Miniarthrotomy assisted percutaneous screw fixation for displaced medial malleolus fractures – A novel technique

Aim

To describe here a technique of miniarthrotomy assisted percutaneous screw insertion for displaced Herscovici type B and C medial malleolar fractures.

Method

Incision was made centred over the superomedial angle of the ankle mortise, about half a cm medial to tibialis anterior. Arthrotomy was done and reduction obtained. Percuntaneously, two 4 mm cancellous cannulated screws were inserted through medial malleolus.

Results and conclusion

This approach allows direct visualization of reduction, removal of entrapped soft tissue and preservation of saphenous vein and nerve.     

Meta-analysis of self-gripping mesh (Progrip) versus sutured mesh in open inguinal hernia repair

BackgroundThis metaanalysis was designed to systematically analyse all published randomized controlled trials comparing self-gripping mesh (ProGrip) and sutured mesh to analyse early and long term outcomes for open inguinal hernia repair.MethodsA literature search was performed using the Cochrane Colorectal Cancer Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials in the Cochrane Library, MEDLINE, Embase and Science Citation Index Expanded. Randomized trials comparing self-gripping mesh with sutured mesh were included. Statistical analysis was performed using Review Manager Version 5.2 software. The primary outcome measures were hernia recurrence and chronic pain after operation. Secondary outcome measures included surgical time, wound complications and perioperative complications.ResultsFive randomized trials were identified as suitable, including 1170 patients. There was no significant difference between the two types of mesh repairs in perioperative complications, wound haematoma, chronic groin pain and hernia recurrence. Wound infection was lower in self gripping mesh group compared to sutured mesh but this was not statistically significant (risk ratio (RR) 0.57, 95% confidence interval 0.30–1.06, P = 0.08). The duration of operation was significantly shorter with self-gripping mesh compared to sutured mesh with a mean difference of ?5.48 min [?9.31, ?1.64] Z = 2.80 (P = 0.005).ConclusionSelf-gripping mesh was associated with shorter operative time compared to sutured mesh. Both types of mesh repairs have comparable perioperative and long term outcomes.     

Surgical resection techniques for locally advanced hilar cholangiocarcinoma

Background

Resection of perihilar cholangiocarcinoma involves major hepatectomy including caudate lobectomy. It is technically challenging because of the complex, intimate and variable relationship between biliary and vascular structures in the liver hilum. Resectability rates vary from 30 to 80 % and about one third of patients have microscopically involved margins. However, adequately performed resections provide 5-year survival of 30–40 % and are worth pursuing.

Purpose

Better understanding of anatomy, better imaging, improved surgical techniques and progress in perioperative care of these patients have pushed the limits of resection of these tumours. Many of the traditional indicators of inoperability such as bilateral involvement of second-order hepatic ducts, contralateral biliary and vascular involvement, and need for arterial resection have been overcome or are being challenged. This review discusses techniques that may increase margin-free resectability of Bismuth–Corlette type III and IV perihilar cholangiocarcinoma.

Conclusion

Advanced perihilar cholangiocarcinoma requires extended liver resection and often vascular resection, despite which the margin may be compromised in about one third of patients. Right sided tumours are likely to need right trisectionectomy and portal vein resection, best served by an en bloc hilar resection or Rex-recess approach. Left-sided tumours often involve contralateral blood vessels and require left trisegmentectomy with possible right portal vein or right hepatic artery reconstruction. These tumours are best tackled by hepatobiliary surgeons with experience in microvascular techniques. Salvage procedures when arterial reconstruction is not feasible are still under evaluation.     

“Dynamic” liver retraction at laparoscopy: An easy and effective technique

Liver retraction is an essential step during any laparoscopic upper gastrointestinal operation, especially during dissection at the oesophageal hiatus. However, the generally employed Nathanson retractor may cause significant postoperative liver dysfunction secondary to congestion of the liver.1,2 It may be technically cumbersome to systematize its frequent use intraoperatively and it may not be readily available at large. Furthermore, the unabated pressure it inflicts on the left lobe of the liver, especially during prolonged surgeries, may lead to hepatic ischaemic necrosis, gangrene, or even unexpected mortality.1 While few recently developed innovative liver retraction techniques seem useful in this context, 2-5 they tend to offer a “static” liver retraction. In this paper, we describe an easy-to-use method of laparoscopic liver retraction wherein any 5mm laparoscopic instrument can be used to manipulate the “heavy” liver so as to provide a “dynamic” counter-traction at will.     

Patterns of Failure and Determinants of Outcomes Following Radical Re-resection for Incidental Gallbladder Cancer

Background

Better appreciation of the course and factors that influence incidental gallbladder cancer is needed to develop treatment strategies aimed at improved outcomes. The purpose of this study was to determine pattern of disease recurrence and influencing factors in patients undergoing radical re-resection for incidental gallbladder cancer.

Methods

Patients undergoing radical re-resection from February 2003 to May 2010 were analyzed. Influence of variables (lymph node ratio, ASA grade, gender, adjuvant treatment, time interval between cholecystectomy and radical re-resection (in months), and TNM stage) on disease-free survival was assessed.

Results

Of 163 patients, 127 (92 female and 35 male patients; median age 50 years) underwent successful radical re-resection. Median duration between two surgeries was 2 months (range 1–10). Twenty-five percent of patients with pT1b disease had lymph node metastases. Two-year disease-free survival rate was 79.6 % (median follow-up, 16 months). On follow-up, 18 of 24 patients developed recurrences at distant sites. Lymph node metastasis was the single variable significantly influencing disease-free survival. Adjusting for disease stage when analyzing time interval between cholecystectomy and radical re-resection on a continuous scale as a prognostic factor for recurrence revealed no significant impact of increasing interval between surgeries (hazard ratio 1.12; 95 % confidence interval 0.95–1.34; p = 0.17).

Conclusions

The most important predictor of disease recurrence is lymph node metastases. In patients who undergo curative radical re-resection for incidental gallbladder cancer, recurrent disease is more likely to occur at distant sites. Patients with pT1b disease should be offered radical re-resection with a radical lymphadenectomy. It is not the delay in revision surgery but TNM stage that influences outcomes in incidental gallbladder cancer.     

WNT pathway signaling is associated with microvascular injury and predicts kidney transplant failure

Microvascular injury is associated with accelerated kidney transplant dysfunction and allograft failure. Molecular pathology can identify new mechanisms of microvascular injury while improving on the diagnostic and prognostic capabilities of traditional histology. We conducted a case‐control study of archived kidney biopsy specimens stored up to 10 years with microvascular injury (n = 50) compared with biopsy specimens without histologic injury (n = 45) from patients of similar age, race, and sex. We measured WNT gene expression with a multiplex quantification platform by using digital barcoding, given the importance of WNT reactivation to the response to wounding in the kidney microvasculature and other compartments. Of 210 genes from a commercial WNT panel, 71 were associated with microvascular injury and 79 were associated with allograft failure, with considerable overlap of genes between each set. Molecular pathology identified 46 biopsy specimens with molecular evidence of microvascular injury; 18 (39%) were either C4d negative, donor‐specific antibody negative, or had no microvascular injury by histology. The majority of cases with molecular evidence of microvascular injury had poor long‐term outcomes. We identified novel WNT pathway genes associated with microvascular injury and allograft failure in residual clinical biopsy specimens obtained up to 10 years earlier. Further mechanistic studies may identify the WNT pathway as a new diagnostic and therapeutic target.     

Dynamic gadolinium-enhanced echo-planar MR imaging of the liver: Effect of pulse sequence and dose on enhancement

To develop guidelines for clinical magnetic resonance imaging of the liver, the authors undertook an animal study to investigate the effect of dose and pulse sequence on liver signal intensity in gadopentetate dimeglumine—enhanced echo-planar imaging. Serial imaging of the liver was performed in anesthetized rats after intravenous administration of five different doses (0.01, 0.05, 0.1, 0.2, and 0.5 mmol/kg) of contrast agent, with six different pulse sequences. The results show that gadopentetate dimeglumine—enhanced echo-planar images obtained during the perfusion phase can yield either positive (due to increased T1 relaxation rates) or negative (due to susceptibility-induced increased T2 relaxation rates) liver enhancement depending on choice of pulse sequence and dose. At the current clinically recommended dose of 0.1 mmol/kg, maximal liver signal enhancement was seen with a T1-weighted inversion-recovery sequence, while maximal liver signal diminution was seen with a T2*-weighted gradient-echo sequence. The authors conclude that gadopentetate dimeglumine—enhanced echo-planar imaging can provide T1, T2, and T2* contrast that may be exploited for both lesion detection and lesion characterization.     

Bilateral simultaneous laparoscopic adrenalectomy in Cushing's syndrome: safe, effective, and curative

INTRODUCTION: Surgical morbidity and mortality rates are high in patients with Cushing's syndrome. Nevertheless, simultaneous bilateral laparoscopic adrenalectomy (LA) is feasible in these patients with less morbidity and good long-term results. BACKGROUND AND RESULTS: Consecutive 22 patients who underwent LA for Cushing's syndrome between 2003 and 2010 in our institute were retrospectively studied. Ninteen patients underwent bilateral simultaneous and three underwent unilateral LA. Seven patients had Cushing's syndrome after failed pituitary surgery and five each had ectopic adrenocorticotrophic hormone dependent syndrome and bilateral macronodular hyperplasia respectively. LA was bilaterally done by lateral transabdominal adrenalectomy in 15 patients and retroperitoneal endoscopic adrenalectomy in 4 on the right side. Mean operative time for simultaneous bilateral cases was 199.45±72.43 minutes with mean blood loss of 72.72±48.6 mL. Patients were fit for discharge by the fifth postoperative day from the surgical aspect. Surgical complication rate was 26% that included wound infections in two, port site hernia, pleural effusion, and atelectasis in one each. One patient died of sepsis (5% mortality). Satisfactory metabolic control was achieved in all observable patients in the long term although Addisonian crisis and Nelson syndrome were seen in 26% and 15% respectively. CONCLUSION: LA has all advantages of minimal access surgery in patients with Cushing's syndrome who are immunocompromised and at high risk of delayed wound healing and infections. Magnification decreases the risk of retained adrenal remnants. Despite advances in minimal access surgery, perioperative morbidity continues to be significant for the procedure.     

Extracorporeal management of poisonings

Extracorporeal methods have been an integral part in the management of poisonings. The elimination of a drug or toxin by extracorporeal techniques (ECT) is governed by the properties of the toxin and the chosen extracorporeal therapy. The various ECT include hemodialysis, hemoperfusion, hemofiltration, continuous renal replacement therapy and peritoneal dialysis, all of which have been used some time or another for the management of poisonings. This review highlights the concepts forming the basis for selecting one modality over the others.     

Reconstructive challenges in war wounds

War wounds are devastating with extensive soft tissue and osseous destruction and heavy contamination. War casualties generally reach the reconstructive surgery centre after a delayed period due to additional injuries to the vital organs. This delay in their transfer to a tertiary care centre is responsible for progressive deterioration in wound conditions. In the prevailing circumstances, a majority of war wounds undergo delayed reconstruction, after a series of debridements. In the recent military conflicts, hydrosurgery jet debridement and negative pressure wound therapy have been successfully used in the preparation of war wounds. In war injuries, due to a heavy casualty load, a faster and reliable method of reconstruction is aimed at. Pedicle flaps in extremities provide rapid and reliable cover in extremity wounds. Large complex defects can be reconstructed using microvascular free flaps in a single stage. This article highlights the peculiarities and the challenges encountered in the reconstruction of these ghastly wounds.KEY WORDS: Delayed reconstruction, reconstructive challenges, war wound, wound debridement