Ari Halldorsson

Effect of electrocautery on wound healing in midline laparotomy incisions

The effect of electrocautery on midline fascial wound healing was studied in 108 Sprague-Dawley rats. Midline wound tensile strength was significantly reduced in fascia incised with the coagulation current compared with the cutting current or scalpel. In addition, tissue necrosis and inflammation as well as adhesion formation between the incision and abdominal viscera were more extensive in animals with incisions made using coagulation current. The results of the study indicate that the use of electrocautery coagulation current is associated with increased tissue damage and a significant reduction in the tensile strength of healing wounds. The contribution of electrocautery to wound complications in patients needs further evaluation.

Using Cognitive Task Analysis to Identify Critical Decisions in the Laparoscopic Environment

Objective: The aim of this study was to identify the critical decisions surgeons need to make regarding laparoscopic surgery, the information these decisions are based on, the strategies employed by surgeons to reach their objectives, and the difficulties experienced by novices. Background: Laparoscopic training focuses on the development of technical skills. However, successful surgical outcomes are also dependent on appropriate decisions made during surgery, which are influenced by critical cues and the use of appropriate strategies. Novices might not be as adept at cue detection and strategy use. Method: Participants were eight attending surgeons. The authors employed task-analytic techniques to identify critical decisions inherent in laparoscopy and the cues, strategies, and novice traps associated with these decisions. Results: The authors used decision requirements tables to organize the data into the key decisions made during the preoperative, operative, and postoperative phases as well as the cues, strategies, and novice traps associated with these decisions. Key decisions identified for the preoperative phase included but were not limited to the decision of performing a laparoscopic versus open surgery, necessity to review the literature, practicing the procedure, and trocar placement. Some key decisions identified for the operative phase included converting to open surgery, performing angiograms, cutting tissue or organs, and reevaluation of the approach. Only one key decision was identified for the postoperative phrase: whether the surgeon’s technique needs to be evaluated and revised. Conclusion: The laparoscopic environment requires complex decision making, and novices are prone to errors in their decisions. Application: The information elicited in this study is applicable to laparoscopic training.

Nottingham grades of lobular carcinoma lack the prognostic implications they bear for ductal carcinoma.

BACKGROUND Invasive lobular cancer (L) differs clinically and morphologically from invasive ductal cancer (D); differences notwithstanding, Nottingham grades are provided in both. This study compared 22,719 lobular carcinomas with 201,517 ductal carcinomas, dividing them into the grades: well differentiated (W), moderately differentiated (M), poorly differentiated (P), and ungraded to see if differences between comparable grades of lobular and ductal cancer were uniform, consistent with the notion the grading system provides similar information for both cancer subtypes. METHODS The Surveillance, Epidemiology and End Results (SEER) database was used to limn relationships among grades, as respects proportions of patients with T3 tumors and nodal metastases, as well as cancer-specific survival. Taken into account were age, estrogen and progesterone receptor status, and the administration of radiotherapy. RESULTS More lobular than ductal carcinomas were T3; grades were not homogenous, with the incidence rate ratio (IRR) comparing lobular and ductal carcinomas being 8.2 for well differentiated, 4.1 for moderately differentiated, and 2.48 for poorly differentiated. With respect to nodal metastases, the 1.16 W L:W D IRR (P < 0.05) was not explicable by chance, but both the 0.97 M L:M D IRR (P > 0.05) and the 0.96 P L:P D IRR (P > 0.05) could have been due to chance. As respects survival, neither the 1.4 P L:P D time ratio (TR) (P < 0.05) nor the 1.23 M L:M D TR (P < 0.05) could have been explained by chance; the 1.05 W L: W D (P > 0.05) might have been due to chance. CONCLUSION Grades of lobular carcinoma imply different meanings than do grades of ductal carcinoma. Studies of breast cancer should not assume commonality with respect to grade.

Prognosis of metastatic carcinoma of the lung in the bevacizumab era: comparison between the major histologic types of lung cancer.

BACKGROUND In October 2006, bevacizumab was approved for treatment for patients with metastatic non-small-cell lung cancer other than squamous carcinoma. Our hypothesis was that the change in survival after approval of bevacizumab for metastatic adenocarcinoma would show differences from that of small-cell carcinoma and squamous carcinoma. METHODS Data was obtained from the National Cancer Institute Surveillance Epidemiology and End Results (SEER) registry for patients with lung cancer diagnosed between January 2004 and November 2007. In addition to known characteristics predicting survival differences (histotype, age, gender, and race) we compared 1-year survival experience in those diagnosed before (January 2004-September 2006) and after (October 2006-November 2007) introduction of bevacizumab. RESULTS Of 24,575 patients meeting criteria, 16,081 (65.4%) died within 1 y. Adjusted for age, gender, and race, patients with squamous carcinoma showed a 13% decline (95% CI 7%-20%) in survival times. By contrast, the 1% increment for adenocarcinoma and the 1% decrement for small cell carcinoma might well have been due to chance (P > 0.05 for each analysis). CONCLUSIONS Life expectancy for metastatic adenocarcinoma (for which bevacizumab is approved) and metastatic small-cell carcinoma (bevacizumab not approved) did not change statistically. On the other hand, life expectancy for patients with metastatic squamous carcinoma (bevacizumab not approved) of the lung has declined since the approval of bevacizumab. This likely reflects increased classification of tumors previously diagnosed as poorly differentiated non-small-cell carcinoma as poorly differentiated squamous carcinoma. Hence, life expectancy of metastatic adeno, squamous, and small-cell-lung cancer has not improved after introduction of bevacizumab.

Suprapubic catheter placement through ileal mesentery causes mechanical small bowel obstruction six years later in a female patient with turners syndrome

Percutaneous suprapubic cystostomy (SPC) is a procedure performed to manage urinary retention when urethral catheterization is contraindicated or to improve the quality of life in cases such as neurogenic bladder. Although a simple procedure, it is associated with serious complications, increasing the morbidity and mortality. This case study demonstrates a delayed presentation of small bowel obstruction caused by a suprapubic catheter traversing through the ileal mesentery in a patient with no prior bowel surgeries. Few cases report this complication and this is possibly the first case to be reported six years after SPC placement.