Indications For Operative Intervention Research Articles

Management of patients with adrenal myelolipoma: experience from a tertiary referral centre.

Adrenal myelolipomas are rare, benign, tumours of the adrenal cortex. This study reports the experience of a tertiary adrenal surgery referral centre's approach to the management of patients with adrenal myelolipoma. A retrospective observational cohort study was conducted on all adult patients (> 18years age) diagnosed with adrenal myelolipoma from January 1, 2014, to December 30, 2022. Demographics, imaging characteristics, histological diagnosis (where applicable) and follow-up data were compared between patients undergoing surgery and those referred to surveillance. Indications for operative intervention were recorded at the time of multidisciplinary team discussion, consisting of surgeons, endocrinology physicians, radiologists, pathologists and specialist nursing representatives. Of the 522 patients with an adrenal lesion discussed in adrenal tumour meeting between 2014 and 2022, n = 15 (2.8%) were diagnosed with adrenal myelolipoma. Of the 15 patients, 4 underwent adrenalectomy at first presentation (27%), while 1 patient underwent adrenalectomy after interval follow-up. Indications for operative intervention were as follows: 'indeterminate lesion' (n = 3), 'abdominal pain and size (> 4cm)' (n = 1) and 'mass effect on adjacent organs' (n = 1). The mean rate of lesion growth in patients referred for surveillance (n = 10) was 0.13cm/year. Histology confirmed adrenal myelolipoma as the diagnosis in all resected tumours. For patients with adrenal myelolipoma, the presence of symptoms and/or indeterminate features on imaging may be more clinically useful indications for operative intervention over size alone. The surveillance of adrenal myelolipomas, even in patients with adrenal lesions > 4cm, is a safe clinical strategy, provided the imaging characteristics are benign and patients remain asymptomatic.

CLAVICULAR OSTEOTOMY FOR SURGICAL EXPOSURE OF THE SHOULDER JOINT: FUNCTIONAL OUTCOMES, COMPLICATIONS, AND SURGICAL TECHNIQUE. A REGIONAL NZ EXPERIENCE

AimClavicular osteotomy was described as an adjunct to deltopectoral approach for improved exposure of the glenohumeral joint. This study aims to present contemporary outcomes and complications associated with the routine use of clavicular osteotomy by a single surgeon in a regional setting within New Zealand.MethodsA retrospective case series of patients who have undergone any shoulder arthroplasty for any indication between March 2017 to August 2022. This time period includes all patients who had clavicular osteotomy(OS) and patients over an equal time period prior to the routine use of osteotomy as a reference group (N-OS).Oxford Shoulder Score (OSS) and a Simple Shoulder Test (STT) were used to assess functional outcomes and were compared with the reported literature. Operative times and Complications were reviewed.Results66 patients were included in the study. 33 patients in the OS group and 33 in the N-OS group. No difference in age, sex, indications for operative intervention and the surgery provided was identified. No significant difference in operative time between groups (N-OS 121 minutes; OS 128 minutes).No clinically significant difference was identified in the OSS (N-OS; mean 38 vs OS 39) or the STT (N-OS 8.3 vs OS 9). The outcomes scores of both groups are in keeping with published literature.Two post operative clavicle fractures, one prominent surgical knot occurred in the OS that required further surgical intervention. Two cases of localized pain over the clavicle and one case of the prominent lateral clavicle were reported in the OS group. Two cases of localized pain over clavicle reported in the N-OS group.ConclusionUse of clavicular osteotomy is not associated with inferior patient reported. The osteotomy introduces specific risks, however, the study provides evidence that these complications are infrequent and avoidable. Surgeons should feel confident in using this adjunct when exposure to the shoulder is difficult.

GASTROINTESTINAL BLEEDING DUE TO A MALIGNANT COLODUODENAL FISTULA: CASE REPORT AND LITERATURE REVIEW

Background: Coloduodenal fistulas are a rare occurrence seen in 0.1% to 0.14% of colon cancer patients. Malignant coloduodenal fistulas are associated with poor prognosis given presence of locally advanced, and often times metastatic disease at the time of diagnosis. Patients can present with abdominal pain, vomiting and occasionally, bleeding. Intractable symptoms, obstruction and bleeding are indications for operative intervention. Surgical management can vary depending on the extent of duodenal involvement; from sleeve or segmental resection of the duodenum to pancreaticoduodenectomy. We describe a patient that underwent a right hemicolectomy and pancreaticoduodenectomy for a bleeding malignant coloduodenal fistula.

Diagnosis and treatment strategies of the multiligament injured knee : a scoping review protocol.

Multiligament knee injuries (MLKI) are devastating injuries that can result in significant morbidity and time away from sport. There remains considerable variation in strategies employed for investigation, indications for operative intervention, outcome reporting, and rehabilitation following these injuries. At present no study has yet provided a comprehensive overview evaluating the extent, range, and overall summary of the published literature pertaining to MLKI. Our aim is to perform a methodologically rigorous scoping review, mapping the literature evaluating the diagnosis and management of MLKI. This scoping review will address three aims: firstly, to map the current extent and nature of evidence for diagnosis and management of MLKI; secondly, to summarize and disseminate existing research findings to practitioners; and thirdly, to highlight gaps in current literature. A three-step search strategy as described by accepted methodology will be employed to identify peer-reviewed literature including reviews, technical notes, opinion pieces, and original research. An initial limited search will be performed to determine suitable search terms, followed by an expanded search of four electronic databases (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Web of Science). Two reviewers will independently screen identified studies for final inclusion. We will map key concepts and evidence, and disseminate existing research findings to the wider orthopaedic and sports medicine community, through both peer-reviewed and non-peer-reviewed literature, and conference and in-person communications. We will highlight gaps in the current literature and determine future priorities for further research.Cite this article: Bone Jt Open2022;3(11):894-897.

Surgery Is Underutilized in the Management of Tertiary Hyperparathyroidism.

Tertiary hyperparathyroidism (3HPT) is observed in up to 40% of renal transplant patients. Standard guidelines defining 3HPT and indications for operative intervention are not well described. We conducted a retrospective, single-institution cohort study of patients who underwent renal transplant between January 1, 2012 and January 30, 2018, with a minimum of 13-month follow-up and at least 1y of allograft function. We defined 3HPT as having elevated serum level parathyroid hormone (>88 pg/mL) after successful renal transplantation or multiple instances of elevated serum calcium starting at least 3mo after transplant. We compared graft failure rates after stratifying the cohort based on management strategy: expectant, medical management with cinacalcet, and parathyroidectomy. Out of the 381 transplanted patients with functional grafts at 1y, 178 patients (46.6%) were found to have 3HPT. One hundred twenty-nine patients (72.5%) were managed expectantly without medications, 35 patients (19.7%) were managed medically, and 14 patients (7.8%) were managed with parathyroidectomy. Twenty-two patients (17.1%) in the observation group had graft failure, 4 patients (11.4%) in the medically managed group had graft failure, and 0 patients in the surgery group had graft failure. Surgical intervention was associated with decreased renal allograft failure when compared to the combined cohort of nonoperative 3HPT patients (P=0.03). All patients who underwent parathyroidectomy were cured and did not have graft failure as of December 30, 2019. Calcium elevation, but not PTH elevation, was associated with referral for parathyroidectomy on multivariable logistic regression analysis (P<0.01). At our institution, the referral rate for parathyroidectomy among patients with 3HPT remains low. Parathyroidectomy was associated with high cure rates and reduced graft failure. Surgery may be underutilized in the management of 3HPT.

Bilateral clavicle fractures: A Case Report and Review of Literature's

Clavicle fracture is one of common injuries in young adult and fracture in the middle third is the most common injury cases in clavicle fractures. Although clavicle fractures are often seen, in some circumstances bilateral clavicle fractures can occur due to high-energy impact injury, but this is an extremely rare and seldom reported on. Clavicle fracture is not commonly mentioned as an indication for operative intervention, but in cases of bilateral clavicle fracture surgical intervention managed to limit the duration of functional disability and allowing for an earlier functional recovery.

Role of Gastrografin in Patients With Small Bowel Obstruction.

IntroductionGastrografin (GGF) is a radiopaque contrast medium commonly used for diagnostic examination of the gastrointestinal (GI) tract. Available evidence suggests it has therapeutic and predictive value in the management of adhesional small bowel obstruction (ASBO). Thus, we investigated the use of GGF amongst patients who had a small bowel obstruction and audited the practice in University Hospital, Ayr.MethodsInitial retrospective data of patients who had gastrografin for small bowel obstruction were extracted from April 2015 to August 2019 and analysed. After our local presentation and on implementing a GGF protocol, we prospectively collected data from February to June 2020 to close our audit.ResultsGGF showed a comparable therapeutic effect on ASBO in both audit cycles (72.2%-66.7%). Approximately 50% of unresolved cases were operated within 24 hours of GGF administration in both cycles. GGF consistently demonstrated a therapeutic benefit in refractory faecal impaction (100% in both cycles) and postoperative ileus (≥ 80%). Early use of computed tomography (CT) (less than 24 hrs) did not confer any added advantage (82.5% v 61.5%), however, it helped in making an appropriate diagnosis and the subsequent early gastrografin usage (78.3% v 92.3%) in ASBO.ConclusionGGF serves a very good therapeutic purpose in resolving ASBO, refractory constipation, and in rare non-resolving cases of postoperative ileus. Early CT diagnosis of ASBO is advocated before the administration of gastrografin. Unsuccessful resolution after 24 hrs of GGF is an indication for operative intervention.

Anatomic Considerations and Reconstruction of the Thumb Flexor Pulley System.

Disruption to the flexor pulley system of the thumb is an infrequent but devastating injury that can lead to significant compromise in both strength and function. Acute rupture leads to pain, weakness, reduced range of motion (ROM), and potential bowstringing of the flexor tendons. Conservative treatment with a pulley ring should be considered in all patients. However, failure of conservative treatment and bowstringing of the thumb are indications for operative intervention. Reconstruction of the oblique pulley system can be performed either in situ or using a free palmaris longus graft. Care should be taken to identify the neurovascular bundles to avoid compression during the reconstruction. Conscious sedation protocols augmented by ultrasound-guided sheath blocks allow the patient to actively and strongly contract the flexor pollicis longus tendon intraoperatively to appropriately tension the construct for optimal results. Rehabilitation should be performed in a stepwise manner beginning with early passive ROM, active ROM, and finally strengthening at around 8 weeks postoperative.

Complex Liver Injury—a Quagmire to a Trauma Surgeon

Non-operative management has become a norm in patients with liver trauma and operative management is guided by hemodynamic status. Introduction of haemodynamic status. Introduction of contrast enhanced computed tomography (CECT) abdomen has made NOM possible by helping in exclusion of other injuries and identification of vascular injuries. Haemodynamic instability is now considered as an only absolute indication for operative intervention in liver injuries. However, liver trauma is associated with a large number of complications in the form of perihepatic abscess, hepatic necrosis, bile leak, etc. Patient’s undergoing operative intervention for liver trauma are more at risk for these complications. As such regular dynamic assessment is required for early identification and management of these complications. We present a case of a complex liver injury in a 27-year-old male who underwent operative intervention for liver trauma and had a varied number of liver trauma associated complications, with enterohepatic fistula as one of the rarest associated complications.

Peculiarities of vertebro-spinal cord injuries in the polytrauma patients

Objective. Elaboration of diagnostic criteria and qualitative methods of treatment in the polytrauma patients.&#x0D; Маterials and methods. The results of miniinvasive surgical and conservative treatment of 379 polytrauma and vertebral injuries patients on the base of the Clinic of Surgery and Orthopedics of the Medical Faculty in 2010 - 2018 yrs were analyzed. Characteristics of vertebral injuries in accordance to its segments and severity, as well as to other systems and abdominal organs were adduced.&#x0D; Results. Following strict indications for operative intervention and its conduction in the first 6 - 8 h in cases of complicated vertebral fractures constitutes a guarantee for improvement of the patient’s state and restoration of some functions of a spinal cord functions.&#x0D; Conclusion. The measures, directed towards early activization of the injured persons, must include primarily performance of surgical intervention on the injured organs, аnd then, when the possibility appears (if an adequate anesthesiological support is affordable) - the one-staged intervention on the injured vertebral column, especially in the patients, suffering complicated trauma, together - in its anterior and posterior segments.

Treatment of Acute Seymour Fractures.

Seymour fractures are distal phalanx fractures in children with a juxta-epiphyseal pattern. The purpose of our study was to investigate the treatments, outcomes, operative ;indications, and antibiotic choice for acute Seymour fractures (presenting within 24 h of injury), to better define optimal management. We hypothesized that: (1) cephalexin provides adequate antibiotic coverage for acute Seymour fractures; (2) most injuries will achieve good outcomes with management in the emergency department (ED) alone; and (3) indication for operative intervention is unsuccessful or unstable reduction in the ED. We performed a retrospective study of patients under 18 years old treated at a large pediatric hospital from 2009 to 2017 for an acute Seymour fracture. Study outcomes included management and antibiotic type, infection, fracture healing, malunion, physeal disturbance, nail dystrophy, antibiotic failure, and need for unplanned operative intervention. Mean age of patients was 10 years, with 43 males and 22 females sustaining 65 Seymour fractures. Fifty-eight cases (89%) were initially managed in the emergency department. Seven cases were initially managed with an operative intervention that included I&D, open reduction, and K-wire fixation. The most commonly cited surgical indication was unsuccessful closed reduction. Four patients initially managed in the ED required an unplanned operation, usually because of fracture redisplacement. Complications were rare, with superficial infections being most common. Most acute Seymour fractures can be successfully managed in the emergency department if stable reduction is achieved. Level IV, therapeutic.

Successful non-operative management of haemodynamically unstable traumatic splenic injuries: 4-year case series in a UK major trauma centre.

Management of traumatic splenic injury may be operative or non-operative (including embolization and conservative management). Traditionally, haemodynamic instability has been an indication for operative intervention. We aimed to report our experience of managing traumatic splenic injury at a regional major trauma centre in the UK over a 4-year period, with a particular focus on the non-operative management (NOM) of haemodynamically unstable patients. All patients with splenic injuries admitted to North Bristol NHS Trust from April 2012 to March 2016 were included. Patients were classified for analyses by injury severity (low or high grade), haemodynamic instability (defined as a reverse shock index < 1) and management category (operative or non-operative). 106 patients were included. Overall 85.8% of patients received NOM: 79.2% conservative and 6.6% interventional radiology. Two patients (2.4%) managed conservatively required further intervention. Haemodynamically stable and unstable patients were equally likely to receive NOM (89.7 and 81.3% respectively, p = 1). All unstable patients with low-grade injuries were managed conservatively and only one (2.7%) required further intervention. Two unstable patients with high-grade injuries (28.6%) underwent NOM successfully. These data support the safe application of non-operative management to haemodynamically unstable patients with traumatic splenic injury, particularly in those with low-grade injuries. Additional prospective work is required to define the subgroup of patients for whom this is appropriate and to determine the long-term outcomes of NOM.

Minimally invasive surgery for thoracolumbar spinal trauma.

The indications for operative intervention after thoracolumbar spine trauma have been well described. Advances in minimally invasive techniques, including percutaneous pedicle screw fixation and mini-open anterolateral retractor-based approaches can improve surgical outcomes when appropriately applied by reducing blood loss, operative duration and post-operative pain. Moreover, they allow for theoretical advantages by preservation of muscular and skeletal blood supply and innervation that is typically lost during the muscular dissection of open approaches. For thoracolumbar spine fractures, percutaneous fixation allows for internal bracing of unstable fractures during healing while maintaining sagittal alignment. In instances of neurological compromise from fracture retropulsion, corpectomies may be required, and mini-open lateral approaches adopted from degenerative disease applications allow for a minimally invasive manner to treat the defect. These further allow for placement of wide rectangular-footprint expandable vertebral body replacement devices to provide anterior column support. We believe this allows for lower rates of subsidence and helps to maintain the biomechanical integrity necessary to prevent post-traumatic malalignment and kyphosis. Together, these minimally invasive techniques combined supply the spine surgeon with a minimally invasive armamentarium to treat nearly all thoracolumbar spine trauma. Surgeons should be comfortable with the strengths and shortcomings of these approaches in order to successfully apply them for this pathology.

Abdominal Exploration in Neonates Using Transumbilical Exposure Compared with Transverse Laparotomies.

The vertical transumbilical incision (TU) technique during neonatal abdominal exploration involves dissection and ligation of umbilical vessels, which allow access to all quadrants of the abdomen and complete bowel evisceration with minimal violation to the anterior abdominal wall. We compared patient characteristics and outcomes for neonates undergoing TU with standard transverse exploration. A single-center retrospective review of neonates who underwent abdominal exploration between January 2010 and September 2015 was conducted after obtaining Institutional Review Board approval. Data included patient demographics, indication for operative intervention, operative details, complications, including incisional hernias, and long-term outcomes. There were 88 neonates under 4 months of age who underwent abdominal exploration, with a median age of 5.5 ± 17 days and a median gestational age of 32.8 ± 16 weeks. Exploration was emergent in 38 patients (43%) and 49 (56%) required ostomy formation. A transverse incision (TV) was used in 30 patients and a TU in 58 patients. Both groups had similar postoperative complication rates; 27 (47%) in the TU group and 11 (36%) in the TV group, P = .51. Median length of follow-up in the TU group was 5.1 ± 18 months and 6.2 ± 16 months in the TV group, P = .48. The TU group had 4 incisional/umbilical hernias (7%), none have required repair. TUs for abdominal explorations in neonates have similar outcomes as the standard TV while preserving the integrity of the anterior abdominal wall.

THE MANAGEMENT OF TURF TOE – A SYSTEMATIC REVIEW

Background. Turf toe is used to describe an injury occurring at the plantar aspect of the metatarsophalangeal- sesamoid complex of the hallux. Typically seen in athletes, it occurs due to hyperdorsiflexion and axial loading of the hallux metatarsophalangeal joint with the foot fixed in equinus. The injury causes pain and joint instability, missed athletic activity and potentially end careers. Turf toe can be managed conservatively or operatively, with controversy regarding the indications for operative intervention. This study aims to conduct a systematic review to determine whether and in what circumstances operative intervention is superior to conservative management of turf toe in adults. Methods. A systematic review of the literature was performed using PubMed, Embase, Cochrane and Scopus databases. The search terms used were “turf toe”, “first metatarsophalangeal joint injury”, “conservative”, “nonoperative”, and “operative”. All articles published in English reporting on the management of turf toe were reviewed. The primary outcome measure was the time to return to pre-injury activity with the secondary outcome of the time to symptom resolution. Results. Seven studies met the inclusion criteria. Three patients were successfully managed conservatively returning to athletic activity, on average at 12 weeks. Seventeen patients underwent surgical intervention with an average return to athletic activity at 18 weeks. Conclusion. Operative intervention was shown to give a successful outcome in patients with grade three turf toe injuries or those who have failed conservative management. However, there is insufficient evidence to determine whether operative intervention is superior to conservative management.

Adhesive disease of the abdominal cavity

After operations on the abdominal adhesions occur in 80-90% of cases, adhesive disease develops in 12-64% of cases. First about the causes of adhesions said George Punter in 1793. For the first time in the Russian literature on intraperitoneal adhesions mentioned V.P. Dobrovolsky in 1838. According to modern notions, adhesive disease is a separate nosological form, characterized by the formation of intra-abdominal adhesions, as a rule, manifested by recurrent episodes of intestinal obstruction or pain. The basis for the development of peritoneal commissures in abdominal cavity are a complex, diverse violations of the functions of various body systems. Trigger in the development of adhesion formation in abdominal cavity considered: mechanical, physical, infectious, implant, chemical factors and congenital anomalies (bands of lane, membranes of Jackson and others). As a result of inflammation of the peritoneum dystrophic process, accompanied by desquamation of the mesothelium and other connective tissue layers of the peritoneum, there is an allocation of exudate, coagulation of protein components and formation of fibrinous adhesions, which under normal fibrinolytic activity within 24-72 hours lysed. There are four degrees of prevalence of adhesions: grade I – local adhesions, occupying not more than 1/3 of one floor; II degree – additionally determined by single spikes in other areas. III and IV degree – adhesions, occupying 1/3 and 2/3 of the abdominal cavity, respectively. The clinical picture of adhesive disease is expressed aching pain in the abdomen, changing its character with the change of body position; periodic bloating, unstable chair; vomiting during exercise or after violation of the diet, the phenomena of complete or partial adhesive intestinal obstruction. Diagnostic informativeness of traditional x-ray methods is only 50-60%. The most informative is the use of contrast enterography and ultrasound examination of the abdomen with a directed study of problem areas of the abdomen. Prevention of adhesions is an important problem of practical surgery. Methods of preventing the formation of adhesions are the following: reduction of abdominal trauma, reducing inflammation in the area of operations, reducing the likelihood of deposition of fibrin in the free abdominal cavity, the suppression of postoperative paresis of the intestine, delimitation of the damaged serosal surfaces and interfere with adhesion by applying a protective film on the mesothelium. Application drugs does not negate the careful attitude to the tissues and accurate surgical interventions. Conservative treatment includes: electrophoresis lidazy, hydrocortisone, application of paraffin, ozokerite on the anterior abdominal wall, injection antispasmodics, nasogastric drainage, staging of hypertension and cleansing enemas and others. Indications for operative intervention are: absence of effect of conservative treatment, the deterioration of the patient, the symptoms of acute intestinal obstruction. The following types of surgery: enteroclysis, the imposition of intestinal anastomosis with or without bowel resection laparoscopic lysis of adhesions, entropicalia.

Concurrent Biliary Disease Increases the Risk for Conversion and Bile Duct Injury in Laparoscopic Cholecystectomy: A Retrospective Analysis at a County Teaching Hospital

Biliary tract disease remains a common indication for operative intervention. The incidence of concurrent biliary tract disease (>2 biliary tract disease processes) is unknown and the impact of more than one biliary tract diagnosis on outcomes remains to be defined. The objective of this study was to determine the effect of concurrent biliary tract disease on conversion rate and outcomes after laparoscopic cholecystectomy. A 5-year retrospective analysis of all patients who underwent a laparoscopic cholecystectomy was performed comparing those with a single biliary diagnosis to patients with concurrent biliary tract disease. Variables analyzed were conversion to open cholecystectomy, incidence of bile duct injury, use of endoscopic retrograde cholangiopancreatography and/or intraoperative cholangiogram, length of surgery, and duration of hospitalization. The incidence of concurrent biliary tract disease was 9 per cent and a conversion to open cholecystectomy was performed in 16 per cent of patients. After adjusting for confounding factors, concurrent biliary tract disease was predictive of conversion (odds ratio 1.6, 95% confidence interval 1.1-2.3, P = 0.03) and bile duct injury (odds ratio 2.5, 95% confidence interval 0.8-5, P = 0.01). Concurrent biliary tract disease patients were more likely to undergo intraoperative cholangiogram or endoscopic retrograde cholangiopancreatography, as well as longer operation and length of stay.

Performance-Based Outcomes after Operative Management of Athletic Pubalgia / Core Muscle Injury in National Football League Players

Objectives:Athletic pubalgia is a condition in which there is an injury to the core musculature that precipitates groin and lower abdominal pain, particularly in cutting and pivoting sports. These are common injury patterns in the National Football League (NFL); however, the effect of surgery on performance for these players has not been described.Methods:Athletes in the NFL that underwent a surgical procedure for athletic pubalgia / core muscle injury (CMI) were identified through team injury reports and archives on public record since 2004. Outcome data was collected for athletes who met inclusion criteria which included total games played after season of injury / surgery, number of Pro Bowls voted to, yearly total years and touchdowns for offensive players and yearly total tackles sacks and interceptions for defensive players. Previously validated performance scores were calculated using this data for each player one season before and after their procedure for a CMI. Athletes were then matched to control professional football players without a diagnosis of athletic pubalgia by age, position, year and round drafted. Statistical analysis was used to compare pre-injury and post-injury performance measures for players treated with operative management to their case controls.Results:The study group was composed of 32 NFL athletes who underwent operative management for athletic pubalgia that met inclusion criteria during this study period, including 18 offensive players and 16 defensive players. The average age of athletes undergoing this surgery was 27 years old. Analysis of pre- and post-injury athletic performance revealed no statistically significant changes after return to sport after surgical intervention; however, there was a statistically significant difference in the number of Pro Bowls that affected athletes participated in before surgery (8) compared to the season after surgery (3). Analysis of durability, as measured by total number of games played before and after surgery, revealed no statistically significant difference.Conclusion:National Football League players who undergo operative care for athletic pubalgia have a high return to play with no decrease in performance scores when compared to case-matched controls. However, the indications for operative intervention and the type of procedure performed are heterogeneous. Further research is warranted to better understand how these injuries occur, what can be done to prevent their occurrence, and the long term career ramifications of this disorder.

Outcomes of Anterolateral Thoracotomy With or Without Partial Sternotomy for Kommerell Diverticulum

Kommerell diverticulum is a rare aortic arch anomaly. The indications for operative intervention and surgical strategy are still controversial. The standard surgical procedure at our institution is total aortic arch plus descending aortic replacement using anterolateral thoracotomy with partial sternotomy. The aberrant subclavian artery is reconstructed anatomically or extraanatomically. From 2002 to 2014, 6 patients (1 woman), aged 55 to 78 years, underwent graft replacement through an anterolateral thoracotomy or anterolateral thoracotomy with a partial sternotomy approach for Kommerell diverticulum. All patients underwent graft replacement of the descending aorta or total aortic arch plus descending aorta in addition to aberrant subclavian artery reconstruction. No hospital deaths or major complications occurred. Recurrent nerve injury developed at discharge in 1 patient. All patients were well during the follow-up period (range, 11 to 116 months). Kommerell diverticulum and its associated symptoms were surgically treated with acceptable outcomes.

Ureterocele in newborns, infants and children: Ten year prospective study with primary endoscopic deroofing and double J (DJ) stenting

AimTo evaluate the success of endoscopic deroofing with double J (DJ) stenting as a primary treatment modality of uncomplicated ureterocele. Patients and methodsAll babies with uncomplicated ureterocele referred to us between 2005 and 2015 were to be prospectively recruited into the study without any exception. The preoperative management would include ultrasound KUB on a fixed protocol, micturating cystourethrogram, DTPA scan and MRU (magnetic resonance urography) or IVP (intravenous pyelography). Those who had non-obstructing ureterocele were to be followed conservatively. The indications for operative intervention were to be obstructed ureterocele, bladder outlet obstruction, recurrent UTI or progressive renal scarring. They were then to be taken for cystoscopy in diuretic phase for endoscopic deroofing and DJ stenting with 9F resectoscope. Four weeks later, the DJ stent was to be removed after examining the deroofing in each patient. They were then followed up for future development of symptoms and need for secondary surgery with anatomical and functional imaging as necessary. ResultsForty three consecutive patients (47 ureterocele units) with ureterocele were recruited into the study between 2005 and 2015. Thirty four patients were managed by endoscopic first approach with ureterocele deroofing and DJ stenting. Four babies were asymptomatic and did not show obstructed drainage pattern on DTPA and hence were managed conservatively and kept on follow-up. Four patients underwent primary open surgery and reconstruction because of presentation with complications. Ectopic ureteroceleThere were 17 patients with ectopic ureterocele. Thirteen underwent primary endoscopic deroofing. Three underwent open surgery and one underwent robotic bilateral ureterocele excision and ureteric reimplantation. Eight children out of thirteen are completely asymptomatic after the endoscopic incision. On ultrasound evaluation 8/13 have resolution of the hydronephrosis and 5/13 have stable hydronephrosis with no increase in dilatation. None of these 13 children have required a second endoscopic procedure for inadequate decompression of the ureterocele. None of the 13 patients have any voiding difficulty or incontinence. 2/13 cases with recurrent UTI and persistent symptoms, required secondary surgery. This constituted 15% secondary surgery in the ectopic ureterocele category. Orthotopic ureteroceleThere were 21 patients out of 22 with orthotopic ureterocele who underwent endoscopic deroofing. Six out of these 21 patients had episodes of UTI, of which three had resolution of the reflux and two had downgrading of reflux. One child continued to have recurrent UTI and needed a laparoscopic nephroureterectomy. Eighteen children are completely asymptomatic after the initial endoscopic deroofing. The rate of secondary surgery was 4.7% in orthotopic ureterocele group, where nearly 50% have more than five years follow-up. None of our patients who are more than five years, have had any urinary incontinence or voiding dysfunction. All patients remain on follow-up from 6months to 10years (median 5years). ConclusionAt this stage of our study with median follow-up of 5years (6months–10years), we suggest that primary endoscopic deroofing with DJ stenting for obstructing ureterocele is the best initial approach for adequate decompression and reducing the rate of secondary surgery.