Area Of Dissection Research Articles

Reply: Facial Contouring by Targeted Restoration of Facial Fat Compartment Volume: The Midface.

Sir: We thank Drs. Oranges et al. for their in-depth analysis and comments on our recent article entitled “Facial Contouring by Targeted Restoration of Facial Fat Compartment Volume: The Midface.”1 The concept of facial fat compartments revealed by Drs. Rohrich and Pessa updated our understanding of facial fat distribution,2,3 and the monumental work by Dr. Gierloff further revealed the aging changes of facial fat distribution and volume and explained beautifully the mechanism of facial groove formation in elderly populations.4 These understandings are fundamental for facial rejuvenation by either fat grafting or fillers for both volume restoration and effacement of aesthetically unpleasant grooves. In their letter, Dr. Oranges et al. mention the importance of ethnic consideration during facial rejuvenation when fat grafting or fillers are considered. We concur with this statement. Indeed, in our recent study of masseteric nerve anatomy in Asian populations, we did find ethnic differences in the dissection area for the masseter nerve compared with currently available data from the literature, which are mostly from Caucasian populations (unpublished data). This is because of both the skeletal and the soft-tissue differences between Caucasians and Asians. As already mentioned by Oranges et al. in their article, the Asian individual tends to have a wider but shorter face compared with Caucasian faces.5 What we provided in our article is a general principle of applying the idea of fat compartment–based fat grafting for the midface: to sculpture the facial contour by deep fat compartment restoration and achieve a smooth transition by superficial fat grafting. Fat grafting in the superficial fat compartment can also be very helpful for other cosmetic considerations. To avoid a balloon face, a golden triangle connecting the most prominent point of the zygoma and the mandibular tubercle was also recommended in our article, which concurs with the suggestion by Oranges et al. that fat grafting in Asian individuals should be limited to medial maxilla volumization, to enhance central projection and avoid the creation of facial disharmony by further widening the midface. Indeed, when fat grafting is performed for patients from different ethnicities, the difference of anatomical features should be appreciated. It is also worthwhile to mention that people from different ethnicities and cultural backgrounds possess different views of the aesthetic ideal. Although more Asians tend to appreciate “European beauty” nowadays and want to appear more European, given the anatomical differences stated above, clinicians need be cautious and appreciate the ethnic differences in these scenarios despite the strong desire from the patients, as the improper combination of European and Asian features in one face could appear odd and disharmonious. The “restoration versus augmentation” approach suggested by Dr. Oranges et al. is worthy of taking into consideration when treating patients of different ethnicities. However, a detailed and thorough study might be needed to determine the difference of fat distribution and volume changes in different populations, because both age and body mass index can also be variables affecting the fat grafting plan for each individual, in addition to ethnicity. Before that, either ethnic or individualized appreciation of beauty should be taken into consideration with each individual in the clinic, and thorough analysis and communication are also prerequisite. ACKNOWLEDGMENT This study was supported by the National Science and Technology Pillar Program during the Twelfth Five-Year Plan Period (project no. 2012BA/11B03) and by the State Key Program of the National Natural Science Foundation of China (project no. 81230042). DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Wenjin Wang, M.D., Ph.D.Yun Xie, M.D., Ph.D.Ru-Lin Huang, M.D., Ph.D.Jia Zhou, M.D., Ph.D.Department of Plastic and Reconstructive SurgeryShanghai Ninth HospitalShanghai, People’s Republic of China Tanja Herrler, M.D., Ph.D.Department of Plastic and Reconstructive SurgeryShanghai Ninth HospitalShanghai, People’s Republic of ChinaDepartment of General, Trauma, Hand, and Plastic SurgeryLudwig-Maximilian University of MunichMunich, Germany Peijuan Zhao, M.D., Ph.D.Chen Cheng, M.D., Ph.D.Sizheng Zhou, M.D., Ph.D.Department of Plastic and Reconstructive SurgeryShanghai Ninth HospitalShanghai, People’s Republic of China Lee L. Q. Pu, M.D., Ph.D.Division of Plastic SurgeryUniversity of California, DavisSacramento, Calif. Qingfeng Li, M.D., Ph.D.Department of Plastic and Reconstructive SurgeryShanghai Ninth HospitalShanghai, People’s Republic of China

Low-dose radiation therapy for massive chylous leakage after subtotal gastrectomy.

Massive chylous leakage is a rare postoperative complication that can prolong hospital stay and cause secondary morbidities. Conservative management strategies are the treatment of choice; however, radiation therapy (RT) can be used as an alternative for cases that are refractory to conservative treatment. Herein, we report a 69-year-old female patient who suffered from massive chylous leakage after subtotal gastrectomy. Due to persistent massive chylous leakage, she was scheduled to undergo low-dose RT. Radiation was delivered with a daily dose of 1 Gy, using an anterior-posterior and posterior-anterior beam arrangement. The clinical target volume encompassed the entire lymph node area of the D2 dissection. RT was completed at the total dose of 8 Gy because the amount of chylous leakage declined rapidly. Percutaneous drainage tube was removed after 3 days of RT. The patient did not complain of any symptoms related to massive chylous leakage 2 years after the completion of RT.

The masseteric nerve: An anatomical study in Thai population with an emphasis on its use in facial reanimation

The use of the masseteric nerve has been escalated as a donor nerve for facial reanimation in facial palsy patient (Wang etal., 2014; Manktelow etal., 2006; Klebuc, 2011; Bianchi etal., 2012; Zuker etal., 2000; Bae etal., 2006; Terzis, Konofaos, 2013; Terzis, Olivares, 2009; Bianchi etal., 2014). Previous studies had been done in Euro-Caucasian cadavers (Kaya etal., 2014). However, difference in anatomical details does exist between Asian and Euro-Caucasian population (Tzou etal., 2005; Farkas etal., 2005). In this study, we have conducted a detailed anatomical study of masseteric nerve in adult Thai cadavers which might elaborate better details of masseteric nerve anatomy in Asian population. Twenty eight hemifaces from 14 adult Thai non-formaldehyde preserved soft cadavers were used in this study. The anatomical pathway of the masseteric nerve was defined relating to four surgical landmarks which are auricular tragus, zygomatic arch, posterior border of the temporomandibular joint, and alar base. The suitable starting area for the masseteric nerve dissection is 3.7±0.4cm anterior to the auricular tragus at the level of 0.8±0.2cm inferior to the zygomatic arch. The nerve was found 1.1±0.2cm deep to the superficial surface of the masseteric fascia and 1.7±0.2cm anterior to the posterior border of the temporomandibular joint. The point where the nerve giving off its first branch as it courses distally is 7.3±0.7cm from the ipsilateral alar base. The mean diameter of this nerve is 1.59±0.42mm. The anatomy of the masseteric nerve during its course in the muscle is consistent. In our study, the details of its anatomy is slightly different from the previous works which were performed in the Euro-Caucasian cadavers.

Approaching the Atrium Through the Intraparietal Sulcus: Mapping the Sulcal Morphology and Correlating the Surgical Corridor to Underlying Fiber Tracts.

Although the operative corridor used during the intraparietal transsulcal approach to the atrium has been previously investigated, most anatomical studies focus on its relationship to the optic radiations. To study the intraparietal sulcus (IPS) morphology and to explore the subcortical anatomy with regard to the surgical trajectory used during the intraparietal transsulcal tranventricular approach. Twenty-five adult, formalin fixed, cerebral hemispheres were investigated. Fifteen underwent the Klingler procedure and were dissected in a lateromedial direction using the fiber microdissection technique. The trajectory of the dissection resembled that of real operative settings. The remaining 10 hemispheres were cut along the longitudinal axis of the sulcus in order to correlate its surface anatomy to corresponding parts of the ventricular system. IPS demonstrated an interrupted course in 36% of the specimens while its branching pattern was variable. The sulcus anterior half was found to overly the atrium in all occasions. Four discrete, consecutive white matter layers were identified en route to the atrium, ie, the arcuate fibers, the arcuate segment of the superior longitudinal fasciculus, the corona radiata and tapetum, with the arcuate segment being near to the dissection trajectory. Given the angle of brain transgression during the intraparietal approach, we found the optimal dissection area to be the very middle of the sulcus. The IPS-postcentral sulcus meeting point, in contrast to previous thought, proved to risk potential injury to the arcuate segment of the superior longitudinal fasciculus, thus affecting surgical outcome.

The Novel Technique of Transabdominal Preperitoneal Hernioplasty Herniorrhaphy for Direct Inguinal Hernia: Suture Repair of Hernia Defect Wall

Conventional laparoscopic surgeries of direct inguinal hernia include two methods, transabdominal preperitoneal hernioplasty (TAPP) and totally extraperitoneal hernioplasty. Both methods are performed using synthetic mesh without suturing the hernia defect and require extensive mesh coverage for not only Hesselbach's triangle but also indirect ring. For minimally invasive operation, suture of direct hernia defect was devised and performed. The purpose of this study is to evaluate the efficacy of defect wall suture of laparoscopic herniorrhaphy for direct inguinal hernia patients. We evaluated 210 direct inguinal hernia patients who received TAPP in Damsoyu Hospital, Seoul, Republic of Korea from September 2012 to December 2015. The patients were categorized into two groups according to TAPP techniques; cTAPP group had conventional TAPP without defect wall suture, and rTAPP group had defect wall suture TAPP. There were 99 patients in a cTAPP group and 111 patients in rTAPP group. Operation time and postoperative hospital stay showed no difference between two groups. The postoperative pain score within the first week was significantly lower in rTAPP group than in cTAPP group (P < .001). The mean timing of a return to normal activities for rTAPP group was 3.8 days, which was shorter than 4.6 days of cTAPP group (P < .001). There was no difference in complication and recurrence rates between two groups. Defect wall suture for direct inguinal hernia had shorter operation time, faster recovery time, reduced pain, and an acceptable rate of recurrence and complication. This TAPP surgery with hernia defect wall suture that requires smaller dissection area is an effective method for treating direct inguinal hernia.

Left video-assisted thoracic surgery thymectomy.

Video-assisted thoracic surgery (VATS) for the management of non-thymomatous myasthenia gravis (MG) as well as the management of small thymomas and other benign thymic pathology has been gaining in acceptance and popularity as an alternative to the traditional median sternotomy approach. Although VATS thymectomy has been described in several variations, our current preference is a left sided VATS approach due to the exposure it provides in critical areas of dissection. Here we describe our technique for the left sided VATS thymectomy including patient selection, preoperative preparation, operative steps, and postoperative care. We also share pitfalls and tips to prevent them at each step of the procedure learned from our experience with this approach.

Distant nodal metastasis: is it always an unresectable disease?

This article aims at analyzing the published literature concerning the treatment of patients with gastric cancer and distant nodal metastases, actually considered metastatic disease. A systematic search was undertaken using Medline, Embase, Cochrane and Web-of-Science libraries. No specific restriction on year of publication was used; preference was given to English papers. Both clinical series and literature reviews were selected. Only 11 papers address the issue of surgery for nodal basins outside the D2 dissection area. From these papers, in selected cases extended surgery may prove useful in prolonging survival, when a comprehensive therapeutic pathway including chemotherapy is scheduled. In conclusion, in presence of nodal metastases outside the loco-regional nodes, surgery may be considered for metastatic nodes in stations 13 and 16, in selected cases.

Transoral endoscopic thyroidectomy for papillary thyroid microcarcinoma: initial experience of a single surgeon.

PurposeRecently, transoral endoscopic thyroidectomy (TOET) is receiving attention because it is regarded as a true minimally invasive surgery in that it does not leave scars on any part of the body and the area of flap dissection is similar to that of open surgery. In this study, we present the surgical procedures and initial outcomes of TOET in the treatment of papillary thyroid microcarcinoma (PTMC) patients.MethodsThe medical records of patients who underwent TOET for PTMC between July 2016 and February 2017 were retrospectively reviewed. Indication of TOET was PTMC without capsular invasion or lymph node metastasis on preoperative imaging studies.ResultsTen female patients were enrolled. Seven patients underwent thyroid lobectomy and three patients underwent isthmusectomy. The mean age and tumor size was 43.3 ± 11.5 years and 0.6 ± 0.2 cm, respectively. Operation time for lobectomy and isthmusectomy was 121.1 ± 30.7 (range, 65–148) and 90.0 ± 9.2 minutes (range, 82–100 minutes), respectively. The mean number of retrieved lymph nodes was 2.7 ± 1.7. Two patients had transient vocal cord palsy, which recovered in three months. There was no case with subcutaneous emphysema, surgical site infection, postoperative bleeding, or mental nerve injury.ConclusionTOET was feasible and could be performed safely for PTMC. TOET might become a new treatment option for the patients who do not want to leave visible scars on the body.

Catheter induced aortocoronary dissection during percutaneous coronary intervention: successful aortoostial stenting

Iatrogenic acute dissection of the ascending aorta is a serious but rare complication of cardiac catheterization and percutaneous coronary intervention (PCI). Although treatment of ascending aortic dissection may require surgical repair, stenting at the origin of the dissection area may be sufficient in aortocoronary dissection (AD) following PCI. Described is the case of a 64-year-old female patient who was treated with PCI for a critical lesion of the right coronary artery (RCA). Immediate stenting at the source of the dissection was sufficient to repair the RCA lesions and successfully seal the site of retrograde propagation of the dissection. The ascending aortic dissection was monitored with computed tomography and the dissection was spontaneously repaired within 72 hours.

An original technique for lymph node dissection along the left recurrent laryngeal nerve after stripping the residual esophagus during video-assisted thorocoscopic surgery of esophagus.

A clear operative view of the middle and lower mediastinum is possible in prone position during video-assisted thorocoscopic surgery of esophagus (VATS-E), but the working space in the upper mediastinum is limited and lymph node dissection along the left recurrent laryngeal nerve (RLN) is difficult in this position. Esophagectomy and lymph node dissection are performed for pneumothorax by maintaining CO2 insufflation in the prone position. Working space in the left upper mediastinal area for lymph node dissection around RLN is limited in this position. To create space, the residual esophagus is stripped in the reverse direction and retracted toward the neck after the stomach tube is removed through the nose. Lymph node dissection is performed after stripping the residual esophagus. We could obtain a clear operative field in the upper left mediastinum by stripping the residual esophagus in the prone position, enabling safe and straightforward lymph node dissection along the left RLN. The rate of permanent RLN paralysis was 1.2%. Lymph node dissection along the left RLN after esophageal stripping is possible in the prone position during VATS-E.

Incidence and risk factors for breast cancer-related lymphedema: a retrospective cohort study

Objective To determine the incidence of breast cancer-related lymphedema (BCRL) in China and to analyze the associated risk factors. Methods A retrospective analysis was performed on the clinical data and the incidence of BCRL in 281 patients who were newly diagnosed with breast cancer and received surgery. The incidence of BCRL was evaluated using arm circumference measurement and Norman questionnaire. The risk factors for lymphedema were analyzed using chi-square test and logistic regression model. Results In all patients, the incidence rates of BCRL determined by arm circumference measurement and Norman questionnaire were 31.7% and 27.0%, respectively. The multivariate analysis showed that postoperative radiotherapy, a preoperative body mass index no less than 24 kg/m2, a large axillary lymph node dissection area, and a large number of positive axillary lymph nodes significantly increased the risk of BCRL (HR=2.87, P=0.042; HR=2.54, P=0.011; HR=1.97, P=0.037; HR=1.06, P=0.023). Moreover, patients with breast cancer and hypertension had 1.74-fold higher risk of BCRL than those with normal blood pressure. Conclusions The incidence of BCRL is still very high. However, most of patients only have mild edema. Postoperative radiotherapy, a large axillary lymph node dissection area, a large number of positive axillary lymph nodes, a high preoperative body mass index, and hypertension are risk factors for BCRL. Key words: Lymphedema; Incidence rates; Risk factors; Breast neoplasms/surgery; Breast neoplasms/radiotherapy

Structuring Quality Education by Proposing Physical Infrastructure of a Medical School

Background: Due to cost containment considerations, it is common to have medical schools beinglocated in buildings or campuses built for some other purposes. These buildings are converted intomedical schools which often compromising the functional architectural aspects. Objectives: Thepaper examines, explores and proposes an architectural concept of a purpose-built medical school. Thearchitectural design proposed is sensitive to the values and norms of many schools around the globe.Methods: An Internet search and personal communication were conducted, focusing on the conceptsof the functionality of medical school. It emphasises on general design of the main building, keepingin mind the various kinds of teaching, learning and assessment activities. We examined lecture hall,pre-clinical laboratory, skill laboratory, general facilities of Objective Structured Practical Examination(OSPE) and Objective Structured Clinical Examination (OSCE). Results: We present hypotheticalstructural designs based on built-functions concepts. For example, for the better vision of studentsaround a demonstration table, an inclined floor surface is proposed. The concept is as illustrated byanatomy dissection area built inclined upward from the cadaver table. It inevitably provides a bettervisual access to the students around the table. Other teaching and learning areas are also illustratedwherever appropriate in the text. Conclusion: The paper is hypothetical and explores innovativestructural designs of modern medical schools. While most are built to meet the demands of currenttechnology, it cannot however completely replace face-to-face teaching and learning processes.Research in architectural designs of education buildings and facilities may be further developed into anew research niche of medical education.

Analysis of Aortic Growth Rates in Uncomplicated Type B Dissection

Uncomplicated type B dissections have historically been treated medically with hemodynamic control. Early progression of the disease and late aneurysmal dilation have been considered indications for intervention. The aim of this study was to analyze growth rate patterns of type B dissections based on computed tomography (CT) measurements over time. We conducted a retrospective review of patients with acute type B dissection from 2008 to 2014 who had at least two follow-up CT scans. Patients with rapid progression requiring interventions were also included. Using M2S software (M2S, Lebanon, NH), we calculated the mean centerline diameter of the true and false lumens at three different sites of the descending aorta. Growth rate was calculated as the change in maximal diameter between the first, interval, and last available CT scans. Primary outcome was to compare the growth rate pattern between the two time intervals. Secondary outcomes included early and delayed aortic intervention and overall mortality. A total of 108 patients were included. Average age of patients was 58.7 years. Median follow-up time was 3 months for the first CT scan and 32 months for the second. Disease-specific mortality was 5.6% (6 patients) at 30 days, 12% (13 patients) at 12 months, and 19.4% (21 patients) at >1-year follow-up. Overall mortality was 27.8%. Thirty-seven percent (40 patients) required operative intervention (18 open, 22 endovascular repair): 20 at 30 days, 12 at 12 months, and 8 patients at >1 year. Mean aortic growth rate was higher in the first time interval compared with the second: 0.88 vs 0.19 mm/month (P < .05) at the dissection flap, 1.01 vs 0.18 mm/month (P < .05) at the mid-descending aorta, and 0.65 vs 0.28 mm/month (P < .05) at the diaphragm. The growth rate at dissection area was higher in those requiring operation (P < .05). Age and number of comorbidities were associated with overall mortality. Thrombosis of the false lumen did not affect the mortality and intervention rate. During the study period, the overall aortic growth rate was not linear, with a more prominent initial phase. A relevant number of patients ultimately required interventions. Prospectively designed studies are needed to identify the subgroup of patients who may benefit from early intervention based on growth rate measurements.

Therapeutic strategy for small-sized lung cancer.

Minimizing the volume of lung resection without diminishing curability has recently become an important issue in primary lung cancer. In this review, we will discuss the current state of the feasibility of sublobar resection and specific issues for a segmentectomy procedure. A previous randomized controlled trial showed that lobectomy must still be considered the standard surgical procedure compared with sublobar resection for T1N0 non-small cell lung cancer with a tumor less than 3cm in size. Since then, supporting studies for segmentectomy of lung cancer with a tumor less than 2cm in size were reported. In addition, segmentectomy seems to be feasible for clinical stage I adenocarcinoma less than 2cm in size, in women younger than 70years old, with a low tumor 18F-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) standardized uptake value (SUV) from propensity-matching studies. In a meta-analysis of sublobar resection vs. lobectomy, intentionally performed sublobar resection showed equivalent outcomes to lobectomy. In the near future, two ongoing prospective, randomized trials will report results. As specific issues for the surgical procedure of segmentectomy, achieving a sufficient surgical margin is an important issue for preventing loco-regional recurrence. More studies regarding the regional lymph node dissection area for segmentectomy are needed. Sublobar resection has the potential to become the standard procedure for peripheral small-sized lung cancer less than 2cm. However, more information is needed about the characteristics of this cancer and the surgical procedure, including nodal dissection.

Endoscopic thyroidectomy: retroauricular approach.

The incidence of thyroid cancer has abruptly increased recently, with a female predominance. Conventional thyroidectomy using transcervical incision inevitably leaves an unfavorable neck scar; therefore, various extracervical approaches have been introduced to improve cosmetic satisfaction after thyroidectomy. Several reports demonstrated that these extracervical approaches have advantages not only in terms of cosmesis but also in terms of surgical outcomes and postoperative functional preservation. The retroauricular approach has advantages as the dissection area is smaller than that in the transaxillary approach (TA) and surgical anatomy is familiar to the head and neck surgeons. In addition, there is no concern about paresthesia around the nipple or anterior chest, and surgical direction makes central neck dissection easier than with the other extracervical approaches. Herein, we aim to introduce the surgical procedure of retroauricular approach thyroidectomy and present our experiences of postoperative outcomes.

Bowel function and quality of life after superior mesenteric nerve plexus transection in right colectomy with D3 extended mesenterectomy.

The aim of this study was to ascertain the impact of injury to the superior mesenteric nerve plexus caused by right colectomy with D3 extended mesenterectomy as performed in the prospective multicenter trial: "Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic Multi-detector Computed Tomography" in which all soft tissue surrounding the superior mesenteric vessels from the level of the middle colic artery to that of the ileocolic artery was removed. Bowel function and gastrointestinal quality of life in two consecutive cohorts that underwent right colectomy with and without D3 extended mesenterectomy were compared. Main outcome measures were the Diarrhea Assessment Scale (DAS) and Gastrointestinal Quality of Life Index (GIQLI). The data were collected prospectively through telephone interviews. Forty-nine patients per group, comparable for age, sex, length of bowel resected but with significantly shorter follow-up time in the experimental group, were included. There was no difference in total DAS scores, subscores or additional questions except for higher bowel frequency scores in the D3 group (p=0.02). Comparison of total GIQLI scores and subscales showed no difference between groups. Regression analysis with correction for confounding factors showed 0.48 lower bowel frequency scores in the D2 group (p=0.022). Within the D3 group presence of jejunal arteries cranial to the D3 dissection area showed 1.78 lower DAS scores and 0.7 lower bowel frequency scores. Small bowel denervation after right colectomy with D3 extended mesenterectomy leads to increased bowel frequency but does not impact gastrointestinal quality of life. Individual anatomical variants can affect postoperative bowel function differently despite standardized surgery.

The Inferolateral Transorbital Endoscopic Approach: A Preclinical Anatomic Study

In recent years, transorbital endoscopic approaches are increasing in popularity as they provide several corridors to reach lateral areas of the ventral skull base through the orbit. The aim of this study is to investigate the feasibility of the inferolateral transorbital endoscopic approach (ILTEA) by detailing the step-by-step dissection, anatomic landmarks, and target anatomic areas. Seven cadaveric specimens (14 sides) were dissected in the Laboratory of Endoscopic Anatomy of the University of Brescia. Step-by-step dissection of ILTEA was performed to identify the main anatomic landmarks and corridors. Skin incision, dural incision, and boundaries of craniectomy were measured. Neuronavigation was used to check landmarks, track boundaries of surgical volumes, and measure orbital dislocation. The study on the 14 ILTEAs defined 1 anatomic area ("waterline door") that leads to 4 corridors: Meckel's cave corridor, carotid foramen corridor, petrous corridor, and transdural middle fossa corridor. Crucial anatomic landmarks were identified and analyzed. Orbital dislocation was <10 mm. ILTEA provides the surgeon with a direct route to the region of the "waterline door," lateral areas of the ventral skull base, and middle cranial fossa. In addition, it allows an optimal view of the intracranial and extracranial portions of the maxillary and mandibular nerves. Further anatomic and clinical studies are needed to validate ILTEA in surgical practice.

Subcutaneous dissection area contributes less to endoscopic thyroidectomy-related invasiveness

To clarify the contribution of the subcutaneous area during breast approach endoscopic thyroidectomy (BAET), with regard to invasiveness-related outcomes. Seventy-two patients were randomly assigned to two groups: standard dissection and limited dissection. Postoperative pain and inflammatory response were compared between groups. The groups were well matched except for subcutaneous dissection area (137.11±21.10 vs. 83.69±12.10cm(2), p<0.0001). No significant difference was found with regard to VAS score and postoperative inflammatory response. Our RCT indicated that the subcutaneous area plays a less important role with regard to BAET-related postoperative pain.

The incidence of hoarseness after mediastinoscopy and outcome of video-assisted versus conventional mediastinoscopy in lung cancer staging*

ABSTRACTObjectives Theoretically, video-assisted mediastinoscopy (VM) should provide a decrease in the incidence of hoarseness in comparison with conventional mediastinoscopy (CM). Methods An investigation of 448 patients with the NSCLC who underwent mediastinoscopy (n = 261 VM, n = 187 CM) between 2006 and 2010.Results With VM, the mean number of sampled LNs and of stations per case were both significantly higher (n = 7.91 ± 1.97 and n = 4.29 ± 0.81) than they were for CM (n = 6.65 ± 1.79 and n = 4.14 ± 0.84) (p < 0.001 and p = 0.06). Hoarseness was reported in 24 patients (5.4%) with VM procedures resulting in a higher incidence of hoarseness than did CM procedures (6.9% and 3.2%) (p = 0.08). The incidence of hoarseness was observed to be more frequent in patients with left-lung carcinoma who had undergone a mediastinoscopy (p = 0.03). Hoarseness developed in 6% of the patients sampled at station 4L, whereas this ratio was 0% in patients who were not sampled at 4L (p = 0.07). A multivariate analysis showed that the presence of a tumor in the left lung is the only independent risk factor indicating hoarseness (p = 0.09). The sensitivity, NPV, and accuracy of VM were calculated as to be 0.87, 0.95, and 0.96, respectively. The same staging values for CM were 0.83, 0.94, and 0.95, respectively.Conclusion VM, the presence of a tumor in the left-lung, and 4L sampling via mediastinoscopy are risk factors for subsequent hoarseness. Probably due to a wider area of dissection, VM can lead to more frequent hoarseness.

Evaluation of Lymphorrhea and Incidence of Lymphoceles: 4DryField® PH in Radical Retropubic Prostatectomy.

Purpose. To investigate impact of polysaccharide hemostat 4DryField PH (4DF) applied on lymph node dissection area after radical retropubic prostatectomy (RRP) on lymphorrhea and lymphocele (LC) formation. Methods. 104 consecutive patients underwent RRP, 51 without 4DF treatment (CT-group) and 53 with 4DF treatment (4DF-group). Groups were comparable (age, risk profile, and lymph node numbers). Postoperative drain loss (PDL) and development of early and late LC were analyzed (mean follow-up at 7 months: 100%). Results. PDL was 452.5 ± 634.2 mL without and 308.5 ± 214 mL with 4DF treatment. PDL > 1000 mL only occurred in CT-group (5/51). Overall, 45 LC (26 in CT- versus 19 in the 4DF-group) were diagnosed. At day 8, LC were equally distributed between groups. Incidence of late LC, however, was twice in controls (16/51) versus 4DF-patients (8/53). Symptomatic LC (4 in untreated patients, 2 in 4DF-patients) were treated with percutaneous drainage (duration: 45 days in untreated patients versus 12 days in 4DF-patients). Conclusion. Application of 4DF on lymph node dissection areas lessened total drain loss and significantly lowered high volume drain loss. Furthermore, 4DF reduced frequency of late lymphoceles and lymphoceles requiring treatment by half, as well as duration of percutaneous drainage by more than two-thirds.