Specific Surgical Approaches Research Articles

Individual management and prognostic assessment for long-term outcomes using a novel classification system of craniopharyngiomas: a retrospective study of single institution

PurposeThis study aims to propose a classification system to more accurately understand the features and nature of different CPs, to investigate the correlation between different topographies of CPs and their surgical outcomes.MethodsA retrospective analysis was conducted on 91 surgically resected CPs. They were categorized into six types based on their location and origin. Simultaneously, the patients were divided into four categories based on the degree of pituitary stalk(PS) preservation postoperatively. Statistical analysis was performed to compare the variables among the different tumor type groups.ResultsA total of 91 patients were included. The follow-up data for 59 cases were complete. Tumor volume varied significantly, with the suprasellar-third ventricle type II and ectopic type exhibiting larger volumes (P < 0.05). The choice of surgical approach differed significantly. The recurrence rates were significantly lower for the intrasellar-suprasellar type, suprasellar-third ventricle type II, and third ventricle type (P < 0.05). Patients with intra-stalk tumor growing pattern have a lower degree of PS preservation than those with peri-stalk pattern (P < 0.05). Patients’ BMI after surgery was generally higher than before, and the incidence of pituitary dysfunction increased significantly. The proportion of long-term endocrine dysfunction was significantly higher in patients with complete disconnection of PS compared to those with preservation of the PS(P < 0.05).ConclusionsThis system holds significant importance in foretelling the rates of recurrence, alterations in postoperative body weight, long-term endocrine status, and potential complications. Furthermore, this study identified preoperative pituitary function status and specific surgical approaches as potential protective factors.

Surgical Decision-Making: Who Should Be Offered Sacrocolpopexy?

Women undergoing surgery for apical pelvic organ prolapse have several medically sound options for specific surgical approaches. We review the principles of shared decision-making as they pertain to surgery for prolapse. We review the literature supporting the superior sacrocolpopexy as a durable treatment for prolapse and the factors that may differentiate it from other repairs in risk and benefit. We emphasize the importance of collaboration between patients and surgeons in surgical decision-making. All medically appropriate patients who desire reconstructive surgery for prolapse should be offered sacrocolpopexy.

Long-term outcomes among survivors of childhood osteosarcoma: A report from the Childhood Cancer Survivor Study (CCSS).

Treatment strategies for osteosarcoma evolving between 1970 and 1999 improved 5-year survival and continue as standard of care today. This report evaluates the impact of these evolving therapies on long-term health outcomes. Five-year survivors of childhood osteosarcoma in CCSS treated from 1970 to 1999 were evaluated for late (>5years from diagnosis) mortality, chronic health conditions (CHCs), and health status using piecewise-exponential and logistical models. Comparisons were made between survivors and siblings without cancer, and among survivors examining historical and current standard chemotherapies (e.g., methotrexate/doxorubicin/cisplatin [MAP] vs. others), specific chemotherapy agents and surgical approaches (amputation vs. limb salvage [LS]). Models were evaluated adjusting for attained age, sex, race, ethnicity, and age at diagnosis. A total of 1257 survivors of osteosarcoma were followed on average for 24.4years. Twenty-year all-cause late mortality was 13.3% (95% confidence interval [CI]: 11.7%-14.9%) overall and 11.7% (95% CI: 6.9%-16.5%) for the subset treated with MAP plus LS. Survivors were at higher risk of CHCs (rate ratio [RR] 3.7, 95% CI: 3.2-4.3) than the sibling cohort, most notably having more serious cardiac, musculoskeletal, and hearing CHCs. Within the survivor cohort, the risk of severe CHCs was twice as high with MAP versus no chemotherapy (RR 2.1, 95% CI: 1.3-3.4). Compared with primary amputation, serious musculoskeletal CHCs were higher after LS (RR 6.6, 95% CI: 3.6-13.4), without discernable differences in health status. Contemporary osteosarcoma therapy with MAP plus LS, while improving 5-year disease-free survival, continues to be associated with a high burden of late mortality, CHCs, and health status limitations.

SURG-28. MULTI-STAGE, OPEN CRANIAL APPROACHES FOR RESECTION OF PRIMARY INTRACRANIAL NEOPLASMS: A SYSTEMATIC REVIEW OF THE HISTORY AND CURRENT APPLICATIONS

Abstract Staged surgery for skull base lesions has been utilized to facilitate maximal safe resection and optimize outcomes while minimizing morbidity and complications. Conversely, staged surgery for primary intraparenchymal neoplasms is less commonly performed and has not been reported as extensively within the literature. As such, we performed a systematic review to examine the unique surgical indications for staging, timing between stages, specific surgical approaches utilized, and postoperative complications of staged surgery for primary intra-axial neoplasms. METHODS: A literature search was conducted in August 2021 using PubMed, Web of Science, and Cochrane databases using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations. Titles and abstracts were evaluated independently by 2 authors, after which articles were selected for final analysis based on application of strict inclusion criteria during full text screen. Each included article was then qualitatively assessed and relevant variables—including operative approaches, timing, and outcomes—were extracted for synthesis. RESULTS: Of 115 results, 7 articles were included for final analysis and consisted of 17 pediatric and 4 adult patients. Staged approaches were more commonly utilized in the pediatric patient population for resection of astrocytoma and glioma. Pediatric patients had a timing of surgeries ranging from 5–10 days between operations, compared with 18 days to 4 months in adult patients. Complications in pediatric patients were most commonly hemiparesis, hydrocephalus, cranial nerve VI and VII palsies, truncal ataxia, and cerebellar mutism, while complications in adult patients included language and abstract thinking deficits, respiratory failure, and motor weakness. CONCLUSION: This study reports the first comprehensive review of staged surgical procedures for primary, intra-axial cranial neoplasms. There exists a large degree of heterogeneity in complications resulting from staged surgeries for intra-axial neoplasms, which are similar to complications associated with single-stage surgery for intraparenchymal lesions as well as multi-stage surgeries for skull base lesions.

Staged Open Cranial Surgery for Primary Intra-axial Neoplasms: A Systematic Review

Staged surgery for skull base lesions has been utilized to facilitate maximal safe resection and optimize outcomes while minimizing morbidity and complications. Conversely, staged surgery for primary intraparenchymal neoplasms is less commonly performed and has not been reported as extensively within the literature. As such, we performed a systematic review to examine the unique surgical indications for staging, timing between stages, specific surgical approaches utilized, and postoperative complications of staged surgery for primary intra-axial neoplasms. A literature search was conducted in August 2021 using PubMed, Web of Science, and Cochrane databases using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations. Titles and abstracts were evaluated independently by 2 authors, after which articles were selected for final analysis based on application of strict inclusion criteria during full text screen. Each included article was then qualitatively assessed and relevant variables-including operative approaches, timing, and outcomes-were extracted for synthesis. Of 115 results, 7 articles were included for final analysis and consisted of 17 pediatric and 4 adult patients. Staged approaches were more commonly utilized in the pediatric patient population for resection of astrocytoma and glioma. Pediatric patients had a timing of surgeries ranging from 5-10 days between operations, compared with 18 days to 4 months in adult patients. Complications in pediatric patients were most commonly hemiparesis, hydrocephalus, cranial nerve VI and VII palsies, truncal ataxia, and cerebellar mutism, while complications in adult patients included language and abstract thinking deficits, respiratory failure, and motor weakness. This study reports the first comprehensive review of staged surgical procedures for primary, intra-axial cranial neoplasms. There exists a large degree of heterogeneity in complications resulting from staged surgeries for intra-axial neoplasms, which are similar to complications associated with single-stage surgery for intraparenchymal lesions as well as multi-stage surgeries for skull base lesions.

Current Approaches in Surgical and Immunotherapy-Based Management of Renal Cell Carcinoma with Tumor Thrombus.

Renal cell carcinoma (RCC) accounts for 2-3% of all malignant disease in adults, with 30% of RCC diagnosed at locally advanced or metastatic stages of disease. A form of locally advanced disease is the tumor thrombus (TT), which commonly grows from the intrarenal veins, through the main renal vein, and up the inferior vena cava (IVC), and rarely, into the right cardiac chambers. Advances in all areas of medicine have allowed increased understanding of the underlying biology of these tumors and improved preoperative staging. Although the development of several novel system agents, including several clinical trials utilizing immune checkpoint inhibitors and combination therapies, has been shown to lower perioperative morbidity and increase post-operative recurrence-free and progression-free survival, surgery remains the mainstay of therapy to achieve a cure. In this review, we provide a description of specific surgical approaches and techniques used to minimize intra- and post-operative complications during radical nephrectomy and tumor thrombectomy of RCC with TT extension of various levels. Additionally, we provide an in-depth review of the major developments in neoadjuvant and adjuvant immunotherapy-based treatment and the impact of ongoing and recently completed clinical trials on the surgical treatment of advanced RCC.

Sagittal alignment in patients with flexion contracture of the hip before and after total hip arthroplasty.

In hip osteoarthritis, hip flexion contracture can severely alter the patient's alignment, and, therefore, affect the patient's quality of life (QOL). Hip contracture is not well-studied, partly because of the difficulties of its diagnosis. The aim of this study was to propose a quantitative definition of hip flexion contracture, and to analyse sagittal alignment in these patients compared to non-contracture ones, before and 12months after total hip arthroplasty (THA). Consecutive patients with hip arthrosis and an indication for THA were included (N = 123). Sagittal full-body radiographs were acquired in free standing position and in extension. QOL questionnaires were administered before and after surgery. Spinopelvic parameters were measured, including the pelvic-femur angle (PFA). Patients with low pelvic incidence (< 45°) were included in the hip contracture group if PFA > 5°, or PFA > -5° when pelvic incidence ≥ 45°. 29% of patients were in the hip flexion contracture group, and they showed lower pelvic tilt than the no-contracture group (p < 0.001), larger lumbar lordosis (LL) and smaller PI-LL (p < 0.001), as well as a forward position of the head. 16% of patients still had hip contracture 12-months postop. Contracture patients showed higher QOL scores after surgery. The proposed method to diagnose hip contracture group allowed to define a group of patients who showed a specific pattern of sagittal spinopelvic alignment. These patients improved their alignment and quality of life postoperatively, but their hip mobility was not always restored. Diagnosing these patients is a first step toward the development of more specific surgical approaches, aiming to improve their surgical outcome.

Resection of a Dumbbell-Shaped Facial Nerve Schwannoma With Preservation of Facial Nerve Function Through the Extended Middle Fossa Approach: 2-Dimensional Operative Video.

Facial nerve schwannomas are rare and can arise from any segment along the course of the facial nerve.1 Their location and growth patterns present as distinct groups that warrant specific surgical management and approaches.2 The management challenge arises when the facial nerve maintains good function (House-Brackmann grade I-II).3 Hence, a prime goal of management is to maintain good facial animation. In large tumors, however, resection with facial nerve function preservation should be sought and is achievable.4,5 While tumors originating from the geniculate ganglion grow extradural on the floor of the middle fossa, they may extend via an isthmus through the internal auditory canal to the cerebellopontine angle forming a dumbbell-shaped tumor. Despite the large size, they may present with good facial nerve function. These tumors may be resected through an extended middle fossa approach with preservation of facial and vestibulocochlear nerve function. The patient is a 62-yr-old man who presented with mixed sensorineural and conductive hearing loss and normal facial nerve function. Magnetic resonance imaging (MRI) revealed a large tumor involving the middle fossa, internal auditory meatus, and cerebellopontine angle. The tumor was resected through an extended middle fossa approach with a zygomatic osteotomy and anterior petrosectomy.6 A small residual was left at the geniculate ganglion to preserve facial function. The patient did well with hearing preservation and intact facial nerve function. He consented to the procedure and publication of images. Image at 1:30 © Ossama Al-Mefty, used with permission. Images at 2:03 reprinted from Kadri and Al-Mefty,6 with permission from JNSPG.

Echinococcosis of the liver: evolution of surgical treatment

To analyze the development of surgical approaches for hepatic echinococcosis. We have analyzed diagnosis and treatment of 349 patients with liver echinococcosis; 97 patients were treated at the Botkin Clinical Hospital for the period from 2009 to 2019 and 252 patients were treated in surgical hospitals of Moscow city for the period from 2014 to 2019. General and specific postoperative complications, relapses and surgical approaches were assessed. The number of echinococcectomies performed in surgical hospitals of Moscow is 3 times higher compared to the Botkin Hospital. The number of liver resections is comparable in both groups. The number of pericystectomies is more than 2 times higher in the Botkin Hospital. PAIR technique was more common in surgical hospitals of Moscow. Evolution of surgical treatment from open echinococcectomy to anatomical liver resections and subsequent pericystectomy with PAIR technique becomes another round of evolutionary spiral in the development of surgical treatment of liver echinococcosis.

Narrative review of assessing the surgical options for double outlet right ventricle.

The individualized surgical approach in individuals with both arterial trunks arising from the morphologically right ventricle is dictated by the extreme morphological variability encountered in this setting, with each patient being unique. An individualized surgical approach has been designed to take account of the morphological variations, identifying the anatomy with the preoperative three-dimensional CT scan reconstruction. The key features have been considered the distance between tricuspid and pulmonary valves, the size and location of the interventricular communication, and the relationship between the outflow tracts. The surgical approach is tailored, whenever feasible, to create a connection between left ventricle and aorta, but primarily to achieve biventricular repair. Account has been taken of all available surgical options already reported in the literature, identifying the most suitable to provide the best outcomes for each unique morphology. To date, meaningful comparison between different reported surgical series has been difficult because of the marked variation of individual intracardiac morphology, and the lack of reports of specific surgical approaches for well-categorized groups of patients. Our approach, being tailored to the individual cardiac morphology, can be offered to any patient with this ventriculo-arterial connection. Given the difficulties of diagnosis, and the multiple therapeutic indications, very close collaboration between cardiologists and surgeons is indispensable for further progress in the understanding and management of this complex congenital cardiac lesion.

Abordagem clínico-cirúrgica de desvio portossistêmico congênito em pequenos animais: quais as novidades?

Foi realizada uma revisão sobre a fisiopatogenia, sinais clínicos, diagnóstico e principais tratamentos e técnicas para o desvio portossistêmico em pequenos animais. As fontes pesquisadas foram: CAB, MEDILINE por um período retrospectivo de 20 anos e acervos da Biblioteca da Faculdade de Medicina Veterinária e Zootecnia (FMVZ) da Universidade de São Paulo (USP). O desvio portossistêmico congênito (DPSC) é uma das anormalidades vasculares mais comuns em cães, as raças de pequeno porte apresentam maior incidência. Os DPSCs em cães e gatos são comunicações vasculares que ocorrem do sistema venoso portal para o sistema venoso sistêmico, ou seja, fazem uma via secundária. Há dois tipos de DPSCs, intra-hepático e extra-hepático, observados com frequência em raças de grande porte e miniaturas, respectivamente. O diagnóstico é baseado no histórico de animais jovens com retardo de crescimento, letargia, convulsão ou distúrbio de comportamento principalmente após alimentação, retorno demorado de anestesia ou sedação, crise de encefalopatia hepática, em raças predispostas. A confirmação do vaso anômalo é realizada pela ultrassonografia com doppler, angiografia por tomografia computadorizada ou por ressonância magnética. O manejo clínico pode aliviar sinais clínicos de encefalopatia hepática, porém em longo prazo, é questionável, pois o fluxo sanguíneo portal continua desviado para a circulação sistêmica, comprometendo a distribuição de fatores hepatotróficos ao fígado e ocorrendo uma contínua atrofia do mesmo. O único tratamento definitivo é o cirúrgico, idealmente com técnica que atenue progressivamente o vaso anômalo e evite a hipertensão portal aguda. Dentre as técnicas de tratamento cirúrgico descritas o uso de ameroide constrictor apresenta-se como uma das formas mais seguras a obtenção do fechamento do desvio. Entretanto, os portadores de DPSC podem sofrer de complicações perioperatórias graves e necessitam de abordagem clínicocirúrgica específica, associado a um diagnóstico por imagem precisa para a correta localização do vaso anômalo e sucesso cirúrgico.

Prognostic role of positron emission tomography and computed tomography parameters in stage I lung adenocarcinoma.

BackgroundAccording to the current pathological classification, lung adenocarcinoma includes histological subtypes with significantly different prognoses, which may require specific surgical approaches. The aim of the study was to assess the role of CT and PET parameters in stratifying patients with stage I adenocarcinoma according to prognosis.Patients and methodsFifty-eight patients with pathological stage I lung adenocarcinoma who underwent surgical treatment were retrospectively reviewed. Adenocarcinoma in situ and minimally-invasive adenocarcinoma were grouped as non-invasive adenocarcinoma. Other histotypes were referred as invasive adenocarcinoma. CT scan assessed parameters were: ground glass opacity (GGO) ratio, tumour disappearance rate (TDR) and consolidation diameter. The prognostic role of the following PET parameters was also assessed: standardized uptake value (SUV) max, SUVindex (SUVmax to liver SUVratio), metabolic tumour volume (MTV), total lesion glycolysis (TLG).ResultsSeven patients had a non-invasive adenocarcinoma and 51 an invasive adenocarcinoma. Five-year disease-free survival (DFS) and cancer-specific survival (CSS) for non-invasive and invasive adenocarcinoma were 100% and 100%, 70% and 91%, respectively. Univariate analysis showed a significant difference in SUVmax, SUVindex, GGO ratio and TDR ratio values between non-invasive and invasive adenocarcinoma groups. Optimal SUVmax, SUVindex, GGO ratio and TDR cut-off ratios to predict invasive tumours were 2.6, 0.9, 40% and 56%, respectively. TLG, SUVmax, SUVindex significantly correlated with cancer specific survival.ConclusionsCT and PET scan parameters may differentiate between non-invasive and invasive stage I adenocarcinomas. If these data are confirmed in larger series, surgical strategy may be selected on the basis of preoperative imaging.

Treatment Strategy for Petroclival Meningiomas Based on a Proposed Classification in a Study of 168 Cases

Petroclival meningiomas (PCMs) are regarded as one of the most formidable challenges in neurosurgery. We retrospectively assessed the surgical outcomes of PCMs based on a tumor classification to evaluate the long-term outcomes. A series of 168 patients with PCMs from July 1996 to January 2017. On the basis of the difference in the origin of dural attachment and patterns of growth, the PCMs were classified into 4 different types. The clinical characteristics, surgical record, and follow-up data of each type were reviewed. The study included 138 females (82.1%) with an average age of 49.9 ± 16.2 years. And 138 cases (82.1%) had developed neurological deficits preoperatively with the average tumor size of 44.0 ± 10.6 mm. Specific surgical approaches were applied depended on the tumor classification. Gross total resection (GTR) was achieved in 119 cases (70.8%) with the complications of 46 cases (27.7%). With a median follow-up of 86.5 months, there were 41 cases of recurrence/progress (25.7%) and 39 cases of morbidity (26.4%). Compared with the non-GTR group, the GTR significantly decreased the R/P rate (P = 0.001), prolonged the R/P-FS time (P = 0.032) and improved the follow-up neurological status (P = 0.026). Favorable outcomes and acceptable morbidity were achieved with the treatment strategy of the choice of specific approaches for each type. Meanwhile, the differences of each type in diverse clinical characteristic were verified. Individualized assessment and suitable approach choice should be based on the tumor classification to improved the GTR and quality of life for patients.

Risk factors for infection following ingrowing toenail surgery: a retrospective cohort study

BackgroundIngrowing toenails are a common and painful condition often requiring surgical management. Practitioners who perform surgery on ingrowing toenails include orthopaedic surgeons, general practitioners, podiatrists and podiatric surgeons. There has been limited investigation into the specific surgical approaches used by Australian podiatric surgeons for ingrowing toenails, or the associated infection rates for these procedures. The aim of this study was to assess the frequency and type of ingrowing toenail surgery performed by podiatric surgeons, and identify risk factors for post-operative infection.MethodsData was entered into the Australian College Podiatric Surgeons (ACPS) National Audit Tool for all patients who underwent foot and ankle surgery performed by podiatric surgeons in Australia between January 2014 and December 2017. Infection within the first 30 days following surgery was recorded according to the ACPS national audit descriptors. Infection rates, risk ratios (RR) and 95% Confidence Intervals (CI) were calculated to determine postoperative infection risk.ResultsOf 7682 records, 1831 reported 2712 diagnoses of ingrowing nails. Patients with a diagnosis of ingrowing toenails were younger, less likely to have systemic disease, and a lower proportion were female compared to those without ingrowing toenails. Furthermore, they were more likely to be diagnosed with a post-operative infection than those without ingrowing toenails (RR = 2.72; CI = 2.00–3.69; P < 0.01). Univariate risk factors for post-operative infection following ingrowing toenail surgery include age greater than 60 years (RR = 3.16; CI = 1.53–6.51; P < 0.01), surgery performed in an office setting (RR = 1.77; CI = 1.05–2.98; P = 0.04), and radical excision of toenail bed procedure (RR = 2.35; CI = 1.08–5.01; P = 0.04). Patients that underwent radical excision or office based procedures were on average older, and more likely to have systemic disease. Further, radical excision procedures were more likely to be performed in office base settings.ConclusionsIngrowing toenail surgery carries a greater risk of postoperative infection than other procedures performed by podiatric surgeons. Radical excision of toenail bed was associated with higher postoperative infection rates compared to other ingrowing toenail procedures. Procedures performed in an office setting carry a higher risk of infection. Further research into these associations is recommended.

Laminectomy Versus Corpectomy for Spinal Metastatic Disease—Complications, Costs, and Quality Outcomes

The landmark Patchell trial established surgical decompression followed by adjuvant radiotherapy as standard-of-care for patients with spinal cord compression caused by metastatic cancer. However, little comparative evidence exists with regard to the choice of specific surgical approaches for these patients. We sought to conduct a comparative analysis of outcomes of surgical options for spinal metastatic disease. This was an epidemiologic study using national administrative data from the MarketScan database. We queried the MarketScan database (2007-2016), identifying patients with a diagnosis of spinal metastasis treated with surgical decompression (N= 1054). We used descriptive statistics and hypothesis testing to compare baseline characteristics, complications, quality metrics, and costs. We identified patients with spinal metastases undergoing laminectomy (N= 760), corpectomy (N= 193), or both combined procedures (laminectomy and corpectomy, N= 101). No significant differences in baseline demographics, follow-up time, or primary tumor histology were observed. We found a greater 30-day postoperative complication rate among patients undergoing corpectomy (P < 0.0001), driven by increased rate of postoperative anemia and pulmonary complications. Length of stay and 30-day readmission rates did not vary between surgical approaches. Total index hospitalization and 30-day payments were greatest among patients undergoing combined procedures and lowest for patients undergoing laminectomy alone. Our findings highlight distinct complication profiles and quality outcomes associated with selection of surgical approach for patients with spinal metastases. These findings must be interpreted with a clear understanding of the limitations.

How can the articular surface of the tibial plateau be best exposed? A comparison of specific surgical approaches.

The correct choice of a fracture-specific surgical approach with an articular accessibility in complex tibial plateau fractures to facilitate durable fracture fixation of the anatomic articular reconstruction is under debate, as the most important risk factor for malreduction in complex tibial plateau fractures is an impaired visualization of the articular surface. Six established surgical approaches were simulated on 12 cadaver knees. The visible articular surface was labeled with an electrocautery device for each approach and subsequently analyzed with ImageJ. Areas of each hemiplateau were compared using the Student's t test. In the lateral tibial plateau, the dorsal 19.0 ± 5.8% of the articular surface could be exposed via the postero-lateral approach. Via the antero-lateral arthrotomy, 36.6 ± 9.4% of the anterior articular surface was visible. The additional osteotomy of the lateral femoral epicondyle significantly increased the exposure to 65.6 ± 7.7% (p < 0.001). In the medial tibial plateau, the osteotomy of the medial femoral epicondyle significantly improved visualization of the medial articular surface (62.3 ± 8.6%) compared to the postero-medial approach (14.0 ± 7.3%) and the antero-medial approach (36.9 ± 9.2%) of the articular (p < 0.001). Visualization of the tibial articular surface is limited through specific surgical approaches. Extension by osteotomy of the femoral epicondyle led to a significant improvement in the articular exposure without, however, obtaining sufficient visibility of the posterior joint segments, which should be included in the preoperative strategy. The proposed surgical approach-specific map of the tibial plateau may constitute an important instrument in the toolbox of an experienced surgeon to treat complex tibial plateau fractures at the highest level. Level IV.

Computed tomography for guidance in the diagnosis and surgical correction of recurrent pediatric acute dacryocystitis.

ImportanceThis is the first retrospective study of the effect of computed tomography (CT) in diagnosis and surgical correction of recurrent pediatric acute dacryocystitis (PAD).ObjectiveTo explore the pathogenesis of recurrent PAD and the impact of CT in guidance of surgical planning.MethodsMedical histories, clinical manifestations, and CT results of 10 patients with recurrent PAD were reviewed. Etiologies and treatment effectiveness were recorded for all patients.Results CT revealed that three patients had congenital dacryocystocele with lacrimal sac cyst, enlargement of the nasolacrimal canal, and intranasal cyst of affected sides. After regression of local inflammation, marsupialization was performed. CT showed that four patients had PAD secondary to congenital nasolacrimal canal dysplasia; these patients exhibited normal upper portions of the nasolacrimal canals, but had stenotic or atretic middle and terminal segments. After improvement of local inflammation, endonasal dacryocystorhinostomy was performed. Three patients had PAD secondary to congenital lacrimal sac diverticulum; after contrast injection, CT showed that the cysts at the lacrimal sac area were filled with contrast, and were connected to the normal lacrimal sac. After the topical infection was controlled, transcutaneous dacryocystorhinostomy was performed in combination with excision of the lacrimal sac diverticulum. No recurrence of PAD was detected at 6‐month follow‐up.InterpretationCauses of PAD include congenital dacryocystocele, congenital lacrimal sac diverticulum, or congenital nasolacrimal canal dysplasia. Marsupialization with endoscope, endonasal dacryocystorhinostomy, and transcutaneous dacryocystorhinostomy constitute distinct surgeries for PAD treatment. CT provides an important diagnostic function and facilitates selection of specific surgical approaches for recurrent PAD.

Orbital Tumors: Report of 70 Surgically Treated Cases

The orbital cavity is an anatomically complex region and an area of interest of many specialists, each of whom is familiar with specific surgical approaches. We retrospectively reviewed clinical and outcome data of 70 patients who underwent surgery for resection of an orbital tumor with a mean follow-up of 111.9± 79.6 months. The clinical outcome was reported and the role of sex, age, histology, tumor location, tumor size, and surgical approach on the extent of tumor removal was assessed. Total removal was achieved in 74.3%, subtotal removal in 20%, and partial removal in 5.7% of patients. A fronto-orbital craniotomy was used in 57.1% of cases, frontal approach in 17.1%, fronto-orbit-zygomatic approach in 10%, and endoscopic endonasal approach in 11.4%. Complications included visual acuity decrease (4.3%), cerebrospinal fluid leak (4.3%), nerve palsy (10%; supra-orbital nerve 4.3%; frontal branches of facial nerve 2.9%, third cranial nerve 2.9%), and enophthalmos (1.4%). Lateral orbitotomy, combined fronto-orbital and maxillotomy, and trans-eyelid approaches were used in the remaining cases. The fronto-orbital, frontal, and lateral orbitotomy approaches were associated with greater rates of total resection as compared with the fronto-orbit-zygomatic approach, which was used in difficult cases in which the tumor involved several regions. We recommend, 1) the endoscopic endonasal approach for primary orbital tumors located in the medial or inferior orbital walls without extra-orbital extension; 2) the trans-eyelid approach for tumors of the upper and upper-lateral quadrants extraconally located, and 3) the fronto-orbital approach for intraconally located tumors involving more than one quadrant.

Surgical Treatment of Posterior Circulation Aneurysms – Anatomical Study and Surgical Technique

AbstractPosterior circulation aneurysms represent 10–15% of intracranial aneurysms. The diagnosis is usually secondary to subarachnoid hemorrhage due to its initial asymptomatic presentation and higher risk of rupture compared with aneurysms in the anterior circulation. The surgical treatment of posterior circulation aneurysms is complex and challenging for neurosurgeons because of the particular anatomy of the posterior circulation with its close relation to the brainstem and cranial nerves and also because of the depth and narrowness of the surgical approach. Aneurysms from different locations have specific anatomical relationships and surgical approaches for better visualization and dissection. Therefore, a detailed anatomy knowledge of the posterior circulation is mandatory for an individualized preoperative planning and good neurological and angiographic outcomes. We selected the main aneurysm sites on the posterior circulation, such as: posterior inferior cerebellar artery, basilar trunk, basilar bifurcation, posterior cerebral artery (PCA) and superior cerebellar artery for a detailed description of the relevant anatomy related to aneurysm, and the main surgical approaches for its surgical treatment. Furthermore, we performed a literature review with the most recent outcomes regarding to the surgical treatment of posterior circulation aneurysms.

Interval Female Sterilization.

Female sterilization is relied on by nearly one in three women aged 35-44 years in the United States. Sterilization procedures are among the most common procedures that obstetrician-gynecologists perform. The most frequent sterilization procedures include postpartum tubal ligation, laparoscopic tubal disruption or salpingectomy, and hysteroscopic tubal occlusion. The informed consent process for sterilization is crucial and requires shared decision-making between the patient and the health care provider. Counseling should include the specific risks and benefits of the specific surgical approaches. Additionally, women should be counseled on the alternatives to sterilization, including intrauterine contraceptives and subdermal contraceptive implants. Complications, including unplanned pregnancy after successful female sterilization, are rare. The objectives of this Clinical Expert Series are to describe the epidemiology of female sterilization, access to postpartum sterilization, advances in interval sterilization techniques, and clinical considerations in caring for women requesting sterilization.