Evidence-based surgery: The obstacles and solutions

Surgeons are often accused of lagging behind their medical colleagues in embracing evidence based medicine and utilizing new research tools to conducting high quality randomized controlled trials. Although there has been a noticeable improvement in the quantity and quality of high quality studies in surgical journals, the widespread practice of evidence based surgery is still poor. Unlike evidence based medicine, the practice of evidence based surgery is hampered by inherent problems and obstacles. This article reviews these difficulties and the limitations of randomized controlled trials in surgical practice. It also outlines some solutions that may help remedy this ongoing problem.

Controversy of hand-assisted laparoscopic colorectal surgery

Laparoscopically assisted colorectal procedures are time-consuming and technically demanding and hence have a long steep learning curve. In the technical demand, surgeons need to handle a long mobile organ, the colon, and have to operate on multiple abdominal quadrants, most of the time with the need to secure multiple mesenteric vessels. Therefore, a new surgical innovation called hand-assisted laparoscopic surgery (HALS) was introduced in the mid 1990s as a useful alternative to totally laparoscopic procedures. This hybrid operation allows the surgeon to introduce the non-dominant hand into the abdominal cavity through a special hand port while maintaining the pneumoperitoneum. A hand in the abdomen can restore the tactile sensation which is usually lacking in laparoscopic procedures. It also improves the eye-to-hand coordination, allows the hand to be used for blunt dissection or retraction and also permits rapid control of unexpected bleeding. All of those factors can contribute tremendously to reducing the operative time. Moreover, this procedure is also considered as a hybrid procedure that combines the advantages of both minimally invasive and conventional open surgery. Nevertheless, the exact role of HALS in colorectal surgery has not been well defined during the advanced totally laparoscopic procedures. This article reviews the current status of hand-assisted laparoscopic colorectal surgery as a minimally invasive procedure in the era of laparoscopic surgery.

Adult intussusception caused by a lipoma in the small bowel: report of a case

Adult intussusception represents only about 5% of all intussusceptions and is usually caused by a malignant small bowel lesion acting as the apex of intussusception. We report an unusual case in a male patient of adult intussusception caused by a lipomatous lesion located in the terminal ileum, very close to the ileocecal valve, acting as the lead point. After repeated admissions to several hospitals for investigation of nonspecific abdominal symptoms, the possibility of intussusception was finally raised by a computed tomography (CT) scan of the abdomen. The patient underwent a limited right hemicolectomy, which achieved long-lasting cure of his symptoms. This case highlights the difficulties of diagnosing adult intussusception promptly, and the fact that it can also be caused by a benign lesion.

Appendiceal mass: is interval appendicectomy "something of the past"?

The need for interval appendicectomy (I.A) after successful conservative management of appendiceal mass has recently been questioned. Furthermore, emergency appendicectomy for appendiceal mass is increasingly performed with equal success and safety to that performed in non-mass forming acute appendicitis. There is an increasing volume of evidence -although mostly retrospective- that if traditional conservative management is adopted, there is no need for routine I.A except for a small number of patients who continue to develop recurrent symptoms. On the other hand, the routine adoption of emergency laparoscopic appendicectomy (LA) in patients presenting with appendiceal mass obviates the need for a second admission and an operation for I.A with a considerable complication rate. It also abolishes misdiagnoses and deals promptly with any unexpected ileo-cecal pathology. Moreover, it may prove to be more cost-effective than conservative treatment even without I.A due to a much shorter hospital stay and a shorter period of intravenous antibiotic administration. If emergency LA is to become the standard of care for appendiceal mass, I.A will certainly become 'something' of the past.

Daflon for haemorrhoids: a prospective, multi-centre observational study

BACKGROUND

Daflon, a phlebotropic agent, is of proven efficacy in the treatment of various venous disorders. Although it has been tried in the treatment of haemorrhoids, its efficacy in alleviating various haemorrhoidal symptoms has not been assessed properly. The aim of this study was to confirm the efficacy of Daflon in the treatment of haemorrhoidal symptoms.

METHODS

Two hundred and sixty eight patients presenting with haemorrhoidal symptoms were recruited. This was a multicentre non-randomised observational study with no placebo arm. After establishing the extent of their symptoms and determining the position, size and degree of haemorrhoids by proctoscopy, all patients were started on Daflon, four tablets per day, in two divided doses for four weeks. Patients were seen weekly during the study period and carefully questioned as regard to symptoms, and a proctoscopy was carried out.

RESULTS

There was a statistically significant improvement (p<0.001) in all haemorrhoidal symptoms (pain, heaviness, bleeding, pruritus and anal discharge) and in the proctoscopic appearance of the 'piles,' comparing baseline visit findings with the last visit four weeks after treatment with Daflon.

CONCLUSIONS

Daflon has been shown to be effective in alleviating (variable degree) haemorrhoidal symptoms and improving the proctoscopic appearance of haemorrhoids. Therefore, it should be considered initially for patients presenting with haemorrhoidal symptoms. However, prospective randomised trials and longer follow-up are needed to confirm the findings of this study and delineate more precisely the role of Daflon in the management of haemorrhoidal disease

A rare cause of small bowel obstruction: Abdominal cocoon

INTRODUCTION

The clinical manifestations of abdominal 'cocoon' are non-specific and hence its diagnosis is rarely made preoperatively and the management is often delayed. Surgery remains the main stay of treatment with satisfactory outcome and comprises excision of the fibrous membrane, meticulous adhesionolysis and release of the entrapped small bowel.

PRESENTATION OF CASE

A 45-year-old male patient presented with 6-month history of progressive subacute small bowel obstruction. After initial radiological investigations, he underwent diagnostic laparoscopy and was misdiagnosed as abdominal tuberculosis. He was started on anti-tuberculous therapy, but exploratory laparotomy was carried out after failure to respond to anti-tuberculous therapy. At laparotomy, the abdominal 'cocoon' which was encapsulating the entire small bowel was excised, and the adhesions were carefully lysed. The patient remained well and without recurrence at 1-year follow-up.

DISCUSSION

Abdominal 'cocoon' is a rare cause of subacute, acute and chronic small bowel obstruction. Its diagnosis is rarely made preoperatively.

CONCLUSION

Abdominal 'cocoon' should be thought of as a rare cause of small bowel obstruction. It may be mistaken with abdominal tuberculosis. Surgery remains the mainstay of curative treatment.

A rare approach to entero-atmospheric fistula

PATIENT

Female, 60 FINAL DIAGNOSIS: Recurrent incisional hernia Symptoms: -

MEDICATION

- Clinical Procedure: Limited ileo-cecal resection Specialty: Surgery.

OBJECTIVE

Diagnostic/therapeutic accidents.

BACKGROUND

Iatrogenic entero-atmospheric fistula is devastating and its management is extremely difficult because it is often associated with fluid and electrolyte disturbances, nutritional problems, and life-threatening sepsis.

CASE REPORT

A 60-year-old woman underwent laparoscopic repair of a recurrent incisional hernia that was complicated by iatrogenic cecal injury necessitating a limited ileocecal resection and onlay prosthetic mesh repair of the hernia. Postoperatively, sloughing of the overlying skin led to mesh exposure. An attempted rotational flap coverage was complicated by small bowel injury, which was recognized and repaired. However, an entero-atmospheric fistula developed after the removal of contaminated mesh. The fistula was initially treated by vacuum-assisted closure dressing and later was converted to a 'stoma'. Six months later, the small bowel segment bearing the fistula was excised and bowel continuity was restored.

CONCLUSIONS

In selected cases, the conversion of entero-atmospheric fistula to a 'stoma' allows the patient to be discharged home early and maintain good nutritional status while awaiting the definitive surgical intervention.

Portal vein thrombosis after restorative proctocolectomy for familial adenomatous polyposis and sigmoid cancer

Postoperative portal vein thrombosis (PVT) is rare, but has been described after various open as well as minimal access abdominal operations, especially splenectomy and colorectal surgical procedures. We report the case of a 39-year-old female who underwent restorative proctocolectomy and ileal pouch-anal anastomosis for familial adenomatous polyposis with sigmoid cancer. She presented 14 days later with vague upper abdominal pain, nausea, vomiting and high output stoma. Doppler ultrasonography confirmed PVT and therefore anticoagulant therapy was started. Her condition improved dramatically and she underwent closure of ileostomy after finishing adjuvant chemotherapy. She remained well at 3-year follow-up with good pouch function and no local or distant recurrence. A high index of suspicion is essential for early diagnosis and prompt treatment of postoperative PVT after restorative proctocolectomy. Early anticoagulation is essential to avoid subsequent complications.

Laparoscopic excision of abdominal wall desmoid tumor

Open surgical resection is the mainstay treatment for desmoid tumors. Laparoscopic resection is rarely used and not well described in the literature. We report a case of a single, 35-year-old woman who presented with palpable abdominal wall desmoid tumor. The patient had had laparoscopic cholecystectomy 2 years earlier, and the tumor was at the insertion site of the right upper quadrant trocar. The diagnosis was made by a Tru-Cut biopsy at another institution, after the lesion had increased in size and caused increased discomfort. The patient underwent successful laparoscopic resection of the tumor. This report aimed to promote laparoscopic resection of abdominal wall desmoid tumors, whenever feasible, and describe the laparoscopic technique. We believe this is the second case of laparoscopic excision of desmoid tumor reported in the English-language literature.

Retained enteroscopy capsule in a patient with diaphragm disease

INTRODUCTION

Diaphragm disease is a rare consequence of small-bowel enteropathy, and usually occurs as a result of longstanding ingestion of non-steroidal anti-inflammatory drugs. DD is characterized by multiple strictures and saccular dilatations leading to symptoms of subacute intestinal obstruction. Often, the diagnosis is made on histological examination after laparotomy and resection of diseased small bowel.

CASE HISTORY

Here, we report a case of an elderly female who suffered for many years from chronic, colicky abdominal pain and anaemia due to undiagnosed diaphragm disease. Eventually, she was referred to our surgical team because of a retained enteroscopy capsule. The diagnosis was made after laparotomy and bowel resection. This surgical intervention alleviated chronic symptoms, and the patient remained well at 1-year follow-up.

CONCLUSIONS

This case highlights the difficulty of diagnosing diaphragm disease without laparotomy and bowel resection. A high index of suspicion must be exercised in any patient with chronic, colicky abdominal pain and anaemia together with multiple strictures and saccular dilatations on computed tomography even in the absence of longstanding NSAID ingestion. Moreover, capsule enteroscopy should be avoided as a diagnostic modality of small-bowel disease if computed tomography raises the suspicion of strictures.

Iatrogenic oesophageal transection during laparoscopic sleeve gastrectomy

Laparoscopic sleeve gastrectomy has been hailed as an easy and safe procedure when compared with other bariatric operations. However, it may be associated with well-recognised early complications such as leaks and bleeding, as well as late ones such as stenosis and weight regain. Iatrogenic complete oesophageal transection has never been reported before as a complication. We report a case of complete oesophageal transection during laparoscopic sleeve gastrectomy that was not recognised intraoperatively. The repair of this iatrogenic injury was staged, with the final stage carried out some 3 months after the initial procedure. This case report highlights the possible occurrence of complete oesophageal transection during laparoscopic sleeve gastrectomy, and suggests steps to avoid and correct such complications.

Pitfalls of diagnostic laparoscopy in abdominal tuberculosis

BACKGROUND

Diagnostic laparoscopy currently is emerging as an important tool in the diagnostic armamentarium for abdominal tuberculosis (TB). However, the laparoscopic view may be deceiving even to the most experienced eyes, and it is not uncommon for TB to be diagnosed erroneously before the final histologic confirmation is received.

METHODS

A retrospective review of 20 diagnostic laparoscopies was conducted. The cases erroneously diagnosed at laparoscopy were collected and analyzed.

RESULTS

Five cases (20%) were identified. For two patients, the laparoscopic findings were thought to be those of carcinomatosis, but histology showed TB. For the other three patients, TB was suspected laparoscopically, but the final diagnoses were carcinomatosis, spontaneous bacterial peritonitis, and panniculitis. Two patients died: one due to delayed diagnosis and treatment of abdominal TB and the other due to carcinomatosis.

CONCLUSION

For a percentage of patients, the laparoscopic features of abdominal TB at diagnostic laparoscopy may be mistaken for other pathologies. Caution should be exercised before disclosure of the provisional diagnosis to the patient based on laparoscopy alone without histologic confirmation.

Late metastatic colon cancer masquerading as primary jejunal carcinoma

Metastasis to the small bowel from a previously resected colorectal cancer is rare and may erroneously be diagnosed as a primary small bowel carcinoma. It usually occurs several years after the primary resection. We present the case of a 67-year-old man who had undergone left hemicolectomy for colon cancer 3 years earlier and returned with subacute small bowel obstruction. This was initially thought, based on preoperative radiological findings and normal colonoscopic examination, to be due a primary jejunal cancer. Even at surgery, the lesion convincingly appeared as an obstructing primary small bowel carcinoma. However, the histology of the resected small bowel revealed metastatic colon cancer. This rare and an unusual metastatic occurrence some years after the primary resection is described and reviewed.