ウィスコンシン大学マディソン校の研究と臨床のプログラムとその支援のためにとリササンプソン、月Ketzlerとマーシーセンター、著者らは、臨床腫瘍アブレーションプログラムで彼のリーダ​​ーシップのためのフレッドリー、ジュニアを、感謝したいと思います。

1。はじめに/ケースプレゼンテーション： 例の場合：後腹膜平滑筋肉腫、S / P主切除では50歳の女性。化学療法に反応肝臓や肺に転移性病変の証拠を持っていた。単一の化学療法難治性肝病変を持っていた。学際的な議論は、患者の若い年齢、併存疾患の欠如と代替療法治療の選択肢の少なさを考えると、可能な治療選択肢としてアブレーションにつながった。病変は転移性疾患を確認するために治療前に生検した。計画の超音波検査は、肝左葉の下と後面に病変を示した。膵臓と腸に近接して与え、hydrodissectionの必要性が協議の時に患者に見直された。 2。患者の選択<ol><li>手順の中で最も重要な側面の一つは、患者が適切な候補であることを確認することです。これには含めて腫瘍と患者の両方に関連する要因の多因子の評価が含まれます。 <ol><li>腫瘍のタイプ、サイズ、位置およびfocality（図1）。 </li><li>患者の併存疾患と全体的な健康。 </li></ol></li><li>患者は、可能な治療の選択肢を決定し、最も効果的かつ適切なオプションを選択する学際的な腫瘍のボードで議論されるべきである。 </li><li>臓器内の腫瘍の位置、隣接する構造物の近接性と精度のため、関連する必要性、オペレータの経験、基礎肝疾患の有無や出血：最も適切なアブレーションのモダリティでは、変数のような同様に多くの異なる要因に依存diathesisの複数形。これらの要因のすべてと多くは最も適切なアブレーションのモダリティを決定し、選択することを考慮する必要があります。 </li><li>患者はよく手順、期待されるリスクを、完全な治療の可能性、および可能性の利点について、知らされなければならない。したがって、我々は通常、以下のように超音波を計画する時に、前の手順に、すべての患者に相談してください。 </li><li>患者と手順の全体的な評価では、ケースのための安全かつ有効でもある鎮静/麻酔の度合いを決定します。 </li></ol> 3。前処理計画<ol><li>我々は、最適な患者位置決めとapproach.Thisを決定するために事前にアブレーションのプランニング超音波でも私たちは他の画像診断法を指導し、より特に、モニタリングのために必要とされるかどうかを判断するのに役立ちます行います。それは標的腫瘍の概要評価のためのアブレーションの手順の時に使用可能なCT、アブレーションゾーン、および隣接する構造を持つが、しばしば参考になります。 </li><li>我々はまた、安全性と有効性（図2）に重点を置いて、現時点では補​​助療法のテクニックの必要性を評価する。 </li><li>この時間の間に我々は、治療だけでなく、それらの最適な配置を完了するために必要になりそうアプリケーターの数を決定します。 </li></ol> 4。アブレーションの手順<ol><li>患者の準備<ol><li>評価/考慮すべき要因が含まれます：腸の準備、周術期/プリ抗生物質、機能肝臓/腎臓、IVアクセスは、血圧の監視のための動脈ライン、等のために必要なこれらの決定はケースバイケースで行われるが、続くことができると、これらが説明されるいくつかの一般的な原則があります。 </li><li>全身麻酔が一般的ですが、アブレーションはしばしば深い鎮静、または一部のシナリオでさえ意識下鎮静を行うことができます。個々の患者に最適化する必要があります。 </li></ol></li><li>機器のセットアップ（セットアップの多くの側面は、ベンダーに依存していることに注意してください） <ol><li> RF、冷凍アブレーション、およびMW​​アブレーション装置および接地パッドの配置、接続、およびテストを含むセットアップの例が表示されます。このケースでは、ラジオ波焼灼術が利用されます。 </li></ol></li><li>アブレーションのセッション<ol><li>指導<ol><li>正確かつ適切な画像誘導アプリケータの配置が重要です。これは多くの場合、特に大きな腫瘍のために、複数のアプリケータの配置が含まれているので、検討し、（図3）を用いることができるいくつかの&quot;トリック&quot;が存在する多くの要因があります。 </li></ol></li><li>アジュバント技術<ol><li>経皮的アブレーションを行うときは、熱的ダメージに対して脆弱である可能性のある隣接構造がしばしばあります。これはhydrodissectionと適切に適用した場合、物理的、熱的、および電気的保護を可能にする他の変位の技術、の開発につながりました。我々は、これらの技術の使用を検討します。 </li><li>我々はまた、他の治療法/することが示されている、または理論的には治療の有効性と安全性を高めることができるテクニックを説明します。 </li></ol></li><li>モニタリング<ol><li>米国、CT、及びMRIは、すべての効果的かつ正確に成長するアブレーションゾーンを監視する能力について、特定の強みと弱みを持っている。このため、私たちはしばしば米国とCTの両方でマルチモダリティのアプローチを採用しています。これは、私たちは安全かつ効果的に手順を実行することができます。 </li><li>後のアブレーションの評価<ol><li>後のアブレーションの評価は、治療の有効性の測定を可能にします。いつ、どのようにそれが実行さは可変であり、リソースの可用性、米国またはCTのコントラストを管理するための実用性、および治療の技術的成功（図4）に関する不確実性に依存します。アブレーションのセッションが締結された直後に我々の施設で、我々は適切な患者に造影CTを行います。これは、私たちは完全な治療（再治療即時、必要であれば、患者は麻酔下にまだある間）のために評価することができます、後の手順のベースラインを確立し、任意の初期の合併症を識別する。しかし、多くの機関が月以上のアブレーションのセッション後の初期評価を行います。 </li></ol></li></ol></li></ol></li><li>フォローアップ<ol><li>評価のフォローアップの間隔と最適なモダリティは、腫瘍の種類や患者の要因によって異なります。我々はこの決定に影響を与えると認められたプロトコル（図5）を記述するさまざまな要因について説明します。 </li></ol></li></ol> 5。結果： 手順が正常にCTや超音波モニタリングと超音波ガイドの組み合わせを使用して実施した。水中5％デキストロース（D5W）の直接の注射はhydrodissection（図2）を使用しました。腫瘍が超音波画像診断によってではなく、非造影CT（多くの場合、肝臓の病変と同様です）と簡単に可視化したので、超音波は、指導のために利用された。我々の経験では、超音波ガイドでアプリケーターを配置すると、CTと比べて高速です。超音波は、電離放射線を使用するため、患者と職員の両方にとって安全であり、そして腫瘍と正確で一貫性のある配置を可能にアプリケーターの位置のリアルタイムフィードバックを提供していません。正確なターゲティングがプロシージャの成功にとって非常に重要なので、アプリケーターのガイダンスは、多くの場合、手続きが完了する治療法につながるかどうかが決まります。 超音波とCTの監視の組み合わせが利用された。 CTは、アプリケータの配置の安全性や近隣構造物への巻き添え被害の可能性の優れた評価をできるように、隣接する構造にアプリケーターの配置と近接のグローバルな概観を与えながら、超音波は、開発途上アブレーションのリアルタイム評価が可能になります。従って、より安全な治療の超音波検査とCT画像の結果の組み合わせ。 D5Wは、2つの主な理由hydrodissectionのために利用された：それは、加熱の物理的および電気的障壁の両方として動作し、従って、隣接する構造（すなわち、膵臓および腸）の損傷を防止し、腹腔内D5Wはの後の手続きの痛みを減少させることが示されている肝腫瘍のRFアブレーションを受けている患者。従って、この介入は、患者のための両方がより安全で快適な手順になります。プロシージャが関連付けられていない合併症で腫瘍の完全な治療をもたらしたと最小限の患者の不快感だけがあったことをイメージングショーをフォローアップ。 肝腫瘍の切除は、肝硬変患者で、大腸、乳房または神経内分泌腫瘍の患者さんに限られた肝転移性疾患における肝細胞癌への最も一般的に適用されます。肝転移性疾患を持っている他の腫瘍タイプの患者は、しばしば全身性疾患を持っており、アブレーションの恩恵を受ける場合があります。これらの患者は、ケースバイケースで検討されています。転移性肉腫患者における長期的なデータの相対的な不足があります。この場合のアブレーションを続行するかどうかの決定は、この若い患者の病気の他のすべてのサイトが単一の難治性肝​​病変との化学療法に応答したことを与えられるとした。これは短期的には彼女の病気を制御し、このタイプの腫瘍で、彼女の化学療法からの猶予を与える可能性がありますが、治癒はほとんどありません。患者は、後で追加の肝臓の病変二肺結節を開発した。すべては、アブレーションで治療された。患者は、継続的な監視下に、現在です。 6。代表的な結果： <img src="/files/ftp_upload/2596/2596fig1.jpg" alt="図1" /> 図1前の手順CTだけで劣ると胃がすぐ横に位置する十二指腸と膵臓（P）を当接して肝左葉（矢印）で、低減衰の病変を示す。 <img src="/files/ftp_upload/2596/2596fig2.jpg" alt="図2" /> 図2仰臥位で患者との計画超音波は密接に隣接胃（スター）と膵臓を（表示されません）当接して低エコー病変（矢印）を示しています。したがって、意思決定手順の実行中に、解凍にNGチューブを配置しようとしましたndは後部構造を保護するためにhydrodissectionを使用。 <img src="/files/ftp_upload/2596/2596fig3.jpg" alt="図3" /> 図3：超音波画像（左）は肝臓と流体の注入による膵臓の間の空間に肝左葉を通って延びるhydrodissection針（矢印）を示しています。腹部CT（右）胃の後方変位（スター）と肝臓と膵臓（P）との間の流体の蓄積のある場所で針（矢印）を示しています。 <img src="/files/ftp_upload/2596/2596fig4.jpg" alt="図4" /> アブレーション中に得られた図4。超音波画像は、横方向左葉（矢印）でのガスの雲を示しています。液体の薄層は、肝臓と膵臓（P）との間で観察することができます。 <img src="/files/ftp_upload/2596/2596fig5.jpg" alt="図5" /> 図5。即時の術後CT（左）は、アブレーション領域（矢印）を示しています。アブレーションゾーン一ヶ月のフォローアップCT（右、矢印）に縮小した。

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J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cryotherapeutic+ablation+of+liver+tumours.">Cryotherapeutic ablation of liver tumours.</a> Br J Surg. 89, 1396-1401 (2002).</li><li>Callstrom, M. R., Atwell, T. D., Charboneau, J. W., Farrell, M. A., Goetz, M. P., Rubin, J., Sloan, J. A., Novotny, P. J., Welch, T. J., Maus, T. P., Wong, G. Y., Brown, K. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Painful+metastases+involving+bone:+percutaneous+image-guided+cryoablation--prospective+trial+interim+analysis.">Painful metastases involving bone: percutaneous image-guided cryoablation--prospective trial interim analysis.</a> Radiology. 241, 572-580 (2006).</li></ol>

CLB：アブレーション技術を開発NeuWave医療、株式会社、のための株主およびコンサルタント。 Triagenics、LLCのコンサルタント。

熱腫瘍アブレーションは手術に抵抗性、または放射線療法/化学療法による治療を失敗している多くの腹部腫瘍のための安全かつ効果的な治療法です。さらに、それは速く、一部の患者に認められた第一選択療法となりつつあります。利点は次のとおりです。優れた安全性プロファイル、従来の外科的治療、コストの削減、そして適切にトリアージ患者における優れた局所制御率はより速い回復期を。経皮的手順は、安全性を向上させるようなhydrodissectionなどの技術を使用し、さらに罹患率を制限するので、腫瘍を標的とする場合は特に、一般的に実現可能である。この技術は数十年の間に実際に活用されており、長期的な成果と腫瘍学的効果に関する質問の多くは、有望な結果と答えている。熱アブレーションは確かに、今後数年間がん患者の管理において重要かつ成長している役割を果たすことになるでしょう。

ボルダーのCovidien社/ ValleylabからクールチップRFアブレーションシステム、（株）

thermal ablation for the treatment of abdominal tumors

経皮焼灼療法は、従来の治療法に対応するものではありません腹部の多くの腫瘍のための新興治療法の選択肢です。熱アブレーションの手順の間に、細いアプリケーターは、イメージングの指導の下で標的腫瘍に導かれる。気温が細胞毒性のレベル（50〜60℃）に上昇するまでのエネルギーは、組織に適用されます。様々なエネルギー源は、高周波（RF）電流、マイクロ波、レーザー光や超音波を含む生物学的組織を、加熱するために用意されています。これらのうち、RFおよびマイクロ波アブレーションは、最も一般的に世界中で使用されています。 RFアブレーションの間に、電流を交互に（〜500 kHzの）間質電極の周囲に抵抗加熱を生成します。皮膚の表面電極（接地パッド）は、電気回路を完成するために使用されます。 RFアブレーションは、腫瘍の局所制御、拡張された生存率と低い合併症率の1,2の良い結果で、20年近く使用されています。最近の研究では、RFアブレーションの小肝細胞癌と腎細胞癌3-5ファーストライン治療の選択肢となることを示唆している。ただし、RF加熱は、ローカルの血流と高い電気インピーダンスの組織（例えば、肺、骨、乾燥または炭化組織）6,7によって妨げられている。マイクロ波は速く、体積加熱8-10を生産し、これらの問題のいくつかを軽減するかもしれません。 RF電極がその効率を制限するシーケンシャル動作を必要としながら大きくしたり、コンフォーマルアブレーションを作成するには、複数のマイクロ波アンテナを同時に使用することができます。マイクロ波システムとの初期の経験は、有効性と似て、または11から13までのRFデバイスよりも優れた安全性を示唆している。 また、凍結外科療法は、致死レベル（-20〜-40 ° C）に標的組織を凍結。経皮的凍結外科療法は、肝臓14-16、、特に大腸癌RCCと多くの転移性腫瘍に対して有効であることが示されている。冷凍アブレーションは、以下の術後の痛みやいくつかの兆候17の迅速な復旧に関連付けることができます。冷凍アブレーションは多くの場合、基本的な凝固障害としばしば肝硬変患者に見られるように関連する出血のリスクに起因する原発性肝癌に対しては禁忌である。さらに、腫瘍細胞内容物の突然のリリースには、ときに凍結組織の融解はcryoshock 16として知られている潜在的に深刻な状態になる可能性があります。 熱腫瘍切除は、開腹手術で行う腹腔鏡検査や経皮的アプローチを使用することができます。経皮的に行うときは、アブレーションの手順は、診断用イメージング、計画、アプリケーターの指導、治療のモニタリング及びフォローアップに依存しています。超音波は、指導や治療のモニタリング、世界中の最も人気のあるモダリティですが、コンピュータ断層撮影（CT）や磁気共鳴イメージング（MRI）は、一般にも使用されています。造影CTやMRIは、通常、診断とフォローアップ撮影のために採用されている。

Watch this Scientific Journal Video about Thermal Ablation for the Treatment of Abdominal Tumors at JoVE.com

Thermal Ablation for the Treatment of Abdominal Tumors

熱腫瘍アブレーションの手順が説明されています。全体の手順は、前処理の計画とイメージング研究、麻酔、腫瘍への経皮的アプローチ、アブレーションデバイスのイメージング指導を促進するためにアジュバント技術、熱処理、後処理のケアとフォローアップを含め、詳しいです。

腹部腫瘍の治療のための熱的アブレーション

Percutaneous thermal ablation is an emerging treatment option for many tumors of the abdomen not amenable to conventional treatments. During a thermal ...

thermal-ablation-for-the-treatment-of-abdominal-tumors

Research

JoVE Journal

Medicine

34.2K ビュー.  University of Wisconsin-Madison. 熱腫瘍アブレーションの手順が説明されています。全体の手順は、前処理の計画とイメージング研究、麻酔、腫瘍への経皮的アプローチ、アブレーションデバイスのイメージング指導を促進するためにアジュバント技術、熱処理、後処理のケアとフォローアップを含め、詳しいです。

ビデオ: Thermal Ablation for the Treatment of Abdominal Tumors

The C-seal: A Biofragmentable Drain Protecting the Stapled Colorectal Anastomosis from Leakage

Colorectal anastomotic leakage (AL) is a serious complication in colorectal surgery leading to high morbidity and mortality rates1. The incidence of AL varies between 2.5 and 20% 2-5. Over the years, many strategies aimed at lowering the incidence of anastomotic leakage have been examined6, 7. 
The cause of AL is probably multifactorial. Etiological factors include insufficient arterial blood supply, tension on the anastomosis, hematoma and/or infection at the anastomotic site, and co-morbid factors of the patient as diabetes and atherosclerosis8. Furthermore, some anastomoses may be insufficient from the start due to technical failure.
Currently a new device is developed in our institute aimed at protecting the colorectal anastomosis and lowering the incidence of AL. This so called C-seal is a biofragmentable drain, which is stapled to the anastomosis with the circular stapler. It covers the luminal side of the colorectal anastomosis thereby preventing leakage.
The C-seal is a thin-walled tube-like drain, with an approximate diameter of 4 cm and an approximate length of 25 cm (figure 1). It is a tubular device composed of biodegradable polyurethane. Two flaps with adhesive tape are found at one end of the tube. These flaps are used to attach the C-seal to the anvil of the circular stapler, so that after the anastomosis is made the C-seal can be pulled through the anus. The C-seal remains in situ for at least 10 days. Thereafter it will lose strength and will degrade to be secreted from the body together with the gastrointestinal natural contents.
The C-seal does not prevent the formation of dehiscences. However, it prevents extravasation of faeces into the peritoneal cavity. This means that a gap at the anastomotic site does not lead to leakage.
Currently, a phase II study testing the C-seal in 35 patients undergoing (colo-)rectal resection with stapled anastomosis is recruiting. The C-seal can be used in both open procedures as well as laparoscopic procedures. The C-seal is only applied in stapled anastomoses within 15cm from the anal verge. In the video, application of the C-seal is shown in an open extended sigmoid resection in a patient suffering from diverticular disease with a stenotic colon.

The C-seal is a biofragmentable drain protecting the stapled colorectal anastomosis. In this video, details of the manufacturing, deployment and use are shown.

C -シール：漏れから結腸直腸器械吻合を保護Biofragmentableドレイン

Colorectal anastomotic leakage (AL) is a serious complication in colorectal surgery leading to high morbidity and mortality rates1. The incidence of AL ...

医学

Quantitative Visualization and Detection of Skin Cancer Using Dynamic Thermal Imaging

In 2010 approximately 68,720 melanomas will be diagnosed in the US alone, with around 8,650 resulting in death 1. To date, the only effective treatment for melanoma remains surgical excision, therefore, the key to extended survival is early detection 2,3. Considering the large numbers of patients diagnosed every year and the limitations in accessing specialized care quickly, the development of objective in vivo diagnostic instruments to aid the diagnosis is essential. New techniques to detect skin cancer, especially non-invasive diagnostic tools, are being explored in numerous laboratories. Along with the surgical methods, techniques such as digital photography, dermoscopy, multispectral imaging systems (MelaFind), laser-based systems (confocal scanning laser microscopy, laser doppler perfusion imaging, optical coherence tomography), ultrasound, magnetic resonance imaging, are being tested. Each technique offers unique advantages and disadvantages, many of which pose a compromise between effectiveness and accuracy versus ease of use and cost considerations. Details about these techniques and comparisons are available in the literature 4.
Infrared (IR) imaging was shown to be a useful method to diagnose the signs of certain diseases by measuring the local skin temperature. There is a large body of evidence showing that disease or deviation from normal functioning are accompanied by changes of the temperature of the body, which again affect the temperature of the skin 5,6. Accurate data about the temperature of the human body and skin can provide a wealth of information on the processes responsible for heat generation and thermoregulation, in particular the deviation from normal conditions, often caused by disease. However, IR imaging has not been widely recognized in medicine due to the premature use of the technology 7,8 several decades ago, when temperature measurement accuracy and the spatial resolution were inadequate and sophisticated image processing tools were unavailable. This situation changed dramatically in the late 1990s-2000s. Advances in IR instrumentation, implementation of digital image processing algorithms and dynamic IR imaging, which enables scientists to analyze not only the spatial, but also the temporal thermal behavior of the skin 9, allowed breakthroughs in the field.
In our research, we explore the feasibility of IR imaging, combined with theoretical and experimental studies, as a cost effective, non-invasive, in vivo optical measurement technique for tumor detection, with emphasis on the screening and early detection of melanoma 10-13. In this study, we show data obtained in a patient study in which patients that possess a pigmented lesion with a clinical indication for biopsy are selected for imaging. We compared the difference in thermal responses between healthy and malignant tissue and compared our data with biopsy results. We concluded that the increased metabolic activity of the melanoma lesion can be detected by dynamic infrared imaging.

We demonstrated that malignant pigmented lesions with increased metabolic activity generate quantifiable amounts of heat and the measurement of the transient thermal response of the skin to a cooling excitation allows quantitative identification of melanoma and other skin cancers (vs. non-proliferative nevi) at an early stage of the disease.

定量的な可視化と動的な熱画像を用いた皮膚癌の発見

In 2010 approximately 68,720 melanomas will be diagnosed in the US alone, with around 8,650 resulting in death 1. To date, the only effective treatment ...

Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions of individuals worldwide 1-3. The rapid, irregular, and disordered electrical activity in the atria gives rise to palpitations, fatigue, dyspnea, chest pain and dizziness with or without syncope 4, 5. Patients with AF have a five-fold higher risk of stroke 6.
Oral anticoagulation (OAC) with warfarin is commonly used for stroke prevention in patients with AF and has been shown to reduce the risk of stroke by 64% 7. Warfarin therapy has several major disadvantages, however, including bleeding, non-tolerance, interactions with other medications and foods, non-compliance and a narrow therapeutic range 8-11. These issues, together with poor appreciation of the risk-benefit ratio, unawareness of guidelines, or absence of an OAC monitoring outpatient clinic may explain why only 30-60% of patients with AF are prescribed this drug 8.
The problems associated with warfarin, combined with the limited efficacy and/or serious side effects associated with other medications used for AF 12,13, highlight the need for effective non-pharmacological approaches to treatment. One such approach is catheter ablation (CA), a procedure in which a radiofrequency electrical current is applied to regions of the heart to create small ablation lesions that electrically isolate potential AF triggers 4. CA is a well-established treatment for AF symptoms 14, 15, that may also decrease the risk of stroke. Recent data showed a significant decrease in the relative risk of stroke and transient ischemic attack events among patients who underwent ablation compared with those undergoing antiarrhythmic drug therapy 16.
Since the left atrial appendage (LAA) is the source of thrombi in more than 90% of patients with non-valvular atrial fibrillation 17, another approach to stroke prevention is to physically block clots from exiting the LAA. One method for occluding the LAA is via percutaneous placement of the WATCHMAN LAA closure device. The WATCHMAN device resembles a small parachute. It consists of a nitinol frame covered by fabric polyethyl terephthalate that prevents emboli, but not blood, from exiting during the healing process. Fixation anchors around the perimeter secure the device in the LAA (Figure 1). To date, the WATCHMAN is the only implanted percutaneous device for which a randomized clinical trial has been reported. In this study, implantation of the WATCHMAN was found to be at least as effective as warfarin in preventing stroke (all-causes) and death (all-causes) 18. This device received the Conformit&eacute; Europ&eacute;enne (CE) mark for use in the European Union for warfarin eligible patients and in those who have a contraindication to anticoagulation therapy 19.
Given the proven effectiveness of CA to alleviate AF symptoms and the promising data with regard to reduction of thromboembolic events with both CA and WATCHMAN implantation, combining the two procedures is hoped to further reduce the incidence of stroke in high-risk patients while simultaneously relieving symptoms. The combined procedure may eventually enable patients to undergo implantation of the WATCHMAN device without subsequent warfarin treatment, since the CA procedure itself reduces thromboembolic events. This would present an avenue of treatment previously unavailable to patients ineligible for warfarin treatment because of recurrent bleeding 20 or other warfarin-associated problems.
The combined procedure is performed under general anesthesia with biplane fluoroscopy and TEE guidance. Catheter ablation is followed by implantation of the WATCHMAN LAA closure device. Data from a non-randomized trial with 10 patients demonstrates that this procedure can be safely performed in patients with a CHADS2 score of greater than 1 21. Further studies to examine the effectiveness of the combined procedure in reducing symptoms from AF and associated stroke are therefore warranted.

Catheter ablation is combined with placement of the WATCHMAN Left Atrial Appendage Closure Device to prevent ischemic stroke in a patient with non-valvular atrial fibrillation.

心房細動に対する左心耳閉鎖との組み合わせでカテーテルアブレーション

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions of individuals worldwide 1-3. The rapid, irregular, and ...

The Goeckerman Regimen for the Treatment of Moderate to Severe Psoriasis

Psoriasis is a chronic, immune-mediated inflammatory skin disease affecting approximately 2-3% of the population. The Goeckerman regimen consists of exposure to ultraviolet B (UVB) light and application of crude coal tar (CCT). Goeckerman therapy is extremely effective and relatively safe for the treatment of psoriasis and for improving a patient's quality of life. In the following article, we present our protocol for the Goeckerman therapy that is utilized specifically at the University of California, San Francisco. This protocol details the preparation of supplies, administration of phototherapy and application of topical tar. This protocol also describes how to assess the patient daily, monitor for adverse effects (including pruritus and burning), and adjust the treatment based on the patient's response. Though it is one of the oldest therapies available for psoriasis, there is an absence of any published videos demonstrating the process in detail. The video is beneficial for healthcare providers who want to administer the therapy, for trainees who want to learn more about the process, and for prospective patients who want to undergo treatment for their cutaneous disease.

Psoriasis is a chronic, immune-mediated inflammatory skin disease. The Goeckerman regimen, formulated for the treatment of psoriasis, consists of exposure to ultraviolet B (UVB) light and application of crude coal tar (CCT). The following protocol is for the administration of Goeckerman therapy for the treatment of moderate-to-severe psoriasis.

中等度から重度の乾癬の治療のためにGoeckermanレジメン

Psoriasis is a  chronic, immune-mediated inflammatory skin disease affecting approximately 2-3%  of the population. The Goeckerman regimen consists of ...

Ex Vivo Treatment Response of Primary Tumors and/or Associated Metastases for Preclinical and Clinical Development of Therapeutics

The molecular analysis of established cancer cell lines has been the mainstay of cancer research for the past several decades. Cell culture provides both direct and rapid analysis of therapeutic sensitivity and resistance. However, recent evidence suggests that therapeutic response is not exclusive to the inherent molecular composition of cancer cells but rather is greatly influenced by the tumor cell microenvironment, a feature that cannot be recapitulated by traditional culturing methods. Even implementation of tumor xenografts, though providing a wealth of information on drug delivery/efficacy, cannot capture the tumor cell/microenvironment crosstalk (i.e., soluble factors) that occurs within human tumors and greatly impacts tumor response. To this extent, we have developed an ex vivo (fresh tissue sectioning) technique which allows for the direct assessment of treatment response for preclinical and clinical therapeutics development. This technique maintains tissue integrity and cellular architecture within the tumor cell/microenvironment context throughout treatment response providing a more precise means to assess drug efficacy.

Ex Vivo Treatment Response of Primary Tumors and/or Associated Metastases for Preclinical and Clinical Development of Therapeutics

Established cancer cell lines and xenografts have been the mainstay of cancer research for the past several decades. However, recent evidence suggests that therapeutic response is greatly influenced by the tumor cell microenvironment. Therefore, we have developed an ex vivo analysis of primary tumor specimens for drug development purposes.

エキソビボ処理前臨床のための原発腫瘍および/ ​​または関連した転移の応答と治療薬の臨床開発

The molecular analysis of established cancer cell lines has been the mainstay of cancer research for the past several decades. Cell culture provides both ...

Creation of Abdominal Adhesions in Mice

Abdominal adhesions consist of fibrotic tissue that forms in the peritoneal space in response to an inflammatory insult, typically surgery or intraabdominal infection. The precise mechanisms underlying adhesion formation are poorly understood. Many compounds and physical barriers have been tested for their ability to prevent adhesions after surgery with varying levels of success. The mouse and rat are important models for the study of abdominal adhesions. Several different techniques for the creation of adhesions in the mouse and rat exist in the literature. Here we describe a protocol utilizing abrasion of the cecum with sandpaper and sutures placed in the right abdominal sidewall. The mouse is anesthetized and the abdomen is prepped. A midline laparotomy is created and the cecum is identified. Sandpaper is used to gently abrade the surface of the cecum. Next, several figure-of-eight sutures are placed into the peritoneum of the right abdominal sidewall. The abdominal cavity is irrigated, a small amount of starch is applied, and the incision is closed. We have found that this technique produces the most consistent adhesions with the lowest mortality rate.

Abdominal adhesions that form after surgery are a major cause of pain, infertility, and hospitalization and reoperation for small bowel obstruction. Our surgical procedure for creating abdominal adhesions in mice is a reliable tool to study the mechanisms underlying the formation of adhesions.

マウスの腹部癒着の作成

Abdominal adhesions consist of fibrotic tissue that forms in the peritoneal space in response to an inflammatory insult, typically surgery or ...

Network Analysis of Foramen Ovale Electrode Recordings in Drug-resistant Temporal Lobe Epilepsy Patients

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control seizures. However, a significant minority of patients continues to exhibit post-operative seizures, even in those cases in which the suspected source of seizures has been correctly localized and resected. The protocol presented here combines a clinical procedure routinely employed during the pre-operative evaluation of temporal lobe epilepsy (TLE) patients with a novel technique for network analysis. The method allows for the evaluation of the temporal evolution of mesial network parameters. The bilateral insertion of foramen ovale electrodes (FOE) into the ambient cistern simultaneously records electrocortical activity at several mesial areas in the temporal lobe. Furthermore, network methodology applied to the recorded time series tracks the temporal evolution of the mesial networks both interictally and during the seizures. In this way, the presented protocol offers a unique way to visualize and quantify measures that considers the relationships between several mesial areas instead of a single area.

This protocol describes a procedure to track the evolution of mesial network measures in temporal lobe epilepsy (TLE) patients. It is based on the combination of intracranial recordings with a novel numerical technique for data analysis. Specifically, we present a protocol for network analyses of foramen ovale recordings.

薬剤耐性側頭葉てんかん患者における孔開存電極レコーディングのネットワーク解析

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control ...

Multicolor 3D Printing of Complex Intracranial Tumors in Neurosurgery

Three-dimensional (3D) printing technologies offer the possibility of visualizing patient-specific pathologies in a physical model of correct dimensions. The model can be used for planning and simulating critical steps of a surgical approach. Therefore, it is important that anatomical structures such as blood vessels inside a tumor can be printed to be colored not only on their surface, but throughout their whole volume. During simulation this allows for the removal of certain parts (e.g., with a high-speed drill) and revealing internally located structures of a different color. Thus, diagnostic information from various imaging modalities (e.g., CT, MRI) can be combined in a single compact and tangible object.
However, preparation and printing of such a fully colored anatomical model remains a difficult task. Therefore, a step-by-step guide is provided, demonstrating the fusion of different cross-sectional imaging data sets, segmentation of anatomical structures, and creation of a virtual model. In a second step the virtual model is printed with volumetrically colored anatomical structures using a plaster-based color 3D binder jetting technique. This method allows highly accurate reproduction of patient-specific anatomy as shown in a series of 3D-printed petrous apex chondrosarcomas. Furthermore, the models created can be cut and drilled, revealing internal structures that allow for simulation of surgical procedures.

The protocol describes the fabrication of fully colored three-dimensional prints of patient-specific, anatomical skull models to be used for surgical simulation. The crucial steps of combining different imaging modalities, image segmentation, three-dimensional model extraction, and production of the prints are explained.

脳神経外科における複雑頭蓋内腫瘍の多色3D印刷

Three-dimensional (3D) printing technologies offer the possibility of visualizing patient-specific pathologies in a physical model of correct dimensions. ...

Cooling or Warming the Esophagus to Reduce Esophageal Injury During Left Atrial Ablation in the Treatment of Atrial Fibrillation

Ablation of the left atrium using either radiofrequency (RF) or cryothermal energy is an effective treatment for atrial fibrillation (AF) and is the most frequent type of cardiac ablation procedure performed. Although generally safe, collateral injury to surrounding structures, particularly the esophagus, remains a concern. Cooling or warming the esophagus to counteract the heat from RF ablation, or the cold from cryoablation, is a method that is used to reduce thermal esophageal injury, and there are increasing data to support this approach. This protocol describes the use of a commercially available esophageal temperature management device to cool or warm the esophagus to reduce esophageal injury during left atrial ablation. The temperature management device is powered by standard water-blanket heat exchangers, and is shaped like a standard orogastric tube placed for gastric suctioning and decompression. Water circulates through the device in a closed-loop circuit, transferring heat across the silicone walls of the device, through the esophageal wall. Placement of the device is analogous to the placement of a typical orogastric tube, and temperature is adjusted via the external heat-exchanger console.

The goal of this protocol is to describe the use of esophageal temperature modulation to counteract esophageal thermal injury from left atrial ablation for the treatment of atrial fibrillation.

心房細動治療における左心房切除中の食道損傷を軽減する食道の冷却または温暖化

Ablation of the left atrium using either radiofrequency (RF) or cryothermal energy is an effective treatment for atrial fibrillation (AF) and is the most ...

Laparoscopy-endoscopy Cooperative Surgery for the Treatment of Gastric Gastrointestinal Stromal Tumors

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this approach makes an innovative improvement in the treatment of G-GISTs that are less than 5 cm in size. Laparoscopy-endoscopy cooperative surgery (LECS) is used to combine endoscopic and laparoscopic surgeries, fully realizing their respective advantages and avoiding their drawbacks. The main steps are as follows. First, gastroscopy and laparoscopy are combined to confirm the location and boundary of the tumor. Tumor resection is carried out laparoscopically, guided by a gastroscope. The specimen is removed orally and the gastric wound closed laparoscopically. Then, gastroscopy and laparoscopy are combined to determine whether there is wound bleeding, if the suture is satisfactory, and if the gastric cavity is deformed.
LECS has natural advantages in the treatment of G-GISTs that are less than 5 cm in size. The accurate estimation of tumor location and boundary greatly improves the complete resection rate of tumors. The risk of tumor rupture is substantially reduced, and the long-term prognosis of patients is significantly improved. The process allows for accurate resection of the tumor, maximum preservation of normal gastric tissue and organ function, and avoids postoperative gastric deformation. The patient's postoperative rehabilitation is greatly accelerated, and oral feeding can resume on the day of the operation. The specimen is taken out through the mouth to avoid the need for an extended abdominal incision. This greatly reduces the patient's postoperative pain and scarring. The method greatly shortens the postoperative hospital stay (i.e., discharge is possible on the day after the operation), increasing the turnover of hospital beds.

Laparoscopy-endoscopy cooperative surgery is appropriate for the treatment of gastric gastrointestinal stromal tumors less than 5 cm in size. It can achieve the respective advantages of endoscopic and laparoscopic surgeries while avoiding their drawbacks.

胃腸間質腫瘍の治療のための腹腔鏡内視鏡検査共同外科

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this ...