Correlation of narrow-band imaging findings using the Ni and European Laryngeal Society classification systems during in-office flexible laryngoscopy with histopathology.

OBJECTIVE: This study used the European Laryngeal Society (2016) and Ni (2011 and 2019) classifications for narrow-band imaging and correlated the findings with histopathology. METHODS: Retrospective analysis was conducted by retrieving data of patients who underwent micro-laryngoscopy for suspicious glottic lesions. The narrow-band imaging findings were classified using both classification systems. Retrieved histopathology report findings were correlated with narrow-band imaging data. RESULTS: Using the European Laryngeal Society and Ni classifications, 37 (69.8 per cent) and 35 (66 per cent) patients, respectively, were suspected to have malignant lesions. Upon histopathology, 37 (69.8 per cent) lesions were malignant. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy using the European Laryngeal Society classification were 91.9 per cent, 81.3 per cent, 91.9 per cent, 81.3 per cent and 88.7 per cent, and using the Ni classification were 91.9 per cent, 93.8 per cent, 97.1 per cent, 83.3 per cent and 92.5 per cent, respectively. CONCLUSION: The Ni classification had better specificity and accuracy. The European Laryngeal Society classification is simple to use and may serve as a useful screening tool. For optimum results, both European Laryngeal Society and Ni classifications may be used together, in that order.

Corpos riziformes em localização inusitada / Unexpected riziform bodies

Corpos riziformes são estruturas que podem ser encontradas no líquido sinovial ou aderidas à sinóvia, que se assemelham macroscopicamente a grãos de arroz. São frequentes em pacientes com artrite reumatoide e decorrem de resposta inflamatória crônica. São encontrados em 25% dos procedimentos de aspiração ou cirurgias das articulações. Porém, ainda não existem publicações relatando sua presença no subcutâneo. Relatamos, pela primeira vez, a ocorrência de corpos riziformes no subcutâneo da região palmar em paciente com artrite reumatoide, confirmados por exames ultrassonográfico e anatomopatológico, tratados com sucesso com drenagem cirúrgica, sem recidivas após dois anos de seguimento

Riziform bodies are structures in the synovial fluid or attached to the synovium, which macroscopically resemble rice grains. They are common in patients with rheumatoid arthritis and result from a chronic inflammation. They are found in 25% of aspiration procedures or joint surgery. However, there are still no publications reporting its presence in the subcutaneous tissue. We report for the first time the occurrence of riziform bodies in the subcutaneous plane of the palmar region in a patient with rheumatoid arthritis, confirmed by sonographic and anatomopathological examination, successfully treated with surgical drainage, without recurrences after two years of follow-up.

Recording natural head position using an accelerometer and reconstruction from computed tomographic images.

OBJECTIVES: The concept of natural head position (NHP) was first introduced by Broca in 1862, and was described as a person's stable physiologic position "when a man is standing and his visual axis is horizontal." NHP has been used routinely for clinical examination; however, a patient's head position is random during cone-beam computed tomography (CBCT) acquisition. To solve this problem, we developed an accelerometer to record patients' NHP and reproduce them for CBCT images. In this study, we also tested the accuracy and reproducibility of our accelerometer. MATERIALS AND METHODS: A total of 15 subjects participated in this study. We invented an accelerometer that measured acceleration on three axes and that could record roll and pitch calculations. Recorded roll and pitch data for each NHP were applied to a reoriented virtual image using three-dimensional (3D) imaging software. The data between the 3D models and the clinical photos were statistically analyzed side by side. Paired t-tests were used to statistically analyze the measurements. RESULTS: The average difference in the angles between the clinical photograph and the 3D model was 0.04° for roll and 0.29° for pitch. The paired ttests for the roll data (P=0.781) and the pitch data (P=0.169) showed no significant difference between the clinical photographs and the 3D model (P>0.05). CONCLUSION: By overcoming the limitations of previous NHP-recording techniques, our new method can accurately record patient NHP in a time-efficient manner. Our method can also accurately transfer the NHP to a 3D virtual model.

Recording natural head position using an accelerometer and reconstruction from computed tomographic images

OBJECTIVES: The concept of natural head position (NHP) was first introduced by Broca in 1862, and was described as a person's stable physiologic position “when a man is standing and his visual axis is horizontal.” NHP has been used routinely for clinical examination; however, a patient's head position is random during cone-beam computed tomography (CBCT) acquisition. To solve this problem, we developed an accelerometer to record patients' NHP and reproduce them for CBCT images. In this study, we also tested the accuracy and reproducibility of our accelerometer. MATERIALS AND METHODS: A total of 15 subjects participated in this study. We invented an accelerometer that measured acceleration on three axes and that could record roll and pitch calculations. Recorded roll and pitch data for each NHP were applied to a reoriented virtual image using three-dimensional (3D) imaging software. The data between the 3D models and the clinical photos were statistically analyzed side by side. Paired t-tests were used to statistically analyze the measurements. RESULTS: The average difference in the angles between the clinical photograph and the 3D model was 0.04° for roll and 0.29° for pitch. The paired ttests for the roll data (P=0.781) and the pitch data (P=0.169) showed no significant difference between the clinical photographs and the 3D model (P>0.05). CONCLUSION: By overcoming the limitations of previous NHP-recording techniques, our new method can accurately record patient NHP in a time-efficient manner. Our method can also accurately transfer the NHP to a 3D virtual model.

Nerve-sparing techniques and results in robot-assisted radical prostatectomy.

Nerve-sparing techniques in robot-assisted radical prostatectomy (RARP) have advanced with the developments defining the prostate anatomy and robotic surgery in recent years. In this review we discussed the surgical anatomy, current nerve-sparing techniques and results of these operations. It is important to define the right and key anatomic landmarks for nerve-sparing in RARP which can demonstrate individual variations. The patients' risk assessment before the operation and intraoperative anatomic variations may affect the nerve-sparing technique, nerve-sparing degree and the approach. There is lack of randomized control trials for different nerve-sparing techniques and approaches in RARP, therefore accurate preoperative and intraoperative assessment of the patient is crucial. Current data shows that, performing the maximum possible nerve-sparing using athermal techniques have better functional outcomes.

Percutaneous Pedicle Screws Positioning by means of the "Scotty Dog" Imaging Monitoring Technique in Spine Surgery: A Case Series / Posicionamento de parafuso pedicular percutâneo por meio do método Scotty Dog de monitoramento de imagem em cirurgia de coluna: uma série de casos

Objectives Vertebrae, when looked at in x-rays with oblique incidence (45°), seem similar in shape to a Scottish Terrier dog. The "Scotty Dog" incidence is commonly used in spinal pain treatments such as radiofrequency and transforaminal blockages for correct insertion of the needle, because it allows complete visualization of the pedicle. The objective is to describe a series of cases of spinal surgery using the "Scotty Dog" monitoring technique and to evaluate safety. Methods In this study, we describe all consecutive patients operated by the same surgeon from August 2011 to August 2012 using the "Scotty Dog" technique of fluoroscopic monitoring. Patients were operated for spondylolisthesis, lumbar canal stenosis, spinal disc herniations, and fractures. All patients underwent computed tomography (CT) after surgery to confirm the correct positioning of screws. Results During the study period, 42 patients with a mean age of 64.5 years underwent operation, most of them for spinal disc herniation correction. In all cases, visualization of the pedicle was possible in all its length and no case of foramen invasion was registered. Surgical time was 98 minutes on average, with no need for transfusion or complications requiring admission to the ICU. There was one case of infection. Conclusions The Scotty Dog technique for imaging monitoring of the spine provides easy visualization of the whole pedicle, allowing a safe screw insertion. In this case series, there was no case of foramen invasion.

Objetivos As vértebras, visualizadas pela incidência oblíqua (45°) nos raios-X, têm o formato de um cão da raça Scottish Terrier. A incidência Scotty Dog é usada em tratamentos de dor na coluna, como radiofrequência e bloqueios transforaminais, para correta inserção da agulha, porque permite completa visualização do pedículo. O objetivo deste trabalho é descrever uma série de casos de cirurgia de coluna usando a técnica de monitoramento Scotty Dog e avaliar segurança. Métodos Todos os pacientes consecutivos operados pelo mesmo cirurgião de agosto de 2011 a agosto de 2012 usando a técnica Scotty Dog de monitoramento fluoroscópico foram descritos. Pacientes foram operados devido a espondilolistese, estenose do canal vertebral, hérnias e fraturas. Todos os pacientes foram submetidos a tomografia computadorizada após a cirurgia para confirmação do correto posicionamento dos parafusos. Resultados No período do estudo, 42 pacientes foramoperados, commédia de idade de 64,5 anos, a maioria para correção de hérnia de disco. Em todos os casos, a visualização do pedículo foi possível emtoda a sua extensão e não foi registrado caso de invasão do forame. O tempo de cirurgia foi de 98 minutos em média, sem necessidade de transfusões ou complicações exigindo internação em unidade de terapia intensiva. Houve um caso de infecção. Conclusões A técnica Scotty Dog de monitoramento por imagem da coluna permite fácil visualização de todo o pedículo e inserção do parafuso com segurança, com nenhum caso de invasão foraminal nesta série de casos.

[Fine-needle aspiration in an extremely late post-traumatic iris cyst]. / Punción-aspiración con aguja fina en quiste iridiano postraumático de aparición muy tardía.

CLINICAL CASE: A 45 year-old woman with unknown ophthalmology history complained of pain, redness and visual acuity (VA) loss in her left eye for the last three weeks. A serous iris cyst with an overlying peripheral corneal leukoma was located in the iris stroma using ultrasonic biomicroscopy. It was assumed that it was secondary to a penetrating trauma from her childhood. The cyst healed and VA improved after fine-needle aspiration and partial posterior synechiolysis. DISCUSSION: Iris inclusion cysts may appear many years after penetrating trauma or surgery. Fine-needle aspiration is a good choice for its diagnosis and treatment.

Transferring innovative freehand SPECT to the operating room: first experiences with sentinel lymph node biopsy in malignant melanoma.

PURPOSE: The purpose of this study was to report on the first experiences with freehand single-photon emission-computed tomography (freehand SPECT) in sentinel lymph node biopsy (SLNB) in patients with malignant melanoma. Freehand SPECT is a novel imaging modality combining gamma probes, surgical navigation systems, and emission tomography algorithms, designed to overcome some of the limitations of conventional gamma probes. METHODS: In this study 20 patients with malignant melanoma underwent conventional planar scintigraphy prior to surgery. In the operating room, the number and location of separable SLNs were detected first by a pre-incisional scan with freehand SPECT to render a 3D-image of the target site and afterwards by a scan with a conventional gamma probe. After SLNB another scan was performed to document the removal of all targeted SLNs. RESULTS: Planar scintigraphy identified 40 SLNs in 26 nodal basins. Pre-incisional freehand SPECT mapped 38 of these nodes as well as one additional node in one patient (95.0% node based sensitivity). The results of freehand SPECT were identical to those of planar scintigraphy in 25 basins, while it missed one basin (96.2% basin based sensitivity). In comparison, the gamma probe failed to detect 7 nodes in 4 basins (82.5% node based sensitivity and 84.6% basin based sensitivity). After resection freehand SPECT detected 9 remaining radioactive spots, two of whichwere resected as they matched the position of SLNs detected on preoperative planar scintigraphy. CONCLUSIONS: Freehand SPECT provides a real-time, intraoperative 3D-image of the radioactive labelled SLNs, facilitating their detection and resection.

Closure or non-closure of peritoneum in cesarean section: outcomes of short-term complications.

BACKGROUND: Cesarean section (CS) is one of the most frequently performed surgical procedures worldwide. The complications following a CS include fever, wound infection, post-operative pain and bleeding which are not usually found in a normal vaginal delivery. Traditionally, suturing of peritoneal layers for CS patients has been done, but in some studies it has been shown that this procedure could be eliminated without affecting the rate of morbidity. OBJECTIVES: The objective of this study was to assess the short-term outcomes of two different cesarean delivery techniques. PATIENTS AND METHODS: A total of 100 cases who underwent CS were randomly assigned equally to either closure of both the visceral and parietal peritoneum or no peritoneum closure. Duration of operation, pain scores, analgesic requirements, alterations in hemoglobin levels and febrile morbidity were assessed accordingly. RESULTS: Pain scores, analgesic requirements assessed at 24 hours and operation duration were significantly lower in the non-closure group as compared to the closure group. Febrile conditions and changes in hemoglobin levels were similar in both groups. CONCLUSIONS: Non-closure of both visceral and the parietal peritoneum when performing a CS produces a significant reduction in pain, fewer analgesic requirements and a shorter operation duration without increasing the febrile morbidity and changes in hemoglobin levels as compared to the standard methods.

O valor da marcação tumoral prévia à quimioterapia neoadjuvante e sua relação com a resposta patológica e o tratamento cirúrgico do carcinoma mamário localmente avançado / The role of tumor marking prior to neoadjuvant chemotherapy and its relationship with pathologic response and surgicaltreatment of locally advanced breast cancer

As pacientes com carcinoma de mama localmente avançado da mama são candidatas à quimioterapianeoadjuvante. A grande maioria delas apresenta resposta parcial ao tratamento, isto é, redução dadimensão do tumor. Entretanto, a taxa de resposta patológica completa é de apenas 24%, mesmo nosesquemas mais efetivos, como na associação de antraciclina com taxano. Um dos benefícios da quimioterapianeoadjuvante é a possibilidade da cirurgia conservadora da mama, e um dos desafios é avaliarcom exatidão o grau de resposta tumoral ao tratamento. A resposta clínica é determinada por meiode exames físicos e de imagem, os quais não são suficientes para predizer com acurácia o tamanho dotumor ou a resposta patológica completa em relação ao exame padrão-ouro, que é o histopatológico dapeça cirúrgica. Além disso, é necessário considerar que após a quimioterapia neoadjuvante pode ocorrerfragmentação do tumor, originando-se lesões residuais multifocais, de difícil detecção aos métodosde imagem. Em estudos sobre a quimioterapia neoadjuvante, observou-se que não há uniformidadeno tipo de exame utilizado para a avaliação clinicopatológica da resposta tumoral; não há descriçãoexata sobre a metodologia utilizada na marcação pré-operatória do tumor, e nem sempre toda a áreatumoral pré-quimioterapia neoadjuvante é ressecada, fato que dificulta a avaliação exata da resposta aeste tipo de quimioterapia. Portanto, resta a dúvida: em quais circunstâncias a cirurgia conservadorada mama após a quimioterapia neoadjuvante está bem indicada? Neste artigo, discute-se as diferentesformas de marcação do tumor, a avaliação da resposta patológica e sua importância, principalmentequando se pretende realizar a cirurgia conservadora no carcinoma de mama localmente avançado.

Patients with locally advanced breast carcinoma are candidates for the neoadjuvant chemotherapy.The majority of them have partial response to treatment, i.e., reduction in tumor size; however, therate of pathological complete response is of only 24%, even with the association of anthracycline and taxane. One benefit of the neoadjuvant chemotherapy is the possibility of breast-conserving surgery, and the challenge is the accurate assessment of the tumor response degree to treatment. Clinical response is determined by physical exam and imaging studies, which are not sufficient to predict accurately the tumor size or the pathological complete response in relation to the golden-standard test, which is the surgical histopathology. Moreover, it is necessary to consider that after the neoadjuvant chemotherapy there may be tumor fragmentation, originating multifocal lesions, which are difficult to be detected by imaging methods. In studies regarding neoadjuvant chemotherapy, there is no uniformity in the type of test used for clinical and pathological assessments of tumor response, and there is no exact description of the methodology used in the preoperative markup of the tumor bed, which is not always resected after the neoadjuvant chemotherapy. This is a fact that hinders the accurate assessment of response to the neoadjuvant chemotherapy. Therefore, the question is: under which circumstances a breast-conserving surgery after neoadjuvant chemotherapy is well indicated? This article has discussed the different ways of tumor marking, the evaluation of pathological response and its importance, especially considering breast-conserving treatment of locally advanced breast carcinoma.

The role of transillumination phleboscopy in the planning of cosmetic operations for varicose veins

Background: The cosmetic treatment of varicose veins is the main activity of most vascular surgeons in Brazil. In order to obtain satisfactory cosmetic results, careful planning of varicose vein operations is necessary. Objective: Marking (or "mapping") the varicose veins with indelible ink is an essential step in planning cosmetic surgeries for lower limb varicose veins. In the present study, the role of transcutaneous phleboscopy (TcPh) in planning varicose vein operations is evaluated. Methods: A series of 100 consecutive patients, all female, were evaluated with TcPH as part of their varicose vein operations planning. A total of 171 limbs with varicose veins (71 bilateral and 29 unilateral) were evaluated. The process of marking the varicose veins followed the same protocol in all cases. Firstly, the varicose veins were marked by inspection and palpation, with the patient standing, using an indelible black ink pen. Secondly, with the patients resting in supine and prone positions, the varicose veins detected with TcPh were marked again with red or blue ink. The marks made by the two methods were then compared. Results: In 41 patients, for a total of 80 limbs (46.8 percent), the marks were altered after use of TcPh. Reasons for such changes were: 1) identification of other varicose veins; 2) identification of reticular veins draining complex telangiectasias; and 3) changes in the position of the marks placed with the patient standing. Conclusions: TcPh has altered the planning of varicose vein surgeries in 46.8 percent of all limbs evaluated, especially when the patients had complex telangiectasias, associated with reticular varicose veins.

Contexto: O tratamento estético de varizes é a principal atividade da maioria dos cirurgiões vasculares do Brasil. Para se obter resultados estéticos satisfatórios, é necessário um planejamento adequado da cirurgia de varizes. Objetivo: A marcação (ou "mapeamento") das varizes com tinta indelével é uma etapa essencial do planejamento das cirurgias de varizes dos membros inferiores com finalidade estética. Neste estudo, é avaliado o papel da fleboscopia por transiluminação na marcação pré-operatória de varizes. Métodos: Uma série de 100 pacientes consecutivas, todas do sexo feminino, foram avaliadas através de fleboscopia por transiluminação, como parte do planejamento de suas operações de varizes. Do total de 171 membros com varizes, 71 pacientes tinham varizes bilaterais e 29 tinham varizes unilaterais. Em todos os casos, a marcação das varizes a serem operadas seguiu o mesmo protocolo. Na primeira etapa, as varizes foram marcadas de forma tradicional, por inspeção e palpação, com as pacientes de pé, usando canetas de tinta indelével de cor preta. Na segunda etapa, as pacientes assumiram a posição de decúbito e as varizes foram re-marcadas, com o auxílio da fleboscopia por transiluminação, com tinta de cor vermelha ou azul. Em seguida, foram comparadas as marcações pelos dois métodos. Resultados: Em 41 pacientes, totalizando 80 membros (46,8 por cento), foram alteradas as marcações depois da fleboscopia por transiluminação. Os motivos para as alterações foram: 1) identificação de novos trajetos varicosos; 2) identificação de veias de drenagem de telangiectasias complexas; e 3) mudanças no trajeto de varizes marcadas da forma tradicional. Conclusões: A fleboscopia por transiluminação alterou o planejamento da cirurgia de varizes em 46,8 por cento dos membros avaliados, especialmente quando as pacientes tinham telangiectasias complexas associadas a varizes reticulares.