Safe Surgical Strategy Research Articles

Safe Reentry for False Aneurysm Operations in High-Risk Patients

In the absence of a standardized safe surgical reentry strategy for high-risk patients with large or anterior postoperative aortic false aneurysm (PAFA), we aimed to describe an effective and safe approach for such patients. We prospectively analyzed patients treated for PAFA between 2006 and 2015. According to the preoperative computed tomography scan examination, patients were divided into two groups according to the anatomy and extension of PAFA: in group A, high-risk PAFA (diameter ≥3 cm) developed in the anterior mediastinum; in group B, low-risk PAFA (diameter <3 cm) was situated posteriorly. For group A, a safe surgical strategy, including continuous cerebral, visceral, and coronary perfusion was adopted before resternotomy; group B patients underwent conventional surgery. We treated 27 patients (safe reentry, n= 13; standard approach, n= 14). Mean age was 60 years (range, 29 to 80); 17 patients were male. Mean interval between the first operation and the last procedure was 4.3 years. Overall 30-day mortality rate was 7.4% (1 patient in each group). No aorta-related mortality was observed at 1 and 5 years in either group. The Kaplan-Meier overall survival estimates at 1 and 5 years were, respectively, 92.3% ± 7.4% and 73.4% ± 13.4% in group A, and 92.9% ± 6.9% and 72.2% ± 13.9% in group B (log rank test, p= 0.830). Freedom from reoperation for recurrent aortic disease was 100% at 1 year and 88% at 5 years. The safe reentry technique with continuous cerebral, visceral, and coronary perfusion for high-risk patients resulted in early and midterm outcomes similar to those observed for low-risk patients undergoing conventional surgery.

Repeat Double-Opposing Z-Plasty for the Management of Persistent Velopharyngeal Insufficiency.

Persistent velopharyngeal insufficiency occurrence after double-opposing Z-plasty has been treated with either posterior pharyngeal flap or sphincteroplasty. Both these methods can be accompanied by mild discomfort, such as mouth breathing and hyponasal resonance, and can lead to severe complications, such as sleep apnea and upper airway compromise. The purpose of this study was to review the efficacy of repeat double-opposing Z-plasty for the management of persistent velopharyngeal insufficiency in patients who received a prior surgical intervention by double-opposing Z-plasty. All patients who were treated by repeat double-opposing Z-plasty between January 2000 and December 2014 were reviewed. Patient demographics, cleft type, surgical technique, and complications, such as wound dehiscence, infection, fistula, and upper airway obstruction, were evaluated. Preoperative and postoperative speech evaluations were reviewed for comparison. Fourteen patients underwent repeat double-opposing Z-plasty, with an average follow-up of 34 months. There was no complication including wound dehiscence, flap necrosis, fistula, or upper airway compromise. Velopharyngeal competence (resonance, nasal emission, intraoral pressure, social/personal problems) was significantly improved postoperatively (P < 0.05). Only 1 patient required posterior pharyngeal flap for persistent velopharyngeal insufficiency. Repeat double-opposing Z-plasty is an effective and safe surgical strategy for the management of persistent velopharyngeal insufficiency, in patients who received a prior surgical intervention by double-opposing Z-plasty. This strategy allows speech improvement and reduces the risk of postoperative upper airway compromise.

Extraperitoneal versus transperitoneal laparoscopic radical cystectomy for selected elderly bladder cancer patients: a single center experience.

ABSTRACTObjective:This study reports the initial experience of extraperitoneal laparoscopic radical cystectomy (ELRC) and compared with transperitoneal laparoscopic radical cystectomy (TLRC) in the treatment of selected elderly bladder cancer patients.Patients and Methods:A total of forty male bladder cancer patients who underwent ELRC (n=19) or TLRC (n=21) with ureterocutaneostomy were investigated. Demographic parameters, perioperative variables, oncological outcomes and follow-up data were retrospectively analyzed.Results:A significantly shorter time to exsufflation (1.5±0.7 vs 2.1±1.1 d; p=0.026) and liquid intake (1.8±0.9 vs 2.8±1.9 d; p=0.035) were observed in the ELRC group compared with the TLRC group. The incidence of postoperative ileus in the ELRC group was lower than the TLRC group (0 vs 9.5%). However, the difference had no statistical significance (p>0.05). The removed lymph node number in the ELRC group was significantly lower than the TLRC group (p<0.001). No significant differences were observed between the two groups in the overall and cancer-free survival rates (p>0.05).Conclusions:ELRC seems to be a safe and feasible surgical strategy for the selected elderly bladder cancer patients with ≤ T2 disease. The surgical and oncological efficacy of the ELRC is similar to that of the TLRC, but with faster intestinal function recovery. Further studies with a large series including different urinary diversions are needed to confirm our results and to better evaluate the benefit of ELRC in bladder cancer patients.

Management of large mediastinal masses: surgical and anesthesiological considerations.

Large mediastinal masses are rare, and encompass a wide variety of diseases. Regardless of the diagnosis, all large mediastinal masses may cause compression or invasion of vital structures, resulting in respiratory insufficiency or hemodynamic decompensation. Detailed preoperative preparation is a prerequisite for favorable surgical outcomes and should include preoperative multimodality imaging, with emphasis on vascular anatomy and invasive characteristics of the tumor. A multidisciplinary team should decide whether neoadjuvant therapy can be beneficial. Furthermore, the anesthesiologist has to evaluate the risk of intraoperative mediastinal mass syndrome (MMS). With adequate preoperative team planning, a safe anesthesiological and surgical strategy can be accomplished.

Mediastinal Mass Excision-Simple and Safe in Non-specialised Centres

Introduction: The mediastinum is a site for a wide range of various neoplasms, with often rare histologies[1,2], imposing both diagnostic and therapeutic challenges. Particularly large mediastinal masses, or intrathoracic masses with mediastinal compression, offer surgical challenges, due to the complex anatomy of the mediastinum, with obstruction, compression, or invasion of vital surrounding structures. In addition, anesthesiological management during surgery can be complicated by the so-called “Mediastinal Mass Syndrome” (MMS)[3], characterized by acute respiratory and hemodynamic decompensation, due to mechanical compression of mediastinal structures. Therefore, meticulous preoperative assessment, preparation and collaboration between the surgeon and anesthesiologist are essential. Case Presentation: A 26-year old man asymptomatic presented to our hospital with obliteration of the right cardiophrenic sinus by a mass on Chest X-ray (Figure 1). He has no history of fever, weight loss, previous disease, or any neoplasm in his family. A noninvasive investigation CECT of chest demonstrated a tumoral mass which was continuous to the pericardium and caused extrinsic compression to the SVC and right atrium (Figure 2). The diagnosis of this tumor is very difficult through non-invasive investigation. The patient underwent surgical resection en-block via right thoracotomy (Figure 3). Slow and meticulous dissection is must to remove the mass encapsulated without causing it to rupture (Figure 4). Suspicion was a thymoma but surgical and anatomopathologic findings led to the diagnosis of a mature cystic teratoma (Figure 5). Discussion: The typical radiographic appearance of mature teratoma is that of a rounded, sometimes lobulated anterior mediastinal mass with the borders of the mass sharply marginated against the adjacent lung. Calcification has been reported in approximately 20-43% of cases and may be central, curvilinear, or peripheral (Michel et al.) [4]. The radiographic visualization of teeth is pathognomonic of teratoma (Rosai and Levine) [5]. Computed Tomography (CT) is the modality of choice for the diagnostic evaluation of these tumors. Meditational mature teratomas typically manifest on CT as heterogeneous sharply marginated, spherical or lobulated anterior mediastinal masses containing soft tissue, fluid, fat, or calcium attenuation, or any combination of the four. Malignant transformation must be ruled out if contrast enhanced CT scanning reveals a non-homogeneous cystic mass with a fat or oil component and a thick wall with calcification with invasion of the pericardium and great vessels (Dobranowski et al.) [6]. The patient underwent surgical excision. The treatment of mature teratoma consists of complete surgical excision of the mass. The prognosis is very good and 5 year survival rates approach 100%, in contrast to the prognosis of immature teratomas, which may exhibit an aggressive behaviour in adults and may have a poor prognosis (Hueb et al.) [7]. Conclusion: In the perioperative management of surgical treatment of large mediastinal masses or intrathoracic tumors with mediastinal compression, attention to anatomical details of the tumor and it relations with vital mediastinal surrounding structures is essential. Preoperative preparation measures include appropriate preoperative multimodality imaging, with emphasis on the vascular anatomy of the tumor. Multidisciplinary team discussions should assess whether neoadjuvant therapy can be beneficial on a case-by-case basis. With adequate preoperative team planning, a safe anesthesiological and surgical strategy can be realized. The management of these tumors are simple and safe if properly planned and with good anatomical knowledge and technique surgical excision can be done in nonspecialized centers.

Clinical Outcome after Laminectomy without Fusion for Cervical Spondylotic Myelopathy

Dorsal decompression in patients, presenting with cervical spondylotic myelopathy with no signs of instability, is a standard surgical option. Laminectomy or laminoplasty is applied to reduce the pressure on the myelon. The aim of this study was to evaluate the clinical outcome in a consecutive series of patients. This retrospective study included a total of 65 patients who underwent laminectomy or laminoplasty at a single or more levels, without fusion for cervical spondylotic myelopathy, during an 8-year period (2000-2007). The clinical data evaluation included pre- and postoperative patient history and neurological and surgical variables. The radiological assessment included MRI, CT, and plain anterior-posterior, lateral, and lateral flexion-extension X-rays. The mean follow-up time was 15 months. Improvement of gait disturbance was documented in 74% of the patients concerned. Radicular pain in the upper limbs (UL) and lower limbs (LL) improved in 87% and 50% of the patients, respectively. Sensory deficits improved in the UL and LL in 76% and 54%, respectively. Motor deficits improved in the UL and LL in 70% and 56% of the patients, respectively. Clinical deterioration after surgery was documented in one patient. Based on our results, laminectomy without fusion can be advocated as a safe and effective surgical strategy to treat cervical spondylotic myelopathy in patients without preoperative instability. In these patients, the occurrence of post-procedural clinical deterioration and instability was low, and overall improvement of neurological deficits and amelioration of radicular pain can be expected in a significant number of patients.

Surgical Management of Solitary Nerve Sheath Tumors of the Cervical Spine: A Retrospective Case Analysis Based on Tumor Location and Extension

Complete resection of spinal nerve sheath tumors (NSTs) does not always result in significant neurological deficit. The purpose of this retrospective case analysis was to discuss the optimal surgical strategy for spinal NST of the cervical spine. Twenty-four patients who underwent surgery for solitary cervical NST over the past decade were included in this retrospective study. Patients with neurofibromatosis or schwannomatosis were excluded. Seventeen of the 24 cases (70.8%) showed extradural dumbbell extension, most frequently at the C1 or C2 vertebral level. Neurological condition was assessed using the modified McCormick functional schema and sensory pain scale. Total removal of the tumor was achieved in 20 of 24 cases (83.3%). Staged surgery using combined anterior and posterior approaches was applied for 2 of 17 cases with extradural dumbbell extension. Tumor involvement with nerve root fibers critical for upper extremity function (C5–C8) was recognized in 6 of 24 cases (25.0%), with complete resection in all 6 cases. Final assessment of neurological function revealed satisfactory or acceptable recovery in all 6 patients. Spinal NSTs with extradural dumbbell extension are a common condition in the cervical spine. Complete removal of spinal NST of the cervical spine may carry a risk of permanent neurological deficit, but such sequelae appeared to be the exception in the present case analysis. A radical and safe surgical strategy, including staged surgery combining anterior and posterior approaches, should be tailored to the individual case.

Single-Port Laparoscopic Retroperitoneal Surgery Using a Modified Single-Port Device in Urology

Objectives: To investigate the use of a flexible instrument platform in performing single-port laparoscopic retroperitoneal urologic surgeries and to verify the safety and feasibility of these surgeries. Methods: The homemade instrument platform consisted of two control loops and a powder-free surgical glove to form multichannels. 56 patients underwent this kind of single-port surgery for different urologic diseases, including radical nephrectomy in 31 patients, nephroureterectomy in 7 patients, partial nephrectomy in 8 patients, living donor nephrectomy in 4 patients, adrenalectomy in 3 patients, renal cyst surgery in 2 patients and ureterolithotomy in 1 patient. Results: All surgeries were completed successfully with no switch to conventional laparoscopic or open surgery. The mean hospital stay was 13.13 days (range 6-36). All patients were satisfied without major complications. Conclusions: Retroperitoneal laparoendoscopic single-site surgery using our cost-effective homemade instrument platform appears to be a feasible and safe surgical strategy to perform retroperitoneal laparoscopic urologic surgery.

Komplikationsvermeidung und -management bei „Descemet membrane endothelial keratoplasty“ (DMEK) und „Descemet stripping automated endothelial keratoplasty“ (DSAEK)

Posterior lamellar keratoplasty, in the form of Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSAEK), has become a standard procedure for therapy of endothelial diseases of the cornea. The aim of this article is to describe strategies to prevent and manage complications in DMEK and DSAEK surgery. The article is based on a PubMed literature search and own clinical data. Key words used were "DMEK", "DSAEK", "Descemet membrane endothelial keratoplasty" and "Descemet stripping automated endothelial keratoplasty". The DMEK and DSAEK procedures are safe surgical strategies for treating endothelial corneal diseases if the indications are made correctly. The DMEK procedure is the standard procedure for improvement of visual acuity especially for younger patients with Fuchs' dystrophy and DSAEK is particularly suitable for eyes with complicated anterior chamber situations.

Gamma Knife thalamotomy for tremor in the magnetic resonance imaging era

The surgical management of disabling tremor has gained renewed vigor with the availability of deep brain stimulation. However, in the face of an aging population of patients with increasing surgical comorbidities, noninvasive approaches for tremor management are needed. The authors' purpose was to study the technique and results of stereotactic radiosurgery performed in the era of MRI targeting. The authors evaluated outcomes in 86 patients (mean age 71 years; number of procedures 88) who underwent a unilateral Gamma Knife thalamotomy (GKT) for tremor during a 15-year period that spanned the era of MRI-based target selection (1996-2011). Symptoms were related to essential tremor in 48 patients (19 age ≥ 80 years and 3 age ≥ 90 years), Parkinson disease in 27 patients (11 age ≥ 80 years [1 patient underwent bilateral procedures]), and multiple sclerosis in 11 patients (1 patient underwent bilateral procedures). A single 4-mm isocenter was used to deliver a maximum dose of 140 Gy to the posterior-inferior region of the nucleus ventralis intermedius. The Fahn-Tolosa-Marin clinical tremor rating scale was used to grade tremor, handwriting, and ability to drink. The median follow-up was 23 months. The mean tremor score was 3.28 ± 0.79 before and 1.81 ± 1.15 after (p < 0.0001) GKT; the mean handwriting score was 2.78 ± 0.82 and 1.62 ± 1.04, respectively (p < 0.0001); and the mean drinking score was 3.14 ± 0.78 and 1.80 ± 1.15, respectively (p < 0.0001). After GKT, 57 patients (66%) showed improvement in all 3 scores, 11 patients (13%) in 2 scores, and 2 patients (2%) in just 1 score. In 16 patients (19%) there was a failure to improve in any score. Two patients developed a temporary contralateral hemiparesis, 1 patient noted dysphagia, and 1 sustained facial sensory loss. Gamma Knife thalamotomy in the MRI era was a safe and effective noninvasive surgical strategy for medically refractory tremor in the elderly or those with contraindications to deep brain stimulation or stereotactic radiofrequency (thermal) thalamotomy.

Retroperitoneal Laparoendoscopic Single-Site Radical Nephrectomy Using a Low-cost, Self-Made Device

To introduce a low-cost, self-made device for single-port retroperitoneal laparoscopic radical nephrectomy and to evaluate outcomes compared with conventional laparoscopy after initial experience using this device. Twenty-nine renal cancer patients underwent retroperitoneal laparoendoscopic single-site radical nephrectomy using a self-made single-port device with multiple manipulation channels for passage of routine laparoscopic instruments and specimen removal. A control group of 29 patients who were matched by age, gender, and cancer stage underwent conventional laparoscopy. Outcomes were analyzed retrospectively. There were no significant differences in age, gender, body mass index, T stage, and maximum tumor diameter between groups (P > .05). The laparoendoscopic single-site surgery group had a significantly shorter duration of postoperative hospitalization than the conventional laparoscopy group (7.14 ± 1.38 days vs 8.17 ± 1.54 days, P = .009). Retroperitoneal laparoscopic radical nephrectomy using our self-made single-port device appears to be a feasible, safe, and low-cost surgical strategy.

Safe surgical strategy for extracardiac conduit replacement in common arterial trunk

Repair of common arterial trunk using an extracardiac right ventricular to pulmonary arterial conduit is the preferred method in most cardiac surgical centres. Reoperation is a fact of life for survivors of common arterial trunk and related cardiac lesions who have undergone such repairs. Long-term survivors may require periodic conduit revisions, with a potentially escalating technical difficulty and risk. Herein we present an analysis of the currently available choices for extracardiac conduits, and outline what we consider to be a safe and reliable surgical strategy for conduit revision.

Stapled diverticulectomy for solitary caecal diverticulitis

Caecal diverticulitis is an uncommon phenomenon in western countries. The clinical diagnosis is often difficult as it mimics other acute abdominal conditions like appendicitis, colitis or neoplasia. Diagnosis is often made at operation. Operative strategy has been controversial and there is no broad consensus emerging. We report the case of a 71-year-old woman, known to have chronic obstructive pulmonary disease, who presented acutely with right iliac fossa pain. A clinical diagnosis of appendicitis was made. At laparoscopy, a solitary, inflamed, gangrenous caecal diverticulum was found. A laparoscopic stapled diverticulectomy was performed. The patient made a steady post-operative recovery. Histology confirmed diverticulitis. We conclude that stapled diverticulectomy for solitary caecal diverticulitis is a safe and effective surgical strategy when confronted with this scenario.

Combined simultaneous transcranial and transsphenoidal resection of large-to-giant pituitary adenomas

BackgroundWhile large-to-giant pituitary adenomas (PAs) may be safely removed by experienced surgeons through a single route, the procedure is technically challenging. We present the outcome of a simultaneous combined transcranial and transsphenoidal approach and discuss its applications.MethodsA retrospective review was conducted on 12 consecutive patients. Surgical complications, visual and endocrinological functions, and tumour control were reviewed.ResultsThere were four men and eight women, with a mean age of 47.6 years. All but one patient had non-functioning PAs. The mean tumour height was 4.1 cm (range: 2.3–5.5). The predominant presenting symptoms were visual field loss in eight patients, headache in three patients and mental confusion in one patient. There was no operative mortality. Post-operative cerebrospinal fluid leakage occurred in one patient. Five of the eight patients who presented with visual field loss achieved full recovery, and three had partial improvement. Two patients developed permanent diabetes insipidus after surgery. Panhypopituitarism occurred in one patient. Gross total removal (GTR) was achieved in five, and subtotal removal (STR) in seven patients. Seven patients received post-operative external irradiation. All patients who had GTR remained tumour-free and all those with STR had stable diseases after a mean follow-up period of 53.1 months (range: 14.1–92.1).ConclusionThe simultaneous ‘above and below’ approach is a safe and effective surgical strategy for large-to-giant PAs, particularly when expertise in endoscopic transsphenoidal surgery is unavailable. Its use, however, should be limited to a carefully selected group of patients, and tailored to individual user’s expertise and experience.

Operative Therapie von akral lokalisierten Melanomen

Acral lentiginous melanomas (ALM) represent 4-10% of cutaneous melanomas in white populations. Patients with ALM seem to have a poor prognosis, often due to late diagnosis. Micrographic surgery (3D-histology) is not seen as surgical procedure but more as histopathological technique. With micrographic surgery, continuously spreading ALM can be excised with smaller excision margins and good functional and cosmetic outcomes. In a recent study, 244 patients with ALM were compared using conventional histology versus 3D-histology. Clinical and surgical risk factors influence the prognosis of ALM. Tumor thickness and ulceration are the most important prognostic factors. 3D-histology with paraffin technique (optionally combined with immunohistological methods) can reduce excision margins and avoid local recurrences. Subungual melanomas represent only 2-3% of cutaneous melanomas in Caucasian and 20% in African or Asian skin type and are often clinically misdiagnosed. They are often localized on the thumb or great toe, which are most important for the function of the affected limb. The excision of subungual melanoma with 3D-histology and tumor-free excision margins including the nail matrix can be seen as a safe surgical strategy, which does not hazard the prognosis of the patient. Function and cosmesis of the finger or toe are preserved. Amputation in subungual melanoma is not recommended and should be reserved only for infiltrating melanomas with affection of the bone or joint.

Anatomic relations of the arachnoidea around the pituitary stalk: relevance for surgical removal of craniopharyngiomas

PurposeThe growth pattern of craniopharyngiomas (CP) is yet to be understood due to challenges arising from the diversity of morphological features that exist. This in turn has had implications on the development of safe surgical strategies for management of these lesions. The aim of this study is to propose a morphological classification of CP based on their tumor–membrane relationship. It is hoped that this will contribute to better understanding of CP morphology and prediction of the intraoperative classification.MethodsHistological techniques were used to study eight fetuses. Following Masson staining, the membranes around the pituitary stalk were observed under microscope. Pre-operative MRI and intraoperative images of 195 patients with CP were also analyzed.FindingsThe arachnoidal sleeve around the pituitary stalk (ASPS) was noted to be comprised of a compact fibrous component and a related loose trabecular component. The pituitary stalk was divided into four segments in accordance with the folds of the ASPS. Correspondingly, the growth of CPs was divided into four basic patterns—infra-diaphragmatic (ID), extra-arachnoidal (EA), intra-arachnoidal (IA) and sub-arachnoidal (SA) growth. The IA growth pattern can be further subdivided into two subtypes—namely, IA1 (with tumor growing within the fibrous component of the ASPS) and IA2 (with tumor growing within the trabecular component). This method of topographical division can be used to understand the growth of CP—infra-diaphragmatic CP show growth pattern ID or ID together with EA. Suprasellar CP can show an extra-ventricular growth pattern (EA or IA2), an extra- and intra-ventricular (IA2 + SA) growth pattern, a trans-infundibular growth pattern (ID + IA1 + SA) and an infundibulo-tuberal growth pattern (SA or SA + IA1). There is a statistically significant difference between CP growth patterns in children and adults. A predominance of ID growth is noted in children while adults tend to show a pattern of predominantly Extra-ventricular (EV) growth.ConclusionOur proposed classification details the relationship of the surrounding structures to CPs and purports to predict and identify the intraoperative anatomical stratification. It also attempts to help predict the growth patterns of these tumors. A knowledge of the intimate relations of the tumor and its key surrounding structures allows for safe surgical removal.

When to address level I lymph nodes in neck dissections?

Objective To investigate the involvement of level I neck lymph node groups in head and neck carcinoma and compare the effect of primary tumor sites, such as oral cavity (OC), oropharynx (OP), hypopharynx (HP), and larynx (Lx), on level I lymph node metastasis. Study Design Case series with chart review. Setting Comprehensive Cancer Center. Subjects and Methods A total of 243 patients with OC and laryngopharyngeal carcinoma who underwent neck dissections in the last three years were included in the study. The primary tumor site was OC, followed by OP, Lx, HP, and carcinoma of unknown primary (CUP). Results Level I was involved in 29 of 243 (11.9%) patients. The other levels were also positive in all but five (17.2%) level I–involved patients. The primary tumor site with level I lymph node metastasis was OC (19.1%), followed by CUP (11.1%), OP (9.8%), Lx (4.4%), and HP (0%). The Lx primary site involved level I only if there were multiple other adverse prognostic features, such as N3 neck, extracapsular spread, pathologic involvement of all resected lymph nodes, involvement of all levels I-V, and invasion of the submandibular gland. Conclusion Although the submandibular content is resected as part of radical and modified radical neck dissections, level I–sparing selective neck dissections could be a safe and effective surgical neck management strategy in appropriately selected patients with OP, Lx, and HP carcinoma.

Endoscopic Endonasal Trans-sphenoidal Optic Nerve Decompression for Traumatic Optic Neuropathy -Technical Note-

The endoscopic endonasal trans-sphenoidal approach can decompress the traumatized and swollen optic nerve without brain retraction. Three cases of traumatic optic neuropathy (TON) were treated by this endoscopic approach. We performed 58 endoscopic endonasal trans-sphenoidal approaches in 52 patients between April 2006 and December 2007. Three patients, 2 men and a woman aged 42-66 years, with TON were treated by endoscopic endonasal trans-sphenoidal optic nerve decompression. Adequate decompression of the optic canal was observed in all three patients. Two experienced improved visual function, but the third did not. No surgical complications were observed in any patient. We were able to reach the optic canal above the opticocarotid recess near the orbit. Endoscopic endonasal trans-sphenoidal optic canal decompression using a navigation system may be a safe and effective surgical strategy in carefully selected patients with TON.

Traumatic pancreatic fistula with sinistral portal hypertension: Surgical management

Combined ductal and vascular injuries are awesome complications of pancreatic injury. We report on a 29-year-old male unrestrained driver who sustained a blunt abdominal injury from the steering wheel in a high velocity head-on car collision. He developed a pancreatic fistula, portosplenic venous thrombosis and sinistral portal hypertension as a result of complete duct disruption at the pancreatic neck. We describe a safe surgical strategy of spleen-preserving distal pancreatectomy after failed medical and endoscopic management.

Surgical Treatment of Inferior Vena Cava Tumor Thrombus in Patients with Renal Cell Carcinoma

Radical nephrectomy with inferior vena cava (IVC) thrombectomy remains the most effective therapeutic option in patients with renal cell carcinoma and IVC tumor thrombus. Cephalic extension of the thrombus is closely related to perioperative morbidity. We purposed to design a safe and successful surgical strategy through a review of our surgical experience and treatment results in 35 patients (male:female=28:7, mean age=56 yr [32-77]) who underwent IVC thrombectomy with radical nephrectomy between January 1997 and December 2006. The limit of tumor extension was level I in 10 patients (28.6%), level II in 17 (48.6%), and level III and IV in 4 patients each (11.4%). Liver mobilization with hepatic vascular exclusion was performed in 12 patients and cardiopulmonary bypass in 7. Thirty-two primary closures, 2 patch closures, and 1 graft interposition were performed. One patient underwent simultaneous pulmonary embolectomy because of an operative pulmonary embolism. There was no operative mortality, and the overall survival at 5-yr was 50.8%. Complete thrombus removal without tumor fragmentation under long venotomy on fully exposed involved IVC is recommended for successful result in a bloodless operative field. The applicability of liver mobilization, hepatic vascular exclusion, and cardiopulmonary bypass, can be determined by the level of thrombus.