Integrated surgery and radiology: trans-oral robotic surgery guided by real-time radiologist-operated intraoral ultrasound.

PURPOSE: We aimed to evaluate the feasibility and utility of intraoral ultrasound as a real-time guidance technique in trans-oral robotic surgery (TORS). METHODS: We report our early experiences of radiologist-operated intraoral ultrasound during TORS, providing information on tumour margin and important adjacent structures. Resection specimens were sonographically imaged for margin assessment. RESULTS: Four patients underwent ultrasound-guided TORS, with a close correlation between intraoperative and preoperative imaging in each case. The tumour was fully excised in three cases (one did not proceed due to difficult access). No ultrasound-related adverse events occurred, surgical margins were negative, and the treated patients are currently in a state of remission, with functional swallows. CONCLUSION: Intraoperative ultrasound can allow previously inaccessible disease to be robotically resected with confidence. Sonographic interrogation of the resected specimen correlated closely with histological margin analysis, and a novel technique of using saline to improve ultrasound conductance and therefore image quality is described.

Malignant Solitary Fibrous Tumor Metastatic to Widely Invasive Hurthle Cell Thyroid Carcinoma: A Distinct Tumor-to-Tumor Metastasis.

We illustrate a case of synchronous malignant solitary fibrous tumor of the thoracic cavity, and widely invasive thyroid Hurthle cell carcinoma. The Hurthle cell carcinoma was found to harbor distinct areas of malignant solitary fibrous tumor. This is a unique case of tumor-to-tumor metastasis that, to the best of our knowledge, has not been previously reported.

A successful free fibula transfer in the patient with chronic peroneal vein thrombosis.

Despite the rare incidence, occult chronic thrombosis of peroneal veins of the fibula graft during the flap harvest presents a challenge to produce a successful reconstruction. In this article, we present a case of a 54-year-old man with chronic thrombosis of peroneal veins found during the harvest of the free fibula osteocutaneous flap for reconstruction of the mandible defect after tumor ablation. With near-total obliteration of the lumens, a small lumen with residual blood outflow was identified under microscopic magnification. A successful flap transfer was made possible by using the recanalized lumen around the chronic thrombus of the vein for microanastomosis. The pathological analysis of the vein revealed that the recanalized lumens and the endothelial cells-specific CD31 immunohistochemical stain highlighted the endothelium of regenerative lumen around the chronic thrombus. The abundant deposition of thick collagen fibers also suggested a chronic nature of the thrombus. However, although a successful microsurgical free osteocutaneous flap transfer might be possible in the patient with lower-limb chronic peroneal vein thrombosis, a careful preoperative evaluation with imaging study is recommended for high-risk patients.

Anteromedial thigh perforator free flap: report of 41 consecutive flaps and donor-site morbidity evaluation.

BACKGROUND: The anterolateral thigh (ALT) flap is a workhorse flap in free tissue transfer but an alternative is needed in case of failure, no sizable perforators and for those cases where the ALT flap has already been used. The anteromedial thigh (AMT) flap provides a good amount of soft tissues, not increasing the number of donor sites. In this study, we reviewed a single-centre series of AMT flaps, evaluated the donor-site morbidity and discussed the indications for head and neck reconstruction. METHODS: From 2006 to 2010, 41 consecutive AMT flaps in 39 patients were done. Donor-site morbidity was evaluated with subjective and functional assessment. At least 6 months after surgery, patients received a standard questionnaire and a bilateral kinetic test was performed to compare the AMT donor leg and the contralateral leg. RESULTS: In every case, a sizable perforator was found and an AMT flap was harvested and revascularised. The average size of the flaps was 14.0±5.5×6.2±1.5 cm. The mean pedicle length was 8 cm (6-10 cm) and 30 of the perforators (73.2%) were true myocutaneous perforators. Two flaps were lost postoperatively and the assessed success rate was 95%. Donor-site morbidity evaluation showed very good subjective perception and good kinetic functional tests. No impairment in daily activity was found. CONCLUSION: The AMT flap is a very good and reliable option whenever the ALT flap is not available. It does not increase the number of donor sites, preserving a good lower-limb function. LEVELS OF EVIDENCE: Therapeutic study: level III.

The nasolabial flap as a one-stage procedure for reconstruction of intermediate-to-large lip defects with functional and aesthetic assessments.

OBJECTIVES: The primary function of the lip is oral competence. The lips are also fundamental in facial aesthetics. Thus in lip reconstruction, it is paramount to achieve both good functional and aesthetic outcomes. Local flaps are able to provide the best tissue match in intermediate and large lip defects. Nevertheless, there has been limited literature on using the musculocutaneous nasolabial flap as a one-stage procedure for lip reconstruction. METHODS: The authors recruited 21 patients who underwent a one-stage nasolabial musculocutaneous flap reconstruction for lip defects for the study. The modiolus at the mouth angle was preserved and the nasolabial flap was de-epithelised and tunnelled subcutaneously in all patients for reconstructing the lips. Electromyography was performed for 14 flaps to detect muscle activity. Oral competency was assessed using the Drooling Rating Scale and aesthetic outcomes were also analysed postoperatively with the Patient and Observer Scar Assessment Scale. RESULTS: All patients successfully underwent lip reconstruction with the musculocutaneous nasolabial flap. There were no flap failures. Electromyographic activity was detected in 10 out of the 14 flaps tested. Oral competencies were well preserved and there were no cases of microstomia. Aesthetic results were also good. CONCLUSION: The nasolabial flap for one-stage reconstruction of lip defects following lip resection is feasible. Good functional and aesthetic outcome can be achieved.

The outcome of prostaglandin-E1 and dextran-40 compared to no antithrombotic therapy in head and neck free tissue transfer: analysis of 1,351 cases in a single center.

Free tissue transfer has become a popular technique for soft tissue defect reconstruction in head and neck cancer ablation. Although high success rates and good reliability of free flaps are proven, microvascular thrombosis is still the most critical issue for microsurgeons. Pharmacological antithrombotic agents are widely used but their efficacy is still debated. In this study, we analyzed whether prostaglandin-E1 (PGE1) and dextran-40 can improve the outcomes compared to no antithrombotic therapy at all. We retrospectively reviewed 1,351 free flaps performed for head and neck reconstruction after cancer ablation. Three groups defined were 232 flaps received PGE1, 283 flaps received dextran-40, and 836 received no antithrombotic therapy. The demographics of these three groups indicated no statistical differences. The results showed that flap survival revealed no significant difference among PGE1, dextran-40, and control group (P = 0.734). There was a tendency to hematomas in PGE1 group (P = 0.056) when compared with other two groups. Dextran-40 significantly increased flap failure rate in high-risk patients with diabetes mellitus (P = 0.006) or hypertension (P = 0.003), when compared with PGE1 and control group. These results revealed antithrombotic therapy with PGE1 and dextran-40 do not determine a significant improvement in flap survival.