Two-step Surgery Research Articles

Exploring Patients' Perceptions of One-step Surgery for Primary Cutaneous Melanoma: A Qualitative Study.

High-frequency ultrasonography (> 20 MHz) has allowed for preoperative measurement of melanoma thickness and thus a one-step surgery strategy. The potential benefits of one-step surgery to patients remain unexplored. From June 2022 to August 2023, 2 dermatologists conducted semi-structured individual interviews with patients who had undergone HFUS examination allowing the choice for one-step surgery (group A) and with patients who had had standard two-step surgery (group B). Analysis of interviews with 21 patients (age range 31-81 years) revealed 5 main themes: (a) understanding the diagnosis, highlighting the significance of clear and comprehensive medical explanations; (b) personal factors considered in treatment decisions, including preferences for minimizing surgical procedures; (c) making choices, bearing responsibility, thus showcasing different levels of patient involvement in decision-making; (d) high- frequency ultrasonography reassurance emphasizing the role of medical reassurance, and (e) patient satisfaction, discussing surgical outcomes and the decision-making process. The majority of participants expressed a clear preference for one-step surgery, perceived as a pragmatic and fast surgical strategy while minimizing interventions. In conclusion, the results emphasize the importance of patient-centred care. These insights can guide improved preoperative consultations and enhance shared decision-making between healthcare professionals and patients regarding melanoma treatment strategies.

Treatment of a Rare Case of Giant Vertebral Extracranial Aneurysm

Extracranial vertebral artery (VA) aneurysms are extremely rare and are usually associated with trauma or dissection. Primary extracranial VA aneurysms are far less common. They may be of mycotic origin or associated with systemic diseases such as neurofibromatosis. The presentation and natural history remains idiopathic, and operative management can be often difficult. Angiography remains the gold standard in diagnosis and characterisation of these lesions. We hereby present a case of a primary aneurysm of the extracranial portion of the vertebral artery and its surgical management, which implied an initial endosvacular approach followed by a two-step surgery in order to resect the aneurysm and stabilise the spine.

Resection of a giant intraspinal and extraspinal schwannoma with cystic change using a two-step surgery: a case report

BackgroundSchwannomas originating from the intravertebral canal rarely extend into the paravertebral region or form large masses. There are few reports on such medical cases, and their clinical diagnosis and management are poorly understood. Here, we report a case of an intraspinal schwannoma with a giant extraspinal mass in a middle-aged Chinese woman and the clinical implications of the symptoms, diagnosis, and treatment of thoracic vertebral schwannoma.Case presentationA 59-year-old female patient who presented with sudden lower limb numbness and difficulty in walking was referred to our department. Magnetic resonance imaging (MRI) revealed a tumor compressing the T11-T12 spinal canal and extensively invading the left thoracic cavity to form a giant paravertebral mass. Schwannoma was diagnosed after intraoperative pathological examination, in which tumor cells were immunoreactive to S100 and Sox10 but negative for smooth muscle actin (SMH). Intraspinal mass resection through the posterior approach and extraspinal chest mass resection under video-assisted thoracoscopy through the left lateral approach were performed simultaneously, and instrumentation was used to maintain thoracic spinal stability.ConclusionIn patients with large schwannomas, customized treatment plans are crucial. Tailoring the approach to an individual’s specific condition by considering factors such as tumor size and location is essential for optimal outcomes.

Comparing total mesorectal excision with partial mesorectal excision for proximal rectal cancer: evaluating postoperative and long-term oncological outcomes.

The treatment role of Total Mesorectal Excision (TME) in proximal rectal cancers (PRC) is still debated. Partial Mesorectal Excision (PME) can reduce morbidity in PRC patients. The purpose of this study was to compare short-term clinical and long-term oncological outcomes between the two groups. A total of 157 PRC patients were enrolled in this study (114 performed with PME and 43 with TME). The two groups were compared in terms of perioperative and long-term oncological outcomes. The overall postoperative complications rate was higher in TME group (18.4% vs. 32.5%, p < 0.05). The incidence of diverting ileostomy was also significantly higher in TME group (86.0% vs. 2.6%, p < 0.001). Overall survival rates for 3, 5, and 7years in PME and TME group accordingly were: 94.6%, 89.3%, 81.5% and 93.2%, 87.6%, 78.4% (p = 0.324). Disease-free survival rates for 3, 5, and 7years in PME and TME group were: 90.2%, 84.5%, 78.6% and 88.7%, 81.2%, 75.3% (p = 0.297), respectively. Local recurrence rates for 3, 5, and 7years in PME and TME group were: 2.6%, 6.1%, 8.8% and 4.6%, 9.3%, 11.2% (p = 0.061), respectively. PME is feasible and can be safely performed in PRC patients with favorable oncological outcomes. TME is associated with increasing risk of surgical complications and requires a two-step surgery for stoma takedown.

Exploring the local field potential signal from the subthalamic nucleus for phase-targeted auditory stimulation in Parkinson's disease

BackgroundEnhancing slow waves, the electrophysiological (EEG) manifestation of non-rapid eye movement (NREM) sleep, could potentially benefit patients with Parkinson's disease (PD) by improving sleep quality and slowing disease progression. Phase-targeted auditory stimulation (PTAS) is an approach to enhance slow waves, which are detected in real-time in the surface EEG signal. ObjectiveWe aimed to test whether the local-field potential of the subthalamic nucleus (STN-LFP) can be used to detect frontal slow waves and assess the electrophysiological changes related to PTAS. MethodsWe recruited patients diagnosed with PD and undergoing Percept™ PC neurostimulator (Medtronic) implantation for deep brain stimulation of STN (STN-DBS) in a two-step surgery. Patients underwent three full-night recordings, including one between-surgeries recording and two during rehabilitation, one with DBS+ (on) and one with DBS- (off). Surface EEG and STN-LFP signals from Percept PC were recorded simultaneously, and PTAS was applied during sleep in all three recording sessions. ResultsOur results show that during NREM sleep, slow waves of the cortex and STN are time-locked. PTAS application resulted in power and coherence changes, which can be detected in STN-LFP. ConclusionOur findings suggest the feasibility of implementing PTAS using solely STN-LFP signal for slow wave detection, thus without a need for an external EEG device alongside the implanted neurostimulator. Moreover, we propose options for more efficient STN-LFP signal preprocessing, including different referencing and filtering to enhance the reliability of cortical slow wave detection in STN-LFP recordings.

A Single-Centre Retrospective Analysis of Pregnancies with Placenta Accreta Spectrum (PAS): From One-Step Surgery towards Two-Step Surgical Approach.

Background: Placenta accreta spectrum (PAS) can be the cause of major morbidity and its optimal management is still controversial. The aim of this study was to compare the traditional one-step surgery with a two-step surgical approach in which the placenta is left in situ and the second final operation is delayed to minimise blood loss. Methods: We conducted a single-centre retrospective cohort study including all patients managed for PAS between 2007 and 2023. The number of units of red blood cells (RBCs) needed during surgery was the primary outcome used to compare these two approaches. Results: A total of 43 cases were included in this analysis. Twenty of these were managed with the delayed two-step surgical approach, whereas 23 received one-step surgery. The median estimated blood loss during surgery was 2000 mL and 2800 mL for two-step and one-step surgery, respectively (p = 0.095). In the two-step surgical approach, the median number of RBC units transfused during surgery was significantly lower (p = 0.049) and the odds ratio for needing more than four units of RBCs was 0.28 (95%-CI: 0.08-0.98, p = 0.043). A longer interval between the caesarean section and the second operation showed a trend toward lower blood loss (p = 0.065) and was associated with a significantly lower number of RBC units needed during surgery (p = 0.019). Conclusions: Two-step surgery for the treatment of PAS was safe in our cohort and could lead to a reduction in blood transfusion. Leaving the placenta in situ and delaying the final operation represents a possible alternative to traditional caesarean hysterectomy.

A Two-Step Approach to the Surgical Treatment of Soft-Tissue Sarcomas.

Background: Nowadays, limb-sparing procedures are the gold standard in the treatment of soft-tissue sarcomas of the limbs. Wide tumor resection with appropriate oncological margins, reconstruction, and stabilization of the involved bone and joint and restoration of the soft tissue lost are essential in order to obtain good clinical and functional outcomes. Tumor excision and soft-tissue reconstruction performed in one-step surgery is chosen by many centers as the preferred approach; however, according to our experience in some selected patients, two-step surgery performed using a dermal regeneration template first and then a margin revision, taking into account the definitive results of the anatomopathological exam conducted over the surgical specimen from the previous surgery, associated with definitive reconstruction surgery over a healthy bed of granulated tissue, showed many potential benefits. Methods: A retrospective observational study was conducted on thirteen patients who underwent a two-step reconstruction procedure using dermal substitution after soft-tissue sarcoma excision. Results: Clinically, the enrolled patients achieved excellent contour and cosmesis of their surgical wounds, with a mean VSS value of 3.07. During the follow-up period, no local recurrences were observed in any patient. Conclusions: Two-step surgery represents the most suitable solution to allow surgical radicality with minimal recurrency and adequate soft-tissue reconstruction, avoiding the possibility of wasting autologous tissue. Our patients generally embraced this approach and the management that followed.

Клинико-морфологическое обоснование двухэтапной хирургии осложненной катаракты и глаукомы

Aim: to provide a clinical and morphological basis for the efficacy of two-step surgery (phaco and trabeculectomy/TE) in patients with cataract and glaucoma. Patients and Methods: this study enrolled 87 patients with cataract and glaucoma. 18 patients (20.7%) were diagnosed with moderate glaucoma and 69 patients (79.3%) were diagnosed with advanced glaucoma. The intraocular pressure (IOP) was 28.4±1.4 mm Hg. Uncorrected visual acuity (UCVA) was 0.18±0.07 and best corrected visual acuity (BCVA) was 0.29±0.09. The first step was phaco with lens implantation. After 14 days, TE with scleral trephination was performed. Samples of the deep scleral flap, iris, and Tenon's capsule were collected during STE and sent for morphological examination to describe the nature of the tissue inflammatory response after cataract surgery. Results: 3 cases (3.4%) of malignant hypertension were detected after phaco. In the early postoperative period, ocular hypertension with corneal edema was diagnosed in 14 eyes (16.1%), Descemet's membrane folds in 16 eyes (18.4%), anterior chamber fibrin in 5 eyes (5.8%), and choroidal effusion in 1 eye (1.1%). After 14 days, IOP was 25.5±0.9 mm Hg, UCVA 0.5±0.06, and BCVA 0.56±0.05. After TE, hyphema and choroidal effusion were diagnosed in 29.9% (n=26) and 5.7% (n=5), respectively. One year after the two-step surgery, IOP was 18.5±1.1 mm Hg, UCVA 0.53±0.08, and BCVA 0.6±0.05. Two years after the two-step surgery, IOP was 18.8±0.7 mm Hg, UCVA 0.48±0.06, and BCVA 0.51±0.05. Morphological examination revealed signs of edema in all specimens and moderate congestion of Tenon's capsule. No cells typical of inflammation were detected. Conclusion: two-step surgery can be recommended for patients with cataract and uncontrolled glaucoma to control IOP and improve vision. KEYWORDS: glaucoma, cataract, phacoemulsification, trabeculectomy, intraocular lens, intraocular pressure, morphological examination. FOR CITATION: Ivachev E.A., Fedorova M.G. Clinical and morphological basis of two-step surgery for cataract and glaucoma. Russian Journal of Clinical Ophthalmology. 2024;24(1):19–24 (in Russ.). DOI: 10.32364/2311-7729-2024-24-1-4.

Diagnosis of Hepatic Alveolar Echinococcosis with Massive Peritoneal Seeding Treated Surgically- A Case Report

The diagnosis of Alveolar Echinococcosis is often a difficult diagnosis due to its low incidence and a long asymptomatic incubation period. We report a case of a 32-year-old man with an uncommon location of Alveolar Echinococcosis. He presented abdominal pain, conjunctival icterus and dark urine. Abdominal ultrasonography, CT scan and MRI demonstrated the presence of a hepatic lesion and a pararectal mass associated with peritoneal and omental implants. The lesions showed perilesional hypermetabolism on 18F-fluorodeoxiglucose (FDG) positron emission tomography magnetic resonance imaging (PET/MRI). Para-rectal biopsy, serological test, and sample taken during exploratory laparoscopy all suggested Echinococcus multilocularis infection that was later confirmed by PCR test. The patient was treated with Albendazole and underwent curative-intent twostep surgery by right-extended hepatectomy, resection of all peritoneal implants and total mesorectal excision. Thirty months after initial surgery, the patient is doing well and is followed up with MRI and 18F-FDG-PET without morphological signs of recurrence. This case illustrates the capacity of alveolar echinococcosis to affect different organs by infiltration or metastatic dissemination and highlights the role of 18F-FDG-PET/MRI in diagnosis and disease monitoring.

Roux-en-Y Gastric Bypass as Conversion Procedure of Failed Gastric Banding: Short-Term Outcomes of 1295 Patients in One Single Center

PurposeLaparoscopic adjustable gastric band (LAGB) has high technical and weight loss failure rates. We evaluate here the 1-year morbidity, mortality, and weight loss of laparoscopic Roux-en-Y-gastric bypass (LRYGB) as a feasible conversion strategy.MethodsPatients with a failed primary LAGB who underwent LRYGB from July 2004 to December 2019 were selected from an electronic database at our center. Patients had a conversion to LRYGB at the same time (one-stage approach) or with a minimum of 3 months in between (two-stage approach). Primary outcomes included 30-day morbidity and mortality. Secondary outcomes were body mass index (BMI), percent excess weight loss (%EWL), and percent excess BMI lost (%EBMIL) at 1 year postoperatively.ResultsA total of 1295 patients underwent a conversion from LAGB to LRYGB at our center: 1167 patients (90.1%) in one stage and 128 patients (9.9%) in two stages. There was no mortality. An early (30-day) postoperative complication occurred in 93 patients (7.2%), with no significant difference found between groups. Hemorrhage was the most common complication in 39 patients (3.0%), and the reoperation was required in 19 patients (1.4%). At 1 year postoperatively, the mean BMI was 28.0 kg/m2, the mean %EWL 72.8%, and the mean %EBMIL 87.0%. No statistically significant difference was found between the groups.ConclusionConversion to LRYGB can be considered as a safe and effective option with low complication rate and good weight loss outcomes at 1 year. One-stage conversion provides the same early outcome as two-step surgery with a competent surgeon.Graphical

Management of Pediatric Traumatic Cataract With An Open Globe Injury

Introduction: Traumatic cataract is one of the leading causes of monocular blindness in children. The management of pediatric traumatic cataract is challenging; the growing size of the affected eyes and the risk of amblyopia further complicate things. The timing of cataract removal and IOL implantation remain controversial until today. Case Report: A thirteen-years-old boy came with his left eye punctured by a pencil tip. He came in with a visual acuity of 1/300, a full-thickness 5 mm paracentral corneal laceration and traumatic cataract. The patient went through a two-step surgery. Cataract surgery and IOL implantation was conducted one week following corneal laceration suture. Discussion: Two-step surgery was performed on this patient with consideration being cataract removal performed when the inflammation of the eye was subside and also a more accurate IOL calculation. One study stated, even with 43.4% of patient’s anterior capsule ruptures, it would postponed cataract surgery for 2 days up to 6 months. In this case, a week after first surgery, it revealed anterior capsule rupture and the lens material was touching corneal endothelium. Therefore, lensectomy was performed because it touches the corneal endothelium causing further damage Conclusion: The two-step procedure performed was a preferable surgery for a traumatic cataract in a quiet eye, because it has better potential for visual improvement and IOL calculation. However, since the anterior lens capsule ruptured and the lens material prolapsed into the anterior chamber, it would have been even better to perform lensectomy as an early procedure to prevent inflammation.

Twenty-four months of bacterial colonialization and infection rates in patients with transcutaneous osseointegrated prosthetic systems after lower limb amputation-A prospective analysis.

Transcutaneous osseointegrated prosthesis systems (TOPS) are alternative rehabilitation methods to socket prosthetics, after limb amputation. TOPS compromise a two-step surgery: starting with the implantation of the stem which is then followed by the creation of the transcutaneous stoma through which the exoprosthesis can be connected. Immediately after surgery, this opening is permanently exposed to pathogens. This study aimed to investigate the dynamics of bacterial colonization of the stoma to analyze whether obligate bacterial colonization leads to a risk of periprosthetic infections after TOPS treatment. This prospective study analyzed data from 66 patients (aged 26-75 years) after TOPS treatment between 2017 and 2019. Microbiological swabs from the stoma were analyzed on the first postoperative day and 3, 6, 12, and 24 months after stoma creation. Infection rates, laboratory values (CRP, leukocyte count, hemoglobin), and body temperature were recorded at these points in time. Statistical analysis was performed using SPSS 28. The results show the formation of a stable environment dominated by Gram-positive bacteria in the stoma of TOPS patients over 24 months. Staphylococcus aureus, Staphylococcus spp., and Streptococcus spp. were the most common species found. With regard to the cohort up to the 3 months follow-up, 7.9% (five patients) developed infections surrounding the TOPS procedure. In relation to the whole cohort with loss to follow-up of 80.3% at the 24 months follow-up the infection rates increased up to 38.3%. The soft tissue inside and around the transcutaneous stoma is colonialized by multiple taxa and changes over time. A stable Gram-positive dominated bacterial taxa could be a protective factor for ascending periprosthetic infections and could possibly explain the relatively low infection rate in this study as well as in literature.

The role of intraoperative frozen section of central neck lymph nodes in the management of patients preoperatively diagnosed with low- risk differentiated cancer.

Histological examination during surgery (FS) has a place in the surgical management of differentiated thyroid carcinoma (DTC). Extending the indication for limited surgery to 4 cm tumor size (ATA guidelines 2015) cytologically verified DTCs, increases the emphasis on accurate patient selection. In our work, we reflected on the effectiveness of FS and its relationship to optimal patient management. In a single-center retrospective study, we evaluated the documentation of patients indicated for primary surgery for DTC from January 1, 2016 to December 31, 2020 - there was 489 patients collectively, 121 were men, median age was 50 years (1681), 73 patients (female, age 1845 years) with preoperatively identified low-risk DTC (size 1140mm) were indicated for lobectomy. 34 patients (46.6%) did not meet the criteria for limited surgery 15 patients were identified from FS of the lymph nodes of the central compartment (LNCK) (15 of 25 patients) - 1 patient with false negative result and 6 patients with FS of the thyroid gland (SH) (6 / 41) - 11 patients with false negative findings. Two-step OP surgery was performed on 13 patients (17.8%). FS of LNCK identified high-risk cancer and reduced the risk of two-step surgery compared to the group of patients in whom FS was not performed or was performed from thyroid gland. The difference was statistically significant (OR 1.93, p=0.026). Approximately ½ of the patients from preoperatively identified low-risk cancers in our cohort met the criteria for limited surgery. About 30% of them eventually needed a two-step operation. Perioperative examination of LNCK helps to perform radical surgery at one time.

Retrospective evaluation of the utility of two-stepsurgery for facial basal cell carcinoma and squamous cell carcinoma.

In older patients with facial basal cell carcinoma (BCC) or squamous cell carcinoma (SCC), surgery should be aimed to reduce treatment-related sequelae and burden with achieving local tumor care. Therefore, we adopted a two-step surgery (TSS) involving the application of a dermal regeneration template onto the skin defect after tumor resection and subsequent reconstruction by full-thickness skin grafting. We performed a detailed comparison of conventional one-step surgery (OSS) and TSS, including evaluation of local tumor curability, postoperative cosmetic and/or functional impairments, and patient burden. Forty-six patients who underwent TSS and 104 patients treated with OSS were retrospectively investigated. The cohort consisted of 77 men and 73 women (median age, 83 years). The BCC: SCC ratio was 56.7%: 43.3%. The tumor size and excision margin were significantly larger in the TSS group than in the OSS group (p = 0.03). The histopathological margin was positive after the first surgery in six cases, but was negative after additional resection in all cases, regardless of OSS or TSS. Local recurrence was not observed in this study. The frequency of postoperative sequelae (POS) in TSS was slightly lower than in OSS (17.4% vs. 27.9%, p = 0.16). A shorter average operation time per session was significantly associated with the location of the vertical defect [below adipose tissue vs. within adipose tissue, estimate: −0.28 (hour), p < 0.001] and surgical procedure [OSS vs. TSS, estimate: −0.13 (hour), p = 0.03] by multiple regression models. The ratio of general anesthesia was relatively lower in TSS than in OSS (9.8% vs. 17.3%, p = 0.12). Thus, TSS showed a good local curability and POS statistically equivalent to OSS, reducing the surgical burden, particularly shortening each operation time without any adverse events, despite the TSS group having significantly larger tumors than the OSS group. Since TSS is a simple procedure, it can be an outstanding option for facial BCC and SCC.

Evolution of the Surgical Management of Lung Cancer Invading the Spine: A Single Center Experience.

For patients with locally advanced non-small cell lung cancer invading the spine, induction chemoradiotherapy combined with radical en bloc resection is the key to obtaining long-term survival. With time, our operative technique evolved to a two-step surgery as we experienced numerous perioperative complications during one step surgery. The aim of our study was to assess postoperative morbimortality and long-term survival of both techniques. We retrospectively reviewed all patients who underwent en bloc resection for lung cancer invading the spine between October 2012 and June 2020. Every patient underwent induction therapy. Sixteen patients were included: nine patients were operated on with one step surgery, seven patients were operated on with two step interventions. Twenty-five percent of patients had major perioperative complications and 56.2% of patients had major post-operative complications. Patients in the “one step” group tended to have more perioperative complications whereas patients in the “two step” group tended to have more post-operative complications. Overall 3-year survival was 40% in the one-step and 86% in the two-step surgery group. Although our practice has been improved by two-step interventions, post-operative morbidity remains significant. As long term survivals are encouraging, this type of treatment should still be proposed for highly selected patients, in specialized centers.

A successful case of complete surgical resection via left upper and right lower lobectomy for bilateral lung metastases of a perivascular epithelioid cell tumor in the colon: a case report

BackgroundPerivascular epithelioid cell tumors (PEComas) are rare mesenchymal neoplasms with malignant potential. No effective treatment other than surgical resection has been established for lung metastases of PEComas. We describe a patient who underwent complete surgical resection via bilateral lobectomy involving a two-step procedure for lung metastases 8 years after undergoing radical surgery for a colonic PEComa.Case presentationA 53-year-old woman underwent partial colectomy for a PEComa in the transverse colon 8 years ago. She presented with an abnormal chest shadow during a health examination. Chest computed tomography (CT) revealed a solid nodule 2 cm in diameter located centrally in the right lower lobe and a solid nodule 3 cm in diameter located centrally in the left upper lobe. Positron emission tomography revealed 18F-fluorodeoxyglucose uptake in these nodules. These nodules were suspected to be metastatic tumors of the colonic PEComa and were considered for complete surgical resection. Segmentectomy could not be performed because of the anatomical location of the tumors straddling the segments; therefore, bilateral lobectomy was required for complete surgical resection. Therefore, we performed two-step lobectomy safely with the expectation of pulmonary function recovery. Microscopically, the tumors were diagnosed as lung metastases of the PEComa. One year after the last surgery, no recurrence was detected, and the patient’s pulmonary function improved.ConclusionsThis case indicates that even if multiple lung metastases of a PEComa require bilateral lobectomy, complete resection with a two-step surgery may be considered.

Focal Cortical Resection and Hippocampectomy in a Cat With Drug-Resistant Structural Epilepsy.

Epilepsy surgery is a common therapeutic option in humans with drug-resistant epilepsy. However, there are few reports of intracranial epilepsy surgery for naturally occurring epilepsy in veterinary medicine. A 12-year-old neutered male domestic shorthair cat with presumed congenital cortical abnormalities (atrophy) in the right temporo-occipital cortex and hippocampus had been affected with epilepsy from 3 months of age. In addition to recurrent epileptic seizures, the cat exhibited cognitive dysfunction, bilateral blindness, and right forebrain signs. Seizures had been partially controlled (approximately 0.3–0.7 seizures per month) by phenobarbital, zonisamide, diazepam, and gabapentin until 10 years of age; however, they gradually became uncontrollable (approximately 2–3 seizures per month). In order to plan epilepsy surgery, presurgical evaluations including advanced structural magnetic resonance imaging and long-term intracranial video-electroencephalography monitoring were conducted to identify the epileptogenic zone. The epileptogenic zone was suspected in the right atrophied temporo-occipital cortex and hippocampus. Two-step surgery was planned, and a focal cortical resection of that area was performed initially. After the first surgery, seizures were not observed for 2 months, but they then recurred. The second surgery was performed to remove the right atrophic hippocampus and extended area of the right cortex, which showed spikes on intraoperative electrocorticography. After the second operation, although epileptogenic spikes remained in the contralateral occipital lobe, which was suspected as the second epileptogenic focus, seizure frequency decreased to <0.3 seizure per month under treatment with antiseizure drugs at 1.5 years after surgery. There were no apparent complications associated with either operation, although the original neurological signs were unchanged. This is the first exploratory study of intracranial epilepsy surgery for naturally occurring epilepsy, with modern electroclinical and imaging evidence, in veterinary medicine. Along with the spread of advanced diagnostic modalities and neurosurgical devices in veterinary medicine, epilepsy surgery may be an alternative treatment option for drug-resistant epilepsy in cats.

Open Total Thyroidectomy with Continuous Intraoperative Nerve Monitoring

Introduction: Continuous intraoperative nerve monitoring (C-IONM) during thyroid surgery can be used to assess the recurrent laryngeal nerve (RLN) function and preventing unilateral and bilateral palsy. The main advantage of C-IONM using temporary implantable vagus electrode compared with the intermittent format (I-IONM) is the real-time monitoring of RLN integrity during thyroid mobilization and RLN dissection.1 Indeed, the I-IONM format using the handheld stimulation probe exposes the RLN to the risk of injury in between two stimulations. Therefore, the injury of the nerve can only be detected after the damage has already occurred, allowing to set to zero only bilateral RLN palsy by means of avoiding contralateral procedure (two-step surgery).2 In contrast, C-IONM provides the opportunity to perform the critical surgical actions necessary to avoid the impending RLN injury and enables to recover the RLN function after loss of signal, allowing to avoid even unilateral RLN palsy. Hereby we presented a video of a total thyroidectomy for a huge multinodular goiter performed with the help of C-IONM. Materials and Methods: A 54-year-old woman presented with a huge multinodular goiter. A total thyroidectomy performed with the help of C-IONM was planned. The surgical steps were illustrated and the anatomical structures identified. Results and Conclusions: C-IONM is a safe additional tool for thyroidectomy, which enables to perform the corrective maneuvers to avoid permanent nerve injury. If adequately used, it could prevent bilateral and unilateral RLN palsy. It results of great help in difficult cases, such as huge or recurrent multinodular goiter. No competing financial interests exist. Runtime of video: 7 mins 13 secs

Comparison of results utilizing one-step and two-step triple innervation techniques

A retrospective comparison between two groups of patients who underwent one-step or two-step triple innervation was performed to reveal the role of scar tissue in axonal regeneration.The surgical technique used was the same in all cases, but the first group underwent a one-time triple innervation procedure, while patients in the second group underwent delayed performance of neurorrhaphies between the distal ends of the cross-face grafts and the terminal branches of the injured facial nerve.The Wilcoxon signed-rank test for paired groups showed a statistically significant improvement in both facial symmetry and voluntary movements in both groups of patients. Separately, the Mann–Whitney test confirmed no statistically significant difference between the two groups regarding the restoration of facial symmetry and voluntary movements, and the development of postoperative synkinesis. A comparison of median values for each spontaneous parameter between the groups revealed greater effectiveness of the two-step surgery, with both blinking and laughing demonstrating better results.The greater effectiveness of the double-step technique in restoring spontaneous movements strongly supports the use of a two-stage triple innervation technique in patients with facial palsy.

Two-step cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei with high peritoneal carcinomatosis index

BackgroundComplete cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is the only curative treatment for pseudomyxoma peritonei (PMP) arising from the appendix. High peritoneal carcinomatosis index (PCI) is associated with an increased risk of surgical complications. The objective of this study was to present the results of a planned two-step surgical strategy to decrease postoperative morbidity and improve resectability of patients with very high PCI.MethodsAll consecutive patients who underwent a planned two-step surgical approach for PMP between January 2012 and March 2020 were retrospectively included. This approach was offered for patients with low-grade PMP with PCI > 28 for which feasibility of a complete CRS in one operation was uncertain. The first surgery included a complete CRS of the inframesocolic compartment and omentectomy. HIPEC was delivered at the second surgery, after complete CRS of the supramesocolic compartment. Postoperative morbidity was assessed using the Clavien-Dindo classification and survival results were also collected.ResultsEight patients underwent the two-step approach. The median PCI was 33 (29–39) and the median time between the two procedures was 111 days (90–212 days). One patient was deemed unresectable at the second surgery. The rate of major morbidity was 0% for the first step and 25% for the second step, with no mortality. Median follow-up was 53.8 months (3–73 months).ConclusionA two-step surgical management for low-grade PMP patients with very high PCI is safe and feasible, with acceptable postoperative morbidity and no compromise on oncological outcomes.