Endoscopic Surgery: Ideal for Endocrine Surgery?

The laparoscopic approach of endocrine tumors is recent, the first reported resection of an adrenal gland in 1992. It represents a revolution in endocrine surgery equivalent to that observed in general surgery after the first cholecystectomy was performed in 1987. This new approach needs evaluation in terms of feasibility, indications, safety, and surgical procedure to define its potential advantages. The surgical technique and operative approaches of laparoscopic adrenalectomies are at the present time well defined and mostly accepted. Pancreatic approaches and resections, thyroidectomies, and parathyroidectomies are more confidential and performed only by rare teams. Nevertheless, the development of this technique is ineluctable. The spread of this technique, partly due to the increased quality of the technologies available, especially cameras, encounter a major brake that limits its generalization: If general surgeons commonly perform laparoscopy in their daily practice, they treat few patients presenting endocrine disorders. On the other hand, endocrine surgeons to whom many patients are referred do not have regular videoscopic practice. Endocrine surgery benefit few patients for these reasons. An analysis of the present state of the art allows us to imagine the evolution and future of videoscopic endocrine surgery.     

Endoscopic Surgery: Fit for Malignancy?

Neither experimental nor clinical data confirm the repeatedly published opinion that video-endoscopic surgery promotes tumor growth or the occurrence of implantation metastases in cancer patients. On the contrary, alterations due to pneumoperitoneum by the application of different gases, pressures, and temperatures might provide the basis for a new therapeutic approach to cancer surgery. Oncologically adequate resections defined by such terms as “no touch isolation” and “monobloc resection” can be performed video-endoscopically in a variety of intraabdominally or intrathoracically located cancers if a standardized technique is used. The benefit of video-endoscopic surgery is limited in large tumors, especially if they have reached the organ surface. There is still a major deficit in the clinical evaluation of video-endoscopic interventions in most oncologic diseases. Randomized studies comparing video-endoscopic and conventional surgery have been reported only for the resection of colorectal carcinoma. They show that laparoscopic resections can be performed with a minimum of postoperative complications to the same extent as conventional resections and offer several advantages during the early postoperative period. No reliable data from comparative trials are as yet available on the long-term results.     

Is Robotic Surgery Superior to Endoscopic and Open Surgeries in Thyroid Cancer?

Background

Endoscopic thyroidectomies have been performed using various approaches, and indications have expanded with the development of new surgical techniques and instruments. Endoscopic thyroid surgery using bilateral axillo-breast approaches have excellent cosmetic results and a symmetrical, optimal operative view. However, because of the two-dimensional view and the nonflexible instruments, these approaches are not easy to use in performing a central lymph node dissection (CND). Robotic surgery has drawn attention as a potentially safe and effective method for treating thyroid cancer. The aim of the present study was to determine whether robotic surgery is superior to endoscopic and open surgery through comparing technical aspects and surgical outcomes.

Methods

From October 2008 to December 2009, 302 patients had total thyroidectomies and CND with cancer less than 1?cm. Patients were divided into three groups according to operation methods (open group; n?=?138), (endo group; n?=?95), (robot group; n?=?69).

Results

Young patients preferred the robotic and endoscopic surgery. The number of retrieved lymph nodes in the open group (4.8?±?2.8) was not different from the robot group (4.7?±?2.7) and the endo group (4.6?±?3.7). The operative time of the robot group was longer than the open and the endo group. The total drain amount in the robot group was more than the open and endo groups; however, there was no difference in the length of hospitalization and complication rates. There were no differences between the open (0.8?±?2.0) and robot groups (0.8?±?1.4), but the endo group (2.4?±?6.3) showed higher postoperative serum thyroglobulin off thyroid hormone (Off-Tg) when compared to the open and robot groups.

Conclusions

Robotic surgery was equal to open surgery except with respect to operative time and was superior to endoscopic surgery in Off-Tg levels presenting completeness of the operation in thyroid cancer surgery. Because it has excellent cosmetic results and various technical advantages, it should be considered in young, low-risk patients with thyroid carcinoma less than 1?cm.     

Intraoperative Ultrasonography during Drainage for Chronic Subdural Hematomas: A Technique to Release Isolated Deep-seated Hematomas—Technical Note

After the drainage of chronic subdural hematomas (CSDHs), residual isolated deep-seated hematomas (IDHs) may recur. We introduce intraoperative ultrasonography to detect and remove such IDHs. Intra-operative ultrasonography is performed with fine transducers introduced via burr holes. Images obtained before dural opening show the CSDHs, hyper- and/or hypoechoic content, and mono- or multilayers. Images are also acquired after irrigation of the hematoma under the dura. Floating hyperechoic spots (cavitations) on the brain cortex created by irrigation confirm the release of all hematoma layers; areas without spots represent IDHs. Their overlying thin membranes are fenestrated with a dural hook for irrigation. Ultrasonographs were evaluated in 43 CSDHs (37 patients); 9 (21%) required IDH fenestration. On computed tomography scans, 17 were homogeneous-, 6 were laminar-, 16 were separated-, and 4 were trabecular type lesions. Of these, 2 (11.8%), 3 (50%), 4 (25%), and 0, respectively, manifested IDHs requiring fenestration. There were no technique-related complications. Patients subjected to IDH fenestration had lower recurrence rates (11.1% vs. 50%, p = 0.095) and required significantly less time for brain re-expansion (mean 3.78 ± 1.62 vs. 18 ± 5.54 weeks, p = 0.0009) than did 6 patients whose IDHs remained after 48 conventional irrigation and drainage procedures. Intraoperative ultrasonography in patients with CSDHs facilitates the safe release of hidden IDHs. It can be expected to reduce the risk of postoperative hematoma recurrence and to shorten the brain re-expansion time.     

Suprasellar Hemangioblastoma Mimicking a Craniopharyngioma: Result of Extended Endoscopic Transsphenoidal Approach—Case Report

Hemangioblastoma in the suprasellar region is rare. We present a case of a suprasellar hemangioblastoma that underwent surgical resection using an extended endoscopic transsphenoidal approach. A 64-year-old female patient presented with headache and decreased visual acuity for the last four years, computed tomography (CT) and magnetic resonance imaging (MRI) revealed a 2.5 cm irregular lesion in the suprasellar region. Our preoperative presumptive diagnosis was craniopharyngioma. The patient underwent an extended endoscopic transsphenoidal approach, the mass was subtotally removed. An endoscopic endonasal repair was needed due to the cerebrospinal fluid (CSF) leak. However, 1 month later, the patient got disturbance of consciousness because of the hydrocephalus. Ventriculoperitoneal shunt was used to solve the problem. Pathological findings were compatible with hemangioblastoma. Suprasellar hemangioblastoma is very rare. Any highly vascular lesions located in the suprasellar region should alert the surgeon to the possibility of hemangioblastoma. Extended endoscopic transsphenoidal approach adopted by us should not be the first choice of the treatment procedure for this kind of large and vascular tumor.     

An Operating Microscope with Higher Magnification and Higher Resolution for Cerebral Aneurysm Surgery: Preliminary Experience—Technical Note

We describe a higher magnifying power operating microscope system to improve one method of high-quality microsurgical clipping for cerebral aneurysm in some cases. This higher magnification is achieved by a new lens design in the optical system, which makes the image of the object very clear at high magnifications (distinctiveness of 7 μm). This higher-resolution operating microscope system provides the surgeon with higher-magnified images (at the maximum of more than 30× magnifications as each working distance) in the operating field. The magnifications can be changed from low power (2.9×) to high power (62.0×) depending on the circumstances in a given procedure. We have used this operating microscope system on 11 patients with microsurgical clipping for cerebral aneurysms. Microsurgical treatment could be performed safely and precisely. All aneurysms were treated without any technical complications. We think that the use of this microscope would have potential benefits for microsurgical treatment for cerebral aneurysms because of better visualization.     

Screening for Recurrences in Patients Treated with Breast-Conserving Surgery: Is there a Role for MRI?

Background Although it has been shown that magnetic resonance imaging (MRI) is more sensitive than mammography in the detection of breast cancer in high-risk populations, there is little data on the use of MRI as a screening tool to detect recurrence after breast-conserving surgery. Our objective was to determine the potential role of MRI in the screening of breast cancer patients treated with breast-conserving surgery. Methods Retrospective chart review of all patients undergoing margin-negative lumpectomy and adjuvant radiation therapy for infiltrating breast carcinoma between 1^st January 1993 and 1^st January 2004. Patients were followed for recurrence in the ipsilateral or contralateral breast by physical exam and mammography. Results Four hundred and seventy-six primary tumor excisions were performed. Patients were followed for a median of 5.4 years. Ipsilateral breast recurrences developed in eight patients (1.7%) with a mean diameter of 1.6 cm. All of these women are alive and free of metastases. Contralateral cancers developed in 11 patients (2.3%) with a mean diameter of 1.5 cm. Ten of these 11 women are alive and free of disease. Conclusions In a contemporary patient population the risk of local recurrence after lumpectomy and radiation therapy is very low. If screening MRI had been a part of annual follow-up, a total of 2570 MRIs would have been performed. Given the small tumor size at detection and the excellent survival of those who recurred, annual screening MRI would have incurred significant cost and would have been unlikely to improve overall survival.     

Inflammatory Breast Cancer: Is There a Role for Deescalation of Surgery?

Inflammatory breast cancer (IBC) is a rare and aggressive presentation of breast cancer, characterized by higher propensity for locoregional recurrence and distant metastasis compared with non-IBC. Because of extensive parenchymal and overlying dermal lymphatic involvement by carcinoma, IBC is unresectable at diagnosis. Trimodality therapy (neoadjuvant chemotherapy followed by modified radical mastectomy and adjuvant comprehensive chest wall and regional nodal radiotherapy) has been a well-accepted treatment algorithm for IBC. Over the last few decades, several innovations in systemic therapy have resulted in rising rates of pathologic complete response (pCR) in both the affected breast and the axilla. The latter may present an opportunity for deescalation of lymph node surgery in patients with IBC, as those with an axillary pCR may be able to avoid an axillary dissection. To this end, feasibility data are necessary to address this question. There are very limited data on the safety of breast conservation of IBC; therefore, mastectomy remains the standard of care for this disease. There are also no data addressing the safety of immediate reconstruction in patients with IBC. Considering that some degree of deliberate skin-sparing to facilitate immediate breast reconstruction would be expected, given the extensive skin involvement by disease at diagnosis, the safest oncologic strategy to breast reconstruction in IBC would be the delayed approach.

     

Is there a Role for Surgery with Adequate Nodal Evaluation Alone in Gastric Adenocarcinoma?

Introduction  

The extent of lymphadenectomy and protocol design in gastric cancer trials limits interpretation of survival benefit of adjuvant therapy after surgery with adequate lymphadenectomy. We examined the impact of surgery with adequate nodal evaluation alone on gastric cancer survival.     

Subfascial Endoscopic Perforator Surgery: New Life for an Old Procedure?

Background:

Division of incompetent perforating veins has long been regarded as an appropriate approach for treatment of venous stasis ulcers. The development of endoscopic techniques using standard laparoscopic instrumentation has permitted the application of this therapy without the need for long open incisions, fraught with complications.

Methods:

We report our experience with 20 cases of subfascial endoscopic perforator surgery (SEPS) in 19 patients. Seventeen limbs had active ulceration at the time of operation. A gas insufflation technique with two 10 mm ports was used in most cases.

Results:

An average of four perforating veins were divided in each case. Mean operating time was 1.5 hours. At a mean follow-up of eight months, initial complete healing occurred in 14 of 17 ulcers, three ulcers improved, and three healed ulcers at the time of SEPS have remained healed. One patient developed a small area of recurrent ulceration after initial healing. There were no thromboembolic complications. One procedure was technically unsuccessful because of morbid obesity. One patient developed a wound infection, and one patient required re-exploration for a subfascial hematoma.

Conclusion:

SEPS is a safe, minimally invasive procedure which should become an important part of the surgical armamentarium in treating patients with venous ulcers.     

ECIRS (Endoscopic Combined IntraRenal Surgery) in the Galdakao-modified supine Valdivia position: a new life for percutaneous surgery?

Background  

Percutaneous nephrolithotomy (PNL) is still the gold-standard treatment for large and/or complex renal stones. Evolution in the endoscopic instrumentation and innovation in the surgical skills improved its success rate and reduced perioperative morbidity. ECIRS (Endoscopic Combined IntraRenal Surgery) is a new way of affording PNL in a modified supine position, approaching antero-retrogradely to the renal cavities, and exploiting the full array of endourologic equipment. ECIRS summarizes the main issues recently debated about PNL.     

Superficial Venous Disease Treatment - Is There Still a Role for Open Surgery in 2011 ?

The treatment of superficial venous disease (commonly described as varicose veins by the general public) has remained relatively constant over the past 100 years until the refinements of endovenous treatments such as sclerotherapy and more recently, the development of endovenous ablation. This has radically changed the treatment profile of this disease with treatments easily administered and well tolerated even in those patients who would not be considered fit for open surgery previously. With the advent of day surgery and improved general and local anaesthetic techniques, venous surgery has forged a path towards the end goal of outpatient treatment with no requirement for inpatient stay. The end goal of all superficial venous surgery is an improvement in quality of life, and with such new treatments reducing the impact of the actual intervention, such gains are easier to make.

This review assesses and presents the current literature describing superficial venous disease treatments covering all treatment modalities.

With endovenous treatment, true ambulatory treatment is available, providing high quality treatment at speed and convenience for patients.     

Predictors of Axillary Lymph Node Metastases in Breast Cancer: Is There a Role for Minimal Axillary Surgery?

Introduction  Axillary nodal status is one of the most important prognostic factors in breast cancer. In the present study we used it to determine the predictors of axillary lymph node metastases in breast cancer and to determine if there is a group of patients in whom minimal axillary surgery is indicated. Methods  This article reports a retrospective study of 953 patients with T1 and T2 invasive breast carcinomas seen in the University Malaya Medical Centre between January 2001 and December 2005, where axillary dissection was done. Results  Of the 953 patients, 283 (29.7%) had breast-conserving surgery, and the rest had mastectomies. In this series, 463 patients (48.6%) were younger than 50 years of age; 365 patients (38.3%) had lymph node involvement. The Malays tend to have more axillary node metastases (45.1%) than the Chinese (36.9%); however, there was no significant relationship between age and race and lymph node involvement. Some 23.9% of grade 1 cancers were node positive, compared to 42.9% of grade 2/3 cancers. Tumor size ranged from 0.2 cm to 5 cm; 55.5% of tumors were T2 (>2–5 cm). There were only 13 (1.4%) T1a tumors (>0.1–0.5 cm). Node involvement was documented in 7.7% of T1a tumors, 12.3% of T1b tumors (>0.5–1 cm), 29.2% of T1c tumors, and 48.2% of T2 tumors. In patients who had no lymphovascular invasion (LVI), 24.4% had axillary node metastases, compared with 52.2% of patients where LVI was reported. On univariate analysis, our study found that tumor diameter >2 cm, presence of lymphovascular invasion, and higher tumor grade (2 & 3) were factors significantly associated with a higher risk of nodal metastases. On multivariate analysis, however, only lymphovascular invasion and tumor size were independent predictors based on the logistic regression. Conclusions  In T1 tumors, axillary lymph node dissection will overtreat almost 75% of cases; therefore a sentinel lymph node biopsy is justified in these tumors. Sentinel lymph node biopsy has been shown to reduce the complications of formal axillary dissection, such as shoulder stiffness, pain, and lymphedema. In patients with T2 tumors, where almost 45% have lymph node involvement, sentinel node biopsy may not be cost effective.     

Endoscopic Combined Intrarenal Surgery in Galdakao-Modified Supine Valdivia Position: A New Standard for Percutaneous Nephrolithotomy?

Background

Percutaneous nephrolithotomy (PCNL), the gold standard for the management of large and/or complex urolithiasis, is conventionally performed with the patient in the prone position, which has several drawbacks. Of the various changes in patient positioning proposed over the years, the Galdakao-modified supine Valdivia (GMSV) position seems the most beneficial. It allows simultaneous performance of PCNL and retrograde ureteroscopy (ECIRS, Endoscopic Combined Intra-Renal Surgery) and has unquestionable anaesthesiological advantages.

Objective

To prospectively analyse the safety and efficacy of endoscopic combined intrarenal surgery (ECIRS) in GMSV position for the treatment of large and/or complex urolithiasis.

Design, setting, and participants

From April 2004 to December 2007, 127 consecutive patients who were followed in our department for large and/or complex urolithiasis were selected for surgery (American Society of Anesthesiologists [ASA] score 1–3, no active urinary tract infection [UTI], any body mass index [BMI]).

Intervention

All the patients underwent ECIRS in GMSV position. Technical choices about percutaneous access, endoscopic instruments and accessories, and postoperative renal and ureteral drainage are detailed.

Measurements

Patients’ mean age plus or minus standard deviation (± SD) was 53.1 yr ± 14.2. Of the 127 patients, 5.5% had congenital renal abnormalities, 3.9% had solitary kidneys, and 60.6% were symptomatic for renal colics, haematuria, and recurrent UTI. Mean stone size ± SD was 23.8 mm ± 7.3 (range: 11–40); 33.8% of the calculi were calyceal, 33.1% were pelvic, 33.1% were multiple or staghorn, and 4.7% were also ureteral.

Results and limitations

Mean operative time ± SD was 70 min ± 28, including patient positioning. Stone-free rate was 81.9% after the first treatment and was 87.4% after a second early treatment using the same percutaneous access during the same hospital stay (mean ± SD: 5.1 d ± 2.9). We registered overall complications at 38.6% with no splanchnic injuries or deaths and no perioperative anaesthesiological problems.

Conclusions

ECIRS performed in GMSV position seems to be a safe, effective, and versatile procedure with a high one-step stone-free rate, unquestionable anaesthesiological advantages, and no additional procedure-related complications.