Absolute Indication For Surgery Research Articles

A double‐blind placebo controlled study of tamsulosin in the management of benign prostatic hyperplasia in an Indian population

Objective: Benign prostatic hyperplasia is a common disorder in ageing males worldwide affecting one out of four males over 50 years of age. The aim of the present study is to demonstrate safety and efficacy of tamsulosin in its medical management.Methods: A total of 72 patients were enrolled; 38 patients given tamsulosin and 34 in the placebo group were enrolled. The mean age group was 61 years. Patients with an International Prostate Symptom Score (IPSS) of> 10, maximum flow rate < 13 mL/s and average flow rate < 6 mL/s with post residual urine volume (PRUV) > 100 mL and prostate‐specific antigen < 4 ng/mL, were given 0.4 mg of tamsulosin/placebo daily on a randomized double‐blind controlled study for 2 months. Patients with renal or hepatic failure, carcinoma prostate, stricture urethra, neurogenic bladder were excluded. All patients were followed up at the end of the second, fourth and eighth week.Results: There were three dropouts leaving 69 patients for evaluation. Improvement in the IPSS score was significantly greater with tamsulosin compared with the placebo. Similarly there was significant improvement in uroflowrate with tamsulosin compared to the placebo. The PRUV decreased by 38.8% with tamsulosin compared with the placebo. No significant change in blood biochemistry was noted between the two groups excepting for blood pressure, which showed a fall with tamsulosin compared to placebo. Adverse reaction was noted in five patients (7%), but none were withdrawn from the study.Conclusions: Our study confirms tamsulosin as a very effective and safe drug in the management of benign prostatic hyperplasia patients not having absolute indication for surgery with excellent patient compliance.

(Impending) pathological fracture

Pathological fractures will be encountered in increasing frequency due to more patients with cancer, surviving a longer period. The skeleton is the third most frequent localization for metastases. Breast cancer is still the most common primary tumor, but bone metastases from lung cancer seem to be diagnosed more and more. Despite of finding metastases most often in the spinal column, fractures are seen mostly at the femoral site. A pathological fracture and, in almost all cases, an impending fracture are absolute indication for operation. An exact definition of an "impending fracture" is still lacking; it is widely accepted, that 50 per cent of bone mass must be destroyed before visualization in X-ray is possible, thus defining an impending fracture. The score system by Mirels estimates the fracture risk by means of four parameters (localization, per cent of destructed bone mass, type of metastasis, pain). Improving quality of life, relieving pain, preferably with a single operation and a short length of stay are the goals of (operative) treatment. For fractures of the proximal femur, prosthetic replacement, for fractures of the subtrochanteric region or the shaft, intramedullary nails are recommended. Postoperative radiation therapy possibly avoids tumor progression. In patient with a good long term prognosis, tumor should be removed locally aggressive.

Intracranial arachnoid cysts in children: related signs and associated anomalies

Intracranial arachnoid cysts are benign development anomalies that may be clinically asymptomatic. The authors describe 30 children with intracranial arachnoid cysts in terms of clinical manifestations and relations to the associated brain anomalies or lesions. The mean age at onset of clinical manifestations was 4 years, 7 months (range 1 day to 14 years). The mean age at diagnosis was 6 years, 2 months (range 10 days to 16 years). Most patients with nonprogressive symptoms, such as seizures and headache, had focal epileptiform discharges on electroencephalogram, and they benefited from antiepileptic drugs. Surgery resulted in only partial reduction in both cyst size and seizure frequency in patients with intractable seizures, and it also failed to improve some neurologic signs, such as sexual precocity or cranial neuropathy resulting from long-term compression of arachnoid cysts. We conclude that the only absolute indication for surgery is the presence of progressive hydrocephalus or intracranial hypertension. The associated anomalies or lesions include brain tumors, giant nevocellular nevi, achondroplasia, microphthalmia, intracystic hemorrhage, dysgenesis of the corpus callosum, and heterotopia.

The incidence of main pancreatic duct disruption in severe biliary pancreatitis

Background: Little is known regarding the incidence of main pancreatic duct disruption in patients suffering from acute necrotizing pancreatitis and whether the occurrence of this disruption may contribute to the decision to intervene surgically. The aim of this prospective study was to assess these findings in a group of patients with acute necrotizing biliary pancreatitis. Patients and Methods: Seventy-five consecutive patients with necrotizing acute pancreatitis and suspected biliary etiology underwent endoscopic retrograde cholangiopancreatography within the first week upon admission. Biliary pancreatitis (common bile duct stones or endoscopic features probative for recent transpapillary stone migration in patients with gallstones) was confirmed in 70 patients. Imaging not only of the biliary tract but also of the pancreatic ducts was pursued. Fifty-one patients (72.8%) were conservatively treated, 19 (27.1%) underwent surgery: indication for surgery was infection of necrosis in 15 cases, pseudocysts in 3 cases, and fistula in 1 case. Results: Satisfactory visualization of the main pancreatic duct was achieved in 59 cases (84.3%). Disruption of the main pancreatic duct was observed in 18 cases (30.5%), ie, 5 of the 17 patients who underwent surgery and 13 of the 42 patients who were nonoperatively managed (NS). Conclusions: Our results suggest that the loss of integrity of the main pancreatic duct, as verified with endoscopic pancreatography, constitutes quite a frequent event in acute biliary pancreatitis, and it should not be considered as an absolute indication for surgery in patients with sterile necrosis. Most of these patients can be safely managed without surgery.

PATELLAR TENDON SONOGRAPHY IN 99 ASYMPTOMATIC BASKETBALLERS REVEALS HYPOECHOIC REGIONS

1711 Ultrasonography (US) is commonly used to diagnose tendon disorders but recent research suggests that asymptomatic tendons can contain hypoechoic sonographic regions. We performed ultrasound examination of 99 (53F,46M) elite, currently asymptomatic basketballers' patellar tendons (PTs) to compare prevalence of hypoechoic regions with that in PTs of 27 (17F, 10M) nonathletic individuals. Controls were older, shorter & lighter than basketballers(all p<0.05). The anteroposterior PT dimensions were greater in male than female basketballers (p<0.01). Of 106 female and 92 male basketballers' tendons 19 (18%) & 39 (42%) respectivelycontained hypoechoic regions. Female and male controls each had 1 tendon with a hypoechoic region (3%, 5%). By chi-square analysis, sonographic hypoechoic regions were more common in PTs of basketballers than controls (29% v 4%) (p<0.001) and more common in the PTs of male than of female basketballers (42% v 18%) (p<0.001). Both male and female basketballers with a history of jumper's knee (patellar tendinosis) had a greater prevalence of hypoechoic regions than their never-symptomatic counterparts (M, p<0.001; F, p<0.025), but even the never-symptomatic players had hypoechoic regions in their patellar tendons (17% of never-symptomatic male and 14% of never-symptomatic female tendons). Thus, the presence of a hypoechoic region on patellar tendon US should not be considered an absolute indication for surgery.

A Survey Concerning the Attitudes of Urologists Toward Prostatism Patients

In a questionnaire all urological units in Norway were asked about: 1. The examinations they routinely used for prostatism patients before deciding upon treatment. 2. How they would score different objective and subjective information about these patients on a scale from 0 to 10. 3. How the physicians classified different prostatism symptoms into categories of weak, moderate and severe. The results were: Urinary retention occurring more than once or residual urine greater than 500 ml was considered an absolute indication for surgery. Agreement about indications for surgery was good for information which received a high median score, but was much poorer for information which received a lower median score. Agreement on how to classify different symptoms into categories according to severity was not good. Using the median classification of symptoms it was estimated that urologists believe that 0.1-5.8% of men over 60 years of age have severe symptoms, 2.1-36.4% have moderate symptoms and 57.8-97.8% weak or no symptoms.

Die Therapie der prämaturen Sagittalnaht-synostose

Premature synostosis of a sagittal suture supplies an absolute indication for operation, becaue of inevitable later complications through chronic pressure in the brain. The results of 47 operations on children are described. Subsequently, only excision of sagittal-suture and formation of two parietal lobes should be carried out. This is a safe method and leads to excellent results.

A prospective longitudinal study of observation versus surgical intervention in the management of necrotizing pancreatitis

Pancreatic necrosis is now recognized as a principal determinant of survival in acute pancreatitis. However, it is currently unknown how frequently pancreatic necrosis develops in acute pancreatitis, how often pancreatic necrosis becomes secondarily infected, and whether sterile pancreatic necrosis represents an indication for surgery or can be treated by conservative means. In 194 patients with unequivocal acute pancreatitis, pancreatic necrosis developed in 38 (20%), as documented by dynamic pancreatography, and was confirmed by histologic diagnosis at surgery in 28. All patients were prospectively treated by medical means. Patients with pancreatic necrosis who remained persistently febrile underwent fine needle aspiration for bacterial culture. Infected pancreatic necrosis was demonstrated in 27 of the 38 patients (71%) with pancreatic necrosis and was treated by open drainage, yielding a mortality rate of 15%. All 11 patients with demonstrated sterile pancreatic necrosis, including 6 with pulmonary and renal insufficiency, were successfully treated without surgery. Pancreatic necrosis occurs in approximately 20% of patients with acute pancreatitis and is necessary for the development of secondary pancreatic infection. However, pancreatic necrosis by itself, even when accompanied by organ failure, is not an absolute indication for surgery. A trial of medical treatment for all patients with sterile pancreatic necrosis is in order.

Pneumopericardium Following Penetrating Chest Injuries

The presence of pneumopericardium following penetrating injuries of the chest is highly suggestive of a cardiac injury. For this reason, it is generally considered that its presence should be an indication for surgery. In the present study 20 patients with pneumopericardium were selected for conservative treatment. All patients were closely observed by means of clinical examination, serial chest roentgenography, electrocardiography, and Doppler echocardiography. In five patients the electrocardiogram showed pericarditis, and in three patients the echocardiogram demonstrated small pericardial effusions. One patient developed tension pneumopericardium 36 hours after admission and required surgical intervention. The remaining 19 patients had an uneventful recovery. We suggest that the presence of a pneumopericardium following penetrating chest trauma is not an absolute indication for surgery. Electrocardiographic and echographic studies may help in the selection of patients for conservative treatment; but the final decision should be made on the basis of clinical signs and symptoms.

Selective non-surgical management of subperiosteal abscess of the orbit: computerized tomography and clinical course as indication for surgical drainage

Subperiosteal abscess of the orbit (SPA) in childhood is an uncommon but serious sequela of sinusitis, with partial or complete visual loss as the most common complication. Traditional management of SPA has combined systemic antibiotics with immediate surgical drainage. The records of 120 children admitted from 1982–1986 with the diagnosis of periorbital or orbital cellulitis were reviewed. Ten cases of SPA were documented by CT scan (8%). Antecedent ethmoid sinusitis was present in all cases. Five SPA patients were managed with intravenous antibiotics and nasal decongestants alone. All had complete clinical and radiographic resolution without complication. The remaining 5 patients underwent surgical drainage. Two patients required immediate drainage due to total ophthalmoplegia upon presentation. One case of postoperative epidural abscess occurred one week after external fronto-ethmoidectomy among these two patients. The remaining 3 patients did not respond adequately to medical therapy alone and underwent surgical drainage without complication. Length of hospital stay in both medical and surgical groups was similar. We conclude that SPA can be safely managed by medical therapy alone in selected cases. Criteria for surgical intervention of documented SPA while on optimal medical therapy should include: worsening of visual acuity or ocular motility, or failure to improve clinically within 48 h. The presence of SPA alone should no longer be considered an absolute indication for surgery.

An Effective Surgical Technique for Limb Salvage in Femorodistal Bypass

Usually, the extension of revascularization of lower extremities to the distal arteries is performed to avoid limb amputation. Technical errors in the performance of the distal anastomosis or poor runoff cause early failure of the bypass; myointimal fibroplasia or new atherosclerosis at the distal suture edges cause long-term failure. A new modified technique was used in 20 patients to facilitate the perform ance of the distal anastomosis. A vein patch is employed to widen the distal arteriotomy, and then, the graft is sutured into the vein patch so that the caliber of the distal artery is increased; potential technical defects and the risk of an early thrombosis are thus avoided. Care is always taken to guarantee a backflow in the vessel, which will permit limb salvage even if the distal runoff is not maintained in long-term follow-up because of occlusion of the outflow. From 1979 to 1985, 20 patients underwent 21 distal arterial reconstructive procedures with this new technique. All patients presented an absolute indica tion for surgery: rest pain (6), gangrene or ulcer (12), and severe ischemia (2). For the bypass procedure, the great saphenous vein was employed in 13 cases and PTFE in 8. Three major amputations were necessary within eight days of the operation. There was no operative mortality. Long-term patency rate was very high (85%).

The management of hypospadias: its relevance to surgical training in the principles and practice of plastic surgery

The practice of specialist medicine demands expertise not only in the therapeutic manoeuvres routine to the discipline but also in analysis of the clinical problems encompassed by the speciality. Training aims to educate in the widest sense, achieving the competence in both which, practised with compassion, is the hallmark of a clinician. Following diagnosis, the need for medical intervention may be a difficult decision. If necessary, treatment should be carried out e~caciously: its intention, likely effects and possible complications should be clear. Surgery should be of meticulous design and be executed without undue risk to the patient. Follow-up may be brief or otherwise but should be sufficient to maintain the benefits of therapy and allow critical analysis of the treatment. The latter is essential not only to the well-being of the individual patient but also to that of those who follow, whether confined to the clinician’s own practice or in the wider sphere which follows dissemination of experience by teaching and writing. In practice the pursuit of such ideals is not easy, particularly in respect of those ailments for which treatment is complicated and not entirely satisfactory. Reappraisal of the philosophy of management of such conditions by successive generations is not only necessary to progress but also essential to the training of a new generation of specialists. The anatomical defect of hypospadias is clearly defined and diagnosis is usually evident. While complete failure of ventral fusion of the prepuce is a constant feature, the degree of chordee and meatal retroposition are both variable, giving rise to a spectrum of severity of this condition. Not many patients have an absolute indication for surgery : all can pass urine and few will be incapable of

Indications for thoracotomy in stab injuries of the chest: A prospective study of 543 patients

This is a prospective study of 543 patients with stab wounds of the chest treated in a 15 month period. Four hundred and sixty-seven patients (86 per cent) were selected for conservative treatment with no mortality. Of the 76 patients in the operatively treated group 68 were operated on in the operating theatre with a mortality of 17 per cent, while the remaining eight had a thoracotomy in the resuscitation room with a mortality of 87.5 per cent. Indications for early operation would appear to be the presence of signs of cardiac or major vascular injury (i.e. tamponade, profuse bleeding, an absent or diminished peripheral pulse, and shock not responding to aggressive resuscitation). A cautious digital exploration of the chest wound may help identify these injuries by obtaining information about the knife tract (towards or away from the heart or major vessels). The presence of shock on admission should not be an absolute indication for operation. Half the 156 patients with shock on admission were treated conservatively with no mortality. The presence of a wound over the precordium is not in itself an absolute indication for surgery. Seventy-two such patients, including 14 with shock, were successfully treated non-operatively. Massive air leaks are usually self-controlled and none of the 24 such cases required operation. The amount or rate of blood loss via the thoracotomy tube is not a reliable index of the severity of the injury and it should not be a sole criterion for the selection of the type of treatment.

Long-term follow-up results of 97 finger replantations.

From a total number of 664 finger replantations (DII-DV) we were able to carry out a follow-up of 97 postoperative cases using the follo-wing assessment criteria: mobility, sensitivity, type of amputation, mechanism of injury, level and extent of amputation. Subjective criteria were also taken into account. Using the results of the study we have been able to formulate an evaluation as to the absolute indication for operation of fingers DII-DV.

Surgical prevention of pulmonary embolism.

AbstractIn an autopsy study of 919 patients who died during the decade from 1964 to 1973 with emboli (731 cases) or thrombi (188 cases) in the pulmonary arteries, the source of the emboli was believed to be the iliocaval segment in 63.8% and the femoral‐popliteal segment in 36.2%. Phlebography was performed in 353 patients with acute phlebothrombosis or pulmonary embolism, and radioisotopic scintiscans with125I‐fibrinogen were performed in 309 patients. Phlebography, particularly with the method of retrograde iliocavography, was of decisive importance in determining the indications for surgery to prevent pulmonary embolism by demonstrating floating thrombi in 37.5% of the cases. During the period 1971 to 1977, 173 operations were performed to prevent pulmonary emboli. These were thrombectomy in 59 patients, filter implantation in 44, vein plication in 10, vein ligation in 3, and combinations of these procedures in 57. Demonstration of a floating venous thrombus was considered an absolute indication for operation. The postoperative mortality rate was 9.2%, and the incidence of postoperative pulmonary embolism was 1.5%

Therapy of fracture of epicondylus medialis humeri (author's transl)

The fracture of the medial epicondylus humeri is an injury tipical for the age of growth. It is a preliminary stage of the luxation of the elbow, which again is associated with one third of the fractures of the medial epicondylus humeri. We report about 27 own patients with fractures of the medial epicondylus humeri. 15 cases were treated conservatively, 12 cases underwent operative treatment. Operating procedure: extirpation, reinsertion or fixation with tension band principle. In all but 3 cases the results were good. These 3 patients had concomitant injuries. Immobilisation lasted for 4.1 weeks on the avarage, full motility was attained after 2.2 months on an avarage. Based on the good results in the mentioned patients, we recommend indication for operative resp. conservative therapy as follows: 1. Conservative: If the joint is not injured and If dislocation is less than 3 mm. 2. Operative: if dislocation is 3 mm or more, or if the fracture includes the articular surface. An absolute indication for operation is given if there is an interposition of fragments into the joint or a lesion of the nervus unlnaris.