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Editorial Board
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Reviewer of the month – May 2012: Dr Mohammad Bashashati
Dr. Bashashati earned his MD from Lorestan University of Medical Sciences, Iran. He started his research on the epidemiology of urological diseases during his medical training. Managing patients with gastrointestinal motility disorders since 2004 shifted Dr. Bashashati’s research interest to neurogastroenterology, gastrointestinal motility disorders and the role of inflammation on the gastrointestinal function.
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Perspectives – May 2012
Health and Social Welfare are high on the Agenda of politicians in the United Kingdom and the USA at the moment. Surgery has been at the forefront in both countries. But whatever change is introduced, it is patient care and safe surgical practice that must remain at the core of our profession. In the UK the basic tenets of the Health and Social Care Bill are commissioning led by healthcare professionals based on quality, greater patient involvement, less bureaucracy, limited use of any qualified provider, integration between secondary and social care, and all care to be provided free of charge at the point of delivery (a core principle enshrined in the National Health Service since its foundation). In the USA, the President's Health Bill concentrates more on how to pay for the ever increasing costs of healthcare. The introduction, to a majority of the population, to be privately insured by law, is a step too far in many voters' beliefs.
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General surgery: Present and future
Abstract: General surgery is going through critical moments in recent years. Problems associated with the evolution and development of the specialty and training programs. Appearance of a sub-especialization in general surgery. All this in the context of an economic crisis of global impact. These changes have resulted in a state of emotional and mental fatigue known as burn out syndrome, in many cases.However not everything is negative and the development of the minimally invasive surgery techniques, NOTES, and single port surgery have been an incentive for surgeons in recent years. We must not fail to take into account the increase in cost of these procedures at the present time.I make some reflections about this topics, that although they reflect a very particular opinion I think they show the feeling of many surgeons. I think that in these times we are living in, we must fundamentally improve our efficiency and safety in daily practice.
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Minimal access maximal success; A myth or a reality
Abstract: Minimal invasive surgery is one of the most challenging advances in the craft of surgery in last 2 decades. In our country the advanced craft has been in practice for more than one and a half decade and some of our committed surgeons have mastered this craft and made an impact not only on national level but also on international level. Many times we may get impressed by watching the masters in the craft but forgetting the efforts the master has put in to reach the Zenith and in a bid to imitate the master we may ignore the awaiting disaster. In this article I will be discussing the overall impact of this surgical craft globally and its various evidence based pros and cons with a particular reference to colorectal surgery to ascertain whether the craft of minimal access with maximal success is a myth or a reality.Highlights: ► This article is aimed at testifying the claim of “Minimal access Maximal success” in colorectal surgery. ► The article discusses colon and rectal surgery separately based on present evidence available in literature. ► The evidence taken into consideration for the comparison is mainly level 1. ► Authors personal conclusions on basis of the evidence and personal experience.
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Colorectal surgery: Current practice & future developments
The first report of laparoscopic colorectal resections in 1991 represented a major advance in the progress and practice of colorectal surgery. Since then, the rate of new evolutions and innovations seems to have acquired a rapid momentum for change. A critical overview of the published literature in colorectal surgery over the last year confirms that this drive for progress and change in practice is likely to get stronger and the debate on various unresolved issues in the contemporary practice of colorectal surgery is far from over.
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Pancreas cancer treatment: A surgeon's perspective today
In 1968 John Howard, one of the pioneers of pancreatic surgery, reported the first series of patients submitted to pancreatic resection without mortality. This contributed to reduce skepticism about pancreas surgery and to open a new surgical era. Nowadays, perioperative mortality after pancreaticoduodenectomy in high-volume centers does not exceed 2–3% of cases, and the goal of zero-mortality surgery has been reached by some centers. These data have an outstanding value, since safe surgical resection remains the only potentially curative treatment for pancreas cancer.
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Current knowledge on pancreaticobiliary reflux in normal pancreaticobiliary junction
Abstract: Knowledge on pancreaticobiliary reflux in normal pancreaticobiliary junction and their pathologic implications has experienced tremendous progress during the last few years. This article reviews the current knowledge on this condition and its pathological implications on gallbladder diseases. Many publications with different levels of evidence were found supporting biliary carcinogenesis associated with pancreaticobiliary reflux in normal and abnormal pancreaticobiliary junction. Also, there are many publications supporting the common occurrence of pancreaticobiliary reflux in normal pancreaticobiliary junction, and sphincter of Oddi dysfunction as the most plausible cause of this condition. Although an important body of research has been published regarding pancreaticobiliary reflux in normal pancreaticobiliary junction and their clinical significance, the current evidence does not fully support what has been suggested. The reflux of pancreatic enzymes into the bile tract and gallbladder is a fascinating subject of study which is open to active research. The final demonstration of the pathophysiology and consequences of PBR in NPBL and support by evidence level type I would constitute a major breakthrough in the understanding and eventually in the treatment of gallbladder diseases.
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Enteral vs total parenteral nutrition following major upper gastrointestinal surgery
Abstract: A best evidence topic in surgery was written according to a structured protocol. The question addressed was in patients undergoing elective major upper gastrointestinal surgery requiring post-operative nutritional support, does enteral feeding as compared to total parenteral feeding confer any clinical benefits. Thirty-two papers were identified by a search of the Medline and Embase databases, of which seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group, study group, relevant outcomes and results of these papers were tabulated. All seven of these papers were randomised controlled trials which demonstrated enteral nutrition to be associated with shorter hospital stay, lower incidence of severe or infectious complications, lower severity of complications and decreased cost as compared to parenteral nutrition. For patients undergoing elective major upper gastrointestinal surgery requiring post-operative nutritional support, enteral feeding should be considered as the most desirable form of post-operative feeding.
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In patients with radiologically-staged resectable oesophago-gastric junctional tumours, is diagnostic laparoscopy useful as an additional staging procedure?
Abstract: A best evidence topic in surgery was written according to a structured protocol. The question addressed was in patients with oesophago-gastric junctional tumours which have been radiologically-staged as potentially resectable, is diagnostic laparoscopy useful as an additional staging procedure. 292 papers were found using the reported search, of which 5 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group, study type, relevant outcomes and results of these papers are tabulated. We conclude that as an additional tool following radiological staging of oesophago-gastric junctional tumours, diagnostic laparoscopy does appear to detect previously occult peritoneal metastases as well as liver metastases and lymph nodes and these findings do in turn lead to changes in management in over ten percent of patients. The procedure is however associated with some morbidity and its efficacy in changing management in the era of routine PET scanning remains to be evaluated.
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Does ligation of the thoracic duct during oesophagectomy reduce the incidence of post-operative chylothorax?
Abstract: A best evidence topic in surgery was written according to a structured protocol. The question addressed was whether prophylactic thoracic duct ligation during oesophagectomy results in a lower incidence of post-operative chylothorax. 29 relevant papers were found using the reported search, of which 5 papers represented the best evidence to answer the clinical question. The authors, date and country of publication, patient group, study type, relevant outcomes and results of these papers are tabulated. Of these studies, only one was a prospective randomised controlled study with sizeable patient numbers. This was also the most recent study and demonstrated a significant decrease in post-operative chylothorax incidence following intra-operative thoracic duct ligation. Of the four remaining retrospective studies, one showed an increase in chylothorax rate following ligation whilst three showed a reduction in the incidence of chylothorax (although in only one of these three studies was this decrease statistically significantly). We conclude that for patients undergoing oesophagectomy, although there are conflicting results from retrospective studies, prospective randomised controlled trial evidence points to prophylactic ligation of the thoracic duct as an effective measure to reduce the incidence of post-operative chylothorax.
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Sliding inguinal hernias
Abstract: Purpose: To evaluate the frequency and anatomic presentation of sliding inguinal hernias as well as to analyze the technical difficulties during surgery and recurrence rate.Methods: During 18 months we have recorded in a prospective manner data on all patients operated in one hospital for non-complicated inguinal hernia. All patients suspected of sliding variant have had their hernia sac opened and the sliding organ identified. All repairs were done using tension free technique. One year after discharge a telephone interview was performed with all patients to verify if they are free of recurrence.Results: 464 patients were electively operated on for inguinal hernia during the study period. Sliding variant was diagnosed in 16 patients (3,4%). The sliding organs were: sigmoid colon in 10 patients (62,5%), urinary bladder in 2 patients (12,5%), appendix in 2 cases (12,5%) and caecum in 2 cases (12,5%). The tension free repair according to Lichtenstein or Rutkow-Robbins technique was performed in all cases. No major surgical complication was recorded. During 18 months follow-up we have seen one recurrence 3 months postoperatively.Conclusions: The sliding inguinal hernia is a rare finding. The risk of injury of sliding organ is minimal. If tension free technique is used, the risk of recurrence is similar to that of patients with non-sliding inguinal hernia.
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The future of trauma care in a developing country: Interest of medical students and interns in surgery and surgical specialties
Abstract: Background: Attracting the best medical graduates to trauma-related specialties is pivotal for excellent injury management in future, especially with the rising global incidence of injuries. We sought to explore the interest of Nigerian medical students and interns in Orthopaedics, Cardiothoracic, Neurological, Burns and Plastic and General Surgery specialties.Methods: A cross-sectional study was conducted using a self-administered questionnaire to assess interest in selected trauma-related specialties among 177 senior medical students and interns at the Lagos State University Teaching Hospital and Lagos University Teaching Hospital in Lagos, Nigeria. Stratified random sampling method was employed and Chi-square test was performed in data analysis using SPSS v15.0 statistical package.Results: Majority (80%) showed interest in post-graduate specialization. Surgery topped the list of specialties chosen by participants while 55% were likely to choose one of the selected trauma-related specialties. Exposure to positive role models, male gender and being single were significantly associated with interest in trauma-related future career. Opportunities for career fulfilment, carrying out difficult procedures, research and discovery, intellectual challenges during practice, use of modern technology, financial remuneration of specialists, patient outcomes and previous theatre experience had significant positive influence on participants who had strong interest in trauma-related specialty. Lifestyle issues like workload, call schedules, stress and duration of residency, training conditions and facilities and time commitment to practice had negative influence on choice of specialty.Conclusion: Interest of medical students and interns in trauma-related specialties may be sustained and enhanced by practicing surgeons through mentoring and by serving as role models. Training programs in surgery should be revisited and made less stressful while lifestyle issues need to be made more favourable.
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Postoperative port-site pain after gall bladder retrieval from epigastric vs. umbilical port in laparoscopic cholecystectomy: A randomized controlled trial
Abstract: Objective: To determine whether gall bladder (GB) retrieval from umbilical port is associated with more pain at port site as compared to GB retrieval from epigastric port in adult patients undergoing four port elective laparoscopic cholecystectomy at a tertiary care hospital.Methods: Adult patients, who were undergoing elective laparoscopic cholecystectomy during a six month period in 2010 at our institute, were randomized to either group A (n = 60, GB retrieval through epigastric port) or group B (n = 60, GB retrieval through umbilical port). VAS for pain was assessed by a registered nurse at 1, 6, 12, 24 and 36 h after surgery.Results: The VAS for pain at umbilical port was less than epigastric port at 1, 6, 12, 24 and 36 h after surgery (5.9 ± 1.1 vs. 4.1 ± 1.5, 4.6 ± 0.94 vs. 3.5 ± 1.05, 3.9 ± 0.85 vs. 2.4 ± 0.79, 3.05 ± 0.87 vs. 2.15 ± 0.87, respectively) and the difference was statistically significant (p-value < 0.001). Multiple linear regression was done for port site pain at 24 h and the VAS at umblical port was less than epigastric port with VAS difference of 0.9 after adjusting for age, sex, duration of surgery and additional analgesia use (r2 = 0.253, p-value < 0.001).Conclusion: Gall bladder retrieval from umbilical port is associated with lower port site pain than GB retrieval from epigastric port in patients undergoing elective laparoscopic cholecystectomy. We recommend umbilical port for gall bladder retrieval.
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The utility of CT angiography in planning perineal flap reconstruction following radical pelvic surgery
Abstract: Introduction: Closure of the perineum following radical excision of pelvic tumours can prove to be a complex surgical problem. A number of pedicled flaps have been used for perineal reconstruction in order to reduce post-operative complications such as infection and abscess formation. The aim of this case series was to analyse the use of pre-operative computer tomography (CT) angiography to guide flap selection for perineal reconstruction following radical excision of pelvic tumours.Methods: We conducted a retrospective review to identify all patients who underwent CT angiography prior to radical excision of pelvic tumours and planned flap reconstruction over an 18 month period. Six patients were identified and are presented in this case series. Patients' medical records, histology reports, pre-operative investigations and CT angiograms, complications and follow-up were reviewed.Results: The mean patient age was 58.3 years, with a male to female ratio of 1:2. Four out of six patients (66.6%) underwent pre-operative radiotherapy. The deep inferior epigastric arteries (DIEA) were visualised in all six cases (100%) and the pre-operative CT angiography helped guide flap choice in all cases (100%). In one case, narrowing of the DIEA vessels was noted precluding the use of a DIEA-based flap. One patient had a minor superficial wound dehiscence.Conclusion: Pre-operative CT angiography allows accurate visualisation of the DIEA system including perforator vessels. CT angiography is a useful tool, providing the surgical team with significant additional information to aid pre-operative planning and optimise reconstructive choice and outcome.
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