Long-term Conservative Treatment Research Articles

SURGEON EXPERIENCE WITH PENILE FRACTURE

The experience of a single surgeon with a series of 34 penile fractures, including 29 corrected surgically and 5 managed conservatively, at 3 large inner city medical centers in an 11-year period is presented. Standard diagnostic and therapeutic modalities are described that have evolved with time. Between 1989 and 1999, 34 patients 18 to 38 years old (mean age 27 at presentation) were evaluated after blunt trauma to the erect penis. The interval from injury to presentation was between 6 and 72 hours. Of these patients 32 and 2 had been injured during sexual intercourse and masturbation, respectively. Surgery in 29 cases involved a degloving incision, and intraoperative evaluation of the corpora and urethra by radiography or saline injection. Five patients were treated conservatively for presumed penile fracture after they refused diagnostic confirmation and/or surgery. Injury involved unilateral and bilateral corporeal rupture in 25 and 3 cases, respectively, and urethral injury in 5. Urinalysis in 6 patients demonstrated microscopic hematuria with 5 to 10 red blood cells, although there were several false-negative urethrograms and cavernosograms. At followup 33 of the 34 patients available reported erection adequate for intercourse without erectile or voiding dysfunction, while 2 reported mild to moderate curvature. A degloving procedure with a urethral catheter in place provides the best exposure and orientation. In addition, saline injection may demonstrate additional corporeal body and/or urethral pathology as well as assess the integrity of repair. Although surgical repair was not associated with serious sequelae, a small subgroup of patients with presumed penile fracture also had no sequelae.

クローズドロック症例（非ロック解除例）における臨床所見の推移について

We investigated the changes of signs and symptoms in 18 cases suffering from persistent closed lock.The results were as follows:1. Severe pain was present in all patients at the beginning of treatment. At the end of treatment, severe pain was noted in only one patient. Pain disappeared or improved in the other patients. Continued improvement was found during follow-up.2. Average maximum mouth opening was increased from 25.2 mm to 35.3 mm after conservative treatment. This trend also continued during follow-up (ave. 37.3 mm).3. Crepitation was noted in 44.4% of the patients at first visit. It increased during conservative treatment, and was noted in 77.8% at the end of treatment. However, crepitation decreased, and was recognized in 55. 6% during follow-up.4. The incidence of radiographic bone changes (erosion, osteophytes and/or deformity) of the condylar head was 66.7% initially and increased during treatment and follow-up.5. These results indicate that severe pain and trismus in these patients improved to some degree by long-term conservative treatment, but prolonged careful follow-up is required in persistent cases, especially those with bone changes and/or crepitation.

Spontaneous regression of oesophageal varices after long-term conservative treatment: Retrospective study in 20 patients with alcoholic liver cirrhosis, posthepatitic cirrhosis and haemochromatosis with cirrhosis

Spontaneous regression of oesophageal varices in liver cirrhotics without sclerotherapy or shunt operation has only been known in alcoholic cirrhosis after alcohol abstinence. Therefore, 20 liver cirrhotics of different aetiologies were controlled over 13 years (six alcohol, nine hepatitis, five haemochromatosis). Under strict alcohol abstinence, all underwent treatment with lactulose and ammonia-reducing amino acids to improve the urea synthesis in the liver. Since gastrointestinal bleeding was not observed, neither sclerotherapy nor shunt operation were performed. Initially, all patients had oesophageal varices (nine stage III, three stage II–III, eight stage II). Following conservative therapy, eight cirrhotics showed total regression and twelve showed stage I–II. Their Child-Pugh index, and urea synthesis rate unproved significantly. Possible causes for the spontaneous regression of oesophageal varices are strict abstinence from alcohol, spontaneous seroconversion in six posthepatitic B-cirrhoses and consequent phlebotomy in haemochromatosis.

Natural history of atrial septal defect of secundum type in the middle-aged. Medical versus surgical therapy.

10 middle-aged patients with atrial septal defect of the secundum type (ASD II) were referred to surgery, but for several noncardiological reasons the operation was not performed. 5 patients were reexamined after an interval from 6 1/2 to 15 years. During the follow-up period only relatively minor changes in pulmonary arteriolar resistance had occurred and all patients were still acceptable candidates for surgical treatment. The other 5 patients died after a period of time ranging from 2 weeks to 16 1/2 years from conditions directly or indirectly related to the cardiac malformation. During the same period of time, 84 ASD II patients underwent surgery with a mortality rate of 8.3% after 74 months, including 2 hospital deaths. These results suggest that middle-aged patients with ASD II without obstructive pulmonary hypertension should be operated on without delay, but that in a significant number of cases, long-term conservative treatment is not associated with an increase in pulmonary arteriolar resistance.

Arguments against long-term conservative treatment of oesophageal strictures due to corrosive burns.

Thirty-two patients are presented with late complications after a corrosive burn of the oesophagus. From this group of 32 cases 11 had fistulae and mediastinal abscesses after perforation of the gullet; 11 patients developed a tight peptic stricture in the narrowed oesophagus due to traction-type hiatal hernia as a result of the longitudinal contraction of the fibrotic oesophagus; cancer developed in the corrosive stricture in 10 patients, inoperable in five. Arguments against long-term conservative treatment of narrowed and fibrotic oesophageal strictures are presented. Early operation gives final relief from dysphagia and prevents late complications. The risk of intrathoracic oesophageal replacement with a segment of bowel/colon or jejunum in uncomplicated cases is 2·4% in our series of 42 cases.