Surgical options for the management of visceral artery aneurysms

Visceral artery aneurysm (VAA) is a rare entity but increased use of abdominal imaging has led to an increased prevalence. Rupture is related to a high mortality rate. Open repair, endovascular treatment and laparoscopic techniques have been described as treatment options. In this systematic review we describe the surgical options for treating VAA. A literature search identified articles focussing on the key issues of visceral artery aneurysms and surgical options using the Pubmed and Cochrane databases. Case reports dominate the literature about VAA. Twenty-seven small case series and ten review articles have been published in the last 20 years concerning the surgical options for VAA. The evidence does not exceed level 3. Surgical treatment is dictated by both patient and aneurysm characteristics. Whether VAA should be treated largely depends upon age, gender, presence of hypertension (e.g. in renal aneurysm), aneurysm size and presentation. Aneurysm size and characteristics, anatomical location and presence of collateral circulation dictate the surgical option to be chosen. The mortality and morbidity rates after elective open repair are low. Literature about surgical options for treating VAA remains scarce. Only a few clinical trials have shown the possibilities and results of open surgical repair. In general, there is no consensus on the surgical treatment of VAA and the highest level of evidence is based upon expert opinions.     

Management of elbow osteoarthritis

Primary osteoarthritis of the elbow is characterized by painful stiffness, mechanical symptoms, and the presence of hypertrophic osteophytes. Preservation of the joint space is common and may account for the good results that are usually achieved with nonoperative treatment and nonprosthetic arthroplasty. Elbow osteoarthritis typically affects middle-aged men who engage in strenuous manual activity. Open or arthroscopic capsular release and removal of impinging osteophytes are the primary surgical treatment options. The relative sparing of joint cartilage makes elbow osteoarthritis unique in this regard and amenable to this treatment. Arthroplasty is rarely indicated for primary osteoarthritis of the elbow and should be reserved for elderly individuals with low demands for whom other treatment options have failed.     

Aortic dissection. A six year experience with 117 patients

Acute aortic dissection is a medical emergency that demands immediate recognition and early precise angiographic diagnosis. One hundred seventeen patients were found to have aortic dissection between 1980 and 1986. Clinical presentation is of importance since hypertension favors the presence of type B dissection, whereas normotension or hypotension is usually indicative of a type A lesion. Supportive treatment should allow stabilization for diagnosis by angiography or computerized tomography in order to proceed with early surgical repair of all type A dissections. Management of the acute type B patient should initially be medical, but immediate surgical treatment should be carried out if there is failure to control the hypertension, continued pain, expansion or rupture of the aneurysm (including appearance of a pleural collection), development of a neurologic deficit, or evidence of compromise of a major infradiaphragmatic aortic branch. Any delay in surgical treatment once an indicative complication is identified will have an early adverse effect on prognosis. By applying these guidelines, an overall 65 to 75 percent hospital survival rate should be achieved.     

Orthopaedic perspective on bone metastasis

The incidence of cancer is increasing worldwide, with the advent of a myriad of new treatment options, so is the overall survival of these patients. However, from an orthopaedic perspective, there comes the challenge of treating more patients with a variety of metastatic bone lesions. The consequences of such lesions can be significant to the patient, from pain and abnormal blood results, including hypercalcemia, to pathological fracture. Given the multiple options available, the treatment of bone metastasis should be based on a patient-by patient manner, as is the case with primary bone lesions. It is imperative, given the various lesion types and locations, treatment of bone metastasis should be performed in an individualised manner. We should consider the nature of the lesion, the effect of treatment on the patient and the overall outcome of our decisions. The dissemination of primary lesions to distant sites is a complex pathway involving numerous cytokines within the tumour itself and the surrounding microenvironment. To date, it is not fully understood and we still base a large section of our knowledge on Pagets historic “seed and soil” theory. As we gain further understanding of this pathway it will allow us develop more medical based treatments. The treatment of primary cancers has long been provided in a multi-disciplinary setting to achieve the best patient outcomes. This should also be true for the treatment of bone metastases. Orthopaedic surgeons should be involved in the multidisciplinary treatment of such patients given that there are a variety of both surgical fixation methods and non-operative methods at our disposal.     

Multimodality aesthetic skin rejuvenation

Patients requesting skin correction and rejuvenation are motivated by a number of clinical problems. Photo damage, abnormal pigmentation or vascularity, textural problems, rhytides, and laxity due to chronological aging are the primary complaints of the majority of patients. Advances in new technology in the past decade have provided the skin correction specialist with new options for treatment. Specialists with multiple technology options then face a new dilemma. What is the best treatment plan for individual patients when many options exist? Over the past five years we have developed an approach to our patients based on an individualized treatment plan consisting of a prescribed series of skin correction treatments utilizing the most specific rejuvenation techniques for each clinical problem. Multimodality aesthetic skin rejuvenation (MMASR) emphasizes the corrective process and utilization of the most appropriate technology for the patient's clinical skin problem as evidenced by the clinical examination. MMASR also takes into consideration patient bias, cost concerns, expectations of treatment, and feasibility of combining different technologies in the same treatment session. Combining skin rejuvenation techniques with surgical rejuvenation is also reviewed as an option for patients with both facial laxity and clinical skin problems.     

Total gastrectomy in the surgical treatment of acute massive hemorrhage caused by Dieulafoy lesion of the gastric fundus

GI bleeding caused by Dieulafoy lesion in the gastric fundus: a case report Dieulafoy lesion is a rare cause of massive gastrointestinal (GI) hemorrhage that can be fatal. It arises from an abnormally large eroded submucosal artery and in more than 75% of cases the lesion is mostly found within 6 cm of the cardia. The severity of bleeding and the site of the lesion render the diagnosis sometimes difficult, more than one endoscopic exam is often required. Surgery was regarded as the treatment of choice in the past, but recently endoscopic management has become the standard approach. We report a case of an 42-year-old man presented with upper GI hemorrhage. Repeated upper GI endoscopies revealed a missed diagnosis of subcardial gastric ulcer and Mallory-Weis lesion. Following conservative treatment, the frequency and amount of haemorrhage decreased and totally stop. 48 hours after admission patient developed sudden massive upper GI bleeding and underwent emergency total gastrectomy. The diagnosis of Dieulafoy lesion was made histologically. The patient recovered uneventfully and discharged on the postoperative day 11th. Therefore, Dieulafoy disease represent a diagnostic and therapeutic challenge. Advances in endoscopic technique have greatly assisted in earlier diagnosis and added options to the treatment regimen for this lesion. The relationship of this anomaly to possible exsanguination makes it essential that both endosopical and surgical approach play an important role in the management of this pathology.     

Morel-Lavallée lesion diagnosed 25 years after blunt trauma

IntroductionMorel-Lavallée lesions are closed degloving injuries in which the skin and subcutaneous tissues separate from the underlying fascia secondary to a shearing force. These injuries are uncommon and can be misdiagnosed in acute settings. If treated incorrectly, they can recur, causing complications requiring multiple surgical interventions. Therefore, it is important to discuss the clinical presentation and imaging characteristics in order to improve their diagnosis and management.Presentation of caseThis is the case of a 44-year-old male patient with a Morel-Lavallée lesion of the left thigh that presented 25 years after trauma. He was successfully treated with open surgical excision. The patient underwent multiple surgical interventions before the lesion was accurately diagnosed and treated.DiscussionMorel-Lavallée injuries can lead to chronic symptoms, such as pain and swelling, affecting the patient’s quality of life. Treatment options include minimally invasive procedures, such as compression bandages or percutaneous drainage. However, if diagnosed late, a fibrotic capsule can form, which may require surgical excision. Our patient was diagnosed more than 20 years after the trauma. Earlier noninvasive treatment options were unsuccessful.ConclusionThe patient was treated with open surgical excision of the chronic lesion. There was no report of any recurrence up to 10 months after surgery. Such lesion treatments should be guided based on the chronicity of the injury and the patient’s symptoms. To the best of our knowledge, this is the first case with such delayed presentation.     

Trattamento ottimale delle lesioni degli arti inferiori nel polifratturato

Distal femur and proximal tibial fractures are the most common occurrence in multiple-fracture patients after motor vehicle injuries. The association of distal femur and proximal tibia, commonly known as “floating knee”, is relatively common in motorcycle accidents. This typical lesion has an unfortunately high incidence of associated neurovascular lesions. The presence of multiple fractures or serious soft tissue injuries addresses our strategy towards a “damage control” approach. The recent technological and surgical evolution of intramedullary nailing has noticeably enhanced our treatment options in these patients. In this setting, rigid internal fixation should be limited to minimally invasive anatomical plating.     

Acquired Melanocytic Lesions and the Decision to Excise: Role of Color Variegation and Distribution as Assessed by Dermoscopy

BACKGROUND: Because melanoma may sometimes be difficult to differentiate from nevi with clinical atypia, many benign lesions also undergo surgical removal. OBJECTIVE: To assess color type and distribution in dermoscopic melanocytic lesion images and to analyze the influence of color parameters on the diagnostic process and the decision to excise. METHODS: Overall, 603 images, referring to 112 melanomas and 491 nevi, were retrospectively subdivided into four groups: "clearly benign," "follow-up," "dermoscopic atypical nevi," and "dermoscopic melanomas," according to their dermoscopic aspects. The frequency of color type, number, and asymmetry were evaluated on digital images. RESULTS: With respect to lesions not eligible for excision according to dermoscopy (but excised for cosmetic reasons), those excised with a suspicion of malignancy showed a higher number of colors, whose distribution was also more asymmetric. Moreover, the frequency of the presence of black and blue-gray progressively increased from clearly benign lesions to atypical nevi and dermoscopic melanomas. CONCLUSION: In dermoscopic images, color parameters are essential elements for the diagnosis of atypical nevus, which can be differentiated from both a clearly benign lesion and a melanoma. Furthermore, pigmentation asymmetry and the presence of blue-gray represent the main color features, which should lead to the decision to excise.     

Treatment of Nevoid Hyperkeratosis of the Nipple and Areola Using a Radiofrequency Surgical Unit

BACKGROUND: Nevoid hyperkeratosis of the nipple and areola (NHNA) is a rare condition of unknown etiology. Verrucous thickening and pigmentation of the nipple and areola are the main features of the condition. Different therapeutic options, both medical and surgical, have been described. OBJECTIVE: To use a radiofrequency surgical unit to treat an NHNA case, which was unresponsive to keratolytic therapy. MATERIALS AND METHODS: The lesions of the nipple and areolas were excised tangentially with a diamond-shaped electrode of a radiofrequency surgical unit under local anesthesia. RESULTS: The patient had a good cosmetic appearance after the treatment, and there was no recurrence at the ninth postoperative month. CONCLUSION: Radiofrequency for tangential excision in the treatment of NHNA lesions that have not responded to medical therapy can be an alternative surgical method.     

Hydatid cyst of the pancreas. Apropos of 2 cases]

Two new cases of pancreatic hydatidosis are reported. The diagnosis of a cystic lesion of the pancreas has been easily established owing to the modern imaging techniques, especially to computed tomography. The hydatid nature has also been recognized before surgery on the basis of the epidemiological data, the existence of a calcified shell in one case, and positive serology in the other. Retrograde endoscopic cholangiowirsungography allowed specifying the relationships between the cyst and the pancreatic duct in one case. The treatment consisted in the resection of the protruding dome and in total cystectomy. There were no postoperative complications. The preoperative diagnosis of the lesion must no longer be regarded as difficult. The treatment does not raise any specific difficulties when there is no fistula into the pancreatic duct. Retrograde endoscopic cholangiowirsungography is a good means of recognizing a possible fistula and makes a scheduled surgical treatment possible.     

The coexistence of abdominal aortic aneurysm and early gastric cancer: Report of three cases

The surgical approach for patients with abdominal aortic aneurysm (AAA) and coexistent abdominal malignancy remains controversial. We report herein three cases of coincident AAA and early gastric cancer, all of whom were treated by a two-stage operation and underwent curative surgery for their gastric cancer. The principles of our surgical approach are as follows: (1) the lesion which requires urgent surgery should be operated on first, and if both lesions show absolute indications, a one-stage surgical procedure should then be performed; (2) a two-stage surgical procedure in which aneurysmectomy is performed first should be undertaken when no absolute indications for urgent surgery exist for either lesion; (3) a one-stage surgical procedure should only be performed when surgery on one lesion makes the other lesion highly dangerous; and (4) in patients with a poor prognosis because of far advanced cancer in whom the AAA shows no sign of rupturing, only a gastrectomy should be performed.     

Extrinsic compression of the renal artery by diaphragmatic crus

Extrinsic compression of the renal artery due to a fibromuscular band originating from the diaphragm was encountered in a 26-year-old patient who had systemic hypertension associated with stenosis and kinking of one of her renal arteries. After surgical decompression, the renal artery assumed a normal expansion with disappearance of hypertension. Six other cases of extrinsic compression of the renal artery have been found in the literature. Surgical treatment is mandatory in all cases because the mechanism that causes the lesion makes percutaneous transluminal angioplasty illusory.     

Spinal metastases of differentiated thyroid cancers. Disease picture, diagnosis, therapy]

Thyroid malignancy should be ruled out, whenever an osteolytic lesion in the spine is detected. In the presence of a single bone lesion, surgical procedure should be the treatment of choice. Even if these patients will not be "tumour-free" after the orthopedic correction they can live without pain and no mobility problem.     

强脉冲光在预防深Ⅱ度烧伤患者皮肤色素沉着的应用

目的探讨强脉冲光（intense pulse light,IPL）对面部深Ⅱ度烧伤后皮肤色素沉着的预防效果。方法60例面部深Ⅱ度烧伤患者被随机分为两组IPL治疗组及对照组各30例,治疗组采用IPL（皇后光子嫩肤仪）进行预防性治疗,一般治疗4-5次,每次间隔3-4周,并辅助性进行防晒等措施;对照组只采取防晒等作为预防方法,不做IPL治疗。结果经过12个月的随访,IPL治疗组烧伤皮肤不出现明显的色素沉着及脱失,而对照组烧伤皮肤愈合后大多数出现明显的色素沉着及脱失,两组比较差异有统计学意义（P〈0.05）。结论IPL是一种有效的预防烧伤后皮肤色素沉着的美容技术。     

Elastofibroma dorsi: case report and review of the literature

Elastofibroma dorsi (ED) is a rare, benign, often bilateral lesion of the thoracic wall, occurring most commonly in the infra-scapular region beneath the muscular tissue, generally found in elderly women. Whether ED should be considered as a true neoplasm or merely as a reaction of connective tissue to repetitive minor trauma is still debated. ED has characteristic features but a low incidence and is therefore not always easily distinguished from other benign and malignant soft-tissue tumors. Inappropriate treatment may thus be administrated in the absence of a definitive diagnosis. We report a case of a 51-year-old woman who presented with a right infra-scapular swelling associated with pain and a clicking sensation during selective arm movements. Upon clinical and ultrasound examination, the lesion had the appearance of a deep dorsal lipoma, but intraoperative findings were suggestive of a sarcoma originating from the periosteum of ribs. Nonetheless, marginal surgical excision was performed and the tumor was histologically diagnosed as ED. In conclusion, ED should be always considered in the differential diagnosis of tumors deeply located in the infra-scapular area, especially in elderly women. As it is a benign lesion, surgical treatment is recommended only in symptomatic cases or if a large swelling is present.     

Posterior shoulder fracture-dislocation: A systematic review of the literature and current aspects of management

Purpose Posterior fracture-dislocation of shoulder is an infrequent traumatic event;however,most orthopaedic surgeons may face the challenge of treating it.The aim of this study is to review and summarise systematically the current principles of the management of this complex injury,and create a treatment algorithm.Methods Both PubMed and Scopus Databases were systematically searched for the terms“posterior shoulder fracture-dislocation”or“posterior glenohumeral fracture-dislocation”or“posterior glenoid fracture-dislocation”for articles written in English and published in the last decade.Results A total of 900 articles were identified,of which 13 were retained for analysis.A total of 153 patients(161 shoulders)were identified.These patients were treated either with open reduction and internal fixation,modified McLaughlin procedure,allograft/autograft humeral head reconstruction or shoulder arthroplasty.The mean age was 40.15 years.The mean postoperative Constant score in cases treated by open reduction and internal fixation was 86.45,whereas by bone graft was 84.18.Further,the mean postoperative Constant score was between 79.6 and 67.1 in those that were managed by modified McLaughlin and arthroplasty procedure,respectively.Conclusion The management of posterior shoulder fracture-dislocation may be challenging,and the best surgical option depends on many variables such as the chronicity of the injury,the presence of a fracture at the level of the surgical neck or tuberosities and the extend of the Hill-Sachs lesion if any.A treatment algorithm is proposed,based on the current literature in an effort to create a consensus for these injuries.For the acute shoulder fracture-dislocations,an open reduction should be performed.For the chronic fracture/dislocations in the elderly low-demand patients,conservative treatment should be performed.For the rest of the patients,depending on the severity of the Hill-Sachs lesion different surgical options are available such as the McLaughlin technique,the use of an allograft,osteotomy or arthroplasty.     

Other arthroscopic procedures for the treatment of chondral injuries of the knee joint

Cartilage injuries can be treated through conservative or surgical approaches upon evaluation of the lesion. In surgical approach, arthroscopic treatment has proven to be both very popular and efficient. Through arthroscopy, treatment options such as lavage, chondral shaving, debridement, microfracture, abrasion, and chondroplasty have been successfully performed in patients with appropriate indications.     

Partial rupture of the hamstring muscle complex: a literature review on treatment options

Injuries of the hamstring muscle complex (HMC) often affect athletes participating in specific sporting activities. Mild injuries that constitute a mere strain of the muscle can be managed symptomatically, while severe injuries often require surgical intervention to precipitate a return to function. Neglected injuries usually result in a long-term functional impairment. Therefore, surgical reconstruction of the HMC is advised for both partial and complete lesions. Without acute repair, a chronic lesion referred to as hamstring syndrome can result due to dysfunction of the HMC. Surgical intervention is usually recommended. A case of a chronic severe partial injury to the HMC managed conservatively in a 49-year old female is presented to illustrate the level of function that can be achieved after non-operative management. The clinical and radiological findings are presented 18 months post-injury along with a review of the current literature. There are no previous reports in the literature describing this scenario. This case indicates the need for re-evaluation in treatment options in partial hamstring muscle ruptures. A surgical treatment of partial rupture should be considered more often as an adequate treatment option and cofactors that influence the prognosis must be revealed. The indication of surgical intervention should be re-evaluated within the first months in case of conservative treatment.     

Surgical management of deep venous reflux

Axial deep venous reflux can be found in the majority of extremities with advanced skin changes and ulceration. It frequently is associated with recurrent disease and tends to progress with time. More than 30 years' experience with deep venous reconstructive surgery, as well as recent advances in diagnostic imaging, makes possible the rational use of such techniques in the management of chronic venous insufficiency. This report reviews the role of deep venous reflux in the natural history and progression of venous disease, the options for surgical correction of deep venous reflux, the current diagnostic abilities and limitations, and the results of surgical interventions.