A forgotten debate in the history of medicine: vascular anastomoses, from open functional relationships to tight structural connections

Head transplantation has become a hot spot in the field of organ transplantation. After more than a century of exploration, the technology and methods of head transplantation have continuously improved, but head transplantation still faces some tough problems, such as immunosuppression, vascular and spinal cord anastomosis, spinal cord fusion, pain control, ischemia reperfusion injury and so on. This paper will review the relevant research on these problems and solutions, trying to provide theoretical basis for human head transplantation. Key words: Head transplantation; Immunosuppression; Vascular anastomosis; Spinal cord anastomosis; Spinal cord fusion; Pain control; Ischemia reperfusion injury

Objective To discuss the clinical effect of transplantation of slice nail bed flap of great toe with vascular anastomosis in repair of partial nail-bed and soft tissue defect at fingers. Methods From January, 2015 to March, 2018, 16 cases (16 fingers) of partial nail-bed defect at fingers were repaired with transplantation of slice nail bed flap of great toe with vascular anastomosis. All cases were combined with palmar soft tissue defect at distal segment fingers. The area of nail bed defects were from 0.8 cm×0.5 cm to 1.2 cm×1.0 cm. The area of soft tissue defects were from 1.2 cm×1.0 cm to 2.5 cm×1.5 cm. The average time from injury to operation was 3.6 hours after injuries(ranging from 1 hour to 8 hours). The area of slice nail bed flap incised during operation were from 2.5 cm×1.2 cm to 3.2 cm×1.8 cm, and the donor site was sutured directly. All patients were followed-up regularly for nail appearance, function and donor healing. Among them, 11 cases were followed-up by clinic, 4 cases by WeChat, and telephone follow-up was performed in 1 case. Results The nail-bed flap after transplantation survived successfully. The followed-up time were from 6 to 18 months, the average time was 9 months. Longitudinal spine and rough appearance occurred in 1 case. Others were flat, smooth, complete attachment of nail body and nail bed. The flaps had good appearance, texture and elasticity at 6 months after surgery, and two-point discrimination was 6-12 mm(average, 8 mm). The toenails at donor sites grew well. No walk-associated pain after long-term following-up. Six months after surgery, according to standard for efficacy evaluation of nail regeneration, 12 cases were excellent, 3 cases were good and 1 case was acceptable. Conclusion Transplantation of slice nail bed flap of great toe with vascular anastomosis in repair of partial nail-bed and soft tissue defect at fingers is one of the effective methods for repairing nail-bed defect at fingers. Key words: Nail bed defect; Nail bed fiap of great toe; Vascular anastomosis; Repair

To solve the serious shortage of transplantation donors, the use of donors after circulatory death (DCDs) has been promoted in association with the recently developed normothermic machine perfusion.1 Since Dr. Alex Carrel first reported the experimental vascular anastomosis surgical technique for organ transplantation in 1902, its clinical use has promoted the maintenance of organs in a warm ischemic state until reperfusion during transplantation. In cases requiring vessel anastomoses for the transplanted organs, ex vivo to in situ continuous machine perfusion is a novel technique that overcomes the need for intraoperative warm ischemia from put-in to resumption of blood flow in the recipient.2 Herein, the authors propose a surgical technique that establishes in situ perfusion for vascular anastomoses and promotes ischemia-free transplantation.3 Previously, hard wire-reinforced circular cannulas have been used in this setting. However, in this study, we introduce a newly developed soft triangular insertion tube for use with ex vivo machine perfusion that facilitates vascular anastomoses in the graft liver, thereby achieving ischemia-free transplantation. This novel tube was manufactured using medical-grade soft silicone to avoid damage to inner vessel walls. To maintain good circulation from the standpoint of fluid dynamics, this new insertion tube, which maintains its triangular shape and circular lumen in blood vessel cross-sections, was developed based on the tri-stapled anastomosis performed by Carrel (Figure 1). The benefit of the triangular shape of the tube was tested by bending both triangular and cylindrical silicon tubes. The triangular tube showed excellent tolerance to kinking and maintained flow even with a 180° bend. The cylindrical tube was completely occluded and prevented all flow at bend angles ranging from 140° to 160° (Figure 2).FIGURE 1: Method of using newly developed triangular insertion tube. The tube comprises an insertion head with 3 grooves for ligation (arrow head), a triangular tube with a triangular-shaped cross-section and an inner hole, and a connecting port. The inserted tube allows efficient and continuous suturing of the inferior segment of the vessel. PV, portal vein.FIGURE 2: Rigidity mechanism of a novel triangle tube for portal vein. A, The diameter of the inner hole of the tube is about 4 mm. The thickness of the cylindrical tube wall is 1 mm and that of the triangular tube is 0.5 to 3 mm. White cursors show the direction of the applied stress when the tube kinks and blue cursors show the direction of the diffused stress. B, The cylindrical tube collapses into a flat shape and the triangular tube collapses into the shape that maintains gaps allowing continued perfusion flow. C, Bending test environment.Our authors tested liver engraftments using this novel device by performing porcine orthotropic transplantations after cardiac arrest. Liver grafts from DCDs were maintained using subnormothermic perfusion with 10% red blood cells. Blood vessel anastomoses were created by inserting the newly developed triangular silicone tubes into blood vessels on the side of the organs undergoing anastomosis. After interrupted suturing at the bilateral ends, the flat bottom of the triangular tube allowed smooth and continuous suturing of the posterior wall (Figure 1). The anterior wall was sutured continuously from the bilateral ends while the tube was carefully avoided. These sutures were tied up immediately after removing the tube, and the vascular clamp was subsequently released. After reestablishing blood flow, hemostasis was confirmed and the vascular anastomoses were performed. Perfusion was maintained during the vascular anastomosis process and there were no excessive pressure fluctuations from the perfusion machine. Compared with previous blood vessel suturing methods, the anastomotic time using this technique was shortened for all 6 patients in each group. Although the benefits of ischemia-free liver transplantation using a perfusion machine have been reported clinically, the strategies for transplantation using DCDs could be dramatically changed by maintaining continuous resuscitation in donor organs.1,2 Herein, we present our novel tube device in a technical “Materials and Methods” communication.

Microvascular manual suture technique is invented by doctor Carrel in 1912, it had become a core technique in microsurgery. This vascular anastomosis technique is effective. However, it also has some disadvantages such as time-consuming and labor- consuming. And as a residual foreign body, suture can also cause inflammation. In recent years, vascular couplers have been widely applied in clinic, this method ensuring the quality of anastomosis with faster speed. The four principles on ideal vascular anastomosis, which put forward by Carrel, is the target of improvement on vascular anastomosis tools. In recent years, Ring-coupling using negative pressure, vascular stents, hook stapling anastomat, fibrin glue, P407 and other new technologies have been reported, this paper will focus on the advantages and disadvantages of these technologies. Key words: Vascular anastomosis tools; Vascular anastomosis techniques; Research progress

Transplantation at 100 Years: Alexis Carrel, Pioneer Surgeon

Large Doses of Topical Lidocaine during Microvascular Surgery Are Not Associated with Toxic Blood Concentrations

Preoperative 3-dimensional Magnetic Resonance Imaging of Uterine Myoma and Endometrium Before Myomectomy

Since the first experimental report of the vascular anastomosis surgical technique for organ transplantation by Dr. Alex Carrel in 1902, its clinical use has become widespread and has come to define the surgical course in the 20th century. Among the various surgical techniques used during organ transplantation, a common technique includes blocking of blood vessels to prevent blood flow to the target organ, thereby reducing perfusion. However, warm ischemia, or the exposure of the tissue parenchyma to ischemia under normothermic conditions, has recently been established as a concern during transplantation. Herein, we describe a technique of establishing vascular anastomoses the organ undergoing transplantation involving tubes that can be inserted into the organ. By using this technique, it is possible to quickly establish anastomotic blood vessels without the loss of blood flow. The inserting tubes holds the cross section of blood vessel in a triangular shape when the triple-stapled anastomosis of Carrel is operated. As a result, blood vessel anastomoses can easily and quickly be established while the organ is in an intubated state. In addition, the triangle shape enhances the rigidity of the tube, thereby reducing the risk of defects that result in perforation due to twisting or kinking of the tubes, which are made of soft materials. Additionally, it improves the stability of the tubes used during this procedure (Figure1).We operated 6 porcine transplantation to evaluate this technic. Perfusion flows was maintained during the vascular anastomosis without excessive pressure fluctuations. In addition, compared with previous ways of suturing blood vessels, it was possible to shorten the anastomotic time using this technique, and it could be suppressed within 1 minute from stop of perfusion to restart of blood flow. This technique reduces the severity of warm ischemia during organ transplantation and remarkably improves the health of the donor organs from cardiac death, as shown in porcine models. Therefore, this medical device merits consideration for use as a novel surgical technology.

We investigated the usefulness of nonpenetrating titanium vascular closure staple (VCS) clips developed for anastomosis of peripheral blood vessels. VCS clip applier systems (Autosuture; United States Surgical Corporation, Norwalk, CT) were used for 10 patients on hemodialysis who needed peripheral vascular anastomoses for blood access. Two arteriovenous (AV) fistulas, one closure of a fistula with reconstruction of the radial artery, six vascular graft implantations, and one vascular graft closure were performed. Medium clips were used for AV fistulas and large clips for vascular graft implantation. It took 12 min, on average, for vascular access graft anastomoses and 8.5 min, on average, for the AV fistulas. In two patients, bleeding from the anastomosed site occurred after declamping and additional sutures were required; however, neither hematoma nor wound infection occurred at 9 to 12 months after surgery. In one patient, stenosis of the graft-venous junction was found and was successfully treated by percutaneous transluminal angioplasty. The VCS clip applier is easy to manipulate, is as safe as hand-suture methods, and has time saving potential. We conclude that these VCS clips are useful for vascular anastomoses of blood access.

Objective To investigate the clinical effects of two different repair methods on submental island flap and free flap of vascular anastomosis after resection of oral cancer, and to evaluate the quality of life and analyze the influencing factors after 1 year after operation. Methods The clinical effects of 32 patients with oral cancer were analyzed and the Chinese fourth edition of the Washington University Students' memory quality scale (UWQOL) was used to evaluate the use of submental island flap and free flap with vascular anastomosis for reconstruction of maxillofacial defects. After the evaluation score, the data were analyzed for analyzing its influencing factors. Results Among the 32 patients with oral squamous cell carcinoma after surgery, there was no significant difference in the therapeutic effect between patients with submental island flap and patients with free flap anastomosed with blood vessels (P>0.05). There was no significant difference in the overall quality of life of the patients with submental island flap and free flap with vascular anastomosis (P>0.05), but there was difference in the single score between the patients. Conclusions There is no significant difference in the clinical effect and overall quality of two group of patients. Proper flap repair scheme should be choosed according to the patient’s own situation. Key words: Oral cancer; Reconstruction of defects; Quality of life analysis

Objective To investigate the anatomy and clinical effect of the anterolateral skin flap in the lower leg and the reversed superficial pereneal neuracutaneous island flap. Methods Seven cases of hand skin defect were treated with anterolateral skin flap in the lower leg with vascular anastomosis. 7 cases of ankle soft tissue loss were repaired with reversed superficial peroneal neurocutaneous island flap. 4 cases of the tissue defects in the middle and proximal parts of the leg and 13 cases of the tissue defects in the middle and distal parts of the leg were repaired with sequential superficial peroneal artery island flap and combined flap of super-ficial peroneal artery island flap and superficial peroneal neurocutaneous island flap respectively. Results Seven cases of the anterolateral skin flap in the lower leg with vascular anastomosis, 4 cases of the sequential superficial peroneal artery island flap and 13 cases of the combined flap of superficial peroneal artery island flap and superficial peroneal neurocutaneous island flap were survived.Becanse of vein drainage disturbance which led to partial necrosis of flap, one case of the reversed superficial peroneal neurocutaneous island flap was de-layed healing with epluehage and skin grafting. Conclusion The anterolateral skin flap in the lower leg and the reversed superficial peroneal neurocutaneous island flap compensate each other anatomically. The operation based on the anatomy enlarges the size of the flap and extends the scope of reconstruction. Key words: Anterotateral flap of lowerleg; Superficial peroneal nerve; Transplantation; Micro-surgery

This article explores conceptual and methodological challenges surrounding the recovery of patients’ voices in the history of medicine. We examine the debate that followed Roy Porter’s seminal article, ‘The Patient’s...

The contribution of microglia to ischemic cortical stroke is of particular therapeutic interest because of the impact on the survival of brain tissue in the ischemic penumbra, a region that is potentially salvable upon a brain infarct. Whether or not tissue in the penumbra survives critically depends on blood flow and vessel perfusion. To study the role of microglia in cortical stroke and blood vessel stability, CX3CR1(+/GFP) mice were subjected to transient middle cerebral artery occlusion and then microglia were investigated using time-lapse two-photon microscopy in vivo. Soon after reperfusion, microglia became activated in the stroke penumbra and started to expand cellular protrusions towards adjacent blood vessels. All microglia in the penumbra were found associated with blood vessels within 24 h post reperfusion and partially fully engulfed them. In the same time frame blood vessels became permissive for blood serum components. Migration assays in vitro showed that blood serum proteins leaking into the tissue provided molecular cues leading to the recruitment of microglia to blood vessels and to their activation. Subsequently, these perivascular microglia started to eat up endothelial cells by phagocytosis, which caused an activation of the local endothelium and contributed to the disintegration of blood vessels with an eventual break down of the blood brain barrier. Loss-of-microglia-function studies using CX3CR1(GFP/GFP) mice displayed a decrease in stroke size and a reduction in the extravasation of contrast agent into the brain penumbra as measured by MRI. Potentially, medication directed at inhibiting microglia activation within the first day after stroke could stabilize blood vessels in the penumbra, increase blood flow, and serve as a valuable treatment for patients suffering from ischemic stroke.

Primary vascular anastomosis in growing pigs: Comparison of polypropylene and polyglycolic acid sutures

Optic disc haemorrhages are associated with active glaucomatous neurodegeneration and ongoing visual field loss. We sought to determine whether automated alternation flicker enhances the detection of disc haemorrhages in serial images from patients with glaucoma when compared to side-by-side photographic evaluation and single-image display. Serial sets of optic nerve photographs of 394 eyes from 234 patients followed for glaucoma at the authors' institutions were included in this study. Eyes with disc haemorrhages were graded for difficulty level and randomized along with nondisc haemorrhage control images into one of three presentation groups (automated alternation flicker, side-by-side or single image). Seven graders viewed all images and assessed for the presence or absence of disc haemorrhages. The sensitivity of automated alternation flicker for disc haemorrhage detection (0.878) was higher than side-by-side (0.705; p = 0.002) and single photographs (0.757; p = 0.01). There was no specificity difference between pairs of presentation groups (all p ≥ 0.7). Automated alternation flicker was a more sensitive method for disc haemorrhage detection than the current clinical standards and may have an important role in the management of glaucoma.