Transposition Procedure Research Articles

Basilic Vein Transposition: A Good Vascular Route for Hemodialysis Patients

Introduction: Hemodialysis is a necessary treatment for life in patients with chronic renal failure when peritoneal dialysis and renal transplantation can not be an option. In this study, the results of basilic vein transposition (BVT) procedures performed in our clinic for hemodialysis were retrospectively analyzed. Materials and Methods: In our study, 21 patients who underwent BVT between January 2018 and November 2019 were evaluated retrospectively. Eight patients had previously undergone a brachiobasilic fistula in another center, and one patient previously had a brachiaobasilic fistula in our center. Twelve patients underwent both brachiobasilic fistula and BVT in the same session, while the other nine patients had only BVT, duration of dialysis, fistula maturation, follow-up, and follow-up complications. Results: BVT was performed at both non-dominant arms and in the fistula arm if the patient had brachiobasilic fistula before and in the other patients. Arteriovenous fistula (AVF) was created at a dominant arm if the non-dominant arm was non-suitable. Bleeding occurred in two patients that did not require surgery again. Two patients had superficial tissue infection resolved by antibiotherapy, and two patients underwent thrombectomy and provided patency at one patient. Conclusion: Although BVT is not the first choice, it is a method that can be used safely if the radiocephalic and brachiocephalic fistulas do not work or if there is no suitable vessel in these regions.

PERGESERAN MAKNA DALAM CERPEN HACHI NO JI YAMA

(Title: Meaning Shift in Japanese Short Story “Hachi No Ji Yama”) A literary work will be translated properly according to the original text if an interpreter does the translation procedure appropriately. The translation procedure itself is divided into 14 types, but in the translation process from Japanese into Indonesian, there are three types which commonly used in procedures of the translation process. It is Transposition, Modulation, and Adaptation. This paper tried to explain the use of that three types of translation procedures in a Japanese short story. The short story used as the object of this paper was a children's short story entitled Hachi no Ji Yama by Tsuchida Kohei. Referring to the translation rules, the results are that the Hachi no Ji Yama short story uses 2 translation procedures, which is transposition and modulation. With the differences in the rules of language and grammatical structure between Indonesian and Japanese, the most widely used of transposition procedures are the first and second types, while the modulation used is free modulation.

Radiographic Analysis of Glenoid Morphology After Arthroscopic Latarjet Versus Distal Tibial Allograft in the Treatment of Anterior Shoulder Instability

The Latarjet procedure for autograft transposition of coracoid to the anterior rim of the glenoid remains the most common procedure for reconstruction of the glenoid after shoulder instability. The anatomic glenoid reconstruction using distal tibial allograft has gained popularity and is suggested to better match the normal glenoid size and shape. However, there is concern for decreased healing and increased resorption using an allograft bone. The purpose of this study was to evaluate the arthroscopic reconstruction of the glenoid with respect to the size, shape, healing, and resorption of autograft coracoid vs allograft distal tibia.

369. Obstetric outcomes following atrial and arterial switch procedures for transposition of the great arteries – A single, tertiary referral centre experience over 20 years

Complete transposition of the great arteries (TGA) accounts for approximately 5–7% of CHD. Almost all patients with TGA surviving until adulthood have undergone complex, reparative, cardiac surgery, which can complicate physiological adaptation to the demands of pregnancy. The atrial switch procedure (Mustard or Senning procedure) was the first operation to enable survival beyond infancy, as such, pregnancy outcomes have been well described. Cardiac risks of pregnancy include cardiac deterioration, heart failure and arrhythmias. The pregnancy risks include; pre-term delivery (31–38%) and neonates which are small for gestational age (SGA) (22–38%). The arterial switch operation (ASO) has now largely superseded the atrial switch procedures, this involves transection and ‘re-plumbing’ of the great arteries to restore near normal anatomy, it follows that adult survivors are now undertaking the challenges of pregnancy. Our unit is an adult congenital heart disease (ACHD) centre and tertiary level maternal medicine service with over twenty years’ experience in the multi-disciplinary team (MDT) management of women with surgically corrected TGA in pregnancy. Here we report and compare obstetric outcomes in women born with TGA, corrected with either an atrial switch procedure or ASO. This is the largest, cohort of pregnancies, with complete obstetric and neonatal outcomes, born to women following an ASO, reported to date and the only comparison of outcomes by procedure. There were 48 completed pregnancies in 23 women, 19 women who had undergone an atrial switch procedure delivered 38 babies and 4 who had undergone an ASO had 10 babies. We report obstetric and neonatal outcomes for all pregnancies, based upon which we make recommendations for the obstetric care of women with this condition.

Comparison of the efficiency of various muscle transposition procedures using a novel three-dimensional model.

AimTo investigate the performance of a newly developed three-dimensional (3D) biomechanical model in various transposition procedures for correction of complete sixth nerve palsy with educational purpose.MethodsA 3D biomechanical eye model was created using Hyperworks software based on geometry data and the biochemical properties of the eyeball and extraocular muscles. A complete sixth nerve palsy model was achieved via modification of lateral rectus muscle strength. Four different muscle transposition procedures (the Hummelsheim, Jensen, Foster, and muscle union procedures) were set up, and the objective surgical effect of each procedure was calculated using 3D model simulation.ResultsIn the 3D simulation, sixth nerve palsy was modeled by rotating the eye 34.16 degrees in the medial direction, consistent with 70 prism diopter (PD) esotropia. In surgical model simulation, the Hummelsheim procedure resulted in a 28 PD reduction of total deviation, the Jensen procedure achieved a 34 PD reduction, the Foster procedure led to a 57 PD reduction, the muscle union procedure yielded a 57 PD reduction in esotropia in sixth nerve palsy.ConclusionThe 3D simulation provided a consistent model of sixth nerve palsy and objective data excluding the potential for variation of surgical skill. It could also help predict surgical outcomes.

Vertical Strabismus - Indication of Surgical Techniques on the Inferior Rectus Muscle.

Surgery technique “cul-de-sac” is aprocedure with fixed adjustable sutures (non-absorbable suture), which are guided in parallel on both peaks original insertion of inferior rectus muscle. The node itself of suture is done in cutting the muscle and through the original insertion only leads arc suture. During „counterclockwise transposition“ procedure sec. Knapp, the horizontal rectus muscles are fixed at the straight inferior rectus muscle level. The author included their graphical diagrams. At the Department of Ophthalmology in the Faculty Hospital Královské Vinohrady in Prague (Czech Republic, EU) in the years 1996 - 2014 arelease relaxing operation of the inferior rectus musle by the technique “cul-de-sac” on 49 eyes. Indication was double elevator palsy in 31 patients, congenital fibrosis of the extraocular muscles in 15 patients and in 3 cases, it was thyroid eye disease. “Counterclockwise transposition” procedure sec. Knapp was indicated twice for paresis of the inferior rectus muscle in 2015 and 2016. For the first time, it was acongenital form. It was detected histologically atrophy of stripped muscle with hypertrophy collagen. The second traumatic form was formed after an orbital injury. We provided adequate relaxation of the inferior rectus muscle and practical restoration of eye elevation by the technique “cul-de-sac“ in 18 preschool children with the double elevator palsy and three adult patients with thyreiod eye disease. We had to restore motility to complete the procedure by classical transposition procedure sec. Knapp of both horizontal rectus muscles to the direct superior rectus muscle in elderly children and adults with the double elevator palsy, as well as in all patients with the congenital fibrosis of the extraocular muscles. Indicate the inclusion of this transposition influenced the degree of fibrotic rectus inferior muscle given by age. “Counterclockwise transposition“ procedure sec. Knapp ensured the practical disappearance hypertropie in both cases of paresis of the inferior rectus muscle. The alignment of the position of the eyes without diplopia in the direct view was ensured by prismatic correction. To release the fibrotically altered inferior rectus muscle in the double elevator palsy, the congenital fibrosis of the extraocular muscles and the thyroid eye disease, the operation of adjustable sutures was necessary in accordance with our experience with the technigue “cul-de-sac“ in its own modification. The transposition procedure sec. Knapp, either classical or “”counterclockwise” “ in its own modification, was of paramount importance for the solution of the vertical deviation of aparetic ethiology. Key words: adjustable sutures, congenital fibrosis of the extraocular muscles, double elevator palsy, thyroid eye disease, transposition procedure sec. Knapp, vertical strabismus.

Microvascular Decompression for Hemifacial Spasm Associated with Vertebral Artery: Biomedical Glue−Coated Teflon Sling Transposition Technique

Microvascular decompression is the most effective treatment for hemifacial spasm. However, when encountering hemifacial spasm associated with vertebral artery (VA), the procedure is more challenging and requires complicated operation techniques. The authors retrospectively analyzed the clinical characteristics of this group of cases and investigated reasonable transposition procedures for different anatomic classifications. We retrospectively analyzed 117 cases that underwent their first microvascular decompression for hemifacial spasm between June 2010 and December 2016, which had all associated with vertebral artery compression diagnosed by preoperational radiology examination. The study first classified offending vessels into 3 types according to operative anatomy and designed personalized decompression management according to different forms of neurovascular conflict. Curative effects and complications were assessed. The offending vessels were artificially divided into 3 types according to both arterial pattern and compression direction: 1) ipsilateral VA plus anterior inferior cerebellar artery compressing the facial nerve from the ventrolateral direction in 72 (61.5%) cases; 2) ipsilateral VA plus posterior inferior cerebellar artery compressing the facial nerve from the caudal-medial direction in 31 (26.5%) cases; 3) bilateral VA compressing the facial nerve in 14 (12.0%) cases. We selected corridors to expose the neurovascular conflict site between the suprafloccular-transhorizontal fissure approach and subtonsillar-transcerebellomedullary fissure approach. The methods of decompression consist of anteromedial and posterolateral transposition by using biomedical glue-coated Teflon sling. Sufficient decompression of the offending vessels was safely performed in all cases. All cases had total relief of symptoms immediately after their operations. Follow-up periods ranged from 16-90 months, and total recovery occurred in 110 cases (94.0%). In 7 cases (6.0%), 90% recovery occurred. Accuracy and comprehensive recognition of anatomic features of the offending vessels are crucial for the management of hemifacial spasm associated with vertebral artery compression. Appropriate approaches combined with the biomedical glue-coated Teflon sling transposition technique can allow adequate mobilization of the vertebral artery and bring complete postoperative symptom relief for most cases.

Radiographic Analysis of Glenoid Size and Shape After Arthroscopic Coracoid Autograft Versus Distal Tibial Allograft in the Treatment of Anterior Shoulder Instability

Background: The Latarjet procedure for autograft transposition of the coracoid to the anterior rim of the glenoid remains the most common procedure for reconstruction of the glenoid after shoulder instability. The anatomic glenoid reconstruction using distal tibial allograft has gained popularity and is suggested to better match the normal glenoid size and shape. However, concerns about decreased healing and increased resorption arise when an allograft bone is used. Purpose: To use radiological findings to evaluate the arthroscopic reconstruction of the glenoid with respect to the size, shape, healing, and resorption of coracoid autograft versus distal tibial allograft. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was performed of 48 consecutive patients who had an arthroscopic bony reconstruction of the glenoid (12 coracoid autograft, 36 distal tibial allograft), diagnosed anterior shoulder instability, and computed tomography (CT)–confirmed glenoid bone loss more than 20%. Coracoid autograft was performed only when tibial allograft was not accessible from a bone bank. Two fellowship-trained musculoskeletal radiologists reviewed pre- and postoperative CT scans at a minimum follow-up of 6 months for the following: graft position, glenoid concavity, cross-sectional area, width, version, total area, osseous union, and graft resorption. Clinical outcome was noted in terms of instability, subluxation, and dislocation at a minimum follow-up of 2 years. Simple logistic regression, 2-tailed independent-sample t tests, paired t tests, and Fisher exact tests were performed. Results: Graft union was seen in 9 of the 12 patients (75%) who had coracoid autograft and 34 of the 36 patients (94%) who had tibial allograft (odds ratio, 5.66; 95% CI, 0.81-39.20; P = .08). The odds ratio comparing allograft to coracoid for overall resorption was 7.00 (95% CI, 1.65-29.66; P = .008). Graft resorption ≥50% was seen in 3 (8%) of the patients who had tibial allograft and none of the patients who had coracoid autograft. Graft resorption less than 50% was seen in the majority of patients in both groups: 27 (73%) patients with tibial allograft and 5 (42%) patients with coracoid autograft. No statistically significant difference was found between the 2 procedures regarding anteroposterior diameter of graft (P = .81) or graft cross-sectional area (P = .93). However, a significant difference was observed in step formation between the 2 procedures (P < .001). Two patients experienced subluxations in the coracoid group (16%) as well as 2 patients in the tibial allograft group (6%) with a P value of .25. Conclusion: Arthroscopic anatomic glenoid reconstruction via distal tibial allograft showed similar bony union but higher resorption compared with coracoid autograft. Even so, no statistically significant difference was found between the 2 procedures regarding final graft surface area, the size of grafts, and the anteroposterior dimensions of the reconstructed glenoids. These short-term results suggest that distal tibial allografts can be used as an alternative to coracoid autograft in the recreation of glenoid bony morphologic features.

Radiographic Analysis of Glenoid Morphology after Arthroscopic Latarjet vs Distal Tibial Allograft in the Treatment of Anterior Shoulder Instability

Objectives:The Latarjet procedure for autograft transposition of coracoid to the anterior rim of the glenoid remains the most common procedure for reconstruction of the glenoid after shoulder instability. The anatomic glenoid reconstruction using distal tibial allograft has gained popularity and is suggested to better match the normal glenoid size and shape. However, there is concern for decreased healing and increased resorption using an allograft bone. The purpose of this study was to evaluate the arthroscopic reconstruction of the glenoid with respect to the size, shape, healing, and resorption of autograft coracoid vs allograft distal tibia.Methods:A retrospective review of 50 consecutive patients who had an arthroscopic boney reconstruction of the glenoid (13 coracoid; 37 distal tibial), diagnosed with anterior shoulder instability, and CT confirmed glenoid bone loss >20%. Pre-and post-operative CT scans were reviewed by two fellowship trained musculoskeletal radiologists for: graft position, glenoid concavity, cross sectional area, width, version, total area, osseous union, and graft resorption.Results:Graft nonunion was seen in 3 (23.07%) of the coracoid patients, and in 2 (5.4%) of the tibial allograft patients (OR 5.25; 95% CI: 0.768-35.89). Odds ratios comparing allograft to coracoid for overall resorption was 5.00 (CI: 1.276-19.597). Graft resorption greater than 50% was seen in 3 (8.11%) of the allografts and was absent within the coracoid patients. Graft resorption lesser than 50% was greater in both groups with 27 (72.97%) allograft and 6 (46.15%) coracoid patients. However, no statistically significant difference was found between the two procedures regarding AP diameter of graft (p=0.818) or graft cross sectional area (p=0.797).Conclusion:Arthroscopic anatomic glenoid reconstruction using distal tibial allograft showed greater boney union but higher resorption compared to coracoid autograft. Even so, there was no statistically significant difference between the two procedures regarding final graft surface area and size of grafts. These short-term results suggest distal tibial allograft as an alternative to coracoid autograft in the recreation of glenoid boney morphology.

Novel Technical Variations and Increased Adhesive Strength in the “Birdlime” Transposition Technique for Microvascular Decompression

Vessel transposition is the standard procedure in microvascular decompression (MVD), which necessitates more complex and difficult surgical techniques, including suturing in the deep operative field. We recently reported the usefulness of TachoSil tissue sealing sheets soaked with fibrin glue for vessel transposition in MVD, known as the "birdlime" technique. Here we describe various technical variations and improved adhesive strength of this material for safe and optimal vessel transposition without complications. We retrospectively reviewed the operative findings of 31 consecutive patients who underwent MVD with the transposition procedure using TachoSil tissue sealing sheet soaked with fibrin glue between January 2012 and June 2017. The adhesive strength of TachoSil soaked with fibrin glue was measured using porcine dura mater. A single piece of this material was required in 13 patients, a single piece for multiple lesions was required in 5 patients, multiple pieces for a long segment were required in 12 patients, mainly with the offending vertebral artery in 9 patients, stacked pieces in 2 patients, and direct adhesion of vessels in 6 patients. All patients except 1 had total remission of symptoms immediately after the procedure. There were no severecomplications, recurrences, adhesions, or cranial nerve dysfunction in any patient. TachoSil soaked with fibrin glue showed significantly higher adhesive tensile strength compared with fibrin glue or Teflon felt with fibrin glue. Modifications of the birdlime technique and reinforcement of the adhesive strength provide an easy and adjustable way to perform MVD safely and effectively to reduce the risk of intraoperative neurovascular injury.

Foster Modification of Full Tendon Transposition of Vertical Rectus Muscles for Sixth Nerve Palsy

Since 1907 a variety of muscle transposition procedures for the treatment of abducens nerve palsy has been established internationally. Full tendon transposition of the vertical rectus muscle was initially described by O'Connor 1935 and then augmented by Foster 1997 with addition of posterior fixation sutures on the vertical rectus muscle. Full tendon transposition augmented by Foster belongs to the group of the most powerful surgical techniques to improve the abduction. Purpose of this study was to evaluate the results of full tendon vertical rectus transposition augmented with lateral fixation suture for patients with abducens nerve palsy. Full tendon transpositions of vertical rectus muscles augmented with posterior fixation suture was performed in 2014 on five patients with abducens nerve palsy. Two of the patients received Botox injections in the medial rectus muscle: one of them three months after the surgery and another during the surgery. One of the patients had a combined surgery of the horizontal muscles one year before. On three of the patients, who received a pure transposition surgery, the preoperative deviation at the distance (mean: + 56.6 pd; range: + 40 to + 80 pd) was reduced by a mean of 39.6 pd (range 34 to 50 pd), the abduction was improved by a mean of 3 mm (range 2 to 4 mm). The other two patients, who received besides the transposition procedure additional surgeries of the horizontal muscles, the preoperative deviation at the distance (+ 25 and + 126 pd respectively) was reduced by 20 and 81 pd respectively. The abduction was improved by 4 and 8 mm respectively. After surgery two patients developed a vertical deviation with a maximum of 4pd. None of the patients had complications or signs of anterior segment ischemia. The elevation and/or depression was only marginally affected. There was no diplopia in up- or downgaze. Full tendon transposition of vertical rectus muscles, augmented with lateral posterior fixation suture is a safe and effective treatment method for abducens nerve palsy and in most cases recession of the medial rectus can be avoided. Upgaze and downgaze are affected very slightly. Diverse studies have shown that the risk of anterior segment ischemia is low.

KESALAHAN GRAMATIKAL DAN PENERJEMAHAN LITERAL BUKU DURUSUN IQTISHADIYATUN MIN RAMADLAN

Abstra ck: This study aims to describe the grammatical meaning of the translation errors and the use of literal translation in the translation procedure book Durusun Iqtishadiyatun min Ramadlan. This research is qualitative, descriptive, in accordance with the data collected in the form of words, phrases and sentences. Researchers found: (1) the translation of the meanings of grammatical errors include (a) error of morphology, which is caused by three factors, among others errors recognize form words, diction selection mistakes and errors recognize variations of word meaning, and (b) the syntax error is caused by an error in the interpretation of syntax elements in a sentence. (2) The literal translation procedure usage error in the fix uses some other procedures that; (a) transposition procedures, (b) cultural equivalence procedures, (c) the procedure modulation, (d) the procedure modulation-transposition-culture equivalence. (e) the procedure of modulation-transposition and transposition procedures (f)-modulation. permalink/DOI: dx.doi.org/10.17977/um015v46i12018p082

A Median Nerve Anterior Transposition Procedure for Multi-Recurrent Hemodialysis-Related Carpal Tunnel Syndrome.

Some long-term hemodialysis patients suffer from multi-recurrent carpal tunnel syndrome because amyloid originating from β2-microglobulin continues to be deposited mainly in the flexor tendons, tendon sheaths and flexor retinaculum during maintenance hemodialysis. These amyloid deposits inside carpal canal (tunnel) tissues increase carpal canal pressure and this leads to compression of the median nerve. When multi-recurrent carpal tunnel syndrome occurs, previous operative scarring of soft tissue may prohibit further enlargement of the carpal canal even if any carpal canal decompression procedure is used. For this reason, we developed a median nerve anterior transposition procedure, as a new approach in the treatment of multi-recurrent hemodialysis-related carpal tunnel syndrome. Median nerve anterior transposition procedures were performed on seven hands in six patients with multi-recurrent carpal tunnel syndrome. The mean age of the patients was 68.3 years and the mean hemodialysis duration was 35.3 years. Mean follow-up period was 9.9 months. The median nerve is transposed from inside to outside of the carpal canal under local and infiltration anesthesia without a pneumatic tourniquet on an outpatient basis. This procedure is based on the same principles applied in ulnar nerve anterior transposition procedures for cubital tunnel syndrome. Main preoperative patient complaints were intolerable tingling and/or pain in the diseased hands throughout the day. Following the surgeries, preoperative clinical symptoms began to subside and eventually improved in all hands. Postoperative abductor pollicis brevis muscle power using manual muscle testing improved except in one hand. Abnormal preoperative distal motor and sensory latency were improved except in two hands following the surgeries. The median nerve anterior transposition procedure is a beneficial treatment for patients suffering from hemodialysis-related multi-recurrent carpal tunnel syndrome.

Fibrotic Venous Remodeling and Nonmaturation of Arteriovenous Fistulas.

The frequency of primary failure in arteriovenous fistulas (AVFs) remains unacceptably high. This lack of improvement is due in part to a poor understanding of the pathobiology underlying AVF nonmaturation. This observational study quantified the progression of three vascular features, medial fibrosis, intimal hyperplasia (IH), and collagen fiber organization, during early AVF remodeling and evaluated the associations thereof with AVF nonmaturation. We obtained venous samples from patients undergoing two-stage upper-arm AVF surgeries at a single center, including intraoperative veins at the first-stage access creation surgery and AVFs at the second-stage transposition procedure. Paired venous samples from both stages were used to evaluate change in these vascular features after anastomosis. Anatomic nonmaturation (AVF diameter never ≥6 mm) occurred in 39 of 161 (24%) patients. Neither preexisting fibrosis nor IH predicted AVF outcomes. Postoperative medial fibrosis associated with nonmaturation (odds ratio [OR], 1.55; 95% confidence interval [95% CI], 1.05 to 2.30; P=0.03, per 10% absolute increase in fibrosis), whereas postoperative IH only associated with failure in those individuals with medial fibrosis over the population's median value (OR, 2.63; 95% CI, 1.07 to 6.46; P=0.04, per increase of 1 in the intima/media ratio). Analysis of postoperative medial collagen organization revealed that circumferential alignment of fibers around the lumen associated with AVF nonmaturation (OR, 1.38; 95% CI, 1.03 to 1.84; P=0.03, per 10° increase in angle). This study demonstrates that excessive fibrotic remodeling of the vein after AVF creation is an important risk factor for nonmaturation and that high medial fibrosis determines the stenotic potential of IH.

Subcutaneous versus submuscular ulnar nerve transposition in cubital tunnel syndrome

Introduction There are different surgical procedures for treatment of cubital tunnel syndrome (CubTS), which can be divided into two types, decompression and transposition procedures. Decompressive procedures include simple decompression with or without medial epicondylectomy without mobilizing the nerve. The transposition procedures mobilize the nerve anteriorly for more protection by subcutaneous, intramuscular, and submuscular methods, depending on the position in which the ulnar nerve is placed. Patients and methods A total of 24 patients with moderate CubTS (according to Dellon’s grading system) between March 2011 and April 2013 were classified according to age and sex into anterior subcutaneous transposition and anterior submuscular transposition groups. The two groups were prospectively followed up for 2 weeks, 6 months, and 12 months postoperatively, and outcome was assessed using the Bishop rating system. Results A total of 24 patients with moderate CubTS were used in this study to compare the operative technique (incision length and operative time), postoperative care (postoperative pain and complications), and the outcome between subcutaneous transposition and submuscular transposition of the ulnar nerve as two surgical modalities in treating moderate CubTS. Final results present that the subcutaneous transposition of the ulnar nerve was associated with shorter incision, shorter operative time, less postoperative pain, less postoperative complication, and better outcome compared with the submuscular transposition. Conclusion Subcutaneous ulnar nerve transposition in the treatment of CubTS, as compared with the submuscular approach, is an easier surgical technique with less operative time and postoperative pain, earlier postoperative mobilization, and better postoperative outcome.

Similar degree of intimal hyperplasia in surgically detected stenotic and nonstenotic arteriovenous fistula segments: a preliminary report

BackgroundIntimal hyperplasia has been historically associated with improper venous remodeling and stenosis after creation of an arteriovenous fistula. Recently, however, we showed that intimal hyperplasia by itself does not explain the failure of maturation of 2-stage arteriovenous fistulas. We seek to evaluate whether intimal hyperplasia plays a role in the development of focal stenosis of an arteriovenous fistula. MethodsThis study compares intimal hyperplasia lesions in stenotic and nearby nonstenotic segments collected from the same arteriovenous fistula. Focal areas of stenosis were detected in the operating room in patients (n = 14) undergoing the second-stage vein transposition procedure. The entire vein was inspected, and areas of stenosis were visually located with the aid of manual palpation and hemodynamic changes in the vein peripheral and central to the narrowing. Stenotic and nonstenotic segments were documented by photography before tissue collection (14 tissue pairs). Intimal area and thickness, intima-media thickness, and intima to media area ratio were measured in hematoxylin and eosin stained cross-sections followed by pairwise statistical comparisons. ResultsThe intimal area in stenotic and nonstenotic segments ranged from 1.25 to 11.61 mm2 and 1.29 to 5.81 mm2, respectively. There was no significant difference between these 2 groups (P = .26). Maximal intimal thickness (P = .22), maximal intima-media thickness (P = .13), and intima to media area ratio (P = .73) were also similar between both types of segments. ConclusionThis preliminary study indicates that postoperative intimal hyperplasia by itself is not associated with the development of focal venous stenosis in 2-stage fistulas.

Clinical effect observation of vascularized anterior transposition of ulnar nerve for treatment of severe cubital tunnel syndrome

Objective To evaluate the clinical outcomes of a modified procedure of ulnar nerve anterior transposition in the treatment of severe cubital tunnel syndrome. Methods From September 2015 to May 2016, 25 patients with cubital tunnel syndrome underwent vascularized ulnar nerve anterior transposition were followed up after operation. All the patients had severe muscular atrophy and deformity of elbow joint before operation. According to Gu Yudong's classification of cubital tunnel syndrome, they were graded as severe. In this modified procedure, the sufficient neurolysis of ulnar nerve as well as the anterior transposition of ulnar nerve accompanied with superior ulnar collateral artery were conducted. Results All the 25 patients were follow-up from 12 to 21 months with an average of 15.3 months. All the patients achieved sensory recovery in different degrees without temporary worsening of clinical symptoms. Completely sensory recovery was observed in 20 patients (80%). 4 patients (16%) remained occasional sensory symptoms while only 1 patient (4%) remained persistently moderate sensory symptoms. The mean two-point discrimination of little finger pulp was improved from preoperative 6.08 mm to postoperative 2.93 mm. Obvious improvement of intrinsic muscular atrophy was observed in 17 patients (68%). According to the Gu Yudong's function evaluation standard of cubital tunnel syndrome, the results were excellent in 16 patients, good in 6 patients and fair in 3 patients with the excellent and good rate being 88%. Conclusion The modified technique of vascularized anterior transposition of unlar nerve appears to be an effective and safe procedure for the treatment of severe cubital tunnel syndrome. It might reduce the incidence of postoperative nerve symptoms caused by devascularization of ulnar nerve. Key words: Cubital tunnel syndrome; Ulnar nerve; Vascularized; Anterior transposition

The EU Antitrust Damages Directive: Transposition in the Member States - Portugal

This paper describes the current status of the transposition of the Private Enforcement Directive (Directive 2014/104/EU) in Portugal. It analyses the transposition procedure itself, as well as the main innovative characteristics of the proposed national law. There are many issues in which the Portuguese legislator has gone beyond the requirements of the Directive, which may be of interest for reflection at EU level and in other Member States.

Efficacy of Vertical Muscle Transpositions with and without Simultaneous Rectus Muscle Recession for Unilateral Sixth Nerve Palsy

We report results of a modified vertical muscle transposition procedure according to the Hummelsheim principle - with and without simultaneous rectus muscle recession - for unilateral sixth nerve palsy. We examine the influence of the duration of the palsy, preoperative angle of squint and preoperative abductive capacity on surgical results of the procedures. Retrospective study of 29 consecutive patients with unilateral abducens nerve palsy who underwent surgery between 2001 and 2012. 21 patients had a modified vertical rectus muscle transposition according to the Hummelsheim principle (HUM); 8 patients had this operation combined with simultaneous medial rectus muscle recession (HUM+I). Surgery was performed at least 9 months after onset of the palsy (HUM: 9 to 98, median 19, mean 30months; HUM+I: 12 to 65, median 25, mean 29 months). The median preoperative angle of squint (far distance) for the HUM group was 27.0° (20.0 to 45.0; mean 28.1°), and for the HUM+I group 30.5° (21.8 to 50.0; mean 33.4°). The median preoperative abductive capacity was for - 1,6 mm before midline (- 8.0 to + 1.2; mean - 1.8 mm) for the HUM group, and - 3.0 mm before midline (- 10.0 to - 1.0; mean - 4.1 mm) for the HUM+I group. The median postoperative angle of squint (far distance) was 0° (- 11.3 to + 20.0; mean 0.1°) for the HUM group, and - 2.3° (- 11.3 to + 12.0; mean - 2.1°) for the HUM+I group. The median postoperative abductive capacity was 1.0 mm (0 to + 3.0; mean + 1.1 mm) for the HUM group, and 1.1 mm (- 1.2 to + 3.0; mean + 0.9 mm) for the HUM+I group. The median reduction of squint angle was 27.0° (9.1 to 45.0; mean 28.0°) for the HUM group, and 36.8° (25.2 to 41.4; mean 35.5°) for the HUM+I group. The median effect on abductive capacity was 2.5 mm (0 to 11.0; mean + 2.9 mm) for the HUM group, and 4.6 mm (2.4 to 8.8; mean + 5.0 mm) for the HUM+I group. In the HUM group, the effect on squint angle reduced with the duration of the palsy, whereas, in the HUM+I group, the effect improved with the duration of the palsy. For patients with unilateral sixth nerve palsy, simultaneous medial rectus recession increases the effect of modified vertical rectus muscle surgery according to the Hummelsheim principle. The duration of the palsy is a relevant parameter for the selection of a sole or combined intervention with medial rectus recession.

Ileal Transposition (IT) Surgery Changing the Ultrastructure of the Transposed Segment as well as Jejunum. Histomorphometric and Electron Microscopy Analysis

ObjectiveIleal transposition (IT) procedure leads to higher secretion of incretin hormones what is associated with a beneficial metabolic effect. However, IT will also have an influence on the related jejunum and ileum function. The aim of this research was to investigate the morphology of the jejunum and transposed ileum with the use of light and transmission electron microscopy (TEM) in order to determine the local alternations in the intestine resulting from the transposition.MethodsTwenty male, 8-week-old, obese Zucker rats underwent IT and six of them sham surgery. To compare both groups, the transection was made at all corresponding ileum positions among both groups of animals. The ileal anastomoses among the rats of sham procedure were subsequently formed accordingly without IT. Three months following the surgery, the tissue samples of jejunum and ileum were harvested.ResultsA significant increase in villus length, a decrease in the crypt depth, and an increased thickness of mucosa-muscularis-serosa (MMS) as well as cellular hyperplasia, with increased mitochondrial density of the transposed ileum segment, were observed among the group of rats which underwent IT comparing to the ones undergoing sham surgery. In rats undergoing IT, microvillus degeneration in jejunum regions was observed.ConclusionsIleal transposition alters the morphology and ultrastructure of the ileum as well as the jejunum. Given that the microvillus membrane represents an important aspect of the enterocyte functions, a further biochemical and molecular research is necessary in order to assess whether the observed changes are beneficial or not and to explore the phenomenon of gut adaptability after metabolic surgery.