Background/Aims: There are no consensus guidelines for patients with acute cholecystitis undergoing percutaneous cholecystostomy who are unfit for interval cholecystectomy. The current study aimed to ...compare the clinical outcomes of endoscopic gallbladder drainage, i.e. conversion from percutaneous cholecystostomy (including endoscopic transpapillary gallbladder stenting and endoscopic ultrasound-guided gallbladder drainage), and conservative treatment after percutaneous cholecystostomy tube removal.
Methods: This retrospective review included patients who underwent percutaneous cholecystostomy for acute cholecystitis between January 2017 and December 2020. Consecutive patients who underwent endoscopic gallbladder drainage or percutaneous cholecystostomy tube removal without interval cholecystectomy were included. Outcome measures included recurrent acute cholecystitis and unplanned readmission due to gallstone-related diseases.
Results: During the study period, 238 patients were selected (63 underwent endoscopic gallbladder drainage conversion and 175 underwent conservative treatment). Patients who underwent endoscopic gallbladder drainage conversion had lower rates of recurrent acute cholecystitis (3 4.76% vs 31 17.71%, p=0.012) and unplanned readmission due to gallstone-related diseases (6 9.52% vs 40 22.86%, p=0.022) than those who underwent conservative treatment following percutaneous cholecystostomy tube removal. In the univariate and multivariate analyses, calculus cholecystitis (odds ratio, 13.75; 95% confidence interval, 1.83 to 102.83; p=0.011) and conversion of endoscopic gallbladder drainage (odds ratio, 0.23; 95% confidence interval, 0.06 to 0.78; p=0.019) were significant predictive factors for recurrent acute cholecystitis.
Conclusions: Endoscopic gallbladder drainage conversion led to more favorable outcomes than conservative treatment after percutaneous cholecystostomy tube removal. Therefore, endoscopic gallbladder drainage conversion may be considered a promising treatment option for patients undergoing percutaneous cholecystostomy who are at a high surgical risk. (Gut Liver 2024;18:348-357)
Desmoid tumors (DTs) are rare benign neoplasms but cause significant mortality due to their locally infiltrative nature and propensity to recur. Most DTs occur in the extremities and trunk. Head and ...neck DTs are uncommon but can have a significant impact on a patient's facial appearance. However, there is limited information available about the diagnosis and treatment for multiple DTs located in head and neck. We report the first case of multiple maxillofacial DTs in a 14-year-old boy. He had painless submandibular masses for three months and MRI imaging reveals abnormal high signals on the submandibular and bilateral zygomatic regions. Considering facial aesthetics, via intraoral incision we obtained a biopsy from the largest mass. Pathological examination confirmed a diagnosis of DT. We selected the wait-and-see strategy and clinically monitored the rest of the masses. During the subsequent 1-year follow-up, the masses were stagnant and appeared to involute. According to the development and outcome of this case, a conservative treatment for craniofacial DTs is suggested; however, greater clarity concerning management and prognosis could derive from prospective study of a larger patient cohort in the future.
Introduction: This study aims to find the predictive factors of acute pyogenic spondylitis that resist conservative treatment.Methods: We studied 76 cases (men: 49 and women: 27, average age: 74 ...years, average follow-up period: 198 days) of acute pyogenic spondylitis where conservative treatment was followed. Subjects were compared by dividing into groups R of 30 and NR of 46 cases with and without resist of conservative treatment, respectively.Results: Average of age, men, periods from medical institution consultation to a diagnosis, the number of the infected vertebral bodies, compromised host, infection progress case of the MRI and resistant bacteria in groups R and NR were 76 and 72 years old, 20 and 29 cases, 7.4 and 8.3 days, 2 and 1.7 vertebral bodies, 20 and 23 cases, 9 and 14 cases, 7 and 8 cases, respectively. Notable differences were observed in the number of infected vertebral bodies. The average of body temperature at the first examination, 1 week, 2 weeks, 3 weeks, and 4 weeks after treatment, were 38.5°C and 38.6°C, 37.3°C and 37.2°C, 36.9°C and 37.0°C, and 37.0°C and 36.9°C, and 36.9°C and 36.8°C, respectively. The average of WBC at the first examination, 1 week, 2 weeks, 3 weeks, and 4 weeks after treatment were 10,847 and 13,776, 8,253 and 9,254, 8,011 and 7,533, 6,370 and 6,460, and 6,642 and 6,639 μL, respectively. Notable difference was observed in the WBC of the first examination. Average of CRP at the first examination, 1 week, 2 weeks, 3 weeks, and 4 weeks after treatment were 15.0 and 15.7, 8.6 and 6.4, 5.4 and 3.0, 5.4 and 2.9, and 4.8 and 1.9 mg/dl, respectively. Notable differences were observed among the CRP of 1 week, 2 weeks, 3 weeks, and 4 weeks after treatment. Using the multiplex logistic-regression analysis, only CRP of 4 weeks was notably different and the cutoff level was CRP = 2.0 mg/dl.Conclusions: Acute pyogenic spondylitis that resists conservative treatment was predictable using CRP of 4 weeks after treatment and the cutoff level was CRP = 2.0 mg/dl.
OBJECTIVE:The aim of this meta-analysis was to summarize the current available evidence on nonoperative management (NOM) with antibiotics for uncomplicated appendicitis, both in adults and children.
...SUMMARY BACKGROUND DATA:Although earlier meta-analyses demonstrated that NOM with antibiotics may be an acceptable treatment strategy for patients with uncomplicated appendicitis, evidence is limited by conflicting results.
METHODS:Systematic literature search was performed using MEDLINE, the Cochrane Central Register of Controlled Trials, and EMBASE databases for randomized and nonrandomized studies comparing antibiotic therapy (AT) and surgical therapy-appendectomy (ST) for uncomplicated appendicitis. Literature search was completed in August 2018.
RESULTS:Twenty studies comparing AT and ST qualified for inclusion in the quantitative synthesis. In total, 3618 patients were allocated to AT (n = 1743) or ST (n = 1875). Higher complication-free treatment success rate (82.3% vs 67.2%; P < 0.00001) and treatment efficacy based on 1-year follow-up rate (93.1% vs 72.6%; P < 0.00001) were reported for ST. Index admission antibiotic treatment failure and rate of recurrence at 1-year follow-up were reported in 8.5% and 19.2% of patients treated with antibiotics, respectively. Rates of complicated appendicitis with peritonitis identified at the time of surgical operation (AT21.7% vs ST12.8%; P = 0.07) and surgical complications (AT12.8% vs ST13.6%; P = 0.66) were equivalent.
CONCLUSIONS:Antibiotic therapy could represent a feasible treatment option for image-proven uncomplicated appendicitis, although complication-free treatment success rates are higher with ST. There is also evidence that NOM for uncomplicated appendicitis does not statistically increase the perforation rate in adult and pediatric patients receiving antibiotic treatment. NOM with antibiotics may fail during the primary hospitalization in about 8% of cases, and an additional 20% of patients might need a second hospitalization for recurrent appendicitis.
Background: Generally presents in childhood, orbital lymphangioma is an uncommon unencapsulated vascular malformation of the lymphatic system. These benign cystic lesions represent 1%-4% of all ...orbital masses and may appear after an upper respiratory infection or minor trauma. Because of its nature, the management can be challenging and depends on the clinical presentation. We report an 8-year-old boy with orbital lymphangioma presented with acute proptosis. Then, we discuss different features of this disorder plus its management Case Presentation: An 8-year-old boy was presented with sudden left eye proptosis. He had normal visual acuity and color vision without ocular pain or diplopia. An infiltrative and diffused intraconal plus extraconal mass was detected in orbital computed tomography. Contrast-enhanced MRI revealed a multilobulated infiltrative heterogeneous lesion with fluid-fluid levels. The diagnosis was made on imaging, and he went under treatment with an oral corticosteroid. The symptoms were entirely resolved, and no recurrence occurred during the follow-up. There are several surgical and nonsurgical therapies for orbital lymphangioma. Still, the priority is conservative management, such as sclerotherapy (including OK-432, doxycycline, sodium tetradecyl sulfate, etc.), bleomycin, carbon dioxide laser, systemic corticosteroids, and so on. Conclusions: In most cases, the current imaging methods make a noninvasive diagnosis of orbital lymphangioma possible. Conservative management should be considered the first treatment.
The objective was to characterize the growing body of literature regarding nonoperative management of blunt thoracic aortic injury (BTAI).
A systematic search of MedLine, Embase, and Cochrane Central ...was completed to identify original articles reporting injury characteristics and outcomes in patients with BTAI managed nonoperatively during their index hospitalization. Article title and abstract screening, full-text review, and data abstraction were performed in duplicate, with discrepancies resolved by a third reviewer. The quality of each study was evaluated using the Oxford Centre for Evidence-Based Levels of Evidence.
Of 2162 identified studies, 74 were included and reported on 8606 patients with BTAI who were managed nonoperatively between 1970 and 2016. Only one study was prospective. The median nonoperative sample size per study was 11 patients. The characterization of aortic injury grade differed across studies. Follow-up varied widely from 1 day to 118 months. Injury healing or improvement on follow-up imaging occurred in 34% (226 of 673 patients; reported in 37 studies), most often in the context of grade I intimal injury. Injury progression or requirement for a thoracic endovascular aneurysm repair for injury progression was 7.6% (66 of 873 patients; reported in 46 studies). A total of 37 studies reported aortic-related death, with an overall rate of 4.5% (37 of 827 patients) and a rate of 1% in grade I and II injuries (1 of 153 patients) and 18% in grade III and IV (9 of 50 patients).
An increasing number of reports support nonoperative management of grade I intimal injury, consistent with Society for Vascular Surgery guidelines. However, a retrospective interpretation of the determinants of management, heterogeneous injury characterization, and variable follow-up remain major limitations to the informed use of nonoperative management across all BTAI grades.
Background and purpose - Following the outbreak of COVID-19 in December 2019, in China, many hip fracture patients were unable to gain timely admission and surgery. We assessed whether delayed ...surgery improves hip joint function and reduces major complications better than nonoperative therapy.
Patients and methods - In this retrospective observational study, we collected data from 24 different hospitals from January 1, 2020, to July 20, 2020. 145 patients with hip fractures aged 65 years or older were eligible. Clinical data was extracted from electronic medical records. The primary outcomes were visual analogue scale (VAS) score and Harris Hip Score. Major complications, including deep venous thrombosis (DVT) and pneumonia within 1 month and 3 months, were collected for further analysis.
Results - Of the 145 hip fracture patients 108 (median age 72; 70 females) received delayed surgery and 37 (median age 74; 20 females) received nonoperative therapy. The median time from hip fracture injury to surgery was 33 days (IQR 24-48) in the delayed surgery group. Hypertension, in about half of the patients in both groups, and cerebral infarction, in around a quarter of patients in both groups, were the most common comorbidities. Both VAS score and Harris Hip Score were superior in the delayed surgery group. At the 3-month follow-up, the median VAS score was 1 in the delayed surgery group and 2.5 in the nonoperative group (p < 0.001). Also, the percentage of complications was higher in the nonoperative group (p = 0.004 for DVT, p < 0.001 for pulmonary infection).
Interpretation - In hip fracture patients, delayed surgery compared with nonoperative therapy significantly improved hip function and reduced various major complications.
Spontaneous Isolated Coeliac Artery Dissection (SICAD) is a rare disease with few reports of management strategies. This study reports the mid- to long-term outcomes of conservative management and ...endovascular intervention of SICAD treatment.
Sixteen patients presenting with symptomatic SICAD from September 2006 to October 2018 were reviewed retrospectively. The clinical manifestations, initial radiological findings, methods of treatment, and serial follow up studies were analysed.
The mean age of the patients was 51.2 ± 7.9 years, with a median follow up of 33.3 (range 1.0–118.9) months. Four patients received early intervention because of aneurysmal dilatation or distal hypoperfusion. Four patients who received conservative management showed progression of disease and were recommended for delayed intervention. Although collaterals prevented further hepatic ischaemia, one of these four patients failed in delayed intervention because of extensive thrombi completely occluding the hepatic artery. In the remaining eight patients who were managed conservatively, three (37.5%) showed regression of disease, one (12.5%) showed partial regression, and five (62.5%) showed no change in intimal flap or thrombosis, but all had symptomatic improvement. The median follow up duration for the seven patients who underwent successful intervention was 77.3 (range 34.3–118.9) months, and all stenting remained patent during the follow up period.
Early intervention in symptomatic SICAD patients may be necessary in over 50% of patients, and endovascular stenting has durable long term outcomes.
OBJECTIVE:To assess the efficacy of conservative management of women with femoroacetabular impingement (FAI) using trunk stabilization.
DESIGN:Randomized controlled trial (level of evidenceI).
...SUBJECTS:Twenty FAI female patients who met the inclusion FAI criteria.
METHODS:A prospective, randomized, controlled study was performed on 20 female patients with symptomatic FAI comprising 2 groups (10 hips in trunk stabilization exercise group vs 10 hips in control group). We evaluated hip range of motion, isometric muscle strength using a handheld dynamometer (μ-TasMF-01; Anima, Co), and patient-reported outcome measures, including modified Harris hip score, Vail hip score, and international hip outcome tool 12 (iHOT12) before and at 4 weeks and 8 weeks after the intervention.
RESULTS:There was a significant improvement in the range of motion of hip flexion in the trunk training group detected as early as 4 weeks after the intervention compared with the control group (P < 0.05). Hip abductor strength significantly improved in the trunk training group at 4 weeks after the intervention, whereas it did not improve in the control group (P < 0.05). Vail hip score and iHOT12 were significantly increased at 8 weeks after the intervention in the trunk training group compared with the control group (iHOT1278.7 ± 22.4 vs 53.0 ± 22.3; P < 0.01, Vail hip score81.6 ± 18.5 vs 61.1 ± 11.6; P < 0.05). There was no significant difference in the modified Harris hip score between both the groups at 4 and 8 weeks after the intervention.
CONCLUSIONS:The addition of trunk stabilization exercise to a typical hip rehabilitation protocol improves short-term clinical outcomes and may augment nonoperative and postoperative rehabilitation.
Background and purpose - There are few reports on the outcome of distal radius fractures after 1 year. Therefore we investigated the long-term patient-reported functional outcome and health-related ...quality of life after a distal radius fracture in adults.
Patients and methods - We reviewed 823 patients, treated either nonoperatively or operatively in 2012. After a mean follow-up of 3.8 years 285 patients (35%) completed the Patient-Rated Wrist Evaluation (PRWE) and EuroQol-5D.
Results - The mean PRWE score was 11. The mean EQ-5D index value was 0.88 and the mean EQ VAS for self-rated health status was 80. Nonoperatively treated type A and type B fractures had lower PRWE scores compared with operatively treated patients, whereas the EQ-5D was similar between groups. The EQ VAS for patients aged 65 and older was statistically significantly lower than that of younger patients.
Interpretation - Patients had a good overall long-term functional outcome after a distal radius fracture. Patients with fractures that were possible to treat nonoperatively had less pain and better wrist function after long-term follow-up than patients who needed surgical fixation.
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