Local Dissection Research Articles

Three-dimensionally-navigated cross-cannulated screw fixation for traumatic pubic symphysis diastasis: an anatomical study

The aim of this study was to design and optimize the secure corridor of cross-cannulated screw implantation in pubic symphysis through Orbic 3D (Siemens Medical Solutions, Erlangen, Germany) computerized navigation and to provide an anatomic basis through the study of regional anatomy. Fifteen embalmed adult cadavers (8 males, 7 females) were used in this study. All pelvic specimens were placed in the supine position on a radiolucent carbon fiber table. The ideal angle of screw placement, appropriate screw diameter, and perfect attachment point were determined by the computerized navigation system. According to the above data, cross-cannulated screws 6.5 mm in diameter were implanted by the guide pins. Based on detailed local dissection, the entry-exit points of double screws were exposed in the pelvis. The distances were measured between the entry-exit points and the major structures. Radiographs and computed tomography (CT) scans of the pelvis were performed to reassess the position of screws. The trajectory of the first screw originated from the trailing edge of the pubic tubercula to the anterior-lower corner of the contralateral pubic tubercula. The second screw was directed from the base of the pubic tubercula to the junctional zone between the pubic tubercula and inferior ramus of the pubis of the opposite side of the body. Both screws maintained a safe distance from the surrounding major structures. All screw corridors were found intact without any damage under X-ray and CT images. The Orbic 3D computer navigation system is a reliable and new method of achieving a secure corridor for screw implantation in the pubic symphysis.

Surgical management of pleomorphic adenoma of parotid gland in elderly patients: Role of morphological features

The neoplasms of the salivary glands account for 2% of head and neck tumors and the most common form is the Pleomorphic adenoma (PA). Parotid gland is affected from 80% to 90% of cases. In elderly these tumors occur mostly in females. These benign tumors are composed of epithelial and myoepithelial cells that are arranged with various morphological patterns and subtypes. The classification of these tumors is also based on the amount and nature of the stroma. In literature there is an almost complete consensus that, in the major salivary glands, PAs are enclosed by a layer of fibrous tissue often called “capsule” but there is disagreement about the form, extension and thickness of this layer. The treatment is surgical and there are two main different surgical approaches: an enucleation (local dissection) or so-called subtotal superficial parotidectomy and lateral or superficial total parotidectomy. Histopathological characteristics of PAs especially of capsular alterations such as thin capsule areas, capsule-free regions, capsule penetration, satellite nodules and pseudopodia in the different subtypes are important for the choice of surgical treatment and the first explanation for tumor recurrence. In our study we describe a morphological features of 84 cases of pleomorphic adenoma of parotid gland from elderly patients treated by a surgical “enucleation like” method called nucleoresection.

Oral squamous cell carcinoma positive for p16/human papilloma virus in post allogeneic stem cell transplantation: 2 cases and review of the literature

Complications of allogeneic hematopoietic stem cell transplantation (allo-HSCT) includes the risk of secondary malignancies. This may be related to mechanisms including radiation and chemotherapy regimens, chronic graft-versus-host disease, inflammation, and prolonged imunosuppression. Oral squamous cell carcinoma (OSCC) is a complication associated with chronic graft-versus-host disease after allo-HSCT. Although human papillomavirus (HPV) is known to be associated with OSCC, the role of HPV in development of OSCC in post-HSCT patients has not been studied. We identified 2 cases of OSCC in allo-HSCT recipients. Both biopsy specimens tested positive for p16(INK4A), a surrogate marker for HPV. We propose that the association of OSCC and HPV in patients after allo-HSCT may not be incidental. Clinical implications of these cases may imply the need for a HPV screening, early intervention, and consideration of anti-HPV vaccination in this population. The effectiveness of such interventions could be validated in a prospective clinical study.

Surgical education using a multi‐viewpoint and multi‐layer three‐dimensional atlas of surgical anatomy (with video)

Trainee surgeons must have a good understanding of surgical anatomy. Especially in the hepatobiliary-pancreatic field, beginning surgeons often find it difficult to recognize the three-dimensional structure of the target organ and its complex anatomical correlation with surrounding organs. Conventional anatomy textbooks are not written with the aim of teaching these three-dimensional structures and complex correlations. We developed a novel teaching atlas of surgical anatomy using a multi-viewpoint and multi-layer three-dimensional camera system. Layer-by-layer dissection of the upper abdominal organs of a cadaver was performed by expert surgeons. A stereoscopic camera system was used to capture a series of anatomical views. The images were remodeled in a multi-viewpoint and multi-layer manner. Images of each dissection layer could be viewed serially from the appropriate angle, which was tilted up to 90° along the anteroposterior axis. The clinical anatomy specific to the surgical procedure could thus be learned using this atlas system. Rotatable three-dimensional panoramic views of local dissection of the upper abdominal organs of a cadaver were developed for educational purposes. Trainee surgeons could use these anatomical images instead of conventional anatomical atlases to learn how to perform surgical procedures such as pancreaticoduodenectomy and major hepatectomy.

Simultaneous cusp-sparing aortic root replacement and coarctectomy with total arch replacement from the midline incision

Four cases of simultaneous surgery for aortic root aneurysm with aortic regurgitation and coarctation of the aorta were presented. Age at surgery ranged from 18 to 37 years and all were male. All had annuloaortic ectasia and dilatation of the ascending aorta, 3 had bicuspid aortic valve and 1 had acute localized aortic dissection. Preoperative grade of aortic regurgitation was trivial in 1, moderate in 2 and severe in 1. Three had aortic valve-sparing root replacement with reimplantation technique and 1 had plication of the sinotubular junction. All patients had total arch replacement, coarctectomy and orthogonal anastomosis to the descending aorta. Antegrade cerebral perfusion was used for brain protection. All patients survived and postoperative pressure difference between the upper and lower extremities disappeared. Postoperative aortogram was satisfactory.

A NOVEL ENDOVASCULAR NITINOL IMPLANT PROVIDES A MINIMALLY INJURIOUS STENT ALTERNATIVE FOR CREATING TISSUE APPOSITION: A 90-DAY FEMORAL ARTERY STUDY IN SWINE

The Tack-It Endovascular Stapler System™ is a novel metallic 6mm spot-treatment technology designed to create tissue apposition to treat local vascular dissections and decrease the risk of vascular injury through low outward radial force and minimal nitinol material in contact with the vessel

Temporary streams in a peatland catchment: pattern, timing, and controls on stream network expansion and contraction

ABSTRACTIn peatlands, poorly maintained baseflows mean that network expansion during storm events can be rapid and pronounced, resulting in large changes in catchment connectivity. This has implications for the timing and magnitude of material fluxes from these environments, understanding of which is becoming increasingly important due to peatlands' significance as global carbon stores. In this study, electrical resistance (ER) technology has been used to create sensors capable of detecting the presence and absence of flow in ephemeral portions of the channel network. These sensors provide data on the patterns of network variation in the Upper North Grain research catchment, a small peatland headwater in the South Pennines, UK. Networks of around 40 sensors were deployed in autumn 2007 and summer 2008, giving a total of almost four months of high‐resolution monitoring data. Drainage density in the catchment was found to vary between 1.4 and 30.0 km/km2, suggesting significant differences in connectivity between the expanded and contracted networks. Water table depth was identified as the key factor determining the temporal pattern of streamflow at both the site‐ and catchment‐wide scales. Spatially, network expansion and contraction occurred in a disjointed manner, following a similar pattern between events, suggesting that localized controls are important for flow generation. Spatial controls on flow generation relate to local water table levels, and include drainage area, local dissection, channel slope and gully morphology. The importance of water table as the key control on catchment connectivity suggests that potential future change in catchment water tables, associated with projected climate change or with peatland restoration by rewetting, will modify the frequency of full catchment connectivity. Copyright © 2014 John Wiley & Sons, Ltd.

Airbag inflation-related left main coronary artery dissection, localized aortic dissection and aortic valve dehiscence in a patient with previous coronary artery surgery

Airbag inflation-related left main coronary artery dissection, localized aortic dissection and aortic valve dehiscence in a patient with previous coronary artery surgery

Rapid Diagnostics and Treatment of Early Complications after CABG Surgery: A Life Saver

Early graft failure after CABG surgery may lead to severe adverse events and death. Because the cause of the graft failure can vary, rapid diagnostic management is mandatory in order to address these complications appropriately. In the present 2 cases, patients who underwent CABG procedures showed typical electrocardiograms and serology of a perioperative myocardial ischemia shortly after surgery. In the first case, a rapidly performed coronary angiogram revealed a torqued right CABG, which was detorqued and, in order to avoid further torsion, fixated to the pericardium in a redo procedure. In the second case, the patient underwent a revascularization by means of percutaneous coronary intervention with stent implantation for severe stenosis due to a localized dissection of the vein graft, diagnosed on coronary angiogram. The further postoperative course of both patients was smooth and both could be discharged on day 8 and 11 after initial surgery, respectively.

Penile primary melanoma: analysis of 6 patients treated at Brazilian national cancer institute in the last eight years

To describe our experience in treating penile melanoma in 06 patients followed at our institution. Between 2004 and 2012 six consecutive patients with penile melanoma were treated at our Institution. Stage of the disease was classified according to the 2002 AJCC pathologic system. Melanoma in situ (TIS) was diagnosed in one patient. One patient was staged as T1b, two patients as T2b and two patients as T4b. The clinical and pathological findings were evaluated. Immunohistochemical tests were performed for Melan-A, HNB-45, S-100 and C-KIT. All histological specimens were examined by the same pathologist (ABSS). The patients with Cis, stages T1b and one patient T2b underwent only local excision. One patient T2b underwent local excision and sentinel lymph node dissection. Two patients with melanoma stage T4b underwent partial penile amputation. One of these last patients had palpable inguinal lymph nodes at diagnosis and underwent bilateral inguinal lymphadenectomy and received systemic chemotherapy (dacarbazine, 30 cycles). Mean follow-up was 36.3 months. One patient, with stage T2b, died after 12 months due to disease recurrence with bilateral inguinal involvement. The patient who underwent chemotherapy progressed with lung metastases and died after 14 months of follow up. The disease-free survival at five years was 33.3%. Penile melanoma is a disease with poor prognosis in most cases. Local excision or partial penile amputation may have effective control for stages T1 and T2 lesions. Patients who have clinically proven metastases died despite surgical and adjuvant chemotherapy.

An Unusual Case of Epigastric and Back Pain

A 63-year-old African woman immigrated to Europe presented to our hospital with increasing epigastric pain radiating to back, unresponsive to proton-pump inhibitors, lasting for a week. There was no nausea, vomiting, diarrhea, or fever. History was positive for diabetes mellitus, hypertension, and previously treated pulmonary tuberculosis. On examination, the patient was afebrile, and there was no lymphadenopathy. Amylase and lipase levels were normal, whereas erythrocyte sedimentation rate (120 mm/h) and C-reactive protein (14 mg/dL) were increased. Superior endoscopy showed normal findings; abdominal ultrasound was negative. Computed tomography (CT) angiography revealed a 10×23-mm saccular aneurysm of thoracic aorta (D9 level) with localized dissection and thickening of the aortic wall (Figure 1). There was lymph node enlargement at hilum and along bronchopulmonary, thoracic, and lumbosacral chains. Apical pleural thickness and …

TCT-553 A Novel Endovascular Stapling Device Provides a Minimally Injurious Stent Alternative for Maintaining Lumen Patency: A 28-Day Femoral Artery Study in Swine

The Tack-It, a novel metallic 6mm spot-scaffolding technology was designed to seal local vascular dissections and decrease the risk of vascular injury. This is achieved through a lower outward radial force and reduction in the material surface in contact with the vessel compared to the current

OP225: The predictive value of dendritic cells in early carcinoma of the tongue

Purpose Dendritic cells were suggested to play a role in the immunologic response against oral cancer. However, population heterogeneity in previous studies (a mixture of oral cavity subsites, different stages and various treatments) makes it impossible to apply this knowledge into clinical practice. The aim of our study was to examine whether dendritic cell density can predict disease outcome in a homogenous population of low-risk patients with squamous cell carcinoma of the tongue. Materials and Methods Twelve patients with small local disease (T1-2, N0, M0), and no pathologic adverse features were included. All patients were treated by local excision and elective selective neck dissection and none had incomplete resection. Representative samples were immunostained with antibodies against S100 and CD1a. Clinical information was retrospectively collected from patients’ charts and disease free survival (DFS) and overall survival (OS) were compared against dendritic cell density. Results Median dendritic cell densities were 17, 11.5, 17, 12 cells/HPF for tumoral S100, peritumoral S100, tumoral CD1a and peritumoral CD1a counts, respectively. No association was found between dendritic cell density and patients’ age and gender, tumor size, depth of invasion and resection margins. An improved DFS was found in patients with low dendritic cell density according to peritumoral S100 and CD1a ( p = 0.036 and p = 0.022, respectively). Improved overall survival was associated with low tumoral and peritumoral CD1a counts ( p = 0.042 and p = 0.036, respectively). Conclusions We found that low dendritic cell density is associated with improved DFS and OS in patients with early carcinoma of the mobile tongue. This finding opposes the theory that increase in the number of dendritic cells indicates an intensified immunologic reaction against the malignant tumor. Although our small sample size limits us in terms of statistical power, our findings were consistent both in tumoral and peritumoral tissues and by using two immunohistochemical markers for dendritic cells.

Innominate truncal and arch blowout with left hemiparesis and right hemothorax followed by delayed cheese-wire perforation of innominate graft

We present the case of a 68 year old Caucasian woman, in extremis, with left hemiparesis and right hemothorax, in hypovolemic shock, secondary to a blow-out of a large penetrating ulcer at the junction of innominate trunk and aortic arch. She underwent interposition graft replacement of innominate trunk and repair of aortic arch, on cardiopulmonary bypass, employing total circulatory arrest and selective antegrade cerebral perfusion and had total resolution of hemiparesis. She, however, represented, 6 months later, with threatened exsanguination after a sternal wire cheese-wired through the sternum and perforated the anteriorly lying innominate graft. Following successful repair, she was found to have an old intramural hematoma of distal arch and descending thoracic aorta and changes suggestive of chronic dissection of the whole of abdominal aorta. This was managed conservatively.We believe this patient’s presentation initially with a spontaneous innominate blow-out, cardiogenic shock, hemothorax and hemiparesis, and later with cheese-wire perforation of the innominate graft is unique. Her surgical rescue at both presentations was equally unusual, and without surgical precedent to the best of our knowledge. Was the initial innominate blow-out the result of localised innominate dissection, or more unusually, part of retrograde descending thoracic dissection with skip penetration of innominate artery and sparing of the intervening arch? Was it secondary to the minor fall she had sustained 1 week prior to the event, resulting in a false aneurysm or a contained hematoma next to the innominate artery? More intriguingly, did diffuse aortopathy underpin these diverse etiologies and result in penetrating intimal ulcer with blow out in the innominate artery, intramural hematoma in the arch and descending thoracic aorta and dissection in abdominal aorta at different points in time?We review the current literature for these unusual afflictions of innominate trunk and its origin from the arch of aorta.

Feasibility of a “resect and watch” strategy with endoscopic resection for superficial pharyngeal cancer

After endoscopic resection (ER) for superficial pharyngeal cancer (SPC), additional treatments such as radical surgical resection or radiation therapy may be needed in cases of possible incomplete resection. However, the benefit of prophylactic additional treatment is unclear. To evaluate the feasibility of a "resect and watch" strategy with ER for SPC. Retrospective, single-center cohort study. Tertiary cancer center. A total of 32 patients with 47 SPCs were eligible. A "resect and watch" strategy of initial ER and observation until development of secondary diseases, including local recurrence, neck lymph node metastasis (LNM), and metachronous pharyngeal cancer. Complications, tumor recurrence, development of metachronous pharyngeal cancer, overall survival, and cause-specific survival. There were no severe complications related to ER. Median length of follow-up was 43 months (range, 7-76 months). Cumulative development of secondary diseases at 5 years was 44% (95% CI, 24.5%-63.8%). Local recurrence (N = 4) and neck LNM (N = 5) were successfully treated by local resection (2 partial surgical resections and 2 additional ERs) and neck dissection, respectively. Metachronous pharyngeal cancers (N = 6) were completely removed by ER. The overall survival and cause-specific survival rates at 5 years were 84.4% (95% CI, 70.0%-98.8%) and 100%, respectively. No patient needed radical surgery as an additional therapy. Thus, the larynx and its function were preserved in all patients. Retrospective nature, single-center setting, relatively small sample size. A "resect and watch" strategy with ER for SPC is feasible and rational.

How should we treat iatrogenic aortic dissection as a complication of percutaneous intervention?

Cardiologia CROATICA Iatrogenic acute dissection of the ascending aorta following coronary angiography and percutaneous intervention is rare with an overall incidence of 0.02%. We report four cases of aortic dissection during coronary angioplasty with a disparate evolution that was due to the different location of the entry port of the dissection. Three cases of iatrogenic coronary dissection with extensive propagation into the ascending aorta during angioplasty of the right coronary artery are presented. The aortic dissection was successfully treated by stenting at the right coronary artery ostium. Follow-up computed tomography and coronary angiography showed complete resolution of aortic dissection. One case of coronary dissection of LAD/LMCA with propagation into the ascending aorta required surgical intervention. This case also has angiographic and computed tomography follow-up. We conclude that most of localized aortic dissections can be treated by sealing the entry point with a coronary stent. However, more extensive dissections may require a surgical intervention.

Complications after hybrid repair of aortic arch aneurysm

Hybrid repair can be an alternative to conventional open repair of aortic arch aneurysms especially in high risk cases. A 77 year male patient presented to us with complaints of breathlessness and chest pain. Investigations revealed aortic arch aneurysm with healthy ascending and descending aorta. Hybrid repair including supra aortic debranching and relocation of the arch vessels to the ascending aorta was performed. Complications like poststent-implant syndrome, cerebrovascular accident and localized dissection of ascending aorta at the site of stenting occurred.

Carcinoma of the Ectopic Breast

A 43-year-old woman presented with bilateral ectopic breasts in both the axillae in Chittagong Medical College Hospital in July 1996. She was diagnosed having carcinoma in the left ectopic breast. She was successfully treated with local surgical excision and regional lymph node dissection, adjuvant chemotherapy, loco-regional radiotherapy and hormone therapy. The patient continued tamoxifen for 5 years. Till last follow-up in December 2011, the patient was asymptomatic without any evidence of residual disease or local recurrence and evidence of metastases. DOI: http://dx.doi.org/10.3329/jemc.v3i1.13874 J Enam Med Col 2013; 3(1): 47-49

Saccular ascending aortic aneurysm arising within localized chronic dissection

An asymptomatic saccular ascending aortic aneurysm was diagnosed during workup for renal transplantation in a 39-year-old man. At operation, the aneurysm was noted to arise from within a localized and healed dissection, and was managed by ascending aortic replacement and sinotubular junction refashioning.

One-Stage Triple Hybrid Arch Debranching

Traditionally, repair of complex arch and descending aortic disease has required a two-stage surgical approach. We describe a novel one-stage repair that combines primary revascularization of the subclavian with stent coverage of diffuse aortic disease. A 31-year-old woman with Marfan syndrome presented with a growing arch aneurysm. At age 16 years, she had undergone the Ross procedure followed by a redo sternotomy and valve conduit. On follow-up, a distal arch aneurysm measuring 6 cm with an aneurysmal upper thoracic aorta and a localized distal thoracic aortic dissection was identified. In one stage, triple hybrid off-pump arch debranching with endovascular stent grafting was performed using two GORE Hybrid Vascular Grafts to perform the distal left carotid and subclavian anastomoses, which provided complete primary arch debranching without requiring a carotid-subclavian shunt. The patient had no complications, was discharged home on postoperative day 3, and continues to do well 3 months postoperatively. We conclude that one-stage repair of complex aortic arch disease with primary revascularization of the subclavian is feasible.