Science topic

General Surgery - Science topic

A specialty in which manual or operative procedures are used in the treatment of disease, injuries, or deformities.
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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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elevated, CRP, surgery
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La proteína C reactiva (PCR) es una proteína producida por el hígado que aumenta en respuesta de la inflamación, es decir, cuando existe alguna inflamación en el cuerpo, y no es específica. Antes de la cirugía tener una PCR significa que existe un proceso inflamatorio y como no es específico, se debe investigar la razón, y ayuda mucho la clínica que presente el paciente, es decir, una adecuada Historia Clínica y las investigaciones en relación con la sintomatología deben confirmar la hipótesis planteada. Los niveles muy altos puede significar la existencia de una infección grave u otro trastorno.
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Can we consider photodynamic therapy of cancer (PDT) as an alternative method of conventinal cancer therapies like surgery, radiotherapy, chemotherapy ?? or it is just a complementary modality that can be combined with these therapies?
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Hello Issawi, PDT depends on how and where the cancer is too. If the patiente has a big tumor, probably the doctor will operate and PDT can be used as a complementary tecnique, but if cancer is on surface and not so deeper, PDT can be used as an alternative method.
I hope it has helped you.
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The patient should consult which specialty if he wants to know, will he stop aspirin prior to the operation or not? Will he consult the Cardiologist, the surgeon or the anesthesiologist?
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Dear Respected Colleagues ,
Cardiologists, Surgeons and Anesthesiologist All are concerned with this management whether this operation is elective or emergency .... but the main controller for the Pre-operative antiplatelet therapy management is the anesthesiologist with help of the cardiologist ... because the indication for using this antiplatelet theray is mainly for a cardiac problem and rarely for neurological problem ....
Best Regards and Respect
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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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There are many techniques for managing pilonidal sinus disease. I would be interested to know which you refer and how you decide which technique to perform if you use more than one.
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Could you possibly describe your technique to us Dr. Hofer?
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Excuse my naive experience in this area.
Lets assume we have a patient with 2nd degree hemorrhoids, and we want to apply topical product to reduce the swelling of hemorrhoids, do we apply the product on the hemorrhoids after it prolapse or we wait till it return to its position spontaneously then we apply using an applicator? I mean the proper timing for the application of the product.
Second scenario, we have a patient with third degree hemorrhoids, will we apply the product on the prolapsed hemorrhoids or we reduce it manually then we apply the product afterwards using the applicator?
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According to my experience,there is no difference but the patient may be more comfortable when it is reduced
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in these days , are the oncologists and clinicans still used transcatheter oily chemoembolization for treating hepatoma cancer ?
hepatoma is the live cancer that sticks to the liver's vessels so it cant be treated by surgery , so this method is used , but I dont know that this method is still working or some new approaches came for treatment .
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Yes it is still used in advanced HCC provided that preserved liver fiumctio and performance status of the patient.
it also can be used as a bridge for OLT
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What is your preferred treatment in a seroma after repairing ventral hernia. Do you insert a suction drain in an overlay technique and for how long? Do you also use the aspiration and argon and talk or glue, to treat it? For how long do you wait in case of conservative treatment without intervention? When is your deadline for reoperation in such seromas regarding overlay, sublay and inlay technique? Laparoscopic redo or not? Additionally what is your preferred timing of redo in the inlay technique?
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All my cases are done as Day case and No follow ups. If I started using drains, my managers will kill me. Welcome to NHS
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Is there any good reason to open urinary bladder for any open surgery vertically or horizontally ?
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I don't remember that I read or do vesicotomy in transverse direction, we usually open the bladder in the Medline vertically, because it is always away from ureters, easily and safely extended, so you can bifid the bladder without risk, though if the bladder is opened by trauma in a transverse direction, it can be sutured in the same direction with the same healing rate.
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The techniques used for oesophagectomy can vary greatly amongst countries, units and surgeons. This is also true for outcomes and historically oesophagectomy has been associated with significant morbidity and mortality. Operative access, anastomostic technique and the treatment of leaks (conservative, stent, endoVac or reoperative) have been continued areas of disagreement amongst oesophago-gastric surgeons and their influence on mortality and morbidity has long been disputed. This audit seeks to provide up to date information in the international variances in practice.
Please complete this Google Form:  https://goo.gl/LzvECw 
Please see attached invitation letter for some further details. 
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Study is underway! 120 oesophagectomy patients have been entered in to the online database in the 5 weeks of opening. We are accepting new centre registrations until July 2018 - so if your centre wants to be involved please get in touch. All the best, Ewen.
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I have been thinking if there is any practical treatment for spinal cord deseases!
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what about the terminals of the neurons, how we shall guarantee the right nerve reaches the right end.
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Is there anyone who knows/or has made/written/done, and validated, a questionnaire for follow-up phone calls to parents of children who have undergone anesthesia in day surgery?
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actually we adopted the saying: no news, good news.
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Different opinions arose in the last few years about the timing for operating chidren with congenital esotropia? What do you suggest and why on the basis of strong scientific evidence?
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1. The CEOS found that infantile esotropia persists in 98% of infants who have large-magnitude (≥20° or 40 PD) constant esotropia with onset after 10 weeks of age and refractive error ≤3.00 diopters. Thus these patients will benefit from early surgery.
2. Go through doi:  10.3129/i08-115 , Wong et al. The protocol attached is from this study.
3. The ELISS study (early vs. late infantile strabismus surgery study) also reported that children operated early had better gross stereopsis at age six as compared to children operated late .
4. Rule out an unstable angle of deviation and a paralytic component, then do early surgery for chances of stereopsis. This study also confirms the same.
Hirabe H, Mori Y, Dogru M, et al
Early surgery for infantile esotropia
British Journal of Ophthalmology 2000;84:536-538.
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Patients for orthognathic treatment involves various factors that may ultimately influence levels of
patient satisfaction. These include: physiological; medical; interpersonal and psychological. The majority of studies investigating the psychological aspects of patients undergoing orthognathic treatment, have shown that patients seeking orthognathic treatment are psychologically well
adjusted prior to surgery, and appear to have fewer deficits in their personality dimensions than those patients seeking other ‘cosmetic-type’ procedures.
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It is important your teeth are moved into the correct position before surgery so that they will meet properly after surgery. Therefore, as the teeth are lined up before the surgery, your bite may actually look worse. This is done purposely to give the best result and provide maximum improvement in your bite and facial/dental appearance.You will need to wear a fi xed brace for approximately 24 months before surgery and for 6 to 9 months afterwards. However this varies from patient to patient and your orthodontist should be able to advise you on this. Fixed braces are used as they allow the most accurate positioning of your teeth prior to surgery. During your operation, they also help the surgeon position your jaws correctly. The brace will consist of metal brackets, it is not possible to use tooth coloured braces or invisible aligners.The operation will be done from inside your mouth. If there is a possibility of scars on your face, this will be discussed with you before starting treatment. Some operations involve surgery on both your top and bottom jaw. Others involve only one jaw. Operations to reposition the jaw bones are called “osteotomies”. Your surgeon will tell you exactly what type of osteotomy you need. • All operations carry risk related to the general anaesthetic. This risk is rare, but potentially very serious. • It is common for you to have numbness or tingling of the lower lip, chin and tongue after an operation on the lower jaw. This is usually temporary and may last for a number of weeks or months. It may feel a bit like a dental injection that has not worn off. The numbness will not affect the appearance or movement of your lower lip or tongue, only the feeling in it. • There is a risk that you may experience permanent nerve damage. This can range from mild tingling through to a feeling of complete numbness. Your surgeon will discuss this with you in more detail. • Numbness of your upper lip, cheek, nose, palate and gums can occur after an operation on the upper jaw. Again, this usually resolves over a number of weeks. • Some bleeding is unavoidable during surgery but it is rare that patients need to be given extra blood during the operation. • It is usual to feel tired and weak for two to six weeks after surgery as your body makes up for any blood loss that has occurred. Patients who are having upper jaw surgery can fi nd their nose and sinuses feel blocked and can often taste blood from the operation for several days afterwards. • A small amount of bleeding or oozing after your operation is normal and you will have blood-stained saliva initially. This usually stops after 24 to 48 hours. If the bleeding is excessive, you will have to go back to theatre for the bleeding point to be located and sealed, however this is extremely rare. • There is about a fi ve per cent chance that at the end you will feel that the fi nal result was not worth all the trouble of the treatment. The reasons that patients feel like this are often complex but include their experience of the treatment process and their expectations of what the treatment will change in their life. • There are also risks associated with the braces and your orthodontist should have already provided you with some of the following information leafl ets, however if you have not been given these leafl ets, please ask your orthodontist when you see them next: i) Fixed braces ii) Risks of treatment iii) Retainers. The body’s usual response to surgery is one of mild depression. This seems particularly true of facial surgery. Most patients feel a bit low for a couple of weeks after the surgery. You might feel like you want to stay in bed, or at least at home, for a little while. You will need someone to look after you, both physically and emotionally, during this time.Patients who have signifi cant changes to their facial appearance can lose that comforting feeling of seeing a familiar face when they look in the mirror. This can be worrying until you get used to your new appearance. It takes time and patience.While patients often do experience psychological benefi ts as a result of the treatment, we cannot guarantee that this will happen. As a result of this potential change, we have a liaison psychiatrist on our team. You can meet them to: • clarify your current concerns • work out what you are hoping to achieve through treatment • weigh up the possible risks and benefi ts of the proposed treatment They can also help you to make the most of the physical changes that result from treatment. Some patients are extremely sensitive about their appearance and fi nd it diffi cult to talk to professionals about what they want. The liaison psychiatrist can support you so that your views are heard and considered We know that patients who have the support of family and friends are more likely to feel satisfi ed with the fi nal outcome. We suggest that you discuss decisions about your treatment with those close to you. Our liaison psychiatrist is happy to see patients with their friends or family. For patients who hope that they will feel more confi dent etc. after treatment, they may fi nd that this happens quickly after surgery, or gradually over a period of months, and occasionally not at all. If you do not experience the psychological or social benefi ts that you hoped for, you can see our liaison psychiatrist again to explore other ways of improving the situation.
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Thyroxine treatment in hypothyroidism.
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A well taken answer but may not prove effective in younger individuals always .Serum TSH levels are to be estimated before as well as during dose titration.
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Some times I face female patients who undergo implant surgery. When they come back for the healing period , they will be pregnant in their first trimester. I always postpone them after their delivery.
Want to hear if any guidelines or recommendations from your experience in handling such situation.
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I doubt that you're going to find many, if any, controlled studies on this topic. Pregnancy is an exclusion criteria for most studies. You may find case reports but as I say this I have not been able to find case reports on dental implant treatment during pregnancy.
My recommendation to a patient would be that, since implants are an elective procedure, if they discovered that they were pregnant after an implant was placed I would still suggest that they wait until they had delivered. the reason for this is just precautionary. As I said I cannot find any evidence suggesting a high risk but I can't see any obvious reason for taking even a low risk.
I searched my database, which includes about 50,000 articles and the only hits that came up were describing pregnancy as an exclusion criteria for the research protocols that were presented. I can't imagine someone designing a study to specifically test implants in pregnant women, I don't see the logic in doing that. I don't know how they would get an IRB approval.
If you go to Medline you will find a few reports discussing pyogenic granulomas, just what you might expect.
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Standard precautions are meant to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources. (WHO) It is also recommended to assume that every person is potentially infected or colonized with an organism that could be transmitted in the health-care setting and apply the following infection control practices during the delivery of health care. (Guideline recommendation). Personal Protective equipment are to be used as one such measure. But I am unable to find whether the OT table and floor should also be covered with plastic? Please give your opinion with logic (reasoning) and evidences.
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The built environment should be appropriate to allow cleaning and disinfection e.g. Impervious and intact surfaces for floors , walls , coverings on the mattresses, that allow ease of cleaning and prevent ingress. The principles of environmental decontamention after any patient is based on cleaning then disinfection if needed Including after spillage of blood or body fluids or patient known to be infected e.g. MRSA! CPE etc . All medical devices which includes the theatre table and any device used for treatment and therapy must be provided with manufacturer instructions for decontamination which must include method, product for risk levels of contamination low, medium, high risk!. In the UK, decontamination is guided by medical devices directives and Health technical memorandum's on decon. There are also national standards for environmental cleanliness and infection control in the built environment guidance to refer to. Therefore plastic covering for floor and table is not needed as the environment should be appropriate to prevent infection and allow decontaminationalongside management and decontamination of equipment and medical devices.
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Recently i checked the folder of a patient treated initially treated conservativly for an advanced malignant ovarian germline cell tumor sixteen years ago
with no relapse and with a good fertility outcome three full term natural preganancy.
i ve done a little literature review showing the feasability of conservative surgery in advanced malignant ovarian germline tumor.
So what do you think about the topic and do you have any experience to share?
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I would suggest the work of Dr. Kukak Oktay who has published extensively on this issue “or add. Excuse the typo which I cannot delete.
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Why some patients develop lid retraction following glaucoma filtration surgery?
Lid retraction is dangerous for the filtration bleb. How should it be managed?
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Lid retraction following glaucoma filtering surgery: a case series and literature review.
Saldana M, Gupta D, Khandwala M, Beigi B. Orbit. 2009; 28(6):363-7.
This article would answer your concerns.
The exact pathogenesis of lid retraction in patients with glaucoma filltering blebs remains unknown. Mechanical and chemical causes have been suggested.
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Adjuvant therapy for rectal caner stage II and III after radical TME surgery without preoperative chemoradiotherapy - Observation, Standard De Gramont, FOLFOX ,FOLFIRI, CAPOX, FOLFOXIRI - is there strong evidence to support one over another regiment in term of overall survival (OS) . And what is your opinion ?
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thamkyou
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Cost-effective yet quality health care delivery is one important objective worldwide now. Routine testing costs billion but without much impact. If a patient is not having pallore preop, planned for intermediate surgery; is it justified that only to know MABL and be prepared for unexpected hemorrhage, we should do preop Hb level? Hb level can even be done in point of care facility in such unexpected situations to decide transfusion...so, will it be a deficit if Hb not done in preop?
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What you call intermediate surgeries encompass a vast majority of procedures, some of them being with a higher risk of unexpected hemorrhages. So, In my practice, pre-op Hb for similar operations is mandatory in order to avoid troubles when unexpected bleeding occurs. Moreover, we have in the algorityms and protocols of our health care system such a requirement for lab minimum parameters for different grade of surgeries. It should be fulfilled.
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Is it 10hour or 12hrs time period for finding exact blood sugar level and evaluating lipid profile.
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For fasting blood glucose 8- 10 hrs are suitable. For Lipid Profile you need 12 - 14 hrs are recommended. Its important to clarify that Total cholesterol does not need fasting, In addition, you can calculate LDL-C by Friedewald Equation ( [LDL-chol] = [Total chol] - [HDL-chol] - ([TG]/2.2) where all concentrations are given in mmol/L (note that if calculated using all concentrations in mg/dL then the equation is [LDL-chol] = [Total chol] - [HDL-chol] - ([TG]/5))
The Friedewald equation should not be used under the following circumstances: . fasting, is mandatory for teiglycerides analysis.
  • when chylomicrons are present
  • when plasma triglyceride concentration. exceeds 400 mg/dL (4.52 mmol/L)
  • in patients with dysbetalipoproteinemia
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Old patient with cardiovascular disease submitted to dental implant surgery present higher failure rate than those without cardiovascular disease.
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I completely agree both with Profs Eckert and D'Netto, but would like to add information about the study of Wu et. al. (1), who reported a higher survival rate of implants in patients treated with anti-hypertensive therapy. Thus, not only the disease itself, but also the therapy need to be considered as it might influence bone metabolism directly, or via an indirect pathway.
However, in patients with cardiovascular disease, managing surgical risks is imperative (2).
(1) Wu, X., Al-Abedalla, K., Eimar, H., Arekunnath Madathil, S., Abi-Nader, S., Daniel, N. G., Nicolau, B. & Tamimi, F. (2016) Antihypertensive Medications and the Survival Rate of Osseointegrated Dental Implants: A Cohort Study. Clinical Implant Dentistry & Related Research 18: 1171-1182.
(2) Schimmel, M., Müller, F., Suter, V. & Buser, D. (2017) Implants for Elderly Patients. PERIODONTOLOGY 2000 73: 228-240.
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Our goal is to map the grid locations in MNI space. The electrode positions are registered during surgery and visible in Brainlab, however I see no way to export them in a standard format, except .stl (or individual screenshots can be exported as 2d DICOMs). Because these are surgical patients and the grids are only positioned during surgery, we don't have CT scans with the grids in place.
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Thank you I will try that!
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As intervention cardiology expanding do you think adult cariac surgery is fading out ?
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Procedures left for the cardiac surgeon in the next decade:
1-CABG for small CAD , cardiogenic shock
2-stuck mechanical valves ? thrombus or nidus
3- prosthetic valve endocarditis
4- ascending with or without arch dissection
5- cardiac trauma
6- cardiac tumors
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The systematic tumor cavity shaving in different studies its ability to reduce the rate of reexcision in breast conserving surgery helping gain OR time avoiding additionnal surgery
and inducing more cost savings.
It also showed it ability to detect other tumor loci in the remaning bteast.
So why its not mandatory?
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Its okay Montassar
Things like that happens!
By the way, the research shows that Cavity shaving halved the rates rates of positive margins and re-excision. Hope one day cavity shaving will become a standard procedure.
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There are so many researchers developing inhibitors for tumor.
For those tumor that has a single and specific shape, what is the main treatment? Isn't the tumor removal surgery much more faster than those drug inhibitors?
I know most of time it is hard to clean all the cancer cells by surgery, by you can do surgery first and then use those drug inhibitors to clean the rest of cells to prevent relapse. I'm just thinking those inhibitors work slower than the surgery and would cause other side effects. And also, tumor cells are smart, they can always develop resistance against inhibitors.
I'm wondering if removal surgery is the main treatment for this kind of cancer.
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I think surgery may be helpful if the tumor cells are localized at a distinct anatomical site.
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Relation between methotrexate and wound healing
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Wait until she is no remission with psoriasi. There is no need to performe abdominoplasty under MTX. Better wait and push the surgery for a while. Otherwise pause mtx two weeks before and after.
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I can't find a clinic and histology protocol for the surgical treatment (mm exactly) to know how much to cut in the surgery.
Thank for responses
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Considering the histological studies, usually 3 to 4mm is enough
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Is corpus callosotomy surgery still carried out for refractory epilepsy? If not, since when has it been stopped?
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Please read the article that has the answer to your question
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it is a common observation to see high lactate post uneventful surgery that clear gradually without any clear reason?
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Hyperlactatemia can occur in the setting of adequate tissue perfusion, intact buffering systems, and adequate tissue oxygenation.
Lactic acidosis, on the other hand, is associated with major metabolic dysregulation, tissue hypoperfusion, the effects of certain drugs or toxins, and congenital abnormalities in carbohydrate metabolism. It also occurs as a result on markedly increased transient metabolic demand (eg, postseizure lactic acidosis). Congenital lactic acidosis is secondary to inborn errors of metabolism, such as defects in gluconeogenesis, pyruvate dehydrogenase, the tricarboxylic acid cycle, or the respiratory chain. These disorders generally reflect situations in which the disposal of pyruvate by biosynthetic or oxidative routes is impaired.
Lactic acidosis may not necessarily produce acidemia in a patient. The development of lactic acidosis depends on the magnitude of hyperlactatemia, the buffering capacity of the body, and the coexistence of other conditions that produce tachypnea and alkalosis (eg, liver disease, sepsis). Thus, hyperlactatemia or lactic acidosis may be associated with acidemia, a normal pH, or alkalemia.
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this may help us to modify our Rx plan..
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Use of 2% lignocaine with adrenaline at least 10 minutes before putting incision controls bleeding to a larger extent. use of electrocautery judiciously along with neat incisions in right planes helps a lot. use of fingers of the assistant to put pressure over incised part of cleft lip also minimize the bleeding. Use of Betadine soaked gauze over incised tissue helps in reducing bleeding.
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Dear all,
Could I perform Lymphatic sac surgery by Endoscope?
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If you are talking about lymphatic sac of the vestibulocochlear system then it is not possible because of the limitations imposed by the current size of operative endoscopes.
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Patient with history of esophagitis underwent laparoscopic sleeve gastrectomy, how often endoscopy is mandatory in the years after surgery?
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Yes indeed. You must do a complete upper endoscopy with several biopsies from the esophagus and the stomach and also to see the status of H. Pylori infection
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Research question: Does early surgery predict a better functional outcome for severe CTS patients?
Predictor: Days of surgery post Ax
Functional outcome: ordinal (0 to 5, "deteriorate" to "fully recovered)
What do you think is the best analytical method?
Thanks.
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You can use a Wilcoxon rank sum test since the dependent variable is at least ordinal but considering this I would choose an ordinal logistic regression because it will give me an easier interpretation of the ordered log-odds coefficient which would be that for a one unit increase in the predictor, the response variable level is expected to change by its respective regression coefficient in the ordered log-odds scale while the other variables in the model are held constant.
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The incidence of splenic abscesses is currently 0.14-0.7% with a reported mortality of 0-47%. The diagnosis of splenic abscess which has ruptured into the abdomen is often overlooked because of its rarity and its misleading clinical presentations. Percutaneous coronary interventions (PCIs) and coronary stenting procedures increased from 184,000 to 885,000 (from 335 to 1,550) and from 3,000 to 770,000 (from 5 to 1,350 per one million inhabitants), respectively. A 40-year-old Asian male presented to our emergency department with upper abdominal pain 5 days after a percutaneous transluminal coronary angioplasty. Clinical examination raised the possibilities of acute pancreatitis and intraabdominal sepsis. An initial ultrasound of the abdomen and blood tests were negative. A computed tomography scan of the abdomen revealed a splenic abscess that had ruptured into the abdomen. Pus culture revealed a multidrug-resistant strain of Klebsiella pneumoniae that was sensitive to meropenem. The patient recovered quickly after open surgical drainage and antibiotic therapy. As this is the second case of splenic abscess and the first case report of a ruptured splenic abscess following a PCI, it will be rational to administer a short course of antibiotic prophylaxis for high-risk immunocompromised patients who are undergoing percutaneous transluminal coronary intervention.
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It is of course true that cardiac catheterization carries a negligible risk of bacteremia but with PCI bacteremia occurs frequently (in approximately 30% of cases); however, clinical sequelae occur rarely in such cases. PCI has a greater bacteremic potential, probably because of the length of the procedure and the repeated insertion of interventional devices into the vascular system . Infective mycotic aneurysm presenting as transient acute coronary occlusion and infectious pericarditis [Badshah A, Younas F, Janjua MSouth Med J. 2009 Jun; 102(6):640-2.]
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Has any one else tried mixing betadine ointment 50/50 with bone wax before using  the mixture on the cut sternum to reduce the risk of infection? We started this at Dameron Hospital in 1990 but we never published the results. It was my distinct impression that it significantly reduced post-op sternal infections.
The other problem I have seen is micro tears jn rubber gloves after applying bone wax to the cut bone. The way to avoid this is to use a wooden spatula.
I would be interested in any comments.
Sincerely,
Alan Coulson
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I completely agree!
Alan Coulson
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I'm  a general surgery resident and I would like to find out more about this project ?
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dear dr cordos
may you explain in detail please
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During FESS
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Adding to what have been mentioned there are 2 very important factors;
1- The training, skills and abilities of the surgeon and being familiar and mastering what he is doing.
2- The available facilities including the operative room settings and the availability of a multidisciplinary team for assessing when needed.
The message here is that being a safe surgeon is the mean goal 
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Nosocomial infections are common with multiple antibiotic resistant (MDR) strains and often prove difficult to be treated. We examined hand swab of 15 medical doctors and 13 medical attendants working in medical surgeries for the presence of meropenem resistant bacteria. Of these, two doctors and two ICU attendants carried meropenem resistant MDR strains (resistant to 19 to 24 antimicrobials) of Acinetobacter baumannii (1, neurosurgeon) and Staphylococcus carnosus (3, one plastic surgeon, two ICU attendants).
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Superbugs, also known as drug-resistant bacterial infections, can cause infections that are hard to treat.  According to the CDC, health care workers (including surgeons) should keep their hands clean to prevent the spread of MDR bacteria. In fact, surgeons have a greater access to open tissues and therefore high infection rates.
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42 years, female presented to the emergency department with fever for 2 days along with  acute onset pain in the right iliac fossa for the duration of 1 day associated with three episodes of bilious vomiting. She had underwent laparoscopic cholecystectomy 2 years back and two Cesarean section. Her menstrual periods were normal. On evaluation she was found to have tachycardia with tenderness in the right iliac fossa, no guarding or rebound tenderness. White cell counts 10,600 cells/mm3. CRP was not done. X- ray chest and ECG were normal. Ultrasound abdomen showed probe tenderness in RIF only.  
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In response to your title question, I would say "Clinically"!! Treat the patient, not the signs! 
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Aman of 70 years DM, Hypertension and CAD had CBD partial injury(3/4 of circumference) during a difficult lap chole with frozen callots.No energy source was used.Corners were secured with 4o prolene and an antigrade stenting was attemted with 10 f Amsterdam stent.It was not successful as the division was on the CHD as the flaps were coming out through the defect despite several attepmts to place it.Hence a 12 f T-tube was placed and the CBD was repaired well.No leak of bile post operatively.The recovery of the of the patient was uneventful.Tube drain in the sub hepatic space was removed on 4th post op day and pt was discharged.T-tube out put is around 300mls in 24 hours.
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Sir , follow the classical approach, wait for 4 weeks atleast before considering ERCP
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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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The elderly patient can be challenging in the emergency setting. Comorbidities and disabilities are well established as contraindications for surgical procedures, but not rarely these patients surprise us with their outcome: the coronary-diseased nonagenarian behaves as expected for a thirty-year-old, and the middle-aged needs longer hospital stay after equal operations for the same disease.
There are studies using Fried's approach (J Gerontol A Biol Sci Med Sci. 2001) (http://biomedgerontology.oxfordjournals.org/content/56/3/M146.full.pdf) to oncological patients, but some of the measures are not easily feasible in the surgical emergency room.
What's the best method to assess and grade frailty in the surgical patients , presenting with acute abdomen?
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The simplest and fastest method to assess "low resistance" to any stress is the CBC.
Specifically when anypatient is under severe stress the White Blood Cell PMN)
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We had a 23 years old who had a gunshot injury in the right 3rd space 2 hours ago. A right chest tube was inserted and it drained 250 cc blood with complete lung expansion. ECG and cardiac enzymes were normal. Echo was performed which showed a mild hemopericardium with no tamponade. CT Chest showed a right sided lung contusion with mild pericardial collection and the bullet in the subcaribal region. He was monitored in ICU on IV fluids, Tramal 50 mg TID and perfalgan 1gm QID. Patient was fully conscious initially and remained same for 8 hours then started to be agitated. He was ventilated electively due to CO2 retension 9 hours after trauma because of respiratory acidosis. F UP ECHO showed mild rim of pericardial effusion with no tamponade. F UP CT showed the same CT findings presented earlier. Patient was kept ventilated for 3 days on no inotropes. Suddenly he became severely agiatated again on ventilator with good blood gases. He arrested for 40 minutes despite good CPR. An urgent subxiphoid drainage window was performed and drained only 50cc. ECG regained again for 2-3 minutes then arrested again and he was declared dead. Where was the problem? What we missed in the management? What are the possible causes of death?
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Sorry do you mean subcarinal? 
Could this patient have had embolism and the culprit being cerebral rather than cardiopulmonary? The fact of good blood gases and no tamponade suggests this.
it would be interesting what the autopsy would reveal.
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We have been practicing the Local Injection of Gentamicin for Prophylaxis Against Infection in Open Fractures and Intravenous Cephalosporins for prophylaxis of Surgical wound infection.
But, Does anyone has the experience/ evidence of using Local injection of Gentamicin for prophylaxis of Surgical wound infection???
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We do not use local antibiotics for prevention of SSI and I agree with the colleagues above. Recently, I read a RCT on gentamycin-containing collagen sponges in THA. No benefit was found. Perhaps, you may extrapolate to have an answer to your question. S. below: 
Effectiveness of gentamicin-containing collagen sponges for prevention of surgical site infection after hip arthroplasty: a multicenter randomized trial
Clin Infect Dis. 2015 Jun 15;60(12):1752-9
Westberg M. et al.
739 patients with a displaced femoral neck fracture to be treated with hemiarthroplasty were randomized into two groups, which received either routine intravenous antibiotic prophylaxis alone or intravenous antibiotic prophylaxis and local application of 2 gentamicin-containing collagen sponges into the hip joint. The purpose of the study was to determine the efficacy of these sponges in reducing surgical site infections (SSIs) within 30 days of surgery, in addition to routine antibiotic prophylaxis. The results indicated that gentamicin-collagen sponges did not provide any added benefit in terms of SSI incidence.
Level of Evidence: 2  (RCT) , Study Type: Therapy
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Current evidence indicates that appendectomy puts patients at increased risk for recurrent clostridium difficile-associated colitis.
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Whilst the arguments for removing a normal-looking appendix are understandable, this undermines the logic for a diagnostic laparotomy. It must be explained to the patient that the appendix will be removed, unless other significant pathology is found, regardless of its appearance. Many patients may not wish to accept this logic. 
Furthermore the reported high risk of recurrence still does not mandate surgery. The same argument used to be made for diverticulitis, but now indications for sigmoid colectomy are very much more stringent. The difference, of course, lies in the relative simplicity (and lack of complication) of appendicectomy. No studies have been made on the application, however, of Sod's Law! If appendicitis recurs (but inflammation remains clinically localized, and not complicated by bacteraemia, constitutional upset or other factors are at play, a second, or even third course of antibiotics may still be reasonable.
It is important to involve the patient in this discussion, because it is ultimately him or her that will carry the consequences. The drawback of this approach is that social reasons for or against intervention may then predominate. 
I remember well, as an SHO in UK, how a well-to-do patient persuaded the consultant to perform surgery, which was strictly not necessary, because he had an important up-coming business job interview in Cape Town. He had been on a boat holiday in the Mediterranean and no-one noted that in fact he had a tinge of jaundice. He died of the post-operative consequences of liver failure induced by halothane used for his GA.
For RIF pain without obvious clinical and laboratory signs of inflammation, of course, antibiotics are probably not indicated, and a wait-and-see policy entirely appropriate. There is rarely need for an instant confirmatory diagnosis, as has been proven by institutions which have abandoned appendicectomy operations at night.
All this said, it is dangerous to be fixed in a belief. Learned opinion in 1900 was that 5 days should elapse to allow inflammation to settle before intervening to perform an appendicectomy. Sir Frederick Treves had become the authority on the subject, having performed over 2000 appendicectomies by 1902. In that year, Kind Edward VII fell ill and developed an appendicular abscess; two days before his scheduled coronation, Treves insisted on drainage, despite  the fact that many guests had already arrived. The big event had to be postponed several weeks. Treves had learnt how conservative treatment of his daughter two years earlier, when she was suffering flagrant appendicitis, led to her death. He did not want the guests to be attending a royal funeral... 
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Acute appendicitis is the most common diagnosis in young patients admitted to hospital for acute abdominal pain, with a lifetime prevalence of about 7%. Since in 1883 Grooves performed the first appendectomy, surgery has been the most accepted treatment of choice. Over the past twenty years, there has been a renewed interest on the conservative management of uncomplicated acute appendicitis. What are, in your personal opinion, the most effective criteria to identify a subgroup of patients with uncomplicated acute appendicitis for whom antibiotic treatment can be highly effective ?
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In my opinion, the  resurgence of the conservative treatment of acute appendicitis  - which used to be the state of the art 200 yrs ago- is  a matter where evidence and experience clash.  Common sense dictates a surgical treatment for most  cases of acute appendicitis, whatever scientific evidence there is  to support a nonoperative treatment. 
Which healthy young wants to  take antibiotics and wait for a complication to happen  or happen not and moreover risk a relapse  just to avoid a laparoscopic appendectomy which will  make him leave the hospital, cured,  one day later ?   No patient with an ounce of common sense. Let  us not rewrite history.
 We operate on all cases of acute appendictits if there is no appendicular mass or another specific reason to choose for a non-operative treatment. 
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I would like to hear about your clinical experience - Do you like trying antibiotics first? or do you prefer surgery?
There are positive and negative points about conservative management: 
Positive points: Fewer complications, better pain control, and shorter recovery time.
Negative points: The combined failure and recurrence rates in patients treated non-operatively may suggest that conservative treatment is a less effective treatment overall.
Thank you!!
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This is very interesting topic as you are rightfully trying to expand the current discussion of a possible paradigm change for the disease of appendicitis to children. My main struggle with the results of recent, well conducted RCTs in adults is that it is not at all clear to me how we should be able to expand their findings to the general, population of patients presenting with appendicitis. As Dimitri pointed out, we would first have to establish if they have an appendicolith or not. This is not at all trivial, as CTs whilst displaying highest sensitivities for appendicitis, are not a standard diagnostic tool in most countries. Furthermore, there is a false-negative rate diagnostic rate even when integrating all modalities that requires consideration as well. Then there are other factors that require consideration, which in an RCT-setting are usually exclusion criteria: comorbidities, immunosuppression, previous surgeries, and and and. Then also, in a regular every day setting, you would want to provide the patient with a treatment and discharge them, but with appendicitis and conservative therapy, we tend to keep them in extremely close follow-up, which might even prove less cost-effective than uncomplicated surgery with discharge within 24 hours. Finally, one must never forget, that RCTs represent highly selected patient populations and therefore any 'effect-size' seen in an RCT will most often be 'watered down' when the same approach is applied to the more general population. In this case, I would assume failure rates of antibiotic treatment alone to increase if this were to become the new 'gold-standard'. Thus, with all of these issues in mind - how should we even conceive taking this debate to children already? Whilst I strongly support trying to answer this important question in a paediatric RCT, I still think there's quite a bit of work left to do with this disease in adults. 
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Which one would you prefer most of the time and why?
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I agree with Hamin. But if you take all these facts together it is better to have excellent training and expertize in laparosocopic appendectomy so the surgeon could have less preoperative strategic difficulties. When I started laparoscopic appendectomy it was easier for me to do open appendectomy. Now after more than 200 lap appendectomies I realise that it is more simple procedure technically (for me) and the easiest operations last 15 min and the patients recover ealier.
Therefore whatever the studies claim, my opinion is that laparoscopic appendectomy is better procedure in experienced hands.
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Antibiotic Prophylaxis
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In a child without any underlying congenital cardiac diseases, or any immuno compromising reasons in a clean settings , we usually do not give any prophylactic antibiotics in the elective day case surgeries.  
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What is the best treatment option for appendicular mass, conservative management (Ochsner-Sherren regimen) vs early appendectomy?
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Best treatment - conservative management . There's already a metaanalysis by Andersson RE, Petzold MG. Ann Surg. 2007 Nov;246(5):741-8.
Intervention when failed conservative management. Even then, it is commonly due to appendicular abscess - options include percutaneous drainage or surgical drainage ( laparoscopic or open) if technically difficult for radiologists
There's no option of early appendectomy. Presentation is always late, as the omentum and small bowel attempt to seal off the inflammed appendix.
If you're asking about interval appendectomy - not recommended anymore as the risk of recurrence is low.
If the mass is palpable on presentation, then not much of issues - imaging to confirm findings and to assess for appendicular abscess feasible for drainage , then CT abdomen/pelvis and colonoscopy after 6 weeks , in order not to miss a tumor in those more than 40 years old
The problem occurs with findings of appendicular mass intraoperatively , in a patient initially diagnosed with perforated appendicitis. Options then include peritoneal lavage and drainage of pus or right hemicolectomy. Appendicectomy is almost never possible unless in very early formed mass where the structures can still be easily identified. Otherwise, dissection through inflammatory mass will only cause more damage.
Some people practise performing right hemicolectomy in this situation. I would not do it. The risk of appendicular neoplasm is <1% and can be identified as such during surgery as a mass anywhere along the appendix with distally distended part containing mucoid material, or perforation with pseudomyxoma peritonei. A caecal tumor causing appendicitis? Possible but still uncommon. Therefore, a CT scan and colonoscopy performed in those more than 40 years old.
My personal opinion- right hemicolectomy unnecessary in this situation, unless very high suspicion of a tumor in a patient more than 40 years old with high risk of second surgery due to multiple comorbidities. Otherwise, elective surgery can be planned later.
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General surgery, Surgical anatomy, Hernia.
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Mid-inguinal point is halfway between the ASIS and pubis symphysis.
Mid-point of the inguinal ligament is halfway between ASIS and pubic tubercle (i.e. sites of ligament insertion).
Mid-point of inguinal ligament is therefore lateral to the mid-inguinal point.
Mid point of inguinal ligament is where we find the deep ring. The vessels pass under the ligament at the mid-inguinal point i.e. medial to the deep ring.
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General surgeon should begin the reconstruction of the excised portal vein during laparoscopic cholecystectomy or send him to a reference center ?
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If the bleeding is already controlled, and there is no availability for a surgeon with experience in HBP or cardiovascular surgery I think is better to reffer. 
On the other hand I think that you should prevent this. If the anatomy is not clear you should convert to laparotomy. In this scenario, if the hepatoduodenal ligament is severly  inflamed, especially in a chronic fashion, I think is safer an incomplete cholecistectomy, abandoning the gallbladder infundibulum. 
If you have a portal vein injury, more frequent are right branch injuries. In this case the referral is better.
In case of complete transection early repair is necessary. I am very curios about other answers. 
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I am researching if pre-op education and follow up visits before a CABG decreases anxiety and depression in the surgical patient.
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 Anxiety and coronary heart disease (CHD) are associated with each other. It is quite controversial whether anxiety is the cause or the result of CHD.
Please read the attached file:
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I've done continent perineal colostomy for long time, the technique we used is the confection of three valves 5 cm from each other, in which we do seromiotomies e then a seromuscular suture covering the incision. We select rigorously the patient since is necessary doing irrigation every two or three days do keep clean. Recently we did in a young woman with Chron's disease whose rectum was destroyed, fibrotic and stenotic but had a good colon and ileum. The outcome was great. Thank you.
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We perfom perineal colostomy. However we don't perform the seromiotomies like you but a musclar graft, easy to do. I was interested by your technique that i saw in an article. However the seromiotomies seems to me more complicate than my own technique.
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In recurrent dislocation shoulder after failure of arthroscopic repair we do modified bristow operation .is it better to leave the insertion of pectoralis minor to the transferred coracoid and what its value?
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Yes ,it,s posible ta atacch with a cortical screw plus washer.
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Which approach is the best of a thymectomy by myasthenia gravis?
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best approach is throcoscopic.Preferred on right side
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It happens only in India. Even now a days folklore practices are exists. A female aged about 45 yrs herself (as she claimed) / her husband ligated a mass around anus by Strands of Horse tail, though it was excised and treated later by us. Do you have any comment ?
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Probably the same Idea as ruberband ligature for Hemoroids
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According to international guidelines, we should start internal examination of the body with the opening of the skull and with the investigation of the intracranial content. At our department, we respect this rule. But what are meaningful reasons for such a strategy?
Firstly, textbooks usually recommend dissection of the head prior to the rest of the body. And the advantage? A bloodless field within cervical organs, which is important in asphyxia-related deaths especially in stranglings.
Secondly, it is quite logical to follow a process of dissection "a capite usque ad calcem". External inspection is, also, done from head till feet, sometimes in a counter-clockwise pattern (head - right upper limb - right part of the trunk - right lower limb - left lower limb - left part of the trunk - left upper limb).
Thirdly, after the opening of the skull we may immediately smell the presence of volatile, poisonous substances (e.g., ethanol, cyanide, solvents, etc.) without competing odors from thoracic and abdominal cavity.
How do you see it colleagues? Please advise... Let's share our knowledge.
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As Dr.Henja and Dr. Asirdizer in most of the cases we routinely start opening the skull and then from head to heel, but in those cases where are involved injuries to the neck we always left it to the end. In this way the anatomic structure can drain not only to the head but also to the chest cavity, in our experience we have a better and "clean" neck dissection. So if head should be the first, why don´t let the neck to the end in asphyxia-related deaths?
Best Regards
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In recent literature there have been many studies, with quite a few using ACS-NSQIP data, that have concluded that prolonged operative duration "leads" to more infective and "other" complications ... but I have been unable to find any article that can discuss and describe the patho-physiological mechanisms and basis of these findings. I will be grateful if someone can shed some light on this aspect of the notion that prolonged surgeries lead to more averse outcomes...  
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Well need to find some sources for you
however there are several obvious reasons
1. longer operation times are usually associated with more complex operations or procedures where something is not fitting well and the surgeons has to take longer to complete the task at hand.
2. in long surgeries usually the staff and operating team changes again due to several reasons resulting in greater staff movement and greater risk of contamination.
3. bacterial flora flourishes back to normal in 2 hours time and double there on exponentially if the kits are not changed and surgeon does not re0scrib
4. These procedures are associated with infusion of larger amount of fluids including colloids, This change in homeostasis is a major risk factor in development of complications
5. Longer surgeries specially laparoscopy are assocaited with greater CO2 Level absorption and risk of hyper carbia and poor ventilatory effort is more common
6. recovery time from longer complex surgeries are extended and usually associated with elective or manadatory mechanical ventialtion postoperatively
I can think of these only . I think other can add a few points
regards
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I found this case of Ano-vestibular Fistula in 30 year old female. The P/V examination reveals no extension and the patient has no previous H/O of any surgical treatment. What should be the course of treatment for this fistula? Should it be as for every fistula: follow/ drain through an anatomical structure?
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If it is a congenital ano-vestibular, it will have an epithelial lining. If it is, then does it cause enough symptoms to warrant excision? In infants I would normally excise with a covering colostomy, but I know that in places where there is a lot more experience (India & China) it is often done without.
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Patients with perforated cholecystitis, what is the best treatment option?
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Cholecystectomy have to be considered if the patient general condition is well and good but if not as in emergency situations do cholecystostomy. 
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50 year old male patient after a car accident, multiple abdominal and pelvic surgeries with a stoma presents an anal fistula 5cm higher from the anal verge in the rectum. I am most interested in experienced trauma and anal surgeons treatment options.
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Dear Sirs,
I am quite satisfied from your contributions in such a difficult topic, and I was interested in reading the latest recommendation by Prof. Phillips citing Dr. Patsouras recent publication on similar issues.
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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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I would love to design a simple questionnaire in which I Intend to find out if a surgeon would want to treat a condition "X" using procedure " A" or " B" and the reasons for the procedure (A or B) chosen.
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Hi everyone! does anyone knows a website that I can use to do an on line survey other than survey monkey? Please help if you do. Thanks for reading.
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Had a problem with one patient recently.
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The best way to prevent lymphorrea is to ligate all tissues. 
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I remember during my training days, how difficult it is to inject local anesthetic for corn excision. Where the local spilt all over.
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I use a posterior tibial nerve block with lidocaine 2%. It is quite simple. Find the artery and leave a depot near the artery. Take care not to puncture the artery. With this technique the whole foot sole is numb. A number 11 blade is ideal to remove the corn with an elliptical excision. Sharp spoons are also useful. I close the skin with an absorbable suture.
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What is the ideal way to scrub and with what and for how long?
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Hi Awad Ali,
first of all I would like to point out some essential ideas about procedures to reduce infectivity of hands before surgery. I therefore add some notes I found in the internet:
How To Perform Surgical Hand Scrubs
By Deborah Gardner, LPN, OPAC, and Ellen Anderson-Manz, RN, BSN
"Human hands are the most important tools for caring. Hands feel, diagnose, cure, prod, and provoke as they are placed upon each patient who is hoping for answers, understanding, and healing remedies. The hands can also be a portal and transmitter of infection. While handwashing may be the simplest way to control infection, it is often not practiced where warranted.
Surgical site infections greatly contribute to nosocomial infections. Some of the risk factors for nosocomial infections include the behavior of OR personnel regarding decontamination practices, hand hygiene/antisepsis, and compliance with universal precautions. Most surgical professionals agree on the importance of good surgical hand-washing practices in infection prevention. Hand transmission is a critical factor in the spread of bacteria, pathogens, viruses that cause disease, and nosocomial infections in general.
The purpose of surgical hand scrub is to:
Remove debris and transient microorganisms from the nails, hands, and forearms
Reduce the resident microbial count to a minimum, and
Inhibit rapid rebound growth of microorganisms.1
Surgical Scrub Techniques
All sterile team members should perform the hand and arm scrub before entering the surgical suite. The basic principle of the scrub is to wash the hands thoroughly, and then to wash from a clean area (the hand) to a less clean area (the arm). A systematic approach to the scrub is an efficient way to ensure proper technique.
There are two methods of scrub procedure. One is a numbered stroke method, in which a certain number of brush strokes are designated for each finger, palm, back of hand, and arm. The alternative method is the timed scrub, and each scrub should last from three to five minutes, depending on facility protocol.
The procedure for the timed five minute scrub consists of:
Remove all jewelry (rings, watches, bracelets).
Wash hands and arms with anitmicrobial soap. Excessively hot water is harder on the skin, dries the skin, and is too uncomfortable to wash with for the recommended amount of time. However, because cold water prevents soap from lathering properly, soil and germs may not be washed away.
Clean subungual areas with a nail file.
Start timing. Scrub each side of each finger, between the fingers, and the back and front of the hand for two minutes.
Proceed to scrub the arms, keeping the hand higher than the arm at all times. This prevents bacteria-laden soap and water from contaminating the hand.
Wash each side of the arm to three inches above the elbow for one minute.
Repeat the process on the other hand and arm, keeping hands above elbows at all times. If the hand touches anything except the brush at any time, the scrub must be lengthened by one minute for the area that has been contaminated.
Rinse hands and arms by passing them through the water in one direction only, from fingertips to elbow. Do not move the arm back and forth through the water.
Proceed to the operating room suite holding hands above elbows.2
If the hands and arms are grossly soiled, the scrub time should be lengthened. However, vigorous scrubbing that causes the skin to become abraded should be avoided.
At all times during the scrub procedure care should be taken not to splash water onto surgical attire.2
Once in the operating room suite, hands and arms should be dried using a sterile towel and aseptic technique. You are now ready to don your gown and sterile gloves.
When gowning oneself, grasp the gown firmly and bring it away from the table. It has already been folded so that the outside faces away. Holding the gown at the shoulders, allow it to unfold gently. Do not shake the gown.
Place hands inside the armholes and guide each arm through the sleeves by raising and spreading the arms. Do not allow hands to slide outside the gown cuff. The circulator will assist by pulling the gown up over the shoulders and tying it.
To glove, lay the glove palm down over the cuff of the gown. The fingers of the glove face toward you. Working through the gown sleeve, grasp the cuff of the glove and bring it over the open cuff of the sleeve. Unroll the glove cuff so that it covers the sleeve cuff. Proceed with the opposite hand, using the same technique. Never allow the bare hand to contact the gown cuff edge or outside of glove.
The scrubbed technologist or nurse gowns the surgeon after he or she has performed the hand and arm scrub. After handing the surgeon a towel for drying, the technologist or nurse allows the gown to unfold gently, making sure that there is enough room to prevent contamination by nonsterile equipment. To glove another person, the rules of asepsis must be observed. One person's sterile hands should not touch the nonsterile surface of the person being gloved.
Pick up the right glove and place the palm away from you. Slide the fingers under the glove cuff and spread them so that a wide opening is created. Keep thumbs under the cuff.
The surgeon will thrust his or her hand into the glove. Do not release the glove yet.
Gently release the cuff (do not allow the cuff to snap sharply) while unrolling it over the wrist. Proceed with the left glove, using the same technique.
Formal guidelines and recommended practices for hand washing have been published by professional organizations (e.g., Association for Professionals in Infection Control (APIC), Association of periOperative Registered Nurses, Inc. (AORN). AORN recommends the use of a traditional standardized anatomical timed scrub or counted stroke method for surgical hand scrub and encourages institutions to follow the scrub agent manufacturer's written recommendations when establishing policies and procedures for scrub times. On this basis, for example, the typical scrub procedure for a PVPI-containing product based on manufacturer's labeling would require the use of a scrub brush and two applications of five minutes each, whereas the typical procedure for a CHG-based product would require a three-minute scrub followed by a three-minute wash. In actual practice, however, variations in surgical hand scrubbing times may be of shorter duration than manufacturer's recommendations for a number of reasons:
Staff time constraints.
Desire to reduce poor hand health.
Acceptance of data from other sources suggesting those scrub times shorter than those recommended by manufactures are adequate.3
Hand condition is emerging as an increasingly important factor in personnel compliance and infection control. Frequent surgical scrubbing can cause dermatitis of the hands and arms. Most antimicrobial agents are drying to the skin, especially when coupled with a scrub brush.
Characteristics of a Surgical Scrub
Performance characteristics for a surgical scrub agent generally fall into four categories:
1. Antimicrobial Action--an ideal agent would have a broad spectrum of antimicrobial activity against pathogenic organisms. This agent would have to work rapidly. An agent that does not work rapidly may not provide adequate bacterial reduction before being rinsed off.
2. Persistent Activity--an agent offering persistent activity keeps the bacterial count low under the gloves. It is not unusual for a surgery to last in excess of two hours. Studies have shown the rate of glove failures (non-visible holes) increases with the duration of surgery.4 In addition, studies show bacteria grow faster under gloved than ungloved hands.5,6,7
3. Safety--the ideal agent would be non-irritating and non-sensitizing. It must have no appreciable ocular or ototoxicity, be safe for use on the body, and not be damaging to the skin or environment.
4. Acceptance--probably most important to achieving compliance in using a new product is its acceptance by the healthcare worker. A product that has ideal antimicrobial action and an excellent safety profile is of little value to good infection control if the user population fails to support its use. Although each is important in its own right, all four characteristics should be present for a complete package.
Surgical scrub agents come in many forms. Not all forms meet all characteristics.
1. Liquid or foam soaps. These are the most common products for surgical scrubs and are used in conjunction with water and dry scrub brushes or sponges. The most common antimicrobial agents in these products are CHG (chlorhexidine gluconate), iodophor, or PCMX (parachlorometaxylenol). These agents are very drying and with repeated scrubbing with the scrub brush can cause skin damage.
2. Impregnated scrub brushes/sponges. Scrub brushes/sponges are preloaded with CHG, iodophor, or PCMX and are water-aided products.
3. Brush-free surgical scrub. These products use an antimicrobial agent and water but no scrub brush.
Conclusion
No matter what agent is used, or which scrub technique you practice, there is only one goal: infection prevention. Effective surgical scrubs are one of the most powerful strategies of infection prevention in the OR. Glove usage gives a false sense of security against bacteria. Gloves provide an ideal environment for bacterial growth, moisture and warmth, which makes good hand-scrub techniques and aseptic gowning and gloving an important part of the total infection prevention platform. It is important for healthcare management to help the personnel understand the cause/effect cycle of surgical scrubs as they relate to infection prevention."
Coming to your question I am sure that a hand brush to scrub prior to surgery is an essential even if you use socalled "modern desinfectants". I would never rely on what the products call "modern" unless there is evidence of a significant reduction of infective risk proved by the reduction of bacterial growth, describing the method of hand desinfection applied etc. in comparison to traditional techniques of hand brushing and cleaning with so called "old" desinfectants. All above mentioned methods (time of brushing, how to brush etc.) must be standardized for a comparison. To rely on the notes of the manufacturer alone may otherwise be desastrous for the patients.
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Do you prefer open or Laparoscopic repair for uncomplicated hernias. For open repair, do you go for the high or low approach. What should be the strategy for acute presentations of these hernias?
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Dear Raza and all,]
Thank you for starting a nice topic. I will give my answer and operative strategy and reasons:
Dr. Heemskerk is making sense, but almost certainly in cases of acute incarceration I would recommend a swift (with 4-6 hrs) operation and do an open modified McEvedy approach. This without a doubt gives the best access for every contingency. Anyone doing a low Lockwood and lower midline is missing out on a much more elegant and sensible approach. A low approach that requires cutting the inguinal ligament is not ideal also, as is a Lotheissen approach which inherently weakens the inguinal canal and thus necessitates mesh in a case where translocation of gut organisms and transient bacteraemia is likely. TAPP is an option but will double the operating time I suspect in most peoples hands.
The modified McEvedy as I do it (unlike the description from Peter McEvedy from Manchester in the 1950's) is through a transverse incision about 4cm above the ipsilateral inguinal (Poupart) ligament - somewhere midway between an appendix and an inguinal hernia incision. The original description was all vertical. Unlike the description once I get down to the fascia I open it transversely, i.e. EOA and anterior rectus sheath. If you now retract the rectus abdominis muscle medially, then inferiorly with a Langenbeck retractor and you will have a great view of the extraperitoneal space and femoral canal. Palpate the bony landmarks to orientate yourself if need be. Occasionally the epigastrics appear - ligate them.
Once you see the sac, apply external pressure to reduce it. If you struggle I divide the lacunar ligament (being cognisant of the possibility of an aberrant obturator artery!). The best way to do this is to place a Lahey forceps in the lacunar ligament very superficially (i.e. immediately under it) and diathermy its most lateral edge with the hand held finger-switch diathermy (Bovie) - often this is enough to release the sac. Then open it using clips, when you'll almost certainly find a Richter's hernia and wrap in warm wet swabs, and fix the defect.
The simplest and probably best way to do this is an emergency is to use braided suture i.e. Ethibond on a J needle. Inguinal to pectineal ligament - by the time this is complete you will notice that the bowel is viable. Naturally beware the femoral vein laterally.
Then a layered closure and post-op VTE prophylaxis, mobilisation and E+D as tolerated and your patient will be ready for home soon. Of note, I give 1 shot of ABx on induction and if the bowel is viable no further doses.
In the elective setting a low Lockwood approach is sufficient, and in those cases indeed a mesh can be used, either normal polypropylene cut as a long rectangle and rolled up as a cigarette and pushed in, or a Bard plug. To be honest, I think simple sutures work fine also. As I say, Dr. Heemskerk makes a point that a co-existing inguinal hernia can exists also, in which case TEP is an option. I suspect in the most NHS trusts, for a unilateral femoral hernia, would only fund open surgery.
Hope that helps!
BW,
John.
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Many patients show underweight before surgical treatment of esophageal cancer. Which methods can be used to interpret the surgical/anesthetical risk when performing surgery/anesthesia on an underweight patient. Are there any 'weight'- criteria you'd use to refuse/postpone esophagectomy for cancer? Are there any risk assesment models who use a criterium of underweight?
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Our unit doesn't have a precise weight cut off for refusing surgery - but we do evaluate patients carefully from a nutritional point of view. We won't resect patients who are grossly malnourished with low albumins etc. We place feeding jejunostomies in patients with severe dysphagia and / or significant weight loss who are suitable for resection. Patients who don't respond to chemo and still have dysphagia get a NG /NJ feeding tube if they don't have a feeding jejunostomy. This allows nutrition during neoadjuvant chemotherapy. All patients see a dietician.
We avoid PEGs - as they can knacker the stomach or more importantly prang its blood supply. Also PEGs can pull tumour cells and implant they into the abdominal wall rendering the patient palliative.
I avoid covered stents pre oesophagectomy, as they
1. often migrate with chemotherapy causing shrinkage
2. make the resection more difficult if they stay insitu (fibrosis etc)
3. some evidence they may compromise survival - free tumour cells in blood after stenting colorectal cancer and progression to surgery in patients who require stenting pre-oesophagectomy is very poor (althought this may be due to their advanced stage
See the attached commentery on the safety of stents in the neoadjuvant setting for oesophageal cancer.
Perhaps a need for a RCT comparing,,,,,,,
NG/J
Feeding jejunostomy
Possibly covered stents
In resectable patients with dysphagia who need chemo or CRT prior to oesophagectomy?
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The initial age of therapy/prophylaxis with cimetidine made possible a dramatic reduction of the issue. Nowadays, starting from two or three years although we have last generation antiulcer drugs and sophisticated diagnostic technique, we are assisting a new era of acute gastric perforations. It seems a jump in the past. The problem is observed not only in ethnic minorities where is more difficult to reach a good quality of life, but even in resident people with a good wellness of life. Whats going on? Self prescription medications? Changing in lifestyles? Escape from official medicine?
I'm very interested in your eventually observations and opinions.
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we in a major corporate setup,do not see that many DU perforations.Incidence of peptic ulcer disease was very common in south India attributed once to High spicy food,but after the advent of H2receptor antagonists and ppis,it was almost disappeared except few perforations in public hospitals.Certainly now there seems to be a reappearance due to above mentioned reasons by Dr Ireradi and also due to modern life style changes adopted in this part of the world as well.
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In the absence of a Gynae, I had to attend this case. A female of 27 yrs in her honeymoon visited due to profuse vaginal bleeding after having normal coitus. P/S examination reveals a laceration of about 0.75 cms in Post Fornices. There were no tear or scratches on Introitus. No sign of any Hymen rupture were noted. She denied any use of DILDO/Vibrator etc. What can be the reason of laceration too deep ? I sent blood sample to rule out STI.
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Quite interesting but rare in human.
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Thanks in advance.
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Implantation was the consequence of appendectomy whereas appendix was primarily infiltrated by carcinoid tumor. The treatment is local R0 excision.
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Dear Colleagues,
The West Midlands Research Collaborative (http://www.wmresearch.org.uk) is preparing the largest, prospective audit of Cholecystectomies - called the 'CholeS study' in response to the recently published commissioning guidelines from the Royal College [http://www.rcseng.ac.uk/providers-commissioners/docs/rcs-eng-augis-commissioning-guide-on-gallstone-disease]
A brief synopsis is provided below and can be found at www.choles-study.org. You can register your interest via this website or email directly.
We would like 1-2 StRs (surgical registrars) with 2-3 CSTs (interns or resident level surgeons) in each hospital to help plus you will need to identify a supervising consultant. Medical students are welcome to be a part of a team.The audit will be for a 2 month period with an additional month for follow up. Only 28 data points on each patient will be needed.
As ever, ALL contributors to data collection will be citable authors on any subsequent publications. Individual centres can use this data to inform their local commissioning groups.
Let me know if you are interested and I will forward on protocols, audit standards, data collection forms and spreadsheets.
With best wishes
Ravi Vohra (On behalf of the WMRC)
Ewen Griffiths, Consultant Upper GI Surgeon
ABSTRACT: Clinical Variation in Practice of Laparoscopic Cholecystectomy and Surgical Outcomes: a multi-centre, prospective, population-based cohort study (CholeS Study)
Background: Cholecystectomy is one of the most common general surgical operations performed in the UK. Increasing proportions of patients have surgery in the acute setting for severe biliary colic, cholecystitis and following gallstone pancreatitis. Randomised clinical trials in acute cholecystitis and gallstone pancreatitis suggest early laparoscopic surgery performed in specialist units is safe. Despite this, management still differs between surgeons and centres across the UK. This has been highlighted in a recent commissioning guide produced jointly by the Royal College of Surgeons and the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland. The impact of these variations on outcomes is unclear.
Aim: To investigate surgical outcomes following acute, ‘delayed’ and elective cholecystectomies in a population-based cohort
Audit standard: All-cause 30-day readmission rate should be less than 10% following cholecystectomy (primary outcome measure). Secondary outcome measures are all highlighted variable within the commissioning guide: pre-operative (demographics, admission type, diagnostic tests) peri-operative (conversion rates of laparoscopy to open surgery, complications,) and post-operative (length of stay, in-hospital morbidity) factors.
Methods: The study will be performed over a two-month period in 2014. Participation from centres in the West Midlands alone is estimated to recruit 1,300 patients. Participation from centres across the UK is estimated to recruit 10,000 patients. The study will be performed using a standardised spreadsheet at each centre. Inclusion criteria will be: All patients undergoing cholecystectomy will be categorised into one of three groups: (1) Acute Cholecystectomy (first acute admission with biliary disease through A&E or GP and cholecystectomy performed during that index admission); (2) Elective Cholecystectomy (planned elective admission for cholecystectomy who have been referred from their GP and added to the routine surgical waiting list from the outpatient department only and (3) Delayed Cholecystectomy (all other planned cholecystectomies). Variation in practice will be assessed by all-cause 30-day readmission rates, by centre. In addition, the influence of pre-operative factors and effects on peri- and post-operative measures will be investigated.
Discussion: This multi-centre, prospective, population-based study will be delivered by a trainee-led collaborative research networks to ensure high volume without compromising quality
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Thanks for your interest Jean. We did initially ask for international interest, but it was minimal and therefore we are concentrating now on UK and Irish centres. The study period opens in two weeks time.
There is a global study which you may be interested in. More details can be found at www.globalsurg.org. In brief, this study will help identify variation in outcome of emergency midline laparotomy across the globe to determine whether there are globally relevant quality markers for emergency surgery. It you are interested simply fill in the registration form at http://globalsurg.org/register/
All the best
Ewen
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Spleen completely replaced by soap bubble like cysts of varying sizes with no parenchyma, bones [skull, vertebrae, ribs pelvis] are also studded with hundreds of cysts. There are two groups of lymphangioma each (2 by 2 cm approx) over right supraclavicular and right axilla both asymptomatic now.The supraclavicular swelling was partly removed surgically 3 months back elsewhere. Rest of solid organs and brain is not affected.
Should he be ventured, especially the role of splenectomy?
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This is typical Gorham Stout Disease, or vanishing bones disease, or generalized lymphangiomatosis.
This is a really orphan disease and most of the patients do not survive the adolescence. We could survive only one patient (out of two we had seen within 25 years) since now nearly 17 years by using even radiation therapy and multiple operations after interferon without significant benefit, bleomycin, ligation of thoracic duct because of recurrent life threatening pleural effusions due to the lymphatic malformation (therapy resistent massive chylothorax- 2l per day). Splenectomy and resection of pancreatic tail was indicated also, because at the age of 6 months the huge abdominal lymphangiomatosis caused Klebsiella Sepsis and Kassabach Merritt syndrome as a sequelae. Also involvement of the pancreas, but no brain involvement as in your patient.
Very difficult to treat, Interferon 2 alpha (Wellferon, 3Mio every three days units for a year) had only limited benefit, but high side effects. Nevertheless it is recommended and most likely helpful to survive, even we cannot say from our experience what the real effect on the lymphatic malformation was.
At least we administered cytostatic therapy and by this in combination with multiple surgical interventions he survived with significant defects - but, he will start to study at University this year.
Therefore my recommendation is a multimodal combined symptomatic and systemic treatment by interferon, cytostatics, radiation and surgery as well as local use of Picibanil.
Maybe the treatment by Rapamycin will be a good idea as Israel Fernandez-Pineda and Jose Matute advises - we did not use because at that time -15 years ago- was not available yet.