Primary Brainstem Hemorrhage: A Review of Prognostic Factors and Surgical Management

Primary brainstem hemorrhage (PBSH) is the most fatal subtype of intracerebral hemorrhage and is invariably associated with poor prognosis. Several prognostic factors are involved, of which the two most predominant and consistent are the initial level of consciousness and hemorrhage size. Other predictors, such as age, hyperthermia, and hydrocephalus, are generally not dependable indicators for making prognoses. Scoring systems have now been developed that can predict mortality and functional outcomes in patients suffering from PBSH, which can thus guide treatment decision-making. A novel grading scale, entitled “the new primary pontine hemorrhage (PPH) score,” represents the latest approach in scoring systems. In this system, patients with a score of 2–3 points appear to benefit from surgical management, although this claim requires further verification. The four main surgical options for the treatment of PBSH are craniotomy, stereotactic hematoma puncture and drainage, endoscopic hematoma removal, and external ventricular drainage. Nevertheless, the management of PBSH still primarily involves conservative treatment methods and surgery is generally not recommended, according to current practice. However, the ongoing clinical trial, entitled Safety and Efficacy of Surgical Treatment in Severe Primary Pontine Hemorrhage Evacuation (STIPE), should provide additional evidence to support the surgical treatment of PBSH. Therefore, we advocate the update of epidemiological data and re-evaluation of PBSH treatment in a contemporary context.

Art of operative techniques: treatment options in arch penetrating aortic ulcer

Penetrating aortic ulcer (PAU) of the arch has a focal extent which often represents an adequate anatomic target for thoracic endovascular aortic repair (TEVAR). However, the anatomic constraints represented by the supra-aortic vessels pose either clinical or technical challenges that increase when the PAU develops proximally in the arch. Currently, different types of endografts are commercially available and have been used to treat aortic arch lesions. These include branched/fenestrated endografts for a total endovascular approach, and standard devices that can be used in combination with open/hybrid surgical operations, with the aim to exploit the minimally invasive nature of TEVAR by extending the proximal landing zone when necessary. We describe several current techniques adopted in such settings.

Pathological Features and Prognosis of Thymoma With or Without Myasthenia Gravis

INTRODUCTION

To evaluate the different pathological and clinical characters of thymoma with and without myasthenia gravis (MG) and to determine whether the presence of MG influences the prognosis in patients with thymoma.

METHODS

Four hundred and twenty-five consecutive patients operated was analyzed. A median sternotomy was used in 189 cases, and video-assisted thoracoscopic thymectomy was used in 236 cases. These patients with thymoma were subdivided into two groups: thymoma with myasthenia gravis MG (n = 220) and thymoma without MG (n = 205). All thymic epithelial tumors were classified according to the WHO histologic classification and the Masaoka clinical staging system. The result was evaluated according to the Myasthenia Gravis Foundation of America's criterion. The clinical features of the 2 test were compared between the two groups, and the survival analysis of Cox treatment effects was compared between the two groups.

RESULTS

There were no perioperative deaths. The proportions of type A and thymic carcinoma were 0% in the group with MG and 10.7% (22/205) and 11.2% (23/205), respectively, in the group without MG. Thymic hyperplasia around the thymoma was 29.1% (64/220) in patients with MG and only 6.3% (13/205) in patients without MG (χ2 = 23.63, P = 0.000). The overall survival curve showed that the 5- and 10-year survival rates in the group without MG were 89.2 and 77.4%, respectively, while those in the MG group were 91.1 and 80.5%.

CONCLUSIONS

The existence of MG has little influence on the prognosis of thymomas, but it is suitable for early diagnosis and treatment. Extended thymectomy should be performed on all patients with thymoma, whether they have MG or not.

Imaging work-up and endovascular treatment options for aorto-enteric fistula

Aorto-enteric fistula (AEF) is a rare life-threatening condition. Early recognition and diagnosis are of paramount importance to improve outcome. In this article four cases of AEF with relevant pre- and post-procedural images are presented to demonstrate the utility of cross-sectional imaging in the work-up of AEF. The literature is reviewed to describe the typical presentation of AEF, the diagnostic work-up of AEF, and the different methods used to treat AEF. Endovascular repair of AEF is gaining increasing attention due to its decreased short-term mortality compared to open surgical techniques.

Surgical Options for Pediatric Bilateral Vocal Cord Palsy: State of the Art

Management of pediatric bilateral vocal cord palsy (BVCP) is a controversial and challenging topic. It may represent a severe obstructive condition usually associated with respiratory distress, and, in such condition, tracheostomy has been considered the gold standard for a long time. Many surgical options have been described and used to increase the glottic space in BVCP (1), with ongoing research of less invasive techniques. The challenge and current trend in our department and in many major pediatric centers is to avoid tracheotomy through an early treatment. Many techniques introduced in the last decade reduced the number of tracheotomies and increased the decannulation rate. Furthermore, we observed a recent increase in attention to preserve the quality of the voice with new techniques, such as endoscopic arytenoid abduction lateropexy which is in our opinion an important innovation to improve glottic space with satisfactory voice results. We present a review of the literature about the evolution of the treatment options for pediatric BVCP during the years.

The Prognoses of Young Women With Breast Cancer (≤35 years) With Different Surgical Options: A Propensity Score Matching Retrospective Cohort Study

Background

Compared with older patients, young women with breast cancer (YWBCs) have a poorer prognosis and a higher risk of recurrence. Ages ≤35 years are independent risk factors for local recurrence of breast cancer. Surgery is the most important local treatment for YWBC, and there is still a lack of prospective studies comparing surgical options for recurrence and survival. We retrospectively compared the effects of surgical options on disease-free survival (DFS) and overall survival (OS) of YWBC at Fudan University Shanghai Cancer Center (FUSCC).

Methods

YWBCs (age ≤35 years) who underwent surgery at FUSCC between 2008 and 2016 were retrospectively analyzed and divided into three groups according to surgical options: 1) breast-conserving surgery (BCS), 2) mastectomy alone (M), and 3) mastectomy with reconstruction (RECON). The DFS and OS outcome rates from the three surgical options were compared using the Kaplan-Meier method and Cox regression model. Propensity score matching (PSM) was also used to balance the baseline characteristics to eliminate selection bias.

Results

A total of 1,520 YWBCs were enrolled with a median follow-up of 5.1 years, including 524 patients (34.5%) who underwent BCS, 676 patients (44.5%) who underwent M, and 320 patients (21.1%) who underwent RECON. The 5-year DFS rates were 96%, 87%, and 93%, respectively (P < 0.001); the 5-year OS rates were 98%, 94%, and 97%, respectively (P = 0.002). Multivariate Cox analysis showed that DFS and OS were significantly improved in patients undergoing BCS compared with those undergoing M, with hazard ratios (HR) of 0.448 (95% CI 0.276-0.728; P = 0.001) and 0.405 (95% CI 0.206-0.797, P = 0.009), respectively. After PSM, DFS and OS rates were significantly improved in patients undergoing BCS compared to patients undergoing M (DFS, P = 0.001; OS, P = 0.009); RECON was also improved compared to patients undergoing M in terms of DFS and OS, but the difference was not statistically significant (DFS, P = 0.164; OS, P = 0.130).

Conclusions

The surgical options were independent factors affecting DFS and OS in YWBC, and the DFS and OS rates were significantly improved in the BCS group compared to those in the M group. BCS is preferred for early YWBC, and RECON is the best option for remodeling the body images of YWBC who do not have breast-conserving conditions.

Appraisal of clinical profile and management of juvenile nasopharyngeal angiofibroma in malaysia

Juvenile nasopharyngeal angiofibroma (JNA) is a benign but locally invasive tumour. Patients are usually in their adolescent age and present with epistaxis and nasal blockage. Diagnosis is based on clinical evaluation and the C.T. scan findings. Pre-operative superselective embolisation (SSE) and surgical excision is the treatment of choice. The out patient clinic of ORL-HNS hospital of University Science Malaysia received 25 referrals, all male, majority between 9-13 years of age and few adolescents. Clinically the patients were consistent with symptoms of recurrent epistaxis and nasal blockage. They reported from October 1998 to October 2001 from with in the state of Kelantan and the nearby states of Pahang, Kedah and Terenganu. Diagnosis was mostly made on typical radiological findings and the tumours were classified accordingly into four stages. SSE and surgical excision was carried out in all cases. Regular follow-up helped us to identify early recurrences which were treated with salvage surgery or radiotherapy in one case with extensive intracranial extension. A retrospective review of presenting features, diagnostic difficulties, surgical approaches and its outcome is presented. Maxillary swing procedure performed in three cases as a new surgical option in the management of JNA is also discussed.

Risk Stratification of Local Flaps and Skin Grafting in Skin Cancer-Related Facial Reconstruction: A Retrospective Single-Center Study of 607 Patients

Background: Non-melanoma skin cancer (NMSC) takes up a substantial fraction of dermatological and plastic surgical outpatient visits and surgeries. NMSC develops as an accumulated exposure to UV light with the face most frequently diagnosed. Method: This retrospective study investigated the risk of complications in relation to full-thickness skin grafts (FTSG) or local flaps in 607 patients who underwent facial surgery and reconstruction at a high-volume center for facial cancer surgery at a tertiary university hospital. Results: Between 01.12.2017 and 30.11.2020, 304 patients received reconstructive flap surgery and 303 received FTSG following skin cancer removal in the face. Flap reconstruction was predominantly performed in the nasal region (78%, n = 237), whereas FTSG reconstruction was performed in the nasal (41,6%, n = 126), frontal (19.8%, n = 60), and temporal areas (19.8%, n = 60), respectively. Patients undergoing FTSGs had a significantly higher risk of hematoma (p = 0.003), partial necroses (p < 0.001), and total necroses (p < 0.001) compared to flap reconstruction. Age and sex increased the risk of major complications (hematoma, partial or total necrosis, wound dehiscence, or infection) for FTSG, revealing that men exhibited 3.72 times increased risk of major complications compared to women reconstructed with FTSG. A tumor size above 15 mm increased the risk of hematoma and necrosis significantly. In summary, local flaps for facial reconstruction after skin cancer provide lower complication rate compared with FTSGs, especially in elderly and/or male patients. The indication for FTSG should be considered critically if the patient’s tumor size and location allow for both procedures.

Septic Tibial Nonunions on Proximal and Distal Metaphysis-A Systematic Narrative Review

BACKGROUND

Infected nonunion of the tibia represents a challenging complication for orthopedic surgeons and poses a major financial burden to healthcare systems. The situation is even more compounded when the nonunion involves the metaphyseal region of long bones, a rare yet demanding complication due to the poor healing potential of infected cancellous bone; this is in addition to the increased likelihood of contamination of adjacent joints. The purpose of this study was to determine the extent and level of evidence in relation to (1) available treatment options for the management of septic tibial metaphyseal nonunions; (2) success rates and bone healing following treatment application; and (3) functional results after intervention.

METHODS

We searched the MEDLINE, Embase, and CENTRAL databases for prospective and retrospective studies through to 25 January 2021. Human-only studies exploring the efficacy of various treatment options and their results in the setting of septic, quiescent, and metaphyseal (distal or proximal) tibia nonunions in the adult population were included. For infection diagnosis, we accepted definitions provided by the authors of source studies. Of note, clinical heterogeneity rendered data pooling inappropriate.

RESULTS

In terms of the species implicated in septic tibial nonunions, staphylococcus aureus was found to be the most commonly isolated microorganism. Many authors implemented the Ilizarov external fixation device with a mean duration of treatment greater than one year. Exceptional or good bone and functional results were recorded in over 80% of patients, although the literature is scarce and possible losses of the follow-up were not recorded.

CONCLUSION

A demanding orthopedic condition that is scarcely studied is infected metaphyseal tibial nonunion. External fixation seems promising, but further research is needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO No. CRD42020205781.

Endoscopic Endonasal Surgery for Dermoid Cysts Arising From the Middle Cranial Fossa Floor: A Rare Case Series

OBJECTIVE

Dermoid cysts (DCs) are congenital, slowly growing, and may cause nervous system symptoms. Related literature is limited and mainly includes case reports. We report a case series of DCs originating from the middle cranial fossa floor (MCFF) and investigate their demographic information, clinical characteristics, imaging findings, surgical procedures, and prognostic outcomes.

METHODS

We reviewed the patients with DCs arising from the MCFF undergoing endoscopic endonasal surgery (EES) in our center between 2012 and 2022.

RESULTS

A total of 5 patients with DCs were enrolled (2 males and 3 females), with a mean age of 46.2 years at the onset. All DCs originated from the MCFF with 1 case involving the middle cranial fossa bone and another 1 case affecting the dura mater. One (20.0%) patient had neurological involvement. After admission, all patients received EES with a total resection rate of 100.0% (5 of 5). After a median follow-up of 73.2 months, all patients achieved complete clinical and radiological improvements. No surgical-related complications or relapses were observed during the long-term follow-up.

CONCLUSION

Endoscopic endonasal surgery is considered a safe and effective approach for the treatment of DCs in the MCFF. A larger sample size and longer follow-up time are needed.

Total Cystectomy in the Management of Primary Retroperitoneal Echinococcal Cysts: Current Evidence and Future Directions

Echinococcal cysts (ECs) are a significant public health concern globally, particularly in endemic regions. Among these, primary retroperitoneal echinococcal cysts (PRECs) present unique challenges due to their location and complex presentations. Total cystectomy, involving complete removal of the EC and surrounding tissue, is a surgical option for managing PRECs. However, evidence regarding its efficacy and safety is limited. We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to evaluate the role of total cystectomy in managing PRECs. A comprehensive search of databases yielded four relevant studies. These studies reported favorable outcomes following total cystectomy, including low recurrence rates and minimal postoperative complications. However, challenges such as technical complexity and proximity to vital structures were noted. Future research should focus on evaluating minimally invasive approaches, exploring adjuvant therapies, identifying predictors of recurrence, and assessing cost-effectiveness. This systematic review underscores the need for further investigation to optimize the management of PRECs and improve patient outcomes.

Updates on Treatment Modalities for Primary Rhegmatogenous Retinal Detachment Repair

Rhegmatogenous retinal detachment, a severe eye condition, presents anatomic separation of the neurosensory retina from its outermost layer-the retinal pigment epithelium. Early recognition of this relatively common finding and proper referral of patients to the retinal surgery department is essential in order to minimize its consequent possible severe reduction in vision. Several major surgical methods for the repair of primary rhegmatogenous retinal detachment have been in use over the last several decades, and they all aim to find and close the break in the retina that has caused the detachment. Surgery can be performed as pneumatic retinopexy, pars plana vitrectomy, and/or episcleral surgery (buckling). General surgical trends for reattaching the retina include moving from extraocular to intraocular surgery and from bigger gauge to smaller gauge via minimal invasive vitrectomy surgery (MIVS), with implementing shorter-lasting intraocular tamponades. Surgical options for rhegmatogenous retinal detachment treatment nowadays emphasize gaining retinal reattachment, preferably with one surgery and with minimum damage to the eye. The procedure should not bring secondary eye conditions and complications with severe impairment of visual acuity, and it should be performed on as much as a smaller budget, with possibly peribulbar anesthesia, enabling the patient the quickest possible recovery. It should be adjusted to the patient's condition, not to the surgeon's skills or preferences.