The role of the multidisciplinary team in surgical management of intractable tubo-ovarian abscess as a late sequelae of challenging Crohn's disease in the modern era: A case report and review of current literature

Chronic, severe Crohn's disease in a young female patient can result in surgical complexity. The rarity of the presentation of intractable pelvic abscesses within this etiology with additional considerations given to fertility concerns and hence requirement for input from a multi-disciplinary team makes this a vital case in building a consensus for evidence-based surgical management. A 29-year-old nulliparous woman was referred to our tertiary centre for surgical management of Crohn's disease with known tubo-ovarian abscess and abdominoperineal and abdominal wall sinuses. Her previous surgical history included 4 midline laparotomies, subtotal colectomy and proctectomy with stoma formation. The patient underwent egg collection to preserve fertility. This was followed by midline laparotomy and abdominoperineal resection, which involved a retrograde radical modified hysterectomy using the Hudson technique, alongside excision of the perineal sinus, with reconstruction of the perineal defect using an internal pudendal artery perforator gluteal fold flap, and in addition to excision and drainage of the abdominal wall abscess. Involvement was sought from gynecological oncology, colorectal, urology, plastics, stoma, fertility, microbiology, and gastroenterology teams, which enabled successful preservation of end organ function and improvement in patient psychological well-being. This case is a paradigm of surgical challenge, requiring expert gynecological oncology techniques including a retroperitoneal approach, nerve and vessel sparing considerations alongside colorectal and urological procedures. Moreover, we believe that our blueprint for effective multi-disciplinary practice will inform the future management of gynecological surgery. Therefore this report aims to contribute towards the optimum management of the gynecological sequelae of Crohn's disease.

Multipoint fixation with vascularised fibular bone graft and myotomy for atlanto-axial instability in cervical dystonia: a case report

Spinal instability is a challenging condition to manage in patients with cervical dystonia. Standard surgical stabilisation approaches may fail to cope with additional stress forces created by spasmodic muscles leading to construct failure either in the immediate or late post-operative period. Long-term stabilisation relies on the management of dystonic symptoms and adjunctive strategies to increase fusion success rate. We discuss the management of a challenging patient with translational C1/2 instability who had three metalwork failures with standard occipito-cervical fixation techniques within a 12 month period. A combined surgical approach using multipoint fixation, sternocleidomastoid myotomy and a vascularised fibular occiput-C2 bone graft successfully prevented further metalwork failure at over 2 years follow up.

A Systematic Review on Outcomes of Anterior Skull Base Reconstruction

INTRODUCTION

Anterior skull base resection often results in large defects that need to be reconstructed. This can be done using loco-regional, free flaps or both.

OBJECTIVE

The aim of this systematic review is to evaluate the surgical outcomes (mortality, complication rates and functional outcomes) for patients undergoing anterior skull base reconstruction.

METHODS

Electronic databases (MEDLINE, EMBASE and Scopus) were systematically searched for relevant articles from 1974 to March 2018. A total of 41 studies were included in this systematic review. No randomized controlled trials were identified; therefore, a meta-analysis was not performed.

RESULTS

Mortality from anterior skull base reconstruction were about 0-4% for loco-regional flaps while free flaps were around 0-7%. Overall complications ranged from 0% to 43% in loco-regional flaps, while rate of complications for free flaps ranged from 25% to 66.7%. Flap complications ranged from 0% to 14% for free flaps and 0% to 35% for local flaps. Quality-of-life measures did not differ significantly depending on surgical approach but were worse for patients with malignancies.

CONCLUSION

Due to varying standards of reporting of outcomes, lack of a standardized classification system for anterior skull base defects and absence of clinical trials, we were unable to perform a meta-analysis in this systematic review. Recommendations to guide future studies are proposed.

Ectropion following excision of lower eyelid tumours and full thickness skin graft repair

A retrospective review was performed to define the incidence of post operative lower eyelid ectropion after excision and full thickness grafting of lower eyelid tumours. In a 7-year period (1995-2001) 106 consecutive patients were identified who had undergone such surgery with mean follow-up period of 7.4 months (median 5 months, range 1-41.5 months). The majority of lesions were basal cell carcinomas 89/106 (84%). A total of 15/106 (14.2%) patients developed ectropion. The length of follow-up for patients with ectropion was on average 11.7 months (median 10 months, range 2-34 months). Ten patients underwent corrective surgery with five of these showing cosmetic and symptomatic improvement. Of five patients treated conservatively, three showed spontaneous improvement. The incidence of lower eyelid ectropion after lower eyelid skin grafting is defined and this does not seem to have been reported before for a consecutive series of patients. We offer a classification for eyelid zones with regard to ectropion and anatomical and pathological factors that may be important for ectropion formation are discussed. Finally we suggest a new classification of ectropion based on cosmetic and functional consequences.

Complex fractures of the distal humerus in the elderly. The role of total elbow replacement as primary treatment

Between 1995 and 2000, 19 consecutive patients with fractures of the distal humerus were treated by primary total elbow replacement using the Coonrad-Morrey prosthesis. No patient had inflammatory or degenerative arthritis of the elbow. The mean age at the time of injury was 73 years (61 to 95). According to the AO classification, 11 patients had suffered a C3 injury, two a B3 and two an A3. One fracture was unclassified. Two patients died from unrelated causes and one was unable to be assessed because of concurrent illness. The mean time to follow-up was three years (1 to 5.5). At follow-up 11 patients (68%) reported no pain, four (25%) had mild pain with activity and one had mild pain at rest. The mean flexion arc was 24 degrees to 125 degrees. The mean supination was 90 degrees (70 to 100) and pronation 70 degrees (50 to 110). No elbow was unstable. The mean Disabilities of the Arm, Shoulder and Hand score was 23 (0.92 to 63.3) and the mean Mayo elbow performance score was 93 (80 to 100). Of the 16 patients, 15 were satisfied with the outcome. Radiological evaluation revealed only one patient with a radiolucent line at the cement-bone interface. It was between 1 and 2 mm in length, was present on the initial postoperative radiograph and was non-progressive at the time of follow-up. Primary total elbow arthroplasty is an acceptable option for the management of comminuted fractures of the distal humerus in elderly patients when the configuration of the fracture and the quality of the bone make reconstruction difficult.

Complex fractures of the distal humerus in the elderly

Between 1995 and 2000, 19 consecutive patients with fractures of the distal humerus were treated by primary total elbow replacement using the Coonrad-Morrey prosthesis. No patient had inflammatory or degenerative arthritis of the elbow. The mean age at the time of injury was 73 years (61 to 95). According to the AO classification, 11 patients had suffered a C3 injury, two a B3 and two an A3. One fracture was unclassified. Two patients died from unrelated causes and one was unable to be assessed because of concurrent illness.

The mean time to follow-up was three years (1 to 5.5). At follow-up 11 patients (68%) reported no pain, four (25%) had mild pain with activity and one had mild pain at rest. The mean flexion arc was 24° to 125°. The mean supination was 90° (70 to 100) and pronation 70° (50 to 110). No elbow was unstable. The mean Disabilities of the Arm, Shoulder and Hand score was 23 (0.92 to 63.3) and the mean Mayo elbow performance score was 93 (80 to 100). Of the 16 patients, 15 were satisfied with the outcome.

Radiological evaluation revealed only one patient with a radiolucent line at the cement-bone interface. It was between 1 and 2 mm in length, was present on the initial postoperative radiograph and was non-progressive at the time of follow-up.

Primary total elbow arthroplasty is an acceptable option for the management of comminuted fractures of the distal humerus in elderly patients when the configuration of the fracture and the quality of the bone make reconstruction difficult.