Search

Subjective factors of the patient such as age, weight, occupation, expectations, etc. must be carefully evaluated in terms of surgery. It is always important to remember life expectancy, and the choice of a surgical procedure must be based on it. Limited survival and possible radiation therapy must eliminate methods that require long healing times: we no longer use bone grafts because the risk of healing time taking up too much of the time left for the patient is too high. Reconstructions must have an immediate solidity allowing early use of the limb. Thus, in the proximal femur, we above all use protheses (traditional or modular RPS); in acetabular lesions that do not involve the joint surface, our treatment of choice is curettage with liquid nitrogen and cement, armed with screws and nails. Prostheses, which are always cemented, are assembled using bipolar cups; cases where lysis is so wide on the cotyloid side as to require THR are rare. The cotyles, in cases such as these, are those that allow for anchoring with several sites (Octopus type), the McMinn or, at times, common cotyles in PE.

In the surgical treatment of metastatic lesions of the proximal humerus it is important to find solutions that eliminate pain and solve the mechanical problem in a short time and with reduced costs. In 90% of cases, intralesional curettage, freezing with liquid nitrogen and cement enhanced intramedullary instrumentation is capable of brilliantly solving the problems of these patients. When, instead, osteolysis involves the greater tuberosity and/or the joint region, resection of the proximal humerus followed by reconstruction with a modular prosthesis is indicated. Of those available on the market, the RPS system (LIMA) has features that make it equivalent to others, but at costs considerably lower. However, in reconstructions with prostheses, active abduction is significantly limited. A personal series of 20 patients is presented.

Trans-sternal closure of the bronchial stump is an effective procedure to treat bronchopleural fistula after pneumonectomy. The paper reports a modified video-assisted Abruzzini technique that, maintaining the same results, should determine a lower surgical risk. Three simultaneous approaches are used: cervical video-mediastinoscopy, right anterior parasternal mediastinotomy, left parasternal thoracoscopic access. The dissection of the bronchial stump is performed entirely through the mediastinotomy approach after having controlled mediastinal vessels. The bronchial stump reamputation is achieved by a roticulator endoGIA introduced through the cervicotomy either for the right or left fistulae. The technique proposed might reach the same result as the classic approach with lower surgical risks.

Localized fibrous tumor is an unfrequent mesenchymal neoplasm. The malignant variant of the pleura is exceptional and differential diagnosis with the more frequent benign type or with other neoplasms such as soft tissue sarcoma and mesothelioma is rarely possible in a preoperative setting. The best treatment of this disease is radical surgical resection. No definitive data exist about the role of chemotherapy. We report a case of a giant right intrathoracic mass whose preoperative diagnosis, from an open biopsy, was consistent with sarcoma and, in a second review, with fibrous tumor of the pleura without any indication about malignancy. A right pleuropneumonectomy and pericardial resection was performed through a right hemiclam-shell approach. Histology demonstrated an aggressive behaviour: high mitosis rate, Ki 67 of 34% and diffuse necrosis were present. In consideration of the apparent local radicality we did not perform any adjuvant treatment. Six months after the operation a wide local recurrence was evident and a systemic treatment with Ifosfamide and Adriamicina is still in progress. So far a good response has been documented. Preoperative diagnosis of malignancy has an important role as a therapeutic strategy in management of fibrous tumours of the pleura. When there is suspicion of a malignant form neoadjuvant chemotherapy can represent a further tool to control poorly differentiated and large tumors, and a wide surgical resection of the lesion must be performed.

Improvements in surgical equipment have rendered video-assisted thoracic surgery (VATS) an effective device for thoracic surgeons and nowadays several intrathoracic diseases can benefit from this approach. This development has expanded potential use and recently the technical feasibility of major lung resections by VATS has been demonstrated. The authors present their experience with a standard muscle-sparing utility thoracotomy (UT) utilized for all VATS procedures, including major lung resections.From November 1996 to October 1997, 30 patients were operated on. There were 22 males and 8 females (medium age 58 years; range 24-78). There were 13 anatomical lung resections (i.e.: 11 lobectomies, 1 left pneumonectomy, 1 segmental resection), 8 wedge resections, 3 lung biopsies, 2 debridements of pleural empyema, 2 mediastinal nodes biopsies, 1 esophageal resection for leiomyoma, 1 excision of benign mediastinal cyst.No mortality or major morbidity were recorded, as well as no rib fractures due to the rib spreader. Two patients suffered from prolonged air-leaks after respectively left upper lobectomy and lung biopsy and required prolonged chest drainage. Concerning anatomic major lung resections the medium hospital stay was 7.9 days and medium chest tube time was 5.6 days. The utility thoracotomy through the auscultatory triangle proved to be a safe approach and confirmed the technical feasibility of various type of surgical procedures with results comparable to standard open thoracotomy. Our data shows that VATS approach did not seriously affect the duration of hospital stay, chest tube time, the overall morbidity or lung function.As the real benefit of this approach remains controversial, the majority of the studies comparing the VATS approach to conventional muscle-sparing thoracotomy neither nor prospective nor randomized, and several parameters are difficult to evaluate in the literature further study are mandatory.

Two cases of infected aneurysms of the subrenal abdominal aorta observed in the last year are reported. In this study some specific aspects of this unusual pathology are analyzed: the high mortality rate, the difficulties involved in the diagnosis and the surgical solutions.

Consumption coagulopathy with clinical symptoms reveals aortic arterial aneurysms in less than 5% of cases. The authors report a case of abdominal aortic aneurysm: surgical repair is able to remove the hemostasis abnormalities for a long time. Implications of the consumption coagulopathy are analyzed: diagnosis, preoperative correction of the coagulopathy, surgical technique.

Percutaneous Transthoracic Needle Biopsy (PTNB) is an accepted technique for the diagnosis of suspected intrathoracic malignancy and, although the appropriate indications have not been clearly defined yet, its use has rapidly expanded in the last years. The authors reviewed retrospectively their experience over one-year time biopsies and analyzed some controversies regarding this diagnostic procedure.

Resection of pulmonary recurrences after pneumonectomy for metastases is exceptional. Nevertheless in carefully selected patients surgery on the residual lung might be successfully performed. From January 1987 to February 1996, 5 patients underwent metastasectomy on single lung after pneumonectomy performed for the same metastatic disease. There were 3 male and 2 female with a mean age of 38 years at the time of surgery on single lung. All patients had a FEV140%. One patient (n degree 1) had 2 consecutive operations (wedge resections) on the right lower lobe followed 17 months later by right inferior lobectomy for metastases of soft tissue sarcoma. Three patients had only an operation on the residual lung (patient n degree 2 had 2 wedge resections for carcinoma; patient n degree 3 had 7 wedge resections for carcinoma; patient n degree 4 had 6 wedge resections for osteogenic sarcoma). The last patient (n degree 5) had 2 wedge resections on the right upper lobe and a large wedge resection on the right lower lobe for metastases of malignant corticosurrenaloma using a cardiopulmonary femoro-femoral by-pass without cardiac arrest. She postoperatively developed a right lower lobe venous infarction treated subsequently with a completion right lower lobectomy. She died in the postoperative course from cardiorespiratory insufficiency. The other patients had an uneventful postoperative course. Two patients (n degree 2 and n degree 4) died of their disease 14 and 12 months respectively after the surgery on the residual lung; by contrast 2 patients (40%) (n degree 1 and n degree 3) are still alive without recurrences 36 and 27 months after the last resection. In selected patients aggressive surgery for metastases on the residual lung can be successfully performed but the benefits in terms of long-term disease-free survival remain to be determined.

Bronchioloalveolar carcinoma (BAC) is a subtype of adenocarcinoma of the lung that accounts for 3% of the total pulmonary malignancies. On the basis of literature on the topic, the following were taken into consideration, the history, the incidence, the epidemiology, the aetiopathogenesis, the clinical characteristics, the diagnostic as well as the surgical therapy of this kind of cancer. The authors reviewed our surgical experience of 23 patients treated at the Department of General, ThoracicVascular Surgery of the University of Parma during a 10-years period from 1985 to 1995.

A considerable difficulty in surgical management of apical chest tumors is represented by the potential involvement of the thoracic outlet anatomic structures (i.e.: vertebral body, subclavian vessels, first rib). Among the various techniques proposed, the anterior trans-cervical approach popularized by Dartevelle significantly improved the radical treatment of these tumors. This approach offers a wide access to the thoracic outlet with satisfactory control of subclavian vessels, safe dissection of brachial plexus and upper part of the mediastinum, permitting a radical treatment. However, this approach is associated invariably with aesthetic deformity, severe impairment in shoulder mobility (due to medial half clavicle sacrifice) and respiratory failure in case of chest wall resection. The authors present their experience with an alternative approach, the trans-manubrial osteomuscular sparing approach to anteriorly situated apical chest tumors recently standardized by Grunenwald and Spaggiari. From June 1996 to June 1997 5 patients were operated on through this approach: 3 non-small-cell lung cancer, 1 pseudotumor, 1 desmoid tumor of the first rib. In 2 cases the resection was extended respectively to the vertebral body (D1-2-3 hemivertebrectomy) and to the subclavian vessels. This patient died on 10-postoperative day for massive pulmonary ernbolism, whereas no other complications were recorded. This technique compared to the approach popularized by Dartavelle presents the same oncological radicality, with a better surgical exposure and with the complete sparing of osteomuscular components that allow the maintainance of shoulder girdle movements associated excellent functional and cosmetic results.

New applications of the video-assisted technique for the management of intrathoracic diseases continue to be developed, including major lung resections for cancer. The differences in the techniques proposed from various centers reflect the fact that the procedure is not accurately standardized yet and that prospective randomized trials with long-term follow-up data are needed. The authors report the results of their preliminary experience with a mini-invasive modern approach for video-assisted anatomic lobectomy: an utility muscle-sparing minithoracotomy through the auscultatory triangle. Eight patients successfully undergone this surgical procedure (7 for non-small cell lung cancer in early stage, 1 for benign disease). No mortality, nor complications (including minor morbidity: i.e. rib fractures) were recorded. Medium hospital stay time was 9.25 days (range 7-16) and chest drainage time 6 days (range 4-11). This operation proved to be technically feasible, although an accurate selection of patients and an adequate training in thoracoscopic procedures are mandatory. According to the more recent literature no significant differences are noted in operation's time, postoperative pain, chest drainage time, hospital stay compared to the standard posterolateral thoracotomy incisions. Otherwise the approach described enables to perform a truly "conservative" operation in conformity with the philosophy of the minimal invasive surgery and the patient's comfort and functional recover 2-3 weeks after surgery seems to be improved.

The preoperative diagnosis of the involvement of the N2 lymph nodes is very important in patients with NSCLC for the most appropriate treatment. The classical diagnostic techniques for mediastinal exploration, mediastinoscopy and left anterior mediastinotomy, have been recently integrated by videothoracoscopy. FromJanuary 1993 to April 1994 186 patients with NSCLC suitable for surgery, were observed in our Department. 18 patients (9%) had CT evidence of N2 disease. In 10 cases the sites of the nodal enlargement were the right paratracheal station (#2 according to Naruke) and the right tracheobronchial station (#4), in 4 the subcarinal station (#7), in 2 the subaortic (#5) and in the remaining 2 cases the paraaortic station (#6). 14 mediastinoscopies were performed to investigate the stations 2,4 and 7,2 videothoracoscopies for station 5 and 2 left anterior mediastinotomies for station 6. The histological diagnosis was obtained in all cases without intraoperative or postoperative complications. Because the sequence chemotherapy-surgery seems to obtain the best results in the treatment of N2 disease the preoperative diagnosis of nodal involvement is of outstanding importance. Until recently mediastinoscopy and anterior left mediastinotomy were considered the standard techniques to explore mediastinum, now also videothoracoscopy has been introduced. In our experience, the integration of all the above techniques allowed a complete study of each suspect N2 site. Particularly the videothoracoscopy is very useful to safely biopsy under direct vision the aortic window lymph nodes.

Primary pulmonary lymphomas are uncommon tumours arising from mucosa associated lymphoid tissue (MALT). The authors report a case diagnosed by transbronchial biopsy and treated by surgery only. They discuss the distinct clinicalpathological features and debate the different ways of treating this condition.

Postero-lateral thoracotomy is the standard access in thoracic surgery, and can be carried out dividing or preserving the serratus anterior muscle. This last method, besides its advantages, is still a matter of discussion, in fact traction has been claimed to cause severe muscular damage equal to section. We have studied 20 patients (16 males and 4 females, mean age 63 years), who underwent postero-lateral thoracotomy sparing the serratus anterior, after 6 months from surgery, both clinically and by means of electromyography (EMG), to evaluate the functional status of the spared muscles. In 4 cases (20%) there wasn't any neurogenic damage nor clinical evidence of winging scapula; 3 cases (15%) had medium neurogenic damage. The remaining 13 (65%) cases had a medium neurogenic damage and only one patient showed a winging scapula, neverthless being able to lift the arm to shoulder level. Our data confirmed that retraction during surgery does not damage the serratus anterior, leaving a functionally valid muscle.

In well selected cases, in which preoperative investigations allow us to plan a tracheal resection-anastomosis, surgery is the best current treatment also for secondary tumours involving the trachea. We report a case of a patient suffering from severe dyspnoea for tracheal stenosis due to recurrence of an epidermoid cancer of the tongue. Surgical treatment allowed us to obtain very good palliation.

Hepatic artery aneurysms are infrequent vascular lesions, difficult to diagnose preoperatively manifesting themselves usually by acute rupture. We report our experience in both diagnosis and surgical treatment of 3 cases. The selective angiograph of the celiac tripod and of superior mesenteric artery, is an indispensable means able, not only to put forward a certain diagnosis, but also to supply precious notions on the possibilities of compensation on the side of the collateral circle and of consequence, to suggest operative tactics. Surgical management may range from the simple binding to the reconstruction of the hepatic arterial axis by means of prosthesis grafts and if possible to the simple excision and termino-terminal regraft.

The Authors report a case of peritoneal echinococcal cyst and discuss the pathogenetic and clinical aspects as well as the diagnostic and therapeutic approaches of such a particular localization. They underline the need of a radical surgical treatment in order to definitively eliminate the parasite and the disease.

Chylopericardium as an isolated complication after open heart surgery is a rare event. We present here a case of late postoperative chylopericardium and comment on the clinical course, the aetiopathology and treatment.

Tracheobronchial disruption is one of the less common injury associated with blunt thoracic trauma and the diagnostic evaluation is often misleading. Early diagnosis and repair of these injuries are essential to minimize the risk of patient's death and his future respiratory performances. Mechanisms of injury, clinical presentation, diagnosis and management of 5 our patients are reviewed. The good results achieved encourage an aggressive approach in these disruptions that can be life threatening.

Chest wall tumors are rare being less than 1% of all the neoplasms. While the treatment of benign tumor and of solitary metastatic is standardized, the therapy of the primary malignant is not the same for all the authors. From January 1980 to December 1993 46 patients affected by chest wall neoplasms, 29 men (63%) and 17 women (37%), mean age of 51 yrs. (range 31-77 yrs.), were treated surgically. For benign tumors only resection was performed while for malignant and metastatic tumors after the resection the reconstruction was performed respectively: in 11 cases with Marlex mesh, in 1 case with the omentum, in 2 cases with Marlex and Methyl Methacrylate. Muscle transposition was performed in 1 case with pectoralis major covering a Dura Mater prosthesis. We have no peroperative death and no complications in 37 (80%) patients. Minor complications in 9 cases; in 1 case the sternal prosthesis was removed for infection. The median follow up was of 40.50 months. Actually the 48% of patients with primary and metastatic tumor are alive. From our results we conclude that the wide radical resection with reconstruction when necessary is the treatment of choice for the tumors of the chest wall.

To perform ambulatorial surgery with local anaesthetics, it is important to carry out a correct postsurgical NSAID therapy avoiding the risks induced by these drugs. Two groups of patients submitted to ambulatorial hemorrhoidectomy were enrolled in a randomized study to evaluate the safety of NSAID therapy with or without the coadministration of misoprostol, a PGE1 analogue with gastroprotective action. Aim of this study was to evaluate if misoprostol in coadministration with NSAID could permit a correct domiciliary postsurgical NSAID therapy without gastric symptoms related to the NSAID therapy. From January 1990 to December 1991, 95 patients underwent hemorrhoidectomy and were discharged with analgesic therapy: the first group (n = 45) without gastroprotective therapy, the second group (n = 50) with the coadministration of misoprostol 200 mcg bid. After 7 and 14 days of treatment patients showed the following symptoms: in the first group 13.3% of the cases showed mild epigastric pain, 8.8% moderate epigastric pain and 4.4% severe epigastric pain with heartburn; in the second group (NSAID + misoprostol) only 4% of the cases showed moderate epigastric pain. The incidence of epigastric pain was statistically higher (p0.05) in patients treated with NSAID alone in comparison with the group treated with NSAID + misoprostol. The results, according to international literature, show that correct gastro-protective therapy with synthetic prostaglandins (misoprostol) is necessary for patients in treatment with NSAIDs.

With the aim of studying the physiopathological mechanism of lung preservation, we have valued the Pneumocytes Type II viability after six hours of incubation at 4 degrees C in extracellular (Ringer Lactate) and intracellular (Collins, Euro-Collins and Belzer) solutions. The cells have been cut off from adult rat's lung using the modified Dobbs' method. Alveolar Type II viability have been valued using two methods: the total protein content in each culture and the metabolic function of the cells using the rate of protein synthesis by means of 35 S methionine uptake assay. The results have demonstrated a significant difference (p0.05) using extracellular solution instead of intracellular. Besides, we have observed a better Pneumocytes Type II survival during Belzer's solution incubation comparing with Collins and Euro-Collins (p0.05). Pneumocytes type II require for a better preservation a specific solution that must be similar to extracellular fluid and added with substances able to minimize noxious events during preservation.

The authors report the treatment of a case of contralateral spontaneous pneumothorax during single lung transplantation. This is a unusual complication that must be treated to avoid life-threatening problems. There is no consensus of opinion on therapeutic procedures. This work underline the success obtained with a simple thoracostomic drainage.

Thoracoscopy is the most important method for the diagnosis, and in particular cases for the treatment, of chronic pleural effusion of unknown aetiology. The Authors report their experience of 4 cases, 2 males and 2 females, that underwent a thoracoscopy from June to December 1992. The method was done in 3 cases in general anesthesia and in one case in local anaesthesia.

The recent development in thoracoscopic instrumentation has widely improved their surgical applications so to allow lung resection whether for diagnostic of therapeutic purpose. From June to December 1992, we performed 14 segmental atypical lung resections in 12 patients. The indications were: recurrent spontaneous pneumothorax due to bullae or blebs in 7 cases, solitary peripheric lung nodule in 6 cases, for diagnostic purposes in suspicious interstitial lung disease in one case. Lung resection were carried out using stapling device (EndoGIA). In the cases of solitary lung nodule, the frozen section confirmed the presence of metastases in 4 subjects and thus it was proceeded towards an exploratory mini-thoracotomy (3 cm long) so to allow a further palpatory video-assisted evaluation of the lung surface. The remaining 2 patients were diagnosed to have hamartomas. The wedge resection in the patient with interstitial lung disease allowed diagnosis of sarcoidosis. There were no postoperative complications, nor deaths. Video-thoracoscopic lung wedge resections are indicated for treating bullae and blebs while performing pleurectomy for spontaneous pneumothorax, for removing benign and metastatic peripheral lung nodules. The procedure is substantially diagnostic in case of interstitial lung diseases. It's important to underline that the therapeutic value of thoracoscopic approach for metastatic lung nodules has not proved to be less or more efficient than the thoracotomy one and for this reason further investigations are required.

The Authors present a case of post traumatic pseudocyst of the pancreas added to their observations and treated with an endoscopic cytogastric deviation. The incidence of such pathology has increased during the last few years thanks also to the improvement of the diagnostic techniques (TAC, U/S, Rm and eco-endoscopy) on hard today; in the second place the technological evolution has allowed, improving the diagnostic definition, the ability to heat pseudocysts, in selected patients, with minor surgery techniques with result equal to those of conventional surgery, but with complications and mortality decisively reduced. The morbidity and mortality rates of internal deviation surgery has respectively worsened varying between 21% and 50% and from 5% to 12%. The results of endoscopic deviations, even if the cases are less, report positive results from 80% to 100%, with complications and mortality greatly reduced. To be able to propose an endoscopic indication certain requirement are necessary of which one is indispensable: the distance between the two adjacent lumen must not be more than one centimeter. The Authors are of the opinion that such methods, in expert hand an on selected patients, should be the first surgical choice for the treatment of pancreatic pseudocysts.

The spastic pelvic floor syndrome, caused by a paradox contraction of the sphincteric apparatus at defaecation instead of relaxing, leads to constipation with difficult evacuation. Forty patients (15 males and 25 females, average age 49 years, age range 15-78) affected by serious chronic idiopathic constipation, underwent, at our Institute, from June 1989 to September 1990, the following instrumental examinations: anal manometry; electromyography of the pelvic floor; proctogram; intestinal transit time; anorectal endoscopy; in addition, in 6 cases at risk for colorectal cancer, left colonoscopy. Fifteen patients showed dyskinetic functioning of the voluntary sphincteric apparatus. The following diagnostic methods proved to be of fundamental importance: proctogram, which revealed failure to open of the anorectal angle at defaecation (mean values: at rest 88.93 degrees +/- 6.62; at defaecation 88.93 degrees +/- 9.44); electromyography of the pelvic floor, which showed the anomalous contraction of the external anal sphincter. These patients were treated by means of an air inflated endoampullary balloon to evoke the sensation of a stool and its subsequent expulsion. The correct evacuating function was resumed definitely in 9 patients (60%); for the remaining 6 patients, regular sessions of re-education are still necessary. The spastic pelvic floor syndrome is a major cause of constipation and requires an accurate diagnostic method of investigating the correct functioning of the recto-pelvic region by means of the above-mentioned methods.(ABSTRACT TRUNCATED AT 250 WORDS)

In the period between May and October 1992 we have admitted in our department 14 patients (M/F: 11/3) with recurrent spontaneous pneumothorax, being the entity more than 40% in 8 of them. All the patients were treated with video-assisted thoracoscopic pleurectomy, beginning from the 2nd to the 6th rib, completing by abrasing the further ribs below. Whenever the causative bullae or blebs were found, those were resect using and endoGIA. At the end of the procedure a pleural drain (no. 24) was positioned and maintained on suction until a complete lung reexpansion was ensured for at least a couple of days. Neither postoperative nor delayed complications and no recurrences have been observed. Our results of such an approach, once indicated the pleurodesis for the treatment of spontaneous pneumothorax, are undoubtedly encouraging both for the technical simplicity and the reduction in hospitalization time.

The authors report their experience about the esophageal manometry in patients with Progressive Systemic Sclerosis (PSS). From January 1987 to December 1991, 32 patients (27 females and 5 males, in the ratio of 5.4 to 1; mean age of 56.6 years, range 18-84) were send to our Department with the diagnosis of PSS. The patients were divided in two group according to the presence or absence of esophageal symptoms. The first group (A) of 12 patients without symptoms, was examined only with manometry, while the second (B) was studied with the 24-hour pH-monitoring and esophagoscopy. In the group A the manometry noticed in 9 cases (75%) various degrees of esophageal motility disorders; in B the 90% of cases had a more or less severe disorder of the peristalsis. Moreover the grade of esophagitis and the importance of the gastroesophageal reflux were proportioned to the motility disorders. The conclusion is that also the subjects with PSS, but without esophageal symptoms, have in a high percentage motility disorders of the viscera. The alterations of the peristalsis increases in the group of symptomatic patients associated with esophagitis and severe reflux. On account of the fact that the esophageal lesions involve not only the LES but also the esophageal body, it is clear that the anti-reflux surgical procedures fail and an early medical therapy is the more adequate treatment.

The authors present a report of their study on a group of patients affected by serious chronic constipation undergoing multidisciplinary evaluation by a radiologist, a neurologist and, if necessary, also a psychiatrist. From June 1989 to October 1990, 40 patients were examined using anal manometry, intestinal transit time, proctogram and electromyography of the pelvic floor. The examinations carried out by the different specialists led to the following results: 10 patients were found to be affected by slowed transit due to right colon constipation; in 16 cases, spastic pelvic floor syndrome (S.P.F.S.) was diagnosed; 5 subjects showed a rectocele which in 3 was associated with S.P.F.S.; 3 patients presented with an anterior rectal prolapse; in 6 cases the diagnosis was perineal descent syndrome, associated in 3 cases with S.P.F.S.; the remaining 6 subjects manifested a diminished ampullary sensitivity. This experience reveals the complexity of the alterations that, alone or in association, cause chronic idiopathic constipation. The authors' conclusion is that a correct diagnostic approach requires close collaboration between various specialists, who, by careful examination of different aspects of the colo-recto-anal region, arrive at an accurate physiopathological diagnosis leading to the most suitable therapy.