Multidisciplinary Surgical Management Research Articles

Case Report: Multidisciplinary management of severe blast-related craniofacial and ocular injuries at artisanal gold mining sites in Niger: An unusual case report and comprehensive literature review

Blast-related craniofacial and ocular injuries have traditionally been associated with battlefields. In civilian populations, these injuries were infrequent, primarily arising from accidental explosions or terrorism incidents. Explosions can inflict severe damage to the neurological, ocular, and auditory systems through blast waves, high-velocity foreign bodies, and thermal radiation. The pathophysiology of blast-related craniofacial injuries is specific and complex, with severe cases often involving both penetrating and blunt trauma, leading to high mortality and morbidity rates. These injuries necessitate multidisciplinary management and can be defined as intracranial polytrauma. Recently, Niger has seen a surge in blast injuries, predominantly due to the increase in clandestine artisanal gold mining. Managing these injuries in resource-limited settings poses significant challenge. Comprehensive national data on these injuries are sparse due to high pre-hospital mortality rates and their infrequent occurrence, resulting in limited experience among our local physicians in their management. We present a rare case involving an artisanal gold miner with a history of smoking and previous concussions from explosion exposures. The patient was transferred to our hospital following severe craniofacial and ocular injuries caused by an accidental dynamite explosion at a mining site. On admission, the patient presented altered consciousness, agitation, unstable vital signs, multiple craniofacial wounds, including a large frontal wound with brain substance extrusion, diffuse facial burns, left globe rupture, and rhinorrhagia. After resuscitation and stabilization, brain imaging revealed multiple complex craniofacial fractures with foreign bodies. The patient underwent multidisciplinary surgical management. However, the postoperative course was complicated by post-concussive syndrome, and infection of the surgical wounds, necessitating surgical revision. Following the second surgery, the postoperative course was uneventful, although the patient experienced reduced visual acuity. This case highlights the management challenges in Niger and underscores the urgent need for clinical studies and training for gold miners to enhance safety practices in their activities.

Multidisciplinary surgical management of severe posterior compartment endometriosis

BackgroundEndometriosis is a chronic, inflammatory, and hormone-dependent disease that affects approximately 10% of women in reproductive age. Endometriosis is categorized into different types, as superficial, deep, and ovarian endometriosis. When deep endometriosis occurs, the sigmoid and rectum are often affected (Becker et al. in Hum Reprod Open, 2022, https://doi.org/10.1093/hropen/hoac009). In the following article, we aim to demonstrate stepwise surgery for stage IV endometriosis involving the anterior rectosigmoid.MethodsWe present the case of a 26-year-old obese (BMI 35.87) woman with severe posterior pelvic compartment endometriosis, persistent abdominal pain, and constipation. On preoperative MRI of the pelvis, a 13 cm conglomerate incorporating both ovaries (kissing ovaries), uterine serosa, and the anterior rectosigmoid was observed (Fig. 1). Accordingly, interdisciplinary laparoscopic surgery with a gynecologist and colorectal surgeon was planned.ResultsThe total laparoscopic approach is demonstrated step by step in the video.ConclusionsDeep endometriosis is a rare condition. When involvement of other organs (e.g., the bowel) is suspected, preoperative endometriosis-specific imaging should be performed for optimal surgical planning. Experienced endometriosis multidisciplinary surgical teams can provide specialized and high-quality care for patients suffering from this debilitating disease (Luna Russo et al. in Minerva Ginecol, 2020, https://doi.org/10.23736/S0026-4784.20.04544-X).

Multidisciplinary surgical management of deep endometriosis with single robot port set-up

Multidisciplinary surgical management of deep endometriosis with single robot port set-up

Combined Multidisciplinary Gender-Affirming Surgery During the Covid-19 Pandemic: A Model to Optimize Access to Care, Resource Utilization andMedical Readiness forMilitary Patients.

Access to surgical care for gender-affirming surgery (GAS) has been a persistent challenge within the DoD due to long waiting lists, strict insurance requirements, and surgeon/subspecialty scarcity. These issues were magnified during the COVID-19 pandemic response, as limited resources led to postponement of "elective" surgeries. To remedy this, our center organized a multidisciplinary collaboration to perform simultaneous GAS. This model is necessary to optimize the quality-of-life and medical readiness for a particularly marginalized population within the U.S. Military who now constitute roughly 1% of all active duty personnel. In addition, one-stage surgery provides a feasible solution to streamlining care and decreasing DoD personnel health care costs. We present a case describing successful multidisciplinary surgical management of a transgender woman desiring multiple GASs. We include a comparative, cost-benefit analysis to emphasize the advantages of single-stage over multistage surgeries. Our patient is a 24-year-old active duty transgender female who underwent breast augmentation and fat harvesting with plastic surgery, which was immediately followed by simultaneous simple orchiectomy by urology and facial feminizing surgery with otolaryngology. Total operative time was 8.3 hours. Our patient was discharged on post-operative day 1 and had an uneventful recovery without complications. Keys to successful implementation included the judicious, coordinated use of local analgesia as well as the organization of separate operating room bedside tables and scrub techs for each team. Total convalescent leave time and temporary profile duration were reduced by 50% relative to the staged approach: 4 weeks and 3 months versus 8 weeks and 6 months, respectively. Of note, anesthesia provider fees total ∼$8,213 when surgeries are performed as three separate events. For one-stage surgery, anesthesia fees amount to only $1,063 (assuming ∼10 hour anesthesia time with a CRNA provider). Our case study demonstrates that one-stage multidisciplinary surgery can be accomplished without added risk to the patient. Judicious surgical planning, including having surgeons operating at the same time, reduces operative time and provides for efficient operating room utilization. Simultaneous GAS is an effective approach to improve access to surgical care for transgender patients. A single anesthetic enables patients to achieve their surgical goals sooner and to lessen their overall recovery time. This allows service members to return to duty sooner, supporting the Defense Health Agency mission to ensure a medically-ready force. This model should become the standard within MTFs across the DoD, as it promotes improved quality-of-life for patients, decreases personnel costs, and ensures medical readiness.

(473) Simultaneous Multidisciplinary Gender Affirming Surgery during COVID-19: Improving Access to Care for Military Patients

Abstract Introduction Access to surgical care for the transgender population has been a persistent challenge. Frequently cited barriers include long waiting lists, strict insurance prior authorization protocols, surgeon scarcity, financial cost, and social stigma. These issues have been magnified throughout the COVID-19 pandemic response, as the diversion of resources has led to the postponement of surgeries deemed “routine” or “non-essential.” Many medical societies and healthcare organizations have classified gender-affirming surgery (GAS) as such despite the World Professional Association for Transgender Health (WPATH) defining surgical care for gender dysphoric individuals as medical necessity. Unfortunately, delays in care for this population contribute to prolonged mental health distress. Another important barrier to access centers on the issue of surgical timing. Many patients cannot afford to postpone school and work obligations to undergo multiple surgeries each with long recovery times. Furthermore, staffing shortages nationwide have limited operating room (OR) availability. To respond to these issues, our center organized a multidisciplinary collaboration among various surgical subspecialties to perform simultaneous GASs (e.g., top and bottom surgeries). In this way, the patient can undergo multiple GASs in a single procedure, thus limiting anesthesia exposure, expediting postoperative recovery, improving patient satisfaction and maximizing limited healthcare resources. Objective To describe a multidisciplinary model for GAS involving simultaneous top and bottom surgery to improve access to care for the transgender population in a resource-limited environment. Methods Case report describing successful multidisciplinary surgical management of a transgender female desiring multiple simultaneous GAS. Results Patient is a 24-year-old active duty transgender female who met WPATH criteria for top and bottom surgery. She desired numerous procedures including simple orchiectomy, breast implants and facial feminization. Given our limited OR availability during COVID-19, the decision was made to perform all of these surgeries under the same anesthetic. She underwent breast augmentation and fat harvesting with plastic surgery, which was immediately followed by simultaneous simple orchiectomy by urology and facial feminizing surgery with otolaryngology. Total operative time was 8.3 hours. Patient was discharged on post-op day 1 and had an uneventful recovery without surgical or anesthetic complications. Conclusions Simultaneous GAS is an effective approach to improve access to care during the COVID-19 pandemic. A single anesthetic enables the patients to achieve their surgical goals sooner and to lessen their overall recovery time compared to staged procedures. Disclosure No

Age- and Population-Adjusted Trends in Inpatient Surgical Management of Vaginal Prolapse, Rectal Prolapse, and Concurrent Vaginal and Rectal Prolapse Surgery

ObjectiveTo report age- and population-adjusted trends in the prevalence of inpatient vaginal prolapse (VP), rectal prolapse (RP), and concurrent VP/RP surgical procedures in women in Washington State over a 12-year period.MethodsThe Comprehensive Hospital Abstract Reporting System, an inpatient claims database, was queried for female patients aged 20 years or older with a diagnosis of VP and/or RP and associated surgical procedures from 2008 to 2019. Rates for female patients were adjusted by age and population based on census results.ResultsBetween 2008 and 2019, inpatient admissions for concurrent VP/RP surgery remained stable, with adjusted rates ranging from 1.42 to 3.38 per 100 000, with a majority performed in patients < 80 years old. The population-adjusted rate of inpatient RP repairs remained stable at 3.12 to 5.14 per 100 000. The population-adjusted rate of inpatient VP repairs decreased dramatically, from 81.79 to 6.96 per 100 000.ConclusionsThe rate of inpatient RP and combined RP/VP surgical procedures was low and remained stable, while inpatient VP surgical repairs decreased substantially. Since the dataset is limited to inpatient surgery, this trend may reflect a shift to outpatient settings for VP surgeries. Nationally in the United States, there has been a trend toward multidisciplinary surgical management of concurrent VP/RP. However, this same trend does not appear to be reflected in Washington State, suggesting that nationwide trends may not be reflective of trends within each state. Further study is needed to understand how and why local trends in the management concurrent VP/RP may differ from national trends, and potentially improve concurrent VP/RP management using multidisciplinary approaches.

Subdural empyema secondary to pansinusitis after coronavirus disease 2019 infection in an immunocompetent patient: illustrative case.

Superimposed intracranial infection is an uncommon but clinically significant complication in patients with active coronavirus disease 2019 (COVID-19), particularly in those with predisposing immunocompromising conditions. The authors describe a case of subdural empyema, secondary to extension from pansinusitis, in a 20-year-old otherwise healthy immunocompetent male who was recently diagnosed with COVID-19. Despite his critical condition at time of presentation, he made a full clinical recovery with aggressive multidisciplinary surgical management between neurosurgery and otolaryngology, despite negative cultures to guide directed antimicrobial therapy. Ultimately, use of molecular-based polymerase chain reaction testing diagnosed Aspergillus fumigatus as the offending pathogen after the patient had already recovered and was discharged from the hospital. This case demonstrates the potential for significant superimposed intracranial infection even in young, healthy individuals, infected by COVID-19 and suggests an aggressive surgical approach to achieve source control, particularly in the absence of positive cultures to guide antimicrobial therapies, may lead to rapid clinical improvement.

Multidisciplinary Surgical Management of Extensive Basal Cell Carcinomas

Basal Cell Carcinoma (BCC) is the most common malignancy that can cause local tissue destruction. While treatment options for BCC vary depending on the degree of malignant progression, surgical intervention is generally required when there is significant tissue involvement. We present a case of a 40-year-old woman with extensive BCCs requiring a multidisciplinary surgical approach for treatment. Our case highlights the importance of utilizing a multidisciplinary team as well as different surgical management options for late stage BCCs.

Thoracic endometriosis: A case of one step multidisciplinary surgical treatment

We describe a case of thoracic endometriosis in a patient with a repeated episode of spontaneous pneumothorax. Investigations revealed diaphragmatic fenestrations and right-sided pleural and lung endometriosis. Considering the ultrasound evidence of pelvic endometriosis, the patient was scheduled for multidisciplinary surgical management, to treat in one step thoracic and pelvic endometriosis.

Combined transcranial and transnasal endoscopic approach in transnasal-penetrating intracranial injury: A rare case report.

IntroductionTransnasal-penetrating intracranial injuries are rare traumatic brain injuries that can cause serious and fatal brain damage and a high mortality rate and necessitate immediate multidisciplinary surgical management. We describe an uncommon case whereby a patient who presented with an accidental penetrating injury of the brain was found to have a wooden transnasal-penetrating intracranial object.Case presentationA 28-year-old man consulted an ear, nose, and throat (ENT) surgeon after complaints of headache for two days, a history of epistaxis, and vomitus. The right side of the nose had been punctured by wood as a result of falling from a motorcycle. A computed tomography (CT) scan led to diagnosis of a transnasal penetrating intracranial injury. Removal of the transcranial foreign body was carried out jointly by a neurosurgeon and ENT surgeon. Postoperatively, antibiotics were given for 14 days, and the patient was discharged without neurological deficit.Clinical discussionEarly diagnostic procedures, such as CT scan of the skull to assess trajectory and extent of vascular and brain tissue injury, are required for appropriate surgical planning and post-operative treatment of such patients. Surgery was performed by combined transcranial and transnasal endoscopy to identify the skull base, dura mater defect, and brain tissue damage. Removal of the corpus alienum by transnasal endoscopy yielded a good outcome.ConclusionCombined transcranial and transnasal endoscopic approach showed better result than transcranial approach only. The wooden foreign body can be completely eliminated transnasally without active bleeding using this approach. The patient was discharged with good outcome.

Complex Surgical Management of Radiation-Associated Left Retroperitoneal Sarcoma.

Radiation-associated sarcomas (RASs) are rare entities that tend to have an aggressive course and poor prognosis. Criteria for diagnosis of radiation-associated sarcoma include therapeutic radiation preceding the development of sarcoma, sarcoma arising within or near the irradiated field, and tumor histology that is distinct from the primary tumor necessitating radiation. Despite their relatively uncommon occurrence, RASs are a well-established complication of radiation therapy. We present the complex, multidisciplinary surgical management of a patient with multi-compartmental radiation-associated sarcoma of the left retroperitoneum occurring nearly 25years after undergoing whole trunk radiation for Hodgkin's lymphoma.

Transverse colon adenocarcinoma with direct cutaneous extension: complex multidisciplinary surgical management.

Article Transverse colon adenocarcinoma with direct cutaneous extension: complex multidisciplinary surgical management was published on June 1, 2022 in the journal Journal of Osteopathic Medicine (volume 122, issue 6).

Medium-term outcomes of multi-disciplinary surgical management of non-ischemic diabetic heel ulcers

BackgroundHeel ulcers in patients with peripheral neuropathy and diabetes pose a significant challenge to treating physicians. Infection spreading to the os calcis is associated with a poor prognosis. There is no consensus on which method of surgical treatments results in better outcomes. The aim of this study was to assess patients’ survival, rate of ulcer healing following surgical treatment, along with limb salvage rate, time taken for healing, ulcer recurrence and patients’ functional outcome after healing. MethodsWe studied 29 patients (20 men, 9 women) presenting with diabetic neuropathic heel ulcers (30 feet) and no critical limb ischemia, were managed surgically in our unit and followed-up for a minimum of 12 months. We assessed their clinical and functional outcomes within a mean follow-up period of 28 months (12–83). Results11 out of 29 patients died (38%) with mean duration of post op survival being 31months (range 4–70). 14 ulcers (50%) healed fully within a mean of 360 days (131–1676). Limb salvage was achieved in 29 feet (97%). Only 5 out of 17 patients with diabetic nephropathy (p value 0.016) and 9 out of 24 ulcers with calcaneal osteomyelitis (p value 0.044) achieved full ulcer healing. Ulcer recurrence rate was 36% (5/14) within 12 months of achieving ulcer healing. Six patients were able to return to independent walking in surgical shoes while 11 patients were mobilising using either a crutch or frame. ConclusionWhile excellent limb salvage can be anticipated from the outcome of surgically managed infected heel ulcers in patients with diabetes, complete healing can still be slow and unpredictable. Significant medical co-morbidities in these patients make them vulnerable to medium-term post-operative complication and survival.

Trabecular Juvenile Ossifying Fibroma Management by Virtual Surgical Planning, Piezoelectric Surgery, and Simultaneous Patient Specific Implant (PSI) Reconstruction

Trabecular juvenile ossifying fibroma is a rare fibro-osseous lesion affecting the craniofacial skeleton occurring commonly in children and young adults. Tumor clinical behavior is highly aggressive with invasion of adjacent anatomic structures. Because of its high recurrence rate complete excision is necessary, but this one could be facial mutilating. This case report presents a 23-year-old female patient with a trabecular juvenile ossifying fibroma of the right maxilla, expanding into the orbit and zygomatic bone. The report also shows the multidisciplinary surgical management of this lesion with successful preservation of optic nerve function and facial aesthetics.

Multidisciplinary surgical management of an unusual penetrating foreign body of the face

IntroductionFacial injuries by penetrating foreign body are unusual and require specific multidisciplinary surgical management. Case reportThis case report concerns a 20-year-old man who experienced a penetrating injury by a piece of wood to the face and describes the surgical approach to remove the wood and repair the injury. The foreign body had penetrated the infratemporal fossa, with an entry wound situated below the right eye and an exit wound in the neck, in contact with the left internal carotid artery. An adapted surgical strategy was necessary in view of the site of the foreign body. The internal carotid artery was controlled in order to follow the foreign body as far as its entry into the base of the skull. The proximity of the eye and carotid and jugular vessels and the deep penetration of the foreign body required the participation of interventional radiologists, head and neck and vascular surgeons and ophthalmologists. DiscussionThe site of the foreign body, precisely determined preoperatively, justified management by a multidisciplinary team to ensure rapid extraction, while limiting the risk of additional lesions. With a follow-up of 6 months, the patient did not present any sequelae of his facial injury.

MP79-04 CONTEMPORARY REPORT OF A MULTI-INSTITUTIONAL EXPERIENCE WITH FOURNIER's GANGRENE

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) I1 Apr 2017MP79-04 CONTEMPORARY REPORT OF A MULTI-INSTITUTIONAL EXPERIENCE WITH FOURNIER's GANGRENE Barbara E Kahn, Alexander J Tatem, Daniel J Mazur, James Wren, Marah Hehemann, Anuj S Desai, Mary Kate Keeter, Patrick Hensley, Jonathan Walker, James B Angel, Kevin Lewis, Matthew J Mellon, Jason R Bylund, Nelson E Bennett, and Robert E Brannigan Barbara E KahnBarbara E Kahn More articles by this author , Alexander J TatemAlexander J Tatem More articles by this author , Daniel J MazurDaniel J Mazur More articles by this author , James WrenJames Wren More articles by this author , Marah HehemannMarah Hehemann More articles by this author , Anuj S DesaiAnuj S Desai More articles by this author , Mary Kate KeeterMary Kate Keeter More articles by this author , Patrick HensleyPatrick Hensley More articles by this author , Jonathan WalkerJonathan Walker More articles by this author , James B AngelJames B Angel More articles by this author , Kevin LewisKevin Lewis More articles by this author , Matthew J MellonMatthew J Mellon More articles by this author , Jason R BylundJason R Bylund More articles by this author , Nelson E BennettNelson E Bennett More articles by this author , and Robert E BranniganRobert E Brannigan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2488AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Fournier's gangrene is a rare necrotizing soft tissue infection requiring emergent surgical debridement that is often morbid, disfiguring, and can be fatal. Mortality rates reported in the literature have historically been as high as 20-40%. However, contemporary series suggest survival rates are improved. Our objective was to determine the patient characteristics, clinical course, and outcomes for patients treated for Fournier's gangrene at three large, urban, academic, tertiary care institutions. METHODS In this multi-institutional retrospective study, cases of Fournier's gangrene were identified by ICD-9 (608.83) and CPT (11004, 11005, 11006) codes after obtaining institution-specific review board approval. Accurate diagnosis was confirmed on chart review. Data on comorbidities, hospital course, length of stay, and mortality were extracted from the medical record. RESULTS A total of 147 men (ages 24-81, median 52 years) treated for Fournier's gangrene between 2006 and 2016 were identified. Sixty-seven percent of these men had diabetes mellitus. Patients underwent an average of 2.5 (range 1-7, median 2) debridements while hospitalized, with an average length of stay of 19 (range 2-96, median 15) days. Fifty-five percent of patients required multidisciplinary surgical management with some combination of urologic, general, plastic, trauma, and colorectal surgeons, with 22% requiring fecal diversion. Seventy-six percent of men were admitted to the ICU, and 59% required mechanical ventilation. Most wounds were managed with wet to dry dressings, though 27% were covered with a wound vac. Inpatient mortality was 7.4%, which is lower than prior small case series and consistent with contemporary population based studies. Diabetics were significantly more likely to undergo more than one debridement than non-diabetics (p=0.009). CONCLUSIONS Great strides have been made in reducing the mortality rate of Fournier's gangrene, but high percentages of patients require multiple operations, fecal diversion, and multidisciplinary surgical management. Patients with diabetes are more likely to return to the operating room for repeat debridements. These findings offer insight into contemporary outcomes for men affected by this devastating condition. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1074 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Barbara E Kahn More articles by this author Alexander J Tatem More articles by this author Daniel J Mazur More articles by this author James Wren More articles by this author Marah Hehemann More articles by this author Anuj S Desai More articles by this author Mary Kate Keeter More articles by this author Patrick Hensley More articles by this author Jonathan Walker More articles by this author James B Angel More articles by this author Kevin Lewis More articles by this author Matthew J Mellon More articles by this author Jason R Bylund More articles by this author Nelson E Bennett More articles by this author Robert E Brannigan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Multidisciplinary Surgical Management of Cherubism Complicated by Neurofibromatosis Type 1

Cherubism is a rare, autosomal dominant, mostly self-limiting disease of the jaw. It is characterized by bilateral fibrous tissue hyperplasia, giant cell proliferation, and bony degeneration in the lower facial skeleton, which can result in a massive and severely deforming prominence of the maxillomandibular structure. This case study examines the multidisciplinary management of a severe case of cherubism complicated by neurofibromatosis type 1, 2 codominant nonsegregating conditions that were clinically and genetically diagnosed, an extremely rare combination. Adequate mandibular reduction, reconstruction, and dental implantation afforded good restoration of oral function as well as a marked aesthetic improvement. A 14-year-old Fijian girl was referred to our unit for management of severe overgrowth of her mandible that compromised her speech and deglutition. In addition, she displayed clinical features consistent with neurofibromatosis type 1. Radiologic, histologic, and genetic analyses confirmed the diagnosis of both conditions. Our craniofacial multidisciplinary team undertook mandibular reconstruction followed by placement of osseointegrated dental implants. Mandibular reduction, reconstruction, and dental implantation resulted in a significantly improved functional and aesthetic outcome with no further regrowth at 3-year follow-up when she returned to the United Kingdom for osseointegrated dental implant insertion. The successful outcome of this surgically challenging, grossly disfiguring, and rare condition was largely a result of the combined input from our multidisciplinary team, adequate preoperative planning, and the use of a novel surgical technique in debulking and reconstructing her mandible.

Surgical Management of Locally Advanced Adenoid Cystic Carcinoma of the Lacrimal Gland

To review our experience with multidisciplinary surgical management of locally advanced adenoid cystic carcinoma of the lacrimal gland. We present a case series of 7 patients with lacrimal gland adenoid cystic carcinoma treated at our institution between June 2001 and October 2003. Clinical records, histologic sections, and radiographic images were reviewed. The study included 3 men and 4 women (mean age at diagnosis, 44 years). All 7 patients underwent an orbital exenteration with bone removal. Five patients had an orbitectomy through a craniotomy approach and 2 patients had an exenteration through a fronto-orbito-zygomatic approach, all with removal of the bone of the superior and lateral wall. Six patients underwent reconstruction of the socket through the use of a vascularized flap. The surgical approach involved a neurosurgeon, an oculoplastic or head and neck surgeon, and a plastic surgeon. Six patients received postoperative radiation therapy. One patient with a recurrent tumor had already received radiation therapy, which precluded additional radiation therapy after surgical resection. The radiation field included the orbit and the skull base because all patients had evidence of perineural invasion. As of this writing, there have been no local recurrences. Five patients had development of distant metastases and died of disease, at follow-up times from 12 to 32 months after surgery. Two patients are alive without evidence of disease, both at 24 months' follow-up. Orbitectomy with bone removal may be indicated for achieving local and regional control in advanced cases of adenoid cystic carcinoma of the lacrimal gland. This surgery does not decrease the risk of distant metastasis. The cases in our series highlight the locally invasive and metastatic behavior of this cancer.