Tumor Extirpation Research Articles

DS28 In search of salivation? Management of parotid duct injury following Mohs micrographic surgery

Abstract Parotid duct injury is a rare complication of cutaneous surgery usually occurring after excision of deep infiltrating tumours on the cheek. The existing literature is limited to case reports. We present our experience of two cases encountered in our unit over the last 15 years. Our first patient was an 87-year-old man referred for Mohs excision of a biopsy-confirmed morphoeic basal cell carcinoma (BCC) on his right cheek. During tumour extirpation, it was necessary to sacrifice a short section of the parotid duct. This was confirmed by direct visualization of the duct and a visible salivary leak. Immediate referral was made to the plastic surgery department, who also noted ipsilateral weakness in the distribution of the buccal branch of the facial nerve. The parotid duct was repaired over a lacrimal stent secured to his buccal mucosa. The wound was reconstructed with a large rhombic transposition flap and the parotid gland infiltrated with botulinum toxin. Four weeks later, the salivary stent had spontaneously fallen out and fresh-looking saliva was noted emerging from the parotid ampulla. Our second patient was a 65-year-old man referred for Mohs excision of a 3-cm nodular BCC on the left cheek. During tumour extirpation, a short section of the parotid duct was resected, which was clearly visible in the Mohs layer. On this occasion, the patient was referred to colleagues in the maxillofacial surgery department who attended the dermatology surgical unit. Under local anaesthesia, the parotid duct was cannulated using an epidural catheter secured both intraorally and to the residual duct using an absorbable monofilament suture (intraoperative pictures will demonstrate the technique). The Mohs defect was reconstructed with a bilobed transposition flap. Hyoscine patches were supplied to help reduce salivary flow. Marked swelling of the parotid gland developed postoperatively, which settled without further intervention. After 4 weeks, the epidural catheter was removed, and saliva was noted to be flowing from the parotid ampulla. Weakness of the lip elevators was noted in keeping with facial nerve injury. Despite the infrequency of parotid duct injury, it is important that cutaneous surgeons/Mohs surgeons are aware of how to proceed in these cases. In cases where assistance is not available from other specialties, the technique could be undertaken by an appropriately trained dermatological surgeon/Mohs surgeon using local anaesthesia.

P44 Can dermatologists help save the planet?

Abstract The National Health Service (NHS) is England’s largest contributor to public greenhouse gas emissions, accounting for 6.3% of the country’s carbon footprint (Tennison I, Roschnik S, Ashby B et al. Health care’s response to climate change: a carbon footprint assessment of the NHS in England. Lancet Planet Health 2021; 5:e84–92). Promoting sustainable practices within dermatology is often overlooked and remains an understudied area of research. Dermatologists should consider environmental sustainability when choosing their day-to-day personal protective equipment (PPE). An over-reliance on sterile PPE for minor surgical practices costs millions of pounds annually, ultimately occupying landfills and causing detrimental effects to our ecosystem. Are these sterile practices really improving clinical outcomes and reducing the prevalence of surgical site infections (SSIs)? Over the last decade, there has been an emphasis on comparing the use of sterile vs. nonsterile gloves and associated SSI rates in dermatology and Mohs micrographic surgery (MMS). MMS is often conducted with two sterile gloves and two surgical gowns. According to the sustainability guidance published by the British Society for Dermatological Surgery, surgical aprons and nonsterile gloves are preferred to surgical gowns and sterile gloves in procedures such as diagnostic biopsies, simple excision, tumour extirpation stages in MMS and outpatient reconstructive surgeries (https://bsds.org.uk/wp-content/uploads/2022/09/2022-BSDS_Sustainability_Guidance.pdf). Based on this guidance and to reduce our carbon footprint, we decided to use two plastic aprons, one pair of nonsterile and one pair of sterile gloves from August 2020 to September 2022. Of 410 MMS procedures conducted, only 1.7% resulted in a minor postoperative complication related to infection. Our data suggest no significant difference in postoperative wound infections with the use of nonsterile PPE vs. sterile PPE. Moreover, the use of nonsterile PPE has saved our department £1471.90, allowing funding to be distributed to other areas. In line with the NHS multiyear plan to become the world’s first carbon net zero national health system by 2040, we should invest in processes that facilitate sustainable alternatives to construct a fully operational eco-friendly healthcare system. By using less PPE in reconstructive surgeries, we reduce plastic waste. Despite not being able to remove PPE completely, we can make dermatology more sustainable, to help save the planet we live on.

The Future of Minimal-Access Myoma Surgery with In-Bag Contained Morcellation.

Contained electromechanical morcellation has emerged as a safety approach for laparoscopic myomatous tissue retrieval. This retrospective single-center analysis evaluated the bag deployment practicability and safety of electromechanical in-bag morcellation when used for big surgical benign specimens. The main age of patients was 39.3 years (range 21 to 71); 804 myomectomies, 242 supracervical hysterectomies, 73 total hysterectomies, and 1 retroperitoneal tumor extirpation were performed. A total of 78.7% of specimens weighed more than 250 g (n = 881) and 9% more than 1000 g. The largest specimens, weighing 2933 g, 3183 g, and 4780 g, required two bags for complete morcellation. Neither difficulties nor complications related to bag manipulation were recorded. Small bag puncture was detected in two cases, but peritoneal washing cytology was free of debris. One retroperitoneal angioleiomyomatosis and three malignancies were detected in histology (leiomyosarcoma = 2; sarcoma = 1); therefore, patients underwent radical surgery. All patients were disease-free at 3 years follow-up, but one patient presented multiple abdominal metastases of the leiomyosarcoma in the third year; she refused subsequent surgery and was lost from follow-up. This large series demonstrates that laparoscopic bag morcellation is a safe and comfortable method to remove large and giant uterine tumors. Bag manipulation takes only a few minutes, and perforations rarely occur and are easy to detect intraoperatively. This technique did not result in the spread of debris during myoma surgery, potentially avoiding the additional risk of parasitic fibroma or peritoneal sarcoma.

Solitary Extremity Schwannoma: A 20-Year Review of Outcomes.

Background: Reports on benign peripheral nerve sheath tumour extirpation over the last number of decades describe varying patient outcomes. We present our outcomes following excision of solitary extremity schwannoma over a 20-year period. Methods: A regional histopathology review was conducted for, "benign nerve sheath tumour" and schwannoma between 2000 and 2020. This search provided 131 histologically confirmed schwannomas that were excised from the extremities of 123 patients. Individual charts were reviewed retrospectively to establish presenting features and post-operative outcomes. Results: One hundred and twenty three patients underwent schwannoma excision, including 8 patients with synchronous tumours. The mean age at presentation was 49 years (range 11-92 years). The most common presenting symptoms were the following: palpable mass (88%), pain (70%), paraesthesia (21%), numbness (13%), and motor deficit (4%). Post-operative follow-up ranged from 1 to 168 months (mean 12.3 months) (N = 99). Fifty-eight cases reported complete resolution of symptoms by end of outpatient follow-up (59%). The remaining reported either residual or new numbness (21%), paraesthesia (11%), pain (10%), weakness (4%), hypertrophic or keloid scar (3%), or a combination. Thirty patients (30%) developed new symptoms post-operatively including numbness (13%), paraesthesia (10%), pain (2%), and weakness (2%). There was a trend towards higher risk of post-operative pain, numbness or paraesthesia in patients undergoing excision of schwannomas on larger mixed nerves than in patients undergoing excision on smaller sensory nerves (P = .0531). Conclusion: Surgical excision of benign schwannomas is a successful procedure, especially for pain management, however, complete symptom resolution cannot be guaranteed, and the risk of new or persisting numbness, paraesthesia, pain, and weakness should be highlighted to patients during the consent process.

Minimally Invasive Extirpation of Benign Atrial Cardiac Tumors: Clinical Follow-Up and Survival.

Evidence determining the optimal treatment for cardiac tumors is rare. We report our midterm clinical outcome and patient characteristics of our series undergoing atrial tumor removal through a right lateral minithoracotomy (RLMT). From 2015 to 2021, 51 patients underwent RLMT for atrial tumor extirpation. Patients receiving concomitant atrioventricular valvular, cryoablation, and/or patent foramen ovale closure surgery were included. Follow-up was performed using standardized questionnaires (mean: 1,041 ± 666 days). Follow-up involved any tumor recurrence, clinical symptoms, and any recurrent arterial embolization. Survival analysis was successfully achieved in all patients. Successful surgical resection was achieved in all patients. Mean cardiopulmonary bypass and cross-clamping times were 75 ± 36 and 41 ± 22 min, respectively. The most common tumor location was the left atrium (n = 42, 82.4%). Mean ventilation time was 12.74 ± 17.23 h, intensive care unit stay ranged from 1 to 1.9 days (median: 1 day). Nineteen patients (37.3%) received concomitant surgery. Histopathological analysis showed 38 myxoma (74.5%), 9 papillary fibroelastoma (17.6%), and 4 thrombus (7.8%). Thirty-day mortality was observed in 1 case (2%). One patient (2%) suffered a stroke postoperatively. No patient had a relapse of cardiac tumor. Three patients (9.7%) showed arterial embolization during follow-up. Thirteen follow-up patients (25.5%) were in New York Heart Association class ≤II. Overall survival was 90.2% at 2 years. A minimally invasive approach for benign atrial tumor resection is effective, safe, and reproducible. Of the atrial tumors, 74.5% were myxoma and 82% were located in the left atrium. A low 30-day mortality rate with no manifestation of recurrent intracardiac tumor was observed.

Adjuvant multimodal treatment for spinal intradural extramedullary capillary hemangioma with subpial growth: illustrative case.

Spinal intradural extramedullary capillary hemangiomas are rare vascular lesions. Although total resection is the first treatment, the efficacy of adjuvant therapies, such as steroid or radiation therapy, has not been investigated. A 74-year-old man presented with progressive back pain, gait disturbance, and left chest pain. Spinal magnetic resonance imaging (MRI) revealed an intradural extramedullary lesion at the middle thoracic level. Preoperatively, systemic steroid administration improved his chest pain and reduced the tumor size. The authors performed tumor extirpation. Because the tumor strongly adhered to the pia matter, in short, the tumor accompanied with partial subpial growth, subtotal resection was performed, leaving a thin layer of the tumor. A pathological examination revealed capillary hemangioma. His gait disturbance showed rapid improvement. Stereotactic cyber knife treatment was performed for the residual tumor at 1 month after the operation. Serial MRI showed a gradual decrease in the tumor size and no recurrence at 2 years after the operation. When a tumor adheres to the spinal cord or nerve root, immoderate total resection should not be performed to avoid exacerbating the clinical symptoms. Adjuvant therapies, such as a systemic steroid administration or radiation therapy, may provide satisfactory control of spinal capillary hemangiomas.

The Use of Patient-Specific Orbital Reconstruction Implants During Maxillectomy Reconstruction.

Background: Reconstruction of the orbital floor after maxillectomy can result in significant functional and aesthetic morbidity. Study Objective: To measure eyelid position, self-reported visual outcomes, and complications in patients undergoing concurrent maxillectomy and reconstruction with a patient-specific orbital reconstruction implant (PSORI). Design Type: Case series. Materials and Methods: Case series including 12 patients who received PSORI for orbital floor reconstruction after tumor extirpation. Primary outcomes gathered were diplopia, ectropion, and wound healing complications. Results: The majority of patients were men (75%) and the mean age was 53.3 years. Ten patients underwent free flap reconstruction with the majority receiving fibula free flaps (n = 6). Median follow-up was 415.5 days. Three patients (25%) experienced long-term complications, including diplopia (n = 1) and hardware extrusion (n = 3). Each of these occurred in the context of total maxillectomy and radiation. This prompted subsequent use of a modified implant design for the final six patients and the preferential use of a midface-degloving approach. These interventions eliminated extrusions in subsequent patients. Conclusion: PSORIs can be used for orbital floor reconstruction following maxillectomy in combination with free tissue transfer. Implant design is critical to reduce complications. The use of a midface degloving approach and a modified low-profile design was associated with a low rate of complications.

Ablative Therapy in Non-HCC Liver Malignancy.

Surgical extirpation of liver tumors remains a proven approach in the management of metastatic tumors to the liver, particularly those of colorectal origin. Ablative, non-resective therapies are an increasingly attractive primary therapy for liver tumors as they are generally better tolerated and result in far less morbidity and mortality. Ablative therapies preserve greater normal liver parenchyma allowing better post-treatment liver function and are particularly appropriate for treating subsequent liver-specific tumor recurrence. This article reviews the current status of ablative therapies for non-hepatocellular liver tumors with a discussion of many of the clinically available approaches.

Management of Palatal Defects after Free-Flap Reconstruction and Radiotherapy.

Palatal fistulas have significant effects on quality of life. Traditional prosthetic rehabilitation and surgical reconstruction of palate defects in radiation-naïve tissues are well described. However, palatal fistulas developing after initial tumor extirpation, free-flap reconstruction, and adjuvant radiation or chemoradiation are associated with challenging secondary tissue effects. In this review, we will discuss the management of palatal fistulas after surgical reconstruction and radiotherapy.

Factors Leading to Gastrostomy Tube and Tracheostomy Requirements in Patients Treated Initially With Radiotherapy and Salvaged With Surgery and Free Flap Reconstruction.

Patients with recurrent oropharyngeal cancer can achieve survival benefits from surgical salvage, and often require simultaneous free-flap reconstruction. Resection and reconstruction can impact function, leading to tube dependence. describe rates of tracheostomy and gastrostomy tube dependence after oropharyngeal resection and free flap after prior radiation. evaluate patient, tumor, and treatment factors associated with tube dependence. Retrospective, multi-institutional cohort study. Patients treated from 2003 to 2020. Average follow-up 21.4 months. Five tertiary care centers. Consecutive cohort of patients undergoing resection and simultaneous free-flap reconstruction for oropharyngeal squamous cell carcinoma after head and neck radiation. gastrostomy tube dependence and tracheostomy or tracheostoma 1 year after surgery. Univariable and multivariable logistic regression were performed to identify factors associated with dependence. 89 patients underwent oropharyngectomy and free-flap reconstruction; 18 (20%) underwent total laryngectomy as part of tumor extirpation. After surgery, 51 patients (57%) lived 12 months. Among patients alive at 12 months, 22 (43%) were at least partially-dependent on gastrostomy tube, and 15 (29%) had either tracheostomy or tracheostoma. On multivariable analysis, extensive glossectomy (OR 16.6, 95% CI 1.83-389, p=0.026) and total laryngectomy (OR 11.2, 95% CI 1.71-105, p=0.018) were associated with long-term gastrostomy tube. No factors were associated with long-term tracheostomy on multivariable analysis. Even among long-term survivors after salvage resection and free-flap reconstruction, rates of tube dependence are significant. This multi-institutional review is the largest such study to the date and may help inform shared decision-making. 4 Laryngoscope, 133:2141-2147, 2023.

Differences in sentinel lymph node biopsy utilization in eligible melanoma patients treated with Mohs micrographic surgery or wide local excision: A population-based logistic regression model and survival analysis

Primary melanoma management relies on tumor extirpation and staging sentinel lymph node biopsy (SLNB) in eligible patients. This study compares SLNB utilization in patients undergoing wide local excision (WLE) or Mohs micrographic surgery (MMS). American Joint Committee on Cancer seventh edition≥patients with T1b melanoma undergoing WLE or MMS in the Surveillance, Epidemiology, and End Results program were included. Propensity score matching was performed to compare patients who underwent MMS or WLE. Kaplan-Meier analysis and Fine-Gray cumulative incidence functions were used for overall and melanoma-specific survival. Eight hundred twenty-five MMS cases and 38,760 WLE cases were identified. SLNB was performed in 32.61% of MMS patients and 61.77% of WLE patients with positive rates of 12.5% and 14.82%, respectively. Multiple logistic regression of factors associated with SLNB utilization revealed that WLE, male gender, younger age, extremity location, and nodular and rare melanoma subtypes were significantly associated with increased odds of receiving SLNB whereas head and neck location and lentigo maligna melanoma subtype were significantly less likely to receive SLNB. Potential selection bias from a retrospective data set. Patients receiving WLE for≥T1b melanoma are more likely to receive a SLNB than patients undergoing MMS.

Endoscopic transoral approach to the lateral poststyloid space.

The lateral poststyloid space (LPSS) located at the posterolateral aspect of the styloid process. This study aims to explore the anatomical relationships in LPSS via a transoral corridor, providing reference for addressing lesions extending to this region. An endoscopic transoral approach for exposure of the LPSS was performed on 6 cadaveric specimens (12 sides). Related landmarks were explored, and transoral extirpation of tumors extended into LPSS was employed in 12 patients. The deep lobe of the parotid gland, extratemporal facial nerve, and the accompanying artery in the LPSS were sufficiently exposed via the transoral corridor in all 12 cadaveric sides. The transoral corridor provided adequate exposure for tumors extending to the LPSS, and en bloc resection was achieved in these 12 patients. No facial nerve or vascular injury occurred, and no recurrence observed in this cohort with an average follow-up of 26 months. An endoscopic transoral approach provides a direct access to the LPSS. Appreciation of the anatomical relationships within the LPSS is valuable for employing a transoral extirpation of tumors extending to this specific region.

Geometric Design and Outcome of Transposition Flaps for Scalp Reconstruction

Background: The scalp is a unique part of the human body and various etiological factors, such as tumor extirpation, avulsion, infection, burns, or trauma, can lead to scalp defects. Primary closure, skin grafting, local flaps, tissue expansion or free tissue transfer is modalities available for scalp reconstruction. Local flap coverage is best option for full thickness loss with exposed bone. Among various local flap transposition flap is reasonable and flexible option with good outcome for scalp reconstruction.
 Objective: The purpose of this study was to evaluate the geometric design of transposition flap for scalp reconstruction concerning the dimension of the defect and outcome the surgery.
 Methods: This was a prospective observational study, conducted in the Burn & Plastic Surgery department of Rangpur medical college hospital, Rangpur and different private hospitals of Rangpur city over a period of three years from June 2018 to July 2021 through purposive sampling. All aged patients having single full thickness scalp wound with loss of pericranium were included in this study. In all cases transposition flaps were used. All the flaps were elevated through sub galeal lose areolar plane. Flap donor site was covered with split thickness skin graft taken from thigh. Surgical technique, patient factors and outcome were evaluated.
 Results: A total 50 patients were operated. The age range was 07-68 years, among them 36% patient were in the age range of 21 – 30 years. 80% patients in this series were male. In this series 64 % patients were construction and electric worker by profession. Electric burn was the main (64%) cause of soft tissue defect of scalp. The majority (46%) of the patients had a wound dimension of 51-70 cm2, smallest was (5x6) = 30cm2 and largest was (9x15) = 135cm2, indicating that extent of soft tissue defects in this series is quite extensive. 12 (24%) patients had complication and all were due to infection, seven patients had infection in flap recipient site, 2 patients had infection in flap donor site and 3 patients developed infection in skin donor site. There was no flap loss in our study.
 Conclusion: Sound knowledge of flap geometry and clear evaluation of the defect is mandatory for successful reconstruction of scalp defect. A local transposition flap with donor site skin grafting is reliable option for reconstruction of full thickness scalp defect in most instances.
 J Rang Med Col. September 2022; Vol. 7, No. 2:52-57

Salvage Reconstruction of Oncologic Humeral Defects with Free Fibula Flap after Failure with Prosthesis-based Reconstruction

PURPOSE: Advancements in orthoplastic reconstructive surgery have enabled surgeons to perform limb salvage surgery successfully after long bone tumor extirpation of upper extremities. A variety of reconstructive options (allograft, prosthetics, allograft-prosthetic combination, non-vascularized autografts) exist for surgical rehabilitation of such cases. Even though reconstruction by prosthesis is most commonly used in this setting, the associated risks of mechanical failure, aseptic loosening, and infection, can potentially lead to failure and amputation. Furthermore, revision procedures of the primary surgery after implant failure are complicated by unfavorable local tissue properties like massive bone loss, unreliable local tissue, and osteopenic process of the host bone. Therefore, prosthetic reconstruction is usually undesirable; whereas vascularized bone flaps have proven to be an excellent alternative to restore the biomechanical framework of the limb. Herein, we present the free fibula flap (FFF) used to reconstruct oncological humeral defects previously treated with prosthetic based reconstruction which failed. METHOD: We conducted a retrospective review of patients who underwent salvage of the humeral reconstructions in which the prosthesis failed, during 2009 and 2019. We included patients with previous reconstruction of humeral defects only with prosthetic material and no tissue transfer. All cases were reconstructed with the FFF. The Musculoskeletal Tumor Society (MSTS) scoring system was used to evaluate functional outcomes. RESULTS: The mean age was 24 ± 5.54 years. Six male patients (85.7%) and one female were included (14.3%). None of the patients had comorbidities. Four patients had primitive neuro-ectodermal tumors (57.1%) while three had osteogenic sarcomas (42.9%). All patients had the radial nerve preserved during onco-resection. The average gap between implant surgery and salvage with FFFs was 77.5 ± 49.024 months. The indications for salvage with the FFF were infection of implants (42.9%) and aseptic loosening (57.1%). The defects were located proximally in seven patients (85.7%) and mid-shaft in one patient (14.3%). Seven patients had adjuvant chemotherapy (85.7%), while two had neoadjuvant radiotherapy (28.6%). The defect length after debridement and implant removal was 13 ± 5.62 cm. The fibula head was incorporated in 57.1% of the flaps (n=4). For flap fixation dynamic compression plates was used in one patient (14.3%); number 20 cerclage wiring, prolene mesh, and ethibond was used in another patient (14.3%); K wires were used in four patients (57.1%); and ethibond in 1 patient (14.3%). Only one flap had a double venous anastomosis. Two patients underwent re-exploration of the anastomosis (57.1%), the only flap harvested with a skin paddle required debridement of the cutaneous component (14.3%), and one patient had wound dehiscence (14.3%). Six flaps survived (85.7%). Bone union was achieved at 17 ± 1.25 weeks on average. The average MSTS score was 74.9%. The average follow up was 59.57 ± 43.48 months. CONCLUSION: The FFF is a resourceful alternative for the management of a failed prosthesis after oncologic resection of the proximal and mid-humerus, especially with previously infected prosthetic material. Due to its anatomical shape and the vascularized nature of tissue, the FFF provides a long bone segment for humeral reconstruction.

Parotid Surgery With Concurrent Bilateral Rhytidectomy

Facial reconstruction after parotid surgery can present an aesthetic challenge. This case series describes an asymmetric cervicofacial rhytidectomy technique at the time of parotid surgery to achieve defect closure as well as volume augmentation of the postablative deformity. While unilateral superficial musculoaponeurotic system (SMAS) flaps after parotid tumor extirpation have been described many times, this is the first reported case series of parotid tumor resection with concurrent bilateral cervicofacial rhytidectomy. This series consists of two adult females with unilateral facial swelling who also desired facial rejuvenation surgery. They separately presented to the University of Texas Southwestern Maxillofacial Surgery team and proceeded to have unilateral parotid tumor removal with concurrent bilateral cervicofacial rhytidectomy. To give context to this case series, the authors also searched the PubMed, Scopus, and Google Scholar databases to look for previously reported similar cases. The authors were able to address the patients’ functional as well as aesthetic concerns with a single surgery in a safe manner. Ipsilateral to the tumor resection, there was a sizeable loss in volume in both cases. Therefore, a vascularized SMAS flap was imbricated to provide volume, while a selective SMAS removal and plication was used on the contralateral side to achieve symmetric volume bilaterally. A comprehensive literature search demonstrated one previous report of concurrent bilateral cervicofacial rhytidectomy with parotid tumor extirpation. Despite the prevalence of utilizing a rhytidectomy incision for parotid surgery, there is a dearth of literature describing concurrent bilateral cervicofacial rhytidectomy with parotid tumor extirpation. Functionally, it has been shown to decrease the incidence of gustatory sweating on the side of reconstruction. Aesthetically, the surgeon is not only re-establishing the volume by augmenting the ablative defect, but also creating a symmetrical postoperative appearance by performing a reductive rhytidectomy on the contralateral side. Utilizing an asymmetric bilateral cervicofacial rhytidectomy at the time of parotid surgery can be an efficient technique for aesthetically reconstructing a patient with a parotid mass. It should be considered in patients with benign parotid disease who have the desire for facial rejuvenation surgery.

Multidiscipline management of giant reccurent nasopharyngeal angiofibroma which extends to paranasal sinuses, orbita, and intracranial in adult

Nasopharyngeal angiofibroma (NA) is a benign, slowly growing tumour that affects males in their early puberty, and rarely men over 25 years of age. There was an interesting case of a giant recurrent NA in a 62-year-old male, which is challenging to manage due to wide tumour expansion to paranasal sinuses, orbital and intracranial. In cases of large angiofibromas disease, preoperative embolization should be performed to prevent profuse bleeding. Wide expansion of NA can cause post extirpation large defects of the tumour so that optimal defect closure techniques are needed to restore the aesthetics and function of the disturbed organs. This case's diagnosis and management of this disease was carried out by multidisciplinary discussion, and surgical extirpation of the joint tumour was performed in Dr. Soetomo General Academic Teaching Hospital. The tumour was removed by medial maxillectomy with an extended Killian right lateral rhinotomy approach followed by tumour defects reconstruction. The follow up showed that there were still tumour residue and suspicious intracranial abscess, but the patient had no complaint during follow-up for ten months after surgery.

“A PROSPECTIVE AND COMPARATIVE STUDY OF CARCINOMA OF BUCCAL MUCOSA CASES WITH EXCISION FOLLOWED BY PRIMARY CLOSURE VERSUS USE OF RECONSTRUCTIVE FLAP”

Introduction: Carcinoma of buccal mucosa is the most common cancer of the oral cavity in India.1 Increasing trend of incidence of these cancers in the developing countries, most likely due to a higher exposure to alcohol, tobacco, health ignorance, poor access to health care facilities. Buccal mucosa cancers primarily occurs along the occlusal plane and are characterized by pain and ulceration, which are usually accompanied by a buccal mass. Aim: To compare the clinical outcome in cases of surgery with primary closure and surgery with reconstructive aps after standard surgery for extirpation of tumor. Material And Method: The study was carried out as a prospective study in the Department of General Surgery at Gajra Raja Medical College and J.A. Group of Hospitals, Gwalior (M.P.) for one and half year from January 2020 to June 2021.Atotal of 30 patients with histopathologically conrmed carcinoma of buccal mucosa were studied. The study was approved by ethical committee of the Hospital. Results: In the present study, the result of primary closure vs ap reconstruction for defects extirpation of tumor, the maximum cases lie in age group of 41- 50 years (12 i.e. 40%) age group of 61-70 years (6 i.e. 20%) and 51-60 years (5 i.e. 17%). Carcinoma of buccal mucosa had higher incidence in male. Total number of male cases were 26(87%) and female cases were 4(13%).The male to female ratio was 6.5:1. Out of 30 patients, in 18 cases neck management done by modied radical neck dissection and in 11 cases neck managed by radical neck dissection. After resection of primary lesion and neck dissection, the defect which was either covered by use of reconstructive ap or primary closed. Out of 30 cases, in 18 cases defect was closed by use of reconstructive ap and in 12 cases defect was primary closed. Out of 30 cases, in 13 cases(72%) reconstruction was done by use of pectoralis major myocutaneous ap. In 3 cases(17%), reconstruction was done by use of free bular graft and in 2 cases(11%), reconstruction was done by use of Radial forearm free ap. Conclusion: In carcinoma buccal mucosa, No neck patients was treated with modied radical neck dissection and N+ neck patients was treated by Radical neck dissection. Eleven carcinoma buccal mucosa underwent Radical neck dissection and 18 patients had Modied radical neck dissection. For Mandible reconstruction, bular bone graft is best option for form and function. Two patients underwent mandibular reconstruction by use vascularized bular bone. Primary closure of defect was possible if surrounding tissue was lax. Primary closure after excision of tumor done in 12 cases(40%). In buccal mucosa carcinoma, free ap provides reconstruction for complex defect. In present study, Pectoralis major myocutaneous ap mostly used for reconstruction of defect. In 13 patients (72%) PMMC ap was used. The complication noted was, immediate was ap necrosis and late was recurrence. In immediate post operative period there was ap necrosis in 2 cases and recurrence was seen in 4 cases.

Impact of Obesity on Perioperative Complications on Treatment of Spinal Metastases: A Multicenter Surveillance Study from the German Spine Registry (DWG-Register).

Background The spine is a common location for the development of primary and metastatic tumors, spinal metastases being the most common tumor in the spine. Spinal surgery in obesity is challenging due to difficulties with anesthesia, intravenous access, positioning, and physical access during surgery. The objective was to investigate the effect of obesity on perioperative complications by discharge in patients undergoing surgery for spinal metastases. Methods Retrospective analysis of data from the DWG-register on patients undergoing surgery for metastatic disease in the spine from January 2012 to December 2016. Preoperative variables included obesity (≥ 30 kg/m 2 ), age, gender, and smoking status. In addition, the influence of pre-existing medical comorbidity was determined, using the American Society of Anesthesiologists (ASA) score. Results In total, 528 decompressions with and without instrumentation undergoing tumor debulking, release of the neural structures, or tumor extirpation in metastatic disease of the spine were identified; 143 patients were obese (body mass index [BMI] ≥ 30 kg/m 2 ), and 385 patients had a BMI less than 30 kg/m 2 . The mean age in the group with BMI 30 kg/m 2 or higher (group 1) was 67 years (56.6%). In the group with BMI less than 30 kg/m 2 (group 2), the mean age was 64 years. Most of the patients had preoperatively an ASA score of 3 and 4 (patients with severe general disease). The likelihood of being obese in the logistic regression model seems to be protective by 47.5-fold for blood loss 500 mL or higher. Transfusions occurred in 321/528 (60.7%) patients (group 1, n = 122 and group 2, n = 299; p = 0.04). A total of 19 vertebroplasties with percutaneous stabilization (minimally invasive spine [MIS]), 6 vertebroplasties, and 31 MIS alone were identified. The variables between these groups, with exception of preoperative status (ASA-score; p = 0.02), remained nonsignificant. Conclusion Obese patients were predisposed to have blood loss more than 500 mL more often than nonobese patients undergoing surgery for spinal metastases but with perioperative blood transfusions, invasiveness, nor prolonged hospitalization. Early postoperative mobilization and a low threshold for perioperative venous thromboembolism (VTE) are important in obese patients to appropriately diagnose, treat complications, and minimize morbidity.

EP05.03-011 Bilateral Orthotopic Lung Transplantation for a Patient with Advanced Invasive Mucinous Adenocarcinoma

Invasive mucinous adenocarcinoma (IMA) is a rare type of lung cancer associated with poor prognosis since systemic chemo- and immunotherapies are generally ineffective and lack of actionable genomic alterations often preclude targeted therapy. While organ transplantation is excluded in patients with solid malignancies, we hypothesized that tumor extirpation through bilateral lung transplantation in a patient with lack of systemic metastasis could be a life-saving treatment in medically refractory IMA.

Oropharyngeal reconstruction after transoral robotic surgery.

Transoral robotic surgery (TORS) has experienced an evolution in recent years. This technique has proved to be a safe and effective method for extirpation of select oropharyngeal tumors. Advances in technology as well as improved surgeon experience allow for the resection of larger, more complex cancers. Although healing by secondary intention remains the current standard for limited oropharyngeal defects, larger resections demand reconstruction with vascularized tissue to minimize morbidity and optimize functional outcomes. The objective of this review is to evaluate recent literature regarding oropharyngeal reconstruction after TORS. A variety of reconstructive options to manage oropharyngeal defects exist. Several reconstructive algorithms have been suggested; however, careful consideration must be used to select the most ideal flap type. Locoregional flaps have shown excellent functional outcomes with limited morbidity. An increase in free flap reconstruction has been demonstrated, particularly among patients with larger TORS defects and following chemoradiation therapy. Despite limited data, robotic-assisted flap inset and microvascular anastomosis has recently shown promise. Reconstruction and flap selection following TORS should be tailored to the patient and unique oropharyngeal defect. Functional outcomes are promising with low complication rates among these patients.