NOTES: transvaginal for cancer diagnostic staging: preliminary clinical application

Laparoscopy is now a reliable method for staging gastrointestinal cancer, orienting the therapy, and avoiding unnecessary laparotomy. Natural orifice transluminal endoscopic surgery (NOTES) is an emerging concept with potential advantages for patient recovery. The first case of clinical diagnostic application of transvaginal NOTES for diagnostic cancer staging is presented. Informed consent and Institutional Commission approval were obtained for transvaginal clinical trials. On February 28, 2007, a patient with elective surgical indication for diagnostic cancer staging was submitted to transvaginal NOTES procedure, and intra- and postoperative parameters were documented. In a 50-year-old female patient presenting with ascitis, diffuse abdominal pain, and weight loss for 2 months, diagnosis of peritoneal carcinomatosis was suspected, which was also found when a CT scan was performed. Transvaginal NOTES was used for diagnostic staging of the patient, using a colonoscope introduced into the abdomen through a small incision in the vagina. Biopsies of liver, diaphragm, ovaries, and peritoneum were successfully performed. Operative time was 105 min, vaginal access and closure was obtained in 15 min. Abdominal inventory was reliable, and all 16 biopsies taken were positive for ovarian adenocarcinoma. The patient was dismissed 48 hours after the procedure without complications. Recent literature and experience of the study group suggest possibilities for preliminary clinical applications by transvaginal natural orifice surgery for diagnostic purposes.     

Natural orifice translumenal endoscopic surgery (NOTES) renal cryoablation in a porcine model

OBJECTIVE

To present our laboratory experience with natural orifice translumenal endoscopic surgery (NOTES) renal cryoablation.

MATERIALS AND METHODS

In two female farm pigs, we performed four procedures of NOTES renal cryoablation. In each pig, NOTES was performed through a transgastric approach and a transvaginal approach for each kidney, respectively. The pig was placed in the flank position and pneumoperitoneum obtained using a transabdominal Veress needle. In the first pig, we started with the left kidney with a transgastric approach: a dual‐channel video gastroscope (Olympus, Tokyo, Japan) was used, the stomach wall was punctured using a needle‐knife, a guidewire was passed into the abdominal cavity and the access dilated using a controlled radial expansion balloon. The bowel was mobilized medially and the Gerota’s fascia overlying the upper pole was dissected. Under direct endoscopic vision, a cryoablation probe was introduced percutaneously into the anterior upper pole of the kidney. The pig was then flipped to the right flank position and a transvaginal approach was used: the gastroscope was introduced through the posterior fornix of the vagina. For the second pig, we performed initially a transgastric right‐side cryoablation then a transvaginal left‐side cryoablation as described for the first pig.

RESULTS

All four procedures were performed successfully, with no intraoperative complications. No additional laparoscopic ports or open conversions were necessary. The vision of the kidney and the ice‐ball was adequate for all cases. The mean operative duration was 83 min. Stomach closure was tested watertight, and there were no abdominal or pelvic injuries found at autopsy.

CONCLUSIONS

NOTES can provide adequate minimal surgical dissection for safe and effective percutaneous renal cryoablation under direct videoscopic monitoring at kidney locations otherwise not accessible percutaneously. Both transgastric and transvaginal approaches can be used effectively for renal cryoablation providing a minimally invasive scar‐less surgery.     

Magnetic resonance imaging detects and predicts early brain injury after subarachnoid hemorrhage in a canine experimental model

Abstract The canine double hemorrhage model is an established model to study cerebral vasospasm, the late sequelae of subarachnoid hemorrhage (SAH). The present study uses magnetic resonance imaging (MRI) to examine the recently reported early brain injury after SAH. Double hemorrhage SAH modeling was obtained by injecting 0.5 mL/kg of autologous arterial blood into the cisterna magna of five adult mongrel dogs on day 0 and day 2, followed by imaging at day 2 and day 7 using a 4.7-Tesla (T) scanner. White matter (WM) showed a remarkable increase in T2 values at day 2 which resolved by day 7, whereas gray matter (GM) T2 values did not resolve. The apparent diffusion coefficient (ADC) values progressively increased in both WM and GM after SAH, suggestive of a transition from vasogenic to cytotoxic edema. Ventricular volume also increased dramatically. Prominent neuronal injury with Nissl's staining was seen in the cortical GM and in the periventricular tissue. Multimodal MRI reveals acute changes in the brain after SAH and can be used to non-invasively study early brain injury and normal pressure hydrocephalus post-SAH. MR can also predict tissue histopathology and may be useful for assessing pharmacological treatments designed to ameliorate SAH.     

Evaluation of a training method for transtracheal punction for emergency oxygenation

Introduction

Transtracheal oxygenation is a lifesaving technique in a cannot-ventilate, cannot-intubate situation, in setting percutaneous transtracheal catheter.

Objective

To assess training for cricoid membrane puncture performed with a Ravussin needle.

Method

Ten residents in anaesthesiology nearing completion of their training participated in the study. Following a didactic session and a video demonstration, participants performed percutaneous transtracheal punctures on fresh cadavers. Success rate and time to perform the puncture were measured. Results are expressed as mean ± SD.

Results

By the third attempt, all procedures were successful. Mean performance time at the first attempt was 31.2 ± 21.8 s, progressively decreasing with the following attempts to reach a plateau by the third attempt (20.6 ± 19.3s). Performance time varies with the cadaver's morphology and the ability to recognize anatomic landmarks. However, whatever the difficulty, performance time is 40 s or less by the third attempt.

Conclusion

Percutaneous transtracheal catheter setting is a life saving technique with which every anaesthesiologist should be familiar. Viewing a pedagogic videotape and training on cadavers provides a rapid and effective training method for cricoid membrane puncture. Four attempts seem necessary to obtain an optimal success rate.     

Treatment of symptomatic lower extremity acute deep venous thrombosis: role of mechanical thrombectomy

Systemic anticoagulation with heparin or its unfractionated derivatives followed by warfarin therapy has been the mainstay of treatment in patients with lower extremity deep venous thrombosis (DVT). Although heparin is an effective treatment modality in preventing thrombus propagation, it provides minimal therapeutic effect in dissolving preexisting venous thrombus. The clinical consequence of DVT, owing in part to loss of venous endothelial and valvular function, is postphlebitic syndrome or chronic venous insufficiency. Current advances in endovascular therapy have resulted in various endovascular thrombectomy systems that can effectively remove a large venous thrombus burden, which may represent a potential advantage of preserving venous valvular function and thereby reduce the likelihood of postphlebitic syndrome. In this article, we review a variety of surgical and interventional methods in venous thrombus removal. Current treatment modalities using mechanical thrombectomy devices and pharmacomechancial thrombectomy strategy are also discussed.     

Initial fixation strength of a new hybrid technique for femoral ACL graft fixation: the bone wedge technique

Background Aperture fixation with interference screws matching the diameter of the tunnel is associated with the risk of graft laceration and graft rotation. Hypothesis A hybrid fixation technique (extracortical and aperture fixation) with undersized interference screw placed behind a bone wedge provides a higher fixation strength as aperture fixation with a screw alone matching the size of the tunnel. Study design Experimental laboratory study. Methods We evaluated the initial fixation strength (single cycle and cyclic loading tests) of hybrid and interference screw aperture fixation using different sized interference screws in porcine knees. Results Analysis of yield load, maximum load and stiffness in the single cycle loading test showed no statistically significant differences for hybrid fixation with a 1 mm undersized screw and aperture fixation with a screw matching the size of the tunnel. The use of an undersized screw alone resulted in low fixation strength. Conclusion The initial fixation strength of the hybrid technique with undersized screws is comparable to that of interference screw fixation matching the size. Clinical relevance The new “bone wedge fixation” is an alternative for ACL graft fixation without the risk of graft laceration and graft rotation.     

Genetic variation, C-reactive protein levels, and incidence of diabetes

C-reactive protein (CRP) has been shown to be associated with type 2 diabetes, but whether CRP has a causal role is not yet clear. We examined the association in the Rotterdam Study, a population-based prospective cohort study. The association of baseline serum CRP and incident diabetes during follow-up was investigated, and a meta-analysis was conducted on the BMI-adjusted relation of CRP and diabetes. Furthermore, the association of CRP haplotypes with serum CRP and risk of diabetes was assessed. The age- and sex-adjusted hazard ratio for diabetes was 1.41 (95% CI 1.29-1.54) per 1 SD increase in natural logarithm of CRP, and it was 1.88, 2.16, and 2.83 for the second, third, and fourth quartiles of CRP, respectively, compared with the first quartile. The risk estimates attenuated but remained statistically significant after additional adjustment for obesity indexes, which agreed with the results of the meta-analysis. The most common genetic haplotype was associated with a significantly lower CRP level compared with the three other haplotypes. The risk of diabetes was significantly higher in the haplotype with the highest serum CRP level compared with the most common haplotype (OR 1.45, 95% CI 1.08-1.96). These findings support the hypothesis that serum CRP enhances the development of diabetes.     

Safety and efficacy of a novel polyethylene glycol hydrogel sealant for watertight dural repair

OBJECT: The authors prospectively evaluated the safety and efficacy of a novel polyethylene glycol (PEG) hydrogel sealant in patients undergoing elective cranial surgery with documented cerebrospinal fluid (CSF) leakage after sutured dural repair. METHODS: The PEG hydrogel sealant was used at 11 different study sites in 111 patients with documented intraoperative CSF leakage after neurosurgical dural repair for a variety of conditions. Intraoperative CSF leakage was either spontaneous or induced by a Valsalva maneuver. Patients were monitored for 3 months postoperatively with physical examinations, clinical laboratory analyses, and diagnostic imaging. The PEG hydrogel sealant was 100% effective in stopping CSF leakage in all patients. There were no sealant-related adverse events and all clinical outcomes were consistent with expectations for seriously ill patients undergoing prolonged neurosurgical procedures. CONCLUSIONS: The PEG hydrogel sealant provides a safe and effective watertight closure when used as an adjunct to sutured dural repair during cranial surgery.     

The Selective Non-operative Management of Penetrating Cervical Venous Trauma is Safe and Effective

Background

This paper reviews our experience with penetrating cervical venous trauma and aims to validate the selective non-operative management (SNOM) of these injuries.

Methods

This was a retrospective review of a prospectively maintained registry. All patients presenting alive with an injury to the internal jugular vein, subclavian vein or innominate vein following a PNI were reviewed for a 6-year period.

Results

Among 817 patients admitted for the management of PNI, 76 (9.3%) had a venous injury. Of these, 37 (48.7%) patients were managed non-surgically, 20 (26.3%) required immediate surgical exploration, seven of whom had an associated arterial injury, and 19 (25%) underwent surgery following a diagnostic CTA, 16 of whom had an associated arterial or aero-digestive injury. In total, only 16 (21.1%) of the 76 patients required exploration for venous injury alone. The majority (63.2%) of patients had a history of severe bleeding or hemodynamic instability prior to arrival, but only 20 (26.3%) required immediate exploration. Two (2.6%) patients died as a result of venous injury. No patients developed complications related to the venous injury.

Conclusions

SNOM is applicable to a well-defined subset of patients with isolated penetrating cervical venous trauma to the IJV and SCV identified on CTA.