New Online Studies
Tiffany Cox, MD, Fellow, Minimally Invasive Surgery, Laurel Blair, MD, Fellow, Minimally Invasive Surgery, Ciara Huntington, MD, Resident, General Surgery, Amy Lincourt, PhD, Research Group Director, Ronald Sing, DO, Attending, Surgical Critical Care, B. Todd Heniford, MD, Chief, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Charlotte, North Carolina
Purpose: A multitude of vascular closure devices (VCDs) are currently on the market for femoral arteriotomy closure after diagnostic and interventional angiography. Randomized, controlled trials (RCTs) comparing these devices to manual compression (MC) and their effect on time to hemostasis, time to ambulation, time to discharge, and immediate as well as long term complications have been studied. A systematic and through review of these evaluations and outcomes has not previously been performed.
Materials and methods: A systematic review was completed to include all available RCTs comparing vascular closure device use to manual compression. Devices meeting inclusion criteria were as follows: VasoSeal® (Datascope Corporation, Montvale, NJ), AngioSeal™ (Sherwood-Davis & Geck, St Louis, MO/St Jude Medical, St Paul, MN), ProGlide® (Abbott Vascular, Abbott Park, IL), ProStar® (Abbot Vascular, Menlo Park, CA), StarClose SE® (Abbott Vascular, Redwood City, CA), ExoSeal™ (Cordis, Warren, NJ), Boomerang™ Wire (Cardiva Medical, Mountainview, CA), FemoSeal™ (St Jude Medical Systems, Uppsala, Sweden), EVS™ (expanded vascular stapling, Angiolink Co, Taunton, MA), X-PRESS™ (X-Site Medical, Blue Bell, PA), Duett™ (Vascular Solutions, Minneapolis, MN), EpiClose-T® (CardioDex Ltd., Tirat Ha Carmel, Israel), and FISH™ (femoral introducer sheath and hemostasis, FISH Device, Bloomington, IN). Vascular closure devices were compared both to manual compression and across all devices used for the following outcomes: time to hemostasis, time to ambulation, time to discharge, and outcomes such as bleeding, hematoma, pseudoaneurysm, limb ischemia, and overall major and minor complications, as well as impact on quality of life, cost analysis, and trends over time. Both diagnostic and interventional procedures were included.
Results: PUBMED and MEDLINE searches were carried out for VCDs identifying 1,363 articles. Manuscripts that included manual compression in the study numbered 176. Of these, 34 randomized controlled trials were included. Studies that met inclusion criteria were published from 1992–2015 and described a total of 14,401 patients, 5,659 patients undergoing MC, and 8,742 patients undergoing VCD placement. Overall, the rate of procedural success for VCD patients was 95.7%. The highest rate of unsuccessful device deployment was seen in the ExoSeal™ subset, which averaged 37.9% failure. The overall median time to hemostasis for manual compression was 22.9 minutes compared to VCDs at 5.95 minutes; FemoSeal™ had the shortest median time to hemostasis of 0.75 minutes. When comparing the type of procedure and its median time to hemostasis, MC versus VCD was 17 minutes versus 3.7 minutes for diagnostic procedures and 29.1 minutes versus 7.6 minutes for interventional procedures with similar sheath sizes at 6 and 7 French, respectively. Similarly, median time to ambulation for MC was eight hours compared to 3.5 hours for patients who received a VCD. Median time to discharge was similar at 1.6 days. However, time to discharge has diminished over the last decade comparing MC to VCD, with a median time to discharge of 3.1 versus 2.2 days compared to current trends at 0.8 versus 0.5 days, respectively. The overall rates of complications were similar between MC at 13.1% versus VCDs at 12.2% but varied significantly according to the VCD that was selected. For patients randomized to the vascular closure device who had undergone prior angioplasty, 94.4% of these patients preferred the use of VCD if a further angioplasty were to be performed in the future. A 13% reduction in overall costs with VCD was demonstrated due to earlier discharge and less required time with physician and nursing staff.
Conclusion: Overall, the review of 34 RCTs demonstrates the utility of VCDs has shortened time to hemostasis, ambulation, and discharge compared to patients receiving MC. Over the last decade, with emphasis on and implementation of same-day procedures, use of VCDs has resulted in a reduction in time to discharge to half a day and a significant decrease in cost. Overall complication rates are similar, but vary between different devices on the market. Better short-term quality of life has also been described with the use of VCDs compared to MC. Further clinical and financial improvements may be found as newer technological advances of VCDs become available.
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Fatih Küçükdurmaz, MD, Post Doc Research Fellow, Department of Orthopaedic Research, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, Eric A. Levicoff, MD, Assistant Professor, Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Bryn Mawr, PA, Robert P. Good, MD, Clinical Associate Professor, Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Bryn Mawr, PA, Peter F. Sharkey, MD, Associate Professor, Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, King of Prussia, PA
Purpose: Accurate alignment and balanced flexion and extension gaps are critical elements in achieving a successful outcome following total knee arthroplasty (TKA). The ability to make accurate and precise bone cuts is essential in the creation of balanced gaps. We sought to determine if one type of modern-day standard surgical instrument using an intramedullary rod and posterior referencing produces accurate and precise distal and posterior femoral bone resections.
Materials and Methods: Seventy-five consecutive patients undergoing TKA were divided into three groups, with 25 patients in each group receiving one of three implant designs: 25 Stryker Triathlon® CR (Stryker, Mahwah, NJ), 25 Zimmer NexGen® Flex CR (Zimmer, Warsaw, IN), and 25 StelKast Proven Gen-FlexTM CR (StelKast, Pittsburgh, PA). Flexion-extension gap matching was determined using only the medial flexion and extension gaps. Accuracy was determined by comparing actual resection thickness to desired resection thickness. “Optimal” accuracy was considered to be within 1.0mm of desired, and “near-optimal” accuracy was considered to be within 2.0mm of the desired resection thickness. Precision was determined by the variability of resection thicknesses within each system.
Results: Data demonstrated a lack of accuracy and precision across all three tested systems, with each system resulting in certain unique tendencies. Only one out of 75 cases resulted in optimal resection accuracy with all three cuts (Zimmer). When lowering the threshold to include both optimal and near-optimal (within 2mm of error) with all three cuts, only one third of Stryker and Zimmer cases and two thirds of StelKast cases achieved this threshold, representing 44% of cases (33/75).
Conclusions: Improvements in instrumentation to increase accuracy and precision may be warranted. Errors in fixation may be due to the instrumentation itself, and altering instrumentation to include less modularity, provide more stable fixation, and more reliably seal the implant on the femur may be of benefit.
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An In Vivo Comparison of Hemostatic Gelatin Matrix Products in a Porcine Spleen Biopsy-punch Model
Richard W. Hutchinson, DVM, PhD, Research Fellow, Stephanie Werrlein, SRA, RLATG, CVT, Associate Scientist, Douglas B. Johns, PhD, Director Research & Development, Gary Zhang, PhD, Engineering Fellow, Jeffrey W. Clymer, PhD, Biostatistician, Richard Kocharian, MD, PhD, Franchise Medical Director, Ethicon Inc., Somerville, New Jersey
....
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Current Developments and Unusual Aspects in Gastrointestinal Surgical Stapling
Francesco Frattini, MD, General Surgeon, Insubria University, Department of Surgery, Varese, Italy, Francesco Amico, MD, General Surgery Registrar, Insubria University, Department of Surgery, Varese, Italy, Research Fellow, University of Melbourne, Department of Medicine, Melbourne, Australia, Stefano Rausei, MD, PhD, Associate Professor of Surgery, Insubria University, Department of Surgery, Varese, Italy, Luigi Boni MD, FACS, Professor of Surgery, Insubria University, Department of Surgery, Varese, Italy, Francesca Rovera, MD, Professor of Surgery, Insubria University, Department of Surgery, Varese, Italy, Gianlorenzo Dionigi, MD, FACS, Director 1st Division of Surgery, Professor of Surgery, Insubria University, Department of Surgery, Varese, Italy
Stapling devices are used in gastrointestinal, gynecologic, thoracic, and many other surgeries to resect organs, transect tissues, and anastomose different structures. These devices became widely accepted standard practice in many gastrointestinal operations, especially since the successful advent of minimally invasive surgery. Despite the relevant advantages related to the use of a surgical stapler, we must also consider that these instruments may be at risk of failure. When any component fails, the patient is at risk of operative morbidity. Gastrointestinal surgical stapling technique still needs refinement in order to increase its reliability. Staple line reinforcement has been widely used and seems to effectively reduce anastomotic complications. Literature provides us with examples of studies supporting both bleeding and leakage reduction after staple line reinforcement, but high-quality evidence is not available to date. Semi-absorbable and nonabsorbable materials have been the earliest available. The use of bioabsorbable staple line reinforcement materials has recently become more widespread, and these materials are more widely used these days. Powered staplers were made available to the market some time ago and represent a rather unheard of aspect of endosurgical stapling. Despite powered staples being supposedly convenient compared with manual ones only one relevant article was found when searching the U.S. National Library of Medicine for “powered stapler.” New surgical stapling devices are constantly developed and introduced on the market. Results with such devices depend on the stapler features but also surely vary according to the surgeon experience.
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Laparoscopic Paravaginal Defect Repair: Surgical Technique and a Literature Review
Dr. Orawee Chinthakanan, MD, MPH, Urogynecologist, International Urogynecology Associates , of Atlanta and Beverly Hills, Alpharetta, Georgia, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand , Dr. John R. Miklos, MD, Urogynecologist, International Urogynecology Associates of Atlanta and Beverly Hills, Alpharetta, Georgia, Dr. Robert D. Moore, DO , Urogynecologist , International Urogynecology Associates of Atlanta and Beverly Hills, Alpharetta, Georgia
Paravaginal defects, commonly seen in patients with anterior vaginal wall prolapse, are due to the detachment of pubocervical fascia from the arcus tendineus fascia pelvis (ATFP), at or near its lateral attachment. The majority of anterior vaginal wall prolapse is thought to be caused by paravaginal defects. Richardson et al. first described and demonstrated the anatomy of the paravaginal defect, as well as described the initial technique of the abdominal approach to repair. Since that time, the laparoscopic approach for repair has been developed and described with success rates of laparoscopic paravaginal defect repair reported in the range of 60% to 89%. This minimally invasive approach to address anterior wall prolapse eliminates the need for a vaginal incision, reduces risk of vaginal shortening and can be completed at the same time as other laparoscopic procedures, such as hysterectomy, sacralcolpopexy, and/or Burch Urethropexy. Compared to the open abdominal approach, there is improved visualization, less risk of bleeding, and faster recovery with the laparoscopic method. Compared to an anterior colporrhaphy, laparoscopic paravaginal repair is a much more anatomic repair of lateral defects and does not result in vaginal shortening. The laparoscopic paravaginal repair should be considered as the first-line treatment of anterior vaginal wall prolapse caused by lateral defects, including at time of laparoscopic/robotic sacralcolpopexy.
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Innovations in Bariatric Surgery
Catherine Zhu, BA, Medical Student, Stony Brook School of Medicine, Stony Brook, New York, Aurora D. Pryor, MD, FACS, Professor and Chief, Division of Bariatric, Foregut and Advanced Gastrointestinal Surgery, Stony Brook University, Stony Brook, New York
Surgery has consistently been demonstrated to be the most effective long-term therapy for the treatment of obesity. However, despite excellent outcomes with current procedures, most patients with obesity- and weight-related comorbidities who meet criteria for surgical treatment choose not to pursue surgery out of fear of operative risks and complications or concerns about high costs. Novel minimally invasive procedures and devices may offer alternative solutions for patients who are hesitant to pursue standard surgical approaches. These procedures may be used for primary treatment of obesity, early intervention for patients approaching morbid obesity, temporary management prior to bariatric surgery, or revision of bypass surgery associated with weight regain. Novel bariatric procedures can in general be divided into four categories: endoluminal space-occupying devices, gastric suturing and restrictive devices, absorption-limiting devices, and neural-hormonal modulating devices. Many of these are only approved as short-term interventions, but these devices may be effective for patients desiring low-risk procedures or a transient effect. We will see the expansion of indications and alternatives for metabolic surgery as these techniques gain approval.
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The Use of Haemostatic Agents and Sealants for the Prevention of Lymphocele After Urological Surgery: A Review of the Literature
Michele Marchioni, MD, Urology Resident, Biomedical Science, Università degli Studi “G.D’Annunzio”, Chieti-Pescara, Chieti, Italy, Manuela Ingrosso, MD, Urology Resident, Biomedical Science, Università degli Studi “G.D’Annunzio”, Chieti-Pescara, Chieti, Italy, Piergustavo De Francesco, MD, Urology Resident, Biomedical Science, Università degli Studi “G.D’Annunzio”, Chieti-Pescara, Chieti, Italy, Giulia Primiceri, MD, Urology Resident, Biomedical Science, Università degli Studi “G.D’Annunzio”, Chieti-Pescara, Chieti, Italy, Rossella Manco, MD, Urology Resident, Biomedical Science, Università degli Studi “G.D’Annunzio”, Chieti-Pescara, Chieti, Italy, Raffaele Lanfranco Tenaglia, MD, Urology Professor, Biomedical Science, Università degli Studi “G.D’Annunzio”, Chieti-Pescara, Chieti, Italy
Background: Despite the continuous technological innovation in urological surgery procedures, lymphocele represents one of the major and more frequent complications both in tumour and transplant surgery. Haemostatic agents have been used hypothesizing a beneficial effect on the prevention of lymphoceles. We aimed to review the published literature to establish whether haemostatic agents and sealants are an effective option for lymphocele prevention following urological procedure. Materials and methods: An extensive PubMed search was performed including the following keywords: “lymphocele”, “lymphocele prevention”, “fibrin glue”, “collagen patch”, “fibrin patch”, and “haemostatic material”. The search, which collected data until January 2000, was restricted to the full text available articles in the English language and human studies. Results: Our research identified 64 articles, among these only four fulfilled the inclusion criteria. A total of 133 patients underwent surgery and were treated with haemostatic agents and/or sealants to reduce the lymphoceles formation. The mean age was 56.1 years. A negligible variability in study design and in results and complication reporting is common. The 6.45% of patients treated with haemostatic biomaterials developed lymphocele. The rate difference of lymphoceles formation and recurrence between patient groups treated with sealant than in the controls groups is small (6.45% vs 6.88%). Conclusions: The evidences presented in the examined studies are only preliminary and insufficient to draw significant conclusions. A major, multicentre, randomized controlled trial is strongly needed.
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Unloader Bracing for Knee Osteoarthritis: A Pilot Study of Gait and Function
Michael A. Mont, MD, Director, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland, Jeffrey J. Cherian, DO, Research Fellow , Rubin Institute for Advanced Orthopedics, Baltimore, Maryland, Anil Bhave, PT, Director of Department of Physical Therapy, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland , Roland Starr, MS, Director of Gait Lab, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland , Randa K. Elmallah, MD, Research Fellow , Rubin Institute for Advanced Orthopedics, Baltimore, Maryland, Walter B. Beaver, Jr., MD, Medical Director, OrthoCarolina, Charlotte, North Carolina, Steven F. Harwin, MD, FACS, Director, Center of Reconstructive Joint Surgery, Beth Israel Medical Center, New York, New York
Knee osteoarthritis (OA) is increasing in the United States, and some have proposed the use of unloader bracing as an adjunct to current standard treatments. Our purpose was to evaluate outcomes of this brace for the treatment of knee osteoarthritis compared with standard non-operative treatment. Specifically, we evaluated: (1) pain relief, (2) objective functional improvement, (3) subjective functional improvement, (4) quality of life, (5) isokinetic quadriceps muscle strength, and (6) gait changes. A prospective, randomized, study was performed on 18 patients who had Kellgren-Lawrence grade 1 and 2 osteoarthritis. Patients were randomized to receive either standard treatment or an unloader brace. End points evaluated included: functional tests, Knee Society Score, Short Form 36 (SF-36) health survey, Visual Analog Scale (VAS) for pain, Lower Extremity Functional Scale, isokinetic quadriceps and hamstring muscle strength, and 3-dimensional gait analysis. There were no differences between cohorts in evaluation of pain (VAS), objective functional tests, subjective functional outcomes (Knee Society Scores and LEFS), quality of life assessment with SF-36, isokinetic quadriceps and hamstring muscle strength, and gait parameters. The use of unloader brace demonstrated similar improvements compared with standard treatments for knee osteoarthritis, and we believe that it can be a beneficial or equivalent adjunct to continuum of care for the treatment for knee osteoarthritis.
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Readmission Rates in Patients Who Underwent Total Hip Arthroplasty
Randa K. Elmallah, MD, Research Fellow, Jeffrey J. Cherian, DO, Research Fellow, Hiral Amin, MD, Research Assistant, Julio J. Jauregui, MD, Research Fellow, Todd P. Pierce, MD, Research Fellow, Michael A. Mont, MD, Director, Center for Joint Preservation and Replacement , Rubin Institute for Advanced Orthopedics , Sinai Hospital of Baltimore, Baltimore, Maryland
Readmission rates remain a concern following total hip arthroplasty (THA). This study: 1) evaluated 30-day, 90-day, and total readmission rates after THAs; 2) assessed causes of readmission; 3) determined differences in demographic factors between those who were and were not readmitted; and 4) compared readmission rates to other large-scale studies. We retrospectively reviewed 232 primary THAs (224 patients) using the same prosthesis at 7 institutions. This included 79 men and 145 women who had a mean age of 69 years (range, 44 to 88). Descriptive analyses were used to evaluate readmission, and rates were compared with those from large cohort studies. There were 11 unplanned readmissions (4.7%) in 10 patients during the first 90 days post-discharge. Seven (3%) readmissions were due to surgical and 4 (1.7%) were due to medical reasons. Surgical causes were found in 70% of early (0 to 30 days) readmissions but none of late (60 to 90 days) readmissions. No differences existed in mean age, gender, and body mass index between readmitted patients and the remainder of the population. We observed lower readmission rates when compared with large cohort studies. The positive performance of the prosthesis may have contributed to the lower readmission rates.
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Pseudotumor Formation in a Metal-on-polyethylene Total Hip Arthroplasty Due to Trunnionosis at the Head-neck Taper
Jake T. Stahnke, BSc, Medical Scribe, OrthoArizona-Mezona Division , Gilbert, Arizona, Kipling P. Sharpe, MD, FAAOS, Orthopedic Surgeon , OrthoArizona-Mezona Division , Gilbert, Arizona
We present here a case of pseudotumor formation likely due to metal wear debris generated at the head-neck taper (trunnion) of the femoral stem and head components in a metal-on-polyethylene (MOP) total hip arthroplasty. Over the last few years, this recently described diagnosis, trunnionosis, has been recognized and reported more frequently. This patient presented with a rather large (12-cm diameter) pseudotumor with accompanying loss of abductors and a pelvic discontinuity making reconstruction more challenging. We believe the psuedotumor in this patient developed from trunnionosis. This is an interesting case of aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL) in a MOP total hip arthroplasty.
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Classification of Hypertrophy of Labia Minora: Consideration of a Multiple Component Approach
Pablo I. González, MD, Chief, Division Of Urogynecology and Pelvic Reconstructive Surgery, Department Of Obstetrics And Gynecology, Hospital Universitario San Jorge, Pereira, Colombia
Labia minora hypertrophy of unknown and under-reported incidence in the general population is considered a variant of normal anatomy. Its origin is multi-factorial including genetic, hormonal, and infectious factors, and voluntary elongation of the labiae minorae in some cultures. Consults with patients bothered by this condition have been increasing with patients complaining of poor aesthetics and symptoms such as difficulty with vaginal secretions, vulvovaginitis, chronic irritation, and superficial dyspareunia, all of which can have a negative effect on these patients' sexuality and self esteem. Surgical management of labial hypertrophy is an option for women with these physical complaints or aesthetic issues. Labia minora hypertrophy can consist of multiple components, including the clitoral hood, lateral prepuce, frenulum, and the body of the labia minora. To date, there is not a consensus in the literature with respect to the classification and definition of varying grades of hypertrophy, aside from measurement of the length in centimeters. In order to offer patients the most appropriate surgical technique, an objective and understandable classification that can be used as part of the preoperative evaluation is necessary. Such a classification should have the aim of offering patients the best cosmetic and functional results with the fewest complications.
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Antibiotic Coating of Hernia Meshes: The Next Step Toward Preventing Mesh Infection
Arnab Majumder, MD, Allen Research Scholar, Surgery Resident, Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio, Ruel Neupane, BS, Research Fellow, Department of Surgery, Case Comprehensive Hernia Center, University Hospitals Case Medical Center, Cleveland, Ohio, Yuri W. Novitsky, MD, FACS, Professor of Surgery, Department of Surgery, Director, Case Comprehensive Hernia Center, University Hospitals Case Medical Center, Cleveland, Ohio
Mesh bacterial colonization/infection remains a critical issue in complex ventral hernia repair. Despite the recent emergence of biologic meshes, current strategies to prevent and treat mesh infection are largely ineffective, often leading to device failure and subsequent explantation along with the associated costs and effect on patient welfare. Unacceptably high rates of morbidity and hernia recurrence following mesh infection highlight the need for innovation in the area of hernia repair for the complex patient. One recent strategy to address such shortcomings is local antibiosis in the form of polymer coatings applied to the mesh itself. Current literature regarding the use of antibiotic-coated hernia mesh is limited but does illustrate the ability of these devices to inhibit bacterial growth and prevent mesh infection in both in vitro and in vivo studies. Although there is a paucity of literature regarding long-term clinical efficacy, this provides opportunity for further inquiry into a promising new development to combat mesh infective complications.
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Gastric Wall Thickness in Sleeve Gastrectomy Patients: Thickness Variation of the Gastric Wall
Pim W.J. van Rutte, MD, Surgeon in Training, Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands, Bertus J. Naagen, MSc, Lab Manager, Faculty of Industrial Design, Technical University of Delft, Delft, The Netherlands, Marinus Spek, BSc, Instrument Maker, Leiden Instrument Makers School, Leiden, The Netherlands, Jack J. Jakimowicz, MD, PhD, FRCS, EdD, Professor of Safety in Health Care, Faculty of Industrial Design, Technical University of Delft, Delft, The Netherlands, Simon W. Nienhuijs, MD, PhD, Surgeon, Department of Surgery, Catharina Hospital , Eindhoven, The Netherlands
The sleeve gastrectomy has been accepted as a primary bariatric procedure. One of the most feared complications is staple line leakage. It is important to use the right staple sizes to minimize the risk of leak. Knowledge of gastric thickness is important. The goal of this study was to measure the thickness of the gastric wall after elimination of the gastric folds in the mucosa. An electronic thickness gauge was developed that measured the anterior and posterior wall of the fresh stomach specimen together at 5 points at a pressure based on the finger pressure necessary to flatten the gastric folds. Thirty-three fresh specimens were measured. The mean compression pressure was 714 grams, and no difference was found between the 5 measure points. There was a significant difference in stomach wall thickness. The gastric antrum was more than 1 mm thicker than the fundus. No difference was found between BMI groups <40Kg/m2, 40-50Kg/m2, or >50Kg/m2. No bleeding occurred, leakage occurred in 1 case. There is a significant difference in thickness of the stomach wall between the gastric fundus and the antrum. A pressure 2.5 times lower than applied in prior studies was necessary to achieve full tissue compression. Choosing thinner staple sizes for the gastric fundus might be the optimal technique for compression. However, there are several additional factors that influence the risk of staple line leaks.
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Laparascopic Neurolysis of Deep Endometriosis Infiltrating Left Femoral Nerve: Case Report
Cláudia Andrade, MD, Minimally Invasive Gynecologic Surgery Fellow, Department of Obstetrics and Gynecology, Centro Hospitalar Lisboa Norte – Hospital Universitário de Santa Maria, Lisbon, Portugal, Gynecology and Obstetrics Resident, Department of Obstetrics and Gynecology, Centro Hospitalar Tondela-Viseu, Viseu, Portugal, Sónia Barata, MD, Clinical Assistant, Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Centro Hospitalar Lisboa Norte – Hospital Universitário de Santa Maria, Lisbon, Portugal, Francisco António, MD, Clinical Assistant, Department of Neurosurgery , Centro Hospitalar Lisboa Norte – Hospital Universitário de Santa Maria, Lisbon, Portugal, Conceição Alho, MD, Clinical Assistant, Department of Obstetrics and Gynecology, Centro Hospitalar Lisboa Norte – Hospital Universitário de Santa Maria, Lisbon, Portugal, Carlos Calhaz-Jorge, PhD, Professor of Gynecology , Department of Obstetrics and Gynecology, Centro Hospitalar Lisboa Norte – Hospital Universitário de Santa Maria, Lisbon, Portugal, Faculdade de Medicina de Lisboa, CAM – Centro Académico de Medicina de Lisboa, Lisbon, Portugal, Filipa Osório, MD, Clinical Assistant, Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Centro Hospitalar Lisboa Norte – Hospital Universitário de Santa Maria, Lisbon, Portugal, Faculdade de Medicina de Lisboa, CAM – Centro Académico de Medicina de Lisboa, Lisbon, Portugal
Pelvic endometriosis may infiltrate somatic nerves causing severe neuropathic symptoms with a high impact on quality of life. It is a medical condition poorly known, and few published data about involvement of femoral nerve are available. We report an isolated unilateral endometriosis lesion of the left lumbar region infiltrating the femoral nerve in a 38-year-old woman. She described severe dysmenorrhea, dyspareunia, dischezia, and chronic pelvic pain with irradiation to the anterior part of the left thigh. After investigation, it was identified as a 5-centimeter endometriotic nodule involving the femoral nerve and the psoas muscle. The patient was treated by two laparoscopic surgeries with neurolysis of the involved somatic nerve by a multidisciplinary team, with improvement of the symptoms. Laparoscopic neurolysis is the first approach advocated in these cases, leading to relief of neurological symptoms resulting from nerve infiltration by endometriosis.
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Prospective Randomized Controlled Trial of Two Different Intramedullary Nails for Pertrochanteric Fractures of the Femur
Lorenzo Andreani, MD, Consultant Orthopaedic Surgeon, Enrico Bonicoli, MD, Consultant Orthopaedic Surgeon, Nicola Piolanti, MD, Consultant Orthopaedic Surgeon, Paolo Parchi, PhD, Consultant, Francesco Niccolai MD, Resident, Alessandra Carmignani, MD, Resident, Michele Lisanti, MD, Professor, Chief, Orthopaedic Department, University of Pisa, Pisa, Italy
ORDER
The purpose of this prospective randomized trial was to assess whether an intramedullary nail is superior or not to another one in the treatment of pertrochanteric fractures. Eighty-one patients with a 31-A1 or A2 Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) pertrochanteric fracture were randomly allocated to fixation with either the Gamma® or the ENDOVIS® nail. In order to estimate the functional outcome the Parker-Palmer mobility score, Barthel Index, and EuroQol-5D (EQ-5D) were used. All patients were followed up at 1, 3, 6, and 12 months postoperatively. There was no statistical difference in Parker mobility score between groups. The statistical analysis revealed that there was no significant difference between the two patient groups as far as the operating time, the amount of blood transfused, and the latest functional outcome. Both kinds of intramedullary nails used in our study provide effective methods of treatment for intertrochanteric fractures in elderly patients. Our data showed slightly worse results for the ENDOVIS nail compared with the Gamma nail, but this did not reach a statistical significance.
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Technique of Robotic-assisted Total Proctocolectomy with Lymphadenectomy and Ileal Pouch-Anal Anastomosis for Transverse Colitic Cancer of Ulcerative Colitis, Using the Single Cart Position
Tsunekazu Hanai, MD, PhD, Associate Professor, Koutarou Maeda, MD, PhD, Professor, Koji Masumori, MD, PhD, Associate Professor, Hidetoshi Katsuno, MD, PhD, Associate Professor, Hiroshi Matsuoka, MD, PhD, Assistant Professor , Gastrointestinal Surgery , Department of Surgery, Fujita Health University School of Medicine, Aichi, Japan
Robotic surgery offers advantages for operating in a narrow space such as inside the pelvis. We report on the technique of robotic-assisted laparoscopic total proctocolectomy with lymphadenectomy and ileal pouch-anal anastomosis for ulcerative colitis with transverse colitic cancer, using the single cart position. A 46-year-old female patient was diagnosed with colitic cancer of the transverse colon during the surveillance of ulcerative colitis. Six port sites were used. Mobilization of the left-sided colon through to the rectum and mobilization of the transverse colon with lymphadenectomy around the middle colic artery were performed using the robotic surgical system. After rectal mobilization was conducted near the anus, the right side of the colon was mobilized and the ileum resected laparoscopically. Thereafter, a mucosectomy of the proctorectum was carried out through a trans-anal approach, and a hand-sewn J-pouch was performed. Finally, a diverting ileostomy was constructed through the right lower abdomen. The operative time was 460 minutes, including the console time of 361 minutes. The amount of blood loss was 76 g. The patient was discharged on postoperative day nine. Pathological results demonstrated that the depth of the lesion was T3, and the positive lymph node was 1 of 115 retrieved lymph nodes. There were no complications or mortality. Robotic-assisted total proctocolectomy and lymphadenectomy with ileal pouch-anal anastomosis for transverse colitic cancer of ulcerative colitis was performed safely using the single cart position.
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