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The induced membrane technique is a simple, effective, and reproducible treatment method for segmental bone defects. It is a 2-stage approach that requires eventual autologous bone graft to manage the deficit. The first stage requires debridement of all nonviable tissue while preserving a healthy soft tissue envelope. A polymethylmethacrylate is implanted between the osseous segments to maintain length. The osseous defect can be stabilized internally or externally. During the second stage, a vascularized induced membrane is formed and produces multiple growth factors. The induced membrane technique is a valuable option for limb salvage in cases of segmental bone defects.

Radical prostatectomy (RP) is a common treatment choice for localized prostate cancer. While there is increasing utilisation of robotic assisted RP in some centres, open RP (ORP) remains well established and commonly performed in many parts of the world. The goals of modern ORP are to remove the prostate en-bloc with negative surgical margins, while minimising blood loss and preserving urinary continence and erectile function. We present a technical review of ORP incorporating contemporary techniques for control of the deep venous complex, additional haemostatic measures, nerve-sparing and vesicourethral reconstruction.

Acute pancreatitis (AP) is one of the most common general acute surgical presentations. Current recommendations are that idiopathic acute pancreatitis (IAP) should account for no more than 20% of AP cases. Some studies suggest gallbladder microlithiasis is the aetiology in up to 75% of IAP patients. Endoscopic ultrasound (EUS) has been reported to be effective in the detection of microlithiasis and choledocholithiasis as well as pancreatic parenchymal, ductal and ampullary disorders. The aims of this study were to evaluate the usefulness of EUS in establishing aetiology in IAP patients and to assess if there is a role for EUS in the selection criteria for laparoscopic cholecystectomy to treat a potential biliary cause in IAP patients. A systematic review following PRISMA guideline was performed to gather data on patients with IAP undergoing EUS for further investigation. Three databases (MEDLINE, PubMed, and EMBASE) were searched to 28 July 2018. Our systematic review included 28 studies, comprising 1850 patients with an initial diagnosis of IAP prior to having EUS. Diagnosis of a potential aetiology or associated pancreatic pathology was established in 1095 (62%, p

The sural flap procedure is a versatile technique that can be used to cover many types of defects about the lower extremity. The management of soft tissue defects of the lower extremity with underlying osteomyelitis is difficult. The goal for any of these patients is to create a biomechanically stable foot for weight-bearing purposes with no continued infection. Data were gathered using multiple databases from the years 2000 to 2016. Data were compiled looking at the number of subjects, age, comorbidities, number of complications, number of failures, and average flap size of complications/failures. A total of 110 patients were gathered using 5 separate articles. Twenty-two of the 110 patients had short-term complications. Flap failure was seen in 9/110 patients. A significant difference was noticed in flap size between flap failure and complication groups and nonfailure groups. The average flap size of patients who had some form of complication or failure was 51.87 cm2 in size. The average graft size for patients without complications during their recovery was 36.54 cm2. Within our study, the failure rate of 8.9% and complication rate of 13.7% are consistent with previous reports on sural perforator flaps. Last, with regard to the effect of flap size, there were significant differences between patients with a successful outcome and those who experienced complications or failures. Levels of Evidence: Therapeutic, Level III: Systematic review

A 49-year-old man presented with a 2-week history of gradual onset progressively worsening left upper quadrant pain. Ten months prior, he had a laparoscopic roux-en-Y gastric bypass (LRYGBP) for severe gastro-oesophageal reflux disease and obesity. On examination, his abdomen was not distended and was soft to palpation. The haemoglobin, white cell count, liver function test, lipase and lactate were normal. An abdominal CT scan demonstrated swirl sign. Given the suspicion of internal herniation, laparoscopy was performed demonstrating only partial closure of the jejuno-jejunal mesodefect resulting in herniation of the small bowel alimentary limb. Internal herniation should be considered as a differential diagnosis in all patients with previous LRYGBP and unexplained abdominal pain, nausea or vomiting. If closure of a mesodefect is to be attempted, a running, braided, non-absorbable suture should be used as a purse-string to avoid small defects with subsequent weight and mesenteric fat loss following bariatric surgery.

An 81-year-old man presented to medical services with pelvic pain and evolving urinary retention over 3 months. The patient was found to have a tense glans and penile shaft with surrounding induration consistent with malignant priapism. The extent of the induration included the suprapubic region, scrotum, left iliac region and left flank. A CT scan demonstrated an enhancing, pedunculated lesion arising from the anterior bladder wall measuring 30×31×20 mm. There were multiple enlarged left inguinal lymph nodes. Core biopsies of the subcutaneous tissue on the anterior abdominal wall demonstrated plasmacytoid urothelial carcinoma. The majority of patients with plasmacytoid variant of transitional cell carcinoma will present with >stage 3 bladder disease

A 35-year-old man presented to a regional hospital after being kicked by a horse in the right upper quadrant. He was transferred to our hepatobiliary unit with bile peritonitis 8 days post trauma. Laparoscopic cholecystectomy and intraoperative cholangiography were performed, demonstrating distal common bile duct (CBD) obstruction with contrast extravasation from the distal duct. The CBD was drained with a T-tube via laparotomy. On postoperative day 14, T-tube cholangiography demonstrated no extravasation of contrast from the distal CBD and minor stricturing with eventual duodenal drainage. The T-tube was clamped and 5 weeks later, the patient represented with peri-T-tube bile leakage and right upper quadrant pain. A T-tube cholangiogram confirmed a complex distal CBD stricture. Two attempts at ERCP with intent of stenting the stricture were unsuccessful. The patient underwent an end to side Roux-en-Y choledochojejunostomy and was discharged home 4 days postoperatively on simple analgesia.

Background Extrahepatic bile duct injuries (EHBDIs) are a rare consequence of blunt abdominal trauma. The purpose of this study was to establish mechanisms of injury, clinical indicators of EHBDI following blunt trauma (both with investigative modalities and intraoperatively), method and timing of injury detection, and definitive treatment options. Methods A systematic review was performed to gather data on patients with an EHBDI secondary to blunt trauma. Three databases (MEDLINE, PubMed, and EMBASE) were searched to July 19, 2018. Results Our systematic review included 51 studies, compromising a study population of 66 patients with EHBDIs sustained from blunt trauma. The three most common injuries included complete transection of the suprapancreatic common bile duct (29%, n = 19), complete transection of the intrapancreatic common bile duct (23%, n = 15) and partial laceration of the left hepatic duct (20%, n = 13). Of the hemodynamically stable group managed nonoperatively (n = 23), mean timing postinjury to diagnosis of EHBDI was 11 days. An EHBDI was recognized at initial laparotomy in 87% (n = 13) of hemodynamically stable patients. An EHBDI was recognized at initial laparotomy in 57% (n = 8) of hemodynamically unstable patients. Conclusion The EHBDIs are a rare yet serious consequence of blunt trauma. To establish a timely diagnosis and limit complications of missed injuries, a heightened awareness is required by the attending surgeon with particular attention to subtle yet important clinical indicators. These vary depending on the hemodynamic stability of the patient and decision to manage injuries conservatively or surgically on presentation. Level of evidence Systematic review, level III.

Background A left-sided gallbladder (LSGB) is a rare anatomical anomaly that is often not discovered until surgery. Two cases of LSGB managed with laparoscopic cholecystectomy (LC) stimulated this systematic review. The aims of this study were in LSGB to define the rate of pre-operative detection, variations in biliary anatomy, laparoscopic techniques employed and outcomes of surgery for symptomatic gallstones. Methods A systematic review was performed using Preferred Reporting Items for Systematic reviews and Meta-Analyses principles. Results Fifty-three studies with 112 patients of which 90 (80.4%) had symptomatic gallstones. Pre-operative imaging was performed in 108 patients (96.4%) with an LSGB reported on imaging in 32 (29.6%) patients. The remainder of LSGB were discovered at surgery. Ultrasound detected an LSGB in three (2.7%) patients. Five variants of cystic union with the common hepatic duct (CHD) were identified. The most common (67.8%) was union on the right side of the CHD after a hairpin bend anterior to the CHD. A cholecystectomy for gallstone disease was performed in 90 patients, 23.3% open and 76.7% LC. Common variations in LC technique were different port site placement and techniques related to the falciform ligament to improve exposure. Common bile duct injury occurred in four (4.4%) patients. Conclusion LSGB is a rare anatomical variation that in patients with symptomatic gallstones is usually discovered at surgery. Cholecystectomy is associated with a higher incidence of common bile duct injury.

Small bowel diaphragm disease (SBDD) is characterised by circumferential lesions of short length (

Biliary colic is a pain in the right upper quadrant or epigastrium thought to be caused by functional gallbladder spasm from a temporary obstructing stone in the gallbladder neck, cystic duct or common bile duct. A 56-year-old man presented with frequent episodes of typical biliary colic. At initial laparoscopy, the gallbladder was absent from its anatomic location. Further inspection revealed a left-sided gallbladder (LSGB), suspended from liver segment 3. Preoperative ultrasound, the most common imaging modality for symptomatic gallstones, has a low positive predictive value for detecting LSGB (2.7%). Laparoscopic cholecystectomy (LC) was delayed to attain additional imaging. A magnetic resonance cholangiopancreatography demonstrated the gallbladder left of the falciform ligament with the cystic duct entering the common hepatic duct from the left. The patient underwent an elective LC 8 weeks later. The critical view of safety is paramount to safe surgical dissection and could be safely achieved for LSGB.

The dense, intact rainforests of the Guianas (northern Amazonia) are important for the regulation of the local and regional climate, but preclude easy access so a large data gap exists. The rainforest–savannah boundary may also be particularly susceptible to increasing pressures from ecosystem exploitation and climate change. It is important therefore to establish a baseline climate regime so that the impacts of any future change can be determined. Currently this area is not covered by the publicly available climate data sets, so interpolated data sets are not an accurate representation of the climate of this area, emphasizing the need for a more detailed analysis in this region. Here, we collate the available data sets and use these to derive maps of observed precipitation and temperature across the region. To overcome the limitations in the inadequate observational data sets, we also test and use the ECMWF ERA-40 reanalysis data set for the period 1958–2001 at a ∼125 km2 (1.125°) resolution. Mean differences (biases) and annual average spatial correlations are examined between modelled and observed time series comparing the seasonal cycles and the yearly, monthly and monthly anomaly time series. The results show that with the exception of sub-grid resolution mountain environments, reanalysis data for the Guianas provide a consistent and relatively accurate spatial distribution of temperature. Precipitation is modelled less accurately, with best results for the average timings, length and severity of the dry periods. This study provides consistent and quantitative details on the spatial variations in seasonality, particularly in areas lacking observations, thereby advancing beyond previous studies. Precipitation is highly variable in the region so care must be taken when averaging modelled data over large geographical areas for comparisons with gridded data sets based on few observations. This is the first comprehensive study of the recent historical climate and its variability in this area. Copyright © 2011 The Authors. Journal compilation © 2011 The Royal Meteorological Society

A 57-year-old man presented with a 6-month history of pelvic fullness. He had no lower urinary tract symptoms or altered bowel habits. On examination, there was a non-tender pelvic mass which extended from the pubic symphysis to the level of the umbilicus. CT scan of the abdomen demonstrated a 22×11×11 cm cystic mass arising from the pelvis extending into the midline and superiorly to the umbilicus. Other than raised carcinoembryonic antigen of 7.6 ng/mL (

Although the small GTPase Ran is best known for its roles in nucleocytoplasmic transport, mitotic spindle assembly, and nuclear envelope formation, recent studies have demonstrated the overexpression of Ran in multiple tumor types and that its expression is correlated with a poor patient prognosis, providing evidence for the importance of this GTPase in cell growth regulation. Here we show that Ran is subject to growth factor regulation by demonstrating that it is activated in a serum-dependent manner in human breast cancer cells and, in particular, in response to heregulin, a growth factor that activates the Neu/ErbB2 tyrosine kinase. The heregulin-dependent activation of Ran requires mTOR (mammalian target of rapamycin) and stimulates the capped RNA binding capability of the cap-binding complex in the nucleus, thus influencing gene expression at the level of mRNA processing. We further demonstrate that the excessive activation of Ran has important consequences for cell growth by showing that a novel, activated Ran mutant is sufficient to transform NIH-3T3 cells in an mTOR- and epidermal growth factor receptor-dependent manner and that Ran-transformed cells form tumors in mice.