Laparoscopic vs. open appendicectomies: results obtained by junior surgeons at a British University Hospital.

BACKGROUND: The laparoscopic approach for appendicectomies remains a frequent topic of debate. In this study we report the experience with laparoscopic (LA) and open appendicectomies (OA) achieved in a British University Hospital over one year where most of these operations have been conducted by junior trainees. METHODS: Retrospective review of LA and OA performed at the Whipps Cross University Hospital of London (U.K.). Outcomes measured were the operating time, length of hospital stay and post-operative complications. RESULTS: Between January and December 2008 205 appendicectomies have been performed on adult patients. Eighty-eight per cent of the procedures were conducted by junior surgeons. The operating time was significantly shorter for the OA vs. LA patients (55 +/- 26.8 vs. 83 +/- 26.9 min, p < 0.01). The hospital stay confirmed a significant advantage for LA (2.2 vs. 3.7 days, p = 0.02). No significant differences were present among techniques for the overall morbidity, post-operative intra-abdominal abscesses and rate of readmissions. CONCLUSIONS: Under adequate supervision LA can be safely performed by junior surgeons and reduces the hospital stay.

Bronchoscopically-guided conformal radiation therapy for radiographically occult lung carcinoma.

Radiographically occult lung carcinoma has a very good prognosis after complete surgical resection. In medically inoperable patients three-dimensional conformal radiation therapy cannot be performed, as computed tomography scan images fail to localize the disease. Presented here is an original technique of marking radiographically occult tumors by fiberoptic bronchoscopy, applied on four patients. No short-term complications were recorded. All the patients are alive, with no evidence of disease, after a mean follow-up of 15 months.

Latissimus dorsi reverse flap to substitute the diaphragm after extrapleural pneumonectomy.

BACKGROUND: The standard procedure for diaphragm reconstruction after extrapleural pneumonectomy for a malignancy consists of the use of prosthetic patches. Our original technique utilizing the reverse flap of the latissimus dorsi is evaluated. METHODS: Once the extrapleural pneumonectomy is performed, the distal portion of the latissimus dorsi, which has been divided with a standard posterolateral thoracotomy at the level of the fifth to sixth rib, is elevated into the chest through the passage obtained by resection of the tenth rib and sutured to the lower pericardium and to the chest wall. Nine patients were evaluated. RESULTS: No operative death occurred. No flap-related complication nor infection was postoperatively assessed. Six patients received adjuvant radiotherapy. No late complication was observed. CONCLUSIONS: The distal latissimus dorsi can be used for total reconstruction of one hemidiaphragm, ensuring a watertight separation between the pleural and peritoneal cavities and avoiding paradoxical respiratory motion. In our opinion, the technique was easier, faster, and more reliable than the standard procedure employing prosthetic materials. We recommend that the procedure be integrated with the standard technique of extrapleural pneumonectomy.

Extrapericardial solitary fibrous tumour of the pericardium.

Solitary fibrous tumour (SFT) occurs most commonly in the pleura and is extremely rare in the pericardium. The authors report a case of a 60-year-old man in whom a large mediastinal mass was accidentally discovered. Computed tomography showed involvement of the left anterosuperior mediastinum with displacement of the trachea, large vessels and oesophagus; histopathological findings after complete resection of the neoplasia demonstrated an SFT of the pericardium, the first reported case with extrapericardial pattern of growth. A review of the literature on SFTs of the pericardium is provided.

Intrathoracic benign metastasizing leiomyoma with extrapulmonary growth pattern. A case report.

The authors report a case of a woman in whom complete resection of an extrapulmonary differentiated leiomyomatous tumor of uterine origin was performed 39 years after hysterectomy for uterine leiomyomas.

Re-exploration of the saphenofemoral junction in the treatment of recurrent varicose veins.

A retrospective study of 61 patients (61 legs) with recurrent varicose veins (RVV) and saphenofemoral junction (SFJ) incompetence was set up to assess the efficacy of re-exploration of the SFJ through a lateral approach. All the patients underwent re-exploration of the SFJ by a single surgeon (MPV) through a lateral approach. Thirty-one patients (50.8%) presented an intact SFJ. Twenty-seven patients (44.2%) presented intact major tributaries emerging from the stump of SFJ. In 2 patients (3.2%) the recurrence was related to neovascularization and in 1 case (1.6%) to cross groin venous connection. Follow-up averaged 2.81 years. Three (4.9%) patients were lost, 56 out of 58 patients (96.55%) were asymptomatic, 2 out of 58 (3.4%) presented a new recurrence in the groin. Complete isolation of the FV to identify every tributary and ligation of the SFJ flush with the FV are essential to avoid further recurrences.

Crohn's disease of the vulva.

Crohn's involvement of the Vulva is unfamiliar and difficult to treat. The aim is to review the presentation, clinical course and different treatments of Vulva Crohn's disease (CD). We have reviewed the literature without language barrier from 1966 to 2009 through Pubmed with the following words: vulva and CD, vulvitis and CD, genital CD. We included articles that had Crohn's involvement of the vulva arising from a distant site (metastatic) or arising from a Crohn's fistula from the perineum and/or anorectum. We excluded CD of other gynaecological organs. One hundred thirty six abstracts were identified and related articles reviewed. Fifty-five cases of CD of the vulva were included in the final anlaysis of this review. Vulva involvement is rare and gives long-term discomfort. A combined medical therapy (metronidazole with prednisolone) appears to be the most effective treatment. The surgical approach should be reserved for non-responding cases. CD is often unrecognized cause of vulva pain and difficult to diagnose. However if diagnosed and adequately treated it usually responds to conservative therapies.

Meta-analysis of the use of glyceryl trinitrate ointment after haemorrhoidectomy as an analgesic and in promoting wound healing.

INTRODUCTION: Glyceryl Trinitrate (GTN) ointment has been used to treat anal fissure and pain relief in haemorrhoids, but the value of its use post-haemorrhoidectomy as an analgesic and in wound healing is unclear. The side effect of headache has often been an associated problem. Therefore, a meta-analysis of randomised controlled trials was carried out investigating the role of GTN post-haemorrhoidectomy as an analgesic, its role in would healing and the unwanted incidence of headache. METHOD: A structured literature search from 1966 to 2009, both paper and online, with no language barrier was carried out. 760 papers were identified and 5 randomised control trials which met the entry criteria were included in this study. RESULTS: A total of 333 patients were included in the meta-analysis. The results revealed that GTN ointment was statistically significant in reducing pain on Day 3 and 7 compared to the placebo group. Day 3 shows a pain score of - 1.51 (p value of 0.029) and Day 7 by - 1.66 (p value of 0.014) respectively. However, it was not significant in reducing pain on Day 1. The Odds ratio for wound healing after GTN treatment at 3 weeks was 3.57 (P < 0.0001) when compared to the placebo group. Side effect of headache was not statistically significant. CONCLUSION: This meta-analysis has shown that GTN ointment used post-haemorrhoidectomy has a significant analgesic effect in the intermediate time period (ie. Days 3-7). It also significantly improved wound healing at 3 weeks.

Rectovaginal fistula in Crohn's disease.

PURPOSE: Crohn's disease is characterized by transmural bowel inflammation and a tendency to form fistulas with adjacent structures. Several different fistulas have been described: enterocutaneous, enteroenteric, enterovesical, enterovaginal, and perineal. Rectovaginal fistulas are difficult to treat despite multimodal therapy. This study was designed to review the current strategic options to best manage this condition. METHODS: We reviewed the English-language literature from 1966 to 2006, using PUBMED, targeting Crohn's disease involving vagina using key words "rectovaginal fistula and CD," "anovaginal fistula and CD," "anovaginal fistula," and "rectovaginal fistula." We excluded the involvement of the vagina from a pouch after a proctectomy. A total of 776 articles were found; 206 articles were identified and judged as being relevant on the basis of title-related articles and links were reviewed. Fifty-three articles were selected after reading the abstract or full manuscript. RESULTS: The management of rectovaginal fistula, representing 9 percent of all fistulas, remains a challenge in the setting of Crohn's disease. Medical treatments are not favorable with low rates of long-term symptomatic control and unacceptable high rates of recurrence. Several novel and new surgical techniques have been described, and rectal advancement flap, in selected patients, seems to have the most successful results. CONCLUSIONS: The management of rectovaginal fistula of Crohn's origin should involve both gastroenterologists and coloproctologists, with the best surgical results being achieved in patients receiving optimum medical therapy. More focused studies targeting these patients with the use of combined medical and surgical therapy are necessary.

Gasless laparoscopic gastrostomy.

Percutaneous endoscopic gastrostomy (PEG) is the procedure of choice in the nutritional management of patients requiring gastrostomies. Laparoscopic gastrostomy is usually performed when PEG is contraindicated, for example, in patients with esophageal strictures, large gastric tumors, or a history of multiple abdominal surgery. We report herein a case of gasless laparoscopic gastrostomy performed for carcinoma associated with a severe respiratory distress syndrome in a malnourished patient with a tight esophageal stricture. The gasless technique uses the Laparolift System (Laparolift, Origin Medsystem, Inc.), a device composed of a fan-shaped retractor and a mechanical lifting arm that produces an abdominal wall distention resembling a truncated pyramid. Gasless laparoscopy was a safe alternative approach to CO2 pneumoperitoneum in this patient.