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Functional outcome after perineal stapled prolapse resection for external rectal prolapse
Franc HetzerAmir RoushanKatja WolffUlrich BeutnerJan BorovickaJochen LangeLukas Marti Mon, 08 Mar 2010 00:00:00 -0000
Background: A new surgical technique, the Perineal Stapled Prolapse resection (PSP) for external rectal prolapse was introduced in a feasibility study in 2008. This study now presents the first results of a larger patient group with functional outcome in a mid-term follow-up. Methods: From December 2007 to April 2009 the PSP was performed by the same surgeon on patients with external rectal prolapse. The prolapse was completely pulled out and then axially cut open with a linear stapler at three and nine o'clock in lithotomy position. Finally, the prolapse was resected stepwise with the curved Contour(R) TranstarTM stapler at the prolapse's uptake. Perioperative morbidity and functional outcome were prospectively measured by appropriate scores. Results: 32 patients participated in the study; median age was 80 years (range 26-93). No intraoperative complications, 6.3% minor postoperative complications occurred. Median operation time was 30 minutes (15-65), hospital stay 5 days (2-19). Functional outcome data were available in 31 of the patients after a median time of 6 months (4-22). Preoperative severe faecal incontinence disappeared postoperatively in 90% of patients with median reduction of the Wexner score from 16 (4-20) to 1 (0-14) (P <0.0001) and no new incidence of constipation was reported. Conclusions: The PSP is an elegant, fast and safe procedure, with good functional results.Trial registration: ISRCTN68491191
Moderately differentiated colorectal adenocarcinoma as a lymph node metastatic phenotype: comparison with well differentiated counterparts.
Shozo YokoyamaKatsunari TakifujiTsukasa HottaKenji MatsudaToshiji TominagaYoshimasa OkuToru NasuKoichi TamuraJunji IedaHiroki Yamaue Mon, 08 Mar 2010 00:00:00 -0000
Background The differences between the metastatic property of moderately (Mod) and well (Wel) differentiated colorectal adenocarcinoma remain unclear. Since Mod is unable to form complete acini, therefore an epithelial-mesenchymal transition (EMT) can occur in that structure. Herein, we hypothesized that Mod metastasizes more easily than the Wel counterparts.Methods The medical records of 283 consecutive patients with Mod (n=71) or Wel (n=212) who underwent surgery were reviewed between January 1, 2001, and December 31, 2003, for actual 5-year overall survival. We examined the differences between the clinicopathological characteristics of the Mod and the Wel groups.Results The lymph node involvement (p<0.0001), lymphatic permeation, venous permeation, depth of invasion, liver metastasis, and carcinomatous peritonitis were significantly higher in the Mod group in comparison to the Wel group. The independent risk factors by a logistic regression analysis for lymph node involvement were as follows: lymphatic permeation, liver metastasis, and Mod (p=0.0291, Relative Risk of 1.991: 95% Confidence Interval: 1.073-3.697). A Kaplan-Meier survival curve showed that Mod had a trend towards a poor survival (p=0.0517).Conclusion Mod metastasizes to the lymph nodes more easily in comparison to Wel. Therefore, patients with Mod may be considered the existence of lymph node involvement.
Acute paranoid psychosis as sole clinical presentation of hepatic artery thrombosis after living donor liver transplantation
Armin GoralczykVolker MeierGiuliano RamadoriAiman ObedThomas Lorf Mon, 22 Feb 2010 00:00:00 -0000
Background: Hepatic artery thrombosis is a devastating complication after orthotopic liver transplantation often requiring revascularization or re-transplantation. It is associated with considerably increased morbidity and mortality. Acute cognitive dysfunction such as delirium or acute psychosis may occur after major surgery and may be associated with the advent of surgical complications.Case presentationHere we describe a case of hepatic artery thrombosis after living-donor liver transplantation which was not preceded by signs of liver failure but rather by an episode of acute psychosis. After re-transplantation the patient recovered without sequelae. Conclusion: This case highlights the need to remain cautious when psychiatric disorders occur in patients after liver transplantation. The diagnostic procedures should not be restricted to medical or neurological causes of psychosis alone but should also focus vascular complications related to orthotopic liver transplantation.
Emergency open cholecystectomy is associated with markedly lower incidence of postoperative nausea and vomiting (PONV) than elective open cholecystectomy: a retrospective cohort study
Jeffrey EastDerek Mitchell Fri, 12 Feb 2010 00:00:00 -0000
Background: During a previous study to define and compare incidence risks of postoperative nausea and vomiting (PONV) for elective laparoscopic and open cholecystectomy at two hospitals in Jamaica, secondary analysis comparing PONV risk in elective open cholecystectomy to that after emergency open cholecystectomy suggested that it was markedly reduced in the latter group. The decision was made to collect data on an adequate sample of emergency open cholecystectomy cases and further explore this unexpected finding in a separate study. Methods: Data were collected for 91 emergency open cholecystomy cases identified at the two paricipating hospitals from May 2007 retrograde, as was done for the 175 elective open cholecystectomy cases (from the aforementioned study) with which the emergency cases were to be compared. Variables selected for extraction and statistical analysis included all those known, suspected and plausibly associated with the risk of PONV and with urgency of surgery. Results: Emergency open cholecystectomy was associated with a markedly reduced incidence risk of PONV compared to elective open cholecystectomy (6.6% versus 28.6%, P<0.001). The suppressive effect of emergency increased after adjustment for confounders in a multivariable logistic regression model (odds ratio 0.103, P<0.001). This finding also identifies, by extrapolation, an association between reduced risk of PONV and preoperative nausea and vomiting, which occurred in 80.2% of emergency cases in the 72 hour period preceding surgery. Conclusions: The incidence risk of postoperative nausea and vomiting is markedly decreased after emergency open cholecystectomy compared to elective open cholecystectomy. The study, by extrapolation, also identifies a paradoxical association between pre-operative nausea and vomiting, observed in 80.2% of emergency cases, and suppression of PONV. This association, if confirmed in prospective cohort studies, may have implications for PONV prophylaxis if it can be exploited at a sub-clinical level.
Experimental investigation of the elasticity of the human diaphragm
Gerhard SteinauChristian HohlAndreas PrescherDaniel KaemmerGabriele Boehm Sat, 30 Jan 2010 00:00:00 -0000
Background: Traumatic diaphragmatic ruptures affect mainly the left side. In an experimental study in human corpses we examined the stretch behaviour of the left and right diaphragmatic halves.MethodIn a total of 8 male and 8 female corpses each diaphragmatic half was divided into 4 different segments. Each segments stretch behaviour was investigated. In steps of 2 N the stretch was increased up to 24 N. Results: In the female the left diaphragm showed a stronger elasticity compared to the right. Additionally the left diaphragm in females showed a higher elasticity in comparison to the left in males. Traumatic diaphragmatic ruptures affect mostly the central tendineous part or the junction between tendineous and muscular part of the diaphragmatic muscle. Accordingly we found a lower elasticity in these parts compared with the other diaphragmatic segments. Conclusion: In summary it can be said that albeit some restrictions we were able to determine the elasticity of different diaphragmatic segments quantitatively and reproduceably with our presented method. Thereby a comparison of results of different diaphragmatic segments as well as of both diaphragmatic halves and of both genders was possible
Potential hospital cost-savings attributed to improvements in outcomes for colorectal cancer surgery following self-audit
Louisa GordonAndreas Obermair Wed, 27 Jan 2010 00:00:00 -0000
Background: One of the potential benefits of surgical audit is improved hospital cost-efficiencies arising from lower resource consumption associated with fewer adverse events. The aim of this study was to estimate the potential cost-savings for Australian hospitals from improved surgical performance for colorectal surgery attributed to a surgical self-audit program. Methods: We used a mathematical decision-model to investigate cost differences in usual practice versus surgical audit and synthesized published hospital cost data with epidemiological evidence of adverse surgical events in Australia and New Zealand. A systematic literature review was undertaken to assess post-operative outcomes from colorectal surgery and effectiveness of surgical audit. Results were subjected to both one-way and probabilistic sensitivity analyses to address uncertainty in model parameters. Results: If surgical self-audit facilitated the reduction of adverse surgical events by half those currently reported for colorectal cancer surgery, the potential cost-savings to hospitals is AU $48,720 (95% CI: $18,080-$89,260) for each surgeon treating 20 cases per year. A smaller 25% reduction in adverse events produced cost-savings of $24,960 per surgeon (95%CI: $1,980-$62,980). Potential hospital savings for all operative colorectal cancer cases was estimated at AU $30.3 million each year. Conclusions: Surgical self-audit has the potential to create substantial hospital cost-savings for colorectal cancer surgery in Australia when considering the widespread incidence of this disease. The study is limited by the current availability and quality of data estimates abstracted from the published literature. Further evidence on the effectiveness of self-audit is required to substantiate these findings.
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Functional outcome after perineal stapled prolapse resection for external rectal prolapse
Franc HetzerAmir RoushanKatja WolffUlrich BeutnerJan BorovickaJochen LangeLukas Marti Mon, 08 Mar 2010 00:00:00 -0000
Background: A new surgical technique, the Perineal Stapled Prolapse resection (PSP) for external rectal prolapse was introduced in a feasibility study in 2008. This study now presents the first results of a larger patient group with functional outcome in a mid-term follow-up. Methods: From December 2007 to April 2009 the PSP was performed by the same surgeon on patients with external rectal prolapse. The prolapse was completely pulled out and then axially cut open with a linear stapler at three and nine o'clock in lithotomy position. Finally, the prolapse was resected stepwise with the curved Contour(R) TranstarTM stapler at the prolapse's uptake. Perioperative morbidity and functional outcome were prospectively measured by appropriate scores. Results: 32 patients participated in the study; median age was 80 years (range 26-93). No intraoperative complications, 6.3% minor postoperative complications occurred. Median operation time was 30 minutes (15-65), hospital stay 5 days (2-19). Functional outcome data were available in 31 of the patients after a median time of 6 months (4-22). Preoperative severe faecal incontinence disappeared postoperatively in 90% of patients with median reduction of the Wexner score from 16 (4-20) to 1 (0-14) (P <0.0001) and no new incidence of constipation was reported. Conclusions: The PSP is an elegant, fast and safe procedure, with good functional results.Trial registration: ISRCTN68491191
Moderately differentiated colorectal adenocarcinoma as a lymph node metastatic phenotype: comparison with well differentiated counterparts.
Shozo YokoyamaKatsunari TakifujiTsukasa HottaKenji MatsudaToshiji TominagaYoshimasa OkuToru NasuKoichi TamuraJunji IedaHiroki Yamaue Mon, 08 Mar 2010 00:00:00 -0000
Background The differences between the metastatic property of moderately (Mod) and well (Wel) differentiated colorectal adenocarcinoma remain unclear. Since Mod is unable to form complete acini, therefore an epithelial-mesenchymal transition (EMT) can occur in that structure. Herein, we hypothesized that Mod metastasizes more easily than the Wel counterparts.Methods The medical records of 283 consecutive patients with Mod (n=71) or Wel (n=212) who underwent surgery were reviewed between January 1, 2001, and December 31, 2003, for actual 5-year overall survival. We examined the differences between the clinicopathological characteristics of the Mod and the Wel groups.Results The lymph node involvement (p<0.0001), lymphatic permeation, venous permeation, depth of invasion, liver metastasis, and carcinomatous peritonitis were significantly higher in the Mod group in comparison to the Wel group. The independent risk factors by a logistic regression analysis for lymph node involvement were as follows: lymphatic permeation, liver metastasis, and Mod (p=0.0291, Relative Risk of 1.991: 95% Confidence Interval: 1.073-3.697). A Kaplan-Meier survival curve showed that Mod had a trend towards a poor survival (p=0.0517).Conclusion Mod metastasizes to the lymph nodes more easily in comparison to Wel. Therefore, patients with Mod may be considered the existence of lymph node involvement.
Acute paranoid psychosis as sole clinical presentation of hepatic artery thrombosis after living donor liver transplantation
Armin GoralczykVolker MeierGiuliano RamadoriAiman ObedThomas Lorf Mon, 22 Feb 2010 00:00:00 -0000
Background: Hepatic artery thrombosis is a devastating complication after orthotopic liver transplantation often requiring revascularization or re-transplantation. It is associated with considerably increased morbidity and mortality. Acute cognitive dysfunction such as delirium or acute psychosis may occur after major surgery and may be associated with the advent of surgical complications.Case presentationHere we describe a case of hepatic artery thrombosis after living-donor liver transplantation which was not preceded by signs of liver failure but rather by an episode of acute psychosis. After re-transplantation the patient recovered without sequelae. Conclusion: This case highlights the need to remain cautious when psychiatric disorders occur in patients after liver transplantation. The diagnostic procedures should not be restricted to medical or neurological causes of psychosis alone but should also focus vascular complications related to orthotopic liver transplantation.
Emergency open cholecystectomy is associated with markedly lower incidence of postoperative nausea and vomiting (PONV) than elective open cholecystectomy: a retrospective cohort study
Jeffrey EastDerek Mitchell Fri, 12 Feb 2010 00:00:00 -0000
Background: During a previous study to define and compare incidence risks of postoperative nausea and vomiting (PONV) for elective laparoscopic and open cholecystectomy at two hospitals in Jamaica, secondary analysis comparing PONV risk in elective open cholecystectomy to that after emergency open cholecystectomy suggested that it was markedly reduced in the latter group. The decision was made to collect data on an adequate sample of emergency open cholecystectomy cases and further explore this unexpected finding in a separate study. Methods: Data were collected for 91 emergency open cholecystomy cases identified at the two paricipating hospitals from May 2007 retrograde, as was done for the 175 elective open cholecystectomy cases (from the aforementioned study) with which the emergency cases were to be compared. Variables selected for extraction and statistical analysis included all those known, suspected and plausibly associated with the risk of PONV and with urgency of surgery. Results: Emergency open cholecystectomy was associated with a markedly reduced incidence risk of PONV compared to elective open cholecystectomy (6.6% versus 28.6%, P<0.001). The suppressive effect of emergency increased after adjustment for confounders in a multivariable logistic regression model (odds ratio 0.103, P<0.001). This finding also identifies, by extrapolation, an association between reduced risk of PONV and preoperative nausea and vomiting, which occurred in 80.2% of emergency cases in the 72 hour period preceding surgery. Conclusions: The incidence risk of postoperative nausea and vomiting is markedly decreased after emergency open cholecystectomy compared to elective open cholecystectomy. The study, by extrapolation, also identifies a paradoxical association between pre-operative nausea and vomiting, observed in 80.2% of emergency cases, and suppression of PONV. This association, if confirmed in prospective cohort studies, may have implications for PONV prophylaxis if it can be exploited at a sub-clinical level.
Experimental investigation of the elasticity of the human diaphragm
Gerhard SteinauChristian HohlAndreas PrescherDaniel KaemmerGabriele Boehm Sat, 30 Jan 2010 00:00:00 -0000
Background: Traumatic diaphragmatic ruptures affect mainly the left side. In an experimental study in human corpses we examined the stretch behaviour of the left and right diaphragmatic halves.MethodIn a total of 8 male and 8 female corpses each diaphragmatic half was divided into 4 different segments. Each segments stretch behaviour was investigated. In steps of 2 N the stretch was increased up to 24 N. Results: In the female the left diaphragm showed a stronger elasticity compared to the right. Additionally the left diaphragm in females showed a higher elasticity in comparison to the left in males. Traumatic diaphragmatic ruptures affect mostly the central tendineous part or the junction between tendineous and muscular part of the diaphragmatic muscle. Accordingly we found a lower elasticity in these parts compared with the other diaphragmatic segments. Conclusion: In summary it can be said that albeit some restrictions we were able to determine the elasticity of different diaphragmatic segments quantitatively and reproduceably with our presented method. Thereby a comparison of results of different diaphragmatic segments as well as of both diaphragmatic halves and of both genders was possible
Potential hospital cost-savings attributed to improvements in outcomes for colorectal cancer surgery following self-audit
Louisa GordonAndreas Obermair Wed, 27 Jan 2010 00:00:00 -0000
Background: One of the potential benefits of surgical audit is improved hospital cost-efficiencies arising from lower resource consumption associated with fewer adverse events. The aim of this study was to estimate the potential cost-savings for Australian hospitals from improved surgical performance for colorectal surgery attributed to a surgical self-audit program. Methods: We used a mathematical decision-model to investigate cost differences in usual practice versus surgical audit and synthesized published hospital cost data with epidemiological evidence of adverse surgical events in Australia and New Zealand. A systematic literature review was undertaken to assess post-operative outcomes from colorectal surgery and effectiveness of surgical audit. Results were subjected to both one-way and probabilistic sensitivity analyses to address uncertainty in model parameters. Results: If surgical self-audit facilitated the reduction of adverse surgical events by half those currently reported for colorectal cancer surgery, the potential cost-savings to hospitals is AU $48,720 (95% CI: $18,080-$89,260) for each surgeon treating 20 cases per year. A smaller 25% reduction in adverse events produced cost-savings of $24,960 per surgeon (95%CI: $1,980-$62,980). Potential hospital savings for all operative colorectal cancer cases was estimated at AU $30.3 million each year. Conclusions: Surgical self-audit has the potential to create substantial hospital cost-savings for colorectal cancer surgery in Australia when considering the widespread incidence of this disease. The study is limited by the current availability and quality of data estimates abstracted from the published literature. Further evidence on the effectiveness of self-audit is required to substantiate these findings.
