The Paper Mache Bra: A Postsurgical Breast Taping Technique.

Little has been published about dressing the breast after surgery and the potential benefits of added support to the routine use of a nonwired bra postoperatively. We report a postsurgical breast taping method and suggest its use might help reduce minor postsurgical complications and subsequent impaired scarring.

[LAPAROSCOPIC APPROACH AND SURGICAL CONSIDERATIONS IN RESECTION OF A LARGE EPIPHRENIC ESOPHAGEAL DIVERTICULUM].

Epiphrenic diverticulum of the esophagus is an uncommon finding. Small diverticula are usually asymptomatic in nature. Large diverticula may present with dysphagia, chest or upper abdominal discomfort, vomiting, irritating cough or halitosis. There are a few different surgical approaches to epiphrenic diverticulum resection. It can be performed with an abdominal or a thoracic approach and in an open or a laparoscopic manner. In this case report we present a 70 years old male patient with a giant epiphrenic diverticulum and dysphagia. The patient was operated upon via a laparoscopic abdominal approach with intra-operative endoscopic assistance and underwent a diverticulum resection. We present a review of the different kinds of esophageal diverticula, the mechanism of their formation, and the surgical considerations associated with choosing the appropriate surgical approach.

Effect of sleeve gastrectomy on thyroid hormone levels.

BACKGROUND: Weight loss in morbidly obese patients is associated with changes in thyroid function. Studies have demonstrated equivalent changes following bariatric surgery. Changes in thyroid function were reported following laparoscopic Roux-en-Y gastric bypass (LRYGB), biliopancreatic diversion (BPD), and laparoscopic adjustable gastric banding (LAGB). No data exists on changes in thyroid function following laparoscopic sleeve gastrectomy (LSG). The aim of the current study is to evaluate changes in thyroid function following LSG in patients with normal thyroid function. METHODS: Data were retrieved from a prospectively collected database of patients who underwent LSG for morbid obesity. Euthyroid patients were evaluated for changes in TSH and free thyroxine (FT4), 6-12 months after surgery. Correlation between changes in thyroid hormone levels, excess weight loss (EWL), and baseline TSH were evaluated. RESULTS: Thirty-eight patients were included in the study. Mean BMI decreased from 42.4 to 32.5 kg/m(2) (P < 0.0001). Mean TSH levels decreased from 2.45 ± 0.17 mU/L at baseline to 1.82 ± 0.18 mU/L (P < 0.0001), whereas mean FT4 levels remained the same after surgery (13.27 ± 0.45 pmol/L compared to 12.96 ± 0.42 pmol/L, P = NS). TSH decrease was directly related to baseline TSH but did not correlate with EWL. CONCLUSIONS: This is the first study to evaluate changes in thyroid hormone levels following LSG for morbid obesity. TSH decrease and steady levels of FT4 are expected following LSG. These findings are comparable to reported changes following LRYGB. TSH decrease was not associated with EWL. Further studies are required to elucidate the exact mechanism of this effect.

Predictive factors for perioperative blood transfusions in laparoscopic colorectal surgery.

BACKGROUND: Allogeneic perioperative blood transfusion (PBT) has been associated with higher rates of postoperative complications in patients undergoing colorectal surgery and increased tumor recurrence in cancer patients. Our aim is to evaluate possible predictive factors for PBT, specifically, in patients undergoing laparoscopic colorectal surgery, in order to identify patients who could benefit from alternatives to allogenic PBT such as erythropoietin administration, autologous blood transfusion, and possibly preoperative blood transfusion. METHODS: Five hundred patients who underwent laparoscopic colorectal surgery between the years 2003 and 2011 were reviewed. Patient demographics and clinicopathologic variables were collected prospectively. Other clinical data were collected directly from the computerized records of the in-hospital blood bank. PBT was defined as transfusion of allogenic red blood cells during the day of operation or within the postoperative hospitalization. The associations between PBT and patient variables were assessed by univariate and multivariate analyses. RESULTS: Of the 500 patients, 134 patients (26.8 %) received PBT. Multivariate analysis revealed four preoperative variables as significant risk factors for PBT: preoperative hemoglobin (P = 0.001), lower rectal surgery (P = 0.009), Charlson comorbidity score (P = 0.001), and malignancy (P = 0.024). CONCLUSIONS: Preoperative Charlson score, hemoglobin level, carcinoma, and lower rectum pathologies were found to be independent risk factors for PBT in patients undergoing laparoscopic colorectal surgery. Evaluation of these risk factors prior to surgery may be helpful in selecting the patients who could benefit from possible alternatives to perioperative allogeneic blood transfusion and help constitute guidelines for a more responsible use of these alternatives.

Laparoscopic colorectal surgery in patients with impaired renal function: impact on postoperative renal function compared with open surgery.

BACKGROUND: Laparoscopic surgery has been associated with a perioperative decrease in renal function. As a result, an open approach may be preferred in patients with impaired renal function when prolonged laparoscopic procedures are anticipated. The aim of this study was to examine changes in renal function following colorectal operations and compare between the open and the laparoscopic approaches, in patients with preoperative impaired renal function. PATIENTS AND METHODS: This is a single-center retrospective study. Records of all patients with impaired renal function (estimated glomerular filtration rate [eGFR] <60 mL/minute) who underwent elective colorectal resection between 2007 and 2011 were reviewed. The changes in eGFR were examined and compared between open and laparoscopic procedures. RESULTS: Ninety consecutive patients with impaired renal function who underwent elective colorectal surgery from 2007 to 2011 were identified. Forty-seven patients underwent laparoscopic surgery, and 43 had an open surgery; 23.2% of the patients who had open surgery and 21.7% of the patients who underwent a laparoscopic procedure demonstrated a decrease in eGFR at the time of discharge (P=not significant). The mean decrease in eGFR did not differ between the two groups (6.3 ± 6.8 mL/minute versus 4.04 ± 4.01 mL/minute; P=.34). None of the patients required dialysis. Postoperative complications were found to be a risk factor for a significant decrease in renal function. CONCLUSIONS: Renal function may deteriorate in patients with chronic kidney disease who undergo elective colorectal surgery. No difference was noted in the incidence or severity of such deterioration between open and laparoscopic approaches. Postoperative complications are associated with deterioration in renal function regardless of the operative approach.

Use of reflectance spectrophotometry to predict the response of port wine stains to pulsed dye laser.

Reflectance spectroscopy can be used to quantitate subtle differences in color. We applied a portable reflectance spectrometer to determine its utility in the evaluation of pulsed dye laser treatment of port wine stains (PWS) and in prediction of clinical outcome, in a prospective study. Forty-eight patients with PWS underwent one to nine pulsed dye laser treatments. Patient age and skin color as well as PWS surface area, anatomic location, and color were recorded. Pretreatment spectrophotometric measurements were performed. The subjective clinical results of treatment and the quantitative spectrophotometry results were evaluated by two independent teams, and the findings were correlated. The impact of the clinical characteristics on the response to treatment was assessed as well. Patients with excellent to good clinical results of laser treatments had pretreatment spectrophotometric measurements which differed by more than 10%, whereas patients with fair to poor results had spectrophotometric measurements with a difference of of less than 10%. The correlation between the spectrophotometric results and the clinical outcome was 73% (p < 0.01). The impact of the other clinical variables on outcome agreed with the findings in the literature. Spectrophotometry has a higher correlation with clinical outcome and a better predictive value than other nonmeasurable, nonquantitative, dependent variables.

Grading of complications and risk factor evaluation in laparoscopic colorectal surgery.

BACKGROUND: A grading system for postoperative complications is important for quality control and comparison among investigations. The objective of the current study was to evaluate complications associated with laparoscopic colorectal surgery according to a standardized grading system, and to examine risk factors associated with different complication grades. METHODS: Data of all patients who underwent elective laparoscopic colorectal surgery at two medical centers between September 2003 and January 2011 were collected prospectively. Complications were graded retrospectively into five categories based on a previously proposed grading system for colorectal operations. Age, gender, BMI, Charlson comorbidity score, indication for surgery, pathology site, conversion rate, learning curve, operative times, previous abdominal surgery, concurrent surgical procedures performed, and length of hospital stay were evaluated as risk factors and outcome measures for complications. RESULTS: A total of 501 patients were included in the study. Of them, 30.5 % suffered at least one complication and 6.5 % more than one. Complications that were mainly medical or surgical site infections requiring minor intervention (grades 1 and 2) occurred in 22.9 % of patients. Surgical complications requiring invasive interference (grades 3 and 4) occurred in 7.4 % of patients and mortality (grade 5) occurred in 0.2 % (1 patient). Length of hospital stay was directly related to complication grade. Average hospital stay was 6.8 ± 3.5, 10.5 ± 5.1, and 20.2 ± 12.3 days for patients with no complications, grade 1-2 complications, and grade 3-4 complications, respectively (p < 0.01). Minor complications (grades 1-2) were associated with conversion (p < 0.01), high Charlson score (p = 0.004), and additional surgical procedures (p = 0.04). Major complications (grades 3-4) were associated solely with conversion (p < 0.01) and rectal pathology (p < 0.01). CONCLUSION: This study demonstrates the use of a uniform grading system for complications in laparoscopic colorectal surgery. Conversion was found to be associated with all grades of complications.

One stop screening for multiple cancers: the experience of an integrated cancer prevention center.

BACKGROUND: Cancer is a leading cause of mortality worldwide. Screening is a key strategy for reducing cancer morbidity and mortality. METHODS: We aimed to describe the experience of an integrated cancer prevention center in screening an asymptomatic population for the presence of neoplasia. One-thousand consecutive asymptomatic, apparently healthy adults, aged 20-80 years, were screened for early detection of 11 common cancers that account for 70-80% of cancer mortality. RESULTS: Malignant and benign lesions were found in 2.4% and 7.1% of the screenees, respectively. The most common malignant lesions were in the gastrointestinal tract and breast followed by gynecological and skin. The compliance rate for the different screening procedures was considerably higher than the actual screening rate in the general Israeli population - 78% compared to 60% for mammography (p<0.001) and 39% compared to 16% for colonoscopy (p<0.001). Advanced age, family history of cancer and certain lifestyle parameters were associated with increased risk. Moreover, polymorphisms in the APC and CD24 genes indicated high cancer risk. When two of the polymorphisms existed in an individual, the risk for a neoplastic lesion was extremely high (OR 2.3 [95% CI 0.94-5.9]). CONCLUSIONS: One stop shop screening for 11 common cancers in the setting of a multidisciplinary outpatient clinic is feasible and can detect cancer at an early stage.

Impact of conversion on short and long-term outcome in laparoscopic resection of curable colorectal cancer.

INTRODUCTION: Long-term outcome of patients following conversion during laparoscopic surgery for colorectal cancer is not often reported. Recent data suggest a negative impact of conversion on long-term survival. This study aimed to evaluate the impact of conversion on the perioperative outcome and on long-term survival in patients who underwent laparoscopic resection for curable colorectal cancer. METHODS: Evaluation of our prospective in-hospital collected data of patients who underwent laparoscopic surgery for curable colorectal cancer over a 5-year period. Long-term data were collected from our outpatient's clinic data and personal contact when necessary. RESULTS: During the study period, 175 patients were operated on laparoscopically for curable colon cancer (stage I-III). Mean follow-up was 33±18 months with a minimum follow-up of 12 months. For various reasons, 25 patients (14.4%) had to be converted to open surgery. Short-term outcome revealed a trend towards longer operations, a higher rate of surgical complications, and a longer hospital stay in the converted group. Five-year, Kaplan-Meier, disease-free analysis was worse for converted patients. Overall survival did not differ between the 2 groups. Cox proportional hazards regression analysis revealed that conversion and AJCC stage were independent risk factors for recurrence. CONCLUSIONS: Conversion in laparoscopic surgery for curable colorectal cancer is associated with a worse perioperative outcome and worse disease-free survival.

Current changes in the management and outcome of patients with curable colorectal cancer.

BACKGROUND: Major changes in the evaluation and treatment of curable colorectal cancer (CRC) have emerged in the last two decades. These changes have led to better patient outcome overtime. OBJECTIVES: To evaluate the impact of these changes as reflected in the difference in long-term outcome of a consecutive group of recently laparoscopically operated curable CRC patients and a consecutive group of patients operated 20 years earlier in the same department. METHODS: Data of the new group were taken from our prospectively collected data of patients who underwent elective laparoscopic surgery for CRC in recent years. Data regarding patients operated on 20 years ago were retrieved from previous prospectively collected data on the long-term survival of CRC patients operated in the same department. RESULTS: The recently operated group comprised 203 patients and the previous group 199 patients. Perioperative mortality was 0.5% in the new group versus 1.5% in the old group (not significant). There were more early-stage and more proximal tumors in the recently operated group. A Kaplan-Meier 5-year survival analysis revealed no difference between stage I patients of the two groups. However, there was a significant increase in 5-year survival in the new group for stage II (85% vs. 63%, P = 0.004) and for stage III patients (57% vs. 39%, P = 0.01). This trend was maintained after removing the rectal cancer patients from the calculated data. CONCLUSIONS: We have demonstrated improved survival for stage II and ILL CRC patients overa 20-year period in the same medical center. This change most likely reflects advances both in imaging techniques leading to more accurate staging and in adjuvant treatments.

Anti-platelet therapy: no association with increased blood loss in patients undergoing open or laparoscopic appendectomy.

BACKGROUND: The effect of anti-platelet drugs on surgical blood loss and perioperative complications has not been studied in depth and the management of surgical patients taking anti-platelet medications is controversial. OBJECTIVE: To assess the effect of anti-platelet therapy on perioperative blood loss in patients undergoing appendectomy either laparoscopically or via open surgery. METHODS: We reviewed the files of all patients 40 years old who underwent open or laparoscopic appendectomies from 2007 to 2010. Excluded were patients with short hospitalization and no follow-up of hemoglobin level, patients on warfarin treatment and patients who underwent additional procedures. Estimation of blood loss was based on decrease in hemoglobin level from admission to discharge. Risk factors for blood loss, such as anti-platelet therapy, age, gender, surgical approach, surgical time, surgical findings and complications, were analyzed. RESULTS: The final cohort included 179 patients (mean age 61 +/- 14 years, range 40-93) of whom 65 were males. The mean perioperative hemoglobin decrease was 1.59 +/- 1.07 mg/dl (range 0-5 mg/dl). Thirty-nine patients received anti-platelet therapy prior to surgery and 140 did not. No significant differences in decrease of hemoglobin level were found between patients receiving anti-platelet therapy and those who were not (1.73 +/- 1.21 vs. 1.55 +/- 1.02 mg/dl, P = 0.3). In addition, no difference was found between patients on anti-platelettherapy operated laparoscopically and those operated in an open fashion (1.59 +/- 1.18 vs. 2.04 +/- 1.28 mg/ dl, P = 0.29). Five patients required blood transfusions, two of whom were on anti-platelet therapy. Blood loss was significantly greater in patients with a perforated appendicitis and in those with an operative time of more than one hour. CONCLUSIONS: Anti-platelet therapy does not pose a risk for increased blood loss following emergent appendectomy performed either laparoscopically or in an open fashion.

First report of screening an asymptomatic population for cancer: the yield of an integrated cancer prevention center.

BACKGROUND: Cancer is a leading cause of mortality worldwide. The most effective way to combat cancer is by prevention and early detection. OBJECTIVES: To evaluate the outcome of screening an asymptomatic population for the presence of benign and neoplastic lesions. METHODS: Routine screening tests for prevention and/or early detection of 11 common cancers were conducted in 300 consecutive asymptomatic apparently healthy adults aged 25-77 years. Other tests were performed as indicated. RESULTS: Malignant and benign lesions were found in 3.3% and 5% of the screenees, respectively, compared to 1.7% in the general population. The most common lesions were in the gastrointestinal tract followed by skin, urogenital tract and breast. Advanced age and a family history of a malignancy were associated with increased risk for cancer with an odds ratio of 9 and 3.5, respectively (95% confidence interval 1.1-71 and 0.9-13, respectively). Moreover, high serum C-reactive protein levels and polymorphisms in the APC and CD24 genes indicated high cancer risk. When two of the polymorphisms existed in an individual, the risk for a malignant lesion was extremely high (23.1%; OR 14, 95% CI 2.5-78). CONCLUSIONS: Screening asymptomatic subjects identifies a significant number of neoplastic lesions at an early stage. Incorporating data on genetic polymorphisms in the APC and CD24 genes can further identify individuals who are at increased risk for cancer. Cancer can be prevented and/or diagnosed at an early stage using the screening facilities of a multidisciplinary outpatient clinic.

[Three hundred laparoscopic colorectal operations--safety, levels of difficulty and survival].

INTRODUCTION: The accumulated data in recent years on the safety of laparoscopy in colorectal cancer patients encourage more surgeons to use this approach for different colorectal pathologies. However, laparoscopic colorectal surgery consists of different heterogeneous complex procedures that necessitate extensive experience and laparoscopic surgical skills PURPOSE: To evaluate safety, levels of difficulty and oncological outcome in a consecutive series of patients that underwent elective laparoscopic colorectal surgery during a 5-year period. METHODS: Evaluation of our prospective collected data of patients that underwent laparoscopic colorectal surgery during a 5-year period by our surgical team. RESULTS: A total of 300 patients were operated on electively for different indications during this time period. Indications for surgery included cancer (58%), benign polyps (16%), Crohn's disease (6%), diverticular disease (10%) and others (10%). Operations for diverticular disease were associated with higher conversion rates and operative times. The mortality rate was 0.3% (one patient). There were 4.6% major surgical complications that necessitated a second operation and another 4.6% moderate surgical complications that were treated conservatively. Wound infection occurred in 7.2% of all patients. The conversion rate was 14.3%. A total of 171 patients underwent operations for curable colorectal cancer. In this group, the mean number of harvested nodes was 16 and 2-year disease-free survival was 87%. Stage I patients had no recurrent disease during follow-up time. CONCLUSIONS: Laparoscopic colorectal surgery is safe. Immediate oncological results and 2-year survival in colorectal cancer patients, as demonstrated in our study, are adequate and comparable to the open approach. The authors believe that adequate results in laparoscopic colorectal operations can be achieved by a dedicated laparoscopic colorectal team.