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1.  Robotic transthoracic esophagectomy 
BMC Surgery  2015;15:47.
We have initially published our experience with the robotic transthoracic esophagectomy in 32 patients from a single institute. The present paper is the extension of our experience with robotic system and to best of our knowledge this represents the largest series of robotic transthoracic esophagectomy worldwide. The objective of this study was to investigate the feasibility of the robotic transthoracic esophagectomy for esophageal cancer in a series of patients from a single institute.
A retrospective review of medical records was conducted for 83 esophageal cancer patients who underwent robotic esophagectomy at our institute from December 2009 to December 2012. All patients underwent a thorough clinical examination and pre-operative investigations. All patients underwent robotic esophageal mobilization. En-bloc dissection with lymphadenectomy was performed in all cases with preservation of Azygous vein. Relevant data were gathered from medical records.
The study population comprised of 50 men and 33 women with mean age of 59.18 years. The mean operative time was 204.94 mins (range 180 to 300). The mean blood loss was 86.75 ml (range 50 to 200). The mean number of lymph node yield was 18. 36 (range 13 to 24). None of the patient required conversion. The mean ICU stay and hospital stay was 1 day (range 1 to 3) and 10.37 days (range 10 to 13), respectively. A total of 16 (19.28%) complication were reported in these patents. Commonly reported complication included dysphagia, pleural effusion and anastomotic leak. No treatment related mortality was observed. After a median follow-up period of 10 months, 66 patients (79.52%) survived with disease free stage.
We found robot-assisted thoracoscopic esophagectomy feasible in cases of esophageal cancer. The procedure allowed precise en-bloc dissection with lymphadenectomy in mediastinum with reduced operative time, blood loss and complications.
Electronic supplementary material
The online version of this article (doi:10.1186/s12893-015-0024-2) contains supplementary material, which is available to authorized users.
PMCID: PMC4417322  PMID: 25898903
2.  Appendicitis within Morgagni Hernia and simultaneous Paraesophageal Hernia 
BMC Surgery  2015;15:15.
Morgagni hernia is a congenital diaphragmatic defect that rarely presents with symptomatic findings in adults. The presence of one diaphragmatic defect may decrease the occurrence of a separate diaphragmatic defect. Appendicitis may be a unique presentation of incarcerated bowel in a Morgagni defect.
Case presentation
Review of recent literature and presentation of a patient with Morgagni defect. Only five cases of simultaneous Morgagni hernia and paraesophageal hernia have been described in the English-language literature since 1958. Here, we report the first case of acute appendicitis within an incarcerated right Morgagni hernia in a 76-year-old patient who also had a paraesophageal hernia.
This case illustrates that there is no role for watchful waiting in the management of Morgagni Defects when diagnosed in adult patients.
PMCID: PMC4417238  PMID: 25644716
Morgagni; Paraesophageal; Defect and appendicitis
3.  Treatment of gallbladder stone with common bile duct stones in the laparoscopic era 
BMC Surgery  2015;15:7.
Laparoscopic common bile duct exploration (LCBDE) for stone can be carried out by either laparoscopic transcystic stone extraction (LTSE) or laparoscopic choledochotomy (LC). It remains unknown as to which approach is optimal for management of gallbladder stone with common bile duct stones (CBDS) in Chinese patients.
From May 2000 to February 2009, we prospective treated 346 consecutive patients with gallbladder stones and CBDS with laparoscopic cholecystectomy and LCBDE. Intraoperative findings, postoperative complications, postoperative hospital stay and costs were analyzed.
Because of LCBDE failure,16 cases (4.6%) required open surgery. Of 330 successful LCBDE-treated patients, 237 underwent LTSE and 93 required LC. No mortality occurred in either group. The bile duct stone clearance rate was similar in both groups. Patients in the LTSE group were significantly younger and had fewer complications with smaller, fewer stones, shorter operative time and postoperative hospital stays, and lower costs, compared to those in the LC group. Compared with patients with T-tube insertion, patients in the LC group with primary closure had shorter operative time, shorter postoperative hospital stay, and lower costs.
In cases requiring LCBDE, LTSE should be the first choice, whereas LC may be restricted to large, multiple stones. LC with primary closure without external drainage of the CBDS is as effective and safe as the T-tube insertion approach.
PMCID: PMC4417333  PMID: 25623774
Cholecystectomy; Laparoscopic; Common bile duct stones (CBDS); Transcystic; Choledochotomy; Primary closure
4.  Socio-economic disadvantage at the area-level poses few direct barriers to smoking cessation for Australian smokers: Findings from the International Tobacco Control (ITC) Australian cohort survey 
Drug and alcohol review  2012;31(5):653-663.
Area-level indicators of socio-economic variation are frequently included in models of individual health outcomes. Area disadvantage is linearly related to smoking prevalence, but its relation to cessation outcomes is less well understood.
To explore the relationship between area-level disadvantage and prospective data on smoking cessation.
Design and Methods
The Australian cohort of the International Tobacco Control 4-Country survey (N = 3503) was used to prospectively examine the contribution of area-level socio-economic disadvantage to predicting three important smoking-cessation outcomes: making a quit attempt, achieving 1 month abstinence, and achieving 6 months abstinence from smoking, while controlling for individual-level socio-economic indicators and other individual-level covariates related to smoking cessation.
Only two independent associations were observed between socio-economic disadvantage and cessation outcomes. Area-level disadvantage was related to 1-month abstinence in a non-linear fashion, and the individual experience of smoking-induced deprivation was associated with a lower likelihood of making quit attempts.
Despite the documented higher prevalence of smoking among the more disadvantaged and in more disadvantaged areas, socio-economic disadvantage was not consistently related to making quit attempts, nor to medium-term success. Nevertheless, indirect effects of disadvantage, like its impact on psychological distress, cannot be ruled out, and considering smokers’ individual psychosocial circumstances is likely to aid cessation efforts.
Socio-economic disadvantage, particularly at the area-level poses few direct barriers to smoking cessation.
PMCID: PMC4594828  PMID: 22385265
Smoking; Socio-economic status; area-based measures; Australia
5.  Protective effect of pioglitazone on morphine-induced neuroinflammation in the rat lumbar spinal cord 
Morphine-induced tolerance is associated with the spinal neuroinflammation. The aim of this study was to explore the effects of oral administration of the pioglitazone, the peroxisome proliferator activated receptor gamma (PPAR-γ) agonist, on the morphine-induced neuroinflammation in the lumbar region of the male Wistar rat spinal cord.
Co-administration of the pioglitazone with morphine not only attenuated morphine-induced tolerance, but also prevented the up-regulation of pro-inflammatory cytokines (tumor necrosis factor alpha, interleukin-1beta, and interleukin 6) and nuclear factor-kappa B activity. Administration of the GW-9662 antagonized the above mentioned effects of the pioglitazone.
It is concluded that oral administration of the pioglitazone attenuates morphine-induced tolerance and the neuroinflammation in the lumbar region of the rat spinal cord. This action of the pioglitazone may be, at least in part, due to an interaction with the spinal pro-inflammatory cytokine expression and the nuclear factor-kappa B activity.
PMCID: PMC4580127  PMID: 26394827
Pioglitazone; Morphine; Neuroinflammation; GW-9662; PPAR-γ
6.  Women's position and attitudes towards female genital mutilation in Egypt: A secondary analysis of the Egypt demographic and health surveys, 1995-2014 
BMC Public Health  2015;15:874.
Female genital mutilation (FGM) is still widespread in Egyptian society. It is strongly entrenched in local tradition and culture and has a strong link to the position of women. To eradicate the practice a major attitudinal change is a required for which an improvement in the social position of women is a prerequisite. This study examines the relationship between Egyptian women’s social positions and their attitudes towards FGM, and investigates whether the spread of anti-FGM attitudes is related to the observed improvements in the position of women over time.
Changes in attitudes towards FGM are tracked using data from the Egypt Demographic and Health Surveys from 1995 to 2014. Multilevel logistic regressions are used to estimate 1) the effects of indicators of a woman’s social position on her attitude towards FGM, and 2) whether these effects change over time.
Literate, better educated and employed women are more likely to oppose FGM. Initially growing opposition to FGM was related to the expansion of women’s education, but lately opposition to FGM also seems to have spread to other segments of Egyptian society.
The improvement of women’s social position has certainly contributed to the spread of anti-FGM attitudes in Egyptian society. Better educated and less traditional women were at the heart of this change, and formed the basis from where anti-FGM sentiment has spread over wider segments of Egyptian society.
PMCID: PMC4566495  PMID: 26357927
9.  The Intricate Relationship Between a Medical School and a Teaching Hospital: A Case Study in Uganda 
The relationship between medical schools and teaching hospitals is full of opportunities but also challenges even though they have complementary goals that could enhance each other. Although medical schools and teaching hospitals may face some similar challenges around the world, there could be context-specific observations that differ in resource-rich versus resource-limited settings. The purpose of this study was to investigate factors that are perceived to have influenced the relationship between a medical school and a teaching hospital in Uganda, a resource-limited setting.
This was a cross-sectional, descriptive study in which key informant individual interviews were conducted with senior administrators and senior staff members of the Mulago Hospital and Makerere University Medical School. The interviews explored factors perceived to have favoured the working relationship between the two institutions, challenges faced and likely future opportunities. Both quantitative and qualitative data were generated. Thematic analysis was used with the qualitative data.
Respondents reported a strained relationship between the two institutions, with unfavourable factors far outweighing the favourable factors influencing the relationship. Key negative reported factors included having different administrative set-ups, limited opportunities to share funds and to forge research collaborations, unexploited potential of sharing human resources to address staff shortages, as well as a lack of a memorandum of understanding between the two institutions.
This study identifies barriers in the existing relationship between a teaching hospital and medical college in a resource-poor country. It proposes a collaborative model, rather than competitive model, for the two institutions that may work in both resource-limited and resource-rich settings.
PMCID: PMC4536290  PMID: 25758388
Collaborative model; medical school; relationship; teaching hospital
10.  l-Methionine repressible promoters for tuneable gene expression in Trichoderma reesei 
Trichoderma reesei is the main producer of lignocellulolytic enzymes that are required for plant biomass hydrolysis in the biorefinery industry. Although the molecular toolbox for T. reesei is already well developed, repressible promoters for strain engineering and functional genomics studies are still lacking. One such promoter that is widely employed for yeasts is that of the l-methionine repressible MET3 gene, encoding ATP sulphurylase.
We show that the MET3 system can only be applied for T. reesei when the cellulase inducing carbon source lactose is used but not when wheat straw, a relevant lignocellulosic substrate for enzyme production, is employed. We therefore performed a transcriptomic screen for genes that are l-methionine repressible in a wheat straw culture. This analysis retrieved 50 differentially regulated genes of which 33 were downregulated. Among these, genes encoding transport proteins as well as iron containing DszA like monooxygenases and TauD like dioxygenases were strongly overrepresented. We show that the promoter region of one of these dioxygenases can be used for the strongly repressible expression of the Aspergillus niger sucA encoded extracellular invertase in T. reesei wheat straw cultures. This system is also portable to other carbon sources including d-glucose and glycerol as demonstrated by the repressible expression of the Escherichia coli lacZ encoded ß-galactosidase in T. reesei.
We describe a novel, versatile set of promoters for T. reesei that can be used to drive recombinant gene expression in wheat straw cultures at different expression strengths and in an l-methionine repressible manner. The dioxygenase promoter that we studied in detail is furthermore compatible with different carbon sources and therefore applicable for manipulating protein production as well as functional genomics with T. reesei.
Electronic supplementary material
The online version of this article (doi:10.1186/s12934-015-0308-3) contains supplementary material, which is available to authorized users.
PMCID: PMC4536894  PMID: 26271614
Trichoderma reesei; Promoter; Repressible promoter; Tuneable promoter; TauD/TfdA like dioxygenase; l-Methionine; Wheat straw
11.  Spatial video geonarratives and health: case studies in post-disaster recovery, crime, mosquito control and tuberculosis in the homeless 
A call has recently been made by the public health and medical communities to understand the neighborhood context of a patient’s life in order to improve education and treatment. To do this, methods are required that can collect “contextual” characteristics while complementing the spatial analysis of more traditional data. This also needs to happen within a standardized, transferable, easy-to-implement framework.
The Spatial Video Geonarrative (SVG) is an environmentally-cued narrative where place is used to stimulate discussion about fine-scale geographic characteristics of an area and the context of their occurrence. It is a simple yet powerful approach to enable collection and spatial analysis of expert and resident health-related perceptions and experiences of places. Participants comment about where they live or work while guiding a driver through the area. Four GPS-enabled cameras are attached to the vehicle to capture the places that are observed and discussed by the participant. Audio recording of this narrative is linked to the video via time stamp. A program (G-Code) is then used to geotag each word as a point in a geographic information system (GIS). Querying and density analysis can then be performed on the narrative text to identify spatial patterns within one narrative or across multiple narratives. This approach is illustrated using case studies on post-disaster psychopathology, crime, mosquito control, and TB in homeless populations.
SVG can be used to map individual, group, or contested group context for an environment. The method can also gather data for cohorts where traditional spatial data are absent. In addition, SVG provides a means to spatially capture, map and archive institutional knowledge.
SVG GIS output can be used to advance theory by being used as input into qualitative and/or spatial analyses. SVG can also be used to gain near-real time insight therefore supporting applied interventions. Advances over existing geonarrative approaches include the simultaneous collection of video data to visually support any commentary, and the ease-of-application making it a transferable method across different environments and skillsets.
PMCID: PMC4528811  PMID: 26253100
Spatial video geonarrative (SVG); Geographic information system (GIS); Global positioning system (GPS); Narrative; Context; Post-disaster recovery; Crime; Mosquito control; Tuberculosis
12.  Dioxin receptor regulates aldehyde dehydrogenase to block melanoma tumorigenesis and metastasis 
Molecular Cancer  2015;14:148.
The dioxin (AhR) receptor can have oncogenic or tumor suppressor activities depending on the phenotype of the target cell. We have shown that AhR knockdown promotes melanoma primary tumorigenesis and lung metastasis in the mouse and that human metastatic melanomas had reduced AhR levels with respect to benign nevi.
Mouse melanoma B16F10 cells were engineered by retroviral transduction to stably downregulate AhR expression, Aldh1a1 expression or both. They were characterized for Aldh1a1 activity, stem cell markers and migration and invasion in vitro. Their tumorigenicity in vivo was analyzed using xenografts and lung metastasis assays as well as in vivo imaging.
Depletion of aldehyde dehydrogenase 1a1 (Aldh1a1) impairs the pro-tumorigenic and pro-metastatic advantage of melanoma cells lacking AhR expression (sh-AhR). Thus, Aldh1a1 knockdown in sh-AhR cells (sh-AhR + sh-Aldh1a1) diminished their migration and invasion potentials and blocked tumor growth and metastasis to the lungs in immunocompetent AhR+/+ recipient mice. However, Aldh1a1 downmodulation in AhR-expressing B16F10 cells did not significantly affect tumor growth in vivo. Aldh1a1 knockdown reduced the high levels of CD133+/CD29+/CD44+ cells, melanosphere size and the expression of the pluripotency marker Sox2 in sh-AhR cells. Interestingly, Sox2 increased Aldh1a1 expression in sh-AhR but not in sh-AhR + sh-Aldh1a1 cells, suggesting that Aldh1a1 and Sox2 may be co-regulated in melanoma cells. In vivo imaging revealed that mice inoculated with AhR + Aldh1a1 knockdown cells had reduced tumor burden and enhanced survival than those receiving Aldh1a1-expressing sh-AhR cells.
Aldh1a1 overactivation in an AhR-deficient background enhances melanoma progression. Since AhR may antagonize the protumoral effects of Aldh1a1, the AhRlow-Aldh1a1high phenotype could be indicative of bad outcome in melanoma.
Electronic supplementary material
The online version of this article (doi:10.1186/s12943-015-0419-9) contains supplementary material, which is available to authorized users.
PMCID: PMC4524442  PMID: 26242870
Dioxin receptor; Aldehyde dehydrogenase; Tumorigenesis; Lung metastasis; Cancer stem cells; Invasion
13.  Symptomatology of irritable bowel syndrome and inflammatory bowel disease during the menstrual cycle 
Gastroenterology Report  2015;3(3):185-193.
Gender-related physiological variations in gastrointestinal (GI) symptomatology have been observed in women of reproductive age. Many women experience cyclical changes in GI symptomatology during their menstrual cycle, particularly alteration in their bowel habits. Physiological studies of healthy women during the menstrual cycle showed a prolonged GI transit time during the luteal phase, either in the oro-cecum route or in the colon. Worsened GI symptoms, such as abdominal pain, bloating or diarrhea are observed in patients with irritable bowel syndrome (IBS) during menses. This may be due to elevated prostaglandin levels during menses, with an enhanced perception of viscera-somatic stimuli resulting in nausea, abdominal distension and pain. Also patients with IBS or IBD demonstrate a cyclical pattern more closely related to their bowel habits than healthy controls. Women with inflammatory bowel disease (IBD) also have exacerbated symptoms during menses; however, it is unclear whether this relates to physiological variation or disease exacerbation in IBS or IBD. Studies examining the association of the menstrual cycle and GI symptomatology in patients with IBS or IBD, have not yet clarified the underlying mechanisms. Moreover medications—such as non-steroidal anti-inflammatory drugs and oral contraceptive pills used for dysmenorrhea and menstrual migraine in those patients have not well been controlled for in the previous studies, which can contribute to further bias. Understanding changes in GI symptomatology during the menstrual cycle may help to determine the true extent of disease exacerbation and proper management strategy.
PMCID: PMC4527267  PMID: 25788484
inflammatory bowel disease; irritable bowel syndrome; menstrual cycle; symptomatology
14.  Development of the Japanese National Disaster Medical System and Experiences during the Great East Japan Earthquake 
Yonago Acta Medica  2015;58(2):53-61.
After the Great Hanshin-Awaji Earthquake in 1995, the Japanese national disaster medical system (NDMS) was developed. It mainly consists of four components, namely, a disaster base hospital, an emergency medical information system, a disaster medical assistance team (DMAT), and national aeromedical evacuation (AE). The NDMS was tested for the first time in a real disaster situation during the Great East Japan Earthquake in 2011. Two airports and one base were appointed as DMAT gathering places, and approximately 393 DMAT members divided into 78 teams were transported by Japan Air Self-Defense Force (JASDF) aircrafts to two AE staging bases the following day. Staging care units were installed at Hanamaki Airport, Fukushima Airport, and the Japan Ground Self-Defense Force Camp Kasuminome, and 69, 14 and 24 DMAT teams were placed at those locations, respectively. In total, 19 patients were evacuated using JASDF fixed-wing aircraft. Important issues requiring attention became clear through the experiences of the Great East Japan Earthquake and will be discussed in this paper.
PMCID: PMC4546956  PMID: 26306054
air ambulance; disaster planning; earthquake; emergency; natural disaster
15.  Low-Velocity Nail-Gun Injuries to the Interventricular Septum: Report of Two Cases, One in a Child 
Texas Heart Institute Journal  2015;42(4):393-396.
Nail-gun injury to the heart is rare. Nail-gun injury to the interventricular septum is rarer: we could find only 5 reported cases, and none involving a child. We report 2 additional cases, in which nails penetrated the interventricular septum without causing acute pericardial tamponade, heart block, or shunt across the septum. Transesophageal echocardiography provides a dynamic way to evaluate the patient preoperatively, intraoperatively, and postoperatively.
In the cases reported here, both the adult with multiple interventricular nails and the child with a single nail underwent foreign-object removal via median sternotomy. The child needed cardiopulmonary bypass for removal of the nail. There were no short-term or long-term sequelae from these interventricular septal injuries.
PMCID: PMC4567114  PMID: 26413027
Adenosine; construction materials/nail gun; echocardiography, transesophageal; foreign bodies/ultrasonography; heart injuries/diagnosis/surgery; interventricular septum; suicide, attempted; wounds, penetrating/surgery
16.  A case report of a solitary pancreatic metastasis of an adrenocortical carcinoma 
BMC Surgery  2015;15:93.
Solitary metastases to the pancreas are rare. Therefore the value of resection in curative intention remains unclear. In the literature there are several promising reports about resection of solitary metastasis to the pancreas mainly of renal origin.
Case presentation
Here we report for the first time on the surgical therapy of a 1.5 cm solitary pancreatic metastasis of an adrenocortical carcinoma. The metastasis occurred almost 6 years after resection of the primary tumor. A partial pancreatoduodenectomy was performed and postoperatively adjuvant mitotane treatment was initiated. During the follow-up of 3 years after surgery no evidence of tumor recurrence occurred.
Resection of pancreatic tumors should be considered, even if the mass is suspicious for metastatic disease including recurrence of adrenocortical cancer.
PMCID: PMC4520015
Adrenocortical Carcinoma; Metastases to pancreas; Surgical treatment
17.  Methane-rich saline attenuates ischemia/reperfusion injury of abdominal skin flaps in rats via regulating apoptosis level 
BMC Surgery  2015;15:92.
In plastic surgery, skin damage induced by ischemia/reperfusion (I/R) is a multifactorial process that often occurs. Methane gas has been reported to be a new therapeutic gas for attenuating I/R injury. In this study, we assessed the effects of methane-rich saline (MRS) in regulating apoptosis on skin flap I/R injury.
Male Sprague–Dawley rats, 6–8 weeks old, were divided randomly into three groups: one sham surgery group (SH) and two surgery groups. After undergoing 6 h of I/R management of an abdominal skin flap, surgery groups were treated with physiological saline (I/R-P) or methane-rich saline (I/R-M). On the 3rd postoperative day, a laser Doppler flowmeter was used to measure flap blood supply, and hematoxylin and eosin (H&E) staining was used to observe morphological changes. TdT-mediated dUTP-X nick end labeling (TUNEL) staining was also used to observe early apoptosis and is presented as the percentage of TUNEL-positive cells. Moreover, pASK-1, pJNK, Bcl-2 and Bax were detected by immunohistochemical technology. Caspase-3 activity was also measured to evaluate the effects of MRS.
Compared to the I/R-P group, the flaps in the I/R-M group presented a larger survival area and better blood perfusion with less inflammatory infiltration and cell apoptosis, a higher expression of Bcl-2, a lower expression of pASK-1, pJNK and Bax, and a lower caspase-3 activity.
According to the results, MRS attenuated I/R injury by regulating apoptosis and has the potential to be applied as a new therapy for improving skin flap survival.
PMCID: PMC4520019
Methane-rich saline; Ischemia/reperfusion injury; Skin flaps; Apoptosis
18.  Initial experience of reduced port surgery using a two-surgeon technique for colorectal cancer 
BMC Surgery  2015;15:91.
With the decreasing number of surgeons on surgical teams, reduced port surgery (RPS) operations have become popular. We herein present our initial experience with RPS, which was successfully performed using a two-surgeon technique. A retrospective analysis was performed to compare the two-surgeon technique with conventional laparoscopic colectomy and evaluate its efficacy.
A total of 535 patients were eligible among 749 registered patients. Conventional multiport laparoscopic colectomy with three surgeons and RPS using the two-surgeon technique with a surgeon and surgeon’s assistant were performed in 429 and 106 cases, respectively. The patient characteristics, short-term outcomes (including intraoperative and postoperative findings) and pathological results were recorded and analyzed.
The two groups were similar with respect to age, gender, BMI, history of abdominal surgery, depth of tumor invasion and TNM classification. Reconstruction via extracorporeal functional end-to-end anastomosis was performed in a significantly higher number of patients in the two-surgeon technique group (74 %) than in the conventional laparoscopic colectomy group (57 %). Furthermore, the mean operative time in the two-surgeon technique group (117.9 min) was significantly shorter than that observed in the conventional laparoscopic colectomy group (170 min), and the median postoperative hospital stay was significantly shorter in the two-surgeon technique group (6 days) than in the conventional laparoscopic colectomy group (7 days). There were no major postoperative complications. The final TNM stage was similar in both procedures.
RPS using the two-surgeon technique compares favorably with conventional laparoscopic colectomy and is considered to be a safe and successful procedure.
PMCID: PMC4518600  PMID: 26219424
Reduced port laparoscopic surgery; Colorectal cancer; 2-surgeon technique; Conventional laparoscopic colectomy
19.  Enhanced recovery after surgery (ERAS) protocols for colorectal cancer in Japan 
BMC Surgery  2015;15:90.
Japan has one of the highest five-year relative survival rates for colorectal cancer in the world, with its own traditions of perioperative care and a unique insurance system. The benefits of enhanced recovery after surgery (ERAS) protocols in the Japanese population have yet to be clarified.
We evaluated 352 consecutive cases of colorectal cancer resection at Tokyo Metropolitan Bokutoh Hospital between July 2009 and November 2012. Of these, 95 cases were performed according to traditional protocols (traditional group), and 257 according to ERAS protocols (ERAS group), which were introduced to the hospital in July 2010. Primary endpoints included length of postoperative hospital stay, postoperative short-term morbidity, and rate of readmission within 30 days. Intensive pre-admission counselling, no pre- and postoperative fasting (provision of oral nutrition), avoidance of sodium/fluid overload, intraoperative warm-air body heating, enforced postoperative mobilization, and multimodal team care were among the main changes brought about by the introduction of ERAS protocols.
The median (interquartile range) length of postoperative hospital stay was 10 (10–12.75) days in the traditional group and seven (6–8) days in the ERAS group, i.e., a three-day reduction (p < 0.05) in the ERAS group. Moreover, the proportion of patients discharged within one week dramatically increased from 1 % to 77 % in the ERAS group. The overall incidence of grade 2 and 3 postoperative complications according to the Clavien-Dindo classification was 9.5 % in the traditional group and 9.3 % in the ERAS group, and 30-day readmission rates were 8.3 % and 6.6 % in the traditional and ERAS groups, respectively. There were no significant differences between the two groups. Although operative time and blood loss did not differ significantly between the two groups, the volume of intraoperative infusion was significantly decreased in the ERAS group (p < 0.05), possibly due to ERAS recommendations to avoid dehydration (i.e., avoidance of sodium/fluid overload, no preoperative fasting).
ERAS protocols for colorectal surgery helped reduce the length of postoperative hospital stay without adversely affecting morbidity, indicating that ERAS protocols are feasible and effective in Japanese settings as well.
PMCID: PMC4517644  PMID: 26215107
ERAS; Colorectal cancer; Japan; Length of hospital stay; Fast-track surgery
20.  Long-term efficacy of subtotal splenectomy due to portal hypertension in cirrhotic patients 
BMC Surgery  2015;15:89.
Portal hypertension (PHT) requires invasive measures to prevent rupture and bleeding of esophagogastric varices; however, the long-term results of subtotal splenectomy plus fixation of the retrosternal omentum majus (SSFROM) have not been reported. Specifically, the advantages and disadvantages of surgery that preserves the spleen and the long-term hematologic effects have not been described.
Study design
Our studies relating to SSFROM commenced in February 1999. As of April 2014 we have performed 256 subtotal splenectomies The records of 65 patients with PHT who underwent SSFROM were reviewed retrospectively.
Four patients died within 4 years of surgery, with a 4-year survival rate of 94 %; the 11-year survival rate was 60 %. Eleven patients (17 %) had re-bleeding from esophagogastric varices. The white blood cell and platelet counts were higher 6 and 11 years post-operatively compared with pre-operative values (P < 0.01). Portal venous diameter, portal venous flow volume, splenic artery flow volume, as well as splenic length, thickness, and average cross-sectional areas were shown to be significantly constricted or decreased (P < 0.01). The proportion of serum CD3+ T cells, CD4+ T cells, and CD8+ T cells was increased (P < 0.01), while the serum levels of macrophage colony-stimulating factor and granulocyte-macrophage colony-stimulating factor were significantly decreased (P < 0.01). There was no significant change in the serum levels of IgA, IgM, IgG, and Tuftsin (P > 0.05). DSA demonstrated that 15 cases formed collateral circulations between the portal vein and superior vena cava.
SSFROM provide long-term hemostasis for esophagogastric variceal bleeding in PHT and corrected hypersplenism. SSFROM is an effective treatment for patients with PHT in whom long-term survival is expected.
PMCID: PMC4511991  PMID: 26205377
Portal hypertension; Splenomegaly; Subtotal splenectomy; Shunt
21.  Long-term effects of laparoscopic sleeve gastrectomy versus roux-en-Y gastric bypass for the treatment of Chinese type 2 diabetes mellitus patients with body mass index 28-35 kg/m2 
BMC Surgery  2015;15:88.
To compare long term effects of two bariatric procedures for Chinese type 2 diabetes mellitus (T2DM) patients with a body mass index (BMI) of 28-35 kg/m2.
Sixty four T2DM patients with Glycated hemoglobin A1c (HbA1c) ≧ 7.0 % were randomly assigned to receive laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) procedure. Weight, percentage of excess weight loss (%EWL), BMI, waist circumference, HbA1c, fasting blood glucose (FBG), and C-peptide were measured. Serum lipid levels were also measured during three-year postoperative follow-up visits.
Fifty five patients completed the 36-month follow-up. Both groups had similar baseline anthropometric and biochemical measures. At the end point, 22 patients (78.6 %) in SG group and 23 patients (85.2 %) in RYGB group achieved complete remission of diabetes mellitus with HbA1c < 6.0 % (P = 0.525) and without taking diabetic medications, and 25 patients in each group (89.3 % vs. 92.6 %) gained successful treatment of diabetes with HbA1c≦6.5 % (P = 0.100). Change in HbA1c, FBG and C peptide were comparable in the two groups. The RYGB group had significantly greater weight loss than the SG group [percentage of total weight loss (%TWL) of 31.0 % vs. 27.1 % (P = 0.049), %EWL of 92.3 % vs. 81.9 % (P = 0.003), and change in BMI of 11.0 vs. 9.1 kg/m2(P = 0.017), respectively]. Serum lipids in each group were also greatly improved.
In this three-year study, SG had similar positive effects on diabetes and dyslipidemia compared to RYGB in Chinese T2DM patients with BMI of 28-35 kg/m2. Longer term follow-ups and larger sample studies are needed to confirm these outcomes, however.
PMCID: PMC4509558  PMID: 26198306
Bariatric surgery; Roux-en-Y gastric bypass; Sleeve gastrectomy; Type 2 diabetes; Mild obesity
22.  BariSurg trial: Sleeve gastrectomy versus Roux-en-Y gastric bypass in obese patients with BMI 35–60 kg/m2 – a multi-centre randomized patient and observer blind non-inferiority trial 
BMC Surgery  2015;15:87.
Roux-en-Ygastric bypass (RYGB) and sleeve gastrectomy (SG) rank among the most frequently applied bariatric procedures worldwide due to their positive risk/benefit correlation. A systematic review revealed a similar excess weight loss (EWL) 2 years postoperatively between SG and RYGB. However, there is a lack of randomized controlled multi-centre trials comparing SG and RYGB, not only concerning EWL, but also in terms of remission of obesity-related co-morbidities, gastroesophageal reflux disease (GERD) and quality of life (QoL) in the mid- and long-term.
The BariSurg trial was designed as a multi-centre, randomized controlled patient and observer blind trial. The trial protocol was approved by the corresponding ethics committees of the centres. To demonstrate EWL non-inferiority of SG compared to RYGB, power calculation was performed according to a non-inferiority study design. Morbidity, mortality, remission of obesity-related co-morbidities, GERD course and QoL are major secondary endpoints. 248 patients between 18 and 70 years, with a body mass index (BMI) between 35–60 kg/m2 and indication for bariatric surgery according to the most recent German S3-guidelines will be randomized. The primary and secondary endpoints will be assessed prior to surgery and afterwards at discharge and at the time points 3–6, 12, 24, 36, 48 and 60 months postoperatively.
With its five year follow-up, the BariSurg-trial will provide further evidence based data concerning the impact of SG and RYGB on EWL, remission of obesity-related co-morbidities, the course of GERD and QoL.
Trial registration
The trial protocol has been registered in the German Clinical Trials Register DRKS00004766.
PMCID: PMC4506636  PMID: 26187377
Sleeve gastrectomy; Roux-en-Ygastric bypass; Randomized controlled trial; Patient and observer blind trial; Long-term excess weight loss; Obesity related co-morbidity; Gastroesophageal reflux disease; Quality of life; Morbidity; Mortality
23.  The TICAP-Study (titanium clips for appendicular stump closure): A prospective multicentre observational study on appendicular stump closure with an innovative titanium clip 
BMC Surgery  2015;15:85.
To evaluate the effectiveness and safety of the DS Titanium Ligation Clip for appendicular stump closure in laparoscopic appendectomy.
Overall, 502 patients undergoing laparoscopic appendectomy were recruited for this observational multicentre study in nine study centres between October 2011 and July 2013. The clip was finally applied in 390 patients. Primary outcome variables were feasibility of the clip, intra-abdominal surgical site (abscesses, stump leakages) and superficial wound infections. Patients were followed 30 days after surgery.
The clip was applicable in nearly 80 % of patients. Reasons for not applying the clip were mainly an inflamed caecum or a too large diameter of the appendix base. Superficial wound infections were found in nine (2.31 %), intra-abdominal abscesses in five (1.28 %), appendicular stump leak in one (0.26 %), and other adverse events in 22 (5.64 %) patients. In total, 12 (3.08 %) patients were re-admitted to hospital for treatment. Seven re-admissions were surgery-related; ten (2.56 %) patients had to be re-operated. One patient died during the course of the study due to persisting peritonitis (mortality 0.26 %).
The results suggest that the DS Titanium Ligation Clip is a safe and effective option in securing the appendicular stump in laparoscopic appendectomy. The complication rates found with the use of the DS-Clip are comparable to the rates in the literature when other methods are used.
Trial Registration
PMCID: PMC4504402  PMID: 26185103
Laparoscopic appendectomy; Appendix stump closure; Acute appendicitis
24.  Transversal incision of the vagina favors the remaining of the tape in the middle-third urethra compared to longitudinal incision during transobturator sling procedures for stress urinary incontinence 
BMC Surgery  2015;15:84.
To describe a new type of incision of the vagina during transobturator sling procedure and to evaluate by ultrasound the tape position at 3, 6 and 12 months after surgery.
We conducted a prospective study including 51 patients with urinary stress incontinence who underwent sling procedure using the transversal vaginal incision. Tape position was evaluated by ultrasound at 3, 6 and 12 months after surgery and expressed as a percentage of the urethral length (the proximal third of the urethral length 0–39 %, the middle third 40–60 %, and the distal third 60–100 %).
Informed consent was obtained from all patients prior to their inclusion in the study. All procedures have been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments and were approved by the Institutional Review Board and Ethical Committee of “Victor Babeş” University of Medicine and Pharmacy Timisoara before the beginning of the study (no 7/17.04.2012).
At 3 months after surgery, 3.92 % of the slings were located in the proximal third of the urethra, 88.23 % in the middle third of the urethra and 7.84 % in the distal third. At 6 and 12 months after surgery we obtained similar results: 9.81 % of the slings were located in the proximal third of the urethra, 82.35 % in the middle third and 7.84 % in the distal third of the urethra.
The transversal incision of the vagina offers a minimal dissection along the long axis of the urethra favoring the remaining of the tape in the middle third of the urethra.
PMCID: PMC4504411  PMID: 26182915
Transobturator sling; Urinary incontinence; Transversal incision; Mid-urethra; de novo urgency
25.  The impact of health literacy in the care of surgical patients: a qualitative systematic review 
BMC Surgery  2015;15:86.
Inadequate health literacy affects more than 90 million Americans and it has been associated with adverse outcomes in the medicine field including increased hospitalization rates and greater mortality. Since surgical patients are often required to make complex decisions and adhere to complex instructions, health literacy may have a profound impact in the surgical practice. The main objective of the current study was to systematically evaluate the role of health literacy in surgical patients.
A systematic search was performed to identify studies that evaluated the role of health literacy in the perioperative setting following the PRISMA guidelines. Only studies that examined health literacy using a validated instrument in the perioperative setting were included.
Ten studies including data on 1147 patients were included. The median (IQR) number of patients in the included studies was 101 (30 to 152). The majority of studies used the Short Test of Functional Literacy in adults (STOFHLA) to evaluate patients’ health literacy. Five studies evaluated the patients preoperatively, four studies evaluated patients in the postoperative period and in one study the time of evaluation in relation to the surgical procedure was not defined. The lowest prevalence of inadequate health literacy was detected in kidney transplant patients, 6 out of 124 (5 %), while the highest prevalence of inadequate health literacy was detected in orthopedic patients having total joint replacement, 86 out of 126 (60 %). Inadequate health literacy in the preoperative period was associated with poor medical information comprehension and it may adversely affect adherence to preoperative medications and even modulate surgical disparities. Inadequate health literacy in the postoperative period was associated with poor comprehension of discharge instructions and worse kidney function in transplant recipients.
Health literacy seems to have a very significant impact in the care of surgical patients. More studies to establish the impact of poor health literacy on perioperative outcomes are needed.
PMCID: PMC4504415  PMID: 26182987

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