Microsurgical Operations Research Articles

Results of surgical treatment of symptomatic cysts of lateral fissure in children

<p><strong>Aim.</strong> The study aims to analyze the clinical and radiological results of treating arachnoid cysts of lateral fissure, which present a frequent pathology accounting for 30-50% of all brain arachnoid cysts. At present, the strategy of surgical treatment is controversial. For a long time, treatment included both microsurgical and shunt operations, however, in modern neurosurgery many authors prefer endoscopic techniques or endoscopic-assisted microsurgery. Determining the indications for intervention also remains disputable. Some authors tend to believe that "preventive" surgery of asymptomatic arachnoid cysts of lateral fissure with minimal clinical manifestations is also debatable.<br /><strong>Methods.</strong> 22 pediatric patients underwent surgery at Novosibirsk Center of Neurosurgery from 2013 to 2015. Successful interventions by using mostly an endoscopic approach were carried out in 18 (81.8%) patients resulting in regression of clinical symptoms. A positive effect was not achieved in 4 (18.1%) patients with primary endoscopic cysto-cisternostomy who required additional operations. <br /><strong>Conclusion.</strong> Endoscopic fenestration in our series is a safe, effective and minimally invasive procedure of the first stage of treatment in patients with a symptomatic arachnoid cyst of lateral fissure.</p><p>Received 5 May 2016. Accepted 14 September 2016.</p><p><strong>Funding:</strong> The study had no sponsorship.<br /><strong>Conflict of interest:</strong> The authors declare no conflict of interest.</p>

Suture of Minimal-diameter Vessels Using Fingertip Support Technique

Dear Sir, During micro-surgical operations, complications may occur, which may endanger anastomoses. One of the basic factors is physiologic tremor, what is impeding the surgeon and the development of accurate sutures [1]. By using the fingertip support technique, the tips of the thumb, index- and middle fingers are supported on the fixed platform (bridge) which overpasses the operational area [2]. This bridge is commercially available in different shapes and sizes (Bethlehem-bridge) [2]. This technique may decrease the tremor by up to one third. Tese data have been verified with PAM tremorometry [2]. In plastic- and restorative surgery it is common to have to unify micro-vessels and nerves under diameter of 0.6 mm (finger-replantations, lobe-transplants). In such cases, decrease of high-level tremor can bring significant benefits in terms of operation result. During our measurements, we have searched, whether the significant tremor-decrease achieved by the fingertip support technique would enable us to create anastomoses with greater security. Furthermore we have analyzed, what is the vessel diameter, where this technique has to be used in order to create micro-vascular bypasses. A chicken wing (artery) is an adequate in vitro model [3]. We have measured the perimeters on various sections. We specified the average diameter in the most proximal, most distal and middle sections in vitro. Following these measurements we have found that the two main arteries are on average 1.1 mm in diameter in the proximal, 0.54 mm in the middle, and 0.29 mm in the distal area. On these sections, we have created end-to-end anastomoses (in comfortable sitting position, 90° positioning of the elbows, towel-support under the arm) with 10.0 thread (Ethicon®-Prolene). At the beginning of the modelling, the operator (medical student) did not have any prior experience either in traditional micro-surgical procedures or in the fingertip support technique. The learning of the two methods and microscopic stitching techniques has happened at the same time. He has performed both in approximately equal numbers (ca. 100 times each) in 1.5 years of preliminary practice, before he started comparative measurements. Afterwards, we have documented certain parameters we observed during the stitching of anastomoses including minimum and maximum times of stitching, knotting, the average of these values, and vessel ruptures have all been recorded. We have measured stitching time from the first penetration to the finishing to the last knot, and also knotting time from the beginning of looping to the cutting off of spare thread. We have classified all events as ruptures when the ends of vessels ripped in (from the edge of the vessel to the entry point of the needle), or were misplaced (donor and acceptor did not fit precisely, because one of the ends slipped under the other one. We have done 20 recorded procedures with each technique on vessels averaging 0.54 mm in diameter, and have compared the results. Furthermore, we have identified the vessel-sections that are inoperable due to the physiologic tremor causing overly frequent ruptures and where secure anastomoses cannot be created using traditional support technique. We have observed the possible accuracy on this section, and have recorded the parameters described earlier. A high degree of difference has shown between the traditional support technique and the fingertip support technique in every recorded parameter. The stitching time was with 26, the knotting time with 23, the numbers of ruptures with 86 percent lower. We could not perform anastomoses using traditional support technique on vessels averaging 0.29 mm in diameter in 10 attempts. Using fingertip support technique the average stitching time through 10 attempts was 3 min 5 sec and the average knotting speed was 45 sec. Out of 10 anastomoses, 3 ruptures have occured. It has been proven that under in vitro circumstances, the fingertip support technique can significantly decrease tremor, thereby decreasing operational time. Therefore, in situations where time is a critical factor (e.g. neurosurgery) it may be an important innovation. Furthermore, from the significant decrease in stitching time and the minimization of vascular ruptures, it is obvious that this technique yields a significant advantage over the traditional manual techniques in the more accurate placement of sutures and the secure and stable looping of knots. We would like to emphasize that under a certain diameter, this is the only technique that can be applied with confidence, hence in cases of operational procedures where the development of anastomoses of vessels with such properties is required, this may be the primarily chosen method.

Fluorescence diagnostics in the near-IR: apparatus, application

The extension of fluorescence diagnosis into the near-IR region is promising, because this radiation penetrates more deeply into biological tissue, has higher contrast due to the absence of intrinsic fluorescence of the tissue, and can work in brightly lit operating rooms, as well as because new drugs have been developed that can specifically accumulate in pathological foci. The FLUM-808 multispectral system has been developed and makes it possible to visualize and simultaneously make quantitative estimates in IR fluorescence light and reflected white light or in as many as four spectrally separated fluorescences in the 410–950-nm range. Using the latter phenomena as an example, produced on experimental animals and during the performance of open, microsurgical, and endoscopic operations with indocyanine green as an IR fluorescence marker, it has been shown to be possible to employ the system to solve crucial medical problems: the detection of malignant tumors, metastases, and sentinel lymph nodes in the presence of cancer and the visualization of the circulatory and lymphatic systems and of bile ducts.

Mathematical modeling of the resistance welding of living tissues by the specialized microsurgical tweezers

Microsurgery is a separate surgery section, dealing with surgical treatment of small size structures of the human body, which are often not available to the naked eye. The operating microscope and miniature surgical instruments perform all microsurgical operations. Tweezers is one of the most important tools in conducting microsurgical operations. They hold small portions of tissue and very thin sutures for tying knots. The Paton Welding Institute designed tweezers for welding tissue in microsurgery. The aims of the study are: to create a model of welding tweezers; to determine of the distribution of mechanical stresses in the tissue, depending on the compression force of the electrodes and mechanical properties of the tissue; to determine the optimal shape of the jaws and electrodes; to consider the influence of the angle between the electrodes at the welding. 3D CAD Packages SolidWorks performed analysis and modeling of electrosurgical forceps. SolidWorks allows to create design documentation and to perform mathematical modeling of welding. The paper presents a method of mathematical modeling of microsurgery tweezers, needed for their design. The electrodes should converge at an angle for secure grasping of the tissue. The angle between the electrodes reverses upon further compression, leading to expulsion of tissue. The resonant frequency of the system forceps-tissue analyzed. The electrodes glide over the tissue in opposite directions at certain resonant frequencies, which reduces the strength of the welding. Tweezers can become unstable under certain conditions. Modeling can be useful in the design of conventional tweezers

Full-endoscopic interlaminar operations in lumbar compressive lesions surgery: prospective study of 350 patients - "ENDOS" Study.

Full-endoscopic operations of lumbar spine are truly minimally invasive surgical procedures. Endoscopic techniques have become the standard in many areas because of the advantages they offer intraoperatively and after surgery. With the interlaminar and transforaminal approach, two full-endoscopic procedures are available for lumbar compressive lesion operations. Our aim was to present and explain all aspects of the full-endoscopic operative technique, and presentation of results of lumbar discectomies and monosegmental decompression in full-endoscopic interlaminar technique performed during 3-year period in comparison with conventional microsurgical operations reported in literature. A series of 350 patients underwent full-endoscopic interlaminar lumbar discectomy, and spinal canal decompression, during a 3-year period, is analyzed. In addition to general and specific parameters, VAS and ODI scale are used as measuring instruments. In our clinical series of full-endoscopic operations 88% of the patients no longer had leg pain postoperatively, and 7% had only occasional pain. In 7 (2%) patients minor nerve damage resulted in transient paresthesias, and in 2 patients resulted in neurological deficit. Dural tear occurred in 8 (2.3%) patients, and only 1 had reoperation for direct dural repair. The recurrence rate was 5.7% (3.7% had reoperation). Resection of the herniated disc and sufficient decompression was technically possible in all cases. The clinical results of the full-endoscopic technique are at least equal to those of the conventional microsurgical discectomy with advantages such as reduced tissue trauma, improved patient mobility, and lower overall complication rate. With the possibility of selecting the most adequate approach, lumbar disc herniations inside and outside the spinal canal, can be sufficiently removed using the full-endoscopic technique, when taking the appropriate indication criteria into account.

Assessment of The Lymphatic System of the Genitalia Using Magnetic Resonance Lymphography Before and After Treatment of Male Genital Lymphedema.

Treatment for chronic male genital lymphedema (GL) is limited. No standard treatment or validated instrument to assess GL is available. The aim of this study was to explore whether magnetic resonance lymphography (MRL) could be used to assess GL, select proper treatment for patients, and monitor postoperative progress.This is a retrospective analysis of a prospectively acquired cohort of men with GL presenting for MRL over a 7-year period. Thirty-six of 47 eligible men were included. All men were offered preoperative and postoperative MRL and assigned a morphology and function classification. Men with mild, moderate, and severe nodal dysfunction underwent complex decongestive physiotherapy (CDP), lymphoveneous microsurgery, and surgical excision, respectively. The volume reductions in the genitalia of patients with mild and moderate nodal dysfunction were recorded and compared using Student t test.The abnormal superficial and deep lymphatic vessels in the lymphedematous genitalia were detected by MRL, and inguinal lymph node dysfunction was classified by MRL. Seven patients with mild dysfunction who underwent CDP showed a more significant mean volume reduction in the genitalia than did 9 patients with moderate dysfunction. Three patients with hyperplasia and moderate dysfunction who underwent microsurgical operations and 17 patients with hypoplasia and moderate or severe nodal dysfunction who underwent surgical excision had excellent cosmetic results with no lymphedema at the 3- to 5-year follow-up.MRL can be used to assess morphological and functional lymphatic abnormalities in GL, preoperatively select appropriate treatment, and postoperatively evaluate treatment outcomes.

Surgical treatment of «Mirror» aneurysms of the internal carotid artery

A relatively high occurrence of "mirror" aneurysms of the anterior cerebral circulation in neurosurgical practice necessitates generalization of experience of using different surgical approaches. The choice of treatment is usually associated with the number of surgical stages. Forty nine patients (19 males and 30 females) with mirror aneurysms of the anterior circulation underwent one- and two-step surgery at the Novosibirsk Federal Center of Neurosurgery in 2013-2015. The total number of bilateral aneurysms was 51 couples (102 aneurysms). The patients' age ranged from 19 to 66 years (mean age, 47.1±11.6 years). Most of the patients (47) underwent elective surgery; 2 patients were operated on in acute subarachnoid hemorrhage. Sixty nine microsurgical operations and 19 endovasal interventions were performed during the main step. Microsurgery alone was used in 34 cases; endovascular surgery alone was performed in 6 cases; a combination of the techniques was used in 9 cases. Ten patients underwent one-step surgery, and 39 patients underwent two-step surgery. The radicalness of surgery amounted to 94.1% for the microsurgical technique and 83.3% for the endovasal technique. The excellent and good functional outcome (modified Rankin scale, 0-2) was achieved in 46 (93.9%) patients, and the poor outcome (mRs, 3-5) was observed in 3 (6.1%) patients. Generalization of the results indicates that one-stage surgery is more preferable in the treatment of mirror cerebral aneurysms. However, the two-stage approach remains important and, in the case of certain anatomical peculiarities, is the only possible treatment. A combination of microsurgical and endovascular techniques improves clinical outcomes in treatment of mirror aneurysms of the anterior part of the cerebral arterial circle.

Studying the modes of automated destruction of malignant tumors using laser radiation

In this work, we have manufactured the experimental setup to study the modes of automated destruction of biological tissue in vitro. We have implemented the setup in microsurgical operations, which allows us to verify the modes of tissues destruction.

Microsurgeons do better--tactile training might prevent the age-dependent decline of the sensibility of the hand.

Recent data demonstrate that the normal sensibility of the hand seems to be age-dependent with the best values in the third decade and a consecutive deterioration afterwards. However, it is not clear if long-term tactile training might prevent this age-dependent decline. We evaluated sensibility of the hand in 125 surgeons aged between 26 and 75 years who perform microsurgical operations, thereby undergoing regular tactile training. We examined sensibility of the radial digital nerve of the index finger (N3) and the ulnar digital nerve of the small finger (N10) using static and moving two-point discrimination (2PD) tests and compared the results to 154 age-matched individuals without specific long-term tactile training. We found significantly lower static and moving 2PD values for the sixth, seventh, and eighth decade of life in the microsurgery group compared to the control group (p < 0.05). This study demonstrates that long-term tactile training might prevent the known age-dependent decline of the sensibility of the hand.

Full-Endoscopic Interlaminar versus Microsurgical Operations in Lumbar Compressive Lesions Surgery

Introduction Full-endoscopic operations of lumbar spine are truly minimally invasive surgical procedures. Endoscopic techniques have become the standard in many areas because of the advantages they offer intraoperatively and after surgery. With the interlaminar and transforaminal approach, two full-endoscopic procedures are available for lumbar compressive lesion operations.

Reversal of intraoperative arterial thrombosis with a fibrinolytic agent when treating large and giant partially thrombosed aneurysms of the middle cerebral artery

Thrombosis of the cerebral arteries is one of the complications of microsurgical operations for partially thrombosed intracranial aneurysms. The object of this study was to assess the frequency of intraoperative arterial thrombosis (IAT) during microsurgical treatment of large and giant partially thrombosed aneurysms of the middle cerebral artery (MCA) and also to assess the efficacy of the treatment of this complication. The authors analyzed a consecutive series of 53 patients who underwent surgery for partially thrombosed aneurysms of the MCA at the Burdenko Neurosurgical Institute between January 2005 and September 2014. Thirty-two patients had large aneurysms (15-25 mm) and 21 had giant aneurysms (> 25 mm). Clipping of aneurysms was performed in 47 patients, trapping was performed in 3, and wrapping was performed in 3. IAT was diagnosed in 10 patients (18.9%). The authors describe a technique for IAT reversal involving the injection of modified human recombinant prourokinase (mr-proUK). Of the 7 patients who underwent injection of mr-proUK in the thrombosed artery, 5 (71.4%) were discharged without any change in neurological status, 1 (14.3%) experienced moderate deterioration (modified Rankin Scale [mRS] score of 2), and 1 (14.3%) experienced severe deterioration (mRS score of 4). Among the 3 patients who had complications and did not receive an injection of mr-proUK, 2 experienced severe deterioration (mRS score of 3 and 4) and 1 had moderate deterioration (mRS score of 2). The primary risk factor of thrombectomy with temporary trapping is thrombosis in the MCA branches. The injection of a fibrinolytic agent into thrombosed MCA branches is an effective method for the treatment of IAT.

A novel method of edema fluid drainage in obstructive lymphedema of limbs by implantation of hydrophobic silicone tubes.

Lymphedema of limbs is caused by partial or total obstruction of lymphatic collectors as a consequence of skin and deep soft tissue inflammation, trauma of soft tissues and bones, lymphadenectomy, and irradiation in cancer therapy. According to the statistics of the World Health Organization, around 300 million people are affected by pathologic edema of limbs. Effective treatment of such large cohorts has been a challenge for centuries. However, none of the conservative and surgical methods applied so far proved to restore the shape and function of limbs to normal conditions. Actually, physiotherapy is the therapy of choice as a main modality or supplementary to surgical procedures divided into two groups: the bridging drainage and excisional techniques. The microsurgical operations can be performed if some parts of the peripheral collecting lymphatics remain patent and partially drain edematous regions. However, in advanced cases of lymphedema, all main lymphatics are obstructed and tissue fluid accumulates in the interstitial spaces, spontaneously forming "blind channels" or "lakes." The only solution would be to create artificial pathways for edema fluid flow away to the nonobstructed regions where absorption of fluid can take place. The aim of this study was to form artificial pathways for edema fluid flow by subcutaneous implantation of silicone tubes placed along the limb from the lower leg to the lumbar or hypogastric region. In a group of 20 patients with obstructive lymphedema of the lower limbs that developed after lymphadenectomy and irradiation of the pelvis because of uterine cancer with unsuccessful conservative therapy, implantation was done, followed by external compression as intermittent pneumatic compression and elastic support of tissues. Postoperative circumference measurements, lymphoscintigraphy, and ultrasonography of tissues were carried out during 2 years of follow-up. There was a fast decrease of calf circumference since the day of implantation during weeks by a mean 3% with stabilization afterward. Patency of tubes and accumulation of fluid around them were seen on ultrasonography and lymphoscintigraphy in all cases. No tissue cellular reaction to silicone tubes was noted. The simplicity of the surgical procedure, decrease of limb edema, and lack of tissue reaction to the implant make the method worth applying in advanced stages of lymphedema with large volumes of accumulated tissue edema fluid.

High-flow venous pouch aneurysm in the rabbit carotid artery: A model for large aneurysms.

Currently one of the most widely used models for the development of endovascular techniques and coiling devices for treatment of aneurysm is the elastase-induced aneurysm model in the rabbit carotid artery. Microsurgical techniques for creating an aneurysm with a venous pouch have also been established, although both techniques usually result in aneurysms less than 1 cm in diameter. We investigated whether an increase in blood flow toward the neck would produce larger aneurysms in a microsurgical venous pouch model. Microsurgical operations were performed on 11 New Zealand white rabbits. Both carotid arteries and the right jugular vein were dissected, and the right carotid artery was temporarily clipped followed by an arteriotomy. The left carotid artery was also clipped proximally, ligated distally, and sutured onto the proximal half of the arteriotomy in the right carotid artery. The venous graft was sutured onto the distal half of the arteriotomy. Digital subtraction angiography was also performed. Angiography showed patent anastomosed vessels and aneurysms in the seven surviving rabbits. Mean aneurysm measurements among surviving rabbits with patent vessels were: 13.9 mm length, 9.3 mm width, and neck diameter 4.7 mm. The resulting mean aspect ratio was 3.35 and the mean bottleneck ratio was 3.05. A large venous graft and increased blood flow toward the base of the aneurysm seem to be key factors in the creation of large venous pouch aneurysms. These large aneurysms allow testing of endovascular devices designed for large and giant aneurysms.

Transient Hair Loss after Finger Replantation

Transient hair loss is characterized as localized hair loss without scar formation. Hair loss can be in a localized part of the occipital area that develops 2-3 weeks after long-lasting surgery. Ischemic changes in the scalp exposed to pressure during long-term surgery are blamed for the hair loss. Its first signs are tenderness, swelling, and ulceration in the area subjected to pressure. In the histopathologic examination, chronic inflammation, an effect on hair follicles in the catagen phase, and cell death by apoptosis are observed [1,2]. Totally amputated second and third fingers of a 21-year-old male were replanted under general anesthesia in 8 hours (Figs. 1, ​,2).2). There were no postoperative complications, but the patient described tenderness and redness in the occipital area in the postoperative period. There were no pathologic signs except hyperemia. On postoperative day 10, hair loss was detected in a restricted area in the occipital region, and in postoperative week 3, this area was totally bare (Fig. 3). No fungi were detected in the microbiological examination. This condition was considered hair loss resulting from pressure ischemia related to the head position during long-term surgery. Hair started to grow again in postoperative month 3, and the condition completely resolved in postoperative month 6 (Figs. 4, ​,55). Fig. 1 Preoperative photography of the amputated fingers. Fig. 2 Appearance of fingers in postoperative month 6. Fig. 3 Appearance of transient hair loss at postoperative week 3. Fig. 4 Appearance of transient hair loss at postoperative month 6. Fig. 5 Appearance of transient hair loss at postoperative year 1. Postoperative transient hair loss was first described after long-lasting gynecological operations [1]. Subsequently, it has been reported after cardiac, gynecologic, abdominal, aesthetic, and breast reconstruction surgery [3,4]. However, to the best of our knowledge, postoperative transient hair loss after finger replantation surgery has not been reported before. Ischemia secondary to localized pressure and perioperative stress plays an important role in the etiology of postoperative transient hair loss. Its general presentation in the occipital area supports the pressure effect. Hair loss begins between postoperative day 3 and 28. Normal hair structure is expected to be acquired within 120 days. Physiological disorders were reported to trigger postoperative transient hair loss [5]. Microsurgical operations are usually long-lasting surgical procedures. In hand surgery operations where microsurgery is intensely performed, attention should be paid to this rare complication. In multiple replantation cases, we think that changing the head position intermittently and controlling perioperative stress may reduce the effect of the long surgery time on the scalp skin.

Comparative analysis of results of early and late microsurgical reconstructive operations in patients with extensive posttraumatic tissue defects of lower extremities

Comparative analysis of patient treatment results with extensive and deep posttraumatic defects of different segments of lower limbs has been done in this article. Early (n=71) and late (n=127) microsurgical reconstructive operations with using island flaps and free axial skin flaps have been performed to all these patients. According to authors, early microsurgical reconstructive operations have significant opportunities due to similar but later done operations. In particular, operative treatment makes necessary conditions for reliably more frequent using of less difficult operations with island flaps and creates statistically reliable reduce of additional operations demand. This treatment also provides the best long-term results and a more complete functional recovery of the damaged lower extremities in terms from two to six years.

Learning curve of vessel cannulation in rats using cumulative sum analysis

BackgroundIntravascular access routes are widely used for administering agents or taking blood samples in rodents. Vessel cannulation in rats is a technically challenging procedure with a risk for significant complications. The use of cumulative sum (CUSUM) analysis allows continuous monitoring of the performer's outcomes to evaluate the learning curve for a particular procedure. The aim of the present study was to assess a researcher's learning curve in the cannulation of the jugular and femoral vein in rats using CUSUM analysis. Materials and methodsA single researcher performed two hundred microsurgical operations between September 2012 and September 2013. The animals (male Wistar rats) were anesthetized with isoflurane whereas the right jugular vein and the left femoral vein were catheterized. Prospective data were collected and analyzed using CUSUM analysis. For the purposes of the study, the rat population was divided in four groups based on the order of studies; group 1 represents the first 50 animals cannulated, group 2 the next batch of 50 animals, and so forth. ResultsThe operating times required for cannulation of the jugular vein for groups 1, 2, 3, and 4 were 24.6 ± 4.8, 15.9 ± 2.5, 15.2 ± 3.2, and 15.7 ± 3.3 min, respectively. Group 1's operating time was significantly longer than all the other groups (P < 0.001 compared with all other groups). The operating times for groups 2, 3, and 4 did not differ significantly (P > 0.05). The cannulation of the femoral vein required a mean of 32 ± 5.3 min for group 1, 24.9 ± 5.7 min for group 2, 18.4 ± 4 min for group 3, and 17.2 ± 3.4 min for group 4. The operating time of group 1 was significantly longer when compared with all groups (P < 0.001 for all groups). Group 2 also had a longer operating time than groups 3 and 4 (P < 0.001 compared with both groups). Groups 3 and 4 did not show any statistical significant difference when their operating time was compared (P > 0.05). CUSUM analysis suggested that the number of cases required to achieve the required experience to most effectively cannulate the jugular and femoral vein is approximately 50 and 100 cases, respectively. The adverse effects of the procedure included two unexpected deaths, both of which occurred in group 1 (0.5% in total). ConclusionsThe authors' experience regarding the learning curve of the cannulation of the femoral and jugular vein in rats from 200 animals operated over a period of 1 y for the evaluation of the pharmacokinetic properties of drug candidates suggests significant experience is required to optimize the operating time required for the procedure.

Comparison of 2 Different Barrier Solutions (icodextrin 4% vs. dextran 70) used as Adhesion-prevention Agents after Microsurgical Adnexal Operations

In this prospective randomized clinical trial, 2 different barrier solutions (icodextrin 4% vs. dextran 70) were compared with regard to their antiadhesive properties, their tolerance and their persistence in situ. To this end, 45 patients suffering from infertility due to adnexal adhesions with indication for microsurgical adhesiolysis were randomized to 2 treatment groups. In advance of abdominal closure, patients were randomized to receive either 1,000 mL of icodextrin 4% solution (n = 23) or 300 mL dextran 70 instillation (n = 22). Serial transvaginal ultrasonographic scans were conducted on days 1, 3, 5 and 7 after surgery to measure the remaining volumes of each barrier solution. Seven days after initial surgery, a second-look laparoscopy was performed; remaining fluids were aspirated and measured and adhesions were rescored (final adhesion score). Differences between treatment groups were not significant (p = 0.775). With regard to their tolerance, the advantages of the icodextrin 4% solution became obvious, as edema of vulva and abdomen occurred more frequently after dextran 70 instillation. In conclusion, microsurgical adhesiolysis and application of icodextrin 4% solution or dextran 70 as adhesion-prevention agent resulted in reduction of incidence, extent and severity of adhesions. Both solutions were well tolerated.

Flow Diversion Is Not Yet the Complete Package

arsaut et al. prepared an article on their results after flow diversion in giant curved and bifurcation experiD ments with very low porosity flow diversion devices. This was done to improve on their prior experience to occlude aneurysms with flow diverters as a stand-alone therapy by progressively increasing the metal density of devices (1). They demonstrated that increasing the metal content of flow diversion devices (from 48 to 64 wire devices and then to double overlapping 64 wire devices) remained insufficient to reliably cause giant end wall bifurcation and curved sidewall aneurysm occlusion. Angiography at 3 months in most cases showed widely patent aneurysms and microscopic photography consistently revealed apertures through the neointima covering the devices, permitting blood flow to keep aneurysms, and branches, patent. As they point out, fundamental problems with devices deployed in a curved configuration include the incident angle of flow and the increased porosity found at the device convexity (2). They did note that the models they constructed were more challenging than previous animal models used as aneurysms were larger, and necks wider. This is an interesting article and many researchers would have argued, as Darsaut et al. did, that low porosity devices would occlude the aneurysm. The classic surgical treatment for giant aneurysms has been either microsurgical direct clip-reconstruction or occlusion followed by a cerebral bypass for those patients who fail in a balloon test occlusion. Nevertheless, the emergence of new endovascular techniques, especially flowdiverting devices, has promised to revolutionize the treatment of giant aneurysms, possibly avoiding major microsurgical operations. However, this article highlights the fact that endovascular therapy is not yet the standard for the treatment of all giant intracranial aneurysms, even in the controlled situation such as

Animals and Animal Toxins in Traditional and Modern Medicine

Background: Animals and animal toxins have a long-lasting tradition in diverse human cultures all over the world. In addition to medicinal plants, animals are important components of many traditional medicines. Methods: By using selected examples, we give an overview of animals, animal toxins, and derivatives to illustrate their pharmacological and therapeutic potential and use. Results: Animals have been used in traditional and modern medicines for treatment purposes. Medicinal leeches (Hirudo medicinalis) are applied for microsurgical operations and for prevention of tissue necrosis due to congestion and insufficient supply of blood capillaries. Patches of blister beetles (Cantharis vesicatoria) have been topically applied in China since centuries against warts and poxvirus-caused molluscum contagiosum. Snake venoms are a rich source for drug development. Some examples are batroxobin (reptilase) from Bothrops moujeni and B. atrox, and others. Bioactive peptides have also been identified from spider and scorpion venoms such as GsMTx-4 from the Chilean rose Tarantula (Grammostola spatulata) or chlorotoxin from the Yellow Israeli scorpion (Leiurus quinquestriatus quinquestriatus). Amphibian venoms have frequently been used as arrow poisons by indigenous tribes. The marine biodiversity is also a rich resource for new drugs. A large array of toxins can be found in sea snails. Important examples are ωconotoxin from Conus purpurascens, contukalin-G from C. geographus, and ACV1 from Review Article British Journal of Applied Science & Technology, 4(4): 578-593, 2014 579 C. victoriae. Examples among many others are aplidine from Aplidium albicans, pseudopterosin from the Pseudopterogorgia genus, and dolastatin from Dolabella auricularia. Conclusion: Animals or compounds isolated from snake, spider or scorpion venoms, frog toxins, and toxins from marine organisms reveal astonishing pharmacological activities. Cross-disciplinary approaches between organic and medicinal chemistry, pharmacology, toxicology, molecular biology, and medicine are required to explore the full potential of animal toxins and their derivatives as important candidates in the drug development pipeline.

Visualization of luminal thrombosis and mural Iron accumulation in giant aneurysms with Ex vivo 4.7T magnetic resonance imaging.

Background:Better diagnostic tools to identify rupture-prone saccular intracranial aneurysms (sIA) are needed. Inflammation and luminal thrombus associate with degeneration and rupture of the sIA wall. Iron-uptake has been detected in the inflammatory cells of the sIA wall and thrombus is the likely source of this iron. We investigated ex vivo the use of magnetic resonance imaging (MRI) to detect iron accumulation and luminal thrombus in giant sIAs.Methods:Giant sIAs (n = 3) were acquired from microsurgical operations, fixed with formalin, embedded in agar and imaged at 4.7T. Samples were sectioned maintaining the orientation of the axial plane of MRI scans, and stained (hematoxylin-eosin and Prussian blue).Results:All three giant sIAs showed a degenerated hypocellular wall with both mural and adventitial iron accumulation and displayed different degrees of luminal thrombus formation and thrombus organization. Signal intensity varied within the same sIA wall and associated with iron accumulation in all tested sequences. Wall areas with iron accumulation had significantly lower signal to noise ratio (SNR) compared with areas without iron accumulation (P = 0.002). Fresh and organizing thrombus differed in their MRI presentation and differed in signal intensity of the aneurysm wall (P = 0.027).Conclusion:MRI can detect ex vivo the accumulation of iron in giant sIA wall, as well as fresh and organizing luminal thrombus. These features have been previously associated with fragile, rupture-prone aneurysm wall. Further studies of iron accumulation as a marker of rupture-prone aneurysm wall are needed.