Visible Implants Research Articles

Escudo de Blumer: signo diagnóstico de la diseminación a distancia del cáncer gástrico difuso

Introducción. Se conoce como escudo de Blumer al engrosamiento neoplásico del fondo de saco de Douglas,palpable al tacto rectal como una protrusión en forma de resalte, presente en pacientes afectados por carcinomas con infiltración difusa. A pesar de haber sido descrito hace más de un siglo, se trata de un proceso diagnosticado infrecuentemente y con escasa mención en la literatura científica. Es preciso tener un alto nivel de sospecha clínica para correlacionar los síntomas pélvicos con la presencia de un tumor, habitualmente gástrico.Casos clínicos. Presentamos dos pacientes con hallazgo de escudo de Blumer, asociado a cáncer gástrico difuso, uno como diagnóstico primario de enfermedad metastásica y otro como recidiva de la enfermedad, meses después de ser operado. Ambos casos presentan un complejo proceso diagnóstico, en el que prima la sospecha clínica, apoyado sobre pruebas de imagen como tomografía computarizada y resonancia nuclear magnética, ya que tanto las biopsias obtenidas por endoscopia, como las biopsias intraoperatorias fueron negativas. Discusión. En el escudo de Blumer, las células tumorales infiltran el fondo de saco de Douglas de forma difusa por debajo de la serosa, sin necesidad de que existan implantes macroscópicamente visibles en el peritoneo visceral.La infiltración tumoral puede afectar extrínsecamente al recto, causando una estenosis del mismo, lo que produce sintomatología pélvica inespecífica, como tenesmo rectal y proctalgia. Por lo tanto, este ominoso proceso debe ser sospechado en pacientes con sintomatología pélvica, que presenten o hayan presentado cáncer gástrico.

Matrix levels of metalloproteinase-2 (MMP-2) and toxicity evaluation of carbonate apatite-based endodontic sealer in rat subcutaneous implantation

ObjectiveThe aims of this study is to investigate the matrix metalloproteinase-2 (MMP-2) levels and the toxicity evaluation to determine the safety of carbonate apatite material that will be used as an endodontic sealer. MethodsCarbonate apatite as endodontic sealer material is fabricated with a size of 2 × 2 × 1 mm, sterilized, and then implanted in the subcutaneous area on the murine back. Total of 28 rats was divided into 2 groups: the implantation group and the control group (positive and negative). We observed behavior, macroscopic and microscopic images (through hematoxylin-eosin/HE staining) and MMP-2 levels in the serum (through ELISA examination) to determine the reaction of implant material in experimental animals. ResultsBehavioral test shows impaired motor function within 2–24 h in all rats, autonomic behavioral test does not show any disturbance, macroscopic images show appearance of tumor and rubor within 2–72 h in all rats, microscopic images shows an increase in the mean neutrophils number with the highest point located in the 24 h (3.92×103/μL) and lymphocytes with the highest point in the 14 days (15.31×103/μL). The average value of MMP-2 levels of the negative control group was 1.33 ng/ml, 1.29 ng/ml of the positive control group, and 7.32 ng/ml of the implantation group. Level of MMP-2 in rats with visible implants increased on day 3 (0.75 ng/ml), day 10 (1.49 ng/ml) and day 14 (17.67 ng/ml). ConclusionThe implantation of carbonate apatite material did not cause behavioral disorders or abnormalities in the tissues surrounding of the implant site and did not show signs of toxicity or death.

Preferences for Long-Acting Pre-exposure Prophylaxis (PrEP), Daily Oral PrEP, or Condoms for HIV Prevention Among U.S. Men Who Have Sex with Men.

HIV prevention method preferences were evaluated among 512 U.S. men who have sex with men (MSM; median age: 22years). Approximately 90% consistently preferred one option across pairwise comparisons of condoms, daily oral pre-exposure prophylaxis (PrEP), and long-acting PrEP delivered via either an injectable or one of two types of PrEP implants differing in visibility. Condoms were most frequently preferred (33.8%), followed by non-visible implants (21.5%), and oral PrEP (17.0%); HIV risk was reported by more choosing implants. In a follow-up question comparing the four PrEP options only, daily oral pills and non-visible implants were most frequently preferred (35.5 and 34.3%, respectively), followed by injections (25.2%) and visible implants (4.3%). An inductive, open-coding approach determined that convenience, duration of protection, and privacy were the most commonly cited reasons for a PrEP method choice, and associated with self-report of HIV risk. Tailoring PrEP product development to privacy and other concerns important to those at highest HIV risk may improve HIV prevention.

Magnetic resonance-visible meshes for laparoscopic ventral hernia repair.

Background and Objectives:We aimed to evaluate the first human use of magnetic resonance–visible implants for intraperitoneal onlay repair of incisional hernias regarding magnetic resonance presentability.Methods:Ten patients were surgically treated with intraperitoneally positioned superparamagnetic flat meshes. A magnetic resonance investigation with a qualified protocol was performed on postoperative day 1 and at 3 months postoperatively to assess mesh appearance and demarcation. The total magnetic resonance–visible mesh surface area of each implant was calculated and compared with the original physical mesh size to evaluate potential reduction of the functional mesh surfaces.Results:We were able to show a precise mesh demarcation, as well as accurate assessment of the surrounding tissue, in all 10 cases. We documented a significant decrease in the magnetic resonance–visualized total mesh surface area after release of the pneumoperitoneum compared with the original mesh size (mean, 190 cm2 vs 225 cm2; mean reduction of mesh area, 35 cm2; P < .001). At 3 months postoperatively, a further reduction of the surface area due to significant mesh shrinkage could be observed (mean, 182 cm2 vs 190 cm2; mean reduction of mesh area, 8 cm2; P < .001).Conclusion:The new method of combining magnetic resonance imaging and meshes that provide enhanced signal capacity through direct integration of iron particles into the polyvinylidene fluoride base material allows for detailed mesh depiction and quantification of structural changes. In addition to a significant early postoperative decrease in effective mesh surface area, a further considerable reduction in size occurred within 3 months after implantation.

Gluteal implant displacement: diagnosis and treatment.

First reported in 1969, buttocks implant surgery has evolved greatly since the introduction of the intramuscular technique. This technique provides good implant coverage and protects the sciatic nerve from compression. However, it enables the occurrence of a new complication, intramuscular hernia or implant displacement. The goal of this research study is to describe, classify, and standardize the treatment of gluteal implant displacement. The treatment algorithm was developed after dissection of fresh human cadavers and analysis of computed tomographic scans in patients with implant displacement. After elaborating the treatment protocol for implant displacement, it was prospectively applied in 24 patients that presented with visible implants. Intramuscular dissection has proven to be technically possible when a minimum of 2 cm of muscle thickness is achieved. One-stage surgery was applied in 41 buttocks (21 patients). The control computed tomographic scan obtained 3 months after surgery has shown fibrosis in the buttocks area, corresponding to the subcutaneous capsule housing the implant in the anomalous position. The operative wound complications were more frequent, and treatment failure with relapse of the implant superficial displacement occurred in only one of 47 buttocks (2.1 percent). The treatment of gluteal implant displacement can be a one-stage surgical procedure for most patients. This decision is based on the thickness of the gluteus maximus muscle just below the implant. Therapeutic, IV.

Laparoscopic restaging of borderline ovarian tumours (BLOT): a retrospective study of 142 cases

ObjectivesPrimary objective: To analyse the impact of restaging, on recurrences and survival, in BLOT. Secondary objective: To cluster patients who could be exempted from restaging. Study designThis retrospective study, included patients operated for a BLOT, between January 1990, and December 2007, in gynaecological surgery units of the University Hospital of Clermont-Ferrand.Two groups were evaluated: patients with and without optimal restaging. ResultsOne hundred and forty-two patients were included. Optimal initial staging rate was 38.7% (n=55). Among the eighty-seven women not initially staged, two groups were compared: restaged (n=45) and non-restaged patients (n=42). Mean follow-up was 80.5 months. Overall survival was 93.7%. Relapse rate was 7.7% (n=11). Disease free survival (DFS) was 88% after a mean follow-up of 80.5 months. One death was noted.Optimal restaging rate was 31.7% (n=45, 43 by laparoscopy). Mean follow-up was of 87.1 months among restaged patients, 84.5 months among non-restaged patients (p=0.93).Relapse incidence was significantly higher in non restaged, than in restaged patients (p=0.008). DFS was significantly longer among restaged than non-restaged patients, (p=0.072). Younger age (p=0.04), conservative treatment (p<10−4) or non-diploidy (p=0.04) increased the incidence of relapse. ConclusionsWhen initial staging is missing, restaging improves the patients outcome in comparison to non-restaged groups. Laparoscopy is a valuable surgical option. This study suggests that a selected group of patients, older than 30 years old, submitted to a radical treatment, presenting a diploid, non micropapillar, mucinous BLOT, without visible implants during careful peritoneal inspection, could be exempted from restaging. They represented 11.6% of our population.

Intraoperative Detection of Subtle Endometriosis: A Novel Paradigm for Detection and Treatment of Pelvic Pain Associated with the Loss of Peritoneal Integrity

Endometriosis is a common disease affecting 40 to 70% of reproductive-aged women with chronic pelvic pain (CPP) and/or infertility. The purpose of this study was to demonstrate the use of a blue dye (methylene blue) to stain peritoneal surfaces during laparoscopy (L/S) to detect the loss of peritoneal integrity in patients with pelvic pain and suspected endometriosis. Forty women with CPP and 5 women without pain were evaluated in this pilot study. During L/S, concentrated dye was sprayed onto peritoneal surfaces, then aspirated and rinsed with Lactated Ringers solution. Areas of localized dye uptake were evaluated for the presence of visible endometriotic lesions. Areas of intense peritoneal staining were resected and some fixed in 2.5% buffered gluteraldehyde and examined by scanning (SEM) electron microscopy. Blue dye uptake was more common in women with endometriosis and chronic pelvic pain than controls (85% vs. 40%). Resection of the blue stained areas revealed endometriosis by SEM and loss of peritoneal cell-cell contact compared to normal, non-staining peritoneum. Affected peritoneum was associated with visible endometriotic implants in most but not all patients. Subjective pain relief was reported in 80% of subjects. Based on scanning electron microscopy, we conclude that endometrial cells extend well beyond visible implants of endometriosis and appear to disrupt the underlying mesothelium. Subtle lesions of endometriosis could therefore cause pelvic pain by disruption of peritoneal integrity, allowing menstrual or ovulatory blood and associated pain factors access to underlying sensory nerves. Complete resection of affected peritoneum may provide a better long-term treatment for endometriosis and CPP. This simple technique appears to improve detection of subtle or near invisible endometriosis in women with CPP and minimal visual findings at L/S and may serve to elevate diagnostic accuracy for endometriosis at laparoscopy.

Intraoperative Detection of Subtle Endometriosis: A Novel Paradigm for Detection and Treatment of Pelvic Pain Associated with the Loss of Peritoneal Integrity

Endometriosis is a common disease affecting 40 to 70% of reproductive-aged women with chronic pelvic pain (CPP) and/or infertility. The purpose of this study was to demonstrate the use of a blue dye (methylene blue) to stain peritoneal surfaces during laparoscopy (L/S) to detect the loss of peritoneal integrity in patients with pelvic pain and suspected endometriosis. Forty women with CPP and 5 women without pain were evaluated in this pilot study. During L/S, concentrated dye was sprayed onto peritoneal surfaces, then aspirated and rinsed with Lactated Ringers solution. Areas of localized dye uptake were evaluated for the presence of visible endometriotic lesions. Areas of intense peritoneal staining were resected and some fixed in 2.5% buffered gluteraldehyde and examined by scanning (SEM) electron microscopy. Blue dye uptake was more common in women with endometriosis and chronic pelvic pain than controls (85% vs. 40%). Resection of the blue stained areas revealed endometriosis by SEM and loss of peritoneal cell-cell contact compared to normal, non-staining peritoneum. Affected peritoneum was associated with visible endometriotic implants in most but not all patients. Subjective pain relief was reported in 80% of subjects. Based on scanning electron microscopy, we conclude that endometrial cells extend well beyond visible implants of endometriosis and appear to disrupt the underlying mesothelium. Subtle lesions of endometriosis could therefore cause pelvic pain by disruption of peritoneal integrity, allowing menstrual or ovulatory blood and associated pain factors access to underlying sensory nerves. Complete resection of affected peritoneum may provide a better long-term treatment for endometriosis and CPP. This simple technique appears to improve detection of subtle or near invisible endometriosis in women with CPP and minimal visual findings at L/S and may serve to elevate diagnostic accuracy for endometriosis at laparoscopy.

Gluteal Implants: The “XYZ” Intramuscular Method

Gluteal implants are an effective and predictable way to remodel the buttocks. However, depending on the anatomical plane employed and the manner in which the implant pocket is dissected, the results can be frustrating. The only way to prevent palpable or visible implants (the major causes of a poor result) is through the intramuscular plane. The author presents his XYZ technique, which provides anatomical reference points to guide the intramuscular dissection procedure in a feasible and safe way, resulting in a low complication rate.

Laparoscopic conservative surgery for stage IV symptomatic endometriosis: short-term surgical complications

To study severe endometriosis as a cause of pelvic pain, which represents one of the most challenging disorders in gynecology. Retrospective study. Teaching hospital. A total of 1,363 women with severe endometriosis (revised American Society for Reproductive Medicine [rASRM] stage IV). A detailed survey of all patients with severe endometriosis (rASRM stage IV) who underwent laparoscopy at our center between January 2004 and December 2007 was carried out. Clinical and surgical data were retrieved and assessed according to the extent of surgery performed. Intraoperative, ultra-short, and short-term clinical complications were assessed. A total of 1,201 women underwent laparoscopic radical surgery with excision of all visible endometriotic lesions, with a significant improvement of symptoms at 1-month follow-up evaluation. The overall intraoperative complication rate was 2.0%. The morbidity was significantly increased when bowel surgery was performed, with a risk of intraoperative complications that was threefold higher. Of the patients who had bowel surgery, 18 (4.1%) required reintervention within the first week after surgery. We report on the safety and efficacy of laparoscopic eradication of all visible implants in cases of rASRM stage IV endometriosis when surgery is performed in a referral center.

Vers une évolution du dogme de la chirurgie «optimale» dans les cancers de l'ovaire

The dismal outcome of ovarian, fallopian tube, and primary peritoneal carcinomas calls for an increase in surgical aggressiveness. After a long era during which incomplete cytoreduction was considered acceptable, it has been established that the outcome is directly related to the amount of diseased tissue left in place. Probably as a result of technical imitations of surgeons and anesthesiologists, the majority of teams have fixed a cut-off value of 2 cm to define what was called "optimal" cytoreduction. Although it is now established that reaching the 2 cm cut-off value is the minimal required target, the target has moved towards complete removal of visible implants. However, the methods of assessment of residual disease and the very concept of complete cytoreduction suffer from limitations.

Malignant fibrous histiocytoma of the ovary: a case report

Malignant fibrous histiocytoma is the most common type of soft tissue sarcoma in adults. Primary malignant fibrous histiocytoma of the ovary is extremely rare, with only three previously reported cases. We reported a rare and uncommon localization of malignant fibrous histiocytoma in a 22-year-old woman. She was referred for adjuvant chemotherapy to our center with the diagnosis of storiform-pleomorphic malignant fibrous histiocytoma. A left adnexal mass was detected by computed tomography of the lower abdomen. Therefore, we decided to perform reoperation for debulking, and left salpingo-oopherectomy, total hysterectomy, infracolic omentectomy, and resection of all visible peritoneal implants were performed. Histopathologic examination revealed inflammatory, malignant fibrous histiocytoma. Immunohistochemical staining confirmed positive reactions to alpha 1-antitrypsin, vimentin, CD68, and S100. The management of malignant fibrous histiocytoma is controversial because of the heterogenous nature of the disease. Resection of all macroscopic disease is independently associated with improved disease-specific survival, and adjuvant chemotherapy for nonmyxoid variants could be acceptable alternatives if the surgical margins are tumor free.

Malignant fibrous histiocytoma of the ovary: a case report

Malignant fibrous histiocytoma is the most common type of soft tissue sarcoma in adults. Primary malignant fibrous histiocytoma of the ovary is extremely rare, with only three previously reported cases. We reported a rare and uncommon localization of malignant fibrous histiocytoma in a 22-year-old woman. She was referred for adjuvant chemotherapy to our center with the diagnosis of storiform-pleomorphic malignant fibrous histiocytoma. A left adnexal mass was detected by computed tomography of the lower abdomen. Therefore, we decided to perform reoperation for debulking, and left salpingo-oopherectomy, total hysterectomy, infracolic omentectomy, and resection of all visible peritoneal implants were performed. Histopathologic examination revealed inflammatory, malignant fibrous histiocytoma. Immunohistochemical staining confirmed positive reactions to alpha 1-antitrypsin, vimentin, CD68, and S100. The management of malignant fibrous histiocytoma is controversial because of the heterogenous nature of the disease. Resection of all macroscopic disease is independently associated with improved disease-specific survival, and adjuvant chemotherapy for nonmyxoid variants could be acceptable alternatives if the surgical margins are tumor free.

Reproductive disorders affecting fertility in endometriosis

AbstractThe classical concept of endometriosis as a cause of infertility is challenged. Traditionally, both surgical and medical therapy of endometriosis-associated infertility has focused on eliminating or reducing the visible implants. The classic 6-month medical approach has been a failure, and surgery may moderately enhance fertility, but its benefit in the absence of adhesions is still doubtful. Recent studies have shown that endometriosis is characterized by an aberrant response to sex steroid hormones, resulting in pleiotropic dysfunctions of the reproductive system involving the uterine, peritoneal and ovarian micro-environment. Studies on endometriosis and IVF have been highly relevant in revealing the pleiotropic dysfunctions in patients with endometriosis, although the results should be interpreted with caution. The conclusion seems to support the view that infertility in patients with endometriosis is primarily dysfunctional, rather than lesional, in origin. It is concluded that the place of medical therapy in endometriosis should be reviewed and that the surgical approach needs to be complemented by appropriate medical therapy to restore fertility.

Clinical Pathway for the Management of Resectable Gastric Cancer with Peritoneal Seeding: Best Palliation with a Ray of Hope for Cure

Peritoneal seeding from primary gastric cancer occurs in 10–20% of patients. The diagnosis of this advanced disease is usually not provided by clinical studies prior to abdominal exploration. From the data available in the literature, the surgeon is forced to make an intraoperative judgement concerning the risks and benefits of an aggressive management plan versus supportive care. A strategy has evolved that utilizes peritonectomy and extended gastrectomy to maximally cytoreduce tumor combined with perioperative intraperitoneal chemotherapy. In the current state of the art, the perioperative intraperitoneal chemotherapy is heated and manually distributed to provide uniform treatment to all peritoneal surfaces and the resection site. The pharmacologic parameters have been established and the results of phase II studies are reported. Five-year survival of patients in whom a complete cytoreduction was possible is approximately 10% with a median survival of 12 months. Gastrectomy with peritonectomy to eliminate all visible implants combined with perioperative intraperitoneal chemotherapy should be used in selected patients with primary gastric cancer and carcinomatosis.

The effects of combining norethindrone with a gonadotropin-releasing hormone agonist in the treatment of symptomatic endometriosis

Treatment of endometriosis with gonadotropin-releasing hormone agonists (GnRH-a) is associated with side effects secondary to the induced hypoestrogenic state. In an effort to ameliorate these symptoms, 10 patients with symptomatic endometriosis self-administered the GnRH-a [D-His6(Imbzl)-Pro9-NET]-GnRH in combination with norethindrone daily for 24 weeks. Painful symptoms were significantly suppressed after therapy (P less than 0.005). Objective review of photographs taken at laparoscopy before and after therapy demonstrated significant reduction of visible implants (P less than 0.005). Vasomotor symptoms were minimized when compared with a group of 16 patients previously treated with GnRH-a alone. Bone mineral density of the distal radius assessed by single photon absorptiometry was not reduced during therapy, although lumbar spine bone density assessed by quantitative computerized tomography was minimally but reversibly reduced. No metabolic derangements were detected. The combination of norethindrone with GnRH-a is a well tolerated and effective means of treating symptomatic endometriosis.

The effects of combining norethindrone with a gonadotropin-releasing hormone agonist in the treatment of symptomatic endometriosis

Treatment of endometriosis with gonadotropin-releasing hormone agonists (GnRH-a) is associated with side effects secondary to the induced hypoestrogenic state. In an effort to ameliorate these symptoms, 10 patients with symptomatic endometriosis self-administered the GnRH-a [D-His 6 (Imbzl)-Pro 9 -NET]-GnRH in combination with norethindrone daily for 24 weeks. Painful symptoms were significantly suppressed after therapy ( P < 0.005). Objective review of photographs taken at laparoscopy before and after therapy demonstrated significant reduction of visible implants ( P < 0.005). Vasomotor symptoms were minimized when compared with a group of 16 patients previously treated with GnRH-a alone. Bone mineral density of the distal radius assessed by single photon absorptiometry was not reduced during therapy, although lumbar spine bone density assessed by quantitative computerized tomography was minimally but reversibly reduced. No metabolic derangements were detected. The combination of norethindrone with GnRH-a is a well tolerated and effective means of treating symptomatic endometriosis.