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1.  VA Vascular Injury Study (VAVIS): VA-DoD extremity injury outcomes collaboration 
BMC Surgery  2015;15(1):13.
Background
Limb injuries comprise 50-60% of U.S. Service member’s casualties of wars in Afghanistan and Iraq. Combat-related vascular injuries are present in 12% of this cohort, a rate 5 times higher than in prior wars. Improvements in medical and surgical trauma care, including initial in-theatre limb salvage approaches (IILS) have resulted in improved survival and fewer amputations, however, the long-term outcomes such as morbidity, functional decline, and risk for late amputation of salvaged limbs using current process of care have not been studied. The long-term care of these injured warfighters poses a significant challenge to the Department of Defense (DoD) and Department of Veterans Affairs (VA).
Methods/Design
The VA Vascular Injury Study (VAVIS): VA-DoD Extremity Injury Outcomes Collaborative, funded by the VA, Health Services Research and Development Service, is a longitudinal cohort study of Veterans with vascular extremity injuries. Enrollment will begin April, 2015 and continue for 3 years. Individuals with a validated extremity vascular injury in the Department of Defense Trauma Registry will be contacted and will complete a set of validated demographic, social, behavioral, and functional status measures during interview and online/ mailed survey. Primary outcome measures will: 1) Compare injury, demographic and geospatial characteristics of patients with IILS and identify late vascular surgery related limb complications and health care utilization in Veterans receiving VA vs. non-VA care, 2) Characterize the preventive services received by individuals with vascular repair and related outcomes, and 3) Describe patient-reported functional outcomes in Veterans with traumatic vascular limb injuries.
Discussion
This study will provide key information about the current process of care for Active Duty Service members and Veterans with polytrauma/vascular injuries at risk for persistent morbidity and late amputation. The results of this study will be the first step for clinicians in VA and military settings to generate evidence-based treatment and care approaches to these injuries. It will identify areas where rehabilitation medicine and vascular specialty care or telehealth options are needed to allow for better planning, resource utilization, and improved DoD-to-VA care transitions.
doi:10.1186/1471-2482-15-13
PMCID: PMC4328065  PMID: 25644593
Extremity vascular injury; Limb salvage; Outcomes; Transitions of care; Service members; Veterans; Iraq; Afghanistan
2.  Sciatic nerve course in adult patients with unilateral developmental dysplasia of the hip: implications for hip surgery 
BMC Surgery  2015;15(1):14.
Background
Sciatic nerve injury is a disastrous adverse complication of surgery and can cause debilitating pain, functional impairment and poor quality of life. Patients with developmental dysplasia of the hip (DDH) have a high incidence of sciatic nerve injury after total hip arthroplasty (THA). A better understanding of the course of the sciatic nerve in patients with DDH may help minimise the risk of sciatic nerve injury after THA.
Methods
A total of 35 adult patients with unilateral DDH were enrolled in this retrospective study. We reviewed the patients’ computed tomography (CT) scans, which included the area from the iliac crest to below the lesser trochanter. The distance between the sciatic nerve and regional anatomic landmarks in four different sections on CT scans was measured to identify the course of the sciatic nerve.
Results
The distance from the sciatic nerve to the spine’s midline was shorter on the affected side than on the healthy side (p < 0.05); the same difference was also detected in the distance to the ilium/ischium outside the true pelvis (p < 0.05). The distance to the greater trochanter was longer on the affected side (p < 0.05). However, the two sides showed no significant difference in the distance from the sciatic nerve to the lesser trochanter (p > 0.05).
Conclusions
For patients with unilateral DDH, the sciatic nerve was located near the ischium and ilium but relatively far from the femur of the affected hip joint, compared to its location on the healthy side. These findings reveal that sciatic nerve becomes shorter in the affected low-limb and is relatively unlikely to be directly injuried using the posterolateral approach in patients with unilateral DDH.
doi:10.1186/1471-2482-15-14
PMCID: PMC4327784  PMID: 25638152
Sciatic nerve course; Injury; Developmental dysplasia of the hip; Hip surgery; Posterolateral approach
3.  A novel single-port laparoscopic operation for colorectal cancer with transanal specimen extraction: a comparative study 
BMC Surgery  2015;15(1):10.
Background
Extension of a single incision for the purpose of specimen extraction in single-port laparoscopic surgery (SPLS) can undermine the merits of SPLS, either by hurting cosmesis or by increasing wound morbidity.
Methods
We retrospectively analyzed the clinical outcomes of patients undergoing SPLS sigmoidectomy, either with transanal specimen extraction (TASE, n = 15) or transumbilical specimen extraction (TUSE, n = 68), for colorectal cancer between March 2009 and March 2013. The inclusion criterion was a tumor diameter of ≤ 5 cm. The median follow-up was 93 months (range 13 – 149).
Results
Most of intraoperative and postoperative variables were comparable between the two groups, except for lengthening of operation time in TASE (287 ± 87 min vs. 226 ± 78 min, P = 0.011). TUSE did not lengthen the duration of postoperative recovery, hospital stay, or pain, or increase the incidence of postoperative complications. Whereas TUSE showed 8.8% (6/68) of wound-related complications, TASE did not show wound-related complications during follow-up period (P = 0.586).
Conclusion
With the exception of a prolonged operation time, TASE showed equivalent surgical outcomes as TUSE in SPLS sigmoidectomy. Thus, the implement of TASE is expected to provide one way of reducing wound-related complications in SPLS in patients with a tumor diameter of ≤5 cm.
doi:10.1186/1471-2482-15-10
PMCID: PMC4328051  PMID: 25633605
Colorectal cancer; Laparoscopy; Sigmoidectomy; Single-port laparoscopic surgery; Specimen extraction
4.  Acute bilateral mass-occupying lesions in non-penetrating traumatic brain injury: a retrospective study 
BMC Surgery  2015;15(1):6.
Background
Traumatic acute bilateral mass-occupying lesions (TABML) is a common entity in head injury, with high morbidity and mortality. Our aim in this study was to evaluate the benefits of different treatment options and the outcome predictors in patients with TABML.
Methods
From October 2010 to November 2012, a consecutive cohort of patients aged 16–70 years with TABML were retrospectively analyzed based on the clinical and radiological characteristics. Patients with TABML were included if admitted within 24 h after injury and were excluded if they presented with infratentorial lesions, unilateral lesions within the first 24 h after injury, or penetrating head injury. According to their treatment option, patients were divided into three groups: a conservative treatment group, a unilateral surgery group, and a bilateral surgery group. Outcomes were assessed using the Glasgow Outcome Scale (GOS). Binary logistic regression analysis was applied to determine the outcome predictors.
Results
Forty-seven patients (58.8%) had severe injuries (Glasgow Coma Scale score (GCS), 3–8) upon admission, and the overall mortality was 31.3% at 6 months post-injury. The mortality was 55.6% in patients who underwent conservative treatment (N = 18), 17.9% in unilateral surgery patients (N = 39), and 34.8% in the bilateral surgery group (N = 23). In the surgical group, the mortality was 53.3% (8 of 15) in those with a GCS of 3–5, which decreased steeply to 14.9% (7 of 47) of those with GCS ≥ 6. On logistic regression analysis, the absence of pupillary reactivity, disappearances of basal cisterns and conservative treatment were related to higher mortality. A lower initial GCS score was associated with an unfavorable outcome. Midline shift tended to be associated with mortality and an unfavorable outcome, although statistical analysis did not show a significant difference.
Conclusions
TABML is suggestive of severe brain injury. As conservative treatment is always associated with a poorer outcome, surgery is advocated, especially in patients with a GCS score of ≥ 6. Whereas the prognostic value of midline shift might be limited because of the counter-mass effect in TABML, the GCS score, the pupillary reactivity, and particularly, the compression of basal cisterns should be emphasized.
doi:10.1186/1471-2482-15-6
PMCID: PMC4324851  PMID: 25618576
Bilateral; Head injury; Lesions; Surgery; Traumatic brain injury
5.  Salvage surgery after chemotherapy with S-1 plus cisplatin for α-fetoprotein-producing gastric cancer with a portal vein tumor thrombus: a case report 
BMC Surgery  2015;15(1):5.
Background
Patient with α-Fetoprotein (AFP)-producing gastric cancer usually has a short survival time due to frequent hepatic and lymph node metastases. Gastric cancer with portal vein tumor thrombus (PVTT) is rare and has an extremely poor prognosis.
Case presentation
A 63-year-old man was found to have a huge Type 3 gastric cancer with a PVTT and a highly elevated serum AFP level. Chemotherapy with S-1 plus cisplatin was given to this patient with unresectable gastric cancer for 4 months. The serum AFP level decreased from 6,160 ng/mL to 60.7 ng/mL with chemotherapy. Since the PVTT disappeared after the chemotherapy, the patient underwent total gastrectomy. Histological findings of the primary tumor after chemotherapy showed poorly differentiated adenocarcinoma without hepatoid cells and viable tumor cells remaining in less than 1/3 of the neoplastic area of mucosa and one lymph node. The cancerous cells were immunohistochemically stained by anti-AFP antibody. The patient has survived for 48 month without recurrence.
Conclusions
AFP-producing gastric cancer with a PVTT has an extremely poor prognosis, but long-term survival was achieved for this dismal condition by salvage surgery after chemotherapy.
doi:10.1186/1471-2482-15-5
PMCID: PMC4324668  PMID: 25591731
Neoadjuvant chemotherapy; α-fetoprotein-producing gastric cancer; Portal vein tumor thrombus
6.  Health Education England, Local Education and Training Boards (LETBs) and reform of healthcare education: implications for surgical training 
BMC Surgery  2015;15(1):3.
Background
National Health Service (NHS) reforms have changed the structure of postgraduate healthcare education and training. With a Government mandate that promotes multi-professional education and training aligned with policy driven initiatives, this article highlights concerns over the impact that these changes may have on surgical training.
Discussion
The creation of Health Education England (HEE) and its local education and training boards (LETBs), which are dominated by NHS healthcare providers, should result in greater accountability of employers in workforce planning, enhanced local responsibility and increased transparency of funding allocation. However, these changes may also create a potential poacher-turned-gamekeeper role of employers, who now have responsibility for junior doctors’ training. Analysis of LETB membership reveals a dearth of representation of surgeons, who comprise only 2% of board members, with the input of trainees also seemingly overlooked. A lack of engagement with the LETBs by the independent sector is a concern with increasing numbers of training opportunities potentially being lost as a result.
The new system also needs to recognise the specific training needs required by the craft specialties given the demands of technical skill acquisition, in particular regarding the provision of simulation training facilities and trainer recognition. However, training budget cuts may result in a disproportionate reduction of funding for surgical training. Surgical training posts will also be endangered, opportunities for out-of-programme experience and research may also decline and further costs are likely to be passed onto the trainee.
Summary
Although there are several facets to the recent reforms of the healthcare education and training system that have potential to improve surgical training, concerns need to be addressed. Engagement from the independent sector and further clarification on how the LETBs will be aligned with commissioning services are also required. Surgical training is in danger of taking a back seat to Government mandated priorities. Representation of trainees and surgeons on LETB committees is essential to ensure a surgical viewpoint so that the training needs of the future consultant workforce meet the demands of a 21st century health service.
doi:10.1186/1471-2482-15-3
PMCID: PMC4324039  PMID: 25592885
Education; Training; Surgery; Reform; NHS; Workforce
7.  Surgical assessment: measuring unobserved health 
BMC Surgery  2015;15(1):4.
Background
The federal and provincial governments in Canada have invested an enormous amount of resources to measure, report and reduce surgical wait times. Yet these measures under-report the wait period that patients’ actually experience, because they do not capture the length of time a patient spends waiting to see the surgeon for a surgical assessment. This unmeasured time is referred to as the “wait one” (W1). Little is known about W1 and the effects that this has on patients’ health. Similarly, it is not understood whether patients waiting for surgical assessment actually want or need surgery. Existing administrative and clinical dataset do not capture information on health and decision-making while the patient is waiting for care form a specialist. The objective of this proposed study is to understand the impact that W1 for elective surgeries has on the health of patients and to determine whether this time can be reduced.
Methods/Design
A prospective survey design will be used to measure the health of patients waiting for surgical assessment. Working with the support of the surgical specialities in Vancouver Coastal Health, we will survey patients immediately after being referred for surgical assessment, and every four months thereafter, until they are seen by the surgeon.
Validated survey instruments will be used, including: generic and condition-specific health status questionnaires, pain and depression assessments. Other factors that will be measured include: patients’ knowledge about their condition, and their desired autonomy in the decision making process. We have piloted data collection in one surgical specialty in order to demonstrate feasibility.
Discussion
The results from this study will be used to quantify changes in patients’ health while they wait for surgical assessment. Based on this, policy- and decision-makers could design care interventions during W1, aimed at mitigating any negative health consequences associated with waiting. The results from this study will also be used to better understand whether there are factors that predict patients’ desire to proceed to surgery. These could be used to guide future research into experimenting with interventions to minimize inappropriate referrals and where they are best targeted.
doi:10.1186/1471-2482-15-4
PMCID: PMC4324857  PMID: 25591412
Waiting lists; Access to health care; Referral and consultation; Secondary care; Elective surgical procedures; Health status; Quality of life; Health surveys; Longitudinal survey
8.  “Clinical significance of multifocal and multicentric breast cancers and choice of surgical treatment: a retrospective study on a series of 1158 cases” 
BMC Surgery  2015;15(1):1.
Background
The biological and clinical significance of multifocal and multicentric (MF/MC) breast cancers and the choice of appropriate surgical treatment for these tumors are still debated.
Methods
1158 women operated on for a stage I-III breast cancer were included in this retrospective study; clinical and pathological data were obtained from the institutional database of the Department of Oncology of the University of Siena, Italy. The impact of MF/MC breast cancers on patterns of recurrence and breast cancer specific survival (BCSS) was investigated in relation to the type of surgical treatment.
Results
MF and MC cancers were present in 131 cases (11.3%) and 60 cases (5.2%) respectively and were more frequently treated with mastectomy (55 MF and 60 MC cancers, 81.2%) than with breast conserving surgery (36 MF cancers, 18.9%; p < 0.001). MF and MC breast cancers were associated with a worse prognosis with a BCSS of 154 months compared to 204 months of unicentric cancers (p < 0.001). In multivariate analysis, MF/MC cancers were independent prognostic factors for BCSS together with higher number of metastatic axillary nodes, absence of estrogen receptors and high proliferative activity. MF and MC cancers were related to a significantly shorter BCSS in patients submitted to mastectomy as well as those submitted to breast conserving surgery. Relapse at any site was higher in the subgroup of MF and MC cancers but the incidence of loco-regional and distant recurrences did not differ between patients treated with mastectomy or breast conserving surgery.
Conclusions
Our results indicate that MF/MC cancers have a negative impact on prognosis and are related to higher loregional and distant relapse independently from the type of surgery performed. Adjuvant therapies did not modify the poorer outcome, but in patients receiving adjuvant anthacyclines, the differences with unicentric tumors were reduced. Our data support the hypothesis that MF/MC tumors may have a worse biological behavior and that the presence of multiple foci should be considered in planning adjuvant treatments.
doi:10.1186/1471-2482-15-1
PMCID: PMC4324662  PMID: 25586679
Breast cancer; Multifocal breast cancer; Multicentric breast cancer; Breast cancer surgery; Breast cancer prognosis
9.  Predictive factors for successful limb salvage surgery in diabetic foot patients 
BMC Surgery  2014;14(1):113.
Background
The goal of salvage surgery in the diabetic foot is maximal preservation of the limb, but it is also important to resect unviable tissue sufficiently to avoid reamputation. This study aims to provide information on determining the optimal amputation level that allows preservation of as much limb length as possible without the risk of further reamputation by analyzing several predictive factors.
Methods
Between April 2004 and July 2013, 154 patients underwent limb salvage surgery for distal diabetic foot gangrene. According to the final level of amputation, the patients were divided into two groups: Patients with primary success of the limb salvage, and patients that failed to heal after the primary limb salvage surgery. The factors predictive of success, including comorbidity, laboratory findings, and radiologic findings were evaluated by a retrospective chart review.
Results
The mean age of the study population was 63.9 years, with a male-to-female ratio of approximately 2:1. The mean follow-up duration was 30 months. Statistical analysis showed that underlying renal disease, limited activity before surgery, a low hemoglobin level, a high white blood cell count, a high C-reactive protein level, and damage to two or more vessels on preoperative computed tomography (CT) angiogram were significantly associated with the success or failure of limb salvage. The five-year survival rate was 81.6% for the limb salvage success group and 36.4% for the limb salvage failure group.
Conclusion
This study evaluated the factors predictive of the success of limb salvage surgery and identified indicators for preserving as much as possible of the leg of a patient with diabetic foot. This should help surgeons to establish the appropriate amputation level for a case of diabetic foot and help prevent consecutive operations.
doi:10.1186/1471-2482-14-113
PMCID: PMC4320552  PMID: 25551288
Diabetic foot; Major limb amputation; Limb salvage
10.  Quality improvement practices used by teaching versus non-teaching trauma centres: analysis of a multinational survey of adult trauma centres in the United States, Canada, Australia, and New Zealand 
BMC Surgery  2014;14(1):112.
Background
Although studies have suggested that a relationship exists between hospital teaching status and quality improvement activities, it is unknown whether this relationship exists for trauma centres.
Methods
We surveyed 249 adult trauma centres in the United States, Canada, Australia, and New Zealand (76% response rate) regarding their quality improvement programs. Trauma centres were stratified into two groups (teaching [academic-based or –affiliated] versus non-teaching) and their quality improvement programs were compared.
Results
All participating trauma centres reported using a trauma registry and measuring quality of care. Teaching centres were more likely than non-teaching centres to use indicators whose content evaluated treatment (18% vs. 14%, p < 0.001) as well as the Institute of Medicine aim of timeliness of care (23% vs. 20%, p < 0.001). Non-teaching centres were more likely to use indicators whose content evaluated triage and patient flow (15% vs. 18%, p < 0.001) as well as the Institute of Medicine aim of efficiency of care (25% vs. 30%, p < 0.001). While over 80% of teaching centres used time to laparotomy, pulmonary complications, in hospital mortality, and appropriate admission physician/service as quality indicators, only two of these (in hospital mortality and appropriate admission physician/service) were used by over half of non-teaching trauma centres. The majority of centres reported using morbidity and mortality conferences (96% vs. 97%, p = 0.61) and quality of care audits (94% vs. 88%, p = 0.08) while approximately half used report cards (51% vs. 43%, p = 0.22).
Conclusions
Teaching and non-teaching centres reported being engaged in quality improvement and exhibited largely similar quality improvement activities. However, differences exist in the type and frequency of quality indicators utilized among teaching versus non-teaching trauma centres.
doi:10.1186/1471-2482-14-112
PMCID: PMC4320430  PMID: 25533153
Trauma quality improvement; Teaching status; Survey
11.  Clinical value of exogenous factor XIII for prolonged air leak following pulmonary lobectomy: a case control study 
BMC Surgery  2014;14(1):109.
Background
We examined the effect of exogenous factor XIII (FXIII) concentrate in patients with prolonged air leak (PAL) after pulmonary lobectomy for non-small cell lung cancer.
Methods
We performed a retrospective analysis of 297 patients who underwent pulmonary lobectomy between July 2007 and March 2014: 90 had an air leak on the first postoperative day, which resolved spontaneously within 5 days in 53 cases (SR group). FXIII concentrate was administered to the remaining 37 patients (PAL group) for 5 days. This group was subdivided into those in whom the air leak resolved during FXIII treatment (EF group) and those who needed additional intervention (inEF group). The clinical and perioperative characteristics of the groups were compared.
Results
Although plasma FXIII activity did not differ significantly between the SR and PAL groups before surgery or on the fifth postoperative day, the proportional perioperative fall in FXIII activity was significantly greater in the SR group (33%) than the PAL group (22%, p = 0.044) and inEF group (14%, p = 0.048). On the fifth postoperative day, FXIII activity was significantly lower in the EF group than in the inEF group (74% versus 91%, p = 0.030). The optimal cut-off point for postoperative plasma FXIII activity to distinguish between the EF and inEF groups was 86%.
Conclusions
Insufficient plasma FXIII consumption and lower postoperative FXIII activity may play a role in the resolution of PAL, and exogenous FXIII concentrate may be an effective, safe and non-invasive treatment.
doi:10.1186/1471-2482-14-109
PMCID: PMC4274675  PMID: 25511431
Pleural air leak; Postoperative care; Lung cancer surgery
12.  Pancytopenia in a surgical patient, a rare presentation of hyperthyroidism 
BMC Surgery  2014;14(1):108.
Background
Pancytopenia is a rare complication of hyperthyroidism. Various mechanisms have been described such as immunological, bone marrow suppression. The possibility of hyperthyroidism should be considered in patients with unexplained pancytopenia. There are many case reports showing the association between hyperthyroidism and pancytopenia. All of these reports show association between Graves disease and pancytopenia but our case shows association between Multinodular goitre and pancytopenia. Besides it is uncommon to find such association in a surgical patient.
Case presentation
This case report describes a 62 yr old hindu female with splenic injury and pancytopenia. On further investigations the patient was found to have hyperthyroidism.
Conclusion
Though the definite mechanism regarding the association of pancytopenia with hyperthyroidism isn’t clear, various cases have been described in the literature. This case shows the diagnostic dilemma that can occur in patients with pancytopenia. Any patient with unexplained pancytopenia should undergo thyroid function tests to rule out hyperthyroidism.
doi:10.1186/1471-2482-14-108
PMCID: PMC4277835  PMID: 25511310
Hyperthyroidism; Pancytopenia
13.  A case of splenic rupture: a rare event after laparoscopic cholecystectomy 
BMC Surgery  2014;14(1):106.
Background
Laparoscopic cholecystectomy (LC) is generally safe and well-accepted. In rare cases, it is associated with complications (intra- e postoperative bleeding, visceral injury and surgical site infection). Splenic lesion has been reported only after direct trauma. We report an unusual case of splenic rupture presenting after “uncomplicated” LC.
Case presentation
A 77-year-old woman presented with distended abdomen, tenderness in the left upper quadrant and severe anemia 12 hours after LC. Clinical examination revealed hypovolemic shock. Abdominal computed tomography confirmed the diagnosis of splenic rupture, and the patient required an urgent splenectomy through midline incision. The post-operative course was uneventful and the patient was discharged on 7th postoperative day.
Splenic injury rarely complicates LC. We postulate that congenital or post-traumatic adhesions of the parietal peritoneum to the spleen may have been stretched from the splenic capsule during pneumoperitoneum establishment, resulting in subcapsular hematoma and subsequent delayed rupture.
Conclusions
Splenic rupture is an unusual but life-threatening complication of LC. Direct visualization of the spleen at the end of LC might be a useful procedure to aid early recognition and management in such cases.
doi:10.1186/1471-2482-14-106
PMCID: PMC4279895  PMID: 25495070
Splenic injury; Ruptured spleen; Laparoscopic cholecystectomy
14.  Transumbilical single-incision laparoscopic distal pancreatectomy: preliminary experience and comparison to conventional multi-port laparoscopic surgery 
BMC Surgery  2014;14(1):105.
Background
Single-incision laparoscopic surgery (SILS), which has been demonstrated to be safely applied on kinds of surgeries, may represent an improvement over conventional multi-port laparoscopic surgery. However, there are still few clinical experiences of SILS in pancreatic surgery until now. In this study, we will summarize our experience of transumbilical single-incision laparoscopic distal pancreatectomy (TUSI-LDP), and compare its related parameters with conventional multi-port laparoscopic distal pancreatectomy (C-LDP).
Methods
A retrospective analysis was conducted for the patients who underwent C-LDP or TUSI-LDP in our department. The demographic data, operative parameters, and postoperative complications in the two groups were summarized and compared.
Results
Laparoscopic distal pancreatectomy was performed in a total of 21 cases, among which TUSI-LDP was performed in 14 cases. As far as the demographical results concerned, there were no significant differences between the two groups. The conversion to open surgery was conducted in one case in the TUSI-LDP group because of severe adhesion between pancreatic cyst and surrounding tissues, while in the C-LDP group the only one conversion was for the difficult detection of small lesion. The mean operating time and intraoperative blood loss in TUSI-LDP group was a little shorter (166.4 ± 57.4 versus 202.1 ± 122.5 minutes, p > 0.05, and 157.1 ± 162.4 versus 168.6 ± 157.4 ml, p > 0.05). The postoperative pain and post-operation lengths of hospital stay in the TUSI-LDP group were also less, though there was no significant statistical difference between the two groups. For the post-operation complications, in TUSI-LDP group the pancreatic leakage occurred in only one case, and ceased spontaneously with only a drain for 61 days. There were no other complications including postoperative hemorrhage, venous thrombosis, infections and so on in both groups.
Conclusion
For the experienced laparoscopic surgeons, in selected patients, TUSI-LDP is a feasible technique, with excellent cosmetic effect, less postoperative pain and post-operation lengths of hospital stay. With the experience accumulated, the operating time and intraoperative blood loss of TUSI-LDP could also gradually reduce.
doi:10.1186/1471-2482-14-105
PMCID: PMC4277826  PMID: 25494969
Single-incision laparoscopic surgery; Distal pancreatectomy; Minimally invasive surgery; Multi-incision laparoscopic surgery
15.  Psoas haematoma as a complication of Veress needle insertion: description of a case and literature review 
BMC Surgery  2014;14(1):104.
Background
In terms of gynaecological laparoscopic surgery, major complications affecting great vessels, and especially the retroperitoneal ones, are unusual.
Case presentation
We introduce a case of a retroperitoneal haematoma associated with psoas muscle pseudoaneurysm, as a side effect of Veress needle insertion, during laparoscopic surgery. Such complication was managed conservatively at first, requiring finally arterial embolisation.
Conclusion
Even though potential complications associated with laparoscopic surgery are infrequent, they must not be underestimated, and in some cases might need a multidisciplinary management.
doi:10.1186/1471-2482-14-104
PMCID: PMC4268806  PMID: 25488585
Veress needle; Psoas; Haematoma; Accidental vascular injury
16.  Randomized control trial to evaluate the effects of acute testosterone administration in men on muscle mass, strength, and physical function following ACL reconstructive surgery: rationale, design, methods 
BMC Surgery  2014;14(1):102.
Background
The anterior cruciate ligament (ACL) is one of four major ligaments in the knee that provide stability during physical activity. A tear in the ACL is characterized by joint instability that leads to decreased activity, knee dysfunction, reduced quality of life and a loss of muscle mass and strength. While rehabilitation is the standard-of-care for return to daily function, additional surgical reconstruction can provide individuals with an opportunity to return to sports and strenuous physical activity. Over 200,000 ACL reconstructions are performed in the United States each year, and rehabilitation following surgery is slow and expensive. One possible method to improve the recovery process is the use of intramuscular testosterone, which has been shown to increase muscle mass and strength independent of exercise. With short-term use of supraphysiologic doses of testosterone, we hope to reduce loss of muscle mass and strength and minimize loss of physical function following ACL reconstruction compared to standard-of-care alone.
Methods/design
This study is a double-blinded randomized control trial. Men 18–50 years of age, scheduled for ACL reconstruction are randomized into two groups. Participants randomized to the testosterone group receive intramuscular testosterone administration once per week for 8 weeks starting 2 weeks prior to surgery. Participants randomized to the control group receive a saline placebo intramuscularly instead of testosterone. Lean mass, muscle strength and physical function are measured at 5 time points: 2 weeks pre-surgery, 1 day pre-surgery, and 6, 12, 24 weeks post-surgery. Both groups follow standard-of-care rehabilitation protocol.
Discussion
We believe that testosterone therapy will help reduce the loss of muscle mass and strength experienced after ACL injury and reconstruction. Hopefully this will provide a way to shorten the rehabilitation necessary following ACL reconstruction. If successful, testosterone therapy may also be used for other injuries involving trauma and muscle atrophy.
Trial registration
NTC01595581, Registration: May 8, 2012
doi:10.1186/1471-2482-14-102
PMCID: PMC4267143  PMID: 25481088
Anterior cruciate ligament; Rehabilitation; Testosterone; Orthopedic surgery
17.  Spontaneous complete migration of suture material after subcuticular continuous suture in cesarean section: a case report 
BMC Surgery  2014;14(1):103.
Background
Skin closure during cesarean section is often performed with subcuticular running sutures by using a nonabsorbable suture material. However, this material has the risk of incomplete removal after wound healing and can migrate to other sites in rare cases.
Case presentation
A 34-year-old Korean woman who had undergone a cesarean section 5 months prior presented with a fine, blue object visible through the skin on her left lower abdomen. No pain or any other signs of inflammation were observed. The foreign body was revealed to be 10-cm-long suture material that had migrated laterally approximately 15 cm in intradermal layer during the previous 5 months, without tangling of the entire length.
Conclusions
Small remnants of suture materials in the subcutaneous tissue are known to migrate toward the superficial layer. The mechanism of these migrations is often thought to be related to foreign body immune reaction or the force generated in wound contracture. Long-distance migration of relatively long suture materials, as in the present case, has not been reported yet. Such a steady tension in a uniform direction within a human tissue layer cannot be explained clearly by the previously described mechanisms. That migration might have occurred in superficial subcutaneous tissue layers through the horizontal flow or movement of those layers during the recovery process that have not been revealed yet.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2482-14-103) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2482-14-103
PMCID: PMC4268889  PMID: 25481274
Suture material migration; Subcuticular suture; Wound recovery; Cesarean section
18.  Laparoscopic bariatric surgery training program model: gastric bypass 
BMC Surgery  2014;14(1):101.
Background
Laparoscopy for bariatric surgery became the surgery of choice for surgeons worldwide. However, it is also more difficult to learn and has a great potential for complications. The specific training is fundamental to maintain the benefits without increasing the complications. This study presents a laparoscopic surgery training method for the treatment of obesity and to analyze its efficiency.
Method
A training program for 36 surgeons with experience in open bariatric surgery was proposed, and the surgical results of their first laparoscopic surgeries were accompanied as for greater complications, such as death, intestinal obstruction, bleeding and fistula within the first 30 days.
Results
Of the 36 surgeons who completed the program, thirteen who performed 403 surgeries were accompanied for 18 months to evaluate morbidity and mortality. There were 4 cases of greater complications (1%).
Conclusions
The proposed program was efficient for this specific group of surgeons, as it permitted the participants to learn the procedure without increasing the initial complications in the learning curve.
doi:10.1186/1471-2482-14-101
PMCID: PMC4265423  PMID: 25468138
Bariatric surgery; Morbid obesity/surgery; Gastric bypass/education; Learning curve; Training; Laparoscopy; Inservice training; Staff development
19.  The utility of the preoperative neutrophil-to-lymphocyte ratio in predicting severe cholecystitis: a retrospective cohort study 
BMC Surgery  2014;14(1):100.
Background
To evaluate whether the neutrophil-to-lymphocyte ratio (NLR), as a prognostic indicator, in patients can differentiate between simple and severe cholecystitis.
Methods
A database of 632 patients who underwent cholecystectomy due to cholecystitis during approximately a seven-year span in a single institution was evaluated. Severe cholecystitis was defined when the cholecystitis was complicated by secondary changes, including hemorrhage, gangrene, emphysema, and perforation. The NLR was calculated at admission as the absolute neutrophil count divided by the absolute lymphocyte count. We used receiver operating characteristic curve analysis to identify the optimal value for the NLR in relation to the severity of cholecystitis. Thereafter, the differences in clinical manifestations according to the NLR cut-off value were investigated.
Results
Our study population comprised 503 patients with simple cholecystitis (79.6%) and 129 patients with severe cholecystitis (20.4%). The NLR of 3.0 could predict severe cholecystitis with 70.5% sensitivity and 70.0% specificity. A higher NLR (≥3.0) was significantly associated with older age (p =0.001), male gender (p =0.001), admission via the emergency department (p <0.001), longer operation time (p <0.001), higher incidence of postoperative complications (p =0.056), and prolonged length of hospital stay (LOS) (p <0.001). Multivariate analysis found that patient age ≥50 years (odds ratio [OR]: 2.312, 95% confidence interval [CI]: 1.472–3.630, p <0.001), preoperative NLR ≥3.0 (OR: 1.876, 95% CI: 1.246–2.825, p =0.003), and admission via the emergency department (OR: 1.764, 95% CI: 1.170–2.660, p =0.007) were independent factors associated with prolonged LOS.
Conclusions
NLR ≥3.0 was significantly associated with severe cholecystitis and prolonged LOS in patients undergoing cholecystectomy. Therefore, preoperative NLR in patients undergoing cholecystits due to cholecystitis seemed to be a useful surrogate marker for severe cholecystitis.
doi:10.1186/1471-2482-14-100
PMCID: PMC4280770  PMID: 25428640
Cholecystitis; Prognosis; Neutrophil-to-lymphocyte ratio; Length of hospital stay
20.  Spontaneous intraperitoneal rupture of hepatic hydatid cyst: a rare cause of ascites 
BMC Surgery  2014;14(1):99.
Background
Hydatid disease is endemic in certain areas of the world and it is located mostly in the liver. Intraperitoneal rupture is rare. Rupture may result from trauma or may occur spontaneously from increased pressure of the cystic fluid. Ruptured hydatid cyst is a rare cause of ascites, but should be considered in the differential diagnosis, especially in endemic areas. The diagnosis of ruptured hydatid cyst should be prompt because it requires emergency intervention.
Case presentation
The present case refers to a 62 year old Tunisian male admitted in our institution for diffuse abdominal distension. Physical examination was unremarkable except for the presence of ascites. Abdominal ultrasonography showed a large amount of fluid into the peritoneal cavity associated with many intraperitoneal cysts with a scalloping on the liver. It showed also a heterogeneous cystic lesion of the segment II of the liver. Abdominal computed tomography (CT) revealed in addition a fat infiltration and a thickening of the peritoneum. Thus intraperitoneal hydatid cyst rupture was suspected and emergency laparotomy was performed. A yellow serous fluid , containing many daughter vesicles disseminated through the peritoneal cavity was noted. A mass consistent with a hydatid cyst was noted at segment II of the liver with a tear on the inferior surface. Thus, intraperitoneal rupture of hepatic hydatid cyst was diagnosed.
Conclusion
The rupture of hydatid cyst into the peritoneal cavity is rare but presents a challenge for the radiologist and the surgeon. This condition is included in the differential diagnosis of ascites in endemic areas.
doi:10.1186/1471-2482-14-99
PMCID: PMC4256059  PMID: 25427421
Hydatid disease; Spontaneous rupture; Liver
21.  Trends and results in treatment of gastric cancer over last two decades at single East European centre: a cohort study 
BMC Surgery  2014;14(1):98.
Background
A steady decline in gastric cancer mortality rate over the last few decades is observed in Western Europe. However it is still not clear if this trend applies to Eastern Europe where high incidence rate of gastric cancer is observed.
Methods
This was a retrospective non-randomized, single center, cohort study. During the study period 557 consecutive patients diagnosed with gastric cancer in which curative operation was performed met the inclusion criteria. The study population was divided into two groups according to two equal time periods: 01-01-1994 – 31-12-2000 (Group I – 273 patients) and 01-01-2001 – 31-12-2007 (Group II – 284 patients). Primary (five-year survival rate) and secondary (postoperative complications, 30-day mortality rate and length of hospital stay) endpoints were evaluated and compared.
Results
Rate of postoperative complications was similar between the groups, except for Grade III (Clavien-Dindo grading system for the classification of surgical complications) complications that were observed at significantly lower rates in Group II (26 (9.5%) vs. 11 (3.9%), p = 0.02). Length of hospital stay was significantly (p = 0.001) shorter (22.6 ± 28.9 vs. 16.2 ± 17.01 days) and 30-day mortality was significantly (p = 0.02) lower (15 (5.5%) vs. 4 (1.4%)) in Group II. Similar rates of gastric cancer related mortality were observed in both groups (92.3% vs. 90.7%). However survival analysis revealed significantly (p = 0.02) better overall 5-year survival rate in Group II (35.6%, 101 of 284) than in Group I (23.4%, 64 of 273). There was no difference in 5-year survival rate when comparing different TNM stages.
Conclusions
Gastric cancer treatment results remain poor despite decreasing early postoperative mortality rates, shortening hospital stay and improved overall survival over the time. Prognosis of treatment of gastric cancer depends mainly on the stage of the disease. Absence of screening programs and lack of clinical symptoms in early stages of gastric cancer lead to circumstances when most of the patients presenting with advanced stage of the disease can expect a median survival of less than 30 months even after surgery with curative intent.
doi:10.1186/1471-2482-14-98
PMCID: PMC4258015  PMID: 25428767
Gastric cancer; Complications; Survival; Mortality
22.  Impact of comorbidities on postoperative complications in patients undergoing laparoscopy-assisted gastrectomy for gastric cancer 
BMC Surgery  2014;14(1):97.
Background
Comorbidity is a predictor of postoperative complications (PCs) in gastrectomy. However, it remains unclear which comorbidities are predictors of PCs in patients who undergo laparoscopy-assisted gastrectomy (LAG). Clinically, insufficient lymphadenectomy (LND) is sometimes performed in high-risk patients, although the impact on PCs and outcomes remains unclear.
Methods
We retrospectively studied 529 patients with gastric cancer (GC) who underwent LAG. PCs were defined as grade 2 or higher events according to the Clavien-Dindo classification. We evaluated various comorbidities as risk factors for PCs and examined the impact of insufficient LND on PCs in patients with risky comorbidities.
Result
A total of 87 (16.4%) patients had PCs. There was no PC-related death. On univariate analysis, heart disease, central nervous system (CNS) disease, liver disease, renal dysfunction, and restrictive pulmonary dysfunction were significantly associated with PCs. Both liver disease and heart disease were significant independent risk factors for PCs on multivariate analysis (odds ratio [OR] = 3.25, p = 0.022; OR = 2.36, p = 0.017, respectively). In patients with one or more risky comorbidity, insufficient LND did not significantly decrease PCs (p = 0.42) or shorten GC-specific survival (p = 0.25).
Conclusion
In patients who undergo LAG for GC, the presence of heart disease or liver disease is an independent risk factor for PC. Insufficient LND (for example, D1+ for advanced GC) might be permissible in high-risk patients, because although it did not reduce PCs, it had no negative impact on GC-specific survival.
doi:10.1186/1471-2482-14-97
PMCID: PMC4251931  PMID: 25416543
23.  Handoffs and transitions in critical care (HATRICC): protocol for a mixed methods study of operating room to intensive care unit handoffs 
BMC Surgery  2014;14(1):96.
Background
Operating room to intensive care unit handoffs are high-risk events for critically ill patients. Studies in selected patient populations show that standardizing operating room to intensive care unit handoffs improves information exchange and decreases errors. To adapt these findings to mixed surgical populations, we propose to study the implementation of a standardized operating room to intensive care unit handoff process in two intensive care units currently without an existing standard process.
Methods/Design
The Handoffs and Transitions in Critical Care (HATRICC) study is a hybrid effectiveness- implementation trial of operating room to intensive care unit handoffs. We will use mixed methods to conduct a needs assessment of the current handoff process, adapt published handoff processes, and implement a new standardized handoff process in two academic intensive care units. Needs assessment: We will use non-participant observation to observe the current handoff process. Focus groups, interviews, and surveys of clinicians will elicit participants’ impressions about the current process. Adaptation and implementation: We will adapt published standardized handoff processes using the needs assessment findings. We will use small group simulation to test the new process’ feasibility. After simulation, we will incorporate the new handoff process into the clinical work of all providers in the study units. Evaluation: Using the same methods employed in the needs assessment phase, we will evaluate use of the new handoff process. Data analysis: The primary effectiveness outcome is the number of information omissions per handoff episode as compared to the pre-intervention period. Additional intervention outcomes include patient intensive care unit length of stay and intensive care unit mortality. The primary implementation outcome is acceptability of the new process. Additional implementation outcomes include feasibility, fidelity and sustainability.
Discussion
The HATRICC study will examine the effectiveness and implementation of a standardized operating room to intensive care unit handoff process. Findings from this study have the potential to improve healthcare communication and outcomes for critically ill patients.
Trial registration
ClinicalTrials.gov identifier: NCT02267174. Date of registration October 16, 2014.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2482-14-96) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2482-14-96
PMCID: PMC4255652  PMID: 25410548
Implementation; Quality improvement; Patient safety; Handoffs; Intensive care unit; Postoperative care; Simulation
24.  Medical student recognition of benign anorectal conditions: the effect of attending the outpatient colorectal clinic 
BMC Surgery  2014;14(1):95.
Background
Benign anorectal conditions are fairly common. Physicians of various specialties usually see patients with these conditions before being referred to colorectal specialists, frequently with an incorrect diagnosis.
We sought to evaluate the effect of attending an outpatient colorectal clinic by medical students on the diagnostic accuracy of these conditions.
Methods
Over a 1-year period, medical students were randomized into a group that attended the clinic, and one that did not. Both groups were shown images of six common benign anorectal conditions. The overall diagnostic accuracy as well as the diagnostic accuracy for each one of these conditions was prospectively evaluated for both groups.
Results
Nineteen students attended clinic and 17 did not. Overall diagnostic accuracy was 80.6% for students attending clinic and 43.1% for non-attending students. (p < 0.05) In the attending group, diagnostic accuracy was significantly greater for prolapsed internal hemorrhoids (73.6% versus 35.2%, p < 0.05), thrombosed external hemorrhoid, (73.6% versus 17.6%, p < 0.05) fissure (100% versus 47%, p < 0.05), and anal tags (68.4% versus 11.7%, p < 0.05%).
Conclusion
Exposure to these conditions during surgical clerkships in medical school may help future specialists provide better care for patients with benign anorectal disorders.
doi:10.1186/1471-2482-14-95
PMCID: PMC4256749  PMID: 25410432
25.  Neutrophil-lymphocyte ratio predicts pathologic tumor response and survival after preoperative chemoradiation for rectal cancer 
BMC Surgery  2014;14(1):94.
Background
Neutrophil-lymphocyte ratio (NLR) reflects the balance between pro- and anti-tumor immune activities. We evaluated whether NLR is associated with pathologic tumor response and prognosis in rectal cancer patients that underwent preoperative chemoradiaton therapy (CRT) with surgery.
Methods
One hundred two patients with rectal cancer that were treated by preoperative CRT followed by surgery were enrolled. A total of 50.4 GY of radiation and 5-FU-based chemotherapy were delivered. An NLR ≥ 3 was considered to be elevated. Pathologic tumor response based on ypTNM stage was categorized into two groups, good response (n = 35, pathologic complete response and ypTNM I) and poor response groups (n = 67, ypTNM II, III, and IV).
Results
Twenty-five patients (24.5%) had elevated NLR. Multivariate analysis showed that an elevated CEA level (p = 0.001), larger tumor (p = 0.03), and elevated NLR (p = 0.04) were significant predictors for a poor response. Poor pathological tumor response and elevated NLR were risk factors for cancer-specific and recurrence-free survivals.
Conclusion
An elevated NLR before CRT can be used as predictors for poor tumor response and unfavorable prognostic factors. Dominant pro-tumor activities of neutrophils or reduced anti-tumor immune response by lymphocytes, as determined by NLR, may have a impact on poor tumor response and unfavorable prognosis.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2482-14-94) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2482-14-94
PMCID: PMC4242604  PMID: 25406793
Neutrophil-lymphocyte ratio; Preoperative chemoradiation; Rectal neoplasm

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