Early Surgical Management Research Articles

Descending necrotizing mediastinitis after a trigger point injection.

Descending necrotizing mediastinitis (DNM) is a rare form of mediastinal infection. Most cases are associated with esophageal rupture. DNM after a trigger point injection in the upper trapezius has not been described previously. We present a case of DNM after a trigger point injection in the upper trapezius. A 70-year-old man visited the emergency department with chest discomfort and fever after a trigger point injection in the left upper trapezius. Chest computed tomography showed evidence of DNM, and antibiotic therapy was immediately administered intravenously. Because of the risk of sudden death, poor prognosis due to underlying disease, and his age, he declined surgical treatment and died of septic shock. Although trigger point injections are generally considered safe, caution should be used in patients with an underlying disease or in the elderly. Early diagnosis, broad-spectrum antibiotics, and aggressive surgical management are essential to improve the prognosis.

Leverage of an Existing Cervical Cancer Prevention Service Platform to Initiate Breast Cancer Control Services in Zambia: Experiences and Early Outcomes

PurposeIn 2005, the Cervical Cancer Prevention Program in Zambia (CCPPZ) was implemented and has since provided cervical cancer screen-and-treat services to more than 500,000 women. By leveraging the successes and experiences of the CCPPZ, we intended to build capacity for the early detection and surgical treatment of breast cancer.MethodsOur initiative sought to build capacity for breast cancer care through the (1) formation of a breast cancer advocacy alliance to raise awareness, (2) creation of resource-appropriate breast cancer care training curricula for mid- and high-level providers, and (3) implementation of early detection and treatment capacity within two major health care facilities.ResultsSix months after the completion of the initiative, the following outcomes were documented: Breast health education and clinical breast examination (CBE) services were successfully integrated into the service platforms of four CCPPZ clinics. Two new breast diagnostic centers were opened, which provided access to breast ultrasound, ultrasound-guided core needle biopsy, and needle aspiration. Breast health education and CBE were provided to 1,955 clients, 167 of whom were evaluated at the two diagnostic centers; 55 of those evaluated underwent core-needle biopsy, of which 17 were diagnosed with invasive cancer. Newly trained surgeons performed six sentinel lymph node mappings, eight sentinel lymph node dissections, and 10 breast conservation surgeries (lumpectomies).ConclusionThis initiative successfully established clinical services in Zambia that are critical for the early detection and surgical management of breast cancer.

Trends in PROMIS scores following various lateral ankle ligament reconstruction techniques

Complicated appendicitis is common in children, yet the timing of surgical management remains controversial. Some support initial antibiotics with delayed operation whereas others support immediate operation. While a few randomized trials have evaluated this question, they have been small, single-center trials with limited follow-up. We present a database analysis of outcomes in early versus late surgical management of complicated appendicitis with one-year follow-up.We conducted a retrospective review of children with complicated appendicitis presenting between 2000 and 2013, utilizing a New York State database. We compare children undergoing later versus early appendectomy with a primary outcome measure of any complication within one year as determined from ICD-9 codes.8840 children were included in the analysis, 7708 of whom underwent early appendectomy. Patients with late appendectomy were significantly more likely to have at least one complication when compared to those undergoing early appendectomy (34.6% vs 26.7%, p < 0.01).We present the first population-level study evaluating early versus late appendectomy in children with complicated appendicitis with a one-year follow-up period. Children undergoing late appendectomy were more likely to have a complication than those undergoing early appendectomy. These data corroborated previous studies supporting early operative management.This study provides level III evidence of a treatment study.

Origins and consequences of congenital heart defects affecting the right ventricle.

Congenital heart disease is a major health issue, accounting for a third of all congenital defects. Improved early surgical management has led to a growing population of adults with congenital heart disease, including patients with defects affecting the right ventricle, which are often classified as severe. Defects affecting the right ventricle often cause right ventricular volume or pressure overload and affected patients are at high risk for complications such as heart failure and sudden death. Recent insights into the developmental mechanisms and distinct developmental origins of the left ventricle, right ventricle, and the outflow tract have shed light on the common features and distinct problems arising in specific defects. Here, we provide a comprehensive overview of the current knowledge on the development into the normal and congenitally malformed right heart and the clinical consequences of several congenital heart defects affecting the right ventricle.

Management of a high thoracic chance fracture.

Chance fracture of the high thoracic spine is rare, and its impact on the adjacent cervical spine can be important. We present the case of a 16-year-old male, who fell down from a 2m height, in an unknown context as he has a mental retardation, and no witness saw the accident. Initial CT scan revealed a comminuted depressed fracture of the right parietal bone, associated with a chance fracture at the level of T3 with a kyphosis and bilateral lung contusion. The patient underwent neurosurgical treatment for elevation and reconstruction of the parietal fracture; he also underwent, 2days later, a posterior spinal correction and fusion with T1-to-T5 instrumentation. The patient returned to normal walking on day 7 with a satisfactory clinical and radiological result at 1year. Literature is sparse on the treatment of high thoracic chance fractures. The current case shows that early surgical management should prevent a secondary kyphotic deformity that may need a more aggressive treatment at a later stage.

Efficacy of holmium laser enucleation of the prostate (HoLEP) in men with bladder outlet obstruction (BOO) and non-neurogenic bladder dysfunction

We aimed to compare the short-term outcomes of men who had urodynamic evidence of detrusor underactivity (DU) or detrusor overactivity (DO) of a non-neurogenic etiology as well as bladder outlet obstruction (BOO) and who underwent Holmium Laser Enucleation of the prostate (HoLEP). A database of 322 patients who underwent HoLEP between 2010 and 2014 was analyzed. Patients were classified into three groups according to the results of a preoperative urodynamic study. Preoperative parameters such as International Prostate Symptom Score (IPSS), Quality of Life (QoL) index, IPSS grade, uroflowmetry were compared with postoperative parameters measured at 6 months. There were 138 patients with BOO-only and 89 patients with BOO and detrusor dysfunction including 56 with DO and 33 with DU. The degree of improvement in IPSS-total (BOO: 10.7, DO: 8.3, DU: 7.0; p = 0.023) was greater in the BOO-only group than in the DU group. There were more patients whose IPSS grade improved in the BOO-only group (71%) than in the detrusor dysfunction group (DO: 53.6% and DU: 45.5%). Postoperative IPSS-voiding (4.5 vs 7.0), and Qmax (18 vs 13.7) in the BOO-only group were significantly better than those in the DU group. Additionally, postoperative IPSS-storage (4.7 vs 6.7), and IPSS-total (9.1 vs 12.3) in the BOO-only group were significantly better than in the DO group (all p < 0.05). In conclusion, early surgical management for men with severe LUTS and associated BPH before secondary degeneration occurs may be beneficial for preserving detrusor function and yield better treatment outcomes.

Spectrum of neonatal surgical emergency- a study in rural area tertiary care center of western U.P

Introduction: Neonatal Intestinal obstruction is commonest surgical cause in emergency, in which rapid intervention is required to prevent undesirable side effect of obstruction that includes death. This study provides spectrum of intestinal obstruction in neonates and sex prediction. Material and Method: This is prospective study done in neonates with feature of intestinal obstruction attending emergency and outdoor of Pediatrics Surgery, Pediatrics Medicine and General Surgery of U.P.U.M.S , Saifai, Etawah during period of January 2016–December 2016. Result: During the study period of one year total 44 patents admitted to our side with features of neonatal obstruction in which male female ratio was 3.8:1. Out of these 44 neonates Anorectal malformation was found in 61.36% neonates, Hirschsprung’s Disease in 9.09%, Duodenal obstruction in 6.81%, Hernia of umbilical cord in 4.54%, Atresia in 4.54, Congenital peritoneal band in 2.27%, Meconium obstruction in 2.27%, Malrotation in 2.27%, Meckel’s band obstruction in 2.27%, Ileal knotting in 2.27%, Idiopathic hypertrophic pyloric stenosis (IHPS) in 2.27%. Conclusion: Early identification and surgical management in neonatal intestinal obstruction decrease morbidity and motilities in neonates. Reason of male sex predominance is not known, it may be due to less attention towards female child by social custom in our society.

A Unique Presentation of an Accessory Cavitated Uterine Mass: A Case Report [33G

INTRODUCTION: An accessory cavitated uterine mass (ACUM) is defined as an isolated mass lined by functional endometrium and encapsulated by smooth muscle. The typical clinical presentation is age less than 30 years old, severe dysmenorrhea, and chronic pelvic pain. ACUM is considered to be a rare diagnosis. However, this pathology may be less rare and more commonly misdiagnosed than originally believed. METHODS: The clinical case was analyzed and followed with a literature review. RESULTS: The patient is a 28-year-old G2P1011 who presented with shortness of breath and abdominal distention. Imaging revealed a 15 cm x 13.9 cm x 14.7 cm complex pre-sacral mass, severe ascites, and pleural effusion. Her pre-operative diagnosis was Meigs syndrome. Final surgical pathology of the mass confirmed it to be an ACUM. Post-operatively, there was complete resolution of the ascites and pleural effusion. CONCLUSION: A high index of suspicion for ACUM followed by early surgical management is imperative for proper diagnosis and management. Pleural effusion and ascites may be clinical indications of ACUM and should lower one's threshold to consider ACUM on the differential diagnosis.

Spontaneous Regression of a Gigantic Cardiac Rhabdomyoma

A fetal echocardiogram was performed at 37 weeks of gestation in a primi-gravida on detection of a cardiac mass in an obstetric ultrasound scan. A single homogeneous, hyper-echogenic 37×32mm cardiac mass in the interventricular septal region spilling into ventricular cavities was noted (Figure 1A). The echocardiographic examination of valves, chambers and other cardiovascular structures did not reveal any other abnormality. There was no family history suggestive of tuberous sclerosis. The family received counselling regarding a multidisciplinary team approach and the need for early surgical management.

Diagnostic post-natal d’un volvulus gastrique révélant une hernie diaphragmatique congénitale

Postnatally diagnosed congenital diaphragmatic hernias (CDH) are rare and have a better prognosis than those diagnosed prenatally. Postnatal symptoms can be respiratory, digestive, or mixed. Gastric volvulus can reveal CDH. Symptoms are pain, abdominal distension, and/or vomiting. Upper gastrointestinal barium X-ray radiography provides the diagnosis. Prognosis is related to early surgical management in complicated forms with intestinal occlusion or sub-occlusion. We report on an infant who presented with vomiting, which revealed gastric volvulus associated with a CDH. Progression was favorable after surgical treatment.

Early Diagnosis and Surgical Treatment for Necrotizing Fasciitis: A Multicenter Study.

Necrotizing fasciitis (NF) is a group of relatively rare infections, usually caused by two or more pathogens. It affects the skin and subcutaneous tissues of lower and upper limbs, perineal area (Fournier's gangrene), and the abdominal wall. Early diagnosis and aggressive surgical management are of high significance for the management of this potentially lethal disease. We conducted a retrospective study in patients who presented, during the last decade, at four University Surgical Departments in the area of Athens, Greece, with an admission diagnosis of NF. Demographic, clinical, and laboratory data were gathered, and the preoperative and surgical treatment, as well as the postoperative treatment was analyzed for these patients. A total of 62 patients were included in the study. The mean age of patients was 63.7 (47 male patients). Advanced age (over 65 years) (P < 0.01) and female sex (P = 0.04) correlated significantly with mortality. Perineum was the mostly infected site (46.8%), followed by the lower limbs (35.5%), the upper limbs, and the axillary region (8.1%). Diabetes mellitus was the most common coexisting disease (40.3%), followed by hypertension (25.8%) and obesity (17.7%). The most common symptom was local pain and tenderness (90.3%). Septic shock occurred in eight patients (12.9%) and strongly correlated with mortality (P < 0.01). Laboratory data were used to calculate the LRINEC score of every patient retrospectively; 26 patients (41.9%) had LRINEC score under 6, 20 patients (32.3%) had LRINEC score 6-8, and 16 patients (25.8%) had LRINEC score >9. Surgical debridement was performed in all patients (mean number of repeated debridement 4.8), and in 16 cases (25.8%) the infected limb was amputated. The mean length of hospital stay was 19.7 days, and the overall mortality rate of our series was 17.7%. Diagnosis of NF requires high suspect among clinicians, as its clinical image is non-specific. Laboratory tests can depict the severity of the disease; therefore, they must be carefully evaluated. Urgent surgical debridement is the mainstay of treatment in all patients; the need of repetitive surgical debridement is undisputed.

Erectile Dysfunction Secondary to a Posttraumatic Corpus Cavernosum-Spongiosum Fistula Treated by a Cellular Matrix Interposition

Traumatic urethrocavernous fistula may develop as an acute or late complication after blunt penile trauma, however reports on corpus spongiosum-cavernosum fistula have rarely been described. We report the case of a 24- year-old man with a corpus cavernosum-spongiosum fistula secondary to an untreated penile fracture, and it surgical management with acellular matrix graft. Penile fractures are urologic emergencies that, if not handled opportunely, can lead to serious sequels, early surgical management should be the treatment of choice. The appearance of a post-traumatic cavernospongous fistula is a rare complication with almost non-existent literature reported. However, ignorance of this pathology can significantly compromise the patient's quality of life.

Antioxidants in experimental ischemia-reperfusion injury of the testis: Where are we heading towards?

Testicular torsion (TT) is a medical emergency that primary affects newborns and young adolescents. It causes testicular injury due to the torsion of the spermatic cord and its components, initially in the venous blood flow and finally in the arterial blood flow. Prompt diagnosis and early surgical management are necessary in managing this urgent situation. The process of the pathophysiological events in ischemia-reperfusion is multifactorial and deals with the perception of the oxidative stress responsible for the consequences of ischemia/reperfusion (I/R) stress following TT. Duration and severity of torsion also play a significant role in the oxidative stress. A detrimental result of the defense system of the testes takes place resulting finally in testicular atrophy and impaired function. Antioxidant factors have been experimentally studied in an effort to front this state. They have been classified as endogenous or exogenous antioxidants. Endogenous antioxidants comprise a structure of enzymic enzymatic and non-enzymic enzymatic particles presented within cytoplasm and numerous other subunits in the cells. Exogenous antioxidants include a variety of natural and pharmaceutical agents that may prevent or ameliorate the harmful effects of I/R injury. In this study we review those factors and their ability to enhance the oxidative status of the testis. A feature insight into where we are heading is attempted.

Successful Outcome of Spontaneously Conceived Heterotopic Pregnancy masquerading Ovarian Torsion

ABSTRACT Aim To sensitize clinicians regarding possibility of heterotopic pregnancy even in spontaneous conceptions. Background Though heterotopic pregnancy is a rare condition, its incidence is rising, which varies from one in 8,000 to 30,000, more in assisted reproductive technique conceptions. It is being commonly misdiagnosed. Here, we present a case of heterotopic pregnancy after spontaneous conception, diagnosis of which was confused with ovarian torsion. Case Report A 31-year-old second gravid para one with one living issue at 12 week 6 day period of gestation presented to emergency with acute-onset pain in right lower abdomen for 3 days. On examination, an ovarian tumor with ascitis with probable torsion was suspected along with intrauterine pregnancy. These findings were further supported by similar ultrasound picture. Patient was taken up for laparotomy. Intraoperative finding was suggestive of heterotopic pregnancy with ruptured left tubal ectopic pregnancy. Left salpingectomy was done with minimal uterine manipulation. Histopathology showed blood clots, hyalinized villi, and acute inflammatory cell infiltrate suggestive of ectopic pregnancy. Ultrasonography (USG) done in the postoperative period showed viable intrauterine pregnancy. The patient is currently following with us and is in her second trimester of pregnancy. Conclusion Heterotopic pregnancy is a diagnostic and therapeutic challenge; a high index of suspicion is required. It is important for clinicians to see adnexal in detail even if intrauterine pregnancy has been seen clearly during USG, especially in high-risk cases. Clinical significance Heterotopic pregnancies can occur even in the absence of high-risk factors. In patients with intrauterine pregnancy, who present with adnexal mass with free fluid in abdomen, clinicians should keep their mind open for possible diagnosis of heterotopic pregnancy. Early diagnosis and surgical management will decrease maternal morbidity and increase chances of survival of intrauterine pregnancy. How to cite this article Vatsa R, Meena J, Kumar S, Zangmo R, Bharti J, Roy KK. Successful Outcome of Spontaneously Conceived Heterotopic Pregnancy masquerading Ovarian Torsion. J South Asian Feder Obst Gynae 2017;9(1):60-62.

Untreated Craniostenosis causing severe Mental retardation with X-ray skull showing Silver beaten appearance skull on: Role of physician in early diagnosis and surgical Management

Untreated Craniostenosis causing severe Mental retardation with X-ray skull showing Silver beaten appearance skull on: Role of physician in early diagnosis and surgical Management

Herlyn—Werner—Wunderlich Syndrome: Premenarche

ABSTRACT Aim To increase awareness about this rare condition in order to aid early diagnosis and effective treatment which can eventually prevent complications and infertility issues in the future. Materials and methods A case of a 10 year old pre-menarchal girl, who presented with this syndrome, was managed surgically. After this, a literature search was done and similar case reports were reviewed. Results The Herlyn-Werner-Wunderlich syndrome (HWW) is a rare Müllerian anomaly with an incidence of 0.1-3.8%. It is characterised by uterus didelphys with obstructed hemivagina and ipsilateral renal agenesis. This condition can be treated with surgery. Since delay in diagnosis may lead to complications, early diagnosis and treatment is beneficial. When Müllerian anomalies are encountered, a screening should also be made for congenital renal abnormalities and vice versa. This condition usually presents postmenarche with abdominal pain due to hematocolpos or dysmenorrhoea. However, there are rare occasions when this condition can present even before menarche. Conclusion The clinical presentation of HWW syndrome requires a high index of clinical suspicion. Though computed tomography or ultrasound can be used to confirm the diagnosis, magnetic resonance imaging is considered to be the preferred imaging modality. Early diagnosis and surgical management is important in order to prevent complications like retrograde tubal reflux, leading to endometriosis and infertility. How to cite this article David A, Gudi SN, Shankar R. Herlyn— Werner—Wunderlich Syndrome: Premenarche. J South Asian Feder Obst Gynae 2017;9(2):207-210.

Surgical vs Non-Surgical Management of Pleural Empyema: A Meta-Analysis

Purpose: There is currently no consensus on the optimal treatment regimen for pleural empyema, with surgical decortication attracting interest due to recent advances in video-assisted thoracoscopic surgery (VATS). Some centres advocate early decortication, whilst others continue to prefer a trial of chest tube drainage (CTD) prior to surgical intervention. This meta-analysis sought to assess the evidence regarding non-surgical vs early surgical options. Methodology: Electronic searches were performed using six databases from their inception to July 2015, identifying all relevant randomised controlled trials (RCT) that compared a surgical versus a non-surgical method of pleural empyema management. Results: Eight RCTs with 391 participants were included. Six of these focussed on paediatric population and two on adults, with seven comparing CTD to VATS decortication, whilst one paediatric trial compared CTD to open decortication. The study (n = 30) comparing open decortication to CTD reported no deaths in either arm, but showed a reduction in length of hospital stay (9.5 vs 15.4 p < 0.05), and less procedural complications (p = < 0.05). In the seven studies (n = 361) comparing VATS decortication versus CTD, there were one mortality in each group, and a reduction in length of hospital stay (mean difference -2.52 p < 0.05). There was no statistically significant difference in procedural complications rate. Conclusions: Our findings suggest early surgical management of pleural empyema may reduce length of hospital stay when compared to CTD, without an increased risk of procedural complications. However, these were based on a limited number of studies and sample size. Future RCTs with larger sample sizes are required to validate our findings.

Single-Stage Combined Craniofacial Repair for Frontoethmoidal Meningoencephalocele.

Frontoethmoidal meningoencephalocele (FMEC) is a rare congenital anomaly characterized by herniation of brain tissue and meninges through a defect in the cranium and associated with facial dysmorphism. Treatment modalities include extra cranial, transcranial, or combined craniofacial approaches. The combined approach is considered the best treatment choice. Twelve patients with FMEC aging from 6 months to 4 years were treated by single-stage combined craniofacial approach between July 2011 and July 2015. They were followed up for evaluation of outcome and detection of complications. Seven patients (58.3%) were males and 5 patients (41.7%) were females. Eight patients (66.7%) were less than 2 years while 4 patients (33.3%) were between 2 and 4 years. The main presentations were external mass, telecanthus and hypertelorbitism, radiologically, frontobasal bone defect and herniated dural sac with brain tissue were detected in all patients. Excision of the mass with dural repair, craniofacial reconstruction, and medial canthopexy were done for all patients. Orbital translocation was done for 8 patients (75%), nasal reconstruction for 7 patients (58.3%), while dacryocystorhinostomy in 3 patients (25%). Venticuloperitoneal shunt was done before correction of FMEC in one patient (8.3%). The follow-up period ranged from 6 to 48 months with mean 29.2 months. The esthetic results were satisfactory in 9 patients (75%). Ugly facial scars were recorded in 3 patients (25%). Early surgical management for FMEC is advisable to avoid deleterious effects on facial growth. Meticulous perioperative care is important for successful surgery. The authors recommend combined craniofacial approach to achieve good outcome and decrease the incidence of complications.

Primary exploration for radial nerve palsy associated with unstable closed humeral shaft fracture.

The treatment of radial nerve palsy caused by closed humeral shaft fracture is a matter of debate. The purpose of this study is to evaluate the outcome of early surgical management of radial nerve palsy in patients with unstable closed humeral shaft fractures and to determine whether patients with this injury should be surgically explored. Medical records of 15 consecutive patients who had undergone open reduction and internal fixation for unstable closed humeral shaft fractures were reviewed. Injury mechanisms, radiographs, intraoperative findings of the injured nerve, and clinical improvement were analyzed. Of the 15 patients, two were injured during simple falls, two during baseball pitching, one by a fall from a height, one during skiing, and one by direct machine impaction during work. Fracture locations were middle humerus in six patients, middle-distal in eight patients, and middle-proximal in one patient. Fracture patterns were transverse fracture in six patients, butterfly segment fracture in four patients, oblique segment fracture in three patients, and spiral fracture in two patients. Eleven patients showed macroscopically intact nerves, and four had total nerve transection. All four patients with total nerve transection were injured in traffic accident. Of these four patients, one showed comminuted fracture with butterfly fragment on the middle-distal shaft and the other three showed displaced transverse fracture on the middle to middle-distal shaft area. Transected nerves were directly repaired in two patients. In the other two patients, humerus shortening and nerve grafting were performed because of mangled nerve endings. All patients who had intact nerves showed fully recovered function at the last follow-up. For radial nerve palsy accompanied by unstable humeral shaft fracture, primary exploration of the radial nerve and open reduction and plate fixation of the fracture should be considered as a treatment of choice. High-energy trauma, fracture location at the middle-distal humerus, and simple transverse fracture or comminuted fracture with butterfly fragment seems to be risk factors for radial nerve transection.

Surgically Correctable Congenital Fetal Anomalies: Ultrasound Diagnosis and Management

ABSTRACT A great number of lifelong disabilities are due to congenital malformations. Evolution of prenatal ultrasound diagnosis and improvement of surgical technique have enabled us to detect most of these malformations in utero early and accurately with a possibility of early surgical management in selected cases even in utero. Advances in pre-/perinatal management have enabled us to interfere and change the origin of the disease in order to optimize the best postsurgical outcome. Only a multidisciplinary team of specialists could provide such appropriate treatment. How to cite this article Zaputović S, Medić N. Surgically Correctable Congenital Fetal Anomalies: Ultrasound Diagnosis and Management. Donald School J Ultrasound Obstet Gynecol 2016;10(3):338-349.