Limits of the transoral approach in craniospinal malformations

Over a 15-year period, 15 patients with craniospinal malformations were operated on using the transoral route. Ten patients had basilar impression and five had atlantoaxial dislocation; nine patients had associated lesions. Patients treated with reposition and dorsal fusion recovered well without ventral decompression. We found that transoral odontoidectomy is suitable as a primary decompressing measure only in ventral compression or nondislocated atlantoaxial conditions.     

Transoral transclival removal of anteriorly placed cavernous malformations of the brainstem

BACKGROUND: The natural history of brain stem cavernous malformations is unfavorable because of their high hemorrhage rate and resulting neurological deterioration among patients. However, direct surgery of intrinsic and anteriorly situated cavernomas is hazardous and leads to a bad postoperative outcome because of trauma to lateral and dorsally situated eloquent areas of the brain stem. METHODS: We review the cases of two patients with symptomatic cavernous malformations of the anterior brain stem and describe the usefulness of a transoral-transclival approach. A 23-year-old man developed progressive hemihypaesthesia and paraesthesia, hemiparesis with gait ataxia, dysarthria, dysphonia, and dysphagia. A 38-year-old woman suffered from an acute onset of vertigo with nausea and vomiting, diplopia, and paraesthesia of the left hand and foot. In both patients, computed tomography demonstrated the presence of brain stem hemorrhage, because of cavernous malformation. Magnetic resonance imaging showed a close proximity of the lesions to the pia mater only on the ventral surface of the brain stem. RESULTS: In both patients, the cavernomas could be safely approached and completely resected via a transoral transclival route. Three months after surgery, neurological examination revealed marked neurological improvement. The 23-year-old patient showed slight gait ataxia, no hemiparesis, no cranial nerve palsies; the 38-year-old woman demonstrated no neurological symptoms except for minimal motor dysfunction of the left hand. In both cases, under perioperative prophylactic antibiotics, no meningitis was observed. The patients could subsequently return to their previous employment. CONCLUSION: The transoral transclival approach for ventrally situated brain stem cavernomas allows a largely atraumatic resection of the lesion.     

Development of pulmonary arteriovenous malformations after modified Fontan operations

Two patients with complex cyanotic congenital heart disease and without previous Glenn anastomosis underwent modified Fontan operations. Postoperatively, pulmonary arteriovenous malformations developed that resulted in cyanosis from significant intrapulmonary right-to-left shunting. These malformations were detected by pulmonary angiograms and contrast echocardiograms. Pulmonary arteriovenous malformations may be a major cause of late clinical deterioration in patients treated with modified Fontan operations.     

Transoral odontoidectomy

The transoral approach for odontoidectomy is described in detail, and the operating room setup and surgical positioning are demonstrated. We also discuss our methods of retractor placement and techniques for optimal surgical exposure. The microsurgical technique used for decompression is presented in detail. The surgical pearls and pitfalls of transoral odontoidectomy, learned from a 70-case experience, are described and illustrated.     

经口甲状腺切除术

经口甲状腺切除术是近年发展起来的新术式。通过口腔前庭向颈部建立手术腔隙施行微创手术。适用于甲状腺良性病变以及没有侧颈淋巴结转移的甲状腺癌。优点是颈部无疤痕;手术入路相对临近;暴露良好并可以一次处理双侧甲状腺病变和中央区淋巴结。本例患者诊断为甲状腺癌,经口施行了甲状腺全切除和中央区淋巴结清扫。术中清晰暴露上位甲状旁腺并全程解剖喉返神经。利用超声刀安全稳固处理甲状腺上动脉和下动脉,失血少,术野清晰,而且术后无需置放引流管。术后并发症主要是术野区疼痛以及下唇周围麻木,通过术后镇痛和休息可以得到完全恢复。经口甲状腺切除术需要严格选择病例并由经验丰富的外科医生施行才能安全,有效。     

Transoral fusion for high cervical fractures

We report three patients having transoral fusion at C2/3 or C3/4 after fractures, with no infections or surgical complications and sound union. The operative technique and the relative merits of different approaches to the upper cervical spine are discussed and the transoral approach to the anterior aspect of the upper three cervical vertebrae is commended to the specialist surgeon.     

Transoral laser surgery for supraglottic cancer

The goal of treatment for supraglottic cancer is to achieve cure and to preserve laryngeal function. Organ preservation strategies include both endoscopic and open surgical approaches as well as radiation and chemotherapy. The challenge is to select the correct modalities for each patient. Endoscopic procedures should be limited to tumors that can be completely visualized during diagnostic microlaryngoscopy. If complete resection can be achieved, the oncologic results of transoral laser surgery appear to be comparable to those of classic supraglottic laryngectomy. In addition, functional results of transoral laser resection are superior to those of the conventional open approach, in terms of the time required to restore swallowing, tracheotomy rate, incidence of pharyngocutaneous fistulae, and shorter hospital stay. The management of the neck remains of paramount importance, as survival of patients with supraglottic cancer depends more on cervical metastasis than on the primary tumor. Most authors advocate bilateral elective neck dissection. However, in selected cases (T1,T2 clinically negative [N0] lateral supraglottic cancers), ipsilateral selective neck dissection could be performed without compromising survival. The authors conclude that with careful selection of patients, laser supraglottic laryngectomy is a suitable, and often the preferred, treatment option for supraglottic cancer.     

Transoral access for endoscopic thyroid resection

BACKGROUND: Endoscopic neck surgery is requested by an increasing number of patients. The access trauma of the axillary, breast, and chest approaches is greater than with open or video-assisted surgery. The authors tested the feasibility of the sublingual transoral access, which they believe is the most promising minimally invasive endoscopic access to the thyroid gland from outside the neck region. METHODS: The sublingual transoral access was first evaluated in two fresh human cadavers. An experimental investigation then was performed using a porcine model. A total of 10 endoscopic transoral thyroidectomies were performed in 10 pigs using a modified axilloscope with an obturator, ultrasonic scissors, and a neuromonitoring system to identify the recurrent laryngeal nerve. RESULTS: A complete transoral thyroid resection was achieved with both the human cadavers and all the living pigs. Despite the complexity of the anatomic region, the transoral procedure was astonishingly easy to perform. In the animal study, the time from the introduction of the obturator just above the larynx to its removal was 59 s. The average overall operation time was 50 min. The neuromonitoring system permitted the regular function of the recurrent laryngeal nerves on both sides to be proved after removal of the thyroid gland. The pigs were observed for another 2 h after the operation. No complications occurred during the operation or afterward. CONCLUSIONS: Endoscopic transoral thyroid resection is possible. It proved to be a safe procedure in living pigs and astonishingly easy to perform. The results may be helpful for thyroid resections in humans using a similar access, as suggested by the thyroidectomies in human cadavers preceding this study.     

经口内镜缝合治疗胃食管反流病的临床研究

目的　评估经口内镜缝合治疗胃食管反流病 (GERD)近期疗效及并发症。　方法　对经胃镜、上消化道X线钡餐、食管PH检测等确诊的GERD 1 6例在电子胃镜下采用美国BARD缝合器缝合胃食管部 ,缝合部位选择齿状线下 1cm ,2针间距 1 5cm ,2结间距 2 0cm。比较术前及术后 1月症状积分、食管 2 4hpH变化、食管炎程度变化。　结果　 1 6例共缝合 4 2针 ,2 1个结 ;平均手术时间 30min。术前烧心总积分 39,平均 2 4 4 ;反流总积分 32 ,平均 2 0。术后烧心总积分 1 1 ,平均 0 6 8;反流总积分 1 0 ,平均 0 6 3。烧心及反流术前术后比较差别均有显著性 (χ2 =1 9 5 ,1 6 33;P <0 0 0 5 )。术后 1月病人酸反流次数、最长酸反流时间、pH <4 0时间百分比均较术前明显减少 (P <0 0 0 1 )。术后 1月食管炎程度明显好转 (χ2 =2 5 78,P <0 0 0 5 )。本组总有效率 93 8% (1 5 / 1 6 ) ,完全缓解 6 2 5 % (1 0 / 1 6 ) ,部分缓解 31 3% (5 / 1 6 ) ,无效 6 3% (1 / 1 6 )。并发症主要有 :出血 ,胸骨后疼痛。　结论　经口内镜缝合治疗胃食管反流病近期疗效肯定 ,并发症少。     

Transoral kyphoplasty for tumors in C2

BACKGROUND CONTEXT: The management of tumors of the C2 body remains controversial. In cancer patients, major procedures may be contraindicated, and nonoperative treatment could fail. PURPOSE: To describe a new surgical technique, the transoral kyphoplasty, that we performed in 3 cases of tumors in C2 after nonoperative treatment failure. STUDY DESIGN: Case series of three patients. PATIENT SAMPLE: Three patients from the senior author's practice. OUTCOME MEASURES: To reduce pain and avoid both C2 collapse and prolonged immobilization, transoral kyphoplasties were performed. METHODS: From February 2004 to January 2006, three cases of tumors in C2 did not show healing after nonoperative treatments. RESULTS: No complications and/or complaints were related to the procedure. There were no C2-related symptoms or neurological problems. The first patient died 8 months after surgery. The second and the third are alive with follow-ups of 2 years and 6 months, respectively. In all cases, cervical motion was restored, and patients are pain free, with no findings regarding pathologic mobility/instability on X-ray and computed tomography scan. CONCLUSIONS: Transoral kyphoplasty proved to be safe, quick, and effective in reducing pain and avoiding vertebral collapse in patients with tumors in C2 not responding to nonoperative treatment.