Aggressive Surgical Treatment Research Articles

Cardiogenic shock and tumor resection due to cardiac synovial sarcoma: a case report

BackgroundCardiac synovial sarcoma of the heart is a rare, aggressive mesenchymal tumor with poor prognosis, since complete resection is seldom feasible.Case presentationA 23-year-old man was referred in cardiogenic shock. Emergency computed tomography (CT) revealed a large tumor with obstruction of the right atrium (RA) and prolapse into the right ventricle (RV). Resection and pericardial patch plasty were performed. Histology confirmed a G-3 spindle-cell sarcoma. At 21 months postoperatively, CT and cardiac magnetic resonance (MR) angiography showed a tumor emerging from the lateral wall of the superior caval vein (SCV) and the RA. The RA and SCV were completely resected and replaced with a tailored Dacron tunnel prosthesis. Histology confirmed R0 resection of a G-3 spindle-cell sarcoma. Reverse transcription-polymerase chain reaction (RT-PCR) confirmed a monophasic fibrous synovial sarcoma. Echocardiography upon discharge showed normal biventricular function. The heart was tumor-free upon PET-CT 24 months thereafter. A sudden progression with innumerable pulmonary nodules caused only minimal exertional dyspnea, and the patient received palliative monochemotherapy with ifosfamide. Thirty months after the first operation, he succumbed to hemorrhage from a brain metastasis.ConclusionsWe report an unusually long postoperative period of 30 months in our patient after resection of a very large right atrial sarcoma. Early diagnosis, aggressive surgical treatment, adjunctive chemotherapy and radiotherapy affect survival. Systematic inclusion of patients in multicenter initiatives, including biobanking, is necessary. Better knowledge of genetic defects relevant to these cardiac tumors will promote accurate diagnoses and suggest novel and personalized gene-based therapies.

Therapeutic Interventions and Outcomes in Civilian and Military Isolated Gunshot Wounds to the Head: A Department of Defense Trauma Registry and ACS TQIP-matched Study.

The purpose of this study was to compare therapeutic strategies and outcomes, following isolated gunshot wounds of the head, between military and civilian populations. Recent military conflicts introduced new concepts in trauma care, including aggressive surgical intervention in severe head trauma. This was a cohort-matched study, using the civilian Trauma Quality Improvement Program (TQIP) database of the American College of Surgeons (ACS) and the Department of Defense Trauma Registry (DoDTR), during the period 2013 to 2016. Included in the study were patients with isolated gunshots to the head. Exclusion criteria were dead on arrival, civilians transferred from other hospitals, and patients with major extracranial associated injuries (body area Abbreviated Injury Scale >3). Patients in the military database were propensity score-matched 1:3 with patients in the civilian database. A total of 136 patients in the DoDTR database were matched for age, sex, year of injury, and head Abbreviated Injury Scale with 408 patients from TQIP. Utilization of blood products was significantly higher in the military population ( P <0.001). In the military group, patients were significantly more likely to have intracranial pressure monitoring (17% vs 6%, P <0.001) and more likely to undergo craniotomy or craniectomy (34% vs 13%, P <0.001) than in the civilian group. Mortality in the military population was significantly lower (27% vs 38%, P =0.013). Military patients are more likely to receive blood products, have intracranial pressure monitoring and undergo craniectomy or craniotomy than their civilian counterparts after isolated head gunshot wounds. Mortality is significantly lower in the military population. Level III-therapeutic.

A prospective case series on rhino orbital cerebral mucormycosis in Egypt: Epidemiology, systemic implications, and treatment

Introduction and importanceTo identify and recognize systemic implications, clinical, characteristics, and management of a group of patients with rhino orbitocerbral mucormycosis infection. Case presentationThe study included twenty-five patients aged range (12–71 years) with rhino orbital cerebral mucormycosis infection who were admitted to the oral and maxillofacial department in Cairo, Egypt from January 2016 to January 2021. The diagnosis was based on clinical examination, radiographic evaluation, and histopathological reports. Cases were managed according to severity and extension of the infection. Clinical discussionsixteen (64%) males and 9 (36%) females mean age was 44.17 years in a presented sample. 98% of orbital involvement was unilaterally always related to the Right eye (for unknown cause) mortality rate of about six patients (25%). Identified risk factors included eighteen patients (72%) who had diabetes mellitus of these patients ten were undiagnosed at the time of examination, while seven (18%) patients with the hematological disorder as Hodgkin or non-Hodgkin lymphoma, aplastic anemia, and Wegener's disease. These patients were managed by aggressive surgical debridement, antifungal drugs (Amphotericin B), and adjunctive treatment with hyperbaric oxygen Hyperbaric oxygen was used in five patients post-surgically. All investigations were done with mean values of blood glucose level, hemoglobin and WBC were noticeably abnormal. ConclusionsEarly identification and reorganization of systemic implications, early clinical diagnosis of patients with mucormycosis infection will facilitate and improve management strategies and outcome of those patients. Understanding this disease will help in rapid and proper management into place to face this lethal opportunistic infection. The most common predisposing factor was diabetes mellitus followed by patients with hematological malignancies.

A surgical protocol for sinogenic brain abscess: the Oxford experience and a review of the literature.

Rhinosinusitis-induced brain abscesses are rare but can result in devastating long-term sequalae and mortality; they require a high index of suspicion with early imaging to start early empiric parenteral antibiotic treatment covering aerobes and anaerobes. Our study was a retrospective analysis on 32 patients who were treated at Oxford University Hospitals for rhinosinusitis-induced brain abscess between February 2013 and June 2020. Mean age of presentation was 45.83 for adults and 11.14 for children. Subdural collection was the most frequent abscess but 25% of patients had multiple sites of collection; the majority were in the frontal lobe. The most commonly identified pathogens were Streptococcus milleri group and Staphylococcus aureus; 93.75% of the patients were treated with combined Ceftriaxone and Metronidazole for an average of 8 weeks. In our series most patients received also a prompt and aggressive surgical treatment with combined neurosurgical and ENT procedures in the majority; this was especially important in case of subdural empyema, Streptococcus milleri infection and direct intracranial spread of infection. More than half of the patients were treated with a single surgical procedure. Despite aggressive treatment, one third of patients experienced long-term neurological sequelae; there were no deaths.

Nosocomial Infections Associated with Caesarean Section

Nosocomial infections, also called health-care-associated or hospital-acquired infections, are a subset of infectious diseases acquired in a health-care facility. Historically, Staphylococci, Pseudomonas, and Escherichia coli have been the common known as nosocomial infection bacteria. Moreover, nosocomial pneumonia, surgical wound infections, and vascular access-related bacteremia have caused the most illness and death in hospitalized patients; and intensive care units have been the epicenters of antibiotic resistance . Acquired antimicrobial resistance is the major problem, and vancomycin-resistant Staphylococcus aureus is the pathogen of greatest concern. The shift to outpatient care is leaving the most vulnerable patients in hospitals. Aging of our population and increasingly aggressive medical and surgical interventions, including implanted foreign bodies, organ transplantations, and xenotransplantation, create a cohort of particularly susceptible persons. Moreover, renovation of aging hospitals increases risk of airborne fungal and other infections . To prevent and control these emerging nosocomial infections, we need to increase national surveillance, "risk adjust" infection rates so that inter hospital comparisons are valid, develop more noninvasive infection-resistant devices, and work with health-care workers on better implementation of existing control measures such as hand washing . In this review we aimed to review the previous projects which study incidence of hospital infection among delivery women with caesarean section in hospitals. Also, to discuss about the nosocomial infections and its types. We will also review the most common way a nosocomial infection is acquired, and the most common cause of nosocomial infection. In order to the modes of transmission of infection. In addition to a way to prevent nosocomial infections in hospitals. KEYWORDS: nosocomial infections, caesarean section

Nosocomial Infections Associated with Caesarean Section

Nosocomial infections, also called health-care-associated or hospital-acquired infections, are a subset of infectious diseases acquired in a health-care facility. Historically, Staphylococci, Pseudomonas, and Escherichia coli have been the common known as nosocomial infection bacteria. Moreover, nosocomial pneumonia, surgical wound infections, and vascular access-related bacteremia have caused the most illness and death in hospitalized patients; and intensive care units have been the epicenters of antibiotic resistance.&#x0D; Acquired antimicrobial resistance is the major problem, and vancomycin-resistant Staphylococcus aureus is the pathogen of greatest concern. The shift to outpatient care is leaving the most vulnerable patients in hospitals. Aging of our population and increasingly aggressive medical and surgical interventions, including implanted foreign bodies, organ transplantations, and xenotransplantation, create a cohort of particularly susceptible persons. Moreover, renovation of aging hospitals increases risk of airborne fungal and other infections.&#x0D; To prevent and control these emerging nosocomial infections, we need to increase national surveillance, "risk adjust" infection rates so that inter hospital comparisons are valid, develop more noninvasive infection-resistant devices, and work with health-care workers on better implementation of existing control measures such as hand washing.&#x0D; In this review we aimed to review the previous projects which study incidence of hospital infection among delivery women with caesarean section in hospitals. Also, to discuss about the nosocomial infections and its types. We will also review the most common way a nosocomial infection is acquired, and the most common cause of nosocomial infection. In order to the modes of transmission of infection. In addition to a way to prevent nosocomial infections in hospitals.

Rapid sequential development and rupture of mycotic aneurysms within a period of days in a patient with graft-versus-host disease and angiotropic Scedosporium apiospermum infection

Background: Fungal origin mycotic aneurysms are rare and carry a high mortality rate. Scedosporium apiospermum is an ubiquitous fungus which has been described to cause devastating infections in immunocompromised hosts.Case Description: We report a case of a 23-year-old patient with Burkitt’s lymphoma and graft-versus-host disease admitted with intracerebral hemorrhage and sequential development of 12 anterior circulation aneurysms from disseminated Scedosporium infection. Despite aggressive surgical and antimicrobial treatment, the patient died 6 months later from multiorgan failure. The notable feature of this case is the rapid angioinvasiveness of the infection with new aneurysm formation within days of clear angiographic imaging despite the apparent lack of skull base osteomyelitis.Conclusion: We highlight the difficulties in treating fungal mycotic aneurysms and the associated high mortality. While a less aggressive approach might have been appropriate given the known poor outcomes, the age of the patients as well as the family wishes dictated the treatment decisions.

Racial Disparities in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: Does Aggressive Surgical Treatment Overcome Cancer Health Inequities?

BackgroundAdvanced cancer states perpetuate health-related disparities. Peritoneal-based cancers are clinically advanced cancers that present a significant clinical dilemma. Peritoneal cancers are managed aggressively with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). While racial and ethnic disparities are prevalent in cancer, there are no studies investigating if racial disparities exist in patients with peritoneal carcinomatosis managed with CRS and HIPEC. We hypothesized that this advanced disease state further delineates racial disparities.MethodsA retrospective chart review was conducted on patients with peritoneal carcinomatosis receiving CRS and HIPEC at a single institution from January 1, 2017-October 4, 2021. Descriptive statistics were used to compare racial groups. The Cox Proportional Hazards Model and Log Rank Test were used for multivariate and overall survival analysis.ResultsIn total, 67 patients underwent CRS and HIPEC, of which 41 (61.2%) were White, 20 (29.8%) were Black, 3 (4.5%) were Asian, and 3 (4.5%) were Other race. When compared to White patients, Black patients had lower income (p=0.0011), higher incidence of hypertension (p=0.0231), and lower performance status (p=0.0441). Cancer type, including colorectal, appendiceal, ovarian, etc., was similar between groups (p=0.8703). Despite these differences in sociodemographic and morbidity factors, when comparing Black patients to White patients, there were no differences in peritoneal cancer index score (13.2 vs. 12.3, p=0.6932), estimated blood loss (748 vs. 655 mL, p=0.6332), minor/major complication rates (1.1 vs. 1.2, p=0.7281; 0.4 vs. 0.7, p=0.3470, respectively), 30-day readmission rates (25.0% vs. 17.1%, p=0.6210), disease recurrence (40.0% vs. 51.2%, p=0.3667), or 30-day mortality (0.0% vs. 2.4%, p=1.0000). Overall survival was similar for Black and White patients (p=0.2693). The occurrence of a major complication was the only factor associated with overall survival (HR 2.188 [1.502, 3.188], p< 0.0001).ConclusionsDespite differences in patient socioeconomic factors and comorbid conditions, outcomes were similar between Black and White patients receiving CRS and HIPEC at our institution. While larger studies with more diverse patient populations are needed to confirm these findings, our data provide evidence that aggressive surgical management across diverse patient populations allows for equitable outcomes.

Predictive Factors of Functional Outcome in World Federation of Neurosurgical Societies Grade V Subarachnoid Hemorrhage

Patients with World Federation of Neurosurgical Societies (WFNS) grade V subarachnoid hemorrhage (SAH) frequently have poor outcomes. The current understanding of the predictors of functional outcome only in WFNS grade V SAH is limited. Patients with WFNS grade V SAH were retrospectively analyzed between April 2008 and August 2019. Surgical treatment is commonly delayed until clinical improvement is observed using a less aggressive approach. Clinical and radiologic data on admission were assessed, and disease-related characteristics were compared between patients with favorable outcomes (modified Rankin Scale score 0-3) and those with unfavorable outcomes (modified Rankin Scale score 4-6). A total of 144 patients were included, and 22 patients (15.3%) achieved favorable outcomes, whereas 122 patients (84.7%) had unfavorable outcomes. Surgical aneurysm repair was performed in all patients with favorable outcomes and in 21.3% of those with unfavorable outcomes. Multivariate analysis showed that Glasgow Coma Scale score of 3, high-grade Early Brain Edema Score, absence of bilaterally light reflex and neurologic improvement, and hypertension were significantly associatedwith unfavorable outcomes (odds ratio [OR], 9.54, P= 0.03; OR, 5.37, P= 0.04; OR, 11.80, P= 0.009; OR, 0.14, P= 0.02 and OR, 6.53, P= 0.04, respectively). The final outcome of patients with WFNS grade V SAH was still poor and highly predicted by Glasgow Coma Scale score of 3, high-grade Early Brain Edema Score, absence of bilaterally light reflex and neurologic improvement, and a history of hypertension. The efficacy of aggressive surgical treatment for these patients remains controversial, and the indications should be clearly defined in patients with desolate clinical status on admission.

CLINICAL PROFILE OF MUCORMYCOSIS IN TERTIARY CARE CENTER IN NORTHERN INDIA

Purpose: The objective of the study is to study the clinical prole of Mucormycosis in tertiary care center in Northern India. Materials And Methods: This was prospective study which analyzed patients with rhino-orbital mucormycosis, referred to our department from May 2021 to August 2021.After taking a detailed ocular and systemic history, each patient underwent a complete eye examination. Diagnosis was based on nasal swab KOH mount and fungal culture and was conrmed on MRI brain, orbit and PNS in all patients. The characteristics studied were demographic details, clinical features, predisposing factors and co-morbid illnesses. The treatment in terms of usage of antifungal (amphotericin B and posaconazole), antibiotics and surgery was also noted. Statistical Methods: Descriptive analyses were used to study the parameters. Results: A total of 138 patients of mucormycosis were referred to our department. Seventy patients were male and sixty eight patients were female. Uncontrolled diabetes mellitus was the most common underlying predisposing factor. Patients presented with wide range of symptoms of which visual disturbance was the most common symptom. 35 (25.3%) patients were treated with conventional Inj Amphotericin-B and 26 (18.8%) patients were treated with oral antifungal drug due to complications such as hypotension, elevated urea/ creatinine levels. 31 patients underwent surgical debridement of the eschar within the nose/ paranasal sinuses. 8 patients underwent orbital exenteration of the involved orbit for complete clearance of disease and to limit the spread of infection intracranially. Conclusion: Early diagnosis with pathological conrmation and aggressive surgical treatment gives a better outcome.

P-295 Prognostic impact of clinico-pathologic parameters in early- and average-onset curatively resected colorectal cancer

Nearly a third of patients with curatively resected colorectal cancer experience recurrence. However, prognostic data do not discern sporadic early onset colorectal cancer (EO-CC) from average onset colorectal cancer (AO-CC). The aim of this study was to estimate the incidence and relevance of routinely assessed clinico-pathologic prognostic parameters across age cohorts. We compared a comprehensive array of clinico-pathologic characteristics in patients with non-metastatic EO-CC (age 60) treated in a tertiary cancer center between 2000-2020, using Fisher’s Exact Test. Logistic regressions and Kaplan Meier curves were performed to determine correlations with patient outcomes. A total of 216 patients with surgically resected non-metastatic primary colon adenocarcinoma met criteria for inclusion in the study (EO-CC: n=73, mean age 42 years, 44.4% male gender; AO-CC: n=143, mean age 71 years, 52.5% male gender). Compared with AO-CC, the EO-CC group was more likely to have family history of cancer (52.4% vs 28.4%, p=0.002), present with tumor obstruction (58.7% vs 24.8%, p 20 nodes removed, 71.4% vs 40.4%, p < 0.001; adjuvant chemotherapy stage 2: 54.3% vs 22.9%, p=0.003, stage 3: 95.2% vs 75%, p=0.08). Overall survival was longer in EO-CC (87.3% vs 78.4% log-rank p=0.001) as expected, however cancer-specific outcomes were significantly inferior for EO-CC with a shorter relapse-free survival (76% vs 86%, log-rank p=0.002) and 1.6 shorter time to recurrence during the designated study period. In both groups, 10% of patients died of cancer. In the EO-CC group, all deaths were cancer-related, most due to active disease and one of capecitabine toxicity, while in AO-CC, 47% of all deaths were cancer related. Recurrence and survival were equally associated with prognostic factors across age cohorts. The prognostic impact of clinico-pathologic parameters were confirmed among EO-CC and AO-CC patients. However, EO-CC had significantly inferior cancer-specific outcomes despite exhibiting identical histopathological features and receiving more aggressive surgical and oncological treatment. Further research should aim to elucidate the causes and manifestations of a potentially more aggressive disease biology.

Idiopathic Granulomatous Mastitis; Radio-pathologic findings and Grading based on Clinical Presentation and treatment outcome in 224 patients

Background: Idiopathic granulomatous mastitis (IGM) is a rare inflammatory disease of the breast with unknown etiology. Clinico-radiologic findings can mimic breast cancer. Further pathologic evaluation to rule out malignancy is mandatory. Recognizing the severity of the disease is crucial to choosing the most effective therapeutic modality. The aim of this study is to evaluate clinical and radio-pathologic features of IGM, and the treatment outcome in a large series of IGM patients in Iran.Methods: The retrospective charts of 243 patients suspicious of IGM, between December 2007 and September 2017 were reviewed. Patients with confirmed diagnosis of IGM were classified into four grades of severity. Demographic information, clinical and radio-pathologic findings, severity and treatment outcomes were collected.Results: Overall, 224 patients were confirmed to have IGM. Breast mass and erythema were the most common clinical findings. Mammographic findings mimicked malignancy in 34%. Lobulo-centric non-caseating granulomas were the most common pathologic finding. Also, 61.5% of the patients had mild to moderate symptoms and 49.5% of them recovered completely by observation. In addition, 53 (25.9%) patients had severe symptoms and 30.8% of them were resistant to treatment. Conclusion: IGM is a diagnostic challenge. Its diagnosis is based on exclusion and a close cooperation between the clinician, the radiologist and the pathologist. Mild to moderate cases can be managed conservatively; however, severe cases may need further aggressive medical or surgical treatments.

Severe skin and soft tissue pythiosis acquired in a hot spring in the southwestern United States, a case report and review of North American cases

BackgroundHuman pythiosis, caused primarily by the aquatic oomycete, Pythium insidiosum, is an emerging but uncommon infection in North America. The infection is frequently life-threatening and is often initially unrecognized due to its rarity and similar presentation to certain fungal infections. MethodsWe report a case of skin and soft tissue pythiosis in a patient without significant underlying comorbidities acquired in a New Mexico hot spring and review its successful treatment. We also review all reported pythiosis cases in North America. ResultsEleven confirmed cases of human pythiosis acquired in North America were identified. The majority of cases occurred in children (64%), ten of eleven cases were acquired in the southern U.S., Mexico, Central America or the Caribbean and four of the eleven individuals succumbed to the infection. ConclusionsWith recognition and aggressive surgical and medical treatment good clinical outcomes can be achieved when treating human pythiosis.

For Patients With Acute PJI Treated With Debridement, Antibiotics, and Implant Retention, What Factors Are Associated With Systemic Sepsis and Recurrent or Persistent Infection in Septic Patients?

Periprosthetic joint infection (PJI) can lead to a severe systemic inflammatory response and may result in systemic sepsis. However, little is known about how often systemic sepsis may occur in patients with PJI, and whether sepsis is associated with a greater likelihood of persistent or recurrent PJI. (1) Among patients who present with acute or acute hematogenous PJI and who were treated with debridement, antibiotics, and implant retention (DAIR), what proportion have sepsis and what factors are associated with a presentation with sepsis? (2) For patients presenting with sepsis, what factors are associated with persistent or recurrent PJI? In all, 320 patients who underwent DAIR for the treatment of acute postoperative or acute hematogenous PJI between January 2000 and December 2019 were included in this study. Exclusion criteria were patients with other known sources of infection, such as pneumonia or urinary tract infections, which could contribute to systemic sepsis (6% [18 of 320]), patients with chronic PJI, and those with less than 6 months of follow-up (21% [66 of 320]). Our final cohort consisted of 236 patients presenting with an acute postoperative or acute hematogenous PJI who underwent an irrigation and debridement procedure. Sepsis was defined by the criteria for systemic inflammatory response syndrome (SIRS) or bacteria-positive blood culture results. Inclusion of patients with positive blood culture by organisms that caused their joint infection was important as all patients presented with fulminant acute infection of a prosthetic joint. Data, including vital signs, surgical variables, and treatment outcomes, were collected retrospectively through a chart review of an electronic medical record system. The statistical analysis comparing patients with sepsis versus patients without sepsis consisted of logistic regression to identify factors associated with sepsis. After confirming its ability to identify patients with a higher association with the development of sepsis through area under the curve models, a nomogram was generated to standardize our results from the regression, which was supported by the area under the curve model, to help readers better identify patients who are more likely to develop sepsis. A total of 44% (103 of 236) of patients had infections that met the criteria for sepsis. After controlling for confounding variables, including congestive heart failure, anemia, serum C-reactive protein (CRP), and the male sex, it was revealed that serum CRP (odds ratio 1.07 [95% confidence interval 1.04 to 1.11]; p < 0.001) and male sex (OR 1.96 [95% CI 1.03 to 3.81]; p = 0.04) were associated with the development of systemic sepsis. For patients presenting with sepsis, persistent or recurrent PJI were associated with an increased CRP level (OR 1.06 [95% CI 1.02 to 1.11]; p = 0.01) and number of prior surgical procedures on the joint (OR 2.30 [95% CI 1.21 to 4.89]; p = 0.02). Overall, our findings support that patients with systematic sepsis may benefit from two-stage revision rather than DAIR to decrease the bioburden more effectively, especially in those with methicillin-resistant Staphylococcus aureus and polymicrobial infections. High serum CRP levels and a history of prior surgical procedures on the involved joint should trigger prompt, aggressive surgical treatment if the patient's overall clinical status can tolerate such an intervention. Level III, therapeutic study.

Role of orbital exenteration in rhino-orbital-cerebral mucormycosis

Purpose–Mucormycosis is an uncommon, rapidly progressive, commonly fatal, opportunistic serious fungal infection.The high mortality rate highlights the importance of early detection and treatment. The purpose of this study to determine theoutcome of orbital exenteration in Rhino-orbital-cerebral mucormycosis(ROCM) patients. Methods and materials–This study includesall proven ROCM patients who had underwent orbital exenteration based on SION Scoring system from 1st may 2021 to 30 june 2021 in MYH hospital, Indore.Those patients were reviewedand the outcome of orbital exenterationwas analysed. Results- Total 29ROCM patients were underwent for orbital exenteration based on SION Scoring system. 19(65.5 %)out of 29 patients had intracranial extension and 10 (34.480%) did not have intracranial extension.&#x0D; Out of 29, 6 (20.68%) patients hadsuccumbed to death within 10 days of orbital exenteration was having bilateral orbital involvement with intracranial extension.23(79.34%) patientshave favorable outcome with regular follow up. Conclusion- Survival of mucormycosis patients depends on the their good glycemic control,immune status, laterality of the orbital involvement and early detection of intracranial extensionof the disease.With prompt medical (high dose intravenous amphotericin B) and early aggressive surgical intervention involving FESS and orbital exenteration can preventintracranial extension and may improve survival rate .Intracranial extension of the disease has invariably been associated with high mortality.

Direct Fixation of Fractures of the Posterior Malleolus Through a Postero-Medial Approach

Abstract Background and objective: Fractures of the posterior malleolus have long been neglected in the past. The decision for their fixation should be based on plain lateral radiographs. Recent studies have emphasized the important biomechanical function of the posterior tibial ridge. This has caused a trend towards more aggressive surgical treatment. The aim of this study was to present our experience with the direct fixation of complex ankle fractures engaging the posterior malleolus. We also tried to clarify the advantages and limitations of the posterior-medial surgical approach. Materials and Methods: For a period of 1,5 years we have operated 14 patients with posterior malleolus fractures. Their average age was 51 years. Eight of the patients were male, the rest 6 were females. Fractures were classified according to Bartoníček classification system. All patients had type 3 fractures. Direct open reduction was performed in all cases. Posterior buttress plate was used for the fixation of the fracture. Bone grafting was found necessary in one case. Functional assessment was done according to the criteria of the AOFAS (American Orthopedic Foot and ankle score). Follow up was done for an average period of 10 months. Results: All fractures united for an average period of 9 weeks (8-10 weeks). Six patients achieved an excellent functional result, 5 – a good one and 3 had an average result. The average AOFAS rating score was 84,02 (54-100). The average range of motion was 38° (15°-50°). There were no deep infections or septic arthritis. Three ankles had superficial skin necrosis that healed without any additional procedures. One patient had prolonged and substantial swelling of the leg, despite of the routine antithrombotic prophylaxis. Five patients needed their fibular plates removed due to local irritation. Conclusion: The direct reduction and fixation of the posterior malleolus fractures allow anatomical restoration of the ankle mortise. This is a prerequisite for an optimal functional recovery and appears to be a safe treatment strategy.

Early Surgery Prolongs Professional Activity in IDH Mutant Low-Grade Glioma Patients: A Policy Change Analysis.

BackgroundUntil 2015, Dutch guidelines recommended follow-up and biopsy rather than surgery as initial care for suspected low-grade gliomas (LGG). Given evidence that surgery could extend patient survival, our center stopped following this guideline on January 1, 2010 and opted for early maximal safe resection of LGG. The effects of early surgery on the ability of patients to work remains little documented.MethodsA total of 104 patients operated on at our center between January 2000 and April 2013 and diagnosed with the WHO 2016 grade 2 astrocytoma, IDH mutant or oligodendroglioma, IDH mutant and deleted 1p19q were included. The clinical characteristics, survival, and work history of patients operated on before or after January 2010 were obtained from the patients’ records and compared. The minimal follow-up was 8 years.ResultsAs per policy change, the interval between radiological diagnosis and first surgery decreased significantly after 2010. Likewise, before 2010, 25.8% of tumors were initially biopsied, 51.6% were resected under anesthesia, and 22.5% under awake conditions versus 14.3%, 23.8%, and 61.9% after this date (p < 0.001). The severity of permanent postoperative neurological deficits decreased after 2010. In total, 82.5% of the patients returned to work postoperatively before 2010 versus 100% after 2010. The postoperative control of epilepsy increased significantly after 2010 (74.4% vs. 47.9%). The median time from diagnosis to a definitive incapacity to work increased by more than 2 years after 2010 (88.7 vs. 62.2 months).ConclusionA policy shift towards early aggressive surgical treatment of IDH mutant LGG is safe and prolongs the patients’ ability to work.

Importance of early diagnosis and surgical treatment of calcified amorphous tumor-related native valve endocarditis caused by Escherichia coli: a case report

BackgroundUnlike Escherichia coli bacteremia, which is common, E. coli endocarditis is uncommon, particularly in patients with native valve, leading to its delayed diagnosis.Case presentationWe present a case of infective endocarditis caused by E. coli in a 78-year-old Japanese man with type 2 diabetes, involving persistent bacteremia and vegetation on the mitral valve (measuring 18 × 4.2 mm in diameter). He presented with recurrent fever after antimicrobial treatment for pyelonephritis. He received antibiotic therapy for 6 weeks and required surgical removal of a calcified amorphous tumor and vegetation with mitral valvuloplasty 7 days after admission. Despite an episode of multiple cerebral infarctions, he recovered fully from the infection.ConclusionsFollow-up blood cultures should be performed for Gram-negative bacilli bacteremia among patients with unknown focus and an atypical clinical course after treatment. Early diagnosis and aggressive surgical intervention are paramount to achieving good clinical outcomes.

Two cases of resected gallbladder carcinosarcoma with a contrasting course.

IntroductionCarcinosarcoma of the gallbladder is a rare tumor with both carcinoma and sarcoma components.Case presentationIn this paper, we report two cases. The first case is of a man in his 60s who was preoperatively diagnosed with gallbladder carcinosarcoma and has achieved 6 years and 6 months survival through aggressive surgical treatment. The second case is of a woman in her 70s who was diagnosed with locally advanced gallbladder cancer; she underwent multidisciplinary treatment for the same, but died 8 months after the surgery. While the primary disorder was the same in both cases, the clinical courses contrasted sharply.DiscussionThere is no established chemotherapy or radiation therapy for gallbladder carcinosarcoma, and the only curative treatment is surgery. However, it has a very poor prognosis.ConclusionCarcinosarcoma of the gallbladder may progress very rapidly, and the treatment management should be carefully decided.

Surgical Interventions in Cases of Esophageal Hiatal Hernias among Older Japanese Adults: A Systematic Review.

Background and Objectives: Given Japan’s superaging population, an increasing number of older adults in the country need surgical treatment for esophageal hiatal hernias. Accordingly, this systematic review examines surgical interventions for symptomatic esophageal hiatal hernias in older Japanese patients and explores treatment outcomes. Materials and Methods: Articles on single operations for hiatal hernias published after 1991 were found on Google Scholar and Ichushi using specific keywords. Subsequently, articles fulfilling the predetermined inclusion criteria were considered in the study. Results: The mean patient age was 81.4 years, and the male-to-female ratio was 1:11.5. The main reasons for surgery were vomiting, dyspnea, and chest tightness. In terms of hernia classification, type IV was the most common (48%). Surgical modalities were laparoscopy in 15 cases, and laparotomy in 10 cases. Mean postoperative course was 26.47 days until hospital discharge, and there were no cases of perioperative death. Conclusions: Findings showed that multiple factors were involved in older adults’ prognoses, and age was not the only biological factor. Therefore, aggressive surgical intervention should be considered for symptomatic older patients, even in the absence of surgery indicators.