The authors previously described a graded approach to skull base repair following endonasal microscopic or endoscope-assisted tumor surgery. In this paper they review their experience with skull base ...reconstruction in the endoscopic era.
A retrospective review of a single-institution endonasal endoscopic patient database (April 2010–April 2017) was undertaken. Intraoperative CSF leaks were graded based on size (grade 0 no leak, 1, 2, or 3), and repair technique was documented across grades. The series was divided into 2 epochs based on implementation of a strict perioperative antibiotic protocol and more liberal use of permanent and/or temporary buttresses; repair failure rates and postoperative meningitis rates were assessed for the 2 epochs and compared.
In total, 551 operations were performed in 509 patients for parasellar pathology, including pituitary adenoma (66%), Rathke’s cleft cyst (7%), meningioma (6%), craniopharyngioma (4%), and other (17%). Extended approaches were used in 41% of cases. There were 9 postoperative CSF leaks (1.6%) and 6 cases of meningitis (1.1%). Postoperative leak rates for all 551 operations by grade 0, 1, 2, and 3 were 0%, 1.9%, 3.1%, and 4.8%, respectively. Fat grafts were used in 33%, 84%, 97%, and 100% of grade 0, 1, 2, and 3 leaks, respectively. Pedicled mucosal flaps (78 total) were used in 2.6% of grade 0–2 leaks (combined) and 79.5% of grade 3 leaks (60 nasoseptal and 6 middle turbinate flaps). Nasoseptal flap usage was highest for craniopharyngioma operations (80%) and lowest for pituitary adenoma operations (2%). Two (3%) nasoseptal flaps failed. Contributing factors for the 9 repair failures were BMI ≥ 30 (7/9), lack of buttress (4/9), grade 3 leak (4/9), and postoperative vomiting (4/9). Comparison of the epochs showed that grade 1–3 repair failures decreased from 6/143 (4.1%) to 3/141 (2.1%) and grade 1–3 meningitis rates decreased from 5 (3.5%) to 1 (0.7%) (p = 0.08). Prophylactic lumbar CSF drainage was used in only 4 cases (< 1%), was associated with a higher meningitis rate in grades 1–3 (25% vs 2%), and was discontinued in 2012. Comparison of the 2 epochs showed increase buttress use in the second, with use of a permanent buttress in grade 1 and 3 leaks increasing from 13% to 55% and 32% to 76%, respectively (p < 0.001), and use of autologous septal/keel bone as a permanent buttress in grade 1, 2, and 3 leaks increasing from 15% to 51% (p < 0.001).
A graded approach to skull base repair after endonasal surgery remains valid in the endoscopic era. However, the technique has evolved significantly, with further reduction of postoperative CSF leak rates. These data suggest that buttresses are beneficial for repair of most grade 1 and 2 leaks and all grade 3 leaks. Similarly, pedicled flaps appear advantageous for grade 3 leaks, while CSF diversion may be unnecessary and a risk factor for meningitis. High BMI should prompt an aggressive multilayered repair strategy. Achieving repair failure and meningitis rates lower than 1% is a reasonable goal in endoscopic skull base tumor surgery.
ObjectivesIn 2001, we instituted a protocol for the removal of retained tympanostomy tubes, delaying elective removal until 2.5 years after placement. It was hoped that this would decrease the number ...of surgeries without increasing the rate of permanent tympanic perforations compared to removal at 2 years.MethodsProtocol: Fluoroplastic Armstrong beveled grommet tympanostomy tubes were placed by a single surgeon supervising the residents. The children were seen at 6‐month intervals after placement. Children with a retained tympanostomy tube(s) at 2 years were seen again at 2.5 years, and the retained tubes were removed under general anesthesia with patch application. All were evaluated 4 weeks after surgery by otoscopy, otomicroscopy, behavioral audiometry, and tympanometry. Study: A computerized collection of patient letters and operative reports was queried to identify children treated according to the protocol between 2001 and 2022. Those with examinations at 2 years ± 1 month and 2.5 years ± 1 month and complete follow‐up were included.ResultsOf the 3552 children with tympanostomy tubes, 497 (14%) underwent tube removal. One‐hundred and forty seven children fit the strict inclusion criteria. Among those with retained tubes at 2 years, 67/147 (46%) had lost any remaining tube or tubes at 2.5 years and did not need surgery, 80/147 (54%) required unilateral or bilateral tube removal, 9/147 (6%) had a persistent perforation at 1‐year follow‐up, and 4/147 children (3%) required tympanic re‐intubation after either spontaneous extrusion or removal and patching at 2.5 years.ConclusionsDelaying tympanostomy tube removal until 2.5 years can cut the need for surgery in half with, an acceptable (6%) incidence of persistent perforations.Level of EvidenceFour case series—historical control Laryngoscope, 134:439–442, 2024
Pelvic exenteration was first described by Alexander Brunschwig in 1948 in New York as a palliative procedure for recurrent carcinoma of the cervix. Because of initially high rates of morbidity and ...mortality, the practice of this ultraradical operation was largely confined to a small number of American centers for most of the 20 century. The post-World War II era saw advances in anaesthesia, blood transfusion, and intensive care medicine that would facilitate the evolution of more radical and heroic abdominal and pelvic surgery. In the last 3 decades, pelvic exenteration has continued to evolve into one of the most important treatments for locally advanced and recurrent rectal cancer. This review aimed to explore the evolution of pelvic exenteration surgery and to identify the pioneering surgeons, seminal articles, and novel techniques that have led to its current status as the procedure of choice for locally advanced and recurrent rectal cancer.
Interdisciplinary Cleft Care: Global Perspectives draws from the rich national and international relationships between the Global Smile Foundation and world experts in cleft care to provide ...comprehensive, clear, and user-friendly content for all cleft care professionals. This text is designed to be an inclusive resource that addresses the educational needs of all cleft care providers, from novice learners looking to develop their area's first multidisciplinary cleft team to seasoned specialists looking to improve their outcomes.v.
In front of a primary retroperitoneal tumour, it is necessary to have in mind all possible diagnoses in order to specify the diagnostic strategy and the treatment. According to the World Health ...Organization (WHO) classification of tumours, mesenchymal benign and malignant tumours (including sarcomas and, currently, neurogenic tumours), parasympathetic tumours, extragonadal germ cell tumours, and lymphoid tumours have been identified. By definition, primary retroperitoneal tumours start independently from the retroperitoneal organs. Secondary lesions, carcinoma metastasis, and adenopathy are excluded from this definition, but they can also develop in the retroperitoneal space and lead to misdiagnoses. In the absence of positive tumour markers or an evocative biology, percutaneous biopsy is necessary. Pathological diagnosis is necessary to decide whether surgery must be done, its timing among the other treatments, and its extension. This paper summarizes all the diagnostic possibilities.
-Retro- and infraperitoneal tumours: Percutaneous biopsy is the standard of care. In fact, the indications for and extent of surgery depends on the diagnosis.-Both the early complication rate and the incidence of needle tract seeding of per cutaneous biopsy of an RP mass are very low.-The well-differentiated components of liposarcomas are often underestimated, leading to incomplete surgery, which definitely worsens prognosis.-The surgical standard of care for sarcoma is a complete, non-fragmented, en bloc resection with clear margins on the larger surface. Typical resection is a compartmental surgery, with en bloc resection of the kidney, colon, and psoas fascia. Adjustments are made according to the histological subtype.-Sarcoma surgery must be performed in a referral sarcoma centre.
Abstract Facial feminization surgery (FFS) is a group of surgical procedures; the objectives of which are to change the features of a male face to that of a female face. This surgery does not aim to ...rejuvenate the face. FFS is carried out almost exclusively on transsexual women (males who are transitioning into females) and who have gender dysphoria. Some non-transsexual women may undergo some feminizing surgical procedures if they feel that they have male facial characteristics. Most transsexual women will have lived in role for sometime and they often undergo FFS before any other form of gender reassignment surgery as it assists them in passing as a female and integrating into everyday society. Various specific facial surgical procedures are utilized to feminize the face, often involving sculpture and contouring of the facial skeleton. These include correction of the hairline by scalp advance, contouring the forehead, brow lift, rhinoplasty, cheek implants, resection of the buccal fat pads of Bichat, lip lift and lip augmentation with dermis graft, mandible angle reduction and taper, genioplasty and thyroid shave. This article discusses the current state of the art in facial feminization surgery.
Background
This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing ...recommendations for each ERAS item within the ERAS® protocol.
Methods
A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations.
Results
The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries.
Conclusion
A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.
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