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Abdominal Surgery - Science topic

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Dear Colleague,
Following the success of the OGAA Delphi and OG Covid-19 survey, we would like to invite you to participate in our multicenter project titled ‘Chyle LEak following Oesophagectomy for oesophageal cancer (CLEO)’.
• Please enter the email in the survey if you are willing to take part in the second round
• We are offering collaborative authorship for those taking part in both rounds (we need email for that- to contact you back)
• This study is open only for fully qualified Upper GI Consultants/ attendings performing Oesophagectomy
You can access the online Delphi survey by following this link
We look forward to your reply and again appreciate your participation.
Best wishes,
Manju Subramanya
Ewen Griffiths
Sivesh Kamarajah
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Thanks Matti and Tageja.
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With the predominancy of minimal invasive surgery (MIS) , we will have a new generations of surgeons that are highly skilled in MIS but they are less expert in open traditional operation. which some times needed to be done obligatory. what do you think about that?
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Every kind of procedures have a place in the treatment of patients and the surgeon must use the best for the patient (personalized surgery) For example ,Robotic surgery for gallbladder is not indicated for the cost and not superiority ,Some kinds of trauma due to the emergency situation, it is obvious, robotic procedure is not indicated. I think residents must learn all the kind of procedures to be used in specific situations .
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In our practice, an estimated bullet trajectory is almost always used as a guide to intro-abdominal injuries during management of abdominal gunshot patients. While it seems logical to expect that the bullet would have damaged all structures that came in its path, what are the global practices of using an estimated trajectory when in the present era there are increasing trends of selective non operative management of gunshot patients based on objective clinical and diagnostic findings?
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= I treated a 7 yr old boy whose injury resulted from a .30 Cal deformed solid point which ricocheted from a granite wall. It penetrated his khaki trouser, scrotal skin and dartos muscle and located itself in the right testicular sac.
= Another case of a .22 Cal. solid point bullet ricochet on lagoon water fired from 500 yards on a 9 yr old. It penetrated her dress, anterior midline abdominal wall and was found sitting on top of her omentum,
= Another case was a .22 Cal ricocheted solid point bullet through the right flank of a 17 year old to lodge in his liver, right lobe. He developed and died of gas gangrene.
= Dr. Ordog, do you have studies on injuries of spent, ricocheted bullets?
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A milestone by Theodor Billroth in surgery and cancer surgery.
It is
- the 139th anniversary day (Jan 29, 1881)
Christian Albert Theodor Billroth (1829-1894)
performed
the first successful distal gastrectomy
for gastric cancer within 90 min
However, we may should be aware that everything in medicine surgery cancersurgery science needs teamwork
We are nothing without the Team!
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Theodor Billroth *26 Apr 1829 †06 Feb 1894
Remembering giants in science, medicine and surgery - German Surgeon & Co-Founder of academic surgery
Happy Birthday
"I can not understand how someone can read receptively only"
"Only those who know the past & present of science and art, will boost their progress with awareness"
~ Theodor Billroth
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Pure tissue repair? Prosthetic repair? Modern specific device like Ventralex and PVP devices?
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I Have always used a mesh despite size in adults. usually light weight mesh and placed between the anterior and posterior sheet ideally. the reults have been very good with no removal of meshes in the last 24 months and the infection rate less that 5%.
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Clot sustained in a accident, however patient doesn't has any sign or difficulties. Some physician suggest it may dissolve itself and other recommends a surgery. Please explain.
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Please de-identify the photos (remove patients name)
Do diagnostic thoracentesis, if pus, insert chest tube.
If no infection with free fluid, insert pigtail
Clotted blood or encysted, decortication
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1.What is the function of Appendix(Cecal Appendix) in the body?
2.What will happen for a person after Appendectomy?(with Appendicitis)
3.What will happen if the normal Appendix remove?(without Appendicitis)
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In addition to the earlier answers, recent studies suggest very early appendectomy may be associated with autoimmune disease development, including inflammatory bowel disease (IBD), rheumatoid arthritis and lupus. This is probably due to an exaggerated immune response, one that has not been adequately primed for appropriate reaction due to the absent appendix - a seat of lymphoid tissue. The 'hygiene hypothesis' applied to IBD may also be applied to this phenomenon. Further, this indicates a possible role of the appendix in "post-natal" immune tolerance, akin to the role of the thymus in-utero.
The other theory put-forth recently is the protective benefit of appendectomy in preventing neurodegenerative disease. The immune response initiated by the lymphoid tissue in the appendix each time they are stimulated result in free radicals, reactive oxygen species and other metabolic byproducts that have been implicated in the pathogenesis of neurodegenerative diseases including Parkinson's. The model of hepatic encephalopathy is a good comparison.
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According to international and local guideline, cefazolin is to be prescribed.
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Maybe it is due to OR conditions and lack of standard asepsis precautions or using it in just contaminated abdominal surgeries like entrotomies. It is believed ceftriaxone was superior in contaminated operations as a prophylactic antibiotic.
But, better to remind antibiotics should never be substitutes for “surgical conscience.”
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general surgeon had debate regarding immediate or delayed traumatic abdominal wall hernia , so which is better and according to what size or condition do we need to decide to do immediate or delayed repair 
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Early repair is better
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We are involved in an animal experiment to compare results of diferent abdominoplasty techniques, finding exact position and preservation of the umbilicus stalk has been quite difficult in pilot studies. Sugestions? 
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I suppose it's anatomically determined by any median scar or depressed point in the middle of the abdomen less than 10cm distal to xiphoid apêndix region below clavicle.   
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PD chronic therapy
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The changing of the titanium adaptor should always be performed with strict aseptic technique. However, since the titanium adaptor can be difficult to remove, it is always a concern that the PD nurse could accidentally contaminate the distal end of the PD catheter or the new titanium connector, thus putting the PD patient at risk for peritonitis from touch contamination.
In general, unless the titanium adaptor for some reason is obviously soiled, we would not recommend changing the adaptor routinely with each episode of peritonitis.
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What are the current indications for the use of Diagnostic Peritoneal Lavage (DPL) in abdominal trauma patients?
ATLS 
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In the last twenty years in our emergency  hospital  we have performed only less than five DLP, I think. This extremely low number is explained because we have routinely performing FAST in the emergency department to all patients admitted with blunt  or open abdominal trauma. In some cases, when the diagnosis was uncertain we performed abdominal puncture under US guidance. Hemodinamic stable patients, in the last years, were referred to the CT scan for a thoroughly abdominal exam.
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A Beaurocrat 62 years on his annual checkup found to have a cystic leision in the pelvis reaching up to the Right Iliac fossa on U/S.Suspected as a case of Enteric duplication cyst, hence he was referred for further management.He is a Hypertnsive on medication.Clinical exam was normal , could not feel any mass.
Rest of the work up was normal except cect showed tubular cystic structure measuring 15cmsx6.2 cmsx6.3 cms extending from the Right iliac fossa .Endoscopic and colonoscopic assessmennt was not done.would a simlpe appendicetomy suffiecient !
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Mucocele of appendix in itself is not common. Most of the cases remain silent till they   present as acute appendicitis and diagnosis is per-op or HPE. But to such a giant lump lying asymptomatic without any mass effect or pain, and not ruptured till this size is reached, is very uncommon.
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A man of 49years presented with a history of constipation for over 5years, bleeding,feeling of mass per rectum on straining and used various methods to regulate his bowel habits with out success.He is not a diabetic or hypertensive.CBC(Hb dropped from 12Gr to 10 Gr) , LFT,TSH,PTH, Calcium,U/S scan are normal.Colonoscopy is normal except congested haemorroids. 2degree.
Anorectal manometry-normal squeeze pressure,50 mls balloon was expelled without difficulty and shicters are normal.Psychological assessment is not significant.
He says that his life style is getting affected.
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Just as today's science fiction is tomorrow's science so too is today's pharmaceutical wonder tomorrow's poison. For example, Warfarin, a rat poison will soon be phased out with the APPROPRIATE introduction of DOACs - even the term has changed! A year ago they were called NOACs! They're not novel anymore. 
Personally, I would be very wary of any loco-regional recommendations, due to the fear of starting unscientific trends and vogues. I do believe while the information you provide above might be of some relevance to the Indian society, if freely and easily available (I.e. Unadulterated spices and legumes at a price cheaper than reliable pharmaceuticals) then by all means start a well- designed randomised controlled trial, with at least 5-10 years follow up, given the vast number of compounding variables. If not, one is only able to make suggestions based on personal observation to individual patients in good faith. Faith, albeit well- intended is not science! 
Please remember, all this is an international forum of communication, and it's called research gate! In the interim, thank you for providing the linked article. I will definitely go through it to look at the quality of the data provided. 
Please remember, Charaka Samhiti, the origins of Ayurveda, lists the ethical duties of the Doctor, the nurse, the patient and the drug - the drug must do what it is expected to do! There was an ethical requirement for the doctor to study all the international literature he could get hold of, and make intelligent adjustments to his prescriptions accordingly, so the nurse-compounder could mix better potions and the patient remained trusting and the doctor respected and trustworthy. 
If one has knowledge of ancient cultural practices, and if one wishes to utilise such information in treating another - human or non-human person, I believe they are duty-bound to do so in a scientific manner!
It is not without unfortunate reason that despite an exceedingly high level of knowledge and information in the East those of us from the Western scientific community do not publish our work nor rely upon information published in Eastern journals. 
Again, Dr Reddy please do source locally relevant dietary modifications and do not rely too much on surgical techniques tried and tested in a different part of the world in an area where John Bunni will tell you there remains a lot of controversy, because colleagues "treat" using techniques on which there is little consensus data. 
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66 year old who had Liver transplant in 2011 presented with  a blow out at the left edge of the Bilateral subcoastal incision for 6 months. Immunosuppression has been titrated and antiplatlet drugs were stopped. His LFT are normal.He prefers to avoid open surgery.
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Dear Deborah. We have, analogously to Your experience, in our study report speculated that, besides choosing a mesh with good ingrowth features - which excludes ePTFE and biological material - a permanent fixation is advisable in immunosuppressed organ transplanted incisional hernia patients repaired with IPOM+. Additionally, allowance of a generous overlap; advises not followed in the presented case. But we are short on scientific evidence.
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36 year old male underwent Laparoscopic sleeve gastrectomy 2 year ago and his BMI was 43.4. After the surgery his BMI was 36.2 . He is Diabetic but insulin requirement did not come down significantly . For 2 years he was maintained  his weight loss , but now he regained about 20 kgs. His main complaint is severe disabling GERD affecting his lifestyle .
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Conversion to RYGB
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Richter's hernia is a rare form of hernia when an antimesenteric part only of the circumference of the small bowel is strangulated in a hernial sac. This kind of hernia is reported for the narrowest openings in the abdominal wall: umbilical, femoral, and obturator.
Mechanisms of the Richter's to develop were suggested as early as in the 18th century.
The first hypothesis was coined by A. Littre, 1701, that that sort of herniation may occur if adhesions between an intestinal loop and hernial sac have developed before the hernia formation. There are no adhesions found in the majority of cases, though.
The second mechanism was suggested by A. Richter, 1778, that the hernia develops due to the so-called 'elastic constriction' by a narrow opening after coughing, etc.
However, all these openings (umbilical, femoral, and obturator) are not elastic absolutely, so that this mechanism seems to be almost improbable.
Is there any news on the matter since the 18th century?
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Yes, in that case the mechanism would be as suggested by Littre
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Hi guys.
I would appreciate your thoughts.
As a postop analgesic adjunct for major open abdominal surgery, most of the conventional research uses ketamine at conventional doses of i.e 0.1-0.2 mg/kg/hr.
Using ketamine in my regular practice for managing patients having complex prolonged open hepatobiliary surgery, I am using ketamine using "ultra-ultra-low doses: i.e 0.025-0.05 mg/kg/hr for 48 hrs with almost no side effects, yet outstanding analgesia (combined with other multimodal strategies i.e opioid PCA, NSAID and paracetamol). I also notice that at this dose there appears to be excellent opioid sparing properties.
Do you have any experience with using ketamine as these doses?
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Very interesting at such low doses
Our research was looking at use for anaesthesia (sedation/ analgesia) doses, combined with propofol at different ratios
We modelled on the McFarlan regime (initial bolus dose followed by an infusion) and then reductions in the McFarlan regime thereafter, and found rates of 15-50µcg/kg/min were satisfactory up to 90 min anaesthesia in combination with propofol.
So, pure analgesia use is 60 times lower dose, albeit as part of a multimodal strategy
I don't think our work is easily applicable to your patients – awake with pure analgesia aims. The ultra-low dose numbers are very interesting though.
Do you use a loading dose? We found LD 15-16 times the per minute dose rate were useful. Again, with an aim of early loss of conscious being the aim.
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35 years old lady presented with mesenteric ischemia, resection of small bowel and double barrel stoma matured, 10cm from DJ and distal stoma (~100cm small bowel left behind with intact ileocaecal junction).
Post op 3 weeks now and viability of rest of small bowel is out of question. Enteral feed being a better option than parentral, what are possible improvised method to feed through the distal Enterostomy?
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Hello,
I feel you need to do a number of things;
1).  Long term TPN, the patient is young, and there are lots of successful instances when patients have be maintained on parenteral feeding long term, for example, complete intestinal failure, whilst awaiting definitive treatment, in intestinal failure units.
2). Feed through the distal stoma, this might be technically difficult but you could try passing a fine bore tube through the stoma using an endoscope, a good distance, to reduce reflux of feed back out. Reduce her intestinal secretions with octreotide 150 micrograms tds, give her St. Marks solution orally, and NO hypotonic fluids. I can send you the instructions if you need them. Replace intestinal losses IV and by adding to the TPN. Get the dieitian involved.
3). Early reversal of stoma. I would wait about 20 weeks or longer, and also site a feeding enterostomy at time of Surgery well distally.
If anything else comes to mind I will let you know.
Hope that helps,
Gurpreet Singh Ranger 
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A 23-year-old male patient was admitted to ER with active, abondance hematochezia.The patient was anxious and pale; pulse was 140/bpm, blood pressure was 80/40 mmHg and no urine output after 1000 cc Ringer's Lactate and three packages of whole blood infusion via central venous catheter. Anal- rectal inspection and digital examination were unremarkable. Abdominal ultrasound was revealed that hematoma-like appearance was present throughout from cecum to the sigmoid colon. We could not able to reach  CT, CT angio, angio and colonoscopy.
Nearest colonoscopist was 10 km. and nearest angio was 150 km. away from the current rural hospital.
The patient's condition could not changed in spite of another infusion of fluids and blood products ( We could able to reach  just whole blood and fresh frozen plasma)as well as hematochezia was continued.
In this condition, what could we do? 
Is the (blind) total abdominal colectomy feasible option in this condition?
Thank you in advance for your comments. 
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Bleeding requiring four units of blood in 24 hours or 10 units in total must be treated surgically. The laparotomy, in the absence of a reliable source of bleeding will most likely be a "blind colectomy". This still happens, though rarely, in western countries also. That for which I totally disagree with what has been done is the absolute lack of any attempt to diagnostics. An endoscopy service at Km 10 is not unattainable, plus 150 km there was a service of Angio CT. If the patient had been kept in hemodynamically stable conditions, a helicopter could transfer the patient to a center of high-volume where a diagnostic CT would be of great help. Then no one can say what would have happened, but doing so was not given any chanche the patient and the surgeon.
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A 19 year old who was operated for Heirshprung's disease (Ileoanl anstamosis) 2years ago elsewhere presented with subacute small bowel obstruction. Abdomen is distended and small bowel loops are seen. It is not tender. Digital rectal examination is normal. CT scan showed distended small bowel loops up to the anus and Anus is collapsed.
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I quite agree with Dr. Prasanna's circumstance of moment, to maintain a conservative treatment to ensure daily evacuation of stool and occasional enema, "Primum Non Nocere".
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I would like to share the experience about groin hernia in children and the use of ultrasound to assess the presence of contralateral PPV.
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I also feel that  u/s is an unhelpful investigation. A patent processus on its own does not warrant surgery. I only operate on the side of the hernia. Unfortunately many of our patients present to us with an u/s which had been requested by their GP.
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Of course, the main stay in Roux en Y GJ is to separate the bilio-pancreatic limb from the gastrojejunal limb so as to prevent reflux biliary gastritis. It's more demanding however effective. It can be made as classical roux en Y or modified one without any jejunal division by doing simple GJ followed by entero-enteric anastomosis between the afferent and efferent jejunal limbs to the stomach and then ligating the afferent limb DISTAL to the entero-enteric anastomosis. 
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A large proportion of umbilical hernias will self resolve with age. At what stage do you tell the parents that their child's hernia will not improve further, and you would consider a repair for cosmetic reasons.
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In an ideal situation beyond 3-4 years  and before the 5th birthday
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The continued mechanical stress caused by the chronic presence of a relatively high fill volume is at least a cause of interstitial remodeling and therefore contributes to the burden of inflammation.
In each exchange, the tissues bordering the peritoneal cavity are exposed to a mechanical stress of 2 kg. Do the mass to calculate the mechanical stress over the peritoneum in one year! 
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We are working on it
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Do you use standard heparin or low molecular weight heparin?
Do you use it selectively or routinely?
In case of selective use: who is given thromboprophylaxis?
Have you encountered DVT or Pulmonary embolism after laparoscopic cholecystectomy or TAPP? If so, what is your incidence?
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Thank you Dr. Bobowicz for your valuable comment. It is reassuring to know from that none of the lap group had thrombotic event with LMWH prophylaxis in your center.
Thank you also for bringing to our attention the important issue of giving the spinal anaesthesia during surgery and epidural analgesia in the postoperative period so the LMWH is given at the latest 12 hours prior to surgery. My question: will you restart LMWH on the same day of surgery and when? Thank you
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Although most surgeons may claim to master all current hernia surgery techniques, a recent analysis show that outcomes of hernia surgery in different hospitals show a large variability. Additionally to two major problems of groin hernia surgery (chronic pain and hernia recurrence) remain a continuous challenge. A few networks (e.g. Denmark, Germany) have come up with a hernia database to monitor surgical quality and set benchmarks. 
Do you think we need more quality management in hernia surgery?
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The RCS England have published a document which includes at the end some 'quality' specifications.   
Its not amazing, but these criteria are designed to be easily obtained using administrative databases.
Cheers
Ewen
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A 45 years male with R inguinal hernia (size 42 by 34 cms) of 6 years duration with no symptoms of obstruction.
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Thanks all of you for your valuable comments. Is it possible to reduce this huge hernia in staged procedure.? There will be increased intra abdominal pressure to a dangerous levels if we attempt reduction of all contents without initially increasing the abdominal 
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We know that R0 resection is clearly desirable in preventing local recurrences, but in the setting of large resections, e.g. extended or trisegmentectomy, with potential R1 resection due to positive margins, has anyone had experience with IORT to supplement margins?  The use of IORT in rectal cancer and breast cancer have been demonstrated, but little reports for primary intrahepatic cholangiocarcinoma or HCC.  
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Maybe a  better question to ask is: do you use Stereotactic body radiotherapy (SBRT) aka Cyberknife, for treatment of any liver tumors?  There has been a wealth of experience from Asia that SBRT is as effective and less toxicity than TACE or RFA.
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30 year old who under went an attempted lap chole converted to open,also underwent a diagnostic Lap 8months ago,presented with complaints of abdominal pain,feels full with small quantity ,no vomitings and no significant  loss of weight.She was hospitalised twice after surgery for pain and was treated conservatively as per her hospital records.OGD in their hospital showed a gastric ulcer and a repeat was said to have the ulcer healed.Clinical exam is normal except Right subcoastal incision and multiple Lap port scars.OGD in our hospital showed the above suspected diagnosis and technically difficult to extract.CECT report is awaited.
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If a foreign body is present without doubt, it should be extracted if the surgical risk is not prohibitive. Open abdominal exploration seems the best approach. Once you have diagnosed it, you have to inform the patient about what happened and what you are intending to do to help her. Failure to do so is potentially dangerous to her and to yourself.
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I just started with laparoscopic abdominoperineal resections for low rectal cancer. There was a patient with rectal cancer on 1 cm, without neoadjuvant therapy. It was a thin man, and operation went smoothly. I put some sutures on peritoneum to close the pelvis, like in open procedure. But after operation patient went in ileus and I had to operate him again (laparoscopicaly) on day 8 and found cca 30cm of terminal ileum in pelvis, which slipped between sutures. Bowel was vital but affected, no perforation, no peritonitis. I closed the pelvis with dual mesh. After two days patient became more and more septic and our team decided to make laparotomy and we found diffuse peritonitis with fibrin and pus everywhere. The mesh was in situ, there was no bowel perforation. We performed only lavage and treated the abdomen with negative pressure. After two sessions we managed to close the abdomen, and the patient is now OK.
How do you act in APR? Do you close the peritoneum over pelvis or leave it open?
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Never, because the peritoneum generally doesn't meet easily and small gaps will be left (which are much more dangerous than big gaps for causing internal small bowel obstruction). Its the same reason I never close mesenteric defects after segmental resection.
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Inguinal seems to be safer but less effective. Is this true?
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I agree with Darby
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Most cases of acute anal fissure don't respond to conservative measures.
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I THINK THAT NO PLACE FOR MAD IN MODERN SURGICAL PRACTICE...USAGE OF TOPICAL NG OR NEFIDIPINE WILL GIVE GOOD RESULTS IN ADDITION TO SALTY WARM BATHS AND STOOL SOFTENERS, TOPICAL LIDOCAINE CAN BE ADDED
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A repeat LSCS was done on a patient with previous LSCS, at term. Previous LSCS scar was subumbilical midline longitudinal. The second LSCS was done through the same incision. Sutures were removed on 8th postoperative day. Initially wound appeared healthy. After few hours, there was serous discharge from the wound and on opening the dressing burst abdomen was evident. The wound was unhealthy. There was difference of opinion on whether patient should be taken up immediately for repair or delay till evident infection subsides.
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I think if the burst abdomen  has the big dehiscence with bowels herniating out of it sometimes with the cough also should be taken to operation theater.collection of pockets of infected material should be drain out,the stucked bowels can sometime goes in to the obstruction so  mass closure with interrupted sutures as already said by Prasanna  will help the situation.
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63 y.o. patient with small + large bowel diverticulas. CT-scan shows large amount of free gas in the abdomen. Symptoms of abdominal dispension, but no pain or symptoms of perforation. No previous surgery. Laparoscopy found no signs of perforation, but small bowel and large bowel diverticulas as well as a few diaphragmatic bullae. Ct-scan with oral constrast showed no signs of perforation. Any suggestions of pathology or relevant examinations?
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Your case report seems to be a case of cystic intestinal pneumatosis. Almost always is simptomatic with abdominal pain and free abdominal gas (see the attached file ), but sometime could be asymptomatic or light symptomatic. I remember two cases of CIP operated on, one symptomatic and one not. The procedure was the resection of the small bowel affected by the cystic formations. It's not so rare and affected not only elderly patients.
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Measuring 'quality' in surgery has become important, as its only with measuring 'quality' that we can begin to make improvements in care.   Various measures have been suggested, such as 
Mortality
Length of stay
Reoperation rate
Readmission rate
Intra-operative injury rate (for example CBD injury / ureteric injury)
Rate of laparoscopic surgery
Rates of conversion to open surgery
to be measured to compare quality in surgery specifically.
Lots of these factors can vary naturally, with a hospitals patient population (rich, poor, age group, comorbidities, hospital size, urban, rural, delays in presentation, access to healthcare etc) and other factors such as surgeon training / experience etc and many other reasons.    So variability in these factors is to be expected.
What makes a good 'quality marker' in surgery?
Your thoughts would be appreciated. 
All the best
Ewen
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Very very excellent question! The same as what I want to ask.
It's true as indicated by above answers that in a broad sense, surgical quality could be evaluated by numerous layers of parameters: blood loss, postoperative recovery, pain, patient experience, you name it. I can assure you, viewing in this bird-view angle, it is impossible to evaluate surgical quality or the quality of a surgeon.
Answer my question first: what is a SURGEON? What makes you different from other physicians? What makes you proud of what you are doing?--- Yes! SURGERY! YOU ARE "FIXING" A LIVING PERSON AND SAVING LIFE WITH YOUR KNIFE AND NEEDLES!!!
A long time ago, it was said that a surgeon should have "eagle's eyes, a lion's heart, and women's hands". I was inspired by these words and struggled out of my country to come here to join the team of the best. I don't know how many of you guys still remember this verse, but I'm sure no one is paying any attention to it. However, from my "stupid" point of view, this is EXACTLY the parameters you MUST look for to qualify a surgery and a surgeon--- A profound vision into surgical science, a superior knowledge-based decision maker, and the finest skillful craftsman with prudent responsibility. This is the core parameter that decides the outcome of a surgery. This decides all other above mentioned measures. Yet you are asking: how to measure these?!
I tell you, it's very simple, but I'll ask: do you DARE and do you really CARE? All these properties boils down to only one element: "Surgical skill". If a surgeon, who loves surgery, looks at his operation from the point of view of a craftsman, he would die to make his surgery flawless. And a flawless operation will beat all the indirect measurements like hospital stay, patient feeling, what-so-ever! In such an advanced world, this is very easy to achieve: every surgery should be recorded with video and sound, then reviewed anonymously by a board of superior surgeons. Scores placed on intraoperative bleeding, intraoperative decision making, collateral damage level, surgical cleanliness, intraoperative patient status, suturing skill, tying skill, incision skill, fine movement of instruments, etc. I'll assure you, if you really do so, you will see a tremendous difference between our current attendings. You will be shocked to see why some guy is still working here! How he was selected to be a surgeon!? So answer my question: do you dare to?
Quality control by this means would be most efficient and cost-effective, because this catches problems in ahead, instead of wasting resources to "manage" them after they do occur, which though is the requirement of "evidence-based-medicine", correct? :) LOL
Unfortunately, the quality of surgeons is drifting downwards these years globally. We have a saying: " to attend to the superficials and neglect the essentials". Way too much emphasis placed on candidates' communication skills and their ability to handle textbook knowledge or even their research experiences, but ignoring the most important part of a surgeon: his potential on mastering surgical skills. We are producing more speakers instead of doers. I was told that surgical skill is not viewed as an essential part of surgery......
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Abdominal abscesses, free abdominal fluid, bile leakage or hemorrhagic collections could be some laparoscopic complications: what's the best way to manage these problems,"'re-laparoscopy" or open surgery?
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It largely depends on the surgeon's experience and the importance of the complication. The policy of our institution generally is to use laparoscopic access if the patient was previously operated laparoscopically. Then, if the surgeon is not able to successfully treat the complication, a open surgery conversion is advised. However, open surgery is avoided in many cases.
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I wonder what do you think of the "bedside ultrasonography"?
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I agree with the notion that all surgeons should have experience with ultrasound; in fact, I think that it should be incorporated in the surgical curriculum. Eastern Virginia Medical School is leading the charge in integrating ultrasound into the medical school clinical curriculum. From a surgeon standpoint, I think that it will help with ED triaging, trauma bay, ICU evaluation, and routine floor management.
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I am working in a research about the mortality among elderly, underwent surgery in my hospital. Anybody can help me?
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Depends on what you have and your aim. There are many published researches on mortality of elderly surgical patients. Going through some may help
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Personally, I would point out HerQLes -- however, several different questionnaires are used world-wide. Which would you prefer?
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Dear Jensen
Zieren et al [1] studied the quality of life after elective hernia repair by using the Short-Form 36 questionnaire and found significant improvement in preoperative quality of life regarding freedom from pain, vitality, and physical
activity. Patients with scrotal hernia suffer preoperatively from an impaired quality of life, and it is unclear whether the quality of sexual lifeis improved by hernia repair.
The International Index of Erectile Function (IIEF) is a 15-item, self-administered questionnaire to assess male erectile function in the previous 4 weeks and is used to detect treatment-related changesIIEF was used to assess quality of sexual
function[2].
Ref
1 Zieren J, Kupper F, Paul M, Neuss H, Muller JM. Inguinal hernia:
obligatory indication for elective surgery? A prospective assessment
of quality of life before and after plug and patch inguinal hernia
repair. Langenbecks Arch Surg 2003;387:417–20.
2.Ertan T, Keskek M, Kilic M, Dizen H, Koc M, Tez M. Recovery of sexual function
after scrotal hernia repair. Am J Surg. 2007 ;194:299-303.
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It is not unusual to find a case of long distal ileal stricture in terminal 2 feet of ileum. Causes may be tubercular, post perforation closure( Inflammatory). It is always a dilemma to resect the segment and perform ileoascending anastomosis or less radical approach by ileotransverse bypass. Useful posts in this situation are invited from literature search with personal experience series.
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Depends on the length of ascending colon left after resection. Have done  both without any undue consequences.
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The current recommendation is that mesh size should be calculated with a 5cm margin all around from the defect edge. So if defect size is 4cm, mesh size should be (5+4+5) 14cm. Now this means the mesh should be circular with a diameter of 14cm, but most of the meshes available in the market are rectangular.
A German center recommends mesh covering the entrire previous incision from which the hernia occured.
Any comments?
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Habeeb, how much evidence do you have on that rule? Who published it and who has proven it? What about the patients characterics beyond the hernia margins (4cm in a 50KG Body are never the same as 4 cm in a 90 KG Body, etc.)
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I have operated a case of post gastrojejunostomy patient. He had huge projectile bilious vomiting with efferent loop obstruction and afferent loop syndrome. During surgery, I found excessive bleeding tendency. What may be the cause? 
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Prevention is the best.One must avoid the efferent obstruction and blind afferent loop syndrome(ALS) by adopting the basic principles of GI Surgery.However in this case one can predict coagulation disorder only in presence of a very longstanding and long loop afferent loop syndrome(chronic ALS) and not if in case it has been an early(ALS) complication of GJ in GOO.
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I had an appendectomy on a 25 years old man with an unexpected mass in cecum. I did a right hemicolectomy at that stage. Now I have the pathologic result: Esosinophilic entropathy! Is there any guideline for unexpected masses in cecum during appendectomy? Was my procedure right?
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This is an interesting but not uncomon case, particularly in the younger population. Most cases are indeed benign and usually due to inflammatory causes e.g. abscess from the appendicitis itself, associated inflammatory bowel disease, worms in certains parts of the globe, and occasional diverticulitis. There is several good reasons to perform an resection:
1) Provides pathological diagnosis of the unknown mass
2) If the tissue is inflammed, it may compromise the healing of your appendiceal stump
3) If the mass left untreated, it can precipitate subsequent small bowel obstruction
4) And very occasionally the diagnosis is malignant which will significantly change the patient's subsequent treatment, And a delay in diagnosis in this situation will be unsatisfactory. We had a patient who was diagnosed of angiosarcoma presenting with a appendiceal mass: Small intestinal angiosarcoma masquerading as an appendiceal abscess, Ann R Coll Surg Engl. 2013 Jan;95(1):e22-4. doi: 10.1308/003588413X13511609955373
Depending on comfort and expertise, ileocaecal resection should suffice, otherwise right hemi is fine too
Another relevant reference: Inflammatory cecal masses in patients presenting with appendicitis World J Surg. 1999 Jul;23(7):713-6; discussion 716
Hope this helps
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Hi, Does anyone know of this Author and the availability of the published paper?
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Dr. Suman Das is a plastic surgeon in Flowood, Mississippi and is affiliated with multiple hospitals in the area, including River Oaks Hospital and St. Dominic-Jackson Memorial Hospital. He received his medical degree from RG Kar Medical College Calcutta and has been in practice for 47 years. He is one of 14 doctors at River Oaks Hospital and one of 7 at St. Dominic-Jackson Memorial Hospital who specialize in Plastic Surgery. He also speaks multiple languages, including Hindi/Urdu and Bengali.
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52 year old male presented with acute abdominal pain, vomiting. History of similar episodes 2 to 3 times earlier settled spontaneously. This episode was severe hence attended ER at their own place. Plain x-Ray abdomen showed 3 to 4 fluid levels. CECT
in their place suspected to have paraduodenal hernia. When he was transferred to our hospital, started passing flatus and was feeling better but clinically mass was felt in the left hypochondrium. Exploration confirmed the diagnosis and the sac was excised, small was released placed in order. Could not close the the sac as it was too small.
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And particular thanks to Dr.Raza for an article on the paraduodenal hernia downloaded! The thing is worth to read.
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Hydrolipoclasy is an alternative technique less invasive than liposuction. It uses normal saline or hypotonic solution and ultrasound waves to directly act on local adiposity. In theory the saline solution applied makes the fat cells easily eliminated.
It is being used for aesthetic reasons and/or after a bariatric surgery or after loosing a lot of weight.
Is the ultrasound effective to eliminate/break fat cells?
Is the hydrolipoclasy effective?
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Hydrolipoclasy have been introduced in aesthetic market basically for the treatment of cellulite (just orange skin, or mild cellulite), supporting in the idea of removing the superficial fat, up to 1 cm below the skin surfece.
For this treatment, a high power ultrasound device (more than 20 watts per sq. inch), is needed. Besides, the ultrasound must be 3 MHZ type. Other physioterapist ultrasound are 1 MHZ, and those are not useful.
Although it is somewhat effective, these high power devices are dangerous, and may cause skin burns, so it is mandatory to use them with a temperature sensor during all the procedure.
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A 70 year old male) patient was incidentally diagnosed with a Mixed-andeno- neuroendocrine-carcinoma (manec) pT4, pN1, V1, ,L1, Pn1 grading G3, . No metastases. He unterwent a Whipple's procedure with good recovery. He started chemotherapy Cisplatin/Etoposid. The first reevaluation showed 3 "lesions " in his liver suggestive for metastases (60% of examiners) or asymptomatic cholangitis (the other 40% examiners). Without any other intervention the chemotherapy was continued and after 4 months the lesions have all disappeared.
Beeing an extremely maligne cancer type with low survival rates. The question has deep implications for our further planing of therapy.
PubMed did not give any answeres.
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It is clearly not a common problem but it exists. I had similar case few years ago – a male patient after PPPD who had two low-attenuating lesions in the left liver at CT, and PET-CT demonstrates hypermetabolic activity (as you can see at the attached figures below). As patient refused chemotherapy we did left hepatectomy. Histology revealed both lesions to be an inflammatory pseudotumors and the presence of marked chronic cholangitis was also noted by pathologists.
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For the most number of cases, there is not any difference, so that a surgeon can choose any on the bases of other conditions, like the given patient's body mass index, comorbidity, etc. The personal experience of the surgeon does matter as well.
The interrupted or intradermal suturing do not alter the wound infectious complication's rate in either case. On the other hand, the former might be used even in case of frank abscess formation providing that a system for acitve irrigation and drainage was carefully placed and insert through the separate stab wound.
The only reliable explanation not to use the latter way of the skin closure (intradermal running suture) seems to be not to waiste time and efforts if the risque of purulent complication is too high.
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There is ambiguous evidence that urological procedures are safe in a patient who is taking Aspirin. Currently, many surgeons would accept operating on patients who are on low dose (75 mg) aspirin, rather than risk an adverse cardiac event by stopping the drug. Is that a safe threshold from the increased post-operative bleeding point of view? What is the evidence?
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There is good evidence that it is ok to operate on and perform almost all urologic procedures if a patient is on Aspirin. In my practice, I like to take patients off of aspirin if possible and I routinely discuss this with the patient's cardiologist. If the procedure is necessary in a certain amount of time (Cystectomy) and the patient cannot come off of aspirin, I will proceed with the operation. Hope that helps.
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Would you will treat varicose veins before, simultaneously, or after abdominal intervention?
Varicose veins are generally considered to be a risk factor for venous thrombotic complications in general surgery.
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I agree that varicose vein disease is not a contraindication for abdominal surgery even in the case of elective procedures for non malignant disease. However the varicose veins are a risk factor for dvt. In my hospital we have a score chart to quantify the risk of dvt in order to select the best prevention of dvt in where varicose veins count as obesity age etc......stocking and lwmh are all excellent even combined to prevent dvt
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Can inferior vena cava diameter variations (cava index) be used to optimize intraoperative fluid management?
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Actually during liver resection we ask the surgeon to measure inferior cava vein diameter and its variation by intraoperative ultrasounds. We are trying to find a correlation between it and other volemia related parameters (cardiac index, central venous pressure, stroke volume variation, fluid balance)
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The WSES Consensus Conference (Bergamo, 2013) guidelined the Cruse visual criteria as cornerstone for a desicion making whether or not a mesh should be implanted in the emergency repair of complecated abdominal hernia.
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Dear Dr Borodach..
Thank you for bringing attention to this guideline document. While going through the document, I could not find the Cruse Visual Criteria. I will be grateful if you can elaborate on this criteria and how it helps in the decision making process.
Regards, raza
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There are concerns regarding mesh infection during emergency hernia repair especially if a segment of bowel has compromised blood supply requiring resection. On the other hand, anatomical repair of these hernias will lead to a high recurrence rate. In these circumstances, what is your preferred technique of repair?
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we are loosing the core of disease. In strangulated inguinal, crural or incisional hernias the real problem is quoad vitam. The hernia recurrence is secondary. I confirm that is better a recurrence in an healthful patient than the risk of infected mesh. i'll read with interest the article you cited but i think that in in emergency surgery the common sense should prevail
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Several million cholecystectomies are performed every year in the world.
On the other hand, a tiny group of people exist which lack the gallbladder from birth and which may serve for comparing and prognosing. Moreover, there are several species of mammals evolved that divorced with the gallbladder from the Pleistocene or earlier. Why and how do they live, forage, and do they have any physiological features that may be a reason for concern for us, human beings?
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Dear colleague,
Thank you very much for this profound answer!
Of course, I have read your article already when I asked the question, and I did not expect (and this is honour for me) that you personally were that one who give an answer.
My article on the GBA is to be published in a journal 'Annaly Khirurgicheskoy Gepatologii' (Moscow) in the end of this or in the beginning of next year, so that I invite you, in my turn, to read my article. A summary is in a docx. file below.
Thank you again!
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Nowadays the best practice for grade I and more or less for grade II acute cholecystitis is early laparoscopic surgery, suggested in Tokyo Guidelines. For Grade III cholecystitis of Tokyo Guidelines scoring, an alternative procedure, the cholecystostomy like bridge to surgery or as definitive treatment for critically ill patients is suggested.
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It is not possible to make definitive recommendations
regarding treatment by PC or cholecystectomy in elderly or critically ill patients with acute cholecystitis, but pending the results of the CHOCOLATE trial, I think that in acute calculous cholecystitis, percutaneous cholecystostomy can be used like "bridge to surgery", instead the same method in acute acalculous cholecystitis can be considered, on the basis of each patient, a definitive method
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In those cases, a contrast CT scan seems to be more effective to locate and diagnose the nature of the bleeding. What do you think?
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I do not think that diverticular disease is the only cause of lower gastrointestinal bleeding. In emergancy settings a CT scan may be indicated only after a proctologic examination does not find other source of bleeding (haemorroids, fissures, rectal or anal polyops, solitary ulcer syndrome). Anyway, a successive colonoscopy is mandatory expecially in old patients.
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The identification of a definite point of obstruction, the ‘transition zone’, with dilated small bowel loops proximal to the site of obstruction and collapsed loops distally, is the most reliable CT criterion for diagnosing small bowel obstruction .
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I've been studying in some books and found differents values, none consensus.
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The best studies to answer to this question come from cancer registries. In western countries, the SEER is the most accurate. Tumors are located with the same rate in the right colon, left colon and rectum.
(right colon 28%, sigmoid 23%, rectum 25%, rectosigmoid 10%: Anatomic subsite of primary colon colorectal cancer.... Cancer 2013)
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I want to compare prognostic indicator like RANSON,GLASGOW and MODIFIED ORGAN SYSTEM SCORE according to length of stay.
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Length of hospital stay is due to many factors - personal, medical and cultural. Not that it is a consequence of severity not a cause and as such would not be an appropriate parameter by which to define severity. See Petrov et al Gastroenterology 2010 for determinants of severity and Dellinger et al Ann Surg 2012 for definitions of severity.
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Distention of the small intestine loops by liquid and gas content, along with contemporarily disappearance of the colon 'pneumatization', are characteristic for the severe secondary and for the tertiary peritonitis cases. One may suggest that either phenomena are developed due to, or connected, with dramatic changes of both the small and large intestines microflora quantity and quality.
However, I could find no data on this matter. I would be obliged for any help on the topic.
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Interesting question but to the best of my knowledge this has not been studied.
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Placing the device like a "bridge to surgery" has lowered the incidence of colic stomas and eventually improved the results with respect to patients operated on in emergency settings without placing SEMS.
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The first Dutch study was aborted because of high rate of complications, but other three study are on going. The UK CReST Trial, a second Dutch trial and a swedish trial. I think that we have to wait these results for better understanding the value of the procedure.
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With such a variation in techniques and types if abdominoplasty you will probably receive as many answers as surgeons. My regime for standard abdominoplasty with rectus plication is overnight stay, clexane and TEDS till mobile, elasticated abdominal binder, mobilise semi-erect first morning post op, drains out and patient home on day one post op. Abdominal binder , ted stocking for six weeks. Micropore (paper tape) on scar for three months.
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BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2156 (Published 5 April 2012)
Cite this as: BMJ 2012;344:e2156
What do you think about non surgical therapy of acute appendicitis and what's the firs line exam for diagnosis of uncomplicated appendicitis? US exam? CT exam?
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Uncomplicated acute appendicitis that you can treat without surgery, often are not acute appendicitis but someone else.
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Mesh versus tissue repair?
Intraperitoneal drain?
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There are some crucial questions in such cases: which organ exactly is incarcerated, and wheter the incarcerated content is vital or not, and is there an infection? So in my opinion laparoscopy is the most reliable option – you can reduce the hernia, can see what is incarcerated and wheter there are signs of necrosis, and also take fluid for culture. If there is a bowel necrosis the need of resection is clear. But if it is not the problem is always whether there is an infected ascites, as there is never been a good idea to place a mech in infected conditions. So better reduce the hernia, apply external pressure of the sac, for example with gauzes and fix them with adhesive bands or folio drape. Start antibiotics keeping the guidelines for the treatment of bacterial peritonitis in cirrhosis. Do not remove ascites if not visibly purulent, no drains, as they usually caused nearly uncontrollable homeostatic disturbances due to huge amount of fluid losed. When the patient is stable and infection is controlled by antibiotics you can move back to OR and do that what you prefer. I think the laparoscopic repair is better. So the philosophy is that there is absolutely no need to address both problems – incarceration and hernia itself in one stage in a patient that is usually not fit for surgery and had severe comorbidities. The exception might be the patients requiring bowel resection.
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Laparoscopic peritoneal lavage for perforated sigmoid diverticulitis appears to be a potentially effective and more conservative alternative to a Hartmann’s procedure. Although randomized control trials are needed to better evaluate its role, what do you think about this procedure?
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Our hospital has used laparoscopic lavage as the treatment of choice for all cases of non fecal perforated divericulitis for the last three years with very good results. It is surprising how well it works and it has revolutionised the treatment. No stoma. Much quicker mobilisation and shorter hospital stays. For us, there is no turning back to Hartmans procedure.
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This can to be the reason itself for a surgical procedure in an emergency setting due to gastroenteral bleeding, rectus abdominis hematoma, psoas muscle hematoma, or can complicate the recovery of a surgical procedure. The question is, shall we prefer: thrombosis prophylaxis or hemorrhagic prevention?
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This is a very important question.
There is a major push to implement DVT prophylaxis in the US. This is motivated by the so-called SCIP Core Measure Set implemented by The Joint Commission, the primary accrediting organization for hospitals.
It has been my personal experience that I have an increase in bleeding-related complications with DVT prophylaxis according to these guidelines. These include difficulties with intraoperative hemostasis, wound hematomas, and, rarely, bleeding requiring re-operation.
I have asked my colleagues informally about this and the result is universally similar. It is interesting that the SCIP Core Measure Set does not include identifying and reporting anticoagulant-related complications. The argument is usually that bleeding complications are rarely fatal and easily treated while pulmonary embolism is more likely fatal. I suppose internists all agree that bleeding is easily treated. Just call the surgeon!
Still, we need to collect all relevant data when experiments like this are imposed on a very large population.
It appears to me that the SCIP Core Measure Set is weighted toward a one-size-fits-all standard of measures that are very easy to quantify. Perhaps that is one reason why early data does not show differences in outcome between patients that meet SCIP Core Measures and those that do not. (There are other factors influencing these data as well.)
You also referenced patients coming in with ongoing anti-platelet and anticoagulant therapy. I do not know of any simple answer. It is always a trade-off between the urgency of surgery, the risk of bleeding, and the indication for the anti-platelet or anticoagulant therapy.
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The current literature is very sparse on this topic and I would be grateful to hear any unpublished reports.
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I've just reviewed a couple of articles; LeGoo has been used for femorodistal bypasses and there is a paper out by Davies group from London, and a couple of recent ones in the European Journal of Vascular and Endovascular Surgery. Have a look and see what you think.
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I am interested to know your current approach – do you think that patient deemed unresectable by general/colorectal surgeon or medical oncologist needs an opinion from experienced liver surgeon?
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In our centre both oncology and HPB surgery see every patient, even the initially unresectable patients since some of these will become respectable in the future after chemotherapy. This is important since a portal vein embolization or a staged resection can render some of these patients operable but the opportunity may be missed if surgery is not also following these patients. After the initial visits the patients are presented at HPB Tumor Board. The oncologists, surgeons, interventional radiologists, and radiation oncologists are present, every one is trying to determine how many patients can be converted to a resectable state, i.e. everyone believes that a resected patients is better off. There is no question about the patients that is resectable at presentation, barring other medical conditions they will be offered surgery. it is important that every centre bring all the parties to the table and have a discussion driven by the literature and get buy in for an in-house protocol for these patients, this may need to be done every 2-3 years. The protocol should reflect the centres strengths and attempt to boost their weaknesses.
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Acute cholecystitis in elderly patient is almost always a septic condition that can be life threatening. Patients are generally in poor physical status graded in IV ASA score. What is your experience and what do you do?
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It is better to do an early laparoscopic surgury after a short corse of medical resuscitation. But in your special poorly medical condition a percutaneous gall bladder drainage with local anesthesia is prefered.
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Open abdomen is an effective procedure mandatory in ACS with organ failure. Sometimes during this period, the small bowel develops one or more fistulas. The question is: are fistulas secondary to suction devices like the VAC system by KCL or will they develop without suctions related to the viscera exposition?
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The UK National Institute for Clinical Excellence (NICE as was) has just completed an audit of VAC therapy and fistula risk in ICU patients following the paper from Gordon Carlsson's unit published a couple of years ago
Ann Surg. 2008 Mar;247(3):440-4. doi: 10.1097/SLA.0b013e3181612c99.
Outcome of reconstructive surgery for intestinal fistula in the open abdomen.
Connolly PT, Teubner A, Lees NP, Anderson ID, Scott NA, Carlson GL.
SourceIntestinal Failure Unit, Department of Surgery, Salford Royal NHS Foundation Trust, Salford, United Kingdom.
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For repair of inguinal hernia in infants and children, what age is appropriate for opening the external oblique muscle before herniotomy?
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Above 12 months. Before 1 year of age there is no need to open the external oblique aponeurosis provided you do dissect the sac high enough to avoid residual patent processus vaginalis that would end up with a recurrency in a 2 to 3 years