Simple Transposition Technique for Microvascular Decompression Using an Expanded Polytetrafluoroethylene “Belt”: Technical Note

Microvascular decompression (MVD) is a standard surgical procedure for treating vascular compression syndromes. There are two basic ways to perform MVD: interposition using a prosthesis and transposition. With the transposition technique, adhesions and granuloma around the decompression site are avoided, but the required operation is more complex than that for the interposition method. We describe a simple, quick MVD transposition procedure that uses a small “belt” cut from a sheet of 0.3-mm-thick expanded polytetrafluoroethylene membrane. The belt has a hole at the wide end and the other end tapered to a point. The belt is encircled around offending vessels by inserting the pointed end into the hole. The pointed end is then passed through a dural tunnel over the posterior wall of the petrous bone and is tied two or three times. This method avoids the risks involved in handling a surgical needle close to the cranial nerves and vessels.     

The Significance of Histologically “Large Normal” Parathyroid Glands in Primary Hyperparathyroidism

Introduction

We investigated outcomes in a cohort of patients with a biochemical diagnosis of primary hyperparathyroidism (pHPT) undergoing surgery for asymptomatic disease or target organ damage, where a focussed or four-gland operation was undertaken and the histopathology only reported a “large normal” parathyroid gland (LNP).

Methods and materials

Patients subjected to a parathyroidectomy for pHPT between 2012 and 2018 with a pathology of LNP were included. Patients with fat depletion or additional histological features of adenoma or hyperplasia in any of the resected glands were excluded. A control group was formed from 50 consecutive patients with the histological finding of adenoma or hyperplasia during the same study period. The primary outcome was biochemical normalisation of pHPT at 1–2 weeks and after 6 months post-operatively.

Results

Forty-eight LNP patients (2% of all parathyroidectomies) were included in the study group with 50 matched controls. LNP patients had a lower biochemical cure rate (81% vs. 98% P < 0.05) and a higher risk of recurrence (10% vs. 0%, P = 0.06). LNP patients had a milder form of pHPT (Ca²⁺ 2.63 vs. 2.68 P < 0.05) with a smaller PTH and Ca²⁺ drop post-operatively. For LNP patients with failure, a definite additional cause of pHPT was found in only two patients.

Conclusion

This study highlights a controversial area in pHPT and reports LNP as a cause of pHPT. The biochemical analysis of this LNP group supports a benefit in resection in the setting of pHPT, although the risk of failure (persistence/recurrence) is higher than those with adenoma or hyperplasia. Stricter post-operative follow-up of LNP patients should be considered.

     

The Role of Psychiatric Diagnoses for Outcome After Hip and Knee Arthroplasty

Background

Surgical patients receiving psychopharmacologic treatment have been associated with adverse outcomes in total hip and knee arthroplasty (THA and TKA). The purpose of this study was to investigate whether a specific high-risk group of patients receiving psychopharmacologic treatment could be identified based upon a nationwide psychiatric diagnosis register.

The Outcome of Bariatric Surgery in Patients Aged 75 years and Older

Background

Bariatric surgery has been shown to be safe and effective in patients aged 60–75 years; however, outcomes in patients aged 75 or older are undocumented.

Methods

Patients aged 75 years and older who underwent bariatric procedures in two academic centers between 2006 and 2015 were studied.

Results

A total of 19 patients aged 75 years and above were identified. Eleven (58%) were male, the median age was 76 years old (range 75–81), and the median preoperative body mass index (BMI) was 41.4 kg/m² (range 35.8–57.5). All of the bariatric procedures were primary procedures and performed laparoscopically: sleeve gastrectomy (SG) (n?=?11, 58%), adjustable gastric band (AGB) (n?=?4, 21%), Roux-en-Y gastric bypass (RYGB) (n?=?2, 11%), banded gastric plication (n?=?1, 5%), and gastric plication (n?=?1, 5%). The median operative time was 120 min (range 75–240), and the median length of stay was 2 days (range 1–7). Three patients (16%) developed postoperative atrial fibrillation which completely resolved at discharge. At 1 year, the median percentage of total weight loss (%TWL) was 18.4% (range 7.4–22.0). The 1-year %TWL varied among the bariatric procedures performed: SG (21%), RYGB (22%), AGB (7%), and gastric plication (8%). There were no 30-day readmissions, reoperations, or mortalities.

Conclusion

Our experience suggests that bariatric surgery in selected patients aged 75 years and older would be safe and effective despite being higher risk. Age alone should not be the limiting factor for selecting patients for bariatric surgery.

     

The significance of some reflections in “Echo-encephalography”

Summary A great deal of the ultrasound reflections in echo-encephalography originate from the boundaries between brain and C. S. F. For many echoes identification with known anatomic structures is possible.The cause of the midline-echo is discussed. In clinical practice the determination of the midline-echo is already used for a quick diagnostic of space-occupying processes in the cerebral hemispheres where this reflection is displaced to the opposite side.The reflections of the ventricular walls were identified with the aid of pneumencephalography.

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Zusammenfassung Ein Großteil der Ultraschallwellenreflektionen bei der Echo-Encephalographie entstehen an den Grenzen zwischen Hirn und Liquor. Für viele Echos ist es möglich, sie bekannten anatomischen Strukturen zuzuordnen.Die Ursache des Mittellinien-Echos wird diskutiert. In der klinischen Praxis wird die Bestimmung des Mittellinien-Echos bereits angewendet, um einen raumbeengenden Prozeß im Bereich der Großhirnhemisphären rasch nachweisen zu können. In solchen Fällen ist die Reflektion zur Gegenseite verlagert.Die Reflektionen der Ventrikelwände wurden mit Hilfe der Pneumencephalographie identifiziert.

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Resumen Una gran parte de las ondas de reflexión de los ultrasonidos en la ecoencefalografia se origina en los limites entre el cerebro y el liquido. Algunos ecos se pueden identificar con estructuras anatomica conocidas. Se discute la causa de los ecos de la linea media. Desde el punto de vista practico se aplica el eco de la linea media para poder diagnosticar rapidamente procesos expansivos de los hemisferios cerebrales, si la reflexión es desplazada hacia el lado opuesto.Las reflexiones de la pared ventricular fueron identificadas con la ayuda de la neumoencefalografia.

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Résumé Une quantité d'ultra-sons réfléchis en écho-encéphalographie par les frontières situées entre le cerveau et le liquide céphalo-rachidien. Pour beaucoup d'échos l'identification avec des structures anatomiques connues est possible. La cause de l'écho de la ligne médiane est exposée. En pratique clinique la détermination d'un écho de la ligne médiane est déjà utilisée pour un rapide diagnostic de processus expansifs d'un hémisphère cérébral où cette réflexion est déplacée vers le côté opposé.La reflexion des parois ventriculaires fut identifiée avec l'aide de la pneumoencéphalographie.

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Riassunto Molte delle riflessioni di ultrasuoni che si osservano in eco-encefalografia originano dai confini fra sostanza cerebrale e liquor. Per diversi echi è possibile l'identificazione con strutture anatomiche conosciute.Viene discussa l'origine dell'eco della linea mediana. Nella pratica clinica la determinazione dell'eco della linea mediana viene già utilizzata per una rapida diagnosi di processo espansivo emisferico in quanto questa riflessione viene spostata dal lato opposto.Le riflessioni da parte delie pared ventricolari sono state identificate con l'impiego della pneumoencefalografia.

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Supported by a grant from the Dutch National Health Research Council T. N. O.     

Desmoplastic Stromal Reaction in Medullary Thyroid Cancer—An Intraoperative “Marker” for Lymph Node Metastases

Background Medullary thyroid cancer (MTC) disseminates early to lymph nodes (LN). There is no pre- or intraoperative marker to exclude LN involvement and thereby avoid lateral neck dissection in LN-negative patients. Materials and Methods This study was intended to verify the observation that patients with MTC lacking desmoplastic stromal reaction (DSR) never have LN metastases. In 120 patients undergoing primary operation for sporadic MTC the prognostic value of DSR with respect to LN involvement was evaluated. Results Thirty-two (27%) of 120 tumors were DSR negative, and 88 (73%) were DSR positive. All 32 (100%) DSR-negative tumors were LN negative (N0), and all patients were biochemically cured. Of 88 DSR-positive tumors, 57 (65%) were staged N0, and 31 (36%) were staged N1(LN positive; Fisher’s exact test: P = 0.0001). In a comparison of the LN involvement to the DSR characteristics, 32 (36%) of the 89 N0 patients and none of the 31 N1 patients were DSR negative. The sensitivity of DSR in predicting N0 is 38% (95% confidence interval: CI 95% = 27 %–55%), the specificity is 100% (CI 95% = 88%–100%). The sensitivity and specificity for the parameter DSR to differentiate between N0 or N1 were 100% and 36%, respectively. Conclusions The desmoplastic stromal reaction appears to be an excellent intraoperative marker to predict LN involvement with a high specificity but low sensitivity. We therefore propose to avoid initial lateral neck dissection in MTC patients without DSR.     

ASO Author Reflections: The Magic of Clinical Research—The Student-Led PATRONUS Study Unveils Two Patient-Reported Outcome Measures for Use in Surgical Oncology

Annals of Surgical Oncology -