Resection In Conjunction Research Articles

Update on the Surgical Management of Craniopharyngiomas

Despite advances in microsurgical and skull base techniques, the surgical treatment of craniopharyngiomas continues to pose a challenge to surgeons. Controversy continues to exist between proponents of subtotal resection in conjunction with radiotherapy, who argue that this less aggressive approach can yield equivalent control rates with lower morbidity, and others who argue for the superiority of gross total resection. Regardless of whether gross total or subtotal resection is the goal, surgical planning must include a thorough endocrine and neuroophthamological evaluation as well as imaging, and the approach, whether trans-sphenoidal or transcranial, must take into account the nature of the tumour and its location. In addition, optimal management of craniopharyngiomas must consist of individualised and multidisciplinary therapy including an array of subspeciality fields such as endocrinology, neuro-ophthalmology, neuropsychology and radiation oncology.

Surgical management of craniopharyngiomas

Surgical treatment of craniopharyngiomas has been historically challenging and, despite advancements in microsurgical and skull base techniques, continues to pose a challenge to modern day surgeons. In particular, proponents of subtotal resection in conjunction with radiotherapy argue that this less aggressive approach can yield equivalent control rates with lower morbidity, while others argue that gross total resection is superior. Regardless of whether gross total or subtotal resection is the goal, surgical planning must include a thorough endocrine and neuro-ophthalmologic evaluation as well as imaging, and the approach, whether transsphenoidal or transcranial, must take into account the nature of the tumor and its location. In addition, optimal management of craniopharyngiomas must consist of an individualized and multidisciplinary approach not only including neurological surgery, but also including endocrinology, neuro-ophthalmology, neuropsychology, and, often, radiation-oncology.

In vitro results of a new minimally invasive aortic valve resecting tool☆☆☆

Aortic valve replacement (AVR) using extracorporeal circulation is currently the treatment of choice for symptomatic aortic stenosis. However, patients with multiple high-risk comorbid conditions may benefit from reduced ECC time by a simplified and faster resection in conjunction with quick sutureless valve implantation. A prototype of a new minimally invasive aortic valve resection tool equipped with rotating and foldable Nitinol cutting edges was designed. Commercially available aortic valve bioprostheses were artificially calcified (group 1: moderate calcified, n=8, group 2: severely calcified, n=8). In vitro resection was performed using a 21mm cutting blade. Resection time (RT), maximum turning moment (MTM) and number of required rotations (NR) were measured. Furthermore, particle generation during the process of cutting was obtained and quantified. Aortic valve cutting could be obtained without any complications in all cases. Cutting process resulted in a RT of 15.5+/-3s in group 1 compared to 34.9+/-15s in group 2 (p=0.005), MTM was 3+/-0.6Nm in group 1 compared to 3.5+/-0.6Nm in group 2 (p=0.068) and NR were 30.6+/-2.3 in group 1 compared to 48.1+/-15.5 in group 2 (p=0.007). Particle generation was 1.77+/-0.17g in group 1 compared to 1.41+/-0.44g in group 2 (p=0.047). These first in vitro results confirm feasibility and accelerated aortic valve resection within 30s. This new concept holds promise for very fast AVR in combination with insertion of sutureless aortic valve prosthesis, targeting for ischemic times less than 10min in the open heart situation. Finally, resection and percutaneous AVR within 1min in the beating heart situation is envisioned.

Incidental carcinoma of the prostate: What’s the best procedure to discover residual disease?

16106 Background: Incidental prostate cancer (CaP) presents a highly different risk of progression for T1a and T1b disease (T1a: 10–26% at 7–10 years; T1b: up to 30 % at 2 years), even in more recent series. An incorrect definition of stage can strongly impact on patient’s survival, so we restaged our patients after transurethral resection of the prostate (TURP) by means of a second procedure, consisting of a repeated TURP plus ultrasound-guided biopsies (BxP). The study investigated prospectively these two diagnostic modalities with the aim to discover which one provides the best detection rate. Methods: Between January 1997 through January 2006, 50 T1a CaP were discovered in patients submitted to TURP (1021pts). Median prostate-specific antigen (PSA) before the operation was 5.25 ng/ml (range 0.6 - 17). After three months, prior PSA reevaluation, all patients underwent a second resection in conjunction with an ultrasound-guided transrectal biopsy (six cores). Results: After the first TURP median PSA was 1.35 ng/ml (range 0 - 4.02). Residual disease was demonstrated in 20 patients (40%) [median PSA 1.19 (range 0.4 - 4.02)], then treated surgically or not, depending on age or comorbidities. Among them, in 7 cases (14%) both re- TURP and BxP were positive; in 7 patients (14%) repeated TURP was positive and BxP negative (p n.s.), while in the remaining 6 (12%) repeated TURP was negative and BxP positive (p n.s.). Twelve out of 20 patients (median age 68) with persistent cancer underwent radical surgery and locally advanced disease was revealed in 3 (25%), with one patient having a Gleason score 9. Conclusions: In these series 40% of patients, initially diagnosed in stage T1a, revealed residual tumor after restaging. This high percentage warranted the discomfort and the costs of a second procedure. Either repeated TURP and BxP failed to demonstrate an advantage over each other in terms of “detection rate”. A 10% false negative rate for both prompts us to associate the two modalities instead of choosing between them, in order to discover a potentially lethal residual disease for which, in many cases, a definitive treatment is to be considered. No significant financial relationships to disclose.

Vocal Outcomes After Laser Resection of Early-Stage Glottic Cancer With Adjuvant Cryotherapy

To evaluate the vocal outcomes of patients with early-stage glottic carcinoma undergoing laser resection with adjuvant cryoablative therapy. Retrospective review. Tertiary care center. Patients Twenty patients with early-stage glottic carcinoma. Intervention Treatment of early-stage glottic carcinoma with endoscopic carbon dioxide laser resection in conjunction with cryoablation. Disease-free survival and subjective and objective measures of posttreatment voice quality, based on serial videolaryngostroboscopy. There was 1 local treatment failure, with an overall mean disease-free follow-up of 32.6 months (range, 3-93 months). Carbon dioxide laser resection and cryoablative therapy were associated with a significant improvement in subjective voice quality (P<.001). Long-term dysphonia was uniformly improved vis-à-vis the pretreatment condition, even among patients with the most advanced disease undergoing the widest resections. Posttreatment web formation was not noted among 4 patients with anterior commissure involvement. Endoscopic laser laryngeal surgery performed in conjunction with cryotherapy for early-stage glottic carcinoma yielded excellent primary site control, while improving subjective and objective measures of voice quality. Combined laser surgery and cryotherapy is a possible alternative to radiotherapy for selected patients with early-stage glottic carcinoma who desire curative therapy, while optimizing vocal outcomes.

Loading of the Index Metacarpal After Trapezial and Partial Versus Complete Trapezoid Resection

To examine the effects of partial or complete trapezoidectomy in conjunction with trapezium resection on proximal migration of the index metacarpal during axial loading. Five specimens from below the elbow were obtained from fresh-frozen cadavers. A customized vise was used to position the wrist in 20 degrees extension and 5 degrees ulnar deviation, simulating a power grip. The index metacarpal was instrumented to allow axial loading at 125 N and 250 N. Specimens were tested under 4 experimental conditions: (1) in the intact state, (2) after trapezial resection, (3) after partial trapezoid resection, and (4) after complete trapezoid resection. Specimens were tested 5 times under each experimental condition, displacement was measured with a linear variable differential transformer, and stiffness was calculated. There was no difference in stiffness between the different treatments at either 125 N or 250 N. Displacement was not significantly different between treatments for loads of 125 N. For loads of 250 N the displacement was approximately 1 mm greater with complete trapezoid resection than with any of the other treatment conditions. Displacement did not differ significantly between the other 3 treatments. The addition of a partial trapezoid resection performed at the time of trapezial resection does not affect proximal migration of the second metacarpal. When a complete trapezoidectomy is performed at the time of trapezial excision, however, the loading characteristics of the index metacarpal do change statistically significantly, although the magnitude of that change is only approximately 1 mm. Further testing will be necessary to elucidate the biomechanical effects of a partial trapezoid resection in conjunction with a trapezial resection on the second metacarpal in other planes.

Management for chest wall implantation of non-small cell lung cancer after fine-needle aspiration biopsy.

The implantation of cancer cells in the chest wall after percutaneous needle biopsy of the lung is rare. We investigated the clinical outcomes of implantation metastasis after percutaneous fine-needle aspiration biopsy of pulmonary mass suggestive of lung cancer. Between January 1990 and December 2001, nine patients were treated for implantation metastasis of the chest wall. We retrospectively reviewed the patients' records and analyzed their clinical outcomes. During an 11-year period, 4365 patients underwent percutaneous fine-needle aspiration biopsy for indeterminate pulmonary nodule at Seoul National University Hospital. Eight patients developed implantation metastasis related to the procedure. One patient was presented to us after being biopsied in another hospital. A wide, full-thickness excision of the chest wall was performed in eight patients. In one patient, palliative chemotherapy was performed due to the presence of distant metastases in addition to the local recurrence. In six patients, postoperative adjuvant radiation was given. There was no surgical mortality or morbidity. The median survival was 96.5 months (range, 15-128 months) after pulmonary resection and 75 months (range, 8-93 months) after chest-wall resection. Six patients developed recurrence of the primary cancer in a median of 52 months (range 5-93 months). Three patients recurred at the chest-wall excision site and a wide, full-thickness chest-wall re-resection was performed for two patients who recurred only at the previous chest-wall excision site. Four patients are alive, four have died of recurrent disease, and one died of underlying lung disease. None died of implantation metastasis per se. The incidence of chest-wall implantation metastasis after fine-needle aspiration biopsy is extremely rare. With successful resection, the prognosis for the patient seems to depend on the primary cancer. A radical and wide resection in conjunction with irradiation may provide long-term survival in patients with an initial early stage cancer.

Sacropelvic resection and intraoperative radiation therapy: feasibility, technical description and early clinical results

Sarcomas and locally recurrent colorectal carcinomas are disease entities in which sacral resection is an effective alternative for meaningful palliation with a limited cure expectation.To provide local control, pain palliation and a marginal expectation of definitive cure, a multimodality approach including external beam radiation therapy, surgical resection, and intraoperative radiation therapy (IORT), has been developed for patients with locally recurrent rectal cancers and primary sarcomas of the sacro-pelvic región.Seven consecutive patients (5 females; 2 males; ages, 40–75) underwent surgical exploration, sacrectomy, and IORT, between 1997 and 2000. IORT doses ranged from 10 to 12.5 Gy. External beam irradiation (EBRT) was used in six patients not previously irradiated (85%). Only 1 patient (14.2%) had received postoperative chemotherapy.Level of sacral resection: S2–S3 in 3 patients and S3–S4 in 2 patients. One patient with osteosarcoma underwent a posterior approach only, requiring removal of the posterior sacral table exclusively. An exclusively anterior approach was used in another patient with recurrent rectal cancer involving uterus, vagina and presacral fascia, requiring selective removal of the anterior sacral table. Margins: clear in 5 and microscopically involved in 2 patients. Postoperative mortality rate: 1 patient (14.2%). Three patients (42%) suffered major postoperative complications. Follow-up was available on six patients: time from surgery ranging from 1 to 36 (median 12.5) months. At the time of analysis, 5 out of 6 patients were alive without recurrent symptoms.Intensified local radiosurgical treatment with sacropelvic resection in conjunction with IORT provides palliation and offers potential for cure in patients with locally recurrent rectal cancer and sacropelvic sarcomas.

Metastasectomy as a cytoreductive strategy for treatment of isolated pulmonary and hepatic metastases from breast cancer

The authors sought to examine the utility of resection in conjunction with adjuvant chemotherapy for treatment of metastases from breast cancer isolated to the liver or lungs. Limitations of regional therapy were examined and potential agents for systemic therapy were reviewed. As resection of metastases is a controversial therapeutic approach, no clinical trials are available for review. Rather, evidence for a potential role for surgery rests on retrospective studies of small series of patients. Technical advances have rendered resection of liver and lung metastases safe. Long-term results as reported by other investigators support the role of metastasectomy in selected patients. The site of failure following ablation of liver metastases is usually in the liver. Following resection of lung metastases, nonpulmonary and disseminated recurrences are most common. Adjuvant therapy with docetaxel or any other agent or combination with significant activity against visceral metastases might potentiate long-term results.

Missed lipoma of the spermatic cord. A pitfall of transabdominal preperitoneal laparoscopic hernia repair.

Missed lipoma of the spermatic cord is a pitfall unique to the transabdominal preperitoneal (TAPP) laparoscopic hernia repair. This problem occurs when a palpable inguinal mass is noted preoperatively, but no identifiable hernia defect is found at time of laparoscopy and the procedure is terminated. Our group encountered six patients without intraperitoneal defects that had large cord lipomas on preperitoneal exploration. Two of these patients had undergone previous intraabdominal laparoscopy for a proposed TAPP repair, which was aborted when no defect was seen. Both patients were referred for continued symptomatic groin masses, which were subsequently treated by lipoma resection in conjunction with inguinal floor repair. When patients present with a groin mass, exploration of the preperitoneal space and cord structures is indicated during TAPP repair, even in the presence of a normal-appearing abdominal floor. Abandoning a transabdominal approach without exploration of the preperitoneal structures may lead to a failure to identify symptomatic and/or palpable cord lipomas.

Management of Colonoscopic Perforations

To document our evolving surgical management of colonoscopic perforation and examine factors crucial to the improvement of patient care. We conducted a computer-based retrospective analysis of medical records (1980 through 1995). Among 57,028 colonoscopic procedures performed, 43 patients (0.075%, or 1 perforation in 1,333 procedures) had a colonic perforation. Two additional patients were treated after colonoscopy performed elsewhere. The outcomes analyzed included surgical morbidity and mortality. Twenty-six women and 19 men who ranged in age from 28 to 85 years (median, 69) were treated for colonic perforation. More than 80% of perforations occurred during the latter half of the study period because of the increased volume of colonoscopic procedures (8 perforations among 12,581 examinations from 1980 through 1987 versus 35 perforations among 44,447 colonoscopies from 1988 through 1995). Emergency laparotomy was performed in 42 patients (93%). Perforations occurred throughout the colon: right side = 10; transverse = 9; and left side = 23. Three patients without evidence of peritoneal irritation fared well with nonoperative management. Most patients underwent primary repair or limited resection in conjunction with end-to-end anastomosis. In 14 patients (33%), an ostomy was created. One patient underwent laparotomy without further treatment. Intra-abdominal contamination ranged from none (31%) to local soiling (48%) to diffusely feculent (21%). Postoperative complications occurred in 12 patients and were associated with older age (P = 0.01), large perforations (P = 0.03), and prior hospitalization (P = 0.04). No postoperative deaths occurred. Despite a consistently low risk of colonic perforation, the increasing use of colonoscopy in our practice has resulted in an increased number of iatrogenic colonic perforations. In order to minimize morbidity and mortality, prompt operative intervention is the best strategy in most patients. Non-operative management is warranted in carefully selected patients without peritoneal irritation.

Impact of radical tumour resection in conjunction with immediate flap coverage on the prognosis of oral cancer

Impact of radical tumour resection in conjunction with immediate flap coverage on the prognosis of oral cancer

Limbal Wedge Resection at the Time of Intraocular Lens Surgery for Reducing Postkeratoplasty Astigmatism

Thirteen limbal wedge resections performed to reduce postkeratoplasty astigmatism in patients undergoing secondary intraocular lens placement were reviewed. Eleven of the 13 procedures reduced preoperative astigmatism 3.12 diopters (+/- 1.77 D; range, 0.50 D to 6.25 D). The average follow-up time was 17 months (range, 4 to 36 months). The average flat/steep ratio was 1.19 (+/- 0.96), indicating approximately equal degrees of corneal flattening and steepening. Average central corneal keratometric values steepened 0.47 D, with a range of 0.56 D of flattening to 2.41 D of steepening. Keratometric values were stable by 4 months in most patients. All patients except one with amblyopia had a corrected visual acuity of 20/60 or better. A dellen formation developed in one case, but it caused no permanent negative visual complications. As generally found in previous studies, each 0.1-mm wedge-width resected induced 1 D of astigmatic correction. Limbal wedge resection in conjunction with intraocular lens implantation can safely and effectively reduce astigmatism following penetrating keratoplasty.

Aggressive Pulmonary Resection for Metastatic Osteogenic and Soft Tissue Sarcomas

From July, 1974, to July, 1979, 36 patients with osteogenic sarcoma and 25 patients with soft tissue sarcoma underwent a total of 95 thoracotomies for resection of isolated pulmonary metastases. In only 6 patients could all palpable disease not be resected, although it was certain that microscopic disease remained in some patients. Twenty-six patients underwent more than 1 thoracotomy. The pulmonary lesions were found not to be metastases in 4 patients with osteogenic sarcoma and 4 with soft tissue sarcoma. The four-year survival for patients with nonsynchronous metastases from osteogenic sarcoma was 44%, not significantly different from a survival of 35% for patients with soft tissue sarcomas. The 6 patients with synchronous osteogenic sarcoma metastases all died within 16 months. Survival following thoracotomy did not correlate statistically with time from primary tumor resection to lung recurrence, unilateral versus bilateral disease, or number of nodules. For the 33 patients in whom tumor doubling time could be calculated, survival with either type of sarcoma was significantly better in patients with a tumor doubling time greater than 40 days versus a tumor doubling time less than or equal to 40 days. Any patient with metastatic osteogenic sarcoma or soft tissue sarcoma confined to the lungs should be considered for resection in conjunction with chemotherapy.

Tumors arising in accessory parotid tissue

A summary is presented of our experience with 23 patients who had accessory parotid tumors, comprising 1 per cent of all primary parotid neoplasms seen during a 40 year period. Although more than half of the tumors proved malignant, adequate excision was usually curative. We prefer to approach these tumors through an extended cheek-flap incision. Once the lesion is exposed, either local excision or resection in conjunction with subtotal parotidectomy can be performed, depending on the clinical findings.

Urinary oxalate excretion related to ileocolic surgery in patients with Crohn's disease.

Urinary oxalate excretion was studied in healthy subjects and before and after surgery in patients with Crohn's disease. Urinary oxalate excretion in relation to the length of diseased or resected ileal segment in patients subjected to restorative and colectomy procedures, as well as in relation to faecal excretion of fat and bile salts and to urinary excretion of vitamin B12 and calcium, was also studied. The studies were performed in patients on a free diet or standard hospital diet and on a high-oxalate and/or high-fat diet. When patients subjected to ileal resection in conjunction with minor colonic resection were studied on a high-oxalate diet, urinary oxalate excretion increased with length of ileum resected and correlated with faecal fat excretion and urinary excretion of vitamin B12 but not with faecal excretion of bile salts. Increasing the dietary fat intake in these patients further increased urinary oxalate excretion. Although urinary oxalate excretion increased somewhat in colectomized patients on a high-oxalate diet, indicating an increased absorption of dietary oxalate, this increase showed no correlation either to faecal fat or bile salt excretion, or to urinary excretion of vitamin B12. The result are consistent with the "solubility theory". A diet low in fat and oxalate and high in calcium is recommended in patients with hyperoxaluria.

Normothermic Coronary Perfusion during Aortic Valve Replacement

Normothermic coronary perfusion was used in 121 patients undergoing aortic valve replacement from 1969 to 1976. Isolated aortic valve replacement was performed in 69% of the patients (84/121), and 31% (37/121) had combined procedures consisting of aortocoronary bypass, mitral valve replacement or repair, or ascending aortic aneurysm resection in conjunction with aortic valve replacement. The left ventricle was vented in all. Sinus rhythm was maintained in 105 patients, but spontaneous fibrillation persisted in 16. Postbypass hemodynamic data indicated satisfactory ventricular performance, and postoperative morbidity and mortality were low. Postoperative myocardial infarction (new Q waves, loss of R waves, persistent S-T and T wave changes) or a serum glutamic oxaloacetic transaminase (SGOT) level of more than 100 units (colorimetric) occurred in 13% of isolated and 27% of combined procedures. In patients with electrocardiographic and SGOT changes suggesting myocardial damage and in those with persistent spontaneous fibrillation, coronary perfusion was technically unsatisfactory owing to either excessive flow, low flow, inability to perfuse the right coronary artery, or high perfusion pressures. Evidence of myocardial damage was absent when coronary perfusion was appropriately applied. In order to obtain satisfactory results with normothermic coronary perfusion, both coronary arteries must be perfused at total flow rates of 200 to 350 ml per minute and at mean pressures of less than 120 mm Hg.

Modern Concepts of Diagnosis and Treatment of the Thoracic Outlet Syndrome

Neurovascular compression at the thoracic outlet results from one or several local anatomic abnormalities, all involving the first rib to some extent. The pathologic processes produced involve syndromes usually affecting the ulnar nerve, the subclavian artery, or the subclavian vein. The majority of these cases should be managed in a nonoperative fashion and surgical treatment reserved for patients who are unresponsive to these measures. Initial conservative nonoperative treatment with physiotherapy and patient education produces satisfactory results in 70 per cent of the patients. Operative intervention, when necessary, results in satisfactory results in 90 per cent of the cases and requires first rib resection in conjunction with repair of all other attendant mechanisms. The anterior operative approach is strongly recommended whenever vascular repair is contemplated.

Actinomycosis: its recognition and treatment.

Excerpt INTRODUCTION Although many of the strains of Actinomyces are highly sensitive in vitro to many antimicrobial agents, the disease caused in human beings by these microorganisms continues to ...