Clip Placement Research Articles

574 Role of Prophylactic Endoscopic Clipping for Prevention of Delayed Post-Polypectomy Bleeding: Meta-Analysis of Randomized Controlled Trials

INTRODUCTION: Post-polypectomy bleeding is a common complication of colonoscopy. Several endoscopic techniques including prophylactic endoscopic clip placement are used for prevention of post-polypectomy bleeding. However, several studies have reported mixed results on the efficacy of this approach. We conducted a meta-analysis of randomized controlled trials (RCTs) to assess the efficacy of prophylactic endoscopic clipping for prevention of delayed post-polypectomy bleeding. METHODS: Several databases (Embase, Pubmed, Cochrane database, Google Scholar) and abstracts of gastrointestinal and surgical meetings were searched extensively for relevant articles. Studies comparing prophylactic endoscopic clipping alone to standard colonoscopy with no endoscopic clipping were included. Studies that combined prophylactic clipping with other hemostatic techniques were excluded. Data was extracted using a standard form by two reviewers. Data regarding patient characteristics, types of polyps resected, post-polypectomy bleeding and other complications were extracted. Effect sizes were computed either using the fixed effects or random effects model using the Comprehensive Meta-analysis software. Publication bias, quality of studies and heterogeneity were analyzed. RESULTS: Nine RCTs were included in this study. The studies recruited subjects from USA, Japan, Canada and Spain. There were 3762 controls and 3658 patients in the treatment arm. Studies evaluated both small (<20mm) and large polyps (>20 mm), sessile and pedunculated polyps. The polyps were predominantly removed with standard polypectomy or endoscopic mucosal resection (for larger polyps). Delayed post-polypectomy bleeding occurred in 2.4% of controls and 1.6% in patients with endoscopic clipping. On analysis of all polyps, prophylactic endoscopic clipping decreased the risk of delayed post-polypectomy bleeding (RR = 0.71: 95% CI 0.51-0.99, P = 0.04, I2= 20%). The risk reduction was seen mainly with larger polyps(>20 mm), RR = 0.53 (95% CI : 0.32-.90, P = 0.02, NNT 28) and with sessile polyps (RR = 0.52, 95% CI: 0.32-0.83, P = 0.006, NNT 100). The protective effect was not seen for small polyps (<20 mm) (P = 0.91, P = 0.7) or pedunculated polyps (RR = 0.58, P = 0.29). All studies were of high quality. No publication bias or heterogeneity was present. CONCLUSION: Prophylactic clipping decreased the risk of delayed post-polypectomy bleeding. The benefit was mainly seen in patients with sessile polyps or large polyps (>20 mm).

1263 Endoscopic Management of a Surgical Clip Found Within the Common Bile Duct Following Remotely Performed Laparoscopic Cholecystectomy

INTRODUCTION: Minimally invasive surgery with surgical clip placement has become the gold standard for management of cholecystitis and biliary colic due to its favorable safety profile and low risk of complications. Though generally safe, surgical clips can serve as a source of complication years after cholecystectomy by migrating into the common bile duct and serving as a nidus for stone formation. To date, very few cases of this have been reported. While uncommon, this complication should be considered in the differential diagnosis for choledocholithiasis and cholangitis. CASE DESCRIPTION/METHODS: Here we present a 35-year-old female with a past medical history of invasive rectal adenocarcinoma who underwent laparoscopic cholecystectomy over ten years ago. She presented to the hospital with a two-week history of RUQ abdominal pain, chills, and nausea. Physical exam showed scleral icterus and RUQ abdominal tenderness. Labs showed elevated WBC count and LFTs in a cholestatic pattern. Patient was started on antibiotics for suspected cholangitis and underwent MRCP which suggested presence of metallic clip within the common bile duct. Subsequent ERCP revealed large stone impacted against the ampulla of Vater. Sphincterotomy and balloon sweep of the common bile duct were performed with extraction of large stone formed around surgical clip, followed by release of copious amount of purulent bile. Following procedure LFTs showed downward trend and symptoms resolved. DISCUSSION: Though the exact incidence and mechanism of surgical clip migration into the common bile duct is unknown, it is thought to be a slow process with the potential for subsequent stone formation years after surgery. Clinical presentation is the same as non-iatrogenic choledocholithiasis. In most reported cases, stone extraction required surgical intervention due to large size. Here we present a case successfully managed with sphincterotomy and balloon extraction over ten years after laparoscopic cholecystectomy. Though rare, the potential for surgical clip within the common bile duct serving as a nidus for stone formation should be considered in post-cholecystectomy patients presenting with symptoms of choledocholithiasis and cholangitis, regardless of how recently surgery was performed. Minimally invasive surgery and the use of surgical clips has become almost ubiquitous; thus clinicians should be aware of this possible complication and options for management.

2747 A Rare Case of Esophageal Squamous Cell Carcinoma With Intramural Gastric Metastasis

INTRODUCTION: Esophageal cancer makes up about 1% of all cancers diagnosed in the United States . Gastric metastasis from esophageal cancer is relatively rare. Four different types of metastatic mechanisms were reported: 1) via peri-gastric lymph nodes; 2) gastric intramural metastasis; 3) direct invasion of the gastric wall, and 4) intra-epithelial spread to the gastric epithelium . Here we present a case with intramural gastric metastasis in a patient with esophageal squamous cell carcinoma. CASE DESCRIPTION/METHODS: A 76-year-old Indian male with past medical history significant for idiopathic pulmonary fibrosis and coronary artery disease, recently started on aspirin and clopidogrel, presented with new onset fatigue and five days of black tarry stools. Hemoglobin (Hgb) on admission was 7.1 g/dL. Despite transfusion of one unit of packed red blood cells, repeat Hgb dropped to 6.6 g/dL. Emergent upper endoscopy was performed for suspected active gastrointestinal bleeding in the setting of blood thinner use. Endoscopy showed a 3 cm, non-bleeding, fungating and ulcerated mass in the middle third of the esophagus, as well as a 4-5 cm fungating, infiltrative and ulcerated gastric mass in the cardia with stigmata of recent bleeding (adherent clot) (see Figure 1). Removal of the clot revealed underlying oozing from the ulcer bed which was treated successfully with dilute epinephrine injection followed by hemostatic clip placement. Forceps biopsies of both the esophageal and cardia masses were obtained. Histopathology of both lesions revealed keratinized squamous cell carcinoma. CT of the chest, abdomen and pelvis showed no evidence of other metastatic disease. Oncology consultation was scheduled to discuss potential chemotherapy, radiation, and endoscopic interventions. DISCUSSION: Esophageal cancer with intramural gastric metastasis is very rare compared to other mechanisms of tumor spread. The prognosis is very poor with the mean survival time reported to be 8.6 months . Conventional chemotherapy or radiotherapy after surgery were ineffective in improving prognosis in current report, suggesting other techniques could provide a benefit when used adjunctively or in combination with more traditional approaches.

1922 The Use of a New Hemostatic Powder in Refractory Pseudocyst Wall Bleeding

INTRODUCTION: Despite multiple endoscopic hemostatic devices available, GI bleeding can still be difficult to treat. A new hemostatic device was recently approved by the FDA as an non-surgical treatment option of upper and lower GI bleeding. The hemostatic powder forms a mechanical and adhesive barrier by absorbing water and promotes thrombus formation by concentrating and activating platelets and coagulation factors with high primary hemostasis rates. It has been reported as a successful hemostatic technique for common causes of GI bleed, but not for pseudocyst bleeding. CASE DESCRIPTION/METHODS: 84-year-old male admitted to our institution ten days after a surgical cystgastrostomy with one day history of abdominal pain associated with nausea and vomiting. Hemoglobin decreased from 11 to 8 mg/dl after the surgery and occult blood in stool was positive. Initial CT angiogram revealed no active bleeding but a large complex fluid collection 13.1 × 11.6 × 12.9 cm from the pancreatic tail and involving the stomach. Gastroenterology was consulted to assess the cystgastrostomy patency and evaluate for GI bleeding as the cause of anemia. Endoscopy was performed and revealed that the pseudocyst gastrostomy in the proximal gastric body had stenosed to 0.5 cm from 6 cm and the pseudocyst cavity was filled with large clots but no evidence of active bleeding. Due to the stenosis, double pig tail plastic stents were placed. Patient developed melena and hemoglobin decreased again from 9 to 7 mg/dl. Repeated endoscopy revealed active bleeding within the pseudocyst wall near the anastomosis. The tissue was very friable. Epinephrine injection, coaptive coagulation with bipolar cap and hemostatic clip placement were all unsuccessful to stop the bleeding. Finally, hemostasis was achieved using a new hemostatic powder through endoscopic delivery catheter. The powder was sprayed successfully to the anastomosis and proximal cavity of the pseudocyst without complication or further bleeding. Follow up a month later did not showed any evidence of active bleeding. Repeat CT abdomen revealed decreased in size of the pancreatic pseudocyst with plastic stents still in place. DISCUSSION: To our knowledge, this is the first report of the use of hemostatic powder delivered via endoscopy outside the GI tract to achieve hemostasis from pancreatic pseudocyst wall bleeding. This device can be considered as a rescue modality for those cases where the standard treatment has failed. Further studies are needed to assess its safety in this setting.

Magnet-Assisted Robotic Prostatectomy Using the da Vinci SP Robot: An Initial Case Series.

Introduction: Tissue retraction during minimally invasive surgery has been achieved to date with patient positioning or additional instrumentation. The Levita™ Magnetic Surgical System (San Mateo, CA), a novel, noninvasive, magnetic retraction device for minimally invasive surgery, has been used to facilitate reduced-port robotic prostatectomy using a multiport robotic platform. With the release of the da Vinci SP robotic system (Intuitive, Sunnyvale, CA), we now report a multi-institutional initial case series of magnet-assisted robotic prostatectomy using the single-port robotic platform. Materials and Methods: An IRB-approved, retrospective chart review was performed of all patients undergoing robot-assisted radical prostatectomy using the da Vinci SP surgical system and a single Levita magnetic retractor in treatment of prostatic adenocarcinoma at two institutions from November 2018 to January 2019. Preoperative, intraoperative, and postoperative data were collected for descriptive analysis. Results: A total of 15 men, median age 62 years (range 57-71), with mean PSA 7.0 ± 2.3 underwent surgery. The robotic cannula and a single 12-mm assistant port were utilized in all cases, the latter for suction, suture passage, and clip placement; the magnetic retractor aided with posterior dissection, dorsal venous complex stitch placement, bladder neck dissection, and lymphadenectomy. No cases required conversion to a multiport robotic platform, laparoscopy, or open surgery, nor placement of additional assistant ports. No intraoperative or postoperative complications occurred. Average operative time was 224 ± 43 minutes and blood loss was 198 ± 115 mL. All patients were discharged home within 2 days of surgery. Conclusions: Robotic prostatectomy utilizing the da Vinci SP system is feasible, safe, and effective. Use of the magnetic retractor facilitates tissue exposure and improves procedure ergonomics, mimicking the conventional multiport technique. Further exploration of magnet utilization in robotic surgery and optimization of assistant port placement for true single-site surgery is warranted.

Vasospasm and delayed cerebral ischemia after uneventful clipping of an unruptured intracranial aneurysm \u2013 a case report

BackgroundDue to improvements in both the quality and availability of intracranial imaging as well as the evolution of surgical and endovascular techniques during the last decade, the number of treatments of unruptured intracranial aneurysms (UIA) has increased steadily. However, it is not generally known that vasospasm can arise after an uneventful clipping.Case presentationWe present a case of a 69-year-old woman who suffered from vasospasm and delayed cerebral ischemia that occurred after an uneventful clipping of a UIA.The aneurysm of the right middle cerebral artery was found incidentally via magnetic resonance imaging ordered after the patient complained of a short period of slight gait disturbances. To avoid a subarachnoid hemorrhage and consecutive complications like vasospasms, the patient elected microsurgical treatment. Clipping was managed by keyhole approach. Temporal clipping of the M1 was not necessary. After clip placement, appropriate flow in all distal segments was confirmed by indocyanine green video-angiography and micro-Doppler. The patient was discharged seven days after surgery without neurological deficits.After 12 days, the patient developed at home a sudden drooping on the left side of the face. Upon admission to the emergency room, the patient was alert but slightly confused. Neurological examination revealed a left-sided hemiparesis and motor speech disorder. In contrast to the preoperative transfemoral catheter angiography, the subsequent right internal carotid angiogram showed clear signs of vasospasm along the M1 and M2 segments of the right middle cerebral artery.Antithrombotic treatment with acetylsalicylic acid was begun. In accordance with guidelines for the treatment of subarachnoid hemorrhage and vasospasm, nimodipine was added. After 11 days the patient was discharged with no symptoms.ConclusionCerebral vasospasm as a cause of ischemic stroke after uneventful surgery for a UIA seems to be a rare but possibly underestimated etiology that demands particular attention with respect to providing appropriate treatment. In future, it may be prudent to perform follow-up transcranial ultrasonography testing after the clipping of a UIA, especially considering the availability of potentially neuroprotective medications like nimodipine.

Extended Endoscopic Endonasal Clipping of Intracranial Aneurysms: An Anatomic Feasibility Study

Intracranial aneurysms (IAs) located in the midline region represent formidable challenge owing to their deep location. The objective of this study was to assess feasibility and identify the limitations of endoscopic endonasal clipping of IAs. We further aimed to describe the locations and characteristics of aneurysms that may be amenable for endoscopic endonasal clipping; thus outlining the indications of these approaches. Fifteen latex-injected cadaveric heads were used for endoscopic endonasal exposure of anterior and posterior cerebral circulations. An aneurysm simulator model with 2 different sizes was used at the common sites for IAs to emulate a real surgery. Key measured parameters included "exposure of vessels and their respective perforators," "ability to gain proximal/distal control," and "possibility of clip placement" according to the size, direction, and location of the aneurysm model. Maneuverability of instruments and the need for pituitary gland transposition were assessed and recorded as well. Exposure of the anterior communicating artery complex and the common sites of posterior circulation aneurysms were feasible. The size, location, and direction of the aneurysm model had an impact on obtaining proximal and/or distal control, and the ability of clip placement. Clipping of midline aneurysms of the posterior circulation is feasible via endoscopic endonasal approach. Small-sized ventrally and medially directed aneurysm models carried a better probability of getting proximal and/or distal control, as well as better overall ability to place a clip. The endonasal route seems to provide a limited condition for proper management of anterior circulation aneurysms.

Short and Intermediate Term Outcomes of the Convergent Procedure: Initial Experience in a Tertiary Referral Center.

Purpose: The Convergent procedure is a hybrid, multidisciplinary treatment for symptomatic atrial fibrillation (AF) consisting of minimally invasive surgical epicardial ablation and percutaneous/catheter endocardial ablation. We investigated outcomes following introduction of the Convergent procedure at our institution.Methods: Retrospective study examining single-center outcomes. Demographic, procedural, and post-procedural variables were collected with follow-up data obtained at 3, 6, and 12 months.Results: In all, 36 patients with paroxysmal (11%) or persistent/long-standing persistent (89%) AF underwent the Convergent procedure. 36% also underwent concomitant left atrial appendage (LAA) exclusion by thoracoscopic placement of an epicardial clip. Mean age 60.6 ± 8.0 years with mean arrhythmia burden of 3.9 ± 2.7 years. All patients had failed prior attempts at medical management, 81% had failed prior cardioversion, and 17% had failed prior catheter ablation. Convergent was performed successfully in all patients with no peri-procedural deaths or major complications. At 3 and 12 months, 77.8% and 77.3% of patients, respectively, were free from symptomatic arrhythmia. 65.8% were off anti-arrhythmic medication at 12 months.Conclusions: The Convergent procedure is safe and has good short- and intermediate-term clinical success rates. This unique hybrid approach combines strengths of surgical and catheter ablation and should be part of any comprehensive AF treatment program.

Displacement of Surgical Clips in Patients with Human Acellular Dermal Matrix in the Excision Cavity during Whole Breast Irradiation Following Breast-Conserving Surgery.

PurposeThe purpose of this study was to investigate the displacement of surgical clips in the excision cavity during whole breast irradiation following breast-conserving surgery (BCS) with or without acellular dermal matrix (ADM) insertion, and to analyze clinicopathologic factors associated with the displacement of surgical clips.Materials and MethodsFrom 2016 to 2017, 100 consecutive breast cancer patients who underwent BCS with the placement of surgical clips (superior, inferior, medial, lateral, and deep sides) in the tumor bed were included in this study. All patients took first planning computed tomography (CT) scan (CT 1) before whole breast irradiation and second CT scan (CT 2) before boost irradiation. Between two sets of planning CT, the displacement of surgical clips was calculated from the ΔX (lateral–medial), ΔY (anterior–posterior), ΔZ (superior–inferior), and three-dimensional (3D) directions. Patients were divided into two groups according to the breast volume replacement with ADM: group A with ADM and group B without ADM.ResultsThe means and 1 standard deviations of 3D displacement for superior, inferior, medial, lateral and deep clips were 5.2±2.9, 5.2±3.2, 5.6±4.5, 5.6±4.3, and 4.9±4.9 mm in entire cohort (n=100); 5.6±2.6, 6.0±3.5, 6.7±5.8, 6.7±5.7, and 6.1±7.4 mm in group A (n=38); 4.9±3.1, 4.8±3.0, 5.0±3.5, 5.0±2.9, and 4.3±2.8 mm in group B (n=62), respectively. The 3D displacements of group A were longer than those of group B, but only significant difference was observed in lateral clip (p=0.047).ConclusionThis study demonstrated displacement of surgical clips during whole breast irradiation in patients with ADM insertion. For patients who had breast volume replacement using ADM, adaptive boost planning should be considered.

Live from New York – It’s Pre-Op Instructions!

Breast surgery patients go to a myriad of appointments unseen by the PACU staff. Nuclear Medicine, Mammography, Ultrasound, Seed Placement, Clip Placement, Imaging, Biopsies and consultative appointments all occur prior to being booked for surgery. In a time where the patient experience matters most, focus needs to be given to the patient population undergoing the most amount of pre-surgical, stressful appointments.

Contralateral approach for the treatment of a distal supraclinoid aneurysm: a technical case report

Background When treating intracranial aneurysms with open microsurgery, rare cases arise in which an ipsilateral approach leads to poor visualization, lack of proximal control, or potential damage to nearby vital structures due to the anatomy of the aneurysm. Case Description We describe a patient with a small, unruptured aneurysm arising from the medial aspect of the distal supraclinoid internal carotid artery (ICA), just below the ICA bifurcation. A contralateral surgical approach was chosen because our view of the aneurysm from an ipsilateral approach would have been obstructed by the ICA. The contralateral approach provided excellent exposure of the aneurysm and allowed for precise clip placement without complications. Conclusions Contralateral approaches may be a good option for some small medially pointing aneurysm of large proximal cerebral arteries.

Application of Intraoperative FLOW 800 Indocyanine Green Videoangiography Color-Coded Maps for Microsurgical Clipping of Intracranial Aneurysms

Indocyanine green (ICG) videoangiography (VAG) is an established method for assessment of cerebral blood flow during microsurgical clipping of intracranial aneurysms. FLOW 800 is a surgical microscope-integrated software program that shows the cerebral blood flow in color-coded maps, thus providing semi-quantitative and real-time analysis of ICG data. We aimed to establish reference values for FLOW 800 parameters before and after microsurgical clipping of intracranial aneurysms and to evaluate the potential of FLOW 800 to guide intraoperative decisions. We retrospectively reviewed 54 patients (mean age, 53.6 ± 11.6 years) who underwent microsurgical clipping for 60 aneurysms and intraoperative evaluation of ICG fluorescence dynamics using FLOW 800 color-coded maps. FLOW 800 data were correlated with patient characteristics, clinical outcomes, and intraoperative decision making. There were no significant differences in FLOW 800 data between ruptured and unruptured aneurysms (P>0.05). Likewise, the hemodynamic parameters were not significantly different before and after definite clip placement (P > 0.05). However, in 2 cases, analysis of transit times by FLOW 800 analysis showed a hemodynamically significant clip stenosis that might have been missed by conventional ICG-VAG and resulted in adjustment of the clip position. Overall, there was 1 cerebral infarction, which was not related to clip placement. FLOW 800 is a useful adjunct to ICG-VAG for intraoperative assessment of cerebral perfusion and may help to identify hemodynamically relevant clip stenosis. The beneficial impact of FLOW 800 on clinical outcome after microsurgical clipping needs to be confirmed by comparative studies.

Melatonin attenuates renal sympathetic overactivity and reactive oxygen species in the brain in neurogenic hypertension.

Sympathetic overactivation contributes to the pathogenesis of both experimental and human hypertension. We have previously reported that oxidative stress in sympathetic premotor neurons leads to arterial baroreflex dysfunction and increased sympathetic drive to the kidneys in an experimental model of neurogenic hypertension. In this study, we hypothesized that melatonin, a potent antioxidant, may be protective in the brainstem regions involved in the tonic and reflex control of blood pressure (BP) in renovascular hypertensive rats. Neurogenic hypertension was induced by placing a silver clip (gap of 0.2 mm) around the left renal artery, and after 5 weeks of renal clip placement, the rats were treated orally with melatonin (30 mg/kg/day) by gavage for 15 days. At the end of melatonin treatment, we evaluated baseline mean arterial pressure (MAP), renal sympathetic nerve activity (rSNA), and the baroreflex control of heart rate (HR) and rSNA. Reactive oxygen species (ROS) were detected within the brainstem regions by dihydroethidium staining. Melatonin treatment effectively reduced baseline MAP and sympathoexcitation to the ischemic kidney in renovascular hypertensive rats. The baroreflex control of HR and rSNA were improved after melatonin treatment in the hypertensive group. Moreover, there was a preferential decrease in ROS within the rostral ventrolateral medulla (RVLM) and the nucleus of the solitary tract (NTS). Therefore, our study indicates that melatonin is effective in reducing renal sympathetic overactivity associated with decreased ROS in brainstem regions that regulate BP in an experimental model of neurogenic hypertension.

An analysis of postoperative adverse events following laparoscopic cholecystectomy in a tertiary care hospital

Background: Being one of the most commonly performed surgery in the modern era, post-operative complications following laparoscopic cholecystectomy deserve special mention. Though not very life threatening, they are quite common. Considering these aspects, this study aims to identify them and possibly a potential remedy for decreasing the incidence in the future.Methods: This is a retrospective, institution-based, observational and cross-sectional analysis conducted in R.G. KAR Medical College and Hospital over 5 years on 1000 patients undergoing surgery. Here we intend to observe the adverse events following laparoscopic cholecystectomy in the post-operative period.Results: Most of the complications were seen in the age group greater than 40 years(63%) followed by the age group 30-40 years (26%).Adverse events were much more common in females (85%) followed by males (15%). The symptoms appeared mostly during 3-7 days post operatively (57%) followed by 20% within the first 6 hours. Non-specific abdominal pain (28%) was the most common adverse event followed by port-site infection in 16.5% cases.Conclusions: Proper pre-anaesthetic check-up with proper instrument handling with proper caution and before closing confirmation of proper placement of clip and no other unintentional injury anywhere can decrease the post-operative complication.

Rapid Implementation of Intraoperative Ultrasonography to Reduce Wire Localization in The Permanente Medical Group.

Preoperative wire localization (WL), the most common localization technique for nonpalpable breast lesions, has drawbacks including scheduling constraints, cost, and patient discomfort. To reduce WL use in our health care system, we investigated using hydrogel clips to facilitate intraoperative ultrasonography-guided lumpectomies. We retrospectively reviewed electronic medical records of patients with nonpalpable, ultrasound-visible breast lesions who underwent lumpectomy by 7 surgeons at 4 pilot sites in Kaiser Permanente Northern California between January 2015 and October 2015. Hydrogel clips, used for several years before the study period, were placed routinely during core-needle biopsy in all patients with nonpalpable, ultrasound-visible breast lesions. Localization method, lesion size, margin positivity, and receipt of neoadjuvant therapy. One hundred forty-three patients underwent hydrogel clip placement and lumpectomy by pilot-site surgeons. Localization consisted of intraoperative ultrasonography alone, preoperative skin marking, or WL. Of the 143 patients, 71.3% did not need WL (60.8% ultrasonography alone and 10.5% skin marking). The non-WL and WL groups had similarly sized lesions, and the positive margin rate was 7.2% overall, with no significant difference between the non-WL and WL groups (5.9% vs 11.5%, p = 0.33). Of the 12 patients who underwent neoadjuvant chemotherapy, 8 (67%) did not require WL. A multifacility protocol using intraoperative ultrasonography to visualize hydrogel clips was implemented, which decreased WL procedures and produced no significant difference in margin positivity between the WL and non-WL groups. This technique can be a cost-effective alternative to WL in patients who are candidates for hydrogel clip placement.

Feasibility of Magnetic Seeds for Preoperative Localization of Axillary Lymph Nodes in Breast Cancer Treatment.

OBJECTIVE. The objective of this study was to evaluate the feasibility of using a magnetic seed system for preoperative localization of axillary lymph nodes in patients with breast cancer. MATERIALS AND METHODS. We performed a retrospective analysis that included patients with breast cancer who underwent preoperative magnetic seed localization of axillary lymph nodes at our institution between January 1, 2017, and January 1, 2019. Magseed (Endomag) is a nonradioactive inducible magnetic seed that is induced to become a magnet when under the influence of its detector in the operating room. Clinical history, prior axillary sampling and clip placement, and procedure details and surgical outcomes were determined from a search of our PACS and electronic medical records. RESULTS. Thirty-five patients (34 women and one man) composed our study cohort. The mean patient age was 56 years (range, 32-78 years). One patient underwent two separate consecutive localizations for two separate operations, and another patient had bilateral lesions, for a total of 37 axillary lymph node localizations. One case of seed misplacement occurred during the ultrasound-guided localization procedure, resulting in immediate placement of a second seed, for a total of 38 Magseeds placed. All seeds were placed under ultrasound guidance. The mean number of days from seed placement to surgery was 5 days (range, 0-31 days). Thirty-seven of 38 Magseeds (97%) were documented to be successfully retrieved in the operating room. CONCLUSION. Magseed localization appears to be a safe, nonradioactive way to accurately localize axillary lymph nodes preoperatively.

Effect of Prolonged Infusion of Alamandine on Cardiovascular Parameters and Cardiac ACE2 Expression in a Rat Model of Renovascular Hypertension.

Alamandine is a new member of the angiotensin family. Here, we studied the mRNA and protein expression of cardiac angiotensin-converting enzyme 2 (ACE2) in the chronic phase of a rat model of 2-kidney, 1-clip hypertension (2K1C), and the effects of 2-week alamandine infusion on blood pressure, cardiac indices, and ACE2 mRNA and protein expression in the hearts. The rats were subjected to to sham-operation or placement of plexiglass clips around the left renal artery. Alamandine, at a dose of 600 µg/kg/d, was administered for 2 weeks via an osmotic mini-pump. At 18 weeks, after induction of hypertension, blood pressure and cardiac indices of contractility were measured using a Powerlab Physiograph system. The ACE2 mRNA and protein levels were determined using real time-PCR and Western blotting, respectively. In the hypertensive rats, alamandine caused a significant decrease in systolic blood pressure (p < 0.001), diastolic blood pressure (p < 0.001), left ventricular end-diastolic pressure (p < 0.001) and, left ventricular systolic pressure (p < 0.001) and increase in the maximum rate of pressure change in the left ventricle (dP/dt(max)) (p < 0.05). Also, the ACE2 mRNA expression in the heart increased in the hypertensive rats compared to the normotensive rats (p < 0.05), and alamandine restored this to normal values, although these changes were only seen at the mRNA and not the protein level. Histological analysis of cardiac tissue confirmed that alamandine decreased cardiac fibrosis and hypertrophy in 2K1C hypertensive rats. Our results indicate that alamandine, which acts as a depressor arm of the renin-angiotensin system, could be developed for treating hypertension.

LTP Nanoparticles Seeded with Plasmid for Vascular Endothelial Growth Factor Receptor 2 Improve Fetal Morphometrics in a Rat Model of Preeclampsia

Recent studies by our lab have demonstrated that the delivery of L‐Tyrosine Phosphate nanoparticles seeded with plasmid for Vascular Endothelial Growth Factor Receptor 2 (LTP VEGFR2) normalizes mean arterial pressure, uterine vessel myogenic reactivity, and fetal growth restriction in the reduced uterine perfusion pressure (RUPP) animal model. The goal of this study was to investigate fetal morphometrics in RUPP+LTP VEGFR2 dams. For the RUPP procedure, silver clips are placed on the abdominal aorta (0.2mm i.d.) below the kidneys and the utero‐ovarian arteries (0.1mm i.d.) on day 14 of pregnancy in Sprague‐Dawley rats. SHAM pregnant rats undergo the same surgery without the clip placement. On the same day as surgery, LTP nanoparticles encapsulated with plasmid DNA encoding for VEGF Receptor 2 (VEGFR2), or nonsense were injected into the uterine wall. On day 21 of gestation, the uterus was removed and fetal weights, placental weights, and head circumference were recorded on three fetuses from each dam. The fetuses were selected based on position in the uterus in relation to the site of injection of the LTP nanoparticles. Fetal position was designated as the following: Site 1 was selected as the closest to the injection site, Site 6 was distal in the same uterine horn, and Site 14 was contralateral to Site 6. Fetal weight for pups at Site 1 was significantly increased in RUPP rats treated with VEGFR2 nanoparticles compared to RUPP treated with nonsense nanoparticles (4.70g ± 0.44 vs. 3.89g ± 0.31; p&lt;0.05). Placental weight at Site 1 was significantly increased in RUPP rats treated with VEGFR2 nanoparticles compared to RUPP treated with nonsense nanoparticles (0.635g ± 0.06 vs. 0.491g ± 0.04; p&lt;0.05). Head circumference was also significantly increased in pups at site 1 in RUPP rats treated with VEGFR2 nanoparticles as compared RUPP rats treated with nonsense nanoparticles (2.37cm ± 0.32 vs. 1.45cm ± 0.07; p&lt;0.05). There were no significant differences in fetal weights, placental weights and head circumference in the SHAM group at any of the fetal positions. Furthermore, there were no significant differences when comparing between the SHAM and RUPP groups. The fetal measurements (fetal weight, placental weight and fetal head circumference) from RUPP treated with nonsense nanoparticles tended to be lower compared to the other groups (SHAM treated with VEGFR2 nanoparticles, SHAM treated with nonsense nanoparticles or RUPP treated with VEGFR2 nanoparticles; however, it failed to reach significance in this preliminary study. In conclusion, uterine injection of LTP nanoparticles with plasmid DNA encoding for VEGFR2 improved fetal morphometrics in RUPP animals.Support or Funding InformationAmerican Heart Association‐18AIREA3396032This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

253 Descriptive Outcomes of Patients Undergoing UroLift for Extended Indications

The incidence of benign prostatic hyperplasia (BPH), often causing significant lower urinary tract symptoms (LUTS) and urinary retention, increases with age. Recently, new minimally invasive technologies have increased the compliment of therapeutic modalities we can offer patients. One such modality is the placement of prostatic urethral clips, also known as UroLift. One advantage of UroLift is that it may be done on an outpatient setting under the use of local anesthesia. Presence of a median lobe was previously felt to be a contraindication, and urinary retention requiring catheterization is still felt to be a contraindication. However, we have encountered patients with significant cardiac or other comorbidities, unfit for general anesthesia, who require treatment of BPH due to severe symptoms or acute urinary retention who desire to be catheter free. The objective of this study is to determine the success of UroLift in a small cohort of patients who underwent the procedure for these extended indications.

Microsurgical Clip Placement for a Giant Anterior Communicating Artery Aneurysm With Intraluminal Thrombus: 2-Dimensional Operative Video

Giant brain aneurysms account for approximately 5% of all intracranial aneurysms. Although treatment modalities can vary widely, none is ideal for every patient. Endovascular treatment is usually preferred, especially when the large size of the aneurysm limits visualization of the brain parenchyma and parent vessels that arise from the aneurysm, making surgical clip placement across the neck a difficult task. However, despite the higher chances of morbidity, microsurgery is an effective treatment modality due to lower recurrence rates. Surgically, a wide neck, calcifications, or atheroma are complicating factors to be considered while planning the best treatment. Thus, with an appropriate case selection, a favorable outcome is feasible in most cases. Here, we present the case of a 27-yr-old female who presented with a severe headache for 7 mo and 3 mo of progressive left temporal vision loss, which was confirmed by visual field perimetry using the Humphrey visual field analyzer. Magnetic resonance angiography and digital subtraction cerebral angiography showed an anterior communicating artery complex inferiorly and medially oriented aneurysm measuring 25.4×16.5 mm, with a 3 mm neck. It was fed by the right A1, associated with a hypoplastic left A1, incorporating the proximal right and left A2 segments, with an intraluminal thrombus and causing mass effect on the optic chiasm and hypothalamus. This video demonstrates the microsurgical steps required to perform this operation, through a right orbitozygomatic craniotomy. At a 3-mo follow-up, the patient was neurological intact without complaints. The patient signed the Institutional Consent Form, which allows the use of his/her images and videos for any type of medical publications in conferences and/or scientific articles.