Conservative management of chylous ascites after oncological surgery for peripheral neuroblastic tumors in pediatric patients.

Chylous ascites may complicate the postoperative course of abdominal surgery mainly due to the iatrogenic disruption of the lymphatic channels during extensive retroperitoneal dissection. Sparse data are available regarding treatment; however, in many cases a recommended first-line treatment approach is by way of enteral feeding, consisting of a formula high in medium-chain triglycerides (MCTs) together with a complete total parenteral nutrition teamed with somatostatin (or an equivalent). Nonetheless, the ligation of chylous fistulae, together with the application of Fibrin glue, as well as the creation of peritoneal-venous shunts have also been documented. The aims of this study are to document incidence of postoperative chylous ascites following resection of abdominal peripheral neuroblastic tumors, evaluate efficacy of the management of chylous ascites, and investigate the main risk factors. A survey was carried out over a span of six years, from March 2010 to March 2016 at Giannina Gaslini Children's Hospital involving seventy-seven children with resections of peripheral neuroblastic tumors. Incidence rate of postoperative chylous ascites following a normal diet was 9% (n=7). Treatment using total parenteral nutrition with octreotide resulted in a complete recovery from chylous ascites within a 20 day period without recurrence. Length of operative time, nephrectomy, and the extension of lymphadenectomy were all significantly associated with a higher incidence of postoperative chylous ascites (p<0.05) which also lengthened hospital stay (p<0.05) and possibly delayed beginning adjuvant chemotherapy.

Repetitive nerve block for neuropathic pain management: a case report.

Schwannoma is a common neoplasm in the peripheral and central nervous systems. Sciatic nerve schwanommas are rare. We report the case of a 50-year-old woman who was referred for treatment of persistent neuropathic pain in the left lower limb after resection of a schwannoma on the left S1 nerve root. The patient's history goes back when she was 27 years old and started to have electric-like pain in her lower left limb upon intercourse. Examination revealed a left ovarian cyst which was surgically removed. Her pain persisted despite taking nonsteroidal anti inflammatory drugs (NSAIDs). Several years later a schwannoma on the left S1 nerve root was detected. The patient had surgical excision of the left S1 nerve root at the plexus along with the schwannoma. Following the surgery, she experienced pain upon sitting and touch, and had a limp in her left leg. She was prescribed NSAIDs, antidepressant and pregabalin. Despite the pharmacological treatment, the patient had persistent mild pain. Upon physical examination, the incision from her previous surgery was 4 cm away from the sacral midline and parallel to S1 and S2. The length of the incision was 3 cm. The patient had severe allodynia upon palpation at the area between S1 and L5 and the visual analog scale (VAS) score increased from 3 to 10. She had severe pain at rest and movement. Her neurologic exam revealed that the left lower extremity motor power showed mild weakness in the leg abduction, foot eversion, plantar and toes flexion, and in the hip extension. The sensory exam showed severe reduction in pinprick and temperature sensation in the lateral aspect of foot, lower leg and dorsolateral thigh and buttocks. Nerve stimulator guided injection was performed at the pain trigger point being 1 cm above the midline of the incision. Upon nerve stimulation the contraction of the gluteal muscle was observed. Then, 20 mL of the anesthetic mixture were injected. The patient had immediate pain relief after the block (VAS 1/10). She remained pain free for 15 days after which pain reappeared but with less severity (3/10). Repetitive sciatic nerve block was performed in a progressive manner and was shown to be effective in managing neuropathic pain.

Primary benign brachial plexus tumors: an experience of 115 operated cases.

Primary benign brachial plexus tumors are rare. They pose a great challenge to the neurosurgeon, because the majority of patients present with minimal or no neurological deficits. Radical to complete excision of the tumor with preservation of neurological function of the involved nerve is an ideal surgical treatment option with benign primary brachial plexus tumor surgery. We present a review article of our 10-year experience with primary benign brachial plexus tumors surgically treated at King Edward Memorial Hospital and P.D. Hinduja National Hospital from 2000 to 2009. The clinical presentations, radiological features, surgical strategies, and the eventual outcome following surgery are analyzed, discussed, and compared with available series in the world literature. Various difficulties and problems faced in the management of primary benign brachial plexus tumors are analyzed. Irrespective of the tumor size, the indications for surgical intervention are also discussed. The goal of our study was to optimize the treatment of patients with benign brachial plexus tumors with minimal neurological deficits. It is of paramount importance that brachial plexus tumors be managed by a peripheral nerve surgeon with expertise and experience in this field to minimize the neurological insult following surgery.

Spinal arteriovenous fistulae with a concomitant cauda equina schwannoma.

BACKGROUND: Perimedullary spinal arteriovenous malformations or direct spinal arteriovenous fistulaes (AVFs) may be associated with other vascular abnormalities, such as arteriovenous malformations, venous ectasis, and aneurysms, but rarely have been reported with intraspinal intradural tumors. PURPOSE: The authors present an interesting case of type IV-A spinal AVF concomitant with a cauda equina schwannoma. STUDY DESIGN: The diagnostic procedures and surgical outcome were described. METHODS: The patient underwent surgery, the vessel feeding the AVFs was identified and cauterized, and the spinal tumor was removed. The fistula was small and located inside the tumor. The pathology revealed AVF and schwannoma, respectively. RESULTS: After surgery, the patient's symptoms began to improve and subside. Two years after surgery, follow-up magnetic resonance imaging showed no vascular lesion and tumor in the spinal canal. CONCLUSIONS: The association of spinal AVFs and cauda equina schwannoma has not been reported previously in any literature. The patient presents the symptoms of myelopathy associated with a spinal vascular lesion; it has to be noted that a concomitant and related intradural spinal tumor may exist.

Perineural invasion in prostatic carcinoma treated with radical prostatectomy: the role of TR systematic biopsy.

Perineural invasion (PNI) is a morphological entity which has been known for many years, though its significance in prostatic neoplasms has only been studied recently. Therefore, we tried to assess, with the help our experience, its presence and its significance. Ninety-four patients, aged between 49 and 74 (average 65.8)--with a PSA between 2.69 and 52 ng/ml (average 11.44)--underwent RP for prostatic carcinoma; 58 patients had stage T2 and 36 had T3. 48 patients had Gleason 7 or higher, and 46 had G 6 or lower. Fifty patients (53,1%) were PNI+ and 44 (46,9%) PNI-. Between the two groups there was no significant difference as to age (1" group: average age 67 years; 2nd group: 68) and PSA (1st group: average 9.73 ng/ml, 2nd group: average 8,17) (Z 0,639). The distribution according to the stage showed that 24 patients (48%) PNI+ were T2 and 26 (52%) PNI+ T3, 34 (77.2%) PNI- T2 and 10 (22%) PNI- T3 and therefore 72,23% of the T3's were PNI+ and 41.3% of the T2's were PNI+; 34 patients (70.8%) with G>7 were PNI+ and 14 (29.16%) PNI-, 16 patients (34,78%) with G<6 were PNI+ and 30 (65.2%) PNI-. Among the PNI+ 50 patients, 36 had undergone biopsy in our hospital, and therefore we re-examined the operation tissue and found out that 16 (44%) were biopsy PNI+ while for 22 (55.5%) it was not possible to assess the PNI on the biopsy tissue. PNI is an important morphological element in the staging of prostatic cancer and is connected with the disease negative prognostic factors: in fact, it can be traced with a high frequency in stage diseases and higher Gleasons. It does not seem to be connected with PSA, above all for values between 4 and 20 ng/ml. We think that a very important element to be stressed is the fact that this condition is not always detected with biopsy (about 45%) and this does not allow, in such cases, an adequate therapy plan. Also our experience seems to confirm that, therefore, in spite of the above said limits, it is advisable to search PNI both with biopsy--in order to have a further prognostic element and therefore arrange the most suitable therapy plan--and on the surgery piece, in order to better determine the biological nature of the disease and to be able to suggest adequate integrative therapies.

Surgical treatment of painful neuroma in medial antebrachial cutaneous nerve.

The branches of the medial antebrachial cutaneous nerve (MACN) are located at the medial site of the elbow. The MACN, especially the posterior branches, may be injured or transected during cubital tunnel surgery or other medial approaches to the elbow. Damage to the nerve can cause a neuroma, which leads to disabling pain and restriction of elbow movement. The initial treatment of the neuroma is nonsurgical, and includes local massage, desensitization, physiotherapy, and systemic medication. If after 6 months of these nonsurgical treatments there is no improvement, surgery is indicated. The authors report their experience with 12 patients treated surgically for painful neuroma by high resection of the proximal end or its implantation into the triceps muscle. After surgery there was a high success rate of pain relief and functional improvement in both elbow movement and handgrip strength.

Schwannoma of the cauda equina.

OBJECTIVE: To review the features of spinal schwannoma in a case that mimicked a lumbar disc herniation. CLINICAL FEATURES: A 37-yr-old woman suffered from a 4-yr history of progressive low back and leg pain, with progressive neurological involvement of several nerve roots. Noteworthy symptomatology included increased pain when lying recumbent and urinary and fecal incontinence. Several health care practitioners diagnosed her with a lumbar disc herniation. Investigations with myelography, computed tomography (CT) with myelographic contrast and magnetic resonance imaging (MRI) revealed the presence of an intradural tumor at the T12-L2 region. INTERVENTION AND OUTCOME: The tumor was surgically resected via laminectomies at T12-L2. The patient experienced a decrease of pain intensity but continued to complain about the low back and posterior thigh pain and has been unable to return to work. She continues to suffer from urinary incontinence, which is controlled by medication. There has been no recurrence of the tumor. CONCLUSION: Spinal pathology such as schwannoma of the cauda equina can mimic common complaints of low back pain seen in clinical practice. Differentiating features of cauda equina tumors from lumbar disc prolapse include: pain on lying recumbent, progressive nature of the pain and neurological deficit, involvement of several nerve root levels and intractability of the condition to conservative therapy. The most appropriate methods for imaging these tumors are CT with myelography or MRI. Patient prognosis is improved with early detection and removal. Chiropractors can play a pivotal role in the care of these patients by being suspicious of patients who do not respond as expected to a course of manipulative therapy, by investigating or referring appropriately and by aiding in active rehabilitation postoperatively.

Pretreatment with [131I] metaiodobenzylguanidine and surgical resection of advanced neuroblastoma.

Pretreatment with [131I] metaiodobenzylguanidine (MIBG) followed by surgical resection in advanced neuroblastoma (stage 3 and 4) has been studied in relation to resectability, morbidity and mortality, survival rate after two years, control of distant metastasis and serum levels of LDH as prognostic factors. Twenty-one patients with advanced neuroblastoma were primarily treated with MIBG radiotherapy, followed by surgical resection. Sixteen patients had stage 4 disease. Between 2 and 6 courses of MIBG treatment were given per patient. In 17 patients gross complete resection was achieved. Two patients developed complications directly related to the operation, one died as a result of this. The overall mortality was 38%. MIBG therapy resulted in partial response in 13 patients and in stable disease in 8 patients. Two years survival in the group with partial response was 86% and in the group with stable disease 28%. Because of the resulting excellent general condition of the patients the interval between pretreatment with MIBG and surgery could be very short. Follow-up till December 1994 showed that 13 children were alive for 3 to 47 months. Seven had no evidence of disease. Preoperative MIBG de novo treatment in advanced neuroblastoma is equal to induction chemotherapy, but less toxic.

[Hyponatremia following surgery for tumors in the hypophyseal or hypothalamic region (author's transl)].

Following surgery for tumors in the hypophyseal or hypothalamic region, low serum Na level (hyponatremia) is sometimes noted and causes clinical manifestations. Therefore, on the care of patients within 1 to 2 weeks following operation for tumors in this region, stabilization of serum Na level is one of the most important problems.

[Anesthetic technics for surgery in otoneurology]. / Techniques anesthésiques pour les interventions en oto-neurologie

A description is given of a technique named "Protected Sleep", which produces a deep and residual analgesia and neurolepsia, without interfering with spontaneous respiration. A deep, stable and reliable neuroanesthesia is achieved by means of a partial pharmacodynamic blockage of the neuro-humoral reaction system. It is recognisable by the following features: 1 degree a smooth transition through pre-, per- and post-operative stages, avoiding in particular immediate awakening; 2 degrees a relative arterial hypotension, low venous pressure good peripheral circulation and tissular perfusion; 3 degrees light hypothermia; 4 degrees completely spontaneous respiration. This last factor is, to our way of thinking, of great importance: The venous return remains physiologically unchanged during inspiration in the peroperative as well as in the pre- and postoperative phases, enabling the maintenance of a constant, low venous pressure. Furthermore, should danger exist, the preservation of spontaneous respiration facilitates the immediate control of the respiratory centre. In this way we can obtain: 1. An almost perfect bloodless surgical field with good conditions for dissecting. 2. A low cerebro-spinal fluid pressure. 3. Decreased brain volume. 4. Absence of postoperative haemorrage. 5. Little of no postoperative oedema. 6. Little or no postoperative hyperthermia. "Protected sleep" is a pharmacodynamic technique realised mainly through administration of a combined and sufficient dose of pethidine, N-allyl-normorphine and levome promazine. For induction, a given dose of diazepam is combined with a single dose of succinyl-choline, to facilitate intubation, followed by a large dose of the narco-neuro-leptanalgesic mixture. For maintenance, nitrous oxide, oxygen, methoxyflurane and additional doses of the mentioned mixture are administered. Undirectional gas flow, without rebreathing, is provided, using the Ruben valve. In this paper on neuroanaesthesia, the technique of "Protected Sleep" and the pre-, per- and postoperative management and positioning of the neurosurgical patient are described in detail.