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ABSTRACT: BACKGROUND: Incisional hernia is a significant complication in patients undergoing elective laparotomy. Its incidence is increased in patients with risk factors, such as obesity and chronic respiratory disease. The purpose of this pooled analysis was to evaluate the use of prophylactic mesh placement following laparotomy in high-risk patients. METHODS: A systematic literature search of MEDLINE, Embase, Web of Science, and Cochrane database was conducted. Outcome measures were incidence of postoperative incisional hernia, seroma, and wound infection rates. RESULTS: Five randomized, controlled trials (RCTs) and four comparative studies that met the inclusion criteria were identified. In total, 464 patients who underwent laparotomy closure with mesh placement and 755 patients who underwent conventional laparotomy closure were included. A reduced incidence of incisional hernia was observed when laparotomy was combined with prophylactic mesh placement in pooled analysis of RCTs (pooled odds ratio = 0.32; 95 % confidence interval = 0.12-0.83; P = 0.02) and comparative studies (pooled odds ratio = 0.11; 95 % confidence interval = 0.04-0.33; P < 0.001) respectively. No significant differences were observed in the incidence of seroma or wound infection following prophylactic mesh placement. CONCLUSIONS: The results of this pooled analysis suggest a benefit to prophylactic mesh placement during laparotomy closure in high-risk patients with a significantly reduced incidence of incisional hernia without any significant differences in seroma formation and wound infection rates. Further studies must evaluate the incidence of mesh-specific complications, including foreign body sensation and chronic pain, before strong recommendations can be made.
World Journal of Surgery 04/2013; · 2.36 Impact Factor
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ABSTRACT: BACKGROUND: Elderly patients are often regarded as high-risk patients for major abdominal surgery because of a lack of functional reserve and associated medical comorbidities. The aim of this systematic review and pooled analysis was to review the current data published regarding the differences in operative outcomes of laparoscopic and open surgery in the elderly population. METHODS: A systematic literature search of Medline, Embase, Web of Science, and Cochrane databases was performed. Studies that compared outcome following laparoscopic and open colorectal resections in the elderly (≥70) population were included. Primary outcomes were operative death, anastomotic leak, pneumonia, length of hospital stay, and return to bowel function. Secondary outcomes were operative time, intraoperative blood loss, postoperative cardiac morbidity, ileus, and postoperative wound infection. RESULTS: The results of this systematic review and pooled analysis demonstrate the safety and potential benefits of laparoscopic colorectal resection in the elderly population. The latter include reduction in length of hospital stay, intraoperative blood loss, incidence of postoperative pneumonia, time to return of normal bowel function, incidence of postoperative cardiac complications, and wound infections. CONCLUSION: The results of this pooled analysis demonstrate the potential short-term advantages of laparoscopic colorectal resection in the elderly population. Further studies are required to examine the long-term survival following laparoscopic and open colorectal resections in the elderly population.
Surgical Endoscopy 06/2012; · 4.01 Impact Factor
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ABSTRACT: Colonoscopic perforation is a rare but serious complication of colonoscopy. Factors known to increase the risk of perforation include colonic strictures, extensive diverticulosis, and friable tissues. We describe the case of a man who was found to have perforation of the sigmoid colon secondary to an undiagnosed connective tissue disorder (Ehlers-Danlos syndrome type IV) while undergoing surveillance for hereditary non-polyposis colorectal cancer.
A 33-year-old Caucasian man presented to our hospital with an acute abdomen following a colonoscopy five days earlier as part of hereditary non-polyposis colorectal cancer screening. His medical history included bilateral clubfoot. His physical examination findings suggested left iliac fossa peritonitis. A computed tomographic scan revealed perforation of the sigmoid colon and incidentally a right common iliac artery aneurysm as well. Hartmann's procedure was performed during laparotomy. The patient recovered well post-operatively and was discharged. Reversal of the Hartmann's procedure was performed six months later. This procedure was challenging because of dense adhesions and friable bowel. The histology of bowel specimens from this surgery revealed thinning and fibrosis of the muscularis externa. The patient was subsequently noted to have transparency of truncal skin with easily visible vessels. An underlying collagen vascular disorder was suspected, and genetic testing revealed a mutation in the collagen type III, α1 (COL3A1) gene, which is consistent with a diagnosis of Ehlers-Danlos syndrome type IV.
Ehlers-Danlos syndrome type IV, the vascular type, is a rare disorder caused by mutations in the COL3A1 gene on chromosome 2q31. It is characterized by translucent skin, clubfoot, and the potentially fatal complications of spontaneous large vessel rupture, although spontaneous uterine and colonic perforations have also been reported in the literature. The present case presentation describes the identification of Ehlers-Danlos syndrome type IV in a patient with a non-spontaneous colonic perforation secondary to an invasive investigation for another hereditary disorder pre-disposing him to colorectal cancer. Invasive procedures such as arteriograms and endoscopies are relatively contra-indicated in Ehlers-Danlos syndrome type IV. Alternatives with a lower risk of perforation, such as computed tomographic colonography, need to be considered for patients requiring ongoing colorectal cancer surveillance. Furthermore, management of vascular aneurysms in patients with Ehlers-Danlos syndrome type IV requires consideration of the risks of endovascular stenting, as opposed to open surgical intervention, because of tissue friability. Genetic and reproductive counseling should be offered to affected individuals and their families.
Journal of Medical Case Reports 06/2011; 5:229.
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ABSTRACT: Virtual reality (VR) simulation provides unique training opportunities. This study evaluates whether the deliberate practice (DP) can be successfully applied to simulated laparoscopic cholecystectomy (LC) for enhancement of the quality of surgical skills.
Twenty-six inexperienced surgeons underwent a training program for LC on a VR simulator. Trainees were randomly allocated to 1 of 2 specific protocols of 10 sessions comprising a total of 20 LCs. For each session, the control group performed 2 LCs separated by 30 minutes of occupational activities; the DP group were assigned 30 minutes of DP activities in between 2 LCs. Each participant then performed 2 LCs on a cadaveric porcine model. Quantitative parameters were recorded from the simulator and a motion tracking device; qualitative assessment utilized validated rating scales.
Twenty-two subjects completed training. Learning curves on the VR simulator were significant for time taken and number of movements in both groups. The DP group was slower from the third LC (1373 vs. 872 seconds, P = 0.022) and utilized more movements from the seventh (942 vs. 701, P = 0.033). Global rating scores improved significantly in both groups over repeated LCs. The DP group revealed higher scores than control from tenth (19.5 vs. 14, P = 0.014) until the twentieth LC (22 vs. 16, P = 0.003). On the porcine model, the DP group also achieved higher global rating scores (25.5 vs. 19.5, P = 0.002).
VR training improved dexterity for both groups, and led to transfer of skill onto a porcine LC model. The DP group achieved higher quality, and demonstrated superior transfer onto real tissues.
Annals of surgery 06/2011; 253(6):1216-22. · 7.90 Impact Factor
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ABSTRACT: We report the case of a 65-year-old Caucasian woman who experienced two separate episodes of acute renal failure within an 18-month period, both requiring emergency admission and complicated treatment. Each episode was precipitated by hypovolaemia from intestinal fluid losses, but from two rare and independent pathologies. Her first admission was attributed to community-acquired Clostridium difficile-associated diarrhoea (CDAD) and was treated in the intensive therapy unit. She returned 18 months later with volume depletion and electrolyte disturbances, but on this occasion a giant hypersecretory villous adenoma of the rectum (McKittrick-Wheelock syndrome) was diagnosed following initial abnormal findings on digital rectal examination by a junior physician. Unlike hospital-acquired C. difficile, community-acquired infection is not common, although increasing numbers are being reported. Whilst community-acquired CDAD can be severe, it rarely causes acute renal failure. This case report highlights the pathological mechanisms whereby C. difficile toxin and hypersecretory villous adenoma of the rectum can predispose to acute renal failure, as well as the values of thorough clinical examination in the emergency room, and early communication with intensivist colleagues in dire situations.
Case Reports in Gastroenterology 05/2011; 5(2):438-44.
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ABSTRACT: Inguinal hernia repair procedures are often one of the first surgical procedures faced by junior surgeons. The biggest challenge in this procedure for novice trainees is understanding the 3D spatial relations of the complex anatomy of the inguinal region, which is crucial for the effective and careful handling of the present anatomical structures in order to perform a successful and lasting repair. Such relationships are difficult to illustrate and comprehend through standard learning material. This paper presents our work in progress to develop a simulation-based teaching tool allowing junior surgeons to train the Lichtenstein tension-free open inguinal hernia repair technique for direct and indirect hernias, as well as to enforce their understanding of the spatial relations of the involved anatomy.
Studies in health technology and informatics 01/2011; 163:202-8.
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ABSTRACT: Peritoneal metastasis occurs in up to 30% of patients with gastric cancer. The aim of this experimental study is to develop and validate a novel ex vivo model of the human peritoneum to better identify factors involved in the development of peritoneal metastasis in order to improve its management and prognosis.
Peritoneal discs harvested from hernia sacs obtained at inguinal hernia surgery were suspended in media using Teflon rings. Viability of the tissue was investigated using MTS assay, light and scanning electron microscopy (LM and SEM) over 72 h. To assess validity of the model, phenotypic changes in tumor cells were investigated. Changes in matrix metalloproteinases (MMP)-2 and -9 activities in HGC and AGS gastric adenocarcinoma cells after co-culture were investigated using zymography. Modulation of tumor cell adhesion to peritoneum after exposure to heparin was assessed using a fluorometric adhesion assay. Analysis was performed using Kruskal-Wallis for multiple comparisons and Mann-Witney U for comparisons between each group.
MTS assay showed reduced viability after 72 h (P = 0.047, compared with 24 h). Mesothelial cell loss at 48 h was demonstrated by LM and SEM, confirming peritoneal viability for at least 24 h after tissue harvesting. Zymography confirmed increased MMP2 and -9 activities in tumor cells and peritoneal tissue during co-culture compared with controls, and heparin significantly reduced tumor cell adherence (P = 0.04), as observed in published in vivo models.
A validated complete model of peritoneum was developed that has shown potential to determine realistic mechanisms of peritoneal metastasis.
Journal of Surgical Research 10/2010; 164(2):e265-72. · 2.25 Impact Factor
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ABSTRACT: Proctalgia fugax (PF) is a benign anorectal condition which has been described in the literature since the nineteenth century commonly presenting to general surgeons. There is little high level evidence on the subject and its therapeutic modalities. We aimed through this systematic literature review to outline the definition and diagnostic criteria of this condition, the aetiology and differential diagnoses and describe the different treatment modalities that have been attempted and their success.
A literature search of Google Scholar and Medline using Pubmed as the search engine was used to identify all studies directly related to the definition, aetiology and treatment options for this condition (latest at 12 August 2008) was performed.
The search produced 61 references with three others obtained from the references of these papers. The prevalence of PF in the general population ranges from 4% to 18%. The diagnosis is based on the presence of characteristic symptoms as defined by Rome III guidelines and physical examination. The mainstay of treatment is reassurance and careful counselling with evidence in the literature for warm baths, topical treatment with glyceryl trinitrate or diltiazem and salbutamol inhalation. In persistent cases, local anaesthetic blocks, clonidine or Botox injections can be considered after clarification of risk and benefit.
Based on this we suggest that diagnosis should be made through exclusion of common organic causes such as haemorrhoids, anal fissure or anorectal carcinoma and on the fulfillment of Rome III criteria. The main treatment for this benign condition remains reassurance and topical treatment.
International Journal of Colorectal Disease 09/2010; 25(9):1037-46. · 2.38 Impact Factor
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ABSTRACT: Merkel cell carcinoma is an uncommon skin malignancy that has a high propensity for metastatic spread. A systematic literature search identified 17 cases describing metastasis to the gastrointestinal tract, with 7 cases involving the small or large bowel. To the best of our knowledge, this is the only case described of Merkel cell carcinoma metastasising to the ileocaecal valve.
We present a 74-year-old Filipino woman diagnosed with Merkel cell carcinoma of the skin with regional node involvement. Following excision and radiotherapy, the tumour recurred with metastasis to the ileocaecal valve. The patient died 28 months after the initial diagnosis.
The prognosis of metastatic Merkel cell carcinoma is poor. Currently the optimal management for metastatic disease is unclear and lacks a firm evidence base due to the small number of cases reported.
Journal of Medical Case Reports 02/2010; 4:43.
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ABSTRACT: The frequency of anorectal symptoms amongst pregnant women has not been objectively investigated in the United Kingdom. The aim of this study was to determine the frequency of anorectal symptoms during each trimester of pregnancy.
Women attending the antenatal clinics at a London teaching hospital were asked to complete a questionnaire. The presence or absence of common anorectal symptoms experienced both before and during the current pregnancy together with demographic and pregnancy data was collected. Statistical analysis was performed using Fisher's exact test.
Two hundred seventeen patients (first trimester n=75, second trimester n=70 and third trimester n=72) participated. A significant increase in the frequency of symptoms was observed in the third (43.1%) compared to the first (16.0%, p<0.001) and second (22.9%, p=0.013) trimesters. The incidence of per rectal bleeding was significantly greater in the third trimester (30.6%) compared to the first (10.6%, p=0.004) and the second (12.9%, p=0.014) trimesters. Similarly, anal pain was significantly more frequent in the third trimester (34.7%) compared to the first (13.3%, p=0.003) and the second (12.9%, p=0.003) trimesters.
The frequency of anorectal symptom reporting appears to increase as pregnancy progresses. Further investigation and research is warranted to determine the configuration of services that may be required to treat those affected.
International Journal of Colorectal Disease 11/2009; 25(3):375-9. · 2.38 Impact Factor
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ABSTRACT: Peutz-Jeghers syndrome is a rare autosomal dominant disorder characterized by intestinal harmatomatous polyps and associated with circum-oral pigmentation affecting the skin and oral mucous membranes (Utsunomiya et al, 1975). The prevalence of this condition is not exactly known, but is approximately 1 in 120 000, affecting males and females equally (Zanoni et al, 2003). This article describes two very different presentations of this rare condition.
British journal of hospital medicine (London, England: 2005) 09/2009; 70(8):476-7. · 0.19 Impact Factor
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American journal of surgery 11/2008; 196(4):617-8. · 2.36 Impact Factor
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ABSTRACT: Hepatic metastasis can occur following curative colorectal cancer surgery despite favorable prognostic indicators, raising the question of whether detecting circulating tumor cells in the venous drainage of colorectal cancers at resection using reverse-transcriptase polymerase chain reaction would help determine prognosis. This study compares lymph node positivity, hepatic metastasis rates, and disease-free survival in circulating tumor positive versus negative patients.
A Medline, Embase, Ovid, and Cochrane database search was conducted on all studies between 1999 and 2006 reporting the outcomes of interest. Meta-analysis was performed in line with recommendations from the Cochrane Collaboration and the Quality of Reporting of Meta-Analyses guidelines.
Nine studies reporting on 646 subjects published between 1998 and 2006 matched the selection criteria and were suitable for inclusion in this meta-analysis. There was a significantly higher incidence of circulating tumor cells (50%) in lymph node positive compared with negative groups (21%) [odds ratio (OR) = 3.83, confidence interval (CI) = 2.46-5.94], and a significantly increased hepatic metastases rate (21%) in circulating tumor cells positive compared with in negative patients (8%, OR = 6.38; CI = 2.67-15.25. Disease-free survival was significantly higher in the circulating tumor cell negative versus positive groups at 1 year [hazard ratio (HR) = 0.04, CI = 0-0.46], 2 years (HR = 0.05, CI = 0.01-0.31), and 3 years (HR = 0.08, CI = 0.02-0.34) post resection.
This study highlights the potential importance of free cancer cell detection in the venous drainage of colorectal cancers as a prognostic indicator and a mode of staging colorectal cancers.
Annals of Surgical Oncology 10/2008; 15(11):3083-91. · 4.17 Impact Factor
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ABSTRACT: Groin pain in athletes presents a diagnostic and therapeutic challenge, particularly in distinguishing between those that will respond to nonoperative management and those that require surgery. Repair of sportsman's hernia, using the Modified Bassini darn or tension-free Lictenstein mesh technique, have been well described. The aim of this study was to assess the role of laparoscopy in the management of these hernias.
Seventeen consecutive male patients (median age, 27 years), presenting with symptoms and signs of sportsman's hernia to a district general hospital were reviewed. Five patients presented with unilateral groin pain, whereas 12 had bilateral symptoms. All patients underwent a diagnostic laparoscopy, followed by transabdominal preperitoneal polypropelene mesh (15 x 10 cm) repair. All patients except 1 were discharged within 24 hours of surgery, and their rehabilitation was supervised by a single physiotherapist. All patients were assessed postoperatively by the authors and at a median follow-up of 23 weeks.
The laparoscopy confirmed posterior wall weakness in all patients with bilateral symptoms and in 4 of 5 patients with unilateral groin pain. Following repair, no surgical morbidity occurred and the median return to sporting activities was 42 days. All but 1 patient returned to the level of sport reached prior to injury, and mild pain was experienced in 5 groins, which did not interfere with either normal daily or sports activity.
The transabdominal preperitoneal laparoscopic approach is safe and feasible in the diagnosis and treatment of Sportsman's hernia, enabling a full return to sports activities.
Journal of Laparoendoscopic & Advanced Surgical Techniques 09/2008; 18(5):669-72. · 1.40 Impact Factor
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ABSTRACT: In this study, the authors review their initial results with the laparoscopic approach for parastomal hernia repair. Between 2006 and 2007, 4 patients were treated laparoscopically at our institution. The hernia sac was not excised. A piece of Gore-Tex DualMesh with a central keyhole and a radial incision was cut so that it could provide at least 3 to 5 cm of overlap of the fascial defect. The mesh was secured to the margins of the hernia with circumferential metal tacking and trans-fascial sutures. No complications occurred in the postoperative period. After a median follow-up of 9 months, recurrence occurred in 1 patient. This was our first patient in whom mesh fixation was performed only with circumferential metal tacking. The laparoscopic repair of parastomal hernias seems to be a safe, feasible and promising technique offering the advantages of minimally-invasive surgery. The success of this approach depends on longer follow-up reports and standardization of the technical elements.
Surgical Innovation 07/2008; 15(2):85-9. · 2.13 Impact Factor
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ABSTRACT: The aim of the study was to evaluate the diagnostic precision of serum carcinoembryonic antigen (CEA) in the detection of local or distant recurrence following resectional surgery for colon and rectal cancer.
Quantitative meta-analysis was performed on 20 studies, comparing serum CEA with radiological imaging and/or pathology in detecting colorectal cancer (CRC) recurrence in 4285 patients. The cut-off for a 'positive' CEA ranged from 3 to 15 ng/ml between the various studies. Sensitivity, specificity and diagnostic odds ratio (DOR) were calculated for each study. Summary receiver operating characteristic curves (SROC) and sub-group analysis were undertaken.
The overall sensitivity and specificity of CEA for detecting CRC recurrence was 0.64 (95% CI: 0.61-0.67) and 0.90 (95% CI: 0.89-0.91), respectively. The area under the SROC curve was 0.75 (SE=0.04) and the diagnostic odds ratio was 18.44 (95% CI: 11.94-28.49). A CEA cut-off of 5 ng/ml yielded a higher diagnostic odds ratio than a cut-off of 3 ng/ml (15.5 vs. 11.1). Using meta-regression analysis the optimum CEA cut-off point for the best combination of sensitivity and specificity was 2.2 ng/ml. On sub-group analysis high quality studies, and those involving > or =100 patients yielded a marginal improvement in the sensitivity and specificity with minimal change to the SROC.
Serum CEA is a test with high specificity but insufficient sensitivity for detecting CRC recurrence in isolation. A cut-off of 2.2 ng/ml may provide an ideal balance of sensitivity and specificity. It may be useful as a first-line surveillance investigation in patients during surgical follow-up based on serial CEA measurements using temporal trends in conjunction with clinical, radiological and/or histological confirmation.
Surgical Oncology 07/2008; 18(1):15-24. · 2.44 Impact Factor
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ABSTRACT: Transanal endoscopic microsurgery (TEMS) will play an even greater role in the treatment of rectal cancer as the UK national colorectal cancer screening program becomes national. With more rectal tumors being uncovered at earlier stages, a greater emphasis will be placed on treatment options that do not involve radical surgery and the possibility of a stoma. This article reviews the data surrounding TEMS, focusing on its current role in the treatment of early rectal cancer but with a view on how this option may develop in the future, particularly with regards to the more advanced rectal cancers and in view of the improved chemoradiotherapy regimens available. The data is reviewed and some of the more controversial issues discussed.
Future Oncology 03/2008; 4(1):113-24. · 3.16 Impact Factor
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ABSTRACT: We report an unusual case of a patient with strangulated Meckel diverticulum in a femoral hernia. A 65-year-old woman presented with a nonradiating, constant pain in the right groin with associated nausea and anorexia. Physical examination revealed a tender, irreducible lump in the right groin area. At operation, a hernia sac containing a strangulated Meckel diverticulum was clearly recognized going through the femoral ring. A diverticulectomy was performed, and the femoral ring was closed with a polypropylene plug. No recurrence has been observed during the 3 year follow-up. Strangulated Meckel diverticulum in a femoral hernia remains a challenging diagnosis due to its extremely rare occurrence. Surgical exploration provides definite diagnosis of this rare condition.
Southern medical journal 02/2008; 101(1):96-8. · 0.92 Impact Factor
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ABSTRACT: Accurate staging of colorectal cancer is important for predicting prognosis and guiding treatment. This study uses meta-analysis to investigate if the pre- or post-resection detection of intraperitoneal free cancer cells can predict recurrence in patients undergoing curative colorectal cancer surgery.
A literature search was performed on all studies between January 1990 and July 2007 comparing the detection of intraperitoneal free cancer cells either pre- or post-resection with prognosis in colorectal cancer. The following prognostic outcomes were meta-analyzed: overall recurrence rate and local recurrence rate. A random-effect model was used and heterogeneity was assessed.
Nine studies reporting on a total of 1182 subjects matched the selection criteria. Free cancer cells were detected prior to tumor resection in 125/822 (15.2%) of patients and following resection in 64/533 (12%) of patients. Preresection, the absence of tumor cells was associated with a lower overall recurrence (25.2%) compared to the presence of tumor cells [46.4%, odds ratio (OR) = 0.41, confidence interval (CI) 0.19-0.88]; as well as a significantly lower local recurrence (12.2% versus 21.1%, OR = 0.42, CI 0.21-0.82). Postresection, the absence of tumor cells also resulted in significantly lower overall recurrence (17.3%) when compared to the presence of tumor cells (52.6%, OR = 0.07, CI 0.03-0.18).
The detection of intraperitoneal free cancer cells is associated with higher recurrence and poorer prognosis. Use of these techniques can identify patients at higher recurrence risk. This could be particularly valuable in stage II disease to identify patients who may benefit from adjuvant chemotherapy.
Annals of Surgical Oncology 02/2008; 15(1):60-8. · 4.17 Impact Factor
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ABSTRACT: The aim of this study is to describe a single institution's experience in the use of transanal endoscopic microsurgery for rectal tumors.
Between 1996 and 2005, transanal endoscopic microsurgery was performed in 76 patients. The histologic diagnosis was adenoma in 48 and adenocarcinoma in 28 patients.
Clear resection margins were achieved in 71 of 74 patients (95.9%). Overall morbidity was 18.9% because 14 patients developed minor (10 patients) or major complications (4 patients). During the follow-up, benign tumor recurrence was detected in 3 patients (6.3%). The recurrence rates among patients with T1, T2, and T3 malignant tumors were 7.1%, 42.8%, and 66.6%, respectively.
Transanal endoscopic microsurgery is a safe and feasible technique with low incomplete excision rates and may be the preferred method in patients with benign rectal tumors. Its role in the management of malignant tumors should be limited to selected patients with T1 lesions.
American journal of surgery 12/2007; 194(5):694-8. · 2.36 Impact Factor
