Whiplash: fact or fiction?

Cervical sprain/strain or whiplash injuries are a common cause of acute and chronic musculoskeletal impairments and are ubiquitous after rear-end automobile collisions. The diagnosis is largely subjective and the ideal treatment controversial. Unfortunately, the majority of compensated litigation claims are associated with whiplash-type injuries secondary to motor vehicle accidents. Fortunately, many recent advances have led to better understanding of the collision and injury biomechanics and to development of a prognostic classification system, objective diagnostic tests, an array of treatment modalities, and, most important, safer automobiles. These advances will undoubtedly lead to decreased incidence, a more accurate diagnosis, and a tailored management regimen resulting in improved outcomes and ultimately fewer legal proceedings.     

Scar lymphedema: fact or fiction?

BACKGROUND: Few concepts are as fundamental to plastic surgery as scarring, yet swelling within a scar and its adjacent tissues is a common observation which is not well understood. Mechanical forces, scar contracture, fibrosis, and lymph stasis have been considered as possible explanations for these edematous-appearing areas, but conclusive evidence of a cause of swelling has not been established. The purpose of this study was to evaluate the possible role of microlymphatic stasis or disruption as a causal factor. PATIENTS AND METHODS: Eleven patients (mean age: 43; range: 15 to 70) with localized swelling in conjunction with linear or curvilinear scars were evaluated, 9 with facial scars and 2 with scars of the chest wall and abdomen. Swelling within the scar had been present for an average of 4.5 years (range: 9 months to 13 years). Two patients had undergone previous Z-plasty revisions to the limbs of their curvilinear scars. Radiocolloid lymphoscintigraphy with technetium-99m Sb2S3 was performed on all patients by single or multiple injection technique into the site of the scar corresponding to local edema. RESULTS: Following injection, rapid egress of radiotracer was visualized along lymphatic pathways posterior to the scar, with continuation to locoregional nodes in all patients with U-shaped "trapdoor" or linear scar configuration. However, in 8 cases there was no evidence of lymphatic drainage traversing or bridging the scar. In 2 patients with multiple prior Z-plasty revisions to the limbs of curvilinear scars, no visualization of lymph channels across the Z-plasty flaps was apparent. In total, 8 patients were diagnosed with lymphedema of the area adjacent to or enclosed within the scar. CONCLUSIONS: These findings suggest that undrained lymphatic fluid contributes to the pathogenesis of the raised and swollen tissues seen abutting a U-shaped scar. Furthermore, as lymphatic pathways do not reestablish themselves across scars, attempts at improving lymphatic flow with Z-plasty revisions may not succeed in patients with clinical trapdoor scar deformities. Determination of scar lymphedema can assist in the selection of proper management for patients seeking scar revision.     

Angiosome theory: fact or fiction?

The angiosome concept delineates the human body into three-dimensional blocks of tissue fed by specific arterial and venous sources named "angiosomes." Adjacent angiosomes are connected by a vast compensatory collateral web, or "choke vessels." This concept may provide new information applicable to improving targeted revascularization of ischemic tissue lesions. A few dedicated studies available seem to favor this strategy, as encouraging ulcer healing and limb preservation are reported in connection with both bypass and endovascular techniques based on these principles. The theory on the angiosome model of revascularization (AMV) may help the clinician to better refine vessel selection, vascular access, and specific strategies in the revascularization of critically ischemic legs with tissue lesions. Specific applications of angiosome-guided revascularization were recently suggested for patients with diabetes or renal insufficiency, with ischemic tissue lesions of the lower limb, and extended large- and medium-size collateral network decay. For these cases, the concept may allow deliberate arterial reconstruction following individual wound topographies in specific ischemic areas, although deprived from "rescue-vessel" supply. The AMV theory may contribute to a shift in common reperfusion options. However, the data available is suggestive and does not provide strong evidence as factors such as case mix and the severity of ischemia are unsatisfactorily controlled. At present, the evidence is scarce as to the effect of the severity of the arterial disease. In all comparisons, the groups treated are likely to be dissimilar and mismatched. The angiosome concept is postulated to be valid especially in diabetics, whose ischemic lesions tend to heal worse than those of non-diabetics.     

Endoscopic treatment of tracheo-esophageal fistulas: fact or fiction?

Tracheo-esophageal fistulas as a sequelae of esophageal atresia surgery are usually a severe complication whose correction requires an important surgical aggression, often with uncertain results. The possibility of treating this problem through the use of non-aggressive endoscopic methods has been described in medical literature over the last years, applying several products for occlusion with conflicting results in different publications. We present three cases of tracheo-esophageal fistulas, describing the technique of trans-tracheal endoscopic approach based on the novelty of employing a laryngeal mask which facilitates ventilation during the procedure, as well as the possibility to use endoscopic material of greater diameter. We comment on the different occlusion materials employed (Tissucol & Histoacryl) and the difficulties of their management. In one case two attempts of occlusion were made, and three in the other two, varying the application method and product. In two cases the fistulas initially reopened and in the other an occlusion was demonstrated by esophagogram and remission of respiratory symptoms during eight months was achieved. In a posterior control, a thread-like fistula reappeared but did not affect clinical improvement. The possibility to employ endoscopic techniques always seemed very promising for this type of pathology. The appearance on the market of various substances with capacity of occlusion has allowed us to employ them in comparative studies and simultaneously test the efficacy of the laryngeal mask in this kind of situations. The results show the complete ineffectiveness of some of these products and the relative possibilities of others, although in our experience we have yet to achieve any definitive occlusion.     

Constipation after hysterectomy: fact or fiction?

Hysterectomy is responsible for numerous postoperative complications largely urological, but sometimes of sexual or colorectal function. The latter involve modifications of bowel function resulting in constipation as a result of delayed transit, infrequent evacuations and greater difficulty in expelling faeces. We have reviewed the topic, and consider the various hypotheses whereby these modifications may result from hormonal alterations, iatrogenic causes, or variations in recto-bladder sensitivity. Any of these could justify the modifications in bowel function detected in these patients. The studies carried out so far provide no clear information about the type of constipation that develops after hysterectomy, as we lack prospective studies that compare bowel function before and after operations. Nor is it clear whether we are dealing with constipation as a result of delayed transit or obstructed defaecation, nor which pathogenetic mechanisms are involved. In view of the large number of hysterectomies that are done, sometimes prophylactically, controlled prospective studies are warranted to address these issues more fully.     

Nephroprotection, fact or fiction?

Clinical studies of the last 15 years have shown the benefit of pharmacological interventions on the progression of chronic kidney disease, confirming the concept of nephroprotection. Pharmacological blockade of the renin angiotensin system remains the cornerstone of the nephroprotective treatment but the benefits and limitations are now better defined. The RAS blockers are all the more efficient than the proteinuria is abundant and nephroprotection is obtained in proportion to the reduction in proteinuria. Combinations of ACEI+ARA are not validated and their use should be considered only under the supervision of a specialist when optimal monotherapy has failed. The target blood pressure has been the subject of recent controversies, particularly in type 2 diabetic patients with nephropathy. The target should be individualized based on the main risk, renal or cardiovascular. Recent maneuvers have also shown a nephroprotective effect, including the correction of metabolic acidosis with sodium bicarbonate.     

Laparoscopic appreciation of the adrenal artery: fact or fiction?

BACKGROUND: It is well accepted that identification and control of the adrenal vein is a critical step in laparoscopic adrenalectomy. The surgical and anatomic literature propagates the notion of a dominant or multiple dominant adrenal arteries that should likewise be controlled during surgical extirpation. MATERIALS AND METHODS: We assessed the frequency of adrenal-artery identification and the need for formal ligation in an extensive series of laparoscopic adrenalectomies. RESULTS: In our experience, even using a magnified laparoscopic view, we found it possible to identify and necessary to formally ligate an adrenal artery in only 3 of 265 cases (1.1%). Further, in this series, only the inferior adrenal artery was ever seen definitively to require formal clip ligation, while a discrete middle or superior adrenal artery was almost never seen, and the vasculature in these areas could be controlled with electrocautery or ultrasonic energy alone during routine dissection. CONCLUSIONS: The need to search for and ligate the arterial supply during laparoscopic adrenalectomy is not as clinically significant as once thought, and formal control appears unnecessary unless the vessels are serendipitously encountered during the routine dissection.     

The sheath of the brachial plexus: fact or fiction?

BACKGROUND: The concept of the axillary "sheath" has been a central tenet of brachial plexus regional anesthesia for many years. Recent investigations have cast doubt on its nature and existence. This study further examines the issue. METHODS: Computerized axial tomographic dye studies were performed using continuous catheter systems for the sciatic nerve and the brachial plexus. The resultant images were compared and contrasted. RESULTS: The images of the two catheter systems were the same, with the exception that one was of the upper extremity and the other was of the lower extremity. CONCLUSIONS: The sciatic nerve is not surrounded or enveloped by a "sheath"--it lies in the tissue plane between rigid anatomical structures. Similarly, the brachial plexus lies in the tissue plane between the rigid anatomy of the chest wall, scapula, humerus, and pectoral fascia. This finding is inconsistent with the concept of the axillary sheath.     

Testosterone insufficiency in women: fact or fiction?

Androgen deficiency in women is a valid diagnosis in premenopausal, as well as in postmenopausal women, under certain conditions. This diagnosis is hampered by a lack of precise definitions and sensitive assays for testosterone. Precise normal ranges for control populations are lacking, and thus many studies have used pharmacological instead of physiological levels of testosterone in treatment protocols. Despite these shortcomings, and a shortage of controlled studies, there is ample evidence that testosterone treatment has helped many women with signs and symptoms of deficiency.     

Autoimmunity and hernia mesh: fact or fiction?

Hernia - There is an increasing number of patients following hernia surgery with implanted mesh reporting symptoms that could indicate autoimmune or allergic reactions to mesh....     

Capillary pressure-induced lung injury: fact or fiction?

Lung capillary pressure in healthy humans at rest ranges between 6 and 10 mmHg. At maximal effort or in pathophysiological conditions such as left sided heart disease or massive pulmonary vasoconstriction, for example in high-altitude pulmonary disease, capillary pressure may be markedly elevated. Increased capillary pressure directly affects transendothelial fluid dynamics and thus results in the formation of hydrostatic lung edema. Excessive pressure increases may cause capillary stress failure. Recent studies, however, suggest that the microvascular response to lung capillary hypertension is more complex. Pressure, strain and shear stress cause dysfunction of the capillary endothelium characterized by an imbalanced release of vasoactive mediators. Endothelial dysfunction evokes a multicellular response with features of vasoconstriction, inflammation, and vascular leakage, thrombosis, and remodeling. These active cellular reactions contribute to the pathophysiological process and may be specifically targeted by new therapeutic strategies.     

Drains for thyroidectomy/parathyroidectomy: fact or fiction?

BACKGROUND: Many authorities advocate draining the neck routinely after thyroid and parathyroid surgery with no scientific evidence to support this practice. We aimed to establish if the routine use of drains following thyroid/parathyroid surgery is of any value. METHOD: Medical records of patients who underwent thyroidectomy or parathyroidectomy under the care of a single endocrine surgeon (GP) over a 14-year period were reviewed. For the first 6 years, the neck was routinely drained (drain group) and for the subsequent 8 years the neck was only drained if the surgeon felt it necessary according to the operative situation (selective group). RESULTS: A total of 606 procedures (425 thyroidectomy and 181 parathyroidectomy) were performed on 582 patients. Drains were routinely used in 134 (22%) procedures (drain group) and were selectively used in 472 (78%) (selective group) of which 191 (40%) were drained. In all patients, there was a significant increase in the rate of postoperative bleeding/haematoma in patients with a drain (8/314 versus 1/282, Fisher's exact, P < 0.05). Wound infection occurred only in the patients with a drain. There was no difference in the incidence of postoperative bleeding and airways obstruction between the drain and selective groups. CONCLUSION: We conclude that the routine use of neck drains is unnecessary and may indeed be harmful, drain insertion being associated with an increased incidence of wound infection. Drains should, therefore, be used selectively after thyroidectomy and parathyroidectomy.     

Non‐invasive methods of penile lengthening: fact or fiction?

What's known on the subject? and What does the study add? Penile lengthening methods remain a controversial issue. Surgical procedures of “lengthening phalloplasty” are characterized by poorly defined indications and an unacceptably high rate of complications, as recently outlined by a literature review, while non‐surgical techniques are largely popularized by the media but often lack scientific evidence. In the literature we found only ten articles/abstracts of studies pertaining to the topic of our review. With our review, we aimed to explore whether non‐surgical methods of penile lengthening may have some scientific background. We focused specifically on penile extenders, which among conservative methods are those whose efficacy is supported by some scientific evidence. It seems that penile traction devices should be proposed as the first‐line treatment option for patients seeking a penile lengthening procedure. Penile size is a matter of great interest among men who are affected by ‘short penis syndrome’ or just believe themselves to have a small penis, even though the dimensions of the organ fall within the normal range. Surgical procedures of ‘lengthening phalloplasty’ lack standardized indications and carry a high risk of complications. Several non‐invasive methods of penile lengthening have been described, such as vacuum devices, penile traction devices and penoscrotal rings; even ‘physical exercises’ have been popularized through the media. Most of these techniques, however, are not supported by any scientific evidence. We briefly analyse the efficacy and scientific background of such non‐surgical methods of penile lengthening. It seems that penile extenders represent the only evidence‐based technique of penile elongation. Results achieved do not seem to be inferior to surgery, making these traction devices an ideal first‐line treatment option for patients seeking a penile lengthening procedure.     

Bone graft osteogenesis -- fact or fiction?

It has been argued in this journal (Souza-Ramos, 1980) that the term "bone graft" is inappropriate, as the cells of a transplanted autologous fragment of bone do not contribute directly to new bone formation. In the present paper, experimental evidence that the living cells of an autologous bone graft can contribute directly to osteogenesis is discussed and it is concluded that, although the graft osteocytes do not play a part in new bone formation, endosteal and periosteal cells do so. Thus a bone graft is a living tissue whose cells can make a direct contribution to healing.