Resection Techniques Research Articles

Functional alignment in total knee arthroplasty best achieves balanced gaps and minimal bone resections: an analysis comparing mechanical, kinematic and functional alignment strategies.

Key concepts in total knee arthroplasty include restoration of limb alignment and soft-tissue balance. Although differences in balance have been reported amongst mechanical alignment (MA), kinematic alignment (KA) and functional alignment (FA) techniques, it remains unclear whether there are differences in gap imbalance or resection thicknesses when comparing different constitutional alignment subgroups. MA (measured resection technique), KA (matched resections technique) and FA (technique based on the restricted KA boundaries) were compared in 116 consecutive patients undergoing 137 robotic-assisted cruciate-retaining total knee arthroplasties. The primary outcome was the proportion of balanced gaps (differential laxities ≤ 2mm) for extension, flexion, medial and lateral gap measurements. Manual pre-resection laxity measurements were obtained for MA and KA and manual post-resection measurements were obtained for FA in 10° and in 90° of knee flexion. Secondary outcomes were resection depths and implant alignment. All outcomes were analysed per constitutional coronal alignment and joint line obliquity subgroups. The proportions of balance in all four gap measurements were 54.7%, 66.4% and 96.5%, with MA, KA and FA, respectively. Across all constitutional alignment types, FA achieved the highest proportion of balance. MA resected the least amount of bone from the medial tibial plateau. KA had femoral components in most valgus and most internally rotated, tibial components in most varus and was the most bone-preserving for the posteromedial femoral condyle. FA had the most externally rotated femoral components and was most bone-preserving for the distal femoral resections. The study shows that implant alignment to the mechanical axis or joint line anatomy (equal resections) alone does not guarantee a balanced total knee arthroplasty. FA resulted in the highest proportion of balanced knees across all analysed subgroups. Future research will consider whether one alignment philosophy leads to superior outcomes for different constitutional alignment subgroups. Level II.

Resection of a large multisegmental filum terminale ependymoma through a multisegmental hemilaminectomy.

This video demonstrates a gross-total resection of a multisegmental intradural extramedullary tumor using only multisegmental hemilaminectomy. The patient is a 21-year-old woman presenting with only backache. MRI of the lumbar spine demonstrates a large multisegmental heterogeneously enhancing intradural extramedullary tumor extending down from the eleventh dorsal vertebrae down to the fifth lumbar vertebrae. The surgical video demonstrates the technique of multisegmental hemilaminectomy and microsurgical resection of the tumor without posterior spinal instrumentation. Postoperatively, the patient had no neurological deficit and was discharged on postoperative day 5. Three-month postoperative MRI shows no residual disease or spinal deformity.

Surgical resection of an intradural extramedullary spinal tumor.

Large ventrally located spinal meningiomas are typically resected via a posterolateral or lateral approach. Optimal outcomes are associated with good preoperative functional status (i.e., modified McCormick grade < 4), while recurrence rates may be predicted by degree and quality of resection (i.e., low Simpson grade). This video describes the operative techniques for resection of a large ventral C2 intradural extramedullary meningioma in a 71-year-old male presenting with hemibody sensory loss and abnormal gait. A paramedian approach was performed, allowing for adequate exposure and gross-total resection. The patient was discharged on postoperative day 2 and showed near-complete resolution of sensory deficits.

Therapeutic Challenges for Gastric Neuroendocrine Neoplasms: Take It or Leave It?

Background and Objectives: Gastric neuroendocrine neoplasms (gNENs) represent rare but increasingly recognized tumors. They are distinguished into three main clinical types (type-1, type-2, and type-3) according to gastrin level and at histological evaluation in well-differentiated G1, G2, or G3 lesions, as well as poorly-differentiated lesions. Small type-1 and type-2 neoplasms with low proliferation indices demonstrated excellent survival without progression during an extended follow-up period, and for these reasons, active endoscopic observation or endoscopic resection are feasible options. On the other hand, surgery is the treatment of choice for more aggressive type-3, G3, or infiltrating neoplasms. The present study aims to comprehensively review and compare the available therapeutic strategies for gNENs. Materials and Methods: A computerized literature search was performed using relevant keywords to identify all of the pertinent articles with particular attention to gNEN endoscopic treatment. Results: In recent years, different endoscopic resective techniques (such as endoscopic mucosal dissection, modified endoscopic mucosal resection, and endoscopic full-thickness resection) have been developed, showing a high rate of complete resection for advanced and more aggressive lesions. Conclusions: Overall, gNENs represent a heterogeneous group of lesions with varying behavior which require personalized management. The non-operative approach for small type-1 gNENs seems to be feasible and should be promoted. A step-up approach with minimally invasive endoscopic therapies might be proposed, particularly for type-1 gNEN. On the other hand, it is important to recognize the negative prognostic factors in order to identify those rare cases requiring more aggressive approaches. A possible therapeutic algorithm for localized gNEN management is provided.

Pediatric Spinal Giant Cell-rich Osteosarcoma: Case Report and Brief Literature Review.

Osteosarcoma, the most common primary malignant bone tumor in childhood, very rarely occurs in the spine. Criteria of complete tumor resection/stable reconstruction of osteosarcoma and the latest protocol of neoadjuvant chemotherapy of the spine have not been reported because of its rarity, technical difficulties, and its continued severe surgical risk. A 11-year-old female complained of back pain for several months and walking disability. The workup discovered a large destructive bone lesion in the thoracic 12th (Th12) with vertebral body collapse and subluxation, large amount of associated anteroposterior soft tissue components, and narrowing of the spinal canal. Histology at the 1st decompression and emergent instrumentation surgery revealed giant cell-rich osteosarcoma. Following the 1st surgery, we performed three cycles of neoadjuvant chemotherapy based on the osteosarcoma 95J (NECO95J) protocol and evaluated efficacy of chemotherapy on the Th12 tumor. The tumor was isolated only to Th12 spine following chemotherapy. Therefore, following vascular embolization of the Th12 tumor, we performed surgical resection by single posterior approach that included total en bloc spondylectomy (TES). She recovered well postoperatively, without motor or sensory deficit and no back pain. Six cycles of postoperative neoadjuvant chemotherapy were administered after the 2nd surgery and TES. The patient was disease-free at the 8-months clinical and radiological follow-up and showed no neurological involvement at 8-months. We reported a case of pediatric spinal osteosarcoma, the surgical technique of complete tumor resection, and stable reconstruction of spinal osteosarcoma. We also discussed the recent neoadjuvant chemotherapy protocol for osteosarcoma.

Endoscopic Submucosal Dissection for Early Gastric Cancer in A Cirrhotic Patient: Case Report and Review of Literature

AbstractEndoscopic resection techniques like endoscopic mucosal resection and endoscopic submucosal dissection have become the cornerstone for the management of early cancers of the gastrointestinal tract. Risks associated with endoscopic resection may be exacerbated by the presence of background cirrhosis with its attendant complications. With complex alterations in hemostasis in patients with cirrhosis, management of patients undergoing endoscopic resection is more challenging. In this article we discuss a case of early gastric cancer in a patient with background chronic liver disease and thrombocytopenia managed using endoscopic submucosal dissection.

Optimal endoscopic treatment and partial cystectomy with or without bladder augmentation for Hunner-type interstitial cystitis.

Interstitial cystitis/bladder pain syndrome (IC/BPS) presents a significant challenge for urologists in terms of management, owing to its chronic nature and adverse impact on patient quality of life. Given the potential distinction between two disease entities within IC/BPS, namely Hunner-type IC and BPS without Hunner lesion, there is a need for an optimal therapeutic approach that focuses on the bladder lesions in Hunner-type IC. In cases where Hunner lesions are observed, complete transurethral ablation of these lesions should be prioritized as the initial intervention, as it has demonstrated effectiveness in symptom control. However, recurrence remains a limitation of this intervention. The techniques of resection and coagulation are equally effective in terms of symptom relief and recurrence prevention. Reconstructive surgery becomes necessary in cases of end-stage IC/BPS where various therapeutic approaches have failed. Patient selection is crucial in reconstructive surgery, particularly for patients with clear Hunner lesions and small bladder capacity who have not responded to previous treatments. Furthermore, it is vital to consider the patients' expectations and preferences adequately. Based on a comprehensive review of the literature and our own clinical experiences, subtotal cystectomy followed by bladder augmentation is considered a safe and effective surgical option. This stepwise and tailored therapeutic approach aims to optimize patients' quality of life by specifically targeting Hunner-type IC.

Endoscopic Submucosal Dissection of a Giant Rectal Adenoma Manifesting as McKittrick-Wheelock Syndrome.

McKittrick-Wheelock syndrome (MKWS) is an uncommon clinical manifestation of large, villous, epithelial lesions of the distal colon and rectum. Excessive secretion of electrolyte-rich mucus from these lesions leads to secretory diarrhea, electrolyte disorders and acute renal failure. Several cases of MKWS have been reported since its initial description in 1954. The definitive treatment for the great majority of MKWS cases has consisted of surgical resection of the affected part of the colorectum, usually in the form of a low anterior resection or an abdominoperineal resection with the formation of an ostomy. Recent developments in endoscopic resection techniques now offer new, minimally invasive treatment alternatives for MKWS patients. We present the first reported case in the Western world of MKWS caused by a rectal adenoma with a size of 19 × 10 cm, treated through endoscopic submucosal dissection. Through the lessons learned by this case, as well as by a thorough review of the literature, we discuss this uncommon syndrome, focusing on treatment alternatives.

Local recurrence rates after resection of large colorectal serrated lesions with or without margin thermal ablation

Introduction Serrated lesions (SLs) including traditional serrated adenomas (TSA), large hyperplastic polyps (HP) and sessile serrated lesions (SSLs) are associated with high incomplete resection rates. Margin ablation combined with EMR (EMR-T) has become routine to reduce local recurrence while cold snare polypectomy (CSP) is becoming recognized as equally effective for large SLs. Our aim was to evaluate local recurrence rates (LRR) and the use of margin ablation in preventing recurrence in a retrospective cohort study. Methods Patients undergoing resection of ≥15 mm colorectal SLs from 2010-2022 were identified through a pathology database and electronic medical records search. Hereditary CRC syndromes, first follow-up > 18 months or no follow-up, surgical resection were excluded. Primary outcome was LRRs (either histologic or visual) during the first 18-month follow-up. Secondary outcomes were LRRs according to size, and resection technique. Results 191 polyps in 170 patients were resected (59.8% women; mean age, 65 years). The mean size of polyps was 22.4 mm, with 107 (56.0%) ≥20 mm. 99 polyps were resected with EMR, 39 with EMR-T, and 26 with CSP. Mean first surveillance was 8.2 mo. Overall LRR was 18.8% (36/191) (16.8% for ≥20 mm, 17.9% for ≥30 mm). LRR was significantly lower after EMR-T when compared with EMR (5.1% vs. 23.2%; p = 0.013) or CSP (5.1% vs. 23.1%; p = 0.031). There was no difference in LRR between EMR without margin ablation and CSP (p = 0.987). Conclusion The local recurrence rate for SLs ≥15 mm is high with 18.8% overall recurrence. EMR with thermal ablation of the margins is superior to both no ablation and CSP in reducing LRRs.

ALPPS technique for two-stage liver resections: immediate and long-term results

Aim. To evaluate the immediate and long-term results of two-stage liver resection performed by means of ALPPS technique.Materials and methods. The retrospective analysis involved 7 patients (mean age 62 years) with intact liver parenchyma volume (Future Liver Remnant, FLR) &lt;25%. All patients underwent ALPPS from 2014 to 2021. Both stages of ALPPS were performed in the traditional way. The increment of intact parenchyma on days 6–8 after stage I was evaluated by CT volumetry. The main operative characteristics, incidence of postoperative complications according to Clavien-Dindo and ISGLS, time without progression and life expectancy were analyzed.Results. The median duration of ALPPS stage I was 250 min, median blood loss was 600 ml, and stage II – 210 min and 300 ml, correspondingly. The median FLR before and after ALPPS stage I was 15.3% and 31.6%. The median FLR hypertrophy after ALPPS stage I accounted for 123%. The median interval between stage I and II of ALPPS was 10 days. All patients underwent R0 resection. The incidence of postoperative complications after ALPPS stage I was 14.3% (Clavien–Dindo I), after stage II – 57.1% (Clavien–Dindo III–V). The mortality rate within 90 days after ALPPS stage II accounted for 14.3%. Median follow-up was 25 months. The median time without progression in 6 patients operated for colorectal cancer metastases was 6 months, the median life expectancy was 31 months. The patient who underwent ALPPS for hepatocellular carcinoma is alive, no signs of disease progression have been detected.Conclusion. ALPPS provides a rapid and more than two-fold growth in FLR and increases the likelihood of R0 resection in patients with initially unresectable primary and secondary liver tumors. However, the immediate results of ALPPS are unsatisfactory. The indications for surgery are extremely controversial due to the development of drug therapies, ablation techniques and radiotherapy.

Endoscopic Resection of Gastrointestinal Stromal Tumors.

Surgical resection is regarded as the main modality for the treatment of gastrointestinal stromal tumors (GISTs). With the advancement of endoscopic techniques and the concept of super minimally invasive surgery (SMIS), endoscopic resection has been an alternative option for surgery. Recently, various endoscopic resection techniques have been used for the treatment of GISTs, including endoscopic submucosal dissection (ESD), endoscopic submucosal excavation (ESE), endoscopic full-thickness resection (EFR), submucosal tunneling endoscopic resection (STER), and laparoscopic and endoscopic cooperative surgery (LECS). Studies on the safety and efficacy of endoscopic treatment of GISTs have emerged in recent years and have demonstrated that endoscopic resection techniques are effective and safe for the treatment of GISTs. However, there is currently no consensus on the optimal follow-up strategy and the appropriate tumor size cutoff value for ER treatment. This review aims to discuss the indications, preoperative preparation, procedures, efficacy, safety, postoperative evaluation, follow-up, and perspectives of ER for GISTs. This article is protected by copyright. All rights reserved.

Pain, gastrointestinal function and fertility outcomes of modified nerve-vessel sparing segmental and full thickness discoid resection for deep colorectal endometriosis - A prospective cohort study.

There is an ongoing debate on surgical techniques for colorectal deep endometriosis (DE) and their effects on gastrointestinal (GI) function. The aim of this study was to prospectively investigate the differences in pre- and postsurgical GI function, health profiles and pain symptoms in women undergoing colorectal surgery for symptomatic DE either with a modified segmental resection technique, so-called nerve-vessel sparing segmental resection (NVSSR), or full thickness discoid resection (FTDR). Complication rates and fertility outcomes were also evaluated. A total of 162 consecutive patients, 125 (77.2%) of whom underwent NVSSR and 37 (22.8%) FTDR, were evaluated regarding complication rates. Furthermore a lower anterior resection syndrome (LARS) scores, gastrointestinal function-related quality of life index(GIQLI), pain symptoms, endometriosis health profile (EHP-30) parameters were analyzed pre- and post-surgery in a final cohort of 121 patients. There was no difference between postsurgical prevalence of LARS in either surgery group (14/98, 14.1% NVSSR; 2/23, 8.6% FTDR), with significantly decreased LARS scores and increased GIQLI values before vs after surgery in both groups (P < 0.001). The overall grade III complication rate was 7/162 (4.3%) with no significant differences between NVSSR and FTDR groups. Overall, EHP-30 and pain scores significantly decreased after a median follow-up of 41 (± 17.6) months (EHP-30 51.1, SD 21.5 vs 12.7, SD 19.3, P < 0.001; dysmenorrhea, dyspareunia, dyschezia all P < 0.001 both cohorts, respectively). The overall life birth rate and postsurgical pregnancy in infertile patients undergoing NVSSR and FTDR was respectively 58.1% in 25/43 patients; 55.6% in 5/9 patients; 56.0% in 14/25 patients and 100% in 5/5 patients. NVSSR and FTDR for symptomatic colorectal DE confer a significant amelioration of GI function reflected by decreased LARS symptoms and increased GIQLI scores with no differences in postsurgical function in between the two techniques. Both techniques confer similar complication rates and effects on pain reduction and health profiles.

Tape Eyelid Closure: An Effective Solution for Nocturnal Lagophthalmos in Patients with Ptosis and Poor Bell's Phenomenon.

Poor Bell's phenomenon is often considered a relative contraindication for ptosis surgery, as it increases the risk of corneal exposure and dry eye symptoms after surgery. However, the Bell's phenomenon may vary in different individuals and sleep stages, making it inaccurate to predict the position of the eye during sleep based on awake examination. This study aimed to investigate the role of Bell's phenomenon in ptosis surgery and the management of nocturnal lagophthalmos. We conducted a retrospective case series of 23 patients with ptosis and poor Bell's phenomenon who underwent different surgical techniques at Xijing Hospital from April 2020 to June 2021. We assessed Bell's phenomenon at different stages of sleep and collected data on ptosis degree, surgical approach, lagophthalmos, complications, and outcomes. Of the total 23 patients originally considered for study, 9 with frontalis muscle advancement technique, 8 with conjoint fascial sheath suspension, 4 with levator resection technique, and 2 with levator aponeurosis plication technique. All patients achieved satisfactory correction of ptosis. One patient had prolonged lagophthalmos and underwent reoperation to lower the eyelid height. Other complications were minor and resolved with conservative treatment. We conclude that poor Bell's phenomenon is not a relative contraindication for ptosis surgery. Nocturnal lagophthalmos should be monitored after ptosis surgery regardless of the Bell's phenomenon results. Tape eyelid closure can be an effective solution to protect the corneal surface during nocturnal lagophthalmos. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Supramaximal resection based on en-bloc technique reduces tumor burden and prolongs survival in primary supratentorial lobar glioblastoma.

Resection beyond the contrast-enhanced zone contributed to reduce tumor burden and prolong survival in glioblastomas. The optimal extent of resection (EOR) and how to achieve it are worthy of continuous investigation for obtaining a satisfactory balance between maximal resection and the preservation of neurological function. A total of 340 adult supratentorial lobar glioblastomas (included astrocytoma, WHO 4, IDH mutation and glioblastoma) were retrospectively evaluated. The clinical data, EOR, technique of resection, postoperative complications, overall survival (OS) and progression-free survival (PFS) were assessed by univariate, multivariate and propensity score matched analysis. Histological staining was performed to comprehend the effect of the membranous structures and the cell distribution in tumoral and peritumoral regions. Supramaximal resection (SMR) was confirmed as resection with 100% EORCE and > 50% EORnCE in glioblastomas by Cox proportional hazards model. Histological results showed SMR reduced the cell density of surgical edge compared to total resection. En-bloc technique based on membranous structures, which had blocking effect on tumoral invasion, contributed to achieve SMR. Moreover, applying en-bloc technique and achieving SMR did not additionally deteriorate neurological function and had similarly effects on the improvement of neurological function. Multivariate analysis confirmed that IDH1 status, technique of resection and EOR were independently correlated with PFS, and > 64 years old, IDH1 status, technique of resection, EOR and preoperative NIHSS were independently correlated with OS. Applying en-bloc technique and achieving SMR, which could reduce tumor burden and did not increase additional complications, both had remarkedly positive effects on clinical outcomes in patients with primary supratentorial lobar glioblastomas.

A rare case of pedunculated ampulloma: EUS view and resection.

Video 1Video showing a rare case of pedunculated ampulloma: imaging evaluation and resection technique.

Cold Versus Hot Snare Polypectomy for Colorectal Polyps: An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials.

Endoscopic polypectomy is an excellent tool for colon cancer prevention. With the innovation of novel resection techniques, the best method is still being investigated. Hence, we aim to evaluate the efficacy and safety of cold snare polypectomy (CSP) versus hot snare polypectomy (HSP) for colorectal polyp resection. A systematic review and meta-analysis synthesizing evidence from randomized controlled trials retrieved from PubMed, EMBASE, WOS, SCOPUS, and CENTRAL until July 16, 2022. We pooled dichotomous outcomes using risk ratio (RR) with the corresponding CI. This review's protocol was prospectively registered in PROSPERO with ID: CRD42022347496. We included 18 randomized controlled trials with a total of 4317 patients and 7509 polyps. Pooled RR favored HSP regarding the complete resection rate (RR: 0.96 with 95% CI: 0.95, 1, P = 0.03) and local recurrence incidence (RR: 5.74 with 95% CI: 1.27, 25.8, P = 0.02). Pooled RR favored CSP regarding the colonoscopy time (mean difference: -6.50 with 95% CI: -7.55, -5.44, P = 0.00001) and polypectomy time (mean difference: -57.36 with 95% CI: -81.74, -32.98, P = 0.00001). There was no difference regarding the incidence of immediate bleeding ( P = 0.06) and perforation ( P = 0.39); however, HSP was associated with more incidence of delayed bleeding ( P = 0.01), abdominal pain ( P = 0.007), and postresection syndrome ( P = 0.02). HSP is associated with a higher complete resection and lower recurrence rates; however, HSP is also associated with a higher incidence of adverse events. Therefore, improving the complete resection rate with CSP still warrants more innovation, giving the technique safety and shorter procedure duration.

Perforation-free removal of gastric gastrointestinal stromal tumors: Endoscopic inversion and strangulation of muscle layer and resection (EISMR).

Endoscopic resection for GIST has become more widespread in recent years because it is less invasive than surgery. However, when endoscopic resection is performed, a full-layer resection of the gastric wall is often necessary, and extensive suturing is required if perforation occurs, which is a technically challenging procedure. Recently, we reported a new method called endoscopic inversion and strangulation of the muscle layer and resection (EISMR), which consists of endoscopically inverting the muscle layer into the gastric lumen and strangulating the muscle layer with a detachable snare, followed by resection. The study comprised five consecutive patients with gastric GIST ≤50 mm in diameter who underwent EISMR procedures. The main outcomes of the study were en bloc resection rate, R0 resection rate, procedure time, and complications. The results showed that all five patients successfully underwent complete resection without perforation, and the en bloc resection and R0 resection rates were 100%. The median procedure time was 93 min (range, 58-120 min), and there were no major complications. We concluded that EISMR would be a safe and effective technique for endoscopic resection of gastric GISTs and may be an alternative to surgery or endoscopic submucosal dissection.

Endoscopic En-Bloc Resection of Neurilemmoma of the Foot Dorsum

Neurilemmoma (schwannoma) is a benign, slow-growing, encapsulated tumor originating from the Schwann cells of the peripheral nerve sheath. The purpose of this technical note is to describe the technique of endoscopic en-bloc resection of neurilemmoma of the foot dorsum. This has the advantage of better cosmetic result and less postoperative perineural fibrosis.

VE65 - Not all renal tumors are resected equal: Resection strategy and technique do not always coincide during robotic partial nephrectomy

VE65 - Not all renal tumors are resected equal: Resection strategy and technique do not always coincide during robotic partial nephrectomy

Efficacy of cold snare polypectomy techniques for small polyp (≤ 10 mm) in the colorectum

Background: Colonoscopic polypectomy is the best important intervention for the prevention of colorectal cancer progression. The hot polypectomy with electrocautery is a standard technique, effective. However, this technique has been associated with an increased risk of electrocautery-related complications, including bleeding or perforation and incomplete resection. To reduce these complications, Cold snare polypectomy: a mechanical method that uses a snare without electrical current, which has proven to be simple and safe without the potential risks involved in electrically induced heat. Cold snare polypectomy (CSP): a mechanical method that uses a snare without electrical current, which has proven to be simple and safe without the potential risks involved in electrically induced heat. Objective: Evaluation of the success rate of colon polypectomy ≤ 10 mm by cold snare polypectomy. Investigate complications of this technique and some related factors. Methods: Comparative study on 96 colonoscopy patients with polyps ≤ 10 mm in size, randomly divided into two groups to receive endoscopic polypectomy with cold noose (CSP) and hot noose (HSP). Results: Complete polypectomy (94.5%), complete polypectomy results in a higher percentage in the CSP group (95.8% compared to HSP 93.8%) (p &gt; 0.05); Specifically, the rate of complete removal of polyps with sizes &lt; 5 mm, 5 - 8 mm and 9 - 10 mm, respectively, is 100%; 95.9 and 83.3% (p &gt; 0.05). Complications of early bleeding occurred 3.1% (4.2% CSP group compared with 2.1% HSP group), 1 case of late bleeding in HSP group (2.1%) Conclusion: CSP or HSP can is safely used as one of the standard techniques for resection of 4 - 10 mm colorectal polyps. Key words: cold snare polypectomy (CSP), hot snare polypectomy (HSP), colonscopy, completely removed.