BioMed Research International: Surgery The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Are Internal or External Pancreatic Duct Stents the Preferred Choice for Patients Undergoing Pancreaticoduodenectomy? A Meta-Analysis Thu, 30 Mar 2017 10:03:38 +0000 The technique of pancreatic duct stenting during pancreatic anastomosis can markedly reduce the incidence of postoperative pancreatic fistula (PF) after pancreaticoduodenectomy (PD). The method of drainage includes using either an external or an internal stent; the meta-analysis result shows us that there were no differences in the rates of postoperative complications between PD using internal stents and PD using external stents; internal stents may be more favorable during postoperative management of drainage tube. What is more, internal stents could reduce the digestive fluid loss and benefit the digestive function. Yajie Zhao, Jianwei Zhang, Zhongmin Lan, Qinglong Jiang, Shuisheng Zhang, Yunmian Chu, Yingtai Chen, and Chengfeng Wang Copyright © 2017 Yajie Zhao et al. All rights reserved. A Modified Translaminar Osseous Channel-Assisted Percutaneous Endoscopic Lumbar Discectomy for Highly Migrated and Sequestrated Disc Herniations of the Upper Lumbar: Clinical Outcomes, Surgical Indications, and Technical Considerations Thu, 30 Mar 2017 08:48:00 +0000 Objective is to describe a safe and effective percutaneous endoscopic approach for removal of highly migrated and sequestrated disc herniations of the upper lumbar spine and to report the results, surgical indications, and technical considerations of the new technique. Eleven patients who had highly migrated and sequestrated disc herniations in the upper lumbar were included in this study. A retrospective study was performed for all patients after translaminar osseous channel-assisted PELD was performed. Radiologic findings were investigated, and pre-and postoperative visual analog scale (VAS) assessments for back and leg pain and Oswestry disability index (ODI) evaluations were performed. Surgical outcomes were evaluated under modified MacNab criteria. All of the patients were followed for more than 1 year. The preoperative and postoperative radiologic findings revealed that the decompression of the herniated nucleus pulposus (HNP) was complete. After surgery, the mean VAS scores for back and leg pain immediately improved from 8.64 (range, 7–10) and 8.00 (range, 6–10) to 2.91 (range, 2–4) and 2.27 (range, 1–3), respectively. The mean preoperative ODI was 65.58 (range, 52.2–86), which decreased to 7.51 (range, 1.8–18) at the 12-month postoperative follow-up. The MacNab scores at the final follow-up included nine excellent, one good, and one fair. The modified translaminar osseous channel-assisted PELD could be a safe and effective option for the treatment of highly migrated and sequestrated disc herniations of the upper lumbar. Zhijun Xin, Wenbo Liao, Jun Ao, Jianpu Qin, Fang Chen, Zhiyuan Ye, and Yuqiang Cai Copyright © 2017 Zhijun Xin et al. All rights reserved. Atypical Femoral Shaft Fractures in Female Bisphosphonate Users Were Associated with an Increased Anterolateral Femoral Bow and a Thicker Lateral Cortex: A Case-Control Study Tue, 28 Mar 2017 09:27:21 +0000 The purpose of our study was to investigate the radiographic characteristics of atypical femoral shaft fractures (AFSFs) in females with a particular focus on femoral bow and cortical thickness. We performed a fracture location-, age-, gender-, and ethnicity-matched case-control study. Forty-two AFSFs in 29 patients and 22 typical osteoporotic femoral shaft fractures in 22 patients were enrolled in AFSF group and control group, respectively. With comparing demographics between two groups, radiographically measured femoral bow and cortical thicknesses of AFSF group were compared with control group. All AFSF patients were females with a mean age of 74.4 years (range, 58–85 years). All had a history of bisphosphonate (BP) use with a mean duration of 7.3 years (range 1–17 years). Femoral bow of AFSF group was significantly higher than control group on both anteroposterior (AP) and lateral radiographs after age correction. Mean femoral bow on an AP radiograph was in AFSF group and in control group (). Mean femoral bow on the lateral radiograph was in AFSF group and in control group (after age correction ). And cortical thicknesses of AFSF group demonstrated marked disparity between tensile and compressive side of bowed femurs in this study. An adjusted lateral cortical thickness was  mm in AFSF group and  mm in control group (after age correction ) while medial cortical thickness of AFSF group was not statistically different from control group. Correlation analysis showed that the lateral femoral bow on the AP radiograph was solely related to lateral CTI (, ). AFSFs in female BP users were associated with an increased anterolateral femoral bow and a thicker lateral cortex of femurs. Seung Pil Jang, Ingwon Yeo, Sang-Yeon So, Keunbyuel Kim, Young-Wan Moon, Youn-Soo Park, and Seung-Jae Lim Copyright © 2017 Seung Pil Jang et al. All rights reserved. Preservation of Myocardial Perfusion and Function by Keeping Hypertrophied Heart Empty and Beating for Valve Surgery: An In Vivo MR Study of Pig Hearts Mon, 20 Mar 2017 07:11:39 +0000 Objectives. Normothermic hyperkalemic cardioplegia arrest (NHCA) may not effectively preserve hypertrophied myocardium during open-heart surgery. Normothermic normokalemic beating perfusion (NNBP), keeping hearts empty-beating, was utilized as an alternative to evaluate its cardioprotective role. Materials and Methods. Twelve hypertrophied pig hearts at 58.6 ± 7.2 days after ascending aorta banding underwent NNBP and NHCA, respectively. Near infrared myocardial perfusion imaging with indocyanine green (ICG) was conducted to assess myocardial perfusion. Left ventricular (LV) contractile function was assessed by cine MRI. TUNEL staining and western blotting for caspase-3 cleavage and cardiac troponin I (cTnI) degradation were conducted in LV tissue samples. Results. Ascending aortic diameter was reduced by at approximately fifty-eight days after banding. LV wall thickness was significantly higher in aorta banding than in sham operation. Myocardial blood flow reflected by maximum ICG absorbance value was markedly higher in NNBP than in NHCA. The amount of apoptotic cardiomyocyte was significantly lower in NNBP than in NHCA. NNBP alleviated caspase-3 cleavage and cTnI degradation associated with NHCA. NNBP displayed a substantially increased postoperative ejection fraction relative to NHCA. Conclusions. NNBP was better than NHCA in enhancing myocardial perfusion, inhibiting cardiomyocyte apoptosis, and preserving LV contractile function for hypertrophied hearts. Jian Wang, Bo Xiang, Jixian Deng, Hung-Yu Lin, Darren H. Freed, Rakesh C. Arora, and Ganghong Tian Copyright © 2017 Jian Wang et al. All rights reserved. Treatment and Patient Reported Outcome in Children with Hirschsprung Disease and Concomitant Congenital Heart Disease Wed, 08 Mar 2017 08:32:07 +0000 Purpose. Congenital heart disease (CHD) is reported to be associated with Hirschsprung disease (HD). The aim was to evaluate any differences between children with HD with and without CHD, respectively, with regard to patient characteristics, medical care, and patient reported bowel function. Method. This is a retrospective chart study and a cross-sectional long-term follow-up of patients older than 4 years old, including all children with HD operated on with transanal endorectal pull-through (TERPT) at a tertiary center of pediatric surgery. Information about patient characteristics, diagnostics, surgery, and medical care was compiled. At long-term follow-up, bowel function was assessed by Bowel Function Score. Results. Included were 53 HD-patients, 13 with CHD and 40 without CHD. Children with CHD more commonly presented with failure to thrive; 4 (23%) compared to those without CHD (0%) (). In the long-term follow-up, including 32 patients (6 with CHD), constipation was more commonly reported by children with CHD 5 (83%) than by children without CHD 4 (27%) (). No differences were shown in the other parameters such as fecal control and incontinence. Conclusion. HD-patients with CHD more commonly presented with failure to thrive and more frequently reported constipation than HD-patients without CHD. The findings indicate that HD-patients with CHD might need special consideration in their initial care and long-term follow-up. Johan Hasserius, Josefine Hedbys, Christina Graneli, Kristine Hagelsteen, and Pernilla Stenström Copyright © 2017 Johan Hasserius et al. All rights reserved. Duodenal Atresia: Open versus MIS Repair—Analysis of Our Experience over the Last 12 Years Thu, 23 Feb 2017 07:14:05 +0000 Objective. Duodenal atresia (DA) routinely has been corrected by laparotomy and duodenoduodenostomy with excellent long-term results. We revisited the patients with DA treated in the last 12 years (2004–2016) comparing the open and the minimally invasive surgical (MIS) approach. Methods. We divided our cohort of patients into two groups. Group 1 included 10 patients with CDO (2004–09) treated with open procedure: 5, DA; 3, duodenal web; 2, extrinsic obstruction. Three presented with Down’s syndrome while 3 presented with concomitant malformations. Group 2 included 8 patients (2009–16): 1, web; 5, DA; 2, extrinsic obstruction. Seven were treated by MIS; 1 was treated by Endoscopy. Three presented with Down’s syndrome; 3 presented with concomitant malformations. Results. Average operating time was 120 minutes in Group 1 and 190 minutes in Group 2. In MIS Group the visualization was excellent. We recorded no intraoperative complications, conversions, or anastomotic leakage. Feedings started on 3–7 postoperative days. Follow-up showed no evidence of stricture or obstruction. In Group 1 feedings started within 10–22 days and we have 1 postoperative obstruction. Conclusions. Laparoscopic repair of DA is one of the most challenging procedures among pediatric laparoscopic procedures. These patients had a shorter length of hospitalization and more rapid advancement to full feeding compared to patients undergoing the open approach. Laparoscopic repair of DA could be the preferred technique, safe, and efficacious, in the hands of experienced surgeons. Salvatore Fabio Chiarenza, Valeria Bucci, Maria Luisa Conighi, Elisa Zolpi, Lorenzo Costa, Lorella Fasoli, and Cosimo Bleve Copyright © 2017 Salvatore Fabio Chiarenza et al. All rights reserved. Application of Pneumatic Lithotripter and Holmium Laser in the Treatment of Ureteral Stones and Kidney Stones in Children Sun, 19 Feb 2017 00:00:00 +0000 Objective. Treatment options for urolithiasis in children include URSL and RIRS. Various types of energy are used in the disintegration of deposits in these procedures. We decided to evaluate the usefulness of URSL and RIRS techniques and compare the effectiveness of pneumatic lithotripters and holmium lasers in the child population based on our experience. Materials and Methods. One hundred eight (108) children who underwent URSL and RIRS procedures were enrolled in the study and divided into two (2) groups according to the type of energy used: pneumatic lithotripter versus holmium laser. We evaluated the procedures’ duration and effectiveness according to the stone-free rate (SFR) directly after the procedure and after fourteen (14) days and the rate of complications. Results. The mean operative time was shorter in the holmium laser group. A higher SFR was observed in the holmium laser but it was not statistically significant in the URSL and RIRS procedures. The rate of complications was similar in both groups. Conclusions. The URSL and RIRS procedures are highly efficient and safe methods. The use of a holmium laser reduces the duration of the procedure and increases its effectiveness in comparison with the use of a pneumatic lithotripter. Marcin Życzkowski, Rafał Bogacki, Krzysztof Nowakowski, Bartosz Muskała, Paweł Rajwa, Piotr Bryniarski, and Andrzej Paradysz Copyright © 2017 Marcin Życzkowski et al. All rights reserved. Ligation of Intersphincteric Fistula Tract Is Suitable for Recurrent Anal Fistulas from Follow-Up of 16 Months Wed, 08 Feb 2017 08:24:59 +0000 Since 2007, ligation of the intersphincteric fistula tract (LIFT) for the management of anal fistula was all introduced with initial success and excitement. It remains controversial which surgical procedure is suitable for transsphincteric fistula, especially to complex anal fistula. This retrospective study was designed to evaluate the results in patients with recurrent anal fistula by LIFT. A retrospective study of 55 complex fistula patients who underwent LIFT procedure in a single medical center was analyzed. Patients and fistula characteristics, complications, and recurrences were reviewed. All 55 patients underwent the procedure with a median follow-up of 16 months. Median operative time was 44 (range 23–88) minutes. Of the 55 patients, 33 (60%) healed completely and did not require any further surgical treatment at end of follow-up. Twenty-two (40%) recurrences and six complications were observed. Compared with patients who had undergone more than two surgical procedures, LIFT was more suitable for patients who had undergone one to two surgical procedures, and significant difference was observed in number of operations before LIFT (). Clinicians can consider the use of LIFT for the treatment of recurrent anal fistulas. A larger number of patients and prospective study are needed to be performed. Yansong Xu and Weizhong Tang Copyright © 2017 Yansong Xu and Weizhong Tang. All rights reserved. Alveolar Ridge Split Technique Using Piezosurgery with Specially Designed Tips Sun, 29 Jan 2017 08:33:55 +0000 The treatment of patients with atrophic ridge who need prosthetic rehabilitation is a common problem in oral and maxillofacial surgery. Among the various techniques introduced for the expansion of alveolar ridges with a horizontal bone deficit is the alveolar ridge split technique. The aim of this article is to give a description of some new tips that have been specifically designed for the treatment of atrophic ridges with transversal bone deficit. A two-step piezosurgical split technique is also described, based on specific osteotomies of the vestibular cortex and the use of a mandibular ramus graft as interpositional graft. A total of 15 patients were treated with the proposed new tips by our department. All the expanded areas were successful in providing an adequate width and height to insert implants according to the prosthetic plan and the proposed tips allowed obtaining the most from the alveolar ridge split technique and piezosurgery. These tips have made alveolar ridge split technique simple, safe, and effective for the treatment of horizontal and vertical bone defects. Furthermore the proposed piezosurgical split technique allows obtaining horizontal and vertical bone augmentation. Alessandro Moro, Giulio Gasparini, Enrico Foresta, Gianmarco Saponaro, Marco Falchi, Lorenzo Cardarelli, Paolo De Angelis, Mario Forcione, Umberto Garagiola, Giuseppe D’Amato, and Sandro Pelo Copyright © 2017 Alessandro Moro et al. All rights reserved. Comparison of Treatment Outcomes of Surgical Repair in Inguinal Hernia with Classic versus Preperitoneal Methods on Reduction of Postoperative Complications Mon, 23 Jan 2017 00:00:00 +0000 Background. This study aims to evaluate and compare the results of inguinal herniorrhaphy with mesh in classic and preperitoneal method. Methods. Our study community includes 150 candidate patients for inguinal herniorrhaphy with mesh. Totally, 150 candidate patients for inguinal herniorrhaphy were randomly divided into two groups: (1) classic group in which the floor of the canal was repaired and the mesh was located on the floor of the canal and (2) preperitoneal group in which the mesh was installed under the canal and then the floor was repaired. Results. The frequency of recurrence was 10 (13.3%) and 2 (2.66%) in the classic and preperitoneal group, respectively. The frequency of postsurgical pain was 21 (28%) in the classic group and 9 (12%) in the preperitoneal group. The postsurgical hematoma was observed in 7 (9.3%) and 9 (12%) in the classic and preperitoneal group, respectively. Also, the frequency of postsurgical seroma was 8 (10.7%) and 1 (1.3%) in the patients treated with the classic and preperitoneal method, respectively. Conclusion. The findings of the present study demonstrated that the preperitoneal method is a more suitable method for inguinal herniorrhaphy than the classic one because of fewer complications, according to the findings of this study. Hormoz Mahmoudvand, Shahab Forutani, and Sedigheh Nadri Copyright © 2017 Hormoz Mahmoudvand et al. All rights reserved. Evaluation of Laser Speckle Contrast Imaging for the Assessment of Oral Mucosal Blood Flow following Periodontal Plastic Surgery: An Exploratory Study Mon, 23 Jan 2017 00:00:00 +0000 The laser speckle contrast imaging (LSCI) is proved to be a reliable tool in flap monitoring in general surgery; however, it has not been evaluated in oral surgery yet. We applied the LSCI to compare the effect of a xenogeneic collagen matrix (Geistlich Mucograft®) to connective tissue grafts (CTG) on the microcirculation of the modified coronally advanced tunnel technique (MCAT) for gingival recession coverage. Gingival microcirculation and wound fluid were measured before and after surgery for six months at twenty-seven treated teeth. In males, the flap microcirculation was restored within 3 days for both grafts followed by a hyperemic response. During the first 8 days the blood flow was higher at xenogeneic graft comparing to the CTG. In females, the ischemic period lasted for 7–12 days depending on the graft and no hyperemic response was observed. Females had more intense and prolonged wound fluid production. The LSCI method is suitable to capture the microcirculatory effect of the surgical intervention in human oral mucosa. The application of xenogeneic collagen matrices as a CTG substitute does not seem to restrain the recovery of graft bed circulation. Gender may have an effect on postoperative circulation and inflammation. Eszter Molnár, Bálint Molnár, Zsolt Lohinai, Zsuzsanna Tóth, Zoltán Benyó, Laszló Hricisák, Péter Windisch, and János Vág Copyright © 2017 Eszter Molnár et al. All rights reserved. Osteogenic Differentiation Capacity of In Vitro Cultured Human Skeletal Muscle for Expedited Bone Tissue Engineering Sun, 22 Jan 2017 11:49:13 +0000 Expedited bone tissue engineering employs the biological stimuli to harness the intrinsic regenerative potential of skeletal muscle to trigger the reparative process in situ to improve or replace biological functions. When genetically modified with adenovirus mediated BMP2 gene transfer, muscle biopsies from animals have demonstrated success in regenerating bone within rat bony defects. However, it is uncertain whether the human adult skeletal muscle displays an osteogenic potential in vitro when a suitable biological trigger is applied. In present study, human skeletal muscle cultured in a standard osteogenic medium supplemented with dexamethasone demonstrated significant increase in alkaline phosphatase activity approximately 24-fold over control at 2-week time point. More interestingly, measurement of mRNA levels revealed the dramatic results for osteoblast transcripts of alkaline phosphatase, bone sialoproteins, transcription factor CBFA1, collagen type I, and osteocalcin. Calcified mineral deposits were demonstrated on superficial layers of muscle discs after an extended 8-week osteogenic induction. Taken together, these are the first data supporting human skeletal muscle tissue as a promising potential target for expedited bone regeneration, which of the technologies is a valuable method for tissue repair, being not only effective but also inexpensive and clinically expeditious. Chunlei Miao, Lulu Zhou, Lufeng Tian, Yingjie Zhang, Wei Zhang, Fanghong Yang, Tianyi Liu, Shengjian Tang, and Fangjun Liu Copyright © 2017 Chunlei Miao et al. All rights reserved. Reported Male Circumcision Practices in a Muslim-Majority Setting Tue, 17 Jan 2017 00:00:00 +0000 Introduction. Male circumcision is a recommended practice in Muslim tradition. It is important to ensure that this procedure is performed as safely as possible in these communities. Methods. Five hundred adult men and women with at least one male child less than 18 years were interviewed in Karachi, Pakistan, regarding details of their child’s circumcision. The survey focused on actual and perceived delays in circumcision and perceptions about appropriate age and reasons and benefits and complications of the procedure. Circumcisions done after two months of age were defined as delayed. Results. Religious requirement was the primary reason for circumcision in 92.6% of children. However, 89.6% of respondents were of the opinion that circumcision had medical benefits as well. Half of the children (54.1%) had delayed circumcision (range 2.5 months to 13 years), even though 81.2% of parents were of the opinion that circumcisions should be done within 60 days of birth. Facility-delivered babies had less delay in circumcisions (49.1%) as compared to home-delivered babies (60.5%). Conclusion. Understanding the perceptions and practices around male circumcision can help guide national strategies for designing and implementing safe circumcision programs in Muslim-majority settings, with the potential to benefit an annual birth cohort of 20–25 million boys worldwide. Abdul Wahid Anwer, Lubna Samad, Sundus Iftikhar, and Naila Baig-Ansari Copyright © 2017 Abdul Wahid Anwer et al. All rights reserved. Expression Profile of Long Noncoding RNAs in Human Earlobe Keloids: A Microarray Analysis Thu, 22 Dec 2016 09:14:47 +0000 Background. Long noncoding RNAs (lncRNAs) play key roles in a wide range of biological processes and their deregulation results in human disease, including keloids. Earlobe keloid is a type of pathological skin scar, and the molecular pathogenesis of this disease remains largely unknown. Methods. In this study, microarray analysis was used to determine the expression profiles of lncRNAs and mRNAs between 3 pairs of earlobe keloid and normal specimens. Gene Ontology (GO) categories and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses were performed to identify the main functions of the differentially expressed genes and earlobe keloid-related pathways. Results. A total of 2068 lncRNAs and 1511 mRNAs were differentially expressed between earlobe keloid and normal tissues. Among them, 1290 lncRNAs and 1092 mRNAs were upregulated, and 778 lncRNAs and 419 mRNAs were downregulated. Pathway analysis revealed that 24 pathways were correlated to the upregulated transcripts, while 11 pathways were associated with the downregulated transcripts. Conclusion. We characterized the expression profiles of lncRNA and mRNA in earlobe keloids and suggest that lncRNAs may serve as diagnostic biomarkers for the therapy of earlobe keloid. Liang Guo, Kai Xu, Hongbo Yan, Haifeng Feng, Linlin Chai, and Guozheng Xu Copyright © 2016 Liang Guo et al. All rights reserved. Establishment of a Novel Simplified Surgical Model of Acute Liver Failure in the Cynomolgus Monkey Wed, 21 Dec 2016 13:38:02 +0000 Models using large animals that are suitable for studying artificial liver support system (ALSS) are urgently needed. Presently available acute liver failure (ALF) models mainly involve pigs or dogs. Establishment of current surgical ALF models (hepatectomy/devascularization) requires either very good surgical skills or multistep processes—even multiple stages of surgery. Therefore, it is necessary to develop a simplified surgical method. Here we report a novel simplified surgical ALF model using cynomolgus monkeys. Six monkeys underwent portal-right renal venous shunt combined with common bile duct ligation and transection (PRRS + CBDLT). Postoperatively, the monkeys had progressively increased listlessness, loss of appetite, and obvious jaundice. Blood biochemistry levels (Amm, ALT, AST, TBiL, DBiL, ALP, LDH, CK, and Cr) and prothrombin time (PT) were significantly increased (all ) and albumin (ALB) was markedly reduced () compared with baseline values. Histological examination of liver specimens on postoperative day 10 revealed cholestasis and inflammation. PRRS + CBDLT produced ALF that closely correlated with clinical situations. Compared with other surgical or drug ALF models, ours was simplified and animals were hemodynamically stable. This model could provide a good platform for further research on ALSS, especially regarding their detoxification functions. Lei Cai, Jun Weng, Lei Feng, Guolin He, Jiasheng Qin, Zhi Zhang, Yang Li, Qing Peng, Zesheng Jiang, Mingxin Pan, and Yi Gao Copyright © 2016 Lei Cai et al. All rights reserved. Surgical Outcome of Two-Level Transforaminal Percutaneous Endoscopic Lumbar Discectomy for Far-Migrated Disc Herniation Wed, 14 Dec 2016 11:06:31 +0000 Objective. To describe the two-level percutaneous endoscopic lumbar discectomy (PELD) technique in transforaminal approach for highly migrated disc herniation and investigate its clinical outcomes. Methods. A total of 22 consecutive patients with highly migrated lumbar disc herniation were enrolled for the study from June 2012 to February 2014. Results. There were 12 males and 10 females, with a mean age of 41.1 (range 23–67) years. The mean follow-up period was 18.05 (range 14–33) months. According to the modified MacNab criteria, the clinical outcome at the final follow-up was excellent in 14, good in 6, and fair in 2 patients and the satisfactory rate (excellent and good) was 90.9%. The improvements in VAS and ODI were statistically significant. One patient had recurrent herniation in 18 months after the first surgery and underwent open discectomy. One patient showed symptoms of postoperative dysesthesia (POD), but the POD symptom was transient and partial remission was achieved in two months after conservative treatment. Conclusion. Two-level PELD in transforaminal approach can be a safe and effective procedure for highly migrated disc herniation. Xinbo Wu, Guoxin Fan, Xin Gu, Xiaofei Guan, and Shisheng He Copyright © 2016 Xinbo Wu et al. All rights reserved. Experience in Perioperative Management of Patients Undergoing Posterior Spine Fusion for Neuromuscular Scoliosis Mon, 12 Dec 2016 14:32:09 +0000 The objective of this investigation was to determine the outcome of spine fusion for neuromuscular (NM) scoliosis, using Unit Rod technique, with emphasis on complications related to preoperative general health. Between 1997 and 2007, 96 consecutive patients with neuromuscular scoliosis operated on with Unit Rod instrumentation were retrospectively reviewed. The inclusion criteria were diagnosis of NM scoliosis due to cerebral palsy (CP) and muscular dystrophy (DMD). Patient’s preoperative general health, weight, and nutrition were collected. Different radiographic and clinical parameters were evaluated. There were 66 CP patients (59 nonwalking) and 30 DMD patients (24 nonwalking). Mean age at surgery was 16.5 years and 13.9 years, respectively. All radiographic measurements improved significantly. Wound infection rate was 16.7% (11% of reoperation rate in CP; 10% in DMD; 3 hardware removal cases). No pelvic fracture due to rod irritation was observed. Unit Rod technique provides good radiographic and clinical outcomes even if this surgery is associated with a high complication rate. It is a quick, simple, and reliable technique. Perioperative management strategy should decrease postoperative complications and increases outcome. A standardized preoperative patient evaluation and preparation including respiratory capacity and nutritional, digestive, and musculoskeletal status are mandatory prior to surgery. Sébastien Pesenti, Benjamin Blondel, Emilie Peltier, Franck Launay, Stéphane Fuentes, Gérard Bollini, Elke Viehweger, and Jean-Luc Jouve Copyright © 2016 Sébastien Pesenti et al. All rights reserved. One-Piece Zirconia Ceramic versus Titanium Implants in the Jaw and Femur of a Sheep Model: A Pilot Study Mon, 12 Dec 2016 13:55:24 +0000 Reports have documented titanium (Ti) hypersensitivity after dental implant treatment. Alternative materials have been suggested including zirconia (Zr) ceramics, which have shown predictable osseointegration in animal studies and appear free of immune responses. The aim of the research was to investigate the bone-to-implant contact (BIC) of one-piece Zr, compared with one-piece Ti implants, placed in the jaws and femurs of domestic sheep. Ten New Zealand mixed breed sheep were used. A One-piece prototype Ti (control) and one Zr (test) implant were placed in the mandible, and one of each implant (Ti and Zr) was placed into the femoral epicondyle of each animal. The femur implants were submerged and unloaded; the mandibular implants were placed using a one-stage transgingival protocol and were nonsubmerged. After a healing period of 12 weeks, %BIC was measured. The overall survival rate for mandibular and femur implants combined was 87.5%. %BIC was higher for Zr implants versus Ti implants in the femur (85.5%, versus 78.9%) (). Zirconia implants in the mandible showed comparable %BIC to titanium implants (72.2%, versus 60.3%) (). High failure rate of both Zr and Ti one-piece implants in the jaw could be attributed to the one-piece design and surface characteristics of the implant that could have influenced osseointegration. Further clinical trials are recommended to evaluate the performance of zirconia implants under loading conditions. A. Siddiqi, W. J. Duncan, R. K. De Silva, and S. Zafar Copyright © 2016 A. Siddiqi et al. All rights reserved. Risk Factors and Treatment for Hemorrhage after Pancreaticoduodenectomy: A Case Series of 423 Patients Wed, 16 Nov 2016 11:30:20 +0000 The study aimed to investigate the risk factors of postpancreatectomy hemorrhage (PPH) after pancreaticoduodenectomy (PD). A retrospective analysis of 423 patients who underwent PD between January 2008 and January 2014 was conducted. The overall incidence and all-cause mortality of PPH were 9.9% (42/423) and 2.1% (9/423), respectively. Independent risk factors of early PPH were revascularization (odds ratio (OR) = 6.786; 95% confidence interval (95% CI): 1.785–25.792; ), history of abdominal surgery (OR = 5.009; 95% CI: 1.968–12.749; ), and preoperative albumin levels (OR = 4.863; 95% CI: 1.962–12.005; ). Independent risk factors of late PPH included postoperative pancreatic leakage (OR = 4.696; 95% CI: 1.605–13.740; ), postoperative biliary fistula (OR = 6.096; 95% CI: 1.575–23.598; ), postoperative abdominal infection (OR = 4.605; 95% CI: 1.108–19.144; ), revascularization (OR = 9.943; 95% CI: 1.900–52.042; ), history of abdominal surgery (OR = 8.790; 95% CI: 2.779–27.806; ), and preoperative albumin levels (OR = 5.563; 95% CI: 1.845–16.776; ). Feng Gao, Jianguo Li, Shengwei Quan, Fujun Li, Donglai Ma, Lei Yao, and Ping Zhang Copyright © 2016 Feng Gao et al. All rights reserved. Understanding the Pathophysiology of Portosystemic Shunt by Simulation Using an Electric Circuit Thu, 27 Oct 2016 14:16:56 +0000 Portosystemic shunt (PSS) without a definable cause is a rare condition, and most of the studies on this topic are small series or based on case reports. Moreover, no firm agreement has been reached on the definition and classification of various forms of PSS, which makes it difficult to compare and analyze the management. The blood flow can be seen very similar to an electric current, governed by Ohm’s law. The simulation of PSS using an electric circuit, combined with the interpretation of reported management results, can provide intuitive insights into the underlying mechanism of PSS development. In this article, we have built a model of PSS using electric circuit symbols and explained clinical manifestations as well as the possible mechanisms underlying a PSS formation. Moonhwan Kim and Keon-Young Lee Copyright © 2016 Moonhwan Kim and Keon-Young Lee. All rights reserved. Structural Preservation Percutaneous Endoscopic Lumbar Interlaminar Discectomy for L5-S1 Herniated Nucleus Pulposus Mon, 10 Oct 2016 08:41:48 +0000 Objective. Structures such as ligamentum flavum, annulus, and lamina play an important role in the segmental function. We proposed the surgical technique for achieving the sufficient preservation of segmental structures, in spite of sufficient removal of pathologic disc in the L5-S1 using the ligamentum flavum splitting and sealing technique. Methods. We retrospectively analyzed 80 cases that underwent percutaneous endoscopic lumbar discectomy for L5-S1 herniated nucleus pulposus, using the ligamentum flavum splitting and sealing technique between January 2011 and June 2013. Outcomes were assessed using VAS (leg, back), MacNab’s criteria, and the immediate postoperative MRI for all patients. Structural preservation was classified as complete, sufficient, and incomplete. Results. The surgical results are as follows: 65 cases were complete, 15 cases were sufficient, and 0 cases were incomplete. The VAS was decreased at the last follow-up (leg: from to ; back: from to ). A favorable outcome (excellent or good outcome by MacNab’s criteria) was achieved in 77 patients (96.25%). During the follow-up period, 2 cases (2.5%) of recurrence have occurred. Conclusion. According to the result, we could obtain the favorable clinical and radiological outcomes while simultaneously removing pathologic discs using the ligamentum flavum splitting and annular fissure sealing technique. Jung-Sup Lee, Hyeun-Sung Kim, Jee-Soo Jang, and Il-Tae Jang Copyright © 2016 Jung-Sup Lee et al. All rights reserved. Relationship between Frontal Gap and Postoperative Stability in the Treatment of Mandibular Prognathism Tue, 27 Sep 2016 11:25:58 +0000 Objectives. To investigate the correlation between frontal gaps and skeletal stability after intraoral vertical ramus osteotomy (IVRO) for correction of mandibular prognathism. Materials and Methods. Thirty-three patients with frontal gaps after IVRO-based mandibular prognathism correction were included. Three lateral and frontal cephalometric radiographs were obtained: preoperatively (T1), immediately postoperatively (T2), and 2 years postoperatively (T3). Two linear measurements (menton [Me] and frontal gap) were compared from T1 to T3 (T21: immediate surgical changes; T32: postoperative stability; T31: 2-year surgical change). Data were analyzed using Pearson’s correlation coefficient and multiple linear regression. Results. The T21 mean surgical horizontal change in the Me position was  mm. Vertically, the mean downward Me movement was  mm. The mean frontal gaps were  mm and  mm in the right and left gonial regions, respectively. Postoperative stability (T32) significantly correlated with the amount of setback. Frontal gaps did not have a significant effect on postoperative stability. However, multiple regression model (, ) showed value predictability, especially in the amount of setback. Conclusion. Frontal gaps occur after IVRO but have no significant effect on long-term postoperative skeletal stability. The primary risk factor for postoperative relapse remains the amount of mandibular setback. Yu-Chuan Tseng, Kun-Jung Hsu, Ker-Kong Chen, Ju-Hui Wu, and Chun-Ming Chen Copyright © 2016 Yu-Chuan Tseng et al. All rights reserved. The Management of Patients after Surgical Treatment of Maxillofacial Tumors Mon, 26 Sep 2016 16:39:40 +0000 Morphological and functional disturbances induced by postsurgical defects and loss of tissues in the stomatognathic system due to the treatment of tumors in the maxillofacial region determine the therapeutic needs of patients. The study aimed at clinical and epidemiological evaluation of patients under prosthetic treatment in order to establish the algorithm for rehabilitation. The study group was composed of the patients after midface surgery (45.74%); surgery in a lower part of the face (47.38%); mixed postoperative losses (3.44%); loss of face tissues and surgery in other locations in the head and neck region (3.44%). The supplementary treatment was applied in 69.63% of patients. Clinical and additional examinations were performed to obtain the picture of postoperative loss, its magnitude, and location to plan the strategy of prosthetic rehabilitation. The management algorithm for prosthetic rehabilitation in patients after surgical treatment of maxillofacial neoplasms was based on its division in stages. The location and magnitude of postoperative losses, as well as the implementation of supplementary treatment of the patients after treatment of maxillofacial tumors, influence the planning of prosthetic rehabilitation that plays a key role and facilitates the patients’ return to their prior living situation, occupational and family lives. D. Rolski, J. Kostrzewa-Janicka, P. Zawadzki, K. Życińska, and E. Mierzwińska-Nastalska Copyright © 2016 D. Rolski et al. All rights reserved. The Effect of File Size and Type and Irrigation Solutions on the Accuracy of Electronic Apex Locators: An In Vitro Study on Canine Teeth Mon, 26 Sep 2016 10:59:57 +0000 Measurements of the root canal during endodontic treatment have a significant influence on the course of the therapeutic process as well as on its final result in both human and veterinary medicine. The apical constriction should be the termination point for the preparation and filling of the root canal. This research was conducted with the use of a Septodont kit consisting of a small chamber filled with the examined solution in which a healthy second incisor was placed. The step back method was applied for the root canal preparation and master apical file of 30 was used. The working length was 22 mm. The examination was conducted with the use of steel as well as nickel titanium hand instruments. Different irrigation solutions and two types of apex locators were used. Measurements of the working length of the root canal showed dependence on the size of the instrument. Examinations carried out in various environments showed that analogical measurements were obtained only for sodium hypochlorite solutions. In other environments the measured sections were shortened. Comparative examinations with the use of steel instruments demonstrated insignificant measurement differences. Compared to these results, the measurements in nickel titanium group were characterized by more considerable deviations. Maciej Janeczek, Piotr Kosior, Dagmara Piesiak-Pańczyszyn, Krzysztof Dudek, Aleksander Chrószcz, Agnieszka Czajczyńska-Waszkiewicz, Małgorzata Kowalczyk-Zając, Aleksandra Gabren-Syller, Karol Kirstein, Aleksandra Skalec, Ewelina Bryła, and Maciej Dobrzyński Copyright © 2016 Maciej Janeczek et al. All rights reserved. Clinical Outcomes of Posterior Lumbar Interbody Fusion versus Minimally Invasive Transforaminal Lumbar Interbody Fusion in Three-Level Degenerative Lumbar Spinal Stenosis Mon, 26 Sep 2016 06:17:53 +0000 The aim of this study was to directly compare the clinical outcomes of posterior lumbar interbody fusion (PLIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in three-level lumbar spinal stenosis. This retrospective study involved a total of 60 patients with three-level degenerative lumbar spinal stenosis who underwent MIS-TLIF or PLIF from January 2010 to February 2012. Back and leg visual analog scale (VAS), Oswestry Disability Index (ODI), and Short Form-36 (SF-36) scale were used to assess the pain, disability, and health status before surgery and postoperatively. In addition, the operating time, estimated blood loss, and hospital stay were also recorded. There were no significant differences in back VAS, leg VAS, ODI, SF-36, fusion condition, and complications at 12-month follow-up between the two groups (). However, significantly less blood loss and shorter hospital stay were observed in MIS-TLIF group (). Moreover, patients undergoing MIS-TLIF had significantly lower back VAS than those in PLIF group at 6-month follow-up (). Compared with PLIF, MIS-TLIF might be a prior option because of noninferior efficacy as well as merits of less blood loss and quicker recovery in treating three-level lumbar spinal stenosis. Guoxin Fan, Xinbo Wu, Shunzhi Yu, Qi Sun, Xiaofei Guan, Hailong Zhang, Xin Gu, and Shisheng He Copyright © 2016 Guoxin Fan et al. All rights reserved. Intercondylar Route of Prosthetic Infragenicular Femoropopliteal Bypass Has Better Primary, Assisted, and Secondary Patency but Not Limb Salvage Rate Compared to the Medial Route Wed, 07 Sep 2016 16:39:39 +0000 Aim. To compare the differences between medial and intercondylar infragenicular femoropopliteal prosthetic bypasses in terms of their midterm patency and limb salvage rates. Methods. Ninety-three consecutive patients with peripheral arterial disease who underwent a simple distal femoropopliteal bypass using a reinforced polytetrafluorethylene graft were included in this retrospective study. The bypass was constructed in the intercondylar route in 52 of the patients (group A) and in 41 in the medial route (group B). Results. Median observation time of the patients was 12.7 (IQR 4.6–18.5) months. There were 22 and 24 interventional or surgical procedures (angioplasty, stenting, thrombolysis, thrombectomy, or correction of the anastomosis) performed to restore patency of the reconstruction in groups A and B, respectively (). The 20-month primary, assisted, and secondary patency rates and limb salvage rates were 57%, 57%, 81%, and 80% in group A compared to 21%, 23%, 55%, and 82% in group B (, 0.0052, 0.022, and 0.44, resp.). Conclusion. Despite better primary, assisted, and secondary patency rates in patients with a prosthetic infragenicular femoropopliteal bypass embedded in the intercondylar fossa compared to patients with the medial approach, there is no benefit in terms of the limb salvage rate and the number of interventions required to maintain patency of the reconstruction. Tomas Grus, Lukas Lambert, Rohan Banerjee, Gabriela Grusova, Vilem Rohn, Tomas Vidim, and Petr Mitas Copyright © 2016 Tomas Grus et al. All rights reserved. Improvement in Cerebral and Ocular Hemodynamics Early after Carotid Endarterectomy in Patients of Severe Carotid Artery Stenosis with or without Contralateral Carotid Occlusion Tue, 23 Aug 2016 15:44:37 +0000 Purpose. To investigate the alternation in cerebral and ocular blood flow velocity (BFV) in patients of carotid stenosis (CS) with or without contralateral carotid occlusion (CO) early after carotid endarterectomy (CEA). Patients and Methods. Nineteen patients underwent CEA for ≥50% CS. Fourteen patients had the unilateral CS, and five patients had the ipsilateral CS and the contralateral CO. Transcranial Doppler (TCD) and Color Doppler Imaging (CDI) were performed before and early after CEA. Results. In patients with unilateral CS, significant improvements in BFV were observed in anterior cerebral artery (ACA) and middle cerebral artery (MCA) on the ipsilateral side after CEA. In patients of ipsilateral CS and contralateral CO, significant improvements in BFV were observed in the ACA and MCA not only on the ipsilateral side but also on the contralateral side postoperatively. The ipsilateral ophthalmic artery (OA) retrograde flows in two patients were recovered to anterograde direction following CEA. The BFV in short posterior ciliary artery (SPCA) of the ipsilateral side significantly increased postoperatively irrespective of the presence of contralateral CO. Conclusions. CEA improved cerebral anterior circulation hemodynamics especially in patients of unilateral CS and contralateral CO, normalized the OA reverse flow, and increased the blood perfusion of SPCA. Jian Wang, Weici Wang, Bi Jin, Yanrong Zhang, Ping Xu, Feixiang Xiang, Yi Zheng, Juan Chen, Shi Sheng, Chenxi Ouyang, and Yiqing Li Copyright © 2016 Jian Wang et al. All rights reserved. Experimental Forelimb Allotransplantation in Canine Model Mon, 15 Aug 2016 11:08:25 +0000 As reconstructive transplantation is gaining popularity as a viable alternative for upper limb amputees, it is becoming increasingly important for plastic surgeons to renew surgical skills and knowledge of this area. Forelimb allotransplantation research has been performed previously in rodent and swine models. However, preclinical canine forelimb allotransplantation studies are lacking in the literature. The purpose of this paper is to provide an overview of the surgical skills necessary to successfully perform forelimb transplantation in canines as a means to prepare for clinical application. A total of 18 transplantation operations on canines were performed. The recipient limb was shortened at the one-third proximal forearm level. The operation was performed in the following order: bones (two reconstructive plates), muscles and tendons (separately sutured), nerves (median, ulnar, and radial nerve), arteries (two), and veins (two). The total mean time of transplantation was 5 hours ± 30 minutes. All of the animals that received transplantation were treated with FK-506 (tacrolimus, 2 mg/kg) for 7 days after surgery. Most allografts survived with perfect viability without vascular problems during the early postoperative period. The canine forelimb allotransplantation model is well qualified to be a suitable training model for standard transplantation and future research work. Sa-Hyeok Hong and Seok-Chan Eun Copyright © 2016 Sa-Hyeok Hong and Seok-Chan Eun. All rights reserved. Placebo in Surgical Research: A Case-Based Ethical Analysis and Practical Consequences Wed, 10 Aug 2016 10:13:20 +0000 Placebo is a form of simulated medical treatment intended to deceive the patient/subject who believes that he/she received an active therapy. In clinical medicine, the use of placebo is allowed in particular circumstances to assure a patient that he is taken care of and that he/she receives an active drug, even if this is not the case. In clinical research placebo is widely used, as it allows a baseline comparison for the active intervention. If the use of placebo is highly regulated in pharmacological trials, surgery studies have a series of particularities that make its use extremely problematic and regarded less favorably. The purpose of this paper is to present three famous cases of placebo use in surgical trials and to perform an ethical analysis of their acceptability using the Declaration of Helsinki as a main regulatory source. Sorin Hostiuc, Irina Rentea, Eduard Drima, and Ionut Negoi Copyright © 2016 Sorin Hostiuc et al. All rights reserved. Total 3D Airo® Navigation for Minimally Invasive Transforaminal Lumbar Interbody Fusion Wed, 27 Jul 2016 12:53:29 +0000 Introduction. A new generation of iCT scanner, Airo®, has been introduced. The purpose of this study is to describe how Airo facilitates minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Method. We used the latest generation of portable iCT in all cases without the assistance of K-wires. We recorded the operation time, number of scans, and pedicle screw accuracy. Results. From January 2015 to December 2015, 33 consecutive patients consisting of 17 men and 16 women underwent single-level or two-level MIS-TLIF operations in our institution. The ages ranged from 23 years to 86 years (mean, 66.6 years). We treated all the cases in MIS fashion. In four cases, a tubular laminectomy at L1/2 was performed at the same time. The average operation time was 192.8 minutes and average time of placement per screw was 2.6 minutes. No additional fluoroscopy was used. Our screw accuracy rate was 98.6%. No complications were encountered. Conclusions. Airo iCT MIS-TLIF can be used for initial planning of the skin incision, precise screw, and cage placement, without the need for fluoroscopy. “Total navigation” (complete intraoperative 3D navigation without fluoroscopy) can be achieved by combining Airo navigation with navigated guide tubes for screw placement. Xiaofeng Lian, Rodrigo Navarro-Ramirez, Connor Berlin, Ajit Jada, Yu Moriguchi, Qiwei Zhang, and Roger Härtl Copyright © 2016 Xiaofeng Lian et al. All rights reserved. Minimally Invasive Transforaminal Lumbar Interbody Fusion at L5-S1 through a Unilateral Approach: Technical Feasibility and Outcomes Tue, 28 Jun 2016 11:55:03 +0000 Background. Minimally invasive spinal transforaminal lumbar interbody fusion (MIS-TLIF) at L5-S1 is technically more demanding than it is at other levels because of the anatomical and biomechanical traits. Objective. To determine the clinical and radiological outcomes of MIS-TLIF for treatment of single-level spinal stenosis low-grade isthmic or degenerative spondylolisthesis at L5-S1. Methods. Radiological data and electronic medical records of patients who underwent MIS-TLIF between May 2012 and December 2014 were reviewed. Fusion rate, cage position, disc height (DH), disc angle (DA), disc slope angle, segmental lordotic angle (SLA), lumbar lordotic angle (LLA), and pelvic parameters were assessed. For functional assessment, the visual analogue scale (VAS), Oswestry disability index (ODI), and patient satisfaction rate (PSR) were utilized. Results. A total of 21 levels in 21 patients were studied. DH, DA, SLA, and LLA had increased from their preoperative measures at the final follow-up. Fusion rate was 86.7% (18/21) at 12 months’ follow-up. The most common cage position was anteromedial (15/21). The mean VAS scores for back and leg pain mean ODI scores improved significantly at the final follow-up. PSR was 88%. Cage subsidence was observed in 33.3% (7/21). Conclusions. The clinical and radiologic outcomes after MIS-TLIF at L5-S1 in patients with spinal stenosis or spondylolisthesis are generally favorable. Won-Suh Choi, Jin-Sung Kim, Kyeong-Sik Ryu, Jung-Woo Hur, and Ji-Hoon Seong Copyright © 2016 Won-Suh Choi et al. All rights reserved. Diagnostic Value of White Blood Cell and C-Reactive Protein in Pediatric Appendicitis Wed, 04 May 2016 09:29:58 +0000 Background. Acute appendicitis (AA) associated with acute phase reaction is the most prevalent disease which requires emergency surgery. Its delayed diagnosis and unnecessarily performed appendectomies lead to numerous complications. In our study, we aimed to detect the role of WBC and CRP in the exclusion of acute and complicated appendicitis and diagnostic accuracy in pediatric age group. Methods. Appendectomized patient groups were constructed based on the results of histological evaluation. The area under a receiver operating characteristic (ROC) curve (AUC) was performed to examine diagnostic accuracy. Results. When WBC and CRP were used in combination, based on cut-off values of ≥13.1 × 103/μL for WBC counts and ≥1.17 mg/dL for CRP level, diagnostic parameters were as follows: sensitivity, 98.7%; specificity, 71.3%; PPV, 50.6%; NPV, 99.5%; diagnostic accuracy, 77.6%; LR(+), 3.44; LR(−), 0.017. AUC values were 0.845 (95% CI 0.800–0.891) for WBC and 0.887 (95% CI 0.841–0.932) for CRP. Conclusions. For complicated appendicitis, CRP has the highest degree of diagnostic accuracy. The diagnosis of appendicitis should be made primarily based on clinical examination, and obviously more specific and systemic inflammatory markers are needed. Combined use of cut-off values of WBC (≥13100/μL) and CRP (≥1.17 mg/L) yields a higher sensitivity and NPV for the diagnosis of complicated appendicitis. Sevgi Buyukbese Sarsu and Fatma Sarac Copyright © 2016 Sevgi Buyukbese Sarsu and Fatma Sarac. All rights reserved. Efficiency Analysis of Direct Video-Assisted Thoracoscopic Surgery in Elderly Patients with Blunt Traumatic Hemothorax without an Initial Thoracostomy Thu, 14 Apr 2016 11:16:33 +0000 Hemothorax is common in elderly patients following blunt chest trauma. Traditionally, tube thoracostomy is the first choice for managing this complication. The goal of this study was to determine the benefits of this approach in elderly patients with and without an initial tube thoracostomy. Seventy-eight patients aged >65 years with blunt chest trauma and stable vital signs were included. All of them had more than 300 mL of hemothorax, indicating that a tube thoracostomy was necessary. The basic demographic data and clinical outcomes of patients with hemothorax who underwent direct video-assisted thoracoscopic surgery without a tube thoracostomy were compared with those who received an initial tube thoracostomy. Patients who did not receive a thoracostomy had lower posttrauma infection rates (28.6% versus 56.3%, ) and a significantly shorter length of stay in the intensive care unit (3.13 versus 8.27, ) and in the hospital (15.93 versus 23.17, ) compared with those who received a thoracostomy. The clinical outcomes in the patients who received direct VATS were more favorable compared with those of the patients who did not receive direct VATS. Wen-Yen Huang, I-Yin Lu, Chyan Yang, Yi-Pin Chou, and Hsing-Lin Lin Copyright © 2016 Wen-Yen Huang et al. All rights reserved. Retracted: How to Perfuse: Concepts of Cerebral Protection during Arch Replacement Thu, 07 Apr 2016 12:34:50 +0000 BioMed Research International Copyright © 2016 BioMed Research International. All rights reserved. Minimally Invasive Surgical Treatment of Acute Epidural Hematoma: Case Series Wed, 06 Apr 2016 10:00:35 +0000 Background and Objective. Although minimally invasive surgical treatment of acute epidural hematoma attracts increasing attention, no generalized indications for the surgery have been adopted. This study aimed to evaluate the effects of minimally invasive surgery in acute epidural hematoma with various hematoma volumes. Methods. Minimally invasive puncture and aspiration surgery were performed in 59 cases of acute epidural hematoma with various hematoma volumes (13–145 mL); postoperative follow-up was 3 months. Clinical data, including surgical trauma, surgery time, complications, and outcome of hematoma drainage, recovery, and Barthel index scores, were assessed, as well as treatment outcome. Results. Surgical trauma was minimal and surgery time was short (10–20 minutes); no anesthesia accidents or surgical complications occurred. Two patients died. Drainage was completed within 7 days in the remaining 57 cases. Barthel index scores of ADL were ≤40 (), 41–60 (), and >60 (); scores of 100 were obtained in 48 cases, with no dysfunctions. Conclusion. Satisfactory results can be achieved with minimally invasive surgery in treating acute epidural hematoma with hematoma volumes ranging from 13 to 145 mL. For patients with hematoma volume >50 mL and even cerebral herniation, flexible application of minimally invasive surgery would help improve treatment efficacy. Weijun Wang Copyright © 2016 Weijun Wang. All rights reserved. Infrared Thermographic Assessment of Cooling Effectiveness in Selected Dental Implant Systems Tue, 15 Mar 2016 12:42:57 +0000 The excessive temperature fluctuations during dental implant site preparation may affect the process of bone-implant osseointegration. In the presented studies, we aimed to assess the quality of cooling during the use of 3 different dental implant systems (BEGO®, NEO BIOTECH®, and BIOMET 3i®). The swine rib was chosen as a study model. The preparation of dental implant site was performed with the use of 3 different speeds of rotation (800, 1,200, and 1,500 rpm) and three types of cooling: with saline solution at room temperature, with saline solution cooled down to 3°C, and without cooling. A statistically significant difference in temperature fluctuations was observed between BEGO and NEO BIOTECH dental systems when cooling with saline solution at 3°C was used (22.3°C versus 21.8°C). In case of all three evaluated dental implant systems, the highest temperature fluctuations occurred when pilot drills were used for implant site preparation. The critical temperature, defined in the available literature, was exceeded only in case of pilot drills (of all 3 systems) used at rotation speed of 1,500 rpm without cooling. Karol Kirstein, Maciej Dobrzyński, Piotr Kosior, Aleksander Chrószcz, Krzysztof Dudek, Katarzyna Fita, Olga Parulska, Zbigniew Rybak, Aleksandra Skalec, Magdalena Szklarz, and Maciej Janeczek Copyright © 2016 Karol Kirstein et al. All rights reserved. Penis Allotransplantation in Beagle Dog Mon, 08 Feb 2016 13:22:04 +0000 This is an original research of penis allotransplantation. The paper presents an experiment allogenic penis transplantation model in Beagles, with a focus on recovery of blood supply and changes in tissue architecture. Twenty adult Beagles were allocated to 10 pairs for penile transplantation. After operation, the skin and glans were observed. If adverse symptoms occurred, the transplanted penis was resected and pathologically examined. Frequency of urination, urinary stream, and patency level were recorded 7 days after transplantation. Cystourethrography was performed on Day 10. The transplanted penises were resected on Day 14 for pathological examination. The research showed that transplanted penises survived after allotransplantation, and the dogs regained urination ability. Penis autotransplantation in Beagles is feasible. This preliminary study shows a potential for application of this new procedure for penis transplantation in humans. Yongbin Zhao, Weilie Hu, Lichao Zhang, Fei Guo, Wei Wang, Bangqi Wang, and Changzheng Zhang Copyright © 2016 Yongbin Zhao et al. All rights reserved. Numbers of Beauty: An Innovative Aesthetic Analysis for Orthognathic Surgery Treatment Planning Tue, 19 Jan 2016 07:07:40 +0000 The aim of this study was to validate a new aesthetic analysis and establish the sagittal position of the maxilla on an ideal group of reference. We want to demonstrate the usefulness of these findings in the treatment planning of patients undergoing orthognathic surgery. We took a reference group of 81 Italian women participating in a national beauty contest in 2011 on which we performed Arnett’s soft tissues cephalometric analysis and our new “Vertical Planning Line” analysis. We used the ideal values to elaborate the surgical treatment planning of a second group of 60 consecutive female patients affected by skeletal class III malocclusion. Finally we compared both pre- and postoperative pictures with the reference values of the ideal group. The ideal group of reference does not perfectly fit in Arnett’s proposed norms. From the descriptive statistical comparison of the patients’ values before and after orthognathic surgery with the reference values we observed how all parameters considered got closer to the ideal population. We consider our “Vertical Planning Line” a useful help for orthodontist and surgeon in the treatment planning of patients with skeletal malocclusions, in combination with the clinical facial examination and the classical cephalometric analysis of bone structures. Tito Matteo Marianetti, Giulio Gasparini, Giulia Midulla, Cristina Grippaudo, Roberto Deli, Daniele Cervelli, Sandro Pelo, and Alessandro Moro Copyright © 2016 Tito Matteo Marianetti et al. All rights reserved. Outcomes of Various Interventions for First-Time Perianal Abscesses in Children Tue, 05 Jan 2016 12:23:44 +0000 Introduction. In children treated surgically for first-time perianal abscesses, discovery and excision of concomitant fistulas may also be warranted. Aim. To evaluate children of varying age after incision and drainage of first-time perianal abscesses, examining recurrences rates with and without search for a fistula. Method. A retrospective review was conducted, analyzing children (ages 0–15 years) treated for first-time perianal abscesses at a tertiary pediatric surgical center, with a minimum follow-up of 6 months. Results. A total of 104 patients subjected to 112 treatments for first-time perianal abscesses were eligible. Surgical procedures constituted 84 (75%) of treatments, searching for fistulas in 49 (58%). In 34 (69%), fistulas were confirmed and treated. In the surgically treated subset, the recurrence rate was higher if no attempt was made to exclude a fistula (46%), as opposed to confirmed absence of a fistula (27%) or concurrent fistulotomy (9%; ). Younger patients showed a higher recurrence rate (12/26; 46%), compared with older counterparts (11/58; 19%) (). Conclusion. In children surgically treated for first-time perianal abscess, recurrence rates appear to be lowered by locating and treating coexisting fistulas. Alexander Juth Karlsson, Martin Salö, and Pernilla Stenström Copyright © 2016 Alexander Juth Karlsson et al. All rights reserved. Immediate Radical Cystectomy for Massive Bleeding of Bladder Cancer Thu, 24 Dec 2015 11:15:40 +0000 Objective. To investigate feasibility and safety of our surgical strategy and clinical and oncological efficacy. Materials and Methods. In a high volume tertiary institution 225 radical cystectomies were performed from January 2012 to December 2014. We prospectively collected data of a cohort of 12 patients who underwent immediate open radical cystectomy for bladder cancer causing massive haematuria, acute anemia, and impossibility of postponing surgery. A retrospective study was carried out to evaluate operative data, intra- and postoperative complications, and oncologic outcomes. The Clavien-Dindo Classification was used to grade complications. The oncologic outcome was evaluated in terms of positive overall and soft tissue surgical margins and cancer specific survival at a median follow-up of 26 months. Results. Mean preoperative haemoglobin was 6.8 mg/dL. Mean operative time was 278 minutes. Mean blood loss was 633 mL. The overall transfusion rate was 100% with a mean of 3.6 blood units per patient before surgery and 1.8 units postoperatively. No intraoperative complications occurred. Major complications (defined as grades III, IV, and V according to Clavien-Dindo Classification) were 18,5%. In fact grade III complications were 14.8% and grade IV complications were 3.7%. Grade V did not occur. The positive surgical margin rate was 33.3% and cancer specific survival was 58,3% at median follow-up of 26 months. Conclusions. Immediate surgical management seems feasible, safe, and efficacious. Giovanni Cochetti, Francesco Barillaro, Andrea Boni, and Ettore Mearini Copyright © 2015 Giovanni Cochetti et al. All rights reserved. Natural Hirudin Increases Rat Flap Viability by Anti-Inflammation via PARs/p38/NF-κB Pathway Mon, 07 Dec 2015 12:44:08 +0000 The present study aimed to evaluate the effect of natural hirudin on rat random skin flap viability and to determine the mechanism. Forty-eight rats were randomly divided into 2 groups. After the dorsal skin flap operation (3 cm × 10 cm in size), subcutaneous injections of 6 ATU hirudin were administered to group H () every 12 h, while group C () received an equal volume of 0.9% normal saline. Six rats from each group were euthanized 1, 2, 4, and 7 days after the operation. A full skin sample was collected from these rats to measure the p38-mitogen-activated protein kinase (p38-MAPK), phospho-p38- (Pp38-) MAPK, nuclear factor-κB (NF-κB) p65, phosphor-NF-κB (pNF-κB) p65, tumour necrosis factor- (TNF-) α, interleukin- (IL-) 6, and intercellular adhesion molecule- (ICAM-) 1 levels via western blot (WB) assays. The results showed that flap viability was significantly higher in the hirudin-treated group, which showed a reduced inflammatory response compared with the control group. The Pp38/p38, pNF-κB p65/NF-κB p65, TNF-α, IL-6, and ICAM-1 levels in the hirudin-treated group were lower than those in the control group. The results demonstrated that hirudin could improve random skin flap viability and suggested that this effect maybe occurs by blocking the thrombin/proteinase-activated receptors (PARs)/p38/NF-κB signalling pathway, thus decreasing the inflammatory response. Liu Peng, Xinyuan Pan, and Guoqian Yin Copyright © 2015 Liu Peng et al. All rights reserved. How to Perfuse: Concepts of Cerebral Protection during Arch Replacement Wed, 02 Dec 2015 11:03:55 +0000 Arch surgery remains undoubtedly among the most technically and strategically challenging endeavors in cardiovascular surgery. Surgical interventions of thoracic aneurysms involving the aortic arch require complete circulatory arrest in deep hypothermia (DHCA) or elaborate cerebral perfusion strategies with varying degrees of hypothermia to achieve satisfactory protection of the brain from ischemic insults, that is, unilateral/bilateral antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion (RCP). Despite sophisticated and increasingly individualized surgical approaches for complex aortic pathologies, there remains a lack of consensus regarding the optimal method of cerebral protection and circulatory management during the time of arch exclusion. Many recent studies argue in favor of ACP with various degrees of hypothermic arrest during arch reconstruction and its advantages have been widely demonstrated. In fact ACP with more moderate degrees of hypothermia represents a paradigm shift in the cardiac surgery community and is widely adopted as an emergent strategy; however, many centers continue to report good results using other perfusion strategies. Amidst this important discussion we review currently available surgical strategies of cerebral protection management and compare the results of recent European multicenter and single-center data. Andreas Habertheuer, Dominik Wiedemann, Alfred Kocher, Guenther Laufer, and Prashanth Vallabhajosyula Copyright © 2015 Andreas Habertheuer et al. All rights reserved. Developing an International Combined Applied Surgical Science and Wet Lab Simulation Course as an Undergraduate Teaching Model Tue, 03 Nov 2015 09:37:14 +0000 Background. Essential Skills in the Management of Surgical Cases (ESMSC) is an international, animal model-based course. It combines interactive lectures with basic ex vivo stations and more advanced wet lab modules, that is, in vivo dissections and Heart Transplant Surgery on a swine model. Materials and Methods. Forty-nine medical students (male, , female , and mean age = 23.7 years) from King’s College London (KCL) and Greek Medical Schools attended the course. Participants were assessed with Direct Observation of Procedural Skills (DOPS), as well as Multiple Choice Questions (MCQs). Paired t-test associations were used to evaluate whether there was statistically significant improvement in their performance. Aim. To evaluate the effectiveness of a combined applied surgical science and wet lab simulation course as a teaching model for surgical skills at the undergraduate level. Results. The mean MCQ score was improved by 2.33/32 (). Surgical skills competences, as defined by DOPS scores, were improved in a statically significant manner ( for all paired t-test correlations). Conclusions. ESMSC seems to be an effective teaching model, which improves the understanding of the surgical approach and the basic surgical skills. In vivo models could be used potentially as a step further in the Undergraduate Surgical Education. Michail Sideris, Apostolos Papalois, Georgios Tsoulfas, Sanjib Majumder, Konstantinos Toutouzas, Efstratios Koletsis, Panagiotis Dedeilias, Nikolaos Lymperopoulos, Savvas Papagrigoriadis, Vassilios Papalois, and Georgios Zografos Copyright © 2015 Michail Sideris et al. All rights reserved. Intraoperative Hemorrhage and Postoperative Sequelae after Intraoral Vertical Ramus Osteotomy to Treat Mandibular Prognathism Mon, 12 Oct 2015 06:07:39 +0000 Objective. To investigate the factors affecting intraoperative hemorrhage and postoperative sequelae after orthognathic surgery. Materials and Methods. Eighty patients with mandibular prognathism underwent surgical mandibular setback with intraoral vertical ramus osteotomy (IVRO). The correlation between the blood loss volume and postoperative VAS with the gender, age, and operating time was assessed using the -test and Spearman rank correlation coefficient. The correlation between the magnitude of mandibular setback with the presence of TMJ clicking symptoms and lip sensation was also assessed. Results. The mean operating time and blood loss volume for men and women were 249.52 min and 229.39 min, and 104.03 mL and 86.12 mL, respectively. The mean VAS in men and women was 3.21 and 2.93, and 1.79 and 1.32 on the first and second postoperative days. There is no gender difference in the operating time, blood loss, VAS, TMJ symptoms, and lip numbness. The magnitude of mandibular setback was not correlated with immediate and long-term postoperative lip numbness. Conclusion. There are no gender differences in the intraoperative hemorrhage and postoperative sequelae (pain, lip numbness, and TMJ symptoms). In addition, neither symptom was significantly correlated with the amount of mandibular setback. Chun-Ming Chen, Steven Lai, Ker-Kong Chen, and Huey-Er Lee Copyright © 2015 Chun-Ming Chen et al. All rights reserved. A Prospective Randomized Study of Brain Tissue Oxygen Pressure-Guided Management in Moderate and Severe Traumatic Brain Injury Patients Thu, 27 Aug 2015 07:23:21 +0000 The purpose of this study was to compare the effect of PbtO2-guided therapy with traditional intracranial pressure- (ICP-) guided treatment on the management of cerebral variables, therapeutic interventions, survival rates, and neurological outcomes of moderate and severe traumatic brain injury (TBI) patients. From 2009 to 2010, TBI patients with a Glasgow coma scale <12 were recruited from 6 collaborative hospitals in northern Taiwan, excluding patients with severe systemic injuries, fixed and dilated pupils, and other major diseases. In total, 23 patients were treated with PbtO2-guided management (PbtO2 > 20 mmHg), and 27 patients were treated with ICP-guided therapy (ICP < 20 mmHg and CPP > 60 mmHg) in the neurosurgical intensive care unit (NICU); demographic characteristics were similar across groups. The survival rate in the PbtO2-guided group was also significantly increased at 3 and 6 months after injury. Moreover, there was a significant correlation between the PbtO2 signal and Glasgow outcome scale-extended in patients from 1 to 6 months after injury. This finding demonstrates that therapy directed by PbtO2 monitoring is valuable for the treatment of patients with moderate and severe TBI and that increasing PaO2 to 150 mmHg may be efficacious for preventing cerebral hypoxic events after brain trauma. Chien-Min Lin, Ming-Chin Lin, Sheng-Jean Huang, Cheng-Kuei Chang, Dan-Ping Chao, Tai-Ngar Lui, Hsin-I Ma, Ming-Ying Liu, Wen-Yuh Chung, Yang-Hsin Shih, Shin-Han Tsai, Hung-Yi Chiou, Mau-Roung Lin, Sen-Li Jen, Li Wei, Chung-Che Wu, En-Yuan Lin, Kuo-Hsing Liao, Yung-Hsiao Chiang, Wen-Ta Chiu, and Jia-Wei Lin Copyright © 2015 Chien-Min Lin et al. All rights reserved. The Effect of Young Age in Hormone Receptor Positive Breast Cancer Sun, 16 Aug 2015 11:38:17 +0000 Background. Studies have shown that young breast cancer patients have more advanced disease and worse survival compared to older patients. Our objective was to study disease characteristics and survival in the subset of young women with hormone receptor positive (HR+) and HER2 negative (HER2−) cancer. Methods. We retrospectively analyzed HR+/HER2− breast cancer patients who underwent surgery at our institution between 2002 and 2010. We compared clinical characteristics, pathology, treatment, and recurrence-free survival between younger (≤40 years) and older (>40 years) patients. Results. Of 669 HR+/HER2− breast cancer cases, 54 (8.1%) patients were 40 years or younger. Younger patients had more luminal B subtype, high grade, poor differentiation, and increased lymphovascular invasion. Younger women were treated more often with mastectomy and adjuvant chemotherapy. Although the unadjusted recurrence-free survival at median 55-month follow-up was lower in younger women, adjusting for stage, there was no significant difference (90.7% versus 89.3%, ) between groups. Conclusion. Younger patients with HR+/HER2− breast cancer had more advanced disease and more aggressive treatment than older patients. The unfavorable pathologic features suggest a biologically different tumor in young women. After adjusting for these factors, younger patients have a recurrence-free survival similar to older patients. Minna K. Lee, Leo A. Varzi, Debra U. Chung, Minh-an Cao, Jeffrey Gornbein, Sophia K. Apple, and Helena R. Chang Copyright © 2015 Minna K. Lee et al. All rights reserved. Increased Postoperative Bleeding Risk among Patients with Local Flap Surgery under Continued Clopidogrel Therapy Thu, 06 Aug 2015 17:09:08 +0000 Purpose. The purpose of the study was to evaluate the influence of a continued antiplatelet therapy with clopidogrel on postoperative bleeding risk in patients undergoing skin tumor resection and reconstruction with local flaps or skin grafts under outpatient conditions. Patients and Methods. The authors designed and implemented a retrospective clinical cohort study at the General Hospital Balingen. The primary endpoint was the bleeding ratio in patients with clopidogrel treatment in comparison to patients without any anticoagulant or antiplatelet therapy. Wound healing was evaluated on days 1, 3, 5, 7, 10, and 14. Results. 650 procedures were performed, 123 of them under continued clopidogrel therapy. There were significantly more postoperative bleeding complications among patients with continued antiplatelet therapy. Regarding the whole study population, malignant lesions, a larger defect size, and skin grafts were accompanied by a higher rate of bleeding incidents. However, there were no significant findings in the univariate analysis of the clopidogrel group. All bleeding incidents were easily manageable. Conclusion. Despite an increased bleeding ratio among patients under continued clopidogrel therapy, the performance of simple surgical procedures can be recommended. However, cautious preparation and careful hemostasis are indispensable. Wolfgang Eichhorn, Martina Haase, Lan Kluwe, Jürgen Zeuch, Ralf Smeets, Henning Hanken, Manfred Wehrmann, Alexander Gröbe, Max Heiland, Moritz Birkelbach, and Carsten Rendenbach Copyright © 2015 Wolfgang Eichhorn et al. All rights reserved. The Twin Forceps: A New Instrument for SILS Tue, 04 Aug 2015 12:05:45 +0000 In the last ten years, the single incision laparoscopic surgery (SILS) is gaining more interest than the traditional laparoscopic surgery (LAP). Many studies make a comparison between the performances of the SILS and the LAP. The results show that the single incision laparoscopic surgery reduces pain, length of period of postoperative hospitalization, and loss of blood. This technique is also able to reduce the infection sites. In spite of many advantages, SILS reveals some problems: laparoscopic instruments triangulation and small workspace. The surgeon has to be more skillful to make a surgery in SILS because the surgeon has only three laparoscopic instruments and only one hole in the abdomen cavity. In this paper, a novel laparoscopic instrument to help the surgeon during a SILS operation is presented. This instrument is innovative forceps with double graspers. Different designs of this instrument are presented, with the final one which greatly simplifies both construction and operation. The initial experience in the laboratory with the innovative instrument is presented. The surgeon experienced in laparoscopic surgery and with the help of assistants performed a training program based on predetermined task performed in simulation box (laparoscopic box-trainer). Antonia Rizzuto, Mario Donnici, Paola Nudo, Basilio Sinopoli, Rosario Sacco, and Guido Danieli Copyright © 2015 Antonia Rizzuto et al. All rights reserved. Cardioprotection during Adult and Pediatric Open Heart Surgery Thu, 28 May 2015 09:24:15 +0000 M-Saadeh Suleiman, Malcolm Underwood, Hajime Imura, and Massimo Caputo Copyright © 2015 M-Saadeh Suleiman et al. All rights reserved. Monoamine Oxidases as Potential Contributors to Oxidative Stress in Diabetes: Time for a Study in Patients Undergoing Heart Surgery Mon, 25 May 2015 13:27:02 +0000 Oxidative stress is a pathomechanism causally linked to the progression of chronic cardiovascular diseases and diabetes. Mitochondria have emerged as the most relevant source of reactive oxygen species, the major culprit being classically considered the respiratory chain at the inner mitochondrial membrane. In the past decade, several experimental studies unequivocally demonstrated the contribution of monoamine oxidases (MAOs) at the outer mitochondrial membrane to the maladaptative ventricular hypertrophy and endothelial dysfunction. This paper addresses the contribution of mitochondrial dysfunction to the pathogenesis of heart failure and diabetes together with the mounting evidence for an emerging role of MAO inhibition as putative cardioprotective strategy in both conditions. Oana M. Duicu, Rodica Lighezan, Adrian Sturza, Raluca A. Ceausu, Claudia Borza, Adrian Vaduva, Lavinia Noveanu, Marian Gaspar, Adina Ionac, Horea Feier, Danina M. Muntean, and Cristian Mornos Copyright © 2015 Oana M. Duicu et al. All rights reserved. Changes in Heart Rate Variability after Coronary Artery Bypass Grafting and Clinical Importance of These Findings Wed, 20 May 2015 11:05:37 +0000 Heart rate variability is a physiological feature indicating the influence of the autonomic nervous system on the heart rate. Association of the reduced heart rate variability due to myocardial infarction and the increased postinfarction mortality was first described more than thirty years ago. Many studies have unequivocally demonstrated that coronary artery bypass grafting surgery generally leads to significant reduction in heart rate variability, which is even more pronounced than after myocardial infarction. Pathophysiologically, however, the mechanisms of heart rate variability reduction associated with acute myocardial infarction and coronary artery bypass grafting are different. Generally, heart rate variability gradually recovers to the preoperative values within six months of the procedure. Unlike the reduced heart rate variability in patients having sustained myocardial infarction, a finding of reduced heart rate variability after coronary artery bypass surgery is not considered relevant in predicting mortality. Current knowledge about changes in heart rate variability in coronary patients and clinical relevance of such a finding in patients undergoing coronary artery bypass grafting are presented. Nenad Lakusic, Darija Mahovic, Peter Kruzliak, Jasna Cerkez Habek, Miroslav Novak, and Dusko Cerovec Copyright © 2015 Nenad Lakusic et al. All rights reserved. Gab1 Is Modulated by Chronic Hypoxia in Children with Cyanotic Congenital Heart Defect and Its Overexpression Reduces Apoptosis in Rat Neonatal Cardiomyocytes Tue, 19 May 2015 13:58:43 +0000 Gab1 (Grb2 associated binding protein 1) is a member of the scaffolding/docking proteins (Gab1, Gab2, and Gab3). It is required for fibroblast cell survival and maintaining cardiac function. Very little is known about human Gab1 expression in response to chronic hypoxia. The present study examined the hypothesis that hypoxia regulates Gab1 expression in human paediatric myocardium and cultured rat cardiomyocytes. Here we showed that Gab1 is expressed in myocardial tissue in acyanotic and cyanotic children with congenital heart defects. Gab1 protein was upregulated in cyanotic compared to acyanotic hearts suggesting that Gab1 upregulation is a component of the survival program initiated by hypoxia in cyanotic children. The expression of other Gab1 interacting partners was not affected by hypoxia and Gab1 regulation. Additionally, using an in vitro model, we demonstrated that overexpressing Gab1 in neonatal cardiomyocytes, under hypoxic condition, resulted in the reduction of apoptosis suggesting a role for this protein in cardiomyocyte survival. Altogether, our data provide strong evidence that Gab1 is important for heart cell survival following hypoxic stress. Myriam Cherif, Massimo Caputo, Yoshikazu Nakaoka, Gianni D. Angelini, and Mohamed T. Ghorbel Copyright © 2015 Myriam Cherif et al. All rights reserved. Endothelial Injury Associated with Cold or Warm Blood Cardioplegia during Coronary Artery Bypass Graft Surgery Tue, 19 May 2015 12:51:32 +0000 The aim of this investigation was to analyze the impact of intermittent cold blood cardioplegia (ICC) and intermittent warm blood cardioplegia (IWC) on endothelial injury in patients referred to elective on-pump coronary artery bypass graft (CABG) surgery. Patients undergoing CABG procedures were randomized to either ICC or IWC. Myocardial injury was assessed by CK-MB and cardiac troponin T (cTnT). Endothelial injury was quantified by circulating endothelial cells (CECs), von Willebrand factor (vWF), and soluble thrombomodulin (sTM). Perioperative myocardial injury (PMI) and major adverse cardiac events (MACE) were recorded. Demographic data and preoperative risk profile of included patients (ICC: , IWC: ) were comparable. No deaths, PMI, or MACE were observed. Levels of CK-MB and cTnT did not show intergroup differences. Concentrations of CECs peaked at 6 h postoperatively with significantly higher values for IWC-patients at 1 h (ICC: 10.1 ± 3.9/mL; IWC: 18.4 ± 4.1/mL; ) and 6 h (ICC: 19.3 ± 6.2/mL; IWC: 29.2 ± 6.7/mL; ). Concentrations of vWF (ICC: 178.4 ± 73.2 U/dL; IWC: 258.2 ± 89.7 U/dL; ) and sTM (ICC: 3.2 ± 2.1 ng/mL; IWC: 5.2 ± 2.4 ng/mL; ) were significantly elevated in IWC-group at 1 h postoperatively. This study shows that the use of IWC is associated with a higher extent of endothelial injury compared to ICC without differences in clinical endpoints. Elmar W. Kuhn, Yeong-Hoon Choi, Jung-Min Pyun, Klaus Neef, Oliver J. Liakopoulos, Christof Stamm, Thorsten Wittwer, and Thorsten Wahlers Copyright © 2015 Elmar W. Kuhn et al. All rights reserved. Steroid Anti-Inflammatory Effects Did Not Improve Organ Quality in Brain-Dead Rats Tue, 19 May 2015 11:09:45 +0000 Effect of glucocorticoid administration on improving the outcomes of kidney and liver allografts has not been clearly elucidated. This study investigated the effect of prednisolone administration after onset of brain death (BD) on kidney and liver in a controlled rat model of BD. BD was induced in rats by inflating an epidurally placed balloon catheter. Animals were treated with saline or prednisolone (5, 12.5, or 22.5 mg/kg) one hour after the onset of BD. After 4 hours of BD, experiments were terminated and serum and tissues were collected. Tissue gene and protein expression were measured for markers of inflammation, apoptosis, and cellular stress response markers. Prednisolone caused a reduction of plasma levels of IL-6, while the tissue expression of IL-6, IL-1β, and MCP-1 in both kidney and liver were also reduced. Creatinine plasma levels, complement (C3) expression, HSP-70, HO-1, Bcl2/BAX ratio, and PMN influx did not significantly change in kidney nor liver. Plasma AST and LDH levels were increased in the prednisolone treated group. Our results demonstrate prednisolone can has an anti-inflammatory effect mediated through reducing serum circulating cytokines. However, this anti-inflammatory effect does not translate into improved kidney function and indeed was associated with increased liver injury markers. Rolando A. Rebolledo, Bo Liu, Mohammed Z. Akhtar, Petra J. Ottens, Jian-ning Zhang, Rutger J. Ploeg, and Henri G. D. Leuvenink Copyright © 2015 Rolando A. Rebolledo et al. All rights reserved. Influence of Preoperative Peripheral Parenteral Nutrition with Micronutrients after Colorectal Cancer Patients Mon, 27 Apr 2015 13:43:42 +0000 Background. The inflammatory reactions are stronger after surgery of malnourished preoperative patients. Many studies have shown vitamin and trace element deficiencies appear to affect the functioning of immune cells. Enteral nutrition is often inadequate for malnourished patients. Therefore, total parenteral nutrition (TPN) is considered an effective method for providing preoperative nutritional support. TPN needs a central vein catheter, and there are more risks associated with TPN. However, peripheral parenteral nutrition (PPN) often does not provide enough energy or nutrients. Purpose. This study investigated the inflammatory response and prognosis for patients receiving a modified form of PPN with added fat emulsion infusion, multiple vitamins (MTV), and trace elements (TE) to assess the feasibility of preoperative nutritional support. Methods. A cross-sectional design was used to compare the influence of PPN with or without adding MTV and TE on malnourished abdominal surgery patients. Results. Both preoperative groups received equal calories and protein, but due to the lack of micronutrients, patients in preoperative Group B exhibited higher inflammation, lower serum albumin levels, and higher anastomotic leak rates and also required prolonged hospital stays. Conclusion. Malnourished patients who receive micronutrient supplementation preoperatively have lower postoperative inflammatory responses and better prognoses. PPN with added fat emulsion, MTV, and TE provides valid and effective preoperative nutritional support. Ming-Yi Liu, Hsiu-Chih Tang, Shu-Hui Hu, Hui-Lan Yang, and Sue-Joan Chang Copyright © 2015 Ming-Yi Liu et al. All rights reserved. Correlation between the Pharyngeal Airway Space and Head Posture after Surgery for Mandibular Prognathism Wed, 22 Apr 2015 13:11:40 +0000 Purpose. The aim of this study was to determine the correlation between the pharyngeal airway space and head posture after mandibular setback surgery for mandibular prognathism. Materials and Methods. Serial lateral cephalograms of 37 patients with mandibular prognathism who underwent intraoral vertical ramus osteotomy (IVRO) were evaluated before (T1) and immediately (T2), between 6 weeks and 3 months (T3), and more than 1 year (T4) after surgery. Paired t-tests and Pearson’s correlation analysis were used to evaluate the postoperative changes in all cephalometric parameters, including the mandible, hyoid, head posture (craniocervical angle), and pharyngeal airway space. Results. The mandible and hyoid were set back by 12.8 mm and 4.9 mm, respectively, at T2. Furthermore, the hyoid showed significant inferior movement of 10.7 mm, with an 8 mm increase in the tongue depth. The upper oropharyngeal airway (UOP) shortened by 4.1 mm, the lower oropharyngeal airway (LOP) by 1.7 mm, and the laryngopharyngeal airway by 2 mm. The craniocervical angle showed a significant increase of 2.8°. UOP and LOP showed a significant correlation with the craniocervical angle at T2 and T4. Conclusions. Our findings conclude that the oropharyngeal airway space is significantly decreased and correlated with a change in the head posture after mandibular setback surgery. Chun-Ming Chen, Steven Lai, Ker-Kong Chen, and Huey-Er Lee Copyright © 2015 Chun-Ming Chen et al. All rights reserved. Survival Rate of Short, Locking Taper Implants with a Plateau Design: A 5-Year Retrospective Study Thu, 16 Apr 2015 12:19:13 +0000 Background. Short implants have become popular in the reconstruction of jaws, especially in cases with limited bone height. Shorter implants, those with locking tapers and plateau root shapes, tend to have longer survival times. We retrospectively investigated the cumulative survival rates of Bicon short implants (<8 mm) according to patient variables over a 5-year period. Materials and Methods. This study included 111 consecutively treated patients with 371 implants supporting fixed or removable prosthetics. Data were evaluated to acquire cumulative survival rates according to gender, age, tobacco use, surgical procedure, bone quality, and restoration type. Statistics were performed using chi-square, Mann-Whitney, and Kruskal Wallis H tests. Results. The survival rate was 97.3% with, on average, 22.8 months of follow-up. Patients older than 60 years had higher failure rate than the other age groups (). Placed region, age, and bone quality had adverse effects on survival rate in the <8 mm implant group with statistically significant difference (). Conclusions. Approximately 23-month follow-up data indicate that short implants with locking tapers and plateau-type roots have comparable survival rates as other types of dental implants. However, due to limitations of study, these issues remain to be further investigated in future randomized controlled clinical trials. Kemal Özgür Demiralp, Nihat Akbulut, Sebnem Kursun, Didem Argun, Nilsun Bagis, and Kaan Orhan Copyright © 2015 Kemal Özgür Demiralp et al. All rights reserved. RC-3095, a Selective Gastrin-Releasing Peptide Receptor Antagonist, Does Not Protect the Lungs in an Experimental Model of Lung Ischemia-Reperfusion Injury Sun, 29 Mar 2015 11:02:51 +0000 RC-3095, a selective GRPR antagonist, has been shown to have anti-inflammatory properties in different models of inflammation. However, its protective effect on lungs submitted to lung ischemia-reperfusion injury has not been addressed before. Then, we administrated RC-3095 intravenously before and after lung reperfusion using an animal model of lung ischemia-reperfusion injury (LIRI) by clamping the pulmonary hilum. Twenty Wistar rats were subjected to an experimental model in four groups: SHAM, ischemia-reperfusion (IR), RC-Pre, and RC-Post. The final mean arterial pressure significantly decreased in IR and RC-Pre compared to their values before reperfusion (). The RC-Post group showed significant decrease of partial pressure of arterial oxygen at the end of the observation when compared to baseline (). Caspase-9 activity was significantly higher in the RC-Post as compared to the other groups (). No significant differences were observed in eNOS activity among the groups. The groups RC-Pre and RC-Post did not show any significant decrease in IL- () and TNF- (), as compared to IR. The histological score showed no significant differences among the groups. In conclusion, RC-3095 does not demonstrate a protective effect in our LIRI model. Additionally, its use after reperfusion seems to potentiate cell damage, stimulating apoptosis. Vera L. Oliveira-Freitas, Leonardo Dalla Giacomassa Rocha Thomaz, Lucas Elias Lise Simoneti, Christiane Malfitano, Kátia De Angelis, Jane Maria Ulbrich, Gilberto Schwartsmann, and Cristiano Feijó Andrade Copyright © 2015 Vera L. Oliveira-Freitas et al. All rights reserved. Platelet-Rich Plasma in the Treatment of Subcutaneous Venous Access Device Scars: A Head-to-Head Patient Survey Tue, 24 Mar 2015 14:16:55 +0000 Introduction. Platelet-rich plasma (PRP) is a product widely used in sports medicine, tissue repair, and general surgery. A recent meta-analysis showed this product to be beneficial when introduced into a wound area, be it intra-articular (i.e., joint-injections) or direct introduction onto the wound surface. Methods. Between the years of 2012 and 2014 a questionnaire evaluating surgical outcome after port (venous access device) removal was answered by 100 patients in the control group and 20 patients in a PRP group, leading to a total of 120 patients in this single center, retrospective, subjective outcome evaluation. Results. No statistical difference was shown in postsurgical complication rates, postsurgical pain, decreased mobility, and overall quality of life. A significant difference was shown in overall patient satisfaction and the desire to further improve port area scarring. Results differed significantly in favor of the PRP group. Interestingly, approximately 40.2% of patients are dissatisfied with the surgical outcome after port removal in the control group. This result, though surprising, may be improved to 10% dissatisfaction when a PRP product is used. Conclusion. PRP products such as Arthrex ACP are safe to use and present an additional option in improving surgical outcome. C. Eichler, M. Najafpour, A. Sauerwald, J. Puppe, and M. Warm Copyright © 2015 C. Eichler et al. All rights reserved. The Place of Extensive Surgery in Locoregional Recurrence and Limited Metastatic Disease of Breast Cancer: Preliminary Results Wed, 18 Mar 2015 14:39:51 +0000 The aims of this study were first to clearly define two different entities: locoregional recurrences and limited metastatic disease and secondly to evaluate the place of extensive surgery in these two types of recurrence. Material and Methods. Twenty-four patients were followed from June 2004 until May 2014. All patients underwent surgery but for 1 patient this surgery was stopped because the tumour was unresectable. Results. The median interval between surgery for the primary tumour and the locoregional recurrence or metastatic evolution was 129 months. Eight patients had pure nodal recurrences, 4 had nodal and muscular recurrences, 5 had muscular + skin recurrences, and 8 had metastatic evolution. Currently, all patients are still alive but 2 have liver metastases. Disease free survival was measured at 2 years and extrapolated at 5 years and was 92% at these two time points. No difference was observed for young or older women; limited metastatic evolution and locoregional recurrence exhibited the same disease free survival. Conclusion. Extensive surgery has a place in locoregional and limited metastatic breast cancer recurrences but this option must absolutely be integrated in the multidisciplinary strategy of therapeutic options and needs to be planned with a curative intent. M. Berlière, F. P. Duhoux, L. Taburiaux, V. Lacroix, C. Galant, I. Leconte, L. Fellah, F. Lecouvet, D. Bouziane, Ph. Piette, and B. Lengele Copyright © 2015 M. Berlière et al. All rights reserved. Autologous Bone Marrow Mesenchymal Stem Cells Associated with Tantalum Rod Implantation and Vascularized Iliac Grafting for the Treatment of End-Stage Osteonecrosis of the Femoral Head Mon, 23 Feb 2015 10:30:08 +0000 Tantalum rod implantation with vascularized iliac grafting has been reported to be an effective method for the treatment of young patients with osteonecrosis of the femoral head (ONFH) to avert the need for total hip arthroplasty (THA). However, there have been unsatisfactory success rates for end-stage ONFH. The authors describe a modified technique using bone marrow mesenchymal stem cells (BMMSCs) associated with porous tantalum rod implantation combined with vascularized iliac grafting for the treatment of end-stage ONFH. A total of 24 patients (31 hips) with end-stage ONFH were treated with surgery; ARCO IIIc stage was observed in 19 hips and ARCO IV stage was observed in 12 hips. All patients were followed for a mean time of 64.35 ± 13.03 months (range 26–78). Operations on only five hips were converted to THA. The joint-preserving success rate of the entire group was 89.47% for ARCO stage IIIc and 75% for ARCO stage IV. The mean Harris hip score of the 31 hips improved significantly from 38.74 ± 5.88 points (range 22–50) to 77.23 ± 14.75 points (range 33–95). This intervention was safe and effective in delaying or avoiding total hip replacement for end-stage ONFH. Dewei Zhao, Baoyi Liu, Benjie Wang, Lei Yang, Hui Xie, Shibo Huang, Yao Zhang, and Xiaowei Wei Copyright © 2015 Dewei Zhao et al. All rights reserved. Myofibroblast Expression in Skin Wounds Is Enhanced by Collagen III Suppression Thu, 19 Feb 2015 09:49:50 +0000 Generally speaking, the excessive expression of myofibroblasts is associated with excessive collagen production. One exception is seen in patients and animal models of Ehlers-Danlos syndrome type IV in which the COL3A1 gene mutation results in reduced collagen III but with concurrent increased myofibroblast expression. This paradox has not been examined with the use of external drugs/modalities to prevent hypertrophic scars. In this paper, we injected the rabbit ear wound model of hypertrophic scarring with two doses of a protein called nAG, which is known to reduce collagen expression and to suppress hypertrophic scarring in that animal model. The higher nAG dose was associated with significantly less collagen III expression and concurrent higher degree of myofibroblast expression. We concluded that collagen III content of the extracellular matrix may have a direct or an indirect effect on myofibroblast differentiation. However, further research is required to investigate the pathogenesis of this paradoxical phenomenon. Mohammed M. Al-Qattan, Mervat M. Abd-Elwahed, Khalid Hawary, Maha M. Arafah, and Medhat K. Shier Copyright © 2015 Mohammed M. Al-Qattan et al. All rights reserved. Navigation of Pedicle Screws in the Thoracic Spine with a New Electromagnetic Navigation System: A Human Cadaver Study Wed, 11 Feb 2015 14:28:54 +0000 Introduction. Posterior stabilization of the spine is a standard procedure in spinal surgery. In addition to the standard techniques, several new techniques have been developed. The objective of this cadaveric study was to examine the accuracy of a new electromagnetic navigation system for instrumentation of pedicle screws in the spine. Material and Method. Forty-eight pedicle screws were inserted in the thoracic spine of human cadavers using EMF navigation and instruments developed especially for electromagnetic navigation. The screw position was assessed postoperatively by a CT scan. Results. The screws were classified into 3 groups: grade 1 = ideal position; grade 2 = cortical penetration <2 mm; grade 3 = cortical penetration ≥2 mm. The initial evaluation of the system showed satisfied positioning for the thoracic spine; 37 of 48 screws (77.1%, 95% confidence interval [62.7%, 88%]) were classified as group 1 or 2. Discussion. The screw placement was satisfactory. The initial results show that there is room for improvement with some changes needed. The ease of use and short setup times should be pointed out. Instrumentation is achieved without restricting the operator’s mobility during navigation. Conclusion. The results indicate a good placement technique for pedicle screws. Big advantages are the easy handling of the system. Patrick Hahn, Semih Oezdemir, Martin Komp, Athanasios Giannakopoulos, Richard Kasch, Harry Merk, Dieter Liermann, Georgios Godolias, and Sebastian Ruetten Copyright © 2015 Patrick Hahn et al. All rights reserved. Impact of Ischemic Preconditioning on Outcome in Clinical Liver Surgery: A Systematic Review Tue, 10 Feb 2015 09:23:34 +0000 Background. Ischemia-reperfusion injury is a major cause of post-liver-surgery complications. Ischemic preconditioning (IPC) has been demonstrated to protect against ischemia-reperfusion injury. Clinical studies have examined IPC in liver surgery but with conflicting results. This systematic review aimed to evaluate the effects of IPC on outcome in clinical liver surgery. Methods. An electronic search of OVID Medline and Embase databases was performed to identify studies that reported outcomes in patients undergoing liver surgery subjected to IPC. Basic descriptive statistics were used to summarise data from individual clinical studies. Results. 1093 articles were identified, of which 24 met the inclusion criteria. Seven topics were selected and analysed by subgroup. There were 10 studies in cadaveric liver transplantation, 2 in living-related liver transplantation, and 12 in liver resection. IPC decreases hepatocellular damage in liver surgery as determined by transaminases but does not translate to any significant clinical benefit in orthotopic liver transplant or liver resection. Conclusions. Available clinical evidence does not support routine use of IPC in liver surgery as it does not offer any apparent benefit in perioperative outcome. Further clinical studies will need to be carried out to determine the subset of patients that will benefit from IPC. Michael J. J. Chu, Ryash Vather, Anthony J. R. Hickey, Anthony R. J. Phillips, and Adam S. J. R. Bartlett Copyright © 2015 Michael J. J. Chu et al. All rights reserved. Effects of Surgical and Dietary Weight Loss Therapy for Obesity on Gut Microbiota Composition and Nutrient Absorption Sun, 01 Feb 2015 12:38:53 +0000 Evidence suggests a correlation between the gut microbiota composition and weight loss caused by caloric restriction. Laparoscopic sleeve gastrectomy (LSG), a surgical intervention for obesity, is classified as predominantly restrictive procedure. In this study we investigated functional weight loss mechanisms with regard to gut microbial changes and energy harvest induced by LSG and a very low calorie diet in ten obese subjects ( per group) demonstrating identical weight loss during a follow-up period of six months. For gut microbiome analysis next generation sequencing was performed and faeces were analyzed for targeted metabolomics. The energy-reabsorbing potential of the gut microbiota decreased following LSG, indicated by the Bacteroidetes/Firmicutes ratio, but increased during diet. Changes in butyrate-producing bacterial species were responsible for the Firmicutes changes in both groups. No alteration of faecal butyrate was observed, but the microbial capacity for butyrate fermentation decreased following LSG and increased following dietetic intervention. LSG resulted in enhanced faecal excretion of nonesterified fatty acids and bile acids. LSG, but not dietetic restriction, improved the obesity-associated gut microbiota composition towards a lean microbiome phenotype. Moreover, LSG increased malabsorption due to loss in energy-rich faecal substrates and impairment of bile acid circulation. This trial is registered with NCT01344525. Antje Damms-Machado, Suparna Mitra, Asja E. Schollenberger, Klaus Michael Kramer, Tobias Meile, Alfred Königsrainer, Daniel H. Huson, and Stephan C. Bischoff Copyright © 2015 Antje Damms-Machado et al. All rights reserved. Differential Regulation of MicroRNAs in End-Stage Failing Hearts Is Associated with Left Ventricular Assist Device Unloading Sun, 01 Feb 2015 10:21:51 +0000 Mechanical unloading by left ventricular assist devices (LVADs) in advanced heart failure (HF), in addition to improving symptoms and end-organ perfusion, is supposed to stimulate cellular and molecular responses which can reverse maladaptive cardiac remodeling. As microRNAs (miRNAs) are key regulators in remodeling processes, a comparative miRNA profiling in transplanted hearts of HF patients with/without LVAD assistance could aid to comprehend underlying molecular mechanisms. Next generation sequencing (NGS) was used to analyze miRNA differential expression in left ventricles of HF patients who underwent heart transplantation directly () or following a period of LVAD support (). After data validation by quantitative real-time PCR, association with functional clinical parameters was investigated. Bioinformatics’ tools were then used for prediction of putative targets of modulated miRNAs and relative pathway enrichment. The analysis revealed 13 upregulated and 10 downregulated miRNAs in failing hearts subjected to LVAD assistance. In particular, the expression level of some of them (miR-338-3p, miR-142-5p and -3p, miR-216a-5p, miR-223-3p, miR-27a-5p, and miR-378g) showed correlation with off-pump cardiac index values. Predicted targets of these miRNAs were involved in focal adhesion/integrin pathway and in actin cytoskeleton regulation. The identified miRNAs might contribute to molecular regulation of reverse remodeling and heart recovery mechanisms. Cristina Barsanti, Maria Giovanna Trivella, Romina D’Aurizio, Mariama El Baroudi, Mario Baumgart, Marco Groth, Raffaele Caruso, Alessandro Verde, Luca Botta, Lorena Cozzi, and Letizia Pitto Copyright © 2015 Cristina Barsanti et al. All rights reserved. Blood Vessel Matrix Seeded with Cells: A Better Alternative for Abdominal Wall Reconstruction—A Long-Term Study Wed, 28 Jan 2015 09:30:39 +0000 Purpose. The aim of this study was to present abdominal wall reconstruction using a porcine vascular graft seeded with MSC (mesenchymal stem cells) on rat model. Material and Methods. Abdominal wall defect was prepared in 21 Wistar rats. Acellular porcine-vascular grafts taken from aorta and prepared with Triton X were used. 14 aortic grafts were implanted in place, of which 7 grafts were seeded with rat MSC cells (Group I), and 7 were acellular grafts (Group II). As a control, 7 standard polypropylene meshes were used for defect augmentation (Group III). The assessment method was performed by HE and CD31 staining after 6 months. The mechanical properties have been investigated by Zwick&Roell Z0.5. Results. The strongest angiogenesis and lowest inflammatory response were observed in Group I. Average capillaries density was 2.75, 0.75, and 1.53 and inflammatory effect was 0.29, 1.39, and 2.72 for Groups I, II, and III, respectively. The means of mechanical properties were , , and  N/cm in Groups I and II and control, respectively. Conclusions. Cell-seeded grafts have better mechanical properties than acellular grafts but worse than polypropylene mesh. Cells improved mechanical and physiological properties of decellularized natural scaffolds. Maciej Nowacki, Arkadiusz Jundziłł, Łukasz Nazarewski, Andrzej Kotela, Tomasz Kloskowski, Joanna Skopińska-Wisniewska, Magdalena Bodnar, Aleksander Łukasiewicz, Sławomir Nazarewski, Ireneusz Kotela, Marek Kucharzewski, Marta Pokrywczyńska, Andrzej Marszałek, and Tomasz Drewa Copyright © 2015 Maciej Nowacki et al. All rights reserved. Comparison and Efficacy of LigaSure and Rubber Band Ligature in Closing the Inflamed Cecal Stump in a Rat Model of Acute Appendicitis Wed, 28 Jan 2015 08:22:46 +0000 Safety of either LigaSure or rubber band in closing inflamed appendiceal stump in acute appendicitis has been less investigated. In this study, cecal ligation followed by resecting inflamed cecum was performed to mimic appendectomy in a rat model of acute appendicitis. Rats were sacrificed immediately (Group A) and 7 days (Group B) after cecal resection, respectively. The cecal stumps were closed by silk ligature (S), 5 mm LigaSure (L), or rubber band (R). Seven days after cecal resection, the LigaSure (BL) and silk subgroups (BS) had significantly less intra-abdominal adhesion and better laparotomy wound healing than rubber band subgroup (BR). The initial bursting pressure at cecal stump was comparable among the three methods; along with tissue healing process, both BL and BS provided a higher bursting pressure than BR 7 days after appendectomy. BL subgroup had more abundant hydroxyproline deposition than BS and BR subgroup. Furthermore, serum TNF-α in BR group kept persistently increasing along with time after cecal resection. Thus, the finding that LigaSure but not rubber band is safe in sealing off the inflamed cecal stump in rat model of acute appendicitis suggests the possibility of applying LigaSure for appendectomy via single port procedure or natural orifice transluminal endoscopic surgery (NOTES). Chun-Chieh Yeh, Chia-Ing Jan, Horng-Ren Yang, Po-Han Huang, Long-Bin Jeng, Wen-Pang Su, and Hui-Chen Chen Copyright © 2015 Chun-Chieh Yeh et al. All rights reserved. Functional and Physical Outcomes following Use of a Flexible CO2 Laser Fiber and Bipolar Electrocautery in Close Proximity to the Rat Sciatic Nerve with Correlation to an In Vitro Thermal Profile Model Wed, 28 Jan 2015 08:02:49 +0000 This study compared functional and physical collateral damage to a nerve when operating a Codman MALIS Bipolar Electrosurgical System CMC-III or a CO2 laser coupled to a laser, with correlation to an in vitro model of heating profiles created by the devices in thermochromic ink agarose. Functional damage of the rat sciatic nerve after operating the MALIS or CO2 laser at various power settings and proximities to the nerve was measured by electrically evoked nerve action potentials, and histology of the nerve was used to assess physical damage. Thermochromic ink dissolved in agarose was used to model the spatial and temporal profile of the collateral heating zone of the electrosurgical system and the laser ablation cone. We found that this laser can be operated at 2 W directly above the nerve with minimal damage, while power settings of 5 W and 10 W resulted in acute functional and physical nerve damage, correlating with the maximal heating cone in the thermochromic ink model. MALIS settings up to 40 (11 W) did not result in major functional or physical nerve damage until the nerve was between the forceps tips, correlating with the hottest zone, localized discretely between the tips. A. M. Robinson, A. J. Fishman, B. R. Bendok, and C.-P. Richter Copyright © 2015 A. M. Robinson et al. All rights reserved. Third-Degree Hindpaw Burn Injury Induced Apoptosis of Lumbar Spinal Cord Ventral Horn Motor Neurons and Sciatic Nerve and Muscle Atrophy in Rats Wed, 28 Jan 2015 07:00:00 +0000 Background. Severe burns result in hypercatabolic state and concomitant muscle atrophy that persists for several months, thereby limiting patient recovery. However, the effects of burns on the corresponding spinal dermatome remain unknown. This study aimed to investigate whether burns induce apoptosis of spinal cord ventral horn motor neurons (VHMNs) and consequently cause skeletal muscle wasting. Methods. Third-degree hindpaw burn injury with 1% total body surface area (TBSA) rats were euthanized 4 and 8 weeks after burn injury. The apoptosis profiles in the ventral horns of the lumbar spinal cords, sciatic nerves, and gastrocnemius muscles were examined. The Schwann cells in the sciatic nerve were marked with S100. The gastrocnemius muscles were harvested to measure the denervation atrophy. Result. The VHMNs apoptosis in the spinal cord was observed after inducing third-degree burns in the hindpaw. The S100 and TUNEL double-positive cells in the sciatic nerve increased significantly after the burn injury. Gastrocnemius muscle apoptosis and denervation atrophy area increased significantly after the burn injury. Conclusion. Local hindpaw burn induces apoptosis in VHMNs and Schwann cells in sciatic nerve, which causes corresponding gastrocnemius muscle denervation atrophy. Our results provided an animal model to evaluate burn-induced muscle wasting, and elucidate the underlying mechanisms. Sheng-Hua Wu, Shu-Hung Huang, Kuang-I Cheng, Chee-Yin Chai, Jwu-Lai Yeh, Tai-Cheng Wu, Yi-Chiang Hsu, and Aij-Lie Kwan Copyright © 2015 Sheng-Hua Wu et al. All rights reserved. TLR4/NF-κB-Responsive MicroRNAs and Their Potential Target Genes: A Mouse Model of Skeletal Muscle Ischemia-Reperfusion Injury Mon, 26 Jan 2015 06:49:57 +0000 Background. The aim of this study was to profile TLR4/NF-κB-responsive microRNAs (miRNAs) and their potential target genes in the skeletal muscles of mice following ischemia-reperfusion injury. Methods. Thigh skeletal muscles of C57BL/6, Tlr4−/−, and NF-κB−/− mice isolated based on femoral artery perfusion were subjected to ischemia for 2 h and reperfusion for 0 h, 4 h, 1 d, and 7 d. The muscle specimens were analyzed with miRNA arrays. Immunoprecipitation with an argonaute 2- (Ago2-) specific monoclonal antibody followed by whole genome microarray was performed to identify mRNA associated with the RNA-silencing machinery. The potential targets of each upregulated miRNA were identified by combined analysis involving the bioinformatics algorithm miRanda and whole genome expression. Results. Three TLR4/NF-κB-responsive miRNAs (miR-15a, miR-744, and miR-1196) were significantly upregulated in the muscles following ischemia-reperfusion injury. The combined in silico and whole genome microarray approaches identified 5, 4, and 20 potential target genes for miR-15a, miR-744, and miR-1196, respectively. Among the 3 genes (Zbed4, Lrsam1, and Ddx21) regulated by at least 2 of the 3 upregulated miRNAs, Lrsam1 and Ddx21 are known to be associated with the innate immunity pathway. Conclusions. This study profiled TLR4/NF-κB-responsive miRNAs and their potential target genes in mouse skeletal muscle subjected to ischemia-reperfusion injury. Johnson Chia-Shen Yang, Shao-Chun Wu, Cheng-Shyuan Rau, Yi-Chun Chen, Tsu-Hsiang Lu, Yi-Chan Wu, Siou-Ling Tzeng, Chia-Jung Wu, and Ching-Hua Hsieh Copyright © 2015 Johnson Chia-Shen Yang et al. All rights reserved. Genetic Association between Methylenetetrahydrofolate Reductase Gene Polymorphism and Risk of Osteonecrosis of the Femoral Head Mon, 26 Jan 2015 06:19:39 +0000 Background. Methylenetetrahydrofolate reductase (MTHFR) SNP rs1801133 has been frequently investigated in recent years. Relevant candidate gene association studies with this SNP and osteonecrosis of the femoral head (ONFH) reported conflicting results. Meta-analysis provides a method to combine these data and to determine the association in a larger sample size. Method. We conducted a systematic search to identify possible studies. Four pooled ORs (odds ratios, T versus C, TT versus CC, TT/CT versus CC, and TT versus CT/CC), along with 95% confidence interval (CI), were calculated to evaluate the association between SNP rs1801133 and ONFH susceptibility. Both fixed effects model and random effects model were used. Findings. We eventually included twelve studies in this analysis, with results showing no overall association between ONFH susceptibility and SNP rs1801133 (T versus C: , 95% –1.38; TT versus CC: , 95% –1.46; TT/CT versus CC: , 95% –1.25; and TT versus CT/CC: , 95% –1.45). When stratified based on ethnicity, the results were still not significant. Conclusion. Our findings are generally supportive of no association between MTHFR SNP rs1801133 and the etiology of ONFH. Wei Chai, Zhendong Zhang, Ming Ni, Peiliang Geng, Zijian Lian, Guoqiang Zhang, Lewis L. Shi, and Jiying Chen Copyright © 2015 Wei Chai et al. All rights reserved. Zoledronic Acid May Reduce Intraoperative Bleeding in Spinal Tumors: A Prospective Cohort Study Thu, 22 Jan 2015 14:36:33 +0000 Between June 2010 and June 2011, 176 patients were divided into 2 groups: a group with spinal metastasis of solid tumors () and a group with multiple myeloma (). Both groups were further divided into 2 subgroups: a group receiving zoledronic acid before surgery and a control group. The zoledronic acid subgroup of the solid tumors group was group A (), the control subgroup of the solid tumors group was group B (), the zoledronic acid subgroup of the multiple myeloma group was group C (), and the control subgroup of the multiple myeloma group was group D (). The average intraoperative blood loss during spinal surgery was as follows:  mL in group A and  mL in group B () and  mL in group C and  mL in group D (). Patients receiving zoledronic acid before surgery had significantly less intraoperative bleeding than those who did not receive it. Preoperative use of zoledronic acid can effectively reduce intraoperative bleeding during surgery for the treatment of spinal tumors. Juan Wu, Wei Zheng, Yan Tan, Xiao-Yuan Hu, Quan Huang, Kai-Hua Fan, Jie Ma, Wen-Jing Xiao, Jian-Dong Ren, Jun Hou, and Jian-Ru Xiao Copyright © 2015 Juan Wu et al. All rights reserved. Intracranial Biodegradable Silica-Based Nimodipine Drug Release Implant for Treating Vasospasm in Subarachnoid Hemorrhage in an Experimental Healthy Pig and Dog Model Thu, 22 Jan 2015 12:39:34 +0000 Nimodipine is a widely used medication for treating delayed cerebral ischemia (DCI) after subarachnoid hemorrhage. When administrated orally or intravenously, systemic hypotension is an undesirable side effect. Intracranial subarachnoid delivery of nimodipine during aneurysm clipping may be more efficient way of preventing vasospasm and DCI due to higher concentration of nimodipine in cerebrospinal fluid (CSF). The risk of systemic hypotension may also be decreased with intracranial delivery. We used animal models to evaluate the feasibility of surgically implanting a silica-based nimodipine releasing implant into the subarachnoid space through a frontotemporal craniotomy. Concentrations of released nimodipine were measured from plasma samples and CSF samples. Implant degradation was followed using CT imaging. After completing the recovery period, full histological examination was performed on the brain and meninges. The in vitro characteristics of the implant were determined. Our results show that the biodegradable silica-based implant can be used for an intracranial drug delivery system and no major histopathological foreign body reactions were observed. CT imaging is a feasible method for determining the degradation of silica implants in vivo. The sustained release profiles of nimodipine in CSF were achieved. Compared to a traditional treatment, higher nimodipine CSF/plasma ratios can be obtained with the implant. Janne Koskimäki, Miikka Tarkia, Tuula Ahtola-Sätilä, Lasse Saloranta, Outi Simola, Ari-Pekka Forsback, Aki Laakso, and Janek Frantzén Copyright © 2015 Janne Koskimäki et al. All rights reserved. Endoscopic Transsphenoidal Cisternostomy for Nonneoplastic Sellar Cysts Thu, 22 Jan 2015 11:57:02 +0000 Background and Importance. Sellar arachnoid cysts and Rathke’s cleft cysts are benign lesions that produce similar symptoms, including optochiasmatic compression, pituitary dysfunction, and headache. Studies have reported the use of various surgical treatment methods for treating these symptoms, preventing recurrence, and minimizing operative complications. However, the postoperative cerebrospinal fluid (CSF) fistula and recurrence rate remain significant. Clinical Presentation. In this paper, we present 8 consecutive cases involving arachnoid cysts and Rathke’s cleft cysts, which were managed by using drainage and cisternostomy, the intentional fenestration of the cyst into the subarachnoid space, and then meticulously closing sellar floor using dural sutures. The postoperative images, CSF fistula rate, and the recurrence rate were favorable. Conclusion. We report this technique and discuss the benefit of this minimally invasive approach. Yukai Su, Yudo Ishii, Chien-Min Lin, Shigeyuki Tahara, Akira Teramoto, and Akio Morita Copyright © 2015 Yukai Su et al. All rights reserved. Bone Cement Solidifiliation Influence the Limb Alignment and Gap Balance during TKA Thu, 22 Jan 2015 11:53:25 +0000 Introduction. Mechanical alignment deviation after total knee arthroplasty is a major reason for early loosening of the prosthesis. Achieving optimum cement penetration during fixation of the femoral and tibial component is an essential step in performing a successful total knee arthroplasty. Bone cement is used to solidify the bone and prosthesis. Thickness imbalance of bone cement leads to the deviation of mechanical alignment. To estimate the influence of bone cement, a retrospective study was conducted. Materials and Methods. A total of 36 subjects were studied. All the TKA were performed following the standard surgical protocol for navigated surgery by medial approach with general anaesthesia. Prostheses were fixed by bone cement. Results. We compared the mechanical axis, flexion/extension, and gap balance before and after cementation. All the factors were different compared with those before and after cementation. Internal rotation was reached with statistical significance (). Conclusion. Bone cement can influence the mechanical axis, flexion/extension, and gap balance. It also can prompt us to make a change when poor knee kinematics were detected before cementation. Dongquan Shi, Xingquan Xu, Anyun Guo, Jin Dai, Zhihong Xu, Dongyang Chen, and Qing Jiang Copyright © 2015 Dongquan Shi et al. All rights reserved. Postoperative Bleeding Risk for Oral Surgery under Continued Clopidogrel Antiplatelet Therapy Tue, 06 Jan 2015 09:35:08 +0000 Object. To determine the incidence of postoperative bleeding for oral osteotomy carried out under continued monoantiplatelet therapy with clopidogrel and dual therapy with clopidogrel/aspirin. Design. Retrospective single center observatory study of two study groups and a control group. Methods. A total of 64 and 60 oral osteotomy procedures carried out under continued monoclopidogrel therapy and dual clopidogrel/aspirin therapy, respectively, were followed for two weeks for postoperative bleeding. Another 281 similar procedures were also followed as a control group. All oral osteotomy procedures were carried out on an outpatient basis. Results. We observed postoperative bleeding in 2/281 (0.7%) cases in the control group, in 1/64 (1.6%) cases in the clopidogrel group, and in 2/60 (3.3%) cases in the dual clopidogrel/aspirin group. The corresponding 95% confidence intervals are 0–1.7%, 0–4.7%, and 0–7.8%, respectively, and the incidences did not differ significantly among the three groups (). Postoperative hemorrhage was treated successfully in all cases with local measures. No changes of antiplatelet medication, transfusion, nor hospitalisation were necessary. No major cardiovascular events were recorded. Conclusions. Our results indicate that minor oral surgery can be performed safely under continued monoantiplatelet medication with clopidogrel or dual antiplatelet medication with clopidogrel/aspirin. Alexander Gröbe, Meike Fraederich, Ralf Smeets, Max Heiland, Lan Kluwe, Jürgen Zeuch, Martina Haase, Johannes Wikner, Henning Hanken, Jan Semmusch, Ahmed Al-Dam, and Wolfgang Eichhorn Copyright © 2015 Alexander Gröbe et al. All rights reserved. Intraoperative Scintigraphy Using a Large Field-of-View Portable Gamma Camera for Primary Hyperparathyroidism: Initial Experience Tue, 06 Jan 2015 06:43:37 +0000 Background. We investigated a novel technique, intraoperative 99 mTc-Sestamibi (MIBI) imaging (neck and excised specimen (ES)), using a large field-of-view portable gamma camera (LFOVGC), for expediting confirmation of MIBI-avid parathyroid adenoma removal. Methods. Twenty patients with MIBI-avid parathyroid adenomas were preoperatively administered MIBI and intraoperatively imaged prior to incision (neck) and immediately following resection (neck and/or ES). Preoperative and intraoperative serum parathyroid hormone monitoring (IOPTH) and pathology (path) were also performed. Results. MIBI neck activity was absent and specimen activity was present in 13/20 with imaging after initial ES removal. In the remaining 7/20 cases, residual neck activity and/or absent ES activity prompted excision of additional tissue, ultimately leading to complete hyperfunctioning tissue excision. Postexcision LFOVGC ES imaging confirmed parathyroid adenoma resection 100% when postresection imaging qualitatively had activity (ES) and/or no activity (neck). The mean ± SEM time saving using intraoperative LFOVGC data to confirm resection versus first IOPTH or path result would have been 22.0 ± 2 minutes (specimen imaging) and 26.0 ± 3 minutes (neck imaging). Conclusion. Utilization of a novel real-time intraoperative LFOVGC imaging approach can provide confirmation of MIBI-avid parathyroid adenoma removal appreciably faster than IOPTH and/or path and may provide a valuable adjunct to parathyroid surgery. Nathan C. Hall, Robert L. Plews, Amit Agrawal, Stephen P. Povoski, Chadwick L. Wright, Jun Zhang, Edward W. Martin Jr., and John Phay Copyright © 2015 Nathan C. Hall et al. All rights reserved. More Becomes Less: Management Strategy Has Definitely Changed over the Past Decade of Splenic Injury—A Nationwide Population-Based Study Mon, 05 Jan 2015 13:09:17 +0000 Background. Blunt spleen injury is generally taken as major trauma which is potentially lethal. However, the management strategy has progressively changed to noninvasive treatment over the decade. This study aimed to (1) find out the incidence and trend of strategy change; (2) investigate the effect of change on the mortality rate over the study period; and (3) evaluate the risk factors of mortality. Materials and Methods. We utilized nationwide population-based data to explore the incidence of BSI during a 12-year study period. The demographic characteristics, including gender, age, surgical intervention, blood transfusion, availability of CT scans, and numbers of coexisting injuries, were collected for analysis. Mortality, hospital length of stay, and cost were as outcome variables. Results. 578 splenic injuries were recorded with an estimated incidence of 48 per million per year. The average 12-year overall mortality rate during hospital stay was 5.28% (29/549). There is a trend of decreasing operative management in patients (, ). The risk factors for mortality in BSI from a multivariate logistic regression analysis were amount of transfusion (OR 1.033, , CI 1.017–1.049), with or without CT obtained (OR 0.347, , CI 0.158–0.889), and numbers of coexisting injuries (OR 1.346, , CI 1.010–1.842). Conclusion. Although uncommon of BSI, management strategy is obviously changed to nonoperative treatment without increasing mortality and blood transfusion under the increase of CT utilization. Patients with more coexisting injuries and more blood transfusion had higher mortality. Kwan-Ming Soo, Tsung-Ying Lin, Chao-Wen Chen, Yen-Ko Lin, Liang-Chi Kuo, Jaw-Yuan Wang, Wei-Che Lee, and Hsing-Lin Lin Copyright © 2015 Kwan-Ming Soo et al. All rights reserved. Comparing Miniopen and Minimally Invasive Transforaminal Interbody Fusion in Single-Level Lumbar Degeneration Mon, 05 Jan 2015 13:07:51 +0000 Degenerative diseases of the lumbar spine, which are common among elderly people, cause back pain and radicular symptoms and lead to a poor quality of life. Lumbar spinal fusion is a standardized and widely accepted surgical procedure used for treating degenerative lumbar diseases; however, the classical posterior approach used in this procedure is recognized to cause vascular and neurologic damage of the lumbar muscles. Various studies have suggested that using the minimally invasive transforaminal interbody fusion (TLIF) technique provides long-term clinical outcomes comparable to those of open TLIF approaches in selected patients. In this study, we compared the perioperative and short-term advantages of miniopen, MI, and open TLIF. Compared with open TLIF, MI-TLIF and miniopen TLIF were associated with less blood loss, shorter hospital stays, and longer operative times; however, following the use of these procedures, no difference in quality of life was measured at 6 months or 1 year. Whether miniopen TLIF or MI-TLIF can replace traditional TLIF as the surgery of choice for treating degenerative lumbar deformity remains unclear, and additional studies are required for validating the safety and efficiency of these procedures. Wei-Lun Lo, Chien-Min Lin, Yi-Shian Yeh, Yu-kai Su, Yuan-Yun Tseng, Shun-Tai Yang, and Jai-Wei Lin Copyright © 2015 Wei-Lun Lo et al. All rights reserved. Normoxic and Hyperoxic Cardiopulmonary Bypass in Congenital Heart Disease Thu, 18 Sep 2014 09:08:39 +0000 Cyanotic congenital heart disease comprises a diverse spectrum of anatomical pathologies. Common to all, however, is chronic hypoxia before these lesions are operated upon when cardiopulmonary bypass is initiated. A range of functional and structural adaptations take place in the chronically hypoxic heart, which, whilst protective in the hypoxic state, are deleterious when the availability of oxygen to the myocardium is suddenly improved. Conventional cardiopulmonary bypass delivers hyperoxic perfusion to the myocardium and is associated with cardiac injury and systemic stress, whilst a normoxic perfusate protects against these insults. Amir Mokhtari and Martin Lewis Copyright © 2014 Amir Mokhtari and Martin Lewis. All rights reserved. Collagen-Glycosaminoglycan Matrix Implantation Promotes Angiogenesis following Surgical Brain Trauma Wed, 17 Sep 2014 06:02:11 +0000 Surgical brain injury (SBI) is unavoidable during many neurosurgical procedures intrinsically linked to postoperative neurological deficits. We have previously demonstrated that implantation of collagen glycosaminoglycan (CG) following surgical brain injury could significantly promote functional recovery and neurogenesis. In this study we further hypothesized that this scaffold may provide a microenvironment by promoting angiogenesis to favor neurogenesis and subsequent functional recovery. Using the rodent model of surgical brain injury as we previously established, we divided Sprague-Dawley male rats (weighting 300–350 g) into three groups: (1) sham (2) surgical injury with a lesion (L), and (3) L with CG matrix implantation (L + CG). Our results demonstrated that L + CG group showed a statistically significant increase in the density of vascular endothelial cells and blood vessels over time. In addition, tissue concentrations of angiogenic growth factors (such as VEGF, FGF2, and PDGF) significantly increased in L + CG group. These results suggest that implantation of a CG scaffold can promote vascularization accompanied by neurogenesis. This opens prospects for use of CG scaffolds in conditions such as brain injury including trauma and ischemia. Kuo-Feng Huang, Wei-Cherng Hsu, Jong-Kai Hsiao, Gunng-Shinng Chen, and Jia-Yi Wang Copyright © 2014 Kuo-Feng Huang et al. All rights reserved. Risk Factors for Chronic Subdural Hematoma after a Minor Head Injury in the Elderly: A Population-Based Study Thu, 11 Sep 2014 05:37:49 +0000 Chronic subdural hematoma (CSDH) is one of the major comorbidities in elderly resulting in disability and death. Early recognition of CSDH is important for early management. However, manifestations of CSDH are nonspecific and subtle. Therefore, identification of risk factors of CSDH can offer clinical follow-up strategies for patients after episodes of head injury. The purpose of the study aimed at identifying risk factors of CSDH of Taiwanese. Analysis of data from the National Health Insurance provides important information on predictive factors influencing the early diagnosis of CSDH in elderly patients following minor head injuries. The current study is the first nationwide population-based study in Taiwan, showing that old age (≥75 years), male gender, and coexisting hydrocephalus are significantly predictive factors, irrespective to their medical comorbidities. Jen-Ho Tseng, Ming-Yuan Tseng, Ann-Jeng Liu, Wen-Hsiung Lin, Hsiao-Yun Hu, and Sheng-Huang Hsiao Copyright © 2014 Jen-Ho Tseng et al. All rights reserved. Cardioprotection: A Review of Current Practice in Global Ischemia and Future Translational Perspective Mon, 08 Sep 2014 06:15:58 +0000 The idea of protecting the heart from ischemic insult during heart surgery to allow elective cardiac arrest is as old as the idea of cardiac surgery itself. The current gold standard in clinical routine is a high potassium regimen added either to crystalloid or blood cardioplegic solutions inducing depolarized arrest. Ongoing patient demographic changes with increasingly older, comorbidly ill patients and increasing case complexity with increasingly structurally abnormal hearts as morphological correlate paired with evolutions in pediatric cardiac surgery allowing more complex procedures than ever before redefine requirements for cardioprotection. Many, in part adversarial, regimens to protect the myocardium from ischemic insults have entered clinical routine; however, functional recovery of the heart is still often impaired due to perfusion injury. Myocardial reperfusion damage is a key determinant of postoperative organ functional recovery, morbidity, and mortality in adult and pediatric patients. There is a discrepancy between what current protective strategies are capable of and what they are expected to do in a rapidly changing cardiac surgery community. An increased understanding of the molecular players of ischemia reperfusion injury offers potential seeds for new cardioprotective regimens and may further displace boundaries of what is technically feasible. Andreas Habertheuer, Alfred Kocher, Günther Laufer, Martin Andreas, Wilson Y. Szeto, Peter Petzelbauer, Marek Ehrlich, and Dominik Wiedemann Copyright © 2014 Andreas Habertheuer et al. All rights reserved. Propofol Protects the Immature Rabbit Heart against Ischemia and Reperfusion Injury: Impact on Functional Recovery and Histopathological Changes Wed, 27 Aug 2014 05:58:58 +0000 The general anesthetic propofol protects the adult heart against ischemia and reperfusion injury; however, its efficacy has not been investigated in the immature heart. This work, for the first time, investigates the cardioprotective efficacy of propofol at clinically relevant concentrations in the immature heart. Langendorff perfused rabbit hearts (7–12 days old) were exposed to 30 minutes’ global normothermic ischemia followed by 40 minutes’ reperfusion. Left ventricular developed pressure (LVDP) and coronary flow were monitored throughout. Lactate release into coronary effluent was measured during reperfusion. Microscopic examinations of the myocardium were monitored at the end of reperfusion. Hearts were perfused with different propofol concentrations (1, 2, 4, and 10 μg/mL) or with cyclosporine A, prior to ischemic arrest and for 20 minutes during reperfusion. Propofol at 4 and 10 μg/mL caused a significant depression in LVDP prior to ischemia. Propofol at 2 μg/mL conferred significant and maximal protection with no protection at 10 μg/mL. This protection was associated with improved recovery in coronary flow, reduced lactate release, and preservation of cardiomyocyte ultrastructure. The efficacy of propofol at 2 μg/mL was similar to the effect of cyclosporine A. In conclusion, propofol at a clinically relevant concentration is cardioprotective in the immature heart. Makoto Shirakawa, Hajime Imura, and Takashi Nitta Copyright © 2014 Makoto Shirakawa et al. All rights reserved. Evaluation of the TMJ by means of Clinical TMD Examination and MRI Diagnostics in Patients with Rheumatoid Arthritis Tue, 26 Aug 2014 11:04:26 +0000 This study included 30 patients with diagnosed rheumatoid arthritis (RA) and 30 test subjects without RA (control group). The objective of the study was to examine both groups for the presence of temporomandibular disorders (TMD) and morphological changes of the temporomandibular joint (TMJ). All individuals were examined using a systematic detailed clinical TMD examination as well as magnetic resonance imaging (MRI). The clinical TMD examination yielded significant differences between the RA patients and the control group concerning crepitus of the TMJ, and palpation tenderness of the masticatory muscles as well as the unassisted mandibular opening. The evaluation of the MRI images for the RA group showed significantly more frequent deformations of the condyle, osteophyte formations and erosions in the condylar compacta, and degenerative changes in the spongiosa. Increased intra-articular accumulation of synovial liquid and signs of inflammatory changes of the spongiosa were only found in the RA group. Statistical analysis showed a significant correlation between crepitus and specific osteoarthrotic changes (MRI), respectively, and between crepitus and a complete anterior disk displacement without reduction (MRI). The duration of the RA disease correlated neither with the anamnestic and clinical dysfunction index by Helkimo nor with RA-specific MRI findings. Silke Witulski, Thomas J. Vogl, Stefan Rehart, and Peter Ottl Copyright © 2014 Silke Witulski et al. All rights reserved. Adjuvant Cardioprotection in Cardiac Surgery: Update Tue, 19 Aug 2014 00:00:00 +0000 Cardiac surgery patients are now more risky in terms of age, comorbidities, and the need for complex procedures. It brings about reperfusion injury, which leads to dysfunction and/or loss of part of the myocardium. These groups of patients have a higher incidence of postoperative complications and mortality. One way of augmenting intraoperative myocardial protection is the phenomenon of myocardial conditioning, elicited with brief nonlethal episodes of ischaemia-reperfusion. In addition, drugs are being tested that mimic ischaemic conditioning. Such cardioprotective techniques are mainly focused on reperfusion injury, a complex response of the organism to the restoration of coronary blood flow in ischaemic tissue, which can lead to cell death. Extensive research over the last three decades has revealed the basic mechanisms of reperfusion injury and myocardial conditioning, suggesting its therapeutic potential. But despite the enormous efforts that have been expended in preclinical studies, almost all cardioprotective therapies have failed in the third phase of clinical trials. One reason is that evolutionary young cellular mechanisms of protection against oxygen handling are not very robust. Ischaemic conditioning, which is among these, is also limited by this. At present, the prevailing belief is that such options of treatment exist, but their full employment will not occur until subquestions and methodological issues with the transfer into clinical practice have been resolved. Robert Wagner, Pavel Piler, Zufar Gabbasov, Junko Maruyama, Kazuo Maruyama, Jiri Nicovsky, and Peter Kruzliak Copyright © 2014 Robert Wagner et al. All rights reserved. Insulin Preconditioning Elevates p-Akt and Cardiac Contractility after Reperfusion in the Isolated Ischemic Rat Heart Wed, 13 Aug 2014 12:14:50 +0000 Insulin induces cardioprotection partly via an antiapoptotic effect. However, the optimal timing of insulin administration for the best quality cardioprotection remains unclear. We tested the hypothesis that insulin administered prior to ischemia provides better cardioprotection than insulin administration after ischemia. Isolated rat hearts were prepared using Langendorff method and divided into three groups. The Pre-Ins group (Pre-Ins) received 0.5 U/L insulin prior to 15 min no-flow ischemia for 20 min followed by 20 min of reperfusion. The Post-Ins group (Post-Ins) received 0.5 U/L insulin during the reperfusion period only. The control group (Control) was perfused with KH buffer throughout. The maximum of left ventricular derivative of pressure development (dP/dt(max)) was recorded continuously. Measurements of TNF-α and p-Akt in each time point were assayed by ELISA. After reperfusion, dP/dt(max) in Pre-Ins was elevated, compared with Post-Ins at 10 minutes after reperfusion and Control at all-time points. TNF-α levels at 5 minutes after reperfusion in the Pre-Ins were lower than the others. After 5 minutes of reperfusion, p-Akt was elevated in Pre-Ins compared with the other groups. Insulin administration prior to ischemia provides better cardioprotection than insulin administration only at reperfusion. TNF-α suppression is possibly mediated via p-Akt leading to a reduction in contractile myocardial dysfunction. Tamaki Sato, Hiroaki Sato, Takeshi Oguchi, Hisashi Fukushima, George Carvalho, Ralph Lattermann, Takashi Matsukawa, and Thomas Schricker Copyright © 2014 Tamaki Sato et al. All rights reserved. Early Surgery Does Not Seem to Be a Pivotal Criterion to Improve Prognosis in Patients with Frontal Depressed Skull Fractures Tue, 12 Aug 2014 11:39:51 +0000 Introduction. There has been much debate about the ideal timing of surgery of frontal depressed skull fractures (DSF). In this paper, we assess whether timing of surgery may have influenced outcome. Methods. Retrospective cohort of 40 consecutive patients with frontal DSF who underwent surgical treatment over a 36-month period. The patients were divided into early surgery group (ESG) which were operated within 24 h and delayed surgery group (DSG). Results. The population comprised 39 (97.50%) men and the mean age was 27.9 years (range, 2–81 yr). There was no difference of age (), gender male (), presence of focal lesion on head CT (), hypotension (), and hypoxia (). Mean Glasgow Coma Scale (GCS) was significantly lower in patients of ESG than DSG (8.75 and 11.7, resp., ). There was no difference between the groups in relation to death (), unfavourable outcome (), late posttraumatic epilepsy (), and smell-and-taste disturbances (). Only one patient (3.5%) evolved meningitis during follow-up. Conclusion. We found no difference between the ESG and DSG in respect to death, unfavourable outcome, LPE, and STD. Iuri Santana Neville, Robson Luis Amorim, Wellingson Silva Paiva, Felipe Hada Sanders, Manoel Jacobsen Teixeira, and Almir Ferreira de Andrade Copyright © 2014 Iuri Santana Neville et al. All rights reserved. The Effect of Age, Gender, and Insertion Site on Marginal Bone Loss around Endosseous Implants: Results from a 3-Year Trial with Premium Implant System Tue, 12 Aug 2014 08:58:50 +0000 Objectives. The goal of this study was to evaluate bone changes around endosseous implants in partially edentulous patients. Materials and Methods. A total of 632 two-stage implants were placed in 252 patients. The implants had straight emergence profile, ZirTi surface, 3.3 to 5 mm diameter, and 8.5 to 13 mm length. Bone levels were assessed on orthopantomography immediately after surgery and after 36 months and marginal bone loss (MBL) was calculated from their difference. Results. Cumulative survival rate was 98.73%. Overall MBL was 0.8 mm ± 0.03 (mean ± SEM). Higher MBL was observed around implants in the maxilla than in the mandible (). A relation between implant diameter and MBL () was observed in male and, more limitedly, female patients. Older patients had higher MBL in the maxilla, but not in the mandible (). MBL progressively increased with age in male patients, but reached a peak already in the 50–60 years age group in the female subset (). Conclusions. The overall MBL is consistent with the available literature. Site difference and patient age and gender appear to significantly affect MBL, representing important factors to be considered during implant placement. Massimiliano Negri, Carlo Galli, Arianna Smerieri, Guido M. Macaluso, Edoardo Manfredi, Giulia Ghiacci, Andrea Toffoli, Mauro Bonanini, and Simone Lumetti Copyright © 2014 Massimiliano Negri et al. All rights reserved. Remote Effects of Lower Limb Ischemia-Reperfusion: Impaired Lung, Unchanged Liver, and Stimulated Kidney Oxidative Capacities Sun, 10 Aug 2014 06:28:07 +0000 Remote organ impairments are frequent and increase patient morbidity and mortality after lower limb ischemia-reperfusion (IR). We challenged the hypothesis that lower limb IR might also impair lung, renal, and liver mitochondrial respiration. Two-hour tourniquet-induced ischemia was performed on both hindlimbs, followed by a two-hour reperfusion period in C57BL6 mice. Lungs, liver and kidneys maximal mitochondrial respiration (), complexes II, III, and IV activity (), and complex IV activity () were analyzed on isolated mitochondria. Lower limb IR decreased significantly lung ( versus  μmol O2/min/g dry weight, resp.; ) and tended to reduce and . IR did not modify liver but increased kidneys mitochondrial respiration ( versus , , and versus  μmol O2/min/g dry weight for and , resp.). Kidneys mitochondrial coupling was increased after IR ( versus , ). There were no histological changes in liver and kidneys. Thus, lung mitochondrial dysfunction appears as a new early marker of hindlimb IR injuries in mice. Further studies will be useful to determine whether enhanced kidneys mitochondrial function allows postponing kidney impairment in lower limb IR setting. Z. Mansour, A. L. Charles, M. Kindo, J. Pottecher, T. N. Chamaraux-Tran, A. Lejay, J. Zoll, J. P. Mazzucotelli, and B. Geny Copyright © 2014 Z. Mansour et al. All rights reserved. The Effect of Alcohol Intoxication on Mortality of Blunt Head Injury Mon, 04 Aug 2014 00:00:00 +0000 Alcohol is found to have neuroprotection in recent studies in head injuries. We investigated the association of blood alcohol concentration (BAC) with mortality of patients with blunt head injury after traffic accident. All patients sustaining blunt head injury caused by traffic accident brought to our emergency department who had obtained a brain computed tomography scans and BAC were analyzed. Patients with unknown mechanisms, transfers from outside hospitals, and incomplete data were excluded. Logistic regression was used to identify independent predictors of mortality. During the study period, 3,628 patients with brain computed tomography (CT) were included. Of these, BAC was measured in 556 patients. Patients with the lowest BAC (less than 8 mg/dl) had lower mortality; intoxicated patients with BAC between 8 and less than 100 mg/dl were associated with significantly higher mortality than those patients in other intoxicated groups. Adjusted logistic regression demonstrated higher BAC group and Glasgow coma scale (GCS) scores, and lower ISS and age were identified as independent predictors of reduced mortality. In our study, we found that patients who had moderate alcohol intoxication had higher risk of mortality. However, higher GCS scores, lower ISS, and younger age were identified as independent predictors of reduced mortality in the study patients. Hsing-Lin Lin, Tsung-Ying Lin, Kwan-Ming Soo, Chao-Wen Chen, Liang-Chi Kuo, Yen-Ko Lin, Wei-Che Lee, and Chih-Lung Lin Copyright © 2014 Hsing-Lin Lin et al. All rights reserved. Innovations in Pancreatic Surgery Mon, 21 Jul 2014 10:28:48 +0000 Masahiko Hirota, Juhani Sand, Ralf Segersvärd, and Roberto Cirocchi Copyright © 2014 Masahiko Hirota et al. All rights reserved. Current and Future Intraoperative Imaging Strategies to Increase Radical Resection Rates in Pancreatic Cancer Surgery Tue, 15 Jul 2014 12:02:45 +0000 Prognosis of patients with pancreatic cancer is poor. Even the small minority that undergoes resection with curative intent has low 5-year survival rates. This may partly be explained by the high number of irradical resections, which results in local recurrence and impaired overall survival. Currently, ultrasonography is used during surgery for resectability assessment and frozen-section analysis is used for assessment of resection margins in order to decrease the number of irradical resections. The introduction of minimal invasive techniques in pancreatic surgery has deprived surgeons from direct tactile information. To improve intraoperative assessment of pancreatic tumor extension, enhanced or novel intraoperative imaging technologies accurately visualizing and delineating cancer cells are necessary. Emerging modalities are intraoperative near-infrared fluorescence imaging and freehand nuclear imaging using tumor-specific targeted contrast agents. In this review, we performed a meta-analysis of the literature on laparoscopic ultrasonography and we summarized and discussed current and future intraoperative imaging modalities and their potential for improved tumor demarcation during pancreatic surgery. Henricus J. M. Handgraaf, Martin C. Boonstra, Arian R. Van Erkel, Bert A. Bonsing, Hein Putter, Cornelis J. H. Van De Velde, Alexander L. Vahrmeijer, and J. Sven D. Mieog Copyright © 2014 Henricus J. M. Handgraaf et al. All rights reserved. Protection of Coronary Endothelial Function during Cardiac Surgery: Potential of Targeting Endothelial Ion Channels in Cardioprotection Sun, 13 Jul 2014 12:06:54 +0000 Vascular endothelium plays a critical role in the control of blood flow by producing vasoactive factors to regulate vascular tone. Ion channels, in particular, K+ channels and Ca2+-permeable channels in endothelial cells, are essential to the production and function of endothelium-derived vasoactive factors. Impairment of coronary endothelial function occurs in open heart surgery that may result in reduction of coronary blood flow and thus in an inadequate myocardial perfusion. Hyperkalemic exposure and concurrent ischemia-reperfusion during cardioplegic intervention compromise NO and EDHF-mediated function and the impairment involves alterations of K+ channels, that is, and , and Ca2+-permeable TRP channels in endothelial cells. Pharmacological modulation of these channels during ischemia-reperfusion and hyperkalemic exposure show promising results on the preservation of NO and EDHF-mediated endothelial function, which suggests the potential of targeting endothelial K+ and TRP channels for myocardial protection during cardiac surgery. Qin Yang, Cheuk-Man Yu, Guo-Wei He, and Malcolm John Underwood Copyright © 2014 Qin Yang et al. All rights reserved. Aesthetic Evaluation of the Nasolabial Region in Children with Unilateral Cleft Lip and Palate Comparing Expert versus Nonexperience Health Professionals Sun, 13 Jul 2014 07:01:07 +0000 Esthetic evaluation of cleft lip and palate rehabilitation outcomes may assist in the determination of new surgical interventions and aid in reevaluation of treatment protocols. Our objective was to compare esthetics assessments of the nasolabial region in children with a unilateral cleft lip and palate between healthcare professionals who were experienced in the treatment of cleft lip and palate and those who were inexperienced. The study group included 55 patients between 6 and 12 years of age who had already undergone primary reconstructive surgery for unilateral cleft lip. Standardized digital photographs were obtained, and the esthetic features of the nose, lip, and nasolabial region were evaluated. We used only cropped photographic images in the assessments of healthcare professionals with and without experience in cleft lip and palate. Interrater analysis revealed highly reliable assessments made by both the experienced and inexperienced professionals. There was no statistically significant difference in the esthetic attractiveness of the lip and nose between the experienced and inexperienced professionals. Compared with the inexperienced professionals, the experienced professional evaluators showed higher satisfaction with the esthetic appearance of the nasolabial region; however, no difference was observed in the analysis of the lip or nose alone. Tatiana Saito Paiva, Marcia Andre, Wellingson Silva Paiva, and Beatriz Silva Camara Mattos Copyright © 2014 Tatiana Saito Paiva et al. All rights reserved. Current Evidence regarding Prophylactic Antibiotics in Head and Neck and Maxillofacial Surgery Tue, 08 Jul 2014 06:50:56 +0000 Antibiotic prophylaxis is commonly used to decrease the rate of infections in head and neck surgery. The aim of this paper is to present the available evidence regarding the application of antibiotic prophylaxis in surgical procedures of the head and neck region in healthy patients. A systemic literature review based on Medline and Embase databases was performed. All reviews and meta-analyses based on RCTs in English from 2000 to 2013 were included. Eight out of 532 studies fulfilled all requirements. Within those, only seven different operative procedures were analyzed. Evidence exists for the beneficial use of prophylactic antibiotics for tympanostomy, orthognathic surgery, and operative tooth extractions. Unfortunately, little high-level evidence exists regarding the use of prophylactic antibiotics in head and neck surgery. In numerous cases, no clear benefit of antibiotic prophylaxis has been shown, particularly considering their potential adverse side effects. Antibiotics are often given unnecessarily and are administered too late and for too long. Furthermore, little research has been performed on the large number of routine cases in the above-mentioned areas of specialization within the last few years, although questions arising with respect to the treatment of high-risk patients or of specific infections are discussed on a broad base. Kilian Kreutzer, Katharina Storck, and Jochen Weitz Copyright © 2014 Kilian Kreutzer et al. All rights reserved. Preoperative Arrhythmias Such as Atrial Fibrillation: Cardiovascular Surgery Risk Factor Thu, 03 Jul 2014 10:12:21 +0000 Atrial fibrillation is still the most common arrhythmia that occurs in heart surgery. However, there is few literature data on the manner in which preoperative atrial fibrillation may influence the postoperative outcome of various heart surgery procedures. The purpose of our research is to assess the effects of preoperative atrial fibrillation on patients having undergone different heart surgery procedures. The results of our research are a review of clinical data which were collected prospectively, over a 10-year period, from all the patients who had undergone heart surgery in our Institute. The study group included 1119 heart surgery patients, who were divided as follows: the preoperative AFib group (, 20.19%) and the sinus rhythm group (, 79.80%). Major postoperative complications and hospital mortality rates were analyzed. According to our statistical analysis, preoperative atrial fibrillation significantly increased the mortality risk (), the patients’ mechanical ventilation needs (), the rate of occurrence of infectious complications (), the rate of occurrence of complications such as acute kidney failure (), and the time spent by the patients in the intensive care ward (). In conclusion, preoperative atrial fibrillation in heart surgery patients increases the mortality and major complication risk further to heart surgery. Diana Anghel, Radu Anghel, Flavia Corciova, Mihail Enache, and Grigore Tinica Copyright © 2014 Diana Anghel et al. All rights reserved. P-Selectin: An Unpredicted Factor for Deep Vein Thrombosis after Total Hip Arthroplasty Wed, 25 Jun 2014 09:25:30 +0000 Introduction. Deep vein thrombosis (DVT) is a severe complication after total hip arthroplasty (THA). It leads to acute pulmonary embolism, a life-threatening disease. P-selectin is a 140-kDa transmembrane glycoprotein. Elevated P-selectin was associated with 1.7-fold increase in the risk of venous thrombosis. Materials and Methods. To confirm the association, a total of 91 subjects who received primary total hip arthroplasty using lateral approach performed by one skilled orthopedic surgeon were studied. All the patients were consecutively enrolled at the Center of Diagnosis and Treatment for Joint Diseases, Drum Tower Hospital affiliated to the Medical School of Nanjing University from 2010 to 2012. All the subjects received venography 3–5 days after operation. We measured P-selectin by means of a highly sensitive sandwich ELISA technique and a commercially available test reagent set. Results. No significant association was detected between P-selectin and DVT (all   ). ΔsP-selectin was correlated with weight, APTT after operation, history of DVT, and diagnosis of primary disease ( values were 0.03, 0.03, 0.04, and 0.02, resp.). Conclusion. P-selectin may not be a predicted factor for deep vein thrombosis after total hip arthroplasty. Dongquan Shi, Xingquan Xu, Zhihong Xu, Takahiro Nakamura, Yong Pang, Chen Yao, Feng Wang, Dongyang Chen, Jin Dai, and Qing Jiang Copyright © 2014 Dongquan Shi et al. All rights reserved. Correlation between Density and Resorption of Fresh-Frozen and Autogenous Bone Grafts Tue, 24 Jun 2014 13:25:35 +0000 Trial Design. This analysis compared the outcome of fresh-frozen versus autologous bone block grafts for horizontal ridge augmentation in patients with Cawood and Howell class IV atrophies. Methods. Seventeen patients received autologous grafts and 21 patients received fresh-frozen bone grafts. Patients underwent CT scans 1 week and 6 months after surgery for graft volume and density analysis. Results. Two autologous and 3 fresh-frozen grafts failed. Autologous and fresh-frozen grafts lost, respectively, 28% and 46% of their initial volume . It is noteworthy that less dense fresh-frozen blocks lost more volume than denser grafts (61% versus 16%). Conclusions. According to these 6-month results, only denser fresh-frozen bone graft may be an acceptable alternative to autologous bone for horizontal ridge augmentation. Further studies are needed to investigate its behaviour at longer time points. Simone Lumetti, Carlo Galli, Edoardo Manfredi, Ugo Consolo, Claudio Marchetti, Giulia Ghiacci, Andrea Toffoli, Mauro Bonanini, Attilio Salgarelli, and Guido M. Macaluso Copyright © 2014 Simone Lumetti et al. All rights reserved. Biomarkers as Predictors of Recurrence following Curative Resection for Pancreatic Ductal Adenocarcinoma: A Review Tue, 24 Jun 2014 12:13:35 +0000 Pancreatic ductal adenocarcinoma (PDA) is the fourth most common cancer causing death in the United States. Early tumor recurrence is an important contributor to the dismal prognosis. The availability of an accurate prognostic biomarker for predicting disease recurrence following curative resection will be beneficial for patient care. Most of the currently studied biomarkers remain in the investigational phase, with CA 19-9 being the only biomarker currently approved by the FDA. Herein, we review the utility of CA 19-9 and other investigational cellular, gene, and molecular tumor markers for predicting PDA recurrence following curative surgical resection. Sylvester N. Osayi, Mark Bloomston, Carl M. Schmidt, E. Christopher Ellison, and Peter Muscarella Copyright © 2014 Sylvester N. Osayi et al. All rights reserved. A New Surgical Technique of Pancreaticoduodenectomy with Splenic Artery Resection for Ductal Adenocarcinoma of the Pancreatic Head and/or Body Invading Splenic Artery: Impact of the Balance between Surgical Radicality and QOL to Avoid Total Pancreatectomy Thu, 12 Jun 2014 13:13:04 +0000 For pancreatic ductal adenocarcinoma (PDAC) of the head and/or body invading the splenic artery (SA), we developed a new surgical technique of proximal subtotal pancreatectomy with splenic artery and vein resection, so-called pancreaticoduodenectomy with splenic artery resection (PD-SAR). We retrospectively reviewed a total of 84 patients with curative intent pancreaticoduodenectomy (PD) for PDAC of the head and/or body. These 84 patients were classified into the two groups: conventional PD () and PD-SAR (). Most patients were treated by preoperative chemoradiotherapy (CRT). Postoperative MDCT clearly demonstrated enhancement of the remnant pancreas at 1 and 6 months in all patients examined. Overall survival rates were very similar between PD and PD-SAR (3-year OS: 23.7% versus 23.1%, ), despite the fact that the tumor size and the percentages of UICC-T4 determined before treatment were higher in PD-SAR. Total daily insulin dose was significantly higher in PD-SAR than in PD at 1 month, while showing no significant differences between the two groups thereafter. PD-SAR with preoperative CRT seems to be promising surgical strategy for PDAC of head and/or body with invasion of the splenic artery, in regard to the balance between operative radicality and postoperative QOL. Ryosuke Desaki, Shugo Mizuno, Akihiro Tanemura, Masashi Kishiwada, Yasuhiro Murata, Yoshinori Azumi, Naohisa Kuriyama, Masanobu Usui, Hiroyuki Sakurai, Masami Tabata, and Shuji Isaji Copyright © 2014 Ryosuke Desaki et al. All rights reserved. Is Roux-Y Binding Pancreaticojejunal Anastomosis Feasible for Patients Undergoing Left Pancreatectomy? Results from a Prospective Randomized Trial Wed, 11 Jun 2014 09:28:38 +0000 Background. After pancreaticoduodenectomy, the Finnish binding pancreaticojejunal anastomosis (FBPJ) seems to reduce the risk for pancreatic fistula (POPF). Our aim was to investigate whether FBPJ is feasible and prevents the risk for POPF even after left pancreatectomy (LP). Patients and Methods. 47 consecutive patients underwent LP. 27 patients were recruited on the basis of CT and, of these, 16 patients were randomized on the basis of findings during surgery (transection line must be left of portal vein, as 2-3 cm pancreatic mobilization is required for FBPJ) to receive either Roux-Y FBPJ or hand-sewn closure of the pancreatic remnant. Results. Only 34% (16/47) of the patients met the randomization criteria. Clinically significant POPF rate was higher in FBPJ group (60%) compared to thand-sewn closure group (13%; ). POPF rate in FBPJ group was higher even when compared to all patients with hand-sewn closure (60% versus 37%; ). Overall, FBPJ was technically feasible for only 28% of patients. Conclusion. FBPJ cannot be recommended for the routine closure of the pancreatic remnant after LP, as it was not technically achievable in 72% of the cases. Moreover, the technique does not seem to reduce the risk for POPF compared to the hand-sewn closure. Anne Antila, Juhani Sand, Isto Nordback, Sari Räty, and Johanna Laukkarinen Copyright © 2014 Anne Antila et al. All rights reserved. Translational Research of Telecare for the Treatment of Hepatitis C Tue, 10 Jun 2014 04:56:17 +0000 Objective. Chronic hepatitis C virus (HCV) infection is a serious health problem in Taiwan. The high dropout rate due to side effects limits the efficacy of treatment. The objective of this study is to investigate the effectiveness of telecare for the treatment of chronic hepatitis. Material and Methods. Two hundred and ninety-eight patients randomly chose either of the two support programs. Group 1 was offered public health nurse consultation at outpatient clinic. Group 2 was offered telecare program with 24 hours of consultation services via a health communication center. All patients were treated with standard therapy and followed up for 72 weeks. Results. Normalization of serum biochemistry was noted in both Group 1 (150 patients) and Group 2 (148 patients). The most common types of side effect in both groups were influenza-like symptoms. Patient compliance was 88% (Group 1) and 94.6% (Group 2). Total dropout cases were 18 (12%) in Group 1 and 8 (5.4%) in Group 2. The program costs were 232,632 USD (Group 1) and 112,500 USD (Group 2). Conclusion. Telecare system with health care communication center model is significant in reducing dropout rate and is more effective with easy access. Wan-Lin Chen, Wen-Ta Chiu, Ming-Shun Wu, Mei-Huang Hsu, and Shin-Han Tsai Copyright © 2014 Wan-Lin Chen et al. All rights reserved. Face Transplantation: On the Verge of Becoming Clinical Routine? Mon, 09 Jun 2014 09:12:33 +0000 Introduction. Face transplantation (FT) is an innovative achievement of modern reconstructive surgery and is on the verge of becoming a common surgical opportunity. This review article was compiled to provide an update on this surgical field, especially regarding clinical outcomes, benefits, and complications implied. Methods. We performed an extensive research on all English-language Medline articles, case reports, and reviews published online until September 15, 2013. Used search terms were “face transplantation,” “face transplant,” “facial transplantation,” “facial transplant,” “face allograft,” and “facial allograft.” Results. To date 27 FTs have been performed worldwide. 19 of these cases have been published in the Medline database. Long-term follow-up reports of FT cases are rare. Three deaths associated with the procedure have occurred to date. The clinical outcomes of FT are satisfying. Reinnervation of sensation has been faster than motor recovery. Extensive functional improvements have been observed. Due to strict immunosuppression protocols, no case of hyperacute or chronic rejection and no graft-versus-host disease have occurred to date. Conclusions. As studies on long-term outcomes are missing, particularly regarding immunosuppression-related complications, FT will stay experimental for the next years. Nevertheless, for a small group of patients, FT already is a feasible reconstructive option. Ralf Smeets, Carsten Rendenbach, Moritz Birkelbach, Ahmed Al-Dam, Alexander Gröbe, Henning Hanken, and Max Heiland Copyright © 2014 Ralf Smeets et al. All rights reserved. Evaluation of Human Amniotic Membrane as a Wound Dressing for Split-Thickness Skin-Graft Donor Sites Mon, 09 Jun 2014 07:27:56 +0000 Human amniotic membrane (HAM) has been used as a biomaterial in various surgical procedures and exceeds some qualities of common materials. We evaluated HAM as wound dressing for split-thickness skin-graft (STSG) donor sites in a swine model (Part A) and a clinical trial (Part B). Part A: STSG donor sites in 4 piglets were treated with HAM or a clinically used conventional polyurethane (PU) foil ( each). Biopsies were taken on days 5, 7, 10, 20, 40, and 60 and investigated immunohistochemically for alpha-smooth muscle actin (SMA: wound contraction marker), von Willebrand factor (vWF: angiogenesis), Ki-67 (cell proliferation), and laminin (basement membrane integrity). Part B: STSG donor sites in 45 adult patients (16 female/29 male) were treated with HAM covered by PU foam, solely by PU foam, or PU foil/paraffin gauze ( each). Part A revealed no difference in the rate of wound closure between groups. HAM showed improved esthetic results and inhibitory effects on cicatrization. Angioneogenesis was reduced, and basement membrane formation was accelerated in HAM group. Part B: no difference in re-epithelialization/infection rate was found. HAM caused less ichor exudation and less pruritus. HAM has no relevant advantage over conventional dressings but might be a cost-effective alternative. Denys J. Loeffelbein, Nils H. Rohleder, Matthias Eddicks, Claudia M. Baumann, Mechthild Stoeckelhuber, Klaus-D. Wolff, Enken Drecoll, Lars Steinstraesser, Simone Hennerbichler, and Marco R. Kesting Copyright © 2014 Denys J. Loeffelbein et al. All rights reserved. Pancreas-Preserving Approach to “Paraduodenal Pancreatitis” Treatment: Why, When, and How? Experience of Treatment of 62 Patients with Duodenal Dystrophy Thu, 05 Jun 2014 08:45:04 +0000 Background. The term “paraduodenal pancreatitis” (PP) was proposed as a synonym for duodenal dystrophy (DD) and groove pancreatitis, but it is still unclear what organ PP originates from and how to treat it properly. Objective. To assess the results of different types of treatment for PP. Method. Prospective analysis of 62 cases of PP (2004–2013) with histopathology of 40 specimens was performed; clinical presentation was assessed and the results of treatment were recorded.  Results. Preoperative diagnosis was correct in all the cases except one (1.9%). Patients presented with abdominal pain (100%), weight loss (76%), vomiting (30%), and jaundice (18%). CT, MRI, and endoUS were the most useful diagnostic modalities. Ten patients were treated conservatively, 24 underwent pancreaticoduodenectomies (PD), pancreatico- and cystoenterostomies (8), Nakao procedures (5), duodenum-preserving pancreatic head resections (5), and 10 pancreas-preserving duodenal resections (PPDR) without mortality. Full pain control was achieved after PPRDs in 83%, after PDs in 85%, and after PPPH resections and draining procedures in 18% of cases. Diabetes mellitus developed thrice after PD. Conclusions. PD is the main surgical option for PP treatment at present; early diagnosis makes PPDR the treatment of choice for PP; efficacy of PPDR for DD treatment provides proof that so-called PP is an entity of duodenal, but not “paraduodenal,” origin. V. I. Egorov, A. N. Vankovich, R. V. Petrov, N. S. Starostina, A. Ts. Butkevich, A. V. Sazhin, and E. A. Stepanova Copyright © 2014 V. I. Egorov et al. All rights reserved. Efficacy of Combined Endoscopic Lithotomy and Extracorporeal Shock Wave Lithotripsy, and Additional Electrohydraulic Lithotripsy Using the SpyGlass Direct Visualization System or X-Ray Guided EHL as Needed, for Pancreatic Lithiasis Thu, 05 Jun 2014 07:44:17 +0000 Introduction. To evaluate the efficacy of combined endoscopic lithotomy and extracorporeal shock wave lithotripsy (ESWL), and additional electrohydraulic lithotripsy (EHL) as needed, for the treatment of pancreatic duct stones, we retrospectively evaluated 98 patients with chronic pancreatitis and pancreatic lithiasis. Methods. For the management of main pancreatic duct (MPD) stones in 98 patients, we performed combined endoscopic treatment (ET)/ESWL therapy as the first treatment option. When combined ET/ESWL was unsuccessful, EHL with the SpyGlass Direct Visualization system or X-ray guided EHL was performed. Outpatient ESWL was reserved as one of the final treatment options. Results. Fragmentation was successful in 80 (81.6%) patients as follows: combined ET/ESWL: 67 cases; SpyGlass EHL: 4 cases; X-ray guided EHL: 3 cases; and outpatient ESWL: 6 cases. Successful outcome was obtained by combined ET/ESWL in 67 of the 98 patients (74.5%), by EHL in 7 of 14 patients (7.1%), and by outpatient ESWL in 6 of 6 patients (6.1%). Negotiating the guidewire through a severe MPD stricture was significantly associated with a higher rate of stone fragmentation (). Conclusions. In cases where combined ET/ESWL was not successful for stone clearance, EHL using the SpyGlass system or X-ray guided EHL was effective in cases where the guidewire could be negotiated through the MPD stricture and it increased the fragmentation rate. Ken Ito, Yoshinori Igarashi, Naoki Okano, Takahiko Mimura, Yui Kishimoto, Seiichi Hara, and Kensuke Takuma Copyright © 2014 Ken Ito et al. All rights reserved. Comparison of Venous Thromboembolism after Total Hip Arthroplasty between Ankylosing Spondylitis and Osteoarthritis Wed, 04 Jun 2014 08:34:40 +0000 Objective. Ankylosing spondylitis (AS), an inflammatory rheumatic disease, will gradually lead to severe hip joint dysfunction. Total hip arthroplasty is a useful method to improve patients’ quality of life. The aim of this study was to compare the incidence and risk factors of deep vein thrombosis (DVT) between AS and hip osteoarthritis. Methods. In a retrospective study, a total of 149 subjects who underwent cementless THA were studied. Clinical data, biochemical data, and surgery-related data were measured between AS and OA groups. Results. The incidence of DVT in AS group was lower than that of OA group, although no significant difference was detected (). The patients of AS group were much younger () and thinner () compared with those of OA group. AS patients had higher ejection fraction (EF) (), higher platelet counts (), and lower hypertension rate (). The values of APTT, PT, and INR in AS patients were higher than those in OA patients (all ). The values of D-dimer and APTT were both significantly higher in DVT subjects than those in non-DVT subjects. Conclusion. AS patients potentially had a lower incidence of DVT compared with OA patients. Dongquan Shi, Xingquan Xu, Kai Song, Zhihong Xu, Jin Dai, Dongyang Chen, and Qing Jiang Copyright © 2014 Dongquan Shi et al. All rights reserved. Surgical Technique in Distal Pancreatectomy: A Systematic Review of Randomized Trials Thu, 29 May 2014 13:10:06 +0000 Despite recent improvements in surgical technique, the morbidity of distal pancreatectomy remains high, with pancreatic fistula being the most significant postoperative complication. A systematic review of randomized controlled trials (RCTs) dealing with surgical techniques in distal pancreatectomy was carried out to summarize up-to-date knowledge on this topic. The Cochrane Central Registry of Controlled Trials, Embase, Web of Science, and Pubmed were searched for relevant articles published from 1990 to December 2013. Ten RCTs were identified and included in the systematic review, with a total of 1286 patients being randomized (samples ranging from 41 to 450). The reviewers were in agreement for application of the eligibility criteria for study selection. It was not possible to carry out meta-analysis of these studies because of the heterogeneity of surgical techniques and approaches, such as varying methods of pancreas transection, reinforcement of the stump with seromuscular patch or pancreaticoenteric anastomosis, sealing with fibrin sealants and pancreatic stent placement. Management of the pancreatic remnant after distal pancreatectomy is still a matter of debate. The results of this systematic review are possibly biased by methodological problems in some of the included studies. New well designed and carefully conducted RCTs must be performed to establish the optimal strategy for pancreatic remnant management after distal pancreatectomy. Filip Čečka, Bohumil Jon, Zdeněk Šubrt, and Alexander Ferko Copyright © 2014 Filip Čečka et al. All rights reserved. Hip Joint Replacement Using Monofilament Polypropylene Surgical Mesh: An Animal Model Thu, 29 May 2014 00:00:00 +0000 Hip joint dysplasia is a deformation of the articular elements (pelvic acetabulum, head of the femur, and/or ligament of the head of the femur) leading to laxity of the hip components and dislocation of the femoral head from the pelvic acetabulum. Diagnosis is based on symptoms observed during clinical and radiological examinations. There are two treatment options: conservative and surgical. The classic surgical procedures are juvenile pubic symphysiodesis (JPS), triple pelvic osteotomy (TPO), total hip replacement (THR), and femoral head and neck resection (FHNE). The aim of this experiment was to present an original technique of filling the acetabulum with a polypropylene implant, resting the femoral neck directly on the mesh. The experiment was performed on eight sheep. The clinical value of the new surgical technique was evaluated using clinical, radiological, and histological methods. This technique helps decrease the loss of limb length by supporting the femoral neck on the mesh equivalent to the femoral head. It also reduces joint pain and leads to the formation of stable and mobile pseudarthrosis. The mesh manifested osteoprotective properties and enabled the formation of a stiff-elastic connection within the hip joint. The method is very cost-effective and the technique itself is simple to perform. Jacek Białecki, Marian Majchrzycki, Antoni Szymczak, Małgorzata Dorota Klimowicz-Bodys, Edward Wierzchoś, and Krzysztof Kołomecki Copyright © 2014 Jacek Białecki et al. All rights reserved. The State of the Art of Robotic Pancreatectomy Wed, 28 May 2014 05:47:22 +0000 During the last decades an increasing number of minimally invasive pancreatic resections have been reported in the literature. With the development of robotic surgery a new enthusiasm has not only increased the number of centers approaching minimally invasive pancreatic surgery in general but also enabled the use of this technique for major pancreatic procedures, in particular in minimally invasive pancreatoduodenectomy. The aim of this review was to define the state of the art of pancreatic robotic surgery. No prospective randomized trials have been performed comparing robotic, laparoscopic, and open pancreatic procedures. From the literature one may conclude that robotic pancreatectomies seem to be as feasible and safe as open procedures. The general idea that the overall perioperative costs of robotic surgery would be higher than traditional procedures is not supported. With the current lack of evidence of any oncologic advantages, the cosmetic benefits offered by robotic surgery are not enough to justify extensive use in cancer patients. In contrast, the safety of these procedure can justify the use of the robotic technique in patient with benign/low grade malignant tumors of the pancreas. Marco Del Chiaro and Ralf Segersvärd Copyright © 2014 Marco Del Chiaro and Ralf Segersvärd. All rights reserved. Propeller Flaps: A Review of Indications, Technique, and Results Mon, 26 May 2014 11:10:48 +0000 In the last years, propeller flaps have become an appealing option for coverage of a large range of defects. Besides having a more reliable vascular pedicle than traditional flap, propeller flaps allow for great freedom in design and for wide mobilization that extend the possibility of reconstructing difficult wounds with local tissues and minimal donor-site morbidity. They also allow one-stage reconstruction of defects that usually require multiple procedures. Harvesting of a propeller flap requires accurate patient selection, preoperative planning, and dissection technique. Complication rate can be kept low, provided that potential problems are prevented, promptly recognized, and adequately treated. This paper reviews current knowledge on propeller flaps. Definition, classification, and indications in the different body regions are discussed based on a review of the literature and on the authors’ experience. Details about surgical technique are provided, together with tips to avoid and manage complications. Salvatore D'Arpa, Francesca Toia, Roberto Pirrello, Francesco Moschella, and Adriana Cordova Copyright © 2014 Salvatore D'Arpa et al. All rights reserved. Prognostic Significance of Sentinel Lymph Node Mapping in Merkel Cell Carcinoma: Systematic Review and Meta-Analysis of Prognostic Studies Mon, 26 May 2014 10:51:46 +0000 Aim. To assess through a systematic review and meta-analysis of the literature the prognostic implication of sentinel lymph node mapping in Merkel cell carcinoma (MCC). Materials and Methods. PubMed and SCOPUS databases were searched by using “Merkel AND sentinel” as keywords. All studies with prognostic information regarding SLN mapping in cN0 MCC patients were included. Hazard ratio (HR) for overall survival (OS) and disease free survival (DFS) was used as effect size. Results. SLN biopsy predicted better DFS and OS as compared to the nodal observation in cN0 MCC patients (pooled HR for DFS: 1.61 (95% CI: 1.05–2.46), ; pooled HR for OS: 1.08 (95% CI: 0.55–2.10), ). Pathologically negative SLN (SLN−) patients had better OS (pooled HR: 4.42 (95% CI: 1.82–10.7), ) and DFS (pooled HR: 2.58 (95% CI: 1.78–3.73)) as compared to SLN+ patients. Conclusion. SLN mapping can provide strong prognostic information regarding OS and DFS in cN0 MCC patients. More importantly, SLN mapping can improve DFS and possibly OS in cN0 MCC patients as compared to nodal observation. As MCC is a rare tumor, large multicenter prospective studies are still needed to validate the survival benefit of SLN mapping. Ramin Sadeghi, Zohreh Adinehpoor, Masoud Maleki, Babak Fallahi, Luca Giovanella, and Giorgio Treglia Copyright © 2014 Ramin Sadeghi et al. All rights reserved. Endoscopic Evacuation of Basal Ganglia Hemorrhage via Keyhole Approach Using an Adjustable Cannula in Comparison with Craniotomy Sun, 18 May 2014 08:52:15 +0000 Neuroendoscopic (NE) surgery as a minimal invasive treatment for basal ganglia hemorrhage is a promising approach. The present study aims to evaluate the efficacy and safety of NE approach using an adjustable cannula to treat basal ganglia hemorrhage. In this study, we analysed the clinical and radiographic outcomes between NE group (21 cases) and craniotomy group (30 cases). The results indicated that NE surgery might be an effective and safe approach for basal ganglia haemorrhage, and it is also suggested that NE approach may improve good functional recovery. However, NE approach only suits the selected patient, and the usefulness of NE approach needs further randomized controlled trials (RCTs) to evaluate. Heng-Zhu Zhang, Yu-Ping Li, Zheng-cun Yan, Xing-dong Wang, Lei She, Xiao-dong Wang, and Lun Dong Copyright © 2014 Heng-Zhu Zhang et al. All rights reserved. Long Term Follow-Up in Inferior Alveolar Nerve Transposition: Our Experience Tue, 13 May 2014 07:47:45 +0000 Introduction. Inferior alveolar nerve transposition (IANT) is a surgical technique used in implantoprosthetic rehabilitation of the atrophic lower jaw which has not been well embraced because of the high risk of damage to the inferior alveolar nerve (IAN). There are cases in which this method is essential to obtain good morphologic and functional rebalancing of the jaw. In this paper, the authors present their experience with IANT, analyzing the various situations in which IANT is the only surgical preprosthetic option. Methods. Between 2003 and 2011, 35 patients underwent surgical IANT at our center. Thermal and physical sensitivity were evaluated in each patient during follow-up. The follow-up ranged from 14 to 101 months. Results and Conclusion. Based on our experience, absolute indications of IANT are as follows: (1) class IV, V, or VI of Cawood and Howell with extrusion of the antagonist tooth and reduced prosthetic free space; (2) class V or VI of Cawood and Howell with presence of interforaminal teeth; (3) class V or VI of Cawood and Howell if patient desires fast implantoprosthetic rehabilitation with predictable outcomes; (4) class VI of Cawood and Howell when mandibular height increase with inlay grafts is advisable. Giulio Gasparini, Roberto Boniello, Gianmarco Saponaro, Tito Matteo Marianetti, Enrico Foresta, Andrea Torroni, Giuliana Longo, Camillo Azzuni, Daniele Cervelli, and Sandro Pelo Copyright © 2014 Giulio Gasparini et al. All rights reserved. Morphohistological Features of Pancreatic Stump Are the Main Determinant of Pancreatic Fistula after Pancreatoduodenectomy Tue, 13 May 2014 00:00:00 +0000 Introduction. Pancreatic surgery is challenging and associated with high morbidity, mainly represented by postoperative pancreatic fistula (POPF) and its further consequences. Identification of risk factors for POPF is essential for proper postoperative management. Aim of the Study. Evaluation of the role of morphological and histological features of pancreatic stump, other than main pancreatic duct diameter and glandular texture, in POPF occurrence after pancreaticoduodenectomy. Patients and Methods. Between March 2011 and April 2013, we performed 145 consecutive pancreaticoduodenectomies. We intraoperatively recorded morphological features of pancreatic stump and collected data about postoperative morbidity. Our dedicated pathologist designed a score to quantify fibrosis and inflammation of pancreatic tissue. Results. Overall morbidity was 59,3%. Mortality was 4,1%. POPF rate was 28,3%, while clinically significant POPF were 15,8%. Male sex (), (), prolonged surgery (), soft pancreatic texture (), small pancreatic duct (), pancreatic duct decentralization on stump anteroposterior axis, especially if close to the posterior margin (), large stump area (), and extended stump mobilization () were related to higher POPF rate. Our fibrosis-and-inflammation score is strongly associated with POPF (). Discussion and Conclusions. Pancreatic stump features evaluation, including histology, can help the surgeon in fitting postoperative management to patient individual risk after pancreaticoduodenectomy. Cristina Ridolfi, Maria Rachele Angiolini, Francesca Gavazzi, Paola Spaggiari, Maria Carla Tinti, Fara Uccelli, Marco Madonini, Marco Montorsi, and Alessandro Zerbi Copyright © 2014 Cristina Ridolfi et al. All rights reserved. Current Innovations in Endoscopic Therapy for the Management of Colorectal Cancer: From Endoscopic Submucosal Dissection to Endoscopic Full-Thickness Resection Wed, 30 Apr 2014 07:24:52 +0000 Endoscopic submucosal dissection (ESD) is accepted as a minimally invasive treatment for colorectal cancer. However, due to technical difficulties and an increased rate of complications, ESD is not widely used in the colorectum. In some cases, endoscopic treatment alone is insufficient for disease control, and laparoscopic surgery is required. The combination of laparoscopic surgery and endoscopic resection represents a new frontier in cancer treatment. Recent developments in advanced polypectomy and minimally invasive surgical techniques will enable surgeons and endoscopists to challenge current practice in colorectal cancer treatment. Endoscopic full-thickness resection (EFTR) of the colon offers the potential to decrease the postoperative morbidity and mortality associated with segmental colectomy while enhancing the diagnostic yield compared to current endoscopic techniques. However, closure is necessary after EFTR and natural transluminal endoscopic surgery (NOTES). Innovative methods and new devices for EFTR and suturing are being developed and may potentially change traditional paradigms to achieve minimally invasive surgery for colorectal cancer. The present paper aims to discuss the complementary role of ESD and the future development of EFTR. We focus on the possibility of achieving EFTR using the ESD method and closing devices. Shintaro Fujihara, Hirohito Mori, Hideki Kobara, Noriko Nishiyama, Tae Matsunaga, Maki Ayaki, Tatsuo Yachida, Asahiro Morishita, Kunihiko Izuishi, and Tsutomu Masaki Copyright © 2014 Shintaro Fujihara et al. All rights reserved. The Osteogenesis of Bone Marrow Stem Cells on mPEG-PCL-mPEG/Hydroxyapatite Composite Scaffold via Solid Freeform Fabrication Tue, 29 Apr 2014 14:18:32 +0000 The study described a novel bone tissue scaffold fabricated by computer-aided, air pressure-aided deposition system to control the macro- and microstructure precisely. The porcine bone marrow stem cells (PBMSCs) seeded on either mPEG-PCL-mPEG (PCL) or mPEG-PCL-mPEG/hydroxyapatite (PCL/HA) composite scaffold were cultured under osteogenic medium to test the ability of osteogenesis in vitro. The experimental outcomes indicated that both scaffolds possessed adequate pore size, porosity, and hydrophilicity for the attachment and proliferation of PBMSCs and the PBMSCs expressed upregulated genes of osteogensis and angiogenesis in similar manner on both scaffolds. The major differences between these two types of the scaffolds were the addition of HA leading to higher hardness of PCL/HA scaffold, cell proliferation, and VEGF gene expression in PCL/HA scaffold. However, the in vivo bone forming efficacy between PBMSCs seeded PCL and PCL/HA scaffold was different from the in vitro results. The outcome indicated that the PCL/HA scaffold which had bone-mimetic environment due to the addition of HA resulted in better bone regeneration and mechanical strength than those of PCL scaffold. Therefore, providing a bone-mimetic scaffold is another crucial factor for bone tissue engineering in addition to the biocompatibility, 3D architecture with high porosity, and interpored connection. Han-Tsung Liao, Yo-Yu Chen, Yu-Ting Lai, Ming-Fa Hsieh, and Cho-Pei Jiang Copyright © 2014 Han-Tsung Liao et al. All rights reserved. Stereotactic Ablative Radiotherapy for Oligometastatic Disease in Liver Tue, 29 Apr 2014 09:07:27 +0000 Liver metastasis in solid tumors, including colorectal cancer, is the most frequent and lethal complication. The development of systemic therapy has led to prolonged survival. However, in selected patients with a finite number of discrete lesions in liver, defined as oligometastatic state, additional local therapies such as surgical resection, radiofrequency ablation, cryotherapy, and radiotherapy can lead to permanent local disease control and improve survival. Among these, an advance in radiation therapy made it possible to deliver high dose radiation to the tumor more accurately, without impairing the liver function. In recent years, the introduction of stereotactic ablative radiotherapy (SABR) has offered even more intensive tumor dose escalation in a few fractions with reduced dose to the adjacent normal liver. Many studies have shown that SABR for oligometastases is effective and safe, with local control rates widely ranging from 50% to 100% at one or two years. And actuarial survival at one and two years has been reported ranging from 72% to 94% and from 30% to 62%, respectively, without severe toxicities. In this paper, we described the definition and technical aspects of SABR, clinical outcomes including efficacy and toxicity, and related parameters after SABR in liver oligometastases from colorectal cancer. Myungsoo Kim, Seok Hyun Son, Yong Kyun Won, and Chul Seung Kay Copyright © 2014 Myungsoo Kim et al. All rights reserved. Splanchnicectomy for Pancreatic Cancer Pain Sun, 27 Apr 2014 00:00:00 +0000 Persistent pain is a serious problem that often contributes to a poor quality of life in pancreatic cancer patients. Medical management by opioid analgesics is often accompanied by side effects and incomplete pain relief. A celiac plexus block is a simple treatment which relieves pain, but the procedure demands a certain degree of proficiency and the duration of the effects obtained can be rather limited. Transhiatal bilateral splanchnicectomy achieves a certain denervation of splanchnic nerves, but it requires a laparotomy. Unilateral thoracoscopic splanchnicectomy is a minimally invasive procedure to cause definite denervation. Bilateral thoracoscopic splanchnicectomy is recommended for unsatisfactory cases or recurrent pain occurring after the initial unilateral splanchnicectomy. It is important to select the most suitable treatment depending on patients’ actual medical state and the predicted outcomes. Toshiro Masuda, Masafumi Kuramoto, Shinya Shimada, Satoshi Ikeshima, Kenichiro Yamamoto, Kenichi Nakamura, and Hideo Baba Copyright © 2014 Toshiro Masuda et al. All rights reserved. Immunohistochemical Detection of Cancer Stem Cell Related Markers CD44 and CD133 in Metastatic Colorectal Cancer Patients Tue, 22 Apr 2014 09:38:06 +0000 Aim. The goal of this study was to semiquantitatively detect presence of cancer stem cells markers CD44 and CD133 in immunohistochemically stained paired samples of colorectal cancer (CRC) and colorectal liver metastases (CLM). Level of staining intensity was compared to clinical and pathological characteristics of tumors with the aim to identify impact of CD44 or CD133 expression on tumor behavior. Patients and Methods. Formalin fixed paraffin embedded samples from 94 patients with colorectal tumor and liver metastases were collected at Sikl’s Department of Pathology. Samples were stained by antibodies against CD44 and CD133. Presence and intensity of staining was assessed semiquantitatively by three trained researchers. Results. Patients with higher level of CD133 staining in CRC had longer disease free interval (Cox-Mantel ), whereas we found no relation between CD44 expression and overall survival or disease free interval. CD133 expression in CRC and CLM differed based on CRC grading; in case of CD44 we found differences in staining intensity in individual stages of tumor lymph node invasion. Conclusion. Effect of cancer stem cell markers on prognosis of colorectal cancer can vary depending on pathological classification of tumor, and we have shown that CD133, generally considered to be a negative marker, can bear also clinically positive prognostic information in group of patients with colorectal liver metastases. Pavel Pitule, Miroslava Cedikova, Ondrej Daum, Jan Vojtisek, Ondrej Vycital, Petr Hosek, Vladislav Treska, Ondrej Hes, Milena Kralickova, and Vaclav Liska Copyright © 2014 Pavel Pitule et al. All rights reserved. Laparoscopic Resection for Rectal Cancer: What Is the Evidence? Wed, 16 Apr 2014 13:54:00 +0000 Laparoscopic colectomy for colon cancer is a well-established procedure supported by several well-conducted large-scale randomised controlled trials. Patients could now be conferred the benefits of the minimally invasive approach while retaining comparable oncologic outcomes to the open approach. However, the benefits of laparoscopic proctectomy for rectal cancer remained controversial. While the laparoscopic approach is more technically demanding, results from randomised controlled trials regarding long term oncologic outcomes are only beginning to be reported. The impacts of bladder and sexual functions following proctectomy are considerable and are important contributing factors to the patients’ quality of life in the long-term. These issues present a delicate dilemma to the surgeon in his choice of operative approach in tackling rectal cancer. This is compounded further by the rapid proliferation of various laparoscopic techniques including the hand assisted, robotic assisted, and single port laparoscopy. This review article aims to draw on the significant studies which have been conducted to highlight the short- and long-term outcomes and evidence for laparoscopic resection for rectal cancer. Dedrick Kok-Hong Chan, Choon-Seng Chong, Bettina Lieske, and Ker-Kan Tan Copyright © 2014 Dedrick Kok-Hong Chan et al. All rights reserved. Total Reconstruction of the Auricle: Our Experiences on Indications and Recent Techniques Mon, 14 Apr 2014 00:00:00 +0000 Introduction. Auricular reconstruction is a great challenge in facial plastic surgery. With the advances in surgical techniques and biotechnology, different options are available for consideration. The aim of this paper is to review the knowledge about the various techniques for total auricular reconstruction based on the literature and our experience. Methods. Approximately 179 articles published from 1980 to 2013 were identified, and 59 articles were included. We have focused on the current status of total auricular reconstruction based on our personal experience and on papers of particular interest, published within the period of review. We have also included a prospective view on the tissue engineering of cartilage. Results. Most surgeons still practice total auricular reconstruction by employing techniques developed by Brent, Nagata, and Firmin with autologous rib cartilage. Within the last years, alloplastic frameworks for reconstruction have become well established. Choosing the reconstruction techniques depends mainly on the surgeon’s preference and experience. Prosthetic reconstruction is still reserved for special conditions, even though the material is constantly improving. Tissue engineering has a growing potential for clinical applicability. Conclusion. Auricular reconstruction still receives attention of plastic/maxillofacial surgeons and otolaryngologists. Even though clinical applicability lags behind initial expectations, the development of tissue-engineered constructs continues its potential development. K. Storck, R. Staudenmaier, M. Buchberger, T. Strenger, K. Kreutzer, A. von Bomhard, and T. Stark Copyright © 2014 K. Storck et al. All rights reserved. Technical Development of a New Semispherical Radiofrequency Bipolar Device (RONJA): Ex Vivo and In Vivo Studies Wed, 09 Apr 2014 14:23:29 +0000 The aim of this study is to inform about the development of a new semispherical surgical instrument for the bipolar multielectrode radiofrequency liver ablation. Present tools are universal; however they have several disadvantages such as ablation of healthy tissue, numerous needle punctures, and, therefore, longer operating procedure. Our newly designed and tested semispherical surgical tool can solve some of these disadvantages. By conducting an in vivo study on a set of 12 pigs, randomly divided into two groups, we have compared efficiency of the newly developed instrument with the commonly used device. Statistical analysis showed that there were no significant differences between the groups. On average, the tested instrument RONJA had shorter ablation time in both liver lobes and reduced the total operating time. The depth of the thermal alteration was on average 4 mm larger using the newly tested instrument. The new radiofrequency method described in this study could be used in open liver surgery for the treatment of small liver malignancies (up to 2 cm) in a single application with the aim of saving healthy liver parenchyma. Further experimental studies are needed to confirm these results before clinical application of the method in the treatment of human liver malignancies. Petr Vavra, Marek Penhaker, Jan Grepl, Jana Jurcikova, Jiri Palecek, Michal Crha, Jana Nowakova, Martin Hasal, Martina Skrobankova, Petr Ostruszka, Peter Ihnat, Patricie Delongova, Dana Salounova, Nagy A. Habib, and Pavel Zonca Copyright © 2014 Petr Vavra et al. All rights reserved. Patterns in the Parathyroid Response to Sodium Bicarbonate Infusion Test in Healthy Volunteers Tue, 08 Apr 2014 07:42:58 +0000 Background. The sodium bicarbonate infusion test evaluates the function of the parathyroid glands. The present study aims to evaluate the range of parathyroid response in healthy individuals and the potential influence of various factors. Methods. Fifty healthy volunteers were subjected to the test. Levels of vitamin D, calcium, albumin, and PTH were measured before infusion. PTH was measured at 3, 5, 10, 30, and 60 minutes after infusion. Results. A curve describing the response of parathyroids to the test was drawn. Twenty percent of the subjects had blunted PTH response. No significant difference was observed between normal and blunted responders concerning age, BMI, baseline PTH, or calcium levels. Nonetheless, there was a significant difference in vitamin D levels (). Interpretation. The test is easy to perform and may be used for everyday screening. It has to be clarified whether our observations are, at least partly, produced due to the presence of individuals with a constitutively blunted response or if low levels of vitamin D decrease the ability of the parathyroids to respond. Whichever the case, PTH response of normal individuals to sodium bicarbonate infusion test is more varied than previously thought and vitamin D levels influence it. Theodossis S. Papavramidis, Olympia E. Anastasiou, Ioannis Pliakos, Nick Michalopoulos, Mike Polyzonis, Konstantina Triantafyllopoulou, Georgia Kokaraki, and Spiros Papavramidis Copyright © 2014 Theodossis S. Papavramidis et al. All rights reserved. The Use of the Phrenic Nerve Communicating Branch to the Fifth Cervical Root for Nerve Transfer to the Suprascapular Nerve in Infants with Obstetric Brachial Plexus Palsy Mon, 31 Mar 2014 10:11:29 +0000 Traditionally, suprascapular nerve reconstruction in obstetric brachial plexus palsy is done using either the proximal C5 root stump or the spinal accessory nerve. This paper introduces another potential donor nerve for neurotizing the suprascapular nerve: the phrenic nerve communicating branch to the C5 root. The prevalence of this communicating branch ranges from 23% to 62% in various anatomical dissections. Over the last two decades, the phrenic communicating branch was used to reconstruct the suprascapular nerve in 15 infants. Another 15 infants in whom the accessory nerve was used to reconstruct the suprascapular nerve were selected to match the former 15 cases with regard to age at the time of surgery, type of palsy, and number of avulsed roots. The results showed that there is no significant difference between the two groups with regard to recovery of external rotation of the shoulder. It was concluded that the phrenic nerve communicating branch may be considered as another option to neurotize the suprascapular nerve. M. M. Al-Qattan and A. A. F. El-Sayed Copyright © 2014 M. M. Al-Qattan and A. A. F. El-Sayed. All rights reserved. Recombinant nAG (a Salamander-Derived Protein) Decreases the Formation of Hypertrophic Scarring in the Rabbit Ear Model Sun, 30 Mar 2014 10:04:30 +0000 nAG (newt-Anterrior Gradient) protein is the key mediator of regrowth of amputated limbs in salamanders. In a previous work in our lab, a new nAG gene (suitable for humans) was designed and cloned. The cloned vector was transfected into primary human fibroblasts. The expression of nAG in human primary fibroblasts was found to suppress collagen expression. The current study shows that local injection of recombinant nAG reduces scar hypertrophy in the rabbit ear model. This is associated with lower scar elevation index (SEI), lower levels of collagen I & III, higher levels of MMP1, and a higher degree of scar maturation in experimental wounds compared to controls. Mohammad M. Al-Qattan, Mervat M. Abd-Al Wahed, Khalid Hawary, Ahmed A. Alhumidi, and Medhat K. Shier Copyright © 2014 Mohammad M. Al-Qattan et al. All rights reserved. Colorectal Cancer: Prevention and Management of Metastatic Disease Mon, 24 Mar 2014 07:50:13 +0000 This paper compared the similarities and differences of the two most common types of colorectal cancer metastases. The treatment of liver metastases by surgery combined with systemic chemotherapy was explained. The different natural history of liver metastases as compared to peritoneal metastases and the possibility for prevention of peritoneal metastases were emphasized. Perioperative cancer chemotherapy or second-look surgery must be considered as individualized treatments of selected patients who have small volume peritoneal metastases or who are known to be at risk for subsequent disease progression on peritoneal surfaces. However, the fact that peritoneal metastases, when diagnosed in the follow-up of colorectal cancer patients, can be cured with a combination of cytoreductive surgery and hyperthermic perioperative chemotherapy cannot be ignored. Careful follow-up and timely intervention in colorectal cancer patients with progressive disease are a necessary part of the management strategies recommended by the multidisciplinary team. After a critical evaluation of the data currently available, these strategies for prevention and management of colorectal metastases are presented as the author’s recommendations for a high standard of care. As more information becomes available, modifications may be necessary. Paul H. Sugarbaker Copyright © 2014 Paul H. Sugarbaker. All rights reserved. TFIIB-Related Factor 2 Is Associated with Poor Prognosis of Nonsmall Cell Lung Cancer Patients through Promoting Tumor Epithelial-Mesenchymal Transition Mon, 17 Mar 2014 07:05:19 +0000 In this study, we found that increased BRF2 protein expression was prevalent in NSCLC. Overexpression of BRF2 correlated with abnormal expression of E-cadherin, N-cadherin, and snail. Additionally, expression of BRF2 was found to be an independent prognostic factor in NSCLC patients. Furthermore, we showed that targeted knockdown of BRF2 expression could inhibit the migratory and invasive abilities of NSCLC cells and induced loss of the epithelial-mesenchymal transition of NSCLC cells. These results suggested that BRF2 overexpression in tumor tissues is significantly associated with the poor prognosis of NSCLC patients through promoting epithelial-mesenchymal transition (EMT) program. Yu Tian, Ming Lu, Weiming Yue, Lin Li, Shuhai Li, Cun Gao, Libo Si, Lei Qi, Wensi Hu, and Hui Tian Copyright © 2014 Yu Tian et al. All rights reserved. Does Intraoperative Ulinastatin Improve Postoperative Clinical Outcomes in Patients Undergoing Cardiac Surgery: A Meta-Analysis of Randomized Controlled Trials Sun, 09 Mar 2014 07:14:47 +0000 Introduction. The systematic meta-analysis of randomized controlled trials (RCTs) evaluated the effects of intraoperative ulinastatin on early-postoperative recovery in patients undergoing cardiac surgery. Methods. RCTs comparing intraoperative ulinastatin with placebo in cardiac surgery were searched through PubMed, Cochrane databases, Medline, SinoMed, and the China National Knowledge Infrastructure (1966 to May 20th, 2013). The primary endpoints included hospital mortality, postoperative complication rate, length of stay in intensive care unit, and extubation time. The physiological and biochemical parameters illustrating postoperative cardiac and pulmonary function as well as inflammation response were considered as secondary endpoints. Results. Fifteen RCTs (509 patients) met the inclusion criteria. Ulinastatin did not affect hospital mortality, postoperative complication rate, or ICU length of stay but reduced extubation time. Ulinastatin also increased the oxygenation index on postoperative day 1 and reduced the plasma level of cardiac troponin-I. Additionally, ulinastatin inhibited the increased level of tumor necrosis factor-alpha, polymorphonuclear neutrophil elastase, interleukin-6, and interleukin-8 associated with cardiac surgery. Conclusion. Ulinastatin may be of value for the inhibition of postoperative increased inflammatory agents and most likely provided pulmonary protective effects in cardiac surgery. However, larger adequately powered RCTs are required to define the clinical effect of ulinastatin on postoperative outcomes in cardiac surgery. Qiu-Lan He, Fei Zhong, Fang Ye, Ming Wei, Wei-Feng Liu, Mei-Na Li, Qiao-Bo Li, Wen-Qi Huang, Lai-Bao Sun, and Hai-Hua Shu Copyright © 2014 Qiu-Lan He et al. All rights reserved. Tissue Factor and Tissue Factor Pathway Inhibitor in Chronically Inflamed Gallbladder Mucosa Thu, 27 Feb 2014 15:52:02 +0000 We characterised a tissue factor (TF) and tissue factor pathway inhibitor (TFPI) expression in relation to severity of inflammatory infiltration of the gallbladder mucosa in a chronic cholecystitis. We prospectively studied the gallbladder specimens obtained from 54 patients who had undergone cholecystectomy due to chronic calculous cholecystitis and 16 calculosis-free gallbladder specimens obtained from patients who underwent cholecystectomy due to the polyp/polyps as well as in cases of gallbladder injury. To assess TF and TFPI immunoreactivity by immunohistochemistry, the monoclonal anti-human TF and TFPI antibodies were used. The inflammatory infiltration of the gallbladder mucosa was reflected by the number of CD3 and CD68 positive cells. The expression of TF and TFPI differed significantly between the cholecystitis and the control group. Most capillary endothelial cells of the cholecystitis group presented weak expression for TFPI. The mean number of CD3 positive lymphocytes in the cholecystitis group was 18.6 ± 12.2, but the mean number of CD68 positive cells was 29.7 ± 13.9. In the control sections, it was 3.1 ± 1.9 and 8.8 ± 3.9, respectively (). The results of the current study suggest that the tissue procoagulant state found may be engaged in the etiopathogenesis of the cholecystitis. Jacek Liczko, Tomasz Stawski, Małgorzata Żaba, Józef Kurek, Daniel Sabat, Grzegorz Wyrobiec, Dorota Domal-Kwiatkowska, Damian Dudek, Marek Kucharzewski, and Krzysztof Helewski Copyright © 2014 Jacek Liczko et al. All rights reserved. Cone Beam Computed Tomographic Analyses of the Position and Course of the Mandibular Canal: Relevance to the Sagittal Split Ramus Osteotomy Thu, 27 Feb 2014 07:54:09 +0000 Purpose. The aim of this study was to document the position and course of the mandibular canal through the region of the mandibular angle and body in dental patients, using cone beam computed tomographic imaging. Methods. The position and course of the mandibular canal from the region of the third molar to the first molar were measured at five specific locations in the same plane: at three different positions just between the first and second molars; between the second and third molars; and just distal to the third molar. Results. The study sample was composed of 500 hemimandibles from 250 dental patients with a mean age of 26.32. Significant differences were found between genders, distances, and positions. B decreased significantly from the anterior positions to the posterior positions in both females and males. The mean values of S and CB increased significantly from the posterior positions to the anterior positions in both females and males. Conclusion. Because the sagittal split ramus osteotomy is a technically difficult procedure, we hope that the findings of the present study will help the surgeon in choosing the safest surgical technique for the treatment of mandibular deformities. Ahmet Ercan Sekerci and Halil Sahman Copyright © 2014 Ahmet Ercan Sekerci and Halil Sahman. All rights reserved. Relative Contribution of Haptic Technology to Assessment and Training in Implantology Thu, 20 Feb 2014 13:22:55 +0000 Background. The teaching of implant surgery, as in other medical disciplines, is currently undergoing a particular evolution. Aim of the Study. To assess the usefulness of haptic device, a simulator for learning and training to accomplish basic acts in implant surgery. Materials and Methods. A total of 60 people including 40 third-year dental students without knowledge in implantology (divided into 2 groups: 20 beginners and 20 experiencing a simulator training course) and 20 experienced practitioners (experience in implantology >15 implants) participated in this study. A basic exercise drill was proposed to the three groups to assess their gestural abilities. Results. The results of the group training with the simulator tended to be significantly close to those of the experienced operators. Conclusion. Haptic simulator brings a real benefit in training for implant surgery. Long-term benefit and more complex exercises should be evaluated. David Joseph, Jean-Philippe Jehl, Pablo Maureira, Cyril Perrenot, Neal Miller, Pierre Bravetti, Pascal Ambrosini, and Nguyen Tran Copyright © 2014 David Joseph et al. All rights reserved. Clinical Outcomes after Treatment of Periodontal Intrabony Defects with Nanocrystalline Hydroxyapatite (Ostim) or Enamel Matrix Derivatives (Emdogain): A Randomized Controlled Clinical Trial Sun, 09 Feb 2014 13:13:08 +0000 Introduction. Periodontitis is an inflammatory process in response to dental biofilm and leads to periodontal tissue destruction. The aim of this study was the comparison of outcomes using either an enamel matrix derivative (EMD) or a nanocrystalline hydroxyapatite (NHA) in regenerative periodontal therapy after 6 and 12 months. Methods. Using a parallel group, prospective randomized study design, we enrolled 19 patients in each group. The primary outcome was bone fill after 12 months. Attachment gain, probing pocket depth (PPD) reduction, and recession were secondary variables. Additionally, early wound healing and adverse events were assessed. Data analysis included test of noninferiority of NHA group (test) compared to EMD group (reference) in bone fill. Differences in means of secondary variables were compared by paired t-test, frequency data by exact χ2 test. Results. Both groups showed significant bone fill, reduction of PPD, increase in recession, and gain of attachment after 6 and 12 months. No significant differences between groups were found at any time point. Adverse events were comparable between both groups with a tendency of more complaints in the NHA group. Conclusion. The clinical outcomes were similar in both groups. EMD could have some advantage compared to NHA regarding patients comfort and adverse events. The trial is registered with NCT00757159. Elyan Al Machot, Thomas Hoffmann, Katrin Lorenz, Ihssan Khalili, and Barbara Noack Copyright © 2014 Elyan Al Machot et al. All rights reserved. Transverse Skin Crease versus Vertical Midline Incision versus Laparoscopy for Right Hemicolectomy: A Systematic Review—Current Status of Right Hemicolectomy Thu, 30 Jan 2014 09:59:00 +0000 Purpose. The right hemicolectomy may be conducted through laparoscopic or laparotomic surgery, transverse or midline incisions. The transverse laparotomy offers some advantages compared to the midline laparotomy and laparoscopy. A literature review was performed to evaluate the possible advantages of the transverse incision versus midline incision or laparoscopic right hemicolectomy. Methods. A systematic research was performed in Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, BioMed Central, and the Science Citation Index. Results. Laparotomic right hemicolectomy with transverse incision is preferable to laparotomic hemicolectomy with midline incision. A transverse incision offers a lessened postoperative pain following physical activity, a lessened need to administer analgesic therapy during the post-operative time, better aesthetic results, and a better post-operative pulmonary function. Open surgery with transverse or midline incision ensured a shorter operative time, lower costs and a greater length of the incision compared to the laparoscopic. However, there are no differences in the oncological outcomes. Conclusions. It was not possible to identify significant differences between the open right hemicolectomy with transverse incision versus the open right hemicolectomy with midline incision or laparoscopic hemicolectomy. Alberto Santoro, Carlo Boselli, Claudio Renzi, Francesca Gubbiotti, Veronica Grassi, Giorgio Di Rocco, Roberto Cirocchi, and Adriano Redler Copyright © 2014 Alberto Santoro et al. All rights reserved. Long-Term Use of Probiotics Lactobacillus and Bifidobacterium Has a Prophylactic Effect on the Occurrence and Severity of Pouchitis: A Randomized Prospective Study Tue, 21 Jan 2014 13:55:58 +0000 Aim. The aim of the study was to assess the impact of the long-term use of the composite probiotics in patients after restorative proctocolectomy. Method. Forty-three patients (20 females and 23 males, aged 21 to 68 years) after restorative proctocolectomy were included in the study. After randomization patients were divided into placebo group and treatment group with oral intake of probiotic containing Lactobacillus acidophilus, Lactobacillus delbrueckii subsp. bulgaricus, and Bifidobacterium bifidus. Patients were investigated during initial visit and during final visit after 9 months. All patients were subjected to standard clinical and endoscopic examination with microscopic study of the specimens. Concentrations of calprotectin and pyruvate kinase isoenzyme M2-PK were determined in all cases. Results. The average severity of pouchitis and the number of patients with pouchitis significantly decrease after 9 months of the probiotic taking. The concentrations of calprotectin and pyruvate kinase isoenzyme M2-PK significantly decreased after the therapy. Conclusions. Nine months of the probiotic treatment (Lactobacillus acidophilus, Lactobacillus delbrueckii subsp. bulgaricus, and Bifidobacterium bifidus) reduced the number of patients with pouchitis, decreased the PDAI score, and also decreased the fecal pyruvate kinase and calprotectin. The long-term probiotics use is safe and well accepted and can be an effective method of the pouchitis prevention. Banasiewicz Tomasz, Stojcev Zoran, Walkowiak Jarosław, Marciniak Ryszard, Grochowalski Marcin, Burdyński Robert, Krokowicz Piotr, Krokowicz Lukasz, Paszkowski Jacek, Gronek Piotr, Pyda Przemysław, and Drews Michał Copyright © 2014 Banasiewicz Tomasz et al. All rights reserved. The Evidence for Nerve Repair in Obstetric Brachial Plexus Palsy Revisited Thu, 16 Jan 2014 08:29:25 +0000 Strong scientific validation for nerve reconstructive surgery in infants with Obstetric Brachial Plexus Palsy is lacking, as no randomized trial comparing surgical reconstruction versus conservative treatment has been performed. A systematic review of the literature was performed to identify studies that compare nerve reconstruction to conservative treatment, including neurolysis. Nine papers were identified that directly compared the two treatment modalities. Eight of these were classified as level 4 evidence and one as level 5 evidence. All nine papers were evaluated in detail to describe strong and weak points in the methodology, and the outcomes from all studies were presented. Pooling of data was not possible due to differences in patient selection for surgery and outcome measures. The general consensus is that nerve reconstruction is indicated when the result of nerve surgery is assumedly better than the expected natural recovery, when spontaneous recovery is absent or severely delayed. The papers differed in methodology on how the cut-off point to select infants for nerve reconstructive surgical therapy should be determined. The justification for nerve reconstruction is further discussed. Willem Pondaag and Martijn J. A. Malessy Copyright © 2014 Willem Pondaag and Martijn J. A. Malessy. All rights reserved. Extending the Indications for Primary Nerve Surgery in Obstetrical Brachial Plexus Palsy Sun, 12 Jan 2014 16:45:08 +0000 Purpose. This study identifies a small subset of patients with obstetrical brachial plexus palsy who, while they do not meet common surgical indications, may still benefit from primary nerve surgery. Methods. Between April 2004 and April 2009, 17 patients were offered primary nerve surgery despite not meeting the standard surgical indications of the authors. The authors performed a retrospective analysis of these 17 patients using prospectively collected data. Results. This group of 17 patients were identified as having poor shoulder function at about 9 months of age despite passing the Cookie Test. Fourteen patients underwent surgical intervention and three families declined surgery. All patients in the operative group regained some active external rotation after surgery. Five patients in this group have required further interventions. Two of the three patients for whom surgery was declined have had no subsequent spontaneous improvement in active external rotation. Discussion. The commonly used indications for primary nerve surgery in obstetrical brachial plexus palsy may not adequately identify all patients who may benefit from surgical intervention. Patients who pass the Cookie Test but have poor spontaneous recovery of active shoulder movements, particularly external rotation, may still benefit from primary nerve surgery. Stuart A. Bade, Jenny C. Lin, Christine G. Curtis, and Howard M. Clarke Copyright © 2014 Stuart A. Bade et al. All rights reserved. Median Nerve to Biceps Nerve Transfer to Restore Elbow Flexion in Obstetric Brachial Plexus Palsy Thu, 09 Jan 2014 09:53:39 +0000 Median nerve to biceps nerve transfer in the arm has been reported only in adults. The following paper reports on 10 cases of this transfer in obstetric brachial plexus palsy. All patients had upper palsy (ERb’s or extended ERb’s palsy) and presented to the author late (13–19 months of age) with poor or no recovery of elbow flexion. Following the nerve transfer, nine children recovered elbow flexion (a score of 6 in one child and a score of 7 in eight children by the Toronto scale). The remaining child did not recover elbow flexion. M. M. Al-Qattan and T. M. Al-Kharfy Copyright © 2014 M. M. Al-Qattan and T. M. Al-Kharfy. All rights reserved. Obstetric Brachial Plexus Palsy: The Mallet Grading System for Shoulder Function—Revisited Sun, 05 Jan 2014 11:57:17 +0000 The Mallet grading system is a commonly used functional scoring system to assess shoulder abduction/external rotation deficits in children with obstetric brachial plexus palsy. One feature of the Mallet score is that each grade is translated into certain degrees of deficiencies in both shoulder abduction and external rotation. The aim of the current study is to investigate the percentage of children in which the Mallet score could not be applied because of a discrepancy between the deficiency of shoulder abduction and shoulder external rotation. The study group included 50 consecutive unoperated older children (over 5 years of age) with Erb’s palsy and deficits in shoulder movements. The Mallet score could be applied in 40 cases (80%). In the remaining 10 cases (20%), the Mallet score could not be applied either because shoulder abduction had a better grade than the grade of shoulder external rotation () or vice versa (). It was concluded that documenting the deficits in shoulder abduction and external rotation are best done separately and this can be accomplished by using other grading systems. M. M. Al-Qattan and A. A. F. El-Sayed Copyright © 2014 M. M. Al-Qattan and A. A. F. El-Sayed. All rights reserved. Triceps Innervation Pattern: Implications for Triceps Nerve to Deltoid Nerve Transfer Mon, 30 Dec 2013 07:42:17 +0000 There are multiple nerve branches supplying the triceps. Traditionally, the nerve to the long head of triceps is utilized for nerve transfer to neurotize the deltoid muscle in patients with brachial plexus injuries. However, no anatomical studies were done to investigate which triceps nerve would be preferred for nerve transfer. This anatomical study was carried out to describe the innervation pattern of the triceps muscle to investigate the preferred triceps nerve for nerve transfer. Twenty-five cadaveric arms were dissected. The long head of the triceps received a single branch in 23 cases (92%) and double branches in 2 cases (8%) only. The medial head had a single branch in 22 cases (88%) and double branches in 3 cases (12%). The lateral head was the most bulky one and received more than one branch in all cases (100%), ranging from 2 to 5 branches. The transfer of the most proximal branch to the lateral head of the triceps seems to be the most preferred choice for deltoid muscle innervation. Obaid Al-Meshal and Alain Gilbert Copyright © 2013 Obaid Al-Meshal and Alain Gilbert. All rights reserved. Bilateral Single-Port Sympathectomy: Long-Term Results and Quality of Life Sat, 07 Dec 2013 16:04:56 +0000 Object. Video-assisted thoracoscopic sympathectomy is a safe, effective, and minimally invasive procedure for primary hyperhidrosis. This study aims to evaluate long-term results and patients’ quality of life and investigate potential variables responsible for compensatory sweating after one-stage bilateral single-port thoracoscopic sympathectomy. Methods. Between 2005 and 2011, 260 consecutive bilateral thoracoscopic sympathectomies were performed in 130 patients for primary palmar and axillary hyperidrosis through one-port access. Residual pain, postoperative complications, recurrence of symptoms, heart rate adjustment, and quality of life were analyzed. Multivariate analysis was performed. Results. No operative mortality and conversion to open surgery were recorded. Mean operative time was 38 ± 5 minutes. Mean hospital stay was 1.1 ± 0.6 days. Eight patients (6%) had unilateral pneumothorax. Twenty-five cases (19%) were complicated by compensatory sweating. Winter and fall were identified as protective factors for compensatory sweating occurrence. Decreased heart rate was observed 1 year after surgery and permanently over the time. No recurrence during the follow-up period (31.5 months) was observed and 90% of patients showed improved quality of life. Conclusions. One-stage bilateral miniuniportal thoracoscopic sympathectomy is a valid and safe treatment for primary hyperhidrosis, achieving definitive and esthetic results, with excellent patients’ satisfaction. Compensatory sweating may potentially occur in a season-dependent manner. Mohsen Ibrahim, Cecilia Menna, Claudio Andreetti, Anna Maria Ciccone, Antonio D'Andrilli, Giulio Maurizi, Leda Marina Pomes, Francesco Cassiano, Federico Venuta, and Erino A. Rendina Copyright © 2013 Mohsen Ibrahim et al. All rights reserved. Rotational Transport of Islets: The Best Way for Islets to Get around? Wed, 13 Nov 2013 08:47:37 +0000 Islet transplantation is a valid treatment option for patients suffering from type 1 diabetes mellitus. To assure optimal islet cell quality, specialized islet isolation facilities have been developed. Utilization of such facilities necessitates transportation of islet cells to distant institutions for transplantation. Despite its importance, a clinically feasible solution for the transport of islets has still not been established. We here compare the functionality of isolated islets from C57BL/6 mice directly after the isolation procedure as well as after two simulated transport conditions, static versus rotation. Islet cell quality was assessed using real-time live confocal microscopy. In vivo islet function after syngeneic transplantation was determined by weight and blood sugar measurements as well as by intraperitoneal glucose tolerance tests. Vascularization of islets was documented by fluorescence microscopy and immunohistochemistry. All viability parameters documented comparable cell viability in the rotary group and the group transplanted immediately after isolation. Functional parameters assessed in vivo displayed no significant difference between these two groups. Moreover, vascularization of islets was similar in both groups. In conclusion, rotary culture conditions allows the maintenance of highest islet quality for at least 15 h, which is comparable to that of freshly isolated islets. Rupert Oberhuber, Christof Mittermair, Bettina Zelger, Daniela Pirkebner, Anna Draxl, Annemarie Weissenbacher, Thomas Resch, Christian Margreiter, Robert Sucher, Raimund Margreiter, Johann Pratschke, Paul Hengster, and Martin Hermann Copyright © 2013 Rupert Oberhuber et al. All rights reserved. Comparison of New Technology Integrated and Nonintegrated Arterial Filters Used in Cardiopulmonary Bypass Surgery: A Randomized, Prospective, and Single Blind Study Mon, 11 Nov 2013 14:10:12 +0000 Background. Innovative cardiopulmonary bypass (CPB) settings have been developed in order to integrate the concepts of “surface-coating,” “blood-filtration,” and “miniaturization.” Objectives. To compare integrated and nonintegrated arterial line filters in terms of peri- and postoperative clinical variables, inflammatory response, and transfusion needs. Material and Methods. Thirty-six patients who underwent coronary bypass surgery were randomized into integrated (Group In) and nonintegrated arterial line filter (Group NIn) groups. Arterial blood samples for the assessments of complete hemogram, biochemical screening, interleukin-6, interleukin-2R, and C-reactive protein were analyzed before and after surgery. Need for postoperative dialysis, inotropic therapy and transfusion, in addition to extubation time, total amount of drainage (mL), length of intensive care unit, and hospital stay, and mortality rates was also recorded for each patient. Results. Prime volume was significantly higher and mean intraoperative hematocrit value was lower in Group NIn, but need for erythrocyte transfusion was significantly higher in Group NIn. C-reactive protein values did not differ significantly except for postoperative second day's results, which were found significantly lower in Group In than in Group NIn. Conclusion. Intraoperative hematocrit levels were higher and need for postoperative erythrocyte transfusion was decreased in Group In. Özgür Gürsu, Selim Isbir, Koray Ak, Fethullah Gerin, and Sinan Arsan Copyright © 2013 Özgür Gürsu et al. All rights reserved. Gastric Stump Cancer: More Than Just Another Proximal Gastric Cancer and Demanding a More Suitable TNM Staging System Mon, 16 Sep 2013 13:21:45 +0000 Background. Considerable controversy persists about the biological behavior of gastric stump cancer (GSC). The aim of this study is to clarify if this cancer is just another proximal gastric cancer or if it emerges as a distinctive clinicopathologic entity. Methods. This review of a prospectively collected gastric cancer database identified 73 patients with GSC in a single institution between January 1980 and June 2012 and compared them with 328 patients with proximal gastric cancer (PGC) and 291 patients with esophagogastric junction cancer (EGJC). Results. Patients with GSC were predominantly males. Eighty-three percent of GSC penetrated the subserosal or the serosal layers. The median number of lymph nodes retrieved in GSC patients was significantly lower than in PGC patients or in EGJC patients. Cumulative survival curves were not different between GSC, PGC, or EGJC patients. Unlike that observed in PGC and in EGJC, no significant differences in cumulative survival according to the TNM staging system were observed in GSC cases. Conclusions. The outcome of patients with GSC displayed significant differences when compared to those with other proximal gastric cancers concerning the lack of survival association with the TNM staging system. Therefore a more suitable staging system should be designed for these unique cancers. André Costa-Pinho, J. Pinto-de-Sousa, José Barbosa, and J. Costa-Maia Copyright © 2013 André Costa-Pinho et al. All rights reserved. Preliminary Results of Implantation in Animal Model and Osteoblast Culture Evaluation of Prototypes of Biomimetic Multispiked Connecting Scaffold for Noncemented Stemless Resurfacing Hip Arthroplasty Endoprostheses Mon, 29 Jul 2013 13:57:29 +0000 We present the new fixation method for RHA (resurfacing hip arthroplasty) endoprostheses by means of the biomimetic multispiked connecting scaffold (MSC-Scaffold). Such connecting scaffold can generate new type of RHA endoprostheses, that is stemless and fixed entirely without cement. The preprototypes of this MSC-Scaffold were manufactured with modern additive laser additive technology (SLM). The pilot surgical implantations in animal model (two laboratory swine) of MSC-Scaffold preprototypes have showed after two months neither implant loosening, migration, and nor other early complications. From the results of performed histopathological evaluation of the periscaffold spikes bone tissue and 10-day culture of human osteoblasts (NHOst) we can conclude that (1) the scaffolding effect was obtained and (2) to improve the osseointegration of the scaffold spikes, their material surface should be physicochemically modified (e.g., with hydroxyapatite). Some histopathological findings in the periscaffold domain near the MSC-Scaffold spikes bases (fibrous connective tissue and metallic particles near the MSC-Scaffold spikes bases edges) prompt considering the necessity to optimize the design of the MSC-Scaffold in the regions of its interspike space near the spikes bases edges, to provide more room for new bone formation in this region and for indispensable post-processing (glass pearl blasting) after the SLM manufacturing. Ryszard Uklejewski, Piotr Rogala, Mariusz Winiecki, Andrzej Kędzia, and Piotr Ruszkowski Copyright © 2013 Ryszard Uklejewski et al. All rights reserved. Growth Factors Serum Levels in Coronary Artery Disease Patients Scheduled for Bypass Surgery: Perioperative Dynamics and Comparisons with Healthy Volunteers Mon, 29 Jul 2013 08:39:37 +0000 Background. Vascular endothelial growth factors are important mediators for neovascularization of chronically ischemic adult heart, but their elevated values have also been connected with acute ischemia. Coronary artery bypass grafting (CABG) is associated with activation of inflammatory processes. We aimed to clarify whether the latter is also accompanied with acute changes in concentrations of vascular growth factors. Methods. Concentrations of growth factors VEGF and EGF, monocyte chemoattractant protein-1 (MCP-1), and a set of cytokines of 39 patients with stable coronary artery disease (CAD) were evaluated before and after CABG. Preoperative values were compared with data of healthy volunteers. Results. In comparison with CAD patients, healthy controls had significantly higher values of VEGF (15.5 (10.05–35.3) and 119.4 (55.7–136.9) pg/mL, resp.), EGF (1.70 (1.14–3.18) and 37.3 (27.1–51.9) pg/mL, resp.), and MCP-1 (111.6 (81.75–171.9) and 156.9 (134.7–241.3) pg/mL, resp.). MCP-1, but not others, demonstrated a significant rise throughout the postoperative period. Proinflammatory interleukin-6 was significantly higher and anti-inflammatory IL-4 and IL-10 lower in patients with CAD. Conclusions. Patients with stable CAD have lower serum levels of growth factors than healthy volunteers. MCP-1, but not VEGF and EGF, becomes elevated immediately after CABG. Inflammatory status of CAD patients was drifted towards proinflammatory state. Inga Karu, Joel Starkopf, Kersti Zilmer, and Mihkel Zilmer Copyright © 2013 Inga Karu et al. All rights reserved. The Investigation of Laparoscopic Instrument Movement Control and Learning Effect Wed, 24 Jul 2013 09:06:30 +0000 Laparoscopic surgery avoids large incisions for intra-abdominal operations as required in conventional open surgery. Whereas the patient benefits from laparoscopic techniques, the surgeon encounters new difficulties that were not present during open surgery procedures. However, limited literature has been published in the essential movement characteristics such as magnification, amplitude, and angle. For this reason, the present study aims to investigate the essential movement characteristics of instrument manipulation via Fitts' task and to develop an instrument movement time predicting model. Ten right-handed subjects made discrete Fitts' pointing tasks using a laparoscopic trainer. The experimental results showed that there were significant differences between the three factors in movement time and in throughput. However, no significant differences were observed in the improvement rate for movement time and throughput between these three factors. As expected, the movement time was rather variable and affected markedly by direction to target. The conventional Fitts' law model was extended by incorporating a directional parameter into the model. The extended model was shown to better fit the data than the conventional model. These findings pointed to a design direction for the laparoscopic surgery training program, and the predictive model can be used to establish standards in the training procedure. Chiuhsiang Joe Lin and Hung-Jen Chen Copyright © 2013 Chiuhsiang Joe Lin and Hung-Jen Chen. All rights reserved. Minimally Invasive Thoracic Surgery in Pediatric Patients: The Taiwan Experience Thu, 30 May 2013 09:01:56 +0000 Minimally invasive technology or laparoscopic surgery underwent a major breakthrough over the past two decades. The first experience of thoracoscopy in children was reported around 1980 for diagnosis of intrathoracic pathology and neoplasia. Up until the middle of the 1990s, the surgical community in Taiwan was still not well prepared to accept the coming era of minimally invasive surgery. In the beginning, laparoscopy was performed in only a few specialties and only relatively short or simple surgeries were considered. But now, the Taiwan’s experiences over the several different clinical scenarios were dramatically increased. Therefore, we elaborated on the experience about pectus excavatum: Nuss procedure, primary spontaneous hemopneumothorax, thoracoscopic thymectomy, and empyema in Taiwan. Yu-Kai Huang, Chieh Chou, Chung-Liang Li, Hui-Gin Chiu, and Yu-Tang Chang Copyright © 2013 Yu-Kai Huang et al. All rights reserved. Soft Tissue Response to the Presence of Polypropylene-G-Poly(ethylene glycol) Comb-Type Graft Copolymers Containing Gold Nanoparticles Sun, 25 Dec 2011 13:01:09 +0000 The aim of this study is to evaluate the soft tissue response of the pure and Au-embedded PPg-PEG. PP-g-PEG2000, PP-g-PEG4000, Au-PP-g-PEG2000, and AuPP-g-PEG4000 were obtained via chlorination of polypropylene and polyethylene glycol in the presence of a base with a “grafting onto” technique. Solvent cast films of these four copolymers with PP as a control group were embedded into five different rats. After 30 days of implantation, microscopic evaluation of inflammation and SEM analysis were done. PP had the most intense inflammatory reaction among the other polymers. PP-PEG block copolymers with high molecular weight and gold-nanoparticles-embedded ones revealed mild inflammatory reaction independently. SEM assessment revealed punched hole-like defects on the surface of all polymer samples except for PP. Graft copolymers with PEG, especially Au-attached ones, have favorable soft tissue response, and inflammatory reaction becomes milder as the number of PEG side chains increases. Derya Burcu Hazer, Baki Hazer, and Nazmiye Dinçer Copyright © 2011 Derya Burcu Hazer et al. All rights reserved. Relative Quantification of Several Plasma Proteins during Liver Transplantation Surgery Sat, 10 Dec 2011 13:34:49 +0000 Plasma proteome is widely used in studying changes occurring in human body during disease or other disturbances. Immunological methods are commonly used in such studies. In recent years, mass spectrometry has gained popularity in high-throughput analysis of plasma proteins. In this study, we tested whether mass spectrometry and iTRAQ-based protein quantification might be used in proteomic analysis of human plasma during liver transplantation surgery to characterize changes in protein abundances occurring during early graft reperfusion. We sampled blood from systemic circulation as well as blood entering and exiting the liver. After immunodepletion of six high-abundant plasma proteins, trypsin digestion, iTRAQ labeling, and cation-exchange fractionation, the peptides were analyzed by reverse phase nano-LC-MS/MS. In total, 72 proteins were identified of which 31 could be quantified in all patient specimens collected. Of these 31 proteins, ten, mostly medium-to-high abundance plasma proteins with a concentration range of 50–2000 mg/L, displayed relative abundance change of more than 10%. The changes in protein abundance observed in this study allow further research on the role of several proteins in ischemia-reperfusion injury during liver transplantation and possibly in other surgery. Ville Parviainen, Sakari Joenväärä, Eija Tukiainen, Minna Ilmakunnas, Helena Isoniemi, and Risto Renkonen Copyright © 2011 Ville Parviainen et al. All rights reserved. Preparation and Characterization of a Novel Skin Substitute Wed, 22 Sep 2010 16:09:22 +0000 Autologous epidermal cell cultures (CEA) represent a possibility to treat extensive burn lesions, since they allow a significative surface expansion which cannot be achieved with other surgical techniques based on autologous grafting. Moreover currently available CEA preparations are difficult to handle and their take rate is unpredictable. This study aimed at producing and evaluating a new cutaneous biosubstitute made up of alloplastic acellular glycerolized dermis (AAGD) and CEA to overcome these difficulties. A procedure that maintained an intact basement membrane was developed, so as to promote adhesion and growth of CEA on AAGD. Keratinocytes were seeded onto AAGD and cultured up to 21 days. Viability tests and immunohistochemical analysis with specific markers were carried out at 7, 14, and 21 days, to evaluate keratinocyte adhesion, growth, and maturation. Our results support the hypothesis that this newly formed skin substitute could allow its permanent engraftment in clinical application. Carlotta Castagnoli, Mara Fumagalli, Daniela Alotto, Irene Cambieri, Stefania Casarin, Alessia Ostorero, Raffaella Casimiri, Patrizia Germano, Carla Pezzuto, and Maurizio Stella Copyright © 2010 Carlotta Castagnoli et al. All rights reserved.