Akiteru Maeda

A New Paradigm of Endoscopic Cricopharyngeal Myotomy

tions that include level IV, due to injury of the thoracic duct or of one of its major branches. Despite being unusual, this complication carries substantial postoperative morbidity and even mortality. So far, no effective intraoperative maneuver has been reported to detect this fistula at the end of a neck dissection. The objective is to describe a simple new maneuver, intraoperative abdominal compression (IAC), which can effectively help to identify an open major lymphatic duct on level IV, at the end of a neck dissection. METHOD: Design: Cohort study. From March 1989 to September 2009, 185 patients were submitted to neck dissections involving left level IV, and underwent IAC. There were 101 males and 84 females, with age ranging from 18 to 76 years (median: 54 years). One-hundred and twenty-nine patients had squamous cell carcinomas, 48 had thyroid carcinomas, five had malignant melanomas and three had salivary cancers (two high-grade mucoepidermoid carcinomas and one poorly differentiated adenocarcinoma. The type of left neck dissection was: selective including levels II, III and IV (68 cases 36.7%), selective including levels II, III, IV and V (44 cases 23.8%), selective including levels I, II, III and IV (11 cases 5.9%), modified radical (43 cases 23.2%) and radical (19 cases 10.3%). In all cases, at the end of the procedure, after checking any unexpected bleeding under pulmonary hyperpressure, the endotracheal tube was temporarily disconnected from the ventilator. Keeping the dissected level IV area under clear visualization, an abdominal compression (IAC) was performed. At this moment, any detected lymphatic leak was carefully clamped and tied with non-absorbable sutures. After ventilating the patient, the IAC was repeated to reassure complete occlusion of the lymphatic vessel. In all patients, a multiperforated suction drain was placed on the operative field before closure. RESULTS: In 11 cases (5.9%), a chyle leak was detected after performing the IAC. All except two were successfully controlled after one attempt. In these two patients, a patch of muscle and fat tissue was applied, with fibrin glue on the top. In one of these patients, another chyle leak in a different location was detected only at the second IAC, and was also effectively closed. Postoperatively, there were two (1%) chyle fistulas, both among these eleven cases, and all were successfully managed with clinical measures only. No fistulas occurred among the remaining 174 patients in whom IAC did not demonstrate lymphatic leak. CONCLUSION: To our knowledge, this is the first description of a specific maneuver to actively detect a lymphatic fistula at the end of a left neck dissection involving level IV. In this study, IAC was able to detect an open lymphatic vessel in 5.9% of the cases, as well as to assure its effective sealing in 80%. Moreover, no life-threatening high volume fistula was noted in this study. A New Paradigm of Endoscopic Cricopharyngeal Myotomy Shun-Ichi Chitose, MD (presenter); Kiminori Sato, MD, PhD; Hirohito Umeno, MD; Akiteru Maeda, MD; Tadashi Nakashima, MD

Skull Base Surgery of a Rhabdomyosarcoma in the Ethmoid Sinus

Rhabdomyosarcoma occurs predominantly in infants and children, but less frequently in adolescents and young adults. We experienced a 33-year-old female with a rhabdomyosarcoma which originated in the ethmoid sinus and extended into the brain. After systemic neoadjuvant chemotherapy (ACT-D, VCR, CPA), an extended anterior skull base surgery with reconstruction was successfully performed. Additional radiotherapy of 41.2 Gy and chemotherapy (VP-16, IFM, CDDP, VCR, CPA, THP) were also carried out. The postoperative course of the patient was uneventful for one year. However, there has been recurrence in the oropharynx, cervical lymph node, anterior mediastinum and the brain. For each recurrence, operation, chemotherapy, radiotherapy, and cyberknife were performed, and the patient is presently doing well without any obvious recurrent tumor. Additional immunochemotherapy is now underway.