Importance of malnutrition and associated diseases in the management of Zenker's diverticulum

AbstractObjectivesTo study the impact of malnutrition on a population treated for Zenker's diverticulum and to look for the causes of persistence or recurrence of dysphagia after endoscopic surgery.Material and methodsThis retrospective study included 30 patients with Zenker's diverticulum treated by endoscopy. All swallowing disorders and manifestations of malnutrition and postoperative improvement in and/or recurrence of symptoms were noted.ResultsNutritional status was evaluated for 26 patients. Before surgery, 54% suffered from malnutrition, which was severe in 31%; 28.6% of the cases with malnutrition showed postoperative complications, versus 8.3% of cases without baseline malnutrition. Ninety percent of patients (n=27) declared complete resolution of symptoms. Nine patients presented recurrence of dysphagia, including 6 with recurrence of Zenker's diverticulum and 3 with, respectively, inclusion body myopathy, esophageal hypertonia and central disease.ConclusionMalnutrition should be quantified and treated before and after surgery for Zenker's diverticulum to prevent complications and decrease mortality. Associated pathologies should be systematically screened for, especially in case of recurrence of swallowing disorder without recurrence of Zenker's diverticulum

Adenocarcinoma of the ethmoid sinus: Retrospective study of 42 cases

SummaryObjectivesRetrospective analysis of the oncological results and morbidity of ethmoid sinus adenocarcinoma surgery, and identification of survival factors.Material and methodsForty-two patients were treated from 1990 to 2009. The study covered clinical presentation, medical imaging, histologic data, TNM grade, treatment, morbidity and overall recurrence-free survival.ResultsForty-one men and one woman, with mean age at diagnosis of 61.5 years, were included. 85.7% had been exposed to wood dust. Twenty patients (47.6%) were graded T4 at diagnosis. Thirty-three (78.5%) were treated by surgery followed by radiation therapy; nearly half of these showed recurrence. Overall specific 5-year survival was 44.2% at 5 years and recurrence-free 5-year survival 46.4%. The factors of poor prognosis found were cerebromeningeal or orbital invasion and local recurrence.ConclusionThis series confirms the epidemiological literature on ethmoid adenocarcinoma and the influence of poor prognosis factors. Survival depended directly on local tumor control and seemed to be enhanced on an isolated transfacial approach

Toward the development of 3-dimensional virtual-reality video tutorials in the French neurosurgical residency program

BACKGROUND: The present study developed 3D video tutorials with commentaries, using virtual-reality headsets (VRH). VRHs allow 3D visualization of complex anatomy from the surgeon\u27s point of view. Students can view the surgery repeatedly without missing the essential steps, simultaneously receiving advice from a group of experts in the field. METHODS: A single-center prospective study assessed surgical teaching using 3D video tutorials designed for French neurosurgery and ENT residents participating in the neuro-otology lateral skull-base workshop of the French College of Neurosurgery. At the end of the session, students filled out an evaluation form with 5-point Likert scale to assess the teaching and the positive and negative points of this teaching tool. RESULTS: 22 residents in neurosurgery (n=17, 81.0%) and ENT (n=5) were included. 18 felt that the 3D video enhanced their understanding of the surgical approach (81.8 %). 15 (68.2%) thought the video provided good 3D visualization of anatomical structures and 20 that it enabled better understanding of anatomical relationships (90.9%). Most students had positive feelings about ease of use and their experience of the 3D video tutorial (n=14, 63.6%). 20 (90.9%) enjoyed using the video. 12 (54.5%) considered that the cadaver dissection workshop was more instructive. CONCLUSIONS: 3D video via a virtual reality headset is an innovative teaching tool, approved by the students themselves. A future study should evaluate its long-term contribution, so as to determine its role in specialized neurosurgery and ENT diploma courses

Post-surgical vestibular schwannoma remnant tumors: What to do?

AbstractBackgroundVestibular schwannomas (VS) are benign tumors of the vestibular nerve's myelin sheath. The current trend in VS surgery is to preserve at the facial function, even if it means leaving a small vestibular schwannoma tumor remnant (VSTR) after the surgery. There is no defined therapeutic management VSTR. The aim of this study was to assess the evolution of the VSTR to define the best therapeutic management and identify predictive factors of VSTR progression.MethodsAmong the 256 patients treated surgically for VS in the Department of Neurosurgery at Angers University Hospital, 33 patients with a post-surgical VSTR were included in this retrospective study. For all surgical patients, the data collected were age at diagnosis, the Koos classification, the surgical access, the existence of a type 2 neurofibromatosis (NF2), the TR location and size on control MRI-scans. Patients had a bi-annual follow-up with clinical status and VSTR size assessment with MRI-scan. Survival analyzes were performed to determine the time and rate of VSTR progression, and identify factors of progression.ResultsThe mean follow-up of the population was 51 months. All VS remnant progression occurred between 38 and 58 months after surgery. In non-NF2 patients with first follow-up MRI-scan three months after surgery, 43% presented a spontaneous regression, 50% a stability and 7% a progression of the VSTR. In the same population with the 1-year MR-scan after surgery as baseline, 25% presented a spontaneous regression, 62.5% a stability and 12.5% a VSTR progression. These data are consistent with the data reported in the literature. The post-operative facial function impairment and an initial remnant ≥ 1.5cm3 were found to be significant risk factors of VS remnant progression in non-NF2 population in univariate analysis (P=0.048 and 0.031) but not in multivariate analysis.ConclusionIn our experience, the best therapeutic management of the post-surgical VSTP in non-NF2 patients with no risk factor of progression is a simple clinical radiological follow-up otherwise complementary radiosurgery should be considered

Stereoscopic Surgical Video of Combined Petrosectomy With Virtual Reality Headset: 3-Dimensional Operative Video

The use of 3-dimensional (3D) videos allows students to visualize surgical procedures from the perspective of the surgeon without missing the essential parts.1 This 3D commented video demonstrates the operative technique and surgical nuances of the combined petrosectomy, visualize using virtual reality headsets. Historically, traditional intradural cisternal routes using suboccipital and pterional approaches have been proposed to remove petroclival tumors.2-5 It allows rapid identification of neurovascular structures and a short exposure time. However, access to the petroclival region is far, not direct, and requires intradural cerebral retraction.6 In order to improve the access for tumoral dissection, lateral transpetrosal approaches have been proposed.7-12 The extradural route shortened the distance to the petroclival region, allows to better preserve the veins, to decrease the cerebral retraction, to interrupt early the tumor vascular supply, and a larger extent of resection.6 Transpetrosal approaches includes middle fossa approach8,10 (removing the petrous apex), posterior petrosal approach9,13,14 (removing of presigmoid retrolabyrinthine bone), and translabyrinthine petrosectomy.12 A combined petrosectomy may be used to approach larger tumor extending across the clival midline, upward to the tentorium or downward to the lower cranial nerves.6,10,15,16 Alternatively, according to Nanda, a retro-sigmoid approach may need to be performed to avoid critical draining veins injury.10,17 Good resection and outcomes are obtained when experienced surgeons use familiar approaches and microsurgical techniques.1

Maxillofacial brown tumours: Series of 5 cases.

OBJECTIVES: Brown tumours are benign bone tumours secondary to hyperparathyroidism. The authors describe the various clinical features, diagnostic methods and treatment modalities for maxillofacial brown tumours. MATERIAL AND METHODS: This multicentre retrospective study comprised 5 patients (four women and one man, between the ages of 29 and 70 years) with one or several maxillofacial brown tumours observed over a 16-year period from January 2000 to December 2016. RESULTS: Four patients presented secondary hyperparathyroidism in a context of chronic renal failure, one patient presented primary hyperparathyroidism due to parathyroid adenoma. Three patients presented a mandibular brown tumour, and two patients presented a maxillary brown tumour. The diagnosis was based on histological examination and laboratory tests. Brown tumours were treated either surgically or conservatively. A favourable outcome was observed in all cases. CONCLUSION: Brown tumours are rare lesions. This diagnosis must be considered in a context of giant cell tumour associated with hyperparathyroidism. Brown tumours should be treated conservatively

Organ preservation surgery for laryngeal cancer

The principles of management of the laryngeal cancer have evolved over the recent past with emphasis on organ preservation. These developments have paralleled technological advancements as well as refinement in the surgical technique. The surgeons are able to maintain physiological functions of larynx namely speech, respiration and swallowing without compromising the loco-regional control of cancer in comparison to the more radical treatment modalities. A large number of organ preservation surgeries are available to the surgeon; however, careful assessment of the stage of the cancer and selection of the patient is paramount to a successful outcome. A comprehensive review of various organ preservation techniques in vogue for the management of laryngeal cancer is presented

Radiologic versus Endoscopic Placement of Percutaneous Gastrostomy in Amyotrophic Lateral Sclerosis: Multivariate Analysis of Tolerance, Efficacy, and Survival

PurposeTo compare percutaneous radiologic gastrostomy (PRG) and percutaneous endoscopic gastrostomy (PEG) in terms of tolerance, efficacy, and survival in patients with amyotrophic lateral sclerosis (ALS). Materials and Methods Forty patients with ALS (17 men; mean age, 66.1 years; range, 39–83 y) underwent 21 PEG and 22 PRG attempts (including three unsuccessful PEG attempts) from 1999 to 2005. To assess tolerance and efficacy, a successful and well tolerated placement was defined as any successful placement with no major or minor local complications or pain requiring opioid analgesic agents. Univariate analysis was performed for all recorded parameters, followed by multivariate analysis for successful and well tolerated placement, 6-month mortality rate, and survival. Results General success rates were 85.7% for PEG and 100% for PRG. Pain was more frequent in PRGs (81.8% vs 52.4%; P = .05). Successful and well tolerated placement was seen in 81.8% of PRGs and 57.1% of PEGs (P = 0.1). Advanced age (P = .02) and PRG (P = .07) were predictive of successful and well tolerated placement. The interval from diagnosis to placement (P = .001) and ability to perform spirometry (P = .002) were predictive of survival. Oximetry measurements (P = .007) and interval from diagnosis to placement (P = .02) were predictive of mortality at 6 months. Conclusions PRG is more efficacious and better tolerated than PEG, essentially because it avoids the respiratory decompensation that may occur in PEG. Therefore, PRG should be preferred in cases of ALS. Survival is linked to ALS evolution and not to the choice of PRG or PEG placement

A not so solitary fibrous tumor of the liver

SummarySolitary fibrous tumor (SFT) is a rare neoplasm. Liver parenchyma is a rare location of SFT and, in this case, it usually follows a benign course. We report here the case of a 54-year-old man who presented a large SFT tumor of the right hepatic lobe. The tumor was surgically resected. Local recurrence occurred 6 years later as a 15 cm diameter liver tumor. Histological examination of the resected lesion showed features of an aggressive form of SFT. Two years later, the patient presented with complaints of neck pain and ensuing examinations revealed a tumor of the cranial base. A new surgical resection was performed and histological examination confirmed a metastasis of the SFT. Few weeks later, the patient presented an irreducible psoitis due to an iliac bone metastasis. He died within 1 month