Necrotizing fasciitis: Diagnosis and management of an occult infective focus

Necrotizing fasciitis is a life-threatening, fulminant disease that is a diagnostic and therapeutic challenge. Presenting with a triad of findings including progressive erythema, severe dermatological edema and severe pain disproportionate to the physical findings, this disease is a surgical emergency. Delayed diagnosis and surgical debridement lead to higher mortality. Early extensive surgical debridement, aggressive antibiotic therapy, invasive monitoring and intensive care management determine the outcome in most cases. In patients who fail to demonstrate clinical improvement, profound sepsis and its sequela –systemic inflammatory response – have frequently been implicated. It is these patients that need to be carefully re-evaluated for ‘hidden’ foci of infection that may be the real cause of the patient’s decline. Once detected, these occult foci can be surgically debrided, resulting in dramatic improvement. Two illustrative cases, one with occult endo- and panophthalmitis and the other with an unusual involvement of deeper muscle planes and the nodal basin, demonstrate this point. This consumptive process gathers momentum at an alarming speed, hence, the treatment must be aggressive and prompt.     

Splenectomy in severe haemophilia

The management of any surgical condition in a haemophilia patient is a challenging problem for the surgeon. It is particularly difficult if the patient presents in extremis, with no apparent cause for their collapse. We report a case of successful management of spontaneous splenic rupture in a severe haemophiliac, and review the literature associated with this unusual condition.     

Current rehabilitation strategy: clinical evidence for erection recovery after radical prostatectomy

Erectile function (EF) recovery remains a prominent functional outcome underachievement of radical prostatectomy (RP), despite the success of anatomic “nerve-sparing” technique and its recent refinements in the modern surgical era. Delayed (for as much as a few years) or incomplete (partial and unusable) EF recovery commonly occurs in many men still today undergoing this surgery. “Penile rehabilitation”, alternatively termed “EF rehabilitation”, originated formally as a therapeutic practice approximately 15 years ago for addressing post-RP erectile dysfunction (ED) beyond conventional ED management. Although the premise of this therapy is conceptually sound and generally accepted, in reference to the implementation of strategies for promoting EF recovery to a naturally functional level in the absence of erectile aids (distinct from the premise of conventional ED management), the optimal manner and efficacy of currently suggested therapeutic strategies are far less established. Such strategies include regimens of standard ED-specific therapies (e.g., oral, intracavernosal, and intraurethral pharmacotherapies; vacuum erection device therapy) and courses of innovative interventions (e.g., statins, erythropoietin, angiotensin receptor blockers). An endeavor in evolution, erection rehabilitation may ideally comprise an integrative program of sexual health management incorporating counseling, coaching, guidance toward general health optimization and application of demonstrably effective “rehabilitative” interventions. Ongoing intensive discovery and rigorous investigation are required to establish efficacy of therapeutic prospects that fulfill the intent of post-RP erection rehabilitation.     

Lipodystrophy of Abdominal Pannus: A Severe Complication of Phosphatidyl Choline Injections

“Injection lipolysis” or “mesotherapy” is done for introducing various substances into deeper layers of the skin with the aim to dissolve subcutaneous fat. However, the safety profile of these chemicals is poorly regulated. Therefore, they may cause side effects or long-term sequelae that can be disastrous for the patient. We present such a case that required surgical management to salvage it and to give an aesthetically acceptable result.     

Managing Chondral Lesions: A Literature Review and Evidence-Based Clinical Guidelines

BackgroundArticular cartilage lesions are becoming increasingly common. Optimum diagnosis and management of chondral defects cause a lot of dilemma. A number of surgical methods have been reported in the literature for treating focal cartilage defects. There is a lack of consensus on the most effective management strategy, with newer surgical and cell-based treatments being advocated regularly.Study Design and MethodsA clinical review is constructed by appraising the published literature about clinical evaluation and diagnostic modalities for articular cartilage defects and subsequent surgical procedures, management strategies employed for such lesions. Prominent available databases (PUBMED, EMBASE, Cochrane) were also searched for trials comparing functional outcomes following cartilage procedures. Synthesis of a practical management guideline is then attempted based on the evidence assessed.ResultsSystematic examination and optimal use of diagnostic imaging are an important facet of cartilage defect management. Patient and lesion factors greatly influence the outcome of cartilage procedures and must be considered while planning management. Smaller lesions < 2 cm² respond well to all treatment modalities. Autologous osteochondral transplants (OATs) are effective in high activity individuals with intermediate lesions. For larger lesions > 4 cm², newer generation autologous chondrocyte implantation (ACI) has shown promising and durable results. Stem cells with scaffolds may provide an alternate option. Orthobiologics are a useful adjunct to the surgical procedures, but need further evaluation.ConclusionsMost treatment modalities have their role in appropriate cases and management needs to be individualized for patients. The search for the perfect cartilage restoration procedure continues.     

Can peri-operative quality be maintained in the drive for operating room efficiency? An American perspective

Hospitals in privately (US) and publicly funded medical systems around the world are scrutinizing every aspect of the financing and delivery of surgical care. Whereas many physicians believe championing operating room efficiency will compromise quality, this is not necessarily the case. Higher quality care could be less costly because ‘defects’ (e.g. complications) and rework of products and services are avoided. The challenge is to innovate in the surgical suite and to promote efficiency and quality concurrently. This chapter discusses different definitions of quality with emphasis on the Six Sigma methodology, opportunities for cost reduction with clinical pathways and Internet-related tools and insights obtained from recently published advances in applying sophisticated analytical tools from management science to the peri-operative environment. Healthcare providers will have to use innovations in information technologies, as well as scientifically derived operating room management analytical tools, to help control costs while maintaining the quality that each ‘customer’ of the surgery suite expects.     

Surgical Management of Giant Transdural Glomus Jugulare Tumors with Cerebellar and Brainstem Compression

Objective The objective of this study is to discuss the management of advanced glomus jugulare tumors (GJTs) presenting with intradural disease and concurrent brainstem compression.Study Design This is a retrospective case series.Results Over the last decade, four patients presented to our institution with large (Fisch D₂; Glasscock-Jackson 4) primary or recurrent GJTs resulting in brainstem compression of varying severities. All patients underwent surgical resection through a transtemporal, transcervical approach resulting in adequate brainstem decompression; the average operative time was 12.75 hours and the estimated blood loss was 2.7 L. All four patients received postoperative adjuvant radiotherapy in the form of intensity-modulated radiation therapy or stereotactic radiosurgery. Combined modality treatment permitted tumor control in all patients (range of follow-up 5 to 9 years).Conclusion A small subset of GJTs may present with intracranial transdural extension with aggressive brainstem compression mandating surgical intervention. Surgical resection is extremely challenging; the surgical team must be prepared for extensive operating time and the patient for prolonged aggressive rehabilitation. Newly diagnosed and recurrent large GJTs involving the brainstem may be controlled with a combination of aggressive surgical resection and postoperative radiation.     

Surgery and Conservative Management of Camptodactyly in Pediatric Patients: A Systematic Review

Camptodactyly is a pediatric hand condition, the treatment of which remains controversial. The authors’ aim was to improve patient care through clarifying the definition of camptodactyly and indications for surgical and/or conservative management, summarizing outcomes, and defining risks. A systematic review was conducted of articles in all languages on outcomes following surgical and/or conservative management of idiopathic camptodactyly in children using MEDLINE (Medical Literature Analysis and Retrieval System Online), PubMed, EMBASE (Excerpta Medica database), AMED (Allied and Complementary Medicine), and CINAHL (Cumulative Index of Nursing and Allied Health Literature) (until January 2017). The primary outcome was posttreatment flexion contracture, and the secondary outcomes were indications for surgery, complications, and patient satisfaction. Database searching generated 16 final articles, with 7 case series and 9 retrospective cohort studies. There was a lack of consistency on the definition of camptodactyly and in outcome reporting. All 16 studies received a “Weak” global rating and demonstrated low-quality evidence, suggesting that treatment of camptodactyly with operative or nonoperative measures reduces the degree of flexion contracture in most patients (from pretreatment averages of 20°-85° to posttreatment averages of 5°-37°). There was general agreement that surgery should be reserved for contracture >30° or failure to respond to conservative management. Surgery generally led to more complications compared with conservative management. Only one study reported on functional limitations, and another reported on patient-reported outcomes. Current evidence of the effectiveness of camptodactyly treatment in addressing both joint-specific deformity and patient-perceived function and appearance is insufficient to guide patient care. Future research may consider the development of decision aids to guide patients and families through selecting management strategies and to promote shared decision making.     

“Acute postoperative open abdominal wall”: Nosological concept and treatment implications

The so-called “burst abdomen” has been described for many years and is a well-known clinical condition, whereas the concept of the “open abdomen” is relatively new. In clinical practice, both nosological entities are characterized by a complex spectrum of symptoms apparently disconnected, which in many cases poses a great challenge for surgical repair. In order to assess the management of these disorders in a more comprehensive and integral fashion, the concept of “acute postoperative open abdominal wall” (acute POAW) is presented, which in turn can be divided into “intentional” or planned acute POAW and “unintentional” or unplanned POAW. The understanding of the acute POAW as a single clinical process not only allows a better optimization of the therapeutic approach in the surgical repair of abdominal wall-related disorders, but also the stratification and collection of data in different patient subsets, favoring a better knowledge of the wide spectrum of conditions involved in the surgical reconstruction of the abdominal wall.     

Do patients with haemophilia undergoing cardiac surgery have good surgical outcomes?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether patients with haemophilia undergoing cardiac surgery have good surgical outcomes. Haemophilia A and haemophilia B are sex-linked recessive inherited diseases affecting males only, with females acting as carriers. The conditions result in various degrees of factor VIII or factor IX deficiency, respectively. The life expectancy of haemophilia patients is increasing and now approaches that of the general male population, and they are confronted with age-related co-morbidity, including ischaemic cardiovascular disease. Replacement of the deficient factor (VIII for haemophilia A and IX for haemophilia B) is the cornerstone of treatment; other therapeutic options include tranexamic acid, desmopressin and aprotinin. Recently, the advent of recombinant factor VIII and IX has eliminated the infective risk of using factor concentrates, such as prothrombin complex concentrate or fresh frozen plasma. A total of 84 papers were found using the reported search criteria, and out of this 25 papers, selected with reference to a more modern date range, provided the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results were tabulated. We conclude that there is lack of good-quality evidence and that, in all probability, these papers are subject to publication bias as poor outcomes are unlikely to have been reported. However, all the reported series showed that good outcomes are possible in this specific subgroup of patients given the correct approach. The data accrued from these studies (a total of 30 adults and three children) suggest that routine cardiac surgery can be performed safely in patients with haemophilia, with minimal morbidity and mortality. We identified the following key points to achieve this result: a team approach, a factor replacement protocol and perioperative monitoring of factor levels. Intraoperative plasma factor levels can be easily measured before heparin and after protamine sulphate administration, whereas during cardiopulmonary bypass this will require a chromogenic method. Exposure to factor concentrates early in the life might predispose a patient with severe haemophilia to the development of inhibitors. Moreover, the absence of inhibitors should be confirmed before any surgical procedure.     

Successfully Treated Isolated Posterior Spinal Artery Aneurysm Causing Intracranial Subarachnoid Hemorrhage: Case Report

There are very few published reports of rupture of an isolated posterior spinal artery (PSA) aneurysm, and consequently the optimal therapeutic strategy is debatable. An 84-year-old man presented with sudden onset of restlessness and disorientation. Neuroradiological imaging showed an intracranial subarachnoid hemorrhage (SAH) with no visible intracranial vascular lesion. Spinal magnetic resonance imaging (MRI) detected a localized subarachnoid hematoma at Th10–11. Both contrast-enhanced spinal computed tomography and enhanced MRI and magnetic resonance angiography revealed an area of enhancement within the hematoma. Superselective angiography of the left Th12 intercostal artery demonstrated a faintly enhanced spot in the venous phase. Thirteen days after the onset of symptoms, a small fusiform aneurysm situated on the radiculopial artery was resected. The patient''s postoperative course was uneventful and he was eventually discharged in an ambulatory condition. To our knowledge, this 84-year-old man is the oldest reported case of surgical management of a ruptured isolated PSA aneurysm. This case illustrates both the validity and efficacy of this therapeutic approach.     

Current Concepts of Polytrauma Management

Abstract In recent years, the implementation of standardized protocols of polytrauma management led to a significant improvement of trauma care in European countries and to a decrease in posttraumatic morbidity and mortality. As such, the “Advanced Trauma Life Support” (ATLS^®) protocol for the acute management of severely injured patients has been established as a gold standard in most European countries since the 1990s. Continuative concepts to the ATLS^® program include the “Definitive Surgical Trauma Care” (DSTC™) algorithm and the concept of ”damage control” surgery for polytraumatized patients with immediate life–threatening injuries. These phase–oriented therapeutic strategies appraise the injured patient in the whole extent of the sustained injuries and are in sharp contrast to previous modalities of “early total care” which advocate immediate definitive surgical interventions. The approach of “damage control” surgery takes the influence of systemic posttraumatic inflammatory and metabolic reactions of the organism into account and is aimed at reducing both the primary and the secondary – delayed – mortality in severely injured patients. The present paper shall provide an overview on the current state of management algorithms for polytrauma patients.* Both authors contributed equally to this paper.     

Severe truncal valve stenosis: diagnosis and management

Severe truncal valve stenosis, due to dysplastic valve, may be found in a small number of patients with truncus arteriosus. Its presence complicates the surgical management of this anomaly due to lack of optimal therapeutic options and associated ventricular dysfunction. We report a case of truncal root replacement using a homograft for the management of such condition, and review the literature related to its management and outcome.     

Evolving role of cardiac transplantation for end-stage congestive heart failure

The dramatic efficacy of cardiac replacement therapy, an expanding population of potential recipients, and a shrinking donor supply have converged to create thorny medical and ethical issues for practitioners and patients. Based on scientific evaluation of current practice, new policies are being considered to optimize outcomes for end-stage heart failure patients in an equitable way. Meanwhile, improving efficacy of mechanical assist devices may soon justify transitioning from “bridge-to-transplant” to “destination therapy” as a standard approach for those who cannot safely await a transplant, further altering the landscape of surgical therapy for end stage heart failure. In this review, selected aspects of heart transplantation of interest to the broader transplant community are briefly reviewed, focusing on recipient and donor selection, surgical considerations, and subsequent management.     

Chylopericardium following thoracoscopic resection of a mediastinal cyst: A case report

IntroductionThoracic duct cysts are very rare, and diagnosis is often difficult. We report a rare case of chylopericardium following thoracic duct cyst resection. There are no established guidelines on the management of such cases. We reviewed the literature on postoperative complications after thoracic duct cyst resection, and conducted the first thorough review of the etiology and management of chylopericardium in surgical cases.Presentation of caseA 54-year-old male presented with cardiac tamponade due to chylopericardium. He had undergone resection of a thoracic duct cyst 2 years previously, which was complicated by postoperative chylothorax. Chyle accumulation resolved with conservative treatment.DiscussionChylothorax is a frequent complication following thoracic duct cyst resection, especially in cases where no intraoperative diagnosis is reached. Diagnosis may be difficult due to anomalous location of the cyst, as in our case. Chylopericardium is rarely reported, and may have occurred in our case because of prior pleurodesis. Chyle accumulation can reportedly be managed with diet restrictions in over half of reported cases, especially in cases of lung or mediastinal tumor resection.ConclusionThe most important points highlighted by this rare case of chylopericardium secondary to thoracic duct cyst resection are: 1) pedicles should be ligated in cyst resections, regardless of location; 2) careful assessment in the initial surgery may help identify the point of leakage; 3) low-fat diet is the first choice in the initial management of postoperative chylopericardium, but surgical repair may be considered in cases with no response after > 2 weeks of conservative treatment.     

Nesidioblastosis in the Adult Surgical Management

Nesidioblastosis is an exceedingly rare occurrence in the adult and, when it appears, it is usually part of a MEA1 syndrome.We present a case of nesidioblastosis in a young woman, with no concurrent endocrine pathology, while we discuss in detail the diagnostic and therapeutic problems posed by this condition.The selected treatment was sub-total pancreatectomy (70–80%) and the histopathologic and immunohistochemical tests of the surgical specimen showed: “Diffuse Nesidioblastosis”.The histopathologic and immuno-histochemical features of the resected pancreas are analysed in detail.     

A case of acute upper and lower airway obstruction due to retropharyngeal haemorrhage secondary to acquired haemophilia A

We report the first known case of acute upper and lower airway obstruction due to retropharyngeal haemorrhage secondary to acquired haemophilia A. The patient required tracheal intubation and ventilation followed by surgical tracheostomy, prior to transfer to the intensive care unit for management of her coagulopathy with recombinant clotting factor products under the care of the haematologists.     

Surgical management of chordoma: A systematic review

Context: Chordomas are rare primary tumors of bone characterized by local aggressiveness and poor prognosis. The surgical exeresis plays a critical role for their management.Objective: The aim was to provide an overview of the surgical management of chordomas of the mobile spine and sacrum, describing the most common surgical approaches, the role of surgical margins, the difficulties of en block resection, the outcomes of surgery, the recurrence rate and the use of associated therapies.Methods: We performed a systematic search using the keywords “chordoma” in combination with “surgery”, “spine”, “sacrum” and “radiotherapy”.Results: Fifty-eight studies, describing 1359 patients with diagnosis of chordoma were retrieved. 17 studies were performed on subjects with cervical chordomas and 49 focused on patients with sacrococcygeal chordomas. The remaining studies included patients with chordomas in cranial region and/or mobile spine and/or sacroccygeal region. The recurrence rate ranged from 25% to 60% for cervical chordomas, and from 18% to 89% for sacrococcygeal chordomas.Conclusion: Despite the remarkable advances in the local management of chordoma performed in the last decades, the current results of surgery alone are still unsatisfactory. The radical en bloc excision of tumour is technically demanding, particularly in the cervical spine. Although radical surgery must still be considered the gold standard for the management of chordomas, a multidisciplinary approach is required to improve the local control of the disease in patients who undergo both radical and non-radical surgery. Adjuvant radiation therapy increases the continuous disease-free survival and the local recurrence-free survival.Level of evidence: Systematic review; level III.     

Recurrent varicocele

Varicocele recurrence is one of the most common complications associated with varicocele repair. A systematic review was performed to evaluate varicocele recurrence rates, anatomic causes of recurrence, and methods of management of recurrent varicoceles. The PubMed database was evaluated using keywords “recurrent” and “varicocele” as well as MESH criteria “recurrent” and “varicocele.” Articles were not included that were not in English, represented single case reports, focused solely on subclinical varicocele, or focused solely on a pediatric population (age <18). Rates of recurrence vary with the technique of varicocele repair from 0% to 35%. Anatomy of recurrence can be defined by venography. Management of varicocele recurrence can be surgical or via embolization.     

The female carrier of haemophilia--a problem for the anaesthetist

Three case histories reflect the difficulties of pre-operative assessment and management of female obligatory carriers for Factor VIII or Factor IX deficiency (haemophilia). The dangers of operation in these individuals is emphasized in view of the often confusing laboratory and clinical findings in this group of patients. A protocol is presented which, if used by the anaesthetist, will provide for logical and safe diagnostic and therapeutic approaches for these patients.