The role of routine groin ultrasonography in the management of inguinal hernia.

BACKGROUND: Groin ultrasonography (US) has been used as an adjunct to inguinal hernia diagnosis, but there is limited evidence as to whether its use affects surgical decision-making. The primary aim of this study was to examine whether groin US affects surgical management of inguinal hernia; the secondary goal was to estimate the frequency of groin US ordered before surgical consultation. METHODS: We performed a retrospective chart review of 400 consecutive patients aged older than 18 years referred to 1 of 4 general surgeons in Calgary, Alberta, for inguinal hernia between January 2014 and January 2015. Bilateral groin examinations were entered as separate entries into the database. Outcomes assessed included the frequency of groin US examinations performed within 1 year before the general surgery consultation, presence of inguinal hernia on clinical examination (CE), presence of inguinal hernia on groin US, and whether the hernia proceeded to herniorrhaphy. RESULTS: A total of 476 groins in the 400 patients (354 [88.5%] male; mean age 53.5 yr [standard deviation 15.2 yr]) were evaluated for a hernia during the study period. Groin US was performed before general surgery consultation in 336 cases (70.6%). Overall, 364 (76.5%) of the hernias were clinically palpable; of the 364, 220 (60.4%) had preconsultation US, even in the presence of a positive CE finding. Of the 112 groins that did not have a clinically palpable hernia, 103 (92.0%) underwent preconsultation US. Of the 476 groins, 315 (66.2%) underwent inguinal hernia repair: 310 (85.2%) of the 364 with clinically palpable hernias and 5 (4.8%) of the 103 with clinically negative findings but positive groin US findings. Surgical decision-making based on CE findings occurred in 390 cases (81.9%) overall, whereas surgery based on groin US findings alone occurred in 5 of 336 cases (1.5%). CONCLUSION: Routine groin US was frequently performed before general surgery consultation, whether a hernia was detectable on clinical examination or not. Positive groin US results alone infrequently affected whether the patient proceeded to surgery. Clinical examination findings played a larger role in surgical decision-making than groin US results. Eliminating the practice of routine groin US may provide considerable health care cost savings.

Is an optical illusion the cause of classical bile duct injuries?

We sought to determine if lateral-inferior traction on the Hartmann pouch could produce bile duct kinking and subsequent misinterpretation of the space on the left side of the bile duct as the hepatobiliary triangle. Once traction was applied, we measured the angle between the cystic duct and inferior gallbladder wall hepatobiliary triangle) in 76 cases, and the angle between the common bile duct and common hepatic duct (porta hepatis "triangle") in 41 cases. The mean angles were significantly different (hepatobiliary triangle mean 68.2°, standard deviation [SD] 16.0°, range 23-109°; porta hepatis "triangle" mean 112.0°, SD 18.4°, range 72-170°; p < 0.01). The ranges, however, overlapped in 26 cases. In many cases, lateral-inferior traction on the Hartmann pouch produced substantial kinking of the bile duct that could easily elicit the illusion that it is the hepatobiliary triangle rather than the centre of the porta hepatis.

Prevalence of anatomic landmarks for orientation during elective laparoscopic cholecystectomies.

BACKGROUND: We sought to determine the prevalence of common anatomic landmarks around the gallbladder that may be useful in orienting surgeons during laparoscopic cholecystectomy. METHODS: The subhepatic anatomy of 128 patients undergoing elective cholecystectomy was recorded. We searched and recorded the presence of five anatomic landmarks: the bile duct (B), the Sulcus of Rouviere (S), the left hepatic artery (A), the umbilical fissure (F), and the duodenum (E). These are the previously described B-SAFE landmarks. RESULTS: We found that the duodenum and umbilical fissure were present reliably in almost all patients. The position of the left hepatic artery could be reliably determined by its pulsation in 84% of patients. A portion of the bile duct could be seen in 77% and the Sulcus of Rouviere was present in 80%. Furthermore, the hepatobiliary triangle was always found superior or at the same level as the Sulcus of Rouviere. CONCLUSIONS: We found that these five anatomic landmarks were reliably present. This suggest that using the B-SAFE landmarks may allow a surgeon to more easily orient before and during laparoscopic cholecystectomy and prevent bile duct injuries.

Gastric cancer management in elderly patients: a population-based study of treatment patterns and outcomes in gastric cancer patients ≥ 75 years from Alberta, Canada.

BACKGROUND: As Canada's population ages, incidence of gastric cancer in elderly patients is increasing. There is little data on treatment and outcomes of gastric cancer in patients older than age 75. This study aimed to assess treatment patterns and outcomes of non-metastatic elderly gastric cancer patients in Alberta, Canada. METHODS: Records of elderly patients (age 75 or older) diagnosed with localized gastric or gastroesophageal junction cancer between 2007 and 2012 who received curative intent surgery were retrospectively collected from the Alberta Cancer Registry. A chart review was completed to gather demographics; treatment details of surgery, chemotherapy, and radiotherapy; and outcomes. Descriptive analyses were undertaken, and variables were compared with parametric and nonparametric tests where appropriate. RESULTS: 130 predominantly male (69%) patients, median age 80 (range 75-96) were included. 17 patients (13%) received multimodality therapy. 115 (88.5%) had negative margins on final pathology. Mean lymph nodes retrieved were 16 (range 0-43). 46 surgical patients (35.4%) had grade II or higher complications. 13 patients had a perioperative death (Clavien grade V). Four (3.1%) patients completed perioperative chemotherapy, and 13 (10%) patients had adjuvant chemo/radiotherapy. 50 (38.5%) recurred at median 13 months, while 80 (61.5%) did not have a recurrence of their cancer at any time during follow up. The 5 year DFS for the surgery only group was 67.3% and multimodality group was 52.9% (p = 0.25). The 5 year OS for the surgery only group was 38.9% and multimodality group was 47.1% (p = 0.52). CONCLUSIONS: Our findings suggest that even with surgery alone, selected elderly patients with non-metastatic gastric cancer can obtain apparent prolonged survival, despite not receiving standard of care multimodality therapy. More studies are needed to optimise elderly patients' treatment selection.