Failure Of Surgical Treatment Research Articles

Evaluation of patients who underwent resympathectomy for treatment of primary hyperhidrosis.

Video thoracoscopic sympathectomy is the recommended surgical treatment for primary hyperhidrosis and has a high success rate. Despite this high success rate, some patients are unresponsive and eventually need a resympathectomy. Few studies have previously analysed exclusively the results of these resympathectomies in patients with primary hyperhidrosis. None of the studies have objectively evaluated the degree of response to surgery or the improvement in quality of life after resympathectomies. This is a retrospective study, evaluating 15 patients from an initial group of 2300 patients who underwent resympathectomy after failure of the primary surgical treatment. We evaluated sympathectomy levels of resection, technical difficulties, surgical complications preoperative quality of life, response to treatment and quality-of-life improvement 30 days after each surgery. Regarding gender, 11 (73.3%) patients were women. The average age was 23.2 with SD of 5.17 years, and the mean body mass index was 20.9 (SD 2.12). Ten patients had major complaints about their hands (66%) and 5 (33%) patients about their forearms. A high degree of response to sympathectomy occurred in 73% of patients. In 11 of these patients, the improvement in quality of life was considered high, 3 showed a mild improvement and 1 did not improve. No major complications occurred; the presence of adhesions was reported in 11 patients and pleural drainage was necessary in 4 patients. Resympathectomy is an effective procedure, and it improves the quality of life in patients with primary hyperhidrosis who failed after the first surgery.

Predictive factors of long-term outcomes of surgery for mesial temporal lobe epilepsy associated with hippocampal sclerosis.

The reasons for failure of surgical treatment for mesial temporal lobe epilepsy (MTLE) associated with hippocampal sclerosis (HS) remain unclear. This retrospective study analyzed seizure, cognitive, and psychiatric outcomes, searching for factors associated with seizure relapse or cognitive and psychiatric deterioration after MTLE-HS surgery. Seizure, cognitive, and psychiatric outcomes were reviewed after 389 surgeries performed between 1990 and 2015 on patients aged 15-67 years at a tertiary center. Three surgical approaches were used: anterior temporal lobectomy (ATL; n = 209), transcortical selective amygdalohippocampectomy (SAH; n = 144), and transsylvian SAH (n = 36). With an average follow-up of 8.7 years (range = 1.0-25.2), seizure outcome was classified as Engel I in 83.7% and Engel Ia in 57.1% of patients. The histological classification of HS was type 1 for 75.3% of patients, type 2 for 18.7%, and type 3 for 1.2%. Two factors were significantly associated with seizure recurrence: past history of status epilepticus and preoperative intracranial electroencephalographic recording. In contrast, neither HS type, the presence of a dual pathology, nor surgical approach was associated with seizure outcome. Risk of cognitive impairment was 3.12 (95% confidence interval = 1.27-7.70), greater in patients after ATL than in patients after transcortical SAH. A presurgical psychiatric history and postoperative cognitive impairment were associated with poor psychiatric outcome. The SAH and ATL approaches have similar beneficial effects on seizure control, whereas transcortical SAH tends to minimize cognitive deterioration after surgery. Variation in postsurgical outcome with the class of HS should be investigated further.

35-Year Experience with Surgical Treatment of Hidradenitis Suppurativa.

Hidradenitis suppurativa is a painful and disfiguring chronic inflammatory condition affecting both men and women. Medical treatments, such as antibiotics and immunosuppressive agents, are often ineffective. Over time, patients can suffer from recurrent abscesses, chronic purulent drainage, scarring, and contractures that can only be corrected by surgical excision. There is no agreement, however, on the best way for the surgeon to manage this condition. The purpose of this review is to describe the results of surgical treatment of this condition in a large cohort of patients managed by local excision of hidradenitis, healing by secondary intention and reoperation as needed. A retrospective review was conducted of all patients operated on by the author for hidradenitis over a 35-year period. Specific data abstracted included patient age, weight, admission, length of stay, wound size, type of wound care, number of post-op visits, time to heal, and recurrence. Most wounds healed by secondary intention and were managed using simple tap water-moistened plain gauze dressings changed three times a day. From 1979 through 2014, 122 patients (56 men and 66 women), median age 38, underwent 245 operations for hidradenitis suppurativa. Patients underwent from 1 to 10 procedures; 61 patients (50%) underwent two or more procedures; and 26 (21%) underwent three or more. Wound sizes at operation ranged from quite small to over 1500cm2. Men were older (42 vs 34years, p<0.001) and had larger median wound size (98 vs 55cm2, p<0.001). A total of 197 wounds healed by secondary intention: 83 of these (median size 159cm2) were left completely open at the time of surgery; 117 (median size 100cm2) were partially closed. A total of 30 wounds (median size 38cm2) were closed primarily; 15 (median size 196cm2) were closed by skin graft. Patients undergoing 139 procedures were admitted to the hospital for the initial wound care. Their median combined total wound size was 160cm2; length of stay was 5.5days; and median time to heal was 60days. In total, 106 procedures were ambulatory; median wound size was 30cm2; and median time to heal was 40days. Recurrent or new disease was common, with some patients requiring multiple procedures over many years to maintain control of symptoms. Although wound healing can take up to several months, patients quickly learned how to care for themselves and were usually pain-free after the first two or three weeks. Surgical treatment of hidradenitis suppurativa by wide local excision with healing by secondary intention using tap water-moistened plain gauze dressings changed 2-3 times per day is a simple, practical approach that has good results. Recurrence of disease is common and should not be thought of as a failure of surgical treatment, but rather as a feature of the disease that must be anticipated and managed.

Multimodality management of borderline resectable pancreatic adenocarcinoma.

Patients with borderline resectable pancreatic adenocarcinoma have primary tumors within the pancreas that involve the mesenteric vasculature to a limited degree. Their tumors are nonetheless at high-risk for a microscopically positive surgical resection margin and/or early treatment failure when pancreatectomy is performed de novo. The optimal treatment strategy for these patients has not been established; however, relatively favorable outcomes can be achieved with systemic chemotherapy and radiation therapy (RT) prior to intended resection. In this article, we discuss the modalities used to stage localized pancreatic cancer, the concept of borderline resectable pancreatic cancer (BRPC), the rationale for the use of preoperative therapy, and review recent publications, placing special emphasis on the necessity of appropriate patient selection and coordinating multimodality management to maximize outcomes.

Loop Gain Predicts the Response to Upper Airway Surgery in Patients With Obstructive Sleep Apnea.

Upper airway surgery is often recommended to treat patients with obstructive sleep apnea (OSA) who cannot tolerate continuous positive airways pressure. However, the response to surgery is variable, potentially because it does not improve the nonanatomical factors (ie, loop gain [LG] and arousal threshold) causing OSA. Measuring these traits clinically might predict responses to surgery. Our primary objective was to test the value of LG and arousal threshold to predict surgical success defined as 50% reduction in apnea-hypopnea index (AHI) and AHI <10 events/hour post surgery. We retrospectively analyzed data from patients who underwent upper airway surgery for OSA (n = 46). Clinical estimates of LG and arousal threshold were calculated from routine polysomnographic recordings presurgery and postsurgery (median of 124 [91-170] days follow-up). Surgery reduced both the AHI (39.1 ± 4.2 vs. 26.5 ± 3.6 events/hour; p < .005) and estimated arousal threshold (-14.8 [-22.9 to -10.2] vs. -9.4 [-14.5 to -6.0] cmH2O) but did not alter LG (0.45 ± 0.08 vs. 0.45 ± 0.12; p = .278). Responders to surgery had a lower baseline LG (0.38 ± 0.02 vs. 0.48 ± 0.01, p < .05) and were younger (31.0 [27.3-42.5] vs. 43.0 [33.0-55.3] years, p < .05) than nonresponders. Lower LG remained a significant predictor of surgical success after controlling for covariates (logistic regression p = .018; receiver operating characteristic area under curve = 0.80). Our study provides proof-of-principle that upper airway surgery most effectively resolves OSA in patients with lower LG. Predicting the failure of surgical treatment, consequent to less stable ventilatory control (elevated LG), can be achieved in the clinic and may facilitate avoidance of surgical failures.

Results of surgical treatment of chronic pancreatitis and cysts of the pancreas in view of their morphological condition during surgery

Background. To date, reasonable indications and contraindications have not yet been developed for the implementation of draining, resection-draining and resection procedures with preoperative consideration of risk factors of their performance, there are no modern diagnostic and treatment algorithms for the treatment of patients with complications of chronic pancreatitis and pancreatic pseudocysts. Therefore, a retrospective analysis of failures during the surgical interventions on the pancreas would contribute to the creation of diagnostic and therapeutic algorithm with maximum consideration of the risk factors that would enable the individualization of treatment program and provide a long therapeutic effect to the patient with minimal risk of disease recurrence and minimal surgical trauma. This is an actual problem of modern surgery. The aim of the study was to define principal causes, which resulted in failures at surgical treatment for complications of chronic pancreatitis and cysts of the pancreas. Materials and methods. There was performed the retrospective analysis of 108 follow-up cards of patients operated for complications of chronic pancreatitis (n = 66) and pseudocysts of the pancreas (n = 42) with application of draining, resection-draining and resection surgical interventions. During the retrospective analysis, we took into account the morphological state of pancreatic parenchyma and presence of pseudocysts of the pancreas at the time of operation, blood loss during the surgery, the incidence and nature of intra- and postoperative complications depending on the type of surgical interventions, extent and adequacy of the operation, lethality. Results. The nature of the complications of chronic pancreatitis and pancreatic pseudocysts: a constant or recurrent pain, dilatation of pancreatic duct, calculus of pancreatic duct, calcifications of the parenchyma of the pancreas, stenosis of the intrapancreatic part of the common bile duct, biliary hypertension, obstructive jaundice, duodenal obstruction, segmental suprahepatic or subhepatic portal hypertension, ascites, abscess of the pancreas, external pancreatic fistula, fistula choledochoduodenalis. Failures during the surgical treatment for complications of chronic pancreatitis and pseudocysts of the pancreas were detected in 57 (57.0 %) cases, including 33 (57.9 %) cases in the treatment for complications of chronic pancreatitis and in 24 (42.1 %) cases during the treatment of pseudocysts of the pancreas. Lethal cases were registered in 4 (3.7 %) patients at the implementation of draining (longitudinal pancreatojejunostomy, cystopancreatojejunostomy) and resection surgical interventions (pancreatoduodenal resection). The nature of failures in most cases (64.9 %) was presented by impossibility of performing adequate surgical intervention (n = 21), insufficiency of seams of anastomosis (n = 6), postoperative bleeding (n = 5) and significant blood loss during the surgery (n = 5). Most of the major causes of failure of surgical treatment for complications of chronic pancreatitis and pancreatic pseudocysts were related to the morphological state of the pancreas and pancreatic pseudocysts during the operation: active inflammation and its combination with varying degrees of fibrosis of pancreatic parenchyma (n = 47); early fibrosis of pancreatic parenchyma (n = 15), immature pancreatic pseudocyst (n = 5), as well as soft “juicy” pancreas (lipomatosis on the background of active inflammation of the pancreatic parenchyma) (n = 8). Conclusions. Basic factors, which determine the risks and failures of surgical treatment for complications of chronic pancreatitis and pseudocysts of the pancreas, are: a) activity of inflammation, degree of fibrosis of pancreatic parenchyma at the time of surgery; b) maturity of the wall of pancreatic pseudocysts, its connection with pancreatic duct, localization, size and nature of complications of pseudocysts of the pancreas; c) inadequately chosen term and type of surgical intervention; d) inadequate performance of surgical intervention.

Salvage of Lesser Toes Deformities: “Revision Forefoot”

Deformity of the digits and lesser metatarsals is a common surgical problem presenting to the foot and ankle surgeon. Although elective operative management is usually straightforward, even the most routine cases carry the risk of surgical complication, spanning from the simple to the devastating. Most often, it is difficult to determine the exact cause of failure in surgical treatment of lesser toe deformities. Some possibilities are: inadequate surgical procedure; choosing inadequate surgical technique; complications related to the surgical procedure; underestimation of the inherent risks and unrealistic expectations. This paper describes the authors’ approach to failed lesser toes surgical treatment. It presents a particular view of the problems resulting from lesser toes surgery, and an emphasis on revision operative procedures. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Embolization of the superior rectal arteries for chronic bleeding due to haemorrhoidal disease.

The aim of this study was to assess the safety and efficacy of the emborrhoid technique (embolization of the superior haemorrhoidal arteries) in patients ineligible for surgery. Between January 2014 and April 2015, 30 consecutive patients (average age 58years) suffering from disabling chronic bleeding due to haemorrhoidal disease and with a contraindication for surgery (n=23) or with a failure of instrumental or surgical treatment (n=7) underwent embolization. All cases were discussed at multidisciplinary meetings including a proctology specialist or a surgeon and an interventional radiologist. We performed super selective micro coil embolization (pushable 2-3mm fibre coils) of the distal branches of the superior rectal arteries with a microcatheter, via a right femoral approach, under local anaesthesia. We assessed clinical outcome by evaluating bleeding and specific clinical scores relating to bleeding and changes in quality of life. Immediate technical success, with no complication, was achieved in 93% of cases. A mean of 3.1 arteries per patient was embolized, with a mean of 7.6 coils per patient. Median follow-up was 5months. Clinical score improvement was observed in 72%, in 17 patients after a single embolization session, and in four additional patients after a second embolization session. No improvement in bleeding was observed in eight patients (28%). Distal coil embolization of the superior rectal arteries for disabling chronic bleeding due to haemorrhoidal disease is safe and effective in patients untreatable by surgery.

Strategies to improve local control of resected pancreas adenocarcinoma

BackgroundOnly approximately one in ten pancreas cancer patients is a candidate for potentially curative resection of this disease. Even this small fraction of patients has a poor prognosis following pancreatico-duodenectomy. The disease has an anatomic location that makes it difficult for the surgeon to maintain adequate margins of resection and prevent tumor spillage at the time of resection. Also, the disease is biologically aggressive and even with a complete visible resection of the disease, micrometastases are likely to remain behind. MethodsA survey of the sites for surgical treatment failure of resected pancreas cancer was performed. Also, the multiple modalities used in an attempt to improve the results of cancer resection are scrutinized. ResultsThe surgical treatment failures are regional in nature and occur at the resection site and on peritoneal surfaces, within the liver, and within the regional lymph nodes. These anatomic sites account for nearly 100% of the initial sites of disease progression. Current hypothesis suggests that micrometastases released from the cancer specimen by the trauma of surgery account for the high incidence of resection site progression and peritoneal metastases. Although surgical trauma may contribute to micrometastases within the liver and lymph nodes, these are most likely present though not detected by preoperative radiologic studies. Adjuvant treatments such as neoadjuvant chemotherapy or combination systemic chemotherapy have not been associated with improved survival. Extended resections such as total pancreatectomy or extended lymphadenectomy have not been associated with benefit. However, resection with a negative margin of excision along with the removal of at least 12 lymph nodes in and around the pancreaticoduodenectomy specimen is associated with superior outcomes. A regional chemotherapy treatment that consists of hyperthermic intraperitoneal chemotherapy (HIPEC) with gemcitabine and long-term normothermic intraperitoneal chemotherapy (NIPEC-LT) gemcitabine for 6 months postoperatively is suggested as a new treatment that has demonstrated decreases in local-regional failure and promises to more adequately target micrometastases in the peritoneal space, in the liver and lymph nodes. ConclusionsPancreas cancer surgery should attempt to achieve negative margins of resection with the removal of at least 12 lymph nodes. Hyperthermic intraperitoneal gemcitabine can adequately eradicate malignant cells dislodged from the cancer specimen into the bed of the resection at high density and on distant peritoneal surfaces as peritoneal metastases. Long-term intraperitoneal gemcitabine may act on micrometastases in the liver through absorption into the portal vein blood and the lymph nodes as a result of gemcitabine absorption by subperitoneal lymphatic channels. The use of HIPEC and NIPEC-LT gemcitabine may improve local control of resected pancreas cancer.

Outcome, Treatment, and Treatment Failures in Patients Suffering Localized Embryonal Paratesticular Rhabdomyosarcoma: Results From the "Cooperative Weichteilsarkom Studiengruppe" Trials CWS-86, -91, -96, and -2002P.

To evaluate outcome in respect to local treatment strategies in 4 prospective CWS trials in patients with paratesticular rhabdomyosarcoma (PTRMS). PTRMS patients have a high number of surgical treatment failures. Retroperitoneal lymph node (LN) involvement is common in patients more than 10 years, and the optimal treatment is unknown. A total of 173 patients with diagnosis of PTRMS were enrolled. Of these, 26 were excluded and 147 patients were finally analyzed. All patients were treated according to the Cooperative Soft Tissue Sarcoma (CWS) trial protocols. The 5-year overall survival was 95.5%, and the 5-year event-free survival (EFS) was 89.8%. Positive predictive factors for EFS were age younger than 10 years and tumor size less than 5 cm. Surgical treatment failures were observed in 34 of 135 patients undergoing primary resection. Primary inguinal/iliacal LN sampling was carried out in 15 of 147 patients with no impact on the EFS (87.5%; P = 0.666). Secondary retroperitoneal LN dissection was done in 32 of 147 patients, of which only 8 patients had viable tumor and a worse outcome (EFS: 50%; P = 0.01). Loco-regional, combined, and metastatic relapses were observed in 13 of 147 patients. The outcome of PTRMS patients is excellent and is hardly improvable. Positive predictors for outcome are age younger than 10 years and tumor size less than 5 cm. Primary LN sampling seems to have no impact on the EFS and should not be recommended. Inadequate surgery can be avoided by treatment in specialized centers. Secondary retroperitoneal LN dissection revealed a high number of unnecessary procedures, but patients with positive LN had a poor prognosis and require additional local therapy.

Impact of Muscular Arteries State on the Results of Surgical Treatment of Lower Limb Obliterating Atherosclerosis

The failure of surgical treatment of obliterating atherosclerosis of the lower extremities may be associated with underestimation of changes in local hemodynamics, particularly in arterial hypertension.The objective of the research was to study the state of small muscular arteries in patients with arterial hypertension and its impact on the course of obliterating atherosclerosis and the results of surgical treatment.Materials and methods. There were examined 281 patients with obliterating atherosclerosis and 32 patients with arterial hypertension. Patients with obliterating atherosclerosis received presumptive treatment: an intravenous infusion of 4.2 g of L-arginine, forceful intra-arterial injection of 20-80 ml of infusate (heparin, pentoxifylline, procaine), femoral and gluteal nerve block. Results. Among hypertensive patients without obliterating atherosclerosis 13 persons had paraesthesia, feeling of coldness in the feet, platypodia, hypomyotonia, slow (63.7±1.3 sec) reactive hyperemia, arterial stenosis (40-45%), and low-amplitude or nonpulsative local blood flow. Among 97 patients with stable course of obliterating atherosclerosis 49 (50.5%) persons were diagnosed with uncomplicated arterial hypertension. Most of patients (80.3%) had single level occlusions of the iliac-femoral or femoral-popliteal segment. Presumptive treatment was effective in 87.1% of cases, reactive hyperemia was rapid (26.2±0.4 sec), local blood flow was pulsative. Arterial reconstruction with limb preservation for more than 1 year was performed in 12 (12.4%) cases. Among 184 patients with progressive course of obliterating atherosclerosis 162 (88.0%) persons were diagnosed with complicated arterial hypertension. Most of patients (83.7%) had multilevel lesions with diffuse stenosis or occlusions of the tibial arteries. Presumptive treatment was effective in 9.5% cases, reactive hyperemia was slow (106.3±2.7 sec), local blood flow was nonpulsative. Within 2 months 83 patients underwent above-knee amputation. Arterial reconstruction with limb preservation for more than 1 year was performed in 17 cases. Patients with arterial hypertension and obliterating atherosclerosis developed sclerosis of muscular arteries, intimal hyperplasia.Conclusions. Arterial hypertension causes lesions of small muscular arteries of the lower limbs. Hypertensive arteriopathy initiates the ascending development of obliterating atherosclerosis, causes hypertensive foot syndrome and unsatisfactory results of arterial reconstructions.

Failure of Surgical Treatment in the De Quervain Tenosynovitis

Background: The De Quervain tenosynovitis is a rather common “easy to treat” syndrome. The majority of patients are successfully treated with conservative treatment. If the symptoms persist, the surgical release of the first dorsal compartment of the wrist usually definitively solves the problems. Sometimes, we observe patients whose problems are not solved by the surgical treatment. Aim: Our aim was to analyze the failed surgically treated cases selecting those patients whose symptoms did not disappear after a surgical treatment and find out the reason for the failure. Patients and Methods: We analyzed the last 9 years looking for those patients who returned with the persistence or the reappearance of the same symptoms like before the operation. We analyzed the intraoperative findings of the first operation, the clinical examination, and the applied treatment. In case of second operation, we analyzed the results of this. Results: In the period of 2007-2015, we found a total of 42 patients with unsuccessful operations for the De Quervain tenosynovitis. Careful clinical examination demonstrated in 7 cases the presence of a Wartenberg syndrome. All these patients underwent a successful operation for this. In 4 cases, trapezo-metacarpal osteoarthritis caused the problems. They received conservative treatment with infiltration and splinting. Ten cases presented hyper sensibility of the operated area. Six cases were treated successfully by physiotherapy. Four cases underwent reoperation. In 3 cases, the lesion, and in 1 case, the compression of the superficial branch of the radial nerve was found. Nineteen patients of the remaining 21 accepted a second operation. In all these cases, we found an unreleased tendon in an additional compartment. Conclusion: We can conclude that the failure of an operation in the De Quervain tenosynovitis is due to anatomical variations, the involvement of the radial superficial nerve, and the ignoration of another syndrome in the proximity.

What MRI Findings Predict Failure 10 Years After Surgery for Femoroacetabular Impingement?

Magnetic resonance arthrogram (MRA) with radial cuts is presently the best available preoperative imaging study to evaluate chondrolabral lesions in the setting of femoroacetabular impingement (FAI). Existing followup studies for surgical treatment of FAI have evaluated predictors of treatment failure based on preoperative clinical examination, intraoperative findings, and conventional radiography. However, to our knowledge, no study has examined whether any preoperative findings on MRA images might be associated with failure of surgical treatment of FAI in the long term. The purposes of this study were (1) to identify the preoperative MRA findings that are associated with conversion to THA, any progression of osteoarthritis, and/or a Harris hip score of < 80 points after acetabuloplasty and/or osteochondroplasty of the femoral head-neck junction through a surgical hip dislocation (SHD) for FAI at a minimum 10-year followup; and (2) identify the age of patients with symptomatic FAI when these secondary degenerative findings were detected on preoperative radial MRAs. We retrospectively studied 121 patients (146 hips) who underwent acetabuloplasty and/or osteochondroplasty of the femoral head-neck junction through SHD for symptomatic anterior FAI between July 2001 and March 2003. We excluded 35 patients (37 hips) with secondary FAI after previous surgery and 11 patients (12 hips) with Legg-Calvé-Perthes disease. All patients underwent preoperative MRA to further specify chondrolabral lesions except in 19 patients (32 hips) including 17 patients (20 hips) who presented with an MRI from an external institution taken with a different protocol, 10 patients with no preoperative MRA because the patients had already been operated on the contralateral side with a similar appearance, and two patients (two hips) refused MRA because of claustrophobia. This resulted in 56 patients (65 hips) with idiopathic FAI and a preoperative MRA. Of those, three patients (three hips) did not have minimal 10-year followup (one patient died; two hips with followup between 5 and 6 years). The remaining patients were evaluated clinically and radiographically at a mean followup of 11 years (range, 10-13 years). Thirteen pathologic radiographic findings on the preoperative MRA were evaluated for an association with the following endpoints using Cox regression analysis: conversion to THA, radiographic evidence of any progression of osteoarthritis, and/or a Harris hip score of < 80. The age of the patient when each degenerative pattern was found on the preoperative MRA was recorded. The following MRI findings were associated with one or more of our predefined failure endpoints: cartilage damage exceeding 60° of the circumference had a hazard ratio (HR) of 4.6 (95% confidence interval [CI], 3.6-5.6; p = 0.003) compared with a damage of less than 60°, presence of an acetabular rim cyst had a HR of 4.1 (95% CI, 3.1-5.2; p = 0.008) compared with hips without these cysts, and presence of a sabertooth osteophyte had a HR of 3.2 (95% CI, 2.3-4.2; p = 0.013) compared with hips without a sabertooth osteophyte. The degenerative pattern associated with the youngest patient age when detected on preoperative MRA was the sabertooth osteophyte (lower quartile 27 years) followed by cartilage damage exceeding 60° of the circumference (28 years) and the presence of an acetabular rim bone cyst(31 years). Preoperative MRAs with radial cuts reveal important findings that may be associated with future failure of surgical treatment for FAI. Most of these factors are not visible on conventional radiographs or standard hip MRIs. Preoperative MRA evaluation is therefore strongly recommended on a routine basis for patients undergoing these procedures. Findings associated with conversion to arthroplasty, radiographic evidence of any progression of osteoarthritis, and/or a Harris hip score of < 80 points should be incorporated into the decision-making process in patients being evaluated for joint-preserving hip surgery. Level III, therapeutic study.

Management for Locking Compression Plate/Dynamic Compression Plate Implant Failure in Non Union Osteoporotic Humerus Shaft Bone Fracture

Abstract Introduction To introduce the experience of treating nonunion osteoporotic of humeral fractures with interlocking nailing for failed surgical treatment by plating. Etiology for non-union after failed surgical management of humeral shaft fractures is multi-factorial. Following factors may play a role in nonunion – inadequate fracture fixation with poor contact between the fracture segments, osteomalacia, osteoporosis, infection, devitalization of bone and many more. Materials and methods A retrospective comparative study of twenty four patients who had locking compression plate failure in osteoporotic humerus shaft fractures treated with interlocking nail and iliac crest bone graft at Gandhi Hospital from 2007 to 2010. Results Twenty extremities had a return to nearly normal function within twelve weeks after nailing. According to Rommens criteria excellent results seen in 79.2%, moderate 16.7%, poor 4.1%. The mean Constant-Murley score improved from pre operative 45.9 ± 17.6 to 79.1 ± 12.6 (p Conclusion Interlocking intramedullary nailing of the humerus provides immediate stability and can be accomplished with a closed technique, brief operative time, and minimum morbidity, with a resultant early return of function to the extremity. LEVEL OF EVIDENCE: iii retrospective cohort study.

Hyaluronic Acid - Innovative Therapeutic Principle

The article presents the experience of a new therapeutic method, addressing postoperative implant pathology.Methods: Hyaluronic acid has been used in the management of various mucoperiosteal pathologies (directing secondary healing of oral wounds, restoration / increasing the volume of connective tissue – periosteal preoperativ or the papillary volume).Hyaluronic acid used had different concentration. The presentation forms both viscous and fluid particle size and type/acid’s grade of complexation) provided various therapeutic effects with specific indication of administration respected by the authors. Different products available at this time in Romania were used analyzing the results in time.Results: This therapeutic approach provided a good management in secondary granulation and wound healing of oral tissues in difficult cases (GBR, implant therapy) in which the persistence of dehiscence wound can cause a failure of surgical treatment (loss of membrane, alloplastic material or implant).Conclusion: This results places this innovative therapeutic method with others successful therapeutic solutions in usual dental practice, providing a quick and efficient settlement of some difficult clinical cases.

Sonographic Appearance of the Median Nerve Following Revision Carpal Tunnel Surgery.

The main objective of this pictorial essay is to illustrate the sonographic appearance of the postoperative carpal tunnel and median nerve. Carpal tunnel surgical treatment failures have been shown to occur in up to 19% of a large series requiring re-exploration. Surgical management options for recurrent carpal tunnel syndrome (CTS) include revision release, neurolysis, vein wrapping, and fat grafting procedures. While several descriptions of median nerve entrapment in CTS exist in the ultrasound literature, little is written regarding its postoperative appearance. We report the sonographic changes in the appearance of the median nerve and postoperative carpal tunnel.

Effects of Therapy in Patients Suffering from Chronic Back Pain Treated with Spinal Cord Stimulation

Pain in the lumbosacral part of the spine in the course of degenerative disease is the most common cause of physical activity limitation in adults. Treatment includes pharmacotherapy, physiotherapy, psychotherapy, health promotion, and sometimes surgery. Surgical treatment is not always successful, and the various clinical and psychosomatic symptoms that result from surgical treatment failure are known as failed back surgery syndrome. For some patients with this condition, spinal cord stimulation can provide relief. The aim of the work was to define subjective and objective spinal cord stimulation effects by assessing chosen disability and physical activity limitation ratios. Pain intensity, level of disability, and presence of neurological symptoms were assessed. The examination was performed twice: before the stimulator implantation and at least 6 months postimplantation. The study was conducted at the Department of Neurosurgery and Paediatric Neurosurgery in Lublin. Thirty-six patients suffering from failed back surgery syndrome were recruited for this study. The Visual Analog Scale, modified Laitinen's pain questionnaire, and Oswestry Disability Index were used in this work. The study showed that spinal cord stimulation was effective in treating spinal and lower limb pain in 64% of patients, similar to results obtained in other departments. Although back pain and neuropathic pain radiating to the lower limbs decreased, moderate physical activity impairment was still observed according to the Oswestry Disability Index scale. The decrease in neuropathic pain radiating to the lower limbs had the most significant influence on reducing physical activity impairment.

478 Surgical Endoscopic Vacuum Therapy for Defects of the Upper GI Tract

S A T A b st ra ct s of esophagogastric junction (EGJ) relaxation. Indeed, the diagnosis of achalasia is established by HRM on the basis of an IRP>15mmHg and absence of normal peristalsis in the esophageal body. Our aim was to assess the effect of Heller myotomy on IRP in achalasia patients. Patients and Methods: We evaluated all consecutive patients who underwent laparoscopic Heller myotomy as first treatment from 2009-2014 and had a HRM evaluation before and after surgery. Patients who had already been treated for achalasia (with Heller myotomy, endoscopic treatment) were excluded from the study. The diagnosis of primary achalasia was established by esophageal manometry on the basis of accepted esophageal motility characteristics (i.e. absence of normal peristalsis in the esophageal body). Symptoms were collected and scored using a detailed questionnaire for dysphagia, regurgitation, and chest pain; barium swallow, endoscopy, HRM were performed, before and 6 months after surgical treatment. Treatment failure was defined as a postoperative symptom score >10th percentile of the preoperative score (i.e. > 10). Results: 139 consecutive achalasia patients (M:F= 72:67) represented the study population. All the patients had 100% simultaneous waves but 11 had a IRP<15 mmHg. According to the HRM classification, patients were classified as having: 58 (42.3%) type I, 63 (46%) type II and 16 (11.7%) type III. At a median follow-up of 24 months, the symptom score was significantly lower after surgery (median preoperative score 18 [IQR 11-20] vs median postoperative score 0 [IQR 0-3]; p<0.0001). The resting LES pressure (median preoperatively 27 [IQR 19-36] vs median postoperatively 11 [IQR 8-14]; p<0.001) and IRP (median preoperatively 27.4 [IQR 20.4-35] vs median postoperatively 7.1 [IQR: 4.4-9.8]; p<0.001). The surgical procedure was completed laparoscopically in all the patients. The failures of surgical treatment were 7 (5%). At univariate analysis IRP was correlated with the gender, LES basal and resting pressure, and the dysphagia score. Conclusion: This is the first study evaluating the role of IRP in achalasia and its modifications after surgery. An increased preoperative IRP directly correlated with dysphagia severity in achalasia patients. Heller myotomy was able to resolve this symptom by reducing the IRP to a value lower than 10 mmHg.

Prolactinomas in children under 14. Clinical presentation and long-term follow-up.

Pediatric prolactinomas are rare, especially in children under 14 years of age. In this study, we evaluated the clinical presentation and microsurgical outcome of prolactinomas in prepubertal children. Nine patients with prolactinomas who had undergone surgical removal of the tumor before the age of 14 years were included in this retrospective study. Data on their clinical presentation, medications, physical and laboratory evaluations, radiological findings, and long-time follow-up were obtained from their medical records. The main presenting symptom in the four female patients was galactorrhea (n = 4, 100%), whereas the five male patients most commonly presented with headache (n = 4, 80%) and growth retardation (n = 3, 60%). Six (66.6%) of the patients who had undergone transsphenoidal surgery were medication-free postoperatively. In three (33.3%) patients with giant adenomas, complete resection of the tumor was not achieved. One (11.1%) patient received radiotherapy after failed surgical and medical treatment. Postoperatively, electrolyte disturbances occurred in five (55.6%) patients, diabetes insipidus in two (22.2%), and thyroid dysfunction in two (22.2%). These complications resolved spontaneously. During follow-up, growth and puberty were usually normal. Tumor compressive symptoms and/or gonadal and growth arrest may be the primary clinical presentations of pediatric prolactinoma. Patients who are not candidates for dopamine agonist therapy are best treated surgically, based on the low mortality and high cure rates. Hypopituitarism is a rare complication and may resolve spontaneously. Following successful treatment of a prolactinoma, growth and puberty in these children are normal.

Failure of surgical treatment in methamphetamine body-stuffers

Body stuffing is defined as ingestion of unpackaged or packaged illicit drugs in a quick process. The drugs have usually been wrapped loosely in cellophane, plastic bags, paper, or aluminum foil. Methamphetamine toxicity is a dangerous state that occurs during methamphetamine leakage from the ingested packages in the gastrointestinal tract. This is usually occurring with cocaine and heroin, but methamphetamine body stuffing may less commonly happen, as well. Accordingly, management of methamphetamine body-stuffers is an important subject that has remained a controversy in clinical and legal aspects.We have reported two body-stuffer cases who underwent exploratory laparotomy. Although surgery was done, it was not useful to exit packs and even led to severe methamphetamine toxicity.These cases show that surgical treatment may be ineffective and even harmful in body-stuffers. On the other hand, this report suggests that pre and post-operation abdominal CT-scan is necessary for evaluating surgical treatment in patients who are still symptomatic.