The American Journal of Surgery

Laparoscopic sentinel node mapping using combined detection for endometrial cancer: a study of 33 cases—is it a promising technique?

2009-01-01

Abstract: Background: To evaluate the feasibility of a laparoscopic sentinel node (SN) procedure based on combined method in patients with endometrial cancer.Methods: Thirty-three patients (median age 66.1 years) with endometrial cancer of apparent stage I or stage II underwent a laparoscopic SN procedure based on combined radiocolloid and patent blue injected pericervically. After the SN procedure, all the patients underwent laparoscopic bilateral pelvic lymphadenectomy.Results: SNs were identified in only 27 patients (81.8%). The mean number of SNs was 2.5 per patient (range 1–5). Only 18 patients (54.5%) had an identified bilateral SN. The most common site of the SNs was the medial external iliac region (67.6%). Fourteen SNs (19.7%) from 8 patients (24.2%) were found to be metastatic at the final histological assessment. No false-negative SN results were observed.Conclusions: A SN procedure based on a combined detection and laparoscopic approach is feasible in patients with early endometrial cancer. However, because of a low rate of bilateral and global SN detections and problems of injection site using pericervical injection of radiocolloid and blue dye, alternative methods should be explored. Pericervical injections should be avoided.

Laparoscopic peritoneal dialysis catheter implantation using a Tenckhoff trocar under local anesthesia with nitrous oxide gas insufflation

2009-01-01

Abstract: Background: Laparoscopic implantation of peritoneal dialysis catheters has many advantages over conventional methods. The ability to perform laparoscopy with the patient under local anesthesia allows renal failure patients, who ordinarily might not be considered candidates for general anesthesia, an opportunity to undergo this procedure.Methods: Using local anesthesia and nitrous oxide pneumoperitoneum, 175 catheters were implanted in long musculofascial tunnels under laparoscopic guidance to minimize the risk of catheter migration and flow dysfunction.Results: Nitrous oxide pneumoperitoneum was well tolerated, allowing all procedures to be safely completed with the patients under local anesthesia. The overall 1- and 2-year catheter survival rates were 92.7% and 91.3%, respectively. The incidence of catheter tip migration and omental entrapment was 1.7% and 2.9%, respectively. Temporary pericatheter leak occurred in 7.4% of cases.Conclusions: Nitrous oxide insufflation enables safe performance of laparoscopic surgery with the patient under local anesthesia. Patients benefit from a minimally invasive technique with the assurance of obtaining successful long-term catheter function.

Radiofrequency energy delivery to the anal canal: is it a promising new approach to the treatment of fecal incontinence?

Duck-Woo Kim, Hong-Man Yoon, Jun-Seok Park, Young Hoon Kim, Sung-Bum Kang — 2009-01-01

Abstract: Background: The present study was conducted to assess the efficacy and safety of the delivery of radiofrequency energy to the anal canal (the SECCA procedure).Methods: Eight patients with fecal incontinence underwent the SECCA procedure. The Fecal Incontinence Severity Index (FISI) score and the Fecal Incontinence-related Quality of Life (FIQL) scale were completed at baseline and after the procedure. Anorectal manometry and endoanal ultrasound also were conducted.Results: Seven of the 8 patients were women, and the median age of the patients was 59 years (range, 28–73 y). The mean FISI score and all of the parameters in the FIQL scale with the exception of the embarrassment scale measured at 6 months after the procedure was not improved significantly. We observed no changes in the anal manometry and endoanal ultrasound parameters. Complications associated with the procedure developed in 7 of the 8 patients, including anal bleeding, anal pain, and anal mucosal discharge.Conclusions: The FISI score and FIQL scale were not improved significantly after the SECCA procedure, and considerable complications were associated with the procedure.

Laparoscopic diagnosis and treatment of postoperative complications

Boris Kirshtein, Sergey Domchik, Solly Mizrahi, Leonid Lantsberg — 2009-01-01

Abstract: Background: There is no unequivocal attitude to a laparoscopy as to the means in the diagnosis and treatment of postoperative surgical complications. Our study sought to determine the role of laparoscopy in the management of suspected postoperative complications.Methods: We performed a retrospective review of the patients who underwent laparoscopy for complications of previous surgery over a 6-year period.Results: Sixty-four patients underwent laparoscopy for complications during the study period including 49 laparoscopies, 14 laparotomies, and 1 endoscopic procedure. The median delay between operations was 2 ± 4.5 days. In 18 (28.1%) patients, laparoscopy did not find intra-abdominal pathology. The conversion to open surgery was necessary in 9 (14.1%) patients. Seven patients underwent more than 1 relaparoscopy. No cases of misdiagnosis were observed. Morbidity was 12.5%. There was no laparoscopy-related death.Conclusions: Laparoscopy is an effective tool for the management of postoperative complications after open and laparoscopic surgery. It avoids diagnostic delay and unnecessary laparotomy.

Single-stage closure of enterocutaneous fistula and stomas in the presence of large abdominal wall defects using the components separation technique

Jan Wind, Paul J. van Koperen, J. Frederik M. Slors, Willem A. Bemelman — 2009-01-01

Abstract: Background: Closure of an enterocutaneous fistula and/or stomas in the presence of large abdominal wall defects is a challenging problem. In the present study, the results of the components separation technique are described.Methods: All patients with an enterocutaneous fistula and/or stomas in the presence of large abdominal wall defects (ie, laparostomy of ventral hernia) who underwent a single-stage repair using the components separation technique in the period from January 2000 to July 2007 were reviewed retrospectively.Results: A total of 32 patients were included. The median operating time was 204 minutes (range 87–573). In 18 patients, additionally to the components separation, an absorbable mesh was used. Postoperatively, in 16 patients 22 complications were reported. There were 9 patients with local wound problems. The median postoperative hospital stay was 12 days (range 5–74). Seven patients developed a ventral hernia. Four of them were small asymptomatic recurrences. Four out of the 15 patients with an enterocutaneous fistula developed a recurrent fistula. The median follow-up was 20 months (range 3–54).Conclusion: Closure of enterocutaneous fistula and/or stomas and simultaneous repair of large abdominal wall defects is feasible using the components separation technique but morbidity is considerable. Early recurrence of abdominal hernia and fistula is acceptable.

Does increased emergency medical services prehospital time affect patient mortality in rural motor vehicle crashes? A statewide analysis

2009-01-01

Abstract: Background: Fatality rates from rural vehicular trauma are almost double those found in urban settings. It has been suggested that increased prehospital time is a factor that adversely affects fatality rates in rural vehicular trauma. By linking and analyzing Alabama's statewide prehospital data, emergency medical services (EMS) prehospital time was assessed for rural and urban vehicular crashes.Methods: An imputational methodology permitted linkage of data from police motor vehicle crash (MVC) and EMS records. MVCs were defined as rural or urban by crash location using the United States Census Bureau criteria. Areas within Alabama that fell outside the Census Bureau definition of urban were defined as rural. Prehospital data were analyzed to determine EMS response time, scene time, and transport time in rural and urban settings.Results: Over a 2-year period from January 2001 through December 2002, data were collected from EMS Patient Care Reports and police crash reports for the entire state of Alabama. By using an imputational methodology and join specifications, 45,763 police crash reports were linked to EMS Patient Care Reports. Of these, 34,341 (75%) were injured in rural settings and 11,422 (25%) were injured in urban settings. A total of 714 mortalities were identified, of which 611 (1.78%) occurred in rural settings and 103 (.90%) occurred in urban settings (P < .0001). When mortalities occurred, the mean EMS response time in rural settings was 10.67 minutes and 6.50 minutes in urban settings (P < .0001). When mortalities occurred, the mean EMS scene time in rural settings was 18.87 minutes and 10.83 minutes in urban settings (patients who were dead on scene and extrication patients were excluded from both settings) (P < .0001). When mortalities occurred, the mean EMS transport time in rural settings was 12.45 minutes and 7.43 minutes in urban settings (P < .0001). When mortalities occurred, the overall mean prehospital time in rural settings was 42.0 minutes and 24.8 minutes in urban settings (P < .0001). The mean EMS response time for rural MVCs with survivors was 8.54 minutes versus a mean of 10.67 minutes with mortalities (P < .0001). The mean EMS scene time for rural MVCs with survivors was 14.81 minutes versus 18.87 minutes with mortalities (patients who were dead on scene and extrication patients were excluded) (P = .0014).Conclusions: Based on this statewide analysis of MVCs, increased EMS prehospital time appears to be associated with higher mortality rates in rural settings.

Use of human acellular dermal matrix for abdominal wall reconstructions

Samuel M. Maurice, Dionne A. Skeete — 2009-01-01

Abstract: Background: Acellular dermal matrix (ADM) represents a promising new fascial substitute for repairing abdominal wall defects.Methods: We retrospectively studied 63 patients who underwent fascial reconstruction with ADM and analyzed risk factors for recurrence and infectious wound complications.Results: Postoperative wound infections, noninfectious wound complications, and recurrences developed in 35%, 44%, and 41% of patients, respectively. No patients required ADM removal. Long surgical times (≥300 min), implants of 100 cm2 or greater, and repairs using 3 or more ADM sheets were associated significantly with the development of a postoperative wound infection. The approximation of ADM directly to the fascial edge (P = .02), long surgical time (P < .01), implant size of 100 cm2 or greater (P = .01), and the presence of a postoperative wound infection (P = .02) were associated significantly with recurrence.Conclusions: Recurrences and complications after ADM fascial repairs may be higher than previously reported and associated with implant size and method of implantation. Postoperative infection, although not necessitating implant removal, is associated with more recurrences.

A single nucleotide polymorphism in the Mdm2 promoter and risk of sepsis

2009-01-01

Abstract: Background: The Mdm2-SNP309(T/G) polymorphism has been shown to upregulate transcription of Mdm2 and subsequently attenuate the p53 pathway. Its role in regulating the human response to acute illness has not been reported.Methods: Patients from the surgical intensive care unit were prospectively enrolled. SNP309 genotype was determined, and a genotype-based comparison of clinical outcomes was performed.Results: Of the 85 enrolled patients, 41 had wild type (T/T) and 44 had mutant (32 T/G and 12 G/G) genotypes. The mutant-genotype group tended to have a longer LOS in both the surgical intensive care unit (P = .40) and the hospital (P = .08), but these trends did not reach significance. No observable genotype-based differences were noted in any other measured parameters.Conclusions: The Mdm2-SNP309(G) allele may be associated with longer LOS. However, it does not appear to influence any other clinical characteristics, nor can it be used to predict clinical outcome.

The role of estrogen in the formation of experimental abdominal aortic aneurysm

Xiao-Fei Wu, Jian Zhang, Saulius Paskauskas, Shi-Jie Xin, Zhi-Quan Duan — 2009-01-01

Abstract: Objective: The current study sought to investigate the role of estrogen in the formation of experimental abdominal aortic aneurysm (AAA).Methods: Elastase perfusion of infrarenal AAA animal model was performed in 20 female and 20 male Wistar rats that were randomly divided into an ovariectomized/sham-operated group and an estradiol (E2) experimental/saline control group, respectively. At day 14, E2 was detected, while the mRNA and protein expressions of matrix metalloproteinases 2 and 9 (MMP-2 and -9) in AAA tissue were detected by immunohistochemistry and polymerase chain reaction (PCR).Results: The ovariectomized group showed lower estrogen levels and a higher aneurysm dilatation rate and significantly higher MMP-2 and -9 expression compared with the sham-operated group (P < .01), which was in accordance with MMP-2 and -9 mRNA expression. The E2 group showed higher estrogen levels and a lower aneurysm dilatation rate and significantly lower MMP-2 and -9 expression than did the saline control group (P < .01), which was in accordance with MMP-2 and -9 mRNA expression.Conclusions: In the pathogenesis of AAA, estrogen may play an inhibitory role by decreasing expression of MMP-2 and MMP-9 synthesis.

Intraoperative cerebral high-intensity transient signals and postoperative cognitive function: a systematic review

2009-01-01

Abstract: Background: Much attention in the literature has focused on the relationship between perioperative microemboli during cardiac and vascular surgery and postoperative cognitive decline. Transcranial Doppler ultrasonography (TCD) has been used to measure high-intensity transient signals (HITS), which represent microemboli during cardiac, vascular, and orthopedic surgery. The purpose of this study was to systematically examine the literature with respect to HITS and postoperative cognitive function.Methods: Systematic PubMed searches identified articles related to the use of TCD and cognitive function in the surgical setting.Results: The literature remains largely undecided on the role of HITS and cognitive impairment after surgery, with most studies being underpowered to show a relationship. Although the cognitive effects of HITS may be difficult to detect, subclinical microemboli present potential harm, which may be modifiable.Conclusions: TCD represents a tool for intraoperative cerebral monitoring to reduce the number of HITS during surgery.

Laparoscopic versus open repair of incisional/ventral hernia: a meta-analysis

2009-01-01

Abstract: Background: The aim of this article is to analyze laparoscopic versus open repair of incisional/ventral hernia (IVH).Methods: A systematic review of the literature was undertaken to analyze clinical trials on IVH.Results: Five randomized controlled trials involving a total of 366 patients were analyzed. There were 183 patients in each group. Open repair of IVH was associated with significantly higher complication rates and longer hospital stays than laparoscopic repair. There was also some evidence that surgical times may be longer for open repair of IVH. However, statistically there was no difference in wound pain or recurrence rates.Conclusions: Laparoscopic repair of IVH is safe, with fewer complications and shorter hospital stays, and possibly a shorter surgical time. However, postoperative pain and recurrence rates are similar for both techniques. Hence, the laparoscopic approach may be considered for IVH repair if technically feasible, but more trials with longer follow-up evaluations are required to strengthen the evidence.

Implications of laparoscopy on surgery residency training

Traci Hedrick, Florence Turrentine, Hilary Sanfey, Bruce Schirmer, Charles Friel — 2009-01-01

Abstract: Background: With the advent of laparoscopy, many traditional junior-level cases now require advanced laparoscopic skill. We sought to ascertain the implications of laparoscopy on residency training through the use of a large national database.Methods: American College of Surgeons National Surgical Quality Improvement Program data were gathered for patients undergoing elective open and laparoscopic inguinal herniorrhaphy, appendectomy, and partial colectomy during 2005 and 2006. Cases were stratified by resident level and compared using univariate analysis.Results: A total of 14,729 cases were performed during the study period. For inguinal hernia repair, 72% of open repairs were performed by postgraduate year 3 residents or below versus 41% of laparoscopic repairs (P < .0001). Similarly, 61% of open appendectomies were performed by postgraduate year 3 residents or below compared with 48% of laparoscopic appendectomies (P < .0001). Forty-six percent of open colectomies were performed by postgraduate year 3 and postgraduate year 4 residents versus 33% of laparoscopic resections (P < .0001).Conclusions: These data show an upward shift in cases traditionally performed by junior-level residents. The implications of this shift are unknown but may lead to decreased surgical experience during the early years of training.

Efficacy of cognitive feedback in improving operative risk estimation

Rosamond Jacklin, Nick Sevdalis, Ara Darzi, Charles A. Vincent — 2009-01-01

Abstract: Background: Decision-making is an essential skill for surgeons, but systematic objective feedback is lacking. Cognitive feedback provides information about how risk factors relate to outcomes, and how individual surgeons mentally synthesize these relationships.Methods: Pre-feedback, we assessed accuracy and reliability of 105 trainee surgeons'/medical students' estimates of operative mortality for major surgery for 28 patient vignettes with varying risk factors, using a published risk model as a gold standard. Post-feedback, participants were retested on a second case set.Results: Post-feedback, both groups' estimates became more reliable. Pre-feedback, medical students were less accurate than trainee surgeons; post-feedback, their accuracy improved to match that of trainee surgeons, who did not improve further.Conclusions: Cognitive feedback improved risk estimate reliability in both groups and accuracy in the medical students group. Lack of improvement in the surgical group implies a ceiling effect. These findings have implications for training and assessment of surgical decision-making.

Acquiring basic surgical skills: Is a faculty mentor really needed?

2009-01-01

Abstract: Background: We evaluated the impact of expert instruction during laboratory-based basic surgical skills training on subsequent performance of more complex surgical tasks.Methods: Forty-five junior residents were randomized to learn basic surgical skills in either a self-directed or faculty-directed fashion. Residents returned to the laboratory 2 days later and were evaluated while performing 2 tasks: skin closure and bowel anastomosis. Outcome measures included Objective Structured Assessment of Technical Skill, time to completion, final product quality, and resident perceptions.Results: Objective Structured Assessment of Technical Skill, time to completion, and skin esthetic ratings were not better in the faculty-directed group, although isolated improvement in anastomotic leak pressure was seen. Residents perceived faculty-directed training to be superior.Conclusions: Our data provided minimal objective evidence that faculty-directed training improved transfer of learned skills to more complex tasks. Residents perceived that there was a benefit of faculty mentoring. Curriculum factors related to training of basic skills and subsequent transfer to more complex tasks may explain these contrasting results.

Online spaced education to teach urology to medical students: a multi-institutional randomized trial

B. Price Kerfoot, Erica Brotschi — 2009-01-01

Abstract: Background: We investigated whether online spaced education could prospectively improve students' acquisition and retention of knowledge.Methods: One hundred fifteen third-year medical students at 2 schools were randomized to receive weekly/biweekly spaced education e-mails on 2 of 4 urology topics: prostate cancer (PC) and prostate-specific antigen (PSA) screening, or benign prostatic hyperplasia (BPH) and erectile dysfunction (ED). E-mails began in month 1 of their third year. During their 3-month surgery clerkships, students completed a 28-item validated pre-test on all 4 topics, 8 web-based teaching cases, and a 28-item post-test. This test was administered again a mean of 280 days later to assess long-term retention.Results: Under an intention-to-treat analysis, students who received the spaced education e-mails demonstrated significant, topic-specific increases in pre-test scores (P < .001 and P = .03 for PC/PSA and BPH/ED, respectively). Spaced education improved long-term retention of PC/PSA (P = .04) but not of BPH/ED (P = .60).Conclusions: Spaced education delivered prospectively can generate significant, topic-specific learning.

Psychometric properties of an integrated assessment of technical and communication skills

2009-01-01

Abstract: Purpose: The Integrated Procedural Performance Instrument (IPPI) consists of clinical scenarios in which bench-top models are positioned to simulated patients. Trainees are required to perform technical skills while engaging with the patient. The purpose of this study was to determine whether an IPPI format examination could discriminate between different levels of trainees.Methods: Sixteen fourth-year medical students and 16 first-year surgery residents participated in 4 IPPI scenarios. Videotaped performances were scored by 2 blinded independent clinician raters on previously validated instruments: checklist of technical skills, Global Rating Scale of technical skills, and communication scale. We conducted separate mixed design analyses of variance (level × cases) on the 3 scales.Results: Residents performed better than medical students on the checklist (74% vs 60%, P < .05), the Global Rating Scale of technical skills (75% vs 56%, P < .01), and the coherence communication subscale (79% vs 69%, P < .05).Conclusions: An IPPI examination discriminated between students' and residents' technical skills and coherence in communication skills. It also highlighted a potential gap in the training of residents' communication skills.

A pilot study to integrate an immersive virtual patient with a breast complaint and breast examination simulator into a surgery clerkship

2009-01-01

Abstract: Background: We aimed to determine if an immersive virtual patient (VP) with a breast complaint and a breast mannequin could prepare third-year medical students for history-taking (HT) and clinical breast examination (CBE) on a real patient.Methods: After standardized instruction in breast HT and CBE, students (n = 21) were randomized to either an interaction with a VP (experimental) or to no VP interaction (control) before seeing a real patient with a breast complaint. Participants completed baseline and exit surveys to assess confidence regarding their HT and CBE skills.Results: Students reported greater confidence in their HT (Δ value = 1.05 ± 1.28, P < .05) and CBE skills (Δ value = 1.14 ± .91, P < .05) and less anxiety when performing a CBE (Δ value = −.76 ± 1.10, P < .05). The VP intervention group had a significantly higher mean HT confidence than the control group at the conclusion of the study (4.27 ± .47 vs 3.50 ± .71, respectively, P < .05).Conclusions: A single interaction with a VP with a breast complaint and breast mannequin improves student confidence in breast HT during a surgery clerkship.

Moral distress in the third year of medical school; a descriptive review of student case reflections

Kimberly D. Lomis, Robert O. Carpenter, Bonnie M. Miller — 2009-01-01

Abstract: Background: Medical students may find certain clinical experiences particularly difficult. Moral distress occurs when a trainee sees a situation or behavior as undesirable, but, because of a position in the hierarchy, declines to address the problem. To prompt our students to reflect on such experiences, students are required to submit a brief case description and are assigned to mentor groups to discuss cases.Methods: After exemption from our Institutional Review Board, a database of student submissions was de-identified. A total of 192 case descriptions were analyzed by a single reviewer to identify recurrent themes. Submissions were categorized in a binary fashion as higher or lower levels of distress. Frequency and correlation with levels of distress were assessed for each theme.Results: Sixty-seven percent of the submissions were classified as higher distress. Seven major themes were identified, the most common being problems of communication (n = 179). Those students taking action correlated to lower distress.Conclusions: Our review shows that specific situations can be expected to generate moral distress in trainees. Addressing such distress may support the ongoing professional growth of trainees.

Teaching communication skills using the integrated procedural performance instrument (IPPI): A randomized controlled trial

2009-01-01

Abstract: Background: The Integrated Procedural Performance Instrument (IPPI) uses various bench-top models positioned to standardized patients (SP) to recreate realistic clinical encounters. This study assessed the effectiveness of using an IPPI format as a teaching tool for communication skills.Method: Thirty-two participants underwent 2 videotaped IPPI scenarios before randomization into 2 groups—experimental (SP-led feedback) or control (no feedback). Participants then completed 2 further IPPI format scenarios. Videotapes were scored by 2 blinded independent raters using validated assessment scales (communication and technical).Results: The experimental group performed significantly better on the communication scores following feedback compared with the control group (mean 77% vs 66%, P < .05). No difference in scores for technical skills post-intervention were demonstrated (checklist: experimental mean = 64% vs control = 59%, P = .40; global ratings: experimental mean = 66% vs no control = 62%, P = .37).Conclusions: The IPPI is an effective tool for teaching communication skills in residents and medical students and should be considered for incorporation into undergraduate and surgical curricula.

Low-fidelity exercises for basic surgical skills training and assessment

Niyant V. Patel, James M. Robbins, Charles J. Shanley — 2009-01-01

Abstract: Background: The goal of this study was to develop and validate low-fidelity exercises for basic surgical skills training and assessment.Methods: Five low-fidelity exercises were developed and administered to 40 participants. Participants were classified as novice or proficient based on level of training. Objective metrics were used for scoring. The cost for assembling 1 complete set of 5 exercises and all necessary supplies for practice and evaluation was $150. Once this set was assembled, the subsequent cost for replacement material was $5/participant examined.Results: Twenty-four participants were categorized as novice and 16 as proficient. Proficient participants scored significantly higher than novice participants (P <.05) for exercises assessing needle-driving skills, 2-hand coordination, and knot tying, thus establishing construct validity. Cronbach's alpha coefficient for internal consistency was .78, which demonstrates the exercises' reliability as a testing instrument.Conclusions: These data provide preliminary evidence of construct validity and internal consistency for a cost-effective series of low-fidelity basic surgical skills exercises.

What is the ideal interval between training sessions during proficiency-based laparoscopic simulator training?

Dimitrios Stefanidis, K. Christian Walters, Ana Mostafavi, B. Todd Heniford — 2009-01-01

Abstract: Background: The aim of this study was to identify the ideal interval between training sessions in a proficiency-based laparoscopic suturing simulator curriculum.Methods: We analyzed performance data from 3 randomized controlled trials of novices (n = 66) who followed a similar proficiency-based simulator curriculum in laparoscopic suturing on the Fundamentals of Laparoscopic Surgery model. The change in performance and intertraining interval were correlated.Results: Overall participant performance improved from 530 ± 58 seconds at baseline to 81 ± 14 seconds at training completion (P < .001). Intertraining intervals ranged from 1 to 43 days and performance change between training sessions varied widely. There was no correlation of performance change with intertraining interval (r = .05, P = .30). Performance deterioration was similar at different intertraining intervals. Shorter intervals were associated, however, with shorter training duration (r = .35, P = .005).Conclusions: No association was found between intertraining interval and change in performance during proficiency-based laparoscopic simulator training but shorter intervals were associated with improved skill acquisition. Further study is needed to confirm these findings.

John R. Clarke — 2009-01-01

This hefty, but portable, handbook contains 318 ways to avoid problems in critically ill patients, grouped into 14 logical sections. Each self-contained topic addresses a very specific situation in about 2 to 3 pages. Some topics bring attention to broader issues. For instance, Remember that there are two “Neos” discusses the dangers of confusing the sound alike/look alike drugs Neo-Synephrine and neostigmine, especially when abbreviated to “Neo.” This point should make the reader aware of the problem for a large number of drugs, such as MSO4 (morphine sulfate) and MgSO4 (magnesium sulfate).

The importance of reconstruction of the abdominal wall after gastrointestinal fistula closure

Josef E. Fischer — 2009-01-01

Abstract: Operation for gastrointestinal cutaneous fistula almost always requires resection and anastomosis. Those of use who do this surgery frequently have learned the hard way that closure of the abdominal wall, preferably with native tissue, is essential for refistulization to not occur. What is one to do when component separation or an Abramson type of approach is insufficient and flaps either can not be done or are not available? Recently, it has been proposed that inert biological material may be the answer for abdominal closure and somehow it is more resistant to infection and less likely to fistulize than totally synthetic material. However, data has slowly been coming available that suggests that use of inert biological material may in fact not be satisfactory and may in fact have an increased tendency to infection, wound breakdown, and refistulization.

How to avoid unnecessary laparotomies in iatrogenic bile duct injuries?

Juha M. Grönroos — 2009-01-01

I read with interest the fine article by Nuzzo et al on the advantages of the multidisciplinary management of bile duct injuries occurring during cholecystectomy. I fully agree with the authors that patients with bile duct injuries often require a variety of interventions that may range from endoscopic and percutaneous procedures to complex open surgery to repair the injuries and that all patients with iatrogenic bile duct injuries should be treated at specialized referral centers that have extensive endoscopic, percutaneous, and surgical experience in the treatment of these severe lesions.

Unrecognized risk factors in acute appendicitis

Weekitt Kittisupamongkol — 2009-01-01

I read with interest the article by Tsai et al. They do not mention high body mass index and smoking history as important causes of complicated appendicitis. Such factors are common findings in both diabetic and nondiabetic patients. Failure to be aware of these factors would bias measurement of the incidence of complicated appendicitis in the study.

Atypical midcycle pain

Mazen Alsinnawi, Fergal J. Fleming, Bryan J. Kenny, David Waldron — 2009-01-01

Abstract: A 16-year-old female presented with acute-onset abdominal pain and an initial diagnosis of midcycle pain. Subsequent pelvic ultrasound and diagnostic laparoscopy showed a large mass in the pouch of Douglas. The patient underwent a laparotomy and excision of a mass from a loop of jejunum. This case highlights the difficulties in diagnostic differentiation relating to large pelvic masses in young females.

Massive Meckel's enterolith mimicking urachal carcinoma

2009-01-01

Abstract: Meckel's enterolith is a rare clinical entity that may be found on imaging and at surgery, as seen in this case of a 68-year-old man presenting for esophagogastrectomy. Images are presented with differential diagnosis and treatment choices.

Gastric perforation caused by metastatic lung carcinoma

2009-01-01

Abstract: A case of gastric perforation caused by metastases of small-cell lung carcinoma in an 85-year-old man is reported. This complication revealed the neoplasm. Biopsy should always be done in patients with gastric perforations, even if there is no palpable tumor. Minimal surgery is warranted because this event occurs often in patients with advanced disease and poor prognosis.

Extragastrointestinal stromal tumor of lesser omentum mimicking a liver tumor

Hai Liu, Wanmeng Li, Shaihong Zhu — 2009-01-01

Abstract: Extragastrointestinal stromal tumors are rare, so clinicopathologic features are not fully elucidated. We report a large extragastrointestinal stromal tumor of the lesser omentum mimicking a liver tumor.

Gallbladder torsion showing a “whirl sign” on a multidetector computed tomography scan

Yoshitsugu Tajima, Noritsugu Tsuneoka, Tamotsu Kuroki, Takashi Kanematsu — 2009-01-01

Abstract: An 82-year-old woman presented with a 5-day history of right upper quadrant pain. A physical examination showed a palpable tender mass in the right upper quadrant with Murphy's sign. The contrast-enhanced multidetector computed tomography (MDCT) scan clearly showed the twisted pedicle of the cystic duct and gallbladder mesentery on the right side of the gallbladder, thus showing a “whirl sign,” and a definitive diagnosis of gallbladder torsion was made. The patient underwent a cholecystectomy, resulting in a favorable outcome. Therefore, the whirl sign on MDCT imaging can be a key to making a definitive diagnosis of gallbladder torsion.

Primary non-Hodgkin's lymphoma of the sigmoid colon in a child

Ke Ren Zhang, Hui Min Jia — 2009-01-01

Abstract: Primary non-Hodgkin's lymphomas of the gastrointestinal tract are rare in children, and few of these lymphomas are located in the sigmoid colon. The preoperative diagnosis rate is low. Complete resection is indicated if it can be done safely. Combination chemotherapy after resection is indicated.

A simple and safe technique for esophagojejunostomy using the hemidouble stapling technique in laparoscopy-assisted total gastrectomy

2009-01-01

Abstract: In laparoscopy-assisted total gastrectomy, esophagojejunostomy is technically difficult. We describe a safe and simple technique for circular-stapled esophagojejunostomy. After mobilization of the stomach and the esophagus, a semicircumferential esophagotomy is made at the anterior esophageal wall. An anvil of a circular stapling device, secured with a Prolene suture (Ethicon, Inc, Somerville, NJ), is introduced via the esophagotomy. The suture is advanced anteriorly so that the center rod penetrates the esophageal wall. The esophagus is staple transected at this point. The circular-stapled esophagojejunostomy is then performed using the hemidouble stapling technique. Laparoscopy-assisted total gastrectomies were performed in 10 patients with gastric cancers. All patients were completed laparoscopically without any complications. The time of anvil placement was 9 minutes in median. Although a wound infection occurred in 1 patient, there were no major complications. There was no mortality in this series. Esophagojejunostomy using this technique is safe and simple. Its practical value is the elimination of the need for pursestring suture placement.

Pancreatic duct holder for facilitating duct-to-mucosa pancreatojejunostomy after pancreatoduodenectomy

2009-01-01

Abstract: Duct-to-mucosa pancreatojejunostomy after pancreatoduodenectomy may be technically difficult, particularly in cases in which the remnant pancreas is soft with a small main pancreatic duct. We devised a pancreatic duct holder for duct-to-mucosa pancreatojejunostomy. The holder has a cone-shaped tip. A one-third circle of the tip is cut away, which makes a slit. As the tip is inserted gently into the pancreatic duct, the duct can be adequately expanded. The holder provides a good surgical field for anastomosis. A slit of the tip allows needle insertion. The holder facilitates stitches of the jejunum also. Twelve patients underwent pancreatoduodenectomy, followed by duct-to-mucosa pancreatojejunostomy using the holder. The holder allowed 8 or more stitches in duct-to-mucosa anastomosis, even in patients with a small pancreatic duct. No patients developed prolonged pancreatic leakage or pancreatic fistula postoperatively. In conclusion, the pancreatic duct holder is a simple and useful tool for facilitating duct-to-mucosa pancreatojejunostomy.

2009-01-01

The American Journal of Surgery

Laparoscopic sentinel node mapping using combined detection for endometrial cancer: a study of 33 cases—is it a promising technique?

Laparoscopic peritoneal dialysis catheter implantation using a Tenckhoff trocar under local anesthesia with nitrous oxide gas insufflation

Radiofrequency energy delivery to the anal canal: is it a promising new approach to the treatment of fecal incontinence?

Laparoscopic diagnosis and treatment of postoperative complications

Single-stage closure of enterocutaneous fistula and stomas in the presence of large abdominal wall defects using the components separation technique

Does increased emergency medical services prehospital time affect patient mortality in rural motor vehicle crashes? A statewide analysis

Use of human acellular dermal matrix for abdominal wall reconstructions

A single nucleotide polymorphism in the Mdm2 promoter and risk of sepsis

The role of estrogen in the formation of experimental abdominal aortic aneurysm

Intraoperative cerebral high-intensity transient signals and postoperative cognitive function: a systematic review

Laparoscopic versus open repair of incisional/ventral hernia: a meta-analysis

Implications of laparoscopy on surgery residency training

Efficacy of cognitive feedback in improving operative risk estimation

Acquiring basic surgical skills: Is a faculty mentor really needed?

Online spaced education to teach urology to medical students: a multi-institutional randomized trial

Psychometric properties of an integrated assessment of technical and communication skills

A pilot study to integrate an immersive virtual patient with a breast complaint and breast examination simulator into a surgery clerkship

Moral distress in the third year of medical school; a descriptive review of student case reflections

Teaching communication skills using the integrated procedural performance instrument (IPPI): A randomized controlled trial

Low-fidelity exercises for basic surgical skills training and assessment

What is the ideal interval between training sessions during proficiency-based laparoscopic simulator training?

The importance of reconstruction of the abdominal wall after gastrointestinal fistula closure

How to avoid unnecessary laparotomies in iatrogenic bile duct injuries?

Unrecognized risk factors in acute appendicitis

Atypical midcycle pain

Massive Meckel's enterolith mimicking urachal carcinoma

Gastric perforation caused by metastatic lung carcinoma

Extragastrointestinal stromal tumor of lesser omentum mimicking a liver tumor

Gallbladder torsion showing a “whirl sign” on a multidetector computed tomography scan

Primary non-Hodgkin's lymphoma of the sigmoid colon in a child

A simple and safe technique for esophagojejunostomy using the hemidouble stapling technique in laparoscopy-assisted total gastrectomy

Pancreatic duct holder for facilitating duct-to-mucosa pancreatojejunostomy after pancreatoduodenectomy

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