Vijay Pillai

Versatility of Adipofascial Anterolateral Thigh Flap for Reconstruction of Maxillary Defects with Infratemporal Fossa Extension

Tumors arising from the posterior hard palate or posterolateral maxilla may extend to involve the infratemporal fossa (ITF). Resection of these tumors results in infrastructural maxillectomy with ITF defects. In this study, we describe the use of an adipofascial anterolateral thigh flap (ALT) specifically for such defects. This case series includes four patients who underwent an infrastructure maxillectomy with ITF clearance and the resultant defects were reconstructed using adipofascial anterolateral thigh flaps. The complications as well as the functional outcomes were assessed. This study included patients with lesions involving the hard palate, posterolateral part of maxilla with extension into the ITF. The mean flap dimension was 150 cm2 (range, 120–180 cm2). All flaps were harvested based on a single perforator. The flap was used to obliterate the ITF defect and also to achieve oroantral separation. All flaps mucosalized well within 6 weeks. All patients were on oral diet and had adequate mouth opening. There were no donor-site complications. Adipofascial ALT is an excellent choice for infrastructural maxillectomy defects with ITF extension. The intraoral part got mucosalized well and provided a smooth and taut surface. A large adipofascial tissue flap helps obliterate the ITF, thus minimizing complications.

Improving bethesda reporting in thyroid cytology: A team effort goes a long way and still miles to go…

Context: Fine-needle aspiration cytology is the first step in evaluation of thyroid nodules. Although the Bethesda classification for reporting thyroid cytology has been purported that this uniformity in reporting cytology thereby facilitating clinical decision-making, there are also studies indicating that the reporting percentage and the rates of malignancy in each category vary considerably from center to center making the clinical decision more difficult. Aim and Materials and Methods: We looked at our retrospective cytology and histopathology data of thyroid nodules operated between 2012 and 2014 and then prospectively collected data during 2015–2016. In the prospective arm, for every thyroid nodule that was sampled, there was a discussion between the endocrinologist and the cytopathologist on the risk of thyroid cancer (based on the patients history, examination findings, sonographic pattern, and the cytological appearance). Results: We noted that there was considerable improvement in reporting standards with the rates of nondiagnostic cytology dropping from 11% to 5%, an increased reporting of Bethesda Category 2 and 6 which are the definitive strata of benign and malignant nodules (38% to 41% in Category 2 and 7% to 11% in Category 6) with a high specificity (100%). There was a decline in numbers of Category 4 and 5 (13% to 9% in Category 4 and 12% to 3% in Category 5). The reporting prevalence of Category 3 increased from 19% to 27%. Conclusions: We conclude that a team approach between the clinician who performs the ultrasound and the reporting cytopathologist improves Bethesda reporting, its predictive value, and thus potentially avoiding unnecessary thyroidectomies in benign thyroid nodules and hemithyroidectomies in thyroid cancers.

Surveillance in Oral Cancer

Oral cancer management involves a multidisciplinary approach with integration of surgical, radiation and medical oncology modalities. In addition, it also needs inputs from the rehabilitative team encompassing speech and swallow, dental, nutrition, psychosocial counselling, behavioural modification and substance abuse. Treatment-related complications and issues manifest across all the disciplines involved in the cancer treatment. Hence, the importance of surveillance arises in patients treated for oral cancer.

Pearls and Pitfalls in Oral Cancer Management

Complications are an integral part of any medical interventions, however they are potentially avoidable. Sequelae on the other hand are inevitable. The art of medical practice aims to recognize high-risk scenarios and take measures to minimize pitfalls. The clinical outcome should be periodically audited to recognize patterns of complications and to implement remedial actions to correct these errors. The effectiveness of the remedial actions also needs to be evaluated. This is a continuous process.

Total Glossectomy Defect Reconstruction

Advanced tumours of oral tongue or base of the tongue have poor oncological outcome and are functionally debilitating. The procedure of total glossectomy for surgical management of such locally advanced disease of the tongue was described in 1950s by Kremer [1]. However, total glossectomy procedure with laryngeal preservation was associated with significant morbidity due to aspiration; therefore, this procedure often has been mentioned as a “morbid procedure for a morbid disease”. Due to poor functional outcomes, it was relegated as a palliative procedure, and validity of such a procedure without laryngectomy was questioned [2, 3]. Due to the procedure-related morbidity, there was a trend towards organ preservation, and a variety of modalities such as chemoradiation and neoadjuvant chemotherapy followed by chemoradiation are now recommended for management of advanced carcinomas of oral and base of the tongue. However, many patients undergoing organ preservation treatment require surgical salvage for a residual or locally recurrent disease. Also, reports suggest unacceptable compromise with oncological outcome following organ preservation protocols. Recent development in microvascular reconstructive techniques has enabled better functional outcomes in patients undergoing total glossectomy [2, 4]. Therefore, in order to improve the oncological outcome without debilitating morbidity, there is renewed interest in considering total glossectomy as primary modality for management of advanced tongue tumours. The main factors that underlined this transition were better understanding of the dynamics associated with tongue reconstruction and availability of reconstructive options (Fig. 7.1).

Radio-guided minimally invasive parathyroidectomy: A descriptive report of the experience from tertiary center in Bangalore

Overview: Minimally invasive parathyroidectomy (MIP) is an accepted surgical procedure for parathyroid adenomas. In the patients with parathyroid adenoma localized by dual phase 99mTc-Sestamibi scan, a focused approach utilizing the gamma probe intra-operatively helps in ensuring complete resection and avoiding exploration of the other parathyroid glands. Objective: The aim of the study was to evaluate the performance of radio-guided MIP for parathyroid adenomas detected by dual phase 99mTc-MIBI preoperatively, without intra-operative parathyroid hormone (ioPTH) monitoring for patients who had evidence of single-gland disease. Patients and Methods: A retrospective dataset of 30 patients diagnosed with solitary parathyroid adenoma operated between 2009 and 2014 were reviewed. All of the patients underwent radio-guided MIP and were followed up for at least 6 months post-operatively. The biochemical parameters (serum calcium and serum parathyroid hormone levels), imaging parameters (ultrasonography and 99mTc-MIBI), and operative times were analyzed. Results: Our study consisted of 30 patients with 50% females, with a mean age of 42.5 + 12 years. The mean surgical duration was 20 + 12 min. All of the patients achieved biochemical cure (normalization of serum calcium) and remained eucalcemic at follow-up. No major surgical complications were noted. Conclusions: Focused parathyroidectomy using the gamma probe localization could be a potential alternative for ioPTH assay in ensuring the completeness of surgical resection of parathyroid adenoma. It is also likely to shorten operative time.