Extensive Surgical Management Research Articles

Pedunculated Angiomyofibroblastoma of Labia Minora: A Case Report and Review of the Literature

Background: Angiomyofibroblastoma was first described by Fletcher et al. in the year 1992. It is a distinctive benign tumor that most often occurs in the superficial area of the vulva and is rarely reported in men in the inguinoscrotal region. Case Presentation: A 23-year-old female presented with a painless pedunculated labial mass which was initially pea-sized and reached 7 cm in maximum dimension over four months. The case was diagnosed on morphology, IHC and the patient was treated surgically. The interesting feature of the case was the rarity of its incidence at labia minora and pedunculated form and its resemblance to other benign and more aggressive tumours. To the best of our knowledge, the extensive English literature search revealed only seven cases of pedunculated angiomyofibroblastoma at labia majora in middleaged female and one case of labia minora in a young female. Conclusion: The lesion must be differentiated from another benign mesenchymal tumor of vulva which requires extensive surgical management.

Prolonged Inflammatory Reaction to Fractured Calcium Phosphate Cement Cranioplasty Secondary to Sequestration Within the Diploe.

Calcium phosphate cement remains the choice biomaterial for cranial reconstruction and augmentation in pediatric patients after 90% completion of cranial growth, especially compared with other nonallograft alternatives. While trauma to the site of calcium phosphate augmentation is a known risk for cement fracture, subsequent micro-fragmentation and sequestration of the cement beneath the fracture site can produce a localized inflammatory reaction that requires surgical intervention to adequately address. The authors present the course of a patient undergoing a prolonged inflammatory reaction to calcium phosphate micro-fragmentation after trauma to the site of previous augmentation performed to mend bitemporal hollowing. Cement microfragmentation and migration through an associated nondisplaced fracture of the outer table required extensive debridement of the underlying diploe before the resolution was achieved. This case illustrates the need for appropriate evaluation in cases of trauma to areas with cement to mitigate the need for extensive surgical management.

Early treatment of corneal abrasions and ulcers-estimating clinical and economic outcomes.

SummaryBackgroundIn low-and-middle income countries, corneal abrasions and ulcers are common and not always well managed. Previous studies showed better clinical outcomes with early presentation and treatment of minor abrasions, however, there have been no formal studies estimating the financial impact of early treatment of abrasions and ulcers compared to delayed treatment.MethodsWe used the LV Prasad Eye Institute's (LVPEI's) electronic health record system (eyeSmart) to estimate the impact of early presentation on clinical outcomes associated with abrasions and ulcers. 861 patients with corneal abrasion and 1821 patients with corneal ulcers were studied retrospectively, and 134 patients with corneal abrasion prospectively. A health economic model was constructed based on LVPEI cost data for a range of patient scenarios (from early presentation with abrasion to late presentation with ulcer).FindingsOur findings suggest that delayed presentation of corneal abrasion results in poor clinical and economic outcomes due to increased risk of ulceration requiring more extensive surgical management, increasing associated costs to patients and the healthcare system. However, excellent results at low cost can be achieved by treatment of patients with early presentation of abrasions at village level health care centres.InterpretationTreatment of early minor corneal abrasions, particularly using local delivery of treatment, is effective clinically and economically. Future investment in making patients aware of the need to react promptly to corneal abrasions by accessing local healthcare resources (coupled with a campaign to prevent ulcerations occurring) will continue to improve clinical outcomes for patients at low cost and avoid complex and more expensive treatment to preserve sight.FundingThis research was funded by the Medical Research Council, grant MR/S004688/1.

Successful Clinical Remission of Perianal Extramammary Paget Disease with Intralesional IL-2 and Topical Imiquimod Treatment: A Case Report

Extramammary Paget disease is a rare intraepithelial adenocarcinoma that affects mainly in the perianal, genital and axillary regions. While wide local excision remains the gold-standard, not all patients are candidates for extensive surgical management due to metastases, poor baseline function, and patient preference. Herein, we present a case of successful clinical remission in a 63-year-old male with a perianal extramammary Paget disease.

Role of the consultant in restorative dentistry in managing head and neck cancer patients undergoing radiotherapy: a novel intraoral shield appliance design.

Oral cancer incidence is rising, with both the consequences of the disease and sequelae of treatment often having a significant impact on patient oral health and functionality. As a result, the restorative dentist has a key and varied role within the head and neck multidisciplinary team, from dental pre-assessments to complex oral rehabilitations following extensive surgical management. Radiotherapy is a key pillar of head and neck cancer treatment but also presents a particular set of issues for patients and their management by clinicians. Communication between all team members is vital to ensure optimal patient treatment, and ultimately led to the development of two novel intraoral shield appliances for dentate and edentulous patients to help combat some of these undesirable side effects.

Early Mortality in Patients who Received Extensive Surgical Management for Acute Type A Aortic Dissection - Analysis of 452 Consecutive Cases from a Single-center Experience.

Objective To detect the potential risk factors associated with early mortality in patients who received extensive surgical management, in the form of total arch replacement plus frozen elephant trunk and arch debranching (hybrid repair technique), for acute type A aortic dissection.Methods The clinical and surgical data of 452 surgically treated patients with acute type A aortic dissection at our center, between March 2010 and December 2016, have been retrieved. Uni and multivariate logistic regression analyses were carried out to detect the effect of various preoperative demographics and different perioperative variables on early mortality.Results Overall 30-day mortality occurred in 70 out of 452 patients (15.4%). The principal causes of death were multiple organ failure (n=38), cardiac failure (n=18), and severe pulmonary infection (n=10). Risk factors for early mortality were identified with multivariate analysis. Preoperatively, overweight (P<0.025), alcohol drinking (P<0.002), coronary artery disease (P<0.014), hemodynamic shock (P<0.006), and elevated white blood cells count (P<0.002) were associated with higher mortality rate. Postoperatively, prolonged operation time (P<0.008), stroke (P<0.0001), and acute renal dysfunction (P<0.0001) were highly associated with death.ConclusionConsidering the advantages of extensive surgical management for acute type A aortic dissection over the other less aggressive surgical approaches, it should be advised whenever indicated, provided that being carried out by experts in the field of adult aortic surgery in high-volume centers. The surgeon should be aware of the patient’s preoperative comorbidities and other risk factors for early mortality, in particular, prolonged operation time.

Cognitive Linguistic Profile Post Road Traffic Accident

In India the incidence of Road Traffic accidents is reported to be 4,64,910 in 2017 among which 1,47,913 lives were dead and 4,70,975 persons were injured.Road traffic accidents result in various complications which will affect the person’s quality of life. One such complication is cognitive linguistic deficit. This case study is about a young man who has cognitive linguistic deficit which is a result of road traffic accident. The patient exhibited several complex cognitive- linguistic issues during the assessment. This includes reduced semantic memory, spared generative memory, reduced speech intelligibility, extensive surgical management and other behavioural problems. And he has speech and language difficulties such as reduced speech intelligibility, paraphasia, circumlocutions were present.

Does use of axillary ultrasound in clinically node-negative patients receiving neo-adjuvant systemic therapy for breast cancer lead to surgical overtreatment?

Increased use of neo-adjuvant chemotherapy (NAC) for breast cancer has raised uncertainty regarding staging of the axilla, particularly for patients with a clinically negative axillary physical examination (PE). We sought to determine whether axillary ultrasound (AUS) prior to NAC to identify occult nodal disease is beneficial in patients with a clinically negative examination by evaluating the difference in nodal burden on final pathology in those with abnormal vs normal AUS. A retrospective review of an institutional cancer registry identified patients who underwent NAC for breast cancer and had a pretreatment AUS. Differences in the number of positive lymph nodes (PLN) in patients with a normal axillary PE and abnormal vs normal AUS prior to NAC were determined. A total of 120 patients who received NAC had a negative axillary PE prior to treatment. Fifty-three had an abnormal AUS and biopsy-proven lymph node (LN) involvement. In patients with an abnormal AUS, median number of PLNs at surgery was 1 vs 0 for those with a normal AUS (mean difference of 2.12, P<.0001). Of those patients with an abnormal AUS and biopsy-proven LN involvement, 87% underwent axillary lymph node dissection (ALND) and nearly half had no PLN on final pathology (N=23, 43%). Patients with a clinically negative axilla and an abnormal AUS were more likely to have PLN at the time of surgery. However, almost half of those patients had no residual LN involvement. Routine AUS prior to NAC may lead to more extensive surgical management of the axilla.

The effect of military clothing on gunshot wound patterns in a cadaveric animal limb model

The majority of injuries in survivors of gunshot wounds (GSW) are typically to the extremities. Novel wound ballistic research is encouraged to try and capture corporate knowledge on the management of these injuries gained during recent conflicts and understand the wounding patterns seen. With recent work examining the effect of UK military clothing on extremity GSW patterns in a synthetic model, a model with greater biofidelity is needed for ballistic testing. The aim of this study was to assess the effect of UK military clothing on GSW patterns within a cadaveric animal limb model using two types of ammunition commonly used in recent conflicts—7.62 × 39 mm and 5.45 × 39 mm. In total, 24 fallow deer hind limbs were shot, 12 by 7.62 mm projectiles and the remaining 12 shot by 5.45 mm projectiles, further divided into four with no clothing layers (Cnil), four with a single clothing layer (Cmin) and four with maximum clothing layers (Cmax) as worn on active duty by UK military personnel. Limbs were analysed after ballistic impact using contrast CT scanning to obtain measurements of permanent cavity damage, and results were compared using analysis of variance (ANOVA). Results showed significantly different damage measurements within limbs with Cmax for both ammunition types compared with the other clothing states. This may result in GSWs that require more extensive surgical management, and invites further study.

The effect of military clothing on gunshot wounding patterns in gelatine

With no two gunshot wounds (GSW) being the same, novel research into wound ballistics is challenging. It is evident that the majority of previous wound ballistic research has been conducted without the presence of clothing. Whilst the effect of clothing on wound contamination has been explored, there is a paucity of literature examining the effect of clothing on GSW patterns. The aim of this study was to test the effect of Multi-Terrain Pattern (MTP) UK military clothing on GSW patterns within calibrated blocks of 10% by mass gelatine, using two types of ammunition commonly used in recent conflicts—7.62 × 39 mm and 5.45 × 39 mm. In total, 36 blocks were shot, 18 by each projectile type, further divided into 6 with no clothing layers (Cnil), 6 with a single clothing layer (Cmin) and 6 with maximum clothing layers (Cmax) worn on active duty. Blocks were analysed with high-speed video and dissection to capture measurements of damage, and results compared using analysis of variance (ANOVA). Results showed significantly different damage measurements within blocks with Cmax for both ammunition types compared to the other clothing states. This may result in GSWs that require more extensive surgical management, inviting further study.

Burns from illegal cannabis oil manufacturing: a case series.

The increasing consideration of cannabis legalization in Canada and the United States has motivated physicians to assess its prospective impact on the health care system. Health care providers in the burns community are concerned about injuries sustained as a result of the illegal manufacturing of cannabis oil because it involves highly flammable reagents. We report a retrospective case series of patients with cannabis oil burns (identified by evidence of combustion during cannabis oil manufacturing) treated from April 2012 to March 2014 at the Foothills Medical Centre in Calgary, Alberta, Canada. We compare the characteristics of these patients with those of patients admitted over the same period with any burns. We found that 12 (out of 161 patients) admitted over the review period sustained burns from cannabis oil manufacturing. Compared with patients in the total burn group, patients with cannabis oil burns were younger (75% and 48% were younger than 41 years in the group with cannabis oil burns and the total burn group, respectively), were more likely to be male (83% in the group with cannabis oil burns v. 74% in the total burn group) and sustained burns over a larger percentage of their total body surface area (24% v. 9%). Patients with cannabis oil burns also required extensive surgical management (skin grafting in 75% of cases) and spent a substantial amount of time (mean 32 d) in the burn unit. Burns from illegal cannabis oil manufacturing are large, require extensive management and involve younger patients than burns in general. Given that the frequency of cannabis oil burns may increase in Canada after legalization, Canadian burn centres are encouraged to monitor and report on cases with this injury mechanism.

Preliminary testing for endometriosis and gene polymorphisms

We read your review on the relation between endometriosis and ovarian cancer 1. Endometriosis is characterized by inflammation and invasion of endometrial cells into other tissues and organs. It is a serious condition associated with complications such as infertility, dysmenorrhea, and dyspareunia in females of reproductive age, and the pathophysiology of the disease occurrence and progression is unclear. An evaluation for endometriosis should be considered for adolescent female patients with chronic pelvic pain because early diagnosis and management are important to maintain quality of life and reduce the need for extensive surgical management 2. Your review is highly informative for gynecologists to follow up patients with endometriosis and investigate the condition. We believe that it is important for gynecologists to know that ovarian cancer is associated with endometriosis. However, identification of a biomarker of the relation between endometriosis and ovarian cancer is needed. Single-nucleotide polymorphisms are currently under investigation in terms of the prediction and prevention of many diseases. Endometriosis is known to be an estrogen-dependent disease. Single-nucleotide polymorphisms of the CYP17 GG and GA genotype, which is related to steroidogenic genes, are significantly increased in infertile females with endometriosis 3. We have reviewed the estrogen receptor (ER) gene polymorphisms associated with endometriosis 4. Polymorphism in PvuII of ERα is associated with an increased tendency for endometriosis in Europe, and polymorphism in XbaI of ERα is associated with a risk of occurrence in both Asia and Europe 4. We also investigated the relation between MUC4 and endometriosis. Epithelial surfaces secrete mucous components composed of mucin-glycosylated proteins. The MUC series has been investigated with other mucous secretory-related cancer markers. MUC1 is overexpressed in ovarian tumors and is present in endometriotic lesions 5. We preliminarily studied associations between patients with two types of functional cysts and two patients with endometriosis in the ER and MUC4 genes by PCR, restriction fragment length polymorphism, or DNA sequencing. The clinical characteristics of the two patients with functional cysts and two patients with endometriosis are shown in Table 1, which shows that patients with endometriosis had four mutant haplotypes in MUC4 (rs882605, intron 22 + 66, intron 23 + 45, and intron 23 + 47) and a double-mutant haplotype in ESR1 PvuII and ESR1 XbaI (figure available on request). We also found that MUC4 (introns 23 + 45 and introns 23 + 47), ESR PvuII, and XbaI may be associated with endometriosis. However, small case reports cannot confirm the effect of polymorphisms on the relation between endometriosis and functional cysts. We plan to investigate the effect of ESR and MUC4 (introns 23 + 45 and introns 23 + 47) on the relation between endometriosis and functional cysts. One report showed that the MUC4 polymorphism was related to endometriosis and infertility in a Taiwanese population 6. No other reports have described endometriosis in association with polymorphisms of both the MUC4 and ER genes. We believe that a study of concurrent MUC4 and ERα polymorphisms would provide useful information for the diagnosis and prevention of recurrence of endometriosis.

Neuroendocrine Tumors of the Gallbladder

Gallbladder neuroendocrine tumors (GB-NETs) represent only 0.5% of all NETs, and little is known about their biological behavior. We sought to provide an overview of the current state of knowledge about GB-NETs and provide a recommendation for management. A PubMed search was undertaken using the following criteria: primary gallbladder and carcinoid or NET. We also interrogated the SEER 9, 13 and 17 registries (1973 to 2005) and the Niigata registry (2003) to assess the epidemiology and clinicopathological characteristics. Finally, we compared the clinical presentation, management and prognosis of GB-NETs to that of gallbladder adenocarcinoma. GB-NETs probably derive from either a multipotent stem cell or neuroendocrine cells in intestinal or gastric metaplasia of the gallbladder epithelium, which occurs consequent upon cholelithiasis/chronic inflammation. Clinically and at surgery, GB-NETs are indistinguishable from gallbladder cancer (GBC) and "carcinoid syndrome" is evident in only ∼1%.The median survival was only 9.8 months among 278 cases of GB-NETs reported in SEER. The 5 year survival rate for tumors classified as carcinoids/neuroendocrine carcinoma or small cell cancer (SCC) was 36.9 and 0%, respectively. Soga divided GB-NETs into typical and variant carcinoids with 5 year survival rates of 60.4% and 21.3% respectively. GB-NETs have an aggressive behavior, and once diagnosed, extensive surgical management and careful NET follow up with CT scan is mandatory to facilitate early detection of recurrence. Since more aggressive surgical management for GBC has shown increased survival rates for these tumors, a similar strategy seems reasonable for GB-NETs. However, in high grade metastatic tumors, the primary management is mainly medical.

Unsuccessful Frontal Balloon Sinuplasty for Recurrent Sinus Barotrauma

The standard of care treatment for diffuse recurrent sinus barotrauma (RSB) is an endoscopic sphenoethmoidectomy with a complete frontal dissection. Successful healing leaves the RSB patient with no ethmoid sinuses and endoscopically patent frontal, sphenoid, and maxillary ostia. In persistent cases, patients with small frontal ostia will go on to require a frontal drillout. Patients presenting for surgical management of RSB generally have minimal sinus disease despite significant symptoms during flight and the prospect of extensive surgical management can be unappealing. With the advent of balloon sinuplasty, military otolaryngologists anticipated this technology would permit therapeutic dilation of sinus ostia without the extensive surgical dissection and prolonged recovery typical for standard of care management. This case report is a cautionary note to the wider flight community to recognize a mechanism for recurrence of the underlying pathology when balloon sinuplasty is used that is not possible after properly performed standard of care sinus surgery for RSB.

Severe abdominal dog bite wounds in a pregnant cat

Bite wounds are one of the most common reasons for admission of cats to veterinary clinics. Appropriate wound management seems to be more important in the successful outcome of bite wound injuries than antibiotic therapy alone. This report describes a heavily pregnant cat that suffered severe abdominal bite wounds necessitating treatment with extensive surgery. A necrotic herniated kidney, abdominal wall hernias, internal peritoneal ruptures and fracture of the thirteenth rib, gravid cornu rupture, an extrauterine dead foetus and its free kidney were all observed at laparotomy. At surgery the extrauterine dead foetus was removed, and two live foetuses were retrieved by en bloc ovariohysterectomy. A right nephrectomy and partial costectomy were also performed. Two weeks postoperatively, the cat had fully recovered without a problem. Bite wounds encountered in cats, though severe and invasive, can be tolerated and extensive surgical management can result in successful outcomes even under suboptimal conditions.

Surgical Management of Pouch-Vaginal Fistula after Restorative Proctocolectomy

Pouch-vaginal fistula (PVF) is a devastating complication after restorative proctocolectomy with ileal pouch anal anastomosis (IPAA). The aim of this study was to evaluate the surgical management of PVF. After Institutional Review Board approval, all patients treated for PVF between 1988 and 2003 were retrospectively reviewed. Success of treatment was defined as the complete absence of symptoms or no radiologic evidence of fistula. The study included 23 female patients; indications for IPAA were mucosal ulcerative colitis in 20 (87%), indeterminate colitis in 1 (4.3%), and familial adenomatous polyposis in 2 (8.7%) patients. Seven patients with mucosal ulcerative colitis were postoperatively diagnosed with Crohn's disease. Mean time interval from initial IPAA to development of symptomatic fistula was 17.2 months. Mean number of surgical treatments was 2.2. Overall, success was achieved in 17 (73.9%) patients at a mean followup of 52.3 months. Fistulas in patients with Crohn's disease occurred relatively late after IPAA (p = 0.015) and required a median of three (p = 0.001) surgical procedures, compared with patients without Crohn's disease. Pelvic sepsis after original IPAA occurred in eight (35.8%) patients, four (50%) of whom ultimately required pouch excision. Fecal diversion and local procedures are effective in the majority of patients with PVF after IPAA. Patients with Crohn's disease tend to have a delayed onset of fistula occurrence and require more extensive surgical management. Pelvic sepsis can be a predictive factor of poor outcomes.

Extensive surgical management for renal tumors with inferior vena cava thrombus.

The aim of this study was to evaluate the outcome in patients with renal cell carcinoma (RCC) and the inferior vena cava (IVC) or the right atrium tumor thrombus that were treated with radical nephrectomy and thrombectomy. Eleven of a total of 105 patients who underwent radical nephrectomy due to RCC had tumor thrombus extended to the IVC and/or the right atrium. We evaluated the surgical techniques used and the perioperative mortality and morbidity in these patients. The median age of the patients was 47 years (range, 16 to 59 years). They all underwent radical nephrectomy with cavotomy, tumor thrombus removal, and lymphadenectomy. Eight patients underwent extracorporeal circulation and hypothermic circulatory arrest; 2, temporary venovenous bypass by chevron incision and median sternotomy; and 1, only chevron incision with mobilization of the right lobe of the liver and cross-clamping proximal to the tumor thrombus and cavotomy. In 1 case, a solitary liver metastasis was excised and the patient died within 30 days postoperatively because of massive hemorrhage due to liver metastatectomy. Two patients had invasion to the IVC wall and 7 had pathological lymph node involvement. Four patients were tumor free (follow-up range, 9 to 18 months) and 7 died due to multiple metastases during the follow-up. This study supports the role of extensive surgical treatment as the best initial management of patients with renal cancer extended to the IVC only in highly selected cases.

Cystoprostatectomy and neobladder construction for florid cystitis glandularis

Cystitis glandularis is a benign proliferative disease of the bladder mucosa with a characteristic histopathologic appearance. If a mass lesion is identified, it is resected transurethrally. More extensive surgical management for severe or recurrent cases is poorly characterized in published studies. We present a patient with multiple rapid recurrences of polypoid masses on the trigone causing irritative voiding symptoms. He developed a low-compliance small-capacity bladder and bilateral ureteral obstruction. The patient underwent total cystoprostatectomy with cavernosal nerve sparing and ileal neobladder construction. We advocate such aggressive surgical management in select cases of this disease.