Current Surgical Management Research Articles

Congenital infundibulopelvic stenosis: Indications for intervention, surgical technique, and review of literature

Congenital infundibulopelvic stenosis (IFPS) is a rare renal dysmorphism marked by dilated calyces proximal to diminutive infundibulum and renal pelvises. The entity is theorized to exist on the spectrum of congenital obstructive renal diseases between ureteropelvic junction obstruction and multicystic dysplasia. This case series sought to review and present the surgical management of three cases of IFPS with progressive renal insufficiency. After Institute Review Board approval, we reviewed three cases of IFPS treated by a single surgeon over a 20-year period. All cases displayed evidence of progressive renal decline. The first case of a 16-year-old female had IFPS in a solitary kidney, with previous contralateral nephrectomy of a multicystic dysplastic kidney. The second case, a 17-year-old male, presented after blunt trauma to the ipsilateral flank. The third case of a 10-year-old female presented with microhematuria, mild azotemia and bilateral IFPS. Our current surgical management has evolved from renal sinus exposure and multiple infundibuloplasties in the first case to preoperative three-dimensional mapping of the dilated calyceal system with intraoperative ultrasonography for selective calicocalicostomies draining to a lower pole ureterocalicostomy in the third case. Our first case, treated with multiple infundibuloplasties experienced slow renal decline into her 20s, and the later cases, treated with calicocalicostomies, have experienced stable to mild loss of renal function with ongoing nephrological follow-up. IFPS is a complex pediatric urology problem without a clear treatment algorithm. The goal of surgical intervention is to offer an opportunity to halt or reduce progressive renal insufficiency. Our current surgical approach utilizes preoperative three-dimensional modeling via magnetic resonance urography to guide placement of multiple calicocalicostomies draining to a lower pole ureterocalicostomy. Not all cases of IFPS require surgical intervention. We have intervened in cases of IFPS with progressive hydronephrosis or worsening renal insufficiency with acceptable results.

Survey on Current Postnatal Surgical Management of Myelomeningocele in Germany.

Background and Study Aims Although postnatal surgery can be regarded as the standard of care for open myelomeningocele (MMC), there is no uniform treatment for this condition in Germany. This study assessed the current situation regarding the management of open MMC, a first and essential step toward the development of standards of practice. Patients and Methods In the second half of 2009, we had sent standardized questionnaires to 139 neurosurgery departments and 73 pediatric surgery departments (number of returned questionnaires: 98 and 62, respectively) to identify the principles of MMC management. Newborns with open MMC are treated in 57 of the neurosurgery departments and in 18 of the pediatric surgery departments. Results Overall, 41 of the 57 neurosurgery departments and 16 of the 18 pediatric surgery departments providing care for newborns with MMC perform MMC closure within 24 hours of delivery. In 52 neurosurgery departments and 15 pediatric surgery departments, infants with spina bifida are delivered by planned cesarean section. The diagnostic investigations performed between the time of caesarean delivery and plastic surgical closure vary from none to magnetic resonance imaging of the spine. The criteria underlying the placement of shunts and the time to plastic surgical closure are highly variable. Conclusions The type of treatment that infants with open MMC receive in Germany differs from institution to institution. Clear and consistent guidelines must be established using an interdisciplinary approach to improve treatment and standardize the care provided by surgical specialists for infants with MMC.

Article Commentary: Surgical Management of the Axilla in Breast Cancer

This article offers a review of the literature on current surgical management of the axilla in breast cancer. This includes the decision-making process involved in clinically node-negative patients versus clinically node-positive patients, with discussion of the indications for sentinel lymph node biopsy versus axillary dissection. It also examines the surgical axillary management of patients who receive neoadjuvant chemotherapy. This article will help update practicing surgeons on the evolving research and guidelines for the management of breast cancer axillary disease.

Negative EBUS-TBNA Predicts Very Low Prevalence of Mediastinal Disease in Staging of Non-Small Cell Lung Cancer.

Confirmation of mediastinal disease (N2/3) in non-small cell lung cancer (NSCLC) generally precludes curative surgical management. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become a routine first test in mediastinal staging of NSCLC; however, it remains unclear whether a negative EBUS-TBNA should be followed by mediastinoscopy before proceeding to surgery. Understanding the prevalence of metastases in lymph nodes with benign findings on EBUS-TBNA will inform decision making following negative EBUS-TBNA. We examined a retrospective cohort of patients who underwent EBUS-TBNA before resection with mediastinal lymph node sampling for NSCLC between December 2009 and June 2014 in 3 hospitals in Melbourne, Australia. All patients had integrated positron emission tomography/computed tomography (PET/CT) before EBUS-TBNA. Eighty-two matched mediastinal lymph node stations were sampled in 57 patients by both EBUS-TBNA and surgical resection, 47 nodes in patients staged cN0/1 by PET/CT and 35 nodes in patients staged cN2/3. All patients had a negative EBUS-TBNA. Four malignant nodes were identified surgically (4.9% of lymph nodes). The mean size of malignant deposits was 5.5 mm. Per-node negative predictive value was 78/82=0.95. All malignant nodes were located in patients with moderate-high risk disease (cN2/3), giving a disease prevalence in cN2/3 patients of 11%, and 0% in cN0/1. In patients staged cN2, per-node NVP was 0.89. The prevalence of mediastinal nodal disease following negative EBUS-TBNA is very low, at 4.9%. The per-node NVP of EBUS-TBNA is 0.95, decreasing to 0.89 in moderate-high risk patients. We suggest that a negative EBUS-TBNA of mediastinal nodes does not need to be confirmed by mediastinoscopy of those nodal stations, regardless of PET/CT findings.

Herbal remedies against gastric cancer in experimental rats

Gastric cancer is the fourth most prevalent cancer worldwide, which claims more than 700,000 lives every year. However, the current chemical and surgical management of this mortal cancer remains far from successful. A recent safe approach to preventing or treating tumorigenesis has been the re-introduction of traditional herbal medicine, taking advantage of efficient, yet natural healthy products. In this review, we have focused on a number of such popular agents, mostly introduced by the Traditional Chinese medicine (TCM), which have exhibited highly significant preventive/therapeutic effects against various gastric pathologies, ranging from gastritis to premalignant lesions and confirmed malignancies, in experimental rats. The underlying mechanisms of action seem to concentrate on shifting the balance between in vivo oxidant and anti-oxidant activities. In addition, the existing reports on the potential toxicity of these compounds, as well as their interactions with chemical drugs, have been presented. However, far more details are required to recommend herbal medicine as an effective and reliable plan of action in gastric cancer management.

Current and Future Perspectives in Craniosynostosis.

Craniosynostosis has a varied clinical spectrum, ranging from isolated single suture involvement to multi-sutural fusions. Greater understanding of the pathogenesis of craniosynostosis has led to the development of practical treatment protocols. Three stages of growth have determined the approach to managing craniosynostosis : the early period, up to 12 months; the intermediate period, from 1 to 10 years; and the late period, beginning at 10 years. This review discusses current surgical management and future perspectives in craniosynostosis.

Review of the current surgical management of vulval cancer

Review of the current surgical management of vulval cancer

An Innovative Surgical Management of Complicated Bile Duct Variant in Emergency Living Donor Adult Liver Transplantation: Initial Experience

Background: The incidence of biliary complications after living donor adult liver transplantation (LDALT) is still high due to the dile duct variation and necessity reconstruction of multiple small bile ducts. The current surgical management of the biliary variants is unsatisfactory. We evaluated the role of a new surgical approach in a complicated hilar bile duct variant (Nakamura type IV and Nakamura type II) under emergent right lobe LDALT for high MELD score patients. Methods: The common hepatic duct (CHD) and the LHD of the donor were transected in a right-graft including short common trunks with right posterior and anterior bile ducts, whereas the LHD of the donor was anastomosed to the CHD and the common trunks of a right-graft bile duct and the recipient CHD was end-to-end anastomosed. Results: Ten of 13 grafts (Nakamura types II, III, and IV) had two or more biliary orifices after right graft lobectomy; seven patients had biliary complications (53.8%). Later, the surgical innovation was carried out in five donors with variant bile duct (Four Nakamura type IV and one type II), and, consequently, no biliary or other complications were observed in donors and recipients during 47-53 months of follow-up, significant differences (P<0.05) were found when two stages were compared. Conclusions: Our initial experience suggests that, in the urgent condition of LDALT when an alternative live donor was unavailable, a surgical innovation of cutting part of the CHD trunks including variant RHDs in a complicated donor bile duct variant may facilitate biliary reconstruction and reduce long-term biliary complications.

Current Surgical Management of Carotid Body Tumors

Carotid body tumors (CBT) are rare, and vascular surgeons are frequently involved in their care. Current guidelines for management are varied and may include genetic testing consisting of identification of succinate dehydrogenase (SDH) gene mutations. We performed a review of the surgical management of CBT at our institution to evaluate current outcomes and genetic testing impact. A retrospective analysis of all surgically treated CBTs at our institution was performed on all patients who underwent surgical excision of a CBT from 1996 to 2015. Data were obtained regarding preoperative demographics, intraoperative details, postoperative morbidity, and long-term outcomes. A total of 199 CBT were excised from 183 patients (122 female [66.6%]). A total of 113 patients (56.8%) presented with a neck mass, and 44 patients (22.1%) presented with tenderness or neck pain. Four patients (2%) had dysphagia on presentation, and three patients (1.5%) had cranial nerve dysfunction, CT (118 patients [59.3%]) or MRI (104 patients [52.2%]) were the most commonly used imaging modalities. Ultrasound was used in the diagnosis of 55 (27.6%) tumors. A total of 81 patients (40.7%) underwent preoperative angiography, and 68 of these patients (83.9%) underwent angiographic intervention consisting of embolization and/or internal carotid artery balloon occlusion testing. Mean tumor diameter on preoperative imaging was 3.15 cm (range, 0.4-7.2 cm). There were 81 (40.7%), 77 (38.7%), and 41 (20.6%) Shamblin type 1, 2, and 3 tumors, respectively. Average operating time was 222 minutes (range, 52-696 minutes). Average operative blood loss was 138 mL (range, 10-2000 mL). A total of 30 patients (15.1%) underwent arterial ligation, most commonly the external carotid artery. Arterial reconstruction with an interposition graft was required in 11 patients (5.5%), which consisted of saphenous vein (n = 7) or Dacron (n = 4). Patch angioplasty was performed in 4 cases (2%) with bovine pericardium used in 3 (1.5%) and Dacron used in 1 (0.5%). A total of 110 patients (55%) underwent concurrent lymph node excision (415 total nodes excised), and all were found to be benign. There were no deaths ≤30 days. A total of 37 patients (20.2%) had a family history of carotid body tumors. A total of 18 of 19 patients (9%) had genetic testing positive for a SDH mutation. Positive genetic testing for SDH mutations had a statistically significant correlation with positive family history of CBT (P < .0001), earlier age of presentation (P < .0001), symptomatic presentation of CBT (P < .0001), and postoperative complications after CBT excision (P < .0001). Mean age at diagnosis of patients with SDH mutations was 38.8 years, whereas patients without SDH mutations presented at a mean age of 51.3 years. In patients with SDH mutations, mean tumor diameter, average operating time, average operative blood loss, and distribution of Shamblin type 1, 2, and 3 lesions were not significantly different from patients without SDH mutations. Carotid body tumors can be treated with minimal morbidity and mortality; however, the subgroup of patients with positive SDH mutations may represent a variant group of younger patients with greater postoperative morbidity. Vascular surgeons should be aware of genetic testing to identify patients who may be at greater risk of operative morbidity. Concomitant lymph node excision does not appear to add value in the absence of clinic suspicion for malignancy.

Current Surgical Management of Pediatric Idiopathic Constipation: A Systematic Review of Published Studies.

Surgery for pediatric idiopathic constipation (IC) is undertaken after failure of bowel management programs. Decisions are influenced by rectal biopsy, transit studies, megacolon/megarectum, degree of soiling/incontinence, and anorectal manometry profile(s). A systematic review of ALL published studies critically evaluates outcomes of surgery for IC. MEDLINE (PubMed), Google Scholar, and EMBase were searched for English-language articles only. Studies included (1) peer-review publications with 3 or more patients, and (2) clinical outcomes defined by authors. Forty-five reports (1157 patients) met full inclusion criteria. Only 2 papers were randomized controlled trials. Many had small patient numbers (median n = 16; range: 3-114). Twenty-three described heterogenous populations with variant pathology. Follow-up was short (median = 1.5 years: range: 3 months-14 years). The antegrade continence enema operation (ACE)-[open/laparoscopic assisted, cecostomy, or "left sided" ACE]-was judged as successful in 82% of cases, although high morbidity and reoperations were reported. Colon resection and pull through operations had "good" outcome(s) in 79% of children with 17% reporting significant morbidity and a 10% incidence of revisional surgery. Anal dilatation did not improve outcome(s). Botulinum toxin injection scored equally effective compared to internal sphincter myectomy in short-term follow-up. Permanent colostomy was considered successful in 86% of refractory IC cases. Surgical management and outcome(s) for pediatric IC are based on low-quality evidence. No single operation was considered "best practice." This study crucially highlights that surgeons must develop better care strategies.

Current Surgical Management of Empyema Thoracis in Children: A Single-center Experience

Empyema is a morbid complication of pneumonia in children, whose gold standard of surgical treatment technique remains undefined. Historically, treatment consisted of open thoracotomy with decortication. We evaluate the effectiveness and safety of video-assisted thoracoscopic surgery (VATS) as a surgical treatment in for empyema thoracis in a pediatric population at a single institution from 2005 to 2013. After receiving Institutional Review Board approval, we performed a retrospective chart review of children surgically treated for empyema as a complication of pneumonia from 2005 to 2013. Charts were reviewed for the type of procedure performed (VATS or open thoracotomy), comorbid conditions, preoperative status, operative outcomes, and postoperative status. A total of 112 pediatric patients were treated surgically for empyema. Surgical treatment consisted of VATS in all cases; no open thoracotomy procedures were performed. The success rate of VATS in our study was 96.4 per cent. Mean total length of stay was found to be 8.8 days, whereas postoperative length of stay was 6.3 days. Mean postoperative chest tube duration was 3.4 days. Perioperative complication rate was 11.6 per cent, with respiratory failure being the most common complication. The data from our study demonstrate that the exclusive use of VATS in children for the surgical management of all stages of empyema was safe and produced results with high efficacy. We consider VATS to be the new gold standard for surgical drainage of empyema.

Current surgical management of macroglossia.

To discuss the current surgical management of macroglossia. Traditional surgical management of severe macroglossia has been with anterior wedge or keyhole resection. Long-term follow-up has been limited, and only recently have assessments been done regarding functional and aesthetic outcomes. New methods including double stellate and combination approaches have shown promise, though with limited case size reports. Addressing macroglossia in three dimensions may be the most effective way of achieving positive positional, speech and aesthetic outcomes, but comparative studies are lacking. Other causes of macroglossia, such as vascular malformations, can be managed with less aggressive measures such as laser and radio-frequency ablation. The aggressiveness of the management should match the severity of the symptoms. The anterior wedge resection and modified keyhole incisions are the most well studied operative strategies. Short and long-term outcome data are limited, and neither method is definitively superior. Less aggressive measures are options for less severe macroglossia. Surgical management of macroglossia should be tailored to each individual patient and in accordance to surgeon experience and expertise.

Current trends in the surgical management and treatment of adult glioblastoma.

This manuscript discusses the current surgical management of glioblastoma. This paper highlights the common pathophysiology attributes of glioblastoma, surgical options for diagnosis/treatment, current thoughts of extent of resection (EOR) of tumor, and post-operative (neo)adjuvant treatment. Glioblastoma is not a disease that can be cured with surgery alone, however safely performed maximal surgical resection is shown to significantly increase progression free and overall survival while maximizing quality of life. Upon invariable tumor recurrence, re-resection also is shown to impact survival in a select group of patients. As adjuvant therapy continues to improve survival, the role of surgical resection in the treatment of glioblastoma looks to be further defined.

Current surgical management of intestinal rotational abnormalities.

At present, there is a debate as to the management of malrotation in pediatric patients. This review highlights recent literature including the role of laparoscopy, and the management of asymptomatic patients with and without congenital cardiac disease. Symptomatic patients are still recommended to undergo open Ladd's procedure. Laparoscopic Ladd's procedure in asymptomatic patients confers a shorter time to tolerating feeds, shorter length of stay, and a decreased rate of bowel obstruction and other complications. It may, however, carry a higher risk of postoperative volvulus. Diagnostic laparoscopy is recommended in asymptomatic patients in whom the diagnosis is uncertain on upper gastrointestinal imaging. Asymptomatic patients with congenital heart disease may be managed with initial observation or operation, based upon individualized risk benefit assessment. If an elective Ladd's procedure is performed, it should take place after palliative cardiac operations have resulted in stable cardiac function. Screening upper gastrointestinal studies in heterotaxy patients may be unnecessary as the reported rates of volvulus in recent studies are low. Laparoscopic Ladd's procedure may be an acceptable alternative to an open procedure for asymptomatic patients. Observation of asymptomatic patients with congenital cardiac disease is a reasonable alternative in selected patients.

Surgical management for early-stage bilateral breast cancer patients in China.

BackgroundThe aim of this study was to investigate the current surgical management strategy for bilateral breast cancer (BBC) patients and to assess the changes in this strategy in China.MethodsThis is a retrospective review of all patients with early-stage BBC who underwent surgical treatment at the Fudan University Shanghai Cancer Center between June 2007 and June 2014.ResultsA total of 15,337 patients with primary breast cancer were identified. Of these patients, 218 (1.5%) suffered from synchronous bilateral breast cancer (sBBC), and 296 (2.0%) suffered from metachronous bilateral breast cancer (mBBC). Patients with a lobular carcinoma component, those with estrogen receptor-positive cancer, and those with an accompanying sclerosing adenosis in the affected breast tended to develop BBC. The rates of bilateral mastectomy, breast conserving therapy, reconstruction, and combined surgeries were 86.2%, 6.4%, 3.7%, and 3.7%, respectively, for patients with sBBC and 81.1%, 4.4%, 3.0%, and 11.5%, respectively, for patients with mBBC. The interval between bilateral cancers, age at first diagnosis of breast cancer, histopathological type, and stage have significant impacts on the choice of surgery for patients with BBC.ConclusionsBilateral mastectomy was the dominant surgical management for patients with BBC in China, despite the increased application of breast reconstruction surgery observed in recent years. Bilateral prosthetic breast reconstruction was the ideal choice for patients with sBBC. Chinese surgeons should take responsibility for patient education and inform their patients about their surgical options.

Validation of a grading system for complicated diverticulitis in the prediction of need for operative or percutaneous intervention.

The current surgical management of acute complicated diverticulitis has seen a major paradigm shift from routine operative intervention to a more conservative approach. This has been made possible by the widespread availability of computed tomography (CT) to enable stratification of the disease severity of acute complicated diverticulitis. The aim of this study was to retrospectively validate a CT grading system for acute complicated diverticulitis in the prediction of the need for operative or percutaneous intervention. Hospital and radiology records were reviewed to identify patients with acute complicated diverticulitis confirmed by CT. A consultant gastrointestinal radiologist, blinded to the clinical outcomes of patients, assigned a score according to the CT grading system. Three hundred and sixty-seven patients (34.6%) had CT performed for acute diverticulitis during the study period. Forty-four patients (12.0%) had acute complicated diverticulitis (abscess and/or free intraperitoneal air) confirmed on CT. There were 22 women (50%) and the overall median age was 59 years (range: 19-92 years). According to the CT findings, there was one case with grade 1, eighteen patients with grade 2, four with grade 3 and twenty-one with grade 4 diverticulitis. Three patients with grade 2, three patients with grade 3 and ten patients with grade 4 disease underwent acute radiological or surgical intervention. The use of a CT grading system for acute complicated diverticulitis did not predict the need for acute radiological or operative intervention in this small study. Decision making guided by the patient's clinical condition still retains a primary role in the management of acute complicated diverticulitis.

Current surgical management of penile cancer

Penectomy for PC is useful in staging, disease prognosis, and treatment. Limited studies have evaluated its surgical complications. We sought to assess these complications and determine predictive models to create a novel risk score for penectomy complications.A retrospective review of patients undergoing PC surgical management from the 2005-2016 American College of Surgeons National Surgical Quality Improvement Program was performed. Data were queried for partial and total penectomy among those with PC. To develop predictive models of complications, we fit LASSO logistic, random forest, and stepwise logistic models to training data using cross-validation, demographic, comorbidity, laboratory, and wound characteristics as candidate predictors. Each model was evaluated on the test data using receiver operating characteristic curves. A novel risk score was created by rounding coefficients from the LASSO logistic model.A total of 304 cases met the inclusion criteria. Overall incidence of penectomy complications was 19.7%, where urinary tract infection (3.0%), superficial surgical site infection (3.0%), and bleeding requiring transfusion (3.9%) were most common. LASSO logistic, random forest, and stepwise logistic models for predicting complications had area under the curve (AUC) [95% confidence interval] values of 0.66 [0.52-0.81], 0.73 [0.63-0.83], and 0.59 [0.45-0.74], respectively. Eleven variables were included in the risk score. The LASSO model–derived risk score had moderately good performance (area under the curve [95% confidence interval] 0.74 [0.66-0.82]). Using a cutoff point of 6, the score attains sensitivity 0.58, specificity 0.74, and kappa 0.26.PC management through penectomy is associated with appreciable complications rates. Predictive models of penectomy complications performed moderately well. Our novel prognostic risk score may allow for improved preoperative counseling and risk stratification of men undergoing surgical management of PC.

Congenital Adrenal Hyperplasia: Current Surgical Management at Academic Medical Centers in the United States

Controversy exists on the necessity for and timing of genitoplasty in girls with congenital adrenal hyperplasia. Our knowledge of surgical preferences is limited to retrospective series from single institutions and physician surveys, which suggest a high rate of early reconstruction. We evaluated current surgical treatment for congenital adrenal hyperplasia at academic centers. We queried the Faculty Practice Solutions Center database to identify all female patients younger than 18 years with a diagnosis of congenital adrenal hyperplasia between 2009 and 2012. Procedures were identified by CPT codes for vaginoplasty, clitoroplasty and other genital procedures. Reconstruction type, age at surgery and surgeon volume were analyzed. We identified 2,614 females in the database with a diagnosis of congenital adrenal hyperplasia who were seen at a total of 60 institutions. Of infants younger than 12 months between 2009 and 2011 as few as 18% proceeded to surgery within a 1 to 4-year followup. Of those referred to a pediatric urologist 46% proceeded to surgery. Of patients who underwent surgery before age 2 years clitoroplasty and vaginoplasty were performed in 73% and 89%, respectively, while 68% were treated with a combined procedure. A medium or high volume surgeon was involved in 63% of cases. Many patients with congenital adrenal hyperplasia in the database did not proceed to early reconstructive surgery. Of those referred to surgeons, who were possibly the most virilized patients, about half proceeded to early surgery and almost all underwent vaginoplasty as a component of surgery. Abouttwo-thirds of the procedures were performed by medium or high volume surgeons, indicative of the surgical centralization of disorders of sexual development.

50 Years Ago in TheJournal ofPediatrics: Spontaneous Closure of Ventricular Septal Defect Following Cardiac Failure in Infancy

50 Years Ago in TheJournal ofPediatrics: Spontaneous Closure of Ventricular Septal Defect Following Cardiac Failure in Infancy

Progressive design concepts in off-pump left ventricular remodeling mitral valve repair devices.

Functional mitral regurgitation (FMR) occurs in the myopathic ventricle when papillary muscle displacement with leaflet tethering and/or annular dilatation causes valvular insufficiency. The resultant left ventricular (LV) volume overload then potentiates further negative remodeling. Current surgical management of FMR involves either mitral valve repair (MVr) or mitral valve replacement (MVR), each of which are associated with significant perioperative risk and poor late outcomes. This has led to the development of novel methods of reshaping the left ventricle and mitral valve to treat FMR while minimizing the operative risk and preventing negative ventricular remodeling. While off-pump devices for mitral leaflet repair including percutaneous mitral clips, trans-apical neochordae and percutaneous mitral replacement devices are under investigation, this report reviews the current status of both passive and active off-pump ventricular and mitral annular reshaping devices.