Outcomes following surgical repair using layered closure of unrepaired 4th degree perineal tear in rural western Uganda

Introduction

In many rural low-income countries, perineal tears at time of vaginal birth are not repaired at time of delivery. The aims of this study are to describe the surgical technique for management of the unrepaired 4th degree tear, performed without flaps, and short-term follow up on anal incontinence symptoms using a validated questionnaire.

Methods

Women presenting to fistula camps in western Uganda with unrepaired 4th degree tears were interviewed using the Cleveland Clinic Continence Score. Interviews were undertaken pre-operatively, at 4–6 weeks post-operatively and 12 months following surgery. Repair of the 4th degree tear was performed in layers, with an overlapping anal sphincter repair and reconstruction of the perineal body, without flaps. All women were examined prior to discharge.

Results

68 women completed pre-operative Cleveland Clinic Continence Scores. Prior to surgery, 59 % of women complained of daily incontinence to solid stools. Over 70 % of women complained of restriction to lifestyle due to the unrepaired 4th degree tear. About 50 % of the women are rejected by their husbands because of the condition. Only 1 woman had wound breakdown on Day 2. At 4 to 6 weeks follow-up, 61 women were contacted and all reported perfect continence.

Conclusion

This study highlights the hidden problem of unrepaired 4th degree tears in rural areas of low-income countries where most deliveries are undertaken in the village without professional health care workers. These tears have significant impact on quality of life and anal incontinence. Short-term outcomes following surgical repair using a layered closure are promising.

     

A Systematic Review and Meta-analysis Comparing Pancreaticoduodenectomy Versus Limited Resection for Duodenal Gastrointestinal Stromal Tumors

Purpose

This study was designed to compare the clinical outcomes of patients who underwent limited resection (LR) versus pancreaticoduodenectomy (PD) for duodenal gastrointestinal stromal tumors (GISTs).

Methods

A systematic review of the literature was performed to identify studies analyzing the clinical outcomes of LR and PD for duodenal GISTs.

Results

Eleven studies were included, of which 7 that compared 162 patients who underwent LR versus 98 patients who underwent PD were suitable for meta-analysis. Patients who underwent PD were more likely to have tumors which were large (≥ 5 cm) [76.0 vs. 36.6 %, odds ratio (OR) 5.49, 95 % confidence interval (CI) 1.8–16.76], with high mitotic count ≥5/50 high-power field (HPF) (33.7 vs. 18.5 %, OR 2.23, 95 % CI 1.22–4.08), classified as high risk (60.3 vs. 32.0 %, OR 3.23, 95 % CI 1.65–6.34), and which were located at D2 (80.5 vs. 28.6 %, OR 10.33, 95 % CI 5.22–20.47) compared with LR. PD was associated with a higher postoperative morbidity rate than LR [48.3 vs. 20.7 %, relative risk (RR) 2.34, 95 % CI 1.61–3.42]. LR was not associated with an increased local recurrence rate, had a better DFS [hazard ratio (HR) 2.07, 95 % CI 1.07–4.01], and lower rate of distant metastasis (8.9 vs. 25.8 %, OR 0.28, 95 % CI 0.13–0.59) compared with PD.

Conclusions

LR should be the procedure of choice for duodenal GIST whenever technically feasible, because it is associated with good oncologic outcomes and lower morbidity compared with PD. The oncologic outcome of GIST is more likely to be dependent on tumor biology rather that the type of surgical resection. The use of Imatinib in patients with duodenal GIST may potentially allow a proportion of patients who would otherwise require a PD to undergo LR instead.     

Systematic Review and Meta-Analysis Comparing the Surgical Outcomes of Invasive Intraductal Papillary Mucinous Neoplasms and Conventional Pancreatic Ductal Adenocarcinoma

Objective

The aim of this study was to summarize the current literature comparing the surgical outcomes of invasive intraductal papillary mucinous neoplasms (IPMN^INV) and conventional pancreatic ductal adenocarcinomas (PDAC) in order to determine the differences in disease characteristics and prognosis.

Methods

Systematic review of the literature yielded 12 comparative studies reporting the clinicopathological characteristics and overall survival (OS) of 1,450 patients with IPMN^INV with 19,304 patients with conventional PDAC.

Results

IPMN^INV had a significantly lower likelihood of tumors extending beyond the pancreas [27.6 vs. 94.3 %; T4 vs. T1: odds ratio (OR) 0.111, 95 % confidence intervals (CI) 0.057–0.214], nodal metastasis (45.4 vs. 62.9 %: OR 0.507, 95 % CI 0.347–0.741), positive margin (14.2 vs. 28.3 %; OR 0.438, 95 % CI 0.322–0.596), perineural invasion (49.2 vs. 76.5 %; OR 0.304, 95 % CI 0.106–0.877) and vascular invasion (25.2 vs. 45.7 % OR 0.417, 95 % CI 0.177–0.980) when compared with PDAC. The 5-year OS of IPMN^INV was significantly better than PDAC [31.4 vs. 12.4 %: hazard ratio (HR) 0.659, 95 % CI 0.574–0.756]. The tubular subtype had a poorer 5-year OS and demonstrated significantly more aggressive features such as nodal metastases, vascular invasion, and perineural invasion compared with the colloid subtype.

Conclusion

IPMN^INV were significantly more likely to present at an earlier stage and were less likely to demonstrate nodal involvement, perineural invasion and vascular invasion. When controlled for stage, IPMN^INV had an improved OS when compared with PDAC in the early stages.     

“When nothing happens,nobody is afraid!” beliefs and perceptions around self‐care and health‐seeking behaviours: Voices of patients living with diabetic lower extremity amputation in primary care

Self‐management and self‐care are the cornerstone of diabetes care and an essential part of successfully preventing or delaying diabetes complications. Yet, despite being armed with the required information and guidance for self‐management, self‐care and adherence to foot self‐care recommendations and compliance to medication among patients with diabetic foot ulcer and diabetic lower extremity amputations remain low and suboptimal. This study reveals in‐depth account of nine such patients'' beliefs and perceptions around their illness, their self‐care, and their health‐seeking behaviours. Patients living with diabetic lower extremity amputation displayed profound lack of knowledge of self‐care of diabetes and foot and passive health‐related behaviours. The overarching sense that "when nothing happens, nobody is afraid," points to a lack of motivation in taking charge of one''s own health, whether this is with reference to treatment or care adherence, following recommended self‐care advice, or seeking timely treatment. The Health Beliefs Model provides the theoretical framework for probing into the factors for the participants'' suboptimal self‐care and passive health‐seeking behaviours. Two themes emerged from data analysis: profound knowledge deficit and passive health‐related behaviours. The beliefs and perceptions around self‐care and health‐seeking behaviours for patients with lower extremity amputation are interpreted as the “ignorant self” with passive health‐seeking behaviours. Patients with diabetes and diabetic foot diseases may benefit from personalized education, motivational interviewing, and family support.     

“Chopstick” surgery: a novel technique improves surgeon performance and eliminates arm collision in robotic single-incision laparoscopic surgery

Introduction

Single-incision laparoscopic surgery (SILS) is limited by the coaxial arrangement of the instruments. A surgical robot with wristed instruments could overcome this limitation, but the arms often collide when working coaxially. This study tests a new technique of “chopstick” surgery to enable use of the robotic arms through a single incision without collision.

Methods

Experiments were conducted utilizing the da Vinci S^® robot (Intuitive Surgical, Inc., Sunnyvale, CA) in a Fundamentals of Laparoscopic Surgery (FLS) box trainer with three laparoscopic ports (1 × 12 mm, 2 × 5 mm) introduced through a single “incision.” Pilot work determined the optimal setup for SILS to be a triangular port arrangement with 2-cm trocar distance and remote center at the abdominal wall. Using this setup, five experienced robotic surgeons performed three FLS tasks utilizing either a standard robotic arm setup or the chopstick technique. The chopstick arrangement crosses the instruments at the abdominal wall so that the right instrument is on the left side of the target and the left instrument on the right. This results in separation of the robotic arms outside the box. To correct for the change in handedness, the robotic console is instructed to drive the “left” instrument with the right-hand effector and the “right” instrument with the left. Performances were compared while measuring time, errors, number of clutching maneuvers, and degree of instrument collision (Likert scale 1–4).

Results

Compared with the standard setup, the chopstick configuration increased surgeon dexterity and global performance through significantly improved performance times, eliminating instrument collision, and decreasing number of camera manipulations, clutching maneuvers, and errors during all tasks.

Conclusion

Chopstick surgery significantly enhances the functionality of the surgical robot when working through a small single incision. This technique will enable surgeons to utilize the robot for SILS and possibly for intraluminal or transluminal surgery.     

Ondansetron in the prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy

Background: There is an increased incidence of postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy. The aim of the study was to evaluate the efficacy of intravenous ondansetron, a 5-HT anatagonist, for prevention from PONV after laparoscopic cholecystectomy. Methods: Sixty-eight patients were entered into the study. Thirty-six patients were randomized to receive a single intravenous dose of 4 mg of ondansetron before extubation. Thirty-two patients received no prophylaxis. There were no differences in terms of sex ratio, age, ASA status, and duration of operation between the two study groups. Patients were interviewed by an independent observer to assess the postoperative pain and nausea using visual analog score. Patients' satisfaction scores to the procedure were measured. Results: There was no complication in the series. Pain scores at 2 and 24 h after operation and analgesics consumption were not different between the two groups. For the patients who received ondansetron, the mean (SD) nausea score at 2 and 24 h was 1.5 (1.2) and 1.4 (1.4), respectively. The score for the control group was 1.4 (1.0) and 1.2 (0.5), respectively. There was also no difference in episodes of vomiting and usage of antiemetics between the two groups. Both groups were equally satisfied with the procedures. Conclusion: Routine use of ondansetron does not reduce the incidence of postoperative nausea and vomiting after laparoscopic cholecystectomy.     

Pancreatic tuberculosis

A 63-year-old Japanese man visited our institute with fever of unknown origin. Findings on preoperative imaging modalities were consistent with pancreatic carcinoma, but a positive tuberculin skin test indicated tuberculosis infection. Negative results for MycobacteriumDNA polymerase chain reaction from sputum and bone-marrow aspiration biopsy specimens ruled out pulmonary and miliary tuberculosis, respectively. Positron emission tomography (PET) with 2-[fluorine-18]-fluoro-2-deoxy- d-glucose (FDG) showed multiple labeled spots within the pancreas body and chest. Distal pancreatectomy was performed with a diagnosis of suspected pancreatic carcinoma, but the histological and microbiological diagnosis was Mycobacterium infection. A rare case of pancreatic tuberculosis evaluated by FDG PET is reported and discussed herein.     

Bone Mineral Density and Hip Axis Length in Singapore''s Multiracial Population

Ethnic differences in bone density and hip geometry are known to exist, even within the same population. A recent study in Singapore showed that there were significant racial differences in hip fracture rates, with Chinese having the highest incidence of hip fractures. The aim of this study was to compare the bone mineral density (BMD) and hip axis length in Chinese, Malay, and Indian women. A total of 1575 women aged 20-59 yr were recruited, of which 77.6% (1222) were Chinese, 7.7% (122) Malays, and 14.7% (231) Indians. There was no significant difference in peak BMD of both lumbar spine and femoral neck among the three ethnic groups. However, in the older age group (50-59 yr), both Chinese and Malay women had significantly lower femoral neck BMD compared to Indian women. There was no significant loss in BMD of the lumbar spine between the second and fifth decades in all the three races. Between the second and fifth decade, Chinese and Malay women had significant bone loss in the femoral neck of 6.6% and 8.2%, respectively, whereas Indian women did not show any significant bone loss. Chinese women had significantly longer hip axis length compared to either Malay or Indian women (9.87 +/- 0.52 cm vs 9.67 +/- 0.49 cm; p < 0.005; and 9.69 +/- 0.55 cm, p < 0.05, respectively). The initial findings suggest racial differences in bone density and hip geometry exist in the local community. Future research should include prospective, longitudinal studies to determine the age-related bone loss in these three racial groups. It is also important to investigate the differences of spine and hip fracture rates and their relationship with bone density and hip axis length.     

Embolization for Hemoptysis: A Six -Year Review

Purpose: To review our method of embolization for hemoptysis. Methods: Between 1993 and 1999, 134 patients were treated in our department for hemoptysis. One hundred and sixteen patients were followed up (18 were lost to follow-up) over a period ranging from 1 to 66 months (median 9.5 months, SD 14.81 months). Most cases were due to tuberculosis (83.6%) and malignancy (9.5%). One hundred and three required embolization. Vascular access was obtained via the femoral route but two cases required a brachial approach for abnormal branches of the subclavian artery. All abnormal vessels found were embolized using polyvinyl alcohol particles alone or in combination with gelfoam. Results: Bronchial artery hypertrophy was found in 88.3% of cases; about a third of which had a nonbronchial systemic contribution. No angiographic abnormalities were found in 11.2%. Our failure rate was 18.4% (58% required surgery while 42% died from massive hemoptysis). Sixteen cases required multiple embolization sessions. No major complications were encountered. Conclusion: Embolization is effective for treatment of moderate to massive hemoptysis. The majority of our cases were due to tuberculosis. Approximately one third had nonbronchial systemic artery contributions, indicating that a concerted search for these is mandatory.     

The therapeutic impact of abdominal ultrasound in patients with acute abdominal symptoms

AIM: The technical performance of abdominal ultrasound in the investigation of acute abdominal pain has been thoroughly investigated but its therapeutic effects are less well understood. We aimed to determine the therapeutic effect of abdominal ultrasound in the investigation of acute abdominal pain. MATERIAL AND METHODS: A pre- and post-intervention observational study design was used to determine the diagnostic and therapeutic effects of abdominal ultrasound for acute abdominal pain. Referring clinicians completed a pre-ultrasound questionnaire that detailed their leading diagnosis, confidence in this and intended management in 100 consecutive adult patients. Following ultrasound a second questionnaire was completed. This again detailed the leading diagnosis, confidence in this and their intended management. Clinicians quantified the management contribution of ultrasound both for the individual case in question and in their clinical experience generally. RESULTS: The leading diagnosis was either confirmed or rejected in 72 patients and a new diagnosis provided where no prior differential diagnosis existed in 10. Diagnostic confidence increased significantly following ultrasound (mean score 6.5 pre-ultrasound vs 7.6 post-ultrasound, P < 0.001). Intended management changed following ultrasound in 22 patients; 15 intended laparotomies were halted and a further seven patients underwent surgery where this was not originally intended. Ultrasound was rated either 'very' or 'moderately' helpful in 87% of patients, with 99% of clinicians finding it either 'very' or 'moderately' helpful generally. CONCLUSION: Abdominal ultrasound has considerable diagnostic and therapeutic effect in the setting of acute abdominal pain.