Selective Surgical Intervention Research Articles

Standardized pilonidal protocol as rescue therapy for excision-refractory pilonidal disease.

Severe pilonidal diseases have refractory symptoms despite multiple surgeries and optimal therapy remains unclear. We hypothesized that standardized minimally invasive protocol could be an effective rescue treatment. We prospectively collected data from symptomatic patients who underwent ≥ 1 pilonidal excision prior to presentation at our clinic 2019-2023. We treated these patients with standardized protocol incorporating local wound care, regular manual/laser epilation, and selective debridement/pit trephination. We treated 34 refractory patients (23 males) with median follow-up 405days. Median age of first symptoms was 17.1years; presentation to our clinic 20.0years. Prior to our clinic, 27 received one surgery (cleft lift-2, excision no closure-1, excision primary closure-18, wound vac after excision-3, excision flap closure-3); 7 had two surgeries (excision without closure + cleft lift-1, primary closure after excision twice-3, flap closure after excision twice-2, excision primary closure + excision without closure-1). We treated all patients with regular epilation ± local wound care. 14 (41%) underwent trephination ± debridement. All patients achieved complete resolution after median 52days. Five (14.7%) recurred and were treated with trephination + debridement-2 or wound care alone-3. Symptom length had no correlation with resolution time, skin type, hair amount. Standardized minimally invasive protocol requiring only selective surgical intervention can treat refractory pilonidal disease with low recurrence rate.

Lower extremity chronic venous diseases in children in pediatric practice

The article provides a view on the problem of chronic venous disease syndrome in children, summarizing the pediatric and vascular surgical approaches. Varicose veins in children are a combination of problems of varicose veins in the legs, a cosmetic defect, and the task of management by pediatric specialists in outpatient settings. The article reflects many years of experience of the authors in the treatment of patients with venous diseases. The purpose of the article is to present the features of managing patients with chronic venous diseases in primary care medical institutions. The modern level of diagnosis and treatment of the disease is reflected. Peculiarities in children related to the development of complications, the formation of chronic venous insufficiency and the need for surgical interventions are shown. Conclusions: the role of an outpatient pediatrician is important in the identification and verification of children with chronic venous diseases; further examination and management of the patient is carried out in strong relationship between the pediatrician and the pediatric (pediatric vascular) surgeon. To achieve satisfactory results, timely and selective surgical and laser interventions and an ongoing individual conservative treatment program are required.

Cryoneurotomy to Reduce Spasticity and Improve Range of Motion in Spastic Flexed Elbow: A Visual Vignette.

The flexed-elbow pattern of spasticity causes pain and reduced function and greater caregiver burden.1 Genet et al.1 reported the brachialis as the dominant muscle limiting extension. The musculocutaneous nerve (MSCN)–innervated brachialis and biceps brachii as well as the radial nerve–innervated brachioradialis are all implicated.1 Refractory spasticity after rehabilitation and chemodenervation with botulinum toxin type A may require selective surgical or neurolytic interventions to improve outcomes. The diagnostic anesthetic nerve block (DNB) has been used to assist in the evaluation of a muscle’s contribution to spasticity.1 The DNB can differentiate between spasticity and contracture and predict the outcome of surgical neurotomy. It was proposed in 2019 that cryoneurotomy is a safe percutaneous treatment for refractory spasticity.2 Long used in the anesthetic literature, cryoneurotomy is a mini-invasive technique that introduces a hand-held cryoprobe to a peripheral nerve and using the expansion of gas at the cannula tip to create an ice ball, which disrupts the nerve structure, causing axonotmesis. The distal fibers undergo Wallerian degeneration while the basal lamina and endoneurium are preserved, providing a scaffold for regeneration. A hallmark of the procedure is the lack of neuritis or neuroma formation.3 This retrospective chart review identified 11 adult patients with a flexed-elbow spasticity who had previously undergone a screening DNB then a subsequent cryoneurotomy from February 1, 2018, to February 28, 2020, in one clinic (Table 1). All patients had spasticity of at least grade 2 on the Modified Ashworth Scale (MAS), improvement in elbow range of motion, and/or reduction in spasticity after DNB to the MSCN ± radial nerve. All had previously been treated with botulinum toxin type A for their flexed-elbow spasticity with nine of our patients with ongoing botulinum toxin type A at a relatively high average dose of 444 U, with 231 U in the upper extremity. Images were hosted on a secure cloud server. This study was approved by the local institutional ethics board, with patient consent to participate. TABLE 1 - Patient demographics (N = 11) Age at first DNB, mean (SD), yr 53 (15) Sex, female/male, n 4/7 Etiology of spasticity, n Spinal cord injury 2 Stroke (hemorrhagic/ischemic) 7 (4/3) Multiple sclerosis 1 Traumatic brain injury 1 Affected side, right/left, n 4 / 7 Disease onset to first DNB, mean (SD), yr 9 (5) Our video presentation provides an illustration of the interventional techniques, the reduction in spasticity, and increased range of motion over a mean follow-up of 12.5 mos. Each patient was screened with a DNB to the brachialis branch of the MSCN and three patients with additional radial nerve blocks to the brachioradialis. The MSCN and radial nerves were localized with ultrasound guidance. A small bore, Teflon-coated hypodermic needle was inserted. Needle placement was confirmed with ultrasound guidance and electrical stimulation at less than 1 mA causing brachialis or brachioradialis contraction. One millilitre of 2% lidocaine was injected around the target nerve. A positive response was determined by a reduction in MAS, an improvement in passive ± active range of motion, no adverse outcomes, and no loss of function, on DNB. All patients in this study had positive DNB results and went on to cryoneurotomy of the MSCN with three additional to the radial nerve branch to the brachioradialis with the technique described by Winston et al.2 Documenting outcomes in spasticity remain a challenge for research. Our vignette illustrates the changed range of motion and spasticity.

Therapeutic options in juvenile idiopathic arthritis : Part1: Nonsurgical treatment

The treatment of children and adolescents with juvenile idiopathic arthritis (JIA) has progressed substantially during recent years. Multiple different factors have played a role in this advancement: improved medical treatment due to the introduction of new drugs, structural improvements with provision of units specializing in childhood rheumatology, multidisciplinary treatment concepts, structured educational programs for patients and parents, improved functional treatment including sports therapy, and selective surgical and orthopedic interventions improving functional capacities. Current treatment strategies in JIA are aimed at achieving disease remission, i.e., control of disease activity and re-establishment of age-appropriate functional capacities. This review summarizes important developments in the conservative treatment of JIA. Part2 deals with orthopedic and surgical treatment strategies.

Diagnosis and management challenges of acute mesenteric venous thrombosis in patients with liver cirrhosis: a single institution's experience

Background: Acute mesenteric venous thrombosis (MVT) is a dreadful complication of liver cirrhosis that requires prompt diagnosis and aggressive management for better outcome. The aim of this work was to study the diagnostic tools and the optimal management of acute MVT in patients with liver cirrhosis.Methods: It was a retrospective study including 40 patients with liver cirrhosis who were admitted to the surgical emergency and were eventually diagnosed as acute MVT between May 2011 to September 2016. The preoperative clinicopathological data, operative data and postoperative follow up were recorded.Results: Forty patients had acute MVT. Twenty five patients (62.5%) had prolonged prothrombin time, 18 patients (45%) had thrombocytopenia and 22 patients (55%) had low protein C. triphasic CT scan was the main diagnostic image in 28 patients, with sensitivity 100% and accuracy 96.9% in detection of intestinal infarction. Ten patients (25%) underwent conservative treatment with anticoagulant, while 30 patients (75%) were surgically explored and 28 patients of them had gangrenous bowel loops and underwent primary resection and anastomosis. Three patients underwent second look operation. Three patients had recurrent symptoms after 1 month of the first presentation. The overall 30- and 90-day mortality was 27.5% and 37.5% respectively.Conclusions: Cirrhotic patients may have hypercoagulable state and the usual laboratory tests don’t accurately assess the coagulation status in these patient. Acute MVT in cirrhotic patients has a high early morbidity and mortality that needs early diagnosis and urgent management with selective surgical intervention and proper anticoagulant.

Clinical Prediction of Pathologic Complete Response in Superior Sulcus Non-Small Cell Lung Cancer

Management of superior sulcus non-small cell lung cancer (NSCLC) continues to evolve, with preoperative chemoradiotherapy (CXRT) followed by surgical intervention supported by several studies. Rates of pathologic complete response (pCR) have varied, and previous attempts to identify clinical predictors of pCR have been unsuccessful. We analyzed our experience with resected superior sulcus NSCLC to elucidate clinical features suggestive of pCR among patients after preoperative treatment. A multiinstitutional retrospective review was performed in patients who underwent resection for superior sulcus NSCLC between January 1988 and July 2013. Data pertaining to comorbidities, staging, therapy, imaging, and outcomes were collected. Logistic regression was performed to identify predictors of survival and pCR. During the study, 102 patients underwent preoperative therapy, consisting of CXRT in 75 (73.5%), chemotherapy in 15 (14.7%), and radiotherapy in 12 (11.8%). After median follow-up of 18.0 months, overall and disease-free survivals were 51.0% and 45.1%, respectively. On multivariate regression, independent predictors of survival included pCR (p = 0.001; hazard ratio [HR], 0.243; 95% confidence interval [CI], 0.106-0.555) and age (p = 0.007; HR, 1.049; CI, 1.013-1.085). Among those who received CXRT, 24 of 75 (32%) achieved pCR. Multivariate regression analysis of the CXRT group revealed that pCR was independently predicted by extent of size reduction on imaging (p = 0.015; HR, 1.042; CI, 1.008-1.078), with histologic examination showing a trend toward significance (p = 0.073). Preoperative chemoradiation frequently resulted in pCR, and treatment response on imaging was associated with the likelihood of achieving pCR. Future investigations are warranted to further predict pCR from preoperative clinical variables such as symptom resolution, as identification of accurate predictors may ultimately permit the application of selective surgical intervention in superior sulcus NSCLC.

Penetrating Neck Trauma in a 4-Year-Old Child

Penetrating neck injuries are uncommon in children and a post traumatic common carotid artery to internal jugular vein fistula rarely occurs. We present one case of a 4-year-old girl with a penetrating injury from flying glass fragments in the midportion of the neck, caused by an explosion in a military warehouse. She was referred to our facility upon a request of a hospital of a neighbour country, two days after sustaining a penetrating cervical trauma. The presentation, diagnostic procedures and surgical management of this very rare injury are discussed. No neck penetrating trauma should be underestimated and a selective surgical intervention based on clinical examination and investigation tests findings is associated with good long-term outcomes.

Combined biological therapy with lanreotide autogel and cabergoline in the treatment of MEN-1-related insulinomas

Multiple endocrine neoplasia type 1 (MEN1) is a hereditary syndrome associated with the development of many endocrine tumors, involving mainly pituitary, parathyroids, pancreas, although a proliferative state interests all neuroendocrine system. MEN1 pancreatic neuroendocrine tumors (pNETs) are multiples and can secrete different hormones. The therapeutic approach is based on surgery which usually is followed by tumor relapse or persistence unless to be highly aggressive. Biotherapy with somatostatin analogs and dopamine agonists could be of great benefit to manage these patients without altering their life quality. We report a case of a 36-year-old MEN1 man affected with multicentric pNETs associated with insulinoma syndrome. Therapy with symptomatic agents (diazoxide), as well as biotherapy (lanreotide, cabergoline) was started. At 6-month follow-up, symptomatic agents were stopped and disease control was only based on lanreotide plus cabergoline. This combined biotherapy was able to control endocrine syndromes and tumor growth. Subsequently, a safer and selective surgical intervention on pNETs was performed. An excellent response to therapy with lanreotide autogel and cabergoline has been observed in a MEN1 patient with pNETs associated with insulinoma syndrome. The potential synergistic effects of lanreotide autogel and cabergoline on insulin-secreting neuroendocrine tumors are discussed.

Charcot Arthropathy of the Foot and Ankle Associated With Rheumatoid Arthritis

Diabetic peripheral neuropathy is now well recognized as the most common cause of Charcot arthropathy of the foot and ankle, but it may be associated with other peripheral neuropathies. While not well known, it is well documented that rheumatoid arthritis is correlated with peripheral neuropathy. However, despite rheumatoid neuropathy, Charcot arthropathy has never been associated with rheumatoid arthritis. We report a series of Charcot arthropathy patients with concomitant rheumatoid arthritis. The medical records of patients treated between 1986 and 2009 with Charcot arthropathy and rheumatoid arthritis were reviewed. Recorded data included neuropathy risk factors, medications, history of ulcerations, ambulatory status, shoe wear, and treatment course. Radiographs of Charcot joints were categorized according to the Brodsky anatomic classification. Patient care was based on published treatment algorithms, emphasizing accommodative, nonoperative treatment with selective surgical interventions. Surgery was indicated for recalcitrant, nonhealing lesions of the soft tissue and/or unbraceable, nonplantigrade feet. A successful outcome was considered an ambulatory patient without amputation and a closed skin envelope at last follow-up. Four men and 16 women met the diagnostic criteria, resulting in 33 feet in the series. Average age was 61 years, and average follow-up was 4.3 years. In addition to rheumatoid arthritis, 4 patients (7 feet) had hypothyroidism, 4 patients (6 feet) had diabetes, 1 patient (2 feet) had megaloblastic anemia and diabetes, and 1 patient (1 foot) had hypothyroidism and diabetes; however, 17 feet (52%) had no known sources for neuropathy. Charcot involvement was type 1-midfoot in 21 feet (64%), type 2-hindfoot in 7 (21%), type 3a-ankle in 4 (12%), and type 3b-calcaneus in 1 (3%). Twenty-three feet (70%) were treated with conservative modalities. Ten feet (30%) required 15 surgeries, of which an exostectomy was the most common procedure. Of the 33 feet, 3 had persistent ulcerations and 1 underwent major amputation, representing 4 failures. Raising awareness within the orthopaedic community, we report a Charcot arthropathy population with a concomitant rheumatoid arthritis diagnosis, emphasizing a relationship between the 2 diseases. Through a conservative treatment regimen combined with selective surgical interventions, satisfactory outcomes were achieved in 88% of the rheumatoid Charcot feet. While several patients had additional neuropathy sources which could cause Charcot arthropathy (eg, diabetes), the majority of feet had no etiologies accounting for neuropathy or neuroarthropathy except rheumatoid arthritis. Further study is required to expand on this relationship between the 2 diseases. Level IV, retrospective case series.

Combined Biological Therapy is Effective to Control all Neuroendocrine Tumor Manifestations in a Patient with MEN1 Syndrome

Multiple endocrine neoplasia type 1 (MEN1) is a hereditary syndrome predisposing to the development of many endocrine tumors. Mainly pituitary, parathyroids and pancreas are involved although a proliferative state interests all neuroendocrine system. MEN1 pancreatic neuroendocrine tumors (pNET) are multiples and can secrete different hormones resulting in specific endocrine syndrome. The therapeutic approach is based in surgery which usually is followed by tumor relapse or persistence unless to be highly aggressive. Biotherapy with somatostatin analogs (SSAs) and dopamine agonists could be of great benefit to manage these patients without altering their life quality. We report a case of a 36-year-old MEN1 man affected with multicentric PNETs associate with insulinoma and Zollinger-Ellison syndrome, pituitary prolactinoma and primary hyperparathyroidism. Therapy with symptomatic agents (proton pump inhibitors, diazoxide) as well as biotherapy (lanreotide, cabergoline) was started. At six month follow-up, symptomatic agents were stopped and disease control was only based on lanreotide plus cabergoline. This combined biotherapy was able to control endocrine syndromes and tumor growth, resulting in the possibility to perform a safer and selective surgical intervention on pNETs. Somatostatin and dopamine receptor expression has been evaluated and related to clinical response to biotherapy. Therapy with lanreotide and cabergoline was able to control multiple secreting tumors in a patient with MEN1, due to high expression of specific receptors. The combined use of somatostatin analogues and dopamine agonists is suggested in patients with MEN1.

Autologous Blood Donation Programs in Surgical Correctionof Spinal Scoliotic Deformity

Objective. To develop the programs of autologous blood deposition to compensate blood loss in surgical correction of spinal deformity. Material and Methods. The study included 145 patients with spinal deformities who underwent one- and two-stage selective surgical interventions. In the study group (n = 100) autologous blood components were preoperatively deposited for intra- and postoperative blood loss compensation; in the control group (n = 45) prior deposition was not performed. Results. It was found that, taking into account the terms of autologous blood shelf life and efficacy, a prior deposition of 20 % of total blood volume (TBV) providing compensation of blood loss up to 40–45 % of TBV is optimal for one-stage surgical intervention, and deposition of 30 % of TBV allowing loss compensation of 50–55 % of TBV is enough for twostage surgery. Conclusion. Autologous blood deposition is an effective method for blood loss compensation. Blood deposition volume and techniques are determined by an expected blood loss associated with specific surgical intervention.

Duplex ultrasound factors predicting persistent type II endoleak and increasing AAA sac diameter after EVAR

While the significance of type II endoleaks (T2ELs) on the long-term outcome of endovascular abdominal aneurysm repair (EVAR) to repair abdominal aortic aneurysms (AAAs) is debatable, duplex ultrasonography (DU) parameters have been suggested to be predictive of their closure or persistence. The purpose of this study was to determine which, if any, of these variables was associated with persistent T2EL or increased AAA sac diameter. Between 1998 and 2009, 278 patients underwent EVAR and post-operative DU surveillance during long-term follow-up (1-11 years) in our accredited non-invasive vascular laboratory by one of three experienced technologists. DU measured intra-sac flow velocity (IFV), spectral doppler waveform (SDW) patterns, post-EVAR sac diameter, and number of T2ELs. T2ELs developed in 14% (38/278) of patients post-EVAR. Fourteen patients had T2ELs that resolved, and sac diameter decreased or remained the same: the average IFV was 42 cm/second; SDW patterns were monophasic in five, biphasic in seven and bidirectional in two; and multiple T2ELs were not present (0%) in any patient. Twelve patients had T2ELs that persisted, but sac diameter decreased or remained the same: the average IFV was 47 cm/second; SDW patterns were monophasic in one, biphasic in five, bidirectional in five, and undetermined in one; and multiple T2ELs were found in 17% (2) of patients. Twelve patients had T2ELs that persisted and were associated with increased sac diameter: the average IFV was 43 cm/second, SDW patterns were monophasic in one, biphasic in two, and bidirectional in nine; and multiple T2ELs were identified in 75% (9) of patients. None of the 38 patients with T2ELs treated with selective surgical or endovascular intervention for enlarging sac diameters (11/12) experienced a ruptured aneurysm. Contrary to previous smaller reports of T2ELs and DU surveillance, parameters such as IFV did not correlate with increased post-EVAR sac diameter. The presence of multiple T2ELs and bidirectional SDW may be the strongest factors predictive of increased sac diameter.

Computed Tomographic Angiography as an Aid to Clinical Decision Making in the Selective Management of Penetrating Injuries to the Neck: A Reduction in the Need for Operative Exploration

Improvements in imaging technology, particularly computed tomographic angiography (CTA), have altered the management of patients with penetrating injuries in the neck. The purpose of this retrospective study is to evaluate our 5-year experience with the management of penetrating injuries to the neck, to the further elucidate the role of CTA in clinical decision making, and to assess treatment outcome. Clinical variables were collected and evaluated on all patients with penetrating injuries to the neck presenting to the Legacy Emanuel Hospital Trauma Service from 2000 to 2005. For comparison, the patients were divided into two groups based upon whether the patient had received a CTA before operative intervention: group 1, CTA; group 2, no CTA. A statistical analysis using the Fisher exact test and t test was performed to analyze whether the rate of neck exploration or the findings at the time of neck dissection were significantly different between the groups. Of the 120 consecutive patients with penetrating injuries to the neck, 55 were excluded from the study because the injury was superficial, the patient died before operative intervention, or they underwent emergent neck exploration to control hemorrhage. Sixty-five patients with neck injuries penetrating the platysma were identified that met the criteria for inclusion in the study. Group 1 (CTA) consisted of 24 patients and group 2 (no CTA) had 41 patients. Group 1 (CTA) had significantly fewer formal neck explorations (N = 6) compared with group 2 (no CTA) (N = 27) (p < 0.01). All six of the operations in the CTA group had clear indications for and positive findings on surgical exploration, and there were no clinically significant missed injuries. Of the 27 patients in group 2 who underwent neck exploration, only 14 had a positive finding, 4 of which were simply superficial bleeding vessels, yielding a rate of negative neck exploration of 48%, compared with 0% for group 1 (p < 0.01). The number of adjunctive studies such as esophagography, angiography, and various endoscopic procedures were similar in both groups. The management of stable patients with penetrating injuries to the neck that penetrate the platysma has evolved at our institution into selective surgical intervention based on clinical examination and CTA. The use of CTA has resulted in fewer formal neck explorations and virtual elimination of negative exploratory surgery.

Double-balloon enteroscopy reliably directs surgical intervention for patients with small intestinal bleeding

To evaluate preoperative double-balloon enteroscopy for determining bleeding lesions of small intestine, thus directing selective surgical intervention. We retrospectively reviewed 56 patients who underwent double-balloon enteroscopy to localize intestinal bleeding prior to surgical intervention, and compared enteroscopic findings with those of intraoperation to determine the accuracy of enteroscopy in identifying and localizing the sites of small intestinal bleeding. Double-balloon enteroscopy was performed in all 56 patients in a 30-mo period. A possible site of blood loss was identified in 54 (96%) patients. Enteroscopy provided accurate localization of the bleeding in 53 (95%) of 56 patients, but failed to disclose the cause of bleeding in 4 (7%). There was one case with negative intraoperative finding (2%). Resection of the affected bowel was carried out except one patient who experienced rebleeding after operation. Gastrointestinal stromal tumor (GIST) was most frequently diagnosed (55%). Double-balloon enteroscopy is a safe, reliable modality for determining bleeding lesion of small intestine. This technique can be used to direct selective surgical intervention.

PS11 PANCREATITIS – INDICATIONS FOR SURGERY IN CHILDREN

Purpose With modern imaging techniques, multidisciplinary management, and advances in supportive care, what are the indications for surgery in children with pancreatitis and have outcomes improved?Methods During a 12 year period, 62 children [31 girls, median age 12.0 (2.3 –16.9) years] with pancreatitis were managed in a single centre. All were investigated using a combination of ultrasound, ERCP, MRCP, and CT. Management comprised supportive care and treatment of any primary pathology. Severe acute pancreatitis (pancreatic necrosis, pseudocyst/abscess, and/or organ failure) was managed with broad spectrum intravenous antibiotics, H2 antagonists, prophylactic antifungal agents, and early parenteral nutrition followed by naso‐jejunal feeding.Results 51 children had acute pancreatitis, 14 (27%) of whom had severe disease. The leading causes were trauma (12), pancreaticobiliary malunion (6), gallstones (5), drug‐induced (4) and viral (4). In 10 patients no cause was found. Twenty four (47%) of these 51 children required surgery (20) and/or interventional procedures (4) to treat primary pathology (13) or pseudocysts (11) with resolution of pancreatitis in all. Eleven children had chronic pancreatitis: 6 required surgery (5) or an interventional procedure (1).All 62 patients survived. Only two experienced surgical complications.Conclusions In this series, using modern investigative techniques, only 20% of children with acute pancreatitis had no identifiable etiology. Half of the total series of children with pancreatitis required surgery either to treat primary pathology or to treat complications of the disease. Selective surgical intervention in children with pancreatitis is both beneficial and safe.

Management of Penetrating Neck Injuries: A New Paradigm for Civilian Trauma

Improvements in imaging technology, particularly computed tomographic angiography (CTA), have altered the management of patients with penetrating neck injuries. Although some centers still advocate routine exploration for all zone 2 neck injuries penetrating the platysma, many civilian centers in the United States have adopted a policy of selective exploration based on clinical and radiographic examination. The purpose of this retrospective study is to evaluate our 5-year experience with the management of penetrating neck injuries, to further elucidate the role of CTA in clinical decision-making, and to assess treatment outcome. One hundred thirty-four consecutive patients were identified from the Legacy Emanuel Trauma Registry as having sustained penetrating neck injuries from 2000 to 2005. Using data collected from the Trauma Registry, as well as individual chart notes and electronic records, variables were collected and evaluated including age, gender, mechanism of injury, number of associated injuries, and the Injury Severity Score, Glasgow Coma Scale on admission, initial hematocrit, airway management techniques, diagnostic and therapeutic modalities, missed injuries, length of hospital stay, disposition, and outcome. Descriptive statistics were used to describe demographics, treatment, and outcome. One hundred twenty patients met the inclusion criteria, 55 of which had only superficial injuries that did not penetrate the platysma. The primary study group consisted of 65 patients who sustained more significant injuries that violated the platysma including deep, complex, and/or avulsive wounds, vascular injuries, injuries to the aerodigestive tract, musculoskeletal system, cranial nerves, or thyroid gland. The overall mortality rate for the 65 patients with injuries penetrating the platysma was 3.0% (n = 2). Complications occurred in 7 of the surviving 63 patients (10.7%): 2 patients with zone 3 internal carotid artery injuries developed hemispheric ischemic infarcts and hemiplagia; as well as other complications including: infection (n = 2); deep venous thrombosis (n = 1); aspiration pneumonia (n = 1); and hematoma (n = 1). All surviving patients except the 2 stroke patients eventually healed uneventfully without significant functional deficit. The use of CTA as a guide to clinical decision-making led to a significant decrease in the number of neck explorations performed and a virtual elimination of negative neck explorations. The management of stable patients with neck injuries that penetrate the platysma has evolved at our institution into selective surgical intervention based on clinical examination and CTA and has resulted in minimal morbidity and mortality.

Pro-inflammatory cytokine response of the fluid contents of spermatoceles and epididymal cysts.

The aim of the study was to determine the cellular contents and concentrations of interleukin 6 (IL-6), interleukin 8 (IL-8) and tumour necrosis factor alpha (TNF-alpha) in fluids of patients with spermatocele or epididymal cyst. Twenty-five symptomatic patients, 14 with epididymal cysts and 11 with spermatoceles, were included in the study. Fluids were obtained during surgical excision of the cysts and cytological smears were stained with May-Gruenwald-Giemsa to establish cell components. The concentrations of IL-6, IL-8 and TNF-alpha were measured by chemiluminescent immunometric assay. Cytological analysis of the fluids demonstrated various sperm forms ranging from immature germ cells to degenerated spermatozoa without inflammatory cells such as neutrophils and macrophages. The concentrations (mean+/- SEM, pg/mg protein) of IL-6, IL-8 and TNF-alpha were 13.52 +/- 1.40, 22.20 +/- 2.43, 3.51 +/- 1.43 in spermatocele fluids and 5.76 +/- 0.48, 11.57 +/- 1.89, 2.53 +/- 0.41 in epididymal cyst fluids. Both IL-6 and IL-8 concentrations in the spermatocele group were higher than in the epididymal cyst group (P < 0.0001). There were no differences in TNF-alpha concentrations between the groups (P > 0.05). These findings indicate that local production of pro-inflammatory cytokines is involved in cyst formation. The presence of immunologic activation in these fluids advocates a policy of selective surgical intervention in patients with spermatocele or epididymal cyst.

Benign scrotal pathology: should all patients undergo surgery?

To evaluate the justification for operative intervention in patients undergoing surgery for benign scrotal pathology, and to assess the associated morbidity. Consecutive patients in two surgical firms who underwent surgery for benign intrascrotal pathology over a 5-year period were studied retrospectively. In all, 102 patients were included in the study (mean age 51.6 years, range 16-86). Most patients had either epididymal cysts (59) or hydroceles (31) or a combination of the two (eight). Some patients (37) underwent ultrasonography before surgery. The indications for surgery were deemed to be strong in 25% of patients but weak or absent in the remainder. Complications occurred in 31 patients, being minor in 18, but significant in 13, resulting in four re-admissions to hospital. There was no significant difference in the complication rate between those patients with strong indications for surgery (37%) and those with weak indications (28%). Surgery for benign intrascrotal pathology is frequently undertaken for weak clinical indications and carries significant associated morbidity. This could be avoided in many cases by simple reassurance. Judicious use of ultrasonography is advised. A policy of selective surgical intervention is strongly advocated.

Cinematic nuclear scintigraphy reliably directs surgical intervention for patients with gastrointestinal bleeding.

Cinematic technetium Tc 99m red blood cell ((99m)Tc-RBC) scans, in which real-time scanning is performed and analyzed, can accurately localize gastrointestinal bleeding and thus direct selective surgical intervention. Retrospective medical record review with historical controls. Large, university-affiliated public hospital in urban setting. Twenty-six patients presenting with upper and lower gastrointestinal hemorrhage who underwent cinematic (99m)Tc-RBC scan examinations between 1990 and 1997 and required surgical intervention to control the bleeding. All patients with gastrointestinal bleeding underwent open surgical procedures to provide cessation of bleeding and resection of appropriate abnormalities. Patient outcome was based on correlation between preoperative RBC scans and intraoperative findings, surgical pathology, and postoperative clinical course. Twenty-five (96%) of 26 scans were interpreted as positive for gastrointestinal bleeding. In 22 of these 25 scans, the site of bleeding was correctly identified for a sensitivity of 88%. One or more additional diagnostic tests were performed on 19 (73%) of 26 patients, and included angiography and flexible endoscopy. The most common operation performed to control bleeding was a hemicolectomy (14/26). Diverticulosis was the most prevalent diagnosis (46%). Two patients (8%) experienced rebleeding after operation. The overall mortality rate was 19% (5/26). Cinematic (99m)Tc-RBC scintigraphy is a sensitive, noninvasive alternative to mesenteric angiography for accurately localizing the site of gastrointestinal hemorrhages. As such, this technique can be reliably used to direct selective surgical intervention.

Selective Amygdalohippocampectomy: Indications and Follow-up

Selective amygdalohippocampectomy (AHE) offers a real chance of cure only in patients with well-defined, precisely localized "epileptogenic area", i.e. seizure focus. Therefore, a priori only a small proportion of all patients with epilepsy can meet the criteria for selective surgical interventions. From the evidence in patients meeting the criteria for AHE, we conclude that this technique is to be preferred to the "standard" anterior temporal lobectomy and represents a more selective but still effective surgical treatment of epilepsy.