Surgery Research and Practice The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Surgical Audit of Patients with Ileal Perforations Requiring Ileostomy in a Tertiary Care Hospital in India Mon, 13 Jul 2015 12:32:59 +0000 Introduction. Ileal perforation peritonitis is a frequently encountered surgical emergency in the developing countries. The choice of a procedure for source control depends on the patient condition as well as the surgeon preference. Material and Methods. This was a prospective observational study including 41 patients presenting with perforation peritonitis due to ileal perforation and managed with ileostomy. Demographic profile and operative findings in terms of number of perforations, site, and size of perforation along with histopathological findings of all the cases were recorded. Results. The majority of patients were male. Pain abdomen and fever were the most common presenting complaints. Body mass index of the patients was in the range of 15.4–25.3 while comorbidities were present in 43% cases. Mean duration of preoperative resuscitation was hours. Operative findings showed that 78% patients had a single perforation; most perforations were 0.6–1 cm in size and within 15 cm proximal to ileocecal junction. Mesenteric lymphadenopathy was seen in 29.2% patients. On histopathological examination, nonspecific perforations followed by typhoid and tubercular perforations respectively were the most common. Conclusion. Patients with ileal perforations are routinely seen in surgical emergencies and their demography, clinical profile, and intraoperative findings may guide the choice of procedure to be performed. Hemkant Verma, Siddharth Pandey, Kapil Dev Sheoran, and Sanjay Marwah Copyright © 2015 Hemkant Verma et al. All rights reserved. Guidelines for Perioperative Management of the Diabetic Patient Tue, 19 May 2015 07:22:09 +0000 Management of glycemic levels in the perioperative setting is critical, especially in diabetic patients. The effects of surgical stress and anesthesia have unique effects on blood glucose levels, which should be taken into consideration to maintain optimum glycemic control. Each stage of surgery presents unique challenges in keeping glucose levels within target range. Additionally, there are special operative conditions that require distinctive glucose management protocols. Interestingly, the literature still does not report a consensus perioperative glucose management strategy for diabetic patients. We hope to outline the most important factors required in formulating a perioperative diabetic regimen, while still allowing for specific adjustments using prudent clinical judgment. Overall, through careful glycemic management in perioperative patients, we may reduce morbidity and mortality and improve surgical outcomes. Sivakumar Sudhakaran and Salim R. Surani Copyright © 2015 Sivakumar Sudhakaran and Salim R. Surani. All rights reserved. Hiatus Hernia Repair with Bilateral Oesophageal Fixation Thu, 30 Apr 2015 07:24:04 +0000 Background. Despite advances in surgical repair of hiatus hernias, there remains a high radiological recurrence rate. We performed a novel technique incorporating bilateral oesophageal fixation and evaluated outcomes, principally symptom improvement and hernia recurrence. Methods. A retrospective study was performed on a prospective database of patients undergoing hiatus hernia repair with bilateral oesophageal fixation. Retrospective and prospective quality of life (QOL), PPI usage, and patient satisfaction data were obtained. Hernia recurrence was assessed by either barium swallow or gastroscopy. Results. 87 patients were identified in the database with a minimum of 3 months followup. There were significant improvements in QOL scores including GERD HRQL (29.13 to 4.38, ), Visick (3 to 1), and RSI (17.45 to 5, ). PPI usage decreased from a median of daily to none, and there was high patient satisfaction (94%). 57 patients were assessed for recurrence with either gastroscopy or barium swallow, and one patient had evidence of recurrence on barium swallow at 45 months postoperatively. There was an 8% complication rate and no mortality or oesophageal perforation. Conclusions. This study demonstrates that our technique is both safe and effective in symptom control, and our recurrence investigations demonstrate at least short term durability. Rajith Mendis, Caran Cheung, and David Martin Copyright © 2015 Rajith Mendis et al. All rights reserved. Evaluation of Early versus Delayed Laparoscopic Cholecystectomy in Acute Cholecystitis Tue, 03 Feb 2015 08:45:29 +0000 Background. The role of early laparoscopic cholecystectomy for acute cholecystitis with cholelithiasis is not yet established. The aim of our prospective randomized study was to evaluate the safety and feasibility of early LC for acute cholecystitis and to compare the results with delayed LC. Methods. Between March 2007 to December 2008, 50 patients with diagnosis of acute cholecystitis were assigned randomly to early group, (LC within 24 hrs of admission), and delayed group, (initial conservative treatment followed by delayed LC, 6–8 weeks later). Results. We found in our study that the conversion rate in early LC and delayed LC was 16% and 8%, respectively, Operation time for early LC was 69.4 min versus 66.4 min for delayed LC, postoperative complications for early LC were 24% versus 8% for delayed LC, and blood loss was 159.6 mL early group versus 146.8 mL for delayed group. However early LC had significantly shorter hospital stay (4.1 days versus 8.6 days). Conclusions. Early LC for acute cholecystitis with cholelithiasis is safe and feasible, offering the additional benefit of shorter hospital stay. It should be offered to the patients with acute cholecystitis, provided that the surgery is performed within 96 hrs of acute symptoms by an experienced surgeon. Rati Agrawal, K. C. Sood, and Bhupender Agarwal Copyright © 2015 Rati Agrawal et al. All rights reserved. Appendicitis in Children: Evaluation of the Pediatric Appendicitis Score in Younger and Older Children Wed, 10 Dec 2014 10:26:04 +0000 Background. This study aimed to evaluate Pediatric Appendicitis Score (PAS), diagnostic delay, and factors responsible for possible late diagnosis in children <4 years compared with older children who were operated on for suspected appendicitis. Method. 122 children, between 1 and 14 years, operated on with appendectomy for suspected appendicitis, were retrospectively analyzed. The cohort was divided into two age groups: ≥4 years () and <4 years (). Results. The mean PAS was lower among the younger compared with the older patients (5.3 and 6.6, resp.; ), despite the fact that younger children had more severe appendicitis (75.0% and 33.3%, resp.; ). PAS had low sensitivity in both groups, with a significantly lower sensitivity among the younger patients. Parent and doctor delay were confirmed in children <4 years of age with appendicitis. PAS did not aid in patients with doctor delay. Parameters in patient history, symptoms, and abdominal examination were more diffuse in younger children. Conclusion. PAS should be used with caution when examining children younger than 4 years of age. Diffuse symptoms in younger children with acute appendicitis lead to delay and to later diagnosis and more complicated appendicitis. Martin Salö, Gustav Friman, Pernilla Stenström, Bodil Ohlsson, and Einar Arnbjörnsson Copyright © 2014 Martin Salö et al. All rights reserved. Team Training (Training at Own Facility) versus Individual Surgeon’s Training (Training at Trainer’s Facility) When Implementing a New Surgical Technique: Example from the ONSTEP Inguinal Hernia Repair Wed, 19 Nov 2014 12:38:42 +0000 Background. When implementing a new surgical technique, the best method for didactic learning has not been settled. There are basically two scenarios: the trainee goes to the teacher’s clinic and learns the new technique hands-on, or the teacher goes to the trainee’s clinic and performs the teaching there. Methods. An informal literature review was conducted to provide a basis for discussing pros and cons. We also wanted to discuss how many surgeons can be trained in a day and the importance of the demand for a new surgical procedure to ensure a high adoption rate and finally to apply these issues on a discussion of barriers for adoption of the new ONSTEP technique for inguinal hernia repair after initial training. Results and Conclusions. The optimal training method would include moving the teacher to the trainee’s department to obtain team-training effects simultaneous with surgical technical training of the trainee surgeon. The training should also include a theoretical presentation and discussion along with the practical training. Importantly, the training visit should probably be followed by a scheduled visit to clear misunderstandings and fine-tune the technique after an initial self-learning period. Jacob Rosenberg, Kristoffer Andresen, and Jannie Laursen Copyright © 2014 Jacob Rosenberg et al. All rights reserved. A Surgeon’s Perspective of Abdominal Wall Endometriosis at a Caesarean Section Incision: Nine Cases in a Single Institution Mon, 22 Sep 2014 07:03:27 +0000 Abdominal wall endometriosis in a Caesarean section scar (AEC) is an infrequent type of extrapelvic endometriosis which rarely transforms into a malignant lesion. A painful mass located in the scar of a Caesarean section is a typical sign of AEC. This condition is diagnosed preoperatively using imaging modalities such as computed tomography and ultrasonography, as well as fine-needle aspiration. Although AEC has typical signs, general surgeons often misdiagnose it due to its rarity. Herein, we report our experience of AEC in a single institution. Eun Mee Oh, Won-Suk Lee, Jin Mo Kang, Sang Tae Choi, Keon Kuk Kim, and Woon Kee Lee Copyright © 2014 Eun Mee Oh et al. All rights reserved. Pre- and Postoperative Vomiting in Children Undergoing Video-Assisted Gastrostomy Tube Placement Tue, 12 Aug 2014 09:30:54 +0000 Background. The aim of this study was to determine the incidence of pre- and postoperative vomiting in children undergoing a Video-Assisted Gastrostomy (VAG) operation. Patients and Methods. 180 children underwent a VAG operation and were subdivided into groups based on their underlying diagnosis. An anamnesis with respect to vomiting was taken from each of the children’s parents before the operation. After the VAG operation, all patients were followed prospectively at one and six months after surgery. All complications including vomiting were documented according to a standardized protocol. Results. Vomiting occurred preoperatively in 51 children (28%). One month after surgery the incidence was 43 (24%) in the same group of children and six months after it was found in 40 (22%). There was a difference in vomiting frequency both pre- and postoperatively between the children in the groups with different diagnoses included in the study. No difference was noted in pre- and postoperative vomiting frequency within each specific diagnosis group. Conclusion. The preoperative vomiting symptoms persisted after the VAG operation. Neurologically impaired children had a higher incidence of vomiting than patients with other diagnoses, a well-known fact, probably due to their underlying diagnosis and not the VAG operation. This information is useful in preoperative counselling. Torbjörn Backman, Helén Sjövie, Malin Mellberg, Anna Börjesson, Magnus Anderberg, Carl-Magnus Kullendorff, and Einar Arnbjörnsson Copyright © 2014 Torbjörn Backman et al. All rights reserved. Residual Prolapse in Patients with III-IV Degree Haemorrhoids Undergoing Stapled Haemorrhoidopexy with CPH34 HV: Results of an Italian Multicentric Clinical Study Sun, 15 Jun 2014 10:16:54 +0000 CPH34 HV, a high volume stapler, was tested in order to assess its safety and efficacy in reducing residual/recurrent haemorrhoids. The clinical charts of 430 patients with third- to fourth-degree haemorrhoids undergoing SH in 2012-2013 were consecutively reviewed, excluding those with obstructed defecation (rectocele >2 cm; Wexner’s score >15). Follow-up was scheduled at six and 12 months. Rectal prolapse exceeding more than half of CAD was reported in 341 patients (79.3%); one technical failure was reported (0.2%) without any serious untoward effect; and 1.3 stitch/patient (SD, 1.7) was required to achieve complete haemostasis. Doughnuts volume was higher (13.8 mL; SD, 1.5) in patients with a large rectal prolapse than with smaller one (8.9 mL; SD, 0.7) ( value <0.05). Residual and recurrent haemorrhoids occurred in 8 of 430 patients (1.8%) and 5 of 254 patients (1.9%), respectively. A high index of patient satisfaction (visual analogue scale = 8.9; SD, 0.9) coupled with a persistent reduction of constipation scores (CSS = 5.0, SD, 2.2) was observed. The wider prolapse resection well correlated with a clear-cut reduction of haemorrhoidal relapse, a high index of patient satisfaction, and clinically relevant reduction of constipations scores coupled with satisfactory haemostatic properties of CPH34 HV. Giuliano Reboa, Marco Gipponi, Andrea Rattaro, Giovanni Ciotta, Marco Tarantello, Angelo Caviglia, Antonio Pagliazzo, Luigi Masoni, Giuseppe Caldarelli, Fabio Gaj, Bruno Masci, and Andrea Verdi Copyright © 2014 Giuliano Reboa et al. All rights reserved. Awareness and Attitude of Healthcare Workers to Cosmetic Surgery in Osogbo, Nigeria Wed, 11 Jun 2014 07:14:49 +0000 This study aimed at understanding the level of awareness and elucidates the attitude and disposition of healthcare workers to cosmetic surgery in Osogbo, Nigeria. A questionnaire-based survey was done at LAUTECH Teaching Hospital, Osogbo, in 2012. Questionnaires were administered to 213 workers and students in the hospital. These were then analysed using SPSS version 16.0 with frequencies, means, and so forth. Respondents were 33 doctors, 32 nurses, 79 medical students, 60 nursing students, 4 administrative staff, 1 pharmacist, and 4 ward maids. There is fair awareness about cosmetic surgery generally with 94.5% and its availability in Nigeria with 67.0%. A fewer proportion of the respondents (44.5%) were aware of the facility for cosmetic surgery in their locality. A large percentage (86.5%) favorably considers facilities outside Nigeria when making choice of facility to have cosmetic surgery done. 85.5% considered the information about cosmetic surgery reliable while 19.0% objected going for cosmetic surgery of their choice even if done free. Only 34.0% consider cosmetic surgery socially acceptable. Although the awareness of health workers about cosmetic surgery is high, their disposition to it is low. There is a need to increase the awareness in order to increase cosmetic surgery practice in Nigeria. Opeyemi Adeniyi Adedeji, Ganiyu Oladiran Oseni, and Peter Babatunde Olaitan Copyright © 2014 Opeyemi Adeniyi Adedeji et al. All rights reserved. Management of Superficial Abscesses: Scope for Day Case Surgery Mon, 26 May 2014 07:05:50 +0000 Background. Patients presenting with superficial abscesses are often regarded as low priority and given a less efficient service. Aim. The aim of this study was to investigate the efficiency of emergency treatment of superficial abscesses and to identify areas for service improvement. Method. A retrospective case review of patients admitted to Derriford Hospital, Plymouth, over a four-month period. Results. Ninety-seven patients were included in the study. Seventy two (74%) arrived between 08.00 and 16.00 hours. Overall, 75 patients (77%) were referred on weekdays with 22 patients (23%) during weekends. Seventy-two patients (74%) had treatment under a general anaesthetic. Sixty-three percent of operations occurred within the working day. The time interval between admission and surgery ranged from 52 minutes to 38 hours (mean ± SD 16 ± 9.15). The length of admission ranged from 5.3 hours to 11 days (mean 36 hours). Of the one hundred overnight beds used by the 97 patients, 30 nights were spent awaiting surgery and 70 following surgery and awaiting discharge. Conclusion. Eighty-nine percent of the patients would have been suitable for treatment as day cases. This review shows that a simple service redesign has the potential of reducing inpatient bed occupancy and improving the patient’s journey. Martha Nixon and Jacob A. Akoh Copyright © 2014 Martha Nixon and Jacob A. Akoh. All rights reserved. Six-Year Experience of a Nurse-Led Colorectal Cancer Follow-Up Clinic Tue, 20 May 2014 12:52:43 +0000 Aims and Objectives. To review the experience of a nurse-led colorectal cancer follow-up clinic in a tertiary referral colorectal cancer centre. Methodology. Data from the nurse-led colorectal cancer follow-up clinic in our unit was prospectively maintained in a colorectal cancer database. Data was analysed from January 1, 2006 until the December 31, 2011. Results. 1125 patients were diagnosed with colorectal cancer, and referred to our unit as a tertiary centre for specialised colorectal cancer. Nine hundred and four patients had surgical resection of their colorectal cancer. Four hundred and seven patients were referred to the nurse-led colorectal cancer clinic for surveillance. The mean age of the patient cohort was 67 years (range 32–88) and 56% of patients were male. One hundred and seventeen patients were discharged to their general practitioner having been disease free after 5 years of followup. Fifty-four patients were diagnosed with either local or distant recurrence. Conclusion. A nurse-led colorectal cancer follow-up clinic is running according to strict follow-up protocols. This type of clinic significantly reduces the number of routine follow-up patients that have to be seen by the colorectal surgical consultant. Hasan Al Chalabi, James M. O’Riordan, Alex Richardson, Delia Flannery, Katrina O'Connor, Charlotte Stuart, John Larkin, Paul McCormick, and Brian Mehigan Copyright © 2014 Hasan Al Chalabi et al. All rights reserved. PET/CT Is Complementary to Fine-Needle Aspiration Cytology in Assessment of Irradiated Neck in Head and Neck Cancers Sun, 18 May 2014 08:08:25 +0000 Background. Accurate assessment of irradiated neck in squamous cell carcinoma of the head and neck (HNSCC) is essential. Fine-needle aspiration cytology is often performed for suspicious lesions but it is limited by its low negative predictive value (NPV). We postulated that F-18 fluorodeoxyglucose (FDG) positron emission tomography combined with computed tomography (PET/CT) can overcome this limitation by its high NPV value and allow for a more accurate assessment of irradiated neck in HNSCC. Methods. Fifty-four HNSCC patients were included for the study. They all received previous irradiation to the neck. Clinical characteristics, details of radiotherapy, PET/CT results, follow-up findings, and final histological diagnosis were analyzed. Results. The sensitivity, specificity, positive predictive value (PPV), and NPV were 95.8%, 96.7%, 95.8%, and 96.7%, respectively. Age, sex, radiation dose, interval between PET/CT and radiotherapy completion, nature of radiotherapy, and use of second course of radiotherapy were not found to affect diagnostic accuracy of PET/CT. A new algorithm for investigation of masses in irradiated neck is proposed. Conclusions. PET/CT is an effective diagnostic tool and has a complementary role to FNAC in the management of irradiated neck in head and neck cancers, particularly in cases where suspicious lesions were identified but FNAC showed negative results. R. C. L. Chan and Y. W. Chan Copyright © 2014 R. C. L. Chan and Y. W. Chan. All rights reserved. Percutaneous Vertebral Body Augmentation: An Updated Review Mon, 28 Apr 2014 13:29:56 +0000 There are many medical conditions like osteoporosis, tumor, or osteonecrosis that weaken the structural strength of the vertebral body and prone it to fracture. Percutaneous vertebral augmentation that is usually applied by polymethylmethacrylate is a relatively safe, effective, and long lasting procedure commonly performed in these situations. In this paper, we updated a review of biomechanics, indications, contraindications, surgical techniques, complications, and overall prognosis of these minimally invasive spinal procedures. Farzad Omidi-Kashani Copyright © 2014 Farzad Omidi-Kashani. All rights reserved. Skin Staples: A Safe Technique for Securing Mesh in Lichtensteins Hernioplasty as Compared to Suture Thu, 03 Apr 2014 11:06:12 +0000 Background. Lichtenstein tension free repair is the most commonly used technique due to cost effectiveness, low recurrence rate, and better patient satisfaction. This study was done to compare the duration of surgery and postoperative outcome of securing mesh with skin staples versus polypropylene sutures in Lichtenstein hernia repair. Materials and Methods. A total of 96 patients with inguinal hernia undergoing Lichtenstein mesh repair were randomly assigned into two groups. The mesh was secured either by using skin staples (group I) or polypropylene sutures (group II). Results. The operation time was significantly reduced from mesh insertion to completion of skin closure in group I (mean 20.7 min) as compared to group II (mean 32.7 min) with significant value and less complication rate in group I as compared to group II. Conclusion. Mesh fixation with skin staples is as effective as conventional sutures with added advantage of significant reduction in the operating time and complications or recurrence. The staples can be applied much more quickly than sutures for fixing the mesh, thus saving the operating time. Infection rate is significantly decreased with staples. Anand Munghate, Sushil Mittal, Harnam Singh, Gurpreet Singh, and Manish Yadav Copyright © 2014 Anand Munghate et al. All rights reserved. Resection Leads to Less Recurrence Than Strictureplasty in a Paediatric Population with Obstructive Crohn’s Disease Tue, 01 Apr 2014 08:17:45 +0000 Introduction. Resection and strictureplasty are used to treat patients with obstructive Crohn’s disease. Strictureplasty is preferable in adults as it retains bowel length. This study aims to identify differences in outcomes of children undergoing strictureplasty and resection for obstructive Crohn’s disease. Method. Patients under 20 years undergoing surgery over a nine-year period were included. Data was collected on procedures for stenotic Crohn’s disease. Patients were divided into 2 groups: Group 1 treated with strictureplasties and Group 2 resections. Postoperative complications and recurrence rates were recorded. Kaplan-Meier method was used to analyze the data. Results. Twenty-six patients and 40 operations were identified. Mean age was 15.6 years (7.2–19.4) with equal numbers of males and females. Mean follow-up was 45.9 months (0.1–149.9). 20/40 procedures involved the terminal ileum; 9/40, the ileocolic junction; 8/40, the upper GI tract; and 3/40, the colon. Group 1 consisted of 19 strictureplasties and Group 2 consisted of 13 resections and 8 combined procedures. Significantly more patients in Group 1 required further surgery (11/19 versus 3/21; ). Conclusion. Allowing for variations in disease duration, severity, and previous medical management, these data suggest that resection is preferable to strictureplasty in treating obstructive Crohn’s disease in children and adolescents. Richard Bamford, Ashley Hay, and Devinder Kumar Copyright © 2014 Richard Bamford et al. All rights reserved. A Comparative Study between the Outcome of Primary Repair versus Loop Ileostomy in Ileal Perforation Thu, 27 Mar 2014 09:57:01 +0000 Introduction. Ileal perforation peritonitis is a common surgical emergency in the Indian subcontinent and in tropical countries. It is reported to constitute the fifth common cause of abdominal emergencies due to high incidence of enteric fever and tuberculosis in these regions. Methods. Sixty proven cases of ileal perforation patients admitted to Surgical Emergency were taken up for emergency surgery. Randomisation was done by senior surgeons by picking up card from both the groups. The surgical management was done as primary repair (group A) and loop ileostomy (group B). Results. An increased rate of postoperative complications was seen in group A when compared with group B with 6 (20%) patients landed up in peritonitis secondary to leakage from primary repair requiring reoperation as compared to 2 (6.67%) in ileostomy closure. A ratio of 1 : 1.51 days was observed between hospital stay of group A to group B. Conclusion. In cases of ileal perforation temporary defunctioning loop ileostomy plays an important role. We recommend that defunctioning ileostomy should be preferred over other surgical options in cases of ileal perforations. It should be recommended that ileostomy in these cases is only temporary and the extra cost and cost of management are not more than the price of life. Sushil Mittal, Harnam Singh, Anand Munghate, Gurpreet Singh, Anjna Garg, and Jyoti Sharma Copyright © 2014 Sushil Mittal et al. All rights reserved. Treatment of Sternoclavicular Joint Osteomyelitis with Debridement and Delayed Resection with Muscle Flap Coverage Improves Outcomes Wed, 12 Mar 2014 08:07:32 +0000 The objective of this study was to evaluate the efficacy of various treatment options for sternoclavicular joint osteomyelitis. We evaluated patients with a diagnosis of sternoclavicular joint osteomyelitis, treated at our hospital from 2002 to 2012. Four treatment options were compared. Three out of twelve patients were successfully cured with antibiotics alone (25%). Debridement with or without negative pressure therapy was successful for one of three patients (33%). Simultaneous debridement, bone resection, and muscle flap coverage of the acquired defect successfully treated one of two patients (50%). Debridement with delayed bone resection and muscle flap coverage was successful in five of five patients (100%). Osteomyelitis of the sternoclavicular joint is a rare disease that has become more prevalent in recent years and can be associated with increasing use of long-term indwelling catheters. Initial debridement with delayed bone resection and pectoralis major muscle flap coverage can effectively treat sternoclavicular joint osteomyelitis. Jason L. Muesse, Shanda H. Blackmon, Warren A. Ellsworth IV, and Min P. Kim Copyright © 2014 Jason L. Muesse et al. All rights reserved. What Is the Role of Hysteroscopic Surgery in the Management of Female Infertility? A Review of the Literature Mon, 03 Mar 2014 12:55:43 +0000 The position of hysteroscopy in current fertility practice is under debate. There are many randomized controlled trials on technical feasibility and patient compliance demonstrating that the procedure is well tolerated and effective in the treatment of intrauterine pathologies. However, no consensus on the effectiveness of hysteroscopic surgery in improving the prognosis of subfertile women is available. A literature review was performed to explore the available information regarding the role of hysteroscopy in the evaluation and management of female infertility as well as to ascertain evidence that treatment of these uterine abnormalities improves fertility. The debate regarding the role of hysteroscopic surgery in the management of female infertility remains as the published studies did not reach a consensus on the benefit of such an intervention in this setting. The randomized trials do not clearly demonstrate that surgical correction of all intrauterine abnormalities improves IVF outcome. However, published observational studies suggest a benefit for resection of submucosal leiomyomas, adhesions, and endometrial polyps in increasing pregnancy rates. More randomised controlled studies are needed to substantiate the effectiveness of the hysteroscopic removal of suspected intrauterine pathology in women with unexplained subfertility or prior to assisted reproductive technology. Márcia Mendonça Carneiro Copyright © 2014 Márcia Mendonça Carneiro. All rights reserved. Utility of Preoperative CA125 Assay in the Management Planning of Women Diagnosed with Uterine Cancer Thu, 27 Feb 2014 11:50:18 +0000 Objective. This study assesses the role of preoperative serum CA125 levels in the planning treatment options for women diagnosed with uterine cancer. Material and Method. Ninety five consecutive patients diagnosed with uterine cancer during a four-year period were identified. Age ranged from 35 to 89 years with a mean age of 69 years. The preoperative CA125 levels were dichotomised at 28 U/mL (using ROC analysis to identify the best discriminating threshold for 5-year survival). This level was then correlated with preoperative prognostic indicators: patient age, tumour grade, and histopathological tumour cell type. Survival data was plotted using Kaplan-Meier curves and analysed using the log-rank test. Univariate and multivariate analysis were performed to identify the predictors of overall survival. Results. The mean age of patients was 69 years (range: 35–89). On univariate analysis, the use of preoperative CA125 levels of greater or less than 28 U/mL correlated significantly with age , the grade of disease and unfavourable tissue type . This threshold CA125 level had a sensitivity of 75%, specificity of 76%, positive predictive value of 35% and negative predicative value of 96.25%, and a likelihood ratio of 3.12 for predicting nodal disease. Using a threshold of preoperative CA125 level of 28 U/mL (area under curve: 0.60) was also a significant predictor of 5-year survival (log-rank test, ). Using Cox multivariate survival analysis to identify predictive preoperative factors overall, unfavourable cell type was the strongest predictor of survival (Chi square = 36.5, df = 4, and ), followed by preoperative CA125 level (CA125 > 28 U/mL, ) and unfavourable preoperative grade (). Amongst patients with a favourable histological tissue type (endometrioid), preoperative CA125 levels predicted overall survival (Chi square = 6.039, df = 2, ); however unfavourable preoperative grade did not (). Overall, at five-year follow-up, while there were no deaths among the women with preoperative serum CA125 less than 12 U/mL, eleven of the twenty-three deaths (47.82%) in the study occurred in women with a preoperative CA125 more than 28 U/mL. Conclusions. A preoperative CA125 assay for women with uterine cancer is a relatively inexpensive, reproducible, and objective test which provides valuable information regarding the risk of metastatic disease and overall likelihood of long term survival. Patients with a low likelihood of metastatic/nodal disease (favourable tissue type and CA125 level < 28 U/mL) and significant comorbidities may benefit from avoiding an extended complete staging procedure. Alternatively, a high level of CA125 may prompt further imaging and multidisciplinary discussions to plan for individualised management and consideration for recruitment to clinical trials. N. Povolotskaya, N. Das, K. Dhar, D. Brinkmann, F. Gardner, and R. Woolas Copyright © 2014 N. Povolotskaya et al. All rights reserved. Alterations in the Coagulation System during Major Visceral Surgery in Children Wed, 26 Feb 2014 08:44:33 +0000 Purpose. The description of the alterations in the hemostatic system in children undergoing abdominal surgery is sparse. Enhanced clinical outcomes for previously untreatable conditions have led to an increased incidence of venous thromboembolic complications. Alterations in children’s coagulation system during major abdominal operations compared to minor procedures were examined. Methods. Children (0–12 years) undergoing either laparotomy, thoracotomy, or minor surgery were included. Participants were divided into two groups: group 1 was open laparotomy including operations for solid abdominal tumours and thoracotomy, while group 2 was minor surgery. Activated partial thromboplastin time (aPTT), D-dimer, INR, and fibrinogen were measured. Results. Both groups had a shorter aPTT, higher INR, and lower fibrinogen concentrations after the operation, while D-dimer was unaltered. The changes were, however, discrete and probably not clinically significant. On day 3, all parameters except aPTT in group 1 (not measured in group 2) indicated a continuous coagulation activity. Conclusion. The tendency for coagulation activity altered based on the length and degree of surgery. A continuously altered activity was observed compatible with the reported increased risk of venous thromboembolism at day 3. However, before introducing thromboprophylaxis guidelines larger series of multicentre studies are needed. Hayarpi H. Kordjian, Mads Nybo, and Niels Qvist Copyright © 2014 Hayarpi H. Kordjian et al. All rights reserved. Nonfunctional Metastatic Parathyroid Carcinoma in the Setting of Multiple Endocrine Neoplasia Type 2A Syndrome Thu, 20 Feb 2014 09:57:23 +0000 Parathyroid carcinoma is a very rare malignancy. It has been associated with hyperparathyroidism-jaw tumour syndrome, familial isolated primary hyperparathyroidism, and multiple endocrine neoplasia type 1 (MEN-1) and 2A (MEN-2A) syndromes. We report a 54-year-old man with a MEN-2A which presents with a nonfunctional metastatic parathyroid carcinoma and a pheochromocytoma in the absence of medullary thyroid carcinoma. Only a few cases of parathyroid carcinoma have been reported in the literature associated with this syndrome. María Posada-González, Joaquín Gómez-Ramírez, Manuel Luque-Ramírez, Mercedes Guijarro, Elena Martín-Pérez, Ana Rodríguez-Sánchez, Iñigo García-Sanz, and Eduardo Larrañaga Copyright © 2014 María Posada-González et al. All rights reserved. Flow Cytometric Evaluation of T Cell Activation Markers after Cardiopulmonary Bypass Thu, 06 Feb 2014 09:16:17 +0000 Background. Cardiopulmonary bypass surgery (CPBS) is associated with an increased risk for infections or with subsequent organ dysfunction. As T cell activation is a central mechanism during inflammatory processes, we developed an assay to evaluate T cell activation pathways in patients undergoing CPBS. Methods. Blood was obtained from eleven patients undergoing CPBS preoperatively, on postoperative day (POD)-3, and on POD-7 and was stimulated with different concentrations of Concanavalin A (ConA). Cyclosporine and sirolimus, inhibiting different pathways of the T cell cycle, were added to blood ex vivo. Expression of T cell activation markers CD25 and CD95 was analyzed by flow cytometry. Results. In untreated blood, expression of CD25 and CD95 significantly increased with higher ConA concentrations and decreased for all ConA concentrations for both antigens over the study time . Independently from the ConA concentration, inhibition of CD25 and CD95 expression was highest preoperatively for sirolimus and on POD-3 for cyclosporine. At all time points, inhibition of CD25 and CD95 expression was significantly higher after cyclosporine compared to sirolimus treatment . Conclusion. Our results showed that different pathways of T cell activation are impaired after CPBS. Such knowledge may offer the opportunity to identify patients at risk for postoperative complications. Maja-Theresa Dieterlen, Hartmuth B. Bittner, Attila Tarnok, Jens Garbade, Stefan Dhein, Friedrich W. Mohr, and Markus J. Barten Copyright © 2014 Maja-Theresa Dieterlen et al. All rights reserved. Complications following Treatment of Trochanteric Fractures with the Gamma3 Nail: Is the Latest Version of Gamma Nail Superior to Its Predecessor? Thu, 06 Feb 2014 00:00:00 +0000 Gamma nail is a cephalomedullary implant that was developed for the treatment of pertrochanteric hip fractures and has been successfully used for over 20 years. During this period, modifications of design and instrumentation have occurred to combat the intra- and postoperative complications that were associated with the use of early designs. The purpose of this study was to compare the complications observed with the use of the Gamma3 nail (G3N) with those seen following use of the previous trochanteric gamma nail (TGN). This study prospectively recorded the intra- and postoperative complications of 175 patients treated with the Gamma3 nail and compared them with those of a historical cohort of 192 patients treated with the trochanteric gamma nail. We encountered less intra- and postoperative complications with the use of Gamma3 nail. Femoral fractures and lag screw cutout were significantly lower. The reoperation rate was significantly higher in the TGN group. Gamma3 nail has proved to be a safe and efficient implant for the treatment of pertrochanteric fractures. The improvement of the biomechanical characteristics has led to a significant decrease in complication rates, demonstrating superiority over its predecessor. Dimitrios Georgiannos, Vasilios Lampridis, and Ilias Bisbinas Copyright © 2014 Dimitrios Georgiannos et al. All rights reserved. Melanoma of the Urinary Bladder: A Review of the Literature Sun, 12 Jan 2014 11:59:22 +0000 Background. Melanomas of the urinary bladder and urethra are rare. Aims. To review the literature on the disease. Methods. Various Internet databases were used to identify reported cases of the disease. Results. Less than 30 cases of primary melanoma of the urinary bladder and urethra have been reported in the literature and they have been associated with melanosis and commonly with metastases. The lesions may be primary or metastatic with no gender preference. The diagnostic features include pigmented raised lesions which histologically exhibit spindled or epitheliod cells, necrosis, mitotic figures, and atypical melanocytes. Immunohistochemically they stain positively with S100; HMB45; and other melanocyte markers, but negatively with Keratin and Vimentin. The treatment involves excision and possibly IL-2. The prognostic factors include size and depth of invasion as well as metastatic lesions. Conclusions. Less than 30 cases (about 24 cases) of the disease have been reported. There are also reports of metastatic melanomas of the urinary bladder emanating from primary melanomas originating elsewhere. Diagnosis of the primary disease is based upon the histological appearance of the lesion, positive staining with S100 and HMB45, and evidence of absence of melanoma elsewhere. Primary melanoma of the bladder is usually a fatal lesion. Anthony Kodzo-Grey Venyo Copyright © 2014 Anthony Kodzo-Grey Venyo. All rights reserved. Solitary Fibrous Tumour of the Pleura Presenting as a Spontaneous Massive Haemothorax Thu, 09 Jan 2014 06:08:52 +0000 Solitary fibrous tumours of the pleura are rare neoplasms. These tumours are generally asymptomatic and incidentally diagnosed. Symptoms, if present, are nonspecific such as cough, dyspnea, and chest pain. This report describes the case of a 38-year-old woman admitted to our department after the onset of a right massive spontaneous haemothorax requiring emergency surgical treatment. Intraoperatively a bleeding pleural mass was found to be the cause of the haemothorax. The tumour was successfully resected and the patient made an uneventful recovery. Histological examination revealed the mass to be a solitary fibrous tumour of the pleura. Giampiero Negri, Alessandro Bandiera, Paola Ciriaco, Giulio Melloni, Angelo Carretta, George Ian Cremona, and Piero Zannini Copyright © 2014 Giampiero Negri et al. All rights reserved. Autologous Fat Transfer: An Aesthetic and Functional Refinement for Parotidectomy Wed, 08 Jan 2014 16:33:05 +0000 Parotidectomy is a surgical procedure associated to functional (Frey’s syndrome) as well as aesthetic (facial asymmetry) complications that can be very disturbing for the patient. Several procedures have been described to primarily avoid or secondarily reconstruct the facial defect and treat the neurological iatrogenic syndrome. Autologous fat transfer was primarily used in 10 cases to avoid such complications. It is an easy technique widely used in cosmetic and reconstructive surgery. This technique gives very satisfying long-term results on the cosmetic as well as on the physiological point of view. Pierre G. Vico, Axel Delange, and Axel De Vooght Copyright © 2014 Pierre G. Vico et al. All rights reserved. Modern Management of the Exstrophy-Epispadias Complex Sun, 05 Jan 2014 12:42:06 +0000 The exstrophy-epispadias complex is a rare spectrum of malformations affecting the genitourinary system, anterior abdominal wall, and pelvis. Historically, surgical outcomes were poor in patients with classic bladder exstrophy and cloacal exstrophy, the two more severe presentations. However, modern techniques to repair epispadias, classic bladder exstrophy, and cloacal exstrophy have increased the success of achieving urinary continence, satisfactory cosmesis, and quality of life. Unfortunately, these procedures are not without their own complications. This review provides readers with an overview of the management of the exstrophy-epispadias complex and potential surgical complications. Brian M. Inouye, Ali Tourchi, Heather N. Di Carlo, Ezekiel E. Young, and John P. Gearhart Copyright © 2014 Brian M. Inouye et al. All rights reserved. An Intra-Abdominal Pseudocyst around a Ventriculoperitoneal Shunt due to Streptococcus Infection 7 Years after Shunt Surgery Sun, 05 Jan 2014 11:55:08 +0000 In 1999, a 50-year-old woman underwent ventriculoperitoneal (VP) shunt surgery for hydrocephalus after subarachnoid hemorrhage. She was hospitalized for fever and recurrent systemic seizures in November 2006. Head computed tomography (CT) showed only old changes. The seizures and fever were controlled by medicinal therapy. However, in December, her consciousness level suddenly decreased, and she showed progressive lower abdominal distension. Head CT showed marked ventriculomegaly, and abdominal CT showed a giant cystic mass at the shunt-tube tip in the lower abdominal cavity. Because thick pus was aspirated from the intra-abdominal mass, we diagnosed the patient with acute obstructive hydrocephalus due to an infected abdominal pseudocyst. Laparotomy and direct cyst drainage were performed, and antibiotic therapy against Streptococcus, the causative pathogen, was administered. The VP shunt tube was replaced. The postoperative course was uneventful, and postoperative CT showed hydrocephalus improvement and no pseudocyst recurrence. Abdominal pseudocysts, which are rare after VP shunt surgeries, usually occur after the subacute postoperative course in younger cerebral hemorrhagic cases. Our case was quite rare because the cyst developed in the chronic phase in an older patient and was caused by streptococcal infection. The cyst components should be examined before cyst drainage when choosing surgical strategies. Arata Tomiyama, Jun-ichi Harashina, Hitoshi Kimura, Keisuke Ito, Yoshihiko Honda, Hiroyuki Yanai, and Satoshi Iwabuchi Copyright © 2014 Arata Tomiyama et al. All rights reserved. Endoscopic Endonasal Transsphenoidal Resection for Pituitary Apoplexy during the Third Trimester of Pregnancy Thu, 02 Jan 2014 13:34:45 +0000 Pituitary apoplexy is an uncommon phenomenon typically characterized by vascular insufficiency or acute hemorrhage into a pituitary adenoma. The overall incidence of pituitary apoplexy ranges between 1 and 25% of all pituitary adenomas. With the widespread use of MRI technology, the diagnosis of asymptomatic intratumoral hemorrhage is closer to 10%. The authors report a case of a 27-year-old female in her 36th week of pregnancy who presented with severe onset headache and acute left-sided vision loss. MRI of the brain revealed a large hemorrhagic mass occupying the sella turcica. The patient underwent an emergent endoscopic endonasal transsphenoidal resection for pituitary apoplexy. Postoperatively, the patient’s neurologic deficit resolved. Minimally invasive endoscopic endonasal transsphenoidal resection of pituitary apoplexy can be safely utilized in third trimester pregnant women presenting with acute severe neurologic deficits. Adesh Tandon, Juan Alzate, Patrick LaSala, and Marvin P. Fried Copyright © 2014 Adesh Tandon et al. All rights reserved.