Current Surgical Management Research Articles

Current medical and surgical management of Raynaud's syndrome

Raynaud's syndrome (RS) is characterized by episodic digital ischemia induced by cold or emotional stress. Pathophysiologic mechanisms include temporary vasospasm and fixed digital artery obstruction. A number of pharmacologic and invasive therapies have been studied to treat RS symptoms; however, there are no specific treatments that are currently approved by the U.S. Food and Drug Administration specifically for RS. Of the available pharmacologic agents, calcium-channel blockers remain the preferred initial treatment for vasospastic RS, although many vasodilators have been studied and found to be efficacious. Vasodilators are less effective in treating digital artery obstruction, and no treatments have been found to be universally beneficial, although the phosphodiesterase V inhibitors have been gaining in popularity. Invasive therapies may have a role in selective cases. In this review, the current evidence of treatment for RS is summarized.

Cadaver Study to Trace Intramuscular Tendons of the Leg With Application to Muscle Laceration Repair

Current surgical management of muscle tendon lacerations is usually restricted to epimysial repair because of limited understanding of leg tendon anatomy and the retraction of visible tendon ends during repair. Direct tendon repair yields better results. Studies have traced tendons to their intramuscular ends for surgical application in the forearm but not the leg. This study traces the muscle tendons of the leg in relation to the length of the entire leg and creates a practical anatomic guide for surgeons.

Surgical management of chronic thromboembolic pulmonary hypertension

Chronic thromboembolic pulmonary hypertension results from occlusion of the pulmonary vascular bed by non-resolving thromboembolism. This article reviews the pathogenesis, diagnosis and surgical management of chronic thromboembolic pulmonary hypertension with a focus on current literature and surgical management.

Gastrointestinal Complications of Cystic Fibrosis

The cystic fibrosis transmembrane regulator protein (CFTR) is an ion channel in the apical surface of epithelial membranes that regulates other ion channels. Dysfunction of CFTR leads to the clinical entity of CF when mutations in CFTR are inherited in an autosomal recessive fashion. Although airway obstruction, inflammation, and infection are usually the most serious consequences of CFTR dysfunction because they lead to respiratory failure, CFTR dysfunction affects the intestinal tract and the pancreatic and hepatobiliary ducts in a similar fashion, leading to significant morbidity. This review outlines pathophysiology and common gastrointestinal ailments in the CF population along with current medical and surgical management.

The Surgical Treatment of Breast Cancer in the Elderly: A Single Institution Comparative Review of 5235 Patients with 1028 Patients ≥70 years

As the wave of the baby boomers shifts the age demographic of patients, the current surgical management of breast cancer in elderly women (≥70 years of age) becomes relevant because deviation from standard treatment often occurs in this group. The purpose of this study was to determine the operative mortality when treated with standard surgical procedures and to investigate trends in the surgical management of breast cancer in the elderly. A total of 5,235 patients undergoing either mastectomy or breast conservation surgery (BCS) for invasive and ductal carcinoma in situ (DCIS) were identified in a retrospective review of a prospectively accrued data base between the years of 1994 and 2007 at the Moffitt Cancer Center. Of the 5,235 patients, 1,028 (20%) patients were ≥70 years of age. The 30-day and 90-day mortality in the elderly group (age ≥70 years) was 0.2% (95% CI 0.02-0.7%) and 0.7% (95% CI 0.3-1.4%), respectively. The 30-day and 90-day mortality among patients <70 years was 0 and 0.05% (2 of 4,207 patients) (95% CI 0.005-0.2), respectively. BCS rates for invasive carcinomas were the highest for patients between 40 and 70 years of age, whereas the mastectomy rates were higher among patients <40 years of age (53%). Elderly women were as likely as women <40 years to have BCS for invasive carcinoma (OR 1.1, 95% CI 0.8-1.5), but more likely to have BCS for DCIS (OR 1.9, 95% CI 1.1-3.3). Surgical mortality in elderly women treated for breast cancer was extremely low and was related to the extent of surgery performed. Breast cancer treatment differed by age groups.

CSF diversion in refractory idiopathic intracranial hypertension: single-centre experience and review of efficacy

The current surgical management strategies for refractory cases of idiopathic intracranial hypertension (IIH) remain unresolved. We evaluated the outcome of our paediatric patients who were offered a CSF diversion procedure in order to control their symptoms. We retrospectively reviewed the medical notes of the patients under 16 years of age, who presented in our centre from 2005 to 2010, with a confirmed diagnosis of IIH, and ultimately had a lumboperitoneal shunt (LPS). We describe their immediate postoperative course, shunt-related complications and recent outcome. Seven patients presented at a mean age of 8.7 years. Two presented with significant visual loss and had a shunt acutely; the remaining five presented with headaches and were shunted within 2 years. In the immediate postoperative period two patients experienced low-pressure symptoms. All patients required shunt revisions; in total 15 revisions took place, mainly secondary to symptomatic overdrainage or obstruction. After a mean follow-up of 26 months, two patients have diminished visual acuity at least on one side; only one patient became headache-free, despite resolution of the CSF pressure post diversion in four out of the six remaining patients. All patients required shunt revisions and 6/7 (85.7%) had persisting headaches at their last follow-up. It is apparent that once functional, the LPS seems adequate to lower the CSF pressure but not effective in eliminating symptoms.

Surgical Treatment of Carotid In-Stent-Restenosis: Novel Strategy and Current Management

Associated with increasing use of carotid artery stenting (CAS), the occurrence of late complications is likely to rise. The surgical strategies of CAS complications like in-stent-restenosis (ISR) are not yet to be determined. Thus different situations require individual operative techniques. This study contains our experience in the operative management for significant recurrent carotid stenosis following angioplasty and stent placement. As a novel strategy, we report successful stent removal and endarterectomy with eversion technique (ECEA). Four complete stent removals were performed in three patients with three different techniques and anesthesiological protocols (general anesthesia n = 1, regional anesthesia n = 3). First stent removal with excision of common carotid artery (CCA) and internal carotid artery (ICA) following interposition of CCA-ICA with Dacron graft (n = 1). Second carotid endarterectomy with stent removal followed by patch angioplasty (n = 2). Third stent removal and ECEA and thus biological reconstruction without synthetic material (n = 1). Mean operative time was 131 minutes (±19.25). Mean follow-up was 11.5 months (±7.7). As postoperative complications, one major bleeding, one transient neurologic deficit and one postoperative neck hematoma, requiring operative revision, occurred. During a 30-day follow-up, all patients made an uneventful recovery. There was no evidence of restenosis or neurological deficit during the following postoperative controls. A review and comparison of the current surgical management and strategies in the treatment of ISR was also performed (Pubmed). Surgical treatment of ISR after CAS is beneficial but in literature infrequently reported. We could demonstrate in this study that even stent removal and ECEA is feasible and safe with durable outcome. The current strategies are therefore extended as well as the reported performance under regional anesthesia. However, surgical treatment in ISR remains a challenging option and larger series are highly recommended.

Surgical management and follow-up of patients with cervical cancer: Survey of gynaecological oncologists in the UK

We investigated current surgical management and follow-up of women with cervical cancer focusing on treatment of recurrent disease and the use of routine imaging during follow-up among gynaecological oncologists in the UK. A questionnaire including questions regarding perioperative management of primary disease in cervical cancer, follow-up post-treatment, assessment and management of recurrent cervical cancer, was sent to 84 gynaecological oncologists. Some 87% responded. Considerable variations in surgical management and follow-up were identified. With central recurrence of cervical cancer without prior radiotherapy, 90% would recommend radiotherapy instead of an exenteration. For central recurrence in irradiated women, only three (4%) would not recommend an exenteration. In women with pelvic sidewall relapse without prior radiotherapy, 65 responders (96%) would offer radiotherapy, while in pelvic sidewall relapse post-radiation 25 (37%) would recommend pelvic sidewall resection in a specialised centre. A total of 21% used routine imaging during follow-up. The wide variation in clinical practice indicates that there is a need to establish national guidelines for surgical management and follow-up of primary and recurrent cervical cancer.

Current Surgical Management of Bilateral Cleft Lip in North America

This study was undertaken to determine contemporary surgical management of bilateral cleft lip. A survey was sent to North American cleft surgeons. Variables included number of bilateral cleft lip repairs per year, surgical specialty, and methods of nasolabial correction. The authors analyzed possible relationships between surgical specialty/volume and operative techniques. The response rate was 40 percent (241 of 600). Annual bilateral nasolabial repairs per surgeon were as follows: zero to two, 30 percent; three to five, 46 percent; and six or more, 25 percent. For bilateral complete cleft lip, dentofacial orthopedics was used by 71 percent of respondents; synchronous closure was most commonly performed (88 percent); infrequent techniques were preliminary labial adhesions (11 percent) and staged labial closure (1 percent); and 50 percent undertook primary nasal repair. One half of respondents used nostril splinting following primary or secondary nasal correction. For bilateral incomplete cleft lip, 90 percent of surgeons performed synchronous labial repair and 36 percent did primary nasal correction. For both complete and incomplete bilateral cleft lips, high-volume surgeons were more likely to excise prolabial vermilion and use lateral vermilion-mucosal flaps to form the median tubercle. For bilateral asymmetrical cleft lip, 85 percent of surgeons practiced synchronous labial repair and 54 percent used dentofacial orthopedics on the complete side. Synchronous repair was the most frequent method for bilateral cleft lip; one-half of surgeons practiced primary nasal correction. There were no associations between surgical specialty/volume and operative principles or techniques for bilateral nasolabial repair, except for construction of the median tubercle.

Patent Ductus Arteriosus in Premature Neonates

Persistent patency of the ductus arteriosus is a major cause of morbidity and mortality in premature infants. In infants born prior to 28 weeks of gestation, a haemodynamically significant patent ductus arteriosus (PDA) can cause cardiovascular instability, exacerbate respiratory distress syndrome, prolong the need for assisted ventilation and increase the risk of bronchopulmonary dysplasia, intraventricular haemorrhage, renal dysfunction, cerebral palsy and mortality. We review the pathophysiology, clinical features and assessment of haemodynamic significance, and provide a rigorous appraisal of the quality of evidence to support current medical and surgical management of PDA of prematurity. Cyclo-oxygenase inhibitors such as indomethacin and ibuprofen remain the mainstay of medical therapy for PDA, and can be used both for prophylaxis as well as for rescue therapy to achieve PDA closure. Surgical ligation is also effective and is used in infants who do not respond to medical management. Although both medical and surgical treatment have proven efficacy in closing the ductus, both modalities are associated with significant adverse effects. Because the ductus does undergo spontaneous closure in some premature infants, improved and early identification of infants most likely to develop a symptomatic PDA could help in directing treatment to the at-risk infants and allow others to receive expectant management.

Current Surgical Management of Erectile Dysfunction

Since the introduction of PDE5, oral systemic therapy has become the first line of therapy for men with erectile dysfunction (ED). Men who are not candidates for, or who fail treatment with an oral agent may choose second-line therapies such as intraurethral prostaglandins, penile injection therapy, sex therapy, or a vacuum erection device. These second-line therapies may be unpalatable or inadequate for some men, and these constitute the candidates for surgical intervention for ED. This article reviews the surgical management of vascular ED, and surgical management of penile prosthesis implantation. Currently, the appropriate candidate for penile revascularization is a young man with proven arterial insufficiency resulting from pelvic trauma. (JAREM 2011; 1: 61-4)

Primary leiomyosarcoma of gallbladder

Malignant mesenchymalneoplasms of the gallbladder are extremely rare with only 105 cases of primary gallbladder sarcoma having been described. It has a very aggressive behavior and is usually diagnosed at advanced stages. Therefore, curative surgical management may not be possible. We performed a radical cholecystectomy (S4b + S5 segmentectomy), omentectomy and small bowel resection in a 54-year-old patient with locally invasive leiomyosarcoma of the gallbladder. Further studies are needed to confirm the benefit of aggressive treatment for patients with leiomyosarcoma of the gallbladder.

Current Curative Surgical Management of Gallbladder Cancer: A Brief Review

G allbladder cancer has a dismal prognosis, radical surgical resection offers the only chance of cure, but it is possible in only small proportion due to advanced disease and the recurrence is high. The extent of resection depends on the extent of disease. The aim of any therapeutic operation must be the radical removal of the tumor with no residual disease (R0 resection). Crucial for the surgical strategy is the TNM staging and the planning is decided in accordance with the T stage. In T1a simple cholecystectomy is considered as an adequate treatment. In T1b there is a controversy; some advocate simple cholecystectomy and others more extensive radical cholecystectomy. In T2 either extended radical cholecystectomy or resection of liver segments IV b and V . In all cases a radical lymph node dissection along the hepatoduodenal ligament is needed additionally. In T3 either hepatic segmentectomy IV b and V at least or extended right hepatectomy, both combined always with radical lymph node dissection. In T4 usually palliative operation; an extensive en-block resection with removal of included organs is rarely attempted. doi:10.4021/ jcs50w

Does mucosal remodeling in chronic rhinosinusitis result in irreversible mucosal disease?

Mucosal remodeling in the sinuses is a recently described phenomenon in which the mucosa undergoes potentially irreversible changes as a result of ongoing underlying inflammatory processes. Research into remodeling that occurs in the bronchial airways in asthmatic patients has led to modification of asthma treatment guidelines. However, remodeling in the sinuses has still not led to changes in current medical or surgical management of chronic rhinosinusitis. Upper airway remodeling constitutes a new area of research that poses many unanswered clinical questions and may potentially alter the management of patients with severe chronic rhinosinusitis.

Current surgical status of thyroid diseases

Thyroid nodules are a common clinical problem for surgeons. The clinical importance of nodules is the need to exclude thyroid cancer, which occurs in 5%–15% of patients. If fine needle aspiration cytology is positive, or suspicious for malignancy, surgery is recommended. During the past decade, with the tendency to develop smaller incisions, an endoscopic approach has been applied to thyroid surgery, called minimally invasive video-assisted thyroidectomy. This approach was immediately followed by other minimally invasive or scarless neck techniques, such as the breast approach, axillary-breast approach, and robot-assisted method. All these techniques follow the same principles of surgery and oncology. This review presents the current surgical management of the thyroid gland, including the surgical techniques and compares them by describing benefits and drawbacks of each one.

Long-Term Outcome of Comprehensive Central Compartment Dissection in Patients with Recurrent/Persistent Papillary Thyroid Carcinoma

Persistent or recurrent papillary thyroid carcinoma (PTC) occurs in some patients after initial thyroid surgery and often, radioactive iodine treatment. Here, we identify the efficacy, safety, and long-term outcome of our current surgical management paradigm for persistent/recurrent PTC in the central compartment in an interdisciplinary thyroid cancer clinical and research program at a tertiary thyroid cancer referral center. We retrospectively analyzed our standardized approach of comprehensive bilateral level VI/VII lymph node dissection (SND [VI, VII]) for cytologically confirmed PTC in the central compartment. From 1994 to 2004, 210 patients, median age 42 (range 12-82) underwent SND (VI, VII). Most patients (106, 51%) had already undergone ≥2 surgical procedures for persistent or recurrent disease, and 31 (15%) had distant metastases at presentation. Postoperatively, 104 (71%) of the 146 patients who were thyroglobulin (Tg) positive had no evidence of disease. Anti-Tg antibodies were present in 38 patients (18%), 17 of whom (53%) did not have anti-Tg antibodies postoperatively. Fourteen patients (7%) were hypoparathyroid at presentation, and 2 more (1%) became permanently hypoparathyroid after surgery. Four patients (2%) experienced recurrent laryngeal nerve paralysis (RLNP) of a previously functioning nerve. Unanticipated RLNP was observed in only one nerve at risk. External beam radiation was given to 33 patients (17%). An additional 17 patients (8%) developed distant metastases during follow-up. At the last follow-up, 130 (66%) of the 196 patients had no detectable Tg; of these, 99 (76%) had no further evidence of disease. A median of 7.25 years after surgery, 167 (90%) of the 185 patients were without evidence of central disease, and 18 (10%) had developed central compartment recurrences within a median interval of 24.3 months. Of those with recurrence, 16 out of 18 patients (89%) underwent a subsequent surgical procedure, thus resulting in an overall 98% central compartment control rate. Kaplan-Meier disease-specific survival at 10 years was 98.9% for patients <45 years old and 77.9% for those ≥45 years old (log-rank p<0.00001). The only predictor of central compartment recurrence was malignancy in a thyroid remnant noted within the central compartment surgical specimen. Bilateral comprehensive level VI/VII dissections are safe and effective for long-term control of recurrent/persistent PTC in the central lymphatic compartment.

Surgical management of transitional cell carcinoma of the lacrimal sac: Is it time for a new treatment algorithm?

Transitional cell carcinoma (TCC) arising in the lacrimal sac is a rare neoplasm. Despite radical surgery and radiotherapy, these tumors generally have a poor prognosis due to an often late diagnosis, high rate of loco-regional recurrence and mortality. There are only a relatively small number of documented cases of TCC when compared to other epithelial malignancies of the lacrimal drainage system. As would be anticipated, there are currently no evidence-based clinical practice guidelines for the treatment of these lesions. We present an illustrative case and consider the literature in relation to current surgical management of these tumors. We propose an alternate management consideration for these tumors.

Excision of Extensive Midfoot Pigmented Villonodular Synovitis With Microvascular Anastamosis of Iliac Crest Bone Graft Using External Fixation

Pigmented villonodular synovitis (PVNS) is a relatively rare lesion in the foot and ankle, most commonly involving the ankle joint and atypically, the subtalar and midtarsal joints. It is a benign proliferative disease characterized by an increase in villous or nodular synovium in joints. Resection of the tumor is often indicated in most cases because of the potentially aggressive joint destructive nature of this lesion. This report presents a case of chronic enlarging pervasive midtarsal and metatarsal-cuneiform joint PVNS in a 28-year-old male. This patient had a midtarsal mass that enlarged over a period of 2 years, causing increased pain, deformity, and difficulty with ambulation. Cross-sectional imaging studies identified evidence of erosive disease through much of the midfoot articulations, with biopsy confirming the mass as PVNS. The dimensions of the mass approximated 5.5 cm × 4.1 cm × 2.8 cm. Simple resection was problematic because of the size and multiple joints involved. Amputation was most commonly advised by multiple consultants. The patient preferred attempt at limb salvage. En bloc resection and placement of a revascularized iliac crest bone graft was used to fill the defect. The graft was microvascularly anastamosed and fixated with standard external fixation. Pathologic and histologic specimens from surgical biopsy reconfirmed the diagnosis of PVNS postoperatively. Second-stage arthrodesis was performed when the patient was stable and disease free. The patient was followed postoperatively for 10 years without recurrence and was able to return to full function and partake in moderate athletic activity at last visit. This case describes a retrospective review of the procedure and reconstruction, as well as an overview of current surgical management of PVNS.

Pediatric Nasoorbitoethmoid Fractures

The pediatric craniofacial trauma literature largely focuses on the management of mandible fractures, with very little information focusing on pediatric midface fractures, specifically nasoorbitethmoid (NOE) fractures. Because the diagnosis and surgical treatment plan for adult NOE fractures is well established in the literature, the treatment algorithms for NOE are essentially a transfer of adult practices to pediatric patients. This article reviews the differences between the pediatric and adult facial skeleton and the pathology and presentation of NOE fractures in the pediatric craniomaxillofacial skeleton. It also presents the effects of NOE fractures on the growth and development of the pediatric facial skeleton and describes the current surgical management for NOE fractures.

Temporal pattern of left ventricular structural and functional remodeling following reversal of volume overload heart failure

Current surgical management of volume overload-induced heart failure (HF) leads to variable recovery of left ventricular (LV) function despite a return of LV geometry. The mechanisms that prevent restoration of function are unknown but may be related to the timing of intervention and the degree of LV contractile impairment. This study determined whether reduction of aortocaval fistula (ACF)-induced LV volume overload during the compensatory stage of HF results in beneficial LV structural remodeling and restoration of pump function. Rats were subjected to ACF for 4 wk; a subset then received a load-reversal procedure by closing the shunt using a custom-made stent graft approach. Echocardiography or in vivo pressure-volume analysis was used to assess LV morphology and function in sham rats; rats subjected to 4-, 8-, or 15-wk ACF; and rats subjected to 4-wk ACF followed by 4- or 11-wk reversal. Structural and functional changes were correlated to LV collagen content, extracellular matrix (ECM) proteins, and hypertrophic markers. ACF-induced volume overload led to progressive LV chamber dilation and contractile dysfunction. Rats subjected to short-term reversal (4-wk ACF + 4-wk reversal) exhibited improved chamber dimensions (LV diastolic dimension) and LV compliance that were associated with ECM remodeling and normalization of atrial and brain natriuretic peptides. Load-independent parameters indicated LV systolic (preload recruitable stroke work, Ees) and diastolic dysfunction (tau, arterial elastance). These changes were associated with an altered α/β-myosin heavy chain ratio. However, these changes were normalized to sham levels in long-term reversal rats (4-wk ACF + 11-wk reversal). Acute hemodynamic changes following ACF reversal improve LV geometry, but LV dysfunction persists. Gradual restoration of function was related to normalization of eccentric hypertrophy, LV wall stress, and ECM remodeling. These results suggest that mild to moderate LV systolic dysfunction may be an important indicator of the ability of the myocardium to remodel following the reversal of hemodynamic overload.