Christian T. Hamel

Nonoperative treatment of splenic rupture in malaria tropica: review of literature and case report.

In many parts of the world malaria still is a major medical problem. Heavy international and transcontinental traveling carries malaria to non-endemic areas. Practicing physicians must be aware of the common, but also the rare and severe complications of malaria. During malaria changes in splenic structure can result in asymptomatic enlargement or complications such as hematoma formation, rupture, hypersplenism, ectopic spleen, torsion, or cyst formation. An abnormal immunological response may result in massive splenic enlargement. Spontaneous rupture of the spleen is an important and life threatening complication of Plasmodium vivax infection, but is rarely seen in Plasmodium falciparum malaria. The ability to properly diagnose and manage these complications is important. Spleen-conserving procedures should be the standard whenever possible especially in patients with a high likelihood of future exposure to malaria.

Long-term follow-up of a randomized controlled trial of Lichtenstein's operation versus mesh plug repair for inguinal hernia.

Objective:To compare long-term results of Lichtensteins operation versus mesh plug repair for open inguinal hernia repair. Background:The technique of best choice in open prosthetic inguinal hernia repair remains a subject of ongoing debate. Methods:In this prospective, randomized controlled multicenter trial, patients with primary or recurrent inguinal hernias were randomized to undergo either Lichtensteins operation or mesh plug repair. The primary endpoint was the long-term recurrence rate. Secondary endpoints included chronic pain, sensibility disorders, and reoperation rate. Results:In total, 697 hernias in 594 patients were randomized (297 patients per group). At a median follow-up of 6.5 years, 528 (76%) operated hernias in 444 (75%) patients were clinically evaluated. The recurrence rate was similar in both groups [mesh plug: 21/268 hernias = 7.8%; Lichtenstein: 21/260 hernias = 8.1%; adjusted odds ratio (OR): 0.92; 95% confidence interval (CI): 0.51, 1.68; P = 0.795]. We did not find a significant difference for chronic pain (Visual Analog Scale score >3) (OR: 0.58; 95% CI: 0.31, 1.09; P = 0.088) and sensory testing (17% vs 20% of patients; OR: 0.53; 95% CI: 0.21, 1.37; P = 0.190) between the 2 groups. There were less reoperations in the mesh plug than in the Lichtensteins operation group (OR: 0.43; 95% CI: 0.22, 0.85; P = 0.016). Conclusions:The long-term results of this trial indicate not enough evidence for differences in recurrence, chronic pain, and sensibility disorders between mesh plug repair and Lichtensteins operation but a lower likelihood for reoperation for mesh plug repair. Estimates for all endpoints were statistically not significant or based on large CIs. Clinical Trials Registration:ClinicalTrials.gov Identifier: NCT01637818.

Carbon Dye Staining of Sentinel Lymph Nodes Facilitates Microstaging of Colon Cancer Patients

BackgroundCarbon dye, when peritumourally injected, permanently marks the drainage site of sentinel lymph nodes (SLN). The objective of the current study was to evaluate whether the use of carbon dye facilitated the detection of small nodal tumour infiltrates in colon cancer patients.MethodsIn a prospective trial, 19 patients underwent open, oncological resections of localized colon cancer and SLN procedure according to a standardized protocol. Isosulfan blue 1% and sterile filtered carbon dye (mixed 1:1) were injected into the subserosa circumferentially around the tumour. Lymph nodes staining blue were marked as SLN. Serial sections of each SLN were stained with hematoxylin and eosin (H&E) and with the pancytokeratin marker AE1/AE3. The intranodal presence and site of carbon particles were noted and compared with the location of possible tumour infiltrates.ResultsIdentification of at least one SLN was successful in 18 patients (identification rate 95%). Four patients (22%) were pN+, 11 (61%) were pN0(i−). Three patients (17%) were upstaged from pN0(i−) to pN0(i+) as isolated tumour cells were detected in their SLN: in two (11%) of the three patients, carbon dye and isolated tumour cells were found in the same nodal compartment, hence facilitating the recognition of isolated tumour cells by the pathologist.ConclusionThe use of carbon dye in the SLN procedure for colon cancer may facilitate the detection of small nodal tumour infiltrates.

Ileocecal segment transposition does not alter whole gut transit in humans.

OBJECTIVES We have recently described a reservoir for rectal replacement after total mesorectal excision for rectal carcinoma. The ileocecal segment with its intact extrinsic nerve and blood supply is placed between the ascending colon and the anal canal. This reconstruction has been shown to provide good defecation quality and anorectal function. Whether gastric emptying and small as well as large bowel transit are affected by this transposition remains unclear. Our aim was to quantify whole gut transit in such patients and compare it with that of a matched group of controls. METHODS Gastric emptying rates and small intestinal and colonic transit times were assessed scintigraphically in 12 patients aged 46 to 87 years with ileocecal reservoir reconstruction after total mesorectal excision and compared to a sex-matched group of asymptomatic healthy volunteers of similar age. Gastric emptying rates and small intestinal and colonic transit times were calculated as described previously. Data were compared using Wilcoxons signed rank test for gastric emptying rates and small bowel transit or by analysis of variance for colonic transit; p < 0.05 was considered significant. RESULTS Gastric time for half of the meal (T50) was 161 +/- 16 minutes for patients and 201 +/- 22 for the controls. Small bowel transit time was 150 +/- 15 minutes for patients and 177 +/- 22 for the controls. Geometric center at 6 hours was 1.53 +/- 0.13 for patients and 1.27 +/- 0.16 for the controls. Geometric center at 24 hours was 2.96 +/- 0.23 for patients and 2.57 +/- 0.25 for the controls. Data are mean +/- SEM. SUMMARY Gastric emptying rates and small bowel transit and colonic transit times (expressed as geometric center at 6 and 24 hours) were similar in patients with ileocecal reservoir reconstruction and in a sex- and age-matched group of healthy controls. We conclude that the transposition of an ileocecal segment with intact extrinsic neurovascular supply between the sigmoid colon and the anal canal does not alter whole gut transit, not even in any of the presumably key regions.

Simplified placement and management of cutting setons in the treatment of transsphincteric anal fistula: technical note

BackgroundWe report one safe and standardized technique of seton placement and management.ConclusionsA simplified way to manage cutting setons helps to minimize manipulation and may reduce pain. In most patients our technique can be used with no additional anesthesia and in an outpatient setting.

Multislice CT in adult colocolic intussusception: case report and review of the literature

Intussusception in adults is generally a rare diagnosis and generally different from intussusception in children in terms of clinical presentation, etiology, and incidence (Begos et al., Am J Surg, 173:88–94, 1997; Watson and Bisset, Clin Radiol, 49:723–726, 1994; Felix et al., Am J Surg, 131:723–726, 1976). One third of these affect the large bowel. Adult intussusception shows clinically uncharacteristic symptoms of bowel obstruction; thus, the diagnosis is often clinically missed. We report the case of a 39-year-old woman suffering from long-term abdominal pain. This case report discusses the clinical advantages of multislice computed tomography for the diagnosis of adult intussusception and shows a comprehensive overview of the literature.

Performance on a Virtual Reality Angled Laparoscope Task Correlates with Spatial Ability of Trainees

The aim of the present study was to investigate whether trainees’ performance on a virtual reality angled laparoscope navigation task correlates with scores obtained on a validated conventional test of spatial ability. 56 participants of a surgery workshop performed an angled laparoscope navigation task on the Xitact LS 500 virtual reality Simulator. Performance parameters were correlated with the score of a validated paper-and-pencil test of spatial ability. Performance at the conventional spatial ability test significantly correlated with performance at the virtual reality task for overall task score (p < 0.001), task completion time (p < 0.001) and economy of movement (p = 0.035), not for endoscope travel speed (p = 0.947). In conclusion, trainees’ performance in a standardized virtual reality camera navigation task correlates with their innate spatial ability. This VR session holds potential to serve as an assessment tool for trainees.