我们要感谢明尼苏达大学的胸肠和前肠外科以及外科系帮助我们进行这项研究。

此处描述的协议和方法已获得批准，并遵循明尼苏达大学机构审查委员会 （IRB） 的道德准则。这里描述的是一名 73 岁女性的再次手术裂管裂孔疝修补术和先前的 Nissen 胃底折叠术的拆除术。患者因腹腔镜食管裂孔疝修补术和 5 年前在室外医院接受过胃底折叠术到诊所就诊，因餐后上腹痛和饱胀感。她还主诉摄入固体食物时出现严重反流和吞咽困难。她的症状在第一次手术后暂时消退，但现在又复发了。值得注意的是，咨询时她的体重指数 （BMI） 为 40。在会诊前无法获得先前的术前检查。患者在重做前肠手术前提供了书面知情同意书。
1. 患者准备和手术设置
<ol><li>术前检查和检查<ol><li>讨论再次手术的可能性，并进行彻底的检查，如上所述：<ol><li>进行食管造影。该患者的食管造影显示中度至重度食管运动障碍（图1）。</li>
			<li>进行内窥镜检查。对于这名患者，上消化道内镜检查未显示狭窄或狭窄，但在后反射镜上显示胃的一部分通过横膈膜向上突出，证实了食管裂孔疝。</li>
			<li>进行腹部计算机断层扫描。该测试还证实了疝出的包裹物（图2）。</li>
			<li>进行无线食管 pH 值测试。结果显示，DeMeester 评分为24,25 分，得分为 38.4，胃酸反流的临界症状关联概率。</li>
			<li>执行高分辨率测压。在该患者中，它表现出非特异性运动障碍。</li>
		</ol></li>
	</ol></li>
	<li>术前规划<ol><li>确保最初的建议包括减轻体重，因此如果需要，应转诊给减肥外科医生。 注意：患者在减肥计划中做得很好，可以将她的体重降低到 32 的 BMI。此时，她仍然出现症状，她的病例在多学科食管手术计划会议上进行了讨论。共识是，测压结果可能是由于反流和疝气引起的，并且使用松散的胃底折叠术再次手术疝修补术是合适的。</li>
	</ol></li>
	<li>麻醉<ol><li>按照机构指南进行麻醉。使用单腔气管插管对患者进行插管，并快速顺序插管，因为存在反流误吸和食管裂孔疝的风险。她有一条用于血流动力学监测的动脉管路。</li>
	</ol></li>
	<li>定位<ol><li>将患者仰卧位，双臂伸出，脚踏板，以利于陡峭的反向特伦德伦堡定位26.胸部和腹部始终为前肠手术做好准备，以便在需要时有足够的时间进入腹部和胸部。</li>
	</ol></li>
	<li>端口放置和对接<ol><li>使用开放的 Hasson 技术27 进入左脐上腔的腹膜腔。在此处插入相机端口。</li>
		<li>在左上象限再插入两个 8 mm 端口，在右上象限插入一个 8 mm 端口。将端口放置在脐部上方约 10 厘米处，并确保端口之间留有手宽空间。</li>
		<li>将辅助端口放在右下象限。将肝牵开器（参见 材料表）插入放置在右上象限最外侧部分的 5 毫米端口。 注：作者倾向于在手术过程中放置左侧胸管，因为疝囊往往与胸膜相连，尤其是在再次手术中。</li>
		<li>在开始解剖之前执行此操作，以最大程度地减少在手术过程中必须断开和重新定位的机会，如果在解剖过程中急性发展的气胸出现显着的血流动力学变化。</li>
		<li>对接机器人（参见 材料表）。</li>
	</ol></li>
</ol>2. 手术程序
<ol><li>减少食管裂孔疝<ol><li>去除肠与腹壁的粘连，并使用机器人双极手术能量装置打开胃肝韧带。</li>
		<li>通过去除粘连和额外的短胃动脉分支来打开小囊。</li>
		<li>在裂孔处使用钝性解剖和电烙术的组合与机器人一起沿圆周解剖疝囊。</li>
		<li>用腹腔镜剪刀仔细解剖肝脏和胃之间的密集粘连（见 材料表）。</li>
	</ol></li>
	<li>删除以前的胃底折叠术。 注意：上一次包裹的部分但不是全部缝合线是可见的。<ol><li>用腹腔镜剪刀进行锐利的解剖，并解开包裹物以完全释放胃。</li>
		<li>小心地留在薄的疤痕组织中，以避免对胃或食道造成损害。</li>
	</ol></li>
	<li>食管动员<ol><li>在纵隔中经裂孔动员食管。通过钝性和尖锐的解剖相结合来做到这一点，并尽量减少在食道附近使用能量。</li>
		<li>接下来，确认腹内食管长度至少为 3 厘米。使用内窥镜检查定位胃食管交界处 （GEJ），并测量从食管裂孔到 GEJ 的食管，以确认足够的长度。</li>
	</ol></li>
	<li>泄漏测试<ol><li>进行内窥镜检查并清楚地观察粘膜，以确保没有受伤。用温水填充上腹部，并吹入食道和胃，以确保没有空气泄漏。</li>
	</ol></li>
	<li>食管裂孔修复<ol><li>使用 0-丝缝合线进行小腿修复，其中两条后小腿缝线和一条前小腿缝合线。</li>
		<li>将 56 Fr bougie（参见 材料表）放入食道，将 bougie 就位后，将抓取器舒适地放入食管裂孔中。这是为了确保大腿修复不会太紧。</li>
	</ol></li>
	<li>尼森胃底折叠术<ol><li>将胃底穿过右侧、食管后方和迷走神经下方。</li>
		<li>将 58 Fr bougie（见 材料表）放入食管。</li>
		<li>用三根 2-0 的蚕丝缝合线在 bougie 上进行松散的胃底折叠术。 注意：内窥镜检查证实了一堆松散的硬币状外观。</li>
	</ol></li>
	<li>胃固定术和 G 管<ol><li>将经皮内窥镜胃造瘘管插入胃中，用作胃固定术和通气管。</li>
	</ol></li>
</ol>3. 后续处理
<ol><li>术后，使用止吐药以最大限度地降低术后恶心和呕吐的风险，因为干呕会破坏疝修补术或导致早期复发。</li>
	<li>最初，胃管保持打开状态，作为通风口以防止胃胀。最后，一旦患者能够耐受液体，在术后第 2 天或第 3 天夹紧它。</li>
	<li>在手术当晚为患者提供冰片。在术后第 1 天，要求患者在胃管保持打开的情况下开始啜饮透明液体。术后第 2 天，开始清流质饮食，如果患者耐受性良好，则夹住胃管。 注意：如果在夹紧时耐受透明液体，则开始全流质饮食。</li>
	<li>最后，指导患者在 1 周后逐渐转向软饮食，并计划在 4 周内进行食管造影的门诊随访，如果不需要大量通气，则计划切除胃管。</li>
</ol>

再次手术食管裂孔疝修复术

<ol>
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T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pseudoachalasia:+a+diagnostic+challenge.+When+to+consider+and+how+to+manage.">Pseudoachalasia: a diagnostic challenge. When to consider and how to manage.</a> Scandinavian Journal of Gastroenterology. 56 (7), 747-752 (2021).</li><li>Felix, V. N., Murayama, K. M., Bonavina, L., Park, M. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Achalasia:+what+to+do+in+the+face+of+failures+of+Heller+myotomy.">Achalasia: what to do in the face of failures of Heller myotomy.</a> Annals of the New York Academy of Sciences. 1481 (1), 236-246 (2020).</li><li>Gorecki, P. J., Hinder, R. A., Libbey, J. S., Bammer, T., Floch, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Redo+laparoscopic+surgery+for+achalasia.">Redo laparoscopic surgery for achalasia.</a> Surgical Endoscopy. 16 (5), 772-776 (2002).</li><li>Markakis, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Belsey+Mark+IV:+an+operation+with+an+enduring+role+in+the+management+of+complicated+hiatal+hernia.">The Belsey Mark IV: an operation with an enduring role in the management of complicated hiatal hernia.</a> BMC surgery. 13, 1-6 (2013).</li><li>Cowgill, S. M., Arnaoutakis, D., Villadolid, D., Rosemurgy, A. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=34;Redo&amp;#34;+fundoplications:+satisfactory+symptomatic+outcomes+with+higher+cost+of+care.">34;Redo&amp;#34; fundoplications: satisfactory symptomatic outcomes with higher cost of care.</a> Journal of Surgical Research. 143 (1), 183-188 (2007).</li><li>Makris, K. I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+role+of+short-limb+Roux-en-Y+reconstruction+for+failed+antireflux+surgery:+a+single-center+5-year+experience.">The role of short-limb Roux-en-Y reconstruction for failed antireflux surgery: a single-center 5-year experience.</a> Surgical Endoscopy. 26 (5), 1279-1286 (2012).</li><li>Wendling, M. R., Melvin, W. S., Perry, K. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+transoral+incisionless+fundoplication+(TIF)+on+subjective+and+objective+GERD+indices:+a+systematic+review+of+the+published+literature.">Impact of transoral incisionless fundoplication (TIF) on subjective and objective GERD indices: a systematic review of the published literature.</a> Surgical Endoscopy. 27 (10), 3754-3761 (2013).</li><li>Parker, B., Reavis, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Benign+Esophageal+Disease.">Benign Esophageal Disease.</a> , 71-89 (2021).</li></ol>

作者没有什么可透露的。

再次手术前肠手术在技术上具有挑战性，但可以通过精心策划和深思熟虑的手术方法安全地进行。彻底的术前评估对于确定症状的病因和指导诊断辅助治疗至关重要。在再次干预之前确定正确的诊断，以确定正确的手术和方法至关重要。例如，在 Nissan 胃底折叠术后接受重做抗反流手术 （ARS） 的患者中，应该了解患者正在经历的主要症状。在那些以胀气症状、疼痛和吞咽困难为主要问题的人中，...

在过去的一个世纪里，对前肠疾病的理解和诊断的改进导致了更好的手术和手术方法的发展。这项创新为前肠外科医生带来了与并发症和再次手术相关的新挑战。从技术角度来看，由于多种因素，包括致密粘连、瘢痕形成、组织平面闭塞和解剖结构改变，手术再干预尤其具有挑战性 1,2,3,4,5。这些重做前肠手术增加了食管穿孔、胃排空延迟和迷走神经损伤发生率较高的患者的发病率 1,6,7,8。裂孔处的网片修复使再次干预进一步复杂化，需要复杂重建的大切除率更高 9,10。先进的内窥镜疗法的出现给前肠外科医生在处理其相关并发症或失败时带来了不断变化的挑战 11,12,13。此外，与主要干预相比，重做前肠手术与连续再手术的成功率和患者满意度恶化有关14,15,16,17。这凸显了在重做手术之前选择患者和准确诊断以获得最佳结果的重要性。
虽然传统上使用开放式方法进行，但腹腔镜方法重做前肠手术是安全有效的14,18。然而，由于与解剖结构和粘连改变相关的更大困难，转为开放手术仍然是一种可能性。随着机器人辅助手术在泌尿科和妇科手术中的出现19,20，与腹腔镜检查相比，其卓越的可视化和灵活性似乎也可能在重做前肠手术中产生一些好处。事实上，新兴研究表明安全性和改善的结果，包括与腹腔镜下方法相比，重新进行前肠手术的转化率更低，住院时间减少21,22,23。
尽管最终由前肠外科医生确定最安全的手术，但本文旨在展示重做前肠手术的方法和技术考虑因素，以便在面对这一挑战时提供一个“框架”。虽然描述了机器人辅助方法，但所描述的原理也可以类似地应用于腹腔镜检查。

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Bravo calibration-free reflux testing system</td>
			<td>Medtronic</td>
			<td>FGS-0635</td>
			<td>Wireless esophageal pH testing system</td>
		</tr>
		<tr>
			<td>Cadiere forceps</td>
			<td>IS</td>
			<td>470049</td>
			<td>Used as a grasper</td>
		</tr>
		<tr>
			<td>da Vinci Surgeon Console</td>
			<td>IS</td>
			<td>SS999</td>
			<td>Used to control surgical robot</td>
		</tr>
		<tr>
			<td>da Vinci Vision Cart</td>
			<td>IS</td>
			<td>VS999</td>
			<td>Houses advanced vision and energy technologies to provide communication across the platform components</td>
		</tr>
		<tr>
			<td>da Vinci Xi</td>
			<td>IS</td>
			<td>K131861</td>
			<td>The surgical robot</td>
		</tr>
		<tr>
			<td>da Vinci Xi Endoscope with Camera, 8 mm, 30&#176;</td>
			<td>IS</td>
			<td>470027</td>
			<td>The camera for the da Vinci robot</td>
		</tr>
		<tr>
			<td>Lapro-Flex Articulating Retractors</td>
			<td>Mediflex</td>
			<td>91682</td>
			<td>Used as liver retractor</td>
		</tr>
		<tr>
			<td>Large needle driver</td>
			<td>IS</td>
			<td>470006</td>
			<td>Used as a needle driver</td>
		</tr>
		<tr>
			<td>Maloney Tapered Esophageal Bougie, 56 Fr</td>
			<td>Pilling</td>
			<td>507956</td>
			<td>Esophageal bougie for hiatal repair</td>
		</tr>
		<tr>
			<td>Maloney Tapered Esophageal Bougie, 58 Fr</td>
			<td>Pilling</td>
			<td>507958</td>
			<td>Esophageal bougie for wrap creation</td>
		</tr>
		<tr>
			<td>Mega SutureCut needle driver</td>
			<td>IS</td>
			<td>470309</td>
			<td>Used as a needle driver</td>
		</tr>
		<tr>
			<td>Monolithic FlexArm Plus</td>
			<td>Mediflex</td>
			<td>99045-QC</td>
			<td>Used to hold liver retractor to OR bed</td>
		</tr>
		<tr>
			<td>Round tip scissors</td>
			<td>IS</td>
			<td>470007</td>
			<td>Used for cutting</td>
		</tr>
		<tr>
			<td>Shiley Hi-Lo oral/nasal endotracheal tube cuffed, 8.0 mm</td>
			<td>Covidien</td>
			<td>86113</td>
			<td>Endotracheal tube for intubation</td>
		</tr>
		<tr>
			<td>SynchroSeal</td>
			<td>IS</td>
			<td>480440</td>
			<td>Used for dissecting, vessel sealing, and dividing</td>
		</tr>
		<tr>
			<td>Tip-Up fenestrated grasper</td>
			<td>IS</td>
			<td>470347</td>
			<td>Used as a grasper</td>
		</tr>
	</tbody>
</table>

technical considerations and approach to redo foregut surgery

多年来，前肠手术技术取得了长足的进步，并且越来越受欢迎。然而，在处理因并发症或手术失败而再次手术时，出现了新的挑战和技术考虑。本研究的重点是处理再次手术前肠手术，特别是重做食管裂孔疝修补术时的技术考虑因素和方法。我们描述了我们的方法，从术前检查到手术的程序步骤。本研究描述了一名既往接受过腹腔镜食管裂孔疝修补术并未出现反流和吞咽困难症状复发的患者进行机器人再手术食管裂孔疝修补术的主要步骤。患者仰卧位，双臂伸出，脚踏板用于陡峭的特伦德伦堡。我们放置了六个套管针，包括一个辅助端口和一个肝脏牵开器端口，以方便可视化和回缩。在对接机器人后，我们使用电烙术和锐器解剖相结合的方式，释放疝囊并减少食管裂孔疝。然后小心地取下先前的胃底折叠术，并通过经裂孔入路结合钝性清扫和锐性清扫来动员食管，直到达到至少 3 cm 的腹内食管长度，然后进行渗漏试验。然后，我们进行小腿修复，通过两根后缝线和一针前缝线重新近似裂孔。最后，在 bougie 上进行重做 Nissen 胃底折叠术，并使用内窥镜检查来确认松散的硬币堆外观。通过强调重做食管裂孔疝修补术的关键步骤，包括术前评估，我们的目标是为前肠外科医生提供一种方法，以最大限度地提高患者的治疗效果。

患者术后病程平安无事。她在 3 天内慢慢进展为全流质饮食，然后在 1 周后指示以流质饮食出院，并指示她转为软饮食。
作为四级转诊中心和大型大学医院，我们经常管理需要再次进行前肠手术的患者。我们过去 5 年的数据显示，43 名接受食管裂孔疝修复术的患者再次接受手术，平均住院时间为 7 天，30 天并发症率为 23%。表1总结了研究结果。大多数已发表的关?...

Watch this Scientific Journal Video about Technical Considerations and Approach to Redo Foregut Surgery at JoVE.com

作者聚焦：再手术前肠手术的最新进展

重做前肠手术与患者发病率增加有关，对外科医生提出了技术挑战。我们描述了在进行重做食管裂孔疝修补术时我们的方法和注意事项，为其他外科医生提供指导并改善患者的治疗效果。

重做前肠手术的技术考虑因素和方法

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical ...

我们的研究重点是胸外科，特别是前肠再手术。很大一部分是基于手术结果的研究，但我们也强调手术质量的提高，例如使用此协议。在这段视频中，我们讨论了我们的再手术前肠手术方法。在前肠手术中，术中和术前设置的技术不断取得进步。诊断技术的改进，例如 Endoflip 系统和高分辨率测压法，为前肠诊断提供了更准确的信息，而机器人技术和术中监测帮助我们在手术中提供最好的护理。大多数文献在研究前肠再手术时都强调结果，但不一定是手术的方法。我们描述了一种循序渐进的手术方法，同时大致保持一般原则，因此为其他前肠外科医生提供了参考。未来，我们将继续专注于审查其他前肠再手术的结果，目标是制定指南并规范这些病例的管理。

technical-considerations-and-approach-to-redo-foregut-surgery

Research

JoVE Journal

Medicine

Technical Considerations and Approach to Redo Foregut Surgery

397 次观看.  University of Minnesota. 我们的研究重点是胸外科，特别是前肠再手术。很大一部分是基于手术结果的研究，但我们也强调手术质量的提高，例如使用此协议。在这段视频中，我们讨论了我们的再手术前肠手术方法。在前肠手术中，术中和术前设置的技术不断取得进步。诊断技术的改进，例如 Endoflip 系统和高分辨率测压法，为前肠诊断提供了更准确的信息，而机器人技术和术中监测帮助我们在...

视频: 作者聚焦：再手术前肠手术的最新进展

Microvascular Decompression: Salient Surgical Principles and Technical Nuances

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports indicate that 80-90% of cases are related to compression of the trigeminal nerve by an adjacent vessel. The majority of patients with trigeminal neuralgia eventually require surgical management in order to achieve remission of symptoms. Surgical options for management include ablative procedures (e.g., radiosurgery, percutaneous radiofrequency lesioning, balloon compression, glycerol rhizolysis, etc.) and microvascular decompression. Ablative procedures fail to address the root cause of the disorder and are less effective at preventing recurrence of symptoms over the long term than microvascular decompression. However, microvascular decompression is inherently more invasive than ablative procedures and is associated with increased surgical risks. Previous studies have demonstrated a correlation between surgeon experience and patient outcome in microvascular decompression. In this series of 59 patients operated on by two neurosurgeons (JSN and PEK) since 2006, 93% of patients demonstrated substantial improvement in their trigeminal neuralgia following the procedure&#x2014;with follow-up ranging from 6 weeks to 2 years. Moreover, 41 of 66 patients (approximately 64%) have been entirely pain-free following the operation.
In this publication, video format is utilized to review the microsurgical pathology of this disorder. Steps of the operative procedure are reviewed and salient principles and technical nuances useful in minimizing complications and maximizing efficacy are discussed.

There are many available options for management of the patient with trigeminal neuralgia. Microvascular decompression, while the most invasive of all options, is also the most effective at achieving long term remission of symptoms. Video instruction on how to maximize efficacy and minimize complications with this procedure is described.

微血管减压：突出的手术原则和技术的细微差别

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports ...

科研

医学

Technical Aspects of the Mouse Aortocaval Fistula

Technical aspects of creating an arteriovenous fistula in the mouse are discussed. Under general anesthesia, an abdominal incision is made, and the aorta and inferior vena cava (IVC) are exposed. The proximal infrarenal aorta and the distal aorta are dissected for clamp placement and needle puncture, respectively. Special attention is paid to avoid dissection between the aorta and the IVC. After clamping the aorta, a 25 G needle is used to puncture both walls of the aorta into the IVC. The surrounding connective tissue is used for hemostatic compression. Successful creation of the AVF will show pulsatile arterial blood flow in the IVC. Further confirmation of successful AVF can be achieved by post-operative Doppler ultrasound.

The goal is to produce an arteriovenous fistula that is simple and reproducible. This method does not use sutures or glue adhesive. Therefore the samples can be used with the least amount of foreign materials for analysis.

在的鼠标Aortocaval瘘的技术方面

Technical aspects of creating an arteriovenous fistula in the mouse are discussed. Under general anesthesia, an abdominal incision is made, and the aorta ...

Tissue-simulating Phantoms for Assessing Potential Near-infrared Fluorescence Imaging Applications in Breast Cancer Surgery

Inaccuracies in intraoperative tumor localization and evaluation of surgical margin status result in suboptimal outcome of breast-conserving surgery (BCS). Optical imaging, in particular near-infrared fluorescence (NIRF) imaging, might reduce the frequency of positive surgical margins following BCS by providing the surgeon with a tool for pre- and intraoperative tumor localization in real-time. In the current study, the potential of NIRF-guided BCS is evaluated using tissue-simulating breast phantoms for reasons of standardization and training purposes.
Breast phantoms with optical characteristics comparable to those of normal breast tissue were used to simulate breast conserving surgery. Tumor-simulating inclusions containing the fluorescent dye indocyanine green (ICG) were incorporated in the phantoms at predefined locations and imaged for pre- and intraoperative tumor localization, real-time NIRF-guided tumor resection, NIRF-guided evaluation on the extent of surgery, and postoperative assessment of surgical margins. A customized NIRF camera was used as a clinical prototype for imaging purposes.
Breast phantoms containing tumor-simulating inclusions offer a simple, inexpensive, and versatile tool to simulate and evaluate intraoperative tumor imaging. The gelatinous phantoms have elastic properties similar to human tissue and can be cut using conventional surgical instruments. Moreover, the phantoms contain hemoglobin and intralipid for mimicking absorption and scattering of photons, respectively, creating uniform optical properties similar to human breast tissue. The main drawback of NIRF imaging is the limited penetration depth of photons when propagating through tissue, which hinders (noninvasive) imaging of deep-seated tumors with epi-illumination strategies.

Near-infrared fluorescence (NIRF) imaging may improve therapeutic outcome of breast cancer surgery by enabling intraoperative tumor localization and evaluation of surgical margin status. Using tissue-simulating breast phantoms containing fluorescent tumor-simulating inclusions, potential clinical applications of NIRF imaging in breast cancer patients can be assessed for standardization and training purposes.

组织鬼怪模拟，以评估乳癌手术潜在的近红外荧光成像中的应用

Inaccuracies in intraoperative tumor localization and evaluation of surgical margin status result in suboptimal outcome of breast-conserving surgery ...

A Murine Model of Arterial Restenosis: Technical Aspects of Femoral Wire Injury

Cardiovascular disease caused by atherosclerosis is the leading cause of death in the developed world. Narrowing of the vessel lumen, due to atherosclerotic plaque development or the rupturing of established plaques, interrupts normal blood flow leading to various morbidities such as myocardial infarction and stroke. In the clinic endovascular procedures such as angioplasty are commonly performed to reopen the lumen. However, these treatments inevitably damage the vessel wall as well as the vascular endothelium, triggering an excessive healing response and the development of a neointimal plaque that extends into the lumen causing vessel restenosis (re-narrowing). Restenosis remains a major cause of failure of endovascular treatments for atherosclerosis. Thus, preclinical animal models of restenosis are vitally important for investigating the pathophysiological mechanisms as well as translational approaches to vascular interventions. Among several murine experimental models, femoral artery wire injury is widely accepted as the most suitable for studies of post-angioplasty restenosis because it closely resembles the angioplasty procedure that injures both endothelium and vessel wall. However, many researchers have difficulty utilizing this model due to its high degree of technical difficulty. This is primarily because a metal wire needs to be inserted into the femoral artery, which is approximately three times thinner than the wire, to generate sufficient injury to induce prominent neointima. Here, we describe the essential surgical details to effectively overcome the major technical difficulties of this model. By following the presented procedures, performing the mouse femoral artery wire injury becomes easier. Once familiarized, the whole procedure can be completed within 20 min.

The mouse femoral artery wire injury model of restenosis is technically challenging. In this protocol we show the key technical details essential for successfully performing wire injury to induce consistent&#160;neointima for studies of restenosis.

动脉再狭窄小鼠模型：股导线损伤的技术方面

Cardiovascular disease caused by atherosclerosis is the leading cause of death in the developed world. Narrowing of the vessel lumen, due to ...

A Clinical Trial Assessing the Safety, Efficacy, and Delivery of Olive-Oil-Based Three-Chamber Bags for Parenteral Nutrition

Limited evidence exists to precisely estimate efficacy and safety differences between parenteral nutrition (PN) prepared using olive-oil-based three-chamber bags (3CBs) and soybean-oil-based compounded bags (CoBs) in hospitalized adult patients. We designed a multicenter, randomized, prospective, open-label, noninferiority protocol to compare the efficacy, safety, and distribution of olive-oil-based 3CBs and soybean-oil-based CoB formulations in adult Chinese patients requiring PN during surgical intervention. Subjects were randomized to receive either one of the study treatments using an interactive voice or web-based recognition system in accordance with the randomization code. Randomization was further stratified based on the study site and surgical category. Both treatment groups received similar amounts of calories and protein. In addition, the two study treatments contained a similar composition of the amino-acid component. The only difference between the two PN formulations was the lipid constitution. The duration of administration of study treatments was a minimum of 5 days up to a maximum of 14 days after the surgical procedure. The primary efficacy endpoint was serum prealbumin levels on day 5 of the study. Noninferiority was proved if the anti-log of the lower bound of the 95% confidence interval (CI) of the treatment difference was at least 0.80. Other efficacy measures included treatment preparation time; duration to achieve tolerability of oral nutrition; associated infectious complications; length of hospitalization; and laboratory assessment of markers of nutrition, inflammation, metabolism, and oxidative stress. A total of 458 patients were enrolled in the study. The results showed that olive-oil-based 3CBs were non-inferior to soybean-based CoBs, besides being well tolerated. The infection rate was found to be significantly lower in the olive-oil-based 3CB group. Thus, this study may be used as a reference for future research on lipid emulsion and 3CBs.

Here, we present a protocol for a study comparing the efficacy, safety, and delivery of olive-oil-based 3CB and soybean-oil-based CoB formulations in adults requiring parenteral nutrition. The results revealed that olive-oil-based 3CBs is non-inferior and well tolerated compared to soybean formulations.

一项临床试验，评估基于橄榄油的三腔袋的亲子营养的安全性、有效性和交付

Limited evidence exists to precisely estimate efficacy and safety differences between parenteral nutrition (PN) prepared using olive-oil-based ...

Designing CAD/CAM Surgical Guides for Maxillary Reconstruction Using an In-house Approach

Computer-aided design/computer-assisted manufacturing (CAD/CAM) is now being evaluated as a preparative technique for maxillofacial surgery. Because this technique is expensive and available in only limited areas of the world, we developed a novel CAD/CAM surgical guide using an in-house approach. By using the CAD software, the maxillary resection area and cutting planes and the fibular cutting planes and angles are determined. Once the resection area is decided, the necessary faces are extracted using a Boolean modifier. These superficial faces are united to fit the surface of the bones and thickened to stabilize the solids. Not only the cutting guides for the fibula and maxilla but also the location arrangement of the transferred bone segments is defined by thickening the superficial faces. The CAD design is recorded as .stl files and three-dimensionally (3-D) printed as actual surgical guides. To check the accuracy of the guides, model surgery using 3-D-printed facial and fibular models is performed. These methods may be used to assist surgeons where commercial guides are not available.

Methods for designing a computer-aided design/computer-aided manufacturing (CAD/CAM) surgical guide are shown. Cutting planes are separated, united, and thickened to easily visualize the necessary bone transfer. These designs can be three-dimensional printed and checked for accuracy.

用内部方法设计上颌重建的 cad/cam 手术指南

Computer-aided design/computer-assisted manufacturing (CAD/CAM) is now being evaluated as a preparative technique for maxillofacial surgery. Because this ...

Orthotopic Rat Kidney Transplantation: A Novel and Simplified Surgical Approach

Kidney transplantation offers increased survival rates and improved quality of life for patients with end-stage renal disease, as compared to any type of renal replacement therapy. Over the past few decades, the rat kidney transplantation model has been used to study the immunological phenomena of rejection and tolerance. This model has become an indispensable tool to test new immunomodulatory pharmaceuticals and regimens prior to proceeding with expensive preclinical large animal studies.
This protocol provides a detailed overview of how to reliably perform orthotopic kidney transplantation in rats. This protocol includes three distinctive steps that increase the probability of success: perfusion of the donor kidney by flushing through the portal vein and the use of a cuff system to anastomose the renal veins and ureters, thereby decreasing cold and warm ischemia times. Using this technique, we have achieved survival rates beyond 6 months with normal serum creatinine in animals with syngeneic or tolerant kidney transplants. Depending on the aim of the study, this model can be modified by pre- or posttransplant treatments to study the acute, chronic, cellular, or antibody-mediated rejection. It is a reproducible, reliable, and cost-effective animal model to study different aspects of kidney transplantation.

The purpose of this manuscript and protocol is to explain and demonstrate in detail the surgical procedure of orthotopic kidney transplantation in rats. This method is simplified to achieve the correct perfusion of the donor kidney and shorten the reperfusion time by using the venous and ureteral cuff anastomosis technique.

大鼠原位肾移植: 一种新的简化的手术方法

Kidney transplantation offers increased survival rates and improved quality of life for patients with end-stage renal disease, as compared to any type of ...

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic platform, including three-dimensional vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate the principles of open pancreatoduodenectomy allowing safe oncologic dissection, hemostasis, and meticulous reconstruction. Over the course of the past decade, significant strides have been achieved in outlining the safety, feasibility, and learning curve of the robotic Whipple. When performed by high volume pancreatic surgeons experienced in RPD, recent comparative effectiveness studies show potential advantages compared to the open technique, including reductions in hospital stay and morbidity. National data also show reductions in conversion rates compared to its laparoscopic counterpart. Although long-term oncologic data are still needed, short-term oncologic surrogates of margin resection and lymph node harvest suggest no compromise in oncologic outcomes. As pancreatic surgeons increasingly integrate robotics into their practice, proficiency-based training and credentialing will be necessary for the safe application and dissemination of RPD. Here, we provide the detailed steps of a robotic pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.&#160;

The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

机器人辅助胰腺切除术的技术细节

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic ...

The Microscopic Transcanal Approach in Stapes Surgery Revisited

The microscopic transcanal (aka transmeatal) surgical approach was first described in the 60s, offering a minimally invasive means of reaching the external auditory canal, the middle ear, and epitympanon. Such an approach avoids a retroauricular or endaural skin incision; however, working through a narrow space needs angled microsurgical instruments and specific training in otologic surgery. The transcanal approach restricts the working space; however, it offers a binocular microscopic vision into the middle ear without extended skin incisions and thus, reducing post-operative pain and bleeding. In addition, this minimally invasive approach avoids scar tissue complications, hypoesthesia of the auricle, and potential protrusion of the pinna. Despite its numerous advantages, this method is still not routinely performed by otologic surgeons. Since this minimally invasive technique is more challenging, there is a need for extensive training in order for it to be widely adopted by otologic surgeons. This article provides step-by-step surgical instructions for stapes surgery and reports possible indications, pitfalls, and limitations using this microscopic transcanal technique.

This article describes the microscopic transcanal technique for stapes surgery, providing step-by-step surgical instructions for familiarizing surgeons with this approach.

重新审视镫骨手术中的显微经管入路

The microscopic transcanal (aka transmeatal) surgical approach was first described in the 60s, offering a minimally invasive means of reaching the ...

Combining 3D-Printing and Electrospinning to Manufacture Biomimetic Heart Valve Leaflets

Electrospinning has become a widely used technique in cardiovascular tissue engineering as it offers the possibility to create (micro-)fibrous scaffolds with adjustable properties. The aim of this study was to create multilayered scaffolds mimicking the architectural fiber characteristics of human heart valve leaflets using conductive 3D-printed collectors.
Models of aortic valve cusps were created using commercial computer-aided design (CAD) software. Conductive polylactic acid was used to fabricate 3D-printed leaflet templates. These cusp negatives were integrated into a specifically designed, rotating electrospinning mandrel. Three layers of polyurethane were spun onto the collector, mimicking the fiber orientation of human heart valves. Surface and fiber structure was assessed with a scanning electron microscope (SEM). The application of fluorescent dye additionally permitted the microscopic visualization of the multilayered fiber structure. Tensile testing was performed to assess the biomechanical properties of the scaffolds.
3D-printing of essential parts for the electrospinning rig was possible in a short time for a low budget. The aortic valve cusps created following this protocol were three-layered, with a fiber diameter of 4.1 &#177; 1.6 &#181;m. SEM imaging revealed an even distribution of fibers. Fluorescence microscopy revealed individual layers with differently aligned fibers, with each layer precisely reaching the desired fiber configuration. The produced scaffolds showed high tensile strength, especially along the direction of alignment. The printing files for the different collectors are available as Supplemental File 1, Supplemental File 2, Supplemental File 3, Supplemental File 4, and Supplemental File 5.
With a highly specialized setup and workflow protocol, it is possible to mimic tissues with complex fiber structures over multiple layers. Spinning directly on 3D-printed collectors creates considerable flexibility in manufacturing 3D shapes at low production costs.

The presented method offers an innovative way for engineering biomimetic fiber structures in three-dimensional (3D) scaffolds (e.g., heart valve leaflets). 3D-printed, conductive geometries were used to determine shape and dimensions. Fiber orientation and characteristics were individually adjustable for each layer. Multiple samples could be manufactured in one setup.

结合3D打印和静电纺丝来制造仿生心脏瓣膜传单

Electrospinning has become a widely used technique in cardiovascular tissue engineering as it offers the possibility to create (micro-)fibrous scaffolds ...

Methods Article

重做前肠手术的技术考虑因素和方法