Aggressive Operative Intervention Research Articles

Conservative Management of Placenta Previa Percreta in a Jehovah's Witness

Hemorrhage is a serious threat with placenta accreta, often requiring aggressive operative intervention by hysterectomy and resuscitative measures with large-volume blood replacement to ensure survival. Refusal to accept transfusion makes management especially difficult. We report a Jehovah's Witness patient who had 9 previous cesarean deliveries and presented with anemia and placenta previa percreta invading the bladder wall. Management objectives were to enhance the patient's status, using erythropoietin and autologous transfusion, and to minimize the chance of hemorrhage by prophylactic uterine artery embolization. The placenta was left in situ after the delivery with no untoward consequences. Methotrexate was held in readiness, but was not required as adjuvant therapy. Effective care of such patients requires close collaborative team effort and advanced planning to ensure a good outcome.

Beyond sepsis pathophysiology with cytokines: what is their value as biomarkers for disease severity?

Sepsis is a major challenge in medicine. It is a common and frequently fatal infectious condition. The incidence continues to increase, with unacceptably high mortality rates, despite the use of specific antibiotics, aggressive operative intervention, nutritional support, and anti-inflammatory therapies. Typically, septic patients exhibit a high degree of heterogeneity due to variables such as age, weight, gender, the presence of secondary disease, the state of the immune system, and the severity of the infection. We are at urgent need for biomarkers and reliable measurements that can be applied to risk stratification of septic patients and that would easily identify those patients at the highest risk of a poor outcome. Such markers would be of fundamental importance to decision making for early intervention therapy or for the design of septic clinical trials. In the present work, we will review current biomarkers for sepsis severity and especially the use of cytokines as biomarkers with important pathophysiological role.

Spinal deformity in neurofibromatosis type-1: diagnosis and treatment.

Spinal deformity is the commonest orthopaedic manifestation in neurofibromatosis type-1 and is categorized into dystrophic and non-dystrophic types. Management should be based on a meticulous assessment of the spine with plain radiography and magnetic resonance imaging (MRI) to rule out the presence of dysplastic features that will determine prognosis and surgical planning. MRI of the whole spine should also be routinely obtained to reveal undetected intraspinal lesions that could threaten scheduled surgical interventions. Non-dystrophic curvatures can be treated with similar decision-making criteria to those applied in the management of idiopathic scoliosis. However, close observation is necessary due to the possibility of modulation with further growth and due to the increased reported risk of pseudarthrosis after spinal fusion. The relentless progressive nature of dystrophic curves necessitates aggressive operative treatment, which often has a significant toll on the quality of life of affected patients through their early childhood. Bracing of dystrophic curves has been unsuccessful. Combined anterior/posterior spinal arthrodesis including the entire structural component of the deformity is indicated in most cases, particularly in the presence of associated sagittal imbalance. This should be performed using abundant autologous bone graft and segmental posterior instrumentation to minimize the risk of non-union and recurrence of the deformity.

Nonoperative management of solid organ injuries in children results in decreased blood utilization

Background: The administration of blood products to injured children has been recognized as a potential risk of nonoperative management. The purpose of this study was to evaluate blood utilization in the management of solid organ injuries in pediatric blunt abdominal trauma victims. Methods: One hundred sixty-one children (≤16 years old) with solid organ injuries over an 8-year study period (1990 through 1997) were identified from the trauma registries at 2 urban regional trauma centers. Results: Mean age of the study patients was 7.9 ± 0.4 years, 95 (59%) were boys, and their mean injury severity score (ISS) was 17.8 ± 1.2. Patients were divided into 4-year study cohorts (1990 through 1993 and 1994 through 1997) to examine changes in operative management and blood utilization. For each time period examined, those treated nonoperatively received fewer blood transfusions (46% v 9% and 44% v 13%, P < .05 by Fisher's Exact test), and the hospital length of stay was shorter (12.3 ± 2.1 v 5.0 ± 0.7 and 7.8 ± 1.9 v 4.2 ± 0.4 days, P < .0001 by analysis of variance/Scheffe's) compared with the laparotomy cohort. Conclusions: The appropriate nonoperative management of injured children actually reduces the risks of receiving blood transfusion and decreases the length of hospital stay compared with aggressive operative intervention. Blood transfusion should be reserved only for those injured children with solid organ injuries who are hemodynamically unstable.

Follow-up evaluation of open intra-articular fractures of the calcaneus.

The results of a follow-up evaluation of open intra-articular calcaneal fractures are presented. A modified Merle d'Aubigné functional score and Zwipp radiographic score were used. A retrospective analysis of 35 patients with 36 open intra-articular fractures represents the basis of the study. At the time of follow-up examination (on average 44 months after the injury), 5 amputations of the affected extremity and 4 ankle arthrodeses had been carried out. The 23 patients still able to bear weight on the affected hindfoot and possessing a functional ankle joint were radiographically and functionally evaluated. No excellent results were documented. Only 6 good functional and 2 good radiographic outcomes were noted. In 17 instances, a poor functional or radiographic score was given. Devastating results were seen in the course of treatment of third-degree open joint depression or comminuted intra-articular fractures (n = 15): 9 cases of osteomyelitis, 5 amputations, 1 partial calcanectomy, 1 arthrodesis. An open reduction as part of the primary treatment (n = 6) led to local complications in all instances. The most favorable results were seen after nonoperative fracture management: complication-free course of treatment in 4 of 11 patients. All workmen's injuries led to a permanent disability, and these patients received compensation. The treatment and salvage of the soft-tissue envelope should be paramount in all therapeutic decisions. The fracture treatment must not further jeopardize these tissues. An aggressive operative treatment of local complications, including arthrodesis or amputation, is recommended.

IMMUNE DYSFUNCTION IN MURINE POLYMICROBIAL SEPSIS

Despite recent advances in antibiotic therapy, aggressive operative intervention and intravenous hyperalimentation, sepsis, and multiple organ failure are still reported to contribute to significant morbidity and mortality in the surgical intensive care unit. In light of this, it is essential to determine the mechanism underlying the pathophysiology of sepsis so that better therapeutic interventions can be designed. Experimental studies indicate that murine polymicrobial sepsis induces a marked suppression in both lymphocytic and macrophage function associated with decreased cellular adenosine triphosphate levels and increased Ca2+. However, such changes are not detectable until approximately 12 h after the onset of sepsis. Alternatively, early (0-4 h) in sepsis, macrophages from the liver and peritoneum exhibit augmented innate secretion of proinflammatory cytokines, tumor necrosis factor, interleukin (IL)-6, and IL-1, associated with the systemic release of these agents. Sustained release of immunosuppressive agents transforming growth factor-beta, IL-4, IL-10, and PGE2, as well as glucocorticoids, are also observed during sepsis. In this regard, many investigators, including us, have suggested that an agent(s) released as a part of this systemic inflammatory response to sepsis may be responsible for the protracted suppression of immune cell function. Studies examining the effects of these mediators in vitro on various immune cells have shown that many of these agents also have the capacity to induce a process referred to as programmed cell death (PCD) or apoptosis (Ao). We have presented evidence of marked changes in the rate of Ao in immune cells after the onset of sepsis. These data suggest the possibility that mediators released in response to septic insult contribute to the observed changes in immune cell function through the induction of Ao. Inasmuch, understanding the contribution of PCD to the pathophysiology of sepsis, should provide a better basis from which to develop more effective therapy for the septic patient.

Extended Resection for Carcinoma of Colon and Rectum

Although surgery has been the mainstay of treatment for patients with colorectal carcinoma for more than a century, debate continues regarding the appropriate magnitude of operation for optimal survival. Invasion of contiguous organs is a legitimate indication for extended en bloc resection, including pelvic exenteration, in appropriately selected individuals. Extended lymphadenectomy, especially in resections for carcinoma of the rectum, is being reexamined with renewed enthusiasm. Improved perioperative care has permitted performance of more aggressive operative intervention, with improved cure rates for patients with colorectal neoplasms.

Pulmonary resection for fungal infection in children undergoing bone marrow transplantation

Recipients of bone marrow transplants for hematologic malignancies are at risk for a variety of infectious complications. We have reviewed our experience with six patients 2 to 15 years of age who developed significant fungal infections of the lungs before or after bone marrow transplant. No patient was known to have active fungal or bacterial infection at the time bone marrow transplant was performed. In two patients fungal infections were diagnosed before bone marrow transplant, and operations were performed to permit bone marrow transplant under optimal conditions. Four patients had pulmonary mycoses discovered after bone marrow transplant, and underwent operation 12 to 24 days following transplant. Operations consisted of lobectomy (three), multiple unilateral wedge resections (one), staged segmentectomy and contralateral wedge resection (one), and staged bilateral wedge resection (one). Survival following bone marrow transplant was achieved for 6 months and 11 months in patients undergoing lung resection before transplant, and for 24, 30, 39, and 60 days in patients undergoing lung resections after transplant. Bone marrow transplant recipients are at high risk of pulmonary mycoses, and a vigorous search for occult fungal infections should be carried out before transplant. Aggressive operative treatment of fungal infections of the lungs combined with antifungal chemotherapy before transplant may offer the best hope of extended survival.

Evolving changes in the pathogenesis and treatment of the perforated gallbladder: A combined hospital study

Perforation of the gallbladder occurred in 35 patients in this 6 year review, with a 2.3:1 male predominance in contrast with a female dominance in nonperforated acute cholecystitis. Thirty-three percent of patients with gallstones had a history of symptomatic cholelithiasis which emphasizes that if elective cholecystectomy had been performed, this complication could have been avoided. Further, a large number of cases (40 percent) were found to be of the acalculous variety which suggests a possible changing trend in the pathogenesis of perforated gallbladder. Cholecystectomy with intraoperative cholangiography and adequate drainage appears to be the procedure of choice, and aggressive operative intervention without delay is thought to contribute to the relatively low mortality of 8.6 percent in this series.

Parenteral Nutrition in Esophageal Cancer Patients

A review of operative therapy in 244 patients with esophageal cancer from 1960 to 1980 was done to evaluate the impact of TPN in 72 patients treated from 1973 to 1980 with 43 non-TPN patients treated during the same period and to 129 patients operated upon before 1973. Mean age, sex distribution, site, stage, and treatment of the disease were similar for the two study groups. The TPN group lost less weight during treatment (3 lbs vs. 11 lbs) and had fewer overall complications postoperatively (24% vs. 41%). Significant reductions in major wound, infectious, and postoperative complications were noted in these patients who received at least 5 days of preoperative TPN compared with postoperative TPN or the non-TPN groups (4% vs. 24% and 23%). Malnourished esophageal cancer patients can more safely undergo aggressive operative therapy and radiation treatment when adequate perioperative nutritional support is added to the treatment armamentarium.

Paediatric urethral injures: initial management and long-term results (author's transl)

Thirteen cases of urethral trauma in childhood are reported. The nature and management of such injuries are discussed. As a rule urethral ruptures are difficult to treat but long term results are surprisingly good irrespective of the initial procedure. Nevertheless, we do have the impression that with an initially aggressive operative treatment - aimed at a good anatomic reconstruction of the urethra - this goal is achieved much faster and with less complications.

Surgical experience in infants with the VATER association

The surgical experience in 30 infants with the VATER association of multiple congenital anomalies is detailed. These infants can be satisfactorily managed by a thorough multisystem (cardiac, renal, digestive, orthopedic) evaluation, well planned operative therapy, and sophisticated neonatal intensive care. Survival was achieved in 77% of patients. Satisfactory growth and development and few longterm complications have been observed in this complicated group of infants. These data indicate that infants with the VATER association can lead reasonably normal lives following aggressive operative treatment and supportive care.

Operative management of penetrating wounds of the chest in civilian practice

Although most patients with penetrating chest wounds can be managed successfully with early tube thoracostomy, blood volume replacement, and close observation, the remainder can be saved only by an aggressive operative intervention. Between July, 1972, and June, 1977, 600 patients with penetrating chest wounds were treated at the Martin Luther King, Jr./Drew Medical Center, with an over-all mortality rate of 2.2 percent. One hundred twenty-five patients required thoracotomy. They included 110 male and 15 female subjects with an average age of 29 years. Fifty-four percent had stab wounds and 46 percent gunshot wounds. On admission 92 percent were in shock. Hemothorax was the most common x-ray finding, being significant (average 1,200 ml.) in 88 percent. Fourteen patients (11 percent) had cardiac arrest before reaching the hospital. They underwent immediate thoracotomy in the emergency room, and two survived. Eighty-five percent of the deaths were due to severe cardiac wounds. Ninety-nine patients (79 percent) underwent early thoracotomy (within 24 hours), with only one death; 92 percent were operated upon within 2 hours of admission. Persistent hemorrhage was the indication in 60 percent. There were no deaths among the 24 patients with cardiac wounds who reached the operating room alive or among the 26 patients who underwent both thoracotomy and exploratory laparotomy. Other indications for early thoracotomy included pulmonary and hilar wounds and perforations of the esophagus, trachea, and major bronchi. Late thoracotomy (after 24 hours) was required in 12 patients. The indications included significant clotted hemothorax in nine, infected hemothorax in one, and subclavian arteriovenous fistula in two patients. All survived. The over-all mortality rate was 10.4 percent, but less than 1.0 percent for the 111 patients who reached us alive. The over-all complication rate was 7 percent, and the average period of hospitalization was 11.8 days.

Mesenteric infarction

The most common etiologies of mesenteric infarction in fifty-one patients were arterial thrombosis (in 42 per cent), bowel infarction without major vessel occlusion (in 28 per cent), and arterial embolus (in 22 per cent), but the etiology also included some very rare vascular diseases—two cases of the malignant atrophic papulosis of Degos. In the group of forty-four operative patients the mortality was 70 per cent. All the patients treated medically died. Mesenteric infarction should be suspected in all elderly cardiac patients with symptoms of acute abdomen. The value of an early diagnosis, fast resuscitation, and aggressive operative treatment cannot be overstated. Bowel resections yielded the best results in this series. However, the operative treatment of the mesenteric infarction should be individual, depending on the etiologic factors and the time which has elapsed from the onset of the symptoms.

Occasional Survey: EFFECT OF EARLY SURGERY FOR SPINA BIFIDA CYSTICA ON SURVIVAL AND QUALITY OF LIFE

Two series of liveborn spina-bifida cases (myelocele and meningocele) in South Wales, an unoperated series of 290 cases born between 1956 and 1962 (with 54 survivors in 1968) and an aggresively treated series of 113 cases born between 1964 and 1966 (with 57 survivors in 1973), were compared to assess the effect of surgery on survival and quality of survival. Significantly more cases survived as a result of the modern surgical approach, but these survivors were significantly more handicapped. Of 100 liveborn cases only 17 can expect to survive into the teens without operation, with 8 minimally handicapped and 5 dependent on wheelchairs; but with aggressive operative treatment 50 out of 100 can expect to survive, with 15 minimally handicapped and 27 dependent on wheelchairs. The operated cases were significantly more mentally handicapped, probably because of hydrocephalus. It is concluded that these results must influence future treatment policy and should spur effort toward antenatal detection of spina bifida.