Annals of surgical innovation and research最新文献

Background: The history of surgical reconstruction of the left ventricle after an anterior myocardial infarction shows an evolution of techniques which tend to a more and more physiologic restoration of ventricular shape and volume, with increasing attention to the orientation of myocardial fibers.

Methods: We set a new surgical procedure for endoventricular patch reconstruction technique with the aim to rebuild a physiologic shape and volume of the left ventricle caring about realignment of myocardial fibers orientation. Peculiarities of this reconstruction are the shape of the patch (reduction of minor axis compared with currently used oval-shaped patch) and the asymmetrical way of suturing it inside the ventricle.

Results: We present a detailed description of operative steps of this procedure, and we add some relevant surgical hints to clarify its peculiarities. Most of the patients operated on with this technique showed the original renewal of apical rotation and left ventricular torsion as specific index of the restoration of physiologic fiber orientation: we report an exemplary case of at-sight recovery of apical rotation in the operating room.

Conclusion: This technique can represent a reproducible new way to realign myocardial fibers in a near-normal setting, improving the physiological restoration of ischemically injured left ventricle. It could be also the basis to reconsider surgical treatment for heart failure.

Background: The treatment of forearm fracture-nonunions continues to represent a therapeutic challenge, and reported outcomes are moderate at best. Limiting aspects of this particular anatomic location include the relation between restoration of shaft length with the anatomy and long-term functional outcome of adjacent joints, as well as the risk of elbow and wrist stiffness related to prolonged immobilization. The present study was designed to assess the outcome of autologous bone grafting with compression plating and early functional rehabilitation in patients with forearm fracture non-unions.

Methods: Prospective follow-up study in 31 consecutive patients presenting with non-unions of the forearm diaphysis (radius, n = 11; ulna, n = 9; both bones, n = 11). Surgical revision was performed by restoring anatomic forearm length by autologous bone grafting of the resected non-union from the iliac crest and compression plating using a 3.5 mm dynamic compression plate (DCP) or limited-contact DCP (LC-DCP). The main outcome parameters consisted of radiographic bony union and functional outcome, as determined by the criteria defined by Harald Tscherne in 1978. Patients were routinely followed on a short term between 6 weeks to 6 months, with an average long-term follow-up of 3.6 years (range 2 to 6 years).

Results: Radiographically, a bony union was achieved in 30/31 patients within a mean time of 3.5 months of revision surgery (range 2 to 5 months). Clinically, 29/31 patients showed a good functional outcome, according to the Tscherne criteria, and 26/31 patients were able to resume their previous work. Two postoperative infections occurred, and one patient developed a persistent infected nonunion. No case of postoperative failure of fixation was seen in the entire cohort.

Conclusion: Revision osteosynthesis of forearm nonunions by autologous iliac crest bone grafting and compression plating represents a safe and efficacious modality for the treatment of these challenging conditions.

Small bowel contractility may be more prominent in obese subjects, such that there is enhanced nutrient absorption and hunger stimulation. However, there is little evidence to support this. This study examined in vitro small bowel contractility in obese patients versus non-obese patients. Samples of histologically normal small bowel were obtained at laparoscopic Roux-en-Y gastric bypass from obese patients. Control specimens were taken from non-obese patients undergoing small bowel resection for benign disease or formation of an ileal pouch-anal anastomosis. Samples were transported in a pre-oxygenated Krebs solution. Microdissected circular smooth muscle strips were suspended under 1 g of tension in organ baths containing Krebs solution oxygenated with 95% O2/5% CO2 at 37 degrees C. Contractile activity was recorded using isometric transducers at baseline and in response to receptor-mediated contractility using prostaglandin F2a, a nitric oxide donor and substance P under both equivocal and non-adrenergic, non-cholinergic conditions (guanethidine and atropine). Following equilibration, the initial response to the cholinergic agonist carbachol (0.1 mmol/L) was significantly increased in the obese group (n = 63) versus the lean group (n = 61) with a mean maximum response: weight ratio of 4.58 +/- 0.89 vs 3.53 +/- 0.74; (p = 0.032). Following washout and re-calibration, cumulative application of substance P and prostaglandin F2a produced concentration-dependent contractions of human small bowel smooth muscle strips. Contractile responses of obese small bowel under equivocal conditions were significantly increased compared with non-obese small bowel (p < 0.05 for all agonists). However, no significant differences were shown between the groups when the experiments were performed under NANC conditions. There were no significant differences found between the groups when challenged with nitric oxide, under either equivocal or NANC conditions. Stimulated human small bowel contractility is increased in obese patients suggesting faster enteric emptying and more rapid intestinal transit. This may translate into enhanced appetite and reduced satiety.

Gastro-intestinal (G-I) motility is impaired ("paralytic ileus") after abdominal surgery. Premature feeding attempts delay recovery by inducing "feeding intolerance," especially abdominal distention that compromises respiration. Controlled studies (e.g., from Sloan-Kettering Memorial Hospital) have lead to recommendations that patients not be fed soon after major abdominal surgery to avoid this complication. We postulate that when total fluid inflow of feedings, digestive secretions, and swallowed air outstrip peristaltic outflow from the feeding site, fluid accumulates. This localized stagnation triggers G-I vagal reflexes that further slow the already sluggish gut, leading to generalized abdominal distention. Similarly, vagal cardiovascular reflexes in susceptible subjects could account for the 1:1,000 incidence of unexplained bowel necrosis reported with enteral feeding. We re-evaluated our data, which supports this postulated mechanism for the induction of "feeding intolerance." We had focused our efforts on postoperative enteral nutrition, with the largest reported series of immediate feeding of at least 100 kcal/hour after major surgery. We found that this complication can be avoided consistently by monitoring inflow versus peristaltic outflow, immediately removing any potential excess from the feeding site. We fed intraduodenally immediately following "open" surgery for 31 colectomy and 160 consecutive cholecystectomy patients. The duodenum was aspirated simultaneously just proximal to the feeding site, efficiently removing all swallowed air and excess feedings. To salvage digestive secretions, the degassed aspirate was re-introduced manually (and later automatically) via a separate feeding channel. Hourly assays were performed for nitrogen balance, serum amino acids, and for the presence of removed feedings in the aspirate. The colectomy patients had X-ray motility studies initiated 5-17 hours after surgery. Clinically normal motility and absorption resumed within two hours. Fed BaSO4 traversed secure anastomoses, to exit in bowel movements within 24-48 hours of colectomy. All patients were in positive protein balance within 2-24 hours, with elevated serum amino acids levels and without adverse G-I effects. Limiting inflow to match peristaltic outflow from the feeding site consistently prevented "feeding intolerance." These patients received immediate full enteral nutrition, with the most rapid resolution of postoperative paralytic ileus, to date.

Background: Positron emission tomography (PET) identifies cancer deposits by detecting sites of gamma emissions that are released from radioactively labeled molecules targeting tumor to formulate a PET image. Correlating preoperative PET scans with intraoperative findings remains a challenge. We investigated whether high-energy gamma emissions detected by a novel hand-held PET probe would detect tumors and offer a real-time method to localize tumor intraoperatively. Furthermore, we investigated the novel beta probe, which detects emissions at a shorter range than gamma emissions, making them undetectable by PET scanners, but potentially valuable for close range intraoperative detection of tumor deposits.

Methods: Six-to-eight-week-old athymic mice were injected with one of four possible tumor cell lines: gastric, pancreas, squamous cell and breast cancer. After tumors reached at least 1 cm in size, they were euthanized and imaged with a micro-PET imager. Hand-held gamma and beta probes were then used in vivo and ex vivo to measure high-energy gamma and beta emissions.

Results: The portable PET probes detected high-energy gamma and beta emissions from all tumors evaluated. These emissions were reproducible and we established that beta emissions correlate with high-energy gamma emissions and conventional PET scans. There was a strong positive correlation (R = 0.8) between gamma and beta counts. Beta emission showed a stronger correlation than gamma emission with overall tissue radioactivity.

Conclusion: This study is the first to demonstrate that gamma emission detected by conventional PET imaging correlates with beta emissions. This study shows that compared to detection of gamma emissions, beta counts may offer superior real-time localization of tumor deposits. Intraoperative portable PET probe may become a useful way to exploit tumor biology and PET technology to guide real-time tissue characterization during surgery.

Introduction: Gastro-oesophageal reflux disease (GORD) is a common problem in the Western countries, and the interest in the minimal access surgical approaches to treat GORD is increasing. In this study, we would like to discuss the presentations and management of complications we encountered after Laparoscopic Nissen's fundoplication in our District General NHS Hospital. The aim is to recognise these complications at the earliest stage for effective management to minimise the morbidity and mortality.

Methods: 301 patients underwent laparoscopic treatment for GORD by a single consultant surgeon in our NHS Trust from September 1999. The data was prospectively collected and entered into a database. The data was retrospectively analysed for presentations for complications and their management.

Results: Surgery was completed laparoscopically in all patients, except in five, where the operation was technically difficult due to pre-existing conditions. The complications we encountered during surgery and follow-up period were major intra-operative bleeding (n = 1, 0.33%), severe post-operative nausea and vomiting (n = 1, 0.33%), wound infection (n = 3, 1%), port-site herniation (n = 1, 0.33%), wrap-migration (n = 2, 0.66%), wrap-ischaemia (n = 1, 0.33%), recurrent regurgitation (n = 4, 1.32%), recurrent heartburn (n = 29, 9.63%), tension pneumothorax (n = 2, 0.66%), surgical emphysema (n = 8, 2.66%), and port-site pain (n = 4, 1.33%).

Conclusion: Minimal access approach to treat GORD has presented with some specific and unique complications. It is important to recognise these complications at the earliest possible stage as some of these patients may present in an acute setting requiring emergency surgery. All members of the department, and not just the members of the specialised team, should be aware about these complications to minimise the morbidity and mortality.

Objective: The aim of this study is to clinically test the efficacy of author's approach of suture ligation and mucopexy for patients having symptomatic and prolapsing hemorrhoids.

Materials and methods: 616 patients (255 females) complaining of symptoms of hemorrhoids were included in the study. The hemorrhoids were suture ligated with an absorbable suture material under vision. Operating time, postoperative complications, time to return to work, and outcome of the procedure were analyzed. Follow-up was planned following discharge after 1 month, 6 months and after at least 1 year. Patient satisfaction was also assessed.

Results: The mean procedure time was 8 +/- 0 minutes (range, 6-15 minutes), and the total admission period was 12 +/- 4 Hours. Perianal thrombosis and skin tags were the commonest post-operative complications. The mean total analgesic dose and duration of pain control using analgesics was 19 +/- 4 tablets, and 9 +/- 3 days respectively.The postoperative follow up after 4 weeks revealed therapeutic success in 589 patients (95.6%), who presented with hemorrhoidal bleeding. Prolapse was no longer observed in 98% of patients and 96% patients experienced no pain after defecation. 93% patients completed the one-year follow-up and 89 percent of them were asymptomatic. The patient satisfaction scoring was 8.2% on visual analogue scale.

Conclusion: Suture ligation and mucopexy of hemorrhoids is an easy-to-perform technique that is well accepted by patients and has good results for prolapsing hemorrhoids.

Background: Scapular hypoplasia, elevation, and rotation (SHEAR) deformity and posterior subluxation of the humeral head are common tertiary sequelae of obstetric brachial plexus injuries (OBPI). Interpretations of images from bilateral computed tomography (CT) scans of the upper extremities are critical to the diagnosis and treatment plan for patients with these bony deformities resulting from OBPI.

Methods: We conducted a retrospective study to investigate the accuracy of radiologic reports in the diagnosis of SHEAR or posterior subluxation of the humeral head in OBPI patients. CT studies from 43 consecutive patients over a 33-month period were used in the study. For each patient, we compared the results from the radiologic report to those from a clinical examination given by the attending surgeon and to measurements taken from the CT studies by biomedical researchers.

Results: A comparison of SHEAR measured from the 3-D CT images to the diagnoses from the radiologists, revealed that only 40% of the radiological reports were accurate. However, there was a direct correlation between the use of the 3-D CT images and an accurate SHEAR diagnosis by the radiologists (p < 0.0001). When posterior subluxation was measured in the affected and contralateral shoulders, 93% of the patients that had greater than a 10% difference between the two shoulders did not have their deformity diagnosed. The radiological reports diagnosed 17% of these patients with a 'normal' shoulder. Only 5% of the reports were complete, accurately diagnosing SHEAR in addition to posterior subluxation.

Conclusion: Due to the low incidence rate of OBPI, many radiologists may be unfamiliar with the sequelae of these injuries. It is therefore critical that radiologists are made aware of the importance of an accurate measurement and diagnosis of the SHEAR deformity. Due to their lack of completeness, the radiological reports in this study did not significantly contribute to the clinical care of the patients. In order for OBPI patients to receive the highest standard of care, the final diagnosis from their radiological imaging should be deferred to a brachial plexus specialist who is experienced with these types of injuries.

Background: Esophagogastric fistula following an esophagectomy for cancer is very common. One of the most important factors that leads to its development is gastric ischemia. We hypothesize that laparoscopic gastric devascularization and partial transection is a safe operation that will enhance the vascular flow of the fundus of the stomach.

Method: Our study included eight pigs. Each animal had two operations. In the first one, a laparoscopic gastric devascularization and mobilization took place. Vascular flow was measured previous to the procedure and immediately after it with a laser doppler (endoscopic probe). After three weeks, a second operation took place. We re-measured the vascular flow and sent a sample of gastric fundus for histopathologic evaluation.

Results: The gastric fundus showed signs of neovascularization after both macroscopic and microscopic evaluation. These findings correlated with laser doppler measurements.

Conclusion: Laparoscopic gastric devascularization and partial transection is a safe procedure that increases the vascular flow of the stomach in a three week period. This finding can have a positive impact in terms of decreasing fistula formation.

Background: Epidural fibrosis is regarded as a cause of failed back surgery syndrome (FBSS) when excessive adhesional/fibrotic scar tissue causes compression, pain or discomfort by tethering of nerve tissue to the surrounding muscle or bone. Fibrosis inhibitors could therefore increase the success rate of spinal surgery and decrease the need for reoperations. In recent years, bio-resorbable gels or films for the prevention of peridural fibrosis and post-operative adhesions have been developed that look clinically promising. This included a 100% synthetic, sterile, absorbable gel combinations of carboxymethylcellulose (CMC) and polyethylene oxide (PEO) used to coat the dura to reduce scarring after discectomy which became available in Europe in 2002. However, given the burden of the problem and unfavorable experience with other types of adhesion-reduction agents, our unit decided to evaluate the safety of CMC/PEO in a large population of patients undergoing spinal microdiscectomy for herniation.

Methods: To determine the safety and assess efficacy of carboxymethylcellulose/polyethylene oxide (CMC/PEO) gel as an anti-adhesion gel, a consecutive series of 396 patients undergoing lumbar discectomy performed by one surgeon had CMC/PEO gel administered at the end of surgery. The patients were followed up in accordance with standard clinical practice and records reviewed for side effects, such as skin reactions, general reactions or local fluid collections. Reoperations for recurrent herniation included an evaluation of fibrosis reduction.

Results: No product related complications were observed. Five patients needed reoperations for recurrent herniation. Significant but subjective reduction in fibrosis was observed in these patients.

Conclusion: The findings provide confidence that CMC/PEO gel is well tolerated as an agent to achieve reduction of fibrosis in lumbar disc surgery. Further formal prospective study is recommended in this area of unmet need.