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PubMed2004

Blood management for patients with hemoglobin level lower than 130 g/l in total knee arthroplasty.

INTRODUCTION: The risk of requiring allogeneic blood transfusion after total knee arthroplasty has been recently decreased with several methods such as blood donation, blood salvage, and hematinic. For patients with a low baseline hemoglobin level, however, the rate of allogeneic transfusion is still high, and an effective method for avoiding allogeneic blood transfusion has not been established. We introduced intra- and postoperative blood salvage with the Cell Saver for patients with a baseline hemoglobin level lower than 130 g/l and analyzed the frequency of allogeneic blood transfusion. MATERIALS AND METHODS: From 1993 to 1997, 218 consecutive total knee arthroplasties were performed, and 155 knees with baseline hemoglobin lower than 130 g/l were included in this study. Baseline hemoglobin ranged from 62 to 129 g/l, with a mean of 110 g/l. All patients were managed with intra- and postoperative blood salvage with the Cell Saver. Preoperative autologous blood donation and/or use of hematinic was performed for 129 knees (group 1) and was not performed for 26 knees (group 2). There were no significant differences between the two groups with regard to preoperative factors. To examine the role of perioperative factors (age, sex, baseline hemoglobin level, revision procedure, preoperative blood donation, and use of hematinic) in determining the requirements for allogeneic transfusion, backward elimination logistic regression analysis was used. RESULTS: Seven knees (4.5%) required allogeneic transfusion. Group 1 (2.3%) exhibited a lower rate of allogeneic blood transfusion than group 2 (15.4%) (p=0.016). Hemoglobin levels on the day (p=0.016), 1 week (p=0.0001), and 2 weeks (p=0.007) after surgery were lower in group 1 than in group 2. Backward elimination logistic regression analysis showed that preoperative blood donation (p=0.048) and use of hematinic (p=0.040) were significantly associated with a requirement for allogeneic blood transfusion. CONCLUSION: Preoperative blood donation and use of hematinic were associated with a low incidence of allogeneic blood transfusion after total knee arthloplasty with intra- and postoperative blood salvage, even for patients with a baseline hemoglobin level below 130 g/l.

Aged↗

PubMed1994

[Portal vein embolization via a fine needle guided by angio-echography: experimental and clinical study].

This paper introduced a technique of portal vein embolization by injection of ethanol via fine needle under guidance of angio-echography. First introportal ethanol injection were done in 28 dogs to evaluate its embolic efficacy and safety. The result showed if a dose of injected ethanol was chosen properly, expected embolization could be obtained with slight toxicity to hepatic parenchyma and function. For clinical application, selective portal vein puncture was percutaneous transhepatic under echo guidance. Ultrasound angiography by injecting carbon dioxide (CO2) into portal vein was introduced initially. After confirmed that the injected branch was that supplied the tumor and there was no retrograde overflow of portal blood, ethanol was injected at a dose no more than 10ml. Eighteen patients with hepatocellular carcinoma and underlying liver cirrhosis underwent the procedure preoperatively. Of 14 cases who received hepatectomies, portal vein embolization developed in 12. Since the procedure was guided by angio-echography it could be used for indicated cases with satisfactory embolic effect and not harmful to liver. The procedure had advantages of simple manipulation and made selective embolization easier compared to interventional transcatheter portal vein embolization.

Adult↗

PubMed2001

Radical retropubic prostatectomy. Preoperative management.

The morbidity of radical prostatectomy is minimized by identifying men who are at significant cardiovascular risk and excluding them from the procedure. Preoperative management designed to minimize surgical and medical complications and exposure to allogenic blood products increases the benefit-to-risk ratio of radical prostatectomy over other treatment options for localized prostate cancer.

Anesthesia↗

PubMed2000

Orthotopic heart transplantation: standard versus bicaval technique.

We compared orthotopic heart transplantation (HT) by bicaval technique with the standard technique. Between January 1995 and December 1997, 117 patients underwent 118 HTs; 71 patients (15 women and 56 men) had 72 HTs by standard technique and 46 patients (9 women, 37 men) underwent HT using bicaval procedures. Preoperative parameters were similar in both groups; 5 patients who underwent the standard technique and no patients who underwent bicaval procedures required permanent pacemakers (p = NS). Isoproterenol infusion was significantly longer in the standard technique. Major perioperative arrhythmias (ventricular tachycardia and fibrillation, asystole) appeared in 8.2% and 7.0% of standard and bicaval HTs, respectively; atrial fibrillation appeared in 13.1% and 4.6%, respectively (p = NS). At 1 month, mitral and tricuspid regurgitation rates were higher in the standard group (p = NS); at 1 year only tricuspid regurgitation was still higher (p = NS). Right atrial pressure, Wood units, cardiac output, and cardiac index were examined (p = NS). At multivariate analysis, interaction between preoperative Wood units and transplant type was elicited for Wood units at 1 month and for right atrial pressure at 1, 3, and 6 months. In the high resistance subgroup, the patients who underwent bicaval procedures had higher resistances at 1 month. In the low resistance subgroup, right atrial pressure was higher in patients who underwent standard techniques at 1, 3, and 6 months follow-up. Thus, bicaval HT was found to be safe, without surgically related complications, it provoked significantly less blood loss, and required less isoproterenol use. No significant advantages were observed in conduction disturbances and major arrhythmias or regarding the need for temporary or permanent pacemakers.

Adolescent↗

PubMed1987

Biliary tract obstruction secondary to cancer: management guidelines and selected literature review.

Malignant biliary tract obstruction (MBTO) due to either primary biliary tract cancer or metastasis to the porta hepatis is a common clinical problem. The most common metastatic tumors causing MBTO in order of frequency are gastric, colon, breast, and lung cancers. Radiographic diagnostic procedures should proceed in a cost-effective sequence from ultrasonography, computerized tomography (CT), percutaneous transhepatic cholangiography (PTHC), and endoscopic retrograde pancreatography with the goal of establishing the site of the biliary tract obstruction. The identification of the site of obstruction could be established by ultrasound 70% to 80%, CT scan 80% to 90%, PTHC 100%, and endoscopic retrograde cholangiography (ERCP) 85%. Therapeutic intervention by radiographic decompression (PTHC or endoscopic prosthesis), surgical bypass, or radiation therapy with or without chemotherapy may be selectively used based on (1) the site of obstruction; (2) the type of primary tumor; and (3) the presence of specific symptoms related to the obstruction. ("Prophylactic" biliary tract decompression to prevent ascending cholangitis is not supported by the literature in that the frequency of sepsis in the face of malignant obstruction is small (in contrast to sepsis associated with stone disease). Furthermore, PTHC with drainage as a long-term procedure is associated with a substantial frequency of sepsis and is unnecessary and possibly problematic as a preoperative procedure simply to reduce the bilirubin level. The use of radiation therapy in conjunction with chemotherapy for patients not deemed suitable for a surgical bypass because of the presence of proximal obstruction is an important alternative to PTHC.

Algorithms↗

PubMed2006

[Stent-graft implantation in the thoracic aorta. Results of an interdisciplinary survey in Germany].

BACKGROUND AND OBJECTIVE: Endovascular stent-graft placement is emerging as a novel therapeutic option in patients with disease of the descending thoracic aorta. Quality standards for performing stent-graft procedures as well as for pre- and postoperative patient management are lacking, so far. It was the aim of this present survey to assess the current therapeutic standard of thoracic aortic stent-graft placement in Germany. METHODS: In a nationwide survey, a total of 206 vascular surgical, radiologic, cardiologic, and cardiothoracic surgical departments were contacted. Data concerning preoperative procedure planning, logistics, practical/technical issues of stent-graft placement, and postoperative patient management were evaluated using a standardized questionnaire comprising 29 items. Data analysis was performed using univariate analysis. RESULTS: 184 (89.3 %) of the 206 departments participated in the survey. Of these, 71 centers reported intending to perform or having performed thoracic aortic stent-graft placement. The survey overall represents 2267 endovascular stent-graft procedures performed in Germany between 1997/98 and 2003. On average, 7.4 stent-graft procedures/year were performed by each center, with half the centers performing fewer than 5 procedures/year. Thoracic aortic aneurysms was the main indication for endovascular stent-graft placement, followed by aortic dissection. There were significant differences between the different medical specialties which perform stent-graft procedures with respect to indications, choice of preoperative and intraoperative imaging methods, and technical equipment. There was strong agreement between the different centers concerning the necessity of a life-long follow-up after stent-graft placement, with computed tomography being the preferred imaging technique (90 % of centers). CONCLUSION: The present survey documents an increasing use of endovascular stent-graft placement in patients with disease of the descending thoracic aorta. There were differences regarding the technical execution of this procedures between specialties with respect to indication, procedure planning, and practical-technical aspects of stent-graft placement.

Analysis of Variance↗

PubMed1984

Low-dose preoperative radiation therapy for adenocarcinoma of the endometrium. A pilot study.

A pilot study using low-dose preoperative radiation therapy, i.e., 10 Gy in 3 to 4 days as an adjuvant preoperative procedure for grade 2 or 3 (FIGO classification) endometrial carcinoma, was done. The concept of low-dose preoperative radiation therapy is to administer treatment, either surgical or radiotherapeutic, postoperatively according to the surgical and pathologic findings, allowing identification of those patients with previously undiagnosed extensive metastatic disease outside the pelvis found at laparotomy in whom routine pelvic radiation therapy is futile, as well as those patients with relatively low risk of recurrence who may not require further radiotherapy. Forty-four patients with clinical Stage I, grade 2 or 3 with adenocarcinoma of the endometrium were entered into the pilot study. Following surgery, 68% remained Stage I by pathologic examination, and in the remaining patients the stages were changed to II in seven, III in three, and IV in four. Postoperative treatment was administered according to extent of the disease found at surgery. The 4-year actuarial probability of survival rate for the entire group of patients with clinical Stage I disease was 80%; corresponding disease-free rate was 77%. For the Stage I disease confirmed by pathologic examination, the corresponding rate was 96%. The rates for Stages II through IV, as shown by pathologic findings at laparotomy, were 53% and 42%, respectively. In this pilot stud, a treatment policy for clinical Stage I, grade 2 or 3 adenocarcinoma of the endometrium using low-dose preoperative radiation therapy is recommended.

Adenocarcinoma↗

PubMedDate not supplied

Use of sentinel node lymphoscintigraphy in malignant melanoma.

Lymphoscintigraphy is a sensitive, inexpensive, relatively noninvasive method of identifying lymphatic drainage patterns and sentinel lymph nodes in patients with malignant melanoma. Lymphoscintigraphy with filtered technetium-99m sulfur colloid allows prompt visualization of the lymphatic system, produces high-quality images, and delivers a low radiation dose to the patient. In addition, good regional lymph node retention is seen with filtered Tc-99m sulfur colloid, improving the success rate of intraoperative gamma probe localization. In combination with surgical localization, lymphoscintigraphy allows preoperative and intraoperative identification of the sentinel node in patients with intermediate thickness melanomatous lesions, obviating radical lymph node dissection in most patients and possibly prolonging their survival. Variables such as tumor location, type and preparation of radiopharmaceutical, injection technique, imaging technique, and prior surgical intervention influence the efficacy of lymphoscintigraphy. Nevertheless, lymphoscintigraphy is recommended as a cost-effective preoperative procedure in all patients planning to undergo elective lymph node dissection. Because of the unpredictability of lymphatic drainage, preoperative scintigraphic findings may lead to changes in surgical management.

Animals↗

PubMed1995

Current concepts in anticoagulant therapy.

An understanding of the international normalized ratio (INR)--which was developed to standardize reporting of the prothrombin time (PT) and provide consistent regulation of anticoagulation--is important. The recommended therapeutic range for the INR (which is calculated from the patient's PT, a mean control PT, and the international sensitivity index) for oral anticoagulant treatment of most conditions is 2.0 to 3.0. In patients with mechanical cardiac valves, the INR should be at least 2.5 to 3.5. A common cause for progression of venous thromboembolic disease and treatment failure is inadequate heparinization during the first day of treatment. Therefore, an intravenous bolus of 5,000 to 10,000 U of heparin should be administered before a maintenance infusion is initiated. Also during the first day of treatment, warfarin therapy can be implemented. Overlap treatment with heparin and warfarin for 4 or 5 days is recommended. Low-molecular-weight heparins, a new class of anticoagulants, have been shown to be more effective than standard heparin in preventing venous thrombosis in orthopedic surgical patients, but at a higher cost. Patients with mechanical cardiac valves who are receiving anticoagulant therapy and are scheduled for noncardiac operations must have a risk-to-benefit assessment of the need for continuous anticoagulation performed preoperatively. Many of these patients can safely discontinue warfarin therapy for several days as outpatients before the surgical procedure. Preoperative heparin therapy and warfarin withdrawal in the hospital are recommended only for those patients with cardiac valves at high risk for systemic embolization (with a mitral valve prosthesis, cardiomyopathy, or previous thromboembolism). The concurrent use of certain drugs or presence of comorbid conditions can predispose to hemorrhagic complications of anticoagulant therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Anticoagulants↗

PubMed1988

Control of blood loss during scoliosis surgery.

By combining surgical and anesthetic techniques that minimize blood loss with the use of autotransfusion, it should now be possible to complete a routine posterior spinal fusion without using allogeneic blood transfusions. Surgical efforts should include careful preoperative planning, positioning with the abdomen hanging free, use of topical hemostatic agents, and decortication late in the procedure. Preoperatively donated autogeneic blood or reclaimed red cells from suction can take the place of allogeneic transfusions. Blood loss during scoliosis surgery correlates closely with left ventricular stroke work index (LVSWI), a measure of blood flow calculated from systemic vascular resistance, cardiac output, and heart rate. All of these parameters are under the anesthesiologist's control, making him the primary determinant of blood loss in scoliosis surgery. Induced hypotensive anesthesia may be ineffective in controlling blood loss if the cardiac output or heart rate is high. Halothane, a commonly used hypotensive agent, is not very useful for scoliosis surgery because spinal cord monitoring and wake-up testing are not possible. Rebound hypertension has been noted with the use of sodium nitroprusside. Trimethaphan works well clinically but experimentally it reduces spinal cord blood flow, which may increase the risk of spinal cord injury.

Anesthesia↗

PubMedDate not supplied

Radiologic aspects of inverted papilloma.

A series of 42 patients with inverted papilloma is presented. Of these, 38 patients had radiologic examinations. Thirty patients had comparable radiologic examinations in the form of X-ray of the sinuses and/or tomography and/or CT scan. The preoperative findings were compared and related to the extent of the tumor at surgery. Clinical examination combined with CT appears to be the optimal preoperative procedure. Follow-up should include CT in order to allow comparison with postoperative status and, preferably, also with preoperative radiologic findings.

Biopsy↗

PubMed2005

Nitrous oxide anxiolysis for elective cesarean section.

STUDY OBJECTIVE: To determine if inhaled 40% nitrous oxide (N(2)O) via facemask is an effective anxiolytic in women undergoing elective cesarean section under spinal anesthesia. STUDY DESIGN: Prospective, randomized, double-blinded study. SETTING: Tertiary-care women's hospital. PATIENTS: Sixty American Society of Anesthesiologists physical status I and II patients scheduled for elective cesarean section under spinal anesthesia. INTERVENTIONS: Patients were randomized to 2 groups to receive either 100% O2 via facemask or 40% N2O in O2 via facemask. MEASUREMENTS: Vital signs (blood pressure, heart rate, and oxygen saturation) and measured variables (visual analog scale [VAS] anxiety, VAS pain, and sedation scores) were obtained at specific periods during the procedure (preoperatively, entering the operating room, spinal injection, skin incision, uterine incision, delivery, and at the conclusion of the surgical procedure). In addition, surgical time and delivery time, mean dose and percentage of patients requiring ephedrine or phenylephrine boluses, the emesis rate, and Apgar scores were measured. MAIN RESULTS: No differences were noted with respect to maternal mean blood pressure, heart rate, pulse-oximeter oxygen saturation, and sedation or VAS pain scores during the measured periods. No differences were noted in surgical and delivery times, mean dose, or percentage of patients who required ephedrine or phenylephrine to maintain maternal blood pressure, the emesis rate, or 1- and 5-minute Apgar scores. Mean anxiety scores for the N2O group were significantly lower at the time of spinal injection, skin incision, and uterine incision. Multivariate analysis of variance for high-anxiety patients (> or =50 VAS) revealed significantly lower VAS scores in the N2O group, compared with the O2 group again at spinal injection, skin incision, and uterine incision. CONCLUSIONS: Inhaled 40% N2O via facemask provides effective anxiolysis in women undergoing elective cesarean section under spinal anesthesia in patients with high anxiety (> or =50 VAS) at the time of spinal injection, skin incision, and uterine incision.

Adult↗

PubMed1987

[Limb salvage in osteosarcoma. Significance of preoperative isolation perfusion chemotherapy].

In our Department since 1960 isolation perfusion chemotherapy has been performed as a preoperative procedure combined with surgery in 134 patients with osteosarcoma of the extremity. In this paper, the significance of isolation perfusion chemotherapy was presented. The cumulative 5-year survival rate of 114 perfused patients was 42.7%, while that of 41 non-perfused patients before 1960 was 17.1%. Of the 114 patients 102 underwent amputation and 12 had limb salvage surgery. The cumulative 5-year survival rate of the 9 patients who have received limb salvage surgery since 1978 is 68%. Eleven patients who received preoperative aggressive chemotherapy including isolation perfusion chemotherapy showed a 91% clinical and radiological response to the drug. The tumor was microscopically analyzed and the ratio of necrotic to viable tumor cells was calculated. The degree of tumor necrosis was classified as excellent (greater than or equal to 95%), good (80-94%), fair (50-79%) and poor (less than 50%). The response in 22 patients who received preoperative aggressive chemotherapy using adriamycin, methotrexate and cis-platinum including the use of isolation perfusion was excellent in 41%, good in 36%, fair in 14% and poor in 9%. We believe that preoperative isolation perfusion chemotherapy is an effective procedure for limb salvage surgery.

Adolescent↗

PubMed2006

Thoracic aorta endografts: variations in practice among medical specialists.

BACKGROUND: Endovascular stent-graft placement is emerging as a novel treatment option for patients with diseases of the descending thoracic aorta. However, currently no consensus guidelines exist to direct uniformity in stent-graft procedures as well as for pre- and postprocedural patient management, unlike that for the management of other cardiovascular disorder. Accordingly, the aim of the present survey was to assess variations in thoracic aortic stent-graft practice among different subspecialties in Germany. METHODS: An interdisciplinary questionnaire survey was conducted among 206 departments of vascular surgery, radiology, cardiology, and cardiothoracic surgery in Germany that actively performed aortic stent-graft placement. Data on preoperative procedure planning, logistics, practical/technical issues of stent-graft placement, and postoperative patient management were evaluated using a standardized, self-administered questionnaire comprising 29 items. Responses were tabulated for analysis. RESULTS: Of a total of 206 questionnaires, 184 (89.3%) were returned with 71 (38.5%) centers reporting to have performed thoracic aortic stent-graft placement (total number of procedures 2,267) through 1997 and 2003. The average number of stent-graft procedures per year was 7.4 (25-75% percentile, 2.05-10.75) at participating sites, with 49% of the respondents reporting <5 procedures per year. Treatment of thoracic aortic aneurysms was the predominant indication for stent-graft placement, followed by type B-dissection. As anticipated, marked variability existed among the different medical specialties performing stent-graft procedures with respect to all aspects of the procedures including indication for treatment, choice of preoperative and intraoperative imaging modalities, technical equipment and perioperative management. The only consistent agreement was on the need for lifelong follow-up after stent-graft placement, with CT being the preferred imaging technique (90% of centers). CONCLUSION: The present survey documents an increasing adoption of endovascular stent-graft placement for patients with diseases of the descending thoracic aorta in Germany. Despite this, there is a lack of consensus among the different medical specialties performing stent-graft placement with respect to indications and technical execution of stent-grafting. Our data supports the need for consensus practice guidelines endorsed by medical professional societies for stent-graft procedure to standardize the growing number of thoracic stent graft procedures.

Angioplasty↗

PubMed1989

Blood use in head and neck tumor surgery. Potential for autologous blood.

Recent increased concern regarding the risks of homologous blood transfusion led us to examine the use of blood products for head and neck tumor surgery. Major head and neck surgical procedures at three University of Washington (Seattle)-affiliated hospitals during 1987 were reviewed. Seventy-seven patients were identified. Parameters studied included the following: tumor site and stage, prior treatment, surgical procedure, preoperative and postoperative hematocrit values, estimated blood loss, operative and postoperative blood product use, and operative time. Data were grouped by procedure. Maxillectomy/midface procedures showed the highest average estimated blood loss (1037 mL) and the highest average blood use (1.5 units), followed by composite resections (883 mL and 0.8 units) and laryngectomies (724 mL and 0.9 units). When the data were subgrouped, larynogopharyngectomy (1450 mL and 4.0 units) and composite resection with mandibular swing (1300 mL and 1.0 units) showed the highest blood loss and blood product use. In the assessable groups, previous administration of radiation did not make a significant difference in blood loss or procedure time. However, blood loss correlated well with procedure time in all groups. The great majority of patients met all requirements to function as blood donors (84%). Sixty-five percent of patients met all criteria and used less than 2 units of blood, making autologous blood a reasonable option for the majority of patients with head and neck tumors.

Blood Transfusion, Autologous↗

PubMedDate not supplied

Total and partial orbitectomy for the treatment of periorbital tumors in 24 dogs and 6 cats: a retrospective study.

Total or partial orbitectomy were used to treat 24 dogs and six cats with invasive periorbital tumors. The surgical procedure and clinical results were evaluated in this retrospective study. The most common types of tumors treated in this series of patients were multilobular osteochondrosarcoma and squamous cell carcinoma. Two patients died of cardiopulmonary arrest within 24 hours after surgery. One patient developed neurological signs after total orbitectomy that resolved with conservative therapy. Minor complications, which included infection, strabismus, and conjunctivitis, occurred in seven patients. Regrowth of tumor in the periorbital region occurred in 11 patients (36.7%). Tumor resection by orbitectomy provided local disease-free interval of more than 1 year in more than 50% of patients. Survival rate for the first year was 70.4% in this series of patients as determined by life table analysis. Orbitectomy requires detailed knowledge of regional anatomy and experience with performing a combination of surgical procedures. Preoperative diagnostic tests should include imaging techniques to define the extent of the disease. When performed properly, orbitectomy is a valuable procedure that can be used to effectively treat invasive tumors of the orbit.

Animals↗

PubMed2004

[Cancer of the body of the stomach: comparison of results with surgical and combined therapy].

The immediate and end results of surgical and combined treatment of cancer of the body of the stomach have been evaluated. The combined therapy used intensive preoperative procedures. No significant differences in mortality and postoperative complication rates between combined treatment and surgery were reported. The joint use of preoperative irradiation and radical surgery was followed by better end results in therapy of such locally advanced malignancies as invasion through the stomach wall, metastases to the regional lymph nodes, stage III and infiltrative growth.

Female↗

PubMed2002

Tumor above the spinal accessory nerve in papillary thyroid cancer that involves lateral neck nodes: a common occurrence.

OBJECTIVE: To describe the nature and extent of lateral neck node metastases from papillary thyroid cancer in relation to presenting physical examination and staging radiologic studies. DESIGN: Retrospective study. SETTING: Tertiary referral cancer center. PATIENTS: Consecutive patients who underwent comprehensive neck dissection with or without concurrent thyroidectomy for well-differentiated thyroid cancer between 1991 and 2001. Excluded were patients with well-differentiated thyroid cancer diagnosed incidentally at the time of treatment of other primary head and neck cancer, those with previous neck dissection for nonthyroid malignancies, and those undergoing surgery for medullary thyroid cancer. INTERVENTIONS: All pathology and operative and preoperative radiology reports for patients undergoing comprehensive neck dissection for well-differentiated thyroid malignancy were reviewed. Data were collected on previous procedures, preoperative evaluation, operative details, and pathologic findings. MAIN OUTCOME MEASURE: Identification of metastatic thyroid cancer in one or more nodes in anatomically defined drainage basins of the central and lateral neck. RESULTS: A total of 51 neck dissections were performed. All patients had preoperative evidence of metastatic disease. In addition to the usual comprehensive node dissection encompassing all lymphatic tissue in levels II through V, level I nodes and level II nodes above the spinal accessory nerve were labeled as distinct regions in 16 (31%) and 34 (67%) specimens, respectively. Disease was confined to a single nodal level in 20 (39%) of 51 specimens and was present in 4 or more levels in 7 (14%) of 50 neck dissections. There was cancer at 2 or 3 levels in 16 (31%) and 15 (29%) cases, respectively. Seven (21%) of the 34 patients undergoing separate analysis of nodes from above the spinal accessory nerve had cancer there. In 3 of the 34 it was the sole disease in level II. CONCLUSIONS: Tumor involvement at multiple nodal levels occurs in most cases when patients have lateral cervical node metastases. "Skip" metastases and cancer above the spinal accessory nerve are common. Neck dissections should include all node stations likely to be involved because selective node excision is likely to leave metastatic disease in situ.

Accessory Nerve↗