A qualitative study of the development of a multidisciplinary case conference review methodology to reduce involved margins in pelvic exenteration surgery for recurrent rectal cancer

Aim Pelvic exenteration surgery remains the only curative option for recurrent rectal cancer. Microscopically involved surgical margins (R1) are associated with a higher risk of local recurrence and decreased survival. Our study aimed to develop a post hoc multidisciplinary case conference review and investigate its potential for identifying areas for improvement. Method Results Patients who underwent pelvic exenteration surgery for recurrent rectal cancer with R1 resections at a tertiary referral centre between April 2014 and January 2016 were retrospectively reviewed from a prospectively maintained database. Patients with non-rectal cancers or who underwent palliative surgery were excluded. Cases, imaging and histopathology were evaluated by a dedicated panel including colorectal surgeons, an abdominal radiologist and a gastrointestinal pathologist. R1 resections were reported in 32 of 110 pelvic exenterations. Patients with other tumours were excluded and one patient had a palliative resection. Nine male patients with 11 exenterations were included with a median age of 56 years. All patients had positive soft tissue margins, and one patient also had an involved bony margin. Failures were due to (interdisciplinary) communication problems, specific management of tumour biology (multifocality, spiculated tumours), which can lead to radiological undercalling, and inadequate surgical technical planning. In hindsight, surgery would have been withheld from one patient. Conclusion A retrospective multidisciplinary case evaluation of pelvic exenteration patients with involved surgical margins led to a list of recommendations which included the need to plan for wider surgical soft tissue resections and improvement in interdisciplinary communication. Lessons learned may increase clear margin rates in future resections

Reducing wind erosion through agroforestry: a case study using large Eddy simulations

Wind erosion is seen as one of the main risks for modern agriculture in dry and sandy regions. Shelterbelts and agroforestry systems are known for their ability to reduce wind speed and, consequently, wind erosion. The current study considers temperate alley cropping agroforestry systems, where multiple tree strips (shelterbelts) are interleaved with either annual rotating crops or perennial grassland. The aim was to quantify the potential wind erosion reduction by alley cropping agroforestry systems and the effect of design decisions for a case study in Germany. By combining wind measurements and Large Eddy Simulations, the wind speed and potential wind erosion inside an agroforestry system were estimated. Our model simulations result in an average reduction in wind speed between 17% and 67%, and a reduction of average potential wind erosion between 24% and 97%. The most optimal reduction of the average potential wind erosion was larger than 92% for tree strips orientated perpendicular to the main wind direction, whereas for a diagonal orientation of the tree strips to the main wind direction we found an average reduction of 86%. Parallel orientated tree strips reduce wind erosion on average by less than 35%. Tree strips planted with ≤48 m distance provide a strong and constant reduction of wind erosion, even for tree strips of 2 m height the average reduction was 86%, when the tree strips were orientated optimal to the dominant wind direction. Our model simulations showed that alley cropping agroforestry systems in a temperate climate have a large potential to reduce wind erosion by more than 80% when the system is well-designed and managed

Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study

Objective To identify an optimal imaging strategy for the accurate detection of urgent conditions in patients with acute abdominal pain

Perivascular epithelioid cell tumor of the retroperitoneum in a young woman resulting in an abdominal chyloma

Perivascular epithelioid cell tumor (PEComa) is an extremely rare neoplasm which appears to have predominancy for young, frequently Asian, women. The neoplasm is composed chiefly of HMB-45-positive epithelioid cells with clear to granular cytoplasm and usually showing a perivascular distribution. These tumors have been reported in various organs under a variety of designations. Malignant PEComas exist but are very rare. The difficulty in determining optimal therapy, owing to the sparse literature available, led us to present this case. We report a retroperitoneal PEComa discovered during emergency surgery for abdominal pain in a 28-year-old Asian woman. The postoperative period was complicated by chylous ascites that was initially controlled by a wait-and-see policy with total parenteral nutrition. However, the chyle production gradually increased to more than 4 l per day. The development of a bacterial peritonitis resulted in cessation of production of abdominal fluid permitting normal nutrition without chylous leakage. Effective treatment for this rare complication of PEComa is not yet known; therefore, we have chosen to engage in long-term clinical follow-up

Device-independent, real-time identification of bacterial pathogens with a metal oxide-based olfactory sensor

A novel olfactory method for bacterial species identification using an electronic nose device called the MonoNose was developed. Differential speciation of micro-organisms present in primary cultures of clinical samples could be performed by real-time identification of volatile organic compounds (VOCs) produced during microbial replication. Kinetic measurements show that the dynamic changes in headspace gas composition are orders of magnitude larger than the static differences at the end of fermentation. Eleven different, clinically relevant bacterial species were included in this study. For each of the species, two to eight different strains were used to take intra-species biodiversity into account. A total of 52 different strains were measured in an incubator at 37°C. The results show that the diagnostic specificities varied from 100% for Clostridium difficile to 67% for Enterobacter cloacae with an overall average of 87%. Pathogen identification with a MonoNose can be achieved within 6–8 h of inoculation of the culture broths. The diagnostic specificity can be improved by broth modification to improve the VOC production of the pathogens involved

Metachronous peritoneal metastases in patients with pT4b colon cancer: An international multicenter analysis of intraperitoneal versus retroperitoneal tumor invasion

It was hypothesized that colon cancer with only retroperitoneal invasion is associated with a low risk of peritoneal dissemination. This study aimed to compare the risk of metachronous peritoneal metastases (mPM) between intraperitoneal and retroperitoneal invasion

Abdominal wall paresis as a complication of laparoscopic surgery

Purpose: Abdominal wall nerve injury as a result of trocar placement for laparoscopic surgery is rare. We intend to discuss causes of abdominal wall paresis as well as relevant anatomy. Methods: A review of the nerve supply of the abdominal wall is illustrated with a rare case of a patient presenting with paresis of the internal oblique muscle due to a trocar lesion of the right iliohypogastric nerve after laparoscopic appendectomy. Results: Trocar placement in the upper lateral abdomen can damage the subcostal nerve (Th12), caudal intercostal nerves (Th7-11) and ventral rami of the thoracic nerves (Th7-12). Trocar placement in the lower abdomen can damage the ilioinguinal (L1 or L2) and iliohypogastric nerves (Th12-L1). Pareses of abdominal muscles due to trocar placement are rare due to overlap in innervation and relatively small sizes of trocar incisions. Conclusion: Knowledge of the anatomy of the abdominal wall is mandatory in order to avoid the injury of important structures during trocar placement

Inguinal hernia surgery in the Netherlands: are patients treated according to the guidelines?

Purpose In 2003, a dedicated Dutch committee developed vidence-based guidelines for the treatment of nguinal hernia (IH) in children and adults. The aim of this tudy was to describe trends in hernia care before and after he publication of the guidelines on IH surgery in the etherlands. ethods Originally, a retrospective baseline analysis of H surgery in 90 Dutch hospitals was performed among atients treated for IH in 2001. The results of this baseline nalysis were compared with a recently performed second nalysis of patients treated for IH in 2005. esults In children\\4 years of age, the study showed a ignificant decrease of contralateral explorations. In adults, he study showed that significantly more patients were reated with a mesh-based repair in 2005 (95.9 vs. 78.8%, <0.01eover, there was an increase of patients ith bilateral hernia treated with an endoscopic technique 41.5 vs. 22.3%, P<0.01) and more patients were treated n day surgery (53.5 vs. 38.6%, P<0.01). Lastly, a decline n operations performed for recurrent IH in adults was bserved (10.9 vs. 13.3%, P<0.01). onclusion This study showed that most patients with IH n the Netherlands were treated according to the main ecommendations of the Dutch evidence-based guidelines

Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy (CHOCOLATE trial): Study protocol for a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Laparoscopic cholecystectomy in acute calculous cholecystitis in high risk patients can lead to significant morbidity and mortality. Percutaneous cholecystostomy may be an alternative treatment option but the current literature does not provide the surgical community with evidence based advice.</p> <p>Methods/Design</p> <p>The CHOCOLATE trial is a randomised controlled, parallel-group, superiority multicenter trial. High risk patients, defined as APACHE-II score 7-14, with acute calculous cholecystitis will be randomised to laparoscopic cholecystectomy or percutaneous cholecystostomy. During a two year period 284 patients will be enrolled from 30 high volume teaching hospitals. The primary endpoint is a composite endpoint of major complications within three months following randomization and need for re-intervention and mortality during the follow-up period of one year. Secondary endpoints include all other complications, duration of hospital admission, difficulty of procedures and total costs.</p> <p>Discussion</p> <p>The CHOCOLATE trial is designed to provide the surgical community with an evidence based guideline in the treatment of acute calculous cholecystitis in high risk patients.</p> <p>Trial Registration</p> <p>Netherlands Trial Register (NTR): <a href="http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2666">NTR2666</a></p

The use of mesh in acute hernia: frequency and outcome in 99 cases

Background: Incarceration of inguinal, umbilical and cicatricial hernias is a frequent problem. However, little is known about the relationship between the use of mesh and outcome after surgery. The goal of this study was to describe the relationship between the use of mesh in incarcerated hernia and the clinical outcome. Patients and methods: Correspondence, operation reports and patient files between January 1995 and December 2005 of patients presented at one academic and one teaching hospital in Rotterdam were searched for the following keywords: incarceration, strangulation and hernia. The patient characteristics, clinical presentation, pre-operative findings and clinical course were scored and analysed. Results: A total of 203 patients could be identified: 76 inguinal, 52 umbilical, 39 incisional, 14 epigastric, 14 femoral, five trocar and three spigelian hernias. In the statistical analysis, epigastric, femoral, trocar and spigelian hernias were pooled, due to their small group sizes. One patient was excluded from the analysis because the hernia was not corrected during operation. In total, 99 hernias were repaired using mesh versus 103 primary suture repairs. Twenty-five wound infections were registered (12.3%). One mesh was removed during a reintervention for anastomotic leakage, although no signs of wound infection were present. Nine patients died, none of them due to wound-related problems [one cardiovascular, one ruptured aneurysm, two anastomotic leakage, two sepsis e causa incognita (e.c.i.), three pulmonary complications]. Univariate analysis showed that female patients (P = 0.007), adipose patients (P = 0.016), patients with an umbilical hernia (P = 0.01) and patients who underwent a bowel resection (P = 0.015) had a significantly higher rate of wound infections. The type of repair (e.g. primary suture or mesh), use of antibiotic prophylaxis, gender, ASA class and age showed no significant relation with post-operative wound infection. After logistic regression analysis, only bowel resection (P = 0.020) showed a significant relation with post-operative wound infection. Conclusions: Wound infection rates are high after the correction of acute hernia, but clinical consequences are relatively low. Mesh correction of an acute hernia seems to be safe and should be considered in every incarcerated hernia