Endoscopic intermuscular dissection (EID) for removing early rectal cancers and benign fibrotic rectal lesions.

In the current era of screening colonoscopy and increasing incidence of early rectal cancer, interventional endoscopy moves toward resections in deeper planes than the submucosal layer. Several reports support the use of endoscopic intermuscular dissection (EID) instead of endoscopic submucosal dissection (ESD) for the removal of deeply invasive rectal submucosal cancers. The resection plane into the intermuscular space, the space between the longitudinal (external) and circular (internal) muscle layer, allows radical removal of rectal invasive submucosal cancers. Furthermore, the technique offers the potential for dissection of scarred and severe fibrotic lesions in the rectum by cutting deeper and performing a partial myectomy avoiding the narrow submucosal space. We present 23 cases of EIDs both for deeply invasive rectal cancers and benign rectal lesions. This is the first report in the literature of EID resections for malignant and benign disease, including cases of severely fibrotic rectal lesions.

Is the shortened dental arch still a satisfactory option?

Aims Dental practitioners may hold the view that missing posterior teeth should be replaced to ensure a healthy masticatory system and satisfactory oral function. However, the shortened dental arch (SDA) concept is still in use, but after 35 years is it acceptable? This review searches the literature for the evidence and opinions regarding the suitability of the SDA as a current treatment modality.Methods Medline and PubMed databases were searched for relevant terms, all the abstracts were assessed and articles selected according to the pre-set exclusion and inclusion criteria.Results The search yielded 1,895 articles and after the assessment of the abstracts and application of the exclusion and inclusion criteria, 44 articles were selected for this review. These included 11 cohort studies, two longitudinal studies, two animal studies, three cross sectional studies, eight clinical studies and 18 case control studies. There appears to be a trend over the past three decades for more papers to be opposed to the SDA concept.Conclusion Evidence that the SDA causes pathology is lacking. Clinicians, healthcare authorities and patients have shown favourable attitudes towards the SDA and this continues, although there is an increase in studies opposing the concept and some are dissatisfied with this option. The concept remains viable particularly for the medically compromised patient or where restorations are considered unsuitable but further more specific studies are warranted.

Status of level IIb lymph nodes of the neck in squamous cell carcinoma of the oral tongue in patients who underwent modified radical neck dissection and lymph node sentinel biopsy.

Status of lymph nodes of level IIb was examined to identify the incidence of nodal metastasis and the lymphatic drainage in squamous cell carcinoma of the oral tongue in patients undergoing modified radical neck dissection (MRND) and sentinel node biopsy (SNB). Overall, 72 patients were divided into two groups; 38 patients (Group A) of any T and N+ or T3-T4- N0 stage underwent MRND. The surgical specimens were sent to the Pathology Department, divided into specific levels (I, IIa, IIb, III, IV, V) and labelled. The remaining 34 patients (Group B) T1-T2 -N0 stage were submitted to SNB. The histological examination of the specimens of the two groups was performed by staining with haematoxylin and eosin several sections from each node at different levels and then using a molecular marker such as cytokeratin and Epithelial Membrane Antigen (EMA). In Group A: In N0 there were no occult metastases at level IIb; in N+ neck, 8 cases (33.3%) showed metastasis at level IIb (P = 0.04). Metastases at level IIb were observed only in combination with other levels (P = 0.03). In Group B, direct lymphatic drainage was found in 2 patients (5.9%) at level IIb. There were no occult metastases at level IIb. Out of the 54 sentinel nodes harvested, 4 lymph nodes (7.4%) were found to be metastatic; these 4 sentinel nodes were found respectively in 4 patients, 1 at level III, 3 at level II a with an occult metastasis rate of 11.7%. In conclusion, SNB has prospected a new concept of lymphatic drainage that is variable and individual. SNB has demonstrated that direct lymphatic drainage is possible to level II b. In our experience with early cancer of the tongue (T1-T2 NO ), SNB aided with lympho-scintigraphy seems to be a good technique for staging the neck with minimal morbidity.

Conservative laser microsurgery for T1 glottic carcinoma.

OBJECTIVE: The purpose of the study was to assess whether partial cordectomy or complete cordectomy with narrow free margins is a safe oncological procedure for T1 glottic carcinoma. We also studied surgical margins and the involvement of anterior commissure. METHODS: Thirty-one T1 glottic carcinomas underwent endoscopic CO(2) laser excision of the lesion based on the depth of infiltration by the tumor with 1-2mm free margins. If detecting free margins was not macroscopically possible, additional biopsies along all the uncertain margins of the excision's residual area were taken. After excision, the specimen was mounted on a plastic support, flattened and then held in place with fine needles. It was then oriented and mapped. The pathologist measured the lesion's point of maximum infiltration and its distance from the free margins. RESULTS: Local and ultimate control at 36 months was 95% and 100%, respectively. We performed 29 partial and two complete cordectomies. Complete resection of the lesion was obtained in 90.4% of the cases. Re-resection was necessary in 9.6% of the cases due to positive margins. The anterior commissure was affected in 38.7% of the cases, and was the site of maximum infiltration in 9.6% of the cases. The mean maximum infiltration was 0.93mm in the anterior commissure, 2.18mm in the anterior 1/3rd of the vocal cord, 1.71mm in the middle 1/3rd of the vocal cord and 1.5mm in the posterior 1/3rd of the vocal cord. In 83.9% of the cases (p<0.01), the anterior 1/3rd of the vocal cord was the section most frequently involved. In 19 patients (61.3%) (p<0.01), the anterior 1/3rd of the vocal cord was also the area with the highest incidence of maximum infiltration by the tumor. CONCLUSION: We concluded that.

Using remifentanil and sufentanil in functional endoscopic sinus surgery to improve surgical conditions.

The purpose of the study was to compare three types of general anesthesia for functional endoscopic sinus surgery (ESS) with controlled hypotension measuring the quality of visibility of the surgical field and the blood loss during the operation. Seventy-one patients underwent endoscopic ethmoidectomy bilaterally for nasal polyposis and/or chronic sinusitis. The patients were divided into three groups according to the type of anesthesia they had: group A (sufentanil/sevoflurane), group B (remifentanil/propofol), and group C (fentanyl/isoflurane). The mean estimated blood loss for group A was 117.83 ml, for group B it was 100.5 ml and for group C it was 198.89 ml. The average quality of visibility of the surgical field was 1.57 for group A, 1.3 for group B and 2.79 for group C. The quantity of blood loss (p < 0.01) and the visibility of the surgical field (p < 0.001) demonstrated a difference among the three groups. Remifentanil and sufentanil during functional ESS enable controlled hypotension and a general improvement in surgical conditions.

[Endoscopic excisional biopsy with laser CO2 for the diagnosis and treatment of glottic carcinoma (T1-selected T2)]. / Endoscopic excisional biopsy with laser CO2 for the diagnosis and treatment of glottic carcinoma (T1-selected T2).

UNLABELLED: AIMS AND BACKGROUNDS: In T1-T2a glottic carcinoma before considering which type of treatment is the best option a biopsy is necessary. A peculiar aspect of this type of lesions is the fact that in the same specimen it is possible to find different grade of dysplasia even carcinoma in situ or microinvasive or invasive. An incisional biopsy could mislead the diagnosis. The aim of this study was to report the oncological results of the excisional biopsy for T1-T2a glottic cancer. MATERIALS AND METHODS: From November 1999 to December 2001, 18 patients (13 T1, 5 T2a) with carcinoma of the vocal cord underwent excisional biopsy of the lesion. In the case of negative margins no further treatment was done. The average follow-up was 2 years and 3 months. RESULTS: Local control was achieved in 100% for T1, 80% for T2. Radiotherapy was added in 2 cases. CONCLUSION: In our experience "excisional biopsy" for unadvanced glottic tumors is an ideal surgical technique for a one stage procedure of diagnosis and therapy.

[The stapler in total laryngectomy with closed technique]. / The stapler in total laryngectomy with closed technique.

UNLABELLED: AIMS AND BACKGROUNDS: The use of the stapler in total laryngectomy with closed technique is described by the authors. MATERIALS AND METHODS: From October 1999 to December 2002, 27 total laryngectomy were performed, 15 with a stapler and 5 cases had a primary tracheoesophageal puncture. RESULTS: Only one patient developed a pharyngocutaneous fistula, no other patients experienced post-operative complications. All cases in this study had negative surgical margins. CONCLUSION: The correct indication for the use of the stapler is a tumor that needs a total laryngectomy, but completely endolaryngeal. The technique allows to remove the nso-gastric tube at the end of the first week after the operation, to avoid soiling the surgical field, to reduce the time in theatre. This technique seems to be safe as the traditional suture.

[Treatment of the facial nerve and the neck in malignant parotid gland tumors]. / Il trattamento del nervo facciale e del collo nei tumori maligni della ghiandola parotide.

In the surgery of malignancies of the parotid gland the management of the facial nerve and of the neck is very important. In fact, many authors declared as the surgery of parotid gland can be considered as the surgery of facial nerve and others underlined the role of the neck management in a complete treatment of these neoplasms. The features of 47 cases of parotid gland neoplasms observed at the National Cancer Institut of Naples (Naples, Italy) are reported. In all cases a total parotidectomy was performed with neck dissection in case of neck metastases or electively in selected cases and resection of the facial nerve only in case of macroscopic tumor involvement. Radiotherapy was administrated in case of involvement of the facial nerve, and/or of the skin and/or of multiple neck metastases. The results of our experience emphasize as the neoplasms of the parotid gland can be treated sparing the facial nerve when it is clearly not involved without making worse prognosis; on the other side planing a neck dissection should be mandatory in case of high degree malignancies, and/or of tumors larger than T2, and/or of involvement of the facial nerve, and/or of the skin and/or cervical lymph nodes.

Prognostic value of sentinel node in oral cancer.

AIMS AND BACKGROUND: In stage I oral squamous cell carcinoma, clinical examination and imaging techniques are unable to identify 60-90% of patients at risk of micrometastasis, while the sentinel node biopsy technique allows to avoid the morbidity of elective neck dissection in patients not actually affected by micrometastases. MATERIALS AND METHODS: Forty-one T1-T2N0 patients underwent lymphoscintigraphy after peritumoral injection of human albumin labeled with 99Tc. Focal areas of radiotracer uptake were marked on the skin preoperatively. The sentinel lymph node (SLN) was identified by the combined use of blue dye and gamma probe and subsequently removed. Complete neck dissection was then performed in all patients and the histological findings were compared with those of SLN biopsy. RESULTS: The SLN was identified in 95% of the patients; in four cases (10%) two SLNs were isolated. In 18% of our patients the SLNs were located outside the expected drainage area. When the histology of the negative SLNs was compared with the pathological status of the neck dissection specimens no false negatives were found. Five SLNs in four patients contained micrometastases and were the only positive lymph nodes. CONCLUSIONS: SLN biopsy can be a valuable staging technique in T2 and T2 oral cancer with uninvolved neck in patients whose lymphatic drainage of the neck has not been altered by previous surgery or radiotherapy. It provides reliable detection of micrometastasis, indicating which level(s) should be removed ipsilaterally or contralaterally, and allows the surgeon to accurately plan neck dissection, taking into consideration the pattern of lymphatic drainage of each individual patient. In this way unnecessary neck dissection and its morphofunctional sequelae can be avoided in a considerable number of patients.

[Mucociliary clearance after aerobic exertion in athletes]. / Il trasporto mucociliare dopo sforzo aerobico in atleti.

The Authors studied the modifications in nasal mucociliary clearance times before and after aerobic exertion in athletes. A total of 60 athletes with high-level training (age range 18-37 years) were selected for this study. Persons who smoked or had allergies, nasal sinus phlogosis or tumors, altered nasal cavity morphology (i.e. deviation of the septum and/or hypertrophy of the turbinates), fever or who were taking topic and/or systemic drugs or had previously undergone head and neck surgery were all ruled out of the study. The authors then studied the mucociliary clearance time (MCCT) in these subjects using the saccharin test. This test involves placing a small amount of saccharin on the medial face of the lower turbinate, approximately 1.5 cm from the anterior end and then evaluating the time that elapses before the patient perceives the sweet taste. This test was performed: in 30 subjects one hour prior to and 15 minutes after physical aerobic exertion; in the remaining subjects (controls) the test was performed twice with a 75 minute interval between them. The results showed that the mucociliary clearance time increased after exertion which was, on the average, 11.29 minutes. On the basis of these data, the Authors discuss the likely causes for the detected increase, and correlate it to changes in ventilation and nasal secretion viscosity during physical exercise. According to previous research, these variations are also found in untrained subjects who undergo physical exertion; for this reason, the Authors conclude that nasal clearance is not significantly affected by training.