International Journal of Surgery

Editorial Board

Perspectives - IJS Issue No. 5, 2009

R. David Rosin — 2009-10-12

The summer in the northern hemisphere is drawing to a close and with it the end of many of the year's great sporting events. England regained the Ashes against Australia in the oldest cricket test match series. Roger Federer won the French open tennis tournament for the first time and claimed a 6th Wimbledon title after an enthralling, nail biting final. Tiger Woods narrowly failed to regain the PGA golf championship in the USA and Usain Bolt incredibly broke his own world 100 and 200m records, the former in an astounding 9.58s, at the world games in Berlin. We in the Caribbean are immensely proud of him and our other athletes who together collected 27 medals; a large number for a small population.

The affiliation of the IJS and ASiT – Two organisations at a crossroads

David Rosin, J. Edward Fitzgerald, Riaz Agha — 2009-10-19

In the mid 1970s there was great unrest amongst the senior surgical registrars at that time with respect to working hours, overtime payments and the introduction of a part 3 FRCS examination. Not much changes over the years!

Complementary and alternative medicine (CAM) and cancer: The ugly face of alternative medicine

Michael Baum — 2009-08-20

Abstract: This essay describes my thoughts on the role of CAM in cancer and was provoked by some ugly scenes when I was debating the subject at Kings College London. I conclude that when one analyzes what CAM truly has to offer compared with the best of conventional medicine, then CAM does more harm than good. However it is up to modern medical practitioners to raise their game in order to prevent practitioners of alternative medicine slipping into the gaps left unattended by our profession.

Counting on big numbers

Andrew Trehearne — 2009-09-18

In recent months the UK Biobank project – now up and running in cities across the country – reached a landmark in its recruitment of 500,000 people. Research on their wellbeing and lifestyle habits will help to improve the health of future generations.

Breast cancer: Role of neoadjuvant therapy

Muhammad Ishtiaq Ahmed, T.W.J. Lennard — 2009-10-19

Abstract: Breast cancer is now considered to be a systemic disease from the outset, with no correlation seen between the intensity of local treatment and survival or recurrence. Adjuvant therapy has clearly demonstrated a reduction in local and distant relapse; neoadjuvant therapy is similarly being assessed. It aims to treat occult metastases and decrease tumour bulk. Its use has demonstrated down-staging of the tumour with increased rates of breast-conserving surgery. Though neoadjuvant therapy seems to be associated with an increase in loco-regional recurrence compared to adjuvant therapy, no overall difference in survival has been demonstrated. This paper reviews several trials that compare neoadjuvant to adjuvant therapy, and the controversies around managing the axilla in the neoadjuvant setting.

Immunoprophylaxis in asplenic patients

D.P. Harji, S.S. Jaunoo, P. Mistry, P.N. Nesargikar — 2009-08-17

Abstract: The asplenic patient is at risk of overwhelming post-splenectomy infection (OPSI) due to encapsulated bacteria, namely pneumococcus, haemophilus influenza B and meningococcal C pathogens. The lifetime risk is 1–2% with the estimated mortality being in the region of 40–70% (Davidson RN, Wall RA. Prevention and management of infections in patients without a spleen. Clin Microbiol Infect 2001;7:657–60).Preventative measures include appropriate prophylactic vaccination, long term antibiotics and patient education. Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen were first published by the British Committee for Standards in Haematology in 1996, with a revised edition published in 2002. There are a number of permutations of these guidelines published by a number of professional bodies and consequently this has led to variable adherence rates to such guidelines. We review the perioperative administration of prophylactic vaccinations.

Splenic injury in colonoscopy: A review

Jennifer Fong Ha, David Minchin — 2009-08-10

Abstract: Introduction: Splenic rupture secondary to colonoscopy was first reported in 1974 by Wherry and Zehner. It has an incidence of around 0.00005–0.017%, and a mortality rate of 5%.Method: We performed a literature search to identify the demographic profile, risk factors, clinical presentations, diagnosis and management of this rare complication.Results: There were 66 patients (51 females and 14 males), with a median age of 65. The mortality rate was 4.5%. Majority (n=41, 62.1%) occurred in uneventful colonoscopies. Symptoms usually (74%) occurred within 24h, and 55.8% presented within 24h. Majority (93.9%) had some form of work-up done, with blood tests (78.8%) and CT (68.2%) being the most frequent. Laparotomy and splenectomy were done in over half (56.1%) of the patients. Splenic hematoma (47%), laceration (47%) and rupture (33.3%) were the most common findings.Conclusion: Splenic injury is an important complication to be aware of as its number will continue to rise with the increasing numbers of colonoscopies being performed for colorectal diseases, and delayed diagnosis may result in adverse outcome for the patient.

Air embolism in gastroscopy

Jennifer F. Ha, Emma Allanson, Harsha Chandraratna — 2009-08-27

Abstract: Endoscopy of the upper gastrointestinal tract (GIT) is a common medical examination. One of the rare but serious, albeit fatal complications of gastroscopy is venous air embolism.We performed a literature search with the keywords “air embolism”, “gastroscopy”, and “endoscopy”.There were 14 cases of air embolism associated with gastroscopy. The median age was 66years old (range 4months–80years old). The main presenting symptoms were neurological (n=9) and respiratory compromise (n=7). The main investigation used for diagnosis were CT (n=10) and ECHO (n=6). The main risk factor identified was mucosal breach (n=9). Hyperbaric oxygen therapy was used in four cases. The mortality rate is 57.1%.Air embolism is a very rare complication and is often overlooked. Rapid diagnosis is vital for successful treatment. It should be considered in any patient with sudden onset of severe cardiopulmonary and/or neurologic decompensation during gastroscopy.

Current status of robotic assisted pelvic surgery and future developments

2009-09-23

Abstract: Aims: The aim of this review is to assess the role of robotics in pelvic surgery in terms of outcomes. We have also highlighted the issues related to training and future development of robotic systems.Materials and methods: We searched MEDLINE, EMBASE and the Cochrane Databases from 1980 to 2009 for systematic reviews of randomised controlled trials, prospective observational studies, retrospective studies and case reports assessing robotic surgery.Results: During the last decade, there has been a tremendous rise in the use of robotic surgical systems for all forms of precision operations including pelvic surgery. The short-term results of robotic pelvic surgery in the fields of urology, colorectal surgery and gynaecology have been shown to be comparable to the laparoscopic and open surgery. Robotic surgery offers an opportunity where many of these obstacles encountered during open and laparoscopic surgery can be overcome.Conclusions: Robotic surgery is a continually advancing technology, which has opened new horizons for performing pelvic surgery with precision and accuracy. Although its use is rapidly expanding in all surgical disciplines, particularly in pelvic surgery, further comparative studies are needed to provide robust guidance about the most appropriate application of this technology within the surgical armamentarium.

The MRC superficial bladder cancer trial of intravesical mytomicin-c after complete surgical resection. Sequential statistical methods applied to survival data from a randomised clinical trial

2009-10-19

Abstract: Reduction in the duration of a study and in the number of patients required can be obtained when we adopt a sequential design. In this paper we re-analyse a trial completed by the British Medical Research Council on the effects of chemotherapy to prevent the recurrence of surgically removed superficial bladder cancer as if it had been monitored sequentially. The aim is to illustrate the use and benefits of sequential designs (stopping rules) and to highlight how to handle some potential problems when the assumptions of the statistical model are not satisfied. These problems are not exclusive to the sequential design, but are also present when a conventional design is used.

Polyarteritis nodosa of the breast: Presentation and management

2009-08-10

Abstract: Polyarteritis nodosa (PAN) of the breast is a rare condition where literature review identified eleven patients so far. The clinical presentation ranged from localized disease involving the breast parenchyma and skin only to breast manifestations as part of systemic PAN. The diagnosis of PAN could be challenging as it can mimic breast cancer, inflammatory carcinomatosis or breast infection including mastitis and necrotizing fasciitis. The key importance is accurate diagnosis to avoid unnecessary other treatment modalities and the timely recognition of PAN in cases of localized forms. The authors present three new cases which represent the full range of the clinical spectrum and their management.

Evaluating routine diagnostic imaging in acute appendicitis

2009-08-27

Abstract: Aim: To evaluate the impact of selective imaging on clinical management of patients who present with symptoms suggesting acute appendicitis.Materials and methods: During a two-and-half year period, 941 consecutive patients with right lower quadrant pain were analyzed. Patients who underwent selective imaging were compared to those treated without further imaging.Results: In 650 (69%) patients with right lower quadrant pain, diagnosis was based on medical history, physical and laboratory examination only. The diagnostic accuracy was 84%. Another 291 patients (31%) underwent selective imaging reaching a diagnostic accuracy of 71%. Ultrasound was conducted in 277 patients (sensitivity: 59%; specificity: 91%). CT scan was conducted in 43 patients (sensitivity: 100%; specificity: 95%).Conclusion: The present study shows that, in the majority of patients, appendicitis acuta can be diagnosed without the aid of imaging studies. In all these cases, high diagnostic accuracy rates and low morbidity rates were achieved. In all the other cases when clinical diagnosis is uncertain, further evaluation should include imaging. In our series ultrasound is of limited value; CT scan or diagnostic laparoscopy seems superior.

Early experience with single incision transumbilical laparoscopic adjustable gastric banding using the SILS Port™

Alan A. Saber, Tarek H. El-Ghazaly — 2009-08-03

Abstract: Background: The rapid progression of single-incision laparoscopic surgery (SILS) into the realm of advanced surgical procedures has been fueled in recent years by the development of flexible instrumentation necessary to restore triangulation lost in the divergent nature of this approach, and multichannel ports that addressed the challenges regarding the limited range of movement of trocars in close proximity. We herein are reporting our early experience using the SILS Port™ to perform single incision transumbilical laparoscopic gastric banding in five of our patients.Methods: Five carefully selected female patients (body mass indices between 35 and 45kg/m2 with peripheral obesity) underwent laparoscopic gastric banding using this single incision transumbilical technique. The same surgeon performed all surgical interventions. For all five patients, the same perioperative protocol and operative techniques were implemented.Results: A total of five single incision transumbilical laparoscopic gastric banding procedures were successfully performed using this technique. Mean operative time was 111min. There were no mortalities or postoperative complications noted during the mean follow-up period of 1.5 months.Conclusion: Single incision transumbilical laparoscopic adjustable gastric banding using SILS Port™ is a safe and feasible evolving approach. The intraumbilical location of the implanted port facilitates access for subsequent adjustments and provides patients with an improved cosmetic outcome.

Effect of Cytomodulin-10 (TGF-ß1 analogue) on wound healing by primary intention in a murine model

2009-08-03

Abstract: Objective: To evaluate the effect of Cytomodulin-10 (CM-10), a transforming growth factor-beta analogue, on wound healing by primary intention.Method: Sixty male albino rats of Charles Foster strain (100–150g) were used. After intraperitoneal anesthesia, a cutaneous incised wound (4cm) was created on the back of each rat, which was closed by silk stitches and allowed to heal by primary intention. They were equally divided as test and control. CM-10 was applied to the test wounds daily. At the end of 7, 14 and 21 days of wounding, 10 rats from each group were sacrificed and their wounds were compared. Outcome measures were: 1) breaking force of wounds, 2) histological assessment of healing and 3) evaluation of angiogenesis. Statistical significance was assessed by Student's t-test, ANOVA and Bonferroni correction.Result: There was a significant increase in the breaking force (P<0.001). Histological examination showed early epithelization, increased collagen deposition and decreased inflammatory cellular infiltrate at 1st week in the test group. The treated wounds also demonstrated earlier remodeling. Angiogenesis score was significantly higher in the test wounds at 1st week (40.6 vs. 30.8; P<0.001), but not in the subsequent weeks.Conclusion: Cytomodulin is a strong promoter of wound healing by primary intention. It increases tensile strength and induces early epithelization. It also promotes increased collagen deposition, early remodeling and increased angiogenesis.

Early prediction of hypocalcemia after thyroidectomy by parathormone measurement in surgical site irrigation fluid

2009-08-03

Abstract: Background: Improvements in surgical technique cannot eliminate the risk of hypocalcemia. We aimed to evaluate the accuracy of PTH levels in surgical site irrigation fluid (irPTH) in predicting patients at risk for postoperative hypocalcemia.Methods: Prospective analysis of 160 consecutive patients undergoing thyroidectomy was performed. Patients were divided into 2 groups based on postoperative serum calcium levels. Patients with hypocalcemia were assigned to Group 1 (n=38), while those with normocalcemia were assigned to Group 2 (n=122). Preoperative and postoperative serum calcium levels and PTH level of surgical site irrigation fluid (irPTH), and the difference in serum calcium levels before and after thyroidectomy were determined.Results: The difference in serum calcium levels and irPTH levels in Group 1 were significantly higher than those in group 2 (p=0.001). There was a negative correlation between postoperative serum calcium level and irPTH level (r=−0.641, p=0.0001). Patients who had irPTH level higher than 250pg/mL had a 69-fold increased risk for postoperative hypocalcemia (OR=69.88; 95% CI: 15.37–309.94).Conclusions: High irPTH level is significantly associated with postoperative hypocalcemia. The irPTH assay is sufficient to identify hypocalcemia in the majority of patients and it is a sensitive tool to identify patients at risk of developing postoperative hypocalcemia.

Canine lateral thoracic fasciocutaneous flap: An experimental study

Trịnh Cao Minh, Hoàng Văn Lu'o'ng, Phạm Thị NgỌc, Hoàng Mạnh An — 2009-08-13

Abstract: For the purpose of reconstructive surgery training and research, we have developed a new skin flap model: canine lateral thoracic fasciocutaneous flap. Anatomical study found that the lateral thoracic arteries in dogs have similar anatomical characteristics to human's ones. Based on these vessels, if a skin flap was designed within the vessels territory (size 5×8cm) it could survive completely, whereas, if designed beyond the vessels territory (size 5×14cm) would result in partial necrosis of the flap. This fasciocutaneous flap model closely simulates the human surgery and could be valuable for training and research. Furthermore, this flap could be applied in the veterinary practice for reconstruction of canine forelimbs and cervical area.

Splenectomy for haematological disorders: A single center study in 150 patients from Oman

2009-08-28

Abstract: Background: Haematological disorders, in particular sickle cell disease (SCD) and thalassaemia, are relatively common in Oman. We report our experience of splenectomy for haematological disorders and review the literature on splenectomy role in their management.Objectives: To review our experience in the management of 150 patients with haematological disorders undergoing splenectomy with emphasis on indications and outcome. To compare our experience with those reported from outside this region.Methods: The records of 150 patients who underwent splenectomy over a thirteen year period were reviewed retrospectively, analyzing the age and sex of the patients, indication for splenectomy, operative procedures, complications, peri-operative management and outcome.Results: Of the 150 patients, 96 (64%) had SCD and 34 (22.6%) had β-thalassaemia; the rest comprised patients with refractory idiopathic thrombocytopenic purpura (ITP) n=12, hereditary spherocytosis (HS) n=6, and auto-immune haemolytic anaemia (AHA) n=2. In SCD patients, the main indications for splenectomy were recurrent splenic sequestration (60.4%) and hypersplenism (36.4%), whereas in thalassaemic patients it was increased requirement of packed red blood cells (PRBC) transfusion (mean 310ml, range 242–372 of PRBC/kg/year). All patients received prophylactic antibiotics and vaccination against pneumococcal infection and when the vaccine was available for Haemophilus influenzae. PRBC and platelet concentrates as well as intravenous fluids were infused preoperatively as per protocol. Concomitant procedures at laparotomy included liver biopsy (14.6%) and cholecystectomy (8.6%). The postoperative morbidity was low (8.6%) and there was no mortality. All patients were maintained on long term penicillin and proguanil, and the mean follow-up was 4.6 years. In SCD patients splenectomy eliminated the risks of life threatening acute splenic sequestration and improved significantly the blood counts of the hypersplenic cases, while in thalassaemic patients it reduced significantly the mean transfusion requirement by 100ml PRBC/kg/year (p<0.0001). Of the patients with refractory ITP, two thirds had a good response to splenectomy (p<0.0001). All HS and AHA patients benefited from splenectomy.Conclusion: The predominant indications for splenectomy were recurrent acute splenic sequestration and hypersplenism in SCD patients, and increased transfusion demand in the thalassaemics. Overall, splenectomy proved beneficial in eliminating the risk of splenic sequestration in SCD patients, in improving the blood counts in SCD with hypersplenism and in reducing transfusion requirement in thalassaemic patients, while in ITP group two thirds of the patients benefited.

Are we performing enough emergency laparoscopic cholecystectomies? An experience from a district general hospital

I.A. Shaikh, P. Sanjay, K. Joga, S. Yalamarthi, T. Daniel, A.I. Amin — 2009-08-28

Abstract: Background: Emergency Laparoscopic cholecystectomy (LC) is a well established procedure for acute cholecystitis. However a recent report suggested that about 15% were operated on during their emergency admission. The aim of this study was to evaluate our performance in a district general hospital (DGH).Methods: Data of all cholecystectomies performed from 1st April 2003 to 31st March 2008 were analysed. Timing of surgery (Elective vs Emergency), conversion rate, hospital stay and complications were analysed.Results: 2011 cholecystectomies were performed during this period. 740 patients had surgery following emergency admission. 488/740 (66%) had their operation at the time of emergency admission and the remaining 252/740 (34%) were admitted later for elective surgery. 8% of the emergency procedures were performed by open approach and the conversion rate was 14.5%. 1523 patients had elective surgery of which 3.7% patients were operated by open approach and the conversion rate was 6.9%.Conclusion: In a DGH, consultants having a variety of subspecialty interests, who take part in emergency surgical rota, can safely undertake emergency cholecystectomy. We believe that LC can be done in acute gall stone disease during their index admission with acceptable conversion and complication rates.

Delayed presentation by neurosurgical patients in developing economies

Taopheeq Bamidele Rabiu — 2009-08-10

Idowu and Apemiye have highlighted a well-recognized but, probably, inadequately documented problem rampant in the health care services of developing nations. From congenital anomalies to chronic intracranial/spinal infections and neoplasms, late presentations with dire consequences are alarmingly prevalent in such nations.