Journal of Surgery

Objectives: Surgeons and health systems face challenges in achieving healthcare cost containment without compromising patient outcome. This study objective was to correlate operating room costs of elective colectomies with their outcome.

Design: Retrospective observational study. Statistical analysis included t-test, ANOVA and Spearman correlation between continuous variables. Setting: Tertiary care medical center. Patients: 114 consecutive patients who underwent an elective colectomy were analyzed collectively and in subgroups by type of Operation: Laparoscopic right colectomy, Open right colectomy, Laparoscopic left colectomy, Open left colectomy, Open total colectomy/proctectomy, Laparoscopic converted to open colectomy. Operating room cost was calculated as charges for equipment utilized and personnel cost. Main Outcome Measures: Outcome was expressed as a weighted numerical score for each patient, ranging from 0 to 10. The score took into account hospital length of stay, complications, 30-day readmission and mortality

Results: Colectomy cost ranged from $387 to $8262 (mean=$2176 ± 1244). The mean outcome score was 8.01 ± 2.4 (p=0.091). Operating room cost did not correlate with outcome, collectively or per subgroup. Conclusions: Higher operating room expenditures did not achieve a superior outcome for elective colectomy. This preliminary work may prompt further analyses of resource utilization versus outcome in surgical practice.

Background: Abdominal aortic aneurysms (AAA) are a common vascular disease mostly affecting those over the age of 65 years. Open surgical repair (OSR) is considered the gold standard for the treatment of AAA, however longterm mortality and morbidity still remain high in patients with inflammatory AAA, when compared to atherosclerotic AAA. The aim of this study was to evaluate long-term outcomes of both inflammatory and atherosclerotic AAA after OSR.

Methods: Out of 837 aortic interventions, 149 patients were identified as having undergone open surgical repair for AAA between 2003 and 2013. Of the 149 patients, histopathological data was available for 92 patients with open AAA repair. Kaplan-Meier curves were analysed to evaluate probability of survival.

Results: Patients with inflammatory AAA were younger (70 years) by an average of 2 years compared to atherosclerotic AAA (72 years). Morbidity and length of intensive care stay were insignificantly different in both groups. Inflammatory AAA were associated with higher all cause survival rate (82%) compared to atherosclerotic AAA (68%) (P=0.008) after ten years.

Conclusion: There was no difference in clinical outcomes between both atherosclerotic AAA and inflammatory AAA, which is due to the technique used. IAAA were associated with lower mortality rates and improved all cause survival at ten years post open surgical repair.

Introduction: Laparoscopic ventral mesh rectopexy (LVMR) is gaining wider acceptance. The aim of this study is to present that LVMR can be learnt and safely performed with short term results similar to that of establish centres.

Materials and Methods: All underwent anorectal physiology, defecation proctography, colon transit studies, colonoscopy or sigmoidoscopy as appropriate and pelvic floor MDT and biofeedback. Patients with high grade intussusception who did not respond to laxatives and biofeedback were offered LVMR. Surgical technique was as described by D’Hoore et al. and performed by both authors. Data are presented as median, range and proportions.

Results: Median age, ASA & BMI were 60.5 (34-78), 2 (1-3), 26.1 (20.4-33.1). Previous pelvic surgery included hysterectomy (35%), vaginal wall repair (15%) and rectal prolapse surgery (20%). 45% had Oxford prolapse grades 3/4 and rest were grade 5. Median operative time was 229 minutes (175-330). Synthetic mesh was used in 16 patients (Parietex 30%, TiLENE 50%) and Permacol in four (20%). 30 day mortality was zero. There were no conversions and overall complication rate was 10%.Sexual dysfunction was not reported. Median length of stay was 3 (2-6). 17 patients (85%) had 6 months or more follow up. Median patient reported outcome for satisfaction was 9.5 on a scale of 1 to 10 (2-10). Two patients developed recurrences of ODS at 6 and 12 months.

Discussion and Conclusions: We suggest that experienced laparoscopic surgeons can learn and safely perform laparoscopic ventral mesh rectopexy.

Introduction: Cholelithiasis involves the presence of gallstones that form in the biliary tract, usually in the gallbladder. Symptomatic cholelithiasis is an indication for surgical treatment. Quality of life and patient satisfaction following surgery is an important aspect in predicting treatment outcomes.

Aim: Measurement of quality of life, including the level of anxiety state and dynamics of changes of individual components (physical, mental, social, and environmental) over time (from qualifying for operations and the postoperative period, up to 6 months after surgery) in patients undergoing open and laparoscopy cholecystectomy.

Material and methods: The study group consisted of 105 people at the Clinical Department of Surgery, County Hospital in Tychy. The patients were divided into two groups, laparoscopic surgery (n = 83) and classical (n = 22). Tests on selected patients have been carried out before the operation, 1 month after and 6 months after surgery with the "quality of life questionnaire WHOQOL BREF" and "Inventory status and the guild anxiety STAI X1". The results were compared using statistical methods.

Results: In the group treated by laparoscopy better quality of life and lower levels of anxiety were observed after 6 months of treatment. Before surgery and one month after the procedure, significantly lower values of physical and mental disciplines were reported in the group operated laparoscopically than in patients operated by the classical method.

Conclusion: In patients undergoing laparoscopic surgery higher quality of life and lower levels of anxiety in the 6 month follow-up were observed, compared to patients operated conventionally.

Aim: Obesity has become one of the world’s major public health problems. It is now accepted that bariatric surgery is a far better option than nonsurgical treatments for morbid obese patients. Routine upper gastrointestinal (GI) endoscopy as a complementary method for evaluation of bariatric patient’s status prior to surgery is still a matter of debate. Aim of the study was to evaluate the importance of routine upper GI endoscopy before bariatric surgery.

Material and methods: A clinical retrospective study was carried out on a series of 77 patients referred for bariatric surgery between 2012 and 2015 in our surgical unit. We reviewed the medical records of all patients, endoscopy diagnosis, histopatological reports on gastric endoscopic biopsies and the colonisation with H. pylori.

Result: The patients in our study had a median age of 39.25 years and a BMI (body mass index) ranging from 33.3 to 60.5 kg/m2 (median of 44.66 kg/m2). Upper GI endoscopy was performed in all patients before bariatric surgery, regardless of upper gastrointestinal simptomatology. Chronic gastritis was found on upper GI endoscopy prior to bariatric surgery in 36.3% of cases and Helicobacter pylori infection was identified in 26% of cases. 6.5% of the patients were diagnosed with hiatal hernia, a hyperplastic gastric polyp, a intragastric pancreatic tissue ectopy and a case of gastric cancer were also detected.

Conclusion: Although preoperative endoscopy rarely diagnose pathological conditions that may change the surgical approach, we believe that, for a complete work-out of these patients, gastroenterology consultation and upper GI endoscopy should be mandatory prior to bariatric surgery.

Background: Fractures of the femoral head associated with a hip dislocation are relatively rare and often associated with a poor functional outcome. Materials and methods: In the past two years we had nine cases of femoral head Pipkin fracture-dislocations type I, II and IV. Medical data and radiographs, including computed tomography of the patients were reviewed for analysis. All patients were followed postoperatively for a period of minimum 22 months. Functional outcome was evaluated with the Merle d’Aubigne-Postel score.

Results: Of the fractures, four of them were classified as type I Pipkin, of which one was an open type 1 Gustilo- Anderson fracture, two were classified as type II Pipkin, and three were classified as type IV Pipkin. The time from injury to successful closed reduction was 6.7 hours (range 4.5-10 hours). Three type I Pipkin fracture-dislocations were treated by conservative means (no surgery) and one case required excision of intra-articular free bodies. In type II Pipkin fracture-dislocations, open reduction and internal fixation (ORIF) was performed in one case and hemiarthroplasty in the other. In type IV Pipkin lesions, we performed open reduction and internal fixation of the acetabular fracture through posterior Kocher-Langenbeck approach and excision of femoral head intra-articular free bodies The overall outcome was excellent in four cases and good in five cases. Throughout the follow-up period, there was no case of avascular necrosis (AVN) recorded. Heterotopic ossifications (HO) were observed in one case of type I Pipkin, two cases of type II Pipkin and one case of type IV Pipkin fractures.

Conclusion: Treatment aim should always be the anatomic reduction of the fragments with minimal soft tissue injury. Sometimes closed reduction is enough, but in the presence of large fragments, the fracture-dislocation is better treated by ORIF. We should not forget that half of these patients will have good outcomes no matter the treatment strategy; this result depends on the general health of the patient, the severity of the injury, associated injuries, associated cartilage injury, and timing of admission to the hospital.

Background: Breast cancer in men is rare (1% of all breast cancers) and shows some particularities. Methods: We performed a retrospective study analyzing patients admitted and treated in First Surgical Clinic, Emergency Hospital “St. Spiridon” Iasi from 1 January 2008 to 31 December 2015 with malignant breast tumors. Patients included in the study were diagnosed with breast cancer after pathological examination. We followed the clinical data, laboratory and postoperative follow-up of patients.

Results: Between 2008 to 2015 in our clinic were treated 319 breast cancers, of which only 11 men, so 3.4%, higher rate to literature data. Most of the patients were aged and with an advance clinical stage. The mean age of men with breast cancer was 67 years, ten years older than women with same disease. The favoring factors in the study group, were smoking, alcohol consumption in 10 patients, obesity present in 9 patients, blood type IIA, Rh + in 8 patients, periurethral adenoma in 7 patients, diabetes in 6 patients. Neoplastic family histories were recorded in 3 patients, one of Lynch syndrome type II, with BRCA2 mutation. In three cases the breast cancer was the 2nd or 3rd cancer after skin cancer after cancer urothelium and sarcoma soft tissue and in one case with colon cancer, 4 years after breast cancer surgery, with chemotherapy and radiotherapy (Lynch syndrome). We performed radical mastectomy with axillar lymphadenectomy in 9 cases and whiteout lymphadenectomy (sentinel lymphnode negative) in 2 cases. Median survival was 4.2 years (range 1-8 years).

Conclusion: Men have a particular form of breast cancer. Unlike women, this cancer is found in men at an older age, with a higher rate of lymphatic invasion and hormone receptor positivity. Treatment should be personalized by a multidisciplinary team.

Introduction: Stump appendicitis is a very rare complication after appendectomy with possible serious complications in the absence of a correct diagnosis.

Case Presentation: We present the laparoscopic diagnosis and treatment of an extremely rare complication after open appendectomy (remnant stump appendicitis). We report a female patient with a history of open appendectomy performed 7 months ago in another unit. She presented now with persistent typical signs of acute appendicitis, identical with those encountered before the open appendectomy. Repeated US and CT scans were normal. Due to the persistent complaints, a decision for exploratory laparoscopy was made. Intra-operatively we found some adhesions in the right iliac fossa and a 20 mm length appendicular stump which was adherent to the anterior abdominal wall. The stump was dissected, ligated at the base and removed using a 3 trocars approach and standard laparoscopy instruments. The postoperative course was favorable, resolution of the pain and no recurrence at a 3 years follow-up. The pathologic examination showed the typical histologic structure of an inflamed appendix.

Discussions: The diagnostic of stump appendicitis is a difficult one in the absence of a high index of suspicion. The case is interesting due to the rarity and the use of a laparoscopic approach to treat an incomplete open appendectomy.

Conclusions: Laparoscopy is useful in patients with persistent abdominal symptoms after open appendectomy. If an appendicular stump is present, it allows its identification and safe removal.

Among failed parathyroidectomy causes an important role is played by glandular ectopies, encountered in approximately 20% of cases; in 2% of cases they are localized in the mediastinum. In this latter situation there is a need for a thoracic approach which may be either classical or minimally invasive. The minimally invasive surgery is appealing and the results surpass those of classical surgery. Nevertheless, there are situations in which minimally invasive surgery is inefficient, not indicated, or unaffordable, thus, the classical approach remains the only option for surgical treatment. Partial sternotomy could represent a good alternative to classical full sternotomy or thoracotomy. We present the case of a hemodialysed patient with secondary persistent hyperparathyroidism after two failed parathyroidectomies; localization studies identified an ectopic hyperfunctional mediastinal parathyroid gland which was excised through a partial sternotomy. To the best of our knowledge, this is the first case reported in Romanian literature which describes this kind of approach for a mediastinal ectopic parathyroid gland.