International Journal of Surgery - Articles in Press

Surgical workload, risk factors and complications in patients on warfarin with gastrointestinal bleeding - Corrected Proof

Robin Som, James A. Gossage, Anna Crane, Paul H. Rowe — 2009-11-20

Abstract: Introduction: This study aimed to assess surgical workload and risk factors for gastrointestinal bleeding in patients on warfarin admitted to a hospital.Methods: Data was collected for all warfarinised patients admitted between April 2005 and October 2007 with gastrointestinal bleeding.Results: A total of 30 patients (average 80 years) were recorded. Indications for warfarin therapy were atrial fibrillation (80%), mechanical heart valve (6.67%) and embolic disease (13.33%). Fifty percent were admitted with an INR above therapeutic range and of these patients, 83% were on one or more medications known to potentiate the anti-coagulation effect of warfarin. Nine patients were also taking anti-platelet medication. Five of these nine had an admission INR within the intended therapeutic range. Thirteen patients received blood transfusions and had a significantly higher (p<0.05) INR (average 9) than the 17 patients not requiring transfusion (average 2.8). The average cost of transfusion per patient was £470. None of the patients required acute surgical intervention. The average length of stay was 7 days, at a total cost of £1444 per patient. Investigations found the cause of bleeding to be diverticulosis in 9 patients and neoplastic disease in 4 patients. Almost half of the patients received no investigation due to risks from co-morbidity.Conclusions: Uncontrolled anti-coagulation, polypharmacy and age were overwhelming risk factors for major gastrointestinal bleeding. Our results show that adding anti-platelet therapy has to be clearly justified against the increased risk of bleeding. Cost to the surgical department was high and no patients required surgical or radiological intervention.What is already known about this topic?: Warfarin is an important drug, but the complications of its use are difficult and expensive to deal with. Warfarin use is a risk factor for haemorrhage, and this commonly involves the gastrointestinal tract. The use of warfarin is set to increase as the population ages and atrial fibrillation and other cardiovascular risk factors become more prevalent. Consequently, one can expect a rise in warfarin-related gastrointestinal haemorrhage.What does this article add?: Our study aimed to assess the burden of gastrointestinal haemorrhage secondary to warfarin on our surgical department (which was high), and also to assess what the risk factors for haemorrhage for patients on warfarin. One of the risk factors we uncovered was polypharmacy, particularly involving anti-platelets e.g. aspirin. We highlight the need for further guidance with regards to managing patients on warfarin, and suggest possible solutions to the problems uncovered.

Complementary and alternative medicine (CAM) and cancer: The kind face of complementary medicine - Corrected Proof

George Lewith, Nicky Britten, Charlotte Paterson — 2009-11-19

In response to Prof Ernst's article we have just completed a substantial meta-ethnography (synthesis of 26 published qualitative papers) looking at people's experiences of using CAM when they had cancer. We were able to identify one relatively small group of patients who were very ill as a consequence of their cancers and who were using photodynamic therapy to ‘cure’ their disease. However, our analysis suggests that the vast majority of the literature points to the fact that patients see their oncologists as their primary carers and were using a range of complementary medicine to improve their conventional care and personal well-being, as well as managing the symptoms generated by the illness and its treatment.

Multivariate analysis of clinicopathological factors influencing survival following esophagectomy for cancer - Corrected Proof

2009-11-19

Abstract: Background: A number of clinicopathological characteristics can influence survival following esophagectomy for cancer. The aim of this study was to determine the factors affecting survival in a consecutive series of patients undergoing esophagectomy for cancer at a single tertiary centre over a 7 year period.Materials & methods: We analyzed a prospective database of 314 consecutive patients (247 males and 67 females), with a mean age of 62.8 +/− 9.1 years, who underwent esophagectomy for cancer at a single, high-volume centre between January 2000 and June 2007. The impact of 11 variables on survival following esophagectomy was determined by univariate and multivariate analysis.Results: On univariate analysis, gender, ASA grade, blood transfusion, type of cancer, tumor stage, lymph node status, lymphovascular invasion (LVI), longitudinal resection margin (LRM) involvement and circumferential resection margin (CRM) involvement were significant (p<0.05) negative factors for survival. Multivariate analysis using Cox proportional hazard regression demonstrated that the only independent factors negatively impacting on survival were ASA grade (p=0.012), tumor stage (p=0.009), LVI (p=0.009) and LRM involvement (p=0.031).Conclusions: In the current study we demonstrated that independent variables effecting survival after esophagectomy for cancer were ASA grade, tumor stage, lymphovascular invasion and longitudinal resection margin involvement. Contrary to other studies we did not find CRM involvement to be an independent predictor for survival.

Signaling pathways of cardioprotective ischemic preconditioning - Corrected Proof

Umar Sadat — 2009-11-18

Abstract: Background: Ischemia/reperfusion (I/R) injury is a major contributory factor to cardiac dysfunction and infarct size that determines patient prognosis after acute myocardial infarction. During the last 20 years, since the appearance of the first publication on ischemic preconditioning (IP), our knowledge of this phenomenon has increased exponentially.Results and conclusion: Basic scientific experiments and preliminary clinical trials in humans suggest that IP confers resistance to subsequent sustained ischemic insults not only in the regional tissue but also in distant organs (remote ischemic preconditioning), which may provide a simple, cost-effective means of reducing the risk of perioperative myocardial ischemia. The mechanism may be humoral, neural, or a combination of both, and involves adenosine, bradykinin, protein kinases and KATP channels, although the precise end-effector remains unclear. This review describes different signaling pathways involved in acute ischemic preconditioning in detail.

Modified Lanz incision in appendicectomy – The surgical trainees best friend - Corrected Proof

S. O'Neill, E.A. Abdelaziz, S.I. Andrabi — 2009-11-18

Abstract: Appendicitis is one of the commonest acute surgical diseases and treatment by appendicectomy is the most frequently performed surgical procedure in the western world. After obtaining adequate basic surgical experience, an open appendicectomy is an ideal procedure for junior surgical trainees to develop their operative skills and despite a reduction in training hours, recent figures suggest that surgical SHOs still perform about 30% of these cases. Although they are clearly routine and suitable for junior staff to perform under supervision, as many as 20% of appendicectomies, are for a variety of reasons considered difficult. We aim to be the first to present a modified Lanz incision that we believe provides not only a cosmetic scar but also is placed more frequently over the base of the appendix. It gives adequate access in difficult cases and we feel this is the most appropriate incision for a trainee to use when performing an appendicectomy.

Complementary and alternative medicine (CAM) and cancer: The kind face of complementary medicine - Corrected Proof

E. Ernst — 2009-11-16

Abstract: Complementary and alternative medicine (CAM) is a big issue for cancer patients who may feel tempted to use one of the many therapies on offer. In particular, alternative cancer “cures” are being promoted to vulnerable patients. None of these “cures” have been shown to do what they promise, and the very notion of an alternative cancer “cure” is a contradiction in terms. Yet CAM can play an important role in oncology, and that is in supportive and palliative care. Several treatments can decrease the side-effects of cancer drugs or improve quality of life in other ways.

Acute oesophageal necrosis: A case report and review of the literature - Corrected Proof

Andrew Day, Mazin Sayegh — 2009-11-11

Abstract: Aims: We discuss a case of acute oesophageal necrosis and undertook a literature review of this rare diagnosis.Methods: The literature review was performed using Medline and relevant references from the published literature.Results: One hundred and twelve cases were identified on reviewing the literature with upper gastrointestinal bleeding being the commonest presenting feature. The majority of cases were male and the mean age of presentation is 68.4years. This review of the literature shows a mortality rate of 38%.Conclusion: Acute necrotizing oesophagitis is a serious clinical condition and is more common than previously thought. It should be suspected in those with upper GI bleed and particularly the elderly with comorbid illness. Early diagnosis with endoscopy and active management will lead towards an improvement in patient outcome.

Effect of spleen surgeries on Escherichia coli distribution on the mononuclear phagocytic system - Corrected Proof

2009-11-11

Abstract: Objective: To avoid asplenic state, many approaches preserving the spleen have been proposed in the literature: splenorraphy, partial splenectomy with or without preservation of hilar vessels and splenic tissue auto-implants. Subtotal splenectomy, preserving the upper spleen pole nourished only by splenogastric vessels is an alternative when the splenic pedicle must be ligated. The purpose of this study was to evaluate the influence of partial, subtotal and total splenectomies on the distribution of Escherichia coli in the mononuclear phagocytic system.Method: Thirty-two rats divided into four groups were studied: sham operation (total spleen preservation), partial splenectomy, subtotal splenectomy and total splenectomy. Five weeks after surgeries, an aliquot of E. coli marked with tecnetium-99m was injected intravenously. The animals were killed 20min later and the spleen, lungs and liver were removed in order to determine the distribution of labeled bacteria.Results: The amount of E. coli in the splenic tissue was greater in the intact spleen group than in the partial or subtotal splenectomy groups. Phagocytosis through the spleen did not differ between the partial and subtotal splenectomy groups. The amount of bacteria in the lungs was greater in the partial than in the subtotal splenectomy group. The distribution of labeled bacteria was greater in the liver of animals submitted to subtotal splenectomy than in the other groups.Conclusion: The upper splenic pole, supplied only by splenogastric vessels, has the ability to remove live bacteria from the blood stream, showing that effective blood clearance occurs even without vascularization through the splenic pedicle. Thus, the distribution of E. coli through the mononuclear phagocytic system shows different behavior depending on the type of splenectomy to which the animals are submitted.

Sleeve lobectomy for patients with non-small cell lung cancer - Corrected Proof

2009-11-09

Abstract: Purpose: A sleeve lobectomy for lung cancer is a procedure intended both for the maintenance of lung function and for radical treatment. We investigated the clinico-pathological features and treatment responses of lung cancer patients who underwent sleeve lobectomy in our department.Subjects: Among the 984 patients with non-small cell lung cancer who underwent resection in our department between 1994 and 2007, the subjects were 24 patients in whom a sleeve lobectomy was performed.Results: There were 18 male and 6 female patients, with a mean age of 65 years. The histological type was diagnosed as squamous cell carcinoma in 14 patients, and adenocarcinoma in 10. Patients with either mucoepidermoid carcinoma (n=1) or carcinoid tumor (n=1) were excluded. The pathological stage was evaluated as IA, IB, II, IIIA, IIIB, and IV in 4, 1, 8, 8, 2, and 1 patient, respectively. Regarding post-operative complications, 4 patients required sputum aspiration with a bronchoscope from the 2nd to 7th post-operative day due to sputum retention. The 5-year survival rate in patients who underwent sleeve lobectomy was 70.0%. According to the pathological nodal status, the 5-year survival rates of N0, N1, and N2 were 100.0%, 87.5%, and 41.7%, respectively. The 5-year survival rates in squamous cell carcinoma and adenocarcinoma were 83.0% and 45.7%, respectively.Conclusion: Sleeve lobectomy facilitated the maintenance of residual lung function without serious perioperative complications. This finding suggests that patients with direct tumor invasion to the bronchus might be good candidates for a sleeve lobectomy, but not those with extra-nodal invasion.

Traditional polypropylene and lightweight meshes in totally extraperitoneal inguinal herniorrhaphy - Corrected Proof

Brij B. Agarwal, Krishna A. Agarwal, Tapish Sahu, Krishan C. Mahajan — 2009-11-09

Abstract: Background: Placement of a prosthetic mesh is integral to successful totally extraperitoneal (TEP) herniorrhaphy. Available meshes have supported the surgical efforts well but search for an ideal mesh continues. Post-herniorrhaphy pain is an index of patient reported outcomes (PRO). The pain is attributable to balloon dissection, cautery, sutures, tackers and prosthesis. Reducing polypropylene content of the mesh is associated with attenuated inflammatory response by the host and improved compliance and comfort. We report the difference in PROs in TEP herniorrhaphy with either heavy polypropylene (PPM) or light weight mesh (LWM) being used for the repair.Patients and methods: From June 2004 to December 2005, consecutive candidates for TEP herniorrhaphy were enrolled for this prospective study with an informed consent and compliance to Ethics guidelines. They were operated under general anesthesia (GA) on a day care basis using either PPM or LWM meshes as per the patient's choice. Operative and postoperative PRO were statistically analyzed by an independent doctor using the Microsoft Office Excel 2003.Results: One hundred fourteen (84 PPMs and 30 LWMs) TEP herniorrhaphies were performed under GA on 57 male patients without any exclusion, on a day care basis. There was no technical difficulty, operative complications, conversion or prolonged hospital stay in either group. Patients of LWM reported better outcome in regards to pain, NSAID usage, seroma and recurrence. All patients of LWM reported an earlier return to activity.Conclusion: Light weight meshes result in comparatively better “patient reported outcomes” in TEP inguinal herniorrhaphy as compared to heavy polypropylene meshes.

Postcholecystectomy syndrome (PCS) - Corrected Proof

S.S. Jaunoo, S. Mohandas, L.M. Almond — 2009-11-09

Abstract: The term postcholecystectomy syndrome (PCS) comprises a heterogeneous group of symptoms and findings in patients who have previously undergone cholecystectomy. Although rare, these patients may present with abdominal pain, jaundice or dyspeptic symptoms. Many of these complaints can be attributed to complications including bile duct injury, biliary leak, biliary fistula and retained bile duct stones. Late sequelae include recurrent bile duct stones and bile duct strictures. With the number of cholecystectomies being performed increasing in the laparoscopic era the number of patients presenting with PCS is also likely to increase. We briefly explore the syndrome and its main aetiological theories.

Surgical approaches to the submandibular gland: A review of literature - Corrected Proof

2009-11-02

Abstract: Objectives: Surgical excision of the submandibular gland (SMG) is commonly indicated in patients with neoplasms, and non-neoplastic conditions such as chronic sialadenitis, sialolithiasis, ranula and drooling. Traditional SMG surgery involves a direct transcervical approach. In the recent past, alternative approaches to SMG excision have been described in effort to offer minimally invasive options or better cosmetic results. The purpose of this article is to describe the surgical approaches to the SMG and present relevant surgical anatomy via cadaveric dissection and a systematic review of literature to compare and contrast each technique.Study design: Cadaveric dissection with fresh human cadaver heads followed by a review of the literature.Methods: Cadaver heads were dissected via both the transcervical and transoral approaches to the submandibular gland with the use of endoscopic assistance when indicated. Key landmarks and anatomic relationships were recorded via photo documentation. A review of the literature was conducted using a Medline search for approaches to SMG excision, including indications, results and complications.Results: While the traditional SMG excision remains a direct transcervical approach, many other methods of excision are described that include open, endoscopic, and robot assisted resections. The approaches vary from being transcervical, submental, transoral or retroauricular.Conclusions: Alternative approaches to the SMG are feasible but should be tailored to the individual patient based on factors such as pathology, patient preferences, availability of technology, and the experience and skill of the surgeon.

Poor outcome of oesophageal adenocarcinoma after prior antireflux surgery - Corrected Proof

E.M. Mitchell, N. Pal, J.P. Kalyan, M. Rhodes, M.P.N. Lewis — 2009-11-02

Abstract: Aims: Gastro-oesophageal reflux disease is an important risk factor for oesophageal adenocarcinoma, but abolishing reflux through surgery has not been shown to reduce this risk. The purpose of this study is to report on adenocarcinomas occurring after previous antireflux surgery and their long-term outcome.Patients and methods: Six hundred and forty three patients underwent surgical resection in our unit for oesophagogastric adenocarcinoma between 2000 and 2009. Nine of these had antireflux surgery a median of 6.9 (mean of 9.3) years previously. Clinical and pathological characteristics and outcome (in terms of survival) are described for this patient group. The patients who had prior antireflux surgery were compared to matched control patients for disease free survival.Results: Disease free survival in our antireflux patients was 25.1% as compared to 72.1% in controls at 3years. (Log rank test p=0.004).Conclusions: Patients who have undergone antireflux surgery for chronic gastro-oesophageal reflux disease can develop adenocarcinoma and need to be monitored closely. The outcome following surgery appears greatly worse for patients with previous antireflux surgery than age/sex/stage/treatment matched controls in this small study.

Crohn's disease of the vulva - Corrected Proof

2009-11-02

Abstract: Crohn's involvement of the Vulva is unfamiliar and difficult to treat. The aim is to review the presentation, clinical course and different treatments of Vulva Crohn's disease (CD). We have reviewed the literature without language barrier from 1966 to 2009 through Pubmed with the following words: vulva and CD, vulvitis and CD, genital CD. We included articles that had Crohn's involvement of the vulva arising from a distant site (metastatic) or arising from a Crohn's fistula from the perineum and/or anorectum. We excluded CD of other gynaecological organs. One hundred thirty six abstracts were identified and related articles reviewed. Fifty-five cases of CD of the vulva were included in the final anlaysis of this review. Vulva involvement is rare and gives long-term discomfort. A combined medical therapy (metronidazole with prednisolone) appears to be the most effective treatment. The surgical approach should be reserved for non-responding cases. CD is often unrecognized cause of vulva pain and difficult to diagnose. However if diagnosed and adequately treated it usually responds to conservative therapies.

Welcoming Dr John Norcini to the IJS executive committee - Corrected Proof

Jamsheer Talati, Riaz Agha — 2009-11-02

We are very are privileged to announce that Dr John J Norcini, President and CEO of the Foundation for Advancement of International Medical Education and Research has joined the Executive Committee of the International Journal of Surgery.

Polytetrafluoroethylene (Gore-Tex) tube used as a support conduit in open gastrostomy: Report of a new technique - Corrected Proof

Alireza Bakhshaeekia, Hooman Yarmohammadi, Hamid R. Abbasi — 2009-10-30

Abstract: Background: When percutaneous endoscopic gastrostomy (PEG) or percutaneous radiographic gastrostomy (PRG) are not possible or fail, surgical gastrostomy would be the convenient method. Stamm's procedure has increasingly replaced other methods of surgical gastrostomy (SG). However, this procedure has various complications. In this study we used a Gore-Tex tube as a conduit to support a French 18 catheter for gastrostomy and evaluated its safety, efficacy, and usefulness in decreasing postoperative complications.Methods: Forty patients with CNS trauma, swallowing dysfunction or esophageal obstruction and in whom PEG had either failed or was not possible were enrolled. Patients were randomized into two equal groups of Gore-Tex assisted modified Stamm's gastrostomy (GAMSG) and the conventional Stamm gastrostomy (CSG). In the GAMSG group we initially secured a 6–10cm length and 8mm diameter tubular Gore-Tex to the gastric and abdominal wall as a conduit and then passed a French 18 catheter through it. Conventional Stamm procedure was applied to all patients in CSG group. Groups were compared for insertion times, pain, dislodgment, leakage rate, surrounding skin erythema and major complications. These patients were followed monthly for 6months.Results: The overall complication rate after GAMSG group was 5.3% (0% major) compared with 33.3% for Stamm gastrostomies (11.2% major) (p<0.05). Pain, operation site erythema, and tube leakage was significantly less in GAMSG group (p<0.05).Conclusions: Applying a tubular Gore-Tex conduit as a support for a feeding tube in Stamm's method effectively lowers complication rates without significantly increasing operation time or expenses.

A bleeding controversy: Duties and decisions in the face of conflicting advice - Corrected Proof

Nawal Bahal, Andrew Papanikitas, Daniel K. Sokol — 2009-10-28

Abstract: The authors use a composite case based on their experiences to illustrate the ethics of inter-professional conflict. An HDU team receive two telephone calls. One is from the patient's cardiologist, who states that a patient must be anti-coagulated without delay. The other is from the surgeon responsible for the patient's current admission, who states that the patient must under no circumstances be anti-coagulated. We argue that in the absence of a broad understanding of the patient's condition and values, specialists should be cautious when giving categorical orders or, at the very least, should provide the rationale for their advice to help the care leader in his or her decision-making

Adult presentation of giant retroperitoneal cystic lymphangioma: Case report - Corrected Proof

Bryan Richmond, Nathan Kister — 2009-10-26

Abstract: This case describes the rare presentation of a retroperitoneal cystic lymphangioma in a 35 year old female patient. The lymphangioma ultimately progressed to the point of inducing clinical symptoms, thus requiring surgical removal – which was accomplished without incident. The relevant clinical pictures are included for educational value.

Ovarian vein syndrome: A review - Corrected Proof

Hina Y Bhutta, Stewart R Walsh, Tjun Y Tang, Colin A Walsh, James M Clarke — 2009-10-26

Abstract: The Ovarian Vein Syndrome was first reported in 1964, yet its existence as a true pathophysiological entity remains controversial. It may present as an acute or chronic disease, typically affecting young, multiparous women. This review discusses the literature to date on this poorly recognised cause of ureteric obstruction and pelvic pain, including developments in the diagnosis and management of this eminently treatable condition.

Endovascular repair of ruptured abdominal aortic aneurysm in a Jehovah's Witness without blood transfusion - Corrected Proof

Joseph Shalhoub, Farrokh Pakzad, Paul J. Matravers, Ian J. Franklin — 2009-10-26

Surgical repair of ruptured abdominal aortic aneurysm (AAA) continues to carry a poor prognosis, with mortality rates of 45–50% and an overall mortality of 75–90%. The situation becomes especially difficult to salvage in patients who for religious reasons refuse transfusion of all blood components. Since its advent over a decade ago, endovascular aneurysm repair (EVAR) has gained widespread acceptance in the elective setting, with improved short-term survival figures compared to open repair. We have recent experience of a case of ruptured AAA in a Jehovah's Witness who refused allogeneic blood transfusion, in whom we elected to undertake emergency endovascular repair.

Experience with cortical tunnel fixation in endoscopic brow lift: The “bevel and slide” modification - Corrected Proof

Charles M. Malata, Ahid Abood — 2009-10-22

Abstract: Background: Endoscopic brow lift has become a popular method for rejuvenation of the upper third of the face and in the treatment of functional brow ptosis. Controversy, however, remains over the optimum technique for the fixation of the forehead and brow. This paper presents a single surgeon‘s experience with a technical modification to McKinney’s original description of paramedian cortical tunnel fixation in patients undergoing endoscopic brow lifts.Patients and Methods: A case note study of all patients who underwent a modified cortical tunnel endoscopic brow lift fixation by a single surgeon over a 4-year period (2003–2006) was undertaken. The technical modification to cortical tunnel sculpting was introduced to prevent suture associated complications which had occurred in two patients prior to the study. Brow position was maintained with 2/0 polypropylene sutures anchored through modified paramedian cortical bone tunnels. Temporal fixation of superficial parietal to the deep temporal fascia was achieved with the same suture material.Results: Between January 2003 and December 2006, 30 patients had endoscopic brow lifts performed for aesthetic and functional reasons. All cases were bilateral. Twenty-three patients (77%) were female and seven (23%) were male. The median age was 60years (range: 34–76). Patient follow-up ranged from 3 to 24months (mean: 12months). Twelve patients (40%) had another aesthetic procedure carried out at the same time.There were no early postoperative complications (bleeding, VII nerve palsy or infection). One patient had a fixation suture removed under local anaesthetic 6weeks postoperatively due to ongoing dysaesthesia localised to that particular suture site. A second developed significant intermittent forehead/scalp dysaesthesiae, which was treated conservatively. Notably, there were no cases of alopecia at the incision/fixation sites, relapses of brow ptosis, or troublesome scalp itching. No endoscopic cases were converted to an open/coronal brow lift procedure.Discussion and Conclusion: Cortical tunnel suture fixation provided a simple, stable, and reproducible method of maintaining brow position in endoscopically assisted forehead/brow lift with low morbidity. Our modification introduces a refinement to the technique, which allows easy passage of the fixation suture needle and prevents exposure of suture ends, thereby minimising the risk of knot-associated complications.

Four-arm randomized trial comparing laparoscopic and open hernia repairs - Corrected Proof

Yasser Hamza, Esam Gabr, Habashi Hammadi, Rafik Khalil — 2009-10-22

Abstract: Aim: To compare four approaches in primary repair of inguinal hernia as regards operative and postoperative outcome.Methods: One hundred consecutive patients with primary inguinal hernia Nyhus I–III were randomized into four groups. Group I had open pro-peritoneal repair, group II had Lichtenstein tension-free mesh repair, group III had Transabdominal pro-peritoneal (TAPP) repair while group IV had laparoscopic totally extraperitoneal (TEP) hernia repair.Results: Operative time ranged from 10.71 to 120.61min. Laparoscopic operations were significantly longer than open operations (54.5+13.2, 34.21+23.5 versus 96.12+22.5, 77.4+43.21; t=3.891, p<0.001). Open pro-peritoneal approach had significantly longer operative time compared to Lichtenstein approach (54.5+13.2 versus 34.21+23.5). Postoperative pain was significantly higher in patients who had open repairs (7.067+1.831, 6.5+3.5 versus 5.8+1.568, 4.8+2.33; t=3.424, p=0.002). There was one case of conversion in each of the two laparoscopic groups. Laparoscopic operations were associated with significantly faster return to normal domestic activities and to work.Conclusion: Laparoscopic hernia repair offers less postoperative pain and faster recovery on the expense of longer operative time. TEP and TAPP laparoscopic techniques gave similar results.

Evidence based switch to perianal block for ano-rectal surgeries - Corrected Proof

Ramanathan Saranga Bharathi, Vinay Sharma, Ajay Kumar Dabas, Arunava Chakladar — 2009-10-21

Abstract: Background: Evidence suggests that switch from spinal/general anaesthesia (SA/GA) to perianal block (PAB) may prove advantageous for proctologic surgeries. This study evaluates the practicability of this evidence based switch.Methods: Feasibility and efficacy of PAB for proctologic surgeries was prospectively evaluated on 100 consecutive patients over 11 months. Thirty ml of local anesthetic (0.25% bupivacaine+1% lignocaine with adrenaline) was infiltrated into the anal sphincter and perianal skin, under sedation, for achieving PAB. Time taken for onset of anesthesia; success/failure of block; conversion rate to GA; operative ease; operative time; post operative recovery; duration of analgesia; post operative pain based on verbal response score (VRS; scale: 0–100); and complications were analyzed.Results: 54 open haemorrhoidectomies; 27 fistulectomies and 19 lateral sphincterotomies were performed. Average of 3min (range 2–5min) was needed for onset. Block was successful in 97% of cases. 3% needed conversion to GA. Good anesthesia and sphincter relaxation ensured operative ease. Median operative time was 20min (range 10–35min). Analgesia lasted a median of 5hours (range 3–10 hrs). Subsequent pain ranged between VRS 10–40, tapering off, along with analgesic requirement, over a week. Trivial injection site hematoma (1%) and reactionary bleeding (1%) were the complications observed. Post operative recovery was uniformly smooth in all patients.Conclusions: Perianal block is a safe, feasible, reliable, and reproducible mode of anesthesia for ano-rectal surgeries. Its evident efficacy justifies its adoption as anesthesia of choice.

An observational study of timing versus appropriateness of acute plastic surgery referrals in the UK - Corrected Proof

F. Urso-Baiarda — 2009-10-19

Abstract: Aim: A commitment made by the UK government that all patients presenting to Accident and Emergency (A&E) should be treated within 4h of arrival has challenged both A&E departments and those to whom they refer. It has been suggested on one hand that referrals from A&E are not always seen promptly enough to meet waiting time targets, and on the other hand that referrals are sometimes made to help busy A&Es clear their waiting rooms rather than through clinical need.Methods: To investigate these claims ‘Referral Time’ (the time between a patient arriving at A&E and being referred to Plastic Surgery), ‘Review Time’ (the time taken from referral to review by the Plastic Surgery Senior House Officer) and their relationship with referral appropriateness were prospectively examined in a UK teaching hospital.Results: The mean Referral Time was 84min (SD=57.3) and Review Time was 33min (SD=27.4). Review Time did not vary significantly between ‘appropriate’ and ‘inappropriate’ referrals (31.3 vs 36.1min, p=0.357) but Referral Time was significantly quicker for ‘inappropriate’ than ‘appropriate’ referrals (92.8 vs 62.7min, p=0.028).Conclusion: This data suggests that Review Time did not significantly contribute to the risk of patients breaching the A&E waiting time target in this study, but a correlation between reduced Referral Time and decreased referral appropriateness is consistent with referrals sometimes being made for non-clinical reasons. It is felt that such tactics are an inevitable consequence of an unachievable target placed on A&E departments and that this target should be reconsidered.

Prevention of peritoneal adhesions by intraperitoneal administration of vitamin E and human amniotic membrane - Corrected Proof

2009-10-19

Abstract: Background: Our objective was to evaluate the comparative effectiveness of intraperitoneally administered vitamin E and human amniotic membrane in preventing postoperative intraperitoneal adhesion formation.Material and Methods: 75 Wistar-albino rats were separated into 5 groups: Group 1 (control), Group 2 (intraperitoneal olive oil, the diluent of vitamin E), Group 3 (Intraperitoneal vitamin E diluted in olive oil), Group 4 (Amniotic membrane group) and Group 5 (Amniotic membrane and Intraperitoneal vitamin E diluted in olive oil). The same experimental method, consisting of cecal abrasion and ligature of the adjacent parietal peritoneum, was used in all rats to produce adhesions. Relaparotomy was performed on the 15th postoperative day. intra-abdominal adhesions were scored according to macromorphological characteristics and adhesion-carrying tissues underwent standard histologic examination. Inflammation, vascularization and fibrosis in granulation sites were graded in all samples. The results were analyzed using a Mann–Whitney-U test.Results: In terms of inflammation, neovascularization and fibrosis scores obtained by histology and macromorphologic adhesion scores. There were no significant differences between Groups 1 and 2 (p=0.176). The results of Groups 3, 4 and 5 showed a significant difference when compared with both Group 1 and 2 (p=0.001). The difference between Groups 3, 4 and 5 were not significant with respect to these 4 parameters.Conclusion: Intraperitoneal vitamin E and amniotic membrane treatment were both effective in the prevention of peritoneal adhesions. The combination of these agents did not produce a synergistic effect. Easy applicability of the intraperitoneal administration of vitamin E was its major advantage.

The plastic surgery postcode lottery in England - Corrected Proof

James Henderson — 2009-10-15

Abstract: Introduction and aim: The National Health Service (NHS) provides treatment free at the point of delivery to patients. Elective medical procedures in England are funded by 149 independent Primary Care Trusts (PCTs), which are each responsible for patients within a defined geographical area.There is wide variation of availability for many treatments, leading to a “postcode lottery” for healthcare provision in England.The aims were to review funding policies for cosmetic procedures, to evaluate the criteria used to decide eligibility against national guidelines, and to evaluate the extent of any postcode lottery for cosmetic surgery on the National Health Service. This study is the first comprehensive review of funding policies for cosmetic surgery in England.Materials and methods: All PCTs in England were asked for their funding policies for cosmetic procedures including breast reduction & augmentation, removal of implants, mastopexy, abdominoplasty, facelift, blepharoplasty, rhinoplasty, pinnaplasty, body lifting, surgery for gynaecomastia and tattoo removal.Results: Details of policies were received from 124/149 PCTs (83%). Guidelines varied widely; some refuse all procedures, whilst others allow a full range. Different and sometimes contradictory rules governing symptoms, body mass indices, breast sizes, weights, heights, and other criteria are used to assess patients for funding. Nationally produced guidelines were only followed by nine PCTs.Discussion: A “postcode lottery” exists in the UK for plastic surgery procedures, despite national guidelines. Some of the more interesting findings are highlighted.

Traumatic diaphragmatic hernia-our experience - Corrected Proof

Syed Murfad Peer, Patil Mallikarjun Devaraddeppa, Shashidhar Buggi — 2009-10-12

Abstract: Objective: To review our experience in the management of traumatic diaphragmatic hernia.Materials and methods: The records of all patients operated for diaphragmatic hernia between January 1998 and October 2008 at S.D.S Sanitorium and Rajiv Gandhi Institute of Chest Diseases, Bangalore, India were reviewed. Details of their clinical presentation, mode of diagnosis, operative findings and postoperative outcome were analysed.Results: Twenty nine patients underwent surgery for traumatic diaphragmatic hernia. The cause of rupture was blunt trauma in 24(83%) patients and penetrating trauma in 5(17%) patients. In 21 (72%) patients the diagnosis was made within 24hrs and in 8(28%) patients the diagnosis was made after 24hrs. Thoracotomy was the most common surgical approach used in 20(69%) patients. Post operative morbidity was 24% and mortality was 13.8%.Conclusion: X-ray chest is still very useful in the diagnosis of diaphragmatic ruptures. Right sided ruptures are difficult to diagnose. Diaphragmatic hernia repair can be done through a thoracotomy with acceptable results in patients without concomitant intra abdominal injuries.

Polyaxial screws for lumbo-iliac fixation after sacral tumor resection: experience with a new technique for an old surgical problem - Corrected Proof

Syed Faraz Kazim, Syed Ather Enam, Imtiaz Hashmi, Riaz Hussain Lakdawala — 2009-10-09

Abstract: Background: Although numerous reports have been published about various methods for reconstruction after sacrectomies, there are still biomechanical and technical dilemmas that are unaddressed. This report describes the experience at authors' institution of five cases in which polyaxial pedicle screws construct has been successfully used for lumbo-iliac fixation after sacral tumor resection.Methods: Five cases of sacral tumors, two of Ewing's sarcoma and three of giant cell tumor (GCT) underwent surgical resection and then reconstruction was done with hardware using vertical rods placed alongside the spine bilaterally, transfixing monoaxial and polyaxial pedicle screws in lower lumbar levels and polyaxial screws into the ilium bilaterally. Cross links were also used to connect the two vertical members, thus enhancing biomechanical stability of the construct. Use of autologous bone grafts was relied upon to fill the gap created by sacral resection.Results: No instrumentation failure was noted and the continuity of the spine and pelvis was well established with the instrumentation and auto grafts. In follow up of these patients (1–3 years), no complications were seen.Conclusion: Polyaxial pedicle screws fixation is an effective technique to transmit axial load from spine to the appendicular bone and can be used safely in patients in whom sacral integrity is compromised after surgical resection. However, the long term benefits of this technique need to be evaluated.

Ultrasound-guided catheterization of the internal jugular vein in oncologic patients; Comparison with the classical anatomic landmark technique: A prospective study - Corrected Proof

2009-10-05

Abstract: Aim: To compare the traditional anatomic landmark technique with the ultrasound-guided method for central venous catheterization.Material and methods: During three years, 551 patients underwent internal jugular vein catheterization; in 347 patients, the ultrasound-guided technique was used, while in the other 204 patients the catheter was introduced by using the classical anatomic landmark method. Operating time, complications (pneumothorax, puncture of carotid artery with or without hematoma formation), and number of attempts to achieve central venous catheterization were recorded.Results: The ultrasound-guided technique was associated with significantly shorter operating time (9.83±3.1 vs. 20±4.4min, p<0.001) and less morbidity (pneumothorax, 0 vs. 2 patients [p<0.05], carotid artery puncture with or without hematoma formation, 1 vs. 16 patients [p<0.05]). Moreover, the ultrasound-guided technique was highly successful in achieving central venous catheterization (failure, 0 vs. 18 patients [p<0.05]), with significantly fewer attempts (1–3 attempts in 204 vs. 283 [p<0.01]), compared to the classical anatomic landmark technique.Conclusion: The ultrasound-guided method is faster, more efficient, and less morbid procedure compared with the classical anatomic landmark technique. Therefore, it should be preferred over the classical landmark method, especially in high-risk patients for the development of complications.

The UK Biobank project: Trust and altruism are alive and well: A model for achieving public support for research using personal data - Corrected Proof

Hazel Thornton — 2009-10-05

“Reciprocity leads to social cohesion.” “Robert M.L. Winston. Human Instinct.” The paper by Andrew Trehearne about the UK Biobank in this issue of the International Journal of Surgery is to be welcomed. It is important that everybody learns more about this project: most people are aware of it thanks to the fact that it has been widely promoted to both the general public and health professionals. When the UK Biobank opened its doors in Liverpool in January 2009, about 2 years after its launch in April 2007 in Manchester, (already at about the halfway mark in recruiting its target of half a million participants) the excitement of the moment was caught by it being described as a project that would, as it matured, become “an unparalleled treasure chest of vital information on a range of diseases including cancer, heart disease, diabetes, stroke, dementia, depression, arthritis, osteoporosis, skin and lung disorders and many other life-threatening and debilitating conditions.” It leads one to wonder what the factors were that contributed to achieving this very rapid recruitment rate. Perhaps we can learn from this model?

Determinants of wound infections for breast procedures: Assessment of the risk of wound infection posed by an invasive procedure for subsequent operation - Corrected Proof

M. Ashraf, J. Biswas, S. Gupta, N. Alam — 2009-09-27

Abstract: Objective: Wound infection remains a major source of postoperative morbidity leading to prolonged hospital stays and increased total cost, including indirect expenses related to the wound infection. We examined whether there is any higher risk of wound infection in patients undergo a reoperation after an initial operation or excision/incision biopsy.Methods and Results: A retrospective review of medical charts of patients with breast operations between January 1990 and July 2008 was carried out. The overall incidence of wound infection was 18.2% (231/1267). The rate of wound infection was (32%) when reoperation was done after previous modified radical mastectomy, 18.9% and 16.8% when the previous operations were lumpectomy/segmenectomy with axillary dissection and simple mastectomy without axillary dissection, respectively and (10.8%) when reoperation was performed after previous biopsy. Reoperation involving axillary dissection was associated with significantly higher rates of wound infection (p<0.01). Antibiotic prophylaxis continued into the postoperative period was associated with significantly decreased rate of wound infection (p<0.01).Conclusions: Initial procedure affects the risk of wound infection in subsequent operation in patients with breast cancer. Significantly higher risks of wound infection are seen in those patients who had undergone axillary dissection or modified radical mastectomy.

The two-week rule in colorectal cancer. Can it deliver its promise? - Corrected Proof

2009-09-25

Abstract: Despite recent advances in technology, a high percentage of patients with colorectal cancer present with disease that is already advanced, leading to an overall 5-year survival rate of 49.6% in men and 50.8% in women. In order to facilitate access to specialist cancer units, across specialities, the Department of Health formulated the NHS Cancer Plan in 2000 which consisted, in part, of the ‘two-week rule’ (TWR). The TWR was launched to ensure that all patients meeting specific referral criteria for suspected colorectal cancer were seen by a hospital specialist within 14 days of referral. The TWR referral system was set up with the intention of identifying 90% of patients with bowel cancer for prompt treatment.This study was conducted to investigate the difference in presentation between patients referred via the TWR pathway compared to those referred via an elective (non-TWR) route and to examine the impact of these referral routes on the time to treatment and clinical outcome.

Perioperative outcome of colorectal cancer and validation of CR-POSSUM in a Caribbean country - Corrected Proof

2009-09-24

Abstract: Objective: To evaluate the risk-adjusted perioperative outcome of colorectal cancer surgery, applying the Colorectal Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (CR-POSSUM).Methods: A retrospective chart review of patients who underwent colorectal cancer surgery from 2004 to 2007 was done. Data including demographics and physiological data for CR-POSSUM were recorded. Predicted mortality was calculated; validation of CR-POSSUM was done using Hosmer–Lemeshow goodness-of-fit and Receiver Operating Characteristic (ROC) Curve analyses.Results: 232 patients were studied. The overall mean CR-POSSUM score was 18.3±3.8 (SD). Predicted mortality was 7.7%, observed mortality was 6.9% and the standardized mortality ratio was 0.9. 34.4% of patients presented with Duke's Stage C or D and had a higher risk of mortality (Odds Ratio (OR) 3.1, 95% Confidence Intervals (CI) 1.1, 9.1). Emergency surgery was associated with a higher risk of mortality (OR 4.7, 95% CI 1.5, 14.1). CR-POSSUM calibrated well (Hosmer–Lemeshow Chi-square value 4.3; df: 8; p=0.82) and fairly discriminated outcome as shown by the area under the ROC Curve 0.69, (Standard Error: 0.07).Conclusions: Perioperative outcome of colorectal surgery in Trinidad and Tobago is comparable to the developed countries as evaluated by the CR-POSSUM. Patients presenting for emergency surgery and those with advanced stages of cancer had higher perioperative mortality.

WITHDRAWN: The weakest link? - Corrected Proof

Hazel Thornton — 2009-01-27

The Publisher regrets that this article is an accidental duplication of an article that has already been published, doi: 10.1016/j.ijsu.2007.11.001. The duplicate article has therefore been withdrawn.

WITHDRAWN: Hernias Made Easy - Corrected Proof

Tim Brock — 2008-10-06

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.