Mesh-bone cement sandwich for sternal and sternoclavicular joint reconstruction.

Resection of the manubrium including both sternoclavicular joints is occasionally performed in the case of sternal tumours. Sternoclavicular joints are the only true joints connecting the axial skeleton to the upper extremity. Therefore, they play an important role in shoulder function. However, data on their reconstruction are lacking. Here, we described the case of a sternal reconstruction including both sternoclavicular joints using a mesh-bone cement sandwich. The mechanical properties of the construct mimicked those of the original sternoclavicular joints and could therefore restore shoulder strength allowing the patient to perform overhead work.

A multicenter randomized clinical trial of primary anastomosis or Hartmann's procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis.

OBJECTIVES: To evaluate the outcome after Hartmann's procedure (HP) versus primary anastomosis (PA) with diverting ileostomy for perforated left-sided diverticulitis. BACKGROUND: The surgical management of left-sided colonic perforation with purulent or fecal peritonitis remains controversial. PA with ileostomy seems to be superior to HP; however, results in the literature are affected by a significant selection bias. No randomized clinical trial has yet compared the 2 procedures. METHODS: Sixty-two patients with acute left-sided colonic perforation (Hinchey III and IV) from 4 centers were randomized to HP (n = 30) and to PA (with diverting ileostomy, n = 32), with a planned stoma reversal operation after 3 months in both groups. Data were analyzed on an intention-to-treat basis. The primary end point was the overall complication rate. The study was discontinued following an interim analysis that found significant differences of relevant secondary end points as well as a decreasing accrual rate (NCT01233713). RESULTS: Patient demographics were equally distributed in both groups (Hinchey III: 76% vs 75% and Hinchey IV: 24% vs 25%, for HP vs PA, respectively). The overall complication rate for both resection and stoma reversal operations was comparable (80% vs 84%, P = 0.813). Although the outcome after the initial colon resection did not show any significant differences (mortality 13% vs 9% and morbidity 67% vs 75% in HP vs PA), the stoma reversal rate after PA with diverting ileostomy was higher (90% vs 57%, P = 0.005) and serious complications (Grades IIIb-IV: 0% vs 20%, P = 0.046), operating time (73 minutes vs 183 minutes, P < 0.001), hospital stay (6 days vs 9 days, P = 0.016), and lower in-hospital costs (US $16,717 vs US $24,014) were significantly reduced in the PA group. CONCLUSIONS: This is the first randomized clinical trial favoring PA with diverting ileostomy over HP in patients with perforated diverticulitis.

Mucinous cystadenoma arising in a completely isolated infected ileal duplication cyst.

Gastrointestinal duplications are uncommon congenital lesions that can occur anywhere along the alimentary tract, and the symptoms of which generally develop during infancy or childhood. Completely isolated duplication cysts are an extremely rare variant of duplication, where no communication between the cyst and the adjacent bowel segment is present. We report the unique case of an adult who presented with right lower abdominal pain and systemic signs of inflammation caused by infection of a completely isolated ileal duplication cyst. Histological examination of the cyst additionally revealed a low-grade mucinous cystadenoma. We discuss the clinical presentations, diagnosis and treatment of this rare entity.

Recurrent laryngeal nerve monitoring during esophagectomy and mediastinal lymph node dissection.

BACKGROUND: Patients who undergo surgery to the esophagus and lungs are in jeopardy of recurrent laryngeal nerve (RLN) damage during the procedure. This study was designed to investigate the feasibility of intraoperative monitoring of the RLN for single-lung ventilation esophagus and lung surgery. METHODS: Twelve consecutive patients booked for esophagus or lung surgery were included in this prospective, observational study. Six patients underwent transthoracic esophagectomy for carcinoma of the esophagogastric junction or lower esophagus, five had a lobectomy, and one underwent a pneumonectomy for lung carcinoma. Intraoperative, noninvasive RLN identification and monitoring was performed unilaterally (n = 8) or bilaterally (n = 4) using a handheld stimulator and a laryngeal surface electrode. The correct functioning of the nerve monitoring system was tested directly at the vagus nerve. Diagnosis of postoperative RLN paralysis was performed using indirect laryngoscopy. RESULTS: During the surgical procedures, we monitored a nerve signal in all 12 patients. In one patient with lower esophagus carcinoma, a nerve signal could be detected only on one side. Postoperative indirect laryngoscopy showed normal vocal cord movement in all patients. CONCLUSIONS: Intraoperative RLN identification and monitoring during single-lung ventilation surgery is technically feasible, easy, and reliable. The introduction of standardized RLN monitoring during this type of surgery may reduce the incidence of permanent RLN paralysis.

Emergency left colon resection for acute perforation: primary anastomosis or Hartmann's procedure? A case-matched control study.

BACKGROUND: The optimal treatment remains controversial for acute left-sided colon perforation. Therefore, the effectiveness and safety of primary anastomosis versus Hartmann's operation (HP) was compared in a case-matched control study. METHODS: Thirty consecutive patients with primary anastomosis and protective ileostomy (PAS) were matched to 30 HP patients, controlling for age, gender, American Society of Anesthesiologists (ASA) score, body mass index (BMI), and peritonitis severity (Hinchey). In a second analysis, PAS patients with purulent peritonitis (Hinchey 3) were matched to patients with primary anastomosis without ileostomy (PA). RESULTS: Hospital mortality was similar between HP (17%) and PAS (10%). Complication frequency and severity (requiring re-intervention or admission to the Intensive Care Unit [ICU]) were comparable for the first operation (60% versus 56% and 30% versus 32%). The stoma reversal rate was higher in PAS than in HP (96% versus 60%, p = 0.001), with significantly fewer complications (23% versus 66%, p = 0.02), and lower severity (7% versus 33%, p = 0.02). Additional analysis of PAS versus PA showed similar morbidity (52% versus 41%, p = 0.45) and complication severity (18% versus 24%, p = 0.51), whereas overall operation time and hospital stay were significantly shorter in PA (169 versus 320 min, p = 0.003, 17 versus 28 days, p < 0.001). CONCLUSIONS: Primary anastomosis and protective ileostomy is a superior treatment to HP in acute left-sided colon perforation. In the absence of feculent peritonitis an ileostomy appears unnecessary.

Colorectal stenting: an effective therapy for preoperative and palliative treatment.

PURPOSE: To demonstrate the effectiveness of preoperative and palliative colorectal stent placement in acute colonic obstruction. METHODS: Sixty-seven consecutive patients (mean age 67.3 years, range 25-93 years) with clinical and radiological signs of colonic obstruction were treated: 45 (67%) preoperatively and 22 (33%) with a palliative intent. In 59 patients (88%) the obstruction was malignant, while in 8 (12%) it was benign. A total of 73 enteric Wallstents were implanted under combined fluoroscopic/endoscopic guidance. RESULTS: Forty-five patients were treated preoperatively with a technical success rate of 84%, a clinical success rate of 83%, and a complication rate of 16%. Of the 38 patients who were successfully stented preoperatively, 36 (95%) underwent surgery 2-22 days (mean 7.2 days) after stent insertion. The improved general condition and adequate bowel cleansing allowed single-stage tumor resection and primary end-to-end anastomosis without complications in 31 cases (86% of all operations), while only 5 patients had colostomies. Stent placement was used as the final palliative treatment in 22 patients. The technical success rate was 95%, the clinical success rate 72%, and the complication rate relatively high at 67%, caused by reocclusion in most cases. After noninvasive secondary interventions (e.g., tube placement, second stenting, balloon dilatation) the secondary patency of stents was 71% and mean reported survival time after stent insertion was 92 days (range 10-285 days). CONCLUSION: Preoperative stent placement in acute colonic obstruction is minimally invasive and allows an elective one-stage surgery in most cases. Stent placement also proved a valuable alternative to avoid colostomy in palliation.

Synchronous laparoscopic sigmoid resection and hysterectomy with transvaginal specimen removal.

INTRODUCTION: Laparoscopic sigmoid resection for recurrent or complicated diverticulitis and laparoscopically assisted hysterectomy for leiomyomas of the uterus are common procedures. A synchronous combination of these two interventions with the advantage of using the vaginal stump as a route for removal of the specimen has not previously been described. MATERIALS AND METHODS: We used a transvaginal extraction of the uterus and the colorectal segment, followed by a totally intra-abdominal circular stapler anastomosis. The procedure is performed via four trocar incisions, obviating the need for a laparotomy. RESULTS: Two women suffering from diverticulitis and symptomatic uterus myomatomas were treated by combined laparoscopic sigmoid resection and laparoscopically assisted transvaginal hysterectomy. Both patients had an uneventful intraoperative course. DISCUSSION: This new approach, combining two operations, is feasible and leads to almost perfect cosmetic results, cumulatively shorter hospitalization, and good patient satisfaction. Cooperation with a gynecologist as well as experience in advanced laparoscopic surgery is essential.

Open and laparoscopic treatment of nonparasitic splenic cysts.

BACKGROUND: Nonparasitic splenic cysts are rare. Therefore, there is no 'evidence-based' information regarding their optimal surgical management. In the last years the laparoscopic approach has gained increasing acceptance in splenic surgery. The aim of this study is to present our experience with the laparoscopic management of splenic cysts. METHODS: The medical records of 7 patients with splenic cysts were reviewed retrospectively. RESULTS: One patient had an open partial splenic resection. Five patients, 3 of them with a posttraumatic and 2 with an epidermoid splenic cyst, underwent laparoscopic unroofing of the cyst. In 4 of these cases the postoperative course was uneventful, whereas in 1 case the patient developed a cyst relapse soon postoperatively. Later on this patient successfully underwent an open partial splenic resection. The 7th patient had an explorative laparoscopy. The cyst was located intrasplenically, entirely covered with unaffected splenic parenchyma, and reached the splenic hilus. Therefore, a conversion to open partial splenectomy was performed. CONCLUSION: Open partial splenectomy and laparoscopic cyst wall unroofing are both effective tools in the management of splenic nonparasitic cysts. Surgeons must master both techniques as nowadays spleen-preserving techniques should be attempted in every case of splenic nonparasitic cyst.