 was used for data entry and analysis. Results. The study cohort was 402 patients of the 757 patients admitted in the study period. The average age was 36.7 years, a female to male ratio of 1 : 2.5. The majority (69.7%) of patients required surgery. Trauma was the most common reason for admission (44.5%). Year 2 residents received the most clinical exposure. Consultant was available in only 34.5% of the cases. Conclusion. The junior residents performed the vast majority of procedures with an unsatisfactory amount of supervision from the senior residents and faculty. Daniel Kinyuru Ojuka, Jana Macleod, and Catherine Kwamboka Nyabuto Copyright © 2015 Daniel Kinyuru Ojuka et al. 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.