Robotic distal pancreas-sparing duodenectomy (duodenal sleeve resection) with transmesenteric approach: robotic approach for tumors in the third and fourth parts of the duodenum

BACKGROUND

Minimally invasive resection of the retroperitoneal duodenum is complicated because of its anatomical location, and the proximity of the ampulla of Vater and vascular structures. Benign or indolent pathology can add complexity to operative decision-making for these already challenging surgeries, and operations associated with lower morbidity may be considered. This study describes a novel robotic transmesenteric approach to duodenal sleeve resection for non-malignant lesions.

METHODS

A retrospective review was performed on a prospectively maintained institutional database between 2011 and 2021. The Da Vinci XI or SI platform (Intuitive Surgical, Sunnyvale, CA) was used in all cases.

RESULTS

Critical steps in robotic sleeve duodenectomy include the following: (1) techniques for avoiding damage to the ampulla; (2) Kocherization and reverse Kocherization; and (3) A transmesenteric approach for further mobilization of the duodenum. Nineteen patients were referred by experienced gastrointestinal endoscopists after endoscopic management was deemed unsuitable or their resections were incomplete. The histological diagnoses were either symptomatic benign or indolent duodenal pathology. All 19 patients underwent robotic duodenal sleeve resection during the study period. Lesions were located in the third to fourth parts of the duodenum. The median operative time was 216 min (IQR: 199-225), and the estimated intraoperative blood loss was 50 ml (IQR: 50.0-93.7). The 90 day readmission rate was 15.7% (3/19), and no 90-day mortality was observed.

CONCLUSION

This small case series of a transmesenteric approach for robotic sleeve duodenectomy demonstrates its feasibility and safety in this potentially challenging operation.

The effect of haemorrhagic shock and resuscitation on fracture healing in a rabbit model: an animal study

Aims

Little is known about the effect of haemorrhagic shock and resuscitation on fracture healing. This study used a rabbit model with a femoral osteotomy and fixation to examine this relationship.

Materials and Methods

A total of 18 male New Zealand white rabbits underwent femoral osteotomy with intramedullary fixation with ‘shock’ (n = 9) and control (n = 9) groups. Shock was induced in the study group by removal of 35% of the total blood volume 45 minutes before resuscitation with blood and crystalloid. Fracture healing was monitored for eight weeks using serum markers of healing and radiographs.

Results

Four animals were excluded due to postoperative complications. The serum concentration of osteocalcin was significantly elevated in the shock group postoperatively (p < 0.0001). There were otherwise no differences with regard to serum markers of bone healing. The callus index was consistently increased in the shock group on anteroposterior (p = 0.0069) and lateral (p = 0.0165) radiographs from three weeks postoperatively. The control group showed an earlier decrease of callus index. Radiographic scores were significantly greater in the control group (p = 0.0025).

Conclusion

In a rabbit femoral osteotomy model with intramedullary fixation, haemorrhagic shock and resuscitation produced larger callus but with evidence of delayed remodelling.

Cite this article: Bone Joint J 2018;100-B:1234–40.

Bradykinin system is involved in endometriosis-related pain through endothelin-1 production

BACKGROUND

Endometriosis is a gynaecological disease exhibiting severe pelvic pain, but the mechanism of pain production remains unknown. Bradykinin (BK) is known as an inflammatory mediator, and shows elevated levels in inflammatory diseases such as rheumatoid arthritis. In the present study, we evaluated whether BK is involved in endometriosis-related pain.

METHODS

Endometriotic lesions were used for immunohistochemistry. Primary cultures of endometriotic stromal cells (ESC) were stimulated with IL-1β and/or BK. Quantitative RT-PCR was used to evaluate the mRNA expressions of BK receptors (BKR) and endothelin-1 in ESC. The concentration of endothelin-1 in cystic fluid of endometrioma or non-endometrioma was measured with ELISA. The conditioned medium of ESC stimulated with IL-1β and/or BK was injected intraplantarly in mice, and evaluated whether pain-related licking behaviour was elicited.

RESULTS

The expressions of BK and BKR in endometriotic lesions were observed by immunohistochemistry. In vitro experiments showed that IL-1β induced BKR-B1 and B2 on ESC. Activation of these receptors by BK significantly induced endothelin-1 expression in ESC, which was negated completely by HOE-140, a BKR-B2 antagonist. The cystic fluid of endometrioma contained higher amount of endothelin-1 compared to non-endometrioma. Intraplantar injection of the conditioned medium of ESC treated with IL-1β and BK significantly induced licking behaviour, which was suppressed with BQ-123, an endothelin type-A receptor antagonist.

CONCLUSIONS

The present study demonstrated the presence and the function of the BK axis in endometriosis, and established a potential new therapy target for endometriosis-related pain.

SIGNIFICANCE

The present study demonstrated (1) the presence and the function of the BK system in endometriosis, (2) activation of BKR induced endothelin-1 in endometriotic lesion and (3) blocking endothelin-1 was effective to decrease pain.

Reamed locked intramedullary nailing for studying femur fracture and its complications

Morbidity associated with femur fractures in polytrauma patients is known to be high. The many unsolved clinical questions include the immunological effect of the fracture and its fixation, timing of fracture fixation, management of fracture non-union, effect of infection and critical size of bone defects. The aim of this study was to establish a clinically-relevant and reproducible animal model with regards to histological, biomechanical and radiological changes during bone healing. A custom-designed intramedullary nail with interlocking system (RabbitNail, RISystem AG, Davos Platz, Switzerland) was used for fixation, following femur fracture. New Zealand White rabbits were assigned to two groups: 1. closed fracture model (CF; non-survival model: n = 6, survival model: n = 3) with unilateral mid-shaft femur fracture created by blunt force; 2. osteotomy model (OT; survival model: n = 14) with unilateral transverse osteotomy creating femur fracture. There were no intraoperative complications and full-weight bearing was achieved in all survival rabbits. Significant periosteal reaction and callus formation were confirmed from 2 weeks postoperatively, with a significant volume formation (739.59 ± 62.14 mm3) at 8 weeks confirmed by micro-computed tomography (µ-CT). 2 months after fixation, there was no difference between the osteotomised and contralateral control femora in respect to the maximum torque (3.47 ± 0.35 N m vs. 3.26 ± 0.37 N m) and total energy (21.11 ± 3.09 N m × degree vs. 20.89 ± 2.63 N m × degree) required to break the femur. The data confirmed that a standardised internal fixation technique with an intramedullary nail for closed fracture or osteotomy produced satisfactory bone healing. It was concluded that important clinically-relevant studies can be conducted using this rabbit model.

The treatment of traumatic shock: recent advances and unresolved questions

Uncontrolled bleeding remains a leading cause of potentially preventable death after trauma. Timely, adequate resuscitation in traumatic shock is an essential, lifesaving aspect of polytrauma care. Whilst basic principles in the treatment of traumatic shock remain the same-achieving hemorrhage control and replacing lost volume, the way this is achieved has changed significantly in the last five years. The abandonment of blood pressure driven uncontrolled fluid resuscitation, the introduction of the concept of hemostatic resuscitation, and the increasing use of massive transfusion protocols have all contributed to an improvement in timely access to various blood products. The increase in knowledge regarding the pathophysiology of trauma, the availability of adjuncts, and the array of resuscitation monitoring options available have all contributed to a potentially improved approach to resuscitation. The purpose of this report is to review the most important advances in traumatic shock therapy in the last five years.

Decreased pregnancy rate is linked to abnormal uterine peristalsis caused by intramural fibroids

BACKGROUND

The relationship between fibroids and infertility remains an unsolved question, and management of intramural fibroids is controversial. During the implantation phase, uterine peristalsis is dramatically reduced, which is thought to facilitate embryo implantation. Our aims were to evaluate (i) the occurrence and frequency of uterine peristalsis in infertile women with intramural fibroids and (ii) whether the presence of uterine peristalsis decreases the pregnancy rate.

METHODS

Ninety-five infertile patients with uterine fibroids were examined using magnetic resonance imaging (MRI). Inclusion criteria were as follows: (i) presence of intramural fibroids, excluding submucosal type; (ii) no other significant infertility factors (excluding endometriosis); and (iii) regular menstrual cycles, and MRI performed at the time of implantation (luteal phase day 5-9). The frequency of junctional zone movement was evaluated using cine-mode-display MRI. After MRI, patients underwent infertility treatment for up to 4 months, and the pregnancy rate was evaluated prospectively.

RESULTS

Fifty-one patients fulfilled the inclusion criteria, and 29 (57%) and 22 (43%) patients were assigned to the low (0 or 1 time/3 min) or high frequency (≥ 2 times/3 min) uterine peristalsis group, respectively. Endometriosis incidence was the same in both groups. Ten out of the 29 patients (34%) in the low-frequency group achieved pregnancy, compared with none of the 22 patients (0%) in the high-frequency group (P< 0.005). Comparing pregnant and non-pregnant cases, 4 of 10 patients (40%) and 9 of 41 patients (22%), respectively, had endometriosis (not significant).

CONCLUSIONS

A higher frequency of uterine peristalsis during the mid-luteal phase might be one of the causes of infertility associated with intramural-type fibroids.

Recurrence of ovarian endometrioma after laparoscopic excision

BACKGROUND

To analyse risk factors that influence the recurrence of endometrioma after laparoscopic excision.

METHODS

A total of 224 patients who had a minimum of 2 years of post-operative follow-up after laparoscopic ovarian endometrioma excision were studied retrospectively. Recurrence was defined as the presence of endometrioma more than 2 cm in size, detected by ultrasonography within 2 years of surgery. Fourteen variables (age, presence of infertility, pain, uterine myoma, adenomyosis, previous medical treatment of endometriosis, previous surgery for ovarian endometriosis, single or multiple cysts, the size of the largest cyst at laparoscopy, unilateral or bilateral involvement, co-existence of deep endometriosis, revised American Society for Reproductive Medicine (ASRM) score, post-operative medical treatment and post-operative pregnancy) were evaluated to assess their independent effects on the recurrence using logistic regression analysis.

RESULTS

The overall rate of recurrence was 30.4% (68/224). Significant factors that were independently associated with higher recurrence were previous medical treatment of endometriosis [odds ratio (OR) = 2.324, 95% confidence interval (95% CI) = 1.232-4.383, P = 0.0092) and larger diameter of the largest cyst (OR = 1.182, 95% CI = 1.004-1.391, P = 0.0442). Post-operative pregnancy was associated with lower recurrence (OR = 0.292, 95% CI = 0.028-0.317, P = 0.0181).

CONCLUSIONS

Previous medical treatment of endometriosis or large cyst size was a significant factor that was associated with higher recurrence of the disease. Post-operative pregnancy is a favourable prognostic factor.

Usefulness of epidural anesthesia in gynecologic laparoscopic surgery for infertility in comparison to general anesthesia

BACKGROUND

Although the advantages of epidural anesthesia in open surgery have been established, its usefulness in the setting of laparoscopic surgery remains to be studied.

METHODS

Patients undergoing laparoscopic surgery for infertility were randomly administered epidural anesthesia (group A, n = 11) or general anesthesia (group B, n = 9). The operation was performed under 4 mmHg pneumoperitoneum and in the 20 degrees Trendelenburg position. Respiratory function tests using a spirometer and blood gas analysis were performed during the intra- or perioperative period. Pain status was evaluated with visual analog scale scoring. The number of postoperative recovery days needed to resume daily activities was obtained by a questionnaire.

RESULTS

Respiratory rate, minute volume, P(a)CO2, % vital capacity (VC), and forced expiratory volume in 1 s (FEV1) % were virtually constant throughout the study period in group A, whereas %VC was decreased immediately after operation in group B (p < 0.05). Minute volume immediately after operation was significantly increased in group B compared with group A (p < 0.01), suggesting shallow respiration in women undergoing general anesthesia. Observed pain scores on abdominal pain, shoulder pain, and dyspnea were very low during operation in group A. Pain scores immediately and 3 h after operation were also minimal in group A, whereas abdominal pain scores at these points were significantly higher in group B than those in group A (both p < 0.01). The number of days required for a half reduction in wound pain, trotting, and full recuperation for group A were less than those for group B (p < 0.05).

CONCLUSIONS

Epidural anesthesia, when used in laparoscopic surgery for infertility treatment, has advantages over general anesthesia in terms of analgesic effects, postoperative respiratory function, and a return to preoperative daily activities.

Demonstration of angiogenin in human endometrium and its enhanced expression in endometrial tissues in the secretory phase and the decidua

Angiogenesis is thought to be crucial for normal physiology of the endometrium, where dynamic vascular remodeling occurs during the menstrual cycle and pregnancy. We investigated the presence of angiogenin, a potent inducer of angiogenesis, and the regulatory mechanisms of its production in the human endometrium. Western blot analysis demonstrated that angiogenin protein expression increased by 3- to 4-fold in the endometrium in the mid and late secretory phases and in early gestation relative to that during the proliferative phase. Quantitative mRNA analysis showed the similar tendency in the expression of angiogenin mRNA in the endometrium, with the highest levels observed in the mid and late secretory phases and early gestation. An immunohistochemical study showed that angiogenin was expressed in both stromal cells and epithelial cells, with indistinguishable intensity between these cells regardless of phases of the menstrual cycle. In support of the Western blot analysis, the intensity of staining appeared to be highest in the mid to late secretory phases relative to other phases. Consistent with these in vivo results, decidualized cultured stromal cells, after treatment with progesterone or progesterone plus E2, exhibited the capacity to secrete significantly increased amounts of angiogenin compared with untreated or E2 alone-treated control group. Both the treatment with (Bu)2cAMP and hypoxic conditions stimulated angiogenin secretion by stromal cells. For isolated epithelial cells, hypoxia stimulated angiogenin secretion, whereas (Bu)2cAMP had no appreciable effect. In summary, we demonstrated the presence of angiogenin in human endometrium and its possible local regulatory factors, such as progesterone, cAMP, and hypoxia. These findings along with its enhanced expression in the endometrium in the secretory phase and in decidual tissues raise the possibility that angiogenin may play a role in establishing pregnancy.

Evidence for the expression of interleukin (IL)-18, IL-18 receptor and IL-18 binding protein in the human endometrium

To see whether the interleukin (IL)-18 system is operative in the endometrium, we examined the expression of IL-18, IL-18 receptor (IL-18R) and IL-18 binding protein (IL-18BP), the substance known to neutralize IL-18 activity, in this tissue. Reverse transcription-polymerase chain reaction analyses showed that IL-18, IL-18R and IL-18BP mRNA were constitutively expressed without significant fluctuation throughout the menstrual cycle. When epithelial cells and stromal cells were cultured separately, the expression levels of IL-18 mRNA in epithelial cells were about 18-fold higher compared to those in stromal cells. Furthermore, the IL-18 precursor protein was detected by Western blot analysis in cultured epithelial cells but not in stromal cells. Recombinant human IL-18 stimulated the secretion of interferon (IFN)-gamma by resident bone marrow-derived cells in the endometrium. On the other hand, IFN-gamma up-regulated the IL-18BP expression both in cultured epithelial cells and stromal cells. Thus, we have presented evidence for the presence of the IL-18 system in the human endometrium. In light of its immunomodulatory roles in a variety of tissues, this system may afford protection against pathogenic micro-organisms and provide a regulatory mechanism for controlled trophoblast invasion by modulating a local cytokine network.

Axial symptoms after en bloc cervical laminoplasty

Eighty-two patients were evaluated after cervical laminoplasty to explore measures that could minimize future postoperative axial complaints. Patients were divided into two groups: Group A--severe postoperative axial symptoms, and Group B--mild axial complaints. Japanese Orthopaedic Association outcomes scores were similar for the two groups. Radiologic studies demonstrated greater restriction of range of motion in Group A patients who had undergone longer and more extensive surgical procedures.

Acquired dural arteriovenous malformations of the lumbar spine: case report

OBJECTIVE AND IMPORTANCE

Although dural arteriovenous malformations (AVMs) are considered to be acquired, no conclusive evidence has been obtained. The first case of dural AVMs of the lumbar spine that showed evidence supporting their being acquired lesions is described.

CLINICAL PRESENTATION

A 27-year-old man was admitted to our hospital in November 1994, presenting with increasing pain and numbness in the left buttock to the left lower limb. Myelography and arteriography showed dural AVMs of the lumbar spine. However, the myelogram obtained before surgery for lumbar disc herniation in 1987 provided no findings suggestive of intradural vascular anomalies.

INTERVENTION

Embolization procedures via the left iliolumbar arteries were performed. However, there was no improvement of the symptoms, and the patient underwent surgical treatment.

CONCLUSION

The present report documents a case of dural AVMs of the lumbar spine that showed evidence supporting their being acquired lesions.