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In JoVE (1)
Other Publications (26)
- World Journal of Emergency Surgery : WJES
- International Journal of Surgery (London, England)
- Annals of Vascular Surgery
- Diseases of the Colon and Rectum
- Journal of Surgical Education
- The American Surgeon
- The American Surgeon
- American Journal of Surgery
- American Journal of Surgery
- The American Surgeon
- The American Surgeon
- The American Surgeon
- The American Surgeon
- Journal of the American College of Surgeons
- HPB : the Official Journal of the International Hepato Pancreato Biliary Association
- The American Surgeon
- The American Surgeon
- American Journal of Surgery
- Bulletin of the American College of Surgeons
- American Journal of Surgery
- HPB : the Official Journal of the International Hepato Pancreato Biliary Association
- International Journal of Colorectal Disease
- International Surgery
- International Surgery
- American Journal of Surgery
- Journal of Gastrointestinal Surgery : Official Journal of the Society for Surgery of the Alimentary Tract
Articles by Gokulakkrishna Subhas in JoVE
JoVE Clinical and Translational Medicine
Creation of Reversible Cholestatic Rat Model
Department of General Surgery, Providence Hospital and Medical Centers
Cholestasis is a clinical condition commonly encountered by both surgeons and gastroenterologists. Creation of a reversible cholestatic rat model can be challenging in view of the smaller size and unique hepatopancreatobiliary anatomy in rats. This video article demonstrates the creation of a reversible cholestatic model.
Other articles by Gokulakkrishna Subhas on PubMed
Complicated Diverticular Disease of the Colon, Do We Need to Change the Classical Approach, a Retrospective Study of 110 Patients in Southeast England
Complicated diverticular disease of the colon imposes a serious risk to patient's life, challenge to surgeons and has cost implications for health authority. The aim of this study is to evaluate the management outcome of complicated colonic diverticular disease in a district hospital and to explore the current strategies of treatment.
C-reactive Protein Estimation Does Not Improve Accuracy in the Diagnosis of Acute Appendicitis in Pediatric Patients
Appendectomy is the treatment of choice in acute appendicitis in children. Delayed diagnosis of acute appendicitis in children can lead to complications like perforation. Studies on the diagnostic value of WBC and CRP in establishing the diagnosis of appendicitis have contradictory results. Our study evaluates the role of CRP in diagnosing appendicitis in a pediatric population.
Spontaneous Isolated Superior Mesenteric Artery Dissection: a Case Report and Literature Review with Management Algorithm
An isolated spontaneous superior mesenteric artery (SMA) dissection is the most frequent type of digestive artery dissection. Hepatic, splenic, left gastric, and celiac artery dissections are much less frequently observed. Dissection of the SMA is usually an extension of an aortic dissection. A true isolated SMA dissection is a relatively rare clinical cause of abdominal pathology. Only 106 cases (including the present case) of isolated spontaneous SMA dissection without associated aortic dissection were identified from the literature.
Oral Vitamin A Enhances the Effectiveness of Formalin 8% in Treating Chronic Hemorrhagic Radiation Proctopathy
Chronic radiation proctopathy occurs in 5 to 20% of patients receiving radiation therapy, with rectal bleeding as its most common presentation. Although formalin treatment for rectal bleeding is promising, improvement is possible. Given the success of vitamin A in other radiation-induced treatments, we studied the efficacy of combining formalin with vitamin A in controlling bleeding symptoms of chronic radiation proctopathy.
Pancreatic Schwannoma: Literature Review
Pancreatic schwannoma is a rare neoplasm. Accurate preoperative diagnosis remains difficult, but computed tomography (CT) scanning and magnetic resonance imaging (MRI) help to establish the diagnosis, and definitive diagnosis requires immunohistochemical examination. Cystic pancreatic schwannomas should be considered in the differential diagnosis of cystic neoplasms and pseudocysts. Simple enucleation may be adequate for pancreatic schwannoma. In this report, we examine a case of benign pancreatic schwannoma in a 56-year-old woman. She was being evaluated for an ovarian teratoma, and an 8-cm cystic mass was incidentally found in the head of the pancreas. She underwent a pylorus preserving Whipple procedure with bilateral oopherectomy. Only 37 cases have been reported in the English literature. We present a thorough review with an emphasis on the clinical presentation, diagnostic modalities, and treatment options in the management of this rare clinical entity.
Benefits of Mock Oral Examinations in a Multi-institutional Consortium for Board Certification in General Surgery Training
The Southeast Michigan Center for Medical Education (SEMCME) is a consortium of teaching hospitals in the Greater Detroit metropolitan area. SEMCME pools its resources for several educational means, including mock oral board examinations. The educational and cost benefits to mock oral examinations on a multi-institutional basis in preparation for the American Board of Surgery (ABS) certifying examination were analyzed. Ten-year multi-institution data from the mock oral examinations were correlated with ABS certifying examination pass rates. Mock oral examination scores were available for 107 of 147 graduates, which included 12 candidates who failed their certifying examination on the first attempt (pass rate = 89%). Four of 31 examinees who had a low score (4.9 or less) in their mock oral exams failed their certifying examination in their first attempt. The cost of running the mock examination was low (approximately $35/resident for 50 residents). When graduates from the last 10 years were surveyed, the majority of respondents believed that the mock oral examination helped in their success and with their preparation for the certifying examination. Thus, the many benefits of administering the examination with the resources of a consortium of hospitals result in the accurate reproduction of real-life testing conditions with reasonable overall costs per resident.
Extraluminal Rectal Mucocele Resulting from Bowel Sequestration at the Anastomotic Site After Sigmoidectomy
Necessity for Improvement in Endoscopy Training During Surgical Residency
The Residency Review Committee for Surgery has recently increased the required number of cases needed to achieve competency in endoscopy training.
Protective Effect of Methylprednisolone on Warm Ischemia-reperfusion Injury in a Cholestatic Rat Liver
Cholestasis has been identified as a risk factor for oxidative stress, and it potentially enhances after ischemic-reperfusion injury. The aim of this study was to evaluate the role of methylprednisolone on warm ischemia-reperfusion injury in the presence of cholestasis.
Review of Re-excision for Narrow or Positive Margins of Invasive and Intraductal Carcinoma
The trend in breast surgery has shifted towards breast conservation. Re-excision rates for narrow or positive margins have been variable in published reports. A retrospective analysis of 3246 patients who underwent either a lumpectomy for a palpable mass or a needle localization biopsy between January 2003 and December 2007 was done. Five hundred and eighty-five patients underwent re-excision surgery for margins. The mean patient age was 59-years-old (range 25-93). Needle localization was used to guide initial excision in 372 of 585 patients (64%). Invasive carcinoma was seen in 402 (69%) patients, ductal carcinoma in situ (DCIS) alone in 183 (31%) patients, and 308 (53%) patients had both invasive carcinoma and DCIS. Well-differentiated carcinomas accounted for only 24 per cent of the re-excisions. Four hundred and sixteen patients underwent re-excision of margins, whereas 169 underwent mastectomy as the second surgery. Residual carcinoma was seen in 38 per cent of cases with involved margins, as compared with 24 per cent with <1 mm margins and only 12 per cent cases with >1 mm margins. Residual DCIS was seen in 65 per cent with involved margins, 50 per cent with <2 mm margins, and 35 per cent of cases with 2 to 5 mm margins (P < 0.001, chi2 association). Lesser re-excision was noted in well-differentiated invasive carcinomas. Only 12 per cent of patients with margins greater than 1 mm had residual tumor on re excision, which raises the possibility of nonoperative management in such cases.
Internal Ring Occlusion and Floor Support: a Novel Technique for Inguinal Hernia Mesh Repair
Tension-free, open-mesh, inguinal herniorrhaphies have gained wide acceptance. Current mesh techniques reinforcing the internal ring do not provide a comfortable lay to the mesh. To address this, we used the internal ring occlusion and floor support (IROFS) technique. A retrospective review was undertaken of all hernias operated on with the IROFS technique from January 2001 to December 2006. Five hundred twenty-five inguinal hernia repairs were done in 477 male patients. Telephone questionnaires looking into their postoperative course and recurrence were recorded. We contacted 275 (58%) patients. Patients' ages ranged from 29 to 81 years (mean, 57 years). The hernia was indirect in 50 per cent (n=146), direct in 35 per cent (n=102), or both in 15 per cent (n=44) of patients. The average operative time was 40 minutes. Acute wound pain lasted for less than 1 week in 55 per cent (n=151) and for 1 to 2 weeks in 24 per cent (n=66). Postoperative analgesic requirement was less than 1 week in 54 per cent (n=147) and 1 to 2 weeks in 27 per cent (n=74). Most patients returned to their daily activities in 2 weeks (75%) and to work in 3 weeks (74%). Chronic pain lasted for 6 to 48 months (mean, 20 months) in only seven patients. No recurrence of hernia was observed during follow-up visits (range, 26-96 months; mean, 53 months). In conclusion, IROFS can be performed with little difficulty, is cost-effective, and is well tolerated by the patient.
A Novel Nonoperative Orthotopic Colorectal Cancer Murine Model Using Electrocoagulation
Orthotopic mouse models of human colorectal cancer represent an important in vivo tool for testing chemotherapeutic agents and studying intraluminal factors that may alter the growth of cancers. Currently the orthotopic mouse models of colorectal cancer require either an operative procedure or creation of colitis to implant the cancer cells in rectum. We have developed a nonoperative, minimally invasive technique to create a true orthotopic colon cancer mouse model.
Laparoscopic Three-port Distal Pancreatectomy
Laparoscopic distal pancreatectomy is becoming a more commonly used procedure, which may involve the use of four to seven ports, depending on the technique. Initial data on feasibility, safety and outcome with the three-port laparoscopic distal pancreatectomy are presented.
Minimally Invasive Training During Surgical Residency
The field of postgraduate minimally invasive surgery training has undergone substantial growth and change. A survey was sent to all program directors in surgery. Minimally invasive training patterns, facilities, their views, and performance of residents were examined. Ninety-five directors (38%) responded to the questionnaire. Of these, 51 per cent (n = 48) had a program size of three to four residents and 33 per cent (n = 31) had a program size of five to six residents. In 3 per cent of programs (n = 3), residents could not achieve the minimum Accreditation Council for Graduate Medical Education required numbers for advanced laparoscopic cases. Only 47 per cent of programs (n = 45) had dedicated rotations in minimally invasive surgery, ranging from 2 to 11 months. Up to 10 per cent (n = 9) of program directors felt that the current training in minimally invasive surgery was insufficient. Fifty-five per cent (n = 52) felt that laparoscopic adhesiolysis was an advanced laparoscopic procedure, and 33 per cent (n = 31) felt that there should be a separate minimum requirement for each of the commonly performed basic and advanced laparoscopic cases by Accreditation Council for Graduate Medical Education. Fifty-six per cent (n = 53) of programs were performing robotic surgery. Minimally invasive surgery training for surgical residents needs to increase opportunities so that they are able to perform laparoscopic procedures with confidence. There should be specific number requirements in each category of individual basic and advanced laparoscopic procedures.
Prolonged (longer Than 3 Hours) Laparoscopic Cholecystectomy: Reasons and Results
For the experienced surgeon, the average operative time for a laparoscopic cholecystectomy is less than 1 hour. There has been no study documenting the causes and results of prolonged (longer than 3 hours) surgery. A retrospective study was done of patients who underwent cholecystectomy between January 2003 and December 2007. A total of 3126 cholecystectomies were done. After excluding patients who had a planned open cholecystectomy and patients who had additional laparoscopic surgeries, we identified 70 patients who had a planned laparoscopic cholecystectomy with operative time exceeding 3 hours. Multivariate stepwise logistic regression was performed analyzing the various factors leading to prolonged surgery. Of the 70 patients, ranging in age from 21 to 92 years (mean, 57 years), most (n = 53) were female. Operative time ranged from 3 hours to 6 hours 40 minutes (mean, 3 hours 37 minutes). Emergency:elective admission ratio was 9:5 and acute cholecystitis (n = 40) was the most common indication. Common characteristics were obesity (n = 44, P = 0.031), intra-abdominal adhesions (n = 43, P = 0.004), and previous abdominal surgeries (n = 40, P = 0.002). Intraoperative complications included spillage of stones (n = 6), bile duct injury (n = 3), and bleeding (n = 3). The possibility of prolonged laparoscopic cholecystectomy should be anticipated in patients with obesity and previous abdominal operations. Prolonged surgery increases the risk of complications (bile duct injury, bleeding) and prolongs the postoperative hospital stay.
Receptor Changes in Metachronous Breast Tumors-our Experience of 10 Years
INTRODUCTION: Patients with primary breast cancer (PBC) are at 2 to 6 times higher risk for developing synchronous and metachronous breast cancer (MBC). The pathology and behavior of MBC still remains unclear. METHODS: We reviewed the charts of 108 women with MBC at our hospital over the past 10 years. Profile patterns of the estrogen receptor (ER), the progesterone receptor (PR), and Her2/neu receptors were explored. RESULTS: Of 33 patients with ER(+)/PR(+) in the primary tumor, 23 (70%) retained the status in MBC. Forty-five (92%) of 49 patients with ER(-)/PR(-) in the primary tumor remained the same in MBC. Most Her2(-) tumors (22/31, 71%) remained negative, but 50% (8/16) of Her2(+) tumors became negative. CONCLUSIONS: Most MBC retained the ER/PR expression patterns irrespective of the treatment for the primary tumor, thus suggesting a common origin. Because MBCs tend to be triple negative and thus more aggressive, early detection and close surveillance techniques must be devised.
Topical Gentamicin Does Not Provide Any Additional Anastomotic Strength when Combined with Fibrin Glue
We evaluated the effect of a combination of fibrin sealant and topical gentamicin on a colonic anastomosis in a rat model.
Training Minimal Invasive Approaches in Hepatopancreatobilliary Fellowship: the Current Status
There has been an increasing role of advanced minimally invasive procedures in hepatopancreatobilliary (HPB) surgery. However, there are no set minimum laparoscopic case requirements.
Non-cutting Setons for Progressive Migration of Complex Fistula Tracts: a New Spin on an Old Technique
We introduced a modification of the loose seton for high transsphincteric fistula which involved daily self-rotation of the seton by 360°, which we call the progressive migration technique. The outcomes were evaluated.
Review of Third and Fourth Re-excision for Narrow or Positive Margins of Invasive and Intraductal Carcinoma
The trend in breast surgery has shifted toward breast conservation. We reviewed our third and fourth breast re-excision cases, with an analysis of various factors used in making this decision. A retrospective analysis identified 585 patients who underwent re-excision surgery for positive or close margins of invasive carcinoma or ductal carcinoma in situ (DCIS). Of these patients 75 (13%) and 17 (3%) underwent third and fourth re-excisions, respectively. The indication for a third re-excision was the presence of positive and/or close (< or = 1 mm) margins for invasive carcinoma or DCIS in 72/75 patients. A third re-excision was done 31 days (range 8-123 days) after the second re-excision. Re-excision of margins was done in 45 (60%) patients, whereas 30 (40%) patients underwent mastectomy. Residual tumor mandated a fourth re-excision in 17 patients, which was done 45 days (range 14-87 days) after the third surgery. Re-excision of margins was done in 6 patients, whereas 11 patients underwent mastectomy. Involved or close margins with DCIS were the most common indication for re-excision, accounting for 61/75 (82%) of third and 16/17 (94%) of fourth re-excisions. Histopathology revealed that 28/75 (37%) of third and 7/17 (41%) of fourth re-excision patients had no residual tumor. In conclusion, the majority of re-excisions was done for margins < 1 mm. Lower rates of re-excision were noted in well-differentiated invasive carcinomas. A close or involved DCIS margin was more likely to lead to a third and even a fourth re-excision. The absence of residual tumors in 40% of patients undergoing third and fourth re-excisions calls for a review of margin guidelines for breast re-excision.
Hydatid Disease Presenting As Cutaneous Fistula: Review of a Rare Clinical Presentation
Hydatid disease has a worldwide distribution as a result of more global travel. Liver and lungs are the most common sites for the primary hydatid cysts in the human body. We managed a 68-year-old man who presented with abdominal distension and umbilical fistula, discharging daughter cysts. Ultrasound imaging of the abdomen showed hepatic hydatid cyst forming a fistula at the umbilicus. The patient underwent a laparotomy with partial cystectomy and excision of the fistula tract. The umbilicus healed after the procedure. The patient did not have any recurrences in 5 years of follow-up. Spontaneous cutaneous fistulization of liver hydatid cyst is a rare presentation. A detailed literature search revealed 15 cases published in all languages. Hydatid disease presenting as an umbilical fistula has not been reported yet. We summarize all these cases including the presentation, findings, management, and outcome. Combined surgical and medical treatment is successful in healing of hepatic hydatid cutaneous fistula.
