International survey and surgeon's preferences in diagnostic work-up towards treatment of anterior shoulder instability.

PURPOSE: Recurrent anterior shoulder instability after surgical treatment can be caused by bony defects. Several diagnostic tools have been designed to measure the extent of these bony lesions. Currently, there is no consensus which measurement tool to use and decide which type of surgery is most appropriate. We therefore performed an evaluation of agreement in surgeons' preference of diagnostic work-up and surgical treatment of anterior shoulder instability. METHODS: An international survey was conducted amongst orthopaedic shoulder surgeons. The survey contained questions about surgeons' experience, clinical and radiological examination and the subsequent treatment for anterior shoulder instability. Descriptive statistics were used to present the data, and percentages of responding surgeons were calculated. RESULTS: The questionnaire was completed by 197 delegates from 46 countries. 55 % of the respondents think evidence in current literature is sufficient on diagnostic work-up for anterior shoulder instability. Anamnestic, number of dislocations was most frequently asked (by 95 % of respondents), the most frequently used test is the apprehension test (91 %). For imaging, conventional X-ray in various directions was most performed, followed by MR arthrography and plane CT scan respectively. The responding surgeons perform surgery (labrum repair or Latarjet) in 51 % of the patients. A median of 25 % glenoid bone loss was given by the respondents, as cut-off from when to perform a bony repair. CONCLUSION: Many different diagnostic examinations for assessing shoulder instability are used and a high variety is seen in the use of diagnostic tools. Also no consensus is seen in the use of different surgical options (arthroscopic and open procedures). This implies the need for more research on diagnostic imaging and the correlation with specific subsequent surgical treatment. LEVEL OF EVIDENCE: Survey, level of evidence IV.

A new accurate method of physical examination for differentiation of inguinal hernia types.

BACKGROUND: It is generally stated that preoperative differentiation between indirect and direct inguinal hernias by physical examination is inaccurate and irrelevant. With the expansion of the laparoscopic technique, new relevance has emerged. Laparoscopic correction of an indirect hernia is more challenging and time consuming than laparoscopic correction of a direct hernia. Preoperative knowledge concerning the type of hernia informs the laparoscopic surgeon about the required expertise and the expected operative time, and this knowledge is useful for training programs and management. The authors therefore developed a new accurate and easy method of physical examination to differentiate types of inguinal hernia. A prospective study was conducted to determine the accuracy of this new method that combines physical examination with a hand-held Doppler device (not ultrasound) to differentiate types of inguinal hernia. METHODS: This prospective diagnostics study consisted of two consecutive parts. Each part included 100 consecutive patients presenting with an inguinal hernia. The inguinal occlusion test was used to differentiate the types of inguinal hernia during physical examination in the first part of the study. A hand-held Doppler device was used for adequate localization of the epigastric vessels in addition to the occlusion test in the second part of the study. Preoperative remarks were compared with findings during laparoscopic inguinal hernia repair. The McNemar symmetry χ (2) test was used for statistical evaluation RESULTS: The first part of the study showed a preoperative accuracy of 35 % for direct inguinal hernias and 86 % for indirect inguinal hernias (p < 0.001). The second part of the study showed a preoperative accuracy of 79 % for direct inguinal hernias and 93 % for indirect inguinal hernias (p < 0.001) CONCLUSION: The inguinal occlusion test combined with the use of a handheld Doppler device is accurate in distinguishing direct and indirect inguinal hernias and provides useful management information in laparoscopic inguinal hernia repair.

Oncologic colorectal resection, not advanced endoscopic polypectomy, is the best treatment for large dysplastic adenomas.

INTRODUCTION: Endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), and partial circumference resection are used for large benign polyps to avoid an "Oncologic" Colorectal Resection (OCR); polyps with invasive cancer require OCR. This review of polyp patients who had OCR was done to stratify polyps into risk groups to guide treatment. METHODS: Colonoscopy, operative, and pathology reports of patients with adenoma (+/- dysplasia) who had OCR were reviewed. Polyp size, location, and pathology were assessed. RESULTS: Three hundred eighty-six polyp patients who had OCR were studied. Polyp locations were: right, 263 (68.1%); transverse, 33 (8.6%); sigmoid, 38 (9.8%); rectum, 23 (6.0%); and multiple sites, 13 (3.4%). The preoperative diagnosis was adenoma for 288 (74.6%) and dysplastic adenoma for 98 patients (25.4%). Final pathology revealed 62 invasive cancers (16.1%); 35% (34 out of 98) with dysplasia preoperatively had cancer versus 9.7% (28 out of 288) with adenoma alone (p < 0.0001). The mean lymph node count was 16.0 ± 10.2. Cancer stage breakdown was: stage 1, 74%; stage 2, 8.1%; stage 3, 16%; and stage 4, 1.6%. The mean benign polyp size was 3.0 ± 1.9 versus 3.9 ± 2.4 cm for malignant polyps (p = 0.0008). CONCLUSION: Over one out of three of dysplastic polyps and 10% of adenomas were invasive cancers. OCR is advised for dysplastic polyps; ESD, EMR, and wedge resection are appropriate for non-dysplastic adenomas.