Minor Leakage Research Articles

Emergency surgery for hemobilia due to hepatic artery pseudoaneurysm rupture complicated by Mirizzi syndrome type II: a case report

BackgroundHemobilia refers to bleeding into the biliary tract. Hepatic artery pseudoaneurysm (HAP) rupture is an uncommon cause of hemobilia, and cases of HAP associated with Mirizzi syndrome are extremely rare. Although transarterial embolization is recommended as the first-line treatment for hemobilia, surgery is sometimes required.Case presentationA 76-year-old woman was referred to our hospital with epigastric pain. She was febrile and had conjunctival icterus and epigastric tenderness. Laboratory tests revealed abnormal white blood cell count and liver function. An abdominal computed tomography (CT) revealed multiple calculi in the gallbladder, an incarcerated calculus in the cystic duct, and a slightly dilated common hepatic duct. Based on examination findings, she was diagnosed with Mirizzi syndrome type I, complicated by cholangitis. Intravenous antibiotics were administered, and we performed endoscopic retrograde cholangiopancreatography (ERCP) to place a drainage tube. The fever persisted; therefore, contrast-enhanced CT (CECT) was performed. This revealed portal vein thrombosis and hepatic abscesses; therefore, heparin infusion was administered. The following day, she complained of melena, and laboratory tests showed that she was anemic. ERCP was performed to change the drainage tube in the bile duct; however, bleeding from the papilla of Vater was observed. CECT demonstrated a right HAP with high-density fluid in the gallbladder and gallbladder perforation. Finally, she was diagnosed with hemobilia caused by HAP rupture, and emergency surgery was performed to secure hemostasis and control the infection. During laparotomy, we found that a right HAP had ruptured into the gallbladder. The gallbladder made a cholecystobiliary fistula, which indicated Mirizzi syndrome type II. Although we tried to repair the right hepatic artery, we later ligated it due to arterial wall vulnerability. Then, we performed subtotal cholecystectomy and inserted a T-tube into the common bile duct. There were no postoperative complications except for minor leakage from the T-tube insertion site. The patient was discharged after a total hospital stay of 7 weeks.ConclusionsWe experienced an extremely rare case of emergency definitive surgery for hemobilia due to HAP rupture complicated by Mirizzi syndrome type II. Surgery might be indicated when controlling underlying infections was required.

Role of percutaneous radiological treatment in biliary complications associated with adult left lobe living donor liver transplantation: a single-center experience.

Biliary complications develop at a higher rate in living donor liver transplantation (LDLT) compared with cadaveric liver transplantation. Almost all studies about biliary complications after LDLT were made with the right lobe. The aim of this study was to determine the frequency of biliary complications developing after adult left lobe LDLT and to evaluate the efficacy of the algorithm followed in diagnosis and treatment, particularly percutaneous radiological treatment. A total of 2185 LDLT operations performed in our center between May 2009 and December 2019 were retrospectively reviewed and patients receiving left lobe LDLT were analyzed regarding biliary complications and treatments. Biliary complications were treated via percutaneous drainage under ultrasound (US) guidance, endoscopic retrograde cholangiopancreatography (ERCP), and percutaneous transhepatic cholangiography (PTC)/ percutaneous transhepatic biliary drainage (PTBD). Patient demographics, ERCP procedures before percutaneous treatment, and percutaneous treatment indications were analyzed. A total of 69 adult patients received left lobe LDLT. Biliary complications requiring endoscopic and/or percutaneous treatment developed in 28 patients (40%). Of these patients, 4 had bile leakage (14%), 20 had anastomosis stricture (72%), and 4 had both leakage and anastomosis stricture (14%). External drainage treatment under ultrasound guidance was sufficient for 2 of 4 patients with bile leakage, and these cases were accepted as minor bile leakage (7%). Overall, 26 patients underwent ERCP; of these, 8 were referred for PTC/PTBD because the guidewire and/or balloon-stent could not pass the anastomosis stricture (n=7) and common bile duct cannulation could not be obtained because of duodenal diverticulum (n=1). Diagnostic PTC was performed in 10 patients, 8 were referred after inadequate/failed ERCP procedure and two were referred directly without ERCP. Anastomosis stricture was found in 7 patients and anastomosis stricture and bile leakage in 3. In 7 patients determined to have stricture, balloon dilatation was applied and then biliary drainage was performed. In 3 patients who had leakage and anastomosis stricture, balloon dilatation was applied for stricture; after dilatation, an IEBD catheter was placed through the leakage region in 2 patients, while a covered metallic stent passing through the leakage region was placed in one patient. Generally, ERCP is the first preferred method in biliary complications of LDLT; however, in cases where a response cannot be obtained by endoscopic treatment or require complex and/or aggressive treatment, percutaneous radiological treatment should be the treatment of choice before surgery in left lobe LDLT.

Pure laparoscopic living donor left lateral sectionectomy in pediatric transplantation: First case in Western India

Pure laparoscopic left lateral sectionectomy (LLS) is fast becoming the standard technique for donor hepatectomy in pediatric liver transplantation. We present the first case of pure laparoscopic LLS performed in Western India. An 11-month-old male child suffering from biliary atresia with history of failed Kasai operation at the age of 3 months presented to our center in Mumbai for a living donor liver transplantation. The donor was his father, 32-year-old with body mass index of 22, LAI +10 and MRE fat fraction of 1%-3%. Projected graft weight of LLS was 187 grams with GRWR of 2.4. He had favorable vascular and biliary anatomy with left hepatic artery (LHA) arising from hepatic artery proper and segment 4 artery from LHA, type A portal vein and A1B1 biliary anatomy. Patient underwent pure laparoscopic LLS. The technique of pure laparoscopic LLS is demonstrated in the attached video. The graft warm ischemic time was 7 minutes, blood loss 300 mL and operating time 7 hours. The donor was discharged on 5th post-operative day with a minor post-operative bile leak that resolved spontaneously and is well at 1 month follow-up. Pure laparoscopic living donor LLS is safe and should be performed by a team experienced in open donor hepatectomy, advanced laparoscopic surgery after specific training in the procedure and negotiating the learning curve under supervision. The operative time was long, but consistent with worldwide data for early cases, which we anticipate will reduce with more experience.

Laparoscopic CBD Exploration (LCBDE) a better and safe option for large CBD stones

Background: Conventionally, common bile duct stones (CBDS) are removed with help of ERCP. However, if CBDS are larger than 10 mm, then the ERCP failure rate to retrieve CBDS becomes high. In that case, open or laparoscopic common bile duct exploration (LCBDE) is other alternative. In this era of minimally invasive surgery, laparoscopic CBD exploration (LCBDE) seems to be a better option than open approach, but in our set up the safety of LCBDE is questioned. Aim: To see the conversion rate as well as complications associated with LCBDE. Material & Methods: Methods: This is a retrospective analysis of data of patients who underwent Laparoscopic Common Bile Duct Exploration (LCBDE) for large CBD stones at Fatima Memorial Hospital Lahore. Results: Since 2012, 29 patients of large (≥10 mm) CBD stones were included in this study. Among them 20(69.9%) were females and 9(31.01%) were males. The mean CBD stone size was 13 mm. Stones were extracted transcystically in 4 case and Transcholedochal stone extraction was done in 25 cases. The average duration of surgery was 130 minutes, but all cases were completed successfully without converting to open approach. There was minor bile leak in 3 patients which was managed successfully without any further intervention. No other complication was observed with LCBDE and even no retained stone was reported. Conclusion: Laparoscopic CBD exploration is safe and effective method of dealing CBD stones especially of large size when the chances of ERCP failure to retrieve stones are high. Keywords: Laparoscopy, ERCP, common bile duct,

Laparoscopic common bile duct exploration with primary closure over an ante-grade biliary stent-our experience

Background: Aim of study was the assessment of laparoscopic common bile duct (CBD) exploration with primary closure over an ante-gradely placed endo-biliary stent for CBD stones in terms of operating time, rate of conversion to open procedure, hospital stay, postoperative complications and residual disease.Methods: Our data was analysed retrospectively over a period of 5 years (2015-2020) on all the patients who underwent laparoscopic CBD exploration with primary closure over an ante-gradely placed endo-biliary stent followed by cholecystectomy at SMHS hospital, Srinagar, J and K, India. Total of 30 such patients were identified.Results: The mean procedure time was 93.5±23.16 minutes. There were no intra operative complications encountered in the study. Four patients were converted to open (13.33%). The mean duration of hospital stay was 4.56±1.99 Days. The total number of patients that developed post-operative complications was 7 (23.33%). The most frequently encountered post-operative complication was stent migration (13.33%). The next most common post-operative complication was minor biliary leak (10%) which resolved spontaneously. There was no mortality experienced during the study. Two patients (6.66%) had residual stones and 28 (93.33%) patients had complete clearance of the CBD.Conclusions: Laparoscopic CBD exploration with primary closure over an ante-gradely placed endo-biliary stent is a feasible option and is a safe procedure. Endoscopic removal of the stent can safely be done after an interval of 6-8 weeks.

First Experience of Intra-Operative Radiation Therapy (IORT) during Kyphoplasty in Patients Diagnosed with Spinal Metastasis in Iran

Object: Based on previous studies, 30 to 40% of cancer patients are diagnosed with bone metastasis. Median Overall Survival (OS) of patients who are diagnosed with spinal metastasis (vertebral structures) is about 7 to 9 months which with recent progresses in oncologic and radiotherapy treatment modalities, their prognosis is slightly developed. In this study, authors plan to evaluate the effects of Intra-operative Radiation Therapy (IORT) in patients who are candidate for Kyphoplasty procedure. Methods: In this study, we have included patients who are diagnosed with spinal metastasis with radiological and histopathological confirmation. From July 2017 to December 2018, we have included 9 patients who fulfilled our predefined inclusion and exclusion criteria into our case-series study performed on Shohada Tajrish Hospital. Patients underwent radiotherapy during Kyphoplasty by our IORT device INTRABEAM (Carl Zeiss AG, Germany) as “Kypho-IORT’ procedure. We have evaluated these patients in post-operative period, as well as on 2 weeks, 1 month, 2 months and 6 months on post-operative period as our follow-up plan. Results: In this study, 9 patients (5 males and 4 females) with mean age of 68 years with spinal metastasis from breast (4 cases), prostate (2 cases), lung (2 cases) and gastrointestinal tract (1 case), underwent Kypho-IORT for 15 vertebrae levels with individualized radiation dose and interval. In postoperative follow-up period, patients exhibit pain relief (in 78%) assessed by Visual Assessment Score (VAS) and improvement in their Quality of Life (QoL). No major complications including new neurological deficit, major cement leak and embolic disorders were encountered during the study; however, minor cement leak encountered in 4 cases, and 2 patients have expired during follow up period; however, other patients are still alive and under follow-up with mean OS of 10 months. Conclusion: This study is the first experience of evaluation of IORT effects during Kyphoplasty in Iran, in patients diagnosed with spinal metastasis with poor prognosis, to improve their quality of life, local control rate and their OS. This study could be considered as one of the pioneers in continuing the evaluation of Kypho-IORT as a novel technique in these group of patients.

Mucosal blood flow in the remaining rectal stump is more affected by total than partial mesorectal excision in patients undergoing anterior resection: a key to understanding differing rates of anastomotic leakage?

PurposeAnterior resection is the procedure of choice for tumours in the mid and upper rectum. Depending on tumour height, a total mesorectal excision (TME) or partial mesorectal excision (PME) can be performed. Low anastomoses in particular have a high risk of developing anastomotic leakage, which might be explained by blood perfusion compromise. A pilot study indicated a worse blood flow in TME patients in an open setting. The aim of this study was to further evaluate perianastomotic blood perfusion changes in relation to TME and PME in a predominantly laparoscopic context.MethodIn this prospective cohort study, laser Doppler flowmetry was used to evaluate the perianastomotic colonic and rectal perfusion before and after surgery. The two surgical techniques were compared in terms of mean differences of perfusion units using a repeated measures ANOVA design, which also enabled interaction analyses between type of mesorectal excision and location of measurement. Anastomotic leakage until 90 days after surgery was reported for descriptive purposes.ResultsSome 28 patients were available for analysis: 17 TME and 11 PME patients. TME patients had a reduced blood perfusion postoperatively compared to PME patients in the aboral posterior area (mean difference: −57 vs 18 perfusion units; p = 0.010). An interaction between mesorectal excision type and anterior/posterior location was detected at the aboral level (p = 0.007). Two patients developed a minor leakage, diagnosed after discharge.ConclusionPatients operated on using TME have a decreased blood flow in the aboral posterior quadrant of the rectum postoperatively compared to patients operated on using PME. This might explain differing rates of anastomotic leakage.Trial registrationClinicalTrials.gov Identifier: NCT02401100

Identifying superior drought-tolerant Bermudagrass accessions and their defensive responses to mild and severe drought conditions

The natural variation of drought tolerance among eight Iranian bermudagrass (Cynodon dactylon L.) accessions was evaluated and compared with a commonly used variety by measuring various morphological, growth, physiological and molecular responses during mild and severe drought stress conditions. A combined multivariable analysis using principal component analysis, hierarchical clustering analysis, as well as drought-tolerance ranking measurement showed that the accessions were clustered into three groups in terms of drought tolerance. This method evaluated three accessions (Maragh, Abyaneh, and Badrood) as superior drought-tolerant, three (Karshahi, Josheghan, and Kashan) as relatively drought-tolerant, and three (Ardeha, SWI-7, and Khonb) as drought-sanative genotypes. Drought-tolerant accessions generally showed improved growth and relative water content (RWC), minor electrolyte leakage (EL) and lipid peroxidation (MDA), higher content of pigments (Chlorophyll and carotenoid) and dark green color index (DGCI), more significant up-regulation of two stress-related genes (ECERIFERUM1 and Delta 1-pyrroline-5-carboxylate synthetase), as well as higher accumulation of proline content compared to sensitive accessions under drought stress. On the other hand, drought-sensitive accessions typically had more activity of antioxidant enzymes (catalase and ascorbate peroxidase), and higher amounts of soluble sugars (glucose, mannose, and rhamnose), compared to tolerant accessions under drought stress. In conclusion, different defensive strategies may be recruited by tolerant or sensitive bermudagrass genotypes during encountering to drought stress.

Significantly enhanced desalination performance of flow-electrode capacitive deionization via cathodic iodide redox couple and its great potential in treatment of iodide-containing saline wastewater

Flow-electrode capacitive deionization (FCDI) is attracting growing attention owing to its advantages such as effective ion removal capacity and easy management of the electrodes. Optimization of the flow-electrode comprising carbon materials and aqueous electrolyte is always a research hotspot aimed at improving FCDI performance. Herein, we innovatively introduced appropriate amount of KI3 into the cathodic flow-electrode to provide a highly efficient means of enhancing FCDI desalination performance with a stable behavior in salt electrosorption and desorption over multi-cycle consecutive runs. The accelerated salt removal rate originated from the reversible redox reaction of I3−/I− and the maintenance of the electro-neutrality of the global electrolyte. Although possible minor release or leakage of I−/I3− through the cation-exchange membrane and into the treated water occurred, which makes the proposed approach not quite suitable for potable water production, we demonstrated that this system has great application prospects in treatment of iodide-containing saline wastewater without causing secondary pollution.

Automated Quantitative Analysis of ex vivo Blood-Brain Barrier Permeability Using Intellesis Machine-Learning.

BackgroundAn increase in blood brain barrier permeability commonly precedes neuro-inflammation and cognitive impairment in models of dementia. Common methods to estimate capillary permeability have potential confounders, or require laborious and subjective semi-manual analysis.New methodHere we used snap frozen mouse and rat brain sections that were double-immunofluorescent labeled for immunoglobulin G (IgG; plasma protein) and laminin-α4 (capillary basement membrane). A Machine Learning Image Analysis program (Zeiss ZEN Intellisis) was trained to recognize and segment laminin-α4 to equivocally identify blood vessels in large sets of images. An IgG subclass based on a threshold intensity was segmented and quantitated only in extravascular regions. The residual parenchymal IgG fluorescence is indicative of blood-to-brain extravasation of IgG and was accurately quantitated.ResultsAutomated machine-learning and threshold based segmentation of only parenchymal IgG extravasation accentuates otherwise indistinct capillary permeability, particularly frequent in minor BBB leakage. Comparison with Existing Methods: Large datasets can be processed and analyzed quickly and robustly to provide an overview of vascular permeability throughout the brain. All human bias or ambiguity involved in classifying and measuring leakage is removed.ConclusionHere we describe a fast and precise method of visualizing and quantitating BBB permeability in mouse and rat brain tissue, while avoiding the confounding influence of unphysiological conditions such as perfusion and eliminating any human related bias from analysis.

Hyperspectral Imaging: A New Intraoperative Tool for Pouch Assessment in Patients Undergoing Restorative Proctocolectomy

Introduction: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is a challenging operation. Especially the mobilization of the pouch into the pelvis can be complex. Adequate perfusion of the pouch is required for optimal healing and functioning. Methods: With hyperspectral imaging (HSI) wavelengths between 500 and 1,000 nm can be analyzed in addition to visible light and by reflecting patterns. This intraoperative procedure is non-invasive, contact-free, and no contrast medium is needed. Fifteen patients undergoing IPAA were examined prospectively, and the pouch was evaluated by HSI intraoperatively. HSI was measured in standardized fashion at 4 defined locations of the J-pouch. Each measurement took about 10 s. The clinical postoperative course was assessed in all patients and correlated to the intraoperative HSI findings. Results: Mean near-infrared perfusion and oxygenation of patients showed values ≥74% for all defined pouch areas, revealing good blood supply. Three minor anastomotic leaks were detected by standard pouchoscopy in the postoperative course, which could be treated conservatively with endosponge therapy. Conclusion: HSI values of perfusion and oxygenation of the IPAA were high. The leak rate is associated with redo procedures. This is reflected by the current literature and most likely related to the higher complexity of the revisional pouch operation. HSI has proved itself as a quick and effective new intraoperative tool to evaluate pouch perfusion objectively and quantitatively.

Feasibility of Laparoscopic Closed Cystectomy for Hepatic Hydatid Cyst in Segments VI, VII, and VIII.

BackgroundLaparoscopic closed cystectomy of the hepatic hydatid cyst (HHC) is increasingly being performed as it has improved postoperative recovery and reduced morbidity. However, laparoscopic closed cystectomy of HHC is difficult when located in segments VI, VII, and VIII. This study aimed to assess the laparoscopic closed cystectomy feasibility of the HHC when cysts are located at the difficult access site.MethodologySeven patients out of 13 patients of HHC treated laparoscopically in the surgery department from 2014 to 2018 were included. These patients had cysts located in segments VI, VII, and VIII of the liver. All patients received perioperative albendazole, underwent ultrasonography (USG) and contrast-enhanced computed tomography for diagnosis. We noted the demographic character of all the patients, cyst’s location, cyst size, type of the cyst, mean operative time, intraoperative and postoperative complications, duration of the hospital stay, and recurrence of the cyst. ResultsAll patients underwent laparoscopic closed cystectomy of HHC. One patient had a conversion to open procedure, and one patient had an additional thoracoscopic approach added. The mean operative time was 191.86 minutes. There were no intraoperative complications. One patient had developed a surgical site infection, and three had a minor bile leak postoperatively. The hospital stay’s mean duration was four days, and there was no recurrence in the 21 months follow-up.ConclusionThe laparoscopic closed cystectomy of HHC located at segments VI, VII, and VIII is feasible, safe, and cost-effective. A thorough preoperative evaluation, preparation, and radiological planning of the procedure should be done.

Surgical Outcome of Pharyngocutaneous Fistula After Total Laryngectomy: A Retrospective Study.

The management of pharyngocutaneous fistula is challenging. We typically treat postlaryngectomy pharyngocutaneous fistulas with a pedicled pectoralis major flap transfer. This study analyzed the outcomes of our surgical treatments for pharyngocutaneous fistula to propose considerations for surgical strategies. This retrospective review included all patients who underwent surgical repair of a postlaryngectomy pharyngocutaneous fistula at the National Cancer Center Hospital East in Kashiwa, Japan, from January 2005 to December 2019. The final analysis included 33 cases (median age, 71 years). Twenty-two cases had a history of radiotherapy to the head and neck region. Wound closures were performed with a pedicled pectoralis major musculocutaneous flap (n = 26) or pedicled pectoralis major muscle flap (n = 7). In 1 case, a deltopectoral flap was combined with the pectoralis major musculocutaneous flap. The median total operation time was 236 minutes, the median blood loss during surgery was 144 mL, and the median hospital stay after the reconstructive surgery was 39 days. Minor leakage occurred in 19 cases, and major leakage occurred in 2 cases. The fistula was finally cured successfully in 31 cases. We compared the outcomes in patients with leakage after surgical repair to those in patients without leakage after surgical repair to determine the risk factors for leakage after surgical repair of a pharyngocutaneous fistula. Five patients in the nonleakage group and 17 in the leakage group had a history of preoperative radiation (P = 0.052). The median preoperative blood values in the nonleakage and leakage groups were as follows: albumin, 3.6 and 3.2 g/dL (P = 0.061), and C-reactive protein, 2.36 and 6.77 mg/dL (P = 0.031), respectively. The time between the occurrence of the fistula and reconstructive surgery was 32 and 9 days in the nonleakage and leakage groups, respectively (P = 0.009). Our surgical treatment for postlaryngectomy pharyngocutaneous fistula succeeded in 31 of 33 cases (94%). This study demonstrated that pedicled pectoralis major flap transfer is useful for the treatment of postlaryngectomy pharyngocutaneous fistula.

Estimation of sensor measurement errors in reactor coolant systems using multi-sensor fusion

A nuclear power plant is typically instrumented with a variety of sensors to continually monitor its variables, and their sensor’s measurements may be used to assess the plant state and initiate safety actions, if needed. Errors in sensor measurements, due to factors such as calibration drifts, critically affect such state assessments. We address a problem of estimating sensor errors using physics-informed machine learning methods that use measurements collected under known plant conditions. For a given sensor, we propose an information fusion method that uses measurements from other sensors to estimate its output assuming it is error-free and provides its difference from an actual measurement as an error estimate. We present the ensemble of trees and support vector machine fusers, and evaluate their performance using measurements collected over an emulated test loop of a pressurized water reactor. The plant variables are related to each other through the underlying physical laws under inertial constraints that place bounds on their derivatives, which analytically justify the applicability of machine learning methods for computing these fusers. Under twenty scenarios, we assess their sensor error estimates for pressure sensors of the heat exchanger of a reactor’s primary coolant system. Multiple types of errors are captured by both fusers under externally induced calibration drifts, blockages, minor leaks and air gaps in sensing lines, and electromagnetic interference; the root mean square error of the estimation of error is under 2.2% percent of the maximum measurement. We present generalization equations, in the framework of statistical learning theory, for these methods that characterize the confidence probability that the estimation error is bounded by a specified parameter in future test scenarios.

ITriangular Stapling Technique: A Novel Reconstruction Method and Clinical Outcomes of Cervical Esophagogastric Anastomosis after Esophagectomy.

We herein report the feasibility and safety of cervical end-to-end anastomosis by the iTriangular stapling technique (iTST), which was developed as an extension of the triangular stapling technique (TST) after minimally invasive esophagectomy (MIE). A total of 45 patients with thoracic esophageal cancer who underwent reconstruction with cervical esophagogastric anastomosis by iTST using a linear stapler after MIE between January 2016 and January 2019 were retrospectively reviewed. We modified and improved upon the TST by adding a 1- to 2-cm vertical incision on the anterior wall of the remnant esophageal stump to enlarge the anastomotic lumen and thereby reduce the risk of anastomotic stenosis. The short-term patient outcomes were determined to assess the safety and feasibility of our procedures. The median operating time was 686 (range, 319-1110) minutes, and the median blood loss was 170 (range, 5-1180) ml. There were no cases of anastomotic stenosis in this study, although 2 patients (4.4%) developed minor anastomotic leakage. A case (2.2%) of tracheal fistula due to the apex of the triangular anastomosis was resolved simply by delaying the patient's oral intake. The mean length of the hospitalization was 21days. The iTST provides a larger lumen unlimited by the size of the esophagus in cervical esophagogastric anastomosis. This technique is feasible, and sufficient short-term results have been achieved. Further studies with the accumulation of more cases will be required to prove the benefits of iTST for reconstruction after MIE.

Stroke Microsurgical Thrombectomy Human Placenta Simulator

Stroke microsurgical cerebrovascular thrombectomy reports are limited, although this technique could be used in many centers as a primary treatment or a salvage intervention option. It requires great ability, so our aim is to describe and validate a stroke microsurgical thrombectomy exvivo simulator with operative nuances analysis. Human placenta (HP) models simulated middle cerebral artery vessels with intraluminal thrombus to be microsurgically excised. Six neurosurgeons performed 1-mm and 2-mm longitudinal and transverse arteriotomy in different arteries to remove a 1.5-cm length thrombus. Validation through construct validity compared time to complete the task, complete vessel cleaning, vessel manipulation, vessel stenosis, and leakage in both techniques. All 6 HP models reproduced with fidelity stroke microsurgical thrombectomy, so participants completed 24 sessions, 4 for each neurosurgeon on the same model in different arteries. Construct validity highlighted microsurgical technical difficulties with positive results obtained by parameters variation during performance. Transverse arteriotomy with 1-mm length had best results (P < 0.05) allowing complete thrombus removal, less stenosis, and minor leakage in abbreviated time. A HP simulator can reproduce with high fidelity all stroke microsurgical thrombectomy part tasks. Transverse 1-mm arteriotomy followed by thrombectomy and 2 simple sutures can fulfill all quality assurance aspects in such intervention accordingly to training model, due to easier vessel opening, complete thrombus removal, no stenosis, and faster microsuture.

Aneurysmal subarachnoid hemorrhage accompanied by changes in the patterns of chronic migraine: a case report

Subarachnoid hemorrhage (SAH) has a high mortality rate, and cerebral aneurysm ruptures account for 80% of all cases. Although several previous case studies have reported a headache before aneurysmal SAH, no previous study has reported a case of SAH after a change in the existing migraine pattern without any other clinical signs. A 43-year-old male patient who had suffered chronic migraines for 10 years visited the emergency department due to migraine symptoms, which exacerbated 3 days before the visit. He was admitted for symptom management, and his condition improved after taking migraine-specific medication. However, his consciousness deteriorated, and he became drowsy 8 days from the onset of headache aggravation. Brain computed tomography angiography revealed SAH. A small ruptured aneurysm, which was not detected by brain magnetic resonance angiography performed a few days earlier, was found in the A1 segment of the right anterior cerebral artery. We performed emergency endovascular coil embolization in the right A1 without any other complications. After the procedure, his neurological symptoms no longer exacerbated during hospitalization. He showed only a mild headache after 2 weeks and was discharged. Aneurysmal SAH is one of the most devastating neurological diseases, but early detection and treatment of aneurysms before major rupture may facilitate a good prognosis. If the pattern of previously diagnosed chronic migraine changes suddenly, a minor leak before the major rupture of a cerebral aneurysm should be considered, even if a sentinel headache has not been suggested.

Computed tomography-guided microwave ablation combined with percutaneous vertebroplasty for treatment of painful high thoracic vertebral metastases

Purpose To retrospectively evaluate the efficacy and safety of computed tomography (CT)-guided microwave ablation (MWA) combined with percutaneous vertebroplasty (PVP) as a treatment for painful high thoracic vertebral metastases (T1–T4). Materials and Methods In this retrospective study, 23 adult patients (33 high thoracic vertebral metastases) with moderate to severe pain were treated with CT-guided MWA and PVP. The procedural effectiveness was evaluated using a Visual Analog Scale (VAS), daily morphine consumption, and the Oswestry Disability Index (ODI) before and immediately after the procedure and during follow-up. Results Technical success was achieved in all patients. The mean pre-procedure VAS score and morphine doses were 6.7 ± 1.7 (5–10) and 105.2 ± 32.7 (30–150) mg, respectively. The mean VAS scores and daily morphine doses at 24 h and 1, 4, 12, and 24 weeks post-operatively were 3.2 ± 1.4 and 41.3 ± 9.6 mg; 1.8 ± 1.0 and 31.5 ± 12.2 mg; 1.4 ± 1.3 and 19.6 ± 12.4 mg; 1.1 ± 0.8 and 14.5 ± 9.6 mg; and 1.0 ± 0.7 and 13.9 ± 9.3 mg, respectively (all p < 0.001). ODI scores significantly decreased (p < 0.05). Minor cement leakage occurred in 10 patients (30.30%) with no symptoms. Follow-up imaging showed no local tumor progression. Conclusions Preliminary results suggest MWA combined with PVP is an effective and safe treatment for painful high thoracic vertebral metastases (T1–T4) and can significantly relieve pain and improve the quality of life of patients. However, its efficacy should be confirmed by mid- and long-term studies.

Totally Laparoscopic and Conventional Open Living Donor Right Hepatectomy: A Comparative Study of Outcomes

Although laparoscopic liver resection has progressively developed with increased surgical experience and the improvement of laparoscopes and specialized instruments, only a limited number of centers have performed laparoscopic living donor hepatectomy(LDRH) . We describe the experiences and outcomes associated with LDRH in adult-to-adult LDLT in order to assess the safety of the totally laparoscopic technique in donors. Between December 2014 and October 2018, we performed 97 cases of living donor right hepatectomy. Among them, 50 donors underwent totally laparoscopic living donor right hepatectomy and 47 donors underwent conventional open living donor right hepatectomy. We retrospectively reviewed the medical records to ascertain donor safety and the reproducibility of LDRH. The total operation time was longer (367.0±74.3 vs 323.5±62.5; P=.002) and the warm ischemic time was also longer(9.2±4.6 vs 1.8±1.6;P< .002) in LDRH group. However, the length of postoperative hospital stay was similar in both groups and no donors in LDRH group required blood transfusion, conversion to open surgery, or reoperation. There was no postoperative mortality. Postoperative complication of Clavien-Dindo classification III or more was identified in only one donor who had a minor bile leakage from the cutting edge of the right hepatic duct stump requiring endoscopic biliary stent insertion. All the liver function tests returned to normal ranges within 2 weeks. In conclusion, our study reveals LDRH seems to be a safe and feasible procedure with acceptable outcomes. However, LDRH can be initially attempted after attaining sufficient experience in laparoscopic hepatectomy and LDLT techniques.

Fast, Easy, and Safe Establishment of Pneumoperitoneum in Laparoscopic Surgery: The Fingertip Technique.

Background and Objectives:There is no consensus on an ideal abdominal entry in laparoscopic surgery; as such, we aimed to assess the feasibility of the fingertip technique for safe entry and the establishment of pneumoperitoneum in transperitoneal laparoscopic surgery.Methods:We prospectively assessed 96 consecutive patients who underwent laparoscopic transperitoneal surgery between December 2018 and September 2019. For all patients, pneumoperitoneum was performed using the fingertip technique, which we recently defined. The duration of time for initial entry, the occurrence of gas leakage, and the complications were evaluated.Results:The median duration of initial entry was 90 (75 – 145) seconds. Pneumoperitoneum was established on the first attempt in all patients. Some events were encountered at the time of implementation of the fingertip technique, such as subcutaneous minor bleeding (5.2%) and gas leakage (4.1%). These events were controlled with cauterization and suturing. There was no visceral or major vascular injury in any patient case.Conclusions:The fingertip technique is a fast, safe, and feasible method for establishing pneumoperitoneum in transperitoneal laparoscopic surgery.