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Journal of Surgery: Open access

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1 Collaboration-The Key to Meaningful Plastic Surgery Research , Umar Choudry
Does the use of post-operative antibiotics decrease the risk of infections in implant-based breast reconstruction? Does the use of acellular dermal matrix increase the risk of infections? Does every patient undergoing a cosmetic abdominoplasty need venous thromboembolism chemoprophylaxis? The list goes on. We still don’t have a good answer to many important clinical questions in plastic surgery because we don’t have convincing data that categorically answers them
2 The Best Exposure of the Mitral Valve: The Pulmonary Veins Isolation Approach , Ovidio A Garcia-Villarreal
Optimal exposure is one of the key factors for a successful MV surgery. Because the left atrium is located at the back of the heart, MV exposure may be very difficult. This article describes an approach which consists in sectioning the antrum of the pulmonary veins. By rotating and pulling out the heart, the mitral valve can be fully exposed. This technique is highly recommended for those cases with small left atrium.
3 Forgotten Intrauterine Contraceptive Device - An Unusual Cause Of Enterouterine Fistula , Abhay Y Desai , Dnyaneshwar S , and Vishwas D Pai
Intrauterine contraceptive device is one of the most popular forms of reversible contraception. Though considered as a safe method, uterine perforation and migration of IUCD into the peritoneal cavity or invasion into one of the adjacent viscera has been reported in English literature. We are presenting the case of an elderly lady presenting with persistent vaginal discharge which on investigations was found to be due to enterouterine fistula. As the lady had forgotten about the IUCD placed more than 20 year back, diagnosis could only be established only on examination of the resected specimen of entero uterine fistula. This case stresses the importance of creating awareness among the users of IUCD regarding the need for periodic examination to confirm the normal position of IUCD as well as its timely removal once family is complete.
4 Giant Parovarıan Cyst: A Case Report , Volkan Sarper Erikci, Demet Payza and Münevver Hoşgör
Giant parovarian cysts in adolescents are rare clinical entities. They usually arise in the broad ligament predominantly from mesothelium covering the peritoneum but may also be observed between the fallopian tube and ovary. Although they are usually asymptomatic, symptoms due to pressure effect to neighbourhood organs or symptoms due to complications such as enlargement, torsion, perforation and hemorrhage may also be observed.
5 A Case of an Endovascular Stent-Graft Infection Presenting as a Psoas Abscess , C Swain and S Ashley
Case report: A patient with history of endovascular aortic aneurysm repair and urosepsis presenting systemically unwell with hip pain, later diagnosed as a psoas abscess communicating with the aneurysmal sac. Conclusion: There is a relationship between urosepsis and stent graft infection. Interventional procedures require careful planning and there is a role for prophylactic antibiotics. Surgeons should be vigilant to the possibility of late onset infection of variable presentation.
6 Splenogonadal Fusion: Laparoscopic Diagnosis and Treatment , Mustafa Erman Dörterler, Mehmet Emin Boleken and Kemal Deniz
Splenogonadal fusion (SGF) is a rare congenital anomaly in which the spleen is connected to the gonad. Two types of SGF have been described: continuous and discontinuous. SGF is frequently associated with cryptorchidism or congenital orofacial/limb anomalies. We herein present a case involving a 7-year-old boy who underwent surgical repair of an undescended left testis. When laparoscopy was performed intra operatively because of bleeding, the patient was diagnosed with SGF and laparoscopically treated accordingly.
7 NK-Cell Lymphoma Involving the Parotid Gland: A Rare Case , Merih Onal, Gultekin Ovet, Esra Yılmaz and Necat Alatas
Malignancies arising from putative natural killer (NK) cells are recently recognized distinct lymphoma subtype. Clinically, these lymphomas present most commonly as destructive lesions in the nasal cavity and other midline facial structures. Lymphomas of putative NK cells occur primarily in nonnasal areas including skin, gastrointestinal tract, salivary gland, testis and muscle. The molecular mechanisms leading to malignant transformation of NK cells remain undefined but one of the pathogenetic association is EBV infection. Lymphoma infiltration is seen with prominent necrosis and vascular destruction. Although the clinicopathological features of NK cell lymphomas are well defined, the optimal therapy and treatment outcomes are unclear. Unfortunately, the treatment of NK cell lymphoma has been unsatisfactory. Conventional chemotheraphy treatment regimens have resulted in very poor complete remission rates and long-term survival. Here we presented an unusual case of NK cell lymphoma involving the parotid gland.
8 Post-liver Transplantation Pancreatic Pseudocyst without Pancreatitis , Francesco Caruso, Marco Nencioni, Andrea Chierici, Giorgio Rossi and Lucio Caccamo
Pancreatic pseudocysts rarely complicate acute pancreatitis after liver transplantation. We describe a case of post-transplant pancreatic pseudocyst occurring in the absence of pancreatitis. A 53-year-old post-hepatitis C cirrhotic man with no history of pancreatic or biliary abnormalities underwent liver transplantation. However, at the time of surgery, a T-tube cholangiogram revealed a mild dilation of the native bile duct and, two months later, a large pancreatic pseudocyst was diagnosed and surgically resected. After two years, biochemical cholestasis developed and a liver biopsy showed biliary damage. ERCP revealed a stenosis of Vater’s papilla, which was successfully treated by sphincterotomy. Pancreatic pseudocyst may arise as a complication of OLT in the absence of postoperative acute pancreatitis or a history of chronic pancreatitis. In our patient, it is suspected that ampullary dysfunction associated with ischemic pancreatic injury and bacterial infection played a role in generating both the early pancreatic pseudocyst and the late cholestasis.
9 Quick Repair of Medium Sized Umbilical Hernias with a Self Gripping Preperitoneal Mesh , Arkadiusz Peter Wysocki
Introduction: Mesh repair is indicated for medium sized umbilical hernias (larger than 2 – 4 cm). Preperitoneal placement of self gripping mesh would be expected to be difficult due to its self gripping property and the small working space. Method: The author evaluated the time taken to place CovidienParietexProGrip mesh in the preperitoneal plane during adult medium sized umbilical hernia repair. Results: 13 primary umbilical hernias were repaired. Defects ranged between 3 cm and 4 cm. Median mesh diameter was 7 cm. Median time taken to place the mesh was 180 seconds. There have been no recurrences or surgical site complications. Conclusion: With good outcomes, a short learning curve and easy placement, ParietexProGrip mesh is well suited to preperitoneal repair of adult medium sized primary umbilical hernias. Keywords: Umbilical hernia; Repair; Mesh
10 Next Generation Surgeons , Ajay K Khanna, Seema Khanna and Piyush Gupta
Surgery as a discipline has progressed tremendously over the last century. It has been an ever evolving science, achieving feats never imagined before. William Halstead regarded, as one of the founders of the modern surgery had once stated “The future of surgery now, is not what it used to be.”
11 Simulation Based Training and its Role within Foundation Training Programme: Does it Benefit us all? , Gilchrist J, Mirza O, and Kumar BN
Simulation-based training is a form of experiential learning, and can be used to teach basic skills right up to specialized techniques. It is gaining greater acceptance within the medical field after several demonstrated positive studies, and is further supported by similar high-fidelity training platforms used in training other highly-skilled professionals, such as in the field of aviation where great advances in airline safety have been achieved.
12 No Additional Morbidity Associated with Adding Neck Dissection to A Thyroidectomy: A NSQIP Analysis Of 44,887 Patients , Laura Washburn, Ryan Meacham, Aaron Smith, Kevin Shih, Charles Du Qin, Umang Jain, Sujata Saha, Sandeep Samant, and Jon Ver Halen
Background: The potential oncologic benefit of adding neck dissection to thyroidectomy procedures is balanced with a presumed increased morbidity from more extensive surgery. Although there has been some literature documenting the risks of adverse events (AE) from neck dissection in single institutions, there has not been a large volume analysis to investigate this issue. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) 2005–2012 registry was queried to identify all patients undergoing thyroidectomy, with or without associated neck dissection. Patients were propensity-score matched 1:1 for preoperative factors. Outcomes of interest included surgical wound and medical complications, reoperation, and mortality. Univariate and multivariate analyses were utilized to identify predictors of these events. Odds ratios were calculated for adverse events between cohorts. Results: A total of 44,887 patients were identified for analysis. Of these, 38,449 (85.4%) underwent an isolated thyroidectomy (IT) procedure without neck dissection, and 6,438 (14.6%) underwent a thyroidectomy with neck dissection (TND). After matching, there were 4,814 patients found to have similar pre-operative co morbidities, demographics and operative factors. There was a higher rate of overall complications in the IT group (4.25%) than the TND group (3.00%, p<0.001). There was no statistically significant difference in surgical complications. There was, however, a statistically significant increase in medical complications in the IT group (3.83%) over the TND group (2.68%, p=0.005). There was no difference in post-operative mortality between both groups. There was a higher rate of return to the operating room for the IT group (2.54%) compared to the TND group (1.54%, p=0.004). Conclusions: The morbidity and mortality of thyroid surgery is relatively low overall. In this analysis there was no measurable increase in the complications conferred by the addition of a neck dissection. These data are important for patient informed consent, risk stratification, and surgical planning.
13 Frequency of Late Complications After Two Staged Aivar Bracka(AB) Repair of Hypospadias , Habibullah Shah, Uzair Ahmed Qazi , Huma Gul and Saadia Atta Khan
Hypospadias is a congenital anomaly in which due to the incomplete fusion of urethral folds the meatus opens on the ventral surface of the penis. It is the most common congenital malformation of the urethra with the prevalence of 1 in 200-300 live male births. The late complications of two stage AB repair of hypospadias are Urethrocutaneous fistula formation, urethral strictures, meatal stenosis and persistent chordee which occur within 6 weeks after the 2nd stage of the procedure. The aim of the study is to determine the frequency of late complications of two staged AB repair. The rationale of the study is that if the late complications rate of two staged AB repair comes out significantly lower than other studies then it will help reconsider the existing guidelines of hypospadias surgery. Material and methods: This study was conducted at Plastic and reconstructive unit Hayatabad Medical Complex Peshawar for the period of 24 months (from August 2011 to July 2013). The total sample size was 370 patients. More over this was a descriptive cross-sectional study in which non-probability consecutive sampling technique was used. Results: In this study mean age was 3 years with standard deviation ± 1.24. All the patients were male in which 28% patients had Urethrocutaneous fistula, 8% patients had urethral structure. Frequency of complications among 370 patients was analyzed as late complications n=104(28%) patients had Urethrocutaneous fistula, n=30(8%) patients had urethral stricture, n=44(12%) patients had meatal stenosis and n=19(5%) patients had persistent chordee. Conclusion: The most common late complication is Urethrocutaneous fistula and it can be reduced by adding a water proofing layer over the urethroplasty, keeping the suture line of subsequent layers eccentric and meticulous tissue handling under loupe magnification.
14 Octogenarians Experience Outcomes Similar to Other Elderly Patients after Surgery for Acute Ascending Aortic Dissections , W Brent Keeling, Bradley G Leshnower, Edward P Chen, Eric L Sarin, Jose Binongo, Omar M Lattouf, Robert A Guyton, Michael E Halkos and Vinod H Thourani
Introduction: Acute ascending aortic dissection (AAAD) is a potentially lethal disease that affects elderly patients with some frequency. The purpose of this study was to evaluate the short- and mid-term outcomes of elderly patients following surgery for AAAD. Methods: A retrospective review of the local STS database of patients ≥ 60 years of age who underwent surgery for AAAD from 2003-2013 at a US academic center was performed (n=311). Patients were compared based on age groups: 60-69 years (n=183), 70-79 years (n=95) and 80-89 years (n=33). Additionally, chart review based on ICD-9 codes was undertaken to evaluate medically managed patients during the same timeframe. The Social Security Death Index was accessed for survival data. Unadjusted outcomes were compared, and mid-term survival was calculated using Kaplan-Meier curves. Results: Octogenarians had comparable preoperative risk profiles compared to other elderly patients excepting lower body mass index (p=0.006) and underwent similar operations with no difference in concomitant coronary artery bypass grafting (p=0.19), cardiopulmonary bypass time (p=0.75), or aortic cross clamp time (p=0.71). In-hospital mortality rates by age group showed no statistical difference (p=0.69): 60-69 (18.0%), 70-79 (20.0%), and 80-89 (24.2%). There were no survivors in the group of octogenarians who underwent medical management only (0/2, p=0.07). Additionally, rates of postoperative stroke (p=0.73), renal failure (p=0.55), and myocardial infarction (p=0.49) were similar across age groups. Postoperative transfusion requirements were lower in octogenarians: 60-69 (82.0%), 70-79 (84.2%), 80-89 (72.7%) [p=0.34]. Mean 5-year survival was 62.3% for 60-69, 56.7% for 70-79, and 52.2% for 80-89. Mid-term survival was similar across all age groups (p=0.63). Conclusion: Most octogenarians can safely undergo surgery for repair of AAAD with no difference in short-term outcomes compared to other elderly patients. Short-term survival for octogenarians compares favorably to previously published results, and mid-term survival is similar to other elderly patients
15 The Use of An Anthropometric - Based PreOperative System to Choose Implants in Primary Breast Augmentation – An Outcome Analysis , Umar Choudry, Nicholas Kim and Bruce Cunningham
Purpose: Preoperative systems that mathematically select “the one best implant” have been developed. However, they fail to take into account the patient’s desires regarding aesthetic outcome. This prospective study evaluates an anthropometrically-based system, which enables both the surgeon and patient to choose an appropriate implant. Methods: Nine plastic surgeons enrolled every patient operated on for primary breast augmentation from September 2008 - 2010. They based all their implant choices on the described system. Postoperative outcomes in terms of satisfaction and reoperation rates were studied. Results: One hundred and forty two primary breast augmentation patients were enrolled and followed during the 2-year enrollment period. The mean overall and breast size satisfaction rates at the 3-month and 12-month time periods reported by patients were 94.7% and 93.64%, respectively; and by surgeons were 94.86% and 94.84%, respectively. There were no reoperations reported for size change at 5 years. We found that 44 (31%) patients had ≥ 3 high risk factors (HRF) for poor outcome. Eleven (25%) of them had a ≤ 80% satisfaction rate, compared to 8 (8.2%) of the patients who had <3 HRF (p=0.014). Despite this, the vast majority of this difficult patient population (n=33, 75%) had a >80% satisfaction rate with the use of this system. Conclusions: The anthropometrically-based system guided surgeons and patients effectively in choosing implants that resulted in high outcome satisfaction rates and no reoperations for size change. This system was especially successful in difficult cases that have a high risk for poor outcome.
16 Role of Preoperative Biliary Drainage in Resectable Hilar Cholangiocarcinoma , Francesco Caruso, Marco Nencioni, Arianna Zefelippo, Lucio Caccamo, and Giorgio Rossi
Background: To review the literature to investigate indications, advantages and complications of the different procedures for biliary drainage (percutaneous or endoscopic techniques) for resectable hilar cholangiocarcinoma. Methods: Pubmed and Medline databases were interrogated for articles published between January 1970 and November 2014. After screening for relevance, 56 articles were selected for the review. Results: Hilar cholangiocarcinoma is the most common primitive adenocarcinoma of the bile ducts, involving the proximal extra hepatic biliary system. Prognosis has been strongly related to tumour’s resectability and extended combined hepatic and biliary resections are often required in order to achieve radical margin and survival benefit. Obstructive jaundice is the most common clinical presentation; preoperative hyperbilirubinemia is an independent risk factor for increased operative morbidity and mortality. Conclusion: PBD was shown to be helpful only in those patients having a bilirubin level greater than 3-10 mg/dl; we might conclude that PBD is probably useless with bilirubin level below 3 mg/dl, advisable between 3-10 mg/dl and mandatory above 10 mg/dl especially in patients undergoing an extended hepatic resection. In the initial management of HC, ENBD should be preferred as it is characterized by a less invasive approach and less complications (lower morbidity) . In case of suboptimal jaundice regression or in presence of complications PTBD might be combined, leaving EBD as last option. Drain should be limited to FLR. The optimal drain duration is debated: the drain should be left in place the time needed to reduce bilirubin level, meanly 2-6 weeks.
17 Bladder Endometriosis; An Under Diagnosed cause of Bladder Pain Syndrome: Report of Two New Cases Managed with Endoscopic Resection , Rocio Barrabino, Antonio Fernández-Sánchez and Hernani Gil-Julio
Endometriosis is a severely debilitating disease which affects primarily women of reproductive age. Endometriotic nodules involving the urinary tract is less common and can occur in 1–2% of all patients with endometriosis, and affects the bladder in 90% of these cases. In this article we report two cases of bladder endometriosis in two young females who were referred for macroscopic haematuria and the finding of exophytic intravesical lesions by transabdominal ultrasound imaging. In both cases a transurethral resection of the bladder lesions was performed. There was no evidence of symptoms or cystoscopic relapse in the follow-up period.
18 Surgical Management of Benign Tumors of the Heart: A Rare but Important Pathology , Krishna S. Vyas, John Whitaker, and Sibu P. Saha
Objectives: Primary neoplasms of the heart are relatively uncommon, but represent an important cardiovascular pathology since early diagnosis can be curative. The purpose of this study was to share our institutional experience and surgical management of benign cardiac tumors. Methods: In this retrospective chart review of patients, we evaluate the incidence, demographics, clinical presentation, histopathological findings, surgical management, and outcomes of patients undergoing procedures at a single tertiary care center for treatment of benign cardiac tumors from January 2000 to October 2013. Results: 16 patients (4 male and 12 female) with a mean age of 47.3 years (range of 23-79 years) were identified. The most common presenting symptoms were dyspnea (53%), constitutional symptoms (32%), chest pain (26%), and neurological symptoms (16%) and endocarditis (11%). All benign tumors were grossly resected on cardiopulmonary bypass. Myxomas were the most common cardiac tumors, most occurring in the left atrium. There was postoperative mortality. No tumors recurred during our follow-up period. Conclusions: Early clinical suspicion and use of multiple imaging modalities is a key to early diagnosis of benign cardiac tumors. Although these tumors have a risk for severe cardiac and systemic symptoms, referral to experienced centers for prompt surgical resection under cardiopulmonary bypass provides excellent early and long-term results.
19 Surgical Management of Benign Tumors of the Heart: A Rare but Important Pathology , Krishna S. Vyas, John Whitaker, and Sibu P. Saha
Objectives: Primary neoplasms of the heart are relatively uncommon, but represent an important cardiovascular pathology since early diagnosis can be curative. The purpose of this study was to share our institutional experience and surgical management of benign cardiac tumors. Methods: In this retrospective chart review of patients, we evaluate the incidence, demographics, clinical presentation, histopathological findings, surgical management, and outcomes of patients undergoing procedures at a single tertiary care center for treatment of benign cardiac tumors from January 2000 to October 2013. Results: 16 patients (4 male and 12 female) with a mean age of 47.3 years (range of 23-79 years) were identified. The most common presenting symptoms were dyspnea (53%), constitutional symptoms (32%), chest pain (26%), and neurological symptoms (16%) and endocarditis (11%). All benign tumors were grossly resected on cardiopulmonary bypass. Myxomas were the most common cardiac tumors, most occurring in the left atrium. There was postoperative mortality. No tumors recurred during our follow-up period. Conclusions: Early clinical suspicion and use of multiple imaging modalities is a key to early diagnosis of benign cardiac tumors. Although these tumors have a risk for severe cardiac and systemic symptoms, referral to experienced centers for prompt surgical resection under cardiopulmonary bypass provides excellent early and long-term results.
20 Bacterial Profile of Paediatric Burn Wounds and their Antibacterial Sensitivity Patterns , Habibullah Shah, Huma Gul, Rashid khan and Atifullah khan
Objective: To determine the bacterial profile of paediatric burn wounds and their antibacterial spectrum in order to understand and help in planning for better antibiotic selection and overall management. Methods: Retrospective review of prospectively collected data of paediatric age burn patients at Habib Burn Centre Peshawar between January 2013 and December 2015. Culture& sensitivity tests were performed using wound surface swabs and tissue culture over the three-year period. Their results were collected in a predesigned digital form. Statistical analysis was done and results plotted. Results: 1204 (67.8%) patients tested positive with the commonest bacterial isolate of coagulase negative Staphylococcus species (14.5%, n=258), followed in frequency by E. coli (10.7%, n=190), Enterobacter species (9.9%, n=176) and Pseudomonas species (9.6%, n=170). Multidrug resistant Staphylococcus aureus (MRSA) was found in 114 (6.4%) of cases. The most effective antibacterial was Imipenem with a susceptibility rate of 64.3% in 1143 patients. This was followed in efficacy by Tigecycline (63.9%) and Ofloxacin (54.3%). The least effective antibacterial was Cephradine with effectiveness of only 25.4%. Linezolid and Vancomycin were the most effective against MRSA at 91.2% and 100% efficacy. Conclusions: Resistance to antibiotics is rapidly increasing in our community and burn wounds are frequently infected by these multidrug resistant organisms. Careful antibiotic selection and effective control of these strains can be translated into lower morbidity and mortality for these patients.
21 Bacterial Profile of Paediatric Burn Wounds and their Antibacterial Sensitivity Patterns , Habibullah Shah, Huma Gul, Rashid khan and Atifullah khan
Objective: To determine the bacterial profile of paediatric burn wounds and their antibacterial spectrum in order to understand and help in planning for better antibiotic selection and overall management. Methods: Retrospective review of prospectively collected data of paediatric age burn patients at Habib Burn Centre Peshawar between January 2013 and December 2015. Culture& sensitivity tests were performed using wound surface swabs and tissue culture over the three-year period. Their results were collected in a predesigned digital form. Statistical analysis was done and results plotted. Results: 1204 (67.8%) patients tested positive with the commonest bacterial isolate of coagulase negative Staphylococcus species (14.5%, n=258), followed in frequency by E. coli (10.7%, n=190), Enterobacter species (9.9%, n=176) and Pseudomonas species (9.6%, n=170). Multidrug resistant Staphylococcus aureus (MRSA) was found in 114 (6.4%) of cases. The most effective antibacterial was Imipenem with a susceptibility rate of 64.3% in 1143 patients. This was followed in efficacy by Tigecycline (63.9%) and Ofloxacin (54.3%). The least effective antibacterial was Cephradine with effectiveness of only 25.4%. Linezolid and Vancomycin were the most effective against MRSA at 91.2% and 100% efficacy. Conclusions: Resistance to antibiotics is rapidly increasing in our community and burn wounds are frequently infected by these multidrug resistant organisms. Careful antibiotic selection and effective control of these strains can be translated into lower morbidity and mortality for these patients.
22 Minimal Invasive Surgical Release of the Median Nerve at the Wrist: A Study about 36 patients , James YE, Walla A, Abalo A, Akpoto MY, Bakriga B and Dossim MA
Surgical treatment of carpal tunnel syndrome (CTS) has evolved those recent years. Endoscopic and minimal invasive techniques have grown considerably, to limit the incidence of cutaneous complications associated with conventional open surgery, reducing hospitalization time and allow rapid functional recovery of the hand. Purpose: The purpose of this work is to analyze in our practical conditions, the results of surgical treatment of CTS with a minimal invasive technique using a transverse palmar incision made in the wrist crease. Patients and methods: This was a prospective study of 36 patients who underwent surgical treatment by minimal invasive CTS technique. The series consisted of 24 women and 12 men, whose average age was 43 years. 47.22% of patients were hand workers. All patients had a CTS confirmed by electromyography. The intervention took place under loco regional anesthesia with axillary block. All patients have been operated by the same surgeon. For each patient, the same surgical procedure has been applied. After a transverse incision of about 1cm in the crease of the wrist, it was directed anterograde section of flexor retinaculum (RDF) using a special curved bistoury. A simple bandage was made and no immobilization has been made. Results: In the immediate post-operative follow up, local hematoma was found in 04 patients. Locally, the evolution of the scar was favorable in all patients. At 30th day, 34 patients had more functional impairment, or pain in the scar, and had recovered more than 50% grip strength. They could use all their hand for daily activities. At three months, 83% of patients had the same grip strength on both sides. Discussion and conclusion: the interest of this minimal invasive technique is based on the quality of short term postoperative follow up that are more comfortable for the patient, allowing faster functional recovery of the hand, without being more iatrogenic.
23 Adductor Muscle Echinococcosis: A Rare Presentation , Seema Khanna, Satendra Tiwary, Puneet and Ajay K Khanna
Hydatid cyst disease caused by Echinococcus granulosus may at times affect unusual sites and present a diagnostic challenge especially if found at rare locations. A 51 year male presented with a slowly progressive swelling in the upper medial aspect of the left thigh without pain and any discharge.
24 Integrating Surgical Skills into Pre-Clinical Years of Medical School , Vicki Sharma, Christopher Surek, Haley Stewart, Robert Stephens, Barth Wright, Julie Vircks and Erich Wessel
Introduction: Current literature indicates that medical students lack competency and understanding of basic surgical principles when entering clinical rotations. Studies show early surgical exposure can improve student competence and confidence upon entering surgical clerkships. The purpose of this study is to create early exposure to routine operative procedures, surgical anatomy and dissection planes before entering surgical clerkships. Methods: Twenty-one pre-clinical medical students interested in pursuing surgical careers were selected to participate in this study. The course consisted of 3 educational presentations followed by a surgical procedure. The procedures, led by surgical residents, consisted of a skin cancer resection with adjacent tissue flap closure, hysterectomy, and cholecystectomy. All students completed a pre- and post-study competency exam of surgical anatomy and surveys to determine confidence levels with surgical skills. Basic statistics were utilized to evaluate the data. Results: An overall 51% improvement in knowledge of surgical anatomy was shown in the competency exam. In the pre-survey 90% (n=19) reported lack of confidence in suturing and preparedness for clerkships. In the post-survey 95% (n=20) reported confidence in these areas. Also, in the pre-survey 76% (n=16) felt unprepared to handle surgical tools while assisting in surgery. However, post-survey all students reported confidence. All students indicated that the experience reinforced the surgical relevance of gross anatomy and encouraged incorporation of the study into the curriculum. Conclusion: This study improved confidence in pre-clinical medical students understanding of surgical anatomy and basic surgical skills. This may enhance learning and improve performance during surgical clerkships.
25 Integrating Surgical Skills into Pre-Clinical Years of Medical School , Vicki Sharma, Christopher Surek, Haley Stewart, Robert Stephens, Barth Wright, Julie Vircks and Erich Wessel
Introduction: Current literature indicates that medical students lack competency and understanding of basic surgical principles when entering clinical rotations. Studies show early surgical exposure can improve student competence and confidence upon entering surgical clerkships. The purpose of this study is to create early exposure to routine operative procedures, surgical anatomy and dissection planes before entering surgical clerkships. Methods: Twenty-one pre-clinical medical students interested in pursuing surgical careers were selected to participate in this study. The course consisted of 3 educational presentations followed by a surgical procedure. The procedures, led by surgical residents, consisted of a skin cancer resection with adjacent tissue flap closure, hysterectomy, and cholecystectomy. All students completed a pre- and post-study competency exam of surgical anatomy and surveys to determine confidence levels with surgical skills. Basic statistics were utilized to evaluate the data. Results: An overall 51% improvement in knowledge of surgical anatomy was shown in the competency exam. In the pre-survey 90% (n=19) reported lack of confidence in suturing and preparedness for clerkships. In the post-survey 95% (n=20) reported confidence in these areas. Also, in the pre-survey 76% (n=16) felt unprepared to handle surgical tools while assisting in surgery. However, post-survey all students reported confidence. All students indicated that the experience reinforced the surgical relevance of gross anatomy and encouraged incorporation of the study into the curriculum. Conclusion: This study improved confidence in pre-clinical medical students understanding of surgical anatomy and basic surgical skills. This may enhance learning and improve performance during surgical clerkships.
26 Pediatric Ganglion Cysts: Case Series and Review of the Literature , Adam Gendy, Haripriya S Ayyala and Ramazi Datiashvili
Background: Although there is an abundance of information about hand and wrist ganglion cysts in the adult patient population, there is limited data about these lesions in children. The purpose of this article is to present our clinical experience and review the epidemiology, etiological factors, clinical presentation, treatment, and outcomes of pediatric patients with hand and wrist ganglion cysts. Methods: A literature review was thoroughly conducted along with a chart review of all cases of ganglion cysts operated on at a single institution, University Hospital, between May 2014 and October 2015. Results: Five consecutive patients, between ages 2-16 years, who presented with symptomatic lesions of the hand or wrist, underwent treatment by a single surgeon (R.D.). The mean age of patients was 9.4 years, with one of the patients being female. Functional limitation was the most common indication for surgical treatment. Only one patient had a history of previous trauma. In 80% of the cases, the diagnosis was made clinically. The most common site of occurrence was the dorsal wrist (4/5), followed by the volar wrist. Surgical excision was the treatment of choice for all patients that presented with symptomatic lesions (100%). Patients were followed up on one week post-operatively and told to return if they developed any recurrences. Conclusions: While observation has been reported to be worthwhile in the cases of the asymptomatic pediatric hand and wrist ganglia, surgical excision should be employed in those lesions that are symptomatic or do not resolve with observation alone.
27 Pseudoaneurysm of the Breast-A Case Report and Literature Review , Jason Ramsingh, Martin Mariappan, Stephen Henderson, Kyalo Musyoka, Marzi Davies and Mike McKirdy
Triple assessment plays an integral role in the investigation of breast disease. Core biopsy is a useful adjunct as it provides definitive histological diagnosis for many abnormalities detected on clinical examination and mammography. Haematoma formation is a well recognised complication of core biopsy and most tend to resolve with conservative management. Pseudoaneurysm of the breast, while described in the literature, is quite rare and tends to occur following core needle biopsy. Both interventional and surgical options are available for the treatment of these pseudoaneurysms. We present the case of a patient who presented with a pseudoaneurysm of her right breast following core biopsy and discuss her subsequent management.
28 Single-Port Laparoscopy-Assisted Appendectomy in Children: A Method Described , Maria Naredi, Magnus Anderberg, Pernilla Stenström, Einar Arnbjörnsson and Martin Salö
Single-incision laparoscopic appendectomy (SILA) has gained popularity in children, and several different techniques have been described, including intracorporeal and extracorporeal techniques and single-channel and multi-channel single-port techniques. However, there has been a concern that exteriorizing an infected appendix through the umbilical channel would increase the risk of postoperative wound infections. This report aims to describe a technique for single-port laparoscopy-assisted appendectomy (SPLAA) using an operative laparoscope and conventional laparoscopic instruments, as well as a VersaStep™ sheath to protect the wound edge while removing the appendix from the abdomen.
29 Exposure, Exposure, Exposure , Brent Keeling
There have been many different approaches to the mitral valve documented in the cardiac surgical literature. The most commonly employed approaches include the left atrial approach through Sondergaard’s groove and the trans-septal approach. For surgeons seeking to employ complex mitral valve repair techniques, exposure of the entirety of the mitral valve complex is of utmost importance. It is with this import that Dr. Ovidio adds yet another crucial weapon in the practicing surgeon’s armanetarium of exposure of the mitral valve.
30 Case Presentation - Atypical Mycobacterial Cervical Lymphadenitis , Neelam Patel, Ranganathan B, Faris C and Kumar N
Neck lumps are a very common presentation to hospital in pediatric patients. Lymphadenitis secondary to atypical mycobacterium infections are rare but recently there has been an increase in prevalence in the UK. The treatment of such cases is controversial; the options of medical, surgical or combination of both are practiced, with variations, in different centres around the world. We report a case of a 4 year old girl who presented with a short history of a neck lump due to Mycobacterium Avium Complex (MAC) infection which was surgically excised, with good post-op and aesthetic outcome. This article aims to educate upon the background, clinical features and management of patients presenting with MAC associated neck lumps.
31 Foreign Body (Chicken Bone) Leading to Perforation of the Small Bowel within Irreducible Paraumbilical Hernia: Case Report , Mohammad Bukhetan Alharbi
Introduction: Poor chewing process in older people can lead to situations where they do not expel hard food particles like small chicken bones. In cases of abnormal sharp angulation of the chime passage through gut, like paraumbilical hernia, the hard, sharp content of an ingested chicken bone may cause local perforation at the antimesenteric side of the bowel, creating a surgical emergency. Case presentation: We report the case of a 53-year-old female known to have a recurrent paraumbilical hernia. The patient presented to the emergency department with features of incarcerated paraumbilical hernia. Operative findings were a perforation at the antimesenteric side of the small bowel by a chicken bone, contained within the hernia sac, with localized abscess within the hernia sac. The patient was discharged postoperatively in good condition, patient showed uneventful recovery in her outpatient visits afterwards. Conclusion: Small, sharp, difficult-to-digest food particles like chicken bones may cause bowel perforation in irreducible paraumbilical hernias
32 Two Cases with Perforation of the Large Intestine after Upper Gastrointestinal Series with Barium , Miho Tachioka, Masaaki Saito, Iku Abe, Tamotsu Obitsu, Hirofumi Imoto, Soutoku Someya, Daisuke Ishioka, Hirokazu Kiyozaki and Toshiki Rikiyama
Upper gastrointestinal series (UGIS) with barium is a routine investigation, and the incidence of serious complications associated with this procedure is very rare. We report 2 cases of perforation of the large intestine after UGIS with barium, and review relevant literature. Case 1: A 72-year-old woman presented with nausea and vomiting that had started on the 4th day after UGIS with barium. She was brought to our hospital by ambulance. The abdomen was rigid with muscle guarding. Computed tomography (CT) of the abdomen revealed retention of barium in the sigmoid colon, with free air at its periphery. Upon diagnosis of pan peritonitis related to perforation of the digestive tract, emergency partial sigmoidectomy and colostomy were performed on the same day. The patient recovered uneventfully and was discharged on postoperative day 15. Colostomy closure was performed 6 months after the first surgery. Case 2: A 66-year-old woman presented with abdominal pain on the day after UGIS with barium. She was brought to our hospital by ambulance. The abdomen was rigid with muscle guarding. Abdominal CT revealed barium outflow into the abdominal cavity, and free air at its periphery. Upon diagnosis of pan peritonitis related to perforation of the digestive tract, emergency partial sigmoidectomy and colostomy were performed on the same day. Postoperatively, the patient received antimicrobial therapy for protracted fever, and was discharged on postoperative day 24.
33 Breast Implants–Current Insights on a Common Medical Device , Umar Choudry
Breast Implants are one of the most commonly utilized medical prostheses in surgical procedures performed today. The main use is in breast augmentation (enhancing the female breast) and breast reconstruction (recreation of the female breast). Many surgeons and physicians deal with a variety of breast problems ranging from pathology to cosmesis. Having a good understanding of the up-to-date information regarding breast implants is important to deal with questions or concerns from patients when they arise. This review article will highlight some important aspects concerning breast implants; and give a general overview about the manufacturing process and device characteristics, the current issues surrounding implants, and the scope of their use in breast surgery.
34 The 21st Century Silicone Breast Implant , Marcos Sforza, Scott Spear and Dennis Hammond
According to some, conventional anatomically shaped breast implants provide a more natural appearance as compared to round implants. However, despite this possible advantage, three critical drawbacks associated with anatomical implant shave limited their adoption and created concern amongst both plastic surgeons and patients alike: 1. Anatomically shaped breast implants have the potential to rotate and shift thus causing distortion leading to revision surgery and likely implant replacement. Rotation by definition is not an issue with round implants. 2. Macro textured surfaces were developed to improve tissue adherence and reduce the incidence of implant rotation. However, this shift to aggressive macro textured surfaces lead to an unanticipated increase in the occurrence of double capsules and late seroma.
35 The Risk of Spinal Cord Ischemia in ThoracoLumbar Spine Surgery: Attempt to Quantify Predictive Factor , Hallout Sabrina
Background: The anterior spinal network is a major vascular system irrigating more than ¾ of the spinal cord. The origin of Adamkiewicz’s Artery (AKA) is located between the 9th thoracic (T9) segment to the 2nd lumbar (L2) segment, coming from the left side for 85% of cases; between T12- L3 for 84% of cases or between T9-T10 for 50% of cases. The anterior spinal artery’s syndrome (ASA syndrome) is involved in more than 90% of cases of spinal cord ischemia. The spinal cord ischemia remains one of the most serious complications after thoracolumbar spine surgery. It is difficult to quantify the risk depending on the type of surgery, the vertebral level implicated in surgery, the patient’s vascular network. During planification before an elective spine surgery, the patient must receive complete information about potential risk focused on neurological and vascular damage. The objective of this work is to provide a review of the literature relating the frequency to such complications in order to inform as precisely as possible to our patient about the risk of neurologic event. It seems to be difficult to assess the risk of paraplegia during thoracolumbar spine surgery or to predict the neurological impact of an arterial sacrifice of the anterior spinal artery system. Secondary aim of this work is a reporting of the spinal cord ischemia risk factors encountered in spinal surgery in the literature. Methods: The inclusion criteria used are about patients who have suffered from neurovascular complications after thoraco-lumbar spine surgery, in relationship to the anterior spinal vascular system. We used the following key words in English: spinal cord ischemia, vascular surgical procedures, spine surgery and injury of Adamkiewicz’s artery. We focused our review on major spinal surgery series of the literature which described neurologic and/or vascular complications occurring on deformity, tumoral or degenerative indications for spinal surgery. We excluded surgical complications related to traumatic spine, to another artery not directly involved in the anterior spinal network (aorta, iliac artery), to the vascular complications secondary to acute or chronic spinal vasculopathy or any ischemia not induced by spinal surgery. Results: Focusing on spine thoracic vascularization, an area devoided of artery feedings towards the second and the third thoracic segments (T2-T3) is well identified as a high risk of spinal ischemia. If an injury occurred, this area has no vascular suppleance, a possible paraplegia due to hypoperfusion can’t be avoided. The surgical approaches with a higher risk of AKA’s meeting are vertebrectomies for spinal metastasis removing, anterior spinal approaches or transforaminal approach for performing an arthrodesis, surgical approaches for deformity spinal surgery (scoliosis) or herniated disc surgery in thoracolumbar spinal surgery (T7-L4). The rate of neurological complications in spinal surgery is less than 6% depending on the type of surgery. Conclusions: The AKA is considered as a vascular moderator, associated with variation of blood flow from the aorta. It is involved in a spinal vascular network with a large number of anastomosis.
36 Has VATS Become Too Expensive? A Cost Analysis of VATS versus Open Lobectomy in a Canadian Tertiary Care Hospital , Daniel G French and Gordon Buduhan
Background: Video-assisted thoracoscopic surgery (VATS) lobectomy is a minimally invasive anatomic lung resection that has been associated with decreased pain and hospital stay compared to open resection. However, with the higher costs of disposable VATS instruments it is unclear whether or not the overall hospital costs are equivalent. The objectives of this study are to compare the overall in-hospital costs of VATS to open lobectomy and assess the financial impact of performing VATS lobectomy procedures in a Canadian tertiary care hospital. Methods: A retrospective cost analysis was done comparing 78 VATS to 151 open lobectomies. Intraoperative costs, postoperative costs, total costs and length of hospital stay were compared. A regression analysis was done adjusting for age, gender, tumor size and tumor stage. Results: The mean intraoperative, postoperative and total costs for VATS and open lobectomy were $4,770 and $2,166 (p=0.01), $3929 and $5,604 (p<0.0001), and $8,499 and $7,771 (p=0.3), respectively. The median hospital stay for VATS and open lobectomy were 4 and 5 days (p<0.0001), respectively. The mean intraoperative costs of VATS lobectomy in the first and second 39 VATS lobectomies were $4894 and $4246 (p = 0.003), respectively. Conclusions: The total cost of VATS lobectomy is equivalent to open lobectomy. Increased cost of disposables and longer operating time account for higher intraoperative cost of VATS lobectomy. A shorter hospital stay and lack of requirement for the acute pain service (APS) reduce the postoperative cost of VATS. The intraoperative costs of VATS lobectomies decrease with experience.
37 A Solitary Neurofibroma of the Thumb: Literature Review and Case Report , Samantha Zwiebel, Christian Curcio, Laurel Karian, Jennifer Maerki and Ramazi O Datiashvili
Solitary neurofibroma of a digit is a rare presentation. Diagnostic workup of this lesion highlights the wide scope of differential entities. Patients should undergo both imaging studies and biopsy. Ultrasound and MRI can often narrow the differential diagnosis but must be read by a skilled interpreter. Biopsy should always be performed as a seemingly benign lesion may prove to be malignant. Literature review and a case report are presented.
38 Current Opinion on MRONJ , Jeong Keun Lee
Patients on antiresorptive medication have been increasing since the introduction of the bisphosphonates as an effective agent. As an antiresorptive agent bisphosphonate has substantial effect in treatment of osteoporosis, and its antiangiogenic potential renders it a powerful anticancer effect. With all the fantastic effect, it has a critical result of jaw bone necrosis, namely bisphosphonate-related osteonecrosis of the jaw (BRONJ). Although extremely rare, the number of cases reporting this phenomenon is growing worldwide. The special committee dealing with the problem of osteonecrosis found on the jaw bones of patients on bisphosphonate recommends changing the nomenclature BRONJ for medication-related osteonecrosis of the jaw (MRONJ).
39 Medical Management of BPH: Is it the End for Surgical Options , Ajay K Khanna and Piyush Gupta
The concept of medical management of symptomatic benign prostatic hyperplasia (BPH) is not new. It came in the early 80s when for the first time it was noticed that the symptoms attributed to prostatic enlargement could be managed with pharmacotherapy alone. However, marginal improvement in comparison to the surgical options and increasing awareness of the side effects led to a lack of acceptance of pharmacotherapy as a standard of treatment for the next two decades. It was during this time that minimal access surgeries like transurethral resection of prostate also took precedence over open surgeries leading to much safer and faster convalescence; that further hindered the development of medical therapy as the forerunner in the management of BPH for quite some while.
40 360° in Making Acellular and Biocompatible Xenografts for Surgical Applications , Aishwarya Satish, Jaikanth Chandrasekaran, Indhumathi T, Kotturathu Mammen Cherian and Balasundari Ramesh
There goes a famous saying - “We can judge the heart of a man by his treatment of animals”. Now these animals help a man save his heart and vital organs through xenografts. The concept for xenograft is an explosive phenomenon in regenerative and tissue engineering. It has a wide application in many fields of medicine-Cardiology, Orthopedics, Dentistry, Gastrointestinology, Opthalmology and Dermatology. This comprehensive review presents in detail the current methods and procedures followed in the preparation of a xenograft. It helps us in the optimal selection of a suitable method the potential barriers and challenges faced during processing and clinical application with a view towards the future direction.
41 Combination of Glabellar and V-Y Cheek Advancement Flaps for Large Skin Defects of the Medial Canthal Area , Laurel Karian and Ramazi O Datiashvili
Reconstruction of large soft tissue defects of the medial canthal area represents a challenge, because of the thin skin, concave contour, and proximity to important nearby structures. Tension-free closure is important in avoiding distortion of the eyelid and nasal ala. Skin graft closure is not aesthetically appealing, and there are limitations in the use of local tissues for reconstruction. We present our experience (two cases) of reconstruction of very large medial canthal defects with a combination of a V-Y cheek advancement flap and glabellar rotation flap, with satisfactory aesthetic and functional results.
42 The Rate of Neovascular Glaucoma following Pars Plana Vitrectomy for Diabetic Tractional Retinal Detachment , Shyam A Patel and John O Mason III
Purpose: To evaluate the rate and possible risk factors of the development of neovascular glaucoma (NVG) in eyes with pars plana vitrectomy (PPV) for diabetic tractional retinal detachment (TRD). Methods: A retrospective review of 65 eyes from 55 patients who had PPV for diabetic TRD from 2007 to 2014 at the Retina Consultants of Alabama and University of Alabama School of Medicine. Exclusion criteria included history of glaucoma, iris neovascularization, previous vitrectomy, ocular hypertension, and other causes of NVG, such as vein occlusion and ocular ischemia syndrome. Results: The average age of patients studied was 49.8 years, and more than 70% of the eyes studied were affected by diabetes mellitus type 2. 1 (1.5%) of the 65 eyes developed NVG after PPV for diabetic TRD at 6 months, and 7 (10.8%) developed ocular neovascularization (ONV). None of the factors studied showed statistically significant differences between eyes that did not develop ONV to the eyes that did develop ONV. Overall, average best-corrected visual acuity (BCVA) improved from a logMAR of about 1 to 0.8 at 6 months, regardless of ONV. Our one eye with NVG had minimal BCVA improvement at 6 months. Conclusion: With no known risk factors, NVG is a very rare complication in eyes with PPV for diabetic TRD within the first six postoperative months, and BCVA improvement is possible for these eyes.
43 Extranodal NK/T-Cell Lymphoma, Nasal Type (ENKTL) Presenting with Odynophagia , Christopher J Broadfield, Jennifer R M Gilchrist, Vijaya Pothula, Usman Ahmad and B Nirmal Kumar
Odynophagia is a common symptom in both otolaryngology and general practice. We report a case that presented with persistent odynophagia, diagnosed initially as inflammatory after examination and investigations including panendoscopy. Due to persistent symptoms despite medical management, further investigations in the form of scans and biopsies were undertaken. Eventually biopsies were reported as NK/T cell lymphoma, nasal type (ENKTL). We report this unusual case and discuss the literature of extranodal NK/T lymphoma (ENKTL) in head and neck. Clinical awareness of this condition and a high index of suspicion is the key to identifying this insidious but potentially serious disease.
44 Minimally Invasive Hand Surgery and Treatment , Milton B Armstrong, Fernando Herrera and M Lance Tavana
Modern surgery has seen a dramatic change in access to anatomic areas of the body. Much smaller incisions utilizing advanced endoscopic techniques and instrumentation has helped lessen patient morbidity and the need for prolonged hospitalization. As experience is gained in the various techniques, operative times for these operations continue to improve as well. The use of these techniques has quickly become mainstays for surgical procedures in the United States, UK, Canada, Europe, Asia and other counties around the world.
45 Large Omental Cyst-Case Report and Literature Review , Moisés A Perdomo Galván, E Simón Nacif, H Bizueto Rosas, M Romero López, Jorge A Villar-Tapia, M Bárcenas Díaz, J Rivera Bañuelos, Y Gómez Solís, A López Borel, P Cardona Ochoa, O Gutiérrez Olivares and A Jiménez Canet
The following case over view summarizes diagnostic approach of a large omental cyst regarding a 52-year-old male with vague abdominal pain. While most literature reports incidental diagnosis of this pathology, there are clinical and radiologic data which can lead to its consideration as a differential diagnosis. Cyst throughout omental leaves are a rare condition usually found in patients who seek medical attention due to abdominal distention in addition to a painless abdominal tumor. The most frequent sign at the clinical exploration suspecting an omental cyst is described as an abdominal tumor not attached to deep structures. The approach to the diagnosis of an omental cyst incorporates a complete radiologic overview with ultrasonography and CT scan. Full resection of the tumor is established as the therapeutic of choice. CT is a key component in the election of either laparotomy or laparoscopic approach. In our patient, a loculated cystic tumor measuring 23 cm × 25 cm × 9.9 cm was reported in CT scan. Due to the radiologic findings, we opted an open approach. After 5-day surveillance in this unit, the patient was sent home. The tumor was identified as a loculated inclusion-type cyst by histopathology. A 6-month follow-up showed no recurrence of cystic lesions upon radiologic study.
46 A Rare Case of Penis Fracture after Nocturnal Unconscious Manipulation in a Child: A Case Report , Marcos Sforza, Renato Zaccheddu, Bruno Lopes Cancado, and Deborah Sforza
Introduction: The penis fracture is a pathological condition that calls for immediate treatment. Nocturnal penile fracture has previously been described; however, the occurrence of such an event in a child is unprecedented in the current medical literature. Case presentation: In this paper, we present a case of a black child with penis fracture caused by nocturnal unconscious manipulation. The current report delineates the most common aspects of this pathology in addition to its associated surgical treatment. Conclusion: Penile fracture is classified as an emergency condition that cannot be excluded from the differential diagnosis, even at a young age.
47 Serious Open Injury of Elbow: Support Strategy in a Developing Country , Yaovi James, KomlaSena Amouzou, Messanvi Yao Akpoto and Assang Dossim
The elbow bone traumas are very serious lesions that can compromise the function of this joint in the future. These lesions are most severe when there is a defect of bone which affects one component of the joint. We report a case of open trauma of the left elbow from a right-handed girl of 21 years, during an accident on the highway. On admission, the victim had a significant defect of skin-muscle of the anterior medial aspect of the elbow. The exploration revealed a major loss of bone affecting the humeral trochlea which was completely absent. In emergency the patient has benefited from joint stabilization by an external fixation, with a filling-in of the humeral-ulnar joint space with a cement spacer. The loss of muscle substance was filled with a latissimus dorsi flap followed by a skin graft made the days that followed. After a brief review of the literature, the authors emphasize on the need to preserve the joint space through the establishment of the spacer which is the only guarantee for maintaining the stability of the elbow, which also allows considering arthroplasty surgery later.
48 Post-Operative Cervical Subcutaneous Emphysema and Cellulitis following Iatrogenic Oropharyngeal Trauma during Intubation and Microlaryngoscopy: A Rare Complication , R Anmolsingh, O Mirza, V Narayan, J Gilchrist, J Rocke, A Ismail and BN Kumar
Oropharyngeal trauma sustained through instrumentation during laryngoscopy is not uncommon. In most cases this is minor and can be managed conservatively without any significant sequelae. A mucosal breach, however, can lead to subcutaneous emphysema and allow an entry point for pathogens which can track along the cervicofacial planes of the neck. We present a case of cervical subcutaneous emphysema with superadded cellulitis secondary to the use of a postoperative continuous positive airway pressure (CPAP) device following trivial oropharyngeal trauma sustained during an elective microlaryngoscopy. Although there are similar documented cases, reports of this complication following microlaryngeal surgery are rare.
49 Specialised Burn Wound Management and its Outcome: A 3-Year Perspective from a Plastic Surgery Specialist Centre , Habibullah Shah, Huma Gul, M Mukhtar Khan and Rashid Khan
Objective: Specialised burn wound management is the need of the hour. We conducted this study to present our 3-year experience of burn wound management and its outcome from a specialist burn centre in Peshawar Pakistan. Methods: This is a retrospective analysis of prospectively collected data about burn patients who were managed at Habib Burn Centre Peshawar between January 2013 and December 2015 (3 years). Data was collected prospectively about patient demographics, burn types, burn thickness, total burn surface area (TBSA) and the body sites involvement. The outcome was measured in terms of rates of wound healing, the length of stay, early and late complications and mortality. Data was analysed to observe associations between patient and burn characteristics to the outcome parameters. Results: Mean TBSA was 20.83 ± 10.81 SD, mean total healing time was 18.15 days ± 8.50 SD while mean LOS was 9.51 days ± 5.45 SD. On Chi-square analysis for mortality versus burn thickness, no statistical significance was noted (p=0.53, OR: 0.93, 95% CI, 0.73 to 1.18) while mode of treatment (dressing versus grafting) was significantly affected by the thickness of the burn (p<0.001, OR: 0.69, 95% CI, 0.58 to 0.81). TBSA above 40% was strongly associated with mortality as well as with the presence of inhalational injury. TBSA was also associated with prolonged healing times and increased the length of stay (R2 =0.48 and 0.73 respectively). Conclusion: Good outcome can be achieved with antibiotic and silver sulphadiazine dressing technique for partial thickness wounds while those with full thickness or deep partial thickness wounds will ultimately require split skin grafting.
50 Myoepithelioma of the Posterior Oropharyngeal Wall: A Difficult Diagnosis , R Anmolsingh, B Yu, O Mirza, J Rocke, B Ranganathan, A Ismail and BN Kumar
Myoepithelioma is an extremely rare tumour subtype and diagnosis is based on a wide variation of cellular morphology. They are poorly characterised in terms of their clinical behaviour, histopathological appearance and immunochemical profile, which makes their diagnosis and the onward management of a patient challenging. We present a case where the lesion was initially thought to be a paraganglioma, but following a second histological opinion was found to be a myoepithelioma. To the best of our knowledge, this is the first reported case of a myoepithelioma arising from the posterior oropharyngeal wall.
51 Implementing a “One Stop” Consultant Led Ultrasound and Fine Needle Aspiration Service for Thyroid Lumps , John Rocke, Vijay Pothula, Baskaran Ranganathan and Nirmal Kumar
The British Thyroid Association has recently aimed to clarify the management of thyroid lumps. They released guidelines, in 2014, recommending Ultrasound (US) examination in all thyroid lesions and Fine Needle Aspiration Cytology (FNAC) if positive findings are localised. Grading systems for both US and FNA were introduced allowing the clinician to compare these results with clinical findings and determine the most appropriate next step. The current target is 62 days for potential malignant disease from urgent referral to the first definitive treatment. We implemented a “One-Stop” Consultant led US and FNAC service for patients presenting with thyroid lesions to streamline our service and ensure this target is reached. Following this introduction we significantly increased the quality of USS grading and the number of successful FNAC investigations.
52 Surgical Closure of the Left Atrial Appendage. Basal Considerations before attempting with Occluder Devices , Ovidio A Garcia-Villarreal
Despite a lot of publications in favor of left atrial appendage occlusion, basal considerations regarding the closure of the left atrial appendage seem to be missed. Surgical closure of the left atrial appendage is the most direct method to analyze all the most common arising contingencies. The most effective method to achieve a successful left atrial appendage closure is surgical “cut-and-sew” with total removal of the left atrial appendage. Surgical suture exclusion and stapler exclusion show 23% and 0% of success rate, respectively. A high percentage of patients with suture exclusion have persistent flow into the appendage documented by color Doppler (60%), and a high percentage of those with stapler exclusion exhibit a persistent left atrial appendage stump >1 cm (58%). Incomplete closure of the left atrial appendage is an independent predictor of stroke or systemic embolism, and the stroke risk is 5-fold higher than expected. All these data may have important implications for cardiologists regarding left atrial appendages occluder devices.
53 An Unusual Presentation of a Primary Parapharyngeal Space Warthins Tumour , Anmolsingh R, Stobbs N, Izzat M, Pothula V and Kumar BN
Warthin’s tumours of the deep lobe of the parotid gland can present as a parapharyngeal space swelling. This occasionally makes their diagnosis a somewhat significant challenge. We present a rare case of a primary parapharyngeal Warthin’s tumour which presented unusually with a failure of Continuous Positive Airways Pressure (CPAP) therapy due to a choking sensation and excessive saliva production. Examination revealed the cause for the symptoms was due to a large left-sided oropharyngeal swelling, causing displacement of the tonsil and uvula deviation. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) revealed a parapharyngeal space tumour, separate to the deep lobe of the parotid gland and histology found this to be a Warthin’s tumour. This case is the first noted where this is a primary tumour, not connected to the parotid gland. Additionally, this case highlights the importance of a thorough oral cavity and oropharyngeal examination of patients presenting with Obstructive sleep apnoea, prior to commencement of CPAP treatment.
54 Breast Giant Cystic Lymphangioma with An Axillary Origin. A Case Report , Carlos Daniel Gómez-Calvo, Ilich Sandino Ríos-García, Héctor Bizueto-Rosas1, Hugo Alonso Pérez-González, Luisa Fernanda Hernández-Rivera, Rafael Aburto-Pérez and Rafael Armenta-López
Background: Cystic lymphangioma is a rare congenital anomaly that affects children under two years of age. In adults, it´s even more rare, especially in an axillary location. It is related to trauma, infection and has an iatrogenic cause. Case: We report the case of a 26-year-old woman with a history of a left hemithorax hemangioma at age 12, with multiple previous interventions, that at 25 years old, presents sudden growth of the lesion associated with pregnancy. The CT scan ruled out a deep tissue and contralateral breast compromise, so we performed resection with mammoplasty and nipple-areola replantation altogether with the Plastic Surgery department. She was discharged with a closed suction drain. The histopathology conclusion was of cystic lymphangioma and lymph fluid without malignancy data. Conclusions: The diagnosis and treatment of these lesions must be done early, take a multidisciplinary approach and surgical resection is recommended. The MRI imaging is the preferred study of choice.
55 Current State of Training and Evaluation of Laparoscopic Surgical Skills , Sandeep Ganni, Sanne MBI Botden, Benjamin F Hamilton , Arjun S Bedi, Davide Lomanto, Bhaskara Rao G and Jack J Jakimowicz
Objective: The aim of this study is to understand the current state of training practices and evaluation in laparoscopic surgery in a global context. Design: An open-ended three part questionnaire was designed to gather the opinions about the current state of, adequacy of, and the need for a standard in laparoscopic surgical training. Participants: Members of the European Association for Endoscopic Surgery (EAES), Endoscopic and Laparoscopic Surgeons of Asia (ELSA) and Association of Surgeons of India (ASI) were asked to participate in the survey. Results: Of the 663 responses received, 83.6% were surgeons (64.6% in a teaching position) and 12.6% were surgical residents in training. Most respondents (75.4%) had performed over 200 laparoscopic procedures. Most (72.1%) training programs were approved/endorsed by local surgical associations or government health authorities and of the courses taught by surgical associations the majority had certified trainers (71.1%). In lower Human Development Index (HDI) countries significantly less courses are taught by certified trainers (68.2% versus 54.6%, p<0.001). Only 26.8% stated that their respective government health authorities participated in the certification of laparoscopic surgery; certification was considered important by 63.6%. However, only 17.8% of government health authorities contributed to ensure the quality of laparoscopic training, mostly in very high HDI. Only 3.3% of respondents considered the laparoscopic training and education in their country to be optimal and 51.9% rated it insufficient. Most respondents (86.3%) stated that there is a need for the standardization of laparoscopic training and 88.3% stated that standardization of laparoscopic training is important. Conclusion: Regardless of demographic and experience factors, there was a general consensus that that there is a need for standardisation in mandatory training of laparoscopic surgical skills, although currently not obligatory in most countries.
56 Is HMG-Co A Reductase Inhibitor Use Associated with Improved Outcomes in Patients Undergoing Colorectal Cancer Resection? , JJR Richardson, C Roberts-Rhodes, NR Suggett, F Gao-Smith and DR Thickett
Purpose: HMG-CoA reductase inhibitors (statins) modulate the immune system and have anti-inflammatory effects. It has been proposed that their use in the peri-operative period may reduce surgical complications by modulating the post-operative pro-inflammatory response. This study aims to evaluate the effect of statins on surgical outcomes following colorectal cancer resection. Methods: A retrospective analysis of all colorectal cancer resections performed at University Hospital Birmingham, between June 2008 and July 2013, was conducted. Patients were divided into ‘Statin Users’ and ‘Non-statin Users’. Their outcomes and survival were evaluated using univariate, multivariate and cox-regression analysis. Results: 246/703 patients (35.0%) were statin users. There were no differences in disease stage between the groups. Statin users were found to have a higher proportion of colonic, compared to rectal, cancers than non-statin users (60.2% vs. 48.1%, p=0.0023) and a reduced incidence of stoma formation (OR 0.65, 95% CI 0.45-0.95, p=0.0280). Despite significant increases in age, BMI and co-morbidity, statin users had equivalent rates of complications, re-operations, re-admissions and mortality than non-statin users. Statin users were however more likely to be admitted to Critical Care (OR=1.83, 95% CI=1.16-2.87, p=0.0090) and have a prolonged hospital stay (12% increase in LOS, 95% CI=0.002-0.10, p=0.0420). No significant dose related differences were identified in patient outcomes and mortality were observed, although an overall risk reduction in mortality with increasing dose of statin remains possible (HR=0.67, 95% CI=0.41-1.09, p=0.1100). Conclusions: Statin users achieved equivalent short-term and long-term outcomes to non-statin users despite an increased operative risk and their use in the peri-operative period, particularly at high doses, merits further investigation.
57 The Effect of Standardized Order Set for Intravenous Calcium Treatment on the Length of Hospital Stay in Secondary Hyperparathyroidism following Parathyroidectomy. Retrospective Pre-Post Study , Kelsey Hinther, Suzie Harriman, Gary Groot and Judith Klassen
Objective: The objective of this study is to assess if administering a post-operative standardized order set for intravenous calcium treatment for dialysis patients with secondary hyperparathyroidism who have undergone a parathyroidectomy will reduce the length of the hospital stay. Methods: The medical records of dialysis patients who underwent subtotal PTX for symptomatic secondary hyperparathyroidism were reviewed prior to and after the introduction of a standard postoperative order set. The genders, duration of hospital stay as well as readmission rates of all patients were analyzed. Results: The study population included 50 patients, with a mean age of 49 years. 25 patients were administered the standardized order set of intravenous calcium treatment following a subtotal parathyroidectomy. There was no statistical difference (p=0.7063) between the length of hospital stay in the group of the patients that received the post- operative standardized order set of intravenous calcium and the group that did not. Only 1 patient was readmitted during the study period. Conclusion: There was no statistical difference in the length of hospital stay between the dialysis patients with secondary hyperparathyroidism who received the standardized order set of intravenous calcium and the patients who did not following a PTX.
58 Amyand’s Hernia: Report of Three Cases and Review of the Literature , Renato Pricolo, Roberto Accordino, Vincenzo Casaburi, Francesca Abbiati, Angela De Leonardis and Luigi Percalli
Amyand’s hernia is a rare clinical condition. We report three cases of hernias containing a uninflammed appendix. Review of the literature includes an analysis of clinical symptoms, diagnostic findings, and therapeutic options.
59 Giant Colorectal Lipoma of Left Colon: Case Report and Literature Review , Renato Roriz da Silva, Tiago Costa do Amaral and Marcos Alberto de Mendonça Veiga
Lipoma of the colon is a rare type of benign gastrointestinal tumor, occurring in around 0.035-4.4% of the population, according to statistics. In most cases, it is identified by colonoscopy as a yellowish sub epithelial nodule, and has no associated symptoms. This tumor of the colon occasionally produces symptoms, which may be associated with large lesions. The main symptoms are abdominal pain, changes in bowel habits, and lower digestive tract bleeding. Treatment can be performed via colonoscopy or surgical approach. The objective is to report a case of a large, symptomatic giant colorectal lipoma of unusual location (sigmoid colon), and of the treatment performed.
60 An Unsusual Extrapulmonary Neuroendocrine Tumour of Head and Neck , Rajesh Anmolsingh, Rachel Edmiston, Anisa Ali, Paul W Bishop, Anshuman Chaturvedi and Vijay Pothula
Neuroendocrine tumours (NET) of the head and neck are a rare diverse group of tumours. In 2005 World Health Organisation (WHO) Classification of Head and Neck tumours lists 4 types of Neuroendocrine carcinomas: (a) typical carcinoid (b) atypical carcinoid, (c) small cell carcinoma, neuroendocrine type and (d) combined small cell carcinoma, neuroendocrine type with non-small cell carcinoma. There has been considerable debate about non-inclusion of large cell neuro endocrine carcinoma and need for further classification with inclusion of different terminology. We report a case of squamous cell carcinoma of the tongue base with bilateral neck nodes containing NET differentiation of small cell on one side and a large cell on the other. No such case is reported in the literature so far.
61 Continuous Intraoperative Nerve Monitoring during Thyroid Surgery: Realistic Utility , Giuditta Mannelli, George Mochloulis, Owain Rhys Hughes, Oreste Gallo and Roberto Santoro
Objectives: Intraoperative nerve monitoring (IONM) with intermittent stimulation, can predict recurrent laryngeal nerve injury after the damage has been already done; on the other hand, continuous IONM (CIONM) via stimulation of the vagus nerve (VN) by the automated periodic stimulation (APS) electrode, should permit more reliable monitoring of the nerve’s functional integrity during surgery. Methods: The advantages CIONM offers over its intermittent counterpart are indeed related to its ability to provide accurate and real-time feedback to enable the surgeon to act before damage has been inflicted on the nerve. Furthermore, these characteristics do not compromise safety and effectiveness of the surgical procedure. Results: The indications for its use have been progressively expanding, despite the still living surrounding skepticism, and recurrent thyroid disease, thyroidectomy with neck dissection, pre-existing unilateral vocal cord paralysis, previous neck treatment and high risk for intraoperative hemorrhage, represent the main situations with strong indications for CIONM use. Conclusions: This article provides a detailed description of this effective, patient’s safety tool. Here we enclose IONM with APS technical and practical steps, in order to give the idea of a clear awareness of its benefits and to encourage surgeons to widen their skills and knowledge about its potential use.
62 Urinary Bladder and Left Hypogastric Artery Paraganglioma. A Case Report and Literature Review , Héctor Bizueto-Rosas, Hugo Alonso Pérez-González, Carlos Daniel GómezCalvo, Luisa Fernanda Hernández-Rivera, Rafael Aburto-Pérez, Rafael ArmentaLópez, Javier Ismael Hernández-Vázquez, Gloria Selene López-Arce, Carla Isabel Moreno-Ramírez, Rodrigo Marcelo Maitret-Velázquez, Perla Elín Leyva-Rivera, Nayely Leticia Jiménez-Tejeda, Martha Carolina Rosales-Ramos, Delio Felipe Martínez-Blanco and Noemí Antonia Hernández- Pérez
Objective: We report the case of a 77-yeard old female with history of urinary bladder paraganglioma that during follow-up was diagnosed with a tumor in the left hypogastric artery. Introduction: Paragangliomas are tumors that can be found in the cervical, thoracic, and abdominal spaces. Distal locations surrounding arterial structures such as the aortic bifurcation or iliac arteries are rare, as is the involvement of other pelvic organs like the urinary bladder. Iliac artery and urinary bladder paragangliomas can be considered as paragangliomatosis, or metastasis of each other. The preferred study to locate the non-adrenal paraganglioma is Magnetic Resonance Imaging (MRI). Stage T2 has an excellent definition of size, vascular relationship and metastasis location, being sensible up to 100%. Scintigraphy using I-131-metaiodobenzylguanidine (I-MIBG) has a sensibility of 95% and specificity of 100%, useful at metastasis detection. Surgical resection is the preferred treatment. Pre-operative preparation involving imaging study and pre-medication is vital to avoid hypertensive crisis or vascular collapse due to ceased catecholamine production, as most tumors are functional. Discussion: Being a rare disease there is no standard surgical approach; partial or radical cystectomy, with lymphadenectomy, is recommended depending on size, location and surrounding tissue involvement. Conclusion: Determination of catecholamine levels is vital in asymptomatic patients. Levels of metanephrines serum is the most sensitive and specific test. Genetic study in multiple paraganglioma is mandatory. MRI is the preferred location study
63 Blunt Diaphragmatic Rupture Involving the Esophageal Hiatus: Case Report of an Extremely Rare Situation , Mohamed Hamid, Youssef Chaoui, Mohamed Mountasser, Anas Majbar, Farid Sabbah, Mohammed Raiss, Abdelmalek Hrora, Mouna Alaoui and Mohammed Ahallat
Acute traumatic diaphragmatic rupture in blunt trauma is a rare entity. The crural extension of a hemidiaphragmatic tear been reported only once. The aim of this study is to report a case of a blunt diaphragmatic rupture involving the esophageal hiatus. ] Case: A 27-year-old male, a truck driver, was admitted to the emergency department following a violent road traffic accident causing a blunt thoraco-abdomino-pelvic trauma. After stabilization of the patient, a radiological evaluation showed a complex fracture of the pelvis and left clavicle, and a left lung contusion. Seventy-two hours later, the patient presented an uncontrollable vomiting and respiratory distress. A new CTscan revealed a left diaphragmatic rupture. An emergency surgery was performed. After a midline laparotomy, exploration revealed a large central tear of the left hemidiaphragm. The stomach, transverse colon and greater omentum had herniated through the defect into the left hemithorax. The diaphragmatic defect was repaired. During a final exploration of the abdomen, the left triangular and falciform ligaments were divided by electrocautery while caudal traction was placed on the liver. A second rupture involving the esophageal hiatus was identified. It was repaired and the esophageal hiatus reconstructed using interrupted silk sutures. Postoperatively, the patient was managed in the intensive care unit for 4 days. Subsequent recovery was uncomplicated.
64 Current State of Training and Evaluation of Laparoscopic Surgical Skills , Sandeep Ganni, Sanne MBI Botden, Benjamin F Hamilton, Arjun S Bedi, Davide Lomanto, Bhaskara Rao G and Jack J Jakimowicz
Objective: The aim of this study is to understand the current state of training practices and evaluation in laparoscopic surgery in a global context. Design: An open-ended three part questionnaire was designed to gather the opinions about the current state of, adequacy of, and the need for a standard in laparoscopic surgical training. Participants: Members of the European Association for Endoscopic Surgery (EAES), Endoscopic and Laparoscopic Surgeons of Asia (ELSA) and Association of Surgeons of India (ASI) were asked to participate in the survey. Results: Of the 663 responses received, 83.6% were surgeons (64.6% in a teaching position) and 12.6% were surgical residents in training. Most respondents (75.4%) had performed over 200 laparoscopic procedures. Most (72.1%) training programs were approved/endorsed by local surgical associations or government health authorities and of the courses taught by surgical associations the majority had certified trainers (71.1%). In lower Human Development Index (HDI) countries significantly less courses are taught by certified trainers (68.2% versus 54.6%, p<0.001). Only 26.8% stated that their respective government health authorities participated in the certification of laparoscopic surgery; certification was considered important by 63.6%. However, only 17.8% of government health authorities contributed to ensure the quality of laparoscopic training, mostly in very high HDI. Only 3.3% of respondents considered the laparoscopic training and education in their country to be optimal and 51.9% rated it insufficient. Most respondents (86.3%) stated that there is a need for the standardization of laparoscopic training and 88.3% stated that standardization of laparoscopic training is important. Conclusion: Regardless of demographic and experience factors, there was a general consensus that that there is a need for standardisation in mandatory training of laparoscopic surgical skills, although currently not obligatory in most countries.
65 Rectal Perforation after Anal Intercourse , Michael Kornaropoulos, Marinos C Makris, Evripides Yettimis and Nicolaos Varsamidakis
Introduction: Injuries during intercourse can range from superficial vaginal bleeding to severe ones that can lead to recto - vaginal fistulas and hemorrhage, which are usually related with rape and foreign body insertion. Presentation of case: We report a 24-year old female with history old chronic constipation, who presented in our emergency department with acute abdominal pain 24 hours after consensual anal intercourse, while denying any sex toy , fisting or foreign body insertion. In surgery a Hartman procedure was performed, due to fecal peritonitis from a large rectal tear in the upper third of the rectum. Discussion: The unique feature of this case is that the post coitus tear of the rectum caused by anal intercourse between two heterosexual adults resulted in intraperitoneal peritonitis, while the anal sphincters were left intact. Conclusion: Sexual related traumas are taboo subjects as well as the cause of embarrassment and distress to most patients. It is vital that they are treated in a professional manner that respects their dignity, and that clinical care is aimed at correcting the situation as safely and painlessly as possible.
66 Coronal Hypospadias: Meatal Advancement and Glanuloplasty or Tubularized Incised Plate Urethroplasty? , Osman Hakan Kocaman, Tansel Günendi, Ali İhsan Anadolulu, Mustafa Erman Dörterler and Mehmet Emin Boleken
Introduction: Hypospadias is a congenital anomaly of urethra and penil foreskin. In this setting urethral mea may place anywhere in penil shaft along corona to perineum. More than 300 surgical techniques for hypospadias repair have been described. Method: In this study we aimed to present our cases operated with either Meatal Advancement and Glanuloplasty (MAGPI) or Tubularized Incised Plate Urethroplasty (TIPU) procedures for coronal hypospadias. Results: Ninety six patients involved in the study, the urethral meae were located coronally. The average age was 6,6. MAGPI was performed in 28 patients and TIPU was performed in 68 patients. Patients operated with MAGPI were carried in outpatient setting. Average hospital stay in patients operated with TIPU was 6,3 days. There were only complication in MAGPI procedure but in TIPU procedure 2 patients had fistula, 6 patients had meatal stenosis and 1 patient had glanular dehissence. On follow up families were asked for cosmetic satisfaction, there were no difference between these procedures. Conclusion: Many procedures were introduced for coronal hypospadias. MAGPI can be performed in selected cases because of low complication rate and short hospital stay.
67 Invasive Procedures with Questionable Indications: Prevention of a Negligent Custom , Sergei V Jargin
This is an update and continuation of preceding reports on invasive methods used with questionable indications in the former Soviet Union. Among others, the following is discussed: the surgical treatment of diabetes mellitus, of bronchial asthma and some other respiratory conditions, the overuse of gastrectomy for peptic ulcers, of Halsted and Patey mastectomy, coagulation of cervical pseudo-erosions without epithelial dysplasia, enhanced negative appendectomy rate. The use of endoscopy with diagnostic, therapeutic and scientific purposes is discussed. The purpose of this review was to comment on some reports from the recent past with questionable recommendation for the practice, to stress that the risk-to-benefit ratio should be kept possibly low, and informed consent obtained.
68 Effectiveness of Cdp-Choline in the Treatment of Slight and Moderate Head Injuries , Arrotegui JI
Material & Methods: A single blind randomized study has been conducted on 110 patients with mild or moderate head injuries. With the aim of comparing the evolution of those that received only conventional treatment with the evolution of those treated with CDP-choline. Results: Our results show that CDP-Choline improves patients’ overall progress with regard to the following functions: motor, cognitive and psychic alterations, along with a reduced stay on the ward in relation to the control group. Conclusion: The Conclusion of our study regarding the use of CDP-choline in Head injuries with GCS between 13-10 insomuch as the symptoms and results obtained is deemed satisfactory.
69 Does Electronic Identification Enablement for Silicone Gel Implants Impact Patient Safety? , Michael T Nelson, Kurt A Brattain and Jeffrey M Williams
Life-Cycle traceability for medical devices is critical for assurance of patient safety and of great concern for manufacturers, healthcare providers and global regulatory authorities. Electronic tracking technologies are relied upon to maintain traceability integrity throughout the supply chain until device use, or in the case of implantable medical devices, placement in the patient. Active implantable medical devices, such as cardiac pacemakers can be identified in vivo but passive medical device traceability post-implantation must rely on patient registration cards and patient history records. Motiva Implants® with Q Inside Safety Technology™ silicone gel-filled breast implants contain a radiofrequency identification device and are the first passive devices that can be identified in vivo, but its presence creates an artifact during MRI, raising the concern of possibly missing a cancer diagnosis during surveillance of high-risk patients. Dual-modality imaging, using MRI and ultrasonography when the artifact is present is essentially equivalent to MRI alone when the artifact is not present, based on a number of potentially missed cancer detections per 1,000 screening exams. The Number Needed to Harm (NNH) with MRI with artifact present and obstructing 5.37% of the breast implant image indicates one high-risk patient with a cancer reoccurrence would likely be missed for every 596 high-risk patient screening exams performed. Likewise, when dual modality of MRI and ultrasonography are used to study the high-risk patient group, it would take 17,892 screening exams before a patient with cancer recurrence is likely to be missed (false negative). The addition of ultrasonography to the artifact void area mitigates the impact of the artifact quite substantially. Concerning traceability, the ratio of electronic in vivo assures a 100% traceability benefit (high-risk patients with cancer not missed in imaging studies) to the harm caused by the artifact (high-risk patients with cancer missed in imaging studies). Even for the MRI study alone with the artifact, 100% traceability finds a 22.84-fold increase in the number of patients benefiting over the number of patients harmed. Dual-modality improves this ratio up to a 710.96-fold increase of the number of patients benefiting over the number of patients harmed.
70 Use of Enalapril to Prevent Myointimal Hyperplasia in Arm’s Arteriovenous Fistula for Hemodialysis Access , Héctor Bizueto-Rosas, Javier Ismael Hernández-Vázquez, Hugo Alonso Pérez-González, Carlos Daniel GómezCalvo, Carla Isabel Moreno-Ramírez, Rodrigo Marcelo Maitret-Velázquez, Perla Elín Leyva-Rivera, Nayeli Leticia Jiménez-Tejada, Martha Carolina Rosales-Ramos, Delio Felipe Martínez-Blanco, Noemí Antonia Hernández-Pérez, Sofía Muñoz-Vega, Rafael Mejía-Espinosa, Armando Guzmán-Caballero and Jesús Herminio Rivera-Bañuelos
End-point: Evaluate the effect of Enalapril in preventing Myointimal Hyperplasia (MIH) in arm’s arteriovenous fistula (AVF) for hemodialysis access. Method: Inclusion criteria consisted on patients with no ACEI, or angiotensin II receptor blockers (ARB) treatment, or no intake up to 3 months before procedure, declared suitable for AVF access, and having thrill and bruit after AVF construction procedure. Under these criteria, we selected eighty-eight patients and assigned them randomly in case group and control group. Case group received Enalapril 48 hours before AVF construction procedure and during study. We did evaluations of efferent vein diameter, myointimal complex, and flow velocities with Doppler Ultrasound (DU) during six weeks after procedure. MIH risk factors according to medical history and obtained data analysis were performed using student test. Results: After medical history analysis, the main MIH risk factors presented were diabetes, hypertension and active smoking p=0.05. Within control group, MIH was higher as three patients had AVF failure vs one patient in case group, the Enalapril group. Conclusion: We found no statistical difference in both groups (p=0.637).
71 Effectiveness in the Prevention of Superficial Infection of Polluted and Dirty Wounds with “Gasmanvac Drainaje”, in the General Surgery Service of Iess Riobamba Hospital since August 2009-July 2013 , Gasman Humberto Ochoa Alvarez, Diego Fabricio Erazo Mogrovejo, Benjamín Pérez Erazo, Marlene Josefa DíazLópez, David Gabriel RoseroArévalo and Edison RobertoNúñez Moina
Objective: To identify the effectiveness of the management of contaminated and dirty wounds with aspiration tubular drainage (GASMANVAC DRAINAJE) in subcutaneous cellular tissue in the General Surgery Service IESS Riobamba Hospital. Location: IESS Riobamba General Hospital. Design: Prospective, Transversal, Descriptive and Quasi-Experimental Study. Statistical analysis: Measures of central tendency. Patients and methods: A total of 675 postsurgical patients were analyzed in the IESS Riobamba Hospital between August 2009 and July 2013, who presented injuries classified as contaminated and dirty in which GASMANVAC DRAINAJE was used. The variables analyzed were age, gender, mass index surgery, surgery, aspiration tubular drainage, surgical wound infection and length of hospital stay. Results: Of the 675 patients, 4% presented superficial infection of the surgical wound, while 96% did not, considering it a favorable evolution for the majority of patients. Conclusions: The use of “GASMANVAC DRAINAJE” has demonstrated the reduction of surgical wound infection in the postoperative patient. If we compare the present study with the literature, which indicates that the infection in the case of contaminated wound is 15-30% and in the dirty one>30%, we can conclude that our investigation showed that this type of drainage is effective in the prevention of superficial infection of surgical wound presenting 4% of infection (1.6% contaminated wound and 2.4% dirty wound).
72 Efficacy of Multiple Doses of Antibiotics in Anterior Abdominal Wall Hernia Repair at a Tertiary Rural Hospital , Asadulla Baig, Pavan BK, Bhaskaran A, Akarsh YG and Karthik Hareen TVK
Background: Mesh repair of the anterior abdominal wall hernias is a popular technique and commonly accepted among the majority of surgeons. The technique used most frequently today is the tension free technique. It is uncertain whether extended period of antibiotic prophylaxis is necessary to prevent postoperative wound infection, especially when a foreign body like a polypropylene mesh is used. Methods: We have studied retrospectively the patients who received surgical treatment in department of Surgery at R L Jalappa Hospital, Tamaka, Kolar for anterior abdominal wall hernia during the period of December 2017- January 2013. Patients were divided into 3 groups based on the doses of antibiotics administered. Results: In 280 out of 340 cases, a mesh of polypropylene was used. In our sample, we excluded 68 patients due to diseases that made the use of antibiotics necessary. We have studied the frequency of superficial and deep infections in correlation with the use of antibiotics (cephalosporins of third generation). Conclusion: No difference was observed in the incidence of surgical infection in relation to the duration and the doses of antibiotic cover. The wound infection rate in the current study does not support the use of multiple doses of antibiotics, as this rate does not differ from the rates of infection reported in the literature. Further studies are needed to clarify if antibiotic chemoprophylaxis with one dose or no chemoprophylaxis should be recommended.
73 Comparison of the Effects of Diclofenac Sodium or Celecoxib on the Healing Tooth Socket. A Study in Rats , Samira Hajisadeghi, Farimah Sardari, Mostafa Sadeghi, Sayyed Mohammad Razavi and Michael W Roberts
Introduction: There is extensive evidence in the orthopedic literature that prolonged use of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) can hinder long bone fracture healing and new bone formation around implants. The aim of this study was to investigate if short time administrations of NSAIDs such as diclofenac or celecoxib interfere with the course of healing of alveolar bony socket following tooth extraction. Materials and Methods: Forty-five rats (15 per group) were used. After extraction of the right maxillary first molar, 15 rats received 5 mg/kg/day of diclofenac, 15 rats received 15 mg/kg/day of celecoxib and 15 rats received normal saline. The animals were sacrificed at 7, 14 and 21 days following tooth extraction. The number of osteoclasts, osteoblast and new bone formation were determined by using histological analyses. Data were analyzed by one-way ANOVA followed by Tukey’s post hoc test (α=0.05). Results: On the 7th day, the osteoblast number in the control group was higher than the diclofenac and celecoxib groups. Tartrate-Resistant Acid Phosphatase (TRAP) immunolabeling of the control group was more than the diclofenac group on the 7th day and more than the celecoxib group on the 14th day. On the 21st day, no significant differences were noted among the three studied groups. On the 14th and 21st day, new bone formation in the NSAID treated rats was not significantly different from that in the control rats. Conclusion: Short-term treatment with diclofenac or celecoxib, although they have the capacity to inhibit the enzyme cyclooxygenase, did not cause a significant delay in alveolar bone healing during the experimental period in rats.
74 Abdominal Wall Endometrioma at Laparoscopic Port Site: Case Report with Literature Review , Nawfal S Al-Khayat and Ali E Joda
Background: The ectopic growth of functional endometrial tissue outside the uterine cavity is called endometriosis. It could be in pelvic or extra-pelvic locations. Abdominal wall endometriosis is rare and mostly reported following various surgical procedures mostly cesarean section or pelvic surgery. A few case reports have described abdominal wall endometriosis following laparoscopy at trocar port sites. We report a new case of abdominal wall endometriosis with review of the literatures. Case report: This is a report of abdominal wall endometriosis at the laparoscopic port site in a 34-year-old woman who had previous diagnostic laparoscopy 4 years ago for gynecological problem when she presented with recurrent attacks of mild abdominal pain and discomfort for 4 months duration. Operative intervention was decided depending on ultrasound and abdominal CT scan findings, we performed a complete surgical resection of the lesion with a free macroscopic margin. Conclusion: Due to a wide range of mimicking conditions and a relative rarity, a significant delay is often observed from the onset of symptoms to proper diagnosis. Although rare, if a painful mass in the surgical scar, such as the trocar site, is found in women of reproductive age with a history of pelvic or obstetric surgery, the physician should consider endometriosis.
75 Pseudoaneurysm Formation after Laparoscopic Partial Nephrectomy , Bruno Lopes Cancado Machado
The Laparoscopic Partial Nephrectomy (LPN) is the “gold standard” to management of small renal masses. The patient, a 38 year Male at 8th post-operatory day from right upper pole PN, presented at ER with a voluminous gross hematuria. The clinical diagnosis was a renal pseudoaneurysm. The patient was hemodynamically stable, and a medical approach was tried. After 12 hours of clinical management, the hematuria had not stopped. A transfemoral arteriography was done, and the Pseudoaneurysm diagnosis was confirmed. An intravascular embolization was performed and the hematuria ceased in the day after.
76 Inguinal Lymph Node Dissection for Lower Limb Cancer: Indications, Technics and Results about 70 Cases , Sidy KA, Abdourahmane N Dong, Mamadou M Dieng, Jaafar Thiam, Adja Coumba Diallo, Doudou Diouf, Macoumba Gaye and Ahmadou Dem
Background: Inguinal lymph node dissection helps to prevent groin and systemic metastasis during surgery for limb and lower genitourinary cancers. The objective of this work was to report the indications, techniques and results of inguinal lymph node dissection in cancers of the lower limb at the Dakar Cancer Institute. Methods: This was a retrospective study over a 7-year period. Included patients were over 15 years of age and had lower limb cancer regardless of the tissue involved. The parameters studied were age, gender, histological type, lymph node involvement, postoperative morbidity, recurrence and survival. Results: There were 70 patients operated over a period of 7 years. The average age of our patients was 53.4 years. The sex ratio was 0.94 with 34 men and 36 women. The most common histological type was squamous cell carcinoma with 30 cases (42.8%). There were more clinical and histological involved nodes in the case of sarcomas. Histological findings were done in 26 of 54 patients (48%). We noted 3 cases of death (4.2%) in a context of kidney failure for 1 case and respiratory distress 2 cases. The local complications consisted of suture release in 2 cases, 1 operative wound necrosis, 1 amputation wound suppuration. After five years of follow up, no patients had chronic sequels following inguinal dissection, 5 patients (7.7%) had local recurrence, 4 patients (7.7%) had node metastases and 1 patient developed liver metastases. We have recorded 20 deaths (28.6%) related to cancer. Conclusions: Inguinal lymph node dissection showed good results in limb cancer treatment. Squamous cell carcinoma is the main histologic cancer and lymph involvement is more frequent in case of sarcomas. Complications are rare and death occurred mostly for related to cancer stage.
77 Minimally Invasive Esophagectomy in the Elderly: Short and Long-Term Outcomes , Thomas Fabian, Jeremiah Martin and Dorothy Chiaravalle
Background: Age is considered a significant risk factor for mortality following esophagectomy. We sought to evaluate surgical outcomes in elderly patients undergoing Minimally Invasive Esophagectomy (MIE) for cancer. Study design: Utilizing a prospectively maintained MIE database outcomes of elderly patients (age ≥ 70 years) between (June 2005-August 2008) undergoing esophagectomy for cancer are reported. Primary outcome measures included operative mortality, length of stay, complications and long term survival. Results: Twenty elderly patients underwent MIE for malignancy during the 4 year period and median survival follow-up as 79 months (59-96). Complications occurred in 12 (60%) of 20. Mean length of stay was 12 days (8-34). Hospital mortality was 0 (0%) of 20 and overall two, three, and five year survival were 74%, 60%, and 50% respectively. Conclusions: Appropriate patients in this age group have excellent short, intermediate and long term survival following MIE. In experienced hands MID has a low mortality and should be considered an appropriate approach in the elderly population.
78 Safety of Sacral Neuromodulator in Pregnancy-A Case Report , Hani Albadawe, Naser Alhazani and Yahia Alghazwani
Fowler’s syndrome described as a disorder that consists of chronic urinary retention and abnormal electromyography (EMG) activity in the absence of any structural pathology. Among females the prevalence of Fowler’s syndrome is rare. One of the treatment options for Fowler’s syndrome is using Sacral Neuromodulator device that can restore voiding. Most physicians advise the pregnant women to turn off the device during their pregnancy and labor to keep the mother and infant health. However, our case went against medical advice and kept the device on based on her request and responsibility. Unexpectedly the pregnancy was uneventful, healthy term infant was born and without complication. All labs were within normal range, and no abnormality showed in the imaging. In conclusion, using Sacral Neuromodulator device during pregnancy and labor may be safe in some cases, but it requires continuous follow-up.
79 Gallstone Ileus: A Case Report , Katyayani Kumari Chaubey, SK Tiwary, Puneet, Ajay K Khanna and Soumya Khanna
Intestinal obstruction is a common emergency in surgical practice but rarely, it may be caused by gallstone impaction leading to a condition what is called as “Gallstone Ileus” (GI). The intestinal obstruction due to Gallstone impaction occurs due to a fistula in the biliary-enteric tract. It is a rare presentation accounting for only 0.1% of all causes of intestinal obstruction. A 70 year old female, presented with features of Intestinal obstruction for 1 week. Ultrasound of the abdomen revealed distended bowel loops and contracted gallbladder. Computerized tomography scan suggested contracted gallbladder with hyperdense contents with air foci in the gallbladder and common bile duct with a hypodense lesion in the jejunal loop with air foci and calcifications causing luminal occlusion with dilated proximal bowel loop. Laparotomy revealed a 3 cm stone impacted in jejunum 2 feet distal to Duodenojejunal (DJ) flexure with proximal dilatation of the jejunum. Enterotomy was done and the stone was removed. The bowel was decompressed and enterotomy was closed primarily. The patient has been on follow up without any complaints for the last 6 months.
80 Diagnosis and Treatment of Gastric Duplication in Neonates-A Case Report and Review of the Literature , Kun Wang, Jing Cai, Xiao Wei Li, Guo Min Zhai, Ying Chou Lu, Wei Bing He, Xiong Sheng Guo and Gang Quan Wu
Background: Gastric duplication is an extremely rare digestive tract malformation with an incidence rate of approximately 17 cases per million, accounting for 2-8% of all digestive tract duplications. Infants the disease lacks obvious symptoms. The incidence of acute cases rarely reported in the neonatal period. Through a review of this case and the historical literature we have accumulated valuable surgical and clinical experience in the treatment of this acute disease. Case presentation: In this case report, the patient presented with abdominal distension, abdominal pain, fever, vomiting at one week after birth, abnormal abdominal masses were identified by color Doppler ultrasound and X-ray. In order to make a further diagnosis, we performed abdominal puncture on the side of the bed. Through the nature of the peritoneal puncture fluid, we identified the indication of emergency operation in the children. In the operation we found a large amount of brown liquid was identified in the abdominal cavity. A mass was identified in the greater curvature adherent to the transverse colon. That was difficult to separate from the surrounding tissues. The cyst was encased in the greater omentum, and perforation was identified after adhesion separation. The diagnosis of gastric duplication was confirmed by surgery and pathology. Conclusion: Gastric duplication is an extremely rare digestive tract malformation especially in newborns. Not all gastric duplications are accompanied by obvious clinical symptoms and this condition is typically detected upon examinations. Preoperative diagnosis by ultrasound and X-ray and abdominal puncture facilitated urgent treatment in this case. Surgery is an effective treatment for gastric duplication. The wide local resection of the gastric mass and the cysts performed in this case achieved satisfactory results. Abdominal puncture, as an effective auxiliary examination, plays an important role in the management of neonatal acute abdomen. It also reminds the pediatric surgeon that all kinds of methods should be used in the treatment of neonatal acute abdomen to save lives.
81 Tonsillectomy and Adenoidectomy: Indications, Complications and their Management , Anmolsingh R, Ali A, Edmiston R, Mirza O, Rocke J, Ranganathan B and Kumar BN
Tonsillectomy and Adenoidectomy are common operative procedures in field of Ear, Nose and Throat (ENT) Surgery. Over 17000 tonsillectomy procedures were undertaken in England in the year 2014-2015 and the number for children is likely to be much higher. Tonsillectomy may be performed for recurrent tonsillitis, histological diagnosis or for the management of snoring. Adenoidectomy is rarely performed in isolation but instead employed in combination with other interventions. Adenoidectomy and tonsillectomy (Adenotonsillectomy) is indicated for the paediatric population to manage obstructive sleep apnoea.
82 Breast Implants Associated ALCL (BIA-ALCL): A Personal Overview for Patients , Marcos Sforza
According to the International Society of Aesthetic Surgery, plastic surgery involving breast implants is still one of the most common procedures in the world. Hundreds of thousands of new patients have implants for the first time every year while another group just as large will have them replaced. For many years breast implants have been considered safe and harmless for patients. So, what has happened? Recently, there has been a lot of fuss in the media about the safety of breast implants, especially referring to a new type of cancer related to them. They are talking about the ALCL. ALCL stands for anaplastic large cell lymphoma and according to the Lymphoma.org website it represents 16% of all T-cell lymphomas diagnosed every year [1]. So, what is new?
83 Cocaine Induced Pharyngeal Perforation-an Unusual Case Presentation of Facial and Cervical Emphysema with Pneumomediastinum , Herman A, Anmolsingh R, Alappatt A, Pothula VB and Kumar BN
Objectives: Causes of cervical and facial surgical emphysema with pneumomediastinum are uncommon but can be life threatening and need urgent management in a high dependency setting. We present a case secondary to cocaine induced hypopharyngeal perforation which was not easy to diagnose as the patient was not forthcoming with his history of cocaine use. Clinicians should maintain a high index of suspicion when patients present with spreading cervical emphysema and also suggest an algorithm for management of non-iatrogenic subcutaneous emphysema and odynophagia. Case summary: We presented a case report of a 39 year old man presented with three days history of sudden severe odynophagia and coughing frothy blood stained sputum. Initial chest and neck soft tissue radiograph revealed cervical surgical emphysema. After further questioning, he admitted to recent regular cocaine nasal inhalation. Subsequent CT neck and thorax showed extensive subcutaneous emphysema likely due to an esophageal perforation. This was confirmed by gastrografin swallow test, which demonstrated a posterior hypopharyngeal perforation. The patient was managed conservatively in a HDU by keeping him nil by mouth and treatment with IV Piperacillin/Tazobactam and Clindamycin. He initially received total parenteral nutrition but subsequently refused further intravenous nutrition. He was discharged with nasogastric feeding in the community. Follow-up swallow test two weeks following discharge showed resolution of the perforation. Subsequent to this, we developed an algorithm with an emphasis on early stabilisation and thorough assessment prior to definitive investigation to improve management. Conclusion: Cocaine induced pharyngeal perforation is a rare but potentially life-threatening condition if left undiagnosed and without prompt and aggressive conservative treatment. Thorough history taking is vital with maintenance of high level of suspicion as the likely pathologies can be life threatening. Early involvement of multidisciplinary team advice is also critical.
84 Left Inguinal Hernia, Sigmoid Diverticulum and a Probable B4 Type Duplicated Appendix , Bizueto-Rosas Héctor, Hernández-Pérez Noemí Antonia, Bizueto-Blancas Noelly Noemí, Pérez-González Hugo Alonso, López-Borel Luis Alfonso, Buendía-García Ana Laura, Jiménez-Canet Atilano Alejandro, Gutiérrez-Olivares Omar Marino, Mijangos-Montaño Ared, González-López Annel Ivonne, Caltenco-Solis Raul Beder, Radilla-Flores Mariana, MagañaSalcedo Jaime Roberto, Echeverry-Fernández Camilo Andrés, Torrejón-Hernández Carlos Adrián, Hidalgo-Delgado Jesús Nicolas, Ramírez-Landeros Joshua, and Gamboa-Ramírez Fernando
Objective: We present a case report of an 89 years old male with a diagnosis of incarcerated left inguinal hernia, with surgical findings of a complicated sigmoid diverticulum and a tubular structure of 0.5 mm attached to the sigmoid colon, fixed to the inguinal ligament with a true lumen that could correspond to a duplicated appendix B4 type. Introduction: Colon diverticular disease is more frequent in western countries, present in 30% of 60 years old patients and in more than 50% in 80 years old patients, with 95% of the times located at sigmoid colon. The most frequent complication is the acute diverticulitis (25%) and in 30% of these patients, surgery is required. Discussion: Acute, complicated, diverticular disease is an infrequent pathology, even more, a colonic diverticulum included within the hernia sac. Of the appendix congenital malformations, a duplicated appendix is the rarest; usually found in asymptomatic adults as an incidental find during abdominal surgery or during contrasted abdominal scans. Conclusion: Awareness must be raised within first-contact health care professionals about diagnosing surgical entities with high mortality rates, in asymptomatic patients with unclear clinical findings, especially with the occurring of a demographic transition in most countries. In this specific patient, Hartman surgical procedure and a second time inguinal plasty were the best surgical options for this patient; even considering the mortality rates (25%) of a perforated diverticulum, considering added surgical site infection.
85 Treatment of Jejunal Angiodysplasia by Video-Assisted Intestinal Resection, a Case Report and Literature Review , Jiménez-Canet Atilano Alejandro, García-Chávez Jesús, Bizueto-Rosas Héctor, Pérez-González Hugo Alonso, MagañaSalcedo Jaime Roberto, Echeverry-Fernández Camilo, Gutiérrez-Olivares Omar Marino, Buendía-García Ana Laura, Mijangos-Montaño Ared, González-López Annel Ivonne, Caltenco-Solís Raúl Beder, Radilla-Flores Mariana, TorrejónHernández Carlos Adrián, Hidalgo-Delgado Jesús Nicolás, Ramírez-Landeros Joshua, and Gamboa-Ramírez Fernando
Intestinal angiodysplasia is one of the main etiologies of bleeding within elderly patients. This entity can present in any portion of the intestinal tract, however, when it affects the small intestine it appears as obscure gastrointestinal bleeding up to 30 to 40% of the cases and it represents a diagnosis and management challenge. Early diagnosis is important to establish the most adequate treatment. We present the case of a 69 years old male patient with obscure gastrointestinal bleeding due to a jejunal angiodysplasia, requiring endoscopic location of varicose vessels and dye instillation followed by surgical management with a video-assisted intestinal resection. Conclusions: Intestinal angiodysplasia is an important etiology of bleeding and should be considered when treating an obscure gastrointestinal bleeding case. The combination of endoscopic procedures to precise diagnosis and surgical management is possible and has low rates of complications, morbidity or mortality.
86 Clinical Study on Postpartum Urinary Retention with Compound Chinese Medicine , Wang Huaying and Zhang Yuemei
Postpartum urinary retention is a common complication in obstetrics; its incidence in spontaneous labor is on average 14%, while the incidence in midwifery is as high as 26% to 38%. If the treatment is not timely, postpartum urinary retention will affect the contraction of the uterus and aggravate postpartum hemorrhage, affect the restoration of postpartum reproductive organs, can also lead to urinary tract infection, and bring physical and mental pain to the puerperal.
87 Cochlear Implant Merits in Patients with Meniere’s Disease , Mohamed Salah Elgandy
Meniere’s disease is a chronic inner ear disease characterized by fluctuating sensorineural hearing loss, recurrent vertiginous attacks, tinnitus with aural fullness. Whether hearing loss is secondary to natural progressive course of disease or due to interventions, noticeable number of patients with Meniere’s disease has unilateral non-serviceable hearing. So, cochlear implantation provides hope for those patients not only for hearing rehabilitation but also its positive effect on other non-auditory symptoms of Meniere’s disease. Our article aims to review the beneficial effects of implanting patients with Meniere’s disease regarding their hearing gain as measured by standard audiometric testing and discuss the effect of implantation on auditory and vestibular outcomes.
88 Abdominal Wall Endometrioma in Previous Cesarean Section Scar: Case Report , Jiménez-Canet Atilano Alejandro, Pompa-de la Rosa Cayetano, Bizueto-Rosas Héctor, Pérez-González Hugo Alonso, Magaña-Salcedo Jaime Roberto, Echeverry-Fernández Camilo, Gutiérrez-Olivares Omar Marino, Buendía-García Ana Laura, Mijangos-Montaño Ared, González-López Annel Ivonne, Caltenco-Solis Raúl Beder, Radilla-Flores Mariana, Torrejón-Hernández Carlos Adrián, Hidalgo-Delgado Jesús Nicolás, Ramírez-Landeros Joshua, Gamboa-Ramírez Fernando
Endometriosis is defined as the presence of functional endometrial tissue, glands and stroma outside the uterine cavity, mainly at ovaries and at pelvic peritoneum, causing a chronic inflammatory reaction. The abdominal wall endometrioma is an infrequent pathology; occurs after abdominal surgery, by minimal invasion, open surgery or gin-obs surgery. It happens in about 0.03 to 1.5% women after having a cesarean section, presenting transvaginal bleeding, endometrial ultrasound with 9 mm thickness and uterine myomatosis, having a painful node at the infra-umbilical abdominal scar, with skin colour change and due to increasing pain is diagnosed with an incarcerated hernia. Urgent surgery was performed, finding a 6 × 6 × 4 cm vesicle, with brownish secretion, attached to the muscular aponeurosis. Conclusion: Not every node or bulge within the abdominal wall should be considered hernia. in the scenario of a painful node and skin colour change at a surgical scar, with a medical history of cesarean section, hysterectomy and laparoscopic procedures, diagnosis of endometriosis should be considered and therefore always perform histopathological exams.
89 Volvulus of the Cecum Due to Intestinal Malrotation in an Adult Woman, a Case Report , Buendía-García Ana Laura, Bizueto-Rosas Héctor, Hernández-Pérez Noemí Antonia, Bizueto-Blancas Noelly Noemí, Pérez-González Hugo Alonso, Gómez-Calvo Carlos Daniel, Jiménez-Canet-Atilano Alejandro, Caltenco-Solís Raúl Beder, Mijangos-Montaño Ared and Radilla-Flores Mariana
We present the case of an adult woman with a medical history of repetitive episodes of intestinal subocclusion and occlusion that remitted with medical treatment. During hospital admission due to acute abdominal pain and secondary to CT scan results, an urgent surgical approach was decided with findings of a malrotation anomaly consisting in a short, dilated and volvulus cecum behind hepatoduodenal ligament and a collapsed transversal colon, requiring intestinal resection and ileocolic primary intestinal anastomosis. Conclusion: Repetitive intestinal occlusion and subocclusion symptoms also in an adult patient with history of repetitive episodes that were always treated conservatively should be considered as a possible malrotation anomaly. Cecal volvulus is a very rare clinical entity, difficult to early diagnose and can be associated to a malrotation anomaly. Early surgery in this types of patients, that are used to conservative treatment, require a high index of diagnostic suspicion but can be associated with lower mortality and morbidity