Displacement Of Organs Research Articles

EP.TU.425Visceroptosis - obsolete condition or missed opportunity to intervene early?

Abstract Visceroptosis is defined as displacement or prolapse of abdominal organs below their natural position, most commonly stomach – gastroptosis – or bowel - enteroptosis. It is also known as Glénard’s disease, first described in 1885, when there is evidence of generalised visceroptosis. The aetiology of visceroptosis remains unknown, however some authors have suggested this condition to result from weakness of the ligaments that hold the abdominal organs in their anatomical place. Although patients with visceroptosis are often asymptomatic, this condition can also present with various gastrointestinal symptoms depending on its severity. The most common symptoms reported include anorexia, severe constipation or diarrhoea, abdominal distention, gastroparesia, nausea, intractable abdominal pain. The aim of this study is to review the most updated literature reporting cases of visceroptosis, the diagnostic approach and its subsequent management, encouraging all surgeons to be more attentive towards and accurately identify visceroptotic habitus. Method Literature review using PubMed, Web of science and other reliable sources using the possible combinations of the following key words: visceroptosis, gastroptosis, enteroptosis, gastrointestinal complications, surgery. Results Current literature is scant regarding this unusual presentation and it is often referred as a rare complication of Ehlers-Danlos Syndrome. Due to its rarity, it often remains underdiagnosed potentially leading to sub-optimal treatment of patients, and ultimately significant morbidity and mortality. Conclusion We believe this condition should be repopularised as serious complications such as visceral torsion might arise from it which may require immediate surgical treatment, affecting quality of life and a high rate of relapses after surgical procedures.

Quantifying displacement of urogenital organs after abdominoperineal resection for rectal cancer.

AimThis study aimed to quantify displacement of urogenital organs after abdominoperineal resection (APR), and to explore patient and treatment characteristics associated with displacement.MethodPatients from 16 centres who underwent APR for primary or recurrent rectal cancer (2001–2018) with evaluable preoperative and 6–18 months postoperative radiological imaging were included in the study. Anatomical landmarks on sagittal images were related to a coordinate system based on reference lines between fixed bony structures and absolute displacements were calculated using the Pythagorean theorem. Rotation of landmarks was measured relative to a pubic‐S5 reference line.ResultsThere were 248 patients included of which 171 were men and 77 women. The median displacement of the internal urethral orifice was 25 mm in men (maximum 65), and 17 mm in women (maximum 50). Rotation of the internal urethral orifice was in a caudal direction in 160/170 (94%) of men and 65/73 (89%) of women, with a median of 32 degrees (maximum 85) and 33 degrees (maximum 83), respectively. Displacements of the posterior bladder wall, distal end of prostatic urethra and cervix were significantly correlated with the internal urethral orifice. In linear regression analysis, biological mesh reconstruction of the pelvic floor and visceral interposition were significantly associated with increased displacement of the internal urethral orifice, and female gender and any filling of the presacral space with decreased displacement.ConclusionsSubstantial absolute displacement and rotation of urogenital organs after APR for rectal cancer were observed, but with high variability among both men and women, and being significantly associated with reconstructive interventions.

Deep-Learning-Based Automatic Segmentation of Head and Neck Organs for Radiation Therapy in Dogs.

Purpose: This study was conducted to develop a deep learning-based automatic segmentation (DLBAS) model of head and neck organs for radiotherapy (RT) in dogs, and to evaluate the feasibility for delineating the RT planning.Materials and Methods: The segmentation indicated that there were potentially 15 organs at risk (OARs) in the head and neck of dogs. Post-contrast computed tomography (CT) was performed in 90 dogs. The training and validation sets comprised 80 CT data sets, including 20 test sets. The accuracy of the segmentation was assessed using both the Dice similarity coefficient (DSC) and the Hausdorff distance (HD), and by referencing the expert contours as the ground truth. An additional 10 clinical test sets with relatively large displacement or deformation of organs were selected for verification in cancer patients. To evaluate the applicability in cancer patients, and the impact of expert intervention, three methods–HA, DLBAS, and the readjustment of the predicted data obtained via the DLBAS of the clinical test sets (HA_DLBAS)–were compared.Results: The DLBAS model (in the 20 test sets) showed reliable DSC and HD values; it also had a short contouring time of ~3 s. The average (mean ± standard deviation) DSC (0.83 ± 0.04) and HD (2.71 ± 1.01 mm) values were similar to those of previous human studies. The DLBAS was highly accurate and had no large displacement of head and neck organs. However, the DLBAS in the 10 clinical test sets showed lower DSC (0.78 ± 0.11) and higher HD (4.30 ± 3.69 mm) values than those of the test sets. The HA_DLBAS was comparable to both the HA (DSC: 0.85 ± 0.06 and HD: 2.74 ± 1.18 mm) and DLBAS presented better comparison metrics and decreased statistical deviations (DSC: 0.94 ± 0.03 and HD: 2.30 ± 0.41 mm). In addition, the contouring time of HA_DLBAS (30 min) was less than that of HA (80 min).Conclusion: In conclusion, HA_DLBAS method and the proposed DLBAS was highly consistent and robust in its performance. Thus, DLBAS has great potential as a single or supportive tool to the key process in RT planning.

Surgical challenges of excision of retroperitoneal germ cell tumors in children: a single institutional study with literature review

BackgroundRetroperitoneal germ cell tumors (GCTs) are rare, commonly large tumors, often diagnosed in infancy. Complete surgical resection may pose a serious challenge as encasement of major vessels and organ displacement can lead to perioperative complications. This study aims to illustrate the surgical challenges of excising retroperitoneal GCTs.ResultsNine patients were included: six patients with a teratoma, two patients with a mixed GCT with a yolk sac tumor component, and one patient with a pure yolk sac tumor. Six were males and seven were younger than 1 year of age at time of presentation. In all cases, perioperative vascular or organ-related complications occurred in one patient; this resulted in short bowel syndrome. There was no recurrence or mortality during the follow-up period. Relevant literature is reviewed and described.ConclusionsThe anatomical relation of a retroperitoneal GCT to the major vessels and organs is unpredictable. Preoperative radiological evaluation can help to improve the understanding of the vascular anatomy and to plan accordingly. Anteriorly displaced veins may appear insignificant and arteries, such as the superior mesenteric artery may be encased. Preoperative imaging may prevent perioperative complications, leading to safer surgical procedures.Level IV evidenceTherapeutic study

Monte Carlo-based patient internal dosimetry in fluoroscopy-guided interventional procedures: A review.

This systematic review aims to understand the dose estimation approaches and their major challenges. Specifically, we focused on state-of-the-art Monte Carlo (MC) methods in fluoroscopy-guided interventional procedures. All relevant studies were identified through keyword searches in electronic databases from inception until September 2020. The searched publications were reviewed, categorised and analysed based on their respective methodology. Hundred and one publications were identified which utilised existing MC-based applications/programs or customised MC simulations. Two outstanding challenges were identified that contribute to uncertainties in the virtual simulation reconstruction. The first challenge involves the use of anatomical models to represent individuals. Currently, phantom libraries best balance the needs of clinical practicality with those of specificity. However, mismatches of anatomical variations including body size and organ shape can create significant discrepancies in dose estimations. The second challenge is that the exact positioning of the patient relative to the beam is generally unknown. Most dose prediction models assume the patient is located centrally on the examination couch, which can lead to significant errors. The continuing rise of computing power suggests a near future where MC methods become practical for routine clinical dosimetry. Dynamic, deformable phantoms help to improve patient specificity, but at present are only limited to adjustment of gross body volume. Dynamic internal organ displacement or reshaping is likely the next logical frontier. Image-based alignment is probably the most promising solution to enable this, but it must be automated to be clinically practical.

Gastric Volvulus Associated with Eventration of Diaphragm

Diaphragmatic eventration is an abnormally elevated hemidiaphragm in thoracic cavity with poorly developed musculature. This condition can lead to abnormal displacement of intra-abdominal organs. It usually remains asymptomatic in early life. It presents later with respiratory and occasionally gastrointestinal complications. A clinical case of eventration of diaphragm, displacement of the splenic flexure of colon, omentum and spleen into thoracic cavity with gastric volvulus is uncommon. Gastric volvulus occurs when the stomach twists around one of its axis. It is commonly along its long axis (organoaxial volvulus) and less commonly along the vertical axis (mesenteroaxial).Mortality rate of gastric volvulus range from 30%-50%. Hence early diagnosis and prompt intervention prevents development of necrosis and perforation of stomach. We report a case of 30year old male having left sided diaphragmatic eventration associated with organoaxial gastric volvulus and displaced intra-abdominal organs treated with successful surgical intervention. Key words: Eventration; Diaphragm; Gastric; Volvulus; Malrotation; Organo-axial; Mesenteroaxial, Gastric outlet obstruction, Derotation; Gastropexy.

Первый опыт применения тканеинженерных конструкций для хирургической коррекции опущения передней стенки влагалища

Objective. To study the effectiveness and safety of new surgical method for correcting the anterior vaginal wall prolapse using tissue-engineered constructs. Patients and methods. After preliminary experimental work on the creation and evaluation of the biocompatibility of tissueengineered constructs based on non-biodegradable (polypropylene and titanium endoprostheses) mesh implants with an autologous cellular component (rat and human dermal fibroblasts), 4 patients aged 44, 54, 70 and 75 years were examined. Inclusion criteria: anterior vaginal wall prolapse (stage II – III); consent to the installation of tissue-engineered construct. A fourstage surgical program providing for the correction of stage II-III anterior vaginal wall prolapse using tissue-engineered constructs of individual size was used. Results. In the early postoperative period, one patient was diagnosed with a small hematoma of the anterior vaginal wall. During the first month after surgery, one patient complained of gradual perineal pain, another patient – of frequent urination. Subsequently, these symptoms stopped. After 3, 6, 9, 12, 15 months after surgery, during the pelvic examination at rest, the Valsalva maneuver and transperineal ultrasound, no displacement of organs was detected, ultrasound clearly visualized a tissueengineered construct without displacement and deformation. Conclusion. We have developed an original method for correcting the prolapse of the anterior vaginal wall using tissueengineered constructs based on polypropylene and titanium with an autologous cellular component, which helps to optimize the results of surgical treatment, reduce the frequency of disease recurrence and the risk of developing mesh-related complications. Key words: pelvic organ prolapse, tissue-engineered constructs, surgical correction

Новый способ органосберегающей хирургической коррекции элонгации шейки матки с использованием сетчатых титановых имплантатов – «Московская» операция

Objective. To study the efficacy and safety of the original technique for surgical correction of cervical elongation with vaginal wall prolapse (stage I–II) in patients of reproductive and menopause age. Patients and methods. The study included 17 patients aged 30 to 56 years with cervical elongation and vaginal wall prolapse. All patients underwent the original surgery – cervical amputation along with combined transobturator and sacrospinous TiMeshligature cervical suspension. Results. The patients were observed 1, 6, 12 and 18 months after surgery. Comparison of the patients’ questionnaire data in the pre- and postoperative periods showed an improvement in their quality of life, an increase in their social and sexual activity. During the first month, 10 (58.8%) patients noted intermittent episodes of perineal pain and 3 (17%) – frequent urination. Comprehensive clinical examination after 6, 12, and 18 months revealed complete preservation of surgical correction of prolapse in all patients. Gynecological and rectal examinations, transperineal and transvaginal ultrasound revealed no displacement of pelvic organs and titanium implants. There were no mesh-associated complications during follow-up. Conclusion. The developed original technique for surgical correction of cervical elongation with vaginal wall prolapse (stage I–II) using a combination of titanium mesh implants and non-absorbable ligatures with two-lateral suture anchor was shown to be effective and safe, as evidenced by normalization of the uterus position in the pelvis and absence of pelvic organ displacement and mesh-associated complications during follow-up. Key words: cervical elongation, stage I–II vaginal wall prolapse, titanium mesh implants, mesh-ligature correction of prolapse

Perineal Hernia in Dogs

Background: Perineal hernia is a serious disease characterized by weakening or atrophy and separation of the muscles and fasciae of the perineal musculature, followed by the caudal displacement of pelvic and abdominal organs to the perineum region. Treatment is invariably surgical and several approaches have been proposed, but complication and recurrence rates remain high. This study aimed to evaluate 120 cases of perineal hernia treated at the Veterinary Hospital of Uberaba (HVU) from 2005 to 2020, addressing the clinical and surgical aspects and the postoperative period, seeking to identify the most relevant factors to improve care and treatment of future patients affected by this disease.Materials, Methods & Results: The medical records of dogs with a definitive diagnosis of perineal hernia were collected. The prevalence of perineal hernia was calculated. Data were obtained regarding sex, being castrated or not, age, body mass, race, clinical signs, affected side, possibility of hernia reduction, treatments used, associated pathologies. Of the 120 cases, only 69 underwent surgery at the HVU and from these cases data were obtained regarding hernia content, surgical techniques, surgical wires used, recurrences and postoperative complications. Fisher's exact test was applied to assess the influence of the type of surgical treatment and surgical thread on the occurrence of complications and recurrences. Perineal hernia was the second most frequently observed hernia. Mixed breed, male, non-neutered and geriatric dogs were the most affected. The most frequently observed clinical signs were related to the digestive and urinary tract, consistent with the most commonly found hernia contents (bladder, prostate and rectum). The simple herniorrhaphy technique was the most used and showed a high number of complications. The second most used technique was the elevation of the internal shutter, which proved to be more efficient than the simple technique. Regardless of the technique used, the association of two or more techniques proved to be more efficient to reduce major complications. The use of the vaginal tunic stood out because it proved to be efficient in the treatment of perineal hernias regardless of whether it is associated with simple herniorrhaphy or obturator elevation. The surgical fixations of abdominal organs (Bladder, Ducto deferente and Colon) proved to be effective, since there were no recurrences or major complications associated with their use and the most used threads for herniorrhaphy were polyamide and catgut. Low recurrence rates were found in patients who received synthetic yarns. The most frequent complications were suture dehiscence and serous secretion.Discussion: Perineal hernia is a very important alteration due to difficulties in treatment, high rates of complications and recurrence, in addition to the large number of affected dogs. Several surgical techniques have already been proposed for the treatment of perineal hernia in dogs and are based on the reconstruction of the perineal musculature through sutures, muscle flaps, biological membranes, synthetic mesh and the reduction of pressure on the perineum through the surgical fixation of organs abdominals such as colon, vas deferens and bladder (in the musculature of the abdominal wall). It is concluded that the perineal hernia affects mainly male, non-neutered and geriatric dogs, being rare in females. Regardless of the techniques used, the association of two or more techniques is more efficient to reduce the rate of recurrences and complications. The autogenous vaginal tunic is a good option for muscle strengthening in perineal herniorraphies. The use of synthetic surgical wires leads to better results in the treatment of perineal hernia when compared to biological wires.

Лапароскопическая билатеральная субперитонеальная коррекция апикального пролапса при помощи сетчатых титановых имплантатов

Objective. To study the efficacy and to assess the safety of the use of titanium ribbon-like implants for surgical correction of various forms of apical prolapse. Patients and methods. 23 patients with apical prolapse (stage III–IV) aged 29 to 74 years were examined. Surgical correction of various forms of apical prolapse was performed using titanium ribbon-like mesh implants, which are more inert to the surrounding tissues than polypropylene scaffold systems. Dynamic outpatient observation of the patients was carried out after 3, 6, 12, 15 months after surgery. Results. The duration of surgery varied from 55 to 80 minutes, on average 74 ± 11.5 minutes. Intraoperative blood loss ranged from 50 to 150 mL (100 ± 35.7 mL). Of the early postoperative complications, only hematomas in the projection of the posterior vaginal wall of small sizes (up to 10 ml) – 2 (8.7%) were noted. Comparison of the questionnaire data from patients in the preand postoperative period showed an improvement in the quality of life of patients, an increase in their social and sexual activity. There was no significant displacement of the pelvic organs, and there were no mesh-associated complications. Conclusion. Laparoscopic bilateral subperitoneal hystero-, cervico-, colposuspension to the aponeurosis using titanium mesh ribbon-like implants improves the efficiency of surgical treatment of various forms and severity of apical prolapse. Key words: apical prolapse, hysterosuspension, titanium mesh implants

S2294 Severe Inflammation Leading to Colonic Varices

INTRODUCTION: Colonic varices are a rare finding during endoscopy, especially in an individual without known liver disease. Based on limited case reports, the estimated incidence of colonic varices is 0.07%, irrespective of the etiology[1]. Common causes of colonic varices include portal hypertension from underlying liver disease, non-cirrhotic portal hypertension, most commonly from pre-sinusoidal disease in the form of splenic vein thrombosis, arteriovenous malformation, and idiopathic colonic varices[1, 2]. We present a case of colonic varices in a non-cirrhotic patient leading to an unexpected diagnosis. CASE DESCRIPTION/METHODS: A 23 year-old male was referred for iron deficiency anemia noted on a routine health visit. Initial labs demonstrated a hemoglobin of 12.4 g/dL and a ferritin level below 15 ng/mL. He was referred to the gastroenterology clinic where he reported a prior diagnosis of iron deficiency anemia 10 years ago without endoscopic investigation and treated with iron supplements, but otherwise was in his usual state of health. He denied change in his bowel movements, but endorsed scant, intermittent blood in his stools with wiping. He underwent EGD which was normal and a colonoscopy which was notable for large submucosal varices at the splenic flexure and in the proximal descending colon, multiple erythematous polyps ranging in size from 5-15 mm from the descending colon to the rectum, and erythematous, ulcerated, and friable mucosa from the descending colon to the rectum. CT angiography was performed which showed marked pelvic and lower abdominal lipomatosis with mass effect on the small bowel and abdominal vasculature. The patient was diagnosed with severe left sided ulcerative colitis with mesenteric adipose tissue hypertrophy resulting in colonic varices. He was lost to follow-up prior to initiation of biologic therapy. DISCUSSION: Mesenteric adipose tissue hypertrophy is a known complication of severe Crohn’s disease[3, 4]. Mechanistically, transmural inflammation in Crohn’s disease allows bacterial translocation into the mesenteric adipose tissue, which elaborates a cascade of adipocytokines resulting in inflammatory cell recruitment and adipose tissue hypertrophy, which serves as an additional barrier to systemic bacterial infection[3-5]. This case is unique in that it demonstrates mesenteric adipose tissue hypertrophy in long-standing, untreated UC that created a mass effect, resulting in colonic varices.Figure 1.: Coronal view - mesenteric adipose tissue hypertrophy resulting in visceral organ displacement and colonic varices.Figure 2.: Coronoal view - mesenteric adipose tissue hypertrophy resulting in visceral organ displacement.Figure 3.: Cross-sectional view - colonic varices in the transverse colon.

Temporary Organ Displacement to Escalate Radiation Dose to Retroperitoneal Tumors and Decrease Toxicity to Organs at Risk

PurposeTo demonstrate that temporary organ displacement (TOD) by drainage catheter placement and hydrodissection is feasible and reproducible for simulation (SIM) and stereotactic body radiation treatment (SBRT). Materials and MethodsBetween February 2010 and December 2018, 31 consecutive patients (20 men and 11 women; median age, 59 years; range 20–80 years) received both SIM and SBRT with TOD. The minimum required displacement was 10 mm between the gross tumor volume (GTV) and the organ at risk (OAR). Complete displacement was defined as the ability to displace the OAR from the GTV a minimum of 10 mm across the entire boundary. SIM was performed with hydrodissection on the same day. On the day of SBRT, displacement was reproduced by hydrodissection. Displacement was measured on computed tomography images of TOD, SIM, and SBRT. The drain was removed after SBRT. ResultsTOD (hydrodissection) was significantly associated with successful displacement of the OAR from a GTV greater than 10 mm (median, 20 mm vs 4.1 mm, P < .001) and maintained displacement at SIM and SBRT (SIM: 29.4 mm vs 4.1 mm, P < .001; SBRT: 32.4 mm vs 4.1 mm, P < .001). The OAR-GTV boundary showed a median reduction of 35 mm (95% confidence interval, 27.5–37.5 mm) after TOD. TOD achieved complete displacement in 22 of 31 (71%) patients, and 25 of 31 (81%) patients were able to undergo single-fraction ablative SBRT. No patients developed procedure-related complications within 30 days. SIM and SBRT were successful without OAR toxicities within a median of 33 months (range, 3–92 months). ConclusionsTOD with placement of drain and hydrodissection is technically feasible and safe and maintains displacement for SIM and SBRT.

Polymyalgische Beschwerden: Steckt ein Tumor dahinter?

A 61-year-old caucasian male presenting with pain in arms and thighs, weight loss of 10 kg in the last 3 months, and subfebrile temperatures, also had abdominal pain. In addition, he reported that his abdominal circumference had increased over the last two years. Based on patient's complaints and the presence of elevated inflammatory markers in the absence of specific antibodies or peripheral synovitis a clinical diagnosis of polymyalgia rheumatica was made. The patient had an immediate clinical response to 20 mg prednisone/day, and inflammatory markers normalized. An abdominal MRI showed no signs of polymyalgia rheumatica but revealed a lipomatous mass with displacement of the adjacent intraabdominal and intrapelvine organs. Histologically a highly differentiated retroperitoneal liposarcoma was described. The patient underwent a complete resection of the tumor. Because the liposarcoma was highly differentiated, the oncologists were reluctant to use any additional therapy. The diagnostic work up of polymyalgic complaints should also include rare paraneoplastic diseases.

Mosquito proboscis-inspired needle insertion to reduce tissue deformation and organ displacement

This study investigates mosquito proboscis-inspired (MPI) insertion applied to the clinically used biopsy needle to reduce tissue deformation and organ displacement. Advanced medical imagining has enabled early-stage identification of cancerous lesions that require needle biopsy for minimally invasive tissue sampling and pathological analysis. Accurate cancer diagnosis depends on the accuracy of needle deployment to the targeted cancerous lesion site. However, currently available needle delivery systems deform and move soft tissue and organs, leading to a non-diagnostic biopsy or undersampling of the target. Two features inspired by the mosquito proboscis were adopted for MPI insertion in prostate biopsy: (1) the harpoon-shape notches at the needle tip and (2) reciprocating needle-cannula motions for incremental insertion. The local tissue deformation and global prostate displacement during the MPI vs. traditional direct insertions were quantified by optically tracking the displacement of particle-embedded tissue-mimicking phantoms. Results show that the MPI needle insertion reduced both local tissue deformation and global prostate displacement because of the opposite needle-cannula motions and notches which stabilized and reduced the tissue deformation during insertion. Findings provide proof of concept for MPI insertion in the clinical biopsy procedures as well as insights of needle–tissue interaction for future biopsy technology development.

The Study of Vowel Space and Formant Structure in Mazani Language

Objective: One of the parameters showing the correct phonetic and phonological development is the correct and clear articulation of vowels is achieved by changing the shape of vocal cords through altering the height and position of the tongue and the movement of the lips and jaw. The tongue’s height and position are the basis of the production and difference of vowels. In other words, the raw sound produced by vocal cords, which has a base frequency, changes and intensifies according to the displacement of organs and vocal tract cavities which makes harmonies from the base sound called formats. These intensified harmonies depend on the shape, size, and material of the cavities, and can affect a person’s speech clarity and, consequently, the listeners’ perception. Due to such effects and the significant role of vowels space and formants on communicative aspects in each language, they are considered as one of the most important acoustic characteristics of any spoken language. Therefore, determining a scale as a tool to assess vowel errors and speech disorders is necessary. This study aimed to investigate vowel space and formant structure of Mazani language in adults. Materials &amp; Methods: This descriptive-analytical study with a cross-sectional design was conducted on 60 adults (30 males and 30 females) with Mazani language aged 18-40 years who were selected randomly and based on the inclusion and exclusion criteria (no history of respiratory diseases, verbal and auditory disorders and having at least 5 years of experience in living in Babol county. After producing the vowels by participants, the first, second, and third formants (F1, F2, and F3) of all 6 vowels were obtained in PRAAT v.6.0 program, and analyzed finally using independent t-test in SPSS v. 18 software. Results: In men, the highest mean value for the base frequency was related to the vowels /i/ and /u/ (136 Hz), and for F1, F2, and F3, it was related to the vowels /æ/ (646 Hz), /i/ (2182 Hz), and /i/ (2888 Hz), respectively. On the other hand, their lowest mean values were related to the vowels /a/ (124 Hz), /i/ (283 Hz), /a/ (1150 Hz), and /e/ (2629 Hz), respectively. In women, the highest mean values of base frequency, F1, F2 and F3 were related to the vowels /u/ (222 Hz), /æ/ (828 Hz), /i/ (2346 Hz), and /i/ (3151 Hz), while the lowest mean values were related to the vowels /æ/ and /e/ (202 Hz), /i/ (364 Hz), /a/ (1167 Hz), and /o/ (2775 Hz), respectively. Conclusion: There was difference in formants and vowel space between men and women with Mazani language. The /a/ was the lowest pitch vowel and /i/ and /u/ were the highest pitch the vowels in men, while /æ/ and /e/ were the lowest pitch vowels and /u/ was the highest pitch vowel in women. Furthermore, the most open, closed, backward and forward vowels were /æ/, /i/, /i/ and /a/, respectively. The /e/ in men and /o/ in women were the most rounded vowels, while the /i/ in both genders was the most unrounded vowel. The results are somewhat different from the results of studies conducted on the production of vowels in standard Persian language. Since the speech clarity and fluency can be affected by the incorrect production of vowels, the results of this study can be used to evaluate and diagnose speech disorders in Mazani language for clinical and research purposes.

Combining Appleby with RAMPS – Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Celiac Trunk Resection

BackgroundRadical Antegrade Modular Pancreatosplenectomy (RAMPS) minimizes the risk of a positive retroperitoneal margin and maximizes lymph node harvest in distal pancreatic cancers.1-7 In those with celiac trunk involvement, resection of the celiac trunk (modified Appleby procedure) is a surgical option in which postoperative liver perfusion relies on blood flow via superior mesenteric artery (SMA) and gastroduodenal artery (GDA).8, 9 PatientA 66-year-old male was diagnosed with a 3.8 × 2.5 cm pancreatic body adenocarcinoma abutting the celiac trunk. Neoadjuvant FOLFIRINOX was initiated with a uniquely good response. TechniquePrior to surgery, a novel preoperative 3D simulation technique accounting for organ displacement during pneumoperitoneum with the goal of optimizing port placement and surgical decision making was employed. At surgery, a RAMPS procedure was performed with the renal vessels and adrenal gland being dissected first (reversed from typical open approach). Following dissection along the SMA towards the celiac axis, desmoplastic reaction enveloping the celiac trunk necessitated its resection. Arterial liver perfusion was confirmed with intraoperative ultrasound. ConclusionL-RAMPS and modified Appleby procedure is a curative option for patients with distal pancreatic cancers that invade the celiac trunk and in whom the tumor biology is well controlled. A preplanned approach with 3D reconstruction accounting for organ displacement due to pneumoperitoneum optimizes surgical decision making and port placement for visual alignment caudally along the SMA.

Causes of unsuccessful surgical treatment of hiatal hernia

Hiatal hernia is the most common type of visceral anatomy disorder, observed in people under 30 years of age in 10%, older than 50 years in 60%. Four types of hiatal hernias (IIV) are distinguished by the variant of the disturbances in the relationship between the esophagus, stomach, and diaphragm. Indications for surgical treatment of hiatal hernias are gastroesophageal reflux or anatomical disorders, which have a risk of developing life-threatening conditions (obstruction or necrosis of the stomach). An unresolved problem in this part of surgery is the high rate of disease recurrence, reaching 1015 4060%. The subjective reasons for the unsatisfactory results of surgical treatment of this pathology include technical errors in performing interventions (insufficient mobilization of the esophagus, stomach, legs of the diaphragm, incomplete excision of the hernial sac) and flaws in perioperative support (insufficient analgesia, vomiting, cough). The objective factors of the repeated displacement of the abdominal organs into the chest are the large size of the hiatal opening (more than 5 cm in maximum dimension), the insufficient mechanical strength of the legs of the diaphragm (hypotrophy, fibrosis) and the shortening of the esophagus (reduction of the abdominal part length less than 5 cm). Each of the noted factors plays a own role, together determining the success or failure of the surgical intervention. Understanding the basic principles and unresolved issues in this field of surgery is a prerequisite for its further development.

Amerotyphlops brongersmianus (Vanzolini, 1976) (Typhlopidae, Serpentes) as a model for scolecophidian ontogenetic shifts of heart topography and relative size

Ontogenetic shifts in the snake heart topography are mostly associated with their life habits and physiological adaptations due to modifications of complex functional-adaptative and developmental constraints. However, such studies are incipient for scolecophidians, and the presence of shifts putatively related to physiological mechanisms are still unexplored for this group. We aimed to evaluate the presence of topological shifts in heart position and the allometry of heart/chambers total length in Amerotyphlops brongersmianus. Our results indicate that there is a craniad ontogenetic shift of the heart position related to total length increase. Heart total length and their chambers also grow isometrically in relation to head and total body length. We discuss the possible functional and evolutionary perspectives of our results with comparison to data available for alethinophidan snakes. We hypothesize the anterior displacement of organs possibly remains as an ancestral state to compensate reproductive constraints imposed by the ancestral scolecoid miniaturized body.

Target miss using PTV-based IMRT compared to robust optimization via coverage probability concept in prostate cancer

Purpose: Cure- and toxicity rates of prostate IGRT can both be affected by ill-chosen planning target volume (PTV) margins. For dose-escalated prostate radiotherapy, we studied the potential for organ at risk (OAR) sparing and compensation of prostate motion with robust plan optimization using the coverage probability (CovP) concept compared to conventional PTV-based IMRT.Material and methods: We evaluated plan quality of CovP-plans for 27 intermediate risk prostate cancer patients treated in a prospective study (78 Gy/39 fractions). Clinical target volume (CTV) and OARs were contoured on three separate CTs to capture movement and deformation. To define the internal target volume (ITV), the union of CTV1-3 was encompassed by an isotropic margin of 7 mm for the planning process. CovP-dose distribution is optimized considering weight factors for IMRT constraints derived from probabilities of systematic organ displacement in the three CTs. CovP-dose volume histograms (DVHs) were compared with additionally calculated conventional PTV-based IMRT plans. PTV-based IMRT was planned on one-single CT with an isotropically expanded CTV to generate the PTV (i.e., CTV1 + 7mm) and was evaluated on the two other CTs.Results: The CovP-concept showed higher robustness in target volume coverage. Target miss was frequently observed with PTV-based IMRT, resulting in cold spots until 70 Gy with the CovP-concept. The target dose at 74 Gy was comparable, while further the dose–escalation (75–78 Gy) was improved with PTV-based IMRT. However, dose–escalation with PTV-based IMRT was associated with increased OAR-doses, especially in high-dose areas.Conclusions: Probabilistic dose-escalated IMRT was feasible in this prospective study. Comparison of the CovP-concept with PTV-based IMRT revealed superiority with regard to target-coverage and sparing of OARs. The CovP-concept implements a robust plan optimization strategy for organ deformation and motions and could, therefore, serve as a less demanding compromise on the way to adaptive IGRT avoiding daily time-consuming re-planning. SUMMARYWe evaluated the robustness of coverage probability (CovP)-based IMRT plans within a prospective study for prostate cancer radiotherapy. The treatment plans were compared with newly calculated conventional PTV-based IMRT plans. We were able to show that CovP led to a clearly more robust target coverage by avoiding hot spots at OARs compared to conventional PTV-based IMRT. In addition, negative consequences of an inflated PTV can be ameliorated by a more relaxed CovP-based dose prescription.

Tumor volume regression during neoadjuvant chemoradiotherapy for esophageal cancer: a prospective study with weekly MRI

Background: Neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer causes tumor regression during treatment. Tumor regression can induce changes in the thoracic anatomy, with smaller target volumes and displacement of organs at risk (OARs) surrounding the tumor as a result. Adaptation of the radiotherapy treatment plan according to volumetric changes during treatment might reduce radiation dose to the OARs, while maintaining adequate target coverage. Data on the magnitude of the volumetric changes and its impact on the thoracic anatomy is scarce. The aim of this study was to assess the volumetric changes in the primary tumor during nCRT for esophageal cancer based on weekly MRI scans.Material and methods: In this prospective study, patients with adeno- or squamous cell carcinoma of the esophagus treated with neoajduvant chemoradiotherapy according to the CROSS regimen (carboplatin + paclitaxel + 23 × 1.8 Gy) were included. Of each patient, six sequential MRI scans were acquired: one prior to nCRT, and five in each subsequent week during nCRT. Tumor volumes were delineated on the transversal T2 weighted images by two radiation oncologists. Volumetric changes were analyzed using linear mixed effects models.Results: A total of 170 MRI scans from 29 individual patients were included. The mean (± standard deviation (SD)) tumor volume at baseline was 45 cm3 (± 23). Tumor volume regression started after the first week of nCRT with a significant decrease in tumor volumes every subsequent week. A decrease to 42 cm3 (91% of initial volume), 38 cm3 (81%), 35 cm3 (77%), and 32 cm3 (72%) was observed in the second, third, fourth and fifth week of nCRT, respectively.Conclusion: Based on weekly MRI scanning during nCRT for esophageal cancer, a considerable decrease in tumor volume was observed during treatment. Volume regression and consequential anatomical changes suggest the possible benefit of adaptive radiotherapy.