Conservative management of esophageal perforation after a fall

INTRODUCTIONEsophageal perforation in the setting of blunt trauma is rare, and diagnosis can be difficult due to atypical signs and symptoms accompanied by distracting injury.PRESENTATION OF CASEWe present a case of esophageal perforation resulting from a fall from height. Unexplained air in the soft tissues planes posterior to the esophagus as well as subcutaneous emphysema in the absence of a pneumothorax on CT aroused clinical suspicions of an injury to the aerodigestive tract. The patient suffered multiple injuries including bilateral first rib fractures, C6 lamina fractures, C4–C6 spinous process fractures, a C7 right transverse process fracture with associated ligamentous injury and cord contusion, multiple comminuted nasal bone fractures, and a right verterbral artery dissection. Esophageal injury was localized using a gastrograffin esophagram to the cervical esophagus and was most likely secondary to cervical spine fractures. Because there were no clinical signs of sepsis and the esophagram demonstrated a contained rupture, the patient was thought to be a good candidate for a trial of conservative management consisting of broad spectrum intravenous antibiotics, oral care with chlorhexadine gluconate, NPO, and total parenteral nutrition. No cervical spine fixation or procedure was performed during this trial of conservative management. The patient was received another gastrograffin esophagram on hospital day 14 and demonstrated no evidence of contrast extravasation.DISCUSSIONEarly diagnosis and control of the infectious source are the cornerstones to successful management of esophageal perforation from all etiologies. Traditionally, esophageal perforation relied on a high index of clinical suspicion for early diagnosis, but the use of CT scan for has proved to be highly effective in diagnosing esophageal perforation especially in patients with atypical presentations. While aggressive surgical infection control is paramount in the majority of esophageal perforations, a select subset of patients can be successfully managed non-operatively.CONCLUSIONIn the setting of blunt trauma, esophageal perforation is rare and is associated with a high morbidity. In select patients who do not show any clinical signs of sepsis, contained perforations can heal with non-operative management consisting of broad spectrum antibiotics, strict oral hygiene, NPO, and total parenteral nutrition.     

Conservative management of pneumatosis intestinalis and massive pneumoperitoneum in the acute abdomen: a case report

We present a case of massive pneumoperitoneum in association with pneumatosis intestinalis that was successfully managed without surgery despite a clinical picture of an acute abdomen and biochemical evidence of inflammation and systemic upset. Recognition of non-surgical pneumoperitoneum is important to avoid unnecessary laparotomy, and clinical examination for the presence of peritonitis is the most important determinant of the need for emergency surgery.     

Conservative management of spondylolysis and spondylolisthesis

Spondylolysis and spondylolisthesis are pathologic defects that can cause low back pain. While they are often asymptomatic, a thorough radiologic evaluation and correlation with the clinical presentation is necessary to guide appropriate intervention. The physician׳s role in these cases is a timely diagnosis, treatment, and follow-up given the risk of progression that accompanies this type of pathology. Conservative management is currently the first-line for many instances of mild-to-moderate spondylolysis and spondylolisthesis, with the goal of pain relief and return of function.     

Lesser curve ischemia after proximal gastric vagotomy and splenectomy: Conservative management with endoscopical surveillance

A case of lesser curvature ischemia after proximal gastric vagotomy and splenectomy is described. Division of the right gastroepiploic vessels had caused further impairment of the stomach circulation. Deep seromuscular invagination of the lesser curvature was performed at the end of the operation to protect the ischemic area. Sequential changes were seen at repeated endoscopic examinations, and further operation was not necessary.

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Resumen Se informa un caso de isquemia de la curvatura menor como consecuencia de vagotomía gástrica proximal y esplenectomía. La división de los vasos gastroepiploicos derechos causó una mayor interferencia con la circulación gástrica. Se hizo una invaginación seromuscular profunda al término de la operación con el objeto de proteger el área isquémica. Las alteraciones secuenciales fueron visualizadas mediante exámenes endoscópicos repetidos, y no fué necesario tratamiento quirúrgico adicional.

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Résumé Un cas d'ischémie de la petite courbure gastrique après vagotomie hypersélective et splénectomie est rapporté par les auteurs. La section des vaisseaux coronaires stomachiques a déterminé une altération de la circulation gastrique. En fin d'intervention une invagination de la séromusculeuse fut réalisée pour protéger la région ischémiée. Sous contrôle endoscopique répété des modifications de la région intéressée furent constatées.

     

Conservative management of urachal anomalies

PurposeThe purpose of this study was to evaluate trends in management of urachal anomalies at our institution and the safety of nonoperative care.MethodsBased on our experience managing urachal remnants from 2000 to 2010 (reported in 2012), we adopted a more conservative approach, including preoperative antibiotic use, refraining from using voiding cystourethrograms (VCUG), postponing surgery until at least six months of age, and considering nonoperative management. A retrospective analysis of urachal anomaly cases was conducted (2011–2016) to assess trends in practice. Charts indicating anomalies of the urachus were pulled and trends in management (nonoperative versus surgical treatment), VCUG and antibiotic use, and outcomes were reviewed.ResultsData from 2000–2010 and 2013–2016 were compared. Our findings indicate care has shifted towards nonoperative management. A smaller proportion of patients from 2013–2016 was treated surgically compared to 2000–2010. Patients receiving nonoperative treatment exhibited lower rates of complication relative to surgically managed cases. VCUGs were eliminated as a diagnostic tool for evaluating urachal anomalies. Prophylactic preoperative antibiotic use was standardized. No patients with a known urachal remnant presented later with an abscess or sepsis.ConclusionsWe find that a shift towards nonoperative treatment of urachal anomalies did not adversely affect overall outcomes. We recommend observing minimally symptomatic patients, especially those under six months old.Study typePerformance improvement.Level of evidenceLevel IV.     

Conservative management of vesical rupture

Eight cases of ruptured bladder managed solely by indwelling urethral catheter drainage and administration of antimicrobial agents are presented. Criteria used to select patients for this form of treatment are discussed. Urethral catheter drainage alone is not advocated as treatment for most ruptured bladders. However, at this time, a cautious recommendation is made for this conservative form of treatment in selected cases of vesical rupture.     

Conservative management of extradural haematomas

Summary The personal experiences with a series of 57 conservatively treated extradural haematomas (EDH) are presented and the criteria for conservative management outlined. Main preconditions are absence of neurological deficit, close clinical supervision and repeated CT check-ups.     

Conservative management of cardiac haemangioma

Cardiac haemangiomas are rare forms of cardiac tumours which can present at any age and in any cardiac location. The clinical presentations of patients vary and preoperative diagnosis of cardiac haemangiomas is usually made using echocardiography and magnetic resonance imaging (MRI). Surgical resection is the treatment of choice and follow-up is recommended to avoid any recurrence. We report a particular case of cardiac haemangiomas which was referred to us and eventually managed conservatively. The medical history, physical examination and surgical/non-surgical management are discussed.