Andre Chow

Appendicectomy and Cholecystectomy Using Single-Incision Laparoscopic Surgery (SILS): The First UK Experience

Introduction. Single-incision laparoscopic surgery (SILS) has the potential advantages of reduced postoperative pain and reduced port-site complications. Careful attention to closure can lead to virtually “scarless” surgery. In this article, we present our first experiences with SILS appendicectomy and cholecystectomy. Method . SILS appendicectomy and cholecystectomy was performed in 12 and 14 patients, respectively. Data were collected prospectively and analyzed retrospectively from case notes and the theater database. Results. The average operating times were 61.3 and 142.9 minutes for SILS appendicectomy and SILS cholecystectomy, respectively. There was a good correlation between increasing experience and a reduction in operative time with Pearson’s coefficient being −1 for appendicectomy and −0.56 for cholecystectomy. There were no postoperative complications in the SILS appendicectomy group. One patient in the SILS cholecystectomy group suffered a postoperative biliary leak from an accessory duct of Lushka. Conclusions. In our series, we have demonstrated SILS to be a safe and efficacious method for appendicectomy and cholecystectomy. Further studies are required to investigate any potential advantages of this method over standard laparoscopic techniques.

Patient-reported outcome measures: The importance of patient satisfaction in surgery

In recent years, much attention has been paid to the assessment of the quality of health care. This focus has been driven mainly by a desire to improve health care and decrease inequalities within health care systems. As well as addressing key areas such as structure, process, and outcome, which are normally taken from the providers viewpoint, it is also necessary to address the patients perspective. Patient-reported outcomes are an increasingly popular method of assessing the patients experience within the health care system. Along with well-known patient reported outcomes such as health-related quality of life and current health state, patient satisfaction can provide an ultimate end point to health care quality. It is thus an essential part of quality assessment. The concept of patient satisfaction and its measurement, however, has often been overlooked by researchers. Therefore, current measures of satisfaction may not be adequate to assess quality of health care. This article aims to provide an overview of the concept of patient satisfaction. It also discusses current methods of patient-reported outcome assessment and suggests methodology to create new instruments to measure patient satisfaction.

Single incision laparoscopic surgery for appendicectomy: a retrospective comparative analysis

BackgroundSingle incision laparoscopic surgery (SILS) may further reduce the trauma of surgery leading to reduced port site complications and postoperative pain. The improved cosmetic result also may lead to improved patient satisfaction with surgery.MethodsData were prospectively collected and retrospectively analyzed for all patients who underwent SILS appendicectomy at our institution and were compared with those who had undergone conventional laparoscopic appendicectomy during the same time period. This included patient demographic data, intraoperative, and postoperative outcomes.ResultsThirty-three patients underwent conventional laparoscopic appendicectomy and 40 patients underwent SILS appendicectomy between January 26, 2008 and July 14, 2009. Operative time was shorter with SILS appendicectomy compared with conventional laparoscopic appendicectomy (pxa0<xa00.05). No patients in the SILS appendicectomy group required conversion to open surgery compared with two patients in the conventional laparoscopic appendicectomy group. Patients stayed an average of 1.36xa0days after SILS appendicectomy, and 2.36xa0days after conventional laparoscopic appendicectomy.DiscussionSILS appendicectomy seems to be a safe and efficacious technique. Further work in the form of randomized studies is required to investigate any significant advantages of this new and attractive technique.

A Meta-Analysis of Probiotic and Synbiotic Use in Elective Surgery: Does Nutrition Modulation of the Gut Microbiome Improve Clinical Outcome?

BACKGROUNDnPerioperative nutrition modulation of gut microbiota is increasingly used as a strategy for reducing the infective complications of elective surgery. This meta-analysis assessed the effect of probiotic and synbiotic preparations on the incidence of postoperative sepsis.nnnMETHODSnRandomized controlled trials that compared preoperative dosing of probiotics and synbiotics in patients undergoing elective general surgical procedures were included. The primary outcome measure was the postoperative sepsis rate. Pooled outcome measures were determined using random effects models.nnnRESULTSnThirteen randomized controlled trials totaling 962 patients were included in this analysis (304 received synbiotics and 182 received probiotics). The incidence of postoperative sepsis was reduced in the probiotic group vs the control (pooled odds ratio [OR] = 0.42; 95% confidence interval [CI], 0.23-0.75; P = .003) and in the synbiotic group vs the control (pooled OR = 0.25; 95% CI, 0.1-0.6; P = .002). However, subgroup analysis failed to identify a significant reduction in the incidence of pneumonia, urinary tract infections, or wound infections in the postoperative phase for either treatment group. Synbiotics reduced the length of postoperative antibiotic use (weighted mean differences = -1.71; 95% CI, -3.2 to -0.21; P = .03).nnnCONCLUSIONnProbiotic and synbiotic nutrition strategies reduce the incidence of postoperative sepsis in the elective general surgery setting. These effects appear more pronounced with the use of synbiotics. High-powered, mechanistic studies are now required for the optimization of pro- and prebiotic regimens to further improve their efficacy.

Does Serum Procalcitonin Have a Role in Evaluating the Severity of Acute Pancreatitis? A Question Revisited

PurposeThis study was designed to evaluate the diagnostic accuracy of serum procalcitonin (PCT) for the diagnosis of severity in acute pancreatitis (AP), compared with routine clinical, biochemical, radiological, and combination severity scoring systems.MethodsQuantitative meta-analysis was performed on prospective studies, comparing serum PCT, against validated scoring systems for diagnosing severe AP. The sensitivity, specificity, and diagnostic odds ratio were calculated for each study. Summary receiver operating characteristic (SROC) curves and subgroup analysis were undertaken. Study quality and heterogeneity were evaluated. Meta-regression meta-analysis was used to evaluate the effect of using serum PCT in the diagnostic accuracy severity scoring in AP.ResultsSummary receiver operating characteristic analysis of nine studies showed an overall sensitivity and specificity of 74% (range: 66%–81%) and 83% (range: 79%–87%), respectively. Overall unweighted area under the curve (AUC) was 0.91 (DOR = 16.26 95% CI: 5.68–46.60), demonstrating significant heterogeneity (Q-value = 25.32; P = 0.001). When high-quality studies alone were evaluated, there was an increase in the overall sensitivity (89%); however, specificity was similar (82%), with an overall unweighted AUC of 0.94 (DOR 41.46, 95% CI: 17.95–95.80), with no significant heterogeneity. Meta-regression analysis confirmed the significant effect of study quality on the diagnostic accuracy of severity scoring using serum PCT (P = 0.025).ConclusionsThe use of PCT for severity scoring in AP has a moderate sensitivity but higher specificity. However, the overall accuracy for predicting severity in AP is high. The prognosis of severity, especially early on (<48 hours from onset of symptoms), and the evaluation of potential infectious complications of AP may be the most useful factors to assess in subsequent clinical trials to identify its exact application in clinical practice in the management of AP.

Proctalgia fugax, an evidence-based management pathway

PurposeProctalgia fugax (PF) is a benign anorectal condition which has been described in the literature since the nineteenth century commonly presenting to general surgeons. There is little high level evidence on the subject and its therapeutic modalities. We aimed through this systematic literature review to outline the definition and diagnostic criteria of this condition, the aetiology and differential diagnoses and describe the different treatment modalities that have been attempted and their success.MethodA literature search of Google Scholar™ and Medline using Pubmed as the search engine was used to identify all studies directly related to the definition, aetiology and treatment options for this condition (latest at 12 August 2008) was performed.ResultsThe search produced 61 references with three others obtained from the references of these papers. The prevalence of PF in the general population ranges from 4% to 18%. The diagnosis is based on the presence of characteristic symptoms as defined by Rome III guidelines and physical examination. The mainstay of treatment is reassurance and careful counselling with evidence in the literature for warm baths, topical treatment with glyceryl trinitrate or diltiazem and salbutamol inhalation. In persistent cases, local anaesthetic blocks, clonidine or Botox injections can be considered after clarification of risk and benefit.ConclusionBased on this we suggest that diagnosis should be made through exclusion of common organic causes such as haemorrhoids, anal fissure or anorectal carcinoma and on the fulfilment of Rome III criteria. The main treatment for this benign condition remains reassurance and topical treatment.

Human Induced Pluripotent Stem Cell-Derived Cardiomyocyte Encapsulating Bioactive Hydrogels Improve Rat Heart Function Post Myocardial Infarction

Summary Tissue engineering offers an exciting possibility for cardiac repair post myocardial infarction. We assessed the effects of combined polyethylene glycol hydrogel (PEG), human induced pluripotent stem cell-derived cardiomyocyte (iPSC-CM), and erythropoietin (EPO) therapy in a rat model of myocardial infarction. PEG with/out iPSC-CMs and EPO; iPSC-CMs in saline; or saline alone was injected into infarcted hearts shortly after infarction. Injection of almost any combination of the therapeutics limited acute elevations in chamber volumes. After 10 weeks, attenuation of ventricular remodeling was identified in all groups that received PEG injections, while ejection fractions were significantly increased in the gel-EPO, cell, and gel-cell-EPO groups. In all treatment groups, infarct thickness was increased and regions of muscle were identified within the scar. However, no grafted cells were detected. Hence, iPSC-CM-encapsulating bioactive hydrogel therapy can improve cardiac function post myocardial infarction and increase infarct thickness and muscle content despite a lack of sustained donor-cell engraftment.

Myeloproliferative Disorder as the Cause of Peripheral Ischemia in a Young Patient

A 35-year-old patient with rest pain and peripheral gangrene was referred with a diagnosis of Takayasus disease but had myeloproliferative disorder (primary thrombocythemia). The angiogram revealed surgically noncorrectable small vessel occlusive disease with no evidence of atheroma. Medical therapy with cytotoxic and antiplatelet agents achieved satisfactory results with excellent wound healing after surgical amputation of necrotic tissue. The need for early diagnosis of this condition is emphasized.