Combined Techniques for Bilateral Maxillary and Nasal Reconstruction After Ablative Surgery for Adenoid Cystic Carcinoma

Indolent tumor growth up to large tumor masses and broad infiltration of surrounding tissue are the most typical characteristics of malignant tumors of the nasal cavity and paranasal sinuses. If surgery is a therapeutic option, extended resections and complex reconstruction modalities have to be taken into account. We present a combination of different reconstruction techniques to restore midface integrity after bilateral maxillectomy, including parts of the nasal skeleton, for adenoid cystic carcinoma. After obtaining tumor-free margins, reconstruction was performed using a microvascular double-flap technique to achieve a neo-maxilla and soft tissue lining of the oral cavity, dental implantology with prosthetic restoration and the insertion of a patient-specific implant for nasal re-shaping and stability. In cases of extended maxillary resection, a combination of different techniques can achieve sufficient functional and aesthetic rehabilitation, and restore quality of life. Further studies are warranted to evaluate the long-term stability of such complex reconstructions. However, local tumor control remains the highest priority and will be essential for years.

Proposed Prediction Model and Nomogram for Systemic Complications in Patients Undergoing Free Flap Head and Neck Reconstruction

Postoperative complications in head and neck surgery are well-known, but a predictive model to guide clinicians in free flap reconstructions has not been established. This retrospective single-center observational study assessed 131 patients who underwent ablative surgery and received free flap reconstruction. Primary endpoint was the occurrence of systemic complications (PSC). Secondary endpoint was the generation of a nomogram of complications according to the CDC classification. In the ordinal regression model, postoperative administration of furosemide [1.36 (0.63–2.11), p < 0.0001], blood loss [0.001 (0.0004–0.0020), p = 0.004], postoperative nadir hemoglobin [−0.03 (−0.07–0.01), p = 0.108], smoking [0.72 (0.02–1.44), p = 0.043], and type of flap reconstruction [1.01 (0.21–1.84), p = 0.014] as predictors. A nomogram with acceptable discrimination was proposed (Somer's delta: 0.52). Application of this nomogram in clinical practice could help identify potentially modifiable risk factors and thus reduce the incidence of postoperative complications in patients undergoing microvascular reconstruction of the head and neck.

A New Strategy for Patient-Specific Implant-Borne Dental Rehabilitation in Patients With Extended Maxillary Defects

Purpose of the StudyPatients undergoing ablative tumor surgery of the midface are faced with functional and esthetic issues. Various reconstructive strategies, such as implant-borne obturator prostheses or microvascular tissue transfer, are currently available for dental rehabilitation. The present study shows the first follow-up of patients treated with patient-specific implants (IPS Implants® Preprosthetic) for the rehabilitation of extended maxillary defects following ablative surgery.Patients and MethodsAll patients treated with patient specific implants due to postablative maxillary defects were included. 20 implants were placed in the 19 patients (bilateral implants were placed in one of the cases). In 65.75% of the cases, resection was performed due to squamous cell carcinoma. In addition to the primary stability, the clinical implant stability, soft tissue management, successful prosthodontic restoration, and complications were evaluated at a mean follow-up period of 26 months.ResultsAll patient-specific implants showed primary stability and were clinically stable throughout the observation period. Definitive prosthodontic restorations were performed in all patients. No implant loosening was observed. Major complications occurred only in previously irradiated patients with insufficient soft tissue conditions (p = 0.058). Minor complications such as exposure of the underlying framework or mucositis were observed, but they never led to failure of restorations or implant loss.ConclusionsTreatment of postablative maxillary defects with patient-specific implants offers a safe alternative with predictable results for full and rapid dental rehabilitation, avoiding time-consuming augmentation procedures and additional donor-site morbidity.

Mandibular Reconstruction with Bridging Customized Plate after Ablative Surgery for ONJ: A Multi-Centric Case Series

Purpose: Computer-aided methods for mandibular reconstruction have improved both functional and morphological results in patients who underwent segmental mandibular resection. The purpose of this study is to evaluate the overlaying of virtual planning in terms of measures of the Computer Assisted Design/Computer Assisted Manufacturing CAD/CAM plate for mandibular reconstruction in patients who are ineligible for the insertion of reconstructing the titanium plate supported by fibular free flap, due to their poor health status, or in the presence of specific contraindications to autologous bone flap harvest. Materials and methods: The retrospective study performed analyzed the results of nine patients. The patients were treated at the Maxillofacial Surgery Unit of Policlinico S. Orsola of Bologna, Italy, and Policlinico San Marco, Catania, Italy, from April 2016 to June 2021. Superimposition between planning and post operative Computed Tomography CT scan was performed to assess the accuracy. Results: All reconstructive procedures were carried out successfully. No microsurgery-related complications occurred. In two cases, we had plate misplacement, and in one case, plate exposure that led to plate removal. The average accuracy of the series assessed after CT superimposition, as previously described, was 0.95 mm. Conclusions: Considering that microvascular bone transfer is a high-risk procedure in BRONJ patients, we can conclude that the positioning of a customized bridging mandibular prosthesis (CBMP), whether or not it is associated with a microvascular soft tissue transfer, is a safe technique in terms of surgical outcome and feasibility.

Chlorine, chromium, proteins of oxidative stress and DNA repair pathways are related to prognosis in oral cancer

The comparison of chemical and histopathological data obtained from the analysis of excised tumor fragments oral squamous cell carcinoma (OSCC) with the demographic and clinical evolution data is an effective strategy scarcely explored in OSCC studies. The aim was to analyze OSCC tissues for protein expression of enzymes related to oxidative stress and DNA repair and trace elements as candidates as markers of tumor aggressiveness and prognosis. Tumor fragments from 78 OSCC patients that had undergone ablative surgery were qualitatively analyzed by synchrotron micro-X-ray fluorescence for trace elements. Protein expression of SOD-1, Trx, Ref-1 and OGG1/2 was performed by immunohistochemistry. Sociodemographic, clinical, and histopathological data were obtained from 4-year follow-up records. Disease relapse was highest in patients with the presence of chlorine and chromium and lowest in those with tumors with high OGG1/2 expression. High expression of SOD-1, Trx, and Ref-1 was determinant of the larger tumor. Presence of trace elements can be markers of disease prognosis. High expression of enzymes related to oxidative stress or to DNA repair can be either harmful by stimulating tumor growth or beneficial by diminishing relapse rates. Interference on these players may bring novel strategies for the therapeutic management of OSCC patients.

The Role of Video-Assisted Thoracoscopic Surgery in Pediatric Oncology: Single-Center Experience and Review of the Literature

Aim: Video-assisted thoracoscopic surgery (VATS) has been widely used in the last decades. Nevertheless, the pros and cons of thoracoscopy vs. open surgery in pediatric oncology are still under debate. In literature, VATS has been applied for both diagnostic and ablative surgery to treat neurogenic tumors, thymic neoplasms, lung tumors and metastases, germ cell tumors, lymphoproliferative diseases, and other rare tumors. Recent reviews described excellent outcomes in pediatric oncology as well as in the treatment of adult lung cancer, with a significantly higher rate of mortality and complication in thoracotomy compared to VATS. We reviewed our experience on thoracoscopy in pediatric malignancy and compared it to the literature.Materials and Methods: This was a retrospective cohort-study of pediatric oncological patients who underwent VATS at our institution from 2007 to 2020, and a review of the recent literature on the topic.Results: A total of 43 procedures were performed on 38 oncological patients (18 males, 20 females). Median age was years 7.72 (0.35–18.6). Diagnosis: 10 neurogenic tumors, nine hematological diseases, five metastases, four lypoblastomas, three thymic pathologies, three germ cell tumors, two pleuropneumoblastomas, two myofibroblastic tumors, one myoepithelial carcinoma, one liposarcoma, and three suspected oncological mass. In three cases, a 3D model was elaborated to better plan the surgical approach. Diagnostic biopsies were 22 (51.1%), and ablative surgeries, 21 (48.9%). One neurogenic tumor was resected with the Da Vinci Robot. Median operative time was 120 min (30–420). A drain was left in place in 20 (46.5%) for a median of 4 days. Median length of hospitalization was 5 days (1–18). One case (2.3%) was converted (intraoperative bleeding). There were three post-operative complications (7.0%): one pneumonia, one pleural effusion, and one diaphragmatic paralysis (need for plication). Results were compared to recent literature, and morbidity and conversion rate were comparable to reviewed publications.Conclusion: VATS represents a valuable tool for diagnostic and therapeutic procedures in pediatric oncology. Nonetheless, it is a challenging technique that should be performed by expert surgeons on oncological and mini-invasive surgery. Three-dimensional reconstruction can optimize the pre-operative planning and guarantee a safer and more targeted treatment. Finally, the advent of robotics-assisted surgery represents a new challenge that may further implement the advantages of VATS.

Semidirect targeting–based stereotactic mesencephalotomy for the treatment of refractory pain: a case series

OBJECTIVE One of the few resources for treating medically intractable pain is ablative surgery, but its indications have fallen dramatically over the last decades. One such procedure is mesencephalotomy. This study aims to determine current risks and benefits of MR-guided semidirect targeting–based stereotactic mesencephalotomy. METHODS This was a retrospective study based on a review of the medical records of 22 patients with nociceptive (n = 5), neuropathic (n = 10), or mixed (n = 7) refractory pain treated with unilateral mesencephalotomy alone (17 patients) or associated with bilateral anterior cingulotomy (5 patients) between 2014 and 2021 in the authors’ institutions. The confidence interval adopted in this study was 95%. RESULTS The sample included 12 women and 10 men with ages ranging from 23 to 80 years (mean 55.1 ± 17.1 years). Using MR-guided semidirect targeting, the following structures were targeted: spinoreticulothalamic (neuropathic/mixed pain, n = 17), trigeminothalamic (nociceptive/mixed pain in the face, n = 5), and neospinothalamic (nociceptive/mixed pain in the body, n = 7) pathways. The most common response to macrostimulation was central heat/moderate discomfort. Radiofrequency thermocoagulation was made with 70°C–75°C/60 sec. A total of 86.3% (3 months) and 76.9% (12 months) of the patients achieved excellent or good results (improvement of pain > 50%), presenting with a significant mean pain relief of 80.1% at 3 months and 71.4% at 12 months postoperatively. The addition of bilateral anterior cingulotomy did not improve the results. Patients with upper limb, cervicobrachial, and face pain did significantly better than those with trunk pain. The worst results were seen in patients with neuropathic and/or trunk pain. The surgical failure (pain relief ≤ 25%) and recurrence rates were 9.1% each, apparently related to the use of lower lesioning parameters (70°C/60 sec) and to the presence of neuropathic and/or trunk pain. The morbidity rate was 8%, with both complications (vertical diplopia and confusion/agitation) happening in patients lesioned with 75°C/60 sec. There were no deaths in this series. CONCLUSIONS These results show that contemporary stereotactic mesencephalotomy is an effective, relatively low-risk, and probably underused procedure for treating medically intractable pain. Careful semidirect determination of the target coordinates associated with close attention to electrical macrostimulation responses certainly plays an important role in avoiding complications in most of the procedures. A higher lesioning temperature (75°C) apparently prevents recurrence, but at the cost of an increased risk of complications.

Parachute Technique for Head and Neck Free-Flap Inset

The treatment outcome of advanced squamous cell carcinoma involving the head and neck is well known to be dire and usually needs multimodality treatment even including optimal reconstruction after ablative surgery. When a significant area of the soft tissue is resected, reconstruction of oral cavity or pharynx needs to minimize morbidities while achieving adequate functional outcomes. For the better functional outcome, invasive approaching procedures such as lip and jaw splitting, or extensive floor of mouth or pharyngeal muscle ablation should be avoided. Without these surgical procedures, reconstructive surgeons may encounter technical difficulties in flap inset due to deep and narrow space after head and neck cancer resection. In a deep and narrow surgical defect, accurate approximation and suture is extremely difficult. Eventually, repeated flap manipulation and stretch might be inevitable, and even pedicle kinking or injury could happen. Herein, we suggested the “parachute” technique, which was generally used in blood vessels or aortic valve suturing in a narrow surgical field and for avoiding mismatched suture. We applied this “parachute” technique for free-flap inset to head and neck defect, and we herein report our successful outcomes.

Nephrectomy in Patient of Chronic Pyelonephritis with Non Functioning Kidney on Left Side: A Case Report

Introduction: There are two types of renal surgery i.e. partial nephrectomy and one other is total nephrectomy. Mostly, nephrostomy performs in malignant tumors of the renal. Sometimes it performs in kidney injury due to that no longer function and it may create any obstructive disorder in the renal system. Patient Information: A 45-year-old male patient presented with complaints of pain in the abdomen since 4 months. The patient was advised to ultrasonography abdomen and pelvis. Contrast-enhanced computed tomography (CE-CT) abdomen and pelvis were done. Previous treatment was undergone left-sided PCN for gross hydronephrosis of the left kidney. But after 4 months patient developed abdomen pain which was insidious in onset and progressive in nature. The pain was dull aching, in the left loin region, radiating to the back and intermittent. There are no aggravating or relieving factors associated with it and the patient is now referred to our hospital for further management patient was admitted to the male surgical ward. After the surgery planed left simple nephrectomy. Post-operative medication given, Inj. Revotaz (Piperacillin and tazobactam) 4.45 gm, Inj. Nirmet (Metronidazole) 100 ml, Inj Pantomay (Pantoprazole) 40 mg, Inj. Setron (Ondansetron) 4 mg, Inj tramadex (Tramadol hydrochloride) 100 mg, Inj temfix IV (Paracetamol) 100 ml. Discussion: Nephrectomy is one of the urologists conducting the most common ablative surgery. A non-functional kidney or an irreversibly impaired kidney is the commonest sign for a nephrectomy. Chronic infection, obstruction, calculus disease and serious traumatic injury are other typical indications for nephrectomy. Conclusion: In this case, the patient was on a closed monitor. To accomplish overall the situation during the time of surgery. Over all the patient response was positive for conservative and nursing management and after treatment the patient was discharged without any postoperative complications and satisfaction with full recovery.

Bilateral tubal incarceration into the broad ligaments caused by pelvic endometriosis: A case report

Introduction: Endometriosis is characterised by the presence of functional endometrial tissue outside the uterus. Salpinges are a common location of endometriotic implants. Endometriosis located into the broad ligament is a rare event. Case description: A 38-year-old infertile woman presented to our attention with moderate left iliac fossa pain after menses and intermenstrual bleeding. Transvaginal ultrasounds and pelvic magnetic resonance evidenced the presence of bilateral haematosalpinges. At the laparoscopic pelvic exploration, fallopian tubes were absent. Opening and dissecting the apical portion of the broad ligaments, we identified bilateral haematosalpinges incarcerated in the homolateral broad ligaments. We performed bilateral salpingectomy. Histological examination confirmed the presence of endometriosis. Conclusion: Care must be taken to the diagnostic assessment, counselling about the surgical programme before the intervention especially in patients during the reproductive period when the possibility of ablative surgery and subsequent need for an assisted reproductive technique exists.