Preoperative Imaging Examination Research Articles

Atlantoaxial joint release through anterior retrophayngeal approach and staged posterior reduction fixation and fusion for irreducible atlantoaxial dislocation

To discuss the effectiveness of atlantoaxial joint release through anterior retrophayngeal approach and staged posterior reduction fixation and fusion for irreducible atlantoaxial dislocation (IAAD). Fifteen patients with IAAD (9 males, 6 females), aged 14-53 years (mean, 31.4 years) were included in the study. The disease duration was 3 months to 17 years (mean, 5.7 years). IAAD was attributed to trauma in 13 cases, and 2 cases were caused by congenital odontoid disconnection. Preoperative imaging examination showed atlantoaxial dislocation and could not be reset automatically in functional position. The preoperative visual analogue scale (VAS) score was 3-7 (mean, 4.1), and the preoperative Japanese Orthopaedic Association (JOA) score was 10-17 (mean, 13.8). All patients received atlantoaxial joint release through anterior retrophayngeal approach and staged posterior fixation and fusion. Anatomical reduction was achieved in all 15 patients, and the alignment of atlantoaxial joints was restored. After operation, the neck pain and neurological symptom were partially or fully improved in all patients, without deterioration of neurological function. One patient developed pharyngeal discomfort and cough after one-stage operation, 4 patients developed pharyngeal discomfort and foreign body sensation after operation, and 2 patients developed pin-path lipstick swelling during skull traction. All patients were cured by symptomatic treatment. No pulmonary infection, pressure ulcers, venous thrombosis, and incision infection was found during the treatment. All 15 patients were followed up 24-36 months, with an average of 28.6 months. Bony fusion was achieved in all patients, and the fusion time was 3-5 months, with an average of 3.6 months. At last follow-up, the VAS score was 0-2 (mean, 0.5) and the JOA score was 13-17 (mean, 15.9). There was no dislocation, recurrence, or other abnormal sign in the cervical X-ray films and three-dimensional CT. Anatomical reduction can be achieved by atlantoaxial joint release through anterior retrophayngeal approach and staged posterior fixation and fusion for treating IAAD. It is an optional procedure for IAAD.

Postsurgical Spine: Techniques, Expected Imaging Findings, and Complications

Postsurgical spine imaging actually commences with the preoperative and perioperative imaging examinations that are performed before and during the patient's surgical procedure, respectively. It is in this context that postsurgical spine imaging examinations are best evaluated with a better appreciation of the changes, sometimes dramatic, that can occur following spine surgery. Careful follow-up is the rule in spine surgery, and these patients will have multiple imaging examinations over time. Some studies are performed immediately due to possible complications or exacerbation of pain symptoms, whereas others are used to assess the status of a fusion procedure. In any case it is prudent to always be aware of the overlap between the "normal" or expected imaging findings in the postoperative spine and potential pathologic processes that are developing at the postsurgical site. Additionally, a basic understanding of common spine surgical techniques and approaches is paramount toward rendering a thoughtful analysis. In this chapter, the authors discuss these imaging findings in the setting of the most commonly performed spine surgeries and emphasize the importance of active communication between the radiologist and spine surgeon.

Local Recurrence Rates for Early Stage Breast Cancer Treated with Breast Conservation and Single Fraction IntraOperative Electron Radiation Therapy ( IOERT) at a Community Hospital

Patients with early stage breast cancer are offered adjuvant breast irradiation after lumpectomy to reduce the likelihood of recurrence . This is usually in the form of whole breast irradiation. However, large multi-institutional randomized data show that partial breast irradiation using single fraction intraoperative electron radiotherapy ( IOERT) may be safe and appropriate in a subset of patients with early stage disease. Our goal was to prospectively determine the local in-breast tumor recurrence ( IBTR) rate at a single community center using IOERT. Patients with early stage breast cancer treated with breast conservation +/- SLNB and single fraction IOERT were enrolled prospectively in an in-house trial . Patient demographics , clinical/ pathologic staging , tumor histology , grade and receptor status were recorded. Patient eligibility included women age >/=40 yrs , primary tumor </= 2.5 cm and node negative on preoperative clinical and imaging examination. Breast MRI was encouraged. Patient were treated with 6-12 Mev electrons using the IntraOp Mobetron device to a dose of 2100 cGy. A chest wall shield was used. Oncoplastic closure was used as indicated. Patients were scheduled for follow up at post op week 2, months 6,12,18 and then yearly until year five. Patients had mammograms yearly or as clinically indicated. There were 220 single fraction IOERT treatments delivered between 2012 and 2017. Sixteen patients were subsequently excluded from this analysis because they received subsequent whole breast radiation based on adverse pathology. Of the remaining 203 treatment, 6 patients had bilateral IOERT (total pts=197). The median follow up was 2.4 years. The median age was 65 yrs (range 40-91). Pathology was as follows: 23% pure DCIS, 71% IDC +/- DCIS, 5% ILC, 1% mixed. Twenty-four percent were stage 0, 72% were stage 1 and 5% stage 2. Eighty-nine percent were low-intermediate grade while 11% were high grade. Ninety percent were ER/PR positive. Eleven of 197 patients recurred (5.6%). Of those, 7 developed ipsilateral in-breast tumor recurrence (6 local recurrences and 1 new primary). IBTR= 3.6%. Two developed systemic recurrence and two developed a new contralateral primary. Median time to recurrence was 2.7 years. Our results show in-breast tumor recurrence rates for breast conservation with single fraction IOERT at 3.6%. These results are consistent with that of recently published randomized multicenter trials. Median follow-up for this review is 2.4 years and further follow-up is required.

Angio-Computed Tomograph-Guided Immediate Lipiodol Computed Tomograph for Diagnosis of Small Hepatocellular Carcinoma Lesions during Transarterial Chemoembolization.

Background:The diagnosis and treatment of small hepatocellular carcinoma (HCC) play a vital role in the prognosis of patients with HCC. The purpose of our study was to evaluate angio-computed tomography (angio-CT)-guided immediate lipiodol CT (a CT scan performed immediately after transarterial chemoembolization [TACE]) in the diagnosis of potential HCCs ≤1 cm in diameter.Methods:This study retrospectively analyzed 31 patients diagnosed with HCCs after routine imaging (contrast-enhanced CT or magnetic resonance imaging) or pathologic examinations with undefined or undetermined tumor lesions (diameter ≤1 cm) from February 2016 to September 2016. After TACE guided by digital subtraction angiography of the angio-CT system, potential HCC lesions with a diameter ≤1 cm were diagnosed by immediate lipiodol CT. The number of well-demarcated lesions was recorded to calculate the true positive rate. The correlation between the number of small HCCs detected by immediate lipiodol CT and the size of HCC lesions (diameter >1 cm) diagnosed preoperatively was analyzed 1 month after TACE. A paired t-test was used to analyze differences in liver function. Pearson analysis was used to analyze correlation. Chi-square test was used to compare the rates.Results:Fifty-eight lesions were detected on preoperative routine imaging examinations in 31 patients including 15 lesions with a diameter ≤1 cm. Ninety-one lesions were detected on immediate lipiodol CT, of which 48 had a diameter ≤1 cm. After 1 month, CT showed that 45 lesions had lipiodol deposition and three lesions had lipiodol clearance. Correlation analysis showed that the number of small HCCs detected by lipiodol CT was positively correlated with the size of HCC lesions diagnosed by conventional imaging examination (R2 = 0.54, P < 0.05).Conclusion:Immediate lipiodol CT may be a useful tool in the diagnosis of potential HCC lesions with a diameter of ≤1 cm.

Application value of perihilar surgery technique in the reoperation of biliary dilatation of central large intra- and extra-hepatic bile ducts above the hilar convergence

Objective To explore the application value of perihilar surgery technique in the reoperation of biliary dilatation of central large intra- and extra-hepatic bile ducts above the hilar convergence. Methods The retrospective cross-sectional study was conducted. The clinical data of 3 patients with biliary dilatation of central large intra- and extra-hepatic bile ducts above the hilar convergence who underwent the reoperation in the Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine from August 2017 to January 2018 were collected. All three patients had been collected a detailed previous surgical history. After preoperative lab and imaging examinations, evaluation of liver function, residual liver volume and general condition were done, then 3 patients underwent left hemihepatectomy + dilated right hepatic duct and extrahepatic bile duct resection, right anterior and posterior hepatic duct reconstructive surgery and Roux-en-Y anastomosis of the jejunum. The surgical procedures followed as: intra-abdominal adhesions separation, extrahepatic antergrade dissection of porta hepatis, transverse cutting the dilated extrahepatic bile duct, split the cantlie line, exposure of the hilar plate, left hemihepatectomy, dilated right hepatic bile duct resection, right anterior and posterior hepatic duct remodeling and biliary-enteric anastomosis. Observation indicators included: (1) surgical and postoperative recovery; (2) follow-up. Follow-up using outpatient examination and telephone interview was performed to detect general condition, complications, liver function and residual choledochal cysts up to May 2018. Results (1) Surgical and postoperative recovery: All the 3 patients underwent choledochal cysts resection + left hemihepatectomy + dilated right hepatic duct + right anterior and posterior hepatic duct reconstructive surgery and Roux-en-Y anastomosis of the jejunum using the perihilar surgery technique and extrahepatic anterograde combined by intrahepatic retrograde dissection method exposing portal hepatis. There was no perioperative death. The operation time and volume of intraoperative blood loss in 3 patients were 435 minutes, 490 minutes, 395 minutes and 250 mL, 300 mL, 200 mL, respectively. There was no intraoperative blood transfusion. Three patients had no bleeding and abdominal liver function. One patient with bile leakage and delayed gastric emptying at 1 week postoperatively received puncture drainage, gastrointestinal decompression, gastric lavage with hypertonic saline, acupuncture and total parenteral nutrition, then bile leakage was cured after 3-week therapy, gastric motility was improved after 5-week therapy, and then gastric tube was removed. The abdominal drainage tube was removed at 3 weeks postoperatively in 1 patient and at 1 week postoperatively in 2 patients. The postoperative gross specimen examinations showed intra- and extra-hepatic bile duct dilatation in 3 patients, including 2 combined with choledocholithiasis and 1 with left intrahepatic bile duct cancer. The postoperative pathological findings showed that 3 patients had intrahepatic bile duct cystic dilatation with chronic inflammation, peripheral small bile duct hyperplasia with inflammatory cell infiltration, 1 of which had intrahepatic intraductal papilloma with high grade intraepithelial neoplasia. One and 2 patients were discharged from hospital at 7 weeks postoperatively and 2 weeks postoperatively, respectively. (2) Follow-up: All 3 patients were followed up for 4-8 months. During the follow-up, patients had good general condition and no symptoms of cholecystitis such as abdominal pain, chills and fever, liver function was normal, and no residual bile duct cyst was found by enhanced scan of CT. Conclusion The perihilar surgery technique and extrahepatic anterograde combined by intrahepatic retrograde dissection method exposing portal hepatis for the treatment of biliary dilatation of central large intra- and extrahepatic bile ducts above the hilar convergence can increase the radical resection rate and surgical efficacy. Key words: Biliary dilatation; Perihilar technique; Central large hepatic bile duct above the hilar convergence; Extrahepatic anterograde combined by intrahepatic retrograde dissection method exposing portal hepatis; Surgical procedures, operative

Large Forehead Mass Resulting From Chronic Head Banging.

Head banging is a commonly observed movement disorder which is typically self-limited. Complications secondary to this behavior are rare. In this report, the authors present the case of a 15-year-old patient who was treated for a forehead mass which developed secondary to chronic head banging. Surgical excision was performed for treatment of the lesion. Results from surgical pathology were notable for fibrosis consistent with history of chronic head banging. Preoperative magnetic resonance imaging and physical examination were also consistent with this diagnosis. This is a rare clinical entity that should be considered in patients presenting with a forehead mass and a history of head banging.

Study on the preoperative clinical criteria for nerve-sparing radical prostatectomy

Objective To investigate the preoperative clinical criteria for nerve-sparing radical prostatectomy. Methods A retrospective analysis of 79 patients undergoing radical prostatectomy with complete clinical and pathological data in Jinhua Hospital of Zhejiang University from January 2012 to December 2016 was performed. The distance between the edge of the prostate tumor and the neurovascular bundle (NVB) was measured. When the distance between the edge of the tumor and the ipsilateral NVB was >2 mm, NVB retention surgery can be performed; when it was ≤2 mm, NVB retention surgery cannot be performed. The influencing factors of the distance between the tumor edge and NVB were analyzed by χ2 test and logistic regression analysis. Results Univariate analysis showed that side-specific positive biopsy core ≥1/3, side-specific maximum tumor length in biopsy core ≥5 mm, side-specific tumor involvement rate in biopsy core ≥1/2 and extraprostatic cancer extension by preoperative magnetic resonance imaging (MRI) examination were associated with the distance between the tumor edge and NVB (all P < 0.01). Multivariate analysis showed that extraprostatic cancer extension by preoperative MRI examination (OR = 3.66, P = 0.006) and side-specific positive biopsy core ≥1/3 (OR = 3.39, P = 0.008) were the independent influence factors. Conclusion The clinical criteria for a nerve-sparing radical prostatectomy are side-specific positive biopsy core <1/3 and no extraprostatic extension by preoperative MRI examination. Key words: Prostate neoplasms; Radical prostatectomy; Nerve-sparing

The value of preoperative magnetic resonance imaging in detecting the distribution of neurovascular bundles before the nerve-sparing laproscopic radical prostatectomy

Objective To investigate the preoperative magnetic resonance imaging (MRI) examination of the distribution of neurovascular bundles (NVB) around the prostatic capsule, and its clinical value in the nerve-sparing laparoscopic radical prostatectomy (NS-LRP). Methods The clinical data of 42 patients with clinically localized prostate cancer who were admitted from January 2008 to January 2017 were retrospectively analyzed. Age ranged from 58 to 74 years, with an average of 68 years. Preoperative serum PSA range from 0.94 to 12.28 ng/dl, with an average of 7.01 ng/dl. Preoperative Gleason score range from 6 to 8, with an average of 6. Clinical stage: T1-T2 37 cases, T3 5 cases. The average preoperative International Erectile Function Index questionnaire-5 (IIEF-5) 21, of which 23 cases had normal erectile function (IIEF-5>22). All the 42 patients underwent MRI examination before operation. According to the distribution of NVB around the prostatic capsule, they were divided into 3 groups: 17 cases in group A, and no NVB was evident in all cases. In group B, 8 cases were visible but not obvious. In group C, 17 cases were evident NVB. There was no significant difference in age, preoperative serum PSA and Gleason score between the three groups (P>0.05). The preoperative IIEF-5 in group A, B, and C were 19.5, 22.8, and 21.5, respectively, with no statistically significant difference (P>0.05). All 42 cases received NS-LRP under general anesthesia. The differences in IIEF-5 before and after surgery were compared between the three groups. Results In this study, 42 cases were successfully completed. 42 patients were followed up for 12 to 36 months, with an average of 14.1 months. In group A, B, and C, postoperative IIEF-5 was 8.0, 14.1, and 15.5, respectively, which was statistically significant compared with preoperative values (P<0.05). The decrease of IIEF-5 afteroperation in group A was significantly different from that of group Band C (P<0.05). Conclusions Compared with patients with visible NVB on MRI examination, patients have no visible NVB observed on MRI with erectile function-related nerves around the prostatic capsule may be walking on both sides of the prostatic capsule and spreading over the entire anterior ventral surface of the prostate. To maxium-preserve NVB and postoperative erectile function to the utmost, NS-LRP surgery should be more accurately dissected on both sides and ventral side of the prostatic capsule. Key words: Neurovascular bundle; Distribution; Ventral; Magnetic resonance imaging; Erectile function; Nerve-sparing laparoscopic radical prostatectomy

Application value of two-step separation approach in laparoscopic hemihepatectomy

Objective To investigate the application value of two-step separation approach in laparoscopic hemihepatectomy. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 81 patients who underwent laparoscopic hemihepatectomy in the People′s Hospital of Hunan Provincial between January 2015 and December 2017 were collected. Patients underwent laparoscopic hemihepatectomy using two-step separation approach after preoperative assessment. Hepatic pedicle, hepatic vein and branches were processed in the liver parenchyma, without intrathecal anatomy. Observation indicators: (1) preoperative assessment, intra- and post-operative recovery; (2) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed up to February 2018. Patients with hepatolithiasis received abdominal CT reexaminations at 5-7 days postoperatively for observing postoperative residual stones, and patients with malignant tumor were regularly followed up for 1-3 years. Measurement data with normal distribution were represented as ±s. Count data were described as frequency and percentage. Results (1) Preoperative assessment, intra- and post-operative recovery: 81 patients underwent preoperative blood biochemistry, tumor biomarker and imaging examinations, and remaining functional liver volume and a liver model in 9 patients were respectively calculated and built using the 3D reconstruction software and 3D printing technology. Of 81 patients, 68 underwent left hemihepatectomy and 13 underwent right hemihepatectomy; 77 underwent successful laparoscopic hemihepatectomy using two-step separation approach, 4 were converted to open operation, with a rate of 4.9%(4/81). Of 4 patients with conversion to open operation, 1 had difficult tumor separation due to tumor invading port vein induced to close adhesion, 1 had stone removal difficulties under laparoscopy due to hepatolithiasis, and 2 were converted to open operation due to severe liver cirrhosis induced to massive intraoperative bleeding. Of 81 patients, 70 gained dividing line of hemiliver by intraoperatively hemihepatic blood flow occlusion, and then got effectively control of bleeding combined with Pringle blood flow occlusion, and 11 received Pringle blood flow occlusion in whole liver. Laparoscopic fluorescence imaging technology was intraoperatively used for 2 patients. Operation time, volume of intraoperative blood loss, rate of intraoperative blood transfusion and duration of hospital stay in 81 patients were respectively (206±42)minutes, (195±134)mL, 11.1%(9/81) and (11.5±2.7)days. Eighty-one patients were complicated with bile leakage and were cured by conservative treatment, with a bile leakage incidence of 2.5%(2/81), and without severe complications, such as postoperative bleeding, hepatic dysfunction and subphrenic abscess. There was no perioperative death and reoperation within 30 days postoperatively. (2) Follow-up and survival situations: 55 patients with hepatolithiasis were followed up and underwent CT examinations of upper abdomen at 5-7 days postoperatively, including 52 with depletion of stones; 3 with residual stones received removal of stones by choledochoscope at 3 months postoperatively, without residual stones. Seventeen patients with malignant tumor were followed up for 12-36 months, with a median time of 15 months, 16 had tumor-free survival, and 1 was complicated with intrahepatic metastasis at 1 year after resection of hepatocellular carcinoma, and then underwent transcatheter arterial chemoembolization (TACE) and survived with tumor. Nine patients with benign liver diseases had good recovery during follow-up. Conclusion Two-step separation approach that is rationally used in laparoscopic hemihepatectomy is safe, effective and convenient. Key words: Hepatolithiasis; Hepatic neoplasms; Hemangiomas; Hemihepatectomy; Two-step separation approach; Laparoscopy

A Pediatric Foreign Body Appendicitis Can Cause a Pitfall in Imaging

Although foreign body (FB) ingestion is common in childhood, most cases do not have any clinical significance. Radiologic evaluation is crucial to determine the exact location of a persistent foreign body because it dictates the therapeutic approach. In this case report, we present a child with appendiceal perforation caused by a FB and emphasize pitfalls in preoperative imaging assessment. A 3-year-old boy presented with subtle abdominal pain duration for three months. The preoperative imaging examinations were consistent with an intraluminal metallic pin. However, the operative findings and postoperative pathological examination showed that the pin perforated the appendiceal wall, causing chronic inflammatory changes with an omental reaction around the extraluminal part of the pin. The patient underwent appendectomy with an uneventful course. Foreign body is a rare cause of appendiceal perforation with resultant appendicitis. Imaging may reveal some clues regarding the location, but the interpretation of radiologic data could be quite challenging.

Retrieval of a Broken Sewing Needle from the Sacrum Aided by a Permanent Magnet: A Case Report and Literature Review.

Penetrating sacral injuries are very rare, but foreign bodies that penetrate the sacrum often cause pain, cerebrospinal fluid leakage, and neurological symptoms. Careful preoperative medical and imaging examinations, determining the position of the foreign body, and surgical exploration are essential in the management of such cases. We present the case of a woman who visited our emergency department with a broken sewing needle in her sacrum. The incident occurred when the patient accidentally sat on the needle while sewing by hand. Pain while sitting was the main clinical finding after the accident. The patient was treated successfully by surgical exploration aided by a permanent magnet. At follow-up a few months later, she was symptom-free. In clinical practice physicians often encounter patients with metallic foreign bodies. Permanent magnets play an important role in the removal of metallic foreign bodies, and emergency department physicians should master the methods and techniques.

Establishment of nomogram model to predict peritoneal metastasis in colon cancer patients without distant metastasis by preoperative imaging examination

To establish a nomogram model to predict the peritoneal metastasis in colon cancer patients without distant metastasis by preoperative imaging examination. Clinicopathological data of colon cancer patients without distant metastasis by preoperative imaging examination who underwent surgery in our department between January 2000 and December 2014 were retrospectively analyzed. Predictors of peritoneal carcinomatosis were analyzed by univariate and Logistic multivariate analyses. Base on the independent predictors by multivariable analysis results, a nomogram model was formulated with further use of R software. The total score was calculated by the addition of each predictor score, indicating the corresponding risk of peritoneal metastasis. The score was greater in the nomogram, and the risk was higher in peritoneal implantation metastasis. A receiver operating characteristic(ROC) curve was then constructed to evaluate the predictive abilities of the various preoperative factors and nomogram. A total of 1 417 patients were defined as above and enrolled in the study. The median age was (60.5±13.3) years, 835 cases (58.9%) were male, and 132 cases (9.3%, 132/1417) were diagnosed with synchronous peritoneal carcinomatosis during operation. Univariate analysis showed that peritoneal metastasis was associated with age, incidence of abdominal pain, incidence of mucous bloody stool, CEA level, traversible rate, tumor diameter, ratio of infiltrating type cancer, differentiation, histological type, cT staging and cN staging (all P<0.05). Logistic multivariate analysis revealed that younger age (OR:0.974, 95%CI: 0.958 to 0.990, P=0.001), later clinical T stage (OR: 2.949, 95%CI: 1.588 to 5.476, P=0.001), lesion not traversible(OR: 0.519, 95%CI: 0.314 to 0.858, P=0.011), infiltrative gross type (OR: 1.812, 95%CI: 1.099 to 2.987, P=0.020), larger tumor (OR: 1.044, 95%CI: 0.998 to 1.093, P=0.061), higher preoperative serum CEA level(OR:1.004,95%CI: 1.001 to 1.007, P=0.007) and histopathologic type of mucinous or signet ring cell adenocarcinoma (OR:1.642, 95%CI: 1.009 to 2.673, P=0.046) were independent risk factors. The nomogram model was further established based on above 7 independent risk factors, whose total score was 350 and area under the ROC curve was 0.753(P=0.000). The nomogram model can be helpful to screen the colon cancer patients with high risk of peritoneal metastasis and to avoid unnecessary laparotomy for colon cancer patients without distant metastasis by preoperative imaging examination.

Research progress in the use of surgical robotic systems in arthroplasty

With the application of robotic-assisted arthroplasty in the clinical setting during the last two decades, passive, semiautonomous, and autonomous surgical robotic systems have been developed and utilized in a wide range of surgical procedures. Such procedures include total hip arthroplasty, total knee arthroplasty, and unicompartmental knee arthroplasty. These robotic platforms can be divided into open platforms and closed systems. A navigation component is indispensable for all kinds of surgical robotic systems used in arthroplasty. Navigation components need two disparate approaches to realize three-dimensional reconstruction. Some robotic systems require preoperative imaging examination for navigation, while others only need intraoperative anatomic landmark identification. The following four types of FDA-approved surgical robotic systems are currently available for arthroplasty, the Robodoc autonomous system, the Rio haptic system, the iBlock cutting guide, and the Navio handheld system. Robotic-assisted arthroplasty reportedly facilitates more accurate milling, cutting, and drilling, allowing component alignment and bone morphing to be performed with higher precision and closer to preoperative planning. These advantages result in better postoperative function restoration and patient satisfaction. The learning curve is also acceptable for these systems. Nonetheless, robotic systems are still somewhat disappointing, because they are typically associated with prolonged surgical procedures and require adequate surgical field exposure. Moreover, the cost-effectiveness ratio of this technology in China is required for further investigation. Future designs of robotic arthroplasty systems should aim to overcome the current shortcomings in terms of security and reliability, facilitating further automation of more surgical procedures and reduction in the size of the systems.

Clinical features and surgical indications and malignant risk factors analysis of intraductal papillary mucinous neoplasms of the pancreas

Objective To investigate the clinical features and surgical indications of subtypes of intraductal papillary mucinous neoplasm (IPMN) of the pancreas, and analyze its malignant risk factors. Methods The retrospective case-control study was conducted. The clinicopathological data of 77 patients with IPMN of the pancreas who were admitted to the First Hospital of Peking University from January 2008 to December 2016 were collected. The subtypes of IPMN of the pancreas detected by preoperative imaging examination included main-duct type (MD-IPMN) in 46 patients, branch-duct type (BD-IPMN) in 12 patients, mixed type (MT-IPMN) in 19 patients. The surgical indications were consulted from the Guideline for the diagnosis and treatment of pancreatic cystic lesions composed by the Pancreatic Surgery Group of Surgery Branch of China Medical Association. Surgical procedure was selected according to the location and size of the IPMN. Four to 6 cycles of chemotherapy with S-1 and/or Gemcitabine were conducted for patients with malignant IPMN according to the tolerance and baseline characteristics. Observation indicators included: (1) comparison of the clinical features MD-IPMN, MT-IPMN and BD-IPMN; (2) surgical and postoperative conditions; (3) results of postoperative pathological examination and malignant risk factors analysis; (4) accuracy evaluation of Sendai and Fukuoka guidelines for the diagnosis of malignant IPMN of the pancreas; (5) follow-up results and survival. Patients were followed up by outpatient examination and telephone interview till December 2016. The postoperative adjuvant therapy, tumor recurrence and metastasis of malignant IPMN patients and postoperative survival condition of all the patients were collected. Measurement data with normal distribution were expressed as ±s or average (range), and pairwise comparison was analyzed by t test. Measurement data with skewed distribution were expressed by median (range). Comparison between count data and univariate analysis were done by chi-square test. Multiple factors analysis was done by Logistic regression model. The survival curve was drawn and the survival rate were calculated by Kaplan-Meier method. The comparison of survival was done by Log-rank test. Results (1) Comparison of clinical features between MD-IPMN, MT-IPMN and BD-IPMN: The numbers of patients with symptoms, jaundice, those complicated with diabetes and elevated CA19-9 were 55, 20, 43 and 28 in MD-IPMN and MT-IPMN, and 6 , 0, 3 and 1 in BD-IPMN, with statistically significant difference (χ2=5.421, 3.516, 5.525, 3.834, P 0.05), while significant difference in the specificity between the 2 guidelines were detected (χ2=12.500, P<0.05). (5) Follow-up and survival: Seventy of 77 patients were followed up, including 42 with benign IPMN and 28 with malignant IPMN. The median survival time was 35.0 months (range, 6.0-94.0 months). All the malignant IPMN patients received adjuvant therapy. The 1-, 3-, 5-year overall survival rates of 47 patient with benign IPMN were 100.0%, 96.2% and 96.2%, respectively, and 1 patient died of cardiac infarction. The 1-, 3-, 5-year overall survival rates of 30 patients with malignant IPMN were 96.6%, 81.8%, 38.6%, respectively, and 11 patients died of tumor recurrence or metastasis with median time of tumor recurrence or metastasis of 20.5 months (6.0-61.6 months). The 1-, 3-, 5-year overall survival rates of 17 patients with negative lymph node metastasis were 100.0%, 100.0% and 60.0%, respectively, and the 1-, 3-, 5-year overall survival rates of 13 patients with positive lymph node metastasis were 91.7%, 57.1% and 0, respectively. There was statistically significant difference between patients with benign and malignant IPMN (χ2=12.530, P<0.05). There was statistically significant difference between patients with negative lymph node metastasis and those with positive lymph node metastasis (χ2=16.977, P<0.05). Conclusions Patients with MD-IPMN or MT-IPMN are more vulnerable to be complicated with diabetes, jaundice, elevated CA19-9 and high malignancy, and thus surgery is recommended. Jaundice, elevated CEA and CA19-9, tumor diameter≥3.0 cm, MD-IPMN are the independent risk factors influencing the malignancy of IPMN. Key words: Intraductal papillary mucinous neoplasms of the pancreas; Classification; Surgical procedures, operative; Prognosis

Postoperative Spinal Subdural Lesions Following Lumbar Spine Surgery: Prevalence and Risk Factors.

Study DesignRetrospective case–control studyPurposeTo clarify the prevalence and risk factors for spinal subdural lesions (SSDLs) following lumbar spine surgery.Overview of LiteratureBecause SSDLs, including arachnoid cyst and subdural hematoma, that develop following spinal surgery are seldom symptomatic and require reoperation, there are few reports on these pathologies. No study has addressed the prevalence and risk factors for SSDLs following lumbar spine surgery.MethodsWe conducted a retrospective analysis of the magnetic resonance (MR) images and medical records of 410 patients who underwent lumbar decompression surgery with or without instrumented fusion for degenerative disorders. SSDLs were classified into three grades: grade 0, no obvious lesion; grade 1, cystic lesion; and grade 2, lesions other than a cyst. Grading was based on the examination of preoperative and postoperative MR images. The prevalence of SSDLs per grade was calculated and risk factors were evaluated using multivariate logistic regression analysis.ResultsPostoperative SSDLs were identified in 123 patients (30.0%), with 50 (12.2%) and 73 (17.8%) patients being classified with grade 1 and 2 SSDLs, respectively. Among these, one patient was symptomatic, requiring hematoma evacuation because of the development of incomplete paraplegia. Bilateral partial laminectomy was a significantly independent risk factor for SSDLs (odds ratio, 1.52; 95% confidence interval, 1.20–1.92; p<0.001). In contrast, a unilateral partial laminectomy was a protective factor (odds ratio, 0.11; 95% confidence interval, 0.03–0.46; p=0.002).ConclusionsThe prevalence rate of grade 1 SSDLs was 30%, with no associated clinical symptoms observed in all but one patient. Bilateral partial laminectomy increases the risk for SSDLs, whereas unilateral partial laminectomy is a protective factor.

Clinicopathologic characteristics and prognosis of gastric hepatoid adenocarcinoma

To investigate the clinicopathological characteristics, diagnosis, treatment and prognosis of gastric hepatoid adenocarcinoma(HAS). Retrospective analysis of clinicopathological data of 24 cases with gastric HAS diagnosed by surgery and pathology in Chinese PLA General Hospital from January 2013 to May 2016 were carried out. All the patients underwent preoperative serum alpha fetoprotein (AFP), carcinoembryonic antigen (CEA), endoscopy and imaging examination (CT or B-mode ultrasonography), and those with elevated AFP were excluded from liver cancer, cirrhosis, endodermal sinus tumor and other diseases. The follow-up ended in June 2016 or the death of the patient. The survival was from the operation to the death of the patient or the end of follow-up. There were a total of 24 cases with gastic HAS, accounting for 1.03%(24/2 326) of the total number of patients with gastric cancer diagnosed at the same time in our center. There were 19 males and 5 females, the ratio of male to female was 3.8:1.0, the mean age of the patients was 55.9 (31 to 72) years, and 2 of them had liver metastasis. The first symptom in 50% (12/24) patients was epigastric pain, in 25%(6/24) was abdominal distension with vomiting, and the rest included dysphagia (12.5%, 3/24), hematemesis (8.3%, 2/24) and melena (4.2%, 1/24). Preoperative serum levels of AFP and CEA were elevated in 10 (41.7%) and 5 patients (20.8%) respectively. All the patients underwent surgical treatment, including 23 cases with D2 radical resection of gastric cancer and R0 resection, and the other of palliative gastrojejunostomy. Lesions of HAS located in gastric antrum in 11 cases (45.8%), in cardia in 7 cases (29.2%), and in gastric body in 6 cases (25%). Tumor maximum diameter of 10 cases was larger than 5 cm, and the average diameter was 5.7(1.0 to 12.0) cm. Postoperative pathological TNM staging: stage I(b was in 1 cases, stage II( in 7 cases, stage III( in 14 cases, stage IIII( in 2 cases; lymph node metastasis in stage N1-3 in 20 cases (83.3%). Poorly-differentiated tumors were found in 21 cases (87.5%), and no well-differentiated tumors were found. There were 11 cases (45.8%) with formation of intravascular tumor thrombi. In immunohistochemistry, AFP positive expression was found in 11 cases(45.8%). Seventeen HAS cases (70.8%, 17/24) received postoperative SOX(oxaliplatin + S-1) or XELOX (oxaliplatin + capecitabine) as adjuvant chemotherapy, 5 cases postoperative immune therapy, and 2 cases postoperative traditional Chinese medicine. All the patients were followed up for 0.7 to 42.0 months (median 8 months). A total of 9 patients died, of whom, 1 case underwent gastrojejunostomy because of liver and peritoneal metastasis before operation, and died 20 days after surgery; 4 cases died of multiple liver metastases after 1.5 to 12.0 months with survival of 3 to 18 months; 3 cases presented local recurrence after 2 to 17 months with survival of 6 to 22 months; 1 cases had peritoneal metastasis after 12 month with survival of 26 months. HAS is a rare type of gastric cancer with poor prognosis. The diagnosis is mainly based on histopathology, and radical resection is the mainstay treatment.

Diagnosis and treatment of renal cell carcinoma complicated with inferior vena cava tumor thrombus in hepatic segment and upper hepatic segment

Surgical treatment is the only cure treatment for patients with inferior vena cava tumor thrombus in hepatic segment and upper hepatic segment. The accurate diagnosis of tumor thrombus is very important. In preoperative imaging examination, the abdominal enhanced CT scan and the inferior vena cava MRI scan were the best methods for the diagnosis and evaluation of the tumor thrombus in hepatic segment and upper hepatic segment. Compared with the tumor thrombus below the liver, the tumor thrombus in hepatic segment or above hepatic segment extend widely, and the operation are more difficult. For simple inferior vena cava tumor thrombus (the top of the thrombus has reached the level of hepatic vein), Retroperitoneal approach combined with transperitoneal approach should be used. Open surgery is the standard procedure for other tumor thrombus in hepatic segment and upper hepatic segment. In addition to exposure of inferior vena cava below the hepatic vein, the liver and the first hepatic hilum should be exposed. For tumor thrombus in the atrium, after the longitudinal incision of diaphragm, we use Milking technology to squeeze thrombus into inferior vena cava. Then we use catheterization technology to remove thrombus. For difficult atrial tumor thrombus, an extracorporeal circulation should be performed. The median incision in the chest should be performed to open the chest and open the pericardium and remove the tumor thrombus. Patients with tumor thrombus in hepatic segment or upper hepatic segment should be diagnosed as early as possible and they need actively treated by operation. Key words: Renal carcinoma; Tumor thrombus; Inferior vena cava; Hepatic segment

Tumor thrombosis: a peculiar finding associated with pancreatic neuroendocrine neoplasms. A pictorial essay.

While abutment, encasement or vessel occlusion are identified in most patients with a pancreatic tumor, tumor thrombosis is an uncommon finding. In particular, there are no description in the literature of tumor thrombosis associated with ductal adenocarcinoma, the most common pancreatic tumor. On the other hand, surgical series reveal that tumor thrombosis is associated with about 5% of pancreatic neuroendocrine neoplasms (PanNENs), and literature data suggest that this finding is frequently underreported on pre-operative imaging examinations. Tumor thrombosis may be clinically relevant, causing splenoportomesenteric hypertension, possibly responsible for life-threatening upper gastrointestinal bleeding. Bland thrombosis caused by direct infiltration of peri-pancreatic vessels frequently determines surgical unresectability, even in neuroendocrine tumors; on the opposite, tumor thrombosis associated with PanNENs do not exclude surgery per se, even though both morbidity and mortality can be increased by such condition. Considering the favorable prognosis of PanNENs and the frequent need to treat tumor thrombosis in order to prevent complications or to relieve symptoms, it is of paramount importance for radiologists the knowledge of the variety of findings associated with tumor thrombosis in PanNENs.

Yield of Staging Laparoscopy for Incurable Factors in Chinese Patients with Advanced Gastric Cancer.

Although the role of staging laparoscopy (SL) in detecting radiologically occult M1 disease has been widely recognized, it is seldom used in China and its clinical value based on Chinese population has been rarely reported. The aim of this study is to identify the yield of SL for Chinese patients with advanced gastric cancer (AGC) and determine the proportions of patients in whom treatment plan is altered. The clinical data were retrospectively collected from 879 AGC patients who underwent SL without any definite signs of disseminated disease on imaging examination. The primary outcomes were the proportions of patients whose laparoscopy identified incurable factors (including M1 diseases and unresectable T4b diseases), and who had their treatment plan altered. SL revealed incurable factors in 130 (14.8%) patients, including macroscopic peritoneal metastasis (n = 92), positive peritoneal cytology (n = 10), liver metastasis (n = 12), para-aortic lymph node metastasis (n = 1), and unresectable T4b tumor (n = 18). After SL, treatment plans were altered in 123 (14.0%) patients, among which 82 (63.1%) patients were not offered any further procedure and referred for chemotherapy. Among 749 M0 patients who immediately proceeded to radical gastrectomy after SL, new incurable factors were found at subsequent operations in 21 (2.8%) patients. Multivariate analysis showed that tumor size ≥8 cm, Borrmann type III and IV, and tumor invasion of T4a and T4b in preoperative imaging examination were the predictive factors for peritoneal metastasis. SL detects additional incurable factors in Chinese AGC patients with potentially resectable disease and optimizes their treatments. A systematic and painstaking inspection of the whole abdominal cavity, including routine entry into the bursa omentalis, is necessary for improving the yield of SL.

Surgical treatment of parapharyngeal space tumors: A report of 29 cases.

The present study aimed to establish a strategy for parapharyngeal space (PPS) tumor surgery based on preoperative symptoms, clinical signs, imaging and histological examination. A retrospective cohort study was conducted with 29 adult patients who underwent surgery for primary PPS tumors from 2008-2015. The following data was obtained: Preoperative symptoms of the patient, histological type of the tumor, surgical approach and complications. Of the 29 patients who underwent surgery to remove a PPS tumor, 16 presented with neurogenic tumors and 13 with salivary gland tumors. The most common symptom was the presence of a neck mass. Preoperative computed tomography and magnetic resonance imaging were performed to evaluate the size and location of the tumors. The majority of the salivary gland tumors were located in the prestyloid space, whereas all neurogenic tumor cases were poststyloid. A total of 21 of the 29 patients (72.4%) underwent a preoperative fine needle aspiration (FNAC) examination. FNAC contributed to preoperative diagnosis in 9 of these cases (42.9%). In parotid tumors of the prestyloid space, facial nerve palsy was a common postoperative complication. In the case of neurogenic tumors, a common complication was the postoperative palsy of the nerve of tumor origin. The strategy for PPS surgery, from the preoperative diagnosis to the operative method, remains controversial. The data on pre- and postoperative symptoms, imaging and histological diagnosis, and the selection of surgical method depending on a neurogenic or salivary tumor origin in the present study indicated that improving the method of examination, carefully selecting the method of approach and accurately managing surgery leads to complete tumor removal, and that the use of nerve-preserving techniques may reduce the likelihood of complications.