Cemento-ossifying fibroma of the left mandible: A case report

BACKGROUND

Ossifying fibroma is a type of benign fibro-osseous lesion. Most lesions affect the mandible region, particularly the molar and pre-molar areas. It predominantly affects females between the second to fourth decades of life. Larger ossifying fibroma tumors require more extensive resection.

CASE SUMMARY

A 39-year-old female complained of occasional pain and tumor enlargement on her left jaw for the 3 years prior to presentation. Intraoral examination revealed a firm swelling on her left lower gum. Extraoral examination revealed swelling on the left mandible body with no erythema and superficial ulcer. Computed tomography scan revealed a circular-shaped lesion on the patient’s left mandible body with a well-defined radiolucent border, sized 3.2 cm × 2.8 cm × 0.9 cm. The tumor was removed by marginal mandibulectomy. Biopsy from the resected tumor suggested cemento-ossifying fibroma (COF).

CONCLUSION

COF is often unnoticed, but this slow-growing tumor can cause significant symptoms regarding its distortion into adjacent structures.

Superior mesenteric artery syndrome in a patient with esophageal stenosis: A case report

BACKGROUND

Superior mesenteric artery syndrome (SMAS) is a rare condition, characterized by duodenal obstruction caused by compression of its third part by the superior mesenteric artery (SMA). Most cases of SMAS are associated with weight loss, and the most frequent clinical manifestations are nausea, vomiting, postprandial fullness, and abdominal pain. Treatment of SMAS is usually conservative, consisting mainly of adequate nutritional support, but in refractory cases surgery may be necessary, with gastrojejunostomy and duodenojejunostomy being the most commonly performed procedures.

CASE SUMMARY

We describe the case of a man in his forties with a pre-existing diagnosis of esophageal stricture due to sodium hydroxide ingestion, who suffered significant weight loss after replacement of his jejunostomy tube. He was admitted to the hospital due to pain and abdominal distension. A computerized tomography scan showed significant distension of the stomach and duodenum with narrowing of the duodenum at the point at which it is crossed by the superior mesenteric artery, thus establishing the diagnosis of SMAS. Due to the presence of the esophageal stricture, the patient was incapable of emesis; however, passage of a nasogastric tube for decompression was not possible. Considering the risk of gastric perforation due to distention, we opted for surgical treatment in the form of a surgical gastrojejunostomy after which he showed complete resolution of all symptoms and was discharged from the hospital 5 d after the procedure.

CONCLUSION

Diagnosis of SMAS can be challenging in patients with esophageal stenosis, and risk of gastric perforation may preclude conservative treatment.

Freehand-robot-assisted laparoscopic colorectal surgery: Initial experience in the Trinidad and Tobago

BACKGROUND

Laparoscopic colorectal surgery is still developing in the Anglophone Caribbean, having been first performed in the region in the year 2011. We report the initial outcomes using a robot camera holder to assist in laparoscopic colorectal operations.

AIM

To report our initial experience using the FreeHand^® robotic camera holder (Freehand 2010 Ltd., Guildford, Surrey, United Kingdom) for laparoscopic colorectal surgery in Trinidad & Tobago.

METHODS

We retrospectively collected data from all patients who underwent laparoscopic colorectal resections using the Freehand^® (Freehand 2010 Ltd., Guildford, Surrey, United Kingdom) robotic camera holder between September 30, 2021 and April 30, 2022. The following data were recorded: patient demographics, robotic arm setup time, operating time, conversions to open surgery, conversions to a human camera operator, number and duration of intra-operative lens cleaning. At the termination of the operation, before operating notes were completed, the surgeons were administered a questionnaire recording information on ergonomics, user-difficulty, requirement to convert to a human camera operator and their ability to carry out effective movements to control the robot while operating.

RESULTS

Nine patients at a mean age of 58.9 ± 7.1 years underwent colorectal operations using the FreeHand robot: Right hemicolectomies (5), left hemicolectomy (1), sigmoid colectomies (2) and anterior resection (1). The mean robot docking time was 6.33 minutes (Median 6; Range 4-10; SD ± 1.8). The mean duration of operation was 122.33 ± 78.5 min and estimated blood loss was 113.33 ± 151.08 mL. There were no conversions to a human camera holder. The laparoscope was detached from the robot for lens cleaning/defogging an average of 2.6 ± 0.88 times per case, with cumulative mean interruption time of 4.2 ± 2.15 minutes per case. The mean duration of hospitalization was 3.2 ± 1.30 days and there were no complications recorded. When the surgeons were interviewed after operation, the surgeons reported that there were good ergonomics (100%), with no limitation on instrument movement (100%), stable image (100%) and better control of surgical field (100%).

CONCLUSION

Robot-assisted laparoscopic colorectal surgery is feasible and safe in the resource-poor Caribbean setting, once there is appropriate training.

Rare case of perforated giant gastric ulcer with concurrent thyroid storm: A case report

BACKGROUND

Thyroid storm is an uncommon condition manifesting in severe thyrotoxicosis with a high mortality rate. The concurrence of peptic ulcer disease and hyperthyroidism is rare due to concurrent activation of both the sympathetic and parasympathetic pathways. We present a case of perforated giant gastric ulcer with concurrent thyroid storm who underwent damage control surgery with emergency patch repair with falciform ligament and recovered well.

CASE SUMMARY

A 53-year-old male chronic smoker, with no previous medical history, presented with severe generalized abdominal pain and vomiting for one day duration. Further history revealed weight loss, diarrhea, and anxiety over the past three months. On clinical examination, patient was febrile with temperature of 38.6 Degrees Celsius and tachycardic at 130-140 beats per minute, his blood pressure was low at 90/50mmHg. His abdomen was tender with generalized peritonism. In view of his clinical history, a thyroid screen was ordered which showed raised thyroxine (T4) levels of 90.3 pmol/L and low thyroxine stimulating hormone (TSH) levels of 0.005 μU/mL. Chest X-ray showed no sub-diaphragmatic free air, but contrasted CT scan revealed pneumoperitoneum with large amount of intraabdominal free fluid. The working diagnosis was perforated peptic ulcer complicated by thyroid storm. An urgent endocrinologist consult was made, and patient was started on beta blocker and intravenous steroids pre-operatively. The patient underwent emergency laparotomy with washout and patch repair of the perforated gastric ulcer. Patient was monitored post-operatively in intensive care unit and required IV hydrocortisone and Lugol’s iodine. Histology of the ulcer edges showed no malignancy. On post-operative day seven, T4 decreased to 20.4 pmol/L, TSH was 0.005 mLU/L. His thyroid function test subsequently normalized 3 mo post-operatively with T4 18.1 pmol/L, TSH 1.91 mLU/L. Patient’s recovery was otherwise uneventful. Thyroid receptor antibody subsequently was positive, and patient was managed for Grave’s disease by the endocrinologist.

CONCLUSION

This case highlights the rare but life-threatening clinical emergency of peptic ulcer perforation complicated by thyroid storm. Multidisciplinary perioperative management is crucial to optimize patient for surgery and damage control principles should be taken for an acute surgical patient with concurrent endocrine crisis.

Theco-thecal bypass technique elucidating a novel procedure and perspective on treatment of post-arachnoiditis syringomyelia: A case report

BACKGROUND

Post-arachnoiditis syringomyelia is a condition in which there is an intraspinal cerebrospinal fluid (CSF) blockade due to arachnoidal adhesions and bands. Although many of the techniques currently in use, namely, the theco-peritoneal, syringo-pleural, syringo-peritoneal, and syringo-subarachnoid shunts, are effective, the results are often variable.

CASE SUMMARY

A 36-year-old man with a past history of pulmonary tuberculosis, presented with progressive paraesthesia in the feet and progressive paraparesis along with constipation, difficulty in micturition, and decreased libido. He was bedridden a month before presentation. Magnetic resonance imaging revealed a dorsal multiloculated syrinx from D3-D10 vertebral levels. He underwent a D1-2 to D11 theco-thecal shunt bilaterally to abolish the CSF gradient across the level of the syrinx. There was no direct surgical handling of the spinal cord involved. At the 15-mo follow up, the patient had significant improvement in his symptoms and function.

CONCLUSION

We present a novel technique aimed at correcting the primary cause of a post-arachnoiditis syrinx, the subarachnoid cerebrospinal flow obstruction or block, which we believe is simple and effective, involves minimal handling of the normal neural structures, and attempts to restore the physiology of CSF flow across the obstruction, with favorable clinical results.

Cholangioscopy-assisted guidewire placement in a malignant biliary stricture: A case report

BACKGROUND

Cholangioscopy has been described in case reports and series to facilitate guidewire placement in difficult benign biliary strictures. Specifically, it has been infrequently used in difficult benign anastomotic liver transplant biliary strictures to visualize the stricture orifice for guidewire placement. Here we describe a case of guidewire placement through a difficult malignant biliary stricture using single operator cholangioscopy.

CASE SUMMARY

A 74-year-old female presented with jaundice and weight loss. Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) by other endoscopists demonstrated pancreatic adenocarcinoma with a dilated cystic duct (CD) and proximal common bile duct (CBD). The associated distal CBD stricture was dilated and stented with a plastic stent. However she subsequently developed cholangitis, prompting referral for a repeat ERCP. The stent was found to have migrated distally to the confluence of the dilated CD and CBD stricture. Despite using multiple hydrophilic guidewires, the stricture could not be traversed due to preferential wire passage into the dilated CD. SpyGlass DS (Boston Scientific Corp, Marlborough, MA, United States) was then used to visualize the orifices of the CD and CBD stenosis, enabling the guidewire to be placed directly through the stricture into the proximal CBD. A WallFlex covered metal stent (Boston Scientific Corp, Marlborough, MA, United States) was successfully placed, resulting in resolution of her cholangitis.

CONCLUSION

To our knowledge, this is one of the first cases to describe successful cholangioscopic guidewire placement for malignant biliary strictures.

Regional lymphadenectomy in advanced ovarian cancer: The enigma continues

The role of regional lymphadenectomy has always been a matter of discussion in the surgical management of solid tumors – Pelvic and para-aortic lymphadenectomy in ovarian cancer is one such issue. A recently published randomized trial suggested that regional lymphadenectomy in patients with advanced ovarian cancer is unlikely to offer a survival advantage. However, para-aortic and pelvic lymphadenectomy is warranted in the presence of macroscopically suspicious nodes to achieve complete cytoreduction. A long-term follow-up of the trial will demonstrate whether a prophylactic regional lymphadenectomy is associated with survival benefit in a subgroup of patients with advanced ovarian cancer who have grossly normal regional lymphnodes as evident in a widely open retroperitoneum.

Caribbean “substitution culture” is a barrier to effective treatment of persons with diabetic foot infections

Diabetes-related amputation rates are high in the Caribbean. Many authorities have identified independent risk factors for diabetes-related amputations, but cultural factors remain underappreciated. We coined the term “Caribbean substitution culture” to describe the attitude of patients with diabetic foot infections in which they refuse to access medical care, instead voluntarily choosing to substitute “bush medicines” or other alternative therapies in the place of conventional treatment. Recognizing that the Caribbean substitution culture is a barrier to effective treatment of diabetic foot infections is the first step in curbing these practices. In this paper, we discuss the issues related to the Caribbean substitution culture, including the demographics of the population at risk, the alternative therapeutic practices and potential public health strategies to combat this practice.

Can hyperthermic intraperitoneal chemotherapy effectively control gastric cancer-associated peritoneal carcinomatosis?

Gastric cancer-associated peritoneal carcinomatosis leads to a poor prognosis and low quality of life. The current systemic chemotherapy processes cannot effectively improve survival. Hyperthermic intraperitoneal chemotherapy (HIPEC) has been used as an alternative treatment to control this disease through recurrence prevention, definitive therapeutic modality, and symptom palliation. Although HIPEC has been demonstrated to yield favorable results mainly in some Asian studies, widespread adoption of this treatment is still debatable before larger prospective randomized controlled clinical trials confirm its effectiveness.

Role of botulinum toxin a in the management of complex incisional hernias

Despite the technological breakthroughs and discover of abdominal meshes, ventral hernia has always been challenging in therapeutic strategies by the surgeons, with high recurrence rates. The use of botulinum toxin A (BTA) for the management of ventral and incisional hernia (IH) poses an increasingly interesting practice, especially for the intimidating complex one. The preoperative administration of the toxin to the lateral abdominal muscles by use of Ultra-Sound guidance causes muscle paralysis and a reduction of intra-abdominal pressure. Thus, the hernia defect can be primarily closed without tension, if the length of the defect is up to 10 cm. In larger hernia, this method can be combined with component separation techniques or the use of a mesh. The mesh placement seems to be better by laparoscopy. The site of injection and the dosage of BTA are still under discussion amongst authors. The optimal administration is proposed by some authors to be at least 2 weeks before repair. There is also an analgesic effect of BTA to the patients that underwent hernia reconstruction. Ultimately, the role of BTA in the reconstruction of ventral hernia seems to be promising, but there is a necessity for several randomized clinical trials.

A slight glance at peer review

In order to ensure that the highest quality of literature is published, most journals utilize a peer review process for manuscripts submitted. Although the primary purpose for this process is to filter out ”bad science”, the process is not perfect. While there is a general consensus among researchers and clinicians that something must be done to improve upon the method for properly vetting manuscripts, there are conflicting opinions on how to best implement new policies. In this paper, we discuss the most well-supported suggestions to improve the process, with the hopes of increasing rigor and reproducibility, ensuring double-blinding, developing set guidelines, offering early training to reviewers, and giving reviewers better feedback and recognition for their work.

Surgical treatment of a rare complication after endoscopic stent placement for anastomotic leakage after esophageal resection

The best approach to achieve cure in esophageal cancer is a combination of chemo-radiation and surgery. However, complications occur in half of patients. The current report, reports a rare but severe complication: Complete obstruction of the esophagus, induced by preoperative chemo-radiation therapy. Normally, strictures are treated by repeated dilatations, however, in case of complete obstruction, the perforation rate of standard blind anterograde wire access and dilation is severely increased. In order to minimize the risk of perforations, the rendezvous technique was introduced. This technique involves an anterograde approach in combination with a retrograde approach in order to open and dilatate the esophagus. While technical success rates between 83% and 100% have been reported in literature, data on clinical outcomes are scarcer. The limited amount of studies available claim that success was achieved in almost half of patients. The patient in our case currently has an oral diet without restrictions and rates his quality of life with a VAS-score ten out of ten.

Glycemic management in critically ill patients

Hyperglycemia associated with critical illness, also called “stress hyperglycemia” or “stress diabetes”, is a consequence of many pathophysiologic hormonal responses including increased catecholamines, cortisol, glucagon, and growth hormone. Alterations in multiple biochemical pathways result in increased hepatic and peripheral insulin resistance with an uncontrolled activation of gluconeogenesis and glycogenolysis. Hyperglycemia has a negative impact on the function of the immune system, on the host response to illness or injury, and on infectious and overall outcomes. The degree of glucose elevation is associated with increased disease severity. Large randomized controlled trials including the Van den Berghe study, the NICE-SUGAR trial, VISEP and GLUCONTROL have shown that the control of glucose levels in critically ill patients has implications on outcome and that both hyperglycemia and hypoglycemia are detrimental and should be avoided. Glucose variability has also been shown to be detrimental. Aggressive glucose control strategies have changed due to the concerns of hypoglycemia and therefore intermediate target glucose control strategies are most often adopted. Different patient populations may vary with regards to optimal glucose targets, timing and approach for glucose control, and with regards to the prognostic significance of glucose excursions and variability. Medical, surgical, and trauma patients may benefit at different rates from glucose control and the approach may need to be adapted to various medical settings and to correspond to the workflow of health providers. Effect modifiers for the success of insulin therapy for hyperglycemia include the methods of nutritional supplementation and exogenous glucose administration. Further research is required to improve insulin protocols for glucose control, to further define glucose targets, and to enhance the accuracy of glucose measuring technologies.

Surgical outcomes of pulmonary resection for lung cancer after neo-adjuvant treatment

AIM: To evaluate the outcomes of surgery for lung cancer after induction therapy.

METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2012), we identified 4063 patients who underwent a pulmonary resection for lung cancer. Two hundred and thirty-six (5.8%) received neo-adjuvant therapy prior to surgery (64 chemo-radiation, 103 radiation alone, 69 chemotherapy alone). The outcomes were compared to 3827 patients (94.2%) treated with surgery alone. Primary outcome was 30-d mortality, and secondary outcomes included length of stay, operative time and NSQIP measured postoperative complications.

RESULTS: Lung cancer patients who received preoperative treatment were younger (66 vs 69, P < 0.001), were more likely to have experienced recent weight loss (6.8% vs 3.5%; P = 0.011), to be active smokers (48.3 vs 34.9, P < 0.001), and had lower preoperative hematological cell counts (abnormal white blood cell: 25.6 vs 13.4; P < 0.001; low hematocrit 53% vs 17.3%, P < 0.001). On unadjusted analysis, neo-adjuvant patients had significantly higher 30-d mortality, overall and serious morbidity (all P < 0.001). Adjusted analysis showed similar findings, while matched cohorts comparison confirmed higher morbidity, but not higher early mortality.

CONCLUSION: Our data suggest that patients who receive neo-adjuvant therapy for lung cancer have worse early surgical outcomes. Although NSQIP does not provide stage information, this analysis shows important findings that should be considered when selecting patients for induction treatment.

Should multi-gene panel testing replace limited BRCA1/2 testing? A review of genetic testing for hereditary breast and ovarian cancers

Clinical testing of patients for hereditary breast and ovarian cancer syndromes began in the mid-1990s with the identification of the BRCA1 and BRCA2 genes. Since then, mutations in dozens of other genes have been correlated to increased breast, ovarian, and other cancer risk. The following decades of data collection and patient advocacy allowed for improvements in medical, legal, social, and ethical advances in genetic testing. Technological advances have made it possible to sequence multiple genes at once in a panel to give patients a more thorough evaluation of their personal cancer risk. Panel testing increases the detection of mutations that lead to increased risk of breast, ovarian, and other cancers and can better guide individualized screening measures compared to limited BRCA testing alone. At the same time, multi-gene panel testing is more time-and cost-efficient. While the clinical application of panel testing is in its infancy, many problems arise such as lack of guidelines for management of newly identified gene mutations, high rates of variants of uncertain significance, and limited ability to screen for some cancers. Through on-going concerted efforts of pooled data collection and analysis, it is likely that the benefits of multi-gene panel testing will outweigh the risks in the near future.

Patient handoffs in surgery: Successes, failures and room for improvement

Patient handoffs are transitions where communication failures may lead to errors in patient care. Face-to-face handoffs are preferred, however may not always be feasible. Different models and strategies have been described, yet there are few experimental studies. Expanding the problem, the on-call surgeon may be responsible for many patients, few or none that they admitted. Effective handoffs improve the quality of care and result in fewer errors. Herein we review different models of patient handoffs, comment on common pitfalls, and suggest areas for new research.

Review of intraoperative parathormone monitoring with the miami criterion: A 25-year experience

With the development of imaging and localization studies, focused parathyroidectomy with use of intraoperative parathormone monitoring (IPM) is the mainstay of treatment for primary hyperparathyroidism at many health care centers both nationally and internationally. Focused parathyroidectomy guided by IPM allows for surgical excision of the offending parathyroid gland through smaller incisions. The Miami criterion is a protocol that uses a “> 50% parathormone (PTH) drop” from either the greatest pre-incision or pre-excision measurement of PTH in a blood sample taken 10 min following resection of hyperfunctioning glands. Following removal of the hyperfunctioning parathyroid gland, a > 50% PTH drop at 10 min indicates completion of parathyroidectomy, and predicts operative success at 6 mo. IPM using the Miami criterion has demonstrated equal curative rates of > 97%, which is comparable to the traditional bilateral neck exploration. The focused approach, however, is associated with shorter recovery times, improved cosmesis, and lower risk of postoperative hypocalcemia.

Malignant melanoma in the pediatric population

Controversial pigmented lesions in children are a problem for pathologist, clinicians and families that are confronted with this dilemma. Some skin lesions in this population defy diagnosis with pathologists split between a benign diagnosis and a cancer diagnosis. Three cases of controversial pigmented lesions in the pediatric population are presented. Three patients underwent radical resection of the controversial pigmented lesion, intra-operative lymphatic mapping and sentinel lymph node (SLN) biopsy. Due to the low morbidity of the SLN procedure a case is made to perform lymphatic mapping in this clinical scenario. If the SLNs are negative, not much is lost except for the scar and this becomes another line of evidence that perhaps the original lesion was benign. If the SLN shows metastatic cells, then the original skin lesion must be malignant and the patient is offered stage III recommendations that would include complete node dissections and adjuvant Interferon therapy. This strategy provides for adequate treatment of the worse-case scenario, that the skin lesion is malignant. The cost to the patient is a low morbidity procedure, the SLN biopsy.

Are stapler line reinforcement materials necessary in sleeve gastrectomy?

AIM: To investigate the effect of staple line reinforcement materials on decreasing complications related to sleeve gastrectomy.

METHODS: In this retrospective study, we analyzed 84 patients who had sleeve gastrectomy due to obesity between April 2012 and April 2015. Sleeve gastrectomy procedure was performed in patients with a body mass index (BMI) more than 40 kg/m², and the ones with a BMI between 32 and 40 kg/m² in the presence of comorbid diseases. Reinforcement materials were used in 45 patients while they were not used in 39 patients. Materials such as Peristrip, 3/0 prolene, and V-lock were used for reinforcement in the reinforcement group (RG), and the materials used showed variations during the study period. The baseline characteristics, duration of surgery, hospital stay, comorbidities including hypertension, type 2 diabetes mellitus, hypertension, hepatosteatosis, gallstones, osteoarthritis, gastroesophageal reflux, sleep disorders, as well as the complications including leaks and bleeding after surgery were recorded and compared between the reinforcement and non-RGs (NRGs).

RESULTS: There were no differences between the reinforcement and NRGs for baseline characteristics including age (P = 0.689), gender (P = 0.057), height (P = 0.483), weight (P = 0.889), BMI (P = 0.971), hospital stay (P = 0.888), or duration of surgery (P = 0.229). The most common comorbidities in the RG were hypertension (24.4%) and hepatosteatosis (24.4%), while type 2 diabetes mellitus (28.2%) and hepatosteatosis (28.2%) were the most frequent comorbidities in the NRG. There were no differences between the reinforcement and NRGs for the rates of comorbidities (P > 0.05). Leak was observed in one (2.2%) patient in the RG, and there was leak in 2 (5.1%), and bleeding in 2 (5.1%) patients in the NRG. There were no differences between the reinforcement and NRGs for the rate of staple line leaks (P = 0.446) or bleeding (P = 0.213). One of the patients with leak died in the NRG while there were no deaths in the RG.

CONCLUSION: Although staple line reinforcement materials decreased morbidity and mortality, the differences between the two groups were not statistically significant.

Versatility of therapeutic reduction mammoplasty in oncoplastic breast conserving surgery

Oncoplastic breast conserving surgery is the gold standard approach for the surgical treatment of early breast cancer. There is a well defined technique named “therapeutic mammoplasty” which is characterized for using a reduction mammaplasty technique to treat breast cancer conservatively. In our current practice, “therapeutic mammoplasty” or therapeutic reduction mammaplasty is our favorite oncoplastic breast conserving approach which it used in almost half of our patients. This technique is very versatile allows us the resection of tumors located in all breast quadrants of patients with moderate-to large-sized breasts. We describe a series of 57 patients who were treated using a therapeutic reduction mammaplasty. All surgical procedures were carried out by one comprehensive breast surgeon who planned and designed the surgery performing both oncologic and reconstructive procedures. Surgical margins were insufficient in eight patients (14%). Nine patients (15.8%) had a complication in early postoperative period and in one of them adjuvant radiotherapy was delayed four months due to a wound dehiscence. The rate of synchronous contralateral symmetrization was 31.6%. Our conclusion is that reduction mammaplasty is a useful and safe skill to treat breast cancer conservatively playing a very important role therefore it must be situated in the priority of learning objectives.

Central neck compartment dissection in papillary thyroid carcinoma: An update

Papillary thyroid carcinoma (PTC) is the most common thyroid malignancy, accounting for approximatley 90% of thyroid malignancies in areas of the world without deficit of Iodine. It’s universally accepted that total thyroidectomy is the minimal surgical treatment for patients with PTC higher than 1 cm. When a quality surgery is performed, the prognosis for PTC is excellent with 10 and 20-year overall survival rates around 90% and 85%, respectively. Lymph node metastases are very frequent in PTC, occurring in 50%-80% of PTC patients, the most of them being located in the central compartment of the neck (CCN) and with a high rate of occult or clinically undetectable disease. A lot of controversy exists regarding how to treat the central nodal compartment disease of PTC. The first problem is the lack of standardization of the terminology and concepts related to the CCN, which are clearly established and defined in this paper according to the most recent consensus documents of endocrine societies. This uniformity will provide a more consistent and clear communicaction between all the specialist involved in the treatment of PTC. CCN can be performed to treat patients with clinically detectable, radiologically suspected of intraoperative visualized nodal disease (this is defined as therapeutic) or when these findings are absent (also called prophylactic). Indicactions, advantages and disadvantages of both therapeutic and prophylactic CCN dissection are widely discussed and clear recommendations provided.

Comprehensive treatment for the peritoneal metastasis from gastric cancer

Recently, a novel comprehensive treatment consisting of cytoreductive surgery (CRS) and perioperative chemotherapy (POC) was developed for the treatment of peritoneal metastasis (PM) with a curative intent. In the treatment, the macroscopic disease is completely removed by the peritonectomy techniques in combination with POC. This article reviews the results of the comprehensive treatment for PM from gastric cancer, and verifies the effects of CRS and POC, including neoadjuvant chemotherapy (NAC) and hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC). Completeness of cytoreduction, peritoneal carcinomatosis index (PCI) less than the threshold levels after NAC, absence of ascites, cytologic status, pathologic response after NAC are the independent prognostic factors. Among these prognostic factors, PCI threshold level is the most valuable independent prognostic factor. After staging laparoscopy, patients with PM from gastric cancer are recommended to treat with NAC before CRS. After NAC, indication for CRS is determined by laparoscopy. The indications of the comprehensive treatment are patients with PCI less than the threshold levels, negative cytology, and responders after NAC. Patients satisfy these factors are the candidates for the CRS and HIPEC.

Current management of acute type B aortic dissection

Acute type B aortic dissection (TBAD) occurs as a result of an intimal tear within the proximal thoracic aorta. Patients are typically managed acutely with aggressive antihypertensive therapy. Surgical repair is reserved for those who develop complications such as rupture or malperfusion. The surgical management of acute TBAD has changed considerably in the last decade secondary to the advent of thoracic stent grafting. Thoracic endovascular aortic repair (TEVAR) has improved early mortality and morbidity rates for patients presenting with complicated TBAD. The role of TEVAR in patients presenting with acute and subacute uncomplicated TBAD is less clear. TEVAR has been associated with increased late survival and better aortic remodeling, with low perioperative morbidity in selected patients. Recent literature suggests certain radiographic criteria may be used to predict patients developing late aortic events who would benefit from early TEVAR. The purpose of this article is to review the contemporary management of acute TBAD, discuss controversies in management and evaluate the latest research findings.

In utero and exo utero fetal surgery on histogenesis of organs in animals

Until recently, fetal surgery was only used for fetuses with very poor prognosis who were likely to die without intervention. With advances in imaging, endoscopic techniques, anesthesia and novel interventions, fetal surgery is becoming a realistic option for conditions with less severe prognoses, where the aim is now to improve quality of life rather than simply allow survival. Until forty years ago, the uterus shielded the fetus from observation and therapy. Rapid changes in the diagnosis and treatment of human fetal anatomical abnormalities are due to improved fetal imaging studies, fetal sampling techniques (e.g., amniocentesis and chorionic villus sampling), and a better understanding of fetal pathophysiology derived from laboratory animals. Fetal therapy is the logical culmination of progress in fetal diagnosis. In other words, the fetus is now a patient. Now-a-days, in utero (IU) and exo utero (EU) surgical methods are popular for experimental analyses of the histogenesis of organ development. Using these surgical methods, developmental anomalies can be created and then repaired. By applying microinjection and/or fetal surgery with these methods, models of developmental anomalies such as neural tube defects, temporomandibular joint defects, hip joint defects, digit amputation, limb and digit development and regeneration, and tooth germ transplantation in the jaw could be created and later observed. After observing different types of anomalies, novel IU and EU surgical techniques would be the best approach for repairing or treating those anomalies or diseases. This review will focus on the rationale for the IU and EU creation of animal models of different organ defects or anomalies and their repair, based on analyses of organ histogenesis and pathologic observations. It will also focus in detail on the surgical techniques of both IU and EU methods.

Robotic surgery vs conventional laparoscopy for the treatment of rectal cancer: Review of the literature

Laparoscopic surgery has established itself as a safe and effective alternative to open surgery for the treatment of colorectal cancer. However, laparoscopic resection of rectal cancer, and in particular of the lower rectum, remains challenging in view of the limitations of operating in the confined pelvic space, limited movement of instruments with fixed tips, assistant-dependant two-dimensional view, easy camera fogging, and poor ergonomics. The introduction of robotic surgery and its application in particular to pelvic surgery, has potentially resolved many of these issues. To define the role of robotic surgery in total mesorectal excision for rectal cancer, a review of the current literature was performed using PubMed, Embase, Cochrane Library, and Google databases, identifying clinical trials comparing short-term outcomes of conventional laparoscopic total mesorectal excision with the robotic approach. Robotic surgery for rectal cancer is a safe alternative to conventional laparoscopy. However, randomised trials are needed to clearly establish its role.

Ileo-anal pouch excision: A review of indications and outcomes

Restorative proctocolectomy (RP) is the surgical treatment of choice for ulcerative colitis (UC) and patients with familial adenomatous polyposis (FAP). A devastating complication for both patient and surgeon is failure of the pouch that requires excision. There is currently no single paper in the literature that consolidates the indications for ileo-anal pouch excision and the subsequent outcomes following this procedure. A literature search was carried out to identify articles on RP and ileal pouch-anal anastomosis. The main search terms used were “RP”; “ileal pouch-anal anastomosis” or “ileal reservoir” or “ileal pouch”; “failure of ileal pouch-anal anastomosis” and “excision of ileal pouch-anal anastomosis”. The search was completed using electronic databases MEDLINE, PubMed and EMBASE from 1975 to June 2014. Characteristics of patients with pouch failure differ between institutions. Reported overall excision rates of the pouches vary and in this review ranged from 0.93% to 12.8%. Age and lower institutional volume (less than 3.3 cases) were independent predictors of pouch failure; however surgeon case load was not. The main reasons identified for excision are sepsis (early cause), Crohn’s disease and poor functional outcomes (both late causes). Pouch cancers in UC and FAP are still rare but 135 cases exist in the literature. The most common complication following excision is persistent perineal sinus. The decision to excise a pouch should not be taken lightly and an awareness of the technical pitfalls and complications that can occur should be fully appreciated.

Operative management of acute diverticulitis in immunosuppressed compared to immunocompetent patients: A systematic review

AIM: To determine short and long-term outcomes following operative management of acute diverticulitis in immunosuppressed (IMS) compared to immunocompetent (IMC) patients.

METHODS: PRISMA guidelines were followed in conducting this systematic review. We searched PubMed (1946 to present), OVID MEDLINE(R) In-Process and Other Non-Indexed Citations, OVID MEDLINE(R) Daily and OVID MEDLINE(R) (1946 to present), EMBASE on OVID platform (1947 to present), CINAHL on EBSCO platform (1981 to present), and Cochrane Library using a systematic search strategy. There were no restrictions on publication date and language. We systematically reviewed all published cohort comparative studies, case-control studies, and randomized controlled trials that reported outcomes on operative management of acute episode of colonic diverticulitis in IMS in comparison to IMC patients.

RESULTS: Seven hundred and fifty-five thousand five hundred and eighty-three patients were included in this systematic review; of which 1478 were IMS and 754105 were IMC patients. Of the nine studies included there was one prospective cohort, seven retrospective cohorts, one retrospective case-control study, and no randomized controlled trials. With the exception of solid organ transplant patients, IMS patients appeared to be older than IMC when they presented with an acute episode of diverticulitis. IMS patients presented with more severe acute diverticulitis and more insidious onset of symptoms than IMC patients. In the emergency setting, peritonitis was the main indication for operative intervention in both IMS and IMC patients. IMS patients were more likely to undergo Hartmann’s procedure and less likely to undergo reconstructive procedures compared to IMC patients. Furthermore, IMS patients had higher morbidity and mortality rates in the emergency setting compared to IMC patients. In the elective settings, it appeared that reconstruction with primary anastomosis with or without a diverting loop stoma is the procedure of choice in the IMS patients and carried minimal morbidity and mortality equivalent to IMC patients.

CONCLUSION: Emergency operations for diverticulitis in IMS compared to IMC patients have higher morbidity and mortality, whereas, in the elective setting both groups have comparable outcomes.

Surgical treatment of retrorectal (presacral) tumors

Retrorectal (also known as presacral) tumor (RT) is a rare disease of retrorectal space. They can be classified as congenital, inflammatory, neurogenic, osseous, or miscellaneous. The most common presentation is an asymptomatic mass discovered on routine rectal examination, but certain nonspecific symptoms can be elicited by careful history and physical examination. The primary and only satisfactory treatment is surgery for RTs. Three approaches commonly used for resection are abdominal, transsacral, or a combined abdominosacral approach. Prognosis is directly related primary local control, which is often difficult to achieve for malignant lesions.

How would we deal with hypothalamic hamartomas?

Hypothalamic hamartoma (HH) is usually associated with refractory epilepsy, cognitive impairment, and behavioral disturbance. There is now increasing evidence that HH can be treated effectively with a variety of neurosurgical approaches. Treatment options for intractable gelastic seizure in HH patients include direct open surgery with craniotomy, endoscopic surgery, radiosurgery with gamma knife and stereotactic radiofrequency thermocoagulation. Selection of treatment modalities depends on type and size of the HH and the surgeon’s preference. Two surgical techniques, resection and disconnection, had been described with favorable outcomes. Pretreatment evaluation, patient selection, surgical techniques, complications, and possible selection of treatment are discussed.

Mesorectal excision: Surgical anatomy of the rectum, mesorectum, and pelvic fascia and nerves and clinical relevance

Biologic behavior and management of rectal cancer differ significantly from that of colon cancer. The surgical treatment is challenging since the rectum has dual arterial blood supply and venous drainage, extensive lymphatic drainage and is located in a bony pelvic in close proximity to urogenital and neurovascular structures that are invested with intricate fascial covering. The rectum is encased by fatty lymphovascular tissue (mesorectum) that is surrounded by perirectal fascia that act as barrier to the spread of the cancer and constitute the surgical circumferential margin. Locoregional recurrence after rectal cancer surgery is influenced by tumor-related factors and adequacy of the resection. Local recurrence is associated with incomplete excision of circumferential margin, violation of perirectal fascia, transmesorectal dissection, presence of isolated deposits in the mesorectum and tumor in regional lymph nodes and incomplete lymph node clearance. Hence to eradicate the primary rectal tumor and control regional disease, the rectum, first area of lymph node drainage and surrounding tissue must be completely excised while maintaining an intact fascial envelope around the rectum and preserving surrounding structures. This is achieved with extrafascial dissection and removal of the entire mesorectum including the portion distal to the tumor (total mesorectal excision) within its enveloping fascia as an intact unit. Total mesorectal excision is the standard of care surgical treatment of mid and low rectal cancer and can be performed in conjunction with low anterior resection, abdominoperineal resection, extralevator abdominoperineal resection, and extraregional dissection. To accomplish such a resection, thorough knowledge of the surgical anatomy of the rectum and pelvic structures and fascial planes is paramount.

Surgical management of rectal prolapse: The role of robotic surgery

The robotic technique as a safe approach in treatment of rectal prolapse has been widely reported during the last decade. Although there is limited clinical data regarding the benefits of robotic surgery, the safety of robotic surgery in rectal prolapse treatment has been cited by several authors. Also, the robotic approach helps overcome some of the laparoscopic approach challenges with purported advantages including improved visualization, more precise dissection, easier suturing, accurate identification of anatomic structures and fewer conversions to open surgery which can facilitate the conduct of technically challenging cases. These advantages can make robotic surgery ideally suited for minimally invasive ventral rectopexy. Currently, with greater surgeon experience in robotic surgery, the length of the procedure and the recurrence rate with the robotic approach are decreasing and short term outcomes for robotic rectal prolapse seem on par with laparoscopic and open techniques in recent studies. However, the high cost of robotic procedures is still an important issue. The benefits of a robotic approach must be weighed against the higher cost. More research is needed to better understand if the increased cost is justified by an improvement in outcomes. Also, published articles comparing long term outcomes of the robotic approach with other approaches are very limited at this time and further clinical trials are indicated to affirm the role of robotic surgery in the treatment of rectal prolapse.

Sentinel lymph node mapping for malignant melanoma of the external auditory canal

We describe a novel technique for sentinel lymph node mapping and biopsy of a primary cutaneous malignant melanoma in the medial portion of the external auditory canal. The approach is illustrated through a case report and technical description of a procedure performed under general anesthesia on a 19-year-old female patient. Due to the hidden and sensitive location of the primary tumor in the medial external auditory canal, the lymphoscintigraphy injection had to be performed by the surgeon immediately prior to the resection of her cT2aN0M0 lesion. Final pathology revealed clear margins at the primary site resection and 2 intraparotid sentinel lymph nodes with microscopic foci of metastatic malignant melanoma, which led to further surgical management. A completion left parotidectomy and neck dissection yielded no additional metastatic disease in the fifty-five nodes that were evaluated. Using this technique, sentinel lymph node mapping and biopsy accurately predicted the highest risk lymph nodes for the primary lesion of the medial portion of the external auditory canal.

Techniques that accurately identify the sentinel lymph node in cancer

Sentinel lymph node (SLN) biopsy has become the gold standard for patients with melanoma and breast cancer but it’s clinical application in other solid tumor types such as cancers of the esophagus, stomach, colon and rectum, head and neck, penis, uterine cervix and endometrium has been somewhat limited. Commonly used mapping techniques utilizing the combination of radiocolloid and blue dye may result in reduced SLN detection and increased false negative rates when applied to cancers with more complex lymphatic drainage patterns. Novel localization techniques including near infrared fluorescence, high resolution imaging and molecular targeted agents have been developed to address the limitations of conventional SLN detection practices in many solid tumor types. This article reviews the indications, techniques and detection rates for SLN biopsy in several different solid tumor types as well as the promising novel techniques created to address the contemporary limitations of this procedure.

Impact of circulating tumor cells in colorectal cancer patients undergoing laparoscopic surgery

Laparoscopic surgery has recently been widely used for various benign colorectal diseases as well as colorectal cancer. Although laparoscopic surgery has been shown to be with similar prognostic results for certain groups of colorectal cancer patients. The influence of laparoscopic procedures on the oncologist results, especially free tumor cell spreading is still a concern for some surgeons. Tumor cells found in the peripheral blood of patients with cancer are termed circulating tumor cells (CTCs). Presence of CTCs in the peripheral blood of patients with colorectal cancer has been reported to be associated with disease stage, poor prognosis, tumor progression, response to therapy, and drug resistance. Whether laparoscopic procedure enhances tumor spreading during operation remains unknown. Significantly less CTC detected during laparoscopic surgery than open surgery for colorectal cancer has been reported. In our previous experience, no significant elevation in CTC level was found in most patients during laparoscopic resection of colorectal cancer. We have shown that laparoscopic surgery had no significantly deleterious effect on CTCs in colorectal cancer patients. In this review, we aim at the impact of CTCs in patients with colorectal cancer undergoing laparoscopic surgery. The prognostic significance of CTCs in patients with colorectal cancer will also be addressed.

Prevention and management of fractured instruments in endodontic treatment

Intracanal instrument fracture is an unpredictable and problematic occurrence that can prevent adequate cleaning and shaping procedures and influence the prognosis of endodontic treatment. The prevalence of instrument fracture is reported to range between 0.28% and 16.2%. This article presents an overview of the prevention and management of instruments fractured during endodontic therapy on the basis of literature retrieved from PubMed and selected journal searches. Instrument fracture occurs because of reduced metal fatigue and/or torsional resistance. The reasons include canal morphology and curvature, manufacturing processes and instrument design, instrument use times and technique, rotational speeds and operator experience. With the development of various equipment and techniques, most of the retained instrument separations can be removed safely. However, in canals without associated periapical disease not every fractured separation should be removed from difficult locations because of the increased risk for root perforation and fracture. In difficult cases, either retain or bypass the fragment in the root canal and ensure regular follow-up reviews. Fractured instruments retained in the presence of periapical disease reduce significantly the prognosis of endodontically treated teeth, indicating a greater need to attempt the removal or bypass of the file separations. Apical surgery might be required in some instances, emphasizing the importance of preventing instrument fracture.

Role of ablation in the treatment of breast cancer: A review

Breast cancer surgical treatment has evolved from the days of the radical mastectomy to breast conservation surgery. In recent years, there has been much interest in percutaneous treatment modalities for breast cancer, instead of surgery. There are several different methods of percutaneous treatment of breast cancer. These include cryoablation, radiofrequency ablation, microwave ablation, laser ablation, and ultrasound ablation. The advantages of these techniques include an outpatient or office procedure, with local anaesthesia; minimal scarring, which is only from introducing the percutaneous instrument into the breast, instead of a surgical incision; and minimal recovery time, as the procedure does not involve surgery or general anaesthesia. Disadvantages relate mainly to pathologic evaluation, in that the true size of the breast cancer has to be estimated from the pre-procedure imaging, and all molecular profiling must be obtained from the biopsy specimen. In addition, long term patient satisfaction with cosmesis after adjuvant radiotherapy has not been studied. We review these percutaneous ablation modalities in this paper, as well as their individual techniques, associated advantages, and disadvantages. We also review current clinical trials, exploring these methods of breast cancer treatment.

Prophylactic oophorectomy during primary colorectal cancer resection: A systematic review and meta-analysis

AIM: To appraise the current evidence for prophylactic oophorectomy in patients undergoing primary curative colorectal cancer resection.

METHODS: Occult ovarian metastases may lead to increased mortality, therefore prophylactic oophorectomy may be considered for women undergoing colorectal resection. A systematic review and meta-analysis was performed for English language studies from 1994 to 2014 (PROSPERO Registry number: CRD42014009340), comparing outcomes following prophylactic oophorectomy (no known ovarian or other metastatic disease at time of surgery) vs no ovarian surgery, synchronous with colorectal resection for malignancy. Outcomes assessed: local recurrence, 5-year mortality, immediate post-operative morbidity and mortality, and rate of distant metastases.

RESULTS: Final analysis included 4 studies from the United States, Europe and China, which included 627 patients (210 prophylactic oophorectomy and 417 non-oophorectomy). There was one randomized controlled trials, the remainder being non-randomised cohort studies. The studies were all at high risk of bias according to the Cochrane Collaboration’s assessment tool for randomised studies and the Newcastle-Ottawa Score for the cohort studies. The mean age of patients amongst the studies ranged from 56.5 to 67 years. There were no significant differences between the patients having prophylactic oophorectomy at time of primary colorectal resection compared with patients who did not with respect to local recurrence, 5-year survival and distant metastases. There was no difference in post-operative complications or immediate post-operative mortality between the groups.

CONCLUSION: Current evidence does not favour prophylactic oophorectomy for patients without known genetic predisposition. Prophylactic surgery is not associated with additional risk of post-operative complications or death.

Impact of technology on indications and limitations for transanal surgical removal of rectal neoplasms

Transanal surgery has and continues to be well accepted for local excision of benign rectal disease not amenable to endoscopic resection. More recently, there has been increasing interest in applying transanal surgery to local resection of early malignant disease. In addition, some groups have started utilizing a transanal route in order to accomplish total mesorectal excision (TME) for more advanced rectal malignancies. We aim to review the role of various transanal and endoscopic techniques in the local resection of benign and malignant rectal disease based on published trial data. Preliminary data on the use of transanal platforms to accomplish TME will also be highlighted. For endoscopically unresectable rectal adenomas, transanal surgery remains a widely accepted method with minimal morbidity that avoids the downsides of a major abdomino-pelvic operation. Transanal endoscopic microsurgery and transanal minimally invasive surgery offer improved visualization and magnification, allowing for finer and more precise dissection of more proximal and larger rectal lesions without compromising patient outcome. Some studies have demonstrated efficacy in utilizing transanal platforms in the surgical management of early rectal malignancies in selected patients. There is an overall higher recurrence rate with transanal surgery with the concern that neither chemoradiation nor salvage surgery may compensate for previous approach and correct the inferior outcome. Application of transanal platforms to accomplish transanal TME in a natural orifice fashion are still in their infancy and currently should be considered experimental. The current data demonstrate that transanal surgery remains an excellent option in the surgical management of benign rectal disease. However, care should be used when selecting patients with malignant disease. The application of transanal platforms continues to evolve. While the new uses of transanal platforms in TME for more advanced rectal malignancy are exciting, it is important to remain cognizant and not sacrifice long term survival for short term decrease in morbidity and improved cosmesis.

New approaches in laparoscopic surgery for colorectal diseases: The totally laparoscopic and single-incision approaches

More than 20 years have passed since the first report of laparoscopic colectomy in 1991. Thereafter, laparoscopic surgery for the management of colorectal diseases has been widely accepted as a prevailing option because of improved cosmetic outcomes, less postoperative pain, and shorter hospital stay in comparison with open surgery. To further the principle of minimally invasive surgery, two new approaches have been developed in this rapidly evolving field. The first is the totally laparoscopic approach. Currently most of standard techniques inevitably involve an abdominal incision for retrieval of the specimen and preparation for anastomosis, which might compromise the benefits of laparoscopic surgery. The totally laparoscopic approach dispenses with this incision by combining completely intraperitoneal anastomosis with retrieval of the specimen via a natural orifice, such as the anus or the vagina. Our new and reliable technique for intraperitoneal anastomosis is also described in detail in this article. The second is the single-incision approach. While three to six ports are needed in standard laparoscopic surgery, the single-incision approach uses the umbilicus as the sole access to the abdominal cavity. All of the laparoscopic procedures are performed entirely through the umbilicus, in which the surgical scar eventually becomes hidden, achieving virtually scarless surgery. This article reviews the current status of these two approaches and discusses the future of minimally invasive surgery for colorectal diseases.

Feasibility and oncological outcomes of laparoscopic rectal resection following neo-adjuvant chemo-radiotherapy: A systematic review

AIM: To study the feasibility and oncological outcomes following laparoscopic total mesorectal excision (LTME) in patients who have received Neo-adjuvant long course chemo-radiotherapy (LCRT).

METHODS: A protocol driven systematic review of published literature was undertaken to assess the feasibility and oncological outcomes following LTME in patients receiving LCRT. The feasibility was assessed using peri-operative outcomes and short term results. The oncological outcomes were assessed using local recurrence, disease free survival and overall survival.

RESULTS: Only 8 studies-1 randomized controlled trial, 4 Case Matched/Controlled Studies and 3 Case Series were identified matching the search criteria. The conversion rate was low (1.2% to 28.1%), anastomotic leak rates were similar to open total mesorectal excision (0%-4.1% vs 0%-8.3%). Only 3 studies reported on local recurrence rates (5.2%-7.6%) at median 34 mo follow-up. A single study described disease free survival and overall survival at 3 years as 78.8% and 92.1% respectively.

CONCLUSION: LTME following LCRT is feasible in experienced hands, with acceptable short term surgical outcomes and with the usual benefits associated with minimally invasive procedures. The long term oncological outcomes of LTME after LCRT appear to be comparable to open procedures but need further investigation.

Cordotomy procedures for cancer pain: A discussion of surgical procedures and a review of the literature

Treating pain in patients with terminal cancer is challenging but essential part of their care. Most patients can be managed with pharmacological options but for some these pain control methods are inadequate. Ablative spinal procedures offer an alternative method of pain control for cancer patients with a terminal diagnosis that are failing to have their pain controlled sufficiently by other methods. This paper provides a review of ablative spinal procedures for control of cancer pain. Patient selection, surgical methods, outcomes and complications are discussed in detail for cordotomy, dorsal root entry zone (DREZ) lesioning and midline myelotomy. Cordotomy is primarily done by a percutaneous method and it is best suited for patients with unilateral somatic limb and trunk pain such as due to sarcoma. Possible complications include unilateral weakness possibly respiratory abnormalities. Approximately 90% of patients have significant immediate pain relief following percutaneous cordotomy but increasing portions of patients have pain recurrence as the follow-up period increases beyond one year. The DREZ lesion procedure is best suited to patients with plexus invasion due to malignancy and pain confined to one limb. Possible complications of DREZ procedures include hemiparesis and decreased proprioception. Midline myelotomy is best suited for bilateral abdominal, pelvic or lower extremity pain. Division of the commissure is necessary to address bilateral lower extremity pain. This procedure is relatively rare but published case series demonstrate satisfactory pain control for over half of the patients undergoing the procedure. Possible complications include bilateral lower extremity weakness and diminished proprioception below the lesion level. Unlike cordotomy and DREZ this procedure offers visceral pain control as opposed to only somatic pain control. Ablative spinal procedures offer pain control for terminal cancer patients that are not able to managed medically. This paper provides an in depth review of these procedures with the hope of improving education regarding these underutilized procedures.

Caval reconstruction techniques in orthotopic liver transplantation

There are several caval reconstruction techniques currently in use for orthotopic liver transplantation. These include caval replacement or the conventional technique, performed with or without venovenous bypass, piggyback technique with anastomosis with two or three hepatic veins with or without cavotomy and modifications of the piggyback technique including end-to-side and side-to-side cavocaval anastomosis. There are few randomized controlled trials comparing the use of these techniques and our knowledge of their comparability is based on a few multi- and many single-center retrospective and prospective reviews. Although there are advantages and disadvantages for each technique, it is advisable that the surgeon perform the technique with which they have the most the experience and at which they are the most skilled as excellent outcomes can be obtained with any of the caval reconstruction options discussed.

Laparoscopic liver resection for the treatment of hepatocellular carcinoma

Accumulation of experiences and technological advances after the first report of laparoscopic liver resection (LLR) are now revealing the characteristics and specific advantages of this approach, especially for hepatocellular carcinoma (HCC) patients with chronic liver diseases (CLD). In laparoscopic approach, there are minimum needs for: (1) laparotomy and dissection of the attachments and adhesion which may cause destructions in the collateral blood and lymphatic flows; and (2) compression of the liver which may cause parenchymal damage for the liver resection (LR). These are especially beneficial for the patients with CLD. LLR results in minimal postoperative ascites and the other complications, which could potentially lead to lowering the risk of fatal liver failure. These characteristics of LLR facilitate surgical treatment application to the patients of HCC with background CLD. Laparoscopic approach also results in improved vision and manipulation in a small operative field under several conditions, including the cases where it is necessary to perform repeat LR between adhesions. These characteristics make LLR safer and more accessible to the repeat treatment, such as multicentric and metachronous lesions in the cirrhotic liver. These advantages of LLR indicate it is a superior method than open LR under certain conditions in patients of HCC with background CLD.

Recent advances in the management of hemorrhoids

Hemorrhoids are considered one of the most common anorectal diseases with a prevalence of 4.4% up to 36.4% of the general population, and a peak incidence between 45 and 65 years. Hemorrhoidal disease presents with a prolapsed lump, painless bleeding, discomfort, discharge, hygiene problems, soiling, and pruritus. Sliding anal canal lining theory is the most accepted theory as a cause of hemorrhoidal disease; however, it is also associated with hyper-vascularity, and, recently, with several enzymes or mediators involved in the disintegration of the tissues supporting the anal cushions, such as matrix metalloproteinase. A comprehensive search in published English-language literature till 2013 involving hemorrhoids was performed to construct this review article, which discusses advances in the management of hemorrhoids. This includes conservative treatment (life style modification, oral medications, and topical treatment), office procedures (rubber band ligation, injection sclerotherapy, infrared and radiofrequency coagulation, bipolar diathermy and direct-current electrotherapy, cryosurgery, and laser therapy), as well as surgical procedures including diathermy hemorrhoidectomy, LigaSure hemorrhoidectomy, Harmonic scalpel hemorrhoidectomy, hemorrhoidal artery ligation, stapled hemorrhoidopexy (SH), and double SH. Results, merits and demerits of the different modalities of treatment of hemorrhoids are presented, in addition to the cost of the recent innovations.

Endoscopic approaches to biliary intervention in patients with surgically altered gastroduodenal anatomy

Over the past decade the ability of endoscopists to access the biliary tree in patients with surgically altered gastroduodenal anatomy has significantly advanced. Much of the progress has occurred as a result of the development of better tools to navigate the deep small bowel, such as single-balloon- (SBE), double-balloon- (DBE), and spiral-enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP). However, despite using a cap, accessing the papilla or bile duct using these forward-viewing enteroscopy platforms remains challenging, even in expert hands. In patients with Roux-en-Y gastric bypass (RYGB) anatomy, the excluded stomach is a potential point of access for either a delayed transgastric- or immediate laparoscopy-assisted-ERCP approach. However, the parallel advancement of therapeutic endoscopic ultrasound (EUS) also provides alternative approaches through which the biliary system can be accessed and intervened on in patients with surgically altered anatomies. Generally speaking, in patients with short gastro-jejunal “Roux” and bilio-pancreatic limbs, ideally less than 150 cm in length, starting with a (cap-assisted) push-enteroscopy or balloon-enteroscopy approach would offer reasonable diagnostic and therapeutic ERCP success. When available, short-SBE or short-DBE scopes should be used, as they allow the use of conventional ERCP equipment, are associated with shorter procedure times, and are easier to manipulate. In patients with RYGB who have longer Roux and/or bilio-pancreatic limbs (> 150 cm in total length), or in patients who have failed prior attempts at deep enteroscopy-assisted ERCP, transgastric laparoscopy-assisted-ERCP is associated with higher rates of diagnostic and therapeutic success as compared to deep-enteroscopy-assisted ERCP. Finally, EUS-guided biliary access for antegrade biliary intervention or for rendezvous enteroscopy-assisted ERCP is possible. While percutaneous transhepatic biliary drainage and surgical bile duct exploration remain viable alternatives, these methods are not without significant morbidity and mortality and should only be considered if less invasive endoscopic interventions are not feasible or appropriate.

What makes a gastric bypass a good gastric bypass? Opinion and hypothesis

Gastric bypass is widely accepted as the gold standard bariatric operation. It was first reported 1967 and has been the subject of many technical alterations and variations since that time. Each of these variations has the potential to confer different outcomes, in terms of such things as weight loss, ease of surgery, risk, complications and durability of weight loss. All variations being performed these days should be accomplished with high levels of safety, in which case the primary interest of those undergoing surgery is the degree of weight loss that can be expected and the durability of that weight loss. Broadly speaking these two features will also determine the degree to which all co-morbidities are improved, which is also a goal of those undergoing surgery. In this article the authors describe the features of the Fobi Pouch gastric bypass which make it the most predictable and reliable variant of gastric bypass and report such evidence in the literature as exists for their contentions.

Current concepts of laparoscopic splenectomy in elective patients

Formerly, open splenectomy represented the conventional surgical treatment for many hematologic diseases. Currently, thanks to permanent technical development and improved skills, also laparoscopic splenectomy (LS) has become a recognized procedure in the treatment of spleen diseases, even in case of splenomegaly. A systematic review was performed with the aim of recalling the proved concepts of this surgical treatment and to browse new devices and techniques and their impact on the surgical outcome. The literature search was initially conducted in PubMed by entering general queries related to LS. The record identified through PubMed searching (n = 1599) was then screened by applying several criteria (study published in English from 1991 to 2013 with abstract available, by excluding systematic/non-systematic reviews, meta-analysis, practice guidelines, case reports, and study involving animals). The articles assessed for eligibility (n = 160) were primarily evaluated by excluding studies that did not report operative time and conversion to open surgery. For articles that treated multiport LS we included only clinical trials with patients > 20. The studies included in qualitative synthesis were 23. The search strategy carried out in PubMed does not allow to obtain an overview of the items returned by the main queries. With this aim we replicated the search in the Web of Science^TM database, only including the studies published in English in the period 1991-2013 with no other filter/selection criteria. The full records (n = 1141) and cited references returned by Web of Science^TM were analyzed with the visualization of similarities (VOS) mapping technique. Maps of title/abstract text corpus and bibliographic coupling of authors obtained by applying the VOS approach were presented. If in normal-size or moderately enlarged spleens the laparoscopic approach is unquestionable, in massive splenomegaly the optimal technique remain to be determined. In this setting, prospective randomized trials to compare open vs LS are needed. Between the new techniques of LS the robotic single port splenectomy has the ability to join all the positive aspects of both techniques. Data about this topic are too initial and need to be confirmed with further studies.

Outcomes of continuous flow ventricular assist devices

Heart transplantation is commonplace, the supply is limited. Many exciting changes in the field of mechanical circulatory support have occurred in the past few years, including the axial flow pump. Left ventricular assist device (LVAD) therapy is ever evolving. As the use of LVAD therapy increases it is important to understand the indications, surgical considerations and outcomes.

Notaras procedure for incarcerated rectal prolapse

Patients with an incarcerated rectal prolapse usually present in the emergency department where manual reduction is first attempted. If reduction is unsuccessful, an emergency laparotomy and internal reduction is required. Edema in the rectal and perineal tissues and impaired blood flow are the main factors for a high percentage of anastomotic leaks. The traditional single stage perineal rectosigmoidectomy is not a safe surgical procedure for treating incarcerated or strangulated rectal prolapses associated with severe edema. Herein we report a case of an incarcerated rectal prolapse treated with the Notaras procedure.

Diagnostic imaging and interventional procedures in a growing problem: Hepatic alveolar echinococcosis

Alveolar echinococcosis (AE) of the liver is caused by the metacestode of the fox tapeworm Echinococcus multilocularis (E. multilocularis), which is endemic in many parts of the world. AE is a very aggressive and potentially fatal infestation which always affects the liver primarily and metastasizes to any part of the body. Without timely diagnosis and therapy, the prognosis is dismal, with death the eventual outcome in most cases. Diagnosis is usually based on findings at radiological imaging and in serological analyses. The alveolar cysts grow by exogenous proliferation and behave like a malignant neoplasm. Since AE lesions can occur almost anywhere in the body, familiarity with the spectrum of cross-sectional imaging appearances is advantageous. Therefore, AE lesions can cause physicians to generate a long list of differential diagnoses, including malignant tumors. Disseminated parasitic lesions in unusual locations with atypical imaging appearances may make it difficult to narrow the differential diagnosis. For diagnosis, ultrasonography (US) remains the first line examination. For a more accurate disease evaluation, aiming to guide the surgical strategy, computed tomography (CT), magnetic resonance imaging (MRI), including magnetic resonance cholangiography (MRC) imaging, are of importance, providing useful complementary information. However, making the correct diagnosis is possible if imaging findings are correlated with appropriate clinical findings. We present an overview of the radiological patterns produced by E. multilocularis lesions as seen on US, CT and MRI and discuss the interventional procedures in hepatic AE lesions.