Is chronic venous ulcer curable? A sample survey of a plastic surgeon

Introduction:

Venous ulcers of lower limbs are often chronic and non-healing, many a time neglected by patients and their treating physicians as these ulcers mostly do not lead to amputation as in gangrenous arterial ulcer and also cost much to complete the course of treatment and prevention of recurrence.

Materials and Methods:

One hundred and twenty two lower limb venous ulcers came up for treatment between May 2006 and April 2009. Only twenty nine cases completed the treatment. The main tool of investigation was the non invasive Duplex scan venography. Biopsy of the ulcer was done for staging the disease. Patients′ choice of treatment was always conservative and as out-patient instead of hospitalisation and surgery, which required a lot of motivation by the treating unit.

Results:

Out of twenty nine cases, ten cases were treated conservatively and seven (24.13%) healed well. Remaining nineteen cases were given surgical modality in which fifteen cases (51.74%) were successful. Only seven cases (24.13%) failed to heal. Compression stockings were advised to control oedema, varices and pain. Foot care, regular exercises and follow-up were stressed effectively.     

MicroRNAs: relevant tools for a colorectal surgeon?

Colorectal cancer is the third most common malignancy and cause of cancer-related deaths worldwide. Approximately half of the patients diagnosed with colorectal cancer ultimately die of the condition. Death from colorectal cancer can be prevented by early detection, but unfortunately presentation is often late, with a worse prognosis. Screening by fecal occult blood testing reduces disease-specific mortality, but there is a need for sensitive and specific noninvasive biomarkers to facilitate detecting the disease, staging it, and predicting the best therapeutic options. MicroRNAs (miRNAs) are short noncoding RNA sequences that have a crucial role in the regulation of gene expression. They have significant regulatory functions in basic cellular processes, such as cell differentiation, proliferation, and apoptosis. Evidence suggests that miRNAs may function as both tumor suppressors and oncogenes. The main mechanism for changes in the function of miRNAs in cancer cells is due to aberrant gene expression. Accurate discrimination of miRNA profiles between tumor and normal mucosa in colorectal cancer allows definition of specific expression patterns of miRNAs, giving good potential as diagnostic and therapeutic targets. MiRNAs expressed in colorectal cancers are also abundantly present and stable in stool and plasma samples. Their extraction from these three sources is feasible and reproducible. The ease and reliability of determining miRNA profiles in plasma or stool makes them potential molecular markers for colorectal cancer screening. This review summarizes the role miRNAs have in colorectal cancer, highlighting particularly the potential diagnostic, prognostic, and therapeutic implications in the future treatment of the disease.     

Elective surgery for diverticulitis – What does the surgeon need to consider?

Despite less stringent indications, elective colectomy is still commonly performed in the treatment of diverticulitis. Rather than focusing on age-based criteria and number of diverticulitis episodes, current guidelines recommend an individualized approach to elective colectomy for diverticulitis, taking into consideration several patient and disease factors. Given the low risk for complicated recurrences or emergency surgery requiring an ostomy with long-term conservative management, quality of life should be the primary determinant of surgery. Pharmacologic therapies have proven ineffective in reducing the risk of diverticulitis recurrence; however, they may reduce chronic abdominal symptoms associated with diverticular disease. Furthermore, elective colectomy for diverticulitis carries a non-trivial risk for major morbidity, and as with other elective operations, proper patient selection is key. Immunosuppressed patients are a unique, high-risk subgroup with worse diverticulitis and postoperative outcomes, rendering the decision for surgery even more complex.     

Margin index: a useful tool for the breast surgeon?

Background

In breast conservation surgery (BCS) for breast cancer, the appropriate surgical margin is controversial. Margin index, a mathematical relationship between tumor size and closest margin, has been shown to be predictive of the probability of residual cancer after BCS for early stage breast cancer. We applied this tool to the same population of patients at our institution to evaluate its ability to predict residual disease after BCS.

Methods

We retrospectively reviewed a prospectively maintained database of women undergoing BCS between 1980 and 2010 at the University of Pennsylvania. A total of 246 women underwent re-excision because of close margins. Average margin index between groups with and without residual disease in the re-excision specimen was compared using the Student t-test. A receiver operating curve was created using logistic regression to assess the overall diagnostic ability of the margin index on the presence or absence of residual disease.

Results

Of patients who underwent re-excision, 29% of patients had residual disease. We analyzed several cutoff values for margin index, but none proved to be significant predictors of residual disease. Average margin index was significantly higher for patients without residual disease compared with patients with residual invasive cancer but not for patients with residual ductal carcinoma in situ.

Conclusions

In women undergoing BCS for early stage breast cancer at our institution, margin index was not predictive of the presence of residual cancer on re-excision. We hypothesize that the predictive ability of a margin index is likely limited by several factors including the presence of ductal carcinoma in situ and the location and extent of the close margin.     

Does the participation of a senior plastic surgeon improve conditions of hospitalisation in craniosynostosis repair surgery?

IntroductionThe real impact of the participation of other surgical specialties together with neurosurgeons on perioperative care in craniosynostosis repair surgery has not been determined. The purpose of this study was to determine whether the participation of a second senior surgeon (plastic surgeon) during surgical repair of pediatric monosutural craniosynostosis improved perioperative medical care.Material and methodsThe authors retrospectively reviewed 2 cohorts of patients who had consecutively undergone primary repair surgery for trigonocephaly and unicoronal craniosynostosis. Infants were operated on by a single senior pediatric neurosurgeon before December 2017, and with the collaboration of a senior plastic surgeon after January 2018.ResultsOverall, 60 infants were included in the study: 29 in group 1 (single surgeon, 2011–2017), and 31 in group 2 (pair of surgeons, 2018–2021). Median surgery time was significantly shorter in group 2 than group 1: 180 vs. 167 minutes; P = 0.0045. There was no significant difference between the 2 groups in blood loss or intra/postoperative packed erythrocyte transfusion. Postoperative drain output was significantly lower in group 2. Median length of hospital and intensive care stay were significantly shorter in group 2, by 1 and 2 days, respectively; P < 0.0001. Volume of infused solution, diuresis, immediate postoperative hemoglobin level, hematocrit, hemostasis (platelet count, fibrinogen, prothrombin time and activated partial thromboplastin time), and return to oral feeding did not differ from one group to the other.ConclusionResults confirmed our impression of an improvement in perioperative medical care. However, the role of surgical experience and the influence of the medical/nursing staff must not be minimized in these complex surgical procedures.     

A core undergraduate curriculum in plastic surgery – a Delphi consensus study in Scandinavia

Background and aims: In recent years, undergraduate medical education has undergone a transition from a speciality-based to a more competence-based training system. Consequently, whilst medical knowledge is rapidly expanding, time for teaching of the surgical specialties is decreasing. Thus, there appears to be a need to define the core competences that are to be taught. The aim of this study was to establish a Scandinavian core undergraduate curriculum of competences in plastic surgery, using scientific methods.

Methods: The Delphi technique for group consensus was employed. An expert panel was recruited from various plastic surgery subspecialties, institutions, and levels of clinical experience, in four Nordic countries (Denmark, Finland, Norway and Sweden). Questionnaires were sent out and answers collected electronically via Google Forms?. Following completion of three predefined rounds of anonymous questionnaires; a final core curriculum competency list was agreed upon based on a consensus agreement level of 80%.

Results: Two hundred and ninety-five competences were suggested in the first round. In the second round, 76 competences (33 skills and 43 knowledge items) received a score ≥3.00 on a 1–4 Likert scale. Final agreement in the third round resulted in a list of 68 competences with agreement above 80% (31 skills and 37 knowledge items).

Conclusions: This study proposes the first scientifically developed undergraduate core curriculum in plastic surgery. It comprises of a consensus of competences a recently graduated medical doctor should be expected to possess.