Postsurgical Bed Research Articles

8584 Quite High Thyroglobulin Levels in Thyroid Cancer in the Absence of Structural Lesion: Lab Interference or Microscopic Disease with Elevated Thyroglobulin?

Abstract Disclosure: M. Ahmad: None. A.P. Calimag: None. B. Arshad: None. J.T. Chaiban: None. Introduction: Thyroglobulin (Tg) is standard practice for follow-up of differentiated thyroid cancer (TC). Due to existence of thyroglobulin antibodies (Tg Ab) and Heterophile antibodies, Tg immunometric assays may be subject to interference. We present 2 challenging cases of TC with elevated Tg with absence of structural disease. Both tested positive for Epstein-Barr virus antibodies to viral capsid antigen (EBV anti VCA ab). DESCRIPTION: Case 1: 70 y.o Pt found to have calcified thyroid nodule on CT cervical spine. Thyroid ultrasound (U/S) revealed a left thyroid nodule- FNA being papillary thyroid cancer (PTC) with Bethesda 6. She had total thyroidectomy and central left lateral neck dissection. Pathology revealed PTC with 3/14 l.nodes +ve for cancer. Her Tg was 40.5 (1.2 - 35.0 ng/mL) 6 days after surgery, she received 100 mCi of radioactive Iodine (RAI). Subsequent WBS showed uptake in thyroid bed only. On follow ups, Tg started to rise persistently. PET CT unremarkable and her commensurate unstimulated Tg was 12. PET CT with interval development of a hypermetabolic focus in the postsurgical bed of thyroid and hypermetabolic cervical l.nodes. She received 100 mCi RAI + WBS that was negative for recurrence. Her Tg transiently improved but then was persistently elevated in the range 8.1-11.6 ng/ml on multiple checks. Repeat thyroid U/S did not show residual disease. Her Tg antibodies (Tg Ab) as well as Heterophile Antibody and HAMA were negative. Tg by LC-MS, was elevated in the range of 7.5 to 10.8 ng/ml. EBV anti VCA ab, IgG were positive. Case 2: 76 y.o lady initially diagnosed with toxic compressive goiter, found to have follicular thyroid cancer (FTC) after total thyroidectomy: a 5.5 cm FTC with minimal capsular/lymphatic invasion, no extrathyroidal extension, and negative margins. She received 103.7 mCi RAI after surgery. Subsequent WBS showed uptake only in the thyroid bed. Postoperatively Tg levels decreased to the range 1.6 to 5.1 ng/ml. Follow-up WBS a year later was unremarkable, and the Tg started to rise. CT scan of the chest and neck were negative. Tg by LC-MS was elevated in the range 1.6-9.2 ng/ml. PET CT was negative. Tg Ab as well as Heterophile Antibody and HAMA were negative. She tested positive for EBV anti VCA ab, IgG as well. Conclusion: Both case were elderly females- almost similar age, one with PTC and one with FTC- that had excellent structural response, but incomplete biochemical response. Measurement of Tg by LC-MS is recognized as an accurate method for Tg quantification. LC-MS assays are based on peptide quantitation after tryptic digestion which itself can have limitations due to existence of abnormal polymorphic tumor thyroglobulin (for which not much literature is available). The elevated Tg could be related to assay interference from EBV anti VCA ab (a cause or coincidence!?) or a possibility of persistent microscopic disease, hence longitudinal follow up of patients is important. Presentation: 6/2/2024

Adaptive strategies used by surgical teams under pressure: an interview study among senior healthcare professionals in four major hospitals in the United Kingdom

BackgroundHealthcare systems are operating under substantial pressures, and often simply cannot provide the standard of care they aspire to within the available resources. Organisations, managers, and individual clinicians make constant adaptations in response to these pressures, which are typically improvised, highly variable and not coordinated across clinical teams. The purpose of this study was to identify and describe the types of everyday pressures experienced by surgical teams and the adaptive strategies they use to respond to these pressures.MethodsWe conducted interviews with 20 senior multidisciplinary healthcare professionals from surgical teams in four major hospitals in the United Kingdom. The interviews explored the types of everyday pressures staff were experiencing, the strategies they use to adapt, and how these strategies might be taught to others.ResultsThe primary pressures described by senior clinicians in surgery were increased numbers and complexity of patients alongside shortages in staff, theatre space and post-surgical beds. These pressures led to more difficult working conditions (e.g. high workloads) and problems with system functioning such as patient flow and cancellation of lists. Strategies for responding to these pressures were categorised into increasing or flexing resources, controlling and prioritising patient demand and strategies for managing the workload (scheduling for efficiency, communication and coordination, leadership, and teamwork strategies).ConclusionsTeams are deploying a range of strategies and making adaptations to the way care is delivered. These findings could be used as the basis for training programmes for surgical teams to develop coordinated strategies for adapting under pressure and to assess the impact of different combinations of strategies on patient safety and surgical outcomes.

PSOR06 Presentation Time: 12:25 PM: Early Outcomes and Hormone-Free Survival Following Salvage MARS for MRI-Visible Post-Surgical Bed Recurrences and Focal Intraprostatic Recurrences Following External Beam and Following Brachytherapy

PSOR06 Presentation Time: 12:25 PM: Early Outcomes and Hormone-Free Survival Following Salvage MARS for MRI-Visible Post-Surgical Bed Recurrences and Focal Intraprostatic Recurrences Following External Beam and Following Brachytherapy

ODP052 Recurrent Pheochromocytoma Concerning For Surgical Seeding From Prior Partial Adrenalectomy

Abstract Introduction Surgery for a sporadic pheochromocytoma does not always lead to long-term cure, even in patients with a benign tumor, with an estimated recurrence rate of 3% (1). We present a patient with a history of pheochromocytoma s/p partial adrenalectomy 10 years prior found to have recurrence not within the adrenal parenchyma, but in the prior resection bed and diaphragm, concerning for seeding of the surgical bed from prior surgery. Clinical Case A 56-year-old man with a history of pheochromocytoma s/p a laparoscopic left partial adrenalectomy 10 years prior, with no detected rupture of the capsule at time of surgery, presented with symptoms of palpitations and anxiety. The patient had previously tested negative for SDHB, SDHD, MEN2, and VHL. Repeat labs were concerning for recurrence: 24-hour urine normetanephrines 1192 μ g (156-729 μ g) and metanephrines 204 μ g (58-276 μ g), plasma normetanephrine 479.4 pg/mL (0. 0-136.8 pg/mL), metanephrines 38.2 pg/mL (0. 0-88. 0 pg/mL), and chromogranin A 129. 0 ng/mL (0. 0-101.8 ng/mL). MRI with contrast showed a mildly enhancing mass in the left adrenalectomy postsurgical bed with no changes noted in the liver, and an I-123 MIBG scan showed focal uptake in the left adrenal gland corresponding to the mass seen on MRI as well as heterogeneous uptake in the left hepatic lobe. A DOTATE PET scan done prior was negative. The patient underwent laparoscopic left adrenalectomy; the left adrenal gland was dissected and the patient was found to have multiple satellite lesions along the left diaphragm which were excised. On pathology, immunostains were positive for chromogranin and synaptophysin. Multiple nodules of pheochromocytoma/paraganglioma were seen involving the soft tissue of the diaphragm (<0.1-0.6 cm) and the periadrenal soft tissue and prior resection bed (<0.1-2.5 cm), with no tumor seen within the residual adrenal parenchyma. The tumor extended to the cauterized tissue edges and no lymphovascular invasion was seen. No necrosis, no increased mitotic activity, no atypical mitotic figures were noted, and Ki-67 proliferation index was <1%. Testing done six weeks postoperatively showed plasma normetanephrine 49.9 pg/mL, metanephrine <10 pg/mL, and chromogranin A 87.9 ng/mL. Repeat genetic testing was negative for SDHB, SDHD, VHL, and MEN2. One year postoperatively, the patient's blood pressures are well-controlled on a small dose of doxazosin, kept on as a prophylactic measure. Conclusion This case demonstrates a rare presentation of recurrent pheochromocytoma found in the diaphragm, periadrenal tissue, and surgical bed from a prior partial adrenalectomy, concerning for recurrence in setting of surgical seeding from prior surgery. This case highlights the importance of perhaps considering a total adrenalectomy rather than partial when possible. Reference: (1) Holscher I, et al. Recurrence Rate of Sporadic Pheochromocytomas After Curative Adrenalectomy: A Systematic Review and Meta-analysis. J Clin Endocrinol Metab. 2021 Jan 23;106(2): 588-597. Presentation: No date and time listed

Proof of Principle of Combining Fluorescence-Guided Surgery with Photoimmunotherapy to Improve the Outcome of Pancreatic Cancer Therapy in an Orthotopic Mouse Model

BackgroundPancreatic cancer is a recalcitrant disease in which R0 resection is often not achieved owing to difficulty in visualization of the tumor margins and proximity of adjacent vessels. To improve outcomes, we have developed fluorescence-guided surgery (FGS) and photoimmunotherapy (PIT) using a fluorescent tumor-specific antibody.MethodsNude mice received surgical orthotopic implantation (SOI) of the human pancreatic cancer cell line BxPC-3 expressing green fluorescent protein. An anti-carcinoembryonic antigen-related cell adhesion molecule (CEACAM) monoclonal antibody (6G5j) was conjugated to the 700-nm fluorescent dye IR700DyeDX (6G5j-IR700DX). Three weeks after SOI, 16 mice received 50 μg 6G5j-IR700DX via the tail vein 24 h before surgery and were randomized to two groups: FGS-only (n = 8) and FGS + PIT (n = 8). All tumors were imaged with the Pearl Trilogy imaging system and resected under the guidance of the FLARE imaging system. The FGS + PIT group received PIT of the post-surgical bed at an intensity of 150 mW/cm2 for 30 min. Mice were sacrificed 4 weeks after initial surgery, and tumors were imaged with a Dino-Lite digital microscope, excised, and weighed.ResultsThe 6G5j-IR700DX dye illuminated the orthotopic pancreatic tumors for FGS and PIT. The metastatic recurrence rate was 100.0% for FGS-only and 25.0% for FGS + PIT (p = 0.007). The average total recurrent tumor weight was 2370.3 ± 1907.8 mg for FGS-only and 705.5 ± 1200.0 mg for FGS + PIT (p = 0.039).ConclusionsFGS and adjuvant PIT can be combined by using a single antibody–fluorophore conjugate to significantly reduce the frequency of pancreatic cancer recurrence.

In situ gel implant for postsurgical wound management and extended chemoimmunotherapy against breast cancer recurrence

Postsurgical recurrence of breast cancer is closely related to the inflammatory tumor microenvironment evoked by surgical wounds. Toll-like receptor 4 (TLR4) signaling contributes to NF-κB activation thus secreting various inflammatory cytokines. Herein, we developed an in situ photo-crosslinked hydrogel (D/T gel) concurrently loaded with doxorubicin (DOX) and a TLR4 antagonist, resatorvid (TAK-242). Its therapeutic effect against breast cancer postsurgical relapse was accomplished through remodeling the proinflammatory tumor microenvironment. The obtained gel network exhibited ideal biodegradability and biocompatibility, which motivated dermal wound healing in the full thickness wound model in mice. Despite the initial burst release of DOX, D/T gels exhibited extended-release of both DOX and TAK-242 for up to 21 days in vitro. TAK-242 was demonstrated to inhibit the lipopolysaccharide-induced NF-κB activation and downregulate TLR4 levels in both RAW264.7 and 4T1 cells. In a 4T1-Luc tumor postsurgical recurrence model, D/T gel significantly suppressed recurrent tumor growth by elevating the concentrations of DOX and TAK-242 at the tumor sites and remodeling the TLR4 activation-induced proinflammatory microenvironment. Overall, the D/T gel platform technology is proven to deliver therapeutics directly to the surgical wound bed, attenuating the dual inflammatory responses induced by DOX and surgical wounding thus greatly potentiating its efficacy in preventing postsurgical tumor recurrence. Statement of significancePostsurgical recurrence of breast cancer is closely related to the inflammatory tumor microenvironment (TME) evoked by surgical wounds. Although chemotherapeutics lead to extensive residual tumor cell necrosis, multiple inflammatory cytokines are secreted simultaneously, which are conducive to tumor recurrence. In this work, a TLR4 antagonist, TAK-242, was combined with DOX to reverse the dual inflammatory TME induced by surgical wounding and chemotherapy. To elevate the concentration of therapeutics at the tumor site, a photocrosslinked hydrogel (D/T gel) implant coloaded with TAK-242 and DOX was developed and applied on the postsurgical bed. Consequently, D/T gel attenuated the dual inflammatory responses and greatly potentiated its efficacy in preventing postsurgical tumor recurrence.

Imaging Biochemical Recurrence After Prostatectomy: Where Are We Headed?

OBJECTIVE. In this article, we discuss the evolving roles of imaging modalities in patients presenting with biochemical recurrence after prostatectomy. CONCLUSION. Multiple imaging modalities are currently available to evaluate patients with prostate cancer presenting with biochemical recurrence after prostatectomy. Multiparametric MRI (mpMRI) focuses on the postsurgical bed as well as regional lymph nodes and bones. PET/CT studies using 18F-fluciclovine, 11C-choline, and prostate-specific membrane antigen (PSMA) ligands are useful in detecting locoregional and distant metastasis. Multiparametric MRI is preferred for patients with low risk of metastasis for localizing recurrence in prostate bed as well as pelvic lymph node and bone recurrence. Moreover, mpMRI aids in guiding biopsy and additional salvage treatments. For patients with high risk of metastatic disease, both mpMRI and whole-body PET/CT may be performed. PET/MRI using 68Ga-PSMA has potential to enable a one-stop shop for local recurrence and metastatic disease evaluation, and clinical trials of PET/MRI are ongoing.

Surgical Indications and Operative Results of Lumbosubarachnoid-Lumboepidural Shunting in 29 Patients with Idiopathic Normal Pressure Hydrocephalus under Local Anesthesia.

This study consisted of 29 patients with idiopathic normal pressure hydrocephalus (iNPH) who underwent lumbosubarachnoid-lumboepidural (L-L) shunting under local anesthesia in accordance with our surgical indications of L-L shunting. (1) CSF absorption within the lumbar epidural space and shunt clearance were confirmed in all patients after operation. (2) Shunt responders (R) were 25 of 29 cases (86.2%) 3 months after surgery. Among the R, symptom exacerbation was confirmed in three patients (12%) within the follow-up period (mean, 25.1 months). In each of these patients, shunt function were maintained and remained unchanged even with pressure resetting, the cause being an intracranial/extracranial disease other than iNPH. (3) The initial pressure setting for this method was 8 cmH2O, with gradual change to higher pressures, such that the setting for Patient 11 and thereafter became 20 cmH2O. (4) As postsurgical complications, subcutaneous cerebral spinal fluid collection (SCC) was confirmed in five patients (17.2%). In high-pressure resetting and follow-up observation, SCC was not observed in all patients. Epidural catheter displacement was confirmed in three patients (10.3%). No recurrence was noted after the secure fixation of the catheter at the fascia insertion portion and 2 days’ postsurgical bed rest. Hence, L-L shunting is an effective shunt therapy for iNPH.

Minimally Invasive Surgical Approach to Filum Lipoma

Filum terminale lipoma (FTL) causes various spinal symptoms known as tethered cord syndrome. The treatment for FTL is surgical untethering by sectioning the FTL, which can prevent symptom progression and often results in improvement of symptoms. This report describes a minimally invasive surgical strategy that we have introduced for FTL sectioning. The pediatric patients with FTL since 2007 were treated using this minimally invasive surgical strategy, which we refer to as an interlaminar approach (ILA). In summary, the surgical technique involves: minimal skin incision to expose the unilateral ligamentum flavum in the lower lumbar region; ligamentum flavum incision to expose the dural sac, and dural incision followed by identification and sectioning of the filum. Postoperatively, no bed rest was required. Prior to introducing ILA, we had used standard one level laminectomy/laminotomy (LL) with more than 1 week of postsurgical bed rest until 2007, providing an adequate control group for the benefit of the ILA. A total of 49 consecutive patients were treated using ILA. While 37 patients were treated using LL. Surgical complications that need surgery were seen only in one patient, who developed cerebrospinal fluid (CSF) leak in LL patients. No retethering or additional neurological symptoms were seen during follow-up. All patients complained of minimal postsurgical back pain, but no patients required postoperative bed rest in ILA patients, while LL patients need postsurgical bed rest because of back pain. The ILA strategy provides the advantage of a minimal tissue injury, associated with minimal postoperative pain, blood loss, and bed rest.

Safety and efficacy of salvage low-dose-rate brachytherapy for prostate bed recurrences following radical prostatectomy.

PurposeTo report efficacy in our series of nodular recurrences in the post-surgical bed that underwent salvage low-dose-rate (LDR) brachytherapy.Material and methodsPatients with radical prostatectomy (RP) who had biochemical failure with nodular recurrence detected by DRE, ultrasound, and pelvic CT and then salvaged with LDR 125I brachytherapy were included. Nodular recurrences were biopsy confirmed adenocarcinoma, and patients had no evidence of nodal or distant metastasis on imaging including bone scan. Follow up was at least every 6 months with a serial prostate specific antigen (PSA).ResultsTwelve patients had salvage LDR brachytherapy with median age 69 years (range 59-86) and median pre-salvage PSA of 4.22 ng/ml. Nodule biopsy Gleason score was 7, 8, or undifferentiated. Median rectal V100 was 0.00 cc. Compared to pre-salvage, patients reported no additional genitourinary (GU) toxicity. After a median 35 months post-salvage follow up (range 10-81 months), patients had a median PSA nadir of 0.72 ng/ml (range 0.01-22.4). At 6 months post salvage, 90% of patients had a PSA below pre-salvage levels. At last follow up, 4 patients had PSA control.ConclusionsThere was a trend to improved biochemical relapse free survival for lower Gleason score and pre-salvage PSA, which may be indicative of the lack of or only low volume metastatic disease. LDR brachytherapy is an effective salvage technique and can be considered in well selected patients allowing for dose escalation to the nodular recurrence.

Comparing resource balancing criteria in master surgical scheduling: A combined optimisation-simulation approach

This study compares three different scheduling policies in the Master Surgical Scheduling context with respect to three performance criteria: efficiency, i.e. the capability of scheduling a large number of surgeries; balancing, i.e. the capability to distribute workload fairly among the resources involved in surgical activities; and robustness, i.e. the capability to prevent schedule disruptions caused by variability of surgical time and length of stay. We develop a mixed-integer programming model and compare three objective functions, each corresponding to a different scheduling policy. All the policies maximise the number of scheduled surgeries and balance the utilisation of post-surgical beds and operating rooms. However, they implement a different balancing criterion. To assess the robustness of the schedules produced by the optimisation model, we used a discrete event simulation model that samples surgical times and length of stay from a probability distribution and keeps track of schedule disruptions that may occur. The work is based on real data from the Meyer University Children׳s Hospital in Florence. It comprises an experimental campaign that extends to 27 hospital settings and uses both empirical and theoretical probability distributions. Overall, the study reveals that none of the investigated policies allows superior performance in terms of efficiency, balancing and robustness to be achieved concurrently. However, depending on the hospital management׳s priorities and needs, it is always possible to identify a policy that allows for a reasonable trade-off among these performance criteria. In addition, the study reveals the causal mechanisms that, under certain circumstances, make certain balancing criteria perform better than the others.

Addressing the variation of post-surgical inpatient census with computer simulation

This study describes the development of a Discrete Event Simulation (DES) of a large pediatric perioperative department, and its use to compare the effectiveness of increasing the number of post-surgical inpatient beds vs. implementing a new discharge strategy on the proportion of patients admitted to the surgical unit to recover. A DES of the system was developed and simulated data were compared with 1 year of inpatient data to establish baseline validity. Ten years of simulated data generated by the baseline simulation (control) was compared to 10 years of simulated data generated by the simulation for the experimental scenarios. Outcome and validation measures include percentage of patients recovering in post-surgical beds vs. "off floor" in medical beds, and daily census of inpatient volumes. The proportion of patients admitted to the surgical inpatient unit rose from 79.0% (95% CI, 77.9-80.1%) to 89.4% (95% CI, 88.7-90.0%) in the discharge strategy scenario, and to 94.2% (95% CI, 93.5-95.0%) in the additional bed scenario. The daily mean number of patients admitted to medical beds fell from 9.3 ± 5.9 (mean ± SD) to 4.9 ± 4.5 in the discharge scenario, and to 2.4 ± 3.2 in the additional bed scenario. Every hospital is tasked with placing the right patient in the right bed at the right time. Appropriately validated DES models can provide important insight into system dynamics. No significant variation was found between the baseline simulation and real-world data. This allows us to draw conclusions about the ramifications of changes to system capacity or discharge policy, thus meeting desired system performance measures.

A simulation model for perioperative process improvement

Operating rooms (ORs) are a hospital’s largest cost center and greatest source of revenue. Surgical delays and cancellations lead to staff dissatisfaction due to long working hours, patient anxiety from long wait time, and extra costs for staff overtime. A discrete event simulation was used to model the perioperative process in the general surgery service at Toronto General Hospital, aiming to reduce the number of surgical cancellations and thereby improve the overall process. This model considers emergency case interruptions with different levels of urgency and takes into account the availability of five types of post-surgical beds. The effects of three scenarios on the number of surgical cancellations were examined: (1) scheduling the surgeons based on their patients usage length of post-surgical beds, (2) sequencing surgical procedures by length and variance, and (3) increasing the number of post-surgical beds. The results indicate that scheduling the surgeons in a weekly schedule based on the patients’ average length of stay in the ward, sequencing surgeries in order of increasing length and variance, and adding beds to the surgical ward all reduced the number of surgical cancellations, both individually and collectively. The interactions of all of these scenarios were compared against the current system and against each other to provide a basis for future OR planning and scheduling.

A combined optimization-simulation approach to the master surgical scheduling problem

This paper addresses the master surgical scheduling problem. First, we present a mixed integer programming model. The model assumes that the cases in a hospital’s waiting list can be classified into homogeneous surgery groups based on the resources (e.g. operating room, post-surgical beds) that they are expected to require. Hence, it produces a solution that indicates, for each day of the month and for each time slot of the day, the number of cases to treat and the surgery group these cases must belong to. The model maximizes the patient throughput, takes into account the cases’ due dates and allows for control of the waiting list. Secondly, we illustrate the results of a simulation study through which we test the model solution’s robustness against the randomness of surgery duration and the length of stay. Finally, we present a combined optimization‐simulation approach that allows us to fine tune the optimization model to trade-off robustness and efficiency. Our study shows that, by planning surgery groups instead of individual cases and by combining optimization and simulation, it is possible to obtain schedules that are both robust and easy to implement. In addition, it shows that such a combined approach allows for the performance of more accurate scenario analyses. The results presented in this paper are based on real data from the Meyer University Children’s Hospital in Florence, which is one of the most renowned children’s hospitals in Italy.

Brachytherapy as salvage treatment for local nodular recurrence of prostate cancer.

86 Background: Men diagnosed with adenocarcinoma of the prostate treated with radical prostatectomy (RP) have a 10% risk of developing local recurrence within 10 years. While the majority of these recurrences are biochemical failures with no foci of disease, we report on a series of 7 patients who had nodular recurrences in the post-surgical bed and subsequently underwent low-dose rate (LDR) brachytherapy as salvage therapy. Methods: Patients who were initially treated with RP and subsequently with salvage LDR I-125 brachytherapy for a nodular recurrence were included in this series. All patients failed biochemically within 10 years of RP and received no other adjuvant or salvage treatment by choice. Nodular recurrences were biopsy confirmed adenocarcinoma, and patients had no evidence of nodal or distant metastasis on imaging or bone scan. All patients consented to salvage with LDR brachytherapy. Follow up post-salvage was at least every 6 months with a serial PSA. Results: Seven patients underwent salvage LDR brachytherapy with median age of 74 (range 63-77) at time of salvage. The median pre-salvage PSA was 4.56. The biopsy Gleason score of the nodular recurrences was 7 or 8. Median volume of nodular recurrence was 16cc, median number of sources was 30, median D90 for nodule was 155.02 Gy, and median rectum V100 was 0.01. Compared to baseline prior to salvage, patients have reported no additional urinary symptoms or sexual side effects from salvage. Patients have been followed for a median of 28 months post-salvage (range 4-48 months) with a median PSA at last follow up of 1.05. Conclusions: This report presents the first known case series of prostate cancer patients treated with RP who developed local nodular recurrences which were then treated with LDR brachytherapy. For patients who develop a nodular recurrence with no other evidence of distant metastases, LDR brachytherapy offers a novel salvage option. No significant financial relationships to disclose.

Treatment of a persistent iatrogenic cerebrospinal fluid-pleural fistula with a cadaveric dural-pleural graft

Background context A cerebrospinal fluid (CSF)-pleural fistula is a unique condition with which all spine surgeons need to be familiar, particularly those who use anterolateral approaches to the thoracic region. When direct suturing of the dural defect is not possible, techniques for indirect repair must be considered. Purpose To report a novel technique for repair of a thoracic CSF-pleural fistula with a cadaveric dural-pleural graft after failure of initial treatment with Duragen (Integra, Plainsboro, NJ) and fibrin glue. Study design/setting Case report/University of Miami/Jackson Memorial Medical Center. Methods The case of a 65-year-old female is presented. Results The patient represented 5 weeks after the initial operation (left-sided thoracotomy, partial T10–T11 corpectomy and removal of an intradural calcified disc) with dyspnea and severe positional headaches. Imaging of the brain revealed a subdural hematoma and magnetic resonance imaging of the thoracic region demonstrated a pseudomeningocele surrounding the postsurgical bed. She underwent a revision thoracotomy and CSF-pleural fistula repair. We addressed the dural opening indirectly by suturing a piece of cadaveric dural allograft to the thickened pleura, after Duragen and fibrin glue were placed over the dural defect. A lumbar drain and a chest tube were also placed. At 12 weeks post-op, the subdural hematoma had completely resolved and her chest X-rays demonstrated a significant decrease in the CSF-pleural collection. Conclusion Anterolateral thoracic disc surgery poses a great challenge to the spine surgeon but can provide the most direct way of decompressing the spinal cord as a result of ventral pathology. Some of the most difficult aspects of dealing with a CSF leak in this area relates to 1) the relative complexity of suturing the dura directly as it is at a considerable distance from the operating surgeon; 2) the manner in which the contralateral dura slopes away and is hidden from view; and 3) the relatively negative intrathoracic pressure, which encourages the persistent flow of CSF from the intradural to the pleural cavity. We speculate that with open thoracic surgery and the creation of a large potential space with an open dural defect, this technique provided an additional barrier against the formation of a CSF-pleural fistula. Using this technique, we intentionally create a pseudomeningocele into the corpectomy defect that is contained within the confines of our dural-pleural graft.

Xantogranuloma juvenil del sistema nervioso central

Juvenile xanthogranuloma (JXG) is a benign histiocytosis affecting mostly skin, although it may also be extracutaneous. Lesions tend to regress spontaneously, but there are cases of bad prognosis.We report the case of a girl aged 3 months with JXG involving skin and, asymptomatically, central nervous system (CNS) and lungs. At age 4 months, the bigger CNS lesion, placed in the right cavernous sinus and whose growth might have had important neurologic repercussions, was excised. After surgery she presented seizures with initial response to antiepileptic drugs. At age 8 and 10 months surgery was again necessary for appearance of a tension pseudoyst in postsurgical bed; a cystoperitoneal shunt was instaured and seizures were controlled. When the patient was 12 months old, the diagnosis of hypothyroidism was established, with a favourable response to levothyroxine. At present, the patient is 2 years 8 months and has a slightly slow neurologic development, with occasional short seizures. Skin lesion is smaller, lung nodules have regressed and, regarding CNS lesions, the bigger has not recurred and the other one remains stable.Some authors propose doing JXG s extension study only when suggested by clinical findings, so long as an effective therapy and the advantage to presymptomatic treatment are not well established. We wonder whether early diagnostic and therapeutic approach to silent deep lesions might lead to a better outcome of patients with JXG, particularly those with CNS involvement.

Merkel cell carcinoma. Diagnosis and treatment.

Merkel cell carcinoma is an uncommon malignancy of the skin that often portends a poor prognosis. Since its first description by Toker in 1972, a plethora of case reports and articles regarding the etiopathogenesis and treatment have been published spanning multiple medical and surgical disciplines. Much confusion still exists regarding the diagnosis and treatment of this ominous tumor. Through extensive review of the medical, surgical, and pathological literature, to collate the observations of multiple investigators and summarize these findings. Articles from journals of multiple subspecialties were carefully reviewed with particular emphasis placed on epidemiology, prognosis, histology, immunohistochemistry, electron microscopy, tumor origin, treatment, and work-up of Merkel cell carcinoma. Merkel cell carcinoma is an aggressive malignant neoplasm. Local recurrence develops in 26-44% of patients despite therapy. Up to three-fourths of patients eventually develop regional nodal metastases with distant metastases occurring in one-third of all patients. Reported overall 5-year survival rates range from 30% to 64%. Treatment recommendations unfortunately are based more on anecdotal than scientific data because of the rarity of the tumor and its recognized high risk. Most authors recommend wide local excision of the primary lesion and regional lymph node resection if lymph nodes are palpable followed by x-irradiation of both the postsurgical bed and lymph node basin. The role of elective lymph node resection in the absence of clinically positive nodes remains controversial.