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1.  Does recurrent laryngeal nerve lymph node metastasis really affect the prognosis in node-positive patients with squamous cell carcinoma of the middle thoracic esophagus? 
BMC Surgery  2014;14:43.
Recurrent laryngeal nerve (RLN) lymph node metastasis used to be shown a predictor for poor prognosis in esophageal squamous cell carcinoma. The purpose of this study was to evaluate the prognostic impact of RLN node metastasis and the number of metastatic lymph nodes in node-positive patients with squamous cell carcinoma of middle thoracic esophagus.
A cohort of 235 patients who underwent curative surgery for squamous cell carcinoma of middle thoracic esophagus was investigated. The prognostic impact was evaluated by univariate and multivariate analyses.
Lymph node metastasis was found in 133 patients. Among them, 81 had metastatic RLN nodes, and 52 had at least one positive node but no RLN nodal involvement. The most significant difference in survival was detected between patients with metastatic lymph nodes below and above a cutoff value of six (P < 0.001). Multivariate analysis revealed that the number of metastatic lymph nodes was a significant factor associated with overall survival (P < 0.001), but RLN lymph node metastasis was not (P = 0.865).
RLN Lymph node metastasis is not, but the number of metastatic nodes is a prognostic predictor in node-positive patients with squamous cell carcinoma of the middle thoracic esophagus.
PMCID: PMC4105105  PMID: 25016483
Esophageal cancer; Lymph node metastasis; Recurrent laryngeal nerve; Squamous cell carcinoma
2.  A bilateral neoplasm in chest: a case report and literature review 
BMC Surgery  2014;14:42.
Myelolipoma is a rare neoplasm composed of yellowish adipose tissue and reddish-brown tissue corresponding to hematopoietic or hemorrhages. It typically occurs in adrenal glands as a solitary, well-circumscribed mass, and the thoracic location is extremely unusual.
Case presentation
We present a rare case who is a 54 years old male with bilateral Myelolipoma of the posterior mediastinum. He underwent the surgery via video-assisted thoracic surgery both sides interval 3 months. Histological examination showed both tumors consisted of mature fat tissue and hematopoietic tissue, including myeloid, erythroid, and megakaryocytic elements surrounded. We discussed the etiology, histopathology, differential diagnosis and recommended management of extra-adrenal myelolipoma and analyzed the features of the thoracic myelolipoma including mediastinal and pulmonary location.
Literature review showed 16 similar cases, with a 2/1 male/female ratio and a mean age of 58 years. Eight of sixteen cases were observed in the mediastinum and six of sixteen cases were displayed in the pulmonary and one showed on the chest wall. CT and MRI scans are able to indicate the presence of extra-adrenal myelolipoma. Pathological analysis is an effective method to clarify the diagnosis. Observation and surgery are two regular treatment methods. Small, asymptomatic tumors should be monitored, while large tumors that cause unendurable symptoms may be removed by surgery.
PMCID: PMC4094594  PMID: 25005140
Myelolipoma; Pulmonary; Mediastinum
3.  Feasibility of enhanced recovery after surgery in gastric surgery: a retrospective study 
BMC Surgery  2014;14:41.
Enhanced recovery after surgery (ERAS) programs have been reported to be feasible and useful for maintaining physiological function and facilitating recovery after colorectal surgery. The feasibility of such programs in gastric surgery remains unclear. This study assessed whether an ERAS program is feasible in patients who undergo gastric surgery.
The subjects were patients who underwent gastric surgery between June 2009 and February 2011 at the Department of Gastrointestinal Surgery, Kanagawa Cancer Center. They received perioperative care according to an ERAS program. All data were retrieved retrospectively. The primary end point was the incidence of postoperative complications. The secondary end point was postoperative outcomes.
A total of 203 patients were studied. According to the Clavien-Dindo classification, the incidence of ≥ grade 2 postoperative complications was 10.8% and that of ≥ grade 3 complications was 3.9%. Nearly all patients did not require delay of meal step-up (95.1%). Only 6 patients (3.0%) underwent reoperation. The median postoperative hospital stay was 9 days. Only 4 patients (2.0%) required readmission. There was no mortality.
Our results suggest that our ERAS program is feasible in patients who undergo gastric surgery.
PMCID: PMC4099495  PMID: 25001198
Enhanced recovery after surgery; Gastric cancer; Gastrectomy; Feasibility; Postoperative complications
4.  Anatomical study of simple landmarks for guiding the quick access to humeral circumflex arteries 
BMC Surgery  2014;14:39.
The posterior and anterior circumflex humeral artery (PCHA and ACHA) are crucial for the blood supply of humeral head. We aimed to identify simple landmarks for guiding the quick access to PCHA and ACHA, which might help to protect the arteries during the surgical management of proximal humeral fractures.
Twenty fresh cadavers were dissected to measure the distances from the origins of PCHA and ACHA to the landmarks (the acromion, the coracoid, the infraglenoid tubercle, the midclavicular line) using Vernier calipers.
The mean distances from the origin of PCHA to the infraglenoid tubercle, the coracoid, the acromion and the midclavicular line were 27.7 mm, 50.2 mm, 68.4 mm and 75.8 mm. The mean distances from the origin of ACHA to the above landmarks were 26.9 mm, 49.2 mm, 67.0 mm and 74.9 mm.
Our study provided a practical method for the intraoperative identification as well as quick access of PCHA and ACHA based on a series of anatomical measurements.
PMCID: PMC4099027  PMID: 24970300
Axillary artery; Circumflex humeral artery; Proximal humeral fracture
5.  Large twisted ovarian fibroma associated with Meigs’ syndrome, abdominal pain and severe anemia treated by laparoscopic surgery 
BMC Surgery  2014;14:38.
The Meigs' syndrome is a rare but well-known syndrome defined as the triad of benign solid ovarian tumor, ascites, and pleural effusion. Meigs' syndrome always requires surgical treatment. However, the optimal approach for its management has not been sufficiently investigated.
Case presentation
We report a patient with a large twisted ovarian fibroma associated with Meigs’ syndrome, abdominal pain and severe hemolytic anemia that was treated by laparoscopic surgery. This case highlights the difficulties that may be encountered in the management of patients with Meigs’ syndrome, including potential misdiagnosis of the tumor as a malignant ovarian neoplasm that may influence the medical and surgical approach and the adverse impact that Meigs’ syndrome can have on the patient’s condition, especially if it is associated with acute pain and severe anemia. Considering the patient’s serious clinical condition and assuming that she had Meigs' syndrome with a twisted large ovarian mass and possible hemolytic anemia, we first concentrated on effective medical management of our patient and chose the most appropriate surgical treatment after laparoscopic examination. The main aim of our initial approach was preoperative management of the anemia. Blood transfusions and glucocorticoid therapy resulted in stabilization of the hemoglobin level and normalization of the bilirubin levels, which confirmed the appropriateness of this approach. Laparoscopic surgery 4 days after admission enabled definitive diagnosis of the tumor, confirmed torsion and removed the bulky ovarian fibroma, resulting in timely resolution of symptoms, short hospitalization, relatively low morbidity and a rapid return to her social and professional life.
This case highlights the difficulties that may be encountered in the management of patients with Meigs' syndrome, including potential misdiagnosis of the tumor as a malignant ovarian neoplasm that may influence the medical and surgical approach, and the adverse impact that Meigs' syndrome can have on the patient's condition, especially if it is associated with acute pain and severe anemia. The present case suggests that laparoscopic surgery for potentially large malignant tumors is feasible and safe, but requires an appropriate medical and gynecological oncology expertise.
PMCID: PMC4074309  PMID: 24962423
Meigs’ syndrome; Laparoscopy; Hemolytic anemia; Ovarian fibroma
6.  Intractable duodenal ulcer caused by transmural migration of gossypiboma into the duodenum - a case report and literature review 
BMC Surgery  2014;14:36.
Gossypiboma is a term used to describe a mass that forms around a cotton sponge or abdominal compress accidentally left in a patient during surgery. Transmural migration of an intra-abdominal gossypiboma has been reported to occur in the digestive tract, bladder, vagina and diaphragm. Open surgery is the most common approach in the treatment of gossypiboma. However, gossypibomas can be extracted by endoscopy while migrating into the digestive tract. We report a case of intractable duodenal ulcer caused by transmural migration of gossypiboma successfully treated by duodenorrhaphy. A systemic literature review is provided and a scheme of the therapeutic approach is proposed.
Case presentation
A 61-year-old Han Chinese man presented with intermittent epigastric pain for the last 10 months. He had undergone laparoscopic cholecystectomy conversion to open cholecystectomy for acute gangrenous cholecystitis 10 months ago at another hospital. Transmural migration of gossypiboma into the duodenum was found. Endoscopic intervention failed to remove the entire gauze, and duodenal ulcer caused by the gauze persisted. Surgical intervention was performed and the gauze was removed successfully. The penetrated ulcer was repaired with duodenorrhaphy. The postoperative period was uneventful.
We systematically reviewed the literature on transmural migration of gossypiboma into duodenum and present an overview of published cases. Our PubMed search yielded seven reports of transmural migration of retained surgical sponge into the duodenum. Surgical interventions were necessary in two patients.
Transmural migration of gossypiboma into the duodenum is a rare surgical complication. The treatment strategies include endoscopic extraction and surgical intervention. Prompt surgical intervention should be considered for emergent conditions such as active bleeding, gastrointestinal obstruction, or intra-abdominal sepsis. For non-emergent conditions, surgical intervention could be considered for intractable cases in which endoscopic extraction failed.
PMCID: PMC4061322  PMID: 24917191
Gossypiboma; Duodenal ulcer; Transmural migration; Surgical complication; Duodenorrhaphy; Endoscopy; Endoscopic extraction
7.  Spontaneous mesenteric hematoma complicating an exacerbation of Crohn’s disease: report of a case 
BMC Surgery  2014;14:35.
Case Presentation
Spontaneous mesenteric haematoma is a rare condition that occurs due to localized bleeding in the mesenteric vascular tree of a bowel segment in the absence of an identifiable cause. Here we report a case of spontaneous mesenteric haematoma during an inflammatory exacerbation of Crohn’s disease. The patient underwent surgical management for small bowel obstruction secondary to Crohn’s disease, however the concurrent presence of a spontaneous mesenteric haematoma in the mid-jejunal mesentery was successfully managed conservatively.
This case identifies the first association of spontaneous mesenteric haematoma with an exacerbation of Crohn’s disease and highlights the need to consider rare differential diagnoses such as SMH when performing radiological assessment of unexplained symptoms in inflammatory bowel disease patients.
PMCID: PMC4061510  PMID: 24894713
Crohn’s disease; Mesenteric haematoma; Inflammatory bowel disease; Surgery
8.  Perioperative blood transfusion adversely affects prognosis after resection of lung cancer: a systematic review and a meta-analysis 
BMC Surgery  2014;14:34.
It is speculated that blood transfusion may induce adverse consequences after cancer surgery due to immunosuppression. This study was intended to assess the impact of perioperative blood transfusion on the prognosis of patients who underwent lung cancer resection.
Eligible studies were identified through a computerized literature search. The pooled relative risk ratio (RR) with 95% confidence interval (CI) was calculated using Review Manager 5.1 Software.
Eighteen studies with a total of 5915 participants were included for this meta-analysis. Pooled analysis showed that perioperative blood transfusion was associated with worse overall survival (RR: 1.25, 95% CI: 1.13-1.38; P <0.001) and recurrence-free survival (RR: 1.42, 95% CI: 1.20-1.67; P <0.001) in patients with resected lung cancer.
Perioperative blood transfusion appears be associated with a worse prognosis in patients undergoing lung cancer resection. These data highlight the importance of minimizing blood transfusion during surgery.
PMCID: PMC4057617  PMID: 24884867
Lung cancer; Blood transfusion; Survival; Surgery; Meta-analysis
9.  Mesh Or Patch for Hernia on Epigastric and Umbilical Sites (MORPHEUS trial): study protocol for a multi-centre patient blinded randomized controlled trial 
BMC Surgery  2014;14:33.
Evidence is accumulating that, similar to other ventral hernias, umbilical and epigastric hernias must be mesh repaired. The difficulties involved in mesh placement and in mesh-related complications could be the reason many small abdominal hernias are still primary closed. In laparoscopic repair, a mesh is placed intraperitoneally, while the most common procedure is open surgery is pre-peritoneal mesh placement. A recently developed alternative method is the so-called patch repair, in this approach a mesh can be placed intraperitoneally through open surgery. In theory, such patches are particularly suitable for small hernias due to a reduction in the required dissection. This simple procedure is described in several studies. It is still unclear whether this new approach is associated with an equal risk of recurrence and complications compared with pre-peritoneal meshes. The material of the patch is in direct contact with intra-abdominal organs, it is unknown if this leads to more complications. On the other hand, the smaller dissection in the pre-peritoneal plane may lead to a reduction in wound complications.
346 patients suffering from an umbilical or epigastric hernia will be included in a multi-centre patient-blinded trial, comparing mesh repair with patch repair. Randomisation will take place for the two operation techniques. The two devices investigated are a flat pre-peritoneal mesh and a Proceed Ventral Patch®. Stratification will occur per centre. Post-operative evaluation will take place after 1, 3, 12 and 24 months. The number of complications requiring treatment is the primary endpoint. Secondary endpoints are Verbal Descriptor Scale (VDS) pain score and VDS cosmetic score, operation duration, recurrence and costs. An intention to treat analysis will be performed.
This trial is one of the first in its kind, to compare different mesh devices in a randomized controlled setting. The results will help to evaluate mesh repair for epigastric an umbilical hernia, and find a surgical method that minimizes the complication rate.
Trial registration
Netherlands Trail Registration (NTR) 2010 NTR2514 NL33995.060.10
PMCID: PMC4042133  PMID: 24884770
Umbilical; Epigastric; Hernia; Herniorraphy; Mesh repair; Proceed Ventral Patch; Complications; Pain; Recurrence; Costs
10.  Bipolar radiofrequency ablation is useful for treating atrial fibrillation combined with heart valve diseases 
BMC Surgery  2014;14:32.
Atrial fibrillation (AF) is a common arrhymia, and it results in increased risk of thromboembolism and decreased cardiac function. In patients undergoing cardiac surgery, concomitant radiofrequency ablation to treat AF is effective in restoring sinus rhythm (SR). This study is an observational cohort study aimed to investigate the safety and efficacy of bipolar radiofrequency ablation (BRFA) for treating AF combined with heart valve diseases.
Clinical data were analyzed retrospectively from 324 cases of rheumatic heart disease combined with persistent AF patients who underwent valve replacement concomitant BRFA. The modified left atrial and the simplified right atrial ablation were used for AF treatments. Of the 324 patients, 248 patients underwent mitral valve replacement and 76 patients underwent double valve replacement. Meanwhile, 54 patients underwent concomitant thrombectomy and 97 underwent tricuspid valvuloplasty. And all of them received temporary pacemaker implantation. The 24 hours holter electrocardiogram (ECG) monitoring and echocardiography was performed before the operation, on the first day after operation, on discharge day, and at 6 and 12 months after operation.
There were 299 patients with SR on the first day after operation (92.30%), 12 patients with junctional rhythm (3.70%), 11 patients with AF (3.39%), and 2 patients with atrial flutter (0.62%). The temporary pacemaker was used in 213 patients (65.74%) with heart rates less than 70 beat/minute in the ICU. Two patients died early and the mortality rate was 0.62%. Two patients had left ventricular rupture and the occurrence rate was 0.62%. They both recovered. There was no degree III atrioventricular blockage and no permanent pacemaker implantation. Overall survival rate was 99.38% (322 cases) with SR conversion rate of 89.13% (287 cases) at discharge. The SR conversion rate was 87.54% and 87.01% at 6 and 12 months after operation. Sinus bradycardia occurred in 3.42% of patients at 6 months after operation and in 3.03% of patients at 12 months after operation. Echocardiography showed that the left atrial diameter was significantly decreased, and ejection fraction and fractional shortening were significantly improved.
BRFA for treating AF in concomitant valve replacement is safe and with good efficacy.
PMCID: PMC4039985  PMID: 24884667
Radiofrequency ablation; Bipolar; Atrial fibrillation
11.  Urethral metastasis from a sigmoid colon carcinoma: a quite rare case report and review of the literature 
BMC Surgery  2014;14:31.
Urethral metastatic adenocarcinoma is extremely rare. Moreover, only 9 previous cases with metastases from colorectal cancer have been reported to date, and not much information on urethral metastases from colorectum is available so far.
Case presentation
We report our experience in the diagnosis and the management of the case with urethral metastasis from a sigmoid colon cancer. A 68-year-old man, who underwent laparoscopic sigmoidectomy for sigmoid colon carcinoma four years ago, presented gross hematuria with pain. Urethroscopy identified a papillo-nodular tumor 7 mm in diameter in the bulbar urethra. CT-scan imaging revealed the small mass of bulbous portion of urethra and solitary lung metastasis. Histological examination of the tumor obtained by transurethral resection showed moderately differentiated adenocarcinoma, which was diagnosed as a metastasis of a sigmoid colon carcinoma pathologically by morphological examination. Immunohistochemical analysis of the urethral tumor revealed the positive for cytokertin 20 and CDX2, whereas negative for cytokertin 7. These features were consistent with metastatic adenocarcinoma of the sigmoid colon cancer. As the management of this case with urethral and lung metastasis, 6-cycle of chemotherapy with fluorouracil with leucovorin plus oxaliplatin was administered to the patient, and these metastases were disappeared with no recurrence of disease for 34 months.
Urethral metastasis from colorectal cancer is a very rare occurrence. However, in the presence of urinary symptoms, the possibility of the urethral metastasis should be considered.
PMCID: PMC4037280  PMID: 24884559
Urethral metastasis; Colon cancer; Immunohistochemistry
12.  Effect of occipitocervical fusion with screw-rod system for upper cervical spine tumor 
BMC Surgery  2014;14:30.
Craniospinal junction tumors are rare but severe lesions. Surgical stabilization has been established to be an ideal treatment for upper cervical tumor pathology. The purpose of this study was to evaluate the effect of a screw-rod system for occipitocervical fusion.
A total of 24 cases with C1 and C2 cervical tumor underwent occipitocervical fusion with Vertex screw-rod internal fixation from January 2005 to December 2012. Preoperative X-ray and MRI examinations were performed on all patients before the operation, after the operation, and during last follow-up. The JOA score was used to assess neurological function pre and postoperatively.
All the patients were followed up for 6 to 42 months with an average of 24 months. The result of X-ray showed that bony fusion was successful in 18 patients at 3 months and 6 patients at 6 months of follow-ups. There was no deterioration of spinal cord injury. The JOA Scores of neurological function increased significantly.
The screw-rod system offers strong fixation and good fusion for occipitocervical fusion. It is an effective and reliable method for reconstruction of upper cervical spine tumor.
PMCID: PMC4032630  PMID: 24884456
Occipitocervical fusion; Upper cervical spine; Tumor; Reconstruction
13.  Long term follow up and retrospective study on 533 gastric cancer cases 
BMC Surgery  2014;14:29.
Gastric cancer (GC) is the third leading cause of cancer death in China and the outcome of GC patients is poor. The aim of the research is to study the prognostic factors of gastric cancer patients who had curative intent or palliative resection, completed clinical database and follow-up.
This retrospective study analyzed 533 GC patients from three tertiary referral teaching hospitals from January 2004 to December 2010 who had curative intent or palliative resection, complete clinical database and follow-up information. The GC-specific overall survival (OS) status was determined by the Kaplan-Meier method, and univariate analysis was conducted to identify possible factors for survival. Multivariate analysis using the Cox proportional hazard model and a forward regression procedure was conducted to define independent prognostic factors.
By the last follow-up, the median follow-up time of 533 GC patients was 38.6 mo (range 6.9-100.9 mo), and the median GC-specific OS was 25.3 mo (95% CI: 23.1-27.4 mo). The estimated 1-, 2-, 3- and 5-year GC-specific OS rates were 78.4%, 61.4%, 53.3% and 48.4%, respectively. Univariate analysis identified the following prognostic factors: hospital, age, gender, cancer site, surgery type, resection type, other organ resection, HIPEC, LN status, tumor invasion, distant metastases, TNM stage, postoperative SAE, systemic chemotherapy and IP chemotherapy. In multivariate analysis, seven factors were identified as independent prognostic factors for long term survival, including resection type, HIPEC, LN status, tumor invasion, distant metastases, postoperative SAE and systemic chemotherapy.
Resection type, HIPEC, postoperative SAE and systemic chemotherapy are four independent prognostic factors that could be intervened for GC patients for improving survival.
PMCID: PMC4037426  PMID: 24886548
Gastric cancer; GC-specific overall survival; Prognosis; Multivariate analysis; Clinical pathological factors
14.  Pain relief from combined wound and intraperitoneal local anesthesia for patients who undergo laparoscopic cholecystectomy 
BMC Surgery  2014;14:28.
Laparoscopic cholecystectomy (LC) has become the treatment of choice for gallbladder lesions, but it is not a pain-free procedure. This study explored the pain relief provided by combined wound and intraperitoneal local anesthetic use for patients who are undergoing LC.
Two-hundred and twenty consecutive patients undergoing LC were categorized into 1 of the following 4 groups: local wound anesthetic after LC either with an intraperitoneal local anesthetic (W + P) (group 1) or without an intraperitoneal local anesthetic (W + NP) (group 2), or no local wound anesthetic after LC either with intraperitoneal local anesthetic (NW + P) (group 3) or without an intraperitoneal local anesthetic (NW + NP) (group 4). A visual analog scale (VAS) was used to assess postoperative pain. The amount of analgesic used and the duration of hospital stay were also recorded.
The VAS was significantly lower immediately after LC for the W + P group than for the NW + NP group (5 vs. 6; p = 0.012). Patients in the W + P group received a lower total amount of meperidine during their hospital stay. They also had the shortest hospital stay after LC, compared to the patients in the other groups.
Combined wound and intraperitoneal local anesthetic use after LC significantly decreased the immediate postoperative pain and may explain the reduced use of meperidine and earlier discharge of patients so treated.
PMCID: PMC4026815  PMID: 24886449
15.  Totally implantable venous access devices: retrospective analysis of different insertion techniques and predictors of complications in 796 devices implanted in a single institution 
BMC Surgery  2014;14:27.
The aim of this study was to assess the efficacy and safety of totally implanted vascular devices (TIVAD) using different techniques of insertion.
We performed a retrospective study using a prospective collected database of 796 consecutive oncological patients in which TIVADs were inserted. We focused on early and late complications following different insertion techniques (surgical cutdown, blind and ultrasound guided percutaneous) according to different techniques.
Ultrasound guided technique was used in 646 cases, cephalic vein cutdown in 102 patients and percutaneous blind technique in 48 patients. The overall complication rate on insertion was 7.2% (57 of 796 cases). Early complications were less frequent using the ultrasound guided technique: arterial puncture (p = 0.009), technical failure (p = 0.009), access site change after first attempt (p = 0.002); pneumothorax occurred in 4 cases, all using the blind percutaneus technique. Late complications occurred in 49 cases (6.1%) which required TIVAD removal in 43 cases and included: sepsis (29 cases), thrombosis (3 cases), dislocation (7 cases), skin dehiscence (3 cases), and severe pain (1 case).
Ultrasound guided technique is the safest option for TIVAD insertion, with the lowest rates of immediate complications.
PMCID: PMC4024213  PMID: 24886342
Totally implantable venous access device; US guided; Chemotherapy
16.  Total parathyroidectomy with trace amounts of parathyroid tissue autotransplantation as the treatment of choice for secondary hyperparathyroidism: a single-center experience 
BMC Surgery  2014;14:26.
The aim of the study was to evaluate total parathyroidectomy with trace amounts of parathyroid tissue (30 mg) as a surgical option in secondary hyperparathyroidism (sHPT) treatment.
From January 2008 to March 2012, 47 patients underwent parathyroidectomy. Comparisons of demographic data, symptoms, and preoperative or postoperative biochemistry were made between total parathyroidectomy with trace amounts of parathyroid tissue autotransplantation group and total parathyroidectomy group.
Out of 47 cases, 45 had successful operation. 187 parathyroid glands identified at the initial operation were reported in 47 patients. 43 patients had been diagnosed with parathyroid hyperplasia, and 4 patients had a benign adenoma. After operation, pruritus, bone pain and muscle weakness disappeared, also serum PTH and serum phosphate were declined markedly as well. After discharge, two patients (in total parathyroidectomy group) were readmitted because of postoperative hypoparathyroidism. Graft-dependent recurrence was not observed in an average follow-up of 42 months.
Total parathyroidectomy with sternocleidomastoid muscle trace amounts of parathyroid tissue autotransplantation is considered to be a feasible, safe and effective surgical option for the patients with sHPT.
PMCID: PMC4021022  PMID: 24886230
Secondary hyperparathyroidism; Chronic renal failure; Total parathyroidectomy; Parathyroid hormone; Autotransplantation
17.  Abdominal wall reconstruction with components separation and mesh reinforcement in complex hernia repair 
BMC Surgery  2014;14:25.
Abdominal closure in the presence of enterocutaneous fistula, stoma or infection can be challenging. A single-surgeon’s experience of performing components separation abdominal reconstruction and reinforcement with mesh in the difficult abdomen is presented.
Medical records from patients undergoing components separation and reinforcement with hernia mesh at Royal Liverpool Hospital from 2009 to 2012 were reviewed. Patients were classified by the Ventral Hernia Working Group (VHWG) grading system. Co-morbidities, previous surgeries, specific type of reconstruction technique, discharge date, complications and hernia recurrence were recorded.
Twenty-three patients’ (15 males, 8 females) notes were reviewed. Median age was 57 years (range 20-76 years). Median follow-up at the time of review was 17 months (range 2-48 months). There were 13 grade III hernias and 10 grade IV hernias identified. Synthetic mesh was placed to reinforce the abdomen in 6 patients, cross-linked porcine dermis was used in 3, and a Biodesign® Hernia Graft was placed in 14. Complications included wound infection (13%), superficial wound dehiscence (22%), seroma formation (22%) and stoma complications (9%). To date, hernias have recurred in 3 patients (13%).
Components separation and reinforcement with biological mesh is a successful technique in the grade III and IV abdomen with acceptable rate of recurrence and complications.
PMCID: PMC4009060  PMID: 24886111
Hernia; Contamination; Infection; Components separation; Biologic graft; Mesh; Reinforcement
18.  An outcome prediction model for exsanguinating patients with blunt abdominal trauma after damage control laparotomy: a retrospective study 
BMC Surgery  2014;14:24.
We present a series of patients with blunt abdominal trauma who underwent damage control laparotomy (DCL) and introduce a nomogram that we created to predict survival among these patients.
This was a retrospective study. From January 2002 to June 2012, 91 patients underwent DCL for hemorrhagic shock. We excluded patients with the following characteristics: a penetrating abdominal injury, age younger than 18 or older than 65 years, a severe or life-threatening brain injury (Abbreviated Injury Scale [AIS] ≥ 4), emergency department (ED) arrival more than 6 hours after injury, pregnancy, end-stage renal disease, or cirrhosis. In addition, we excluded patients who underwent DCL after ICU admission or later in the course of hospitalization.
The overall mortality rate was 61.5%: 35 patients survived and 56 died. We identified independent survival predictors, which included a preoperative Glasgow Coma Scale (GCS) score < 8 and a base excess (BE) value < -13.9 mEq/L. We created a nomogram for outcome prediction that included four variables: preoperative GCS, initial BE, preoperative diastolic pressure, and preoperative cardiopulmonary cerebral resuscitation (CPCR).
DCL is a life-saving procedure performed in critical patients, and devastating clinical outcomes can be expected under such dire circumstances as blunt abdominal trauma with exsanguination. The nomogram presented here may provide ED physicians and trauma surgeons with a tool for early stratification and risk evaluation in critical, exsanguinating patients.
PMCID: PMC4009036  PMID: 24775970
Blunt abdominal trauma; Damage control laparotomy; Damage control surgery
19.  Infliximab’s influence on anastomotic strength and degree of inflammation in intestinal surgery in a rabbit model 
BMC Surgery  2014;14:23.
Infliximab, a TNF-α inhibitor, is a potent anti-inflammatory drug in the treatment of inflammatory bowel diseases. Recent studies have investigated the effect of infliximab treatment on postoperative complications such as anastomotic leakage, however, with conflicting results and conclusions. The purpose of this study was to investigate whether a single dose infliximab has an adverse effect on the anastomotic healing process, observed as reduced anastomotic breaking strength and histopathologically verified lower grade of inflammatory response, in the small intestine of a rabbit.
Thirty New Zealand rabbits (median weight 2.5 kg) were allocated to treatment with an intravenous bolus of either 10 mg/kg infliximab (n = 15) or placebo (n = 15). One week later all rabbits underwent two separate end-to-end anastomoses in the jejunum under general anesthesia. At postoperative day three, the anastomotic breaking strength was determined and histopathological changes were examined.
The mean value of anastomotic breaking strength in the placebo group was 1.89 ± 0.36 N and the corresponding value was 1.81 ± 0.33 N in the infliximab treated rabbits. There was no statistically significant difference between the groups (p = 0.51). The infliximab-treated rabbits had a significant lower degree of inflammatory infiltration response compared to the placebo group (p = 0.047).
Our conclusion, limited by the small sample sizes in both groups, is that a single dose of infliximab, given one week prior to surgery, does not have an impact on the anastomotic breaking strength on the third postoperative day in the small intestine of rabbits.
PMCID: PMC4017771  PMID: 24762063
Infliximab; Intestinal anastomosis; Rabbits; Tensile strength; Wound healing
20.  High cardiac background activity limits 99mTc-MIBI radioguided surgery in aortopulmonary window parathyroid adenomas 
BMC Surgery  2014;14:22.
Radioguided surgery using 99m-Technetium-methoxyisobutylisonitrile (99mTc-MIBI) has been recommended for the surgical treatment of mediastinal parathyroid adenomas. However, high myocardial 99mTc-MIBI uptake may limit the feasibility of radioguided surgery in aortopulmonary window parathyroid adenoma.
Case presentation
Two female patients aged 72 (#1) and 79 years (#2) with primary hyperparathyroidism caused by parathyroid adenomas in the aortopulmonary window were operated by transsternal radioguided surgery. After intravenous injection of 370 MBq 99mTc-MIBI at start of surgery, the maximum radioactive intensity (as counts per second) was measured over several body regions using a gamma probe before and after removal of the parathyroid adenoma. Relative radioactivity was calculated in relation to the measured ex vivo radioactivity of the adenoma, which was set to 1.0.
Both patients were cured by uneventful removal of aortopulmonary window parathyroid adenomas of 4400 (#1) and 985 mg (#2). Biochemical cure was documented by intraoperative measurement of parathyroid hormone as well as follow-up examination. Ex vivo radioactivity over the parathyroid adenomas was 196 (#1) and 855 counts per second (#2). Before parathyroidectomy, relative radioactivity over the aortopulmonary window versus the heart was found at 1.3 versus 2.6 (#1) and 1.8 versus 4.8 (#2). After removal of the adenomas, radioactivity within the aortopulmonary window was only slightly reduced.
High myocardial uptake of 99mTc-MIBI limits the feasibility of radioguided surgery in aortopulmonary parathyroid adenoma.
PMCID: PMC4003509  PMID: 24758398
99mTc-MIBI scintigraphy; Aortopulmonary window parathyroid adenoma; Radioguided surgery; Primary hyperparathyroidism
21.  Neurofibroma invading into urinary bladder presenting with symptoms of obstructed defecation and a large perineal hernia 
BMC Surgery  2014;14:21.
Pelvic floor hernias pose a diagnostic and a treatment challange. Neurofibromatosis is a rare systemic disease, and urinary tract involvement is rare.
Case presentation
Here we report a case of a 54-year-old female with multiple neurofibromatosis who presented with features of obstructed defecation and was found to have a large perineal hernia. At surgery, we found an unusual herniation of a large neuropathic bladder and rectum through a perineal defect. She underwent reduction cystoplasty and repair of the pelvic floor using a prolene mesh. Subsequent histopathological examination confirmed a large neurofibroma infiltrating the urinary bladder.
Neurofibromatosis of the bladder is rare it should be considered as a differential diagnosis in patients presenting with symptoms of obstructed defecation.
PMCID: PMC3992130  PMID: 24739734
Multiple neurofibromatosis; Obstructive defecation; Perineal hernia
22.  Pylorus preserving loop duodeno-enterostomy with sleeve gastrectomy - preliminary results 
BMC Surgery  2014;14:20.
Bariatric operations mostly combine a restrictive gastric component with a rerouting of the intestinal passage. The pylorus can thereby be alternatively preserved or excluded. With the aim of performing a “pylorus-preserving gastric bypass”, we present early results of a proximal postpyloric loop duodeno-jejunostomy associated with a sleeve gastrectomy (LSG) compared to results of a parallel, but distal LSG with a loop duodeno-ileostomy as a two-step procedure.
16 patients underwent either a two-step LSG with a distal loop duodeno-ileostomy (DIOS) as revisional bariatric surgery or a combined single step operation with a proximal duodeno-jejunostomy (DJOS). Total small intestinal length was determined to account for inter-individual differences.
Mean operative time for the second-step of the DIOS operation was 121 min and 147 min for the combined DJOS operation. The overall intestinal length was 750.8 cm (range 600-900 cm) with a bypassed limb length of 235.7 cm in DJOS patients. The mean length of the common channel in DIOS patients measured 245.6 cm. Overall excess weight loss (%EWL) of the two-step DIOS procedure came to 38.31% and 49.60%, DJOS patients experienced an %EWL of 19.75% and 46.53% at 1 and 6 months, resp. No complication related to the duodeno-enterostomy occurred.
Loop duodeno-enterosomies with sleeve gastrectomy can be safely performed and may open new alternatives in bariatric surgery with the possibility for inter-individual adaptation.
PMCID: PMC3994519  PMID: 24725654
23.  Bony destructive injuries of the calcaneus: long-term results of a minimally invasive procedure followed by early functional exercise: a retrospective study 
BMC Surgery  2014;14:19.
Bony destructive injury of the calcaneus (BDIC) represents one of the most severe comminuted fractures of the calcaneus in which soft tissue coverage remains intact. The features of this injury include a collapsed articular surface, significant widening, severe loss of height and an unrecognisable outline of the calcaneus. This study aims to present the long-term outcomes of BDIC treated in a minimally invasive fashion followed by supervised early exercise.
Twelve patients with unilateral BDICs were treated at our institution. The main surgical procedures included percutaneous traction and leverage reduction and internal compression fixation with anatomic plates and compression bolts. Early functional exercise was encouraged to mould the subtalar joint. The height, length and width of the calcaneus; Böhler’s and Gissane’s angles; reduction of the articular surfaces; and functional recovery of the affected feet were assessed.
The height, length and width of the calcaneus were substantially restored. The mean Böhler’s and Gissane’s angles of the affected calcaneus were 24.5 and 122.8 degrees, respectively. Five patients regained anatomical or nearly anatomical reduction of their posterior facets. Residual articular displacement of more than 3 mm was noted in three patients. Patients were followed for a mean of 93.9 months. The mean American Orthopaedic Foot and Ankle Society score was 83.8. Nine patients showed excellent or good results. Radiographic evidence of post-traumatic subtalar arthritis was observed in four cases. However, no subtalar arthrodesis was required.
BDICs can be treated effectively with percutaneous reduction and internal compression fixation followed by early active exercise. This protocol resulted in satisfactory radiological and functional outcomes.
PMCID: PMC4021046  PMID: 24725606
Calcaneal fracture; Bony destructive injury; Internal compression fixation; Percutaneous leverage; Early exercise
24.  Use of human fibrin glue (Tisseel) versus staples for mesh fixation in laparoscopic transabdominal preperitoneal hernioplasty (TISTA): a randomized controlled trial (NCT01641718) 
BMC Surgery  2014;14:18.
Inguinal hernia repair is one of the most common surgical procedures worldwide. This procedure is increasingly performed with endoscopic techniques (laparoscopy). Many surgeons prefer to cover the hernia gap with a mesh to prevent recurrence. The mesh must be fixed tightly, but without tension. During laparoscopic surgery, the mesh is generally fixed with staples or tissue glue. However, staples often cause pain at the staple sites, and they can cause scarring of the abdominal wall, which can lead to chronic pain. We designed a trial that aims to determine whether mesh fixation with glue might cause less postoperative pain than fixation with staples during a transabdominal preperitoneal patch plastic repair.
The TISTA trial is a prospective, randomized, controlled, single-center trial with a two-by-two parallel design. All patients and outcome-assessors will be blinded to treatment allocations. For eligibility, patients must be male, ≥18 years old, and scheduled for laparoscopic repair of a primary inguinal hernia. One group comprises patients with a unilateral inguinal hernia that will be randomized to receive mesh fixation with either tissue glue or staples. The second group comprises patients with bilateral inguinal hernias. They will be randomized to receive mesh fixation with tissue glue either on the right or the left side and with staples on the other side. The primary endpoint will be pain under physical stress, measured at 24 h after surgery. Pain will be rated by the patient based on a numeric rating scale from 0 to 10, where 10 equals the worst pain imaginable. A total of 82 patients will be recruited (58 patients with unilateral inguinal hernias and 24 patients with bilateral hernias). This number is estimated to provide 90% power for detecting a pain reduction of one point on a numeric rating scale, with a standard deviation of one.
Patients with bilateral hernias will receive two meshes, one fixed with glue, and the other fixed with staples. This design will eliminate the inter-individual bias inherent in comparing pain measurements between two groups of patients.
Trial registration NCT01641718
PMCID: PMC3994239  PMID: 24690207
Hernia repair; Fibrin glue; Staples; Mesh; Laparoscopy; Postoperative pain
25.  Longitudinal plication - a surgical strategy for complete rectal prolapse management 
BMC Surgery  2014;14:17.
Rectal prolapse is a known problem since antiquity and the cause is not fully understood. Despite the presence of more than 100 lines of treatment, none of them is ideal.
Between the years of (2005–2011), thirty patients with full-thickness rectal prolapse were operated upon. Age ranged between (2–65 years) with a mean of 21.5 year. Male to female ratio was (2:1). Each prolapsed rectum was repaired with longitudinal plication (LP) at two or three points accordingly using braded polyglycolic acid – absorbable 1.0 suture material. Plications started by inserting a stitch at the most proximal part of the prolapse, followed by successive similar transverse stiches continuing in a spiral fashion till the mucocutaneous junction. We used three LP in adults and two in children. All of the patients where operated upon as a day-case procedure and discharged 6 hours after the operation.
In this series of patients, twenty-nine of them had complete recovery from the prolapse. Only one patient had recurrence 2 years after the operation, and the same procedure was applied successfully with uneventful post-operative period. Although twenty-three patients had fecal Incontinence, twenty-one of them regained continence after operation.
This method is an easy perineal procedure, with fewer complications. It can be performed for all age groups, in an ordinary surgical unit, by an expert anorectal surgeon. We found that our procedure is simple, safe and less invasive.
PMCID: PMC3994363  PMID: 24655367
Fecal incontinence; Procidentia; Circumferential protrusion; Rectal wall; Anal sphincter complex

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