Bladder cancer: toward state of the art multidisciplinary molecular medicine

Recent advances in bladder cancer research, and clinical diagnosis and therapy are explored. Major advances in biologic understanding are applied toward better early diagnosis and staging. Using molecular medicine to help informed clinical trial design and implementation will lead to more effective therapeutic intervention in transitional cell carcinoma. Interdisciplinary care and multimodal approach will allow better outcomes, stage for stage and grade for grade. The challenge is for clinician-scientists to integrate basic and translational advances efficiently and rapidly into the clinic, recognizing the value of a multifaceted paradigm.     

Medullary thyroid carcinoma: state of the art

Medullary thyroid carcinoma (MTC) constitutes about 3-10% of all thyroid cancers. It arises from the parafollicular C cells that produce calcitonin (CT) and occurs as a sporadic form. or less commonly, as a hereditary form, as part of multiple endocrine neoplasia syndromes types 2A (MEN 2A) and 2B (MEN 2B). The hereditary forms are autosomal dominant traits associated with germline mutations of RET proto-oncogene. Progresses in genetics have permitted an improvement of management, screening and treatment. Surgery is the only successful treatment for MTC, as there is no effective adjuvant therapy for residual disease. A total thyroidectomy and vigilant management and surveillance of the neck are recommended. Interdisciplinary management including surgeons, endocrinologists, pathologists, radiotherapists, radiologists, and oncologists should be considered.     

Hepatic transplantation for hepatocellular carcinoma: state of the art

Hepatic transplantation offers the best treatment for cure for hepatocellular carcinoma arising in the cirrhotic liver as long as patients and indications are carefully selected. The Milan criteria which became established in the 1990's showed that the best results are obtained when there are three or fewer nodules less than 3 cm in size, or a single nodule less than five cm. in size. Today, these criteria seem to be too restrictive, and indications for surgery can be extended by employing criteria based on macroscopic findings, histology, and even molecular biology. It is necessary not only to better define the limits and indications of therapy but also to keep close watch on patients awaiting transplant to prevent exclusion from the list due to tumor progression. Results can also be improved by decreasing late tumor recurrence with an optimal post-operative immunosuppressive regimen and with adjuvant chemotherapy. The choice of using a living donor or transplanting a liver of marginal quality should also be weighed against the tumor characteristics and the anticipated waiting period for a donor liver. The increasing incidence of hepatocellular carcinoma imposes a need to offer curative therapy to more patients than we are able to do under current circumstances. The treatment strategies for hepatocellular cancer should be multidisciplinary from the start; the use of all available treatment tools including liver transplantation should be better evaluated by multicentric studies.     

PCI: state of the art

The restenosis issue which has not been resolved during the history of PCI is now being solved by drug eluting stent. In RAVEL trial which is a randomized control trial addressed to simple lesion, the restenosis rate was 0%. In SIRIUS trial addressed to more real world lesions, the restenosis rate was higher (8.9%) than expectation, especially the proximal margin restenosis was high (5.8%). The new trials preventing the edge injury at the deployment could reduce the edge restenosis rate to 2.1%. Because of the drastic decrease of restenosis rate, the indication of PCI is spreading to the lesions whose main problem is the restenosis before the DES era. They are diffuse diseases, small vessel diseases, bifurcation lesions, chronic total occlusions, instent restenosises and left main diseases in which superiority of DES for BMS is reported. Although there are no evidences so far, DES may have higher incidence of subacute and/or late stent thrombosis than BMS. Because the mortality of late stent thrombosis is high, antiplatelet therapy is considered to be continued for longer time. In Japan, because the DES was introduced before the approval of clopidogrel, it was concerned about that incidence of thrombosis would be higher than other countries. In j-Cypher trial, a observational registry trial in Japan, revealed that the subacute thrombosis rate was lower level of the other studies and safety of DES utilization with ticlopidine based antiplatelet regimen. There are no evidences that DES improves the long-term prognosis of the patients with coronary artery disease. Although in terms of the long-term prognosis in multivessel disease, PCI with BMS was comparable to CABG except for DM, ARTS II trial revealed the superior survival rate of DES at 1 year. The results of on going more real world trials are mandatory.     

Sepsis: state of the art

In recent years, we have considerably widened our knowledge of the pathophysiology of sepsis and some procedures, aiming both to relieve symptoms and control the inflammation/coagulation reaction, have proven to be effective in increasing survival. This improves when mechanical ventilation is applied with low tidal volumes, fluid replacement and the use of cardioactive drugs are titrated on the oxygen saturation of hemoglobin in the central venous system and blood glucose does not exceed certain limits. It is also evident that inflammation and coagulation are closely related to each other. The inhibition of only one pathway, such as the inhibition of inflammation with high dosage steroids or the inhibition of coagulation with antithrombin, does not produce a survival improvement. The only molecule which has proven to be notably effective in reducing mortality is Activated Protein C interacting on coagulation/fibrinolysis, as well as on inflammation processes. Multinodal modulation of several interdependent processes may be the probable reason for the proven effectiveness of this treatment.     

Chemonucleolysis: the state of the art

This review presents the history of chemonucleolysis, the techniques, indications, contraindications, and complications. Presenting an historical overview and comparison of success rates with surgical discectomy may provide a fresh understanding of the controversy surrounding chemonucleolysis and establish its efficacy in relation to more invasive treatments. A review of the literature from 1973 through 1998 for chemonucleolysis, open discectomy, and microdiscectomy provided published success rates for these procedures, and a mean rate with standard deviation was determined. In the experience and opinion of the authors, chemonucleolysis remains a viable alternative for patients who have exhausted all conservative means of treatment. Proper patient selection leads to success rates comparable to open discectomy and microdiscectomy.     

Staplers in surgery: state of the art

After a review of the technical development and application of staplers from their introduction to the present day, the indications to the use of this instrument in all gastroenterological areas from the oesophagus to the rectum as well as in chest, gynaecological and urological surgery specified. The advantages offered by staplers in the creation of intestinal anastomoses are undeniable, but these instruments must be considered alternatives to traditional surgery, the techniques of which should be well known to all surgeons. In certain areas (gastric, ileal and colonic resections etc.), the now widespread return to single thread manual stitches sheds a new light on staplers and reflects the fact that an anastomosis can be performed just as quickly by hand but will be softer and less rigid than a stapled one. It is only in oesophageal and lower rectal surgery that staplers offer a significant advantage, solving problems where hand suturing cannot.     

Paediatric thoracoscopy: state of the art

Brad Rogers reported the first significant use of thoracoscopy in children in the late 1970s. Over the past two decades there has been an exponential growth and expansion of this technique. Many advanced procedures, including lobectomy, repair of tracheo-esophageal fistula, excision of mediastinal tumours and diaphragmatic hernia repairs, are being done routinely in pediatric surgery centres around the world. This article reviews the state of the art of thoracoscopic surgery in children. The author selected five procedures which in his opinion are most relevant for this discussion. The thoracoscopic technique seems to offer a favourable alternative to open surgery, but more clinical research is necessary to confirm the benefits of minimal access surgery.     

Musculoskeletal oncology: state of the art

The outlook for the patient with sarcoma of the musculoskeletal system has improved dramatically because of recent advances in diagnosis and treatment. These new developments, as discussed in this review, allow greater success in achieving the goals of treatment, which include 1) control of the primary lesions, 2) maintenance of function, and 3) long-term survival.     

Feminizing genitoplasty: state of the art

Surgical management of intersex states continues to evolve such that today's efforts achieve near normal cosmetic and functional results. In this article we discuss the reconstruction of the female genitalia in those that have had significant androgen stimulation as well as those with near normal external genitalia but significant urogenital sinus anomalies. The initial evaluation as well as postoperative follow-up management is addressed.     

Peripheral thrombolysis: state of the art

Peripheral thrombolysis has become established in the last decade as an alternative method of treatment for acute limb ischaemia. New techniques of accelerated thrombolysis have expanded the indications to include almost all affected patients. Attention to detail and avoidance of known pitfalls, together with close cooperation between vascular surgeon and radiologist, ensure optimum results with minimum complications. A modern integrated lysis programme may vary from initial thrombolytic treatment for all patients with acute limb ischaemia to a selective policy of surgery and thrombolysis depending on the aetiology and severity of ischaemia.     

Forehead lifting: state of the art

Forehead lifting serves to restore a more youthful appearance as well as a more functional and aesthetically pleasing brow position. The purpose of this review is to describe the pertinent anatomy and forehead aesthetics, then to discuss the patient evaluation, surgical approaches, complications, and nonsurgical adjuncts. Anatomic features reviewed include the layers of the forehead and scalp, blood supply, innervation, musculature, and the temporal branch of the facial nerve anatomy. Forehead aesthetics described include the aging process, with its contributing factors and consequences, and the ideal brow position in women and men. Key aspects of the patient evaluation include assessment of skin type; ptosis; hairline, brow, and lid position; symmetry; and bony contours. Pertinent past medical/surgical history as well as family history are reviewed, and the need for ophthalmology evaluation is discussed. Surgical indications and approaches, including direct, coronal, mid-forehead, endoscopic, and trans-blepharoplasty, are reviewed. The advantages and disadvantages of each approach are discussed and techniques briefly described. Complications are mentioned, and the article concludes with a review of nonsurgical adjuncts.