Keyhole Approach for Clipping Anterior Circulation Aneurysms: Clinical Outcomes and Technical Note

Purpose: Keyhole craniotomy is a minimally invasive approach for the treatment of anterior circulation aneurysm. In this study, we evaluated the benefits and value of the keyhole approach by analyzing the surgical results in 235 patients with anterior circulation aneurysm treated by the keyhole approach and identifying lessons learned from addressing various complications in this approach.Patients and Methods: This was a retrospective study in a single institution of 235 surgical patients with 248 anterior circulation aneurysms who had the supraorbital keyhole approach (SKA) or pterional keyhole approach (PKA) between January 2016 and January 2021. The modified Rankin Scale (mRS) was used to measure long-term results during follow up.Results: All 235 patients' aneurysms were fully clamped and have not recurred. Among them, 31 (13.2%) had intraoperative aneurysm rupture, 8 (3.4%) had cerebral vascular spasm, and 4 (1.7%) had intraoperative brain edema. There were seven (3.0%) cases of postoperative infection, eight (3.4%) cases of postoperative cerebral infarction, one (0.4%) case of postoperative hematoma, and two (0.8%) patients had some form of cognitive impairment after surgery. Follow up after surgery demonstrated that 189 out of the 235 patients (80.4%) had favorable outcomes (mRS score 0–2), and 43 (18.3%) had poor outcomes (mRS from 3–5). There were three deaths (1.28%).Conclusions: The keyhole approach has a quick postoperative recovery, a mild postoperative response, and a good surgical outcome. Our findings indicate that the keyhole approach is a safe and effective surgical method for the treatment of anterior circulation aneurysm.

Surgical hyperthyroidism: Epidemiological aspect and management difficulties in the visceral surgery department of the Donka National Hospital

Introduction: The aim of this study was to assess the epidemiological aspect and the difficulties associated with the surgical management of hyperthyroidism in our context. Hyperthyroidism is an over function of the thyroid gland resulting in thyrotoxicosis. Thyroidectomy is one of the Main treatments. It also uses synthetic antithyroid drugs, radioactive iodine. Methodology: We carried out a descriptive 6-year retrospective from January 1, 2011 to December 31, 2017 inclusively. Our study variables were qualitative and quantitative, Results: During our study, 26 cases were collected between January 2011 and August 2017 with a predominance of 73% female and an average age of 52, 78 years. The clinic was dominated by the signs of thyrotoxicosis which were found in all patients. The exploration identified 14 cases of toxic multi-hetero nodular goiter, ie 53.84%; 9 cases of basal disease 34, 66% and 3 cases of toxic adenoma 11, 54%. Medical preparation was required in all our patients Total thyroidectomy was performed in one patient, i.e. 4%, and Lobo isthmectomy in 24 patients, ie 96%. Postoperatively, complications were collected: 1 case of intraoperative hemorrhage 20%; 1 case of postoperative hematoma 20%; 1 case of dysphonia 20%. Conclusion: Surgery for toxic goiter known to be hemorrhagic and adherent should be performed after obtaining euthyroidism and double vigilance to minimize the morbidity represented mainly by laryngeal paralysis and hyperparathyroidism

The efficacy of wrapping the neurorrhaphy site utilizing dura substitute: A case series

Background: Different procedures have been developed to improve the surgical outcome of peripheral nerve injuries. The purpose of this study was to evaluate the efficacy of wrapping the neurorrhaphy site utilizing dura substitute graft as an alternative conduit in the management of peripheral nerve injury. Methods: This retrospective clinical case series included 42 patients with a single peripheral nerve injury. The mean age was 26.8 ± 11 years, and the mean duration of symptoms was 3 ± 1.8 months. The visual analogue score (VAS) for pain and the Medical Research Council’s (MRC) grading for motor power were used to evaluate the functional outcome among our patients. All patients were operated on for primary microscopic end-to-end repair, followed by wrapping the neurorrhaphy site with dura substitute graft as a conduit. Patients were followed in the outpatient clinic with regular visits for average of 6 months. Results: Thirty-seven patients (83%), showed functional improvement in all aspects, the VAS for pain and the MRC for motor power, as well as the functional state. One patient (2.3%) developed a postoperative hematoma collection, which needed immediate evacuation. Superficial wound infection, reported in two patients (4.7%), was treated conservatively. No postoperative neuroma was observed among our patients during the follow-up period. Conclusion: Wrapping the neurorrhaphy site utilizing dura substitute as conduit appears to be safe and might prove effective in managing peripheral nerve injury.

Comparison of auricle reconstruction with expanded flaps and auricle reconstruction with non-expanded flaps in patients with microtia: A meta-analysis

Objective We conducted this meta-analysis to compare the efficacy of these two surgical methods by comparing the incidence of major evaluation indicators. Methods The databases such as PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure, Wanfang, and VIP information databases were searched. Results The satisfaction rate of patients with auricle reconstruction using expanded flaps was 86.5%, and the satisfaction rate of patients with auricle reconstruction using non-expanded flaps was 87.9%. The incidence of postoperative hematoma was 3.2% in patients with auricle reconstruction using expanded flaps and 18.9% in patients with auricle reconstruction using non-expanded flaps. The incidence of postoperative skin necrosis was 2.2% in patients with auricle reconstruction using expanded flaps and 4.1% in patients with auricle reconstruction using non-expanded flaps. The incidence of postoperative incision infection was 3.1% in patients with auricle reconstruction using expanded flaps and 0.9% in patients with auricle reconstruction using non-expanded flaps. The incidence of cartilage framework exposure was 2.2% in patients with auricle reconstruction using expanded flaps and 1.9% in patients with auricle reconstruction using non-expanded flaps. The incidence of postoperative scar hyperplasia was 3.8% in patients with auricle reconstruction using expanded flaps and 3% in patients with auricle reconstruction using non-expanded flaps. The publication bias of included literature was evaluated by Egger test. There was no publication bias in this Meta-analysis ( P > .05). Conclusion The auricle reconstruction using non-expanded flaps is dominant in four of the six evaluation indexes. Therefore, we believe that the auricle reconstruction using non-expanded flaps has better therapeutic effect in patients with microtia. Due to the limitations of this meta-analysis, the conclusions of this meta-analysis still need to be further verified.

Combined Endoscopic and Exoscopic Resection of Intracranial Epidermoid Cysts

Objective In the past ten years, a fully endoscopic technique has also been widely used. Exoscope has also been developed for microneurosurgery which offers quality image and convenient manipulation. This article aims at introducing an endoscopic-exoscopic technique for the resection of epidermoid cysts. Methods We retrospectively analyzed the patients with intracranial epidermoid cysts who received whole course combined endoscopic and exoscopic resection between 2017 and 2020 at our institution, to explore the benefit of combined endoscopic and exoscopic resection of intracranial epidermoid cysts and evaluated the clinical utility of endoscopic-exoscopic technique. Results A total of 17 patients were enrolled in the study. Of all patients, 6 patients (6/17, 35.3%) underwent total resection, 10 patients (10/17, 58.8%) underwent subtotal resection (residual capsule and/or) and 1 patients (1/17, 5.9%) underwent partial resection. Postoperative surgical complications were seen in 3 patients (3/17, 17.6%), including intracranial infection in 2 patients (2/17, 11.8%), and a delayed postoperative hematoma observed in the seventh day after operation for 1 patient (1/17, 5.9%), who was treated in a conservative manner and recovered smoothly from the hemorrhage. The median follow-up time was 33.3 months (range 14.5-54.5 months). During the follow-up period, there was no recurrence of the tumors that received total resection. 2 patients developed residual tumor regrowth but did not show any symptom therefore no further surgery was required. Conclusions Endoscopic-exoscopic technique is safe and efficient in the resection of intracranial epidermoid cysts with panoramic views and superior maneuverability. With further development and accumulation of practical experiences, the endoscopic-exoscopic technique can also be applied in the resection of other intracranial tumors.

Symptomatic Epidural Hematoma After Elective Cervical Spine Surgery: Incidence, Timing, Risk Factors, and Associated Complications

BACKGROUND As the rate of elective cervical spine surgery increases, studies of complications may improve quality of care. Symptomatic postoperative cervical epidural hematomas (PCEH) are rare but result in significant morbidity. Because of their low incidence, the risk factors and complications associated with symptomatic PCEH remain unclear. OBJECTIVE To clarify the prevalence, timing, variables, and complications associated with PCEH following elective cervical spine surgery. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program database, cervical spine surgeries performed between 2012 and 2016 were identified using Current Procedural Terminology codes. Symptomatic PCEH was defined as readmission or reoperation events specifically associated with International Classification of Diseases code diagnoses of postoperative hematoma within 30 d of index surgery. Multivariate models were created to assess the independent association of symptomatic PCEH with other postoperative complications. RESULTS There were 53233 patients included for analysis. The overall incidence of symptomatic PCEH was 0.4% (n = 198). Reoperation occurred in 158 cases (78.8%), of which 2 required a second reoperation (1.3%). The majority (91.8%) of hematomas occurred within 15 d of surgery. Multivariate analysis identified male gender, American Society of Anesthesiologists classes 3 to 5, bleeding disorder, increasing number of operative levels, revision surgery, dural repair, and perioperative transfusion as independent factors associated with PCEH. Upon controlling for those confounders, PCEH was independently associated with cardiac arrest, stroke, deep vein thrombosis, surgical site infection, and pneumonia. CONCLUSION Postoperative epidural hematomas requiring readmission or reoperation following elective cervical spine surgery occurred at an incidence of 0.4%. Symptomatic PCEHs are associated with increased rates of numerous major morbidities.

Evaluation of Pure Endoscopic Endonasal Approach in Management of Giant Pituitary Adenoma

Background Giant pituitary adenoma represents one of the challenging tumor for neurosurgeons. Many microsurgical approaches in the past were used for its management. Recently and with evolution of the endoscopic equipment and instruments, extended endoscopic transsphenoidal approach become one of the preferable approaches for its surgical excision. Methods We prospectively document the clinical , surgical and follow up data for all patients presented with giant pituitary adenoma to Ain-Shams university hospital and Weill Cornell Medical College, Presbyterian hospital and were surgically treated with extended transsphenoidal approach from 2015 till 2019. Results Our group study formed of 44 patients with mean age 53.03 (range 14.7-82.4) and a male predominance (59%). The main presentation was visual problems in 75% followed by partial hypopituitarism in 31.81% while headache was in 13.64%. Only 4 patients had functioning adenoma (3 prolactinoma and 1 acromegaly). Average tumor volume was 26.95 ± 17.25 cm3, while the mean maximum tumor diameter was 4.73 cm (range 4.0-8.0 cm). Radiographic invasion was found in 97.73% to suprasellar cistern, 61.36% to the cavernous sinus and in 34% to the sphenoid sinus. GTR was achieved in 45.45% with Knosp score is the only significant predictor factor for resection rate (p = 0.04). Visual improvement achieved in 75.76%. 50% (2 patient) of the patients with functioning adenoma were cured. Complications included CSF leak in 3 patients, permanent DI in 4 patients and postoperative hematoma in 2 patients. Recurrence and progression rates without upfront radiation therapy were 5.00 % and 31.81% respectively after mean follow up period 57.90 months. Conclusions Extended endoscopic approaches for achieving maximum resection with minimal morbidity for giant pituitary adenoma are very effective. Lateral tumor extension with cavernous sinus invasion represents the limiting point in achieving gross total resection. Upfront radiation therapy for patients with residual adenoma can be avoided but regular follow up should be warranted.

Nonsteroidal Anti-inflammatory Drugs (NSAID) Do Not Increase Blood Loss or the Incidence of Postoperative Epidural Hematomas When Using Minimally Invasive Fusion Techniques in the Degenerative Lumbar Spine

Objective: Nonsteroidal anti-inflammatory drugs (NSAID) are essential in surgeons’ armamentarium for pain relief and antiphlogistic effects. However, spine surgeons are concerned about the drugs’ impact on coagulation, fearing hemodynamic instability due to blood loss and neurological complications due to postoperative hematoma. Furthermore, there are no clear guidelines for the use of these drugs.Materials and methods: In this retrospective subgroup analysis of a prospective observational study, we investigated 181 patients who underwent minimally invasive spinal fusions in degenerative lumbar spine pathologies. 83 patients were given NSAID perioperatively, 54 of which were female and 29 male. Of these patients who took NSAID, 39 were on NSAID until at least one day before surgery or perioperatively, whilst the others discontinued their NSAID medication at least three days before surgery. Differences in perioperative blood loss, as well as complication rates between patients with and without NSAID treatment, were investigated.Results: A significantly higher amount of blood loss during surgery and the monitoring period was encountered in patients whose spine was fused in more than one level, regardless of whether NSAID medication was taken or not and up until what point. Furthermore, it was found that taking NSAID medication had no effect on the incidence of postoperative epidural hematomas.Conclusion: Perioperatively taking NSAID medication does not increase blood loss or the incidence of postoperative hematoma in patients undergoing minimally invasive lumbar spinal fusion surgery.

A Systematic Review and Meta-Analysis Evaluating the Impact of Tranexamic Acid Administration in Aesthetic Plastic Surgery

Background Recent evidence suggests tranexamic acid (TXA) may improve outcomes in aesthetic surgery patients. Objectives This systematic review aimed to investigate the impact of TXA use in aesthetic plastic surgery on bleeding and aesthetic outcomes. Methods A systematic literature search was conducted to identify studies evaluating TXA use in aesthetic plastic surgery. The primary outcome of interest was perioperative bleeding, reported as total blood loss (TBL), ecchymosis, and hematoma formation. Meta-analyses analyzing TBL, and postoperative hematoma were performed. Results Of 287 identified articles, 14 studies evaluating TXA use in rhinoplasty (6), rhytidectomy (3), liposuction (3), reduction mammaplasty (1), and blepharoplasty (1) were included for analysis. Of 820 total patients, 446 (54.4%) received TXA. Meta-analysis demonstrated TXA is associated with 26.3mL average blood loss reduction (95% CI: -40.0mL to -12.7mL, p < 0.001) and suggested a trend toward decreased odds of postoperative hematoma with TXA use (OR: 0.280, 95% CI: 0.076 - 1.029, p = 0.055). Heterogeneity among reporting of other outcomes precluded meta-analysis; however, 5 of 7 studies found significantly decreased postoperative ecchymosis levels within 7 days of surgery, three studies found statistically significant reductions in postoperative drain output, and one study reported significantly improved surgical site quality for patients who received TXA (p = 0.001). Conclusions TXA is associated with decreased blood loss and a trend toward decreased hematoma formation in aesthetic plastic surgery. Its use has the potential to increase patient satisfaction with postoperative recovery and decrease costs associated with complications, including hematoma evacuation.

DECOMPRESSIVE LAMINECTOMY IN PATIENTS WITH SPINE METASTASIS

The aim is to present the experience of treating patients with spinal metastases, who underwent decompression laminectomy with posterior stabilization.Material and methods. The study included 326 patients with spine metastasis, who underwent posterior thoracic laminectomy (199, 61 %) and lumbar laminectomy (127, 39 %). The mean age of patients was 63 (range, 29–78 years). There were 91 (28 %) males and 235 (72 %) females. Breast cancer was diagnosed in 137 (42 %) patients, kidney cancer in 69 (21 %) patients, prostate cancer in 39 (12 %) patients, lung cancer in 19 (6 %) patients, colorectal cancer in 16 (5 %) patients, thyroid cancer in 13 (4 %) patients, and the remaining 10 % of patients accounted for other more rare forms of malignanciesResults. The mean time of surgery was 95 min. (55–245 min.). Intraoperative blood loss volume was 245 ml (150–3200 ml). The mean hospital stay was 8 days (5–20 days). The pain intensity according to vas reduced in 160 (49 %) patients. According to the frankel classification system, neurological status improved in 85 (26 %) patients. Neurological deterioration was observed in 7 (2 %) patients. Intra-and early-/late postoperative complications were observed in 66 (20 %) patients. Traumatic dural tears occurred in 16 (5 %) patients. Infection rate was 4.5 %. Cardiac complications were observed in 12 (3.5 %) patients. Postoperative hematoma was revealed in 7 (2.4 %) patients.Conclusion. The results obtained indicate that patients with metastatic spine disease represent a difficult group of patients for surgical treatment because of a high risk of developing postoperative complications, the most serious of which are neurological disorders with paraplegia and other fatal outcomes. Nevertheless, modern surgical techniques can improve the quality of life of these patients, improve psycho-emotional abilities and avoid disability.