Aggressive Surgical Care Research Articles

Modulation of Intestinal Flora as an Emerging Therapeutic Approach for the Treatment of Colon Cancer

Abstract: The five-year survival rate for people with colon cancer has increased explosively over the last two decades due to major advances in treatment. Colon cancer survival rates have improved significantly over the past few decades, with some of this success owing to aggressive surgical care and breakthroughs in other complementary treatments. As a new option for Colorectal Cancer (CRC) patients, targeted therapy has been shown to be effective in extending the overall life. A dramatic increase in the number of novel drugs targeting multiple key pathways and immunological checkpoints has been observed after the success of cetuximab (an EGFR inhibitor) and bevacizumab (an anti-angiogenic agent). Neutralizing an already present dysbiosis in the gut microbiome is a novel strategy for combating colorectal cancer and its metastases. Several methods have been employed to date, such as prebiotics, postbiotics, antibiotics, and the transplantation of faecal microbiota. An overview of the epidemiological study and possible mechanisms of colon cancer is presented in this review. We have covered a wide range of targeted treatments for CRC in addition to diagnostic biomarkers as therapeutic targets.

Are Lymph Node Metastases Associated With Survival in Black Patients With Pancreatic Cancer?

IntroductionDespite aggressive surgical care and systemic therapy, patients with pancreatic ductal adenocarcinoma (PDAC) have a poor prognosis. Recent studies show that racial disparities in outcome also exist. We sought to investigate the association lymph node (LN) metastases had with survival between Black and White patients with PDAC after resection. MethodsRetrospective analysis of 226 PDAC patients who underwent resection at a single institution from 2010 to 2018 was performed with attention to LN metastasis and patient race. The number of patients who received chemotherapy was also evaluated. ResultsOne Hundred Seventy Five (77.4%) PDAC patients were White and 51 (22.6%) were Black. 130 (59.3%) patients had LN metastasis (LN+). LN+ and LN- groups were similar in race (P = 0.93), sex (P = 0.10) and age at the time of diagnosis (P = 0.45). Patients with LN + disease were more likely to present with larger tumors (3.4 versus 2.8 cm, P = 0.02) and higher T status (P = 0.001). White and Black patients had similar rates of LN metastasis (59% versus 58.8%, P = 1.0). The median survival for LN- Black and White patients were similar (43.2 versus 30.2 mo, P = 0.82). LN + Black patients trended towards receiving more systemic therapy than White LN + patients (55% versus 42%, P = 0.10). The median survival for LN + Black patients was significantly less than LN + White patients (17.5 versus 24.6 mo, P = 0.04). ConclusionsBlack LN + PDAC patients have an inferior survival rate after resection when compared to their White counterparts. Our disparity in outcome cannot be solely explained by a difference in systemic treatment. Further investigation is warranted to determine racial differences in tumor biology or response to chemotherapy.

Recent advances on novel periodontal drug delivery system

Periodontitis is an infectious disease resulting in inflammation the supporting within tissues of the teeth, progressive attachment loss and bone loss-carranza. Some of the etiology and risk factors are Microbial factors, local factors, systemic factors, genetic factors and behaviour factors. Periodontitis can occur at any age, most frequently observe in adults at the age of 30-35years. It involves the degeneration of periodontal ligaments, resorption of alveolar bone resulting in the disruption of the structure of the teeth. In global population nearly 10-15% of people are suffering with severe periodontitis according to WHO. In management of periodontal infection Antibacterial agents are most widely used. Widening of PDL space, generalised loss of alveolar bone are the radiographic feature. Treatment requires more aggressive surgical care. Because of abundant source, lack of toxicity and high tissue compatibility the Biodegradable polymers are extensively employed in periodontal drug delivery devices. In the last decades, the treatment has been optimized for the use of drug delivery systems to the periodontal pocket, with the advantage of delivering the drug in the specific site, sustaining and/or controlling the drug concentration. Recently, the use of new drug delivery systems has been receiving great interest. This review approaches the main delivery systems for the administration of drugs to the periodontal pocket, their usefulness as well as the advancement of these systems effectiveness in the periodontal therapy.

Adolescent medial epicondyle trash lesion clinic radiological evaluation and treatment

<p class="abstract">Elbow injures in children accounts for 10% of all fractures, ranges from simple sprain to elbow fracture dislocation. Ligamentous injury accounts for 2-3% only and are mostly sports related seen in overhead athletes. Trash lesions (the radiological appearances seemed harmless) around the elbow are reported in children under 10 years which are high energy trauma with initial normal looking X-rays. These are osteochondral or physical injures presenting with soft tissue swelling without any fractures. A high index of suspicion, early additional imaging such as MRI, CT scan, ultrasound examination and aggressive surgical care are usually necessary for prompt diagnosis and successful treatment of these injuries before complications arise. We presented a case of an elbow injury in a 15 year old girl, following a fall on her outstretched hand with initial normal findings in her X-rays. 3 months following the injury she had persisting pain and instability with ulnar nerve impingement symptoms. Her elbow CT scan, nerve conduction study confirmed the avulsion fracture of medial epicondyle with ulnar nerve neuritis and cubital tunnel syndrome. Valgus stress test proved the extent of additional medial instability. Medial epicondyle avulsion fractures are always challenging for fixation. The retracting UCL forces prevents healing and were prone for failure with non-operative splinting once instability is defined. Attempted fixation can also result in failure of fixation. Our case study highlights the possibility of such trash lesion in adolescent and also the modified technique of ulnar collateral ligament (UCL) reconstruction in a cost effective manner.</p>

Presence of Lymph Node Metastasis Has a Greater Impact on Survival in Black Patients with Pancreatic Cancer: An Effect of Tumor Biology or a Disparity in Treatment?

Introduction: Despite aggressive surgical care and systemic therapy, patients with pancreatic ductal adenocarcinoma (PDAC) have a poor prognosis. Recent studies show that racial disparity in outcome also exists. We determined the difference in survival between Black and White PDAC patients after resection. Methods: Retrospective analysis of 226 PDAC patients who underwent resection at a single institution from 2010-2018 was performed with attention to lymph node (LN) metastasis and patient race. The number of patients who received chemotherapy was also evaluated. Results: 175 (77.4%) PDAC patients were White and 51 (22.6%) were Black. 130 (59.3%) patients had LN metastasis (LN+). LN+ and LN- groups were similar in race (p=0.93), sex (p=0.10), and age at the time of diagnosis (p=0.45). Patients with LN+ disease were more likely to present with larger tumors (3.4 vs. 2.8cm, p=0.02) and higher T status (p=0.001). White and Black patients had similar rates of LN metastasis (59% vs.58.8%, p=1.0). Median survival for LN- Black and White patients were similar (43.2 vs. 30.2 months, p=0.82). LN+ Black patients trended towards receiving more systemic therapy than White LN+ patients (55% vs. 42%, p=0.10). Median survival for LN+ Black patients was significantly less than LN+ White patients (17.5 vs. 24.6 months, p=0.04, FIGURE). Conclusion: Black LN+ PDAC patients have an inferior survival rate after resection when compared to their White counterparts. Our disparity in outcome cannot be solely explained by a difference in systemic treatment. Further investigation is warranted to determine racial differences in tumor biology or response to chemotherapy.

A 3-Year Experience with Necrotizing Fasciitis: Favorable Outcomes despite Operative Delays in a Busy Acute Care Hospital

Necrotizing fasciitis is a rare severe soft tissue infection that has historically been associated with high mortality. We sought to evaluate our experience with necrotizing fasciitis focusing on outcomes based on timing of operative intervention. Our study hypothesis was that delays in surgical management would negatively impact outcomes. Fifty-four patients were identified for a retrospective chart review from January 2008 to January 2011. Data analysis included demographics, admission laboratory values, imaging results, examination findings, timing and nature of operations, length of stay (LOS), and outcomes. Surgical intervention in 12 hours or more was considered a delay in care. Our study cohort was high risk based on a high prevalence of intravenous drug abuse, diabetes mellitus, hypertension, and end-stage liver disease. The average time to surgical intervention was 18±25 hours and the overall mortality rate was 16 per cent. A delay to surgery did not impact mortality or the number of débridements and LOS. Mortality was high, 45 per cent, in patients requiring amputation. We observed a high-risk population managed with aggressive surgical care for necrotizing fasciitis. Our mortality was low compared with historical data and surgical delays did not impact outcomes. Those patients requiring amputation had worse outcomes.

Staged Arthroscopic Rotator Cuff Repair with a Bridging Acellular Human Dermal Graft in the Treatment of Infection Following Open Rotator Cuff Repair: A Case Report.

Although infection after rotator cuff repair occurs infrequently, it can be a catastrophic complication. To the best of my knowledge, there are only a small number of reports in the literature regarding management of these infections, and none of these report the outcome of a staged arthroscopic approach1-6. Once the infection has resolved, reconstruction of the residual rotator cuff defect can present a substantial challenge for the treating orthopaedic surgeon. The purpose of this report is to present the clinical, functional, and magnetic resonance imaging (MRI) results of an all-arthroscopic approach for the management of a massive rotator cuff tear defect resulting from an infection after an initial open rotator cuff repair. The patient was informed that data concerning his case would be submitted for publication, and he provided consent. A thirty-two-year-old right-hand dominant man with medical comorbidities including diabetes, hypertension, and obesity (body-mass index [BMI] > 40) was referred to our shoulder clinic in October 2009 for a persistent deep left shoulder infection after an open rotator cuff repair. The patient had initially been treated with an open rotator cuff repair with a mesh reinforcement graft in August 2009. The patient had experienced persistent pain and had developed a draining wound, which had been managed with serial debridement, wound care, and intravenous antibiotics for a period of three weeks, followed by oral antibiotics (Augmentin [amoxicillin and clavulanate] and then Levaquin [levofloxacin]) and dressing changes. Previous culture specimens had been positive for Propionibacterium acnes . Despite the aggressive surgical care and serial debridement, the patient had a persistent arthrocutaneous fistula along with dehiscence of the deltoid muscle. He then was referred to our tertiary care shoulder clinic for definitive management. In addition to a thorough history and physical examination, we also obtained an infectious disease consultation …

Elbow “TRASH” (The Radiographic Appearance Seemed Harmless) Lesions

A small subset of serious injuries to the pediatric elbow, deemed lesions, are easily missed on radiograph because of their benign appearance. These lesions however, represent a group of osteochondral injuries, which if treated insufficiently result in chronic long-term consequences. Epiphyseal separations, a displaced intra-articular medial condyles before ossification of the secondary center, capitellar shear fractures, radial head fractures with radiocapitellar subluxation and osteochondral fractures of the olecranon, radial head or distal humerus with joint incongruity comprise the group of TRASH lesions. These injuries are usually seen in children less than 10 years of age who sustain high-energy trauma. The challenge is a prompt diagnosis requiring a high level of suspicion and early additional imaging. Many of these injuries are displaced and unstable requiring anatomic reduction, internal fixation with or without soft tissue repair for further stability. These injuries when diagnosed late, missed completely or treated improperly without aggressive surgical care can result in long-term complications. Surgical reconstruction of the late presenting malunion is difficult.

Muscle-Invasive Urothelial Carcinoma of the Bladder

Muscle-invasive urothelial (transitional cell) carcinoma is a potentially lethal condition for which an attempt at curative surgery is required. Clinical staging does not allow for accurate determination of eventual pathologic status. Muscle-invasive urothelial carcinoma is a highly progressive disease, and initiation of definitive therapy within 3 months of diagnosis is worthwhile. Age is not a contraindication for aggressive surgical care, and surgical candidates should be evaluated in the context of overall medical comorbidity. In those patients who undergo surgery, clinical pathways may streamline care. Radical cystectomy remains the “gold standard” of therapy, providing 5-year survival rates of 75% to 80% in patients with organ-confined disease, yet organ-sparing procedures demonstrate clinical effectiveness as well. Cystectomy should be undertaken with the intent of performing complete pelvic lymph node dissection and attaining surgically negative margins. In younger female patients, the preservation of reproductive organs may be achieved in many cases. Prostate- and seminal vesicle–preserving cystectomy has been performed, yet the long-term safety and efficacy of such a procedure remains to be determined. Laparoscopic and robotic cystectomy procedures continue to be explored by several investigators. The role of “radical transurethral resection” in muscle-invasive disease is limited to a small cohort of patients, and, when it is performed, cystectomy may be required to consolidate therapy. Postoperative follow-up after cystectomy should occur over short intervals during the first 2 years and can be extended, but not discontinued, beyond that time. Currently, no tumor markers have been prospectively validated to help guide clinical decision making, and prospective trials incorporating marker data should be encouraged.

Osteomyelitis of the tubular bones of the hand

The records of 700 patients with hand infections were reviewed. Forty-six (6%) had osteomyelitis of the metacarpals or phalangeal bones. The cause was post-traumatic in 57%, postoperative in 15%, hematogenous in 13%, spread from contiguous infections in 9%, and unidentified in 6%. Twenty-two percent of the patients had vascular insufficiency and/or were immunocompromised. History, physical exam, plain x-rays, and open biopsy and culture were most helpful in establishing the diagnosis. Laboratory studies and bone scans were less helpful. Cultures were positive in 74% of patients, with a noteworthy number of mixed infections (35%) and gram-positive infections (35%). Gram-negative infections accounted for 15%, fungal infections for 12%, and mycobacterial infections for 3%. Surgical management varied from simple curettage to more elaborate staged reconstructions and/or arthrodeses. Despite provision of aggressive surgical care and use of appropriate antibiotics, the overall amputation rate was 39% (18/46). A delay of more than 6 months from onset of symptoms to diagnosis and definitive treatment led to amputation in 6 of 7 patients (86%), 2 of whom had squamous-cell carcinoma. Of the 12 patients who underwent more than 3 surgical procedures, 8 ultimately underwent amputation and 2 had marked disability.

Hemifacial spasm caused by a venule

Spinal cord compression with resultant myelopathy is a frequent occurrence in patients with mucopolysaccharidoses. Etiological factors include developmental abnormalities of the cervical spine and infiltration of the dura mater by the accumulated products of mucopolyssacharide metabolism. Compression at the thoracolumbar junction is rare, but was found in a child with the characteristic physical and biochemical stigmata of the Maroteaux-Lamy syndrome (mucopolysaccharidosis VI). An anterolateral approach to remove the compressing bony elements resulted in symptomatic improvement. Careful radiological evaluation is required so that all surgical options can be considered. Patients with metabolic storage diseases and the capacity for normal intellectual function warrant aggressive surgical care to optimize neurological function. (Neurosurgery 14:83-88, 1984)