The supraorbital craniotomy for access to the skull base and intraaxial lesions: a technique in evolution

INTRODUCTION

The supraorbital craniotomy was initially described as a minimally invasive means to target extra-axial lesions in the anterior cranial fossa and sellar/parasellar region. Since its initial description, various modifications have been described. We report our recent experience with this approach (and its modifications) for not only extra-axial but also intra-axial neoplastic pathology.

METHODS

Based on patient pathology and anatomic considerations, one of two approaches was performed: supraorbital craniotomy through an eyebrow incision or a combined orbital osteotomy and supraorbital craniotomy through an eyelid incision.

RESULTS

This technique was performed on twenty-eight consecutive patients. Intra-axial pathology ranged from anaplastic astrocytoma to metastasis while extra-axial lesions included meningiomas and skull-based metastases. Excellent lesion resection was achieved in the majority of patients. Complications were infection (2 patients) and CSF leak.

DISCUSSION

The supraorbital craniotomy and its modifications provide an ideal anterior subfrontal approach through which a wide variety of pathology can be approached. This technique has particular considerations in comparison to traditional cranial base approaches that must be taken into account before it is utilized.

Prognostic factors in synovial sarcoma

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Background: Synovial sarcoma (SS) is a relatively rare type of soft tissue sarcoma. Several prognostic factors have been described that modulate patients’ outcome. The aim of this study was to identify prognostic factors in patients with SS. Methods: A retrospective analysis was performed on clinical and histopathological data of patients treated at National Oncology Institute (Panama) between 1995 - 2007. Demographic, clinical, pathological, and therapeutic variables were reviewed. Overall survival and recurrence-free survival were analyzed using Kaplan-Meier and log-rank tests. Results: Twenty seven patients were analyzed, 56% male and 44% female, median age was 28. Tumour site; extremities based 85%, truncal 15%. Median tumour size was 8cm. Presentation; non-metastatic 84%, metastatic 16%. Histological type; monophasic 78%, biphasic 22%. Mitosis/10HPF; twenty and more 33%, less than twenty 67%. Necrosis; absent 63%, less than half 30%, and more than half 7%. Histological grade (FNCLLC); grade 2 48%, grade 3 52%. Surgery; limb sparing surgery 52%, amputation 48%. Treatment: adjuvant treatment 52% (3 chemotherapy only, 7 radiation therapy, 4 both). 90% were doxorubicin based regimens. The median follow up was 25 months. 63% of tumours recurred and 33% of patients died. Univariate analysis revealed a significant positive relationship between histological grade and overall survival (p<0.05). In patients with localized disease, time to recurrence decreased with histological grade (p=0.05 ns). Conclusions: High histological grade is an adverse prognostic factor for overall survival in patients with SS.

No significant financial relationships to disclose.

A real-time multi-channel monitoring system for stem cell culture process

A novel, up to 128 channels, multi-parametric physiological measurement system suitable for monitoring hematopoietic stem cell culture processes and cell cultures in general is presented in this paper. The system aims to measure in real-time the most important physical and chemical culture parameters of hematopoietic stem cells, including physicochemical parameters, nutrients, and metabolites, in a long-term culture process. The overarching scope of this research effort is to control and optimize the whole bioprocess by means of the acquisition of real-time quantitative physiological information from the culture. The system is designed in a modular manner. Each hardware module can operate as an independent gain programmable, level shift adjustable, 16 channel data acquisition system specific to a sensor type. Up to eight such data acquisition modules can be combined and connected to the host PC to realize the whole system hardware. The control of data acquisition and the subsequent management of data is performed by the system's software which is coded in LabVIEW. Preliminary experimental results presented here show that the system not only has the ability to interface to various types of sensors allowing the monitoring of different types of culture parameters. Moreover, it can capture dynamic variations of culture parameters by means of real-time multi-channel measurements thus providing additional information on both temporal and spatial profiles of these parameters within a bioreactor. The system is by no means constrained in the hematopoietic stem cell culture field only. It is suitable for cell growth monitoring applications in general.

Awareness of investigations and treatment of faecal incontinence among the general practitioners: a postal questionnaire survey

OBJECTIVE

Faecal incontinence is a distressing condition that can result in significant embarrassment and limitation of routine activities. General practitioners (GP) are the primary carers of such patients. There are recent developments in the surgical treatment options for this under-reported condition. Awareness of these changes is required to make the best use of them. To the best knowledge of the authors, no studies have examined the awareness of investigations and treatment options for faecal incontinence amongst GPs. This is the focus of our study.

METHOD

A confidential questionnaire was posted to GPs in the Yorkshire region. The questionnaire was designed to assess: first, the basic knowledge of GPs with regard to prevalence, investigations and treatment modalities of faecal incontinence and secondly, the patterns of consultations and referrals of patients with faecal incontinence.

RESULTS

One thousand and one hundred questionnaires were posted. Five hundred and four were returned giving a response rate of 48.5% (n = 504). The prevalence assessed by the GPs is similar to that by population based surveys. Only 32% (n = 162) of GPs were aware of at least one investigation. Similarly only 32% of the GP's were aware of at least one form of surgical treatment. The knowledge of UK centres where these facilities are available was limited (60% not aware). Only one quarter of the GPs referred the patients to the surgical specialties. Surprisingly, there was no significant difference in the level of knowledge of investigation and treatments between the GPs who see patients with faecal incontinence more frequently compared with those who see such patients infrequently (P-values 0.298 and 0.432 respectively).

CONCLUSION

The level of awareness of investigation modalities and treatment options for faecal incontinence is limited among GPs. Knowledge of the existence of diagnostic tests and surgical treatment options for faecal incontinence and the centres with these facilities is needed for the best utilization of the technical resources and expertise. Further studies are needed to assess the impact of this lack of knowledge on the quality of patient care. Better communication between referral centres and GPs, combined with continuing medical education programmes, may be useful tools to improve appropriate patient management.

A classification system for faecal incontinence based on anorectal investigations

Background

Faecal incontinence is a socially disabling condition that affects a heterogeneous population of patients. There is no standardization of investigations, and treatment outcomes are variable. The major limitation for comparing the results from different studies is the lack of a pretreatment classification of incontinence. The aim of this study was to review the anorectal investigation findings and propose a simple, repeatable classification for faecal incontinence.

Methods

Patients who had anorectal investigations for defaecatory disorders from February 2000 to September 2006 were analysed retrospectively. All patients had anorectal manometry, anal mucosal electrosensitivity testing and endoanal ultrasonography.

Results

Of a total of 1294 patients, 135 were excluded, leaving 1159 (460 continent and 699 incontinent) for analysis. The patients were divided into four groups: traumatic incontinence, neuropathic faecal incontinence, combined faecal incontinence and idiopathic faecal incontinence. The manometric variables and demographics were distinct in these groups.

Conclusion

Patients with faecal incontinence can be classified into different groups with distinct pathophysiological variables. Such a classification system will enable comparison and interpretation of the outcomes of different studies and also help in the selection of patients for appropriate treatments.

Surgical management of pelvic organ prolapse in females: functional outcome of mesh sacrocolpopexy and rectopexy as a combined procedure

PURPOSE

Urogenital prolapse is relatively common compared with rectal prolapse and the combination of urogenital prolapse and rectal prolapse is still more infrequent. This study was designed to evaluate the functional outcome of a series of patients who have undergone open mesh sacrocolporectopexy surgery for combined vaginal and rectal prolapse.

METHODS

Consecutive patients from June 2000 to June 2004 with confirmed vaginal and rectal prolapse subsequently underwent open mesh sacrocolporectopexy. The Cleveland Clinic Short Form-20 Pelvic Floor Distress Inventory questionnaire with Urinary Distress Inventory, Pelvic Organ Prolapse Distress Inventory, and Colorectal-Anal Distress Inventory subscales was completed by all patients preoperatively and at six months postoperatively.

RESULTS

There were 29 patients with a median age of 66 (interquartile range, 59-73) years. Median period of follow-up was 26 (interquartile range, 15-33) months. Median global pelvic floor distress inventory scores were lower postoperatively compared with preoperatively (96.4 (interquartile range, 50.8-149.7) vs. 182.3 (interquartile range, 140.6-208.6; P = 0.001). All three median subscales scores also were significantly lower postoperatively compared with preoperatively.

CONCLUSIONS

In patients with concurrent vaginal and rectal prolapse, open mesh sacrocolporectopexy confers good symptomatic improvement for urinary-, vaginal-, and rectal-related symptoms.

The comparison of accuracy between PET and PET/CT for detecting lymph node metastasis in cervical cancer: Prospective surgicopathologic study

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Background: Previosly, we reported the accuracy of positron emission tomography with 2-[fluorine18] fluoro-2-deoxy-D- glucose (FDG-PET) for detecting metastatic lymph node (LN) in cervical cancer (Eur J Cancer 2005: 41; 2086–92). The aim of this prospective study was to evaluate the accuracy of PET/CT for detecting lymph node metastasis in cervical cancer and to compare the accuracy between PET and PET/CT. Methods: From May 2002 to Jul 2006, 86 patients with untreated stage IB-IVA cervical cancer were enrolled. All patients underwent pretreatment clinical staging including PET (May 2002-Aug 2003, 54 patients) or PET/CT (Jan 2004-Jul 2006, 32 patients) followed by surgical staging including systematic pelvic and paraaortic lymph node (PLN and PALN) dissection. To enable region specific comparisons, PALN and PLN were divided into eight regions: both PALN, both common iliac areas, both external iliac areas, and both internal iliac/obturator areas. Each lymph node was sliced at 2-mm intervals perpendicular to the greatest dimension to maximize the likelihood of detecting micrometastases. All metastatic tumor size in each involved lymph node was measured. Histopathologic evaluation of lymph nodes was the diagnostic standard. The study protocol was approved by Institutioal Review Board, and a written informed consent was obtained. Results: A total of 688 LN regions were evaluated. The sensitivity, specificity, positive predictive value, and negative predictive value of PET and PET/CT are shown in Table 1 . As the metastatic tumor size increased, the sensitivity of PET and PET/CT was improved. Although there were no differences in sensitivity for detecting large sized (> 5mm or 10mm) metastatic tumor, PET/CT was more sensitive than PET for all pathologically proven LN metastasis which included small sized (< 5mm) metastatic tumor. Conclusions: PET/CT was more sensitive than PET for detecting small sized (<5mm) lymph node metastasis in cervical cancer.

[Table: see text]

No significant financial relationships to disclose.

Maxillary sinus haematoma

The maxillary sinus haematoma is an uncommon cause of a maxillary sinus mass. It presents with a variety of symptoms, the most common being epistaxis. Although histologically benign, it may be clinically progressive. Radiological findings can range from a benign appearance to a more aggressive process, including bony erosion. Surgical evacuation is the mainstay of therapy. We describe our experience in managing this condition and review available literature on the subject.

Dysbiosis and pouchitis

BACKGROUND AND METHODS

The exact aetiology of pouchitis is unknown, but an association with dysbiosis has been suggested. This is a retrospective review of 17 studies published between 1985 and 2005, identified by a search of the Medline, Pubmed and Embase databases.

RESULTS

The methodology of the studies varied widely. Many were performed at a time when the distinction between a healthy and an inflamed pouch was vague; misclassification of patients makes the analysis of data difficult and conclusions uncertain.

CONCLUSION

The evidence that dysbiosis is a cause of pouchitis is poor. Nevertheless, available data allow the construction of an algorithm to aid management and suggest a structured approach for future research.

Whitehead's varnish nasal pack

Whitehead's varnish is a little known but excellent nasal packing agent. We review available literature on the historical aspects and clinical use of Whitehead's varnish. Our personal experience with Whitehead's varnish is described, and we strongly recommend its use.

Patterns of regional head and neck lymph node metastasis in primary conjunctival malignant melanoma

OBJECTIVE

To correlate patterns of regional lymph node metastasis with the site of origin in primary conjunctival malignant melanoma.

DESIGN

Retrospective analysis (1990-2003) of clinical data.

SETTING

Two London tertiary referral centres.

PARTICIPANTS

12 patients presenting with regional metastases after failed local treatment for conjunctival malignant melanoma.

RESULTS

6 cases predominantly involving the temporal conjunctiva metastasised to the pre-auricular lymph nodes. Two cases predominantly involving the nasal conjunctiva metastasised to the submandibular nodes. Of the two cases with purely multifocal disease, one metastasised to the pre-auricular nodes and another to both submandibular and parotid nodes. One primary conjunctival malignant melanoma had its origin in temporal conjunctiva but metastasised to submandibular nodes, and another case originating from nasal conjunctiva metastasised to pre-auricular nodes.

CONCLUSIONS

Temporal conjunctival melanotic lesions tend to metastasise clinically to pre-auricular lymph nodes and nasal conjunctival melanotic lesions metastasise to the submandibular lymph nodes. Patterns appear consistent with laboratory-based anatomically mapped lymphatic drainage basins of the conjunctiva.

Intra-anal collagen injection for the treatment of faecal incontinence

Background

Intra-anal injectable agents have been used to treat faecal incontinence. The aim of this study was to report the experience of a cohort of patients who underwent intra-anal injection of collagen and to determine which patients benefited from the technique.

Methods

Data, including age, sex, incontinence score, classification of incontinence, baseline resting pressure and vector volume, were collected prospectively for 73 consecutive patients (59 women) undergoing intra-anal collagen injection. Patients were reviewed after treatment and incontinence scores documented. A proportion of patients also underwent repeat anorectal physiological testing 8 weeks after the procedure.

Results

At a median follow-up of 12 months after the intra-anal injection, 63 per cent of patients had an improved incontinence score and 73 per cent reported an overall improvement in symptoms. Logistic regression showed that older age and idiopathic faecal incontinence were predictors of a successful outcome (P = 0·042 and P = 0·048 respectively).

Conclusion

Intra-anal collagen injection appears to have a role in the treatment of faecal incontinence. The majority of patients can expect both objective and subjective improvement. The best results are achieved in older patients and in those with idiopathic incontinence.

Botulinum toxin in the management of sialorrhoea: a systematic review

Sialorrhoea can be a significant problem in both adults and children and can cause both physical and psychosocial problems. Botulinum toxin has enjoyed an emergence in the treatment of sialorrhoea, a systematic review of the evidence for botulinum toxin reveals two randomised controlled trials (RCTs) and four other trials that fulfilled our inclusion criteria. Both RCTs demonstrate the effectiveness of botulinum toxin in the management of sialorrhoea. There was no clear evidence for one antigenic type of botulinum toxin over another and minimal evidence for the optimal dose of botulinum toxin for each antigenic type. No advantage is conferred in using ultrasound guidance in injecting the glands. None of the RCTs or other studies directly compared submandibular versus parotid injection or directly compared botulinum toxin against surgery. Minor side effects were reported in one of the RCTs but overall botulinum toxin is a safe, minimally invasive and effective means in the treatment of sialorrhoea with the potential to become the treatment of choice. Our review demonstrates that further randomised controlled trials are required to more fully evaluate this new modality of treatment.

Day case laparoscopic herniorraphy. A NICE procedure with a long learning curve

BACKGROUND

The aim of this study was to evaluate day case laparoscopic herniorraphy (LH) and to ascertain the impact of trainee surgeons on its performance.

METHODS

We performed a prospective study of ambulatory laparoscopic transabdominal preperitoneal herniorraphies performed in a dedicated day surgical unit between March 1996 and October 2003.

RESULTS

A total of 840 herniorraphies were performed in 706 consecutive patients. Surgery was performed by 15 higher surgical trainees and three consultant surgeons. The mean operating times for trainees were longer for unilateral (48.4 +/- 0.98 vs 41.4 +/- 0.87 min, p < 0.05) and bilateral (69.0 +/- 3.24 vs 53.0 +/- 1.68 min, p < 0.05) repairs than for consultants. Subgroup analysis demonstrated that after an experience of 40 procedures, trainee times approached those of the consultants (41.39 +/- 1.17 vs 41.4 +/- 0.87 min, p= 0.31). LH repair was well tolerated and associated with minimal postoperative pain and nausea. Mean pain scores postoperatively and at 24 h were 2.69 +/- 0.11 and 2.07 +/- 0.09, respectively. Mean nausea scores postoperatively and at 24 h were 0.34 +/- 0.06 and 0.22 +/- 0.06, respectively. Ninety-three percent of patients (n = 657) were discharged within 8 h. There were two conversions to an open procedure (0.1%) and two significant complications (0.1%). Ninety-five percent of patients who responded to our questionnaire (n = 398/419) were satisfied with surgery and would undergo day case laparoscopic herniorraphy again.

CONCLUSIONS

Laparoscopic herniorraphy is a safe technique suitable for day case surgery. Operator experience dictates duration of surgery. Trainees' operating times approach those of consultants after 40 procedures. Prolonged operating times and increased cost are not justifiable reasons for not recommending LH.

Posterior thoracic segmental pedicle screw instrumentation: evolving methods of safe and effective placement

The use of pedicle screw instrumentation in the spine has evolved over the last two decades. The initial use of pedicle screws began in the lumbar spine. As surgeons have become more comfortable with the complex anatomy required for accurate screw placement, the use of pedicle instrumentation has evolved to include their use in the thoracolumbar and thoracic spine. The impetus behind their increased use is a result of the many advantages that pedicle screw anchorage offers over traditional hook and rod constructs. Improved deformity correction and overall construct rigidity are two important advantages of pedicle screw instrumentation due its three-column control over the spinal elements. First, pedicle screw instrumentation obviates the need to place instrumentation within the spinal canal with its inherent risk of neurologic injury. Second, the placement of pedicle screws is independent of facet or laminar integrity and thus has been extremely useful in traumatic, neoplastic, and degenerative conditions. The benefits of pedicle screws in the thoracic spine has been tempered by the potential for catastrophic neurological or soft tissue injuries due to the close proximity of these structures. The narrow and inconsistent shape of the thoracic pedicles, especially in spinal deformity, makes their placement technically challenging. As a result, surgeons have employed a number of techniques to ensure the safe and efficacious placement of thoracic pedicle screws. Detailed anatomic landmarks used to determine pedicle location, intraoperative imaging including navigation, and neurophysiological monitoring are some of the techniques currently used by surgeons. The implementation of these techniques and a thorough understanding of the complex three-dimensional anatomy have allowed surgeons to successfully place thoracic and thoracolumbar pedicle screws.