Simple intraoperative technique for minor dural gap repair using fibrin glue and oxidized cellulose

INTRODUCTION: Several methods have been proposed to achieve a watertight dural closure, including the use of fibrin sealant to reinforce sutures. We propose a fast technique using oxidized cellulose and fibrin glue to achieve firm and watertight closure of minor dural defects in supratentorial cranial surgery. TECHNICAL NOTE: Oxidized cellulose is cut to the shape of the dural defect and applied as an onlay graft. Fibrin sealant is then applied over the cellulose and the dural margins defect. The web conformation of oxidized cellulose avoids adhesion of fibrin glue to the underlying cortical surface of the brain. This technique has been applied in 45 of 467 supratentorial craniotomies during two consecutive years. The procedure was performed in few seconds. Postoperatively, three patients developed subgaleal fluid collection, which resolved conservatively in two cases. There were no other complications or reoperations. CONCLUSION: We used a piece of oxidized cellulose, reinforced by fibrin glue, as a sutureless graft with more ease and less technical demand than other techniques. The reported technique is a fast and valid alternative to small dural defect closure methods.     

President’s Address

For imaging of the female pelvis, transvaginal ultrasound is the method of choice. Magnetic resonance imaging and CT provide important additional information in various disorders. Magnetic resonance imaging is superior to CT in diagnosing benign and malignant disorders of the uterus. The same holds for the characterization of adnexal masses, where MR imaging reliably differentiates dermoids, ovarian fibromas, and most endometriomas. Differentiation of other benign and malignant ovarian tumors by CT and MR imaging is based on identical morphological criteria; no superiority of MR imaging over CT has been established. Computed tomography is still the preferred imaging modality for staging ovarian cancer. A thorough knowledge of the pathomorphological changes associated with the different disorders of the female pelvis not only helps to choose the proper imaging modality and examination protocol, but also improves image interpretation.     

Determinants of surgical morbidity in gastric cancer treatment

BACKGROUND: The occurrence of early surgical complications after gastrectomy as a treatment for gastric cancer has been reported to have a negative impact on longterm survival. The aim of this study was to identify treatment-related factors that can predict morbidity and mortality in patients undergoing operations for gastric cancer. STUDY DESIGN: The charts of 388 patients who underwent different operations for gastric cancer at A Gemelli General Hospital, Catholic University of Rome, Italy, between January 1992 and April 2007, were reviewed. Patients were grouped according to the type of surgical treatment performed. The study end points were postoperative morbidity, mortality, and the length of hospital stay after surgery. RESULTS: Overall morbidity and mortality rates were 16.2% (63 patients) and 2.3% (9 patients), respectively. Overall morbidity rates were higher in patients more than 64 years of age, when a gastric tumor was resected along with the spleen, and when an extended lymphadenectomy was performed. Patients older than 64 years had longer postoperative hospital stays, and Roux-en-Y gastrojejunostomy was predictive of a shorter stay. Mortality was not influenced by any surgically related factors. CONCLUSIONS: Age, splenectomy, and extended lymphadenectomy were independently associated with the development of complications after gastric cancer operations. After subtotal gastrectomy, Roux-en-Y gastrojejunostomy was associated with a shorter postoperative length of stay than conventional Billroth I and Billroth II reconstructions.     

Bile leak after hepatectomy: predictive factors of spontaneous healing

BACKGROUND: Bile leakage after hepatectomy usually has spontaneous healing, but some patients require interventional procedures. To identify early predictive factors of conservative management failure. METHODS: This study focused on patients with bile leak after hepatectomy without extrahepatic biliary resection from 1996 through 2006. RESULTS: Bile leakage occurred in 34 of 593 patients (5.7%). Conservative management was successful in 26 patients (76.5%). At univariate analysis overall associated resections, vascular associated resections, and drainage output on days 1, 3, and 10 from leak onset were significant negative predictors of spontaneous healing. At multivariate analysis drainage output greater than 100 mL on day 10 was the only independent prognostic factor of conservative management failure (relative risk, 55.985; P = .008) with 80% sensitivity, 93.3% specificity, and 90% accuracy. CONCLUSIONS: Wait-and-see treatment is successful in most cases. Patients with drainage output greater than 100 mL 10 days after bile leakage diagnosis should be scheduled for interventional treatments.     

Pregnant woman presenting with a gross retroperitoneal mass: surgical treatment with caval replacement

A 40-year-old woman in the twenty-fifth week of pregnancy presented with a gross retroperitoneal mass. At the end of the pregnancy, the patient was submitted to surgery, and the gross infiltration of the inferior vena cava wall required the resection of the vena cava with its prosthetic substitution. The histopathological examination demonstrated the presence of a leiomyosarcoma of the inferior vena cava. An electronic video supplement showing the most important intraoperative passages is available online at doi:10.1016/j.eururo.2008.06.074.     

Le Fort I osteotomy and the use of bilateral bichat bulla adipose flap: an effective new technique for reconstructing oronasal communications due to cocaine abuse

The aim of the study was to describe a new and effective method for reconstructing small- and medium-sized oronasal communications in cases of deficient blood supply of oronasal mucosa.A male patient, aged 45, was presented with a hard palate defect due to chronic cocaine inhalation. The defect was corrected using bilateral Bichat bulla adipose flap and a Le Fort I osteotomy. The surgical technique was described, together with its advantages.Surgery lasted 2 hours. The reconstructive technique had been easy to execute. Six months after the surgery, the defect has been corrected without complications.Le Fort I osteotomy and the use of a bilateral Bichat bulla adipose flap is an effective technique to correct small- and medium-sized palatal defects not solvable with simple oral mucosa flaps. The technique is easy to execute and it showed a high efficacy with minimal impact on the patient's esthetic appearance.     

Recurrent chyloperitoneum—a rare complication of peritoneal dialysis

We report the spontaneous development of recurrent chyloperitoneum as a complication of peritoneal dialysis in a toddler. An 18-month-old boy with end-stage renal disease (ESRD) on continuous cycling peritoneal dialysis developed spontaneous chyloperitoneum. He was treated conservatively, with a low-fat diet supplemented with medium-chain triglycerides. The chyloperitoneum resolved within 2 days of his being on the low-fat diet, but it recurred after re-institution of regular feeds on four occasions. After 3 months, the chyle leak finally resolved after an extended period of low-fat feeds. Chyloperitoneum is a rare complication of peritoneal dialysis that can be confused with signs of peritonitis, and it is important to differentiate between the two so that appropriate management can be undertaken. This paper discusses the possible causes, management and complications of recurrent chyloperitoneum.     

Benign osteoblastoma of the odontoid process of the axis with secondary aneurysmal bone cyst component: a case report

The authors report their experience on one patient with osteoblatoma of the odontoid process of the axis with secondary aneurysmal bone cyst. According to their knowledge, this is the first case, reported in the literature, of this kind of lesion in that particular anatomical region. Because of the rarity of this lesion, it was difficult to have a certain preoperative diagnosis. Therefore, the patient underwent a biopsy via a transoral route. The biopsy was performed over the noncalcified component of the lesion. The intraoperative histological examination showed the benign nature of the lesion. Thereafter, the lesion was totally removed, succeeding in preserving the remaining part of the odontoid process and the anterior arch of C1. In the follow-up, there was no evidence of cranio-vertebral instability. The histological examination revealed an osteoblastoma of the odontoid process of the axis with a secondary aneurysmal bone cyst. To the best of our knowledge, this is the first case reported in the literature.     

Preformed acrylic bone cement spacer loaded with antibiotics: Use of two-stage procedure in 10 patients because of infected hips after total replacement

In 10 patients having deep infection after total hip replacement, we used a two-stage revision procedure involving implantation of a preformed spacer with a cylindrical rod coated with acrylic cement containing antibiotics (Spacer-G). This device, which remained in situ for an average of 5 months, permitted healing of the infection in 8 cases and reimplantation of a new prosthesis (mean follow-up 35 months). During treatment, 1 dislocation occurred. The spacer maintained the gap between both bone segments and allowed a certain degree of joint mobility. Use of Spacer-G improved the quality of life of the patients during treatment and accelerated recovery of function after reimplantation.     

Hybrid repair of an aortic arch aneurysm with complex anatomy: right aortic arch and anomalous origin of supra-aortic vessels

We performed a one-stage hybrid surgical and endovascular procedure to manage a 6.5-cm right aortic arch aneurysm associated with anomalous origin of the supra-aortic vessels in a 70-year-old man. Complete surgical rerouting of the supra-aortic vessels was followed by the endovascular repair of the right aortic arch aneurysm with a Zenith TX2 stent graft (Cook, Bloomington, Ind) and Z-track plus introducer system. The procedure was successfully completed with exclusion of the aortic arch aneurysm, and the patient was discharged on postoperative day 7. Aortic arch aneurysms with complex anatomy may be successfully treated with a less invasive hybrid approach using new generation devices.