Surgery In Conjunction Research Articles

Laparoscopic‐Assisted and Open High Anterior Resection within an ERAS Protocol

Due to potentially superior short-term outcomes compared with open colorectal surgery, laparoscopic surgery is currently being implemented in clinical practice worldwide. In parallel, enhanced recovery after surgery (ERAS) programs are shown to improve postoperative recovery in open colorectal surgery. This study reports outcomes in laparoscopic versus open surgery in conjunction with compliance to the ERAS protocol. The association between surgical approach (laparoscopic or open surgery), compliance to the ERAS protocol, postoperative symptoms, complications, and length of stay after surgery was studied. Between January 2007 to December 2010, 114 consecutive patients underwent elective high anterior resection with laparoscopic-assisted (n = 55) or open resection (n = 59). All clinical data (114 variables) were prospectively recorded. The overall preoperative ERAS-protocol compliance was 77% for both the laparoscopic and open group. Laparoscopic surgery resulted in shorter total length of stay (median 4 vs. 6 days, p = 0.04), earlier pain control (median 2 vs. 3 days, p = 0.008), shorter need for intravenous infusions, improved mobilization on the first postoperative day (POD1), and lower inflammatory response (CRP (POD1) 54 ± 24 vs. 67 ± 31 mg/l, p = 0.017) compared with open resection. The trends in fewer postoperative complications (9.1 vs. 16.9%; odds ratio (OR) 0.55; 95% confidence interval (CI) 0.17-1.81) and overall postoperative symptoms delaying recovery (20 vs. 30.5%; OR 0.63; 95% CI 0.22-1.34) in laparoscopic surgery were not statistically significant. The use of laparoscopy in colorectal surgery within an ERAS protocol results in faster recovery compared with open resection.

Local application of hyaluronan gel in conjunction with periodontal surgery: a randomized controlled trial

Hyaluronic acid application has been proven to be beneficial in a number of medical disciplines. The aim of the current study was to clinically evaluate the effect of local application of hyaluronan gel in conjunction with periodontal surgery. Fourteen patients with chronic periodontitis having four interproximal intrabony defects (≥3 mm) with probing depth values >5 mm were included in this split-mouth study. Following initial nonsurgical periodontal therapy and re-evaluation, defects were randomly assigned to be treated with modified Widman flap (MWF) surgery in conjunction with either 0.8% hyaluronan gel (test) or placebo gel (control) application. Clinical attachment level (CAL), probing depth (PD), gingival recession (GR), plaque index (PI), and bleeding on probing (BOP) values were taken at baseline and 3 and 6 months. Differences between test and control sites were evaluated using a Wilcoxon signed-rank and a McNemar test. A Friedman and a Cochran test were used to test equal ranks over time. Statistically significant differences were noted for CAL and GR (P < 0.05) in favor of the test sites. No significant differences were found regarding PD, BOP, or PI values (P > 0.05). Hyaluronan gel application in conjunction with periodontal surgery appears to result in significant improvement of CAL and in a reduction in GR. Hyaluronan gel application appears to improve the clinical outcome of MWF surgery.

Locating Perforator Vessels by Dynamic Infrared Imaging and Flow Doppler With No Thermal Cold Challenge

Dynamic Infrared Imaging (DIRI) is a noninvasive technique that precisely analyzes the infrared radiation of any object. We used this technique to locate the dominant perforator vessels in flap surgery in conjunction with conventional Doppler. Ten patients scheduled for deep inferior epigastric artery perforator flap and 6 for free-fibular flaps were selected. Perforator vessels were localized in the donor area, using Doppler and DIRI. The ability to locate the dominant perforators was compared between both techniques. DIRI produced a precise map showing the location of the perforators and their area of perfusion at the skin level. Their dominance can be determined by their size. Flow Doppler located the perforators at the aponeurotic level without size and perfusion information. DIRI produces a skin thermographic map of perforator vessels and their perfusion area. Handheld Doppler locates perforators at the aponeurotic level. Their combination increases safety in the planning of perforator flap surgery.

Prospective, multicentric cohort study of surgery and radiotherapy with concomitant and adjuvant chemotherapy (temozolomide; TMZ) for patients with newly diagnosed and glioblastoma multiforme.

e12534 Background: It is generally accepted that maximum resection is beneficial in patients with glioblastoma treated by adjuvant radiotherapy. However, reliable data on the value of cytoreductive surgery in conjunction with adjuvant concomitant radiochemotherapy are unavailable. It may be that concomitant radiochemotherapy abolishes the need for extensive surgical cytoreduction. We have therefore performed a cohort study of patients treated by surgery and concomitant radiochemotherapy with no or small residual tumor to test for differences in outcome. Methods: 180 patients with newly diagnosed and operated glioblastoma multforme, Karnofsky Performance Score ≥ 70 %, and early post-op. MRI (< 72 hours) demonstrating no or small residual contrast-enhancing tumor (< 1.5 cm) were planned for this prospective, multicenter cohort study. Primary aims were progression-free survival, secondary aims overall survival and safety. Results: Of 143 patients with evaluable early MRI and adjuvant concomitant temozomoide 75 patients had no residual tumor, 32 patients small residual tumor (0-1.5 cm diameter) and 59 patients larger residual tumor > 1.5 cm diameter (average 1.9 ± 1.2 cm), who did not fulfill the entry criteria regarding residual tumor diameter. PFS in patients with complete resection vs. small and larger residual tumors was 14.4 (16.0- 21.3) months, compared to 9.03 (3.04-15.0) and 5.33 (2.86-7.8, p < 0.0001). Median overall survival was not reached in patients with complete resections (95% CI: 21.4-25.9), as opposed to 16.9 (13.3-21.5) or 13.9 (10.3-17.5, p < 0.0001) months. Cox analysis demonstrated degree of resection (HR 1.84, p = 0.001) and age (1.03, p = 0.05) to be the only independent factors affecting survival. Conclusions: Even small residual contrast-enhancing tumor loads in patients with surgery for glioblastoma affect the efficacy of adjuvant concomitant radiochemotherapy in glioblastoma multiforme. Author Disclosure Employment or Leadership Position Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Essex Pharma

Acute Bacterial Suppurative Thyroiditis: A Clinical Review and Expert Opinion

Acute suppurative thyroiditis (AST) resulting from a bacterial infection is an infrequent but potentially life-threatening endocrine emergency. Traditional management of this disease has been surgery in conjunction with targeted antibiotic therapy. Recent nonrandomized reports of small series have demonstrated good outcomes using less invasive approaches. No randomized clinical trials have been performed. Here, we provide a review of the literature and an approach to this problem based on expert opinion. The literature was reviewed utilizing PubMed, and a representative case of AST was presented to a panel of experts. Endocrinology, surgery, and infectious disease experts responded to a series of questions regarding diagnosis, management, prognosis, and harm. Combining a broad spectrum of clinical expertise and the published literature, the authors suggest a clinical algorithm as a guide to management, addressing both diagnosis and acute and long-term management. Published studies indicate a trend toward less invasive management during active inflammation and infection and regarding definite therapy. Remaining questions are presented to foster an evidence-based approach to this disease. Ideally, future randomized, controlled trials will provide data to improve the therapy and outcome of AST.

Perioperative Risks and Outcomes of Atrioventricular Valve Surgery in Conjunction With Fontan Procedure

Perioperative Risks and Outcomes of Atrioventricular Valve Surgery in Conjunction With Fontan Procedure

M631: CT-Guided Surgery: All-on-Four, Guided Zygoma, Maxillofacial Implants Versus Conventional Surgical Approach

The growing interest for flapless surgery in conjunction with immediate loading of the edentulous patients has led to the development of software programs which allow for treatment planning, fabrication of a surgical template as well as the production of a prosthesis which can be secured to the patient immediately following the placement of the implants. This presentation will help the implant team understand the steps required for treatment planning as well as the fabrication of the provisional, immediate-load prosthesis once the surgical template has been produced from the stereolithographic model.

PACU Preparation for Pediatric MRI Patients

Purpose: Our hospital was preparing to begin performing intra-operative MRI pediatric surgery in conjunction with the system's pediatric hospital. Preparation was needed in the PACU to provide care pre-operatively and post-operatively with collaboration of nurses from both hospitals.

Perioperative Risks and Outcomes of Atrioventricular Valve Surgery in Conjunction With Fontan Procedure

Long-term outcomes of staged single-ventricle palliation can be impaired by atrioventricular valve (AVV) regurgitation. Atrioventricular valve repair or replacement has been shown to improve late outcomes, but little data exist regarding the associated perioperative morbidity. This study aimed to evaluate the additional perioperative risks associated with single-ventricle AVV surgery. Two hundred thirty-six consecutive Fontan procedures were retrospectively reviewed. Group 1 (n = 21, with concomitant AVV repair [n = 19] or replacement [n = 2]) was compared with group 2 (n = 215, no AVV surgery) with regard to preoperative characteristics and perioperative outcomes. Atrioventricular valve regurgitation was graded as 1 (none or trivial) to 4 (severe). Group 1 patients were older (4.3 +/- 3.7 versus 3.0 +/- 2.6 years; p = 0.04) and had longer cardiopulmonary bypass (118 +/- 38 versus 85 +/- 28 minutes; p < 0.001) and aortic cross-clamp times (33 +/- 32 versus 14 +/- 21 minutes; p < 0.001). There were no differences between groups regarding diagnosis, weight, hospital or intensive care unit length of stay, ventilator time, or 12-hour chest tube output. Postoperative complications were similar between groups, including bleeding (0 of 21 versus 8 of 215; p = 0.8), neurologic injury (1 of 21 versus 9 of 215; p = 0.7), arrhythmias (1 of 21 versus 24 of 215; p = 0.6), and operative mortality (0 of 21 versus 1 of 215; p = 0.1). Group 1 AVV regurgitation significantly decreased after surgery (3.0 +/- 0.9 preoperatively versus 1.7 +/- 0.9 postoperatively; p < 0.001). Atrioventricular valve surgery has been shown to improve late outcomes for single-ventricle patients. This study demonstrates that AVV surgery performed with the Fontan procedure increased operative times, but did not significantly increase perioperative morbidity or mortality. This information supports appropriate utilization of AVV surgery for single-ventricle patients.

The role of magnetoencephalography in epilepsy surgery

Epilepsy surgery requires the precise localization of the epileptogenic zone and the anatomical localization of eloquent cortex so that these areas can be preserved during cortical resection. Magnetoencephalography (MEG) is a technique that maps interictal magnetic dipole sources onto MR imaging to produce a magnetic source image. Magneto-encephalographic spike sources can be used to localize the epileptogenic zone and be part of the workup of the patient for epilepsy surgery in conjunction with data derived from an analysis of seizure semiology, scalp video electroencephalography, PET, functional MR imaging, and neuropsychological testing. In addition, magnetoencephalographic spike sources can be linked to neuronavigation platforms for use in the neurosurgical field. Finally, paradigms have been developed so that MEG can be used to identify functional areas of the cerebral cortex including the somatosensory, motor, language, and visual evoked fields. The authors review the basic principles of MEG and the utility of MEG for presurgical planning as well as intra-operative mapping and discuss future applications of MEG technology.

Nasal Changes after Surgical Correction of Skeletal Class III Malocclusion in Koreans

To quantify the changes in the nose after bimaxillary surgery to correct skeletal Class III malocclusion and to test the hypothesis that there is no change in the nasal width following bimaxillary surgical correction of skeletal Class III when a nasal cinch is properly used. Sixty-five adult Korean skeletal Class III patients who had received maxillary advancement/impaction and mandibular set-back surgery in conjunction with an alar base cinch suture were evaluated. The anthropometric variables of the nasal region were measured directly on the soft-tissue surface before and 6 months after surgery. After surgery, the alar width and alar base width had increased significantly (P < .001), while the nasal tip projection decreased (P < .001). The nostril morphology also showed widening (P < .001). There was a trend for females with a narrow alar width presurgically to have a larger amount of nasal widening compared with those with a broader alar width (P < .05). There is a high probability of nasal and nostril widening after bimaxillary surgery for skeletal Class III malocclusion in Koreans despite the careful performance of alar cinch suture. Nevertheless, the authors believe that alar cinch suture was positive in limiting the nasal widening to the minimum and would consider routine application during bimaxillary surgery for skeletal Class III especially for female patients with a narrow nose who are susceptible to these changes.

Outcome and Management of Spinal Tuberculosis According to the Severity of Disease

A retrospective study examining the clinical features, management, and treatment outcome of patients with spinal tuberculosis (TB). To determine the influence of disease severity and treatment modality on outcome of patients with spinal TB. Although anti-TB chemotherapy is now the mainstay treatment for spinal TB, it may not be applicable to all situations, especially in patients with risk of deformity, instability, and progression of neurologic deficit. In this retrospective study (1994-2003), medical records and radiographic findings of patients with spinal TB were reviewed at 7 teaching hospitals in South Korea. The duration of triple chemotherapy with isoniazid, rifampin, and ethambutol, disease severity, operative procedures, and outcome were analyzed. The outcome was assessed as both favorable and unfavorable according to predefined criteria. A total of 137 patients were diagnosed with spinal TB during the study period. Twenty-one patients were lost to follow-up and excluded from analysis. The mean age was 44.07 +/- 16.57 years. The most common vertebral area involved was the lumbar (44.8%). The mean number of vertebra involved was 2.25. The mean angle of kyphosis was 21.58 degrees. Forty-seven patients (35.1%) had severe symptoms. Radical surgery was carried out in 84 (62.2%) patients. Twenty patients were treated with short-term chemotherapy, while 96 under long-term. At the end of chemotherapy, 94 patients had achieved a favorable status and 22 an unfavorable one. Statistically, there was no significant difference between the 2 groups in terms of gender, chemotherapy duration, or the severity of spinal TB; however, age (P = 0.025; odds ratio = 0.963; 95% confidence interval 0.932-0.995) and radical surgery (P = 0.043; odds ratio = 3.047; 95% confidence interval 1.038-8.942) were significantly related to a favorable outcome by logistic analysis. Our results showed that a younger age and radical surgery in conjunction with anti-TB chemotherapy were significant favorable prognostic factors.

Revisiting Upper Eyelid Anatomy: Introduction of the Septal Extension

The current trend in plastic surgery of the eyelid has taken on increased dependence on anatomical considerations in the marriage of aesthetic and functional ideals. Often, the plastic surgeon performs ptosis and/or septal surgery in conjunction with blepharoplasty. The relationship between eyelid adnexal structures and upper eyelid function is a delicate but critical one. Current anatomical description states that the septum does not reach the superior tarsal border and inserts at a variable level on the levator aponeurosis. Conflicting observations in clinical practice stimulated this study to delineate the septal relationship to surrounding structures. In addition, this study may help to explain the increased rate of recurrence in ptosis repairs that incorporate plication techniques. Dissection of four fresh cadaveric upper lid specimens in situ along with hematoxylin and eosin and trichrome stains of harvested eyelid tissue were used to redefine septal anatomy. Clinical case correlations are made to illustrate the significance of the histologic findings. A distinct septal extension was demonstrated arising from the orbital septum and covering preaponeurotic fat and tarsus completely. Histology of the anterior lamellae confirmed the presence of this thin fibrous sheet. In vivo assessment of this structure verifies its dynamic role in upper lid function. The clinical ramifications of this anatomical nuance are realized. A septal extension to the ciliary margin of the upper eyelid is established. Suture plication of the septal extension can induce lid elevation, with potential postoperative lid retraction. Intraoperative failure to recognize and distinguish this extension from the aponeurosis proper may lead to the high reported rates of unsuccessful ptosis correction. This refinement of septal anatomy should increase precision and help surgeons avoid complications in advanced blepharoplasty and ptosis surgery.

Dermatofibrosarcome de Darier Ferrand : traitement par chirurgie micrographique de Mohs avec inclusion en paraffine

Dermatofibrosarcoma protuberans is a tumor of intermediate malignancy characterized by its aggressive local growth due to pseudopodium-like outgrowths and marked propensity to recur after surgical excision. To achieve complete cure with conventional surgery, surgical margins up to 5 cm are required, leading to wide scars. Mohs' micrographic surgery is used for the removal of certain malignant tumors, both ensuring complete excision by examination of all margins as well as minimizing normal tissue loss. However, differentiating minimal residual tumor from normal skin can be difficult on the frozen sections used in Mohs' micrographic surgery. Our aim was to develop a procedure of Mohs' micrographic surgery in conjunction with rush formalin-fixed, paraffin-embedded tangential sections. Ten consecutive cases have been prospectively treated since 1998. Under local anesthesia, the tumor was first excised including lateral margin of 1 cm and a deep margin including the underlying muscle aponevrosis. A 2 to 3 mm thick horizontal section of the surgical bed was then removed, rush formalin-fixed, paraffin-embedded, tangentially sectioned, hematin-eosin stained, and eventually stained with an anti-CD34 monoclonal antibody. While waiting for pathology results, the surgical bed was not definitively closed. If excision was incomplete, an oriented complementary excision was performed. Excision was complete after the first stage in 7 patients and incomplete only deeply in 3. Lateral surgical margins were reduced to 1.3 cm in all patients, facilitating wound closure: direct suture (5 patients), controlled wound healing (3 patients) or flap coverage (2 patients). No recurrence has been observed after a mean follow-up of 26 months. The use of Mohs' micrographic surgery in conjunction with rush formalin-fixed, paraffin-embedded tangential sections reduce surgical margins in dermatofibrosarcoma protuberans. This procedure would be interesting in difficult sites, such as the genitalia, the breast, or the periarticular regions. Other cases, and longer follow-up are however necessary to validate this promising technique.

Predictors of Sinus Rhythm Restoration after Maze Operation and Relationship between Pre- and Post-operative Left Atrial Volume

Background and Objectives:The Maze operation is known to be an effective measure for restoring sinus rhythm in patients with atrial fibrillation (AF). The purpose of this study was to identify the relationship of preand post-operative left atrial volume (LAV) and diameter (LAD) with successful restoration of sinus rhythm in the Maze operation. Subjects and Methods:The subjects for this study were 28 patients who underwent open-heart surgery in conjunction with the Maze-III operation for chronic AF from October, 2002, to April, 2003. Electrocardiographic and transthoracic echocardiographic studies were done pre-operatively and three months post-operatively. LAV and LAD were assessed and corrected for body surface area (LAV index=LAV/BSA, LAD index=LAD/BSA). Results:Sinus rhythm was restored and maintained in 22 of the 28 patients (78.6%). Between the group with successful restoration of sinus rhythm (Group A;n=22) and the group with unsuccessful restoration (Group B;n=6), there was no difference in age, gender, and NYHA functional class. The duration of AF in group A was significantly shorter than that of B (3.6±2.7 years versus 15.8±7.5 years, p=0.003). Group A and B did not show any difference in pre-operative left ventricular ejection fraction. However, pre-operative LAV index in group A was significantly smaller than that of group B (80.7±22.4 mL/m versus 118.1±42.5 mL/m , p=0.048). In group A, the LAV index (80.7±22.4 mL/m 2 versus 52.8±14.7 mL/m , p<0.001) and LAD index (35.4±5.3 mm/m 2 versus 31.7±4.7 mm/m , p=0.001) decreased significantly three months after the operation. In group B, however, no significant changes are found in the LAV index (118.1±42.5 mL/m versus 89.2±38.9 mL/m , p=0.116) and LAD index (39.1±7.9 mm/m 2 versus 36.2±9.2 mm/m , p=0.144). Conclusion:Pre-operative LAV index measured by echocardiography and the duration of AF were significant predictors of successful sinus rhythm restoration after the Maze operation. Significant reduction of the LAV index after the Maze operation was found in patients whose rhythm was successfully restored and maintained. (Korean Circulation J 2004; 34(6):574-581)

Injertos óseos estructurales en el tratamiento de las neoplasias de hueso. Complicaciones y hallazgos de imagen

IntroductionThe aim of bone tumor surgery has for several decades focused on local control of disease in the maximum possible preservation of the limb. Reliance on bone banks in the facilitation of suitable bone grafting has become a tool used in repairing damage caused by tumor excision. AimTo acquaint radiologists, through a multidisciplinary approach, with follow-up of bone tumors treated with structural grafts. To describe those complications most frequently observed throughout such follow-up, and to compare correspondent imaging findings with those of normal evolution. Material and methodsThere were reviewed clinical histories, as well as both pre-surgical and post-surgical follow-up imaging results, of 12 patients who had undergone bone tumor surgery in conjunction with structural bone grafts and who subsequently developed complications as a result. ConclusionsThe monitoring of grafts and fixation mechanisms through the use of imaging techniques is essential, providing a method for detecting any complications associated with the procedure. Radiologists must be aware of the most frequently occurring complications of bone graft failure, which include non-union, fracture, infection and tumoral recurrence, as well as their corresponding imaging manifestations. These will allow for early detection of such complications. Also essential is the radiologist’s integration into a multidisciplinary group whose task would be to provide a comprehensive follow-up in bone graft cases.

Primary Orofacial Squamous Cell Carcinoma: A Multicenter Nigerian Study

BACKGROUND: Previous Nigerian reports of primary orofacial squamous cell carcinoma have focused on individual center experiences; hence we decided to undertake a review of cases in order to give a fairly national overview. METHODS: Multicenter retrospective study of 149 histologically diagnosed cases of primary orofacial squamous cell carcinoma seen between 1992-2001 in 3 Nigerian Teaching Hospitals RESULTS: The patients' (85 males (57%) and 64 (43%) females.) whose ages ranged from 11-91years (mean ± SD; 54 ± 15.5 years, median 52.5 years) constituted 78.7% of all orofacial malignancies seen within the study period. Lesions were of 8-67 weeks duration (mean ± SD 28.6± 15.1 weeks, median 24 weeks). Overall, the maxillary antrum (20.3%) was the most commonest site, while intraorally; the alveolus (29.6%) and palate (12.4%) predominated. Most lesions (65.8%) were welldifferentiated and only 35.6% showed individual cell keratinization. Patients with well-differentiated lesions had a comparatively higher mean age than their counterparts with other histological varieties and this was statistically significant (P < 0.05). About 45.6% presented with stages III and IV disease, and significant difference was found between duration of the lesions and clinical staging of disease (P < 0.05). Surgery in conjunction with radiotherapy was undertaken for 36.9% of the cases, followed by surgery alone in 14.4%. Close to a quarter (24.2%) either declined or failed to turn-up for treatment. Whereas treatment was found to be successful in 13.4% of the cases, failure to attend follow-up appointment was observed in 62.4%. CONCLUSIONS: The pattern of orofacial squamous cell carcinoma differs from that of industrialized countries and since the majority of the lesions were well differentiated, there is need for intensive oral health awareness to encourage early presentation, as this will further enhance prognosis.

Successful management of acute pulmonary embolism after surgery for lung cancer.

Although many case reports of acute pulmonary embolism (APE) have been published, the literature dealing with the management of APE after resection of lung cancer is limited. This report describes seven cases of successful management of APE after surgery for lung cancer and discusses how to manage this problematic complication. The medical charts of seven patients with APE after lobectomy and complete mediastinal lymphnode dissection were retrospectively reviewed. Six patients collapsed during their first attempt at walking after surgery in conjunction with a dramatic respiratory change. All these patients promptly underwent enhanced spiral computed tomography (CT) scanning. Bilateral clots were detected in all patients and one patient with a deep venous thrombus (DVT) in the femoral vein had a temporary inferior vena cava filter implanted. Non-surgical therapy was used for six patients: thrombolysis (systemic urokinase) and anticoagulant (heparin or argatroban) for four patients and only anticoagulant therapy started on the day after the operation using argatroban for two. There were no bleeding problems with these thrombolysis and/or anticoagulant therapies except in one case of hemorrhage induced by heparin usage on the day after the operation. None of the cases required allotransfusion in connection with these therapies. Thromboembolectomy was performed for one patient who was hemodynamically unstable due to massive embolism and primary atrial fibrillation. All patients were discharged from our hospital without major complications. Patients with pulmonary embolism after surgery for lung cancer can be treated aggressively with anticoagulants with/without fibrinolitics or even with pulmonary embolectomy on cardiopulmonary bypass, without excessive risk of bleeding complications. Enhanced spiral CT scanning was very helpful for making a simultaneous diagnosis of APE and DVT. The use of argatroban in conjunction with activated clotting time monitoring should be effective without causing bleeding problems during the early stages after pulmonary resection for lung cancer.

Congenital absence of the inferior rectus muscle—diagnosis and management

Background Congenital absence of the inferior rectus muscle is a rare cause of apparent inferior rectus palsy especially in the absence of associated cranial facial anomalies. Methods We report three cases of isolated congenital absence of the inferior rectus muscle and its successful surgical management. Results Failure of the normal embryologic development of the mesodermal complex around the eye can lead to agenesis of the extraocular muscles. In apparent palsies of the inferior rectus muscle and no definite cause, a high index of suspicion and orbital imaging can confirm the diagnosis of congenitally absent inferior rectus preoperatively. Surgical correction may involve inferior transposition of the horizontal rectus muscles. Conclusions Although rare, congenital absence of the inferior rectus muscle is a possible cause of apparent inferior rectus muscle palsy particularly in the absence of another identifiable cause. Strabismus surgery in conjunction with intramuscular botulinum toxin injection can offer significant improvement in function and cosmesis of these patients.

The outcome of CO 2 laser root conditioning in periodontal treatment

The purpose of this pilot study was to evaluate periodontal tissue repair after CO 2 laser applications in the treatment of severe periodontal defects. Five patients, three men and two women, age range 37 to 55 years, were enrolled. All of the participants in the study were in good general health and presented with at least one tooth with PD of 6 to 9 mm and bleeding on probing. At baseline, all patients were treated with full mouth SRP, motivation and oral hygiene instructions. Clinical assessment after cause-related therapy showed need for additional periodontal treatment. The periodontal surgery procedures were performed with the adjunctive use of a CO 2 laser in defocused pulsed mode at 4 W, with a frequency of 20 Hz and a duty cycle of 6%. All the patients participating in the study were re-assessed 12 months after surgery. All the teeth that received periodontal surgery in conjunction with laser treatment showed significant improvement in all periodontal parameters registered. This pilot study pointed out that CO 2 laser treatment could induce predictable clinical improvements when used as an adjunctive tool with traditional periodontal surgery. More extensive, long-term and comparative studies are needed to confirm this hypothesis and to better clarify the effect of laser treatment on periodontal wound healing.