Preservation Of Vessels Research Articles

Automated bone removal in CT angiography: Comparison of methods based on single energy and dual energy scans

To evaluate dual energy based methods for bone removal in computed tomography angiography (CTA) images and compare these with single energy based methods that use an additional, nonenhanced, CT scan. Four different bone removal methods were applied to CT scans of an anthropomorphic thorax phantom, acquired with a second generation dual source CT scanner. The methods differed by the way information on the presence of bone was obtained (either by using an additional, nonenhanced scan or by scanning with two tube voltages at the same time) and by the way the bone was removed from the CTA images (either by masking or subtracting the bone). The phantom contained parts which mimic vessels of various diameters in direct contact with bone. Both a quantitative and qualitative analysis of image quality after bone removal was performed. Image quality was quantified by the contrast-to-noise ratio (CNR) normalized to the square root of the dose (CNRD). At locations where vessels touch bone, the quality of the bone removal and the vessel preservation were visually assessed. The dual energy based methods were assessed with and without the addition of a 0.4 mm tin filter to the high voltage x-ray tube filtration. For each bone removal method, the dose required to obtain a certain CNR after bone removal was compared with the dose of a reference scan with the same CNR but without automated bone removal. The CNRD value of the reference scan was maximized by choosing the lowest tube voltage available. All methods removed the bone completely. CNRD values were higher for the masking based methods than for the subtraction based methods. Single energy based methods had a higher CNRD value than the corresponding dual energy based methods. For the subtraction based dual energy method, tin filtration improved the CNRD value with approximately 50%. For the masking based dual energy method, it was easier to differentiate between iodine and bone when tin filtration was applied. The CNRD value decreased only with 4% in that case. Compared to the dual scan based methods, the dual energy based methods had the advantage that only a single scan was made without the need of image registration. This might be easier to implement in clinical practice. Vessel preservation was better with bone subtraction than with bone masking. Smaller vessels were completely occluded by the bone mask. None of the bone removal methods was dose neutral. In general, dual scan based methods that use the lowest tube voltage available, have a higher CNR than the dual energy based approaches at the same dose level. Tin filtration improves the ability to differentiate between iodine and bone for the dual energy based masking method. In clinical practice, the advantages of the dual energy masking method might outweigh its disadvantage of a slightly higher dose penalty compared to the conventional dual scan masking method.

Flow-Diverting Stent for Ruptured Intracranial Dissecting Aneurysm of Vertebral Artery

The treatment of ruptured dissecting aneurysms of the intracranial vertebral artery (VA) with parent vessel preservation is a challenge for neurosurgeons and interventional neuroradiologists. To propose an indication for flow-diverting treatment for reconstruction of a dissecting VA with acute subarachnoid hemorrhage. Two male patients transferred after acute subarachnoid hemorrhage and dissecting aneurysm on the V4 segment of the dominant VA. An occlusion test was not performed because of their poor clinical state. A flow-diverting stent represented by the Pipeline embolization device was suggested to both patients. Three Pipeline embolization devices were deployed in each VA. One dissecting aneurysm was excluded immediately after 3 stents, and 1 patient had complete exclusion demonstrated at the 48-hour control. No morbidity directly related to the procedure was observed. No recanalization and no rebleeding occurred during the 3 months of follow-up. A flow-diverting stent may be considered an option to treat ruptured dissecting aneurysms of the VA, providing remodeling of the parent vessel and complete exclusion of the aneurysm.

Heritage as Transmission

<p>This paper explores how exclusionary practices resulting from mainstream heritage preservation approaches, policies, and practice can be countered through an analysis of the construction of meaning and its presentation. It is argued that heritage meaning is socially constructed, complex, and multi-faceted. In the process of revealing, decoding, and construing meaning, an ecosystemic approach can reveal an ecology of human culture within which a vessel of meaning resides, together with the multiplicity of meanings inherent to the structural relationships within such an ecology.</p><p>Within the above framework, vessels of meaning are given a function as mnemonic agents that are preserved to retain their potency for a continuously evolving process of re-discovery, decoding, and adding layers to existing constructed meaning. A practice of inclusion is proposed as a subversive strategy to oppose the use of heritage to create divisions and conflict through opening avenues for understanding a multiplicity of meanings. The author describes how current laws and policies of heritage preservation, interpretation, and presentation of vessels of value may be reviewed to be geared towards achieving heritage topographies that are open-ended transmitters of meaning, knowledge, emotion, and experience for the benefit of a multiplex society, with inclusiveness as the dominant narrative. The proposed heritage interpretation process includes open-ended mapping, exposure, and multi-vocal telling of what Dolff-Bonekämper (2011) defines as "memorable moments," in order to reveal traces of events as a topography of memory that may be rediscovered in many ways over time, and from a multiplicity of cultural and sub-cultural perspectives.</p>

Intraductal papillary mucinous neoplasm

A 75-year-old male with a history of dyslipidemia, no alcohol abuse, acute pericarditis and two pancreatitis episodes 16 and 3 years ago, consulted due to a new pancreatitis episode (amylase 536 IU/l). Abdominal CT and MRI showed irregular, rosary-like dilatation of the duct of Wirsung in the body and tail (Fig. 1). In the pancreatic body-tail, echoendoscopy revealed a 15-mm duct of Wirsung with dilatation of the secondary branches and intramural ductal projections. The duct of Wirsung was punctured, yielding mucin material and ductal-type cells without atypias; amylase 38,858 IU/l, CEA 1,604 IU/l and CA19.9 46,000 IU/l. The colonoscopy findings proved normal. Serum CA19.9 was 43 IU/l. With the diagnosis of intraductal papillary mucinous neoplasm of the pancreas (IPMN), a laparoscopic distal pancreatectomy was performed with preservation of the splenic vessels (Fig. 2). The histological study showed an intraductal proliferation affecting the principal duct and secondary branches, with a cylindrical epithelium of intestinal appearance and abundant mucous secretion (Fig. 3). Lacunar mucus accumulations were observed in the pancreatic stroma, without tumour cells. The observed dysplasia proved intense, though without invasive carcinoma (Fig. 3). The surgical margins were free of disease. There has been no evidence of relapse after 18 months of follow-up.

The Role of the Pipeline Embolization Device for the Treatment of Dissecting Intracranial Aneurysms

Intracranial dissecting aneurysms constitute rare lesions with complex management and elevated morbidity and mortality. Results of 23 patients harboring such lesions treated with the PED are reported. Standard dual antiplatelet therapy was instituted. Neurologic and angiographic assessments were obtained at 3, 6, and 12 months. Clinical presentation included SAH (52%), symptoms of mass effect (22%), ischemia (4%), and incidental finding (22%). The posterior circulation was affected in 91% of cases. Total occlusion was demonstrated in 69.5% of patients, with an increment to 87.5% considering only patients with at least 3 months of follow-up. Small aneurysms demonstrated higher rates of total occlusion (6/7) compared with large (5/7) and giant (5/9) ones. Good clinical outcome was achieved in 74% of patients. Reconstructive endovascular treatment of intracranial dissecting aneurysms with the PED provided good clinical and angiographic results with acceptable risks, representing an attractive therapeutic option for this complex disease, especially when parent vessel preservation is mandatory.

Laparoscopic spleen-preserving distal pancreatectomy in elderly subjects: splenic vessel sacrifice may be associated with a higher rate of splenic infarction

BackgroundLaparoscopic spleen-preserving distal pancreatectomy has gained popularity in recent years. Splenic preservation can be achieved with or without splenic vessel preservation (SVP). The potential morbidity of this approach in patients aged >70 years has not been well defined. MethodsTen patients aged >70 years underwent attempted laparoscopic spleen-preserving distal pancreatectomy within a 2-year period. Multiple patient parameters were examined and chi-squared analysis was used to evaluate the association between the operative technique (SVP or splenic vessel division [SVD]) and splenic infarction. The Mann–Whitney test was used to compare the SVP and SVD groups with regard to age, estimated blood loss (EBL), operating time, splenic volume and length of stay (LoS). ResultsMedian age was 81 years (range: 71–92 years). Operating room time, LoS, EBL and complication rates were similar to those reported in published series of younger patients. In four patients, the splenic vessels were divided in a manner relying on short gastric collateral flow; SVP was achieved in all other patients. All four patients who underwent SVD developed splenic infarcts and three required splenectomy to manage this (P= 0.002). Median LoS was increased in the SVD group (9.3 days vs. 4.3 days; P= 0.053). Estimated blood loss was higher in the SVP group (200ml vs. 100ml; P= 0.091). One pancreatic leak occurred. There were no mortalities. ConclusionsSpleen-preserving laparoscopic distal pancreatectomy can be performed safely in elderly patients, with results comparable with those achieved in younger subjects. However, elderly patients undergoing division of the splenic artery and vein may be at higher risk for splenic infarct and the aetiology of this is unclear.

Oncologic Validity of Cervical Recipient Vessel Preservation

Objective: Determine whether preservation of cervical recipient vessels affects surgical resection margins in patients who undergo microvascular free flap procedures for defects of reconstruction of the head and neck after the treatment of neoplasms. Method: Consecutive patients with adventitial biopsies of recipient neck vessels were identified over the previous 6-month period, and pathology was reviewed. Patient clinical information (age, sex, diagnosis, tumor site, tumor stage, prior treatment with surgery, radiation therapy, chemotherapy) was reviewed as potential risk factors for tumor involvement of recipient vessels. Results: A total of 57 patients with recipient vessel biopsies were identified between June 2010 and January 2011. Tumor sites included oral-oropharnygeal (n = 38), laryngopharyngeal (n = 8), scalp (n = 7), skull base-midface (n = 3), and neck (n = 1). Tumor pathology included squamous cell carcinoma (n = 45), osteoradionecrosis with a history of squamous cell carcinoma (n = 4), adenocarcinoma (n = 2), ossifying fibroma (n = 2), as well as a case each of ameloblastma and melanoma. One (1.7%) recipient vessel biopsy was positive for squamous cell carcinoma. This vessel looked grossly abnormal and was sent for frozen section analysis. Conclusion: Microvascular free flap reconstruction uses recipient vessels in the neck, which can potentially adversely affect resection margins by requiring preservation of recipient vessels in proximity to tumors. However, our results show that frozen section biopsy is necessary only when intra-operative findings are concerning for tumor involvement of the recipient vessels.

Lateral approach for laparoscopic splenic vessel-preserving distal pancreatectomy

We sought to evaluate the feasibility of the lateral approach for laparoscopic splenic vessel-preserving distal pancreatectomy (LA-SVPDP). Complete preservation of the splenic vessels is an ideal outcome in spleen-preserving distal pancreatectomy (SPDP). However, the preservation of the vessels is challenging in laparoscopic surgery because the splenic vein is often embedded in the pancreatic parenchyma. Herein we have described LA-SVPDP, the most feasible method for laparoscopic SPDP, and the outcome of our initial experience. Twenty-three patients underwent laparoscopic SPDP. Before we adopted LA-SVPDP, 8 patients underwent the Warshaw method and 6 underwent SVPDP. After the adoption of LA-SVPDP, 8 patients underwent LA-SVPDP and 1 donor underwent the Warshaw method. None of patients undergoing LA-SVPDP required conversion to an open operation, whereas 2 patients undergoing the other procedures were converted to open operations. Five out of 8 patients who underwent the Warshaw method showed engorgement of the gastric veins, revealed by computed tomography. However, only 1 of the 5 patients showed mild gastric varices on endoscopy. Although the Warshaw method is acceptable with a low incidence of gastric varices in our analysis, SVPDP is a feasible approach for SPDP. Our LA-SVPDP technique may contribute to safer and easier SVPDP in laparoscopic surgery.

Single-center experience of laparoscopic left pancreatic resection in 359 consecutive patients: changing the surgical paradigm of left pancreatic resection

Laparoscopic distal pancreatectomy (LDP) is increasingly performed for lesions of the body and tail of the pancreas. We analyzed the clinical characteristics of the largest series of patients to date who underwent LDP at a single center, as well as their outcomes, to reassess the surgical paradigm for left pancreatic resection. We retrospectively reviewed the records of 359 patients who underwent LDP at Asan Medical Center, Seoul, Korea, for pancreatic neoplasms between March 2005 and December 2010. Of the 359 patients, 323 (90%) had benign or low-grade malignant neoplasms and 36 (10%) had malignancies. The most common diagnosis was intraductal papillary mucinous neoplasm (IPMN) in 72 patients (21.2%). There were 24 patients (6.7%) with pancreatic ductal adenocarcinoma (PDAC). We found that 178 patients (49.6%) underwent spleen-preserving LDP (SP-LDP): 150 (84.3%) by main splenic vessel preservation, and 28 (15.7%) supported by short gastric and gastroepiploic vessels (Warshaw technique). Postoperative complications occurred in 43 (12%) patients, including 25 (7%) with pancreatic fistula (ISGPF grade B, C), but there was no death. Median operative time was 195 (range, 78-480) min, and median postoperative hospital stay was 8 (range, 4-37) days. The proportion of patients with pancreatic lesions who underwent LDP increased from 8.6% in 2005 to 66.9% in 2010. Kaplan-Meier analysis showed that the 1- and 2-year overall survival rates in the 24 patients with PDAC were 85.2% each. LDP is feasible, safe, and effective for the treatment of benign and low-grade malignant lesions of the pancreas. The increased use of LDP for left-sided pancreatic lesions, including malignant lesions, represents a paradigm shift from open distal pancreatectomy.

Minilaparoscopic Varicocelectomy with Preservation of Testicular Artery and Lymphatic Vessels by Using Intracorporeal Knot‐tying Technique: Five‐year Experience

In this study we present our experience using minilaparoscopic intracorporeal knot tying to ligate internal spermatic veins (ISV) while sparing the spermatic artery and lymphatics. Minilaparoscopic varicocelectomies were performed in 87 patients between January 2004 and January 2009. All varicoceles were detected clinically according to the World Health Organization (WHO) classification and confirmed by scrotal color Doppler ultrasonography. The surgical indications were scrotal symptoms in 71, infertility in 16, and both conditions in 2. Three 3.5 mm minilaparoscopic ports were used for the operation. The ISVs were dissected and then ligated with intracorporeal knot-tying. The testicular artery and lymphatic vessels were carefully preserved to minimize procedure-related complications. Unilateral laparoscopic varicocelectomy was performed in 21 (24.2%) patients and bilateral in 66 (75.8%). Mean operative time was 71.1 ± 29.2 and 46.8 ± 12.6 min for bilateral and unilateral varicocelectomies, respectively. All patients were discharged within 24 h after surgery. Neither immediate major nor late procedure-related complications were noted. Of the 71 patients with scrotal symptoms, the symptoms completely subsided in 55 (77.5%) and partially subsided in 10 (14.1%). Only one (1.2%) recurrent varicocele was detected within a mean follow-up of 21 months (range = 3-42). Neither hydrocele formation nor testicular atrophy was found during the follow-up period. Our 5-year experience revealed that minilaparoscopic varicocelectomy with sparing of artery and lymphatic vessels could safely and effectively ligate all spermatic veins and preserve spermatic arteries and lymphatic channels without leading to a high varicocele persistence or recurrence.

Splenic Preserving Distal Pancreatectomy: Does Vessel Preservation Matter?

Splenic preserving distal pancreatectomy (SPDP) can be accomplished with splenic artery and vein preservation or ligation. However, no data are available on the relative merits of these techniques. The aim of this analysis was to compare the outcomes of splenic preserving distal pancreatectomy with and without splenic vessel preservation. From 2002 through 2009, 434 patients underwent distal pancreatectomy and 86 (20%) had splenic preservation. Vessel preservation (VP) was accomplished in 45 and ligation (VL) was performed in 41. These patients were similar with respect to age, American Society of Anesthesiologists class, pathology, surgeons, and minimally invasive approach (79%). For comparison, a matched group of 86 patients undergoing distal pancreatectomy with splenectomy (DP+S) was analyzed. The VP-SPDP procedure was associated with less blood loss than VL-SPDP or DP+S (224 vs 508 vs 646 mL, respectively; p < 0.05). The VP-SPDP procedure also resulted in fewer grade B or C pancreatic fistulas (2% vs 12% vs 14%; p = NS) and splenic infarctions (5% vs 39%; p < 0.01), less overall morbidity (18% vs 39% vs 38%, respectively; p < 0.05) and need for drainage procedure (2% vs 15% vs 16%; p < 0.05), and shorter post-operative length of stay (4.5 vs 6.2 vs 6.6 days; p < 0.05). This analysis suggests that outcomes are (1) best for VP-SPDP and (2) VL-SPDP provides no short-term advantage over distal pancreatectomy with splenectomy. We conclude that splenic VP is preferred when SPDP is performed.

Early Outcome Following Endovascular Repair of Pararenal Aortic Aneurysms: Triple- Versus Double- or Single-Fenestrated Stent-Grafts

To review the early outcome following endovascular repair of pararenal aortic aneurysm using fenestrated stent-grafts and to determine if the number of fenestrations required is predicative of outcome. A retrospective analysis was conducted of 20 consecutive patients (18 men; mean age of 75 ± 7 years) treated with stent-grafts containing either ≤ 2 fenestrations (n = 10, group 1) or 3 fenestrations (n = 10, group 2). Target vessels also included those accommodated by a scallop (renal artery or superior mesenteric artery in group 1 and the celiac artery in group 2). Comorbidities were similar in both groups. Aneurysm size [median 6.9 (IQR 6.7-8.3) versus 6.0 cm (IQR 5.8-6.6), p = 0.03], procedure time (mean 6.6 ± 2.1 versus 4.6 ± 1.7 hours, p = 0.04), and intensive care stay [median 4.5 (IQR 2-14) versus 2 (IQR 1-3) days, p = 0.07] were greater in group 2. There were 2 postoperative deaths, both in group 2. Morbidity was significant and similar in both groups (4 patients in group 1 and 3 patients in group 2), including 1 patient requiring long-term hemodialysis. Target vessel preservation was similar in both groups (96% overall). There were 2 type II endoleaks (one in each group) and no type I or III endoleak. Triple-fenestrated stent-grafts allow patients with extensive pararenal aneurysms and significant comorbidity to be treated by endovascular means. Although the number of patients treated was small, which limited the validity of the comparison, longer procedures and greater early morbidity and mortality were seen in the triple-fenestrated group. At present, the procedures are technically more demanding and associated with increased risk compared with double or single fenestrations, but the technology continues to evolve.

Pulsed laser-induced liquid jet for skull base tumor removal with vascular preservation through the transsphenoidal approach: a clinical investigation

The transsphenoidal approach has recently been used to treat complex lesions beyond the sella turcica, but the difficulties of dealing with small vessels, deep and narrow space, and working angle may limit the procedures. To overcome these problems, we have developed a pulsed laser-induced liquid jet (LILJ) system to dissect tumor tissue with preservation of fine blood vessels within deep and narrow working spaces and evaluated its utility and safety. The LILJ system was applied to 14 consecutive patients with uncharacteristically complex skull base tumor treated through the extended transsphenoidal approach. This system consists of a bayonet-shaped catheter incorporating a jet generator formed of stainless tube (external diameter 1.10 mm, internal diameter 0.78 mm), which was surrounded by a coaxial polytetrafluoroethylene 14-G equivalent suction tube to be able to incorporate into the confined working spaces. Minor modifications could be fitted for the catheter (15 to 18 cm length, straight or side flexion tip), and total weight was around 7 g. Precise dissection and mass reduction of the tumor were obtained in all cases except one recurrent case of chordoma with significant fibrosis due to radiation. Both small arteries and veins were preserved, allowing subsequent microsurgical devascularization. Intraoperative blood loss was minimal, and tumor removal rate was satisfactory after the introduction of the system. No complication was related to use of the LILJ system. Although comparison between conventional surgical instruments is mandatory in the future, the present study suggests that the LILJ system can achieve safe and optimum removal of complex skull base tumor. Potential application for minimally invasive endoscopic system, as well as potentials for changing the design of the catheter in according to preference of surgeon with low cost, may give advantages over conventional surgical instruments.

Coil Embolization of a Traumatic Intracranial Aneurysm of the Distal Part of the Azygos Anterior Cerebral Artery Followed Up for 4 Years -Case Report-

Traumatic intracranial aneurysms are rare, usually occur as a result of traffic accidents, and are associated with high rates of morbidity and mortality. A 12-year-old boy was admitted for treatment of cerebral hemorrhage in the left frontal lobe, 3 months after a traffic accident. Angiography revealed an intracranial aneurysm of the distal part of the azygos anterior cerebral artery (ACA). The maximum size of this aneurysm was 9.5 mm. Coil embolization was successfully performed with preservation of the parent arteries. Angiography performed at the 4-year follow-up examination revealed no abnormalities. The present case showed that primary coiling may allow aneurysm occlusion along with parent vessel preservation in selected cases of traumatic intracranial aneurysm of the distal part of the azygos ACA.

Water Jet Dissection in Neurosurgery: An Update After 208 Procedures With Special Reference to Surgical Technique and Complications

Water jet dissection represents a promising technique for precise brain tissue dissection with preservation of blood vessels. In the past, the water jet dissector has been used for various pathologies. A detailed report of the surgical technique is lacking. The authors present their results after 208 procedures with a special focus on surgical technique, intraoperative suitability, advantages, and disadvantages. Between March 1997 and April 2009, 208 patients with various intracranial neurosurgical pathologies were operated on with the water jet dissector. Handling of the device and its usefulness and extent of application were assessed. The pressures encountered, potential risks, and complications were documented. The patients were followed 1 to 24 months postoperatively. A detailed presentation of the surgical technique is given. Differences and limitations of the water jet dissection device in the various pathologies were evaluated. The water jet dissector was intensively used in 127 procedures (61.1%), intermittently used in 56 procedures (26.9%), and scarcely used in 25 procedures (12%). The device was considered to be very helpful in 166 procedures (79.8%) and helpful to some extent in 33 procedures (15.9%). In 8 (3.8%) procedures, it was not helpful, and in 1 procedure (0.5%), the usefulness was not documented by the surgeon. The water jet dissector can be applied easily and very safely. Precise tissue dissection with preservation of blood vessels and no greater risk of complications are possible. However, the clinical consequences of the described qualities need to be demonstrated in a randomized clinical trial.

Effects of flow diversion stents on rabbits' wide necked aneurysms and branches

Objective To observe the effects of flow diversion stents on rabbits' aneurysms and branches.Method 30 New Zealand white rabbits with wide necked aneurysm were randomly divided equally into three groups.In group A and B,flow diversion stents were implanted into parent vessel with metal coverage 30%～35% and 45%～ 50%,respectively.Angiography was performed at 4 weeks after stent implantation.After 3 months all animals were euthanized for pathological examination after angiography.In group C,animals were only performed for angiography without any stent implanted after grouped and at 3 months,and then animals were euthanized for pathological examination after angiography.Results Immediately after stents placement,90% and 70% aneurysms' necks covered by stents successful in group A and B,respectively.The contrast retention in aneurysms were 88.7% and 100%,respectively.intravenous digital subtraction angiography showed that 77.8% and 85.7% aneurysms were completely occluded at 4 weeks fogow -up,respectively.Artery digital subtraction angiography showed that 71.4% and 85.7% aneurysms were occluded at 3 months follow- up,respectively.All branches covered by stents were patency at angiography follow - up.Pathologic analysis showed that the dome of embolized aneurysms was full filled with thrombus and neointimas at neck and parent vessel were found.In group C,mean aneurysm dimensions were not significantly changed in angiography after grouped and before sacrificed at 3 months( P ＞ 0.05).Conclusions The flow diversion stents are effective in the treatment of wide necked aneurysms with preservation of adjacent branch vessels in angiography. Key words: Flow diversion stent; Metal coverage; Intracranial aneurysm; Branch vessel; Rabbit

Der mikrochirurgische anteriore Zugang zur Halswirbelsäule beim zervikalen Bandscheibenersatz

Mono- or bisegmental atraumatic microsurgical approach to the anterior cervical spine between C3 and C7 for total disc replacement. 'Soft' disc herniations C3-C7 with radicular symptoms. Ossified 'hard' disc herniations with preserved segmental motion. Erosive osteochondrosis with signs of activation (MRI: Modic I changes) and neck pain. Relative Indication: Adjacent segment degeneration following fusion. Thyromegalie. Multiple previous cervical operations. Other implant-specific contraindications: Anterior osteophytes. Range of Motion (ROM) less than 5° (flexion/extension). Segmental collapse. Endplate anomalies (e.g. excessive concavity of cranial endplate). Endplate defects (e.g. Schmorl's nodes). Cervical myelopathy (limited postop evaluation of the spinal canal and spinal cord if implant is made out of ferromagentic materials). Through a 2.5-3 cm skin incision, exposure and splitting of the platysma muscle. Blunt dissection between carotis sheath and esophageus/trachea with preservation of the thyroid blood vessels and the strap muscles (especially m. omohyoideus) and the recurrent laryngeal nerve. Exposure of the anterior disc space between the longus colli muscles after splitting of the prevertebral fascia. Mobilisation the same day after 6-8 hrs. Functional postop treatment. Implant-dependent postop soft collar for max. 14 days. Safe and reliable anterior approach with low peri- and postoperative morbidity. In large series (> 900,000 operations) complication rate range between 2-2.9% [20]. Approach related complications are rare: postop Hematoma 0.39%, vascular Injuries (carotid artery, vertebral artery) (0.06%). Vocal cord palsy 0.14%, dysphagia 0.75%. Older age and cervical myelopathy have been identified as significant risk factors. Both situations don't play a significant role in total disc replacement since this type of operation is usually performed in young patients. Moreover, cervical myelopathy is still considered as a relative contraindication for total disc replacement.

Medial plantar flaps based on different cutaneous perforators to repair soft tissue defect of the fingers

Objective To summarize the selection of medial plantar flaps based on different cutaneous perforators to repair soft tissue defect of the fingers and the clinical outcomes. Methods Twenty-nine cases of soft tissue defects of the fingers were treated with medial plantar flaps based on different perforators: medial deep perforator of the medial plantar artery flaps to repair volar and lateral finger defects in 5 cases, superficial branch of the medial plantar artery to repair palmar finger defects and lateral finger defects in 10 cases, the anteromedial malleollous artery to repair dorsal and lateral finger defects in 11 cases, multi-cutaneous branches of medial plantar artery to repair circular defects at proximal and middle phalanx level in 3 cases. Results All 29 flaps survived, with 23 cases followed for 6 to 13 months. The color and texture of the flaps were excellent. Two-point discrimination was 6 to 9 mm. Conclusion These series of flaps are characterized by easy dissection, hidden donor site, preservation of major vessels, flap texture similar to the skin of the fingers. Medial plantar flaps based on different cutaneous perforators are an ideal method to repair finger skin defects. Key words: Surgical flaps; Tissue transplantation; Finger injuries; Treatment outcome

Preferential Effect of Synchrotron Microbeam Radiation Therapy on Intracerebral 9L Gliosarcoma Vascular Networks

Synchrotron microbeam radiation therapy (MRT) relies on spatial fractionation of the incident photon beam into parallel micron-wide beams. Our aim was to analyze the effects of MRT on normal brain and 9L gliosarcoma tissues, particularly on blood vessels. Responses to MRT (two arrays, one lateral, one anteroposterior (2 × 400 Gy), intersecting orthogonally in the tumor region) were studied during 6 weeks using MRI, immunohistochemistry, and vascular endothelial growth factor Western blot. MRT increased the median survival time of irradiated rats (×3.25), significantly increased blood vessel permeability, and inhibited tumor growth; a cytotoxic effect on 9L cells was detected 5 days after irradiation. Significant decreases in tumoral blood volume fraction and vessel diameter were measured from 8 days after irradiation, due to loss of endothelial cells in tumors as detected by immunochemistry. Edema was observed in the normal brain exposed to both crossfired arrays about 6 weeks after irradiation. This edema was associated with changes in blood vessel morphology and an overexpression of vascular endothelial growth factor. Conversely, vascular parameters and vessel morphology in brain regions exposed to one of the two arrays were not damaged, and there was no loss of vascular endothelia. We show for the first time that preferential damage of MRT to tumor vessels versus preservation of radioresistant normal brain vessels contributes to the efficient palliation of 9L gliosarcomas in rats. Molecular pathways of repair mechanisms in normal and tumoral vascular networks after MRT may be essential for the improvement of such differential effects on the vasculature.

Technique for laparobotic distal pancreatectomy with preservation of spleen.

Minimally invasive surgery for pancreas has advanced at a steady pace in recent years. Although proximal pancreatic resection is still a formidable task, distal resection has become routine with a laparoscopic approach. The recent introduction of the Da Vinci Robotic Surgical System has helped to make this complex procedure much more feasible, efficient, and safe. In this paper, we describe our technique for robot-assisted distal pancreatectomy with splenic preservation, which can be broken down into five steps in a medial-to-lateral progression. Preservation of splenic vessels is routine, although in certain instances a Warshaw's technique is employed. The advantages of the robotic approach are described.