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 »

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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The title of a paper 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 is in Germany 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 considers treating of female aneurysms of 45mm. I have to tell him about this nice paper.

Thanks, Dr. Mofidi et al.! :)

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! :)

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 a uncovered stent, pressed against the plaques on the carotid bifurcation, made me feel uncomfortable.
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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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This is a somehow old (mid 2004) but nevertheless very 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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A recent publication from the laboratory institute in the university clinics 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.