Is severe intestinal chronic graft-versus-host disease an indication for surgery? A report of two cases

Chronic graft-versus-host disease (cGVHD) frequently complicates allogeneic hematopoietic stem cell transplantation (HSCT), but small bowel involvement with obstruction is rarely observed. We report two patients who underwent allogeneic sibling HSCT and developed severe cGVHD involving the small bowel, causing unremitting obstructive symptoms and malnutrition despite maximal immunosuppression. Both patients underwent ileal resection and stricturoplasties. The first patient promptly improved, and remains asymptomatic 32 months after transplant. Three weeks after the resection of 90 cm of small bowel, the second patient developed leaking stricturoplasty and peritonitis, with a relapse of chronic myelogenous leukemia in accelerated phase. Later, an enterocutaneous fistula required additional small bowel resection and ileostomy. The patient subsequently died from pulmonary infection a few weeks after the last surgical procedure. Similar to inflammatory bowel disease, these two cases highlight that surgery may be a valuable option in patients who present with obstructive severe cGVHD refractory to aggressive immunosuppression.     

Is Oddi sphincterotomy an indication for hepatolithiasis?

Background

The purpose of treatment for hepatolithiasis is reducing recurrent cholangitis. This study was designed to determine the long-term outcome of Oddi sphincterotomy for hepatolithiasis.

Methods

Thirty-two consecutive hepatolithiasis patients, including 15 cases that had undergone conventional open surgical transduodenal sphincteroplasty (COSTS) and 17 cases with endoscopic sphincterotomy (EST), were followed up for a long term. We compared the post-treatment rates of recurrent cholangitis and acute cholangitis severe type (ACST) with the ones of pretreatment in each group, respectively. Paired χ² test was used.

Results

In the COSTS group, neither the post-operative rate of recurrent cholangitis (86.7%, 13/15 vs. 100%, 15/15) nor ACST (26.7%, 4/15 vs. 46.7%, 7/15) decreased (p > 0.05) compared with before the operation. In the EST group, the situation was the same: neither the rate of post-EST recurrent cholangitis (76.5%, 13/17 vs. 82.4%, 14/17) nor ACST (29.4%, 5/17 vs. 23.5%, 4/17) were reduced significantly (p > 0.05).

Conclusions

Both eradication of hepatobiliary lesions and keeping Oddi sphincter intact should be emphasized in the management of hepatolithiasis. Neither COSTS nor EST is an effective method or can achieve the goal of reducing cholangitis for hepatolithiasis.     

Is the risk of hypertension an indication for prophylactic nephrectomy in patients with unilateral multicystic dysplastic kidney?

OBJECTIVE: Surgery is still proposed by some as the treatment of choice for unilateral multicystic dysplastic kidney (UMCDK) because of the potential complications of hypertension, infection and malignant change. The purpose of this study is to demonstrate that the risk of hypertension does not justify routine nephrectomy. MATERIAL AND METHODS: We report 41 cases of UMCDK, treated between 1980 and 2001, 28 of whom were male (68%). Twenty-one patients were nephrectomized (51%). Twenty patients (49%) underwent clinical and ultrasound follow-up. Blood pressure was controlled every 3-4 months (over a period ranging from 9 months to 6 years) and an ultrasound scan was performed every 6 months during the first 2 years, and annually thereafter. RESULTS: In the patients treated non-operatively we observed a progressive spontaneous involution of their multicystic dysplastic kidneys and the total absence of complications such as hypertension or malignancy. CONCLUSION: It is reasonable to conservatively manage patients with UMCDK by means of repeated ultrasound examinations and blood pressure control.     

Lymph node metastases in bladder cancer disease. Is there an indication for radical cystectomy?

Summary Bladder carcinomas with lymph node metastases are a systemic disease with a poor long term survival (< 10 %) [7]. Surgery has no proofen impact on patients survival. Outcome depends on the extent of lymph node disease [8]. Surgery combined with systemic chemotherapy is controversely discussed. Neoadjuvant chemotherapy has no proofen survival impact [4]. Adjuvant chemotherapy is under investigation in prospective randomized phase III trials. Lymph node metastases are no exclusion criteria for orthotopic bladder replacement [2]. Extended lymph node dissection is not superior to lymph node dissection limited to the fossa obturatoria [6]. Despite excellent long term results of radical cystectomy and lymphadenectomy in selected patients with node positive disease [8], surgery seems to be an individual approach, without no proofen impact on patients survival and quality of life.      

Is the presence of small volume disease in the sentinel node an indication for axillary clearance?

The finding of micrometastases (M_i) and isolated tumour cells (ITC) within the axillary lymph nodes of patients with breast cancer has raised the question whether either/both have some prognostic significance. Several studies have shown that compared to node-negative patients, prognosis is significantly poorer in patients with M_i and ITC. The fact that patients with M_i/ITC in their sentinel lymph nodes have a systemic relapse risk that is higher than that of node-negative patients may be considered as an indication for systemic treatment. Most studies in the literature suggest that in patients with M_i or ITC in their sentinel nodes who receive systemic therapy and whole breast radiotherapy, the risk of axillary relapse without axillary lymphadenectomy is under 2%. Given the fact that axillary lymphadenectomy is associated with a 5–25% risk of lymphoedema, we propose that a policy of close follow up should be adopted in these patients rather than axillary lymphadenectomy.     

The natural history diverticular disease: is there a role for elective colectomy?

BACKGROUND: The natural history of colonic diverticular disease is unclear leading to a debate on the value of elective colectomy in preventing complications of the disease. AIM: To assess whether the complications of diverticular disease requiring emergency surgery are related to previous episodes of diverticulitis and whether elective colectomy might prevent such complications. MATERIALS AND METHODS: A retrospective study was done on all patients admitted with complicated diverticular disease in two adjacent district general hospitals between 1995 and 2000. Information was collected on the details of management of the complications and past history of the investigations and treatment for diverticular disease in these patients. RESULTS: A total of 108 patients were admitted with complicated diverticular disease. Ninety eight (91%) patients were admitted as an emergency for perforated diverticular disease and rectal bleeding. Ten patients were urgent admissions for fistulae and diverticular phlegmons. Ninety eight patients underwent a Hartmann's operation, two had a subtotal colectomy and 4 patients had a sigmoid colectomy. Thirty four (31.4%) patients died in hospital post-operatively. Of the 108 patients, only 28 (26%) patients were known to have diverticular disease previously. Only three (2.7%) patients had had an episode of acute diverticulitis before they presented with further complications. CONCLUSIONS: Complications of diverticular disease occur de novo in the majority of patients who have no previous history of the disease. Further studies are needed to identify risk factors for complicated diverticular disease before adopting a policy of elective interval colectomy.     

Sciatic nerve resection: is that truly an indication for amputation?

En bloc resection of the sciatic nerve with an adjacent bone or soft tissue tumor has been assumed to be associated with a poor functional outcome and, therefore, was considered an indication for amputation. Although many surgical oncologists today challenge this assumption and do limb-sparing resection in these patients, a report of the functional outcome of a series of patients who had this procedure has not been published. Between 1991 and 1999, the authors treated 15 patients who had resection of the sciatic nerve. There were 10 females and five males, ranging in age from 2 to 73 years. Diagnoses included 11 high-grade soft tissue sarcomas, one primary bone sarcoma, and three metastatic bone tumors. Four lesions were located in the pelvis, one in the buttock, and 10 in the posterior thigh. At the most recent followup, 14 patients were ambulatory, seven of whom required a walking aid. Because of peroneal nerve palsy, all patients required a short-leg brace. However, overall function was determined to be good in 11, moderate in three, and poor in one patient. None had a pressure sore of the foot and none required a secondary amputation. Good function is achieved in most patients who have sciatic nerve resection. Therefore, the necessity to resect the sciatic nerve is not an indication for amputation.     

Is massive hemothorax still an absolute indication for operation in blunt trauma?

BackgroundSurgery is usually suggested to treat massive haemothorax (MHT). The MHT criteria are based on penetrating trauma observations in military scenarios; the need for surgery in blunt trauma patients remains questionable. This study aimed to determine the characteristics of blunt trauma patients with MHT who required surgery.MethodsPatients who presented to the emergency department (ED) with traumatic haemothorax or pneumothorax, heart and lung injuries, and thoracic blood vessel injuries from Jan 1, 2014, to Dec 31, 2018, were reviewed. The inclusion criterion was a chest tube drainage amount that met the MHT criteria. Therapeutic operations were defined as those involving surgical haemostasis; otherwise, operations were considered non-therapeutic. The non-therapeutic operation group included the patients who received nonoperative management. The characteristics of the therapeutic and non-therapeutic operation groups were compared.ResultsForty-four patients were enroled in the study. Six patients received conservative treatment and were discharged uneventfully. Eleven patients underwent non-therapeutic operations. The patients with surgical bleeding had a high pulse rate (125.0 (111.0, 135.0) vs. 116.0 (84.0, 121.0) bpm, p = 0.013); low systolic blood pressure (SBP) after resuscitation (106.0 (84.0, 127.0) vs. 121.0 (116.0, 134.0) mmHg, p = 0.040); low pH (7.2 (7.2, 7.3) vs. 7.4 (7.3, 7.4), p = 0.002); and low bicarbonate (17.8 (14.6, 21.5) vs. 21.4 (17.0, 21.5) mEq/L, p = 0.038), low base excess (-9.1 (-13.4, -4.5) vs. -3.8 (-10.1, -0.7), p = 0.028), and high lactate (5.7 (3.3, 7.8) vs. 1.8 (1.7, 2.8) mmol/L, p = 0.002) levels.ConclusionConservative treatment could be performed selectively in patients with MHT. Lactate could be a predictor of the need for surgical intervention in blunt trauma patients with MHT.     

Is there still an indication for pancreatic duct drainage in chronic pancreatitis?

Pain in chronic pancreatitis is supposed to be multifactorial in origin. Pancreatic duct/tissue hypertension is today proved in patients with chronic pancreatitis and pain. Duct drainage reportedly normalizes pancreatic duct/tissue pressure and reduces pain in 70% of the patients. Also, duct drainage by endoscopy may relieve pain. Surgical duct decompression is parenchyma-preserving and even suggested to prevent further progress of exocrine insufficiency. Recent experience indicates that such operations are pain-relieving not only in patients with dilated ducts but also in those with small duct disease.     

Does laparoscopic colorectal resection for diverticular disease impair male urinary and sexual function?

Background Laparoscopic colorectal resection may induce bladder and sexual dysfunction secondary to injury to the autonomic nervous system. The aim of this study was to evaluate urinary and sexual function in male patients after laparoscopic colorectal resection for diverticular disease.Methods From January 1997 to March 2002, we performed a retrospective analysis of urinary and sexual function in 56 consecutive male patients who had undergone laparoscopic colorectal resection for diverticular disease. Preoperative and 6-month postoperative assessment was carried out using data collected via standardized postal questionnaires.Results Three patients were excluded (one had a prior prostatectomy, one had Peyronies disease, and one was treated with neuroleptics). Fifty-three patients with a mean age of 54 ± 2 years were included in the study. There were no conversions. The morbidity rate was 9.4%. Mean follow-up was 27 ± 2 months. There was no significant difference in preoperative and postoperative urinary function. Fifty-one patients (96%) were sexually active preoperatively and were still sexually active postoperatively. Compared with the preoperative period, postoperative impairment of libido, erection, ejaculation, and orgasm were not significant. Every patient was able to achieve ejaculation after the intervention, and no retrograde ejaculations were reported. One patient was unable to have an erection after the intervention.Conclusion Laparoscopic colorectal resection for diverticular disease does not significantly impair urinary and sexual function.Presented in part at the 17^th meeting of the French Society of Digestive Surgery (SFCD), Cernay la Ville, France, 12â€13, December 2002, and published in abstract form in Annales de Chirurgie 2002; 127: 732     

Is arterial proximity a valid indication for arteriography in penetrating extremity trauma? A prospective analysis

Three hundred seventy-three patients with a penetrating extremity injury were studied to assess the yield of arteriography. Patients underwent arteriography if any of the following was present: bruit, history of hemorrhage or hypotension, fracture, hematoma, decreased capillary refill, major soft-tissue injury, or nerve or pulse deficit. In the absence of these findings, arteriography was performed if the injury was in "proximity" to a major neurovascular bundle. In 216 patients, arteriography was performed when an abnormal finding was noted. Sixty-five injuries were identified, 19 requiring intervention. Proximity was the indication for arteriography in 157 patients. Seventeen injuries were identified, of which one required repair. In penetrating extremity trauma, the need for arteriography is based on clinical findings. The use of arteriography to screen for an arterial injury when proximity alone is the indication rarely identifies a significant injury and should be abandoned.     

Is antibiotic prophylaxis necessary in elective soft tissue hand surgery?

Antibiotic prophylaxis for clean soft tissue hand surgery is not yet defined. Current literature focuses on overall orthopedic procedures, traumatic hand surgery, and carpal tunnel release. However, a paucity of data exists regarding the role of antibiotic prophylaxis in a broader variety of soft tissue hand procedures. The goal of the current study was to evaluate the rates of surgical site infection following elective soft tissue hand surgery with respect to administration of prophylactic antibiotics.A multicenter, retrospective review was performed on 600 consecutive elective soft tissue hand procedures. Procedures with concomitant implant or incomplete records were excluded. Antibiotic delivery was given at the discretion of the attending surgeon. Patient comorbidities were recorded. Outcomes were measured by the presence of deep or superficial infections within 30 days postoperatively. The 4 most common procedures were carpal tunnel release, trigger finger release, mass excision, and first dorsal compartment release. The overall infection rate was 0.66%. All infections were considered superficial, and none required surgical management. In patients who received antibiotic prophylaxis (n=212), the infection rate was 0.47%. In those who did not receive prophylaxis (n=388), the infection rate was 0.77%. These differences were not statistically significant (P=1.00).     

Is a thyroid follicular neoplasm a good indication for endoscopic surgery?

Endoscopic thyroidectomy is a safe and feasible alternative as compared with conventional open thyroidectomy in patients with a small thyroid cancer or a benign thyroid tumor. However, despite the many advantages of endoscopic surgery, it can result in unexpected complications. Recently, the authors experienced a case of follicular thyroid cancer recurrence that developed around the operative bed and along the port insertion site after endoscopic thyroidectomy for a large follicular neoplasm. The authors suggest that a smaller follicular neoplasm is a good indication for endoscopic thyroidectomy, but that a large follicular neoplasm should not be viewed as indicators for endoscopic surgery, because of the possibility of malignancy and rupture during manipulation.