Two-step Surgery Research Articles

Bowel obstruction as a result of ischemic colitis: Review of literature with contribution of one case report

The ischemic colitis is comparatively rare disease. In most of the cases it has indistinctive clinical picture and its diagno sis requires persistence in performing of the diagnostic procedures. In very rare cases it can manifest with some of its complications, mucous membrane hemorrhage or subileus symptoms. We present a case of a male patient at the age of 64, who was operated on the occasion of intestinal obstruction, which developed as a result of ischemic colitis in the sigmoid colon region, complicated with stenosis. The consequent two-step surgery led to patient’s health recovery in the three-year period of follow-up.

Two-step surgery for retinal detachment caused by myopic macular hole

PurposeTo report the results of a two-step operation for treating retinal detachments caused by macular holes in high-myopic patients.MethodsIn the first part of the operation, pars plana vitrectomy, air–fluid exchange, and silicone oil injection were performed. At 4–6 months after the first operation, the second part of the operation was performed. This involved silicone oil removal and internal limiting membrane peeling under the aid of triamcinolone acetonide with or without gas tamponade.ResultsFour eyes (four patients) underwent surgery with this technique. All retinas were attached at the time of the second operation, when internal limiting membrane peeling could be performed easily and safely. The retina remained attached in all four eyes (100%) during 24–32 months of follow-up after the second operation.ConclusionFavorable surgical results were obtained with the two-step operation in the treatment of retinal detachments resulting from myopic macular holes.

Analysis of 256 cases of basal cell carcinoma after either one‐step or two‐step surgery in a Japanese institution

Basal cell carcinoma (BCC) is a common skin cancer that arises from the cells of the basal layer of the epithelium or from the external root sheath of the hair follicle. In the present report, 256 cases treated surgically between 1999 and 2008 in our department were retrospectively analyzed. The most frequent BCC locations included the face (77.8%), especially the nose (26.9%) and eyelids (21.5%). Incomplete excisions occurred in 21 cases. Two patients experienced local recurrence; one of these patients exhibited a bone metastasis while the other had a metastasis of the parotid gland without the local recurrence. The rate of local BCC recurrence was 0.78%, which is lower than that described in previous reports. We categorized BCC into four histological types: superficial, solid, adenoid and infiltrative. The solid type was the most frequent histological type (62.1%). For preventive recurrence, we treated BCC patients with two-step surgery when the tumor was large or histologically invasive. At the first step, we excised the tumor with a sufficient safety margin, and at the second step, we performed reconstruction after the histological confirmation that no remnant malignant cells were in the tumor margins. In the present report, no local recurrence occurred in patients following the two-step surgery. Therefore, two-step surgery is recommended for tumors at locations and with histological types related to frequent recurrence.

Transformation of a vascularised iliac crest or scapula bone to a pedicled osteomuscular transplant for reconstruction of distant defects in the head and neck region: A new method of transforming two island flaps to one longer island flap

ObjectiveBone defects in the maxillofacial region after ablative surgery require reconstructive surgery, usually using microvascular free flaps. This paper presents a new method of reconstructing extensive defects in patients not suitable for microvascular surgery using prefabrication of a vascularised osteomuscular flap from the scapula or iliac crest bone. MethodsThree patients who were treated with this new technique are presented. Two patients (one mandibular defect and one defect in the maxillary region) received prefabricated osteomuscular flaps from the iliac crest bone using the latissimus dorsi muscle as a pedicle. One patient also presenting a mandibular defect after tumour surgery received a scapula transplant for reconstruction of the defect using the pectoralis major muscle as pedicle. ResultsIn all three cases vital bone could be transplanted. The pedicle was strainless in all three cases. Minor bone loss could be seen initially only in one case. The results are stable now and one patient received dental implants for later prosthetic treatment. ConclusionThe presented two-step surgery provides an excellent method for reconstruction of bony defects in the maxillofacial region in patients where microvascular surgery is not possible due to reduced state of health or lack of recipient vessels.

Combined Clear Corneal Phacoemulsification and Vitrectomy Versus Two-Step Surgery in Korean Patients With Idiopathic Epiretinal Membrane

Combined Clear Corneal Phacoemulsification and Vitrectomy Versus Two-Step Surgery in Korean Patients With Idiopathic Epiretinal Membrane

Two-Step Surgery for Telecanthus-Epicanthus and Ptosis in Patients with Blepharophimosis

Two-Step Surgery for Telecanthus-Epicanthus and Ptosis in Patients with Blepharophimosis

The results of two-step surgery for spinal disorder

The results of two-step surgery for spinal disorder

Small and Medium-Sized Congenital Nevi in Children

Clinical decisions on whether to follow up or remove small and medium congenital melanocytic nevi (SMCMN) in children have cost implications that have not been studied. To compare the costs of excision of SMCMN in children with lifelong follow-up in a tertiary center. We elaborated models for the evaluation of the costs of excision and long-term follow-up. We retrospectively collected data on 113 consecutive excised SMCMN (105 single-step interventions and 8 multiple-step interventions) from the medical records of our pediatric dermatology unit from 2001 to 2007 and calculated and compared the costs (direct and indirect) of surgery and follow-up. The mean +/- standard deviation and total cohort costs for single-step interventions were euro 1,504.73 +/- 198.33 and 157,996.20, respectively. Median and cohort lifelong follow-up costs were similar if performed every 4 years (1,482.66 +/- 34.98 and 156,679.63). For multiple-step interventions (3 or 4 steps), surgery costs were similar to those of annual lifelong follow-up. In the case of two-step surgery, costs were similar to lifelong follow-up every 2 years. An analysis of the costs of surgery and long-term follow-up in children with SMCMN is possible. Although the clinical judgment of the dermatologist and parental opinion are the main determinants in the management of SMCMN, costs should also be taken into account.

Vitrectomía pars plana, facoemulsificación e implante de lente intraocular para el manejo de catarata y retinopatía diabética proliferativa: comparación de técnica quirúrgica combinada versus en dos tiempos

To report the intra-and postoperative complications and visual acuity outcomes in pars plana vitrectomy (PPV), phacoemulsification and intraocular lens (IOL) implantation in patients with cataract and proliferative diabetic retinopathy (PDR). A comparison of the combined versus two-step surgical approach is given. Retrospective uncontrolled interventional clinical trial. Forty-eight eyes of 48 consecutive patients with PDR were included. Twenty-eight (58.3%) eyes with combined surgery and 20 (41.7%) eyes with sequential surgery were analyzed. Postoperative follow-up time was between 6 and 63 months (mean: 18 months). 1) Combined surgery: Preoperative best-corrected visual acuity (BCVA) ranged from 20/200 to hand motions, and postoperative BCVA ranged from 20/30 to hand motions. BCVA improved in 17 eyes (60.7%), while in 7 (25%) eyes there was no change (> or =2 ETDRS lines) in VA, and in 4 (14.3%) eyes BCVA decreased. Postoperative complications included vitreous hemorrhage (VH) in 10 (35.7%) eyes, and fibrinous exudation in 9 (32.1%) eyes. 2) Two-step surgery: Preoperative BCVA ranged from 10/200 to light perception, and from 20/40 to light perception in the postoperative period. Best-corrected visual acuity improved in 15 (75%) eyes, remained the same in 4 (20%) eyes, and decreased in 1 (5%) eye. Postoperative complications included fibrinous exudation in 6 (30%) eyes, and VH in 3 (15%) eyes. Combined PPV, phacoemulsification and IOL implantation as well as the two-step procedure are safe and effective for the management of cataract in PDR. Sequential surgery could be advantageous to BCVA outcomes by minimizing postoperative VH, which is significantly more frequent after combined surgery.

Laparoscopic Roux-en-Y Gastric Bypass as a Revision Procedure after Restrictive Bariatric Surgery

Adjustable gastric banding (AGB) and vertical banded gastroplasty (VBG) have been extensively used to treat morbid obesity. Patients with insufficient weight loss or complications may require surgical revision. The laparoscopic Roux-en-Y gastric bypass (LRYGBP) is one of the most common procedures currently used for revision. The aim of the study was to analyze surgical outcomes of 30 consecutive patients who underwent revision to LRYGBP in a 2-year period. The prospectively constructed database and the medical records of all patients undergoing revision to LRYGBP were reviewed. Demographics, surgical details, results, and complications were analyzed. There were 23 women and seven men with a mean age of 41.1+/-9.7 years (r=25-61). Mean body mass index (BMI) was 40.0+/-7.5 kg/m(2) (r=27.2-65.2). Initial operation was AGB in 24, VBG in five, and both in one patient. In ten patients, the band had been removed before revision, in 13 cases, band removal and LRYGBP were performed in one surgical intervention, and in two patients, it was performed in a two-step surgery. There were two conversions to open surgery. Five patients presented major surgical complications. Hospital stay averaged 5.1 days (r=3-25). Mean percent excess body weight loss at 6 and 12 months was 61.7+/-27.5 and 81.2+/-20.5 kg/m(2), respectively. Mean percent low body mass index at 6 and 12 months was 22.5+/-9.1 and 29.1+/-11.4 kg/m(2), respectively. LRYGBP as a revision procedure is feasible in most patients. Surgical complications are more frequent.

Two-step Surgery for Synchronous Bilobar Liver Metastases From Digestive Endocrine Tumors: A Safe Approach for Radical Resection

We describe the early and distant results of a 2-step surgical strategy that enables complete resection in selected patients with primary digestive endocrine tumors (DET) and synchronous bilobar liver metastases (LM). Frequent synchronous and bilobar liver involvement limits indications of surgery in LM from DET. From 1996 to 2004, of 41 patients with synchronous bilobar LM from DET, 23 (56%) were selected for 2-step surgery. The first step included resection of the primary tumor and limited (nonanatomic) resection of left LM (segments 1-4) associated with a right portal vein ligation. After 8 weeks, following hypertrophy of the cleared left liver, a right or extended right hepatectomy was planned. At the first step, all primary tumors (bowel = 12, distal pancreas = 10, rectal = 1) were resected and LM were resected in 20 patients (87%). One patient did not have second-step due to tumor progression. The second step (n = 19; 83%) was performed after a median interval of 8 weeks (range, 6-13) and a 54 +/- 21% mean left liver hypertrophy rate. Postoperatively, 4 (17%) and 4 (21%) patients developed nonlethal complications and the median hospital stay was 11 (range, 7-26) and 13 (range, 9-17) days after the first and the second step, respectively. The median number of resected LM was 4 (range, 1-9) and 7 (range, 4-17), respectively. With a median follow-up of 64 months (range, 6-122), of the 19 patients who had complete 2-step surgery, all except one are alive. The 2-, 5-, and 8-year Kaplan-Meier overall and disease-free survival rates were 94%, 94%, 79% and 85%, and 50% and 26%, respectively. This 2-step surgery approach enables complete resection with no mortality, acceptable morbidity, and good long-term survival in selected patients with synchronous bilobar LM from DET.

Two-step vitreoretinal surgery for severe suppurative endophthalmitis

目的 探讨重症化脓性眼内炎分次玻璃体视网膜手术的临床疗效.方法 对21例(21眼)重症化脓性眼内炎急诊行第1次晶状体及玻璃体切除手术,术中抽吸少许房水及玻璃体进行细菌培养和药敏试验,将眼内大部分脓液清除,有异物者摘出异物,术毕眼内注入适量抗生素,经药物治疗7～14 d角膜透明或基本透明后行第2次的玻璃体手术,复位脱离的视网膜、激光封闭裂孔及眼内充填.结果 第1次玻璃体手术后,眼内炎症均得到控制,约6～7 d后角膜逐渐恢复透明,13眼发生视网膜脱离,第2次玻璃体视网膜手术后视网膜均达到解部复位.随访3～24月,视网膜解剖在位17眼,眼球萎缩4眼.最终矫正视力≥0.02者13眼.结论 重症化脓性眼内炎分次行玻璃体视网膜手术,结合合理的药物应用是较好的治疗方法。

Transanal endoscopic tube decompression of acute colonic obstruction: experience with 51 cases

Acute colorectal obstruction is a potentially life-threatening emergency that requires immediate surgical treatment. To avoid major postoperative complications, most surgeons advocate two-step surgery despite the increase in patient discomfort and cost. Various methods for performing one-step surgery have been reported including intraoperative colonic lavage, decompression with self-expandable metal stents, and transanal tube decompression. The authors present their experience performing transanal colonic decompression for 51 patients. Endoscopic tube placement was successful for 43 (84%) of the 51 patients. The emergency clinical situation could be converted to semielective treatment in 37 cases (73%) (30 operations and 6 nonoperative interventions), and to an elective operation in 1 case. After successful colonic decompression, the rate of one-stage operations was 93% (28/30), as compared with 40% (4/10) if the decompression failed. Endoscopic tube decompression of acute colonic obstruction is an easy and cost-effective possibility for avoiding emergency operations with all their sequelae. Emergency surgery can be converted to semielective or elective surgery, markedly reducing the rate of staged operations.

Suitable age for nasal reconstruction after subtotal amputation in a child, with respect to a case involving purpura fulminans

The authors report a case of nasal reconstruction in a 5-year-old boy who had undergone subtotal amputation of the nose 8 months before in the context of meningococcus-induced purpura fulminans. Two-step surgery involved implantation of a forehead expansion graft preliminary to use of a contralateral forehead flap to cover a cartilaginous graft from the concha that reconstituted the ala nasi, columella, and septum. At 1 year of follow-up, the results were considered quite satisfactory esthetically and psychologically beneficial. Nasal amputation in the child is infrequent, and the procedure is not clearly defined. Early reconstruction certainly improves the child's life and social integration. The major risk is unsatisfactory growth of the reconstructed nose, which may persuade some surgeons to postpone the operation.

Improvement of surgical margin with a coupled saline-radio-frequency device for multiple colorectal liver metastases

Complete resection of colorectal liver metastases (LM) has been the only curative treatment. However, when LM are multiple and bilobar, only a few patients are candidates for curative surgery. We report on a 53-year-old woman with synchronous multiple and bilobar LM from sigmoidal cancer who became resectable after a multimodal strategy including preoperative systemic chemotherapy and two-step surgery. The spectacular decrease in tumor size after systemic chemotherapy led us to perform two-step surgery, including right portal-vein ligation and left liver metastasectomies, with a coupled saline-radiofrequency device, in order to improve the surgical margin. An extended right hepatectomy was performed later to remove the remaining right liver lesions. The patient was discharged after 28 days without major complication and was recurrence-free 14 months later. We conclude that improving the surgical margin with a coupled saline-radiofrequency device is feasible and effective, avoiding small remnant liver even after multiple tumorectomies. The multimodal strategy, including preoperative chemotherapy, two-step surgery, and tumorectomies, using a coupled saline-radiofrequency device, could increase the number of patients with diffuse bilobar liver metastases who can benefit from liver resection.

Advantages and disadvantages of one-stage and two-stage surgery for arrhythmias and Ebstein's anomaly☆

To evaluate efficacy of one-step and two-step surgery approach in patients with arrhythmias combined with Ebstein's anomaly. Fifty-three patients with Ebstein's anomaly combined with tachyarrhythmias (58.5% men, 41.5% women, mean age 21.6+/-10.7 years) were operated on. In group A (32 patients), one-step surgical correction (simultaneous intraoperative elimination of arrhythmias and congenital heart defect repair) was performed, whereas in group B (21 patients), two-step surgery was performed with initial elimination of arrhythmogenic substrate by transcatheter radiofrequency ablation (first step) and following surgical repair of congenital heart defect (second step). In group A, total hospital mortality was 3.1% (1 patient) due to initial severe condition of this patient. One-step surgery was effective in 93.5% of cases. Mortality was not observed in group B. Efficacy of transcatheter radiofrequency ablation was 76.2%. One-stage and two-stage surgery of arrhythmias and Ebstein's anomaly are highly effective. First step of surgery of combined pathology reduces cardiopulmonary bypass time, complications and mortality while performing the second step of congenital heart defect surgery. However, simultaneous approach (one-step surgery) is better in terms of arrhythmia elimination.

Giant mycotic aneurysm of the vertebral artery: A case report

Giant mycotic pseudoaneurysms of the vertebral artery are extremely rare. Their management is technically challenging because of the distorted anatomy and intimate relation to the lower cranial nerves. We present a rare case of a 7-year-old boy referred to us by a pediatrician who was treating him for bacterial endocarditis. The pulsatile swelling measured 10 x 5 cm and was located in the left suboccipital triangle. The skin over the swelling was tethered to the underlying pulsatile swelling, suggesting prerupture syndrome. A contrast angiogram revealed a pseudoaneurysm from the third part of the left vertebral artery. Vegetations were seen on the tricuspid valve on echocardiography. Two-step surgery was performed under the cover of antibiotics. Excision of the aneurysm was done after ligation of the third part of the vertebral artery. The postoperative period was uneventful, and there was no neurologic deficit. Repeat magnetic resonance angiogram revealed no residual pseudoaneurysm. The histopathologic examination of the specimen was suggestive of mycotic aneurysm of left vertebral artery.

Management of Perforated Gastric Carcinoma: A Report of 16 Cases and Review of World Literature

Perforated gastric carcinoma is rare; however, it is a serious condition associated with complications. To understand the proper management of this disease and to characterize its clinical course we reviewed available data on 16 patients with perforated gastric carcinoma. We collected data on the age and sex of the patients as well as operative findings and histological features of the primary tumor. The depth of invasion and presence of lymph node metastasis were also recorded. The Union Internationale Contre Cancer stage, extent of resection, and surgical method used were reviewed. We also reviewed published information on the management of perforated gastric carcinoma. The carcinoma was stage I in three cases, stage II in one case, stage III in three cases, and stage IV in nine cases. Many patients had distant metastases. Fourteen patients underwent gastrectomy. Two patients whose preoperative condition was poor died of surgery-related complications, but patients with early-stage carcinoma underwent an R0 resection (resection of the primary tumor with negative margins) and had minimal complications. We conclude that the outcome of patients who were able to undergo radical surgery was good and correlated with the stage of cancer. It is important to perform gastrectomy rather than repair the perforation first, and a proper lymphadenectomy should follow--thus a two-step surgery when necessary.

Results of epiretinal membrane removal combined with PEA and IOL

We examined 558 eyes from 538 surgical cases of idiopathic epiretinal membrane with respect to the effectiveness of the triple surgery that involves concomitant intraocular lens surgery, the most appropriate timing for the evaluation of postoperative visual acuity, and the relationship between the pre- and postoperative visual acuity. From the viewpoint of the timing of the intraocular lens surgery, we classified our patients into 4 groups: (1) a phakic eye group; (2) a two-step surgery group; (3) a triple surgery group; and (4) an intraocular lens group. The visual acuity evaluation was performed in 22 eyes from the phakic eye group based on the patient's age being 45 years or younger, in all 326 eyes from the triple surgery group, and in all 86 eyes from the two-step surgery group. We excluded the intraocular lens group from the visual acuity evaluation. The timing of the visual acuity evaluation was one year after the surgery for the phakic eye and triple surgery groups, and one year after the intraocular lens surgery for the two-step surgery group. The postoperative visual acuity was correlated with the patient's age. When a patient was less than 55 years of age, the postoperative visual acuity correlated positively with age. In contrast, when a patient was 55 years of age or older, it correlated inversely with age. The postoperative visual acuity was significantly correlated with the preoperative visual acuity, and it was possible to predict the postoperative visual acuity based on a regression equation. The preoperative visual acuity necessary for a postoperative visual acuity of 20/20 or more was 20/20 for patients under 40 years old, 20/40 for 40–59 years, 20/32 for 60–79 years, and 20/20 for 80 years and older.

Surgical procedure can explain varying influence of menstrual cycle on prognosis of premenopausal breast cancer patients

Abstract The mechanism of how menstrual cycle influences prognosis of premenopausal breast cancer patients is still unclear. In an analysis of 266 premenopausal patients we could confirm that patients who were operated on during the progestagenic phase (day 0–2 and 13–35) of the menstrual cycle showed an improved clinical outcome. However, if one-step surgery (tumour excision and definitive surgery on 1 day) was performed prognosis did not correlate with menstrual cycle (p = 0.8, log rank test). But, patients who underwent two-step surgery during the progestagenic phase showed a significantly longer disease-free survival (p