Outcomes Following Recent and Distant Neoadjuvant Radiation in Rectal Cancer: An Institutional Retrospective Review and Analysis of NSQIP

BACKGROUND

Neoadjuvant chemoradiotherapy (nCRT) is the standard of care in locally advanced rectal cancer (LARC). However, radiation therapy is thought to increase operative difficulty due to induction of fibrosis. Total neoadjuvant therapy (TNT) protocols increase the time between completion of radiation and surgical resection which may lead to increased operative difficulty and complications.

METHODS

A single institution retrospective review of patients ≥18 years with LARC undergoing nCRT from 2015 to 2022. Patients were dichotomized in 2 cohorts: <90 days from radiation to surgery (recent radiation), and ≥90 days from radiation to surgery (distant radiation). Institutional data was compared to National Surgical Quality Improvement Program (NSQIP) rectal cancer data from 2016 to 2020. Outcomes included intraoperative complications, 30-day morbidity, and oncologic outcomes.

RESULTS

One hundred forty-six institutional patients included, 120 had recent radiation, 26 had distant radiation. Thirty-day morbidity and intraoperative complications did not differ. There was greater radial margin positivity (7% vs. 24%), fewer lymph nodes harvested (17 ± 5 vs. 15 ± 6), and a lower rate of complete mesorectal dissection (88% vs. 65%,) in distant radiation patients 3059 patients were included in NSQIP analysis, 2029 completed radiation <90 days before surgery and 1030 without radiation 90 days before surgery. Patients without radiation 90 days preoperatively had more radial margin positivity (9.2% vs. 4.6%), organ space infection (8.6% vs. 6.4%), and pneumonia (2.2% vs. 0.9%).

CONCLUSION

The present study suggests that increased time between radiation and surgery results in more challenging dissection with less complete mesorectal dissection and increased radial margin positivity without increasing technical complications.

Pulmonary Apical Cap as a Potential Risk Factor for Pleuroparenchymal Fibroelastosis

Pleuroparenchymal fibroelastosis (PPFE) is a progressive and frequently fatal interstitial lung disease that involves the upper lobes. Although its cause remains unknown, the histopathologic evidence underlying PPFE bears striking resemblance to that of the pulmonary apical cap (PAC), a relatively common and benign entity. We describe the case of a patient with PAC that evolved into distinctly asymmetric PPFE over 6 years after unilateral surgical lung injury. Given the histologic similarity between these two conditions, we propose that these two entities underlie common biologic pathways of abnormal response to lung injury, with the presence of a PAC increasing susceptibility to the development of PPFE in the face of ongoing inflammatory insults. This case describes the histopathologic evolution of PAC to PPFE before and after an inciting injury.

VNS implantation in a NF1 patient: massive nerve hypertrophy discovered intra-operatively preventing successful electrode placement. Case report

For the vast majority of surgeons, no specific investigation is necessary before vagal nerve stimulation (VNS) implantation. We report our intraoperative unexpected finding of a massively enlarged vagus nerve in a patient with neurofibromatosis type 1 (NF1). The nerve hypertrophy prevented wrapping the coils of the helical electrode. The patient had no signs of vagus nerve dysfunction preoperatively (no hoarseness or dysphonia). This exceptional mishap is undoubtedly related to NF1-associated peripheral nerve sheath tumors. Even though it is not advisable to routinely perform any imaging prior to VNS, in such specific context, preoperative imaging work-up, especially cervical ultrasound, might be judicious to rule out any asymptomatic enlarged left vagus nerve.

A Rare Case of Fatal Pulmonary Embolism in a Pediatric Spine Surgery

BACKGROUND

An 11-year-old girl had undergone posterior spinal fusion surgery for scoliosis. The surgery was complicated by intraoperative bleeding, and hemostasis was achieved by topically applying gelatin sponges.

CASE DESCRIPTION

She developed acute pulmonary embolism and cardiac arrest during the surgery, which was confirmed by transesophageal echocardiography.

CONCLUSIONS

Autopsy shortly after revealed that her death was associated with unintended intravascular entry of gelatin sponge fragments, resulting in an embolic event and secondary cardiopulmonary collapse.

Photodegradable CuS SERS Probes for Intraoperative Residual Tumor Detection, Ablation, and Self-Clearance

Surface-enhanced Raman scattering (SERS) probes have exhibited great potential in biomedical applications. However, currently reported SERS probes are mainly fabricated by nondegradable Au or Ag nanostructures, which are not favorably cleared from the imaged tissues. This bottleneck hinders their in vivo applications. We herein explore a degradable SERS probe consisting of hollow CuS nanoparticles (NPs) to circumvent the current limitation. We identify, for the first time, the Raman enhancement effects of hollow CuS NPs as a SERS probe for Raman imaging of residual tumor lesions. Uniquely, CuS SERS probes are degradable, which stems from laser-induced photothermal effects of CuS NPs, leading to their disintegration from shell structures into individual crystals, thus facilitating their self-clearance from imaged tissues. This novel CuS SERS probe with photodegradation characteristics opens avenues for applying Raman imaging toward a myriad of biomedical applications.

Unexpected Gallbladder Cancer during or after Laparoscopic Cholecystectomy: Risk Factors and Experience of Diagnosis and Treatment of 22 Cases

This study aims to provide some experience in diagnosis and treatment of unexpected gallbladder cancer (UGBC) and find the major risk factors. Retrospective data were collected and analyzed on 22 patients who were diagnosed with UGBC during or after laparoscopic cholecystectomy from January 2013 to January 2018 at our hospital. Average age of the patients was (60.2 ± 12.8) years (range, 42-83 years). Among them, there were 6 men and 16 women. Gallbladder stones, atrophic gallbladder, uneven thickened wall of the gallbladder, and choledocholithiasis were found to be the major risk factors. Eight patients (36.4%) were diagnosed intraoperatively. Seven cases (31.8%) were at the T1 stage; of these, three were treated with laparoscopic cholecystectomy; two were converted to cholecystectomy; and two underwent cholecystectomy, lymph node dissection, and liver resection. Eight (36.4%) T2 patients, five (22.7%) T3 patients, and one T4 patient had radical cholecystectomy. Partial cholecystectomy and cholecystotomy were carried out in another T4 patient. T1 patients did not receive chemotherapy or radiotherapy. Eleven had chemotherapy and four received chemoradiotherapy. The follow-up period ranged from six months to five years. The one-year survival rate for T1 to T4 patients was 100 per cent, 75 per cent, 40 per cent, and 0 per cent, respectively. A high index of clinical suspicion of UGBC is needed if one patient suffered from both gallbladder stones and choledocholithiasis with atrophic gallbladder or uneven thickened wall of the gallbladder preoperatively. To avoid more UGBC and reoperation, imaging examinations combined with tumor marker tests and intraoperative histopathologic examination are highly recommended.

Spontaneous closure of an iatrogenic coronary artery fistula during recanalization of a chronic total occlusion lesion: A case report

RATIONALE

Coronary perforation leading to fistula directed to the right ventricle is a rare complication of percutaneous coronary intervention (PCI). The reported outcomes vary from a stable state to rapid deterioration.

PATIENT CONCERNS

An 86-year-old man was diagnosed with non-ST elevation myocardial infarction, and arranged to PCI procedure for the chronic total occluded right coronary artery (RCA) after coronary angiography. The guide wire went through the occluded lesion and got to the distal part of the suspected "post lateral artery", which later proved to be in the right ventricle (RV). After dilating with a 2.0 mm balloon, large amount of contrast medium leaked out from the lesion; therefore, we suspected a perforation into the pericardium.

INTERVENTION

Protamine was intravenously injected to convert the effect of heparin and the 2.0 mm balloon in diameter was dilated for about 1 h to obstruct the ejected blood flow shunting into the pericardium, but the leakage persisted. Nevertheless, the patient remained stable, and we were unable to detect an effusion in the pericardium.

DIAGNOSIS

By analyzing the angiogram and echocardiogram, we found that the contrast did not leak into the pericardium, but into the right ventricle (RV) chamber. An iatrogenic coronary artery fistula (ICAF) from the RCA to the RV was confirmed. We thus terminated the procedure.

OUTCOMES

Coronary computed tomography (CT) angiography was performed 2 days after the PCI and no abnormal shunt was found. There was no abnormal Doppler signal in the RV, either. The patient was soon discharged, and there have been no complaints of discomfort during the 10-month follow-up.

LESSONS

ICAFs from coronary to the RV always have favorable outcomes. Even like the one in this case that caused medium leakage could seal spontaneously without any additional management. Echocardiography or coronary CT angiography could be chosen as imaging options to follow-up ICAFs.

Urine can speed up the re-epithelialization process of prostatic urethra wounds by promoting the proliferation and migration of prostate epithelial cells

Objectives

The present study aimed to investigate the influence of urine on re-epithelialization in canine prostatic urethra after prostatectomy and explore possible causes.

Method

We established two groups of prostatic canine models. The first group contained urine that canines underwent the surgery by two-micron laser resection of the prostate-tangerine technique (TmLRP-TT), and no transurethral catheter was required. The second group was without urine that canines accepted the surgery by TmLRP-TT add ureter skin ostomy urine bypass. Histopathology of re-epithelialization of repair in trauma in canine prostatic urethra was observed by hematoxylin and eosin (HE) staining, and immunochemistry was used to determine the expression of transforming growth factor-β₁ (TGF-β₁). Human prostate epithelial line (BPH-1) cells were cultured with or without urine and the abilities of proliferation and migration were tested by CCK-8 and transwell assays, respectively.

Results

The histology displayed that there was distinct proliferation of prostatic cell under the wound after 3 days, re-epithelialization began after 9 days, and finished after 28 days at urine group. The TGF-β1 like-IR in prostatic epithelium cells and fibroblast cells under the wound at urine group were strikingly increased as compared with the cells at no urine group after 3, 9, and 11 days, respectively (p < 0.05). In CCK-8 and Transwell assays, an increase of cells’ proliferation and migration was detected in urine culture group compared with no urine culture group (p < 0.05).

Conclusion

Urine may speed up the re-epithelialization process for prostatic urethra wounds by promoting proliferation and migration of prostate epithelial cells.

Posterior Empty Spaces during Vitreoretinal Surgery

PURPOSE

To study during vitreoretinal surgery the intravitreal posterior empty spaces caused by different posterior relationships between the retina, posterior hyaloid and posterior vitreous.

METHODS

A total of 151 eyes with different vitreoretinal disorders were considered; 97 eyes with retinal detachment (Group I), 54 eyes without retinal detachment (Group II). Intraoperative anatomy was carefully observed. In Group I, intraoperative observations were made with and without the infusion fluid entering the eyes.

RESULTS

Different intraoperative posterior empty spaces were found: (i) within the posterior vitreous, (ii) between the detached posterior hyaloid and the retina, (iii) above and below the detached posterior "isolated hyaloid", and (iv) between the more posterior vitreous and the attached posterior hyaloid. The infusion fluid flux may variously change the size and shape of these posterior empty spaces.

CONCLUSIONS

Many types of posterior empty spaces were observed intraoperatively. Their correct interpretation was important to well-conducted surgery. Dynamic movements of fluids in the vitreous cavity caused many intraoperative artifacts, making it difficult to understand the empty spaces and the vitreoretinal relationships present before surgery.

Case report of refractory pericardial effusion associated with lymphatic fistula due to surgical injury during sternotomy

RATIONALE

A 35-year old Chinese female was admitted to hospital with refractory pericardial effusions 10 days post mitral valve replacement via median sternotomy. We performed an exploratory resternotomy and found lymphatic leakage on the surface of the diaphragm which was continuously emitting a light yellow fluid.

PATIENT CONCERNS

The patient complained of no obvious discomfort except for the concern of massive pericardial effusion drainage.

DIAGNOSES

Exploratory resternotomy and biochemical testing lead to a supradiaphragmatic lymphatic fistula being diagnosed as the cause of the refractory pericardial effusion.

INTERVENTIONS

The fistula was closed with a continuous suture and no other fistulas were found after a thorough exploration.

OUTCOMES

The patient was discharged home on postoperative day 5 and recovery was uneventful.

LESSONS

In this case a timely exploratory resternotomy proved effective in seeking the cause of and treating pericardial effusion following cardiac surgery.

[Non-functioning gallbladder as a risk factor for bile ducts injury during laparoscopic cholecystectomy]

AIM

To analyze the effect of gallbladder's morpho-functional changes as a risk factor for injury of extrahepatic bile ducts during cholecystectomy.

MATERIAL AND METHODS

Laparoscopic cholecystectomy was performed in 20 564 patients. There were 147 64 (71.8%) patients with chronic gallbladder inflammation and 5800 (28.2%) - with acute process. It was performed a retrospective analysis of the incidence and causes of intraoperative trauma of extrahepatic bile ducts and bile outflow. Two groups of comparison were distinguished: acute calculous cholecystitis and chronic inflammation.

RESULTS

There were 93 (0.04%) complications followed by bile outflow (55 (0.94%) in the 1^st group and 38 (0.25%) in the 2^nd group). Marginal injury of the ducts was interoperatively detected in 5 patients of group 1 and 3 patients of 2 groups. In postoperative period it was found in 6 patients of the 1^st group due to electric trauma of common bile duct. Complete transection of common bile duct occurred in 10 (8.8%) cases, while chronic calculous cholecystitis was observed in 8 of them. At the same time, in 6 patients these were surgical interventions in scleroatrophic gallbladder. As a results, we determined the forms of non-functioning gallbladder with morphofunctional changes which promote trauma of extrahepatic bile ducts.

CONCLUSION

Long-term non-functioning gallbladder leads to cicatricial and adhesive processes in its wall and surrounding tissues that significantly complicates cholecystectomy and increases the risk of bile ducts trauma. Scleroatrophic gallbladder is the most dangerous which occurs in 4.1% of patients with chronic calculous cholecystitis. Further trials are advisable to develop optimal therapeutic and diagnostic tactics for various forms of long-term non-functioning gallbladder.

Stray energy transfer during endoscopy

INTRODUCTION

Endoscopy is the standard tool for the evaluation and treatment of gastrointestinal disorders. While the risk of complication is low, the use of energy devices can increase complications by 100-fold. The mechanism of increased injury and presence of stray energy is unknown. The purpose of the study was to determine if stray energy transfer occurs during endoscopy and if so, to define strategies to minimize the risk of energy complications.

METHODS AND PROCEDURES

A gastroscope was introduced into the stomach of an anesthetized pig. A monopolar generator delivered energy for 5 s to a snare without contacting tissue or the endoscope itself. The endoscope tip orientation, energy device type, power level, energy mode, and generator type were varied to mimic in vivo use. The primary outcome (stray current) was quantified as the change in tissue temperature (°C) from baseline at the tissue closest to the tip of the endoscope. Data were reported as mean ± standard deviation.

RESULTS

Using the 60 W coag mode while changing the orientation of the endoscope tip, tissue temperature increased by 12.1 ± 3.5 °C nearest the camera lens (p < 0.001 vs. all others), 2.1 ± 0.8 °C nearest the light lens, and 1.7 ± 0.4 °C nearest the working channel. Measuring temperature at the camera lens, reducing power to 30 W (9.5 ± 0.8 °C) and 15 W (8.0 ± 0.8 °C) decreased stray energy transfer (p = 0.04 and p = 0.002, respectively) as did utilizing the low-voltage cut mode (6.6 ± 0.5 °C, p < 0.001). An impedance-monitoring generator significantly decreased the energy transfer compared to a standard generator (1.5 ± 3.5 °C vs. 9.5 ± 0.8 °C, p < 0.001).

CONCLUSION

Stray energy is transferred within the endoscope during the activation of common energy devices. This could result in post-polypectomy syndrome, bleeding, or perforation outside of the endoscopist's view. Decreasing the power, utilizing low-voltage modes and/or an impedance-monitoring generator can decrease the risk of complication.

Learning curve for laparoscopic Heller myotomy and Dor fundoplication for achalasia

Purpose

Although laparoscopic Heller myotomy and Dor fundoplication (LHD) is widely performed to address achalasia, little is known about the learning curve for this technique. We assessed the learning curve for performing LHD.

Methods

Of the 514 cases with LHD performed between August 1994 and March 2016, the surgical outcomes of 463 cases were evaluated after excluding 50 cases with reduced port surgery and one case with the simultaneous performance of laparoscopic distal partial gastrectomy. A receiver operating characteristic (ROC) curve analysis was used to identify the cut-off value for the number of surgical experiences necessary to become proficient with LHD, which was defined as the completion of the learning curve.

Results

We defined the completion of the learning curve when the following 3 conditions were satisfied. 1) The operation time was less than 165 minutes. 2) There was no blood loss. 3) There was no intraoperative complication. In order to establish the appropriate number of surgical experiences required to complete the learning curve, the cut-off value was evaluated by using a ROC curve (AUC 0.717, p < 0.001). Finally, we identified the cut-off value as 16 surgical cases (sensitivity 0.706, specificity 0.646).

Conclusion

Learning curve seems to complete after performing 16 cases.

Target Sign: Endoscopic Sign of the Colonic Perforation

N/A.

Safety assessment of the use of ultrasonic energy in the proximity of the recurrent laryngeal nerve in a porcine model

BACKGROUND

Advanced bipolar and ultrasonic energy have demonstrated reduction of operating time and blood loss in thyroidectomy. However, these devices generate heat and thermal dispersion that may damage adjacent structures such as the recurrent laryngeal nerve (RLN). This study was designed to evaluate the safety profile of the Harmonic Focus+^® (HF+) device through the evaluation of thermal injury to the RLN using different algorithms of distance and time with state of the art technology.

METHODS

25 Vietnamese pigs underwent activation of HF+ in the proximity of their RLN. They were divided into 4 groups according to activation distance (3 mm, 2 mm, 1 mm and on the RLN). Time of activation, time between tones of the ultrasonic generator, changes in the electromyographic signal using continuous nerve neuromonitoring, vocal fold mobility assessed by direct laryngoscopy and histological thermal damaged were evaluated.

RESULTS

None of the pigs had loss of signal in the electromyography during the procedure; only one pig had isolated transient decrease in amplitude and one increase in latency. One pig had transient vocal fold paresis in the group with activation on the nerve. Evaluation of the nerves by histology and immunohistochemistry did not show significant changes attributed to thermal injury.

CONCLUSIONS

The use of ultrasonic energy close to the RLN is safe, provided that activation time does not exceed the necessary time to safely transect the tissue.

Comparison of 12-month anatomic and functional results between Z6 femtosecond laser-assisted and manual trephination in deep anterior lamellar keratoplasty for advanced keratoconus

The management of severe keratoconus requires corneal transplantation, for which the gold standard is deep anterior lamellar keratoplasty (DALK), preserving the healthy Descemet's membrane and endothelium. The safety and reproducibility of corneal cuts have been improved by the evolution of femtosecond lasers in refractive surgery, and femtosecond laser in DALK would seem to provide the same advantages over the manual method. In our retrospective study, we compare functional and anatomical results of femtosecond-assisted DALK versus manual trephination DALK in patients with keratoconus in stage 4 of the Krumeich classification. It is a retrospective study including all patients with stage 4 keratoconus who underwent femtosecond laser-assisted DALK between November 2012 and November 2015 in Nantes university medical center. We compared those patients to a group of patients who underwent manual DALK in the same period, paired by age and maximal keratometry. We assessed visual acuity, pachymetry, endothelial cell density (specular microscopy), and keratometry before surgery and at 4, 8 and 12 months of follow-up. Laser settings and intraoperative complications were recorded. Nineteen patients underwent surgery by femtosecond-assisted DALK, 6 women and 12 men with average age 30.2±10.8 years at transplantation. They were paired with a group of 17 patients who underwent manual DALK in order to compare results. Before surgery, mean visual acuity in the femtosecond group was 0.90 logMAR versus 0.89 logMAR in the manual group, showing no statistically significant difference (P=0.96). Both groups were similar in terms of preoperative age, mean keratometry, pachymetry and endothelial cell density. Average visual acuity post-surgery was 0.27; 0.26; and 0.14 logMAR for femtosecond DALK versus 0.27; 0.17 et 0.25 for manual DALK at 4, 8 and 12 months follow-up respectively, showing no statistically significant difference. After surgery, at 4, 8 and 12 months, mean pachymetry was similar in both groups, and average endothelial cell density was 2390 cells/mm² for femto DALK versus 2531 cells/mm² for manual DALK at 12 months of follow-up, showing no statistically significant difference (P=0.5726). The rate of Descemet's membrane microperforations during the procedure was low and similar for both groups. Our study allows for a 12-month follow-up, with assessment of visual recovery, anatomic result and endothelial safety in a series of 19 femtosecond laser-assisted DALK with no statistical significant difference versus the manual trephination group. Femtosecond laser allows for increased reproducibility of the DALK procedure without reducing adverse effects during surgery. Femtosecond laser seems to improve the technique of the DALK procedure, and future developments could improve the reproducibility of DALK even further. A medical economics study would be necessary to determine the cost-effectiveness of femtosecond laser-assisted DALK.

[ОPTIMIZATION OF SURGICAL TREATMENT OF HEMORRHOIDAL DISEASE STAGES III-IV]

The treatment results in patients, suffering chronic hemorrhoidal disease stages III- IV, in accordance to the elaborated method of hemorrhoidectomy, using radio-wave scalpel «Surgitron TM» with further welding of vascular pedicle, applying high-frequency electrocoagulator ЕК-301М1, are presented. In the patients, оperated on in accordance to the method proposed, the intraoperative complications rate and the blood loss severity were essentially lesser than in a comparison group. Owing an adequate level of surgical skills, the operative treatment method elaborated guarantees the reduction of early and late postoperative morbidity, rapid coming back to routine way of living postoperatively.

[АNESTHESIOLOGICAL SUPPORT OF PANCREATICODUODENAL RESECTION]

Efficacy of combined and potentiated methods of anesthesiological support of operative interventions on the organs of pancreatoduodenal zone was estimated. In 43 consequently treated patients operative interventions was performed for malignant tumors and fibrous-degenerative changes of pancreatic gland. Efficacy and interchangeability of various methods of anesthesiological support for reduction of the operative risk stage and the risk of intraoperative iatrogenic injury was studied.

[LAPAROSCOPIC PLASTY OF INGUINAL HERNIAS]

Laparoscopic hernioplasty, of them in 19 - for recurrence of hernia after auto- (in 10) and alloplasty in accordance to Liechtenstein procedure (in 9), and in 11, suffering bilateral hernias - were performed in 2011-2016 yrs in 149 patients. All the patients are alive. Complications have occurred in 21 patients. The main technical complexities have occurred in injury of upper epigastric vessels. Оperative interventions, using laparoscopic procedures are effective, pathogenetically substantiated, guaranteeing comfortable course of postoperative period and possibility of early rehabilitation of the patients.

[Perthes syndrome secondary to an asthma attack: A case report in a 15-year-old child]

Perthes syndrome, or traumatic asphyxia syndrome, is a rare clinical entity, associating cyanosis, cervicofacial petechiae and subconjunctival hemorrhage. It is usually secondary to chest trauma, but can occur in any situation of abrupt rise in intrathoracic pressure with closed glottis. In this paper, we present a case of Perthes syndrome that triggered an asthma attack for a child during surgery.

Reducing Cerebral Emboli During Cardiopulmonary Bypass

Neurologic injury is a common complication of cardiac surgery and is associated with significant morbidity, mortality, and resource utilization. The incidence varies widely according to the definition used, patient age, and complexity of surgery. The manifestations of neurologic injury are broad, ranging from subtle neurocognitive dysfunction to frank stroke. An increasing amount of evidence points to cerebral embolization during cardiopulmonary bypass (CPB) as the principal etiologic factor of these neurologic complications. Cerebral emboli may be composed of atherosclerotic debris, calcium, air, fat, platelet thrombi, or CPB tubing. Advancements in perfusion technology, CPB techniques and surgical strategies may lead to a reduction in neurologic injury during cardiac surgery. In the current paper, we discuss the pathophysiology of neurologic injury after cardiac surgery and methods of reducing cerebral embolization. Reducing emboli and neurologic injury during CPB requires a multidisciplinary approach that includes several simple diagnostic and therapeutic strategies. Reducing cerebral emboli should be a major goal for future research in the fields of cardiac anesthesia, surgery and perfusion.

[[Video-assisted pulmonary resection application for pulmonary tuberculosis].]

Results of application of video-assisted (video-assisted thoracic surgery VATS) pulmonary resection for pulmonary tuberculosis in 63 patients in 2008 - 2016 yrs were analyzed. Typical lobectomy was done in 28 (44.4%) patients, pulmonectomy - in 1 (1.6%), lower bilobectomy - in 1 (1.6%), combined resection of upper lobe and the Cv segment - in 1 (1.6%), typical segmentectomy - in 23 (36.5%), atypical one - in 9 (14.3%). Intraoperative complications have occurred in 4,(6.3%) patients, and postop- erative - in 8 (12.7%). Total efficacy of performance of pulmonary VATS-resection have constituted 98.4%. VATS-pulmonary resection is a miniinvasive and perspective treatment procedure. Meticulous selection of patients is needed for such intervention be applied.

Surgical injury-induced early neocortical microvascular changes and characteristics of the cells populating the peri-lesion zone

Adult mammalian brain contains a number of specialized neurovascular structures termed "niches" that act as sources of neuronal cells throughout the individual's life. Some of the niches generate neurons to satisfy the need for 'replacement' neurons within the same or closely located brain structures, whereas the other can provide such cells for more distant destinations in the brain. A common characteristic of known neurovascular niches is the presence of a complex 3-dimensional network of basal lamina processes, called fractones. It apparently plays a major role in communication between the various niche-populating cell types as well as in niche activity and output. We hypothesized that similar niches may form ad hoc after a mechanical brain trauma, and tested this possibility in a rat model of surgical brain injury. Four days after removing a small fragment of sensorimotor cortex, the peri-wound region showed numerous symptoms of active repair and remodeling of brain parenchyma, including the presence of multiple cell types of immature phenotypes. The latter, as shown by a variety of light and electron microscopy techniques, included endothelial cell precursors as well as nestin-positive immature neural cells of astrocytic or non-glial characteristics. However, there was no evidence of in situ neurogenesis or a considerable migration of cells from SVZ. The centers of the said repair processes were capillary blood vessels connected with basal lamina-formed fractones. These results indicate that surgical brain trauma causes the formation of a vascular niche with no apparent neurogenic potential.

BILATERAL ADDUCTOR VOCAL CORD PALSY: COMPLICATION OF PROLONGED INTRAOPERATIVE HYPOTENSION AFTER ENDOTRACHEAL INTUBATION

Endotracheal intubation for general anesthesia is usually a safe procedure. However, postoperative sore throat and mild hoarseness may occur due to laryngeal edema but bilateral vocal cord paralysis as a result of recurrent laryngeal nerve injury is a rare complication. We report a case of bilateral adductor vocal cord palsy following general anesthesia for abdominal surgery. Clinical presentation was hoarseness, aspiration pneumonia and hypoxemia requiring ventilatory support. Neuropraxia of recurrent laryngeal nerve due to prolong intra-operative hypotension, even with normal endotracheal tube cuff pressure was the likely mechanism.

The Impact of Confluence Types of the Right Gastroepiploic Vein on No. 6 Lymphadenectomy During Laparoscopic Radical Gastrectomy

This study investigated anatomical variations in the confluence types of the right gastroepiploic vein (RGEV) to improve knowledge regarding no. 6 lymphadenectomy for laparoscopic gastrectomy.The RGEV drainage patterns of 144 patients who were diagnosed with gastric cancer and underwent laparoscopic distal gastrectomy at our department from July 2010 to June 2011 were prospectively collected and retrospectively analyzed, and we compared the impact of different drainage patterns on no. 6 lymphadenectomy.The RGEV confluence types were classified into 6 categories in this study. Types I, II, and III, which were observed in 53 (36.8%), 27 (18.8%), and 21 (14.6%) cases, respectively, were the most frequently found during gastrectomy. All 3 of these types included a gastropancreatic trunk and were defined as the gastropancreatic group (GP group). In addition, 15 cases (10.4%) were categorized as type IV, 19 (13.2%) were categorized as type V, and 9 (6.3%) were categorized as type VI. These 3 types, which could form a gastrocolic trunk, were defined as the gastrocolic group (GC group). No significant differences were found with respect to the clinicopathological characteristics, postoperative morbidity, perioperative mortality, and 3-year overall survival rates after surgery between the 2 groups (all P > 0.05). However, the mean no. 6 lymph node (No. 6 LN) dissection time, the mean blood loss due to No. 6 LN dissection and the rate of infrapyloric vascular injury were significantly increased in the GC group compared with the GP group (all P < 0.05).The RGEV exhibits 6 types of drainage patterns, and the division points of this vein during laparoscopic gastrectomy depend on the different drainage patterns. For types IV, V, and VI, the surgeon should carefully vascularize and divide the RGEV above its confluences during surgery.

[PECULIARITIES OF METHOD AND RESULTS OF PLASTY, USING INTESTINAL SEGMENT, FOR IATROGENIC INJURY OF URETER]

Basing on analysis of the examination and treatment results in 53 patients, suffering iatrogenic injury of ureter (IIU), the indications for ureteric reconstruction using intestinal segment were the ureter long irreversible changes, while renal function preserved. A segmental ureteric plasty was done in 8 (15.1%) patients, a subtotal one--in 16 (30.2%), total--in 14 (26.4%), and bilateral--in 15 (28.3%). With the objective to prevent the bladder-intestinal reflux occurrence a distal part of the intestinal transplant was modeled. In 35 (66%) patients 2 - 3 cm of distal part of intestinal mucosa were turned out with the wrap formation. In 18 (34%) patients the creation of antireflux wrap was added by its modeling in a kind of intraileal plasty with formation of two separate channels in the intestinal-bladder anastomosis region. While performance of intraileal plasty of the bladder-intestinal reflux have occurred in 2 (11.1%) patients, and after procedure with the wrap formation--in 13 (37.1%).

Retrospective review of predisposing factors for intraoperative pressure ulcer development

STUDY OBJECTIVE

To evaluate the comorbidities and surgical factors involved in the genesis of intraoperative pressure ulcers.

DESIGN

Retrospective chart review.

SETTING

Anesthesiology department of a university medical center.

MEASUREMENTS

The charts of 222 patients with varying illness, who underwent an operation of at least two hours' duration, were analyzed retrospectively. Data on surgery type, case length, comorbidities, intraoperative surgical position, and area of ulceration were recorded.

MAIN RESULTS

Risk factors for intraoperative pressure ulcer development include surgical times of 4 hours or longer; comorbidities affecting tissue perfusion (namely, diabetes, hypertension, and nonspecific cardiac issues); supine placement during surgery; and abdominal, noncardiac thoracic, and orthopedic operations. Regions of the body most at risk for ulceration include the coccygeal/sacral region, the buttocks, genitalia, and heels.

CONCLUSIONS

Pressure ulcers are a costly, debilitating, and avoidable complication of surgery.

Dural involvement in skull base tumors--accuracy of preoperative radiological evaluation and intraoperative assessment

BACKGROUND

Dural involvement is an important consideration in assessment of cranial base tumors dictating resectability and prognosis. Preoperative as well as intraoperative clues are valuable but not always correct. We evaluated a consecutive series of craniofacial resections at our center to correlate radiologically suspected dural involvement vis-à-vis intraoperative assessment and eventual pathology.

METHODS

We conducted a retrospective analysis of cases of skull base tumors where potential dural involvement was considered. We recorded the preoperative radiological impression (contrast-enhanced magnetic resonance imaging) regarding dural involvement (normal, extradural, intradural, parenchymal disease), intraoperative impression (normal, adherent, subdural, parenchymal disease), and final histology (normal, reactive, tumor). We also recorded instances where the dura was resected and/or inadvertently breached and the incidence of postoperative cerebrospinal fluid leak and meningitis.

RESULTS

One hundred twenty-seven cases were evaluated. Transcranial approaches were performed in 68 cases. Nineteen percent (24 cases) were endoscopic procedures. Dural resection was performed in 38 cases (30 being proven pathologically). The incidence of cerebrospinal fluid leak was 4.7%. The sensitivity, specificity, positive predictive value, and negative predictive value of magnetic resonance assessment were 34.5%, 97.9%, 83.3%, and 83.2%, respectively, providing an overall accuracy of 84%, and those for intraoperative dural adherence were 84.6%, 85.6%, 44%, 97.6%, and 85.5.%, respectively.

CONCLUSIONS

Preoperative magnetic resonance imaging, although a good modality for imaging the disease extent, may not always identify the extent of dural involvement. Intraoperative assessment therefore becomes very important especially when it is unequivocally normal. Both should be used to ensure accurate treatment strategies and tailor the need for dural resection.

[Immediate results of complex treatment of resectable rectal neoplasms of distal localization]

The impact of neoadjuvant chemoradiation on immediate results of treatment of resectable cancer recti, using large-fractionized radiation in combination with endolymphatic chemotherapy, was estimated. Using the method proposed 64 patients were treated (the main group). In control groups there were included 63 patients, to whom a course of a large-fractionized radiation on background of intravenous chemotherapy was applied, and in 91 patients a large-fractionized radiation only was used. The intraoperative complications rate in the main and control groups have had constituted, accordingly, 16, 6.3 and 3.3%. Postoperative complications have had occurred in 12.5% of patients in the main group, and in 15.9% and 14.3% - in the control groups. The abscesses formation was noted in a small pelvis cavity in 4.7% patients of the main, and in 4.8 and 4.4% - in the control groups. Necrosis of the descended gut was revealed in 10 (4.6%).

[Areas of risk for ureteral lesion during radical hysterectomy]

INTRODUCTION

The close interrelations of the pelvic ureter with surrounding structures and organs are a prerequisite for complications during surgical interventions in the lesser pelvis.

OBJECTIVE

Exploration and visualization of the areas of risk for lesion of pelvic ureter during minimally invasive radical hysterectomy.

RESULTS

Based on our observations and the available literature, we identified the following areas and steps of the radical hysterectomy as risky: at the entrance in the lesser pelvis, upon ligation of the infundibulopelvic ligament; incision of the back leaf of broad ligament of the uterus; dissection of the pararectal space; ligation of the uterine artery; dissection of the fourth space and transection of the vesicouterine ligaments; transection of the sacrouterine ligaments; incision of the anterior vaginal wall. We registered one uretero-vaginal fistula in a total of 133 patients on the eighth postoperative day. The lesion was identified in area of the distal portion of ureter.

CONCLUSION

Knowledge about the ureter location, its interrelations with surrounding structures, and its blood supply, combined with capable surgical techniques, would contribute to reduction of the incidence of complications.

[Intraoperative complications of surgical treatment of cervical cancer stages I and II in FIGO]

With this study are presented the types of intraoperative complications and their frequency in radical hysterectomy and lymph node dissection (pelvic and paraaortic) as surgical treatment of 294 patients with invasive cervical cancer FIGO stages I and II.

Metastatic undifferentiated pleomorphic sarcoma causing intraoperative stroke

Malignant Fibrous Histiocytoma was historically the most commonly diagnosed soft tissue sarcoma of adults. In 2002, the World Health Organization declassified malignant fibrous histiocytoma as a formal diagnostic entity. They recommended renaming the disease "Pleomorphic Undifferentiated Sarcoma". Current thoughts about the origin of this tumor are being debated. We report a case of a dedifferentiated liposarcoma that metastasized to the lung within one year. The histologic morphology of the metastasis was more aggressive than the primary lesion, and was consistent with a pleomorphic undifferentiated sarcoma. Following surgical resection of the metastatic pulmonary lesion, the patient never fully regained consciousness. He expired the day following his surgery. At autopsy, the patient was found to have died from a massive hemorrhagic stroke involving almost the entire left cerebrum. Tumor emboli from the pulmonary metastasis were seen in the left middle cerebral artery, causing the cerebral infarct. The embolic lesion was consistent with a pleomorphic undifferentiated sarcoma. This case illustrates the evolution that soft tissue sarcomas can undergo as they metastasize and become increasingly undifferentiated, and confirms the surgical risk of resecting such lesions.

Pathophysiology of coronary thrombus formation and adverse consequences of thrombus during PCI

Atherosclerosis is a systemic vascular pathology that is preceded by endothelial dysfunction. Vascular inflammation "fuels" atherosclerosis and creates the milieu for episodes of intravascular thromboses. Thrombotic events in the coronary vasculature may lead to asymptomatic progression of atherosclerosis or could manifest as acute coronary syndromes or even sudden cardiac death. Thrombus encountered in the setting of acute coronary syndromes has been correlated with acute complications during percutaneous coronary interventions such as no-reflow, acute coronary occlusion and long term complications such as stent thrombus. This article reviews the pathophysiology of coronary thrombogenesis and explores the complications associated with thrombus during coronary interventions.

[Endoscopic transpapillary methods of choledocholithiasis treatment, caused by presence of multiple calculi]

The results of endoscopic transpapillary surgical interventions in 115 patients, suffering choledocholithiasis, caused by the multiple calculi presence, were analyzed. The patients were divided on four groups, depending on the treatment provided. In 78 patients (first group) endoscopic papillosphincterotomy with mechanical lithoextraction in conjunction with spasmolytic and infusion therapy were performed. In 16 patients (second group) endoscopic papillosphincterotomy with mechanical lithotripsy and partial lithoextraction, endobiliary stenting with further spasmolytic and infusion therapy were performed. In 11 patients (the third group) endoscopic papillosphincterotomy, mechanical lithotripsy with a partial lithoextraction and nasobiliary drainage were used. In 10 patients (the fourth group) endoscopic papillosphincterotomy, mechanical lithotripsy, nasobiliary drainage and endobiliary stenting were applied. The best results were achieved in the first group: the smallest duration of the operation--(32.2 +/- 12.6) min, the smallest stationary state duration--(3.3 +/- 1.2) days, the lowest rate of intraoperative complications--2.6%.

Intraoperative ultrasound in malformations of cortical development

PURPOSE

Malformations of cortical development (MCD) are a common cause of medically refractory focal epilepsy. However, the intraoperative definition of MCD can be challenging. In this study we assess the feasibility of intraoperative ultrasound (IOUS) for the intraoperative localization of MCD.

MATERIALS AND METHODS

Five epilepsy patients with at least one suspected lesion of MCD were operated with the aid of IOUS. IOUS was compared to preoperative MRI and histopathology.

RESULTS

In three cases of focal cortical dysplasia (FCD) type IIB and one case of periventricular heterotopia, the lesions could be delineated well on IOUS and the configuration of the lesion corresponded to the appearance on MRI. However, only one of two FCD type I lesions could be detected on IOUS.

CONCLUSION

IOUS can be helpful in defining FCD IIB as well as periventricular heterotopia intraoperatively, but this seems to be more difficult in FCD type I.

Integrity of gut mucosa during anaesthesia in major abdominal surgery

The aim of the study was to examine a perfusion and integrity of small bowel in 60 subsequent patients during the major open abdominal surgery which lasted from 2 to 7 hours. Two samples of the intestinal mucosa were removed: at the beginning, and at the end of the surgical procedure in general anaesthesia. A mucosal injury was classified into 4 grades. pH, PCO2 and lactate level were measured in the blood samples from the arterial and mesenteric vein in one hour time intervals. The changes of intestinal mucosa were found in 31 patients (51.7%): in 19 patients (31.7%) grade 1 changes were recorded, in 10 patients (16.7%) grade 2, and in 2 patients (3.3%) grade 3. Grade 4 lesions were not recorded. There was a statistically significant correlation between grades of the mucosal damage and the surgery duration (p = 0.001). Analysis during the one hour intervals showed that there was no exact time point when the significant aggravation of the pathohistological changes in intestinal mucosa occurred. However, when patients were allocated into two subgroups with surgical procedures lasting less than 4 hours and more than 4 hours, there was a statistically significant difference in the grades of mucosal damage between subgroups (p < 0.05). More biopsies without pathohistological changes were observed in the patients whose procedure duration was < 4 hours. A significantly higher lactate concentrations in arterial and mesenteric venous blood were observed in the patients with pathohistological changes at 6 hours time point as compared to 2 hour time point in the patients without pathohistological changes (p < 0.05). During the open abdominal surgery in general anaesthesia, the length of the procedure influences the grade of the intestinal mucosa injury. Deterioration of the pathohistological findings in the intestinal mucosa correlates with high lactate blood level, suggesting that the cause of these changes may result from tissue hypoxia.

[Administration of dalteparin in reconstructive vascular surgery]

The article contains a review of the literature regarding the use of low-molecular-weight heparins (LMWHs) exemplified by dalteparin in the hitherto insufficiently explored area of their implementation, i. e., during the intraoperative period in patients suff ering from atherothrombosis. Presented herein is analysis of alterations in the parameters of the plasmatic and thrombocytic links of haemostatis during intraoperative administration of various molecular-weight fractions of heparin. The obtained findings make it possible to conclude that LMWHs do off er certain advantages when used during surgical interventions in patients with atherosclerotic lesions of the arterial bed.

[Topographically oriented mobilization of the thyroid]

The analysis of clinical experience of the operative treatment of 600 patients with a thyroid pathology has allowed to develop technics of allocation of a return laryngeal nerve depending on the type of an anatomic structure of a gland. It gave the opportunities for the extrafascial removal of a share of a thyroid gland, the more accurate visualization and preservation of the parathyroid glands, located near the nerve and safe central lymphadenectomy.

[Surgical hospital endotoxicosis as a problem of clinical gastroenterology]

The original conception of "surgecal endotoxicosis" is presentation in the artical.

MATERIALS AND RESEARCH METHODS

2064 of a patients and results of 320 autopsies was divided into 4 groups in depending with bowel dysfunctions. There is the new classification of surgecal endotoxicosis in this article. Also the authors propose some technologies of detoxication.

Transarterial coil embolization of a carotid-cavernous fistula which occurred during stent angioplasty

Intracranial endovascular procedures are less invasive and relatively safe; however, these procedures do carry a risk of complications, such as thromboembolization, arterial injury, and vessel occlusion. We present a case of carotid-cavernous fistula development secondary to injury of the cavernous segment of the internal carotid artery (ICA) during stent angioplasty and its treatment by transarterial coil embolization. Probable causes of this complication and its treatment method are discussed. To the best of our knowledge, this is the first report of such a case.

Application of a novel bone osteotomy plate leads to reduction in heat-induced bone tissue necrosis in sheep

Previous studies have shown substantial effect thermal damage can have on new bone formation following osteotomy. In this study we evaluated the extent of thermal damage which occurs in four different methods of osteotomy and the effects it can have on bone healing. We further wanted to test whether a special osteotomy plate we constructed can lead to diminished heat generation during osteotomy and enhanced bone healing. The four methods evaluated included osteotomy performed by chisel, a newly constructed osteotomy plate, Gigly and oscillating saw. Twelve adult sheep underwent osteotomy performed on both tibiae. Bone fragments were stabilized using a fixation plate. Callus size was assessed using standard radiographs. Densitometry and histological evaluation were performed at 8 weeks following osteotomy. Temperature measurements were performed both in vivo during the operation, and ex vivo on explanted tibiae. The defects healed without complications and showed typical course of secondary fracture healing with callus ingrowth into the osteotomy gap. Radiographic examination of bone healing showed a tendency towards more callus formation in bones osteotomized using Gigly and oscillating saw, but this difference lacked significance. Use of Gigly and oscillating saw elicited much higher temperatures at the bone cortex surface, which subsequently lead to slightly impaired bone healing according to histological analysis. BMD was equal among all bones. In conclusion, the time required for complete healing of the defect differed depended greatly on the instruments used. The newly constructed osteotomy plate showed best results based on histological findings of capillary and osteoblast density.

Complications during and after surgery of the lower cervical spine by isolated anterior approach with CSLP implant

BACKGROUND

The merits of different operative approaches in the management of spinal injury is debated. The aim of this study was to assess, retrospectively, the outcome of treatment of injuries of the lower cervical spine by an anterior approach, in terms of fusion rate and complications.

MATERIALS AND METHODS

Between 1995 and 2004, 270 patients with an injury of the lower cervical spine were operated on by an anterior approach in our hospital. There were 67 females and 203 males. Using the Aebi and Nazarian classification, 22% of patients had a type A injury, 23% of patients had a type B injury and 55% of patients had a type C injury. All had an anterior approach with monocortical stabilisation using a cervical spine locking plate [Synthes].

RESULTS

Radiological evidence of fusion was found in all but one patient at 6 months. Complications occurred in a small proportion of the series. Recurrent laryngeal nerve injury was noted in seven patients, an abscess in the wound in one patient, a haematoma requiring re-operation for evacuation in two patients. The cervical locking plate broke in one patient and this patient went on to develop a pseudoarthrosis from failure to fuse. In another patient there was release of the plate osteosynthesis.

CONCLUSIONS

Treatment of the injured lower cervical spine by an anterior operation and plate fixation was successful in achieving bone fusion in almost every patient and was followed by a complication in only a small proportion of our series. Similar results in other reports indicate that this approach is a safe and effective procedure.

[Association between wound size after open cholecystectomy with severity of iatrogenic biliary tract lesions]

BACKGROUND

Transoperative biliary tract injury during open or laparoscopic cholecystectomy is a catastrophic event associated with significant morbidity and mortality. Our objective was to determine if wound size during open cholecystectomy is associated with more complex biliary tract injuries.

METHODS

Prospective cohort study performed between March 2006 and February 2007. Sixty-six patients with biliary tract injuries after open cholecystectomy were included. Wound size was analyzed.

RESULTS

Sixty six patients were included, 70% were female with a median age of 44. Seventy four percent were treated for acute cholecystitis. Most participants were overweight or had various degrees of obesity. Biliary tract injuries were not recognized during the primary surgical procedure in 76% of cases. All patients with severe biliary tract injuries (Strasberg E-3 and E-4) had a wound size less than 10 cm in length. Wound size was associated with unrecognized injuries (p=0.000), as well as with injury severity (p=0.000). We were notable to demonstrate a statistically significant association between biliary tract injuries and elective or emergency surgical procedures and midline or subcostal surgical incision for cholecystectomy.

CONCLUSIONS

Our findings suggest that minor surgical access during open cholecystectomy may constitute a risk factor since smaller incisions were associated with more severe biliary tract injuries and an inability to observe this damage during the surgical procedure. We suggest to adhere strictly to the guidelines of an adequate surgical exposure during open cholecystectomy to prevent biliary tract injuries.

Vertebral artery anomaly with entry at C4--avoiding a surgical pitfall: a case report

We present a case of an unusual course of the vertebral artery (VA) with intra-foraminal entrance at C4. A patient with traumatic fracture of C3 and C4 with dislocation C3/C4, spinal cord compression and ensuing quadriplegia presented with unilateral entrance of the VA at C4 detected on preoperative magnetic resonance imaging (MRI). The patient was surgically decompressed and stabilized by an anterior-posterior approach without intra-operative complications. Apart from anatomical findings no clinical case of entrance of the VA at C4 had been described in recent clinical literature. A physiologic high entrance of the VA is very rare but must be diagnosed preoperatively to avoid potential life threatening complications.