Surgical outcomes of thoracic endovascular aortic repair for retrograde Stanford type a dissection.

OBJECTIVES: The optimal indications and contraindications for thoracic endovascular aortic repair of retrograde Stanford type A acute aortic dissection (R-AAAD) are not well known. The goal of this study was to determine the outcomes of thoracic endovascular aortic repair for R-AAAD at our institution and to discuss optimal indications. METHODS: The medical records of 359 patients admitted to our institution for R-AAAD between December 2016 and December 2022 were reviewed, and 83 patients were finally diagnosed with R-AAAD. We selected thoracic endovascular aortic repair as an alternative, considering the anatomy of aortic dissection and the risk to patients undergoing open surgery. RESULTS: Nineteen patients underwent thoracic endovascular aortic repair for R-AAAD. No in-hospital deaths or neurologic complications occurred. A type Ia endoleak was detected in 1 patient. All other primary entries were successfully closed. All dissection-related complications, such as cardiac tamponade, malperfusion distal to the primary entry and abdominal aortic rupture, were resolved. One patient required open conversion for intimal injury at the proximal edge of the stent graft; all other ascending false lumens were completely thrombosed and contracted at discharge. During the follow-up period, no aortic-related deaths or aortic events proximal to the stent graft occurred. CONCLUSIONS: The indications for thoracic endovascular aortic repair were expanded to low-risk and emergency cases at our institution. The early- and midterm outcomes of thoracic endovascular aortic repair for R-AAAD were acceptable. Further long-term follow-up is required.

Comparing Antegrade and Retrograde Parotidectomy: Surgical Parameters and Complications.

Introduction: Patotidectomy is the treatment of choice for superficial parotid gland lesions. The present study aimed to assess the facial nerve status, as well as peri-and postsurgical complications, in two surgical techniques (antegrade and retrograde) for parotidectomy. Materials and Methods: This study was conducted on 56 patients diagnosed with parotid neoplasms from 2013-2015. The patients were randomly assigned to two groups of antegrade and retrograde. In the retrograde group, the dissection was performed initially to expose the facial nerve branches, while in the antegrade approach, the facial nerve trunk was exposed initially. Different values, such as intraoperative bleeding, mass characteristics, and the time for different sections of the surgery, were noted. The facial nerve was examined after the surgery; moreover, hospital stay and drain removal time was also noted. During the six-month postoperative period, complications and squeals were also noted. Results: Based on the results, antegrade nerve dissection was performed in 24 patients, while retrograde nerve dissection was carried out in 25 patients. The two groups were compared for intraoperative bleeding, drain output, and drain removal time. Hospital stay was found to be statistically higher in the retrograde group (P<0.05). Other complications and morbidities, such as facial nerve trauma, sialoceles, salivary fistulas, Frey's syndrome, skin sensory changes, and surgery time, were not statistically different (P≥0.05). Conclusions: As evidenced by the obtained results, retrograde dissection had higher intraoperative bleeding and longer hospital stay. It seems that skin flap dissection is more extensive in retrograde dissection, leading to more bleeding in this approach. These differences, although statistically significant, are not clinically important; consequently, surgeons' experience and knowledge about the two approaches are of utmost importance.

Surgical Repair of Two Kinds of Type A Aortic Dissection After Thoracic Endovascular Aortic Repair.

Background: Retrograde dissection is now recognized as an important complication following thoracic endovascular aortic repair (TEVAR). The purpose of this study is to describe two different situations of TAAD after TEVAR. We will introduce the surgical methods used to repair TAAD following TEVAR at our center, and evaluate its long-term prognosis. Methods: Between January 2010 and October 2019, 50 patients who had previously received TEVAR treatment for TBAD were admitted to our center for repair of a type A aortic dissection. According to the patients' CT angiographies and intra-operative findings, we identified two distinct groups: a retrograde group (stent-induced new aortic injury, with retrograde extension involving the ascending aorta) and an antegrade group (entry tear located in the aortic root, ascending aorta or the aortic arch, away from the edges of the stent grafts). The options for treatment of the proximal aorta were Bentall procedure (12/50, 24.0%) and ascending aorta replacement (38/50, 76.0%). All patients underwent total arch replacement (TAR) and frozen elephant trunk (FET) implantation. Survival over the follow-up period was evaluated with the Kaplan-Meier survival curve and the log-rank test. Results: The median interval time from prior TEVAR to reoperation was 187 days (IQR: 30.0, 1375.0 days). 18.0% of TAAD after TEVAR did not have any obvious symptoms at the time of diagnosis, most of which were found on routine follow-up imaging. The patients in the retrograde group were younger than those in the antegrade group (44.0 ± 9.4 vs. 51.4 ± 10.5 years, P = 0.012). No significant differences in the incidence of post-operative complications or mortality were noted between the two groups. The mean follow-up time was 3 years. No late death or complications occurred after one year following surgery upon follow-up. The asymptomatic survival rate one year after surgery was 90.0%. Conclusion: The TAR and FET technique was feasible and effective for complicated TAAD after TEVAR. The surgical success rate and long-term prognosis of patients undergoing the timely operation are satisfactory.

Preliminary results of spot-stent grafting in Stanford type B aortic dissection and intramural haematoma.

OBJECTIVES: Optimal treatment for patients with diseased proximal landing zones in acute/subacute Stanford type B dissection and intramural haematoma remains unclear. This study describes the preliminary outcomes of a localized endovascular treatment [spot-stent grafting (SSG)] of main entries/intramural blood pooling located downstream (aortic zones 4 and 5) using one single short device comprising diseased landing zones, looking particularly at the technical and morphological outcomes. METHODS: Patients undergoing thoracic endovascular aortic repair (TEVAR) for acute/subacute aortic dissection Stanford type B/intramural haematoma Stanford type B between 1997 and 2018 were identified from a prospectively maintained institutional database. In a total of 183 cases, 22 patients (7 women; median age 62 years; range 35-79 years) received SSG. The primary study end point was technical success. The primary morphological end point was false lumen thrombosis/aortic remodelling. Secondary end points were TEVAR-related mortality/morbidity and reinterventions. The median follow-up was 28.5 months (5 days-15.6 years). RESULTS: The primary technical success rate was 100% (22/22). During follow-up, false lumen thrombosis was seen in 21 patients (95.5%) at a median of 6 days (0 days to 2.7 years) after the index procedure (limited/extended false lumen thrombosis: n = 9 vs 12). Aortic remodelling was achieved in 15 of 22 patients (68.2%) at a median of 360 days (3 days to 7.2 years). Limited/extended remodelling was observed in 8/15 and 7/15, respectively. Retrograde dissection or stent graft-induced new entry was not observed. No stroke or spinal cord injury occurred. Reinterventions were performed in 4/22 cases. The in-hospital mortality and 30-day mortality were 0%. Overall mortality during the follow-up period was 22.7% (5/22). CONCLUSIONS: This study shows favourable technical and morphological results for SSG in selected patients with acute/subacute aortic dissection Stanford type B/intramural haematoma Stanford type B. Patient allocation to SSG remains individual. Prospective large-scale long-term data may allow refinement of the application.

[Clinical application of midpiece facial nerve dissection in regional parotidectomy].

OBJECTIVE: To propose and evaluate the clinical effect of midpiece facial nerve dissection through transparotid approach in regional parotidectomy. METHODS: A total of 136 patients with benign parotid tumors were categorized into three groups according to the way of facial nerve dissection: anterograde dissection from main trunk (anterograde, n=70), retrograde dissection from distal branches (retrograde, n=34), and midpiece dissection through transparotid approach (middle dissection, n=32). Surgery duration, facial nerve injury, salivary fistula, earlobe sensation, Frey's syndrome, and aesthetic evaluation were compared. RESULTS: The surgery duration in the middle dissection group was significantly shorter than that in the other two groups. The proportion of salivary fistula was higher in the anterograde group (9 cases, 12.9%; P<0.05) compared with that in the other groups. Postoperative facial nerve injury was similar between the middle dissection (1 case, 3.1%) and anterograde groups (3 cases, 4.3%) with lower injury rate compared with the retrograde group (7 cases, 20.6%). The anterograde group had more cases of hypoesthesia of the earlobe (12 cases, 17.1%; P<0.05) than the other two groups. Aesthetic score was higher in the anterograde and middle dissection groups compared with that in the retrograde group (P<0.05). CONCLUSIONS: Midpiece facial nerve dissection is technically feasible and clinically viable in regional parotidectomy.

Clinical application of midpiece facial nerve dissection in regional parotidectomy / 华西口腔医学杂志

OBJECTIVE@#To propose and evaluate the clinical effect of midpiece facial nerve dissection through transparotid approach in regional parotidectomy.@*METHODS@#A total of 136 patients with benign parotid tumors were categorized into three groups according to the way of facial nerve dissection: anterograde dissection from main trunk (anterograde, n=70), retrograde dissection from distal branches (retrograde, n=34), and midpiece dissection through transparotid approach (middle dissection, n=32). Surgery duration, facial nerve injury, salivary fistula, earlobe sensation, Frey's syndrome, and aesthetic evaluation were compared.@*RESULTS@#The surgery duration in the middle dissection group was significantly shorter than that in the other two groups. The proportion of salivary fistula was higher in the anterograde group (9 cases, 12.9%; P<0.05) compared with that in the other groups. Postoperative facial nerve injury was similar between the middle dissection (1 case, 3.1%) and anterograde groups (3 cases, 4.3%) with lower injury rate compared with the retrograde group (7 cases, 20.6%). The anterograde group had more cases of hypoesthesia of the earlobe (12 cases, 17.1%; P<0.05) than the other two groups. Aesthetic score was higher in the anterograde and middle dissection groups compared with that in the retrograde group (P<0.05).@*CONCLUSIONS@#Midpiece facial nerve dissection is technically feasible and clinically viable in regional parotidectomy.

Impact of proximal seal zone length and intramural hematoma on clinical outcomes and aortic remodeling after thoracic endovascular aortic repair for aortic dissections.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) has become standard treatment of complicated type B aortic dissections (TBADs). Whereas adequate proximal seal is a fundamental requisite for TEVAR, what constitutes "adequate" in dissections and its impact on outcomes remain unclear. The goal of this study was to describe the proximal seal zone achieved with associated clinical outcomes and aortic remodeling. METHODS: A retrospective review was performed of TEVARs for TBAD at a single institution from 2006 to 2016. Three-dimensional centerline analysis of preoperative computed tomography was used to identify the primary entry tear, dissection extent, distances between arch branches, and intramural hematoma (IMH) involvement of the proximal seal zone. Patients were categorized into group A, those with proximal extent of seal zone in IMH/dissection-free aorta, and group B, those with landing zone entirely within IMH. Clinical outcomes including retrograde type A dissection (RTAD), death, and aortic reinterventions were recorded. Postoperative computed tomography scans were analyzed for remodeling of the true and false lumen volumes of the thoracic aorta. RESULTS: Seventy-one patients who underwent TEVAR for TBAD were reviewed. Indications for TEVAR included malperfusion, aneurysm, persistent pain, rupture, uncontrolled hypertension, and other. Mean follow-up was 14 months. In 26 (37%) patients, the proximal extent of the seal zone was without IMH, whereas 45 (63%) patients had proximal seal zone entirely in IMH. Proximal seal zone of 2-cm IMH-free aorta was achieved in only six (8.5%) patients. Review of arch anatomy revealed that to create a 2-cm landing zone of IMH-free aorta, 31 (43.7%) patients would have required coverage of all three arch branch vessels. Postoperatively, two patients developed image-proven RTADs requiring open repair, and one patient had sudden death. All three of these patients had TEVAR with the proximal seal zone entirely in IMH. No RTADs occurred in patients whose proximal seal zone involved healthy aortic segment. At 24 months, overall survival was 93% and freedom from aorta-related mortality was 97.4%. Complete thoracic false lumen thrombosis was seen in 46% of patients. Aortic remodeling, such as true lumen expansion, false lumen regression, and false lumen thrombosis, was similar in both groups of patients. CONCLUSIONS: Whereas achieving 2 cm of IMH-free proximal seal zone during TEVAR for TBAD would often require extensive arch branch coverage, failure to achieve any IMH-free proximal seal zone may be associated with higher incidence of RTAD. The length and quality of the proximal seal zone did not affect the subsequent aortic remodeling after TEVAR.

A systematic approach to the recurrent laryngeal nerve dissection at the cricothyroid junction.

BACKGROUND: To describe and evaluate a four step systematic approach to dissecting the recurrent laryngeal nerve (RLN) starting at the cricothyroid junction during thyroid surgery (subsequently referred to as the retrograde medial approach). METHODS: All thyroidectomies completed by the senior author between August 2014 and January 2016 were retrospectively reviewed. Patients were excluded if concurrent lateral or central neck dissection was performed. A follow up period of 1 year was included. RESULTS: Surgical photographs and illustrations demonstrate the four steps in the retrograde medial approach to dissection of the RLN in thyroid surgery. Three hundred forty-two consecutive thyroid surgeries were performed in 17 months, including 213 hemithyroidectomies, 91 total thyroidectomies, and 38 completion thyroidectomies. The rate of temporary and permanent hypocalcemia was 13% (95% confidence interval [CI]: 8-20%) and 3% (95% CI: 1-8%) respectively. The rate of temporary and permanent vocal cord palsy was 9% (95% CI: 6-12%) and 0.3% (95%CI: 0.01-2%) respectively. The median surgical times for hemithyroidectomy, total thyroidectomy, and completion thyroidectomy were 39 min (Interquartile range [IQR]: 33-47 min), 48 min (IQR: 40-60 min), and 40 min (IQR: 35-51 min) respectively. 1% of cases required conversion to an alternative surgical approach. CONCLUSION: In a tertiary endocrine head and neck practice, the routine use of the retrograde medial approach to RLN dissection is safe and results in a short operative time, and a low conversion rate to other RLN dissection approaches.

Application value of perihilar surgery technique in the reoperation of biliary dilatation of central large intra-and extra-hepatic bile ducts above the hilar convergence / 中华消化外科杂志

Objective To explore the application value of perihilar surgery technique in the reoperation of biliary dilatation of central large intra-and extra-hepatic bile ducts above the hilar convergence.Methods The retrospective cross-sectional study was conducted.The clinical data of 3 patients with biliary dilatation of central large intra-and extra-hepatic bile ducts above the hilar convergence who underwent the reoperation in the Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine from August 2017 to January 2018 were collected.All three patients had been collected a detailed previous surgical history.After preoperative lab and imaging examinations,evaluation of liver function,residual liver volume and general condition were done,then 3 patients underwent left hemihepatectomy + dilated right hepatic duct and extrahepatic bile duct resection,right anterior and posterior hepatic duct reconstructive surgery and Roux-en-Y anastomosis of the jejunum.The surgical procedures followed as:intra-abdominal adhesions separation,extrahepatic antergrade dissection of porta hepatis,transverse cutting the dilated extrahepatic bile duct,split the cantlie line,exposure of the hilar plate,left hemihepatectomy,dilated right hepatic bile duct resection,right anterior and posterior hepatic duct remodeling and biliary-enteric anastomosis.Observation indicators included:(1) surgical and postoperative recovery;(2) follow-up.Follow-up using outpatient examination and telephone interview was performed to detect general condition,complications,liver function and residual choledochal cysts up to May 2018.Results (1) Surgical and postoperative recovery:All the 3 patients underwent choledochal cysts resection + left hemihepatectomy + dilated right hepatic duct + right anterior and posterior hepatic duct reconstructive surgery and Roux-en-Y anastomosis of the jejunum using the perihilar surgery technique and extrahepatic anterograde combined by intrahepatic retrograde dissection method exposing portal hepatis.There was no perioperative death.The operation time and volume of intraoperative blood loss in 3 patients were 435 minutes,490 minutes,395 minutes and 250 mL,300 mL,200 mL,respectively.There was no intraoperative blood transfusion.Three patients had no bleeding and abdominal liver function.One patient with bile leakage and delayed gastric emptying at 1 week postoperatively received puncture drainage,gastrointestinal decompression,gastric lavage with hypertonic saline,acupuncture and total parenteral nutrition,then bile leakage was cured after 3-week therapy,gastric motility was improved after 5-week therapy,and then gastric tube was removed.The abdominal drainage tube was removed at 3 weeks postoperatively in 1 patient and at 1 week postoperatively in 2 patients.The postoperative gross specimen examinations showed intra-and extra-hepatic bile duct dilatation in 3 patients,including 2 combined with choledocholithiasis and 1 with left intrahepatic bile duct cancer.The postoperative pathological findings showed that 3 patients had intrahepatic bile duct cystic dilatation with chronic inflammation,peripheral small bile duct hyperplasia with inflammatory cell infiltration,1 of which had intrahepatic intraductal papilloma with high grade intraepithelial neoplasia.One and 2 patients were discharged from hospital at 7 weeks postoperatively and 2 weeks postoperatively,respectively.(2) Follow-up:All 3 patients were followed up for 4-8 months.During the follow-up,patients had good general condition and no symptoms of cholecystitis such as abdominal pain,chills and fever,liver function was normal,and no residual bile duct cyst was found by enhanced scan of CT.Conclusion The perihilar surgery technique and extrahepatic anterograde combined by intrahepatic retrograde dissection method exposing portal hepatis for the treatment of biliary dilatation of central large intra-and extrahepatic bile ducts above the hilar convergence can increase the radical resection rate and surgical efficacy.

Early Outcomes of Acute Retrograde Dissection From the International Registry of Acute Aortic Dissection.

To provide data on the management and outcomes of patients with acute retrograde aortic dissection (AD) originating from a tear in the descending aorta with extension into the aortic arch or ascending aorta. All patients enrolled in the International Registry of Acute Aortic Dissection from 1996-2015 were reviewed. Retrograde AD was defined by primary tear in the descending aorta with proximal extension into the arch or ascending aorta. Primary end points were in-hospital management strategy and mortality. We identified 101 patients with retrograde AD (67 men; 63.2 ± 14.0 years). During index hospitalization, medical (MED), open surgical (SURG), and endovascular (ENDO) therapies were undertaken in 44, 33, and 22 patients, respectively. The SURG group presented with larger ascending aorta (P = 0.04) and more frequent ascending aortic involvement (81.8% [27/33] vs 22.7% [15/66], P < 0.001) compared with the MED and ENDO groups. Early mortality rate was 9.1% (4/44), 18.2% (6/33), and 13.6% (3/22), for the MED, SURG, and ENDO groups (P = 0.51), respectively. A favorable early mortality rate was observed in patients with retrograde extension limited to the arch (8.6% [5/58]) vs into the ascending aorta (18.6% [8/43], P = 0.14). Early mortality rate of patients with retrograde AD with primary tear in the descending aorta (12.9% [13/101]) was significantly lower than those with classic type A AD presenting with primary tear in the ascending aorta (20.0% [195/977], P = 0.001). A subset of patients with acute retrograde AD originating from primary tear in the descending aorta might be managed less invasively with acceptable early results, particularly among those with proximal extension limited to the arch.

Assessment and management of cervico-mediastinal goiter.

Cervico-mediastinal goiter is a particular entity from the point of view of thyroid surgery. Its volume, hardness and intrathoracic extension require the surgeon to adapt technique and perform a painstaking preoperative work-up, so as to draw up fully-fledged plan. CT is now indispensable, to anticipate risks and determine whether sternotomy is needed. Surgery seems to induce more postoperative complications than in conventional surgery, although they can be reduced by retrograde dissection of the inferior laryngeal nerve and downward dissection of the posterior side of the lobe to optimize control of adjacent structures. This surgery requires optimal teamwork between all of the specialties involved in patient management: medical, radiological, anesthesiological and surgical.

An Innovative Emergency Laparoscopic Cholecystectomy Technique; Early Results Towards Complication Free Surgery.

BACKGROUND: The performance of laparoscopic cholecystectomy could be a technical challenge. Procedure success depends on multiple factors namely: hepatobiliary anatomical variations, pathologic changes in the gallbladder and surrounding tissues, pre-operative interventional attempts, the individual surgeon's skill and finally patient co-morbidities. Anticipating the attendant challenges, can help to avoid several known complications associated with this procedure. Searching a more reliable anatomical topography to adopt during laparoscopic cholecystectomy is the basis for a safe surgical technique. METHODS: Between January 2012 and August 2015, 525 cases were presented with acute cholecystitis. Patients were classified in to two groups regarding degree of dissection difficulty. The study concept is defined and applied by the author in all study cases. No single case was excluded from the study. RESULTS: Results are processed in comparative way between both groups of the study. The increased risk results in Group B are related to technical difficulties. CONCLUSION: The study has offered a novel anatomical concept and safe surgical technique avoiding exploration of Calot's triangle. The new concept has minimized dissection demands and risk of injury related to the traditional laparoscopic cholecystectomy. The study has proposed a potentially secure and empirical laparoscopic cholecystectomy technique that could be considered in every case.

Retrograde Type A Aortic Dissection Treated with Continuous Perfusion "Branch-First" Aortic Arch Replacement Technique.

The development of thoracic endovascular aortic repair in recent years has revolutionised the way aortic disease is treated. However, there are potential complications associated with this which can be life threatening and pose a difficult challenge to manage. We present a case of retrograde ascending aortic dissection complicating thoracic endovascular aortic repair, and its repair using a technique of continuous perfusion "branch-first" aortic arch replacement. We discuss the complication of retrograde ascending aortic dissection and the issues that affect its surgical management.

Application of retrograde dissection of the cystic duct in 1 460 cases of laparoscopic cholecystectomy / 中国微创外科杂志

Objective To study a safe and effective method for the dissection of the cystic duct under laparoscope.Methods Laparoscopic cholecystectomy was performed in 1 460 cases,by using the retrograde dissection of the cystic duct,from December 2002 to December 2005 in this hospital. Results The laparoscopic cholecystectomy was successfully completed in 1 442 cases,with an operation time of 15~100 min(mean, 42 min).A conversion to open surgery was required in 18 cases(1.23%).Complications included 5 cases of bile duct injury(0.34%),3 cases of intraabdominal hemorrhage(0.21%),and 3 cases of biliary leakage(0.21%).Follow-up for 2~24 months(mean,11.8 months) found 2 cases of residual calculi in the common bile duct.Conclusions The retrograde dissection of the cystic duct during laparoscopic cholecystectomy is a safe method and simple to perform.