Is there a role for surgery in the treatment of mastalgia?

Breast pain is a common condition affecting most women at some stage in their reproductive life. Mastalgia is resistant to treatment in 6% of cyclical and 26% non-cyclical patients. Surgery is not widely used to treat this condition and only considered in patients with severe mastalgia resistant to medication. The aims of this study were to audit the efficacy of surgery in severe treatment resistant mastalgia and to assess patient satisfaction following surgery. This is a retrospective review of the medical records of all patients seen in mastalgia clinic in the University Hospital of Wales, Cardiff since 1973. A postal questionnaire was distributed to all patients who had undergone surgery. Results showed that of the 1054 patients seen in mastalgia clinic, 12 (1.2%) had undergone surgery. Surgery included 8 subcutaneous mastectomies with implants (3 bilateral, 5 unilateral), 1 bilateral simple mastectomy and 3 quadrantectomies (1 having a further simple mastectomy). The median duration of symptoms was 6.5 years (range 2-16 years). Five patients (50%) were pain free following surgery, 3 developed capsular contractures and 2 wound infections with dehiscence. Pain persisted in both patients undergoing quadrantectomy. We conclude that surgery for mastalgia should only be considered in a minority of patients. Patients should be informed of possible complications inherent of reconstructive surgery and warned that in 50% cases their pain will not be improved.     

Is there a role for rituximab in the treatment of idiopathic childhood nephrotic syndrome?

We each have nephrotic patients who become steroid dependent and in whom multiple immunosuppressive agents are employed. There is a need to balance possible therapeutic benefits with drug toxicity. This case report describes such a patient, who has suffered from nephrotic syndrome for over 11 years and had become resistant to the usual therapies. He was therefore given a single dose of the anti-CD20 drug rituximab, to which he showed a prompt response, leaving him free of proteinuria for the past 10 months.     

Is there a role for surgical resection in the treatment of early-stage pancreatic lymphoma?

BACKGROUND: Pancreatic lymphoma is a rare neoplasm. The role of surgical resection in curing this disease is poorly defined. STUDY DESIGN: From March 1983 to July 1997, eight patients with stage I or II primary pancreatic lymphoma were identified and retrospectively reviewed. All patients received chemotherapy, five patients received radiotherapy, and three patients also underwent surgical resection. A review of the published pancreatic lymphoma experience in the English-language literature was also undertaken. RESULTS: Three patients underwent pancreaticoduodenectomy with successful resection of the lymphoma and are disease free at 64, 62, and 53 months followup. Five patients were treated with nonresectional therapy. Three are disease free at 128, 51, and 24 months. Two patients died of disease at 9 and 37 months. A review of the pancreatic lymphoma experience in the English-language literature identified 122 cases of pancreatic lymphoma. Fifty-eight of these cases represented stage I or II lymphoma, which was treated without surgical resection with a 46% cure rate. Fifteen patients who had surgical resection for localized disease have been reported with a 94% cure rate. CONCLUSIONS: Based on both our single institution experience and the literature, it is suggested that surgical resection may play a beneficial role in the treatment of localized pancreatic lymphoma, although selection factors cannot be absolutely excluded.     

Is there a role for bladder preserving strategies in the treatment of muscle-invasive bladder cancer?

Single modality bladder sparing therapy for muscle-invasive bladder cancer, including transurethral resection, systemic chemotherapy or radiotherapy have been demonstrated to result in insufficient local control of the primary tumor as well as decreased long-term survival of the patients when compared to radical cystectomy. Therefore, multimodality treatment protocols that aim at bladder preservation and involve all of the aforementioned approaches have been established. Arguments for combining systemic chemotherapy with radiation are to sensitize tumor tissue to radiotherapy and to eradicate occult metastases that have already developed in as many as 50% of patients at the time of first diagnosis. It has been shown that the clinical outcome observed with this approach approximates that after radical cystectomy. Additionally, a substantial number of patients survive with an intact bladder. However, bladder preserving approaches are costly, and require close co-operation between different clinical specialists as well as very close follow-up. The good long-term results obtained after cystectomy and creation of an orthotopic neobladder make the possible advantage of a bladder preservation strategy questionable in consideration of quality of life issues. Additionally, side effects related to bladder sparing therapy may result in an increased morbidity and mortality in those patients who in fact need to undergo surgery due to recurrent or progressive disease. Multimodality bladder sparing treatment is a therapeutic option that can be offered to the patient at centres that have a dedicated multidisciplinary team at their disposal. However, radical cystectomy remains the standard of care for muscle-invasive bladder tumors.     

Is there a role of a small dose of propofol in the treatment of laryngeal spasm?

BACKGROUND: Propofol has been found to depress the laryngeal reflexes. We studied whether this property could be utilized to relieve laryngeal spasm. METHODS: This study was conducted over a period of 3 years, and included children aged 3-10 years, ASA status I and II. Most of the children were undergoing minor surgical procedures, under general anaesthesia with Laryngeal Mask Airway (LMA trade mark ) and caudal epidural analgesia. RESULTS: During this period, 20 patients developed laryngeal spasm on removal of the LMA at the end of surgery. Initially, they all were treated with 100% O2, with gentle positive pressure ventilation. Out of 20 patients, seven responded well with 100% O2 and gentle positive pressure ventilation. The remaining 13 were treated with a small dose of propofol (0.8 mg.kg-1 body weight). Laryngeal spasm was relieved successfully in 10 patients and three patients required intubation to improve their oxygenation. CONCLUSIONS: Propofol in a small dose (0.8 mg.kg-1 body weight) was a useful drug to relieve laryngeal spasm in most children (76.9%) following the removal of the LMA. Because it was not found to be effective in all patients, succinylcholine still has a role to play in critical conditions. However, we recommend propofol as a suitable alternative for relieving laryngeal spasm in situations where succinylcholine is contraindicated.     

Is there a role for Ytrrium-90 in the treatment of unresectable and metastatic intrahepatic cholangiocarcinoma?

Background

Selective internal radiation therapy (SIRT) with Ytrrium-90 (Y-90) has been used to treat hepatic malignancies with success. This study focuses on the efficacy and safety of Y-90 in the treatment of unresectable and metastatic intrahepatic cholangiocarcinoma (ICC).

Is testosterone replacement an effective treatment of secondary premature ejaculation?

There are very few studies that have evaluated premature ejaculation characteristics in regard to subtypes. Additionally, to our knowledge, there are no studies which have explored testosterone replacement therapy in secondary premature ejaculation patients with testosterone deficiency. Therefore, our aims were as follows: (a) to determine the characteristics of patients with premature ejaculation in regard to the four subtypes of premature ejaculation and (b) to determine the efficacy of testosterone replacement therapy in the treatment of testosterone-deficient patients with secondary premature ejaculation. Patients who applied to our clinic from May 2010 to August 2018 with premature ejaculation were included in this study. The mean age of the study group was 36.42 (min-max: 24–52) years. Those with secondary premature ejaculation were found to have significantly lower testosterone concentration compared to the other groups. Shortest mean intravaginal ejaculation latency time and lowest International Index of Erectile Function-5 score were found among those with secondary PE. In regard to treatment results, recipients of testosterone replacement demonstrated a 4.8-fold increase in mean intravaginal ejaculation latency time, while dapoxetine recipients had a 1.8-fold increase. Our findings demonstrate that testosterone replacement may be a promising treatment for those with secondary PE in the presence of testosterone deficiency.     

Is there a role for PET in the evaluation of subcentimeter pulmonary nodules?

There are little published data available at this time to determine the appropriate role of positron emission tomography (PET) in the evaluation of subcentimeter pulmonary nodules. The sensitivity for malignancy is lower in these smaller lesions, while one would expect the specificity to be higher. Given that the resolution of current generation PET scanners is only 5 to 6 mm, one will be very unlikely to gain useful information from PET for a lesion below 5 mm. For lesions 5 to 10 mm in size, useful information might be gained from PET in those deemed intermediate risk by CT criteria, but this remains to be established. A positive PET in a small, intermediate risk lesion might push one toward biopsy/excision, though a negative PET in such a lesion must be considered to provide no information whatsoever. Even with advances in PET technologies in the future, we feel it is unlikely that PET will evolve a major role in the evaluation of the subcentimeter nodule.     

Is there a role for incomplete resection in the management of retroperitoneal liposarcomas?

Complete surgical resection is the most effective modality for the treatment of retroperitoneal sarcomas. Previous studies of all types of retroperitoneal sarcomas have not shown a survival benefit of incomplete resection over no resection. Because death often occurs as a result of local progression in retroperitoneal liposarcomas (RPLS), it is possible that incomplete resection may be beneficial in this histologic type. In this study we have sought to determine the clinical outcomes in patients with incompletely resected and unresected RPLS with the aim of defining patients who may benefit from palliative resection. From a prospective clinical database 55 patients with incompletely resected (n = 43) or unresected (n = 12) RPLS were identified between 1982 and 1999. Statistical analyses were performed using the log-rank test and Kaplan-Meier estimates with disease-specific survival as the primary end point. Variables studied included age, gender, recurrent versus primary disease, tumor grade, and tumor size. The patient population consisted of 34 men and 21 women with a mean age of 61 +/- 14 (SD) years. The median time to death was 10 months (range 1 to 83 months) with a median followup of 12 months (range 1 to 60 months) for survivors. Partial resection was an independent factor for increased survival as compared with exploration or biopsy only (median survival 26 versus 4 months, p < 0.0001). Of patients who received incomplete resections, locally recurrent presentation (n = 19) versus primary disease (n = 24) was a negative prognostic variable (median survival 17 versus 46 months, p = 0.009). Successful palliation of symptoms was achieved in 24 of 32 patients (75%) with preoperative symptoms. In select patients with unresectable RPLS, incomplete surgical resection can provide prolongation in survival and successful symptom palliation. Most likely to benefit are those patients presenting with primary tumors, suggesting that surgical resection should be attempted in the majority of patients.     

Is there a role for microsurgery in the prevention of arm lymphedema secondary to breast cancer treatment?

The secondary lymphedema of the upper limb (post-mastectomy lymphedema) has an incidence, in patients who underwent axillary lymphadenectomy for breast cancer, between 5 to 25%, up to 40% after radiotherapic treatment. We studied 50 patients treated for breast cancer. The patients were divided in two groups of 25 each, comparable for age, sex, pathology and treatment and followed up to 5 years after operation for breast. One group of 25 patients was controlled only clinically (physical examination, water volumetry) at 1-3-6 months and 1-3-5 years from breast cancer treatment. The other group of 25 patients was followed also by lymphatic scintigraphy performed pre-operatively and after 1-3-6 months and 1-3-5 years from operation. In the first group, followed only clinically, lymphedema appeared in 9 patients after a period variable from 1 week to 2 years, with highest incidence between 3 and 6 months. In the second group of 25 patients, the preventive therapeutic protocol allowed to have a clinically evident arm lymphedema only in 2 patients. The comparison of the two groups of 25 patients proved a statistically significant difference in the appearance of arm secondary lymphedema (p = 0.01, using Fisher's exact test). The diagnostic and therapeutic preventive procedures allow to reduce the incidence rate of lymphedema significantly, in comparison with patients who did not undergo this protocol of prevention.     

Is there a role for surgery in the management of dropped head syndrome?

We present a 50-year-old chronic epileptic man with a long-standing head drop, who fell sustaining multilevel thoracic vertebral body fractures. The antiepileptic medication was thought to be responsible for his osteoporosis and dropped head. We review the aetiology of the dropped head and report on our experience of surgery for this rare and disabling condition.     

Is there a role for interval appendectomy in the management of acute appendicitis?

Interval appendectomy (IA) remains a controversial subject in surgery. To determine its effectiveness we reviewed our results with this approach. From January 1990 through December 1998 a total of 73 patients underwent appendectomy, five (7%) of which were interval in nature. These IA patients had a palpable abdominal mass or delayed presentation that led to CT scan. The decision to delay surgery was determined by two factors: 1) a CT scan that showed advanced inflammatory changes (phlegmon or abscess) associated with acute appendicitis and 2) a rapid response to conservative management. All patients received antibiotics-first intravenous and then oral. Repeat CT scans were performed before surgery and showed a virtual resolution of the inflammatory process. Appendectomy was delayed from 35 to 66 days from the time of diagnosis (average 51 days). There were no preoperative complications, the operations were uneventful, and there were no significant postoperative sequelae. IA appears to convert an unfavorable surgical situation potentially fraught with complications (fistula, abscess, wound infection) to one that is essentially elective in nature. It should be considered for the patient who is found to have an extensive periappendiceal inflammatory process, is clinically stable, and responds favorably to initial nonoperative management.