Extent Of Surgical Dissection Research Articles

Treatment of persistent/recurrent nodal disease in nasopharyngeal cancer.

Persistent or recurrent disease in the neck lymphatics is an unusual pattern of failure in nasopharyngeal carcinoma (NPC) after definitive radiotherapy or chemoradiotherapy. The purpose of this review is to critically synthesize the current knowledge regarding salvage treatment of this unique form of failure in NPC. Surgery in the form of radical neck dissection has been established as the standard salvage treatment with 5-year regional control of 60--86%. Recent shift in paradigm has resulted in the use of modified or selective neck dissection as salvage surgery in some centers. Risk factors for poor survival outcome include recurrent nodal disease, number of involved lymph nodes, extracapsular extension, high lymph node ratio, and positive resection margin. There are no well controlled studies on the role of additional radiotherapy or chemotherapy to improve local control or survival after salvage neck dissection in this group of patients with regional failure. There is limited literature regarding the extent of surgical dissection in treating nodal persistent or recurrent disease. Prospective studies are also needed to determine whether adjuvant therapy improves treatment outcomes.

Soft tissue management to control nasal changes after Le Fort I Osteotomy

Adverse effects in the nasolabial region should be anticipated after Le Fort I osteotomy. Intraoperative factors such as the extent of surgical dissection, type of closure and perinasal soft tissue reconstruction seem to influence soft tissue response. Attempts to control these changes have been made over the years and several techniques have been proposed. The authors present a minimally invasive alternative surgical technique to control alar base widening as well as lip shortening.

Case cohort study of risk factors for post-thyroidectomy hemorrhage

BackgroundPost-thyroidectomy hemorrhage is a potentially life-threatening complication of thyroid surgery. The goal of our study was to determine potential risk factors for development of post-thyroidectomy hemorrhage. MethodsA retrospective case cohort study of patients with post-thyroidectomy hemorrhage between December 2008 and August 2014 was performed. This group of patients was compared with a stratified randomized control group, and several parameters were assessed for association with post-thyroidectomy hemorrhage. ResultsSixteen patients were identified in this time period as developing post-thyroidectomy hemorrhage requiring reoperation. Postoperative hypertension, vomiting and/or straining, longer operative times, and extent of surgical dissection were found to be statistically significant risk factors. Postoperative hypertension was found to be the most significant risk factor, resulting in a 20.3 times increased likelihood of developing post-thyroidectomy hemorrhage. ConclusionsA number of risk factors for post-thyroidectomy hemorrhage were identified. The most significant was postoperative hypertension. Early control of modifiable risk factors could improve patient outcomes and satisfaction.

Clinical quality measures for intraoperative and perioperative management in carpal tunnel surgery.

BackgroundPrevious research documents suboptimal preoperative or postoperative care for patients undergoing surgery. However, few existing quality measures directly address the fundamental element of surgical care: intra-operative care processes. This study sought to develop quality measures for intraoperative, preoperative, and postoperative care for carpal tunnel surgery, a common operation in the USA.MethodsWe applied a variation of the well-established RAND/UCLA Appropriateness Method. Adherence to measures developed using this method has been associated with improved patient outcomes in several studies. Hand surgeons and quality measurement experts developed draft measures using guidelines and literature. Subsequently, in a two-round modified-Delphi process, a multidisciplinary panel of 11 national experts in carpal tunnel syndrome (including six surgeons) reviewed structured summaries of the evidence and rated the measures for validity (association with improved patient outcomes) and feasibility (ability to be assessed using medical records).ResultsOf 25 draft measures, panelists judged 22 (88%) to be valid and feasible. Nine intraoperative measures addressed the location and extent of surgical dissection, release after wrist trauma, endoscopic release, and four procedures sometimes performed during carpal tunnel surgery. Eleven measures covered preoperative and postoperative evaluation and management.ConclusionsWe have developed several measures that experts, including surgeons, believe to reflect the quality of care processes occurring during carpal tunnel surgery and be assessable using medical records. Although quality measures like these cannot assess a surgeon’s skill in handling the instruments, they can assess many important aspects of intraoperative care. Intraoperative measures should be developed for other procedures.

Functional Outcomes After Surgery for Spinal Fractures: Return to Work and Activity

The literature regarding surgical treatment's impact on patient function after spinal fracture is sparse. Some authors have speculated that operative injury--the dissection of paraspinous muscle tissue, damage to spinal motion segments, implantation of spinal devices--may impair functional recovery in spine trauma patients. Nonoperative care has produced satisfactory results in some hands, but results are difficult to reproduce, treatment is resource-intensive, and functional outcomes are poorly documented. This study reports return to work and functional recovery in a 5-year follow-up of severely injured patients treated with segmental spinal instrumentation. Seventy consecutive patients treated with Cotrel Dubousset instrumentation for unstable thoracic, thoracolumbar, and lumbar spine fractures were followed-up. All had high-energy trauma and were admitted directly to a level 1 university trauma center; 38% were polytraumatized; and 56% had neurologic injuries. Indications for surgery included: (1) segmental instability; (2) incomplete or progressive neurologic injuries with residual spinal canal compromise; (3) concomitant injuries precluding cast treatment; and (4) polytrauma. Two patients died and six were lost to follow-up, leaving 62 (91%) for assessment at a mean 5-year follow-up (range 2-8 y). Clinical outcome has been reported. Functional recovery was assessed based on return to work, level of work, and level of daily activity. Despite the severity of spinal and concomitant injuries, 70% of patients returned to full-time work and another 8% were considered capable: 54% to their previous level of employment without restrictions and 16% to full-time, but lighter, jobs. Twenty-two percent were working part-time or not at all, and 8% were unemployed despite unrestricted functional status. Work status correlated directly with neurologic impairment (P < 0.00005) and was not related to level of injury, hardware failure, extent of surgical dissection, or construct pattern. Of patients with limitations, 18% were limited by pain and 27% by neurologic injury. Neurologic injury had a greater impact on functional outcome than any other variable. Patients limited by pain were more often impaired by residual radicular and neuropathic symptoms than by back pain. Impairment was not related to the extent of either the surgical incision or the instrumentation. Patients with persistent back pain generally had an identifiable and correctable mechanical problem-sagittal imbalance, pseudarthrosis, or persistent instability--as the underlying cause. Our series of trauma patients was predominantly young and male. Among this cohort, individual characteristics of occupation (often physical laborers and craftsmen) and judgment (criminal convictions and incarceration) may have restricted opportunities for re-employment in 40% of the entire study group.

Dual technique for obliteration of small arteriovenous malformations

A 17-year-old man underwent an incomplete excision of a left fronto-parietal arterio-venous malfor mation (AVM), under image guidance. An initial attempt to treat the residual AVM by embolization was unsuccessful. The craniotomy was then re-opened in the angiography suite and the residual AVM was excised by, first, following the microcatheter within the arterial feeding vessel to the AVM and, secondly, by using metallic clips as radiographic markers to locate the position of the AVM during superselective angiography. The dual technique described is likely to be useful in selected cases with small residual AVMs and AVMs near eloquent areas of the brain, where the extent of surgical dissection and postoperative morbidity can be minimized by the precise localization of the AVM.

The biocompatibility, integrity, and positional stability of an injectable microstimulator for reanimation of the paralyzed larynx.

The biocompatibility, integrity, positional stability, and potential use of hermetically sealed injectable wireless micromachined microstimulators were investigated for reanimation of the paralyzed larynx. The device, consisting of silicon and glass, has been tested and proven to be biocompatible with no evidence of pathological tissue reaction or rejection up to one-year implantation in the rat dorsum and canine larynx. By one month, each unit was encapsulated by a thin membrane, which thickened to form a fibrous layer of less than 500 microm at 6-12 months. The microstimulators demonstrated long-term in vivo durability: the hermetic seal of only one in ten devices was breached. Once implanted, migration of the device varied from 0 to 3 cm, depending upon the extent of surgical dissection. No discernable migration was noted when the tissue dissection was minimal. Studies utilizing a modified device equipped with electrodes indicated that migration was nominal with sufficient positional stability to ensure activation of target muscles for glottis opening. This study supported the feasibility of using a microstimulator for reanimation of paralyzed laryngeal muscles that open the airway during breathing. This innovative approach to treatment would alleviate the need for a tracheotomy or surgical resection of the vocal fold.

99m-Technetium sestamibi localized solitary parathyroid adenoma as an indication for limited unilateral surgical exploration

BACKGROUND: Because of its successful localization of solitary adenomas, 99m-Technetium sestamibi (MIBI) may challenge the standard operation for primary hyperparathyroidism. METHODS: Thirty-five consecutive patients underwent preoperative MIBI localization to optimize a surgical approach. Single-site localization in 21 patients directed a limited unilateral neck exploration (UNE) with adenomectomy and ipsilateral gland biopsy. Fourteen patients who did not localize underwent bilateral neck exploration (BNE). Conversion to a bilateral operation was required in 1 UNE patient because no adenoma was found on that side. RESULTS: There were no significant differences in preoperative and postoperative serological markers between the two groups. However, the total operative time for UNE (49 ± 21 minutes) was significantly less than for BNE (103 ± 45 minutes; P <0.001). CONCLUSIONS: Preoperative MIBI scan-directed limited unilateral neck operation may be used reliably for primary hyperparathyroidism due to a single adenoma, and thereby reduce operative time, extent of surgical dissection, and risk.

Long-termresults of carpal tunnel release

To determine the long-term results of carpal tunnel release, we retrospectively reviewed 60 cases, an average of 5.5 years after surgery. 87% reported a good or excellent overall outcome; the average time to maximum improvement of symptoms was 9.8 months. However, 30% reported poor to fair strength and long-term scar discomfort, and 57% noted a return of some pre-operative symptoms, most commonly pain, beginning an average of 2 years after surgery. We found no correlation between pre-operative symptoms or extent of surgical dissection (internal neurolysis) and outcome. Carpal tunnel syndrome was job related in 42%; of these, 26% changed from heavy to lighter work following surgery. Although occupational cases were slower to improve and remained off work longer, the long-term subjective results were the same for both groups. We found significant morbidity from the surgical scar and decreased strength, and often considerable delay until ultimate improvement, especially in patients with job-related carpal tunnel syndrome.

Technique of orchiopexy. Mobilization of cord length.

The various steps in a urological orchiopexy are described in detail; alignment of an everted testis, funiculolysis, retroperitoneal dissection and medial displacement of the cord. The extent of surgical dissection needed and the final position of the testis have been registered in 150 orchiopexies. The results are related to the primary position of the testicle and the anatomy of the gonad. Of five abdominal testicles only one reached a low scrotal position and all steps in the mobilization procedure were used. The remaining four testicles had deformities considered to involve infertility. Of 18 canalicular testes 17 reached the bottom of the scrotum and medial displacement was used in 13 patients. Of 123 subcutaneous testicles 93% were mobilized satisfactorily and all four steps in the mobilization procedure were needed in 72%. In all the patients where a low scrotal position could not be achieved, there was a normal testicle in the other hemiscrotum.

The fate of the free fat graft. A prospective clinical study using CT scanning.

In a prospective clinical study, the fate of free fat grafts used in lumbar decompressive surgery to prevent epidural fibrosis was evaluated. The size of the fat graft was measured at operation and 2 years later by CT scanning. Of 26 consecutive patients, data were available from 21. In 15 patients the fat graft was unchanged, in three patients the fat graft contained fibrous bands, and in another three patients the fat graft was completely replaced by scar tissue. Blood loss at operation, the extent of surgical dissection, and thickness of the fat graft are important prognostic factors relating to the survival of the free fat graft.

Lymphoceles associated with renal transplantation: Report of 15 cases and review of the literature

Within a 27 month period (from July 1, 1971 to October 1, 1973), during which 83 renal allotransplantations were performed at the Cleveland Clinic, a lymphocele developed in 15 patients (18.1 per cent). Early clinical symptoms, occurring within 6 weeks after transplantation, were suprapubic or lower abdominal swelling in 14 patients, leg swelling ipsilateral to the allograft in 12, nonpitting edema in the allograft area in 10 and lymph drainage from the wound in 8. An intravenous pyelogram demonstrated a lymphocele in 13 patients from 1 to 34 weeks after transplantation (mean 7.8 weeks), although an earlier suggestion of bladder displacement and deformity was found retrospectively in 5 patients between 1 and 3 weeks after transplantation. Lymphangiograms aided in the diagnosis in nine patients. The major complication of the lymphoceles was obstructive uropathy that developed in nine patients between 2 and 34 weeks after transplantation (mean 10.3 weeks). Lymphoceles mimicked rejection, urine extravasation, pyelonephritis, thrombophlebitis and a seroma, and occurred concurrently with rejection and pyelonephritis. Treatment by external surgical drainage was more effective than aspiration both in resolving the lymphocele and in avoiding infection. Three lymphoceles drained spontaneously 1 to 2 weeks after transplantation, and three are under observation. Chemical and protein analyses were made of the lymphocele fluid obtained from seven patients. Numerous factors may contribute to the formation of a lymphocele by increasing lymph flow. The most prominent factors are the extent of surgical dissection, the occurrence of rejection, and the use of diuretics, large doses of corticosteroids, and anticoagulants. The literature on lymphoceles in renal allograft recipients is reviewed, and pertinent comparisons are made with the more numerous reports of lymphoceles in nontransplant patients.