经尿道膀胱肿瘤电切联合吡柔比星灌注治疗浅表性膀胱癌疗效观察

[目的]探讨经尿道等离子膀胱肿瘤电切术（TURBT） 联合吡柔比星灌注治疗浅表性膀胱癌的安全性与有效性.[方法]用经尿道等离子体双极电切系统膀胱肿瘤电切（transurethral resection of the bladder tumor,TURBT）治疗膀胱癌90例,肿瘤分级G1为72例,G2为18例.电极切除肿瘤直达深肌层,同时扩大到电切距肿瘤基底1 cm范围的正常组织,术后定期进行膀胱内灌注吡柔比星化疗.[结果]手术时间5～46 min,平均（14±12） min.术中无经尿道电切综合征,发生闭孔神经反射11例,其中腹膜外穿孔1例.随访3～24 个月,8例复发,7例再行TURBT,1例并发尿道移形上皮癌,并行全尿道切除术,术后追踪观察至今未复发.[结论]TURBT联合吡柔比星膀胱灌注是治疗浅表性膀胱癌是的一种理想方法,疗效好,创伤小,副反应低,值得推广应用.     

Experimental comparison of the ultrasonically-activated scalpel to electrosurgery and laser surgery for laparoscopic use

Summary

Energy sources used in laparoscopic surgery are associated with thermal damage to tissues. In this study, we sought to compare the safety and efficacy of the ultrasonically-activated scalpel to electrosurgery and laser surgery in laparoscopic applications using an animal model (cholecystectomy). Variables examined were gall bladder perforation, bile spillage, smoke generation, operative time, tissue injury, bleeding, liver function tests and post-operative adhesion formation following laparoscopic cholecystectomy. Female pigs were randomized to one of three groups: laparoscopic cholecystectomy performed using electrosurgery (ES), laser surgery (LS), or ultrasonically-activated scalpel (UAS). At the termination of the procedure, the animals were either recovered for 7, 14, or 28 days or immediately euthanized with an intracardiac injection of saturated potassium chloride solution for necropsy (0 day). There was no difference in mean operative time between UAS, ES or LS. LS required greater smoke evacuation (67%) than ES (25%) or UAS (0%) (P < 0.001). Gall bladder perforation during dissection with the UAS was 17%, with ES 50% and with LS, 92% (P < 0.001). Post-operative adhesions occurred in 22% of the UAS group, 67% of the ES group and 89% of the LS group (P < 0.001). The ultrasonically-activated scalpel is more ideally suited for laparoscopic cholecystectomy than electrosurgery or laser surgery, and laser surgery is the least desirable of the three modalities.     

Surgical diathermy and electrical hazards: causes and prevention

The hospital environment is both unique and unusual in that electrical equipment is directly applied to the human body. From this application either capacitive or resistive coupling may lead to current flow and harm. Surgical diathermy, patient monitoring and imaging, although universal, are often misunderstood, and many clinicians are ignorant of their principles and hazards. Electrical equipment in hospital therefore has the potential to lead to serious injury or death. This article outlines the basic physics of electricity, in particular the principles behind diathermy, the hazards posed by it and by other devices and the various measures available to reduce the risk of these.     

TUVP联合TURP治疗高危前列腺增生症42例

【目的】探讨经尿道前列腺汽化电切术（TUVP）结合经尿道前列腺电切术（TURP）治疗高危前列腺增生症（BPH）的疗效和安全性.【方法】对42例高危前列腺增生症患者,即年龄≥80岁,或合并有一种以上重要器官系统功能不全者,联合应用TUVP和TURP进行前列腺切除.【结果】全部患者均安全渡过围手术期,术后疗效满意,无永久性尿失禁等严重并发症,提高了高危前列腺增生患者的生活质量.【结论】TUVP结合TURP治疗高危BPH可综合两者的优点,是治疗高危BPH患者的安全和有效的方法.     

The Art of SAPIEN 3 Transcatheter Mitral Valve Replacement in Valve-in-Ring and Valve-in-Mitral-Annular-Calcification Procedures

The SAPIEN 3 is the only transcatheter heart valve commercially available for compassionate transcatheter mitral valve replacement in patients with previous mitral surgical rings and mitral annular calcification (valve in ring [VIR] and valve in mitral annular calcification [VIM]). Reported outcomes have been inconsistent or poor. The review provides an overview of the authors’ approach to achieve largely consistent results despite the intrinsic limitations of SAPIEN 3 VIM and VIR. The approach includes bedside modifications of the valve implant, the delivery system, and of the cardiac substrate itself. Until purpose-built devices are readily available, VIR and VIM procedures will require aggressive multidisciplinary cooperation, meticulous planning and execution, and postprocedure management by experienced, high-volume operators.     

Preventing Coronary Obstruction During Transcatheter Aortic Valve Replacement: From Computed Tomography to BASILICA

Coronary artery obstruction is an uncommon but devastating complication of transcatheter aortic valve replacement (TAVR). Computed tomography appears to be a sensitive but nonspecific predictor of coronary artery obstruction. Transcatheter approaches to prevent and treat coronary artery obstruction, such as “snorkel” stenting, are unsatisfactory because of serious early and late ischemic complications. Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction during TAVR (BASILICA) is an early-stage transcatheter procedure to prevent coronary artery obstruction. It works by splitting the native or bioprosthetic leaflets so that they splay after TAVR and preserve coronary artery inflow. Because of the paucity of suitable alternatives, there is interest in the BASILICA technique despite its infancy. This tutorial review summarizes current thinking about how to predict and prevent coronary artery obstruction using BASILICA. First, the authors depict the main pathophysiological mechanisms of TAVR-associated coronary artery obstruction, along with the factors thought to contribute to coronary obstruction. Next, the authors provide a step-by-step guide to analyzing pre-procedural computed tomographic findings to assess obstruction risk and, if desirable, to plan BASILICA. Next, the authors describe the mechanisms underlying transcatheter electrosurgery. Finally, they provide step-by-step guidance on how to perform the procedure, along with a required equipment list.     

Transcatheter Laceration of Aortic Leaflets to Prevent Coronary Obstruction During Transcatheter Aortic Valve Replacement: Concept to First-in-Human

Objectives

This study sought to develop a novel technique called bioprosthetic or native aortic scallop intentional laceration to prevent coronary artery obstruction (BASILICA).

Tip-to-Base LAMPOON for Transcatheter Mitral Valve Replacement With a Protected Mitral Annulus

ObjectivesThe purpose of this study was to evaluate tip-to-base intentional laceration of the anterior mitral leaflet to prevent left ventricular outflow tract obstruction (LAMPOON) in patients undergoing transcatheter mitral valve replacement (TMVR) in annuloplasty rings or surgical mitral valves.BackgroundLAMPOON is an effective adjunct to TMVR that prevents left ventricular outflow tract obstruction (LVOTO). Laceration is typically performed from the base to the tip of the anterior mitral leaflet. A modified laceration technique from leaflet tip to base may be effective in patients with a prosthesis that protects the aortomitral curtain.MethodsThis is a multicenter, 21-patient, consecutive retrospective observational cohort. Patients underwent tip-to-base LAMPOON to prevent LVOTO and leaflet overhang, or therapeutically to lacerate a long anterior mitral leaflet risking or causing LVOTO. Outcomes were compared with findings from patients in the LAMPOON investigational device exemption trial with a prior mitral annuloplasty.ResultsTwenty-one patients with a annuloplasty or valve prosthesis–protected mitral annulus underwent tip-to-base LAMPOON (19 preventive, 2 rescue). Leaflet laceration was successful in all and successfully prevented or treated LVOTO in all patients. No patients had significant LVOTO upon discharge. There were 2 cases of unintentional aortic valve injury (1 patient underwent emergency transcatheter aortic valve replacement and 1 patient underwent urgent surgical aortic valve replacement). In both cases, the patients had a supra-annular ring annuloplasty, and the retrograde aortic guiding catheter failed to insulate the guidewire lacerating surface from the aortic root. All patients survived to 30 days. Compared with classic retrograde LAMPOON, there was a trend toward shorter procedure time.ConclusionsTip-to-base laceration is a simple, effective, and safe LAMPOON variant applicable to patients with an appropriately positioned mitral annular ring or bioprosthetic valve. Operators should take care to insulate the lacerating surface from adjacent structures.     

Optimizing integration of electrosurgical hand controls within a laparoscopic surgical tool

Abstract

In laparoscopic surgery, electrosurgical equipment is operated by means of one or more foot pedals positioned on the floor in front of the surgeon causing poor ergonomic posture and physical discomfort. The focus of this study was to ergonomically explore the integration of electrosurgical hand controls within the previously designed Intuitool? laparoscopic surgical instrument to optimize functionality. Three different hand control designs (CDs) were implemented within the Intuitool? and each CD contained the standard cutting and coagulation features, previously operated by foot pedals. This study used 26 right-handed participants, with no previous laparoscopic surgery experience. The participants completed simple tasks using all three CDs within a simulated abdomen. Electromyography (EMG) sensors and force sense resistors (FSRs) were utilized to measure muscle activity and button actuation force, respectively. A questionnaire was also utilized to measure comfort level of each CD. The results indicated that the close proximity of CD 1 generated greater actuation force for all tasks, was rated easier to use (P = 0.003) and was preferred more frequently by the participants (53.8%) compared to CD 2 and 3. As a result, CD 1 was determined to be an optimal ergonomic design for electrosurgical hand controls within the Intuitool?.     

History of Wolff-Parkinson-White syndrome

While Drs. Wolff, Parkinson, and White fully described the syndrome that bears their names in 1930, prior case reports had already described the essentials. Over the ensuing century this syndrome has captivated the interest of anatomists, clinical cardiologists, and cardiac surgeons. Stanley Kent described lateral muscular connections over the atrioventricular (AV) groove, which he felt were the normal AV connections. The normal AV connections were, however, clearly described by His and Tawara. True right-sided AV connections were initially described by Wood et al., while Ohnell first described left free wall pathways. David Scherf is thought to be the first to describe our current understanding of the pathogenesis of the Wolff-Parkinson-White (WPW) syndrome in terms of a reentrant circuit involving both the AV node--His axis as well as the accessory pathway. This hypothesis was not universally accepted and many theories were applied to explain the clinical findings. The basics of our understandings were established by the brilliant work of Pick, Langendorf, and Katz who by using careful deductive analysis of ECGs were able to define the basic pathophysiological processes. Subsequently, Wellens and Durrer applied invasive electrical stimulation to the heart in order to confirm the pathophysiological processes. Sealy and his colleagues at Duke University Medical Center were the first to successfully surgically divide an accessory pathway and ushered in the modern area for curative therapy for these patients. Morady and Scheinman were the first to successfully ablate an accessory pathway (posteroseptal) using high-energy direct-current shocks. Subsequently, Jackman, Kuck, Morady, and a number of groups proved the remarkable safety and efficiency of catheter ablation for pathways in all locations using radiofrequency energy. More recently, Gallob et al. first described the gene responsible for a familial form of WPW. The current ability to cure patients with WPW is due to the splendid contributions of individuals from diverse disciplines from throughout the world.