Single-access transumbilical laparoscopic appendectomy using curved reusable instruments: an initial report of three cases.

Introduction: The continuous evolution of laparoscopic surgery and the ambition of better cosmetic results raise the need for less invasive procedures. The umbilicus represents a natural scar and constitutes a wellhealing site of access to the peritoneal cavity. Single-access Transumbilical Laparoscopy (SATL) is gaining popularity and can be an alternative surgical treatment for acute appendicitis. We report three cases of SATL appendectomy using curved reusable instruments.Patients and methods: Three female patients, wanting minimal scarring (mean age - 30 years) were admitted to our hospital in April 2015 with acute abdominal pain in the right iliac area. A SATL appendectomy was performed using a standard 11-mm reusable trocar for a 10-mm, 30°- angled, rigid scope and curved reusable instruments according to DAPRI (Karl Storz-Endoskope, Tuttlingen, Germany) placed transumbilically.Results: Neither a conversion to open surgery nor an insertion of extraumbilical trocars was necessary. The mean operative time was 101.6 +/- 24.66 minutes and the mean blood loss 6.66 +/- 11.54 mL. The mean scar length was 16.66 +/- 0.57 mm. No intraoperative complications were registered and the use of minimal pain killers allowed the discharge after 2 or maximum 4 days. After three months of follow-up no late complications occurred and the umbilical scar was not visible.Conclusion: In young and scarless-demanding females with acute appendicitis SATL appendectomy can be performed safely and offers the possibility of surgical treatment without a visible scar

Conventional vs. Laparoscopic Appendectomy in Emergency Patients. Is There a Better Approach?

Introduction: Surgical treatment of acute appendicitis is relatively easy with a minimally invasive approach. Laparoscopy produces a very good image; applies less trauma, has better cosmetics and patients recover more quickly. However, its routine use requires prepared laparoscopic sets, trained personnel and specific organization. The main difficulties of both methods are associated with atypical anatomical locations and complicated forms of the disease.Aim: The objective of the study is to compare the reasons influencing the decision to choose a laparoscopic or a conventional approach for appendectomy. Surgeries performed in the span of four years in II-nd Surgery, Hospital Alexandrovska (2012-2016) were evaluated.Materials and Methods: The study covered 67 patients with acute appendicitis. Of those 8 (11.9%) were operated on with a laparoscopic approach . The average age was 27.4 years. There were 23 men (34.3%) and 44 women (65.7%). The average conventional intervention duration was 70 minutes, while in the laparoscopic procedure it was 55 minutes (

Optimizing the Learning Curve in Laparoscopic Colorectal Surgery

Introduction: In the recent decades, the surgical treatment of colorectal neoplasms is further developed with a minimally invasive approach, following the complex approach, modern guidelines and classic oncological principles. Any conventional operation can be performed via laparoscopy and in addition to that it produces a better image of the pelvis. Thus, a high-quality surgery, with a maximal sphincter conservation, minimal blood loss and quicker recovery of the patients can be carried out.Aim: The aim of this study was to analyze factors influencing the period of gaining experience with laparoscopic colorectal resections. We evaluated this surgery performed in the Second Surgery at the „Alexandrovska` Hospital (March, 2013-Februrary, 2016) for a period of three years.Materials and Methods: 317 patients with colonic and rectal neoplasms were operated on. Their average age was 61.4 and the gender distribution was - 172 males (54.3%) and 145 females (45.7%). Laparoscopic approach was planned in 37 (11.7%) of them. The following factors were taken into consideration: location of the tumor, the need to use automatic devices, duration of the surgery, etc. The compared indicators, related to decision making for laparoscopic approach, are the technique used and the obtained result, the duration of the intervention, financial resources and the number of conversions.Results: There were 5 are rectal amputations (13.5%), 14 anterior resection (37.8%) and two intersphincteric resections with coloanal anastomosis (5.4%), 6 (16.2%) right hemicolectomies, 5 left colectomies (13.5%) and three sigma resections (8.1%). The average postoperative stay reported was 6.2 days. The mean operative time was 212 minutes. A steady tendency to reduce it was observed (from 330 to 120 min.). Due to the advanced process, conversion was performed in 5 cases (13.5%).Conclusion: The use of automatic stapling devices and high-energy hemostatic devices predetermines the higher cost of the laparoscopic surgery. It gives the advantages of less postoperative pain and shortened hospitalization. The longer training curve depends on resource availability and personal technical skills. This use of this metehod gives the necessary advantage to patients without oncological safety compromise

Visualization of atherosclerosis as detected by coronary artery calcium and carotid intima-media thickness reveals significant atherosclerosis in a cross-sectional study of psoriasis patients in a tertiary care center

BACKGROUND: Psoriasis is a chronic inflammatory disease of the skin and joints that may also have systemic inflammatory effects, including the development of cardiovascular disease (CVD). Multiple epidemiologic studies have demonstrated increased rates of CVD in psoriasis patients, although a causal link has not been established. A growing body of evidence suggests that sub-clinical systemic inflammation may develop in psoriasis patients, even from a young age. We aimed to evaluate the prevalence of atherosclerosis and identify specific clinical risk factors associated with early vascular inflammation. METHODS: We conducted a cross-sectional study of a tertiary care cohort of psoriasis patients using coronary artery calcium (CAC) score and carotid intima-media thickness (CIMT) to detect atherosclerosis, along with high sensitivity C-reactive protein (hsCRP) to measure inflammation. Psoriasis patients and controls were recruited from our tertiary care dermatology clinic. Presence of atherosclerosis was defined using validated numeric values within CAC and CIMT imaging. Descriptive data comparing groups was analyzed using Welch’s t test and Pearson Chi square tests. Logistic regression was used to analyze clinical factors associated with atherosclerosis, and linear regression to evaluate the relationship between psoriasis and hsCRP. RESULTS: 296 patients were enrolled, with 283 (207 psoriatic and 76 controls) having all data for the hsCRP and atherosclerosis analysis. Atherosclerosis was found in 67.6 % of psoriasis subjects versus 52.6 % of controls; Psoriasis patients were found to have a 2.67-fold higher odds of having atherosclerosis compared to controls [95 % CI (1.2, 5.92); p = 0.016], after adjusting for age, gender, race, BMI, smoking, HDL and hsCRP. In addition, a non-significant trend was found between HsCRP and psoriasis severity, as measured by PASI, PGA, or BSA, again after adjusting for confounders. CONCLUSIONS: A tertiary care cohort of psoriasis patients have a high prevalence of early atherosclerosis, increased hsCRP, and psoriasis remains a risk factor for the presence of atherosclerosis even after adjustment of key confounding clinical factors. Psoriasis may contribute to an accelerated systemic inflammatory cascade resulting in increased risk of CVD and CV events. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s12967-016-0947-0) contains supplementary material, which is available to authorized users

MOESM1 of Visualization of atherosclerosis as detected by coronary artery calcium and carotid intima-media thickness reveals significant atherosclerosis in a cross-sectional study of psoriasis patients in a tertiary care center

Additional file 1. Additional supplementary tables

International eDelphi Study to Reach Consensus on the Methotrexate Dosing Regimen in Patients With Psoriasis

IMPORTANCE: A clear dosing regimen for methotrexate in psoriasis is lacking, and this might lead to a suboptimal treatment. Because methotrexate is affordable and globally available, a uniform dosing regimen could potentially optimize the treatment of patients with psoriasis worldwide. OBJECTIVE: To reach international consensus among psoriasis experts on a uniform dosing regimen for treatment with methotrexate in adult and pediatric patients with psoriasis and identify potential future research topics. DESIGN, SETTING, AND PARTICIPANTS: Between September 2020 and March 2021, a survey study with a modified eDelphi procedure that was developed and distributed by the Amsterdam University Medical Center and completed by 180 participants worldwide (55 [30.6%] resided in non-Western countries) was conducted in 3 rounds. The proposals on which no consensus was reached were discussed in a conference meeting (June 2021). Participants voted on 21 proposals with a 9-point scale (1-3 disagree, 4-6 neither agree nor disagree, 7-9 agree) and were recruited through the Skin Inflammation and Psoriasis International Network and European Academy of Dermatology and Venereology in June 2020. Apart from being a dermatologist/dermatology resident, there were no specific criteria for participation in the survey. The participants worked mainly at a university hospital (97 [53.9%]) and were experienced in treating patients with psoriasis with methotrexate (163 [91.6%] had more than 10 years of experience). MAIN OUTCOMES AND MEASURES: In a survey with eDelphi procedure, we tried to reach consensus on 21 proposals. Consensus was defined as less than 15% voting disagree (1-3). For the consensus meeting, consensus was defined as less than 30% voting disagree. RESULTS: Of 251 participants, 180 (71.7%) completed all 3 survey rounds, and 58 participants (23.1%) joined the conference meeting. Consensus was achieved on 11 proposals in round 1, 3 proposals in round 2, and 2 proposals in round 3. In the consensus meeting, consensus was achieved on 4 proposals. More research is needed, especially for the proposals on folic acid and the dosing of methotrexate for treating subpopulations such as children and vulnerable patients. CONCLUSIONS AND RELEVANCE: In this eDelphi consensus study, consensus was reached on 20 of 21 proposals involving methotrexate dosing in patients with psoriasis. This consensus may potentially be used to harmonize the treatment with methotrexate in patients with psoriasis