Safety and Efficacy of Using Staplers and Vessel Sealing Devices for Laparoscopic Splenectomy: A Randomized Controlled Trial.

Background. Laparoscopic splenectomy (LS) is considered the operation of choice on elective basis for managing patients with certain hematological disorders. Hemostatic control of the splenic pedicle is one of the crucial steps in LS. This study compares the safety and efficacy of using endoscopic staplers and vessel sealing devices to control the splenic pedicle in patients with nonsevere splenomegaly. Methods. Fifty-one consecutive patients with different blood disorders including idiopathic thrombocytopenic purpura (ITP), hypersplenism, and lymphoma were randomized for elective LS. Traditional steps of LS, via lateral approach, were followed, and pedicle control was done with either endovascular gastrointestinal anastomosis stapler (n = 26) or vessel sealing device (Ligasure) (n = 25). Results. No difference was noted with different splenic spans when using either methods of pedicle control (P = .145). The volume of blood loss was higher in the Ligasure group compared to the staplers group (182 mL vs 131 mL, respectively), but was not statistically significant (P = .249). Conversion to open was notably higher in the Ligasure group (P = .034), but the intraoperative complications were comparable in both groups (P = .357). Conclusion. The use of vessel sealing devices for splenic pedicle control has comparable surgical outcomes compared with the use of endoscopic staplers for LS, but with higher rate of conversion to open surgery.

Standardizing the Protocols for Enhanced Recovery From Colorectal Cancer Surgery: Are We a Step Closer to Ideal Recovery?

PURPOSE: Enhanced recovery protocols are being implemented into the standard of care in surgical practice. This study aimed to insert a steadfast set of elements into the perioperative care pathway to establish an improved recovery program for colorectal cancer patients. METHODS: Seventy patients planned for elective laparoscopic colorectal resection were randomized into 2 groups: conventional recovery group (n = 35) and enhanced recovery group (n = 35). The primary outcome was the length of hospital stay. Secondary outcomes included the times of removal of nasogastric tubes (NGTs), successful enteral feeding, and removal of drains, postoperative complications, intra-hospital mortality, and rate of readmission. RESULTS: The mean postoperative hospital stay was 4.49 ± 0.85 days vs. 13.31 ± 6.9 days (P < 0.001), the mean time of removal of NGTs was 0.77 ± 1.031 days vs. 3.26 ± 2.737 days (P < 0.001), the mean time of successful enteral feeding was 1.89 ± 1.13 days vs. 5.46 ± 1.67 days (P < 0.001), and the mean time for removal of intra-abdominal drains was 2.94 ± 1.056 days vs. 9.06 ± 3.757 days (P < 0.001) for the enhanced and the conventional groups, respectively. Complications were significantly lower among patients in the enhanced group (25.7% vs. 65.7%) (P = 0.001). The rates of readmission were similar in the 2 groups. CONCLUSION: Applying definite evidence-based elements to the colorectal rehabilitation program significantly boosts the recovery pathway with favorable outcomes, including faster recovery of gastrointestinal tract functions, lower morbidities, and eventually earlier discharge from the hospital.

Outcome of Patients with Cervical and Vaginal Stump Carcinomas Treated with More Conservative Surgical Approaches: a 9-Year Experience of a Tertiary Oncology Center.

The surgical management of stump carcinoma includes the gold standard pelvic exenteration and more conservative approaches. This study aimed to investigate the outcome among a cohort of vaginal and cervical stump carcinomas that were treated with an intent of organ preservation. This is a prospective study of 60 patients with a biopsy confirmed stump carcinomas at a tertiary care oncology center in Egypt. The demographic, surgical, and pathological data were collected and patients underwent radical surgery with an intent of organ preservation guided by margin negativity. The pathologic data were correlated with the postoperative mortality. Correlation coefficients were calculated for simple correlation and regression analysis was used to investigate the independent predictors of survival. Pelvic exenteration was conducted in 30/60 (50%), while wide local excision with safety margins was possible in 26/60 (43%) and in two cases, resection was precluded. Mean hospital stay in days was 19 ± 9 (range 4-61). Overall operative morbidity was 83.3% (50/60). Perioperative mortality was 6.7% (4/60). Five-year disease-free survival was 40% (24/60). Five-year overall survival was 50% (30/60). The resection margin status and the perioperative therapy were independent prognostic factors of DFS (p = 0.003 and 0.02, respectively. Only the resection margin status was significantly associated with overall survival (p = 0.009). There was no increased mortality with introduction of more conservative surgical approaches. The resection margin status is the most important determinant of recurrence free and overall survivals.

The adequacy of lymph node harvest in concomitant neck block dissection and submental island flap reconstruction for oral squamous cell carcinoma; a case series from a single Egyptian institution.

BACKGROUND: Squamous cell carcinoma (SCC) is a fairly common tumor of the oral cavity. This tumor may affect any part of the mucosa of the oral cavity especially the tongue, the floor of the mouth and lips. The encountered intra-oral defects after tumor resection are often large and require climbing up the reconstruction ladder to more complex reconstructive options for accepted functional and cosmetic results to be achieved. However, most of the patients are old with medical co-morbidities requiring fast, simple, less morbid reconstructive option such as local flaps. The myocutaneous submental island flap has emerged as a simple and fast reconstructive technique that provides thin, pliable tissue with adequate volume and reliable blood supply. However, one major concern regarding the utility of the submental flap for repair of post-ablative tumor defects is the presumed interference with adequate lymph node neck dissection. METHODS: In this study, we present a cohort of thirty-six consecutive patients who were operated for oral SCC. All patients were offered submental island flap reconstruction of their resultant defects together with ipsilateral selective neck block dissection of levels I, II, III and IV; and the nodal yield of each level was tested pathologically. RESULTS: Nodal harvest was ≥ 12 in 88 % of the patients. Complications were encountered in two patients (5.5 %). CONCLUSION: Our data suggest that adequate cervical lymph nodes dissection, specifically level I and II cervical lymph nodes, can be fulfilled with concomitant submental island flap elevation.

Pharyngoesophageal reconstruction after resection of hypopharyngeal carcinoma: a new algorithm after analysis of 142 cases.

BACKGROUND: The aim of this study is to define an algorithm for the choice of reconstructive method for defects after laryngo-pharyngo-esophagectomy for hypopharyngeal carcinoma. METHODS: One hundred and forty two cases of hypopharyngeal carcinoma were included and operated on by either partial pharyngectomy, total pharyngectomy or esophagectomy. The reconstructive method was tailored according to the resected segment. RESULTS: Pectoralis flap was used in 48 cases, free jejunal flap in 28 cases, augmented colon bypass in 4 cases, gastric pull up in 32 cases and gastric tube in 30 cases. Mean hospital stay was 12 days. Mortality rate was 10.6% and morbidity rate was 31.7%. Total flap failure occurred in 3 cases of free flap and one case of pectoralis flap. There were 23 cases of early fistula. Late stricture occurred in 19 cases, being highest with myocutaneous flap (early fistula 12/50 and late stricture 13/50). CONCLUSION: Free jejunal flap was the flap of choice for reconstruction when the safety margin is still above the clavicle. In cases with added esophagectomy, we recommend gastric tube as a method of choice for reconstruction.

Therapeutic reduction mammoplasty in large-breasted women with cancer using superior and superomedial pedicles.

BACKGROUND: Surgical management of breast cancer in large-breasted women presents a real challenge. This study aims to evaluate the outcome of therapeutic reduction mammoplasty in large-breasted women with breast cancer using superior and superomedial pedicles, situated at any breast quadrant except for the central and upper medial quadrants. METHODS: Fifty women with breast cancer and large breasts underwent simultaneous bilateral reduction mammoplasty. The weight of the tissue removed ranged from 550 g to 1050 g and the tumor-free safety margins by frozen section were in the range of 4 cm to 12 cm. RESULTS: The age of the patients ranged from 36 to 58 (median 43) years and tumor size ranged from 1 cm to 4 cm. The cosmetic outcomes were excellent in 32 patients (64%), good in 15 (30%) patients, and fair in three patients (6%). The follow-up period was 8-36 (mean 20) months, with no local recurrence or systemic metastasis. CONCLUSION: Therapeutic reduction mammoplasty using superior and superomedial pedicles was shown to be oncologically safer than traditional conservative surgery. This oncoplastic procedure yields a satisfactory esthetic outcome with lower morbidity in large-breasted women with breast cancer.

Can we put a simplified algorithm for reconstruction of large scalp defects following tumor resection?

BACKGROUND: Reconstruction of large scalp defects after tumor resection is a challenging problem. We aimed at putting an algorithm for reconstruction of those defects. METHODS: Forty-two patients with scalp malignancies were enrolled in this study. Tumors were resected to a 1 cm negative margin and defects were reconstructed according to their size and to patient general condition. RESULTS: No peri-operative mortality was encountered. Usage of free flaps was superior in cosmoses and function with an acceptable rate of complications. CONCLUSION: for scalp defects wider than 100 cm2, the best tool of reconstruction is free flaps. Pedicled distant flaps are reserved if free flaps are not feasible or failed. Split thickness skin grafts are cosmetically inferior and not suitable for recurrent and irradiated tumours and better reserved for patients who cannot tolerate major operations.

Levator anguli oris muscle based flaps for nasal reconstruction following resection of nasal skin tumours.

BACKGROUND: surgical excision remains the best tool for management of skin tumors affecting nasal skin, however many surgical techniques have been used for reconstruction of the nasal defects caused by excisional surgery. The aim of this work is the evaluation of the feasibility and outcome of levator anguli oris muscle based flaps. METHODS: Ninety patients of malignant nasal skin tumours were included in this study. Age was ranged from four to 78 years. For small unilateral defects affecting only one side ala nasi, levator anguli oris myocautaneous (LAOMC) flap was used in 45 patients. For unilateral compound loss of skin and mucus membrane, levator anguli oris myocautaneous mucosal (LAOMCM) flap was used in 23 patients. Very large defects; bilateral either LAOMC or LAOMCM flaps combined with forehead glabellar flaps were used to reconstruct the defect in 22 patients. RESULTS: Wound dehiscence was the commonest complication. Minor complications, in the form of haematoma and minor flap loss were managed conservatively. Partial flap loss was encountered in 6 patients with relatively larger tumours or diabetic co-morbidity, three of whom were required operative re-intervention in the form of debridement and flap refashioning, while total flap loss was not occurred at all. CONCLUSIONS: Immediate nasal reconstruction for nasal skin and mucosal tumours with levator anguli oris muscle based flaps (LAOMC, LAOMCM) is feasible and spares the patient the psychic trauma due to organ loss.

Continent catheterizable umbilical low-pressure intestinal pouch with split ileal end seromuscular anti-reflux technique.

BACKGROUND: Cosmesis, better function, and stomal stricture avoidance are important issues in constructing continent urinary abdominal stomas for bladder cancer patients when orthotopic urinary diversion is not feasible. This study aims to evaluate the outcome of continent catheterizable umbilical low-pressure intestinal pouch incorporating a new split ileal end anti-reflux technique. METHODS: Twenty-three patients underwent a continent umbilical low-pressure intestinal pouch incorporating a new seromuscular antireflux technique (split ileal end) after radical cystectomy when orthotopic reconstruction was not feasible. Mean operative time was 210 min (130 min for radical cystectomy and 80 min for reconstruction of the pouch). The mean follow-up after surgery was 18 mo (range 6-30 mo). RESULTS: The most common early postoperative complications were urinary leak that occurred in nine patients: seven were conservatively managed and two by re-exploration. Late postoperative complications occurred in eight patients, of whom three developed stomal stenosis and treated successfully with repeated dilatation. Thirteen patients were totally continent, seven were fairly continent, and only two were poorly continent. CONCLUSIONS: The functional results with this catheterizable umbilical low pressure intestinal pouch incorporating our new anti-reflux technique were satisfactory with better cosmesis.