Second-look surgery in postoperative pediatric low-grade glioma.

OBJECTIVE: To review the literature on second-look surgery in pediatric low-grade gliomas (LGG) with a view to presenting both sides of the picture of re-exploration. METHODS: Collection of material from recent literature on pediatric LGG. This was a retrospective review of these publications. RESULTS: There are a number of publications recommending second-look surgery in selected cases, provided morbidity of the second surgery is minimum, and indeed some in which there is improvement in the neurodeficit after the second resection. CONCLUSION: There seems a fair balance of articles recommending and dissuading the practice of second-look surgery, but in our limited experience we have found it useful in selected patients.

Prevention of peritoneal adhesions after gynecological surgery: a systematic review.

IMPORTANCE: The formation of adhesions after gynecological surgery not only has detrimental impacts on those affected, including pain, obstruction, and infertility, but also imposes a high economic burden on healthcare systems worldwide. OBJECTIVE: The aim of this review was to evaluate the adhesion prevention potential of all currently available adhesion barriers for gynecological surgery. EVIDENCE ACQUISITION: We systematically searched MEDLINE and CENTRAL databases for randomized controlled trials (RCTs) on the use of adhesion barriers as compared with peritoneal irrigation or no treatment in gynecological surgery. Only RCTs with second-look surgery to evaluate adhesions in the pelvic/abdominal (but not intrauterine) cavity were included. RESULTS: We included 45 RCTs with a total of 4,120 patients examining a total of 10 unique types of barriers in second-look gynecological surgery. While RCTs on oxidized regenerated cellulose (significant improvement in 6 of 14 trials), polyethylene glycol with/without other agents (4/10), hyaluronic acid and hyaluronate + carboxymethylcellulose (7/10), icodextrin (1/3), dextran (0/3), fibrin-containing agents (1/2), expanded polytetrafluoroethylene (1/1), N,O-carboxymethylchitosan (0/1), and modified starch (1/1) overall showed inconsistent findings, results for expanded polytetrafluoroethylene, hyaluronic acid, and modified starch yielded the greatest improvements regarding adhesion reduction at 75%, 0-67%, and 85%, respectively. CONCLUSIONS AND RELEVANCE: Best results for adhesion prevention were reported after applying Gore-Tex Surgical Membrane, hyaluronic acid, and 4DryField®. As Gore-Tex Surgical Membrane is nonabsorbable, it is associated with a greater risk of new adhesion formation due to second-look surgery to remove the product. 4DryField® yielded the greatest improvement in adhesion score compared to all other barrier agents (85%). For better comparability, future studies should use standardized scores and put more emphasis on patient-reported outcome measures, such as pain and infertility.

Evolution of neurosurgical advances and nuances in medulloblastoma therapy.

Medulloblastoma, the most common malignant brain tumor in children, presents a complex treatment challenge due to its propensity for infiltrative growth within the posterior fossa and its potential attachment to critical anatomical structures. Central to the management of medulloblastoma is the surgical resection of the tumor, which is a key determinant of patient prognosis. However, the extent of surgical resection (EOR), ranging from gross total resection (GTR) to subtotal resection (STR) or even biopsy, has been the subject of extensive debate and investigation within the medical community. Today, the impact of neurosurgical EOR on the prognosis of medulloblastoma patients remains a complex and evolving area of investigation. The conflicting findings in the literature, the challenges posed by critical surrounding anatomical structures, the potential for surgical complications and neurologic morbidity, and the nuanced interactions with molecular subgroups all contribute to the complexity of this issue. As the field continues to advance, the imperative to strike a delicate balance between maximizing resection and preserving quality of life remains central to the management of medulloblastoma patients.

Surgeon experience in second-look transurethral resection of bladder cancer - a prospective study.

INTRODUCTION AND OBJECTIVES: Transurethral resection of bladder tumor (TURBT) is crucial in the treatment of bladder tumors and when incorrectly performed can cause staging mistakes. To avoid these errors, a second resection is recommended in selected cases. The aim of this study is to evaluate the surgeon's ability to predict histologically complete primary resection of newly diagnosed bladder tumors avoiding the need for a second TURBT. METHODS: This is a prospective, observational study involving 47 consecutive patients with newly diagnosed bladder tumors who had previously undergone primary TURBT, and met EAU criteria for second-look TURBT. Second-look TURBT specimens were analyzed for routine histological assessment and compared with the surgeon's impression of the tumor at initial resection. RESULTS: Of 91 patients submitted to primary TURBT, 47 met the criteria for second-look TURBT. Second-look specimens revealed residual disease in 20.9% of patients and 3 (6.4%) of patients showed upstaging disease. The sensitivity of a senior to detect disease on second-look TURBT in relation to muscle invasion was 75%, and the specificity was 85%. CONCLUSIONS: Second-look TURBT is crucial in the treatment of bladder cancer and cannot be replaced by a surgeon's opinion, so international recommendations should be followed. Supervision of less experienced surgeons is a cornerstone.

Second-look surgery for pineal region tumors.

PURPOSE: Surgical resection of pineal region tumors is challenging because of close proximity to the vein of Galen draining system and the quadrigeminal plate. Surgical resection usually is performed through the narrow corridor by piecemeal resection and en bloc resection is difficult in cases of large tumors. Moreover, in cases of hypervascular tumors, surgical resection through the narrow corridor could entail massive intraoperative bleeding. The effectiveness of neoadjuvant chemotherapy and second-look surgery for pineal region tumors for maximal safe resection was evaluated. METHODS: Retrospective institutional review of pediatric patients with pineal region tumors who underwent second look surgery after neoadjuvant chemotherapy was performed. RESULTS: Nine patients underwent surgical resection after neoadjuvant chemotherapy over the period of September 2017 to February 2022. The mean age was 7.7 years (ranged from 1.4 to 15.3 years). Three patients underwent partial resection via open craniotomy, and 6 underwent endoscopic biopsy as an initial surgery. The histopathological diagnoses were germ cell tumors in 5 patients (yolk sac tumors in 2, germinoma in 2, choriocarcinoma in 1), /rhabdoid tumor (AT/RT) in 2, medulloblastoma in 1, and high-grade glioneuronal tumor in 1. After several courses of chemotherapy, the second-look surgery was performed. The tumor volume was reduced in 8 patients (89%) after chemotherapy except for 1 case of growing teratoma syndrome. The tumor was extended laterally to the ambient cistern in 2 patients, and posteriorly to the tentorial surface of the cerebellum in 3 patients. The lesion was approached through occipital transtentorial approach in 8 patients and infratentorial supracerebellar approach in 1. Intraoperatively, the high vascularity of the tumor was not observed in all cases. Gross total resection (8 patients, 89%) or near total resection (1, 11%) was achieved in all cases. No complications were observed postoperatively in all cases. Eight patients subsequently underwent additional chemo-radiation therapy according to the initial diagnosis. All patients are alive with no evidence of recurrence with a mean follow-up of 33 months. CONCLUSIONS: Neoadjuvant chemotherapy and second-look surgery for pediatric pineal region tumors was considered to be effective in reducing the tumor volume and vascularity, which facilitates the safe maximal tumor resection.

An unusual and life-threatening presentation of a large GIST.

INTRODUCTION: Gastrointestinal stromal tumours (GIST's) are rare tumours of the alimentary tract. They are often discovered incidentally during imaging or intra-operatively. In rare instances, they present acutely with life threatening gastrointestinal (GI) bleeding requiring emergency surgical intervention. CASE PRESENTATION: A 47-year-old gentleman, who is an ex-smoker with normal body mass index (BMI), presented with acute onset of epigastric pain, dizziness, and multiple episodes of melaena. The patient deteriorated rapidly and urgent endoscopy revealed active retrograde bleeding from beyond the duodenojejunal junction. Computed tomography angiography (CTA) suggested a highly vascular ileal exophytic mass resembling a GIST. Emergency exploratory laparotomy was conducted where hemostasis was achieved via segmental enterectomy of the mass that was unexpectedly jejunal in origin. During recovery, he encountered post-operative complications that were managed conservatively and eventually was discharged with a referral to the national cancer centre. CLINICAL DISCUSSION: The clinical presentation of GIST is based on its size and location. Definitive diagnosis of GIST relies on histopathological findings although the clinical presentation and imaging, in particular CTA, can aid in its diagnosis. Management of GIST differs depending on the clinical presentation, size, location and whether metastasis is present. Surgical resection is the standard of treatment; however, Imatinib could be used for non-resectable tumours as well as in cases of recurrence, metastasis or as an adjuvant chemotherapy. CONCLUSION: It is important to acknowledge that small GISTs are often asymptomatic while larger ones may present with non-specific symptoms which can be misleading. This could potentially delay the diagnosis and thus treatment of GIST which can be detrimental in acute cases as illustrated here. It is important to have GIST as one of the differentials when faced with a patient presenting with non-specific GI symptoms.

Second-Look Arthroscopic Findings and Clinical Outcomes after Adipose-Derived Regenerative Cell Injection in Knee Osteoarthritis.

Background: To evaluate the clinical outcomes and second-look arthroscopic findings after intra-articular adipose-derived regenerative cell (ADRC) injection as treatment for knee osteoarthritis (OA). Methods: ADRCs were administered to 11 patients (19 knees; mean age, 61.7 years) with knee OA. Subcutaneous adipose tissue was harvested by liposuction from both thighs, and arthroscopic lavage was performed, followed by ADRC injection (mean dose, 1.40 × 107 cells) into the synovial fluid. Outcome measures included the Knee Injury and Osteoarthritis Outcome Score, Lysholm score, and visual analog scale score. Arthroscopic examinations were performed to assess the International Cartilage Repair Society cartilage injury grade preoperatively and overall repair postoperatively. Noninvasive assessments were performed at baseline and at 1-, 3-, and 6-month follow-ups; arthroscopic assessments were performed at baseline and at 6 months. Results: All outcome measures significantly improved after treatment. This improvement was evident 1 month after treatment and was sustained until the 6-month follow-up. Data from second-look arthroscopy showed better repair in low-grade cartilage lesions than in lesions with a greater degree of damage. No patients demonstrated worsening of Kellgren-Lawrence grade, and none underwent total knee arthroplasty during this period. Conclusions: Clinical outcomes were improved in patients with knee OA after ADRC administration. Cartilage regeneration was more effective in smaller damaged lesions than in bigger lesions.

Management of stage I occult uterine leiomyosarcoma: effects of morcellation, second-look surgery, and adjuvant treatments on survival.

Background: This study sought to analyze the risk of morcellation in patients who underwent surgery for leiomyoma and had a final pathological diagnosis of uterine leiomyosarcoma (uLMS), and evaluate the survival benefits of second-look surgery and chemotherapy in patients with stage I occult uLMS. Methods: A retrospective analysis of the data of patients with occult stage I uLMS in the Peking Union Medical College Hospital database between 2005 and 2018 was conducted. The recurrence rate and progression-free survival (PFS) were compared between patients who underwent morcellation or not. Univariate analyses were used to evaluate the survival impact of lymphadenectomy, oophorectomy and adjuvant chemotherapy. Propensity-score matching methods were used to evaluate the effect of morcellation on recurrence while adjusting for baseline confounding factors using Poisson regression fitted by inverse probability weighting (IPW) estimation. Results: A total of 96 patients with uLMS were identified among the 31,679 surgeries performed for leiomyomas (incidence: 0.303%). Hysterectomy was performed in 60 patients, and myomectomy was performed in 36 patients (power morcellation n=20). There were 36 (37.5%) patients underwent lymphadenectomy, and 76 (79.2%) patients underwent oophorectomy. Among them, 47 (52.8%) patients received postoperative chemotherapy. The median follow-up time was 40 months (range, 12-146 months), and there were 43 cases of recurrence (44.7%). No differences in recurrence were found between the hysterectomy and myomectomy groups (hazard ratio 0.839, P=0.701). The 3-year PFS rates for patients with hysterectomy, power morcellation, and non-power morcellation were 64.3%, 53.8%, and 59.8%, respectively. No survival differences were identified between patients with/without lymphadenectomy [PFS: P=0.513; overall survival (OS): P=0.413] and oophorectomy (PFS: P=0.162; OS: P=0.815). Postoperative chemotherapy was associated with better PFS (P=0.047), but not OS (P=0.36). Conclusions: No survival differences were observed among the initial surgical procedures in stage I patients with occult uLMS. No survival benefits were observed between lymphadenectomy and oophorectomy patients. Compared to continued observation, postoperative chemotherapy was associated with improved PFS, but not OS.

Second-look Surgery Detects Low Volume Recurrent Disease Following Cytoreductive Surgery for Peritoneal Carcinomatosis.

BACKGROUND/AIM: Formation of stoma during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis (PC) is often performed to reduce the risk of anastomotic leak. Subsequent stoma reversal provides a unique opportunity for second-look surgery to detect early peritoneal recurrence. Current surveillance methods often fail to detect disease early, including imaging and biochemical markers. In our study, we examined the safety and efficacy of second-look surgery for detection and treatment of disease recurrence. PATIENTS AND METHODS: We performed a retrospective analysis of prospectively collected data from 35 patients undergoing stoma reversal from 2015 to 2019 with negative pre-operative imaging. RESULTS: A total of 37% of cases had disease recurrence, with a median peritoneal cancer index of 4. Complete cytoreduction was achieved in all patients. The majority of patients (77%) suffered minor complications only. Median length of hospital stay was 12 days. CONCLUSION: Second-look surgery detects early disease recurrence and is a safe alternative to conventional screening methods post primary CRS/HIPEC for PC. Long-term, routine second-look surgery can improve survival.

The Clinical Role of Diffusion-Weighted MRI for Detecting Residual Cholesteatoma in Canal Wall up Mastoidectomy.

OBJECTIVES: The purpose of this study was to assess the value of the diffusion MRI with the non-echoplanar imaging (Non-EPI) technique for follow-up the post-operative patients to detect residual cholesteatomas. STUDY DESIGN: This prospective study was performed on 40 patients. All patients were at least one year after Canal Wall Up mastoidectomy surgery for cholesteatoma and scheduled for a second-look surgery. PATIENTS AND METHODS: This prospective study was performed on 40 patients. All patients were subjected to Canal Wall Up surgery and planned for the second-look operation. After one year as removal of choleasteatoma is uncertain in first surgery. The study done at Tertiary referral centers (Ain shams, Mansoura, and Minia university hospitals), non-echoplanar diffusion MRI (NEP-DWI) technique for follow-up the post-operative patients to detect residual cholesteatomas, then second look surgery done 2 weeks after MRI. RESULTS: Forty patients underwent MRI with Non-echoplanar diffusion-weighted imaging (NEP-DWI). Twenty-six patients had positive MRI results with the remaining 14 patients had negative results. These results were compared to operative findings. All positive MRI cases showed positive intra-operative findings. Ten of negative MRI cases showed negative intra-operative findings. Four of DWI-negative cases showed small cholesteatomas. CONCLUSION: The use of NEP-DWI is a valuable tool in detecting residual cholesteatoma that could replace the second look surgery in many cases.

Non-echo Planar Diffusion-Weighted Imaging in the Detection of Recurrent or Residual Cholesteatoma: A Systematic Review and Meta-Analysis of Diagnostic Studies.

We performed a systematic review and meta-analysis of patients with suspected recurrent cholesteatoma who underwent non-echo planar imaging (non-EPI) using diffusion-weighted magnetic resonance imaging (MRI), with surgery as the reference standard. We searched Medline, Google Scholar, and the Cochrane database for diagnostic test accuracy studies. The following prespecified subgroup analyses were performed: patient age, number of radiologists interpreting MRI, study design, and risk of bias. We used a bivariate model using a generalized linear mixed model to pool accuracies. Of the 460 records identified, 32 studies were included, of which 50% (16/32) were low risk of bias. The overall pooled sensitivity was 92.2% (95% CI 87.3-95.3%), and specificity was 91.7% (85.2-95.5%). The positive likelihood ratio was 11.1 (4.5-17.8), and the negative likelihood ratio was 0.09 (0.04-0.13). The pooled diagnostic odds ratio was 130.3 (20.5-240). Heterogeneity was moderate on visual inspection of the hierarchical summary receiver operating characteristic curve. Subgroup analyses showed prospective studies reporting higher accuracies (p=0.027), which were driven by higher specificity (prospective 93.1% (88.4-96.0%) versus retrospective 81.2% (81.0-81.4%)). There was no difference in subgroups comparing patient age (p=0.693), number of radiologists interpreting MRI (p=0.503), or risk of bias (p=0.074). No publication bias was detected (p=0.98). In conclusion, non-EPI is a highly sensitive and specific diagnostic test able to identify recurrent cholesteatomas of moderate to large sizes. This test can be considered a non-invasive alternative to second-look surgery.

Factors associated with reoperation due to bleeding and outcomes after cardiac surgery: a prospective cohort study / Factores asociados con la reintervención por sangrado y desenlaces después de cirugía cardiaca: un estudio de cohorte prospectivo / Fatores associados à reoperação por sangramento e desfechos após cirurgia cardíaca: estudo de coorte prospectivo

ABSTRACT Objective: Identify the incidence and factors associated with reoperation due to bleeding in the postoperative of a cardiac surgery, in addition to the clinical outcomes of patients. Method: Prospective cohort study, conducted in an Intensive Care Unit (ICU), with adult patients undergoing cardiac surgery. Patients diagnosed with coagulopathies were excluded. The patients were followed up from hospitalization to hospital discharge. Results: A total of 682 patients were included, and the incidence of reoperation was 3.4%. The factors associated with reoperation were history of renal failure (p = 0.005), previous use of anticoagulant (p = 0.036), higher intraoperative heart rate (p = 0.015), need for transfusion of blood component during intraoperative (p = 0.040), and higher SAPS 3 score (p < 0.001). The outcomes associated with reoperation were stroke and cardiac arrest. Conclusão: Reoperation was an event associated with greater severity, organic dysfunction, and worse clinical outcomes, but there was no difference in mortality between the groups.

RESUMEN Objetivo: Identificar la incidencia y los factores asociados con la reintervención por sangrado en el postoperatorio de cirugía cardiaca, además de los resultados clínicos de los pacientes. Método: Estudio de cohorte prospectivo, realizado en una Unidad de Cuidados Intensivos, con pacientes adultos sometidos a cirugía cardiaca. Se excluyeron a los pacientes con diagnóstico de coagulopatías. Los pacientes tuvieron un seguimiento efectuado desde el ingreso hasta el alta hospitalaria. Resultados: Se incluyeron a 682 pacientes, y la incidencia de reintervención fue del 3,4%. Los factores asociados a la reintervención fueron antecedentes de insuficiencia renal (p = 0,005), uso previo de anticoagulante (p = 0,036), mayor frecuencia cardiaca intraoperatoria (p = 0,015), necesidad de transfusión de hemocomponentes en el intraoperatorio (p = 0,040) y mayor puntaje en SAPS 3 (p < 0,001). Los desenlaces asociados con la reintervención fueron accidente cerebrovascular y paro cardiorrespiratorio. Conclusión: La reintervención fue un evento asociado con mayor gravedad, disfunción orgánica y peores desenlaces clínicos, pero no hubo diferencia en la mortalidad entre los grupos.

RESUMO Objetivo: Identificar a incidência e os fatores associados à reoperação devido sangramento no pós-operatório de cirurgia cardíaca, além dos desfechos clínicos dos pacientes. Método: Estudo de coorte prospectivo, realizado em Unidade de Terapia Intensiva (UTI), com pacientes adultos submetidos à cirurgia cardíaca. Foram excluídos pacientes com diagnóstico de coagulopatias. Os pacientes foram acompanhados desde a internação até a saída hospitalar. Resultados: Foram incluídos 682 pacientes e a incidência de reoperação foi 3,4 %. Os fatores associados à reoperação foram: histórico de insuficiência renal (p = 0,005), uso prévio de anticoagulante (p = 0,036), maior frequência cardíaca intraoperatória (p = 0,015), necessidade de transfusão de hemocomponentes no intraoperatório (p = 0,040) e maior pontuação no SAPS 3 (p < 0,001). Os desfechos associados a reoperação foram: acidente vascular encefálico e parada cardiorrespiratória. Conclusão: A reoperação foi um evento associado a maior gravidade, disfunção orgânica, e piores desfechos clínicos, porém não houve diferença de mortalidade entre os grupos.

Acute spinal cord infarction after multilevel en bloc corpectomy: a case report and literature review.

Spinal cord infarction (SCI) is a catastrophic neurologic deficit following spine surgery. Because of the opposite management regimens used for SCI and acute epidural hematoma, accurate diagnosis of SCI is of great importance to maximally reserve neurologic functions and improve outcomes. A 21-year-old man developed acute paralysis and sensory deficits of the bilateral lower limbs shortly after undergoing two-stage combined posterior and anterior multilevel en bloc corpectomy. An emergency second-look surgery revealed wide-spectrum blackness of the thecal sac with no signs of an epidural hematoma. The patient underwent anticoagulation therapy, ventilation support, microcirculation perfusion, and fluid optimization. He regained an ambulatory status without other severe complications. Upon discharge, his muscle strength had returned to grade 4 and his Eastern Cooperative Oncology Group performance score had decreased to 0. At the final 48-month follow-up, the implants were in good position without local recurrence, and the patient was able to lead an independent life and work in his full capacity. An epidural hematoma did not appear to be the cause of SCI after spinal tumor surgery in this case; however, SCI was a possible reason for the acute paralysis. Anticoagulation treatment with adjuvant therapies may be an effective option in managing SCI.

[Complete cytoreductive surgery is the key to improving survival of colorectal cancer patients with peritoneal metastases: comment on PROPHYLOCHIP and PRODIGE 7].

Peritoneal carcinomatosis (PC) is one of the difficult problems in the treatment of colorectal cancer (CRC). Based on several retrospective analyses of large samples and prospective randomized controlled studies (RCTs), NCCN and PSOGI recommend cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) for selected CRC patients with mild to moderate PC. There are two important controversial issues in this field: the survival benefit of second-look surgery plus HIPEC for the patients with high risk of PC, and the specific benefit of HIPEC added to CRS for patients with PC. PROPHYLOCHIP found that second-look surgery plus HIPEC in patients at high risk of PC does not result in increased survival. PRODIGE 7 showed that overall survival (OS, 41.7 months vs. 41.2 months, P=0.99) and recurrence-free survival (RFS, 13.1 months vs. 11.1 months, P=0.43) were similar between the HIPEC group and non-HIPEC group, and suggested that HIPEC is not necessary for patients who underwent complete CRS. However, due to a series of problems in the design and implementation of this trial, the conclusion has caused great controversy and has not been widely recognized. Through detailed analysis and in-depth discussion, we believe that the benefit of HIPEC could not be denied according to PRODIGE 7. CRS + HIPEC is the embodiment and model of the concept of "Solid tumor treatment is surgery-based integrated treatment". CRS is the cornerstone of therapeutic strategies with curative intent for CRC PC and complete CRS is the key to improve the prognosis. Furthermore, HIPEC is an effective supplement to CRS.

Management of Early Glottic Cancer Treated by CO2 Laser According to Surgical-Margin Status: A Systematic Review of the Literature.

Introduction Transoral laser microsurgery (TLM) is the treatment of choice for Tis-T2 squamous cell glottic carcinomas due to its advantages compared with open surgery and radiotherapy. However, the CO 2 laser beam causes changes and damage on the specimens, making the histological assessment of resection margins, the gold standard for confirming radical tumor resection, sometimes difficult. Objective To assess the different ways to manage patients depending on the status of the histopathological margin according to recent studies to detect the most commonly shared therapeutic strategy. Data Synthesis We analyzed the literature available on the PubMed and Web of Science databases, including only articles published since 2005, using specific keywords to retrieve articles whose titles and abstracts were read and analyzed independently by two authors to detect relevant studies. Therefore, we focused on disease-free survival, overall survival, local control, laryngeal preservation, and disease-specific survival. Thus, 17 studies were included in the present review; they were grouped according to the status of the histological margin, and we analyzed the different management policies described in them. This analysis showed that there is not a shared strategy, though in most studies the authors performed a second-look surgery in the cases of positive margins and a close follow-up in cases of negative ones. The main disagreement is regarding the management of close or non-valuable resection margins, since some some authors performed a second-look surgery, and others, a close follow-up. Conclusions Definitely, the most shared policy is the second-look surgery in case of positive surgical margins, and a close follow-up in case of close or non-valuable resection margins. Key Points To date, TLM is the treatment of choice for Tis-T2 squamous cell glottic carcinomas. The CO 2 laser beam could impair the histological assessment of the resection margins, which is the gold standard to confirm radical tumor resection. Second-look TLM is the most performed strategy in case of positive surgical margins.Close follow-up is the most shared policy in case of close or non-valuable resection margins.In cases of negative resection margins, follow-up represents the best approach.

Radiofrequency Versus Cryoballoon Catheter Ablation for Paroxysmal Atrial Fibrillation: Durability of Pulmonary Vein Isolation and Effect on Atrial Fibrillation Burden: The RACE-AF Randomized Controlled Trial.

[Figure: see text].

Management of Early Glottic Cancer Treated by CO2 Laser According to Surgical-Margin Status: A Systematic Review of the Literature

Abstract Introduction Transoral laser microsurgery (TLM) is the treatment of choice for Tis-T2 squamous cell glottic carcinomas due to its advantages compared with open surgery and radiotherapy. However, the CO2 laser beam causes changes and damage on the specimens, making the histological assessment of resection margins, the gold standard for confirming radical tumor resection, sometimes difficult. Objective To assess the different ways to manage patients depending on the status of the histopathological margin according to recent studies to detect the most commonly shared therapeutic strategy. Data Synthesis We analyzed the literature available on the PubMed and Web of Science databases, including only articles published since 2005, using specific keywords to retrieve articles whose titles and abstracts were read and analyzed independently by two authors to detect relevant studies. Therefore, we focused on disease-free survival, overall survival, local control, laryngeal preservation, and disease-specific survival. Thus, 17 studies were included in the present review; they were grouped according to the status of the histological margin, and we analyzed the different management policies described in them. This analysis showed that there is not a shared strategy, though in most studies the authors performed a second-look surgery in the cases of positive margins and a close follow-up in cases of negative ones. The main disagreement is regarding the management of close or non-valuable resection margins, since some some authors performed a second-look surgery, and others, a close follow-up. Conclusions Definitely, the most shared policy is the second-look surgery in case of positive surgical margins, and a close follow-up in case of close or non-valuable resection margins. Key Points To date, TLM is the treatment of choice for Tis-T2 squamous cell glottic carcinomas. The CO2 laser beam could impair the histological assessment of the resection margins, which is the gold standard to confirm radical tumor resection. Second-look TLM is the most performed strategy in case of positive surgical margins. Close follow-up is the most shared policy in case of close or non-valuable resection margins. In cases of negative resection margins, follow-up represents the best approach.

Results of systematic second-look surgery plus hipec in perforated or pt4 colon cancer. Case series.

BACKGROUND: Perforated or pT4 colonic tumors have a bad prognosis with a high rate of relapse, including peritoneal relapse (20-30%). Our aim is to analyze the effectiveness of Second Look surgery (SLS) + hyperthermic intraperitoneal chemotherapy (HIPEC) in these patients for early treatment of peritoneal relapse (PR) or for preventing it. PATIENTS AND METHODS: Patients previously operated for colon cancer, either pT4 or perforated (M0), with no evidence of disease at any level after adjuvant chemotherapy, who undergo systematic SLS + HIPEC (Oxaliplatin 30 min) one year after the initial surgery. RESULTS: Since February 2014 to July 2018, we performed SLS + HIPEC in 42 patients with M0, either pT4 (n = 33) or perforated (n = 9) colon cancer. Although during SLS there were suspicious lesions in 15 cases (37.5%), they were histologically confirmed in only 4 (9.5%). Histologically confirmed peritoneal relapse (PR) rate at SLS was 6% in pT4 (2/33) and 22.2% in perforated tumors (2/9). Prophylactic HIPEC was performed in all the cases. There was no postoperative mortality. Grade III-IV morbidity occurred in 19% (8/42). With a median follow-up of 33.8 months after primary tumor surgery, 6/42 patients (14.3%) presented peritoneal relapse (PR). 3-year peritoneal disease free survival was 86%, with 3-year disease free survival of 78.6% and 5-year overall survival (OS) of 97.4%. CONCLUSION: Peritoneal relapse and survival rates are remarkable in these groups of, a priori, very bad prognosis, which could suggest a beneficial effect of HIPEC.

Application of a novel transcanal keyhole technique in endoscopic cholesteatoma surgery.

BACKGROUND: It is difficult to deal with epitympanic cholesteatoma in otologic surgery. The keyhole technique can realize minimally invasive surgery and reconstruct the middle ear canal. OBJECTIVE: To explore the clinical application of keyhole technique in primary and second-look surgery in middle ear cholesteatoma. MATERIALS AND METHODS: 34 cases were analyzed retrospectively in terms of residual and recurrence rate, safety (adverse events) and hearing performance at long-term follow-up. The application of the technique in primary or second stage operation was evaluated and the operation was performed by transanal endoscopy or combined approach. RESULTS: The cholesteatoma revealed by CT before operation was limited to the attic in 23 patients, of which 16 had the same imaging range as that of the keyhole technique. The preoperative imaging findings of 11 showed that the attic cholesteatoma may have extended into the mastoid, of which only 6 cases were confirmed by keyhole technique. An endoscopic second-look surgery using the keyhole technique was performed for these patients, 2 were confirmed to have residual lesions in the attic. CONCLUSIONS: The keyhole technique under otoendoscopy can be used flexibly and conveniently in the second-look surgery to make up for the shortage of diffusion-weighted magnetic resonance imaging.

Complete cytoreductive surgery is the key to improving survival of colorectal cancer patients with peritoneal metastases: comment on PROPHYLOCHIP and PRODIGE 7 / 中华胃肠外科杂志

Peritoneal carcinomatosis (PC) is one of the difficult problems in the treatment of colorectal cancer (CRC). Based on several retrospective analyses of large samples and prospective randomized controlled studies (RCTs), NCCN and PSOGI recommend cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) for selected CRC patients with mild to moderate PC. There are two important controversial issues in this field: the survival benefit of second-look surgery plus HIPEC for the patients with high risk of PC, and the specific benefit of HIPEC added to CRS for patients with PC. PROPHYLOCHIP found that second-look surgery plus HIPEC in patients at high risk of PC does not result in increased survival. PRODIGE 7 showed that overall survival (OS, 41.7 months vs. 41.2 months, P=0.99) and recurrence-free survival (RFS, 13.1 months vs. 11.1 months, P=0.43) were similar between the HIPEC group and non-HIPEC group, and suggested that HIPEC is not necessary for patients who underwent complete CRS. However, due to a series of problems in the design and implementation of this trial, the conclusion has caused great controversy and has not been widely recognized. Through detailed analysis and in-depth discussion, we believe that the benefit of HIPEC could not be denied according to PRODIGE 7. CRS + HIPEC is the embodiment and model of the concept of "Solid tumor treatment is surgery-based integrated treatment". CRS is the cornerstone of therapeutic strategies with curative intent for CRC PC and complete CRS is the key to improve the prognosis. Furthermore, HIPEC is an effective supplement to CRS.