Innovative surgical approaches for hepatocellular carcinoma

Hepatocellular carcinoma(HCC)is the sixth most common cancer worldwide,with an increasing diffusion in Europe and the United States.The management of such a cancer is continuously progressing and the objective of this paper is to evaluate innovation in the surgical treatment of HCC.In this review,we will analyze the modern concept of preoperative management,the role of laparoscopic and robotic surgery,the intraoperative use of three dimensional models and augmented reality,as well as the potential application of fluorescence.

Standardized surgical approaches to ear surgery in rats

Objective： To describe several approaches of ear surgeries for experimental studies in rats. Methods： Anesthetized rats were prepared for demonstration of various ear surgery approaches designed to optimize experimental outcomes in studies with specific goals and exposure requirements. The surgical approaches included the posterior tympanum, superior tympanum, inferior tympanum and occipital approaches. Results： The middle ear cavity and inner ear were successfully exposed from different angles via the mentioned surgical approaches. For example, electrode placement for recording of cochlear bioelectric responses was easily achieved through the posterior tympanum or inferior tympanum approach. Alternatively, drug delivery or gene transfection via round window membrane was most easily accomplished using the posterior tympanum approach. Cochlear perfusion of protective or ototoxic drugs was best performed using the inferior tympanum approach. Ossicular chain interruption to induce a prolonged conductive hearing loss was readily achieved using a superior tympanum approach. Lastly, surgical destruction of the endolymphatic sac to induce experimental endolymphatic hydrops was readily performed via an occipital surgical approach.Conclusion： These standardized surgical approaches can be applied in scientific studies of the ear with different purposes covering electro- physiology, conductive hearing loss, intra-cochlear drug perfusion and experimental studies relevant to Meniere＇s disease.

Subclavian Artery Pseudoaneurysm following Stab Injury and Its Surgical Approach: A Case Report and Literature Review

Penetrating injuries to the subclavian arteries as well as post traumatic pseudoaneurysm involving Subclavian artery (SCA) are very much uncommon. We present one case of a 21 year-old male sustained a physical assault with a post stab injury left subclavian artery pseudoaneurysm. He was referred to our facility, two days after sustaining a penetrating chest trauma over left infraclavicular area of the chest. The presentation, diagnostic procedures and surgical approach for management of this very rare injury are discussed.

SELECTION OF SURGICAL APPROACH TO TREAT TRAUMATIC INSTABILITY OF SUBAXIAL CERVICAL SPINE

Objective To evaluate the clinical outcomes of surgical therapy in treating traumatic instability of subaxial cervical spine through either anterior or posterior approach. Methods According to the Allen-Fergurson's classification, we retrospectively studied 42 cases of traumatic instability of subaxial cervical spine through either anterior or posterior surgical reconstruction. Patients requiring approach for either reduction or decompression were not included. Results The average follow-up interval was 3 years and 2 months. The anterior and posterior reconstructions were 24 and 18 cases, respectively. Before operation, the average scores of JOA and VAS were: 12.1 and 6.9 for anterior group, and 12.3 and 7.2 for posterior group. At the final assement, the scores of JOA and VAS improved to 16.0 and 2.2 for anterior group, and 15.7 and 2.6 for posterior group. The average ASIA motor scores of anterior and posterior group improved to 68.2 and 65.5 at the final follow-up from 58.4 and 59.7 before operation, respectively. The ASIA grade (A-E) was converted to a numeric score. The average scores before operation in the anterior and posterior group were 3.3 and 3.4, and increased to 3.8 and 3.7 at the final follow-up. After operation, there were different extent improvements of average radiological parameter, such as Cobb angle, vertebral body translation and disc height ratio. The average operation time and blood losing were 122 min and 125 mL for anterior group, and 153 min and 287 mL for posterior group. Fusion was achieved in all patients and 4 and 2 complications occurred at the anterior or posterior group. Conclusion The results showed that there were no obvious difference in parameters, such as neurological assements, functional grades, fusion rate, operation time and blood losing, between anterior and posterior group, except the virtues of anterior group in reconstruction and maintaining physiologic cervical lordosis and intervertrbal disc height occurred.

Surgical approaches of adrenal tumors( report of 1077 cases)

Objective To identify the optimal surgical approaches for the resection of adrenal tumors. Methods The choices and effects of surgical approaches in 1 077 patients with adrenal tumors of varying sizes and types were analyzed. Results An 11th or 10th intercostal incision was used for 567 cases of aldosterone-producing adrenocortical tumors (APA) and Cushing syndrome (CUS). An llth or 10th incision was used in 173 cases of pheochromocytomas and 136 cases of incidental tumors. Transabdominal approach was performed in 136 cases of pheochromocytomas and 22 cases of incidental tumors. Twenty-five patients recieving thoracoabdominal approach were all those with pheochromocytomas or incidental tumors. Nine patients with adrenal tomors less than 4 cm in diameter received laparoscopic surgery. Surgeries included 1 060 cases of tumor resection and 17 cases of biopsies, and splenectomy was procedured in 9 patients simultaneously. The main complication of 11th or 10th intercostal incision approach was pleural

Application of virtual reality in quantified analyses for cavernous sinus surgical approach

Objective To evaluate the utility of virtual reality system in quantitative comparison for cavernous sinus surgical approach. Methods Image data of CT and MRI scan performed in five adult cadaver heads was inputted into the Destroscope virtual reality system to build 3-D model of cavernous sinus.

Clinical diagnosis and surgical approaches of vaginal hyperplasia in bitches

Objective:To describe the breed predisposition, clinical diagnosis, pathological findings and the surgical approach through excision of the hyperplasic mass from the vagina.Methods:Twenty five bitches of different breeds suffering from a protruded mass from the vulva were examined clinically, blood samples were collected to ensure the phase of estrus that were determined by evaluating the exfoliative vaginal epithelium, and a histopathological examination of the hyperplastic mass was done after its surgical excision.Results:The current work revealed that the maximum value of estradiol 17-B was in Alabai breed while the maximum value of progesterone was in Pit bull breed. And Pit bull breed showed cornification and stratification of the vaginal mucosa with abundant eosinophilic cytoplasm and regular round nuclei.Conclusions:As the vaginal hyperplasia is a crucial gynaecological problem that affects different breeds of bitches, the current work provides a comprehensive diagnosis of the case and illustrates the surgical interference for its excision.

Surgical approach affecting long-term urinary continence status after robot-assisted laparoscopic prostatectomy prospectively evaluated using self-reported functional status(Expanded Prostate Cancer Index Composite,EPIC-26)

Purpose:The aim of the study was to examine the influence of the surgical approach for robot-assisted laparoscopic prostatectomy(RALP)on long-term urinary continence status in the era of self-reported functional status measures using the Expanded Prostate Cancer Index Composite 26.Materials and methods:This is a prospective evaluation of 232 patients undergoing RALP between September,2019 and September,2020.Urinary continence status and postoperative incontinence(pad usage)were evaluated 12 months after RALP using Expanded Prostate Cancer Index Composite 26 questionnaires.Patients were categorized according to their surgical approach and outcome into the following groups:successful nerve sparing(NS),primarily without nerve sparing(prim.NNS),and no nerve sparing by secondary resection(NNS by SR).The median levels of their questionnaire outcomes were evaluated and compared using the Wilcoxon rank sum test with continuity correction.Results:Urinary continence status 12 months after RALP differed significantly between the NS and prim.NNS(p=0.0071)and the NS and NNS by SR(p=0.0076)groups.There was no significant difference between the prim.NNS and NNS by SR(p=0.53)groups.Pad usage 12 months after RALP had no significant difference with regard to SR of the neurovascular bundle(p=0.14).Conclusions:Patient-reported outcomes of long-term urinary continence status seem to show no difference in postoperative continence,regardless of whether a non-nerve-sparing result was planned or reached through SR.Instead,preservation of neurovascular bundle seems to lead to better long-term continence rates.

Direct anterior compared to posterior approach for hip hemiarthroplasty following femoral neck fractures

The differences in complication rates between the direct anterior and posterior approaches for hemiarthroplasty in elderly patients with femoral neck fractures are not yet fully understood.Dislocation,a severe complication associated with increased mortality and often requiring additional surgery,may occur less frequently with the direct anterior approach compared to the posterior approach.Careful consideration of patient demographics is essential when planning the surgical approach.Future research in this area should focus on robust randomized controlled trials involving elderly patients recovering from femoral neck fractures.

Proximal gastric cancer： lymph node metastatic patterns according to different T stages dictate surgical approach

Background As a common form of gastric cancer migration,lymph node metastasis largely affects the surgical treatment and prognosis of gastric cancer.Surgery is the fundamental curative option for gastric cancer that varies depending on different stages.The study aimed to compare the clinicopathological characteristics and lymph node metastatic patterns in patients of proximal gastric cancer with different T stages and investigate a reasonable radical gastrectomy approach in terms of the range of lymphadenectomy for proximal gastric cancer.Methods In our retrospective study,the data of 328 patients of proximal gastric cancer with different T stages were analyzed.By comparing the differences of lymph node metastatic rate and ratio,we investigated the clinicopathological characteristics and metastatic patterns of lymph nodes.Also,we were especially interested in the differences in survival rates between patients with and without No.5 and 6 group metastasis with the same TNM stage.Results The overall lymph node metastatic rate and ratio of advanced proximal gastric cancer were 73.4％ and 23.3％,respectively.The tumors of different T stages were statistically significant in size and differentiation degree （P ＜0.05）,multivariate analysis showed that the depth of tumor invasion was an independent risk factor for lymph node metastasis in proximal gastric cancer （RR,12.025; 95％ CI,2.326 to 62.157; P=0.003）.The overall survival rate of patients with No.5,6 group lymph node metastasis and those without was significantly different,but the differences in survival rates between patients with and without No.5 and 6 group metastasis with the same TNM stage were not statistically significant.Conclusions Different T stages in proximal gastric cancer showed different patterns and characteristics of lymph node metastasis.D2 lymphadenectomy in patients with early gastric cancer had little survival benefit because metastasis to level 2 nodes was rare.Therefore the range of the lymph node dissection in radical gastrectomy for earty gastric cancer was considered reasonable.Moreover,to meet the requirements of the lymph node dissection,total gastrectomy plus D2 lymphadenectomy or more are supposed to be applied for the advanced proximal gastric cancer patients.Precise T staging larqely determines the range of gastrectomy and lymphadenectomy.

Surgical approaches to the petrous apex

The petrous apex is a difficult to reach surgical area due to its deep position in the skull base and many vital surrounding structures.Petrous apex pathology ranges from extradural cholesterol granulomas,cholesteatomas,asymmetric pneumatization,and osteomyelitis to intradural meningiomas and schwannomas.Certain lesions,such as cholesterol granulomas,can be managed with drainage while neoplastic lesions must be completely resected.Surgical options use open,endoscopic,and combined techniques and are categorized into anterior,lateral,and posterior approaches.The choice of approach is determined by the nature of the pathology and location relative to vital structures and extension into surrounding structures and requires thorough preoperative evaluation and discussion of surgical goals with the patient.The purpose of this state-of-the-art review is to discuss the most commonly used surgical approaches to the petrous apex,and the anatomy on which these approaches are based.

Therapeutic interventional endoscopic ultrasound in pancreatobiliary disorders:Does it really replace the surgical/percutaneous approach?

Pancreato-biliary disorders are still incredibly challenging in the field of gastroenterology,as they would sometimes require multi-approach interventional procedures.Recently,therapeutic interventional endoscopic ultrasound(EUS)has emerged as a potential alternative to surgical or percutaneous approaches.Unfortunately,considering the high cost of EUS,lack of facility and expertise,most gastroenterologists still often refer cases to undergo surgical interventions without contemplating the possibility of utilizing EUS first.EUS-guided biliary drainage has become one of the best choices for establishing access to biliary system,given the clear visualization of pancreas,gallbladder,and common bile duct.Although there are still only a few studies which directly compare EUSguided and surgical approaches for biliary drainage,current evidence demonstrated the superiority of EUS-guided approach in terms of adverse events and reintervention rates,with similarly high technical and clinical success rates compared to percutaneous and surgical approaches,especially in patients with history of failed endoscopic retrograde cholangiopancreatography attempt.Comparable success rates with shorter length of hospital stay between endoscopic and surgical approaches have also been exhibited for pancreatic pseudocysts and walled-off necrosis.Recent findings about the progress of EUS approach in gastroenterostomy/jejunostomy also indicated a promising potential of EUS,as a less invasive approach,for managing gastric outlet obstruction.

The impact of round window vs cochleostomy surgical approaches on interscalar excursions in the cochlea:Preliminary results from a flat-panel computed tomography study

Objective:To evaluate incidence of interscalar excursions between round window (RW) and cochleostomy approaches for cochlear implant (CI) insertion. Methods:This was a retrospective case-comparison. Flat-panel CT (FPCT) scans for 8 CI users with Med-El standard length electrode arrays were collected. Surgical technique was identified by a combination of operative notes and FPCT imaging. Four cochleae underwent round win-dow insertion and 4 cochleae underwent cochleostomy approaches anterior and inferior to the round window. Results:In our pilot study, cochleostomy approaches were associated with a higher likeli-hood of interscalar excursion. Within the cochleostomy group, we found 29% of electrode contacts (14 of 48 electrodes) to be outside the scala tympani. On the other hand, 8.5%of the electrode contacts (4 of 47 electrodes) in the round window insertion group were extra-scalar to the scala tympani. These displacements occurred at a mean angle of occur-rence of 364? ? 133?, near the apex of the cochlea. Round window electrode displacements tend to localize at angle of occurrences of 400? or greater. Cochleostomy electrodes occurred at an angle of occurrence of 19?e490?.

Posterior approach (Kraske procedure) for surgical treatment of presacral tumors

Presacral tumors are rare,but can comprise a great variety of histological types.Congenital tumors are the most common.Once the diagnosis is established,surgical resection is essential because of the potential for malignancy or infection.Previous biopsy is not necessary or may be even harmful.To decide the best surgical approach(abdominal,sacral or combined) an individual and multidisciplinary analysis must be carried out.We report three cases of cystic presacral masses in which a posterior approach(Kraske procedure) enabled complete resection,the only way to decrease local recurrence.All patients had a satisfactory recovery.A brief overview of retrorectal tumors is presented,focusing on classification,clinical presentation,diagnosis and surgical management.

One-step laparoscopic pancreatic necrosectomy verse surgical step-up approach for infected pancreatic necrosis:a case-control study

BACKGROUND:The surgical step-up approach often requires multiple debridements and might not be suitable for infected pancreatic necrosis(IPN)patients with various abscesses or no safe route for percutaneous catheter drainage(PCD).This case-control study aimed to investigate the safety and effectiveness of one-step laparoscopic pancreatic necrosectomy(LPN)in treating IPN.METHODS:This case-control study included IPN patients undergoing one-step LPN or surgical step-up in our center from January 2015 to December 2020.The short-term and long-term complications after surgery,length of hospital stay,and postoperative ICU stays in both groups were analyzed.Univariate and multivariate logistic regression analyses were performed to explore the risk factors of major complications or death.RESULTS:A total of 53 IPN patients underwent one-step LPN and 37 IPN patients underwent surgical step-up approach in this study.There was no significant difference in the incidence of death,major complications,new-onset diabetes,or new-onset pancreatic exocrine insufficiency between the two groups.However,the length of hospital stay in the one-step LPN group was significantly shorter than that in the surgical step-up group.Univariate regression analysis showed that the surgical approach(one-step/step-up)was not the risk factor for major complications or death.Multivariate logistic regression analysis indicated that computed tomography(CT)severity index,American Society of Anesthesiologists(ASA)class IV,and white blood cell(WBC)were the significant risk factors for major complications or death.CONCLUSION:One-step LPN is as safe and effective as the surgical step-up approach for treating IPN patients,and reduces total hospital stay.

Application of a modified surgical position in anterior approach for total cervical artificial disc replacement

BACKGROUND Total cervical artificial disc replacement(TDR)has been considered a safe and effective alternative surgical treatment for cervical spondylosis and degenerative disc disease that have failed to improve with conservative methods.Positioning the surgical patient is a critical part of the procedure.Appropriate patient positioning is crucial not only for the safety of the patient but also for optimizing surgical exposure,ensuring adequate and safe anesthesia,and allowing the surgeon to operate comfortably during lengthy procedures.The surgical posture is the traditional position used in anterior cervical approach;in general,patients are in a supine position with a pad under their shoulders and a ring-shaped pillow under their head.AIM To investigate the clinical outcomes of the use of a modified surgical position versus the traditional surgical position in anterior approach for TDR.METHODS In the modified position group,the patients had a soft pillow under their neck,and their jaw and both shoulders were fixed with wide tape.The analyzed data included intraoperative blood loss,position setting time,total operation time,and perioperative blood pressure and heart rate.RESULTS Blood pressure and heart rate were not significantly different before and after body positioning in both groups(P>0.05).Compared with the traditional position group,the modified position group showed a statistically significantly longer position setting time(P<0.05).However,the total operation time and intraoperative blood loss were significantly reduced in the modified position group compared with the traditional position group(P<0.05).CONCLUSION The clinical outcomes indicated that total operation time and intraoperative blood loss were relatively lower in the modified position group than in the traditional position group,thus reducing the risks of surgery while increasing the position setting time.The modified surgical position is a safe and effective method to be used in anterior approach for TDR surgery.

Surgical treatment of metachronous rectal liver and lungmetastases： A combined videolaparoscopic andvideothoracoscopic approach

To the Editor：We read with tremendous interest the paper by Del Fabbroet al. [1]. In this thorough article, the authors meticulously underlinethe advantages of a modified j-shaped incision for the simultaneoustreatment of difficult liver colorectal metastases （CRM） and right-lung CRM, reporting their experience in a cohort of 11 patients.

Long-term complications of the transmeatal approach (Open Transcanal) in cochlear implants: A follow-up study

Objective: Multiple alternative approaches of cochlear implant surgery have been described, such as the suprameatal approach, transcanal approach, transmeatal approach and middle cranial fossa approach.Transmeatal(open trnascanal) approach has not been adapted since first described in the clinical field.we aimed to assess the long-term complications of the transmeatal approach in a series of 131 patients at our center between 2004 and 2008.Methods: This study was a retrospective case series of all patients who underwent cochlear implants with the transmeatal(open transcanal) approach from May 2004 to December 2008 at King Faisal Specialist and Research Hospital(Riyadh, Saudi Arabia), which were conducted by the same surgeon.Results: Complications were observed often with various combinations-recurrent otitis externa, posterior tympanic membrane perforation, electrode extrusion, cholesteatoma, and chronic mastoiditis. The overall long-term complication rate was 16%(21/131). The gap between the implantation and the diagnosis of a complication ranged from <1 year to 11 years. Major complications were as follows:cholesteatoma in 5(3.8%) patients, extrusion of the electrode in 5(3.8%) patients, and tympanic membrane perforation or deep retractions in 5(3.8%) patients. Minor complications were as follows: recurrent mastoiditis with/without concomitant temporary facial nerve palsy in 4(3%) patients, recurrent otitis externa infections in 7(5%) patients, and weakness of the posterior canal wall in 1 patient.Conclusion: The transmeatal approach posed an high rate of complications on long-term follow-up such as cholestetoma formation, extrusion of electrode or perielectrode reaction formation to tympanic membrane and external auditory canal.

Surgical resection of intradural extramedullary tumors in the atlantoaxial spine via a posterior approach

BACKGROUND The anatomical features of the atlantoaxial spine increase the difficulty of complete and safe removal of atlantoaxial intradural extramedullary(IDEM)tumors.Studies concerning surgical interventions via a posterior approach are limited.AIM To investigate the safety and efficacy of atlantoaxial IDEM tumor resection using a one-stage posterior approach.METHODS We retrospectively analyzed clinical databases for one-stage atlantoaxial IDEM tumor resection via a posterior approach between January 2008 and January 2018.The analyzed data included tumor position,histopathological type,pre-and postoperative Japanese Orthopedic Association(JOA)scores and Nurick grades,postoperative complication and recurrence status.RESULTS A total of 13 patients who underwent C1-C2 Laminectomy and/or unilateral facetectomy via the posterior approach were enrolled in the study.In all cases reviewed,total tumor resection and concomitant C1-C2 fusion were achieved.The average follow-up was 35.3±6.9 mo(range,26-49 mo).A statistically significant difference was noted between the preoperative JOA score(11.2±1.1)and the score at the last final follow-up(15.6±1.0)(P<0.05).A statistically significant difference was noted between the preoperative Nurick grade(2.3±0.9)and that at the last follow-up(1.2±0.4)(P<0.05).However,no statistically significant difference was noted between the preoperative and last follow-up C1-2 Cobb angle and C2-7 Cobb angle(P>0.05).No mortalities,severe complications or tumor recurrence were observed during the follow-up period.CONCLUSION Total resection of atlantoaxial IDEM tumors is feasible and effective via a posterior approach.Surgical reconstruction should be considered to avoid iatrogenic kyphosis and improve spinal stability and overall clinical outcomes.

Reply to： Surgical treatment of metachronous rectal liver andlung metastases： A combined videolaparoscopic and videothoracoscopic approach

The Author Reply：We thank Dr. Sucameli et al. for the interest toward our article[1] and for the opportunity for further discussing on this issue,providing a case report of single metastastic fore sites in the liverand lung both treated in a minimal access fashion. However, giventhe interest of the authors insight, it appears misleading when related to that discussed in our report which was clearly referred toother patients＇ profiles. Indeed, they described a case with a singleperipheral nodule in the right lung and a single liver metastasesin segment 5. This uncommon situation （less than 2% of patientsaccording to the LiverMetSurvey registry [2]）, is obviouslya more than reasonable indication for a mini-invasive approach.However, our patients received surgery for complex oncological involvementof the liver： as described, this means large and/or multiplelesions, in contact or invading the hepatic veins at caval confluence.For such conditions we have introduced original surgicalapproaches [3,4]： in such conditions we would select a J-shapedthoracophrenolaparotomy for the liver per se [5]. This incision forsuch complex conditions other than allowing the liver clearance in a single operation rather than in staged approach [6], allows justin case the removal of lung nodules. Therefore, we thank again theauthors for their interest to our report, and furthermore we congratulatefor the original management of the shared clinical case.However, the condition recalled by the authors is related to a scenariooncologically and surgically at the opposite side of that discussedin our paper and for that somehow suggesting a comparisonis misleading.