Anterior surgical approaches to the cervicothoracic junction: when to use the manubriotomy?

Background contextThe cervicothoracic junction (CTJ) is always a difficult area for anterior approaches. Among them, low anterior cervical approach alone or combined with manubriotomy is the most frequently used.PurposeTo study the need of manubriotomy.Study design/settingComparison of last guidelines proposed in literature.Patient sampleSeven patients treated between March 2010 and March 2011.MethodsAll the patients were scanned on with computed tomography and magnetic resonance of the spinal column before surgery. Measurements by Teng and Karikari were applied in all the cases. An illustrative case is showed.ResultsThe anterior approaches to the CTJ are reviewed. The most recent guidelines by Teng and Karikari are easy to apply and careful. The results obtained were the same in all the cases with good outcome.ConclusionsManubriotomy permits a good exposure of the CTJ area with a low rate of complications. Either Teng and Karikari's guidelines can be used to estabilish the need of manubriotomy.     

Should laparoscopy be the standard approach used for radical nephrectomy?

Since its inception in June 1990, laparoscopic radical/total nephrectomy for renal tumor has been successfully applied worldwide to hundreds of patients. Recent 5-year follow-up data have shown this procedure to produce cancer control identical to that of open radical/total nephrectomy. Although in most centers the cost of the procedure remains higher than open surgery, the patient benefits of decreased pain, reduced hospitalization, less blood loss, and more rapid convalescence appear to be universal. At this time, we believe that laparoscopic radical/total neph-rectomy for the treatment of renal tumors should become the new standard of care.     

Should laparoscopy be the standard approach used for pelvic lymph node dissection?

Involvement of the pelvic lymph nodes in patients with prostate cancer worsens the overall prognosis of this common disease entity. Prior radiographic staging tech-niques, including fine-needle aspiration, are limited by a poor sensitivity and are not reliable. The gold standard for the evaluation of pelvic lymph nodes in men with prostate cancer involves performing a lymphadenectomy. Historically, this procedure was performed using an open surgical technique. Unfortunately, this invasive procedure is associated with significant morbidity. In response, modern surgical technology has provided newer, less invasive techniques, including laparoscopic pelvic lymphadenectomy (LPLND). Improved detection of localized prostate cancer through the institution of screening protocols and early detection programs has decreased the number of patients presenting with lymph node involvement. Various clinical indicators, including prostate-specific antigen, grade, and stage, have been used to improve the selection of “high-risk” patients that are appropriate candidates for pelvic lymph node dissection. The technique of LPLND is a valid option in the armamentarium for staging of prostate cancer. The laparoscopic approach provides the same staging accuracy as the open surgical technique and is superior with respect to morbidity. LPLND is limited to patients who present with a high risk of advanced prostate cancer. In addition, the urologist must accept the additional training, financial expense, and “learning curve” associated with this technique.     

Anterior video-assisted approach to the craniovertebral junction: transnasal or transoral? A cadaver study

Background

Endoscopy represents both an alternative and useful complement to the standard microsurgical approach to the anterior craniovertebral junction (CVJ). Nevertheless, few studies provide an experimental comparison between transnasal and transoral endoscopic control on CVJ. We compared the surgical exposition angle and the working channel volume of both the transnasal and transoral approaches in the cadaver.

Methods

Eleven fresh non-perfused cadavers were studied. Transnasal and transoral linear and angled exposure of the CVJ were evaluated by means of X-ray and CT scan both in sagittal and lateral planes.

Results

The transoral endoscopic surgical exposition was wider compared with the transnasal in anterior and lateral projections:(1)in the sagittal plane, both in vertical exposition (transnasal inferior to transoral from 5.89 % to 76.48 %, average 35.89 %) and in vertical surgical angle (from 22 % to 77.42 %, average 56.53 %); (2)in the coronal plane, both in coronal exposition (transnasal inferior to transoral from 50.77 % to 83.88 %, average 70.34 %) and in coronal surgical angle (from 65.58 % to 86.71 %, average 76.70 %). The sagittal surgical domain was found to spanning from the inferior third of the clivus to C3 with the transoral and from the middle third of the clivus to the nasopalatal line (NPL) with the transnasal approach. The overlapping surgical domain area was found to be the inferior third of the clivus.

Conclusions

The endoscope assisted transoral approach allows a better surgical control of the CVJ. It provides a better CVJ exposure, in sagittal and transverse planes, providing a larger working channel and an easier manoeuvrability. The transnasal approach is limited in caudal direction down to the NPL, otherwise the transoral approach is limited in the rostral direction with a maximum to the foramen magnum in normal specimen. In every individual case, pros and cons of the appropriate approach have to be taken into account as well as the choice of a combined transnasal and transoral approaches strategy.     

Resection of subaortic stenosis; can a more aggressive approach be justified?

OBJECTIVES: Discrete subaortic stenosis causes left ventricular outflow tract (LVOT) obstruction and often produces aortic regurgitation (AR) which alone may precipitate surgical intervention. Conventional resection relieves the obstruction, but the recurrence rate is high, and the AR is little changed as the thick fibrous membrane which extends onto the valve leaflets remains. We studied whether an aggressive surgical approach could reduce both the severity of AR and rate of recurrence of obstruction associated with discrete subaortic stenosis, and whether this aggressive approach could be justified. METHODS: Between June 1992 and April 1996, 37 patients aged 0.5-35 years (median 7.5) underwent resection of a discrete subaortic membrane. Ten underwent re-operation for recurrent obstruction and eight followed previous ventricular septal defect closure. LVOT gradient was measured using the modified Bernoulli equation and AR was graded on a scale of 0-4 (0 = none, 4 = severe). Postoperative assessment was performed early (<7 days) and at mid-term (27.0 months; range 2-59 months). RESULTS: There was significant improvement in AR from mild/moderate to none/trivial (P = 0.019) immediately postoperatively and LVOT gradient from 66.9+/-30.4 to 15.1+/-12.2 mmHg (P < 0.0001). By stepwise logistic regression preoperative gradient correlated significantly with postoperative mild/moderate AR (P = 0.015) and LVOT gradient (P = 0.0036). Preoperative mild/moderate AR also correlated with postoperative mild/moderate AR (P = 0.034). Five patients developed complete heart block, four undergoing reoperation for recurrent obstruction, and one preoperatively had right bundle branch block from previous ventricular septal defect repair. At mid-term follow-up there was no increase in AR or LVOT gradient (14.8+/-12.8 mmHg). Early post-operative AR was the strongest predictor of late mild/moderate AR (P = 0.02). Early post-operative gradient was a weaker predictor (P = 0.04). Pre-operative and early post-operative gradient were significant predictors of late gradient (P = 0.0038; <0.0001, respectively). No patient required reoperation for recurrent obstruction; one underwent late aortic valve replacement for severe AR. CONCLUSIONS: An aggressive surgical approach to discrete subaortic stenosis produces excellent relief of obstruction and frees the valve leaflets, significantly reducing associated AR at early and mid-term follow-up with low morbidity for primary operation. Long-term follow-up is required to confirm whether this early benefit is maintained.     

Endovascular approach to treat aortic pseudoaneurysms: could it be a safe alternative?

Aortic pseudoaneurysm is a rare complication after blunt chest trauma or cardiac surgical procedures and can occur at the site of cannulation or root vent insertion on the ascending aorta. These pseudoaneurysms have the potential to expand, erode, and rupture, and detecting this condition before complications occur is the key to successful management. We had replaced the mitral valve with a 31-mm bioprosthesis in an 82-year-old patient and repaired an ascending aorta aneurysm, but a computed tomography scan on postoperative day 18 revealed a pseudoaneurysm at the site of the previous aortic cannulation. Because of the patient's advanced age and multiple comorbidities, we sealed off the neck of the pseudoaneurysm with a 12-mm Amplatzer Vascular Plug in the interventional cardiology suite instead of subjecting her to a surgical repair involving redo sternotomy and a period of circulatory arrest. Deployment of the Amplatzer plug effectively shut off flow into the pseudoaneurysm, and the patient recovered well. Although the optimal management strategy for aortic pseudoaneurysms is a matter of controversy, endovascular interventions may be a safer alternative to surgery for patients with multiple comorbidities.     

Raman spectral imaging of prostate cancer: can Raman molecular imaging be used to augment standard histopathology?

Study Type – Diagnostic (exploratory cohort)
Level of Evidence 2b

OBJECTIVE

To evaluate whether Raman molecular imaging (RMI, which combines digital imaging and analytical spectroscopy to evaluate the biochemical composition of interrogated material) can be used to identify biochemical differences in patients with Gleason 7 prostate cancer who progress to metastatic disease and die from prostate cancer.

PATIENTS AND METHODS

We identified 38 patients who had a radical prostatectomy for Gleason 7 adenocarcinoma of the prostate. Half progressed to metastatic disease and half had no evidence of disease after treatment. Patients were matched for preoperative prostate‐specific antigen level, surgical margin status, pathological stage, tumour volume, age at surgery, year of surgery and DNA ploidy. Sequential 5 µm sections were obtained from paraffin‐embedded tissue and one genitourinary pathologist selected areas of tumour for study. Principal component analysis was used to investigate the correlation between spectral response and clinical outcome.

RESULTS

The analysis was able to distinguish between those with progressive disease and those with no evidence of disease, most notably within the Gleason 3 regions when evaluating the epithelium and stroma as separate histological elements. A two‐sample t‐test gave P < 0.01 for both the Gleason 3 and 4 epithelium and stroma classes.

CONCLUSIONS

RMI is a novel technique that shows promise for identifying patients at risk of progression by visualizing molecular information not seen using other current methods. In Gleason 7 disease, RMI shows distinctive chemical differences in patients who progress to metastatic disease in both Gleason pattern 3 and 4 regions. This preliminary work lays the foundation for the further study of RMI for evaluating prostate tissue.     

The umbilical fold approach to pyloromyotomy: is it a safe alternative to the right upper-quadrant approach?

BACKGROUND: Hypertrophic pyloric stenosis has been approached using two standard incisions for pyloromyotomy: the circumumbilical (UMB) and the right upper quadrant (RUQ). The UMB approach produces an almost undetectable scar but has been associated with more complications. STUDY DESIGN: A 5-year retrospective analysis was performed on 344 patients (90 UMB and 254 RUQ) to compare technical and wound complications. The effect of prophylactic antibiotics on wound infection was also evaluated. RESULTS: The intraoperative complication rate was 5.5% (13.3% UMB versus 2.8% RUQ; p = 0.001). The mucosal perforation rate was 3.5% (8.9% UMB versus 1.6% RUQ; p = 0.003). Mucosal perforations increased the mean +/- SD length of hospitalization in UMB patients (3.9 +/- 0.8 versus 2.4 +/- 1.1 days; p < 0.001). The serosal tear rate was 2.0% (4.4% UMB versus 1.2% RUQ; p=0.08). The postoperative complication rate was 5.8% (14.4% UMB versus 2.8% RUQ; p < 0.001), and the wound infection rate was 2.6% (6.7% UMB versus 1.2% RUQ; p = 0.01). Antibiotic prophylaxis decreased the rate of wound infection to 1.8% and eliminated the statistical difference between the groups (4.5% UMB versus 0% RUQ; p=0.16). The rate of other postoperative complications was 3.2% (7.8% UMB versus 1.6% RUQ; p = 0.009). Duration of hospital stay did not differ between the groups overall (2.6+/-1.12 days for UMB versus 2.7+/-1.5 days for RUQ; p = 0.35). CONCLUSIONS: The UMB approach to pyloromyotomy was cosmetically superior but increased complication rates. Technical complications were easily corrected and length of stay was not affected. Wound infections were decreased in both groups by the use of prophylactic antibiotics.