Early Stage Of Surgery Research Articles

Lately Obtained Baseline Waves in Motor Evoked Potential Monitoring during the Surgery of Frontal Lobe Tumor

Intraoperative neurophysiologic monitoring during brain tumor surgery should acquire a baseline data as soon as possible. However, motor unit potentials (MEP) in our case showed baseline data could not be acquired in the early stage of surgery, but consecutive trials had abrupt appearance of MEP just after dura opening. This case shows the acquisition of baseline MEP during brain tumor surgery should not be given up until the dura is open especially in a state of raised intracranial pressure.

Selection of Appropriate Approaches to Preserve Brain Function for Deep Seated Brain Tumors:Our Experience of Two Posterior Thalamic Cases

What is the most important factor to achieve successful surgery for deep-seated brain tumors with preservation of brain functions? Definitely, it is to identify the tumor origin site at which a tumor arose and select appropriate surgical approaches that immediately lead directly to the site in the early stage of surgery, minimizing damages of cortices and important white matter bundles, and controlling main arterial supply to the tumor. For this, neurosurgeons must have thorough knowledge of brain anatomy and function, and tailor the best surgical approach for each patient, based on three-dimensional anatomical simulation. For lesions situated in the posterior and lower part of the thalamus and extending to the lateral part, two "cross-court" approaches; the occipital transtentorial/falcine and infratentorial supracerebellar transtentorial approaches, provide a wide corridor to even the lateral aspect of the thalamus and early access to the posterior choroidal arteries, usually main feeders of this territory tumors, without damaging any cerebral cortices and major white matter bundles. Here, we describe the selection of approaches for two representative cases and demonstrate surgical procedures and postoperative courses.

Left-sided major hepatectomy with en bloc resection of the hepatoduodenal ligament utilizing a liver-transection first approach: A video vignette

TechniqueHepatoduodenal ligamentectomy (HL) is a challenging surgery for advanced perihilar cholangiocarcinoma extensively invading the hepatoduodenal ligament1-3. A liver-transection first approach in HL is a no-touch technique wherein liver transection is performed first, and the affected liver and hepatoduodenal ligament are removed en bloc. This approach allows for the early assessment of resectability and feasibility of vascular reconstruction4. ResultsThis video shows a 57-year-old man with advanced intrahepatic cholangiocarcinoma in the left hepatic lobe, which had directly invaded the perihilar region and the hepatoduodenal ligament via lymph node metastasis. The lymph node was extensively invasive into both the proper hepatic artery and portal vein. The case was initially deemed unresectable, but after three months of chemotherapy, conversion surgery was considered feasible. The common hepatic artery and gastroduodenal artery and then the common bile duct and main trunk of portal vein were secured at the pancreatic superior border. Hepatic dissection was performed along the Cantlie line. The right Glissonean pedicle was secured, including the right hepatic duct, right hepatic artery and right portal vein, and the operation was deemed feasible. The portal vein was dissected and reconstructed using the right external iliac vein. The left and caudate lobe with the middle hepatic vein and hepatoduodenal ligament were resected en bloc. Subsequentially, the common hepatic artery and right hepatic artery were reconstructed using the jejunal artery. ConclusionThe liver-transection first approach allowed us to determine the resectability of en bloc resection of the hepatoduodenal ligament at an early stage of surgery.

Role of Extradural Clinoidectomy and Optic Unroofing in Resection of an Anterior Clinoidal Meningioma with Encasement of the Internal Carotid Artery and Its Branches.

Anterior clinoidal meningiomas (ACMs) remain a major neurosurgical challenge. The skull base techniques, including extradural clinoidectomy and optic unroofing performed at the early stage of surgery, provide advantages for improving the extent of resection, and thereby enhancing overall outcome, and particularly visual function. Additionally, when the anterior clinoidal meningiomas encase neurovascular structures, particularly the supraclinoid internal carotid artery and its branches, this further increases morbidity and decreases the extent of resection. Although it might be possible to remove the tumor from the artery wall despite complete encasement or narrowing, the decision of whether the tumor can be safely separated from the arterial wall ultimately must be made intraoperatively. The patient is a 75-year-old woman with right-sided progressive vision loss. In the neurological examination, she only had light perception in the right eye without any visual acuity or peripheral loss in the left eye. MRI showed a homogeneously enhancing right-sided anterior clinoidal mass with encasing and narrowing of the supraclinoid internal carotid artery (ICA). Computed tomography (CT) angiography showed a mild narrowing of the right supraclinoid ICA with associated a 360-degree encasement. The decision was made to proceed using a pterional approach with extradural anterior clinoidectomy and optic unroofing. The surgery and postoperative course were uneventful. MRI confirmed gross total resection ( Figs. 1 and 2 ). The histopathology was a meningothelial meningioma, World Health Organization (WHO) grade I. The patient continues to do well without any recurrence and has shown improved vision at 15-month follow-up. This video demonstrates important steps of the microsurgical skull base techniques for resection of these challenging tumors. The link to the video can be found at https://youtu.be/vt3o1c2o8Z0

MP70-15 PRECISE PROSTATE CRYOTHERAPY GUIDED BY MAGNETIC RESONANCE IMAGING AND 99MTC-PSMA SPECT/CT

You have accessJournal of UrologyProstate Cancer: Localized: Ablative Therapy II (MP70)1 Apr 2020MP70-15 PRECISE PROSTATE CRYOTHERAPY GUIDED BY MAGNETIC RESONANCE IMAGING AND 99MTC-PSMA SPECT/CT Guo-Wen Lin* Guo-Wen Lin*Guo-Wen Lin* More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000950.015AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prostate cryotherapy can effectively control tumor lesions, relieve symptoms and improve patients' quality of life by killing tumor cells at low temperature. The 99mTc-PSMA SPECT/CT examination has high specificity, sensitivity and cost performance for prostate cancer. This study explored the value of precision magnetic resonance imaging and 99mTc-PSMA SPECT/CT guided precision prostate cryotherapy in early localized prostate cancer. METHODS: We retrospectively collected data from 20 patients with localized prostate cancer who underwent prostate cryotherapy from October 2017 to October 2018. Preoperative pelvic magnetic resonance imaging (MR) and 99mTc-PSMA SPECT/CT were performed to assess the location of lesions and its size. Argon-helium cryoablation technique was used. The intraoperative ultrasound guided the 1.47mm diameter probe into the prostate through the perineum. The argon gas formed the needle tip into a spherical ice hockey with a diameter of 2cm and the ice hockey cooled to -140∼-170°C, after 10-15 minutes, the argon gas was turned off, and then the helium gas was started to rapidly raise the local temperature to 20∼40°C for 3 minutes, and two cycles were performed to completely damage the diseased tissue. Postoperative follow-up was used to assess changes in PSA and imaging. RESULTS: Evaluation of lesions using images, combined with intraoperative ultrasound real-time images. All patients accurately located the lesion location and size, and ice hockey range prostate tissue should be included as much as possible, and at least 1 needle complete including tumor lesions. PSA was reviewed 1 month after cryotherapy, suggesting that the median value was 10.3 ng/mL (45.5% reduction). Three months later, 18 patients underwent MR and/or 99mTc-PSMA SPECT/CT, showing the lesion disappeared completely for 4 cases, 14 patients' local lesions were clearly controlled. Common postoperative adverse reactions included short-term dysuria (6/20, 30%), lower abdominal distension (4/20, 20%), hematuria (1/20, 5%), and local necrosis of the urethra (1/20, 5%). CONCLUSIONS: Prostatic cryotherapy is effective for patients with a life expectancy of <10 years or an early stage of surgery that is not suitable for surgery. The examination of MR and/or 99mTc-PSMA SPECT/CT can guide the precise positioning and treatment of prostate cryopreservation, and has great clinical value. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1060-e1061 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Guo-Wen Lin* More articles by this author Expand All Advertisement PDF downloadLoading ...

Positional disappearance of motor evoked potentials is much more likely to occur in non-idiopathic scoliosis.

PurposeThis study evaluates intraoperative disappearance of motor waveforms related to patient positioning in neurologically asymptomatic patients with spinal deformity.MethodsThis is a retrospective review of 190 neurologically asymptomatic patients aged seven to 17 years planned for posterior instrumentation under neuromonitoring. There were 159 patients with adolescent idiopathic scoliosis and 31 patients with secondary scoliosis. Patients underwent surgery with transcranial electric stimulation motor evoked potentials (TES-MEPs). In case of abnormal findings, surgery was temporarily discontinued and necessary measures undertaken. In case of permanent signal disappearance surgery was definitively discontinued.ResultsSix patients showed permanent loss of signal during early stages of surgery. These patients had a mean major curve of 64° Cobb angle and a mean thoracic kyphosis (D2 to D12) of 72°. The 184 remaining patients had a mean major curve of 50° Cobb angle and a thoracic kyphosis of 35°. A retrospective descriptive review of the patients’ radiographs shows hyperkyphosis to be the common ground between the six secondary scoliosis cases. Gradual preoperative traction maintained during the surgery applied in two of these patients taken back to surgery six months later was associated with maintenance of TES-MEP signals throughout the surgery.ConclusionThis study shows that positional permanent loss of neuromonitoring signals is more likely to occur in patients with secondary scoliosis and hyperkyphosis shown to have sharper spine deformity and suspected to have a more vulnerable spinal cord. Gradual skeletal traction performed in two of these patients and maintained during surgery showed promising results.Level of EvidenceIV

Ultra-Early Optic Nerve Decompression for the Resection of Anterior Clinoidal Meningioma.

Improvement in vision is one of the main goals of surgery for anterior clinoidal meningiomas with visual deficits. Early optic nerve decompression surgery has been advocated in previous studies to achieve the best visual outcome. Through this video, the authors describe their surgical techniques to decompress the optic nerve at the very early stage of surgery.A 35-year-old patient presented with subjective blurry vision in the right eye over the last 8 months. Magnetic resonance images showed a 3.2-cm meningioma arising at the right anterior clinoid. Preoperative ophthalmological test was within the normal range, but the patient wished to have surgical resection after a detailed discussion of benefits and risks related to surgical resection. The surgical strategy consisted of the right lateral subfrontal approach that includes a standard right frontotemporal craniotomy, extradural anterior clinoidectomy, and early optic nerve decompression prior to tumor resection. The tumor was divided into compartments defined by the arteries and resected. Simpson grade II resection was achieved without complications. The patient's symptoms disappeared.In anterior clinoidal meningiomas that cause visual deficits, the optic nerve is assumed very vulnerable to any further injuries related to the operative maneuver. Ultra-early optic nerve decompression can be performed in anterior clinoidal meningiomas regardless of their size by extradural unroofing of the optic canal and sectioning of the optic canal sheath, which we believe contributes to better visual improvement. The link to the video can be found at: https://youtu.be/RIFi4ecWAhQ .

TLR4/NF-κB signaling activation in plantar tissue and dorsal root ganglion involves in the development of postoperative pain

BackgroundSevere postoperative pain remains a clinical problem that impacts patient’s rehabilitation. The present work aims to investigate the role of Toll-like receptor-4 (TLR4) activation in wounded plantar tissue and dorsal root ganglion (DRG) in the genesis of postoperative pain and its underlying mechanisms.ResultsPostoperative pain was induced by plantar incision in rat hind paw. Plantar incision led to increased expression of TLR4 in ipsilateral lumbar 4–5 (L4/L5) DRGs, which occurred at 2 h and was persistent to the third day after surgery. Similar to the change in TLR4 expression, there was also significant increase in phosphorylated nuclear factor-kappa B p65 (p-p65) in DRGs after surgery. Immunofluorescence staining revealed that the increased expressions of TLR4 and p-p65 not only in neuronal cells but also in satellite glial cells in DRG. Furthermore, the enhanced expressions of TLR4 and p-p65 were also detected in plantar tissues around the incision, which was observed starting at 2 h and lasting until the third day after surgery. Prior intrathecal (i.t.) injections of TAK-242 (a TLR4-specific antagonist) or 4',6-diamidino-2-phenylindole-dihydrochloride (PDTC, a nuclear factor-kappa B activation inhibitor) dose dependently alleviated plantar incision-induced mechanical allodynia and thermal hyperalgesia and inhibited the increased expressions of p-p65, tumor necrosis factor-alpha, and interleukin-1 beta in DRG. Prior subcutaneous (s.c.) plantar injection of TAK-242 or PDTC also ameliorated pain-related hypersensitivity following plantar incision. Moreover, the plantar s.c. injection of TAK-242 or PDTC inhibited the increased expressions of p-p65, tumor necrosis factor-alpha, and interleukin-1 beta not only in local wounded plantar tissue but also dramatically in ipsilateral lumbar 4–5 DRGs.ConclusionTLR4/ nuclear factor-kappa B signaling activation in local injured tissue and DRG contribute to the development of postoperative pain via regulating pro-inflammatory cytokines release. Targeting TLR4/ nuclear factor-kappa B signaling in local tissue at early stage of surgery may be an effective strategy for the treatment of postoperative pain.

Positional disappearance of motor evoked potentials (MEPs) is much more likely to occur in non-idiopathic scoliosis

Introduction To evaluate intraoperative disappearance of MEPs related to patient positioning in neurologically asymptomatic patients with spinal deformity planed for posterior instrumentation with or without fusion. Material and methods This is a retrospective review of all neurologically asymptomatic children and adolescents who were planned for posterior instrumentation under MEP control during the last 3 years. A total of 189 patients were included. Age at surgery ranged between 7 and 17 years. There were 159 patients with adolescent idiopathic scoliosis (AIS), 4 neurofibromatosis, 6 connective tissue disease, 6 skeletal dysplasia, 5 metabolic disorder including muccopolysaccharidosis, and 9 early onset scoliosis or kyphoscoliosis of unknown origin. All patients underwent MEP monitoring and general anesthesia according to general guidelines with some personal variations. MEP recording is undertaken 11 times on average between induction of anesthesia and the end of surgery, and in case of abnormal findings, surgery is temporarily discontinued and necessary measures undertaken (increase temperature and blood pressure…), and if needed a wake-up test is performed. In case of permanent signal disappearance and no gross motor function during the wake-up test, surgery is definitively discontinued. Patients with permanent loss of MEP signal requiring definitive surgery discontinuation were thoroughly reviewed and represent the core of this study. Results Six patients showed permanent loss of MEP signal during the early stages of surgery, three of which even before incision. There were one AIS (in which the loss of signal was later found to be related to a simple technical problem), one early onset kyphoscoliosis, one neurofibromatosis, one muccopolysaccharidosis, one Ehlers Danlos disease, and one congenital progressive anterior bloc with multilevel thoracic and lumbar stenosis. All of them resumed normal motor function after wake-up, except for the case with progressive anterior bloc who woke-up paraplegic but has regained ambulation with crutches one year later. An extensive work-up was undertaken secondarily in all 6 cases including total spine MRI, lower limb EMG, etc., to identify any etiology that could explain the loss of signal but was negative in all. The hypothesis of positional temporary suffering of the spinal cord was therefore considered. Discussion AIS seems rarely if ever associated with intraoperative neurological risk even the one related to patient position. When MEPs disappear permanently especially at the very early stages of surgery, this may be due to position, and is much more likely to occur in patients with secondary scoliosis, suspected to have a more vulnerable spinal cord.

Hyaluronidase injection for improved tissue dissection in Baerveldt tube surgery.

To describe a novel technique for tissue dissection during Baerveldt tube surgery. We present a technique for posterior dissection of conjunctiva and Tenon tissue for the placement of a glaucoma drainage device. Hyaluronidase is used in the early stages of surgery in order to minimize tissue trauma and facilitate easy dissection even through existing adhesions and conjunctival scarring. The technique facilitates convenient dissection through tissues. We did not experience any intraoperative or postoperative complications. The described technique has substantial advantages for Baerveldt tube surgery, specifically in cases of previous ocular surgery and subsequent conjunctival scarring. It is safe and easy to perform, and should be considered in cases of glaucoma drainage device implantation surgeries.

Intracameral mydriatics versus topical mydriatics in pupil dilation for phacoemulsification cataract surgery

To evaluate the efficacy and safety of intracameral mydriatics (lidocaine 1.0% and phenylephrine 1.5%) versus topical mydriatics (phenylephrine 2.5% and tropicamide 1.0%) in pupil dilation for phacoemulsification surgery in Malaysians. Department of Ophthalmology, Penang General Hospital, Georgetown Penang, Malaysia. Prospective comparative case series. Patients with immature cataract were randomized tothe topical mydriatic group (topical group) or intracameral mydriatic group (intracameral group). Patients with small pupilsand complicated cataracts were excluded. Pupil diameterchanges were measured throughout the surgery. Additional pupil dilation maneuvers and complications were recorded. The study comprised 112 patients. There was no difference in mean pupil dilation between the intracameral group (4.86mm±0.74 [SD]) and the topical group (4.88±0.91mm) (P=.86). However, the mean pupil size before capsulorhexis in the topical group (7.23±1.08mm) was significantly larger than in theintracameralgroup (6.40±0.80mm)(P=.01). The pupils in the intracameral group continued to dilate during surgery (0.44±0.62mm), while those in the topical group constricted (-0.41±1.04mm) (P<.001). Three patients in the intracameral group and 6 in the topical group required additional maneuvers for pupildilation (P=.49). Each group had 1 complication (P=1.00). Intracameral mydriatic agents dilated heavily pigmented pupils for phacoemulsification cataract surgery. However, in the early stages of surgery, pupil dilation was slower than with topical agents.

Antibacterial activity and cytocompatibility of an implant coating consisting of TiO2 nanotubes combined with a GL13K antimicrobial peptide.

Prevention of implant-associated infections at an early stage of surgery is highly desirable for the long-term efficacy of implants in dentistry and orthopedics. Infection prophylaxis using conventional antibiotics is becoming less effective due to the development of bacteria resistant to multiple antibiotics. An ideal strategy to conquer bacterial infections is the local delivery of antibacterial agents. Therefore, antimicrobial peptide (AMP) eluting coatings on implant surfaces is a promising alternative. In this study, the feasibility of utilizing TiO2 nanotubes (TNTs), processed using anodization, as carriers to deliver a candidate AMP on titanium surfaces for the prevention of implant-associated infections is assessed. The broad-spectrum GL13K (GKIIKLKASLKLL-CONH2) AMP derived from human parotid secretory protein was selected and immobilized to TNTs using a simple soaking technique. Field emission scanning electron microscope, X-ray diffraction, Fourier transform infrared spectroscopy, and liquid chromatography–mass spectrometry analyses confirmed the successful immobilization of GL13K to anatase TNTs. The drug-loaded coatings demonstrated a sustained and slow drug release profile in vitro and eradicated the growth of Fusobacterium nucleatum and Porphyromonas gingivalis within 5 days of culture, as assessed by disk-diffusion assay. The GL13K-immobilized TNT (GL13K-TNT) coating demonstrated greater biocompatibility, compared with a coating produced by incubating TNTs with equimolar concentrations of metronidazole. GL13K-TNTs produced no observable cytotoxicity to preosteoblastic cells (MC3T3-E1). The coating may also have an immune regulatory effect, in support of rapid osseointegration around implants. Therefore, the combination of TNTs and AMP GL13K may achieve simultaneous antimicrobial and osteoconductive activities.

Nonrecurrent Laryngeal Nerve in the Era of Intraoperative Nerve Monitoring.

Nonrecurrent laryngeal nerve (non-RLN) is an anatomical variation increasing the risk of vocal cord palsy. Prediction and early identification of non-RLN may minimize such a risk of injury. This study assessed the effect of intraoperative neuromonitoring (IONM) on the detection of non-RLN. A total of 462 (236 right) nerves in 272 patients were identified and totally exposed, and all intraoperative steps of IONM were sequentially applied on the vagus nerve (VN) and RLN. Right predissection VN stimulation at a distal point did not create a sound signal in three cases (3/236; 1.27%). Proximal dissection of the right VN under IONM guidance established a proximal point, creating a positive signal. The separation point of non-RLN from VN was discovered in all three patients. Non-RLNs were exposed from separation to laryngeal entry. Positive IONM signals were obtained after resection of thyroid lobes, and postoperative period was uneventful in patients with non-RLN. Absence of distal VN signal is a precise predictor of the non-RLN. IONM-guided proximal dissection of the right VN leads to identification of the non-RLN. The prediction of non-RLN by the absence of the VN signal at an early stage of surgery may prevent or minimize the risk of nerve injury.

EComment. Efforts to further enhance the safety of sternal re-opening in the paediatric age group

We thank Gandolfo et al. for their effective and easy reproducible technique for managing major vessel injuries during chest re-entry in children [1]. As diagnostic and therapeutic interventions in congenital heart diseases advance progressively, cardiac surgeons have begun to deal with chest re-opening more frequently. Although major venous damages like innominate vein can be managed by a Fogarty catheter, cardiac surgeons are still facing challenging problems, such as damage of cardiac chambers, retrosternal right ventricle to pulmonary artery conduits and ascending aortic aneurysms during the re-sternotomy procedures performed in children. In such cases, we believe that the inflation of Fogarty catheters may even enlarge the defect and make it more uncontrollable in an incomplete sternotomy. In our practice, patients with a sternotomy history are carefully evaluated before the operation. Although the best option in imaging work-up is computed tomography, its routine usage is avoided so as not to increase the exposure of ionizing radiation in the paediatric age group. In most of the patients with redo cardiac surgery, magnetic resonance angiography or lateral projection of cardiac cine-angiography studies demonstrate the potential adhesions of the anatomic structures to the posterior part of the sternum. At the operation, we regularly mark the femoral vessels with Doppler ultrasonography and prepare a cardiopulmonary bypass (CPB) set-up before initiating the incision. The skin incision is performed subsequently, the sternal wires are untwisted and an oscillating saw is used to open the anterior table of the sternum until contact with the sternal wires at the posterior side is felt. The untwisted wires are held with clamps and the sides of the sternum are pulled upwards in which a lateral retraction force is strictly avoided. Afterwards, the posterior table of the sternum is carefully opened starting with xiphoid process towards the jugular fossa with the aid of Mayo scissors. We believe hyperinflation of the lungs, which decompresses the right atrium and ventricle, is a safe and easy measure during this part of the re-entry process [2]. We neither use electrocautery nor blunt digital manipulation for the dissection of the mediastinum. As described by Holst et al. we can clinically group cardiac injuries during sternal re-entry procedures into two categories [3]. A cardiac injury in re-sternotomy is an anticipated (i.e. expected) injury when there is a conduit, an aortic aneurysm, an enlarged right atrium or ventricle which is adherent to the posterior surface of the sternum. In such cases, we prefer to initiate CPB with femoral arterial and venous cannulation before sternal re-entry. This provides us with a safer re-entry process in the mediastinum with decompressed cardiac chambers. The main disadvantage of initiating CPB at the early stage of surgery is the prolonged duration of CPB and uneasiness of controlling the haemostasis in a heparinized patient. CPB may be discontinued after the safe entry to the mediastinum and dissection may be completed off-pump in order to shorten the CPB time. In unanticipated injuries, when a massive bleeding occurs, we discontinue the re-sternotomy and join the two sides of the sternum with two towel clamps. The femoral artery and vein are then promptly cannulated before further dissection at the mediastinum after which CPB is initiated. As a result, besides meticulous surgical technique and judicious usage of CPB, we believe that simple and easily applicable precautions can decrease the incidence of cardiac injuries being encountered during sternal re-opening procedures. These precautions will obviously stipulate a prudent, safe and bloodless operative field for the surgical team. Conflict of interest: none declared.

Cervical Anterior Fusion with the Williams-Isu Method: Clinical Review

Anterior decompression and fusion of the cervical spine is a widely accepted treatment for cervical canal disease. The Williams-Isu method involves cervical anterior fusion with autologous bone grafts from cervical vertebral bodies. Its advantages are a wide operative field, excellent graft fusion, the absence of problems related to the iliac donor site, and direct visualization of the nerve root. For detailed decompression of the cervical root, an ultrasonic bone curette (SONOPET, Stryker Japan K.K., Tokyo) may be useful. To prevent graft extrusion, bioabsorbable screws featuring a head are placed in 4 corners of the bone graft and are fixed with a tap on a part of the graft. The screws are visualized on postoperative X-ray, computed tomography, and magnetic resonance imaging studies. In 69 patients reported elsewhere there were no complications attributable to screw insertion, screw or graft extrusion, or surgery-related infections. When adequate bone cannot be harvested, a piece of ceramic hydroxyapatite is placed between the bone grafts. This sandwich method reinforces the graft, and radiological evidence suggests that it yields better results with respect to the angle and height of the fused segment. For the surgical treatment of cervical ossification of the posterior longitudinal ligament, a large vertebral bone window and a large bone graft are needed; this may result in postoperative radiological worsening. Radiological studies have shown that cervical ossification of the posterior longitudinal ligament can, as can cervical spondylosis, be addressed with the Williams-Isu method. Detailed radiological studies in patients treated with the Williams-Isu method have demonstrated that the range of motion and the disc height of the fused segment must be considered to prevent worsening in that segment after anterior fusion. The Williams-Isu method cannot completely correct cervical alignment, and great caution must be exercised in patients with preoperative malalignment. To reduce the levels to be fused in patients with multilevel lesions due to cervical disease, the Williams-Isu method can be combined with the transvertebral approach. The transvertebral approach facilitated by the wide Williams-Isu window allows the root bifurcation area to be confirmed during the early stage of surgery and possible decompression along the root. Radiological examination has shown that the combination of the Williams-Isu method and transvertebral approach does not affect the fusion level compared with the Williams-Isu method alone and produces better results than does the transvertebral approach alone.

頭蓋底髄膜腫患者における視機能温存を目的とした術前画像評価と手術治療戦略 －2症例報告－

Two women aged 48 and 73 years, respectively, presented with unilateral visual disturbance. On admission, magnetic resonance imaging (MRI) showed an extraaxial mass in the parasellar region. Contrast-enhanced fast imaging with steady-state acquisition (CE-FIESTA) showed that the optic nerves were compressed and encased by the tumors. At an early stage of surgery, we performed decompression of the optic nerves to avoid optic nerve injury. Both the patients were relieved of visual disturbances without any postoperative neurological deficit. In conclusion, CE-FIESTA is a useful diagnostic tool for preoperative evaluation of the optic nerves in patients with skull base meningiomas. Decompression of the optic nerves should be performed at an early stage of surgery in meningioma patients presenting with visual disturbance.

Surgical Tips for Medial Sphenoid Wing Meningioma

Medial sphenoid wing meningiomas are more problematic than those meningiomas originating at the pterion. Major arteries and perforators are often involved. An essential principle of surgery is given in this paper. In order to do an operation safely, it is important to define at an early stage of surgery whether the arachnoid membrane separates an artery and a tumor. If one cannot find the separating arachnoid, one should decide to leave the part of tumor attached to the artery. I like to use an intradural resection of the anterior clinoid process after removal of the main tumor mass when the tumor is small. In cases of extensive tumors, extradural bone removal is preferred at the initial stage, so that less brain retraction is needed and the feeding artery is managed. Intradurally, one should detach the tumor initially and then debulk it. Tumor can be separated from the brain surface using the arachnoid plane. One must try to preserve large vessels and perforating branches buried in the tumor to avoid major complications. I recommend dividing the tumor into compartments along a blood vessel, so that one can dissect the vessel from the tumor. Simpson 2 removal is usually tried but I do not hesitate to leave part where no arachnoid membrane is separating major vessels or perforators from the tumor. The video shows where to stop removal. In addition, tumor invading into the cavernous sinus is not removed as long as it does not cause ocular motility disorder.

Surgical treatment for choroid plexus tumors in the fourth ventricle: brain stem infiltration hinders total extirpation

The significance of surgery for choroid plexus tumors is well established, but surgical resection of those in the fourth ventricle has not been evaluated. This study reviewed five consecutive patients with choroid plexus tumors in the fourth ventricle treated in our institute between 1996 and 2005, focusing on the factors that hindered total extirpation. Two cases were choroid plexus papillomas, and three cases were choroid plexus carcinomas. Preoperative T2-weighted magnetic resonance imaging showed a diffuse high-intensity lesion in the brain stem in four patients. Infiltration into the fourth ventricle floor was apparent in all five patients during surgery, which hindered total resection of the tumors without neurological deterioration. Intraoperative bleeding was well controlled in all five patients by cauterizing the feeding arteries at the early stage of surgery through the telovelar approach. Performance status was improved in all patients postoperatively. All patients with choroid plexus carcinomas underwent radiation therapy after the surgical removal. No patient suffered tumor progression within the follow-up of 24-129 months (mean 64 months). Total resection of choroid plexus tumors in the fourth ventricle is difficult because of invasion into the fourth ventricle floor. Adjuvant therapy for choroid plexus tumors with brain stem infiltration must be established.

Endoscope-Assisted Microsurgery of Large Vestibular Schwannomas

The application of endoscope-assisted microsurgery in the treatment of small or medium-sized vestibular schwannomas is of proven value. The goal of our study is to evaluate its usefulness in cases of large schwannomas. Eighteen patients were included in this prospective study. Their average tumor diameter was 3.9 cm. The retrosigmoid approach was used in all cases. The endoscope was applied during all stages of tumor removal. The facial nerve was visualized endoscopically at early stages of surgery in 9 patients and the abducent nerve in 7 patients. The source of bleeding was identified in 1 case. Tumor remnants in the region of the fundus of the internal auditory canal after apparently total removal were identified in 2 cases. Exposed and unobliterated temporal bone air cells were not observed. Even in cases of large schwannomas, the location of the facial nerve can be determined endoscopically early in the procedure. The application of endoscope-assisted microsurgery increases the rate of cranial nerve preservation and of total tumor removal. Although the application of the endoscope did not provide useful information in some cases, it is a safe procedure that did not lead to any complications and/or to considerable prolongation of the operative time. Its application is justified in all cases.

赤毛球Ｍ・Ａ・Ｐ「日赤」を使用した自己血輸血の検討

Since April 1991 we have carried out preoperative autologous blood storage using the RC-MAP system (Japanese Red Cross) for elective surgery. Ninety patients with an average age of 59 years and average body weight of 57kg were given Erythropoietin (6, 000 units/day) with oral iron supplements. Four-hundred ml of blood at 4-7 day intervals up to 2, 000ml were drawn 2-3 weeks prior to surgery. The surgical procedures were composed of 78 cardiac disease cases and 12 cancer cases.The blood drawn was separated into red cells stored at 4°C in MAP solution (RC-MAP), and plasma stored as FFP (fresh frozen plasma). During cardiac surgery platelet rich plasma (PRP) was also obtained by means of Hemonetics Ultralite Plasma Collection System at an early stage of surgery. Most of these autologous RC-MAP, FFP and PRP were transfused during surgery, and in a few cases the RC-MAP were also transfused during the post operative period. Average bleeding volume during surgery was 5.97±0.84ml/kg, and various laboratory data collected during hospital stay, excepting the 3 days after surgery, showed values in the normal range. In 71 cases transfusion was satisfied entirely with autologous blood components without hazards; in 19 cases some additional homologous blood was required because of surgical error or other reasons.It is concluded that our predeposit program using the RC-MAP system is both practical and economical when compared with the frozen red cell system.