Step Surgery Research Articles

Хирургическое лечение осложненной начальной катаракты вторым этапом после витреоретинальной хирургии у пациентов с пролиферативной диабетической ретинопатией

Purpose. To evaluate the efficacy of phacoemulsification of primary cataract by the second stage after vitreoretinal surgery of PDR patients. Material and methods. 124 cases of surgery treatment of patients with PDR and complicated primary cataract were enrolled. Thier patients were divided into two groups depending on the treatment tactics. In the 1st group patients were subjected to a two–step surgical procedure: vitreoretinal surgery with silicone oil tamponade performed as the 1st step in their treatment; followed by the 2d step, phacoemulsification surgery and silicone oil removal, and the IOL implantation, respectively. In the 2d group phacoemulsification performed simultaneously with vitreoretinal surgery: phacoemulsification, IOL implantation, vitreoretinal surgery with silicone oil tamponade. The second step differed in the removal of silicone oil from the vitreous cavity. Results. In the long-term postoperative period, functional results were better in group I patients than in group II patients (p < 0.001). Conclusion. Outcomes of the preliminary studies suggest that it is more viable to perform phacoemulsification surgery sometime later along with silicone oil removal on PDR patients with complicated primary cataract. This sequence of treatment procedure ensures a more gentle approach to the anatomic structures of the eye during the first stage (vitreoretinal surgery) and contributes to the reduction in the number of intraoperative and postoperative complications. Keywords: diabetic retinopathy, cataract, vitreoretinal surgery

Этапное хирургическое лечение осложненной начальной катаракты у пациентов с далекозашедшей стадией пролиферативной диабетической ретинопатии

Purpose. To evaluate the efficacy of phacoemulsification of primary cataract by the second stage after vitreoretinal surgery of PDR patients. Material and methods. 187 cases of surgery treatment of patients with PDR and complicated primary cataract were enrolled. This patients were divided into four groups depending on the treatment tactics. In the 1st group patients were subjected to a two–step surgical procedure: vitreoretinal surgery with silicone oil tamponade performed as the 1st step in their treatment; followed by the 2d step, phacoemulsification surgery and silicone oil removal, and the IOL implantation, respectively. In the 2d group phacoemulsification performed simultaneously with vitreoretinal surgery: phacoemulsification, IOL implantation, vitreoretinal surgery with silicone oil tamponade. The second step differed in the removal of silicone oil from the vitreous cavity. In the 3rd group patients were subjected to a two–step surgical procedure: vitreoretinal surgery with gas tamponade performed as the 1st step in their treatment; followed by the 2d step, phacoemulsification surgery and the IOL implantation. In the 4th group phacoemulsification performed simultaneously with vitreoretinal surgery: phacoemulsification, IOL implantation, vitreoretinal surgery with gas tamponade. Results. Outcomes of the preliminary studies suggest that it is more viable to perform phacoemulsification surgery sometime later along on PDR patients with complicated primary cataract. Conclusions. This sequence of treatment procedure ensures a more gentle approach to the anatomic structures of the eye during the first stage (vitreoretinal surgery) and contributes to the reduction in the number of intraoperative and postoperative complications. Keywords: diabetic retinopathy, cataract, vitreoretinal surgery.

V19 - Video-endoscopic inguinal lymphadenectomy (VEIL) in penile cancer: Step by step surgical procedure

V19 - Video-endoscopic inguinal lymphadenectomy (VEIL) in penile cancer: Step by step surgical procedure

Об изменении уровня про- и противовоспалительных цитокинов в слезной жидкости у пациентов с далекозашедшей стадией пролиферативной диабетической ретинопатии в зависимости от объема витреоретинальной хирургии

Purpose. The aim is to estimate the content of pro- and anti-inflammatory cytokines (IL-1β, IL-8, IL-10, MCP-1, ICAM-1, VEGF) in tear of patients with advanced proliferative diabetic retinopathy and complicated primary cataract after phacoemulsification surgery and IOL implantation with vitreoretinal surgery accomplished at once in comparison with vitreoretinal surgery only. Material and methods. 34 cases of surgery treatment of patients with PDR and complicated primary cataract were enrolled. This patients were divided into two groups depending on the treatment tactics. In the 1st group patients were subjected to a two–step surgical procedure: vitreoretinal surgery (VRS) with silicone oil tamponade performed as the 1st step in their treatment; followed by the 2nd step, phacoemulsification surgery and silicone oil removal, and the IOL implantation, respectively. In the 2nd group phacoemulsification performed simultaneously with vitreoretinal surgery: phacoemulsification, IOL implantation, vitreoretinal surgery with silicone oil tamponade. The second step differed in the removal of silicone oil from the vitreous cavity. On the 2nd day after the 1st step surgery and before surgical treatment the tear samples of the patients of both groups have been examined. Results. A concentration of the following cytokines: IL-8, MCP-1, ICAM-1 in the 2nd group was 2,5-5 times higher than in the 1st group. Conclusion. The research revealed that the patients with advanced PDR are accurately determined by the increased concentration of IL-8, MCP-1, ICAM-1 in tear after phacoemulsification surgery and IOL implantation with vitreoretinal surgery accomplished at once in comparison with vitreoretinal surgery only. Keywords: cytokines, diabetic retinopathy, cataract, vitreoretinal surgery.

Сравнительная оценка результатов одномоментного и двухэтапного хирургического лечения пациентов с далекозашедшей стадией пролиферативной диабетической ретинопатии и осложненной начальной катарактой

Aim. Undertake a comparative analysis of the results two-stage or simultaneously vitreoretinal surgery with phacoemulsification of PDR patients. Material and methods. 52 cases of surgery treatment of patients with PDR and complicated primary cataract were analyzed. These patients were divided into three groups. In the 1st group patients were subjected to a two–step surgical procedure: vitreoretinal surgery with gas tamponade performed as the 1st step in their treatment; followed by the 2d step, phacoemulsification surgery and the IOL implantation. In the 2d group phacoemulsification performed simultaneously with vitreoretinal surgery: phacoemulsification, IOL implantation, vitreoretinal surgery with gas tamponade. Results. Outcomes of the preliminary studies suggest that it is more viable to perform phacoemulsification surgery sometime later along on PDR patients with complicated primary cataract. Conclusions. This sequence of treatment procedure ensures a more gentle approach to the anatomic structures of the eye during the first stage (vitreoretinal surgery) and contributes to the reduction in the number of intraoperative and postoperative complications. Key words: diabetic retinopathy, cataract, vitreoretinal surgery.

Phacoemulsification of primary cataract by the second stage after vitreoretinal surgery of PDR patients.

BACKGROUND: The «gold standart» for surgical treatment of patients with proliferative diabetic retinopathy (PDR is vitreoretinal surgery. However, the question of the timing of the removal of primary cataract in this category of patients remains open.AIM: To evaluate the efficacy of phacoemulsification of primary cataract by the second stage after vitreoretinal surgery of PDR patientsMETHODS: 67 cases of surgery treatment of patients with PDR and complicated primary cataract were enrolled. This patients were divided into two groups depending on the treatment tactics. In the 1st group patients were subjected to a two–step surgical procedure: vitreoretinal surgery with silicone oil tamponade performed as the 1st step in their treatment; followed by the 2d step, phacoemulsifi tion surgery and silicone oil removal, and the IOL implantation, respectively. In the 2d group phacoemulsifi tion performed simultaneously with vitreoretinal surgery: phacoemulsification, IOL implantation, vitreoretinal surgery with silicone oil tamponade. The second step differed in the removal of silicone oil from the vitreous cavity.RESULTS: Visual functions improved in 88.6% of cases in group 1, and in 68.7% in group 2.CONCLUSIONS: Outcomes of the preliminary studies suggest that it is more viable to perform phacoemulsification surgery sometime later along with silicone oil removal on PDR patients with complicated primary cataract. This sequence of treatment procedure ensures a more gentle approach to the anatomic structures of the eye during the first stage (vitreoretinal surgery) and contributes to the reduction in the number of intraoperative and postoperative complications.

Computed Tomography And Ultrasound Guided Fine Needle Aspiration Cytology In The Diagnosis Of Intraabdominal And Pelvic Lesions

Background: Fine needle aspiration cytology (FNAC) as an initial screening modality is an important interventional method. Technical advances in the method of radiology have it made it possible for many inaccessible lesions within the abdomen and pelvis to be safely sampled. Although FNA yields limited material, a positive diagnosis can contribute to the treatment, thus limiting the need for a core biopsy or 2 step surgical procedure. The procedure is relatively inexpensive and can also be done on an outpatient basis with minimal morbity to the patient. Methods: The present study is a retrospective study carried out from January 2012 to October 2014. All the patients in whom intra abdominal and pelvic lesions were detected clinically and by imaging modalities such as CT and USG, were included. The alcohol fixed (PAP) and air dried (MGG) smears of the selected cases were retrieved from archives and cytomorphological features were studied. Result: A total of 755 aspirations were carried out under image guidance, of which 208 aspirates (27.54%) included only intraabdominal and intrapelvic lesions. Majority of the patients in the study were males (51%). Total number of inflammatory lesions were 16 cases, benign lesions were 10 cases and malignant lesions were 164 cases. The most commonly encountered malignancy was metastasis to the liver. Conclusion: CT and USG guided FNAC is able to overcome various obstacles such as inaccessibility of deep seated intraabdominal lesions and is a valuable tool for yielding cellular smears.

Treatment of osteochondral defects with a combination of bone grafting and AMIC technique.

Osteochondral defects of the knee may cause functional impairment of young and sportively active patients. Different surgical treatment options have been proposed using either one or two step procedures. The aim of the current study was to evaluate mid-term outcomes of combined bone grafting with autologous matrix-associated chondrogenesis (AMIC) for the treatment of large osteochondral defects. 15 Patients with osteochondrosis dissecans of the medial femoral condyle grade III or IV according to ICRS classification were treated with a single step surgical procedure combining bone grafting and the AMIC procedure. Mean defect size was 4.98 cm2 (± 3.02) and patients were examined at 6, 12 weeks, 6 and 12 month and at mean final follow-up of 49 months (36-61). Patients were evaluated using VAS, IKDC, KOOS, Lysholm, Tegner activity scores and psychological and physical health assessed using the SF 12. MRI evaluation was performed at final follow-up using the MOCART score. Pain had significantly decreased at final follow-up (7.2 ± 1.4 vs. 2.4 ± 2.6) compared to preoperative baseline. All functional scores had improved significantly throughout the follow-up period (IKDC from 36.6 ± 20.6 vs. 72.2 ± 18.7; KOOS 50.0 ± 18.9 vs. 81.7 ± 13.9; LYSHOLM 39.3 ± 19.5 vs. 79.8 ± 15.1). SF12 evaluation showed a significant increase in physical component summary (PCS) (31.2 ± 11.1 preoperative vs. 46.3 ± 9.9at final follow-up), while mental component summary (MCS) remained stable (51.8 ± 8.9 vs. 57.3 ± 3.3). MOCART score revealed a mean overall score of 77 ± 15at final follow-up. Integration to the adjacent cartilage was complete in 79%, incomplete in 21%. Defect filling was complete in 64%, incomplete in 36%. Significant improvement of knee function and restoration of homogenous cartilage morphology could be achieved with simultaneous AMIC procedure and bone grafting in 2/3 of all patients with large osteochondral lesions at 4years postoperatively.

The correlation between Y-balance test and ankle injury in professional baseball players

Surgical treatment for large osteochondral lesions of the talar dome (OLTD) must restore the convexity and curvature of the talus. Here, we present midterm results and describe the modified “sandwich” reconstruction procedure. Bone defects were restored using a biological inlay consists of autologous bone chips that were mixed with bone marrow concentrate and fibrin glue and covered with a xenogeneic collagen membrane infiltrated with bone marrow concentrate and stabilized by fibrin glue.Ten patients who were treated using a modified “sandwich” OLTD reconstruction were assessed after an average follow-up period of 46.4 (±18) months, using the clinical American Orthopaedic Foot and Ankle Society Ankle Hindfoot Scale (AOFAS) score and radiological magnetic resonance observation of cartilage repair tissue (MOCART) score.The mean AOFAS score increased significantly from 58.3 (±8.5) points to 81.8 (±15.5) points as well the mean VAS score reduced significantly from 5.58 (±0.97) to 1.83 (±0.93) points. The average MOCART score was 69.5% (±16.7%) in the final follow-up.The presented modified “sandwich” technique permanently recreates the convexity and curvature in large osteochondral lesions of the talar dome with a single step surgical procedure.

Biological reconstruction of large osteochondral lesions of the talar dome with a modified "sandwich" technique-Midterm results.

Surgical treatment for large osteochondral lesions of the talar dome (OLTD) must restore the convexity and curvature of the talus. Here, we present midterm results and describe the modified "sandwich" reconstruction procedure. Bone defects were restored using a biological inlay consists of autologous bone chips that were mixed with bone marrow concentrate and fibrin glue and covered with a xenogeneic collagen membrane infiltrated with bone marrow concentrate and stabilized by fibrin glue. Ten patients who were treated using a modified "sandwich" OLTD reconstruction were assessed after an average follow-up period of 46.4 (±18) months, using the clinical American Orthopaedic Foot and Ankle Society Ankle Hindfoot Scale (AOFAS) score and radiological magnetic resonance observation of cartilage repair tissue (MOCART) score. The mean AOFAS score increased significantly from 58.3 (±8.5) points to 81.8 (±15.5) points as well the mean VAS score reduced significantly from 5.58 (±0.97) to 1.83 (±0.93) points. The average MOCART score was 69.5% (±16.7%) in the final follow-up. The presented modified "sandwich" technique permanently recreates the convexity and curvature in large osteochondral lesions of the talar dome with a single step surgical procedure.

Influence of Tumor Histology on Preoperative Staging Accuracy of Breast Metastases to the Axilla

Histologic confirmation of axillary nodal metastases preoperatively avoids a sentinel node biopsy and enables a one step surgical procedure. The aim of this study was to establish the local positive predictive value of axillary ultrasound (AUS) and guided needle core biopsy (NCB) in axillary staging of breast cancer, and to identify factors influencing yield. A prospective audit of 142 consecutive patients (screening and symptomatic) presenting from 1st December 2008-31st May 2009 with breast lesions categorized R4-R5, who underwent a preoperative AUS, and proceeded to surgery was undertaken. Ultrasound-guided NCB was performed on nodes radiologically classified R3-R5. Lymph node size, number, and morphological features were documented. Yield was correlated with tumor size, grade, and histologic type. AUS/NCB was correlated with post surgical pathologic findings to determine sensitivity, specificity, positive and negative predictive value of AUS and NCB. A total of 142 patients underwent surgery, of whom 52 (37%) had lymph node metastases on histology. All had a preoperative AUS, 51 (36%) had abnormal ultrasound findings. 46 (90%) underwent axillary node NCB of which 24 (52%) were positive. The smallest tumor size associated with positive nodes at surgery was 11.5 mm. The sensitivity of AUS was 65%. Specificity was 81%, with a positive predictive value (PPV) of 67% and negative predictive (NPV) value of 80%. Sensitivity of U/S-guided NCB was 75%, with a specificity of 100%, PPV 100% and NPV 64%. Sensitivity of AUS for lobular carcinoma was 36% versus 76% for all other histologies. Sensitivity of NCB for lobular cancer was 33% versus 79% for all other histologies. The most significant factor producing discordance between preoperative AUS and definitive histologic evidence of lymph node metastasis was tumor type. Accurate preoperative lymph node staging was prejudiced by lobular histology (p < 0.0019).

Effectiveness of fresh frozen and cryopreserved homologue iliac crest grafts used in sinus lifting: a comparative study

In the last decade, several investigators have reported that autologous and homologous fresh frozen bones (FFB) are effective materials to restore alveolar ridges previous to insert dental implants. Recently we have used cryopreserved homologue grafts (CFFB). Here we reported a retrospective comparative study between implants inserted in FFB and CFFB evaluate their clinical outcome. Patients were treated with a split mouth scheme for bone grafting with FFB and CFFB and spiral family implants (SPI) were inserted in the same surgical time. Several variables (patient, grafts, anatomic site, implant, prosthetic restoration) were investigated. Implant' failure and peri-implant bone resorption were considered as predictor of clinical outcome. A total of 84 SFIs were inserted in 12 patients. Implants were inserted to replace 8 incisors, 4 cuspids, 31 premolars and 41 molars. The mean follow-up was 14months. Three out of 84 implants was lost (i.e. survival rate SVR=96.4%) and no differences were detected among the studied variables. Similar result was obtained by analyzing the crestal bone resorption around implant' neck (i.e. success rate). FFB and CFFB have high and comparable survival and success rate. Implants inserted with one step surgical procedure in native (i.e. not grafted) bone, FFB and CFFB have similar clinical outcome.

Computer planned implant-orthognathic rehabilitation: a case of one step surgical procedure with implants insertion, Le Fort I advancement, grafting and immediate loading

Aim In the last decade several systems for computerplanned implantology have been reported. Among them is a system that uses a software and a threedimensional parallelometer able to transfer the implant position from the virtual project to the master model. To verify the potentiality of this system, a single step oral rehabilitation was planned in a patient with edentulous maxilla. Materials and methods A 52 year old male patient was referred to the Department of Maxillofacial Surgery, Orthopedic Institute Galeazzi, Milan (Italy), in January 2008. He was almost completely edentulous in the maxilla. A CT scan and a computer planning were performed. The one step oral rehabilitation consisted of a single operation composed by a Le Fort I osteotomy, flapless implant insertion, provisional full arch screwing, maxillary advancement and fixation, gaps grafting. Results After 8 months follow-up no implant was lost and clinical and radiological controls demonstrated the stability of the surgical procedure. Conclusion Computer-planned and cast model transferred implantology is a helpful technology not only for planning prosthodontic rehabilitation but also for implant-orthognathic surgery.

Obesity promotes forearm primary arteriovenous fistula creation in chronic haemodialyzed patients

The increase in number of obese people seen in the general population, is also what is seen in the hemodialyzed population. It is generally believed that the location of deep forearm vessels in the subcutaneous fat tissue makes primary arteriovenous fistula (AVF) a disadvantage because of difficulties in vessel puncturing. For obese patients, it is suggested that a fistula with PTFE is created or a central catheter inserted, but these solutions increase already high morbidity rate and significantly increase mortality rate. Methods: The deep location of veins situated on the anterior part of the forearm involved 57 patients (45 female and 12 male) aged 13–87 years (mean 67 ± 15.2 years). Patients’ body mass index (BMI) ranged from 29.1 to 53.73 (mean 34.6 ± 7.8). The causes of the renal failure were diabetic nephropathy in 30 patients, chronic glomerulonephritis in 4, hypertensive nephrosclerosis in 5, lupus nephritis in 2, interstitial nephritis in 4, primary amyloidosis in 1, polycystic kidney disease in 3, and unknown in 3 patients.Two‐step surgical procedure was performed in all patients. In the first stage, the standard distal radiocephalic AVF in the wrist region was created. In case of its failure, the next attempt was performed above the point of the first intervention. In the second stage, superficialization of the venous part of AVF was performed in the mode described by us (Kidney 2002;.1:1170). Results: The first stage of the procedure was successful in 46 patients. In 6 cases it was necessary to perform a second attempt, and 2 cases required three operations. The second stage was undertaken in all of these patients (n = 54), and complete success was achieved in 51. In 3 cases, in spite of superficialization, AVF was not suitable for puncturing because of poor blood flow. The causes of failure of the first stage procedure in 2 patients were severe arteriosclerosis and venous anomaly. All patients had non‐altered cephalic veins in the wrist region, as opposed to patients with cannulated veins. In 51 pts (90%) an efficient flow of the blood through AVF was successfully obtained and allowed satisfactory dialyses. Conclusions: The primary AVF creation on the forearm is feasible in 90% of obese patients. This result is similar to the general population of chronic renal disease patients of our center (95%)(NDT 1998;13:527) and is possible thanks to the location of the veins deep in the subcutaneous fat tissue, which protects against repeated cannulation and hence mechanical destruction in the pre‐dialysis period.

One stage treatment of parathyroid cancer

Aim. To review the methods of treating parathyroid cancer in our series and report successful use of intraoperative frozen section to enable one stage surgical management. Method. Seven cases of parathyroid cancer presented from 1991–2002. The presenting features, diagnosis and treatment are presented. They are separated into two groups based on method of referral and treatment. Results. Patients presented with symptoms of hypercalcaemia. Median corrected calcium was 3.49 mmol/l. Parathyroid hormone levels were raised in seven of eight cases, range 14.5–495 pmol/l. A high index of pre-operative suspicion and use of frozen section enabled a one step surgical procedure. Recurrence was impossible to treat successfully. Radiotherapy appeared successful for residual disease. Conclusion. A high pre-operative index of suspicion for parathyroid carcinoma with use of frozen section at time of operation permits an optimal one step surgical procedure by en bloc resection followed by central lymph node excision. In cases where diagnosis has been made post-operatively radiotherapy may be beneficial.

Impact of stereotactic large-core needle biopsy on diagnosis and surgical treatment of non-palpable breast cancer

Introduction Stereotactic large-core needle biopsy is increasingly replacing needle-localized breast biopsy for the diagnosis of nonpalpable breast disease. In this prospective study, the impact of the introduction of this technique on diagnosis and surgical treatment of nonpalpable breast cancer was assessed in two hospitals in The Netherlands. Patients and methods A total of 84 patients with nonpalpable breast cancer, diagnosed by means of stereotactic large-core needle biopsy (needle biopsy group) were compared with 80 patients diagnosed with nonpalpable breast cancer before the introduction of large-core needle biopsy. These patients were diagnosed by means of needle-localized open breast biopsy (control group). Clinical outcome measures evaluated included: duration of diagnostic and therapeutic intervals and number of surgical procedures required for complete surgical treatment. Subgroup analysis was performed for the category of microcalcifications without tissue distortion.Results For the needle biopsy group, the median interval between initial referral to the surgeon and the availability of histological diagnosis was 9 days and the interval between initial referral and complete surgical treatment was 31 days. These intervals were significantly longer for the control group (19 days and 44 days respectively); 75% of patients in the needle biopsy group were treated in a single step surgical procedure compared to 16% of the patients in the control group (67vs 25% respectively for the subgroup). The mean number of surgical procedures required to complete surgical treatment was 1.31 for needle biopsy group vs 1.91 for the open biopsy group (1.46 vs 1.84 for the subgroup).Conclusion Introduction of stereotactic large-core needle biopsy leads to a reduction of the time to diagnosis and the time to complete surgical treatment of nonpalpable breast cancer. It also reduces the number of surgical procedures required for complete surgical treatment of nonpalpable breast cancer. The benefits of large-core needle biopsy may also be anticipated for patients with microcalcifications without tissue distortion.

Functional reinnervation of the denervated neostriatum by nigral transplants

The denervated neostriatum of adult rats were reinnervated by transplants of fetal substantia nigra. A two step surgical procedure, the delayed transplantation technique, was used and is described in some detail. The partial reinnervation of the neostriatum from the intracortical transplants did not result in a diffuse, partial recovery in all aspects of the dopamine deficiency syndrome. The recovery of function appeared discrete and complete in those behaviors where recovery occurred and the animals performed just as well as a normal rat, whereas in those behaviors where recovery did not occur the animals performed as bad as the lesioned control rats. The results support the conclusion that unilateral reinnervation of the dorsal neostriatum by nigral transplants is capable of inducing recovery in asymmetric motor behavior and posture, in sensory attention on the side contralateral to the transplant (as revealed in spontaneously choice behavior in both unilaterally and bilaterally lesioned rats), and in sensorimotor orientation in bilaterally lesioned rats. By contrast, the severe akinesia, catalepsy, aphagia and adipsia of the bilaterally lesioned rats are unaffected.