Adjacent Vascular Structures Research Articles

Resection of a Lower Clival Meningioma via Posterolateral Approach: Two-Dimensional Operative Video.

Objectives This study aimed to demonstrate resection of a craniovertebral junction (CVJ) meningioma via the posterolateral approach. Design The study is designed with a two-dimensional operative video. Setting This study is conducted at department of neurosurgery in a university hospital. Participants A 50-year-old woman who presented with lower cranial nerve findings due to a left-sided lower clival meningioma ( Fig. 1 ). Main Outcome Measures Microsurgical resection of the meningioma and preservation of the neurovascular structures. Results The patient was placed in park-bench position and a left-sided retrosigmoid suboccipital craniotomy, followed by C1 hemilaminectomy and unroofing the lip of the foramen magnum, was performed. The dural incision extended from the suboccipital region down to the posterior arch of C2 ( Fig. 2 ). The arachnoid overlying the tumor was incised, revealing the course of the cranial nerve (CN) XI on the dorsolateral aspect of the tumor. The left vertebral artery (VA) was encased by the tumor which was originating from the dura below the jugular foramen. The mass was resected in a piecemeal fashion eventually. At the end of the procedure, all relevant cranial nerves and adjacent vascular structures were intact. Postoperative magnetic resonance imaging (MRI) confirmed total resection and the patient was discharged home on postoperative day 3 safely. Conclusions Microsurgical resection of the lesions of the CVJ are challenging as this transition zone between the cranium and upper cervical spine has a complex anatomy. Since adequate exposure of the extradural and intradural segments of the VA can be obtained by the posterolateral approach, this approach can be preferred in cases with tumors anterior to the VA or when the artery is encased by the tumor. The link to the video can be found at: https://youtu.be/d3u5Qrc-zlM .

PNEUMOMEDIASTINUM IN PATIENTS WITH SUBSTANCE ABUSE: A CASE SERIES

SESSION TITLE: Medical Student/Resident Disorders of the Mediastinum Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pneumomediastinum (PM) is the presence of air in the mediastinum. PM is associated with asthma exacerbation, severe cough or vomiting, and other activities associated with breathing maneuvers. Although the majority of cases could be managed conservatively, PM could be potentially fatal if it progresses to malignant PM, which requires thoracotomy or video-assisted thoracoscopy for management. Therefore closely monitoring the patient is necessary. CASE PRESENTATION: Case 1: A 20-year-old male who uses marijuana, was admitted due to 3 days of intractable nausea, vomiting, and right-side anterior pleuritic chest pain. Vital signs were normal. Abdominal exam showed epigastric tenderness, without guarding or rebound. Laboratory showed leukocytosis. CXR revealed subcutaneous emphysema in the left supraclavicular region without PM. Chest CT showed free air in posterior mediastinum (Figure 1). Evaluation did not demonstrate esophageal rupture. He was treated conservatively. The symptoms improved and he was discharged. Case 2: A 20-year-old male with marijuana use for 4 years presented with shortness of breath, intractable vomiting, bloody emesis, chest pain, and shortness of breath. Vital signs were normal. Examination showed subcutaneous emphysema along anterior chest up to neck, with clear and equal breath sound. Laboratory showed leukocytosis. CXR and chest CT showed subcutaneous emphysema and PM (Figure 2). With investigation, there was no evidence of esophageal rupture. The symptoms resolved and he was discharged. Case 3: An 18-year-old male with type 1 diabetes mellitus and polysubstance abuse history presented with sudden severe right-side chest pain, mild shortness of breath, and nausea over 2 days. He admitted smoking methamphetamine prior to his symptoms. Vital signs were normal. Examination was notable for moderate dehydration. Laboratory revealed leukocytosis, elevated blood glucose, and wide-anion gap metabolic acidosis with elevated acetone. Urine drug screen was positive for methamphetamine. CXR showed PM and left supraclavicular subcutaneous emphysema. Chest CT showed isolated PM (Figure 3). The patient was given pain medication and was treated for DKA. He improved and was discharged. DISCUSSION: PM among substance users is believed to be a result from barotrauma during breathing maneuvers. An increase in alveolar pressure with development of a pressure gradient between alveoli and surrounding blood vessels leads to increased alveolar pressure, rupture of the alveolar septa, collapse of the adjacent vascular structures, and air dissection around the peribronchial and perivascular sheaths. Conservative management is sufficient for the majority of PM. CONCLUSIONS: Pneumomediastinum is a rare condition that could be potentially life threatening. PM should be considered in patients with history of inhaled drug use who develop sudden chest pain. Reference #1: Kouritas VK, Papagiannopoulos K, Lazaridis G, et al. Pneumomediastinum. J Thorac Dis 2015;7(Suppl 1):S44–S49. Reference #2: Weiss ZF, Gore S, Foderaro A. Pneumomediastinum in marijuana users: a retrospective review of 14 cases. BMJ Open Respir Res. 2019 Feb 12;6(1):e000391. doi: 10.1136/bmjresp-2018-000391. Reference #3: Miller WE, Spiekerman RE, Hepper NG. . Pneumomediastinum resulting from performing Valsalva maneuvers during marijuana smoking. Chest. 1972 Aug;62(2):233-4. DISCLOSURES: No relevant relationships by Amr Ismail, source=Web Response No relevant relationships by Passisd Laoveeravat, source=Web Response No relevant relationships by Arunee Motes, source=Web Response No relevant relationships by Victor Test, source=Web Response

Complete resections of giant thorax masses and experienced difficulties.

Thoracic giant masses do not have a clear definition. In some publications, giant thoracic mass definition is used in tumors whose long axis is> 10 cm and in other publications covering more than 50% of the hemithorax. In this study, demographic data of patients with a massive resectable giant thoracic mass and the difficulties and experiences experienced in the peroperative process were reviewed with a general perspective. 14 giant intrathoracic masses operated at the department of Thoracic Surgery, School of Medicine, Ankara University were included in the study. The masses occupying more than half of the hemithorax and mediastinal lesions with a long axis of 15 cm or larger radiologically were included and evaluated. 9 (64.3%) of our patients were male and 9 (35.7%) were female. The average age was 49.2 ± 17.1(between18-68). The tumor localizations of our patients were determined as 9 (64.2%) hemithorax and 5 (35.8%) mediastinal. When the radiological and intraoperative dimensions were examined separately, it was observed that the mean of long axis of CT image is average 18 ± 3.8 cm (between 12 cm and 26 cm), and the mean of long axis of specimen is average 18.14 ± 3.6 cm (between 15 cm and 23 cm). The heaviest mass was average 844 ± 473 g (350 g-2204 g). The surgical maneuvers and hence the excision of giant masses become difficult to operate due to the narrow localization of the masses and the frequent invasions of adjacent vascular structures and nerve tissues. However, complete resection of these slowly growing and generally encapsulated masses can provide the cure.

Gallbladder bleeding along with cholecystocolonic fistula: a case report.

Gallstone disease is a major public-health problem, with a high prevalence ranging from 10% to 15% [1]. Acute cholecystitis, chronic cholecystitis, choledocholithiasis, and gallstone pancreatitis are all common complications in clinical practice. However, when gallstones migrate to adjacent viscera or vascular structures, the clinical challenge is far less familiar [2]. Gallbladder (GB) bleeding is seldom reported, which mostly manifests as hemobilia. Some cases are caused by cystic artery aneurysm and rupture and others are due to GB rupture [3]. Gallstones can erode through the gallbladder wall or bile duct into the adjacent portion, resulting in a cholecystocolonic fistula (CCF), which is a rare complication of gallstones with cholecystitis [4]. Here, we share a case of gallbladder bleeding along with cholecystocolonic fistula that has not yet been reported. We hope that, through our unusual case, clinicians gain an enhanced understanding of rare complications caused by gallstones.

Surgical Treatment of Trigeminal Neuralgia Combined with Tumors of the Cerebellopontine Angle

Introduction . Trigeminal neuralgia (TN) develops because of demyelination in the entry zone of the trigeminal nerve root (TNR) into the brainstem, which is accompanied by ectopic and cross-excitation of the nerve impulses with paroxysms of facial pain. One of the causes of TN are tumors of the cerebellopontine angle (CPA), which have a direct or indirect effect on the TNR. The optimal surgical approach in such cases depends on the anatomical relationship between the TNR and the tumor and vascular structures. The aim of the study was to evaluate the relationship between the anatomical variants of the TNR and the outcomes of using various surgical methods to treat TN in CPA tumors. Materials and methods. We performed a retrospective analysis of 52 patients (38 women and 14 men aged 22–82 years) with TN and ipsilateral tumors of the CPA: 29 with apical petrous meningiomas, 11 with epidermoid tumors, 10 with vestibular schwannomas, 1 with haemangioma, and 1 with cavernoma. Results. Six variants of the anatomical relationships of the TNR to CPA tumors and the adjacent vascular structures were identified: where the TNR is completely surrounded by the tumor; where the tumor compresses and displaces the TNR; where the tumor is located inside the TNR; where the tumor, together with the blood vessel, compresses the TNR; where the tumor displaces the TNR towards the vessel; and where the tumor is not in contact with the TNR, but the TNR is compressed by the blood vessel. Displacement and deformation of the TNR by CPA tumors was found in 50 patients, and no direct contact between the TNR nerve fibers and the neoplasm was observed in 2 cases. The neurovascular conflict caused by arterial and venous vessels was identified in 16 subjects. The type of a vascular decompression technique depended on the degree of stretching and deformation of the TNR. Postoperative MRI confirmed the complete removal of CPA tumors in 51 patients, while minor epidermoid residue in the contralateral cerebellopontine angle cistern was found in only one subject. There were no fatalities after surgical interventions, and the postsurgical cranial nerve neuropathies were transient and regressed within 2–3 months. In 15 cases, hypoesthesia developed or worsened in the trigeminal nerve innervation zone, then disappeared within several weeks, and was not accompanied by a recurrence of TN. Facial sensitivity improved in 6 cases, who had not previously undergone any surgical manipulations of the TNR and its peripheral branches. Complete regression of TN in the immediate postoperative period was observed in 51 patients. A percutaneous radiofrequency trigeminal rhizotomy was performed in 1 subject with an epidermoid tumor, to eliminate the intense pain paroxysms that persisted for a week. No recurrent growth of CPA tumors or relapses of TN were observed during the subsequent follow-up period of 2–10 years. Conclusion. TN can be caused by direct compression and deformation of the TNR and brainstem by CPA tumors and vascular structures. A detailed examination of the entire length of the TNR after tumor removal is necessary to evaluate the neurovascular relationships. In cases of vascular compression of the TNR, various methods of microvascular decompression can be used to treat TN.

Role of CT Angiography in the Evaluation of Tumour Vascular Relationship in Patients with Pancreatic Tumours

Abstract Background: Pancreatic cancer is the fourth leading cause of cancer related deaths worldwide. It has poor prognosis especially in locally advanced tumours. Treatment of pancreatic tumours remains a challenge regarding their growth into the adjacent anatomical and vascular structures. Multidetector computed tomography (MDCT) plays an important role in diagnosing of patients with resectable and borderline resectable tumours. Evaluation of borderline resectable tumours should involve the accurate identification of the relationship between the tumour and the surrounding vessels and other vital struc-tures. Aim of Study: Evaluation of the role of CT angiography in the assessment of tumor vascular relationship in patients with pancreatic tumors in order to choose the proper treatment decision. Material and Methods: This study is a prospective study which was conducted in the Radiology Department of Man-soura University Hospital over the period from August 2016 to September 2019. This study included 79 patients, their ages ranged from 45 to 74 years old with mean age 58.3 years old. All patients were referred from oncology Center of Mansoura University and outpatient surgery clinics. The study was approved by our institution's ethics committee, and all patients gave their informed consent before inclusion in the study. CT scans were obtained with a MDCT scanner (Aquilion 64, Toshiba Medical Systems). CT protocols for pancreatic imaging vary at different institutions but typically include a multiphasic technique with a very thin section imaging and multiplanar reconstruction. Contrast enhanced images include: A late arterial or pancreatic phase and a portal or venous phase after injection of 100-120mL of intravenous non-ionic water soluble contrast material usually at rate of 4-5mL/sec. Results: This study included 79 patients, their ages ranged from 45 to 74 years old with mean age was 58.3 years. The most common affected site in the pancreas was the pancreatic head (47 lesions). All the lesions in our study were histopatho-logical proven malignant. The most common histopathological type in our study was pancreatic adenocarcinoma representing 61 lesions (77.21%). As regards the CT appearance of the pancreatic masses, most of the lesions were hypodense (71lesions). Detailed evaluation by CT angiography showed that the hepatic artery was involved in 35 cases, the SMA in 49 cases, the celiac trunk in 29 cases and the gartroduodenal artery in 47 cases. There was no arterial vascular involvement in 25 cases. Finally as regards the anatomical variations; accessory right hepatic artery was detected in 11 cases, Accessory left hepatic artery in 12 cases, replaced left hepatic artery in 14 cases, replaced right hepatic artery in 10 cases, replaced common hepatic artery in 9 cases and 23 cases showed no anatomical variants. Conclusion: Multidetector CT with CT angiography plays a major role in the diagnosis and staging of pancreatic carci-noma. The use of standardized technique and radiologic reporting method can improve the evaluation of the tumor-vessel relationship and precisely evaluate the arterial anatom-ical variants.

Combination of Chemoembolization plus Radiofrequency Ablation May Provide Better Survival Outcomes than Monotherapy for HCC

Combination of Chemoembolization plus Radiofrequency Ablation May Provide Better Survival Outcomes than Monotherapy for HCC

Surgical Management of Intracranial Epidermoid Tumors—An Institutional Review of 234 Cases

Abstract Aim To study the demographics, clinical profile, management strategies, and treatment outcomes of intracranial epidermoid lesions. Materials and Methods A single institutional retrospective analysis from a large institute in Western India was done of all patients operated for intracranial epidermoid tumors over a period of 20 years from January 1997 to January 2017. All patients were investigated with a contrast-enhanced computed tomography (CECT) as well as a magnetic resonance imaging (MRI), with a diffusion-weighted imaging to confirm diagnosis of epidermoid tumor. The presenting complaints and the demographics of all patients were recorded, and all patients underwent planned surgery, with or without a cerebrospinal fluid (CSF) diversion procedure as per requirement. Surgery ranged from a gross total resection to a near-total resection depending on the patient, location of the lesion, and involvement of adjacent structures. All patients underwent an immediate postoperative computed tomographic (CT) scan as well as a follow-up MRI. Patients were followed up to note clinical improvement as well as documentation of all complications. Results Total 234 patients of intracranial epidermoid tumors were operated upon in a 20-year span. Males predominated with a total number of 146 (62.4%). The most common age group was the fourth decade. The most common presentations were headache (118 patients) and neuralgia in the trigeminal distribution (82 patients). Infratentorial compartment was the most common location of the tumors (152 patients), with cerebellopontine angle being the predominant site in the posterior fossa (107 patients). Both supra- and infratentorial compartments were involved in 28 cases. Gross total excision could be achieved in 202 patients. Reoperation was required in 12 cases. The mean follow-up period was 68 months. The most common complication encountered was that of postoperative CSF leak (24 patients). We had eight cases of recurrence and six deaths in our series. Conclusion Epidermoid tumors can arise in virtually all intracranial locations. Gross total excision of the tumor is treatment of choice and can be curative for these benign lesions. Large lesions at presentation with involvement of multiple compartments can be difficult to manage and may require bicompartmental or second look surgery. Complete excision of the capsule with preservation of adjacent neuronal and vascular structures is of utmost importance to decrease postoperative morbidity and chances of recurrence. Perioperative steroids, avoidance of intraoperative spillage, and intraoperative endoscopic assistance are recommended in all cases.

Medial Clavicle Osseous Dimensions With Implication on Plate Fixation

Significantly displaced medial clavicle fractures are associated with high rates of painful nonunion. Operative fixation can be challenging due to limited medial bone stock and adjacent vital vascular structures. Twenty-one consecutive chest computer topography (CT) scans were analyzed to measure anterior-posterior and superior-inferior dimensions of the medial clavicle. Correlation between height and clavicular dimensions were assessed by Pearson correlation coefficient. Two cases using dual T-locking plates are described. From anterior to posterior, the medial clavicle typically measures 1.44 (SD 0.26 cm) and 2.51 cm (SD 0.38 cm) at its narrowest and widest points, respectively. The mean superior-inferior width was 1.56 cm (SD 0.21 cm) and 2.76 cm (SD 0.39 cm) at its narrowest and widest points, respectively. Inter-observer reliability was 0.986 with combined intra-observer reliability between two time points of 0.984. Surgeons may use CT to reliably evaluate the amount of bone available for screw purchase and pre-operatively determine expected screw lengths. Locking plates using both unicortical locking screws and bicortical screws can be used for fracture fixation. Both patients healed fractures with dual T-locking plates without a short-term hardware complication. Dual T-locking plates may be a consideration for medial clavicle fracture fixation when medial bone purchase is a concern.

Making the Most of Focused Ultrasound: Tissue Heating to Improve Chemotherapy Release.

Making the Most of Focused Ultrasound: Tissue Heating to Improve Chemotherapy Release.

Preliminary experience in the management of brain and skull-base tumors with microwave ablation; feasibility guided by ultrasound, report from 23 cases.

Background:In surgery involving brain tumors, the use of new tools or equipment that allows for better results and improvement in the quality of life of the patients is mandatory. Microwave ablation (MWA) is a technique that has been used effectively since 1994 in the management of different kinds of tumors. The authors present their surgical experience with 23 cases of brain and skull-base tumors using MWA technique.Methods:In all, 23 cases diagnosed with brain and skull-base tumors are described; all of these were treated with MWA as unique technique as a complement to conventional microsurgical tumor resection. In all cases, ultrasound imaging guidance was used. A thin antenna (caliber 14.5; MedWaves) was positioned through ultrasound images to a central intratumoral area, and then energy was applied for 1–3 min until the temperature sensor in the proximal position of the antenna reached 80–100°C. Through transoperative Doppler ultrasound images and surgical microscopy, changes in the generated ablation were observed. The said ablation led to a decrease in intratumoral blood flow, and the adjacent vascular and cerebral structures were preserved.Results:The application of MWA during brain surgery was regarded as safe in all cases, as no permanent additional neurological deficit was detected. Intratumoral vascular flow was also reduced and tumor resection was facilitated. Likewise, a reduction in tumor volume was noted, and in others in whom the ablation was applied as a single therapy, a progressive destruction of the tumor was observed.Conclusion:MWA can be a useful tool as a single therapy or as a complement to conventional techniques for the surgical resection of brain and skull-base tumors. It was a safe method in all cases, producing a decrease in intratumoral blood flow, and this procedure facilitates the microsurgical resection of the lesion.

SBRT with Simultaneous Integrated Boost Results in High Rate of R0 Resection in Borderline Resectable Pancreatic Adenocarcinoma

Surgical resection for pancreatic adenocarcinoma offers a significantly improved prognosis with a distinct advantage of potentially curative (R0) versus palliative (R1/R2) surgery. Stereotactic body radiation therapy (SBRT) has emerged as a treatment option that has potential to pull the tumor off adjacent vascular structures and therefore improve surgical outcomes. We reviewed our rates of complete (R0) resection following neoadjuvant chemotherapy and SBRT for borderline resectable patients with pancreatic adenocarcinoma. Retrospective review of patients treated with SBRT to the pancreas between October 2015 and November 2017. A total of 26 patients were treated with SBRT to pancreas. All patients were treated with 5 fraction SBRT after fiducial marker placement and 4D treatment planning. Mean dose is 3250 cGy. Eight of the 26 patients received simultaneous integrated boost (SIB) to tumor vessel interface. Mean SIB dose 4150 cGy. Twelve medically operable patients received neoadjuvant chemotherapy; 7 FOLFIRINOX, 4 gemcitabine/abraxane, and one gemcitabine/pemetrexed. Of the 12 medically operable patients, 9 were classified as borderline resectable, and 3 were classified as unresectable based on NCCN criteria. Eight of 9 borderline resectable patients underwent successful pancreatoduodenectomy with R0 resection (89%). No severe toxicity was observed. SBRT provides a promising way to treat locally advanced and borderline resectable pancreatic cancer. A simultaneous integrated boost (SIB) to the region of vessel abutment or encasement during SBRT has the potential to downstage and improve the likelihood of R0 resection. Further exploration of SIB may be warranted in borderline resectable disease.

Endoscopic Endonasal Transclival Approach to Tumors of the Clivus and Anterior Region of the Posterior Cranial Fossa: An Anatomic Study

To present the basic topographic and anatomic features of the clivus and adjacent structures with an objective of possible improvements and optimization of the extended endoscopic endonasal posterior (transclival) approach when removing tumors of the clivus and anterior regions of the posterior cranial fossa. A craniometric study was conducted on 125 human skulls. A topographic anatomic study was conducted on 25 cadaver head specimens with arterial and venous beds stained with colored silicone, according to the method developed by us, to visualize its features and individual variability. The most important anatomic features of the external and internal regions of the clivus and the adjacent neural and vascular structures were analyzed. An accessible zone for the most effective transclival approach to the posterior cranial fossa is also specified. The endoscopic endonasal transclival approach can be used to obtain access to centrally located tumors of the posterior cranial fossa. It is an alternative to transcranial approaches in the surgical treatment of tumors of the clivus.

Safe Margin beyond Dens Tips to Ventral Dura in Anterior Odontoid Screw Fixation : Analysis of Three-Dimensional Computed Tomography Scan of Odontoid Process.

ObjectiveAnterior odontoid screw fixation is a safe and effective method for the treatment of odontoid fractures. The surgical technique is recommended for perforation of the apical cortex of the dens by the lag screw. However, overpenetration of the apical cortex may lead to potentially serious complications such as damages of adjacent vascular and neural structures. The purpose of this study was to assess the role of three-dimensional computed tomography (CT) scan to evaluate the safe margin beyond dens tip to ventral dura for anterior odontoid screw fixation.MethodsWe retrospectively analyzed the three-dimensional CT scans of the cervical spines in 55 consecutive patients at our trauma center. The patients included 38 males and 17 females aged between 22 and 73 years (mean age±standard deviation, 45.8±14.2 years). Using sagittal images of 3-dimensional CT scan, the safe margins beyond dens tip to ventral dura as well as the appropriate screw length were measured.ResultsThe mean width of the apical dens tip was 9.6±1.1 mm. The mean lengths from the screw entry point to the apical dens tip and posterior end of dens tip were 39.2±2.6 mm and 36.6±2.4 mm. The safe margin beyond apical dens tip to ventral dura was 7.7±1.7 mm. However, the safe margin beyond the posterior end of dens tip to ventral dura was decreased to 2.1±3.2 mm, which was statistically significant (p<0.01). There were no significant differences of safe margins beyond dens tip to ventral dura with patient gender and age.ConclusionExtension by several millimeters beyond the dens tip is safe, if the trajectory of anterior odontoid screw is targeted at the apical dens tip. However, if the trajectory of the screw is targeted to the posterior end of dens tip, extension beyond dens tip may lead to damage immediately adjacent to the vental dura mater.

Fracture of ankle: MRI using opposed-phase imaging obtained from turbo spinecho modified Dixon image shows improved sensitivity.

To evaluate if opposed-phase (OP) imaging obtained from the turbo spin echo (TSE) modified Dixon (mDixon) technique can increase the sensitivity of MRI for diagnosing ankle fractures. This study included 95 CT-confirmed ankle fractures with additional MRI of the ankle using a TSE modified Dixon (mDixon) technique. Two groups of images were analyzed independently: Group 1-imaging group without OP imaging; Group 2-imaging group with OP imaging. Readers assessed the images using a 4-point confidence score to detect fractures. During the first review session, the fracture site was blinded. For the second review session, the fracture site was provided. Sensitivity and positive-predictive value were calculated. In both sessions, the sensitivity for Group2 was significantly greater than that for Group 1 (Session 1: 76.3% vs 62.6%, p < 0.0001; Session 2: 80.5% vs 65.3%, p < 0.0001). The positive-predictive value of Group2 was significantly lower in both sessions 1 and 2 (Session 1: 85.8% vs 97.5%, p < 0.0001; Session 2: 90.5% vs 96.9%, p = 0.0068). Among the 28 false-negative fractures missed in Group 1 (Session 1), 12 (9 minimal displaced and 4 small diameter fractures) were identified in Group 2 (Session 1). While 8.9% showed lower movement, 33.6% showed upper movement in Group2 compared with Group 1. Possible causes of false-positive lesions were subcutaneous fat, bone marrow edema, and intraosseous vessel mimic fractures. OP imaging obtained using the modified Dixon technique provided better sensitivity and improved descriptions of fractures, especially for minimal displaced fractures and small diameter fractures. However, caution is required when diagnosing fractures with OP imaging because pseudofractures can appear as a result of adjacent bone marrow edema, vascular structures, or subcutaneous fat lobules. Advances in knowledge: In MRI, minimal displaced or small chip bone fracture maybe missed, OP imaging obtained using the mDixon technique provided better sensitivity and improved descriptions of fractures using the black boundary artifact.

Current status and progress of comprehensive treatment for locally advanced pancreatic cancer

Locally advanced pancreatic cancer (LAPC) involves with adjacent vascular structures, which is divided into the borderline resectable pancreatic cancer (BRPC) and unresectable pancreatic cancer. BRPC is usually treated with vascular restruction. Neoadjuvant therapy plays an important role in achieving an R0 resection in BRPC. Generally, the goal of treatment for unresectable pancreatic cancer is to control tumor progress and improve patients′ quality of life. The latest cheering clinical trials have shown that some LAPC may be downstaged to resectable tumors after preoperative chemotherapy and chemoradiotherapy. In this article, the rationale for and results following treatment with neoadjuvant chemotherapy, chemoradiation and possibly subsequent surgical resection of the primary tumor are described in detail and existing data are reviewed. Key words: Pancreatic neoplasms; Borderline resec-table pancreatic neoplasms; Locally advanced pancreatic neoplasms; Neoadjuvant therapy; Chemotherapy; Radiotherapy; Surgical procedures, operative

Alliance for clinical trials in oncology (ALLIANCE) trial A021501: preoperative extended chemotherapy vs. chemotherapy plus hypofractionated radiation therapy for borderline resectable adenocarcinoma of the head of the pancreas

BackgroundBorderline resectable pancreatic cancers infiltrate into adjacent vascular structures to an extent that makes an R0 resection unlikely when pancreatectomy is performed de novo. In a pilot study, Alliance for Clinical Trials in Oncology Trial A021101, the median survival of patients who received chemotherapy and radiation prior to anticipated pancreatectomy was 22 months, and 64% of operations achieved an R0 resection. However, the individual contributions of preoperative chemotherapy and radiation therapy to therapeutic outcome remain poorly defined.MethodsIn Alliance for Clinical Oncology Trial A021501, a recently activated randomized phase II trial, patients (N = 134) with a CT or MRI showing a biopsy-confirmed pancreatic ductal adenocarcinoma that meets centrally-reviewed anatomic criteria for borderline resectable disease will be randomized to receive either 8 cycles of modified FOLFIRINOX (oxaliplatin 85 mg/m2, irinotecan 180 mg/m2, leucovorin 400 mg/m2 and infusional 5-fluorouracil 2400 mg/m2 over 2 days for 4 cycles) or to 7 cycles of modified FOLFIRINOX followed by stereotactic body radiation therapy (33–40 Gy in 5 fractions). Patients without evidence of disease progression following preoperative therapy will undergo pancreatectomy and will subsequently receive 4 cycles of postoperative modified FOLFOX6 (oxaliplatin 85 mg/m2, leucovorin 400 mg/m2, bolus 5-fluorouracil 400 mg/m2, and infusional 5-fluorouracil 2400 mg/m2 over 2 days for 4 cycles). The primary endpoint is the 18-month overall survival rate of patients enrolled into each of the two treatment arms. An interim analysis of the R0 resection rate within each arm will be conducted to assess treatment futility after accrual of 30 patients. Secondary endpoints include rates of margin-negative resection and event-free survival. The primary analysis will compare the 18-month overall survival rate of each arm to a historical control rate of 50%. The trial is activated nationwide and eligible to be opened for accrual at any National Clinical Trials Network cooperative group member site.DiscussionThis study will help define standard preoperative treatment regimens for borderline resectable pancreatic cancer and position the superior arm for further evaluation in future phase III trials.Trial registrationClinicalTrials.gov: NCT02839343, registered July 14, 2016.

Alliance for clinical trials in oncology trial A021501: Preoperative extended chemotherapy vs. chemotherapy plus hypofractionated radiation therapy for borderline resectable adenocarcinoma of the head of the pancreas.

TPS4151 Background: Borderline resectable pancreatic cancers infiltrate into adjacent vascular structures to an extent that makes an R0 resection unlikely when pancreatectomy is performed de novo. In a pilot study, Alliance for Clinical Trials in Oncology Trial A021101, the median survival of patients who received chemotherapy and radiation prior to anticipated pancreatectomy was 22 months, and an R0 resection was achieved in 64% of operations. However, the individual contributions of preoperative chemotherapy and radiation therapy are poorly defined.This study, Alliance for Clinical Oncology Trial A021501, will help define a standard preoperative treatment regimen for borderline resectable pancreatic cancer and position the superior arm for further evaluation in future phase III trials. Methods: In this recently activated randomized phase II trial, 134 patients with a biopsy-confirmed pancreatic ductal adenocarcinoma that meets centrally-reviewed radiographic criteria for borderline resectable disease are randomized to receive either 8 cycles of modified FOLFIRINOX (oxaliplatin 85 mg/m2, irinotecan 180 mg/m2, leucovorin 400 mg/m2 and infusional 5-fluorouracil 2400 mg/m2 for 4 cycles) or to 7 cycles of modified FOLFIRINOX followed by stereotactic body radiation therapy (33-40 Gy in 5 fractions). Patients without evidence of disease progression following preoperative therapy undergo pancreatectomy and subsequently receive 4 cycles of postoperative modified FOLFOX6 (oxaliplatin 85 mg/m2, leucovorin 400 mg/m2 and infusional 5-fluorouracil 2400 mg/m2 for 4 cycles). The primary endpoint is the 18-month overall survival rate of patients enrolled into each of the two treatment arms. An interim analysis of the R0 resection rate within each arm will be conducted to assess treatment futility after accrual of 30 patients. Secondary endpoints include rates of margin-negative resection and event-free survival. The trial is activated nationwide and eligible to be opened for accrual at any National Clinical Trials Network cooperative group member site. Clinical trial information: NCT02839343.

Robotic duodenal sleeve resection: The transmesenteric approach

Objective: Duodenal surgery can be challenging, particularly involving the second through forth portions. Considerations include its' deep retroperitoneal location, adjacent vascular structures, and cognizance of the Ampulla of Vater. In this presentation, we describe a novel approach to the performance of a robotic duodenal sleeve resection for an adenoma just distal to the Ampulla. Duodenal exposure, dissection, and resection are performed through a mesocolic window right of the middle colic vessels with concomitant placement of common bile duct stent to aid in the visualization of the ampulla. A side-to-side anastomosis is then performed through this window. This elegant technique can become a useful component of a hepatobiliary surgeon's armamentarium.

A study of the efficacy of stellate ganglion blocks in complex regional pain syndromes of the upper body.

Background and Aims:The effect of stellate ganglion blocks (SGBs) was examined in complex regional pain syndromes (CRPS) of the upper body.Material and Methods:A total of 287 SGB were given to patients with documented CRPS on medications. Spontaneous and provoked pain assessment was done with numeric pain rating scale (NPRS). The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and range of motion (ROM) was recorded before and after each blockade. Difference between a 15-point “global rating of change” scale determined the minimal clinically important difference of the DASH score.Results:The overall mean pain reduction was 73.2% (r = 0.83, P < 0.001) considering spontaneous and 55.8% (r = 0.77, P < 0.001) on provoked pain. Mean DASH score decreased from 53 (range 36–63; P = 0.14) to 10.4 (range 10–49.2; P = 0.005). The sensitivity to change was 6.9 for spontaneous and 4.9 for provoked pain. Increase in ipsilateral limb temperature has a good correlation with Horner's syndrome (HS) and sympathetic blockade. Minor, self-limiting complications, such as hoarseness, dysphagia, local hematoma, and ipsilateral brachial plexus block occurred in 11.5%. A rare complication of contralateral HS was documented. One patient developed a small pneumothorax, but it did not require intervention.Conclusions:SGB are relatively safe and effective management in patients with neuropathic conditions already on pharmacotherapy. Serial blocks attained an average reduction in pain by >3 NPRS points from the baseline for both spontaneous and provoked pain with a decrease in mean DASH score and improvement in ROM.