Robot-assisted laparoscopic surgery. Preliminary results at our Center

The aim of our study was to evaluate the advantages and disadvantages of robot-assisted laparoscopic surgery, in terms of operative times, complications and length of hospital stay, using the Da Vinci Robotic Surgical System (Intuitive Surgical, Inc.). Twenty-five patients underwent robotic procedures. The indications were gastro-oesophageal reflux disease in 13 cases, achalasia in 2, cholelithiasis in 2, adrenal adenoma in Cushing syndrome in 6, pheochromocytoma in 2, and incidentaloma in 1. Robotic surgery was compared with the traditional laparoscopic approach. From January to September 2002 13 Nissen-Rossetti fundoplications, 2 Heller myotomies with Dor fundoplication, 2 cholecystectomies and 9 adrenalectomies (6 left adrenalectomies, 3 right adrenalectomies) were performed. There were no significant differences in age, preoperative body mass index (mean 28; range: 18-32) or sex between patients treated by robotic surgery and those treated by traditional laparoscopy. Operative times were significantly longer in the robotic surgery group (97.1 minutes, range: 77-126 minutes, versus 82.5 minutes, range: 65-100 minutes, for Nissen-Rossetti fundoplication; 132.8 minutes, range 104-181 minutes, versus 82.1 minutes, range 55-120 minutes, for adrenalectomy). There were no intraoperative complications. Conversion to traditional laparoscopy was necessary owing to technical difficulties in 4/9 adrenalectomies (44.4%; 3 left, 1 right). There was no significant difference in length of hospital stay (3.2 days, range 2-7 days, for Nissen-Rossetti fundoplication; 5.7 days, range 4-9 days, for adrenalectomy). Our study confirms the safety and feasibility of robot-assisted laparoscopic surgery. However, operative times were longer and costs higher, with no difference in outcomes. Given the current level of technology and experience, robotic surgery would not appear to afford any advantage over standard laparoscopic approaches.     

Fluoroscopic and Gait Analyses for the Functional Performance of a Custom-Made Total Talonavicular Replacement

The present study evaluated the restoration of joint function in a special clinical case: a professional rock climber who underwent an original total talonavicular replacement with a custom-made prosthesis after a complex articular fracture. Full body gait analysis and 3-dimensional joint kinematics using single-plane fluoroscopy were performed on the same day at the 30-month follow-up examination. Gait analysis was performed using stereophotogrammetric, dynamometric, electromyographic, and baropodometric systems. Gait analysis showed good restoration of rotation, as well as moment patterns in the main lower limb and foot joints in the operated leg. At the artificial tibiotalar joint, videofluoroscopic analysis revealed a flexion capability of about 20°, together with a few degrees of motion in the frontal and transverse planes. The neighboring joints of the foot did not present with severe kinematic abnormalities. A full talonavicular replacement can be a viable and effective solution for complex ankle injury sequelae, even in patients with highly demanding functionality.     

腹腔镜全胃切除术

尽管技术手段不断改良更新,腹腔镜全胃切除术中的腔内食管空肠Roux-en-Y吻合仍然在技术上充满挑战,成为制约其发展的瓶颈之一.据此,我们团队利用“一体化捆绑技术”使用经口抵钉座置入系统改进了这一过程.本文视频展示了1例胃多原发腺癌病例：贲门]（T1）和胃窦（T2）各见一病灶,仅小弯侧幽门周围见1枚可疑淋巴结肿大,未见转移征象.一般地,我中心对于近端胃局部进展期癌常规行No.10组淋巴结清扫,但本例贲门 处为早期病变,故行腹腔镜全胃切除、D2-No.10淋巴结清扫术.     

Minimally invasive video-assisted thyroidectomy in pediatric patients

Background

Minimally invasive video-assisted thyroidectomy (MIVAT) proved to be safe and effective in the treatment of both benign diseases and malignancies. We report our experience in thyroid surgery in pediatric patients.

Methods

From October 1998 to December 2005, 35 patients (27 females and 8 males) underwent MIVAT for thyroid disease. The mean age was 14.0 years (range, 8-18 years); mean ecographically estimated thyroid volume was 11.13 mL (range, 8-25 mL).

Results

A total thyroidectomy was performed in 22 patients, whereas lobectomy was performed in 13. Two patients of the latter group had a second lobectomy for a false-negative result at frozen section during the first operation. One patient underwent also a prophylactic central neck dissection for positive RET oncogene. The histologic examination found a papillary carcinoma in 11 patients, a microfollicular nodule in 7 patients, and multinodular goiter in 17 patients. The mean operative time was 54.1 minutes for thyroidectomy (range, 25-110 minutes) and 38.5 minutes for lobectomy (range, 20-65 minutes). All patients but one was discharged on the first postoperative day. One transient hypoparathyroidism was observed in the patient who underwent total thyroidectomy plus central neck lymphadenectomy.

Conclusions

The MIVAT technique proved to be as safe and effective as conventional thyroidectomy with Kocher approach to treat patients with both benign and malignant diseases of the thyroid gland. The advantages of MIVAT are represented by a better and faster postoperative course and an improved aesthetic result, which is particularly important in this group of patients.     

Late hepaticartery thrombosis after liver transplantation: which strategy? A single‐center retrospective study

The management of late hepatic artery thrombosis (LHAT) after liver transplantation (LT) is not codified. The objective of this study was to retrospectively evaluate outcomes after LHAT. All patients with HAT diagnosed 3 months or later after LT on computed tomography between 1993 and 2017 were included. Our policy was to apply a conservative management for asymptomatic or mild symptomatic patients and reserve retransplantation to symptomatic patients with diffuse cholangitis or liver abscess. A total of 56 patients were analyzed. LHAT diagnosis was made after a median interval of 48 months from LT (ranging from 3 to 368.3). At diagnosis, 28 (50%) patients were asymptomatic, 10 (17.8%) had mild symptoms (transient acute cholangitis), and 18 (32.1%) had severe complications. Asymptomatic patients experienced a 5‐year graft survival of 57% vs. 40% in those with mild symptoms and 11% in those with severe complications (P < 0.001). However, there was no difference in overall patient survival between groups. Our results suggest that conservative management of LHAT for asymptomatic patients or patients with mild complications is safe. Retransplantation should be reserved to patients with severe biliary complications.     

Human ventral parietal cortex plays a functional role on visuospatial attention and primary consciousness. A repetitive transcranial magnetic stimulation study

In this paper, we used repetitive transcranial magnetic stimulation (rTMS) in 18 normal subjects to investigate whether the ventral posterior parietal cortex (PPC) plays a causal role on visuospatial attention and primary consciousness and whether these 2 functions are linearly correlated with each other. Two distinct experimental conditions involved a similar visual stimuli recognition paradigm. In "Consciousness" experiment, number of consciously perceived visual stimuli was lower by about 10% after rTMS (300 ms, 20 Hz, motor threshold intensity) on left or right PPC than after sham (pseudo) rTMS. In "Attentional" Posner's experiment, these stimuli were always consciously perceived. Compared with sham condition, parietal rTMS slowed of about 25 ms reaction time to go stimuli, thus disclosing effects on endogenous covert spatial attention. No linear correlation was observed between the rTMS-induced impairment on attention and conscious perception. Results suggest that PPC plays a slight but significant causal role in both visuospatial attention and primary consciousness. Furthermore, these high-level cognitive functions, as modulated by parietal rTMS, do not seem to share either linear or simple relationships.     

胆囊癌假阴性诊断因素分析

目的: 讨论原发性胆囊癌误诊原因以提高诊断率. 方法: 对近8年50例经病理证实为胆囊癌的临床表现,影像学特点和术中判断进行回顾分析. 结果: ①临床表现:右上腹不适,饱胀感为74%,恶心、呕吐为44%,消瘦为30%,右上腹明显疼痛为26%,黄疸为20%.入院诊断符合率为46%,不符合率为54%.②所有病例均经B超检查,40例行CT检查.B超诊断符合率为74%,假阴性率为26%,CT诊断符合率为92.5%,假阴性率为7.5%.B超联合CT检查提高诊断符合率达94%,对胆囊壁不规则增厚及腔内广基的软组织肿块应警惕胆囊癌的可能.③术中对肉眼和手感发现胆囊壁不规则增厚者,应按常规作胆囊剖开及术中冰冻病理检查. 结论: 重视腹痛、消瘦、黄疸患者的临床表现,对胆囊壁不规则增厚、胆囊腔内广基的软组织肿块影像学特点及术中判断胆囊壁不规则增厚、质稍硬者,应作常规冰冻病理检查,这是提高胆囊癌诊断率的重要环节.     

Management of 100 consecutive cases of pancreatic serous cystadenoma: wait for symptoms and see at imaging or vice versa?

Abstract Pancreatic serous cystadenomas have a low malignancy rate. When nonsymptomatic, in selected patients, they can be managed without surgery; however, a high degree of diagnostic reliability is crucial. We admitted 100 consecutive cases (87 women with a median age of 51.86 years). Of these, 44 were symptomatic and 56 were diagnosed incidentally. Ultrasound correctly diagnosed 53% of the cases, incorrectly 31%, and was nondiagnostic in 16%. Computed tomography scan had similar rates (54%, 34% and 12%, respectively), while magnetic resonance imaging improved diagnostic accuracy to 74% and reduced incorrect diagnoses to 26%. In 21 cases, exploratory needle aspiration of the cyst was carried out; only 8 samples (38%) resulted in a diagnosis; in 12 patients (57%) insufficient material was acquired to allow for diagnosis, one case demonstrated epithelial dysplasia. In 1 patient an exploratory puncture resulted in a very serious bleeding. Sixty-eight patients were treated surgically, the 44 symptomatic cases and another 24 patients with ill-defined oligocystic lesions that could not be differentiated as serous or mucinous in the preoperative period. Two patients underwent resection because of frank tumor growth. In the two time periods analyzed (the first 7 years and the subsequent 6.5 years) the relationship between cases observed/operated on did not significantly change. Twenty-one (30.8%) distal pancreatectomies, 14 (20.5%) intermediate resections, 10 (14.7%) pancreaticoduodenectomies 4 (5.8%) enucleations, and 1 (1.4%) duodenum-preserving pancreatic head resection were carried out. Nine patients (13.2%), underwent exploratory laparotomy with a diagnostic biopsy. Another 9 underwent decompressive interventions with cystojejunostomies. The morbidity was 27.9%, with a reoperation rate of 7.3% and zero mortality. In general the patient’s pain resolved in the postoperative period. Median follow-up was 43 months (range, 4–191 months). One patient died from other causes, and all others are currently alive. In the group of 32 patients who did not undergo operation, the median follow-up is 69 months (range, 8–164 months). Until more sophisticated technologies can be developed, the current diagnostic work-up will not result in increased preoperative diagnosis of serous-cystic tumors of the pancreas. This is mainly relevant to the oligocystic forms, which account for about one fourth of all serous tumors observed. Electronic Publication     

急性脊髓损伤动物模型的建立

目的：建立一种不同程度的脊髓损伤动物模型。方法：自行设计一种脊髓损伤动物模型，以一恒定的外力和打击时间，以观察35只大鼠在不同的打击深度下的运动功能和病理变化。结果：假手术组大鼠，苏醒后能站立行走，脊髓结构正常；打击深度为0.5mm时，动物苏醒后能站立行走，脊髓结构正常，打击度为0.8mm 时，动物出现不瘫，数天后能站立行走，脊髓结构破坏较轻；打击深度为1．0 mm时，动物出现全瘫，4周后不能站立行走，脊髓结构破坏，打击深度为1．5 mm时，动物出现全瘫，4周后不能站立行走，脊髓结构破坏严重。结论：以打击深度为参数建立不同程度的脊髓损伤动物模型，重复性好较