LYMPHOVENOUS ANASTOMOSIS FOR THE TREATMENT OF LYMPHEDEMA: A SYSTEMATIC REVIEW OF THE LITERATURE AND META-ANALYSIS

Lymphovenous anastomosis (LVA) has been described as an effective treatment for early stages of lymphedema (LE). The aim of this study was to deepen the evaluation of the effectiveness of LVA by performing a meta-analysis to provide information about its utility in specific anatomical sites, clinical stages, duration of lymphedema, and surgical technique. A systematic literature search using PubMed/Medline, Google Scholar, and Cochrane Database was performed in November 2019. Only original studies in which exclusively LVA was performed for primary and/or secondary lymphedema in humans were eligible for data extraction. A meta-analysis was performed on articles with a well-defined endpoint and a subgroup analysis was conducted in relation to surgical technique, duration of lymphedema, stage of pathology. Forty-eight studies, including 6 clinical trials and 42 low-risk bias observational studies were included in our meta-analysis. 1,281 subjects were included and the majority of articles reported a pre-post analysis. Lymphaticovenular anastomosis appears to result effectively in treatment of lymphedema with an odds ratio of 0.07 (CI: 0.04, 0.13, p<0.001). All subgroup meta-analyses were statistically significant for LVAs specifically with regard to anatomical site, clinical stage, duration of LE, or type of microsurgical procedure (p<0.05). Our meta-analysis confirmed the efficacy of LVAs for the treatment of lymphedema, even when subgroup analysis was performed for clinical stage, duration of pathology, anatomical site of lymphedema, or type of microsurgical procedure. Further prospective trials with a common clearly defined outcome measure are warranted for an unbiased evaluation.

SURG-14. ENDOSCOPIC SURGERY FOR PEDIATRIC INTRAVENTRICULAR TUMOR WITHOUT HYDROCEPHALUS: INDICATION, SURGICAL TECHNIQUE, AVOIDANCE OF COMPLICATION, AND ITS PROSPECT

INTRODUCTION Neuroendoscopic surgery is useful for intraventricular tumors accompanied by ventriculomegaly. However, it is often challenging for cases with small ventricles. Our institution is actively performing surgeries for pediatric intraventricular tumors without frank ventriculomegaly. METHODS Seven cases of intraventricular tumors without ventriculomegaly (5 cases of subependymal giant cell astrocytoma (SEGA) and 2 cases of germ cell tumors (GCTs)) were analyzed. The age ranged between 3 and 14 years (median 5 years). The sizes of SEGA were between 10-27mm, and all the tumors showed an enlargement around the foramen of Monro, which was the indication for surgery. Biopsy and third ventriculostomy were performed for GCTs. For resection, after making a small craniotomy of 2 x 3 cm, ellipse-cone-like sheath with a diameter of 12mm or 17mm was inserted through it to the lateral ventricle, which enabled a wide surgical view. Under a rigid endoscope of 4mm diameter, 2 types of surgical instruments were employed, making the microsurgical procedure like under a microscope, with a wider view, possible. For the cases of tumor resection, septostomy and placement of a drain in the ventricle were performed at the end of surgery. RESULTS The lesions were safely approached in all the cases. For resection, endoscopic microsurgery was possible, and tumor was totally removed in all the cases. No postoperative complication was observed in any of them. CONCLUSIONS Our experience shows that tumor resection can be safely achieved with the aid of endoscope even for cases without ventriculomegaly.

Combined Extradural and Intradural Pterional Transzygomatic Approach to Large Sphenoid Wing Meningiomas. Operative Technique and Surgical Results

Objectives Describe a unique and safe surgical procedure for the microsurgical management of large sphenoid wing meningiomas (SWMs) aimed to a radical resection of these tumors. Design A prospective series of 26 cases with SWMs larger than 3 cm in one of its main diameter is presented. All patients were studied following the same clinical and imaging procedures. The surgical approach was through a pterional transzygomatic craniotomy. The surgical procedure has the following steps: 1. Extradural tumor devascularization and resection of the hyperostotic and/or infiltrated bone and then intradurally; 2. Intradural tumor debunking; 3. Microdissection of vascular branches and perforators from the capsule; 4. Identification of the optic and oculomotor nerves and internal carotid artery; 5. Tumor capsule dissection and resection; 6. Dural resection or cauterization; 7. Dural and bone reconstruction and closing. Results All lesions were completely removed. Most complications were transient. The most relevant complication was a large middle cerebral artery infarct with permanent hemiplegia despite a decompressive craniotomy. Conclusion Large SWMs can be considered as a single pathology regarding the surgical approach and intraoperative microsurgical procedure strategies. The pterional transzygomatic approach allows an extradural devascularization of the tumor and an extensive bone resection that facilitates the intradural stage of tumor resection. The proposed approach allows a wide and radical resection of the duramater and bone that increases the Simpson grade. However, surgery does not control other biological or molecular prognostic factors involved in tumor recurrence.

Successful replantation of the scalp with a good aesthetic outcome and return of sensation – a case report and literature update.

Replantation of a totally avulsed scalp is a demanding microsurgical procedure with no good alternatives. Here, we present a case of successful scalp replantation after 11 hours of cold ischemia in a 24-year-old woman. The steps of the procedure, the outcomes, and a review of the literature are presented. Adhering to the steps outlined in this report during replantation is vital for success, and allows the serious complications and pitfalls associated with this procedure to be avoided. Following basic plastic surgery principles leads to better aesthetic outcomes. We observed good, even hair growth, and the return of sensation to the skin and frontal muscle function. Replantation of an avulsed scalp is an effective treatment that allows the patient to return to normal life after severe physical and psychological trauma.

Femoral nerve schwannoma

Objective: The authors report a case of femoral nerve schwannoma by MR imaging findings. Case: A patient presenting with right inguinofemoral pain and swelling was submitted to a Gadolinium-enhanced Magnetic Resonance Imaging (MRI): a schwannoma arising from the femoral nerve in the right inguinofemoral area was disclosed. She underwent microsurgical procedure, with total removal of the lesion. Postoperatively, the inguinofemoral pain and swelling disappeared, with complete relief of symptoms. Conclusion: The authors stress that femoral nerve schwannoma in the inguinofemoral place should be considered according to MRI findings.

Microsurgical Technique of Locoregional Injection into the Hepatic Artery in Tumor-Bearing Mice

Background: Intraarterial injection into the hepatic artery represents an important route for locoregional administration for the treatment of hepatic tumors. In the present work, we describe microsurgical methodology for injection into the hepatic artery in mice. The technique was recently used for analysis of the phenomenon of endothelial capture in liver tumors. Methods: Two different models of hepatic tumors in C57BL/6 mice were used. Tumors were induced by intrahepatic cell inoculation. The preferential blood supply of tumors was studied using blocking of bioavailability of nontumoral endothelial epitope and the subsequent injection of fluorescent endothelium-specific antibody. The selective intraarterial injection of labeled antibody was performed in tumor-bearing mice. The procedure addressed variations of vascular anatomy of the hepatic artery in mice and used direct intraarterial injection with dispensable catheterization. Results: Both experimental tumor models showed preferential blood supply from the hepatic artery. The technique of hepatic arterial injection was adapted and performed according to two major anatomic variations of the hepatic artery. Using this technique, the selective enrichment of labeled antibody to tumor and liver blood vessels, which were perfused during the first intravascular passage, was demonstrated. Conclusions: The experimental hepatic arterial injection in mice is a feasible but demanding microsurgical procedure. The choice of subsequent operation steps is dependent on the vascular anatomy of the hepatic artery which has two major variations in mice.