Santulli Procedure Revisited in Congenital Intestinal Malformations and Postnatal Intestinal Injuries: Preliminary Report of Experience

In our experience, the Santulli procedure (SP) can improve bowel recovery in congenital intestinal malformations, necrotizing enterocolitis (NEC), and bowel perforation. All cases managed at our institution using SP between 2012 and 2017 were included in this study. Forty-one patients underwent SP (median age: 39 (0–335) days, median weight: 2987 (1400–8100) g) for intestinal atresia (51%, two gastroschisis), NEC (29%), midgut volvulus (10%), Hirschsprung’s disease (5%), or bowel perforation (5%), with at least one intestinal suture below the Santulli in 10% of cases. The SP was performed as a primary procedure (57%) or as a double-ileostomy reversal. Anal-stool passing occurred within a median of 9 (2–36) days for 95% of patients, regardless of the diversion level or the underlying disease. All three patients requiring repeated surgery for Santulli dysfunction had presented with stoma prolapse (p < 0.01). Stoma closure was performed after a median of 45 (14–270) days allowing efficient transit after a median of 2 (1–6) days. After a median follow-up of 2.9 (0.7–7.2) years, two patients died (cardiopathy and brain hemorrhage), full oral intake had been achieved in 90% of patients, and all survivors had normal bowel movement. Whether used as primary or secondary surgery, the SP allows rapid recovery of intestinal motility and function.

Extensive penile skin necrosis after surgery for Peyronie's disease

The clinical case represents the surgical correction of postoperative complications in a patient with Peyronie's disease. The patient underwent flap corporoplasty using an autovein. The late postoperative period in the patient was complicated by extensive necrosis of the penile skin, which required repeated surgery as follows. The first stage of surgical treatment was performed by excision of necrotic tissues of the penile skin. Within 10 days of the postoperative period, chymotrypsin with an ointment containing dioxomethyltetrahydropyrimidine with chloramphenicol was applied to the penile wound surface to prepare the wound for subsequent skin autotransplantation. Further, within 5 days, the polymeric drainage sorbent «Aseptisorb DT» was applied to the wound surface until the wound was cleansed and granulation tissue was formed. The second stage of the surgical treatment performed penile skin replacement plasty with a free perforated skin graft taken from the patient's femoral surface.

Pretarsal orbicularis oculi muscle tightening with skin flap excision in the treatment of lower eyelid involutional entropion

Background To evaluate a modified technique for involutional entropion correction in a retrospective cohort study. Methods The patients with involutional entropion eyelid were corrected by tightening the pretarsal orbicularis oculi muscle and excising the excess skin of the lower eyelid. The patients received correction surgery from April 2013 to March 2019 were followed up for more than 6 months postoperatively. The outcome measures included the complications and the recurrence rates. Results Total 152 patients (169 eyes) were included. The mean follow-up period was 29.6 months (range: 6–36 months). Postoperative ectropion (over-correction) was observed in 1 patient with 1 eyelid (0.59%); yet, no further surgery was needed for this patient. Recurrence of entropion was found in 1 patient (0.59%). The patient with recurrent entropion received repeated surgery with the same method and achieved a good eyelid position. Conclusions This study demonstrated that tightening the pretarsal orbicularis oculi muscle and excising the excess skin of the lower eyelid could be an effective surgical method to correct lower eyelid involutional entropion. This method is technically easy with a low recurrence rate and not associated with significant complications in Asians.

Postoperative external beam radiotherapy for locoregional control in iodine refractory differentiated thyroid cancer

Background: The role of postoperative external beam radiotherapy (EBRT) in patients with residual iodine refractory differentiated thyroid cancer (IR-DTC) is still inconclusive. The aim of this retrospective study was to evaluate locoregional control (LRC) and overall survival (OS), and potential side effects after postoperative EBRT for both microscopic and macroscopic non-radically resected locally advanced IR-DTC. Methods: Between 1990 and 2016, 49 patients with locally advanced IR-DTC received EBRT for microscopic (R1; n=28) or macroscopic (R2; n=21) locoregional residual disease. For more insight into the added effect of EBRT we performed an intra-patient sub-analysis in 32 patients who had undergone more than one surgical intervention, comparing LRC after primary, curative-intended surgery with LRC after repeated surgery plus EBRT. To estimate LRC and OS we used Kaplan Meier curves. From 2007 onwards, we prospectively recorded toxicity data in our head and neck cancer database (n=10). Results: LRC rates five years after EBRT were higher for R1 (84.3%) than for R2 (44.9%) residual disease (p=0.016). The five-year OS rate after EBRT was 72.1% for R1 and 33.1% for R2 disease (p=0.003). In the intra-patient analysis (n=32) LRC rates were 6.3% five years after only initial surgery, and 77.9% after repeated surgery with EBRT (p=<0.001). Acute toxicity was limited to grade I and II xerostomia, mucositis, and hoarseness; only one patient developed late grade III dysphagia. Conclusions: Postoperative EBRT is associated with long-lasting locoregional control and overall survival with acceptable toxicity in patients with locally advanced IR-DTC, especially in microscopic residual disease.

Orthostatic hypotension after cervicomedullary junction surgery: illustrative case

BACKGROUND Surgery at the cervicomedullary junction carries a risk of damaging vital brainstem functions. Because the nucleus of the solitary tract (NS) is involved in the baroreceptor reflex, damage to its integrity may lead to orthostatic hypotension. OBSERVATIONS A 56-year-old man with a medical history of hypertension, von Hippel-Lindau disease, and previous bilateral adrenalectomy due to pheochromocytoma was referred with symptoms of dysphagia and paralysis of the left vocal cord. Paralysis of the left vagus nerve was suspected. Magnetic resonance imaging revealed a contrast-enhancing cystic process in the cervicomedullary junction. Twenty-three years earlier, the patient had undergone surgical treatment for a hemangioblastoma in the same region. After repeated surgery, the patient temporarily developed orthostatic hypotension. At discharge, the patient no longer needed antihypertensive medication. LESSONS Surgery near the cervicomedullary junction can affect the NS, leading to disruption of the baroreceptor response that regulates blood pressure.

Case Report: Targeted Therapy for Metastatic Solid Pseudopapillary Neoplasm of the Pancreas With CTNNB1 and PTEN Mutations

BackgroundSolid pseudopapillary neoplasm (SPN) of the pancreas shows an indolent clinical behavior in cases undergoing surgical resection. The efficacy of combination therapy in the metastatic extrapancreatic SPN treatment remains largely unknown and a clinical challenge.Case PresentationWe report a case of a metastatic pancreatic SPN in a 45-year-old woman who presented with an aggressive peritoneal dissemination and hepatic metastases and still showed an indolent clinical course with combination therapy with repeated surgery and targeted therapy. Although the follow-up effect remains to be seen, this is the first report of practical experience of the targeted agents sunitinib and everolimus in metastatic SPN tumors based on the mutation status of PTEN (c.379G&gt;A; p.G127R) and CTNNB1 (c.98C&gt;G; p.S33C). To our knowledge, the PTEN variant identified in this case has not been previously reported in SPN.ConclusionEvidence on variant genetics indicates that future molecular studies may not only help to explain the mechanism of SPN occurrence and development but are also more likely to direct to future precision treatments.

Current trends in the treatment of acetabular fractures (literature review)

Acetabular fractures are known for their disabling outcomes, so the search for optimal treatment tactics is an actual problem for modern orthopedics and traumatology. Materials and methods. Randomized trials that reflect the results of acetabular fractures treatment depending on the method of treatment were analyzed. The literature was searched in the PubMed Central database. Hip joint is a complex two-component articulated system. Traumatic lesion of all elements of the joint creates the conditions for the development of a wide range of complications and secondary changes that must be taken into account at preoperative treatment. Aceta­bular fracture is an intra-articular injury, where the visualization methods have the prominent significance. Nowadays the treatment can be conservative and surgical. Surgical treatment can be divided into two areas: osteosynthesis and arthroplasty. Anatomical reposition and stable fixation of fragments, in the most of cases, is the key to a satisfactory functional result, but the development of post-traumatic changes in the joint nullifies the results of even perfect osteosynthesis, encourages repeated surgery and, finally, hip replacement. In recent years, primary arthroplasty has been successfully used to treat acetabular fractures, reducing inpatient and rehabilitation period, compared with osteosynthesis, preventing the possible development of secondary degenerative changes in the joint. Conclusions. Acute hip replacement is an effective treatment, however, the technical aspects of reliable fixation of the ace­tabular component of the implant are insufficiently substantiated and highlighted in actual literature and constitute significant research interest.

Treatment of patients with complicated fractures of the distal humerus using the fixators of limited-contact multiplanar osteosynthesis

Treatment of distal humerus fractures is a complex problem in traumatology. The result of treatment depends on the choice of fixator according to the fracture area. Objective. To improve the techno­logy of treatment in patients with complicated distal humerus fractures with fixators of small contact and multiplanar osteosynthesis and to evaluate its efficacy. Methods. 39 patients were treated for the period 2000–2020 with distal humerus nonunion (types 12-B1, 12-C1, 12-C2) and 23 patients with complicated above- and transcondylar humerus fractures (types 13-A2, 13-C1, 13-C2). Fixation of bone fragments of the distal humerus was made with device for fixation (Patent 17502 UA). It is a shaped plate with a groove on which half rings with threaded holes are stabilized. For the osteosynthesis of above- and transcondylar humerus fractures we used V-shaped plate with the possibility to regulate branch spreading width as for the condylar size (Patent 33358 UA). Autografting was performed as for necessity. Results. Plate osteosynthesis was performed mainly through anterior approach with minimal tissues traumatization. Release of radial nerve we made as for necessity. This device provides the stable fixation even in a case of short distal fragment. Device for bone fragments fixation was placed on the posterior condylar surface and lower part of the humerus through olecranon osteotomy. Osteosynthesis with suggested device is one of the options with bone autografting and can be method of choice at repeated surgery. Follow-up period was 1–2 years and later. In 60 patients we obtained good results with completed bone union. Conclusions. Suggested device can be used in cases of distal humerus nonunion. It allows to decrease the damage of surgery, to avoid many complications. Key words. Complicated fractures of the distal humerus, devices for limited-contact multiplanar osteosynthesis.

Differentiated approach to radical surgical treatment of elderly patients with tumor diseases of the pancreatoduodenal zone

BACKGROUND: In recent years, there has been a widespread increase in the incidence of tumors of the pancreatoduodenal zone, especially noticeable in the older age group. A decrease in the incidence of postoperative complications and mortality after pancreatoduodenal resection made it possible to expand the indications for surgical treatment of elderly and senile patients. AIM: Improvement of the immediate results of pancreatoduodenal resection in the treatment of elderly and senile patients suffering from tumor diseases of the pancreatoduodenal zone. MATERIALS AND METHODS: Pancreatoduodenal resection was performed in 61 elderly and senile patients with tumors of the pancreatoduodenal zone. The main group consisted of 32 patients, whose treatment was carried out in accordance with the developed algorithm for choosing a method for forming a pancreatodigestive anastomosis based on a scale for assessing the risk of developing pancreatic fistulas. The comparison group consisted of 29 patients in whom the method of forming a pancreatodigestive anastomosis was carried out in accordance with the preferences of the operator without taking into account the risk of developing a pancreatic fistula. RESULTS: In the main group, compared with the control group, pylorus-saving interventions were performed significantly more often 27 (84.4%) and 14 (48.3%) (p 0.01). There was also a decrease in the frequency of performing pancreaticojejunostomy 16 (50%) and 22 (75.9%) (p 0.05), due to the use of reservoir terminolateral pancreatojejunostomy 8 (25%) and 0, respectively (p 0.01). Postoperative complications were observed in 14 (43.8%) of the study group and in 21 (72.4%) patients of the comparison group (p 0.05). There was also a decrease in the incidence of postoperative pancreatic fistulas from 8 (27.6%) to 2 (6.2%) (p 0.05) in the study group. Repeated surgery was required in 5 (15.6%) patients of the main group and 11 (37.9%) in the comparison group (p 0.05). The lethal outcome was recorded in 3 (9.4%) patients of the main group and in 7 (24.1%) in the comparison group (p 0.05). CONCLUSIONS: The results of performing pancreatoduodenal resection in the treatment of elderly and senile patients can be comparable with the results of treatment of the general population. The use of the developed algorithm made it possible to reliably reduce the incidence of complications from 72.4 to 43.8% (p 0.05), postoperative pancreatic fistulas from 27.6 to 6.2% (p 0.05), as well as the frequency of repeated interventions. from 37.9 to 15.6 % (p 0.05). In addition, a downward trend in mortality was achieved from 24.1% to 9.4%.