Surgery for adrenal tumours: is operation for the small incidental tumour appropriate?

The last 15 years have seen a change in the indications for adrenalectomy. On the one hand there has been a decline in the number of operations for metastatic breast cancer due principally to the introduction of effective medical therapy. Moreover, the introduction of trans-sphenoidal techniques has reduced the number of adrenalectomies for Cushing's Disease. In contrast the introduction of CT scanning has seen an increase in the diagnosis of incidental adrenal masses, most of which turn out to be benign non-functioning adrenal cortical adenomas. During the period 1970-86, 124 adrenalectomies were performed at Royal North Shore Hospital. From 1970 to 1976 the primary indication for adrenalectomy was metastatic breast carcinoma (84%). Over the past three years one of the primary indications has been the discovery of an asymptomatic, non-functional adrenal mass on CT scan (26%) and, of these tumours, 95% have been less than 5 cm in size. Yet no incidentally discovered adrenal mass was an adrenocortical carcinoma and no adrenocortical carcinoma was smaller than 7 cm in diameter. We recommend that an asymptomatic adrenal mass less than 6 cm in size, with no evidence of function, should be managed conservatively.     

Porcine small intestinal submucosa is not an ideal graft material for Peyronie's disease surgery

PURPOSE: The incidence of Peyronie's disease is up to 7% in some series. While there are numerous nonsurgical methods of treatment, they do not have a high rate of success. Nesbit plication was once the accepted surgery for Peyronie's disease. Tunical lengthening procedures became popular because they avoided penile shortening caused by the Nesbit procedure. More urologists now perform plaque incision or excision, followed by grafting with different materials. Small intestinal submucosa offered promise as an ideal graft material. It is available off the shelf as 1 or 4-ply graft material. In several studies it appeared to function as a collagen based scaffold with graft incorporation in host tissue. MATERIALS AND METHODS: A single reconstructive urologist performed plaque incision and small intestinal submucosa grafting in 4 cases of Peyronie's disease using the same surgical technique. RESULTS: Although early results were positive, we have achieved less than satisfactory results with this material. The penis was straight in the immediate postoperative period but there was recurrent curvature in 3 of the 4 patients, of whom 2 had recurrence within 4 months of the procedure. CONCLUSIONS: We observed disappointing results with small intestinal submucosa for Peyronie's disease surgery with a high percent of recurrent curvature. Further studies are needed to determine if 1 or 4-ply small intestinal submucosa is an ideal graft material for the tunica albuginea.     

Less invasive surgery for the small size peripheral lung cancer: an indication and a review of VATS (video-assisted thoracic surgery) lobectomy

According to increment of detection of the "small" size peripheral lung cancer measuring less than 20 mm in the greatest dimension, the "less" invasive VATS lobectomy has became widespread among the general thoracic surgeon. To decide on the indication of VATS lobectomy, the frequency of nodal metastasis and recurrence were examined in relation to size of the tumor. The diagnostic accuracy of nodal status in clinical and pathological examinations was 88% in the group with tumors less than 20 mm, 79% in the 21 to 30 mm group and 63% in the c-T2 group, respectively. Also, recurrencies were experienced more frequently in c-T2 (44%) than in c-T1 (19%). In our department, the VATS lobectomy was introduced under the condition as follows; the clinical stage should be limited to T1N0M0. Intraoperative histological examination of the locoregional lymph nodes is required to avoid the risk of local recurrence. In these limited conditions, the survival rate of VATS lobectomy is slightly superior to that of the standard thoracotomy in a same clinical stage. In the future, the application of this procedure should be investigated in older patients, and in more advanced cases.     

Enterocele is not a contraindication to stapled transanal surgery for outlet obstruction: an analysis of 170 patients

Aim Enterocele is common among patients suffering from obstructive defecation syndrome (ODS), but it is often considered a contraindication for stapled transanal surgery. The functional results and complication rates were compared in patients with or without enterocele who were treated with stapled transanal rectal resection (STARR) for ODS. Method Patients presenting with ODS were evaluated using standardized clinical and radiological investigations. A total of 170 patients were treated with either PPH01‐STARR or Contour Transtar® and were followed up for a median of 18 months. Results On preoperative defecography, 55 (32%) of 170 patients were found to have an enterocele. The preoperative Cleveland Clinic Constipation Scores (CCCS) in patients with and without enterocele were (mean ± standard deviation) 15.9 ± 5.4 and 15.4 ± 5.2, respectively. At 18 months postoperatively the CCCS were 8.5 ± 2.7 and 8.1 ± 2.6 (P < 0.001), respectively, in patients with and without enterocele. Morbidity was 7.3% (n = 4) in patients with enterocele (anal pain, n = 1; minor bleeding, n = 2; and acute urinary retention, n = 1) and 7.0% (n = 8) in patients without enterocele (anal pain, n = 3; minor bleeding, n = 3; acute urinary retention, n = 1; and staple line dehiscence, n = 1). There were no cases of pelvic sepsis, small bowel injury or postoperative ileus. No patient needed surgical re‐operation. Conclusion There was no difference in functional outcome and postoperative complications in patients with and without enterocele undergoing STARR for ODS.     

Surgical cryoablation as an option for small renal masses in patients who are not ideal partial nephrectomy candidates: intermediate-term outcomes

Objective:

There has been increasing interest in surveillance and ablative techniques for small renal masses (SRM), given the increasing number being diagnosed at smaller sizes. Of the currently available ablative techniques, radiofrequency ablation and cryoablation have been the popular ones. We describe our intermediate-term outcomes with using cryoablation for SRM in patients who were not ideal candidates for partial nephrectomy.

Materials and methods:

Nineteen patients treated with cryoablation were included. Patients with renal lesions <4 cm were considered for cryoablation, and all patients were treated between 2002 and 2007. Access was either laparoscopic (transperitoneal) or via open surgical techniques. From 2002 to 2004, the CryoCare System (Endocare, Inc., Irvine, CA) was used, with probe sizes ranging from 3 to 5 mm. Before 2004, the SeedNet system (Galil Medical, Arden Hills, MN) was used, with 17-gauge (1.47 mm) IceRod cryoneedles. Recurrence-free survival (RFS) and overall survival (OS) were calculated using Kaplan Meier methodology.

Results:

The mean age was 56.7 years. The mean tumour size was 2.6 cm (range 1.2–4.0 cm). There were no intraoperative or postoperative complications in the 19 patients. One patient has been lost to follow-up; mean follow up was 41.6 months (range 7–84 months) in the cohort. Recurrence, defined as either increase in size of lesion or enhancement on follow-up imaging, was seen in 4 patients. There was 1 non-cancer specific death, and 1 cancer specific death.

Conclusions:

The 4-year RFS rate and OS rate were 83.6% and 94.1%, respectively, in patients with SRM who were unsuitable for partial nephrectomy.     

Spinal cord MRI signal changes at 1 year after cervical decompression surgery is useful for predicting midterm clinical outcome: an observational study using propensity scores

Background Context

There is little information on the relationship between magnetic resonance imaging (MRI) T2-weighted high signal change (T2HSC) in the spinal cord and surgical outcome for cervical myelopathy. We therefore examined whether T2HSC regression at 1 year postoperatively reflected a 5-year prognosis after adjustment using propensity scores for potential confounding variables, which have been a disadvantage of earlier observational studies.

Collagen fleece-bound fibrin sealant is not associated with an increased risk of thromboembolic events or major bleeding after its use for haemostasis in surgery: a prospective multicentre surveillance study

Background  

Topical haemostatic agents are used to help achieve haemostasis during surgery when standard surgical techniques are insufficient. The objective of this study was to confirm the safety profile of an equine collagen patch coated with human fibrinogen and human thrombin with particular focus on the occurrence of thromboembolic events (TEEs), major bleeding and immunological events.     

Challenging a classic myth: pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients. A 10-year experience with a nonoperative treatment

Background

In patients presenting with acute diverticulitis (AD) and signs of acute peritonitis, the presence of extradigestive air (EDA) on a computer tomography (CT) scan is often considered to indicate the need for emergency surgery. Although the traditional management of “perforated” AD is open sigmoidectomy, more recently, laparoscopic drainage/lavage (usually followed by delayed elective sigmoidectomy) has been reported. The aim of this retrospective study is to evaluate the results of nonoperative management of emergency patients presenting with AD and EDA.

Methods

The outcomes of 39 consecutive hemodynamically stable patients (23 men, mean age?=?54.7?years) who were admitted with AD and EDA and were managed nonoperatively (antibiotic and supportive treatment) at a tertiary-care university hospital between January 2001 and June 2010 were retrospectively collected and analyzed. These included morbidity (Clavien-Dindo) and treatment failure (need for emergency surgery or death). A univariate analysis of clinical, radiological, and laboratory criteria with respect to treatment failure was performed. Results of delayed elective laparoscopic sigmoidectomy were also analyzed.

Results

There was no mortality. Thirty-six of the 39 patients (92.3%) did not need surgery (7 patients required CT-guided abscess drainage). Mean hospital stay was 8.1?days. Duration of symptoms, previous antibiotic administration, severe sepsis, PCR level, WBC concentration, and the presence of abdominal collection were associated with treatment failure, whereas “distant” location of EDA and free abdominal fluid were not. Five patients had recurrence of AD and were treated medically. Seventeen patients (47.2%) underwent elective laparoscopic sigmoidectomy for which mean operative time was 246?min (range?=?100–450) and the conversion rate was 11.8%. Mortality was nil and the morbidity rate was 41.2%. Mean postoperative stay was 7.1?days (range?=?4–23).

Conclusions

Nonoperative management is a viable option in most emergency patients presenting with AD and EDA, even in the presence of symptoms of peritonitis or altered laboratory tests. Delayed laparoscopic sigmoidectomy may be useless in certain cases and its results poorer than expected.