Surgical Recurrence Rates Research Articles

Surgically Corrected Urethral Diverticula: Long-term Voiding Dysfunction and Reoperation Rates

To present the largest reported cohort of women with urethral diverticula and to evaluate the surgical outcomes and long-term voiding symptoms after urethral diverticulectomy. Studies evaluating the outcomes after urethral diverticulectomy have been limited by small patient numbers and short-term follow-up. Women who had undergone diverticulectomy at our institution from 1996 to 2008 were mailed surveys. Urinary bother was assessed using the Urogenital Distress Inventory 6-item questionnaire, and patients were asked to report subsequent urethral or vaginal surgery and the number of urinary tract infections within the previous year. To determine the rate of surgical recurrence, the charts of women not responding to the survey were reviewed. A total of 122 women were identified as having undergone urethral diverticulectomy during the study period. Of these, 13 (10.7%) had an eventual recurrence that required repeat surgical excision. Patients with a proximal diverticulum, multiple diverticula, or previous pelvic or vaginal surgery (excluding previous diverticulectomy) were more likely to develop recurrence (P = .01, P = .03, and P < .001, respectively). For the 61 women (50%) responding to our survey, the mean follow-up was 50.4 months. Of these 61 women, 24 (39.3%) had had a urinary tract infection within the previous year, with 14 (23%) women having had ≥3 within the previous year. Also, 16 (26.2%) had persistent pain or discomfort with urination. The mean ± SD total Urogenital Distress Inventory-6 score was 31.1 ± 25.5 for the survey responders. To our knowledge, our study represents the largest study with the longest follow-up after urethral diverticulectomy. Patients with proximal or multiple diverticula and those with previous pelvic surgery should be counseled appropriately regarding the risks of recurrence and persistent voiding dysfunction.

Treatment of the anastomotic complications in patients with Crohn's disease

Postoperative anastomotic complications in patients with Crohn's disease undergoing bowel resections have a detrimental influence on the long-term outcome. The aim of this study was to evaluate whether patients' prognosis is affected by various treatment strategies of anastomotic complications. The term anastomosis-related "intraabdominal septic complication" (IASC) was used for anastomotic leaks, intraabdominal abscesses, anastomotic fistula, peritonitis. Only patients with these complications have been included in the study. Outcome parameters were "surgical recurrence" (i.e., need for repeat bowel resections) and "good surgical outcome" (i.e., no death, no surgical recurrence, no stoma, no enterocutaneous fistula). Patients in group 1 were treated by taking the affected anastomosis down and creating an end stoma. The anastomosis has been preserved in patients of group 2. Between 1992 and Aug 2009, IASC occurred after 56 ileocolic resections for ileal disease and after 26 resections for Crohn's colitis. In patients with ileal disease, 5-year surgical recurrence rate was lower (0% vs. 65%, p = 0.0020) and a good surgical outcome was achieved more frequently at 2 years (100% vs. 25%, p = 0.0001) in group 1 than in group 2. There was no significant difference of long-term outcome between groups in patients with Crohn's colitis. In patients suffering anastomotic complications after ileocolic resection for ileal Crohn's disease, the prognosis can be significantly improved by taking down the anastomosis and creating an end ileostomy. Anastomosis can be preserved without an outcome impairment in many patients with Crohn's colitis.

Comparison of strictureplasty and endoscopic balloon dilatation for stricturing Crohn’s disease—review of the literature

Stricturing Crohn's disease is accompanied by a high-risk for bowel resection and subsequent short bowel syndrome. Strictureplasty (SP) and endoscopic balloon dilatation (EBD) have been developed to prevent, or at least delay, the requirement for resection. The goal of this study was to compare the outcome of these two procedures with regard to complications and disease recurrence. We conducted a MEDLINE literature search to give a current overview about the safety and efficacy of EBD and SP. The initial search yielded 744 articles. Case reports, reviews and meta-analyses were excluded. Finally, 63 articles (SP, 40 articles; EBD, 23 articles) were used for the review. None of the studies compared the two methods directly. A total of 2,532 patients (SP, n = 1,958; EBD, n = 574) were included. The incidence of perioperative complications after SP was 11% and the incidence of major complications was 5%. The median surgical recurrence rate was 24% after a median follow-up of 46 months. The median technical success for EBD was 90%. Major complications occurred in 3% of the cases. According to an intention-to-treat protocol, the median surgical recurrence rate was 27.6%. Per-protocol analysis revealed a median surgical recurrence rate of 21.4% after a median follow-up of 21 months. Due to the lack of comparable data, there is currently no reliable information on whether one treatment option is superior to the other. Regarding the limited applicability of EBD in strictures of the small bowel, only a controlled trial would provide evidence as a basis for clinical decision making in CD strictures that are potentially treatable by EBD and SP.

Video-assisted versus open ileocolic resection in primary Crohn’s disease: a comparative case-matched study

Despite the technical difficulties, laparoscopic ileocolic resection for Crohn's disease (CD) has become widely accepted in recent years, due to its potential benefits. There are numerous reports concerning the use of laparoscopy in successfully treating CD, including two randomized trials and few comparative studies. For the most part, these reports outline use of laparoscopic approach in primary distal ileal or ileocolic disease, with a careful selection of the patients. The purpose of this comparative case-control study was to point out potential advantages and disadvantages in short- and long-term outcomes of the laparoscopic approach compared with the open one. From January 1999 to January 2004, 200 patients were admitted in our Surgical Unit for complicated primary CD. 100 patients (group 1) underwent a laparoscopic ileocolic resection, 100 patients (group 2), with alike demographic and clinical characteristics, underwent the same procedure using a traditional approach. The incidence of perforative disease was 32 and 40% in groups 1 and 2, respectively. Average operative time was 140min (range 90-245min) in the video-assisted group and 98min (range 65-255min) in group 2 (P<0.05). Postoperative morbidity was 6 and 8% in groups 1 and 2, respectively (P=NS). Recovery of peristalsis occurred within 2-3days in group 1 and 3-4days in group 2 (P=NS). Median postoperative hospitalization was 7days (range 5-18days) in group 1 and 9days (range 7-22days) in control group (P<0.05). The overall rate of surgical relapse of CD was 8 and 13% in groups 1 and 2, respectively (P=NS), at a mean follow-up of 52 and 60months, respectively. The 1-year surgical recurrence rate was similar (3%) for the two groups. In conclusions, in spite of the technical difficulties, video-assisted surgery for CD offers advantages over laparotomy, including less postoperative pain, reduced postoperative hospital stay, less disability of the patient, and better cosmetic results. Potential advantages are: easier approach for re-resection, lower rate of postoperative adhesions and bowel obstruction, and lower rate of wound complications.

Results and risk factors for recurrence following single-level tubular lumbar microdiscectomy

The use of minimally invasive surgical techniques, including microscope-assisted tubular lumbar microdiscectomy (tLMD), has gained increasing popularity in treating lumbar disc herniations (LDHs). This particular procedure has been shown to be both cost-efficient and effective, resulting in outcomes comparable to those of open surgical procedures. Lumbar disc herniation recurrence necessitating reoperation, however, remains an issue following spinal surgery, with an overall reported incidence of approximately 3-13%. The authors' aim in the present study was to report their experience using tLMD for single-level LDH, hoping to provide further insight into the rate of surgical recurrence and to identify potential risk factors leading to this complication. The authors retrospectively reviewed the cases of 217 patients who underwent tLMD for single-level LDH performed identically by 2 surgeons (J.B., R.H.) between 2004 and 2008. Evaluation for LDH recurrence included detailed medical chart review and telephone interview. Recurrent LDH was defined as the return of preoperative signs and symptoms after an interval of postoperative resolution, in conjunction with radiographic demonstration of ipsilateral disc herniation at the same level and pathological confirmation of disc material. A cohort of patients without recurrence was used for comparison to identify possible risk factors for recurrent LDH. Of the 147 patients for whom the authors were able to definitively assess symptomatic recurrence status, 14 patients (9.5%) experienced LDH recurrence following single-level tLMD. The most common level involved was L5-S1 (42.9%) and the mean length of time to recurrence was 12 weeks (range 1.5-52 weeks). Sixty-four percent of the patients were male. In a comparison with patients without recurrence, the authors found that relatively lower body mass index was significantly associated with recurrence (p = 0.005), such that LDH in nonobese patients was more likely to recur. Recurrence rates following tLMD for LDH compare favorably with those in patients who have undergone open discectomy, lending further support for its effectiveness in treating single-level LDH. Nonobese patients with a relatively lower body mass index, in particular, appear to be at greater risk for recurrence.

Recurrence Rate in Vulvar Carcinoma in Relation to Pathological Margin Distance

This paper describes the results of a retrospective study of surgical approaches and recurrence rates relating to patients with squamous cell carcinoma (SCC) of the vulva. The aim of this study was to analyze the histological margins in relation to recurrence rate and survival. A retrospective chart review of 93 cases of vulvar cancer. The data collected included clinicopathological and surgical characteristics and the following potential risk factors: pathological margin distance, less than 8 mm; stromal invasion depth, more than 2.5 mm; tumor size; and presence of benign or premalignant epithelial disorders. Ninety-three patients (median age, 74 years) underwent modified radical vulvectomy, hemi-vulvectomy, or local wide excision for SCC of the vulva from 2000 to 2005. The tumor was radically removed in 80 patients (86%), although the histopathological margin was less than 8 mm in 50 patients (54%). Eighteen patients (23%) developed a local recurrence. The recurrence rate did not differ between patients in whom the margin distance was 8 mm or more and those in whom the margin distance was less than 8 mm, (23% and 22%, respectively). The median follow-up was 31 months (range, 2-90 months). Several studies showed that pathological margin distance of more than 8 mm is an important predictor for local recurrence. This finding was not confirmed in the present study.

Multicenter prospective randomized trial comparing modified Limberg flap transposition and Karydakis flap reconstruction in patients with sacrococcygeal pilonidal disease

Background There is still no consensus as to the optimal treatment for sacrococcygeal pilonidal disease (SPD). Many recommend off-midline closure, if any excisional procedure is to be selected. Methods The authors prospectively studied 145 patients with SPD who presented at 3 hospitals. Patients were randomly assigned to undergo either modified Limberg flap (MLF) transposition (n = 72) or Karydakis flap reconstruction (n = 73). Surgical findings, complications, recurrence rates, and degree of patient satisfaction, evaluated via a standardized telephone interview, were compared. Results Operation time was longer in the MLF group. There were no significant differences between the two groups in terms of complication rate, length of stay, or recurrence rate. Patients in the Karydakis group reported feeling completely healed more quickly postoperatively. The two groups reported similar rates of satisfaction. Mandatory patient withdrawal from a given study arm because of the orifice straying from the midline occurred more frequently in the Karydakis group. Conclusions The MLF technique and the Karydakis procedure appear to generate comparable outcomes. With laterally situated orifices, however, the applicability of the Karydakis method may be limited.

Efficacy of lamellar resection, cryotherapy, and adjunctive grafting for the treatment of canine limbal melanoma

To evaluate the efficacy and complication rate of partial lamellar resection followed by cryotherapy for the management of canine limbal melanoma. Fourteen dogs with unilateral canine limbal melanoma which were managed surgically by partial lamellar resection, cryotherapy (1,1,1,2-tetrafluoroethane) and an adjunctive graft procedure. The clinical records of dogs treated between June 1998 and June 2008 were reviewed. The signalment, approximate size and location of the melanoma, variation in surgical technique, recurrence rate, short-term (< three months) and long-term (> three months) complications were assessed. Follow-up information was collected by patient re-examination or telephone interview. The mean age at diagnosis was 6.3 years, with a range from 3.2 to 12 years. Seven breeds were affected, including five cross-breed dogs and four Golden Retrievers. The tumour involved the dorsal arc (from the dorsomedial to the ventrolateral quadrant) in 12 eyes and the ventral arc in two eyes. The size of the tumour ranged from 30 to 180 degrees of the limbal circumference. A double freeze-thaw cycle of cryotherapy was performed in 7/14 eyes and a triple freeze-thaw cycle in 7/14 eyes. An adjunctive conjunctival graft was performed in 13/14 eyes (free graft n = 3, posterior nictitans conjunctiva/cartilage n = 4, advancement graft n = 5, small intestinal submucosa/advancement graft n = 1) and a frozen homologous graft in 1/14 eyes. The duration of follow-up ranged from 6 months to 8.5 years with a median of 2.1 years. Recurrence was not clinically detected in any of the 14 eyes. Early complications occurred in 8/14 eyes and included anterior uveitis (7/14), corneal ulceration (5/14), marked corneal granulation tissue at the graft margin (2/14), dyscoria (2/14), corneal lipidosis (1/14) and corneal oedema (1/14). Intra-operative globe perforation had occurred in 5/7 eyes with anterior uveitis and 2/2 eyes with transient dyscoria. Late complications occurred in 3/14 eyes and included corneal lipidosis which was either mild (< 2mm in diameter, 1/14) or marked (>1cm in diameter, 2/14). Marked lipidosis only occurred following the treatment of extensive limbal melanomas which involved approximately 50% of the limbal circumference. Surgical management comprising partial lamellar resection, cryotherapy and adjunctive graft placement is technically straightforward, minimally invasive, well tolerated and highly effective. Marked corneal lipidosis is most likely to occur as a post-operative complication when the limbal melanoma is extensive.

Comparison of fibrin glue with sutures for pterygium excision surgery with conjunctival autografts

To compare pterygium excision conjunctival autograft surgery using Tisseel fibrin glue versus Vicryl sutures. Prospective randomized clinical trial. Fifty patients were randomized into either sutured graft or glued graft groups. Twenty-five received standard conjunctival autograft sutured with Vicryl and 25 received surgery with the autograft placed with Tisseel fibrin glue. Outcome measures include surgical time, patient discomfort, pathology, complications and recurrence rates at 3, 6 and 12 months. Patients were followed up at days 1, 7, 14, 30, 90, 180 and 365. The mean surgical time for the glue group was significantly shorter at 12 min compared with the suture group at 26 min (P < 0.001). Postoperative pain was significantly less at day 1 (P < 0.001) and day 2 (P < 0.05) but was not significantly different following these visits. Complications in the glue group included one patient with an absent graft at week 1 that required revision of the graft. At 3 months there were no recurrences in the glue group and two recurrences in the suture group. The 6- and 12-month recurrence rate was unchanged and not significantly different between the glue and suture groups (both 0/24 and 2/23, respectively). Both glued and sutured conjunctival autografting procedures are safe and effective methods for pterygium surgery. The glued autograft recurrence rate at 12 months was similar to that of sutured grafts. Conjunctival autograft with fibrin glue in pterygium surgery decreased surgical time and resulted in less postoperative pain in the first 48 hours but had a higher complication rate.

CARD15 Gene Variants and Risk of Reoperation in Crohn's Disease Patients

Several studies have investigated, with conflicting results, the risk factors for reoperation in Crohn's disease (CD) patients. CARD15 gene variants have been identified as a major genetic risk factor for CD patients and associated with ileal disease, stenosis, and risk of surgery. However, data regarding the association between these variants and the need for reoperation are very few and conflicting. This study evaluated the risk factors of reoperation, including CARD15 gene variants. A total of 253 consecutive CD patients, recruited in four Italian tertiary-care inflammatory bowel disease (IBD) referral centers, who had submitted to surgery for CD, were included in the study. Clinical characteristics of CD patients, time and main indications for surgery, type of operation, postoperative therapy, and time to second surgery were recorded. CARD15 gene variants were determined by DNA sequencing analysis in each center. Factors related to surgical recurrence, including CARD15 variants, were estimated by Cox proportional hazard regression. In all, 89 patients (35.1%) showed at least one surgical recurrence. Reoperation was significantly correlated with stenosis as indications at initial surgery only. CARD15 variants were found in 36.0% of patients, but did not correlate significantly with the demographic and clinical characteristics of the patients, rate of first surgical recurrence, and time to second operation. CARD15 variants did not significantly affect the reoperation rate, irrespective of indications for surgery. Reoperation for CD is correlated with stenosis at initial surgery, but not with CARD15 gene variants. This finding does not justify more aggressive prophylactic therapy on the basis of CARD15 genotype.

Comparison of Karydakis flap reconstruction versus primary midline closure in sacrococcygeal pilonidal disease: Results of 200 military service members

There is a high incidence of sacrococcygeal pilonidal disease (SPD) among young males. Despite increasing data on the treatment of SPD, no standard treatment has yet been established. The goal of this study was to compare the Karydakis flap reconstruction with a primary midline closure (PMC) in the treatment of patients with SPD. The study included 200 patients treated over a period of 30 months. After a power analysis, the study was run on a two-directional basis (both retrospective reviews of patient charts and a telephone interview for prospective evaluation). The surgical findings, complications, recurrence rates, and degree of satisfaction based on a questionnaire were assessed. The duration of the surgery was longer in the Karydakis group. Complications were more frequently seen in the PMC group. The recurrence rate was 4.6% for the Karydakis group and 18.4% for the PMC group. Of patients who underwent the Karydakis operation, 70.8% were completely satisfied with the procedure, while only 32.6% of patients who underwent the PMC reported excellent satisfaction. A significantly higher number of patients in the Karydakis group recommended the same procedure to other patients with SPD. The Karydakis method may be a preferable option in the treatment of SPD, due to the low rate of recurrence and the promising satisfaction rates.

Construction of an ileocolic neosphincter — Nipple valve anastomosis for prevention of postoperative recurrence of Crohn's disease in the neoterminal ileum after ileocecal or ileocolic resection.: A long-term follow-up study

Objective To test the effect of an ileocolic neosphincter–nipple valve anastomosis after ileocolic resection for Crohn's disease, on the clinical and surgical recurrence-free survival, in a long-term follow-up pilot study. Background and aims Fifty-nine patients, with Crohn's disease were operated on with an ileocecal or ileocolic resection and a nipple valve between 1993 and 2007. Methods The nipple valve is constructed by everting the neoterminal ileum for a length of 4–5 cm and stabilized with 3 or 4 longitudinal stapler rows ( N = 36) or only in a basal zone ( N = 23). The nipple is telescoped with the tip pointed into the colon and the base of the nipple anastomosed to colon. Follow-up at regular intervals included clinical evaluation, Harvey–Bradshaw index, laboratory tests, colonoscopy and small bowel radiology when appropriate. Results The perioperative mortality was nil. Early postoperative complications were: wound infection ( N = 4), anastomotic leak ( N = 1), reoperated, nipple ischemia ( N = 1) reoperated, enterocutaneous fistula ( N = 1). Clinical recurrence in the neoterminal ileum was after 1, 3, 4 and 5 years: 11%, 20%, 23% and 24%. Eleven patients (19%) were reoperated for recurrence in the neoterminal ileum after median 96 months follow-up. The cumulative reoperation rate was after 1, 3, 4 and 5 years: 4%, 13%, 13% and 16%, respectively. Conclusion The low clinical and surgical recurrence rate in the neoterminal ileum may suggest a protective effect of the neosphincter on postoperative recurrence of Crohn's disease. This result should be tested in a randomized controlled trial.

Clinical and surgical recurrence of Crohnʼs disease after ileocolonic resection in a specialist unit

Postoperative clinical and endoscopic recurrence is common in Crohn's disease. We aimed to assess postoperative recurrence and management in a cross-sectional patient cohort in one specialist unit, before the introduction of a uniform postoperative preventive strategy. Review of patients who had an ileocolonic resection for Crohn's disease between 2002 and 2005 in a secondary and tertiary care specialist centre. Ninety-nine patients (42 male; 57 female; mean age, 37 years) with a median disease duration of 10 years, were reviewed. Indications for surgery were obstruction (n=61), failed medical therapy (n=31) and internal fistula(e) (n=7). Thirty patients (30%) were active smokers at the time of resection. Fifty patients (51%) had at least one previous Crohn's resection. Clinical and surgical recurrence rates were 28 and 5%, respectively, at 1 year. All five patients had the same indication for their further surgery as for their index operation (four fistulizing or stricturing). Median time to clinical recurrence was 10 months in those with recurrence. Nineteen percent of patients had an ileocolonoscopy at a median of 6 months after surgery, and 60% had been reviewed by a gastroenterologist, after surgery. Clinical recurrence occurred in nine of 28 (32%) without and 19 of 71 with (26%) postoperative medical therapy (P=NS). Postoperative recurrence of Crohn's disease was high in the short term. The indication for repeat surgery stayed true within patients. Prospective treatment strategies, based on recent trial evidence, are needed to diminish postoperative recurrence.

Efficacy of preoperative gonadotropin‐releasing hormone agonist therapy for laparoscopic myomectomy

AbstractObjective: In this article, we evaluate efficacy of preoperative gonadotropin‐releasing hormone agonist (GnRHa) therapy prior to laparoscopic myomectomy (LM).Materials and Methods: There were 161 subjects who underwent LM between 1995 and 2007. They were divided into two groups: group A (58 cases), who underwent four to six cycles of preoperative GnRHa therapy, and group B (103 cases), the untreated group. To determine the efficacy of preoperative GnRHa therapy, the recurrence rate after LM was evaluated by comparing the number of myoma confirmed on the preoperative MRI and the number actually enucleated. For this purpose, the cases were divided into the matched group (group I) and the discrepancy group (group II) whose enucleated number was smaller than the estimated number.Results: No statistically significant difference was observed between groups A and B in the surgical performance. The 4 year cumulative recurrence rate was estimated to be 27.3% for group A and 25.8% for group B without any significant difference. In group A, the postoperative recurrence rate was statistically significantly higher in group II (44.4%) than in group I (12.1%). While in group I, it was 12.1% in group A and 14.3% in group B without a statistically significant difference.Discussion: Preoperative GnRHa therapy did not compromise surgical outcome or recurrence rate, rather it acted as an effective pretreatment for LM in terms of expanding its indications. Also, completing surgery by enucleating all the myomas without any left in situ, as confirmed by the precise preoperative myoma status on the MRI, contributes to a reduction in the postoperative recurrence rate.

Percutaneous Curettage and Bone Grafting for Humeral Simple Bone Cysts

Traditional treatments for simple bone cysts are associated with significant surgical morbidity and high recurrence rates. The purpose of this study was to evaluate the effectiveness of a percutaneous approach to the treatment of proximal humeral simple bone cysts that includes percutaneous decompression, curettage, and injection of allogeneic cancellous bone combined with autologous bone marrow. Twenty-one children (average age, 10.1+/-4.6 years) with symptomatic simple bone cysts of the proximal humerus were surgically treated with percutaneous cyst decompression, curettage, and cancellous allograft combined with autologous bone marrow. Patients were observed in-clinic with serial examinations and radiographs. Fracture healing and cyst recurrence were determined at follow-up. All patients returned to activities of daily living with full range of motion and were completely asymptomatic. All fractures healed. There were no surgical complications or refractures. Five patients demonstrated radiographic evidence of partial cyst recurrence and required additional surgical treatment. One patient required a third operative procedure for a second recurrence. Three of 8 active cysts demonstrated partial recurrence. Recurrence was associated with younger age. Our goal in the treatment of proximal humeral simple bone cysts is to prevent cyst recurrence and pathologic refracture. Radiographic evidence of cyst resolution occurred in 75% of our patients using percutaneous curettage and bone grafting, and in 95% of patients with a second procedure. As expected, partial recurrence of active cysts after treatment with this method is high. This percutaneous technique is a safe and effective treatment for humeral simple bone cysts.

14 - Clinical course and cost of care in ulcerative colitis: Markov chain analysis of a European prospective population-based cohort

14 - Clinical course and cost of care in ulcerative colitis: Markov chain analysis of a European prospective population-based cohort

Nasal vestibular stenosis after birth trauma during caesarean section

Introduction: Iatrogenic trauma includes injury due to intubation, trauma during nasal examination, management of epistaxis or surgery of nose. As the maternal and child care is improving, the iatrogenic trauma during child birth is becoming very rare. We present a unique case that had nasal vestibular stenosis due to injury during caesarian section. As the treatment of vestibular stenosis is difficult, we reviewed the literature for the management of vestibular stenosis and present our surgical technique for managing this particular case. Patient and surgical method: A two and half year male child was brought to our department with complaint of left nostril obstruction since birth. The child had received multiple cut injuries on the face at the time of lower segment caesarian section of the mother at a peripheral hospital. This deformity was corrected by surgery and nasal stent. Discussion: We searched ‘Pubmed’ and ‘Scopus’ with no keywords limit and found only one case of iatrogenic nasal deformity due to birth trauma in English literature. The surgical correction of vestibular stenosis is very difficult due to small surgical field and high recurrence rate. There are number of techniques described in the literature for correction of vestibular stenosis. We reviewed them and compared our experience in managing this deformity. Conclusion: The very initial management in terms of proper suturing of flaps and nasal stents or referral to a specialist following nasal trauma can avoid this type of deformity. We concluded that the management of vestibular stenosis is very difficult and the result of surgery is influenced by not only the surgical technique but also by cooperation of the patient and family members.

Comparison of Conventional Excision via a Sublabial Approach and Transnasal Marsupialization for the Treatment of Nasolabial Cysts: A Prospective Randomized Study

ObjectivesSurgical excision via a sublabial approach is considered the standard treatment for nasolabial cysts. Although transnasal marsupialization has been proposed as an alternative method, no prospective study has compared the effectiveness of these techniques. We thus compared the surgical procedure, operating time, postoperative pain, complications, and recurrence rate between the two surgical methods.MethodsTwenty patients diagnosed with nasolabial cysts were allocated randomly into two groups according to the surgical technique. In the sublabial approach group, the cysts were excised completely using a sublabial approach, while in the transnasal marsupialization group, the cysts were marsupialized transnasally under the guidance of nasal endoscopes. The pure operating time was measured and postoperative pain was evaluated using a visual analog scale. Complications after the procedure were assessed and recurrence was determined according to the clinical symptoms and postoperative radiologic findings.ResultsThe transnasal marsupialization group had significantly shorter operating times, less postoperative pain, lower complication rates, and shorter duration of side effects than the sublabial approach group. No recurrence occurred in either group after a 1-yr follow-up period.ConclusionAlthough both methods are effective for treating nasolabial cysts, the transnasal marsupialization of nasolabial cysts has many benefits over the conventional sublabial approach. Therefore, we propose that transnasal marsupialization be the treatment of choice for nasolabial cysts.

Allergic fungal sinusitis: pathophysiology, diagnosis and management

Allergic fungal sinusitis (AFS) is a noninvasive form of fungal rhinosinusitis with an incidence of between 6 and 9% of all rhinosinusitis requiring surgery. Regional variation in incidence has been reported, with the southern and southwestern US particularly endemic. Patients with AFS commonly present with chronic rhinosinusitis with nasal polyps, inhalant atopy, elevated total serum immunoglobulin E (IgE), and sinus-obstructing inspissates of a characteristic extramucosal 'peanut buttery' visco-elastic eosinophil-rich material called 'allergic mucin' that contains sparse numbers of fungal hyphae. Sinus CT is always abnormal, showing findings of chronic rhinosinusitis that often include central areas of increased contrast ('hyperattenuation') within abnormal paranasal sinuses that represent the presence of fungal-containing allergic mucin. AFS has been found to be analogous in several ways to allergic bronchopulmonary aspergillosis (ABPA). Both are chronic inflammatory respiratory tract disorders that are driven by hypersensitivity responses to the presence of small numbers of extramucosal fungi found growing within airway-impacting allergic mucin. AFS allergic mucin typically cultures positive for either dematiaceous fungi such as Bipolaris spicifera or Curvularia lunata, or Aspergillus species such as A. fumigatus, A. flavus or A. niger. As with ABPA, patients have type I immediate hypersensitivity to the etiologic mold in AFS. Further, both AFS and ABPA have been found to have association with specific class II major histocompatibility alleles. Proper diagnosis of AFS and differentiation from the other forms of both noninvasive and invasive fungal rhinosinusitis requires strict adherence to published diagnostic criteria. Medical treatment of AFS has been modeled to an extent after treatment approaches for ABPA that includes the use of postoperative oral corticosteroids and aggressive antiallergic inflammation therapy. The use of follow-up measurements of total serum IgE during treatment of both AFS and ABPA patients can help to monitor disease activity. Future AFS research will lead to further insights into pathogenesis, improved treatments, and ultimately decreases in surgical recurrence rates for this highly recurrent hypertrophic rhinosinusitis disorder.

Mastoid and Epitympanic Bony Obliteration in Pediatric Cholesteatoma

The primary goal of cholesteatoma surgery is complete eradication of the disease. To lower the recurrence rate in the pediatric population in canal wall up techniques and to avoid the disadvantages of canal wall down techniques, the bony obliteration technique with epitympanic and mastoid obliteration has been developed. The objective of this study was to evaluate the long-term surgical outcome and recurrence rate of this technique in children. Retrospective case review. : Tertiary referral center. Fifty-two children (<16 yr) were operated on in 90.4% (n = 47) for a primary or recurrent cholesteatoma and in 9.6% (n = 5) for an unstable cavity. In all cases, we closed the tympanoattical barrier and the posterior tympanotomy with sculpted cortical bone and then completed obliteration of the epitympanum and mastoid with bone pâté. A reconstruction of the middle ear was performed by means of an allograft tympanic membrane including the malleus handle and a sculpted allograft malleus or incus for columellar reconstruction. Recurrent rate; residual rate; functional outcome; hygienic status of the ear; long-term safety issues. The mean follow-up time was 49.5 months (range, 12-101.3 mo). Recurrent cholesteatoma occurred in 1.9% (n = 1). Residual cholesteatoma was detected in 15.4% (n = 8) of the cases. Postoperative hearing results revealed a median gain on pure-tone averages of 14.3 dB and a median postoperative air-bone gap of 25.6 dB. The mastoid and epitympanic BOT is an effective technique to lower the recurrence rate of cholesteatoma in the pediatric population. Follow-up by magnetic resonance imaging provides a safe, noninvasive method for postoperative detection of residual cholesteatoma.