Direct Dissection Research Articles

Angiographic description of the anatomy and clinical aspects of the anterior interventricular artery in a group of Colombians individuals

The anterior interventricular artery originates from the left coronary artery and irrigates the anterior surface of the ventricles, apex, and interventricular septum, making it the second most relevant artery of the heart. To describe the anatomical and clinical aspects of the anterior interventricular artery through angiography. A descriptive study was conducted using 200 angiographic reports of Colombian individuals. The anterior interventricular artery's origin, course, patency, and coronary dominance were evaluated. Data related to chest pain, acute myocardial infarction, dyslipidemia, and electrocardiographic abnormalities were included. Statistical tests could not be performed due to this artery's low prevalence of anatomical variations. One anterior interventricular artery was found to have originated from the left coronary sinus without a myocardial bridge, with no alteration in permeability, and with left dominance. The frequency of bridges was 2%, and the most frequent dominance was right in 86%; permeability alterations occurred in 43% mainly affecting S13. Twentyfive per cent presented chest pain; 40%, echocardiographic alterations; 5%, ischemic heart disease, and 59%, electrocardiographic alterations. Variations of origin of the anterior interventricular artery have a low prevalence according to reports from Chile, Colombia, and Spain. anterior interventricular artery myocardial bridges were scarce compared to other studies, suggesting better specificity of computed tomography angiography or direct dissection for these findings. The assessment of coronary permeability is graded with the thrombolysis in myocardial infarction scale; values 0 and 1 indicate occlusive lesion associated with ischemic heart disease. According to various techniques, the most frequent coronary dominance the right, followed by the left in men and balanced circulation in women.

Calcium storage in Malpighian tubules and the putative use for pupal chamber formation in a wood-feeding insect

Cerambycid beetles form a chamber to spend their pupal stages in various forms according to the species. The red-necked longhorn beetle Aromia bungii (Coleoptera: Cerambycidae), which is an invasive pest that severely damages Rosaceae trees, makes a pupal chamber at the end of a tunnel deep in the xylem. Beetle larvae and the closely related species form a calcareous lid at the entrance of a pupal chamber. Previous studies on the closely related species conducted more than a century ago suggested that Malpighian tubules (MTs) play a vital role in calcium carbonate accumulation. However, the association between this Ca2+ accumulation and pupal chamber lid formation utilizing the possible calcium compounds stored in MTs have not yet been demonstrated. First, we artificially reared A. bungii larvae from eggs in host branches for 100 days and identified the larval developmental status and pupal chamber formation, using X-ray computed tomography. Second, we collected larvae from the branches and observed the internal organs by direct dissection under a microscope. Finally, we analyzed the elemental distribution, particularly calcium, in the larval gut with MTs, using energy dispersive X-ray fluorescence. The results suggest that immature larvae of A. bungii can accumulate Ca2+ in the MTs through wood tunneling and feeding activities. Ca2+ was stored at the proximal regions in two of the six MTs located posteriorly in the body. Additionally, larvae that formed a calcareous lid at the entrance of pupal chambers in the branches did not store Ca2+ in the MTs, suggesting that the larvae of A. bungii used the stored Ca2+ in their MTs for lid formation.

(140) Penile Length and Girth Restoration in Mb Peyronie: Less Invasive Approach for Complex Composite Graft Corporplasty and Implantation of Inflatable Penile Prosthesis

Abstract Introduction Peyronie's disease (PD) is a fibrotic disorder of the tunica albuginea. It is both a physically and psychologically devastating disorder that causes penile deformity, curvature, narrowing and shortening, which eventually compromise sexual function. Objective The presented technique is a less invasive approach that gives few complications, has a natural cosmetic outcome with preserved preputium, and high patient satisfaction. Methods In the period between December 2017 and May 2022, 65pts aged 33y to 78y underwent complex corporoplasty with inflatable penile prosthesis implantation. Mean penile curvature was 70 o (60 o -95 o ). Average penile shortening was 3.2cm (1 - 5.5cm), and girth narrowing 2.5cm (0 - 4cm). The surgical approach was thru penos-crotal incision, followed by direct dissection of NVB from tunica albuginea, penile eversion, composite corporoplasty (for transversal grafting 0.5mm thick porcine dermal graft, and for longitudinal graft composite semi-resorbable soft mash), and 3-piece inflatable penile prosthesis implantation. Postoperative vacuum drainage and compressive dressing were left in place for one week. Results Follow-up was 2-58 months (mean 21). Penile shape (corrected curvature, length and girth) was restored in all patients. In the first 4 weeks postoperatively 12pts had mild scrotal oedema; 8pts developed mild scrotal haematoma; 7pts developed penile skin oedema; 5pts had a transitory loss of sensitivity. All patients 5 weeks postoperatively started with sexual intercourse. All patients 12 weeks after surgery reported satisfactory aesthetical and functional results with no visible scaring related to surgery. Five pts (12-23 months after surgery) had prosthesis malfunction that needed reimplantation of the prosthesis. Conclusions Penile eversion thru peno-scrotal incision with preserving the prepuce for complex reconstructive surgery of PD is safe and gives the natural aesthetic appearance and good functional result with low complication rate. The high satisfaction rate for the patients is the most important aspect of this surgical method. Disclosure No

Direct tests of cytochrome c and c1 functions in the electron transport chain of malaria parasites

The mitochondrial electron transport chain (ETC) of Plasmodium malaria parasites is a major antimalarial drug target, but critical cytochrome(cyt) functions remain unstudied and enigmatic. Parasites express two distinct cyt c homologs (c and c-2) with unusually sparse sequence identity and uncertain fitness contributions. P. falciparum cyt c-2 is the most divergent eukaryotic cyt c homolog currently known and has sequence features predicted to be incompatible with canonical ETC function. We tagged both cyt c homologs and the related cyt c1 for inducible knockdown. Translational repression of cyt c and cyt c1 was lethal to parasites, which died from ETC dysfunction and impaired ubiquinone recycling. In contrast, cyt c-2 knockdown or knockout had little impact on blood-stage growth, indicating that parasites rely fully on the more conserved cyt c for ETC function. Biochemical and structural studies revealed that both cyt c and c-2 are hemylated by holocytochrome c synthase, but UV-vis absorbance and EPR spectra strongly suggest that cyt c-2 has an unusually open active site in which heme is stably coordinated by only a single axial amino acid ligand and can bind exogenous small molecules. These studies provide a direct dissection of cytochrome functions in the ETC of malaria parasites and identify a highly divergent Plasmodium cytochrome c with molecular adaptations that defy a conserved role in eukaryotic evolution.

A Modified Digestion Procedure for Recovery of Trematode Metacercariae from Terrestrial Gastropods

Procedures for a digestion technique were modified to identify an optimum approach for recovering trematode metacercariae from large, terrestrial snails. Brachylaima thompsoni and Panopistus pricei were recovered via HCl/pepsin digestion from field-collected snails, Webbhelix multilineata and Neohelix albolabris. The incubation temperature, duration, concentration of digestion fluid, agitation, and centrifugation settings were modified until a set of procedures resulted in thorough digestion of the snail body while minimizing the required time to run the procedure and maximizing the fraction of metacercariae that remained alive and active. Most metacercariae died during lengthy digestions and/or those with high concentrations of HCl and pepsin. The optimal procedure identified included a 2 hr digestion in 0.7% HCl and 0.8% pepsin at 37°C with initial cutting of the snail foot and periodic agitation during digestion. This method resulted in recovery of metacercariae that were nearly always alive and appeared no different than specimens recovered by direct dissection of snails. The method developed here is but one of many used for recovery of parasites, usually nematodes, from their invertebrate or vertebrate hosts, but it focuses on those characteristics that allow live trematode recovery.

Myofibers sarcolemma mechanical properties are affected by the isolation method

For understanding the mechanics and function of skeletal muscle in vivo, isolated cell fibers are used. Single isolated myofibers can be obtained from direct dissection or enzymatic dissociation. Isolation via direct dissection allows control of sarcomere length, preserves tendon attachment and, maintains the physiological environment, but is labor‐intensive and time‐consuming. On the contrary, enzymatic dissociation is fast and facile, produces hundreds of myofibers, reduces the number of muscles/animals needed for studies but alters the physiological environment and sarcomere length cannot be controlled. Biomechanical properties of the sarcolemma from mice were studied using the Elastimetry technique applied on myofibers from the extensor digitorum longus dissected directly and from the flexor digitorum brevis obtained by dissociation. Membrane stiffness, Young’s modulus, strain, and viscoelasticity in single isolated fibers were measured. Results showed that the membrane biomechanical properties were up to two times higher using direct isolation compared to the enzymatic dissociation technique. This leads us to conclude that the method used to obtain the myofibers changes the mechanical properties in cells.

Prevalence of parasitic infections in fish from markets in Zhenjiang City from 2017 to 2020

To investigate the prevalence of parasitic infections in freshwater fish and marine fish from markets in Zhenjiang City, so as to provide the evidene for formulating targeted control measures. Freshwater fish and marine fish were collected from farmers' markets and supermarkets in Zhenjiang City using a random sampling method. The metacercaria and larvae of parasites were detected using microscopy and the direct dissection method. The prevalence of parasitic infections was analyzed in freshwater fish and marine fish. The overall prevalence of parasite infections was 11.21% (208/1 856) in the 1 856 fish (34 species) detected from 2017 to 2020, and the prevalence was 9.81% (117/1 193) in freshwater fish and 13.73% (91/663) in marine fish. Among the 1 193 freshwater fish (23 species), high prevalence of parasitic infections was detected in Gambusia affinis (43.33%), coarse fish (32.93%) and Hemiculter leucisclus (20.20%), and there was no significant difference in the prevalence of parasitic infections among different species of freshwater fish (χ2 = 105.66, P < 0.05). Clonorchis sinensis, Metorchis orientalis and other parasite species were detected in freshwater fish, with detection rates of 0.59% (7/1 193), 1.93% (23/1 193) and 7.29% (87/1 193), respectively, and there was a significant difference in the detection of C. sinensis and M. orientalis in freshwater fish (χ2 = 8.64, P < 0.05). The prevalence and intensity of larval Anisakis infections were 13.73% (91/663) in marine fish and 3.43 parasites per fish. High prevalence of Anisakis infections was seen in little yellow croaker fish (30.28%) and hairtail (27.50%), and there was a significant difference in the prevalence of parasitic infections in different species of marine fish (χ2 = 12.93, P < 0.05). Parasitic infections are prevalent in freshwater fish and marine fish from markets of Zhenjiang City, and there is a risk of parasitic infections following consumption of raw or under-cooked freshwater fish and marine fish.

Revisional Surgery from Vertical Banded Gastroplasty to Roux-en-Y Gastric Bypass with Gastric Resection.

Introduction: Vertical banded gastroplasty (VBG) was a common bariatric procedure by laparotomy and or at the beginning of the laparoscopy, but nowadays it is almost an abandoned procedure. However, the young generation of bariatric surgeons should be aware about this procedure especially for revisional cases. Roux-en-Y gastric bypass (RYGB) is considered the procedure of choice for the revision of VBG. Materials and Methods: The evolution of revisional surgery to RYGB has known several technical steps. At the beginning, the procedure was performed with no gastric resection. Then a limited resection of the ancient staple line along with the fibrous tissue under the previous band or mesh was performed. The purpose of this article is to describe a simplified operative technique to simultaneously resect the ancient staple line and the calibration band. Results: After the initial viscrerolysis, an attempt to distinguish the course of the ancient section line of the stomach during the VBG is done. The dissection can become extremely challenging, with too much fibrosis and nonanatomical planes of dissection. At this point, we counsel to abandon the anterior direct dissection of the upper part of the stomach and to switch to a posterior dissection with the approach of greater curvature. Driven by the potential advantages (no risk of mucocele or gastrogastric fistula), for the past several years, we have changed the technique from resecting only the ancient staple line to perform a partial gastrectomy. The gastrectomy is larger and includes the complete resection of the gastric fundus, ancient staple line, the region with the mesh inside, and part of the gastric body. Once the stomach is extracted, the subsequent steps are similar to those of a primary RYGB. Conclusion: The procedure of choice for the revision of VBG is represented by RYGBP. Associating an atypical gastrectomy of the previous staple line with the region of mesh migration is a safe approach, eliminating the risk of mucocele.

Biochemical Assays to Directly Assess Smoothened Activation by a Conformationally Sensitive Nanobody.

The Hedgehog signaling pathway coordinates early development and is important in various cancers. Classic approaches to test pathway activation rely on transcriptional readouts or ciliary accumulation of specific pathway components. Although these assays have laid the foundation for studying Hedgehog pathway activation, they integrate the complex molecular actions of the transporter Patched and the seven transmembrane protein Smoothened. Though it is clear that cellular sterols are critical for pathway activity, direct dissection of which sterols drive Smoothened activity is precluded by the complex biosynthetic pathways responsible for cellular sterols. Here we describe a direct method of measuring Smoothened activity in vitro. This assay measures the binding of Smoothened to NbSmo8, a single-domain antibody that is selective for the active-state of Smoothened. Binding of purified Smoothened, reconstituted with specific sterols, to fluorescently labeled NbSmo8 can be rapidly evaluated using a fluorescence-detection size-exclusion chromatography assay. This approach enables a reductionist approach to precisely interrogate the regulatory activities of cellular lipids and sterols during Hedgehog signaling.

Talar Dome Access Through Posteromedial Surgical Intervals for Fracture Care.

Posterior talar body fractures are rare injuries without a consensus surgical approach. This study evaluates the accessible area of the talar dome through 2 posteromedial approach intervals (posteromedial [PM] and modified posteromedial [mPM]) both with and without distraction. Ten male cadaveric legs (5 matched pairs) were included. A PM approach, between flexor hallucis longus (FHL) and the tibial neurovascular bundle, and an mPM approach, between FHL and Achilles tendon, was performed on each pair. In total, 4 mm of distraction across the tibiotalar joint was applied with the foot held in neutral position. Accessible dome surface area (DSA) was outlined by drilling with a 1.6-mm Kirschner wire with and without distraction. Specimens were explanted and analyzed by micro-computed tomography with 3-dimensional reconstruction. Primary outcomes were total accessible DSA and sagittal plane access at predetermined intervals. The PM approach allowed access to 19.1% of the talar DSA without distraction and 33.1% of the talar dome with distraction (P < .001). The mPM approach provided access to 20.4% and 35.6% of the talar DSA without and with distraction (P < .001). Both approaches demonstrated similar sagittal plane access at all intervals except the lateral border of the talus, where the mPM approach provided greater access both without distraction (20.5% vs 4.38%, P = .002) and with distraction (34.3% vs 17.8%, P = .02). The mPM approach, using an interval between FHL and Achilles tendon, provides similar access to the posterior surface of talar dome and better sagittal plane access to the most lateral portion of the dome. The mPM interval provides the advantage of avoiding direct dissection of the tibial nerve or posterior tibial artery. Using an external fixator for distraction can improve talar dome visualization substantially. Level V, Cadaveric Study.

Endoscopic Nasopharyngectomy Combined With Internal Carotid Artery Pretreatment for Recurrent Nasopharyngeal Carcinoma

Salvage endoscopic nasopharyngectomy (ENPG) is a reasonable choice for resectable recurrent nasopharyngeal carcinoma (rNPC). However, in past decades, complete removal of the tumor was not feasible when the recurrent lesion was adjacent to the internal carotid artery (ICA). The present article introduces innovative strategies to ensure sufficient surgical margins while avoiding accidental injury to the ICA. Retrospective study. Tertiary care center. We retrospectively reviewed rT2-3 rNPC patients with tumor lesions adjacent to the ICA (<5 mm) who underwent ENPG at the Sun Yat-sen University Cancer Center between January 2015 and June 2020. Thirty-seven patients were selected for this study. Seventeen patients underwent ENPG using direct dissection, 10 patients underwent endoscopic-assisted transcervical protection of the parapharyngeal ICA combined with ENPG, and 10 patients underwent ICA embolization followed by ENPG. With a median follow-up duration of 31 months (range, 5 to 53 months), the 2-year overall survival, progression-free survival, locoregional recurrence-free survival, and distant metastasis-free survival rates of salvage ENPG for rNPC adjacent to the ICA were 88.7%, 72.0%, 72.0%, and 97.3%, respectively. The incidences of grade 1-2 and grade 3-5 postoperative complications were 16.2% and 13.5%, respectively. Two patients experienced ICA rupture during direct dissection but were out of danger after vascular embolization therapy. One patient had a positive margin. Two patients had severe nasopharyngeal wound infections with mucosal flap necrosis. ENPG combined with ICA pretreatment allows the feasible and effective resection of rNPC lesions adjacent to the ICA.

Angle Trisection, Bhaskara’s Proof, and Pythagorean Theorem

This paper deals with 1) angle trisection, 2) Bhaskara’s first proof, and 3) Pythagorean theorem. The purpose of this paper is threefold. First, to show a new, direct method of trisecting the 900 angle using unmarked straight edge and compass; secondly, to show Bhaskara’s first proof of the Pythagorean theorem (c2 = a2 + b2) as embedded in this new, direct trisection of the 900 angle; lastly, to show the derivation of the Pythagorean theorem from this trisection of the 900 angle. This paper employs the direct dissection method. It concludes by presenting four points: a) the concept of trisectability as distinct from concept of constructability; b) the trisection of the 900 angle as really a new, different method; c) Bhaskara’s first proof of the Pythagorean theorem as truly embedded in this trisection of the 900 angle and; d) another way of deriving Pythagorean theorem from this trisection of the 900 angle.

The overshadowed scientific endeavours of Berengario Da Carpi, a renaissance physician and the Forerunner of neurosurgery: a historical vignette

Jacopo Berengario da Carpi was Renaissance-era physician, surgeon, and anatomy lecturer who transformed medieval anatomy and surgery—which were, at the time, dominated mostly by religious dogma—into a modern science based on direct observation, experience, and cadaveric dissection. He was an accomplished and innovative neuroanatomist and educator, a prolific researcher and publisher, and a successful practicing surgeon who treated the head injuries of many renowned patients of that period. He published a landmark commentary on skull fractures that was the first printed book in history devoted to head injuries, which became a model of new medical understanding. Nonetheless, Berengario’s achievements in anatomy, medicine, neuroanatomy, and what would later become neurotraumatology and neurosurgery, would have been more widely known had his work and research not been surpassed by Andreas Vesalius and Ambroise Paré, both of whom advanced anatomic and medical knowledge even further. In this historical vignette, we discuss the political conditions of sixteenth Century Italy and pay a homage to Berengario da Carpi, emphasizing his work in establishing neuroanatomy as a field of medicine that became a precursor to modern neuroscience. We also describe the improvements he made in neurotraumatology technique and instrumentation, and his explanations of skull fractures and other brain injuries outlined in ground-breaking clinical books he published. Finally, we try to elucidate possible reasons why his scientific and professional achievements—despite of their enormous impact—were overshadowed by the achievements of his more famous immediate successors.

1776-P: ROCK1 Deletion in Sim1-Expressing Neurons of the Hypothalamus Leads to Obesity Despite Hypophagia

The paraventricular nucleus of the hypothalamus (PVN) is a key site in the brain for regulating energy balance. ROCK1 has also been shown to be a major regulator of energy balance and metabolism in the hypothalamus, but its role in the PVN is still unclear. To explore this role, mice selectively lacking ROCK1 in single-minded homolog 1 gene (Sim1) neurons (Sim1-ROCK1-/-), which are densely expressed in the PVN and in parts of the amygdala, were studied. ROCK1 deficiency in Sim1 expressing neurons leads to obesity on regular chow in male and female mice after 11-12 weeks. This effect is due to increased fat mass as assessed by EchoMRI and direct dissection of fat depots. Serum levels of insulin, leptin and free fatty acid in Sim1-ROCK1-/- mice were markedly increased compared to control mice. Surprisingly, daily food intake in Sim1-ROCK1-/- mice were significantly decreased compared with control mice. Moreover, the ability of melanocortin to decrease food intake was impaired when ROCK1 was deleted from Sim1-expressing neurons. No differences in O2 consumption and CO2 production measured by the Comprehensive Lab Animal Monitoring System (CLAMS) were found between obese and lean mice with or without ROCK1 deletion. These data identify ROCK1 as an important mediator of energy balance in the PVN, which leads to a paradoxical obese/hypophagic phenotype. The underlying mechanisms for the divergence in obesity, energy expenditure and caloric intake are being further explored in our lab. Disclosure H. Lee: None. J. Han: None. A.G. Uner: None. S.J. Choi: None. R.M. Pereira: None. X. Sun: None. H. Kim: None. Y. Kim: None.

VS-1-5 Penile Eversion and Multiple Slit Technique Corporoplasty With Inflatable Penile Prosthesis - Minimally Invasive Surgical Treatment of Severe MB Peyronie: No Circumcision, No Graft

Peyronie´s disease (PD) is a disorder of the tunica albuginea that diminishes sexual function. The penoscrotal approach for multiple slit technique and penile prosthesis placement without circumcision and without dissection of Dartos fascia from NVB is less common, yet less invasive method that has a natural cosmetic outcome, and delivers very high patient satisfaction. The surgical approach was thru small penoscrotal incision (3-4cm); direct dissection of NVB from tunica albuginea without mobilization of Dartos fascia from NVB; penile eversion thru penoscrotal incision; multiple slit corporoplasty; and 3-piece inflatable penile prosthesis implantation thru the same penoscrotal incision. Postoperative vacuum drainage and compressive penile and scrotal dressing were left in place for one week. In first 2 weeks the patient had a mild scrotal edema that resolved spontaneously. The patient started with normal sexual intercourse 6 weeks after the surgery. The patient reported natural esthetical appearance 10 weeks after surgery with no visible or palpable scars.

Practical value of three-dimensional high resolution magnetic resonance Vessel Wall imaging in identifying suspicious intracranial vertebrobasilar dissecting aneurysms

BackgroundDirect evidence of intimal flaps, double lumen and intramural haematomas (IMH) is difficult to detect on conventional angiography in most intracranial vertebrobasilar dissecting aneurysms (VBDAs). Our purpose was to assess the value of three-dimensional high-resolution magnetic resonance vessel wall imaging (3D HRMR VWI) for identifying VBDAs.MethodsBetween August 2013 and January 2016, consecutive patients with suspicious VBDAs were prospectively enrolled to undergo catheter angiography and VWI (pre- and post-contrast). The lesion was diagnosed as definite VBDA when presenting direct signs of dissection; as possible when only presenting indirect signs; and as segmental ectasia when there was local dilation and wall thickness similar to adjacent normal artery’s without mural thrombosis.ResultsTwenty-one patients with 27 lesions suspicious for VBDAs were finally included. Based on findings of VWI and catheter angiography, definite VBDA was diagnosed in 25 and 7 lesions (92.6%, vs 25.9%, p < 0.001), respectively; possible VBDA in 0 and 20 (0 vs 74.1%), respectively; and segmental ectasia in 2 and 0 (7.4% vs 0%), respectively. On VWI and catheter angiography, intimal flap was detected in 21 and 7 lesions (77.8% vs 25.9%, p = 0.001), respectively; double lumen sign in 18 and 7 (66.7% vs 25.9%, p = 0.003), respectively; and IMH sign in 14 and 0 (51.9% vs 0), respectively.Conclusions3D HRMR VWI could detect direct dissection signs more frequently than catheter angiography. This may help obtain definite diagnosis of intracranial VBDAs, and allow accurate differentiation between dissecting aneurysm and segmental ectasia as well. Further prospective study with larger sample was required to investigate the superiority of HRMR VWI for definite diagnosis of intracranial VBDAs than catheter angiography.

Inframammary approach for addressing anterior mediastinal tumours: initial experience.

BackgroundAnterior mediastinal tumours account for 50% of all mediastinal masses. Surgical intervention is the standard approach for their diagnosis or treatment. Minimally invasive techniques have gained significant popularity in the last few decades due to the obvious advantages that they offer. We will describe a series composed of the first 20 patients who were submitted to a new minimally invasive video-assisted technique, which uses an inframammary incision approach involving a Thoratrak rib spreader and a Rultract Skyhook retractor.MethodsA retrospective study was undertaken, involving all the patients in our department who were submitted to a resection of their anterior mediastinal masses by inframammary incision, using a Thoratrak rib spreader, a Rultract Skyhook retractor and video assistance.ResultsA total of 20 patients were included, with a mean age of 52.6. The mean surgery duration was 47 minutes, with an intraoperative blood loss of 70 mL. The mean period of hospitalisation was 2.9 days. No patients underwent conversion to open surgery, and there were no major complications. The mean size of the masses that were excised was 13.9 cm, with a mean weight of 77.3 g. The surgical margins were all free of tumour tissue, and no early recurrence was observed during the postoperative follow-up period.ConclusionsVideo-assisted thoracoscopic surgery (VATS) and robot assisted thoracic surgery (RATS) account for most of the minimally invasive procedures. However, VATS has certain limitations in terms of deep perception and manoeuvrability, and RATS has the disadvantage of lacking tactile and force feedback for the surgeon. The inframammary technique allows for safe direct dissection around the vascular and nervous structures, ensuring a complete observation of the anterior mediastinum and its structures. The findings in the present study suggest that this technique is useful. We had good surgical results, short surgery times and very low blood loss, and all tumours were totally resected, with tumour-free surgical margins. The size and the right lateralisation of the mass did not present any contraindications, and the learning curve and investment were minimal. In conclusion, the inframammary approach could be a safe and useful approach for treating anterior mediastinal pathology.

The clinical advantage of nano carbon suspension mapping in the number of axillary lymph nodes detected after neoadjuvant chemotherapy for breast cancer

Objective To compare the advantages of nano carbon suspension mapping method and non dye method in the number of axillary lymph nodes detected during axillary lymph node dissection and axillary micro lymph nodes detected after neoadjuvant chemotherapy for breast cancer. Methods From January 1st, 2018 to July 1st, 2018, 66 breast cancer patients who were to undergo axillary lymph node dissection after new adjuvant treatment were selected for the prospective study.Using the method of random number table, the patients were randomly divided into two groups: the group of nano carbon mapping (33 cases) and the control group (33 cases). After 24 hours subcutaneous injection of nano carbon before operation, axillary lymph node dissection and direct axillary lymph node dissection without dye were used.The number of axillary lymph nodes and the number of micro axillary lymph nodes in the two groups were observed. Results The number of axillary lymph nodes and micro lymph nodes in the nano carbon mapping group were higher than those in the control group.The differences were statistically significant (the number of axillary lymph nodes were (19.3±6.2) vs (14.9±6.7), P=0.007; the number of micro-lymph nodes were 2.0(0.5, 3.0) vs 0(0, 1.0), Z=-4.328, P<0.001). Conclusion Nano carbon suspension mapping can increase the number of lymph nodes detected in axillary lymph node dissection after neoadjuvant chemotherapy for breast cancer, and also has advantages in the detection of some small axillary lymph nodes that are not easy to find. Key words: Breast cancer; Carbon nanoparticle suspension; Axillary lymph node dissection; Micro-lymph nodes; Neoadjuvant chemotherapy

Application of Early Splenic Artery Occlusion in Laparoscopic Spleen-preserving Distal Pancreatectomy using Kimura Technique

To present our institutional experience in laparoscopic spleen-preserving distal pancreatectomy (Lap-SPDP) using Kimura technique with or without early occlusion of the root of the splenic artery. In addition, to explore the safety and feasibility of this occlusion technique, especially its advantages in intraoperative hemorrhage control and spleen preservation. From February 2011 to May 2019, 54 consecutive patients who were diagnosed as benign or low-grade malignant space-occupying lesions at the body and the tail of pancreas underwent Lap-SPDP using Kimura technique in our institution. Twenty-five patients before 2015 were allocated into non-occlusion group and 29 patients after 2015 were allocated into occlusion group. The non-occlusion group underwent direct dissection of the distal pancreas with blood supply from the splenic artery as well as traditional traction of the splenic artery without occlusion. Whereas the occlusion group underwent temporary occlusion of the root of the splenic artery by Bulldog clip after transecting the neck of the pancreas and distal pancreas was excised under a relatively bloodless situation. Surgical techniques were described in detail. Data between groups were retrospectively collected and stratification analysis was performed based on the diameter of tumor (>3 cm or ≤3 cm). Before stratification, there was a statistical difference in age between the two groups ( P=0.033), but no difference in body mass index (BMI) ( P=0.069). The median lesion diameter of the two groups was 2.5 cm and 4 cm, respectively, with no statistical difference ( P=0.065). The success rates of spleen preservation in the two groups were 93.1% and 92% respectively, showing no significant difference ( P=1.000). The length of hospital stay was slightly longer in the non-occlusion group than that in the occlusion group ( P=0.020). Comparing with the non-occlusion group, the occlusion group had significantly shorter operation time (median, 165 min vs. 235 min) and less estimated blood loss (median, 100 mL vs. 200 mL) ( P<0.05). After stratification by the tumor diameter, there were 2 cases of failed spleen preservation both in occlusion and non-occlusion group with tumor diameter >3 cm (occlusion group: 2/8, 25% and non-occlusion group: 2/14,14.3%). However there was no statistical difference between the two groups ( P=0.602). When the tumor diameter ≤3 cm, the spleen preservation rate of both groups reached 100%. When the tumor diameter was >3 cm, the operation time of the occlusion group was shorter than that of the non-occlusion group ( P=0.005). In terms of intraoperative blood loss, regardless of tumor size, the occlusion group had less estimated blood loss than that of the non-occlusion group ( P<0.05). In the occlusion group, no conversion or blood transfusion was needed intraoperatively and/or postoperatively. After stratification, there was no difference in the length of hospital stay between two groups ( P>0.05). During the follow-up period (median (Min-Max), 13.5 (3-96) months), no perioperative death, disease recurrence, portal vein or splenic vein thrombosis, gastric varices or upper gastrointestinal bleeding was noted. Lap-SPDP using Kimura technique with early occlusion of the root of splenic artery was safe and feasible and could be generally applied. By using this technique, we could reduce the operation time and blood loss, as well as sustain a high probability of spleen preservation.

Traumatic “TERSON SYNDROME PLUS”: Pneumocephalocele with optic atrophy

Introduction. Terson Syndrome is subarachnoid hemorrhage (SAH) with sub retinal hemorrhage flowing through channel. Reduced vision in such fresh case is due to hemorrhage itself, blocking macula/other photo receptors in the long run macular cellophane retinopathy which causes profound visual loss. SAH causes neurological problems which can become a risk factor for evacuating blood from vitreous. Hypertension is commonest cause to cause Terson Syndrome, but trauma is also devastating cause as it can lead to irreversible visual consequences like total loss of perception of light or blindness. Aim. Here we describe a case of Terson Syndrome plus disease features SAH in frontal lobe. Description of the case. When there is traumatic pneumocephalocele, it gives space to blood to imbibe towards bony optic canal and form hematoma around nerve sheath which causes compression around the same and leads to optic atrophy. Optic nerve can be injured by direct traumatic dissection during road traffic accidents (RTA), but even without that blood may accumulate around optic nerve and in turn leads to formation of hematoma and subsequently pressure induced optic atrophy. Moreover, blood can slowly travel to sub hyaloid space/sub retinal space (beneath internal limiting membrane or sub ILM) with probable gliosis covering typical boat shaped blood as seen in this case. This sub ILM hemorrhage or gliosis may have resolved through three injections of Triamcinolone in the orbital floor (OFTA) near apex, but optic atrophy snatches vision. This protocol was followed to treat traumatic compressive (peri optic hematoma) optic neuropathy and traumatic retinopathy associated with sub hyaloid hemorrhage. Conclusion. Diagnosis of Terson syndrome plus disease was established by addressing all features on computed tomography (CT) scan and magnetic resonance imaging (MRI). Plus, features include pneumocephalus, optic nerve sheath hematoma, optic atrophy and gliosis over sub-hyaloid hemorrhage, typical boat shaped. The part of hemorrhage still endured as seen on optical coherence topography, but vision was lost by virtue of optic atrophy. OCT shows clot in sub hyaloid space.