Area Of Dissection Research Articles

Short-scar facelift without temporal flap: a 10-year experience.

The understanding of facial anatomy and its changes through aging has led to the development of several different facelift techniques that focus on being less invasive and traumatic and, at the same time, providing natural long-lasting results. In this article we describe step by step our facelift technique as it has been done over the past 10 years by the senior author. This is a retrospective, descriptive, transversal study in which all patients who underwent a rhytidectomy using our technique from January 2002 to September 2012 were included. All patients were operated on under local anesthesia and superficial conscious sedation. All surgeries were performed by the same surgeon. A complete step-by-step description of the surgical technique can be found in the main article. Between January 2002 and September 2012, a total of 113 patients underwent facelift surgery. Of these, 88.9 % were women and 11.1 % were men. The mean age was 55.3 (± 8.66) years. Primary surgeries represented 80.3 % (n = 94), secondary 18.8 % (n = 22), and tertiary 0.85 % (n = 1). Only one major complication, representing 0.8 %, consisting of a right-sided temporal paresis with 2 months complete recovery was seen. The minor complications rate was 23.1 %. The most common minor complication was hypertrophic/keloid scars which made up 77.8 % of all minor complications. The technique described provides good and long-lasting aesthetic results with shorter scars, smaller areas of dissection (without temporal and postauricular flaps), and a shorter recovery period. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

A novel microdissection approach to recovering mycobacterium tuberculosis specific transcripts from formalin fixed paraffin embedded lung granulomas.

Microdissection has been used for the examination of tissues at DNA, RNA, and protein levels for over a decade. Laser capture microscopy (LCM) is the most common microdissection technique used today. In this technique, a laser is used to focally melt a thermoplastic membrane that overlies a dehydrated tissue section(1). The tissue section composite is then lifted and separated from the membrane. Although this technique can be used successfully for tissue examination, it is time consuming and expensive. Furthermore, the successful completion of procedures using this technique requires the use of a laser, thus limiting its use. A new more affordable and practical microdissection approach called mesodissection is a possible solution to the pitfalls of LCM. This technique employs the MESO-1/MeSectr system to mill the desired tissue from a slide mounted tissue sample while concurrently dispensing and aspirating fluid to recover the desired tissue sample into a consumable mill bit. Before the dissection process begins, the user aligns the formalin fixed paraffin embedded (FFPE) slide with a hematoxylin and eosin stained (H&E) reference slide. Thereafter, the operator annotates the desired dissection area and proceeds to dissect the appropriate segment. The program generates an archived image of the dissection. The main advantage of mesodissection is the short duration needed to dissect a slide, taking an average of ten minutes from set up to sample generation in this experiment. Additionally, the system is significantly more cost effective and user friendly. A slight disadvantage is that it is not as precise as laser capture microscopy. In this article we demonstrate how mesodissection can be used to extract RNA from slides from FFPE granulomas caused by Mycobacterium tuberculosis (Mtb).

Diagnostic Accuracy of 11C-Choline PET/CT in Preoperative Lymph Node Staging of Bladder Cancer

The aim of this study was to evaluate the role of C-choline PET/CT in the preoperative evaluation of the nodal involvement of patients with bladder carcinoma (BC) suitable for radical cystectomy and extended pelvic lymph node dissection in comparison with contrast-enhanced CT (CECT) using the pathologic specimen as reference standard. Twenty-six consecutive patients (69.5 ± 9.3 years; range, 49-84) with histologically proven transitional cell BC were treated with radical cystectomy and pelvic lymph node dissection and were enrolled from April 2011 to January 2013. In all patients, paravesical, internal, eternal, and common iliac nodes as well as obturatory, presacral, preaortic, and precaval lymph nodes (LNs) were dissected up to the origin of the inferior mesentery artery. The areas of the LN dissection were grouped as follow: region A included preaortic and precaval LNs; region B included paravesical, common, internal and external iliac, obturatory, and presacral LNs in the right pelvis; region C included paravesical, common, internal and external iliac, obturatory, and presacral LNs in the left pelvis. C-choline PET/CT and abdominal CECT were used to assess the presence of lymph node metastases on a per patient, region, and lesion analysis using the results of surgical specimens obtained at operation as criterion standard. Seven of 26 patients (26.9%) showed nodal metastases at pathologic analysis. Overall, 844 LNs were evaluated, and 38 of them (4.5%) showed metastatic involvement. On a patient-based analysis, C-choline PET/CT showed a sensitivity of 42% and specificity of 84%, whereas, CECT showed a sensitivity of 14% and specificity of 89%. On a region-based analysis, C-choline PET/CT showed a sensitivity of 11% and specificity of 82%, whereas CECT showed a sensitivity of 5% and specificity of 80%. On a lesion (LN)-based analysis, C-choline PET/CT showed a sensitivity of 10% and specificity of 64%, whereas CECT showed a sensitivity of 2% and specificity of 63%. C-choline PET/CT could provide additional diagnostic information in preoperative nodal staging of patients with invasive BC in comparison with CECT. A study with a larger population should determine if C-choline PET/CT could be recommended as a routine technique in high-risk patients with BC.

Sa1644 Feasibility of Non-Exposed Endoscopic Wall-Inversion Surgery (NEWS) With Sentinel Node Navigation Surgery (Snns) As a New Method of Minimally Invasive Local Resection for Early Gastric Cancer: a Porcine Survival Study

Non-exposed endoscopic wall-inversion surgery (NEWS) has been developed as endoscopic full-thickness resection without transluminal communication to avoid intraabdominal infection or tumor seeding. We aimed to investigate feasibility and safety of NEWS with sentinel node navigation surgery (SNNS), which can minimize the area of lymph node dissection for early gastric cancer (EGC), in a porcine survival study for a week.

Anatomical skin incisions for window dissections

AbstractSkin incisions for comprehensive study dissection, composite dissection, composite window corridor dissection and comprehensive window dissections are different. Many authors/practical volumes have described skin incisions for comprehensive study dissections. There is great need to establish, describe and define the incisions for comprehensive window dissections. The authors have studied and practiced their skin incisions for window dissections of various regions of limbs, during the last three years(2010-2012). The authors have established superior, inferior and vertical incision lines and skin was incised according to that. Skin incisions for various regions are made on the basic principle of windows. Superior and inferior incision lines limit the dissection area and vertical incision line provides better scope of expansion and exposure in a window view. The authors have established, described and defined the incisions for various dissection topics which gives better exposure and scope for expansion of dissection layer wise and in better window manner.

Video-Assisted Thoracoscopic Pneumonectomy: Retrospective Outcome Analysis of 47 Consecutive Patients

Although video-assisted thoracoscopic surgery (VATS) lobectomy is widely accepted, VATS pneumonectomy remains an uncommon procedure in patients with complicated diseases. Of 47 consecutive patients who were planned to undergo VATS pneumonectomy from May 2000 to May 2012 at the National Hospital Organization Himeji Medical Center, VATS pneumonectomy was completed successfully in 46 patients (2.1% conversion rate). Appropriate tissue retraction and cooperative dissection of hilum structures under only thoracoscopic visualization were applied to all candidates. We retrospectively reviewed morbidity, mortality, local disease control, and surgical considerations to evaluate the validity of this procedure. All patients had malignant tumors, including 45 with primary lung cancer. One patient with a severe adhesion around a tumor required conversion to open thoracotomy, with no subsequent specific complications. Of 46 patients in whom VATS pneumonectomy was completed, the mean operation time was 159 minutes and the mean blood loss was 258 g. Surgery-related death occurred in 1 patient (mortality rate: 2.2%) with recurrent heart failure after discharge. Seven patients (15.2%) had major complications defined as grade 3 or higher (Common Terminology Criteria for Adverse Effects, version 4.0) within 30 days postoperatively; however, no patients exhibited secretion retention that required bronchoscopy. There were no patients with locoregional recurrence within usual lymph node dissection areas and the ipsilateral thoracic cavity among 44 patients with primary lung cancer who underwent VATS pneumonectomy, with the median follow-up time of 27 months. Video-assisted thoracoscopic surgery pneumonectomy has developed into a common procedure with acceptable damage and lower morbidity among selected patients with complicated diseases.

Surgical anatomy of the preauricular anteroparotid approach for mandibular condyle surgery

The different surgical approaches used to treat mandibular condyle fractures are carried out in the periparotid skin area and can lead to facial nerve injury. We conducted a preauricular and anteroparotid surgical approach. Our main aim was to show the anatomical relationship between this approach site and the facial nerve branches, and to define cutaneous landmarks to locate the extraparotid facial nerve branches. A 2-step dissection of 13 fresh human cadaver semi-heads was performed: a preauricular approach followed by a superficial parotidectomy to visualize the facial nerve. Its course and ramifications were studied and compared to cutaneous landmarks. The proximity of the facial nerve branches with the surgical approach site was observed. The approach allowed systematically visualising the zygomatic and/or buccal branches. No facial nerve branches were sectioned. In three cases (23 %), a nerve branch was visualized during the approach. The buccal and zygomatic branches were ramified in 77 % of cases. During our preauricular anteroparotid approach, the buccal and zygomatic branches were visualized but none was sectioned. Most often the approach was carried out between these two branches (46 % of cases). Cutaneous landmarks used were reliable to define a safe and nerve-free area for dissection. The buccal and zygomatic branches are very interesting because their high number of ramifications and anastomoses could serve as nerve relays in case of surgical lesion.

Segmental Masseteric Flap for Dynamic Reanimation of Facial Palsy

The masseter muscle is one of the major chewing muscles and contributes to define facial contour. It is an important landmark for aesthetic and functional surgery and has been used for facial palsy reanimation or as source of donor motor nerve. We present an anatomic study to evaluate the possibility of using a muscle subunit for dynamic eye reanimation. Sixteen head halves were dissected under magnification to study the neurovascular distribution and determine safe muscle subunits; areas of safe/dangerous dissection were investigated. Once isolated, the arc of rotation of the muscular subunit was measured on fresh body to verify the reach to the lateral canthus. The patterns of neurovascular distribution and areas of safe dissection were identified; the anterior third of the muscle represents an ideal subunit with constant nerve and artery distribution. The muscle is too short to reach the lateral canthus; a fascia graft extension is needed. The information provided identified the main neurovascular branches and confirms the feasibility of a dynamic segmental flap. The need of efficient motor units for facial reanimation demands for different surgical options. A detailed anatomic description of the neurovascular bundle is mandatory to safely raise a functional motor subunit.

Prognostic analysis of salvage esophagectomy after definitive chemoradiotherapy for esophageal squamous cell carcinoma: The importance of lymphadenectomy

The objective of this study was to review the prognostic factors for increased survival after salvage esophagectomy after definitive chemoradiotherapy for esophageal squamous carcinoma and determine the importance of lymphadenectomy from a prognostic view. Clinical data for all patients from January 1999 to December 2012 who underwent salvage esophagectomy for residual tumor or tumor recurrence after definitive chemoradiotherapy were retrospectively collected. Survival was determined and prognostic factors were analyzed with univariate and multivariate analyses. Survival after 1, 3, and 5 years postoperatively was 74.4%, 39.8%, and 29.5%, respectively. The independent predictive factors for increased postoperative survival were tumor recurrence rather than residual tumor as the indication for salvage surgery (P < .001; odds ratio [OR], 0.292); complete tumor resection (P < .001; OR, 4.520); N category (P = .089; OR, 1.304); M category (P = .081; OR, 2.215), and total mediastinal dissection with 15 or more dissected mediastinal lymph nodes (P = .034; OR, 0.546). Salvage indications of recurrence, earlier disease, and complete tumor resection are related to longer survival. The total area of mediastinal dissection with a sufficient number of dissected mediastinal lymph nodes improves survival. Additional neck dissection does not add benefit. The optimal procedure for lymph node dissection in salvage esophagectomy should be established in future studies.

Inguinal Lymphadenectomy Assessment Associated with Penile Carcinoma Undergone New Strategies for Nodal Staging

Penile carcinoma is an uncommon urological tumour and provides an opportunity for curation on early stage of the disease. Nodal metastases are one of the most important prognostic factors for survival although detection of inguinal adenopathies could be related with an inflammatory or infectious etiology. A suspicion of bilateral metastasic nodal involvement should be taken with caution. Radical inguinal lymphadenectomy has been associated to a great deal of complications. Several anatomical studies have reported the true lymphatic drainage pathways in order to reduce the area of groin dissection. Nonetheless, a prophylactic modified inguinal lymphadenectomy should not be a systematic surgical procedure in all patients due to morbidity and questioned usefulness when there are not nodal metastasis. Classical imaging studies have a limited contribution to the diagnosis of lymph node metastasis. Nowadays, lymph node involvement may be diagnosed both minimally invasive and noninvasive techniques, such as dynamic sentinel lymph node biopsy in intermediate and high risk patients with nonpalpable lymph nodes, and fine needle aspiration biopsy in cases with palpable nodes. Their high effectiveness has facilitated the radical pelvic or inguinal lymphadenectomy that is only performed when there is histological confirmation of nodal involvement. A new video endoscopic technique has been developed at present to reduce postoperative complications although prospective studies are needed to assess outcomes. The appearance of adenopathies after surgical treatment of the primary tumour could be supported at the same guidelines.An inguinal lymphadenectomy should be carried out in selected patients to support a benefit on early stages with an extended survival.

Imaging of complications associated with port access of abdominal laparoscopic surgery

Advanced techniques and equipment in laparoscopic surgery offer advantages over open surgery, expanding the application of this minimally invasive procedure to a wide range of abdominal operations that used to be performed as an open procedure. Laparoscopic surgery is performed in the closed abdominal cavity in which the space is limited. To create a working space in the abdominal cavity, an artificial pneumoperitoneum is established and multiple ports are placed for the introduction of various laparoscopic instruments. Unlike open surgery in which the incision is made just above the target organ, laparoscopic access is made away from the area of dissection, with the instruments triangulated around the target organ within the abdomen. This fundamental difference in approach between the open and laparoscopic procedures may lead to peculiar postoperative complications after laparoscopic surgery, which may be present away from the target organ or in the abdominal wall, and be easily missed on postoperative imaging studies. These complications include port-related direct organ injuries, such as abdominal organ or vascular injury; abdominal wall complications related to laparoscopic port insertion such as vascular injury, infection, and hernia; abdominal wall complications related to specimen removal, such as port site tumor seeding and endometriosis; and complications related to gas insufflation. The radiologist plays an important role in the diagnosis of complications after laparoscopic surgery, and therefore should be familiar with the features of such complications on imaging scans in the era of laparoscopic surgeries.

Is Atypical Metastasis Obstructive to Sentinel Node Navigation Surgery in Early Gastric Cancer Patients?

Sentinel node navigation surgery (SNNS) is defined as novel, minimally invasive surgery which can avoid unnecessary lymph node dissection based on sentinel node (SN) biopsy and diagnosis for nodal metastasis targeting SN. In the past 10 years, several studies supporting the validity of the SN concept for early-stage gastric cancer have been reported. Single-institutional results of SN mapping for early gastric cancer are being increasingly considered acceptable in terms of detection rate and accuracy of predicting regional lymph node status. We recently conducted a multicenter, prospective trial of SN mapping for early gastric cancer using a dual-tracer method with a radioactive colloid and blue dye. In the trial, SN mapping was performed for 397 patients who had a single tumor (cT1N0M0 or cT2N0M0) with a primary lesion having a diameter of less than 4 cm and not undergone any previous treatments. As a result, the SN detection rate was 98 %, and the accuracy of nodal evaluation for metastasis was 99 %. The results of that clinical trial are expected to provide us with a perspective on the future of SNNS for early gastric cancer. A recent article by Lee et al. reported on the pattern of lymphatic drainage in gastric cancer patients. They retrospectively evaluated the distribution of metastatic lymph nodes according to the longitudinal and circumferential location of tumors in 462 pT1 or pT2 gastric cancer patients with metastasis to 1–3 lymph nodes. A considerable number of atypical metastases (skip or transversal metastasis) were observed, regardless of tumor location. In particular, tumors in the lower third of the stomach and/or lesser curvature side had a significant propensity to exhibit atypical metastasis. They concluded that when applying SNNS in gastric cancer patients, care should be taken with tumors at these locations to prevent false-negative results when applying SNNS in gastric cancer patients. Although this finding should be interpreted with caution as Lee et al. did not attempt SN mapping in their study, they have provided a valuable reference for the clinical application of SNNS in early gastric cancer patients. In fact, the pattern of lymph node metastasis, including atypical metastasis, in their study was remarkably similar to the distribution of SN in our previous multicenter trial. For instance, in our trial, the tumors in the lower third of the stomach had SNs at #8a (in the second compartment) with relatively high probability. This result is in agreement with that obtained by Lee et al. Thus, the similarity of these two results suggests that most of atypical metastasis in their study may not represent false-negative SNs but ‘typical and true’ metastasis to SNs via aberrant lymphatic vessels from the primary tumor. We believe that most false-negative SNs may be owing to technical issues of SN biopsy rather than atypical metastasis. Meanwhile, in our previous trial, SNs were located out of the area of D2 lymph node dissection in 1 % of cases with primary tumors in the upper third, 3 % in the middle third, and 6 % in the lower third of the stomach, respectively. Therefore, caution needs to be taken regarding the application of D2 lymph node dissection even for early gastric cancer. In future studies, appropriate indications for functionpreserving gastrectomy, including proximal gastrectomy, segmental gastrectomy, pylorus-preserving gastrectomy, and partial resection for cT1N0 gastric cancer, should be individually determined on the basis of SN mapping. Various types of laparoscopic function-preserving surgeries can be performed in gastric cancer patients with no metastatic SNs. Previous reports on SN biopsy have Society of Surgical Oncology 2013

Lymphatic Drainage from Renal Cell Carcinoma along the Thoracic Duct Visualized with SPECT/CT

Lymphatic drainage of renal cell carcinoma is unpredictable. Renal lymphatics directly joining the thoracic duct without traversing any lymph nodes have been described in cadaver studies, yet to date, this has never been visualized using functional imaging in vivo. Patients with renal tumors <10 cm (cT1-cT2) and clinical absence of metastases (cN0, cM0) took part in a prospective institutional review board approved study investigating sentinel node mapping. After ultrasound-guided percutaneaus intratumoral injection of (99m)Tc-nanocolloid (0.4 mL, 200 MBq) the day before surgery, planar sequential lymphoscintigraphy was obtained after 20 min and 2-4 h. Subsequently, SPECT/CT imaging was performed. Of 42 patients, 4 showed early lymphatic drainage following the course of the thoracic duct on lymphoscintigraphy and SPECT/CT images. In one patient, this was observed without any retroperitoneal lymph node interposition. In relation to patients with sentinel nodes on SPECT imaging the frequency of this drainage pattern was (4/22) 18.2%. SN mapping of renal tumors using functional imaging modalities such as lymphoscintigraphy and SPECT/CT enables identification and sampling of sentinel nodes outside the area of routine dissection. Direct aberrant drainage through the thoracic duct can be observed in vivo as demonstrated in this study. This may support a hypothesis for certain anatomical metastatic sites and the failure to demonstrate a survival benefit of retroperitoneal lymph node dissections in renal cell carcinoma.

The effect of harmonic scalpel, electrocautery, and scalpel use on early wound complications after modified radical mastectomy

Mastectomy when performed with scalpel and electrocautery is associated with some blood loss and morbidity in the form of prolonged drainage, seroma, wound infection, flap necrosis, and hematoma. A total of 120 patients operated with mastectomy enrolled for the study. The groups were defined by the instruments used for flap preparation: 41 patients operated with electrocautery, 40 patients operated with scalpel, and 39 patients operated with harmonic scalpel formed three groups. The need for closed suction drains, the amount and duration of seroma, surgical site infection, hematoma, and flap ischemia and necrosis were evaluated. The amounts of intraoperative blood loss in electrocautery and harmonic scalpel groups were 560 and 500 mL, respectively, and it was increased to 750 mL in scalpel group (p = 0.001). Total drainage amounts of scalpel and harmonic scalpel groups were 894 and 908 mL, respectively, and it was increased to 1,113 mL in electrocautery group (p = 0.0033). Seroma incidence rates in scalpel, electrocautery, and harmonic scalpel groups were 45, 65 and 28 %, respectively (p = 0.003). The differences between groups in relation to the duration of surgery, breast volume and weight, the areas of flap dissection, the duration of closed suction drainage, and the amount of early drainage were not statistically significant. There was also no difference between groups with regard to hematoma, flap necrosis, and ecchymosis and infection rates. Although the use of harmonic scalpel reduces the risk of seroma formation and intraoperative blood loss, further studies are needed to verify the real impact of such technique.

Minimally Invasive Resection for Mediastinal Ectopic Parathyroid Glands

We reviewed our experience with ectopic mediastinal parathyroidectomy. Between March 1980 and September 2010,mediastinal parathyroidectomy was performed in33 patients with hypercalcemia secondary to hyperparathyroidism. Primary hyperparathyroidism was the main diagnosis in 32 patients (97%). Technetium-sestamibi scan was used in 23 (70%) for preoperative localization. Minimally invasive resections were performed in 18 patients (55%), and 15 (45%) underwent open surgery. The most common minimally invasive surgery approach was video-assisted thoracoscopy in 9 patients (27%); the most common open approach was median sternotomy in 11 (33%). Intraoperative parathyroid hormone monitoring was used in 22 patients (67%). The ectopic glands were intrathymic in 15 patients (45%), in the aortopulmonary window in 7 (21%), and in other intrathoracic locations in the remaining 11 (33%). Parathyroid adenomas were identified in 21 patients (64%); parathyroid hyperplasia and carcinoma were identified in 9 (27%) and 3 (9%), respectively. No early mortality occurred in either group. Reoperation was required in 1 patient in the minimally invasive surgery group because of hemothorax. Morbidity occurred in 8 patients (24%), the most common of which was hypocalcemia in 4 (12%). The mean length of stay was significantly shorter in the minimally invasive surgery group (2 versus 6 days; p < 0.001) but mortality and morbidity were not statistically different between the two groups (p= 0.05). Mean follow-up was 3 ± 3.7 years. Minimally invasive mediastinal parathyroidectomy has similar outcomes to open surgery, with significantly shorter length of hospital stay.

Benefit of skin ultrasound examination in determining the area of inguinal lymph node dissection

Benefit of skin ultrasound examination in determining the area of inguinal lymph node dissection

Aberrant right subclavian artery in video-assisted thoracoscopic esophagectomy.

When performing video-assisted thoracoscopic esophagectomy, the area at the level above the aortic and in the space between the esophagus and the spine, is usually regarded as a safe area for dissection of upper segment of thoracic esophagus. However, an aberrant right subclavian artery may appear in this area and lead to disastrous complications. We reported a case of aberrant artery encountered during video-assisted thoracoscopic esophagectomy. In order to avoid iatrogenic damage to this artery, it was converted to thoracotomy.

Reply to Angouras and Sokolis

We thank the research team of Dr Angouras for their comments [1] regarding our previous article [2] and really appreciate the opportunity to provide clarifications. As you mentioned in your letter, several articles of yours and other researchers based in Greece describing various types of animal experiments involving the ligation of intercostal arteries to shut down the bloodstream of the vasa vasorum of the upper parts of the aorta strongly encouraged us to emphasize the role of the vasa vasorum as a key factor in aortic dissection. However, according to our research team, there are several important differences between the histological features of our human cases and your animal experiments. In the animal experiments, the bloodstream was completely shut down and the results were the necrosis (or infarction) of the smooth muscle cells (SMCs) in the middle zone of the aortic wall and consequent scar formation. In our human cases, the changes around the dissection area in the aortic media were not necrosis but merely mild degeneration, which we believe to be a phenotypic transformation (from a contractile and elastin secretory type to collagen-acid mucopolysaccharide secretory type) of vascular SMCs. We emphasized this hypothesis in our article [2] and it was confirmed recently by molecular biology studies [3]. Moreover, complete obstruction of the vasa vasorum was rare in our cases (14%). Therefore, such medial changes could not be made by complete obstruction. Obstruction is rare but we found intimal thickening, elastosis and even myomatous proliferation in the media of the vasa vasorum. Those features must be the sequelae of hypertension and angiospasms, which we realized during research work in spontaneously hypertensive rats [4]. Lifelong, mild but repeated or intermittent ischaemia and malnutrition could introduce such transformations as a background to dissection. Then, what is the real trigger? We confirmed that the initial sign of dissection was just on the vasa vasorum itself, where vascular necrosis and extravascular leakage of erythrocytes are present. Hence, the vasa vasorum itself is the starting point of dissection. Dramatic angiospasms or rapid increases and decreases in blood pressure could be the trigger of dissection. More than 60% of our cases had a history of hypertension, and histopathological analyses suggested that >75% were hypertensive. In general, in elderly subjects, the number of hypertensive persons is increased but the number of people suffering from aortic dissection seems to be very low. Hypertension could be the ‘necessary factor’ for aortic dissection but not the ‘sufficient factor’. The question is: what is the other necessary factor? Together with epigenetic factors such as aging, infection, inflammation and nutrition, several genes encoding proteins in SMC contractile units as well as signal proteins in SMCs [3] must be involved in host susceptibility genes as polymorphic genes to lead a phenotypic transformation of SMCs. Further immunohistochemical studies and/or in situ hybridization studies should be carried out to clarify the expression and dynamics of these molecules around the dissection site.

Where will the concept of lymph node micrometastasis advance?

There are several morphological pathways by which lymph node metastasis can arise: invasion into a deeper layer; detachment of tumor cells from the primary tumor; infiltration into intramural lymphatics; flow to extramural lymphatics; arrival to afferent lymphatics of a marginal sinus; movement to the lymph node cortex; and implantation of tumor cells into the node and formation of metastasis. Some cancer cells move from an efferent lymphatic vessel to the next lymph node. In terms of the first step toward lymph node metastasis, a small number of cancer cells is thought to be related to the formation of metastasis. Recent research into biological aspects has elucidated various tumor characteristics. What kinds of tumor cells have metastatic potential? Many molecules in the pathways toward lymphatic metastasis are thought to be related. Once tumor cells invade the lymphatics, can all cells implant into lymph nodes? Numerous immune cells are originally present in the lymph nodes, and such cells fight and defend against the invasion of bacteria, viruses, tumor cells, and so on. Thus, it is speculated that only certain special cancer cells can implant and grow to form an overt metastasis. What are these special cancer cells? The recent concept of epithelial-mesenchymal transition and the stem cell theory seems to offer an important key to solving the properties of tumor cells. Tumor cells able to seed a metastasis must presumably have the ability to avoid immune defense cells. Further basic studies will elucidate the mechanisms underlying lymphatic metastasis. Meanwhile, in the clinical field, lymph node metastasis offers an important prognostic factor for gastrointestinal (GI) cancer. The presence of tiny lymph node metastasis, in the form of lymph node micrometastasis (LNM) that is not detectable by routine histological examination, has been reported in carcinomas of various organs. Although overt lymph node metastasis is thought to be related to prognosis, what is the relationship between LNM and prognosis? Recent advances in techniques such as immunohistochemistry (IHC) and reverse transcription-polymerase chain reaction (RT-PCR) have allowed the detection of LNM. Recently, LNM has been defined by the criteria of TNM classification and roughly divided in some categories according to the size of the metastatic foci or the method of detection. Clinical evaluation of LNM is somewhat difficult, because of the differences in study designs and methods of detection, such as the sample size, tumor stage of patients, number of removed nodes based on the area of lymph node dissection, use of immunohistochemistry, RTPCR, or other methods, and the kinds of antibodies or primers used. Several articles have discussed the clinical significance of LNM of GI cancer. The present review articles summarize the current knowledge of LNMs in GI cancer from the perspectives of both molecular and biological characteristics and clinical aspects. These articles will be helpful as an overview of the current understanding of LNM and areas requiring further investigation.

Robotic facelift thyroidectomy

The field of thyroid surgery has evolved to the point where multiple access options are now available. These include conventional approaches, minimally invasive endoscopic and non-endoscopic methods, and even remote access techniques with or without robotic assistance. Remote access surgery is reserved for those individuals who are committed to completely eliminating a neck scar. The procedures require more extensive dissection and robotic technology facilitates their performance. While an axillary approach has been the most commonly pursued, we have developed an easier technique that puts fewer structures at risk and involves a reduced area of dissection. It uses as its access portal a modified facelift incision.