Complications, secondary interventions and long term morbidity after en bloc sacrectomy.

PURPOSE: En bloc sacrectomy is a demanding surgical procedure to remove tumors from the sacrum. Comprehensive data on readmissions for complications endured months to years after initial discharge are scant. The purpose of this study is to present the long-term complications, readmissions and secondary interventions for patients having undergone en bloc sacrectomy. METHODS: Patients were included if en bloc sacrectomy and follow-up were conducted in the authors institution. Correspondence from all specialties involved in the treatment of patients was retrieved. Predefined parameters were scored and assigned to five distinct phases: diagnostic phase; surgery; postoperative period to 1 year after surgery; second year after surgery until follow-up and last follow-up. RESULTS: Sixteen patients underwent anterior-posterior en bloc sacrectomy for a locally aggressive tumor (n=2); malignant tumor (n=13) or solitary metastasis (n=1). The type of resection was low (n=1); middle (n=3); high (n=4); total (n=3) and hemisacrectomy (n=5). The median surgical duration was 12.7 h and median blood lost was 12 l. A total of 73 major complications (average per patient 5; median 4; range 0-12) were recorded and 73 secondary interventions (average per patient 5; median 5; range 0-11) were performed in the first year postsurgery. From the second year until follow-up complications and secondary interventions markedly decreased. At final follow-up (65-266 months), considerable morbidity was found for the eleven patients still alive. CONCLUSIONS: En bloc sacrectomy is a procedure with a high rate of major complications, regardless of tumor histology, often necessitating readmissions and secondary interventions. Long-term survival is associated with considerable morbidity and extensive preoperative counseling should be conducted to discuss the risks and outcome of the procedure.

Transmanubrial osteomuscular sparing approach for sulcus superior tumours.

OBJECTIVE: The authors report their initial experience with the transmanubrial osteomuscular sparing approach for resection of sulcus superior tumours. The feasibility of this technique is evaluated. PATIENTS: Between February 2000 and March 2002 three patients with sulcus superior tumours were surgically treated using the transmanubrial osteomuscular sparing approach. The first two patients had a non-small cell carcinoma of the upper lobe. In the third patient a pathological diagnosis of a plasmocytoma of the first rib was made. In two cases the first thoracic root was resected. RESULTS: In two patients a complete R0 resection was achieved. However, an additional posterolateral thoracotomy was necessary in two patients because the costovertebral angle was difficult to address. In one patient final histologic examination found microscopically positive margins. CONCLUSION: We believe that the transmanubrial osteomuscular sparing technique enables us to approach and control the subclavian vessels and brachial plexus in an oncologically responsible way and permits a radical resection of tumours invading the thoracic inlet.

A double-blind, comparative study of gadodiamide injection and gadopentetate dimeglumine in MRI of the central nervous system.

Seventy-nine patients with known or suspected central nervous system lesions were studied with MRI in a phase III double-blind study. Forty were given gadopentetate dimeglumine (Gd-DTPA) and 39 gadodiamide injection (Gd-DTPA BMA), a new low-osmolar nonionic contrast enhancing medium. The dosage was 0.1 mmol/kg body weight, corresponding to 0.2 ml/kg. Spin-echo sequences were performed before and immediately after injection. The safety and efficacy of the two contrast media were assessed. No changes were observed in blood pressure, heart rate or neurological status. Five adverse effects (two episodes of headaches, two of nausea and one of dizziness) were reported by 2 patients who received gadodiamide injection and 1 who received gadopentetate dimeglumine. All events were mild and their relationship to the contrast media was uncertain. For both contrast media statistically significant changes in serum iron were observed 24 h after injection. More than 70% of the patients had abnormal findings on MRI, and in 56% of these contrast enhancement of the abnormal structure or lesion was seen. Contrast enhancement provided the diagnosis in about 50%, changed it in 40% and increased diagnostic confidence in 95%.