Surgery for Surgeons

Acute anemia is a common reason for transfusion of blood products. The hemoglobin (Hb) threshold for correcting anemia has been a hot topic of discussions for a long time. Here I would like to share my experience and thoughts about this very surgical issue.

About 15 years ago I listened to a talk that was given by a German gastroenterologist who worked at that time in Malawi, a small country in the southern part of Africa. Among other interesting stories, he said that they did not even think about blood transfusion unless there is the number 4 (four!) before the comma in the Hb g/dl level. This was due to a relative lack of blood products but he said also that they never had any problems related to uncorrected acute anemia.
We should assume though, that most of the patients there are generally in a better health that the average patient in the Western world, mostly because of the short life expectancy and very low rate of chronic diseases like Diabetes or Hypertension. Also, as one of my current mentors noted, the rate of patients with sickle cell anemia might be significantly higher there. These patients tend to tolerate much lower Hb levels. Continue Reading »

I have to admit, like many colleagues, I believed for many years that giving Flagyl (Metronidazole) for C. diff. colitis should happen only PO. Now I was corrected.

Recently one of the transplant surgeons in the hospital I work in suggested IV Flagyl for a patient with this diagnosis and I objected. She told me that this is a common mistake and comes most probably with the fact that Vancomycin should be given definitely PO for C. diff. colitis.

When I went home, I couldn’t go to bed until I found some papers about this. Well, of course she was right! :)

Searching PubMed for “intravenous[Title] AND metronidazole[Title] AND clostridium[Title] AND difficile[Title]” gave this result. I pulled the articles from the local electronic database of the hospital and… they convinced me.

Even given PO the drug acts by being first absorbed systemically and its concentration in the mucosa of the bowel is what works then again the bacteria. The PO therapy is cheaper but not superior than the IV one.

Again: Flagyl can be given IV for treating Clostridium difficile colitis!
Good to know!

Thanks to the nice surgeon who pointed this for me! :)

This is the third part of the posting series “The process of organ procurement”. Please start with the first and second part if you have not done so.

The cold dissection is the part with the most surgical variants and I want to stress again the fact that the described way is the one that I use, well knowing that this is only one of many possible ways to perform an organ procurement in general and a cold dissection in particular.

This is the second part of the posting series “The process of organ procurement”. Please start with the first part if you have not done so.

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The preparation in the OR includes placing of two electrosurgery (”Bovie”) pads and two suction lines.

I usually fixate both arms next to the body unless the anesthesia colleagues have a good reason for extending one or both of them. Shaving and decontamination of the skin I perform only in a line about 5-10 cm on both sides of the midline as I never make lateral incisions.

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There are many ways performing most of the surgical procedures. Everyone of the surgeons has established a way to go for a particular surgery that s/he is most familiar with and trusts the most. In this series of postings (”The process of organ procurement”) I will describe the way I perform the liver and kidney procurements in a Standard Criteria Donation (SCD) situation.
Continue Reading »

Recently I had an interesting case with a weird behavior of a suspected metastasis after resection of the primary tumor.

Description
A 43 years old male came in July 2008 to the Medical Service with nausea, vomiting and abdominal pain. The workup showed a tumor in the 3^rd portion of the duodenum as well as a big mass in the right liver lobe, so the IM guys asked us to take a look. They performed two attempts to biopsy the masses which showed no tumor. This was the reason for the decision to resect the tumor.

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Michael DeBakey died at the age of 99.

This surgeon published his first invention in 1933 and had an office at the Baylor College in Houston until his death yesterday (In Memoriam, Baylor College of Medicine).

My former chief retired about a year ago and at the same day I left also the Medical Center where he and Dr. Thorsten Morlang made me a surgeon. At a ceremony because of his retirement Dr. Wolf J. Stelter (1994 president of the Michael E. DeBakey International Surgical Society) showed then pictures of his own chiefs through the years in different medical centers in Germany and in the United States. He started talking about them saying that of all these men, only Michael DeBakey is still alive. …And I was happy that my chief is alive.

Until some hours ago Michael DeBakey was a living legend… I can’t write anything more about this.

Rest in peace, Dr. DeBakey! Rest in peace, Michael!

About a year ago I wrote about a transgastric approach in some gastroenterological experiments. What happened in this year? Well, there is a development! Let us take a look at a paper published last year in Nature Clinical Practice Gastroenterology & Hepatology – a magazine belonging to the Nature publishing group. This publication is a review of the still veterinary experiments concerning the “natural orifice transluminal endoscopic surgery” (NOTES).

This time the paper is written better. The authors are IM guys who are obviously still in the euphory in front of the possibility to perform “operations” as endoscopists. Though they started thinking about things like indications, complications and techniques.

For me the interest in NOTES-publications remain still in the question about the indication and the risks of this experiment. Therefore I don’t want to discuss the other parts of the paper. Also, I will compare the transluminal with the laparoscopic approach only and not with the open surgery, because the laparoscopy is what NOTES compete with. Continue Reading »

Every abdominal surgeon has patients with peritonitis. In severe cases, a “second look” should be planned. At least this is the common opinion.

A  group from Holland published a randomized trial about this topic. Surprisingly the results did not show higher morbidity in the “on-demand” group. Continue Reading »

Since the end of the 70-ies, as the radioiodine therapy was initiated, the prognosis of the well-differentiated thyroid carcinomas improved like no other. Despite the success of the therapy, about 30% of the papillary thyroid carconimas show a recidive. Therefore the question about the followup of these carcinomas is quite interesting.

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