Can the quality of colonic surgery be improved by standardization of surgical technique with complete mesocolic excision?

Aim we analysed the influence of standardization of colon cancer surgery with complete mesocolic excision (CME) on the quality of surgery measured by the pathological end‐points of number of harvested lymph nodes, high tie of supplying vessels, plane of mesocolic resection and rate of R0 resection. Method One hundred and ninety‐eight patients with colonic carcinoma who underwent radical surgery between September 2007 and February 2009 were divided into two groups, including those undergoing surgery before (93) or after (105) 1 June 2008, when complete mesocolic excision (CME) was introduced as standard in our hospital. Results The overall mean high tie increased from 7.1 (CI, 6.5–7.6) to 9.6 (8.9–10.3) cm (P < 0.0001) and the mean number of harvested lymph nodes from 24.5 (22.8–26.2) to 26.7 (24.6–28.8) (P = 0.0095). There were no significant increases in these end‐points in open right hemicolectomy, and in laparoscopic sigmoid resection the number of lymph nodes did not increase significantly. The plane of mesocolic resection, the rate of R0 resection and the risk of complications did not change significantly. The median (range) length of hospital stay increased from 4 (2–62) to 5 (2–71) days (P = 0.04). Conclusion Standardization of colonic cancer surgery with CME seems to improve the quality of surgery without increasing the risk of complications.     

Should the wheel be reinvented in a human study?

Recently, Zimmer and colleagues reported a lack of analgesic efficacy from intraperitoneal nebulization of bupivacaine using the Insuflow^? device for patients undergoing laparoscopic cholecystectomy. This is not surprising. An in vitro study in 2008 showed that hot evaporation-based devices, similar to Insuflow^?, are unable to transport drug molecules dissolved in a water solvent. These results are in keeping with the physical principle that hot evaporation enables only evaporation of the solvent (e.g., water) and not of the solute (e.g., bupivacaine). Although this well-conducted human study has a defendable medical justification and a high theoretical interest, it is not acceptable to choose a human model for an experimental study that attempts to explore a question whose answer has already been published years before in a bench setting.     

Disease recurrence after right hemicolectomy in Scotland: Is there rationale to adopt complete mesocolic excision (CME)?

AimsComplete mesocolic excision (CME) has been proposed as a way to improve the oncological outcomes in patients with colon cancer. To investigate whether there is rationale for adopting the technique in Scotland, our aim was to define the incidence of disease recurrence following standard right hemicolectomy and to compare this with published CME outcomes.MethodsData was collected on consecutive patients undergoing right or extended right hemicolectomy for colonic adenocarcinoma (2012–2017) at three hospitals in Scotland (Raigmore Hospital, Aberdeen Royal Infirmary and Glasgow Royal Infirmary). Emergency or palliative surgery was excluded. Patients were followed up with CT scans and colonoscopy for a minimum of 3 years.Results689 patients (M 340, F 349) were included. 30-day mortality was 1.6%. Final pathological stage was Stage I (14%), Stage II (49.8%) and Stage III (36.1%). During follow-up, 10.5% developed loco-regional recurrence and 12.2% developed distant metastases. The 1, 3 and 5-year disease-free survival (DFS) was 94%, 84% and 82% respectively. Primary determinants of recurrence were T stage (p < 0.001), N stage (p < 0.001), apical node involvement (p < 0.001) and EMVI (p < 0.001). When compared to the literature, 30-day mortality was lower than many published series and DFS rates were similar to the largest CME study to date (4 year DFS 85.8% versus 83%).ConclusionThe outcomes of patients undergoing right hemicolectomy in Scotland compare favourably with many published CME studies. The technique demands further evaluation before it can be recommended for adoption into routine surgical practice.     

Total knee replacement: Should it be cemented or hybrid?

OBJECTIVE: To compare the complication rates associated with total knee arthroplasty against the types of fixation (hybrid or cemented), using a single total knee design (the anatomic modular knee [AMK] prosthesis). DESIGN: A prospective, nonrandomized, controlled trial. SETTING: University Hospital in London, Ont., a tertiary care teaching centre. PATIENTS: Two groups made up of 484 knees in 395 patients (89 bilateral). INTERVENTIONS: In 260 knees a hybrid configuration (cemented tibia and noncemented femur) was used (group 1). In 224 knees the femoral and tibial components were cemented (group 2). All patellae were cemented in both groups. MAIN OUTCOME MEASURES: Clinical results were assessed by The Knee Society Clinical Rating Scores at 3 months, 6 months and yearly intervals. Radiographic results were determined by 3-foot standing radiographs and at each follow-up visit standing knee radiographs, lateral and skyline views. Radiographs were analysed for alignment, presence or absence of radiolucent lines or changes in the position of the implant. All reoperations and nonoperative complications were recorded. RESULTS: At an average follow-up of 4.8 years, 8 knees (1.6%) required reoperation. An analysis of the complications leading to reoperation demonstrated no difference between the 2 groups. CONCLUSIONS: There was no difference in outcome whether the femoral component was cemented or not. Medium-term results of the AMK are excellent with a very low reoperation rate.     

Should aspirin be stopped before carpal tunnel surgery? A prospective study

AIM: To determine whether patients taking aspirin during carpal tunnel release had an increase of complications.METHODS: Between January 2008 and January 2010, 150 patients underwent standard open carpal tunnel release (CTR) under intravenous regional anaesthesia. They were divided into three groups: groups 1 and 2 were made of 50 patients each, on aspirin 100 mg/d for at least a year. In group 1 the aspirin was never stopped. In group 2 it was stopped at least 5 d before surgery and resumed 3 d after. Group 3 acted as a control, with 50 patients who did not take aspirin. The incidence of clinically significant per- or post-operative complications was recorded and divided into local and cardio-cerebro-vascular complications. Local complications were then divided into minor and major according to Page and Stern. Local haematomas were assessed at 2 d (before resuming aspirin in group 2) and 14 d (after resuming aspirin in group 2) postoperatively. Patients were reviewed at 2, 14 and 90 d after surgery.RESULTS: There was no significant difference in the incidence of complications in the three groups. A total of 3 complications (2 major and 1 minor) and 27 visible haematomas were recorded. Two major complications were observed respectively in group 1 (non stop aspirin) and in group 3 (never antiaggregated). The minor complication, observed in one patient of group 2 (stop aspirin), consisted of a wound dehiscence, which only led to delayed healing. All haematomas were observed in the first 48 h, no haematoma lasted for more than 2 wk and all resolved spontaneously. A major haematoma (score > 20 cm²) was observed in 8 patients. A minor haematoma (score < 20 cm²) was recorded in 19 patients. All patients at 90 d after surgery were satisfied with the result in terms of relief of their preoperative symptoms. Major and minor haematomas did not impair hand function or require any specific therapy.CONCLUSION: Our study demonstrates that continuation of aspirin did not increase the risk of complications. It is unnecessary to stop aspirin before CTR with good surgical techniques.     

Should acute anterior dislocations of the shoulder be immobilized in external rotation? A cadaveric study

The high recurrence rate associated with anterior shoulder dislocations may reflect inadequate healing of a Bankart lesion when the arm is immobilized in internal rotation. The effect of external rotation (ER) of the humerus on the glenoid-labrum contact of Bankart lesions was examined in 10 human cadaveric shoulders. The contact force between the glenoid labrum and the glenoid was measured in 60 degrees of internal rotation, neutral rotation, and 45 degrees of ER in 10 human cadaveric shoulders. No detectable contact force was found with the arm in internal rotation. The contact force increased as the arm passed through neutral rotation and reached a maximum at 45 degrees of ER. The contact force returned to 0 g when the arm was returned to neutral rotation. The mean contact force at 45 degrees of ER was 83.5 g. External rotation significantly increases the labrum-glenoid contact force and may influence the healing of a Bankart lesion.     

The surgical stress response: should it be prevented?

Postoperative complications such as myocardial infarction, pulmonary infection, thromboembolism and fatigue are probably related to increased demands, hypermetabolism, catabolism and other physiologic changes included in the global "surgical stress response." Strategies have been developed to suppress the detrimental components of the stress response so as to improve postoperative outcome. Of the various techniques to reduce the surgical stress response, afferent neural blockade with regional anesthesia to relieve pain is the most effective, although not optimal. Data from numerous controlled clinical trials have demonstrated a reduction in various aspects of postoperative morbidity by such a nociceptive blockade. Although a causal relationship has still to be demonstrated, these findings strongly argue the concept of "stress-free anesthesia and surgery" as an important instrument in improving surgical outcome.     

The flipped third fragment in femoral shaft fractures: A reason for open reduction?

ObjectivesFirst introduced by Kuntscher in the 1940s, closed intramedullary nailing of femoral shaft fractures has become the standard of care, with reported union rates up to 99% in some series. However, fractures with large intercalary segments, which are present in 10-34% of femoral shaft fractures, present unique challenges. In particular, how to treat flipped intercalary segments has remained controversial, with some advocating open reduction of these fractures. The purpose of this study was to evaluate the union rates of femoral shaft fractures with flipped intercalary segments treated with closed reduction and intramedullary nail fixation.MethodsA retrospective review of patients with femoral shaft fractures and flipped intercalary segments from January 2000 until January 2018 was performed at a single academic level one tertiary care referral center. All patients between the ages of 16-80 with minimum 6-month follow-up were included. Union rates were evaluated using the radiographic union score of the femur (RUSF). Patients with non-diaphyseal femur fractures, pathologic fractures, incomplete radiographic or clinical follow-up, or open reduction at the time of initial surgery were excluded.ResultsTwenty-six patients (18 male and 8 female) with a mean age of 32 years (SD 12.8, range 19-65 years) and mean follow-up of 15.9 months (range, 6–82 months) met inclusion criteria. Seven patients had open fractures. The mean size of the flipped intercalary segments was 71.3 mm (range: 30-174 mm), with mean displacement of 6.6 mm (range: 1-37 mm). The mean radiographic union scale in femoral (RUSF) at 6 months was 9 (standard deviation: 1.35). There were two patients who went on to non-union. The overall union rate was 92% (24 patients); the non-union rate was 8% (2 patients).ConclusionsThough uncommon, femoral shaft fractures with flipped intercalary segments present unique challenges to surgical treatment. While previous studies have found the presence of large intercalary segments to be associated with higher rates of non-union, the results of this study challenge prior evidence. In conclusion, the presence of flipped intercalary segments may not require different surgical management than the treatment of conventional femoral shaft fractures.Level of evidenceIV     

The idle central venous catheter in the NICU: When should it be removed?

Purpose

There is debate regarding the optimal timing of central line removal in the neonatal intensive care unit (NICU). The purpose was to evaluate outcomes of idle peripherally inserted central catheters (PICCs) and tunneled central venous catheters (TCVCs) and determine the incidence of line-related infections and replacements.

Carotid Stenting: Should it Replace Endarterectomy in Higher-Risk Patients?

Carotid artery stenting (CAS) has emerged as a useful and potentially less-invasive alternative to carotid endarterectomy (CEA) for treatment of extracranial carotid stenoses. It has been suggested that specific patient subgroups, including those with significant medical comorbidities, recurrent stenosis, anatomically inaccessible lesions, and a hostile neck, might benefit from CAS. The purpose of this report is to evaluate whether or not CAS should replace CEA in the treatment of the high-risk patient. Results from a recently published randomized clinical trial and several individual center and multicenter case analyses will be used in this review.     

Outcome Scores Collected by Touchscreen: Medical Audit as it Should be in the 21st Century?

INTRODUCTION

Collecting outcome scores in paper form is fraught with difficulty. We have assessed the feasibility of, and patient''s attitude towards, entering scores using a touchscreen.

PATIENTS AND METHODS

A touchscreen was installed in the orthopaedic out-patient clinic. If relevant, patients were asked to complete either an Oswestry Disability Index (ODI) or Oxford Shoulder Score (OSS) using the screen. Patients were given written instructions and their hospital number by the receptionist who had no further input. Scores were completed with two identifiers. A paper questionnaire was used to assess computer experience and attitude towards the touchscreen.

RESULTS

A total of 1348 patients, average age 50 years, successfully completed a score in the first 12 months. One-third were over 60 years. Overall, 91% correctly entered their hospital number and date of birth, falling to 84% in patients over 70 years. All patients were identifiable. The average time to complete the scores was 4.7 min rising with age. Of 170 patients completing the paper assessment of the touchscreen, one-third had little or no experience of computers and a third were over 60 years. Of patients, 93% were willing to repeat the score using the touchscreen to monitor progress. Two-thirds found it easier to use than expected. Only 10% would prefer a paper score. These results were maintained among patients over 60 years. Only two were unable to complete the score and 80% of those potentially eligible did so. The remainder were called to clinic before the touchscreen was free.

CONCLUSIONS

Orthopaedic outcome scores can be collected in very large volumes using a touchscreen. Data are then in an immediately usable form. The method is acceptable to patients, independent of age and computer experience. Even in the oldest patients, the accuracy is higher than for paper versions of the score. Combined with operative data, this simple method has the potential to provide a very powerful audit tool indeed.     

Kendrick's extrication device and unstable pelvic fractures: Should a trochanteric belt be added? A cadaveric study

IntroductionPre-hospital pelvic stabilisation is advised to prevent exsanguination in patients with unstable pelvic fractures (UPFs). Kendrick's extrication device (KED) is commonly used to extricate patients from cars or crevasses. However the KED has not been tested for potential adverse effects in patients with pelvic fractures. The aim of this study was to examine the effect of the KED on pubic symphysis diastasis (SyD) with and without the use of a trochanteric belt (TB) during the extraction process following a MVC.Materials and methodsLeft-sided “open-book” UPFs were created in 18 human cadavers that were placed in seven different positions simulating pre-extraction and extraction positions using the KED with and without a TB in two different positions (through and over the thigh straps). The SyD was measured using anteroposterior radiographs. The effects of the KED with and without TB, on the SyD, were evaluated.ResultsThe KED alone resulted in a non-significant increase of the SyD compared to baseline, whereas the addition of a TB to the KED resulted in a significant reduction of the SyD (p < 0.001). The TB through the straps provided a significantly better reduction than the TB over the straps in the extracted position (p < 0.05).ConclusionOur study demonstrated that a TB in combination with the KED on UPFs is an effective way to achieve early reduction. The addition of the TB in combination with the KED could be considered for Pre-Hospital Trauma Life Support (PHTLS) training protocols.     

The progression of the penile vein: could it be recurrent?

Our aim was to study retrospectively the destiny of the deep dorsal vein of the penis in the event of its stripping surgery or its simple ligation in patients diagnosed with venoocclusive dysfunction 17 years ago. From June 1986 to May 1987, a total of 31 men were seen for erectile dysfunction due to venous leakage resulting from priapism, aging, or congenital or idiopathic factors. Of these, 23 men underwent venous stripping of the deep dorsal vein and are referred to as the stripping group. The remaining 8 patients received a simple ligation of the deep dorsal vein and are classified as the ligation group. A total of 21 patients (16 of the 23 and 5 out of the 8) were available for follow-up by using the abridged 5-item version of the International Index of Erectile Function (IIEF-5) scoring system and cavernosograms. In the ligation group, the imaging demonstrates some compensatory veins that are commensurate with impotence postoperatively. In the stripping group, however, the follow-up cavernosograms disclosed no venous recurrence, but residual ones that were not crucial to the rigidity. The IIEF-5 scoring in the ligation group changed from a preoperative mean IIEF-5 score of 10.0 +/- 4.5 to 9.8 +/- 3.6 postoperatively. In the stripping group, however, the mean preoperative IIEF-5 score of 9.8 +/- 4.1 increased to a mean postoperative IIEF-5 score of 18.9 +/- 2.1. Although there was no significant difference between the 2 groups' preoperative IIEF-5 score, there was a statistically significant difference between treatments (P <.001). The penile venous vasculature bears no evidence of regeneration even as long as 17 years after their removal. This finding is in contrast to what is commonly believed, that erectile dysfunction will recur about 2 years after ligation of the deep dorsal vein. We therefore believe that the clinical recurrence may not be due to venous regeneration, and penile venous surgery, if properly performed, may be durable, although larger studies will be required.