Management of blunt injuries to the spleen

• Author: P. Renzulli, T. Gross, B. Schnüriger, A. M. Schoepfer, D. Inderbitzin, A. K. Exadaktylos, H. Hoppe, D. Candinas
• Published: Aug 26, 2010
• Pages: 1696-1703
• DOI: 10.1002/bjs.7203

Abstract

Background:

Non‐operative management (NOM) of blunt splenic injuries is nowadays considered the standard treatment. The present study identified selection criteria for primary operative management (OM) and planned NOM.

Methods:

All adult patients with blunt splenic injuries treated at Berne University Hospital, Switzerland, between 2000 and 2008 were reviewed.

Results:

There were 206 patients (146 men) with a mean(s.d.) age of 38·2(19·1) years and an Injury Severity Score of 30·9(11·6). The American Association for the Surgery of Trauma classification of the splenic injury was grade 1 in 43 patients (20·9 per cent), grade 2 in 52 (25·2 per cent), grade 3 in 60 (29·1 per cent), grade 4 in 42 (20·4 per cent) and grade 5 in nine (4·4 per cent). Forty‐seven patients (22·8 per cent) required immediate surgery. Transfusion of at least 5 units of red cells (odds ratio (OR) 13·72, 95 per cent confidence interval 5·08 to 37·01), Glasgow Coma Scale score below 11 (OR 9·88, 1·77 to 55·16) and age 55 years or more (OR 3·29, 1·07 to 10·08) were associated with primary OM. The rate of primary OM decreased from 33·3 to 11·9 per cent after the introduction of transcatheter arterial embolization in 2005. Overall, 159 patients (77·2 per cent) qualified for NOM, which was successful in 143 (89·9 per cent). The splenic salvage rate was 69·4 per cent. In multivariable analysis age at least 40 years was the only factor independently related to failure of NOM (OR 13·58, 2·76 to 66·71).

Conclusion:

NOM of blunt splenic injuries has a low failure rate. Advanced age is independently associated with an increased failure rate. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

New anatomical classification of the axilla with implications for sentinel node biopsy

• Author: K. B. Clough, R. Nasr, C. Nos, M. Vieira, C. Inguenault, B. Poulet
• Published: Aug 26, 2010
• Pages: 1659-1665
• DOI: 10.1002/bjs.7217

Abstract

Background:

The exact anatomical location of the sentinel lymph node (SLN) in the axilla has not ascertained clinically, but could be useful both for teaching purposes and to reduce the morbidity of SLN biopsy. The aim of the study was to determine the position of the SLN in the axilla and to demonstrate that this location is not random.

Methods:

A consecutive series of 242 patients with stage I breast cancer (T1/T2 N0) or ductal carcinoma in situ who underwent SLN localization by peritumoral injection were included in a prospective study to map the location of the SLN in the axilla. A new anatomical classification of the lower part of the axilla based on the intersection of two anatomical landmarks, the lateral thoracic vein (LTV) and the second intercostobrachial nerve (ICBN), is described. These two constant elements form the basis of four axillary zones (A, B, C and D).

Results:

In 98·2 per cent of patients the axillary SLN was located medially, alongside the LTV, either below the second ICBN (zone A, 86·8 per cent) or above it (zone B, 11·5 per cent). In only four patients (1·8 per cent) was the SLN located laterally in the axilla.

Conclusion:

Regardless of the site of the tumour in the breast, 98·2 per cent of SLNs were found in the medial part of the axilla, alongside the LTV. This information should help to avoid unnecessary lateral dissections. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Randomized clinical trial comparing surgery, endovenous laser ablation and ultrasound‐guided foam sclerotherapy for the treatment of great saphenous varicose veins

Background
Endovenous ablation techniques and ultrasound‐guided foam sclerotherapy (UGFS) have largely replaced open surgery for treatment of great saphenous varicose veins. This was a randomized trial to compare the effect of surgery, endovenous laser ablation (EVLA) (with phlebectomies) and UGFS on quality of life and the occlusion rate of the great saphenous vein (GSV) 12 months after surgery.

Methods
Patients with symptomatic, uncomplicated varicose veins (CEAP class C2–C4) were examined at baseline, 1 month and 1 year. Before discharge and at 1 week, patients reported a pain score on a visual analogue scale. Preoperative and 1‐year assessments included duplex ultrasound imaging and the Aberdeen Varicose Vein Severity Score (AVVSS).

Results
The study included 214 patients: 65 had surgery, 73 had EVLA and 76 had UGFS. At 1 year, the GSV was occluded or absent in 59 (97 per cent) of 61 patients after surgery, 71 (97 per cent) of 73 after EVLA and 37 (51 per cent) of 72 after UGFS (P < 0·001). The AVVSS improved significantly in comparison with preoperative values in all groups, with no significant differences between them. Perioperative pain was significantly reduced and sick leave shorter after UGFS (mean 1 day) than after EVLA (8 days) and surgery (12 days).

Conclusion
In comparison with open surgery and EVLA, UGFS resulted in equivalent improvement in quality of life but significantly higher residual GSV reflux at 12‐month follow‐up. 



Author: M. Venermo, J. Saarinen, E. Eskelinen, S. Vähäaho, E. Saarinen, M. Railo, I. Uurto, J. Salenius, A. Albäck,
Published: Aug 26, 2016
Pages: 1438-1444
DOI: 10.1002/bjs.10260

Computed Tomography Utilization for the Diagnosis of Acute Appendicitis in Children Decreases With a Diagnostic Algorithm

Objective: The primary objective of this project was to decrease computed tomography (CT) utilization for the diagnosis of appendicitis in an academic children's hospital emergency department (ED) through a multidisciplinary quality improvement initiative.

Background: Appendicitis is the most common abdominal diagnosis leading to the hospitalization of children in the United States. However, the diagnosis of appendicitis in children can be difficult and many centers rely heavily upon CT scans. Recent recommendations emphasize decreasing CT use among pediatric patients because of an increased lifetime risk of radiation-induced malignancies.

Methods: A retrospective review was conducted of patients diagnosed with appendicitis in the ED at Children's Mercy Hospital from January 1, 2011 to February 28, 2014 to establish a baseline cohort. From August 1, 2014 to July 31, 2015, a newly designed diagnostic algorithm was used in the ED and patients were prospectively followed. Any patient discharged from the ED received a follow-up phone call. Patients treated for appendicitis before and after pathway implementation were compared. In addition, any patient evaluated for appendicitis after implementation of the algorithm was analyzed for adherence to the clinical pathway. Differences between the 2 groups were analyzed using ANOVA, Wilcoxon Rank Sum, χ2, and Fisher Exact tests.

Results: Of 840 patients seen after implementation of the diagnostic algorithm, 267 were diagnosed with appendicitis. After implementation of the algorithm, CT utilization decreased from 75.4% to 24.2% (P < 0.0001) in patients with appendicitis. CT utilization was 27.3% after implementation, regardless of the ultimate diagnosis or algorithm adherence. The diagnostic pathway had a sensitivity of 98.6% and specificity of 94.4%.

Conclusions: Implementation of a diagnostic algorithm for appendicitis in children significantly decreases CT utilization, whereas maintaining a high sensitivity and specificity.journals.lww.com

by Shah, Sohail R.; Sinclair, Kelly A.; Theut, Stephanie B.; Johnson, Kathy M.; Holcomb, George W. III; St. Peter, Shawn D. / Today, 5:30 AM

Systematic review and meta-analysis of the association between diabetes mellitus and incidence and mortality in breast and colorectal cancer

Background Increasing evidence suggests that diabetes mellitus (DM) is associated with increased cancer incidence and mortality. Several mechanisms involved in diabetes, such as promotion of cell proliferation and decreased apoptosis, may foster carcinogenesis. This study investigated the association between DM and cancer incidence and cancer-specific mortality in patients with breast and colorectal carcinoma. Methods A meta-analysis of controlled trials, prospective cohort studies and pooled cohort studies published after 2007 was conducted. Embase, PubMed and the Cochrane Library were searched. Summary hazard ratios (HRs) were calculated using a random-effects model. Sensitivity and subgroup analyses were performed to adjust for confounders, mode of DM assessment and follow-up time. Results Twenty studies were included to investigate the association between DM and breast and colorectal cancer incidence and cancer-specific mortality. The studies predominantly comprised patients with type II DM. The overall HR for breast cancer incidence was 1·23 (95 per cent confidence interval 1·12 to 1·34) and that for colorectal cancer was 1·26 (1·14 to 1·40) in patients with DM compared with those without diabetes. The overall HR was 1·38 (1·20 to 1·58) for breast cancer- and 1·30 (1·15 to 1·47) for colorectal cancer-specific mortality in patients with DM compared with those without diabetes. Conclusion This meta-analysis indicated that DM is a risk factor for breast and colorectal cancer, and for cancer-specific mortality.

British Journal of Surgery
Posted on: Wednesday, September 04, 2013 7:46 PM
Author: K. M. J. De Bruijn, L. R. Arends, B. E. Hansen, S. Leeflang, R. Ruiter, C. H. J. van Eijck
Subject: Systematic review and meta-analysis of the association between diabetes mellitus and incidence and mortality in breast and colorectal cancer

Opportunities and challenges of next-generation DNA sequencing for breast units

Background The aim of this review is to introduce the topic of next-generation DNA sequencing, a new technology that is being introduced into clinical practice, and to explain the potential impact for breast cancer surgeons and the wider breast cancer multidisciplinary team. Methods The PubMed database was used to identify relevant studies relating to breast cancer genetics. This evidence was then used to provide context and background information to demonstrate how next-generation sequencing (NGS) might change breast cancer practice. Results With NGS, breast cancer clinicians will know whether their patients carry high-risk mutations in genes, such as BRCA1 or BRCA2, before the start of treatment. This could alter treatment decisions; for instance, more women might opt for mastectomy instead of breast-conserving surgery, or for bilateral rather than unilateral surgery. Conclusion The introduction of NGS will have a significant impact on breast cancer services in the near future. Speed of testing will improve in regions of the world where NGS is adopted in place of conventional sequencing, and, as costs decrease, genetic testing will also become accessible and realistic in less well funded health economies. This will create opportunities to improve patient treatment and challenges for the breast cancer multidisciplinary team.

British Journal of Surgery
Posted on: Thursday, March 27, 2014 6:25 PM
Author: S. M. Pilgrim, S. J. Pain, M. D. Tischkowitz
Subject: Opportunities and challenges of next-generation DNA sequencing for breast units

Outcome of sleeve gastrectomy as a primary bariatric procedure

Background Sleeve gastrectomy is being performed increasingly in Europe. Data on long-term outcome would be helpful in defining the role of sleeve gastrectomy. The aim of this study was to evaluate the outcome of sleeve gastrectomy as a primary bariatric procedure. Methods Medical charts of all patients who underwent a primary sleeve gastrectomy at the authors' institution between August 2006 and December 2012 were reviewed retrospectively using a prospective online data registry. For evolution of weight loss and co-morbidity, only patients with follow-up of at least 1 year were included. A subgroup analysis was done to compare patients with an intended stand-alone procedure and those with an intended two-stage procedure. Results A total of 1041 primary sleeve gastrectomies were performed in the study period. Median duration of surgery was 47 min, and median hospital stay was 2 days. Intra-abdominal bleeding occurred in 27 patients (2·6 per cent) and staple-line leakage in 24 (2·3 per cent). Some 866 patients had at least 1 year of follow-up. Mean excess weight loss was 68·4 per cent after 1 year (P < 0·001) and 67·4 per cent after 2 years. Smaller groups of patients achieved a mean excess weight loss of 69·3 per cent (163 patients), 70·5 per cent (62) and 58·3 per cent (19) after 3, 4 and 5 years respectively. No difference in postoperative complications was found between the subgroups. Seventy-one (8·2 per cent) of 866 patients had a revision of the sleeve gastrectomy; reflux or dysphagia was the indication in 34 (48 per cent) of these patients. Conclusion Sleeve gastrectomy is a safe and effective bariatric procedure. Maximum weight loss was achieved after 4 years. Long-term results regarding weight loss and co-morbidities were satisfactory.

British Journal of Surgery
Author: P. W. J. van Rutte, J. F. Smulders, J. P. de Zoete, S. W. Nienhuijs
Subject: Outcome of sleeve gastrectomy as a primary bariatric procedure