Enhanced recovery after surgery reduces length of stay after colorectal surgery in a small rural hospital in Ontario.

Introduction: Enhanced recovery after surgery (ERAS) programmes include pre-operative, intraoperative and post-operative clinical pathways to improve quality of patient care while reducing length of stay (LOS) and readmission. This study assessed the feasibility and outcomes of an ERAS protocol for colorectal surgery implemented over 2 years in a small, resource-challenged rural hospital. Methods: A prospective cohort study used retrospectively matched controls to assess the effect of ERAS on LOS in patients undergoing colorectal surgery in a small rural hospital in northern Ontario, Canada. ERAS patients were matched to two patients in the control group based on diagnosis, age and gender. Patients had open or laparoscopic colorectal surgeries, with those in the intervention group treated per ERAS protocol and given instructions on pre- and post-operative self-care. Results: Most of the 47 ERAS patients recruited to the study reported adherence to ERAS protocols before surgery. Adherence to protocol was strongest for chewing gum in the days after surgery. Most patients were sitting in a chair for their afternoon meal by the 1st day and most were walking down the hallway by the 2nd day. The control group had significantly higher (P < 0.001) malignant neoplasm of the colon (C18, 69% vs. 35%) and significantly lower malignant neoplasm of the rectum (C20, 0% vs. 5%). The control group had an average ln-transformed LOS that was significantly longer (exponentiated as 1.7 days) than ERAS patients (t-test, P < 0.001). Conclusion: This study found that ERAS could be implemented in a small rural hospital and provided evidence for a reduced LOS of approximately 2 days.

Résumé Introduction: Les programmes de réhabilitation améliorée après chirurgie (RAAC) comprennent des itinéraires cliniques préopératoires, peropératoires et postopératoires visant à améliorer la qualité des soins aux patients tout en réduisant la durée du séjour et les réadmissions. Cette étude a évalué la faisabilité et les résultats d'un protocole de RAAC pour la chirurgie colorectale mis en oeuvre pendant deux ans dans un petit hôpital rural aux ressources limitées. Méthodes: Une étude de cohorte prospective a utilisé des témoins appariés pour évaluer l'effet de la RAAC sur la durée du séjour des patients subissant une chirurgie colorectale dans un petit hôpital rural du nord de l'Ontario, au Canada. Les patients RAAC ont été appariés à deux patients du groupe témoin sur la base du diagnostic, de l'âge et du sexe. Les patients ont subi une chirurgie colorectale ouverte ou laparoscopique, et ceux du groupe d'intervention ont été traités selon le protocole de RAAC et ont reçu des instructions sur les soins auto-administrés pré et postopératoires. Résultats: La plupart des 47 patients RAAC recrutés pour l'étude ont déclaré adhérer aux protocoles de RAAC avant l'intervention chirurgicale. L'adhésion au protocole a été la plus forte pour la gomme à mâcher dans les jours qui ont suivi l'opération. La plupart des patients étaient assis sur une chaise pour le repas de l'après-midi dès le premier jour et la plupart marchaient dans le couloir dès le deuxième jour. Le groupe témoin présentait un taux significativement plus élevé (P < 0,001) de néoplasme malin du côlon (C18, 69% contre 35%) et un taux significativement plus faible de néoplasme malin du rectum (C20, 0% contre 5%). Le groupe de contrôle avait une durée moyenne de séjour transformée en Ln significativement plus longue (exponentielle de 1,7 jours) que les patients RAAC (test t, P < 0,001). Conclusion: Cette étude a montré que la RAAC pouvait être mise en oeuvre dans un petit hôpital rural et a fourni des preuves d'une réduction de la durée de séjour d'environ deux jours. Mots-clés: Réhabilitation améliorée après chirurgie (RAAC); durée du séjour; hôpitaux ruraux; chirurgie colorectale; Ontario; soins périopératoires.

Delayed Abdominal Pseudohernia in Young Patient After Lateral Lumbar Interbody Fusion Procedure: Case Report.

OBJECTIVE: To describe a rare complication of the extreme lateral interbody fusion technique. BACKGROUND: Lateral lumbar interbody fusion (LLIF) is a minimally invasive technique that has achieved great reputation among spine surgeons because of its advantages over other procedures. However, complication rates of this technique have not been definitively assessed so far. CASE REPORT: A 44-year-old male smoker, presenting with pseudoarthrosis of a previous posterior stabilization, underwent an LLIF procedure. The operation was uneventful, and an appropriate functional recovery was achieved by 2 months after surgery. Nevertheless, 5 months after surgery, the patient developed pulmonary tuberculosis and a mass in the proximity of the LLIF incision appeared. This mass was finally diagnosed as abdominal pseudohernia and had to be surgically repaired. CONCLUSIONS: Abdominal pseudohernia is a rare complication of LLIF procedures. The interest of the present case is 3-fold: 1) it is the first delayed case of abdominal pseudohernia after an LLIF procedure; 2) it is the first case described in a young patient in whom risk factors have been identified and discussed; and 3) it is the first case that did not resolve spontaneously and required surgical repair. This exceptional complication must be borne in the mind of the spine surgeon when using the LLIF technique, and special precautions, such as laxatives or respiratory physiotherapy, apart from meticulous atraumatic dissection and closure of the abdominal wall and specific intraoperative monitoring, should be taken in high-risk patients to prevent it.

Transoral vertebroplasty for a C2 aneurysmal bone cyst.

BACKGROUND CONTEXT: Aneurysmal bone cysts at the cervical spine represent a real challenge both diagnostically and therapeutically, especially in young patients. PURPOSE: We present an unusual case of a C2 aneurysmal bone cyst expanding in the entire vertebral body in a girl successfully treated with a transoral vertebroplasty. STUDY DESIGN: This is a case report study. METHODS: We report the case of a 17-year-old girl with a history of cervical pain and occipital headache after a car accident. Routine x-rays disclosed a C2 lesion. Her neurologic examination was normal. Computed tomography showed a lytic lesion occupying almost the entire body of the C2 vertebra. The cortical bone was intact but notably thinned. Magnetic resonance imaging revealed a cystic image with blood inside. Transoral vertebroplasty was selected among other surgical options for the following reasons: (1) to improve the clinical symptoms, and (2) to prevent future vertebral collapse with devastating neurologic consequences. Under general anesthesia and continuous neurophysiological monitoring, we conducted a fluoroscopic-guided transoral vertebroplasty through a Jamshidi needle. A cytology sample from the cystic lesion was taken through the needle. RESULTS: The blood smear showed no tumoral cellularity. There were no complications during surgery or postoperative infections. After 4 years of follow-up, the patient is pain-free and leads a normal life. CONCLUSIONS: Transoral vertebroplasty seems to be a direct, safe, and effective technique to stabilize cystic lesions that endanger the stability of C2 and to improve symptoms. Aneurysmal bone cysts should be included in the differential diagnosis of lytic lesions at the C2 vertebral body.

Anterior-only Partial Sacrectomy for en bloc Resection of Locally Advanced Rectal Cancer.

Study Design Case report. Objective The usual procedure for partial sacrectomies in locally advanced rectal cancer combines a transabdominal and a posterior sacral route. The posterior approach is flawed with a high rate of complications, especially infections and wound-healing problems. Anterior-only approaches have indirectly been mentioned within long series of rectal cancer surgery. We describe a case of partial sacrectomy for en bloc resection of a locally advanced rectal cancer with invasion of the low sacrum through a combined transabdominal and perineal approach without any posterior incision. Methods Through a midline laparotomy, the tumor was dissected and the sacral osteotomy was performed. Once the sacrum was mobile, the muscular attachments to its posterior wall were cut through the perineal approach. This latter route was also used to remove the whole specimen. Results The postoperative period was uneventful in terms of infection and wound healing, but the patient developed right foot dorsiflexion paresis that completely disappeared in 1 month. Resection margins were negative. After a follow-up of 18 months, the patient has no local recurrence but presented lung and liver metastases. Conclusion In cases of rectal cancer involving the low sacrum, the combination of a transabdominal and a perineal route to carry out the partial sacrectomy is a feasible approach that avoids changes of surgical positioning and the morbidity related to posterior incisions. This strategy should be considered when deciding on undertaking partial sacrectomy in locally advanced rectal cancer.

Stabilization of the cervicothoracic junction in tumoral cases with a hybrid less invasive-minimally invasive surgical technique: report of two cases.

BACKGROUND: Literature about long constructs in the cervicothoracic junction (CTJ) implanted with a minimally invasive surgical technique is practically nonexistent. Our objective is to present a less invasive-minimally invasive (LIS-MIS) surgical technique to stabilize the CTJ. PATIENTS AND METHODS: A midline cervical short incision was made, three or four level lateral mass screws were inserted bilaterally and rods were placed in a conventional technique (LIS field). Percutaneous screws were placed in the upper thoracic spine, and thoracic rods were threaded subfascially through the pedicle sleeves up to the cervical incision (MIS field). Cervical and thoracic rods were linked with parallel connectors. Two cross-links were used in each case. RESULTS: Two patients (33 and 53 years of age) with instability of the CTJ due to metastases were operated on in this way without attempting bone fusion. Mean duration of surgery was 7.5 hours. No patient required blood transfusion. There were no complications related to surgery or the hardware. Opioid consumption diminished after surgery, and both patients remained ambulatory until decease. CONCLUSION: This LIS-MIS technique seems feasible to stabilize the CTJ in very selected cases when fusion is not necessary.

RNA interference in the treatment of colon cancer.

Colorectal cancer is the third most common cancer in both men and women and has shown a progressive increase over the past 20 years. Current chemotherapy has major limitations, and a novel therapeutic approach is required. Given that neoplastic transformation of colon epithelial cells is a consequence of genetic and epigenetic alterations, RNA interference (RNAi) has been proposed as a new therapeutic strategy that offers important advantages over conventional treatments, with high specificity and potency and low toxicity. RNAi has been employed as an effective tool to study the function of genes, preventing their expression and leading to the development of new approaches to cancer treatment. In malignancies, including colon cancer, RNAi is being used for "silencing" genes that are deregulated by different processes such as gene amplification, mutation, or overexpression and may be the cause of oncogenesis. This strategy not only provides information on the involvement of certain genes in colon cancer, but also opens up a new perspective for its treatment. However, most studies have used adenovirus or lentivirus vectors to transport RNAi into tumor cells or tumors in animal models, because several technical obstacles must be overcome before RNAi can be used in the clinical setting. The aim of this study was to review current knowledge on the use of RNAi techniques in the treatment of colon cancer.

Biomechanical evaluation of the craniovertebral junction after anterior unilateral condylectomy: implications for endoscopic endonasal approaches to the cranial base.

BACKGROUND: : Endoscopic endonasal approaches to the craniovertebral junction and clivus, which are increasingly performed for ventral skull base pathology, may require disruption of the occipitocondylar joint. OBJECTIVE: : To study the biomechanical implications at the craniovertebral junction of progressive unilateral condylectomy as would be performed through an endonasal exposure. METHODS: : Seven upper cervical human cadaveric specimens (C0-C2) underwent nondestructive biomechanical flexibility testing during flexion-extension, axial rotation, and lateral bending at C0-C1 and C1-C2. Each specimen was tested intact, after an inferior one-third clivectomy, and after stepwise unilateral condylectomy with an anterior approach. Angular range of motion (ROM), lax zone, and stiff zone were determined and compared with the intact state. RESULTS: : At C0-C1, mobility during flexion-extension and axial rotation increased significantly with progressive condylectomy. ROM increased from 14.3 ± 2.7° to 20.4 ± 5.2° during flexion and from 6.7 ± 3.5° to 10.8 ± 3.0° during right axial rotation after 75% condyle resection (P < .01). At C1-C2, condylectomy had less effect, with ROM increasing from 10.7 ± 2.0° to 11.7 ± 2.0° during flexion, 36.9 ± 4.8° to 37.1 ± 5.1° during right axial rotation, and 4.3 ± 1.9° to 4.8 ± 3.3° during right lateral bending (P = NS). Because of marked instability, the 100% condylectomy condition was untestable. Changes in ROM were a result of changes more in the lax zone than in the stiff zone. CONCLUSION: : Lower-third clivectomy and unilateral anterior condylectomy as would be performed in an endonasal approach cause progressive hypermobility at the craniovertebral junction. On the basis of biomechanical criteria, craniocervical fusion is indicated for patients who undergo > 75% anterior condylectomy.

Acute hemicerebellitis with obstructive hydrocephalus in a young adult.

BACKGROUND: Acute cerebellitis is a rare entity, described in the pediatric population, usually of viral or autoimmune origin, bilateral and symmetric, and with good prognosis. Only 13 cases of unilateral cerebellitis have been reported thus far. To the best of our knowledge, this is the first case of hemicerebellitis in the literature reported in a young adult that caused acute hydrocephalus requiring surgical treatment. CASE DESCRIPTION: We report an unusual case of an 18-year-old man, without previous infectious symptoms, who developed acute obstructive hydrocephalus secondary to hemicerebellitis. A ventricular drainage was placed. The affected cerebellar hemisphere was later explored and biopsied, and edematous tissue, with an inflammatory reaction of the leptomeninges, was obtained. With corticosteroids and antivirals, the neurologic symptoms disappeared and the MRI evolved to normal in 2 week's time. CONCLUSIONS: Hemicerebellitis must be considered in the differential diagnosis of cerebellar mass lesions, even in young adults. Although rare, clinically significant hydrocephalus may develop. Despite the availability of MRI, a high index of suspicion is still required to accurately diagnose this entity. The histologic substrate seems to be localized meningitis. The edematous reaction of the cerebellar parenchyma supports the usefulness of corticoids in the treatment strategy of this disease.

Laparoscopic excision of a large extra-adrenal perirenal myelolipoma.

Extra-adrenal myelolipoma is a very rare type of tumour. Laparoscopic removal of extra-adrenal myelolipoma has not been previously reported. We report the first case of laparoscopic excision of a large extra-adrenal perirenal myelolipoma.