Two-stage Surgical Approach Research Articles

Bouveret Syndrome Resolved by a Two-Staged Endoscopic and Surgical Approach

Bouveret Syndrome Resolved by a Two-Staged Endoscopic and Surgical Approach

Effect of Induced Membrane Formation Followed by Polymethylmethacrylate Implantation on Diabetic Foot Ulcer Healing When Revascularization Is Not Feasible.

No study has investigated the role of induced membrane (IM) formation in treating diabetic foot ulcer (DFU). This retrospective study was aimed (1) at evaluating the potential role of a two-staged surgical approach, comprising polymethylmethacrylate (PMMA) implantation and IM formation, in the treatment of DFU and (2) at comparing the results of those with routine wound debridement in patients with DFUs and nonrevascularized peripheral arterial disease (PAD). Fifty patients with infected DFUs who were not candidates for vascular interventions were enrolled between February 2016 and April 2018 and assigned to the PMMA group (n = 28) and conventional group (n = 22). The healing rate, major amputation rate, duration of healing, frequency of debridement procedures, patient survival rate, and reulceration of DFUs were determined. The Mann-Whitney U test, independent sample t-test, and χ2 or Fisher exact test were used in statistical analysis. Overall clinical outcomes were statistically different between the groups (Z = −2.495, P = 0.013). In the PMMA group, 16 patients (57.1%) with intact IM formation achieved ulceration healing at 13.1 ± 3.7 weeks with a mean number of debridements of 1.3 ± 0.4, which were significantly different compared to those values in 5 patients of the conventional group (22.7%, P = 0.014; healing duration: 26.4 ± 7.8 weeks, P = 0.016; mean number of debridements: 3.6 ± 0.5, P ≤ 0.001). At a mean 16.8 ± 4.3-month follow-up, patient survival rates were 92.9% and 68.2% in the PMMA and conventional groups, respectively (P = 0.032). The major amputation rate and reulceration of DFUs were similar between the groups. The two-staged surgical approach is an available, effective modality for improving healing of DFUs. This study provides preliminary information of IM formation followed by PMMA implantation in the management of DFUs in PAD when revascularization is not feasible.

Management of Metastatic Colorectal Cancer to the Liver and Peritoneal Carcinomatosis with a Two-Stage Surgical Approach

Management of Metastatic Colorectal Cancer to the Liver and Peritoneal Carcinomatosis with a Two-Stage Surgical Approach

Two-stage maxillary distraction osteogenesis using a modified external device: clinical outcome and complications

Rigid external distraction is currently used to correct severe maxillary hypoplasia. The purpose of this retrospective study was to present the clinical results and complications of a two-stage surgical approach using a modified external distraction system that consists of maxillary distraction and then maxillary fixation. We treated eight patients with cleft lip and palate in this way from 2016 to 2018. Lateral cephalograms taken before the first operation, after distraction, two weeks after the second operation, and one year after treatment were used to examine maxillofacial morphology. Velopharyngeal function was evaluated by a speech therapist. The mean movements of the maxilla forwards and downwards at Point A were 12.0mm and 8.0mm at the completion of distraction and those at Point B were 5.0mm backwards and 9.7mm downwards. Mouth opening was limited at this time, and was relieved after maxillary fixation. The mean relapse one year postoperatively was 24.3% horizontally and 52.5% vertically. Velopharyngeal function was unchanged by the operation. We conclude that the method has advantages that include the short duration of wearing distractors and increased acceptance by patients. The modified external device advanced the midface sufficiently.

Calcifying odontogenic cyst treated by a two-stage surgical approach and reconstructed with L-PRF membrane associated to lyophilized bovine bone graft

Calcifying odontogenic cyst treated by a two-stage surgical approach and reconstructed with L-PRF membrane associated to lyophilized bovine bone graft

Two-stage treatment of Barrett's esophagus

To evaluate the results of treatment of Barrett's esophagus using laparoscopic 270° Toupet fundoplication or radiofrequency ablation (RFA) and their combination. We have analyzed data for the period 2011-2018. Antireflux surgery was performed in the first group, RFA - in the second group, both procedures were done in the third group. The majority of patients with hiatal hernia underwent cruroraphy, laparoscopic 270° Toupet fundoplication, endoscopic treatment as the second stage was performed in some of them. Patients without hiatal hernia and no signs of reflux underwent RFA without antireflux surgery. Control endoscopic examination was carried out after 3, 6 and 12 months and then annually. There were 84 patients with Barrett's esophagus. We performed 51 RFA procedures in 47 patients and fundoplication in 71 patients. Antireflux surgery as the first stage was preferred in patients with hiatal hernia (n=60), subsequent radiofrequency ablation (RFA) was performed in 28 of them. Seven patients without hiatal hernia, but with significant gastroesophageal reflux underwent antireflux surgery too. Other 12 patients without hiatal hernia underwent RFA alone. Need for delayed antireflux surgery after endoscopic treatment occurred in 23.5% of patients. Complete regression of metaplasia was noted in 95.2% after 1 procedure and in 100% after 2 procedures. Recurrent metaplasia was registered in 4.3% of patients. Progression to dysplasia was not detected. Two-stage surgical approach including antireflux surgery and radiofrequency ablation in combination with drug therapy is optimal. Endoscopic therapy is recommended for all types and length of metaplasia.

Liver transplantation for metastatic pediatric GIST: first case of a two-stage surgical approach

Liver transplantation for metastatic pediatric GIST: first case of a two-stage surgical approach

Two-stage surgery for a large ventricular septal defect and patent ductus arteriosus associated with severe pulmonary arterial hypertension in an adult patient

Introduction. Adult patients with pulmonary arterial hypertension (PAH) associated with congenital left-to-right shunting are often considered inoperable. Case outline. A 26-year-old man presented with effort intolerance and palpitations. The diagnosis of PAH in the presence of a large perimembranous ventricular septal defect (VSD) and patent ductus arteriosus (PDA) was established. The patient was managed with a two-stage surgical approach involving an initial ligation of PDA, followed by VSD closure using unidirectional valved patch. Treatment decisions were based on the results of both invasive and non-invasive investigations. At follow-up, the patient was asymptomatic with pulmonary arterial pressure and vascular resistance returning to normal levels. Conclusion. There is a possibility for an adult patient to have a congenital heart disease associated with marked pulmonary overcirculation that is still amenable to surgical repair. This implies that there is an individual response to a long-standing left-to-right shunt, and that the therapy should be considered on a case-by-case basis.

Changes in maxillofacial morphology and velopharyngeal function with two-stage maxillary distraction–mandibular setback surgery in patients with cleft lip and palate

Maxillary distraction is increasingly used for the correction of severe maxillary retrusion in patients with cleft lip and palate. However, control of the maxillary movement is difficult, and the need to wear visible distractors for a long period of time causes psychosocial problems. A two-stage surgical approach consisting of maxillary distraction and mandibular setback was developed to overcome these problems. In this study, changes in maxillofacial morphology and velopharyngeal function were examined in 22 patients with cleft lip and palate who underwent this two-stage approach. Lateral cephalograms taken just before the first surgery, immediately after the second surgery, and at completion of the active post-surgical orthodontic treatment were used to examine maxillofacial morphology. Velopharyngeal function was evaluated by speech therapists using a 4-point scale for hypernasality. The average forward movement of the maxilla with surgery at point A was 7.5mm, and the average mandibular setback at pogonion was 8.6mm. The average relapse rate during post-surgical orthodontic treatment was 25.2% for the maxilla and 11.2% for the mandible. After treatment, all patients had positive overjet, and skeletal relapse was covered by tooth movement during postoperative orthodontics. Velopharyngeal function was not changed by surgery. This method can shorten the period during which the distractors have to be worn and reduce the patient burden.

Combined Surgical Resection and Adjuvant High Dose Photon/Proton Radiation Therapy Strategy Results in High Local Control in Cervical Spine Chordomas

Cervical spine chordoma is a rare and challenging tumor often treated with combination surgical resection and radiotherapy. We report the outcomes in the largest series of cervical spine chordoma treated with maximum surgical resection combined with high-dose photon/proton beam radiotherapy in the pre-operative and/or adjuvant setting. We performed an IRB approved retrospective review on 109 patients with cervical spine chordoma treated during the years of 1984-2014 at our institution. CTCAE version 4.0 was used to grade late treatment toxicity. Median age at diagnosis was 51 years old (range:10-83). 79 patients had > 2 years of follow-up. 95 patients (87%) had non-chondroid chordoma histology. 86 (79%) underwent resection followed by adjuvant RT and 11(10%) patients received pre- and post-operative radiotherapy with surgery, respectively. 12 patients (11%) underwent surgery alone, radiotherapy alone or neither. 4 patients (4%) received systemic therapy. Surgical details were available in 74% of patients who underwent surgery and included a transoral (19%), anterior (49%), posterior (41%) or transverse (32%) approach. 22% of patients underwent more than one surgical or a planned two-staged surgical approach. Spinal stabilization was performed in 60% of patients and included a cervical (67%) or occipital (33%) approach. Of 82 patients (75%) with known margin status, 7% had R1 resection and 63% had R2 resection. Median radiotherapy dose was 75.2 GyRBE (range:48.6-83.2 GyRBE). Of 100 patients who received radiotherapy, 74% received combined photon/proton beam radiotherapy with a median 66% of the dose delivered using proton beam. Five-year local control, overall survival and metastasis-free survival was 69.4% (95% CI:58.5-80.3%), 77.7% (95% CI:66.8-88.6%) and 93.6% (95% CI:87-100%), respectively. Hardware failure occurred in 1.8% of patients. Late grade 3 or higher toxicity occurred in 16% of patients, including one grade 5 toxicity secondary to treatment (recurrent chordoma at presentation, perioperative mortality). Combined surgical resection and high dose photon/proton radiotherapy results in good local control with acceptable low rates of grade 3 or higher late toxicity.

Utilities of scrotal flap for reconstruction of penile skin defects after severe burn injury.

In the present study, we aimed to present our experience of an effective two-stage surgical approach using scrotal skin flap for patients with penile skin defects following severe burn injury. A total of 17 patients with penile skin defects underwent scheduled two-stage reconstruction using scrotal skin flap from January 2004 to October 2016. Patients, who were selected as eligible candidates for scrotal flap, exhibited a wide range of indications, including iatrogenic injuries (e.g., diathermy treatment after circumcision), scalding, flame injuries and electrical burns. During the first stage, the denuded penis secondary to debridement was temporally embedded in scrotal skin flap through an intrascrotal tunnel created between the skin and darto's fascia. During the second stage, the skin around the penis was separated and divided from the scrotum after incising the scrotal skin at the ventral penile base. After a mean follow-up of 30months, the reconstructedpenisesyielded satisfactoryaesthetic outcomes and maintained erectile function. The mean age of patients was 35years (19-55years), and the median follow-up was 30months (12-60months). No major perioperative complication occurred except for dehiscence of scrotal skin after 2nd stage in three patients, and split-thickness skin grafts were applied for recovery of scrotum. Of 17 cases, 15 patients (88.2%) were in satisfactory cosmetic appearance. All patients regained penile sensation and normal voiding function in standing position. The International Index of Erectile Function (IIEF) was used to assess sexual function, with 13 patients (76.5%) reported normal erectile function, while the rest 4 reported mild erectile dysfunction. With regards to intercourse satisfaction domain, encouraging results indicated a total of 17 patients resumed sexual intercourse after surgery. In overall satisfaction domain, 11/17 (64.7%) reported a satisfaction from "very" to "moderately" with their overall sex life and sexual relationship with their partners, while only one patient reported "moderately dissatisfied" with his overall sex life. We report a series of particular cases, including rare iatrogenic injury (diathermy treatment after circumcision) and severe compound electrical injury. Meanwhile, we show our successful experience that scrotal skin flap could be used as an effective surgical alternative to cover severe burn injury wound in male genitalia. The scrotal flap, with higher anti-infection ability and flexible contexture, is available for recovering penile skin defects following severe burn injury resulting in good aesthetic and sexual outcomes.

Diagnosis and treatment of extracranial internal carotid artery lesion combined with cerebrovascular malformation

To analyze own experience of diagnosis and treatment of patients with extracranial internal carotid artery lesion and cerebrovascular malformations. There were 16 patients with combined lesion of extracranial and intracranial internal carotid artery for the period January 2013 - December 2014. Occlusive-stenotic lesion and tortuosity of ICA were observed in 11 and 5 cases respectively. Incidence of combined ICA lesion was 5.2% (16 out of 308 observations of extracranial internal carotid artery lesion). Surgical treatment was performed in 7 patients including two-stage intervention in 4 cases and simultaneous surgery in 3 cases. Mean time between neurosurgical and vascular stages was 6 months. Complications and mortality were absent. Two-stage surgical approach with intracerebral vascular malformation correction followed by extracranial ICA reconstruction may be safe and effective in patients with combined lesion of ICA. Further trials are necessary for certain conclusions.

25. Intraoperative neurophysiology in pediatric neurosurgery

Intraoperative neurophysiological monitoring (IONM) techniques commonly used in adults should be tailored to pediatric patients. Below the age of 5–6 years, the classical Penfield’s method for cortical mapping often fails to elicit a muscle response due to the immaturity of the motor cortex and the corticospinal tract, while the motor evoked potential (MEP) short-train technique seems more effective. The use of awake surgery in children remains anecdotal and whenever cognitive function need to be investigated, a two-stage surgical approach with the use of subdural grids represents a valid alternative. In brainstem surgery, mapping techniques are valuable in selecting safe entry zones to the dorsal brainstem and during the removal of fourth ventricle tumors infiltrating the brainstem. Combination of direct mapping and subcontinuous monitoring of the corticobulbar MEPs for lower motor cranial nerves minimizes the risk of compromising swallowing and coughing reflexes. In spinal cord surgery, is difficult to record the D-wave in children younger than two years, but its critical role in predicting long-term motor outcome is confirmed in pediatric spinal cord tumors. During surgery of the conus-cauda for spinal dysraphisms, mapping techniques are essential to identify and spare functional neural tissue and, vice versa, to cut non functional structures that may contribute to cord tethering.

Outcomes of placing short implants in the posterior mandible: a preliminary randomized controlled trial.

Short dental implants can be an alternative to bone augmentation procedures at sites of reduced alveolar bone. Most studies on short implants are retrospective or multicentre reports that lack controlled and consistent comparison between different systems. This study aimed to compare clinical and radiographic outcomes of short implants in two different systems in the posterior mandible. Twenty patients with two adjacent missing posterior teeth were recruited. Patients were assigned equally and randomly into two groups; Bicon(®) (6 or 8 mm) and Ankylos(®) (8 mm) implants. A two-stage surgical approach and singlecrowns were used for implant placement and loading. Outcomes included peri-implant clinical parameters, implant stability (Periotest values; PTVs) and peri-implant bone changes, which were assessed at baseline, 2, 6 and 12 months post-loading. No implant loss was encountered up to 12 months post-loading. No significant difference in the clinical or radiographic parameters was observed except for PTVs (p < 0.05) that was lower in Ankylos(®) implants. The use ofshort dental implants was associated with excellent 12 months clinical and radiographic outcomes.Ankylos(®) and Bicon(®) implants demonstrated similar peri-implant soft tissue and alveolar bone changes. However,Ankylos(®) implants demonstrated better implant stability at all evaluation intervals.

Functional Plasticity of Language Confirmed with Intraoperative Electrical Stimulations and Updated Neuronavigation: Case Report of Low-Grade Glioma of the Left Inferior Frontal Gyrus

Removal of glioma from the dominant side of the inferior frontal gyrus (IFG) is associated with a risk of permanent language dysfunction. While intraoperative cortical and subcortical electrical stimulations can be used for functional language mapping in an effort to reduce the risk of postoperative neurological impairment, the extent of resection is limited by the functional boundaries. Recent reports proposed that a two-stage surgical approach for low-grade glioma in eloquent areas could avoid permanent deficits via the functional plasticity that occurs between the two operations. The report describes a patient with World Health Organization (WHO) grade II oligoastrocytoma in the left IFG, in functional plasticity of language occurred in the interval between two consecutive surgeries. Intraoperative electrical stimulations suggested that a language area and related subcortical fiber crossed the pre-central sulcus during tumor progression owing to functional plasticity. In the present case, we integrated neurophysiological data into the intraoperative neuronavigation system. We also confirmed the peri-lesional shift of language area and related subcortical fiber on image findings. Consequently, the tumor was sub-totally removed with two separate resections. Permanent language disturbance did not occur, and this favorable outcome was attributed to functional plasticity. The present experience sustains the multistage approach for low-grade gliomas in the language area. A combination of intraoperative electrical stimulations and updated neuronavigation may facilitate the characterization of brain functional plasticity.

Surgical therapy of extensive knee joint empyema: mid-term results after two-stage versus one-stage procedures

Untreated knee joint empyema leads to rapid destruction of the joint and, thus far, has proven challenging to treat. This study presents data obtained after one- versus two-stage surgical approaches. Specifically, clinical outcome, complication rate, re-infection rate, duration of operation, and hospital stay are reported. Between 2006 and 2010, 67 patients with extensive knee joint empyema underwent surgical therapy. Patients underwent either a two-stage surgical approach with open joint treatment for 7-10 days or a one-stage procedure with primary closure of the knee joint after radical debridement. The two-stage procedure was performed on 36 patients, whereas the one-stage procedure was performed on 31 patients. Infection duration prior to the index procedure ranged from 3 days to 55 months (two-stage: ~5 months, one-stage: ~2.4 months). The groups did not differ significantly in demographic group characteristics. Hospital stay and duration of operation were significantly (p < 0.01) reduced in the one-stage group compared to the two-stage group (31.1 ± 10.6 vs. 23.4 ± 14.4 days and 105 ± 32 vs. 68 ± 18 min, respectively). Functional outcome improved in both groups from the pre- to post-operative period, but did not differ significantly between groups. The one-stage open surgical approach produced similar results to the two-stage approach in the treatment of extensive knee joint empyemas. However, by waiving the open joint treatment concept, duration of hospital stay and operation time could be significantly reduced. III.

Overall Essen's experience with the E-vita open hybrid stent graft system and evolution of the surgical technique.

The hybrid stent graft prosthesis E-vita open was designed and introduced by us in 2005 to avoid a two-stage surgical approach in the surgical treatment of complex thoracic aortic disease. Experience in ascending aortic and arch replacement with simultaneous stent grafting of the descending aorta was accumulated over the past 8 years. Facilitation of surgical technique by moving the distal suture line from Zone 3 into Zone 2 took place in 2009. We report our mid-term single-center experience comparing both surgical periods. Between January 2005 and July 2013 a total of 132 patients (mean age 59±11 years) underwent one stage surgery for acute (AAD, n=74), chronic aortic dissection (CAD, n=35) or an extensive thoracic aortic aneurysm (TAA, n=23). Patients were separated in two groups according to distal anastomosis level in Zone 2 (Z2, 41/132) and Zone 3 (Z3, 91/132). Outcome, ischemic and operative times as well as adverse events were monitored during follow up. Overall in-hospital mortality was 13% (17/132) without difference between the groups. However, Zone 2 anastomosis resulted in reduction of cardioplegic arrest (117±39 vs. 147±35 minutes; P<0.001), selective cerebral perfusion (52±15 vs. 68±18 minutes; P<0.001) and visceral ischemic time (51±19 vs. 72±23 minutes; P<0.001). The incidence of postoperative temporary hemodialysis decreased from 40% to 20% in Z2 (P=0.028), postoperative re-exploration rate from 15% to 2% (P=0.037). No difference was found in dissection with complete false lumen thrombosis in 83% (90/109) within 10 days, as well as in TAA, where 100% aneurysm exclusion was observed. Three-year survival, freedom from thoracoabdominal aortic surgery and endovascular repair was 93%, 88%, 88%, respectively. Overall 5-year survival was 76% in AAD, 85% in CAD and 79% in TAA patients. The dimension of surgery could be successfully reduced, indicated by significantly shortened ischemic times and postoperative complications. Durable one-stage repair of complex thoracic aortic disease could be achieved in the majority of cases with acceptable mortality. Distal reintervention is infrequent but associated with low risk when indicated.

Bone platform switching: Perpetuating crestal bone preservation - A pilot study

Background: The purpose of this study was to clinically evaluate the peri-implant soft tissue health and to radiographically evaluate the bone height mesial and distal to the Alpha-bio ® SFB platform switched implants for 1 year; post-prosthesis insertion at 3 month regular intervals. Materials and Methods: A total of 2 Alpha-bio ® SFB platform switched implants were placed on selected patients during this study. A two-stage surgical approach was used for healed or immediate extraction sites - for implant insertion and prosthetic rehabilitation under strict aseptic conditions. The patients were subjected to clinical parameters like plaque index, gingival index, and sulcular bleeding index. Standardized radiographs were taken at different intervals and subjected to computer assisted image analysis for assessment of bone loss mesial and distal to the implant. Results: Implant sites of both patients showed an increase in the plaque, gingival, and bleeding scores at each interval compared to the baseline, followed by a decrease in the average plaque, gingival, and bleeding scores in all patients for teeth as well as implants, indicating that neither of the sites had an increased tendency for soft tissue inflammation. No mobility was associated with any of the implants. Width of keratinized mucosa remained constant throughout the study for either of the patients. The total bone loss was lesser for immediate post-extraction implants. Conclusion: This short-term study showed that Alpha-Bio SFB ® implants could be effectively used for single tooth replacement both in conventional healed ridges or immediately post-extraction in fresh extraction sockets.

A Prospective Clinical Study to Evaluate Early Success of Short Implants

Short implants are an alternative to bone augmentation procedures for patients with reduced bone height. This study evaluated the success of short implants in posterior locations prior to loading. Eighteen patients received at least four Astra Tech implants in symmetric posterior locations. Implants (n = 82) ranged from 6 to 11 mm with 70 implants ≤ 9 mm and 38 implants = 6 mm. Placement was planned virtually using software and cone beam computed tomography (CBCT) scans. Computer-generated guides were ordered for all patients; however, lack of interarch distance precluded their use for five patients. In these situations, guides were used to communicate pilot drill position only. Osteotomies were prepared using the guides and accompanying drill sequence following a two-stage surgical approach. Degree of bone mineralization (DBM) parameters for implant osteotomy sites were measured using three-dimensional CBCT images taken before and after implant placement. A paired t test was performed to compare the DBM parameters between failed and successful implantation sites. Early failure occurred for 7 out of 82 implants or 8.5%. All of the failed implants were 6 mm in length and placed using computer-aided design/computer-assisted manufacture (CAD/CAM) surgical guides. Three failures occurred in one patient. Bone grafting was done for failed implant sites, and after healing, new implants were placed using conventional surgical guides. No further failures occurred. The most frequent value (peak) for DBM was significantly higher for failed implant sites than for successful ones (paired t test, P = .043). Current failures suggest that CAD/CAM guides used with external irrigation may pose a greater risk for the success of 6-mm implants placed in posterior areas with advanced bone loss. This may be due to the bone density in these highly resorbed areas combined with limited irrigation reaching the osteotomy sites.

Novel Surgical Approach for Axillary Hidradenitis Suppurativa Using a Bilayer Dermal Regeneration Template

Hidradenitis suppurativa (HS) is a chronic debilitating disease of apocrine gland-bearing skin characterized by recurrent abscesses with subsequent rupture, scarring, and draining sinus tracts, most frequently affecting the axillary, inguinal, and anogenital regions. Conservative and temporizing treatment methods have been used to treat mild to moderate disease, but wide local excision of affected tissue is necessary for advanced disease. This creates a large soft tissue defect for which there is no consensus for reconstruction. Recovery is hampered by disease recurrence, tissue necrosis, and reoperation. The authors have described in this case study an alternative surgical approach to treat severe HS. All surgical procedures were performed by dedicated burn surgeons at a regional burn center using a two-stage surgical approach. The first stage is a wide local excision of all affected axillary tissue with immediate placement of a bilayer dermal regeneration template to cover the defect. This is secured with a negative pressure wound therapy dressing. The second stage uses a thin split thickness skin graft to close the wound. Results of four patients are presented. There were no recurrences of HS. Two patients required reoperations to address granulation tissue overgrowth and small areas of autograft loss. One patient experienced skin substitute loss as a result of infection. Inadequate excision of HS is the leading cause of disease recurrence. Using a bilayer dermal regeneration template with subsequent skin graft, surgeons can be aggressive in their excision of HS, achieving satisfactory functional and cosmetic results and minimizing axillary recurrence.