Surgery Blog for Surgeons

Along the way we shall catch excellence...

Aiming at excellence is the natural goal for a lot of activities in people's lives. Our work is just one, granted a very important, aspect of this process.

Dr. Aloia from the MD Anderson Center in Houston just achieved a point on excellence by publishing a paper about striving for "Zero Harm".

One may not thing of this goal as being a problem but he outlines several issues along his path of improving his outcomes after liver resections. Going for a "Zero" complication rate leads to:

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Can we ligate the celiac trunk?

Branches of the aorta used to be considered vital for the circulation as they often supply a large amount of other vessels. Ligating intercostal or lumbar branches is commonly accepted to be safe if needed. However, the major ventral branches of the aorta were generally thought to be more important. Occlusion of the inferior mesenteric artery (IMA) is being practices routinely ever since the introduction of the endovascular aortic aneurysm repair (EVAR) with often only transient mucosal ischemia of the sigmoid colon observed in about 10% of the cases.

While the occlusion of the superior mesenteric artery (SMA) is widely accepted not to be compatible with life, ligating the celiac axis may be an interesting approach to explore.

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Laparoscopic vs. Open Resection in Rectal Cancer

Open low anterior resection (LAR) and abdominoperineal resections (APR) are not easy procedures, esp. in tight male pelvises. The laparoscopic approach gave us a tool dramatically improving the exposure and making the whole mesorectal excision significantly easier. As frequently in situations like that, we were quite hopeful (and meanwhile biased towards believing) that the advantages in the laparoscopic LAR and APR would translate into better oncological outcomes.

Dr. Fleshman (Dallas, Texas) was one of the most vocal proponents of the laparoscopic approach and wanted to prove it. He recently published a very well designed study:

Effect of Laparoscopic-Assisted Resection vs Open Resection of Stage II or III Rectal Cancer on Pathologic Outcomes
The ACOSOG Z6051 Randomized Clinical Trial

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Surgery podcast

Podcasts are regaining attention after the initial hype in the mid 2000s and the subsequent decline of their popularity. I've always thought that podcasts are a great resource for gaining or maintaining knowledge.

Looking for a good surgery podcast, the residents in the center I work in recommended Behind the Knife (BTK). I gave it a try and was pleasantly impressed. It's not ideal but it is very good and well made. In addition, the guys running it, put a great effort in engaging nationwide renown surgeons.

All kind of topics are discussed in BTK incl. ABSITE and Board reviews but also review and analysis of important literature.

I intend to use some of the episodes for complementary information whenever I write about a particular topic.

Here is another list of the episodes and this one offers easier downloads.

Have fun!

How to close a midline laparotomy - The STITCH trial

A lot, maybe even the majority, of things we do in medicine in general and in surgery in particular, are not evidence based. One of those things, no being supported by good data, is one of the most commonly performed procedures in surgery - closing of the abdominal midline incision.

There is some data supporting the 10mm/10mm running closure with PDS 1 suture. However this data is quite weak and now finally somebody decided to challenge that.

Even before this trial, there was evidence that smaller stitches with a more gentle suture would achieve better results in terms of preventing hernias. However, this paper describes the first double-blind, multicentre, randomised controlled trial addressing this question:

Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial, Lancet. 2015 Sep 26;386(10000):1254-1260. doi: 10.1016/S0140-6736(15)60459-7. Epub 2015 Jul 15

Here I'm sharing some thoughts about the trial and its critics.

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(Ab)Using scientific journals for political purposes

I just read the article "What Liver Transplant Outcomes Can Be Expected in the Uninsured Who Become Insured via the Affordable Care Act?" in the last edition of AJT and would like to share some thoughts about it.

Cohort selection

On page two the authors write:

All charity care candidates were rigorously screened by social workers and neuropsychiatric professionals to ensure that they have 1) a strong social support system, 2) a failsafe transportation mechanism to facilitate access to posttransplant clinics, 3) adequate cognitive function to understand the transplant process, and 4) a personality that predicts that the candidate will be reliable to take medications as prescribed and come to clinic appointments as required.

Besides suggesting high preselection bias of the patients in this group, one would wonder whether the protocols in Alabama don't include this kind of evaluation of all patients and not just of the ones who are uninsured.

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"First pass" mesenteric flow is not necessary - portal vein arterializaton

Portal vein thrombosis (PVT) is such a profound problem that it has been considered to be an absolute contraindication for a liver transplantation (LTx) and I know centers still denying LTx for patients with PVT. In the most cases the donor portal vein is anastomosed with the superior mesenteric vein (SMA) of the recipient using a vascular graft (usually from the same donor). There are some reports about porto-renal anastomoses. The portal vein arterialization (PVA) is the option which recently attracted my interest and I took a look at what was written about this.

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Brenner Tumor

In 1907 Fritz Brenner published his thesis "Das Oophoroma folliculare".

F. Brenner: Das Oophoroma folliculare. Frankfurter Zeitschrift für Pathologie, München, 1907, 1: 150-171)

He described what was later called "Brenner Tumor".

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Single Incision Laparoscopic Surgery (SILS)

The initial hype about NOTES is over!

This is such good news that I couldn't resist starting with it. :)

I wrote twice about this topic and not only my opinion didn't change, I noticed that the general perception regarding NOTES is meanwhile clearly negative. Even people who are usually more open to new approaches share this position now.

Surgeons need new challenges though and the Single Incision Laparoscopic Surgery (SILS) is offering some. Recently I was on Grand Rounds where a general surgeon from a private practice shared his thoughts and experience with the auditorium about SILS. I was hoping that he would focus more on review of the (still scarcely) available data. He decided to just present some of his cases though: just cholecystectomies.

Here are my impressions from this talk:

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There is a breakthrough publication in the last Science about successful Teleportation(!) of quantum particles between Australia and Japan.

This is general science and not surgery; I know that but it might have caught me in an optimistic moment because I just started imagining what would be, should we be able to teleport real objects one day.

I am so impressed that I didn't want to let this news just pass by without having noted it. :)

Work load in surgical education - impact on education and healthcare

The introduction of the 80-hours week for the residents in the USA brought a lot of unhappy faces in the faculty members. Ever since then the residents have to listen to even more "what-do-you-know" and "when-I-was-a-resident" stories on a daily basis. The generation conflict is remarkably expressed in these conversations and it is caused solely by the attending physicians. They urge the residents to protest against these rules arguing that working more than 80 hours per week is essential for a sufficient education.

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Ultrasound/MRI elastography: non-invasive test for liver fibrosis and cirrhosis

While looking for papers about "small-for-size" liver syndrome, I just stumbled upon a relatively new test called FibroScan©. This is an interesting approach in determine the stiffness of the tissue as this reflects a possible fibrosis/cirrhosis of the liver.

The test is performed by Ultra Sound (US) or MRI (the term "FibroScan©" is the commercial name of the US way only). Both methods rely on measuring the response of the liver tissue to an external vibration.

Here is a nice and short description of the tests. Rowen Zetterman points out some possible limitations:

  • "Advanced fibrosis may be underestimated and patients with macronodular cirrhosis may be classified as noncirrhotic.": I don't see this as a problem in real life because macronodular cirrhosis is easily diagnosed just by plain imaging.
  • "Fibrosis may be overestimated in patients with extrahepatic cholestasis or acute hepatocellular injury due to the effects of these conditions on liver stiffness.": I would add here also CHF as it makes a liver stiff as well.
  • "Ultrasound elastography does not distinguish patients with no fibrosis from patients with minimal fibrosis.": Yes, this is understandable. But there is probably no clinical relevance of this distinction.
  • "Ascites can interfere with the generation of a shear wave through the liver.": At the stage of significant ascites, the patients usually have some sort of diagnosis. But I agree that this is a real limitation of the test.

Having those limitations in mind, I think that overall this is a very nice idea. We are challenged now to get some sensitivity and specificity so that we could find the group of patients who could avoid the biopsy.

Happy Holidays!

Everyone who sporadically was or regularly is stopping by, I would like to wish Happy Hanukkah, Merry Christmas or whatever you celebrate these days.

Here is my holiday's gift for you: a very nice surgical story I recently heard.

One of my colleagues told me recently about his father who was a surgeon in the Vietnam War. Back then he (the father) was a youngster and used to work with an elderly surgeon who used to... switched off (!) the lights for 2 minutes before closing the skin. On every case!

The rationale behind this (for us) obviously queer custom was the following.
The postoperative bleedings occur because the vessels start to bleed after the closure of the skin. So, to "trap" them, the old surgeon tried to make them "think" the skin was already closed. After 2 minutes he switched the lights back on and looked for any vessel which might have disclosed itself as a potential troublemaker.

People think about medicine as a science. But there are so many "voodoos" we do.

Being a good surgeon becomes a challenging task if you want to keep up with the recent news in this field and also in the world. Having a "normal" social life is increasingly difficult when you consider the time spent in the OR, taking care of the patients and reading the literature.

This is why I truly appreciate you visiting this blog. Thank you!

Hyperacute rejection in liver transplantation?

The hyperacute rejection in transplant surgery is a devastating event. Prior to the introduction of the crossmatch for kidney transplantation, the hyperacute rejection was not uncommon. However the crossmatch is currently of no importance in the organs other than the kidney.
Despite some published case reports, most transplant surgeons do not even believe in hyperacute (or also antibody-mediated) rejection in liver allotransplantation. In fact, this attitude has been almost supported by most of these papers - they are just not convincing!

Having written the above, I will describe here a case that I have no (other) explanation for its course.

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Anemia and blood transfusions

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 dot/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.

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The process of organ procurement: Liver - the cold dissection

This is the third part of the posting series "The process of organ procurement".
Please start with the first and second parts 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.

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The process of organ procurement: Liver - the warm dissection

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.

The preparation in the OR includes placing of two electrocautery ("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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The process of organ procurement: prior to the surgery

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 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.

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Metastasis dependancy on the primary tumor?

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

A 43 years old gentleman came in July 2008 to the Medical Service with nausea, vomiting and abdominal pain. The workup showed a tumor in the 3rd 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 is dead!

Michael DeBakey died at the age of 99.

Michael E. DeBakey, MD

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

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 for his retirement, Prof. Dr. Wolf J. Stelter (a 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 any more about this.

Rest in peace, Dr. DeBakey!


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 posting is a review of the still veterinary experiments regarding the "natural orifice transluminal endoscopic surgery" (NOTES).

This time the paper is written better. The authors are medical 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 competes with.

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Followup for patients with papillary thyroid cancer

Since the end of the 70-ies, as the radioactive iodine 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 recurrence. Therefore the question about the followup of these carcinomas is quite interesting.

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Breast implants in elderly women from Egypt

A recent case in my ER offered a very interesting finding. A 1930 born woman from Egypt got a CXR. Among the common findings in the CXR of an elderly woman, a couple of breast implants could be seen. The colleague who had the case did not come to the idea of performing breast exam on the woman. All of us were somehow surprised seeing the implants. I first saw the date she was born and noticed that I never saw breast implants in a woman of this age. But the real surprise was that the patient is of Egyptian origin who never lived outside Egypt, being only a visitor in Germany.

Who could imagine that behind the traditional Muslim dress of a 77yo woman with a headscarf, a couple of 2 big breast implants could be find? Wilhelm Conrad Röntgen made it possible. :)

Take a look at the pictures:

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Abdominal aortic aneurysms in women - are 50mm still actual?

The title of a paper, recently published in the British Journal of Surgery, is "Influence of sex on expansion rate of abdominal aortic aneurysms".

This paper describes a trial with a very interesting conclusion:

The growth rate of AAA was significantly greater in women than in men. This may have implications for the frequency of follow-up and timing of repair of AAA in women.

The cutoff size for AAA in Germany is 50mm. I know that the NHS in the UK makes possible the treatment of such aneurysms until they reach 55mm. Since years the head of our Vascular Surgery Division considers treating of female aneurysms at 45mm. I have to tell him about this nice paper.

Thanks, Dr. Mofidi et al.!

Transgastric endoscopy - current adventure in the surgery fashion

In the beginning of most medical books, one can read that the medicine (and of course the surgery) is an ever growing field. Now we know that the laparoscopic cholecystectomy is a good idea, whereas the laparoscopic hernia repair may not be that of a one. Common sense doesn't need much trials. Therefore I dare to share some thoughts about a recent discussions concerning minimizing the "Minimally Invasive Surgery".

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Surgical skills and video games

A very interesting trial was published in the current issue of Archives of Surgery. The conclusion is:

Video game skill correlates with laparoscopic surgical skills. Training curricula that include video games may help thin the technical interface between surgeons and screen-mediated applications, such as laparoscopic surgery. Video games may be a practical teaching tool to help train surgeons.

In discussions with colleagues we compared many times the endoscopy (gastroscopy and colonoscopy) with a video game. The students found this talks very funny.

Now we have the "proof"!
So, dear surgeons, take a good computer machine and play! Play for the sake of your patients! :)

Carotid-Artery Endarterectomy or Stenting

First results of the EVA-3S trials were recently published in the NEJM. The conclusion is clear:

In this study of patients with symptomatic carotid stenosis of 60% or more, the rates of death and stroke at 1 and 6 months were lower with endarterectomy than with stenting.

OK, I am a surgeon and have the thinking of a surgeon. I always had a bad feeling regarding the carotid stents. The idea of an uncovered stent, pressed against the plaques on the carotid bifurcation, made me feel uncomfortable.

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Laparoscopically assisted vs. open colectomy for colon cancer

This is a somehow old (mid 2004) but nevertheless important multicenter trial which aroused my interest due to the fact that I do laparoscopically (hand)assisted colectomies.

The conclusion is:

...the rates of recurrent cancer were similar after laparoscopically assisted colectomy and open colectomy, suggesting that the laparoscopic approach is an acceptable alternative to open surgery for colon cancer.

Though, "no advantage of laparoscopically assisted surgery was evident with respect to either all stages of cancer or high-risk subgroups".

The collecting of data for the trial began 1994. Therefore the new, hand assisted approach in the laparoscopic surgery, could not be considered.

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Detection of tumor DNA in stool samples

A recent publication from the laboratory institute in the University Hospital in Hamburg, Germany discusses a new approach to diagnosing colorectal carcinoma: detection of tumor DNA in stool samples. Here is the abstract of the publication in the german "Aerzteblatt":

Detection of tumour DNA in stool is a new screening approach aimed at improving the early diagnosis of colorectal cancer. DNA from colorectal adenomas or carcinomas can be detected using specific mutations or methylation patterns. Altered DNA can in principle be detected in a high excess of normal DNA with high sensitivity, but low cost routine screening assays have yet to be developed. The combination of markers and methods must be refined to detect early stage tumours reliably. Only a test with high sensitivity could replace colonoscopy as the recommended screening method in the future.

Probability of pancreatic cancer following diabetes

The guys at the Mayo Clinic performed an interesting retrospective study about new-onset diabetes as a marker of underlying pancreatic cancer. They found that approxymately 1% of diabetes subjects aged > or =50 years will be diagnosed with pancreatic cancer within 3 years of first meeting criteria for diabetes.

Especially in patients with a positive family history for pancreatic carcinoma and new-onset of DM, a follow up may be a good idea.