Showing papers in "Acta Chirurgica Belgica in 2007"
TL;DR: Tranexamic acid 15 mg/kg given as a single preoperative bolus dose reduces postoperative and total blood loss, and packed cell transfusion requirements in primary total hip replacement surgery for degenerative osteoarthrosis.
Abstract: Background: In this prospective, placebo-controlled, double-blind, randomized clinical trial, we investigated the effect of a single preoperative bolus dose of tranexamic acid (15 mg/kg) on perioperative blood losses and packed cell transfusion requirements in patients scheduled for primary unilateral total hip replacement surgery for degenerative osteoarthrosis.Patients and methods: 40 patients were randomized to receive either 15 mg/kg tranexamic acid (TA group) or an equal volume of saline (placebo group) given as a single slow intravenous bolus injection 15 minutes before incision. We recorded per-and postoperative blood losses and transfusion requirements up to 24 hours postoperatively. The patients were screened for deep venous thrombosis with bilateral compression ultrasonography using colour Doppler imaging on the tenth postoperative day.Results: Peroperative blood loss was not significantly different between the two treatment groups (TA group: 423 ml, placebo group 516 ml; p = 0.093). Pos...
120 citations
TL;DR: ME’s due to CAS are reduced by filter protection devices, but the cognitive faculties in a great number of “asymptomatic” patients are decreased after CAS.
Abstract: The aim of this study was to assess the prevalence and clinical relevance of microembolism in one hundred unselected patients submitted to 50 carotid endarterectomy (CEA) and 50 carotid stenting (CAS) procedures from January 2005 to January 2006 for hemodynamic lesions of the carotid bifurcation (> 70% stenosis). Material and methods: High-resolution Colour-Flow Mapping (CFM), Transcranial Doppler (TCD), cerebral computed tomography (CT) or magnetic resonance (MR) and four psychometric tests (Mini mental state, Beck depression inventory, Zung anxiety inventory, SF-12) were carried out in the preoperative evaluation in all the patients. In the cEAs loco-regional anesthesia (100%), patch angioplasty (84%) and Pruitt-Inahara shunt (4%) were employed; in the CASs local anesthesia (100%), three different carotid stents (Precise-Cordis, Acculink-Guidant and Carotid Wallstent-Boston Scientific) and three temporary distal filter protection devices (Angioguard-Cordis, Accunet-Guidant, Filterwire-EZ-Boston ...
84 citations
TL;DR: Two cases of PSPG associated with breast surgery are presented and their analysis, combined with a review of the few other cases reported in the literature, show the particular clinical presentation and evolution of this condition.
Abstract: Post-surgical pyoderma gangrenosum (PSPG) represents a specific entity: it shares some clinical aspects of pyoderma gangrenosum (PG), but has a series of its own features. In this paper, two cases of PSPG associated with breast surgery are presented: their analysis, combined with a review of the few other cases reported in the literature, show the particular clinical presentation and evolution of this condition. Firstly, the onset of PSPG follows a sequence. After an apparently normal evolution of scar formation following a surgical procedure, the scar presents with many small dehiscences, which will progressively coalesce to some larger areas of wound ulceration, with no visible granulation tissue. Secondly, the delay between surgery and the beginning of symptoms is variable, from 4 days to sometimes 6 weeks. The process will evolve well beyond what would be expected for the initial wound that was created by surgery, with no self-limitation. The skin ulcerations become larger, despite any local treatment or antibiotics. Thirdly, PSPG can affect any anatomical location with the exception of the nipple-areolar complex. Fourthly, a dramatic response to immunomodulatory drugs will be observed. The pain is an inconstant symptom. Present in the first week after surgery, it can be severe and disproportionate regarding clinical presentation.
64 citations
TL;DR: After caustic ingestion, esophageal rest combined with supporting treatment seems to provide a good success rate with respect to prevention of stricture development and other troublesome complications.
Abstract: Accidental corrosive ingestion is one of the common problems causing serious esophageal strictures in children. The acute phase treatment has a great effect on stricture development. In this study we aim to present our experience in the management of caustic ingestion, particularly during the acute phase. From January 1990 to January 2005, 296 children were admitted to our clinic with caustic ingestion. Ninety-one patients who received dilatation treatment due to esophageal strictures constituted the present study group. Forty-three of them were admitted to our centre immediately after caustic ingestion (Group A) whereas 48 of them received some kind of treatment in other hospitals and were referred us with the diagnosis of stricture 6 to 12 weeks after ingestion (Group B). In the acute phase, the patients were given nothing orally until esophagoscopy was performed in the first 24-48 hours. The patients with grades 2b and 3 lesions underwent a week of esophageal rest by using a nasogastric tube. IV fluids and broad-spectrum antibiotics with a single-dose steroid were given. IV ranitidine was also added to the medical treatment. If there were stricture formations on barium meal after 3 weeks, these patients underwent esophageal dilatation programmes. The response rates to dilatation treatment were higher in group A. In addition, increased perforation rates were observed in group B. Sixty per cent of patients in group A but none of the patients in group B have recovered in the first year. In conclusion, after caustic ingestion, esophageal rest combined with supporting treatment seems to provide a good success rate with respect to prevention of stricture development and other troublesome complications.
60 citations
TL;DR: CNI is still a significant postoperative complication of carotid endarterectomy, but despite increasing use of CEA, the incidence has decreased probably because of increased awareness of the possibility of cranial nerve damage.
Abstract: Objective: In the recent prospective randomised trials on carotid endarterectomy (CEA), the incidence of cranial nerve injuries (CNI) are reported to be higher than in previously published studies....
53 citations
TL;DR: In the experience, laparoscopic parastomal hernia repair with “keyhole techniques” had a disappointing high recurrence rate, so the technique was changed to a “modified Sugarbaker technique” with promising early results.
Abstract: Background : With the increasing experience in laparoscopic ventral and incisonal hernia repair this minimal invasive technique has also been used to repair parastomal hernias Different types of laparoscopic repair have been described Methods : Laparoscopic repairs can mainly be divided in two groups : "keyhole-techniques" and "Sugarbaker techniques" We reviewed the literature and described our current technique, using a "modified Sugarbaker technique" in detail Results : We have used the technique in five patients with good early results, no early recurrences and good functional outcome Conclusions : Laparoscopic repair of parastomal hernias is a safe and feasible technique In our experience, laparoscopic parastomal hernia repair with "keyhole techniques" had a disappointing high recurrence rate Therefore we changed to a "modified Sugarbaker technique" with promising early results
41 citations
TL;DR: It is demonstrated that CAS is associated with a significantly increased risk of any stroke or death within 30 days and a closer inspection of the current literature on elderly patients and those with a contralateral carotid occlusion clearly indicates that CAS and CEA already now have a complementary role.
Abstract: Atherosclerotic disease of the carotid arteries is responsible for a significant portion of ischemic strokes. Carotid endarterectomy (CEA) is currently the accepted standard of treatment for patients with severe symptomatic carotid stenosis. In the past few years, however, carotid angioplasty and stenting (CAS) has emerged as a potential alternative endovascular treatment strategy for this disorder. In fact, spurred by the positive results of single center studies and small, pivotal randomized trials, some even consider CAS as the treatment modality of choice, especially in presumably surgical high-risk patients. Yet, randomized trials directly comparing CAS with CEA are sparse and have produced conflicting results. The aim of this article is to review the current trial data on this issue and to define the role of these techniques for the management of two important subgroups of patients. An updated meta-analysis of seven randomized trials comparing CEA with CAS demonstrates that CAS is associated with a significantly increased risk of any stroke or death within 30 days (OR. 1.41, 95% CI 1.07-1.87, p < 0.05). Focusing on patients with a symptomatic carotid stenosis, there was also a significant difference in the odds of treatment-related stroke and death between CAS and CEA (OR, 1.41 ; CI 1.05 to 1.88, p < 0.05). Data on all disabling strokes and deaths within 30 days was available from five trials. The odds of disabling stroke or death at 30 days were similar in the endovascular and surgical group (OR, 1.33, 95% CI 0.89 to 1.98). Overall, these data do not justify a blind enthusiasm for CAS and a widespread use of this procedure for the treatment of carotid artery stenosis. On the other hand, a closer inspection of the current literature on elderly patients and those with a contralateral carotid occlusion clearly indicates that CAS and CEA already now have a complementary role. While elderly patients should preferentially be treated with CEA, CAS appears to be the treatment of choice in patients with a symptomatic carotid artery stenosis and a contralateral carotid occlusion in experienced centers.
39 citations
TL;DR: Even if many aggressive tumours, mainly adrenal carcinoma, may share some of these radiological features, the presence of all or most of them must made the clinician evoke the diagnosis of GN.
Abstract: Objective: To determinate the MRI and CT scanning appearance of adrenal ganglioneuroma and correlate the imaging with histological features.Summary background data: In the last 10 years, eight pati...
36 citations
TL;DR: The 3-dimensional organization of these extracellular components distinguishes the Surgisis mesh from synthetic materials and is associated with better long-term repairs.
Abstract: The extracellular matrix directs all phases of healing following trauma or disease and is therefore nature's ideal scaffold material. When used strategically to induce the repair and restoration of soft tissues following surgery, exogenous extracellular matrix scaffolds interact with surrounding tissues and cells to form a permanent repair without leaving behind a permanent material that can result in chronic inflammation or infection. Biomaterials derived from natural extracellular matrix, such as Surgisis (Cook Medical Incorporated, Bloomington, IN, USA), provide the extracellular components necessary to direct the healing response, allow for the reconstruction of new, healthy tissue and restore mechanical and functional integrity to the damaged site. The 3-dimensional organization of these extracellular components distinguishes the Surgisis mesh from synthetic materials and is associated with better long-term repairs. The tissue response to this biologic mesh is discussed in the context of recent reports on successful clinical applications.
33 citations
TL;DR: Initial experience with VAC therapy to treat non healing groin wounds following vascular reconstructions is very promising, and negative pressure therapy resulted in control lymph leakage, achieving healing and managing infection.
Abstract: Purpose : In this report we share our experience with the use of the VAC system as a less invasive means of graft preservation and an effective alternative to routine muscle flap closure, in patients with groin wound healing complications following lower limb vascular procedures. We also review the English literature regarding the use of VAC therapy on infected groin wounds when the infection affects the prosthesis. Patients and Methods : eight patients treated with delayed healing of a groin incision following a femoral artery surgery. In six cases local exploration or CT examination showed evidence of graft involvement (Szilagyi grade III). Results : Mean duration of VAC use was 21.5 days (range, 10 to 45). The wounds were filled with granulation tissue by day 10 with no purulent-inflammatory exudates. At the end of VAC therapy, final closure was easily achieved by either healing by secondary intention or delayed primary closure. No patient required use of muscle flaps. There were no re-infections at 1 to 28 month follow-up (mean, 17.2 months/ one case lost to follow-up). Conclusion : Our initial experience with VAC therapy to treat non healing groin wounds following vascular reconstructions is very promising. Negative pressure therapy resulted in control lymph leakage, achieving healing and managing infection.
31 citations
TL;DR: The high rate of positive LVI shows a close relationship with known markers of poor prognosis, suggesting the presence of LVI can predict a worse outcome for patients with invasive breast cancer.
Abstract: Purpose: The markers of prognosis are used to predict the clinical course of disease and the outcome for patients with invasive breast cancer. Our aim is to investigate the relationship of peritumo...
TL;DR: The low response rate to this survey suggests that awareness of ACS in the general surgical community in Belgium is low and those who did respond are mostly surgeons from academic or other large hospitals and have a good basic knowledge of definitions, diagnosis and treatment of ACS.
Abstract: Introduction: Although first described decades ago, the abdominal compartment syndrome (ACS) has been recognized in recent years as a significant factor in organ failure and mortality in critically ill patients. Since the syndrome frequently occurs in surgical patients, mainly after abdominal surgery or trauma and the treatment of ACS, regardless of the cause, is essentially surgical, we conducted this survey to assess the perception of ACS in the Belgian surgical community.Methods: A questionnaire was sent electronically to all E-mail addresses featured in the official website of the Royal Belgian Society for Surgery (www.belsurg.org) in October 2005 and a reminder was sent to the same addresses in December 2005. The questionnaire consisted of six general questions, designed to reflect the clinical practice and experience of the surgeon involved, and 15 ACS specific questions.Results: We received completed questionnaires from 41 surgeons. Most answers came from surgeons working in academic hospit...
TL;DR: Carotid endarterectomy performed under local or general anaesthesia is associated with low morbidity and mortality rates and is also associated with decreased shunt usage, decreased operative time and, in high risk patients, lower intensive care unit requirement and hospital stay.
Abstract: Objective : Carotid artery surgery is safely and commonly performed under general, regional or local anaes thesia. The aim of the study was to compare local and general anaesthesia in carotid artery surgery in order to establish whether differences exist in terms of peri-operative results, use of intra-operative shunts and costs. Methods : We retrospectively reviewed the data on 426 patients who underwent carotid endarterectomy with either local or general anaesthesia at our institution over a four-year period. All available clinical, pathologic and postoperative data were reviewed and analyzed for postoperative results. Surgical indications, outcome, operative techniques, and complications were compared. Results : A total of 306 carotid endarterectomy operations under local, and 127 under general anaesthesia were performed and analyzed. Groups were similar in terms of age, sex and pre-operative risk factor distribution. The local anaesthesia group was associated with a lower incidence of shunt placement and operative time when compared to the general anaesthesia group. Postoperative intensive care unit requirement, hospital stay and costs were also lower with local anaesthesia. Significant difference in neurological complications and mortality rate was not observed between the two groups. Conclusion : Carotid endarterectomy performed under local or general anaesthesia is associated with low morbidity and mortality rates. Local anaesthesia enables the surgeon to assess the neurological status during the procedure. It is also associated with decreased shunt usage, decreased operative time and, in high risk patients, lower intensive care unit requirement and hospital stay.
TL;DR: The need for early referral and investigation in middle-aged patients with recurrent abdominal symptoms with small bowel intussusception secondary to lipomas is stressed, but the rarity of the disease is focused on.
Abstract: Intussusception is rare in adults and it can be a challenge to diagnose on admission. Non-specific and variable signs and symptoms, frequently only occurring episodically, may cause a considerable delay before treatment. However, in 90% a predisposing organic cause can be found in adults. A case is presented of small bowel intussusception secondary to a lipoma in a 54-year-old man in whom diagnosis was suggested by CT-scan. The patient was treated with a laparoscopic-assisted reduction and extracorporeal partial small bowel resection, followed by a latero-lateral anastomosis. This case serves as the basis of a review of small bowel intussusception in adults secondary to lipomas. It focuses on the rarity of the disease, but stresses the need for early referral and investigation in middle-aged patients with recurrent abdominal symptoms.
TL;DR: The low rate of clinical axillary recurrence after an intermediate follow up period suggests that a negative sentinel lymph node biopsy accurately reflects the nodal stage in patients with breast cancer.
Abstract: Sentinel lymph node biopsy (SLNB) has been validated in the treatment of breast carcinoma and is considered to stage the axilla adequately in this disease. However, long-term follow-up data are scarce. We evaluated the results of SLNB with respect to loco-regional failures in the axilla in SN-negative patients with invasive breast carcinoma and analysed their causal factors. Between 1997 and May 2004, 656 patients without clinically palpable lymph nodes were included in our study. Data with regard to demographics, diagnostics, therapy and follow up were gathered prospectively from all patients. Patients treated after May 2004 were excluded from this study to permit at least one year of follow-up. Out of the 656 patients, 344 patients with a negative sentinel lymph node biopsy did not undergo axillary dissection and were followed up clinically. Median follow up was 43 months. In 3 patients (0.9%) axillary recurrences developed. All three patients subsequently underwent a completion axillary dissection, chemotherapy and radiotherapy. The low rate of clinical axillary recurrence after an intermediate follow up period suggests that a negative SN biopsy accurately reflects the nodal stage in patients with breast cancer.
TL;DR: This medico-surgical emergency is a life-threatening invasive soft-tissue infection which primarily involves the fascia superficialis and rapidly extends along subcutaneous tissue with relative sparing of skin and underlying muscles.
Abstract: We report a case of necrotizing fasciitis of the lower limb. This medico-surgical emergency is a life-threatening invasive soft-tissue infection which primarily involves the fascia superficialis and rapidly extends along subcutaneous tissue with relative sparing of skin and underlying muscles. Clinical presentation includes fever, signs of systemic toxicity and pain out of proportion to clinical findings. Paucity of cutaneous findings early in the course of the disease makes diagnosis challenging. The confirmation of the diagnosis is often made after surgical debridement. Delay in diagnosis and/or treatment correlates with poor outcome, leading to sepsis and/or multiple organ failure. Radiologic studies including plain radiographs, CT-scan or MRI may help to diagnose necrotizing fasciitis. Prompt surgical debridement, intravenous antibiotics, fluids and electrolytes management and analgesia are mainstays of the therapy. Adjuvant treatments like clindamycin, hyperbaric oxygen therapy and intravenous immunoglobulins are discussed.
TL;DR: The case of a 56-year old female patient with tuberculosis of the thyroid gland and tubercular lymphadenitis of the neck mimicking thyroid malignancy, established on histological examination after surgery in August 2002, is reported.
Abstract: Thyroid tuberculosis is a very rare condition even if the incidence of extrapulmonary forms of tuberculosis has increased. We report the case of a 56-year old female patient with tuberculosis of the thyroid gland and tubercular lymphadenitis of the neck mimicking thyroid malignancy. The diagnosis was established on histological examination after surgery in August 2002. Total thyroidectomy and central neck dissection were performed for very hard euthyroid multinodular goiter and paratracheal bilateral lymphadenopathy. There were no evidence of tubercular involvement of the other organs. The patient underwent combination treatment with antitubercular drugs for 6 months. During the three years follow-up period there was no evidence of disease recurrence.
TL;DR: The present paper will briefly review the current histologic characteristics of vulnerable plaque and the new imaging tools proposed for its detection, focusing on the most recent serologic biomarkers evaluated in the clinical practice to increase the accuracy in predicting not only the plaque but moreover the patient at risk for an acute cerebrovascular event.
Abstract: Stroke is the second cause of mortality in industrialized countries. Atherosclerotic plaque rupture with atheromatous debris distal embolization is the pathogenetic mechanism responsible for cerebrovascular events due to atherosclerotic carotid disease. Plaque composition rather than lesion burden seems to be the determinant factor producing rupture and subsequent thrombosis. Histologic features of vulnerability are : a large lipid core, a thin fibrous cap, and an inflammatory infiltrate rich of monocytes and macrophages. In the clinical practice, it is difficult to predict the risk of experiencing a major cerebrovascular events especially in asymptomatic patients. New invasive techniques such as intravascular ultrasound with termography, optical coherence tomography, fotons spectroscopy and elastography have been developed to detect atherosclerotic lesion tissue composition. However, such techniques are difficult to apply on a large scale basis in primary prevention. On the contrary, new serologic biomarkers such as Pregnancy Associated Plasma Protein-A, Lp-PLA2, Interleukin-6, Interleukin-12, metalloproteinases, lipoprotein-(a), and plaque oxidative products have been recently proposed for screening general and high risk population. The present paper will briefly review the current histologic characteristics of vulnerable plaque and the new imaging tools proposed for its detection, focusing on the most recent serologic biomarkers evaluated in the clinical practice to increase our accuracy in predicting not only the plaque but moreover the patient at risk for an acute cerebrovascular event.
TL;DR: A 40-year-old male patient presented at the emergency department with a classic history of acute epigastric pain and dyspnoea after an episode of vomiting and underwent surgical repair of the distal oesophageal tear by laparoscopy, and was discharged from the hospital 34 days after admission.
Abstract: Spontaneous rupture of the oesophagus (Boerhaave's syndrome) is a rare life-threatening disease requiring urgent surgical management. Symptoms can masquerade many other clinical disorders like acute myocardial infarction, dissecting aneurysm or upper gastro-intestinal tract diseases. Without prompt diagnosis and treatment, Boerhaave's syndrome has a very high mortality rate. We report a case of perforation of the distal oesophagus. A 40-year-old male patient presented at the emergency department with a classic history of acute epigastric pain and dyspnoea after an episode of vomiting. On clinical examination we found a firm, tender abdomen and cervical subcutaneous emphysema. Boerhaave's syndrome was suspected on a clinical basis and was confirmed by thoraco-abdominal CT scan, showing an apparent pneumomediastinum and fluid at both lung bases. The patient underwent surgical repair of the distal oesophageal tear by laparoscopy. A mediastinal drain was left behind and a feeding gastrostomy was established. After initial improvement, the patient developed fever and dyspnoea. A thoracic CT scan revealed left-sided empyema. A thoracoscopic drainage of pus was performed and antibacterial and antifungal treatment was adapted. The patient recovered well and was discharged from the hospital 34 days after admission.
TL;DR: A case of hydatid cyst of the breast is presented, the diagnosis of which was missed both pre- operatively and intra-operatively.
Abstract: Cystic hydatid disease is caused by the Echinococcus granulosus parasite. Most frequently, cysts develop in liver and lung. The breast is rarely a primary site of the hydatid cyst. A case of hydatid cyst of the breast is presented, the diagnosis of which was missed both pre-operatively and intra-operatively.
TL;DR: Findings support a prophylactic effect of L-arginine in experimentally induced intestinal ischaemia and promotes healing of intestinal mucosa, and reduce the degree of tissue damage after intestinal I/R.
Abstract: Background/Aims: The decreased synthesis of nitric oxide (NO) during ischaemia/reperfusion (I/R) has been implicated as the major underlying mechanism for the pathogenesis of acute ischaemic colitis (A.I.C.). The aim of this study was to investigate the prophylactic effect of L-arginine, a NO donor, on tissue injury during intestinal I/R, and compare its efficacy with that of exogenous vasodilators (molsidomine) and inert nitrogen-containing molecules (casein). Material and methods: One hundred forty four Wistar rats underwent occlusion of the superior mesentery artery for 30, 60 and 90 min for induction of intestinal ischaemia, followed by 90 min of reperfusion. The rats were randomly assigned to receive L-arginine, molsidomine, or casein hydrolysate. In all groups, apart of the histological study, we determined the levels of serum malondialdehyde (MDA), a reliable marker indicating the degree of the tissue damage after intestinal I/R. Results: Serum MDA levels were significantly lower in the L-arginine group compared to the untreated animals or those that had received molsidomine or casein, after a period of ischaemia of 90 minutes (p < 0.0005), as well as after a period of ischaemia of 60 or 90 minutes followed by a 90 minutes reperfusion (p = 0.011, and p < 0.0005, respectively). In addition, lesser histopathological damage was noted after the use of L-arginine compared to that caused by the administration of molsidomine and casein. Conclusion: These findings support a prophylactic effect of L-arginine in experimentally induced intestinal ischaemia. In short, L-arginine attenuates the degree of tissue damage in intestinal ischaemia and promotes healing of intestinal mucosa.
TL;DR: The results show that the occurrence of pressure sores is not reduced but is delayed when patients are nursed on a Kliniplot® pressure-decreasing mattress.
Abstract: Background: Pressure ulcers are a frequent complication of bed rest. The development of an efficient and low cost pressure relieving system for the prevention of bed-sores would be of considerable hospital health and economic interest. Our study was designed to determine the effectiveness in pressure-sore prevention of an interface pressure-decreasing mattress, the Kliniplot® mattress, used in our institution since 1978. Methods: In a prospective randomised controlled 7-month clinical trial we compared the Kliniplot® mattress with our standard hospital mattress in 1729 patients admitted to medical and surgical departments (neurology, cardiology, oncology-haematology, neurosurgery, thoracic surgery and orthopaedic surgery). Two groups (Klinipot® mattress and standard hospital mattress) were monitored for the prevention of pressure sores. The patients were evaluated on a daily basis from their admission until the eventual occurrence of a bed-sore. Patients' characteristics and pressure-sore risk factors were similar at the baseline in both groups. Patients presenting with a pressure sore at the time of admission were excluded. Results: Forty-two of the 1729 patients (2.4%) who entered the study developed at least one pressure sore. Twenty-one of the 657 patients (3.2%) nursed on the Kliniplot® mattress, and 21 of the 1072 patients (1.9%) on the standard mattress developed bed-sores (p = 0.154). The median time for the occurrence of pressure sores was 31 days (range 6-87) with the Kliniplot® mattress and 18 days (range 2 to 38) with the standard mattress (p < 0.001). The risk categories for developing bed-sores using the modified Ek's scale were no different at the baseline between both groups (p = 0.764). The severity of the pressure sores was no different between both groups (p = 0.918). Conclusions: Our results show that the occurrence of pressure sores is not reduced but is delayed when patients are nursed on a Kliniplot® pressure-decreasing mattress.
TL;DR: The efficacy in terms of time to complete haemostasis, the need for blood transfusions and the incidence of bile leakage according to recent trials are evaluated and the clinical benefit for the liver surgery patient is discussed.
Abstract: Hepatic resections are considered as a standard intervention in abdominal surgery. However there is still a remarkable complication rate. Despite all recent developments in surgical techniques during liver surgery, blood loss is still one of the main causes for postoperative morbidity and mortality. In addition to patient-dependent factors, aspects of the surgical technique play a major role, in particular with regard to the occurrence of peri-operative bleeding, fluid accumulation and bile leakage. Nowadays, the use of topical sealants is often recommended as an additional tool to decrease postoperative bleeding and bile fistula. Fibrin sealants are able not only to enhance clot formation and wound healing, but possibly work as a sealing device for the small biliary branches. In this overview we will try to evaluate the efficacy in terms of time to complete haemostasis, the need for blood transfusions and the incidence of bile leakage according to recent trials. Furthermore the clinical benefit for the liver surgery patient will be discussed.
TL;DR: Stable wound closure with high patient satisfaction was achieved in 16 (80%) DFUs and a stable wound epithelization was seen in all full closure patients up to latest follow-up of one year.
Abstract: Objective : Assessing the efficacy of a polyhydrated ionogen impregnated dressing in the treatment of recalcitrant diabetic foot ulcers.
Summary Background Data : Diabetic Foot Ulcers (DFU) continue to present. a formidable challenge in terms of morbidity and health care costs. Increasing evidence ascertains the important role of Matrix MetalloProteinases (MMPs) and their tissue inhibitors, TIMPs, in wound healing. Imbalance of MMPs in the DFU microenvironment has been associated with poor wound healing. Current research is directed towards therapeutic agents that could redress the imbalance of MMPs/TIMPs.
Poly Hydrated Ionogen (PHI) formulation is based on metallic ions and citric acid. PHI application aims to positively restore MMP ratios within chronic wounds. This initial multi-centre pilot study aimed to investigate the efficacy of the PHI formulation in achieving stable wound closure in recalcitrant DFUs.
Material and methods : Twenty patients with therapy resistant DFUs of at least 1 cm(2) and 3 months duration were treated with PHI formulation in an acetate carrier dressing. Wound debridement, digital imaging and wound perimeter tracing was performed weekly. Off-loading was performed by the use of appropriate shoe-wear (cut-out sandals) and crutches. Patient satisfaction was assessed with a questionnaire. A detailed evaluation sheet was kept for every patient and updated at each visit.
Results : Stable wound closure with high patient satisfaction was achieved in 16 (80%) DFUs. The mean time to full closure was 18 weeks. A stable wound epithelization was seen in all full closure patients up to latest follow-up of one year.
Conclusions : Encouraging results of this pilot study prompt us to further investigate the PHI efficacy in DFU treatment in a multi-centre, randomized controlled trial.
TL;DR: Widespread use of neuro-axial techniques in the peri-operative period such as epidural analgesia has probably contributed to improved surgical outcome but has also led to an increased incidence of complications.
Abstract: BACKGROUND: Iatrogenic epidural abscess complicating neuro-axial blockade is rare, but carries significant morbidity and mortality if diagnosis is delayed. First documented in 1974, this disorder is now well described in the literature, and is increasing in incidence. METHODS: A literature review was undertaken using Medline, all relevant papers on this rare, but important, complication of spinal epidural anesthesia or analgesia were used. RESULTS: Widespread use of neuro-axial techniques in the peri-operative period such as epidural analgesia has probably contributed to improved surgical outcome but has also led to an increased incidence of complications. Epidural abscess or epidural catheter sepsis has previously been thought to occur rarely but recent publications suggest that it may be more frequent. Predisposing factors include old age, diabetes mellitus, alcoholism, cancer, and acquired immunodeficiency syndrome. The signs and symptoms of epidural abscess may be nonspecific: including back pain, sepsis, with varying neurological deficits, which may present late. Magnetic resonance imaging (MRI) provides the most accurate definitive diagnosis. The treatment of choice in most patients is early neurosurgical decompression and antibiotic therapy. The most common causative organism in spinal epidural abscess is Staphylococcus aureus. Prompt diagnosis and specific therapy are the most important prognostic factors for a successful outcome. CONCLUSION: Iatrogenic spinal epidural abscess is a rare but serious complication which should be brought to the attention of all surgeons and anesthetists.
TL;DR: Postoperative complications, in particular POPF, are associated with increased LOS and higher hospital costs, and any measure to reduce the incidence and severity of complications after PD will save hospital costs.
Abstract: Aims : In the era of cost-conscious healthcare, hospitals are focusing on costs. Analysis of hospital costs per cost-category may provide indications for potential cost saving measures in pancreaticoduodenectomy (PD). Methods : Between January 2004 and June 2005, 109 consecutive patients underwent curative PD for a pancreatic or peri-ampullary tumour. Costs were defined in different cost categories for each activity centre and were linked to the individual patient via the 'bill of activities'. Results : Postoperative complication rate was 46.8%, postoperative pancreatic fistula (POPF) 12.8%, and mortality rate 1.8%. The overall median LOS was 17 (range 7-52) days. The length of hospital stay (LOS) was significantly (p < 0.0001) different between patients with POPF, those with other complications, and patients without complications i.e. 26 (10-36) vs. 21 (8-52) vs. 14 (7-33) days, respectively. Median hospital cost per patient was 10406 (5570-30999) euros. The total hospital costs were significantly related to the LOS (p < 0.0001). The increase of total hospital costs was influenced by the hospitalization (p < 0.0001) and medical staff (p < 0.0001) costs, but not by the cost for the operation room (p = 0.233). Conclusion: Postoperative complications, in particular POPF, are associated with increased LOS and higher hospital costs. Any measure to reduce the incidence and severity of complications after PD will save hospital costs.
TL;DR: Conversion to open surgery was necessary in one patient due to peroperative bleeding and LigaSure™ use in LS had easy application, provided sufficient hemostasis, and shortened the operative time.
Abstract: Purpose Main causes of conversion to open surgery are uncontrolled bleeding from splenic hilum and capsular injury of spleen during laparoscopic splenectomy (LS). We present the use of LigaSure in laparoscopic splenectomy for hemostasis. Material & method Between January 2005 and May 2006, LS was performed in a total of 29 patients (6 male and 23 female) with a mean age of 35.44 +/- 13.63. Indications for splenectomy were idiopathic thrombocytopenic purpura (ITP) in 20 patients, thrombotic thrombocytopenic purpura (TTP) in 2, hereditary spherocytosis (HS) in 3, lymphangioma in 2, hodgkin lymphoma in 1 and splenic cyst in one patient. LS was performed in the right semilateral position with three 10 mm trocars. LigaSure was used in dissection and division of splenic ligaments and hilar vascular structures. Results Conversion to open surgery was necessary in one patient due to peroperative bleeding. The mean duration of the operation was 71.3 +/- 19.8 minutes and the estimated blood loss was 85 +/- 23 ml. The diameter and the weight of the spleen were 10.7 +/- 2.68 cm and 250 +/- 90 g, respectively. There was no mortality. Postoperative complications included pancreatic fistula, trocar site infection and deep venous thrombosis that were encountered in three patients. These were managed without morbidity. The overall complication rate was 10.3% (n = 3). The mean duration of postoperative hospital stay was 2.86 +/- 1.59 days. Conclusion LigaSureTM use in LS had easy application, provided sufficient hemostasis, and shortened the operative time.
TL;DR: MDCT without contrast will be more useful when used in patients of 6 years old and over, for visualization of the appendix, and a better visualization of retrocaecal appendix by MDCT provides a greater advantage over US.
Abstract: Objective: We studied the proportion of normal appendices, identified on non-contrast MDCT scans of the abdomen and pelvis in children with possible renal stones.Materials and methods: A total of 1...
TL;DR: An idiopathic gastric rupture in a 3-year-old girl who had an episode of nausea and vomiting after a large meal is reported, and the child survived following intensive postoperative care.
Abstract: This case reports an idiopathic gastric rupture in a 3-year-old girl who had an episode of nausea and vomiting after a large meal. Abdominal ultrasound and CT scan revealed free air and fluid in the abdominal cavity, leading to the diagnosis of gastro-intestinal perforation. During emergency surgery, gastric rupture was detected on the anterior wall of the gastric body near the greater curvature and treated by performing a sleeve gastrectomy. The intra-operative course was complicated by a cardiac arrest. The child survived following intensive postoperative care. All articles on spontaneous idiopathic gastric rupture in pre-school age children have only been reported in Japanese and Chinese literature.
TL;DR: HS appears to cause less tissue injury than diathermy and also has comparable results for wound healing and further clinical studies on the impact of HS in fascia incisions are needed.
Abstract: Background: The techniques used for midline laparotomy affect healing in surgical wounds, but the relationship between cold scalpel and haemostatic methods (harmonic scalpel, diathermy) regarding wound healing remains unclear. There are also limited studies concerning the effects of harmonic scalpel on abdominal fascia. This study was aimed at comparing myofascial wound healing following laparotomy incision on fascia by cold scalpel (CS), harmonic scalpel (HS), and diathermy in terms of hydroxyproline content, inflammatory changes and tensile strength. Materials and methods : Twenty-seven male Wistar albino rats underwent midline laparotomy either with cold scalpel (CS), harmonic scalpel (HS) or diathermy. Fascia incisions were closed with continuous 4/0 polypropylene and skin incisions were closed with interrupted 4/0 polypropylene stitches. On the 7 th postoperative day, the abdominal walls of the rats were tested for tensile strength. In addition, each abdominal fascia was evaluated for inflammation scores and hydroxyproline levels. Results : HS caused less inflammation and necrosis in abdominal fascia compared to the diathermy group (p < 0.01 and p < 0.05, respectively), whereas the CS group showed no difference in inflammation scores, but had significantly lower necrosis scores than the HS and diathermy groups (p < 0.05 and p < 0.001, respectively). Hydroxyproline content of the fascia did not differ among groups, while the tensile strength of the wound was obviously higher in the CS group (p < 0.001). Conclusion: HS causes less inflammatory reaction and necrosis than diathermy, but more necrosis than CS. Fascia incisions with CS gains tensile strength faster than in other groups. HS appears to cause less tissue injury than diathermy and also has comparable results for wound healing. Further clinical studies on the impact of HS in fascia incisions are needed.