Surgical strategies for peripheral nerve schwannoma based on the intraoperative neurophysiological monitoring

Objective:To present our classification for peripheral nerve schwannomas as well as explore the surgical strategies and operative management of peripheral nerve schwannomas based on the intraoperative neurophysiological monitoring(INM)technique and to decrease the risk of postoperative neurological deficits in the management of these schwannomas.Materials and methods:A retrospective study was conducted on 92 cases of peripheral nerve microsurgery performed,using the INM technique.We also made the classification for peripheral nerve schwannomas into two types according to operative findings and proceeded corresponding surgical strategies.Results:All tumors were removed completely under microscopy and INM.Three patients developed residual neurological deficits at final follow-up.There were different results about temporary(18/92,19.6%)and permanent(3/92,3.3%)neurological deficits.The incidence of temporary and permanent neurological deficits in type II group was significantly higher than that in type I group(p<0.01).The incidence of permanent neurological deficits in larger size tumors was significantly higher than that of smaller size(p<0.01).Conclusions:We made the classification for peripheral nerve schwannomas according to operative findings based on INM that is helpful to our surgical strategies.Intracapsular enucleation was the preferred strategy with satisfactory results and low risk of nerve injury.The size and location of tumors seem to be related to the risk of fascicular injury.

Surgical strategies for Mirizzi syndrome:A ten-year single center experience

BACKGROUND Mirizzi syndrome(MS)remains a challenging biliary disease,and its low rate of preoperative diagnosis should be resolved.Moreover,technological advances have not resulted in decisive improvements in the surgical treatment of MS.Complex bile duct lesions due to MS make surgery difficult,especially when the laparoscopic approach is adopted.The safety and long-term effect of MS treatment need to be guaranteed in terms of preoperative diagnosis and surgical strategy.AIM To analyze preoperative diagnostic methods and the safety,effectiveness,prognosis and related factors of surgical strategies for different types of MS.METHODS The clinical data of MS patients who received surgical treatment from January 1,2010 to December 31,2020 were retrospectively reviewed.Patients with malignancies,choledochojejunal fistula,lack of data and lost to follow-up were excluded.According to preoperative imaging examination records and documented intraoperative findings,the clinical types of MS were determined using the Csendes classification.The safety,effectiveness and long-term prognosis of surgical treatment in different types of MS,and their interactions with the clinical characteristics of patients were summarized.RESULTS Sixty-six patients with MS were included(34 males and 32 females).Magnetic resonance imaging/magnetic resonance cholangiopancreatography(MRI/MRCP)showed specific imaging features of MS in 58 cases(87.9%),which was superior to ultrasound scan(USS)in the diagnosis of MS and more sensitive to subtle biliary lesions than USS.The overall laparoscopic surgery completion rate was 53.03%(35/66),where the completion rates of MS type I,II and III were 69.05%(29/42),42.86%(6/14)and zero(0/10),respectively.Thirty-one patients(46.97%)underwent laparotomy or conversion to laparotomy including 11 cases of iatrogenic bile duct injury which occurred in type I patients,and 25 of these patients underwent bile duct exploration,repair and T-tube drainage.In addition,25 patients underwent intraoperative choledochoscopy and T-tube cholangiography.Overall,21 cases(31.8%)were repaired by simple suturing,and 14 cases(21.2%)were repaired using the remaining gallbladder wall patch in the subtotal cholecystectomy.The ascendant of the Csendes classification types led to an increase in surgical complexity reflected by increased operation time,bleeding volume and cost.Gender,acute abdominal pain and measurable stone size had no effect on Csendes type of MS or final surgical approach.Age had no effect on the classification of MS,but it influenced the final surgical approach,hospital stay and cost.A total of 66 patients obtained a relatively high preoperative diagnostic rate and underwent surgery safely without serious complications,and no mortality was observed during the follow-up period of 36.5±26.5 mo(range 13-76,median 22 mo).CONCLUSION MRI/MRCP can improve the preoperative diagnosis of MS.The Csendes classification can reflect the difficulty of treatment.The surgical strategies including laparoscopic surgery for MS should be formulated based on full evaluation and selection.

Strategies of surgical treatment of the spinal metastatic tumors

Objective To study the clinical features, surgical treatments and the prognosis of the 103 patients with the metastatic tumors in the spine. Methods From Jan. 1996 to Dec. 2001,103 cases were treated by operation in our department, there were 62 males and 41 females, aging from 33 to 79 years old (average,59 years). The lesions were located at cervical spines in 34 cases, thoracic spines in 39,lumbar spines in 25 and sacrum in 5. The patients underwnet anterior, prosterior,combined or staged antero-posterior operations based on the location of lesions in the spine. Most of the patients were adopted vertebral reconstruction and internal fixation depending on the conditions. Preoperative clinical evaluation included of general conditions,X-ray films,CT scan.MRI and ECT in odrer to decide the endurance of the patient to the surgical treatment. The operation was only considered when the patient could have the expected survival time more than 6 months. Operative indications, surgical methods and prognosis

Reasonable choice of surgical procedures for patients with portal hypertension

OBJECTIVE: To assess individualized therapeutic protocol for patients with portal hypertension on the basis of accumulated knowledge about the mechanism of portal hypertension. DATA SOURCES: Patients data on shunt and other surgical procedures from Ruijin Hospital, Shanghai, China and the published papers. RESULTS: The direction of blood flow of the collateral vessels in the gastro-splenic region is an important factor in deciding surgical strategy because there is a close relationship between surgical risk and the classification of liver function. Clinically it is confirmed that each patient needs an individualized surgical procedure and that prophylactic operation is suitable for patients with splenomegaly, splenism associated with serious esophageal varices and hemorrhagic tendency under endoscopy but acceptable liver function. The shunt diameter (SD) (SD=0.67×PVD) is determined in our patients according to individualized hemodynamics. The rehemorrhagic rate after shunt being higher than that in others may be related to lesioned gastric mucosa caused by portal hypertension or bleeding and temporary melena. This finding is good for prevention of hepatic encephalopathy. The life quality and labor ability of patients will be improved because of hepatopetal flow in the portal vein. With strict indications for reoperation, selective operation is performed as soon as possible when hemorrhage is controlled conservatively and liver function improved. Once the patient with cirrhosis associated with portal hypertension is scheduled for liver transplantation, treatment of hemorrhage should aim to keep the patient in good condition and to avoid the protocol that may be disadvantageous to liver transplantation in the future. CONCLUSION: Surgical procedures for patients with portal hypertension should follow the principle of individualization. To obtain the best outcome, the choice of reasonable surgical procedure is expected.

Surgical strategy used in multilevel cervical disc replacement and cervical hybrid surgery:Four case reports

BACKGROUND Multilevel artificial cervical disc replacement and anterior hybrid surgery have been introduced as reliable treatments for multilevel cervical degenerative disc disease.Surgical techniques are important for resolving patients’symptoms and maintaining the normal functioning of cervical implants.However,the use of inappropriate surgical strategies could lead to complications such as implant migration and neurological deficit.In this paper,we summarize our surgical strategies used in multilevel cervical disc replacement and hybrid surgery into five major notes.CASE SUMMARY We share the key notes and our surgical procedures in the form of four typical case presentations.All patients were diagnosed with cervical degenerative disc disease with myelopathy or radiculopathy and needed multilevel cervical spine surgery.The first case demonstrated that index levels indicating the presence of highly serious spinal cord compression required a prioritized decompression.The second case demonstrated that the disc replacement should be performed before fusion in cervical hybrid surgery.The third and forth cases demonstrated that a top-down implantation sequence was needed in continuous two-level cervical disc replacement.The symptoms of all patients were significantly relieved after surgery.CONCLUSION We hope that our surgical strategies can help improve the performance and outcomes of multilevel cervical spine surgery.

Surgical strategy for high-grade isthmic spondylolisthesis of 5th lumbar vertebrae

Objective To investigate surgical strategy for high-grade isthmic spondylolisthesis(more thanⅡ degree)of 5th lumbar vertebrae.Methods From August 2003 to October 2008,26 patients with high-grade isthmic spondylolisthesis (L5) were

Surgical strategy to dural ossification of thoracic spinal stenosis

Objective To explore the surgical strategies of thoracic spinal stenosis with dural ossification.Methods One-hundred and eight patients with thoracic spinal stenosis were treated.Dural ossification was found in 29 cases during operation

Risk factors and strategy for surgical incision infection in department of abdominal surgery

Objective To study the risk factors of surgical wound infection among the patients in department of abodominal surgery. Methods The factors on surgical wound infection were investigated by retrospective study. The diagnosis standard was based on Diagnosis Standard of Hospital Infection published by Ministry of Health.

The surgical strategy of upper cervical dumbbell tumors

Objective To investigate the surgical strategy and prognosis of upper cervical dumbbell tumors.Methods From January 2001 to December 2009,46 consecutive cases with upper cervical dumbbell tumor were retrospec-tively studied on

Surgical strategy for presacral tumors： analysis of 33 cases

Background Presacral tumors are highly infrequent tumors located in the space known as presacral or retrorectal space. Although there have been substantial improvements in the prognosis of patients with malignant presacral tumors, the development of newer surgical strategy is likely to further improve the oncologic outcomes of malignant presacral tumors. The aim of this article was to report our experience in 33 cases, and to review the surgical strategy, pathological features and the prevention of complications from our experience. Methods A retrospective analysis was conducted on 33 cases （20 male and 13 female） with presacral tumors surgically treated in our hospital between January 1998 and April 2009. The surgical approaches included trans-abdominal in 10 cases （30%）, trans-sacral in 18 cases （55%） and combined abdominal-sacral in 5 cases （15%）. All patients got followed up （14-123 months, mean of 45.1 months）. At last, the general information, clinical symptoms, histodiagnosis, surgical types and postoperative complications of all cases in our series were assessed. Results Ages of 33 patients ranged from 18 to 71 years, with an average of 48.5 years. Pathological findings： 6 epidermoid cysts, 5 teratomas, 3 leiomyomas, 9 neurofibromas, 5 neurilemmomas, 1 enterogenous cyst, 1 liposarcoma, 1 leiomyosarcoma, 1 angiosarcoma, and 1 neurofibrosarcoma. All tumors were excised with no perioperative death. A colostomy was taken in one case with angiosarcoma involving the rectum because of the intraoperative injury of the rectum. Blood loss during surgery was 400-11 000 ml （mean of 2400 ml）. Four （12%） cases had local recurrence during follow-up： 2 because of inadequate drainage after dermoidectomy, both of them were cured by surgical resection and drainage; recurrence occurred in a case of teratoma in 18 months after surgery, cured by a trans-sacral excision; local recurrence and lung metastasis occurred simultaneously in a case of angiosarcoma in 6 months postoperatively and the patient died one month later of respiratory failure. Conclusions The main treatment of most presacral tumors is surgical resection. Selection of surgical approach is very important for complete resection of the presacral tumors. The location, size and peculiarities of tumors, conditions of the skin and soft tissues and the patients＇ somatotype are all determinative factors. Multidisciplinary cooperation is also very necessarv.

Preoperative evaluation and surgical strategy for epileptic spasms in children

Epileptic spasm(ES)is one of the most common types of seizures in children.It is primarily characterized by brief axial contractions lasting less than 2 s and recurring in short clusters.It usually occurs in children of 3 to 12 months of age,although it can also occur after the age of 1 year.In general,children with ES develop other symptoms of epilepsy,such as tonic,tonic-clonic,or focal seizures,after 3 to 5 years of age.ES in children is often damaging and usually results in developmental regression.First-line treatments for spasm seizures include adrenocorticotropic hormone(ACTH)and vigabatrin.However,many patients fail to respond to these medications,and continued to have spasms associated with progressive neurodevelopmental degeneration.Therefore,it is important to consider whether children with drug resistance meet surgical indications to consider surgical treatment in such conditions.In this study,we reviewed and summarized the importance of preoperative evaluation in order to provide surgical options for treatment of children with ES.

Therapeutic strategy for traumatic instability of subaxial cervical spine

Background A simple, safe and effective therapeutic strategy for traumatic instability of the subaxial cervical spine, as well as its prognostic assessment, is still controversial. Methods The therapeutic options for 83 patients of traumatic instability of the subaxial cervical spine, whose average age was 35 years, were determined, according to the Allen-Ferguson classification, general health and concomitant traumatic conditions, neurological function, position of compression materials, concomitant traumatic disc herniation/damage, concomitant locked-facet dislocation, the involved numbers and position, and the patients＇ economic conditions. An anterior, posterior or combination approach was used to decompress and reconstruct the cervical spine. No operations with an anterior-posterior-anterior approach were performed. Results The average follow-up was three years and nine months. Distraction-flexion and compression-flexion were the most frequent injury subtypes. There were 46, 28 and 9 cases of anterior, posterior and combination operations, respectively. The average score of the Japanese Orthopaedics Association, visual analog scale and American Spinal Cord Injury Association （ASIA） motor index improved from 11.2, 7.8 and 53.5, respectively, before operation, to 15.3, 2.6 and 67.8, respectively, at final follow-up. For incomplete spinal cord injury （SCI）, the average ASIA neurological function scale was improved by 1-2 levels. Patients with complete SCI had no neurological recovery, but recovery of nerve root function occurred to different extents. After surgery, radiological parameters improved to different extents. Fusion was achieved in all patients and 12 developed complications. Conclusions The best surgical strategy should be determined by the type of subaxial cervical injury, patients＇ general health, local pathological anatomy and neurological function.