Preoperative Physical Findings Research Articles

Is early appendectomy in adults diagnosed with acute appendicitis mandatory? A prospective study

IntroductionPrompt appendectomy has long been the standard of care for acute appendicitis in order to prevent complications such as perforation, abscess formation, and diffuse purulent or fecal peritonitis, all resulting in increased morbidity and even mortality. Our study was designed to examine whether the time from the beginning of symptoms to operation correlates with the pathological degree of appendicitis, incidence of postoperative complications, or increased length of hospital stay.MethodsA prospective study of 171 patients who underwent emergent appendectomy for acute appendicitis in the course of 2 years was conducted in a single tertiary medical center. The following parameters were monitored and correlated: demographics, time from the onset of symptoms until the arrival to the emergency department (patient interval (PI)), time from arrival to the emergency department (ED) until appendectomy (hospital interval (HI)), time from the onset of symptoms until appendectomy (total interval (TI)), physical examination, preoperative physical findings, laboratory data, pathologic findings, complications, and length of hospital stay.ResultsThe degree of pathology and complications were analyzed according to the time intervals. The time elapsed from the onset of symptoms to surgery was associated with higher pathology grade (p = 0.01). We found that longer time from the onset of symptoms to hospital arrival correlates with higher pathology grade (p = 0.04), while there was no correlation between the hospital interval and pathology grade (p = 0.68). A significant correlation was found between the pathology grade and the incidence of postoperative complications as well as with increased length of hospital stay (p = 0.000).ConclusionTime elapsed from the symptom onset to appendectomy correlates with increased pathology grade and complication rate. This correlation was not related to the HI. Since the HI in our study was short, we recommend an early appendectomy in adults in order to shorten the TI and the resulting complications.

Is epineurectomy necessary in the surgical management of carpal tunnel syndrome?

In this study, it was aimed to determine whether median nerve epineurectomy is beneficial in the surgical management of carpal tunnel syndrome (CTS). The study enrolled 72 patients including 34 patients without epineurectomy (Group A) and 38 patients with epineurectomy (Group B). Surgery was performed in patients with severe electrodiagnostic CTS findings, CTS duration >1 year and flattening along with hypervascularization in median nerve. All patients were assessed by visual analog scale, two-point discrimination test as well as subjective and objective findings at baseline and on the months 1, 3, and 6 after surgery. The mean age was 58.3 years (42-75 years) in 38 patients who underwent an epineurectomy, whereas it was 61.5 years (41-82 years) in 34 patients who did not have an epineurectomy. The groups were similar with regard to age, gender, duration of symptoms, and preoperative physical findings. Mean visual analog scale (VAS) scores were 1.7 in Group A and 1.8 in Group B. Again, these differences were not significant, on physical examination, the average two-point discrimination in the distribution of the median nerve was 4.9 mm (range: 3-11 mm) in Group A and 5.3 mm (range: 3-10 mm) in Group B. In postoperative evaluations, there was a better improvement in visual analog scale scores, two-point discrimination test and subjective symptoms including dysesthesia, pain and nocturnal pain within first 3 months; however, there was no marked difference in objective and subjective findings on the 6th month. No complication or recurrence was observed. We believe that median nerve epineurectomy is unnecessary in the surgical management of primary CTS since it has no influence on the midterm outcomes.

Anterolateral Ankle Pain: Comparison of Two Areas of Clinical Anterolateral Pain Using Imaging and Arthroscopic Findings

Background: Anterolateral ankle pain is a common symptom after ankle sprain in athletes. Although the pathologic conditions producing anterolateral ankle pain have been researched, we still do not know the exact relationship between structural abnormality and anterolateral ankle pain. The aim of this study was to assess two distinct areas of anterolateral ankle pain by comparing magnetic resonance imaging (MRI) and computed tomography (CT) findings with those of arthroscopic examination. Methods: From 2011 to 2014, a total of 32 ankles were examined. Preoperative physical findings, MRI and CT findings, and systematic arthroscopic examination were retrospectively reviewed. Abnormalities of two anterolateral ankle regions, the lateral shoulder and anterior talofibular ligament (ATFL), were recorded. Results: Tenderness over the lateral shoulder region was present in 20 patients (62.5%) and tenderness over the ATFL region was present in 17 patients (54.1%). CT abnormalities were found in 28 patients (87.5%). MRIabnormalities were found in 25 patients (78.1%). On arthroscopy, 32 patients (97.0%) showed abnormalities in the anterolateral area. Statistical analyses showed correlations between pathology on imaging and arthroscopic examinations, and clinical pain. In the lateral shoulder region, synovitis/scar tissue and accessory (Bassett’s) ligament correlated with clinical pain. In the ATFL region, an abnormal ATFL and osteochondrial lesions correlated with clinical pain. Conclusion: Various pathological findings were observed on arthroscopic examination. Although anterolateral impingent syndrome is considered to be due to soft tissue impingement, osteocartilaginous abnormalities were identified in these patients. Inadequate care resulting in scar tissue formation and the presence of microinstability are possibly etiologic factors associated with abnormal findings. In order to prevent these conditions, improvements in the initial treatment of ankle injuries is warranted.

Technical Difficulties and Their Prediction in 2-Portal Endoscopic Carpal Tunnel Release for Idiopathic Carpal Tunnel Syndrome

This study aimed to identify technical difficulties encountered during 2-portal endoscopic carpal tunnel release (ECTR) and to determine their incidence. Furthermore, we assessed the possibility of preoperatively predicting such technical difficulties. We retrospectively reviewed the records of 311 hands of 311 patients with idiopathic carpal tunnel syndrome who underwent ECTR with our modified Chow 2-portal technique. Any technical difficulties during the procedure were reviewed and correlated with preoperative physical findings, nerve conduction studies, and magnetic resonance imaging findings, by use of the t test, χ(2) test, and binary regression analysis. One or more difficulties were encountered in 139 of 311 hands (44.7%), whereas surgery in the remaining 172 hands (55.3%) was performed without any difficulties. Technical difficulties encountered were as follows: tight access in 61 hands, difficulty in identifying the distal part of the transverse carpal ligament through the exit portal in 35 hands, synovial tissue being caught at the cannula tip when pulling it out of the carpal tunnel in 39 hands, steep angle of the cannula assembly with difficulty in emerging from the exit portal in 29 hands, and other difficulties. Postoperative worsening of symptoms was observed in 8 hands (2.6%), in all of which technical difficulties were encountered. Tight access was noted in younger patients and those with a small cross-sectional area at the hook-of-hamate level. The entire ECTR procedure for older female patients was more likely to be easily performed. The surgeon may face a variety of technical difficulties during ECTR. Technical difficulties were most often encountered during introduction of the cannula assembly into the carpal tunnel and pulling it out of the exit portal. Older female patients may be the best candidates for 2-portal ECTR. Level IV, therapeutic case series.

Correlation between the rotational degree of the dial test and arthroscopic and physical findings in posterolateral rotatory instability

Diagnosing posterolateral rotatory instability (PLRI) is difficult because it occurs rarely, takes time to manifest, and no single definitive tool exists in diagnosing posterolateral corner injuries. We sought to evaluate the correlation between rotational degrees in the dial test and physical and arthroscopic findings that surgically verified PLRI in the knee joint. Patients (n = 67) who were diagnosed as having PLRI and received posterolateral reconstruction (n = 57) and repair (n = 10) from 1998 to 2006 were recruited. Preoperative physical findings were evaluated under anesthesia, and arthroscopic findings during surgeries were analyzed. A dial test with post-anesthesia (spinal or general) was conducted. We divided patients into three subgroups (A: <15 degrees, B: 15-20 degrees, and C: >20 degrees), according to differences in rotational degrees in the dial test. All tests showed significant differences among the three groups and positive findings increased as the rotational degrees increased. No test showed a statistically significant difference in the specific group. All tests except for popliteal hiatus widening showed significant differences among the three groups and positive findings also increased as the rotational degrees increased. The total incidence and positive rate of each physical examination and the popliteal hiatus arthroscopic findings in PLRI significantly increased as the rotational degree in the dial test increased. The number of positive findings on physical examination was larger than the number of positive findings by arthroscopy in all three groups.

Clinical significance of the arthroscopic drive-through sign in shoulder surgery

Purpose: During arthroscopy of the shoulder, the ability to pass the arthroscope easily between the humeral head and the glenoid at the level of the anterior band of the inferior glenohumeral ligament is considered a positive drive-through sign. The drive-through sign has been considered diagnostic of shoulder instability and has been associated with shoulder laxity and with SLAP lesions. The goal of this study was to examine the prevalence of the drive-through sign in patients undergoing shoulder arthroscopy and to determine its relationship to shoulder instability, shoulder laxity, and to SLAP lesions. Type of Study: Case series. Methods: We prospectively studied 339 patients undergoing arthroscopy of the shoulder for a variety of diagnosis from 1992 to 1998. The drive-through sign was performed with the patients in a lateral decubitus position and under general anesthesia. The drive-through sign was correlated with preoperative physical findings, intraoperative laxity testing, and with intra-articular pathology at the time of arthroscopy. Results: The arthroscopic evaluation showed that drive-through sign was positive in 234 (69%) shoulders. For the diagnosis of instability, the drive-through sign had a sensitivity of 92%, a specificity of 37.6%, a positive predictive value of 29.9%, a negative predictive value of 94.2%, and an overall accuracy of 49%. There was an association between the drive-through sign and increasing shoulder laxity, but not with SLAP lesions. Conclusions: This study shows that a positive drive-through sign is not specific for shoulder instability but is associated with shoulder laxity. This arthroscopic sign should be incorporated with other factors when considering the diagnosis of instability.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 1 (January), 2001: pp 38–43

An update on the classification of endometriosis.

The challenge of creating a satisfactory classification of endometriosis remains to be answered. The ability of the current classification schemes to predict pregnancy outcome or to aid in the management of pelvic pain is recognized to be inadequate. Further revisions of the current classification scheme are anticipated as the understanding of how endometriosis contributes to infertility and pelvic pain evolves. In any revision of the classification system, use of empirically derived weights and breakpoints to define disease stages based on outcome data in larger clinical trials should be attempted. It is also possible that additional factors such as CA-125 level or lesion characteristics may be shown to play an important role in prognosis. If so, these will need to be accounted for in the classification scheme. Careful and consistent use of the recommendations of the American Society for Reproductive Medicine classification of endometriosis subcommittee should allow for collection of data for use in further revisions. It is quite possible that a classification scheme that is designed to predict outcome with respect to pregnancy may be totally inadequate in assessing patients who have endometriosis and pelvic pain. Factors found to be important in the assessment of pelvic pain may be different from those involved with the pathophysiology of endometriosis and infertility. The AFS form suggested for use in the management of endometriosis in the presence of pelvic pain allows for recording of variables such as depth of invasion, histology, as well as documenting adjunct investigations and preoperative physical findings. Such prospective data collection and review in large centers may provide a large clinical base from which to derive empirical point scores and breakpoints in a classification scheme.

OCCULT BREAST CARCINOMA PRESENTED WITH AN AXILLARY LYMPH NODE METASTASIS-REPORT OF A CASE-

A 52-year-old woman was reffered to the hospital for investigation of a left axillary mass. A biopsy of the left axillary nodes taken 3 months prior to admission had confirmed the presence of metastasis from epithelial carcinoma; however, preoperative physical findings and radiographic studies revealed no malignant disease anywhere in the body. The patient underwent a modified radical mastectomy for the left breast and the obtained specimen was cut longitudinally at intervals of 5mm. Small lesions, 8mm×5mm and 5mm×3mm in diameter, were detected in the area C, the pathological findings of which were identical to those of the left axillary lymph nodes that had been resected preoperatively. The patient was treated with adjuvant chemotherapy for 14 months and no evidence of recurrence has been found as of 14 months after the operation. This case report serves to demonstrate that the patient with occult breast carcinoma presenting with an axillary mass should undergo the treatment for the ipsilateral breast, such as mastectomy and/or radiation with chemotherapy, due to the high possibility of this lesion being a focus of metastasis.

Anatomical, Morphological and Volumetric Analysis: A Review of 759 Cases of Testicular Maldescent

Undescended testis is the most frequent disorder of male sexual differentiation affecting 0.8% of all boys by age 1 year. Anatomical and descriptive features of undescended testis lack standardization, and often do not reflect intraoperative findings. We review a large cohort of patients treated for undescended testis and analyze anatomical, morphological and volumetric findings at orchiopexy. Of 759 patients 1 month to 9 years old entered into the study between 1985 and 1990 at our hospital 55% underwent surgery between ages 8 months and 4 years, 15.5% had bilateral undescended testis and 27.6% had a nonpalpable gonad. Preoperative physical findings correlated poorly with intraoperative observation with respect to testicular position. An ectopic gonad was diagnosed in 15% of the patients, most of whom had a patent processus vaginalis. Gubernacular attachment was in the scrotum in only a third of all cases studied. Undescended testes were softer and smaller than the contralateral gonad in the majority of cases. To our knowledge ours is the first study to correlate preoperative and intraoperative findings in cases of undescended testis. New anatomical as well as morphological and volumetric data are provided.

Irradiation induced salivary gland neoplasia.

Twenty-six patients with a prior history of irradiation for benign conditions of the head and neck and salivary gland abnormalities are reported. All the patients had preoperative physical findings suggestive of tumor, not glandular infection. Forty-six per cent of the patients had one carcinoma and 11% had two carcinomas within the irradiated field. Eight of the 11 malignant tumors in these 26 patients were in the parotid gland. The nonmalignant salivery changes were similar to those previously reported in glands receiving therapeutic irradiation for carcinoma.

Exploratory laparotomy in patients with penetrating wounds of the abdomen

During a seven year period, 370 penetrating wounds of the abdomen were explored surgically. In retrospect, one hundred of these wounds (27 per cent) did not enter the peritoneal cavity. Eighteen per cent of these hundred patients manifested significant intraabdominal symptoms. All hundred patients were operated on with no mortality or serious morbidity. An additional hundred patients with penetration of the parietal peritoneum and serious or minor injury were evaluated with regard to their preoperative physical findings and stability of vital signs. Eighteen of these patients who had no abdominal findings were found to have significant injuries at laparotomy. Prompt operative evaluation of the patient with penetrating wounds of the abdomen is important in decreasing the morbidity and mortality secondary to perforation of vital structures, and we believe that this can be done with minimal risk.