机器人经腹腔镜行前列腺根治性切除术60例的初步结果

目的评价机器人经腹腔镜行前列腺根治性切除术的可行性和效果。方法利用da Vinci机器人外科手术系统对60例局限性前列腺癌患者施行机器人经腹腔镜行前列腺根治性切除术。患者年龄53～75岁，平均63．7岁；Gleason评分5～9，平均6；术前前列腺特异性抗原(PSA)5．5～38．3ng／ml，平均9．4ng／ml。结果术前机器人准备时间平均28(10～90)min，手术平均时间200(95～330)min。术中平均失血量355(50—1200)ml，输血7例(12％)。术后平均1d恢复正常饮食。术后平均导尿管留置时间7d，平均住院时间3d。1例发生吻合口漏尿者紧急手术探查和重新吻合，1例因膀胱颈挛缩行经尿道膀胱颈切开，1例因严重尿路感染行静脉输入抗生素。30例术前有性生活的患者术后6个月内自动恢复或经PDE5抑制剂或PGEl药物治疗后恢复性功能。术后3个月随访38例，完全控尿21例(55％)，轻度尿失禁9例(24％)，中度尿失禁8例(21％)。随访至术后6个月24例，完全控尿17例(71％)，轻度尿失禁4例(17％)，中度尿失禁3例(12％)。结论机器人经腹腔镜前列腺根治性切除术术中失血少、术后患者疼痛小、恢复快、住院时间短，使盆腔内难以进行的腹腔镜手术变得简单、方便，更加灵巧和准确。     

Pancreatic β-cell dysfunction in type 2 diabetes: Implications of inflammation and oxidative stress

Insulin resistance and pancreatic β-cell dysfunction are major pathological mechanisms implicated in the development and progression of type 2 diabetes(T2D). Beyond the detrimental effects of insulin resistance, inflammation and oxidative stress have emerged as critical features of T2D that define β-cell dysfunction. Predominant markers of inflammation such as C-reactive protein, tumor necrosis factor alpha, and interleukin-1β are consistently associated with β-cell failure in preclinical models...     

Neonatal thoracoscopic repair of congenital diaphragmatic hernia: selection criteria for successful outcome

Background/Purpose

Complications of open conversion, hypercarbia, and intestinal injury have plagued minimally invasive approaches to congenital diaphragmatic hernia (CDH) repair in neonates. To safely begin using minimally invasive techniques for neonatal CDH repair, we formulated preoperative selection criteria and operative techniques that would enhance chances for successful thoracoscopic primary diaphragm repair and uncomplicated outcome.

Methods

During the period from January 2003 to October 2004, neonates were selected for thoracoscopic CDH repair using anatomic and physiologic criteria. Anatomically, all patients were required to have stomach in the abdomen by radiography. Physiologically, all patients were required to be on minimal ventilator support with preoperative ventilator peak inspiratory pressures in the low 20s mm Hg. No patient could have clinical evidence of pulmonary hypertension at the time of surgery. Thoracoscopic CDH repair was performed using 3 trocars (3 and 5 mm). The hernia contents were reduced into the abdomen using 5-mm Hg insufflation, and the diaphragms were repaired primarily using interrupted 3-0 Ethibond simple sutures (Ethicon, Inc, Piscataway, NJ). Posterolateral diaphragm stitches were passed around the posterolateral ribs and tied extracorporeally.

Results

Thirty neonates with CDH were admitted to Children's Hospital Boston and Vanderbilt Children's Hospital during the study period. Eight patients (27%) met selection criteria and 7 underwent thoracoscopic CDH repair. Primary diaphragmatic repair was successfully accomplished thoracoscopically in all neonates without perioperative complication. Preoperative anatomic criteria correlated accurately with intact esophageal hiatus and primary diaphragm repair. Physiologically, each patient tolerated intrathoracic insufflation and CDH repair without clinical pulmonary hypertension or blood pressure lability. Three patients had intraoperative respiratory acidosis that was reversed with ventilator changes. Operative times averaged 152 minutes and ranged from 212 to 106 minutes. Postoperative mechanical ventilation ranged from 0 to 7 days, and the length of hospitalization ranged from 5 to 32 days. Longest follow-up has been 17 months. One patient required reoperation for recurrent CDH at 10 months after repair, but there have been no other long-term complications.

Conclusions

Neonatal thoracoscopic CDH repair is safe in selected patients who have good preoperative pulmonary function and anatomy amenable to primary diaphragmatic repair. A wider range of neonates may be acceptable for thoracoscopic CDH repair with increasing surgical experience.     

Assessing the safety and compatibility of silver based wound dressings in a magnetic resonance environment

Introduction

Silver dressings are an integral part of the management of burn patients. Package inserts assert a lack of compatibility and safety with magnetic resonance imaging (MRI) and recommend removal prior to any MRI procedure, although there is no clear evidence to support this recommendation. Dressing removal is associated with increased pain, anxiety, stress, and analgesia use. This study was to determine whether these products produce MRI image distortion or if the agitation of the silver particles generates enough heat which might produce further skin damage.

Methods

Hind limbs from euthanized pigs were used in a 7 T MRI scanner with three standard silver wound dressings. Images were obtained with both dry and wet dressings. Temperature was assessed before and during MRI by probes inserted between the dressing and skin. Images were independently reviewed by a radiologist and MR physicist for distortion.

Results

None of the dressings exhibited significant temperature increases nor produced significant distortion that influenced imaging quality.

Conclusion

Our data suggests silver containing wound dressings do not cause a significant increase in dressing temperature or image distortion and thus their removal is not warranted for clinical MRI examinations.     

Occlusive effect of metallic stents on canine ureters

A three-part study, with successive modifications based on preceding results, was conducted to evaluate ureteral placement of metallic stents. Gianturco self-expanding (10 mm and 4 mm diameter) and balloon-expanded (4 mm diameter) metallic stents were placed in normal and stenotic canine ureters. No migration or ureteral perforation occurred during the follow-up of 10 mm stents. Varying degrees of hydronephrosis and hydroureter were found on all 1-week pyelograms. At 4 weeks, complete occlusion of the stented ureter was noted in all cases because of mucosal hyperplasia around the stent wires. To prevent this reaction, 4 mm self-expanding stents constructed of smaller wire that was uncoated or coated with either Teflon or polyurethane were tested in five dogs. In all cases, results were similar to those obtained with the larger prostheses. Finally, 4 mm balloon-expanded stents were placed in a normal ureter of three dogs. In one dog, the stent migrated out of the ureter. No migration or ureteral perforation occurred in the two remaining dogs. In these animals, mucosal hyperplasia and complete ureteral occlusion occurred 6 and 8 weeks after placement. Therefore, ureteral placement of Gianturco self-expanding as well as balloon-expanded metallic stents leads to occlusion of the ureter instead of maintaining its patency. Stents, therefore, may be useful as ureteral occlusion devices.     

Low-iodine diet revisited: importance in nuclear medicine imaging and management

PURPOSE: The need for a low-iodine diet (LID) to maximize the results of radioactive iodine uptake (RAIU), nuclear medicine thyroid scintigraphy, and ultimately treatment of thyroid cancer patients is widely accepted. Failure to follow the prescribed diet can alter RAIU results, thyroid scan findings, and poststudy management. OBJECTIVE: Provided is a case presentation that illustrates the need for adequate patient understanding and compliance with the LID. METHODS: We present the clinical history, laboratory values, and pertinent imaging of a 21-year-old woman with papillary thyroid cancer. The patient's post-thyroidectomy I-123 and 2 subsequent thyroid (I-123 and post-RAI ablation I-131) scintigraphy examinations are reviewed as well as the patient's urine iodine levels. RESULTS: In this case of a woman with papillary thyroid cancer, the nuclear medicine whole body and neck pinhole images revealed that compliance to an LID positively impacts the overall management. After an LID was followed, the patient's urine iodine level appropriately declined from the previously elevated level. Initial negative results on thyroid scintigraphy caused by noncompliance with the LID became positive when the patient adhered to the prescribed dietary regimen. CONCLUSION: An LID is an integral element in the management of differentiated thyroid cancer. Proper guidance and emphasis on the implementation of the diet needs to be provided to patients. Noncompliance may lead to false negative imaging results, misleading the medical professionals and patient. Potentially inadequate management of the patient's thyroid cancer may follow.     

Role of Selective α and β Adrenergic Receptor Mechanisms in Rat Jejunal Longitudinal Muscle Contractility

Gut motility is modulated by adrenergic mechanisms. The aim of our study was to examine mechanisms of selective adrenergic receptors in rat jejunum. Spontaneous contractile activity of longitudinal muscle strips from rat jejunum was measured in 5-ml tissue chambers. Dose–responses (six doses, 10⁻⁷–3 × 10⁻⁵M) to norepinephrine (NE, nonspecific), phenylephrine (PH, α₁), clonidine (C, α₂), prenalterol (PR, β₁), ritodrine (RI, β₂), and ZD7714 (ZD, β₃) were evaluated with and without tetrodotoxin (TTX, nerve blocker). NE(3 × 10⁻⁵M) inhibited 74 ± 5% (mean ± SEM) of spontaneous activity. This was the maximum effect. The same dose of RI(β₂), PH(α₁), or ZD(β₃) resulted in an inhibition of only 56 ± 5, 43 ± 4, 33 ± 6, respectively. The calculated concentration to induce 50% inhibition (EC50) of ZD(β₃) was similar to NE, whereas higher concentrations of PH(α₁) or RI(β₂) were required. C(α₂) and PR(β₁) had no effect. TTX changed exclusively the EC50 of RI from 4.4 ± 0.2 to 2.7 ± 0.8% (p < 0.04). Contractility was inhibited by NE (nonspecific). PH(α₁), RI(β₂), and ZD(β₃) mimic the effect of NE. TTX reduced the inhibition by RI. Our results suggest that muscular α₁, β₂, and β₃ receptor mechanisms mediate adrenergic inhibition of contractility in rat jejunum. β₂ mechanisms seem to involve also neural pathways. Part of this work was presented as a poster at the annual meeting of the Society for Surgery of the Alimentary Tract, Orlando, FL, May 17–22, 2003, and published as an abstract in Gastroenterology 2003, 124(4):M1342.     

Mohs Micrographic Surgery for Granular Cell Tumor Using S-100 Immunostain

BACKGROUND: Granular cell tumor (GCT) is an uncommon tumor of neural origin. Most commonly it is found in the head and neck region and rarely on the foot. The pathologic diagnosis is often confirmed by immunohistochemical staining for S-100 protein. The standard treatment is complete excision. Two previous cases of GCTs treated by Mohs micrographic surgery (MMS) have been reported in the English literature. The immunohistochemical stain S-100 was not used in these cases. OBJECTIVE: Describe the use of S-100 immunohistochemical stain on MMS frozen sections in clearing a GCT of the foot with extension along nerves without involvement of perineurium. METHODS: Tissue was embedded and cut using standard Mohs surgical methodology. Frozen sections were stained with hematoxylin and eosin and with an immunoperoxidase method for S-100 protein using a Ventana automated stainer. RESULTS: MMS in combination with S-100 was successfully performed on a GCT on the plantar surface of our patient's foot. The S-100 immunohistochemical stain was helpful in tracking the extension along nerves of the GCT which was not evident with hematoxylin and eosin alone. CONCLUSION: Using S-100 immunohistochemical stain on the MMS frozen sections can increase the diagnostic accuracy for complete removal of GCT.