Surgical coaching applied to laparoscopic TME for continuous professional development in rectal surgery: proof of concept.

BACKGROUND: Coaching is maturing as a strategy for surgeons' continuous professional development in different types of surgery. Laparoscopic total mesorectal excision (LAP TME) is one of the recognized difficult procedures in colorectal surgery. Aim of this trial is to introduce the surgical coaching as a tool for a continuous technical education of LAP TME for cancer in a consultant surgeon carrier. METHODS: Twelve Italian colorectal surgeons were enrolled as trainees in the AIMS Academy rectal cancer surgical coaching project and attended a face-to-face 90-min surgical coaching on a pre-edited 45-min-long video of a laparoscopic proctectomy according to pre-determined guidelines. At the end of the coaching, all mentors were asked to fill a questionnaire evaluating the trainee's skills. All trainees had to fill a post-coaching questionnaire addressing the appropriateness of the coaching with respect to their actual level. RESULTS: Trainees were more confident in performing the extra-pelvic part of the surgical procedures compared to the intra-pelvic dissection. The most challenging steps according to the trainees were the seminal vesicles identification and the pelvic floor dissection. Mentors found the trainees quite confident in the approach to the vascular structures, lymphadenectomy, stapler utilization and bleeding control. The sharpness and the efficacy of the dissection, the dissection of the surgical planes and the anastomosis fashioning were reported at a lower level of confidence. The higher grade of satisfaction reported by the trainee came from the attention that the mentors demonstrated towards them, from the availability of the mentors to take into consideration the surgical issues raised and from the willingness to apply the suggestions received during their next proctectomies. CONCLUSIONS: The surgical coaching applied to LAP TME should be considered as an innovative tool for continuous professional development.

Management of temporomandibular joint ankylosis: a case report of joint replacement with piezoelectric surgery.

AIM: Temporomandibular joint (TMJ) ankylosis is a joint disorder which refers to bone or fibrous adhesion of the anatomic joint components and the ensuing loss of function. This report describes the management of a case of bilateral TMJ ankylosis in a 20-year-old patient with prosthetic replacement with the aid of a piezoelectric instrument (MECTRON (R). METHODS: The right ankylotic mass was surgically removed and replaced by a custom-made prosthesis based on data obtained from three-dimensional computed tomography (CT) reconstruction of the skull of the patient using a stereolithography model. RESULTS: At six months postoperative, the opening of the mouth was stable at 36 mm and imaging studies (CT and magnetic resonance imaging [MRI]) showed a great condylar prosthesis and surrounding tissues in addition to partial remodeling of the left TMJ. CONCLUSION: In this patient, despite the bilateral ankylosis, it was sufficient to intervene only on the right TMJ, which presented a serious bone block, with mobilization since surgery gradually restored the anatomical and functional conditions of the left TMJ compatible with normal activities of mastication and speech.

The piezoelectric osteotomy technique compared to the one with rotary instruments in the surgery of included third molars. A clinical study.

AIM: The purpose of this study is to compare surgical times, the saving of bonytissues, the postoperative course of the extraction of included third molars in patients treated with piezoelectric surgery compared to those treated with conventional rotary instruments. METHODS: The study included 140 patients with upper and lower third molars included. 70 of them were treated with osteotomy using conventional rotary instruments (Group 1) and 70 more with osteotomy through piezosurgery Mectron® (GROUP 2). The treatment protocol was the same for both groups. The time of surgery and the saving of bonytissues in the intra-operative have been estimated; moreover, 24-48-72 hours and 7 days after the surgery, two other parameters have been estimated: facial swelling and trismus. The swelling, trismus and the saving of bony tissues were assessed by a surgery gauge. RESULTS: The average surgical time was 15 minutes in Group 1 and 20 minutes in Group 2. The savings of bonytissues was greater in Group 2 than in group 1 by 2.7 mm. The average facial swelling was 6.23 mm for group 1 and 2.86 mm for group 2 24 hours after the surgery, of 5.22 mm for group 1 and 1.76 mm for group 2 48 hours after the intervention, of 3.75 mm for Group 1 and 0.85 for group 2 72 hours after the surgery, of 0.86 mm for group 1 and 0.12 for group 2. The average trismus was of 14.76 mm in Group 1 and 11.15 mm in Group 2. Statistical analysis showed a significant reduction of swelling, trismus and a bigger saving of bony tissues in Group 2 and a reduction in surgical time in Group 1. CONCLUSION: The osteotomy technique with a piezoelectric instrument has produced a significant reduction in facial swelling, trismus and a bigger saving of bony tissues than with conventional rotary instruments. A slight lengthening in terms of surgical time has been recorded, compared to the use of conventional rotary instruments.

Benefits of piezoelectric surgery in oral and maxillofacial surgery. Review of literature.

Piezoelectric surgery is based on the use of ultrasound for the cutting of bones. It represents an innovative technique, as it offers the maxillofacial surgeon the opportunity of making precise bone cuts without damaging any soft tissue, minimizing the invasiveness of surgical procedure, and the opportunity of working in a field which is almost totally blood-free. It reduces the impact on soft tissues (vessels and nerves) which lie adjacent to the areas of treatment. Compared to traditional methods, it enables optimal healing because it reduces the postsurgery swelling and discomfort. In this article the authors realized a review of the literature.

Bilateral lumbar hernia associated with abdominal hernias. A case report.

Multiple abdominal hernias constitute a quite rare event in surgical practice. Lumbar hernias are even rarer and, to our knowledge, this is the first report in the English literature of its association with abdominal hernias. A case of multiple abdominal hernias, namely an epigastric hernia and a left inguinal hernia together with a bilateral lumbar hernia in a 65-year-old man attending the Out-patient department of Hoima Hospital-Uganda is described. A one-stage repair under local anaesthesia was chosen. The patient recovered uneventfully and no recurrence was noted at 1 year follow-up. This case report supports that a "one-stage" procedure under local anaesthesia can be appropriate as surgical treatment of multiple abdominal hernias when abdominal defects are of a small size. A minimal surgical approach to lumbar hernias seems also suitable when transverse muscle aponeurosis defect can be carefully repaired and covered with adjacent muscles.

Blunt splenic rupture--experience in a preserving non-operatively orientated care team in a tropical hospital.

OBJECTIVES: With a view to the prevention of immediate and later complications of splenectomy, especially the risk of overwhelming post-splenectomy sepsis syndrome (OPSS), conservative treatments have been proposed when the haemodynamic condition of the patient permits this. In this study, we present our experience in a preserving non-operatively orientated care team in a tropical hospital. PATIENTS AND METHODS: Twenty patients admitted to Hoima Hospital, Hoima, Uganda with splenic injuries from blunt abdominal trauma between July and December 1995 were included in the study. For every patient, serial monitoring of clinical and haematological data was done. Ultrasonography was used to give an accurate assessment of the severity of splenic and concomitant injuries. In stable patients a conservative approach was adopted. RESULTS: In our study 15 patients were managed non-operatively, while 5 underwent splenectomy. Grades I, II, and IIIa spleen injury was significantly associated with non-operative treatment, while grade V was associated with splenectomy (Student-Newman-Keuls test P < 0.05, Mantel-Haenszel chi-square for trend chi 2 = 8.7, P = 0.003). Comparing the non-operative and laparotomy groups, the length of hospital stay (14.0 v. 12.8 days) was similar (t = 1.71, df 18, P > 0.05), while the average blood transfusion volume given was 1.1 units and 3.0 units respectively (t = 3.58, df 18, P < 0.005). CONCLUSIONS: The present study confirms the ability to preserve an increasing number of traumatised spleens by non-operative therapy. This has become possible as a consequence of increasing experience and confidence in pursuing a non-operative approach based on accurate diagnostic methods. Furthermore, non-operative management does not increase the length of stay in hospital and it reduces the total volume of blood transfusions required. While we agree with others that the choice between operative and non-operative management of splenic trauma should be based mainly on clinical grounds, ultrasonography and peritoneal lavage were important tools in the diagnostic pathway and in decision-making. It is worth noting that a 'safe' grade of spleen injury does not exist, since even minor lesions can lead to massive haemoperitoneum and shock requiring emergency splenectomy. In view of the now well known early and late complications after splenectomy, spleen preservation should be the treatment of choice for splenic trauma, especially in tropical countries.

Post traumatic pseudocyst of the spleen: case report on a conservative management through percutaneous drainage.

Non-parasitic cysts of the spleen are uncommon and often result from blunt abdominal trauma. These lesions are classified as splenic pseudocysts. Until recently, splenectomy has been the primary choice of treatment of these pseudocysts. The trend for treatment of spleen cysts is now towards a conservative management. The case reported herein is an example of a post traumatic splenic pseudocyst successfully treated with a conservative approach (ultrasound aided percutaneous drainage). In most tropical countries, also in view of lack of resources and expertise, a conservative non-surgical of post-traumatic spleen cysts management could be appropriate and feasible under certain circumstances.

[Mechanical entero-enteral anastomosis in surgery of the upper digestive tract]. / L'entero-entero anastomosi meccanica nella chirurgia del TGE superiore.

The authors analyse the results relating to the use of a technical variation of entero-enteroanastomosis preparation in the reconstruction of the continuity of upper digestive tract with a defunctionalised Roux en Y loop. This variation includes the use of a circular Proximate ILS mechanical stapler. The series examined, operated during the period June 1993 to November 1994, includes a total of 57 patients, of which 51 with gastric neoplasia. 43 cases underwent total gastrotectomy with R1-R2 lymphoadenectomy and 8 cases underwent gastroresection; a further 3 emergency operations were performed for benign pathologies responsible for upper digestive tract hemorrhage. Moreover, in the 3 remaining cases 2 cysto-jejunal derivations for pancreatic pseudocysts were also performed using the same method, together with 1 hepaticojejunostomy secondary to calculosis of the common hepatic duct. Attention is focused on the analysis and description of the operating technique in order to identify the basic key stages as accurately as possible. In conclusion, the authors indicate that, in view of the excellence of results and the simple and rapid technical execution of this entero-enteroanastomosis, the use of this method was amply justified and undoubtedly advantageous both for surgeons and patients.

Clinical and endoscopic aspects of hepatosplenic schistosomiasis in Uganda.

INTRODUCTION: Hepatosplenic schistosomiasis is characterized by hepatic periportal fibrosis (Symmers' fibrosis), portal venous obstruction that leads to portal hypertension and its complications, and splenomegaly. Demonstration of pathological lesions due to Schistosoma mansoni can be achieved by using different techniques but because of its sensitivity, specificity and simplicity, ultrasound has replaced wedge biopsy of the liver as the gold standard for detecting schistosomal periportal fibrosis. The aims of the study were to evaluate clinical aspects of schistosomiasis in a well defined area and to assess whether there was a relationship between the grade of periportal fibrosis and the presence of oesophageal varices and their features. MATERIALS AND METHODS: A total of 122 patients with proven schistosome infection were enrolled in the study. Each underwent ultrasound examination to assess hepatosplenic involvement and staging, and upper digestive endoscopy to assess the presence of oesophageal varices and their features. For all the patients, the main characteristics and symptoms, possibly related to schistosomiasis, were also recorded. RESULTS: A close relationship was found between the grade of periportal fibrosis and the presence of oesophageal varices, their grade and localization in the oesophagus. There was also was a relationship between haematemesis and size of varix, localization of varix and presence of cherry-red spots, but no correlation was found with other endoscopic features of varices. CONCLUSION: Clinical aspects of schistosomiasis in Hoima District are similar to what is known from the literature and there are no specific features. The study shows that ultrasonography is an important tool for accurate staging of hepatosplenic schistosomiasis. Although it cannot replace endoscopy, it can direct the need for performing it. In fact, the higher the grade of periportal fibrosis the greater the possibility of having oesophageal varices. Endoscopy is of value in detecting oesophageal varices especially in advanced stages of liver schistosomiasis, in describing their endoscopic features so as to detect those more at risk of bleeding, and for emergency sclerotherapy.

Clinical aspects and imaging patterns with ultrasonography and endoscopy in hepatosplenic schistosomiasis in Uganda.

In patients with hepato-splenic schistosomiasis, a close relationship between the grade of periportal fibrosis and portal vein diameter, spleen size and presence of oesophageal varices and their grade was found.

Randomized study of antibiotic prophylaxis for general and gynaecological surgery from a single centre in rural Africa.

In a district rural hospital in Uganda, 850 surgical patients were evaluated prospectively over a 3-year period to compare the clinical efficacy of conventional postoperative penicillin therapy with single-dose ampicillin prophylaxis for hernia repair and ectopic pregnancy, and with single-dose ampicillin-metronidazole prophylaxis for hysterectomy and caesarean section. The high rate of postoperative infection usually encountered in African hospitals after conventional treatment with penicillin for 7 days was significantly reduced with the new regimen: from 7.5 to 0 per cent in hernia repair and from 10.7 to 2.4 per cent in ectopic pregnancy; from 20.0 to 3.4 per cent in hysterectomy and from 38.2 to 15.2 per cent in caesarean section. Length of hospital stay and postoperative mortality rates were also significantly reduced. Single-dose ampicillin prophylaxis with or without metronidazole, although rarely used in developing countries, is more cost effective than standard penicillin treatment.

A study of breastfeeding and the return of menses in Hoima District, Uganda.

The effect of breastfeeding on reestablishment of ovulation and fertility and on birth spacing are now well known. A study was conducted on lactational amenorrhoea (LAM) at 180 days in Hoima District, Uganda in order to understand whether and how LAM could be applied in fertility control and birth spacing. Since the introduction of supplementary food by Ugandan women does not replace or substitute for breastfeeding, a study was designed to determine if LAM was effective irrespective of supplementation of infant's diet. One hundred and fifty four mother/child pairs were entered into the study and 134 women completed the sixth month of the study. At the end of the period, eighty four women (62.7%) were amenorrhoeic of whom only 33 (39.3%) were exclusively breastfeeding and no woman had dropped out of the study because of pregnancy or the use of other family planning methods other than LAM. The study confirmed that LAM could be applicable in Uganda to the majority of the breastfeeding women (62.7%). It is expected that if health workers increase the intensity of breastfeeding support as well as the women's knowledge and motivation to use LAM for family planning, this would contribute to children's health as well as to birth spacing that is one of the major factors related to infant deaths. According to data from this study, the return of menses is irrespective of whether supplements have been introduced and their frequency.

Kaposi's sarcoma and AIDS in Uganda: its frequency and gastrointestinal distribution.

The frequency and distribution of gastrointestinal Kaposi's sarcoma were investigated in 63 consecutive AIDS patients. The main risk factor for AIDS was heterosexual intercourse. Gastrointestinal lesions were found in 24 cases (38.1%): 12 patients (11.1%) had both upper and lower GI tract involvement, 7 patients (11.1%) had only oesophago-gastroduodenal lesions and 5 (7.9%) only lower tract disease. Our results show that in heterosexual Africans, the tumours closely resemble the tumours of western homosexuals in endoscopic appearance, in being multicentric and in the gastro-intestinal tract involved. We conclude that even in the heterosexual African AIDS population, the gastrointestinal tract is frequently involved and this phenomenon, if more widely studied might give us new elements about the aetiophatogenesis of Kaposi's sarcoma which is still unclear.

PIP: Acquired immunodeficiency syndrome (AIDS) was first reported in Uganda in 1982. As techniques for detecting AIDS have improved, the number of confirmed cases has increased. Kaposi's sarcoma (KS) has been reported in European studies of AIDS patients at a 34% prevalence rate. These studies mainly focused on homosexuals and intravenous drug users (IVDUs). This study aimed at establishing the frequency, distribution, and endoscopic appearance of gastrointestinal KS in Ugandan heterosexual patients and at verifying whether data published in the western international literature, mainly regarding homosexuals and IVDUs, could be applied to heterosexuals with AIDS. 27 Ugandan men and 36 Ugandan women served as study subjects. All had been diagnosed as AIDS-positive. All patients received complete upper and lower gastrointestinal examinations. The upper digestive tract was examined by oral-endoscopic procedures, while the lower portion was examined using flexible rectosigmoidoscopic techniques. 24 patients (38.1%) had gastrointestinal lesions; 21 of these (87.5%) had multiple lesions. 12 patients (19.1%) had KS involvement of both gastrointestinal areas. Tumors closely resembled those described in studies of homosexuals.

Effect of acetyl-L-carnitine treatment on brain adenylate cyclase activity in young and aged rats.

The aim of the present study has been to evaluate the effect of acetyl-L-carnitine (ALCAR) on brain adenylate cyclase (AC) activity in adult and aged rats. In in vitro studies, ALCAR (1, 10 and 100 microM) did not exert any effect on frontal cortex basal AC activity. Acute and subchronic administrations of ALCAR were carried out in 4- and 25-month-old male Fisher rats and AC activity was determined in rat frontal cortex under both basal and stimulated conditions. The acute treatment of young rats with ALCAR (100 and 500 mg/kg s.c.) did not affect AC activity, whereas the subchronic administration of 250 mg/kg s.c. ALCAR enhanced the stimulation of AC by carbamylcholine (CCh), norepinephrine (NE) and dopamine (DA), without affecting the basal AC activity. Basal AC activity in old rats was lower than in young rats and was not modified by acute and subchronic ALCAR administration. Moreover, the response of the enzyme to CCh, NE and DA was potentiated by the subchronic administration of ALCAR. The concentration-response curve of CCh stimulation of AC activity in ALCAR-treated rats is shifted to the left in both young and aged rats. We conclude that ALCAR, subchronically administered, is able to enhance receptor-stimulated AC response in frontal cortex of both young and aged rats.

Diagnostic management of epigastric pain in Uganda

180 patients who attended the out patient department of Hoima Hospital (Uganda) complaining of epigastric pain were studied in order to verify the cause and to assess the most effective diagnostic method. All the patients underwent the following examinations: stool examination for parasites; upper digestive tract endoscopy; ultrasound scan of liver; spleen; pancreas and kidneys. The results suggest that the main causes of epigastric pain in Uganda are: intestinal parasitosis (27 per cent); gastrointestinal upper tract lesions with endoscopic signs of disease (44.5 per cent) and non-ulcer dyspepsia (28.4 per cent). The best approach to epigastric pain is first of all to rule out the presence of parasites in the stool. Upper digestive tract endoscopy is useful as a second step in the diagnosis while ultrasound examination does not add important information