Safeness and efficacy of 2-µm handheld thulium laser during microsurgical resection of supratentorial and infratentorial meningiomas: Experience of a single center

AimsWe performed a retrospective nonrandomized study to analyze the results of a microsurgery of intracranial meningiomas using 2-μm thulium flexible handheld laser fiber (Revolix jr).MethodsFrom February 2014 to December 2021, 75 nonconsecutive patients suffering from intracranial meningiomas, admitted in our department, have been operated on with microsurgical technique assisted by 2-μm thulium flexible handheld laser. We have reviewed demographic and clinical data to evaluate safety and efficacy of the technique.ResultsThere were no complications related to the use of the 2-μm thulium laser. We operated on a high percentage of cranial base and tentorial and posterior fossa meningioma in our series. The neurological outcome and degree of resection did not differ from previous series. The neurosurgical team found the laser easy to use and practical for avoiding bleeding and traction.ConclusionThe use of 2-μm thulium fiber handheld flexible laser in microsurgery of intracranial meningiomas seems to be safe and to facilitate tumor resection, especially in “difficult” conditions (e.g., deep seated, highly vascularized, and hard tumors). Even if in this limited retrospective trial the good functional outcome following conventional microsurgery had not further improved, nor the surgical time was reduced by laser, focusing its use on “difficult” (large and vascularized) cases may lead to different results in the future

Lack of correlation between Ki-67 labelling index and tumor size of anterior pituitary adenomas

AIMS AND BACKGROUND: The Ki-67 is a nuclear antigen detected by the monoclonal antibody MIB-1 and its Labeling Index (LI) is considered a marker of normal and abnormal cell proliferation. Pituitary adenomas are generally well differentiated neoplasms, even if in about one third of cases they are invasive of surrounding tissues. The aim of this study is to evaluate the correlation between Ki-67 labelling index and tumor size of pituitary adenomas extimated by means CT and MRI and confirmed at operation. METHODS: Using the monoclonal antibody MIB-1, we evaluated the expression of Ki-67 in 121 anterior pituitary adenomas consecutively operated on in a 48-month period. RESULTS: In relation to neuroradiological (CT and MRI) and surgically verified tumor size, we identified 24 microadenomas, 27 intrasellar macroadenomas, 34 intra-suprasellar macroadenomas, and 36 intra-supra-parasellar macroadenomas. The adenomas were non-infiltrating (76 cases) and infiltrating (45 cases) adenomas. The wall of the cavernous sinus (CS) was infiltrated in 18 cases. Forty-eight adenomas were non-functioning and 73 functioning. The overall mean ± SD Ki-67 LI was 2.72 ± 2.49% (median 1.6). It was 2.59 ± 1.81 in microadenomas, 2.63 ± 3.45 in intrasellar macroadenomas, 1.91 ± 2.11 in intra-suprasellar macroadenomas, and 3.29 ± 5.45 in intra-supra-parasellar macroadenomas (p = 0.27). It was 3.73 ± 5.13% in infiltrating and 2.03 ± 2.41% in non-infiltrating adenomas (p = 0.02), and 5.61 ± 7.19% in CS-infiltrating versus 2.09 ± 2.37% in CS-non-infiltrating adenomas (p = 0.0005). CONCLUSIONS: Our preliminary results seem to exclude significative correlations between Ki-67 LI and tumor size of anterior pituitary adenomas, even if this index can be considered a useful marker in the determination of the infiltrative behaviour of these tumors

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

Lack of correlation between Ki-67 labelling index and tumor size of anterior pituitary adenomas

Abstract Aims and background The Ki-67 is a nuclear antigen detected by the monoclonal antibody MIB-1 and its Labeling Index (LI) is considered a marker of normal and abnormal cell proliferation. Pituitary adenomas are generally well differentiated neoplasms, even if in about one third of cases they are invasive of surrounding tissues. The aim of this study is to evaluate the correlation between Ki-67 labelling index and tumor size of pituitary adenomas extimated by means CT and MRI and confirmed at operation. Methods Using the monoclonal antibody MIB-1, we evaluated the expression of Ki-67 in 121 anterior pituitary adenomas consecutively operated on in a 48-month period. Results In relation to neuroradiological (CT and MRI) and surgically verified tumor size, we identified 24 microadenomas, 27 intrasellar macroadenomas, 34 intra-suprasellar macroadenomas, and 36 intra-supra-parasellar macroadenomas. The adenomas were non-infiltrating (76 cases) and infiltrating (45 cases) adenomas. The wall of the cavernous sinus (CS) was infiltrated in 18 cases. Forty-eight adenomas were non-functioning and 73 functioning. The overall mean ± SD Ki-67 LI was 2.72 ± 2.49% (median 1.6). It was 2.59 ± 1.81 in microadenomas, 2.63 ± 3.45 in intrasellar macroadenomas, 1.91 ± 2.11 in intra-suprasellar macroadenomas, and 3.29 ± 5.45 in intra-supra-parasellar macroadenomas (p = 0.27). It was 3.73 ± 5.13% in infiltrating and 2.03 ± 2.41% in non-infiltrating adenomas (p = 0.02), and 5.61 ± 7.19% in CS-infiltrating versus 2.09 ± 2.37% in CS-non-infiltrating adenomas (p = 0.0005). Conclusions Our preliminary results seem to exclude significative correlations between Ki-67 LI and tumor size of anterior pituitary adenomas, even if this index can be considered a useful marker in the determination of the infiltrative behaviour of these tumors.</p

Level Specific CE-Chirp® BAEP's: A new faster technique in neuromonitoring cochlear nerve during cerebello-pontine angle tumor surgery

Background: Level Specific (LS) CE-Chirp® Brainstem Auditory Evoked Potentials (BAEP's) are the most recent evolution of classical Click BAEP's, performed both in clinical studies and in intraoperative neuromonitoring (IONM) of acoustic pathways during several neurosurgical procedures. LS CE-Chirp® is a new group of acoustic stimuli, latter evolution of Broadband CE-Chirp®, designed by Claus Elberling to provide faster recording of larger amplitude BAEP's V waves in infants. While the original Broadband CE-Chirp® was conceived for optimal response amplitude of V wave at low and medium stimulation intensities, the LS CE-Chirp® provides clearer I–III–V waves at high intensities. Material and method: We report a consecutive series of 31 cases in which the new LS CE-Chirp® BAEP's were performed during different skull base surgery procedures during the last 24months: 25 vestibular schwannomas, 3 cerebello-pontine angle (CPA) meningiomas and 3 CPA epidermoid tumors. Results: Using LS-CE-Chirp® BAEP's monitoring, neurosurgeon was alerted in 10–15s about variation of conduction parameters of acoustic pathways. At the end of surgery, BAEP's were normal in 11 patients, showed deconstructed waves in 14, and elongated waves in 6. At a minimum clinical and BAEP's follow-up of 6months, hearing function was preserved in 19 cases (61,3%). Conclusions: We herein confirm that LS CE-Chirp® BAEP's provide a fast feedback to surgeons regarding acoustic pathways function, helping them during skull base tumor removal in the attempt to hearing preservation when it is socially useful in the preoperative evaluation. Keywords: CE Chirp®, ABR, BAEP's, Intraoperative neuromonitoring, Cochlear nerve, Skull base surger

Vestibular Schwannomas Microsurgery Assisted by Flexible Hand-Held 2 micro-Thulium-Fiber Laser

Background: Vestibular Schwannoma (VS) is one of the skull base tumors originating from vestibular portion of eighth cranial nerve. Recently, 2 micro-Thulium laser is used in the surgery of some intracranial tumors. Objectives: Assessing the efficacy of 2 micro-Thulium flexible hand-held laser fiber (RevolixjrÒ) in microsurgical removal of VS. Materials and Methods: This retrospective non-randomized study was carried out from July 2012 to November 2015. 39 patients with VS had been operated on with microsurgical technique via retro-sigmoid approach. 2 micro-Thulium-fiber hand-held flexible laser was used for tumor resection in 39 cases. Facial nerves function by House-Brackmann (HB) scale and hearing state were assessed preoperatively and 1 week and 6-month postoperatively. Results: Overall time of surgery changed only in proportion with the size of tumor (185-575 minutes) and was not affected by the use of laser. In 5out of 39cases, preoperative facial nerve palsy HB2, and in one case HB4 (permanent) was observed. On considering 38 cases, at 6-month follow-up facial nerve preservation rate (HB1) was 92.1% (from May 2015 all patients had not postoperative facial palsy). Hearing preservation rate was possible in 12 out of 15 cases with previously acceptable preoperative hearing state (AAO-HNS A and B classes). The mean surgeon satisfaction rate of usefulness of this technic was 2.7 in a 0-3-scale Conclusions: A good functional outcome including facial nerve preservation and hearing preservation was obtained by micro-Thulium-fiber hand-held flexible laser microsurgery

Extradural Middle Fossa Approach. Proposal of a Learning Method: The “Rule of Two Fans.” Technical Note

The extradural middle fossa approach is used to access lesions of the petroclival and cavernous sinus regions. It may be included in combined petrosal and anterolateral transcavernous approaches. Technically, it is a demanding exposure that provides a wide extradural corridor between the 5th, 7th, and 8th cranial nerves. Its major advantages are that it offers extradural dissection, limits temporal lobe retraction, and avoids the transposition of nerves or vessels. Its disadvantages are primarily related to the complicated anatomy of the petrous apex from the middle fossa trajectory, which can be unfamiliar to neurosurgeons. To facilitate the first attempts with this relatively uncommon approach during dissections of human cadaveric injected heads and isolated temporal bones, we developed a simple learning method useful for localizing all anatomical structures. Using this “rule of two fans,” vascular, nervous, fibrous, and osseous structures are localized within two bordering fans with a 90-degree relationship to each other