Annals of surgical innovation and research最新文献

The introduction of laparoscopic cholecystectomy was associated with increased incidences of bile duct injury. The primary cause appears to be misidentification of the biliary anatomy. Routine intra-operative cholangiography has been recommended to reduce accidental duct injury, although in practice it is more often reserved for selected cases. There has been interest in the use of fluorescent agents excreted via the biliary system to enable real-time intra-operative imaging, to aid the laparoscopic surgeon in correctly interpreting the anatomy. The primary aim of this review is to evaluate the ability of fluorescent cholangiography to identify important biliary anatomy intra-operatively. Secondary aims are to investigate its ability to detect important intra-operative pathology such as bile leaks, identify potential alternative fluorophores, and evaluate the evidence regarding patient outcomes.

We report a case of a grade V bladder injury complicating an open-book pelvic fracture following a road traffic accident. The bladder neck injury was primarily repaired in the emergency setting of a poor-resourced area with successful outcome. The dangers of urinary extravasation are still to be considered of importance and we advocate and encourage immediate/emergency open intervention although it remains controversial to say the least in a lesser resourced healthcare set up.

Background: Childhood-to-adult persistent asthma is usually considered to be an atopic disease. However gastroesophageal reflux may also play an important role in this phenotype of asthma, especially when it is refractory to pulmonary medicine.

Methods: Fifty-seven consecutive GERD patients who had decades of childhood-to-adult persistent asthmatic symptoms refractory to pulmonary medication were enrolled. GERD was assessed by a symptom questionnaire, endoscopy, reflux monitoring, and manometry, and treated by Stretta radiofrequency (SRF) or laparoscopic Nissen fundoplication (LNF). The outcomes were followed up with a questionnaire for an average of 3.3 ± 1.1 years.

Results: Upper esophageal sphincter hypotonia, lower esophageal sphincter (LES) hypotonia, shortened LES, and esophageal body dyskinesia were demonstrated by esophagus manometry in 50.9%, 43.9%, 35.1%, and 45.6% of the patients, respectively. The symptom scores for heartburn, regurgitation, coughing, wheezing, and chest tightness significantly decreased from 5.8 ± 2.0, 5.6 ± 2.0, 7.3 ± 1.6, 8.4 ± 1.2, and 8.1 ± 1.5, to 1.2 ± 1.8, 1.1 ± 1.6, 2.8 ± 2.5, 3.8 ± 2.7, and 3.9 ± 2.7, respectively, after anti-reflux treatment (P < 0.001).

Conclusions: Esophagus dysfunction is high in childhood-to-adult persistent asthmatic patients with GERD. SRF and LNF are both effective for esophagus symptoms as well as persistent asthmatic symptoms for these patients. GER may relate with asthmatic symptoms in some patients. Evaluating asthmatic patients for possible treatment of the underlying cause, such as GERD, may improve symptoms and prevent disease persistence.

Lymph node status is the most important prognostic factor in esophageal cancer. Through improved detection of lymph node metastases, using the sentinel lymph node concept, accurate staging and more tailored therapy may be achieved. This review article outlines two principle ways in which the sentinel lymph node concept could dramatically influence current standard of care for patients with esophageal cancer. We discuss three limitations to universal acceptance of the technique, and propose next steps for increasing enthusiasm amongst physicians and surgeons including the development of a universal tracer, and improved contrast agents with novel dual-modality 'visibility'.

Introduction: A female urethral diverticulum is an uncommon pathologic entity. It can manifest with a variety of symptoms involving the lower urinary tract. Our objective is to describe the various aspects of the diverticulum of the female urethra such as etiology, diagnosis and treatment.

Cases presentation: We report five female patients, without prior medical history. They had different symptoms: dysuria in four cases, recurrent urinary tract infection in three cases, stress incontinence in two cases and hematuria in two cases. All patients had dyspareunia. The physical exams found renitent mass located in the endovaginal side of urethra which drained pus in two cases. Urethrocystography found a diverticulum of urethra in all cases. Our five patients underwent diverticulotomy by endovaginal approach. The course after surgical treatment was favorable. The urinary catheter was withdrawn after ten days. Some recurrent symptoms were reported.

Conclusion: Evaluation of recurrent urinary complaints in young women can lead to the finding of a diverticulum of urethra. Urethrocystography can reveal this entity. Diverticulectomy by endovaginal approach is the best choice for treatment.

Background: In 1998, an electrothermal bipolar vessel sealing (EBVS) system was introduced and quickly became an integral component of the surgical armamentarium in various surgical specialties. Currently available EBVS instruments use a scissor-like jaw configuration and closing mechanism, which causes decreasing compression pressure from the proximal to the distal end of the jaws. A new EBVS system is described here which utilizes a different instrument jaw configuration and closing mechanism to enable a more homogeneous pressure distribution despite longer instrument jaws.

Methods: Results of jaw pressure distribution measurements as well as sealing experiments with subsequent burst pressure measurements ex vivo on bovine uterine arteries are demonstrated. Furthermore, an in vivo evaluation of the new EBVS system in a canine and porcine model including histological examination is presented.

Results: The device revealed an even pressure distribution throughout the whole jaw length. The ex vivo burst pressure measurements revealed high average burst pressures, above 300 mmHg, independent of the outer diameter (1 to 7 mm) of the tested vessels. Histological evaluation of sealed vessels 21 days postoperatively demonstrated sealed and fused vessels without adjacent tissue damage.

Conclusions: The even pressure distribution leading to a sufficient tissue sealing in combination with the novel closing mechanism and extended jaw length differentiates the novel device from other available EBVS systems. This might offer a reduction of the overall procedure time, which should be further evaluated in a clinical study.

Background: Sacroiliac (SI) joint pain is an under diagnosed source of low back pain due in part to lack of visible pathology on radiographs and symptoms mimicking other back-related disorders. Open SI joint fusion has been performed since the 1920s. This technique has fallen out of favor with the introduction of minimally invasive options. To date there has been no direct comparison between open and MIS SI joint fusion.

Methods: We conducted a multi-center, retrospective comparative cohort study of patients who underwent SI joint fusion using either an open surgical (OS) technique using a combination of screws and cages or a minimally invasive surgical (MIS) technique with a series of titanium plasma spray (TPS) coated triangular implants. Operative measures including surgical operating time, length of hospitalization and estimated blood loss (EBL) were collected along with demographics and medical history, surgical complications, and 12- and 24-month pain scores. Improvements in pain were compared after matching for age and gender and controlling for a history of lumbar spine fusion using repeated measures analysis of variance.

Results: Data were available for 263 patients treated by 7 surgeons; 149 patients treated with OS and 114 treated with MIS SI joint fusion. Compared to OS patients, MIS patients were on average 10 years older (mean age 57 vs. 46) and 69% of all patients were female. MIS operative measures of EBL, operating time and length of hospitalization were significantly lower than open surgery (p < 0.001). Pain relief, measured as change from baseline to 12 months in VAS pain rating, was 3.5 points lower in the MIS vs. OS group (-6.2 vs. -2.7 points, p < 0.001). When matched for age, gender and a history of prior lumbar spinal fusion, postoperative pain scores were on average 3.0 points (95% CI 2.1 - 4.0) lower in MIS vs. OS (rANOVA p < 0.001).

Conclusions: In this multi-center comparative study, patients who underwent either OS or MIS SI joint fusion showed postoperative improvements in pain score. Compared to OS patients, patients who underwent MIS SI joint fusion had significantly greater pain relief and more favorable perioperative surgical measures.

Background: Hysterectomy dates back to 120BC and is the second most commonly performed gynecological surgery in the world. Cosmetic demands and the necessity of rapid return to work have contributed to the minimally invasive laparoscopic approach for hysterectomy. The majority of reports describe the use of three or four incisions to perform the surgery (two or three for manipulation and one for optics).

Methods: This work describes our experience with using only two ports for 11 patients who underwent video-laparoscopic hysterectomy surgery. One port was used for the optical system, and the second was used for manipulation. Early and late surgery complications, as well as the time to return to work and daily activities, were assessed.

Results: The mean age of the patients was 41.4 years old (range 16 to 52 years) and the mean uterine weight was 133.54 g, ranging from 35 g and 291 g. The operative time ranged from 30 to 60 minutes (average 46.4 minutes) and the hospital stay ranged between 24 and 48 hrs. No intraoperative complications occurred, and no early or late postoperative complications were recorded. Patients reported minimal pain during the first 24-48 hrs in the hospital. Patients returned to their daily activities within seven days after surgery. Clinical care follow-up continued until the 40th postoperative day.

Conclusion: The laparoscopic hysterectomy technique with a single port for manipulation is a feasible procedure when the uterine weight is not greater than 400 mg with little postoperative pain. The patients had an early return-to-work and daily activities and a better cosmetic outcome. These preliminary data led us to make the one-operative port laparoscopic hysterectomy the procedure of choice for patients with a low uterine weight.

Background: Sacroiliac joint (SI) pain is an often-overlooked cause of low back pain due, in part, to lack of specific findings on radiographs and symptoms mimicking other back-related disorders. We report our experience with minimally invasive (MIS) SI joint arthrodesis using a series of triangular, titanium plasma spray (TPS) coated implants in patients refractory to conservative care.

Methods: We report outcomes from 18 patients with 12 months of postoperative follow-up.Demographics, complications, and clinical outcomes using visual analog scale (VAS) for pain, Oswestry Disability Index (ODI) for back function and SF-12 for quality of life were collected preoperatively and at 3, 6 and 12 months post-operatively.

Results: Mean age was 64 years and 67% of patients were female. There were no intraoperative complications and one explant at three months for malposition.All patient-reported outcomes showed both clinically and statistically significant improvement at 12 months (p < 0.001 for each of the following): VAS improved by 6.6 points, ODI scores improved by -37.5 points. One year SF-12 physical and mental component (PCS, MCS) scores approximated population normal scores for both physical and mental functioning. Patient satisfaction with outcomes was high at 95%; 89% said would have the same surgery again.

Conclusions: MIS SI joint fusion using a series of triangular porous TPS coated titanium implants is a safe and effective procedure for patients with SI joint disorders who have failed conservative care.

Background: Zone 2 flexor tendon injuries still represent a challenging problem to hand surgeons despite the well developed surgical techniques and suture materials. Meticulous surgical repair with atraumatic handling of the severed tendon stumps and minimal damage to the tendon sheath are particularly important to prevent postoperative adhesions and ruptures in this area.In zone 2 flexor tendon injuries proximal to the vinculas, the cut ends of the flexor tendons retract to the palm with muscle contraction. To retrieve the severed proximal flexor tendon under tendon sheath and pulley system is very difficult without damaging these structures. Many techniques are described in the literature for the delivery of the retracted proximal tendon stump to the repair site.

Methods: In this report we would like to present a simple and relatively atraumatic technique that facilitates passing of the retracted flexor tendon through the pulleys in zone 2. We sutured the proximal tendon stump at the distal palmar crease with 3-0 polypropylene suture and used a 14 gauge plastic feeding tube, acting like a conduit for the passage of straightened needle to the finger.

Results: We have used this technique 21 times without any complication in our clinic. We have not seen any suture breakage during the passage or needle breakage due to the bending of the needle.

Conclusions: We have found this technique is very simple and very effective in retrieving the retracted tendon stump without causing undue damage to the tendon stump or tendon sheath.