It’s an honor and pleasure to bring you this new edition of The Best Surgical Grand Rounds Carnival.

FIFA WORLD CUP – SOUTH AFRICA 2010

I would like to express my gratitude to Jeffrey Leow of Vagus Surgicalis (Australian medical student with lots of interest and knowledge of surgery) and the creator of this Great Carnival. Australia is in Group D.

Bongi, a lucky SouthAfrican general surgeon who will host the FIFA World Cup in 12 days, shares a story that will push you to learn Afrikaans. South Africa will be head of the Group A and will play with México, Uruguay and France.

rlbates, my favorite (female) plastic surgeon who lives to sew, wrote an excellent review of Scalp avulsion injuries. USA will play against England, Algeria and Slovenia in Group C.

Techknowdoc, a surgeon part of the Indian Medical Industry, shares his point of view about antibiotics use in abscess drainage. Match ball are made of latex bladder of India.

Julia wrote a comparison between nursing informatics and medical informatics, both are related, they are not exactly the same. Julia is an italian name; Italy is head of the Group F and will play against Paraguay, New Zeland and Slovakia.

Medical Transcriptionist, published an article that states the need for nurses and other medical professionals increase with the demand of elderly health care, as in France. France is part of the Group A and will play with México, Uruguay and the host South Africa.

From DrDJ, a surgical case of a giant condyloma acuminatum (also know as Bushke-Löwenstein tumor) and follow-up. Abraham Buschke was a German dermatologist. Germany is head of Group D.

Agravated DocSurg, wrote his 4th test of OR Rorschach. Very Creative. Hermann Rorschach was a swiss psychiatrist. Swiss is in Group H, with Spain, Honduras and Chile.

From Boobcast; writings of a woman’s bad boob job. Finally she got her nipple reconstruction procedure done which includes a video. She is from US, but in Group C is England.

Madoline Hatter presents 50 Great Sites for Menopause Support posted at Nursing School Search Blog. Magdalena is Madoline in Portuguese. Portugal is in Group G, with Brazil.

Dr. Armughan Riaz is a cardiologist from Pakistan; he wrote an article of foods that can lower blood sugar. The Greek term Diabetes, means “one that straddles”. Greece is in Group B.

I have to thank all participants, all publishers and specially all of our readers.

World Cup objectives:

• Developing the game
• Touch the world
• Build a better future

Kidney stones (nephrolithiasis or urolithiasis) affect approximately 12% of men and 5% of women during their lifetime. Nearly half of all first time stone formers will have another stone episode within the next four years.

Stones can form when calcium, oxalate, uric acid or cystine are at high levels in the urine.

Uric acid stones represents 5 – 10% of all kidney stones. But they comprise 40% in areas with hot/arid climates where low urine volume and acid urine pH promote uric acid precipitation.
Prevalence:  In patients with gout without antihyperuricemic treatment is 20%. Hundreds-fold greater than healthy adults.

Risk factors: It primarily occurs in patients without abnormality in uric acid metabolism such as: relatively high serum uric acid levels, comparatively low urinary pH, and low fractional excretion of urate. Clinical gout. Hyperuricosuria, chronic diarrhea (bicarbonate loss and dehydration).  Diabetes, metabolic syndrome and overweight.

How it occurs?:  Two major factors contribute uric acid precipitation

• a high concentration of uric acid in urine
• acid urine pH

Diagnosis: Is suggested from the acute onset of flank pain, a positive non-contrast-enhanced CT scan, and history of a predisposing disease (gout, cancer, etc). Plain X-ray is not helpful because these stones are not radiopaque. Confirmation of the diagnosis is best made by chemical analysis of a stone that has been passed.

Treatment:

• Maintenance of the urine output above 2 L/day to diminish the urine uric acid concentration
• alkalinization of the urine (increase the urine pH) with potassium bicarbonate or potassium citrate (cytra-k; polycitra-k; urocit-k; citro-k) can be given and this regimen can both dissolve preexisting stones and prevent the formation of new ones.
• Allopurinol (zyloprim; aloprim; atisuril)
• Reduction in dietary purine intake (protein)

Image courtesy of: Urocit-K

Roger Frisch, a solo violinist and associate concertmaster for the Minnesota Orchestra, and how he came to Mayo Clinic and Dr. Kendall Lee (neurosurgeon) for relief of a career-threatening tremor.

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Around 42 million couples worldwide rely on vasectomy as a method of family-planning.

Every year 800,000 vasectomies are performed in the US.

Recanalisation: 0.5% of all vasectomies (is defined as the presence of any spermatozoa after one or more previously azoospermic samples were properly collected and documented).

Why are doctors sued following vasectomy?

1. Failure to be sterile (unwanted pregnancy)
2. Failure to inform regarding positive semen sample post-operatively
3. Hematoma/infection
4. Chronic testicular pain
5. Atrophy or loss of testicular volume

Vasectomy Failure

Can be due to technical errors, recanalization, or unprotected intercourse before azoospermia is documented

1. Intraluminal needle cautery (vas not transected, no segment removed): Less than 1%
2. Cautery both ends and fascial interruption: 1.2 % or less
3. Cautery (prostatic end) only and fascial interruption (clip): 0.02 to 2.4%
4. Cautery of both ends and excision of a segment: 4.8% or less
5. Ligation and fascial interruption: 16.7% or less
6. Ligation and excision of segment: 1.5 to 29%

To confirm sterility: Obtain a semen analysis 3 months on the postop period; the patient should have had at least 20 ejaculates since the time of vasectomy. Azoospermia in a semen sample is definitive evidence of infertility.

Sokal DC, Labrecque M. Effectiveness of Vasectomy Techniques. Urol Clin N Am 36 (2009) 317–329.

Fear from cancer

One not uncommon indication for prophylactic mastectomy is carcinophobia (a.k.a. cancerophobia).

Cancerophobia or carcinophobia is an active behavior of extreme fear of cancer that can lead to repeated medical examination without giving full reassurance to the patient. Denial is a mechanism of defense that usually helps the patient to cope with painful, threatening, overwhelming, or awkward thoughts. When it turns out to be ineffective and pathological, it can cause either delay or avoidance in seeking treatment for symptoms relevant for a true malignancy and will lead inexorably to death if not cured. Most people worry about cancer, but those with cancerophobia are unable to perform their activities of daily living.

For example, cancerophobics believe that a simple headache is a symptom of brain cancer/tumor or dysphagia is a symptom of gastric cancer.  This patients need psychological intervention.

In a female patient cancerophobia with a strong family history of breast cancer and a benign tumor in her breast and if psychological intervention doesn’t help her and she still over-anxious, prophylactic mastectomy is indicated.

The Best U.S. Hospitals for 2009

1. Johns Hopkins Hospital, Baltimore
2. Mayo Clinic, Rochester, Minn.
3. Ronald Reagan UCLA Medical Center, Los Angeles
4. Cleveland Clinic
5. Massachusetts General, Boston
6. New York-Presbyterian University Hospital of Columbia and Cornell
7. University of California-San Francisco Medical Center
8. Hospital of the University of Pennsylvania, Philadelphia
9. Barnes-Jewish Hospital/Washington University, St. Louis
10. Brigham and Women’s Hospital, Boston &  Duke University Medical Center, Durham, N.C.
11. University of Washington Medical Center, Seattle
12. UPMC-University of Pittsburgh Medical Center
13. University of Michigan Hospitals and Health Centers, Ann Arbor
14. Stanford Hospital and Clinics, Stanford, Calif.
15. Vanderbilt University Medical Center, Nashville, Tenn.
16. New York University Medical Center
17. Yale-New Haven Hospital, New Haven, Conn.
18. Mount Sinai Medical Center, New York
19. Methodist Hospital, Houston
20. Ohio State University Hospital, Columbus

Top Hospitals by Specialty in the U.S.

• Cancer: M.D. Anderson Center, University of Texas, Houston
• Diabetes and endocrine disorders: Mayo Clinic, Rochester, Minn.
• Digestive disorders: Mayo Clinic
• Ear, nose, throat: Johns Hopkins Hospital, Baltimore
• Geriatric care: Ronald Reagan UCLA Medical Center, Los Angeles
• Gynecology: Brigham and Women’s Hospital, Boston
• Heart and heart surgery: Cleveland Clinic
• Kidney disorders: Brigham and Women’s Hospital
• Neurology and neurosurgery: Mayo Clinic
• Ophthalmology: Bascon Palmer Eye Institute, University of Miami
• Orthopaedics: Mayo Clinic
• Psychiatry: Massachusetts General, Boston
• Rehabilitation: Rehabilitation Institute of Chicago
• Respiratory disorders: National Jewish Hospital, Denver
• Rheumatology: Johns Hopkins Hospital
• Urology: Johns Hopkins Hospital

REFERENCES:

• News release, U.S. News & World Report.
• U.S. News & World Report: “America’s Best Hospitals.”
• Avery Comarow, health rankings editor, U.S. News & World Report.

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image under Creative Commons license

As in Marvin L. Corman’s book (Colon & Rectal Surgery) quotes:

Man should always strive to have his intestines relaxed all the days of his life and that bowel function should approximate diarrhea. This is a fundamental principle in medicine, that whenever the stool is withheld or is extruded with difficulty, grave illnesses result.

Maimonides: Mishneh Torah

Rectal prolapse (a.k.a. Procidentia) is one of the most fascinating surgical pathologies because its complexity in treatment. In 1912 Moschcowitz proposed an herniation of Douglas pouch as a cause for rectal prolapse. Another cause was proposed by Broden and Snellman with the help of defecography described a full thickness rectal intussusception.

Rectal prolapse is 6 times more common in females (as males) aged 50 years or older. Many of male patients has a past medical history of psychiatric disorders. Chronic or lifelong constipation with straining is present in more than 50% of patients.

Patients describe a mass or bulge that they have to push back in after defecation. Often, presentation of rectal prolapse can be dramatic when the prolapsed segment becomes incarcerated below the level of the anal sphincter as in this clinical case and emergency surgical therapy was indicated.

More than fifty types of procedures for repair rectal prolapse have been described, but the treatment is always surgical.

Hand reconstruction

Lakshmi Tatma is a girl who is two years old but she was born with 8 limbs, because she is joined at the pelvis to what is, in fact, a headless, undeveloped twin (parasitic twin or to be more specific, ischiopagus cojoined twin).

This is surely an abnormal feature and it has attracted media attention worldwide.

The 24-hour-long surgery to remove the extra limbs of this Indian girl born with four arms and four legs was a success, doctors announced Wednesday.

A team of more than 30 physicians removed Lakshmi’s extra limbs, salvaged her organs, and rebuilt her pelvis area, Dr. Sharan Patil said from a hospital in the southern Indian city of Bangalore, India.

The organs of a pig are placed within the model.

The model is intubated with an “orotracheal” tube

Abdominal view

Thoracic view

Laparoscopy view

The english organization Marie Stopes International maintains a campaign to alert british citizens on the risks of acquiring venereal diseases or non-wished pregnancies when traveling to Mexico.

“What is more embarrassing, his hat or what he might give you? Make sure don’t come home with any unwanted holiday souvenirs”

This poster is very offensive and annoying. It’s an insult for my Country and it will frighten tourists. MFs, try to think before offend.

Welcome to the third edition of SurgeXperiences, the first carnival of surgery. I’m honored to bring you this surgical carnival.

This will be a practical and concise edition. The objective of blogs (in my point of view) is to answer questions as quickly as possible, so lets start with the HOW-TOs. Enjoy.

• How to classify fingertip injuries and amputations and how to treat them? This is a nice abstract in where we will learn how to close the wound, maximize sensory return, preserve length, maintain joint function, and achieve a satisfactory cosmetic appearance. This is a Must Read!
• How to survive surgical training when your boss is really mean? A touching and insightful story. Luckyly those times are changing.
• How must be your surgeon? How to make the perioperative experience a smooth one for patients, nurses and surgeons? Great tips for all of us. Don’t lose the floor.
• What are the complications of Mitral Valve Replacement? An excellent reminder.
• How to choose a rehabilitation center? What are their services, facilities, costs and credentials?
• How is the clinical presentation of severe pancreatitis? I love hard cases as this one.
• How much farther have we advanced in medicine since the days of trepanation? Do you know that people had holes drilled in their heads voluntarily and they state that this results in more energy and an increased feeling of consciousness and lessens repression?
• How a prosthetic robotic arm works? Nice videos!
• How a simple procedure (lateral sphicterectomy) can lead to a satisfyingly outcome for both the patient and the surgeon?
• How to interpret the new article that assures the relationship between breast implants and suicide rates?
• How to be thankful to a surgeon and how a surgeon can change your life? Charming story that guides me to always give the best of me.
• How an amebic brain abcess looks like? You will never forget to keep it as a differential.
• How a simple order can trigger a defense mechanism? Try to not give orders to therapydoc.
• Should mesalamine be stopped prior surgery? Why?
• How to manage those the difficult situations involving CPR? A very insightful view and nicely written.
• How to back in time for 3 decades and deny the link between AIDS and VIH? Do you think that the truth may prevail?
• What kind of role a military surgeon play in war zone? Sharing his thoughts and feelings about Air Force training.

Thank you for your time and participation. Make sure you read the next edition of SurgExperiences, created by Jeff Leow

Please feel free to post about anything related to surgery, like surgical procedures, mistakes during surgery of your training, lessons learnt, and tips, first operation done solo, memorable operations, memorable patients, jokes. I also accept patient posts.

You can send me your article via:

Blog Carnival Submission Form
Regular e-mail to: j o n m i k e l ( AT ) g m a i l . c o m.

On physical examination we found Grade IV hemorrhoidal disease.

We decide to perform a PPH procedure with an hemorrhoidal circular stapler (33 mm) kit.

Note the tissue removed.

This donut confirms the circular and complete resection of the defect.

On the postoperatory period the patient was in excellent condition without pain and without bleeding.