Cocoa by-product inclusion in dairy sheep diet: effect on sensory, volatile and antioxidant properties of cheese

The possibility of inclusion of agro-industrial by-products in the diet of small ruminants represents both an economical and an environmental strategy for reducing waste management by industries and the cost of feeding as well as the impact of livestock farming. Large amounts of wastes from the cocoa industry are annually produced with a considerable part represented by cocoa bean shells, considered a suitable ingredient to be included in the diet of ruminants within the limits established by European legislation. The aim of this study was to assess the effect of including cocoa bean shells in the diet of dairy sheep on the sensory, volatile, and antioxidant properties of cheese. To this purpose, 20 Comisana lactating ewes were randomly assigned to 2 experimental groups: control (CTRL) and cocoa bean shells (CBS), and received alfalfa hay ad libitum and 800g of conventional (CTRL) or experimental (CBS) concentrate containing 11.7% CBS to partially replace corn and barley of the CTRL concentrate. Bulk milk collected from each group was used to produce a total of 15 cheeses per group, obtained in 5 different days of cheese-making (3 cheeses a day per group). After 60 d of aging, each cheese of each experimental group was sampled for the analyses. The results on chemical composition revealed a greater monounsaturated fatty acids content and an increase in the nutritional indices suggesting a favorable role of cocoa bean shells dietary inclusion on the nutritive value of the cheese. The cheese sensory profile was affected by the cocoa bean shells inclusion, with more pronounced appearance, odor, aroma, and taste attributes in the product. The volatile profile showed only a few significant differences, mainly related to the cheese ripening process, and no differences were found in α-tocopherol contents in cheese fat between the 2 groups. Therefore, the coca bean shells inclusion in the diet of dairy sheep allowed to obtain a good quality cheese, without altering the characteristics associated with the typical profiles of sheep cheese. Furthermore, the use of this by-product could contribute to decrease feed costs and waste management, representing a good practice for increasing the sustainability of dairy products.

Posterior cranial fossa meningiomas: Comparison of results between patients older and younger than 70 years

Introduction

Surgical strategy for meningioma resection in the elderly is controversial: diverse studies in the literature have pointed at the age as a negative prognostic factor in terms of postoperative results.

Research question

The aim of this study is to compare surgical outcomes after resection of posterior fossa meningiomas in <70 and ≥ 70 years-old age groups.

Material and methods

We reviewed 72 patients affected by posterior fossa meningiomas who underwent surgical treatment at San Filippo Neri Hospital, Rome, Italy between September 2010 and December 2022. We analyzed data regarding tumor size, clinical presentation, extent of resection and complication/mortality.

Results

The groups consisted of 52 (72,2%) young and 20 (27,8%) elderly patients. Gross total resection rate was significantly higher among youngsters (p = 0,013), mainly for planned subtotal removal in older patients. At 3-month follow-up, clinical improvement was seen in 19 (36,5%) young and 7 (35,0%) elderly patients, which raised at last follow-up, being 84,6% (44) and 80,0% (16), respectively (p = 0,406). Two cases of progression/recurrence among the elderly and 1 among youngsters were observed; one case of mortality among the elderly was reported.

Discussion and conclusions

Safety data regarding postoperative complications and mortality in our series seem to confirm that there is no significant difference between older and younger patients, as long as older patients are carefully selected. Therefore, if surgery is proposed, it should be radical if gross total resection could be safely attempted.

3-Dimensionally Printed Affordable Nose Model: A Reliable Start in Endoscopic Training for Young Neurosurgeons

BACKGROUND

Training neurosurgical skills is one of the most important tasks of a residency program. Techniques' complexity and pathology rarity define a long learning curve for mastering different surgical skills for which simulation on anatomic samples is extremely important. For this purpose, cadaver laboratory training is the most reliable tool. However, since access to cadaveric specimens is limited, due to costs and availability, surgical skills could be developed using inanimate models. This work aimed to develop a printable 3-dimensional model of the nasal cavity and sellar floor using an open-source downloadable file, to give residents the opportunity to improve their endoscopic surgical skills in a low-risk atmosphere with little cost.

METHODS

The 3D model was realized taking as a sample a real-case CT scan imaging from which the sellar floor was removed. A quail egg was placed underneath the printed model covering the sellar floor opening. Under endoscopic visualization, the "sellar floor" was drilled by each participant with the goal of sparing the egg's inner membrane. Once the task was achieved, surgeons were asked to participate in a satisfaction survey.

RESULTS

The total cost for printing was 6.31€ (6,72$). A satisfaction survey showed technical improvement (90%), increased confidence (80%), and bringing learned skills into the operating room (70%), leading to a 100% agreement in introducing this project into residency programs.

CONCLUSIONS

Training on affordable anatomic models represents a useful tool in technical skills improvement. We believe this model could help residents bring their technical capabilities to more sophisticated levels.

Utility of sodium fluorescein in recurrent cervical vagus schwannoma surgery

Background

Cervical schwannoma is a rare neoplasm that usually occurs like a nondolent lateral neck mass but when growing and symptomatic requires radical excision. Sodium fluorescein (SF) is a dye that is uptake by schwannomas, which makes it amenable for its use in the resection of difficult or recurrent cases.

Methods

We describe the case of a patient presenting with a recurrence of a vagus nerve schwannoma in the cervical region and the step-by-step technique for its complete microsurgical exeresis helped by the use of SF dye.

Results

We achieved a complete microsurgical exeresis, despite the presence of exuberant perilesional fibrosis, by exploiting the ability of SF to stain the schwannoma and nearby tissues. That happens due to altered vascular permeability, allowing us to better differentiate the lesion boundaries and reactive scar tissue under microscope visualization (YELLOW 560 nm filter).

Conclusion

Recurrent cervical schwannoma might represent a surgical challenge due to its relation to the nerve, main cervical vessels, and the scar tissue encompassing the lesion. Although SF can cross both blood-brain and blood-tumor barriers, the impregnation of neoplastic tissue is still greater than that of nonneoplastic peripheric tissues. Such behavior may facilitate a safer removal of this kind of lesion while respecting contiguous anatomical structures.

Removal of grade IV vestibular schwannomas by retrosigmoid approach: results of a cumulative series of two European centers

INTRODUCTION

The aim of our study was to study the association between end-of-surgery facial nerve stimulation threshold and extent of tumor resection in case of grade IV vestibular schwannomas.

MATERIALS AND METHODS

Grade IV VSs represent a surgical challenge as a risk/benefit ratio must be considered in balancing a satisfactory extent of resection against a good postoperative functional outcome. We reviewed a cumulative series of 57 patients with large/giant VSs who were operated on by retrosigmoid approach in the period from 2008 to 2018 in two European centers, namely San Filippo Neri Hospital, Rome, Italy and Masaryk Hospital, Usti nad Labem, Czech Republic. Extent of resection, intraoperative direct electrical stimulation threshold of facial nerve and postoperative facial outcome were examined.

RESULTS

Total or near-total resection was accomplished in 40 (75.5%) cases. Two groups were compared: total or near-total resection (T + NT) and subtotal resection (ST); the end-of-surgery facial nerve stimulation threshold significantly differed (T + NT: 0.24 mA, ST: 0.44 mA, p = 0.036). A critical cutoff was found at 0.2mA; values similar or inferior to this correctly predicted total or near-total resection in 86.7% of cases. Thirty (56.6%) patients had a normal postoperative facial outcome (HB1). Among the 40 patients in T + NT group, 32 (80%) retained an acceptable facial function (HB1-2).

CONCLUSIONS

Lower facial nerve stimulation thresholds positively predict a broader extent of resection and total or -near total resection should be accomplished in such cases. Judicious (subtotal) resection is preferred if threshold values increase while dissecting firmly adherent tumors.

Spinal navigation for small thoracic intradural tumors: The challenge between minimally invasive and exoscopic magnification

Background

Spinal navigation offers significant benefits in the surgical treatment of small thoracic intradural tumors. It enables precise tumor localization without subjecting the patient to high radiation doses. In addition, it allows for a smaller skin incision, reduced muscle stripping, and limited bone removal, thereby minimizing the risk of iatrogenic instability, blood loss, postoperative pain, and enabling shorter hospital stays.

Case Description

This video presents two cases demonstrating the application of spinal navigation technique for thoracic intradural tumors measuring <20 mm. In the first case, which involves a small calcified tumor, navigation can be performed using 3D fluoroscopy or computed tomography images obtained intraoperatively. Notably, as illustrated in the second case, the merging of preoperative magnetic resonance imaging images with intraoperative 3D fluoroscopy enables navigation in the context of soft intradural lesions as well. The setup of the operating room for these procedures is also depicted.

Conclusion

In these procedures, the use of an exoscope, in addition to the well-known advantages in terms of magnification and ergonomics, provides a large space of movement around the surgical field, with greater ease in the use of navigation devices and ultrasound. The minimal invasiveness of the surgical approach is in no way a hindrance to exoscopic visualization and surgical dissection.

Microsurgery of Koos I-II vestibular schwannomas: a case series of 100 consecutive patients

BACKGROUND

Treatment of small vestibular schwannomas (VS) depends on size, growth pattern, age, symptoms, co-morbidities. Watchful waiting, stereotactic radiosurgery and microsurgery are three valid options of treatment.

METHODS

We reviewed clinical sheets, surgical data and results of 100 consecutive patients with Koos Grade I-II VS, operated at our department via a retrosigmoid microsurgical approach between September 2010 and July 2021. Extent of resection was assessed as total, near-total or subtotal. The course of facial nerve (FN) around the tumor was classified as anterior (A), anterior-inferior (AI), anterior-superior (AS) and dorsal (D). FN function was assessed according to House-Brackmann (HB) Scale and hearing level according to AAO-HNS Classification.

RESULTS

Mean tumor size was 1.52 cm. FN course was mainly AS (46.0%) in the overall cohort; in Koos I VS, FN was AS in 83.3%. Postoperative FN function was HB I in 97% and HB II in 3% of cases. Hearing preservation (AAO-HNS class A-B) was possible in 63.2% of procedures. Total/near-total removal was achieved in 98%. Postoperative mortality was zero. Transient complications were observed in 8% of patients; permanent complications never occurred. Tumor remnant progression was observed in one case, 5 years after subtotal removal.

CONCLUSIONS

Microsurgery represents a valid option for management of VS, including Koos I-II grades, with an acceptable complication rate. In particular, in small VS long-term FN facial outcome, HP and total/near-total removal rate are favorable.

Diluted intracisternal papaverine for microvascular protection of cranial nerves during vestibular schwannoma and cerebello-pontine angle surgery. Commentary and review of the literature

Vasospasm after resection of skull base tumors is a rare complication that often produces relevant ischemic sequelae. This review of the literature reports a number of published experiences that can help determine the potential causes of vasospasm after cerebello-pontine angle (CPA) tumor and -in particular-vestibular schwannoma (VS) resection, the ways to prevent it, and the methods to obtain the correct diagnosis. The cause appears to be multifactorial and the surgical approach may contribute to the pathogenesis of vasospasm. Neurosurgeons must pay attention to detect possible vasospasm at an early stage of cerebello-pontine. Cerebral blood flow measurement and transcranial Doppler are useful monitoring tools. Intra-operative prevention of vasospasm during CPA tumor resection with papaverine hydrochloride (PPV) seems to play a relevant role. In particular, PPV is a direct-acting vasodilator used to manage vasospasm during various neurosurgical operations. There is large uncertainty about intracisternal PPV dose-related efficacy and side effects. Dilution of PPV in saline prior to application is recommended to avoid complications. In our experience, in line with the literature, we use a pure PPV without excipients 60 mg/2 ml diluted in 20 cc of 0,9% saline solution (0,3%) to prevent Hearing Loss during Posterior Fossa Microvascular Decompression for Typical Trigeminal Neuralgia and other cranial nerves potentially involved during VS and other CPA tumor resection. The aim of this commentary is to analyze and discuss the role of diluted intracisternal PPV for microvascular protection of cranial nerves during CPA tumor surgery.

Clinical and oncological outcomes in single-stage versus staged surgery for pediatric craniopharyngiomas: a multicenter retrospective study

PURPOSE

Craniopharyngiomas (CPGs) are aggressive brain tumors responsible of severe morbidity in children. The best treatment strategies are under debate. Our study evaluates surgical, pituitary, and hypothalamic outcomes of a tailored staged-surgical approach compared to a single-stage radical approach in children with CPGs.

METHODS

Multicenter retrospective study enrolling 96 children treated for CPGs in the period 2010-2022. The surgical management was selected after a multidisciplinary evaluation. Primary endpoint includes the inter-group comparison of preservation/improvement of hypothalamic-pituitary function, the extent of resection, and progression-free survival (PFS). Secondary endpoints include overall survival (OS), morbidity, and quality of life (QoL).

RESULTS

Gross Total Resection (GTR) was reached in 46.1% of cases in the single-stage surgery group (82 patients, age at surgery 9 ± 4.7 years) and 33.3% after the last operation in the staged surgery group (14 patients age 7.64 ± 4.57 years at first surgery and 9.36 ± 4.7 years at the last surgery). The PFS was significantly higher in patients addressed to staged- compared to single-stage surgery (93.75% vs 70.7% at 5 years, respectively, p = 0.03). The recurrence rate was slightly higher in the single-stage surgery group. No significant differences emerged in the endocrinological, visual, hypothalamic outcome, OS, and QoL comparing the two groups.

CONCLUSIONS

In pediatric CPGs' surgical radicality and timing of intervention should be tailored considering both anatomical extension and hypothalamic-pituitary function. In selected patients, a staged approach offers a safer and more effective disease control, preserving psychophysical development.

Endoscopic Endonasal Transethmoidal-Transsphenoidal Approach to a Cavernous Sinus Chondrosarcoma

Objective  We illustrate a cavernous sinus chondrosarcoma treated with an endoscopic endonasal transethmoidal-transsphenoidal approach.

Design  Case report of a 15-year-old girl with diplopia and esotropia due to complete abducens palsy. Preoperative images showed a right cavernous sinus lesion with multiple enhanced septa and intralesional calcified spots ( Fig. 1 ). Considering tumor location and the lateral dislocation of the carotid artery, an endoscopic endonasal approach was performed to relieve symptoms and to optimize the target geometry for adjuvant conformal radiotherapy.

Setting  The study was conducted at University of Insubria, Department of Neurosurgery, Varese, Italy.

Participants  Skull base team was participated in the study.

Main Outcome Measures  A transethmoidal-transsphenoidal approach was performed by using a four-hand technique. We used a route lateral to medial turbinate to access ethmoid and the sphenoid sinus. During the sphenoid phase, we exposed the medial wall of the cavernous sinus ( Fig. 2 ) and the lesion was then removed using curette. Skull base reconstruction was performed with fibrin glue and nasoseptal flap.

Results  No complications occurred after surgery, and the patient experienced a complete recovery of symptoms. A postoperative magnetic resonance imaging showed a small residual tumor inside the cavernous sinus ( Fig. 1 ). After percutaneous proton-bean therapy, patient experienced only temporary low-grade toxicity with local control within 2 years after treatment completion.

Conclusion  Endoscopic endonasal extended approach is a safe and well-tolerated procedure that is indicated in selected cases (intracavernous tumors, soft tumors not infiltrating the vessels and/or the nerves). A tailored approach according to tumor extension is crucial for the best access to the compartments involved.

The link to the video can be found at: https://youtu.be/TsqXjqpuOws .

Microsurgical treatment of symptomatic vestibular schwannomas in patients under 40: different results before and after age of 30

In 10-15% of cases of vestibular schwannoma (VS), age at diagnosis is 40 years or less. Little is known about the differences in natural history, surgical findings, and postoperative outcomes of such younger patients as compared to those of greater age. To analyze clinical and surgical and imaging data of a consecutive series of n = 50 patients with unilateral sporadic VS, aged 40 years or younger - separated in a very young group (15-30 years) and a moderately young group (31-40 years). Retrospective case series. Fifty consecutive patients under 40 years of age underwent microsurgical resection of unilateral sporadic VS via the retrosigmoid approach. The study cohort was subdivided into two groups according to the age range: group A, age range 15-30 years (n = 23 patients), and group B, age range 31-40 years (n = 27 patients). The adherence of VS capsule to surrounding nervous structures and the tendency of the tumors to bleed were evaluated by reviewing video records; the course of the FN in relation to the tumor's surface was assessed in each case. Microsurgical removal of tumor was classified as total (T), near total (residual tumor volume < 5%), subtotal (residual tumor volume 5-10%), or partial (residual tumor volume > 10%). Mean tumor size of entire cohort was 2.53 (range: 0.6-5.8) cm: 2.84 cm in group A and 2.36 cm in group B (p = NS). Facial nerve course and position within the cerebellopontine angle did not differ significantly between the two groups. At 6-month follow-up, FN functional outcome was HBI-II in 69.5% in group A, versus 96.3% in group B (p < .001). Hearing preservation was achieved in 60.0% of patients of group A and in 58.3% of group B (p = NS). Total and near-total resection was feasible in 95.6% of cases of group A and in 88.9% of group B (p = NS). Tumor capsule was tightly adherent to nervous structures in 69.6% patients of group A and in 22.2% of group B (p < .05). Significant bleeding was encountered in 56.5% of group A tumors, and in 29.6% of group B tumors (p < .01). Microsurgery of VS in patients aged 40 or less is associated with good functional results, and with high rates of total and near total tumor removal. Patients < 30 years of age have more adherent tumor capsules. Furthermore, their tumors exhibit a tendency to larger sizes, to hypervascularization, to profuse intraoperative bleeding and they present worse long-term functional FN results when compared to patients in their fourth decade of life. Our limited experience seems to suggest that a near total resection in very young VS patients with large tumors should be preferred in adherent and hypervascularized cases, in order to maximize resection and preserve function.

Inclusion of cocoa by-product in the diet of dairy sheep: Effect on the fatty acid profile of ruminal content and on the composition of milk and cheese

In this study, we hypothesized that dietary cocoa bean shell (CBS) as a partial replacer of human edible cereal grains in the diet of lactating ewes may affect performance and milk and cheese composition. Twenty Comisana lactating ewes allotted into control (CTRL; n = 10) or cocoa (CBS; n = 10) group received alfalfa hay ad libitum and 800 g of conventional (CTRL) or experimental (CBS) concentrate containing 11.7% CBS to partially replace corn and barley of the CTRL concentrate. Milk yield and composition did not differ between groups, and only urea concentration was lower in CBS milk. Dietary CBS increased cheese fat and reduced protein percentage in CBS group. Fatty acid composition of rumen content partially reflected that of the ingested diet, with total saturated fatty acids (SFA), total monounsaturated fatty acids (MUFA), 16:0, 18:0 and 18:1c9 greater in the CBS group. Moreover, all the identified trans- and cis-18:1 isomers were greater in CBS rumen content. Milk and cheese showed a similar fatty acid composition. Total MUFAs were greater in milk and cheese of CBS, mainly due to the proportion of 18:1c9, and conversely, total polyunsaturated fatty acids (PUFA), PUFAn-6 and PUFAn-6-to-PUFAn-3 ratio was greater in CTRL group. Concluding, the inclusion of CBS in the diet of lactating ewes within the limit imposed by the current legislation did not cause detrimental effects on animal performance and milk composition. Interestingly, dietary CBS reduced milk urea concentration probably due to the phenols contained in CBS concentrate. However, our results support that biohydrogenation was weakly impaired by dietary CBS. Finally, CBS negatively affected cheese nutritional characteristics due to lower protein and greater fat content, but improved fat health indexes in milk and cheese.

Cauda equina syndrome secondary to portal vein thrombosis: case report of favorable outcome with conservative treatment

Epidural varicosis is a rare though well-known cause of cauda equina syndrome (CES). Although inferior vena cava (IVC) obstruction is the most common finding in such cases, portal vein hypertension can lead to epidural venous plexus engorgement by means of lumbar portocaval shunt activation.

A 40-year-old woman presented with right-sided sciatica, which progressed to right foot drop and a 3-day history of vesical tenesmus and fecal retention. She was initially diagnosed with L4–5 lumbar disc protrusion. However, contrast-enhanced lumbar MRI scan showed the presence of epidural varices in the L3–S1 tract. Given the absence of vascular anomalies amenable to resection, etiological conservative treatment was addressed. Therefore, a complete diagnostic workup was performed and revealed deep vein thrombosis (DVT), pulmonary embolism, and portal vein thrombosis. Oral anticoagulant therapy was initiated and prompt resolution of CES was observed. To the authors’ knowledge, this is the first report of CES secondary to epidural varicosis in the setting of acute portal vein thrombosis and extrahepatic portal vein obstruction (EHPVO). In cases of epidural varicosis, conservative etiological treatment is the most appropriate choice as CES may be the epiphenomenon of underlying systemic pathophysiological processes.

Koos grade IV vestibular schwannomas: considerations on a consecutive series of 60 cases-searching for the balance between preservation of function and maximal tumor removal

Koos grade IV vestibular schwannomas (VS) (maximum diameter > 3 cm) compress the brainstem and displace the fourth ventricle. Microsurgical resection with attention to the right balance between preservation of function and maximal tumor removal is the treatment of choice. Our series consists of 60 consecutive patients with unilateral VS, operated on from December 2010 to July 2019. All patients underwent microsurgical removal via the retrosigmoid approach. The adherence of VS' capsule to the surrounding nervous structures and the excessive tendency of tumor to bleed during debulking, because of a redundant vascular architecture, was evaluated by reviewing video records. Microsurgical removal of tumor was classified as total (T), near-total (NT: residue < 5%), subtotal (ST: residue 5-10%), or partial (P: residue > 10%). Maximal mean tumor diameter was 3,97 cm (SD ± 1,13; range 3,1-5,8 cm). Preoperative severely impaired hearing or deafness (AAO-HNS classes C-D) was present in 52 cases (86,7%). Total or NT resection was accomplished in 46 cases (76,7%), 65,8% in cases with, and 95,4% without tight adhesion of capsule to nervous structures (p < 0,001). Endoscopic-assisted microsurgical removal of VS in the IAC was performed in 23 patients: in these cases, a T resection was obtained in 78,3% versus 45,9% of microsurgery only (p < 0,001). The capsule of VS was tightly adherent to nervous structures in 63,3% of patients, whereas hypervascular high-bleeding tumors represented 56,7%. Hearing preservation was possible in 2 out of 8 patients with preoperative class B hearing. At last follow-up, 34 (56,7%) patients had a normal postoperative FN outcome (HBI), 9 (15,0%) were HBII, 8 (13,3%) HBIII, and 9 (15,0%) HBIV. The total NT resection of solid and low-bleeding VS, without tight capsule adhesion, was associated with better FN outcome. Mortality was zero; permanent complications were observed in 2 cases (diplopia, hydrocephalus), transient in 9. Microsurgery of Koos grade IV VS seems to be associated with more than acceptable functional results, with high rate of T and NT removal of tumor. Long-term FN results seem to be worse in patients with cystic Koos grade IV VS, in cases with tight capsule adherences to nervous structures and in high-bleeding tumors.

Fournier's gangrene as a rare complication in patient with uncontrolled type 2 diabetes treated with surgical debridement: A case report and literature review

•

Fournier’s gangrene (FG) is a rare disease which usually affects men. It is characterized by progressive necrotizing fasciitis.

•

A 66-year-old man with uncontrolled type 2 diabetes, obesity with BMI 38, chronic kidney failure and chronic heart failure, reported the onset of symptoms about 14 days before his hospitalization, without consulting any doctor due to Covid-19 pandemic.

•

The combination therapy of surgical debridement and antibiotics infusion was effective.

Introduction

Fournier’s gangrene is a potentially fatal emergency condition, supported by an infection of perineal and perianal region, characterized by necrotizing fasciitis with a rapid spread to fascial planes. FG, usually due to compromised host, may be sustained by many microbial pathogens.

Case report

A 66-year-old man, with a history of uncontrolled type 2 diabetes, obesity with BMI 38, chronic kidney failure and chronic heart failure, was admitted to the Emergency Department with a large area of necrosis involving the perineal and perianal regions.

Discussion

Fournier’s gangrene is favoured by hypertension, obesity, chronic alcoholism, renal and heart failure. Generally, Fournier’s gangrene needs other procedures in addition to wound debridement such as colostomy, cystostomy, or orchiectomy.

Conclusion

We report a case of FG found as complication in a patient with uncontrolled type 2 diabetes, treated with effective combination therapy with surgical debridement and antibiotics infusion.

Cauda equina syndrome secondary to portal vein thrombosis: case report of favorable outcome with conservative treatment

Epidural varicosis is a rare though well-known cause of cauda equina syndrome (CES). Although inferior vena cava (IVC) obstruction is the most common finding in such cases, portal vein hypertension can lead to epidural venous plexus engorgement by means of lumbar portocaval shunt activation.A 40-year-old woman presented with right-sided sciatica, which progressed to right foot drop and a 3-day history of vesical tenesmus and fecal retention. She was initially diagnosed with L4-5 lumbar disc protrusion. However, contrast-enhanced lumbar MRI scan showed the presence of epidural varices in the L3-S1 tract. Given the absence of vascular anomalies amenable to resection, etiological conservative treatment was addressed. Therefore, a complete diagnostic workup was performed and revealed deep vein thrombosis (DVT), pulmonary embolism, and portal vein thrombosis. Oral anticoagulant therapy was initiated and prompt resolution of CES was observed. To the authors' knowledge, this is the first report of CES secondary to epidural varicosis in the setting of acute portal vein thrombosis and extrahepatic portal vein obstruction (EHPVO). In cases of epidural varicosis, conservative etiological treatment is the most appropriate choice as CES may be the epiphenomenon of underlying systemic pathophysiological processes.

The Role of the Transorbital Superior Eyelid Approach in the Management of Selected Spheno-orbital Meningiomas: In-Depth Analysis of Indications, Technique, and Outcomes from the Study of a Cohort of 35 Patients

Objective Primary goal in spheno-orbital meningioma (SOM) surgery still remains complete resection. Nevertheless, given their highly infiltrative nature, a growing body of literature suggests to shift toward function-sparing surgeries. We here present our experience in the management of SOMs through the endoscopic superior eyelid approach (SEA).

Methods Surgical database from our multidisciplinary work group was retrospectively reviewed to identify patients treated for SOMs in the last 10 years by our senior authors, analyzing and correlating clinical, radiological, and outcome variables among the different approaches used.

Results There were 35 patients (mean age of 57.3 ± 12.86 years), with a mean follow-up of 31.5 months (range: 6–84 months). The most common preoperative complaint was proptosis (62.9%) followed by diplopia and visual deficit. Greater and lesser sphenoid wings were the areas mainly involved by the pathology (91.4% and 88.6%, respectively), whereas orbital invasion was evidenced in one-third of cases. Patients were operated on through craniotomic (48.6%), endoscopic superior eyelid (37.1%), and combined cranioendoscopic (14.3%) approaches. Simpson grades 0 to II were accomplished in 46.2% of SEA and 76.5% of craniotomies. All patients with a preoperative visual deficit improved in the postoperative period, independently from the approach used. On patients who underwent endoscopic SEA, there was improved their short-/long-term postoperative Karnofsky Performance Status.

Conclusions Endoscopic SEA is a safe and effective alternative to transcranial approaches in very selected cases of SOMs, where the planned primary objective was to obtain a maximally safe resection, aimed at symptom relief, rather than a gross total resection at any cost.

Pattern of recurrence and survival of c-Ia NSCLC diagnosed by transpleural methods

AIM

The aim of this study was to evaluate if transpleural diagnostic methods as percutaneous fine-needle aspiration biopsy (FNAB) or tumour wedge resection by video-assisted thoracoscopic surgery (VATS) impact on local recurrence and long term survival of patients affected by non-small cell lung cancer (NSCLC).

METHODS

Records concerning 179 patients with peripheral c-Ia NSCLC who underwent complete resection from 1994 to 2000 have been reviewed. Patients were randomized into two groups according to the diagnostic method employed, as follows: in group I (N.=63) diagnosis was obtained by bronchoscopy; in group II (N.=116) diagnosis was obtained by FNAB (N.=59) or tumour wedge resection by VATS (N.=57) after a negative bronchoscopy. Survival curves were compared using log-rank test. Distribution of frequencies was analyzed with Chi-square and Fisher's exact test.

RESULTS

The two groups of patients did not significantly differ in terms of age, gender, forced expiratory volume in 1 second, comorbidities, histological type and tumour size; pathologic stage IIb was more frequent in group I. At a median follow-up of 48 months, (range 2-108 months), local recurrence was found in 9.5% (N.=6) of the patients in group I and in 12.5% (N.=15) of patients in group II (P=NS); distant metastasis were found in 28.6% (N.=18) of patients in group I and in 13.8% (N.=16) in group II (P=0.03). Patients in group II had a statistically better five-year survival rate than patients in group I (70% and 55% respectively P=0.016).

CONCLUSION

FNAB and tumour wedge resection by VATS represent valuable diagnostic methods for lung cancers, since they do not seem to increase the risk of local recurrence. On the other hand, tumours diagnosed by bronchoscopy have a worse prognosis, that may be related to their higher metastatic potential rather than to diagnostic procedure itself.

A case of primary malignant hemangiopericytoma of the heart with fatal outcome

Hemangiopericytoma is a rare, highly vascular tumor which has both malignant and benign varieties. We report a case of a 41-year-old man who underwent surgery in emergency because of cardiac tamponade. The histopathologic examination of the specimens revealed primary malignant cardiac hemangiopericytoma. The patient died 46 days from the beginning of symptoms and 13 days after surgery.

Late outcome and perioperative complications for surgery of locally recurrent bronchogenic carcinoma

AIM

Many doubts involve a 2(nd) surgical approach for local relapse of non small cell lung cancer (NSCLC) since iterative resections represent a well-recognized treatment in second primary lung cancer (SPLC).

METHODS

The medical reports of patients who underwent surgical resection, between 1988 and 2002, were reviewed. All patients submitted to 2(nd) operation were examined according to Martini and Melamed criteria to distinguish between local recurrence and second primary lung cancer.

RESULTS

Complete resection for NSCLC was performed in 1 386 patients. Nineteen patients were submitted to surgery for local recurrence (17 men and 2 women) and mean age at the time of 1(st) operation was 61 years (range 41-78 years). The 1(st) operation consisted of lobectomy in 15 cases, anatomical segmentectomy in 2 and wedge resection in 2. The 2(nd) pulmonary resection was completion pneumonectomy in 16 cases, completion lobectomy in 2, wedge resection in 1. Major complications occurred in 26% and overall hospital mortality was 5%. Five-year survival after 2(nd) intervention was 31% and median survival 27 months. Survival was better when the time between 1(st) resection and cancer relapse was longer than 14 months and when recurrence was intrapulmonary.

CONCLUSIONS

A new malignant lesion can be operated if it is solitary and intrapulmonary, if accurate staging is negative and if the patient is able to go through 2(nd) surgery from cardiopulmonary evaluation.

Ten year experience of bioabsorbable mesh support in pectus excavatum repair

INTRODUCTION

We reviewed 10 years experience in the treatment of this deformity using a retro-sternal bioabsorbable mesh in place of a metallic device to lift and stabilise the sternum. Moreover, the mesh supports the thoracic and upper abdominal wall reconstruction.

MATERIALS AND METHODS

From January 1990 to December 2000, in our Thoracic Surgery Unit, 65 patients with PE were assessed for surgical repair, mean age 16+/- 3.5 years, fronto sagittal thoracic index (FSTI) 0.21, ranging from 0.15-0.33. Twenty-three of them underwent surgical correction after initial assessment, 22 were deferred and sent to physiotherapy. At a subsequent assessment, five of the patients sent to physiotherapy were deemed to require surgery.

RESULTS

Of the 28 patients who underwent surgery, 2 (10%) presented a mild recurrence of PE after 1 year (0.30<FSTI>0.34), meanwhile all other patients maintained a FSTI>0.34. For all patients the improvement in FSTI was statistically significant, p = 0.001. Patients satisfaction after 24 months was thus shared: excellent 18 patients (65%), good seven patients (25%), fair one patient (3.5%) and poor two patients (7%). No major complications were observed in preoperative period. Patients mobilisation was soon achieved thanks to the postoperative pain control and the absence of retro-sternal metallic support.

CONCLUSIONS

The introduction of bioabsorbable mesh in the Robicsek technique is a safe procedure related to a high percentage of success. The high tolerance of the material reduces the inflammatory reaction. Moreover, the procedure prevents patients from having complications caused by retro-sternal device dislodgment, avoiding a second intervention for device reposition and reducing the postoperative chest pain achieving an early patient mobilisation. In the end a complete reconstruction of the upper abdomen wall has been produced.

Sudden onset of thoracic pain: neurofibroma with intracystic haemorrhage

Intercostal nerve sheath tumors are normally benign and asymptomatic. Nevertheless surgical resection can eliminate the risk of malignant transformation and also achieve complete remission in case of symptoms.

Right pneumonectomy for adenocarcinoma stage IIIA-N2 in a heart transplant patient after induction chemotherapy

Lung tumors are the most frequent solid tumor in the heart transplant population. Unfortunately, most of these patients are in an advanced stage of disease at the time of presentation, which carries a poor prognosis. We present a heart transplant patient with histologically proven. Stage IIIA-N2 bronchogenic adenocarcinoma who had complete lymph-node downstaging after induction chemotherapy and underwent a complete tumor resection by right pneumonectomy.

Comparison between segmentectomy and larger resection of stage IA non-small cell lung carcinoma

AIM

Stage IA non small cell lung carcinoma (NSCLC) represents early cancer and is best treated by surgery. The frequency of recurrence and new primary cancer varies from one report to another while the role of sublobar resection is still debated.

METHODS

We retrospectively reviewed 121 consecutive patients with pathological stage IA after radical surgery.

RESULTS

In stage IA NSCLC 1-, 3-, 5-year survival rates were 89%, 76% and 66%. Nearly half of the deaths were unrelated to the original cancer. From statistical analysis we did not find any factor indicative of a better prognosis. We did not find any difference in survival between histologic types. Segmentectomy did not show a worse survival rate compared with larger resection.

CONCLUSION

Survival is neither influenced by the type of resection nor by the histologic types in stage IA. However, we noticed a high incidence of local recurrence, segmentectomy could be a viable choice in patients with cardiopulmonary impairment.

Pneumonectomy vs lobectomy in the treatment of pathologic N1 NSCLC: could the type of surgical resection dictate survival?

AIM

To define the prognostic significance of specific types of N1 lymph node involvement in patients operated on for stage II (N1) NSCLC and to evaluate if the extent of resection affects survival.

METHODS

Of 1117 patients operated on from 1985 to 1998, an homogeneous group of 124 consecutive patients with pathologic T1-T2 N1 disease who had undergone a complete resection with systematic nodal dissection were analysed. No patients received adjuvant radio- or chemotherapy.

RESULTS

The overall 5-year survival rate was 48.8%. Survival was not related to pathologic T factor, histology, number, percentage or level of N1 involved, visceral pleura involvement, number of lymph nodes dissected. Patients were then divided into 3 groups depending on the level of lymph node involvement (stations 10, 11 and 12-13) and survival analysed according to the extent of resection (pneumonectomy vs lobectomy). No significant difference was found, however, in the group of level 10, patients treated by pneumonectomy showed a better 5-year survival (58%) compared to patients treated by lobectomy (33%) with a median survival of 110 against 58 months. This data was confirmed by a lower incidence of local recurrence in the pneumonectomy group than lobectomy group (0% vs 24%), whereas the same incidence of distant metastases was observed in the two groups (29% vs 23%).

CONCLUSIONS

In patients with stage II (N1) NSCLC, only in case of station 10 involved, pneumonectomy could allow a better survival lowering the incidence of local recurrence. However the major part of patients with stage II (N1) NSCLC die for distant metastasis. This supports the necessity to develop a specific systemic treatment.

Which treatment in pericardial effusion?

BACKGROUND

Pericardiocentesis, pleuro-pericardial window, subxiphoid pericardial drainage and pericardioscopy: which methodology to treat pericardial effusion? Each of these surgical treatments can be effective, depending on clinical factors and history of the patients. We considered pericardial effusions during 5 years.

METHODS

We reviewed 64 cases: 14 acute pericardial effusions (5 patients with cardiac tamponade), 39 subacute, 11 chronic. Epidemiology and aetiology: 8 cases were between 20 and 25 years old (all affected by lymphoma), 56 were distributed in every age, especially over 60, and of these 45 were neoplastic and 11 non- neoplastic. Non-neoplastic cases were connectivitis (3 patients), uncertain origin effusion (7 patients), tubercular (1 patient). In neoplastic effusions we found lymphoma (at older age) in 7, small cell lung cancer in 6, NSCLC in 12, mesothelioma in 2, breast cancer in 7.

RESULTS

Acute pericardial effusions with cardiac tamponade underwent echo-guided pericardiocentesis. In 43 we had a subxiphoid pericardial drainage, among these cases we performed 4 pericardioscopies. We created a pleuro-pericardial window on VATS in 13, on thoracotomy in 4 for technical reasons.

CONCLUSIONS

Pericardiocentesis is to be preferred in acute pericardial effusion with cardiac tamponade to avoid general anaesthesia. Pleuro-pericardial window on VATS is better in chronic pericardial effusion (for infective or systemic disease) and in recurrence, after performing subxiphoid drainage. Subxiphoid drainage is suitable for all neoplastic patients, and in case of unknown aetiology in order to perform a pericardioscopy.

Survival after bronchoplastic lobectomy for non small cell lung cancer compared with pneumonectomy according to nodal status

BACKGROUND

In this retrospective study we have compared the results after sleeve lobectomy and pneumonectomy performed for non small cell lung cancer in the period January 1990-December 1995 at the Thoracic Surgery Unit, University Hospital of Siena. Follow-up was updated until December 2000.

METHODS

In that period, 38 patients underwent sleeve lobectomy and 127 underwent pneumonectomy. The bronchoplasty was a full sleeve in 30 patients and a bronchial wedge resection in eight. Systemic nodal dissection was undertaken routinely.

RESULTS

The 30-day postoperative mortality was 5.2% (2/38) in the sleeve lobectomy group and 3.9% (5/127) in the pneumonectomy group. Postoperative complications occurred in 23.6% of patients in the sleeve lobectomy group and in 23.2% of those in the pneumonectomy group. Local recurrences occurred in 5.2% of patients in the sleeve lobectomy group and in 4.8% of those in the pneumonectomy group. The overall 5-year survival for the sleeve lobectomy group was 38% whereas that for the pneumonectomy group was 25% (p=0.03). Regarding lymph-node involvement, in the sleeve lobectomy group, the 5-year survival for N0, N1 and N2 was 62.5, 17.5 and 12.5%, respectively.

CONCLUSIONS

Our data confirm that sleeve lobectomy, when performed in selected patients with non small cell lung cancer, provides at least similar overall long term survival to that seen after pneumonectomy. Long term result are chiefly related to nodal stage with a significantly lower survival for patients with nodal involvement. As most patients with nodal involvement die from distant metastases, adjuvant treatment, instead of type of resection, would play a major role in prolonging survival.