Early Surgical Management Research Articles

Fracture penis: An interesting case report

Penile fracture remains a rare, yet likely underreported condition. Fracture of the penis is a tear in the tunica albuginea of the corpora cavernosa that may be associated with injury to the corpus spongiosum and urethra. Diagnosis is usually clinical, and urethral injury should be suspected in the penile fracture, especially in those cases with bilateral cavernosal rupture. The usual cause is abrupt bending of the erect penis by blunt trauma most commonly during sexual intercourse. A crackling sound, pain, detumescence, bruising, swelling, and bleeding per urethra are the common symptoms reported by the patients. Early surgical management is the treatment of choice with a low incidence of complications. We report a case of fracture penis in a 35-year-old male came to the emergency out-patient department of our hospital.

Early surgical management in patients with benign enlargement of prostate with economical constraints

Early surgical management in patients with benign enlargement of prostate with economical constraints

A clinical study on occurrence of diverse wounds at head and neck region of camels (Camelus dromedarius)

The study was conducted on 61 clinical cases of diverse wounds of head and neck region in camels on the basis of their etiology. Highest occurrence was recorded for lacerated nostril (16.40%) followed by lacerated wound of eyelid (13.11%), penetrating wounds at forehead (11.48%), maggot wounds at nostril (11.48%), ulcerative wounds at nostril (9.84%), soft palate injury (8.20%), sub-mandibular abscess (8.20%), penetrating wound at eyeball (6.56%), maggot wound at eye (3.28%), penetrating wound at buccal cavity (1.22%), firing wound at neck (1.22%), supraorbito-buccal fistula (1.64%), conjunctivitis (1.64%), keratorrhexis (1.64%) and lacerated wound at gingiva and lower lip (1.64%). In animals of present study, the early clinical healing was observed in cases where planned surgery was done, especially in cases of penetrating wound of soft palate, buccal cavity, gingiva, lower lip, eyeball, cornea, lacerated nostrils, and eyelids. Careful clinical judgment, early surgical management with gentle handling of tissue, aqua therapy or thorough wound irrigation, effective topical medication and sufficient rest brought quick and better recovery in clinical wounds in the camels.

Surgical management of congenital scoliosis

Objective The aim of this study was to assess outcomes and complications in patients surgically treated for congenital scoliosis. Background Congenital scoliosis due to hemivertebra and unsegmented bar is most often progressive and requires surgical treatment. The recommended surgical options include 'in-situ' fusion, convex hemiepiphysiodesis, and hemivertebra excision. Patients and methods This study included 20 patients (six boys and 14 girls). The age at operation was between 4 and 18 years. Two techniques were used: the anterior procedure and the posterior procedure. The anterior procedure involves thoracotomy and the thoracoabdominal approach. In this procedure disc excision above and below the level of the anomaly was performed and the segment of the vertebral column (hemivertebra, segment of unsegmented bar) that would be excised was determined. In the posterior procedure, posterior correction, fixation, decortications, and grafting were performed. Fixation was carried out using claw, sublaminar wires, pedicular screws, and rods. Results 'In-situ' fusion does not address the anomaly directly; it allows a moderate correction rate but is associated with long spinal fusion. Hemivertebral resection directly addresses the spinal anomaly; it produces the best correction results and is a safe procedure to perform. The average angle after posterior correction and fusion of congenital scoliosis was 37.5΀ (range from 15 to 60΀). The percentage of correction was 55% (range from 20 to 90%). The early postoperative correction following the staged combined anterior and posterior correction, and fusion was 60%, ranging from 40 to 80΀. Conclusion The treatment of congenital scoliosis focuses on early diagnosis and appropriate surgical management before the development of large curves. All of the procedures described can be effective and safely performed if correctly selected and performed by an experienced team of surgeons.

Molecular enhancement of sentinel node evaluation

Lymphatic mapping and sentinel node biopsy are widely used to stage and manage patients with intermediate and thicker primary cutaneous melanoma. Likelihood of sentinel node metastases can be estimated from patients’ demography and primary tumor characteristics, but is precisely determined only by microscopic evaluation of excised node(s). Molecular/Genetic techniques, such as RT-PCR, Gene Expression Microarray, detection of metastasis-associated gene signatures and gene sequencing are likely to increase precision in future. Recent 10 year results of Multicenter Selective Lymphadenectomy Trial 1 (MSLT1) [1] confirm that biopsy-based management prolongs disease free survival for all node-positive patients (P=0.01-0.03) and significantly increases 10 year distant disease-free survival (P=0.006) and melanoma-specific survival (P=0.02) for node-positive patients with intermediate thickness primaries. The trial also confirmed very clearly that the presence or absence of sentinel node metastases is best determined by close pathological evaluation of sections from nodal tissues, stained conventionally and by immunohistochemistry (S-100 protein, Mart-1, HMB-45). Patients with sentinel node metastases have a significantly unfavorable outcome that correlates with the amount and disposition of nodal tumor as assessed by microscopy, immunohistochemistry and morphometry [2]. Here again precision will be increased by the parallel application of molecular and genetic tests. The accuracy of appropriate patient assignment to early surgical management will be dramatically increased by the addition of molecular testing, more precisely identifying the patients most likely to respond to standard and evolving therapies

Pediatric encephaloceles: A series of 20 cases over a period of 3 years.

Background:Encephalocele is the protrusion of the cranial contents beyond the normal confines of the skull through a defect in the calvarium and is far less common than spinal dysraphism. The exact worldwide frequency is not known.Aims and Objectives:To determine the epidemiological features, patterns of encephalocele, and its postsurgical results.Materials and Methods:The study was carried from year July 2012 to June 2015. Patients with encephalocele were evaluated for epidemiological characteristics, clinical features, imaging characteristics, and surgical results.Results:20 encephaloceles patients were treated during the study period. Out of these 12 (60%) were male and 8 (40%) female. Age range was 1 day to 6 years. The most common type of encephalocele was occipital 12 (60%), occipito-cervical 4 (20%), parietal 2 (10%), fronto-nasal 1 (5%), and fronto-naso-ethmoidal 1 (5%). One patient had a double encephalocele (one atretic and other was occipital) with dermal sinus tract and limited dermal myeloschisis. Other associations: Chiari 3 malformation (2), meningomyeloceles (4), and syrinx (4). Three patients presented with rupture two of whom succumbed to meningitis and shock. Seventeen patients treated surgically did well with no immediate surgical mortality (except a case of Chiari 3 malformation who succumbed 6 months postsurgery to unrelated causes). Shunt was performed in 4 cases.Conclusion:The most common type of encephalocele is occipital in our set up. Early surgical management of encephalocele is not only for cosmetic reasons but also to prevent tethering, rupture, and future neurological deficits.

Surgical outcomes for perforated peptic ulcer: A prospective case series at an academic hospital in Monrovia, Liberia

Introduction The incidence of perforated peptic ulcer remains high in low and middle-income countries. Mortality can be significant, and early surgical management with careful evaluation of pre-operative risk factors is essential. The purpose of this study was to describe the clinical outcomes of surgical treatment for perforated peptic ulcer disease in Liberia and to explore risk factors for adverse outcomes. Methods This study prospectively examined 20 consecutive patients undergoing primary closure with omental patch for perforated pre-pyloric or duodenal peptic ulcer at the John F. Kennedy Medical Centre (JFKMC) in Monrovia, Liberia from May 2009 to March 2010. Pre-operative information was captured in a questionnaire. Risk factors were assessed for univariate and multivariate associations with in-hospital mortality. Results Median age was 33years and 85% were males. A majority of the patients (70%) had a history of gastritis and antacid use. Median time from beginning of symptoms to surgery was 4.5days. Over-all in-hospital mortality following surgical therapy for perforated peptic ulcer disease was 35%. Median length of stay among survivors was 16days, and death occurred at median 1day after admission. Long symptom duration and age >30years of age were significantly associated with in-hospital mortality on univariate ( β =2.60 [0.18–5.03], p =0.035) and multivariate testing ( β =2.95 [0.02–5.88], p =0.049). Conclusion Peptic ulcer disease and its treatment represent a potentially substantial source of morbidity and mortality in limited-resource settings. In this case series, surgical treatment for perforated peptic ulcer disease carried a high mortality, and the results highlight the potential for public health systems strengthening to prevent poor health outcomes. Peptic ulcer disease in low- and middle-income countries presents unique epidemiology and treatment challenges that may differ significantly from evidence-based guidelines in high-income countries.

FRACTURE DE VERGE : RESULTATS DE LA PRISE EN CHARGE AU NIVEAU DE LA REGION DE THIES

Introduction: The aim of this study was to evaluate the clinical and therapeutic aspects of penile fracture at the Thies region. Patients and Methods: This is a retrospective study of 13 patients treated between January 2005 and December 2012 at the St. Jean de Dieu Hospital and Regional Thies Hospital. This study included all patients with a recent or neglected fracture at these two structures. Results: during the period, we have received 13 cases of penis fracture. Among them, one patient had a neglected fracture of the penis of 7 days. The average age of our patients was 32 years, ranging from 18 years to 48 years. Regarding the occurrence mechanism, the "faux pas" coital was found in 8 patients. The average time of consultation was 2 days. The triad acute pain, rapid detumescence and swelling of the penis was observed in all patients. Two patients had urethral bleeding. One patient had received a Doppler ultrasound that allowed to objectify hematoma and rupture of the tunica sitting in the proximal third of the penis. One patient had a neglected fracture of the penis lasting for 7 days. In all our patients the surgical approach was coronal. Two patients had a lesion associated corpus spongiosum and urethra. The average hospital stay was 13 hours. The postoperative period was simple. Patients were followed for a period of 2 years. Conclusion: the penile fracture is a urological emergency requiring taking early and appropriate surgical management. keywords: penile, fracture, clinical, surgery.

Journey to chew: A case of maxillary duplication and bony syngnathia

Tessier no 3 cleft, bony syngnathia, and maxillary duplication are rare as independent anomalies and have never been reported together in a single case. Here we present a patient with congenital bony syngnathia, maxillary duplication, and a Tessier no. 3 nasal cleft. Other abnormalities included situs inversus, dextrocardia, coarctation of the aorta, left choanal stenosis, left coloboma, and hypertelorbitism. Given the unique presentation, we present our early surgical management to this complex problem.

Invasive Gastric Mucormycosis-a Case Report.

Mucormycosis is an opportunistic fungal infection that is associated with high mortality in immunocompromised individuals. While rhinocerebral and pulmonary forms are most common, primary gastrointestinal mucormycosis is very uncommon. The stomach is the most commonly affected organ followed by the colon and ileum in alimentary zygomycosis. We report a rare case of invasive gastric mucormycosis in a 50-year-old diabetic gentleman with a history of chronic alcoholism presenting with complaints of pain and distension of the abdomen for 6days associated with fever, nausea, vomiting and anorexia. At presentation, he was hemodynamically unstable, febrile with uncontrolled blood sugar level and had negative HIV serology. There was generalized guarding, rigidity and distension of the abdomen and investigations confirmed perforative peritonitis. Upon exploration, there was solitary large 4 × 4cm size perforated ulcer in the gastric body with greenish, greyish sloughed out mucosa within. Wedge resection of the ulcer with primary closure was performed. Histopathology revealed aseptate, broad, obtuse angled fungal hyphae, and invasive mucormycosis was confirmed by special stains like Periodic acid-Schiff (PAS) and Gomori's methenamine silver (GMS). Very few cases of invasive gastric mucormycosis associated with uncontrolled diabetes and alcoholism have been reported in the literature. Delayed presentation of the patient along with rapid progression to fungal septicaemia resulted in the case fatality despite early surgical intervention and critical care management.

Superficial siderosis of the central nervous system secondary to spinal ependymoma

Superficial siderosis of the central nervous system is a syndrome caused by deposition of hemosiderin in the subpial layers of the central nervous system, occurring as a result of recurrent asymptomatic or symptomatic bleeding into the subarachnoid space. We report a rare case of superficial siderosis in a 33-year-old man who presented with sensorineural hearing loss. The diagnosis of superficial siderosis on MRI brain studies led to further investigations with detection of a spinal ependymoma at L1–L2, compressing the cauda equina. Gross total resection of the tumor arrested the progression of the neurological deterioration. Our report underlies the importance of early diagnosis and surgical management, with imaging examination of the full neuroaxis to identify the source of bleeding, to halt disease progression and improve prognosis.

Is early surgical management of chylothorax following oesophagectomy beneficial?: Table 1:

A best evidence topic in surgery was written according to a structured protocol. The question addressed was whether the initial surgical management of chylothorax after oesophagectomy results in a better outcome. Altogether 357 papers were found as a result of the reported search, of which 4 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Three studies were retrospective and from single centres with small patient numbers, while one study was a prospective, randomized controlled trial, from which a subgroup analysis was included in our results. We conclude that although all studies to date have had very small patient numbers and some contradictory results, there is some evidence that early surgical intervention of chylothorax following oesophagectomy reduces hospital stay when compared with conservative treatment.

Successful management of hepatic mucormycosis in an acute lymphoblastic leukaemia patient: a case report and review of the literature

We present a case of hepatic mucormycosis in a 9-year-old boy with acute lymphoblastic leukaemia. Despite long-term use of combined liposomal amphotericin B and posaconazole therapy, the lesion persisted and could only be treated by surgical excision. After surgery, antifungal treatment was continued with posaconazole. On follow-up, the patient had two episodes of ascending cholangitis which were responsive to intravenous antibiotics. He is doing well at the moment in remission for 2.5 years. Mucormycosis was long regarded as a fatal infection with poor prognosis. With early medical and surgical management, survival rates increase. Isolated hepatic mucormycosis is rare and only seven cases were reported in the literature up to now. We wanted to emphasise the role of early surgery in patients with hepatic mucormycosis in view of the literature.

English

BACKGROUND: Ovarian torsion presents as acute abdominal pain and early surgical management is required to prevent further adnexal damage. It accounts for 3% of all cases of acute abdominal pain in adult women. As signs and symptoms can mimic other acute abdominal conditions, the preoperative diagnosis often remains a challenge for primary care physicians. AIMS AND OBJECTIVES: To study the characteristics of adnexal torsion and factors influencing adnexal preservation. MATERIAL AND METHODS: All 14 patients were admitted in a tertiary endoscopic surgical unit with the complaints of pain in abdomen, nausea and vomiting of varying duration. The minimum duration of symptoms was 3 days and a maximum of 1 year. All patients were evaluated by ultrasound examination preoperatively. The time interval between the onset of symptoms and definitive surgery varied from 3 days to one year. Laparoscopic approach was offered to all patients except one where the patient was antenatal at 10 weeks of gestation. RESULTS: Out of 14 patients the youngest patient was a neonate 28 days old and oldest was 68 years of age. Most patients (n=9) were between 10 to 30 years of age. Intra operatively complete torsion (torsion of both ovary and fallopian tube) was found in 9 cases, 3 were torsion of hydrosalpinx and one case was torsion of a paraovarian cyst. One case was torsion of the adnexa in antenatal period. Adnexal congestion and edema was the most common finding (n=6) simulating hemorrhagic cyst. One patient the oldest in series age 68 years had torsion of an ovarian mass which was histologically confirmed as mucinous cystadenoma. Two patients had ovarian dermoid where ovary was salvaged in one by doing cystectomy and in the other a salpingoophorectomy was performed. In one patient it was torsion of parovarian cyst where cyst wall excision was performed. In antenatal at 11 weeks gestation a mini laparotomy was performed under epidural analgesia and detorsion was performed. In all 4 patients who had hydrosalpinx (n=3) and parovarian cyst (n=1), a salpingectomy and cyst excision was performed respectively. In rest with complete torsion (n=9, excluding fetal adnexal torsion) ovarian preservation was possible in 4 patients (44.45%) and 5 patients (55.55%) required oophorectomy. CONCLUSION: Adnexal torsion affects all ages of women and ovarian preservation is possible, if detorsion is possible. Delay in diagnosis prevents ovarian preservation. Though limited by small sample size it indicated that ovarian debulking may not be needed and detorsion relieves the venous congestion and edema. Laparoscopic approach remains the gold standard for the management of adnexal torsion and enables quick recovery.

Evaluation of Unilateral Vocal Fold Immobility

Unilateral vocal fold immobility (UFVI) is a highly variable clinical entity that may be neurogenic or mechanical in origin. Patients with UVFI have varying degrees of voice, swallowing, and airway disturbance. The patient should be carefully evaluated, including thorough history, head, neck, and neurologic examination, and laryngoscopy, to determine the etiology of UFVI and the current level of laryngeal function. If the etiology cannot be determined, cross sectional imaging of the skull base through the mediastinum is recommended to evaluate the underlying cause. Laryngeal electromyography is most useful for predicting poor functional recovery and may affect the decision to proceed with early definitive surgical management. Formal swallowing testing is indicated for patients with dysphagia to identify aspiration.

Delayed/non‐union of upper limb fractures with bisphosphonates: systematic review and recommendations

Bisphosphonates (BPs) are widely used for the treatment of osteoporosis. Oversuppression of bone turnover with BPs may paradoxically limit the reserve capacity of bone to heal. The aim of this review was to study the predisposition of some patients to delayed/non-union of upper limb fractures associated with BPs and give recommendations on how they should be treated. A systematic search of two electronic databases was conducted to identify relevant studies for inclusion. All relevant studies found were included and assessed through methodology criteria predetermined by two independent reviewers. Six papers comprising of three case reports, one nested case control study, one restrospective review and one randomized clinical trial were used. In comparative studies of pre-fracture BP use, a 6-day delay in average healing times was reported among BP users. There was no elevation in risk of non-union. Post-fracture BP use was associated with an approximate doubling of the risk of non-union. Timing of BP therapy initiation following a fracture was not associated with a difference in healing times. An atypical ulna fracture treated conservatively resulted in non-union, there was no effect of type of surgical treatment on distal radius fracture healing and there was insufficient evidence to comment on humeral fracture treatment. Differences in union time between BP users and non-users are not significant enough to change current practice patterns and do not outweigh the benefits of BP therapy. There is no evidence to encourage early surgical management of BP-related upper limb fractures.

Genetics, Diagnosis, and Management of Medullary Thyroid Carcinoma and Pheochromocytoma/Paraganglioma

Medullary thyroid carcinoma (MTC) and pheochromocytoma/paraganglioma (PHEO/PGL) are rare neuroendocrine tumors. Because of the increased metastatic rates in certain genetic backgrounds, early diagnosis and treatment are essential to improved patient outcomes. Our objective was to summarize recent findings related to the genetics, diagnosis, and management of MTC and PHEO/PGL. A literature review was performed. MTC is primarily associated with mutations in the rearranged during transfection (RET) proto-oncogene. Determining the specific genetic mutation can guide patient management and screening. Early detection and appropriate surgical management of MTC is critical to prevent or limit metastatic spread, as treatment options for patients with metastatic disease are limited. PHEO/PGL also has a strong genetic component, with approximately 50% of cases linked to germline and somatic mutations in 15 genes. Although most PHEO/PGLs are benign, factors such as genetic background, size, tumor location, and high methoxytyramine levels are associated with higher rates of metastatic disease. The state-of-the-art diagnosis and localization of PHEO/PGLs is based on measurement of plasma metanephrines and methoxytyramine and functional imaging studies. For both PHEO/PGL and MTC, surgery is the only curative treatment. Treatment options for patients with metastatic disease are limited. As genetic testing becomes more widely available, the diagnosis of MTC and PHEO/PGL will be made earlier due to routine screening of at-risk patients. In addition, continued advances in basic science, diagnostic methods, and imaging techniques will improve understanding of the pathogenesis of these diseases and facilitate the introduction of novel treatment strategies for patients with metastatic disease.

Infective gangrene in extremity trauma-are we targeting the right organisms?

Mucormycosis is a rare and fatal infection that is known to occur in immunocompromised and diabetic patients. The infection is caused by a fungus of the class Zygomycetes. It has been associated with open fractures in patients at risk. We report a case of cutaneous mucormycosis leading to gangrene after a closed fracture. We recommend considering mucormycosis as a differential for wound infections not responding to antibiotics, even in closed injuries. Tissue from surgical debridement should be sent for histopathological and microbiological examination to diagnose the condition early. Early recognition, surgical management, and parenteral antifungal therapy are the mainstay of management of this illness.

Blunt Trauma to the Penis Post Penile Augmentation Surgery: Case Report

Introduction: Blunt trauma to the penis is a rare but potentially serious injury that can occur by various mechanisms (e.g., kicks, accidents, sexual activity, and falls). The most common clinical presentation is sudden pain, swelling, and discoloration. Depending on the type and severity of injury, management can include conservative treatment or surgery, with the ultimate goal being the prevention of delayed complications. Case presentation: A 30-year-old male presented with penile pain, swelling, and redness as a result of blunt trauma to his penis 1 week after penile enhancement surgery using a subcutaneous soft silicone implant. Once the patient’s blood pressure was stabilized, surgical management consisted of exploration with evacuation of a large hematoma and removal of the subcutaneous penile implant to avoid further perioperative and postoperative bleeding. Discussion: Postoperative bleeding is a risk factor associated with almost all types of surgical procedures, and its prevention is best achieved by identification and elimination of potential causes pre- and postoperatively. Hypertension is another risk factor for excessive postsurgical bleeding, particularly bleeding associated with prosthetic implant surgeries, and should be considered for any potential surgical patient. Conclusion: With penile prosthesis and implant surgery, hypertension is an especially serious risk factor. Early surgical management is warranted in cases involving a major hematoma and swelling. Even cases with minimal bleeding should be evaluated in a timely manner, with surgical treatment indicated, rather than watchful waiting, to prevent further damage to the penis.

Management of Intraoral Gunshot Injury – A Case Report

ABSTRACT Oral and Maxillofacial gunshot injuries are usually lethal due to close proximity with the vital structures. The severity of injury varies according to the caliber of the weapon used and to the distance from which the patient is shot. A case of gunshot injury that was successfully managed by surgical exploration and removal of bullet from left maxillary antrum under local anesthesia is presented. The initial care of facial gunshot wounds strictly adheres to the basics of trauma resuscitation. Early and appropriate surgical management have proved to be influential on the final outcome and aesthetic result. Treatment of gunshot injuries should be planned and carried out carefully. It takes different stages and procedures to achieve the targeted treatment plan. Prevention and control of infection are important in the success of the treatment.