Radiolucent Lesions of the Extremities

There are numerous conditions that produce a radiolucent lesion in a bone. Many of these are benign and of little consequence and need only occasional observation, as they usually heal spontaneously. A few are benign but do not heal spontaneously and require a limited operation. Others are malignant and must be removed surgically or irradiated. The physician evaluating the radiolucent lesion must be able to distinguish lesions that should be observed from those that should be further evaluated or treated. It is unnecessary to evaluate every radiolucent lesion as if it were a malignant tumor. With an understanding of the potential lesions and how they present, it is possible to construct an algorithm that can be used to organize an efficient and appropriate evaluation.     

Epithelioma developing on a varicose ulcer

While transition of a varicose ulcer to an epithelioma is rare, it should be borne in mind when persistent ulceration occurs which does not heal under the usual therapeutic measures employed.Radiation therapy is the method of choice for the treatment of varicose ulcer epithelioma.A case is reported showing the result of such treatment.Photographs of the lesion before and after treatment are shown.     

Meningiomas

Meningiomas, the most common intracranial tumors, are dura-based tumors that occur in middle-aged or older adults and have a predilection for women and African Americans. They are almost always benign, but atypical and malignant forms exist. The optimal treatment for symptomatic tumors is complete surgical resection when feasible. Tumors in poor locations can have a higher rate of morbidity and often can be only partially removed. Radiation therapy should be used to treat lesions that are partially removed and lesions of higher grade, despite complete removal. Small lesions may be amenable to radiosurgery, which may obviate surgery in high-risk patients. For lesions that recur or grow despite surgery and radiation, the only option is systemic chemotherapy. No agent is optimal, but hydroxyurea is used most often. Newer approaches such as the use of inhibitors of somatostatin receptors or signal transduction pathways are under investigation.     

Surgical treatment of infected necrosis

Over the years, experience has shown that the cornerstone for improved survival in patients with infected pancreatic necrosis is an early, precise diagnosis followed by adequate drainage combined with modern intensive care management. In experienced hands, this goal can be achieved with different surgical approaches, provided that all septic collections are thoroughly removed and that reexploration is performed promptly if there is evidence of ongoing sepsis. If there is any concept preferable, and under what conditions, future large-scale randomized trials with precise and comparable patient stratification will have to demonstrate it.     

Subcutaneous moving bodies

Subcutaneous free or moving bodies are rare. We report two cases of subcutaneous movable bodies. These two bodies were treated by surgical excision. Histopathological findings were free fatty tissues and calcifying epithelioma. The cause of free fatty bodies and the mechanism by which they turn into a widely moving calcifying epithelioma are now obscure; however, trauma may be a possible cause of these lesions.     

Perirenal insufflation

Perirenal air insufflation has proved itself to be of great value m the differential diagnosis of all retroperitoneal lesions in and about the kidney. Its use permits us to draw conclusions concerning the local spread and operability of renal tumors hitherto not possible. The technic is not difficult and can be mastered quite promptly especially by the urologist who is thoroughly acquainted with this part of the human anatomy. Complications are infrequent and of minor degree if ordinary care is taken. We present a consecutive series of 175 cases of perirenal air injection without serious mishap. In all instances added valuable information was obtained. We believe that the urologist need not hesitate to employ this procedure in the indicated case, although we advise against its indiscriminate use. No elaborate or expensive equipment is required.     

Herniated L4-L5 disc after placement of Harrington instrumentation for a fracture of the thoracolumbar spine

The authors report a case in which L5 radiculopathy developed acutely after surgery for placement of Harrington rod instrumentation for an L1 body fracture. Computed tomographic myelography demonstrated a large L4-L5 herniated disc that had not been present in preoperative studies. An emergency laminectomy was performed, and a large, free, subligamentous disc fragment was removed. The patient subsequently regained L5 sensorimotor function. The postoperative development of lumbar radiculopathy is an uncommon complication of Harrington rod instrumentation that may result from several biomechanical features of the instrumentation. These injuries may not be detected by intraoperative monitoring of somatosensory evoked potentials, and therefore, the postoperative neurological examination assumes a crucial role in the early diagnosis of these lesions. As our case demonstrates, these radicular deficits may be reversible if their cause is promptly recognized and treated.     

Epiglottic hematoma leading to airway obstruction after general anesthesia

Bleeding into the upper airway can cause airway obstruction and death if not recognized promptly. Anesthesiologists are quite familiar with potential airway obstruction from acute epiglottitis, but they may be less familiar with the potential for airway obstruction from epiglottic hematoma. We report what we believe is the second case of epiglottic hematoma after anesthesia and surgery that led to an acute upper airway obstruction. Our case was unique in that there was no excessive airway trauma during tracheal intubation. Most important, this case emphasizes that patients receiving multiple anticoagulants--as our patient was--are at risk for airway bleeding, epiglottic hematoma formation, and airway obstruction.     

Management of laryngeal radionecrosis: animal and clinical experience

Radiation necrosis of the laryngeal cartilages is an uncommon complication of radiotherapy for laryngeal carcinoma. It is a devastating process for which there is no one acceptable treatment. Medical management offers only temporary, symptomatic relief, which further necessitates surgical treatment. Surgical management may start with a tracheotomy; however, it often ends with a total laryngectomy. Physiologically, the necrotic cartilages are the source of the problem. It is a general surgical principle that nonviable tissue must be excised to promote healing. Therefore, if the affected laryngeal cartilages were removed, the larynx should heal. Total or near total removal of the thyroid and cricoid cartilages with preservation of the endolaryngeal soft tissues has not been reported in the literature. Theoretically, if the entire cartilaginous framework is removed, there would be no structural support for the airway. We have found using animal models, that submucosal resection of the laryngeal cartilages, leaving the perichondrium and endolaryngeal soft tissues intact can result in a competent airway. Animal and clinical experience will be presented.     

Pulmonary hypertension in pediatric heart surgery]

Congenital heart disease can increase or decrease pulmonary blood flow, pulmonary vascular resistance (PVR) or pulmonary artery pressure (PAP). PAP is the product of PVR and pulmonary minute volume (Qp), such that pulmonary hypertension (PHT) may develop as a result of an increase in either PVR or Qp or both.Given that the pulmonary vascular bed is a low pressure system with high flow, any increase in resistance would generate PHT. The normal value of PVR is 2 Woods units (mm Hg/l/min). Increased PAP is due to hypoxic lesions of the endothelium, which release proteolytic enzymes that alter the balance of metabolites of arachidonic acid, regulators of pulmonary vasomotor tone. Hypoxia and acidosis cause intense pulmonary vasoconstriction (hypoxic vasoconstrictor reflex).An increase of PVR is due to a combination of vasoconstrictive processes and remodeling, with hypertrophy of the pulmonary artery. Structural lesions are related to hypertrophy of the endothelium, the transformation of fibroblasts to myocytes and the decrease of the alveolar/arteriolar ratio with the formation of new vessels.PHT may be primary or secondary to another disease. Primary PHT is a rare genetic disease. The most common secondary forms of PHT in pediatrics are due to persistence of neonatal anatomy (neonatal PHT), to heart diseases with left-right shunt (CIV, DAP, etc.), to diseases of the pulmonary parenchyma (interstitial viral infection, mucoviscidosis), and complications of heart surgery. All congenital heart diseases can lead to PHT if not treated promptly.Clinical signs of PHT are highly non-specific: dyspnea, fatigue, syncopes, exercise intolerance, precordialgia, cyanosis and edema. The best approaches to diagnosis and prognosis are echocardiography and cardiac catheterization with vasodilators.Anesthetics that do not alter PVR should be used in such patients, who are sensitive to changes in pulmonary ventilation, to changes in cardiac output and to anesthetics.The treatment of PHT during intra and postoperative pediatric surgery is based on the use of high inspirated oxygen concentration (100%), an adequate sedation and the use of vasodilators (prostaglandin I2, nitric oxide, sodium nitroprusiate and milrinone).     

Proliferative pancreatic cysts: pathogenesis and treatment options

Proliferative pancreatic cysts are subdivided into microcystic and mucinous cystadenomas. These rare, slow-growing, multilocular lesions usually remain localized for long periods of time, therefore frequently becoming rather sizeable before becoming symptomatic. Patients present with intermittent abdominal or back pain, nausea and vomiting, early satiety, and a palpable mass without a history of trauma or alcoholism. Computed tomographic scanning is the most useful laboratory test. The lesions are more often found in women, with the microcystic adenomas usually located in the head of the pancreas and the mucinous lesions in the pancreatic body or tail. At surgery, if it is at all possible, the lesions should be completely removed, even if it means performance of a Whipple procedure. This is particularly important for mucinous cysts because of their potential for malignant degeneration. Internal drainage or marsupialization procedures should not be done in these patients. The long-term results are excellent if the entire lesion is removed.     

Meningiomas

Meningiomas are extra-axial dural-based tumors. They are the most common intracranial tumors, occur in mid to late life, and have a female predilection. Symptoms are a function of location. Meningiomas are usually benign, but atypical and malignant forms exist. Treatment is indicated for symptomatic lesions or when neurologic symptoms may shortly occur. Surgical resection can be curative; however, because of their location, some lesions are amenable only to partial resection. Radiation therapy is used for incompletely removed symptomatic lesions, lesions that are not surgically accessible, and small symptomatic lesions. For higher grade meningiomas, radiation is used after surgery. For lesions that recur or grow despite surgery and radiation, systemic chemotherapy can be tried. There is no optimal agent, but hydroxyurea is used most often with very modest success; hormonal approaches have not been successful. Targeting somatostatin receptors or receptor tyrosine kinases using novel agents appears to have some activity and is an area of clinical research.     

Pathologic fractures in children

Fractures through bone tumors are often difficult to treat. We reviewed our combined experience with this problem in children, as well as the existing literature, to formulate management guidelines. For this study, prospective databases (1987 to 2002) from three referral centers were screened for pathologic fractures occurring under the age of 14 years. One hundred five patients presented with fracture through unicameral bone cyst, nonossifying fibroma, fibrous dysplasia, aneurysmal bone cyst and osteosarcoma. Seventeen patients were excluded. The most common primary locations were the proximal humerus and proximal femur. Pathologic fracture through nonossifying fibroma had the best outcome; union occurred with nonsurgical treatment in all cases. Unicameral bone cyst required surgical treatment to avoid persistence of the cyst and refracture. However fracture healing was predictable without surgical treatment. Proximal femoral lesions tended to heal in malunion if not fixed surgically. Aneurysmal bone cyst required surgical treatment for the lesion to heal and to allow the fracture to heal as well. Percutaneous sclerotherapy may be the treatment of choice for many of these lesions. Fibrous dysplasia allows fracture healing with nonoperative therapy. Progressive deformity requires followup and surgical correction. Malignant lesions presenting a pathologic fracture are best managed by initial nonoperative therapy during investigation and neoadjuvant therapy when possible, followed by definitive treatment.     

Laparoscopic excision of a retroperitoneal lymphatic malformation in a newborn

Abdominal lymphatic malformations may be challenging to eradicate. Retroperitoneal lesions may more difficult to resect than mesenteric ones; however, the latter may predispose to intestinal volvulus, leading to calls for their prompt excision. Such lesions identified perinatally may pose particular challenges: in one case, respiratory failure caused by abdominal distension required emergency drainage followed by later laparoscopic excision; laparoscopy has also been used promptly to diagnose and resect neonatal mesenteric lymphatic malformations with their inherent volvulus risk. We illustrate that even if neonatal laparoscopy identifies a retroperitoneal rather than mesenteric lymphatic malformation, curative endosurgical excision remains feasible.     

Débridement. The key initial first step in wound healing

Before addressing a wound, whether it is chronic or acute, clinicians must thoroughly assess the wound and the patient. An acute wound in a patient with normal blood flow and good medical and nutritional condition should go on to heal if appropriate care is given. This means that the wound has to be débrided adequately, dressed, and closed when appropriate. Getting back to healthy tissue is the key. In chronic wounds, healing is more difficult because the etiology of the wound is harder to determine, and the measures to reverse the medical abnormalities are often complex. When these have been sorted out and addressed, however, débridement again plays the key role. It converts the chronic wound into an acute wound so that it can then progress through the normal stages of healing. The key is for clinicians to be aggressive and not let concerns about the residual defect limit débridement. Subsequent healing then can be achieved by use of wound-healing adjuncts such as the V.A.C. device, hyperbaric oxygen, skin substitutes, growth factor, or plastic surgical techniques.     

Chemosurgery for the microscopically controlled excision of cutaneous cancer

Cancer of the skin and of other accessible structures can be removed under complete microscopic control if the cancerous area is excised layer by layer, and if the undersurface of each layer is then examined under the microscope through systematic use of frozen sections. If the cancer is extensive and complicated, or if the neoplasm is of a type that is readily disseminated, the tissues are fixed in situ with zinc chloride prior to the excision of each layer (fixed-tissue technique). If the cancer is not overly extensive or complicated, the layers of tissue are excised in the fresh, unfixed state (fresh-tissue technique). Both methods are highly reliable. In two consecutive series of basal-cell carcinomas treated chemosurgically, the five-year cure rate achieved was 99.3% for the 9,351 lesions removed by the fixed-tissue technique, and 98.1% for the 196 lesions removed by the fresh-tissue method.     

Noninvasive technique using thallium-201 for predicting ischaemic ulcer healing of the foot

A post-stress imaging study utilizing single intravenous doses of thallium-201 was performed on feet with trophic skin lesions. Forty-two ischaemic ulcers were classified into four basic types according to the presence and degree of the inherent inflammatory response of the ulcer in both the initial and delayed distributions. Both the relationship between ulcer type and prognosis and the effects of therapy within ulcer type were assessed. The results suggest that ulcers of Type I or Type II heal in response to conservative treatment, while ulcers of Type III, although undergoing healing, require surgical treatment to prevent a protracted hospitalization. In Type IV ulcers, healing is not to be expected at all with conservative therapy; therefore an early decision of amputation may be necessary if surgical measures are not indicated. The technique reported may be helpful not only in the prediction of spontaneous ulcer healing but also in the selection of appropriate treatment.     

New developments in Crohn's disease: unravelling the mystery of its etiopathogenesis and its reinstatement as a surgically treatable condition. Part 3: The rational principles of surgical therapy

The diagnosis of Crohn's disease makes surgery mandatory in any form of the disease, because it is ingravescent, spreads in the bowel, and is unresponsive to any type of pharmacological treatment; it invariably involves major consequences and often leads to serious complications such as perforation and cancer in the long term. The operation has to be performed promptly, because the commonest complications, such as obstruction and perforation, may occur at any stage of the disease, including the initial phase. Moreover, it is advisable to prevent the spread of the disease to the colon and jejunum, which occurs in increasing percentages of patients and is related to duration of the disease. As a rule, surgery has to take the form of a resection of the diseased bowel, which includes not only the lesions already in progress, but also those which may be expected to develop. Therefore, since the disease is segmentary, the resection, too, has to be segmentary, even when part of the diseased segment is apparently sound. Inadequate resection is often followed by dehiscence of the anastomosis and sooner or later by an inevitable recurrence. Three types of resection are performed for Crohn's disease depending on whether it manifests as ileitis, ileitis plus right colitis, or ileitis plus right and left colitis. Ileitis requires an ileocolic resection. Because the resection has to be segmentary and the proximal limit of the segment, i.e. of the lesions, cannot be determined at external examination of the intestine, the surgeon has to perform an approximate, temporary resection and examine the resected specimen, open along its entire length, before constructing the anastomosis. The borderline between the diseased and intact ileum, where convinient valves, appear with their thin, delicate outline, can be identified exactly in the mucosal surface. The resection has a "safety margin" of 10 cm. Section of the ascending colon can be performed wherever the surgeon prefers. The ileitis plus right colitis forms require resection of the ileum according to the procedure described and of the right colon, even when the lesions are confined to the caecum. Section and anastomosis must be performed in the initial tract of the transverse colon. The ileitis plus right and left colitis forms call for total colectomy in addition to resection of the ileum, even when the lesions are confined to the transverse colon. The operation is completed with an ileorectal anastomosis constructed on the lower portion of the intraperitoneal rectum (drained by the hypogastric collectors).     

Removal of broken hardware

Despite advances in metallurgy, fatigue failure of hardware is common when a fracture fails to heal. Revision procedures can be difficult, usually requiring removal of intact or broken hardware. Several different methods may need to be attempted to successfully remove intact or broken hardware. Broken intramedullary nail cross-locking screws may be advanced out by impacting with a Steinmann pin. Broken open-section (Küntscher type) intramedullary nails may be removed using a hook. Closed-section cannulated intramedullary nails require additional techniques, such as the use of guidewires or commercially available extraction tools. Removal of broken solid nails requires use of a commercial ratchet grip extractor or a bone window to directly impact the broken segment. Screw extractors, trephines, and extraction bolts are useful for removing stripped or broken screws. Cold-welded screws and plates can complicate removal of locked implants and require the use of carbide drills or high-speed metal cutting tools. Hardware removal can be a time-consuming process, and no single technique is uniformly successful.     

Takotsubo Cardiomyopathy Following Cardiac Surgery

Background

Takotsubo cardiomyopathy syndrome, commonly occurring in postmenopausal women, is characterized by transient apical systolic dysfunction in absence of coronary lesions. The cardiomyopathy is often observed after intense stressful events such as a major surgical procedure.

Methods

A 72‐year‐old woman symptomatic for dyspnea at rest, chest pain, and peripheral edema successfully underwent surgery for noncoronary sinus aneurysm–right atrium fistula repair. Two days after surgery the patient developed takotsubo syndrome, diagnosed according to the Mayo Clinic criteria. We reviewed the literature on takotsubo cardiomyopathy as a complication of major cardiac surgery procedures.

Results

Takotsubo cardiomyopathy is confirmed as a possible early complication of cardiac surgery. Exaggerated sympathetic stimulation may cause massive endogenous catecholamine release. Hypoperfusion during cardiopulmonary bypass, inotropic drugs administration, and postoperative anxiety and pain are all factors generating stress, possible coronary artery spasm and transient cardiomyopathy, clinically simulating acute myocardial infarction. Several clinical features have been described such as acute mitral insufficiency, systolic anterior motion of the anterior mitral valve leaflet, left ventricular outflow tract obstruction, acute cardiac failure, and cardiogenic shock. Intraventricular thrombi and adverse cerebrovascular events may also be possible complications. Rare catastrophic events such as left ventricular free wall rupture and ventricular septal perforation have been also encountered.

Conclusions

After cardiac surgery takotsubo cardiomyopathy should be suspected if clinical and instrumental criteria are met, and promptly differentiated from the more frequent acute myocardial infarction. Prognosis may be favorable if appropriate conservative medical treatment is promptly started. doi: 10.1111/jocs.12675 (J Card Surg 2016;31:89–95)