ABSTRACT: 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:During the last 10 years, microscope-integrated indocyanine green fluorescence (m-ICG) has been widely used for assessing real-time blood flow during aneurysm surgery. More recently, an endoscope-integrated indocyanine green fluorescence (e-ICG) has been adopted as a versatile tool during different endoscopic neurosurgical procedures. The purpose of the present report is to evaluate multimodal applications of e-ICG during different endonasal, intraventricular, aneurysm and brain tumor surgeries and provide technical nuances. In addition, we reviewed the literature and identified and compare several overlapping case series of patients treated via an endoscopic integrated indocyanine green fluorescence technique. A total of 40 patients were retrospectively evaluated. Patients were divided into four main groups: (1) endoscopic endonasal approaches (n = 14); (2) ventricular endoscopic approach including patients undergoing third ventriculostomy (n = 8) and tumor biopsy (n = 1); (3) aneurysms surgery (n = 9); and (4) brain parenchymal tumors (n = 8). All patients were successfully treated using the e-ICG dynamic endoscopic visualization, and there were no perioperative complications. Such unique features open up a promising field of applications beyond the use of m-ICG in different surgical field due to the longer duration of e-ICG fluorescence up to 35 ± 7 min. E-ICG represents a new and effective technique for longer real-time visualization of vascular structures preserving normal tissues and functions during different transcranial and endonasal approaches. As the technology and e-ICG resolution improves, the technique has the potential to become a critical tool for different applications in neurosurgery.
Project description:Spontaneous cerebrospinal fluid (CSF) rhinorrhea due to a skull base defect requires prompt diagnosis and treatment. Multiple surgical options are available for repairing the fistula, including the two-layer "fascial apposition" method and use of a pedicled nasal-septal flap. A 44-year-old obese woman presented with 4 months of progressive cough, exertional dyspnea, hoarseness, and intermittent fluid drainage from the right nostril. Chest computed tomography (CT) imaging and bronchoscopy showed chronic pneumonitis, which was confirmed by pulmonary wedge resection. CT and magnetic resonance imaging of the skull base, as well as laboratory analysis of the nasal fluid for β2-transferrin, confirmed a skull base defect causing CSF rhinorrhea. During surgery, insertion of a lumbar drain with the intrathecal fluorescein administration was performed, followed by endoscopic endonasal repair using an autologous fascial apposition graft and pedicled nasal-septal flap. Both the CSF leak and the pulmonary complications resolved following the operation with no symptoms at 11-month follow-up. This is the first reported case of spontaneous CSF rhinorrhea complicated by chronic aspiration and pneumonitis. Increased diagnostic complexity due to chronic pulmonary complications resulted in unnecessary interventions and treatment delays. Prompt recognition of spontaneous CSF leaks is essential to prevent potentially harmful complications.
Project description:Wild vertebrate populations all over the globe are in decline, with poaching being the second-most-important cause. The high poaching rate of rhinoceros may drive these species into extinction within the coming decades. Some stakeholders argue to lift the ban on international rhino horn trade to potentially benefit rhino conservation, as current interventions appear to be insufficient. We reviewed scientific and grey literature to scrutinize the validity of reasoning behind the potential benefit of legal horn trade for wild rhino populations. We identified four mechanisms through which legal trade would impact wild rhino populations, of which only the increased revenue for rhino farmers could potentially benefit rhino conservation. Conversely, the global demand for rhino horn is likely to increase to a level that cannot be met solely by legal supply. Moreover, corruption is omnipresent in countries along the trade routes, which has the potential to negatively affect rhino conservation. Finally, programmes aimed at reducing rhino horn demand will be counteracted through trade legalization by removing the stigma on consuming rhino horn. Combining these insights and comparing them with criteria for sustainable wildlife farming, we conclude that legalizing rhino horn trade will likely negatively impact the remaining wild rhino populations. To preserve rhino species, we suggest to prioritize reducing corruption within rhino horn trade, increasing the rhino population within well-protected 'safe havens' and implementing educational programmes and law enforcement targeted at rhino horn consumers.
Project description:Endoscopic endonasal transsphenoidal resection has been accepted as a routine therapy for pituitary adenoma, but the postoperative hospital stay is typically several days long. With the advantages of reduced cost and improved patient satisfaction, the application of ambulatory surgery (AS) has developed rapidly. However, AS was still rarely adopted in neurosurgery. Here we designed an AS treatment protocol for pituitary adenoma with the endoscopic endonasal approach (EEA), and reported our initial experiences regarding the safety and efficacy of the AS protocol. 63 patients who presented with pituitary adenoma were screened at the Department of Neurosurgery, Tangdu Hospital from July to September, 2017. A total of 20 pituitary adenoma patients who met the inclusion criteria underwent EEA surgery using this evidence-based AS protocol, which emphasized adequate assessment for eligibility, full preparation to minimize invasiveness, enhanced recovery, and active perioperative patient education. Of the 20 patients enrolled, 18 were discharged on the afternoon of the operation day with a median total length of stay (LOS) of 31?hours (range, 29-32) hours. The median LOS after surgery was 6.5 (range, 5-8) hours. Two patients were transferred from the AS protocol to conventional care due to intraoperative cerebrospinal fluid leakage (one case) and an unsatisfying post-anesthetic discharge score (one case). Complications included transient and reversible mild postoperative nausea and vomiting [visual analog scale (VAS) score <3], headache (VAS score <3) after the operation or early after discharge. No patient was readmitted. Our results supported the safety and efficacy of the AS protocol for pituitary adenoma patients undergoing EEA resection among eligible patients, and further evaluation of this protocol in controlled studies with a larger sample size is warranted.
Project description:Introduction Carotid artery injury (CAI) is the most feared and potentially catastrophic intraoperative complication an endoscopic skull base surgeon may face. With the advancement of transnasal endoscopic surgery and the willingness to tackle more diverse pathology, evidence-based management of this life-threatening complication is paramount for patient safety and surgeon confidence. Objectives We review the current English literature surrounding the management of CAI during endoscopic transnasal surgery. Data Synthesis The searched databases included PubMed, MEDLINE, Cochrane database, LILACS, and BIREME. Keywords included "sinus surgery," "carotid injury," "endoscopic skull base surgery," "hemostasis," "transsphenoidal" and "pseudoaneurysm." Conclusions Review of the literature found the incidence of CAI in endonasal skull base surgery to be as high as 9% in some surgeries. Furthermore, current treatment recommendations can result in damage to critical neurovascular structures. Management decisions must be made in the preoperative, operative, and postoperative setting to ensure adequate treatment of CAI and the prevention of its complications such as pseudoaneurysm. Emphasis should be placed on surgical competency, teamwork, and technical expertise through education and training.
Project description:The onslaught on the World's wildlife continues despite numerous initiatives aimed at curbing it. We build a model that integrates rhino horn trade with rhino population dynamics in order to evaluate the impact of various management policies on rhino sustainability. In our model, an agent-based sub-model of horn trade from the poaching event up through a purchase of rhino horn in Asia impacts rhino abundance. A data-validated, individual-based sub-model of the rhino population of South Africa provides these abundance values. We evaluate policies that consist of different combinations of legal trade initiatives, demand reduction marketing campaigns, increased anti-poaching measures within protected areas, and transnational policing initiatives aimed at disrupting those criminal syndicates engaged in horn trafficking. Simulation runs of our model over the next 35 years produces a sustainable rhino population under only one management policy. This policy includes both a transnational policing effort aimed at dismantling those criminal networks engaged in rhino horn trafficking-coupled with increases in legal economic opportunities for people living next to protected areas where rhinos live. This multi-faceted approach should be the focus of the international debate on strategies to combat the current slaughter of rhino rather than the binary debate about whether rhino horn trade should be legalized. This approach to the evaluation of wildlife management policies may be useful to apply to other species threatened by wildlife trafficking.
Project description:Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.
Project description:piRNAs guide an adaptive genome defense system that silences transposons during germline development. The Drosophila HP1 homolog Rhino is required for germline piRNA production. We show that Rhino binds specifically to the heterochromatic clusters that produce piRNA precursors, and that binding directly correlates with piRNA production. Rhino colocalizes to germline nuclear foci with Rai1/DXO-related protein Cuff and the DEAD box protein UAP56, which are also required for germline piRNA production. RNA sequencing indicates that most cluster transcripts are not spliced and that rhino, cuff, and uap56 mutations increase expression of spliced cluster transcripts over 100-fold. LacI::Rhino fusion protein binding suppresses splicing of a reporter transgene and is sufficient to trigger piRNA production from a trans combination of sense and antisense reporters. We therefore propose that Rhino anchors a nuclear complex that suppresses cluster transcript splicing and speculate that stalled splicing differentiates piRNA precursors from mRNAs.
Project description:PIWI-interacting RNAs (piRNAs) silence transposons in germ cells to maintain genome stability and animal fertility. Rhino, a rapidly evolving heterochromatin protein 1 (HP1) family protein, binds Deadlock in a species-specific manner and so defines the piRNA-producing loci in the Drosophila genome. Here, we determine the crystal structures of Rhino-Deadlock complex in Drosophila melanogaster and simulans In both species, one Rhino binds the N-terminal helix-hairpin-helix motif of one Deadlock protein through a novel interface formed by the beta-sheet in the Rhino chromoshadow domain. Disrupting the interface leads to infertility and transposon hyperactivation in flies. Our structural and functional experiments indicate that electrostatic repulsion at the interaction interface causes cross-species incompatibility between the sibling species. By determining the molecular architecture of this piRNA-producing machinery, we discover a novel HP1-partner interacting mode that is crucial to piRNA biogenesis and transposon silencing. We thus explain the cross-species incompatibility of two sibling species at the molecular level.
Project description:Objective Transclival endoscopic endonasal approaches to the skull base are novel with few published cases. We report our institution's experience with this technique and discuss outcomes according to the clival region involved. Design Retrospective case series. Setting Tertiary care academic medical center Participants All patients who underwent endoscopic endonasal transclival approaches for skull base lesions from 2008 to 2012. Main Outcome Measures Pathologies encountered, mean intraoperative time, intraoperative complications, gross total resection, intraoperative cerebrospinal fluid (CSF) leak, postoperative CSF leak, postoperative complications, and postoperative clinical course. Results A total of 49 patients underwent 55 endoscopic endonasal transclival approaches. Pathology included 43 benign and 12 malignant lesions. Mean follow-up was 15.4 months. Mean operative time was 167.9 minutes, with one patient experiencing an intraoperative internal carotid artery injury. Of the 15 cases with intraoperative cerebrospinal fluid (CSF) leaks, 1 developed postoperative CSF leak (6.7%). There were six other postoperative complications: four systemic complications, one case of meningitis, and one retropharyngeal abscess. Gross total resection was achieved for all malignancies approached with curative intent. Conclusions This study provides evidence that endoscopic endonasal transclival approaches are a safe and effective strategy for the surgical management of a variety of benign and malignant lesions. Level of Evidence 4.