A Reproducible and Effective Technique for Coronary Sinus Injury Repair

Objective: Coronary sinus injury related to the use of a retrograde cardioplegia catheter is a rare but potentially life-threatening complication with mortality reported as high as 20%. We present a series of iatrogenic coronary sinus injuries as well as an effective method of repair without any ensuing mortality. Methods: There were 3,004 cases that utilized retrograde cardioplegia at our institution from 2007 to 2018. Of these, 15 patients suffered a coronary sinus injury, an incidence of 0.49%. A pericardial roof repair was performed in 14 cases in which autologous pericardium was sutured circumferentially to normal epicardium around the injury with purified bovine serum albumin and glutaraldehyde injected into the newly created space as a sealant. Incidence of perioperative morbidity and mortality, operative time, and length of stay were collected. Results: In our series, there were no intraoperative or perioperative mortalities. Procedure types included coronary artery bypass grafting (CABG), valve replacement and repair, or combined CABG and valve procedures. Median (interquartile range) cross-clamp time was 100 (88 to 131) minutes, cardiopulmonary bypass duration was 133 (114 to 176) minutes, and length of stay was 6 (4 to 8) days. None of the patients returned to the operating room for hemorrhage, and there were no complications associated with the repair of a coronary sinus injury when using the pericardial roof technique. Conclusions: Coronary sinus injuries can result in difficult to manage perioperative bleeding and potentially lethal consequences from cardiac manipulation. Our series supports the pericardial roof technique as an effective solution to a challenging intraoperative complication.

A Trimodality, Four-Step Treatment including Chemotherapy, Pleurectomy/Decortication and Radiotherapy in Early-Stage Malignant Pleural Mesothelioma: A Single-Institution Retrospective Case Series Study

Background: Multimodality treatment is considered the best treatment strategy for malignant pleural mesothelioma (MPM). However, the ideal combination of them is still a matter of controversy. Here, we report a case series of MPM treated with a trimodality approach: induction chemotherapy (CT), pleurectomy/decortication (P/D), postoperative radiotherapy (RT) and post-operative CT. Methods: A retrospective case series of 17 MPM patients treated between 2013 and 2020 is presented. Patients had epithelial or mixed MPM diagnosed by video-assisted thoracoscopy and pathologic IMIG stage I or II disease. Treatment details and radiological data were collected. Induction therapy consisted of combination of cisplatin and pemetrexed, every 21 days for two cycles. P/D was performed 4–6 weeks after induction CT, post-operative RT 3–6 weeks after surgery, while post-operative CT was given 4–6 weeks after RT, with the same schedule of induction. Results: All patients showed objective response or stability of disease at the restaging following induction CT and underwent surgery by posterolateral thoracotomy. There were two cases of cardiac arrest as major intraoperative complication, both resolved by manual cardiac massage. Minor complications included one hemidiaphragm elevation, 1 anemia requiring blood transfusion, one wound infection, and two persistent air leaks. Median overall survival was 32.1 months, median progression free survival was 23.7 months. Conclusions: These results suggest the feasibility of these trimodality treatment scheme for early stage MPM patients. Larger series and long-term prospective studies are needed to confirm the validity of this strategy.

Successful bilateral phacoemulsification and vitrectomy in a Bennett’s wallaby (Macropus rufogriseus)

CASE DESCRIPTION A 7-month-old hand-reared female Bennett’s wallaby (Macropus rufogriseus) was evaluated for bilateral ocular opacity of 3 months’ duration. CLINICAL FINDINGS On physical examination, the wallaby was in good overall condition. An ophthalmic examination revealed mature cataracts in both eyes (OU). The cataracts were suspected to have a nutritional origin as it has been described in hand-reared macropods. Results of tonometry were normal OU. Results of CBC and serum biochemistry were unremarkable. The wallaby was premedicated with medetomidine and ketamine hydrochloride. Ocular ultrasonography performed while the wallaby was anesthetized revealed a thickened and opaque lens, mildly heterogeneous vitreous humor, and no sign of retinal detachment OU. An electroretinogram confirmed functional retinae OU. TREATMENT AND OUTCOME Surgery was considered necessary for welfare reasons. Phacoemulsification and vitrectomy were performed without intraoperative complication. The wallaby recovered uneventfully, and systemic NSAID, topical corticosteroid, and systemic and topical antimicrobial therapy were prescribed. One year later, the animal had vision OU. Physical examination did not show any vision-threatening postoperative complications. CLINICAL RELEVANCE The etiology of nutritional cataracts is not fully understood in macropods, but this condition is rather common in these species. To our knowledge, this is the first detailed report of a successful bilateral phacoemulsification and vitrectomy in a Bennett’s wallaby.

USE OF THREE-DIMENSIONAL ENDOSCOPY IN ENDONASAL AND ANTERIOR SKULL BASE SURGERY

Objectives: The three dimensional (3D) endoscope is considered as a new surgical tool which used in different approaches in intranasal and anterior skull base surgical procedures. There are many advantages of the 3D endoscopy over the two dimensional (2D) one that have been demonstrated along clinical applications, surgical training and different experimental studies. Our study aimed to show the difference between using the 3D & 2D endoscopes during endonasal and anterior skull base surgery and its importance specially when used by novice users. Design: Our study is divided into two phases (clinical & cadaveric phases).In the clinical study we have done 52 endonasal & anterior skull base surgical procedures (26 study cases and 26 control cases).We recorded accuracy, duration and intraoperative complication for each case. The cadaveric study was performed on three cadavers, difference in accuracy and dissection time were recorded using 3D & 2D endoscopy for each side chosen by randomization. Results: In the clinical study, the cases done by 3D endoscope were significantly faster and more accurate with less intraoperative complications compared to cases done using 2D endoscope. In cadaveric dissection while using 3D endoscope there was better depth of perception regarding the anatomical landmarks compared to 2D endoscope. Conclusion: 3D endoscopy is an advanced instrument that allows better training for the coming generation of ENT surgeons. Both clinical and cadaveric studies offer a promising outcomes in both endonasal and anterior skull base surgery.

Diagnostic Laparoscopy in Patients With Peritoneal Carcinomatosis Is Safe and Does Not Delay Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy

Background Outcomes of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) among patients with peritoneal carcinomatosis (PC) depend largely on the extent of peritoneal disease. Since PC is not reliably evaluated with cross-sectional imaging, tumor burden is often evaluated with diagnostic laparoscopy (DLS). The aims of this study are to evaluate the safety of DLS in patients with peritoneal disease and determine if DLS delays time to CRS-HIPEC. Methods We performed an institutional retrospective review of 145 patients who underwent CRS-HIPEC between 2013 and 2020. Patients were divided into 2 groups: those who underwent an electively scheduled DLS prior to CRS-HIPEC and those who did not. Intraoperative and postoperative complications associated with DLS were determined from the surgeon’s operative report. Time from diagnosis of PC to CRS-HIPEC was compared between the 2 groups. Results Of the 145 patients available for analysis, 47% (68) underwent DLS and 44% (64) did not. Of all the diagnostic laparoscopies performed, there was 1 (1.5%) intraoperative complication. The duration between diagnosis of peritoneal carcinomatosis and surgery was 4.9 months among patients who underwent DLS prior to CRS-HIPEC and 4.3 months among patients who did not ( P = .79). Conclusion In this retrospective analysis, diagnostic laparoscopy prior to CRS-HIPEC demonstrated a comparable rate of DLS-associated complications compared to other gastrointestinal malignancies and does not prolong time from diagnosis to CRS-HIPEC. Thus, in patients undergoing evaluation for CRS-HIPEC, diagnostic laparoscopy provides significant value in patient selection without incurring perioperative risk or delay in CRS-HIPEC.

Complications of neuroendoscopic septostomy

OBJECTIVE The advent of neuroendoscopy revolutionized the management of complex hydrocephalus. Fenestration of the septum pellucidum (septostomy) is often a therapeutic and/or necessary intervention in neuroendoscopy. However, these procedures are not without risk. The authors sought to record the incidence and types of complications. They attempted to discern if there was decreased likelihood of septostomy complications in patients who underwent endoscopic third ventriculostomy (ETV)/choroid plexus cauterization (CPC) as compared with those who underwent other procedures and those with larger ventricles preoperatively. The authors investigated different operative techniques and their possible relationships to septostomy complications. METHODS The authors retrospectively reviewed all neuroendoscopic procedures with Current Procedural Terminology code 62161 performed from January 2003 until June 2019 at their institution. Septostomy, either alone or in conjunction with other procedures, was performed in 118 cases. Basic demographic characteristics, clinical histories, operative details/findings, and adverse events (intraoperative and postoperative) were collected. Pearson chi-square and univariate logistic regression analyses were performed. Patients with incomplete records were excluded. RESULTS Of 118 procedures, 29 (24.5%) septostomies had either intraoperative or postoperative complications. The most common intraoperative complication was bleeding, as noted in 12 (10.2%) septostomies. Neuroendocrine dysfunction, including apnea, bradycardia, neurological deficit, seizure, etc., was the most common postoperative complication and seen after 15 (12.7%) procedures. No significant differences in complications were noted between ventricular size or morphology or between different operative techniques or ventricular approaches. There was no significant difference between the complication rate of patients who underwent ETV/CPC and that of patients who underwent septostomy as a part of other procedures. Greater length of surgery (OR 1.013) was associated with septostomy complications. CONCLUSIONS Neuroendoscopy for hydrocephalus due to varying etiologies provides significant utility but is not without risk. The authors did not find associations between larger ventricular size or posterior endoscope approach and lower complication rates, as hypothesized. No significant difference in complication rates was noted between septostomy performed during ETV/CPC and other endoscopic procedures requiring septostomy.

P131 A NEW THREE-STEP HYBRID APPROACH IS A SAFE PROCEDURE FOR INCISIONAL HERNIA: EARLY EXPERIENCES WITH A SINGLE CENTRE RETROSPECTIVE COHORT

Aim In this study, a three-step novel surgical technique was developed for incisional hernia, in which a laparoscopic procedure with a mini-laparotomy is combined: so-called ‘three-step incisional hybrid repair’. The aim of this study was to reduce the risk of intestinal lacerations during adhesiolysis and recurrence rate by better symmetrical overlap placement of the mesh. Material and Methods From 2016 to 2020, 70 patients (65.7% females) with an incisional hernia of > 2 and ≤10 cm underwent an elective three-step incisional hybrid repair in two non-academic hospitals performed by two surgeons specialised in abdominal wall surgery. Intra- and postoperative complications, operation time, hospitalisation time and hernia recurrence were assessed. Results Mean operation time was 100 min. Mean hernia size was 4.8 cm; 45 patients (64.3%) had a hernia of 1–5 cm, 25 patients (35.7%) of 6–10 cm. Eight patients had a grade 1 complication (11.4%), five patients a grade 2 (7.1%), two patients (2.8%) a grade 4 complication and one patient (1.4%) a grade 5 complication. Five patients had an intraoperative complication (7.0%), two enterotomies, one serosa injury, one omentum bleeding and one laceration of an epigastric vessel. Mean length of stay was 3.3 days. Four patients (5.6%) developed a hernia recurrence during a mean follow-up of 19.5 weeks. Conclusions A three-step hybrid incisional hernia repair is a safe alternative for incisional hernia repair. Intraoperative complications rate was low.

Clearance of Bone Substitute in Gel Form Accidentally Dispersed into the Sinus Cavity during Transcrestal Maxillary Sinus Floor Elevation: Two-Case Report

Sinus membrane perforation is the most frequent intraoperative complication occurring during maxillary sinus floor elevation. Although numerous techniques for perforation management are present, grafting material dissemination may still occur, representing a potential trigger factor leading to acute or chronic sinusitis. This case report describes two cases of xenogeneic bone substitute in gel form accidentally dispersed into the sinus cavity during maxillary sinus floor elevation with a transcrestal approach. In both cases, immediately postoperative radiographic imaging showed an important amount of gel graft dislodged into the sinus cavity as a consequence of hidden perforations that remained undetected during surgery. Patients were monitored for 6 months after surgery and reported no signs or symptoms related to possible sinus disease. Control radiographs showed no sinus membrane hypertrophy and/or presence of residual disseminated gel, confirming complete clearance of the accidentally dispersed graft through the ostiomeatal complex. In order to minimize postoperative complications, bone substitutes in gel form could represent an interesting alternative to granular grafts for their easier clearance from the maxillary sinus cavity in case of accidental dissemination during sinus augmentation procedures.

Pterygium surgery using a conjunctival autograft

Surgery is the only effective treatment for pterygium. The most common technique is the use of a conjunctival autograft after excision of the pterygium. However, the frequency of recurrences of this method, as well as possible complications in different sources, are different. Purpose. To evaluate the efficacy, safety and recurrence rate of conjunctival autograft after pterygium excision. Material and methods. 101 patients with pterygium. aged 57.31 ± 14.7 years. The follow-up period was 1 year in 56 patients and 2 years in 45 patients. All patients underwent excision of the pterygium with conjunctival autograft. Results. An intraoperative complication can be attributed to the insufficient area of the autoconjunctival graft during its transfer to the sclera, which occurred in three patients. Postoperative complications: graft edema in 14 cases (13.86%), granuloma in the suture area was observed in 1 case (0.99%). Recurrence of pterygium was noted in only three cases (2.97%). Conclusion. The use of a conjunctival autograft in pterygium surgery has shown its effectiveness and safety, as well as a low recurrence rate. The donor zone in the upper and lateral makes it possible to excise a sufficient area of autoconjunctival graft with preservation of the intact area of possible future surgery for glaucoma. Key words: conjunctival autograft, pterygium, recurrence of pterygium.