‘23 h Model’ for breast surgery: An early experience

The principles of fast track surgery are well established in colorectal surgery. It is an evidence based model aimed at reducing length of stay, convalescence and morbidity by optimising both clinical and organisational factors. Despite this, the implementation of fast track surgery in breast cancer patients has been slow.The 23 h discharge model for breast cancer surgery patients has been outlined by the NHS Improvement Programme and is a breakthrough from traditional inpatient care. This paper outlines the early experience of implementation of this model in a single institution during a 3-month audit period. Over 80% of patients undergoing non-reconstructive breast surgery were discharged safely within ‘23 h’. This suggests that good communication links, reorganisation of existing resources, active user involvement (both patients and clinical team) and strong project management ensures fast-tracking to be safe for the patient with significant economic benefits for the hospital.     

Plastic and reconstructive surgery in Uganda – 10 years experience

We describe our experience of working in plastic and reconstructive surgery in Uganda over the last 10 years. There is a high burden of disease, a health system that is under resourced, and few qualified physicians to provide healthcare for a principally rural population. Training the physicians of the future is essential. Prevention and early wound management needs to be emphasized for traumatic injuries including burns. Subsidized up-country visits by trained specialists with the appropriate equipment are required to provide a service for the rural poor. There appears to be a high mortality rate in babies with unrepaired cleft palate, probably due to feeding difficulties in an environment where intercurrent illness is common. We now offer nutritional support with early combined cleft lip and palate repair in these babies, a practice that has a high success rate and may be suited to other specialist units in the developing world.     

Comment définir une circulation extracorporelle de qualité ?

Extracorporeal circulation (ECC) has to ensure homeostasis of the patient and to minimize pathophysiological disorders inherent in the technique. However, we cannot dissociate it from the surgery and anesthesia knowing that the discipline involves a close partnership with these stakeholders. The purpose of this publication is to review the essential elements that at present can contribute to the quality of the CEC and suggest improvements and developments to be implemented in this area.     

Kidney graft survival of >25 years: a single center report including associated graft biopsy results

Only few centers have reported their observations on patients with very long‐term kidney graft survival of more than 25 years. Eighty‐six subjects were identified in our center with graft survival of >25 years. Donor age was 31.3 ± 18.5 years. Mean duration of transplantation was 30.3 ± 3.6 years. At last follow‐up, the cystatin C clearance was 47 ± 23 ml/min. Transplant biopsies for cause were performed in 30 subjects at a median of 28.4 years (19.1–40.3) after transplantation. Acute or chronic active T cell‐mediated rejection was present in five cases and histological characteristics of acute or chronic active humoral rejection in eight cases. More than 80% of biopsies had inflammatory infiltrates in nonatrophic or atrophic cortical areas. The number of HLA mismatches were higher in biopsied subjects (3.0 ± 1.8 vs. 2.2 ± 1.7 without biopsy). Immunosuppressive therapy was adapted in most biopsied subjects; impaired graft function and proteinuria was unchanged at last follow‐up. Sixty percent of all subjects had hyperparathyroidism (iPTH of the whole group: 132 ± 157 pg/ml), which was predominantly secondary, as judged by serum calcium and graft function. Young donor age was certainly a prerequisite of longterm graft survival. Nonetheless, inflammation or rejection in most biopsied patients suggests an important role of alloreactivity even in this late course.     

Revision surgery after sleeve gastrectomy: a nationwide study with 10 years of follow-up

BackgroundSleeve gastrectomy is the most common bariatric procedure worldwide. Several studies report good short- and midterm results. However, recent studies report alarming long-term outcomes, in particular about the revision rate.ObjectivesThe aim of this study is the assessment of the revisional rate after sleeve gastrectomy and the analysis of most common reasons for surgical conversion and early complications.SettingThis study is based on a national claims database comprehensive of all bariatric procedures performed in a 10-year period.MethodsThe French Programme De Médicalisation des Systèmes d’Information database was used to identify all patients who underwent sleeve gastrectomy between 2008 and 2018. Codes for diagnoses and procedures were used to describe the reason for and the morbidity of revision surgeries. Multivariate Cox proportional hazard regression analysis was performed to compare the risk of having a revision procedure.ResultsDuring the analyzed period, a total of 224,718 sleeve gastrectomies were performed. The rate of revision surgery after sleeve gastrectomy was 4.7%, 7.5%, and 12.2%, at 5, 7, and 10 years post procedure, respectively. A history of gastric banding was associated with a higher risk of revision (hazard ratio, 2.81; 95% CI, 2.66–2.95; P < .001). The most common revision procedure was gastric bypass (75.2%), followed by resleeve (18.7%). The main reasons for revision surgery were persistence of obesity (87.0%) and gastroesophageal reflux disease (5.2%). After revision surgery, we observed the following complications: 5.1% gastric leak, 18% bleeding, and reoperation rate of 6.4%.ConclusionsThis study suggests that a large number of patients who initially underwent a sleeve gastrectomy will undergo a revisional surgery. This information should be considered in the initial choice of the bariatric procedure, and patients should be informed of the mid- and long-term risks.     

Surgical resection of carotid body paragangliomas: 10 years of experience

Background

Carotid body tumors (CBTs) are relatively rare neoplasms, and even if they are considered predominantly benign, there is an indication for early surgical removal. The objective of this study was to conduct a review of the surgical management of CBTs.

Methods

A retrospective study identified 34 cases (12 men and 19 women) of tumors in patients who had undergone surgical resection of pathologically confirmed CBTs over a period of 10 years from 2001 to 2011 in 2 academic departments of general surgery in Italy.

Results

In our series, 10 CBTs (31%) were Shamblin class I, 13 (41%) were class II, and 9 tumors (27%) were class III. Two patients (6%) had transient cerebral ischemia immediately after operation. One patient (3%) died of postoperative cerebral ischemia after surgery for internal carotid artery thrombosis.

Conclusions

The experience of this casuistry shows that the procedure is relatively low risk for Shamblin I and II classes, whereas there is an increasing risk of neurovascular complications for Shamblin III class.     

Brain preservation with selective cerebral perfusion for operations requiring circulatory arrest: protection at 25 °C is similar to 18 °C with shorter operating times

Background: Hypothermic circulatory arrest (HCA) is employed for aortic arch and other complex operations, often with selective cerebral perfusion (SCP). Our previous work has demonstrated real-time evidence of improved brain protection using SCP at 18 °C. The purpose of this study was to evaluate the utility of SCP at warmer temperatures (25 °C) and its impact on operating times. Methods: Piglets undergoing cardiopulmonary bypass (CPB) and 60 min of HCA were assigned to three groups: 18 °C without SCP, 18 °C with SCP and 25 °C with SCP (n = 8 animals per group). CPB flows were 100 ml kg⁻¹ min⁻¹ using pH-stat management. SCP flows were 10 ml kg⁻¹ min⁻¹ via the innominate artery. Cerebral oxygenation was monitored using NIRS (near-infrared spectroscopy). A microdialysis probe placed into the cerebral cortex had samples collected every 15 min. Animals were recovered for 4 h after separation from CPB. All data are presented as mean ± standard deviation (SD; p < 0.05, significant). Results: Cerebral oxygenation was preserved during deep and tepid HCA with SCP, in contrast to deep HCA without SCP (p < 0.05). Deep HCA at 18 °C without SCP resulted in significantly elevated brain lactate (p < 0.01) and glycerol (p < 0.01), while the energy substrates glucose (p < 0.001) and pyruvate (p < 0.001) were significantly depleted. These derangements were prevented with SCP at 18 °C and 25 °C. The lactate/pyruvate ratio (L/P) was profoundly elevated following HCA alone (p < 0.001) and remained persistently elevated throughout recovery (p < 0.05). Piglets given SCP during HCA at 18 °C and 25 °C maintained baseline L/P ratios. Mean operating times were significantly shorter in the 25 °C group compared to both 18 °C groups (p < 0.05) without evidence of significant acidemia. Conclusion: HCA results in cerebral hypoxia, energy depletion and ischaemic injury, which are attenuated with the use of SCP at both 18 °C and 25 °C. Procedures performed at 25 °C had significantly shorter operating times while preserving end organs.     

Interest of awake surgery for ruptured cerebral arteriovenous malformations close to speech areas – Surgical note

BackgroundCerebral arteriovenous malformations (AVMs) are rare, with incidence of 1.12–1.42 cases per 100,000 person-years (Ozpinar et al., 2017). Few studies report applications of awake surgery. The goal of this report was to assess the interest of awake surgery in complete resection of cortical AVMs located close to eloquent speech areas, enabling detection of real functional cortical reorganization due to the AVM and parenchymal hematoma.Case reportA 38-year-old right-handed patient was admitted to the University Hospital of Besançon for dysphasia due to a ruptured left temporal arteriovenous malformation. The patient underwent asleep-awake-asleep surgery. Intraoperative cortical mapping revealed the presence of functional language areas in uncommon locations compared to known neuro-functional anatomy.DiscussionIn this patient, speech areas were redistributed, probably due to neuroplasticity after cerebral hemorrhage, leading to a new cortical architecture, which would have been unrecognized based on preoperative radiological imaging alone.ConclusionWe report the interest of awake surgery to achieve complete safe resection of ruptured AVMs located close to eloquent speech areas, using intraoperative cortical mapping.