Abstract:

Diabetic foot and pressure ulcers are chronic wounds by definition. They share similar pathogeneses; i.e., a combination of increased pressure and decreased angiogenic response. Neuropathy, trauma, and deformity also often contribute to development of both types of ulcers. Early intervention and proper treatment should result in complete healing of non-ischemic diabetic foot and pressure ulcers, as defined by 100% epithelialization and no drainage (if no osteomyelitis is present). We developed the following paradigm, which has proved to be highly effective for complete healing of these wounds: 1) recognition that all patients with limited mobility are at risk for a sacral, ischial, trochanteric, or heel pressure ulcer; 2) daily selfexamination of the sacrum, ischium, buttocks hips, and heels of all bed-bound patients and the feet of patients with diabetes with risk factors (e.g., neuropathy); 3) initiation of a treatment protocol immediately upon recognition of a break in the skin (i.e., emergence of a new wound); 4) objective measurement by planimetry of every wound (at a minimum, weekly) and documentation of its progress; 5) establishment of a moist woundhealing environment; 6) relief of pressure from the wound; 7) debridement of all non-viable tissue in the wound; 8) elimination of all drainage and cellulitis; 9) cellular therapy or growth factors for patients with wounds that do not heal rapidly after initial treatment; and 10) continuous physical and psychosocial support for all patients. If this paradigm is followed, most diabetic foot and pressure ulcers are expected to heal.

Authors:

Prof. Dr. Hubertus Feussner, Dr. Dirk Wilhelm, Dr. Volker Dotzel, Dr. Dimitrios Papagoras, Prof. Dr. Eckhardt Frimberger, II.

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Abstract:

Computed topography colonography (CTC) was first described in 1994 as a rapid, non-invasive imaging method to investigate the colon and rectum. Since the advent of CTC, it has been regarded as a potential alternative technique to conventional colonoscopy for detection of colorectal polyps and cancers. Patients undergo standard bowel preparation 24 to 48 hours before the procedure, using either a standard barium enema preparation or balanced polyethylene glycol (PEG) solution. This rapid examination, without the use of sedation or intervention, is well-tolerated by patients. The potential for limited bowel preparation can reduce discomfort associated with traditional purging techniques significantly, and result in an improved perception of the screening study. CTC is performed using a single or multislice CT scanner, with acquisition of volumetric data from the entire colon. Multislice technology enables fast scanning with high resolution. To minimize the radiation dose, efforts have been made to adapt the tube current to the minimum accepted dose while not diminishing study performance. Acquired CT data are transferred onto a dedicated workstation equipped with navigator software, which permits the radiologist to obtain multiplanar reformations as well as construct an endoluminal model of the air-distended colon. Currently, the most widely accepted application for CTC is following incomplete colonoscopy. Other indications that await further clinical validation include colorectal screening. The collective experience of published studies shows CTC to be an accurate tool for detection of clinically significant colorectal polyps. Specificity and sensitivity of CTC are excellent for polyps larger than 10 mm.

Authors:

Jacob Sosna, M.D., Martina M. Morrin, F.F.R.R.C.S.I., F.R.C.R., Laurian Copel, M.D., Vassilios Raptopoulos, M.D., Jonathan B. Kruskal, M.D., Ph.D.

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Abstract:

One might think there cannot truly be anything new in hernia repair, but nothing could be further from the truth. Hernia repair has been, and continues to be, written about in considerable volume in the medical literature. Part of this has to do with new techniques for repair, some is due to modifications of old techniques, and much of the recent literature addresses many new meshes available for repair. The developments are in both the inguinal hernia arena, as well as an explosion in the area of ventral/incisional (V/I) hernias.

Authors:

Guy R. Voeller, M.D., F.A.C.S., Professor of Surgery, University of Tennessee, Memphis, Tennessee

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Abstract:

Since the gastric bypass was first described for weight-reduction surgery almost 50 years ago, a number of remarkable contributions have been made to the field. These advances have led to significant modifications of the technique, evolution of laparoscopic bariatric surgery equipment, and improvement of long-term results. Despite the currently wide-spread practice of laparoscopic bariatric surgery, the precise technique for laparoscopic gastric bypass still varies from institution to institution, and the surgery continues to carry a morbidity rate. Advances in laparoscopic equipment, technology, and our understanding of the pathophysiology behind weight loss have allowed surgeons to modify the procedure described originally to minimize the morbidity and maximize long-term weight loss. This chapter describes the technique of laparoscopic gastric bypass used at a major academic center that performs over 1000 bariatric procedures a each year. In addition, the many recent advances in methodology and pathophysiology are described in detail.

Authors:

Brian P. Jacob, M.D., Michel Gagner, M.D., F.A.C.S., F.R.C.S.C.

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Abstract:

Since its inception, laparoscopic fundoplication has revolutionized the surgical approach to gastro-esophageal reflux disease (GERD). Endoluminal therapies for GERD are less invasive than surgery, seek to duplicate its efficacy, and may eliminate reliance on proton pump inhibitors (PPI) and other antisecretory drugs. The Stretta® procedure uses radiofrequency (RF) energy delivered to the tissues of the distal lower esophageal sphincter (LES) and gastric cardia, which decreases LES compliance, increases LES muscle mass, and limits the inappropriate transient LES relaxations responsible for GERD in many patients. The Stretta® procedure has been shown to be effective in laboratory studies, randomized sham-controlled studies, and numerous open-label prospective clinical trials. For patients with appropriate indications, the Stretta® procedure is an effective endoluminal therapy for treatment of symptomatic GERD.

Authors:

Robert D. Fanelli, M.D., F.A.C.S., Keith S. Gersin, M.D., F.A.C.S., Adel Bakhsh, M.D.

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Abstract:

A cute cholecystitis is one of the most frequent causes for emergency admissions to General Surgery Departments. Due to the increased morbidity and high-risk of mortality, patients with severe underlying disease or a debilitated general condition are initially treated conservatively by administration of antibiotics, decompression, and drainage of the gallbladder. Percutaneous cholecystostomy (PC) is a minimally invasive method of percutaneous placement of a catheter, under ultrasound guidance, in the gallbladder lumen. PC can be performed at the bed-side and help the patient as well as physicians searching for a site and cause of sepsis. Dynamic ultrasound visualization of the puncture needle and gallbladder is crucial to avoid complications. PC cholecystectomy is an efficacious procedure with reported clinical response rates of 56%-100%. Clinical response is considered when a decrease in white blood cell count, defervescence, and decrease in the need for vasopressors are present. Patients with gallstones and symptoms and signs localized to the right upper quadrant are more likely to respond. Mortality is associated mainly with the underlying medical conditions. Ultrasound-guided PC can be followed by elective cholecystectomy at a later stage if the patient’s condition permits, or by expectant or conservative management in those with acalculous cholecystitis.

Authors:

Jacob Sosna, M.D., Laurian Copel, M.D., Robert A. Kane, M.D., Jonathan B. Kruskal, M.D., Ph.D.

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Abstract:

Laparoscopic repair of large paraesophageal hiatal hernias is associated with several areas of contention. One of these is primary repair of the esophageal hiatus versus repair with the use of a prosthetic mesh material. Those who favor primary repair are concerned because of the risk of erosion of the prosthesis into surrounding viscera. Those who favor hiatal closure with the aid of a prosthetic mesh are concerned because of the relatively high rate of reherniation of the repair. A biodegradable mesh composed of small intestinal submucosa (SIS ES Cook Surgical, Bloomington, IN) may resolve the concerns of the opposing points of view. It has been shown in animal studies to maintain strength while it is gradually resorbed and replaced by native host tissue. Since April of 2000, 12 (8 female, 4 male) patients have had laparoscopic repair of large paraesophageal hiatal hernias with hiatal closure accomplished with this material. Nine of these 12 patients have had barium studies at six months post-procedure and seven at one year. No failures were demonstrated.

Authors:

Paul S. Strange, M.D., F.A.C.S.

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Abstract:

Traditionally, the only curative option for patients with liver tumors has been hepatic resection. Unfortunately, only 10%-20% of patients with liver tumors can undergo surgical resection due to limited hepatic reserve, high surgical risk, or unfavorable tumor location. Ablation of liver tumors is currently the main alternative to formal liver resection. Tumor cell death is achieved through a number of technologies, which may be separated into three categories: chemical (percutaneous ethanol injection), cold-based (cryotherapy), and heat-based (radiofrequency and microwave ablation or laser hyperthermia). Although long-term data are limited, ablation may be curative in some patients with a three- and five-year survival rate approaching that of resection. The main factors to success include proper patient selection, excellent diagnostic and procedural imaging, and careful post-procedure management and follow up. Long-term success following tumor ablation will be most dependent on the underlying tumor biology and the ability to achieve a negative margin. Future directions in ablation will include the use of adjunctive agents such as chemotherapeutics, further advances in energy delivery, improved imaging and lesion targeting, and continued refinements of current technology and technique.

Authors:

Andrew S. Wright, M.D., David M. Mahvi, M.D., Dieter G. Haemmerich, Ph.D., Fred T. Lee, Jr., M.D.

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Abstract:

Percutaneous biopsy of the liver is the most specific test available currently to assess the nature and severity of liver diseases. Image-guidance either before or during the procedure has allowed this technique to be performed on a routine basis. The purpose of this article was to review the indications and contraindications for performing liver biopsy, and describe the spectrum of major and minor complications that can occur following biopsy. Equipment and biopsy needles available currently were compared, and the individual steps involved in ultrasound-guided biopsies described. Blinded versus ultrasound-guided biopsies were compared, and techniques used for selecting the most appropriate site for biopsy, reducing the passes through the liver, and reducing complications were discussed.

Authors:

Laurian Copel, M.D., Jacob Sosna, M.D., Jonathan B. Kruskal, M.D., Ph.D., Robert A. Kane, M.D.

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Abstract:

Although elderly patients have physiologic impairments in wound healing, their wounds should be expected to heal with the same frequency of closure as those in younger populations, albeit at a slower rate. However, compared to the general population, the elderly population has a higher incidence of chronic wounds: diabetic foot ulcers, pressure ulcers, and venous stasis ulcers. Experimental and clinical data indicate physiologically impaired healing is characterized by decreased angiogenesis and synthesis of critical growth factors. Further, compared to younger populations, the elderly have a higher rate of mortality associated with specific morbidities, such as sepsis and acute respiratory distress. As these morbidities may develop directly from the wound, early intervention is mandated. In this report, 40 consecutive elderly patients (65-102 years old) with chronic wounds were analyzed. All patients were provided the same treatment protocol and healing was defined as 100% epithelization and no drainage. Despite the wounds presenting in a nonhealing and/or infected state, 73% of these chronic wounds in elderly patients healed. This suggests that elderly patients with diabetic foot ulcers, pressure ulcers, and venous stasis ulcers close their wounds at a similar frequency as younger patients. Therefore, early intervention and comprehensive treatment that includes safe topical therapies, in addition to growth factors and cellular therapy used for chronic wounds, ensure these patients will be spared the morbidities of pain, amputation, osteomyelitis, and even death. We hypothesize that if all elderly patients with chronic wounds are provided early treatment, morbidities (e.g., amputation, sepsis, pain) and associated costs will decrease.

Authors:

Harold Brem, M.D., Marjana Tomic-Canic, Ph.D., Alina Tarnovskaya, B.A., H. Paul Ehrlich, Ph.D., Edwina Baskin-Bey, M.D., Kiran Gill, B.A., Miriam Carasa, Ed.D., R.N., C.N.A., Sarah Weinberger, D.E.C. Hyacinth Entero, B.A., Bruce Vladeck, Ph.D., Gordon Freedman, M.D., Conrad Cean, M.D., Vincent Duron, B.A., Alina Tarnovskaya, B.A., Harold Brem, M.D.

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Abstract:

Pain must be managed during treatment of a patient with a chronic wound. Failure to do so will significantly impair the patient’s ability to heal. Understanding the wound’s etiology is essential for designing the wound-healing protocol and implementing its pain-management regimen, of which a critical part is the chronic-wound patient’s self-assessed scores of pain and functionality. In this report we present a paradigm for treating all chronic wounds, which was subsequently applied to 32 consecutive patients. Our integratedteam approach to managing the treatment of wounds includes accurate evaluation of the progression of patients’ pain. Directors of the pain-management team and wound team have jointly managed hundreds of patients—either hospitalized or seen in both outpatient clinical practices. The three general categories for etiologies of the 10 most common types of chronic wounds are: ischemia, neuropathy, and direct tissue damage (e.g. pressure ulcers and venous stasis ulcers). Each of these are treated with unique analgesic regimens focused on surgical/medical management of the wound: oral and parenteral medications in combinations designed to facilitate specific additive analgesic effects and nerve blocks and implantable devices for correcting underlying wound pathophysiology. Successful treatment of pain generally results in increased functional independence and improvement of the patient’s quality of life. Our integrated wound-care, pain-management team, established guidelines that delineate the causes of chronic wounds and categorize treatment options for practical clinical use. The expectation is that all pain should be resolved in all patients if both the wound-healing and painhealthcare providers use current technologies and drugs.

Authors:

Gordon Freedman, M.D., Conrad Cean, M.D., Vincent Duron, B.A., Alina Tarnovskaya, B.A., Harold Brem, M.D.

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