Controversies in management of sternal tumors

The rarity of sternal tumors makes a good comparative study a difficult task. Controversies exist on questions of method of surgical diagnosis, the extent of the surgical procedure, and the different ways and means of reconstruction. We describe a case that was believed to be a clear case of chondrosarcoma but was actually a plasmacytoma. From the evidence of this case and a review of the literature we conclude that almost any plasmacytoma should be considered generalized multiple myeloma. Biopsy should be performed in all cases of sternal tumor before any surgical action is taken.     

Controversies in the management of pancreatic pseudocysts

Review of the diagnosis and treatment of patients with pancreatic pseudocysts over the past 8 years has led us to three conclusions regarding controversial aspects of their treatment. We found that patients who present with chronic pseudocysts can be identified with the help of computerized axial tomography and promptly undergo successful internal drainage, whereas patients with acute peripancreatic fluid secondary to pancreatitis can be observed expectantly with a 43 percent frequency of spontaneous resolution. Patients with infected pancreatic pseudocysts can be safely drained internally. The most common cause of extrahepatic biliary obstruction in this group of patients with pancreatic pseudocysts was stricture due to pancreatitis and fibrosis, not extrinsic compression.     

Controversies in the management of splenic trauma

BackgroundThe technologic innovations of the last three decades, coupled with a deeper understanding of the immunologic role of the spleen, have significantly shifted the management of splenic injuries towards non-operative approaches. However, there continuous to be a wide range of practice patterns related to the non-operative management of splenic injuries, from which the authors infer a gap between the best available evidence and its translation into practice. We sought to explore ongoing areas of controversy in the non-operative management of splenic trauma with the aim of further elucidating why these controversies continue to exist.MethodsWe explored areas of ongoing controversy in the management of splenic injury though a series of iterative surveys. We invited 70 experts in trauma care from ten countries around the world to participate. Areas of controversy explored included: indications and frequency for in-hospital and follow-up imaging, definitions of failure of non-operative management, indications for angioembolisation and non-operative management in special populations (i.e. elderly, concomitant traumatic brain injury, penetrating trauma).ResultsA 49% response rate was obtained. Even though a wide range of practice patterns were identified, no controversies were identified in areas that do not involve the adoption of new technologies. In areas where practice pattern variation was observed, the strong influence of the local environment was constantly identified as an impediment to changes in practice.ConclusionsWe have identified that barriers present within local practice environments are the major driving forces behind controversies in the non-operative management of splenic injuries.     

Controversies in the management of subdural empyema

Summary Forty one cases of subdural empyema treated between 1977 and 1988 at the Postgraduate Institue of Medical Education and Research, Chandigarh, have been analysed. The patients ranged from 9 days to 80 years of age. There were 22 children, including 11 infants. Fever, altered sensorium and seizures were the most common symptoms present for 1 day to 6 months. Otogenic infection was the commonest aetiological factor followed by postoperative and post-traumatic causes. Thirty seven patients had supratentorial empyemas, including 4 with parafalcine collections, three had infratentorial empyemas, and in one there was extension of the empyema from the supratentorial to the infratentorial compartment. Therapeutic modalities used included percutaneous needle aspirations in infants and burr hole evacuation and craniotomies in adults. A wide spectrum of organisms was detected. Mortality in this series was 24%, which was mainly attributable to the deteriorated neurological status prior to treatment.A detailed review of the literature has been given, highlighting various controversies in the management of SDE. Important prognostic factors and a treatment plan are suggested.     

Controversies in the management of retromolar trigone carcinoma

Our objective is to discuss the current controversies that surround the management of retromolar trigone (RMT) cancer. We conducted this literature review to discuss trigone cancer. RTM and anterior pillar cancers should be studied separately. Preoperative clinical and radiographic assessments need to be further investigated to establish their reliability at predicting bone invasion. In the absence of suspicion of bone invasion, surgery and radiotherapy seem to give similar results, but recent reports indicate a greater benefit if they are used in combination. Some authors have advocated systematic segmental resection for all RMT cancers but marginal mandibulectomy is a reasonable option in selected cases. Standard treatment for RMT cancers with N0 necks is selective neck dissection or radiation therapy, depending on the modality of treatment of the primary. Allowing a better understanding of the evolution of RMT cancer and its response to different treatment modalities requires efforts to report different institutional experience with this rare tumor. © 2008 Wiley Periodicals, Inc. Head Neck, 2009     

The hypertensive surgical patient. Controversies in management

The authors use data gathered from recent clinical and laboratory studies to deal with the following six questions often facing the physician caring for hypertensive patients before, during, and after surgery. Which hypertensive patient is at increased surgical risk? When must elective surgery be delayed? Should antihypertensive medication be discontinued preoperatively? What is the ideal intraoperative blood pressure? What anesthetic techniques are best suited for hypertensive patients? Which patients are at most risk of a postoperative hypertensive crisis?     

Controversies in management of slipped capital femoral epiphysis

The traditional treatment of the hip with a slip of the capital femoral epiphysis has been an in situ fixation using a single screw.This has the sanctity of a long term result.Recent literature stresses the outcomes of failure to restore the upper femoral alignment and on the basis of the poor results makes a plea for capital realignment.This being a recent development,it lacks the support of long term follow up and it remains to be seen if this is a better alternative of managing displaced and unstable slipped capital femoral epiphysis.The authors look at some of the available literature on the subject to highlight these controversies and their implications for orthopedic surgeons.Other controversies pertain to contralateral fixation,duration of immobilization and amount of weight bearing after an in situ fixation.     

Controversies in the current management of lumbar hernias

BACKGROUND: Abdominal wall surgery has changed dramatically in recent years. The current management of lumbar hernias should reflect the development of modern imaging techniques and new forms of noninvasive treatment. OBJECTIVE: To review and update knowledge on lumbar hernias. DATA SOURCES: Literature review using MEDLINE with the key words "lumbar hernia" for the years 1950 through 2004. For an analysis prior to this date (1750-1950), we used cases reported by Thorek. Our own study of 28 patients was also included. STUDY SELECTION: All articles reporting clinical cases on lumbar hernia. DATA EXTRACTION: Two reviewers analyzed the epidemiological, clinical, and treatment data of the articles. DATA SYNTHESIS: One hundred thirty-five clinical case articles and 8 studies with more than 5 patients, together with our personal experience of 28 cases, were analyzed. Nine percent of acquired lumbar hernia cases presented for emergency surgery, which means that a clinical diagnosis was completed with computed tomography in more than 90% of the cases. None of the published classifications has a therapeutic orientation. We present an original classification based on 6 categories and 4 types. In our study, there was a predominance of incisional hernias (79%), with no difference with regard to sex or location but with a predominance in the upper space (47%). Laparoscopic treatment accounts for 9% of the publications' cases and there is only 1 prospective comparative study. CONCLUSIONS: The use of a complete classification and tomography must be standard practice in the preoperative protocol of patients with lumbar hernia. The laparoscopic approach seems to be the best option for treating small or moderate defects; open surgery can be reserved for large defects and to salvage failures with the laparoscopic approach.     

Controversies regarding the management of hiatus hernia

Herniation through the esophageal hiatus is a controversial and complex matter as regards both the underlying pathophysiology and appropriate therapy. Such hernias are best divided into the paraesophageal and sliding varieties. In a paraesophageal hiatus hernia, the fundus and body of the stomach migrate into the chest, the esophagogastric junction usually remaining more or less in its normal position and maintaining normal function. The condition is potentially life-threatening because of the hazards of incarceration and strangulation. Accordingly, surgical treatment is indicated once the diagnosis has been made. Restoration of normal anatomy is the goal of therapy. An antireflux procedure is included only in those rare instances in which hypotension of the lower esophageal sphincter coexists.A sliding esophageal hiatus hernia is a relatively common condition, particularly in older persons, and is often asymptomatic. When symptoms do occur, they are the result of hypotension of the lower esophageal sphincter, which results in gastroesophageal reflux and its complications. Treatment, whether medical or surgical, must be directed toward restoring gastroesophageal competence and minimizing the deleterious effects of regurgitating acid gastric contents. Most patients can be successfully managed medically, only a small portion requiring surgical therapy. A variety of antireflux procedures are now available to achieve this goal. Because reflux is more effectively controlled after the Nissen fundoplication than after the other procedures, I consider it the procedure of choice. Potential complications can be avoided by attention to the technical performance of the procedure.     

Controversies in the management of pediatric facial fractures.

The treatment of pediatric maxillofacial fractures demands consideration of different factors than those in the adult and, therefore, a different therapeutic approach. We currently believe that certain principles in the management of these injuries can be outlined, recognizing that they may require modification as additional experience accumulates. These management principles are as follows: 1. Maintain a high index of suspicion for maxillofacial injury in the pediatric patient, especially when multiple trauma exists. 2. In addition to careful physical examination, utilize CT scanning on a routine basis, even for apparently trivial injuries. 3. Give consideration to observation only for minimally displaced fractures. 4. Respect the functional matrix and employ the least invasive surgical approach that will access the fracture and allow stable reduction. 5. Employ methods of fixation that adequately stabilize the facial skeleton without rigidly immobilizing long segments. 6. If rigid internal stabilization is necessary, in the form of conventional plate and screw fixation, give consideration to interval removal. 7. Microplates appear to provide enough stability so that their use can be advocated whenever possible. 8. Avoid the use of alloplastic materials, especially in the very young patient. 9. Use bone grafts sparingly, except in instances in which inlay reconstruction is necessary and onlay reconstruction is required to maintain soft-tissue support. 10. Be aware of the pediatric dentition and avoid iatrogenic injury to evolving teeth and tooth buds. Perhaps the most important principle of all is to document injuries and their method of treatment and to follow patients serially. This will allow further definition of fracture patterns and the effects of injury and its treatment on growth, thereby giving the surgeon a better understanding and ability to develop more concise treatment philosophies for the future.     

Controversies in the fluid management of post-traumatic lung disease

The appropriate intravenous therapy for injured patients is controversial. Use of colloid-containing solutions has been advocated in an attempt to maintain intravascular colloid osmotic pressure, minimize pulmonary oedema and draw fluid out of areas of contused lung. Studies of animals with lymph fistulas in the lung do not support such therapy and there is no difference between lung water volumes in animals resuscitated for 3 hours with colloid as opposed to crystalloid solutions after a standardized traumatic insult (colloid = 8.4 + 0.8 ml/kg; crystalloid = 7.5 + 0.6 ml/kg). Increased pulmonary capillary permeability makes such therapeutic attempts to 'dry out' the lungs even less effective. Studies in human patients of the rate of extravasation of labelled albumin from the pulmonary intravascular space indicate that increased permeability of pulmonary capillaries occurs early after injury and remains elevated in many severely injured patients. Low plasma colloid osmotic pressures do not correlate with increases in extravascular lung water. A shift to the use of vigorous crystalloid resuscitation of injured patients at our institution has resulted in decreases in both mortality rate (1976-1979, 35 per cent; 1979-1981, 28 per cent) and the rate of dialysis-dependent renal failure (1976-1979, 6 per cent; 1979-1981, 2 per cent). Current evidence supports the use of crystalloid solutions together with blood for resuscitation after injury.     

Controversies in perioperative management and antimicrobial prophylaxis in urologic surgery

Abstract:   The Japanese Urological Association (JUA) recently published guidelines for the prevention of perioperative urologic infections. Although the general remarks in the JUA guidelines are almost similar to those in guidelines previously published by the Centers for Disease Control and Prevention (CDC) and in the European Association of Urology (EAU) guidelines, their differences leave several questions that need to be answered. To clarify agreements and differences in guidelines for perioperative management in urologic interventions for development of more optimal guidelines, reports and reviews previously published were overlooked and discussed. In terms of surgical site infections (SSI) in urologic surgery, consensus for open and endoscopic-instrumental procedures is still somewhat controversial, while a consensus has not yet emerged for its use in laparoscopic procedures. Further research is required to determine what is an optimal prophylactic protocol to effectively prevent both SSI and remote infections (RI).