Single-stage Excision Research Articles

Choledochal cyst with portal hypertension: A case report

Introduction: Choledochal cysts in adults are commonly associated with hepatobiliary pathology and complications of previous cyst related procedures. Portal hypertension is a rare complication of choledochal cyst. The treatment of choledochal cyst complicated by portal hypertension has evolved from internal drainage of cysts to single stage excision of cyst with bilio­enteric anastomosis. Case Report: A 15­year­old female presented with typical triad of abdominal pain, abdominal lump and jaundice. Magnetic resonance cholangiopan­ creatography (MRCP) was suggestive of type­I choledochal cyst with portal hypertension. An upper gastrointestinal endoscopy revealed grade 1 esophageal varices with proximal gastropathy. Intraoperatively, the posterior wall of the choledochal cyst was densely adherent to the portal vein and hence a partial excision of cyst with stripping of the mucosa of the posterior wall of the cyst along with Roux­en­Y hepaticojejunostomy was done. Conclusion: Single stage excision of choledochal cyst with bilio­enteric anastomosis is the treatment of choice of choledochal cyst with portal hypertension. Portal decompression is reserved for cases with extensive collaterals in the hepatoduodenal ligament.

Hemivertebra Excision for Congenital Scoliosis

Hemivertebrae result from a failure of complete formation of the vertebral body and present as a challenging clinical entity. Progression and ultimate curve magnitude is associated with the degree of segmentation. An accurate assessment and a close follow-up are necessary to make appropriate treatment decisions. The goal of any intervention is to stop progression and provide the smallest degree of deformity at skeletal maturity. If a high degree of deformity is anticipated, intervention should be attempted sooner rather than later. In these cases, an in situ fusion may be appropriate. Single-stage hemivertebra excision is an effective method of both correction and stabilization; however, the procedure is technically demanding.

Single-stage operation for a giant haemangiopericytoma following intracranial feeder embolization

Meningeal haemangiopericytomas (HPC) are malignant intracranial neoplasms that commonly recur and metastasize. Large size at diagnosis, abundant intracranial feeders and the risk of intraoperative bleeding can make them difficult to completely remove in one operation. We report here a rare case of a gaint HPC which was treated successfully using a one-stage operation following superselective intracranial feeder occlusion. A 30-year-old man presented with a left middle cranial fossa tumour extending to the left temporal lobe and cerebellar tentorium. Angiography revealed supply from a dilated left posterior temporal artery branching from the posterior cerebral artery. The tumour was totally removed in a single-stage excision after embolization of the intracranial major feeding artery. The present case suggests the usefulness of preoperative embolization for HPC, particularly of intracranial feeders, to achieve total resection safely in a single operation.

Treatment of Infected Urachal Cysts

The urachus is a fibrous cord that arises from the anterior bladder wall and extends cranially to the umbilicus. Traditionally, infection has been treated using a two-stage procedure that includes an initial incision and drainage which is then followed by elective excision. More recently, it has been suggested that a single-stage excision with improved antibiotics is a safe option. Thus, we intended to compare the effects of the two-stage procedure and the single-stage excision. We performed a retrospective review on nine patients treated between May 1990 and September 2005. The methods used in diagnosis were ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and cystoscopy. The study group was comprised of three males and six females with a mean age of 28.2 years (with a range from three to 71 years). Symptoms consisted of abdominal pain, abdominal mass, fever, and dysuria. The primary incision and drainage followed by a urachal remnant excision with a bladder cuff excision (two-stage procedure) was performed in four patients. The mean postoperative hospitalization lasted 5.8 days (with a range of three to seven days), and there were no reported complications. A primary excision of the infected urachal cyst and bladder cuff (single-stage excision) was performed in the other five patients. These patients had a mean postoperative hospitalization time of 9.2 days (with a range of four to 15 days), and complications included an enterocutaneous fistula, which required additional operative treatment. The best method of treating an infected urachal cyst remains a matter of debate. However, based on our results, the two-stage procedure is associated with a shorter hospital stay and no complications. Thus, when infection is extensive and severe, we suggest that the two-stage procedure offers a more effective treatment option.

Single-Stage Reconstruction of Perforated Choledochal Cyst: Case Report and Review of the Literature

Choledochal cysts represent a rare disease in the Western world. We reviewed our recent experience with a case of perforated choledochal cyst, define the currently accepted treatment options, and review the literature of this unusual disease. An 11-month-old girl presented with abdominal pain and distention as well as non-bilious vomiting. Subsequent workup included endoscopic retrograde cholangiopancreatography revealing a perforated type I choledochal cyst. She underwent single-stage excision and reconstruction with a Roux-en-Y hepaticojejunostomy. Perforated choledochal cyst is a rare event, and prompt surgical intervention is warranted. Single-stage cystectomy and Roux-en-Y reconstruction is possible in select patients. A thorough understanding of the pathophysiology, management, and follow-up is required.

Ethmoidal osteoid osteoma with orbital and intracranial extension – a case report

BackgroundOsteoid osteoma is a benign bone neoplasm which is seen in the long bones of appendicular skeleton. It is rarely seen in the cranium. Skull base osteoid osteoma is extremely rare and has been anecdotally reported.Case presentationThe authors report a case of a large osteoid osteoma of the ethmoid with intraorbital and intracranial extension in a 33 year old male patient. He presented with loss of vision in the left eye. The intra-cranial extension was excised through a single burr-hole fronto-orbitotomy. The ethmoid and orbital portions were approached and excised through a Weber-Ferguson incision and inferior orbitotomy. Radical excision of the tumor could thus be achieved through a craniofacial approach.ConclusionAlthough benign and rare, skull base osteoid osteoma can present with neurological deficit due to its mass effect and involvement of vital structures. A multispeciality team approach is advisable in such cases if radical excision is to be achieved. A craniofacial approach made radical single stage excision of this multicompartmental osteoid osteoma possible with an uneventful postoperative period.

An insidious preauricular sinus presenting as an infected postauricular cyst

Preauricular sinuses are common congenital malformations that usually occur at the anterior margin of the ascending limb of the helix. We present three paediatric patients with postauricular infected cysts and coincidentally discovered auricular pits. Single-stage operations were performed to remove the cysts, pits and involved cartilage. Histopathology revealed a preauricular sinus with inflammation. Although uncommon, a postauricular infected cyst may indicate the presence of a preauricular sinus. Detailed physical examination of preauricular pits should be performed, and the operating microscope may aid during surgery to remove remnants and prevent recurrence. An infected preauricular sinus can be effectively treated with single-stage excision.

A review of the current management of infantile subglottic haemangioma, including a comparison of CO 2 laser therapy versus tracheostomy

Objectives: We reassessed the current practice and treatment options used in the management of subglottic haemangiomas (SGHs), including the place for open submucosal surgical excision, and have compared the results of different therapeutic modalities used for SGHs. Methods: The two studies were conducted as separate exercises; (1) a retrospective review of 36 patients collected over a recent 8-year period to assess the current practice and treatment options in use; (2) a retrospective comparative study of a previous cohort of 51 patients with SGHs treated in one of four groups: (a) tracheostomy alone, (b) tracheostomy and CO 2 laser, (c) systemic steroids and CO 2 laser (no tracheostomy) and (d) intralesional steroid injection, CO 2 laser therapy, or both, followed by intubation. Results: Systemic steroids were the most commonly used modality of treatment. Resolution of the SGH was achieved in 89% of cases at a mean follow up duration of 34 months. However, tracheostomy was required in 58% of cases, with a mean time from diagnosis to decannulation of 30 months. The time to resolution of SGHs does not appear to be reduced by laser therapy compared with treatment by tracheostomy alone. Intralesional steroid injection or laser therapy together with intubation was associated with avoidance of a tracheostomy in 66% of cases. Single-stage open surgical excision in two cases resulted in successful resolution of the SGH and discharge after a mean follow up period of 3 months. Conclusions: Despite the more widespread use of steroids and other treatment modalities, the requirement for tracheostomy has remained unchanged over the last 20 years. The use of laser therapy does not appear to confer any additional therapeutic benefit over and above tracheostomy alone in bringing about resolution of SGHs. Systemic steroids may reduce the size of the haemangioma but are associated with multiple adverse effects. The decision to use the above techniques must, therefore, be made in the light of these observations. Our early experience of single-stage excision suggests that this technique represents an exciting and promising surgical alternative, and its more widespread adoption may be the only way of further improving the outcome of patients with SGHs.

Lateral parascapular extrapleural approach for single-stage excision of dumb-bell neurofibroma

An excision of a T1 dumb-bell neurofibroma via a single-stage lateral parascapular extrapleural approach is described. The different surgical approaches that can be used to approach dumb-bell tumours are reviewed, together with the relevant literature.

The amniotic band syndrome: single-stage correction

Two cases of amniotic band syndrome treated by single-stage excision of the ring and multiple Z-plasty repair are presented. In both cases the author found the procedure technically easy and clinically safe. No complications were encountered in either case.

Staged Excision and Reconstruction of Extensive Facial-Orbital Tumors

Extensive facial-orbital tumors are basal cell carcinomas which are exceptionally difficult to treat by conventional therapy because of: (1) skin involvement of more than one square inch of the eyelids of face; (2) fixation to bone or periosteum at the orbital rim; and (3) extension onto the inner surface of the eyelid or through the orbital septum. Due to indistinct skin margins, visual impressions of the extent of these tumors are unreliable. Radiation is usually contraindicated because of possible bone involvement. Single stage excision of the entire tumor with frozen section evaluation of the margins is difficult because of the extent of the facial and orbital components of the lesion. A technique is described which involves staged excision and reconstruction of such extensive tumors. Stage one involves lamellar resection of the skin tumor. Lamellar resection is a modification of the Mohs technique, using permanent section evaluation of all margins, after which the surgical defect is allowed to heal by granulation or is grafted. Stage two involves en bloc resection of the remaining tumor, with frozen section evaluation of all margins. Stage three involves later cosmetic and functional reconstruction of the orbit and eyelids in a tumor-free location. The use of this technique is demonstrated by the description of a patient who would probably have required exenteration if conventional surgical methods had been used.

RECONSTRUCTION OF THE ESOPHAGUS WITH LEFT COLON

SUMMARY 1. The clinical applications of left colon transplants in the management of irreversible esophageal obstruction in 105 patients, and the early and late results, are reviewed. 2. Left colon transplantation satisfied the five criteria of successful esophageal reconstruction. 3. The procedure permits a single-stage excision and reconstruction of the obstructed esophagus. 4. The left-sided thoracoabdominal approach allows a choice of two methods of restoring esophageal continuity, depending upon anatomical and pathological considerations revealed at operation. 5. On the evidence revealed by this investigation, left colon interposition is preferable to esophagogastrostomy, on the score of operative risks and improved late results, in the management of benign esophageal stenosis. Esophagogastrostomy may still be the method of choice in the majority of cases of malignant obstruction.