New trends in the surgical management of soft tissue sarcoma: The role of preoperative biopsy

Soft tissue sarcoma(STS)accounts for 1%of all malignant neoplasms in adults.Their diagnosis and management constitute a challenging target.They originate from the mesenchyme,and 50 subtypes with various cytogenetic profiles concerning soft tissue and bones have been recognized.These tumors mainly affect middle-aged adults but may be present at any age.Half of the patients have metastatic disease at the time of diagnosis and require systemic therapy.Tumors above 3-5 cm in size must be suspected of potential malignancy.A thorough history,clinical examination and imaging that must precede biopsy are necessary.Modern imaging techniques include ultrasound,computed tomography(CT),new magnetic resonance imaging(MRI),and positron emission tomography/CT.MRI findings may distinguish low-grade from high-grade STS based on a diagnostic score(tumor heterogeneity,intratumoral and peritumoral enhancement).A score≥2 indicates a high-grade lesion,and a score≤1 indicates a lowgrade lesion.For disease staging,abdominal imaging is recommended to detect early abdominal or retroperitoneal metastases.Liquid biopsy by detecting genomic material in serum is a novel diagnostic tool.A preoperative biopsy is necessary for diagnosis,prognosis and optimal planning of surgical intervention.Core needle biopsy is the most indicative and effective.Its correct performance influences surgical management.An unsuccessful biopsy means the dissemination of cancer cells into healthy anatomical structures that ultimately affect resectability and survival.Complete therapeutic excision(R0)with an acceptable resection margin of 1 cm is the method of choice.However,near significant structures,i.e.,vessels,nerves,an R2 resection(macroscopic margin involvement)preserving functionality but having a risk of local recurrence can be an acceptable choice,after informing the patient,to prevent an unavoidable amputation.For borderline resectability of the tumor,neoadjuvant chemo/radiotherapy has a place.Likewise,after surgical excision,adjuvant therapy is indicated,but chemotherapy in nonmetastatic disease is still debatable.The five-year survival rate reaches up to 55%.Reresection is considered after positive or uncertain resection margins.Current strategies are based on novel chemotherapeutic agents,improved radiotherapy applications to limit local side effects and targeted biological therapy or immunotherapy,including vaccines.Young age is a risk factor for distant metastasis within 6 mo following primary tumor resection.Neoadjuvant radiotherapy lasting 5-6 wk and surgical resection are indicated for highgrade STS(grade 2 or 3).Wide surgical excision alone may be acceptable for patients older than 70 years.However,locally advanced disease requires a multidisciplinary task of decision-making for amputation or limb salvage.

Research Progress in Surgical Management of Head and Neck Tumors Involving the Carotid Artery

The surgeons adopt the comprehensive treatment method basing on surgery When head and neck tumors involve the carotid artery. At present, there are four surgical treatments, namely, dissection of carotid artery tumor, resection of carotid artery, revascularization after carotid resection, endoarterial implantation of covered stent combined with surgical resection. However, there is currently no consensus on the standard surgical approach to choose. This paper describes the four surgical methods, which are expected to be helpful for head and neck surgeons to choose the surgical methods for head and neck tumors involving the carotid artery.

Surgical Management of Adrenal Tumors: Experience of Three Tertiary Hospitals in Yaounde, Cameroon

Introduction: Surgical management of adrenal tumors has greatly improved over the past years, with laparoscopic adrenalectomy being the gold standard. However, Open adrenalectomy is indicated in large adrenal tumors, malignant tumors and large phaeochromocytomas. We report surgical outcomes of 18 cases of functional adrenal tumors from 2007 to 2022. Methods: We conducted a retrospective cross-sectional and descriptive study in three tertiary hospitals in Yaounde, Cameroon. We reviewed files of patients who underwent adrenalectomy over a period of 15 years from July 2007 to July 2022. Clinical and diagnostic components of adrenal tumors, indications and surgical outcomes were analyzed. Results: A total of 18 patients were included in our study. The average age of patients was 38.33 years, with a female-to-male sex ratio of 2:1. Weight gain (72.2%) was the most represented clinical sign. The secretory nature of tumor and malignancy represented 55.5% and 33.3% of the operative indications and all 18 (100%) of the patients had open adrenalectomy. Vascular injury was the most common intraoperative complication with 5.63%, while acute adrenal insufficiency (16.7%) was the most common post-operative complication. The average tumor size was 6.22 cm and the mean duration of hospitalization was 11.61 days. Adenoma 7 (38.9%) and adrenocortical carcinoma 5 (27.8%) were the frequent histological types. One patient died two months post-surgery from anemia-related complications. Conclusion: The success of adrenal surgery is linked to multidisciplinary patient care and the experience of the surgeon. Conventional surgery still has indications with satisfactory short- and medium-term results in our context.

Lumbopelvic Fixation and Sacral Decompression for U-shaped Sacral Fractures： Surgical Management and Early Outcome

U-shaped sacral fractures are rare and often difficult to diagnose primarily due to the difficulty in obtaining adequate imaging and the severe associated injuries. These fractures are highly unstable and frequently cause neurological deficits. The majority of surgeons have limited experience in management of U-shaped sacral fractures. No standard treatment protocol for U-shaped sacral fractures has been available till now. This study aimed to examine the management of U-shaped sacral fractures and the early outcomes. Clinical data of 15 consecutive patients with U-shaped sacral fracture who were admitted to our trauma center between 2009 and 2014 were retrospectively analyzed. Demographics, fracture classification, mechanism of injury and operative treatment and deformity angle were assessed. All the patients were treated with lumbopelvic fixation or （and） sacral decompression. EQ-5d score was applied to evaluate the patients＇ quality of life. Of the 15 consecutive patients with U-shaped sacral fracture, the mean age was 28.8 years （range： 15-55 years） at the time of injury. There were 6 females and 9 males. The mean follow- up time was 22.7 months （range： 9-47 months） and mean full weight-bearing time was 9.9 weeks （range： 8-14 weeks）. Ten patients received lumbopelvic fixation and sacral decompression, one lombosacral fixation, and 4 merely sacral decompression due to delayed diagnosis or surgery. The post-operation deformity angle （mean 27.87°, and range： 8°-90°） of the sacrum was smaller than that pre-operation （mean 35.67; range： 15-90） with no significance difference noted. At the latest follow-up, all patients obtained neurological recovery with different extents. Visual analogue score （VAS） was reduced from preoperative 7.07 （range： 5-9） to postoperetive 1.93 （range： 1-3）. All patients could walk without any aid after treatment. Eight patients were able to care for themselves and undertook some daily activities. Five patients had returned to work full time. In conclusion, lumbopelvic fixation is an effective method for stabilization of U-shaped sacral fractures with fewer complications developed. Effective reduction and firm fixation are the prerequisite of early mobilization and neurological recovery. Sacral decompression effectively promotes neurological recovery even in patients with old U-shaped sacral fractures.

Anorectal malignant melanomas: Retrospective experience with surgical management

AIM: To present the experience and outcomes of the surgical treatment for the patients with anorectal melanoma from the Cancer Hospital, Chinese Academy of Medical Sciences. METHODS: Medical records of the diagnosis, surgery, and follow-up of 56 patients with anorectal melanoma who underwent surgery between 1975 and 2008 were retrospectively reviewed. The factors predictive for the survival rate of these patients were identified using multivariate analysis. RESULTS: The 5-year survival rate of the 56 patients with anorectal melanoma was 20%, 36 patients underwent abdominoperineal resection (APR) and 20 patients underwent wide local excision (WLE). The rates of local recurrence of the APR and WLE groups were 16.13% (5/36) and 68.75% (13/20), (P = 0.001), and the median survival time was 22 mo and 21 mo, respectively (P = 0.481). Univariate survival analysis demonstrated that the number of tumor and the depth of invasion had significant effects on the survival (P < 0.05). Multivariate analysis showed that the number of tumor [P = 0.017, 95% confidence interval (CI) = 1.273-11.075] and the depth of invasion (P = 0.015, 95% CI = 1.249-7.591) were independent prognostic factors influencing the survival rate. CONCLUSION: Complete or R0 resection is the first choice of treatment for anorectal melanoma, prognosis is poor regardless of surgical approach, and early diagnosis is the key to improved survival rate for patients with anorectal melanoma.

Current surgical management of pancreatic endocrine tumor liver metastases

BACKGROUND: The management of metastatic disease in pancreatic endocrine tumors (PETs) demands a multidisciplinary approach and the cooperation of several medical specialties. The role of surgery is critical, even when a radical excision cannot always be achieved. DATA SOURCES: A PubMed search of relevant articles published up to February 2011 was performed to identify current information about PET liver metastases regarding diagnosis and management, with an emphasis on surgery. RESULTS: The early diagnosis of metastases and their accurate localization, most commonly in the liver, is very important. Surgical options include radical excision, and palliative excision to relieve symptoms in case of failure of medical treatment. The goal of the radical excision is to remove the primary tumor bulk and all liver metastases at the same time, but unfortunately it is not feasible in most cases. Palliative excisions include aggressive tumor debulking surgeries in well-differentiated carcinomas, trying to remove at least 90% of the tumor mass, combined with other additional destructive techniques such as hepatic artery embolization or chemoembolization to treat metastases or chemoembolization to relieve symptoms in cases of rapidly growing tumors. The combination of chemoembolization and systemic chemotherapy results in better response and survival rates. Other local destructive techniques include ethanol injection, cryotherapy and radiofrequency ablation. CONCLUSION: It seems that the current management of PETs can achieve important improvements, even in advanced cases.

Presentation and surgical management of xanthogranulomatous cholecystitis

Background:Xanthogranulomatous cholecystitis(XGC)is a rare benign chronic inflammatory disease of the gallbladder that often presents as cholecystitis and most of the times requires surgical management.In addition,distinguishing XGC from gallbladder cancer preoperatively is still a challenge.The aim of the present systematic review was to outline the clinical presentation and surgical approach of XGC.Data sources:The present systematic review was designed using the PRISMA and AMSTAR guidelines.We searched MEDLINE,Scopus,Clinicaltrials.gov,EMBASE,Cochrane Central Register of Controlled Trials(CENTRAL)and Google Scholar databases from inception until June 2020.Results:The laparoscopic cholecystectomy rate(34%)was almost equal to the open cholecystectomy rate(47%)for XGC.An important conversion rate(35%)was observed as well.The XGC cases treated by surgery were associated with low mortality(0.3%),limited intraoperative blood loss(58-270 m L),low complication rates(2%–6%),along with extended operative time(82.6–120 minutes for laparoscopic and 59.6–240 minutes for open cholecystectomy)and hospital stay(3–9 days after laparoscopic and 8.3–18 days after open cholecystectomy).Intraoperative findings during cholecystectomies for XGC included empyema or Mirizzi syndrome.In addition,complex surgical procedures,like wedge hepatic resections and bile duct excision were required during operations for XGC.Conclusions:XGC seemed to be a rare,benign inflammatory disease that presents similar features as gallbladder cancer.The mortality and complication rates of XGC were low,despite the complex surgical procedures that might be required in some cases.

Application of Delayed Surgical Managements in Patients with Stensen＇s Duct Injury

The study aimed to retrospectively evaluate surgical treatment outcomes after delayed parotid gland and duct injuries. Nine patients subjected to parotid gland and duct injuries with l- to 3-month treatment delay were retrospectively evaluated with special reference of etiology, past medical history, and injury location. Conservative treatment, microsurgical anastomosis, and diversion of salivary flow or ligation were chosen for delayed parotid gland and duct injuries concerning to their site of injury, time of repair and procedures. Assistant treatment as pressure dressing was adopted thereafter. All patients experienced an uneventful recovery at the time of finalizing the study. Two patients received Stensen＇s duct ligation, 5 received microsurgical anastomosis and 2 accepted salivary flow diversion for 5 patients with sialoceles and 4 patients with fistulas, and no re-occurrence was found. Facial paralysis occurred after surgery in 4 patients, and 3 of them recovered after the nerve nutrition treatment. Our study suggested that appropriate surgical treatment is efficient for the re-establishment of the tissue function and facial aesthetic for delayed injury of the parotid and its duct.

Effectiveness of surgical management of malignant glaucoma in phakic eyes

AIM:To assess the effectiveness of core vitrectomyphacoemulsification-intraocular lens(IOL)implantationcapsulo-hyaloidotomy in treating phakic eye at least 1 mo after the onset of malignant glaucoma.METHODS:A retrospective analysis were performed on malignant glaucoma patients treated in Zhongshan Ophthalmic Center between 2016 and 2018.Demographic and clinical data were described.The preoperative and postoperative visual acuity(VA),intraocular pressure(IOP),number of IOP-lowering medications used,and anterior chamber depth(ACD)of the case series were compared by Wilcoxon signed-rank test.RESULTS:Thirteen phakic eyes with long time intervals between onset and surgery were identified in this case series.Core vitrectomy-phacoemulsification-IOL implantation-capsulohyaloidotomy reduced the IOP(P=0.046)and the number of IOP-lowering medications used(P=0.004),deepened the ACD(P=0.005).Complete success was achieved in 38.5%of the eyes,and anatomical success was achieved in 100%of the eyes without any recurrence.The only postoperative complication observed is corneal endothelial decompensation.It occurred in two cases.CONCLUSION:Core vitrectomy-phacoemulsification-IOL implantation-capsulo-hyaloidotomy is safe and effective for treatment of long onset phakic malignant glaucoma.

Surgical management of non-parasitic hepatic cyst with biliary communication: a case report

Non-parasitic hepatic cysts with biliary communication are rare. qhe clinical symptoms involved are not specific to this condition, thereby making diagnosis difficult and treatment controversial. Here, we report a case of 70-year-old woman complaining of abdominal satiety, combined with non-specific pain in the right upper quadrant, qhe abdominal contrast-enhanced MR.I-scan revealed a large and thick-walled septus cystic lesion in the liver. During operation, the biliary fistula was confirmed in the cyst cavity. A silica gel tube was inserted via the cystic duct for cholangiography, which demonstrated communication between the cyst and biliary tract. We performed wide-scale cyst wall resection; the biliary fistula was completely repaired by the closure of communicated bile ducts. The postoperative course was uneventful, and the patient was discharged with no sign ofcholangitis or any other symptoms. The novel surgical management via wide resection of the cyst wall and closure of biliary communication proved to be an adequate and effective procedure for treating nonparasitic hepatic cysts with biliary communication.

Prognostic Factors of Gastrointestinal Stromal Tumors： A Single Institutional Retrospective Experience with Surgical Management over 20 Years

OBJECTIVE To analyze the pathological features and prognosis factors of gastrointestinal stromal tumor （GIST） after primary resection. METHODS Medical records of the diagnosis, surgery, and follow-up of 327 patients with GISTs who underwent surgery between 1988 and 2007 were retrospectively reviewed. The predic-tive factors for the survival of these patients were identi. ed using multivariate analysis. RESULTS In the 327 tumors, 152 （46.5%） were located in the stomach, 89 （27.2%） in the small intestine, 33 （10.1%） in the colon and rectum, and 43 （13.1%） in other sites including the omentum and mesentery. The 3-year and 5-year overall survival rates of the 327 GIST patients were 74.4% and 62.7%, respectively, and univariate survival analysis demonstrated that factors, such as tumor size, mitotic index, NIH categories, Ki-67 index, tumor location, surgical margins, tumor bleeding, and tumor necrosis have significant effect on survival of the patients （P 〈 0.05）. Multivariate analysis demonstrated that the NIH categories, surgical margins, and Ki-67 index were independent prognostic factors for the survival rate. In the group of patients with postoperative recurrence or metastasis, the median survival time of patients who did not receive imatinib treatment was 30 months and that of patients who received imatinib treatment was 59 months. Their 5-year survival rates were 16.4% and 39.4%, respectively, and the difference was statistically significant （P = 0.017）. CONCLUSION Complete resection is the .rst choice of treat-ment for GISTs. It is reasonable to evaluate the prognosis of resect-able GISTs and guide the adjunctive therapy with NIH categories and Ki-67 index. Imatinib treatment can signi.cantly increase the survival rate of patients with recurrent and metastatic GISTs.

EXPERIENCE ON SURGICAL MANAGEMENT OF RUPTURE OF ABDOMINAL AORTIC ANEURYSM

Objective. To describe our surgical experience on rupture of abdominal aortic aneurysm .Methods. Two cases of ruptured aortic aneurysms with severe complication were analyzed. Aorta reconstruction procedures were performed using bifurcated e-PTFE grafts during emergency operation. Diagnosis, preoperadve resuscitation, emergency surgical intervention, and postoperative complications of these patients were summarized and discussed.Results. Rupture of aortic aneurysm in both patients presented as a huge retroperitoneum haematoma by computed tomography scan. They were successfully saved by prompt body fluid compensation, emergency procedure, intraoperative resuscitation, and postoperative intensive care.Conclusions. Correct diagnosis, prompt surgical management, immediate intraoperative proximal aorta clamping during procedure, and effective management of postoperative complications were the key points to successful treatment of ruptured aortic aneurysm.

SURGICAL MANAGEMENT OF EHLERS-DANLOS SYNDROME:FIRST REPORT OF A PEDIGREE IN CHINA

OBJECTIVE: To describe a case of Ehlers-Danlos syndrome type IV and its pedigree in China. METHODS: Clinical materials of a case of Ehlers-Danlos syndrome type IV and a pedigree of 6 members within 4 generations were analyzed. Dilated internal jugular vein in the proband was removed by operation. The diagnosis, surgical treatment, and postoperative complications were retrospectively reviewed. RESULTS: Vessels of the proband in the pedigree were crisp and easily lacinated during the procedure of removing his internal jugular vein. Repeating postoperative hematomas were found though complete stanching was achieved during the operation. The patient was successfully recovered by promptly debridgement and needle sucking. The other 5 members of the pedigree all had the triads of Ehlers-Danlos syndrome. CONCLUSIONS: Though it was of extremely low morbidity rate, the high mortality rate and complication of Ehlers-Danlos syndrome deserve great attention during surgical management, especially in patients with Ehlers-Danlos syndrome type IV. Surgeons should be aware of the ponderance of its complications and combined diseases to avoid fatal intraoperative vascular lascination and incontrollable hemorrhage.

Surgical management of silicone oil migrated into suprachoroidal space after vitrectomy

AIM: To report a successful surgical management of silicone oil migrated into suprachoroidal space after the repair of the retinal detachment with hemorrhagic choroidal detachment. METHODS: Retrospective observational case report. A 30-year-old man with retinal detachment and hemorrhagic choroidal detachment due to severe corneal penetrating injury, underwent a pars plana lensectomy and vitrectomy, endolaser, and silicone oil tamponade followed by transscleral suprachoroidal hemorrhage drainage in the right eye. One week later, a localised temporal choroid elevation was noted. This persistent elevation was confirmed by operation research to be silicone oil migration into suprachoroidal space. RESULTS: The migrated silicone oil was drained via trans-scleral cut down, and the intravitreal silicone oil was removed and replaced by 16% C2F6. Over the next 2 weeks, the elevation vanished and the choroid became completely flat. CONCLUSION: The migration of silicone oil into suprachoroidal space is a rare complication of vitrectomy. The pathway of the migration is most likely through internal orifice of sclerotonny sites. Trans-scleral drainage surgery is an effective method to remove the migrated silicone oil from suprachoroidal space.

SURGICAL MANAGEMENT OF PSEUDOANEURYSM COMPLICATING ARTERIOVENOUS FISTULA FOR HEMODIALYSIS

Objective To report surgical experience in pseudoaneurysm (PA) repair of arteriovenous fistula (AVF) for renal hemodialysis. Methods Twenty patients undergoing PA repair of AVF for renal hemodialysis were treated in Central Hospital Conde S. Januario of Macao. Sixteen patients had PAs of AVF in upper extremities, 4 in lower extremities. All patients were treated with surgical therapy. Results All operations were finished without death. One patient suffered from acute thrombosis, recovered without any complication through instant thrombectomy. One patient with postoperative incision bleeding recovered after low molecular weight heparin was ceased. And one AVF could not be mature six weeks later, was recovered after ligation of branch vein. And one patient died due to recurrent cerebral infarction. Conclusion Surgical repair is the best choice for PA of AVF for renal hemodialysis.

Recommendations for perinatal and neonatal surgical management during the COVID-19 pandemic

Coronavirus disease 2019(COVID-19)caused by severe acute respiratory syndrome coronavirus 2 has spread rapidly around the world and is a significant threat to global health.Patients in the Neonatal Surgery Department have rapidly progressing diseases and immature immunity,which makes them vulnerable to pulmonary infection and a relatively higher mortality.This means that these patients require multidisciplinary treatment including early diagnosis,timely transport,emergency surgery and intensive critical care.The COVID-19 pandemic poses a threat to carrying out these treatments.To provide support for the health protection requirements of the medical services in the Neonatal Surgery Department,we developed recommendations focusing on patient transport,surgery selection and protection requirements with the aim of improving treatment strategies for patients and preventing infection in medical staff during the current COVID-19 pandemic.

DIAGNOSIS AND SURGICAL MANAGEMENT FOR RETROSTERNAL THYROID MASS

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Surgical management of metastatic disease of long bone

Objective To improve the life quality of cancer patients with metastasis to long bone and to long bone and to select suitable surgical treatment. Methods Fifty-two patients with metastasis 27 men and 25 women, were June 2003 Vol12 No2 treated from 1990 to 1999. Their average age was 56. 8 years (33 - 74). In 16 patients with multiple lesions, underwent surgery at bone shaft (29 patients) and bone epiphysis (26). Thirty patients were treated for pathologic fracture and the rest for impending fracture. Operations included limb-salvage (51 patients) and amputation (4) Limb salvage consisted of intralesional curettage (3 patients ), intramedullary nailing reconstruction (29 ), endoprosthesis ( 18 ), and temporary spacer ( 1 ). 21 patients accepted postoperative chemotherapy or radiotherapy. Results Follow-up of 52 patients for a mean of 28. 2 months (2 - 122 months) showed pain relief (41 patients), (75%) and full or part weight-bearing stability ( 36 ) 69 % . Local tumor recurrence occurred in 11 patients.

Recent advances in surgical management strategies for hepatocellular carcinoma

Hepatocellular carcinoma(HCC)is a significant global health challenge,requiring innovative methods to improve patient survival.Due to different disease backgrounds,different HCC management guidelines have been devel-oped,especially in thefield of surgical treatment,with the aim of reducing the risk of incidence and enhancing the therapeutic effect.Focusing on the progress and challenges in the development of surgical management stra-tegies for HCC in recent years,this article systematically elaborates on the research and clinical application of pre-cision surgical treatment,including improvement of the surgical evaluation system,breakthroughs in surgical tech-niques,and updates in perioperative treatment concepts.In addition,clinical research on surgical treatment for HCC has received unprecedented attention.The conclusions of innovative clinical trials in surgery will provide important guidance for the development of practice guidelines and the selection of appropriate treatment strate-gies for HCC patients.

Innovation in pathogenesis and management of aortic aneurysm

Aortic aneurysm(AA)refers to the persistent dilatation of the aorta,exceeding three centimeters.Investigating the pathophysiology of this condition is important for its prevention and management,given its responsibility for more than 25000 deaths in the United States.AAs are classified based on their location or morphology.various pathophysiologic pathways including inflammation,the immune system and atherosclerosis have been implicated in its development.Inflammatory markers such as transforming growth factorβ,interleukin-1β,tumor necrosis factor-α,matrix metalloproteinase-2 and many more may contribute to this phenomenon.Several genetic disorders such as Marfan syndrome,Ehler-Danlos syndrome and Loeys-Dietz syndrome have also been associated with this disease.Recent years has seen the investigation of novel management of AA,exploring the implication of different immune suppressors,the role of radiation in shrinkage and prevention,as well as minimally invasive and newly hypothesized surgical methods.In this narrative review,we aim to present the new contributing factors involved in pathophysiology of AA.We also highlighted the novel management methods that have demonstrated promising benefits in clinical outcomes of the AA.