Technical Precautions Research Articles

Percutaneous Gallbladder Biopsy: Indications, Technique and Complications

Gallbladder percutaneous tissue sampling is a not-so-common technique in cytohistological diagnosis of gallbladder tissue or masses, which can be useful in cases of surgically unresectable disease and unfeasible endoscopic assessment to address the most adequate chemotherapy course. Nonetheless, gallbladder percutaneous tissue sampling can be of great utility in the patient’s diagnostic and therapeutic work-up. This article summarizes the literature evidence on gallbladder biopsy techniques, complications, and technical precautions for a safe and effective sampling.

MO967: Lymphocele After Renal Transplantation: Management, Risk Factors and Impact on Transplant Survival

Abstract BACKGROUND AND AIMS Lymphocele after renal transplantation remains a common complication, despite all the technical precautions taken, in particular the ligation of lymphatic vessels. Its incidence varies according to the series, depending on the diagnostic methodology, and whether or not it is systematically screened. This study aims to investigate the risk factors for lymphocele and its impact on transplant survival. METHOD We performed a retrospective longitudinal descriptive study including all patients who had a kidney transplant in a Urology department from 1986 to 2017. Clinical presentation and management of lymphocele were studied. Then, the characteristics of patients who presented a lymphocele were compared with those of the rest of the population including characteristics related to the recipient, the donor, the transplant and the procedure to identify risk factors. The impact of lymphocele on patient and transplant survival was then studied. RESULTS A total of 720 patients were included with a mean age of 32.7 years. The transplant was from a living donor in 79% and a brain-dead donor in 21%. Lymphocele occurred in 51 patients (7.1%). The lymphocele was asymptomatic in 80%, and clinical manifestations were related to the compression of the transplant or its important size, requiring active treatment, most often percutaneous (13.7%). The lymphocele did not require treatment in 42 cases (82.4%) with disappearance in 90.5%. Revision surgery for a lymphocele was necessary in two cases. The risk factors for lymphocele were a cadaveric donor (P = 0.003) and an advanced age of the recipient (P < 0.001). No predictive factors related to the transplant (vascular anatomy), or procedure (location and type of anastomoses, ischemia time) were identified. Transplant survival was 77.9% at 5 years, with a median survival of 15.9 years. The occurrence of a lymphocele did not influence the survival of the transplant (P = 0.25) (Figure 1). CONCLUSION Our study showed that lymphocele is usually asymptomatic, not requiring a specific treatment in most cases with a high rate of spontaneous disappearance with no impact on transplant survival. Risk factors were a cadaveric donor which may reflect the absence of careful ligation of the transplant's lymphatic vessels in the context of urgent, sometimes multi-organ, cadaveric procurement and advanced recipient age.

Algorithmengestützte Verwaltungsverfahren – Einsatzfelder, Risiken und Notwendigkeit ergänzender Kontrollen

The digitization of the German public sector is gaining momentum and it now also extends to the use of algorithms and artificial intelligence in administrative procedures. On the basis of recently published official data, a broad spectrum of fields and variants of application can be identified. However, this increasing reliance on algorithms also creates particular challenges to the rule of law. In particular, the reliance on algorithms can increase the risk of systematic unlawfulness and bias in administrative decision-making, whether fully automated or still accounted for by a human official. Recent studies suggest that also in the latter case, those risks are often not properly managed – and are sometimes even exacerbated – by the humans in the loop. The traditional instruments of judicial protection and internal administrative supervision are not well suited to address the aforementioned inherent and operational risks either; moreover, they offer only ex post remedies and have no preventive effect. Therefore, additional technical precautions and institutional arrangements are required to uphold the rule of law. They should include investments in explainable artificial intelligence (“XAI”) and adequate staff training programs, as well as the creation of public registers and independent standard-setting and auditing bodies for public sector algorithms. In particularly sensitive areas of administration, the use of technical or proprietary black box algorithms should be entirely banned until further technological progress on transparency and risk control has been made.

Первинний коло-анальний степлерний анастомоз при хірургічному лікуванні хвороби Гіршпрунга в дітей

Hirschsprung’s disease (HD) belongs to group of severe congenital malformations of the colon that can be only treated surgically. Various methods of radical correction HD have been evolutionarily improved. The Soave–Boley technique is considered to be the most successful, physiological and technically acceptable. Purpose – to evaluate the effectiveness of the use of stapler for primary colo-anal anastomosis as an element of Soave-Boley surgery in the surgical treatment of HD in children. Materials and methods. The analysis of surgical treatment of 125 children with various forms of HD aged from 6 months to 18 years, the formation of the primary colo-anal anastomosis was done using the Soave–Boley technique by mechanical (stapler) method. Results. In 20 patients (16.00%) among 125 with complicated course of HD, it was difficult to do radical single stage surgical treatment they required twostage treatment (stage 1) formation of the protective intestinal stoma and (stage 2) radical surgery. In the remaining 105 (84.00%) patients, single stageradical correction of HD was performed. In 1 (0.80%) of 125 patients operated by the Soave–Boley method with a primary colo-anal stapler anastomosis, in the early postoperative period was diagnosed with hematoma between pull through colon and sero-mascular pouch, which was treated conservatively. Andin one patient (0.80%) of 125 children in the remote postoperative period there was surgical complication – residual agangliosis, which was corrected by sphincteromyectomy by Lynn technique. Conclusions. Soave–Boley surgery with stapler colo-anal anastomosis is an effective method of radical correction of HD in children of different ages with one-stage or two-stage interventions. The use of a stapler for primary colo-anal anastomosis as an element of Soave–Boley surgery for the surgical treatment of HD in children with the consideration of necessary technical precautions has significant advantages over its classic methods. The research was carried out in accordance with the principles of the Helsinki declaration. The study protocol was approved by the Local Ethics Committee of these Institutes. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: Hirschsprung’s disease, children, surgical treatment, results.

Proctotomy leak following laparoscopic total gastrectomy with transrectal specimen extraction for gastric cancer: a case report

BackgroundDespite increasing acceptance in colorectal surgery, natural orifice specimen extraction (NOSE) surgery for the treatment of gastric cancer is still in its infancy, especially via the transrectal approach, which was barely reported. So little is known about its complications. Here we report the first case of proctotomy leak after transrectal NOSE gastrectomy, and our experience in preventive interventions.Case presentationA 62-year-old male patient complaining of upper abdominal pain who underwent open distal gastrectomy for gastric cancer one year ago was diagnosed with recurrent gastric cancer by gastroscopic biopsy. We performed laparoscopic total gastrectomy with transrectal specimen extraction on the patient. The operation was completed in a total laparoscopic approach and the specimen was extracted through a 3 cm longitudinal incision in the anterior wall of the upper rectum, then interrupted sutures were used for full-thickness closure of the rectal incision. The operative time was 470 min and intra-operative blood loss was 100 mL. The postoperative pathological examination showed pT1bN0M0 gastric adenocarcinoma. The patient developed proctotomy leak on the 10th postoperative day. We analyzed the causes of this rare complication and put forward a series of technical improvements. After failure of conservative treatment, a diverting ileostomy was created and the patient eventually recovered. We successfully prevented proctotomy leak in the subsequent 20 transrectal NOSE gastrectomies using improved techniques.ConclusionsProctotomy leak after transrectal specimen extraction should be considered among the complications of NOSE surgery and can be prevented by technical precautions.

Isolation of Primary Rat Hepatocytes with Multiparameter Perfusion Control.

Primary hepatocytes are widely used in basic research on liver diseases and for toxicity testing in vitro. The two-step collagenase perfusion procedure for primary hepatocyte isolation is technically challenging, especially in portal vein cannulation. The procedure is also prone to occasional contamination and variations in perfusion conditions due to difficulties in the assembly, optimization, or maintenance of the perfusion setup. Here, a detailed protocol for an improved two-step collagenase perfusion procedure with multiparameter perfusion control is presented. Primary rat hepatocytes were successfully and reliably isolated by taking the necessary technical precautions at critical steps of the procedure, and by reducing the operational difficulty and mitigating the variability of perfusion parameters through the adoption of a special intravenous catheter, standardized sterile disposable tubing, temperature control, and real-time monitoring and alarm system. The isolated primary rat hepatocytes consistently exhibit high cell viability (85%-95%), yield (2-5 x 108 cells per 200-300 g rat) and functionality (albumin, urea and CYP activity). The procedure was complemented by an integrated perfusion system, which is compact enough to be set up in the laminar flow hood to ensure aseptic operation.

Safe by Design Regulation for Academic Experimentation and Value Conflicts: An Exploration of Solution Directions.

In this paper, we explore solution directions for the implementation of Safe by Design (SbD) in safety regimes for academic experimentation. SbD is a dynamic and anticipatory strategy for safety regulation in academic research. In this strategy, safety is taken in a broader sense including not only issues of technical precaution of avoiding risks of experimentation but also the societal responsibility of researchers and research institutes of identifying possible future risks. In our research, we have interviewed academic researchers from different disciplines and university support personnel about the factors that enable and limit the possibilities of researchers to implement SbD in safety regimes for experimentation. We articulate our findings in terms of a core set of research values and in terms of conflicts between safety and these research values. And we argue that tools for resolving value conflicts as originating in design for values research can provide directions to solve the value conflicts, and thus help academic researchers to adopt SbD in their experimentation.

Ultrasound-guided caudal epidural steroid injection for sciatica: simplicity, efficacy and safety

The possibility of precisely locating the sacral hiatus, which is greatly facilitated by echography, has rekindled interest in epidural infiltrations via this route, particularly as rare but serious complications have been reported for other epidural injection techniques, such as those using the foraminal route or particulate products. Products injected via the sacral hiatus have been shown to ascend efficiently to the lumbar spine. In recalcitrant sciatica, epidural injections of corticosteroids via the three principal routes (sacral hiatus, interlaminar, foraminal) have similar mean efficacies. Injection via the sacral hiatus, or caudal injection, has similar complications to interlaminar and foraminal injections, but these complications appear to be much rarer by this route, and avoidable if several indispensable technical precautions are applied: five-step asepsis, echographic control to check for the absence of pilonidal cysts, avoidance of canal catheterization, avoidance of the injection of air, allergenic products, anesthetic products or particulate products, and slow injection. The sacral hiatus route can be used to ensure epidural infiltration without a risk of dural leak, in patients on antiplatelet treatment, even after surgery. Further studies are required to increase the efficacy and safety of this technique and to evaluate the benefits of injecting therapeutic agents other than corticosteroids via this route.

Oncologic Outcomes of Robotic Radical Hysterectomy (RRH) for Patients with Early-Stage Cervical Cancer: Experience at a Referral Cancer Center.

To evaluate oncologic outcomes of early stage cervical cancer patients who underwent robotic radical hysterectomy (RRH) in a referral center, a retrospective analysis was performed. From January 2010 to December 2018, medical records of stage IA2-IIA1 cervical cancer patients, who underwent radical hysterectomy at our institute, were retrospectively reviewed. We focused our analysis on those who underwent RRH. A total of 198 patients were included in the final analysis. Median follow up was 52months. At last follow-up, 188 (94.9%) women were disease-free, 9 (4.5%) had died, and 1 (0.5%) was alive with recurrent disease. At 4.5years, PFS was 93.1% (SE ± 2.1) and OS was 95.1% (SE ± 1.8). Stratified by tumor size, PFS for tumor < 2cm versus tumor ≥ 2cm was statistically different (96.8% ± 2.3 and 87.9% ± 4.1 respectively, p = 0.01), as well as OS (100% and 89.8% ± 40 respectively, p = 0.01).Stratified by evidence of tumor at time of robotic surgery, PFS was statistically different in women with no residual tumor after conisation versus those with residual disease (100% ± 2.5 and 90.8% ± 2.8 respectively, p = 0.04). A recurrence occurred in 11 patients (5.6%). Based on our results, we could speculate that robotic approach, along with some technical precautions to avoid spillage, might be safe as primary treatment of early-stage cervical cancer, especially for tumor < 2cm and in case of no evidence of disease at time of radical hysterectomy after previous conisation.

Use of non-invasive ventilation in acute respiratory failure due to SARS-CoV-2 pneumonia: typing of patients and choice of respiratory support, the role of internal medicine

The use of non-invasive ventilation (NIV) during de novo acute hypoxemic respiratory failure is not recommended by the guidelines because NIV does not improve the prognosis. With the advent of the new coronavirus, many cases of acute hypoxemic respiratory failure associated with the infection (severe acute respiratory infection) have been observed: data are missing regarding the use of NIV in this particular clinical condition, but a correct typing of patients based on different clinical, pathophysiological and radiological characteristics, could help in prognostic stratification and in the choice of respiratory support (invasive versus non-invasive). During NIV in these patients particular attention is paid to the possibility of environmental dissemination of the virus and consequently adequate technical precautions are taken.

Potential of Circulating Tumor DNA for the Management of Patients With Lymphoma.

The characterization of circulating tumor-derived DNA (ctDNA) has recently emerged in the field of oncology as a powerful method to identify tumor-specific genetic aberrations using peripheral blood testing. Several technical precautions are needed at the pre-analytic stage (given the short half-life of free nucleic acids in plasma), and numerous techniques-with different sensitivities-are available to identify these molecular aberrations, ranging from the detection of single point mutations to extended genetic screening panels. Although a "liquid biopsy" cannot be substituted for the pathological examination of tissue specimens for diagnostic purposes, it can sometimes complement pathology results or serve as a proxy approach for particular lymphoma presentations where biopsies are sometimes difficult to perform. Moreover, ctDNA testing can characterize, at diagnosis or during treatment, mutations that may contribute to the choice of an optimal targeted therapy (such as Bruton tyrosine kinase or EZH2 inhibitors) or detect the emergence of resistance to those therapies. High levels of ctDNA before treatment appear to be correlated with advanced disease stages and prognosis in diffuse large B-cell and follicular lymphomas. Real-time follow-up of ctDNA levels during therapy in several lymphoma subtypes (diffuse large B-cell and Hodgkin lymphomas) has been explored: preliminary studies have demonstrated that this monitoring technique can predict clinical outcomes (end of treatment response and risk of progression after treatment completion) and that this approach may complement the information provided by metabolic imaging assessments. Technical standardization and careful prospective evaluation of the role of ctDNA monitoring in clinical studies represent current important challenges to allowing its application in routine practice.

Esophagectomy for cancer in the obese patient

: Obesity is a prevalent cause of morbidity and mortality worldwide. It is a demonstrated risk factor for the development of many types of cancers, esophageal adenocarcinoma included. Esophagectomy in obese patients is a safe and feasible procedure which leads to good oncological and clinical outcomes. However, the surgical management of esophageal cancer in patients with BMIs in the range of obesity presents specific challenges involving pre-operative testing, anesthesia management, technical precautions and post-operative concerns. These aspects are here reviewed and discussed.

Biopsies disco-vertébrales en rhumatologie

The interventional rheumatologist must master the various technical procedures necessary for his diagnostic activity, in particular percutaneous disco-vertebral biopsies. Their technical aspects, but also the complications and forensic aspects must be known. Their indications will be confirmed in the context of a multidisciplinary medical-surgical consultation meeting: diagnostic biopsy to characterize the nature of a bone lesion, search for pathogenic germs in the context of a vertebral disk infection. The diagnostic profitability remains a subject of debate but some technical precautions and the respect of certain recommendations during their realization will make it possible to increase it. Percutaneous disco-vertebral biopsies will remain in the area of competence of the rheumatologist if he agrees to acquire the appropriate training in a specialized environment.

Phase dependent breakdown in bulk arrival queueing system with vacation break-off

In this queueing model service process is split into two phases called first essential service and second essential service. Here the occurrence of breakdown during first essential service and second essential service are different. When the server got failure during first essential service, service process will be interrupted and sent to repair station immediately. On contrary during second essential service when the server got failure the service will not be interrupted, it performs continuously for current batch by doing some technical precaution arrangements. Server will be repaired after the service completion during renewal period. On service completion, if the queue length is less than 'a' then the server leaves for vacation. During vacation if the queue length reaches the value 'a' then the server breaks the vacation and performs preparatory work to start first essential service. Various performance measures and cost effective model with appropriate numerical solution of the model are presented.

Phase dependent breakdown in bulk arrival queueing system with vacation break-off

In this queueing model service process is split into two phases called first essential service and second essential service. Here the occurrence of breakdown during first essential service and second essential service are different. When the server got failure during first essential service, service process will be interrupted and sent to repair station immediately. On contrary during second essential service when the server got failure the service will not be interrupted, it performs continuously for current batch by doing some technical precaution arrangements. Server will be repaired after the service completion during renewal period. On service completion, if the queue length is less than 'a' then the server leaves for vacation. During vacation if the queue length reaches the value 'a' then the server breaks the vacation and performs preparatory work to start first essential service. Various performance measures and cost effective model with appropriate numerical solution of the model are presented.

Predictive risk factors of urinary tract infection following flexible ureteroscopy despite preoperative precautions to avoid infectious complications.

Urinary tract infection (UTI) is a common complication after flexible ureteroscopy (fURS) despite technical precautions to avoid infectious complications. The aim was to investigate incidence and predictive risk factors of UTI following fURS procedure. We conducted a retrospective study including consecutive fURS performed in our center from January 2015 to March 2019. The indications were: nephrolithiasis management and diagnosis and conservative treatment of upper urinary tract urothelial carcinomas (UTUC). Since 2015, we had technical precautions to avoid postoperative infectious complications: centralized collection of preoperative urine cultures which are examined daily by an urologist and a service provider, systematic use of ureteral access sheath and application of standardized antibiotic prophylaxis measures. The primary endpoint was occurrence of UTI within 15days following fURS. Six hundred and four fURS were included for nephrolithiasis (n = 462) and UTUC management (n = 142). The median (IQR) age in the study cohort was 61(48-68) years, 268 female patients were included (44.4%), the median (IQR) Charlson score was 2(1-4) and single-use fURS were used in 186 cases (30.8%). Postoperative UTI occurred in 41 cases (6.7%). In multivariate analysis, female gender (OR 2.20 [1.02-5.02], p = 0.04), UTI within the last 6months (OR 2.34 [1.12-5.11], p = 0.02), preoperative polymicrobial urine culture (OR 4.53 [1.99-10.56], p < 0.001) and increased operative time (OR 1.02 [1.002-1.031], p = 0.02) remain associated with postoperative UTI. In a large cohort study, female gender, prior UTI, increased operative time and preoperative polymicrobial urine culture were associated with the occurrence of postoperative UTI. Limiting operative time and improving our knowledge of polymicrobial urine cultures could reduce the infectious risk.

A Review of the Capacitive MEMS for Seismology.

MEMS (Micro Electro-Mechanical Systems) sensors enable a vast range of applications: among others, the use of MEMS accelerometers for seismology related applications has been emerging considerably in the last decade. In this paper, we provide a comprehensive review of the capacitive MEMS accelerometers: from the physical functioning principles, to the details of the technical precautions, and to the manufacturing procedures. We introduce the applications within seismology and earth sciences related disciplines, namely: earthquake observation and seismological studies, seismic surveying and imaging, structural health monitoring of buildings. Moreover, we describe how the use of the miniaturized technologies is revolutionizing these fields and we present some cutting edge applications that, in the very last years, are taking advantage from the use of MEMS sensors, such as rotational seismology and gravity measurements. In a ten-year outlook, the capability of MEMS sensors will certainly improve through the optimization of existing technologies, the development of new materials, and the implementation of innovative production processes. In particular, the next generation of MEMS seismometers could be capable of reaching a noise floor under the lower seismic noise (few tenths of ng/) and expanding the bandwidth towards lower frequencies (∼0.01 Hz).

Diagnostic ureteroscopy prior to nephroureterectomy for urothelial carcinoma is associated with a high risk of bladder recurrence despite technical precautions to avoid tumor spillage.

There have recent reports in the literature of increased rates of bladder recurrence (BR) after radical nephroureterectomy (RNU) when diagnostic flexible ureteroscopy (DFU) was performed before RNU. The technical heterogeneity of DFU was a major bias in these studies. Our purpose was to evaluate the impact of a standardized DFU technique before RNU on the risk of BR. A retrospective monocenter study including patients who underwent RNU for upper tract urothelial carcinoma (UTUC) between 2005 and 2017. 171 patients were identified. 78 patients were excluded owing to a history of bladder cancer before RNU or neo-adjuvant/adjuvant chemotherapy. 93 included patients were stratified according to pre-RNU ureteroscopy (DFU + 70 patients) or no pre-RNU ureteroscopy (DFU-23 patients). The standardized DFU technique consisted of systematic ureteral sheath (ch9-10), flexible ureteroscopy, biopsy, and drainage with a mono-J/bladder catheter to avoid contact of contaminated urine of the upper tract with the bladder. Epidemiological, initial staging, and postoperative tumoral characteristics were similar in both groups. Mean follow-up was 35months [2-166], 47(50%) BR occurred with 41(87%) in the DFU + group, and pre-RNU-DFU was an independent predictive factor of BR (OR = 4[1.4-11.9], P = 0.01) (Cox regression model). The characteristics of BR were similar in both groups, although BR occurred earlier in DFU + (427days vs. 226days (P = 0.07)). Bladder recurrence after diagnostic ureteroscopy + nephroureterectomy was high despite technical precautions to avoid contact of bladder mucosa with contaminated urine from the upper urinary tract. Post-DFU endovesical instillation should be investigated.

Anterior cruciate ligament tears in children: Management and growth disturbances. A survey of French Arthroscopy Society members

BackgroundAnterior cruciate ligament (ACL) tears are becoming more common and occurring at earlier ages in the paediatric population. The surgical indications and the optimal time for surgery, technique, and graft type remain controversial in skeletally immature patients. Growth disturbances have been reported after ACL reconstruction, further complicating treatment decisions. The primary objective of this study was to describe current practices of French Arthroscopy Society (Société Francophone d’Arthroscopie, SFA) members regarding ACL tear management in skeletally immature patients. The secondary objectives were to determine the incidence, type, and severity of growth disturbances after ACL reconstruction. HypothesisRecent publications support early surgical reconstruction and the further development of transphyseal techniques, even in pre-pubertal patients. Material and methodsAn email invitation to complete a 52-item questionnaire was sent to all SFA members. Participation was voluntary and replies were kept confidential. The data were collected automatically via the SurveyMonkey® tool. Descriptive statistics were computed. ResultsOf 1280 invited SFA members, 142 replied, yielding a participation rate of 11%. Among respondents, 14% recommended ACL reconstruction within 3 months for pre-pubertal patients, compared to 35% for pubertal paediatric patients. The preferred tibial tunnel was transphyseal for both pre-pubertal patients (44.4% of respondents) and pubertal patients (97.7% of respondents). The preferred femoral tunnel was epiphyseal for pre-pubertal patients (62.2% of respondents) and transphyseal for pubertal patients (55.5% of respondents). Growth disturbances after ACL reconstruction were reported by 7% of respondents. ConclusionNo consensus exists to date about the surgical management of ACL tears in skeletally immature patients. Transphyseal tunnels are gaining in popularity, even for pre-pubertal children. Reports of significant growth disturbances, although relatively rare, warrant the implementation of technical precautions. Level of evidenceIV, descriptive epidemiological survey.

Steroids Spinal Injections.

Spinal pain is a common condition leading to significant disability and high cost. Spinal injections have been demonstrated to be effective short-term treatments with cost-utility superior to numerous other treatments, including surgical procedures. Appropriate patient selection-based on clinical and imaging finding-and the use of image guidance associated with technical precautions improve the safety and effectiveness of spinal injection and overall patient outcomes.