Sonoanatomy and Pathology of the Gluteus Minimus Tendon

Gluteus minimus disorders are a potential source of greater trochanteric or anterior hip pain. Disorders of the gluteus minimus tendon most commonly occur in conjunction with gluteus medius tendon abnormalities but can also occur in isolation. Understanding the sonoanatomy of the gluteus minimus muscle-tendon unit is a prerequisite for recognizing and characterizing gluteus minimus tendon disorders, which, in turn, guides treatment for patients with greater trochanteric or anterior hip pain syndromes.     

Strategies for the treatment of invasive ductal carcinoma of the pancreas and how to achieve zero mortality for pancreaticoduodenectomy

Although various therapeutic modalities are available for carcinoma of the pancreas, “curative resection” is the most important. Thus, the aim of surgery for carcinoma of the pancreas is local complete resection of the carcinoma. Carcinoma of the head of the pancreas invades through the pancreatic parenchyma, following the arteries, veins, and especially nerves between the parenchyma and fusion fascia, and then spreads horizontally toward the superior mesenteric artery or celiac axis. We suggest techniques for resection of the extrapancreatic nerve plexus in the head of the pancreas during a Whipple procedure for carcinoma of the pancreas, from the perspective of surgical anatomy and pathology, to achieve “curative resection”. We suggest that: (1) en-bloc resection of the right side of the superior nerve plexus and the first and second nerve of the pancreatic head should be performed. With this technique, it is possible to avoid cutting these nerves. It is easy to perform this procedure, as follows. First, the superior mesenteric artery and vein are encircled with tape. Next, the superior mesenteric artery should be moved to the right side of the superior mesenteric vein under this vein. In addition, (2) the entire cut end of the nerve plexus should be investigated during the operation, using frozen specimens, and confirmed to be negative for cancer. If the cut end is positive for cancer, additional resection of the nerve plexus should be performed to achieve curative resection. It is impossible to completely determine whether the cut end of the nerve plexus is positive or negative for carcinoma after surgery, because the cut end is long and some specimens are deformed by formalin fixation; thus, it is difficult to identify the true surgical cut end. With regard to reconstruction, we perform a modified Child method with pancreaticojejunostomy (end-to-side), choledochoduodenostomy (also end-to-side), and gastrojejunostomy with Braun’s anastomosis. The greater omentum is set around the pancreaticojejunostomy to prevent pancreatic juice from spreading in the abdomen. Careful management of the intraabdominal drainage tubes after the operation is crucial. With the operative procedure and postoperative controls described above, operative mortality was zero in 114 consecutive patients in our series who underwent pancreaticoduodenectomy.     

Targeted Endodontic Microsurgery: Implications of the Greater Palatine Artery

IntroductionTargeted Endodontic Microsurgery (TEMS) combines trephine burs and 3D-printed guides to make flapless maxillary palatal root-end surgery possible. This study assessed the location of the greater palatine artery (GPA), the relationship of the GPA to maxillary molar root ends, and the feasibility of flapless palatal-approach TEMS.MethodsThree endodontists analyzed 250 cone-beam computed tomographic images of maxillary molars for (1) transition morphology between the hard palate and the alveolar process adjacent to first and second molars as an indication of the most likely location of the GPA, (2) the superior-inferior relationship between the GPA and root ends, and (3) the feasibility of palatal-approach TEMS.ResultsPalatal transition morphology included 20% Spine, 72% Bridge, and 8% Smooth. GPA position as related to palatal root ends was classified as 34% superior, 40% adjacent, and 21% inferior. Five percent of classifications were undefined. TEMS was deemed feasible for 47% of maxillary first molars and 52% of second molars, and was significantly more feasible with GPAs superior to palatal root ends. Reasons for infeasibility included GPA proximity and unfavorable resection angle or level. Maxillary first molar palatal roots were 11.13 ± 2.68 mm from the greater palatine foramen (GPF) and 2.37 ± 1.46 mm from the GPA. Second molar palatal roots were 4.94 ± 2.55 mm from the GPF and 2.53 ± 1.77 mm from the GPA.ConclusionsPalatal transition morphology and GPA position adjacent to maxillary molars, as manifested in cone-beam computed tomographic coronal views, suggested maxillary palatal root TEMS could be accomplished with a 2-mm safety margin in 47% of first molars and 52% of second molars. Historical paradigms that do not consider flapless palatal surgical approaches may need to be revised.     

肠系膜上动脉灌注化疗治疗大网膜转移癌所致肠梗阻的疗效观察

目的探讨肠系膜上动脉灌注化疗治疗大网膜转移癌所致肠梗阻的治疗效果,为临床治疗恶性肠梗阻提供参考。方法 115例因大网膜转移癌患者存在腹痛、腹胀、无排气排便伴或不伴有恶心、呕吐等肠梗阻症状、腹部增强CT明确腹膜转移结节、腹部立位X线平片证实存在肠管扩张、肠内积气伴或不伴有液平等肠梗阻表现、腹部彩色多普勒超声明确腹水情况,随机分为动脉灌注化疗组58例和对照组57例,分别行肠系膜上动脉灌注化疗和内科姑息治疗。比较两组肠梗阻缓解时间、腹水消退情况、治疗效果及患者生存时间,并观察肠系膜上动脉灌注化疗的不良反应。结果动脉灌注化疗组患者腹胀及腹痛缓解时间、恢复排气时间及恢复排便时间均显著短于对照组(t=3.22、5.60、3.81,P<0.05),肠道通畅维持时间较对照组显著延长(t=9.05,P<0.01),腹水改善情况(75.0%)明显较对照组(33.3%)好(χ2=11.35,P<0.01)。动脉灌注化疗组肠梗阻治疗有效率为82.8%,显著高于对照组的42.1%(χ2=14.55,P<0.01);动脉灌注化疗组生存时间(5.3±1.2)个月,较对照组的(2.8±0.9)个月显著延长(P<0.01)。动脉灌注化疗组27例(46.6%)发生腹泻,血液系统及肝肾功能损害较小。结论采用肠系膜上动脉灌注化疗治疗大网膜转移癌所致肠梗阻疗效较好,能够在短期内缓解肠梗阻症状,不良反应少,可以延长患者的生存期。     

The effect of both a thoracic trauma and a soft-tissue trauma on fracture healing in a rat model

Background and purpose There is some clinical evidence that fracture healing is impaired in multiply injured patients. Nothing is known, however, about the effects of various types of injuries and their contribution to a possible disturbance of the fracture-healing process. We investigated the effect of a thoracic trauma and an additional soft-tissue trauma on fracture healing in a rat tibia model.

Methods 3 groups of rats were operated: group A with a simple fracture of the tibia and fibula, group B with a fracture and an additional thoracic trauma, and group C with a fracture, thoracic trauma, and an additional soft-tissue trauma. The fracture and the soft-tissue injury were produced by a special guillotine-like device and the thoracic trauma by a blast wave generator.

After one day, the serum level of IL-6 was quantified, and at the end of the study (28 days) the mechanical properties and the callus volume of the healed tibia were determined.

Results Increasing the severity of the injury caused IL-6 levels to more than double 1 day after injury. It halved the load to failure in mechanical tests and led to reduced callus volume after 28 days of healing.

Interpretation Fracture healing is impaired when additional thoracic trauma and soft tissue trauma occurs.     

Endovenous Glue-Induced Thrombosis in Nonthermal Glue Closure Therapy for Greater Saphenous Vein Insufficiency: A Single-Center Experience

A retrospective analysis of endovenous glue-closure therapy (EVGC) performed in 76 greater saphenous veins (GSVs) from February 2016 to December 2017 was conducted to assess the incidence and characteristics of endovenous glue-induced thrombosis (EGIT), a phenomenon unique to nonthermal EVGC for GSV insufficiency. Kabnick and Lawrence classifications for endovenous heat-induced thrombosis were adopted. Seven instances of EGIT were detected among 54 patients (13%), with median/mode Kabnick and Lawrence classifications of 2/2 and 4/5, respectively. EGIT resolved with observation within an average of 5.2 wk after detection (range, 2–8 wk) without deep vein thrombosis or pulmonary embolism. EGIT was associated with significantly greater mean age (+7.75 y; P = .0308).     

Microinjections of melanin concentrating hormone into the nucleus tractus solitarius of the rat elicit depressor and bradycardic responses

The presence of melanin-concentrating hormone (MCH) containing processes, projecting from the lateral hypothalamus to the medial nucleus tractus solitarius (mNTS), has been reported in the rat. It was hypothesized that MCH acting within the mNTS may modulate the central regulation of cardiovascular function. This hypothesis was tested in urethane-anesthetized, artificially ventilated, adult male Wistar rats. Microinjections (100 nl) of MCH (0.25, 0.5, 0.75, and 1 mM) into the mNTS of anesthetized rats elicited decreases in mean arterial pressure (20.4±1.6, 50.7±3.3, 35.7±2.8 and 30.0±2.6 mm Hg, respectively). The decreases in heart rate in response to these concentrations of MCH were 40.0±8.7, 90.0±13.0, 48.0±7.3 and 48.0±8.0 beats/min, respectively. Maximum cardiovascular responses were elicited by a 0.5 mM concentration of MCH. Cardiovascular responses to MCH were similar in unanesthetized mid-collicular decerebrate rats. Control microinjections of normal saline (100 nl) did not elicit any cardiovascular response. Ipsilateral or bilateral vagotomy significantly attenuated MCH-induced bradycardia. Prior microinjections of PMC-3881-PI (2 mM; MCH-1 receptor antagonist) into the mNTS blocked the cardiovascular responses to microinjections of MCH. Microinjection of MCH (0.5 mM) into the mNTS decreased efferent greater splanchnic nerve activity. Direct application of MCH (0.5 mM; 4 nl) to barosensitive nucleus tractus solitarius (NTS) neurons increased their firing rate. These results indicate that: 1) MCH microinjections into the mNTS activate MCH-1 receptors and excite barosensitive NTS neurons, causing a decrease in efferent sympathetic activity and blood pressure, and 2) MCH-induced bradycardia is mediated via the activation of the vagus nerves.