Clear Indications For Surgery Research Articles

Successful Pedal Bypass in a Patient With Pseudoxanthoma Elasticum.

Pseudoxanthoma elasticum (PXE) is a rare metabolic disease, causing calcification in the arterial media layer and further peripheral artery disease (PAD). A high rate of failure has been reported after endovascular and open surgical management of PAD among patients with PXE. Critical limb ischemia (CLI) rarely develops in PXE, and there are only few reports of its treatment. We present a case report of a 57year-old female diagnosed with pseudoxanthoma elasticum (PXE). She presented with critical limb ischemia (CLI) and was successfully treated with pedal bypass using the great saphenous vein. Despite obtaining suboptimal outcomes through the initial approach of percutaneous transluminal angioplasty to treat critical limb ischemia, the subsequent bypass operation proved to be a success. At the first follow-up appointment at 1month, the patient was asymptomatic and the ulceration had almost healed. The patient underwent an ultrasound examination at 3, 6, 12, and 24months after discharge, and the surveillance was uncomplicated. With a clear indication for surgery, limb-threatening ischemia can be successfully treated with distal bypass, if necessary, in patients with PXE similarly to atherosclerotic PADs. Appropriate diagnostic and surveillance imaging and the utilization of a multidisciplinary team are key components for effective management of PAD in patients with PXE.

Which radial head fractures are best treated surgically?

Despite the common occurrence of radial head fractures, there is still a lack of consensus on which radial head fractures should be treated surgically. The radial head is an important secondary stabilizer in almost all directions. An insufficient radial head can lead to increased instability in varus-valgus and posterolateral rotatory directions, especially in a ligament-deficient elbow. The decision to perform surgery is often not dictated by the fracture pattern alone but also by the presence of associated injury. Comminution of the radial head and complete loss of cortical contact of at least one fracture fragment are associated with a high occurrence of associated injuries. Nondisplaced and minimally displaced radial head fractures can be treated non-operatively with early mobilization. Displacement (>2 mm) of fragments in radial head fractures without a mechanical block to pronation/supination is not a clear indication for surgery. Mechanical block to pronation/supination and comminution of the fracture are indications for surgery. The following paper reviews the current literature and provides state-of-the-art guidance on which radial head fractures should be treated surgically.

Proximal right subclavian artery aneurysms: A case report and review of the literature.

Subclavian aneurysms are rare in clinic; right subclavian artery aneurysms (SAAs) are more common than left SAAs in clinical practice. Although the causes and methods of treating subclavian aneurysms have been studied, it is still unknown how they form naturally. While describing the uncommon subclavian aneurysm, examine the pertinent literature to discuss its etiology and treatment outcomes, and offer some recommendations for this patient's treatment plan. In this case report, we describe a man patient who had a right subclavian proximal aneurysm that was discovered by accident. No clear clinical symptoms or signs were present in the patient. Upon admittance, an examination revealed an aneurysm in the vertebral artery but no peripheral embolization or compression symptoms. The patient refused operation, so we opted for follow-up instead. The patient took an ultrasound examination at our first follow-up appointment 3months after discharge, and the results showed no thrombosis or appreciable aneurysm enlargement. Follow-up appointments for 6months and a year have begun. Follow-up is a good method to monitor the course of subclavian aneurysms without a clear indication for surgery when there is a clear operation mode and risk.

Risk Factors for and Outcomes of Postoperative Entrapped Temporal Horn in Trigone Meningiomas.

Meningioma in the ventricle triangle area is a benign tumor that can be cured by surgery, but postoperative entrapped temporal horn may seriously affect the patient's quality of life and even require a second operation. Currently, there are few reports on this complication. The risk factors and prognosis of postoperative ETH in trigone meningiomas were investigated. A retrospective analysis of the clinical data of 87 patients with trigone meningioma from 2010 to 2018 was performed, and univariate and multivariate analyses were used to assess the risk factors associated with postoperative ETH. The degree of ETH was evaluated using the modified ventriculocranial ratio. The incidence of postoperative ETH in trigone meningioma was 29.9% (26/87). Preoperative ETH [odds ratio (OR): 4.826, 95% confidence interval (CI): 1.820-12.796, P = 0.002] and postoperative meningitis (OR: 12.811, 95%CI: 1.615-101.605, P = 0.016) are independent risk factors for postoperative ETH. Of the 18 patients with ETH syndrome, 12 improved after medical treatment, and finally, a total of 6 patients received ETH surgery. The mean duration from tumor resection to the appearance of ETH syndrome was 3.1 ± 1.9 months (range: 9 days-7 months). Patients with ETH grade II and III are more prone to clinical symptoms. : The incidence of postoperative ETH for trigone meningiomas is high, and clinical symptoms generally appear delayed after surgery. Reducing postoperative infections can reduce the occurrence of postoperative ETH. Patients with symptoms of ETH who have failed medical treatment have clear indications for surgery.

Functional Outcomes of Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension

<h3>Purpose</h3> The aim of the present study was to investigate the long-term outcomes of pulmonary thromboembolis (PEA) in patients with Chronic thromboembolic pulmonary hypertension (CTEPH), with a particular focus on identifying an effect on the improvement of functional class and right ventricular pressure. <h3>Methods</h3> Twenty-six patients underwent PEA surgery between May 2012 to April 2021. The median age was 60 ± 13.48 years, and there were more women (61.5%) than men. 9 patients (34.6%) were diagnosed with deep vein thrombosis (DVT), and 5 patients (19.2%) had cancer history. The mean ACC time for PEA was 96.88 ± 33.97 min and the mean total circulatory arrest time was 25.52 ± 10.66 minutes. Jamieson classification I was 22 patients (84.6%), II was 2 patients (7.6%), and III was 2 patients (7.6%). <h3>Results</h3> After PEA surgery, most patients (88.5%) were weaned from inotropics without extracorporeal membrane oxygenation (ECMO) support during the first few days. After surgery, 96.2% of the patients remained free of continuous renal replacement therapy. The 5-year survival rate was 95.5%, and the 5-year freedom rates of cardiac death was 100%. Our study suggests that after PEA surgery, mortality rate was low and there was marked improvement in NYHA class and health status (p<0.001, Figure) not only significantly lowered RVSP and TR grade (p<0.001, left Table). Cox univariate regression analysis demonstrated that male sex, CKD (grade III-IV), and MPA involvement were independent predictors of non-improvement after PEA surgery, according to RVSP reduction. MPA involvement remained significant predictors of non-improvement after PEA surgery in multivariate Cox regression (right Table). <h3>Conclusion</h3> Despite the increased perioperative risk and mortality, PEA could be a best choice of treatment to patients with elevated RVSP but clear indication for surgery. Furthermore, significant RV pressure reduction and improved functional outcomes can be achieved in especially non-MPA involved patients.

Cryoneurolysis for Digital Neuralgia in Professional Baseball Players: A Case Series

We describe a non-surgical approach to refractory digital neuralgia using cryoneurolysis in a series of 3 professional baseball players. Thumb injuries are common in baseball players and can sometimes be challenging to effectively manage. Depending on the injury, current treatments include anti-inflammatories, immobilization, physical therapy, corticosteroid injections, and/or surgery. A subset of patients, however, fail nonoperative management yet do not have a clear indication for surgery. Cryoneurolysis or cyroanalgesia is an FDA-approved form of neuromodulation, which has been used safely and effectively on a variety of peripheral nerves. The mechanism of action involves percutaneous introduction of a small probe under local anesthetic to nerve tissue using ultrasound guidance. The probe is then cooled to -88°C using nitrous oxide, which results in secondary Wallerian degeneration. Axonal and myelin regeneration occurs completely in 3-6 months. Visualization of the superficial radial sensory and ulnar digital nerve were obtained under ultrasound. The skin was prepared in sterile fashion. A 22-gauge 1-½ inch needle was then advanced with ultrasound guidance, and local anesthetic was applied. Both treatment sites were marked with skin marker. Cryoneurolysis was employed using a 5 mm tip. 60-second treatment cycles were performed at each site. Each of the cycles resulted in a 5 × 7 mm lesion visible as hypoechoic signal. All 3 players endorsed significant and prolonged relief and were able to return to an elite level of play. This manuscript is subject to all of the limitations of a case series, and larger rigorous studies are needed to illuminate causal inferences. Novel, complex technologies may also be more susceptible to placebo effect. Nonetheless, we are able to report marked efficacy and safety from cryoneurolysis of the ulnar digital nerve and the superficial radial sensory nerve in a small group of elite baseball players with refractory digital neuralgia.

Development and Validation of Nomogram to Preoperatively Predict Intraoperative Cerebrospinal Fluid Leakage in Endoscopic Pituitary Surgery: A Retrospective Cohort Study.

BackgroundPituitary adenomas (PAs) are the most common tumor of the sellar region. PA resection is the preferred treatment for patients with clear indications for surgery. Intraoperative cerebrospinal fluid (iCSF) leakage is a major complication of PA resection surgery. Risk factors for iCSF leakage have been studied previously, but a predictive nomogram has not yet been developed. We constructed a nomogram for preoperative prediction of iCSF leakage in endoscopic pituitary surgery.MethodsA total of 232 patients who underwent endoscopic PA resection at the Department of Neurosurgery in Jinling Hospital between January of 2018 and October of 2020 were enrolled in this retrospective study. Patients treated by a board-certified neurosurgeon were randomly classified into a training cohort or a validation cohort 1. Patients treated by other qualified neurosurgeons were included in validation cohort 2. A range of demographic, clinical, radiological, and laboratory data were acquired from the medical records. The Least Absolute Shrinkage and Selection Operator (LASSO) algorithm and uni- and multivariate logistic regression were utilized to analyze these features and develop a nomogram model. We used a receiver operating characteristic (ROC) curve and calibration curve to evaluate the predictive performance of the nomogram model.ResultsVariables were comparable between the training cohort and validation cohort 1. Tumor height and albumin were included in the final prediction model. The area under the curve (AUC) of the nomogram model was 0.733, 0.643, and 0.644 in training, validation 1, and validation 2 cohorts, respectively. The calibration curve showed satisfactory homogeneity between the predicted probability and actual observations. Nomogram performance was stable in the subgroup analysis.ConclusionsTumor height and albumin were the independent risk factors for iCSF leakage. The prediction model developed in this study is the first nomogram developed as a practical and effective tool to facilitate the preoperative prediction of iCSF leakage in endoscopic pituitary surgery, thus optimizing treatment decisions.

Clinical Management of Pancreatic Premalignant Lesions

Clinical Management of Pancreatic Premalignant Lesions

Adenomatous, Unilateral, Retrosternal Extension of the Thyroid Gland presenting as a Mediastinal Mass

Background: Thyroid-related causes of mediastinal masses include retrosternal goiters and thymic enlargement associated with Graves’ disease. Here, we present a case of significant unilateral retrosternal growth of the thyroid gland, presenting as an incidental mediastinal mass, without any evidence of contralateral disease. Associated subclinical hyperthyroidism presents a therapeutic challenge. Clinical Case: A 68-year old gentleman presented to the emergency department with a non-infective exacerbation of known Chronic Obstructive Pulmonary Disease. CT Pulmonary Angiogram revealed a right sided 5.6cm paratracheal mass, which seemed to originate from the posterior aspect of the right lobe of the thyroid and extended to the subcarinal region. The mass displaced the oesophagus and was close to, but did not compress, the trachea. The left thyroid lobe was normal. Thyroid ultrasound was reported as normal, but was later acknowledged to be suboptimal at visualization of the posterior aspect of the gland. Thyroid scintigraphy confirmed increased radionuclide uptake within the mass. Thyroid function tests showed subclinical thyrotoxicosis [TSH 0.04 (0.4-4.0mIU/mL), FT4 17.4 (10-22pmol/L) and FT3 3.36 (2.89-4.88 pmol/L)]. TSH receptor antibody was negative [< 1.1 (<1.75 IU/L)]. On review of prior imaging from other hospitals, the mass had been present since 1999 and was stable in size for at least the past 7 years. The patient was discharged on carbimazole with a plan to perform interval scanning to monitor size. Discussion: Although technetium uptake can be seen in thymus tissue, the identification on imaging that the mass is contiguous with the thyroid gland leads us to believe this is an adenomatous extension of the thyroid gland. Ectopic thyroid tissue is possible, but the size of the mass suggests some prior period of growth. Thyroid carcinoma seems unlikely given the current stability in size, and there are no compressive symptoms, so there is no clear indication for surgery at present. However, given the subnormal TSH level, there is evidence of autonomy, so treatment is indicated. Radio-iodine treatment may be associated with thyroiditis, with attendant swelling of the gland and risk of compression of vital structures, so treatment with ATDs and regular imaging surveillance was deemed most appropriate in his case.

The Interdisciplinary Management of Newly Diagnosed Pituitary Tumors.

The increasing use of cranial tomographic imaging has led to the more frequent discovery of pituitary tumors. In this review, we discuss the clinical symptoms that point toward a pituitary tumor, the required diagnostic studies, the potential need for follow-up studies, and the indications for neurosurgical treatment. This review is based on pertinent publications from the years 2005-2020 that were retrieved by a selective search in PubMed, as well as on the current German S2k guideline, which was created with the present authors playing a coordinating role, and on further guidelines from abroad. Relevant information from older reviews was also considered. The reported prevalence of pituitary tumors varies depending on the method of data acquisition. Autopsy studies yield a figure of 10.7%, while population-based studies reported 77.6-115.6 cases per 100 000 inhabitants. These lesions are nearly always benign, and 85% of them are pituitary adenomas. Pituitary adenomas measuring less than 1 cm in diameter are called microadenomas, while those measuring 1 cm or more are called macroadenomas. According to magnetic resonance imaging (MRI) studies, the prevalence of microadenomas in the general population is in the range of 10-38%, while that of macroadenomas is 0.16-0.3%. Pituitary adenomas can be either hormonally inactive or hormonally active. Half of all patients with hormonally inactive microadenomas display no endocrine abnormality, while 37-85% of patients with hormonally inactive macroadenomas manifest at least partial pituitary insufficiency. The clinical spectrum of pituitary tumors ranges from a fully asymptomatic state to visual disturbances, neurologic deficits, severe hormone excess (e.g., in Cushing disease), and life-threatening pituitary insufficiency. Pituitary adenomas are often diagnosed only after a latency of many years, even when they are symptomatic. If an imaging study shows the tumor to be in contact with the visual pathway, an ophthalmological evaluation should be performed. There are clear indications for surgery, e.g., imminent loss of vision, but most asymptomatic pituitary tumors can be observed only. The manifestations of pituitary tumors are first recognized by primary care physicians. The further diagnostic evaluation of these patients should be carried out in standardized and interdisciplinary fashion.

Medical Malpractice Allegations in Nasal Turbinate Surgery.

Despite studies showing most patients significantly improve their nasal congestion with surgical management of nasal turbinates, not all achieve acceptable results. Rarely, patients report substantial worsening of symptoms leading to litigation risk. Document the United States medicolegal environment for nasal turbinate surgery. We searched the Westlaw database for turbinate related terms for 1987- July 2019, recording demographics, claims, legal arguments, and outcomes in legal cases related to nasal turbinate surgery. We assessed prevalence and correlations with case outcomes. Of the 39 cases identified, the most common complaint was nose/facial pain (53.8% of cases). Surgeons prevailed in 87.2% of cases, with total liabilities of $3,224,606 [mean $97,715.3, ±$283,900.8]. Surgeons had statistically significant favorable outcomes when patients claimed dryness, headache, congestion, crusting, breathing problems, and disfigurement (all p < 0.05). Revision surgery was indicated in 23.1% of cases and was claimed in 40.0% of patient awards. Surgical negligence was claimed in 40.0% of patient awards versus 67.9% of surgeon awards (p = 0.333). Lack of informed consent was claimed in 20.0% of patient awards versus 32.1% of surgeon awards (p = 0.601). There are inherent litigation risks for surgeons when performing nasal turbinate surgery. Most claims against surgeons, are resolved in favor of the surgeon. Understanding the types of claims and legal arguments that are made by patients could help assessing the risks of a proposed litigation. Documenting clear indications for surgery and written informed consent may reduce litigations against surgeons.

Direct myocardial revascularization after 6, 12 and 24 hours of acute coronary syndrome

To evaluate the results of direct myocardial revascularization within 72 hours after manifestation of acute coronary syndrome. A retrospective study included 48 (0.47%) out of 10 193 patients with coronary artery disease who underwent coronary artery bypass grafting for the period 2011-2019. Study patients underwent urgent direct myocardial revascularization. SYNTAX Score >22 points was observed in all cases. All patients were divided into 3 groups depending on timing of surgery: 26 patients - within 6 hours after admission, 15 patients - within 6 - 24 hours, 7 patients - within 24-72 hours. Level of myocardial damage markers was similar after 1 and 2 days (p>0.05). In the 1st group, 1 (3.84%) patient died in hospital, 5 (19.2%) patients - within 1 year after surgery. In the 2nd group, these values were 1 (6.6%) and 0, respectively. There was no mortality in the 3rd group (p>0.05). Overall 5-year survival was 100%. Early active open revascularization is advisable in patients with ACS and clear indications for surgery.

Time to surgery: Is it truly crucial in initially stable patients with penetrating injury?

BackgroundTreatment recommendations for patients with penetrating abdominal injury are well established. Trauma victims with clear indications for surgery, should undergo immediate operative intervention without any delay or additional imaging. However, the optimal time for surgery remains unclear. There are some significant advantages in preoperative abdominal CT, including gathering essential information regarding a few difficult to reach anatomical areas, avoiding unnecessary explorations associated with increased morbidity and assessing the existence of extra-abdominal injuries that may have non-expectable impact on initial therapeutic plan. The aim of this study was to determine the impact of "time-to-surgery" on final medical outcomes in patients with penetrating abdominal trauma with normal blood pressure on admission. MethodsA retrospective cohort study using the Israeli National Trauma Registry was conducted from 2000- 2018. This study included trauma patients with penetrating injuries and a systolic blood pressure of 90mmHg or above on admission. All patients included in the study were divided into three groups according to the time that lapsed from their admission to surgery: half an hour, an hour, and two hours. We assessed the outcome for each patient, including length of hospital stay, need for intensive care and mortality. Statistical analysis was performed using the Chi-square test, ANOVA test. A p-value of less than 0.05 was considered statistically significant. ResultsThe study included 1,136 penetrating trauma patients. Among these, 78.0% (886) had sustained low-energy penetrating injury (SWPI) and 22.0% (250) had sustained high-energy penetrating injury (FAPI). Males accounted for 93.5% (1,062) of the patients. Mean age was 30.4. About 29% (327) of all the patients underwent surgery within 30 minutes from admission, 42% (475) within 30-60 min, and 29% (334) patients were operated within one to two hours. Patients who underwent surgery within 30 minutes, had worse ISS and GCS scores and were, therefore, more likely to have worse clinical outcomes. No other differences in outcomes were found in patients who were operated upon within 2 hours. ConclusionsTime to surgery within two hours from admission has no impact on final outcomes in trauma patients with penetrating injury and normal blood pressure on admission.

Surgery of adrenal diseases

Incidentally discovered adrenal alterations should be separated into those without any clinical importance and adrenal diseases that have to be surgically or conservatively treated. Before operative treatment, in addition to the possible different functional activity of tumors, a differentiation must be made between sporadically arising singular or multiple adrenal tumors or nodular adrenal hyperplasia, adrenal tumors as part of afamilial syndrome and metastases of other primary malignant tumors into the adrenal glands. Benign hormonally active adrenal tumors as well as questionable malignant tumors of the adrenal cortex are resected by minimally invasive techniques. For large malignant tumors infiltrating into surrounding tissues and tumors with proven lymph node metastases, the primarily open approach is indicated. Patients with adrenal diseases should always undergo an interdisciplinary assessment and in cases with clear indications for surgery, sometimes transferred to a center with experience in surgery and postoperative management of these patients.

SAT-260 Resolution of a Cystic Macroprolactinoma with Dopamine Agonist Therapy

Background. Prolactinomas with cystic regions occupying ≥ 50% of tumor volume are classified as cystic prolactinomas. They appear to arise from tumor necrosis or hemorrhage. Though Pituitary Society guidelines recommend surgery as first-line treatment for cystic prolactinomas, there is evidence that cystic prolactinomas are hormonally and anatomically responsive to treatment with dopamine agonists (DA). We present a case of a cystic macroprolactinoma fully responding to treatment with cabergoline. Case. A 31 year old male was referred for evaluation of gynecomastia, diminished libido, and erectile dysfunction that occurred over the course of eight months. Bilateral glandular breast tissue with a slight right asymmetry was present. Testes were 15–20 mL, soft, and without masses. Phallus and pubic hair were unremarkable. Morning (8 AM) testosterone, estradiol, and LH levels were 92 ng/dL (348–1197), 13.4 pg/mL (7.6–42.6), and 2.0 mIU/mL (1.7–8.6), respectively. Prolactin level was 331 ng/mL (4–15), and MRI with pituitary protocol revealed a 1.4 x 1.0 x 1.5 cm cystic mass with peripheral rim enhancement and extension into the suprasellar cistern. No mass effect on the optic chiasm was observed. Somatotroph, thyrotroph, and corticotroph axes were unaffected. Cystic macroprolactinoma causing hyponadotropic hypogonadism complicated by gynecomastia was diagnosed. The patient chose initial management with cabergoline 0.25 mg twice weekly. Three months after starting treatment, libido and erectile function had recovered to baseline, 8 AM testosterone was 607 ng/dL, and hyperprolactinemia was well controlled (4.2 ng/mL). At six months, anatomic resolution of the cystic macroprolactinoma was demonstrated on repeat pituitary MRI. Plastic surgery was required for management of gynecomastia. Conclusions. Surgery is recommended for management of cystic prolactinomas due to concern that a lack of dopamine receptors in the cystic components of tumors will make DA ineffective reducing tumor size. However, this case joins a growing body of evidence that DA can treat hyperprolactinemia and induce regression of cystic macroprolactinomas. For example, in a retrospective case review of patients with cystic macroprolactinomas at Massachusetts General Hospital, persistent cyst reduction occurred in 20 of 22 patients treated initially with DA, and median reduction in cyst volume exceeded 80 percent. Median time to documented cyst reduction was approximately six months, and there was no difference in degree of cyst reduction for patients treated with bromocriptine or cabergoline. The response of cystic prolactinomas to DA is similar to solid prolactinomas, and DA are reasonable initial treatment for cystic macroprolactinomas without clear indications for surgery.

Treatment strategy and long-term functional outcome of traumatic elbow dislocation in childhood: A single centre study

PurposeTraumatic elbow dislocation (TED) is the most common injury of large joints in children. There is an ongoing debate on the optimal treatment for TED. We aimed to assess the functional outcome after operative and nonoperative treatment of TED.MethodsWe analysed the medical records of patients with TED treated at the University Children’s Hospital, Basel, between March 2006 and June 2015. Functional outcome was assessed using the Mayo Elbow Performance Score (MEPS) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) Sport and Music Module score. These scores were compared between nonoperatively and operatively treated patients.ResultsA total of 37 patients (mean age 10.2 years, 5.2 to 15.3) were included. Of these, 21 (56.8%) children had undergone nonoperative treatment, with 16 (43.2%) patients having had operative treatment. After a mean follow-up of 5.6 years (1.2 to 5.9), MEPS and QuickDASH Sport and Music Module scores in the nonoperative group and operative group were similar: MEPS: 97.1 points (SD 4.6) versus 97.2 points (SD 2.6); 95% confidence interval (CI)-2.56 to 2.03); p = 0.53; QuickDASH Sport and Music Module score: 3.9 points (SD 6.1) versus 3.1 points (SD 4.6); 95% CI 2.60 to 4.17; p = 0.94. We noted no significant differences regarding the long-term functional outcome between the subgroup of children treated operatively versus those treated nonoperatively for TED with accompanying fractures of the medial epicondyle and medial condyle.ConclusionFunctional outcome after TED was excellent, independent of the treatment strategy. If clear indications for surgery are absent, a nonoperative approach for TED should be considered.Level of evidenceLevel III - therapeutic, retrospective, comparative study

Out of town guest: A healthy 7 year old from a non-endemic area presents with histoplasmosis granulomatous disease.

Histoplasmosis is a common fungal infection, normally infecting people exposed to demolition sites or bat/bird droppings in the central and eastern states. When a child presents with a chest mass and eosinophilia in a non-endemic region the likelihood of an infectious process like pulmonary histoplasmosis is unknown. A seven year old immunocompetent child with a mediastinal mass and eosinophilia presented with acute cough, fever, non-bloody emesis, and four pound weight loss. A neoplastic work up was negative. Further evaluation showed a positive M band (chronic histoplasmosis infection) and negative H band (acute infection). Tissue obtained by thoracotomy demonstrated necrotizing granulomatous inflammation with calcification consistent with histoplasmosis. Patient recovered after completion of a twelve week course of itraconazole. A mediastinal mass in a symptomatic child has a 50% risk of cancer as the primary diagnosis. The Infectious Disease Society of America guidelines recommend treatment of histoplasmosis granulomatous disease with itraconazole if symptomatic and surgery only for obstruction. Thus our patient did not have a clear indication for surgery. In a child with a mediastinal mass, despite low risk factors should they be evaluated for a fungal infection prior to invasive surgery? This case demonstrates that histoplasmosis can cause a granuloma in a non-endemic region and that an infectious etiology ought to be considered when working up a symptomatic child with a chest mass as it may prevent unnecessary surgery.

Principles for Management of Orbital Fractures in the Pediatric Population: A Cohort Study of 150 Patients.

Pediatric orbital fractures represent a challenging and sometimes controversial clinical problem. Patients may present with clear indications for surgery, but most require balancing benefits against intraoperative and late complications. The authors assessed these fractures at a state-designated ophthalmology referral center to develop criteria for surgery. Institutional review board approval was obtained to retrospectively analyze pediatric trauma registry patients with orbital fracture diagnoses at the Wilmer Eye Institute over 10 years. Patients were excluded if they did not undergo a full ophthalmologic examination, never followed up after their injury, or had significant facial fractures outside of the orbit. One hundred fifty patients met selection criteria; 116 patients (77 percent) completed all follow-up (average, 309 days). Two patients had 20/40 vision or worse at the end of follow-up. One hundred ten patients (71 percent) underwent surgery; 96 underwent acute repair (<3 weeks) and 11 underwent delayed repair (median, 49 days). Three patients required reoperation, two for plate infection and one for hyperglobus, with an overall complication rate of 4.7 percent. The authors analyzed the largest series of operative pediatric orbital fractures to propose criteria for surgical intervention. There are four potential indications: (1) rectus muscle entrapment; (2) early enophthalmos; (3) central-gaze diplopia or extraocular movement restriction after the resolution of swelling; and (4) loss of orbital support likely to produce secondary changes in globe position and/or binocular stereo vision. In our series, application of these principles offered excellent long-term aesthetic and ophthalmic outcomes with an acceptably low complication profile. Therapeutic, III.

Total pancreatectomy for pancreatic cancer

to determine the indications and to evaluate early and long-term outcomes of total pancreatectomy for pancreatic cancer. Treatment of 29 patients who underwent one- and two-stage pancreatectomy for different malignancies was analyzed. Median of surgery duration and intraoperative blood loss was 280 min and 2200 ml respectively. Postoperative complications were observed in 9 (31%) patients. There were 2 (6.9%) deaths. 1- and 3-year overall actual survival was 61% and 16% respectively in case of ductal adenocarcinoma. Median was 18 months. Patients after surgery for primary multiple lesion (cancer of pancreatic body-tail and major duodenal papilla), pancreatic metastases of renal cancer, mucinous cystadenoma and neuroendocrine cancer are still alive. Follow-up periods are 4, 49, 49 and 65 months respectively. Total pancreatectomy is difficult intervention followed by severe metabolic disorders. However it can improve long-term survival with acceptable incidence of postoperative complications and quality of life if clear indications for surgery are present.

Surgical and Nonsurgical Treatment Produced Similar Outcomes for Proximal Humeral Fractures.

Rangan A, Handoll H, Brealey S, Jefferson L, Keding A, Martin BC, Goodchild L, Chuang LH, Hewitt C, Torgerson D; PROFHER Trial Collaborators. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015 Mar 10;313(10):1037-47. ### Question: In patients with displaced proximal humeral fractures involving the surgical neck, does surgical treatment result in better patient-reported outcomes than nonsurgical treatment? ### Design: Randomized (allocation concealed), blinded (data analysts), controlled trial with 2 years of follow-up. ### Setting: 32 acute care hospitals in the United Kingdom. ### Patients: 250 patients (mean age, 66 years; 77% women) who had sustained an acute displaced proximal humeral fracture involving the surgical neck in the past 3 weeks were enrolled. Exclusion criteria included shoulder joint dislocation, open fracture, clear indications for surgery, comorbid conditions precluding surgery or anesthesia, and patient refusal to be randomized to treatment. 215 patients (86%) completed the study. ### Intervention: Patients were allocated to surgery, which involved either internal fixation (plate and screws) that preserved the humeral head or humeral head replacement (hemiarthroplasty) according to surgeon preference (n = 125), or to nonsurgical treatment, which …