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  • ISSN: 2379-0911
    Early Online
    Volume 5, Issue 2
    Research Article
    Joseph Losh*, Ken Waxman, Evan Slater, Robert Ouwendijk, Daniel Kim, Milcah Larks, Emma Huebner, and Shawn Steen
    Certain breast cancers that over-express HER2Neu (H2N) are now considered for neo-adjuvant chemotherapy using dual anti-H2N targeted drugs. Since January of 2013, 14 women with H2N over-expressed breast cancer were treated with a regimen including trastuzumab (Herceptin) and pertuzumab (Perjeta) prior to definitive surgery in our institution. 7 of 14 (50%) were estrogen receptor negative (ER-/H2N+) while the other 50% were ER+/H2N+. 9 of 14 (64%) had six cycles of chemotherapy prior to surgery while the remaining had four or five cycles prior to surgery. 9 of 14 (64%) had a mastectomy while 5 of 14 (36%) had breast conserving therapy. Final pathology showed that 50% had a complete pathologic response (pCR), while the remaining patients all had a significant partial response. Patients who received all six neo-adjuvant cycles had a higher rate of pCR. 6 of 14 (43%) patients had full axillary lymph node dissections (ALND); only 2 of the 6 (33%) contained residual tumor. 7 of 14 (50%) patients had sentinel lymph node biopsies (SLNB) done during definitive surgery. No SLNB specimens contained tumor. We observed a very low rate of residual axillary nodal disease suggesting that ALND may not always be necessary in these cases.
    Review Article
    Gemma Armstrong*, Andrew Smith, and Giles Toogood
    Laparoscopic cholecystectomy (LC) is one of the most common surgical procedures performed globally but continues to carry to an unacceptably high risk of iatrogenic bile duct injury (BDI). In recent years several centres have proposed Near Infrared Fluorescent Cholangiography (NIRFC) with Indocyanine Green (ICG) as a potential method of dynamic intraoperative extra hepatic bile duct mapping. We provide an overview of the current problem of BDI during laparoscopic cholecystectomy including the incidence, aetiology and medico legal ramifications. We also provide a short summary of the enduring argument for and against routine intraoperative cholangiogram (IOC) and we discuss the new technology of NIRFC with ICG in detail. We provide an informative summary of the small number of highly heterogeneous clinical trials of NIRFC with ICG currently available and briefly discuss limitations of the technology.
    Flies A, Becker R, and Kopf S*
    A profound understanding of the biomechanics of the knee joint is crucial in order to develop and improve treatments of knee disorders. Extensive computational and experimental studies showed that the highest contact stress during loading is on the medial tibiofemoral and lateral patellofemoral cartilage. In the tibiofemoral joint, cartilage thickness decreases especially in the region without coverage of the meniscus. Interestingly, average cartilage thickness of the femur did not decrease under loading. Cartilage deformation takes places during the first 20 seconds of loading and remains constant afterwards. In vivo and in vitro determined joint forces show great dispersion. They depend strongly from leg alignment (e.g. varus and valgus deformity), loading conditions (e.g. static or dynamic), activity (e.g. knee bending, single-leg standing) and bodyweight. Beside joint forces shear stress is one of the key contributors to osteoarthritis. Leg alignment and the medial meniscus are important in preventing cartilage damage. The external knee adduction moment is a good parameter to describe load distribution in the tibiofemoral joint and a starting point for treatment strategies (e.g. tibial osteotomy, valgus unloader braces). Ligament injuries are another factor leading to early development of OA. Regarding patellofemoral joint, under loading the patella moves in a more proximal and posterior position shows a medial tilt and less flexion. In healthy cartilage loading leads to an increase in temperature creating optimal conditions for the production of extracellular matrix. Under unloading cartilage thickness recovers. Regular physical activity conditions the cartilage in a way that it experiences less decrease under loading. However, the line between stimulation and degeneration is not yet definite.
    Case Report
    Andrea Sagona*, Angelica Della Valle, Emilia Marrazzo, Erika Barbieri, Lidija Antunovic, Luca Di Tommaso, Fiorenza De Rose, and Corrado Tinterri
    Male breast cancer (MBC) is a rare pathology. The known risk factors include radiation exposure, estrogen administration, and diseases associated with hyperestrogenism, such as cirrhosis or Klinefelter syndrome. An increased risk of male breast cancer has been reported in families in which the BRCA2 mutation on chromosome 13q has been identified. In these report we describe a case of a 40 year-old Klinefelter Syndrome man who underwent Nipple sparing mastectomy, sentinel lymph node biopsy, axillary dissection and contra lateral prophylactic NSM for an invasive mixed ductal-lobular carcinoma of the breast.
    Clinical Image
    Vitorino Modesto dos Santos*, Victor Eduardo de Almeida e França, and Lister Arruda Modesto dos Santos
    This elderly man with diffuse connective tissue disease in outpatient clinical follow-up had an episode of generalized acute abdominal pain of great intensity associated with impairment of general condition, signs of peritoneal irritation, in addition to circulatory instability.
    Review Article
    Thapa PB*, Maharjan DK, and Regmi S
    Background and aims: The foundation of the pancreatojejunostomy was popularized in 1935 by Whipple and colleagues. Despite significant progress in the surgical technique and perioperative management, morbidity of this procedure remains to be considerably high. Post operative pancreatic fistula (POPF) has been one of the major factors for morbidity and even mortality following pancreaticoduodenectomy and pancreaticoenteric anastomosis. This review will focus on various techniques, their modifications, shortcomings and complication in the management of pancreaticoenteric anastomosis.
    Material and methods: A search of various surgical guidelines, prospective randomized controlled trials, systemic Meta analysis, and case series was performed with regards to surgical techniques and complication in the management of a pancreaticoenteric anastomosis.
    Discussion: The major concern of a pancreaticojejunostomy (PJ) is post operative pancreatic leak. Various techniques have been used historically to stop the leakage. Even with the modifications these methods have similar complication rates, so the next factor that should be considered while choosing a PJ method would be related to the individual operator's experience. A pancreaticogastrostomy is the other alternative that was introduced into practice relatively recently and the advent of the laparoscopic and robotic technologies in surgery has provided a newer domain to pancreatic surgery.
    Conclusion: As post-operative pancreatic fistula (POPF) is a major source of morbidity and mortality surgeons should continue to use the familiar anastomotic technique and interchange of these techniques during surgery will result in decrease incidence of pancreatic fistula when done by experienced surgeons.
    Dominic Hegarty*
    The reported incidence of post thoracotomy pain syndrome (PTPS) 3 months after surgery ranges between 22% and 67% and it has a significant impact on patients’ quality of life. The focus in the peri-operative period is to provide analgesia in order to avoid post-operative complications. Unfortunately there is a void in the literature about pain management options that may help PTPS in the weeks and months that follow surgery. All healthcare providers working in this area ought to be alert to the possibility of this syndrome. Pain physicians must be familiar with the range of conservative and interventional options from the simple intercostal blocks to neuromodulation. The objective of this article is (a) to highlight the conservative and interventional options available and (b) to underline that when treatment is utilized rationally, the possibility of controlling the pain becomes a reality.
    Case Report
    Gonzalez W, Altieri PT*, Gonzalez-Cancel IF, Calderon R, and Banchs HL
    Patients presenting with carotid sinus syndrome (CSS) are predominantly from elderly population experiencing dizziness and syncope. According to the World Health Organization, falls lead to 20-30% of mild severe injuries and more than 50% of hospitalizations among people over 65 years and older. CSS is known as one of the main causes of falls and as an age-related factor in previous studies with an elderly population. It is characterized by the presence of an abnormal baroreflex response, leading to a systole and hypotension. In this report, we present a case of a 70 years old male with a history of peripheral vascular disease, severe obstructive carotid stenosis (90%) and the CSS mixed type. He have had syncopal episodes due to carotid hypersensitive, which required pacemaker (dual chamber) prior to surgery.
    Schlatterer Daniel*, Amersi Arish, Kessler Raymond, Eggers Ryan, and Kessler Bradley
    Introduction: Gunshot injuries may present a myriad of surgical challenges in wound closure and soft tissue reconstruction. Due to a broad variation in soft tissue damage and the degree of remaining bony integrity, the treatment of gunshot injuries may only be carried out after a thorough examination of the wound and debridement of all devitalized tissue. The definitive management will vary by case. On occasion, a wound may remain after debridements or infection onset that requires a unique closure approach. Especially, when a previous muscle flap has failed, or the patient refuses additional muscle flaps.
    Materials and method: A young male presented with an isolated GSW to his leg was treated initially with irrigations, debridements and an external fixator. A local soleus muscle flap with skin grafting achieved wound closure. In few weeks, a deep bony infection ensued. The resulting wound after infection debridement was closed with a series of sternal wires over rubber bolsters.
    Results: Following 8 weeks of culture specific antibiotics, the wound healed and the infection resolved. The patient resumed unrestricted weight bearing activities.
    Discussion: The soft tissue reconstructive ladder could benefit from an additional wound closure technique in complex situations such the case presented. Due to prior muscle flap complication, the patient's preference for additional muscle flaps was understandably small.
    Conclusion: This novel closure technique is simple to perform, with little expense to the patient. This method helped close an infected complex wound with a minimal biologic cost. Further work is required to define the limits and indications for this method.
    Editorial
    Dominic Hegarty*
    Every year the International Association for the Study of Pain (IASP) chose a particular chronic pain area to highlight its clinical importance. This year it is the turn of post-operative pain to take center stage and post thoracotomy pain is one area that certainly warrants attention. The incidence of post thoracotomy pain syndrome (PTPS) 3 months after surgery ranges between 22% and 67% making it one of the highest reported causes of post-operative pain demolishingthe suffers quality of life.
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