Radical Procedures Research Articles

Anatomic Cartography of the Hypogastric Nerves and Surgical Insights for Autonomic Preservation during Radical Pelvic Procedures

To clarify the relationship of hypogastric nerves (HNs) with several pelvic anatomic landmarks and to assess any anatomic differences between the 2 sides of the pelvis, both in cadaveric and in vivo dissections. Prospective observational study. An anatomic theater for cadaveric dissections and a university hospital for in vivo laparoscopy. Five nulliparous female cadavers underwent laparotomic dissection; 10 nulliparous patients underwent laparoscopic surgery for rectosigmoid endometriosis without posterolateral parametrial infiltration. Measurements of the closest distance between HNs and ureters, the midsagittal plane, the midcervical plane, and uterosacral ligaments on both hemipelvises. A comparison of anatomic data of the 2 hemipelvises was conducted. The right and left HNs were identified in all specimens, both on cadavers and in vivo dissections. A wide anatomic variability was reported. Regarding the differences between the 2 hemipelvises, we found that the right HN was significantly (p <.001) farther to the ureter (mean = 14.5 mm; range, 10-25 mm) than the left one (mean = 8.6 mm; range, 7-12 mm). The HN was closer to the midsagittal plane on the right side (mean = 14.6 mm; range, 12-17 mm) than on the left side (mean = 21.6 mm; range, 19-25 mm). The midcervical plane was found 2.7 mm (range, 2-4 mm) to the left of the midsagittal one. The right HN was found to be nonsignificantly closer to the midcervical plane and the uterosacral ligament on the right side than on the left side (p >.05). Despite a wide anatomic variability of position and appearance, the HNs are reproducibly identifiable using an "interfascial" technique and considering the ureters and uterosacral ligaments as anatomic landmarks.

"Big trifles" of advanced liver resections for alveococcosis

Aim. Analysis of the techniques of advanced liver resections involving transplantation technologies which affect the results of surgery for advanced liver alveococcosis.Material and methods. There were 65 patients with massive complicated liver alveococcosis for the period from 2008 to 2018. Radical procedures were applied in 82% of cases (n = 53). Mechanical jaundice was observed in 45% ofpatients, portal hypertension — in 25%. Previous palliative surgery was applied in 58% of patients. Thirty-three patients (50.8%) had advanced parasitic lesion with involvement of afferent and (or) efferent vascular structures. Distant metastases were detected in 6 patients: metastatic lung lesions occurred in 5 of them, simultaneous injury of brain and lungs — in 1 case.Results. There were 47 RO-resections with application of transplantation technologies including 4 extracorporeal resections and 6 orthotropic liver transplantations. Reconstruction of great afferent and efferent vascular structures was performed in 47% of cases: IVC repair — 25 cases, PV repair — 25 cases. Resection of extrahepatic bile ducts was made in 33 cases. Postoperative complications occurred in 26 cases: Clavien-Dindo type II — 5, IIIb — 13, IVb — 2, V — 6. Bile leakage ISGLS class B occurred in 6 cases, class C — in 11 cases.Conclusion. Transplantation technologies for advanced liver resections and liver or its segment transplantation allow to achieve radical surgery in 82% of patients. Advanced operations are indicated for advanced liver alveococcosis due to good outcomes. There are various technical aspects of such operations which are useful to avoid most of complications.

Techniques and Current Role of Sentinel Lymph Node (SLN) Concept in Gastric Cancer Surgery.

Gastric cancer patients represent a rather divergent patient group and in certain carefully selected cases of early forms of gastric cancer the D2 gastrectomy could be considered a more radical procedure than the biological and oncological characteristics of the primary tumor on the gastric wall would require. As any unnecessary dissection increases morbidity without always respective survival benefits, an approach that could accurately predict and actually dictate the exact extent of lymph node dissection would be ideal. It is more than logical the assumption that the standard D2 lymphadenectomy could represent an overtreatment in distinct patients groups such as patients with early gastric cancer with favorable pathological characteristics and clinically negative nodes not suitable for endoscopic treatment because this early stage disease shows limited lymph node metastasis incidence and excellent overall survival. Considering that the D2 gastrectomy has a negative impact on the quality of life of gastric cancer patients due to the post-gastrectomy functional results, a concept of a more targeted lymph node dissection, when appropriate, is certainly appealing. It is yet to be proven whether sentinel lymph node navigation surgery can fulfill such expectations providing the appropriate balance between morbidity and oncological safety in selected gastric cancer patients.

Surgical approach on Reccurent Retroperitoneal Liposarcoma with Involvement of Surrounding Organs

Background: Retroperitoneal sarcomas are neoplasm that are only 0,3-3% of all solid tumors. Liposarcomas is most freguent soft tissue sarcomas in adults. Symptoms would only be detected if the liposarcoma presses on the surrounding organs.&#x0D; Case presentation: A 58-year-old woman presented with complaint of progressive abdominal distension, loss of appetite, malaise, constipation and weight loss of about 7 kg. Abdominal CT scanning showed the presence of a retroperitoneal tumor that occupies almost the entire right part of abdominal cavity. 16 months earlier, the patient was operated in another surgical facility due to liposarcom, derived from retroperitoneum (Histopathological finding: Poorly differentiated (G3) liposarcoma pleomorphic cell type). The patient was operated under the diagnosis of retroperitoneal liposarcoma.&#x0D; Conclusions: Treatment of choice is radical surgical procedure including elimination of all the structures and organs involved by the tumour process - RO resection as a basic principle of surgical treatment.

Treatment of ovarian endometrial cysts in the context of recurrence and fertility.

An approach to ovarian endometrial cysts has changed considerably during recent years, especially in regard to treatment of recurrent endometriosis, fertility sparing and infertility management. Surgical treatment is the primary therapeutic option. The most efficient types of treatment are radical procedures involving adhesiolysis, removal of the cyst along with its capsule and any remaining endometriotic foci. However, small asymptomatic cysts should not be treated surgically, especially in patients older than 35 years. Surgical treatment can be considered in infertile women and those who failed to get pregnant despite 1-1.5 years of trials, as well as in cases in which in vitro fertilization is not an option. Also large cysts, with more than 4 cm in diameter, should be treated surgically due to the risk of their rupture or torsion. The most efficient preventive measure for recurrent ovarian endometriosis is unilateral oophorectomy with sparing the contralateral ovary. Such a procedure should be considered in women who are no longer interested in childbearing or present with another endometriotic cyst in the same ovary. The role of pharmacotherapy is fairly limited; it should be considered in patients in whom diffuse endometriosis is associated with pain. Therapeutic agents from the following groups can be used: estrogen-progestin preparation, gestagens, including progesteronereleasing intrauterine systems and gonadotropin-releasing hormone agonists. Women with infertility should get pregnant as soon as possible, and in patients who failed to get pregnant and/or are older than 35 years, in vitro fertilization should be the treatment of choice.

En Bloc Resection with Partial Sacrectomy Helps to Achieve R0 Resection in Locally Advanced Rectal Cancer, Experience from a Tertiary Cancer Center.

Partial sacrectomy is a radical procedure that benefits a select group of patients with locally advanced primary or recurrent rectal cancer with posterior extension and carries potential for significant morbidity. This study was done to evaluate the morbidity and oncological outcome of patients who underwent partial sacral resection for rectal cancer in a tertiary cancer center. Seventeen patients underwent partial sacrectomy during the period from 2011 to 2015. Eleven patients had primary and six had recurrent rectal cancer. All patients were evaluated with MRI pelvis and metastatic evaluation with CT scan of the chest and abdomen and PET scan in patients with recurrent cancer. All patients had resection below the level of S2/S3 junction or lower. Three patients were females and the remaining were males. Median age was 56years. Overall morbidity was 76% and most common morbidity was wound related. The mean estimated relapse-free survival (RFS) for patients treated for primary rectal cancer was 20.3months (95% confidence interval (CI), 12.8-27.9) and the mean estimated overall survival (OS) 23.9months. Estimated mean RFS for patients who were operated for recurrent rectal cancer was 25.6months (95% CI, 17.7-33.5) and the median RFS was yet to reach. Estimated mean OS was 29.7months (95% CI, 15.5-43.8) and the median OS was 39.6months. Partial sacrectomy below the level of S2/S3 junction is a safe approach to facilitate en bloc resection of locally advanced primary and recurrent rectal cancer extending posteriorly with loss of plane with sacrum. In selected patients, this approach can improve survival at the cost of high morbidity.

Total laparoscopic pericystectomy for non complicated hydatid cyst

Background: Laparoscopic total pericystectomy is not a widely used approach for surgical treatment of liver hydatid cyst (LHC). When laparoscopic surgery is perform, less than 10% of patients had a radical procedure. Methods: We present a case of previosly healthy 61 y/o man, who was diagnosed of LHC of segment VI by an abdominal US and CT scan. After serological analysis a LHC was confirmed. A preoperative treatment based in Albendazole was prescribed for 2 months. Under left lateral decubitus position, a four trocars approach was used. After a partial liver mobilization, isolation of field with gauze and hypertonic saline solution was done. Hydatid membranes was removed in a bag and complete pericystectomy using bipolar and ultrasonic scalpel was performed. Intraoperative bleeding was 50ml. A Jackson-Pratts drainage was left at surgical site. Results: Postoperative was uneventful and discharge at 2º postoperative day. Pathological study shows an inactive echinococcus with hyaline degeneration. After 10 months of follow-up are asymptomatic and no recurrence. Conclusion: Laparoscopic total pericystectomy is feasible and could be performed as method of choice to non complicated LHC.

The evaluation of tumor markers and their impact on prognosis in gallbladder, bile duct, and cholangiocellular carcinomas – a pilot study

Background: The behavior of tumor markers in biliary tract malignancies is not well-known and studied enough. This study analyzed the preoperative serum levels of AFP, CEA, CA 19-9, CA 72-4, TPA, TPS, CYFRA 21.1 in patients with gallbladder carcinoma, bile duct carcinoma (Klatskin) and cholangiocellular carcinoma in relation to the patient prognosis. Methods: The study included 43 patients, who underwent either radical surgical procedure (n = 21) or explorative laparotomy (n = 22) for gallbladder carcinoma, bile duct carcinoma and cholangiocellular carcinoma (24, 8 and 11 patients) between 2003 and 2010 at the Department of Surgery, University Hospital and Faculty of Medicine in Pilsen, Charles University. Overall survival (OS) and disease-free interval (DFI) were computed by Kaplan-Meier method and statistically evaluated using LogRank test. Results: The statistical analysis proved TK as a poor prognostic factor for shorter DFI (p < 0.05) and also OS (p < 0.05) in patients with gallbladder carcinoma treated with radical surgery. TPS was demonstrated as a poor prognostic factor for OS in patients with gallbladder carcinoma (p < 0.05). CEA was proved as a factor of poor OS in patients after explorative laparotomy for all cumulated studied diagnoses (p < 0.05). Conclusion: The results of this study suggested the importance of tumor markers for assessment of prognosis. This work was supported by the National Sustainability Program I (NPU I) Nr.LO1503 provided by the Ministry of Education Youth and Sports of the Czech Republic.

Complex reconstruction following traumatic forequarter amputation

Interscapulothoracic amputation is a radical and morbid procedure used for the management of upper extremity trauma and more commonly for resection of solid tumors. Traumatic forequarter amputation poses a unique challenge for achieving adequate tissue coverage depending on the condition of the muscle and soft tissue of the ipsilateral extremity. We present a case of a 38-year-old construction worker who suffered an almost complete forequarter amputation of his right upper extremity secondary to blunt force trauma from a crane pulley that fell from 60 ft. This is a unique mechanism of injury, as most traumatic forequarter amputations occur as a result of traction injury. Details of the case report including the unique challenges, techniques for tissue salvage, fillet flaps, and chest wall reconstruction are presented.

Borderlajn tumor jajnika

Borderline ovarian tumors are most commonly serous or mucinous and account for 1 to 15% of all epithelial tumors. These tumors are characterized by low malignant potential and are most often diagnosed when they reach a significant size, causing abdominal pain or distension of the abdomen. The gold standard in the diagnosis of ovarian tumors is a pathohistological finding obtained by the examination of tumor tissue that has been surgically removed. Female patient 73 years old, reported to the Emergency Medicine Clinic of the General Hospital in Ćuprija, with severe abdominal pain, enlargement of the abdomen, constipation longer than 7 days and urinary incontinence, with the following diagnosis: Dolor abdominalis inferior, referred to Department of Gynecology. One week before her admission, because of suspicion of a bladder tumor, she was hospitalized at the urology department. A gynecological examination revealed that the abdominal wall was above the chest wall, and the tumor filled the small pelvis - a palpable mass of tumor above the navel. Additional diagnostic procedures confirmed the presence of tumors and subsequently underwent surgery. Surgery is a therapy for the treatment of ovarian tumors, and the form of surgical approach depends on the stage of the disease, the age of woman, the general condition, and the desire to preserve fertility. In the treatment of the patient whose case was presented, a radical surgical procedure was applied.

Neoadjuvant imatinib therapy in rectal gastrointestinal stromal tumors.

Rectal gastrointestinal stromal tumor (GIST) is a rare entity. Thus, its clinical features have not been well documented, and optimal treatment strategies have not been established. Surgery for rectal GISTs may be difficult because they are often large in size. In addition, rectal GISTs were found to be associated with high rates of local recurrence, regardless of the surgical procedure, before imatinib was introduced in the early 2000s. Since the introduction of imatinib therapy, accumulating evidence suggests that neoadjuvant imatinib therapy may improve the outcomes of rectal GIST treatment. Neoadjuvant imatinib therapy for rectal GISTs offers a number of potential benefits, including tumor downsizing, reduction in mitotic activity, reduced morbidity, and a reduced risk of recurrence. Less radical procedures may allow for the preservation of the anal sphincter and avoidance of a permanent colostomy. This review summarizes the current status and future perspectives of neoadjuvant imatinib therapy for the treatment of rectal GISTs.

Clinicopathologic Features and Risk Factors for Recurrence of Mucinous Borderline Ovarian Tumors: A Retrospective Study With Follow-up of More Than 10 Years.

This study aimed to evaluate the clinicopathologic features of mucinous borderline ovarian tumors (MBOTs), with an emphasis on the risk factors for recurrence. Data of 76 patients with MBOT diagnosed and treated between 2000 and 2007 at a single institution were analyzed in this retrospective study. The clinicopathologic features of different tumor subgroups were analyzed, including pathology, surgical methodology, recurrence, and overall survival. The median patient age was 40 years (13-85 years). Forty-six patients with gastrointestinal mucinous borderline tumors (intestinal MBOTs) (73.7%) and 20 patients with endocervical MBOT (26.3%) were identified. Forty radical surgeries and 26 conservative surgeries were performed. There were 74.6% patients (50/67) with stage I disease among the 67 patients who received comprehensive surgical staging.During a median follow-up time of 151 months, 9 recurrences were identified. Median duration from surgery to recurrence was 26.4 months (range, 13-50 months). There was no difference in recurrence rate between intestinal MBOT and endocervical MBOT (14.3% vs 5.0%; P > 0.05). The recurrence rate of stage III tumors was significantly higher than that of stage I (33.3% vs 8%; P < 0.05). The recurrence rate after conservative surgery was higher than that after radical procedures (21.4% vs 6.3%; P < 0.05). The majority of patients with MBOT had a favorable prognosis. Patients with later-stage disease had a higher recurrence rate.

ASO Author Reflections: Abandoning the Drains by Eliminating the Radical Procedures Necessitating the Drains.

ASO Author Reflections: Abandoning the Drains by Eliminating the Radical Procedures Necessitating the Drains.

Copper-Catalyzed Unstrained C-C Single Bond Cleavage of Acyclic Oxime Acetates Using Air: An Internal Oxidant-Triggered Strategy toward Nitriles and Ketones.

A copper-catalyzed aerobic oxidative C-C single bond cleavage of acyclic unstrained oxime acetates is reported, providing various aryl nitriles and ketones in good yields. Mechanistic studies indicate a radical procedure is involved in this transformation, and the oxygen atom in the ketone products is originated from O2 in the air. Oxime acetates as an internal oxidant have been proved to be an initiator, which may promote the discovery of novel protocol for C-C bond cleavage and dioxygen activation.

Simple vaginal trachelectomy for early stage cervical cancer: A tertiary cancer center experience.

Less radical fertility sparing procedures have been introduced to reduce morbidity and adverse obstetric outcome in cervical cancer. Our objective was to describe oncological and obstetric outcomes of women with early-stage cervical cancer who underwent a simple vaginal trachelectomy (SVT). From 01/2013 to 05/2017, 14 women underwent SVT preceded by laparoscopic pelvic lymph node dissection. Patients' median age was 32 years and all of them were nulliparous. Histology included squamous cell carcinoma and adenocarcinoma in 12 (85.7%) and 2 (14.3%) patients, respectively. Three patients had stage 1A1 with lymphovascular space invasion, 4 1A2 and 7 1B1. After obtaining final histopathology, one patient underwent radical hysterectomy due to positive surgical margin and excluded from analysis. None of the patients had lymph node metastasis. None of the 13 patients developed a recurrence within a median follow-up of 27 (6-56) months. Seven patients have conceived: 4 were term deliveries, 2 were late preterm deliveries and 1 was spontaneous abortion. SVT in well selected early-stage cervical cancer patients seems to be a safe treatment option with excellent oncologic outcome, preserving reproductive function. Literature data will need to be confirmed in large prospective series.

Management of cystobiliary communication in hepatic hydatidosis

Aim: Communication to the bile duct is the most common complication of hepatic echinococcosis.As non surgical treatment options have no primary role in the management of hepatic hydatidosis with cysto biliary communication, optimization of the surgical approach is imperative. Materials and methods: Medical records of 22 patients who underwent surgical management of Hydatid cyst of liver with cystobiliarycommunication analysed retrospectively.Study Period - between January 2013 and October 2016.All patients were followed up for a period of atleast 2 months to 36 months. Readmission and recurrences were evaluated Results: Cystobiliary communication could be identified pre operatively in 9 out of the 22 patients whereas in the rest it was made intraoperatively.Cyst evacuation with omentoplasty and partial pericystectomy were considered as conservative surgeries whereas total cystopericystectomy and right or left hemi hepatectomies were considered as radical procedures. 2 patients who were offered conservative surgical treatment underwent post op ERCP.CBD exploration and T tube placement was necessitated in 7 patients. Conclusion: Treatment options are multiple. While conservative approaches carried a small but significantly high incidence of recurrence, radical surgery has its own disadvantages in terms of prolonged operating time, higher blood loss and in its need for a HPB surgeon. The need for CBD exploration and T tube drainage was comparable in both approaches. Larger studies are needed to formulate a protocol.

Emphasis on individualized approach in symptomatic annular pancreas

Introduction: Annular pancreas is a rare congenital anamoly,diagnosed frequently in present era due to improved imaging.Various surgical procedures have been described due to variable presentations in adults.Hence we report another such rare presentation and treatment to underline the importance of tailored approach. Methods and results: We report a case of 30 yr old male patient who presented with complaints of recurrent pain abdomen since 10 years. He was evaluated and diagnosed to have annular pancreas with chronic pancreatitis. We performed lateral pancreatic jejunostomy and gastrojejunostomy. Post operative course was uneventful and remained symptomfree for 2 years on follow up. Conclusion: Here we adopted a less radical procedure for a benign disease in form of lateral pancreatic jejunostomy with minimal morbidity. Due to different surgical options available for adult annular pancreas, we advocate a tailored individualised approach.

Radical Mastectomy Increases Psychological Distress in Young Breast Cancer Patients: Results of A Cross-sectional Study

IntroductionThe present study aimed to detect the factors associated with psychological distress (PD) in young Moroccan patients with breast cancer, with a special focus on the type of surgical procedure. Patients and MethodsWe collected social, demographic, and clinical data from female patients, aged < 45 years, with localized stage breast cancer who had undergone either radical mastectomy or conservative surgery and for whom adjuvant chemotherapy was indicated. We used the Hospital Anxiety and Depression Scale (HADS) to assess the psychological status. The relationship between the variables and PD was analyzed using simple and multiple logistic regression analyses. ResultsA total of 122 women were enrolled, of whom 41 (33.6%) had a HADS global score ≥ 15. The HAD anxiety and depression subscores were ≥ 11 for 10 (8.2%) and 8 (6.6%) patients, respectively. On multivariate analysis, adjusted for marital status and receipt of analgesic and/or anxiolytic treatment, we found that radical mastectomy (odds ratio [OR], 5.747; 95% confidence interval [CI], 1.342-24.608), living in a difficult emotional (OR, 7.366; 95% CI, 1.727-31.41) and/or financial (OR, 16.521; 95% CI, 3.574-76.36) situation, and a lack of social and/or family support (OR, 19.617; 95% CI, 3.549-108.43) were independent factors associated with PD. ConclusionBreast-conserving surgery should be performed whenever possible for young women to avoid the psychological repercussions of radical procedures.

Infertility after abdominal trachelectomy.

Despite numerous reports on pregnancy outcomes after trachelectomy, there are few descriptions of fertility treatment after trachelectomy. Moreover, little is known about the differences in fertility outcomes between various radical trachelectomy procedures. The purpose of this report was to clarify the infertility problems that occur in patients who have previously undergone an abdominal trachelectomy. We retrospectively investigated the medical records of 37 patients who received fertility treatments or were evaluated for menstrual disorders after trachelectomies in our institution between 2012 and 2016. Twenty-two of 37 patients had complications which affected fecundity. Six patients had cervical stenosis requiring surgical dilation, 4 had ovarian insufficiency, and 14 had Asherman's syndrome. In spite of efforts to preserve fertility, some patients have severe complications after trachelectomy, such as Asherman's syndrome, resulting in infertility. Clinicians should pay careful attention to the status of the endometrial cavity after trachelectomy.

The Use of Biomarkers in Early Diagnostics of Pancreatic Cancer.

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal solid malignancies with increasing incidence. The poor prognosis is due to the aggressive nature of the tumor, late detection, and the resistance to chemotherapy and radiotherapy. A radical surgery procedure is the only treatment that has been shown to improve the 5-year survival rate to 20-25%. However, the majority of patients (80-85%) are diagnosed with locally advanced or metastatic disease and just 15-20% patients are diagnosed in an early stage allowing them to undergo the potentially curative surgical resection. The early detection of PDAC without the use of invasive methods is challenging and discovery of a cost-effective biomarker with high specificity and sensitivity could significantly improve the treatment and survival in these patients. In this review, we summarize current and newly examined biomarkers in early PDAC detection.