Contemporary management of drug-packers

Experience with management of drug-packers (mules) is variable among different centres. However, despite a recorded increase in drug trafficking in general, as yet, no unified, clear guidelines exist to guide the medical management of those who only occasionally encounter these individuals. We describe our recent experience with this growing problem and discuss the most salient points concerning the contemporary management of body packers. Our recent experience demonstrates that type IV packages may now be managed conservatively for the most part.     

Contemporary management of cystinuria

Cystinuria is an autosomal recessive disorder characterized by a defect in intestinal and renal tubular transport of dibasic amino acids which results in excessive urinary excretion of cystine. Because of the relative insolubility of cystine in urine, patients with this condition are prone to recurrent stone formation. Medical therapy aims both to decrease the urinary concentration of cystine and to increase its solubility. Standard prevention and treatment regimens include hydration, moderate salt and protein restriction, oral alkalinization, and thiol derivatives. Despite aggressive medical management, however, cystinuric patients are likely to suffer frequent recurrent episodes of stones necessitating urologic intervention. Fortunately, the application of safe and efficacious minimally invasive modalities, including advancements in shockwave lithotripsy, ureteroscopic lithotripsy, and percutaneous nephrolithotomy, have obviated open operative intervention in nearly all cases.     

Contemporary management of pineoblastoma

Pineoblastomas (PBs) represent the most aggressive of the pineal parenchymal tumors. Routine treatment consists of operative management of obstructive hydrocephalus and cerebrospinal fluid studies followed by maximal resection and adjuvant chemotherapy/radiotherapy, resulting in a median survival of 20 months. Important prognostic factors for survival of patients with PB include extent of resection, age at presentation, disseminated disease, and craniospinal radiotherapy. Novel strategies being evaluated for the treatment of PB include high-dose chemotherapy with autologous stem cell therapy, stereotactic radiosurgery, and histone deacetylase inhibitors.     

Contemporary management of pineocytoma

Pineocytoma is a rare tumor; therefore, assimilating data from case reports and small case series to generate definitive treatment guidelines is difficult. The authors recently systematically reviewed the existing literature on outcomes for patients with pineocytoma. Gross total resection is associated with significantly increased tumor control and survival compared with subtotal resection combined with radiotherapy. When gross total resection is not possible, adding radiotherapy to subtotal resection is not associated with increases in either tumor control or survival. Although aggressive surgery in the pineal region carries the risk of neurologic injury, gross total resection should be attempted for pineocytoma.     

Contemporary management of lipoblastoma

Purpose

Lipoblastoma is a rare, benign, adipose tissue tumor. We report the largest single institution experience managing these uncommon neoplasms.

Methods

We retrospectively reviewed 32 cases of lipoblastoma entered in the pathology database at our institution between January 1991 and August 2005. We conducted a comprehensive literature review of lipoblastoma and summarized the results of the largest series published.

Results

Most patients presented with an enlarging, palpable, firm, nontender, mobile mass. The male-to-female ratio was 1.9:1. The anatomical distribution was trunk (n = 12), extremity (n = 12), groin (n = 5), and neck (n = 3). Average age at resection was 2.8 years (range, 2.6 months to 12 years). Thirty-one cases were completely excised, although 1 patient underwent staged partial excision to preserve nerve function. Chromosomal analysis performed in selected patients revealed characteristic aberrations in chromosome 8. Complications included keloid formation (n = 3), wound infection/dehiscence (n = 2), wound seroma (n = 1), and transient brachial plexus neurapraxia (n = 1). Average follow-up was 7.4 months (range, 1 day to 6.5 years); 2 patients were lost to follow-up. There were no recurrences.

Conclusions

A staged approach with meticulous sparing of the neurovascular bundle provides excellent functional outcome for patients with large tumors. Nonmutilating surgical excision is the treatment of choice.     

Contemporary management of postprostatectomy incontinence

Context

In recent years, despite improvement in the surgical technique, the prevalence of postprostatectomy incontinence has increased due to a rise in the number of radical prostatectomies performed annually.

Objective

The aim of this review is to evaluate contemporary noninvasive and invasive treatment options for postprostatectomy incontinence.

Evidence acquisition

In August 2010, a review of the literature was performed using the Medline database.

Evidence synthesis

All articles concerning noninvasive and invasive treatment for postprostatectomy incontinence were included.

Conclusions

No randomised controlled trials exist to compare currently used noninvasive and invasive treatments for postprostatectomy incontinence. Pelvic floor muscle training is recommended for the initial treatment of stress urinary incontinence (SUI). Additionally, antimuscarinic therapy should be applied for urgency or urge incontinence. For decades, the artificial urinary sphincter was the reference standard for persistent SUI. Nowadays, male slings are an alternative for men with mild to moderate postprostatectomy SUI.     

Contemporary management of ureteral stones

Context

Ureteral calculi represent a common condition that urologists encounter in everyday practice. Several treatment options are available for calculi that do not pass spontaneously or are unlikely to do so.

Objective

In this nonsystematic review, we summarize the existing data on contemporary management of ureteral stones focusing on medical expulsive therapy (MET) and different treatment modalities.

Evidence acquisition

A PubMed search was performed. We reviewed the recent literature on the management of ureteral calculi. Articles were considered between 1997 and 2011. Older studies were included selectively if historically relevant.

Evidence synthesis

For stones that do not pass spontaneously or with MET, shock wave lithotripsy (SWL) and ureteroscopy (URS) are the most common and efficient treatment modalities. Both techniques have obvious advantages and disadvantages as well as different patterns of complications. For select cases or patients, other modalities may be useful.

Conclusions

Ureteral stones of up to 10 mm and eligible for observation may be offered MET. For most ureteral calculi that require treatment, advances in SWL and URS allow urologists to take a minimally invasive approach. Other more invasive treatments are reserved for select “nonstandard” cases.     

Contemporary management of erectile dysfunction

Erectile dysfunction (ED) is one of the most common sexual disorders in men, and the existence of an underlying cause should always be considered. It is also commonly and closely associated with age and risk factors for cardiovascular disease. Therefore, all men with ED should be screened for medical problems. Treatment of ED can enhance self-esteem, reduce psychological morbidity, and increase the emotional well-being of both partners. Today, unless contraindicated, user-friendly, effective, and safe therapies offered for the treatment of ED are lifestyle and risk factor modification (e.g., exercise and weight loss) and the use of oral phosphodiesterase type 5 inhibitors, such as sildenafil, tadalafil, or vardenafil. Vacuum erection devices, intracavernous injection therapy, and penile prostheses are other options of treatment when oral medication fails. The following minireview provides a practical approach for the management of ED in outpatient departments.     

Contemporary management of meconium ileus

Meconium ileus was noted as an early manifestation of cystic fibrosis in 60 neonates between 1972 and 1991. There were 20 girls and 40 boys. A family history of cystic fibrosis was present in six children. Twenty-five neonates had uncomplicated meconium ileus due to inspissated meconium within the terminal ileum. Thirty-five neonates presented with 56 complications of meconium ileus, including volvulus (n=22), atresia (n=20), perforation (n=6), and giant cystic meconium peritonitis (n=8). Clinical presentation included abdominal distension, bilious vomiting, and failure to pass meconium. In two recent cases, prenatal ultrasonography detected a mass with proximal bowel distension indicative of cystic meconium peritonitis. Mechanical bowel obstruction in the other neonates was diagnosed from plain abdominal radiographs and barium enema. Ten patients with uncomplicated meconium ileus were successfully treated with a diatrizoate meglumine (Gastrografin) enema. The remaining 15 patients required a laparotomy, with 9 treated by bowel resection and enterostomy and 6 recent cases managed with enterotomy and irrigation. Complicated cases were managed by bowel resection and anastomosis (n =15) or enterostomy (n=20). Survival at 1 year was 92% in patients with uncomplicated meconium ileus and 89% for those with complicated meconium ileus. The therapy of choice for uncomplicated meconium ileus is nonoperative Gastrografin enema, with enterotomy and irrigation reserved for enema failures. Complicated cases require exploration and, in the absence of giant cystic meconium peritonitis, are usually amenable to bowel resection and primary anastomosis.

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Resumen El meconium ileus fue observado como manifestación temprana de la fibrosis quística en 60 neonatos en el período 1972 a 1991, 20 niñas y 40 niños. En seis pacientes se encontró historia de fibrosis quística. Veinticinco presentaron meconium ileus no complicado debido a meconio inspisado en el ileon terminal; 35 presentaron 56 complicaciones del meconium ileus, que incluyeron volvulus (22), atresia (20), perforación (6) y quiste gigante por peritonitis meconial. La presentación clínica incluyó distensión abdominal, vómito bilioso y falla en la excreción de meconio. En dos casos recientes la ultrasonografía prenatal detectó una masa con distensión intestinal proximal indicativa de quiste por peritonitis por meconial. En los otros casos se estableció el diagnóstico de obstrucción intestinal mediante radiografías símples de abdomen y enema de bario. Diez pacientes con necomium ileus no complicado fueron tratados exitosamente con enema de gastrografina. Los 15 pacientes restantes requirieron laparotomía; en nueve se hizo resección intestinal y enterostomía y seis casos recientes fueron manejados con resección intestinal y anastomosis (15) o enterostomía (20). La sobrevida a un año fue de 92% en los pacientes con meconium ileus complicado. La terapia de preferencia para el meconium ileus no complicado es no-operatorio con enema de gastrografina, con la enterotomía e irrigación reservadas para los pacientes en que el enema falle. Los casos complicados requieren exploración y, en ausencia de quiste gigante por peritonitis meconial, usualmente son candidatos para resección intestinal y anastomosis primaria.

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Résumé L'iléus méconial est une manifestation précoce dans la maladie fibrokystique, observée chez 60 nouveau-nés, 20 filles et 40 garçons entre 1972 et 1991. Des antécédents familiaux de maladie fibrokystique était connus chez six de ces enfants. Vingt-cinq nouveau-nés se sont présentés avec un iléus méconial non compliqué du à un épaississement méconial dans l'iléon terminal. Trente-cinq nouveau-nés avaient 56 complications de l'iléus méconial y compris un volvulus (n=22), une atrésie (n=20), une perforation intestinale (n=6), et une péritonite méconiale kystique géante (n=8). Parmi les présentations cliniques, on notait une distension abdominale, des vomissements biliaires et l'impossibilité d'évacuer le méconium. Dans deux cas récents, l'échographie prénatale a détecté une masse en rapport avec une distension intestinale proximale indicative d'une péritonite méconiale. Le diagnostic d'occlusion intestinale mécanique chez les autres enfants reposait sur les données de l'abdomen sans préparation et la radiographie barytée. Dix patients ayant un iléus méconial non compliqué ont été traités avec succès par un lavement à la gastrografine. Une laparotomie a été pratiquée chez les 15 patients restants pour réaliser une résection intestinale et une entérostomie chez neuf d'entre eux et chez six cas récents, une entérostomie et une irrigation. Les cas compliqués ont été traités par une résection intestinale avec anastomose (n=15) ou une entérostomie (n=20). La survie à un an était de 92% lorsque l'iléus n'étaient pas compliqué et de 89% lorsque l'iléus était compliqué. La thérapeutique du choix de l'iléus méconial non compliqué est le lavement à la gastrografine, et en cas d'échec, une entérostomie avec irrigation. Les complications nécessitent une exploration chirurgicale, et en l'absence d'une péritonite méconiale, une résection intestinale avec anastomose primaire.

     

肾鹿角形结石的3种治疗方法比较

目的：总结肾鹿角形结石的治疗经验。方法：应用体外冲击波碎石(ESWL)，开放手术，经皮肾镜取石术(PCNL)，治疗鹿角形结石102例．并随访其疗效及并发症的发生率。结果：EWSL57例，3个月后结石排净率86％；开放手术36例．手术均获成功，无石率达92％；PCNL9例，3个月后结石排净率为89％。结论：PCNL加ESWL为首选方法，ESWL适用于无肾盂肾盏扩张的部分鹿角形结石．开放手术可作为适当的补充术式。     

Contemporary management of adrenocortical carcinoma

Context

Adrenocortical carcinoma (ACC) is a rare and typically aggressive malignancy. Available recommendations are based primarily on retrospective series or expert opinions, and only few prospective clinical studies have yet been published.

Objective

To combine the available evidence for diagnostic work-up and treatment of ACC to a contemporary recommendation on the management of this disease.

Evidence acquisition

We conducted a systematic literature search for studies conducted on humans and published in English using the Medline/PubMed database up to 31 January 2011. In addition, we screened published abstracts at meetings and several Web sites for recommendations on ACC management.

Evidence synthesis

In patients with suspected localised ACC, a thorough endocrine and imaging work-up is followed by complete (R0) resection of the tumour by an expert surgeon. In experienced hands, laparoscopic adrenalectomy is probably as effective and safe for localised and noninvasive ACC as open surgery. Most clinicians agree that mitotane should be used as adjuvant therapy in the majority of patients, as they have a high risk for recurrence. An international panel has suggested using tumour stage, resection status, and the proliferation marker Ki67 as guidance for or against adjuvant therapy. In patients with advanced disease at presentation or recurrence not amenable to complete resection, a surgical approach is frequently inadequate. In these cases, mitotane alone or in combination with cytotoxic drugs is the treatment of choice. The most promising regimens (etoposide, doxorubicin, cisplatin plus mitotane, and streptozotocin plus mitotane) are currently compared in an international phase 3 trial, and results should be available by the end of 2011. Several targeted therapies are under investigation and may lead to new treatment options. Management of endocrine manifestations with steroidogenesis inhibitors is required in patients suffering uncontrolled hormone excess.

Conclusions

Detailed recommendations are provided to guide the management of patients with ACC.     

Contemporary surgical management of pheochromocytoma

BACKGROUND: The availability of laparoscopic adrenalectomy led us to review our experience and management of adrenal and extraadrenal pheochromocytoma. METHODS: Seventeen patients undergoing pheochromocytoma resection from January 1997 to August 2001 were categorized as open, laparoscopic, or laparoscopic assisted depending on the surgical approach. Hospital records were reviewed. RESULTS: There was no significant difference between the groups in patient age, weight or preoperative blockade. Operative times for open, laparoscopic, and laparoscopic assisted adrenalectomies were 202, 218, and 260 minutes, respectively. Estimated blood loss was 562 cc, 187 cc, and 925 cc. The average hospital length of stay was 6.2, 3.0, and 5.8 days. CONCLUSIONS: Laparoscopic removal resulted in longer operative times than open, but less operative blood loss and a shorter hospital stay. The laparoscopic assisted approach did not save time nor did it lead to earlier discharge. Laparoscopic adrenalectomy was comparable to the open approach, and is preferential in tumors less than 6 cm. An open approach remains our choice for larger or extraadrenal tumors.     

Contemporary management of pelvic fractures

BACKGROUND: Pelvic fractures occur when there is high kinetic energy transfer to the patient such as would be expected in motor vehicle crashes, auto-pedestrian collisions, motorcycle crashes, falls, and crush injuries. High-force impact implies an increased risk for associated injuries to accompany the pelvic fracture, as well as significant mortality and morbidity risks. Choosing the optimum course of diagnosis and treatment for these patients can be challenging. The purpose of this review is to supply a contemporary view of the diagnosis and therapy of patients with this important group of injuries. METHODS: A comprehensive review of the medical literature, focusing on publications produced in the last 10 years, was undertaken. The principal sources were found in surgical, orthopedic, and radiographic journals. CONCLUSIONS: The central challenge for the clinician evaluating and managing a patient with a pelvic fracture is to determine the most immediate threat to life and control this threat. Treatment approaches will vary depending on whether the main threat arises from pelvic fracture hemorrhage, associated injuries, or both simultaneously. Functional outcomes in the long-term depend on the quality of the rigid fixation of the fracture, as well as associated pelvic neural and visceral injuries.     

Contemporary management of small renal masses

Context

An increasing number of small renal masses (SRMs) with heterogeneous histology and clinical behaviour are being detected with modern radiologic imaging. Although surgical removal is the standard of care for small renal tumours, alternative minimally invasive and conservative treatment options are possible in selected patients with shorter life expectancy.

Objective

To systematically review indications, techniques, and outcomes of surgical and conservative treatments of SRMs.

Evidence acquisition

A literature search of English-language publications was performed using the Medline database from January 2000 to February 2011 using the terms renal mass and renal carcinoma in conjunction with the evaluated management options. The articles that provided the highest level of evidence were selected with the consensus of all the authors and reviewed.

Evidence synthesis

Only one randomised controlled trial comparing the results of elective nephron-sparing surgery and radical nephrectomy for low-stage renal tumours is available. Few comparative studies of different treatment options for SRMs have been published. The assessment of oncologic outcomes is therefore based mainly on observational studies. Most series of nonsurgical therapies have strong selection biases and relatively short follow-up. Treatment selection is based on the clinical and histologic characteristics of SRMs, on patient age and comorbidities, and on personal preferences and experience of the urologist.

Conclusions

Partial nephrectomy (PN) is the standard treatment for solitary SRMs whenever it is technically feasible. Laparoscopic PN is an alternative to open PN in experienced hands. The rationale of ablative treatments is to treat incidental cortical SRMs in patients at high surgical risk with potentially reduced morbidity. Active surveillance is considered an appropriate strategy for the elderly or for patients with significant comorbidity who have a shorter life expectancy. Percutaneous biopsies are increasingly being used to establish histology of SRMs and support treatment decisions, especially for patients who are candidates for nonsurgical treatment.     

Contemporary management of renal calculus disease

The management of renal calculus disease has changed. Non-invasive and minimally invasive techniques of stone disintegration and removal have replaced open stone surgery in managing this condition. In this article we discuss the investigation and management of patients with renal stone disease as currently performed in specialist stone centres.     

Contemporary management of wartime vascular trauma

OBJECTIVE: The treatment of wartime injuries has led to advances in the diagnosis and treatment of vascular trauma. Recent experience has stimulated a reappraisal of the management of such injuries, specifically assessing the effect of explosive devices on injury patterns and treatment strategies. The objective of this report is to provide a single-institution analysis of injury patterns and management strategies in the care of modern wartime vascular injuries. METHODS: From December 2001 through March 2004, all wartime evacuees evaluated at a single institution were prospectively entered into a database and retrospectively reviewed. Data collected included site, type, and mechanism of vascular injury; associated trauma; type of vascular repair; initial outcome; occult injury; amputation rate; and complication. Liberal application of arteriography was used to assess these injuries. The results of that diagnostic and therapeutic approach, particularly as it related to the care of the blast-injured patient, are reviewed. RESULTS: Of 3057 soldiers evacuated for medical evaluation, 1524 (50%) sustained battle injuries. Known or suspected vascular injuries occurred in 107 (7%) patients, and these patients comprised the study group. Sixty-eight (64%) patients were wounded by explosive devices, 27 (25%) were wounded by gunshots, and 12 (11%) experienced blunt traumatic injury. The majority of injuries (59/66 [88%]) occurred in the extremities. Nearly half (48/107) of the patients underwent vascular repair in a forward hospital in Iraq or Afghanistan. Twenty-eight (26%) required additional operative intervention on arrival in the United States. Vascular injuries were associated with bony fracture in 37% of soldiers. Twenty-one of the 107 had a primary amputation performed before evacuation. Amputation after vascular repair occurred in 8 patients. Of those, 5 had mangled extremities associated with contaminated wounds and infected grafts. Sixty-seven (63%) patients underwent diagnostic angiography. The most common indication was mechanism of injury (42%), followed by abnormal examination (33%), operative planning (18%), or evaluation of a repair (7%). CONCLUSIONS: This interim report represents the largest analysis of US military vascular injuries in more than 30 years. Wounding patterns reflect past experience with a high percentage of extremity injuries. Management of arterial repair with autologous vein graft remains the treatment of choice. Repairs in contaminated wound beds should be avoided. An increase in injuries from improvised explosive devices in modern conflict warrants the more liberal application of contrast arteriography. Endovascular techniques have advanced the contemporary management and proved valuable in the treatment of select wartime vascular injuries.