Excessive Resection Research Articles

The effect of large channel-based foraminoplasty on lumbar biomechanics in percutaneous endoscopic discectomy: a finite element analysis

BackgroundThis study aimed to evaluate the effect of foraminoplasty using large-channel endoscopy during TESSYS on the biomechanics of the lumbar spine.MethodsA complete lumbar spine model, M1, was built using 3D finite elements, and models M2 and M3 were constructed to simulate the intraoperative removal of the superior articular process of L5 using a trephine saw with diameters of 5 mm and 8.5 mm, respectively, and applying normal physiological loads on the different models to simulate six working conditions—anterior flexion, posterior extension, left-right lateral bending, and left-right rotation—to investigate the displacement and facet joint stress change of the surgical segment, and the disc stress change of the surgical and adjacent segments.ResultsCompared with the M1 model, the M2 and M3 models showed decreased stress at the L4-5 left FJ and a significant increase in stress at the right FJ in forward flexion. In the M2 and M3 models, the L4-5 FJ stresses were significantly greater in left lateral bending or left rotation than in right lateral bending or right rotation. The right FJ stress in M3 was greater during left rotation than that in M2, and that in M2 was greater than that in M1. The L4-5disc stress in the M3 model was greater during posterior extension than that in the M1 and M2 models. The L4-5disc stress in the M3 model was greater in the right rotation than in the M2 model, and that in the M2 model was greater than that in the M1 model.ConclusionForaminoplasty using large-channel endoscopy could increase the stress on the FJ and disc of the surgical segment, which suggested unnecessary and excessive resection should be avoided in PTED to minimize biomechanical disruption.

Intraoperative fluorescence redefining neurosurgical precision.

Surgical resection is essential for treating solid tumors, with success largely dependent on the complete excision of neoplastic cells. However, neurosurgical procedures must delicately balance tumor removal with the preservation of surrounding tissue. Achieving clear margins is particularly challenging in cases like glioblastoma due to the limitations of traditional white light visualization. These limitations often result in incomplete resections, leading to frequent recurrences, or excessive resection that harms vital neural structures, causing iatrogenic nerve damage which can lead to sensory and functional deficits. Current statistics reveal a 90% recurrence rate for malignant gliomas. Similarly, an 8% incidence of iatrogenic nerve trauma contributes to an estimated 25 million cases of peripheral nerve injury globally each year. These figures underscore the urgent need for improved intraoperative techniques for lesion margin and nerve identification and visualization. Recent advances in neurosurgical imaging, such as fluorescence-guided surgery (FGS), have begun to address these challenges. Fluorescent agents used in FGS illuminate target tissues, although not all do so selectively. Despite the promising results of agents such as 5-aminolevulinic acid and indocyanine green, their applications are mainly limited by issues of sensitivity and specificity. Furthermore, these agents do not effectively address the need for precise nerve visualization. Nerve Peptide 41, a novel systemically administered fluorescent nerve-targeted probe, shows promise in filling this gap. This review assesses the major fluorescent imaging modalities in neurosurgery, highlighting each of their benefits, limitations, and potential.

The Effectiveness of Radiofrequency Thermal Ablation in the Treatment of Patients with Osteoid Osteomas of the Spine

Osteoid osteoma is a rare benign osteogenic bone tumor without malignant potential causing severe night pain relieved by nonsteroidal anti-inflammatory drugs. Pain associated with osteoid osteoma of the spine cannot be treated conservatively and requires surgical approach. Types of surgical treatment include intralesional curettage, marginal resection, or en bloc tumor resection. However, absence of clear intraoperative visualization of the lesion often leads to excessive resection of vertebral structures requiring additional bone reconstruction and fixation with metal structures. In some cases, due to incorrect choice of resection area and segment level, repeat surgeries are performed causing secondary spinal deformations, worsening patient’s condition, and increasing economic expenditures. Currently, minimally invasive methods of transcutaneous treatment of osteoid osteomas such as interstitial laser ablation, cryotherapy, and radiofrequency thermal ablation are becoming more prominent.Aim. To evaluate the effectiveness of radiofrequency thermal ablation treatment in patients with osteoid osteoma.Materials and methods. The prospective study included 12 patients with osteoid osteoma of the spine. Their quality of life was evaluated using the Short Form-36 (SF-36) questionnaire prior to radiofrequency thermal ablation and 30, 90 and 180 days after. At the first visit and during observation, pain syndrome intensity was measured using the Visual Analog Scale (VAS) and R.G. Watkins scale for objective evaluation of pain syndrome per number of analgesics administrations.Results. Follow-up duration varied between 12 and 36 months. In all clinical cases, general, physical, and psychological health improved 2–3-fold. Pain intensity at day 1 after radiofrequency thermal ablation compared to mean pain intensity during the day prior to the procedure was significantly lower (р = 0.05). At the final examination, none of the patients had pain (pain syndrome intensity 0 per VAS); all patients had subjective satisfaction level of 100 %. Analgesics (nonsteroidal anti-inflammatory drugs and paracetamol) were administered on request for 8 ± 2.34 days after the procedure.Conclusion. Based on literature data and our own experience of diagnosis and surgical treatment of osteoid osteoma of the spine, we conclude that in cases of small lesions (<2 cm) in hard to access locations, computed tomography-controlled radiofrequency thermal ablation allows to perform surgical intervention safely, effectively and with minimal number of complications.

Development and evaluation of RFID-integrated endoscopic clips for laparoscopic surgery marking.

As advancements in surgical instruments and techniques continue to evolve, minimally invasive surgery has become increasingly preferred as a means of reducing patient pain and recovery time. However, one major challenge in performing minimally invasive surgery for early gastrointestinal cancer is accurately identifying the location of the lesion. This is particularly difficult when the lesion is confined to the lumen of the intestine and cannot be visually confirmed from the outside during surgery. In such cases, surgeons must rely on CT or endoscopic imaging to locate the lesion. However, if the lesion is difficult to identify with these images or if the surgeon has less experience, it can be challenging to determine its precise location. This can result in an excessive resection margin, deviating from the goal of minimally invasive surgery. To address this challenge, researchers have been studying the development of a marker for identifying the lesion using a radio-frequency identification (RFID) system. One proposed method for clinical application of this detection system is to attach an RFID tag to an endoscopic hemostatic clip and fix it to the intended position, providing a stable marker for the inner wall of the organ. This approach has the potential to improve the accuracy and effectiveness of minimally invasive surgery for early gastrointestinal cancer. In the development of a marker for identifying gastrointestinal lesions using a radio-frequency identification (RFID) system, the shape of the clip and suitable materials for attaching the RFID tag were determined through finite element method (FEM) analysis. A prototype of the clip was then fabricated and ex-vivo experiments were conducted using porcine intestine to evaluate the stability of the clip in relation to its position. To further evaluate the performance of the RFID-integrated clip in vivo, the clip was placed in the gastric wall of the stomach of anesthetized porcine using an endoscopic instrument. The clip was then detected using a RFID detector designed for laparoscopic approach. And later, the accuracy of detection was confirmed by incising the lesion. The design and fabrication of a clip with varying thicknesses using STS316 and STS304 stainless steel were accomplished using the results of finite element method analysis. The stability of the clip was evaluated through ex-vivo experiments, showing it to be a viable option. In-vivo experiments were performed on anesthetized porcine, in which the RFID-integrated clip was placed in the gastric wall and detected using a custom-made RFID detector. The resection margin, measured at about 30 mm from the detector position, was accomplished with low error. These findings indicate the feasibility and efficacy of using an RFID-integrated clip as a marker in minimally invasive surgery for the identification of gastrointestinal lesions. The study evaluated the feasibility of using stainless steel clips for lesion detection in endoscopic surgery using computer-aided engineering analysis and ex-vivo experimentation. Results showed that STS304 was suitable for use while STS316L was not. The ex-vivo experiments revealed that the clip holding force and tissue retention length varied depending on the location of attachment. In-vivo experiments confirmed the accuracy and usefulness of the RFID lesion detection system. However, challenges remain for its use in clinical field, such as ensuring the stability of the clip and the safe attachment of the RFID tag, which requires further research for commercialization.

Intelligent electromagnetic navigation system for robot-assisted intraoral osteotomy in mandibular tumor resection: a model experiment.

Mandibular tumor surgery necessitates precise osteotomies based on tumor boundaries; however, conventional osteotomies often lack accuracy in predicting osteotomy positions and planes, potentially leading to excessive resection of normal bone tissues or residual tumors, thus compromising postoperative quality of life and clinical outcomes. Robotic-assisted surgery (RAS) augmented with artificial intelligence (AI) offers precise localization capabilities, aiding surgeons in achieving accurate osteotomy positioning. This study aimed to evaluate the feasibility and accuracy of a robotic magnetic navigation system for positioning and osteotomy in an intraoral surgical trial of a mandibular tumor model. Patient computed tomography (CT) imaging data of mandibular chin and body tumors were utilized to create 3D printed models, serving as study subjects for mandibular tumor resection. Ten pairs of models were printed for the experimental and control groups. The experimental group (EG) underwent osteotomy using a robot-assisted surgical navigation system, performing osteotomy under robotic navigation following alignment based on preoperative design. The control group (CG) underwent traditional surgery, estimating osteotomy position empirically according to preoperative design. Postoperative CT scans were conducted on both models, and actual postoperative results were compared to preoperative design. Osteotomy accuracy was evaluated by positional and angular errors between preoperatively designed and actual osteotomy planes. For ten randomly selected spots on the left and right sides, respectively, the EG group had mean distance errors of 0.338mm and 0.941mm. These values were obtained from the EG group. In the EG group, on the left side, the mean angular errors were 14.741 degrees, while on the right side, they were 13.021 degrees. For the 10 randomly selected spots on the left and right sides, respectively, the CG had mean distance errors of 1.776mm and 2.320mm. This is in contrast to the results obtained by the EG. It was determined that the left side had a mean angle error of 16.841 degrees, while the right side had an error of 18.416 degrees in the CG group. The above results indicated significantly lower point errors of bilateral osteotomy planes in the experimental group compared to the control group. This study demonstrates the feasibility of electromagnetic navigation robot-assisted intraoral osteotomy for mandibular tumors and suggests that this approach can enhance the precision of clinical surgery.

Frenulum Protection Technique in Disposable Circumcision Suture Device for Adult Males.

To evaluate the efficacy of frenulum protection technique of the disposable circumcision suture device (DCSD) in adult males. Atotal of 53 adult males were diagnosed with redundant prepuce and underwent circumcision with DCSD using frenulum protection technique. The main preoperative and postoperative measure of the length of penile frenulum was evaluated. Other data such as edema rate, intraoperative blood loss, operation time, postoperative pain, staple falling off time, incision infection rate, and evaluation of satisfaction rate with penis appearance were documented in the study. There was no significant difference in preoperative and postoperative frenulum length for each patient. The mean length of the penile frenulum before and after surgery was 2.25 ± 0.36 cm and 2.23 ± 0.39 cm, respectively (p = .31). The rate of frenulum length preservation was 100%. All the patients had no excessive resection of the frenulum and no serious complication happened after surgery. The satisfaction rate of postoperative penis appearance from patients' evaluation was 98.1% (52/53). The frenulum protection technique was simple and operable, which could help the operator to accurately identify the most distal position of the frenulum and retain a sufficient length of frenulum during DCSD circumcision.

Development ofa simulation system forfemoroacetabular impingement detection based on3D images.

Image-based criteria have been adopted to diagnose femoroacetabular impingement (FAI). However, the overlapping property of the two-dimensional X-ray outlines and static and supine posture of taking computed tomography (CT) and magnetic resonance imaging images potentially affect the accuracy of the criteria. This study developed a CT image-based dynamic criterion to effectively simulate FAI, thereby providing a basis for physicians to perform pre-operative planning for arthroscopic surgery. Post-operative CT images of 20 patients with satisfactory surgical results were collected, and 10 sets of models were used to define the flexion rotation centre (FRC) of the three-dimensional FAI model. First, let these 10 groups of models simulate the FAI detection action and find the best centre offset, and then FRC is the result of averaging these 10 groups of best displacements. The model was validated in 10 additional patients. Finally, through the adjustment basis of FRC, the remaining 10 sets of models can find out the potential position of FAI during the dynamic simulation process. Rotational collisions detected using FRC indicate that the patient's post-operative flexion angle may reach 120° or greater, which is close to the actual result. The recommended surgical range of the diagnostic system (average length of 6.4 mm, width of 4.1 mm and depth of 3.2 mm) is smaller than the actual surgical results, which prevents the doctor from performing excessive resection operations, which may preserve more bones. The FRC diagnostic system detects the distribution of FAI in a simple manner. It can be used as a pre-operative diagnosis reference for clinicians, hoping to improve the effect and accuracy of debridement surgery.

Artificial intelligence-based diagnosis of the depth of laryngopharyngeal cancer

ObjectiveTransoral surgery (TOS) is a widely used treatment for laryngopharyngeal cancer. There are some difficult cases of setting the extent of resection in TOS, particularly in setting the vertical margins. However, positive vertical margins require additional treatment. Further, excessive resection should be avoided as it increases the risk of bleeding as a postoperative complication and may lead to decreased quality of life, such as dysphagia. Considering these issues, determining the extent of resection in TOS is an important consideration. In this study, we investigated the possibility of accurately diagnosing the depth of laryngopharyngeal cancer using radiomics, an image analysis method based on artificial intelligence (AI). MethodsWe included esophagogastroduodenoscopic images of 95 lesions that were pathologically diagnosed as squamous cell carcinoma (SCC) and treated with transoral surgery at our institution between August 2009 and April 2020. Of the 95 lesions, 54 were SCC in situ, and 41 were SCC. Radiomics analysis was performed on 95 upper gastrointestinal endoscopic NBI images of these lesions to evaluate their diagnostic performance for the presence of subepithelial invasion. The lesions in the endoscopic images were manually delineated, and the accuracy, sensitivity, specificity, and area under the curve (AUC) were evaluated from the features obtained using least absolute shrinkage and selection operator analysis. In addition, the results were compared with the depth predictions made by skilled endoscopists. ResultsIn the Radiomics study, the average cross-validation was 0.833. The mean AUC for cross-validation calculated from the receiver operating characteristic curve was 0.868. These results were equivalent to those of the diagnosis made by a skilled endoscopist. ConclusionThe diagnosis of laryngopharyngeal cancer depth using radiomics analysis has potential clinical applications. We plan to use it in actual surgery in the future and prospectively study whether it can be used for diagnosis.

Visible trephine-based foraminoplasty in PTED leads to asymmetrical stress changes and instability in the surgical and adjacent segments: a finite element analysis

This study aimed to construct a multi-segment lumbar finite element model (FEM) of PTED surgery to analyze the changes in stress and ROM after visible trephine-based foraminoplasty. The CT scans of a 35-year-old healthy male were used to develop a multi-segment lumbar FEM with Mimic, Geomagic Studio, Hypermesh and MSC.Patran. Different foraminoplasty was performed on the model, and these were grouped into normal group (A), the ventral resection group (B), the apex resection group (C), the ventral + apex + isthmus resection group (D), and the SAP + isthmus + lateral recess resection group (E). A vertical load of 500N and a torque of 10N·M were applied to the upper surface of the L3 vertebral body to simulate the biomechanical characteristics under the motion of flexion, extension, lateral bending, and rotation. The von Mises stress maps of the intervertebral f, vertebral body, facet joints, and the ROM of the L3-S1 intervertebral disk were calculated and analyzed. The changes of peak stress on the vertebral body for each group were not significant in the same motion state. Significant stress differences were observed in the L4/5 intervertebral disks, while no obvious stress changes were observed for the L3/4 and L5/S1 intervertebral disks. The stress of the L3/4 and L5/S1 facet joints decreased after L4/5 foraminoplasty, while the stress of L4/5 facet joints displayed an overall increasing trend. Significant asymmetrical stress changes of bilateral facet joints were observed in all three segments, particularly during bilateral rotation movements. The ROM of L3-S1 gradually increased from Group A to Group E, especially during flexion, left lateral bending, and right rotation, with the highest elevation observed for the L45 ROM. Our FEM indicated that enlarged resection and exposure of the articular surface could lead to significant asymmetrical stress changes in the bilateral facet joints and ROM instability of the surgical and adjacent segments. These findings suggested that unnecessary and excessive resection should be avoided in PTED to reduce the incidence of low back pain and the risk of postsurgical degeneration.

Relationship between the Depth of Acetabuloplasty and Outcomes of Hip Arthroscopy in Patients with Global Pincer Femoroacetabular Impingement: Study with a Minimum Follow‐Up Period of 2 Years

There has been no definite consensus on the ideal depth of acetabuloplasty, especially in cases of global pincer femoroacetabular impingement (FAI). This study aims to determine whether the depth of acetabuloplasty influences postoperative outcomes in cases of global pincer FAI. Data were retrospectively collected from patients with global pincer FAI who underwent hip arthroscopy with a minimum follow-up period of 2 years from May 2014 to December 2018. Patients with global pincer FAI were subdivided into low or high resection depth groups based on whether the intraoperative acetabular rim was resected by more than 3 mm. Radiographic measurements; arthroscopic procedures; preoperative and postoperative PROs were recorded. Achievement of MCID and PASS was compared for the VAS, mHHS, HOS-ADL, and iHOT-12. A paired Student t-test was used to evaluate the significance of preoperative and postoperative PROs and two-tailed unpaired Student t-test was used to compare demographic data and PROs between different groups. MCID and PASS were evaluated using the chi-square test or the Fisher's exact test. A total of 41 hips with global pincer FAI (15 and 26 patients in low or high resection depth groups, respectively) were included in this study. Both groups showed significant postoperative improvements in the scores of all PROs (p < 0.001). Compared to the low resection depth group, the high resection depth group had a lower degree of improvement through hip arthroscopy, which manifested as lower postoperative mHHS scores (94.29 vs. 85.08, p = 0.006), higher VAS scores (0.93 vs. 2.54, p = 0.002), and lower improvements in VAS (-5.00 vs. -3.35, p = 0.028), HOS-ADL (34.99 vs. 23.90, p = 0.017) and iHOT-12 (39.89 vs. 29.27, p = 0.036). Patients in high resection depth group were less likely to achieve the MCID for the VAS score compared to low resection depth group in significant (73.3 vs. 26.9%, p = 0.004). For patients with global pincer, the outcomes in high resection depth group were slightly worse than the the low resection depth group. It is indicated that excessive resection of the acetabular rim during the procedure should be avoided.

Recent Progress in Fluorescent Probes for Real-Time Monitoring of Glioblastoma.

Treating glioblastoma (GBM) by resecting to a large extent can prolong a patient's survival by controlling the tumor cells, but excessive resection may produce postoperative complications by perturbing the brain structures. Therefore, various imaging procedures have been employed to successfully diagnose and resect with utmost caution and to protect vital structural or functional features. Fluorescence tagging is generally used as an intraoperative imaging technique in glioma cells in collaboration with other surgical tools such as MRI and navigation methods. However, the existing fluorescent probes may have several limitations, including poor selectivity, less photostability, false signals, and intraoperative re-administration when used in clinical and preclinical studies for glioma surgery. The involvement of smart fluorogenic materials, specifically fluorescent dyes, and biomarker-amended cell-penetrable fluorescent probes have noteworthy advantages for precise glioma imaging. This review outlines the contemporary advancements of fluorescent probes for imaging glioma cells along with their challenges and visions, with the anticipation to develop next-generation smart glioblastoma detection modalities.

Treatment of rigid post-traumatic thoracolumbar kyphosis by a novel technique of spinal joints release

ObjectiveThe purpose of this study was to evaluate the feasibility of a novel technique named spinal joints release (SJR) and observe its efficacy in treating rigid post-traumatic thoracolumbar kyphosis (RPTK).MethodsRPTK patients who were treated by SJR with facet resection, limited laminotomy, clearance of the intervertebral space, and release of the anterior longitudinal ligament through the intervertebral foramen and disc of injury segment from August 2015 to August 2021 were reviewed. Intervertebral space release, internal fixation segment, operation time, and intraoperative blood loss were recorded. The intraoperative, postoperative, and final follow-up complications were observed. An improvement in the VAS score and ODI index was observed. Spinal cord functional recovery was evaluated by American Spinal Injury Association Impairment Scale (AIS). Improvement of local kyphosis (Cobb angle) was evaluated by radiography.ResultsForty-three patients were successfully treated by the SJR surgical technique. Open-wedge anterior intervertebral disc space was performed in 31 cases, and repeated release and dissection of the anterior longitudinal ligament and callus were performed in 12 cases. There was no lateral annulus fibrosis release in 11 cases, the anterior half release of lateral annulus fibrosis in 27 cases, and complete release in five cases. There were five cases of screw placement failure in one or two side pedicles of the injured vertebrae due to excessive resection of the facets and improper pre-bending of the rod. Sagittal displacement occurred in four cases at the released segment due to the complete release of bilateral lateral annulus fibrosus. Autologous granular bone + Cage was implanted in 32 cases, and autologous granular bone was implanted in 11 cases. There were no serious complications. The average operation time was 224 ± 31 min, and intraoperative blood loss was 450 ± 225 mL. All the patients were followed up with an average of 26 ± 8.5 months. The VAS scores and ODI index improved significantly at the final follow-up. All of the 17 patients with incomplete spinal cord injury achieved more than one grade of neurological recovery at the final follow-up. An 87% correction rate of kyphosis was achieved and maintained, with the Cobb angle decreasing from 27.7° preoperatively to 5.4° at the final follow-up.ConclusionPosterior SJR surgery for patients with RPTK has the advantages of less trauma and less blood loss, and kyphosis correction is satisfactory.

Normalization of lipid oxidation defects arising from hypoxia early posthepatectomy prevents liver failure in mouse.

Surgical liver failure (SLF) develops when a marginal amount of hepatic mass is left after surgery, such as following excessive resection. SLF is the commonest cause of death due to liver surgery; however, its etiology remains obscure. Using mouse models of standard hepatectomy (sHx) (68%, resulting in full regeneration) or extended hepatectomy (eHx) (86%/91%, causing SLF), we explored the causes of early SLF related to portal hyperafflux. Assessing the levels of HIF2A with or without oxygenating agent inositol trispyrophosphate (ITPP) indicated hypoxia early after eHx. Subsequently, lipid oxidation (PPARA/PGC1α) was downregulated and associated with persisting steatosis. Mild oxidation with low-dose ITPP reduced the levels of HIF2A, restored downstream PPARA/PGC1α expression along with lipid oxidation activities (LOAs), and normalized steatosis and other metabolic or regenerative SLF deficiencies. Promotion of LOA with L-carnitine likewise normalized the SLF phenotype, and both ITPP and L-carnitine markedly raised survival in lethal SLF. In patients who underwent hepatectomy, pronounced increases in serum carnitine levels (reflecting LOA) were associated with better recovery. Lipid oxidation thus provides a link between the hyperafflux of O2-poor portal blood, the metabolic/regenerative deficits, and the increased mortality typifying SLF. Stimulation of lipid oxidation-the prime regenerative energy source-particularly through L-carnitine may offer a safe and feasible way to reduce SLF risks in the clinic.

The role of posterior condylar offset ratio on clinical and functional outcome of posterior stabilized total knee arthroplasty: a retrospective cohort study.

Postoperative Range of Motion (ROM) is an important measurement of the success of a Total Knee Arthroplasty (TKA). Much enthusiasm has been recently directed toward the posterior femoral condylar offset (PFCO), with some authors reporting increasing postoperative knee flexion when increasing PFCO. The aim of this study is to retrospectively determine the effect of the PFCO on the clinical and functional outcome of a cohort of patients who underwent a Posterior Stabilized (PS) TKA. Clinical and radiological data of all patients who underwent TKA with PS implant for primary osteoarthritis were retrospectively reviewed. Knee Society Score (KSS), knee ROM, PFCO ratio (PFCOR), and tibial slope (TS) were measured pre and postoperatively. One hundred and twenty-one patients (141 knees) met the inclusion criteria. The mean knee flexion increased from 98 ± 20.2° (range 30-130) to 123 ± 12.1° (range 70-140) and the mean KSS increased from 74.0 ± 3.3 (range 27-130) to 203.9 ± 8.1 (range 26-249). Postoperative PFCOR and TS were 0.492 ± 0.005 (range 0.40-0.57) and 2.36 ± 0.56° (range - 10.9-12.15°), respectively. Neither maximal flexion angle nor KSS showed a significant correlation with postoperative PFCOR (Pearsons'r = - 0.057, p = 0.5 for flexion angle and Pearsons'r = - 0.073, p = 0.5 for KSS) or with postoperative TS (Pearsons'r = 0.042, p = 0.62 for flexion angle and Pearsons'r = 0.002, p = 0.98 for KSS). Posterior femoral condylar offset remains an important parameter and, especially when using anterior femoral referencing TKA, care must be taken to prevent excessive resection of the posterior femoral condyles.

8346 Polypoid Endometriosis: A Distinct Variant

<h3>Study Objective</h3> To examine a case study of polypoid endometriosis and perform a literature review. <h3>Design</h3> Case Report. <h3>Setting</h3> Academic institution <h3>Patients or Participants</h3> 1 Patient. <h3>Interventions</h3> Surgical resection. <h3>Measurements and Main Results</h3> A 34-year-old nulliparous woman with complex adnexal masses and severe left hydronephrosis presented for consultation. Menarche occurred at 12 years-old, followed by regular monthly menses lasting 5 days. The patient reported multiple emergency room visits for severe dysmenorrhea and was taking combined hormonal contraceptives with good effect since adolescence. Of note, she had discontinued her contraceptives as she was trying to conceive. Examination revealed a non-obese female with bilateral lower abdominal tenderness to palpation. Initial labs showed elevations in CA125, HE4, and CA19-9. Imaging demonstrated a complex 7cm right adnexal mass with severe left hydronephrosis secondary to enhancing fibrosis in the left hemipelvis. This was suspicious for deep infiltrating endometriosis. The patient underwent robotic bilateral ovarian cystectomy, excision of endometriosis, right salpingectomy, left ureteral reimplantation with psoas hitch, appendectomy, and cystoscopy. Stage IV endometriosis was noted intraoperatively. Intraoperative frozen pathology was benign. Her recovery was overall uncomplicated. Final pathology was consistent with polypoid endometriosis. Follow up imaging revealed recurrence of bilateral complex adnexal masses. <h3>Conclusion</h3> Polypoid endometriosis is an uncommon, distinct variant of endometriosis with histological features suggestive of an endometrial polyp. Unlike usual-type endometriosis, which commonly affects reproductive-aged women, polypoid endometriosis primarily affects older patients with a mean age of 52.5-years-old. Patients with polypoid endometriosis often present with mass effect or vaginal bleeding. It is characterized by a tendency to mimic neoplastic processes clinically, intra-operatively, and on gross examination. Polypoid endometriosis also demonstrates a high rate of recurrence after surgical excision, as seen in our case study. Given the ability of polypoid endometriosis to mimic malignancy, intraoperative frozen pathology may prevent a more extensive surgery and excessive resection in patients of childbearing age.

Hysteroscopy-guided laparoscopic resection of a cesarean scar defect in 5 steps: the usefulness of nonperfusion hysteroscopy

To demonstrate a 5-step approach to accurately identify the extent of resection of a cesarean scar defect (CSD) and perform excision and repair of the lesion. Technical video introducing laparoscopic scar repair using nonperfusion hysteroscopy for patients with a CSD. Tertiary referral facility for gynecology. A 33-year-old woman who underwent intrauterine insemination for secondary infertility 3 times but did not conceive complained of repeated irregular bleeding caused by a CSD during infertility treatment. This video presents a systematic 5-step approach to laparoscopic repair of a CSD. Step 1: the lesion was coagulated and marked using a hysteroscope. Step 2: the lesion was thinned by cutting it using the hysteroscope. Step 3: after laparoscopic dissection of the bladder from the lower uterine segment and turning off the laparoscope's light source, the thinned lesion could be identified using light from the hysteroscope. Step 4: an incision was made at the lit-up point from the abdominal cavity side using an ultrasonic coagulation incision device to access the uterus. Step 5: once the uterine lumen was reached, reflux from the hysteroscope was stopped. Intraperitoneal insufflation gas then flowed into the uterus through the uterine wall perforation, and the lesion could be observed without the use of a reflux fluid. This technique is called nonperfusion hysteroscopy. By observing the marked lesion using nonperfusion hysteroscopy, it could be resected laparoscopically along the appropriate incision line. Advantage of performing 5 successive surgical steps to completely resect a CSD using laparoscopic repair and resolve the patient's symptoms. Laparoscopic repair using nonperfusion hysteroscopy allowed recognition of the upper and lower edges of the lesion from the abdominal cavity side. The combined use of nonperfusion hysteroscopy allows observation of the uterine lumen without the use of a reflux fluid because pneumoperitoneum gas fills the uterine lumen. Intraoperative monitoring using a hysteroscope and laparoscope allows visualization of the lesion site from both sides while resection is being performed. This 5-step procedure permits precise identification of the lesion area, complete removal of lesions, and prevention of excessive resection that may reduce uterine function and increase perinatal risk.

Impact of intraoperative frozen section pathology on the treatment outcome of unilateral papillary thyroid microcarcinoma and its influencing factors-a retrospective cohort study.

Most patients with papillary thyroid carcinoma have a good prognosis. Excessive resection of thyroid and cervical lymph nodes is an important reason for affecting the quality of life of patients after surgery. Intraoperative rapid frozen pathological examination is an important step in the development of a surgical plan for thyroid cancer (especially micropapillary carcinoma); however, whether it affects the treatment outcome remains unclear. The clinicopathological data of papillary thyroid microcarcinoma (PTMC) patients who underwent surgery in our center from 1 January 2021 to 31 December 2021 were retrospectively analyzed. Patients with unilateral low-risk PTMC who underwent radical surgery were selected as the main research subjects. The negative results of intraoperative frozen section of the central lymph node (CLN) of the affected side were the experimental group, and the positive results were the control group. Subjects with lesions larger than 10 mm and those who did not undergo intraoperative frozen section pathological examination were excluded. After excluding other risk factors for recurrence, we calculated the proportion of patients requiring radioactive iodine (RAI) treatment among those with metastases detected by intraoperative rapid frozen section pathology and its influencing factors. Patient data were analysed using SPSS version 20. Continuous variables were presented as means when symmetrical or as medians and ranges when asymmetrical. Categorical variables were presented as proportions. A P value <0.05 was considered significant. A total of 564 PTMC patients were included, among whom 122 patients (21.6%) underwent total thyroidectomy due to the presence of metastases in the ipsilateral CLNs. Compared with the experimental group, the patients with male, young age and tumor located in the middle and lower pole in the control group had higher lymph node metastasis (P<0.05). The proportion of patients requiring postoperative RAI treatment for unilateral low-risk PTMC is relatively low, and the possibility that an intraoperative frozen pathological finding will change the treatment outcome is low. However, the need for postoperative RAI therapy notably increases when the intraoperative frozen pathological analysis reveals ipsilateral CLN metastases, especially in males, younger patients, and/or patients with lesions located in the middle and lower poles.

Context-dependent pro- and anti-resection roles of ZKSCAN3 in the regulation of fork processing during replication stress

Uncontrolled resection of replication forks under stress can cause genomic instability and influence cancer formation. Extensive fork resection has also been implicated in the chemosensitivity of “BReast CAncer gene” BRCA-deficient cancers. However, how fork resection is controlled in different genetic contexts and how it affects chromosomal stability and cell survival remains incompletely understood. Here, we report a novel function of the transcription repressor ZKSCAN3 in fork protection and chromosomal stability maintenance under replication stress. We show disruption of ZKSCAN3 function causes excessive resection of replication forks by the exonuclease Exo1 and homologous DNA recombination/repair protein Mre11 following fork reversal. Interestingly, in BRCA1-deficient cells, we found ZKSCAN3 actually promotes fork resection upon replication stress. We demonstrate these anti- and pro-resection roles of ZKSCAN3, consisting of a SCAN box, Kruppel-associated box, and zinc finger domain, are mediated by its SCAN box domain and do not require the Kruppel-associated box or zinc finger domains, suggesting that the transcriptional function of ZKSCAN3 is not involved. Furthermore, despite the severe impact on fork structure and chromosomal stability, depletion of ZKSCAN3 did not affect the short-term survival of BRCA1-proficient or BRCA1-deficient cells after treatment with cancer drugs hydroxyurea, PARPi, or cisplatin. Our findings reveal a unique relationship between ZKSCAN3 and BRCA1 in fork protection and add to our understanding of the relationships between replication fork protection, chromosomal instability, and chemosensitivity.

Foraminal Restenosis After Posterior Cervical Foraminotomy for the Treatment of Cervical Radiculopathy.

Retrospective cohort study. To elucidate incidence, risk factor, and clinical effect of bone regrowth after posterior cervical foraminotomy (PCF). Ninety-eight patients who underwent PCF for the treatment of cervical radiculopathy and were followed up for >2 years were retrospectively reviewed. Foraminal dimension, sagittal gap at resected area, facet thickness, lamina length, and cervical range of motion (ROM) were measured. Neck pain visual analogue scale (VAS), arm pain VAS, and neck disability index (NDI) were recorded. Radiographic measures were compared between segments with foraminal narrowing of ≥20% at the 2-years follow-up (restenosis segments) and foraminal narrowing of <20% (patent segments). Sixty-nine patients with 109 segments were included. 73.4% (80/109) of foramens demonstrated foraminal narrowing and decrease of foraminal dimension of ≥20% occurred in 30.3% (30/109). Foraminal dimension at postoperative 2-days was significantly higher in the restenosis segments (P = .047). Furthermore, increase of foraminal dimension was significantly associated with foraminal restenosis of ≥20% (P = .018). Facet thickness was significantly higher in the restenosis segments compared to patent segments at postoperative 2-years follow-up (P = .038). Neck pain VAS was significantly aggravated only in the restenosis group at postoperative 2-years follow-up (P < .001). Foraminal narrowing commonly occurs after PCF due to bone healing. Bone growth occurs in all directions while medial facet growth contributes more to foraminal restenosis. Greater widening of foramen during PCF is a risk factor for postoperative foramen restenosis. Therefore, amount of bone resection should be kept optimal and excessive resection should be avoided to prevent foramen restenosis.

Transfer of the coracoid and conjoined tendon for failed, unstable, short clavicle following excessive outer clavicle resection.

Nineteen patients presented with an unsightly deformity of the shoulder, pain or discomfort at the medial scapular border, pseudo nonparalytic scapular winging, and thoracic outlet symptoms after excessive resection of the clavicle for either complete acromioclavicular separation or displaced fracture of the outer clavicle, which allows the scapula and shoulder to rotate anteriorly and inferiorly on the chest creating traction on the medial scapular muscles and the brachial plexus resulting in pseudo nonparalytic winging and thoracic outlet symptoms. RESULTS: All underwent transfer of the coracoid process with the attached conjoined tendon to the end of the clavicle, restoring length and alignment. Eighteen patients were evaluated at a mean of 13.3 years. Seventeen had resolution of symptoms, restored alignment of the clavicle with the shoulder, improved appearance, healed transfer, and were pleased with the outcome. One patient was lost to follow-up but was considered a failure at his last visit. In a second patient, the transfer healed in a tilted position and the patient was dissatisfied with the appearance but otherwise had resolution of his symptoms. The mean American Shoulder and Elbow Surgeons Outcome Score improved from 53.2 preoperatively to 87.4 postoperatively (P < .02). CONCLUSION: This is the first report of using this transfer to restore length and alignment of an excessively short, unstable clavicle. The transfer succeeded in improving the appearance and symptoms in this complication of an excessively short, unstable clavicle.