Morbidity of en bloc resections in the spine

The morbidity of surgical procedures for spine tumors can be expected to be worse than for other conditions. This is particularly true of en bloc resections, the most technically demanding procedures. A retrospective review of prospective data from a large series of en bloc resections may help to identify risk factors, and therefore to reduce the rate of complications and to improve outcome. A retrospective study of 1,035 patients affected by spine tumors—treated from 1990 to 2007 by the same team—identified 134 patients (53.0% males, age 44 ± 18 years) who had undergone en bloc resection for primary tumors (90) and bone metastases (44). All clinical, histological and radiological data were recorded from the beginning of the period in a specifically built database. The study was set up to correlate diagnosis, staging and treatment with the outcome. Oncological and functional results were recorded for all patients at periodic, diagnosis-related controls, until death or the latest follow-up examination (from 0 to 211 months, median 47 months, 25th–75th percentile 22–85 months). Forty-seven on the 134 patients (34.3%) suffered a total of 70 complications (0.86 events per 100 patient-years); 32 patients (68.1%) had one complication, while the rest had 2 or more. There were 41 major and 29 minor complications. Three patients (2.2%) died from complications. Of the 35 patients with a recurrent or contaminated tumor, 16 (45.7%) suffered at least one complication; by contrast, complications arose in 31 (31.3%) of the 99 patients who had had no previous treatment and who underwent the whole of their treatment in the same center (P = 0.125). The risk of major complications was seen to be more than twice as high in contaminated patients than in non-contaminated ones (OR = 2.52, 95%CI 1.01–6.30, P = 0.048). Factors significantly affecting the morbidity are multisegmental resections and operations including double contemporary approaches. A local recurrence was recorded in 21 cases (15.7%). The rate of deep infection was higher in patients who had previously undergone radiation therapy (RT), but the global incidence of complications was lower. Re-operations were mostly due to tumor recurrences, but also to hardware failures, wound dehiscence, hematomas and aortic dissection. En bloc resection is able to improve the prognosis of aggressive benign and low-grade malignant tumors in the spine; however, complications are not rare and possibly fatal. The rate of complication is higher in multisegmental resections and when double combined approach is performed, as it can be expected in more complex procedures. Re-operations display greater morbidity owing to dissection through scar/fibrosis from previous operations and possibly from RT. The treatment of recurrent cases and planned transgression to reduce surgical aggressiveness are associated with a higher rate of local recurrence, which can be considered the most severe complication. In terms of survival and quality of life, late results are worse in recurrent cases than in complicated cases. Careful treatment planning and, in the event of uncertainty, referral to a specialty center must be stressed.     

Surgery for primary vertebral tumors: en bloc versus intralesional resection

The decision to select en bloc resection or intralesional resection needs to be tailored to each individual patient and circumstance. Though complete resection with long-term progression-free survival is the goal, it is not always feasible, nor advisable, depending on what the patient's expectations are and what the risk of complications may be. However, in cases with favorable circumstances and consensus agreement between physicians, surgeons, and patients, aggressive en bloc removal of spinal tumors can be extremely valuable and may offer the only chance at cure for otherwise devastating malignancies.     

Risk of lymph node metastases after en bloc cold steel, en bloc laser-, and piecemeal laser surgical resection of auricular VX2 carcinoma

There is some controversy in the literature if lymph vessels are enduring sealed during piecemeal CO₂ laser surgery of squamous cell carcinomas of the head and neck or a propagation of tumor cells into the lymphatics occurs. The aim of the present study was to analyze the incidence of lymph node and distant metastases after different methods of resection of a VX2 carcinoma in an animal model. A solid auricular VX2 carcinoma was induced in 200 rabbits. Seven days later, an en bloc cold steel (group A), en bloc laser surgical resection with CO₂ laser in continuous wave mode with 2 W (group B), or piecemeal laser surgical resection after transection of the tumor with CO₂ laser in continuous wave mode with 2 W (group C) or 20 W (group D) was performed. The animals were killed and the incidence of lymph node and distant metastases was compared between the different groups. Of the rabbits, 21.1 % developed lymph node metastases and 10 % pulmonary metastases. The incidence of lymph node metastases was 17.4 % in group A, 20.4 % in group B, 26 % in group C, and 20 % in group D. These differences were not statistically significant. En bloc cold steel, en bloc laser-, or piecemeal laser surgical resections include similar risk of postoperative metastases. Propagation of tumor cells cannot be excluded with certainty by any of these methods.     

Management of the cavernous sinus in en bloc resections of malignant skull base tumors

BACKGROUND: Cavernous sinus involvement represents the most difficult problem in en bloc resection of malignant skull base tumors. We developed three types of surgical procedures for manipulating the cavernous sinus to achieve en bloc resection of these tumors. METHODS: In a type 1 procedure, the cavernous sinus was dissected epidurally and retracted posteriorly. In a type 2 procedure, the anterolateral portion of the cavernous sinus was excised and the carotid artery preserved. In a type 3 procedure, the entire cavernous sinus including the carotid artery was resected. RESULTS: Of 25 malignant skull base tumors, type 1 procedures were used in 7, type 2 in 5, and type 3 in 3. For these 15 patients, 7 are in good condition without evidence of tumor recurrence, 2 are alive with tumor, 4 died of tumor recurrence, and 2 died of complications. Two-year survival rates were 54% for patients with a type 1 procedure, 100% for type 2, and 33% for type 3. CONCLUSIONS: Using our techniques, we could totally excise tumors impinging on the cavernous sinus. However, the advanced tumors requiring resection of the entire cavernous sinus with the carotid artery are associated with major morbidity and mortality.     

经后路全脊椎整块切除术治疗胸腰椎肿瘤

目的:探讨经后路全脊椎整块切除术(TES)治疗胸腰椎肿瘤的方法及其疗效.方法:2005年1月～2007年7月收治胸腰椎肿瘤患者6例,其中男3例,女3例,年龄20～77岁;Tomita分型,Ⅲ型1例,Ⅳ型3例,Ⅴ型2例;T3 1例,,T8 2例,T9 1例.T11 1例,L1 1例;骨巨细胞瘤1例,椎体单发骨髓瘤1例,转移性腺癌4例;术前脊髓功能Frankel分级B级2例,D级1例,E级3例.均应用改良弧形骨刀行一期后入路全脊椎整块切除术,同时采用钛网植骨/钛网骨水泥前方重建,并联合椎弓根钉内固定系统固定.随访观察手术时间、术中出血量、局部疼痛和脊髓功能的恢复情况,以及肿瘤复发、植骨融合、脊柱稳定性情况.结果:6例患者均顺利完成手术,手术时间200～270min,平均230min;失血量1100～3000ml,平均1400ml.随访6个月～3年,术后近期疗效均较满意,局部疼痛和神经症状均有不同程度改善或缓解.术前VAS评分平均8分,术后平均2分,平均下降6分;术前有脊髓神经功能障碍者中1例由Frankel B级恢复至D级,其余均恢复至E级.1例骨巨细胞瘤于术后15个月局部复发,再次手术;1例胃癌转移瘤患者术后14个月因多器官转移死亡;其余患者至末次随访时存活,植骨融合良好,无钛网移位及脊柱失稳,无断钉、断棒现象,无局部复发.结论:后路全脊椎整块切除术是胸腰椎肿瘤一种有效的手术方法,可改善脊髓神经功能,降低脊柱骨肿瘤局部复发率.     

Laparoscopic versus laparotomic radical en bloc hysterectomy and colorectal resection for endometriosis

Background  

Radical en bloc hysterectomy and colorectal resection (REHCR) is the ultimate and radical surgery for extensive pelvic endometriosis. Our aims were to evaluate feasibility, quality of life, and urinary function after REHCR by laparoscopy compared with laparotomy.     

Midline retroperitoneal versus midline transperitoneal approach for abdominal aortic aneurysm repair

PURPOSE: The purpose of this study was to compare the midline retroperitoneal approach with the midline transperitoneal approach for abdominal aortic aneurysm (AAA) repair with respect to operative details, gastrointestinal complications, and wound complications. METHODS: From January 1990 through January 1998, 128 patients underwent elective aortic reconstruction for infrarenal AAA. Of these, 64 patients (the transperitoneal group) underwent conventional transperitoneal midline aortic exposure, whereas the remaining 64 patients (the retroperitoneal group) underwent retroperitoneal midline exposure of the aneurysm. RESULTS: Preclamp time, that is, the time from skin incision to aortic clamping, was significantly shorter in the transperitoneal group than in the retroperitoneal group (P <.001). However, the midline retroperitoneal approach was associated with decreased incidence of ileus (P <.01), earlier resumption of oral intake (P <.01), and decreased wound pain (P <.01), in comparison with the transperitoneal approach. Furthermore, there was no incidence of wound complications such as abdominal bulge or wound pain in any of the patients in the postoperative period or over the long term. CONCLUSIONS: The midline retroperitoneal approach for AAA was associated with fewer postoperative gastrointestinal and wound complications than the midline transperitoneal approach. Over the long term, there was no wound complication such as abdominal bulge and wound pain in any of the patients.     

Predictors for surgical complications of en bloc resections in the spine: review of 220 cases treated by the same team

Purpose

Identify risk factors, enabling reduction of the rate of complications and improve outcome in en bloc resection surgeries.

Methods

A retrospective study of prospective collected data of 1681 patients affected by spine tumors treated from 1990 to 2015 by the same team.

Results

A total of 220 en bloc resections that were performed on 216 patients during that period. Most of the tumors were primary—165 cases (43 benign and 122 malignant), metastases occurred in 55 cases. Median FU was 45 months (0–371). 153 complications were observed in 100 patients (46.2 %). 64 (30 %) suffered one complication, while the rest had two or more. There were 105 major and 48 minor complications. Seven patients (4.6 %) died as a result of complications. The combined approach, neoadjuvant chemotherapy and neoadjuvant radiotherapy were statistically significant independent risk factors for complications occurrence. 33 patients (15.2 %) suffered from local recurrence. Reoperations were mostly due to tumor recurrences, but also to hardware failures, wound dehiscence, hematomas and aortic dissection.

Conclusion

The rate of complication is higher in multisegmental resections and when double combined approach is performed. Reoperations display greater morbidity owing to dissection through scar/fibrosis from previous operations and possibly from RT. Careful treatment planning and, in the event of uncertainty, referral to a specialty center must be stressed. The high risk of complications should not discourage surgeons from performing en bloc resection when needed. Most of the patients who sustain complications benefit from the better local control resulting from en bloc resection.

     

后路单椎体全脊椎整块切除术的麻醉处理

目的总结后路单椎体全脊椎整块切除术的麻醉处理经验。方法对2009年1月～2010年12月所做的15例全脊椎整块切除术的麻醉处理进行分析。结果术中3例患者术中发生较大量出血和严重的低血压;1例发生明显输异体血反应。全部患者术后均苏醒迅速、完全,拔管后安返病房。术后苏醒期有1例患者出现烦躁不能耐受导尿管;1例患者术后48 h内疼痛视觉模拟量表（visual analogue scale,VAS）评分3分,其余均在1～2分。术后输血量≤2单位浓缩红细胞。结论单椎体全脊椎整块切除术的麻醉要特别注意术中出血的管理,维持循环与呼吸的稳定。同时要做好术后镇痛的管理,良好的镇痛是减少术后发生并发症的有力措施。     

一期经前后路全脊椎整块切除术治疗腰椎肿瘤

目的 探讨一期前后路全脊椎整块切除术(TES)治疗腰椎肿瘤的可行性,为临床治疗腰椎肿瘤提供更可靠有效的手术方式.方法 2003年4月至2007年8月,行一期前后路TES治疗2l例腰椎肿瘤患者.其中男性14例,女性7例;年龄28～69岁,平均47.6岁.腰椎原发性肿瘤13例,转移瘤8例(术前已切除原发病灶或同期切除病灶).病灶均为单节段,位于L_1 3例、L_2 3例、L_3 8例、L_4 5例、L_5 2例;按Enneking分期:原发良性肿瘤S3期8例,其中6例伴病理骨折;原发恶性肿瘤I A期3例,Ⅱ期2例;8例转移性肿瘤按Tokuhashi预后评分系统均小于8分,且预计生存时间大于半年以上.按Tomita外科分型,2型3例,3型7例,4型5例,5型5例,6型1例.按Frankel分级:B级1例,c级4例,D级9例,E级7例.18例患者术后按病理类型给予相应的综合治疗.治疗前后资料采用X~2检验进行统计学分析.结果 平均手术时间250 min,术中平均失血量2100 ml.术后随访1.0-5.5年,平均2.7年.所有病例术后疼痛消失或减轻,其中14例疼痛完全消失,7例疼痛明显缓解.除2例转移性肿瘤术后12个月内死亡未行神经功能Frankel分级评估外,19例患者术后1年脊髓神经功能有明显的改善,其中C级1例,D级2例,E级16例;与术前比较差异有统计学意义(x~2=10.950,P<0.01);原发腰椎肿瘤患者中,1例骨巨细胞瘤术后12个月肿瘤局部复发,行局部病灶清理手术,1例骨肉瘤和1例骨巨细胞瘤患者分别与术后13个月和18个月死于肺转移;转移性腰椎肿瘤患者中1例前列腺癌、1例肺癌的患者分别于术后7至12个月由于多器官转移死亡,1例肾癌转移患者局部肿瘤复发放弃治疗.其余的患者均存活至今,未发现局部复发和其他部位转移灶.结论 一期经前后联合人路TES治疗腰椎肿瘤是安全可行的.在严格把握手术适应证条件下,可获得较好的治疗效果.     

后路单椎体全脊椎整块切除术的麻醉处理

【摘要】 目的 总结后路单椎体全脊椎整块切除术的麻醉处理经验。 方法 对2009年1月~2010年12月所做的15例全脊椎整块切除术的麻醉处理进行分析。 结果 术中3例患者术中发生较大量出血和严重的低血压;1例发生明显输异体血反应。全部患者术后均苏醒迅速、完全,拔管后安返病房。术后苏醒期有1例患者出现烦躁不能耐受导尿管;1例患者术后48 h内疼痛视觉模拟量表（visual analogue scale, VAS）评分3分,其余均在1~2分。术后输血量≤2单位浓缩红细胞。 结论 单椎体全脊椎整块切除术的麻醉要特别注意术中出血的管理,维持循环与呼吸的稳定。同时要做好术后镇痛的管理,良好的镇痛是减少术后发生并发症的有力措施。     

改良全脊椎切除技术后路一期切除胸椎肿瘤

目的 探讨改良全脊椎切除技术经后路一期切除胸椎肿瘤的可操作性和安全性.方法 自主研制了系列经后路一期全椎体切除手术器械,包括:新型线锯切割器、椎间盘开口器、线锯导引钳和挡板拉钩,将Tomita提出的由前向后全脊椎切除"一步切割法"改良为由内向外"两步切割法",即:先利用椎间盘开口器由脊柱后方、经硬膜和椎体间隙斜行由椎间盘水平向前方穿刺,穿刺至挡板拉钩后.抽出穿刺针,将自制线锯由椎间盘开口器套简内穿过,利用线锯导引钳将线锯由同侧导出,由内向外完成对一侧椎间盘的切割,同样完成邻位椎间盘的切割,上该侧脊柱固定棒,同法完成对侧两个椎间盘的切割.利用该改良全椎体切除技术对5例胸椎肿瘤进行了经后路一期全椎体切除的临床应用研究.5例患者分别为:骨母细胞瘤1例,骨巨细胞瘤2例,恶性血管瘤1例,前列腺癌骨转移1例.结果 5例患者术后神经症状无加重,3例有明显改善,平均手术时间7.6h,平均术中出血量1750ml,无硬膜破裂和脑脊液漏发生.术后平均随访18.2(10～35)个月,截止到随访结束均无复发.结论 应用改良全脊椎切除技术经后路一期切除胸椎肿瘤在技术上是可行的,其可操作性和安全性较传统的Tomita全椎体切除术有明显提高.     

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.     

Modified total en bloc spondylectomy for thoracolumbar spinal tumors via a single posterior approach

Purpose

The objectives of this study were to describe our surgical management with a modified total en bloc spondylectomy (TES) and to evaluate the clinical effects in patients with thoracolumbar tumors.

Methods

Sixteen consecutive patients with thoracolumbar neoplasms underwent a modified TES via single posterior approach followed by dorsoventral reconstruction from December 2008 to July 2011. Details of the modified technique were described and the patients’ clinical information was retrospectively reviewed and analyzed.

Results

Significant improvements in neurological function were achieved in most of the patients. Local pain or radicular leg pain was relieved postoperatively. The mean operation time was 7.2 h, with an average blood loss of 2,300 ml. No major complications, instrumentation failure or local recurrence was found at the final follow-up. Five patients died of the disease during mean 14-month (3.0–23) follow-up.

Conclusions

The modified TES with a single posterior approach is feasible, safe and effective for thoracolumbar spine tumors.     

Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic body cancer: long-term results

OBJECTIVE: To analyze the long-term results of distal pancreatectomy with en bloc celiac axis resection (DP-CAR), a newly designed extended surgical procedure for locally advanced cancer of the pancreatic body. SUMMARY BACKGROUND DATA: Pancreatic body cancer often involves the common hepatic artery and/or the celiac axis and is regarded as an unresectable disease. We previously reported the feasibility and safety of DP-CAR in 10 patients and 3 preliminary cases; however, the long-term results are unknown. METHODS: Between May 1998 and September 2005, 23 patients underwent DP-CAR. No reconstruction of the arterial system was required because of early development of the collateral arterial pathways via the pancreatoduodenal arcades from the superior mesenteric artery. We routinely used preoperative coil embolization of the common hepatic artery to enlarge the collateral pathways. RESULTS: The postoperative mortality rate was 0%, despite a high morbidity rate (48%). The chief postoperative complications were pancreatic fistula and ischemic gastropathy. Contrary to expectations, postoperative diarrhea was mild. Preoperative intractable abdominal and/or back pain in 10 patients was completely alleviated immediately after surgery. The surgical margins were histologically negative in 21 patients (91%). The estimated overall 1- and 5-year survival rates were 71% and 42%, respectively, and the median survival was 21.0 months. The sites of recurrence were the liver in 6 patients and local recurrence in 2. CONCLUSIONS: DP-CAR offers a high R0 resectability rate and may potentially achieve complete local control in selected patients. The persisting early hepatic recurrence may indicate DP-CAR for the treatment of less advanced disease.