Journal of Aesthetic & Reconstructive Surgery

Description

A systematic review of the literature concerning robotic surgery in oral and maxillofacial (OMF), craniofacial and head and neck surgery was performed. The objective was to give a clear overview of the different anatomical areas of research in the field of OMF, craniofacial and head and neck surgery, in all its fields (pre-clinical and clinical). The present indications are outlined and the critical reader is invited to assess the value of this new technology by highlighting different relevant parameters.

A yielded 838 papers published between 1994 and 2011. After screening the abstracts, 202 articles were considered clinically or technically relevant and were included. These full papers were screened in detail and classified as articles on synopsis, educational aspects (n = 3), technical/practical aspects and clinical papers. Regarding clinical feasibility this systematic review revealed the following main indications: Transoral robotic surgery (TORS) for upper digestive and respiratory tract lesions; TORS for skull base surgery; and TORS for trans-axillary thyroid and endocrine surgery. Regarding functional outcome, this systematic review revealed a promising reduction of morbidity in patients with cancer of the upper digastric and respiratory tract.

Oral and maxillofacial surgery, which involves several sharp instruments and fixation materials, is consistently at a high risk for cross-contamination due to perforated gloves, but it is unclear how often such perforations occur. This study aimed to address this issue. The frequency of the perforation of surgical gloves in 150 oral and maxillofacial surgeries including orthognathic surgery (n = 45) was assessed by the hydroinsufflation technique. Ortho gnathic surgery had the highest perforation rate in at least 1 glove in 1 operation (91.1%), followed by cleft lip and palate surgery (55.0%), excision of oral soft tumour (54.5%) and dental implantation (50.0%). The perforation rate in scrub nurses was 63.4%, followed by 44.4% in surgeons and first assistants, and 16.3% in second assistants. The odds ratio for the perforation rate in orthognathic surgery versus other surgeries was 16.0 (95% confidence interval: 5.3–48.0). The protection rate offered by double gloving in orthognathic surgery was 95.2%. These results suggest that, regardless of the surgical duration and blood loss in all fields of surgery, orthognathic surgery must be categorized in the highest risk group for glove perforation, following gynaecological and open lung surgery, due to the involvement of sharp objects.

Crohn's Disease

Crohn's disease is a chronic unremitting inflammatory disease of the gastrointestinal tract, with no medical or surgery cure. Surgery is performed for complications of the disease and for failure of the medical therapy. From a technical standpoint, the most significant change in surgery for Crohn's disease in the past decade has been the adoption of laparoscopic surgery. In general, upper gastrointestinal cancer (UGC) still carries a poor prognosis, with no significant change in survival in recent years. This might relate, in part, to the relatively late stage at diagnosis, complex surgical management, and lack of effective systemic therapies. The cure of intermediate- and advanced-stage UGC remains the exception rather than the rule. Because progress in adjuvant therapy has been slow, surgery remains the cornerstone of potentially curative therapy for early-stage UGC.

During the past 2 decades, improvements in surgical technique and postoperative care have resulted in improved mortality and morbidity after surgery. For example, in 1 series of patients undergoing resection for esophageal cancer, an improvement in the 5-year survival rate from 18.8% to 42.3% (P < 0.001) was demonstrated from 1980 to 2004 [9]. For earlystage esophageal cancer confined to the mucosa, the 5-year survival rate can exceed 80% after resection. Similarly, a 5-year survival rate of 80% can be achieved after liver transplantation for hepatocellular carcinoma, long-term survival after resection for localized pancreatic cancer approaches 30%, and up to 90% of gastric cancers confined to the mucosa or sub mucosa can be cured by gastrectomy. In addition to improvements in outcomes after surgical therapy, improvements in diagnostic modalities have resulted in many more UGCs diagnosed at an earlier stage.

Despite data establishing surgical resection as the treatment of choice for early-stage disease, many patients never undergo surgical treatment of their disease. Previous studies have consistently reported poor use of surgery for early-stage esophageal, gastric, pancreatic, and hepatocellular cancer, with reported rates of 34%, 63%, 29%, and 10%, respectively. Many factors have been proposed to explain this discrepancy, including no significant survival benefit after surgery, nihilistic attitudes toward the disease, the aging population, diminishing operative experience during training, a lack of patient access to high-volume centers, patient socioeconomic factors, and support for nonoperative treatments, including chemo radiotherapy and local excision.

In the modern era of multimodality therapy, no large population-based studies have evaluated the application of cancer-directed curative intent surgery on the treatment of UGC. The purpose of the present study was to analyze recent population-based patterns of treatment regarding the use versus nonuse of surgical treatment of early-stage UGC. We sought to identify the patient and tumor factors predictive of a nonoperative approach for potentially resectable UGC. We also evaluated whether the socioeconomic and racial differences in treatment use exist on a national level. As a secondary goal, we studied the effect of surgery on cancer survival outcomes.