Formosan Journal of Surgery

Surgical management of a substernal goiter

Liang-Shun Wang — 2012-03-14

Summary: Substernal goiter can be classified as primary or secondary, depending on the site of origin. Primary substernal goiters (< 1% of substernal goiters), also known as mediastinal aberrant goiters, arise from ectopic thyroid tissue in the mediastinum, and receive their blood supply from intrathoracic arteries instead of thyroid arteries. A secondary substernal goiter is defined as one that has descended from the neck to the plane below the thoracic inlet, or one that has more than 50% of its mass lying inferior to the thoracic inlet. Surgical resection should be considered even for elderly patients because of the risks of mass compression symptoms (e.g., dyspnea and dysphasia), malignancy, and low morbidity of surgery. Most of the primary substernal goiters can be resected through the cervical approach. In most instances, sternotomy or thoracotomy is needed only in cases of previous cervical thyroidectomy, invasive carcinoma, or ectopic goiter.

Posterior clinoid process as a landmarker in current endoscopic-assisted neurosurgical approaches

Chi-Tun Tang, Nishanta B. Baidya, Kuan-Yin Tseng, Hsin-I. Ma — 2012-02-23

Summary: Background/Introduction: The morphologic variations of posterior clinoid process (PCP) anatomy have rarely been documented in the neurosurgical literature.Purpose(s)/Aim(s): We investigated the PCP in terms of the endoscopic perspective, which will guide surgeons for safely maneuvering within the paraclinoid region and during the transcavernous approach.Methods: Four alcohol-immersed cadaveric heads injected with pigmented silicone rubber were prepared for skull base dissections. We evaluated the three-dimensional reconstructed anatomy of PCPs. Bilateral pterional and endonasal transclival approaches were performed. In pterional corridors, we advanced the dissection through the optic-carotid triangle to observe the PCP; whereas in transclival approaches, we applied a transclival route to expose the dorsum sellae and PCP. Two angled (0 and 30°) rigid endoscopes with outer diameters of 4 mm were introduced. By endoscopically viewing the surgical anatomy, the PCP and dorsum sellae were seen with ease in both approaches.Results: All of the specimens showed an intact dorsum sellae and both posterior clinoid processes. Morphologic variation was described and recorded in each specimen. The posterior clinoid process is a landmark in important neurosurgical approaches. In our study we described the spatial guidance in either transcranial or transnasal endoscopic routes.Conclusion: Taking advantage of the innovative integration of the video processing system, it facilitates the surgeons to work in a limited confined intracranial space. We are convinced that it provides practical information concerning the trans-PCP maneuver.

Cerebral infarction due to anterior choroidal artery occlusion caused by posterior communicating artery aneurysm compression

Sher-Wei Lim, Chin-Hong Chang, Chao-Hong Yeh, Chung-Ching Chio, Chih-Wei Chen — 2012-03-27

Summary: Cerebral infarction may be associated with underlying aneurysms. Such episodes of ischemia may be caused by thromboembolism, emboli originating from a thrombosed aneurysm, or may be secondary to an occlusion of the parent vessel with a thrombus. Mechanical obstruction of the cerebral artery by a neighbored lesion might be one possible cause of cerebral infarction. This should be considered if the symptoms and signs of cerebral infarction follow such a disorder as subarachnoid hemorrhage or mass are shown by a positive imaging study. Here we report a case of cerebral infarction due to anterior choroidal artery occlusion caused by posterior communicating artery aneurysm.

Brachial plexus injury during axillary thoracotomy

Chou-Ming Yeh, Chia-Man Chou — 2012-03-19

Summary: Brachial plexus injury is a severe neurologic injury that results in functional impairment of the affected upper limb, and it can be difficult to diagnose and manage. We report a woman aged 51 years who developed brachial plexus injury of the right arm after axillary thoracotomy with removal of a mediastinal tumor. Aggressive rehabilitation was promptly neurologic instituted, and the impairment of her arm recovered completely 69 days after surgery.

Repair of lumbar hernia originating from autogenous iliac bone graft with bilayer mesh

Chun-Min Su, Ching-Wen Hsu, Yu-Chiuan Wu, Wen-Yen Chang, Wen-Ching Kung — 2012-03-23

Summary: A 60-year-old female patient, who had previously undergone an iliac bone graft harvest, was diagnosed with the aid of an abdominal CT scan to have an inferior lumbar hernia, complicated with bowel incarceration. Reduction of the protruding sac was performed. The weak point of the inferior lumbar hernia was reinforced by hernioplasty with a bilayer mesh. No evidence of recurrence was noted 16 months after surgery. The iliac bone graft is often adopted for various purposes by orthopedists and neurosurgeons, which may contribute to an unusual lumbar hernia. The purpose of this communication is to emphasize the possibility of complications following such surgical procedures and to provide useful information, including radiographic images and photographs of this extraordinary type of hernia. Hernioplasty with a bilayer mesh is safe, effective and convenient, in spite of a variety of commercially available meshes.

One-stage reconstruction of large lower lip defect and oral competence with free composite anterolateral thigh-tensor fasciae latae flap

2012-03-26

Summary: Reconstruction for a large lower lip defect is a challenge to reconstructive surgeons. The most challenging problem is to maintain oral competence and prevent sialorrhea. We present three cases of such a defect reconstructed with composite anterolateral thigh-tensor fascia lata free flaps in one stage. The patients reported in this communication had advanced squamous cell carcinoma in the lower lip. A large lower lip defect (>90%) resulted in each case from wide excision of the tumor. A composite anterolateral thigh-tensor fasciae latae free flap was used to reconstruct the defect and to restore the dynamic oral competence in one stage. A tensor fasciae latae sling was attached by two strips sutured together to the upper orbicularis oris muscle in the first case. The four-strip method, a modification of the method described by Serkan, was adopted in the second case. The upper two strips bilaterally sutured to the orbicularis oris muscles in a mode somewhat different from Serkan’s method. The tensor fasciae latae sling was attached by two strips sutured to the periosteum of both zygomatic eminences in the third case. The tensor fasciae latae sling of Case 1 failed with persistent sialorrhea. The second case had good oral competence and comprehensible speech ability without sialorrhea. The third case had an acceptable result before he was lost to follow-up. A composite anterolateral thigh-tensor fasciae latae free flap is a good choice for a large lower lip defect to achieve oral competence reconstruction in one stage. Simultaneous dynamic and static suspensions are suggested to maintain oral competence and prevent sialorrhea.

Atypical intraosseous osteolytic meningioma mimicking calvarial metastasis

2012-03-14

Summary: Meningiomas are common benign intracranial neoplasms. Among the subtypes of the meningiomas, primary intraosseous meningiomas are the most uncommon. The authors report a 68-year-old woman who has had headache, dizziness, and a progressively enlarged mass in the forehead for 2 months. Computed tomography of the brain showed an osteolytic skull lesion with brain and scalp invasion. A complete systemic survey for metastatic tumors was negative. The patient underwent Simpson grade I tumor resection via the frontotemporal approach, followed by cranioplasty with bone cement. The pathologic examination revealed atypical meningioma. Postoperatively, she received adjuvant fractionated conformal brain radiotherapy. The result was satisfactory. In this report, in addition to presenting the clinical manifestation and treatment of the patient, the authors emphasize the importance of considering atypical intraosseous meningioma in the differential diagnosis of osteolytic skull tumors.