En Bloc Surgery for Colon Cancer: Report of a Case

(Received for publication on Oct. 28, 1998; accepted on July 13, 1999)     

Recovery of Olfactory Function after an Anterior Craniofacial Approach

We assessed recovery of olfactory function in five consecutive patients who underwent surgical resection of midline skull base tumors using an anterior craniofacial approach in which the cribriform plate was mobilized with the dura. Olfactory function was evaluated before and after surgery using an intravenous olfactory test with prosultiamine and also a standard olfactory acuity test. Before surgery, one patient showed anosmia attributable to obstruction of the nasal cavity and olfactory cleft, and four patients showed normal olfactory function. After surgery, one patient was irreversibly anosmic, probably because of intradural dissection of the olfactory tracts. The other four patients, including the patient showing anosmia preoperatively, reported subjective recovery of olfaction 3 to 8 weeks after surgery. Intravenous and standard olfactory acuity tests indicated recovery of olfaction to the normal range in three patients and decreased olfactory function in one. With careful preservation of the olfactory system and of the integrity of the nasal cavity, olfactory function was found to recover after skull base resections via the anterior craniofacial approach.     

A Modification of Radical Antegrade Modular Pancreatosplenectomy for Adenocarcinoma of the Left Pancreas: Significance of En Bloc Resection Including the Anterior Renal Fascia

Background

Radical antegrade modular pancreatosplenectomy (RAMPS) has theoretical advantages for curative resection of adenocarcinomas of the left pancreas. The anterior renal fascia is a key structure, and resection planes should run posterior to this fascia. However, it is difficult to delineate this fascia and set a precise dissection plane. We modified RAMPS to achieve such a precise dissection plane with ease.

Methods

After clamping the splenic artery, the third duodenal portion was mobilized from the left to the right to locate the inferior vena cava, which was covered by the anterior renal fascia. Here, the anterior renal fascia was incised while approaching the dissection plane. Dissection then continued cephalad, with this plane along the inferior vena cava, and then turned along the left renal vein at the confluence of the left renal vein toward the renal hilum. At this point, dissection continued along the coronal plane to the superior edge of the pancreas.

Results

Between July 2007 and December 2012, a total of 24 pancreatic adenocarcinoma patients underwent modified RAMPS. Tumor extension beyond the pancreatic parenchyma (T3) and lymph node metastases was confirmed in 17 and 13 cases, respectively. Histologically clear surgical margins were achieved (R0 resection) in 21 patients (88 %). The 5-year overall survival rate was 53 %. Six patients survived for over 5 years without recurrence.

Conclusions

This modification of RAMPS is advantageous for en bloc resection while actually including removal of the anterior renal fascia. It is associated with satisfactory survival rates for patients with distal pancreatic carcinomas.     

En Bloc Excision of Proximal Nail Fold for Treatment of Chronic Paronychia

BACKGROUND: Chronic paronychia is a very recalcitrant dermatosis, which is particularly prevalent in housewives. Medical treatment for this condition is unsatisfactory in a significant number of cases. Surgical approach forms an important part of management, however, this area has received little attention. Various surgical approaches have been tried in the past but a comparative analysis has not been attempted. OBJECTIVES: The present study aims at assessing the efficacy of en bloc excision of proximal nail fold (PNF). Moreover, a comparative analysis has been undertaken to assess whether or not simultaneous nail plate avulsion improves the treatment outcome. METHODS: Thirty patients of chronic paronychia with nail plate irregularities were randomly divided into two treatment groups (15 patients each). After a detailed evaluation, en bloc excision of PNF with or without nail plate removal was performed. Postoperative measures were advised and the patients were kept under regular follow-up thereafter. Assessment of postoperative complications was also performed. RESULTS: Twelve patients in group I and 13 patients in group II completed the treatment protocol. Of these, 70% of patients were cured in group II (en bloc excision with nail avulsion) whereas only 41% were cured in group I (en bloc excision without nail avulsion). CONCLUSION: En bloc excision of the PNF is a useful method in recalcitrant chronic paronychia. Simultaneous avulsion of the nail plate improves the surgical outcome. Strict avoidance of irritant exposure is necessary to ensure complete treatment and prevent recurrence.     

Oncological Superiority of Hilar En Bloc Resection for the Treatment of Hilar Cholangiocarcinoma

Purpose

Long-term results after liver resection for hilar cholangiocarcinoma are still not satisfactory. Previously, we described a survival advantage of patients who undergo combined right trisectionectomy and portal vein resection, a procedure termed “hilar en bloc resection.” The present study was conducted to analyze its oncological effectiveness compared to conventional hepatectomy.

Patients

During hilar en bloc resection, the extrahepatic bile ducts were resected en bloc with the portal vein bifurcation, the right hepatic artery, and liver segments 1 and 4 to 8. With this “no-touch” technique, preparation of the hilar vessels in the vicinity of the tumor was avoided. The long-term outcome of 50 consecutive patients who underwent curative (R0) hilar en bloc resection between 1990 and 2004 was compared to that of 50 consecutive patients who received curative conventional major hepatectomy for hilar cholangiocarcinoma (perioperative deaths excluded).

Results

The 1-, 3-, and 5-year survival rates after hilar en bloc resection were 87%, 70%, and 58%, respectively, which was significantly higher than after conventional major hepatectomy. In the latter group, 1-, 3-, and 5-year survival rates were 79%, 40%, and 29%, respectively (P = 0.021). Tumor characteristics were comparable in both groups. A high number of pT3 and pT4 tumors and patients with positive regional lymph nodes were present in both groups. Multivariate analysis identified hilar en bloc resection as an independent prognostic factor for long-term survival (P = 0.036).

Conclusions

In patients with central bile duct carcinomas, hilar en bloc resection is oncologically superior to conventional major hepatectomy, providing a chance of long-term survival even in advanced tumors.

     

Preoperative Nomogram to Predict Risk of Perioperative Mortality Following Pancreatic Resections for Malignancy

Introduction  

The majority of pancreatic resections for malignancy are performed in older patients with major comorbidities. The aim of this study was to develop a preoperative nomogram based on the presence of comorbidities to predict risk of perioperative mortality.     

Pre-operative Nomogram to Predict Risk of Peri-operative Mortality following Liver Resections for Malignancy

Introduction  

The majority of liver resections for malignancy are performed in older patient with major co-morbidities. There is currently no pre-operative, patient-specific method to determine the likely peri-operative mortality for each individual patient. The aim of this study was to develop a pre-operative nomogram based on the presence of co-morbidities to predict risk of peri-operative mortality following liver resections for malignancy.     

Right Trisectionectomy with Principle En Bloc Portal Vein Resection for Right-Sided Hilar Cholangiocarcinoma: No-Touch Technique

Background  

The most favorable long-term survival rate for hilar cholangiocarcinoma is achieved by a R0 resection. A surgical concept involving a no-touch technique, with extended right hepatic resections and principle en bloc portal vein resection was described by Neuhaus et al.1 According to Neuhaus et al.,1 their technique may increase the chance of R0, because the right branch of the portal vein and hepatic artery is in close contact with the tumor and is frequently infiltrated. The left artery runs on the left margin of the hilum and often is free. The 5-year survival rate for their patients is 61% but 60-day mortality rate is 8%.1 ^, 2 Given the increased morbidity, some authors do not agree with routine resection of portal vein and may perform the resection of portal vein only on demand, after intraoperative assessment and confirmation of portal vein invasion.3     

Comparison of Anterior Versus Posterior Approach in the Treatment of Thoracolumbar Fractures: A Systematic Review

Despite extensive research on thoracolumbar fractures, controversy still exists about which approach is the most appropriate. Lack of evidence-based practice may result in patients being treated inappropriately. The objective of study was to perform a systematic review of the effectiveness of the anterior and posterior approaches in the treatment of thoracolumbar fractures. We conducted searches of PubMed and the Cochrane Library, searching for relevant trials up to August 2013 that compared anterior and posterior for the treatment of thoracolumbar fractures. The key words “anterior,” “posterior,” “thoracolumbar fracture,” “CCT,” and “RCT” were used. We assessed all included literature by using the Cochrane handbook (version 5.1). The results were expressed as the mean difference for continuous outcomes and risk difference for dichotomous outcomes, with a 95% confidence interval, using RevMan version 5.2. There were 3 randomized controlled trials and 11 clinical controlled trials included. The meta-analysis showed no significant difference between groups regarding Cobb angle, the Frankel scale, ASIA/JOA motor score, complications, and number of patients returning to work. Compared with the anterior approach, the posterior approach demonstrated superior canal decompression. In the burst fracture subgroup, operative times were significantly shorter and perioperative blood loss was less in the posterior approach group. The posterior approach is more effective for canal decompression, operative times, and perioperative blood loss. However, because of the lack of randomized controlled trials, and because of large sample size studies, heterogeneity was significant between reports. The optimal treatment for thoracolumbar fractures requires further study.Key words: Anterior, Posterior, Thoracolumbar fracture, Systematic reviewApproximately 90% of all spinal fractures occur at the thoracolumbar junction,^1–3 including burst fractures, osteoporotic thoracolumbar vertebral collapse, and chronic thoracolumbar fractures as the primary etiologies. The main treatment modality for thoracolumbar fractures is open reduction and internal fixation.⁴ There are two main surgical approaches: anterior and posterior. However, the best approach remains controversial. We aimed to apply the methodology of systematic review and meta-analysis to thoracolumbar fractures in order to evaluate the effectiveness of the anterior versus posterior approach in their treatment.     

Local Involvement of the Urinary Bladder in Primary Colorectal Cancer: Outcome with En Bloc Resection

Background Colorectal cancers that adhere to the urinary bladder require en bloc partial or total cystectomy to achieve negative tumor margins. Methods This prospective study evaluated the outcome of combined bladder resection for carcinoma of the colon or rectum at a unit specializing in gastrointestinal cancer. Results Patients (n = 63) with colorectal tumors adherent to the bladder at operation and without distal metastases were followed. Fifty-eight patients (92%) had tumors of the sigmoid colon or upper rectum. Operative morbidity and mortality rates were 18% and 1.5%, respectively. Histological staging demonstrated bladder adherence in 46% (29/63) and invasion in 54% (34/63). Overall disease-specific survival was 54%, with a mean follow-up of 7.6 (range 5–12) years. Five-year survival for margin negative patients was 72% (26/36) and 27% (4/15) for node negative and positive tumors, respectively. The bladder was closed primarily in 48 patients and reconstructed by enterocystoplasty in five, with ten patients requiring urinary diversion. Conclusions En bloc bladder resection for adherent or invading tumors of the colon and rectum achieves good local control, but an infiltrative extravesical margin denotes poor prognosis. The potential for cure in completely excised node negative tumors is good. Bladder reconstruction is achievable in most patients.