Questions related to General Surgery
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?
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?
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?
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.
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?
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 .
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?
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.
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?
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.
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.
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.
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?
Why some patients develop lid retraction following glaucoma filtration surgery?
Lid retraction is dangerous for the filtration bleb. How should it be managed?
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 ?
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?
Is it 10hour or 12hrs time period for finding exact blood sugar level and evaluating lipid profile.
Old patient with cardiovascular disease submitted to dental implant surgery present higher failure rate than those without cardiovascular disease.
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.
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?
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.
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
it is a common observation to see high lactate post uneventful surgery that clear gradually without any clear reason?
Patient with history of esophagitis underwent laparoscopic sleeve gastrectomy, how often endoscopy is mandatory in the years after surgery?
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?
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.
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.
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).
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.
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.
What are the current indications for the use of Diagnostic Peritoneal Lavage (DPL) in abdominal trauma patients?
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?
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?
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???
Current evidence indicates that appendectomy puts patients at increased risk for recurrent clostridium difficile-associated colitis.
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 ?
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.
What is the best treatment option for appendicular mass, conservative management (Ochsner-Sherren regimen) vs early appendectomy?
General surgeon should begin the reconstruction of the excised portal vein during laparoscopic cholecystectomy or send him to a reference center ?
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.
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?
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 ?
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.
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...
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?
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.
I am working in a research about the mortality among elderly, underwent surgery in my hospital. Anybody can help me?
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.
I remember during my training days, how difficult it is to inject local anesthetic for corn excision. Where the local spilt all over.
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?
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?
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.
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.
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
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?