Video-assisted sacral nerve stimulation

Background: Sacral nerve simulation (SNS) is an accepted therapy for patients with urinary or bowel dysfunction. However, infection rates are as high as 20% and can result in removal of the expensive device. We present a new video-assisted technique minimizing the risk of infection. Methods: Between April and July 2005, six consecutive women of median age 68 years (range, 60-74), with faecal incontinence (4 patients) and idiopathic constipation (2 patients) underwent video-assisted electrode implantation for SNS. The motor response of the pelvic floor during percutaneous nerve evaluation and implantation of the permanent lead was monitored by a video optic (same as that normally used for laparoscopic or endoscopic procedures) placed between the legs of the patients. The video optic and the perianal area were completely covered with drapes, separating them from the operating field. Results: All but one screening was successful, and no wound infections at the electrode or at the pocket of the stimulator were noted (mean postoperative follow-up, 8 weeks). Conclusions: With the use of a video optic, the anus and the implantation site can be completely separated and contamination during the operation becomes unlikely. Furthermore, the response of the pelvic floor to the stimulation is better visualized. We routinely recommend the use of video equipment for SNS electrode implantatio

Giant extra-hepatic thrombosed portal vein aneurysm: a case report and review of the literature.

BACKGROUND: Extrahepatic Portal vein aneurysm (EPVA) is a rare finding that may be associated with different complications, e.g. thrombosis, rupture, portal hypertension and compression of adjacent structures. It is being diagnosed more frequently with the advent of modern cross-sectional imaging. Our review of the English literature disclosed 13 cases of thrombosed EPVA. CASE PRESENTATION: A 50-years-old woman presented with acute abdominal pain but no other symptom. She had no relevant medical history. Palpation of the right upper quadrant showed tenderness. Laboratory tests were unremarkable. A computed tomography showed portal vein aneurysm measuring 88 × 65 mm with thrombosis extending to the superior mesenteric and splenic vein. The patient was treated conservatively with anticoagulation therapy. She was released after two weeks and followed on an outpatient basis. At two months, she reported decreased abdominal pain and her physical examination was normal. A computed tomography was performed showing a decreased thrombosis size and extent, measuring 80 × 55 mm. CONCLUSIONS: Although rare, surgeons should be made aware of this entity. Complications are various. Conservative therapy should be chosen in first intent in most cases. We reported the case of the second largest thrombosed extra-hepatic PVA described in the literature, treated by anticoagulation therapy with a good clinical and radiological response

A prospective randomized comparison of two instruments for dissection and vessel sealing in laparoscopic colorectal surgery

Background: A newly available, laparoscopic 5-mm bipolar vessel sealing device promises substantial advantages over the 10-mm instrument. This study compared the safety as well as the technical and surgical aspects of these different tools. Methods: For this study, 30 consecutive patients undergoing laparoscopic left-sided colectomy were prospectively randomized for the 5-mm LigaSure or The 10-mm LigaSure. The patients' demographics were analyzed together with their intraoperative and postoperative parameters, and the instruments were assessed by the surgeons with a standardized questionnaire. Results: The two groups were comparable and demonstrated similar mean operation times, blood losses, and hospital stays. The 5-mm LigaSure was applied in more operation steps and resulted in fewer bleeding episodes and less lens cleaning. Monopolar scissors were used less frequently in the 5-mm group, thus minimizing cauteric lesions and their complications (0 in the 5-mm group vs 2 in the 10-mm group). Overall satisfaction with the 5-mm LigaSure was significantly higher (8.4±0.18 vs 6.9±0.41 out of 10; p=0.002), with significant advantages in terms of dissection capacity, visibility, and handling. Conclusion: The 5-mm LigaSure is as secure and fast as the larger 10-mm device and compares favorably in terms of finer dissection as well as trocar flexibility and handling. Therefore, it can be used safely in laparoscopic colorectal surger

Procalcitonin-Guided Antibiotics after Surgery for Peritonitis: A Randomized Controlled Study.

Serum procalcitonin (PCT) is a useful biomarker to tailor the duration of antibiotics in respiratory infections. The objective of this study was to determine whether PCT levels could tailor postoperative antibiotic therapy in patients operated for peritonitis. Patients with peritonitis were randomized postoperatively. The control group received antibiotics for a defined duration according to institutional guidelines. In the study group, antibiotics were stopped based on serum PCT levels. Patients were stratified into three categories: (1) gastrointestinal perforation, (2) perforated appendicitis, and (3) postoperative complication. Primary outcome was duration of antibiotics. We included 162 patients; 83 and 79 patients in the control group and study group, respectively. In the subgroup of patients with peritonitis due to gastrointestinal perforation, we found 7 days of antibiotics in the PCT group versus 10 days in the control group (p value 0.065). There was no difference in infectious complications, mortality, median length of hospital stay, and necessity to restart antibiotics. No significant differences were found in duration of antibiotics when applying PCT guidance. However, in the subgroup of primary perforation of the gastrointestinal tract, there was a difference in duration of antibiotics in favor of the PCT group without obtaining significance, as the study was not powered for subgroup analysis. Further studies including only this subgroup should be performed

Long-term follow-up after combined fissurectomy and Botox injection for chronic anal fissures

Background and aims: Chronic anal fissures are difficult to treat. The aim of this retrospective study was to determine the outcome of combined fissurectomy and injection of botulinum toxin Type A (BT). Materials and methods: Between January 2001 and August 2004, 40 patients (21 women), median age 37years (range 18 to 57), underwent fissurectomy and BT injection. Fissurectomy was performed followed by injection of 10U of BT into the internal anal sphincter on both sides of the fissure. All patients were clinically checked 6weeks after the operation. At 1year, patients were sent a detailed questionnaire regarding symptoms, recurrence and further treatment for evaluation of long-term results. Results/findings: At 6weeks, 38 patients (95%) were free of symptoms. No adverse effects were detected. The response rate of questionnaires was 93%; the median follow-up was 1year (range 0.9 to 1.6). In the long-term, a recurrence was found in four patients. These patients were treated successfully with repeated fissurectomy and BT injections and salvage procedures, respectively. Overall, the success rate of combined fissurectomy and BT injection was 79%. Interpretation/conclusion: Combined fissurectomy and Botox injection for chronic anal fissure is an excellent and safe procedure with low morbidity and a high healing rat

Long-term follow-up after combined fissurectomy and Botox injection for chronic anal fissures

Background and aims: Chronic anal fissures are difficult to treat. The aim of this retrospective study was to determine the outcome of combined fissurectomy and injection of botulinum toxin Type A (BT). Materials and methods: Between January 2001 and August 2004, 40 patients (21 women), median age 37years (range 18 to 57), underwent fissurectomy and BT injection. Fissurectomy was performed followed by injection of 10U of BT into the internal anal sphincter on both sides of the fissure. All patients were clinically checked 6weeks after the operation. At 1year, patients were sent a detailed questionnaire regarding symptoms, recurrence and further treatment for evaluation of long-term results. Results/findings: At 6weeks, 38 patients (95%) were free of symptoms. No adverse effects were detected. The response rate of questionnaires was 93%; the median follow-up was 1year (range 0.9 to 1.6). In the long-term, a recurrence was found in four patients. These patients were treated successfully with repeated fissurectomy and BT injections and salvage procedures, respectively. Overall, the success rate of combined fissurectomy and BT injection was 79%. Interpretation/conclusion: Combined fissurectomy and Botox injection for chronic anal fissure is an excellent and safe procedure with low morbidity and a high healing rat

An unusual location of gouty panniculitis: A case report.

Gouty panniculitis, characterised by the deposition of monosodium urate crystals in subcutaneous tissue, is a rare clinical manifestation of gout. The case of a 67-year-old man is reported, who presented an erythematous nodule on the upper part of the right buttock suspicious for an abscess. This was in the context of chemotherapy for non-Hodgkin's lymphoma. Histopathologic examination demonstrated gouty panniculitis. Because infection was suspected, an incision was performed. The lesion was found to be densely calcified and friable, without purulent discharge. Therefore, a surgical en-bloc resection was performed. The wound healed slowly initially due to a combination of malnutrition, chemotherapy and infection. A wound infection with Enterococcus faecium was treated with antibiotic therapy (carbapenem for seven days) and local therapy. At 6-week follow up the wound showed good granulation tissue and was healing well by secondary intention. The patient was instructed to continue anti-hyperuricaemic treatment. In patients known to have long-standing hyperuricaemia and gout with nonspecific subcutaneous erythematous nodules, gouty panniculitis should be considered

Robotic-Assisted Surgery Improves the Quality of Total Mesorectal Excision for Rectal Cancer Compared to Laparoscopy: Results of a Case-Controlled Analysis.

BACKGROUND: The use of a robotic surgical system is claimed to allow precise traction and counter-traction, especially in a narrow pelvis. Whether this translates to improvement of the quality of the resected specimen is not yet clear. The aim of the study was to compare the quality of the TME and the short-term oncological outcome between robotic and laparoscopic rectal cancer resections. METHODS: 20 consecutive robotic TME performed in a single institution for rectal cancer (Rob group) were matched 1:2 to 40 laparoscopic resections (Lap group) for gender, body mass index (BMI), and distance from anal verge on rigid proctoscopy. The quality of TME was assessed by 2 blinded and independent pathologists and reported according to international standardized guidelines. RESULTS: Both samples were well matched for gender, BMI (median 25.9 vs. 24.2 kg/m(2), p = 0.24), and level of the tumor (4.1 vs. 4.8 cm, p = 0.20). The quality of the TME was better in the Robotic group (complete TME: 95 vs. 55 %; p = 0.0003, nearly complete TME 5 vs. 37 %; p = 0.04, incomplete TME 0 vs. 8 %, p = 0.09). A trend for lower positive circumferential margin was observed in the Robotic group (10 vs. 25 %, p = 0.1). CONCLUSIONS: These results suggest that robotic-assisted surgery improves the quality of TME for rectal cancer. Whether this translates to better oncological outcome needs to be further investigated

Postoperative Albumin Drop Is a Marker for Surgical Stress and a Predictor for Clinical Outcome: A Pilot Study.

Background. Surgical stress during major surgery may be related to adverse clinical outcomes and early quantification of stress response would be useful to allow prompt interventions. The aim of this study was to evaluate the acute phase protein albumin in the context of the postoperative stress response. Methods. This prospective pilot study included 70 patients undergoing frequent abdominal procedures of different magnitude. Albumin (Alb) and C-reactive protein (CRP) levels were measured once daily starting the day before surgery until postoperative day (POD) 5. Maximal Alb decrease (Alb Δ min) was correlated with clinical parameters of surgical stress, postoperative complications, and length of stay. Results. Albumin values dropped immediately after surgery by about 10 g/L (42.2 ± 4.5 g/L preoperatively versus 33.8 ± 5.3 g/L at day 1, P < 0.001). Alb Δ min was correlated with operation length (Pearson ρ = 0.470, P < 0.001), estimated blood loss (ρ = 0.605, P < 0.001), and maximal CRP values (ρ = 0.391, P = 0.002). Alb Δ min levels were significantly higher in patients having complications (10.0 ± 5.4 versus 6.1 ± 5.2, P = 0.005) and a longer hospital stay (ρ = 0.285, P < 0.020). Conclusion. Early postoperative albumin drop appeared to reflect the magnitude of surgical trauma and was correlated with adverse clinical outcomes. Its promising role as early marker for stress response deserves further prospective evaluation

Use of the nutritional risk score by surgeons and nutritionists.

BACKGROUND: The Nutritional Risk Score (NRS) is a validated tool to identify patients who should benefit of nutritional interventions. Nutritional screening however has not yet been widely adopted by surgeons. Furthermore, the question about reliability of nutritional assessment performed by surgeons is still unanswered. METHODS: Data was obtained from a recent randomised trial including 146 patients with an NRS ≥3 as assessed by the surgeons. Additional detailed nutritional assessment was performed for all patients by nutritional specialists and entered prospectively in a dedicated database. In this retrospective, surgeons' scoring of NRS and its components was compared to the assessment by nutritionists (considered as gold standard). RESULTS: Prospective NRS scores by surgeons and nutritionists were available for 141 patients (97%). Surgeons calculated a NRS of 7, 6, 5, 4 and 3 in 2, 8, 38, 21 and 72 patients respectively. Nutritionists calculated a NRS of 6, 5, 4, 3 and 2 in 8, 26, 47, 57, 3 patients, respectively. Surgeons' assessment was entirely correct in 56 patients (40%), while at least the final score was consistent in 63 patients (45%). Surgeons overrated the NRS in 21% of patients and underestimated the score in 29%. Evaluation of the nutritional status showed most of the discrepancies (54%). CONCLUSION: Surgeon's assessment of nutritional status is modest at best. Close collaboration with nutritional specialists should be recommended in order to avoid misdiagnosis and under-treatment of patients at nutritional risk