Perioperative outcomes in patients undergoing the transglabellar/subcranial approach to the anterior skull base.
ABSTRACT: We analyzed the effect of predefined patient demographic, disease, and perioperative variables on the rate of complications in the perioperative period following subcranial surgery for anterior skull base lesion. A secondary goal of this study was to provide a benchmark rate of perioperative mortality and morbidity through comprehensive analysis of complications. Retrospective review of a consecutive series of patients (n = 164) who underwent the transglabellar/subcranial approach to lesions of the anterior skull base between December 1995 and November 2009 in a tertiary referral center. Main outcome measures were perioperative morbidity and mortality. No perioperative mortalities were observed over the period of consecutive review. The overall complication rate was 28.7%, with 30 (18%) patients experiencing major complication. Multivariate analysis revealed that the following variables were independent predictors of perioperative complication of any type: positive margins on final pathology, perioperative lumbar drain placement, and dural invasion. The subcranial approach provides excellent access to the anterior skull base with zero mortality and acceptable morbidity in comparison with other contemporary open surgical approaches. It should be considered a procedure with distinct advantages in terms of perioperative morbidity and mortality when selecting a therapeutic approach for patients with anterior skull base lesions.
Project description:Purely endoscopic resections of transcranial/intracranial pathology represent an exciting minimally invasive option for some patients. There is an abundance of literature on surgical techniques, though very little deals with perioperative management, which is critical for good outcomes. We present a detailed case review and a perioperative management protocol with specific reference to skull base and neuroanatomy. We performed a retrospective chart review and analysis of outcomes and complications by approach and design and prospective employment of a perioperative management protocol in a major tertiary care referral hospital. We included patients undergoing endoscopic skull base approaches by the two senior surgeons from September 2005 to April 2009, selecting of transcranial/intracranial cases for detailed review. Our main outcome measures included perioperative morbidity, mortality, and complications; degree of resection; recurrence rate; and survival. Fifteen patients met study criteria. No perioperative mortality occurred. There were two major and four minor complications. Mean follow-up was 15 months; 11/13 patients with malignancies had no evidence of disease. A perioperative management protocol was designed from these data and has resulted in decreased lumbar drainage and increased fluid/electrolyte monitoring. Endoscopic transcranial/intracranial anterior skull base surgery is both safe and effective when a complete understanding of the surgery and perioperative management is achieved.
Project description:We sought to determine the extent of the frontal sinus by intraoperative transillumination through the superomedial orbital wall in a subcranial approach to the anterior skull base. After raising a bicoronal flap, the frontal sinus was transilluminated through the superomedial orbital wall with a fiber-optic light source, delineating the extent of the frontal sinus. The frontal sinus boundary was marked with a marker pen. A frontal sinus anterior wall osteotomy was performed with a sagittal saw, staying within the confines of the frontal sinus marking. A bone flap was removed, and the posterior wall was drilled out. The remaining procedure was performed in a standard fashion. At the end of the procedure, the bone flap was fixed with a titanium plate. A total of 58 patients had undergone craniofacial resection from January 2004 to December 2007. In 13 patients, a subcranial approach was employed using the transillumination technique. Transillumination was successful in delineating the frontal sinus periphery in all 13 patients. Intraoperative transillumination of the frontal sinus through the superomedial orbital wall is a simple and effective method to delineate the frontal sinus periphery in a subcranial approach to the anterior skull base.
Project description:In the past 2 decades, an innovative and active field of surgical collaboration has been evolved and established combining the expertise of neurosurgery and rhinosurgery in the endonasal treatment of different lesions affecting the anterior skull base together with the adjacent intranasal and intradural areas. Important prerequisites for this development were improvements of technical devices, definitions of transnasal surgical corridors, and approvements in endonasal reconstructions, e.g. by use of pedicled nasal mucosal flaps. Due to these improvements, the rate of perioperative infectious complications remained acceptable. Interdisciplinary surgical teams (4-hands-2-minds) have been established constituting specialized centers of "rhino-neurosurgery". With growing expertise of these groups, it could be shown that oncological results and perioperative complications were comparable to traditional surgery while at the same time the patients' morbidity could be reduced. The present review encompasses the recent literature focusing on the development, technical details, results, and complications of "rhino-neurosurgery".
Project description:This study examined early perioperative complications and subsidence following total hip arthroplasty (THA) with a short femoral stem. A retrospective review of 207 consecutive patients (247 hips) having undergone THA via the direct anterior approach produced only six perioperative complications: two intraoperative fractures, three perioperative femur fractures and one dislocation. Subsidence greater than 5?mm was observed in four hips but subsidence did not progress greater than 3?mm at the latest follow-up. Based on these results, cementless THA though the direct anterior approach with a short femoral stem provides a clinical and radiographic advantage while maintaining low complication rates.
Project description:The aim of the present study was to assess the safety of microsurgical resection of intracranial tumors performed by supervised neurosurgical residents. We analyzed prospectively collected data from our institutional patient registry and dichotomized between procedures performed by supervised neurosurgery residents (defined as teaching procedures) or board-certified faculty neurosurgeons (defined as non-teaching procedures). The primary endpoint was morbidity at discharge, defined as a postoperative decrease of ?10 points on the Karnofsky Performance Scale (KPS). Secondary endpoints included 3-month (M3) morbidity, mortality, the in-hospital complication rate, and complication type and severity. Of 1,446 consecutive procedures, 221 (15.3%) were teaching procedures. Patients in the teaching group were as likely as patients in the non-teaching group to experience discharge morbidity in both uni- (OR 0.85, 95%CI 0.60-1.22, p?=?0.391) and multivariate analysis (adjusted OR 1.08, 95%CI 0.74-1.58, p?=?0.680). The results were consistent at time of the M3 follow-up and in subgroup analyses. In-hospital mortality was equally low (0.24 vs. 0%, p?=?0.461) and the likelihood (p?=?0.499), type (p?=?0.581) and severity of complications (p?=?0.373) were similar. These results suggest that microsurgical resection of carefully selected intracranial tumors can be performed safely by supervised neurosurgical residents without increasing the risk of morbidity, mortality or perioperative complications. Appropriate allocation of operations according to case complexity and the resident's experience level, however, appears essential.
Project description:INTRODUCTION: Severe Epistaxis is common in patients with head trauma, especially when associated with multiple fractures of the face and skull base. Several methods of controlling bleeding that can be imposed. The anterior nasal tapenade associated with posterior Foley catheter is one of the most widespread, and the universal availability of necessary materials or their apparent ease of execution. METHODS: Case report on control of severe epistaxis after severe TBI, with posterior nasal packing by Foley catheter and control tomography showing multiple fractures of the skull base and penetration of the probe into the brain parenchyma. CONCLUSION: This is a rare but possible complication in the treatment of severe nose bleeds associated with fracture of the skull base. This brief report highlights risks related to the method and suggests some care to prevent complications related through a brief literature review.
Project description:The primary objective of this study was to evaluate morbidity associated with facial translocation approaches for skull base and results of various technical modifications. Forty consecutive patients who underwent facial translocation approaches for accessing skull base tumors from July 2005 to June 2010 were included in this study. There were 25 patients who underwent standard facial translocation, 4 patients medial mini, and 11 patients underwent extended facial translocation. Thirteen patients had benign disease and 27 patients had malignant disease. Resection was R0 in 36 and R1 in 4 patients. Most patients had acceptable cosmetic results. None of the patients had problems related to occlusion or speech and swallowing. The commonest complication observed was nasal crusting in 16 patients. Grade 2 trismus and exposure of mini plate was seen in three patients. Two patients developed necrosis of translocated bone. Three patients developed palatal fistula before modification of palatal incision. Facial translocation provides a satisfactory access for adequate clearance of skull base tumors with satisfactory aesthetic and functional results. With modifications of the surgical technique and implementation of new surgical tools, the morbidity of facial translocation approaches will continue to decrease.
Project description:INTRODUCTION:Preoperative anemia and old age are independent risk factors for perioperative morbidity and mortality. However, despite the high prevalence of anemia in elderly surgical patients, there is limited understanding of the impact of anemia on postoperative complications and postdischarge quality of life in the elderly. This study aims to investigate how anemia impacts elderly patients undergoing major abdominal surgery in terms of perioperative morbidity, mortality and quality of life for 6 months postoperatively. METHODS AND ANALYSIS:We will conduct a prospective observational study over 12 months of 382 consecutive patients above 65 years old, who are undergoing elective major abdominal surgery in Singapore General Hospital (SGH), a tertiary public hospital. Baseline clinical assessment including full blood count and iron studies will be done within 1 month before surgery. Our primary outcome is presence of morbidity at fifth postoperative day (POD) as defined by the postoperative morbidity survey (POMS). Secondary outcomes will include 30-day trend of POMS complications, morbidity defined by Clavien Dindo Classification system (CDC) and Comprehensive Complication Index (CCI), 6-month mortality, blood transfusion requirements, days alive out of hospital (DaOH), length of index hospital stay, 6-month readmission rates and Health Related Quality of Life (HRQoL). HRQoL will be assessed using EuroQol five-dimensional instrument (EQ-5D) scores at preoperative consult and at 1, 3, and 6 months. ETHICS AND DISSEMINATION:The SingHealth Centralised Institutional Review Board (CIRB Ref: 2017/2640) approved this study and consent will be obtained from all participants. This study is funded by the National Medical Research Council, Singapore (HNIG16Dec003) and the findings will be published in peer-reviewed journals and presented at academic conferences. Deidentified data will be made available from Dryad Repository upon publication of the results.
Project description:Objectives To compare the complication rates of endoscopic transnasal and open maxillotomy approaches for the central skull base. Design Retrospective review. Setting Single-center study, London, United Kingdom. Participants From 1992 to 2012, 81 patients underwent surgery for skull base lesions, 59 by maxillotomy and 22 by endoscopy. Main Outcome Measures Total time of surgical anesthesia, blood loss, complications, duration of tracheal intubation, duration of hospital stay, myelopathy score, and mortality rate. Results The surgical time, blood loss, and duration of the postoperative intubation period were significantly less with endoscopy (p < 0.001). Requirements for intensive care, ward stay, and total hospital stay were also significantly less in the endoscopic group (p = 0.01, p < 0.001, and p < 0.001, respectively). The complication rate was lower with transnasal endoscopic surgery. Conclusion In patients for whom open maxillotomy or endoscopic surgery are both feasible, the preference should be to perform endoscopic surgery, with better visualization and fewer complications.
Project description:BACKGROUND:Gastrointestinal complications following on-pump cardiac surgery are orphan but serious risk factors for postoperative morbidity and mortality. We aimed to assess incidence, perioperative risk factors, treatment modalities and outcomes. MATERIAL AND METHODS:A university medical center audit comprised 4883 consecutive patients (median age 69 [interquartile range IQR 60-76] years, 33% female, median logistic EuroScore 5 [IQR 3-11]) undergoing all types of cardiac surgery including surgery on the thoracic aorta; patients undergoing repair of congenital heart disease, implantation of assist devices or cardiac transplantation were excluded. Coronary artery disease was the leading indication for on-pump cardiac surgery (60%), patients undergoing cardiac surgery under urgency or emergency setting were included in analysis. We identified a total of 142 patients with gastrointestinal complications. To identify intra- and postoperative predictors for gastrointestinal complications, we applied a 1:1 propensity score matching procedure based on a logistic regression model. RESULTS:Overall, 30-day mortality for the entire cohort was 5.4%; the incidence of gastrointestinal complications was 2.9% and median time to complication 8 days (IQR 4-12). Acute pancreatitis (n = 41), paralytic ileus (n = 14) and acute cholecystitis (n = 18) were the leading pathologies. Mesenteric ischemia and gastrointestinal bleeding accounted for 16 vs. 18 cases, respectively. While 72 patients (51%) could be managed conservatively, 27 patients required endoscopic/radiological (19%) or surgical intervention (43/142 patients, 30%); overall 30-day mortality was 12.1% (p<0.001). Propensity score matching identified prolonged skin-to-skin times (p = 0.026; Odds Ratio OR 1.003, 95% Confidence Interval CI 1.000-1.007) and extended on-pump periods (p = 0.010; OR 1.006, 95%CI 1.001-1.011) as significant perioperative risk factors. COMMENT:Prolonged skin-to-skin times and extended on-pump periods are important perioperative risk factors regardless of preoperative risk factors.