Distal Remnant Research Articles

TCT-38 The Effect of Beta-Blocker on Distal Aorta and Remnant False Lumen in the Distal Thoracic Residual Aorta After Surgery With Frozen Elephant Trunk Technique in Patients With Type A Aortic Dissection

TCT-38 The Effect of Beta-Blocker on Distal Aorta and Remnant False Lumen in the Distal Thoracic Residual Aorta After Surgery With Frozen Elephant Trunk Technique in Patients With Type A Aortic Dissection

Anterior Cruciate Ligament Stump Elongation Technique for Anterior Cruciate Ligament Restoration

There is renewed interest in anterior cruciate ligament (ACL) preservation techniques. Prior studies have shown good outcomes and low failure rates with ACL preservation in patients with good tissue quality and more proximal tears. We describe a technique intended to assist surgeons in obtaining maximal length of the ACL stump during ACL preservation surgery. We find this to be effective in reapproximating the ACL remnant to its origin on the femoral wall in many cases, even those with a relatively short-appearing stump on preoperative imaging. This technique may allow for surgeons to feel more comfortable offering ACL repair or restoration to patients with a smaller distal ACL remnant.

Radiological landmark of syndesmotic ligament complex by magnetic resonance imaging correlate with fibula free flap harvesting procedure

Preservation of syndesmotic ligaments is crucial for preventing adverse sequelae at the donor site following free fibula osteocutaneous flap harvesting. This study sought to determine the relationship between distal tibiofibular ligaments and the fibular segment to identify radiological landmarks that facilitate safe and precise flap. The distances between the distal tibiofibular ligaments (anterior inferior tibiofibular ligament [AITFL], posterior inferior tibiofibular ligament [PITFL]) and the fibular segment, as well as the lower border of the interosseous membrane, were measured on magnetic resonance imaging (MRI) scans of 296 patients without any perceivable ankle abnormalities. The mean distances (± SD) between the distal end of the fibula and the AITFL, PITFL, and lower interosseous membrane border were 3.0 ± 0.4 cm, 2.6 ± 0.4 cm, and 3.9 ± 0.6 cm, respectively. The distance between the talar dome and the PITFL exhibited a range of 0.0–0.5 cm. Our findings support preserving a distal fibular remnant of at least 4 cm to avoid injury to the syndesmotic ligament throughout fibula osteocutaneous flap harvesting. The talar dome could serve as a useful radiological landmark for identifying the upper border of PITFL during preoperative evaluation, and thus facilitating precise and safe flap procurement.

Evaluation of Flexor hallucis tendon transfer in chronic insertional Achilles tendinopathy in over 50-year-old population using validated ankle scores

PurposeChronic insertional Achilles tendinopathy is a common pathology in the over 50 years old population. Patients not relieved with conservative treatment had to undergo surgical intervention for the management. This study evaluates the clinical outcome of FHL transfer in such patients using validated ankle functional scores. MethodIt is a retrospective study including 20 patients of either gender managed with debridement of the distal degenerative remnant Achilles tendon fibers either at the insertion site or the distal end of the torn tendon, resection of Haglund deformity with FHL transfer, and reattachment of Achilles tendon. The average age of the patients was 56.55 + 11 years (50–77 years) followed by over 35.6 months (Range 22–48months). The preoperative FAAM, FADI, SF 36, VAS, and AOFAS scores were calculated and followed every 6 months. The plantarflexion and dorsiflexion of the ankle were also recorded preoperatively and at follow-up visits. ResultsAll the patients were operated on by a single surgeon (MS) with the same surgical technique, implant, and rehabilitation protocol. All the patients were followed for an average of 35.6 months (Range 22–48 months). All the ankle scores, FAAM, FADI, SF36, VAS, and AOFAS improved in follow-ups. The mean plantarflexion and dorsiflexion were 39.300+ 4.90 and 12.50+ 4.70 respectively. Three patients had minor wound complications. All the patients returned to activities of daily living. ConclusionFHL transfer in elderly patients with insertional Achilles tendinopathy improves the validated ankle functional scores and decreases pain significantly. Furthermore, randomized studies with a larger study population and longer follow-ups may ascertain the beneficial effects.

Age and Bone Bruise Patterns Predict Tear Location in the Anterior Cruciate Ligament

To assess the influence of demographic risk factors, anatomic risk factors, and injury mechanisms on anterior cruciate ligament (ACL) tear patterns. All patients undergoing knee magnetic resonance imaging at our institution for acute ACL tears (within 1 month of injury) in 2019 were retrospectively analyzed. Patients with partial ACL tears and full-thickness posterior cruciate ligament injuries were excluded. On sagittal magnetic resonance images, the proximal and distal remnant lengths were measured, and the tear location was calculated as the distal remnant length divided by the total remnant length. Previously reported demographic and anatomic risk factors associated with ACL injury were then reviewed, including the notch width index, notch angle, intercondylar notch stenosis, alpha angle, posterior tibial slope, meniscal slope, and lateral femoral condyle index. In addition, the presence and severity of bone bruises were recorded. Finally, risk factors associated with ACL tear location were further analyzed using multivariate logistic regression. A total of 254 patients (44% male patients; mean age, 34 years; age range, 9-74 years) were included, of whom 60 (24%) had a proximal ACL tear (tear at the proximal quarter). Multivariate enter logistic regression analysis showed that older age (P= .008) was predictive of a more proximal tear location whereas open physes (P= .025), bone bruises in both compartments (P= .005), and posterolateral corner injury (P= .017) decreased the likelihood of a proximal tear (R 2= 0.121, P < .001). No anatomic risk factors were identified to play a role in tear location. Although most patients have midsubstance tears, proximal ACL tears were more commonly found in older patients. Bone contusions involving the medial compartment are associated with midsubstance tears; these findings may indicate that different injury mechanisms play a role in the location at which the ACL tears. Level III, prognostic, retrospective cohort study.

S377 Laparoscopic Assisted ERCP for Choledocolithiasis After Gastric Bypass

Introduction: Choledocolithiasis can occur after gastric bypass. Access to the biliary is endoscopically complicated given the altered anatomy. Laparoscopic access to the distal gastric remnant can be utilized for endoscopic access to the ampulla and biliary tree for endoscopic sphincterotomy and clearance of the biliary tree without disruption of the gastric bypass. Case Description/Methods: This video demonstrates the procedure of a laparoscopic assisted ERCP following gastric bypass for morbid obesity. The patient presented with increased bilirubin and a dilated biliary tree. MRCP revealed gallstones and common bile duct stones with biliary obstruction. Laparoscopic access to the distal stomach is obtained. A cholecystectomy is performed and the distal stomach is cannulated with a 15 mm. laparoscopic trochar. An ERCP endoscope is passed through the abdominal wall, through the trochar into the distal stomach. The ampulla is identified and cannulated. A sphincterotomy was performed and the biliary tree is cleared of stones. The endoscope is withdrawn and the gastric cannulation site is surgically closed. Discussion: Laparoscopic assisted ERCP following gastric bypass for morbid obesity is a safe and effective approach for choledocolithiasis. This approach does not sacrifice or disrupt the gastric bypass. This approach is needed. Watch the video at https://tinyurl.com/ACGAbstractS377

Nonvascularized fibular harvest in children: impact on donor limbs.

Nonvascularized fibular graft is commonly used in children. We investigated periosteal intactness, proportion of harvested fibula and the distal remnant for their association to regeneration and development of ankle valgus in 25 donor limbs (n = 18 patients). The fibulae were harvested from healthy legs with all possible care to preserve periosteum. Intraoperatively, periosteal breach and length of graft obtained were recorded. Follow-up radiographs at 6 months documented lateral distal tibial angle, fibular station, and longitudinal continuous regeneration of fibula in the donor limb. Limbs with and without regeneration/ankle valgus were matched for proportion of harvested length and distal remnant, respectively. Odds ratios for periosteum breach versus nonregeneration and nonregeneration versus ankle valgus were additionally calculated. The average harvest length and distal remnant were 15.1 and 4.5 cm, respectively. The periosteum intactness was maintained in 18 (72%) limbs. At 6 months follow-up, regeneration of fibula was present in 15 (60%) limbs. The postharvest-acquired ankle valgus was present in five limbs (24%). There was almost 2.5 times increased likelihood of nonregeneration, if periosteum was breached. The odds ratio for nonregeneration versus regeneration to the development of ankle valgus stood at 12 ( P = 0.0483). Periosteal breach increased the odds of nonregeneration of harvested fibula. The length of harvested segment did not appear to have significant influence on regeneration nor did distal segment on ankle valgus. The nonregeneration of fibula, however, made the limb prone to ankle valgus.

Beware of the distal last remnant: how we should deal with the remaining dissected aorta after open thoracoabdominal aortic aneurysm repair in case of post-dissection aneurysm.

Beware of the distal last remnant: how we should deal with the remaining dissected aorta after open thoracoabdominal aortic aneurysm repair in case of post-dissection aneurysm.

SYMPTOMATIC MECKELS DIVERTICULUM IN THE NEWBORN: REVIEW OF THE LITERATURE

Meckels diverticulum accounts for 2 to 3% of gastrointestinal tract malformations in children. It is a distal remnant of the incompletely obliterated omphalo mesenteric duct that occurs at 4 weeks gestation, and is located approximately 40 to 60 cm from the last ileal loop. In the majority of cases, its presentation is asymptomatic and discovery is incidental. The symptomatic form represents 4% and is rare in children, including bleeding, occlusion, inflammation and intermittent umbilical oozing. The symptomatic form is exceptional in newborns. This work is a descriptive study of the literature regarding reported cases of newborns diagnosed with symptomatic Meckels diverticulum either as a picture of intestinal obstruction or by spontaneous perforation of the DM The objective of our study is to describe the cases of newborns operated in emergency for symptomatic Meckels diverticulum and to evaluate the surgical management.

Resection of a recurrent solid pseudopapillary neoplasm of the pancreas after duodenal sparing pancreaticoduodenectomy: A case report.

IntroductionSolid Pseudopapillary Neoplasm (SPN) is a rare pancreatic neoplasm with low malignant potential and a relative indolent course. Complete resection of the SPN is curative for most cases and has a high survival rate. Recurrences, though rare, can still occur despite adequate resection. Pancreaticoduodenectomy is commonly performed to treat pancreatic head SPNs. In recent years, duodenum-preserving pancreatic head resection (DPPHR) has been reported as a less radical and acceptable alternative.Case presentationWe are reporting a case of 26-year old female who presented with a 7 month history of epigastric pain and increasing abdominal girth. She was diagnosed by MRI to have a huge but resectable pancreatic head mass and subsequently underwent duodenum-preserving pancreatic head resection (DPPHR) with pancreaticojejunostomy. Histopathologic examination revealed a solid pseudopapillary tumor (SPN) with lymphovascular invasion and negative margins of resection. The patient underwent hepaticojejunostomy 5 months after resection for biliary stricture. Surveillance imaging revealed tumor recurrence warranting re-exploration for recurrence 3 years after the initial surgery. Intraoperative findings revealed the mass at the distal pancreatic remnant, requiring distal pancreatectomy and splenectomy.DiscussionSolid pseudopapillary neoplasms are rare pancreatic neoplasms. Surgical resection of SPNs affords long term cure with good 5-year survival rates for localized tumors Despite the low malignant potential of SPNs, relapse after resection can still occur.ConclusionComplete local resection of the tumor is the treatment of choice in SPNs. DPPHR should be considered as an alternative in young patients with a localized SPN in the pancreatic head.

Recurrent Paravaginal Abscess: An Unusual Presentation of a Distal Ectopic Ureteral Remnant after Prior Nephrectomy

Study Objective Describe a patient with OHVIRA syndrome and demonstrate the surgical technique used to treat her paravaginal abscess and remnant ectopic ureter. Design Video case-presentation. Setting Academic hospital. Patients or Participants Single patient. Interventions Surgery. Measurements and Main Results We describe a patient who initially presented at the onset of menarche with cyclic abdominopelvic pain. She was diagnosed with uterine didelphys with obstructed right hemivagina. She underwent a vaginoplasty, which was followed by postoperative urinary incontinence. Further work-up indicated a dysplastic right kidney with ectopic ureter to the right vaginal sidewall, correlating with diagnosis of OHVIRA syndrome. She then represented at 21 years old with chronic vaginal drainage. She underwent an extensive evaluation including imaging as well diagnostic procedures, including: cystovaginoscopy, hysteroscopy and laparoscopy. She was tested for sexually transmitted diseases, put on multiple courses of antibiotics, and had two drains placed with recurrence of drainage. When she finally presented to our facility, there was concern for abscess secondary to remnant distal ectopic ureter into the vagina. She underwent an office examination and vaginoscopy, confirming drainage from a right vaginal ostium. She was counseled and ultimately underwent a robotic assisted laparoscopic excision of paravaginal abscess and remnant of distal right ectopic ureter. She did well postoperatively. Interval CT scan on post-operative day 15 demonstrated fluid collection, which was drained by interventional radiology. The fluid collection resolved, drain removed and she has had no further recurrence of drainage. Conclusion This is an unusual presentation of a recurrent paravaginal abscess in the setting of prior partial right ectopic ureterectomy. We describe the innovative and successful surgical technique used to identify and excise the paravaginal abscess and distal ectopic ureter. Highlighting this patient's unique anatomy and the importance of complete resection of an ectopic ureter to the vagina at the time of nephrectomy due to potential risk of ascending chronic infection and abscess formation. Describe a patient with OHVIRA syndrome and demonstrate the surgical technique used to treat her paravaginal abscess and remnant ectopic ureter. Video case-presentation. Academic hospital. Single patient. Surgery. We describe a patient who initially presented at the onset of menarche with cyclic abdominopelvic pain. She was diagnosed with uterine didelphys with obstructed right hemivagina. She underwent a vaginoplasty, which was followed by postoperative urinary incontinence. Further work-up indicated a dysplastic right kidney with ectopic ureter to the right vaginal sidewall, correlating with diagnosis of OHVIRA syndrome. She then represented at 21 years old with chronic vaginal drainage. She underwent an extensive evaluation including imaging as well diagnostic procedures, including: cystovaginoscopy, hysteroscopy and laparoscopy. She was tested for sexually transmitted diseases, put on multiple courses of antibiotics, and had two drains placed with recurrence of drainage. When she finally presented to our facility, there was concern for abscess secondary to remnant distal ectopic ureter into the vagina. She underwent an office examination and vaginoscopy, confirming drainage from a right vaginal ostium. She was counseled and ultimately underwent a robotic assisted laparoscopic excision of paravaginal abscess and remnant of distal right ectopic ureter. She did well postoperatively. Interval CT scan on post-operative day 15 demonstrated fluid collection, which was drained by interventional radiology. The fluid collection resolved, drain removed and she has had no further recurrence of drainage. This is an unusual presentation of a recurrent paravaginal abscess in the setting of prior partial right ectopic ureterectomy. We describe the innovative and successful surgical technique used to identify and excise the paravaginal abscess and distal ectopic ureter. Highlighting this patient's unique anatomy and the importance of complete resection of an ectopic ureter to the vagina at the time of nephrectomy due to potential risk of ascending chronic infection and abscess formation.

Detail correction for Gross classification of esophageal atresia based on 434 cases in China.

Detail correction for Gross classification of esophageal atresia based on 434 cases in China.

Trachyandesite of Kennedy Table, its vent complex, and post–9.3 Ma uplift of the central Sierra Nevada

Abstract Tectonic interpretation of the central Sierra Nevada—whether the crest of the Sierra Nevada (California, USA) was uplifted in the late Cenozoic or whether the range has undergone continuous down-wearing since the Late Cretaceous—is controversial, since there is no obvious tectonic explanation for renewed uplift. The strongest direct evidence for late Cenozoic uplift of the central Sierra Nevada comes from study of the Trachyandesite of Kennedy Table, which followed the course of the Miocene San Joaquin River but has a steeper gradient than the modern river. Early workers attributed this steeper gradient to tilting of the Sierra Nevada block since the late Miocene, resulting in 2 km of range-crest uplift. However, this interpretation has been contested on grounds that the Miocene river gradient had to be assumed and that the Sierran Batholith could have warped during tilting, thus failing to uplift the range crest. The objective of this study was to obtain quantitative data that test these criticisms. The Trachyandesite of Kennedy Table is a chain of 33 remnants of a single lava flow as thick as 65 m, preserved for 21 km from Squaw Leap to Little Dry Creek, close to the modern San Joaquin River in the foothills of the Sierra Nevada. Several remnants lie on fluvial gravel of the late Miocene San Joaquin River. Early workers speculated that the lava concealed its own (unrecognized) vent, but in 2011, we identified the vent on the Middle Fork of the San Joaquin River, 13.5 km south of Deadman Pass and 70 km northeast of Kennedy Table. The vent complex intrudes Cretaceous granite, has 285 m relief, and is an intricately jointed intrusion that grades up into a glassy lava flow. Composition (58% SiO2) and 40Ar/39Ar age (9.3 Ma) are identical at the vent and downstream. Basal elevations of remnants were recorded, and the present-day basal gradients of several were adjusted for apparent dip and projected along a vertical plane at 220° (the estimated tilt azimuth). The basal gradients are far steeper than that of the modern river, but they differ slightly from reach to reach and are thus inconsistent measures of the post-Miocene tilt. Likewise, relief eroded atop most remnants renders modeling of upper surfaces suspect. At Little Dry Creek, however, a chain of nine remnants rests on fluvial floodplain sand and gravel; this chain trends 230°, and its smooth basal contact now dips 1.36° (adjusted at 220°). Projection of this dip 89 km from the 207 m base of the most distal remnant at Little Dry Creek to the vent intrusion falls far below the 2760 m intrusion-to-lava-flow transition near the Sierran crest, showing that the Sierran block has not undergone pronounced convex warping. Using elevation data on paleoriver meanders preserved by the lava flow, we show that the paleogradient has a cosine dependence on meander-section azimuth, indicating tilting. Subtraction of 1.07° of dip restores the data to an azimuth-independent configuration, indicating total tilting since 9.3 Ma of 1.07° and an original large-scale gradient of 0.46°, similar to the published value of 0.33° at Squaw Leap, but larger than the previously obtained value of 0.057° at Little Dry Creek. Subtraction of those Miocene estimates from the observable 1.643° tilt along the section from Little Dry Creek to the vent yields vent uplift of 2464 m (for 0.057°), 1835 m (for 0.46°), and 2040 m (for 0.33°). Confirmation of earlier assumptions regarding Miocene river gradient and block rigidity greatly strengthens the case for ~2 km of late Cenozoic uplift of the central Sierra Nevada crest.

Distal remnant length can be measured reliably and predicts primary repair of proximal anterior cruciate ligament tears.

To assess the reliability and predictive value of quantifying anterior cruciate ligament (ACL) tear location on magnetic resonance imaging (MRI) and assess the predictive value of tear location on the eligibility for arthroscopic primary repair of proximal ACL tears. In this case-control study, all adult patients undergoing acute ACL surgery between 2008 and 2020 were retrospectively reviewed. All patients were treated with the treatment algorithm of undergoing primary repair when proximal tears with sufficient tissue quality were present intraoperatively, and otherwise underwent single-bundle ACL reconstruction. Sagittal MRI images were reviewed to measure proximal and distal remnant lengths along the anterior aspect of the torn ligament, and tear location was calculated as distal remnant divided by total remnant length. Interobserver and intraobserver reliability for remnant measurements were calculated. Then, receiver operating curve analysis (ROC) was performed to calculate the optimal cut-off for the possibility of primary repair with the different measurements. Two hundred and forty-eight patients were included, of which 151 underwent repair (61%). Inter- and intraobserver reliability ranged between 0.92 and 0.96 [95% confidence interval (CI) 0.55-0.98] and 0.91-0.97 (95% CI 0.78-0.98, respectively). All patients with a tear location of ≥ 80% on MRI could undergo repair, whereas all patients with tear location of < 60% required reconstruction. The positive predictive value of a proximal quarter tear (≥ 75%) on primary repair was 94%. Older age was correlated with more proximal tear location (p < 0.001), but there was no correlation between tear location and gender, BMI, or timing of surgery (all n.s). This study showed that tear location could reliably be quantified on MRI by assessing distal and proximal remnant lengths. Tear location in the proximal quarter of the ACL was found to have a positive predictive value for repairability of 94%. These findings may assist orthopaedic surgeons in evaluating which patients are eligible for primary ACL repair preoperatively. III.

Surgical Treatment of Pancreatic Metastases From Renal Cell Carcinoma

The pancreas is an unusual site for metastases of renal cell carcinoma origin, sometimes occurring many years after nephrectomy. We herein present two cases of pancreatic metastases of renal cell carcinoma which occurred 17 and 19 years after the primary diagnosis.In the first case, metastases were found in the head of the pancreas, upper right arm and the right lobe of the thyroid gland. In the second case, a tumor was found in the tail of the pancreas and a remnant of the right kidney. This was the third recurrence of the original tumor after an initial left nephrectomy and two subsequent partial right nephrectomies in the past. Treatment in the first case consisted of excision of the tumor in the upper right arm, a Whipple operation, and a thyroidectomy. In the second case, a distal pancreatectomy and remnant right nephrectomy were undertaken. Both patients recovered from the operations without complications and remain free of tumor in follow-up periods of 54 and 8 months respectively.Resection of renal cell carcinoma metastases involving the pancreas provides satisfactory long-term survival, and should be undertaken whenever possible.

1821 Post-Fundoplication Esophageal Bezoar Resolved With Endoscopic Instillation and Oral Ingestion of Cola

INTRODUCTION: We present a difficult bezoar-like esophageal food impaction which occurred 6 months after repair of a giant Type IV hiatal hernia. CASE DESCRIPTION/METHODS: The patient is an active 90-year-old female who had a giant Type IV paraoesophageal hernia containing stomach and colon for many years. She underwent repair with mesh and a loose Nissen fundoplication (58 Fr). Pre-operative esophageal manometry was not performed. Post-operative esophagram showed intact wrap, with “3 mm minimum diameter central luminal channel through the fundoplication.” Preserved esophageal motility was also noted. Recovery was uneventful. Six months later, she presented to the ED complaining of sensation of food stuck in her throat. She was tolerating secretions and tiny sips of water. Barium esophagram revealed “dilated distal esophagus, with contrast pooling above retained material at the GE junction”. EGD was performed under general anesthesia. The distal esophagus was completely obstructed with food. Despite use of multiple tools including net, rat-tooth forceps and pronged graspers, it could not be cleared. Using small instillations of cola through a 60 cc syringe, we were able to “tunnel” through the impaction and create a lumen into the stomach. Retroflexion showed a small hiatal hernia. After more than 2 hours, there was still a significant amount of food adherent to the walls of the esophagus. The patient was extubated and admitted to the hospital. She was instructed to drink small sips of cola and ice chips upright in bed. She ingested 2 L of cola over the next 8 hours without difficulty. EGD the next day noted complete passage of food. There was no frank ring or stricture. Fundoplication was intact with a small(2 cm) hiatal hernia. She was discharged the same day on soft diet. At follow up with thoracic surgery she had no further dysphagia episodes. She was instructed to drink cola once a day for maintenance. DISCUSSION: Although the patient had a loose wrap and no known dysmotility, post-op diameter of the esophageal lumen was fairly small (3 mm). If patient was not adhering to post-fundoplication diet, this likely precipitated “packing” of food into the distal esophagus and remnant small hernia. Removal of esophageal food impaction is most commonly done by pushing food into the stomach, or removing it mechanically. The use of proteolytic enzymes e.g. papain is not recommended due to perforation risk. One can consider adding cola to the arsenal of tools for safely treating difficult esophageal food impactions.

The influence of tenoscopic approaches on radiocarpal joint perforation during carpal sheath tenoscopy in horses.

To report the frequency of radiocarpal joint (RCJ) perforation during two proximolateral carpal sheath (CS) approaches and to investigate whether the presence or absence of a natural communication between the RCJ and CS. Experimental, randomized, controlled study. Twelve adult horses and 12 cadaver front limbs. Proximolateral CS tenoscopy was performed on both carpi of 12 horses under general anaesthesia. Limbs were randomly assigned into two groups. In group 1, the instrument portal was centered at the level of the distal radial physeal remnant (PR). In group 2, the instrument portal was centered 2 cm proximal to the PR. Immediately after tenoscopy, dye-coloured fluid was instilled arthroscopically into the dorsolateral RCJ, and the open tenoscopic portals were evaluated for leakage. Twelve cadaver front limbs were examined for naturally occuring RCJ and CS communication by using positive-contrast computed tomography (CT). Frequency of perforations were compared with McNemar's test for two matched proportions. In group 1, 10 of 12 RCJ were perforated during tenoscopy, and, in group 2, four of 12 RCJ were perforated (P = 0.03). No diffusion of contrast from the RCJ to the CS was detected by CT. Perforation of the RCJ was common when CS instrument portals were placed at the level of the PR. No natural communication was detected between the RCJ and CS. Carpal sheath tenoscopic instrument portals may need to be placed >2 cm proximal to the PR to prevent inadvertent RCJ perforation, especially in horses undergoing tenoscopic treatment of a septic CS.

Robotic Central Pancreatectomy for Well-Differentiated Neuroendocrine Tumor: Parenchymal-Sparing Procedure.

The frequency of pancreatic neuroendocrine tumors (pNETs), representative of benign and borderline malignant pancreatic tumors, has been increasing. For pNETs, pancreas-preserving pancreatectomy can be an appropriate option. Conversely, some articles have recently shown that robotic central pancreatectomy (RCP) is feasible and safe. We demonstrated our standardized technique of RCP. In our technique, pancreaticoenteric reconstruction is performed via a pancreaticogastrostomy to manage the distal pancreatic remnant. We also evaluated our initial experience with four consecutive RCPs for well-differentiated pNETs, retrospectively. In our evaluation, two men and two women had a median age of 45years (range 36-64). Median tumor size was 2.1cm (range 1-5), and median operative time was 315min (range 268-630). No transfusion was given perioperatively. Median hospital stay was 17days (range 13-22). Grade A postoperative pancreatic fistula was identified in two patients, while grade B was identified in the other two patients. One of the patients was managed using an additional percutaneous drainage. No operative mortality was observed. Pathological findings confirmed R0 resection for all well-differentiated pNETs (pT1: two patients; pT2: two patients). Central pancreatectomy can be carefully selected as a relevant surgical option for well-differentiated pNETs circumscribed in the pancreatic isthmus and body. Our robotic procedure might overcome the complexity of central pancreatectomy, a parenchymal-preserving procedure, with adequate oncological outcomes.

Mini thief zones: Subcentimeter sedimentary features enhance fracture connectivity in shales

This study examines the influences on fluid flow within a shale outcrop where the networks of two distinct paleoflow episodes have been recorded by calcite-filled veins and green alteration halos. Such direct visualization of flow networks is relatively rare and provides valuable information of fluid-flow behavior between core and seismic scale. Detailed field mapping, fracture data, and sedimentary logging were used over a 270 m2 (2910 ft2) area to characterize the paleo–fluid-flow networks in the shale. Distal remnants of turbidite flow deposits are present within the shale as very thin (1–10 mm [0.04–0.4 in.]) fine-grained sandstone bands. The shale is cut by a series of conjugate faults and an associated fracture network, all at a scale smaller than seismic detection thresholds. The flow episodes used fluid-flow networks consisting of subgroups of both the fractures and the thin turbidites. The first fluid-flow episode network was mainly comprised of thin turbidites and shear fractures, whereas the network of the second fluid-flow episode was primarily small joints (opening mode fractures) connecting the turbidites. The distribution of turbidite thicknesses follows a negative exponential trend. which reflects the distribution of thicker turbidites recorded in previous studies. Fracture density varies on either side of faults and is highest in an area between closely spaced faults. Better predictions of hydraulic properties of sedimentary-structural networks for resource evaluation can be informed from such outcrop subseismic scale characterization. These relationships between the subseismic features could be applied when populating discrete fracture networks models, for example, to investigate such sedimentary-structural flow networks in exploration settings.

The Dilemma of the Dilated Main Pancreatic Duct in the Distal Pancreatic Remnant After Proximal Pancreatectomy for IPMN

Objective(s)A dilated main pancreatic duct in the distal remnant after proximal pancreatectomy for intraductal papillary mucinous neoplasms (IPMN) poses a diagnostic dilemma. We sought to determine parameters predictive of remnant main-duct IPMN and malignancy during surveillance. MethodsThree hundred seventeen patients underwent proximal pancreatectomy for IPMN (Indiana University, 1991–2016). Main-duct dilation included those ≥ 5 mm or “dilated” on radiographic reports. Statistics compared groups using Student’s T/Mann-Whitney U tests for continuous variables or chi-square/Fisher’s exact test for categorical variables with P < 0.05 considered significant. ResultsHigh-grade/invasive IPMN or adenocarcinoma at proximal pancreatectomy predicted malignant outcomes (100.0% malignant outcomes; P < 0.001) in remnant surveillance. Low/moderate-grade lesions revealed benign outcomes at last surveillance regardless of duct diameter. Twenty of 21 patients undergoing distal remnant reoperation had a dilated main duct. Seven had main-duct IPMN on remnant pathology; these patients had greater mean maximum main-duct diameter prior to reoperation (9.5 vs 6.2 mm, P = 0.072), but this did not reach statistical significance. Several features showed high sensitivity/specificity for remnant main-duct IPMN. ConclusionsRemnant main-duct dilation after proximal pancreatectomy for IPMN remains a diagnostic dilemma. Several parameters show a promise in accurately diagnosing main-duct IPMN in the remnant.