Primary Goal Of Surgery Research Articles

Malignant mesothelioma: current status and perspective in Japan and the world

Malignant pleural mesothelioma (MPM) is associated with a poor prognosis; and to make things worse, its incidence is increasing throughout the world. Surgical management of MPM is comprised of two aspects: diagnosis and resection. Surgical biopsy with thoracoscopy provides a higher yield but a higher rate of tumor cell seeding than blind biopsy. In some surgical cases, extended surgical staging with mediastinoscopy, laparoscopy, and contralateral thoracoscopy is required for the preoperative evaluation for resectablity. There are two types of surgical resection for MPM. Pleurectomy/decortication (P/D) involves removal of as much of the visceral, parietal, and pericardial pleura and the tumor as possible without removing the underlying lung. Because P/D is less radical but less invasive compared to extrapleural pneumonectomy (EPP), it can be tolerated by poor-risk patients. EPP comprises en bloc resection of visceral, parietal, and pericardial pleura and adjacent components such as ipsilateral lung, pericardium, and diaphragm, without opening the pleural cavity. EPP was considered a highly dangerous procedure with a surgical mortality of more than 30% decades ago, but its current operative mortality/morbidity rates are 4%-9% and 60%, respectively. As macroscopic complete resection is the primary goal of surgery for MPM because of its diffuse intrapleural growth, surgical resection alone is associated with poor survival. In this context, combination therapy with surgery plus chemotherapy and/or radiotherapy is currently considered the standard treatment for patients with respectable MPM. A national survey of EPP was conducted recently in Japan, and a few multicenter clinical trials will start soon.

Diagnosis, Staging, and Surgical Treatment of Malignant Pleural Mesothelioma

The clinical presentation of malignant pleural mesothelioma (MPM) is nonspecific. The process to obtain the correct diagnosis can be challenging and requires a high index of suspicion. Once the diagnosis is made, there is no universally accepted standard of care and treatment decisions are strongly influenced by physician bias. Physicians who see few numbers of patients tend to treat based on symptoms alone by drainage of the pleural effusion and talc pleurodesis, while physicians at several tertiary referral centers tend to take an aggressive multimodality approach incorporating surgical resection, chemotherapy, and radiation. The primary goal of surgery in this setting is the resection of all gross disease. The choice of operation, extrapleural pneumonectomy (EPP) or pleurectomy/decortication (P/D), depends on disease stage, pulmonary function, philosophy of the treating physician, and type of planned adjuvant therapy.

Laparoscopic colorectal surgery and vascular endothelial growth factor

The paper ‘‘Persistent elevation of plasma VEGF levels during the first month following minimally invasive colorectal resection’’[1] increases our understanding of the impact that surgery has on the complex universe of tissuederived growth factors, which are critical for wound healing but also have an impact on various malignant tumors. The ‘‘dark side’’ of these healing factors, of which there are several classes, is that overexpression, at least theoretically, can promote the implantation or growth of metastatic cancers. Vascular endothelial growth factor (VEGF) is one of the most potent and well studied of the tissue-derived angiogenic factors, and as such has been closely investigated, particularly for its role in tumor implantation and growth. One of the most important recent chemotherapeutic developments for colon cancer, in fact, has been antiangiogenic therapy, and drugs such as the recombinant humanized anti-VEGF monoclonal antibody bevacizumab are rapidly becoming an important element in chemotherapeutic regimens for advanced colon cancers. At the same time that our knowledge of the relationship between angiogenesis and cancer growth has grown we have seen renewed interest in the use of minimally invasive approaches to gastrointestinal cancers, with multiple studies showing improved short-term outcomes and equivalent cancer outcomes. Such quality-of-life issues are, of course, important, but nonetheless, the primary goal of surgery is one of effective treatment and even cure. The question currently before the surgical community is whether laparoscopy will eventually be shown to improve cancer outcomes. If it does, it will certainly become the absolute standard of practice, to the benefit of all cancer patients. In the past, improved cure rates from surgery were a result of better resection techniques; this is unlikely to be the explanation of any improvements resulting from the use of laparoscopy, as the mechanics of the surgery are seldom altered. Instead it will come from alteration of the physiological impact of the surgery, the effects of which are mediated by tissue-generated and blood-borne factors such as VEGF. So, what is known about colorectal cancer, surgery, and VEGF? We know that colon cancer patients have higher levels of circulating VEGF than comparable patients with benign disease – a finding confirmed by the present study. We know that higher plasma levels of VEGF can predispose patients to tumor implantation and growth [2]. We know that any trauma, including surgery, can increase circulating and tissue levels of VEGF. Minimally invasive surgery may cause less of an increase in circulating VEGF, possibly as a result of smaller incisions generating less tissue-derived VEGF, although the data on this is somewhat mixed in the literature [3,4]. And now, thanks to the present study by Dr Whelen et al., we know that these higher levels of circulating VEGF can remain elevated for days and even weeks after the surgery — a finding that may be important when considering the optimal timing of adjuvant chemotherapy using antiangiogenic therapies. We do not know, however, why some patients, almost a third of those in this study, show no or a very transient rise in VEGF after surgery. Whether this is a flaw in study design, variable expression in individuals or a difference in surgical technique is unknown, but obviously it is of interest from a clinical standpoint as it may turn out to correlate with wound complications, cancer recurrence or choice of adjuvant chemotherapeutic agents. In their discussion, the authors nicely summarize these unknowns and L. L. Swanstrom (&) Dept. of Minimally, Invasive Surgery, Legacy Health System, Portland, Oregon, United States e-mail: lswanstrom@aol.com

A Surgical Technique for the Removal of Clinoidal Meningiomas

Clinoidal meningiomas, also referred to as medial or inner sphenoid wing meningiomas, are often difficult and challenging to remove completely and safely, especially when they become large enough to encircle, compress, or displace the adjacent critical neurovascular structures such as the optic nerve, the internal carotid artery and its branches, and the oculomotor nerve. In this article, the authors describe the detailed surgical technique used in their practice in addition to subtle nuances learned from their experience of operating on more than 40 patients with clinoidal meningiomas over the past several years. The primary goals of surgery are to achieve aggressive tumor removal with avoidance of intraoperative morbidity and, in addition, for those with preoperative compromised vision, to provide improvement in their visual function after surgery.

Macroscopic Complete Resection: The Goal of Primary Surgery in Multimodality Therapy for Pleural Mesothelioma

Macroscopic Complete Resection: The Goal of Primary Surgery in Multimodality Therapy for Pleural Mesothelioma

Macroscopic Complete Resection: The Goal of Primary Surgery in Multimodality Therapy for Pleural Mesothelioma

Macroscopic Complete Resection: The Goal of Primary Surgery in Multimodality Therapy for Pleural Mesothelioma

Nerve Transfers in Severe Obstetrical Brachial Plexus Palsy

Nerve transfers are increasingly utilized for repair of servere brachial plexus injuries and, indeed, are the only option when the proximal spine nerve roots have been avulsed from the spinal cord. The procedure essentially involves the coaption of a proximal foreign nerve to the distal denervated nerve, so that the latter will be reinnervated by the donated axons. The primary goal of surgery in the severe obstetrical brachial plexus palsy case is to return proximal arm function, particularly elbow flexion and a stable, dynamic shoulder that can abduct and externally rotate. Neural input should thus be directed first to the biceps via the musculocutaneous nerve or its branches, and next to reconstructing the suprascapular nerve. Unlike an adult with a complete palsy, where the return of distal hand function is virtually impossible, the infant has better odds of successful reinnervation of the hand. If donor nerve sources are available following repair of the musculocutaneous and suprascapular nerves, grafts can be directed to the radial (for wrist and finger extention) and median (for elbow and finger flexion and critical hand sensibility) nerves. Recovery of intrinsic hand muscle function from plexus reconstruction in the global severe palsy case is not a realistic possibility at present. Cortical plasticity, which is likely more prevelent in the baby than the adult, appears to play an important physiological role in the functional recovery of the reinnervated muscles following nerve transfers.

Tethered spinal cord following repair of myelomeningocele.

The goal of this paper is to elucidate the clinical presentation of tethered cord syndrome (TCS) following repair of a myelomeningocele. Approximately 10 to 30% of children will develop TCS following repair of a myelomeningocele. Because essentially all children with repaired myelomeningocele will have a tethered spinal cord, as demonstrated on MR imaging, the diagnosis of TCS is made based on clinical criteria. The six common clinical presentations of TCS are increased weakness (55%), worsening gait (54%), scoliosis (51%), pain (32%), orthopedic deformity (11%), and urological dysfunction (6%). The primary goal of surgery is to detach the spinal cord where it is adherent to the thecal sac, relieving the stretch on the terminal portion of the cord. Early diagnosis and surgical release of the tethered cord results in stabilization or improvement in most cases. Because TCS may present with orthopedic and/or urological signs or symptoms, children with myelomeningocele should by followed, ideally in a multidisciplinary clinic, by neurosurgeons, orthopedic surgeons, and urologists who are aware of this condition.

Revision anterior cruciate ligament reconstruction surgery.

Revision anterior cruciate ligament (ACL) reconstruction is indicated for selected patients with recurrent instability after a failed primary procedure. The cause of the failure must be carefully identified to avoid pitfalls that may cause the revision to fail as well. Associated instability patterns must be recognized and corrected to achieve a successful result. The choice of graft, the problem of retained hardware, and tunnel placement are the major challenges of revision ACL reconstruction. The patient must have reasonable expectations and understand that the primary goal of surgery is restoration of the ability to perform activities of daily living, rather than a return to competitive athletics. The results of revision ACL reconstructions are not as good as those after primary reconstructions; however, the procedure appears to be beneficial for most patients.

Management of primary intracranial germinomas: diagnostic surgery or radical resection?

Because intracranial germinomas are readily curable with radiation and chemotherapy or radiation therapy alone, the role of radical surgery has become debatable. This study assesses the optimum degree of surgical resection for intracranial germinomas. Twenty-nine patients who underwent surgery for germinoma were retrospectively analyzed (male/female ratio 27:2, median age 18 years). Among these 29 patients there were 10 solitary pineal, seven solitary neurohypophyseal/hypothalamic, and 12 multifocal or disseminated tumors. Biopsy samples were obtained in 16 patients (stereotactically in eight, transsphenoidally in four, and via frontotemporal craniotomy in four). Partial resection was attained in five patients (via a frontotemporal approach in three and occipitotranstentorially in two). Gross-total resection was achieved via an occipitotranstentorial route in eight patients with pineal masses. After surgery, 10 patients were treated with radiotherapy alone, and 19 received radiation and chemotherapy; complete remission was achieved in all 29 patients. The overall tumor-free survival rate was 100% at a median follow-up period of 42 months. There was no significant difference in outcome related to the extent of surgical resection. Postoperative neurological improvement was seen in only two patients, whereas transient postoperative complications, mainly upgaze palsy, were observed in six. One patient experienced a slight hemiparesis, bringing the surgical morbidity rate to 3% (one of 29). It is concluded that radical resection of intracranial germinomas offers no benefit over biopsy. The primary goal of surgery should be to obtain a sufficient volume of tumor tissue for histological examination. If there is strong evidence of germinoma on radiological studies, biopsy samples should be obtained. When a perioperative histological diagnosis of pure germinoma is made during craniotomy, no risk should be taken in continuing the resection.

Facial nerve preservation in patients with large acoustic neuromas treated by a combined middle fossa transtentorial translabyrinthine approach.

With large acoustic neuromas, the primary goal of surgery is safe total removal of the tumors, and the secondary goal is preservation of nearby neural structures, including the facial nerve. In a series of 15 consecutive patients with large cerebellopontine angle tumors, all of which were more than 2.5 cm in diameter, tumor excision was performed by a one-stage combined middle fossa-translabyrinthine approach. There were 13 acoustic neuromas, 10 of which were more than 4 cm in diameter, one petrous apex meningioma 4 cm in diameter, and one facial neuroma 3 cm in diameter. The tumors were totally removed in all 15 patients. The facial nerve was preserved in 12 of 13 evaluable patients. In the 14th patient the nerve had been transected in a previous suboccipital procedure with incomplete removal, and in the 15th patient the nerve was sutured following excision of a facial neuroma. Thus, the nerve was lost at surgery in only one patient. This combined approach provided very clear visualization of the cerebellopontine angle, including the brain stem and the lower cranial nerves. It enabled identification of both the origin of the facial nerve at the brain stem and the lateral segment of the nerve in the internal auditory canal. Anterior extensions of tumor growing through the tentorial hiatus were easily removed. The results in these 15 patients show that this approach is excellent for total removal of large acoustic neuromas with preservation of the facial nerve. It is especially suitable for large tumors with anterior extensions.

Anterior segment surgery early after corneal wound repair.

Penetrating wounds of the cornea require immediate repair, generally within 24 hours. Tight closure of the wound and a reformed anterior chamber are the primary goals of surgery. However, there is no guarantee that further surgery will not be required for maintaining the healthy function of the anterior segment. At the second operation the effect of the procedure on the previously repaired wound is of prime importance, since in many cases the operation needs to be done before corneal healing is completed. In our series the lens, which was either partially or completely cataractous at the initial operation, became intumescent at different times afterwards, and an immediate removal was necessary. No change in the preoperative wound sealing or transparency of the cornea could be detected after lens surgery performed between 24 hours and 21 days from the initial corneal repair.