Laparoscopic Colonic Resection for Rectosigmoid Colonic Tumours: A Retrospective Analysis and Comparison with Open Resection

Laparoscopic approach for treatment of colorectal malignancy is gaining acceptance gradually; however the benefits of laparoscopic surgery in colonic and rectal tumours is still open to debate. This study aims at a retrospective analysis of operative and short term outcome of patients with rectosigmoid tumours. A retrospective analysis of operative, postoperative and short-term outcome of 62 patients who underwent laparoscopic colorectal resection for cancer of rectosigmoid region were compared with a same number of parameters-matched patients who underwent open colorectal resection. Blood transfusion requirement was significantly more in the open group compared to the laparoscopy group (38.7% versus 6.4%, p = 0.001). ICU stay was less in the laparoscopy group (p = <0.05) and they were started on oral liquid diet earlier (p = 0.013). The number of the lymph nodes retrieved, positive distal margin and radial involvement were similar in both groups. The hospital stay was significantly shorter in laparoscopy group (8.4 versus 13.8 days, p < 0.05). Radical operation for rectosigmoid tumors is technically feasible with laparoscopic surgery. Laparoscopic approach is associated with less blood loss, transfusion and significantly less ICU stay. Laparoscopic group recovers early and needs less hospital stay     

Morbidity profile and functional outcome of modified facial translocation approaches for skull base tumors

The primary objective of this study was to evaluate morbidity associated with facial translocation approaches for skull base and results of various technical modifications. Forty consecutive patients who underwent facial translocation approaches for accessing skull base tumors from July 2005 to June 2010 were included in this study. There were 25 patients who underwent standard facial translocation, 4 patients medial mini, and 11 patients underwent extended facial translocation. Thirteen patients had benign disease and 27 patients had malignant disease. Resection was R0 in 36 and R1 in 4 patients. Most patients had acceptable cosmetic results. None of the patients had problems related to occlusion or speech and swallowing. The commonest complication observed was nasal crusting in 16 patients. Grade 2 trismus and exposure of mini plate was seen in three patients. Two patients developed necrosis of translocated bone. Three patients developed palatal fistula before modification of palatal incision. Facial translocation provides a satisfactory access for adequate clearance of skull base tumors with satisfactory aesthetic and functional results. With modifications of the surgical technique and implementation of new surgical tools, the morbidity of facial translocation approaches will continue to decrease.     

Elastic stable intramedullary nailing for displaced proximal humeral fractures in older children

Purpose To demonstrate the effectiveness of intramedullary fixation of severely displaced proximal humeral physeal fractures in skeletally immature children using the elastic stable intramedullary nail (ESIN). Methods Retrospective recruitment of 14 patients aged 10–15-years old with severely displaced proximal humeral physeal fractures between 1999 and 2004 in a single regional specialist paediatric orthopaedic hospital. The fractures were graded using the Neer classification; severe displacement constituted Neer II–IV or displacement >1 cm and angulation >45°. Patients were followed up and assessed using the Disabilities of the Arm, Shoulder and Hand score (DASH) and the Neer Shoulder score. Radiographs were assessed for deformity. Subjective satisfaction was assessed. Results Fourteen patients with mean follow-up of 30 months (12–66 m) from surgery. All fractures were radiologically united at a median time of eight weeks (7–10 weeks). At follow-up, Neer Shoulder mean score was 96.79 (range 83–100) and DASH mean score 2.26 (0–7.5). Subjectively 71% were very satisfied and 29% were satisfied. Conclusions We commend stabilisation using ESIN in the management of the displaced proximal humeral physeal fracture in older children, once reduction of the fracture has been achieved by either closed or open means. ESIN is safe and allows early return to pre-injury function.     

Lymph node micrometastases is a poor prognostic factor for patients in pN0 gastric cancer: a meta-analysis of observational studies

Background

There is no consensus as to the impact of lymph node micrometastases (LNMM) on survival of patients with gastric cancer. The aim of this analysis was to investigate the prognostic significance of LNMM in patients with histologic node-negative gastric cancer.

Methods

We searched relevant studies from PubMed, Embase, and the Cochrane Library (1966–2013.5), used software STATA 12.0 to pool the outcomes of each study. Mantel-Haenszel and Inverse Variance methods were used in a fixed effect model and a random effect model, respectively. The hazard ratios (HR) and odds risk (OR) at their 95% confidence intervals (CIs) were used as measures to investigate the prognostic importance of LNMM, by searching for a correlation between the clinical pathologic features and LNMM.

Results

Our analysis of 18 eligible studies revealed that patients with LNMM had an increased likelihood of having a worse 5-y survival rate (HR 2.81; 95% CI：1.96–4.02). Subgroup analyses showed a more significant result for patients in pT1-2N0 (HR 3.52; 95% CI 1.88–6.62). The analyses also revealed that (OR 1.32; 95% CI 1.17–1.48), lymphatic invasion (OR 2.21; 95% CI 1.42–3.44) and venous invasion (OR 1.41; 95% CI 1.08–1.85) were associated with the occurrence of LNMM.

Conclusions

There is a positive correlation between LNMM and an unfavorable surgical outcome in gastric cancer. Undifferentiated histologic findings, lymphatic invasion, and venous invasion are high risk factors for the occurrence of LNMM.     

Touraine Solente Gole syndrome: The elephant skin disease

Touraine Solente Gole syndrome is a rare hereditary syndrome of primary pachydermoperiostosis, with the characteristic triad of pachydermia (or elephant like skin), periostosis and acropachia. A 27-year-old patient presented with aesthetic deformity of forehead due to deep skin folds and coarsening of facial features due to progressive thickening of skin. Associated palmoplantar hyperkeratosis with broadened of finger and toe tips and digital clubbing were noticed. Dermatologic evaluation revealed cutis verticis gyrata of scalp, seborrhoeic hyperplasia of face and hyperhidrosis. Natural history of the disease and aetiopathogenesis were reviewed. Aesthetic correction of forehead through frontal rhytidectomy was attempted.KEY WORDS: Clubbing, cutis verticis gyrata, frontal rhytidectomy, hypertrophic osteoarthropathy, pachyderma, periostosis     

Cerebral cortical oxygenation: a pilot study

BACKGROUND: Cerebral hypoxia (cerebral cortical oxygenation [Pbro2] < 20 mm Hg) monitored by direct measurement has been shown in animal and small clinical studies to be associated with poor outcome. We present our preliminary results observing Pbro2 in patients with traumatic brain injury (TBI). METHODS: A prospective observational cohort study was performed. Institutional review board approval was obtained. All patients with TBI who required measurement of intracranial pressure (ICP), cerebral perfusion pressure (CPP), and Pbro2 because of a Glasgow Coma Scale score < 8 were enrolled. Data sets (ICP, CPP, Pbro2, positive end-expiratory pressure (PEEP), Pao2, and Paco2) were recorded during routine manipulation. Episodes of cerebral hypoxia were compared with episodes without. Results are displayed as mean +/- SEM; t test, chi2, and Fisher's exact test were used to answer questions of interest. RESULTS: One hundred eighty-one data sets were abstracted from 20 patients. Thirty-five episodes of regional cerebral hypoxia were identified in 14 patients. Compared with episodes of acceptable cerebral oxygenation, episodes of cerebral hypoxia were noted to be associated with a significantly lower mean Pao2 (144 +/- 14 vs. 165 +/- 8; p < 0.01) and higher mean PEEP (8.8 +/- 0.7 vs. 7.1 +/- 0.3; p < 0.01). Mean ICP and CPP measurements were similar between groups. In a univariate analysis, cerebral hypoxic episodes were associated with Pao2 < or = 100 mm Hg (p < 0.01) and PEEP > 5 cm H2O (p < 0.01), but not ICP > 20 mm Hg, CPP < or = 65 mm Hg, or Pac2 < or = 35 mm Hg. CONCLUSION: Cerebral oxymetry is confirmed safe in the patient with multiple injuries with TBI. Occult cerebral hypoxia is present in the traumatic brain injured patient despite normal traditional measurements of cerebral perfusion. Further research is necessary to determine whether management protocols aimed at the prevention of cerebral cortical hypoxia will affect outcome.     

Haemorrhagic complications of pancreaticoduodenectomy

BACKGROUND: Haemorrhagic complication occurs in 5-16% of patients following pancreaticoduodenectomy (PD). We report an analysis of patients with post-PD bleed, to identify predictors of bleed, predictors of survival following bleed and the management of post-PD bleed. METHODS: Two hundred and eighteen patients with periampullary cancers underwent PD from 1989 to 2002. Forty-four (20.2%) patients had a bleeding complication. Of these, 25 patients had an intra-abdominal (IA) bleed and 21 had gastrointestinal (GI) bleed (two had both IA and GI bleed). Clinical, biochemical and tumour characteristics were analysed to identify factors influencing bleeding complications. RESULTS: The median time to presentation was 4.5 days (0-21 days). Serum bilirubin (P = 0.000, OR: 1.090) and pancreaticojejunostomy (PJ) leak (P = 0.009, OR: 3.174) were significant independent factors predicting bleeding complications. Forty-three per cent of patients each had early bleed (<48 h after PD) or delayed bleed (7 days after PD). Comparison of early and late bleeds showed that IA bleed (P = 0.02) presented as early bleeds. Male sex (P = 0.00) longer duration of jaundice (P = 0.02), PJ leak (P = 0.001), HJ leak (P = 0.001), duct to mucosa type of PJ anastomosis (P = 0.03) and IA abscess (P = 0.00) were associated with a significantly higher incidence of late bleeds. Overall mortality after PD was 9.6% with 34% and 3% in bleeders and non-bleeders, respectively. Septicaemia (P = 0.01, OR: 5.49), and acute renal failure (P = 0.01) were associated with increased mortality. CONCLUSIONS: Bleeding complications following PD were seen in one-fifth of patients and were associated with high mortality. Serum bilirubin levels and PJ leak were significant factors associated with bleeding complications. Septicaemia and acute renal failure were significant factors associated with mortality in the bleeders.     

Scarf osteotomy in the management of symptomatic adolescent hallux valgus

Purpose  

This study was designed to assess the utility of the scarf osteotomy in the management of symptomatic adolescent hallux valgus.     

Deep Venous Thrombosis in Lap Band Surgery: A Single Center Study

Bariatric surgery has been demonstrated to be an effective treatment for morbid obesity. The purpose of this study is to investigate the incidence of pre- and post-operative deep venous thrombosis (DVT) in Lap-Band surgical patients. This study group comprised 56 consecutive patients who underwent Lap-Band surgery. Mean age and body mass index were 38 years (range: 18–64 years) and 50.9 kg/m² (range: 53–74 kg/m²), respectively. All the patients were screened with duplex ultrasonography pre- and post-operatively. There were no iliac, femoral, or popliteal vein thromboses detected at any given point of time. No patient had any clinical signs or symptoms of DVT post-operatively. There were no observable differences attributable to DVT prophylaxis. This data suggest that in the setting of chemical and mechanical prophylaxis, the incidence of DVT in patients undergoing Lap-Band surgery at an established bariatric centre is minimal.     

Altered Immunogenicity of Donor Lungs via Removal of Passenger Leukocytes Using Ex Vivo Lung Perfusion

Passenger leukocyte transfer from the donor lung to the recipient is intrinsically involved in acute rejection. Direct presentation of alloantigen expressed on donor leukocytes is recognized by recipient T cells, promoting acute cellular rejection. We utilized ex vivo lung perfusion (EVLP) to study passenger leukocyte migration from donor lungs into the recipient and to evaluate the effects of donor leukocyte depletion prior to transplantation. For this purpose, female pigs received male left lungs either following 3 h of EVLP or retrieved using standard protocols. Recipients were monitored for 24 h and sequential samples were collected. EVLP‐reduced donor leukocyte transfer into the recipient and migration to recipient lymph nodes was markedly reduced. Recipient T cell infiltration of the donor lung was significantly diminished via EVLP. Donor leukocyte removal during EVLP reduces direct allorecognition and T cell priming, diminishing recipient T cell infiltration, the hallmark of acute rejection.