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 »

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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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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In the beginning of the 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 is not a good one. The evidence based knowledge doesn’t need much trials. Therefore I dare to share some thoughts about a recent discussions concerning minimizing the “Minimal Invasive Surgery”.

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A very interesting trial was published in the current issue of “Archives of Surgery“. The clear 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! :)

In the last Friday a patient was brought to my ER from the airport. He was previously reported by the control point as a cerebral commotio. He was a man in the 4 decade who flew from a big city in the USA to Europe accompanied by his wife. It was interesting that he is a nephrologist and his wife is a general surgeon. Continue Reading »

A 75 yo, previously completely healthy patient came to my ER and complained about upper GI pain for 3 days, no other complains. The exam showed a very painful and tense abdominal wall upon pressure. Labs got some elevated WBC (11.2 Bil/l) without elevated CRP or any other parameter. The abdominal plain is shown on the right (click the thumbnail for a larger view).

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Once again a mid 2004 multicenter trial but very interesting because of the high relevance in the daily practice of surgery.

The conclusion is straight and clear: “..for primary hernias, the open technique of tension-free repair is superior to the laparoscopic technique, both in terms of recurrence rates and in terms of safety.”

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