Arieh Eitan

Perioperative Hyperoxygenation and Wound Site Infection Following Surgery for Acute Appendicitis: A Randomized, Prospective, Controlled Trial

OBJECTIVE To assess the influence of hyperoxygenation on surgical site infection by using the most homogeneous study population. DESIGN A randomized, prospective, controlled trial. SETTING Department of surgery in a government hospital. PATIENTS A total of 210 patients who underwent open surgery for acute appendicitis. In the study group, patients received 80% oxygen during anesthesia, followed by high-flow oxygen for 2 hours in the recovery room. The control group received 30% oxygen, as usual. INTERVENTION Open appendectomy via incision in the right lower quadrant of the abdomen. MAIN OUTCOME MEASURES Surgical site infection, mainly assessed by the ASEPSIS (additional treatment, serous discharge, erythema, purulent discharge, separation of deep tissues, isolation of bacteria, and stay in hospital prolonged >14 days) system score. RESULTS Surgical site infections were recorded in 6 of 107 patients (5.6%) in the study group vs 14 of 103 patients (13.6%) in the control group (P = .04). Significant differences in the ASEPSIS score were also found. The mean hospital stay was longer in the control group (2.92 days) compared with the study group (2.51 days) (P = .01). CONCLUSION The use of supplemental oxygen is advantageous in operations for acute appendicitis by reducing surgical site infection rate and hospital stay. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01002365.

Laparoscopic management of lumbar hernia

Abstract. We describe (for the first time) a laparoscopic approach to repair an acquired superior triangle lumbar hernia in a morbidly obese woman by using prosthetic mesh. Such a technique provides an excellent anatomic view, thus avoiding injury to structures in proximity to the hernia during repair; eventually the well-known advantages of such approach result.

Three years of experience with advanced breast biopsy instrumentation (ABBI).

This article reports our experience using the advanced breast biopsy instrument (ABBI) system for excisional biopsy of mammographically visible nonpalpable breast lesions. Patients with nonpalpable mammographically detected breast lesions were evaluated as potential ABBI candidates. Selection criteria included noncystic lesions for which complete removal or large sampling was indicated, compressed thickness of the breast of more than 25 mm, and the patients ability to lie prone for at least 1 hour. During the period August 1997–April 2000 (33 months), 284 patients were found to be potential ABBI candidates. Sixteen patients were subsequently excluded. Biopsies using the ABBI system were performed in 268 cases, yielding an overall technical success rate of 94.4%. The mammographic abnormalities included mass in 125 cases (46.6%), mass with calcifications in 63 cases (23.5%), and microcalcifications without a mass in 80 cases (29.8%). Histologically 56 specimens (20.9%) were malignant (mass in 30 cases, mass with calcifications in 12, and microcalcifications in 14) and 212 (79.1%) were benign. Carcinoma in situ was found in 17 cases (30.4%), invasive carcinoma in 35 cases (62.5%), tubular carcinoma in 2 cases (3.6%), metastatic intramammary lymph node of previously unknown malignant melanoma in 1 case, and malignant lymphoma in 1 case. Open reexcision was performed in 54 cases with primary breast cancer. The histologic investigation revealed that in 26 (48.15%) cases the mammographic lesion was completely excised and in 28 (51.85%) cases the margins involved malignant residue and/or other foci of carcinoma. There were complications in 17 cases: wound infection in 2, ecchymosis in 9, seroma in 5, and a large immediate hematoma in 1 patient. Only the latter patient required immediate revision and drainage; the remainder underwent successful conservative treatment. Most nonpalpable breast lesions, if selected properly, are accessible for ABBI procedure. The biopsy causes minimal complications and minimal distortion of the breast architecture. Should relumpectomy be needed after the ABBI procedure, the tunnel of the cannula path is easily recognized, leaving no need for needle localization.

A simplified laparoscopic technique for mesh placement in ventral hernia repair.

Abstract. The use of a large synthetic mesh for laparoscopic repair of significant ventral abdominal wall defects may be accompanied by technical difficulties resulting from improper orientation and positioning of the mesh over the defect. We suggest a technique based on initial fixation of the mesh center to the central point of the defect, and subsequent centrifugal attachment of the mesh to the abdominal wall. This technique is advantageous because it leads to precise orientation and positioning of the synthetic patch and to significant reduction of the time needed for its reinforcement over and around the defect.

Pelvic Actinomycosis Presenting as Ureteric and Rectal Stricture

Background/Aims: Simultaneous ureteric and rectal stricture due to pelvic actinomycosis is very rare and only a few cases of either rectal or ureteric stricture have been reported. Our aim is to report a case of stricture of the rectum and the right ureter due to pelvic actinomycosis infection in a 63-year-old man. Methods: Explorative laparotomy and biopsies of the inflammatory pelvic mass were the only procedures that led to the definitive diagnosis of actinomycosis. Temporary diverting colostomy, drainage of the right ureter by a pigtail catheter and postoperative treatment with appropriate antibiotics were successful in eradicating the inflammatory process. Conclusions: Extensive pelvic masses involving pelvic viscera should be biopsied before undertaking any major surgery because of the possibility of pelvic actinomycosis.

An unusual presacral mass : Extramedullary hematopoiesis

Presacral masses are a rare finding in the adult patient, confronting the physician with diagnostic and therapeutic challenges. We present an unusual case of a symptomatic presacral mass caused by extramedullary hematopoietic tissue in a thalassemic patient and review the unique aspects of this entity.

The physiological impact of intermittent sequential pneumatic compression (ISPC) leg sleeves on cardiac activity

BACKGROUND Pneumatic sleeves are widely used in surgery to prevent venous stasis and to improve cardiac function. The aim of this study was to assess the underlying cardiovascular mechanism induced by the activation of intermittent sequential pneumatic compression (ISPC) in healthy volunteers. METHODS Twenty male subjects underwent transthoracic echocardiographic and tissue Doppler imaging evaluation before and during the activation ISPC devices. Each patient served as his own control. RESULTS Following ISPC activation, there were significant increases in cardiac output (from 5.1 to 5.5 L/min, P < .05) and stroke volume (from 72 to 78 mL, P < .002), as well as ejection fraction, the velocity-time integral of aortic flow, and fractional shortening of the left ventricle. There was no increase in heart rate. Tissue Doppler imaging was compatible with normal cardiac responses. Total peripheral resistance was significantly reduced during ISPC activation. CONCLUSIONS The activation of ISPC devices in normal volunteers augmented cardiac output because of increased preload as well as decreased afterload.

Prickly pear fruit bezoar presenting as rectal perforation in an elderly patient

Background and aimsPrickly pear fruit rectal seed bezoars are an extremely rare entity. Only nine cases of rectal seed bezoar have been reported, only one of which involved the prickly pear fruit seed. Furthermore, to our knowledge, this is also the first reported case presenting as rectal perforation.Patients and methodsWe report a case of prickly pear fruit bezoar occurring in the elderly whom presented with rectal perforation. Consistent with physical signs, laboratory results, and radiological findings the patient was diagnosed with acute perforation of the rectum. A Hartman procedure was performed, and a colostomy was placed.ResultsCurrently there are very few data regarding seed bezoars reaching the rectum. There are even fewer data concerning this occurrence in the elderly, and the literature contains no report of this phenomenon presenting or even progressing into perforation. We report this rare entity to the existing literature.ConclusionWe report a rare but important case. A prickly pear fruit phytobezoar presenting as rectal perforation. This case may add to the increasing awareness of the danger associated with ingestion of certain foodstuffs. The previously benign sunflower and psyllium seeds are now known to cause bezoar. We feel that the prickly pear fruit should join this small but important list.

The Use of Pneumoperitoneum During Laparoscopic Surgery as a Model to Study Pathophysiologic Phenomena: The Correlation of Cardiac Functionality with Computerized Acoustic Indices—Preliminary Data

BACKGROUND Induction of pneumoperitoneum during laparoscopic surgery leads to diverse cardiovascular changes that can be used as a model to study pathophysiologic phenomena. Application of novel signal processing and figure extraction enabled searching for correlation between various signals and pathophysiologic setting. Our aim was to quantitatively correlate cardiac functionality (as expressed by cardiac output) with the spectral energy of the first heart sound (S1) obtained from the phonocardiogram, during laparoscopic surgery. PATIENTS AND METHODS Patients who were scheduled for elective laparoscopic operations were enrolled in the study. Cardiac output was maximally changed during anesthesia and abdominal insufflation and was obtained from the arterial pressure wave (FloTrac™ sensor and Vigileo™ monitor [Edwards Lifesciences Ltd.]). Heart signals were recorded during surgery from each subject by a computerized digital data acquisition system. The automatic analysis of the heart sounds included segmentation that was based on the energy envelope of the heart sounds together with analysis of the electrocardiogram signal. We analyzed the morphology of the sounds using hierarchial cluster analysis to remove those sounds that were not reliably recorded. The magnitude of the amplitude of heart sounds was obtained by using the Hilbert transform for each heartbeat. Statistical analysis was based on linear regression. RESULTS Following exclusion of 3 patients (mainly because of technical reasons), we were left with 7 patients who demonstrated statistically significant positive correlation between cardiac index and the amplitude of S1 (regression coefficient between 0.4 and 0.9, P<.05). Linear regression analysis was done on the normalized values of all 7 patients and was found to be highly significant. CONCLUSIONS In this study we have demonstrated significant linear correlation between the acoustic amplitude (spectral energy) of S1 and cardiac functionality, through sophisticated computerized analysis, using the pneumoperitoneum model for changing the cardiac output.

Angiodysplasia of the Colon as a Cause of Massive Rectal Bleeding

Lately there is a growing number of reports in the surgical literature about bleeding from the lower gastrointestinal (GI) tract caused by angiodysplasia. Probably, similar previous cases that were described as bleeding from diverticulosis in the right colon were cases of undiagnosed angiodysplasias. In our opinion, the labeled erythrocyte scan is the key examination for suspected bleeding from the lower GI tract, because it is simple, noninvasive, sensitive, and able to follow the patient for 24 h, an important fact in intermittent bleeding. If bleeding is fast and does not stop, an angiography may be performed to demonstrate the lesion. Barium enema is used only to rule out other findings in the colon, and does not help in the diagnosis – sometimes it even interferes with the X-ray and endoscopic clarification. The finding of diverticula in the colon does not rule out angiodysplasia. By adopting this diagnostic procedure, one may reach a preoperative diagnosis of the area of bleeding in the colon, and avoid wide resections in old patients usually suffering from massive rectal bleeding. We describe four characteristic cases with diagnostic procedures. All had a right hemicolectomy, where the bleeding was proved to exist, and in all of them the bleeding did not recur.