Kidney-sparing surgery for upper tract urothelial cancer.

PURPOSE OF REVIEW: This article reviews and summarizes current knowledge on kidney-sparing surgery (KSS) for upper tract urothelial carcinoma (UTUC). RECENT FINDINGS: Radical nephroureterectomy (RNU) has been central to the treatment of UTUC for decades, but KSS has been applied to a rising number of patients to preserve renal function. Ablation or resection through flexible ureteroscopy or the percutaneous route seems to provide comparable cancer-specific survival and overall survival to RNU, but the risk of local and bladder recurrence remains relatively high. Segmental ureterectomy is used for low-risk unifocal UTUC with recent studies confirming its oncologic safety and equivalence to RNU. Antegrade or retrograde instillation therapy may be considered as adjuvant treatment after conservative surgery, but their efficacy needs to be proven. Intravesical single-dose chemotherapy is likely to become part of the therapy algorithm of UTUC treated by KSS or RNU to lower bladder seeding and recurrence. Postoperative vigilant radiographic and endoscopic surveillance are obligatory because of the high probability of recurrence. SUMMARY: KSS should be regarded as a valid alternative to RNU in case of technically resectable low-risk upper tract urothelial cell carcinoma, even in case of a normal contralateral kidney. Advances in technology and biological and clinical risk estimation will make the management of UTUC more evidence based thereby lowering overtreatment.

Investigations of a thermosensitive gel to temporarily occlude crural arteries in femoro-distal bypass surgery.

OBJECTIVES: Long occlusions in calcified crural arteries are a major cause of endovascular technical failure in patients with critical limb ischaemia. Therefore, distal bypasses are mainly performed in patients with heavily calcified arteries and with consequently delicate clamping. A new reverse thermosensitive polymer (RTP) is an alternative option to occlude target vessels. The aim of the study is to report our technical experience with RTP and to assess its safety and efficiency to temporarily occlude small calcified arteries during anastomosis time. METHODS: Between July 2010 and December 2011, we used RTP to occlude crural arteries in 20 consecutive patients with 20 venous distal bypasses. We recorded several operative parameters, such as volume of injected RTP, duration of occlusion and anastomotic time. Quality of occlusion was subjectively evaluated. Routine on-table angiography was performed to search for plug emboli. Primary patency, limb salvage and survival rates were reported at 6 months. RESULTS: In all patients, crural artery occlusion was achieved with the RTP without the use of an adjunct occlusion device. Mean volume of RTP used was 0.3 ml proximally and 0.25 ml distally. Mean duration of occlusion was 14.4 ± 4.5 min, while completion of the distal anastomosis lasted 13.4 ± 4.3 min. Quality of occlusion was judged as excellent in eight cases and good in 12 cases. Residual plugs were observed in two patients and removed with an embolectomy catheter, before we amended the technique for dissolution of RTP. At 6 months, primary patency rate was 75% but limb salvage rate was 87.5%. The 30-day mortality rate was 10%. CONCLUSIONS: This study shows that RTP is safe when properly dissolved and effective to occlude small calcified arteries for completion of distal anastomosis.

Results of Anterior Tucking of the Superior Oblique Muscle Tendon in Bilateral Fourth Nerve Palsy.

Background: Bilateral fourth nerve palsy is characterised by excyclotorsion, which can be corrected by reinforcement of the anterior tendon fibres of the superior oblique muscle. Patients and Methods: A retrospective study of 40 consecutive patients with bilateral acquired fourth nerve palsy operated by a selective tuck of the anterior portion of the superior oblique tendon between 1994 and 2012 was undertaken. Horizontal, vertical and torsional deviations were measured in 9 diagnostic positions of gaze and the field of binocular single vision was evaluated with the Harms tangent screen. Postoperative follow-ups took place at 1 week, 6 months, and ≥ 3 years. Results: Preoperative mean excyclotorsion was 9° in the primary position and 15° in downgaze. These values decreased to 2° and 5° 6 months after surgery, and 2.5° and 6° at ≥ 3 years. Immediate post-operative incyclotorsion in upgaze (28 patients) and Brown syndrome (15 patients) regressed spontaneously. The median score of field of binocular single vision improved from 4 % preoperatively to 76 % postoperatively. Conclusions: The selective tuck of the anterior tendon fibers of the superior oblique tendon enables an efficient and long-lasting correction of the ocular torsion induced by bilateral trochlear palsy.

Percutaneous coronary interventions prior to coronary artery bypass surgery.

BACKGROUND AND AIM OF THE STUDY: Percutaneous coronary interventions (PCI) are frequently performed before coronary artery bypass graft (CABG) surgery. This study sought to evaluate postoperative outcomes, and incidence of recurrent target ischemia in vessels with prior PCI in patients who had PCI prior to CABG compared to only CABG patients. METHODS: A review included CABG patients operated from 2000 to 2012. PCI prior to CABG patients were compared with patients having had CABG on native coronary arteries. Demographic and risk factors, including hospital morbidity, mortality, and recurrent target vessel ischemia at follow-up (FU), were compared. Major end-points were statistical differences of postoperative morbidity and reintervention rates due to symptomatic graft failure or target vessel ischemia during FU. RESULTS: Twenty-four percent of 1669 isolated CABG patients had PCI prior to CABG, with an increasing percentage during recent years. Demographics, risk factors, comorbidities and mortality rates were similar. Incidence of postoperative hemorrhage (OR 1.9; 95% CI 1.1-3.2; p = 0.02), perioperative myocardial infarction rate (p = 0.02), neurological deficits (OR 3.5; 95% CI 1.2-9.7; p = 0.02) and re-intervention rate for symptomatic graft or target vessel occlusion were higher in pretreated patients (OR 1.8; 95% CI 1.1-3.0; p = 0.01). CONCLUSIONS: PCI prior to CABG increases the risk for postoperative morbidity. Increased postoperative hemorrhage could be attributed to ongoing double anti-platelet therapy. doi: 10.1111/jocs.12514 (J Card Surg 2015;30:313-318).

Cure de hernie inguinale en ambulatoire [Outpatient hernia surgery].

Inguinal hernias are frequent and have an enormous socio-economic impact. Surgical treatment is indicated in most of the patients to relieve symptoms and to prevent complications. Modem treatment should focus on low complication and recurrence rates, short recovery times, and--last but not least acceptable costs. Inguinal hernia repair can be carried out by an open or minimal invasive approach. Surgery is traditionally performed under general anesthesia, but local or locoregional anesthesia are other feasible options. Nowadays, inguinal hernia surgery can easily performed as an outpatient procedure. However, stringent selection criteria, an optimized infrastructure and a close and standardized follow-up are mandatory prerequisites in order to obtain excellent results under secure conditions.

Randomized clinical trial on epidural versus patient-controlled analgesia for laparoscopic colorectal surgery within an enhanced recovery pathway.

OBJECTIVE: To compare epidural analgesia (EDA) to patient-controlled opioid-based analgesia (PCA) in patients undergoing laparoscopic colorectal surgery. BACKGROUND: EDA is mainstay of multimodal pain management within enhanced recovery pathways [enhanced recovery after surgery (ERAS)]. For laparoscopic colorectal resections, the benefit of epidurals remains debated. Some consider EDA as useful, whereas others perceive epidurals as unnecessary or even deleterious. METHODS: A total of 128 patients undergoing elective laparoscopic colorectal resections were enrolled in a randomized clinical trial comparing EDA versus PCA. Primary end point was medical recovery. Overall complications, hospital stay, perioperative vasopressor requirements, and postoperative pain scores were secondary outcome measures. Analysis was performed according to the intention-to-treat principle. RESULTS: Final analysis included 65 EDA patients and 57 PCA patients. Both groups were similar regarding baseline characteristics. Medical recovery required a median of 5 days (interquartile range [IQR], 3-7.5 days) in EDA patients and 4 days (IQR, 3-6 days) in the PCA group (P = 0.082). PCA patients had significantly less overall complications [19 (33%) vs 35 (54%); P = 0.029] but a similar hospital stay [5 days (IQR, 4-8 days) vs 7 days (IQR, 4.5-12 days); P = 0.434]. Significantly more EDA patients needed vasopressor treatment perioperatively (90% vs 74%, P = 0.018), the day of surgery (27% vs 4%, P < 0.001), and on postoperative day 1 (29% vs 4%, P < 0.001), whereas no difference in postoperative pain scores was noted. CONCLUSIONS: Epidurals seem to slow down recovery after laparoscopic colorectal resections without adding obvious benefits. EDA can therefore not be recommended as part of ERAS pathways in laparoscopic colorectal surgery.

Patients' preferences on information and involvement in decision-making in gastrointestinal surgery

Contexte et but de l'étude: La relation médecin-patient a subi d'importants changements et l'actuelle émancipation des patients a conduit à un véritable partenariat dans la prise de décisions thérapeutiques. Notre étude a pour but de déterminer les préférences des patients pour différents aspects de la prise de décisions au cours d'un traitement et de ses potentielles complications, de même que la quantité et le type d'information souhaitée avant une intervention chirurgicale digestive. Patients et méthodes : Il s'agit d'une étude prospective non-randomisée basée sur un questionnaire donné lors de la consultation préopératoire à 254 patients consécutifs prévus pour une chirurgie gastro-intestinale élective. Résultats : Pour les potentielles complications chirurgicales et la possibilité d'un séjour aux soins intensifs, 64% des patients souhaitent participer activement aux décisions médicales, et respectivement 89% et 60% des patients aimeraient discuter d'une éventuelle réanimation cardio-pulmonaire et de limitations au traitement. Respectivement 73%, 77% et 47% des patients ont souhaité une information très détaillée, une infoimation pour une possible hospitalisation en soins intensifs ou une éventuelle réanimation cardiaque. Les patients âgés ou avec un niveau de formation bas étaient significativement moins intéressés à une prise de décision partagée (p=0.003 et 0.015) et à une information complète (p=0.03 et 0.05), De plus, l'implication des familles dans les prises de décision n'était favorisée que si le patient est en coma (74%), et significativement moins importante chez les personnes âgées et de sexe masculin (p=0.04 et 0.03 respectivement). Ni le type de chirurgie prévue (majeure ou mineure) ni la sévérité de la pathologie (cancer ou non) ne furent des facteurs statistiquement significatifs pour un désir plus élevé de partager la prise de décision, pour plus d'information ou pour impliquer d'avantage la famille. Conclusions : Notre étude démontre que la majorité des patients chirurgicaux souhaitent recevoir une information préopératoire complète concernant leur maladie et le traitement planifié. Ils considèrent également comme crucial d'être impliqués dans les prises de décisions thérapeutiques pour le traitement et pour les possibles complications. Le rôle de la famille est limité aux situations ou le patient n'est plus en mesure de participer aux décisions.

Rétablissement postopératoire optimisé, applique aux patients après cystectomie [Enhanced recovery after surgery applied to cystectomy patients].

Enhanced Recovery After Surgery (ERAS) is a multimodal concept combining pre, intra and postoperative evidence-based care elements to reduce surgical stress. ERAS pathways have been shown to significantly reduce morbidity, length of hospital stay and total costs when applied to colorectal surgery. It is therefore considered standard of care in this specialty. There can be no doubt that ERAS principles can be applied also in other major surgeries. However, uncritical application of the guidelines issued from colonic procedures seems inappropriate as the surgical procedures in pelvic cancer surgery differ considerably. This article reports on the first steps of an ERAS project and his introduction in urology.

Transanal minimal invasive surgery for rectal lesions: should the defect be closed?

AIM: Transanal minimal invasive surgery (TAMIS) of rectal lesions is increasingly being used, but the technique is not yet standardized. The aims of this study were to evaluate peri-operative complications and long-term functional outcome of the technique and to analyse whether or not the rectal defect needs to be closed. METHOD: Consecutive patients undergoing TAMIS using the SILS port (Covidien) and standard laparoscopic instruments were studied. RESULTS: Seventy-five patients (68% male) of mean age 67 (± 15) years underwent single-port transanal surgery at three different centres for 37 benign lesions and 38 low-risk cancers located at a mean of 6.4 ± 2.3 cm from the anal verge. The median operating time was 77 (25-245) min including a median time for resection of 36 (15-75) min and for closure of the rectal defect of 38 (9-105) min. The defect was closed in 53% using interrupted (75%) or a running suture (25%). Intra-operative complications occurred in six (8%) patients and postoperative morbidity was 19% with only one patient requiring reoperation for Grade IIIb local infection. There was no difference in the incidence of complications whether the rectal defect was closed or left open. Patients were discharged after 3.4 (1-21) days. At a median follow-up of 12.8 (2-29) months, the continence was normal (Vaizey score of 1.5; 0-16). CONCLUSION: Transanal rectal resection can be safely and efficiently performed by means of a SILS port and standard laparoscopic instruments. The rectal defect may be left open and at 1 year continence is not compromised.

Réhabilitation améliorée après chirurgie--L'ere de la prise en charge optimale du patient chirurgical [Enhanced Recovery After Surgery--optimal management of the surgical patient].

Enhanced Recovery After Surgery (ERAS) is a multimodal, standardized and evidence-based perioperative care pathway. With ERAS, postoperative complications are significantly lowered, and, as a secondary effect, length of hospital stay and health cost are reduced. The patient recovers better and faster allowing to reduce in addition the workload of healthcare providers. Despite the hospital discharge occurs sooner, there is no increased charge of the outpatient care. ERAS can be safely applied to any patient by a tailored approach. The general practitioner plays an essential role in ERAS by assuring the continuity of the information and the follow-up of the patient.

Essential surgery: the way forward.

INTRODUCTION: Very little surgical care is performed in low- and middle-income countries (LMICs). An estimated two billion people in the world have no access to essential surgical care, and non-surgeons perform much of the surgery in remote and rural areas. Surgical care is as yet not recognized as an integral aspect of primary health care despite its self-demonstrated cost-effectiveness. We aimed to define the parameters of a public health approach to provide surgical care to areas in most need. METHODS: Consensus meetings were held, field experience was collected via targeted interviews, and a literature review on the current state of essential surgical care provision in Sub-Saharan Africa (SSA) was conducted. Comparisons were made across international recommendations for essential surgical interventions and a consensus-driven list was drawn up according to their relative simplicity, resource requirement, and capacity to provide the highest impact in terms of averted mortality or disability. RESULTS: Essential Surgery consists of basic, low-cost surgical interventions, which save lives and prevent life-long disability or life-threatening complications and may be offered in any district hospital. Fifteen essential surgical interventions were deduced from various recommendations from international surgical bodies. Training in the realm of Essential Surgery is narrow and strict enough to be possible for non-physician clinicians (NPCs). This cadre is already active in many SSA countries in providing the bulk of surgical care. CONCLUSION: A basic package of essential surgical care interventions is imperative to provide structure for scaling up training and building essential health services in remote and rural areas of LMICs. NPCs, a health cadre predominant in SSA, require training, mentoring, and monitoring. The cost of such training is vastly more efficient than the expensive training of a few polyvalent or specialist surgeons, who will not be sufficient in numbers within the next few generations. Moreover, these practitioners are used to working in the districts and are much less prone to gravitate elsewhere. The use of these NPCs performing "Essential Surgery" is a feasible route to deal with the almost total lack of primary surgical care in LMICs.

Prospective motion correction of 3D echo-planar imaging data for functional MRI using optical tracking.

We evaluated the performance of an optical camera based prospective motion correction (PMC) system in improving the quality of 3D echo-planar imaging functional MRI data. An optical camera and external marker were used to dynamically track the head movement of subjects during fMRI scanning. PMC was performed by using the motion information to dynamically update the sequence's RF excitation and gradient waveforms such that the field-of-view was realigned to match the subject's head movement. Task-free fMRI experiments on five healthy volunteers followed a 2×2×3 factorial design with the following factors: PMC on or off; 3.0mm or 1.5mm isotropic resolution; and no, slow, or fast head movements. Visual and motor fMRI experiments were additionally performed on one of the volunteers at 1.5mm resolution comparing PMC on vs PMC off for no and slow head movements. Metrics were developed to quantify the amount of motion as it occurred relative to k-space data acquisition. The motion quantification metric collapsed the very rich camera tracking data into one scalar value for each image volume that was strongly predictive of motion-induced artifacts. The PMC system did not introduce extraneous artifacts for the no motion conditions and improved the time series temporal signal-to-noise by 30% to 40% for all combinations of low/high resolution and slow/fast head movement relative to the standard acquisition with no prospective correction. The numbers of activated voxels (p<0.001, uncorrected) in both task-based experiments were comparable for the no motion cases and increased by 78% and 330%, respectively, for PMC on versus PMC off in the slow motion cases. The PMC system is a robust solution to decrease the motion sensitivity of multi-shot 3D EPI sequences and thereby overcome one of the main roadblocks to their widespread use in fMRI studies.

Biphasic response of a tecto-mesencephalic pilocytic astrocytoma after Gamma Knife surgery - A case report.

Biphasic response (shrinkage-regrowth-shrinkage) of tumors has never previously been reported in the postoperative course, neither after microsurgery, nor after Gamma Knife surgery (GKS). We present the case of an adult with dorsal midbrain syndrome resulting from a pilocytic astrocytoma centered on the mesencephalic tectum. The tumor extended to the third ventricle and the thalamus. Initially, due to tumor growth, a biopsy was performed and histology established. Later, a ventriculocisternostomy for obstructive hydrocephalus was performed. Finally, GKS was performed, as the tumor continued to grow. After GKS, the lesion exhibited a biphasic response, with a major shrinkage at 3 months, regrowth within the target volume at 6 and 9 months and a second phase of important shrinkage at 12 months, which persisted for the next two years. The possible mechanisms for this particular response pattern are discussed.