Subperiosteal vs Subdural Drain After Burr-Hole Drainage of Chronic Subdural Hematoma: A Randomized Clinical Trial (cSDH-Drain-Trial).

BACKGROUND: The use of a subdural drain (SDD) after burr-hole drainage of chronic subdural hematoma (cSDH) reduces recurrence at 6 mo. Subperiosteal drains (SPDs) are considered safer, since they are not positioned in direct contact to cortical structures, bridging veins, or hematoma membranes. OBJECTIVE: To investigate whether the recurrence rate after insertion of a SPD is noninferior to the insertion of a more commonly used SDD. METHODS: Multicenter, prospective, randomized, controlled, noninferiority trial analyzing patients undergoing burr-hole drainage for cSDH aged 18 yr and older. After hematoma evacuation, patients were randomly assigned to receive either a SDD (SDD-group) or a SPD (SPD-group). The primary endpoint was recurrence indicating a reoperation within 12 mo, with a noninferiority margin of 3.5%. Secondary outcomes included clinical and radiological outcome, morbidity and mortality rates, and length of stay. RESULTS: Of 220 randomized patients, all were included in the final analysis (120 SPD and 100 SDD). Recurrence rate was lower in the SPD group (8.33%, 95% confidence interval [CI] 4.28-14.72) than in the SDD group (12.00%, 95% CI 6.66-19.73), with the treatment difference (3.67%, 95% CI -12.6-5.3) not meeting predefined noninferiority criteria. The SPD group showed significantly lower rates of surgical infections (P = .0406) and iatrogenic morbidity through drain placement (P = .0184). Length of stay and mortality rates were comparable in both groups. CONCLUSION: Although the noninferiority criteria were not met, SPD insertion led to lower recurrence rates, fewer surgical infections, and lower drain misplacement rates. These findings suggest that SPD may be warranted in routine clinical practice.

Follow-up after treatment for head and neck cancer: United Kingdom National Multidisciplinary Guidelines.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. In the absence of high-level evidence base for follow-up practices, the duration and frequency are often at the discretion of local centres. By reviewing the existing literature and collating experience from varying practices across the UK, this paper provides recommendations on the work up and management of lateral skull base cancer based on the existing evidence base for this rare condition. Recommendations • Patients should be followed up to a minimum of five years with a prolonged follow-up for selected patients. (G) • Patients should be followed up at least two monthly in the first two years and three to six monthly in the subsequent years. (G) • Patients should be seen in dedicated multidisciplinary head and neck oncology clinics. (G) • Patients should be followed up by dedicated multidisciplinary clinical teams. (G) • The multidisciplinary follow-up team should include clinical nurse specialists, speech and language therapists, dietitians and other allied health professionals in the role of key workers. (G) • Clinical assessment should include adequate clinical examination including fibre-optic rigid or flexible nasopharyngolaryngoscopy. (R) • Magnetic resonance imaging and positron emission tomography combined with computed tomography imaging should be used when recurrence is suspected. (R) • Narrow band imaging can be used in the follow-up in selected sites. (R) • Second primary tumours should be part of rationale of follow-up and therefore adequate screening strategies should be used to detect them. (G) • Patients should be educated with regard to the appearance and detection of recurrences. (G) • Patients with persistent pain should be investigated to exclude recurrent disease. (R) • Patients should be offered support with tobacco and alcohol cessation services. (R).

Diagnostic accuracy of three-dimensional sonohysterography compared with office hysteroscopy and its interrater/intrarater agreement in uterine cavity assessment after hysteroscopic metroplasty.

OBJECTIVE: To compare the diagnostic accuracy of three-dimensional sonohysterography (3D-SIS) and office hysteroscopy in uterine cavity assessment after hysteroscopic metroplasty (HM) and determine the interrater/intrarater agreement for 3D-SIS. DESIGN: Prospective observational study. SETTING: University hospital, private hospital, and clinic. PATIENT(S): One hundred forty-one women undergoing HM for septate uterus with a history of miscarriage and/or infertility. INTERVENTION(S): 3D-SIS and office hysteroscopy at 6-8 weeks after HM. MAIN OUTCOME MEASURE(S): Shape of the uterine cavity, length of the fundal notch (≥1 or <1 cm), and the presence of intrauterine adhesions were assessed, and the interrater/intrarater agreement of 3D-SIS was evaluated in 30 randomly selected patients. RESULT(S): Uterine abnormalities were detected with the use of hysteroscopy in 18 (12.8%) of 141 women. 3D-SIS was highly accurate (97.2%), sensitive (97%), and specific (100%), with a positive predictive value of 100% and a negative predictive value of 85%. The diagnostic values of hysteroscopy and 3D-SIS were not significantly different (McNemar test). 3D-SIS showed substantial interrater/intrarater agreement regarding overall uterine cavity evaluation (κ = 0.79 and 0.78, respectively). CONCLUSION(S): 3D-SIS demonstrated substantial interrater/intrarater agreement for the postoperative evaluation of the uterine cavity, being as diagnostically accurate as hysteroscopy. The use of second-look hysteroscopy may be limited to cases that require reoperation.

Revised guidelines for second-look surgery in patients with colon and rectal cancer.

Proper indications for a second surgical intervention in patients with colorectal cancer have always been a controversial subject. Surgeons find benefit in a second-look operation where a limited extent of cancer is discovered and resected with negative margins. However, a negative exploratory laparotomy or an intervention that is unable to achieve an R0 resection provides little or no benefit. Unfortunately, this type of intervention may place the patient in a worse condition, leading to morbidity or mortality. This manuscript attempts to define clinical parameters of primary colorectal cancer that are associated with a pattern of recurrence and that can be definitively addressed by second-look surgery. Also, new surgical technologies that may assist in achieving a potentially curative resection of local-regional recurrence are described. Cytoreductive surgery with peritonectomy and perioperative intraperitoneal chemotherapy with hyperthermia is presented as a new treatment option for reoperative surgery. A new management plan utilized in patients at high risk for local-regional recurrence may result in a high likelihood of conversion of a second-look cancer-positive patient to a long-term survivor.

Staged excision of lentigo maligna and lentigo maligna melanoma: a 10-year experience.

BACKGROUND: The treatment of lentigo maligna and lentigo maligna melanoma presents a difficult problem for clinicians. Published guidelines recommend a 5-mm excision margin for lentigo maligna and a 1-cm margin for lentigo maligna melanoma, yet these are often inadequate. The authors' purpose is to report their 10-year experience using staged excision for the treatment of lentigo maligna and lentigo maligna melanoma of the head and neck. METHODS: Staged excision was performed on 59 patients over a 10-year period. Data on patient demographics, lesion characteristics, and treatment were collected through an institutional review board-approved chart review. RESULTS: Using staged excision, 62.7 percent of patients required a 10-mm or greater margin to achieve clearance of tumor. Two or more stages of excision were required in 50.9 percent of patients. Invasive melanoma (lentigo maligna melanoma) was identified in 10.2 percent of patients initially diagnosed with lentigo maligna. There was one (1.7 percent) documented recurrence during a median 2.25-year follow-up period (range, 0 to 10.17 years). CONCLUSIONS: Staged excision is an effective treatment for lentigo maligna and lentigo maligna melanoma. Previously published recommendations of 5-mm margins for wide local excision are inadequate for tumors located on the head and neck.

Evaluation of restaging in clinical stage 1A low malignant potential ovarian tumours.

OBJECTIVE: This study was undertaken to evaluate whether restaging clinical stage 1A low malignant potential (LMP) tumours previously incompletely staged in a non-gynaecology oncology centre yields useful information for management and prognosis. METHODS: A retrospective chart review was undertaken of all patients with LMP tumours treated at the Queensland Centre for Gynaecological Cancer (QCGC) from 1982-2000. RESULTS: Fifty-six (69%) of the 81 patients referred with a provisional stage 1A diagnosis underwent a second operation for staging purposes. Four (7%) out of the 56 patients who underwent restaging had their tumours upstaged. A single patient out of the 25 patients who did not undergo restaging had disease recurrence and died as a result. The mean follow-up for all patients in the study was 60 months. CONCLUSION: It is hard to justify routine surgical restaging for patients with a LMP ovarian tumour apparently confined to a single ovary At the very least, hundreds of patients with clinical stage 1A tumours will need to be restaged before a single patient will have data that will change management. Consequently the morbidity of routine restaging is difficult to justify for such a small clinical gain.