Successful Conservative Management Research Articles

Successful Conservative Management of a Rare Surgical Complication of Vascular Ehlers-Danlos Syndrome: A Case Report

Vascular Ehlers-Danlos syndrome is a hereditary disorder of the connective tissue characterized by a reduction in the production of type III collagen. Clinical evolution of the disease is unpredictable because vascular lesions can occur everywhere in the body. Bruising, arterial and bowel fragility, and uterine fragility during pregnancy are the most common symptoms. Thoracic surgeons should take with these patients because, in rare cases, thoracic complications may occur, such as recurrent pneumothorax or spontaneous hemothorax. We report an extra-pleural hematoma in a patient with vascular Ehlers-Danlos syndrome, an unusual complication treated successfully with conservative management.

Risk factors for occurrence of placenta accrete spectrum following primary cesarean delivery

Background: Many maternal and fetal complications werereported during delivery for patients diagnosed to have placenta accrete spectrum (PAS). Cesarean delivery (CD) isconsidered to be the most common risk factor for developing PAS disorders during pregnancy specially with increasing rate of CD in developing countries.Methods: A cross- sectional study over 12 months in a tertiary care obstetric unit between January 2020 and January2021.Results: 47 pregnant females having history of previousone CD were divided into 2 groups after ultrasonic and intraoperative evaluation of placenta site and invasion to theuterine wall.14 cases were in the low risk group ad 33 caseswere in the high-risk group. The mean ages of patients were(27.6 ± 4.6 & 27.6 ± 4.6, p value =0.961) respectively. Themedian gravidity was (3 & 2) in both groups. We found that36.4 % of case in the high-risk group had unreliable indications of the primary CD. Emergency caesarean deliverieswere done in about 18 % of cases in the high-risk group either due to failure to progress in labour or foetal distress.We reported successful conservative management in bothgroups using either cervico-isthmic compression sutureor step wise approach. There was statistically significantin the mean amount of intraoperative blood loss (1000 ml(850-1200) &1600 ml (850-2500), p < 0.001) in the low andhigh-risk groups respectively. We reported 3 cases of intraoperative pulmonary embolism, urinary bladder injury and HELLP (hemolysis, elevated liver enzymesand low platelet count) syndrome among patients in the high-risk group. There was statistically significant longer hospital stay durationamong patients in the high-risk group rangingfrom 2 days up to 21 days. On the other hand,there were no serious complications reportedin the low risk group.Conclusion: Decreasing rate of primary CDand optimizing obstetric care are mandatoryto prevent maternal of fetal complication thatcould happen due to having future PAS. Fertility sparing surgery is feasible during surgical management of PAS disorders.

FACTORS AFFECTING THE EFFECTIVENESS OF CONSERVATIVE MANAGEMENT OF APPENDICULAR MASS

INTRODUCTION/ PURPOSE Acute appendicitis is the most common surgical emergency in children. Appendicular mass is a relatively common complication in improperly treated patients. The management of appendicular mass remains controversial. This study aims at determining factors affecting the effectiveness of conservative management of appendicular mass. PATIENTS AND METHOD This was a retrospective study of 71 children younger than 15 years with appendicular mass who managed at Basra Children's Specialty Hospital during the period between 2015 and 2019. Factors like age of the patient, duration of symptom prior to hospital admission, size of the mass, complications, hospital stay and outcome are reviewed. RESULTS Appendicular mass complicates 3.9% of all cases of acute appendicitis. Conservative management of appendicular mass was effective in 84.5%. Appendicular mass occurred most frequently in children aged 5-10 year (48%). Male is more frequently affected than female with a ratio of 1.4. Regarding age effect on the efficacy of conservative management of appendicular mass, there is a significant association with P-value = 0.017. Duration of symptoms or size of the mass has no significant association with the success of conservative management. No mortality or major surgical complications are encountered. Although effective, conservative management prolong the length of hospital stay. CONCLUSION I concluded that conservative management of appendicular mass in children should be revised particularly in children younger than 5 years old, wherein operative treatment may be the first option. The reasons for that are high rate of failure of conservative management with early progress to appendicular abscess. These could be explained by the underdevelopment of greater omentum and so lacking of its protective effect in limiting the spread of inflammation. In addition, early appendectomy has the advantage of decreased risk of adhesive intestinal obstruction, shortening of hospital stay (so that less economic burden), and avoidance of second readmission for interval appendectomy.

Management of traumatic posterior fossa epidural hematomas in pediatrics: our experience and review of the literature.

Conservative management of posterior fossa epidural hematoma in the pediatric age group has been increasingly considered in the last decade with good clinical outcomes and comparable results to surgical intervention in carefully selected patients. The purpose of this study is to evaluate the outcome of observation in the management of pediatric patients with posterior fossa epidural hematoma (PFEDH) in our tertiary hospital and present a literature review on PFEDH pediatric patients. We conducted a retrospective observational study at King Abdullah University Hospital (KAUH), a tertiary hospital in North Jordan. All pediatric patients (≤ 18years) who were admitted with a diagnosis of PFEDH from January 2010 to December 2020 were included. Demographic data, trauma type, clinical signs and symptoms on admission, CT findings, treatment type, and outcomes were collected and assessed. The outcome was measured using the Glasgow outcome scale (GOS) on discharge from the hospital. A total of 16 patients were identified and included in this study. Nine patients were managed conservatively and 7 surgically. The mean age was 7.7 ± 6years ranging from 1 to 18years. Falls were the most common cause of injury. Vomiting was the most frequent presenting symptom. Except for 1 patient, 14 patients had good outcomes with a GOS of 5. One case of mortality was seen in our series. Posterior fossa epidural hematoma is a rare clinical condition among the pediatric age group. Early and consecutive CT scans must be obtained for all suspected cases. Successful conservative management can be achieved depending on multiple factors such as hematoma thickness or volume, neurological status on admission, and other radiological findings as shown in our study. The overall prognosis was good in our patients.

Left ventricular free wall rupture: A real nightmare.

Left ventricular free wall rupture (LVFWR) is a rarest but often lethal mechanical complication of acute myocardial infarction (AMI). The mortality rate for LVFWR is described from 75% to 90% and it is the cause for 20% of in-hospital deaths after AMI. Death results essentially from the limited time available for emergent intervention after onset of symptoms. Emergency surgery is indicated and normally the rupture site is easily identified, but it may not be apparent macroscopically, corresponding to transmyocardial or subepicardial dissection with an external rupture far from the infarction site, or already thrombosed and contained. Repair of the ventricular wall is usually achieved either by suturing the edges of the tear or closing it with patches of artificial material or biological tissues, usually using some kind of biological glue. However, several cases of successful conservative management have been described. In this Editorial, I comment on the metanalysis conducted by Matteucci et al, published in this issue of the Journal, including 11 nonrandomized studies and enrolling a total of 363 patients, which brings a great deal of new knowledge that can help not only in the prevention but also in the management of this dreadful complication of AMI.

Successful conservative management of an acquired tracheoesophageal fistula.

Pediatrics InternationalVolume 63, Issue 8 p. 980-981 Clinical Notes Successful conservative management of an acquired tracheoesophageal fistula Atsushi Harada, orcid.org/0000-0002-4105-5986 Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, JapanSearch for more papers by this authorNaoki Shimojima, Corresponding Author naoki.shimojima@gmail.com orcid.org/0000-0001-5949-260X Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan Correspondence: Naoki Shimojima, MD PhD, Department of Surgery, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8561, Japan. Email: naoki.shimojima@gmail.comSearch for more papers by this authorHirofumi Tomita, orcid.org/0000-0002-0283-8240 Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, JapanSearch for more papers by this authorAkihiro Shimotakahara, Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, JapanSearch for more papers by this authorSeiichi Hirobe, orcid.org/0000-0003-1386-4476 Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, JapanSearch for more papers by this author Atsushi Harada, orcid.org/0000-0002-4105-5986 Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, JapanSearch for more papers by this authorNaoki Shimojima, Corresponding Author naoki.shimojima@gmail.com orcid.org/0000-0001-5949-260X Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan Correspondence: Naoki Shimojima, MD PhD, Department of Surgery, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8561, Japan. Email: naoki.shimojima@gmail.comSearch for more papers by this authorHirofumi Tomita, orcid.org/0000-0002-0283-8240 Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, JapanSearch for more papers by this authorAkihiro Shimotakahara, Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, JapanSearch for more papers by this authorSeiichi Hirobe, orcid.org/0000-0003-1386-4476 Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, JapanSearch for more papers by this author First published: 04 June 2021 https://doi.org/10.1111/ped.14534Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume63, Issue8August 2021Pages 980-981 RelatedInformation

Postoperative enterocutaneous fistulas: Management outcomes in 23 consecutive patients

BackgroundAbout 75%–85% of enterocutaneous fistulas are postoperative. Such fistulas are still disastrous and frustrating complication for surgeon and the patient and their management remains one of major challenge and dilemma in general surgical practice. Strict adherence to treatment guideline according to SOWATS protocol could results in better outcomes. The objectiveof this study was to assess the management outcomes of 23 patients with postoperative enterocutaneous fistulas. MethodsA total of 23 consecutive patients with postoperative enterocutaneous fistulas during the period of study were included. These fistulas were classified anatomically and physiologically. The predictive factors for spontaneous closure, management outcomes and mortality rate factors for were studied. ResultsOverall Closure of the fistulas was accomplished in 16 patients (69.6%). Spontaneous closure after successful conservative management was seen in 4 patients (17.4%). The average time between fistula development and spontaneous closure was 32 days (range12–66 days). Of 19 patients underwent corrective surgery, closure was achieved in 12 patients (52.2%), thus the surgical success rate was 63.2%. Surgical intervention was performed after an average period of 28 days (range 18–42 days) from diagnosis of the fistula. Five patients with high output (21.7%) died because of sepsis, severe malnutrition and organ failure. Conclusionadherence to standardized protocol and multidisciplinary approach of patients with enterocutaneous fistulas could results in good outcomes. A reasonable period of conservative treatment is always required to optimize patient's general conditions and for spontaneous closure of fistula. Operative correction is usually required for proximal high output and complex fistulas. The complexity of the fistulas, sepsis, high output effluent and comorbidities are the main factors affecting healing rates and fistula related mortality.

A pilot study to evaluate the effectiveness and safety of urgent endoscopy for gastroduodenal perforation.

Gastroduodenal perforation is potentially life threatening and requires early diagnosis and treatment. Urgent endoscopy facilitates detecting bleeding sites and achieving hemostasis. However, there is no consensus on urgent endoscopy for gastroduodenal perforation in Japan. We evaluated the effectiveness and safety of urgent endoscopy for gastroduodenal perforation. We compared clinical characteristics between 140 patients who underwent urgent endoscopy (urgent endoscopy group) and 16 patients did not (no urgent endoscopy group) at Hiroshima City Asa Citizens Hospital between December 2005 and December 2018. Endoscopic diagnosis was possible in all urgent endoscopy group. In contrast, correct diagnosis of the perforation site was made on CT in 99 cases (63%). Furthermore, the proportion of cases with correct diagnosis of the perforation site by CT findings differed significantly between the urgent endoscopy group and the no urgent endoscopy group (66% vs. 38%, p < 0.05). No complications of urgent endoscopy were observed. Primary perforation site was gastric in 42 cases and duodenal in 114. In the 42 gastric perforation cases, 12 gastric perforation cases (29%) were managed conservatively, successfully in 9 (75%); 2 cases (17%) required delayed emergency surgery for worsening peritonitis. In the 114 duodenal perforation cases (duodenal ulcer in all cases), 52 cases (46%) were managed conservatively, successfully in 48 (92%); 3 cases (6%) required delayed emergency surgery for worsening peritonitis. A significantly higher proportion of gastric perforation cases than duodenal perforation cases required surgical treatment (76% vs. 57%, p < 0.05). Multivariate analysis revealed localized abdominal pain (no peritonism) (OR 0.25; 95% CI 0.08-0.75; p < 0.01) and perforation diameter ≤ 5mm (OR 0.13; 95% CI 0.04-0.36; p < 0.01) as significant independent clinical factors for successful conservative management of duodenal ulcer perforation. Urgent endoscopy in gastroduodenal perforation enabled primary diagnosis and perforation site identification, and facilitated deciding the management strategy.

Ultrasonic diagnosis of asymptomatic rupture of uterine in second trimester of pregnancy after laparoscopic surgery for interstitial pregnancy: a case report

BackgroundUterine rupture is a rare, life-threatening event in obstetrics that may be fatal for the mother and fetus. Therefore, obstetricians need to pay attention to and should consider the antenatal diagnosis of uterine rupture in women having its risk factors. Successful conservative management for asymptomatic uterine rupture due to previous laparoscopic surgery for interstitial pregnancy has already been reported but remains understudied.Case presentationA 39-year-old woman was diagnosed asymptomatic uterine rupture at 22 weeks gestation by a routine second-trimester ultrasound scan. She had a history of laparoscopic salpingectomy with cornual wedge resection for interstitial pregnancy 10 months before this pregnancy. Refusing doctor’s twice advice of terminating the pregnancy, the patient insisted carrying on the pregnancy, and followed up by ultrasound and magnetic resonance imaging. Fetal growth was appropriate, fetal movements were good and the patient had no symptoms, without uterine contraction or amniotic fluid loss throughout follow-up period. Caesarean section was carried out at 34 + 1 weeks with a good maternal and neonatal outcome.ConclusionsA previous history of laparoscopic salpingectomy with cornual wedge resection could be a risk factor for uterine rupture in pregnant women. Sonographers should be alert to this potential risk in pregnant women with a history of laparoscopic salpingectomy with cornual wedge resection even in asymptomatic patients.

Biliothoracic Fistula after Microwave Ablation of Liver Metastasis : Literature Review.

Microwave ablation is a safe and effective interventional approach, widely used in the treatment of unresectable primary or metastatic hepatic lesions. Thoracobiliary fistula is a rare postablation complication that can be treated with a conservative or surgical approach. We reviewed aetiology, pathogenesis, clinical picture, diagnostic possibilities, and therapeutic options for biliothoracic fistula developed after microwave ablation of liver metastasis. Furthermore, we reported our experience of successful conservative management of a nonhealing thoracobiliary fistula occurred after percutaneous thermal ablation of colorectal cancer liver metastasis. Our case supports a conservative approach based on percutaneous biliary system decompression and synthetic glue embolization for the treatment of combined biliopleural and biliobronchial fistula.

Conservative management of spontaneous intra-abdominal abscess in Crohn's disease: Outcome and prognostic factors.

To compare the outcomes of different treatments for spontaneous intra-abdominal abscesses (IAA) in active Crohn's disease (CD). A retrospective analysis of patients with CD between January 2007 and December 2018 was performed in two Belgian inflammatory bowel disease centers. Successful conservative management was defined as complete resolution of abscesses without the need for bowel resection. The primary outcome was suboptimal evolution, defined as a composite outcome of recurrence of abscess, postoperative complications or the need for a non-elective resection. Forty CD patients presenting with 43 independent episodes of spontaneous IAA development were included. One underwent immediate bowel resection. In all other 42 cases a conservative approach was taken, which led to a complete abscess resolution rate of 28.6% (12/42). The remaining abscesses required bowel resection. Anti-tumor necrosis factor (TNF) agent use was associated with successful conservative management (odds ratio [OR] 13.36, 95% confidence interval [CI] 11.19-15.52, P=0.006), while the opposite trend was found for corticosteroids (OR 0.14, 95% CI 0.02-1.26, P=0.055). There was a trend towards suboptimal evolution in case of previous bowel resection (OR 4.77, 95% CI 0.77-29.66, P=0.094) or in patients aged above 50 years (OR 5.17, 95% CI 0.86-30.91, P = 0.072). Bowel resection appears to be inevitable in most CD patients presenting with IAA. An attempt at conservative treatment may be particularly successful with anti-TNF agents in younger patients who have not undergone previous bowel resection. Large-scale prospective studies are needed to confirm these findings.

A Conservative Management of Spontaneously Ruptured Liver Hydatid Cyst

Hydatid disease is a zoonotic disease caused mainly by the cestode (tapeworm) Echinococcus granulosus, also known as hydatidosis. It is endemic mainly in areas where dog/horse breeding and sheep farming are common, such as Australia, New Zealand and the Mediterranean region. A rare, yet serious, complication of hydatid cyst of the liver is rupture, which could be spontaneous due to increased intra-cystic pressure or following a traumatic injury of the abdomen. Rupture into the peritoneal cavity may result in an anaphylactic reaction, usually treated by means of emergency surgical intervention. Herein, we present a case of a 55-year-old male patient, known to have liver hydatid cystic disease 3 years ago, who presented to other hospital with acute abdominal pain, tachycardia and hypotension. A computed tomography (CT) scan of the abdomen revealed ruptured liver hydatid cyst into the peritoneal cavity, with free intra-abdominal fluid and dissemination into the mesentery. The patient was treated successfully by conservative means including nil per os (NPO), intravenous fluids, noradrenaline and anthelminthic treatment by albendazole. Two months later the patient underwent laparoscopic resection of the mesenteric as well as the hepatic cyst. The presentation, diagnosis, course of treatment and follow-up are discussed in this report. Reviewing the current English literature reveals that this is the first case to report a successful initial conservative management of spontaneous intraperitoneal rupture of liver hydatid cyst.

A prospective study on appendicular mass

Background: The immediate management of appendicular mass have always been controversial. Early appendicectomy (within 72 hours of presentation) is preferred in some cases, while in others non operative conservative management is advocated. Usually successful conservative management (Ochsner Sherren regimen) is followed by interval appendicectomy (6-8 weeks later). This study determines the outcome of different modalities of intervention in patients with appendicular mass.Methods: A prospective study was conducted in Rajah Muthiah medical college hospital in department of general surgery from June 2018 to December 2020, in cases diagnosed to have appendicular mass. A total of 116 patients were included. After taking detailed history and clinical examination, relevant blood and radiological investigations, were done to achieve the final diagnosis. Presentation, examination findings, investigations, type of surgery, duration of surgery, post-operative complications and duration of hospital stay were studied. Data was collected, compiled, tabulated and analysed.Results: Conservative management followed by interval appendicectomy had lesser incidence of complications like Intraoperative adhesions, surgical site infection, wound dehiscence and enterocutaneous fistula. It also had relatively lesser operative time and lesser period of hospital stay.Conclusions: On comparing the different modalities of intervention, conservative management followed by interval appendicectomy is quite effective and safe method of treatment, with less operative difficulties and better outcome.

Successful Conservative Management of Premature Rupture Membranes of Twin Pregnancy with one Fetus Papyraceus

Fetus papyraceus is a rare obstetrics complication and is characterized by the death of one or more fetuses inthe early gestation period, and the other fetus continues to develop. This report describes a twin pregnancywith one fetus papyraceus and both undergone premature membrane rupture. We reported a 25-year-oldwoman unbooking patient admitted to the Pusura hospital with a complaint of amniotic fluid leaking fromthe vagina after a traffic accident. The patient is a woman with a history of G2P1A0 at 22-week gestationwith twin pregnancies (monochorionic diamniotic twin pregnancy). There was one live fetus with cephalicpresentation and the other one was papyraceus. Conservative management with a corticosteroid regimento complete the lung maturation was done. At 32-week gestation, the patient was admitted back withspontaneous rupture membranes and the live fetus was seen in lie presentation. She underwent a caesariansection and a premature life female baby was delivered with 1800g of weigh, APGAR score of 7 at 1 minuteand 8 at 5 minutes. The fetus papyraceus was weighed 100g. Both the mother and the baby were dischargedhome in good condition. Fetus papyraceus is a rare condition that describes intrauterine fetal demise in earlypregnancies. It can occur in both single or multiple gestation pregnancies. This case report reported case is apremature rupture of the membranes caused by a traffic accident. A life baby weighing 1800g was deliveredand 100g of weigh of fetus papyraceus in a caesarian section. This case is a diamniotic – monochorionicplacenta. Finally, the healthy baby was discharged 18 days after delivery.

Diagnosis and Management of Adult Omental Infarction: 10-Year Case Series.

Omental infarction is a rare cause of an acute abdomen with nonspecific signs that can be easily mistaken with other more common intra-abdominal pathologies. The increased use of radiological imaging has brought this diagnosis to attention with respect to management plan. We present the experience of an Australian hospital network with the diagnosis and management of omental infarction to raise awareness of this uncommon pathology. A retrospective review of medical records of adult patients diagnosed with omental infarction from 2010 to 2020 was conducted across four major hospitals in South Western Sydney. Data relating to clinical presentation, investigations, management and outcomes were obtained. Omental infarction was diagnosed in 61 patients (mean 51.1years, range: 19-76years old). All patients presented with nonspecific abdominal pain with the most common sites being the right iliac fossa followed by the right upper quadrant, respectively, over an average period of 2.7days. Computed tomography and/or diagnostic laparoscopy identified omental infarction in all cases. Forty-two patients (68.9%) had successful conservative management, six failed conservative management and 19 patients had emergency laparoscopic omentectomy. The average hospital length of stay was 3.4days with no significant morbidity or mortality. Omental infarction generally presents with nonspecific clinical signs often masquerading as other more common abdominal diagnosis like cholecystitis or appendicitis. A trial of conservative management initially coupled with appropriate imaging should be recommended within the first 24-48h before considering surgical treatment in refractory cases.

Association of peripartum management and high maternal blood loss at cesarean delivery for placenta accreta spectrum (PAS): A multinational database study.

Placenta accreta spectrum (PAS) carries a high burden of adverse maternal outcomes, especially significant blood loss, which can be life-threatening. Different management strategies have been proposed but the association of clinical risk factors and surgical management options during cesarean delivery with high blood loss is not clear. In this international multicenter study, 338 women with PAS undergoing cesarean delivery were included. Fourteen European and one non-European center (USA) provided cases treated retrospectively between 2008 and 2014 and prospectively from 2014 to 2019. Peripartum blood loss was estimated visually and/or by weighing and measuring of volume. Participants were grouped based on blood loss above or below the 75th percentile (>3500ml) and the 90th percentile (>5500ml). Placenta percreta was found in 58% of cases. Median blood loss was 2000ml (range: 150-20000ml). Unplanned hysterectomy was associated with an increased risk of blood loss >3500ml when compared with planned hysterectomy (adjusted OR [aOR] 3.7 [1.5-9.4], p=0.01). Focal resection was associated with blood loss comparable to that of planned hysterectomy (crude OR 0.7 [0.2-2.1], p=0.49). Blood loss >3500 ml was less common in patients undergoing successful conservative management (placenta left in situ, aOR 0.1 [0.0-0.6], p=0.02) but was more common in patients who required delayed hysterectomy (aOR 6.5 [1.7-24.4], p=0.001). Arterial occlusion methods (uterine or iliac artery ligation, embolization or intravascular balloons), application of uterotonic medication or tranexamic acid showed no significant effect on blood loss >3500 ml. Patients delivered by surgeons without experience in PAS were more likely to experience blood loss >3500 ml (aOR 3.0 [1.4-6.4], p=0.01). In pregnant women with PAS, the likelihood of blood loss >3500 ml was reduced in planned vs unplanned cesarean delivery, and when the surgery was performed by a specialist experienced in the management of PAS. This reinforces the necessity of delivery by an expert team. Conservative management was also associated with less blood loss, but only if successful. Therefore, careful patient selection is of great importance. Our study showed no consistent benefit of other adjunct measures such as arterial occlusion techniques, uterotonics or tranexamic acid.

Loose intra-articular body in the temporomandibular joint: case report of a successful conservative management

Loose intra-articular bodies are a rare finding in the temporomandibular joint. Surgical removal of the loose bodies isoften described as the only treatment option; however, it presents possible postoperative complications. The aim of thispaper is to report the successful conservative management of a temporomandibular disorder associated with a singleloose intra-articular body. A 62-year-old woman presented with pain in the right temporomandibular joint andpre-auricular region, limited mouth opening and open-lock episodes. Panoramic radiography and cone-beam computedtomography exams revealed the presence of a single loose body located anterior to the right condyle. Magnetic resonanceimages showed bilateral anterior disc displacement without reduction. A non-invasive approach consisting of an occlusalsplint and low-level laser therapy associated with home-based physical therapy was performed for management ofclinical signs and symptoms. The patient was followed up for 2 years and presented significant pain reduction andimprovement in the range of mandibular movements. The combination of conservative therapies may be an alternativefor surgical intervention to control pain and improve mandibular function in patients with temporomandibulardysfunction associated with a loose body in the temporomandibular joint.

Treating acute colonic diverticulitis with extraluminal pericolic air: An Acute Care Surgery in the Netherlands (ACCSENT) multicenter retrospective cohort study

BackgroundOwing to improved quality of computed tomography, a new category of complicated acute diverticulitis, including patients with pericolic air but without abscess formation, can be defined (Hinchey 1a). Recent studies question whether this new category of acute diverticulitis could be treated as uncomplicated cases. The aim of our study is to report on the clinical course of acute diverticulitis Hinchey 1a in current clinical practice. MethodsFor this multicenter retrospective cohort study, patients presenting at the emergency department with Hinchey 1a acute diverticulitis as demonstrated by computed tomography scan, were identified. The primary outcome measure was successful conservative treatment with observation alone, antibiotics, and/or hospital admission. Readmissions, percutaneous drainage of abscesses, and emergency operations were considered as failure. ResultsBetween October 2016 and October 2018, 1,199 patients were clinically suspected for acute diverticulitis, of whom 101 (8.4%) were radiologically diagnosed to have type 1a acute diverticulitis (average age 57 (±13) years, 45% female) and started with conservative treatment. This was successful in 86 (85%) patients. One of the 15 unsuccessfully treated patients (1%) received percutaneous drainage of an abdominal abscess. Surgery was required in 9 cases (9%) after a median time of 6 days (range, 3 to 69 days). Although a difference in the volume of extraluminal air on computed tomography scan was found, this was not shown to be a risk factor for the clinical course. ConclusionPatients with type 1a acute diverticulitis can be treated successfully by conservative therapy in the majority of cases (85%). More research is required to define predictive factors for successful conservative management.

Successful conservative management of small bowel obstruction secondary to jejunal mesenteric haematoma after blunt abdominal trauma.

Successful conservative management of small bowel obstruction secondary to jejunal mesenteric haematoma after blunt abdominal trauma.

Most Cesarean Scar Pregnancies Can be Managed with a Single Dose of Methotrexate

Study Objective To investigate the effectiveness of single dose methotrexate (MTX) regimen in cases of cesarean scar pregnancy (CSP). Design A retrospective cohort study of all CSPs from a tertiary medical center between the years 2011-2019. Conservative management included treatment with systemic MTX with ultrasound (US) guided needle aspiration of the gestational sac in the presence of fetal heartbeat. We divided the cohort into two groups: women that were treated according to the conservative protocol, and women treated with additional curettage or hysteroscopy. Maternal and gestational characteristics were compared between the groups. Setting N/A Patients or Participants The final study cohort included 32 women diagnosed with CSP and treated according to the conservative protocol. Interventions N/A Measurements and Main Results 16(47.1%) women underwent additional US guided needle aspiration. Nineteen patients(59.4%) had a successful conservative treatment. Baseline maternal characteristics were similar in both groups. There was no difference between the two groups in the time from last cesarean delivery(25 month vs 32, respectively, p=0.31), gestational age(47 vs 49 days respectively, p=0.63), gestational sac size(23 vs. 21 mm, respectively, p=0.54), level of βHCG at presentation(17049 vs. 18612, respectively, p=0.77), or evidence of fetal heart beat(48% vs. 54%, respectively, p=0.71). The presence of gestational sac hematoma upon admission was identified as a negative predictive factor for successful conservative management(5.3% vs 38.5%,OR [95%CI] 11.2, (1.1-112.5),p=0.02). Conclusion Single dose MTX is an effective mode of treatment in cases of CSP. The presence of a gestational sac hematoma on US was identified as a negative predictor for successful conservative treatment of CSP. No other predictive factors were identified. To investigate the effectiveness of single dose methotrexate (MTX) regimen in cases of cesarean scar pregnancy (CSP). A retrospective cohort study of all CSPs from a tertiary medical center between the years 2011-2019. Conservative management included treatment with systemic MTX with ultrasound (US) guided needle aspiration of the gestational sac in the presence of fetal heartbeat. We divided the cohort into two groups: women that were treated according to the conservative protocol, and women treated with additional curettage or hysteroscopy. Maternal and gestational characteristics were compared between the groups. N/A The final study cohort included 32 women diagnosed with CSP and treated according to the conservative protocol. N/A 16(47.1%) women underwent additional US guided needle aspiration. Nineteen patients(59.4%) had a successful conservative treatment. Baseline maternal characteristics were similar in both groups. There was no difference between the two groups in the time from last cesarean delivery(25 month vs 32, respectively, p=0.31), gestational age(47 vs 49 days respectively, p=0.63), gestational sac size(23 vs. 21 mm, respectively, p=0.54), level of βHCG at presentation(17049 vs. 18612, respectively, p=0.77), or evidence of fetal heart beat(48% vs. 54%, respectively, p=0.71). The presence of gestational sac hematoma upon admission was identified as a negative predictive factor for successful conservative management(5.3% vs 38.5%,OR [95%CI] 11.2, (1.1-112.5),p=0.02). Single dose MTX is an effective mode of treatment in cases of CSP. The presence of a gestational sac hematoma on US was identified as a negative predictor for successful conservative treatment of CSP. No other predictive factors were identified.