Principles Of Surgical Management Research Articles

Surgical management of liver tumors.

Two percent of pediatric malignancies arise primarily in the liver; roughly 60% of these cancers are hepatoblastoma (HB). Despite the rarity of these cases, international collaborative efforts have led to the consistent histological classification and staging systems, which facilitate ongoing clinical trials. Other primary liver malignancies seen in children include hepatocellular carcinoma (HCC) with or without underlying liver disease, fibrolamellar carcinoma (FLC), undifferentiated embryonal sarcoma of the liver (UESL), and hepatocellular neoplasm not otherwise specified (HCN-NOS). This review describes principles of surgical management of malignant pediatric primary liver tumors, within the context of comprehensive multidisciplinary care.

A Systemic Review of Primary Malignant Long Bone Tumors in Children and Adolescents.

Managing bone tumours is complex, relying on limited evidence, expert opinions, and retrospective reviews. Multidisciplinary approaches and early diagnosis are crucial for better outcomes, especially in young patients with growing skeletons. The aim of this systemic review and meta-analysis is to give a comprehensive review of common malignant tumors affecting long bones in children and adolescents. A PubMed/Medline search for "primary malignant long bone tumours in children" initially retrieved 1120 papers, which were subsequently narrowed down to 110 articles based on inclusion and exclusion criteria. These articles were reviewed, focusing on clinical presentation, diagnostic workup, treatment options, surgical planning, and variations in presentation, including rare tumours. The two most commonly reported tumours were osteosarcoma and Ewing sarcoma, leading to the division of studies into five groups. The inclusion criteria encompassed malignancies in patients aged 2-25 years, work-up, imaging, surgical treatment, rare tumour case reports, and surgical management principles, resulting in a heterogeneous group of articles. To enhance categorisation, it was clarified that studies with 10 or more cases were considered retrospective reviews. Reviewing of results thus demonstrate that the two likely tumours in children under consideration were osteosarcoma and Ewing sarcoma. Their presentation findings and clinical features were discussed in detail in the review. It is worth noting here that in case of differential diagnosis this should be the first on the list. Although focus of literature is more on the two most common tumours. However, rare tumours should be considered as they can mimic these common tumors. primary, malignant, bone tumors, children, adolescent.

Principles of Surgical Management of Peritoneal Mesothelioma.

Malignant peritoneal mesothelioma (MPeM) is a rare malignancy and represents 5% to 30% of malignant mesothelioma cases. The primary curative therapy for MPeM is radical cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), with the strongest predictor of long-term survival being complete cytoreduction. There is a paucity of high-quality evidence available to guide management in MPeM; however, NCCN Guidelines for the management of MPeM were updated this year. In well-selected patients, 5-year overall survival exceeds 65%, but achieving optimal results requires careful preoperative evaluation and expert surgical management. Preoperative patient selection includes histology review and staging with cross-sectional imaging. Ideal candidates for curative intent surgery are those with epithelioid MPeM, a low peritoneal cancer index, and a good performance status. Contraindications to curative intent surgery include the sarcomatoid MPeM, distant metastases, extensive nodal metastases, and extensive small bowel serosal or mesentery involvement not amenable to complete cytoreduction. Those with biphasic histology, bicavitary disease, and metastatic lymphadenopathy may be considered for surgery following response to neoadjuvant therapy. CRS involves resection of all peritoneal disease, the extent of which varies case by case. Key aspects involve careful evaluation of all peritoneal surfaces, complete parietal peritonectomy and omentectomy, and evaluating suspicious abdominal lymph node basins. Once maximum cytoreduction is achieved, HIPEC is performed using a platinum-based perfusate. Postoperative protocols are recommended to optimize recovery and mitigate HIPEC-specific complications, namely chemotherapy-mediated nephrotoxicity and bone marrow suppression.

A COMPARATIVE STUDY OF CONVENTIONAL INCISION AND DRAINAGE VERSUS INCISION AND DRAINAGE WITH PRIMARY CLOSURE OF THE WOUND IN ACUTE ABSCESS

Acute soft tissue abscesses are common conditions in our environment. For the treatment of skin and soft tissue abscesses, options include repeated aspiration, incision and drainage, incision and drainage with primary closure and conservatively treated by giving antibiotics. The established principle of surgical management of abscesses has been incision and free drainage; this permits healing by secondary intention or treatment by secondary closure. This modality of treatment has been challenged with the introduction of antibiotics. Ellis taught that the abscess wall prevented access of blood-borne antibiotics to the abscess cavity and that if this wall was curetted away the cavity could ll with antibiotic-laden blood clot, permitting safe primary closure. The primary closure technique is supported by many surgeons who showed its effectiveness in the treatment of breast, anorectal, axillary abscesses. Advantages of primary closure technique include faster healing rate, less hospital stay and early return to work, no greater recurrence than the conventional method, better scar formation and reduced cost of labour and material. It may be recommended as an alternative treatment that is superior to the orthodox technique

Surgical Management of Spinal Tuberculosis-The Past, Present, and Future.

Tuberculosis is endemic in many parts of the world. With increasing immigration, we can state that it is prevalent throughout the globe. Tuberculosis of the spine is the most common form of bone and joint tuberculosis; the principles of treatment are different; biology, mechanics, and neurology are affected. Management strategies have changed significantly over the years, from watchful observations to aggressive debridement, to selective surgical indications based on well-formed principles. This has been possible due to the development of various diagnostic tests for early detection of the disease, effective anti-tubercular therapy, and associated research, which have revolutionized treatment. This picture is rapidly changing with the advent of minimally invasive spine surgery and its application in treating spinal infections. This review article focuses on the past, present, and future principles of surgical management of tuberculosis of the spine.

Updated Principles of Surgical Management of Pancreatic Neuroendocrine Tumours (pNETs): What Every Surgeon Needs to Know.

Simple SummaryIn this narrative review, we update the surgical management of pancreatic neuroendocrine tumours (pNETs) and highlight key elements in view of the recent literature. These tumours are rare and suffer from a lack of data and randomized controlled trials. The pNETs management is difficult due to their heterogeneity and the risks associated with pancreatic surgery. Innovative managements such as “watch and wait” strategies, parenchymal sparing surgery and minimally invasive approach are emerging. The correct use of all these therapeutic options requires a good selection of patients but also a constant update of knowledge.Pancreatic neuroendocrine tumours (pNETs) represent 1 to 2% of all pancreatic neoplasm with an increasing incidence. They have a varied clinical, biological and radiological presentation, depending on whether they are sporadic or genetic in origin, whether they are functional or non-functional, and whether there is a single or multiple lesions. These pNETs are often diagnosed at an advanced stage with locoregional lymph nodes invasion or distant metastases. In most cases, the gold standard curative treatment is surgical resection of the pancreatic tumour, but the postoperative complications and functional consequences are not negligible. Thus, these patients should be managed in specialised high-volume centres with multidisciplinary discussion involving surgeons, oncologists, radiologists and pathologists. Innovative managements such as “watch and wait” strategies, parenchymal sparing surgery and minimally invasive approach are emerging. The correct use of all these therapeutic options requires a good selection of patients but also a constant update of knowledge. The aim of this work is to update the surgical management of pNETs and to highlight key elements in view of the recent literature.

Principles of Surgical Management of Small Intestinal NET.

Simple SummarySmall-intestinal neuroendocrine tumors (siNETs) account for 25% of gastroenteropancreatic NETs. A total of 89% of multiple tumors are located in the ileum, often within 100 cm of the ileocecal valve. According to current guidelines, all localized siNETs should be considered for radical resection with lymphadenectomy. The preoperative workout should focus on symptoms of carcinoid syndrome (flush, diarrhea, and cardiac failure). Morphological evaluation should include a CT scan with a thin-slice arterial CT, a PET/CT with 68 Ga, and a hepatic MRI. Levels of 24 h urinary 5-hydroxyindoleacetic acid are needed. Regarding surgery, the limiting component is the number of free jejunal branches allowing a resection without risk of short small bowel syndrome. In case of emergency surgery, there is expert agreement that it is not reasonable to initiate resection of the mesenteric mass without comprehensive workup and mapping. The challenge lies in the ability to propose a resection without imposing short small bowel syndrome on the patients.Introduction: Small-intestinal neuroendocrine tumors (siNETs) account for 25% of gastroenteropancreatic NETs. Multiple siNETs appear to develop in a limited segment of the small bowel (SB), 89% of them being located in the ileum, most often within 100 cm of the ileocecal valve (ICV). According to the European Neuroendocrine Tumor Society (ENETS) and the American Joint Committee on Cancer (AJCC), all localized siNETs should be considered for radical surgical resection with adequate lymphadenectomy irrespective of the absence of lymphadenopathy or mesenteric involvement. Surgical management of siNETs: The preoperative workout should include a precise evaluation of past medical and surgical history, focusing on the symptoms of carcinoid syndrome (flush, diarrhea, and cardiac failure). Morphological evaluation should include a CT scan including a thin-slice arterial CT, a PET/CT with 68 Ga, and a hepatic MRI in cases of suspected metastasis. Levels of 24 h urinary 5-hydroxyindoleacetic acid are needed. Regarding surgery, the limiting component is the number of free jejunal branches allowing a resection without risk of short small bowel syndrome. The laparoscopic approach has been poorly studied, and open laparotomy remains the gold standard to explore the abdominal cavity and entirely palpate the small bowel through bidigital palpation and compression. An extensive lymphadenectomy is required. A prophylactic cholecystectomy should be performed. In case of emergency surgery, current recommendations are not definitive. However, there is expert agreement that it is not reasonable to initiate resection of the mesenteric mass without comprehensive workup and mapping. Conclusion: The surgery of siNETs is in constant evolution. The challenge lies in the ability to propose a resection without imposing short small bowel syndrome on the patients. The oncological benefits supported in the literature led to recent changes in the recommendations of academic societies. The next steps remain the dissemination of reproducible quality criteria to perform these procedures.

Surgical management and oncological outcome of non-squamous cell carcinoma of the larynx: a bicentric study

PurposeNon-squamous cell carcinoma (non-SCC) accounts for about 5% of laryngeal malignancies. Survival data are limited, and consensus on management principles is lacking. The present study reviews our experience in the surgical treatment of non-metastatic non-SCC of the larynx and compares oncological and functional outcomes in a cohort of patients affected by traditional SCC.MethodsWe collected data on 592 patients affected by laryngeal neoplasms. Univariate and multivariable survival analyses were performed using Cox proportional-hazards models; survival estimates were reported by hazard ratios (HR) with 95% confidence intervals (CI), and survival curves were established with the Kaplan–Meier method.ResultsWe identified 326 patients affected by untreated SCC, while 21 had non-SCC histotypes. The non-SCC cohort was composed of 5 soft tissue sarcomas, 8 chondrosarcomas, 2 adenoid cystic carcinomas, 2 neuroendocrine carcinomas, 2 solitary fibrous tumors, 1 Kaposi’s sarcoma, and 1 malignant peripheral nerve sheath tumor. Overall survival and disease-specific survival were not significantly different according to histology (p = 0.6 and p = 0.349, respectively). The non-SCC group showed an increased risk of recurrence (HR 5.87; CI95 2.15–16.06; p < 0.001). Nonetheless, no significant difference (p = 0.31) was found at multivariable analysis between the two groups in total laryngectomy-free survival with an organ preservation rate over 5 years of 81% for the non-SCC histologies.ConclusionNon-SCC is a broad spectrum pathology, but generalized laryngeal surgical management principles are still feasible and it is possible to identify patients amenable to conservative surgical treatment without affecting survival.

Open tibial fractures: An overview

Open tibial fractures are complex injuries with multifactorial outcomes and variable prognosis. The close proximity of the tibia to the skin makes it prone to extensive soft tissue damage and subsequent detrimental complications, such as infection and non-union. Thus, they were historically associated with high rates of amputation, sepsis, or even death. The advancement of surgical instruments and techniques, along the emergence of evidence-based guidance, have resulted in a significant reduction in complications. Peculiarly though, modern management strategies have a strong foundation in practices described in the ancient times. Nevertheless, post-operative complications are still a challenge in the management of open tibial fractures. Efforts are actively being made to refine the surgical approaches used, while noteworthy is the emergence of the Orthoplastic approach. The aim of this review is to summarise and discuss the historical perspective of the management of open tibial fractures, their epidemiology and classification, up-to-date principles of surgical management and outcomes following injury.

Current Opinions on the Management of Non Thumb Metacarpal Fractures.

Metacarpals are unique bones that support the finger to aid hand function. Metacarpals are also the commonest bones to get fractured in the hand. Historically, most metacarpal fractures were managed conservatively. Due to increased patient expectations as well as advancements in diagnosis and osteosynthesis, various surgical options are now available for metacarpal fractures. The goal of operative management of metacarpal management is no longer limited to achieving clinical or radiological union. To restore hand function to a preinjury level, the surgeon must achieve adequate anatomical reduction and stable fixation with minimal soft tissue damage. Similar to tendon repair, to start early active motion should be the goal after metacarpal fracture fixation. Intraoperative consideration should also include minimizing soft tissue damage and avoiding tendon, ligament or capsular entrapment. The aim of this article is to explain the principles of surgical management, the different options available for metacarpal fractures, the techniques, pearls, advantages and disadvantages of each technique, so the surgeon can choose the ideal option to achieve the best result.

Endocrine surgery during and after the COVID-19 epidemic: Expert guidelines from AFCE.

SummaryThe COVID-19 pandemic commands a major reorganisation of the entire French healthcare system. In France, general rules have been issued nationally and implemented by each healthcare centre, both public and private, throughout France. Guidelines drafted by an expert group led by the French-speaking Association of Endocrine Surgery (AFCE) propose specific surgical management principles for thyroid, parathyroid, endocrine pancreas and adrenal surgery during and after the COVID-19 epidemic.

Chirurgie endocrinienne au cours et au décours de l’épidémie de COVID-19 : recommandations de l’AFCE

RésuméLa pandémie de COVID-19 impose une réorganisation majeure de l’ensemble de notre système de soins. En France, des règles générales ont été diffusées au niveau national et sont déclinées par chaque établissement, public comme privé, sur l’ensemble du territoire. Ces recommandations, rédigées par un groupe d’experts sous l’égide de l’Association francophone de chirurgie endocrinienne (AFCE), ont pour objectif de proposer des principes spécifiques de prise en charge chirurgicale au cours et au décours de l’épidémie de COVID- 19, pour les pathologies chirurgicales de la thyroïde, des parathyroïdes, du pancréas endocrine, et des surrénales.

Results of the treatment of phlegmon of Streptococcus pyogenes aetiology within upper limbs

Abstract Phlegmon is a purulent infection which spreads in loose connective tissue. It occurs most commonly in the limbs as a complication of other local infections. Untreated or inadequately treated infections in the skin of the fingers or hands are susceptible to phlegmon. In most cases, the infecting organism is Staphylococcus aureus. This article reports 7 cases of phlegmon involving upper limbs, caused by the Streptococcus pyogenes organism. The course of these types of infection are more serious, and the range of tissue damage greater, than those caused by staphylococci. This article presents the causes of the phlegmon, the methods and course of management, and the results of these. The principles of surgical management include wide incisions in the skin and an evacuation of pus and necrotic tissue debris. The skin is then sealed with stitches or a skin graft once the wound is clean. Of the 7 treated patients, 1 died in the intensive care unit due to sepsis and mutli-organ failure and 1 patient lost his all fingers due to necrosis. The authors believe that it is desirable that doctors working in emergency units and surgical admission rooms should be familiar with the basic rules of diagnosing and managing these potentially life-threatening or hand crippling disease

Principle of surgical management for rectal cancer patients with complete clinical response after neoadjuvant therapy

A proportion of patients with locally advanced rectal cancer will achieve clinical complete response (cCR) or pathologic complete response (pCR) after neoadjuvant chemoradiotherapy. With the proposal of the concept of total neoadjuvant therapy (TNT), higher complete response rates will be observed. The management of patients with cCR has long been an issue of controversy and is attractive for clinical trials. A "watch and wait" strategy for patients with cCR has been put forward by some scholars. A non-operative approach can preserve the organfunction and avoid complications after radical surgery. The safety and feasibility of a "watch and wait" strategy have been established in several non-randomized controlled studies. There is no consensus on how to make an optimal decision for patients with cCR. For example, it is only observed in partial patients that cCR is consistent with pCR and the molecular biomarkers for predicting pCR are suboptimal. Besides, cCR is inconsistently defined and surveillance recommendations varies. Furthermore, there are insufficient high-level evidence for the "watch and wait" strategy. For patients with good response after chemoradiotherapy, local excision is an attractive alternative to total mesorectal excision, however with uncertain indications and challenged oncological safety. For patients with cCR, we implement the therapeutic principles of goal-orientation, layered treatment and the whole process management.

Cochlear implantation in patients with canal wall down mastoidectomy cavities

Background: Safe cochlear implantation (CI) is challenging in patients with a canal wall down (CWD) mastoidectomy cavity. Objectives: We reviewed the outcomes of CI and proposed surgical management principles according to the presentation status of CWD mastoidectomy cavity. Material and methods: The cases of eight patients (nine ears) with CWD mastoidectomy cavity who underwent CI were retrospectively reviewed. The basis of the surgical decision, postoperative complications, and postimplant auditory performance were analysed. Results: In seven patients (eight ears), implantation was performed in a single stage; in six ears, the external auditory canal (EAC) was oversewn. In two patients with ossification, the electrode array was inserted into the scala tympani by drilling of the basal turn or in the second turn of the cochlea through a drill-out procedure. Seven patients had a follow-up of 12–50 months and one patient was lost to follow-up. None of the followed-up seven patients suffered complications. Conclusions: CI is safe and effective in patients with profound hearing loss after radical mastoidectomy. In patients with CWD mastoidectomy cavity, CI does not cause a higher rate of postoperative complications relative to standard CI procedures. The outcome is excellent and comparable to that in the general CI population.

Assessment and management of infected total knee replacements.

Infection following total knee replacement surgery is a challenging and devastating complication. Clinical assessment including history, examination, radiographs, blood tests and knee aspirations helps to establish the diagnosis. Revision surgery is typically required to eradicate infection and restore function. This has traditionally been performed through two-stage revision surgery, although single-stage revision surgery is gaining popularity with comparable results in carefully selected patients. This article reviews the clinical assessment and principles of surgical management of infected total knee replacements.

Management of peri-prosthetic fractures around total hip arthroplasty: a contemporary review of surgical options

The burden of periprosthetic fractures is increasing with increasing volumes of total hip arthroplasty. These injuries often occur in older patients with more significant co-morbidity and osteopenia. Management of these injuries is often resource intensive and can present significant socioeconomic challenges. Understanding the principles of surgical management these cases and recognising when fixation or replacement is required is critical. The aim of this article is to present a contemporary evidence-based review of the surgical fixation options for management of periprosthetic fractures in the presence of well-fixed or loose components.

Surgical treatment of acquired benign tracheoesophageal fistulas

Acquired benign tracheoesophageal fistulas (TEFs) are a challenging condition which most often arises as a result of iatrogenic injury. Most common causes are prolonged intubation and esophageal or laryngeal surgery. Endoscopic intervention with esophageal or tracheal stenting is of unproven benefit in the management of such lesions, whereas surgical repair is almost invariably required. In this paper, the principles of surgical management of TEFs are described, including preoperative preparation, operative techniques and postoperative care.

Infected total hip replacements: assessment and management.

Infected total hip replacements pose a diagnostic and management challenge. Careful history, clinical examination, blood tests, plain radiographs and hip aspiration are all part of the clinical assessment. International consensus on establishing the diagnosis helps surgeons to formulate management plans. Management strategies include debridement and prosthesis retention, single-stage revision, two-stage revision, suppressive antibiotic treatment and excision arthroplasty. This article reviews the clinical assessment, diagnosis, principles of surgical management and outcomes of revision surgery of infected total hip replacements.

Bouveret syndrome: current management strategies.

Bouveret syndrome is a rare complication of cholelithiasis that usually presents with signs and symptoms of gastric outlet obstruction. Given the relative rarity of this condition, there are no standardized guidelines for the management of this condition. In this paper, we review the diagnosis and management options (endoscopic, laparoscopic, and open approaches) of patients with Bouveret syndrome, including a report of one case to illustrate some of the endoscopic and surgical principles of management.