Accessory muscles around the superior radioulnar joint: a morphological study

During anatomical dissections on 36 human elbow joints, we observed the presence of three muscles around the superior radioulnar joint usually neglected by the classical anatomical literature, the lateral tensor muscle of the annular ligament (with an incidence of 16.6%), the medial tensor muscle of the annular ligament (11.1%) and the accessory supinator muscle (16.6%). We could not establish any association between the subject handedness and the sidedness of these aberrant muscles, neither we found a predominance in sidedness or in gender. Furthermore, we did not notice any significant predominance related to the occupation and specifically to heavy labor occupations. On the contrary we found these muscles to be more common in non-laborers, which supports the assumption that these variants constitute rather genetic than epigenetic traits. The knowledge of such anatomical variants facilitate the surgeon operating in the elbow region to better interpret supernumerary muscular bundles in the operative field

Duplicated gallbladder: surgical application and review of the literature

Duplicated gallbladder is a rare congenital anomaly, usually asymptomatic and occurring as incidental radiographic or surgical finding during upper abdomen, liver and extrahepatic biliary tract surgery. We report on a case of two separate gallbladders, one main and one accessory, each one with its own cystic duct. The main cystic duct drained into the common bile duct while the accessory bile duct extruded into the left side of common bile duct just inferior to the main cystic duct termination. Imaging advances such as computerized tomography, intraoperative endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography may aid in the establishment of accurate diagnosis. The anomaly is of great importance because the surgeon may miss the main or the accessory gallbladder and the patient may need to be re-operated in case of cholelithiasis

Humeral septal aperture associated with supracondylar process: a case report and review of the literature

The supracondylar process is usually a beak-like osseous prominence located at the anteromedial aspect of the distal portion of the humerus. It is usually asymptomatic but occasionally may compress underlying structures such as the median or ulnar nerve, the brachial artery or its branches. The term septal aperture defines an oval or round shaped bony defect of the septum that separates the olecranon from the coronoid fossa of the humerus. It is of significance for surgeons because it may alter the fracture pattern at the region and thus their management. We present a rare case of coexistence of supracondylar process and septal aperture in a macerated left humerus. The reported incidence of the supracondylar process alone varies from 0.28% to 2.78%, while that of the septal aperture from 6.9% to 60%. We have reviewed the literature and emphasized the radiological and surgical significance of the findings

The EUPEMEN (EUropean PErioperative MEdical Networking) Protocol for Bowel Obstruction: recommendations for perioperative care

Mechanical bowel obstruction is a common symptom for admission to emergency services, diagnosed annually in more than 300,000 patients in the States, from whom 51% will undergo emergency laparotomy. This condition is associated with serious morbidity and mortality, but it also causes a high financial burden due to long hospital stay. The EUPEMEN project aims to incorporate the expertise and clinical experience of national clinical specialists into development of perioperative rehabilitation protocols. Providing special recommendations for all aspects of patient perioperative care and the participation of diverse specialists, the EUPEMEN protocol for bowel obstruction, as presented in the current paper, aims to provide faster postoperative recovery and reduce length of hospital stay, postoperative morbidity and mortality rate

Laparoscopic para-aortic lymphadenectomy for metastatic colon cancer in a patient with left-sided inferior vena cava: a case report

Transposition of inferior vena cava, or, left-sided inferior vena cava (LS-IVC) is a rare clinical entity, in which the inferior vena cava ascends along the left side of the abdominal aorta. Literature contains mainly clinical case reports. Although it is usually not associated with clinical symptomatology, this anomaly should be detected during preoperative planning to avoid iatrogenic injuries intraoperatively. We present a case of left-sided inferior vena cava encountered during laparoscopic lymphadenectomy in a 45-year-old man with previous laparoscopic hemicolectomy due to colon adenocarcinoma. Preoperative CT abdomen revealed the left-sided location of infrarenal IVC and laparoscopic trans-peritoneal aortic lymphadenectomy was decided. Intraoperatively, transposition of inferior vena cava was confirmed in accordance with the CT findings. Resection of lymph node block was conducted with no complications and with minimal blood loss. The postoperative course was uneventful, and the patient was discharged from the hospital the day following surgery. In conclusion, transposition of the inferior vena cava, although rare, constitutes an anatomical variant that should be identified preoperatively to decrease intraoperative risks. Several anatomical variants have been associated with left-sided inferior vena cava

High origin of a testicular artery: a case report and review of the literature

<p>Abstract</p> <p>Introduction</p> <p>Although variations in the origin of the testicular artery are not uncommon, few reports about a high origin from the abdominal aorta exist in the literature. We discuss the case of a high origin of the testicular artery, its embryology, classification systems, and its clinical significance.</p> <p>Case presentation</p> <p>We report a very rare case of high origin of the left testicular artery in a 68-year-old Caucasian male cadaver. The artery originated from the anterolateral aspect of the abdominal aorta, 2 cm cranially to the ipsilateral renal artery. Approximately 1 cm after its origin, it branched off into the inferior suprarenal artery. During its course, the artery crossed anterior to the left renal artery.</p> <p>Conclusions</p> <p>A knowledge of the variant origin of the testicular artery is important during renal and testicular surgery. The origin and course must be carefully identified in order to preserve normal blood circulation and prevent testicular atrophy. A reduction in gonadal blood flow may lead to varicocele under circumstances. A knowledge of this variant anatomy may be of interest to radiologists and helpful in avoiding diagnostic errors.</p

Evaluation of Excess Significance Bias in Animal Studies of Neurological Diseases

Animal studies generate valuable hypotheses that lead to the conduct of preventive or therapeutic clinical trials. We assessed whether there is evidence for excess statistical significance in results of animal studies on neurological disorders, suggesting biases. We used data from meta-analyses of interventions deposited in Collaborative Approach to Meta-Analysis and Review of Animal Data in Experimental Studies (CAMARADES). The number of observed studies with statistically significant results (O) was compared with the expected number (E), based on the statistical power of each study under different assumptions for the plausible effect size. We assessed 4,445 datasets synthesized in 160 meta-analyses on Alzheimer disease (n = 2), experimental autoimmune encephalomyelitis (n = 34), focal ischemia (n = 16), intracerebral hemorrhage (n = 61), Parkinson disease (n = 45), and spinal cord injury (n = 2). 112 meta-analyses (70%) found nominally (p≤0.05) statistically significant summary fixed effects. Assuming the effect size in the most precise study to be a plausible effect, 919 out of 4,445 nominally significant results were expected versus 1,719 observed (p<10-9). Excess significance was present across all neurological disorders, in all subgroups defined by methodological characteristics, and also according to alternative plausible effects. Asymmetry tests also showed evidence of small-study effects in 74 (46%) meta-analyses. Significantly effective interventions with more than 500 animals, and no hints of bias were seen in eight (5%) meta-analyses. Overall, there are too many animal studies with statistically significant results in the literature of neurological disorders. This observation suggests strong biases, with selective analysis and outcome reporting biases being plausible explanations, and provides novel evidence on how these biases might influence the whole research domain of neurological animal literature. © 2013 Tsilidis et al

Intra-operative gallbladder scoring predicts conversion of laparoscopic to open cholecystectomy: a WSES prospective collaborative study

Abstract Introduction Laparoscopic cholecystectomy, the gold-standard approach for cholecystectomy, has surprisingly variable outcomes and conversion rates. Only recently has operative grading been reported to define disease severity and few have been validated. This multicentre, multinational study assessed an operative scoring system to assess its ability to predict the need for conversion from laparoscopic to open cholecystectomy. Methods A prospective, web-based, ethically approved study was established by WSES with a 10-point gallbladder operative scoring system; enrolling patients undergoing elective or emergency laparoscopic cholecystectomy between January 2016 and December 2017. Gallbladder surgery was considered easy if the G10 score < 2, moderate (2 ≦ 4), difficult (5 ≦ 7) and extreme (8 ≦ 10). Demographics about the patients, surgeons and operative procedures, use of cholangiography and conversion rates were recorded. Results Five hundred four patients, mean age 53.5 (range 18–89), were enrolled by 55 surgeons in 16 countries. Surgery was performed by consultants in 70% and was elective in (56%) with a mean operative time of 78.7 min (range 15-400). The mean G10 score was 3.21, with 22% deemed to have difficult or extreme surgical gallbladders, and 71/504 patients were converted. The G10 score was 2.98 in those completed laparoscopically and 4.65 in the 71/504 (14%) converted. (p <  0.0001; AUC 0.772 (CI 0.719–0.825). The optimal cut-off point of 0.067 (score of 3) was identified in G10 vs conversion to open cholecystectomy. Conversion occurred in 33% of patients with G10 scores of ≥ 5. The four variables statistically predictive of conversion were GB appearance—completely buried GB, impacted stone, bile or pus outside GB and fistula. Conclusion The G10 operative scores provide simple grading of operative cholecystectomy and are predictive of the need to convert to open cholecystectomy. Broader adaptation and validation may provide a benchmark to understand and improve care and afford more standardisation in global comparisons of care for cholecystectomy

Prospective, observational, multicenter study on minimally invasive gastrectomy for gastric cancer: robotic, laparoscopic and open surgery compared on operative and follow-up outcomes - IMIGASTRIC II study protocol: IMIGASTRIC II

Background:Several meta-analyses have tried to defi ne the role of minimally invasive approaches.&nbsp;However, further evidence to get a wider spread of these methods is necessary. Current&nbsp;studies describe minimally invasive surgery as a possible alternative to open surgery&nbsp;but deserving further clarifi cation. However, despite the increasing interest, the&nbsp;difficulty of planning prospective studies of adequate size accounts for the low level of&nbsp;evidence, which is mostly based on retrospective experiences.A multi-institutional prospective study allows the collection of an impressive amount&nbsp;of data to investigate various aspects of minimally invasive procedures with the&nbsp;opportunity of developing several subgroup analyses.A prospective data collection with high methodological quality on minimally invasive&nbsp;and open gastrectomies can clarify the role of diff erent procedures with the aim to&nbsp;develop specifi c guidelines.Methods and analysis:a multi-institutional prospective database will be established including information on&nbsp;surgical, clinical and oncological features of patients treated for gastric cancer with&nbsp;robotic, laparoscopic or open approaches and subsequent follow-up.The study has been shared by the members of the International study group on&nbsp;Minimally Invasive surgery for GASTRIc Cancer (IMIGASTRIC)The database is designed to be an international electronic submission system and a&nbsp;HIPPA protected real time data repository from high volume gastric cancer centers.Ethics:This study is conducted in compliance with ethical principles originating from the&nbsp;Helsinki Declaration, within the guidelines of Good Clinical Practice and relevantlaws/regulations.Trial registration number:NCT0275108

Colorectal neoplastic emergencies in immunocompromised patients: preliminary result from the Web-based International Register of Emergency Surgery and Trauma (WIRES-T trial)

Association of advanced age, neoplastic disease and immunocompromission (IC) may lead to surgical emergencies. Few data exist about this topic. Present study reports the preliminary data from the WIRES-T trial about patients managed for colorectal neoplastic emergencies in immunocompromised patients. The required data were taken from a prospective observational international register. The study was approved by the Ethical Committee with approval n. 17575; ClinicalTrials.gov Identifier: NCT03643718. 839 patients were collected; 753 (80.7%) with mild-moderate IC and 86 (10.3%) with severe. Median age was 71.9 years and 73 years, respectively, in the two groups. The causes of mild-moderate IC were reported such malignancy (753-100%), diabetes (103-13.7%), malnutrition (26-3.5%) and uremia (1-0.1%), while severe IC causes were steroids treatment (14-16.3%); neutropenia (7-8.1%), malignancy on chemotherapy (71-82.6%). Preoperative risk classification were reported as follow: mild-moderate: ASA 1-14 (1.9%); ASA 2-202 (26.8%); ASA 3-341 (45.3%); ASA 4-84 (11.2%); ASA 5-7 (0.9%); severe group: ASA 1-1 patient (1.2%); ASA 2-16 patients (18.6%); ASA 3-41 patients (47.7%); ASA 4-19 patients (22.1%); ASA 5-3 patients (3.5%); lastly, ASA score was unavailable for 105 cases (13.9%) in mild-moderate group and in 6 cases (6.9%) in severe group. All the patients enrolled underwent urgent/emergency surgery Damage control approach with open abdomen was adopted in 18 patients. Mortality was 5.1% and 12.8%, respectively, in mild-moderate and severe groups. Long-term survival data: in mild-moderate disease-free survival (median, IQR) is 28 (10-91) and in severe IC, it is 21 (10-94). Overall survival (median, IQR) is 44 (18-99) and 26 (20-90) in mild-moderate and severe, respectively; the same is for post-progression survival (median, IQR) 29 (16-81) and 28, respectively. Univariate and multivariate analyses showed as the only factor influencing mortality in mild-moderate and severe IC is the ASA score. Colorectal neoplastic emergencies in immunocompromised patients are more frequent in elderly. Sigmoid and right colon are the most involved. Emergency surgery is at higher risk of complication and mortality; however, management in dedicated emergency surgery units is necessary to reduce disease burden and to optimize results by combining oncological and acute care principles. This approach may improve outcomes to obtain clinical advantages for patients like those observed in elective scenario. Lastly, damage control approach seems feasible and safe in selected patients