Testicular transposition in children undergoing brachytherapy for bladder and/or prostate rhabdomyosarcoma

Background/Purpose

Fertility preservation is a major goal in treatment of children with cancer. We describe a new technique of testicular transposition (TT) in patients treated with pulse-dose-rate (PDR) brachytherapy as part of the multimodal conservative treatment of bladder neck and/or prostate rhabdomyosarcoma (BP RMS).

Laparoscopic ovarian transposition prior to pelvic radiation in young women with anorectal malignancies: a systematic review and meta-analysis of prevalence

Aim

Young women undergoing radiotherapy (RT) for pelvic malignancies are at risk of developing premature ovarian insufficiency. Ovarian transposition (OT) aims to preserve ovarian function in these patients. However, its role in anorectal malignancy has yet to be firmly established. The aim of this review was to determine the effectiveness of laparoscopic OT in preserving ovarian function in premenopausal women undergoing neoadjuvant pelvic RT for anorectal malignancies.

Methods

MEDLINE, Embase and CENTRAL were systematically searched from inception through to May 2022. Articles were included if they evaluated ovarian function after OT in women with anorectal malignancies undergoing pelvic RT. The primary outcome was ovarian function preservation. The secondary outcome was 30-day postoperative morbidity following OT.

Results

From 207 citations, 10 studies with 133 patients with rectal or anal cancer who underwent OT prior to RT were included. Meta-analysis of pooled proportions of preserved ovarian function demonstrated an incidence of 66.9% (95% CI 55.0–79.0%, I² = 43%). The 30-day postoperative morbidity rate was 1.2% (n = 1). There was heterogeneity in interventions and outcome reporting.

Conclusions

Laparoscopic OT in premenopausal patients undergoing pelvic radiation for anorectal malignancies might be an effective technique at reducing ovarian exposure to RT. The meta-analyses must be interpreted within the context of clinical heterogeneity of the included studies. Further studies are required to fully investigate the outcomes of OT in patients undergoing pelvic radiation for anorectal malignancies.     

A new approach for the surgical management of unilateral iliac artery occlusive disease: the iliofemoral crossover transposition

Aortobifemoral bypass remains the standard therapy for aortoiliac occlusive disease. Extraanatomic revascularization has been considered as an acceptable alternative and provides reasonable long-term results. Because some of the causes for its failure are related to the prosthetic material used, a technique that uses autologous material and is applicable in patients with unilateral common iliac lesions was developed. Iliofemoral crossover transposition is a femorofemoral bypass procedure in which the external iliac artery is used as a graft. The procedure is easily performed and avoids the use of prosthetic materials, minimizing the risks of their related complications. Because its biologic behavior, including hemodynamic performance, has proven to be excellent, satisfactory long-term results can be anticipated.     

A new approach for surgical treatment of chronic Monteggia fracture in children

PurposeThe aim of the study was to investigate the clinical outcomes of a combined anterior and posterior approach for the surgical treatment of chronic Monteggia fractures in children.Materials and methodsFrom November 2010 to January 2018, 33 patients (27 boys and 6 girls) with chronic Monteggia fracture who were treated surgically by one surgeon of our department were retrospectively analyzed. In the surgical procedure, open reduction and excision of fibrous scar were performed with the anterior Henry’s approach, while ulnar osteotomy was carried out with a posterior approach. In cases of unstable radial head reduction, a trans-capitellar K wire was applied. Repair or reconstruction of the annular ligament (ALR) was not undertaken.ResultsThe average follow-up of the patients was 33.8 months (range 8–87 months). At the last follow-up, Mayor Score and function of flexion and extension showed significant improvement compared to preoperative condition (p < 0.05). Two patients with palsy of the deep branch of the radial nerve with neurolysis recovered to normal over a 3-month follow-up. Redislocation occurred in two patients while subluxation occurred in one. One patient suffered a mild ischemic contracture but gradually recovered. Other severe complications, nerve injuries, heterotopic ossification, or synostosis, were not noted in the follow-up.ConclusionA combined anterior and posterior approach for surgery resulted in a satisfactory outcome due to the advantages of better exposure, more convenient intraoperative management, and facilitate for radial nerve exploration. Our study provided a new approach for the surgery of chronic Monteggia fractures.     

Laparoscopic sleeve gastrectomy with ileal transposition (SGIT): A new surgical procedure as effective as gastric bypass for weight control in a porcine model

Introduction Bariatric surgery has evolved into multiple forms in the last decades, combining food restriction and malabsorption. The aim of this study was to develop a new technique based on food restriction and early stimulation of the distal gut, thus maintaining the alimentary tract continuity. Methods Thirty-two Yorkshire pigs, weight 22.2 ± 5.4 kg (mean ± SD) were randomly assigned to four laparoscopic procedures: ileal transposition (IT, n = 8); sleeve gastrectomy with ileal transposition (SGIT, n = 8); Roux-en-Y gastric bypass (GBP, n = 8); sham operation (SHAM, n = 8). Firing 45-mm linear staplers over a 60-F bougie, resecting the greater curvature and fundus, constituted a sleeve gastrectomy. Ileal transposition was performed by isolating a 100-cm ileal segment proximal to the ileocecal valve and by dividing the proximal jejunum 15 cm distal to the ligament of Treitz and performing re-anastomosis. Gastric bypass consisted of creating a proximal gastric pouch and a 300 cm alimentary limb. Sham operation was performed by bowel transections and re-anastomosis in the ileum and proximal jejunum together with gastrotomy and closure. Animals were evaluated weekly for weight increase and food intake. We performed a logistic regression analysis to compare weight progression curves, and analysis of variance (ANOVA) and Bonferroni (Dunn) tests to detect differences in weight and food intake. Results We observed significant differences in mean weight after 18 weeks between SGIT (30.9 ± 13.4 kg) and SHAM (72.5 ± 10.7 kg) (p = 0.0002), and GBP (28.6 ± 2.5 kg) and SHAM (p = 0.0001), and IT (56.1 ± 13.4 kg) and SHAM (p = 0.0081). No differences were observed between RYGB and SGIT. We also observed significant differences in food intake (grams per day) in the third month between SGIT (1668 ± 677 g) versus SHAM (3252 ± 476 g) (p = 0.0006), and GBP (2011 ± 565 g) versus SHAM (p = 0.039). No differences were observed in food intake between SGIT and GBP. Conclusion SGIT proved to be as effective in the short term as GBP on weight progression with no bypass of the proximal gut.     

A new surgical approach to subcortical lesions: balloon inflation and cortical gluing. Technical note

A cortical incision performed with inflation of a balloon to create a channel has been used in an approach to deep lesions with minimal damage to cerebral tissue. The balloon is slipped over a blunt needle and, once in place, is inflated through the needle. Postoperative sealing of the incision with fibrin glue avoids the subdural collection of cerebrospinal fluid such as is sometimes observed when the ventricle is opened during surgery.     

Infrarenal transposition of the superior mesenteric artery: a new approach in the surgical therapy for Wilkie syndrome

The superior mesenteric artery syndrome, also known as Wilkie syndrome or as arteriomesenteric obstruction of the duodenum, is a rare condition of upper intestinal obstruction in which the third part of the duodenum is compressed by the overlying, narrow-angled superior mesenteric artery against the posterior structures. It is characterized by early satiety, recurrent vomiting, abdominal distention, weight loss, and postprandial distress. When nonsurgical management is not possible or the problem is refractory, surgical intervention is necessary. Usually a laterolateral duodenojejunostomy or Roux-en-Y reconstruction for reconstruction of the intestinal passage is performed. We report the first successful transposition, to our knowledge, of the superior mesenteric artery into the infrarenal aorta in the therapy of Wilkie syndrome.     

Effects of dexmedetomidine on surgical site wound pain in patients undergoing laparoscopic cholecystectomy: A meta-analysis

This study aimed to evaluate the effectiveness of dexmedetomidine as an adjuvant to local wound infiltration anaesthesia in reducing surgical site wound pain in patients undergoing laparoscopic cholecystectomy. The Cochrane Library, PubMed, EMBASE, China National Knowledge Infrastructure, and Wanfang databases were searched from the time of database creation until February 2023. We performed a randomised controlled trial on the effect of dexmedetomidine as an adjunct to local wound infiltration anaesthesia on postoperative wound pain in patients undergoing laparoscopic cholecystectomy. Two investigators independently screened the literature, extracted data, and evaluated the quality of each study. This study was performed using the Review Manager 5.4 software. Ultimately, 13 publications with 1062 patients were included. The results showed that dexmedetomidine was effective as an adjunct to local wound infiltration anaesthesia at 1 h (standardised mean difference [SMD]: −5.31, 95% confidence intervals [CIs]: −7.22 to −3.40, P < .001), 4 h (SMD: −3.40, P < .001), 12 h (SMD: −2.11, 95% CIs: −3.10 to −1.13, P < .001) and 24 h postoperatively (SMD: −1.98, 95% CIs: −2.76 to −1.21, P < .001) significantly reduced surgical site wound pain. However, there was no significant difference in the analgesic effect at 48 h postoperatively (SMD: −1.33, 95% CIs: −3.25 to −0.58, P = .17). Dexmedetomidine provided good postoperative wound analgesia at the surgical site when used for laparoscopic cholecystectomy.     

Management of Mirizzi syndrome: A new surgical approach

Background : In a prospective study of a patient population of 1340 with biliary calculus disease, that ran from January 1993 to December 1997, 34 patients (2.53%) were identified as having Mirizzi syndrome. Eight patients were found to have type I (A and B) and 26 patients were found to have type II Mirizzi syndrome. A history of recurrent biliary colic and jaundice was present in the majority of patients. Methods : Ultrasonography was helpful in five patients and endoscopic retrograde cholangiopancreatography was helpful in 17 patients in the diagnosis of this condition. Because the amount of gall bladder tissue used in choledochoplasty is not yet standardized, a new policy regarding choledochoplasty was adopted. In type IA, retrograde cholecystectomy with simple closure of cystic duct was carried out. In type IB, retrograde cholecystectomy and choledochoplasty with 5 mm cuff of the gall bladder was carried out. In type II lesions the procedure depended on the size of fistula. Patients with fistula sizes of less than one‐third of the common bile duct diameter underwent choledochoplasty with 5 mm cuff of the gall bladder, and patients with fistula sizes between one‐third and two‐thirds of the diameter of the common bile duct underwent choledochoplasty with 10 mm cuff of the gall bladder. Patients with fistula sizes of more than two‐thirds of the common bile duct diameter underwent Roux‐en‐Y hepaticojejunostomy. Results : There was no operative mortality and the complication rate was 17.64%. Conclusion : Although, out of 26 choledochoplasties, we encountered only one (3.84%) stump stone in a maximum follow‐up period of 59 months, further long‐term follow‐up studies are required to prove the efficacy of the procedure.     

Target controlled priming for rapid onset of intubation dose: A new approach

Purpose To determine the pattern of onset of the intubating dose when given at a monitored target priming block in either phase of the priming drug effect. Methods Sixty consenting ASA I and II patients were premedicated by intramuscular buprenorphine (5 μg·kg⁻¹) 1h before surgery. Neuromuscular junction monitoring was done by stimulating the ulnar nerve at the wrist using Myotest and recording the adductor pollicis response on Myograph-2000. After stabilization of the twitch tension at the titrated supramaximal stimulus (1 Hz), double-burst stimuli (DBS) were given to monitor the priming effect of vecuronium bromide (Vb) (0.015 mg·kg⁻¹). The DBS ratio (DBSr=D ₂/D ₁) was calculated for the DBS response, repeated at 20s. Depending on the target priming block level (DBSr 0.8, 0.6, or 0.5) and the phase of the priming block to give an intubating dose of Vb (0.8 mg·kg⁻¹) injection, all patients were randomly assigned to six study groups: group 1 (DBSr 0.8), group 3 (DBSr 0.6), and group 5 (DBSr 0.5) during the priming block progression phase (before peakD ₁ suppression), and group 2 (DBSr 0.8), group 4 (DBSr 0.6), and group 6 (DBSr 0.5) during the priming block regression phase (after peakD ₁ suppression). Anesthesia was induced by thiopental (5–7 mg·kg⁻¹) just before the intubating dose. The effect of the intubating dose on twitch stimuli (1 Hz) was monitored. Results We observed that in spite of significantly variable priming intervals for identical DBSr in two different phases, the onset time of the intubating dose to 0 response was identical in similar DBSr group patients; i.e., at 0.8 DBSr, 65.0±5.2s (group 1)vs 66.0±8.0s (group 2); at DBSr 0.6, 55.2±3.7s (group 3)vs 55.2±4.9s (group 4); and at DBSr 0.5, 43.5±4.8s (group 5)vs 43.5±4.2s (group 6). At 0 twitch response, the intubating conditions were comparable in patients of the six groups. Conclusion In conclusion, target controlled priming (DBSr) for administration of the intubating dose appears to be a useful double-vision sign to predict the onset of the effect of the intubating dose precisely.     

Second-look laparotomy in advanced ovarian cancer: A critical assessment of morbidity and impact on survival

Background: The routine inclusion of second-look laparotomy in the management of patients with epithelial ovarian cancer is controversial. At issue is the justification of morbidity incumbent upon surgery and the possible survival benefit of secondary cytoreduction. Methods: The rate of major complications of surgery was assessed among 100 consecutive patients with FIGO stage III or IV epithelial ovarian cancer who underwent second-look laparotomy. All patients demonstrated a complete clinical and biochemical (CA125 <35 U/ml) response to first-line therapy. Patients were stratified based on findings at surgery. Patients in group 1 (n=37) had a negative second-look laparotomy. Patients in group 2 (n=35) had only microscopically appreciable disease. Patients in group 3 (n=28) had macroscopic disease. Cytoreductive efforts aimed at resection of all macroscopic disease were carried out for patients in group 3. Results: Thirteen patients (13%) had 15 major complications at surgery. Comparison of the complication rates for patients in groups 1, 2, and 3, of 10%, 8.5%, and 21.4%, respectively, did not achieve statistical significance (p=0.228). The estimated 5-year survival for patients in groups 1, 2, and 3 of 63.9%, 39.8%, and 14.2%, did differ significantly (p<0.0001). Cytoreductive efforts resulted in the resection of all macroscopic disease in 18 of 28 patients (64.2%) in group 3. The median survival for this group of 18 patients was 33 months, and estimated 5-year survival was 20%. These values do not differ significantly from those observed for patients in group 2. Conclusion: The major complication rate associated with second-look laparotomy is not prohibitive Secondary cytoreductive efforts may result in improved survival for patients with epithelial ovarian cancer.     

Robotic intragastric surgery: A new surgical approach for the gastric lesion

Background

Intragastric surgery is accepted as a minimally invasive procedure for mucosal or submucosal lesions. Robotic surgery promises to extend the capabilities of the minimally invasive surgeon and many surgical specialties are applying this new technology. However, there is no report of robotic intragastric surgery. We describe the use of the da Vinci^® Surgical System for intraluminal mucosal resection of the stomach.

Methods

We developed our porcine intragastric surgery model using the Tuebingen MIS Trainer. We set a tentative lesion on the posterior wall near the esophagocardiac junction (ECJ) of the stomach and performed mucosal resection of the lesion using the da Vinci Surgical System. We also performed closure of the defect after mucosal resection and subsequent closure of the intentional gastric perforation.

Results

Using our porcine intragastric surgery model, we successfully performed mucosal resection of the tentative lesion. We also smoothly completed closure of the defect and closure of the perforation without any complications. The mean size of the mucosa was 6 cm and the mean duration of the procedure was only 12 min.

Conclusions

The safety and efficacy of robotic intragastric surgery was preliminarily established in this study. However, further studies are needed to prove its practical feasibility in humans using the da Vinci Surgical System to make it an effective operation.

     

Surgeon-performed ultrasound reliably predicts skin spacing and may decrease the rate of MammoSite balloon catheter explantation in patients undergoing brachytherapy for breast cancer

OBJECTIVE: The purpose of this study was to determine if the distance from the skin to the seroma cavity, as measured with ultrasound (US) before catheter placement, correlated with the distance from skin to MammoSite balloon catheter as measured on computerized axial tomography (CAT) after catheter placement. METHODS: US was used to measure the distance from the skin to the seroma cavity, and then the MammoSite balloon catheter was inserted. Skin-to-balloon distance was then measured using CAT. Statistical analysis was performed to determine correlation between the 2 measurements. RESULTS: Our cohort consisted of 70 patients. US distance correlated with CAT distance (Pearson correlation coefficient .70). Mean US distance was 10.8 mm (SD 4.5 mm); mean CAT distance was 11.9 mm (SD 7.5 mm); and mean difference between the 2 measurements was -1.1 mm (SD 6.1 mm). A US measurement >/=7.6 mm predicted successful completion of MammoSite brachytherapy in 98% of patients. Patients with skin-to-seroma cavity distance <7.6 mm required explantation before treatment completion 39% of the time. CONCLUSIONS: Office-based US performed before insertion of the MammoSite balloon catheter statistically correlates with measurement by CAT. Patients with >/=7.6 mm skin-to-seroma cavity distance on US had a higher completion rate of MammoSite brachytherapy treatment.     

A new,fast LDI for assessment of burns: A multi-centre clinical evaluation

IntroductionLaser Doppler imaging (LDI) provides early accurate determination of wound healing potential. LDI can scan large areas of up to 2500 cm² within 2 min. This duration may require additional sedation in a mobile, uncooperative child. In five burn centres a faster Laser Doppler Line Scanner (LDLS) was assessed. This new imager scans 300 cm² in 4 s with potential benefit for patients and operators. The aim of this study was to assess the accuracy and convenience of the LDLS and to compare this with an established LDI imager.MethodsOutpatients and admitted patients were included. LDI and LDLS images were obtained between 2 and 5 days post burn (PB). Photographs and records of wound and healing were obtained on day of scan and at 14 and 21 days PB. This provided data on three categories of burn wounds: healing within 14 days, 14–21 days and not healed within 21 days.ResultsThe analysis included 596 burn areas from 204 burns patients. An accuracy of 94.2% was found with use of the LDLS compared with 94.4% for the original LDI imager.ConclusionsThe high accuracy of the new line-scan imager was comparable to that of the traditional LDI. Its size and mobility enabled easier ward and outpatient use. The higher scan speed was particularly beneficial for scans in paediatric patients.