Minimal Invasive Surgery for Esophageal Cancer

Thoracoscopic esophagectomy is only established in some centers and affords a cervical anasto-mosis because intrathoracic anastomosis as a routine is technically too difficult.Laparoscopic mobilisationof the stomach (gastrolysis) is an important contribution for minimal invasive surgery of esophageal cancer.This procedure reduces the stress of the two cavity operation for the patient and allows the constructionof a comparable gastric conduit like by open surgery.The technique of laparoscopic gastrolysis as prepa-ration for transthoracic en bloc esophagectomy is described in detail and preliminary results are brieflymentioned.     

Pancreatic cancer–Surgery for recurrent disease

Recurrence of pancreatic ductal adenocarcinoma (PDAC) after a resection with curative intent is inevitable in the majority of cases. Approximately three-quarters of patients ultimately die from metastatic, local, or combined tumor recurrence [1–3]. This may be due to the insuf     

Risk Factors and Prognosis of Surgery for Spinal Metastasis

Objective To evaluate the risk factors and prognosis of surgery for spinal metastasis. Methods A retrospective analysis was performed for 63 patients with spinal metastasis who underwent surgical treatment between June 1992 and June 2002. Forty-one patients underwent anterior en-bloc or partial resection, decompression and reconstruction with internal fixation of the spine. Laminectomy and decompression with internal fixation were done in 8 patients. One-stage anterior-posterior en-bloc resection and decompression followed by reconstructive stabilization were conducted in 14 patients. Results After foiiow-up for more than 6 months, postoperative radiological evaluation revealed that spinal stabilization was evident in all patients. Fiftyseven (91.9%) patients benefited with quality of life significantly improved through pain alleviation, and 41 (66.1% ) patients improved in their neurological status. No serious complications were observed in surgery. The mean survival time after surgery was 6 months in patients with lung and liver carcinoma, 15 months with breast, prostate, and stomach carcinoma as-well as the other miscellaneous malignancies, and 28 months with thyroid and kidney carcinoma. Differences were significant among the 3 groups (P< 0.01). Conclusion Surgical treatment for spinal metastasis is able to relieve neurological symptoms and improve the quality of life. The survival time is related to the site of the primary tumor; shorter survival in lung and liver carcinoma, longer in breast, prostate, stomach carcinoma and longest in thyroid and kidney carcinoma.     

Surgery for primary CNS lymphoma? Challenging a paradigm

The standard of care for primary central nervous system lymphoma (PCNSL) is systemic chemotherapy with or without whole brain radiotherapy or intrathecal chemotherapy. In contrast to treatment for other brain tumors, efforts at resection are discouraged. This is a secondary analysis of the German PCNSL Study Group–1 trial, a large randomized phase III study comprising 526 patients with PCNSL. Progression-free survival (hazard ratio [HR]: 1.39; 95% confidence interval [CI]: 1.10–1.74; P = .005) and overall survival (HR: 1.33; 95% CI: 1.04–1.70; P = .024) were significantly shorter in biopsied patients compared with patients with subtotal or gross total resections. This difference in outcome was not due to age or Karnofsky performance status (KPS). When controlled for the number of lesions, the HR of biopsy versus subtotal or gross total resection remained unchanged for progression-free survival (HR = 1.37; P = .009) but was smaller for overall survival (HR = 1.27; P = .085). This analysis of the largest PCNSL trial ever performed challenges the traditional view that the extent of resection has no prognostic impact on this disease. Therefore, we propose to reconsider the statement that efforts at resection should be discouraged, at least if resection seems safe, as is often the case in treatment of single PCNSL lesions.     

When should Surgery be used for Recurrent Ovarian Carcinoma?

Cytoreductive surgery is an important column in the treatment of primary ovarian cancer. Surgical outcome is one of the most important prognostic factors and one of the few prognostic variables that can be influenced by therapists. Retrospective studies suggested that only complete cytoreduction was associated with a benefit. Therefore, definition of predictors of complete resection is of the utmost importance to avoid surgical burden in patients with both limited benefit of the procedure and limited overall life expectancy. Two prospective multicentre randomised surgical trials in platinum-sensitive recurrent ovarian cancer (DESKTOP III [NCT #01166737] and GOG 213 [NSC #704865]) comparing secondary cytoreductive surgery followed by platinum-based chemotherapy versus chemotherapy alone have been conducted. The results of the DESKTOP III were recently presented at the American Society of Clinical Oncology meeting in Chicago. It showed a benefit of secondary cytoreductive surgery exclusively in patients with complete resection with a progression-free survival of 5.6 months (P < 0.001). This overview aims to support this task and concentrates on the currently available data regarding surgery in recurrent ovarian cancer.     

Ahila’s Diathermy Round Knife for Endoscopic Ear Surgery

As endoscopic ear surgery is evolving day by day there is a constant need for improvisation in terms of instrumentation, visualization and clear bloodless surgical field. The applications of Ahila’s Diathermy Round Knife for Endoscopic Ear Surgery are presented. The development of Ahila’s diathermy round knife will prevent shifting to two handed ear surgery or the need for Endo holders. This new instrument is a game changer in endoscopic ear surgery creating a clean incision and bloodless field to operate. Surgical Instruments represent a major financial asset to the healthcare facility. Careful attention to care, handling and sterilization is essential to avoid costly replacements, enhance patient and surgeon satisfaction, reduce costs and delays in the Operating room and enhance patient safety. Ahila’s round diathermy knife may facilitate the performance of surgery and advance the art of Endoscopic surgery to a higher level.     

Surgery in small-cell lung carcinoma. Where is the rationale?

Chemotherapy and radiotherapy are the keys of current management of SCLC. For many years, the diagnosis of small cell lung cancer has been considered a contraindication to surgery because radiotherapy was at least equivalent in terms of local control and the rate of resectability of SCLC patients was poor. The role of surgery has been defined by evidence accumulated in the last 30 years but conclusions are limited by the fact that the most important studies are dated and conducted when the main staging tool was exploratory thoracotomy. The rationale for surgery in the context of SCLC is based on 3 factors: 1) Several historical series on patients operated for limited SCLC reported some long term survivors, showing that permanent cure can be achieved. For this reason, it is now accepted that for the rare patients with very limited stage disease (T1-T2 tumors) surgical resection followed by platinum-based chemotherapy could be offered. 2) After chemotherapy and radiotherapy, the rate of local relapse is 20-30%. The assumption that surgery might be superior to radiotherapy in local control of limited SCLC has been suggested but not still proved. 3) Surgery can precisely assess pathological response to chemotherapy, identify carcinoids erroneously diagnosed as SCLC, treat the NSCLC component of tumors with a mixed histology. In the case of planned surgery, preoperative investigations should be completed by MRI of the brain, mediastinoscopy (to rule out subclinical N2/N3 patients) and probably PET scan. Even if some controversies exist, it is accepted that surgery can be proposed as the first treatment in patents with T1-T2 lesions without sign of lymph nodes involvement, followed by adjuvant chemotherapy. Surgery in stage II and III must be planned on a multidisciplinary basis, in the context of controlled clinical trials.     

Does Endoscopic Surgery Reduce Recurrence of the Petrous Apex Cholesteatoma?

The aim of this study is to present the clinical symptoms, complications and treatments of the petrous apex cholesteatoma and is to describe the current role of oto-endoscopy. This was a retrospective non-randomized study of 14 petrous apex cholesteatoma surgeries performed between 1994 and 2012. Petrosectomy was performed according to the location of the cholesteatoma, hearing level of the patients and facial nerve function. Oto-endoscopy was used in the petrous apex and the cerebellopontine angle for residual cholesteatoma. 14 patients, seven were men and seven women were included in this study between 1994–2012. The most common symptom was hearing loss (85.7 %) and tinnitus (50 %) at the presentation. During the surgeries, it was observed that cholesteatoma involved most frequently facial nerve, dura and labyrinthines. Labyrinthectomy, middle cranial fossa approach and petromastoidectomy was performed to these patients. Four of six patients operated without the endoscope assistance between 1994–2006 had recurrences after the operation. These patients were re-operated and in the follow up, there was no recurrence. In the endoscopy assisted surgery, there was no recurrence observed (significance level p = 0.014). The most common complication after the surgery was hearing loss (42.8 %) but it was not significant after surgery (p > 0.05). The petrous apex and mastoid cavity was obliterated with fat tissue in eight patients while six patients were exteriorized to follow the recurrence and it was insignificant in recurrences (p > 0.05) Conclusion: Endoscope-assisted surgery allows to remove residual the cholesteatoma around the carotid artery, dura and facial nerve in the petrous apex resulting in less invasive surgery and less recurrence in blind spots.     

Cure is Possible with Salvage Surgery following Downstaging of Hepatocellular Carcinoma

Combined modality non-surgical treatment can effectively downstage unresectable hepatocellular carcinoma in some patients to become resectable. Salvage surgery following tumour-downstaging can be curative in these patients.