Diagnosis and treatment of soft tissue tumors

In the management of soft-tissue tumors, accurate diagnosis, using a combination of clinical, radiographic, and histological data, is critical in optimizing outcome. Radiographic diagnoses can be useful, but they cannot accurately predict histology or whether a lesion is benign or malignant. Therefore, all soft lumps that persist or grow should be biopsied if possible. Fine-needle aspiration biopsy is useful in differentiating benign from malignant lesions. Core-needle biopsies can yield a histological diagnosis when the sample is sufficiently large. When open biopsy is required, the skin incision must be carefully placed so that the biopsy site can be completely excised if the lesion is subsequently found to be malignant. Excisional biopsy should be used only for small lesions or when the surgeon is confident that the lesion is benign. If, following excision, the lesion is found to be malignant or desmoid, additional surgery with an adequate excision margin should be performed. In the resection of high-grade sarcomas treated by surgery alone or resistant to preoperative adjuvant therapies, a "curative (wide) margin" must be achieved. We occasionally use preoperative radiation with or without hyperthermia for malignant lesions in the vicinity of neurovascular structures where adequate surgical margins are unlikely to be achieved. The use of chemotherapy is justified only in small-cell sarcomas in which metastasis occurs frequently and chemotherapy is known to be effective. For high-grade spindle-cell or pleomorphic sarcomas, the value of adjuvant chemotherapy remains controversial and needs investigation. Received for publication on June 9, 1998     

Obstructive complications of the Nissen fundoplication

The obstructive complications of the Nissen fundoplication can be devastating. They are much more easily prevented than treated. The technical considerations in avoiding these complications are conceptually simple. The fundoplication should be done over a large intraesophageal stent. A no. 50 or 60 French dilator is appropriate and, in addition, the fundoplication should be left loose. If the fundoplication is to be left in the chest, the hiatus must be widely enlarged so that there is not the slightest hint of obstruction at the level of the diagphragm. Care must be taken in this case to approximate stomach to diaphragm. The Nissen fundoplication should be carried out using heavy sutures with generous bites of the stomach on both sides as well as bites of the esophageal wall and perhaps also the proximal stomach. If careful attention is paid to these technical details, the obstructive complications of the Nissen fundoplication should be eliminated.     

Staging, evaluation, and nonoperative management of renal injuries

The kidney is the most commonly injured urologic organ and can sometimes be the most challenging to treat. Although most renal injuries may be treated successfully without operative intervention, it is important, and yet sometimes confusing, to delineate which cases should be managed with intervention and which may be observed. The common teaching that blunt renal injuries may be observed and penetrating injury must be explored may be true in most cases, but in select cases this dogma can be misleading and lead to poorer outcomes. The purpose of this article is to explain the important variables in the evaluation of renal trauma (clinical, radiologic, and sometimes surgical),how to stage renal trauma, and how to decide whether nonoperative or operative management is indicated.     

Consent

Consent is a fundamental ethical and legal principle in good medical practice. A patient must have capacity to provide informed consent. There are four key principles that need to be satisfied when establishing if a patient has capacity. For consent to be valid, the patient must be made aware of all associated risks to which they would attach significance. Information provided to patients should be individualized, objective and include all reasonable alternatives. It should be made clear if a procedure is optional, for example, an analgesic regional nerve block. Questions should be encouraged and answered honestly. Patients need adequate time to consider all the information provided. The consent process should be documented but a separate signed consent form is not required for most anaesthetic interventions. Some patients may have an advance care directive or a legally appointed power of attorney and these must be respected. When a patient has not made such arrangements and does not have capacity, treatment should be provided in accordance with their best interests. This must be individualized and consider multiple factors. Specialist advice should be sought in circumstances where there is uncertainty.     

Stents in urethral stricture repair

Summary The human urethra seems remarkably tolerant of foreign material within its lumen. Providing that a stricture has been adequately cut by means of urethrotomy, or dilated with bougies, the majority of urethras will tolerate both permanent and temporary stents with few problems. Temporary stents have the obvious advantage over permanent stents that no foreign material is left in the urethra but before these can be recommended it is essential that more clinical experience is gained and that long term results up to ten years after removal of the stent are published. Great care is also needed in the use of any sort of permanent device, either the Urolume stent, or varieties of the Strecker such as the Memotherm device. These should not be used in children and should be probably be avoided in young adults. The majority of strictures in this age group are in any case treated more easily by single stage urethroplasty procedures. The use of permanent epithelial covering stents should be limited to the bulbo-membranous urethra, with the possible exception of carefully selected sphincters strictures used in combination with an artificial urinary sphincter. Better results will be obtained by using these stents in strictures with a short history before multiple urethrotomies and dilatations have been carried out and before extensive urethral and periurethral fibrosis has occurred. This means that urethral rupture strictures are unsuitable, and in any case these are simple to deal with be means of stricture excision and primary end to end anastomosis of the urethra particularly when the stricture is in the bulbar urethra. Care must also be taken in using these devices in post-urethroplasty strictures if extensive periurethral fibrosis exists, although it has to be admitted that these stents may be very successful in some of these patients. The difficulty at the present time is our inability to define exactly which traumatic stricture or post-urethroplasty stricture will succeed and which will fail. Metal urethral stents should not be used for the first treatment of a urethral stricture. Depending on the aetiology, the site and the length of the stricture there is always a 40–50 % chance that the stricture may be cured by means of a simple urethrotomy or dilatation and this should always be tried at least once before resorting to urethral stenting. There is no doubt that permanent urethral stents have an important role to play in the treatment of recurrent urethral strictures. Careful patient selection is essential in order to achieve the best results and we need more long term results before the final role of these devices in the treatment of urethral strictures can be determined. Temporary stenting of the urethra with non-epithelial covering stents is a simpler and safer treatment but at this point in time we cannot be sure how effective this treatment is and for which patients it is most successful. Long term results must be awaited before the place of these temporary devices can be defined.      

Diagnostik kindlicher Frakturen

During the diagnostic phase children need to be treated differently from adults. Neither the history taking nor the physical examination is so important as in adults. The history can be elicited from relatives accompanying the patient, but should not be allowed to delay further diagnostic procedures and treatment. Fast and accurate diagnosis is needed so that treatment can be selected and implemented, and also to reassure the parents. It is important that inspection and examination should not be painful for a child. Fracture treatment in children needs special experience and should be performed in trauma centers. In addition to accidents that have to be treated privately, accidents for which patients are insured by the German employer’s liability insurance associations are common and need to be treated in qualified trauma centers. The localization of fracture lines depends on the maturity of the physis. This is why the mechanism of the accident is not so important as in an adult and the physical examination has to be reduced to a minimum. A sufficient diagnosis is yielded by two X-rays in perpendicular planes. X-rays in an oblique plane or of the contralateral side are recommended in special situations, e.g. triplane fractures, as are CT and MRT. The maturity of different ossification centers has to be taken in account to avoid false diagnoses. The use of ultrasound is not recommended for the diagnosis of fractures in children.     

肿瘤及重金属相关膜性肾病的诊断与治疗

膜性肾病是引起成人肾病综合征最常见的病因之一,按其病因可分为原发性和继发性,其中继发性膜性肾病约占总体膜性肾病的1/3。肿瘤及药物相关膜性肾病又是继发性膜性肾病中有意义、也有一定争议的病因,临床需要关注并加强甄别。虽然目前尚不能够准确区分肿瘤相关性膜性肾病与肿瘤合并特发性膜性肾病,但临床应注意：对于中老年膜性肾病患者,要警惕肿瘤的存在,注意肿瘤的筛检;对于发现肿瘤的患者,应注意监测肾损害指标,及时发现肾脏损害并给予干预治疗;对于中老年膜性肾病肾病综合征患者,在应用激素免疫抑制剂治疗前及治疗过程中,也要注意排除肿瘤的可能性。对于有汞接触史的膜性肾病患者,要注意排除汞中毒相关膜性肾病。     

Tumour ablation by laser in dermatology

The role of CO₂ laser in plastic surgery and dermatology is nowadays well established. It has proved to be efficient within different contexts (haemorrhagic-infectious-necrotic ...) or on different tissues as skin, muscles and mucosae. But the role of lasers in oncologic cutaneous surgery is not as precise.The CO₂ laser is to be used in a focused mode, to realize the excision of tumour, whatever its size. The advantages lie in minimized blood loss, and in permitting all types of reconstruction (suture, graft or flap). Some clinical cases of photodynamic therapy are reported, but do not appear to be conclusive. Anyhow, PDT is still under investigation and does not seem to be ready yet for routine clinical use. The principle of tissue photo-ablation with excimer of Er-YAG lasers shows some possible interest in the case of tumour treatment. But, here again, this technique has not yet proved to be for any real advantage, as far as technology is concerned. Whatever the type of laser to be used, one basic principle is to completely excise the tumour to meet the classical requirements of oncologic surgery, i.e. to be far enough from the lesion, and to get a microscopic identification of the whole specimen.     

Management of the difficult adult airway. With special emphasis on awake tracheal intubation.

Difficulty in managing the airway is the single most important cause of major anesthesia-related morbidity and mortality. Successful management of a difficult airway begins with recognizing the potential problem. All patients should be examined for their ability to open their mouth widely and for the structures visible upon mouth opening, the size of the mandibular space, and ability to assume the sniff position. If there is a good possibility that intubation and/or ventilation by mask will be difficult, then the airway should be secured while the patient is still awake. In order for an awake intubation to be successful, it is absolutely essential that the patient be properly prepared; otherwise, the anesthesiologist will simply fulfill a self-defeating prophecy. Once the patient is properly prepared, it is likely that any one of a number of intubation techniques will be successful. If the patient is already anesthetized and/or paralyzed and intubation is found to be difficult, many repeated attempts at intubation should be avoided because progressive development of laryngeal edema and hemorrhage will develop and the ability to ventilate the lungs via mask consequently may be lost. After several attempts at intubation, it may be best to awaken the patient, do a semielective tracheostomy, or proceed with the case using mask ventilation. In the event that the ability to ventilate via mask is lost and the patient's lungs still cannot be ventilated, TTJV should be instituted immediately. Tracheal extubation of a patient with a difficult airway over a jet stylet permits a controlled, gradual, and reversible (in that ventilation and reintubation is possible at any time) withdrawal from the airway. Significant advances in the management of the difficult airway have occurred in recent years. Eighty percent of the 127 references in this article were published after 1985. However, there is much more to learn with regard to recognition of the difficult airway, preparation of the patient for an awake intubation, new techniques of endotracheal intubation, and establishment of gas exchange in patients who cannot be intubated or ventilated by mask. As the anesthesiologist's ability to manage the difficult airway significantly improves, respiratory-related morbidity and mortality will decrease.     

Diabetes and the kidney in pregnancy

The prevalence of diabetes in pregnant women is increasing, with 4% of deliveries in the United States occurring in women with pregestational or gestational diabetes. The proteinuria of late pregnancy is exaggerated in women with diabetes. However, diabetic women with preserved renal function before pregnancy appear to have little risk of deterioration of kidney function during pregnancy. Women with impaired renal function before pregnancy may be at risk for permanent decline of renal function during pregnancy, although it is unclear whether this represents the effect of pregnancy or the natural history of their diabetic renal disease. Preeclampsia, which is more common in women with diabetes, may be difficult to diagnose in this group of women. From the currently available literature, there appears to be no negative effect of pregnancy on the long-term progression of diabetic renal disease if renal function is normal and marked proteinuria is absent, but in light of recent findings in which preeclampsia appears to be associated with an increased risk of end-stage renal disease, large cohort studies will be necessary before this question can be definitively answered.     

Sind „Linkshänder” bessere Lokalanästhetika? Zur Relevanz der Stereoisomerie in der klinischen Praxis am Beispiel neuer Lokalanästhetika

S-Ropivacaine is a new, long-acting amide local anaesthetic. It is the first local anaesthetic to be on the market as a single isomer. Its pharmacodynamic and pharmacokinetic profile is similar to that of bupivacaine. In vitro and in vivo experiments have shown ropivacaine to be less cardiotoxic than bupivacaine. When given epidurally, both local anaesthetics are equally effective in producing sensory block, but motor block seems to be less pronounced in the case of ropivacaine. This pharmacodynamic profile suggests that ropivacaine has a greater margin of safety and should be a valuable candidate in applications where motor blockade is to be avoided, e.g. for postoperative epidural analgesia and for epidural analgesia in obstetrics.     

Prophylaxis in idiopathic calcium urolithiasis

Summary The most important measure in the prophylaxis of idiopathic calcium urolithiasis is dietary advice. Patients should be kept to a high-fluid intake, increasing their diuresis by at least 0.51. The mineral content of drinking water seems to be of minor importance, but the liquid should be low in carbohydrates and oxalate. The intake of animal proteins should be reduced to no more than five meals with meat, fish or poultry per week. Excesses of oxalate-rich food must be avoided. The daily intake of calcium in dairy products should be in the range of 800–1200 mg. Sodium and refined carbohydrates should be moderately restricted. Medical treatment is indicated only in cases of recurrence under the appropriate diet. Selective treatment according to urinary chemical composition is favoured; alkali citrate, thiazides, allopurinol, and pyridoxine are of major interest.     

Management of medullary carcinoma of the thyroid

Total thyroidectomy is universally advised for the familial variety of MCT. Although total thyroidectomy is also recommended for sporadic cases, partial thyroidectomy may be adequate. Cervical and upper mediastinal nodes should be sampled for microscopic study, even when they are small and appear to be normal. Appropriate neck or mediastinal nodes should be sampled for microscopic study, even when they are small and appear to be normal. Appropriate neck or mediastinal dissection is done if metastasis is present. External radiation is a valuable adjuvant to surgical excision following the apparent complete resection of the tumor, and is beneficial in the management of unresectable disease. Despite local control, patients continue to die from disseminated disease; therefore, there must be a continued search for an effective chemotherapeutic program. Much remains to be learned from calcitonin monitoring of MCT patients.     

Paraneoplastic Cushing's syndrome in prostate cancer: a difficult management problem

Cushing's syndrome associated with small-cell de-differentiation of prostate cancer is rare, but well described. The detection of Cushing's syndrome in a patient with prostate cancer can be problematical, and when occurring in prostate cancer nearly always implies the development of small-cell transformation. Testosterone levels in these patients are likely to be in the normal range, despite previous castration. The features of Cushing's syndrome contribute considerably to patients' morbidity and probably to their mortality. The syndrome is unlikely to be controlled with inhibitors of steroid synthesis, and chemotherapy is likely to be poorly tolerated, resolving the syndrome in only a few patients. We suggest that bilateral adrenalectomy at an early stage should be considered, possibly as a preliminary to anticancer treatments.     

Airway trauma

Airway trauma can be considered according to the mechanism of injury, which may guide further management. Trauma may be mechanical, either blunt or penetrating, be due to burns or be iatrogenic as a result of instrumentation of the airway. Immediate airway intervention will be required for obvious airway compromise. Such patients may be difficult to manage, and may be complicated by polytrauma. It is important to appreciate the potential for rapid deterioration in patients with an injury to the aerodigestive tract. Delayed diagnosis can result in poor outcomes from airway and neck trauma, and a structured approach to resuscitation, investigations and ongoing care should be adopted. Iatrogenic airway trauma is not confined to patients in whom intubation is difficult or prolonged, although these are risk factors. Pharyngeal and oesophageal perforation are associated with greater risk of mortality than other iatrogenic airway injuries. Cricoarytenoid joint dysfunction, vocal cord palsy, granuloma, haematoma and tracheal stenosis can all occur as a result of airway instrumentation, and may not be apparent until some time later. Specialist referral of these patients is appropriate, and prompt treatment may improve outcomes. Careful sizing of endotracheal tubes and close monitoring of cuff pressures are important in minimizing airway trauma through intubation.     

甲状旁腺功能亢进症致多发棕色瘤诊治经验探讨

骨质疏松患者合并高血钙、低血磷时应注意鉴别甲状旁腺功能亢进症,当甲状旁腺功能亢进症合并骨破坏病例应警惕棕色瘤,棕色瘤临床上易与骨转移瘤、骨巨细胞瘤混淆。棕色瘤早期以保守治疗为主,后期可考虑手术治疗,不能手术患者建议双膦酸盐治疗,但尚需更多证据支持。     

Legal and ethical considerations of informed consent in children: implications for anaesthetists

Based on the moral principle of respect for autonomy, the patient or legal guardian must be aware of the general risks of a procedure about to be undertaken. If inadequate information is provided, then the doctor may be held to be negligent. Anaesthetists, because anaesthesia creates an additional risk to the patient, are also directly involved in the concept of 'informed consent'. How much information needs to be disclosed to avoid a claim of negligence is different in various parts of the world. In some the 'professional medical standard' is the accepted test, that is, what other doctors tell their patients. In other areas, the 'patient-based material risks' or what a patient would consider to be a material risk is the accepted test. Both have disadvantages and a balance must be struck between the two concepts.     

Medical management of chronic pancreatitis

慢性胰腺炎的临床表现包括疼痛、脂肪泻和糖尿病。在西方国家，慢性胰腺炎最常见的病因是酗酒。70％以上的病人在就诊时有疼痛的临床表现，而且，这些患者中又有75％以上会在几年之后出现疼痛减轻或完全消失。对于所有的慢性胰腺炎的病人来说，均应排除非胰源性疼痛和胆道梗阻、胰腺假性囊肿等胰腺局部并发症。应建议所有慢性胰腺炎病人戒烟、戒酒。阿片类镇痛剂仅应用于治疗疼痛严重的病人。尽管有报道认为胰酶替代治疗有助于止痛，但是，对于已经确诊的慢性胰腺炎病人来说，该疗法无效。激素类药物进行腹腔神经丛阻滞术可能有助于病人度过剧烈疼痛期。顽固性疼痛是进行胰液引流或胰腺切除的适应证。建议应用适量胰酶替代联合(或不联合)制酸剂治疗营养不良。慢性胰腺炎导致的糖尿病与原发性糖尿病的治疗原则相似。     

重症急性胰腺炎中西医结合诊治常规(草案)

目的：制定重症急性胰腺炎（SAP）中西医结合治疗试行指南。方法：以循证医学证据为基础，通过查阅大量文献报道，采用系统综述的方法，参阅国内外多项指南内容，广泛征求专家意见和建议，初步制定出《重症急性胰腺炎中西医结合诊治常规》（草案）。指南中的推荐意见依据2001年国际感染论坛（ISF）提出的Delphi分级标准，推荐级别分为A-E，其中A级最高。结果：SAP是临床上常见的一类急腹症，病程通常分为三期。早期的重症监护治疗对SAP患者是至关重要的，而快速恰当的液体复苏又能预防循环并发症的发生。蛋白酶抑制剂如加贝酯，胰酶抑制剂如善得定，抗炎剂如昔帕泛等，尽管早期研究发现有效，但随后的大样本随机研究证实其效果不理想，不推荐常规使用。预防性抗生素应用可能在预防感染方面有效，但是否给予意见不一。如果给予，则疗程不应超过14d。SAP患者的营养支持是必需的，若肠道功能恢复，则优先选择肠内营养，肠内营养中经鼻空肠置管是可行的。胆道结石引起的SAP，有胆管炎、黄疸或胆总管扩张时，应紧急行ERCP治疗。当患者有脓毒症症状时，细针穿刺抽吸物培养是可靠的鉴别无菌性胰腺坏死和感染性胰腺坏死的方法。感染性胰腺坏死合并有脓毒症症状和体征时，是外科干预的指征，包括手术清除坏死组织和影像引导下引流。坏死组织清除的术式选择及术后的处理取决于患者病情和医师经验。中医治疗在降低SAP病死率、缩短病程方面是被实践证实了的有效手段。结论：该指南是以循证医学为指导制定的，随新的证据不断形成则应不断更新。     

Mentoring surgeons in private and academic practice

Mentoring is an essential component of a successful career in any profession, and these relationships are beginning to be explored in great detail in academic surgery. However, it is equally important for surgeons in private practice, and this area has not received nearly as much attention in the literature. The goals for both are similar and include providing career advice, guidance, and counseling, with the only regard being the success of the junior associate. In private practice, the mentor can be a senior colleague who may or may not be part of one's group practice. In academia, it may be someone at another university, although proximity is preferable. It may be necessary to repeat the search for a mentor more than once before a successful relationship evolves. This complex process must be mastered if one is to be successful in either academia or private practice.