Microsurgical Resection of a Left Supramarginal Gyrus AVM Causing Radionecrosis.

Late radiation necrosis is a rare entity presenting in 2.2% to 9% of radiation-treated arteriovenous malformations (AVMs). It occurs by a mean of 3 years following treatment. There are few reports in the literature of radionecrosis and solid lesions treated with surgery.1-4 To the authors' knowledge, this case has the longest interval between radiosurgery and the presentation of cerebral necrosis. In this surgical video, we present the case of a 51-year-old female with a left supramarginal gyrus AVM that received radiosurgery with gamma knife; after 20 years, she began having seizures and aphasia. The magnetic resonance imaging scan revealed a lesion simulating an intra-axial tumor causing important edema and mass effect. Medical treatment was given including high-dose steroids without success, therefore microsurgery was performed. The surgery was presented in a step-by-step basis and correlation was performed with the involved adjacent anatomy, to illustrate the anatomy of the approach and surgical landmarks. The patient's symptoms resolved completely, and the postoperative magnetic resonance imaging scan showed complete resection and resolution of the edema. The histopathological findings were consistent with a radionecrosis and AVM. The patient signed the Institutional Consent Form, which states that she accepts the procedure and allows the use of her images and videos for any type of medical publications in conferences and/or scientific articles.

Treatment for postchemoradiotherapy hypopharyngeal stenosis: Pharyngoesophageal bypass using an anterolateral thigh flap-A case report.

Radiation-induced pharyngoesophageal stenosis is a frequent and unwanted consequence of nonsurgical treatment of hypopharyngeal carcinomas. Current treatment mainly includes endoscopic dilatations, but a poor response to this modality and/or a severe stenosis may lead to a radical resection (pharyngolaryngectomy) and reconstruction with tubed flaps, which allow oral feeding but fail to preserve speech. In this report, we present a case of radiation-induced hypopharyngeal stenosis treated with a pharyngoesophageal bypass using an anterolateral thigh (ALT) flap with the intention of preserving the larynx. We describe the case of a 59-year-old male with severe pharyngoesophageal stenosis after chemoradiotherapy due to a squamous cell carcinoma, where conventional dilatation treatment failed to restore pharyngoesophageal passage of solids or liquids. Since the patient rejected a pharyngolaryngectomy due the loss of speech entailed, a pharyngoesophageal bypass was performed using an ALT flap. The flap measured 13 × 20 cm, which ensured a 4-cm-diameter tube and enough length to communicate the lateral pharyngeal wall with the cervical esophagus. Endoscopy did not reveal flap failure, and during the immediate postoperative period, the patient had a small cervical leak detected only by imaging that did not affect the skin and resolved with antibiotic treatment. The patient also required a tracheostomy on day 4 and initially had no passage of saliva through the bypass; we attributed this to edema that resolved spontaneously after 1 month with complete liquid and solid passage and laryngeal competence that led to tracheal decannulation. Good functional results were achieved both for speech and swallowing at 5-year follow-up. We believe that this procedure may be considered before performing a pharyngolaryngectomy for the treatment of a persistent benign stenosis in patients with a functional larynx.

Insuficiencia mesentérica crónica luego de radioterapia para aórtica / Surgical revascularization for treatment of chronic mesenteric ischemia secondary to radiotherapy

Background: Chronic mesenteric ischemia is observed in older people and is often due to atherosclerosis. Radiotherapy is an important risk factor for atherosclerosis. Aim: To report our experience with chronic mesenteric ischemia secondary to retroperitoneal radiotherapy. Material and methods: Review of medical records of four male patients aged 39 to 65 years, treated for chronic mesenteric ischemia secondary to para-aortic radiotherapy between 1993 and 2011. Results: All of them had the classic symptoms of ischemia characterized by post prandial abdominal pain and weight loss. One had also isolated diarrhea episodes. Revascularization was achieved with open or endovascular surgery, with good results during a follow up period ranging from two to 20 years. Conclusions: Surgical revascularization is a good treatment for chronic mesenteric ischemia secondary to radiotherapy.

Introducción: La insuficiencia mesentérica crónica es un diagnóstico infrecuente, generalmente secundario a enfermedad aterosclerótica, siendo considerada una enfermedad de pacientes añosos. Se sabe que la radioterapia es un factor de riesgo importante para aterosclerosis. Describimos nuestra experiencia en el manejo de la isquemia mesentérica crónica secundaria a radioterapia retroperitoneal. Materiales y métodos: Análisis retrospectivo de las fichas clínicas de los pacientes tratados en nuestro centro por insuficiencia mesentérica crónica posterior a radioterapia del territorio para-aórtico entre 1993 y 2011. Resultados: Un total de 4 pacientes de sexo masculino fueron identificados. Edad promedio: 49 +/- 12 años (rango 39-65). Todos presentaron los síntomas clásicos de insuficiencia mesentérica caracterizados por dolor abdominal postprandial y baja de peso. Uno de ellos además tenía episodios repetidos de diarrea. La revascularización mesentérica se obtuvo mediante cirugía abierta o endovascular con excelentes resultados a corto y largo plazo con un seguimiento promedio de 9,3 años (rango 2-20). Discusión: El curso acelerado de la aterosclerosis posterior a radioterapia se ha descrito en múltiples territorios vasculares. Síntomas de insuficiencia mesentérica crónica pueden ser malinterpretados en estos pacientes debido a su similitud con los síntomas observados en la ileitis actínica. Un diagnóstico y tratamiento oportuno son críticos para evitar complicaciones mayores y deterioro de calidad de vida de estos pacientes. Conclusión: La insuficiencia mesentérica crónica inducida por radioterapia es una condición infrecuente. El manejo con cirugía abierta o endovascular son seguras y otorgan resolución sintomática a largo plazo.

A Novel Approach for the Treatment of Radiation-Induced Hemorrhagic Cystitis with the GreenLightTM XPS Laser.

INTRODUCTION: The treatment of pelvic malignancies with radiotherapy can develop severe sequelae, especially radiation-induced hemorrhagic cystitis. It is a progressive disease that can lead to the need for blood transfusion, hospitalizations, and surgical interventions. This tends to affect the quality of life of these patients, and management can at times be difficult. We have evaluated the GreenLight Xcelerated Performance System (XPS) with TruCoag, although primarily used for management of benign prostatic hypertrophy (BPH), for the treatment of radiation-induced hemorrhagic cystitis. MATERIALS AND METHODS: After International Review Board (IRB) approval, a retrospectivechart review was performed in addition to a literature search. A series of four male patients, mean age of 81 years, with radiation-induced hemorrhagic cystitis secondary to radiotherapy for pelvic malignancies (3 prostate cancer, 1 rectal cancer) were successfully treated with the GreenLight laser after unsuccessful treatment with current therapies described in the literature. RESULTS: All four patients treated with the GreenLight laser had resolution of their hematuria after one treatment and were discharge from the hospital with clear urine. CONCLUSION: The GreenLight XPS laser shows promising results for the treatment of patients with radiation-induced hemorrhagic cystitis, and deserves further evaluation and validation, especially since there is limited data available in the literature regarding the use of this technology for the treatment of this devastating condition.

A Novel Approach for the Treatment of Radiation-Induced Hemorrhagic Cystitis with the GreenLight™ XPS Laser

The treatment of pelvic malignancies with radiotherapy can develop severe sequelae, especially radiation-induced hemorrhagic cystitis. It is a progressive disease that can lead to the need for blood transfusion, hospitalizations, and surgical interventions. This tends to affect the quality of life of these patients, and management can at times be difficult. We have evaluated the GreenLight Xcelerated Performance System (XPS) with TruCoag, although primarily used for management of benign prostatic hypertrophy (BPH), for the treatment of radiation-induced hemorrhagic cystitis.

Severe mitral regurgitation after radiotherapy.

We present the case of a 69-year-old patient with a history of gynecological neoplasia and a pulmonary metastasis, who in 1996 underwent chemotherapy and mediastinal radiotherapy followed by cancer remission. Ten years later she presented with heart failure and her Doppler echocardiogram showed severe mitral regurgitation with pulmonary hypertension. In 2011, she underwent a mitral valve replacement with a biological prosthesis and the pathology exam revealed valve damage consistent with radiotherapy-induced changes. This unusual mechanism of mitral regurgitation can be demonstrated clearly by echocardiography and should be disseminated among cardiology physicians and in patients who have survived for long periods after radiotherapy, it is important to remember that cardiac complications may indeed occur, and the treating physician is responsible for detecting them.

Tratamento da úlcera escleral pós-cirurgia de pterígio e betaterapia por enxerto de esclera autóloga de espessura parcial / Partial thickness autologus scleral graft for treating scleral ulcers following pterygium excision and betatherapy

OBJETIVO: Avaliação dos resultados da utilização de enxerto de espessura parcial de esclera autóloga para o tratamento das úlceras esclerais profundas, como complicação tardia da exérese de pterígio associada à betaterapia. MÉTODOS: Foram tratados doze olhos de doze pacientes, nove femininos e três masculinos, com idade variando entre 48 e 82 anos, média 65,2 anos. RESULTADOS: Houve boa integração do enxerto em todos os casos, com resultado funcional e cosmético favorável e sem complicações. CONCLUSÃO: Várias técnicas de enxertia tem sido propostas para o tratamento da úlcera escleral: esclera e dura-máter homólogas, derme, cartilagem auricular e periósteo autólogos. No entanto, o procedimento com esclera autóloga apresenta reais vantagens em relaçâo aos enxertos empregados anteriormente. Não há referências na literatura quanto ao emprego de enxerto de esclera autóloga de espessura parcial para o tratamento da úlcera escleral.

OBJETICVE: The authors describes a surgical technique that utilizes autologus delaminated scleral graft for the management of deep scleral ulcers. METHODS: In this technique that were perfomed in 12 eyes of 12 patients, 9 female, 3 male, age from 48 to 82 years, mean age 65.2 years. RESULTS: Occurred good integration of the grafting in all cases without any complications. CONCLUSION: Many techniques have been proposed for the management of scleral ulcers: sclera and dura-mater, autologus derme, auricular cartilage and autologus periosteum.There is no reference in relation to autologus scleral grafting with partial thickness for the treatment of scleral ulcers, as proposed in this study.

Treatment of left main coronary artery lesion after late thoracic radiotherapy.

Prevention of late cardiovascular complications after radiation therapy (RT) for treatment of a malignant tumor is challenging. We report the case of a young male patient with Hodgkin's lymphoma treated with RT, who developed ischemic heart disease during follow-up, although he had no cardiovascular risk factors. We conclude that patients undergoing RT who experience chest pain should be fully investigated for coronary artery disease.

Tratamento de lesão de tronco da artéria coronária esquerda após radioterapia do tórax / Treatment of left main coronary artery lesion after late thoracic radiotherapy

A prevenção de complicações cardiovasculares tardias após radioterapia (RT) para tratamento de um tumor maligno é um desafio. Relatamos o caso de um jovem paciente com linfoma de Hodgkin submetido a tratamento com RT que desenvolveu doença cardíaca isquêmica no seguimento, embora não apresentasse fatores de risco cardiovasculares. Concluímos que pacientes submetidos a RT que apresentam dor torácica deveriam ser criteriosamente avaliados em relação à doença arterial coronariana.

Prevention of late cardiovascular complications after radiation therapy (RT) for treatment of a malignant tumor is challenging. We report the case of a young male patient with Hodgkin's lymphoma treated with RT, who developed ischemic heart disease during follow-up, although he had no cardiovascular risk factors. We conclude that patients undergoing RT who experience chest pain should be fully investigated for coronary artery disease.

Comparative study of bipolar eletrocoagulation versus argon plasma coagulation for rectal bleeding due to chronic radiation coloproctopathy.

BACKGROUND AND STUDY AIM: Chronic radiation coloproctopathy (CRCP) is a well-recognized complication of radiotherapy, with rectal bleeding the most common presentation. It is frequently refractory to conservative management, but the optimal endoscopic treatment of bleeding secondary to CRCP is still controversial. The efficacy and safety of bipolar eletrocoagulation (BEC) and argon plasma coagulation (APC) in the management of bleeding from CRCP were evaluated and compared. PATIENTS AND METHODS: 30 patients (mean age 67.4 years) with active and chronic bleeding from telangiectasias, were randomly allocated to BEC or APC and stratified by severity of CRCP according to clinical severity and endoscopic findings (Saunders score). Success was defined as eradication of all telangiectasias, and therapeutic failure as need for more than seven sessions or for other treatment. Complications were categorized as minor (e.g. fever, anal or abdominal pain) or major (hemorrhagic). RESULTS: Both treatments were equally effective for the treatment of CRCP rectal bleeding. Only one failure was observed in each group (P = 1.000). There was no significant difference between the two groups regarding number of sessions, minor or major complications, or relapse. However, overall complication rate was significantly higher in the BEC group (P = 0.003). CONCLUSIONS: BEC and APC are both effective for the therapy of bleeding telangiectasias from CRCP. There are probably no major differences between them. Although APC seemed safer than BEC in this investigation, further studies, involving a much larger population, are needed to assess the complication rates and determine the best management option.

The incidence of bacteraemia after argon plasma coagulation in patients with chronic radiation proctocolitis.

AIM: Argon plasma coagulation (APC) is considered a safe treatment for haemorrhagic chronic radiation proctocolitis (CRPC), but bacteraemia is a rare complication. The study aimed to evaluate the frequency of bacteraemia after APC. METHOD: A prospective study of 21 patients who underwent APC (30 procedures) for CRPC was carried out. Blood cultures (Bactec(®) ) were obtained before and 30 min after the procedure (60 samples total). Patients were monitored for 48 h after the procedure to detect signs of infection. RESULTS: None of the 21 patients had fever or any sign suggestive of infection after any of the 30 sessions. All baseline blood cultures were negative and two (7%) of the 30-min blood cultures were positive (Staphylococcus hominis n = 1; Streptococcus bovis and Rhodotorula sp n = 1). The first was likely to be a contaminant and the second patient had no evidence of any other colonic disease (neoplasia or polyps) beside CRPC. CONCLUSION: APC is a low-risk procedure regarding bacteraemia and does not warrant prophylactic antibiotic administration.

New method of tunnelling for omental transposition in the treatment of a complex radionecrotic groin ulcer.

Omental transposition is often used for reconstruction of soft tissue in the groin. However, the potential for incisional hernia is a relative contraindication. We report the cure of a groin ulcer with omental transposition using a new method of tunnelling to avoid herniation.

Late gastrointestinal complications after pelvic radiotherapy: radiation enteritis.

INTRODUCTION: Radiation enteritis is a complication of radiation therapy for pelvic tumours. It appears after a variable period of time and is often progressive. MATERIAL AND METHODS: We analyse our experience of 77 cases (52 females and 25 males) diagnosed with radiation enteritis or proctitis between 1986 and 2006. RESULTS: The most frequent location of radiation injury is ileum (55 patients, 71%), followed by rectum (22 patients, 28%). Twenty-eight patients (36%) were medically managed and 49 (64%) required surgical treatment. In 41 (53%) of the patients the affected region was resected, in 5 (7%) a by-pass was performed and in 3 (4%) a terminal colostomy. Surgical mortality was 4% (3 cases) and the complication rate 9% (7 cases). Twelve patients (16%) presented recurrence of radiation-related illness. Excluding those cases deceased because of tumoral progression, 5-year survival rate was 90% and 10-year survival rate 83%. CONCLUSION: Radiation enteritis must be initially conservatively managed, but in those cases without response, surgery is indicated. Surgical treatment should not be delayed fearing postoperative complications, which are more susceptible to appear in deteriorated patients. If technically possible, the affected region should be resected, because complications may appear later at this damaged location.

Dorsal root entry zone lesions for treatment of pain-related to radiation-induced plexopathy.

STUDY DESIGN: Case series. OBJECTIVE: Presentation of results of dorsal root entry zone lesions in 10 patients suffering from severe neuropathic pain due to brachial plexopathy or radiation-induced trigeminal neuropathy. SUMMARY OF BACKGROUND DATA: Radiation-induced neuropathy is an uncommon but serious complication of radiotherapy. It may cause delayed motor and sensitive impairment associated with severe treatment-resistant pain. Various therapeutic approaches have been reported aimed at controlling radiation-induced neuropathy-pain, demonstrating poor outcomes. METHODS: Eight patients with plexopathy underwent dorsal root entry zone lesion in the cervical spinal cord, while 2 other subjects received stereotactic trigeminal nucleotractotomy. Subjects were followed prospectively before and after brachial dorsal root entry zone or trigeminal caudal operations (range 0.5-36 months). RESULTS: All patients experienced improvement in pain conditions. A total of 8 patients reported full pain relief (visual analog scale = 0) by the end of the follow-up period. The remaining patients had partial control of pain. One patient required reoperation to achieve optimal pain relief. Both patients who underwent trigeminal nucleotractotomy had transient ataxia in the ipsilateral upper limb. One of the patients treated by dorsal root entry zone lesion had minor aggravation of weakness of the ipsilateral lower limb. CONCLUSION: The present results suggest that the trigeminal nucleotractotomy and dorsal root entry zone lesions in cervical spinal cord are an effective procedure for the treatment of pain associated with actinic peripheral neuropathy.

Complex ulcers due to radionecrosis - pathophysiology, diagnosis and treatment

The authors present a study on the pathophysiology of complex wounds induced by radiotherapy, describing their clinical aspects and histopathological findings.They go on to present six cases in which the lesion developed, and the clinical and surgical treatment established.

[Bipolar electrocoagulation in patients with persistent hemorrhage secondary to second degree postradiation proctopathy]. / Electrocoagulación bipolar en pacientes con hemorragia persistente por proctopatía posradiación grado II.

OBJECTIVE: Our objective was to evaluate response to bipolar electrocoagulation (BICAP) in patients with persistent rectorragia (PR) secondary to PRP (post-radiation proctitis) degree II (telangiectasias). MATERIAL AND METHODS: We had 64 cases prospective and conducted study cohort of 257 patients, with cervicouterine cancer, radiated, PRP degree II, and PR. DESIGN: We conducted prospective, cross-sectional and descriptive study. Patients were divided in three groups: (group 1), with hemodynamical instability; (group 2) with chronic anemia, and (group 3), without data of chronic anemia (Table 1). Clinical evaluation was carried out before and after the intervention (BICAP). BICAP of radial way at level of telangiectasias was applied, of sigmoides up to 2 cm of anal margin. Three sessions were average. RESULTS: A total of 55 patients had PR radiation dose average, with 49.85 Gy. Time average of appearance of rectorragia was 9 months. GROUP 1: A total of 21 patients, age 51.2 years average). Previous to BICAP, week by frequency of rectorragia was 2.23 (average). With hemoglobin (Hb) and hematocrit (Ht) of 7.1 g (average) and 24.4%, respectively (average). A total of 18 patients (85.7%) required hemotransfusion. Average hospital stay was 1.3 days. Cardiac frequency, arterial, blood and hemoglobin pressure, and hematocrit obtained later improvement to intervention with BICAP was statistically significant (p > 0.0001). Patients did not require additional blood transfusions. GROUP 2: A total of 18 patients with age average 56 years (average). Previous to BICAP they had weekly rectorragia of 2.16 (average). Hb was 11.4 g and Ht of 35.5% (average). Subsequent to BICAP, 100% patients had controlled hemostasis. The improvement observed with regard to cardiac frequency and blood pressure after application of BICAP did not have statistical significance despite the fact that it was demonstrated to laboratory parameters as well as diminution of weekly episodes of rectorragia if they were statistically significant (p > 0.0001). No blood transfusion was required. GROUP 3: There were 16 patients with average of 57.1 years of age (average). Previous to BICAP they had weekly 1 rectorragia of 2.06, Hb of 13.5 g and Ht of 41.2% (average). Subsequent to BICAP, there was 100% controlled haemostasis. In this group, diminution of weekly episodes of rectorragia, cardiac frequency, and blood pressure did not have statistically significant changes; nevertheless, hemoglobin and hematocrit had a statistically significant increase (p > 0.0001). No blood transfusion was required. CONCLUSIONS: Electrocoagulation (BICAP) is effective in hemostasis of bleeding telangiectasias, stabilizing to the patient, and diminishing recurrence, hospital stay, and blood requirements.

[Laparoscopically created stomas]. / Estomas por laparoscopia.

PURPOSE: The aim of this paper is to present the results obtained in five cases with a stoma created by the laparoscopic approach. PATIENTS AND METHOD: Analysis of five patients who required a stoma as treatment for their diseases or as a complementary management of another medical problem from March 1999 to May 1999. There were three women and two men. Mean age was 43 years (range 20-59 years). Two women had a rectovaginal fistula secondary to radiation proctitis, another woman presented an infected sacral wound, one man suffered a sphincteric lesion that required sphincteroplasty, and the other man had Fournier's gangrene. Surgical technique included the use of two ports, one at the umbilicus for the camera and the other at the site previously chosen for the stoma. RESULTS: Mean surgical time was 30 min (range 20-40 min), transoperative bleeding was meaningless; all stomas began to function during the first 24 h after the procedure. One patient began oral intake on the first day, three patients on the second day, and one patient was intubated in the intensive care unit and for this reason was unable to eat. All stomas achieved the objective sought and there were no complications related to the procedure. CONCLUSIONS: Stoma creation by the laparoscopic approach may offer advantages over the open-surgery technique.