What is the evidence for the management of urethral amyloidosis? A systematic review of the literature

What's known on the subject? and What does the study add? Urethral amyloidosis is rare and urethrotomy has been proposed as a suitable treatment option. By reviewing the literature and comparing our own experiences, we have shown urethroplasty to have good medium term outcomes in patients with urethral amyloidosis, whereas urethrotomy may lead to recurrence.

OBJECTIVE

• ? Urethral amyloidosis (UA) is a rare condition which may be encountered by an urological surgeon. We reviewed the literature regarding the presentation, investigation and management of UA.

PATIENTS AND METHODS

• ? A systematic review of the English literature on PubMed was conducted and we indentified 39 articles which reported 45 patients. We included our experience with four patients from our tertiary centre.

RESULTS

• ? The majority of patients reported symptoms consistent with a urethral structure. Most patients were treated with urethrotomy, only two patients have been reported to have had a urethroplasty in the literature. Medium and long term outcome data is lacking for urethrotomy and urethroplasty. We found recurrence in our patients after urethromoty and incomplete resection of UA. We describe short (6 month) and medium term (18 month) outcomes in two patients who underwent augmentation urethroplasty.

CONCLUSION

• ? Although urethrotomy and dilatation have been proposed in the past, we found these may still lead to disease progression and therefore urethroplasty may be the most appropriate long term management option.

     

Surgical versus conservative treatment for ankle fractures in adults – A systematic review and meta-analysis of the benefits and harms

IntroductionDespite fractures of the ankle being very common, there is a lack of clarity regarding the relative effectiveness of conservative versus surgical treatment.The purpose of this systematic review and meta-analysis was to investigate the clinical effects, benefits, and harms of surgical versus conservative treatment of ankle fractures in adults.MethodsA systematic search strategy was conducted in the databases: Pubmed, Embase, Web of Science, and Cochrane up until the 16th of August 2017. Eight available randomized controlled trials, regardless of fracture type, reported on patient-reported ankle-specific functional outcome and were included. Analyses were based on random effects models.ResultsThe 8 included studies randomly allocated 1237 patients to either surgical or conservative treatment. Mean age of patients ranged from 38.1 to 71.4 years. Five studies evaluated short-term patient-reported ankle function, with no significant difference between surgery and conservative treatment (SMD = ?0.14, 95%CI = ?0.57 to 0.29, P = 0.51, I² = 84%). Three studies evaluated health-related quality of life, with no significant difference in treatment effect between surgery or conservative treatment (SMD = 0.13, 95%CI = ?0.01 to 0.27, P = 0.06, I² = 0%).ConclusionsThe best available current evidence supports that clinicians can manage ankle fractures by both surgical and conservative means with equal short-term results in selected patient groups with stable and unstable nondisplaced ankle fractures. However, more research is needed including high-quality RCTs investigating the long-term effects. This is especially the case in younger patients, before making significant interpretations about clinical practice.     

Pregnancy and cardiac interventions: What are the optimal management options?

Cardiac disease is the leading cause of maternal mortality in the United Kingdom. Major causes of cardiac death in pregnant women include cardiomyopathies, myocardial infarction, ischemic heart disease, and aortic dissection. Uncorrected congenital heart disease and women who have had corrective or palliative surgery may have complicated pregnancies as well. Some women with significant cardiac disease are unable to meet the increased physiological demands of pregnancy. Of these, those who do not respond to medical treatment may require surgical correction such as coronary artery bypass grafting. The risk of cardiac operations for pregnant women is similar to that for nonpregnant women but the fetal mortality rate remains high. Contributing factors to high fetal mortality rates include timing, urgency of operation, and the fetal/fetoplacental response to cardiopulmonary bypass. The aim of this review is to summarize current evidence in utilizing the different management approaches of cardiac issues during pregnancy.     

What are the guidelines for the surgical and nonsurgical treatment of periprosthetic osteolysis?

Periprosthetic osteolysis is most often diagnosed by plain radiographs. Because these radiographs routinely underestimate the extent of the lesion, three-dimensional imaging should be used early in the evaluation process to confirm the presenting extent of disease. If the osteolytic process is asymptomatic, scheduled regular follow-up should be instituted until the lesion can be confirmed to be stable or until the decision is made to proceed with surgery. Nonsurgical management with pharmacologic agents has not proved to be effective. If surgery is contemplated, a three-dimensional evaluation with magnetic resonance imaging or helical computed tomography can assist in preoperative planning. Surgical intervention requires complete débridement of the lesional membrane and removal of the wear-generator--with or without component removal and with or without bone grafting, depending on the individual circumstances. A standardized follow-up evaluation mechanism for all patients should be a part of total joint arthroplasty management.     

Anastomotic leak won't fix itself. What are the options for management of anastomotic leak?

Anastomotic leak can be a devastating complication. Early recognition is the most important step in avoiding mortality and significant morbidity. Once identified, the surgeon must decide how to best mitigate the problem. A variety of options are available and should be tailored to the unique characteristics of the patient. Choosing between operative and non-operative intervention will be guided by the presentation. Early presentation with septic complications will typically be treated with a more invasive approach, while a delayed or insidious presentation can often be managed with a non-operative approach.     

What are the treatment options for blister-like aneurysms?

Treatment of blood blister-like aneurysms (BBAs) of the supraclinoidal internal carotid artery (ICA) is challenging and the optimal treatment is yet to be defined. The treatment options for ICA BBAS are microsurgery, endovascular therapy, or a combination of the two. The microsurgical armamentarium consists mainly of direct aneurysm clipping with or without protective EC-IC bypass, clip-wrapping, or trap ligation with ICA sacrifice with or without EC-IC bypass. The endovascular treatment options are mainly endovascular ICA ligation, multiple overlapping stents (≥ 3) with or without coiling, covered stents, or flow diverters. In four recent meta-analyses of BBAs, neither microsurgical nor endovascular therapy had an impact on clinical outcome in multivariate analysis. Microsurgery offered aneurysm obliteration rates superior to endovascular techniques, but came at a higher risk of intraoperative bleeding. Endovascular therapy increased the likelihood of a second treatment, conversion to another treatment modality, and incomplete aneurysm obliteration. In this review, we discuss pros and cons of the above approaches while adding our own viewpoints to the discussion.     

Postoperative changes of the microbiome: are surgical complications related to the gut flora? A systematic review

Background

The purpose of this review was to identify the relationship between the gut microbiome and the development of postoperative complications like anastomotic leakage or a wound infection. Recent reviews focusing on underlying molecular biology suggested that postoperative complications might be influenced by the patients’ gut flora. Therefore, a review focusing on the available clinical data is needed.

Methods

In January 2017 a systematic search was carried out in Medline and WebOfScience to identify all clinical studies, which investigated postoperative complications after gastrointestinal surgery in relation to the microbiome of the gut.

Results

Of 337 results 10 studies were included into this analysis after checking for eligibility. In total, the studies comprised 677 patients. All studies reported a postoperative change of the gut flora. In five studies the amount of bacteria decreased to different degrees after surgery, but only one study found a significant reduction. Surgical procedures tended to result in an increase of potentially pathogenic bacteria and a decrease of Lactobacilli and Bifidobacteria. The rate of infectious complications was lower in patients treated with probiotics/symbiotics compared to control groups without a clear relation to the systemic inflammatory response. The treatment with synbiotics/probiotics in addition resulted in faster recovery of bowel movement and a lower rate of postoperative diarrhea and abdominal cramping.

Conclusions

There might be a relationship between the gut flora and the development of postoperative complications. Due to methodological shortcomings of the included studies and uncontrolled bias/confounding factors there remains a high level of uncertainty.

     

Distance education for anatomy and surgical training – A systematic review

Rapid development of COVID-19 has resulted in a massive shift from traditional to online teaching. This review aims to evaluate the effectiveness of distance learning on anatomy and surgical training.This systematic review was conducted in line with the PRISMA statement and current methodological literature. The databases CINAHL, Cochrane, EMBASE and Pubmed were searched using the search terms “Distant learning” OR “Distance learning” AND “Anatomy OR Surgery”. 182 non-duplicate studies were identified. 20 studies were included for qualitative analysis.10 studies evaluated students' performance with distance learning. 3 studies suggested that students’ learning motivation improved with distance learning pedagogy. 5 studies found improved student performance with distance learning (performance or task completion time) when compared to conventional physical method. While 2 other studies found non-inferior student performance.10 studies evaluated students’ feedback on distance learning. Most feedbacks were positive, with flexibility, efficiency, increased motivation and better viewing angles as the most-liked features of distance teaching. 4 studies pointed out some limitations of distance learning, including the lack of personal contact with tutor, poor network and reduced student concentration.7 studies evaluated tutors’ feedback on distance learning. Tutors generally liked online platforms for the ease of tracking silent students, monitoring performance and updating fast-changing knowledge. Yet the lack of hands-on experience for students, technical issues and high costs are the main concerns for tutors.In conclusion, distance learning is a feasible alternative for anatomy and surgical teaching.     

A systematic review of the management of hangman’s fractures

During the past 30 years various treatment protocols for hangmans fractures have been attempted. In order to guide the management of hangmans fractures, different classifications have been introduced. However, opinions on operative or nonoperative treatment have not yet been solidified. To evaluate both conservative and operative management of hangmans fractures in the published literature and to provide appropriate guidelines for treatment of hangmans fractures, a systematic review of the literature regarding the management of hangmans fractures was performed. An English literature search from January 1966 to January 2004 was completed with reference to treatment of hangmans fractures. The classification for treatment guidance from the literature was also reviewed. Regarding a primary therapy for hangmans fractures, there were 20 papers (62.5%) that advocated for a conservative treatment and 11 of the remaining 12 papers suggested that conservative treatment was suitable for some stable fractures. The classification of Effendi et al. modified by Levine and Edwards was used widely. Most hangmans fractures could be managed successfully with traction and external immobilization, especially in Effendi Type I, Type II and Levine-Edwards Type II fractures. It is necessary for Levine-Edwards Type IIa and III fractures to be treated with rigid immobilization. Only for some stable Type I and Levine-Edwards Type II injuries, nonrigid external fixation alone was sufficient. Rigid immobilization alone was necessary for most cases. Surgical stabilization is recommended in unstable cases when there is the possibility of later instability, such as Levine-Edwards Type IIa and III fractures with significant dislocation. The classification system proposed by Effendi et al. and modified by Levine and Edwards provided a clinically reasonable guideline for successful management of hangmans fractures.     

Industry and evidence-based medicine: Believable or conflicted? A systematic review of the surgical literature

Background

Over the last few decades medical research and development has come to depend more heavily on the financial support of industry. However, there is concern that financial relations between the medical community and medical industry could unduly influence medical research and therefore patient care. Our objective was to determine whether conflict of interest owing to authors’/investigators’ financial affiliation with industry associated with their academic research has been identified in the surgical literature. In particular, we sought to answer the following questions: What is the extent of such conflict of interest? Does conflict of interest bias the results of academic surgical research in favour of industry? What are the potential causes of this proindustry bias?

Methods

We conducted a systematic review of the literature in May 2008 using the OVID SP search engine of MEDLINE, EMBASE, CINAHL, the Cochrane Database of Systematic Reviews, DARE and Health Technology Assessment. Quantitative studies that included a methods section and reported on conflict of interest as a result of industry funding in surgery-related research specifically were included in our analysis.

Results

The search identified 190 studies that met our criteria. Author/investigator conflict of interest owing to financial affiliation with industry associated with their academic research is well documented in the surgical literature. Six studies demonstrated that authors with such conflicts of interest were significantly more likely to report a positive outcome than authors without industry funding, which demonstrates a proindustry bias. Two studies found that the proindustry bias could not be explained by variations in study quality or sample size.

Conclusion

The conflict of interest that exists when surgical research is sponsored by industry is a genuine concern.     

What are the actual indications for a surgical parathiroidectomy?

Secondary hyperparathyroidism (HPTH-II) is a major complication of chronic renal insufficiency (CRI). It affects more than 300,000 dialyzed CRI patients in the world and probably more than 3 million as yet non-dialyzed CRI patients. It results from an imbalance in the interaction between calcium, phosphorus, vitamin D and parathyroid hormone (PTH). In fact, CRI is accompanied by phosphorus retention and this accumulation of phosphorus induces an increased synthesis of FGF-23 (Fibroblast Growth Factor-23) which inhibits the activity of lalpha-hydroxylase and the synthesis of calcitriol. Moreover, the hyperphosphaturia induced by PTH and its stimulant effect on calcitriol synthesis and tubular calcium reabsorption are compromised by the reduction in the expression of the renal PTH receptor. All these changes lead to a negative calcium balance and a reduction in calcium-sensitive receptors and vitamin D receptors in parathyroid cells (CaR), thereby releasing the secretion of PTH and the proliferation of parathyroid cells. The chronic stimulation of PTH by these anomalies causes progressive hyperplasia of the parathyroid cells which may be transformed into a benign tumor with a monoclonal appearance. The usual medical treatment of HPTH-II consists in the correction of hypocalcemia by calcium salts and vitamin D and its derivatives, hyperphosphatemia by lifestyle and dietary changes and intestinal phosphorus chelating agents and metabolic acidosis. Very recently, this treatment armamentarium has been expanded by the advent of the calcimimetic agent, cinacalcet HCl. This product increases the calcium sensitivity of CaR in parathyroid cells leading to a rapid and sustained decrease in PTH secretion. However, it is still necessary to resort to surgical parathyroidectomy (PTX) when these treatments prove to be ineffective or involve risks because of adverse effects and in particular an increase in the calcium-phosphorus ion product and the occurrence or worsening of cardiovascular calcifications. The purpose of this article is to revise the current indications of PTX and to discuss changes and the current and future trends for treatment of HPTH-II by surgery alone or combined.     

A systematic literature review of tibial plateau fractures: What classifications are used and how reliable and useful are they?

IntroductionClassification systems such as the Schatzker and AO/OTA have been proposed for standardised assessment of tibial plateau fractures and to guide clinical decision making. However, there has been no comprehensive literature review of all classification systems for tibial plateau fractures, including assessment of their reliability. The aim of this systematic review was to identify and appraise previously established classification systems for tibial plateau fractures and determine their reliability for fracture classification.MethodsSix databases were searched from inception until October 2016. Classification systems for tibial plateau fractures were identified. No restriction was placed on imaging modality (plain film X-ray, CT, MRI). Data synthesis was performed to identify common features of the systems, their prevalence within the literature and studies of intra and inter-rater reliability of fracture classification using Kappa coefficient (κ).ResultsThirty-eight classification systems were identified, five of which were a sub-classification of a single fracture type from a previous tool. The Schatzker and AO/OTA classification systems were the most commonly reported. Of the tools identified only five have been tested for inter and intra-observer reliability (Schatzker, AO/OTA, Duparc, Hohl and Luo). Reliability of more simplistic classification systems, such as that by Luo et al. (three-column) was typically high (intra-κ = 0.67–0.81, inter-κ = 0.71–0.87), but with the disadvantage of providing less information on fracture patterns and morphology. Intra and inter-observer reliability using plain film X-ray was frequently moderate (κ = 0.40–0.60), with 2D and 3D CT typically improving reliability of classification. Only 11 of the 32 complete classification systems identified association of fracture classification with clinical outcome.DiscussionFrequently used systems for classification of tibial plateau fractures display moderate intra and inter-observer reliability. More sophisticated imaging modalities such as 2D and 3D CT typically improve reliability estimates. Using fracture classification based on imaging findings to predict clinical outcome was not a commonly reported goal of newly developed systems. More detailed assessment of fracture patterns and morphology, in conjunction with information on surgical fixation, may be desirable for predicting outcomes and to guide clinical decision making.     

What are the major parameters to follow for the management anaemia in dialysis patients? What is the frequency of survey and what are the guidelines?

Anaemia treatment in dialysis population is a permanent preoccupation for nephrologists. The erythropoiesis stimulating agents have disrupted its management. The international guidelines define the different parameters to follow and the periodicity of survey. It allows us to harmonize our practice and guaranty an optimization of anaemia treatment in the dialysis population.     

Current trends in the management of carcinoma penis – a review

AIMS AND INTRODUCTION: To review the current literature, recent advances and recent trends in the management of squamous cell carcinoma of the penis so as to have a broad overview of penile cancer and its current management. The review was considered keeping in mind that squamous penile carcinoma is an infrequently encountered malignancy and that the etiology is still unclear though certain predisposing conditions are known to exist and also that controversy still exists as to the appropriate management of inguinal adenopathy. We also reviewed the etiological factors, clinical presentation, diagnosis, staging, prognostic factors in addition to management and prophylaxis. METHODS: A literature search was carried out from Pubmed for indexed articles published over the last 50 years using the key words 'Management penile carcinoma', 'Squamous cell carcinoma penis' and 'inguinal lymphadenectomy'. RESULTS: The search yielded over 1500 indexed published articles and reports. Important major reports and studies were reviewed, screened and tracked for recent changes and trends in the management of penile cancer. These were analyzed, tabulated and discussed. CONCLUSIONS: Newer approaches to the management of penile cancer include use of laser, photodynamic therapy, neoadjuvant therapy and sentinel node mapping by lympho-gamma-scintigraphy. The current approach towards managing inguinal adenopathy shows an increasing trend towards the use of these newer modalities as well as the use of certain modifications in lympadenectomy such as (the use of ligasure, modified dissection, saphenous vein sparing and lymphoscintigraphy, etc.) thereby making the procedure considerably less morbid than before.     

What is the best fixation technique for isolated talonavicular arthrodesis? – A systematic review

SummaryTalonavicular arthrodesis is associated with a rate of non-union that ranges from 3 % to 37 %. Various fixation devices have been reported for talonavicular arthrodesis including screws, staples, plates, K-wires and intraosseous fix systems, however there is no definitive gold standard. This systematic review aims to compare clinical outcomes between different fixation devices for talonavicular arthrodesis.MethodsMEDLINE, EMBASE, CENTRAL and Google Scholar were reviewed for studies reporting on outcomes of different fixation techniques for talonavicular arthrodesis indicated for osteoarthritis, inflammatory and post-traumatic arthritis from 1946 to 2021. The primary outcome measure was union rate. Secondary outcome measures included functional improvement, cost, quality of life and patient satisfaction.Results9 articles involving 141 cases of talonavicular arthrodesis were identified. Fusion rates were as follows: screw fixation (n = 75): 87.5 % to 100 %, staple fixation (n = 13): 100 %, intraosseous fix system (n = 16): 100 %, and K-wire fixation (n = 2): 100 %. One study utilised a dorsal locking plate with two supplemented compression screws (n = 9, fusion rate= 100 %) and two studies used a combination of screws with staples (n = 26, fusion rate= 96 %). 7 of 9 studies measured functional outcomes and pain relief with improvement demonstrated in all fixation techniques. Quality of life, satisfaction and cost were inadequately reported amongst the included studies. All studies were rated as serious risk of bias.ConclusionThis systematic review consolidates the evidence for outcomes of different fixation techniques for TN arthrodesis, however a definitive judgement regarding the best fixation technique is unobtainable from current clinical evidence, due to lack of high-quality studies.With review of biomechanical studies and the limited clinical data, fixation with plate plus screw is most promising and would warrant further comparative study.Level of evidenceIV.