Standard Surgical Procedure For Treatment Research Articles

Abstract 134: Lymph node metastases are seeded via two distinct ways in phylogenetic study of gastric cancer

Abstract Backgrounds: Gastric cancer (GC) ranked 5th and 8th on the list of cancer related deaths worldwide and in Taiwan, respectively. Due to its high frequency of lymph node spread, lymph node dissection has become a standard procedure in surgical treatment. A randomized trial showed that patients who underwent D2 lymphadenectomy had a better 5-year survival outcome than ones who had D1 dissection in advanced gastric cancer, implying the D2 lymph node might serve as an outpost before tumor cells spread to distant organs. This clinical observation raises a possibility that the regional lymphatic spread could be under strict selection but not a passive process. Materials and Methods: To understand the evolutionary relationship between primary tumors, perigastric lymph nodes, and second tier of lymph nodes in the extra-perigastric area, we reconstruct their phylogeny using genetic variants in hypermutable DNA regions where the mutation rate is 102~104-fold than unique sequence. We have assembled a cohort of 10 gastric cancer patients, including intestinal-, diffuse- and mixed type GC. For each case, we collected all workable lymph node metastases and intensely sampled primary tumors. On average, we have over fifteen samples per case on the phylogenetic tree. Results: Preliminary data of the first two patients show high heterogeneity within primary tumors as well as between different lesions of lymph nodes or peritoneal metastases in gastric cancer. Interestingly, in stark contrast to all other lymph node metastases which intermingle with primary tumors, a clade consisting of one proximal and one distal lymph node with a bootstrap value above 90% is observed in each phylogeny, and it is worth noting that samples on these clades are from intestinal type tumor. Conclusion: Our results indicate that most tumor cells arrive both regional and distal lymph nodes passively via lymphatic drainage in GC while a selective process also exists which coincides with clinical observation. Whether the existence of tumor cells under a relatively stricter selection process would lead to different clinical outcomes is under investigation. Citation Format: Pei-Chi Cheng, Wei-Ting Hung, Yung-Ming Jeng, I-Rue Lai. Lymph node metastases are seeded via two distinct ways in phylogenetic study of gastric cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 134.

MP51-10 SEXUAL FUNCTION OUTCOMES FOLLOWING HOLEP

You have accessJournal of UrologyCME1 Apr 2023MP51-10 SEXUAL FUNCTION OUTCOMES FOLLOWING HOLEP Chinade Roper, Austen Slade, Ronald J. Caras, Thomas Shelton, and Marcelino Rivera Chinade RoperChinade Roper More articles by this author , Austen SladeAusten Slade More articles by this author , Ronald J. CarasRonald J. Caras More articles by this author , Thomas SheltonThomas Shelton More articles by this author , and Marcelino RiveraMarcelino Rivera More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003299.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Holmium laser enucleation of the prostate (HoLEP) is the platinum standard surgical procedure for treatment of benign prostatic hyperplasia (BPH). As is common with BPH surgeries, many men develop retrograde ejaculation post-operatively. There is some conflicting evidence regarding the sexual function outcomes of this procedure. We sought to examine sexual outcomes post-HoLEP to assess changes in ejaculatory and erectile function. METHODS: With IRB approval, we conducted a retrospective study of patients who underwent HoLEP between Nov 2018 and Feb 2022. 346 patients met inclusion criteria and had completed pre and post operative questionnaires, which included the Male Sexual Health Questionnaire – Ejaculatory Dysfunction (MSHQ- EJD) and the 5 question International Index of Erectile Function/Sexual Health Inventory for Men (IIEF-5/SHIM). Both surveys were provided to patients up to 12 months post procedure. Patient demographics and comorbidities associated with sexual dysfunction were collected. Responses to each question were analyzed to detect sub-categorical improvements or declines in sexual function as the secondary objective. An autoregressive heterogeneous linear mixed model was performed in SPSS 28 to analyze the data. RESULTS: There was a significant decline in the total scores for the MSHQ-EJD from a mean of 7.48 pre-HoLEP to 6.23 post HoLEP (p=0.001) including a significant decline (p<0.005) in questions 1-3 which assess ejaculatory ability, strength, and volume; but there was not a significant decline in question 4 which assesses bother in ejaculatory function with a mean of 2.494 pre-HoLEP compared to 2.922 post-HoLEP (p=0.291). There was not a significant decline in the IIEF-5/SHIM post-operatively with mean pre-HoLEP score 9.21 vs 8.87 post-HoLEP (p=0.98). CONCLUSIONS: These findings suggest that patients undergoing HoLEP do not experience a decline in erectile function. Patients do appear to experience a decline in ejaculatory function post-operatively, but do not find the decline to be more bothersome. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e696 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Chinade Roper More articles by this author Austen Slade More articles by this author Ronald J. Caras More articles by this author Thomas Shelton More articles by this author Marcelino Rivera More articles by this author Expand All Advertisement PDF downloadLoading ...

Laparoscopic Kasai portoenterostomy can be a standard surgical procedure for treatment of biliary atresia.

BACKGROUNDBiliary atresia (BA) is a rare pediatric disease.AIMTo compare the outcomes of laparoscopic portoenterostomy (Lap-PE) with those of laparotomy (Open-PE) at a single institution. METHODSThe surgical outcomes of PE were retrospectively analyzed for patients with a non-correctable type of BA from 2003 to 2020.RESULTSThroughout the assessment period, 119 patients received PE for BA treatment, including 66 Open-PE and 53 Lap-PE cases. Although the operation duration was longer (medians: for Open-PE, 242 min; for Lap-PE, 341 min; P < 0.001), blood loss was considerably less (medians: for Open-PE, 52 mL; for Lap-PE, 24 mL; P < 0.001) in the Lap-PE group than in the Open-PE group. The postoperative recovery of the Lap-PE group was more favorable; specifically, both times to resume oral intake and drain removal were significantly shorter in the Lap-PE group. Complete resolution of jaundice was observed in 45 Open-PE cases and 42 Lap-PE cases, with no statistically significant difference (P = 0.176). Native liver survival rates were >80% for both groups for the first half year post surgery, followed by a gradual decrease with time; there were no statistically significant differences in the native liver survival rates for any durations assessed.CONCLUSIONLap-PE could be a standard therapy for BA.

Bipolar TURP decreases post-operative morbidity – A prospective study in a tertiary care hospital from north India

Background: Transurethral resection of prostate is considered as gold standard surgical procedure for treatment of benign enlargement of prostate. It can be performed in two forms- monopolar transurethral resection and bipolar transurethral resection.&#x0D; Aims and Objective: This study was conducted to know which energy source among monopolar and bipolar energy leads to more post-operative morbidity after performing transurethral resection of prostate.&#x0D; Materials and Methods: In this study, total eighty (80) cases were included. They were suffering from lower urinary tract symptoms which were diagnosed to be due to benign enlargement of prostate after careful clinical and radiological examination. In forty cases, transurethral resection of prostate was performed by using monopolar energy source and in another forty cases, resection of prostate by transurethral route was done using bipolar energy source.&#x0D; Results: In our study, we found that development of TURP syndrome was more in monopolar TURP group in which pre-operative weight of prostate was more than 50 grams in comparison to bipolar TURP group in which there was no incidence of development of TURP syndrome in same class. Further, post-operative hospital stay and post-operative urethral catheter in situ was less in bipolar TURP group in terms of days as compared to monopolar TURP group.&#x0D; Conclusion: Our study concludes that Bipolar TURP is better in terms of development of less post-operative morbidity as compared to monopolar TURP. Bipolar TURP must be used extensively in teaching hospitals where students take more time than a seasoned surgeon to perform a surgical procedure and bipolar TURP will come handy in that situation.

Reporting Templates for MRI and Water-Soluble Contrast Enema in Patients With Ileal Pouch-Anal Anastomosis: Experience From a Large Referral Center.

Ileal pouch-anal anastomosis (IPAA) surgery is the reference standard surgical procedure for treatment of ulcerative colitis and most patients with familial adenomatous polyposis. This procedure allows preservation of fecal continence and gastrointestinal continuity. However, it is associated with a wide variety of complications, which often have nonspecific and overlapping clinical presentations, making imaging an important part of workup for pouch dysfunction. The purpose of this article is to propose structured reporting templates for MRI and water-soluble contrast enema (WSCE), based on our referral pouch center's experience, in patients who have undergone IPAA surgery. We review salient surgical technique, pouch anatomy, and imaging protocols, with an emphasis on a systematic search pattern for evaluation of ileal pouch complications using proposed structured reporting templates for MRI and WSCE.

Comparison of two surgical suture techniques in uvulopalatopharyngoplasty and expansion sphincter pharyngoplasty

BackgroundUvulopalatopharyngoplasty (UPPP) and expansion sphincter pharyngoplasty (ESP) are two standard surgical procedures for treatment of snoring and sleep apnea. In a prospective clinical trial, we compared a standard simple interrupted suture technique for closure of the tonsillar pillars with a running locked suture.MethodsEach suture technique was randomly assigned either to the left or the right tonsillar pillars in 28 patients. During the first week, patients were daily checked for suture dehiscence and again on days 10 and 21, the end of followup. Time to perform the sutures was measured intraoperative and surgical complications were recorded.ResultsDuring followup, suture dehiscence was observed in 15/28 interrupted and 16/28 running sutures (p > 0.5). If a dehiscence occurred during the observation period, the median day of dehiscence was 10 (1 and 3 quartile: 5.75 and 17) days for the interrupted suture and 10 (5–11) days for the running locked suture technique (p > 0.05). The mean (± SD) surgical time for the interrupted suture was 5.2 ± 1.9 and 3.5 ± 1.8 min for the running locked suture (p < 0.001). Postoperative bleedings occurred in 4/28 running sutures and 2/28 interrupted sutures.ConclusionThe running locked suture technique is an equally safe and time saving way of wound closure in UPPP and ESP.

Clinical Outcomes of Anteroposterior Dissection Holmium Laser Enucleation of the Prostate for Benign Prostatic Hyperplasia

Holmium laser enucleation of the prostate (HoLEP) is a standard surgical procedure for treatment of benign prostatic hyperplasia (BPH). A low incidence of postoperative urinary incontinence in association with anteroposterior dissection HoLEP was recently reported. We evaluated 66 patients with BPH who underwent anteroposterior dissection HoLEP from March 2013 to November 2014. The International Prostate Symptom Score (IPSS), quality of life (QOL) index, maximum flow rate (Qmax), and post-void residual urine volume (PVR) were assessed preoperatively and at 1 and 3 months after treatment. The incidence of postoperative urinary incontinence, which was defined as the requirement of more than one pad per day, was compared between the first and second half of the patient population. Postoperative urination parameters (IPSS, QOL index, Qmax, and PVR) were significantly improved. The incidence of urinary incontinence at 3 months was significantly lower in the second half (4%) than first half (28%) of the patient population (p＝0.020). In conclusion, anteroposterior dissection HoLEP is an effective procedure for the treatment of BPH and can reduce the rate of postoperative urinary incontinence, even in low-volume institutes.

Suprapatellar nailing of tibial fractures–Indications and technique

Intramedullary nailing is the standard procedure for surgical treatment of closed and Gustilo-Anderson Grade I-II° open fractures of the tibial shaft. The use of intramedullary nailing for the treatment of proximal metaphyseal tibia fractures is frequently followed by postoperative malalignment, whereas plate osteosynthesis is associated with higher rates of postoperative infection. Intramedullary nailing of tibial fractures is generally performed through an infrapatellar approach. The injured extremity must be positioned at a minimum of 90° of flexion in the knee joint to achieve optimal exposure of the correct entry point. The tension of the quadriceps tendon causes a typical apex anterior angulation of the proximal fragment.The suprapatellar approach improves reduction of the fracture and reduces the occurrence of malalignment during intramedullary nailing of extra-articular proximal tibial fractures. The knee is positioned in 20° of flexion to neutralise traction forces secondary to the quadriceps muscle, thus preventing an apex anterior angulation of the proximal fragment. An additional advantage of the technique is that it allows the surgeon to avoid or minimise further soft tissue damage because of the distance between the optimal incision point and the usual area of soft tissue damage.

AB101. Diversity and choice in the surgical techniques for benign prostatic hypertrophy

Benign prostatic hypertrophy (BPH) is still one of the most diseases that urologists need to deal with every day. Although conservative and medical therapy for BPH is now well established in terms of alpha-blocker and 5-alpha reductase inhibitor treatment, surgical intervention is still finally irreplaceable for many cases. Open prostectomy has more than 200 years of history since Doctor Guthrie first used the perineum incision to enucleate the hyperplastic prostate adenoma in the year of 1834. From then on, surgical techniques have been evolved and improved constantly and Guthrie’s perineum approach was superseded by Freyer’s suprapubic transvesical approach, Millin’s retropubic transcapsular prostectomy, and more recently laparoscopic and robotic-assisted approach. When it comes to surgical treatment options available for BPH, transurethral surgery of prostate (TUSP) have to be mentioned. Monopolar transurethral resection of the prostate (TURP) have been called for many years as the golden standard treatment for the surgical management of BPH. However, TURP rates have declined over the past two decades due to the significant benefits of medical therapy and, to a lesser extent, the proliferation of other transurethral surgical techniques. Transurethral vaporization and vaporesection of the prostate are reported to have the similar results compared to TURP. With the development of the monopolar to bipolar technique and many electrode designs available, TUSP is becoming more and more safety. In recent years, transurethral plasmakinetic resection of the prostate (TUPKRP/PKRP) is the more and more popular technique of TUSP and considered as the new golden standard procedure for surgical treatment of BPH. In the past 5 years, transurethral laser techniques have been used more and more in the surgical management of BPH. There are several types of lasers used for BPH surgery by either coagulating, vaporizing or enucleating the prostate. Laser techniques for treating BPH appears to have equivalent results to TURP and have superiority to TURP in anticoagulated patients where risks of bleeding and the need for post-operative blood transfusion remain low. Transurethral laser treatment of BPH seems to have a tendency to replace the TURP. In fact, surgical treatment options are far more than the above mentioned, for example, UroLift system can illustrate this point as the latest technique and new technology will appear constantly and apply to clinic. However, so many surgical options exist for BPH and indications are well defined, questions remain in this area. How much prostate volume reduction is necessary to relieve BOO or LUTS, how is bladder underactivity and its associated with LUTS after BPH surgery and which procedure is the best choice for each BPH patient. And more, cost effectiveness of any options should be considered, especially in developing country. It is clear that appropriate counseling is necessary in all patients who undergo BPH surgery.

The percutaneous trigger finger release scalpel - the A knife

Open A1 pulley release is a standard surgical procedure for treatment of trigger finger. The disadvantages of the open technique include injury to the soft tissue, developing a painful palmar scar and patients requiring an extended recovery timethesince the procedure is more complex. Another technique used for treatment of trigger finger is percutaneous release. This technique offers the benefits of smaller incision, faster recovery time and an easier procedure compared tothe open technique. The A-Knife is a new specially designed invention for percutaneous trigger finger release. It is made from stainless steel and has these special features for the follow purposes. 1. The scalpel’s size, angle, curve, and position of the blade are designed to cut only the A1 pulley through a 2 millimeter wound on the skin. 2. The tip of the A-Knife has a round end which is used to guide through the small skin incision and locating the A1 pulley with minimal injuries to the tendon and surrounding tissues, allowing the surgeon to precisely locate the problematic landmark. 3. The curve of the scalpel is appropriate to make effective insertion the tip of the scalpel between the A1 pulley and the flexor tendon. The angle of the scalpel is tailored to cut the A1 pulley in a proper direction. Results of A1 pulley release by the A-Knife show a reduction in injuries to the surrounding soft tissue and lessened risk of the injury to the tendon. There are 6 steps in the surgical technique of percutaneous trigger finger release using the A-Knife. (Figure ​(Figure11) Figure 1 The surgical technique of percutaneous release trigger finger using the A-Knife. 1. The local anesthesia is injected and makes a 2-millimeter incision on the skin. 2. The A-Knife is inserted through the incision. 3. The edge of A1 pulley is identifyby the blunt tip of the A-Knife. 4. A surgeon inserts and passes the tip of the A-Knife under the tendon sheath. 5. After the tip of the A-Knife is in a position between the A1 pulley and tendon, the A-Knife is passed distally parallel to the tendon to cut the A1 pulley. 6. The A-Knife is removed from the incision. The finger motion without locking or snapping should be reach at this end step.

Salpingotomy Versus Salpingectomy in Women With Tubal Pregnancy (European Surgery in Ectopic Pregnancy Study)

The standard surgical procedure for treatment of tubal ectopic pregnancy is salpingectomy, in which the affected fallopian tube is removed. A feasible alternative intervention, salpingotomy, has been promoted since 1957. With this procedure, the pregnancy is removed while the affected tube is preserved. There are 2 risks associated with salpingotomy: a repeated ectopic pregnancy in the same tube and a persistent trophoblast requiring additional treatment. Despite these potential drawbacks, salpingotomy has been widely used and often preferred over salpingectomy because it has been assumed that preservation of both tubes increased the prospects for a future pregnancy. However, limited data support this assumption, and it remains unclear whether the potential benefits of salpingotomy outweigh the risks. The aim of this open-label, multicenter, randomized controlled trial was to determine whether salpingotomy improves rates of ongoing pregnancy by natural conception compared with salpingectomy. Participants were 18 years or older with a laparoscopically confirmed tubal pregnancy and a healthy contralateral tube. All had a desire for a future pregnancy. At surgery, they were randomly assigned to receive salpingotomy or salpingectomy. The primary study outcome was ongoing pregnancy by natural conception. Differences between groups in cumulative ongoing pregnancy rates were expressed as a fecundity rate ratio using Cox proportional hazards analysis with a time horizon of 36 months. Secondary study outcomes were persistent trophoblast, repeated ectopic pregnancy, ongoing pregnancy after ovulation induction, intrauterine insemination, and in vitro fertilization. Patients and investigators who analyzed the data were not masked to the assigned intervention, but researchers who collected data for fertility outcomes were unaware of treatment allocation. Data were analyzed according to the intention to treat. The investigators performed a (nonprespecified) meta-analysis that included the data from the present trial. A total of 446 women were randomly assigned to salpingotomy (n = 215) or salpingectomy (n = 231) between 2004 and 2011. The patients were followed until February 1, 2013. There was no significant difference between the groups in the cumulative ongoing pregnancy rate (60.7% after salpingotomy vs 56.2% after salpingectomy; the fecundity rate ratio was 1.06, with a 95% confidence interval [CI] of 0.81–1.38, log-rank P = 0.678.) Persistent trophoblast occurred significantly more frequently in the salpingotomy group (14 [7%] vs 1 [<1%]; relative risk, 15.0; 95% CI, 2.0–113). The risk for repeated ectopic pregnancy was not significantly increased after salpingotomy (18 [8%] in the salpingotomy group vs 12 [5%] in the salpingectomy group; relative risk, 1.6; 95% CI, 0.8–3.3; P = 0.19).There was no significant difference between the groups in the number of ongoing pregnancies after ovulation induction, intrauterine insemination, or in vitro fertilization. During the initial surgery, 43 women (20%) in the salpingotomy group were converted to salpingectomy because of persistent tubal bleeding. Meta-analysis, which included data from 1 study in the literature and the present study, showed no improvement in fertility rates with salpingotomy. These data show that salpingotomy does not significantly improve fertility prospects over that of salpingectomy.

Standardization of D2 lymphadenectomy and surgical quality control (KLASS-02-QC): a prospective, observational, multicenter study [NCT01283893

BackgroundExtended systemic lymphadenectomy (D2) is standard procedure for surgical treatment of advanced gastric cancer (AGC) although less extensive lymphadenectomy (D1) can be applied to early gastric cancer. Complete D2 lymphadenectomy is the mandatory procedure for studies that evaluate surgical treatment results of AGC. However, the actual extent of D2 lymphadenectomy varies among surgeons because of a lacking consensus on the anatomical definition of each lymph node station. This study is aimed to develop a consensus for D2 lymphadenectomy and also to qualify surgeons that can perform both laparoscopic and open D2 gastrectomy.Methods/DesignThis (KLASS-02-QC) is a prospective, observational, multicenter study to qualify the surgeons that will participate in the KLASS-02-RCT, which is a prospective, randomized, clinical trial comparing laparoscopic and open gastrectomy for AGC. Surgeons and reviewers participating in the study will be required to complete a questionnaire detailing their professional experience and specific gastrectomy surgical background/training, and the gastrectomy metrics of their primary hospitals. All surgeons must submit three laparoscopic and three open D2 gastrectomy videos, respectively. Each video will be allocated to five peer reviewers; thus each surgeon’s operations will be assessed by a total of 30 reviews. Based on blinded assessment of unedited videos by experts’ review, a separate review evaluation committee will decide whether or not the evaluated surgeon will participate in the KLASS-02-RCT. The primary outcome measure is each surgeon’s proficiency, as assessed by the reviewers based on evaluation criteria for completeness of D2 lymphadenectomy.DiscussionWe believe that our study for standardization of D2 lymphadenectomy and surgical quality control (KLASS-02-QC) will guarantee successful implementation of the subsequent KLASS-02-RCT study. After making consensus on D2 lymphadenectomy, we developed evaluation criteria for completeness of D2 lymphadenectomy. We also developed a unique surgical standardization and quality control system that consists of recording unedited surgical videos, and expert review according to evaluation criteria for completeness of D2 lymphadenectomy. We hope our systematic approach will set a milestone in surgical standardization that is essential for surgical clinical trials. Additionally, our methods will serve as a novel system for educating surgeons and assessing surgical proficiency.Trial registrationNCT01283893.

Treatment for superficial non-ampullary duodenal epithelial tumors.

Because of the low prevalence of non-ampullary duodenal epithelial tumors (NADETs), standardized clinical management of sporadic superficial NADETs, including diagnosis, treatment, and follow-up, has not yet been established. Retrospective studies have revealed certain endoscopic findings suggestive of malignancy. Duodenal adenoma with high-grade dysplasia and mucosal cancer are candidates for local resection by endoscopic or minimally invasive surgery. The use of endoscopic treatment including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), for the treatment for superficial NADETs is increasing. EMR requires multiple sessions to achieve complete remission and repetitive endoscopy is needed after resection. ESD provides an excellent complete resection rate, however it remains a challenging method, considering the high risk of intraoperative or delayed perforation. Minimally invasive surgery such as wedge resection and pancreas-sparing duodenectomy are beneficial for superficial NADETs that are technically difficult to remove by endoscopic treatment. Pancreaticoduodenectomy remains a standard surgical procedure for treatment of duodenal cancer with submucosal invasion, which presents a risk of lymph node metastasis. Endoscopic or surgical treatment outcomes of superficial NADETs without submucosal invasion are satisfactory. Establishing an endoscopic diagnostic tool to differentiate superficial NADETs between adenoma and cancer as well as between mucosal and submucosal cancer is required to select the most appropriate treatment.

Hepatectomy for bile duct injuries: When is it necessary?

Iatrogenic bile duct injuries (IBDI) are still a challenge for surgeons. The most frequently, they are caused by laparoscopic cholecystectomy which is one of the commonest surgical procedure in the world. Endoscopic techniques are recommended as initial treatment of IBDI. When endoscopic treatment is not effective, surgery is considered. Different surgical biliary reconstructions are performed in most patients in IBDI. Roux-Y hepaticojejunostomy is the commonest biliary reconstruction for IBDI. In some patients with complex IBDI, hepatectomy is required. Recently, Li et al analyzed the factors that had led to hepatectomy for patients with IBDI after laparoscopic cholecystectomy (LC). Authors concluded that hepatectomy might be necessary to manage early or late complications after LC. The study showed that proximal IBDI (involving hepatic confluence) and IBDI associated with vascular injuries were the two independent risk factors of hepatectomy in this series. Authors distinguished two main groups of patients that require liver resection in IBDI: those with an injury-induced liver necrosis necessitating early intervention, and those in whom liver resection is indicated for treatment of liver atrophy following long-term cholangitis. In this commentary, indications for hepatectomy in patients with IBDI are discussed. Complex biliovascular injuries as indications for hepatectomy are presented. Short- and long-term results in patients following liver resection for IBDI are also discussed. Hepatectomy is not a standard procedure in surgical treatment of IBDI, but in some complex injuries it should be considered.

Surgical management of spasmodic torticollis

IntroductionSpasmodic torticollis (ST) is a neuromuscular disorder characterized by uncontrolled clonic and intermittently tonic spasm of the neck muscles. ObjectiveThis retrospective study was done to study clinical picture and to evaluate the surgical results of different surgical procedures in 11 patients who had spasmodic torticollis. MethodsThe male to female ratio was 1–2 (4 males and 7 females) and their ages ranged from 18 to 65years. The X-ray of the cervical spine was performed before the operation to exclude cervical disorders that can cause symptoms similar to spasmodic torticollis. MRI of the head and neck was performed in all patients, without finding significant brain lesions. Electromyography of the cervical muscles was performed preoperatively and postoperatively. All cases underwent surgery in the form of variable combinations of ventral rhizotomy of C1, C2+ selective peripheral denervation of neck muscles involved according to the type of torticollis. Mean postoperative follow up period was 24months. ResultsThere was no operative mortality. As regards the morbidity, one patient had deficiency of shoulder elevation that was transient and improved after 3months; one patient had wound infection that responded well to antibiotics after culture and sensitivity. Postoperative dysphagia was found in two cases that improved in one of them after two months. At the last follow up examination period, excellent results were obtained in 55% of patients, good results in 18% of patients, fair results in 18% of patients, and poor results in 9% of cases. ConclusionThere is no standard surgical procedure for treatment of ST; this is adapted to each patient according to type of torticollis. Better results were obtained in simple torticollis (excellent results in 100%), than in complex type (excellent and good results in 33.3%).

Rectal Cancer: Function-preserving Surgery

The main goals in the surgical treatment of rectal cancer are to remove the cancer completely and to preserve the anorectal function. Rectal cancer is one of the leading health issues in Korea because of its increasing incidence with changing lifestyles and diets. The optimal treatment of rectal cancer is based on a multimodality approach. Among the modalities, proper surgery is the key for a curative treatment. In the early 20th century, local recurrence was reported to be as high as 30∼40%. However, after the introduction of total mesorectal excision (TME), local recurrence decreased dramatically (to less than 10%). TME includes on sharp pelvic mesorectal dissection and complete clearing of the rectal cancer and the mesorectum along the rectal proper fascia. TME is now considered as a standard procedure for surgical treatment of rectal cancer. These days, sphincter-saving surgical techniques, such as transanal excision, ultralow anterior resection with coloanal anastomosis, and intersphincteric resection, have become popular for the treatment of low rectal cancer. Many researchers reported that oncologic outcomes were not compromised by the increased sphincter preservation rate. In clinical settings, the quality of life should be considered important because of the improved oncologic results in recent years. Surgeon should be aware of changes in the anorectal function after surgery. Reservoir and fecal continence, as well as sexual and voiding functions, should be closely evaluated during follow-up period. Impaired anorectal function may have multiple contributing factors: for example, a reduced reservoir volume, an unnoticed complex injury of the anal sphincter, or a traction injury (anal dilation). In terms of poor sexual and voiding functions, identification of the autonomic nerve plexus in the operative field is not enough for preserving the sexual and voiding functions. During pelvic dissection, traction injury caused by blunt dissection and electrothermal or vasa nervosum injury during sharp perimesorectal dissection should be avoided for better functional results. Preoperative or postoperative radiation may also be a reason for sexual and voiding dysfunction. If the ultimate goal of rectal cancer surgery is to be achieved, precise surgical technique and proper patient selection are mandatory. This issue contains recent advances in sphincter-saving surgery and nerve preservation for rectal cancer, which will be a useful reference for colorectal surgeons.

Surrénalectomie cœlioscopique robotisée

Laparoscopy has emerged as the standard procedure for surgical treatment of benign adrenal diseases. These past 5 years, there have been concurrent improvements in the field of robotic surgery. Almost all urologic procedures initially performed laparoscopically have become performed with robotic assistance. Following a review of anatomic aspects, this paper discusses the indication, resumes the initial laboratory experience, and presents a description of the technique. Robot-assisted laparoscopic adrenalectomy has been performed in very few subjects worldwide. Advantages of robotic assistance over conventional laparoscopy are not acknowledged. Improvement in robotic technology, including addition of tactile feedback, miniaturization of end-effectors, reduced cost, and advances in remote surgery telecommunication technology are awaited. This will help in defining the place of robotics in treatment of adrenal diseases.

Endoscopic Diagnosis and Treatment of Late Complications of Gastric Bandage

Background: Gastric bandage became a standard surgical procedure for treatment of morbid obesity. However, up to 15% of patients develop complications several months or even years after operation. Whenever possible, endoscopic diagnosis and treatment should be the method of choice. Methods: Late complications of gastric bandage include dilatation of proximal gastric pouch, slippage of the pouch, migration of the bandage through the gastric wall into the stomach, gastric ulcers, infections of bandage system, or its mechanical damage. We performed a retrospective assessment of late complications after gastric bandage, and evaluation of utility of upper endoscopy for making correct diagnosis and treatment of such complications. Results: Between January 1998 and October 2005, 32 patients (i.e. 3.9% out of 811 patients operated on in our center) with gastric bandage were sent to our endoscopic unit to perform upper endoscopy due to their acute or chronic complaints. Most of them had nauzea and vomiting, remaining had epigastric pain after meal or without association with meal. All of them underwent upper endoscopy with following findings: 24 pts had dilatation and/or slippage of the pouch, 3 pts were diagnosed with complete or partial migration of the bandage into the stomach, and 1 had a large bezoar formed by coconut. Remaining 4 pts had normal findings. Among patients with dilatation or slippage, in 19 out of 20 cases, the endoscopic examination of entire stomach (including distal part below the bandage) was possible. All cases were diagnosed correctly by endoscopy alone, in 3 patients the diagnosis of the dilatation or slippage was misdiagnosed by previous X-ray examination. Patients with migrating bandage were treated by combination of upper endoscopy plus laparoscopy (1 case), and by endoscopy alone (2 cases), where the migrated bandage was cut by endoscopical scissors. Patient with coconut bezoar in gastric pouch was treated by upper endoscopy followed by surgical removing of the bandage. Conclusions: Upper endoscopy is a usefull method for diagnosing most complications that occur after gastric bandage placement. Some complications my even be treated endoscopically or with endoscopic assistance.

Humeral shaft nonunion: evaluation of uniform surgical repair in fifty-one patients.

To determine whether a standardized treatment of aseptic humeral shaft nonunions results in union after one operation without substantial complications. Retrospective study. University hospital. Between 1975 and 1998, fifty-eight patients sustained a humeral shaft fracture that resulted in an aseptic nonunion. Fifty-one patients between the ages of twenty-three and eighty-six years (mean 50.8 years) were included and evaluated. Surgical treatment consisted of an anterolateral approach with radial nerve identification and subsequent neurolysis, decortication, compression plating, and frequent application of autogenous bone grafts. No immobilization with brace or cast after treatment was functional. Success rate of nonunion repair, reinterventions, complications, range of motion, patient satisfaction. After one year, consolidation was apparent in all cases. All but two patients had an essentially normal range of motion of the shoulder and elbow, and 96 percent rated their result as excellent or good. After nonunion repair, two patients had a transient sensory neuropathy of the radial nerve. In one patient, a second intervention was needed after a fall from bed one week after the index operation. The results of this study indicate that our standard surgical procedure for treatment of nonunion of the humeral shaft is reliable and achieves consolidation in one procedure without significant complications.

Impaired distensibility of neoaorta after arterial switch procedure

Background. Although the arterial switch operation has become the standard surgical procedure for treatment of complete transposition, postoperative problems have not been fully appreciated. One such problem may be the postoperative function of great arteries that are manipulated radically. Methods. The diameters at four levels of the aorta were measured in 36 patients who had undergone arterial switch operation and the distensibilities were calculated. The data were compared with that of age-matched controls. Results. At the level of the Valsalva sinus, aortic diameters after one-staged and two-staged operations were 137.0% ± 21.3%N and 152.4% ± 17.7%N of the normal aorta, respectively. The distensibilities at the Valsalva sinus in patients after one-staged and two-staged operations were 1.2 ± 0.7 and 1.5 ± 0.8 cm 2 · dyn −1 · 10 −6, and at the supraaortic ridge were 2.5 ± 1.5 and 1.9 ± 1.5 cm 2 · dyn −1 · 10 −6, respectively. Conclusions. In patients after arterial switch procedure, the distensibility of the base of aorta is decreased. Long-term follow-up is necessary to clarify the influence of the “stiffness” of the base of aorta.