Surgical Resection Procedures Research Articles

VATS Lobectomy: Surgical Evolution from Conventional VATS to Uniportal Approach

There is no standardized technique for the VATS lobectomy, though most centres use 2 ports and add a utility incision. However, the procedure can be performed by eliminating the two small ports and using only the utility incision with similar outcomes. Since 2010, when the uniportal approach was introduced for major pulmonary resection, the technique has been spreading worldwide. The single-port technique provides a direct view to the target tissue. The conventional triple port triangulation creates a new optical plane with genesis of dihedral or torsional angle that is not favorable with standard two-dimension monitors. The parallel instrumentation achieved during single-port approach mimics inside the maneuvers performed during open surgery. Furthermore, it represents the less invasive approach possible, and avoiding the use of trocar, we minimize the compression of the intercostal nerve. Further development of new technologies like sealing devices for all vessels and fissure, robotic arms that open inside the thorax, and wireless cameras will facilitate the uniportal approach to become the standard surgical procedure for pulmonary resection in most thoracic departments.

Reconstruction of the pulmonary trunk via cardiopulmonary bypass in extended resection of locally advanced lung malignancies

The aim of this retrospective study is to summarize our improvement of surgical procedures for radical resection of left hilar tumors involving the pulmonary trunk and determine its clinical feasibility. From 2001 to 2008, four patients were selected for curative extended resection through multidisciplinary assessment and the pulmonary trunk was reconstructed via cardiopulmonary bypass (CPB). Surgical procedures were performed with posterolateral thoracotomy for two patients and anterolateral thoracotomy for the remaining two. CPB was performed via femoral artery-femoral vein cannulation on one patient and right atrial-aortic cannulation on the other three patients. Polytetrafluoroethylene patch or autologous pericardium was applied for reconstruction in different patients. The duration of the operations ranged from 300 to 440 min and with CPB lasting 35-106 min. Three patients developed non-specific complications with no mortalities and discharged within 12-17 days. One patient had no evidence of recurrence during 50 months follow-up. Three patients died of metastasis 5, 14, and 35 months after surgery. CPB-supported extended resection of lung malignancies involving the pulmonary trunk is feasible. Left anterolateral thoracotomy through the fourth intercostal space with right atrial-aortic cannulation would be the convenient approach. Survival may be prolonged in some selected patients.

Rehabilitation of Partial Maxillectomy Defect with Implant Retained Hollow Bulb Obturator Prosthesis: A Case Report

Tissue integrated oral implants have initiated a new perspective in oral rehabilitation of tumor patients who have had undergone surgical resection procedure. The present case demonstrated a simple and predictable approach to rehabilitate a patient who had partial maxillectomy using dental implants. The use of an implant in conjunction with hollow bulb obturator shared remarkable improvement in retention and stability of the existing complete denture prosthesis.

Sarcomatous transformation in the McCune–Albright syndrome

McCune-Albright syndrome is a relatively rare disease characterized by the trio of fibrous dysplasia, café-au-lait pigmentation, and endocrine disturbances. It predominantly affects females and may be associated with sarcomatous degeneration in 0.4% to 4% of the cases. This article reports on the case of a 24-year-old female patient who had presented a mass in the oral cavity for 30days, probably originating from the left ramus of the mandible. She had a previous diagnosis of polyostotic fibrous dysplasia, along with café-au-lait spots and endocrine disorders, thus characterizing McCune-Albright syndrome. Histopathological examination of a biopsy specimen revealed osteosarcoma of the mandible. The patient underwent chemotherapy and a surgical procedure for lesion resection. One year has now passed since the patient's operation, and the disease is under control. The patient presented sarcomatous degeneration in areas of fibrous dysplasia, consisting of mesenchymal cells that produced osteoid. Malignant degeneration is rare when it is not associated with McCune-Albright syndrome. There is no curative treatment for the syndrome. Attending physicians need to bring endocrine disorders under control, with surgical treatment in cases of significant deformities, as well as providing clinical and psychological care.

Anatomical Reevaluation of the Anococcygeal Ligament and Its Surgical Relevance

With the development and spread of surgical procedures for total mesorectal excision and intersphincteric resection, rectal surgeons have gained frequent opportunities to observe connective tissues around the anal canal. However, uncertainty remains as to the exact identity and location of these structures. The aim of this study was therefore to identify and describe the morphology of connective tissue structures extending between the coccyx and anal canal. This was a descriptive study carried out at university facilities for anatomic research. The study comprised histologic evaluation of paraffin-embedded tissue specimens from preserved cadavers of 20 elderly adults and examination of frozen pelves from 6 fresh cadavers. From each cadaver, we obtained a tissue mass containing the dorsal wall of the distal rectum and anal canal, the coccyx, and the covering skin. Most sections were stained with Masson-Trichrome solution for collagen and smooth muscle fibers. Dissection of fresh cadaver demonstrated the anococcygeal ligament extending from the coccyx to the anal canal between bilateral slings of the levator ani. Histologic examination showed that the anococcygeal ligament was divided into a ventral and a dorsal layer and contained abundant smooth muscles, elastic fibers, and small vessels. The ventral layer extended from the presacral fascia to the conjoint longitudinal layer of the anal canal. The dorsal layer was recognized as a bundle extending between the coccyx and external anal sphincter. The dorsal layer was much thicker along and near the midsagittal plane than the lateral areas. The levator ani was located independently of and dorsal to the anococcygeal ligament. This study used cadavers from elderly donors; thus, the specimens might have had age-related degeneration. The anococcygeal ligament is divided into 2 layers: a thick ventral layer, rich in thin vessels and extending from the presacral fascia to the conjoint longitudinal layer of the anal canal, and a thin dorsal layer extending between the coccyx and external anal sphincter. The anococcygeal ligament is one of the critical structures for decision-making regarding rectal and upper anal canal mobilization.

Double Rib Penetration of the Spinal Canal in a Patient With Neurofibromatosis

Rib head penetration into the spinal canal in patients with severe kyphoscoliosis secondary to neurofibromatosis type-1 (NF-1) is extremely rare. Double rib head penetration has only been reported once earlier. We are reporting on an adolescent male with NF-1 and severe thoracic kyphoscoliosis with adjacent double rib head penetration into the spinal canal without neurological deficits. Only one was recognized on the initial radiographic imaging. A 14-year-old with NF-1 and 74 degrees left thoracic scoliosis and 75 degrees kyphosis was treated at our institution. Preoperative computed tomography (CT) demonstrated protrusion of the left T6 rib head into the spinal canal on the convexity of the curve, compressing the spinal cord. Staged surgical procedures for resection of the rib head and correction of the spinal deformity were planned. After presumed successful resection of the penetrated rib head, a postoperative CT revealed the presence of a second adjacent left T7 rib head in the spinal canal. This was not initially recognized owing to the severe deformity and image obliquity of the CT gantry. Another procedure was performed to remove this rib head. He was then placed in halo traction until anterior and posterior spinal fusion and segmental spinal instrumentation were performed. He achieved good deformity correction and had no neurological deficits throughout his treatment. Rib head protrusion into the spinal canal can occur with spine deformity in NF-1. If present, the imaging should be carefully reviewed for the possibility of an adjacent rib head penetration that may have been obscured by the limitations of CT in the context of a dysplastic spinal deformity. Level V. Case study.

Vertebral Hemangioma

A case report and a discussion of recent published data. To highlight the importance of vertebral hemangioma (VH) as a differential diagnosis in the evaluation of locally aggressive spinal lesions. VH commonly occur as incidental findings, however, locally aggressive VH have been described. Difficulties in diagnosing these lesions are well reported and relate to changes in fat content causing uncharacteristic appearances on imaging. The management options for these lesions include a combination of observation, embolization, sclerotherapy, surgical decompression, or stabilization and radiotherapy. A 45-year-old patient who was previously well presented with back pain and rapidly progressive paraparesis. Imaging confirmed the presence of an extensive lesion centered within the right T3 vertebral pedicle with intrusion into the spinal canal. Urgent surgical decompression was undertaken and was complicated by extensive intraoperative hemorrhage requiring massive transfusion. Histologically, the lesion was shown to be a cavernous VH with no evidence of malignancy. Following radiation oncology review, he was offered adjuvant radiotherapy to minimize the risks of recurrence. He achieved a near full neurologic recovery within 2 weeks and had a full recovery by 12 months. VH should be considered in the evaluation of locally aggressive spinal lesions. Angiography is a useful adjunct in the evaluation of these lesions, both as a diagnostic and therapeutic tool. After diagnosed correctly a wide range of treatment options exist that may prevent the patient from undergoing major surgical resection and reconstruction procedures, which may be associated with high rates of morbidity.

Should the extrahepatic bile duct be resected or preserved in R0 radical surgery for advanced gallbladder carcinoma? Results of a Japanese Society of Biliary Surgery Survey: A multicenter study

We assessed the significance of an extra bile duct resection by comparing the survival of patients with advanced gallbladder carcinoma who had resected bile ducts with those who had preserved bile ducts. A radical cholecystectomy that includes extra bile duct resections has been performed without any clear evidence of whether an extra bile duct resection is preventive or curative. We conducted a questionnaire survey among clinicians who belonged to the 114 member institutions of the Japanese Society of Biliary Surgery. The questionnaires included questions on the preoperative diagnosis, complications, treatment, and surgical treatment, resection procedures, surgical results, pathological and histological findings, mode and site of recurrence, and the need for additional postoperative treatment. A total of 4243 patients who had gallbladder carcinoma and were treated from January 1, 1994 to December 31, 2003 were identified. The 838 R0 patients with pT2, pT3, and pT4 advanced carcinoma of the gallbladder for which there was no cancer invasion to the hepatoduodenal ligament or cystic duct in the final analysis. The 5-year cumulative survival, postoperative complications, postoperative lymph node metastasis, and local recurrence along the hepatoduodenal ligament were not substantially different between the resected bile duct and the preserved bile duct groups. Our retrospective questionnaire survey showed that an extrahepatic bile duct resection had no preventive value in some patients with advanced gallbladder carcinoma in comparison to similar patients who had no such bile duct resection. An extrahepatic bile duct resection may therefore be unnecessary in advanced gallbladder carcinoma without a direct infiltration of the hepatoduodenal ligament and the cystic duct.

Innovative therapy for hepatocellular carcinoma: Three-dimensional high-dose photon radiotherapy

The development of three-dimensional conformal radiotherapy (3DCRT) has enabled high dose radiation to be directed to tumour with a frank sparing of the non-tumour surrounding liver parenchyma without restriction due to tumour topography and size, presence of peritumourous satellite nodules or associated segmental portal vein thrombosis. 3DCRT can be safely delivered alone or concomitantly with transarterial chemoembolization (TACE), giving very encouraging results. Efficacy is strongly related to a smaller tumor size and higher dose of radiation while toxicity closely correlates to the pre-radiotherapy liver functions and the dose delivered to the uninvolved liver. These data has led to integrate 3DCRT in the multimodal treatment of HCC as a possible curative-intent option as well as surgical resection or percutaneous procedures although phase-III controlled studies are warranted to clarify this point. This may represent a promising approach in patients who are inoperable or for whom other ablation therapies are not feasible. The next steps will be the optimization of delivery modes of this type of photon therapy, taking account that other radiation modalities such as proton beam therapy for instance might be shown as of great interest within the next few years.

Significant small-bowel lesions detected by alternative diagnostic modalities after negative capsule endoscopy

Capsule endoscopy (CE) is considered a first-line investigation for obscure GI bleeding (OGIB) and small-bowel polyp or tumor detection. The reliability of a negative CE in excluding gross small-bowel pathology remains unclear. New imaging modalities, such as double-balloon enteroscopy (DBE), CT enterography (CTE) or magnetic resonance enterography (MRE) now provide complementary roles to CE for these indications. We describe our experience of significant small-bowel pathology missed at CE in 5 patients. The lesions were subsequently detected by DBE, CTE, or MRE. A retrospective case series. Single-center academic endoscopy unit in a tertiary-referral hospital. Five patients were evaluated: 4 with a history of OGIB (transfusion dependent in 2) and 1 patient with Peutz-Jeghers syndrome (PJS) under small-bowel surveillance. CE was performed in all patients. Further evaluation via DBE, CTE, or MRE was performed. Definitive treatment was carried out by enteroscopic polypectomy (1 patient), surgical resection (2 patients), and transjugular intrahepatic portosystemic shunt procedure and embolization (1 patient). Detection of significant small-bowel pathology by using DBE, CT, or MRE after a negative capsule study. Significant small-bowel pathology was missed at CE but was detected by alternative modalities in 5 patients. In 4 patients, the lesions were in the proximal small bowel (adenocarcinoma, malignant melanoma, varices, and stromal tumor). The fifth patient had a large PJS polyp in the proximal ileum. Retrospective case series with small numbers. Gross pathology may be missed at CE, especially in the proximal small bowel, and a negative CE study does not exclude significant disease. Alternative imaging modalities, such as DBE, CTE, or MRE, should be considered when clinical suspicion persists.

Sternectomy and Sternum Reconstruction for Infection After Cardiac Surgery

Sternum infection after cardiac surgery represents a severe complication with a high mortality rate. Therapeutic possibilities consist in "open packing" with specific antibiotic irrigation or in "en-block" resection. We report a case of sternum reconstruction using a titanium patch covered with bone-powder.

Neuromodulación quirúrgica: Nuevos horizontes en Neurocirugía

Surgical neuromodulation refers to all those techniques that use implantable devices that discharge electricity or chemical substances that modify nerve signal transmission in order to achieve inhibition, excitation or modulation of the activity of neuronal groups and networks, and to achieve a therapeutic effect. Neuromodulation encompasses different scientific aspects and technologies which need to be defined. From the surgical point of view, neuromodulation is defined as: those intervention techniques that alter the transmission of neuronal signals using implantable electrical or chemical devices with the objective of stimulating, inhibiting or modulating the activity of neurones or neuronal networks to achieve therapeutic effects. A clinical definition makes reference to the use of reversible electrical or chemical stimulation of the nervous system to manipulate its activity in order to treat some specific types of chronic pain and conditions such as spasticity, epilepsy, cardiac ischemia, alterations in the motility of the intestine and of the bladder, lesions of the nervous system, and alterations in mobility, visual, auditory or psychiatric status. Neurosurgeons have been well trained to perform a great number of surgical techniques of neuromodulation, even including helping to significantly increase biomedical activities and the application of high technology to the central and peripheral nervous system. Surgical neuromodulation encourages the neurosurgeon to go also away from the classical techniques of surgical resection and neuroablative procedures, and to enter into the new field of neuroengineering to re-establish lost neurological functions. The inter-relationship between the brain and the computer (brain-machine interface) has already occurred and has been applied in the field of neuroprosthetics and deep brain stimulation. For neurosurgery in general and for Spain in particular, this represents a new opportunity to embark on a high technology path that would involve years of research but, applying these new, non-invasive surgical techniques would help resolve the neurological problems of many of our patients.

Molecular Biologic Staging of Lung Cancer

Clinical and pathologic staging of lung cancer is suboptimal in achieving the goals of assessing prognosis and selecting therapy. Although the technologic developments that allow the generalized use of proteomic and genomic analyses are relatively recent, major progress in understanding the molecular basis of lung cancer has been made. Predicting survival is only the first step in the use of genomics and proteomics. If a reliable gene array or protein profile can be identified that is associated with poor prognosis, these profiles can then be identified and become potential therapeutic targets. It is not difficult to envision the development of a simple serum test that will diagnose a lung cancer perhaps even before it is clinically apparent and at the same time identify the chemotherapeutic agents to which the tumor is sensitive, allowing individually directed treatment. Eventually, a comprehensive staging system should incorporate the prognostic information of biologic variables.

Careful Examination of Thyroid Specimen Intraoperatively to Reduce Incidence of Inadvertent Parathyroidectomy During Thyroid Surgery

To assess the incidence and clinical relevance of inadvertent parathyroidectomy during thyroidectomy, and the possibility of reducing its occurrence. Retrospective study. University hospital. Consecutive patients who underwent thyroidectomy from 1999 to 2005, divided into 2 groups (group 1, those with inadvertent parathyroidectomy; and group 2, those without inadvertent parathyroidectomy). Patients who underwent surgical procedures for recurrent thyroid disease, intentional parathyroidectomy, and resection of central compartment viscera were excluded. All pathology reports were reviewed for the presence of any parathyroid tissue in the resected specimen. Age, sex, preoperative diagnosis, thyroid hormonal status, substernal thyroid extension, number of parathyroid glands identified and spared at the time of surgery, autotransplantation of parathyroid gland, and final histologic findings were recorded. Identification of parathyroid tissue in resected specimens and postoperative symptomatic hypocalcemia. A total of 307 patients were included. Surgical procedures included bilateral or unilateral thyroidectomy (95% and 5% of procedures, respectively). Central neck lymph node dissection was performed in 5% of cases. Pathologic findings showed inadvertent parathyroidectomy in 12% of cases. Of these, 32% were recognized intraoperatively. The parathyroid tissue was found in extracapsular locations in 37% of cases, intracapsular locations in 39%, and intrathyroidal locations in 24%. There was no statistical difference between the 2 groups in terms of sex, preoperative diagnosis, substernal extension, extent of surgery, pathologic diagnosis, and occurrence of postoperative hypocalcemia, except for the presence of thyroiditis. Careful examination of the surgical specimen intraoperatively decreases the incidence of inadvertent parathyroidectomy during thyroidectomy.

Increasing Muscle Strength as a Treatment for Strabismus: Sustained Release of Insulin-like Growth Factor-1 in Rabbit Extraocular Muscle

Currently, no drug treatment is available for strengthening underacting extraocular muscles (EOM) in strabismus. We showed previously that single injections of insulin-like growth factor (IGF-1) result in significant but short-term increases in muscle force generation. This study examined the effects of sustained release of IGF-1 on force generation in rabbit superior rectus muscles. In adult rabbits, slow-release pellets containing IGF-1 were implanted on the global side of one superior rectus muscle. After 1 week, or 1, 2, 3, or 6 months, treated and control muscles were examined for force generation using an in vitro physiology apparatus. All muscles were prepared for histology and mean myofiber cross-sectional areas were determined. One and 3 months after pellet implantation, treated muscles generated significantly greater force than contralateral control muscles, whereas at 2 months, no significant difference was found. Force per cross-sectional area (mN/cm(2)) at 3 months also increased significantly in the treated muscles. Mean muscle cross-sectional area increased significantly after 1, 2, and 3 months of sustained exposure to IGF-1 compared with controls. After an additional 3 months without IGF-1 exposure, mean cross-sectional areas were significantly greater than controls but significantly reduced compared with areas at 1, 2, and 3 months. IGF-1 appears to be highly effective in increasing muscle force generation. Because slow release of IGF-1 results in sustained increases in EOM force generation, it may be a potentially useful alternative to surgical resection procedures because it avoids many of the potential long-term biomechanical hazards of resection surgery.

Long-term outcomes after surgical and nonsurgical management of chronic pelvic pain: One year after evaluation in a pelvic pain specialty clinic

The purpose of this study was to describe long-term outcomes for women with chronic pelvic pain (CPP) after evaluation in a CPP specialty clinic. This was a prospective observational cohort study of women treated for CPP at the UNC Pelvic Pain clinic between 1993 and 2000. The primary outcome was improvement in pain and the main exposure was treatment group: primarily medical (pharmacotherapy, psychotherapy, physical therapy, or combinations of the 3) or surgical (hysterectomy, resection or ablative procedures, oophrectomy, diagnostic surgery, pain mapping, vulvar or vestibular repair). Univariate, bivariate, and multivariable analyses were performed to look for relationships between background characteristics, treatment group, and improvement in pain. Of 370 participants; 189 had surgical treatment and 181 had medical treatment. One year after evaluation, 46% reported improvement in pain and 32% improvement in depression. Improvement in pain was similar in both treatment groups and odds of improvement were equal even after adjusting for background characteristics, psychosocial comorbidity, and previous treatments. One year after evaluation in a CPP specialty clinic, women experienced modest improvements in pain and depression after recommended surgical or nonsurgical treatment.

Liposarcoma Causing Left Ventricular Outflow Tract Obstruction and Syncope: a Case Report and Review of the Literature

Metastatic cardiac myxoid liposarcoma is rare. We present the case of a 56-year-old woman who was admitted for angina and syncope, and in whom a mobile intracardiac mass obstructing the left ventricular outflow tract and protruding into the aortic root during systole was detected by transesophageal echocardiography (TEE). She reported an antecedent of the complete excision of a myxoid liposarcoma of the thigh 12 years before. A surgical resection procedure was performed through an excision of the anterior wall of the left ventricle. The histopathological analysis of the specimens obtained during surgery revealed a low-grade malignancy myxoid liposarcoma, similar to the one resected in the thigh 12 years before. The present case is the first one to report syncope due to left ventricular outflow tract as a cause for admission. TEE was able to visualize the metastatic tumor to the heart, accurately localize its position and allow for prompt surgical treatment that produced relief of the symptoms.

Gastrointestinal stromal tumor involving the second and third portion of the duodenum: Treatment by partial duodenectomy and Roux‐en‐Y duodenojejunostomy

The optimal surgical procedure for duodenal gastrointestinal tumors (GIST) remains undefined because while surgical resection clearly confers survival advantage, there is little submucosal spread in GIST and lymphatic involvement is rare. Various surgical procedures for duodenal GIST, pancreatoduodenectomy, pancreas-sparing duodenectomy, segmental duodenectomy, or local resection, have been described depending on the size and exact site of the lesion. In this report, we describe two cases of GIST involving the second and third portion of the duodenum successfully treated by partial duodenectomy with Roux-en-Y duodenojejunostomy. This surgical technique is ideal when GIST does not involve the ampulla as it avoids a pancreatoduodenectomy and has not been previously described for the management of this malignancy.

Paragangliomes tympaniques: Analyse d’une série de neuf cas

The purpose of this work was to evaluate the diagnostic strategy and outcome of patients treated for tympanic paraganglioma. Nine patients presented with tympanic paraganglioma were treated in our unit from 1996 to 2003. There were eight women and one man, mean age 65 years. Surgery was performed in all nine patients. This retrospective analysis focused on revealing signs, diagnostic tools, surgical procedure for tumor resection, and short-, mid-, and long-term functional outcome. The surgical procedure was well tolerated by all patients. There were no cases of postoperative mastoiditis. None of the patients experienced postoperative dizziness. Total tumor removal was achieved in seven patients. In one patient, incomplete tumor resection was decided in order to preserve facial motion. All patients but one were relieved from their tinnitus in the early postoperative period. In four patients, preoperative hearing levels were worsened by the surgical procedure, essentially through an alteration of preoperative conductive hearing loss. MRI is highly contributive to the diagnosis of tympanic paraganglioma, which should be evoked in patients with pulsatile tinnitus. Diagnosis should be established as early as possible to lower the postoperative morbidity. While surgery can provide cure and relieve tinnitus, there is a high risk of auditory deterioration.

Surgical resection for esophageal carcinoma: Speaking the language

The terminology used to describe esophagectomy for carcinoma can be confusing, even for specialists in gastrointestinal disease. As a result, specific terms are often used out of their intended context. To simplify the nomenclature, two points regarding procedures for surgical resection of the esophagus are critical: the extent of resection (radical vs standard) and the operative approach (choice of incisions). It is important to understand that the radicality of the resection may have little to do with the operative approach, with the exception of esophagectomy without thoracotomy (transhiatal esophagectomy), which mandates the performance of a standard or non-radical resection. Esophagectomy has emerged as the standard curative treatment option for patients with esophageal carcinoma; however, unlike the surgical resection of other types of solid tumors, many different surgical options and/or approaches exist for these patients. This heterogeneity of care may result from the fact that the esophagus is accessible through more than one body cavity (left hemithorax, right hemithorax, abdomen). In addition, and partially as a result of its accessibility, different types of surgical specialists harbor this operation in their armamentarium, including general surgeons, thoracic surgeons, and surgical oncologists. Despite this enthusiasm amongst surgeons, little consensus exists as to which option is most oncologically sound. Further, the details of the various surgical approaches and procedures for resection of the esophagus are often difficult to comprehend, even for specialists in gastrointestinal disease, with much of the relevant terminology used out of its intended context. To facilitate the understanding of the surgical options for esophageal carcinoma, it is useful to view the operation from two angles: the extent of resection (Aradical@ vs Astandard@) and the operative approach (choice of incisions).