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Paediatric facial fractures are relatively rare. The inherent elasticity of the bones with more of the cartilage than that of the mineralised bone accounts for this. The principles involved in the management of facial fractures are the same irrespective of the age of the patient; however, in children, the techniques used are necessarily modified by certain anatomical, physiological, psychological and feeding factors related to childhood and the parents. In an attempt to keep the treatment and fixation technique simple, the case, presented here, describes the management of a mandibular parasymphyseal fracture in a 16-month-old child with the use of a prefabricated adaptable surgical splint.

Objective This study presents the results of an updated clinical protocol for orbital blow-out fractures, with a special emphasis on nonsurgical treatment and orthoptic evaluation of functional improvement. Methods A two-centre multidisciplinary prospective cohort study was designed to monitor the results of a clinical protocol by assessing ductions, diplopia, globe position, and fracture size. Patients underwent clinical assessment and orthoptic evaluation at first presentation and then at 2 weeks and 3/6/12 months after nonsurgical or surgical treatment. Outcome parameters were field of binocular single vision (BSV), ductions, degree of enophthalmos, a diplopia quality-of-life (QoL) questionnaire, and other sequelae or surgical complications. Results 46 of the 58 patients who completed the 3, 6 and/or 12-month follow-up received nonsurgical treatment. There was full recovery without diplopia or enophthalmos (>2 mm) in 45 of the 58 patients. The other 13 patients had limited diplopia, mainly in extreme upward gaze (average BSV 90). Five of those 13 patients did not experience impairment of diplopia in daily life. The average QoL score at the end of follow-up was 97. No patients developed late enophthalmos. Conclusion This study showed that a high percentage of patients with orbital floor and/or medial wall fracture recovered spontaneously without lasting diplopia or cosmetically disfiguring enophthalmos. The conservative treatment protocol assessed here underlines the importance of orthoptic evaluation of functional parameters.

Background Urethral prolapse (UP) is a rare, benign condition that often goes misdiagnosed and mistreated. It consists of the eversion of the distal urethral mucosa through the outer urethral meatus, leading to vascular obstruction and prolapsed tissue edema, which aggravates the prolapse. Although many review articles were reported on this condition, none of them focused on the conservative approach nor targeted the pediatric population. In this paper, we present successful medical management of UP in a 13-month-old Caucasian female and perform an extensive review of the literature to include articles that reported a conservative approach in patients under 18-years-old. We also suggested a practical algorithm for both diagnosis and management of this condition. Case presentation A 13-month-old Caucasian white female was presented with a urinary tract infection and vaginal bleeding. Genital examination showed a hyperemic donut-shaped mass covering the urinary meatus, of 0.7 cm diameter, with an actively bleeding open center. After confirming the diagnosis of UP with catheterization, a conservative approach was decided; antibiotics associated with topical corticosteroids including betamethasone 1% cream. The first-week outcome showed regression of the prolapsed tissue and the examination after four months showed normal vaginal mucosa with no evidence of relapse. Conclusions 20 studies were retained after PubMed search with a total of 278 female patients aged between 1 month and 15 years old. The main reasons for referral were vaginal bleeding and mass, urinary symptoms followed by sexual abuse. Non-surgical treatment was tried for 162 patients. 53 of them were successfully managed, while 92 reported unsuccessful outcomes. The conservative approach was successful in 19% of all patients and raised to 32.7% in the portion of children selected for the initial conservative approach. Even though this review showed good results with medical treatment in children with UP, additional comparative studies are required to evaluate the effectiveness of conservative treatment in comparison with surgical interventions. In addition, Long-term follow-up is required as recurrence was reported up to 2 years following conservative treatment.

Objective: To prevent unnecessary laparotomies by evaluating the effectiveness of conservative approach in abdominal trauma cases due to drilling-cutting instruments. Methods: Demographic data, effected region of the body, additional findings of trauma, hemodynamic parameters, duration of admission, diagnostic methods and treatment modalities were retrospectively evaluated in 217 cases with abdominal injury (lower thoracic region, abdominal wall and back) among 1 128 victims with drilling-cutting instrument injuries between January 1, 2012 and December 31, 2017. The conservative approach was based on physical examination, hemogram follow-up and hemodynamic evaluation. Results: Totally 177 (81.6%) cases of 217 patients were followed conservatively while 25 cases were operated at early (1-8 hours) and 15 were operated at late (9-48 hours) periods. Two patients who underwent surgery in the early period and two patients who underwent surgery in the late period were accepted as negative laparotomy while 1 patient in the late operated group was regarded as non-therapeutic laparotomy. Diagnostic laparoscopy was performed in 81 cases. Complications developed in 7 patients who were operated in the early period and 10 patients who were operated in the late period. The mean hospital stay period was 5.3 days (1-33) in all cases, 4.5 days (2-20) in conservative treatment group and 8.4 days (3-33) in the operated patients; and the difference was statistically significant. Conclusions: Detailed physical examination, accurate assessment and effective use of different diagnostic methods reduce the frequency of negative and non- therapeutic laparotomies in abdominal stab wound injuries.

Locally advanced rectal cancer is usually treated with a preoperative approach with radiochemotherapy followed by surgery. Patients obtaining a pathologic complete response have a very favorable long-term prognosis. This study was intended to assess whether major surgery can reduce tumor recurrences and prolong survival of patients with a complete response after radiochemotherapy. Computerized literature search was performed to identify relevant articles. Comparative studies reporting the outcomes of non-operative and operative management in patients after neoadjuvant treatment were reviewed. Data synthesis was performed using Review Manager 5.0 software. Twelve non-randomized comparative studies with a total of 1812 patients were suitable for analysis. There was no significant difference in overall survival at 3 and 5 years (odds ratio [OR] 1.31; 95% CI 0.64–2.69; p = 0.46 and 1.48; 95% CI 1.00–2.20; p = 0.50) and in disease-free survival at 3 and 5 years (odds ratio [OR] 1.20; 95% CI 0.68–2.14; p = 0.53 and 1.22; 95% CI 0.86–1.74; p = 0.26, respectively) between locally advanced rectal cancer patients treated with and without operative approach. Major surgery does not seem to improve prognosis in patients obtaining a complete response after radiochemotherapy. Clinical trials, using clear criteria to identify complete response patients, are needed to recommend non-operative approach.

Ameloblastoma is the second most common odontogenic tumor arising in the maxillary bones. The WHO classified ameloblastoma in: solid/multicystic (SMA); unicystic; peripheral and desmoplastic. A conservative or radical approach may be performed for SMA treatment to achieve total excision of the lesion. In this case report, a 47-year-old woman, presented a deformation of the left mandibular region and paresthesia of the left hemi-labium, at the ortopanoramic x-ray (OPT) a multilocular osteolytic lesion and the rhizalysis of dental elements 3.7, 3.6, 3.5, 3.4 and the inclusion of 3.8 was appreciated; the CT exam showed erosion of the mandibular canal roof and of the vestibular cortex in the mental nerve region. The patient was subjected to the extraction of the elements in rhizalysis and of 3.8 and subsequently to the enucleation of the lesion followed by an extensive peripheral ostectomy performed with a piezoelectric device. The patient underwent to OPT and CT examinations follow-up and after 5 years was subjected to implant surgery, at the same time of the implant's placement, bone biopsies were performed using core drills in order to evaluate the bone histologically. The patient showed complete clinical and radiographic healing; the histological examination demonstrates the formation of lamellar bone.

Aplasia cutis congenita (ACC) is a rare, heterogeneous group of congenital disorders characterized by the focal or widespread absence of the skin. ACC can occur anywhere on the body ; however, the vast majority of cases occur on the scalp midline. At birth, the lesions may have already healed with scarring or may remain superficially eroded to deeply ulcerated while in approximately 15%–30% of cases, the scalp defect is associated with a defect in the underlying bone and dura mater, with exposure of the brain and sagittal sinus. There is no consensus for early management and treatment modalities for large ACC cases. We present a case of a female infant at the age of 2 days (birth 40 + 3 weeks, vaginal, birth weight 3530 g, birth length 52 cm, and Apgar score 10/ 10) which has been moved from a maternity hospital to our institution due to aplasia cutis congenita of the scalp. She was born of the first regular pregnancy of a 29– year–old mother. At birth, in the parietal skin area above the wide– open fontanel, a 6 cm × 8 cm defect was observed without associated malformations on the rest of the body. Ultrasound of the brain and heart was neat. On the craniogram, partially parietal bone mutually was undeveloped. Neurological status of the newborn was neat. Magnetic resonance brain made using standard techniques and T1 HIRES, and Blackbone technique was neat with sustained continuity of dura without signs of cerebral herniation. Initially, Staphylococcus aureus was isolated, and Garamycin therapy with vaseline gas was initiated twice a day. Daily tracking of local findings was improving. One month after receipt, the eschar was gradually demarcated while the smaller nonepithelialized granulation zone treated merbromin with the baths. A protective helmet was created for the child to temporarily protect the brain and the soft tissue. Successive treatments from week to week have seen the reduction of the eschar with the closure of the bony segments. After 6 months, on the skin, a well–developed subcutaneous with the presence of capillary bleeding was observed. Within 1 month, Suprasorb A + Ag® and Suprasorb H® (Lohmann and Rauscher) wound dressings were introduced in the therapy. The iodine cream and the Mepitel® (Mölnlycke Health Care) were introduced into the therapy by removing the Suprasorb® wound dressing. Ten months since the onset of conservative treatment, the aplastic area was almost completely cured.

A 36-year-old woman presented with pelvic pain and vaginal blood loss and interstitial pregnancy (a single gestational sac located in the proximity of the right uterine horn, without visualization of an embryo and/or attachments inside) on 2- and 3-dimensional ultrasonographic examination. The patient was clinically stable. Her abdomen was soft with normal peristalsis; superficial and deep palpation were painless, as was decompression. With the patient under general anesthesia, an operative hysteroscopy was performed visually via ultrasound. A slow injection of methotrexate solution was pushed through the right cornual region inside the gestational sac and into the myometrial tissue tangentially at the 4 cardinal points. Twelve weeks later, the patient exhibited normal tubal patency via sonohysterography, as well as a viable pregnancy of 7 weeks' gestation. This minimally invasive approach is well tolerated and shows promise for the management of interstitial pregnancy, with no adverse effect on potential subsequent fertility.

Isolated gallbladder injury, secondary to a blunt abdominal trauma, is a rare finding in children.The presence of vague symptoms and the unknown dynamic of the trauma may increase the diagnostic challenge especially in pediatrics.A conservative management has been proposed in some particular cases in adults, but remains controversial in children.We report a case of a 5 year old boy who presented an isolated gallbladder lesion secondary to a blunt abdominal trauma.The surgical treatment was delayed for non-medical reasons, which gave us the possibility to try a conservative approach. Keywords: Isolated, Gallbladder injury, Blunt trauma, Conservative approach

BACKGROUND: Lipomas are benign formations with the mesenchymal origin, which are found in the head and neck region in a very small percentage of cases. In these cases, they usually occur in the posterior neck and usually grow very slowly without causing complaints. However, when they cover the front of the neck, it is necessary to confirm the adipose origin of a tumour and to exclude the connection with the thyroid gland. Although in principle, lipomas are benign, there are three more unfavourable possibilities of 1) malignancy of lipomas, 2) the occurrence of de novo liposarcomas or 3) the association of lipomas with other tumours, such as retinoblastoma. CASE REPORT: We present a 74-year-old woman with a painless subcutaneous formation in the neck. A Fine Needle Aspiration Biopsy (FNA) was performed, with the conclusion of the cytological result for lipoma. Surgical removal was planned under general anaesthesia. CONCLUSION: Usually, lipomas do not require surgery, but when they engage muscles they become indicative of surgical treatment.

The management of choice of non-functioning pituitary adenomas (NFPAs) remains debulking surgery when symptomatic. However, patient series systematically reporting the NFPAs outcome that were not treated either surgically, medically or with radiotherapy during long follow-up thereby giving an indication of their natural history are limited. Aim of the present study was to evaluate the natural course of presumed NFPAs, the outcome of confirmed NFPAs during a long follow-up period. Between 1993 and 2013, 84 patients with presumed NFPA were studied retrospectively. Patients were enrolled based on the following criteria: imaging suggestive of pituitary adenoma, absence of any biochemical/clinical evidence of hormonal excess, exclusion of prolactinomas and at least one sequential imaging during the follow-up. Repeated assessment of the pituitary function, visual fields and imaging was performed at regular intervals. The follow-up duration was evaluated from the first and last imaging dates. In group F (follow-up without surgery, 33 patients), the macroadenomas showed a 15 % probability of tumor growth and reduction. Similar tumor size alterations were observed also for the microadenomas. In group S (surgery, 51 patients), both residual tumors (>1 and

Perforation of the heart or great vessels by orthopedic wires is a rare complication that mostly results in severe or even lethal organ injury. Therefore, such conditions mostly require immediate surgical removal of the wires. However, in some individual cases, a conservative approach may be preferable. We describe a case of a 70-year-old woman whose aortic arch has been penetrated by two Kirschner wires used for fixation of a right clavicle fracture 13 years ago. Notably, the complication was an incidental finding during computed tomography angiography for clarification of transient nonspecific neurological symptoms.

Highlights • Struma ovarii is a rare and asymptomatic ovarian tumor and is usually diagnosed by the pathologist. • Struma ovarii malignancy is from thyroid origin and usually associated with thyroid tumors. • Management and follow up is not well established., Introduction Struma ovarii is a rare ovarian tumor, representing 0.5-1% of all ovarian tumors and 2–5% of ovarian teratomas. It is defined as an ovarian teratoma composed mostly of thyroid tissue. The symptoms are nonspecific, and the imaging studies can help in characterize the mass; however, the definitive diagnosis is usually given by the Pathologist. Classically, the treatment is the surgical resection of the ovarian mass, however there is no consensus regarding the follow-up. Presentation of case An asymptomatic malignant struma ovarii in a 43 year-old patient is presented. The diagnosis was postoperatively following a laparoscopic adnexectomy due to an apparently benign ovarian teratoma. The histopathology results revealed a mature ovarian cystic teratoma with papillary carcinoma with immunohistochemical characteristics suggesting a thyroid origin. Seeing that there was no thyroid affectation or metastatic disease, we decided a conservative management. A yearly follow-up with CT scan and tumor markers was performed. The endocrinologist also performed annual controls with thyroid ultrasound and serum tests. The patient has remained asymptomatic during these last four years. Discussion There is little evidence in literature on the conservative management in cases with evidence of malignancy. If fertility preservation is desired, an unilateral oophorectomy could be performed, along with levels of serum thyroglobulin as a marker of relapse. Other authors claim for aggressive ovarian cancer surgery followed by a total thyroidectomy. There is still no established management for struma ovarii patients and the choice for a conservative or radical approach depends only on the professional decision.

Introduction. Recognition of severe acute pancreatitis (SAP), intensive care, shifting away from early surgical treatment, and monitoring of the intra-abdominal pressure (IAP) is important in the management of SAP. The aim of our study was retrospective evaluation and critical assessment of the experience with SAP management protocol involving new strategy in the university hospital. Methods. Protocols of 274 SAP patients treated in our institution during the last eight years were reassessed. APACHE II, CRP and SOFA score, IAP, pulmonary complications, ventilatory support and infection rate were evaluated. The success of the conservative treatment, surgical interventions and mortality was analysed comparing period 1 from 1999 to 2002 and period 2 from 2003 to 2006. Results. More patients with necrotising SAP were treated in period 2. The average CRP and SOFA score was higher in period 2, p=0.018; p=0.011. A total of 139 patients underwent continuous veno-venouse haemofiltration (CVVH) as a component of fluid resuscitation and IAP control. Application of CVVH increased in period 2, p

Objective The aim of this study is to present our experience with a modification of the Blair approach to the parotid area, by means of a modified endaural component, which provides both excellent exposure and optimal functional and esthetic results, mainly over the preauricular area. Patients and methods A retrospective case series study was performed. It included surgical cases of patients who were operated on the parotid region in which the mentioned approach was indicated. The information was collected from the database available at the Universidad El Bosque Oral and Maxillofacial Surgery Department in Bogota, Colombia from 2008 to 2013. Results The sample consisted of 12 patients, with ages ranging from 23 to 56 years and a mean age of 38 years. A total of 8 patients were women and 4 patients were men. Parotid pathologies included salivary gland tumor (10 patients) and cranial base tumor (2 patients). Procedures executed were: superficial lobe and total parotidectomy resection, pharynx extended and cranial base tumor resections. Conclusions This investigation presents our experience with a modified approach to the parotid region. This approach gives an extended and safe exposure to the region with excellent cosmetic outcomes.

Rectus sheath hematoma is a clinical entity characterized by the presence of blood within rectus abdominis muscle sheath. The aim of this study was to analyze clinical characteristics, diagnostic approach, treatment strategy, and outcomes of patients with rectus sheath hematoma. Patients diagnosed and treated for spontaneous rectus sheath hematoma between March 2010 and March 2014 were included in the study. A total of 10 patients were diagnosed as spontaneous rectus sheath hematoma. The mean age was 66.5 ± 16.9 years, and the mean hospital stay was 4.4 ± 1.8 days. There was no mortality. Six patients were using anticoagulant or antiplatelet agents. Eight patients recovered after conservative treatment. Two patients underwent surgery. Spontaneous rectus sheath hematoma is associated with anticoagulant therapy. Cases with abdominal pain and a non-pulsatile abdominal mass particularly in elderly women should be kept in mind. Treatment is mostly based on supportive care to preserve hemodynamic stability. © 2015, Association of Surgeons of India.

The purpose of this study is to discuss the surgical treatment for ovarian torsion in children and adolescents with a focus on the procedures of adnexal conservation surgery and its frequency in the literature of the last 10 years. We retrospectively reviewed the medical charts of 127 operative ovarian lesions including 30 ovarian torsions (23.6%) treated in two pediatric centers over a 10-year period. Age at presentation, presenting symptoms, diagnostic studies, surgical procedure and pathological findings were analyzed. Mean age was 13.7 years. Conservative surgery has been performed in 46.7% of the cases and laparoscopic approach in 40%. Ovarian torsion occurred in 56.7% on ovaries with functional lesion, in 23.3% on normal adnexa and in 20% on ovaries with benign neoplasm. The article includes a literature review (2000-2010) and a statistical analysis which shows a slow increase in conservative surgery from 28 to 45%. Laparoscopic surgery accounts for 23.5%. Literature review shows 40.5% normal adnexa, 33.2% non-neoplastic lesions, 25.3% benign neoplasms and 1% malignant neoplasms. The surgical treatment of children and adolescents presenting adnexal torsion should be practiced as an emergency and it should be more conservative as possible in order to maximize the future reproductive potential.

Hemophilia A is an inherited, X-linked, recessive disorder caused by deficiency of clotting factor VIII. Intracranial hemorrhage is the leading cause of morbidity and mortality in these patients. Use of factor replacement products and medications had improved outcome in these patients. But in developing countries many such patients are not able to afford factor replacement products. We report a case of traumatic intracerebellar hemorrage in a hemophilia child. This child presented to us as a case of sub-acute intracerebellar hemorrage, he was managed conservatively with six units of fresh frozen plasma transfusion. He improved clinically and on follow-up investigation hematoma was found to have dissolved spontaneously. Through this report we want to emphasize that those cases of hemophilia presenting with acute or sub-acute intracranial bleed, conservative approach through procoagulant transfusion and intravenous fibrinolysis inhibitors should be tried as first line of management. Before daring for surgery sufficient amount of factor replacement should be kept available.

Gingival enlargement is a well recognized unwanted effect associated mainly with anticonvulsant drugs, immunosuppressant drugs and calcium channel blockers. Amlodipine influenced gingival enlargement is comparatively less prevalent amongst calcium channel blockers. It causes aesthetic disfigurement, speech disturbances, abnormal tooth movement and difficulty in mastication. The management of drug influenced gingival enlargement is a challenge for the periodontist, mainly due to less understanding of its pathogenesis, difficulties in selection of proper line of management and recurrence of the enlargement. This report discusses the importance of conservative approach (scaling and root planning along with drug replacement) in the management of a case of amlodipine influenced gingival enlargement. The need for extensive surgery was decreased after this approach.