Indocyanine green fluorescence imaging in the surgical management of liver cancers: current facts and future implications

Imaging detection of liver cancers and identification of the bile ducts during surgery, based on the fluorescence properties of indocyanine green, has recently been developed in liver surgery. The principle of this imaging technique relies on the intravenous administration of indocyanine green before surgery and the illumination of the surface of the liver by an infrared camera that simultaneously induces and collects the fluorescence. Detection by fluorescence is based on the contrast between the (fluorescent) tumoral or peri-tumoral tissues and the healthy (non-fluorescent) liver. Results suggest that indocyanine green fluorescence imaging is capable of identification of new liver cancers and enables the characterization of known hepatic lesions in real time during liver resection. The purpose of this paper is to present the fundamental principles of fluorescence imaging detection, to describe successively the practical and technical aspects of its use and the appearance of hepatic lesions in fluorescence, and to expose the diagnostic and therapeutic perspectives of this innovative imaging technique in liver surgery.

Analytic treatment of tipping points for social consensus in large random networks

We introduce a homogeneous pair approximation to the naming game (NG) model by deriving a six-dimensional Open Dynamics Engine (ODE) for the two-word naming game. Our ODE reveals the change in dynamical behavior of the naming game as a function of the average degree {k} of an uncorrelated network. This result is in good agreement with the numerical results. We also analyze the extended NG model that allows for presence of committed nodes and show that there is a shift of the tipping point for social consensus in sparse networks.

Outcome of extensive descending aorta repair adopting present concepts of spinal cord preservatio

AIM: Preoperative radiological identification of the Adamkiewicz artery and intraoperative neurologic monitoring are known to be helpful for preventing paraplegia after thoracoabdominal aorta replacement. To answer whether they should be used routinely, we investigated the incidence of spinal cord ischemia after extensive descending aortic repair without using such modalities. METHODS: We retrospectively reviewed the outcome of 95 patients who underwent extensive descending thoracic (DTA) or thoracoabdominal aorta (TAA) repair without the Adamkiewicz artery identification or neurologic monitoring from 2006 through 2010. Spinal cord protection strategy consisted of distal aortic perfusion, cerebrospinal fluid drainage, mild hypothermia, and maintenance of hypertension (systolic≥120mmHg) through the second postoperative day. A few segmental arteries were empirically selected for reimplantation based on the size and the amount of backbleeding; overall 1.4 per patient, 0.3 for DTA, 1.4 for type I, 2.4 for type II, 0.9 for type III, and 0 for type IV TAA. RESULTS: Two patients died early after surgery. All the remaining patients awoke without paraplegia or paraparesis. Delayed deficit occurred in 7 patients (7.4%) after hypotensive events caused by sedation, bleeding, respiratory distress, or cardiac dysfunction. Three patients (3.2%) became permanently paraplegic and the other four recovered completely within 48 hours after cerebrospinal fluid drainage and elevation of systemic blood pressure. CONCLUSION: Even without the Adamkiewicz artery identification and neuromonitoring, the incidence of immediate paraplegia could be kept low by applying the strategy based on the modern concept of cord perfusion. The relatively high incidence of delayed deficit suggests the importance of postoperative hemodynamic management and prevention of cardiopulmonary complications.

Microfluidic approach to genotyping human platelet antigens

Centralised laboratories routinely determine blood types by serological and molecular methods. Current practices have limitations in terms of cost, time and accessibility. Miniaturised microfluidic platforms offer an alternative to conventional genotyping methods, since they consume fewer reagents, provide faster analysis and allow for complete integration and automation. As these 'lab-on-a-chip' devices have been used for bacterial and viral detection, the authors investigated blood group genotyping as a novel application of microfluidic technology. To demonstrate the feasibility of microfluidic chip-based genotyping, the authors compared human platelet antigen 1 (HPA-1) genotype results from conventional and chip-based analysis for 19 blood donor specimens. DNA purification was performed with ChargeSwitch™ magnetic beads, DNA amplification (PCR), restriction length polymorphism (RFLP) and capillary electrophoresis (CE) for identification of the DNA on microfluidic chips. It was found that nine donors were HPA-1a/1a and ten were HPA-1a/1b. Concordance between the conventional and on-chip methods was achieved for all but one sample. All the steps were demonstrated for complete blood group genotyping analysis of patient whole blood specimens on separate microfluidic chips. Future work will focus on integration of all the genotyping protocols on a single microfluidic chip.

Portal vein occlusion before major hepatectomy in patients with colorectal liver metastases: rationale, indications, technical aspects, complications and outcome

Surgery is the only curative treatment for colorectal liver metastases (CRLM), but resection should be total with tumor-free margins and the remaining parenchyma, functionally evaluated. The rationale behind portal vein embolization (PVE) to reduce the risk of these hepatic resections is threefold: (i) surgery for CRLM has become more and more aggressive, and hepatocellular insufficiency represents the leading cause of mortality after major hepatectomy for hepatic metastasis (HM), (ii) underlying hepatic disease occurs more frequently than previously thought in these patients having undergone neoadjuvant chemotherapy, and can alter hepatic function and/or hinder postoperative regeneration, and (iii) the operative risk is increased if major hepatectomy is associated with resection of the primary tumor. The goal of this update is to review the reasons behind and the indications for PVE, to analyze the literature pertaining to whether PVE should be routine or selective, and to tackle certain technical aspects, all within the framework of the treatment of CRLM.

P2-16-14: Skin Sparing Mastectomy and Immediate Latissimus Dorsi Flap Reconstruction: Patient Reported Outcome and Factors Affecting the Highest Patient Satisfaction

Background: Skin sparing mastectomy (SSM) and immediate breast reconstruction (IBR) with latissimus dorsi (LD) flap is a tailored surgical procedure for breast cancer patients. In this study the oncologic safety, morbidities, and aesthetic results of SSM and LD IBR, as regards to patient satisfaction, were assessed.

Material and Methods: Between March 2000 and February 2011, single surgeon performed SSM and IBR for 145 patients. Eighty-five patients completed the patient satisfaction survey, and 65 patients with SSM and LD IBR were included. The patients were divided into 2 groups according to their degree of satisfaction, and a stratified analysis was performed.

Results: The mean age of the patients was 48.4 years (range, 21–74), and the pathologic results were infiltrating ductal carcinoma (n=48, 73.8%), ductal carcinoma in situ (n=15, 23.1%), and others (n=2, 3.1%). After a mean follow-up of 34 months (range, 1.6−89.9) no local recurrence occurred, and there were no skin necrosis or LD flap loss. Donor site morbidities were seroma (n=8, 12.3%), scarring (n=8, 12.3%), and back pain (n=6, 9.2%).

[A modified Gritti-Stokes amputation for vascular indications in the elderly: futility or utility?]

AIM

Major lower limb amputation in elderly patients is a dreaded event with high mortality and morbidity. Peripheral arterial disease is the nearly exclusive etiology. The aim of this retrospective study was to assess the feasibility of through-knee amputation, and the morbidity and mortality risk in the elderly (>65 years).

PATIENTS AND METHODS

From January 2000 to October 2010, 65 Gritti-Stokes through-knee amputations were performed in 58 patients (30 women, 28 men; mean age 79 years). Acute limb ischemia was the most common cause (40%). The others indications were: severe peripheral arterial disease with extensive necrotic lesions (19%), diabetic foot ulcers (15%), non-healing below-knee amputation (10%) and vascular graft infection after prosthetic lower extremity bypass surgery (6%).

RESULTS

Overall 30-day mortality was 24% (n=14/58). Vascular morbidity was 9% (n=6/65). The mean hospital stay was 31 days (range 3 to 96). The overall healing rate was 78% (n=51/65). Conversion to above-knee amputation for failed Gritti-Stokes amputation was performed in one patient.

CONCLUSION

Gritti-Stokes amputation is feasible in the elderly with an acceptable one-month mortality and a satisfactory overall healing rate. Most amputations are necessitated by complications of acute limb ischemia. For this subpopulation, Gritti-Stokes amputation should be the standard amputation level. The data collected in this study provide important information that can be useful before amputation for this population, their families and primary care physicians. Ambulation is an important postoperative goal and a multidisciplinary approach in specialized centers is required to achieve good wound healing rates.

Social consensus through the influence of committed minorities

We show how the prevailing majority opinion in a population can be rapidly reversed by a small fraction p of randomly distributed committed agents who consistently proselytize the opposing opinion and are immune to influence. Specifically, we show that when the committed fraction grows beyond a critical value p(c) ≈ 10%, there is a dramatic decrease in the time T(c) taken for the entire population to adopt the committed opinion. In particular, for complete graphs we show that when p < pc, T(c) ~ exp [α(p)N], whereas for p>p(c), T(c) ~ ln N. We conclude with simulation results for Erdős-Rényi random graphs and scale-free networks which show qualitatively similar behavior.

Social influencing and associated random walk models: Asymptotic consensus times on the complete graph

We investigate consensus formation and the asymptotic consensus times in stylized individual- or agent-based models, in which global agreement is achieved through pairwise negotiations with or without a bias. Considering a class of individual-based models on finite complete graphs, we introduce a coarse-graining approach (lumping microscopic variables into macrostates) to analyze the ordering dynamics in an associated random-walk framework. Within this framework, yielding a linear system, we derive general equations for the expected consensus time and the expected time spent in each macro-state. Further, we present the asymptotic solutions of the 2-word naming game and separately discuss its behavior under the influence of an external field and with the introduction of committed agents.

Early-onset osteoarthritis of mouse temporomandibular joint induced by partial discectomy

OBJECTIVE

The objective of this study is to characterize mouse temporomandibular joint (TMJ) following partial discectomy, since there is no documentation of whether or not partial discectomy can induce early-onset osteoarthritis (OA) in mouse TMJ.

METHODS

Partial discs of TMJ in mice were removed by microsurgery. Histology was performed to characterize articular cartilages from the TMJ of mice. The morphology of the articular cartilages was evaluated using a modified Mankin scoring system. Immunohistostaining was carried out to examine the expression of discoidin domain receptor 2 (Ddr2), a type II collagen receptor, matrix metalloproteinase-13 (Mmp-13), and Mmp-derived type II collagen fragments in the articular cartilage of condyles from the mouse TMJ.

RESULTS

Articular cartilage degeneration was seen in the mouse TMJ post-discectomy, including increased proteoglycan staining in the extracellular matrix at 4 weeks, the appearance of chondrocyte clusters at 8 weeks, reduced proteoglycan staining and fibrillation at 12 weeks and the loss of articular cartilage at 16 weeks. Increased immunostaining for Ddr2, Mmp-13, and Mmp-derived type II collagen fragments was detected.

CONCLUSION

Results indicate that partial discectomy induces early-onset OA in mouse TMJ and that increased expression of Mmp-13, likely due to the elevated expression of Ddr2, may be one of the factors responsible for the early-onset OA in mouse TMJ.