Oncologic results and quality of life in patients with squamous cell carcinoma of hypopharynx after transoral laser microsurgery.

OBJECTIVE: Transoral laser microsurgery (TLM) is an alternative method for organ preservation in squamous cell carcinoma of hypopharynx (HPSCC). The purpose of this study was to analyze the oncologic results and quality of life (QOL) in HPSCC patients after TLM. METHODS: Forty-six patients who underwent TLM were included, 34 of them had QOL evaluations. The QOL analyses were measured with EORTC QLQ-C-30, QLQ-H&N35, VHI-30, and MDADI at least 6 months postoperatively. RESULTS: Most patients were male (96%) with a median age of 60 years. Four patients (9%) were at the T1 category, 24 (52%) at T2, 15 (33%) at T3, and 3 (7%) at T4. Twenty-nine patients (63%) had cervical lymph node metastases and 26 (57%) received postoperative radiotherapy. With a median follow-up of 61 months for all patients, 18 (39%) had tumor recurrence, including 4 local, 7 regional, and 7 distant. The 5-year overall and disease-specific survival (DSS) rates were 59% and 77%, respectively. The 5-year laryngeal preservation rate was 89%. Most patients had satisfactory QOLs. CONCLUSION: In early and selective moderately advanced HPSCC, TLM can achieve optimal oncologic results and satisfactory QOL. Lasers Surg. Med. 50:117-124, 2018. © 2017 Wiley Periodicals, Inc.

Sodium hypochlorite chemical burn in an endodontist's eye during canal treatment using operating microscope.

INTRODUCTION: This study describes a case of eye burn induced by sodium hypochlorite used as an irrigant during root canal preparation. METHODS: A 24-year-old female endodontist was using an operating microscope during root canal treatment, and as the root canal was irrigated, the pressure cannula burst and the irrigant (3.5% sodium hypochlorite) came into direct contact with her left eye. She immediately sought ophthalmologic emergency care for pain, redness of the cornea, burning sensation, photophobia, intraocular pressure, and blurred vision. The initial treatment consisted of washing the eye with saline solution and administering analgesic and anti-inflammatory (steroid) medications. One day after the accident, a topical demulcent and hydroxypropyl medication were applied to the eyeball (conjunctiva), the eye was bandaged for 24 hours, and rest was prescribed for 7 days. Eight days later, a corneal ulcer was diagnosed, and antibiotic and anti-inflammatory (steroid) medications were used. RESULTS: Vision was restored without any sequelae 4 weeks after the accident. The endodontist was instructed to apply control medication (Lagricel; Sophia SA, Caracas, Venezuela) for 3 months and to return for ophthalmologic follow-up every 6 months. CONCLUSIONS: Sodium hypochlorite is an effective antibacterial irrigant indicated for the treatment of root canal infections. The tissue cytotoxicity highlights the need to inform the patient of the risk factors of accidents and enhance care with individual protection equipment for the patient and the professional during clinical procedures.

Common-path low-coherence interferometry fiber-optic sensor guided microincision.

We propose and demonstrate a common-path low-coherence interferometry (CP-LCI) fiber-optic sensor guided precise microincision. The method tracks the target surface and compensates the tool-to-surface relative motion with better than ± 5 µm resolution using a precision micromotor connected to the tool tip. A single-fiber distance probe integrated microdissector was used to perform an accurate 100 µm incision into the surface of an Intralipid phantom. The CP-LCI guided incision quality in terms of depth was evaluated afterwards using three-dimensional Fourier-domain optical coherence tomography imaging, which showed significant improvement of incision accuracy compared to free-hand-only operations.

1.9 µm diode laser assisted vascular microanastomoses: Experience in 40 clinical procedures.

BACKGROUND: Since the initial work of Jacobson and Suarez in 1960, microsurgery has evolved greatly. In 2009, we reported our clinical experience with 1.9 µm diode laser-assisted vascular microanastomoses (LAMA) for free flap reconstruction. In this report, the ongoing study is now expanded to include 11 additional procedures which were analyzed prospectively with a focus on the duration of the LAMA technique. METHODS: In total, 40 clinical procedures with LAMA have been performed since 2005. Mean follow-up was 3.3 years (range 0.5-5.5 years). Among those, 11 procedures were performed and prospectively analyzed during the period 2008-2009. LAMA was performed with a 1.9 µm diode laser after placement of equidistant stitches. For vessels size <1.5 mm, the following laser parameters were used: spot size 400 µm, five spots for each wall, power 125 mW, arterial/venous fluence 100/90 J/cm(2) (spot duration 1/0.9 seconds). RESULTS: For the last observed 11 procedures, mean occlusion time of the flap arterial and venous anastomoses was 5.4 ± 0.4 and 6.8 ± 0.7 minutes respectively. One anastomosis required a secondary laser application. Arterial and venous patency rates were 100% at the time of surgery. The success rate for the 11 procedures was 100%. The global success rate of the series (97.5%) is discussed and compared with the literature. CONCLUSION: The success rates for reconstructive free flap surgery realized with LAMA appear excellent. Technical innovation will most likely lead to widespread use of the handpiece laser in the operating room.

Microscope-aided endodontic treatment of maxillary first premolars with three roots: a case series.

Maxillary premolars have a highly variable root canal morphology. However, the presence of three roots is a rare occurrence. This clinical article describes the unusual anatomy detected in maxillary premolars during routine endodontic treatment using microscope. The diagnosis and clinical management of maxillary first premolars with three roots and canals using radiographic interpretation, access cavity modification and visual enhancement with operative microscopes is discussed in the article.

Transoral CO2 laser microsurgery for Tis-T3 supraglottic squamous cell carcinomas.

Eighty patients affected by supraglottic cancer were treated by transoral carbon dioxide laser surgery between 1989 and 2006 in two Italian institutions. Patient staging was as follows: 2 pTis, 20 pT1, 38 pT2, and 20 pT3. Simultaneous or 1-month delayed neck dissection (ND) was performed on 27 (34%) patients, unilaterally in 10 and bilaterally in 17. The pN category was as follows: 9 pN0, 6 pN1, 8 pN2b, and 4 pN2c. A total of 16 (20%) patients received complementary radiotherapy (RT) and 5 (6%) were subjected to chemo-RT for persistent tumor after re-excision due to positive margins, multiple lymph nodes, and/or extracapsular spread after ND. The last follow-up was in December 2008. The 5-year overall, disease-specific and disease-free survivals, local control with laser alone, and organ preservation rates calculated by Kaplan-Meier analysis were 84.4, 97.4, 88.3, 96, and 97.2%, respectively. Univariate analysis showed a statistically significant impact on disease-free survival, local control with laser alone, and organ preservation of pT category (p = 0.009, p = 0.01, and p = 0.03, respectively), while pN category and tumor stage negatively influenced disease-free survival (p = 0.007 and p = 0.01, respectively). This series confirms the good overall oncologic outcomes obtained by transoral laser surgery for Tis, T1, T2, and selected T3 supraglottic cancer with minimal pre-epiglottic space involvement.

Handheld histology-equivalent sectioning laser-scanning confocal optical microscope for interventional imaging.

A handheld, forward-imaging, laser-scanning confocal microscope (LSCM) demonstrating optical sectioning comparable with microtome slice thicknesses in conventional histology, targeted towards interventional imaging, is reported. Fast raster scanning (approximately 2.5 kHz line scan rate, 3.0-5.0 frames per second) was provided by a 2-axis microelectromechanical system (MEMS) scanning mirror fabricated by a method compatible with complementary metal-oxide-semiconductor (CMOS) processing. Cost-effective rapid-prototyped packaging combined the MEMS mirror with micro-optical components into a probe with 18 mm outer diameter and 54 mm rigid length. ZEMAX optical design simulations indicate the ability of the handheld optical system to obtain lateral resolution of 0.31 and axial resolution of 2.85 microm. Lateral and axial resolutions are experimentally measured at 0.5 microm and 4.2 microm respectively, with field of view of 200 x 125 microm. Results of reflectance imaging of ex vivo swine liver, and fluorescence imaging of the expression of cytokeratin and mammaglobin tumor biomarkers in epithelial human breast tissue from metastatic breast cancer patients are presented. The results indicate that inexpensive, portable handheld optical microscopy tools based on silicon micromirror technologies could be important in interventional imaging, complementing existing coarse-resolution techniques to improve the efficacy of disease diagnosis, image-guided excisional microsurgery, and monitored photodynamic therapy.

A novel simulation model for minimally invasive spine surgery.

OBJECTIVE: Minimally invasive spine surgery (MISS) is among the fastest growing technologies in general neurosurgical practice. In addition, great demand exists to teach these skills to neurosurgery residents. With newly enforced work hour restrictions, opportunities to acquire these skills are limited, necessitating development of alternative strategies of education. We describe a novel simulation model for MISS supplemented by resident self-assessment analysis and evaluation. METHODS: The simulator was constructed using a nontransparent Plexiglas frame supplemented with a modified halo frame on which to affix spine specimens. Interchangeable copper tubing was affixed to a 360-degree pivot system to replicate a working portal. Deer skulls and spines were then collected and prepared accordingly. Laboratory exercises were based on the resident's level of training with emphasis on proper drilling techniques. Eight neurosurgery residents were asked to complete the exercises and complete a self-assessment survey regarding their competence level on a scale of 0 to 5, both before and after completing the skill sets. Additionally, they were asked to complete an exit survey that was used to assess the simulation exercises. RESULTS: All exercises were completed successfully with the exception of placing 2 separate pedicle screws through the same portal, which posed difficulty on some specimens because of the of lack of lordosis of the specimens, leading to unfavorable trajectories using a free-hand technique. With regard to the resident self-assessment analysis, the mean confidence rating for performing an MISS laminectomy improved by a difference of 1.25 points (n = 8; 95% confidence interval, 0.66-1.84; P = 0.0015), from 2.50 to 3.75 before and after simulation exercises, respectively, and reached statistical significance. For the senior-level residents, the mean confidence rating for performing MISS placement of pedicle screws using a free-hand technique improved by a difference of 1.00 (n = 3; 95% confidence interval, -1.48-3.48; P = 0.225), from 3.33 to 4.33 before and after simulation exercises, respectively. Results of the exit survey were encouraging. CONCLUSION: The MISS simulator is a feasible, inexpensive, and reproducible adjunct to neurosurgery resident training and provides a new teaching method for spine surgery. Further investigation of this technology is warranted, although multicenter, randomized, controlled trials assessing its validity may not be practical because of ethical constraints with regard to patient safety.

A stereotactic near-infrared probe for localization during functional neurosurgical procedures: further experience.

OBJECT: The authors previously developed an optical stereotactic probe employing near-infrared (NIR) spectroscopy to provide intraoperative localization by distinguishing gray matter from white matter. In the current study they extend and further validate this technology. METHODS: Near-infrared probes were inserted 203 times during 138 procedures for movement disorders. Detailed validation with postoperative imaging was obtained for 121 of these procedures and with microelectrode recording (MER) for 30 procedures. Probes were constructed to interrogate tissue perpendicular to the probe path and to incorporate hollow channels for microelectrodes, deep brain stimulation (DBS) electrodes, and other payloads. RESULTS: The NIR data were highly correlated to imaging and MER recordings for thalamic targets. The NIR data were highly sensitive but less specific relative to imaging for subthalamic targets, confirming the ability to detect the subthalamic nucleus and to provide warnings of inaccurate localization. The difference between the NIR- and MER-detected midpoints of the subthalamic nucleus along the chosen tracks was 1.1 +/- 1.2 mm (SD). Data obtained during insertion and withdrawal of the NIR probe suggested that DBS electrodes may push their targets ahead of their paths. There was one symptomatic morbidity. Detailed NIR data could be obtained from a 7-cm track in less than 10 minutes. CONCLUSIONS: The NIR probe is a straightforward, quick, and robust tool for intraoperative localization during functional neurosurgery. Potential future applications include localization of targets for epilepsy and psychiatric disorders, and incorporation of NIR guidance into probes designed to convey various payloads.

Long-term efficacy of microdebrider-assisted inferior turbinoplasty with lateralization for hypertrophic inferior turbinates in patients with perennial allergic rhinitis.

OBJECTIVES: The aim of the study was to evaluate the long-term efficacy of microdebrider-assisted inferior turbinoplasty with lateralization (MAITL) compared to submucosal resection for hypertrophic inferior turbinates. STUDY DESIGN: Surgical outcomes were evaluated with respect to visual analogue scale, anterior rhinomanometry, and saccharin test results. METHODS: From January 2002 to December 2006 inclusively, 160 patients with perennial allergic rhinitis and hypertrophic inferior turbinates were enrolled into this study. The patients, all suffering from chronic nasal obstruction, were randomly classified into two groups, MAITL group or SR group, each comprised of 80 patients. Ten patients who did not display any nasal discomfort served as normal controls. For the submucosal resection group, patients underwent submucosal resection of the inferior turbinate, whereas patients in the MAITL group underwent microdebrider-assisted inferior turbinoplasty with lateralization. Assessments (visual analogue scale, anterior rhinomanometry, and saccharin test) were conducted prior to the surgery and 1, 2, and 3 years after completion of surgery. RESULTS: Compared to preoperative values, subjective complaints including nasal obstruction, sneezing, rhinorrhea, and snoring improved significantly in both groups at 1, 2, and 3 years after surgery in both groups (P < .05 for all). Rhinomanometric assessment also showed significant improvement at 1, 2, and 3 years postoperatively in both groups (P < .05 for all). Saccharin transit time was significantly decreased (P < .05 for all) compared to preoperative values 1, 2, and 3 years after surgery in both groups. CONCLUSION: Microdebrider-assisted inferior turbinoplasty with lateralization appears to be as effective as submucosal resection at relieving nasal symptoms and decreasing total nasal resistance and saccharin transit times for more than 3 years in patients with perennial allergic rhinitis who have had substantial nasal obstruction.

Blood flow disturbance in perforating arteries attributable to aneurysm surgery.

OBJECT: The object of this study was to investigate patients with cerebral infarction in the area of the perforating arteries after aneurysm surgery. METHODS: The authors studied the incidence of cerebral infarction in 1043 patients using computed tomography or magnetic resonance imaging and the affected perforating arteries, clinical symptoms, prognosis, and operative maneuvers resulting in blood flow disturbance. RESULTS: Among 46 patients (4.4%) with infarction, the affected perforating arteries were the anterior choroidal artery (AChA) in nine patients, lenticulostriate artery (LSA) in nine patients, hypothalamic artery in two patients, posterior thalamoperforating artery in five patients, perforating artery of the vertebral artery (VA) in three patients, anterior thalamoperforating artery in nine patients, and recurrent artery of Heubner in nine patients. Sequelae persisted in 21 (45.7%) of the 46 patients; 13 (28.3%) had transient symptoms and 12 (26.1%) were asymptomatic. Sequelae developed in all patients with infarctions in perforating arteries in the area of the AChA, hypothalamic artery, or perforating artery of the VA; in four of five patients with posterior thalamoperforating artery involvement; and in two of nine with LSA involvement. The symptoms of anterior thalamoperforating artery infarction or recurrent artery of Heubner infarction were mild and/or transient. The operative maneuvers leading to blood flow disturbance in perforating arteries were aneurysmal neck clipping in 21 patients, temporary occlusion of the parent artery in nine patients, direct injury in seven patients, retraction in five patients, and trapping of the parent artery in four patients. CONCLUSIONS: The patency of the perforating artery cannot be determined by intraoperative microscopic inspection. Intraoperative motor evoked potential monitoring contributed to the detection of blood flow disturbance in the territory of the AChA and LSA.

Method of propulsion of a ferromagnetic core in the cardiovascular system through magnetic gradients generated by an MRI system.

This paper reports the use of a magnetic resonance imaging (MRI) system to propel a ferromagnetic core. The concept was studied for future development of microdevices designed to perform minimally invasive interventions in remote sites accessible through the human cardiovascular system. A mathematical model is described taking into account various parameters such as the size of blood vessels, the velocities and viscous properties of blood, the magnetic properties of the materials, the characteristics of MRI gradient coils, as well as the ratio between the diameter of a spherical core and the diameter of the blood vessels. The concept of magnetic propulsion by MRI is validated experimentally by measuring the flow velocities that magnetized spheres (carbon steel 1010/1020) can withstand inside cylindrical tubes under the different magnetic forces created with a Siemens Magnetom Vision 1.5 T MRI system. The differences between the velocities predicted by the theoretical model and the experiments are approximately 10%. The results indicate that with the technology available today for gradient coils used in clinical MRI systems, it is possible to generate sufficient gradients to propel a ferromagnetic sphere in the larger sections of the arterial system. In other words, the results show that in the larger blood vessels where the diameter of the microdevices could be as large as a couple a millimeters, the few tens of mT/m of gradients required for displacement against the relatively high blood flow rate is well within the limits of clinical MRI systems. On the other hand, although propulsion of a ferromagnetic core with diameter of approximately 600 microm may be possible with existing clinical MRI systems, gradient amplitudes of several T/m would be required to propel a much smaller ferromagnetic core in small vessels such as capillaries and additional gradient coils would be required to upgrade existing MRI systems for operations at such a scale.

Briefly occlusive coronary anastomosis with tissue adhesive.

OBJECTIVE: We assessed the feasibility of a facilitated, briefly occlusive, sutureless coronary anastomosis technique in which side-to-side preglued (octylcyanoacrylate adhesive) bounded walls were opened by a conventional arteriotomy. METHODS: In low-flow (prothrombotic milieu,

Segmental mandibular reconstruction by microincremental automatic distraction osteogenesis: an animal study.

We investigated the reconstruction of a surgically created critical size mandibular defect in sheep using a newly developed automatic distraction device. The device has an implantable component, which is fixed to the mandible to allow the transfer of the transport disc across the created defect, and an external component which is mounted on the activation pump and secured away from the site of bone distraction. Compression of the bellows in the external component causes fluid to be forced through the connecting tube into the distraction component. Distraction at a rate of 1 mm over 24 h was achieved in six sheep. New bone generated at the site of the created defects both anterior (compression side) and posterior (tension side) to the transport disc and had similar radiodensity to the adjacent mandibular bone eight weeks after the completion of distraction.

A modified technique of harvesting tibial cancellous bone and its use for sinus grafting.

Autogenous bone is the gold standard graft for sinus augmentation. The harvest of autogenous bone grafts from intraoral sites does often not provide sufficient bone volume and quality. A modified technique of harvesting a tibial cancellous graft is presented. With a micro-bone saw, a bony lid is prepared at the medial condyle of the tibia. The lid stays attached to the tendinous pes anserinus. Following the harvest, the lid is repositioned accurately. This method offers some distinct advantages. A sufficient amount of biologically highly valuable cancellous bone may be harvested for sinus grafting and possibly other surgeries with bone augmentation. The procedure may be performed under local anaesthesia and does not require hospitalisation. Neither major complications nor serious postoperative morbidity were observed.

Microendoscopic posterior cervical laminoforaminotomy for unilateral radiculopathy: results of a new technique in 100 cases.

OBJECT: In this report the author presents surgery-related outcomes after application of a new technique. A posterior microendoscopic laminoforaminotomy was used for the surgical treatment of unilateral cervical radiculopathy secondary to intervertebral disc herniations and/or spondylotic foraminal stenosis. The results of this procedure are compared with those achieved using traditional laminoforaminotomy and anterior cervical discectomy with or without fusion. METHODS: One hundred consecutive patients who experienced unilateral cervical radicular syndromes, which were refractory to conservative therapy, and in whom imaging studies had confirmed lateral canal or foraminal compression, underwent surgical treatment. An endoscopy-assisted posterior laminoforaminotomy was performed using a microendoscopic visualization system for removal of herniated disc and foraminal decompression while the patient was in the sitting position. Excellent or good results were obtained in 97 patients. who returned to their preoperative employment and baseline level of physical activity. One patient returned to work but was unable to perform at baseline level; two patients returned to prior sedentary work but continued to have some activity-related pain and paresthesias. Two patients reported experiencing intermittent paresthesias or numbness, but this did not limit their activities. There were two cases of dural punctures, one case of superficial wound infection, and no deaths. CONCLUSIONS: The microendoscopic posterior laminoforaminotomy is an effective alternative for the treatment of unilateral cervical radiculopathy secondary to lateral or foraminal disc herniations or spondylosis. In this group of patients, it is preferable because it does not require the sacrifice of a cervical motion segment, has a low incidence of complications, and is associated with a much quicker return to unrestricted full activity than that obtained with other techniques.

[The potential uses and limitations of the flexible laryngoscopy under local anesthesia in clinical practice]. / Möglichkeiten und Grenzen der flexiblen chirurgischen Laryngoskopie in Lokalanästhesie.

Microsurgery of the larynx is commonly performed as direct laryngoscopy (DL) under general anesthesia. An alternative in selected cases is flexible laryngoscopy (FSL) under local anesthesia. We used a flexible laryngoscope that contained an additional working tunnel (Olympus ENF Type T3). Local anaesthesia of the larynx was achieved with 1% oxybuprocaine-HCl. Tissue samples were taken under endoscopic view and control. Twenty-five patients were studied and had benign lesions of the larynx or were being followed after treatment for cancer. The examination was tolerated well by all patients. The handling of the endoscope allowed precise targeting and sample taking. Due to the 2.2 mm diameter of the forceps the sizes of the biopsies were also limited. However, nearly all of the biopsies taken allowed sufficient histological examination. The advantage of the FSL was its simplicity and the minor inconvenience for patients. Although true histological results of suspect findings are possible, limitations in examining the hypopharynx prevent true staging of cancer patients. In general, FCL is a worth-while complement to DL.

Office microlaparoscopy under local anesthesia.

Office laparoscopy under local anesthesia is especially suited to meet the current pressures of quality versus cost in an era of managed care. It is likely that this technique will soon become a major part of the practicing gynecologist's diagnostic operative armamentarium. Advantages of office microlaparoscopy under local anesthesia are realized by the practitioner, the patient, and the managed care provider. Office microlaparoscopy under local anesthesia is a safe, effective, and less costly tool for the evaluation of patients with many different indications. To date, the procedure has been primarily used for patients with infertility, chronic pelvic pain, and tubal ligation. The ease of scheduling, reduced costs, and rapid recovery suggest that it may be the preferred initial procedure for these patients.