Higher Perforation Rate Research Articles

1859 Paperclip or Inferior Vena Cava Filter Probe? The Case of an Unusual Foreign Body

INTRODUCTION: Inferior vena cava (IVC) filters are mechanical devices used to prevent pulmonary embolism, often used in patients with recurrent venous thromboembolism while on anticoagulation, or who have a contraindication to anticoagulation. Despite its increasing popularity over the last two decades, they do not come without complications such as migration of the filter or its parts, perforation or protrusion into surrounding structures such as the small or large bowel, vasculature, diaphragm, or the retroperitoneal space. We herein present a case of duodenal perforation caused by a migrating IVC filter, of which there have only been a few reported cases. CASE DESCRIPTION/METHODS: The patient is a 61-year-old female with HTN, GERD, iron-deficiency anemia, and a history of DVT while on anticoagulation (s/p IVC filter placement in October 2011) who initially presented with complaints of dizziness. Her workup revealed a new anemia with no overt GI bleeding for which she underwent endoscopic evaluation. She was found to have a thin piece of metal in the second portion of her duodenum, thought to be a swallowed foreign body, possibly a paperclip, which was later denied by the patient. Several attempts at retrieval were unsuccessful. One week later, she developed sudden-onset, severe, epigastric pain with guarding. She presented to our emergency department where a CT abdomen/pelvis with contrast revealed an infrarenal IVC filter with protrusion of a prong through the lateral wall of the IVC into the duodenum, as well as protrusion of a prong through the posterior wall of the IVC into the superior aspect of the right iliopsoas muscle. Given the pain, she was ultimately taken for successful percutaneous removal via the right internal jugular vein by Vascular Surgery with endoscopic assistance by Gastroenterology. There was no involvement of the ampulla and the duodenum maintained insufflation following removal. DISCUSSION: With the advent of contemporary IVC filters, the migration rates are less than 1%. However, because of new prong hooks to prevent migration, they can lead to perforation of surrounding structures. Retrievable filters have been found to have higher rates of perforation than the permanent form, particularly when the retrievable filters are left in place longer than anticipated. As seen in this case, the importance of IVC filters are paramount to prevent pulmonary embolism, but in a patient with sudden onset abdominal pain, one must rule out IVC filter perforation into surrounding structures.

Postcolonoscopy Appendicitis: A Review of 57 Cases.

The purpose of this study is to review the cases of postcolonoscopy appendicitis (PCA) reported in the literature. A comprehensive search using PubMed, EMBASE, Scopus, and Google Scholar identified 57 cases. The median age at presentations of PCA was 55 years. PCAs typically occurred during the first 24 hours after colonoscopy, and the majority developed after diagnostic colonoscopy. Clinical presentations were similar to those with common acute appendicitis, though with a high perforation rate. Most patients were correctly diagnosed using ultrasound or computed tomography scan. Treatment included open appendicectomy, laparoscopic appendicectomy or cecotomy, radiologic drainage of the abscess, nonoperative treatment with antibiotics. In addition to barotrauma, fecalith impaction into the appendiceal lumen, direct trauma to the appendiceal orifice, and underlying ulcerative colitis, a pre-existing subclinical disease of the appendix seems to play an important role in the pathogenesis. For PCA, timely diagnosis and management are crucial to attain a satisfactory outcome.

Diagnostic efficacy of serum procalcitonin, IL-6, IL-2, and D-dimer levels in an experimental acute appendicitis model.

Acute appendicitis is the most frequent cause of acute abdomen emergency surgery. It continues to be a problem today due to delayed diagnosis and its high perforation rate. For this reason, diagnostic tests continue to be developed. In this experimental study, the diagnostic significance of blood procalcitonin (PCT), interleukin (IL)-6, IL-2, and D-dimer levels in an acute appendicitis model in rabbits was investigated. A total of five groups were included: control group, sham group, and three different acute appendicitis groups. In the appendicitis groups, the appendix was ligated by laparotomy, and the blood PCT, IL-6, IL-2, and D-dimer levels were measured at 12 (group 3), 24 (group 4), and 48 h (group 5). Then, an appendectomy was performed. In the present study, PCT and IL-6 levels increased in parallel with the inflammation of the appendix in all groups and were found to be statistically significant. IL-2 and D-dimer values were higher in the groups diagnosed with appendicitis but were not statistically significant. In our experimental study, PCT and IL-6 levels were determined to be important in the early diagnosis of acute appendicitis, especially IL-6, and that these two parameters are more important markers than IL-2 and D-dimer.

Rate of Glove Perforation in Open Abdominal Surgery and the Associated Risk Factors.

Background: Glove perforation is common during surgery. Surgical gloves are used as personal protective equipment to reduce infection risks from bloodborne pathogens for both the surgical team and patients. This research was conducted to determine the perforation rates of gloves worn in open abdominal surgery performed in a general surgery department and the risk factors affecting perforation. Methods: This research was designed as an observational prospective cohort study including 70 open abdominal operations. There were four members of the surgical team (surgeon, first assistant, second assistant, and scrub nurse). A total of 280 (70 × 4) pairs of gloves in 70 consecutive open abdominal procedures were included in this study. A total of 140 unused gloves were tested as control group to assess perforations and pre-existing leaks. After the operation, all gloves were checked for water impermeability using the EN455-1 method and the presence or absence of a puncture hole was recorded. Results: Glove perforation was detected in 54.3% of operations. The rate of perforation in all gloves was 10.7%, of which 78% unnoticed by the surgical team during surgical procedure. It was determined that the puncture in the gloves was mostly on the non-dominant hand (left). For the left-hand glove, the highest number of holes was observed on the index finger (21.1%) and palm/dorsum of the hand (21.1%). The risk of glove perforation was 5.8 times greater for surgeons compared with the other team members, and operation time of 61 minutes or longer increased the risk of perforation by 12.77 times. Conclusions: Glove perforation rates are high in open abdominal surgery. The highest number of perforations occurred in the non-dominant hand (left) has a high rate of perforation in surgeons and long operations. It may be beneficial for surgical team members to change gloves at certain intervals during surgery or use indicator glove systems.

The effect of body mass index on retropubic midurethral slings

Analyzing surgical databases uses "real-life" outcomes rather than highly selected cases from randomized controlled trials. Retropubic midurethral slings are a highly effective surgical treatment for stress urinary incontinence; however, if modifiable patient characteristics alter outcomes, thereby rendering treatments less effective, patients should be informed and given the opportunity to change that characteristic. The aim of this study was to evaluate the effect of body mass index on patient-reported outcome measures by analyzing midurethral slings from the British Society of Urogynaecology database. The British Society of Urogynaecology approved analysis of 11,859 anonymized midurethral slings from 2007 to 2016. The primary outcome of this retrospective cohort study was to assess how body mass index affects patient-reported outcome measures. Outcomes were assessed at 6 weeks, 3 months, 6 months, or 12 months after surgery, depending on local arrangements. Outcomes were compared by body mass index groups using χ2 tests. As BMI increased, Patient Global Impression of Improvement (PGI-I) scores declined. Women with a normal body mass index (18 to <25) reported feeling better in 91.6% of cases compared to lower rates in BMI groups >30 (87.7-72%) (P < .001). Patient-reported outcome measures for stress urinary incontinence inversely correlated with body mass index, with 97% of women with normal body mass index stating that they were cured/improved compared to women in higher body mass index groups (84-94%) reporting lower rates (P < .005). Patient-reported outcome measures for overactive bladder show that as body mass indexincreases, patients reported higher rates of worsening symptoms (P< .05). There were higher rates of perforation at the low and high extremes of body mass index. Our results suggest increased body mass index is associated with poorer outcomes after midurethral sling surgery, and that patients should be given the opportunity to change their body mass index. These data could help to develop a model to predict personalized success and complication rates, which may improve shared decision making and give an impetus to modify characteristics to improve outcomes.

Damages with High Consequences: Analysis of Perforations in Surgical Latex Operation Gloves from Orthopedic Surgeries.

IntroductionTo prevent surgical site infections (SSIs) during operation, the use of sterile surgical latex gloves is common. The aim of this study was to examine the damage of the gloves in surgeries with different mechanical stress and the influence on the kind of damages. Gloves were collected during primary arthroplasty, revision arthroplasty (hip and knee), and arthroscopy (shoulder, hip, and knee).Materials and methodsSurgical latex operation gloves were collected from surgeons after the operation and were tested with watertightness test (ISO EN 455-1:2000).ResultsA total of 1460 surgical gloves were retrieved from 305 elective operations. On average, 15.9% of the gloves showed postoperative lesions, with the highest incidence occurring in revision arthroplasty with 25%. In primary and revision arthroplasty, the index finger of the dominant hand was most frequently affected (62.7% and 58.6%); in contrast, gloves from arthroscopies had most lesions on thumb and middle finger (42.9% each). Tear and perforation size differed from ≤1 mm to >5 mm, and primary and revision arthroplasty showed bigger damages.ConclusionsSurgical gloves have a high malfunction, which increases with growing mechanical stress. A high rate of perforation occurred mostly in revision arthroplasty. Breaching the integrity of the gloves, especially by high mechanical loads, could lead to an increased rate of infection.

Short- and long-term outcomes of endoscopic submucosal dissection for early gastric cancer in the remnant stomach after gastrectomy.

Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) in the remnant stomach is a minimally invasive treatment. Few studies compared the technical difficulty of ESD involving the suture line and anastomosis, and information on long-term outcomes is insufficient. This study aimed to elucidate the short- and long-term outcomes of ESD for EGC in the remnant stomach. We investigated patients who underwent ESD for EGC in the remnant stomach between September 2002 and March 2016. Clinicopathological data were retrieved to assess en bloc resection rates, complications, and long-term outcomes including overall survival and cause-specific survival. A total of 136 consecutive patients with 165 lesions resected by 157 ESD procedures were retrospectively evaluated. The en bloc resection rate was 95.5%. Complications included 16 intraoperative perforations (10.2%), 2 delayed perforations (1.3%), and 15 delayed bleeding (9.6%), which were successfully treated with endoscopy. The en bloc resection rate was significantly higher in the suture line group (100%) and the non-anastomosis or suture line group (98.8%) than in the anastomosis group (82.9%). However, the intraoperative perforation rate was significantly higher in the anastomosis group (31.4%) than in other groups. The 5-year overall and cause-specific survival rates were 88.4% and 97.6%, respectively, during a median follow-up period of 50.7months (interquartile range 30.8-91.3). The long-term outcomes of ESD for EGC in the remnant stomach were favorable. However, ESD involving the anastomosis was a technically demanding procedure due to the low en bloc resection rate and high perforation rate.

Geographic and socioeconomic predictors of perforated appendicitis: A national Canadian cohort study

Background/PurposeAppendiceal perforation significantly impacts the outcomes of pediatric appendicitis. While socioeconomic status affects perforation risk in the United States, these effects should dissipate in a universal healthcare system. The specific spatial patterns associated with perforation have also never been delineated. This study examined the effect of geography and SES on appendiceal perforation in Canada's universal healthcare system. MethodsUsing administrative databases, Canadian children with appendicitis from 2008 to 2015 were identified. Perforation rates were examined based on rurality, distance from treating hospital, and SES. A spatial analysis identified neighborhoods with high perforation rates. Predictors of high perforation clusters were determined using logistic regression. ResultsOver the study period, 43,055 children with appendicitis were identified. The overall perforation rate was 31.5%. Rural neighborhoods and those >125 km from the treating hospital were more likely to be within a high perforation cluster (OR 2.39, 95%CI 1.31–4. 02, p = 0.001; and OR 2.55, 95%CI 1.35–4.47, p = 0.001, respectively). Children in high perforation clusters were more likely to suffer complications. SES was not associated with perforation rates. ConclusionsIn this population-based study, appendiceal perforation was not a function of SES, but a spatial phenomenon. These findings highlight disparities in access to surgical care in Canada. Level of evidencePrognosis study, level II.

Morbidity and Mortality in Appendicitis in the Elderly.

To assess the factors affecting the morbidity and mortality in patients over 65 years of age who underwent appendectomy. An observational study. Department of General Surgery, Faculty of Medicine, Ahi Evran University, Kirsehir, Turkey, from November 2014 to March 2017. Medical records of the patients over 65 years of age with the diagnosis of acute appendicitis who underwent appendectomy during the study period were retrospectively analyzed. Age and complications were noted. The reviewed outcome measures were perforation rates, morbidity and mortality. Three hundred and seventy-eight patients over 65 years of age presenting with abdominal pain were hospitalized for diagnosis and treatment. Appendectomy was performed in 112 patients. Laparoscopic appendectomy was performed in 70 of these patients. Perforation rate and morbidity were 40% and 28%, respectively. There was no mortality. Elderly patients show a high perforation rate and morbidity after appendectomy.

Risk Factor in Endodontic Treatment: Topographic Evaluation of Mandibular Posterior Teeth and Lingual Cortical Plate Using Cone Beam Computed Tomography (CT).

BackgroundTopographic relationships of mandibular posterior teeth with mandibular cortical plate are extremely important both in terms of infection spread and endodontic and surgical procedures to be performed. The aim of this study was to determine the relationship between root apex of the mandibular posterior teeth and lingual plate of the mandible.Material/MethodsCBCT data of 138 patients were retrospectively analyzed. The topographic relationship between root apex and lingual plate was classified as non-contact, contact, or perforation. Morphology of the mandibular lingual plate was classified into the 4 types (convex, parallel, undercut, slanted) and recorded for each tooth region. The prevalence of each group was calculated.ResultsIn 6.2% of all mandibular posterior teeth, the lingual plate was perforated by at least 1 root of the corresponding tooth. The teeth with the highest perforation rate were the third molar tooth (31.6%) and the second molar tooth (14.7%). The most common mandibular lingual plate morphology type was “undercut type” (61.3%) in the molar teeth region, while “parallel type” (55.7%) was most common in the premolar teeth region.ConclusionsIn conclusion, a high percentage of mandibular second and third molars root apex have topographically close relationships to the lingual plate of the mandible. Hence, endodontic consultants must be aware by this anatomical relationship and be aware of possible complications during endodontic and surgical procedures using radiographical modalities.

Disparities in peptic ulcer disease: A nationwide study

BackgroundWhile advances in diagnosis and treatment of peptic ulcer disease have led to a decrease in hospital admissions the socioeconomic distribution of these benefits is unknown. MethodsWe designed a retrospective cohort study using the National Inpatient Sample from 2012 to 2013 including all patients that were admitted for peptic ulcer disease. We compared the types of ulcer related complications, the rates of intervention and the outcomes based on race and insurance status. ResultsOf 42,046 patients admitted for peptic ulcer disease 80.25% had an ulcer related complication. Black patients had the lowest rates of bleeding and highest rates of perforation and were less likely to undergo surgery for their complication but mortality was not different from white patients. Uninsured patients also had lower rates of bleeding and higher rates of perforation and they were at increased risk for death. ConclusionsUnlike other surgical conditions insurance status, not race, predicts mortality in peptic ulcer disease.

PS02.135: THE BALLOON DILATION WITH AIR INJECTION AGAINST STENOSIS OF ESOPHAGEAL CANCER

Abstract Background Recently the strictures of esophageal cancer were treated by the balloon dilation and/or stenting. These treatments were effective but several cases made to reduce a QOL with perforation after intervention. Especially a radiation-induced esophageal stricture with esophageal cancer presented high rate of perforation after stenting. Therefor we researched retrospective prognostic analysis that patient with stenosis by esophageal cancer was treated the balloon dilation only. Methods We performed the balloon dilation for 10 patients with stenosis by esophageal cancer in our hospital. The age mean was 76.3 years old (68–91). The men were 7. Eight patients were after chemo-radiotherapy (CRT) and two patients were after chemotherapy (CT). We used CRE™ Fixed Wire Balloon Dilators C.R.E. (Controlled Radial Expansion, Boston Scientific®). The balloon dilation was performed with air injection (not used liquid) and not used stent. The air prevented over dilatation. Results The median survival time after dilation was 4.95 months. All patient were improve the dysphagia and possible to swallowing. The perforation induce balloon dilation did not occurred. Conclusion Generally, the prognosis of advanced esophageal cancer patient with stenosis after CRT or CT was short. Therefor it may unnecessary that the stent insertion had risk of perforation against these patients. The insufficient balloon dilation with air injection preserved sufficient inner cavity of esophagus for esophageal cancer patient with stenosis after CRT or CT. Disclosure All authors have declared no conflicts of interest.

Ligation-assisted endoscopic submucosal resection with apical mucosal incision to treat gastric subepithelial tumors originating from the muscularis propria.

This study aimed to evaluate the clinical efficacy, safety, and feasibility of performing endoscopic submucosal resection with a ligation device (ESMR-L) after apical mucosal incision (AMI) for the treatment of gastric subepithelial tumors originating from the muscularis propria (SET-MPs). 14 patients with gastric SET-MPs were treated by ESMR-L with AMI between December 2016 and May 2017. The complete resection rate, operation duration, and postoperative complications were collected. All patients were followed for 2 - 6 months. The complete resection rate was 100 %, the mean tumor size was 10.71 ± 3.45 mm (7 - 18 mm), and the median operative time was 18.5 minutes. Perforation occurred in four patients, with all lesions being completely repaired endoscopically. No delayed bleeding or peritoneal signs were observed. No residual lesions or recurrence were found during the follow-up period. AMI with ESMR-L appears to be an efficient and simple method for the histological diagnosis of gastric SET-MPs, but it carries a high perforation rate and cannot guarantee cure.

Biomechanical evaluation of a new gliding screw concept for the fixation of proximal humeral fractures.

AimsPlating displaced proximal humeral fractures is associated with a high rate of screw perforation. Dynamization of the proximal screws might prevent these complications. The aim of this study was to develop and evaluate a new gliding screw concept for plating proximal humeral fractures biomechanically.MethodsEight pairs of three-part humeral fractures were randomly assigned for pairwise instrumentation using either a prototype gliding plate or a standard PHILOS plate, and four pairs were fixed using the gliding plate with bone cement augmentation of its proximal screws. The specimens were cyclically tested under progressively increasing loading until perforation of a screw. Telescoping of a screw, varus tilting and screw migration were recorded using optical motion tracking.ResultsMean initial stiffness (N/mm) was 581.3 (sd 239.7) for the gliding plate, 631.5 (sd 160.0) for the PHILOS and 440.2 (sd 97.6) for the gliding augmented plate without significant differences between the groups (p = 0.11). Mean varus tilting (°) after 7500 cycles was comparable between the gliding plate (2.6; sd 1.9), PHILOS (1.2; sd 0.6) and gliding augmented plate (1.7; sd 0.9) (p = 0.10). Similarly, mean screw migration(mm) after 7500 cycles was similar between the gliding plate (3.02; sd 2.85), PHILOS (1.30; sd 0.44) and gliding augmented plate (2.83; sd 1.18) (p = 0.13). Mean number of cycles until failure with 5° varus tilting were 12702 (sd 3687) for the gliding plate, 13948 (sd 1295) for PHILOS and 13189 (sd 2647) for the gliding augmented plate without significant differences between the groups (p = 0.66).ConclusionBiomechanically, plate fixation using a new gliding screw technology did not show considerable advantages in comparison with fixation using a standard PHILOS plate. Based on the finding of telescoping of screws, however, it may represent a valid approach for further investigations into how to avoid the cut-out of screws.Cite this article: Y. P. Acklin, I. Zderic, J. A. Inzana, S. Grechenig, R. Schwyn, R. G. Richards, B. Gueorguiev. Biomechanical evaluation of a new gliding screw concept for the fixation of proximal humeral fractures. Bone Joint Res 2018;7:422–429. DOI: 10.1302/2046-3758.76.BJR-2017-0356.R1.

Cerebral Aneurysmal Coiling in Virtual Reality ‐ An Overview of Novice Skill Development

Introduction and AimsCerebral endovascular aneurysm coiling is an interventional angiography technique which requires the use of fine motor and visuo‐spatial skills in order to guide tools throughout relevant vascular anatomy and deposit coils within the aneurysm. With the help of quantitatively limited fluoroscopy, coils are established through microcatheter placement in the aneurysm neck and electrolytically detached after their appropriate rotation and positioning. This procedure requires, and is currently limited to, extensive clinical training in the AngioSuite, where trainees are closely supervised by a consultant. This approach, although providing the current gold standard in training, limits the pace of skill development, exposes patients to unnecessary risk and wastes valuable monetary and personnel resources. The development of the skills needed for these procedures can be facilitated by 3D simulator‐based training. Simulation‐based medical education has recently started focusing on personalized training in reducing errors and development of specific skills.The ANGIO Mentor visual‐haptic simulator has been regarded as an effective training tool, increasing performance in diagnostic cerebral angiography, however, this simulator has not been tested thoroughly in its ability to train interventional skills. In particular, the details of the aneurysm coiling process during simulation‐based training have not been assessed.MethodsIn this study, 12 novice medical students were given simulation‐based diagnostic cerebral angiography training until a procedural plateau in performance, established in our previous work (Zaika et al., 2016). Subsequently, they were trained using video tutorials and written instructions to identify, measure and intervene with cerebral aneurysms using endovascular coils. Over the span of 6 sessions, participants were assessed on their procedural pace, coiling quantity and quality, and perforation rates. Concurrently, their spatial ability was assessed using a mental rotations test (MRT) and used in the performance analysis.Results and DiscussionWe found that all individuals were able to perform the procedure faster after 6 sessions, reducing their average time from 42 to 24 minutes. Coil success rate improved over from 82% to 88% and coil packing rate remained consistent at 30% throughout testing. High perforation rate seen at the start of the study showed a trend of decreasing over the latter sessions, however, over half of aneurysms were still being perforated by the novice participants. No change in aneurysm coiling quality was found, with a slight decrease in number of parent artery coil protrusions. High MRT individuals were also better able to establish guider catheter and associate tools prior to coiling. This work identifies the utility of simulation‐based cerebral angiography training in identifying the particular difficulties trainees experience in learning procedural skills, including prevention of perforations, proper positioning and success of coils within the aneurysm.Support or Funding InformationThis research was funded by the Natural Sciences and Engineering Research Council of Canada (NSERC) and the Canadian Institutes of Health Research (CIHR).This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Endoscopic management of bile duct stones in patients with surgically altered anatomy.

Bile duct stones in patients with surgically altered anatomy still pose a challenge to endoscopists. For successful endoscopic management of bile duct stones, there are multiple hurdles: Intubation to the afferent limb, biliary cannulation, ampullary intervention and stone extraction. The major advancement in this area is the development of dedicated device-assisted endoscopes for endoscopic retrograde cholangiopancreatography (ERCP). In patients with Billroth II reconstruction, a high technical success rate is reported using a duodenoscope but can be complicated by a potentially high perforation rate. In patients with Roux-en-Y reconstruction, device-assisted ERCP shows high technical success and low adverse event rates. Meanwhile, endoscopic papillary large balloon dilation enables safe and effective stone extraction with less use of endoscopic mechanical lithotripsy in patients with a dilated distal bile duct, but intraductal lithotripsy is sometimes necessary for management of very large bile duct stones. In cases with difficult stones, alternative approaches such as laparoscopy-assisted ERCP and endoscopic ultrasound (EUS)-guided intervention are increasingly reported with preliminary but promising results. However, comparative studies are still lacking in this area and prospective randomized controlled trials are warranted in terms of safety, efficacy and cost-effectiveness.

Staged Minimally Invasive Surgical Approach in the Management of Glandular Odontogenic Cyst

ABSTRACT Aim The aim of the study was to report a unique case of glandular odontogenic cyst (GOC) in an unusual location of anterior maxilla. Materials and methods Considering the age, sex, and location of the lesion, a minimally invasive surgical procedure was opted considering esthetics, such as decompression followed by enucleation and fresh frozen bone (FFB) grafting. To arrive at the diagnosis, cytokeratin (CK)-19 was employed to differentiate from suspected intraosseous mucoepidermoid carcinoma. Results With the evidence of pre- and post treatment histopathological changes, the lesion appeared less aggressive justifying the treatment executed. Conclusion Glandular odontogenic cyst is a locally aggressive jaw cyst, which has a high rate of cortical perforation and recurrence that poses both diagnostic and therapeutic challenges. Clinical significance Treatment of decompression, followed by enucleation may be considered as an effective option in comparison to aggressive surgical intervention. How to cite this article Kumari K, Sowmya SV, Vineeth K, Rao RS, Lalitha RM, Augustine D, Haragannavar VC, Nambiar S, Abraham M. Staged Minimally Invasive Surgical Approach in the Management of Glandular Odontogenic Cyst. World J Dent 2018;9(1):48-52.

Critical and Challenging Issues in the Surgical Management of Low-Lying Rectal Cancer.

Despite innovative advancements, the management of distally located rectal cancer (RC) remains a formidable endeavor. The critical location of the tumor predisposes it to a circumferential resection margin that tends to involve the sphincters and surrounding organs, pelvic lymph node metastasis, and anastomotic complications. In this regard, colorectal surgeons should be aware of issues beyond the performance of total mesorectal excision (TME). For decades, abdominoperineal resection had been the standard of care for low-lying RC; however, its association with high rates of tumor recurrence, tumor perforation, and poorer survival has stimulated the development of novel surgical techniques and modifications, such as extralevator abdominoperineal excision. Similarly, difficult dissections and poor visualization, especially in obese patients with low-lying tumors, have led to the development of transanal TME or the “bottom-to-up” approach. Additionally, while neoadjuvant chemoradiotherapy has allowed for the execution of more sphincter-saving procedures without oncologic compromise, functional outcomes remain an issue. Nevertheless, neoadjuvant treatment can lead to significant tumor regression and complete pathological response, permitting the utilization of organ-preserving strategies. At present, an East and West dualism pervades the management of lateral lymph node metastasis, thereby calling for a more global and united approach. Moreover, with the increasing importance of quality of life, a tailored, individualized treatment approach is of utmost importance when taking into account oncologic and anticipated functional outcomes.

Regional variations in outcomes and cost of appendectomy in the United States

BackgroundThe study of regional variations in surgical outcomes and cost has been used to identify areas for improvement and savings. This study investigates potential regional differences in the outcomes and cost of adult appendicitis. We hypothesized that there would be no difference in rates of laparoscopy, perforation, morbidity, length of stay (LOS), and cost among different regions of the United States. Materials and methodsData were obtained from the California (CA), New York (NY), and Florida (FL) State Inpatient Databases from 2005-2011. Patients between the ages of 18-69 who underwent nonincidental appendectomy in the three different states were evaluated with hierarchical and multivariate negative binomial regression analyses. Primary outcomes included laparoscopy, perforation, negative appendectomy, morbidity, LOS, and cost. ResultsThere were 371,354 appendectomies performed. Multivariate analysis revealed multiple regional differences. Patients in FL were most likely to get laparoscopy (P < 0.01). CA had higher rates of perforation than NY (P < 0.01) and FL (P < 0.05). CA also had higher rates of negative appendectomy compared to both NY and FL (P < 0.01). Morbidity was lower in NY compared to CA and FL (P < 0.01). The LOS was shortest in CA (P < 0.01), despite CA having the highest median per patient cost (P < 0.01). ConclusionsSignificant regional variations do exist with CA having the highest rate of perforation and negative appendectomy. Patients in CA also incurred the highest overall costs. A better understanding of the factors that drive these variations will help improve outcomes and lower cost across all states.

Laparoscopic Heller’s Myotomy for Achalasia Cardia by Blunt Dissection: a Safe Technique

Laparoscopic Heller myotomy (LHM) is the “gold standard” surgical treatment for achalasia cardia (AC). Prevailing techniques of LHM have been associated with a high rate (2–33%) of esophageal perforation. The aim of this study is to describe a novel technique of LHM using blunt dissection and to present our initial experience. This study is a retrospective analysis of patients with AC who underwent LHM by a blunt dissection technique (BDT) by a single surgeon from 2011 to 2016. Out of total 35 patients, 22 were males (62.8%) and the mean age was 32 years. None of the patients had endoscopic dilatation and/or other therapeutic procedures before surgery. Median preoperative modified Takita dysphagia grade was 3. The mean lower esophageal sphincter (LES) pressure before surgery was 41.88 mm of Hg. The mean operative time was 72.8 min, and the mean blood loss was 34.5 ml. The median length of postoperative hospital stay was 3 days. No patient required conversion to open surgery and there were no intraoperative and postoperative complications. All patients had sustained symptomatic relief along with significant reduction in dysphagia score. Blunt dissection technique is a safe technique of laparoscopic Hellers’s myotomy in patients with achalasia cardia.