Goal Of Surgical Therapy Research Articles

Combining medical and surgical management strategies for hidradenitis suppurativa: Need for a treat to target approach

AbstractFor optimal management of hidradenitis suppurativa (HS), we propose a treat‐to‐target approach that synergizes medical and surgical therapies to improve outcomes and health‐related quality of life for HS patients. Studies are required to define the optimal targets in HS, however, proposed targets include disease remission or low disease activity. The goals of medical therapy in HS are to reduce existing inflammation and to prevent disease progression. The goals of surgical therapy are removal of permanently damaged fibrotic tissue and removal of biofilm within tunnels. In a treat‐to‐target approach, medical and surgical modalities are combined to optimize HS management. Regular and close monitoring are required to assess treatment response and achieve the predetermined target. Adjustments to the treatment plan can be made until the predetermined target is achieved. Research is needed to establish and evaluate this treat‐to‐target approach to help patients improve quality of life and achieve optimal disease control, and ultimately, disease remission.

Oncoplasty’s Contribution in Breast Cancers: About 48 Cases

Introduction: Oncoplasty has developed for 20 years in order to avoid potentially major deformations of conservative treatment. We report the results of our oncoplastic breast operations. Patients and Methods: We conducted a descriptive and retrospective study of 48 patients treated by oncoplastic technique in the national center of burn and plastic surgery in the U.H. IBN-ROCHD of Casablanca between 2011 and 2014. Patient and tumor characteristics, as well as information on the procedures and complications, were collected from clinical records. Results: Forty-eight cases were reviewed. The tumors were processed for the majority of invasive ductal carcinoma pT2. Seven patients had an inadequate surgical margin. About histology, the rate of recovery for non-positive margins was significantly lower in the CCI alone than that in other types. Morbidity was 14.5% and the average delayed to adjuvant treatment of 72 days. The symmetrization rate was 24%. In terms of oncological results, during a median follow-up of 22 months, the rate of local recurrences was 13%. Conclusion: The oncoplastic operations offer tools for breast conservation in patients and otherwise is destined for mastectomy or poor esthetic outcome. This study shows that the goal of surgical therapy is to identify patients who are suitable for oncoplastic surgery. Proper pre-operative evaluation and diagnosis, surgical planning, adequacy of resection, and pathological evaluation are essential.

Surgery and critical care for anomalous coronary artery from the pulmonary artery

Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital cardiac malformation that accounts for 0.25-0.50% of children with congenital cardiac disease and can cause myocardial dysfunction in young infants. In any infant presenting with ventricular dysfunction, the diagnosis of anomalous origin of the left coronary artery from the pulmonary artery must be suspected and the origin of the coronary arteries must be confirmed. The diagnosis of anomalous origin of the left coronary artery from the pulmonary artery is an indication for surgical repair. A two-coronary arterial system is the goal and is almost always achievable. The goal of surgical therapy is the creation of a two-coronary arterial system, which appears to provide better long-term survival and protection from left ventricular dysfunction and mitral valvar regurgitation than does simple ligation of the anomalous coronary artery. Direct reimplantation of the anomalous coronary artery is the procedure of choice. It is straightforward and borrows from well-practised techniques commonly used in other procedures such as the arterial switch operation. For the rare patient in whom direct reimplantation is not possible, strategies to lengthen the anomalous coronary artery, or baffle it within the pulmonary root, are available. Mitral valvar regurgitation is common at presentation, but following the establishment of a two-coronary arterial system and satisfactory myocardial perfusion, regurgitation of the mitral valve resolves in the vast majority. Therefore, mitral valvuloplasty at the time of initial surgery for anomalous origin of the left coronary artery from the pulmonary artery is not indicated. Post-operative care requires careful manipulation of inotropic support and reduction of afterload. Mechanical support, with either extracorporeal membrane oxygenation or left ventricular assist device, should be available for use if necessary.

Resection of intrathoracic and subdiaphragmatic hydatid cysts

The goal of surgical therapy in pulmonary hydatid disease is to remove the cyst while preserving as much lung tissue as possible. The surgical method may be different in the intact (simple) and ruptured (complicated) cysts. The operation has two steps: a) removal of the germinative layer, b) management of the residual pulmonary cavity. Simple cysts are generally removed after needle aspiration or enucleation without needle aspiration. Enucleation cannot be performed in ruptured cysts. The lung cavity that remains after removal of the cyst may be left as it is or obliterated by sutures from within the cavity in regard to the size and location of the cyst. However, the bronchial openings in the cavity must be closed by sutures in all cases. Rarely, hydatid cysts can occur in other thoracic structures such as pulmonary artery, chest wall or diaphragm. Those cysts located on the liver dome are operated by transthoracic-transdiaphragmatic approach. The surgical methods performed for the resection of hydatid cysts located in the chest or in the subdiaphragmatic area are presented with an overview of the literature.

Laparoscopic treatment of Barrett’s esophagus*

arrett’s esophagus is an acquired abnormality that is characterized rossly by an upward displacement of the squamo-columnar junction, ith replacement of the typical whitish smooth esophageal mucosa by a elvety reddish mucosa. Microscopically, Barrett’s esophagus is characerized by the presence of specialized intestinal metaplasia. It is associted with gastroesophageal reflux disease (GERD), and it is found in 15% o 20% of patients with GERD. The incidence of Barrett’s appears to ave increased dramatically in the last 20 years, a fact that has been inked to the 10-fold increase in the incidence of adenocarcinoma of the sophagus observed during the last decade. The goals of surgical therapy, or of any therapy, for patients with arrett’s esophagus are to provide long-term control of reflux sympoms; provide a durable gastroesophageal barrier to acid and bile; and ffect the elimination of Barrett’s, or at least decrease the risk of eveloping adenocarcinoma. Currently, there is considerable controversy s to whether an operation can achieve these goals. First, these patients ave a much more defective LES and a more virulent form of GERD that eads to greater esophageal damage than is seen in patients with GERD ut no Barrett’s. The operation is therefore more complex, the number f complications greater, and the chances of a successful long-term utcome in terms of competency of the cardia decreased. Second, here is a generalized belief that once Barrett’s develops, correction of eflux does not alter its natural history, although this concept has been ecently challenged. We review the evidence that laparoscopic surgery an achieve each of these goals.

Current treatment options for patients with endocarditis: The evolving indications for cardiac surgery

Infective endocarditis (IE) is a serious and deadly disease. Despite medical advances over the past half century, more than one half of patients with IE suffer a serious complication, and the mortality rate remains approximately 20% during the initial hospitalization and approaches 40% at 1 year. In patients with documented IE, the treatment centers on two main aspects: effective antibiotic therapy and consideration of surgical therapy. Effective antibiotic therapy is the mainstay of treatment and focuses on sustained bactericidal concentrations tailored specifically to the causative microorganism. Surgical therapy is also an important option for many patients with IE. The goals of surgical therapy are to eradicate the focus of infection, to repair endocardial destruction, and to prevent the development of complications and relapse of infection. Ideally, surgical therapy should offer a survival advantage over medical therapy alone. Recent evidence supports the survival benefit of surgery in patients with IE, specifically in those with heart failure and complicated, left-sided IE. Future therapeutic strategies may include broader indications for surgery, as well as new treatments such as immune-modulating agents.

Less invasive anterior fusion of the cervical spine

SummaryTrauma, degenerative and inflammatory diseases, or tumours may destabilise and deform the cervical spine, causing compression of the spinal cord and/or the nerve roots. The goals of surgical therapy are decompression of the neurostructures and restoration of the physiological alignment, along with stabilisation by fusion and fixation of the affected vertebrae. ‘Minimally invasive’ defines an effective surgical treatment with the least morbidity for the patient. The combined use of computed tomography (CT) and MRI, microsurgical techniques, intra-operative fluoroscopy and devices for internal fixation (plates and screws) has significantly improved the outcome. Nowadays bone graft substitutes, endoscopy and image-guided navigation are being introduced for clinical use, in order to reduce the surgical morbidity even further. Benefits of this evolution are: surgical procedures tailored for different pathologies; early mobilisation and rehabilitation, especially of elderly patients. Disadvantages are: a rapidly increasing number of operative procedures with a demanding learning curve, which have to be performed at specially qualified centres; and increasing sophistication (as a potential source of error) of the surgical equipment. A more balanced cooperation between industry and clinicians, along with an ethical agreement on how much surgery should be done, has become mandatory.

Pathologic Fractures due to Metastatic Disease A Retrospective Study of 160 Surgically Treated Fractures

Orthopaedic surgeons are increasingly confronted with metastatic fractures. As the majority of metastatic fractures never heal, surgical treatment is required. The goals of surgical therapy are to achieve early mobilization, relief pain and improve quality of life. One hundred twenty nine patients with 160 metastatic fractures of a long bone, completed or impending, were retrospectively analysed with regard to the type of treatment, effect on pain relief and mobility. Seven of the patients (4.4%) died postoperatively, a good functional result was obtained in 86.9% of the cases and for all patients a good analgesic effect was achieved. In 3.75% of the cases a mechanical complication was seen which needed reintervention. In general, the only indication for endoprosthesis is an intracapsular or very proximal lesion. In almost all other cases, intramedullary nailing is preferred.

Surgery for severe COPD

PREVIEWThe goal of surgical therapy in patients with advanced chronic obstructive pulmonary disease is to prolong life by (1) preventing secondary complications, (2) relieving dyspnea, and (3) enhancing quality of life by improving functional status. In this article, the authors review the newer procedure known as lung volume reduction surgery as well as the established lung transplantation technique. Patient selection, complications, and outcome are discussed.

Upper Gastrointestinal Surgery for Ulcer Disease in Foals

The goals of surgical therapy in foal gastroduodenal ulcer disease are the elimination of abdominal pain, healing of mucosal ulcerations, and prevention of complications. Gastrojejunostomy has been used with success in both pyloric and duodenal ulcerations that have progressed to gastric outflow obstruction. Gastrojejunostomy has resulted in rapid healing of gastritis and esophagitis and resolution of aspiration pneumonia and biliary stasis without recurrence of duodenal ulceration.

Surgical treatment of the short bowel syndrome

Long-term survival after massive intestinal resection is now possible with parenteral nutritional support. The expense, morbidity, and inconvenience of this therapy, however, has led to continued interest in alternatives for the treatment of the short bowel syndrome. The goals of surgical therapy in the short bowel syndrome are to increase the area of absorption, slow intestinal transit, and reduce gastric hyperacidity. Selected patients with dilated bowel segments benefit from intestinal tapering or lengthening. Growing neomucosa to increase surface area is not yet clinically efficacious. The results of transplantation remain unsatisfactory despite recent advances in immunosuppression. Antiperistaltic segments, colon interposition, and intestinal valves may benefit patients with sufficient absorptive area but rapid intestinal transit. Recirculating loops are associated with prohibitive morbidity and mortality. Intestinal pacing is currently being investigated. Surgical treatment of the short bowel syndrome is not sufficiently safe and effective to recommend its routine use. Operations should be performed only on selected patients to achieve specific goals. Adjunct procedures should not be carried out at the initial intestinal resection. Most important is continued emphasis on the prevention of intestinal resection and conservation of the intestine when massive resection is necessary.

Surgical Margins for Basal Cell Carcinoma

Basal cell carcinomas frequently extend beyond their visible borders. Therefore, the goal of surgical therapy must be to eradicate both the clinically apparent tumor and its microscopic extension into the surrounding normal-appearing skin. This entails excising the tumor along with a margin of clinically normal skin. Unfortunately, there is no agreement as to the optimal width of surgical margins. We therefore studied 117 cases of previously untreated, well-demarcated basal cell carcinoma. Prior to excision, the normal-appearing skin surrounding the tumor was marked in 2-mm increments. The tumor was then excised using Mohs micrographic surgery. The extent of the subclinical tumor invasion was calculated from the presurgical skin markings. For tumors with a diameter less than 2 cm, a minimum margin of 4 mm was necessary to totally eradicate the tumor in more than 95% of cases.

Surgical alternatives for the short bowel syndrome.

Since the introduction of total parenteral nutrition an increasing number of patients are surviving massive intestinal resection. However, the expense, morbidity, and inconvenience of this therapy have created interest in surgical alternatives for the treatment of the short bowel syndrome. The goals of surgical therapy in the short bowel syndrome are to slow intestinal transit, increase the area of absorption, and reduce gastric hyperacidity. Antiperistaltic segments or colon interposition benefit patients with sufficient absorptive area, but rapid intestinal transit. Intestinal valves yield inconsistent results. Recirculating loops are associated with prohibitive morbidity and mortality. Experience with intestinal pacing is limited. Patients with dilated bowel segments may benefit from intestinal tapering or lengthening. Growing neomucosa holds promise but has not been evaluated clinically. Despite recent advances in immunosuppression the results of transplantation remain unsatisfactory. Gastric hyperacidity can be effectively controlled by H2 receptor antagonists. None of the operations for treatment of the short bowel syndrome is sufficiently safe and effective to recommend their routine use. Operations should be performed only on selected patients to achieve specific goals. Although investigation continues, our emphasis should continue to be prevention of intestinal resection and conservation of as much of the intestine as possible when massive resection is necessary.

Surgical therapy for the short bowel syndrome

The introduction of total parenteral nutrition has resulted in more patients surviving massive intestinal resection. Long-term parenteral nutrition is expensive, has potential complications, and causes inconvenience for the patient. Therefore, interest persists in surgical therapy for the short bowel syndrome. The goals of surgical therapy in the short bowel syndrome are to slow intestinal transit, increase the area of absorption, and reduce gastric hyperacidity. Patients with sufficient absorptive area, but rapid intestinal transit, benefit from antiperistaltic segments or colon interposition. Intestinal valves yield inconsistent results. Recirculating loops are associated with prohibitive morbidity and mortality. Experience with intestinal pacing is limited. Patients with dilated bowel segments may benefit from intestinal tapering or lengthening. Growing neomucosa holds promise but has not been evaluated clinically. Recent improvement in the results of intestinal transplantation in animals may warrant clinical trials. The efficacy of H 2 receptor antagonists makes procedures for reducing gastric hyperacidity less necessary. None of the operations to treat the short bowel syndrome are sufficiently safe and effective to recommend their routine use. Operations should be performed only on selected patients to achieve specific goals. Although investigation continues, our emphasis should continue to be conservation of as much of the intestine as possible when massive resection is necessary.

The drooling patient: Evaluation and current surgical options

Drooling is a common stigmatizing problem necessitating increased care in the neurologically damaged child or adult. Appropriate physiotherapy frequently reduces drooling but rarely eliminates it. The goal of surgical therapy is to minimize drooling while specifically avoiding the complication of xerostomia. During the past 4 years, 37 of 46 patients assessed have undergone surgery specifically intended to reduce drooling. Good results have been obtained with bilateral transtympanic neurectomy procedures; it is the surgical procedure of choice in the more retarded patient. Encouraging results have been obtained in six patients with bilateral submandibular duct relocation; because of increased operative morbidity, it is the procedure of choice in the less retarded child.

What To Do About Tic Douloureux

Tic douloureux is a common disease that causes excruciating pain. It is a central pain due to a lesion within the trigeminal nerve or brain stem. The majority of patients with tic douloureux are successfully treated by pharmacotherapy with phenytoin or carbamazepine. Those who fail under medical management should promptly be offered modern surgical alleviation of their pain: percutaneous radiofrequency gangliolysis or decompression of the trigeminal nerve at the brain stem (Jannetta procedure). The goal of surgical therapy should be pain relief with minimal sensory loss; the complications of surgery are usually due to denervation of the face or eye. Patients with tic douloureux should not be subjected to extraneous drug therapy or other procedures with a low likelihood of long-term success.

Aortic arch in the neck

In this report we shall describe the first case of cervical aortic arch in which the anomaly was diagnosed clinically and the patient operated upon successfully. The lesion, an aorta with the apex of its arch located in the neck, is rare. Its importance lies (1) in the need to consider it in the differential diagnosis of pulsating neck masses; (2) in its vulnurability to trauma and susceptibility to rupture; and (3) in the need for relief of concomitant symptoms of tracheal and esophageal compression. Anatomic and clinical features of all known cases are presented with a description of noninvasive techniques for differential diagnosis. The goals of surgical therapy are division of the vascular ring with all bands and ligaments, resection of the pulsating neck mass, and restoration of aortic continuity.