Role Of Nonoperative Management Research Articles

Selected anteromedial coronoid fractures can be treated nonoperatively

Surgical fixation is currently recommended for unstable anteromedial coronoid fractures, but the role of nonoperative management is not well defined. Our purpose was to report the functional and radiographic outcomes of select patients managed nonoperatively. Between 2006 and 2012, 10 patients with anteromedial coronoid fractures underwent nonoperative treatment. Outcomes assessed included elbow range of motion (ROM), stability, strength, radiographs, and 3 functional questionnaires, including the Patient-Rated Elbow Evaluation, Disabilities of Arm, Shoulder and Hand, and Mayo Elbow Performance Index. There were 9 anteromedial subtype 2 coronoid fractures and 1 subtype 3. Mean fragment size was 5 mm, with a mean displacement of 3 mm for the subtype 2 fractures. The subtype 3 fracture was 9 mm in size with 1 mm of maximal gap displacement. At a mean follow-up of 50 months (range, 12-83 months), the average ROM of the affected elbow was 137° ± 8° of flexion, 2° ± 5° of extension, 88° ± 5° of pronation, and 86° ± 10° of supination. The mean Patient-Rated Elbow Evaluation score was 9 ± 13, Mayo Elbow Performance Index score was 94 ± 8, and the Disabilities of Arm, Shoulder and Hand score was 7 ± 9. All patients had bony union without radiographic arthrosis. There were no cases of recurrent instability or delayed surgical intervention. Current indications for nonoperative management, based on the results of this study, include fractures that are small, minimally displaced, and most importantly, demonstrate no evidence of elbow subluxation. The elbow joint must be congruent and demonstrate a stable ROM to a minimum of 30° of extension. For selected anteromedial coronoid fractures, nonoperative management is an option that can lead to good clinical and radiographic outcomes.

Role of non-operative management in pediatric appendicitis

Appendectomy is currently considered the standard of care for children with acute appendicitis. Although commonly performed and considered a safe procedure, appendectomy is not without complications. Non-operative management has a role in the treatment of both uncomplicated and complicated appendicitis. In uncomplicated appendicitis, initial non-operative management appears to be safe, with an approximate 1-year success rate of 75%. Compared to surgery, non-operative management is associated with less disability and lower costs, with no increase in the rate of complicated appendicitis. In patients with complicated appendicitis, initial non-operative management with interval appendectomy has been shown to be safe with reported success rates between 66% and 95%. Several studies suggest that initial non-operative management with interval appendectomy may be beneficial in patients with perforated appendicitis with a well-formed abscess or inflammatory mass. Recent data suggest that interval appendectomy may not be necessary after initial non-operative management of complicated appendicitis.

The treatment of abdominoscrotal hydrocele: Is there a role for nonoperative management?

Background/PurposeAbdominoscrotal hydrocele (ASH) is an uncommon entity. Until now, the recommended treatment has been surgical. There is only one successful case of nonoperative management reported in literature. We report the largest series of children with ASH, and provide evidence in support of an initial nonoperative approach. MethodsThis study is a retrospective chart review of patients treated from 1994 to 2015 with ASH at a single institution. ResultsThirty patients were identified with ASH, with 29 included in the analysis. Nine patients (30%) had operative management with an 80% complication rate.Twenty out of 29 patients (70%) were initially managed expectantly. Sixteen (80%) had resolution of their abdominal component, twelve (60%) of which went on to have full resolution of ASH. Four patients (20%) in this group required operative management of ASH. ConclusionsASH should be included in the differential diagnosis of pediatric scrotal swelling. The “Springing Back Ball Sign” should be used as a screening tool. If it is positive, a dynamic ultrasound should be performed to confirm the diagnosis. We recommend observation as the first step in the management of uncomplicated ASH. It can result in avoidance of operation or at least lower the complication risk significantly if operation is required.Level of Evidence: 4.

Acute Achilles Tendon Rupture: A Critical Analysis Review.

There is controversy regarding the appropriate treatment of acute Achilles tendon ruptures, underscored in a recent clinical practice guideline published by the American Academy of Orthopaedic Surgeons, in which twelve of sixteen recommendations were supported by “weak” or “inconclusive” evidence1. The basis of debate has shifted, however, as new functional rehabilitation protocols have altered the risk-benefit analysis inherent to decisions about whether to provide operative or nonoperative management2,3. In this review article, we highlight the expanding role of nonoperative management and delve into its effects on rerupture rates and functional outcomes. In patients opting for operative repair, minimally invasive techniques may assuage some operative risks. We also underscore a potentially heightened risk of thromboembolic events among at-risk populations. The overall incidence of Achilles tendon rupture has increased …

Endoscopic diagnosis and treatment of pancreatic neuroendocrine tumors.

Pancreatic neuroendocrine tumors (PNETs) are rare pancreatic neoplasms comprising only 1% to 2% of all pancreatic tumors. In recent years, the number of incidentally discovered PNETs has greatly increased given the widespread use of axial imaging. However, a significant proportion of PNETs may not be visualized on conventional imaging such as computed tomography, magnetic resonance imaging, and somatostatin receptor scintigraphy. Endoscopic ultrasound (EUS) has become an integral part of the diagnosis of PNETs because of its high sensitivity for detecting, localizing, and diagnosing PNETs. EUS-guided tissue acquisition provides histologic and immunologic confirmation, and may also allow prognostication about tumor behavior. In addition to preoperative assessment of these tumors, EUS has also been shown to have an important role in nonoperative management of small nonfunctional PNETs. Finally, recent developments suggest that interventional EUS may be used to aid intraoperative localization of PNETs and to deliver therapeutic agents for the treatment of PNETs. This review will discuss the endoscopic diagnosis and treatment of PNETs, with focus on recent advances in the utility of EUS in the clinical management of these tumors.

Is There a Role for Non-Operative Management of Congenital Nasal Pyriform Aperture Stenosis (CNPAS)?

Is There a Role for Non-Operative Management of Congenital Nasal Pyriform Aperture Stenosis (CNPAS)? Objective: Describe non-operative management of neonates with congenital pyriform aperture stenosis (CNPAS) and examine clinical features of these patients. Study design: Consecutive case series with chart review. Setting: Tertiary, care referral, academic children’s hospital. Subjects and methods: Comparison of patients diagnosed with CNPAS and treated operatively or non-operatively. Results: Eleven patients were included in our study. Of eight patients treated surgically, four were female and four were male. The average diameter of the pyriform aperture of those patients was 5.55 mm. Of the non-operatively managed patients, two were female and one was male. The average diameter of the pyriform aperture was 4.83 mm. There was no significant difference in pyriform aperture dimension between the two groups, p = 0.54. All of the CNPAS patients managed non-operatively were isolated CNPAS cases, while in the surgical managed group, half of the patients had significant medical comorbidities and congenital abnormalities. Conclusion: Non-operative management may be considered in selected patients with CNPAS. Clinical severity of disease should be the primary indicator for surgical or non-operative management.

The role of non-operative management (NOM) in blunt hepatic trauma

BackgroundNOM in blunt hepatic trauma is the preferred treatment in otherwise stable patients. AimTo evaluate the role of NOM in blunt hepatic trauma, avoiding unnecessary surgery. Methods and patientsForty-four patients who presented with blunt hepatic trauma were admitted to the Emergency Unit. The patients were evaluated clinically. Abdominal computerized tomography was done to all hemodynamically stable patients and who were stabilized by the initial resuscitation. Staging of liver injury was done according to the scoring of the American Association for the Surgery of Trauma (AAST). Initially, all patients were treated conservatively and the patients who needed laparotomy later were considered as failure of NOM. Liver injuries due to penetrating causes were excluded. An informed consent was taken from each patient. ResultsBlunt trauma was the mechanism of injury in 44 patients (60.2%) including road traffic accidents in 42.5%. The peak age was between 20 and 30 years. The male to female ratio was 10:1. The majority of patients have multiple injuries with 10% having isolated liver injury. Thirty-six patients (82%) had one or more associated extra-abdominal injuries. Surgery was indicated in 14 patients (32%). The mean admission systolic pressure was lower in the NOM failure group (90 vs. 122 mmHg with p < 0.04). Complications occurred more in the operative group, chest infection occurred in 21.4% with a p value of 0.001, hyperpyrexia occurred in 21.4% with a p value of 0.001, and wound infection in 14.2% with a p value of 0.025. Mortality occurred in 7 patients. The cause of death in patients with blunt hepatic trauma was liver related in 2 patients due to hemorrhage and DIC. ConclusionNOM in blunt hepatic trauma is the preferred treatment in otherwise stable patients. The factors that can suspect failure of NOM were the development of hemodynamic instability or the presence of associated injury that mandates immediate exploration.

The Modern Management of High Grade Splenic Injury: What is the Role of Non-operative Management in this High-risk Group and can we Predict who will Fail this Approach?

The Modern Management of High Grade Splenic Injury: What is the Role of Non-operative Management in this High-risk Group and can we Predict who will Fail this Approach?

Diagnostic efficacies of computed tomography and ultrasonography in pediatric blunt abdominal trauma

Background: Blunt abdominal trauma is a common cause of morbidity and mortality in children. The objectives of the study are to evaluate the specific patterns of organ injury in pediatric patients as illustrated by ultrasonography and computed tomographic (CT) scan and assess the role of nonoperative management in such cases depending upon the severity of injury and the organ injured. Materials and Methods: This prospective study was conducted on pediatric patients with blunt abdominal trauma that presented to the casualty of Jawaharlal Nehru Medical College over a period of 2 years. A total of 45 patients were examined. The ultrasonographic evaluation of the patients was performed and thereafter CT scan of the patients were performed within 24 h of hospital admission if on ultrasonography any evidence of intraperitoneal free fluid was detected with or without any detectable visceral organ injury. Results: Ultrasonography detected hemoperitoneum in 15 patients (51.72%) as compared to CT which detected it in 23 cases (79.31%). Spleen was the most common solid organ injured, encountered in 10 cases (34.48%) on ultrasonography and 15 cases (51.72%) on CT scan. Liver was the second most common injured organ which was demonstrated by ultrasonography in five cases (17.24%), while CT detected hepatic parenchymal injuries in nine cases (31.03%). CT was also significantly more sensitive than ultrasonography in the detection of renal injuries which were illustrated by ultrasound in only one case (3.44%), while CT showed renal injuries in three cases (10.34%). Pancreatic injuries were least common and were seen in two cases and were detected equally by ultrasound and CT scan. Conclusion: Ultrasonography is a very useful and sensitive investigation for the detection of hemoperitoneum and visceral injuries. However, CT better delineates the solid organs injuries and grades the injury as well, thus guiding the management protocol. Nonoperative management is the rule in hemodynamically stable patients in correlation with radiological and clinical scenario.

Small, nonfunctioning, asymptomatic pancreatic neuroendocrine tumors (PNETs): Role for nonoperative management

Controversy exists regarding the optimal management of incidentally discovered, small pancreatic neuroendocrine tumors (PNETs). Our aim was to review the outcomes of patients who underwent nonoperative and operative management. We retrospectively reviewed patients with nonfunctioning PNETs at our institution from January 1, 2000 to June 30, 2011. Patients were included if the tumor was sporadic and <4 cm without radiographic evidence of local invasion or metastases. Nonoperative patients (n = 77, median age, 67 years; range, 31-94) had a median tumor size of 1.0 cm (range, 0.3-3.2). Mean follow-up (F/U) was 45 months (max. 153 months). Median tumor size did not change throughout F/U; there was no disease progression or disease specific mortality. In the operative group (n = 56, median age, 60 years; range, 27-82), median neoplasm size was 1.8 cm (range, 0.5-3.6). Mean F/U was 52 months (max. 138 months). A total of 46% of the operative patients had some type of complication, more than half due to a clinically significant pancreatic leak. No recurrence or disease specific mortality was seen in the operative group, including 5 patients with positive lymph nodes. Small nonfunctioning PNETs usually exhibit minimal or no growth over many years. Nonoperative management may be advocated when serial imaging demonstrates minimal or no growth without suspicious features.

Abstract No. 155: Distal splenic artery stump pressure, determined during transient occlusion of the splenic artery, is affected by the arterial anatomy

Proximal splenic artery embolotherapy (SAE) may play an important role in non-operative management of blunt splenic injury (BSI). While it is theorized that proximal SAE reduces the perfusion pressure in the distal splenic artery, thus lowering the risk of delayed splenic bleeding, this concept has not been subjected to scientific examination. Before the role of proximal SAE can be carefully defined, the hemodynamic changes in the splenic artery stump must be understood.

Pancreatic Injury in Children: Role of Nonoperative Management

Abstract Background: Pancreatic trauma in children is relatively uncommon, but carries high morbidity and mortality rates when diagnosis is delayed. Preoperative diagnosis of pancreatic lesion might be difficult, especially in the case of isolated injury. Methodology: We analyze two cases of pancreatic trauma in childhood in our institute. Both cases were managed conservatively and discharged from the hospital without any complications. Results: In one case child had development of pseudocyst after about two weeks of trauma which was managed conservatively with percutaneous drainage. In another case, child was managed conservatively without any intervention. Conclusion: We emphasize the importance of CT (Computerized tomography) scan and judiciously use non operative management in the treatment of pancreatic trauma.

Moderne Bildgebung nach Lebertrauma

Involvement of the liver is one of the most common injuries in addition to those of the pancreas following blunt force abdominal trauma. Due to the even now high mortality radiological imaging must provide a rapid, definitive and exact assessment of the extent of the damage. Despite conflicting study results ultrasound has become established as a rapid and relatively simple method in emergency room treatment and is irreplaceable for initial orientation diagnostics. The use of contrast medium-assisted examinations promises to be an advantage for diagnostics in the secondary phase. Due to the high sensitivity and specificity modern multidetector computed tomography is the most effective examination modality for the detection of liver damage and hepatobiliary complications and plays a central role in non-operative management following abdominal trauma. Shorter and shorter scan times even allow the examination of metastable patients and a rapid assessment even of large body volumes.

Tension Chylothorax

Thoracic duct injury resulting in chylothorax is a well-known and documented complication of thoracic surgery. However, chylothorax under tension is a rarely reported complication that results in respiratory and hemodynamic collapse. Early recognition and treatment of this entity are essential for optimal patient outcome. Herein we present two cases of postoperative tension chylothorax followed by a review of the diagnostic work-up and therapy for this complication.

Nonoperative Management of Spontaneous Splenic Rupture in Infectious Mononucleosis: The Role for Emerging Diagnostic and Treatment Modalities

Infectious mononucleosis (IM) is a self-limiting lymphoproliferative disorder affecting teenagers and young adults. Splenomegaly is a common manifestation of IM and results in a compromised organ that may rarely rupture spontaneously, with significant morbidity and mortality. The IM spleen should be protected from even minor trauma. Although traditional management of spontaneous splenic rupture in IM has been splenectomy, the role of nonoperative management is evolving. The advent of endovascular interventional modalities has augmented the physician's armamentarium in managing these patients nonoperatively. We report a case of spontaneous splenic rupture in a patient with IM managed conservatively with the aid of splenic angiography. The option of arteriography, with or without embolization, should be considered in the management of all patients with spontaneous splenic rupture in the setting of IM.

Acalculous cholecystitis in children

Acalculous cholecystitis (AC) is a rare disease in children, and its spectrum has not been well established. Twenty-five children with AC were identified (treated between 1970 and 1994) by retrospective clinical and pathological review. The authors recognized two distinct forms of this disease: acute (duration of symptoms <1 month) and chronic (duration >3 months). Thirteen children had acute AC. Seventy-five percent were males; the age range was from 2 months to 20 years. Of these cases, six occurred in the immediate postoperative period, five were in association with a systemic medical illness, and two had an infectious cause ( Salmonella). The mean time of onset of symptoms ranged from 4 to 30 days after surgery or hospitalization (mean, 16 days). All children presented with fever, right-upper-quadrant pain, and vomiting. Other manifestations included jaundice (38%) and right-upper-quadrant mass (23%). Most had leukocytosis (76%) and abnormal liver function test results (62%). Ultrasonography was the most commonly used radiological test, and all 10 cases tested met the ultrasonographic criteria for acute AC. Cholecystectomy was performed in nine children, and pathological examination confirmed cholecystitis. No postoperative complications occurred. The other four children were managed nonoperatively with intravenous antibiotics. One died, but the other three recovered fully. Twelve children had chronic AC. Sixty-seven percent were females; the age range was 7 to 18 years. All presented with chronic symptoms of right-upper-quadrant pain and nausea or vomiting. The leukocyte count and results of liver function tests were normal. Seventy-five percent had evidence of abnormal gallbladder function (noted by a radionuclide hepatobiliary scan or cholecystography). All children in this group underwent cholecystectomy, with pathological confirmation of chronic inflammation. No complications occurred, and all patients had complete resolution of symptoms. The authors conclude that AC in children occurs in two distinct patterns. The acute and chronic forms differ in their clinical setting and presentation. Cholecystectomy is effective treatment of AC, although there may be a role for nonoperative management in selected cases.

Nonoperative management of adult splenic injury due to blunt trauma: A warning

An analysis of 11 patients with splenic injury initially receiving nonoperative treatment revealed that 73 percent subsequently required surgery for delayed hemorrhage. The influence of age and the anatomic differences between the adult's spleen and child's spleen may account for the increased incidence of delayed bleeding seen in this series. Which patients might avoid surgical intervention cannot be predicted with certainty from the mechanism of injury or the lack of early physical signs and symptoms. The corresponding medical problems that often exist with the older patient may make nonoperative management, with the inherent risk of hypotension and large transfusion requirements, inappropriate. Although not advocating immediate splenectomy, we encourage early operative intervention with splenorrhaphy. Although improved diagnostic techniques will uncover a greater incidence of splenic injury, the inability to identify the nonoperative patient remains a clinical dilemma. The true role of nonoperative management of splenic injuries in the adult and the criteria for selection need to be further defined with larger prospective series. Although this approach may be useful for some patients, its application cannot be universal, and one must be willing to accept the consequences of delayed hemorrhage.