Extensive Surgical Intervention Research Articles

Therapieresistente aggressive zystische Läsion des Unterkiefers

Several extensive surgical interventions of a cystic lesion in the left mandible were followed by recurrences. The lesion extended from the primary mandibular region into the area of pterygopalatine fossa finally infiltrating the orbital region and the skull base. Histological results could never demonstrate a malignancy with certainty. Due to the patient's poor general condition, the refusal for further surgical inventions and due to the malignoma-like growth pattern radiation treatment was performed. However, this had no effect on tumor progression.

Recurrent malignant otitis externa: management and outcome

Necrotizing (malignant) external otitis (NEO) is an infection involving the temporal and the adjacent bones. It is a rare type of external otitis that occurs primarily in immunocompromised persons. The present study aimed to evaluate its management and outcome in recurrent cases. Ten patients attending the ENT Department, Alexandria University were included. They had recurrence of otitis externa over a period of 6 months after-cure, as well as severe night otalgia and high ESR level. Peri-auricular soft tissue swelling, cranial nerve paralysis and trismus were the main persistent or developing presentations in recurrent cases. Extensive surgical intervention was performed in four patients with unsatisfactory outcome. On the other hand, satisfactory results were obtained with those treated with specific medical therapy after culture and sensitivity test and those who underwent minimal surgical intervention. In conclusion, NEO is an aggressive disease that necessitates conservative management and local debridement of sequestrated tissues. The ESR is a good indicator of treatment response. It is recommended to be meticulous in treatment of cases with recurrent NEO and extensive surgical interventions are discouraged.

Small deletions but not methylation underlie CDKN2A/p16 loss of expression in conventional osteosarcoma

Conventional osteosarcoma is characterized by rapid growth, high local aggressiveness, and metastasizing potential. Patients developing lung metastases experience poor prognosis despite extensive chemotherapy regimens and surgical interventions. Previously we identified a subgroup of osteosarcoma patients with loss of CDKN2A/p16 protein expression in the primary tumor biopsies which was significantly predictive of a very poor prognosis. Here we aimed to identify the underlying mechanism(s) of this protein loss in relation to osteosarcoma behavior. The CDKN2A locus was analyzed in osteosarcoma cases with total loss of CDKN2A/p16 expression and in cases with high protein expression using melting curve analysis-methylation assay (MCA-Meth), fluorescent in situ hybridization (FISH), multiplex ligation-dependent probe amplification (MLPA), and mutation analysis. All cases with complete CDKN2A/p16 protein loss showed homozygous deletions at the CDKN2A locus. In none of the cases hyper methylation of the promoter region was seen which was confirmed by sequencing this region. Taken together we show that large or smaller deletions of the CDKN2A locus are evident in patient samples and underlie the CDKN2A/p16 protein expression loss while promoter methylation does not appear to be a mechanism of this expression loss. Genomic loss of CDKN2A instead of promoter methylation might be a plausible explanation for the rapid proliferation and high aggressiveness of osteosarcoma by simultaneous impairment CDKN2A/p14(ARF) function.

Myiasis of the External and Middle Ear

Aural myiasis is a rare otolaryngological disease typically seen in poor hygienic conditions and medically disabled patients. We present a case of aural myiasis in a healthy woman who had no apparent risk factors for infestation and required extensive surgical intervention. We also discuss the literature of documented otolaryngological cases of myiasis and effective therapies. In our patient, symptoms of otalgia, otorrhea, and tinnitus resolved after multiple attempts at extraction resulted in successful eradication of larvae. The patient required tympanoplasty to reconstruct the damaged external and middle ear. Physicians should have a clinical suspicion of aural myiasis in patients with a travel history and an atypical presentation of acute otalgia and otorrhea.

Tratamento endoscópico de fístulas da árvore traqueobrônquica com dispositivos para a correção de defeitos do septo interatrial: resultados preliminares

Fistulas in the tracheobronchial tree (bronchopleural and tracheoesophageal fistulas) have a multifactorial etiology and present a variable incidence in the literature. In general, the related morbidity and mortality are high. Once such a fistula has been diagnosed, surgical closure is formally indicated. However, the clinical status of affected patients is usually unfavorable, which precludes the use of additional, extensive surgical interventions. In addition, attempts at endoscopic closure of these fistulas have seldom been successful, especially when the fistula is large in diameter. We report the cases of three patients submitted to endoscopic closure of fistulas, two of which were larger than 10 mm in diameter, by means of the insertion of atrial septal defect occluders. The procedure was minimally invasive, and the initial results were positive. The results indicate that this is a promising technique for the resolution of tracheobronchial tree fistulas.

Successful Nonoperative Management of Gastrointestinal Mucormycosis: Novel Therapy for Invasive Disease

Invasive opportunistic fungal infections caused by agents of Mucorales that involve the gastrointestinal tract are uncommon but aggressive. These ubiquitous fungal spores typically are inhaled and can germinate in immunocompromised hosts. Standard therapy for invasive mucormycosis includes parenteral amphotericin B (AMB) in combination with radical debridement of infected tissues. Early diagnosis and treatment are of paramount importance. Unfortunately, long-term survival is poor owing to the prohibitive morbidity and mortality rates associated with the medical and surgical therapies. Posaconazole is a novel, extended-spectrum triazole oral antifungal agent with documented success in the treatment of patients with invasive mucormycosis. Case report and literature review. A 50-year-old man presented with invasive mucormycosis of the lower esophagus, stomach, and liver, resulting in gastrointestinal hemorrhage. The infection did not respond to AMB but was treated successfully with a combination of posaconazole and liposomal AMB (LAMB) without surgical debridement. To our knowledge, this is the first reported case of extensive gastric and intrahepatic mucormycosis that responded to combination posaconazole and LAMB without surgical debridement. This approach may be an alternative to surgery in patients who are precluded from extensive surgical intervention.

Clinical Strategies for the Management of Acute Mastoiditis in the Pediatric Population

Although the incidence of acute mastoiditis has been substantially reduced since the introduction of antibiotic therapy, mastoiditis complications are still commonly seen in the pediatric population. Many of these cases require lengthy hospitalizations and extensive medical and surgical interventions. Accordingly, a safe, effective, and resourceful diagnostic and therapeutic plan must be executed for the workup and treatment of each patient suspected of having acute mastoiditis. With thorough clinical evaluations, early diagnosis, and close follow-up, a large proportion of children with severe acute otitis media or early stage mastoiditis can be managed in the primary care setting without immediate surgical specialty involvement. This review presents an overview of the anatomical and pathophysiological considerations in acute mastoiditis and offers pediatricians a practical, evidence-based algorithm for the diagnostic and therapeutic approach to this disease.

Survival following stereotactic radiosurgery for newly diagnosed and recurrent glioblastoma multiforme: a multicenter experience

Despite decades of clinical trials investigating new treatment modalities for glioblastoma multiforme (GBM), there have been no significant treatment advances since the 1980s. Reported median survival times for patients with GBM treated with current modalities generally range from 9 to 19 months. The purpose of the current study is to retrospectively review the ability of CyberKnife (Accuray Incorporated, Sunnyvale, CA, USA) radiosurgery to provide local tumor control of newly diagnosed or recurrent GBM. Twenty patients (43.5%) underwent CyberKnife treatment at the time of the initial diagnosis and/or during the first 3 months of their initial clinical management. Twenty-six patients (56.5%) were treated at the time of tumor recurrence or progression. CyberKnife was performed in addition to the traditional therapy. The median survival from diagnosis for the patients treated with CyberKnife as an initial clinical therapy was 11.5 months (range, 2-33) compared to 21 months (range, 8-96) for the patients treated at the time of tumor recurrence/progression. This difference was statistically significant (Kaplan-Meier analysis, P = 0.0004). The median survival from the CyberKnife treatment was 9.5 months (range, 0.25-31 months) and 7 months (range, 1-34 months) for patients in the newly diagnosed and recurrent GBM groups (Kaplan-Meier analysis, P = 0.79), respectively. Cox proportional hazards survival regression analysis demonstrated that survival time did not correlate significantly with treatment parameters (Dmax, Dmin, number of fractions) or target volume. Survival time and recursive partitioning analysis class were not correlated (P = 0.07). Patients with more extensive surgical interventions survived longer (P = 0.008), especially those who underwent total tumor resection vs. biopsy (P = 0.004). There is no apparent survival advantage in using CyberKnife in initial management of glioblastoma patients, and it should be reserved for patients whose tumors recur or progress after conventional therapy.

Results of Extensive Surgical Treatment of Seven Consecutive Cases of Postoperative Fungal Endophthalmitis

PurposePostoperative endophthalmitis is a dreaded outcome of any intraocular surgery. Fungal endophthalmitis is a particularly severe complication that poses a significant threat of blindness. We experienced seven consecutive cases of postoperative fungal endophthalmitis stemming from a single local clinic in which extensive early intervention resulted in favorable final visual acuity.MethodsThe present study is retrospective observational case series of fungal endophthalmitis. The initial case, as diagnosed by fungal culture, resulted in blindness. In the ensuing eight months, seven consecutive cases were referred to our institution. All were presumed to be fungal endophthalmitis as the cases possessed similar inflammatory findings to the preceding case and occurred in the same environment. Extensive surgical and antifungal treatment was immediately administered, including complete vitrectomy with removal of the intraocular lens and lens capsule and Amphotericin B injections.ResultsRetinal infiltration was identified in three cases and the lesion site was photocoagulated with an endolaser. All cases were confirmed fungal endophthalmitis by culture (4 cases: Candida parapsilosis, one case each: Fusarium, Acremonium, Candida tropicalis) and five cases required secondary intraocular lens implantation. Final corrected visual acuity ranged from 20/20 to 40/200 by the Snellen chart.ConclusionsEarly extensive surgical intervention and antifungal agent administration may result in favorable visual outcomes in patients with fungal endophthalmitis following cataract surgery.

Ein- und Zweikammer-ICD: Sind die Unterschiede zum Schrittmacher in Implantation und Nachsorge heutzutage noch bedeutsam?

Due to bulky generator size, abdominal pocket preparation and epicardial defibrillator lead placement, cardioverter-defibrillator (ICD) implantation was initially an extensive surgical intervention, which had to be performed in the operating room by cardiac surgeons under general anesthesia. The development of transvenously applicable endocardial defibrillator leads rendered thoracotomy unnecessary. The decrease in generator size enabled pectoral implantation. As a consequence of the simplified surgical procedure, implantation by cardiologists or electrophysiologists in the catheterization laboratory under local anesthesia and brief deep sedation with preserved spontaneous respiration was made possible. As a result, the implantation techniques of ICDs and pacemakers are converging. The present article illustrates the still existing significant differences between ICD and pacemaker treatment with regard to implantation and follow-up.

Risk Factors of Acute Lung Injury in Cancer Patients after Operations Accompanied by Excessive Blood Loss

Objective: to evaluate the clinical significance of risk factors of acute lung injury (ALI) in cancer patients who have experienced acute excessive intraoperative blood loss (AEIBL), hemorrhagic shock (HS), and acute disseminated intravascular coagulation (DIC), and massive infusion-transfusion therapy. Subjects and methods. Operative days were analyzed in patients from three groups who had sustained AEIBL of 100 to 550% of the circulating blood volume. Group 1 consisted of 14 patients who had experienced HS or HS + acute DIC after extensive intraperitoneal surgical interventions. Group 2 comprised 16 patients who had undergone extensive surgical interventions involving extended thoracic lymph dissection. Group 3 included 15 patients after extensive intraperitoneal surgical interventions. Patients with evolved ALI were identified in each group. In all the patients, an excess (balance) of fluid and oncotic pressure were detected at the end of operative days. Results. There were 4 patients (2 with ALI and 2 with acute respiratory distress syndrome (ARDS)) in Group 1 and 11 patients (2 with ALI and 9 with ARDS) in Group 2. Patients with ALI were not identified in Group 3. At the end of operative days, the excess of fluid turned out to double in patients with evolved ALI/ARDS than in those without signs of respiratory failure. Conclusion. Of the greatest significance in the natural history of ALI in this cohort of patients are the following risk factors: surgical injury and extended thoracic lymph dissection; HS, with cardiovasotonics being used for more than 8 hours; excess fluid accumulation by the end of operative days. The safe excess fluid volume was determined, which was not greater than 50 ml/kg in the patients who had undergone peritoneal surgery and even experienced HS, but with cardiovasotonics being administered for not more than 4 hours. That was 20 ml/kg in those who had sustained excessive surgical injury + thoracic lymph dissection. Key words: acute lung injury, risk factors, infusion therapy, plasma oncotic pressure, fluid balance.

Reamotio mehr als 1 Jahr nach primär erfolgreicher Ablatiochirurgie: Ursachen und Häufigkeit

Recurrent retinal detachment following initial successful surgery usually occurs in the early postoperative course. Redetachment after 1 or more years of complete retinal reattachment is a rare event. The present study investigates the frequency and causes of late recurrences. A consecutive series of 2,232 eyes that presented with rhegmatogenous retinal detachment (RD) were treated between January 1994 and December 2006. Among them were 30 cases (30 eyes) presenting with late recurrent RD (1.34 %). We compared the clinical characteristics of initial and late recurrent RD. Over the 13-year period, 54.5 % of rhegmatogenous RD cases were treated with scleral buckling, 42.5 % using vitrectomy techniques and 2.55 % with pneumatic retinopexy. Late recurrent RD occurred 1.1 - 10.4 years (average 3.8, SD 2.56) after initially successful surgery. Previous surgery included scleral buckling in 24 eyes (80 %), vitrectomy in 5 eyes (16.7 %) and pneumatic retinopexy in another eye (3.3 %). At the time of initial treatment, primary reattachment rate was 93.3 % and final 100 %. At the time of late redetachment, the anatomic situation appeared more complex. Accordingly, most eyes were treated by vitrectomy (73.3 %), and only 23.3 % using buckling techniques. Furthermore, the numbers of reoperations to achieve reattachment increased from 6.6 % to 23.3 %. Major causes for late failures were vitreous base traction leading to new or reopened breaks and PVR. Three eyes showed these complications immediately after complicated anterior segment surgery. Comparing visual outcomes after initial (preop logMAR 0.57 +/- 0.7 and postop 0.38 +/- 0.43) and late (preop logMAR 0.87 +/- 0.71 and postop 0.66 +/- 0.5) RD, functional prognosis is worse when redetachment occurs. Nonetheless, in 50 % of eyes useful vision (>or= 20 / 50) was retained by repeat surgery. Recurrent retinal detachment that presents after more than 1 year of complete reattachment occurs in 1.34 % of cases according to the present study. We found a higher rate after scleral buckling compared to vitrectomy. The most important reasons for late failures are vitreous base traction and periretinal proliferations that clinically appear as new or reopened tears or as PVR. Recurrences show a more difficult retinal situation and require more extensive surgical interventions. Based on the anatomic and functional success rates, repeat surgical procedures are worth considering.

Recombinant activated factor VII in haemostasis after radical nephrectomy

The paper presents important facts in the application of recombinant human factor VIIa (rFVIIa) and in the treatment of renal cell carcer. A 69-year old male with infiltrative renal cell carcer underwent radical nephrectomy using Hasagawa's approach. The extirpated tumor was 35 cm in diameter. During surgery, the patient suffered cardiac arrest with 3500 ml blood loss. Twenty-four hours after operation, he lost additional 2100 ml of blood. Despite adequate blood substitution with intensive surgical attempts to treat haemostasis, bleeding did not stop until the application of rFVIIa (300 IU). The patient survived and fully recovered. To control massive non-surgical bleeding additionally complicated by paraneoplastic syndrome, extensive surgical intervention, haemodilution and massive blood substitution, the application of rFVIIa has proved to be most successful.

Temporary Pacing in the Correction of Drug-Induced Bradycardia

Objective: to reduce the risk from surgical treatment in geriatric cancer patients with severe concomitant cardiovascular (CV) diseases through the differentiated intra- and postoperative use of pacing technologies for correction of life-threatening cardiac rhythm and conduction disturbances. Subjects and methods. Two hundred and eight patients (mean age 72.0±5.8 years) receiving pulse-reducing cardiotropic therapy to compensate for CV disorders, who had undergone extensive radical surgical interventions for abdominal and small pelvic malignancies of mainly Stage III (mean duration 4.2±1.6 hours) under multimodal general anesthesia, were examined. A pacing technique was chosen depending on the pattern of arrhythmia and antrioventricular (AV) block. Results. During CV therapy, bradycardia at a heart rate of 44 to 57 beats per min was identified in 71 (34.1%) patients. Perioperative pacing correction of bradycardia was required in 58 (27.9%) patients, of them 46 had no AV conduction disturbances, which permitted the use of transesophageal atrial pacing (TEAC). Endocardial pacing was performed in 12 patients with impaired AV conduction and bradysystole in the presence of persistent atrial fibrillation during and early after surgery. In the postoperative period, it was necessary to continue long-term (more than 20 hours) TEAC in the asynchronous mode in 7 patients. Extensive surgical interventions of the planned volume were made in all the patients being examined. None patient had any CV events, including pacing complications. Conclusion. Temporary pacing techniques are effective in correcting critical circulatory disorders during surgical treatment in elderly patients with persistent drug-induced bradycardia when they are treated with cardiotropic drugs.

Management of acquired bronchobiliary fistula: 3 case reports and a literature review

Bronchobiliary fistula (BBF), which often presents with bilioptysis, is an abnormal communication between the bronchial system and biliary tree. It is a complication associated with a high mortality rate and requires a well-planned management strategy. Although hydatid disease is still the leading cause, extensive surgical interventions and invasive procedures of the liver have altered the profile of patients in recent decades. This paper presents 3 cases of BBF and reviews the literature regarding the treatment options generally mandated by clinical presentation and the underlying disease.

Urachal Anomalies: A Longitudinal Study of Urachal Remnants in Children and Adults

Urachal anomalies are often recognized in children but they may persist into adulthood and cause considerable morbidity. We reviewed the clinical findings associated with these embryological structures and evaluated risk factors for cancer to define the optimal timing for intervention. We examined the medical records of 176 patients diagnosed with a urachal anomaly between 1951 and 2005. Association of clinicopathological features with malignancy for adults was evaluated using univariate and multivariate logistic regression studies. Urachal remnants were identified in 46 children and 130 adults. Of the 46 children 20 (43%) presented with umbilical drainage and 23 (50%) could be diagnosed by physical examination. A total of 34 children (74%) underwent simple excision. In contrast, 65 of the 130 adults (50%) presented with hematuria, 78 (60%) required cystoscopy and 53 (41%) required computerized tomography. A total of 66 adults (51%) required more extensive surgical intervention with partial or radical cystectomy. Of adult urachal anomalies 66 (51%) were malignant. Patient age 55 years or older and hematuria were the strongest predictors of urachal malignancy (each p <0.001). Cancer risk increased with advancing adult age. Urachal anomalies present and progress differently in pediatric and adult populations. Adults are at high risk for urachal cancer but children usually incur lower morbidity. Urachal lesions noted early in childhood should be excised to prevent problems in adulthood.

Dexrazoxane for anthracycline extravasation

Accidental extravasation of anthracycline-containing anticancer chemotherapy is a feared complication that may lead to progressive tissue damage. The condition may require extensive surgical intervention and often has severe long-term effects. Until a short while ago, there has been no effective treatment against the devastating effect of extravasated anthracycline. However, dexrazoxane has proven highly effective in preventing necrosis in both preclinical and clinical studies and is now approved in Europe (Savene™), and has orphan drug status in the USA (Totect™) for this indication. Hence, it is the first and only proven effective antidote against anthracycline extravasation injuries.

Portal venous gas – case report and review of the literature

A 74-year-old man with chronic renal failure was admitted to the renal unit with non-specific symptoms and positive blood cultures. He later deteriorated and was admitted to the Intensive Care Unit with septic shock, respiratory failure and deranged liver function. Initial improvement was followed by abdominal distension and discomfort. Portal venous gas (PVG) and thrombosis were diagnosed on computed tomography. A conservative line of management was adopted. Improvement was soon followed by deterioration with septic shock. Extensive portal venous gas and free intra-abdominal gas were now evident on repeat computed tomography. The patient was too unwell to withstand surgery and a decision was made not to escalate therapy. He died on day 16. Portal venous gas is not a disease; it is a diagnostic clue in patients who may be harbouring an intra-abdominal catastrophe. Successful management of these cases requires early identification of the underlying pathology and can range from simple observation to extensive surgical intervention.

18F‐FDG‐PET (Positronenemissionstomografie) zur Differenzialdiagnostik bei simultaner Retroperitonealfibrose und Lymphknotenmetastasierung nach Ovarialkarzinom

Die retroperitoneale Fibrose (M. Ormond) stellt eine seltene Differenzialdiagnose zur Lymphknotenmetastasierung des Ovarialkarzinoms dar. Wir berichten über eine Patientin, bei der im Rahmen der CT-Diagnostik die differenzialdiagnostische Verdachtsdiagnose einer Retroperitonealfibrose (RPF) gestellt und letztendlich über gezielte Stanzbiopsie histologisch gesichert werden konnte. Über eine zusätzliche Ganzkörper-PET-Untersuchung konnte eine simultane Lymphknotenmetastasierung des Ovarialkarzinoms nachgewiesen und die entsprechende Second-Line-Chemotherapie eingeleitet werden. Die ansonsten bei Retroperitonealfibrose mit Harnabflussstörung indizierte, häufig extensive Chirurgie zur Ureterolyse konnte so vermieden werden. Zur Differenzierung unklarer retroperitonealer Läsionen nach gynäkologischen Malignomen sollte für eine sinnvolle Therapieplanung die PET-Diagnostik genutzt werden.

Risikofaktoren perioperativer Komplikationen in der Chirurgie des Wilms-Tumors

There is controversy about preoperative chemotherapy in the treatment of Wilms' tumor. The perioperative morbidity plays a key role in this discussion. Therefore, risk factors of perioperative complications were analysed in our series of patients with Wilms' tumor with a special focus on the effects of preoperative chemotherapy. Case histories of 37 patients [mean age 3.9 (range: 0.6 - 14) years] were retrospectively analysed concerning follow-up, clinical and histopathological stage, size of the primary tumor, as well as duration and extent of preoperative chemotherapy. 35 patients underwent radical nephrectomy, 2 patients had organ-sparing surgery because of bilateral involvement. The mean maximal tumor diameter was 9.5 cm (range: 4 - 24 cm). 11/37 patients had no or shortened preoperative chemotherapy. 6/37 patients (16.2 %) had perioperative complications. There was one intraoperative tumor rupture, 4 small bowel obstructions, 1 pancreatitis. All complications occurred in patients of clinical stages III and IV, maximal tumor diameter > 10 cm after unusually extended operative procedures. 4 patients showed only poor response to preoperative chemotherapy. Patients with doxorubicin pre-treatment showed a higher risk of postoperative small bowel obstruction. The risk of perioperative complications was correlated with the local extent of the primary tumor and was higher with those requiring more extensive surgical interventions. The influence of preoperative chemotherapy on the complications rate is inconstant. Considering a good response of the primary tumor, the complication rate will be decreased. However, the comorbidity of more intense preoperative chemotherapy in patients of stage IV may contribute to a higher risk of surgical complications.