CT and MR imaging features of adnexal torsion.

In adnexal torsion, the ovary, ipsilateral fallopian tube, or both twist with the vascular pedicle, resulting in vascular compromise. Unrelieved torsion is likely to cause hemorrhagic infarction as the degree of arterial occlusion increases. Therefore, early diagnosis is important to preserve the affected ovary. Adnexal torsion commonly accompanies an ipsilateral ovarian neoplasm or cyst but can also occur in normal ovaries, usually in children. Although ultrasonography is typically the initial emergent examination, computed tomography (CT) and magnetic resonance (MR) imaging may also be useful diagnostic tools. Common CT and MR imaging features of adnexal torsion include fallopian tube thickening, smooth wall thickening of the twisted adnexal cystic mass, ascites, and uterine deviation to the twisted side. Uncommon imaging findings in adnexal torsion that are specific to hemorrhagic infarction include hemorrhage in the thickened fallopian tube, hemorrhage within the twisted ovarian mass, and hemoperitoneum. Additional imaging findings that can suggest hemorrhagic infarction include eccentric smooth wall thickening exceeding 10 mm in a cystic ovarian mass converging on the thickened fallopian tube and lack of contrast enhancement of the internal solid component or thickened wall of the twisted ovarian mass. Early diagnosis can help prevent irreversible structural damage and may allow conservative, ovary-sparing treatment.     

Nodular fasciitis in the head and neck: CT and MR imaging findings

BACKGROUND AND PURPOSE: The purpose of this study was to describe the CT and MR imaging findings of nodular fasciitis occurring in the head and neck region. METHODS: CT (n = 6) and MR (n = 4) images obtained from 7 patients (3 men and 4 women; mean age, 19.4 years; age range, 1-48 years) with surgically confirmed nodular fasciitis in the head and neck were retrospectively reviewed. All patients presented with a palpable mass in the head and neck that was noticed 1-3 months earlier: 5 in the face, one in the occipital scalp, and the remaining one in the supraclavicular fossa. We investigated the CT and MR imaging characteristics with emphasis on the location, size, internal content, margin, enhancement pattern, and signal intensity of the lesion. RESULTS: All lesions appeared as a discrete mass on imaging, ranging from 1.0 cm to 4.6 cm in diameter (mean, 2.2 cm). Six lesions, all of which appeared benign, were located in the subcutaneous tissue superficial to the deep cervical fascia. The remaining lesion was located deep to the temporalis muscle and showed an aggressive imaging appearance, markedly eroding the bony orbit and skull. Five lesions were solid, and 2 lesions were partly or completely cystic in appearance. Five lesions were well defined, whereas 2 lesions were ill defined. Four of 5 solid lesions showed moderate to marked diffuse enhancement, whereas the remaining lesion demonstrated mild enhancement. Two cystic lesions showed peripheral, nodular, or rim-like enhancement. Compared with muscle, both solid lesions had isointense signal intensity on T1-weighted images and hyperintense signal intensity on T2-weighted images, whereas the signal intensity of the solid portions of the deep-seated, partly cystic lesion was isointense on both T1-weighted and T2-weighted images. CONCLUSION: Although rare, nodular fasciitis occurs as a discrete solid or cystic mass in the head and neck, depending on the predominant stromal components. When one sees a head and neck mass with a superficial location and moderate to marked enhancement on CT and MR imaging, nodular fasciitis should be included in the differential diagnosis, especially in patients with a recently developed, rapidly growing mass and a history of recent trauma.     

Adult-to-adult living donor liver transplantation at the Asan Medical Center,Korea

Between February 1997 and December 2001, 311 adult-to-adult living donor liver transplants (A-A LDLTs) were performed at the Asan Medical Center for patients above 20 years of age. Indications for A-A LDLT were: chronic hepatitis B (203), chronic hepatitis C (5), hepatocellular carcinoma (64), alcoholic cirrhosis (9), cryptogenic cirrhosis (4), secondary biliary cirrhosis (5), primary biliary cirrhosis (1), Wilson' s disease (2), autoimmune hepatitis (1), hepatic tuberculosis (1), cholangiocarcinoma (1), fulminant hepatic failure (14) and primary non-function of cadaveric liver graft (1). Of 311 A-A LDLTs, 36 were of medical high urgency, 20 were for acute and subacute hepatic failure, 15 were for hepato-renal syndrome and 1 was for primary non-function. Recipient age ranged from 27 to 64 years. Donor age ranged from 16 to 62 years. There was no donor mortality. Implanted liver grafts were categorized into seven types: 175 modified right lobe (MRL), 70 left lobe, 32 right lobe, 20 dual grafts, 10 left lobe plus caudate lobe, three extended right lobe and one posterior segment. In MRL, the tributaries of the middle hepatic vein were reconstructed by interpositioning a vein graft. Indication for dual graft implantation was the same as single graft A-A LDLT, and four of 20 were emergency cases. Of 20 dual grafts, 14 received two left lobes, four received a left lobe and a lateral segment, one received a right lobe and a left lobe and one received a lateral segment and a posterior segment. Graft volume ranged from 28% to 83% of the standard liver volume of the recipients. There were 33 (10.6%) in-hospital mortalities (< 4 months) among the 310 patients after 311 A-A LDLTs. Of the 36 patients receiving emergency transplants, 31 survived. These encouraging results justify the expansion of A-A LDLT in coping with increasing demands, even in urgent situations. We have aimed to introduce the establishment of the efficacy of A-A LDLT in various end-stage chronic and acute liver diseases, as well as new technical advances to overcome small graft-size syndrome by using dual-graft implantation and MRL, both of which were first developed in our department.     

The effects of subluxation of the femoral head with avascular necrosis in growing rabbits

To validate the adverse effects of subluxation of the femoral head in Legg-Calve-Perthes disease, the authors made an experimental model of Perthes disease with subluxation in growing rabbits by interrupting the epiphyseal artery (devascularization) and immobilizing the knee in extension (immobilization). Seventy-two rabbits, 4 to 5 weeks old, were divided into three groups: group A with both devascularization and immobilization (25 rabbits), group B with devascularization only (25 rabbits), and group C with immobilization only (22 rabbits). In each experimental group, four to six rabbits each were killed at 1, 2, 4, 8, and 12 weeks. After reviewing the serial radiographs and gross specimens, the authors found six radiologic and six macroscopic abnormalities. The incidence and the severity of deformity in group A rabbits were higher than that of groups B or C in terms of the overall incidence of deformities (P <0.001), head deformity scores (P <0.001), and the incidence of a total collapse of the capital femoral epiphysis. In conclusion, subluxation of the immature femoral head with avascular necrosis in rabbits increased femoral head deformities.     

A novel anterior decompression technique (vertebral body sliding osteotomy) for ossification of posterior longitudinal ligament of the cervical spine

Background Context

Conventional anterior decompression surgery for cervical myelopathy, including anterior corpectomy and fusion, is technically demanding and is known to be associated with a higher incidence of surgery-related complications, including cerebrospinal fluid (CSF) leakage, neurologic deterioration, and graft failure compared with posterior surgery.

Robot-Assisted Sistrunk’s Operation, Total Thyroidectomy, and Neck Dissection via a Transaxillary and Retroauricular (TARA) Approach in Papillary Carcinoma Arising in Thyroglossal Duct Cyst and Thyroid Gland

Background

Carcinomas arising in the thyroglossal duct cysts are rare, accounting only for about 0.7?C1.5?% of all thyroglossal duct cysts.1 ^?C 3 Synchronous occurrence of thyroglossal duct carcinoma and thyroid carcinoma is reported to be even rarer.4 Traditionally, surgical treatments of such coexisting thyroglossal duct cyst carcinoma (TGDCa) and papillary thyroid carcinoma (PTC) were typically performed through a single transverse or double incisions on the overlying skin. A longer, extended cervical incision might be required if neck dissection is necessary. Though this method provides the operator with the optimal surgical view, the detrimental cosmetic effect on the patient of possessing a scar cannot be avoided, despite the effort of the surgeon to camouflage the scar by placing the incision in natural skin creases. Recently, the authors have previously reported the feasibility of robot-assisted neck dissections via a transaxillary and retroauricular (??TARA??) approach or modified face-lift approach in early head and neck cancers.5 ^, 6 On the basis of the forementioned surgical technique, we demonstrate our novel technique for robot-assisted Sistrunk??s operation via retroauricular approach as well as robot-assisted neck dissection with total thyroidectomy via transaxillary approach.

Methods

This is a case presentation of a 22-year-old woman with synchronous TGDCa and PTC with minimal lymph node metastasis who underwent resection of TGDCa and total thyroidectomy with left neck level III and IV lymph node dissection as well as central compartment lymph node dissection (CCND) via TARA approach with a robotic surgery system after approval from the institutional review board at Severance Hospital, Yonsei University College of Medicine. The incision was just like the TARA approach in head and neck cancer, which has been reported by our institute.6 The operation was proceeded as follows. First, excision of the TGDCa through the retroauricular incision was done followed by total thyroidectomy with CCND via transaxillary approach. Finally, neck dissection of left level III, IV was conducted via transaxillary approach. The da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA) was introduced via retroauricular or transaxillary port. A 30° dual-channel endoscope was used, and the two instrument arms were equipped with 5?mm Maryland forceps and a 5?mm spatula monopolar cautery for TGDCa excision via retroauricular approach. When conducting total thyroidectomy and neck dissection via transaxillary approach, three instrument arms were utilized, each equipped with 5?mm Maryland forceps, ProGrasp forceps and a 5?mm spatula monopolar cautery or Harmonic curved shears. The rest of the surgery was completed with the robotic system (see Video).

Results

The operative procedure was successfully completed utilizing the robotic surgical system with no conversion to open surgery. The operation time for TGDCa excision was 97?min, including the time for skin flap elevation (15?min), setting up the robotic system (5?min), and console time using the robotic system (77?min). Also, the total operation time for the consecutive total thyroidectomy with CCND and level III, IV dissection was 142?min including the time for skin flap elevation (27?min), setting up the robotic system (3?min), and console time using the robotic system (112?min). There were no intraoperative complications. The retroauricular approach for the removal of the TGDCa allowed for an excellent magnified surgical view revealing important structures of the local anatomy. It also created sufficient space for the cutting of the relevant portion of the hyoid bone. Handling of the robotic instruments through the incision was technically feasible and safe without any mutual collisions throughout the operation. The patient??s postoperative parathyroid hormone (PTH) level was within normal range and functions of her both vocal cords were intact. The histopathologic results of the specimens revealed thyroglossal duct cyst with internal papillary carcinoma measuring 1.1?cm with infiltrative tumor margins and papillary microcarcinoma measuring 0.9?cm within the left thyroid lobe with extrathyroidal soft tissue extension. There was no evidence of tumor in the right lobe and the pyramidal lobe of the thyroid gland. As for the lymph nodes resected, 7 out of 9 paratracheal nodes and 2 out of 7 left level III, IV nodes revealed metastatic carcinomas. The patient was discharged on the 8th?day after the operation with no complications. The patient was extremely satisfied with the cosmetic results. The patient has received high-dose radioiodine ablation (RAI) therapy and is currently doing well with no evidence of recurrence.

Discussion

Although there is still a great deal of controversy regarding the treatment of TGDCa, there is little debate that for the cases of synchronous TGDCa and PTC, total thyroidectomy in addition to the Sistrunk procedure must be performed.5 ^?C 6,12 As for the patient in our case where left level IV lymph node metastasis was detected under preoperative ultrasonography (USG), if the usual method of surgical procedure was to be selected, double incisions or a single extended transverse incision must be adopted for the Sistrunk??s operation and total thyroidectomy with lateral neck dissection. The conventional method to remove neck masses was to do so by placing an incision on the overlying skin. This ??open?? approach to viewing the lesion has an advantage of providing the operator with the best surgical view, but the recognizable surgical scar that results from the surgery can be displeasing for patients. Therefore the surgeon can try to make a small incision and camouflage the scar by placing the incision in natural skin creases, yet the cosmetic results can still be displeasing for the patient due to its visibility and permanence. This can be an even greater problem if the patient is young and an active member of his/her society and if the lesion is benign or low-grade malignancy which can be simply dissected and excised. Therefore it is the surgeon??s best interest to perform an operation successfully with a ??least obvious?? or ??hidden?? scar whenever possible. Accordingly, we have adopted a novel approach, the transaxillary and retroauricular approach, in view of our increasing surgical experience with various indications such as submandibular gland (SMG) resections and neck dissections in head and neck cancer or thyroid papillary carcinoma.5 ^?C 7 Some investigators have demonstrated that robot-assisted neck dissections performed on patients with thyroid cancer and lateral neck node metastasis are feasible and safe.13 We conducted total thyroidectomy with bilateral CCND and level III and IV dissection using the same approach. Although the technical feasibility and safety of neck dissection or SMG resection via retroauricular approach has already been reported previously at our institute, Sistrunk??s operation via retroauricular approach will be challenging. In spite of that, we were able to demonstrate successfully Sistrunk??s operation including the hyoid bone resection through the retroauricular approach. There are however, certain areas of potential difficulties which must be considered with caution during the operation procedure. First, when removing the TGDCa through the retroauricular port, identification of the ipsilateral hyoid bone is primarily important and it is also crucial that dissection along the capsule must be done carefully so as not to rupture the tumor. It is essential that sufficient working space must be created for the comfortable movement of the robotic arms through the retroauricular port and in order to do so, sufficient skin flap elevation in both superior and inferior directions must be performed. It is necessary to elevate the superior skin flap up to the level of the inferior border of the mandible but during this process, the platysma muscle must be identified and meticulous dissection along the subplatysmal plane must be carried out so as not to damage the marginal mandibular branch of the facial nerve. Another area of potential pitfalls concerns the total thyroidectomy with neck dissection through the transaxillary port. Sufficient amount of working space must be secured in order to perform comfortably the contralateral thyroidectomy and neck dissection and in order to do so, skin flap elevation must be done at least 2?cm further based on the ipsilateral omohyoid muscle and the contralateral thyroid gland must be adequately exposed. Using the robotic surgical system in removing the thyroglossal duct cyst, the free movement of wristed instrumentation through the retroauricular incision allowed for efficient dissection and easy handling of the tissue. In this particular case we could not identify the tract beyond the hyoid and up to the foramen cecum, but we anticipate that there would be no technical problems of dissection and excision had it been so. To our knowledge, Sistrunk??s operation and total thyroidectomy with lateral neck dissection via TARA approach utilizing the robotic surgical system has never been attempted before. It has some advantages over the conventional surgery in terms of cosmesis. However, careful consideration in selecting appropriate cases is required and prospective trials should be conducted to recognize long-term outcomes and to overcome potential limitations.     

Role of Preoperative Colonoscopy in Patients with Gastric Cancer: A Case Control Study of the Prevalence of Coexisting Colorectal Neoplasms

Background

We evaluated the prevalence of coexisting asymptomatic colorectal neoplasm (CRN) in patients with gastric cancer (GC).

Methods

Preoperative colonoscopic examinations were performed in 495 patients with GC who underwent gastrectomy between January 2009 and December 2010. To compare the prevalence of CRN in these patients with that in a normal population, we selected 495 sex- and age-matched persons who underwent colonoscopies for health screening. Risk factors for CRN were evaluated by univariate and multivariate analyses.

Results

The overall incidence of CRN was 41.8 % (414/990). The prevalence of overall CRN, high-risk CRN, and colorectal carcinoma (CRC) were significantly higher in the GC group than in the control group (overall CRN: 48.9 % vs. 34.7 %; high-risk CRN: 28.3 % vs. 13.5 %; CRC: 2.6 % vs. 0.2 %; all P < 0.001). The presence of GC [odds ratio (OR), 1.82; 95 % confidence interval (CI), 1.4–2.38; P < 0.001], age ≥50 years (OR, 2.58; 95 % CI, 1.75–3.81; P < 0.001), and male sex (OR, 2.28; 95 % CI, 1.72–3.02; P < 0.001) were risk factors for overall CRN. In patients with GC, age ≥40 years (OR, 3.22; 95 % CI, 1.24–8.37; P = 0.016) and male sex (OR, 3.21; 95 % CI, 2.17–4.76; P < 0.001) were risk factors for overall CRN.

Conclusions

The prevalence of coexisting CRN, including CRC, was higher in patients with GC than in the normal population. Preoperative colonoscopy is strongly indicated in patients with GC who are male and/or ≥40 years of age.     

Liver transplantation and conventional surgery for advanced hepatocellular carcinoma

This study intended to discuss the roles of hepatic resection (HR) and liver transplantation (LT) in patients with advanced hepatocellular carcinoma (HCC) through our experience and literature review. For large HCC > 10 cm, HR is regarded as the treatment of choice when hepatic function is preserved. Considering frequent extrahepatic recurrence and acceptable outcome after curative HR, LT has not been recommended. For multiple HCCs, HR has been attempted in different preferences worldwide. HR can offer acceptable survival outcome for patients with small oligo‐nodular HCCs and well‐preserved liver function. Recurrence pattern lowers the applicability of salvage LT, thus primary LT is suggested. For HCC patients with major portal vein tumor thrombus, HR with thrombus removal can be performed, in contrast LT is contraindicated. For HCC with bile duct tumor thrombus, aggressive en bloc resection can lead to prolongation of survival. There is no consensus on transplantability of HCC with bile duct tumor thrombus, but complete resection may provide survival gain after LT. In conclusion, HR and LT have complementary roles, thus they should be associated to rather than being opposed. Multi‐modality treatment strategy especially, for patients with advanced HCC, provides new fields of investigation for diverse indications of HR and LT.     

Age <40Years is an independent prognostic factor predicting inferior overall survival in patients treated with breast conservative therapy

To evaluate the effect of age at diagnosis on the treatment outcome after breast conservative therapy (BCT), retrospective analysis was done for 378 patients undergoing BCT for early breast cancer. Patients were divided into two groups according to their age: 'younger' (<40years, n=108) and 'older' (≥40years, n=270). Multivariate analysis was performed on the variables including tumor characteristics, the use of systemic therapy, and age to assess risk factors for local-regional relapse-free survival (LRRFS), distant metastasis-free survival (DMFS), and overall survival rates (OS). The median follow-up duration was 94months. The 8-year LRRFS, DMFS, and OS for younger and older groups were 88.1% and 96.5% (p=0.0022); 85.7% and 93.7% (p=0.0310); 89.2% and 95.9% (p=0.0205), respectively. On multivariate analysis, younger age was the only significant predictor of poor LRRFS (p=0.0022). Younger age and ER negativity showed borderline significance for DMFS (p=0.0828 and 0.0618, respectively). Younger age had trend toward inferior OS (p=0.0702). In conclusion, age younger than 40years was associated with inferior LRRFS in early breast cancer patients treated with BCT. There was also a trend for inferior DMFS and OS in younger patients. Age at diagnosis should be considered for individualized patient management.     

Specific determination of endothelial cell viability in the whole cell fraction from cryopreserved canine femoral veins using flow cytometry

Abstract: An efficient method for specifically determining the viability of endothelial cells (EC) from cells dissociated from the human saphenous vein was investigated. Three different methods, trypan blue staining assay, [3H]-proline incorporation assay, and flow cytometry (FCM), combined with the fluorescein isothiocyanate conjugated with Griffonia simplicifolia agglutins (GS1-FITC)/propidium iodide (PI) double staining, were used. Both trypan blue staining and [3H] proline incorporation assays demonstrated less sensitivity to determine viability of EC differentially from the other cells. FITC-GS1 showed prominent binding to the vascular EC and could be counted by FCM including PI on dead cells. Following the cryopreservation process, the GS1-FITC/PI FCM analytical method was adopted to test simultaneously the viability of whole cells and EC from the same tissue, human saphenous veins, and mongrel dogs' femoral veins after harvesting, antibiotic solution treatment, and thawing. The viability of the whole cells from veins decreased with a significant difference (p < 0.05) from that of EC after thawing.