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Microsurgery is being applied with considerable advantage to tubal reconstruction, particularly in relation to improved pregnancy rates. These results justify the additional costs in equipment and time which are required.
The clinical outcome of 122 patients with pituitary adenomas treated by microsurgery and/or Gamma Knife radiosurgery (GKRS) was analyzed to evaluate patient selection criteria and the role of GKRS. Sixty-six resections were performed in 59 patients. All tumors were macroadenomas, except for 5 ACTH-producing adenomas. Twenty-four of the 31 hypersecreting adenomas showed normal serum hormone values after treatment. Postoperative complications were rhinorrhea, cranial nerve palsies, and a small thalamic infarct. GKRS was performed on 18 of the operated patients because of residual tumors, mostly in the cavernous sinus. Thirty-five of the 63 patients treated by GKRS were followed for more than 2 years. All adenomas except 2 were stable or had decreased in size. Eleven of 17 functioning adenomas showed normal serum hormone values after treatment. It is concluded that tumors that compress the optic pathway should be removed and that residual tumors in the cavernous sinus are good indications for radiosurgery.
BACKGROUND: Transanal endoscopic microsurgery (TEM) has been suggested as a minimally invasive procedure of low morbidity for rectal tumor excision. However, the complicated setup of TEM instruments and the expensive cost are disadvantages to wider acceptance. The aims of this study are to introduce a new modality of modified video-assisted gasless TEM (V-TEM) using a video system and no CO(2) insufflation of the rectum, and discuss our experience during past 10 years. METHODS: 217 patients, with a mean follow-up of 61 months, underwent V-TEM for adenoma (n = 102), Tis (n = 83), T1 (n = 28) and T2 (n = 4) rectal tumors, located 3-20 cm from the dentate line. RESULTS: The mean size of the tumor was 39 mm, and the mean duration of the operation was 63 min including setup time, and the mean duration of hospital stay was 5.8 days. Seven (3.2%) patients underwent conversion to radical surgery owing to T1 with massive invasion or T2 tumors histopathologically. Two (0.9%) patients had recurrent disease which was managed by repeat V-TEM. The postoperative course in all patients was free from any significant complications. Transient fecal soiling was present in 12 (5.5%) patients. The cost of V-TEM was decreased compared to that of conventional TEM (USD 40000). CONCLUSION: V-TEM was a cheap, safe, simple and minimally invasive procedure for benign and early cancer in the proximal rectum.
BACKGROUND: Transanal endoscopic microsurgery (TEM) can access the whole rectum up to 20 cm from the anal verge. Due to its excellent view and accurate dissection, TEM is useful for the removal of adenoma and selected low risk cancers of the rectum. We report our experience with the first 70 patients presenting. METHODS: A prospective descriptive study of 70 patients treated for rectal tumor with TEM from December 99 until October 2002 at Haukeland University Hospital. RESULTS: TEM was performed in 37 men and 33 women, median age 70.5 (19-90) years, for anticipated adenoma (n = 64), adenocarcinoma (n = 3), rectal ulcer (n = 1), and re-resection after snare resection of rectal polyp with adenocarcinoma (n = 1) and carcinoid tumor (n = 1). The median observation time was 12 (1-33) months. The distance from the anal verge to the lower tumor border was 5.5 (2.5-14) cm. The median resected area was 15.4 (1.5-132) cm(2). 56 of the 64 anticipated adenomas were true adenoma, resected without recurrences; 8 (12.5%) were unexpected adenocarcinoma. Three of these underwent a secondary rectal resection and 5 patients have been observed without recurrence. Of the 3 patients with known adenocarcinoma, there was one recurrence which was treated with a secondary curative rectal resection. CONCLUSIONS: TEM can access tumors in the whole rectum. Large tumors may be removed with low frequency of per- and postoperative complications and short hospital stay. TEM is highly useful for removal of rectal adenoma. A role for primary treatment of selected low-risk rectal cancers may emerge.
AIMS: This review of literature aimed to assess the role and establish the current status of transanal endoscopic microsurgery (TEM) in the management of benign and malignant rectal lesions. METHODS: A review of the literature was undertaken through the Medline database and by cross-referencing previous publications, thus identifying 54 relevant publications on TEM in the management of rectal lesions. Aggregated results of various parameters were calculated but statistical comparisons deemed unsuitable due to heterogeneity of data. RESULTS: The TEM procedure is associated with good functional results, morbidity of 4% and zero procedure-related mortality. The local recurrence rates after TEM excision is 4.5% (range 0-14) for benign rectal lesions, 6% (0-13) for T(1) cancers, 14% (range 0-50) for T(2) cancers and 20% (range 14-67%) for T(3) cancers. Local recurrences after TEM can be surgically salvaged with good disease free survival rates. CONCLUSIONS: The TEM procedure clearly offers the benefits of good exposure of the operative field allowing extremely precise dissection and access to high rectal lesions unresectable by other methods. For pTis and low risk pT(1) lesions, the oncological results are comparable to the more traditional formal resection. The routine use of TEM for high-risk pT(1) and higher stage lesions is not an oncologically sound choice at the present moment.
Tubal microsurgery is a valuable tool to study tubal reproductive physiology and various infertility problems. Microsurgical tubal resection reanastomoses of the rabbit fallopian tube and their impact on fertility are reviewed. Data obtained from experimental work on the function of cilia and muscle activity in tubal transport are discussed.
73 consecutive aphakic retinal detachments were operated on by microsurgery combined with intra-operative biomicroscopic control of the ocular fundus. Retinal reattachment was achieved in 60 cases (82%), 59 eyes had only one operation. A visual acuity of 0.5 or better was achieved in 50% of all cases and in 57% of the cases which were not failures of previous conventional surgery. 69% of the eyes recovered the same visual acuity after surgery as before the occurrence of retinal detachment. One macular pigment migration and one cystoid macular edema were the only postoperative macular complications observed in this series.
Heavy cryotreatment of the fibrous ingrowth remnants at the inner surface of the scleral wound was performed, as an adjunct to vitreo retinal microsurgery, in a series of 32 eyes affected with retinal detachment after penetrating scleral wound. Surgical success, with a follow-up of 6-42 months after gas disappearance, was achieved in 25 eyes (71%). However, permanent retinal reattachment was achieved with a single operation in only 64% of the eyes successfully operated on (16/25). Thirty-six per cent (9/25 eyes) of the retinal detachments that were eventually successfully operated on showed clinical evidence of gradual contraction of the vitreous base in the postoperative course, and required 2 or more operations. Experimental studies on standardized models are required to determine whether destruction of the fibrous ingrowth remnants with heavy cryo is of any value in the management of retinal detachment after penetrating scleral wound.
Microsurgery for RD repair has brought about significant improvement in the management of easy RD as well as difficult and desperate cases. At present, prevention of severe PVR remains the only major problem in the management of rhegmatogenous RD.
There are a number of tenets regarding endolaryngeal microsurgical management of disease that involves and/or encroaches upon the anterior glottal commissure (AGC). They include avoidance of 1) bilateral epithelial incisions near the AGC, 2) removal of papillomatosis in the AGC, and 3) resection of bilateral keratosis with atypia or carcinoma at the AGC. During the last 6 years, 115 patients underwent microsurgical management of disease at the AGC: carcinoma in 20 (T1 in 15 and T2 in 5), keratosis in 41, papillomatosis in 20, and polypoid corditis (Reinke's edema) in 34. No patients with polypoid corditis developed a synechia or web. All cancers were successfully resected en bloc; 1 of the 20 patients developed a microscopic local failure that was successfully re-resected endoscopically. Eleven of the 20 cancers required excision of part of the supraglottis to establish adequate exposure for the glottic cancer resection. Eight of 15 patients with bilateral keratosis underwent staged resections. Fourteen of 15 patients with bilateral papillomatosis required staged resections. Twelve of the total 115 patients presented with a web secondary to prior microsurgery, and 3 developed a new, clinically insignificant web. The complications of management of disease in or near the AGC described by other authors were not noted in this series. This success was primarily the result of improved exposure in the AGC, which was achieved by use of larger and better-designed laryngoscopes and by resection of supraglottic tissue as necessary. Positioning these prototype laryngoscopes was facilitated by the use of elevated-vector suspension and external counterpressure.
Jet ventilation via the Sanders injector during intravenous general anesthesia provides excellent operative conditions for CO2 laser microsurgery of the larynx. This technique, which includes complete muscle relaxation, is superior to traditional methods of anesthesia because the endotracheal tube is eliminated, thus improving the surgical field and reducing burn hazards owing to ignition of the tube. The laryngoscope has been modified to carry multiple ports into which a 14-gauge needle is inserted and the tip advanced just distal to the vocal cords. This needle is securely attached to the injector and pressure from the oxygen source is adjusted according to the patient's build and total compliance. Satisfactory arterial blood gases, superb operating conditions, safety, and rapid awakening make this the method of choice for most patients.
General anaesthesia was given to 22 patients for laryngeal microsurgery using small cuffed endotracheal tubes. The described technique is relatively simple for the anaesthetist, safe for the patient and provides good conditions for the surgeon.
Recent advances in endoscopic surgery have developed an endonasal route suitable for pituitary surgery. The main goal of this article is to evaluate benefits of our endoscope-assisted endonasal trans-sphenoidal microsurgery for pituitary tumors in 215 consecutive cases. The pathological classifications of the 215 cases are as follows: 163 pituitary adenomas, 23 Rathke's cleft cysts, 17 craniopharyngiomas, and 12 others. The patients were surgically treated via the endonasal trans-sphenoidal approach using an operating microscope as the primary instrument for tumor resection. Endoscopes were used to complement the operating microscope in visualization. We compared the new approach to the sublabial trans-sphenoidal approach (197 cases) with respect to endocrinological outcomes and surgical complications. Our endonasal trans-sphenoidal approach was beneficial in eliminating the complications of lip numbness, which was often observed in patients undergoing sublabial surgery, and nasal septal perforation. In addition, endocrinological outcome comparable to those in the sublabial group was achieved in the endonasal group. We consider that the endoscope, which allows visualization of areas not seen with the operating microscope, should be used actively in conjunction with the operating microscope that provides three-dimensional visualization and is timesaving. Our surgical method for pituitary tumors provides good results with minimal invasion, by exploiting the advantages of a microscope and an endoscope.
Despite our better understanding of the pathophysiology of peripheral nervous system and advancements in microsurgical repair techniques, peripheral nerve injuries are still considered as a reconstructive challenge for all surgeons. For achieving a better nerve regeneration and better end organ reinnervation, advanced microsurgical manipulations are parallel with molecular biological discoveries. The field of peripheral nerve research is still developing and includes more sophisticated approach at the basic science level. In our Microsurgery Research Laboratory we have been working on different nerve repair techniques, including sleeve neurorrhaphy, sleeve grafts, single and polyfascicular nerve grafting techniques and studies on nerves in diabetic rats, in addition to the roles of different growth factors and pharmacological agents on peripheral nerve regeneration. New approaches for filling nerve gaps with nerve allografts and tolerance inducing strategies with their effect on nerve regeneration are included into our research armamentarium. In this overview we will summarize our 15-year experience in peripheral nerve research.
Untreated Cushing's disease and the resultant chronically elevated glucocorticoid levels lead to severe metabolic disturbances, including diabetes mellitus, obesity, hypertension, muscle wasting, and osteoporosis. Although transsphenoidal resection has become the standard of care for Cushing's disease with high initial success rates, little information is available on the long-term morbidity and mortality of patients in remission compared with patients with recurrent or persistent Cushing's disease after such treatment. We therefore conducted a retrospective study of 289 patients with Cushing's disease who underwent transsphenoidal microsurgery for an ACTH-secreting adenoma at a tertiary care center exclusively by one surgeon (C.B.W.). Postoperative remission was achieved in 82% (n = 236) of patients, with best initial remission rates observed in patients with grade I (86%) and II (83%) or stage 0 (88%), A (94%), and B (100%) tumors. Male gender, larger tumor size, and higher stage predicted poorer initial outcome. Long-term follow-up was obtained on 178 patients, with a median follow-up time of 11.1 yr (range, 0.6-24.1 yr). Thirteen of 150 (9%) of patients in initial remission developed recurrent disease, and 12 patients underwent additional treatment. At last follow-up, only two of these patients had active disease. However, of the 28 patients with initial persistent disease who had follow-up greater than 6 months, 10 patients continued to have active disease at last follow-up. Although overall survival rates in patients with initial remission did not differ significantly from expected compared with the general population based on age and sex distribution, patients with initial persistent disease had a significant increase in mortality compared with the expected mortality. Thus, successful treatment of Cushing's disease is associated with normal long-term survival. These results suggest that patients with persistent Cushing's disease require early and aggressive intervention to attempt to prevent this excess mortality.
Treatment of acromegaly has long been recognized as necessary to relieve symptoms, halt progression of deformities, and decompress the sella turcica. More recently, treatment strategies have focused on decreasing GH levels to a point at which mortality rates normalize, thereby redefining previous concepts of a cure. No surgical series to date has investigated the long-term effect of treatment on mortality rates. We retrospectively reviewed 254 consecutive patients with acromegaly who underwent transsphenoidal microsurgery of GH-secreting adenomas between 1974-1992. Seventy-six percent of these patients had basal GH levels <5 ng/mL within 30 days of surgery, and 24% had persistent disease. Multivariate analysis revealed that higher stage, grade, and preoperative GH levels were all predictive of persistence (P < 0.01). Long-term follow-up was obtained on 129 of the patients in initial remission. Of these, 9 (7%) had disease recurrence and 120 remained in remission. The incidence of major postoperative complications was 8% (2% permanent diabetes insipidus, 2% cerebrospinal fluid leaks requiring surgery, 2% meningitis, and 2% hypopituitarism), with no mortality. In contrast to the 2.4- to 4.8-fold increased mortality among untreated acromegalics, the mortality rate among patients with posttherapy GH levels <5 ng/mL was equivalent to that of age- and sex-matched controls. Aggressive therapy to normalize GH levels should therefore be instituted at diagnosis.
Currently, microsurgical resection of acoustic neuromas by an experienced, multidisciplinary team is thought to be the treatment of choice. During the past 20 years stereotactic radiosurgery has been used as an alternative to surgical removal. To compare the results of both microsurgery and stereotactic radiosurgery, we conducted a study of 87 patients with unilateral, previously unoperated acoustic neuromas with an average diameter less than 3 cm treated by the neurosurgical service during 1990 and 1991. Preoperative patient characteristics and average tumor size were similar between the treatment groups. State of the art microsurgical or radiosurgical techniques were used by experienced surgeons in both treatment groups. The treatment groups were compared based on cranial nerve preservation, tumor control, postoperative complications, patient symptomatology, length of hospital stay, total management charges, effect on employment status, and overall patient satisfaction. Stereotactic radiosurgery was more effective in preserving normal postoperative facial function (P < 0.05), and hearing preservation (P < 0.03) with less treatment associated morbidity (P < 0.01). Effect on preoperative symptoms were similar between the treatment groups. Postoperative functional outcomes and patients' satisfaction of their tumor management were greater after stereotactic radiosurgery when compared to the microsurgical group, although they did not reach statistical significance (P = 0.07 and P = 0.10, respectively). Patients returned to independent functioning sooner after stereotactic radiosurgery (P < 0.001). Hospital length of stay and total management charges were less in the radiosurgical group (P < 0.001). When compared to microsurgical removal, stereotactic radiosurgery proved to be an effective and less costly management strategy of unilateral acoustic neuromas less than 3 cm in diameter. For many acoustic neuroma patients, stereotactic radiosurgery should be offered as an alternative management strategy.
BACKGROUND: Local excision of rectal lesions is being increasingly undertaken, especially in those unfit for major surgery. The traditional transanal approach is often cumbersome and limited to low and mid rectal lesions. Transanal endoscopic microsurgery (TEMS) is being used to excise both benign and malignant rectal lesions, including those in the upper rectum. METHODS: Prospective analysis of all patients undergoing a TEMS excision between January 1997 and December 2000 in a specialized colorectal unit. RESULTS: Forty patients underwent a TEMS resection, with a mean age of 72 years (SD, 10 years). The mean distance of the lesions from the anal verge was 9.8 cm (SD, 3.1 cm). In 24 patients, the lesion was located >or=10 cm from the anal verge, making them unsuitable for traditional transanal resection. The mean operative time was 91 minutes (SD, 34 minutes), and the mean postoperative stay was 3 days (SD, 1.5 days). No mortality was associated with the procedure, and there was minimal morbidity in 15%. There has been no recurrence in the 18 patients who had a malignant lesion excised. CONCLUSIONS: The TEMS operating system provides the surgeon with a suitable alternative for the resection of benign and malignant rectal neoplasms in selected patients. It has the advantage of providing visual clarity of the operative field, allowing more precise dissection and a minimally invasive approach to mid and upper rectal lesions. There has been no mortality and minimal morbidity. We advocate its inclusion as part of a colorectal surgeon's operative armamentarium for these selected cases.