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At least 37 records · Page 2Linked to original sources
PubMed2005

Transanal endoscopic microsurgery: a systematic review.

PURPOSE: The aim of this study was to systematically review the evidence relating to the safety and efficacy of transanal endoscopic microsurgery, a relatively new technique used to locally excise rectal tumors, compared with existing techniques such as anterior resections and abdominoperineal resections or local excisions. METHODS: We conducted a systematic review of comparative studies and case series of transanal endoscopic microsurgery from 1980 to August 2002. RESULTS: Three comparative studies (including one randomized, controlled trial) and 55 case series were included. The first area of study was the safety and efficacy of adenomas. In the randomized, controlled trial, no difference could be detected in the rate of early complications between transanal endoscopic microsurgery (10.3 percent) and direct local excision (17 percent) (relative risk, 0.61; 95 percent confidence interval, 0.29-1.29). Transanal endoscopic microsurgery resulted in less local recurrence (6/98; 6 percent) than direct local excision (20/90; 22 percent) (relative risk, 0.28; 95 percent confidence interval, 0.12-0.66). The 6 percent rate of local recurrence for transanal endoscopic microsurgery in this trial is consistent with the rates found in case series of transanal endoscopic microsurgery (median, 5 percent). The second area of study was the safety and efficacy of carcinomas. In the randomized, controlled trial, no difference could be detected in the rate of complications between transanal endoscopic microsurgery and direct local excision (relative risk for overall early complication rates, 0.56; 95 percent confidence interval, 0.22-1.42). No differences in survival or local recurrence rate between transanal endoscopic microsurgery and anterior resection could be detected in either the randomized, controlled trial (hazard ratio,1.02 for survival) or the nonrandomized, comparative study. There were 2 of 25 (8 percent) transanal endoscopic microsurgery recurrences in the randomized, controlled trial, but no figures were given for recurrence after anterior resection. In the case series, the median local recurrence rate for transanal endoscopic microsurgery was 8.4 percent, ranging from 0 percent to 50 percent. The third comparison was cost of the procedures. Transanal endoscopic microsurgery had both a lower recurrence rate and a lower cost than local excision or anterior resection for adenomas. Although the effectiveness of transanal endoscopic microsurgery could not be established for carcinomas, costs were lower than those for either anterior resection or abdominoperineal resection. CONCLUSIONS: The evidence regarding transanal endoscopic microsurgery is very limited, being largely based on a single relatively small randomized, controlled trial. However, transanal endoscopic microsurgery does appear to result in fewer recurrences than those with direct local excision in adenomas and thus may be a useful procedure for several small niches of patient types--e.g., for large benign lesions of the middle to upper third of the rectum, for T1 low-risk rectal cancers, and for palliative, not curative, use in more advanced tumors.

Anal Canal↗
PubMed2002

Treatment of acoustic neuroma: stereotactic radiosurgery vs. microsurgery.

PURPOSE: Two major treatment options are available for patients with acoustic neuroma, microsurgery and radiosurgery. Our objective was to compare these two treatment modalities with respect to tumor growth control, hearing preservation, development of cranial neuropathies, complications, functional outcome, and patient satisfaction. METHODS AND MATERIALS: To compare radiosurgery with microsurgery, we analyzed 96 patients with unilateral acoustic neuromas treated with Leksell Gamma Knife or microsurgery at Memorial Hermann Hospital, Houston, Texas, between 1993 and 2000. Radiosurgery technique involved multiple isocenter (1-30 single fraction fixed-frame magnetic resonance imaging) image-based treatment with a mean dose prescription of 14.5 Gy. Microsurgery included translabyrinthine, suboccipital, and middle fossa approaches with intraoperative neurophysiologic monitoring. Preoperative patient characteristics were similar except for tumor size and age. Patients undergoing microsurgery were younger with larger tumors compared to the radiosurgical group. The tumors were divided into small <2.0 cm, medium 2.0-3.9 cm, or large >4.0 cm. Median follow-up of the radiosurgical group was longer than the microsurgical group, 48 months (3-84 months) vs. 24 months (3-72 months). RESULTS: There was no statistical significance in tumor growth control between the two groups, 100% in the microsurgery group vs. 91% in the radiosurgery group (p > 0.05). Radiosurgery was more effective than microsurgery in measurable hearing preservation, 57.5% vs. 14.4% (p = 0.01). There was no difference in serviceable hearing preservation between the two groups. Microsurgery was associated with a greater rate of facial and trigeminal neuropathy in the immediate postoperative period and at long-term follow-up. The rate of development of facial neuropathy was significantly higher in the microsurgical group than in the radiosurgical group (35% vs. 0%, p < 0.01 in the immediate postsurgical period and 35.3% vs. 6.1%, p = 0.008, at long-term follow-up). Similarly, the rate of trigeminal neuropathy was significantly higher in the microsurgical group than in the radiosurgical group (17% vs. 0% in the immediate postoperative period, p < 001, and 22% vs. 12.2%, p = 0.009, at long-term follow-up). There was no significant difference in exacerbation of preoperative tinnitus, imbalance, dysarthria, dysphagia, and headache. Patients treated with microsurgery had a longer hospital stay (2-16 days vs. 1-2 days, p < 0.01) and more perioperative complications (47.8% vs. 4.6%, p < 0.01) than did patients treated with radiosurgery. There was no correlation between the microsurgical approach used and postoperative symptoms. There was no difference in the postoperative functioning level, employment, and overall patient satisfaction. There was no correlation between the radiation dose, tumor size, number of isocenters used, and postoperative symptoms in the radiosurgical group. CONCLUSION: Radiosurgical treatment for acoustic neuroma is an alternative to microsurgery. It is associated with a lower rate of immediate and long-term development of facial and trigeminal neuropathy, postoperative complications, and hospital stay. Radiosurgery yields better measurable hearing preservation than microsurgery and equivalent serviceable hearing preservation rate and tumor growth control.

Adolescent↗
PubMed2002

Functional outcome after gamma knife surgery or microsurgery for vestibular schwannomas.

OBJECT: Microsurgical excision is an established treatment for vestibular schwannoma (VS). In 1992 the authors used a patient questionnaire to evaluate the functional outcome and quality of life in a series of 224 consecutive patients. In addition, starting with gamma knife surgery (GKS) in 1992, the authors decided to use the same methodology to evaluate prospectively the results of this modality to compare the two alternatives. METHODS: Among the 500 patients who were included prospectively, the authors only evaluated patients in whom GKS was the primary treatment for unilateral VS. Four years of follow up was available for the first 104 consecutive patients. Statistical analysis of the GKS and microsurgery populations has shown that only a comparison of Stage II and III (according to the Koos classification) was meaningful in terms of group size and preoperative risk factor distribution. Objective results and questionnaire answers from the first 97 consecutive patients were compared with the 110 patients in the microsurgery group who fulfilled the inclusion criteria. Questionnaire answers indicated that 100% of patients who underwent GKS compared with 63% of patients who underwent microsurgery had no new facial motor disturbance. Forty-nine percent of patients who underwent GKS (17% in the microsurgery study) had no ocular symptoms, and 91% of patients treated with GKS (61% in the microsurgery study) had no functional deterioration after treatment. The mean hospitalization stay was 3 days after GKS and 23 days after microsurgery. All the patients who underwent GKS who had been employed, except one, had kept the same professional activity (56% in the microsurgery study). The mean time away from work was 7 days for GKS (130 days in the microsurgery study). Among patients whose preoperative hearing level was Class 1 according to the Gardner and Robertson scale, 70% preserved functional hearing after GKS (Class 1 or 2) compared with only 37.5% in the microsurgery group. CONCLUSIONS: Functional side effects happen during the first 2 years after radiosurgery. Findings after 4 years of follow up indicated that GKS provided better functional outcomes than microsurgery in this patient series.

Adolescent↗
PubMed2005

Relative roles of microsurgery and stereotactic radiosurgery for the treatment of patients with cranial meningiomas: a single-surgeon 4-year integrated experience with both modalities.

OBJECT: The authors sought to assess the respective roles of microsurgery and gamma knife surgery (GKS) in the treatment of patients with meningiomas. METHODS: The authors culled from a 4-year prospective database data on 74 cases of meningiomas. Thirty-eight were treated with GKS and 35 with microsurgery. Simpson Grade 1 or 2 resection was achieved in 86.1 % of patients who underwent microsurgery. Patients who underwent GKS received a mean margin dose of 16.4 Gy (range 14-20 Gy). The mean tumor coverage was 94.7%, and the mean conformity index was 1.76. Significant differences between the two treatment groups (GKS compared with microsurgery) included age (mean 60 compared with 50.7 years), volume (mean 7.85 cm3 compared with 44.4 cm3), treatment history (55.3% compared with 14.3%), and tumor location (cavernous sinus/petroclival, 14 compared with three). The median follow up was 21.5 months (range 1.5-50 months). In patients with benign meningiomas GKS tumor control was 96.8% with one recurrence at the margin. The recurrence rate was zero of 27 for Simpson Grade 1 or 2 resection and three of four for higher grades in those patients who underwent microsurgery. There was no procedure-related mortality or permanent major neurological morbidity. The mean Karnofsky Performance Scale score was maintained for both forms of treatment. Symptoms improved in 48.4% of patients undergoing microsurgery and 16.7% of those who underwent GKS. Transient and permanent cranial nerve morbidity was 7.9 compared with 2.9%, and 5.3 compared with 8.5% for GKS and microsurgery, respectively. In a patient satisfaction survey 93.1% of microsurgery patients and 91.2% of GKS patients were highly satisfied. CONCLUSIONS: Both GKS and microsurgery serve important roles in the overall management of patients with meningiomas. Both are safe and effective and provide high degrees of satisfaction when used for differentially selected patients.

Adolescent↗
PubMed2000

Transanal endoscopic microsurgery: experience with 75 rectal neoplasms.

PURPOSE: The aim of this study was to describe a single institution's experience with transanal endoscopic microsurgery in patients with benign and malignant rectal tumors. PATIENTS: Between January 1992 and April 1998, 75 patients with a mean follow up of 38 months, underwent transanal endoscopic microsurgery excision of benign (46) or malignant (29) rectal tumors, located 3 to 18 cm from the dentate line. RESULTS: A total of 3 of 46 (6.5 percent) patients with benign tumors underwent conversion to radical surgery owing to tumor size. During the follow-up period, benign tumor recurrence was observed in four (9 percent) patients, three of whom were managed by repeat transanal endoscopic microsurgery, whereas one required radical surgery. Histologic staging of malignant tumors was T1 (10), T2 (10), and T3 (9). Seven patients with either inadequate resection margins or T3 tumors were complimented with radical surgery. Of the remaining 22 patients, 11 received adjuvant radiation therapy whereas 11 had no further treatment. Four (18 percent) had recurrent disease, which was managed by repeat transanal endoscopic microsurgery in two, radical surgery in one, and laser ablation in one. No cancer-related deaths were observed during the follow-up period. There was one operative mortality in a cardiac-crippled patient. Postoperative complications were mainly of a minor character and included fever, urinary retention, and bleeding; none of which required reintervention. Rectourethral fistula developed in one patient who underwent repeat transanal endoscopic microsurgery excision for a T3 malignancy. Fecal soiling was transient in three patients and persisted in two. CONCLUSION: Transanal endoscopic microsurgery excision is a safe and precise technique that is well tolerated even in high operative risk patients. Transanal endoscopic microsurgery may become a procedure of choice for benign rectal tumors and selected early malignant neoplasms.

Adenocarcinoma↗
PubMed1994

Surgical resection of third ventricle colloid cysts. Preliminary results comparing transcallosal microsurgery with endoscopy.

It is still not determined which is the best surgical option for third ventricle colloid cysts. Since 1990, the authors have used a steerable fiberscope to remove colloid cysts in seven patients and have performed microsurgery via a transcallosal approach in eight patients. The two techniques were compared for operating time, length of hospital stay, incidence of complications, recurrence, and hydrocephalus, and days spent recuperating before return to work to determine if endoscopic removal of colloid cysts is a safe and effective alternative to microsurgery. Statistical analysis was adjusted for age, sex, and presenting symptoms. Microsurgical cases averaged 206 minutes of operating time whereas endoscopic cases averaged 127 minutes (p = 0.01). For combined days spent in the intensive care unit and on the ward, the patients averaged 9.5 days after microsurgery and 4 days after endoscopy (p = 0.05). Postoperative complications occurred in five of eight patients after microsurgery and in one of seven patients after endoscopy (p = 0.09); complications were transient and primarily related to short-term memory loss. In all patients, preoperative symptoms resolved and the cysts have not recurred. Postoperatively, one patient required a ventriculoperitoneal shunt after microsurgery but all patients were shunt-independent after endoscopy. Patients returned to work an average of 59 days after discharge following microsurgery compared with an average of 26 days after endoscopy (p = 0.05). Compared with transcallosal microsurgery for the removal of colloid cysts, these preliminary results show that a steerable endoscope reduced operating time and that patients spent fewer days in the hospital and returned to work sooner after endoscopy.

Adolescent↗
PubMed2003

Loupes-only microsurgery.

Standard magnification in microsurgery is accomplished with the operating microscope. Loupes are perceived by the microsurgical community as technically less safe. However, after several years of microscope-only microsurgery, most of our microvascular procedures are performed under loupes 3.5-4x. Considering our results using loupes-only microsurgery, which are comparable with those obtained when using the microscope, we suggest that loupe-aided microsurgery might represent a natural progression for the experienced microsurgeon. Microsurgical skills and experience outweigh the importance of the magnification factor. While the microscope is mandatory for replantations distal to the palmary arch, microneurosurgery, and supramicrosurgery, loupes should be used in so-called "macro-microsurgery." One may include in this category replantations down to the palmar arch and free flaps with vessels more than 1.5 mm, such as the latissimus, serratus, (para)scapular, fibula, radial forearm, rectus abdominis, dorsalis pedis, omentum, and jejunum. Before starting loupes-only microsurgery, intensive training under the microscope is crucial. Less magnification does not mean less quality.

Adolescent↗
PubMed1990

A survey of microsurgery training in the United States.

The increasing use of clinical and experimental microsurgical techniques has created a need for standardized, high-quality training programs in microsurgery. Toward this end, we conducted a study of the microsurgery instruction available in the United States. The data were collected from responses to surveys mailed to 55 microsurgery training centers across the country. Survey questions asked for a general characterization of each training program and its participants and for a specific description of course content. The results indicated that, even though training programs differed considerably, there were common elements. Total course length ranged from less than 40 hours to 80 hours, with a range of 32-40 hours devoted to basic microsurgery techniques. Forty percent of instructional programs were not certified for continuing medical education (CME) credit. Half of all reported trainees were residents in training. The basic microsurgery techniques common to most programs included instruction in microvascular end-to-end and end-to-side anastomoses of femoral arteries and veins in rats. Instruction in peripheral nerve repair was not offered. We conclude that, although there are merits to a diverse curriculum, it is time to institute a minimum level of standardized basic microsurgery training.

Curriculum↗
PubMed2006

Guidelines for the optimization of microsurgery in atherosclerotic patients.

We review the pathogenesis of atherosclerosis and the issues that must be taken into consideration when performing microsurgery in atherosclerotic patients. Atherosclerosis is a systemic disease, and may affect the success of microsurgery. Atherosclerotic patients have a tendency toward thrombosis, because the nature of the arteries is changed. Such patients are usually old and have additional medical problems. To increase the success rate of microsurgery in atherosclerotic patients, special precautions should be considered. Patients must be evaluated properly for the suitability of microsurgery. The microsurgical technique requires a meticulous approach, and various technical tricks can be used to avoid thrombosis. Recipient-vessel selection, anastomotic technique, and the use of vein grafts are all important issues. Prophylactic anticoagulation is recommended in severely atherosclerotic patients. Close monitoring of the patient and flap is necessary after the operation, as with routine microvascular free-tissue transfers. We conclude that atherosclerosis is not a contraindication for microsurgery. If the microsurgeon knows how to deal with the difficulties in atherosclerotic patients, microsurgery can be performed safely.

Anticoagulants↗
PubMed2003

Microsurgery in children for creation of arteriovenous fistulas in renal and non-renal diseases.

Microsurgery for angioaccess in children includes the use of a surgical microscope, microsurgical instruments, prophylactic tourniquet-induced hemostasis and no-touch surgery. In the recent publications concerning angioaccess in children, the percentages of grafts versus arteriovenous fistulas (AVF) varied from 54 to 76% without microsurgery, and from 0 to 14% with microsurgery. Similarly, the percentages of AVF which failed to mature varied from 30 to 33% without microsurgery, and from 5 to 10% with microsurgery. In a personal series of 380 children receiving hemodialysis, 434 microsurgical angioaccesses were created, 78% being distal autologous AVF. Eighty-five percent of the distal radial-cephalic AVF were patent after 2 years and 60% after 4 years. These results of microsurgically created AVF are probably responsible, at least in part, for the high percentage of end-stage renal disease (ESRD) children treated by hemodialysis on 1 February 2003 in Paris using an autologous fistula (70% of 33 children), while only 24% were hemodialyzed via a central venous catheter and 6% were on peritoneal dialysis. This compares favorably with the annual publication of the North American Pediatric Renal Transplant Cooperative Study in 1996 reporting that two-thirds of the dialysis population were maintained on peritoneal dialysis and that the majority of hemodialysis accesses were external percutaneous catheters. Microsurgical AVF are also created successfully in non-ESRD children requiring frequent blood access for various chronic diseases. It has been possible to create a distal AVF in 68% of cases and the long-term patency rate was just below 60% after 10 years. Microsurgery is mandatory for creation of arteriovenous fistulas, the best form of angioaccess for children treated by hemodialysis or requiring repeated access to blood in various non-renal diseases.

Age Factors↗
PubMed1999

Handgrip-detachable soft tissue retractor for microsurgery: technical note

OBJECTIVE: We developed a modified soft tissue retractor for preventing problems that occur outside of the microscopic view field during microsurgery. INSTRUMENTATION AND OPERATIVE PROCEDURE: The characteristics of the modified soft tissue retractor are detachable handgrips, which can be easily released and fixed with the manipulation of an equipped button, and a new lock adjuster, which changes its form and position so that it is withdrawn into a corner space between both arms in proportion to the open angle of the arms. The retractor is used with handgrips, as in the conventional method, until the microsurgery begins. When microsurgery begins, the handgrips are released. We have used this retractor in 45 microsurgeries and 42 burr-hole surgeries, such as stereotactic or endoscopic operations. RESULTS: The detachable handgrips can resolve problems caused by handgrips and a lock lever in conventional retractors, such as interference with the free movement of the microsurgical operator's hands, restriction of operative approach angle or direction of the light axis of a microscope, and catching or tangling of instrument cords and thin thread. In addition to microsurgery, it was beneficial in burr-hole surgeries, because operators can manipulate instruments, such as a stereotactic arm or an endoscope, without having to handle the retractor handgrips. CONCLUSION: Our modified soft tissue retractor is very useful for performing steady and safe microsurgery.

Journal Article↗
PubMed1982

Microsurgery of the fallopian tube with the carbon dioxide laser: eighty-two cases with follow-up.

In 1974 the carbon dioxide laser was adapted to the operating microscope for reconstructive pelvic surgery and the first 15 cases of laser tubal microsurgery were performed. The instrumentation and techniques were refined. A protocol was designed to test the efficacy of this surgical modality, and a new study was begun in 1980. Complete documentation of laparoscopic findings, surgical techniques, and pre- and postoperative hysterosalpingograms are kept on videotapes. Detailed descriptions of the surgical techniques employed in these cases are presented in this paper. Preliminary results are reported in terms of patency and pregnancy rates experienced to date. Eighty-two women experienced fertility enhancement laser microsurgery at the Reproductive Biology Center at F. Edward Hebert Memorial Hospital in New Orleans. Bilateral patency or patency of the only existing fallopian tube was demonstrated postoperatively in 93% of the cases. Eliminating the women practicing contraception, those on postoperative Danazol therapy for endometriosis, male factors, or other reasons for women or their partners being not at risk, conception has occurred 21 times among 20 of 42 patients at risk. Many of the women were referral cases who had had unsuccessful microsurgery or were rejected for microsurgery by their physicians due to extensive disease. These results indicate that the carbon dioxide surgical laser may be a useful adjunct in reconstructive microsurgery for fertility dysfunction.

Adult↗
PubMed2000

Defining the role of stereotactic radiosurgery versus microsurgery in the treatment of single brain metastases.

Stereotactic radiosurgery (RS) and surgery have proved to be effective treatment modalities for brain metastasis. We followed 133 patients whose treatment for intracranial disease was either RS or a single surgical resection at the University of Vienna from August 1992 through October 1996. All patients who received additional Whole Brain Radiotherapy were included. This was a retrospective, case-control study comparing these treatment modalities. Sixty-seven patients were treated by RS and 66 patients were treated by microsurgery. The median size of the treated lesions for RS patients was 7800 mm3, and 12500 mm3 for microsurgery patients, respectively. The median dose delivered to the tumour margin for RS patients was 17 gray. The median survival for patients after RS was 12 months, and 9 months for patients after microsurgery. This difference was not statistically significant (p = 0.19). Comparison of local tumour control, defined as absence of regrowth of a treated lesion, showed that tumours following RS had a preferred local control rate (p < 0.05). Univariate and multivariate analysis showed that this fact was due to a greater response rate of "radioresistant" metastasis to RS (p < 0.005). Postradiosurgical complications included the onset of peritumoural oedema (n = 5) and radiation necrosis (n = 1). Two patients after microsurgery experienced local wound infection. One postoperative death occurred due to pulmonary embolism in this group. On the basis of our data we conclude that RS and microsurgery combined with Whole Brain Radiotherapy are comparable modalities in treating single brain metastasis. Concerning morbidity and local tumour control, in particular in cases of "radioresistant" primary tumours, RS is superior. Therefore we advocate RS except for cases of large tumours (> 3 cm in maximum diameter) and for those with mass effect.

Brain Neoplasms↗