Medical Library

High Association of Posterior Malleolus Fractures with Spiral Distal Tibial Fractures.

Associations between fracture patterns are important and can ensure proper diagnosis and guide treatment. Occult posterior malleolus fractures associated with distal spiral tibia fractures often are underrecognized and the morbidity of a missed posterior malleolus injury can be substantial. We determined the association between the two injuries and evaluated the ability of a new protocol to improve management of these associated fractures. Of 62 consecutive patients with fractures of the distal third of the tibia, we retrospectively evaluated the first 39 patients and prospectively used a diagnostic protocol including computed tomography of the ankle in the subsequent 23 patients. The minimum followup was 3 months (mean, 25 months; range, 3-68 months). Twenty-four patients (39%) had fractures of the posterior malleolus. Before initiation of the protocol, intraarticular fractures were recognized in 33% (with one delayed diagnosis and one missed diagnosis), and after institution of the protocol, the detection rate was 48% with no known missed injuries and complete followup; however, with the limited power the detection rates were similar without and with the protocol. A spiral distal tibial shaft fracture with a proximal fibula fracture should alert the surgeon to investigate an occult ankle injury, particularly of the posterior malleolus. A protocol including computed tomography of the ankle may detect more injuries in a larger study. Level of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Boraiah S, Gardner MJ, Helfet DL, Lorich DG.

Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA, vab9020@nyp.org.

Laparoscopic Totally Stapled Entero-Enterostomy: A Safe and Reproducible New Technique.

BACKGROUND: Laparoscopic gastric bypass for morbid obesity is a technically demanding procedure partially because of the necessity to construct two anastomoses. In this study, a new technique to perform the entero-enterostomy is presented. METHODS: We evaluated the procedure in a consecutive series of 100 patients who underwent laparoscopic gastric bypass. Intra- and postoperative complications were analyzed. RESULTS: No complications in relation to the construction of the entero-enterostomy occurred. No leakage, kinking, or stenosis was observed during a mean follow-up of 13.5 months (range 6-20 months). CONCLUSION: This new technique for a totally stapled entero-enterostomy can be recommended.

Lannoo M, Smet B, Miserez M, Penninckx F, D\’Hoore A.

Department of Abdominal Surgery, University Hospital Gasthuisberg, Herestraat 49, Leuven, 3000, Belgium.

Experience with the Duodenal Switch Operation in the Presence of Intestinal Malrotation.

The presence of intestinal malrotation (IM) may pose unexpected problems during bariatric operations. We reviewed the records of patients with IM undergoing bariatric operations at our institution over the last 5 years. Three patients underwent four procedures. These included an open duodenal switch, an attempted laparoscopic gastric bypass with open duodenal switch as a second-stage procedure, and lastly a laparoscopic robot-assisted duodenal switch. All patients have had good outcomes. The key anatomic principles of a tension-free duodeno-enterostomy and maintaining appropriate orientation at the distal enteroenterostomy are emphasized.

Puri V, Ramachandran J, Sudan R.

Creighton University Medical Center, Omaha, NE, USA.

Preoperative Upper Gastrointestinal Testing Can Help Predicting Long-term Outcome After Gastric Banding for Morbid Obesity.

BACKGROUND: Gastric banding (GB) is one of the most popular bariatric procedures for morbid obesity. Apart from causing weight loss by alimentary restriction, it can interfere with functions of the esophagus and upper stomach. The aim of this study was to evaluate if the results of extensive preoperative upper GI testing were correlated with long-term outcome and complications after GB. METHODS: Using a prospectively maintained computerized database including all the patients undergoing bariatric operations in both our hospitals, we performed a retrospective analysis of the patients who underwent complete upper gastrointestinal (GI) testing (endoscopy, pH monitoring, and manomatry) before GB. RESULTS: One hundred thirty-four patients underwent complete testing before GB. Abnormal pH monitoring (increased total reflux time, increased diurnal reflux time, increased number of reflux episodes) predicted the development of complications and especially pouch dilatation and food intolerance. The mean De Meester score was higher among patients who developed complications than in the remaining ones (25.4 vs 17.7, P = 0.03). High lower esophageal sphincter pressure also predicted progressive long-term food intolerance. Endoscopic findings were not predictive of the long-term outcome. CONCLUSIONS: There is some association between the function of the upper digestive tract and long-term complications after gastric banding. Abnormal pH monitoring predicts overall long-term complications, especially food intolerance with or without reflux, and pouch dilatation, and a high lower esophageal sphincter pressure predicts long-term food intolerance. Extended upper gastrointestinal testing with endoscopy, 24-h pH monitoring, and esophageal manometry is probably worthwhile in selecting patients for gastric banding.

Suter M, Giusti V, Calmes JM, Paroz A.

Department of Surgery, Hôpital du Chablais, Aigle-Monthey, 1860, Aigle, Switzerland, michelsuter@netplus.ch.

An Unusual Suspect: Coconut Bezoar After Laparoscopic Roux-en-Y Gastric Bypass.

Nausea and vomiting after gastric bypass are common, but some of the underlying causes may be life threatening or, in some cases, unusual. This case report describes a patient who underwent laparoscopic Roux-en-Y gastric bypass and whose postoperative course was complicated by a bezoar in the gastric pouch. To our knowledge, this is the first published report addressing a coconut bezoar in the gastric pouch after gastric bypass surgery. Coconut (cocos nucifera) is known to form emulsions and suspensions, properties likely to have contributed to this patient\’s condition. Nutritional counseling should be an ongoing process in the postoperative care of gastric bypass patients in an effort to prevent serious complications that may arise from dietary indiscretions.

Ionescu AM, Rogers AM, Pauli EM, Shope TR.

Department of Surgery, Section of Minimally Invasive and Bariatric Surgery, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, PO Box 850, MC H149, Hershey, PA, 17033, USA.

A Successful Model of Setting Up a Bariatric Practice.

Vital for any surgeon choosing to perform bariatric surgery is to be financially savvy. Establishing a practice is not a simple matter. This article will describe how physicians can establish their practice in weight loss medicine. To better insure success, wisdom dictates that one perform a geographical study with respect to (1) obesity in the population, (2) number of bariatric surgeons in the area, (3) the nature of the insurance companies, (4) the type of insurance (helath maintenance organization, HMO versus private pay versus Medicare, Medicaid, etc.), and (5) the leverage that the practice might be able to acquire (what is not being done by your competitors). To improve the financial strength of your practice, (1) learn what must be improved within your practice; (2) increase the ratio of time in the operating room to time in the office; (3) increase the number of patients referred to you. Most important is flexibility; the only people who really survive are chameleons because only chameleons adapt to different situations. Setting up a bariatric practice can be quite difficult, especially in the academic setting, but it is not impossible. A team approach is essential, whether one is speaking of a team of characteristics that make an office suitable, a team of experts within the office to appropriately evaluate patients, a team of professionals in the office to ensure efficient insurance approval, or a team of persons in the operating room to ensure that the surgery is optimized. The local environment must always be kept in mind.

Frezza EE, Wachtel MS.

Department of Surgery, Division of General Surgery, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX, 79430, USA, eldo.frezza@ttuhsc.edu.

Cachexia Worsens Prognosis in Patients with Resectable Pancreatic Cancer.

INTRODUCTION: Pancreatic cancer is the fourth leading cause of cancer-related death in Western countries with a poor prognosis (5-year survival rates, 25% in patients after tumor resection with adjuvant treatment; overall, the 5-year survival rate is about 4%; Jemal et al., CA Cancer J Clin, 55:10-30, 2005). Many patients develop a cachectic status during the progression of the disease, and this syndrome accounts for up to 80% of deaths in patients with advanced pancreatic cancer. Remarkably, there are only a few data available on the impact of cachexia in patients with pancreatic cancer scheduled for tumor resection. MATERIAL AND METHODS: Therefore, in this study, 227 consecutive patients with ductal adenocarcinoma of the pancreas were documented over an 18-month period regarding the prevalence of cachexia and its influence on perioperative morbidity and mortality with a special interest to postoperative weight gain and survival in a prospectively designed database and followed up. RESULTS: In 40.5% of the patients, cachexia was already present at the time of operation. The cachectic patients did present in a worse nutritional status, represented by lower protein, albumins, and hemoglobin levels. Despite no significant differences in tumor size, lymph node status, and CA19-9 levels, the resection rate in patients with cachexia was reduced (77.8% vs. 48.9%) due to a higher rate of metastatic disease in patients with cachexia. The morbidity and in-hospital mortality revealed no significant difference. However, patients with and without cachexia lost weight after operation, and the weight gain started not until 6 months after operation. The survival in patients with cachexia was significantly reduced in patients undergoing tumor resection as well as in palliative treated patients. CONCLUSION: Cachexia has a significant impact on survival and performance status in palliative patients as well as in patients operated for pancreatic cancer. But tumor-related cachexia is not necessarily dependent on tumor size or load and that metastatic dedifferentiation of the tumor might be a critical step in the development of tumor-associated cachexia.

Bachmann J, Heiligensetzer M, Krakowski-Roosen H, Büchler MW, Friess H, Martignoni ME.

Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Ismaningerstrasse 22, 81675, Munich, Germany.

The STARD Statement for Reporting Diagnostic Accuracy Studies: Application to the History and Physical Examination.

OBJECTIVE: The Standards for Reporting of Diagnostic Accuracy (STARD) statement provided guidelines for investigators conducting diagnostic accuracy studies. We reviewed each item in the statement for its applicability to clinical examination diagnostic accuracy research, viewing each discrete aspect of the history and physical examination as a diagnostic test. SETTING: Nonsystematic review of the STARD statement. INTERVENTIONS: Two former STARD Group participants and 1 editor of a journal series on clinical examination research reviewed each STARD item. Suggested interpretations and comments were shared to develop consensus. MEASUREMENTS AND MAIN RESULTS: The STARD Statement applies generally well to clinical examination diagnostic accuracy studies. Three items are the most important for clinical examination diagnostic accuracy studies, and investigators should pay particular attention to their requirements: describe carefully the patient recruitment process, describe participant sampling and address if patients were from a consecutive series, and describe whether the clinicians were masked to the reference standard tests and whether the interpretation of the reference standard test was masked to the clinical examination components or overall clinical impression. The consideration of these and the other STARD items in clinical examination diagnostic research studies would improve the quality of investigations and strengthen conclusions reached by practicing clinicians. CONCLUSIONS: The STARD statement provides a very useful framework for diagnostic accuracy studies. The group correctly anticipated that there would be nuances applicable to studies of the clinical examination. We offer guidance that should enhance their usefulness to investigators embarking on original studies of a patient\’s history and physical examination.

Simel DL, Rennie D, Bossuyt PM.

Durham Veterans Affairs Medical Center and Duke University, Durham, NC, USA, david.simel@duke.edu.

A Model for Mechano-Electrical Feedback Effects on Atrial Flutter Interval Variability.

Atrial flutter is a supraventricular arrhythmia, based on a reentrant mechanism mainly confined to the right atrium. Although atrial flutter is considered a regular rhythm, the atrial flutter interval (i.e., the time interval between consecutive atrial activation times) presents a spontaneous beat-to-beat variability, which has been suggested to be related to ventricular contraction and respiration by mechano-electrical feedback. This paper introduces a model to predict atrial activity during atrial flutter, based on the assumption that atrial flutter variability is related to the phase of the reentrant activity in the ventricular and respiratory cycles. Thus, atrial intervals are given as a superimposition of phase-dependent ventricular and respiratory modulations. The model includes a simplified atrioventricular (AV) branch with constant refractoriness and conduction times, which allows the prediction of ventricular activations in a closed-loop with atrial activations. Model predictions are quantitatively compared with real activation series recorded in 12 patients with atrial flutter. The model predicts the time course of both atrial and ventricular time series with a high beat-to-beat agreement, reproducing 96+/-8% and 86+/-21% of atrial and ventricular variability, respectively. The model also predicts the existence of phase-locking of atrial flutter intervals during periodic ventricular pacing and such results are observed in patients. These results constitute evidence in favor of mechano-electrical feedback as a major source of cycle length variability during atrial flutter.

Masé M, Glass L, Ravelli F.

Department of Physics, University of Trento, via Sommarive, 14, 38050, Povo, Trento, Italy, mase@science.unitn.it.

Benefits, Limitations, and Harm of Local Excision for Rectal Cancer.

Ziogas D, Tsekeris P, Fatourou E.

Ioannina University, Ioannina, Greece, deziogas@hotmail.com.