Methylene Blue Dye Injection Research Articles

Evaluation of Facial Allograft Transplantation in Humans in a Cadaver

Evaluation of Facial Allograft Transplantation in Humans in a Cadaver

Technical limitations of lymph node mapping in pancreatic cancer

Aim The high incidence of lymphatic and peri-neural invasion in pancreatic cancer results in poor loco-regional control. Radical pancreatico-duodenectomy may achieve better loco-regional control, but is accompanied by increasing morbidity. Our hypothesis was that if intra-operative mapping of pathological lymph nodes (LN) is technically feasible in pancreatic cancer, it would allow for selective radical resection. Methods In an ethically approved and statistically powered feasibility study of 72 (stopped after 20% enrollment) patients with suspected pancreatic cancer undergoing resection, we injected methylene blue dye peri- and intra-tumorally and studied its progress to identify putative ‘sentinel lymph node(s)’. The Kausch–Whipple procedure (or total pancreatectomy, if required) was carried out in addition to radical LN dissection, which was evaluated histopathologically according to the Japanese criteria. Results Over 18 months, 14/16 patients prospectively recruited underwent lymph node mapping and a mean of 20 (range 11–37) LNs per patient were harvested. Methylene blue dye injection identified blue LN(s) in 4/14 patients, none of which were positive for malignant deposits, whilst 10/14 patients had LN metastases. The commonest stations for LN metastasis were 17A or B (9/10), 8A (2/10) and 6 (3/10). The median survival for the 13 patients with cancer was 22.3 months (IQR: 10.4–30 months). Conclusion Sentinel lymph node mapping is not technically feasible in pancreatic cancer.

The role of sentinel lymph node detection in vulvar carcinoma and the experiences at the Institute of Oncology Ljubljana

Background. Sentinel node biopsy is a promising diagnostic staging procedure for vulvar carcinoma and it decreases postoperative morbidity. However, it has not been yet approved as a standard procedure. Patients and methods. From March 2003 to the end of 2006, 35 patients were treated for vulvar carcinoma with the technique of sentinel lymph node dissection. Mean age of the patient was 65.8 years (range 36-88 years). There had 32 patients squamous cell carcinoma, one malignant melanoma, one basal cell carcinoma, and one adeno-squamous cell carcinoma. Before surgery, sentinel node biopsy was made with performing 99mTc static and dynamic lymphoscintigraphy and with intradermal injection of methylene blue dye. Results. With this method we haven't found metastases in 25 patients (71.4%). In 3 cases, we failed and found groin recurrence after 12, 24 and 26 months, respectively. In the first, the reason was probably lack of experience, in the second case, we couldn't detect the second active node seen on the lymphographic scan, and in the third case, the reason was a prior surgical procedure and a scar in the groin region. In the group of SNB negative 22 patients were alive at the end of the year 2007 with no evidence of disease, one died after 45 months (groin recurrence), another one died of other causes. For one patient there is no current data. Patient with melanoma malignum is alive with liver metastases. Conclusions. In order to recognize the value of the obtained knowledge about the new treatment method and to confirm the efficiency or inefficiency of this method, further multicenter research studies need to be performed on larger randomized groups of patients.

Intraoperative intraductal injection of methylene blue dye to assist in major duct excision

Nipple discharge is not uncommon in women during their reproductive years. The etiology is benign in the majority of cases. Patients presenting with nipple discharge often require major duct excision (MDE) for accurate diagnosis and treatment. MDE is enhanced by the use of intraoperative injection of methylene blue dye into the discharging duct in order to aid visualization. Methylene blue dye–enhanced MDE has several advantages over traditional techniques. Methylene blue dye staining identifies the major discharging duct, as well as its side branches, which allows the surgeon to resect that specific ductal system only. This method allows neighboring major ducts to remain intact, preserving nipple function and permitting future cancer detection. Methylene blue–enhanced MDE allows the surgeon to more accurately determine the precise location and volume of tissue that needs to be excised. Lastly, methylene blue is both safe and inexpensive.

Second branchial cleft fistula: Is fistulogram necessary for complete excision

We present our 10 years experience (1995-2005) of second branchial cleft fistulas and sinuses in the pediatric age group by retrospective analysis of records of 52 patients (with 63 fistulas) whose sinuses or fistulas were excised. It was found to be thrice as common in males as compared to females and was predominantly unilateral. The role of fistulogram and methylene blue dye injection in delineation and complete surgical excision of the tract was evaluated. Twenty-five cases were managed by pre-operative fistulogram and intra-operative dye injections for excision, whereas 38 cases of branchial fistulas and sinuses were excised without fistulogram and dye injection. Fistulogram and dye injection were found to be of no extra help during excision of the tract. There were two recurrences.

Skin and fat necrosis of the breast following methylene blue dye injection for sentinel node biopsy in a patient with breast cancer

Sentinel lymph node biopsy (SLNB) is a simple technique that uses subdermal or peri-tumoral injection of vital blue dye and/or radioactive isotope to identify the first lymph node(s) draining the primary tumor. It has been shown to accurately predict axillary node status in patients with clinically node negative breast cancer. The SLNB is emerging as a new standard of care in patients with early breast cancer. However, the use of methylene blue (MB) dye can be associated with a number of local complications due to its tissue reactive properties. We report a rare case of skin and fat necrosis followed by a dry gangrene of the skin in a female patient with breast cancer who underwent SLNB localization using peri-tumoral injection of MB dye in another institution. This case and literature review suggest that the use of MB dye for SLNB identification should be avoided and replaced with alternative types of blue dye such as Patent Blue V preferably in conjunction with a radioactive isotope tracer.

Endoscopic Repair of a Post-Operative Gastro-Cutaneous Fistula

Post-operative gastrocutaneous or enterocutaneous fistula are frequent surgical complications. They are difficult to treat and have high morbidity and mortality. We present endoscopic repair of one such case with fibrin glue application. A 33-year-old woman with morbid obesity had undergone open Roux-en-Y gastric bypass surgery two years ago. She then underwent laproscopic re-do surgery. Her immediate post op course was complicated by suture line leakage that required repair and jejunostomy tube placement. Three months later she presented with persistent drainage (∼800 mL/ day) through two JP drains. Gastrograffin study showed a gastro-cutaneous fistula. Endoscopically both JP drains were visualized intraluminally just distal to the anastomosis site consistent with erosion through the gastric pouch wall. This was confirmed by methylene blue and contrast dye injection. Both JP drains were removed and the tract was infiltrated with 4 ml of fibrin tissue glue using a 7 french catheter. Complete occlusion was documented. Subsequent computerized tomography with oral contrast as well as gastrograffin study revealed no extravasation. [figure 1] Two repeat endoscopic application of fibrin tissue glue, at one week and four weeks interval, resulted in complete closure of the fistula. Complete closure was documented by gastrointestinal series performed with dilute barium at six weeks. Fibrin tissue glue is a tissue-compatible glue used in various surgical fields for more than a decade to prevent bleeding. It promotes wound healing by forming matrix-building strands, and promoting neovascularization and fibroblast proliferation. In our case it successfully treated the post-operative fistula and prevented the need for a complicated surgical repair. Literature review does not reveal any such case from United States. With increasing number of the bariatric surgeries in US, endoscopic repair of such complications is likely to be increasingly valuable, and fibrin tissue glue can be a very useful adjunct to that.Figure

New observations on endometrial physiology after transcervical injection of methylene blue dye

We describe the in vivo features of endometrium stained with methylene blue dye and observed via microhysteroscopy, showing the patterns of endometrial glands and superficial cell changes during the midproliferative, periovulatory, and midluteal phases. These preliminary observations have allowed us to identify a series of changes occurring in the different phases of the ovulatory cycle of potential value in reproductive medicine for specific groups of infertile patients.

Sentinel Lymph Node Mapping of Breast Cancer: A Case-Control Study of Methylene Blue Tracer Compared to Isosulfan Blue

Isosulfan blue has been traditionally used as a tracer to map the lymphatic system during identification of the sentinel lymph node. However, allergic reactions may be life threatening. We compared the efficacy of methylene blue dye as a tracer for sentinel lymph node biopsy to isosulfan blue dye. In an analysis of 164 cases, there was no clinical or statistically significant difference in the success rate of sentinel node biopsy (P = 0.22), the number of blue sentinel nodes harvested (P = 0.46), the concordance with radioactive sentinel nodes (P = 0.92), or the incidence of metastases (P = 0.87) when methylene blue tracer was compared to isosulfan blue. No adverse reaction to either blue dye was observed. In conclusion, intraparenchymal injection of methylene blue dye is a reliable tracer for the lymphatic system and nodal identification during sentinel node mapping for breast cancer. It is safe, inexpensive, and readily available.

Invited commentary

In this article, Daniel and colleagues describe preoperative CT guided radiotracer localization of small pulmonary nodules using 99mTc MAA prior to thoracoscopic wedge resection. The common preoperative marking methods—hookwire placement or methylene blue dye injection—are generally good but not without failures or complications. Hookwire displacement or inability to recognize methylene blue dye on the pleural surface are responsible for considering conversion to open surgery. Radioguided searching allowed detection of all injected lesions. Technetium compounds have long half-lives (6 hours), so it is suitable for preoperative localization and some delay between labeling and operation.Several marking techniques using a radiotracer—specially human serum albumin, tin colloid, phytate, and sulfa colloid—for thoracoscopic resection of small pulmonary nodules have already been reported. One of the most important concerns for localizing of small pulmonary nodules using radiotracer is “the size of particle”. Diffusion of the injected radioisotope, which is dependent on the size of particles, causes difficulty during thoracoscopic wedge resection of small pulmonary nodules. As occurs with some dyes, the isotope will not spread into the lung parenchyma or bronchus if it is big enough to remain at the injection site. Radioactivity is detected as small hot spots on the lung surface in patients. To improve this technique, larger radioactive particles may be useful for preventing diffusion of the injected isotope and decrease the dosage of radioactivity.In this study, the authors use the 99mTc MAA with a particle size of approximately 10–50 μm. This radioisotope is larger than that of human serum albumin (approximately 10 nm), sulfa colloid (approximately 100 nm), phytate (approximately 200–100 nm), and tin colloid (approximately 400–1500 nm), used in previous reports. By using larger radioactive particles, the authors succeeded in decreasing the dosage of radioactivity for injection, 0.1 ml/0.3 mCi of 99mTc MAA. This is the most valuable contribution in this article.Preoperative radiolocalization may be one of the effective localization procedures with less complication and failure, and this technique using larger radioactive particles seems to be more suitable than other radiolocalization methods. This study should contribute to the development of preoperative localization methods for small pulmonary nodules for thoracoscopic resection, and is certainly worthy of further study. In this article, Daniel and colleagues describe preoperative CT guided radiotracer localization of small pulmonary nodules using 99mTc MAA prior to thoracoscopic wedge resection. The common preoperative marking methods—hookwire placement or methylene blue dye injection—are generally good but not without failures or complications. Hookwire displacement or inability to recognize methylene blue dye on the pleural surface are responsible for considering conversion to open surgery. Radioguided searching allowed detection of all injected lesions. Technetium compounds have long half-lives (6 hours), so it is suitable for preoperative localization and some delay between labeling and operation. Several marking techniques using a radiotracer—specially human serum albumin, tin colloid, phytate, and sulfa colloid—for thoracoscopic resection of small pulmonary nodules have already been reported. One of the most important concerns for localizing of small pulmonary nodules using radiotracer is “the size of particle”. Diffusion of the injected radioisotope, which is dependent on the size of particles, causes difficulty during thoracoscopic wedge resection of small pulmonary nodules. As occurs with some dyes, the isotope will not spread into the lung parenchyma or bronchus if it is big enough to remain at the injection site. Radioactivity is detected as small hot spots on the lung surface in patients. To improve this technique, larger radioactive particles may be useful for preventing diffusion of the injected isotope and decrease the dosage of radioactivity. In this study, the authors use the 99mTc MAA with a particle size of approximately 10–50 μm. This radioisotope is larger than that of human serum albumin (approximately 10 nm), sulfa colloid (approximately 100 nm), phytate (approximately 200–100 nm), and tin colloid (approximately 400–1500 nm), used in previous reports. By using larger radioactive particles, the authors succeeded in decreasing the dosage of radioactivity for injection, 0.1 ml/0.3 mCi of 99mTc MAA. This is the most valuable contribution in this article. Preoperative radiolocalization may be one of the effective localization procedures with less complication and failure, and this technique using larger radioactive particles seems to be more suitable than other radiolocalization methods. This study should contribute to the development of preoperative localization methods for small pulmonary nodules for thoracoscopic resection, and is certainly worthy of further study.

Intraoperative localization of small intestinal bleeding in an infant by methylene blue injection: A case report

During the evaluation of patients with profuse gastrointestinal bleeding, it is often difficult to accurately localize bleeding sites in the small intestine. Moreover, during laparotomy, there may be no intraoperative findings to allow identification and resection of the bleeding lesion. Here the authors report a case of severe intestinal bleeding in an infant in whom the intraoperative injection of methylene blue dye into a terminal branch of the superior mesenteric artery was critical in determining the exact location of bleeding. After accurate localization of the bleeding source and segmental intestinal resection, the child recovered uneventfully with no recurrence of gastrointestinal bleeding. To the author's knowledge, this is the first reported use of this technique in infancy.

The anatomy of the labiomandibular fold.

The anatomy of the labiomandibular fold was evaluated in a series of 12 fresh hemifacial cadaver dissections. The techniques of methylene blue dye injection, histologic evaluation, and gross dissection all confirm that the labiomandibular fold has distinct anatomic boundaries. The superior boundary is formed by the cutaneous insertion of the depressor anguli oris muscle at the labiomandibular crease. The inferior boundary is determined by the mandibular ligament, which has been previously described. The cutaneous insertion of the depressor muscle and the mandibular ligament act as relative points of fixation. The dynamic forces of both aging and facial animation act about these two points to create the typical appearance of the labiomandibular fold. This anatomy is consistent with that seen in other areas of the face such as the nasolabial and nasojugal folds, where the dermal insertion of muscle and/or fascia defines an anatomically distinct region. Clinically, this anatomy may suggest that a subcutaneous plane of dissection during the face lift procedure may allow manipulation and reduction of the fat that was noted lateral to the dermal insertion of the depressor anguli muscle. Subcutaneous dissection also avoids lateral pull on the platysma muscle, which may tend to accentuate and distort the labiomandibular crease due to its intimate association with the overlying depressor muscle.

Femoral nerve “sheath” for inguinal paravascular lumbar plexus block is not found in human cadavers

Study Objective: To determine if a femoral nerve sheath capable of conveying local anesthetic to the lumbar plexus and the obturator nerve exists in human cadavers. Design: Injection of methylene blue dye into the femoral nerves of human cadavers followed by dissection and observation of dye distribution. Setting: University medical center pathology department autopsy room. Patients: Six fresh adult cadavers about to undergo postmortem examination. Interventions: Both femoral nerves of six fresh cadavers were injected with either 20 ml or 40 ml of dye. The abdomen was opened and distribution of the dye was observed. Measurements and Main Results: In all of the cadavers studied there was no evidence of a femoral nerve sheath capable of conveying methylene blue dye to the lumbar plexus. Both 20 ml and 40 ml of dye injected into the femoral nerve failed to reach the lumbar plexus or the obturator nerve. When 40 ml of dye was injected it always stained the femoral nerves, it usually stained the lateral femoral cutaneous nerves, but it never stained the obturator nerves. Conclusions: A femoral nerve sheath capable of conveying a solution to the cadaver lumbar plexus does not exist in human cadavers. Dye injected into the cadaver femoral nerve does not reach either the lumbar plexus or the obturator nerve. When 40 ml of methylene blue dye is injected into the cadaver femoral nerve, some dye usually diffuses under the iliacus muscle fascia to the lateral femoral cutaneous nerve. This study indicates that in patients the “3-in-1 block” always blocks the femoral nerve, it usually blocks the lateral femoral cutaneous nerve, but it probably does not block the lumbar plexus or the obturator nerve.

Preoperative Highly Selective Catheter Localization of Occult Small-Intestinal Hemorrhage With Methylene Blue Dye

In patients with occult lower gastrointestinal bleeding, locating of the source of the hemorrhage can be quite difficult. While multiple diagnostic tests may confirm a small bowel source of bleeding, precise localization allowing a directed, conservative surgical resection may be problematic. We describe three patients each of whom presented with hemorrhage from the small intestine. The preoperative use of highly selective angiographic catheter placement combined with intraoperative methylene blue dye injection allowed us to precisely locate the source of hemorrhage and to resect a conservative length of small intestine. This technique has been successful in the three patients herein, and we believe that it should be included in the options available to the surgeon.

The brachioradialis myocutaneous flap

The vascular anatomy and the cutaneous territorial definition of the brachioradialis myocutaneous flap has been studied by cadaver dissection and intra-arterial injection of methylene blue dye. A case is presented in which a proximal brachioradialis myocutaneous flap, based on the vascular pedicle arising from the radial recurrent artery just distal to the elbow level, was used to cover an exposed open elbow joint. The advantages and disadvantages of this flap are briefly discussed.

Methylene Blue Injection

Injection of methylene blue dye into the superior mesenteric artery of a patient with arteriovenous malformation of the small bowel was helpful in identifying the field of resection. Preoperative selective angiography is essential in identifying this rare cause of gastrointestinal bleeding.