Effectiveness analysis of hybrid endoscopic submucosal dissection in patients with colorectal epithelium-derived tumors / 中华内科杂志

Objective:To compare the clinical benefits of classic endoscopic submucosal dissection (ESD) and hybrid ESD for the treatment of colorectal epithelium-derived tumors.Methods:The current investigation was a retrospective multicenter study of 418 patients who underwent ESD between January 2015 and April 2021 at Beijing Jishuitan Hospital. The patients were assigned to one of two groups based on the surgical procedure they underwent; a classic ESD group or a hybrid ESD group. The primary outcome was the rate of en bloc resection and complete resection. SPSS 26.0 was used for statistical analysis. Homogeneity of variance was assessed via Cochran′s test. Normally distributed data with homogeneity of variance were analyzed via the t-test for independent samples. Non-normally distributed data and data with unequal variance were analyzed via the Kruskal-Wallis non-parametric test. Categorical data were analyzed via the Chi-square test or Fisher′s exact test. Multivariable assessment was performed via logistic regression analysis. Results:The en bloc resection rates [89.4% (84/94) vs. 87.0% (194/223), χ2=0.34, P=0.558] and complete resection rates [85.1% (80/94) vs. 82.1% (183/223), χ2=0.33, P=0.510] were similar. Compared with classic ESD, procedures were shorter in the hybrid ESD group [22(7, 213) vs. 47(12, 680) min, Z=0.23, P<0.001], dissection was completed more rapidly [0.14(0.02, 0.32) vs. 0.10(0.02, 0.41) cm 2/min, Z=0.08, P<0.001], and there was a higher rate of perforation (9.6% vs. 2.2%, χ2=2.67, P=0.006). Laterally spreading tumor granular type nodular mixed, non-granular type pseudo-depressed, flat-elevated type (odds ratio 2.826, P=0.012), and tumor location (odds ratio 6.970, P=0.005) were independently associated with complete resection in the hybrid ESD group. Conclusion:Classic ESD and hybrid ESD had similar en bloc and complete resection rates for colorectal epithelium-derived tumors, but hybrid ESD had shorter operation times. With respect to hybrid ESD, factors associated with failure of complete resection included lesion type and crossing tissue boundaries.

Experimental study of en-bloc resection of bladder tumors by transurethral single-port laparoscopy in vivo animal models / 现代泌尿外科杂志

【Objective】 To explore the feasibility of en-bloc resection of bladder tumors by flexible cystoscope combined with laparoscopic instruments through urethra and to provide reference for the clinical application of this technique. 【Methods】 Self-designed and processed transurethral single-hole PORT and Olympus electronic cystoscope were used as observation mirror; Φ1.8 mm soft grasper, tissue scissors, electric hook, and ultrasonic scalpel were used as instruments; the porcine bladder was used as a model.The PORT was placed through the urethra, and the cystoscope was inserted to observe the inner wall of the bladder and the condition of the mucosa.After the lesion site was identified in the bladder cavity, the soft grasper was inserted to pull the mucosa to be removed, which was then fixed with tension at the target position to maintain a satisfactory feild of view.The surgeon held the cystoscope in the left hand, and operated the laparoscopic instruments into the bladder cavity through the PORT with the right hand.Observing with the cystoscope and lifting and pulling the mucosa with the grasper, the surgeon simulated the cutting and pushing actions to realize the en-bloc resection of the lesioned mucosa. 【Results】 The mucosa at 4 different locations were successfully resected on 2 in vitro porcine bladder models. 【Conclusion】 The in vitro experiments show that the combination of flexible electronic cystoscope and laparoscopic instruments achieves synergistic effects in en-bloc resection of bladder tumor by transurethral single-hole laparoscope without additional iatrogenic bladder injury caused by percutaneous bladder incision.This method is feasible in the treatment of bladder tumors, and has the potential of clinical application after further optimization.

Perioperative complications and risk factors of en bloc resection for thoracic and lumbar spinal tu-mors / 中国脊柱脊髓杂志

Objectives:To investigate the incidence and risk factors of perioperative complications after en bloc resection for thoracic and lumbar spinal tumors.Methods:The data of patients with thoracic and lumbar spinal tumors treated in our department with en bloc resection and anterior column reconstruction were retro-spectively analyzed.Between May 2016 and October 2022,90 consecutive patients underwent en bloc resec-tion on the basis of Weinstein-Boriani-Biagini surgical staging system,and anterior reconstruction was per-formed using 3D-printed artificial vertebral bodies.The demographic,oncological,and operative data of the patients were collected prospectively,and the intraoperative and postoperative complications occurring within three months were categorized into major and minor complications according to their impacts on the recovery process(Major complications were considered as any complication that appeared to substantially alter an other-wise full and expected course of recovery,and other complications were regarded as minor).All the patients were divided into the primary group(n=67)and revision group(n=23)based on their previous surgical history.Differences between the two groups in terms of age,gender,pathological type,tumor-involved segments,oper-ative time,intraoperative blood loss,and perioperative complications were compared.The predictive factors for major and minor complications were explored.Results:En bloc resection was achieved in all the patients,in-cluding total en bloc spondylectomy in 77 cases,sagittal resection in 12 cases,and vertebrectomy in one case.The mean operative time was 553.4min(210-1208min),and the mean intraoperative blood loss was 1534.1mL(260-5500mL).A total of 129 complications were observed in 65(72.2%)patients,including 29 ma-jor complications in 21(23.3%)patients.Two patients(2.2%)died as a result of complications.The revision group was more than primary group in tumor-involved segments(P=0.000)and incidence rate of major compli-cations(P=0.038).In univariate regression analysis,the combined approach[odds ratio(OR)=14.778,P=0.001],total blood loss(OR=1.004,P=0.004),staged surgery(OR=5.250,P=0.008),previous surgical history(OR=2.946,P=0.043),number of tumor-involved vertebrae(OR=1.607,P=0.023)and lumbar tumor(OR=3.509,P=0.015)were statistically significant risk factors for major complication occurrence,while the combined approach(OR= 6.375,P=0.036)was the independent risk factor.Conclusions:En bloc resection and anterior column recon-struction is associated with high risks of complications,especially when a combined approach is needed.

Feasibility study of transurethral en-bloc resection of bladder tumor under electronic flexible cystoscopy combined with adjuvant therapy for bladder-preservation-therapy in T 2 stage bladder cancer / 中华泌尿外科杂志

Objective:To investigate the feasibility of combination of en-bloc resection of bladder tumor (ERBT) with the NBI(narrow band imaging) flexible cystoscopy, immunotherapy and chemotherapy in bladder-preserving treatments(called as TMT) for patients with stage T 2 bladder carcinoma. Methods:We retrospectively reviewed and analyzed a series of 16 patients with pT 2N 0M 0 pathologically confirmed. All patients are male with a median age of 63yr(56, 73yr). The American Association of Anesthesiologists scored ≤Ⅱ in 12 cases and Ⅲ in 4 cases. There were 9 cases with smoking history, 5 cases with hypertension, 3 cases with diabetes, and 2 cases with heart disease. The results of preoperative tissue biopsy were all urothelial carcinoma. All patients were taken lithotomy position and performed ERBT with NBI imaging technique and thulium-laser energy platform under general anesthesia. The tumor was brown and the surrounding normal mucosa was cyan in color. The procedure was ensured with a minimal tumor margin of 1cm and minimal rection depth to the deep musculi, and with the acquirement for the en-bloc specimen of which the basal site was marked afterwards, the patients all took a full length of chemoimmunotherapy (four cycles of Tislelizumab combined with Gemcitabine and cisplatin regimens) followed by a secondary ERBT. The perioperative data from sequential operations including complications were comprehensively analyzed for evaluating the therapeutic outcome and safety. All patients received a follow-up to detect efficacy and safety of the treatment with the primary end point of pCR, downgrading rate and objective response rate. Results:All operations were successfully completed. There was no obturator reflex, severe bleeding or grade Ⅱ bladder perforation, only 4 patients got a grade Ⅰ bladder perforation. The postoperative 30-day complication occured in 2 cases(1 pt with hematuresis, 1 pt with bladder irritation). The pathologic complete response rate and tumor downstaging rate were 100%. One patient recurred during a median follow-up of 13.0 months (6, 36 months).Conclusions:The En Bloc Resection of Bladder Tumor with the narrow band imaging (NBI) flexible cystoscopy has several remarkable advantages, including a better intra-operative visual, a lower complication rate and tumor residual. The combination of ERBT with immunotherapy and chemotherapy lead to affirmative curative effect and the feasibility for clinical application is relatively high.

Factors Associated With Non-en bloc Resection of Endoscopic Submucosal Dissection for Colorectal Neoplasms / 中国微创外科杂志

Objective To explore factors influencing non-en bloc resection of endoscopic submucosal dissection(ESD)for colorectal neoplasms.Methods A retrospective analysis was conducted on clinical and pathological data of 1251 patients(1312 lesions)who underwent colorectal ESD from January 2011 to December 2022 and were pathologically confirmed as adenoma,serrated lesion,or early colorectal cancer.Clinical and pathological characteristics were compared between the en bloc resection group and the non-en bloc resection group.Univariate and multivariate logistic regression analyses were performed to identify factors influencing en bloc resection in ESD.Results The average size of the1312 lesions was(25.8±16.3)mm.Among the included lesions,there were728 adenomas(55.5%),193 serrated lesions(14.7%),and 391 early colorectal cancers(29.8%).ESD was completed in 1306 lesions and stopped due to perforation or technical difficulties in6 cases.The en bloc resection rate was89.5%(1174/1312),the complete resection rate was 73.8%(968/1312),and the curative resection rate was 70.6%(926/1312).Multivariate logistic regression analysis revealed that diameter of the lesions≥40 mm(OR =6.329,95%CI:4.278-9.384,P<0.001),negative lifting sign(OR =2.384,95%CI:1.424-3.903,P =0.005),scar location lesions(OR =2.997,95%CI:1.310-6.484,P = 0.023),protruded lesions(OR =8.458,95%CI:2.678-40.453,P =0.008),lateral spreading lesions(OR =5.898,95%CI:1.917-27.796,P =0.025),and hybrid ESD(OR =10.162,95%CI:5.705-19.692,P<0.001)were independent factors influencing en bloc resection of ESD for early colorectal cancer and precancerous lesions.Conclusions Diameter of the lesions≥40 mm,negative lifting sign,scar location lesions,protruded lesions,lateral spreading lesions,and hybrid ESD were significantly associated with non-en bloc resection of ESD for colorectal neoplasms.Strict evaluation should be conducted preoperatively to improve the efficacy of ESD.

Functional outcome in patient with giant cell tumour distal radius after reconstruction by en-bloc resection and non-vascularized fibular bone graft: a case report

Giant cell tumor (GCT) is a relatively common benign primary bone tumor, commonly seen in end of long bones. Treatment goals for GCT of the distal radius are complete excision of the tumor and preservation of wrist function. Usually it can be treated by en-bloc resection and reconstruction using autogenous non vascularized ipsilateral proximal fibular graft. Authors present a case of twenty two years old female complaining of pain and lump in left wrist since two years ago. The pain worsened since 1 month before consultation, but did not radiate elsewhere. Pain was aggravated by movement and decreased with rest. Physical examination revealed a 3 cm mass with tenderness over left wrist. With clinical suspicion of benign bone tumor on left wrist, further evaluation was needed. Plain radiograph revealed an expansile, lytic lesion and soap bubble appearance on her left distal radius like a GCT. Open biopsy result revealed similar morphology with GCT. Reconstruction by en-bloc surgical excision, followed with non-vascularized fibular bone graft fixed with dynamic compression plate (DCP) and wrist ligament reconstruction and fixation of the head of the fibula with carpal bones and distal end of the ulna using K-wires along with palmaris longus tendon were performed. En-bloc resection of giant cell tumors of the lower end radius is a widely accepted method. Reconstruction with non-vascularized fibular graft, internal fixation with DCP with trans fixation of the fibular head and wrist ligament reconstruction minimizes the problem and gives satisfactory functional results.

Clinical Significance of Resection Type and Margin following Surgical Treatment for Primary Sarcoma of the Spine: A Multi-Center Retrospective Study

STUDY DESIGN: A retrospective multi-center study.OBJECTIVES: To analyze oncological outcomes according to the resection type and surgical margin following surgical treatment for primary spinal sarcoma.SUMMARY OF LITERATURE REVIEW: Previous studies using registry databases have shown that surgery and negative margins were associated with improved survival for primary spinal sarcoma. However, few studies have comprehensively analyzed the clinical significance of the resection type and surgical margin for the oncological outcomes of this rare malignancy.MATERIALS AND METHODS: We retrospectively reviewed consecutive patients who underwent surgical resection for primary spinal sarcoma between 1997 and 2016 at two tertiary medical centers. Overall survival and the occurrence of local recurrence and distant metastasis were compared between the groups using Kaplan-Meier curve analysis and the log-rank test.RESULTS: Thirty-three patients (21 males,12 females) with a mean age of 45.1 years and a median follow-up of 36 months were included. There were 13 (39.4%) chondrosarcomas, 12 (36.4%) osteosarcomas, and eight different histological diagnoses. The cohort was categorized into four groups: 1) total en bloc resection with a negative margin (n=12; 36.4%), 2) total en bloc resection with a positive margin: (n=5; 15.2%), 3) total piecemeal resection (n=12; 36.4%), and 4) subtotal resection (n=4; 12.1%). Total en bloc resection with a negative margin was associated with improved overall survival (p=0.030) and less distant metastasis (p=0.025) and local recurrence (p=0.004).CONCLUSIONS: Achieving a negative margin through total en bloc resection, although technically demanding, improves oncological outcomes in primary spinal sarcoma.

Endoscopic submucosal dissection of colonic lesions: first 50 cases at a local institution

INTRODUCTION@#Endoscopic submucosal dissection (ESD) in the colon and rectum has been developed with good reported outcomes. The main advantage of ESD is the ability to perform en bloc resection, which has implications for complete excision and pathological analysis. Locally, the use of ESD in colonic lesions has seen recent traction. Our study aimed to review the outcomes of the first 50 cases of endoscopic excision of advanced colonic lesions using ESD at our institution.@*METHODS@#This was a retrospective study of all patients who underwent ESD at our institution from September 2010 to October 2016. Data collected included patient demographics, resection technique, conversion rate and morbidity.@*RESULTS@#51 patients underwent ESD during the study period. All patients were of American Society of Anesthesiologists (ASA) class 1-3. Their median age was 60.0 years and the majority (n = 36) were male. The mean procedure time was 80.9 minutes. 36 (76.6%) of cases underwent en bloc resection. 4 (7.8%) cases required conversion to surgery, mainly due to difficulty in raising the colonic lesions. 3 (5.9%) patients had malignancy as the final histology. 2 (4.3%) patients had recurrence during surveillance scope. No cases of early mortality were reported.@*CONCLUSION@#Our results suggest that ESD for advanced colonic lesions can be safely performed. Expertise needs to be developed to achieve satisfactory en bloc resection rates.

Sacrectomía parcial por abordaje posterior único / Partial sacrectomy by single posterior approach

Introducción: Los tumores del sacro representan <7% de los tumores espinales, prevalecen los tumores secundarios por mieloma múltiple o carcinomas de próstata, mama, pulmón o colón. El cordoma es el tumor maligno primario más frecuente y el tumor de células gigantes es la lesión benigna más común. Por su evolución, compromiso de estructuras extraóseas y la escasa respuesta a los tratamientos coadyuvantes, la cirugía es el tratamiento más utilizado, la vía de abordaje y la necesidad de instrumentación dependerán del tumor por tratar. Los objetivos de este trabajo son: evaluar el uso de la resección parcial del sacro, analizar la técnica quirúrgica y reconocer las complicaciones. Materiales y Métodos: Cuatro pacientes con diagnóstico de tumor sacro ubicado por debajo de S1, que consultan por dolor y cuyas imágenes confirman la lesión. A todos se les realiza una resección en bloque por vía posterior preservando S1. Se describe la técnica. Resultados: Los estudios anatomopatológicos revelaron: un cordoma, un tumor maligno de vaina nerviosa, un condrosarcoma y una metástasis de carcinoma prostático. Se preservó la función de S1 en todos los pacientes; uno tiene disfunción vesical permanente. Se observaron una dehiscencia de la herida, una infección y una fístula de líquido cefalorraquídeo. Todos permanecen sin la enfermedad tras un seguimiento de entre 6 y 24 meses. Conclusiones: La resección parcial del sacro por abordaje posterior único se puede indicar cuando la lesión compromete desde S2 hacia distal y no hay compromiso sacroilíaco. La preservación de raíces es de vital importancia para garantizar mejores resultados posoperatorios y una menor tasa de infección. Nivel de Evidencia: IV

Introduction: Tumors of the sacrum represent less than 7% of spinal tumors. Secondary tumors due to multiple myeloma or prostate, breast, lung and colon carcinomas predominate. Chordoma is the most frequent primary malignant tumor and giant cell tumor is the most common benign lesion. For its evolution, involvement of extra bone structures and poor response to the adyuvant therapy, surgery is the most commonly used treatment, the approach and the need for instrumentation depend on tumor to treat. The objectives of this study are to evaluate the use of partial resection of sacrum, analyze the surgical technique and assess complications. Methods: Four patients with diagnosis of sacral tumor below S1, who presented with pain and images confirming the injury. All underwent an en bloc resection by posterior via preserving S1. The technique is described. Results: The pathological results were: a chordoma, a malignant nerve sheath tumor, a chondrosarcoma and a metastasis of prostatic carcinoma. S1 function was preserved in all patients; one has permanent bladder dysfunction. Wound dehiscence, infection and cerebrospinal fluid fistula were detected. Patients are free of disease after a follow-up of 6-24 months. Conclusions: Partial resection of the sacrum using a unique posterior approach may be indicated when the injury involves from S2 distally and no sacroiliac involvement is observed. Root preservation is vital to guarantee the best postoperative results and a lower rate of infection. Level of Evidence: IV

The clinical efficacy of transurethral plasma needle electrode en bloc resection of bladder cancer / 中华泌尿外科杂志

Objective To summarize the clinical experience and analyze the efficacy of transurethral plasma needle electrode en bloc resection for bladder cancer.Methods From February 2015 to August 2016,a total of 26 patients,including 21 males and 5 females,with bladder cancer received transurethral plasma needle electrode en bloc resection of bladder tumor.Their age ranged from 42 to 75 years,mean (56 ± 13) years.The size of tumor ranged from 1 to 4 cm,mean (2.3 ± 1.6) cm.The solitary tumor was found in 19 cases and multiple tumors were found in 7 cases,including 2 tumors in 5 cases,3 tumors in 2 cases.In 6 cases,the tumor located in the lateral bladder wall.All the pre-operative biopsy showed the urethelial carcinoma in all cases,No bladder extravasion or upper urinary tumor was noticed in the CTU before surgery.By using the electrode needle tip inserted into the bladder mucosa,blunt release or cut the tumor bases until the deep muscularis or the serosal layer,complete removal of the tumor.The specimen was removed from the bladder and sent to the pathological examination.The operation time,the volume of blood loss during operation,surgical complications,pathological diagnosis and the wounds recovery were recorded and analyzed.Results All surgeries were undergone successfully.Totally 35 tumors were resected with diameter of 1.0-4.0 cm,mean (2.3 ± 1.6)cm.The estimated blood loss was less than 10 ml.The operative duration ranged from 20 to 50 min,mean (30 ± 16)min.The duration for removing the single tumor ranged from 5 to 25 min.No obturator nerve reflex were observed during surgery.No blood loss and complications occurred after operation.All patients received 30 mg pirarubicin bladder instillation chemotherapy immediately and no adverse reaction was noticed.Postoperative pathological stages of enrolled cases were distributed as 33 cases of T1G1 staging,2 cases of T1G3 staging.No positive margin was observed.3 months after operation,cystoscopy showed that the wound healed well.A total of 26 cases followed up for 3-10 months (mean 6.0 ± 2.3 months).No one developed recurrence.Conclusions Transurethral plasma needle electrode en bloc resection of bladder tumor would reduce the incidence of complications and obturator nerve reflex.It can provide sufficient specimens for histological diagnosis.

Ten-year experience of esophageal endoscopic submucosal dissection of superficial esophageal neoplasms in a single center

BACKGROUND/AIMS: Endoscopic submucosal dissection (ESD) of a superficial esophageal neoplasm (SEN) is a technically difficult procedure. We investigated the clinical outcomes of ESD to determine its feasibility and effectiveness for the treatment of SEN. METHODS: Patients who underwent ESD for SEN between August 2005 and June 2014 were eligible for this study. The clinical features of patients and tumors, histopathologic characteristics, adverse events, results of endoscopic resection, and survival were investigated. RESULTS: ESD was performed in 225 patients with 261 lesions, including 70 cases (26.8%) of dysplasias and 191 cases (73.2%) of squamous cell carcinomas. The median age was 65 years (range, 44 to 86), and the male to female ratio was 21.5:1. Median tumor size was 37 mm (range, 5 to 85) and median procedure time was 45 minutes (range, 9 to 160). En bloc resection was performed in 245 of 261 lesions (93.9%), with complete resection in 234 lesions (89.7%) and curative resection in 201 lesions (77.0%). Adverse events occurred in 33 cases (12.6%), including bleeding (1.5%), perforation (4.6%), and stricture (6.5%). During a median follow-up period of 35.0 months (interquartile range, 18 to 62), none of the patients showed local recurrence. The 5-year overall and disease-specific survival rates were 89.7% and 100%, respectively. CONCLUSIONS: ESD is a feasible and effective procedure for the treatment of SEN based on our 10-year experience, which showed favorable outcomes.

Clinical analysis of pin-shaped bipolar plasmakinetic electrode used in transurethral en bloc resection of non muscle-invasive bladder urothelial carcinoma / 中华泌尿外科杂志

Objective To introduce the surgery procedure of pin-shaped bipolar plasmakinetic transurethral en bloc resection of non muscle-invasive bladder urothelial carcinoma and investigate the clinical outcomes.Methods 42 cases of non muscle-invasive bladder urothelial carcinoma who received bipolar plasmakinetic transurethral en bloc resection from May 2015 to March 2016 were recruited in the present study.Male 29 cases, female 13 cases, average age 52-82 years old, average (65.6 ±12.3) years old.Wide basal tumors were noticed by preoperative cystoscopy, bladder tumors were confirmed by tumor biopsy.Full-thickness specimens were obtained in procedures, including tumor, mucosa, lamina propria layer, muscular layer, to accurately assess tumor infiltration depth and staging.Results All 42 cases were done by this procedure successfully.A total of 65 pieces of tumors were excised:36 in lateral wall, 19 in posterior wall, 10 in bladder triangle.Tumor diameter ranged from 0.5 to 3.5 cm, with an average (2.1 ± 0.6) cm.Postoperative pathological stages were clear:16 cases were Ta stage and 49 cases were T1 stage ( of which 32 were T1 G3 ) .Intraoperative obturator nerve reflex happened in 2 cases.Followed up for 2-11 months, average 6 months.Tumor recurrence in 3 cases, no progression case.Conclusions Pin-shaped bipolar plasmakinetic electrode transurethral en bloc resection of non muscle-invasive bladder urothelial carcinoma is safe and reliable and should be recommended in management of non muscle-invasive bladder urothelial carcinoma.Full-thickness postoperative specimens can provide accurately judgement of the depth of tumor invasion and pathological staging.

Treatment of superior sulcus tumors using the improved antero-cervical parasternal approach / 中国医师进修杂志

ObjectiveTo investigate the experience of resection of superior sulcus tumors using the improved antero-cervical parastemal approach.MethodsThe clinical data of 3 patients with superior sulcus tumor from July 2005 to May 2010 were analyzed retrospectively.Three patients with superior sulcus tumor underwent en bloc resection using the improved antero-cervical parastemal approach.The 1st to 3rd rib were excised,1 case with 1/5 centrum vertebra excision,1 case with the 1st transverse process of thoracic vertebra excision,1 case with the 1 st and 2nd transverse process of thoracic vertebra excision,1 case with T1 nerve root and sellate ganglion excision.ResultsAll the patients recovered well after operation.There was no serious complication except for 1 case with secondary Horner syndrome.The mild paradoxicalbreathing was found in 3 cases postoperative dressing change,but they had no dyspnea and tolerance well.The paradoxical breathing was disappeared when the mediastinum was fixed after 14 d thoracic wall pressure dressing.The pathological diagnosis after operation:2 cases with squamous-celled carcinoma,1 case with adenosquamous carcinoma,there was no mediastinal lymph node metastasis,cutting edge was negative.Stage:2 cases with T3N0M0,1 case with T4N0M0.Three cases were treated with chemotherapy (NP plan) for 4 cycles after operation without radiotherapy.Three cases were followed up for 53,37, 13 months after operation,they were all survival without recurrence and good quality life.ConclusionsFor the treatment of especially anterior and middle seated superior sulcus tumors,improved antero-cervical parasternal approach provides a safe and effective exposure.The improved antero-cervical parasternal approach is worthy of promotion.

Computer-Assisted Modified Mid-Sacrectomy for En Bloc Resection of Chordoma and Preservation of Bladder Function

A 67-year-old woman presented for evaluation of severe coccygeal pain. The computed tomography scans and magnetic resonance imaging showed an asymmetric midline sacral tumor invading the right lower portion of S2. To preserve both S2 nerve roots and to obtain negative surgical margins, a modified mid-sacrectomy with an aid of a computed navigation system was performed. The sacral tumor was excised en bloc with negative tumor margins. Both S2 nerve roots were preserved and additional reconstruction was not necessary because of minimal resection of the sacroiliac joint. We report a case of a sacral chordoma which was excised en bloc with adequate surgical margins by a computer-assisted modified mid-sacrectomy. The computed navigation system may be a useful tool for tumor targeting and safe osteotomies in sacral tumor surgery via the posterior only approach.

Giant Cell Tumour of the Distal Ulna: A Rare Presentation

Giant-cell tumour (GCT) of bone, a primary yet locally aggressive benign tumour, commonly affects patients between the ages of 20 and 40 years, with the peak incidence occurring in the third decade. Women are affected slightly more than men. The distal end of the ulna is an extremely uncommon site for primary bone tumours in general and giant cell tumours in particular. Wide resection of the distal ulna is the recommended treatment for GCT in such locations. Radio-ulna convergence and dorsal displacement of the ulna stump are known complications following ulna resection proximal to the insertion of the pronator quadratus. This leads to reduction in grip power and forearm rotatory motion. Stabilization of the ulna stump with extensor carpi ulnaris (ECU) tendon after wide resection of the tumour has been described in the literature. We report a case of GCT of distal end of ulna treated with wide resection and stabilization with ECU tendon.

Recurred Parathyroid Carcinoma: A Case of Cervical Recurrence Presenting Discrepancy between Image Findings and Operative Findings / 대한내분비외과학회지

Parathyroid carcinoma is a rare malignancy presenting hyperparathyroidism. At times, diagnosis and localization are difficult. The optimum treatment for parathyroid carcinoma is en bloc resection when malignancy is highly suspicious or diagnosed. However, even after the adequate surgical treatment, persistent or recurrent disease is well encountered. Here we report a case with recurred parathyroid carcinoma presenting discrepancy between image findings and operative findings.

The Efficacy and Safety of Endoscopic Submucosal Dissection in Colorectal Neoplasms: Single Center Study / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic submucosal dissection (ESD) is not commonly used in the colorectal area because of technical difficulty and due to the characteristics of the organ. We therefore wanted to determine the efficacy and safety of endoscopic submucosal dissection in colorectal neoplasms. METHODS: Colorectal tumor lesions resected by ESD in a single medical center were analyzed retrospectively. RESULTS: A total of 47 patients were treated for 50 lesions. Mean age was 64.3+/-9.8 (43~85) years. Laterally spreading tumors were the most common type (44, 88%) followed by Is+IIa type tumors (6, 12%). The en bloc resection rate was 76% and the complete resection rate was 74%. The mean procedure time was 81.1+/-44.7 (20~180) minutes. The mean size of resected specimen was 26.9+/-10.4 (10~50) mm. The histological diagnosis determined that 24 lesions (48%) were tubular adenoma, 18 lesions (36%) were intramucosal cancer, 7 lesions (14%) were sm1 cancer and 1 lesion (2%) was over sm2 cancer. Bleeding occurred in 6 (12%) and perforations in 13 (26%) of the patients and all were treated successfully by endoscopic or conservative treatment. The concordance rate of pre and post ESD pathological diagnosis was only 47%. CONCLUSIONS: ESD is a feasible technique for treating superficial colorectal tumors with a high complete resection rate, minor invasiveness, and a high safety rate. In addition, ESD might be useful in establishing the complete pathological evaluation of colorectal epithelial neoplasm.

Concomitant Adjacent Organ Resection in Locally Advanced Colon Cancer

PURPOSE: In locally advanced adherent colon cancer surgery, a mutivisceral resection is known to reduce local recurrence and improve survival. Practically, the benefit of using this procedure may outweigh the risk of associated morbidity, but the procedure may not be performed uniformly. We reviewed the results of multivisceral resections for locally advanced colon cancer. METHODS: From 2003 January to 2008 January, 476 colon cancer patients underwent surgery for locally advanced colon cancer in our hospital. Out of the 476 patients, 36 patients with pT3-pT4 who underwent any kind of adjacent organ resection other than a resection of the colon were reviewed retrospectively. RESULTS: Out of the 36 patients, 22 were male and 14 were female, and the mean age was 63.44+/-13.26 yr. The sigmoid colon was the most common location for the primary lesion, followed by the ascending colon, the transverse colon, and the cecum. Invaded organs were the abdominal or pelvic wall in 5 patients, the visceral organs in 26 patients, the retroperitoneum in 2 patients. All patients received an en-bloc resection of the invaded organs. Ten patients were stage II, 14 patients were stage III, and 12 patients were stage IV. Fifteen patients were disease free at the end of this study, local recurrence had occurred in 1 patient, 6 patients had an intraabdominal recurrence, and 2 patients had developed a distant metastasis. The overall complication rate was 28%. The 5-yr survival rate of each stage according to the surgical approach did not show any meaningful difference. CONCLUSION: A multivisceral en-bloc resection has been recommended for locally advanced adherent colon cancer patients. To improve the outcome, we suggest progressive surgical treatment in such patients.

The Usefulness of Endoscopic Subtumoral Dissection for En-bloc Resection of Upper Gastrointestinal Submucosal Tumor / 대한소화기내시경학회지

BACKGROUND/AIMS: The removal of esophageal and gastric submucosal tumors is difficult using conventional endoscopic mucosal resection methods. This study examined the usefulness of an endoscopic subtumoral dissection for an en-bloc resection of submucosal tumors. METHODS: An endoscopic subtumoral dissection was attempted for an en-bloc resection in 15 submucosal tumors (M: F=10 : 5, 13 stomach, 2 esophagus). Before the procedures, endoscopic ultrasonography was performed in all cases. The procedure was carried out using various electrosurgical knives, such as an endoscopic submucosal dissection. RESULTS: Pathological and immunohistochemical studies confirmed a gastrointestinal stromal tumor in 6 cases. Other pathological diagnoses were made in 9 patients with submucosal lesions: leiomyoma (4), ectopic pancreas (3), lipoma (1), and hemangioma (1). An en-bloc resection was performed in 13 of the 15 tumors (86.7%). The mean specimen size was 29.5x21.1 mm. The mean procedure time was 49.4 minutes (range: 8~103 minutes). Gastric perforation was a complication in 2 cases with GIST. However, the two perforated cases were treated with endoscopic closure using endoclips and recovered without the need for surgery. CONCLUSIONS: An endoscopic subtumoral dissection technique is useful for an en-bloc resection of esophageal and gastric submucosal tumors. However, sufficient attention should be paid to the detection of perforations in the case of tumors with a proper muscle origin.

The Clinical Results of En Bloc Proximal Fibula Resection for the Treatment of Fibular Head Tumor / 대한정형외과학회잡지

PURPOSE: We retrospectively reviewed cases of en bloc resection of the proximal fibula for the treatment of tumor arising from the fibular head. MATERIALS AND METHODS: Between April 1996 and August 2006, 10 patients who underwent en bloc proximal fibular resection and were followed for at least 12 months were included in this study. The mean age was 27.1 years (range, 5-60 years) and the mean follow-up duration was 64.7 months (range, 12.7-140.6 months). The type of en bloc resection was classified according to the Malaweros resection criteria and the postoperative clinical results were evaluated according to the range of motion, knee joint stability and Musculoskeletal Tumor Society (MSTS) functional scoring system. RESULTS: All patients were able to move the knee joint from 0degrees extension to 145degrees flexion except one patient with flexion contracture of 5degrees. Grade 1 lateral instability of the knee joint was present in two patients. The average MSTS function score was 92.6% (range, 73-100%). There was one patient with lung metastasis who was underwent lobectomy, but there were no patients with local recurrence. CONCLUSION: En bloc resection of the proximal fibula for the treatment of tumors arising from the fibular head is a useful therapeutic method that preserves the knee stability and promotes good functional outcome.