Avraham Abergel

SKULL BASE APPROACHES IN THE PEDIATRIC POPULATION

This study aimed to examine the surgical, oncologic, and developmental results of infants and children undergoing extirpation of skull base tumors.

Surgical treatment of juvenile nasopharyngeal angiofibroma with intracranial extension. Clinical article.

OBJECT The purpose of this study was to describe the surgical treatment and outcomes of patients with intracranial extension of juvenile nasopharyngeal angiofibroma (JNA). METHODS Twenty-one patients who underwent operations for JNAs between 1994 and 2008 were enrolled in the study. Seven patients (33%) had intracranial tumor extension. The middle cranial fossa and cavernous sinus were involved in 4 patients who underwent operations via the combined infratemporal fossa-midfacial degloving approach. The anterior skull base was involved in 3 patients who underwent the subcranialmidfacial degloving approach. RESULTS Complete tumor removal was achieved in all patients. Postoperative complications included 1 case of soft-tissue infection. None of the patients had tumor recurrence after a mean follow-up of 42 months (range 29-85 months). No adjuvant therapy was required in any patient. CONCLUSIONS Combined approaches can be used effectively for treatment of JNAs with intracranial extension without the need for adjuvant therapy.

Elective Neck Dissection vs Observation in Early-Stage Squamous Cell Carcinoma of the Oral Tongue With No Clinically Apparent Lymph Node Metastasis in the Neck: A Systematic Review and Meta-analysis

IMPORTANCE The elective management of no clinical or radiologic evidence of lymph node metastasis in the neck (cN0) in early stage T1-T2 oral tongue squamous cell carcinoma (OTSCC) has been the subject of much debate during the past 3 decades and continues to be controversial. OBJECTIVE To systematically review the literature and carry out a meta-analysis of studies that compared elective neck dissection (END) with observation in patients with early-stage T1-T2 OTSCC and cN0 neck. DATA SOURCES The MEDLINE, Scopus, Google scholar, and Cochrane databases were systematically searched for articles published between January 1, 1970, and June 1, 2015. Search terms used were squamous cell carcinoma, oral tongue, mobile tongue, T1, T2, early stage, elective neck dissection, no neck treatment, observation, wait and watch, node-negative neck, and N0 neck. STUDY SELECTION Controlled clinical trials, prospective and retrospective cohorts, case-control studies, and case series that compared END with observation in patients with early-stage T1-T2 OTSCC who had no clinical or radiologic evidence of lymph node metastasis to the neck were eligible for inclusion in this meta-analysis. All patients included had a histopathologic diagnosis of SCC and at least 6 months of follow-up. Regional (neck) nodal recurrence, overall survival (OS), and disease-specific survival (DSS) were tested. DATA EXTRACTION AND SYNTHESIS Four researchers independently extracted information on population characteristics, outcomes of interest, and study design. Discrepancies were resolved by consensus. Fixed effects were used to determine hazard ratios (HRs) and odds ratio (ORs) were used for studies including samples without substantial heterogeneity; random effects were evaluated for samples with significant heterogeneity. RESULTS A total of 20 retrospective and 3 prospective randomized studies that met the inclusion criteria, with a total of 3244 patients, were included in the meta-analysis The results showed that END significantly reduced risk of regional recurrence (random-effects model: OR, 0.32; 95% CI, 0.22-0.46; P < .001) and improved DSS (fixed-effects model: HR, 0.49; 95% CI, 0.33-0.72; P < .001) compared with management by observation. However, END did not significantly improve OS (random-effects model: HR, 0.71; 95% CI, 0.41-1.22; P = .21). CONCLUSIONS AND RELEVANCE The findings of this systematic review and meta-analysis indicate that END can significantly reduce the rate of regional nodal recurrence and improve DSS in patients with cT1T2N0 OTSCC.

Elective neck irradiation versus observation in squamous cell carcinoma of the maxillary sinus with N0 neck: A meta-analysis and review of the literature

Elective neck irradiation of a clinical node‐negative (N0) neck in squamous cell carcinoma (SCC) of the maxillary sinus is a controversial issue.

Temperature-controlled two-wavelength laser soldering of tissues.

Laser tissue soldering is a method for bonding of incisions in tissues. A biological solder is spread over the cut, laser radiation heats the solder and the underlying cut edges and the incision is bonded. This method offers many advantages over conventional techniques (e.g., sutures). Past researches have shown that laser soldering, using a single laser, does not provide sufficient strength for bonding of cuts in thick (>1 mm) tissues. This study introduces a novel method for laser soldering of thick tissues, under temperature control, using two lasers, emitting two different wavelengths.

Nasopharyngeal biopsy in adults: a large-scale study in a non endemic area.

BACKGROUND Limited data exist on the referral criteria for endoscopic-guided nasopharyngeal biopsy to rule out nasopharyngeal malignancy among adults in a non-endemic area. METHODS Retrospective study of all adult patients that had been referred to our outpatient clinic to undergo endoscopic-guided nasopharyngeal biopsy to exclude nasopharyngeal malignancy between 1/2006-10/2013. All medical consultation referral letters were reviewed, and statistical analyses were conducted to evaluate clinically significant predictors (demographics, clinical manife- stations, nasopharyngeal endoscopic findings) for nasopharyngeal malignancy. RESULTS A total of 470 patients (470 nasopharyngeal biopsies, 54.9% males and 66% smokers) were included. The most common pathological result was adenoid/lymphoid hyperplasia (76.2%). The overall negative rate of all biopsies for malignancy was 94.2%. Twenty-seven patients had nasopharyngeal malignancy: 22 had squamous cell carcinoma and 5 had non-Hodgkin`s lymphoma. Advanced age, cervical mass, and suspicious nasopharyngeal mass were independent risk factors for nasopharyngeal malignancy on univariate and multivariate analyses. CONCLUSIONS Nasopharyngeal biopsy may safely be avoided in adults living in a non-endemic area for NPC who are free of the risk factors of advanced age, the presence of a cervical mass, and suspicious nasopharyngeal mass.

Impact of preoperative embolization on the outcomes of carotid body tumor surgery: A meta-analysis and review of the literature

There is no consensus on the impact of preoperative embolization (EMB) on the surgical outcomes of carotid body tumor (CBT) resections.

Fascia lata for endoscopic reconstruction of high-flow leaks: the champagne cork technique.

F ailure to reconstruct the cranial base will lead to cerebrospinal fluid (CSF) leak, meningitis, and pneumocephalus. A major challenge of skull base reconstruction in cases of large defects with high-flow CSF leak is overcoming CSF pressure and brain pulsation, which push the inlay graft extracranially. Here we describe an endoscopic technique for reconstruction using a strip of fascia lata as an inlay graft in the shape of a champagne cork aimed to overcome the risk of graft prolapse in patients with intraoperative high-flow CSF leak.

Tetrahedral silicon balloon for endoscopic skull base reconstruction

INTRODUCTION Advances in transnasal endoscopic approaches and the development of instrumentation and imaging technology have turned endoscopic endonasal surgery into the mainstay for treating inflammatory diseases and neoplasms involving the paranasal sinuses and skull base. The expanded endonasal approach (EEA) and its modifications provide access to the anterior skull base, planum, sphenoid, sella, clivus, cervical spine, and infratemporal fossa via the two nostrils. This approach enables endoscopic extradural and intradural tumor resection and skull base reconstruction in a single procedure. Technical advances in reconstruction methods and the development of vascularized locoregional flaps have improved our ability to seal the cranio-basal diaphragm after tumor extirpation. Use of a nasal septal flap (NSF) has reduced the rate of complications and allowed increasing numbers of patients with skull base neoplasms to undergo curative surgical resections by means of minimally invasive techniques. One drawback of this technique is the difficulty of stabilizing the multilayered reconstruction in place after its application. Currently, a 12-French Foley catheter latex balloon is used to support the multilayered reconstruction during the 1st week after surgery. The main disadvantages of this method are: 1) the balloon surface is spherical, thus providing inadequate support to the flat surfaces of the skull base; 2) decrease in the balloon’s volume due to frequent leaks may impair the support of the flap; 3) the latex balloon is weak and frequently bursts due to exposed bone chips; 4) inability to use this balloon in patients who are allergic to latex; and 5) it is inconvenient for patients because it interferes with their nasal breathing. An alternative support for skull base reconstruction that is free of these limitations is needed. In this report we describe a novel anatomically shaped graft stabilizer for endonasal skull base reconstruction.

A multi-wavelength fiber-optic temperature-controlled laser soldering system for upper aerodigestive tract reconstruction: an animal model.

Objective. Laser soldering of a thick multilayer organ using conventional CO2 lasers is ineffective. The purpose of this work was to develop a method for bonding the multilayer tissue of the upper aerodigestive tracts (UADT) without the need of sutures or stapling. Study Design. Animal model. Setting. Academic research laboratory. Subjects and Methods. The authors developed a multi-wavelength laser system, based on 2 fiber-optic lasers applied simultaneously. A highly absorbable CO2 laser interacts with the muscular layer, and a nonabsorbable GaAs laser interacts with indocyanine-green solid albumin, placed between the mucosa and the muscular layer. The authors used an ex vivo porcine model to examine the capability of this system to effectively correct esophageal tears. Results. The soldered esophagi burst pressure was >175 cm H2O (98% success rate) in 88 of the 90 experiments. A conventional CO2 laser soldering resulted in insufficient bonding (mean burst pressure of 40 ± 7 cm H2O, n = 5), while the multi-wavelength laser system provided an ~9-fold tighter seal (359 ± 75.4 cm H2O, P < .0001, n = 15). Burst pressures after conventional suturing of the defect was significantly lower (106 ± 65.8 cm H2O, P < .001) than in the multi-wavelength laser system. Conclusions. Bonding of the UADT mucosa using a multi-wavelength, temperature-controlled laser soldering system can support significantly higher pressures then conventional CO2 laser soldering and suture repair. The mean bonding pressure was 3.5-fold higher than the maximal swallowing pressure. Our findings provide a basis for implementation of new surgical tools for repair of esophageal perforations.