Perforation Peritonitis and the Developing World

Background. Perforation peritonitis is the one of the commonest emergency encountered by surgeons. The aim of this paper is to provide an overview of the spectrum of perforation peritonitis managed in a single unit of a tertiary care hospital in Delhi. Methods. A retrospective study was carried out between May 2010 and June 2013 in a single unit of the department of Surgery, Lok Nayak Hospital, Delhi. It included 400 patients of perforation peritonitis (diffuse or localized) who were studied retrospectively in terms of cause, site of perforation, surgical treatment, complications, and mortality. Only those patients who underwent exploratory laparotomy for management of perforation peritonitis were included. Results. The commonest cause of perforation peritonitis included 179 cases of peptic ulcer disease (150 duodenal ulcers and 29 gastric ulcers) followed by appendicitis (74 cases), typhoid fever (48 cases), tuberculosis (40 cases), and trauma (31). The overall mortality was 7%. Conclusions. Perforation peritonitis in India has a different spectrum as compared to the western countries. Peptic ulcer perforation, perforating appendicitis, typhoid, and tubercular perforations are the major causes of gastrointestinal perforations. Early surgical intervention under the cover of broad spectrum antibiotics preceded by adequate aggressive resuscitation and correction of electrolyte imbalances is imperative for good outcomes minimizing morbidity and mortality.

Pathology Slide Review in Vulvar Cancer Does Not Change Patient Management

Hypothesis. Pathology slide review in vulvar cancer is only necessary in a restricted number of cases. Methods. A retrospective chart review of all cases of vulvar cancer treated in a tertiary centre between January 1, 2000, and April 1, 2006. Histopathology reports from the referring and tertiary centre were compared. Results. 121 pathology reports from 112 patients were reviewed. Of the original reports, 56% were deemed adequate, commenting on tumor type and depth of infiltration; of the reviews, 83% were adequate. Conclusion. There were no discrepancies that influenced patient management. We suggest that vulvar cancer biopsies need to be reviewed only when the tumor is less than 10 mm in linear extension, when the infiltration is 1 mm or less, when there is no residual tumor on inspection, and in any nonsquamous cancer.

An Audit of Operating Room Time Utilization in a Teaching Hospital: Is There a Place for Improvement?

Aim. To perform a thorough and step-by-step assessment of operating room (OR) time utilization, with a view to assess the efficacy of our practice and to identify areas of further improvement. Materials and Methods. We retrospectively analyzed the most ordinary general surgery procedures, in terms of five intervals of OR time utilization: anaesthesia induction, surgery preparation, duration of operation, recovery from anaesthesia, and transfer to postanaesthesia care unit (PACU) or intensive care unit (ICU). According to their surgical impact, the procedures were defined as minor, moderate, and major. Results. A total of 548 operations were analyzed. The mean (SD) time in minutes for anaesthesia induction was 19 (9), for surgery preparation 13 (8), for surgery 115 (64), for recovery from anaesthesia 12 (8), and for transfer to PACU/ICU 12 (9). The time spent in each step presented an ascending escalation pattern proportional to the surgical impact P=0.000, which was less pronounced in the transfer to PACU/ICU P=0.006. Conclusions. Albeit, our study was conducted in a teaching hospital, the recorded time estimates ranged within acceptable limits. Efficient OR time usage and outliers elimination could be accomplished by a better organized transfer personnel service, greater availability of anaesthesia providers, and interdisciplinary collaboration.

Three Ports Laparoscopic Resection for Colorectal Cancer: A Step on Refining of Reduced Port Surgery

Background. Reduced port surgery (RPS) is becoming increasingly popular for some surgeries. However, the application of RPS to the field of colectomy is still underdeveloped. Patients and Methods. In this series, we evaluated the outcome of laparoscopic colorectal resection using 3 ports technique (10 mm umbilical port plus another two ports of either 5 or 10 mm) for twenty-four cases of colorectal cancer as a step for refining of RPS. Results. The mean estimated blood loss was 70 mL (40–90 mL). No major intraoperative complications have been encountered. The mean time for passing flatus after surgery was 36 hours (12–48 hrs). The mean time for oral fluid intake was 36 hours and for semisolid food was 48 hours. The mean hospital stay was 5 days (4–7 days). The perioperative period passed without events. All cases had free surgical margins. The mean number of retrieved lymph nodes was 14 lymph nodes (5–23). Conclusion. Three ports laparoscopy assisted colorectal surgeries looks to be safe, effective and has cosmetic advantages. The procedure could maintain the oncologic principles of cancer surgery. It’s a step on the way of refining of reduced port surgery.

Quantification of Protoporphyrin IX Accumulation in Glioblastoma Cells: A New Technique

Introduction. 5-Aminolevulinic Acid (5-ALA) is a precursor of heme synthesis. A metabolite, protoporphyrin IX (PpIX), selectively accumulates in neoplastic tissue including glioblastoma. Presurgical administration of 5-ALA forms the basis of fluorescence-guided resection (FGR) of glioblastoma (GBM) tumors. However, not all gliomas accumulate sufficient quantities of PpIX to fluoresce, thus limiting the utility of FGR. We therefore developed an assay to determine cellular and pharmacological factors that impact PpIX fluorescence in GBM. This assay takes advantage of a GBM cell line engineered to express yellow fluorescent protein. Methods. The human GBM cell line U87MG was transfected with a YFP expression vector. After treatment with a series of 5-ALA doses, both PpIX and YFP fluorescence were measured. The ratio of PpIX to YFP fluorescence was calculated. Results. YFP fluorescence permitted the quantification of cell numbers and did not interfere with 5-ALA metabolism. The PpIX/YFP fluorescence ratio provided accurate relative PpIX levels, allowing for the assessment of PpIX accumulation in tissue. Conclusion. Constitutive YFP expression strongly correlates with cell number and permits PpIX quantification. Absolute PpIX fluorescence alone does not provide information regarding PpIX accumulation within the cells. Our research indicates that our PpIX/YFP ratio assay may be a promising model for in vitro 5-ALA testing and its interactions with other compounds during FGR surgery.

Prognostic Value of Mandard and Dworak Tumor Regression Grading in Rectal Cancer: Study of a Single Tertiary Center

Goal. To evaluate the prognostic value of Mandard and Dworak grading systems regarding neoadjuvant chemoradiotherapy (CRT) response on rectal cancer. Materials and Methods. We queried our center’s database for patients with colo rectal cancer with locally advanced rectal cancer (LARC) who received neoadjuvant CRT followed by total mesorectum excision (TME) between 2003 and 2011. After excluding 18 patients from the initial query the remaining 139 were reassessed for disease recurrence and survival; the specimens’ slides were reviewed and classified according to two tumor regression grading (TRG) systems: Mandard and Dworak. Based on these TRG scores, two patient groups were created: patients with good response versus patients with bad response (Mandard TRG1+2 versus Mandard TRG3+4+5 and Dworak TRG4+3 versus Dworak TRG2+1+0). Overall survival (OS), disease-free survival (DFS), and disease recurrence were then evaluated. Results. Mean age was 64.2 years and median follow up was 56 months. No significant survival difference was found when comparing patients with Dworak TRG 4+3 versus Dworak TRG2+1+0 (P=0.10). Mandard TRG1+2 presented with significantly better OS and DFS than Mandard TRG3+4+5 (OS P=0.013; DFS P=0.007). Conclusions. Mandard system provides higher accuracy over Dworak system in predicting rectal cancer prognosis when neoadjuvant CRT is applied for tumor regression.

Randomized, Controlled Comparison of Advanced Hemostatic Pads in Hepatic Surgical Models

Blood loss during hepatic surgery leads to poor patient outcomes. This study investigates the hemostatic efficacy of a novel sealing hemostatic pad (polyethylene glycol-coated collagen, PCC) and a fibrin sealant pad (fibrin-thrombin coated collagen, FTC) in a leporine hepatic segmentectomy and a porcine hepatic abrasion model. A segmentectomy was used to compare hemostatic success and hematoma incidence in 20 rabbits (10/group). Hepatic abrasions were used to compare hemostatic success up to 10 min after application in six pigs (42 lesions/group). In the segmentectomy model, PCC achieved 100% hemostatic success within 2 min (95% CI: 72.3% to 100%) and FTC achieved 80% hemostatic success within 3 min (49.0% to 94.3%). PCC had lower hematoma incidence at 15 min (0.0 versus 11.1%) and 24 h (20.0 versus 66.7%). In the abrasion model, PCC provided superior hemostatic success at 3 (odds ratio: 24.8, 95% CI: 8.86 to 69.2, P<0.001), 5 (66.3, 28.5 to 153.9, P<0.001), 7 (177.5, 64.4 to 489.1, P<0.001), and 10 min (777.6, 148.2 to 4078, P<0.001) leading to statistically significant less blood loss. The novel sealing hemostat provides faster and more sustained hemostasis than a fibrin sealant pad in a leporine hepatic segmentectomy and a porcine hepatic abrasion model of hepatic surgery.

Fibrin Sealant: The Only Approved Hemostat, Sealant, and Adhesive—a Laboratory and Clinical Perspective

Background. Fibrin sealant became the first modern era material approved as a hemostat in the United States in 1998. It is the only agent presently approved as a hemostat, sealant, and adhesive by the Food and Drug Administration (FDA). The product is now supplied as patches in addition to the original liquid formulations. Both laboratory and clinical uses of fibrin sealant continue to grow. The new literature on this material also continues to proliferate rapidly (approximately 200 papers/year). Methods. An overview of current fibrin sealant products and their approved uses and a comprehensive PubMed based review of the recent literature (February 2012, through March 2013) on the laboratory and clinical use of fibrin sealant are provided. Product information is organized into sections based on a classification system for commercially available materials. Publications are presented in sections based on both laboratory research and clinical topics are listed in order of decreasing frequency. Results. Fibrin sealant remains useful hemostat, sealant, and adhesive. New formulations and applications continue to be developed. Conclusions. This agent remains clinically important with the recent introduction of new commercially available products. Fibrin sealant has multiple new uses that should result in further improvements in patient care.

Consenting Operative Orthopaedic Trauma Patients: Challenges and Solutions

Guidelines exist to obtain informed consent before any operative procedure. We completed an audit cycle starting with retrospective review of 50 orthopaedic trauma procedures (Phase 1 over three months to determine the quality of consenting documentation). The results were conveyed and adequate training of the staff was arranged according to guidelines from BOA, DoH, and GMC. Compliance in filling consent forms was then prospectively assessed on 50 consecutive trauma surgeries over further three months (Phase 2). Use of abbreviations was significantly reduced (P=0.03) in Phase 2 (none) compared to 10 (20%) in Phase 1 with odds ratio of 0.04. Initially, allocation of patient’s copy was dispensed in three (6% in Phase 1) cases compared to 100% in Phase 2, when appropriate. Senior doctors (registrars or consultant) filled most consent forms. However, 7 (14%) consent forms in Phase 1 and eleven (22%) in Phase 2 were signed by Core Surgical Trainees year 2, which reflects the difference in seniority amongst junior doctors. The requirement for blood transfusion was addressed in 40% of cases where relevant and 100% cases in Phase 2. Consenting patients for trauma surgery improved in Phase 2. Regular audit is essential to maintain expected national standards.

The Presence of Mutations in the K-RAS Gene Does Not Affect Survival after Resection of Pulmonary Metastases from Colorectal Cancer

Introduction. Our objective was to identify mutations in the K-RAS gene in cases of pulmonary metastases from colorectal cancer (CRC) and determine whether their presence was a prognostic factor for survival. Methods. We included all patients with pulmonary metastases from CRC operated on between 1998 and 2010. K-RAS mutations were investigated by direct sequencing of DNA. Differences in survival were explored with the Kaplan-Meier method log-rank tests and multivariate Cox regression analysis. Results. 110 surgical interventions were performed on 90 patients. Factors significantly associated with survival were disease-free interval (P=0.002), age (P=0.007), number of metastases (P=0.001), lymph node involvement (P=0.007), size of the metastases (P=0.013), and previous liver metastasis (P=0.003). Searching in 79 patients, K-RAS mutations were found in 30 cases. We did not find statistically significant differences in survival (P=0.913) comparing native and mutated K-RAS. We found a higher rate of lung recurrence (P=0.040) and shorter time to recurrence (P=0.015) in patients with K-RAS mutations. Gly12Asp mutation was associated with higher recurrence (P=0.022) and lower survival (P=0.389). Conclusions. The presence of K-RAS mutations in pulmonary metastases does not affect overall survival but is associated with higher rates of pulmonary recurrence.