Surgery Research and Practice The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Through Thick and Thin: Identifying Barriers to Bariatric Surgery, Weight Loss Maintenance, and Tailoring Obesity Treatment for the Future Mon, 23 May 2016 13:17:28 +0000 More than one-third of the adults in the United States are obese. This complex metabolic disorder is associated with multiple comorbidities and increased all-cause mortality. Bariatric surgery has been shown to be more effective than medical therapy and has been associated with weight loss maintenance and decreased mortality. In spite of these well-established benefits, less than 1% of candidates undergo surgery due to multiple factors, such as patient and physician perceptions and attitudes, patient-physician interaction, lack of resources, and cost burden. Furthermore, even in patients who do undergo bariatric surgery and/or alternate weight loss interventions, long-term weight control is associated with high-risk failure and weight regain. In this review, we highlight some of the current barriers to bariatric surgery and long-term weight loss maintenance and underscore the importance of an individualized multidisciplinary longitudinal strategy for the treatment of obesity. Donevan Westerveld and Dennis Yang Copyright © 2016 Donevan Westerveld and Dennis Yang. All rights reserved. The Comparison of Lichtenstein Procedure with and without Mesh-Fixation for Inguinal Hernia Repair Thu, 21 Apr 2016 07:51:49 +0000 Aim. Although inguinal hernia repair is the most frequently performed surgical procedure in the world, the best repair method has not gained acceptance yet. The ideal repair must be safe, simple, and easy to perform and require minimal dissection which provides enough exploration, maintain patient’s comfort in the early stage, and also be cost-effective, reducing operation costs, labor loss, hospital stay, and recurrence. Materials and Methods. There were eighty-five patients between the ages of 18 and 75, diagnosed with inguinal hernia in our clinic. Lichtenstein procedure for hernia repair was performed under spinal anesthesia in all patients. Forty-two patients had the standard procedure and, in 43 patients, the polypropylene mesh was used without fixation. All patients were examined and questioned on the 7th day of the operation in terms of pain, scrotal edema, and the presence of seroma and later on in the 6th postoperative month in terms of paresthesia, neuropraxia, and recurrence by a single physician. Results. Operative time and pain scores in the nonfixation group were significantly lower, without any increase in rates of recurrence. Conclusion. Based on these findings, in Lichtenstein hernia repair method, nonfixation technique can be used safely with better results. Feyzullah Ersoz, Serdar Culcu, Yigit Duzkoylu, Hasan Bektas, Serkan Sari, Soykan Arikan, and Mehmet Mehdi Deniz Copyright © 2016 Feyzullah Ersoz et al. All rights reserved. Evaluation of Spontaneous Pneumothorax Surgeries: A 16-Year Experience in Japan Wed, 13 Apr 2016 09:31:37 +0000 Background. Video-assisted thoracoscopic surgery is the surgical procedure of choice for spontaneous pneumothorax due to its noninvasiveness and convenience. A higher recurrence rate with thoracoscopic bullectomy (TB) than that after traditional thoracotomy (TT) led us to adopt thoracoscopic double-loop ligation (TLL) as our standard procedure in 1998. This study compares the effectiveness and safety of these 3 operative procedures. Methods. Patients who underwent their first surgery for spontaneous pneumothorax at our hospital between January 1994 and December 2010 were included. Patients with a history of surgery for spontaneous pneumothorax, those with special clinical conditions such as lymphangioleiomyomatosis, or those with catamenial, traumatic, or iatrogenic pneumothorax were excluded. Results. A total of 777 males (14–91 years old; 814 pneumothorax sides), and 96 females (16–78 years old; 99 pneumothorax sides) were included in the study. TT was performed in 137 patients (143 sides), TB in 106 patients (112 sides), and TLL in 630 patients (658 sides). The postoperative recurrence rates were 3.5%, 16.1%, and 5.3% in the TT, TB, and TLL groups, respectively (). Mean blood loss and operating time were lowest for TLL. Conclusions. The results suggest that TLL should be the surgical procedure of choice for spontaneous pneumothorax. Ryo Takahashi Copyright © 2016 Ryo Takahashi. All rights reserved. Difficulties and Problematic Steps in Teaching the Onstep Technique for Inguinal Hernia Repair, Results from a Focus Group Interview Sun, 10 Apr 2016 09:20:54 +0000 Background. When a new surgical technique is brought into a department, it is often experienced surgeons that learn it first and then pass it on to younger surgeons in training. This study seeks to clarify the problems and positive experiences when teaching and training surgeons in the Onstep technique for inguinal hernia repair, seen from the instructor’s point of view. Methods. We designed a qualitative study using a focus group to allow participants to elaborate freely and facilitate a discussion. Participants were surgeons with extensive experience in performing the Onstep technique from Germany, UK, France, Belgium, Italy, Greece, and Sweden. Results. Four main themes were found, with one theme covering three subthemes: instruction of others (experience, patient selection, and tailored teaching), comfort, concerns/fear, and anatomy. Conclusion. Surgeons receiving a one-day training course should preferably have experience with other types of hernia repairs. If trainees are inexperienced, the training setup should be a traditional step-by-step programme. A training setup should consist of an explanation of the technique with emphasis on anatomy and difficult parts of the procedure and then a training day should follow. Surgeons teaching surgery can use these findings to improve their everyday practice. Kristoffer Andresen, Jannie Laursen, and Jacob Rosenberg Copyright © 2016 Kristoffer Andresen et al. All rights reserved. Effects of Lornoxicam on Anastomotic Healing: A Randomized, Blinded, Placebo-Control Experimental Study Thu, 07 Apr 2016 13:36:19 +0000 Introduction and Aim. With the implementation of multimodal analgesia regimens, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are often administered for optimal pain control and reduction of opioid use. The aim of the study was to examine the effects of lornoxicam, a NSAID, on anastomotic healing employing an animal model. Materials and Methods. A total of 28 Wistar rats were randomly assigned in two groups. All animals underwent ascending colonic transection followed by an end-to-end hand sewn anastomosis. Group 1 received intraperitoneally lornoxicam before and daily after surgery. Group 2 received intraperitoneally an equal volume of placebo. Half of the animals in each group were euthanized on the 3rd pod and the remaining on the 7th pod. Macro- and microscopic indicators of anastomotic healing were compared using a two-tailed Fisher exact test. Results. The lornoxicam group significantly decreased fibroblast in growth and reepithelization of the mucosa at the anastomotic site on the 3rd pod and significantly increased occurrence of deep reaching defects, necrosis, and microabscess on the 7th pod. Conclusion. Lornoxicam administration during the perioperative period adversely affects histologic parameters of intestinal anastomotic healing. These effects of lornoxicam administration were not found to induce significant increase of anastomotic dehiscence in the rat model. Stamatoula Drakopoulou, Elissaios Kontis, Eirini Pantiora, Antonios Vezakis, Despoina Karandrea, Eftychia Aravidou, Agathi Konti-Paphiti, Erifili Argyra, Dionisios Voros, Andreas A. Polydorou, and Georgios P. Fragulidis Copyright © 2016 Stamatoula Drakopoulou et al. All rights reserved. Surgically Resected Gall Bladder: Is Histopathology Needed for All? Wed, 30 Mar 2016 11:38:37 +0000 Background. Laparoscopic cholecystectomy is considered to be gold standard for symptomatic gall stones. As a routine every specimen is sent for histopathological examination postoperatively. Incidentally finding gall bladder cancers in those specimens is around 0.5–1.1%. The aim of this study is to identify those preoperative and intraoperative factors in patients with incidental gall bladder cancer to reduce unnecessary work load on pathologist and cost of investigation particularly in a developing world. Methods. Retrospective records were analyzed from January 2005 to February 2015 in a surgical unit. Demographic data, preoperative imaging, peroperative findings, macroscopic appearance, and histopathological findings were noted. Gall bladder wall was considered to be thickened if ≥3 mm on preoperative imaging or surgeons comment (on operative findings) and histopathology report. AJCC TNM system was used to stage gall bladder cancer. Results. 973 patients underwent cholecystectomy for symptomatic gallstone disease. Gallbladder carcinoma was incidentally found in 11 cases. Macroscopic abnormalities of the gallbladder were found in all those 11 patients. In patients with a macroscopically normal gallbladder, there were no cases of gallbladder carcinoma. Conclusion. Preoperative and operative findings play a pivotal role in determining incidental chances of gall bladder malignancy. Vikash Talreja, Aun Ali, Rabel Khawaja, Kiran Rani, Sunil Sadruddin Samnani, and Farah Naz Farid Copyright © 2016 Vikash Talreja et al. All rights reserved. Haemostasis in Thyroid Surgery: Collagen-Fibrinogen-Thrombin Patch versus Cellulose Gauze—Our Experience Thu, 25 Feb 2016 11:12:50 +0000 Purpose. Postoperative hemorrhage is fortunately uncommon but potentially life-threatening complication of thyroid surgery that increases the postoperative morbidity and the hospital stay. In this study we compare the efficacy of collagen patch coated with human fibrinogen and human thrombin (CFTP) (group C) and oxidized regenerated cellulose gauze (group B) versus traditional hemostatic procedures (group A) in thyroid surgery. Methods. From January 2011 to December 2013, 226 were eligible for our prospective, nonrandomized, comparative study. Patients requiring a video-assisted thyroidectomy without drain, “near total,” or hemithyroidectomy were excluded. Other exclusion criteria were a diagnosis of malignancy, substernal goiter, disorders of hemostasis or coagulation, and Graves or hyperfunctioning thyroid diseases. Outcomes included duration of operation, drainage volume, and postoperative complications. Results. Our results show a significant reduction in drainage volume in group C in comparison with the other two groups. In group C there was no bleeding but the limited numbers do not make this result significant. There were no differences in terms of other complications, except for the incidence of seroma in group B. Conclusion. The use of CFTP reduces the drainage volume, potentially the bleeding complications, and the hospital stay. These findings confirm the efficacy of CFTP, encouraging its use in thyroid surgery. Nicola Tartaglia, Alessandra Di Lascia, Vincenzo Lizzi, Pasquale Cianci, Alberto Fersini, Antonio Ambrosi, and Vincenzo Neri Copyright © 2016 Nicola Tartaglia et al. All rights reserved. High-Volume Transanal Surgery with CPH34 HV for the Treatment of III-IV Degree Haemorrhoids: Final Short-Term Results of an Italian Multicenter Clinical Study Sun, 21 Feb 2016 15:38:20 +0000 The clinical chart of 621 patients with III-IV haemorrhoids undergoing Stapled Hemorrhoidopexy (SH) with CPH34 HV in 2012–2014 was consecutively reviewed to assess its safety and efficacy after at least 12 months of follow-up. Mean volume of prolapsectomy was significantly higher (13.0 mL; SD, 1.4) in larger prolapse (9.3 mL; SD, 1.2) (). Residual or recurrent haemorrhoids occurred in 11 of 621 patients (1.8%) and in 12 of 581 patients (1.9%), respectively. Relapse was correlated with higher preoperative Constipation Scoring System (CSS) (), Pescatori’s degree (), Goligher’s grade (), prolapse exceeding half of the length of the Circular Anal Dilator (CAD) (), and higher volume of prolapsectomy (). At regression analysis, only the preoperative CSS, Pescatori’s degree, Goligher’s grade, and volume of resection were significantly predictive of relapse. A high level of satisfaction (VAS = 8.6; SD, 1.0) coupled with a reduction of 12-month CSS (Δ preoperative CSS/12 mo CSS = 3.4, SD, 2.0; ) was observed. The wider prolapsectomy achievable with CPH34 HV determined an overall 3.7% relapse rate in patients with high prevalence of large internal rectal prolapse, coupled with high satisfaction index, significant reduction of CSS, and very low complication rates. Giuliano Reboa, Marco Gipponi, Maurizio Gallo, Giovanni Ciotta, Marco Tarantello, Angelo Caviglia, Antonio Pagliazzo, Luigi Masoni, Giuseppe Caldarelli, Fabio Gaj, Bruno Masci, and Andrea Verdi Copyright © 2016 Giuliano Reboa et al. All rights reserved. Surgical Management of Local Recurrences of Renal Cell Carcinoma Tue, 26 Jan 2016 15:45:44 +0000 Surgical resection either in the form of radical nephrectomy or in the form of partial nephrectomy represents the mainstay options in the treatment of kidney cancer. In most instances, resecting the tumor bearing kidney or the tumor itself provides durable cancer specific survival rates. However, recurrences may rarely develop in the renal fossa or remnant kidney. Despite its rarity, locally recurrent RCC is a challenging condition in terms of the possible management options and relatively poor prognosis. If technically feasible, wide surgical excision and ensuring negative surgical margins are the most effective treatment options. Repeat surgeries (completion nephrectomy, excision of locally recurrent tumor, or repeat partial nephrectomy) may often be complicated, and perioperative morbidity is a major concern. Open approach has been extensively applied in this context and 5-year cancer specific survival rates have been reported to be around 50%. The roles of minimally invasive surgical options (laparoscopic and robotic approach) and nonsurgical alternatives (cryoablation, radiofrequency ablation) have yet to be described. In selected patients, surgical resection may have to be complemented with (neo)adjuvant radiotherapy or medical treatment. Ömer Acar and Öner Şanlı Copyright © 2016 Ömer Acar and Öner Şanlı. All rights reserved. Comment on “Panniculectomy Combined with Bariatric Surgery by Laparotomy: An Analysis of 325 Cases” Mon, 04 Jan 2016 07:49:37 +0000 R. Vilallonga Copyright © 2016 R. Vilallonga. All rights reserved. Knowledge, Practice, and Associated Factors towards Prevention of Surgical Site Infection among Nurses Working in Amhara Regional State Referral Hospitals, Northwest Ethiopia Tue, 15 Dec 2015 06:44:40 +0000 Knowledge and practice of nurses about surgical site infections (SSIs) are not well studied in Ethiopia. This paper contains findings about Northwest Ethiopian nurses’ knowledge and practice regarding the prevention of SSIs. The main objective of the study was to assess knowledge, practice, and associated factors of nurses towards the prevention of SSIs. The study was done using a questionnaire survey on randomly selected 423 nurses who were working in referral hospitals during the study period. The study showed that more than half of the nurses who participated in the survey had inadequate knowledge about the prevention of SSIs. Moreover, more than half of them were practicing inappropriately. The most important associated factors include lack of training on evidence based guidelines and sociodemographic variables (age, year of service, educational status, etc.). Training of nurses with the up-to-date SSIs guidelines is recommended. Freahiywot Aklew Teshager, Eshetu Haileselassie Engeda, and Workie Zemene Worku Copyright © 2015 Freahiywot Aklew Teshager et al. All rights reserved. Review of Subcutaneous Wound Drainage in Reducing Surgical Site Infections after Laparotomy Sun, 13 Dec 2015 06:44:16 +0000 Purpose. Surgical site infections (SSIs) remain a significant problem after laparotomies. The aim of this review was to assess the evidence on the efficacy of subcutaneous wound drainage in reducing SSI. Methods. MEDLINE database was searched. Studies were identified and screened according to criteria to determine their eligibility for meta-analysis. Meta-analysis was performed using the Mantel-Haenszel method and a fixed effects model. Results. Eleven studies were included with two thousand eight hundred and sixty-four patients. One thousand four hundred and fifty patients were in the control group and one thousand four hundred and fourteen patients were in the drain group. Wound drainage in all patients shows no statistically significant benefit in reducing SSI incidence. Use of drainage in high risk patients, contaminated wound types, and obese patients appears beneficial. Conclusion. Using subcutaneous wound drainage after laparotomy in all patients is unnecessary as it does not reduce SSI risk. Similarly, there seems to be no benefit in using it in clean and clean contaminated wounds. However, there may be benefit in using drains in patients who are at high risk, including patients who are obese and/or have contaminated wound types. A well designed trial is needed which examines these factors. B. Manzoor, N. Heywood, and A. Sharma Copyright © 2015 B. Manzoor et al. All rights reserved. Delorme’s Procedure for Complete Rectal Prolapse: A Study of Recurrence Patterns in the Long Term Thu, 10 Dec 2015 13:01:38 +0000 Introduction. The objective of this study was to determine the recurrence rate and associated risk factors of full-thickness rectal prolapse in the long term after Delorme’s procedure. Patients and Methods. The study involved adult patients with rectal prolapse treated with Delorme’s surgery between 2000 and 2012 and followed up prospectively in an outpatient unit. We assessed epidemiological data, Wexner constipation and incontinence score, recurrence patterns, and risk factors. Data were analyzed by univariate and multivariate studies and follow-up was performed according to Kaplan-Meier technique. The primary outcome was recurrence. Results. A total of 42 patients, where 71.4% () were women, with a median age of 76 years (IQR 66 to 86), underwent Delorme’s surgery. The median follow-up was 85 months (IQR 28 to 132). There was no mortality, and morbidity was 9.5%. Recurrence occurred in five patients (12%) within 14 months after surgery. Actuarial recurrence at five years was 9.9%. According to the univariate analysis, constipation and concomitant pelvic floor repair were the only factors found to be associated with recurrence. Multivariate analysis showed no statistically significant differences among variables studied. Kaplan-Meier estimate revealed that constipation was associated with a higher risk of recurrence (log-rank test, ). Conclusions. Delorme’s procedure is a safe technique with an actuarial recurrence at five years of 9.9%. The outcomes obtained in this study support the performance of concomitant postanal repair and levatorplasty to reduce recurrences. Also, severe constipation is associated with a higher recurrence rate. Carlos Placer, Jose M. Enriquez-Navascués, Ander Timoteo, Garazi Elorza, Nerea Borda, Lander Gallego, and Yolanda Saralegui Copyright © 2015 Carlos Placer et al. 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.