Childhood-to-adult persistent asthma is usually considered to be an atopic disease. However gastroesophageal reflux may also play an important role in this phenotype of asthma, especially when it is refractory to pulmonary medicine.
Fifty-seven consecutive GERD patients who had decades of childhood-to-adult persistent asthmatic symptoms refractory to pulmonary medication were enrolled. GERD was assessed by a symptom questionnaire, endoscopy, reflux monitoring, and manometry, and treated by Stretta radiofrequency (SRF) or laparoscopic Nissen fundoplication (LNF). The outcomes were followed up with a questionnaire for an average of 3.3 ± 1.1 years.
Upper esophageal sphincter hypotonia, lower esophageal sphincter (LES) hypotonia, shortened LES, and esophageal body dyskinesia were demonstrated by esophagus manometry in 50.9%, 43.9%, 35.1%, and 45.6% of the patients, respectively. The symptom scores for heartburn, regurgitation, coughing, wheezing, and chest tightness significantly decreased from 5.8 ± 2.0, 5.6 ± 2.0, 7.3 ± 1.6, 8.4 ± 1.2, and 8.1 ± 1.5, to 1.2 ± 1.8, 1.1 ± 1.6, 2.8 ± 2.5, 3.8 ± 2.7, and 3.9 ± 2.7, respectively, after anti-reflux treatment (P < 0.001).
Esophagus dysfunction is high in childhood-to-adult persistent asthmatic patients with GERD. SRF and LNF are both effective for esophagus symptoms as well as persistent asthmatic symptoms for these patients. GER may relate with asthmatic symptoms in some patients. Evaluating asthmatic patients for possible treatment of the underlying cause, such as GERD, may improve symptoms and prevent disease persistence.
Asthma; Gastroesophageal reflux; Stretta radiofrequency; Laparoscopic nissen fundoplication
Lymph node status is the most important prognostic factor in esophageal cancer. Through improved detection of lymph node metastases, using the sentinel lymph node concept, accurate staging and more tailored therapy may be achieved. This review article outlines two principle ways in which the sentinel lymph node concept could dramatically influence current standard of care for patients with esophageal cancer. We discuss three limitations to universal acceptance of the technique, and propose next steps for increasing enthusiasm amongst physicians and surgeons including the development of a universal tracer, and improved contrast agents with novel dual-modality ‘visibility’.
Sentinel lymph node; Esophageal cancer; Micrometastasis; Isolated tumor cell; Endoscopic mucosal resection
A female urethral diverticulum is an uncommon pathologic entity. It can manifest with a variety of symptoms involving the lower urinary tract. Our objective is to describe the various aspects of the diverticulum of the female urethra such as etiology, diagnosis and treatment.
We report five female patients, without prior medical history. They had different symptoms: dysuria in four cases, recurrent urinary tract infection in three cases, stress incontinence in two cases and hematuria in two cases. All patients had dyspareunia. The physical exams found renitent mass located in the endovaginal side of urethra which drained pus in two cases. Urethrocystography found a diverticulum of urethra in all cases. Our five patients underwent diverticulotomy by endovaginal approach. The course after surgical treatment was favorable. The urinary catheter was withdrawn after ten days. Some recurrent symptoms were reported.
Evaluation of recurrent urinary complaints in young women can lead to the finding of a diverticulum of urethra. Urethrocystography can reveal this entity. Diverticulectomy by endovaginal approach is the best choice for treatment.
Urethra; Diverticulum; Woman; Diverticulectomy; Endovaginal approach
In 1998, an electrothermal bipolar vessel sealing (EBVS) system was introduced and quickly became an integral component of the surgical armamentarium in various surgical specialties. Currently available EBVS instruments use a scissor-like jaw configuration and closing mechanism, which causes decreasing compression pressure from the proximal to the distal end of the jaws. A new EBVS system is described here which utilizes a different instrument jaw configuration and closing mechanism to enable a more homogeneous pressure distribution despite longer instrument jaws.
Results of jaw pressure distribution measurements as well as sealing experiments with subsequent burst pressure measurements ex vivo on bovine uterine arteries are demonstrated. Furthermore, an in vivo evaluation of the new EBVS system in a canine and porcine model including histological examination is presented.
The device revealed an even pressure distribution throughout the whole jaw length. The ex vivo burst pressure measurements revealed high average burst pressures, above 300 mmHg, independent of the outer diameter (1 to 7 mm) of the tested vessels. Histological evaluation of sealed vessels 21 days postoperatively demonstrated sealed and fused vessels without adjacent tissue damage.
The even pressure distribution leading to a sufficient tissue sealing in combination with the novel closing mechanism and extended jaw length differentiates the novel device from other available EBVS systems. This might offer a reduction of the overall procedure time, which should be further evaluated in a clinical study.
Surgical instruments; Tissue sealing; Laparoscopic surgery; Hemostasis; Electrocoagulation; Electrosurgery; Thermal injury; Burst pressure; Equipment design
Sacroiliac (SI) joint pain is an under diagnosed source of low back pain due in part to lack of visible pathology on radiographs and symptoms mimicking other back-related disorders. Open SI joint fusion has been performed since the 1920s. This technique has fallen out of favor with the introduction of minimally invasive options. To date there has been no direct comparison between open and MIS SI joint fusion.
We conducted a multi-center, retrospective comparative cohort study of patients who underwent SI joint fusion using either an open surgical (OS) technique using a combination of screws and cages or a minimally invasive surgical (MIS) technique with a series of titanium plasma spray (TPS) coated triangular implants. Operative measures including surgical operating time, length of hospitalization and estimated blood loss (EBL) were collected along with demographics and medical history, surgical complications, and 12- and 24-month pain scores. Improvements in pain were compared after matching for age and gender and controlling for a history of lumbar spine fusion using repeated measures analysis of variance.
Data were available for 263 patients treated by 7 surgeons; 149 patients treated with OS and 114 treated with MIS SI joint fusion. Compared to OS patients, MIS patients were on average 10 years older (mean age 57 vs. 46) and 69% of all patients were female. MIS operative measures of EBL, operating time and length of hospitalization were significantly lower than open surgery (p < 0.001). Pain relief, measured as change from baseline to 12 months in VAS pain rating, was 3.5 points lower in the MIS vs. OS group (-6.2 vs. -2.7 points, p < 0.001). When matched for age, gender and a history of prior lumbar spinal fusion, postoperative pain scores were on average 3.0 points (95% CI 2.1 – 4.0) lower in MIS vs. OS (rANOVA p < 0.001).
In this multi-center comparative study, patients who underwent either OS or MIS SI joint fusion showed postoperative improvements in pain score. Compared to OS patients, patients who underwent MIS SI joint fusion had significantly greater pain relief and more favorable perioperative surgical measures.
Minimally invasive surgery; Sacroiliac joint; Arthrodesis; Open surgery
Hysterectomy dates back to 120BC and is the second most commonly performed gynecological surgery in the world. Cosmetic demands and the necessity of rapid return to work have contributed to the minimally invasive laparoscopic approach for hysterectomy. The majority of reports describe the use of three or four incisions to perform the surgery (two or three for manipulation and one for optics).
This work describes our experience with using only two ports for 11 patients who underwent video-laparoscopic hysterectomy surgery. One port was used for the optical system, and the second was used for manipulation. Early and late surgery complications, as well as the time to return to work and daily activities, were assessed.
The mean age of the patients was 41.4 years old (range 16 to 52 years) and the mean uterine weight was 133.54 g, ranging from 35 g and 291 g. The operative time ranged from 30 to 60 minutes (average 46.4 minutes) and the hospital stay ranged between 24 and 48 hrs. No intraoperative complications occurred, and no early or late postoperative complications were recorded. Patients reported minimal pain during the first 24–48 hrs in the hospital. Patients returned to their daily activities within seven days after surgery. Clinical care follow-up continued until the 40th postoperative day.
The laparoscopic hysterectomy technique with a single port for manipulation is a feasible procedure when the uterine weight is not greater than 400 mg with little postoperative pain. The patients had an early return-to-work and daily activities and a better cosmetic outcome. These preliminary data led us to make the one-operative port laparoscopic hysterectomy the procedure of choice for patients with a low uterine weight.
Videolaparoscopy; Hysterectomy; Single port
Sacroiliac joint (SI) pain is an often-overlooked cause of low back pain due, in part, to lack of specific findings on radiographs and symptoms mimicking other back-related disorders. We report our experience with minimally invasive (MIS) SI joint arthrodesis using a series of triangular, titanium plasma spray (TPS) coated implants in patients refractory to conservative care.
We report outcomes from 18 patients with 12 months of postoperative follow-up.
Demographics, complications, and clinical outcomes using visual analog scale (VAS) for pain, Oswestry Disability Index (ODI) for back function and SF-12 for quality of life were collected preoperatively and at 3, 6 and 12 months post-operatively.
Mean age was 64 years and 67% of patients were female. There were no intraoperative complications and one explant at three months for malposition.
All patient-reported outcomes showed both clinically and statistically significant improvement at 12 months (p < 0.001 for each of the following): VAS improved by 6.6 points, ODI scores improved by −37.5 points. One year SF-12 physical and mental component (PCS, MCS) scores approximated population normal scores for both physical and mental functioning. Patient satisfaction with outcomes was high at 95%; 89% said would have the same surgery again.
MIS SI joint fusion using a series of triangular porous TPS coated titanium implants is a safe and effective procedure for patients with SI joint disorders who have failed conservative care.
Minimally invasive surgery; Sacroiliac joint; Arthrodesis; Previous spine surgery
Zone 2 flexor tendon injuries still represent a challenging problem to hand surgeons despite the well developed surgical techniques and suture materials. Meticulous surgical repair with atraumatic handling of the severed tendon stumps and minimal damage to the tendon sheath are particularly important to prevent postoperative adhesions and ruptures in this area.
In zone 2 flexor tendon injuries proximal to the vinculas, the cut ends of the flexor tendons retract to the palm with muscle contraction. To retrieve the severed proximal flexor tendon under tendon sheath and pulley system is very difficult without damaging these structures. Many techniques are described in the literature for the delivery of the retracted proximal tendon stump to the repair site.
In this report we would like to present a simple and relatively atraumatic technique that facilitates passing of the retracted flexor tendon through the pulleys in zone 2. We sutured the proximal tendon stump at the distal palmar crease with 3–0 polypropylene suture and used a 14 gauge plastic feeding tube, acting like a conduit for the passage of straightened needle to the finger.
We have used this technique 21 times without any complication in our clinic. We have not seen any suture breakage during the passage or needle breakage due to the bending of the needle.
We have found this technique is very simple and very effective in retrieving the retracted tendon stump without causing undue damage to the tendon stump or tendon sheath.
Flexor tendon retrieval; Atraumatic flexor tendon retrieval; Tendon retrieval; Retracted flexor tendon
Medical devices, including surgical staplers, energy-based devices, and access enabling devices, are used routinely today in the majority of surgical procedures. Although these technically advanced devices have proved to be of immense benefit to both surgeons and patients, their rapid development and continuous improvement have had the unintended consequence of creating a knowledge gap for surgeons due to a lack of adequate training and educational programs. Thus, there is an unmet need in the surgical community to collect existing data on device-tissue interactions and subsequently develop research and educational programs to fill this gap in surgical training. Gathering data and developing these new programs will require collaboration between doctors, engineers, and scientists, from both clinical practice and industry. This paper presents a communications system to enable this unique collaboration that can potentially result in significantly improved patient care.
Access-enabling device; Education; Energy device; Patient outcome; Stapler; Surgeon; Tissue
The quality and viability of mastectomy flaps remain a central challenge in reconstructive surgery, particularly for immediate breast reconstruction. Insufficient perfusion in tissue flaps is a leading cause of early complications following reconstructive procedures, and clinical judgment alone is not completely reliable for the assessment of flap viability. Accurate and reliable intraoperative methods for assessment of tissue perfusion are needed to help surgeons identify tissue at risk for ischemia and necrosis, thereby allowing for maneuvers to improve tissue flap viability.
This study evaluates the use of intraoperative laser angiography using the SPY System (LifeCell Corp., Branchburg, NJ) for the assessment of perfusion in mastectomy flaps for immediate breast reconstruction. The SPY System uses the contrast agent indocyanine green, which has an excellent safety profile and pharmacokinetics that allow for repeat evaluations during the same surgical procedure. In recent work, the SPY System has demonstrated high sensitivity and specificity for detection of tissues at risk for ischemia and necrosis during reconstructive surgery. Using a retrospective, chart-review design, the authors compared consecutive cases of immediate breast reconstruction using a prosthesis, before and after implementation of the SPY System.
Ninety-one subjects were included in the analysis: 52 prior to SPY (Pre-SPY) and 39 after implementation of SPY (Post-SPY). Baseline characteristics were similar between the groups. Both groups had high rates of comorbidities, chemotherapy, and radiation therapy. The rate of postoperative complications was two-fold higher in the Pre-SPY group compared to the Post-SPY group (36.5% vs. 17.9%); this difference was of borderline significance (P = 0.0631). However, mean number of repeat visits to the OR per patient was significantly higher in the Pre-SPY group (1.21 ± 1.47 vs. 0.41 ± 0.71; P = 0.0023). Of the seven patients with complications in the Post-SPY group, five were identified by SPY as having poor flap perfusion; none were identified by clinical judgment alone.
This study suggests that the SPY System can contribute to reduced ischemia-related complications in a population of women undergoing immediate breast reconstruction following mastectomy for breast cancer.
Fibroepithelial stromal polyps are site-specific mesenchymal lesions that are commonly found in the vulvovaginal region in premenopausal females. These polyps usually are less than 5 cm in diameter and are most commonly identified during routine gynecological examination. Although the stromal polyp is benign, its differential diagnosis includes some malignant vulva lesions making it critical to ensure that an accurate pathologic diagnosis is made.
We present a case of a 21 year old female with a giant fibroepithelial stromal polyp of the vulva. Upon review of the literature this is the largest reported fibroepithelial stromal polyp to date.
Fibroepithelial stromal polyps can grow as large as 390 grams and can be 18.5-cm in diameter. Microscopic evaluation of the polyp is critical in the exclusion of malignancy with this diagnosis.
Epidural intracranial hematoma is one of the most common complications of surgeries for intracranial tumors. The non-regional epidural hematoma is related to severe fluctuation of the intracranial pressure during the operation. The traditional management of hematoma evacuation through craniotomy is time-consuming and may aggravate intracranial pressure imbalance, which causes further complications. We designed a method using vaccum epidural drainage system, and tried to evaluate advantage and the disadvantage of this new technique.
Seven patients of intracranial tumors were selected. All of the patients received tumor resection and intra-operative non-regional epidural hematoma was confirmed through intra-operative ultrasound or CT scan. The vaccum drainage system was applied. Another ten patients who received craniotomy for intra-operative non-regional epidural hematoma evacuation were selected as comparison. Regular tests, like serial CT scan, were performed afterward to evaluate the effectiveness and to help deciding when to remove the drainage system.
The vaccum drainage method was effective in epidual hemotoma clearance and prevented recurrent epidural hemorrhage. The drainage systems were removed within 4 days. All of the patients recovered well. No complications related to the drainage system were observed.
Compared to the traditional craniotomy, the new method of epidural hemoatoma management using vaccum epidural drainage system proved to be as effective in hematoma clearance, and was less-invasive and easier to perform, with less complication, shorter hospitalization, less economic burden, and better prognosis.
Intracranial tumor; Operation-related epidural hematoma; Non-regional epidural hematoma; Epidural drainage; Vaccum drainage system
Presented hereunder is probably the first reported case of endometriosis at the vaginal apex following vaginal hysterectomy. No other similar case could be traced in the review of the literature.
Endometriosis; Vaginal Hysterectomy; Vault
Nerve conduction studies or somatosensory evoked potentials (SSEPs) have become an important tool in the investigation of peripheral nerve lesions, and is sensitive in detecting brachial plexus nerve injury, and other nerve injuries.
To investigate whether the modified Quad surgical procedure improves nerve conductivity and functional outcomes in obstetric brachial plexus nerve injury (OBPI) patients.
All nerves were tested with direct functional electrical stimulation. A Prass probe was used to stimulate the nerves, and recording the response, the compound motor action potential (CMAP) in the muscle. SSEP monitoring was performed pre- and post modified Quad surgery, stimulating the median and ulnar nerves at the wrist, the radial nerve over the dorsum of the hand, recording the peripheral, cervical and cortical responses. All patients have had the modified Quad surgery (n = 19). The modified Quad surgery is a muscle release and transfer surgery with nerve decompressions. All patients were assessed preoperatively and postoperatively by evaluating video recordings of standardized movements, the modified Mallet scale to index active shoulder movements.
The cervical responses were significantly lower in amplitude in the affected arm than the un-affected arm. The median nerve conduction was significantly improved from 8.04 to 9.26 (P < 0.022) post-operatively. The shoulder abduction was also significantly improved (pre-op 30° ± 23.3 to 143° ± 33.7, p < 0.0001), with a mean follow-up of 43 months after the modified Quad surgery in these patients.
Median nerve conduction, and shoulder abduction were significantly improved in OBPI children, who have undergone the modified Quad procedure with neuroplasty, internal microneurolysis and tetanic stimulation of the median nerve.
Obstetric brachial plexus nerve injury; Electromyography; Nerve conduction study; Somatosensory evoked potentials; Shoulder abduction; Modified Quad surgery
Urogenital prolapse can have a significant impact on quality of life. The life time risk of requiring surgery for urogenital prolapse is 11%. Prolift mesh has recently been introduced to reduce repeat operation rate and for long-term benefit.
To evaluate the outcome of the treatment of urogenital prolapse with synthetic mesh.
A retrospective review of case notes of all women who underwent prolift mesh insertion for prolapse between July 2004 and June 2005, at Royal Alexandra Hospital Paisley UK. We looked at the presenting complaints, previous operation, intraoperative complications and complications at six weeks and six months follow-up.
Twenty-two procedures were carried out in the twelve months period. Age of the patients ranged from 55 to 82 years (median 64 yrs). Eleven had anterior Prolift (50%), Seven had posterior Prolift 31.8% and four total Prolift 18%. There were no intraoperative complications. All the patients had previous surgery for prolapse. Eight patients had anterior repair, six patients had posterior repair, and three patients had abdominal hysterectomy. Vaginal hysterectomy was carried out with mesh insertion as a concomitant procedure in seven cases (31.25%). All patients were seen at six weeks and six months after the surgery. Complications rate included mesh erosion one patient and suture material protruding in the vagina one patient, one patient had failed prolift operation. All the twenty-one patients were cured giving 95.4% success rate.
The use of prolene mesh in pelvic reconstructive surgery was associated with good outcome and minimal complications in this study.
Prolift; Mesh; Urogenital prolapse
Inadequate tissue perfusion is a key contributor to early complications following reconstructive procedures. Accurate and reliable intraoperative evaluation of tissue perfusion is critical to reduce complications and improve clinical outcomes. Clinical judgment is the most commonly used method for evaluating blood supply, but when used alone, is not always completely reliable. A variety of other methodologies have been evaluated, including Doppler devices, tissue oximetry, and fluorescein, among others. However, none have achieved widespread acceptance. Recently, intraoperative laser angiography using indocyanine green was introduced to reconstructive surgery. This vascular imaging technology provides real-time assessment of tissue perfusion that correlates with clinical outcomes and can be used to guide surgical decision making. Although this technology has been used for decades in other areas, surgeons may not be aware of its utility for perfusion assessment in reconstructive surgery. A group of experts with extensive experience with intraoperative laser angiography convened to identify key issues in perfusion assessment, review available methodologies, and produce initial recommendations for the use of this technology in reconstructive procedures.
SPY; Indocyanine green; Laser angiography; Reconstructive surgery; Perfusion assessment; Flap; Near infrared; Necrosis; Flap; Microsurgery
SI joint pain can mimic discogenic low back pain or even radicular pain. Patient presentations vary considerably and conditions may include low back, groin, and/or radicular pain, leading to the potential for inaccurate diagnosis and treatment. Despite the large number of patients with SI joint pain, treatment options have been limited to conservative care involving physical therapy and joint injections, radiofrequency rhizotomy, or traditional open SI joint arthrodesis surgery. The purpose of this retrospective study is to evaluate the safety and effectiveness of MIS SI joint arthrodesis via an ileosacral approach in patients refractory to conservative care.
We report on the first 11 consecutive patients treated with a novel MIS SI joint fusion system by a single surgeon. Medical charts were reviewed for perioperative metrics and baseline pain scores recorded using a 0-10 numerical rating scale.
Ninety one percent (91%) of patients were female and the average patient age was 65 years (range 45-82). Mean baseline pain score (SD) was 7.9 (± 2.2). Mean pain score at the 12 month follow up interval was 2.3 (±3.1), resulting in an average improvement of 6.2 points from baseline, representing a clinically and statistically significant (p=0.000) improvement. Patient satisfaction was very high with 100% indicating that they would have the same surgery again for the same result.
The results of this small case series illustrate the safety and effectiveness of minimally invasive SI joint fusion using a series of triangular porous plasma coated titanium implants in carefully selected patients. Larger multi centered studies are warranted.
Minimally invasive; Sacroiliac joint; Arthrodesis
Controversies surrounding the efficacy of surgical sealants against alveolar air leaks (AAL) in lung surgery abound in the literature. We sought to test the sealing efficacy of a novel synthetic sealant, TissuePatch™ in an in vitro lung model.
The lower lobe of freshly excised swine lung (n = 10) was intubated and ventilated. A superficial parenchymal defect (40 × 25 mm) was created, followed by AAL assessment. After sealant application, AAL was assessed again until burst failure occurred. The length of defect was recorded to evaluate the elasticity of the sealant.
Superficial parenchymal defects resulted in AAL increasing disproportionally with ascending maximal inspiratory pressure (Pmax). Multiple linear regression analysis revealed strong correlation between AAL and Pmax, compliance, resistance. After sealant application, AAL was sealed in all ten tests at an inspired tidal volume (TVi) of 400 ml, in nine tests at TVi = 500 ml, in seven at TVi = 600 ml and in five at TVi = 700 ml. The mean burst pressure was 42 ± 9 mBar. Adhesive and cohesive sealant failures were found in six and three tests respectively. The length of defect before sealant failure was 8.9 ± 4.9% larger than that at TVi = 400 ml, demonstrating an adequate elasticity of this sealant film.
TissuePatch™ may be a reliable sealant for alternative or adjunctive treatment for repair of superficial parenchymal defects in lung surgery. The clinical benefits of this sealant should be confirmed by prospective, randomised controlled clinical trials.
Die Wirksamkeit von chirurgischen Klebstoffen zur Prävention von alveolo-pleuralem Luftleck (APL) ist trotz zunehmenden klinischen Anwendungen in Lungenchirurgie immer noch kontrovers diskutiert. Wir evaluierten die Abdichtungswirksamkeit von einem neuartigen synthetischen Kleber, TissuePatch™ mittels eines in vitro Lungenmodels.
Der Unterlappen von frisch entnommenen Schweinlungen (n = 10) wurde intubiert und beatmet. Eine pleurale Läsion (40 × 25 mm) wurde erstellt und APL mit steigendem inspiratorischem Tidalvolumen (TVi) untersucht. Nach Applikation von TissuePatch™ wurde APL auf die gleiche Weise gemessen bis zur Auftritt von Kleberbruch. Zur Untersuchung der Elastizität des Klebers wurde die Länge der pleuralen Läsion gemessen.
Pleurale Läsion führte bei aufsteigendem maximalem inspiratorischem Druck (Pmax) zu überproportionalem Anstieg von APL. Multiple lineare Regressionsanalyse ergab eine starke Korrelation zwischen APL und Pmax, Lungencompliance sowie Widerstand. Nach der Applikation von Klebstoff wurde APL bei TVi = 400 ml in allen zehn Testen versiegelt, bei TVi = 500 ml in neun Testen, bei TVi = 600 ml in sieben und bei TVi = 700 ml in fünf Testen. Der mittlere Pmax, der zu Kleberbruch führte, betrug 42 ± 9 mBar. Bei den Versuchen wurden adhäsiver und kohäsiver Kleberbruch in jeweils sechs und drei Testen gefunden. Die Länge der pleuralen Läsion vor dem Kleberbruch war 8,9 ± 4,9% größer als die bei TVi = 400 ml.
Unsere Versuche zeigten eine zuverlässige Versiegelung von TissuePatch™ unter mechanischer Ventilation. Die klinische Nützlichkeit vom Kleber als unterstützende Maßnahme zur Prävention von alveolo-pleuralem Luftleck in Lungenchirurgie sollte durch prospektive, randomisierte kontrollierte klinische Studien bestätigt werden.
Lung; Pleural air leak; Sealant; In vitro model
The purpose of this study was to compare in human cadavers the applicability of a commonly used stapling device, the CONTOUR® curved cutter (CC) (Ethicon Endo-Surgery, Cincinnati, OH) to a newly released, curved stapler, the Endo GIA™ Radial Reload with Tri-Staple™ Technology (RR) (Covidien, New Haven, CT)
Four experienced surgeons performed deep pelvic dissection with total mesorectal excision (TME) of the rectum in twelve randomized male cadavers. Both stapling devices were applied to the ultra-low rectum in coronal and sagittal configurations. Extensive measurements were recorded of anatomic landmarks for each cadaver pelvis along with various aspects of access, visibility, and ease of placement for each device.
The RR reached significantly lower into the pelvis in both the coronal and sagittal positions compared to the CC. The median distance from the pelvic floor was 1.0 cm compared to 2.0 cm in the coronal position, and 1.0 cm versus 3.3 cm placed sagitally, p < 0.0001. Surgeons gave a higher visibility rating with less visual impediment in the sagittal plane using the RR Stapler. Impediment of visibility occurred in only 10% (5/48) of RR applications in the coronal position, compared to a rate of 48% (23/48) using the CC, p = 0.0002.
The RR device performed significantly better when compared to the CC stapler in regards to placing the stapler further into the deep pelvis and closer to the pelvic floor, while causing less obstructing of visualization.
The reverse sural artery flap is a generally accepted means of soft tissue reconstruction for defects of the distal third of the legs. The routine sacrifice of the sural nerve with its consequential temporary loss of sensation on the lateral aspect of the foot can be of concern to early rehabilitation of some patients.
This is a case report of a 24 years old male who had Gustillo and Anderson type IIIB injury involving the upper part of the distal 3rd and the middle 3rd of tibia. A reverse sural artery flap was raised without transecting the sural nerve to cover the distal part of the defect.
The distal part of the exposed bone was covered with the reverse sural artery flap without loss of sensation at anytime to the lateral part of the foot.
The reverse sural artery flap can be raised to cover the upper portion of the distal leg without severing the sural nerve.
Sural nerve; Fasciocutaneous flap; Nerve preservation
Infertility due to pelvic radiation for advanced rectal cancer treatment is a major concern particularly in young patients. Pre-radiation laparoscopic ovarian transposition may offer preservation of ovarian function during the treatment however its use is limited.
The study investigates the safety, feasibility and effectiveness of pre-radiation laparoscopic ovarian transposition and its effect on ovarian function in the treatment o locally advanced rectal cancer.
Charts review of all young female patients diagnosed with locally advanced rectal cancer, underwent laparoscopic ovarian transposition, then received preoperative radiotherapy at king Faisal Specialist Hospital and Research Centre between 2003–2007.
During the period studied three single patients age between 21–27 years underwent pre-radiation laparoscopic ovarian transposition for advanced rectal cancer. All required pretreatment laparoscopic diversion stoma due to rectal stricture secondary to tumor that was performed at the same time. One patient died of metastatic disease during treatment. The ovarian hormonal levels (FSH and LH) were normal in two patients. One has had normal menstrual period and other had amenorrhoea after 4 months follow-up however her ovarian hormonal level were within normal limits.
Laparoscopic ovarian transposition before pelvic radiation in advanced rectal cancer treatment is an effective and feasible way of preservation of ovarian function in young patients at risk of radiotherapy induced ovarian failure. However, this procedure is still under used and it is advisable to discuss and propose it to suitable patients.
Laparoscopic; Ovarian; Transposition; Rectal cancer
Critically ill surgical patients are always at increased risk of actual or potentially life-threatening health complications. Central/peripheral venous lines form a key part of their care. We review the current evidence on incidence of central and peripheral venous catheter-related bloodstream infections in critically ill surgical patients, and outline pathways for prevention and intervention. An extensive systematic electronic search was carried out on the relevant databases. Articles were considered suitable for inclusion if they investigated catheter colonisation and catheter-related bloodstream infection. Two independent reviewers engaged in selecting the appropriate articles in line with our protocol retrieved 8 articles published from 1999 to 2011. Outcomes on CVC colonisation and infections were investigated in six studies; four of which were prospective cohort studies, one prospective longitudinal study and one retrospective cohort study. Outcomes relating only to PICCs were reported in one prospective randomised trial. We identified only one study that compared CVC- and PICC-related complications in surgical intensive care units. Although our search protocol may not have yielded an exhaustive list we have identified a key deficiency in the literature, namely a paucity of studies investigating the incidence of CVC- and PICC-related bloodstream infection in exclusively critically ill surgical populations. In summary, the diverse definitions for the diagnosis of central and peripheral venous catheter-related bloodstream infections along with the vastly different sample size and extremely small PICC population size has, predictably, yielded inconsistent findings. Our current understanding is still limited; the studies we have identified do point us towards some tentative understanding that the CVC/PICC performance remains inconclusive.
Laparoscopic Gastric Plication (LGP) is a new restrictive bariatric surgery, previously introduced by the author. The aim of this study is to explain the modifications and to present the 12-year experience, regarding early and long term results, complications and cost.
We used LGP for morbid obesity during the past 12 years. Anterior plication (10 cases), one-row bilateral plication while right gastroepiploic artery included (42 cases), and excluded from the plication (104 cases) and two-row plication (644 cases). The gastric greater curvature was plicated using 2/0 prolen from fundus at the level of diaphragm preserving the His angle to just proximal to the pylorus. The anatomic and functional volume of stomach was 50cc and 25cc respectively in two-row method. Ordered postop visits also included evaluation of weight loss, complications, change of diet and control of exercise.
LGP was performed in 800 cases (mean age: 27.5, range: 12 to 65 years, nine under 18). Female to male ratio was 81% to 19% and average BMI was 42.1 (35-59). The mean excess weight loss (EWL) was 70% (40% to 100%) after 24 months and 55% (28% to 100%) after 5 years following surgery. 134 cases (16.7%) did not completed long term follow-up. The average time of follow up was 5 years (1 month to 12 years). 5.5% and 31% of cases complained from weight regain respectively during 4 and 12 years after LGP. The mean time of operation was 72 (49–152) minutes and average hospitalization time was 72 hours (24 hours to 45 days). The cost of operation was 2000 $ less than gastric banding or sleeve and 2500 $ less than gastric bypass. Eight patients out of 800 cases (1%) required reoperation due to complications like: micro perforation, obstruction and vomiting following adhesion of His angle. Other complications included hepatitis pneumonia, self-limiting intra-abdominal bleeding and hypocalcaemia.
The percentage of EWL in this technique is comparable to other restrictive methods. The technique is safe with 1.6% complication (1% reoperated), and 31% regain during 12 years. The cost of operation is less than the other methods.
Morbid obesity; Laparoscopy; Gastric plication; Restriction
Duodenal ulcer lesions can represent a surgical challenge, especially if the duodenal wall is chronically inflamed, the defect exceeds a diameter of 3 cm and the ulceration is located in the second part of the duodenum.
Patient and method
We present the case of a 70-year-old male, who suffered from a 3 x 4 cm duodenal defect caused by duodenal pressure necrosis due to a 12.5 x 5.5 x 5 cm gallstone. Additionally, this stone caused intestinal obstruction (Bouveret’s syndrome) and bleeding with signs of shock. Besides the gallstone extraction, the common bile duct was drained by a T-tube and the duodenal defect closure was performed by a gastroduodeno-plasty and Bilroth II gastroenterostomy. The postoperative phase was uneventful. The reconstructed duodenum was endoscopically accessible and showed no pathological findings on follow-up.
The reconstruction of a large defect (> 3 cm) of the second part of the duodenum is safely feasible by a gastroduodeno-plasty. The critical gastroduodenal anastomosis can be protected by duodenal decompression, achieved by placing a T-tube in the common bile duct.
Duodenal defect; Bouveret’s syndrome; Gastroduodeno-plasty
Laparoscopic colectomy is now widely applied to cases of malignancy, supported by early data from several large randomized controlled trials. Long-term follow-up is now available from those trials, supporting equivalency of cancer-free and overall survival for open and laparoscopic resections. This promising data has inspired further exploration of other applications of laparoscopic techniques, including use of single incision laparoscopy. This article reviews recent reports of long-term data for colorectal cancer resection from four randomized, prospective international trials.
Laparoscopy; Colorectal cancer; Cost; Classic; Color