この研究は、ヘルシンキ宣言および地元の臨床倫理委員会(2018/09)に従って実施されました。
1.身体検査
注:TOSを診断するための刺激的なテストを 図1に示します。
<ol><li>アドソンテスト(斜角形テスト、 図1A)では、患者の肩をわずかに外転させ、少し伸ばして外旋させ、橈骨脈拍を触診します。患者の頭を後方に伸ばし、テストされた肩に向かって回転させます。患者に息を吸い、息を止めるように頼みます。<ol><li>頭を側方に回転させることで症状が解消する一方で、橈骨脈拍の再発または消失が起こる場合は、検査が陽性であると考えてください。</li>
	</ol></li>
	<li>肋鎖骨装具テスト(図1B)では、患者の腕を後ろに持ってきて、同側側の患者の肩甲骨を押し下げて引っ込めます。脈拍を確認してください。橈骨脈拍が消えたり、症状が再現されたりした場合、検査は陽性と見なされます。</li>
	<li>過外転検査(図1C)では、患者の腕をわずかに伸ばし、橈骨動脈を触診します。腕を90〜180°外転させます。陽性検査は、ベースラインから新しい位置までの橈骨動脈の脈拍の減少です。</li>
	<li>Roos(East)テスト(図1D)では、座位または立位でテストを実行します。患者の肩を90°外転させ、外旋させ、肘を90°曲げます。肘は正面の平面の少し後ろにある必要があります。患者に3分間手を開閉してもらいます。<ol><li>患者が腕の重さ、虚血性痛み、脱力感、または手のしびれやうずきを経験した場合は、検査が陽性であると考えてください。手の変色もテストに意味があります。 注:VTOS症例では外科的治療が最初の選択肢ですが、NTOS症例では3か月の保存療法後に外科的治療が行われ、日常生活、仕事、睡眠の質は改善されません。</li>
	</ol></li>
</ol>2.術前の臨床的および電気診断的評価
<ol><li>外科的治療による臨床的改善の評価のために、身体検査、筋電図所見、および日常生活の症状と社会的および心理的な術前期間に関連するQuickDASH(Disability of Arm, Shoulder, and Hand: <a href="https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf">https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf</a>)質問票で臨床所見を行います。</li>
	<li>複合運動活動電位 (CMAP)、感覚神経活動電位 (SNAP)、神経伝導速度 (NCV) と F 波潜伏時間を測定して、術前の EMG を決定します。市販のEMG / NCV / EP測定システム(日本光電ニューロパック2など)を使用して記録を行います。</li>
</ol>3.経腋窩第1肋骨切除術(段階的)
<ol><li>0.6 mg / kgの臭化ロクロニウム、0.05 mg / kgのミダゾラム、および1〜2 μg / kgのフェンタニルを含む標準的な麻酔導入プロトコルを使用して麻酔を行います。.</li>
	<li>メンテナンスのためにチオペンタールナトリウムを6 mg / kgで投与します。.</li>
</ol>4.患者の体位(図2)
<ol><li>患者を外側褥瘡の位置に置いた後、腕を巻き、持ち上げて90°の外転位置で吊るします。必要に応じて、術後の合併症を防ぐために、3〜5分ごとに牽引力を減らします。</li>
	<li>局所滅菌には、10%滅菌ポビドンヨードの溶液を使用してください。.腕、腋窩、胸をドレープします。汚染を防ぐために、体の残りの部分に滅菌シートを使用してください。</li>
</ol>5.最初の肋骨に到達する
<ol><li>手術器具の使用は、 図3 と 材料表に示されています。</li>
	<li>胸筋から前方に伸びる腋窩の生え際の下に横方向に、広背筋から後方に5〜7cmの長さで切開します。</li>
	<li>皮膚、皮下組織、筋膜を横切って、前胸壁に到達します。</li>
	<li>鈍い解剖を使用して最初の肋骨に到達します。</li>
</ol>6.筋肉や筋膜から最初の肋骨を解放する
<ol><li>最初の肋骨の上にある筋膜を突き刺し、肋骨の上側にある骨膜を解剖します。肋骨の下端を周囲の筋肉から鈍く解剖し、単極焼灼と肋骨ラスパティリーを使用します。</li>
	<li>胸骨接合部の肋鎖骨靭帯と後肋骨接合部の角肋骨まで肋間筋を分割します。</li>
	<li>第1肋骨の上縁で、前斜角筋を前方に、斜角筋中斜角筋を後方に露出させる。湾曲した鉗子を前斜角筋と中斜角筋の下に置き、神経血管束から最も遠い第1肋骨の上の挿入レベルで筋肉を切断します。</li>
</ol>7.第1肋骨または頸椎肋骨の除去
<ol><li>胸骨肋骨接合部前方で第1肋骨の切除を開始します。まず、上端から回し、次に下端から回して、胸骨からリブカッターを使用して切除します。神経血管構造が保存されていることを確認してください。</li>
	<li>その後、肋骨の後部を切除し、肋骨の角度から遠位に位置する部分を分節化します。したがって、肋骨切除を完了します。</li>
	<li>頸椎肋骨を周囲の組織から完全に解放した後、横突起の関節面が見られるまで肋骨を切除して分節します。</li>
</ol>8. 術後期間
<ol><li>術後、胸部X線検査を行い、気胸などの合併症を除外します。</li>
	<li>問題のない症例では、術後1日目に胸腔ドレーンを取り除きます。</li>
	<li>術後の痛みには、非ステロイド性抗炎症薬、麻薬性鎮痛薬、筋弛緩薬を使用します。</li>
	<li>術後早期に、手術側の腕の動きを調べます。術後最初の2か月間は理学療法を継続します。</li>
	<li>手術側で消耗する活動を行わないように患者にアドバイスします。.</li>
</ol>9.術後の臨床的および電気診断的評価
<ol><li>外科的治療による臨床的改善の評価については、身体検査の臨床所見、EMG所見、およびQuickDASH(Disability of Arm, Shoulder, and Hand: <a href="https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf">https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf</a>)アンケートを比較します 日常生活の症状と社会的および心理的な術前および術後(3か月)期間。</li>
	<li>複合運動活動電位(CMAP)、感覚神経活動電位(SNAP)、神経伝導速度(NCV)とF波潜時を測定して、術前および術後のEMGを比較します。市販のEMG / NCV / EP測定システム(日本光電ニューロパック2など)を使用して記録を行います。</li>
	<li>術後に身体検査を行い、痛みと感覚異常を評価します。</li>
</ol>

<ol>
	<li>Peet, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracic+outlet+syndrome:+evaluation+of+a+therapeutic+exercise+program.">Thoracic outlet syndrome: evaluation of a therapeutic exercise program.</a> InProc Mayo Clinic. 31, 281-287 (1956).</li><li>Han, S., 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=Transaxillary+approach+in+thoracic+outlet+syndrome:+the+importance+of+resection+of+the+first-rib.">Transaxillary approach in thoracic outlet syndrome: the importance of resection of the first-rib.</a> European Journal of Cardio-Thoracic Surgery. 24 (3), 428-433 (2003).</li><li>Yavuzer, &. #. 3. 5. 0. ;., Atinkaya, C., Tokat, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+predictors+of+surgical+outcome+in+patients+with+thoracic+outlet+syndrome+operated+on+via+transaxillary+approach.">Clinical predictors of surgical outcome in patients with thoracic outlet syndrome operated on via transaxillary approach.</a> European Journal of Cardio-Thoracic Surgery. 25 (2), 173-178 (2004).</li><li>Roos, D. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transaxillary+approach+for+first+rib+resection+to+relieve+thoracic+outlet+syndrome.">Transaxillary approach for first rib resection to relieve thoracic outlet syndrome.</a> Annals of Surgery. 163 (3), 354 (1966).</li><li>Jubbal, K. T., Zavlin, D., Harris, J. D., Liberman, S. R., Echo, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Morbidity+of+First+Rib+Resection+in+the+Surgical+Repair+of+Thoracic+Outlet+Syndrome.">Morbidity of First Rib Resection in the Surgical Repair of Thoracic Outlet Syndrome.</a> Hand. , 1558944718760037 (2018).</li><li>Likes, K. 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=Lessons+learned+in+the+surgical+treatment+of+neurogenic+thoracic+outlet+syndrome+over+10+years.">Lessons learned in the surgical treatment of neurogenic thoracic outlet syndrome over 10 years.</a> Vascular and Endovascular Surgery. 49 (1-2), 8-11 (2015).</li><li>Akku&#351;, M., Ya&#287;murlu, K., &#214;zarslan, M., Kalani, M. Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+outcomes+of+neurogenic+thoracic+outlet+syndrome+based+on+electrodiagnostic+tests+and+QuickDASH+scores.">Surgical outcomes of neurogenic thoracic outlet syndrome based on electrodiagnostic tests and QuickDASH scores.</a> Journal of Clinical Neuroscience. 58, 75-78 (2018).</li><li>Peek, J., 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=Long-term+functional+outcome+of+surgical+treatment+for+thoracic+outlet+syndrome.">Long-term functional outcome of surgical treatment for thoracic outlet syndrome.</a> Diagnostics. 8 (1), 7 (2018).</li><li>Sanders, R. J., Annest, S. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technique+of+supraclavicular+decompression+for+neurogenic+thoracic+outlet+syndrome.">Technique of supraclavicular decompression for neurogenic thoracic outlet syndrome.</a> Journal of Vascular Surgery. 61 (3), 821-825 (2015).</li><li>Sanders, R. J., Hammond, S. L., Rao, N. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracic+outlet+syndrome:+a+review.">Thoracic outlet syndrome: a review.</a> The Neurologist. 14 (6), 365-373 (2008).</li><li>Vos, C. G., &#220;nl&#252;, &. #. 1. 9. 9. ;., Vo&#251;te, M. T., van de Mortel, R. H., de Vries, J. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracic+outlet+syndrome:+First+rib+resection.">Thoracic outlet syndrome: First rib resection.</a> Shanghai Chest. 1 (1), (2017).</li><li>Desai, S. S., 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=Outcomes+of+surgical+paraclavicular+thoracic+outlet+decompression.">Outcomes of surgical paraclavicular thoracic outlet decompression.</a> Annals of vascular surgery. 28 (2), 457-464 (2014).</li><li>Peek, J., 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=Long-term+functional+outcome+of+surgical+treatment+for+thoracic+outlet+syndrome.">Long-term functional outcome of surgical treatment for thoracic outlet syndrome.</a> Diagnostics. 8 (1), 7 (2018).</li><li>Urschel, H. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transaxillary+first+rib+resection+for+thoracic+outlet+syndrome.">Transaxillary first rib resection for thoracic outlet syndrome.</a> Operative Techniques in Thoracic and Cardiovascular Surgery. 10 (4), 313-317 (2005).</li><li>Sheth, R. N., Campbell, J. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+treatment+of+thoracic+outlet+syndrome:+a+randomized+trial+comparing+two+operations.">Surgical treatment of thoracic outlet syndrome: a randomized trial comparing two operations.</a> Journal of Neurosurgery: Spine. 3 (5), 355-363 (2005).</li><li>Urschel, H. C., Razzuk, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Neurovascular+compression+in+the+thoracic+outlet:+changing+management+over+50+years.">Neurovascular compression in the thoracic outlet: changing management over 50 years.</a> Annals of Surgery. 228 (4), 609 (1998).</li><li>Povlsen, B., Hansson, T., Povlsen, S. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+for+thoracic+outlet+syndrome.">Treatment for thoracic outlet syndrome.</a> Cochrane Database of Systematic Reviews. 11, (2014).</li><li>George, R. S., Milton, R., Chaudhuri, N., Kefaloyannis, E., Papagiannopoulos, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Totally+endoscopic+(VATS)+first+rib+resection+for+thoracic+outlet+syndrome.">Totally endoscopic (VATS) first rib resection for thoracic outlet syndrome.</a> The Annals of Thoracic Surgery. 103 (1), 241-245 (2017).</li><li>Strother, E., Margolis, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+first+rib+resection.">Robotic first rib resection.</a> Operative Techniques in Thoracic and Cardiovascular Surgery. 20 (2), 176-188 (2015).</li></ol>

TFRRは、TOS 9,10,11の治療に最も使用される外科的技術です。TFRRの利点は、腋窩に隠れた切開があり、手術野に到達するために筋肉を切断する必要がなく、より良い美容結果が得られることです。その欠点は、作業スペースが比較的狭くて深いことです。動脈TOS治療に好まれる鎖骨上アプローチは、鎖骨下動脈の損傷リスク?...

斜角筋三角形の腕神経叢、鎖骨下動脈、または静脈の圧迫は、臨床的に胸郭出口症候群(TOS)として知られており、Peetらによって最初に報告されました1。胸郭出口症候群は、根底にある病因に基づいて、神経原性(NTOS)、動脈性TOS、および静脈TOSに細分されます1。NTOSの患者(TOS症例の93〜95%)は、痛み、しびれ、および同側の脱力感を呈します。静脈TOS(3〜5%)の患者は静脈血栓症を呈し、動脈TOS(1〜2%)の患者は動脈血栓塞栓症および虚血を呈する。TOSの保存的管理には、薬物療法と理学療法が含まれ、TOS症例の最初の選択肢です。外科的治療法には減圧処置が含まれ、保存的管理が失敗した後に実行されます2。減圧術には、経腋窩第一肋骨切除術(TFRR)、鎖骨上第一肋骨切除鞘屯口切除術(SFRRS)、斜角骨切除術(鎖骨上または経腋窩による第一肋骨切除術なし)、後方アプローチ第一肋骨切除術(PA-FRR)3があります。経腋窩第一肋骨切除術は、1966年にRoosらによって報告された技術であり、TOS 4,5の治療に有効な方法である。TFRRの主な目的は、最後の頸部肋骨と第1胸部肋骨を完全に除去し、その下にある神経血管束を減圧することです。
血管TOS(VTOS)はCT血管造影、カラーデュプレックスUSG、動脈造影または静脈造影で診断されますが、NTOSはX線、電気診断検査(針筋電図検査)、カラーデュプレックスドップラーUSG、および子宮頸部MRIで診断されます。理学療法士と精神科医の相談は、術前に他の障害を除外するために取得する必要があります。前斜角筋へのリドカイン注射による症状の緩和は、NTOS患者の診断と外科的利益の予測のための良い指標でもあります6。

<table>
	<tbody>
		<tr>
			<td>Ag Debakey vascular forceps 24 cm, 3.5 mm</td>
			<td>Lawton medizintechnik</td>
			<td>30-0032</td>
			<td>Check the hemorrhage</td>
		</tr>
		<tr>
			<td>Bone chisels curved 13x9.1/2&#39;&#39;</td>
			<td>Aesculap Inc.</td>
			<td>MB-992R</td>
			<td>Dissect the periost of the first rib</td>
		</tr>
		<tr>
			<td>Doyen-stille retractor 24 cm</td>
			<td>Lawton medizintechnik</td>
			<td>20-0650</td>
			<td>Skin- muscle retraction</td>
		</tr>
		<tr>
			<td>Foerster sponge forceps straight</td>
			<td>Lawton medizintechnik</td>
			<td>07-0156</td>
			<td>For swabbing</td>
		</tr>
		<tr>
			<td>Luer stille bone rongeur curved 27 cm</td>
			<td>Lawton medizintechnik</td>
			<td>38-0703</td>
			<td>Bone punches</td>
		</tr>
		<tr>
			<td>Luer stille rongeur straight 22 cm</td>
			<td>Lawton medizintechnik</td>
			<td>38-0400</td>
			<td>Rib cutter</td>
		</tr>
		<tr>
			<td>Mayo hegar needle holder 20.5 cm</td>
			<td>Lawton medizintechnik</td>
			<td>08-0184</td>
			<td>Suturing</td>
		</tr>
		<tr>
			<td>Metzenbaum scissors curved delicate 23 cm</td>
			<td>Lawton medizintechnik</td>
			<td>05-0665</td>
			<td>Dissection</td>
		</tr>
		<tr>
			<td>Overholt curved forceps delicate 30.5 cm</td>
			<td>Lawton medizintechnik</td>
			<td>06-0807</td>
			<td>Split the scalen muscles from the rib</td>
		</tr>
		<tr>
			<td>Roberts art forceps straight 24 cm</td>
			<td>Lawton medizintechnik</td>
			<td>06-0370</td>
			<td>For sponge and remove remain bone</td>
		</tr>
		<tr>
			<td>Roux retractor medium size 15.5 cm</td>
			<td>Lawton medizintechnik</td>
			<td>20-0402</td>
			<td>Wound retraction</td>
		</tr>
		<tr>
			<td>Semb rasparotry 22,5 cm, 12mm</td>
			<td>Lawton medizintechnik</td>
			<td>39-0252</td>
			<td>Dissect the muscle of the first rib</td>
		</tr>
		<tr>
			<td>Smith peterson model curved osteotome 13x205 mm</td>
			<td>Lawton medizintechnik</td>
			<td>46-0783</td>
			<td>Dissect the muscle of the first rib</td>
		</tr>
		<tr>
			<td>Stille -giertz rib shears 27 cm</td>
			<td>Lawton medizintechnik</td>
			<td>38-0200</td>
			<td>First rib cutting</td>
		</tr>
		<tr>
			<td>Stille osteotome 8x205 mm</td>
			<td>Lawton medizintechnik</td>
			<td>46-0248</td>
			<td>Dissect the periost of the first rib</td>
		</tr>
		<tr>
			<td>Wagner rongeur 5.5x210 mm</td>
			<td>Lawton medizintechnik</td>
			<td>53-0703</td>
			<td>Punches</td>
		</tr>
	</tbody>
</table>

transaxillary first rib resection for treatment of the thoracic outlet syndrome

胸郭出口症候群(TOS)は、生産性の著しい低下を引き起こす一般的な障害です。経腋窩第一肋骨切除術(TFRR)プロトコルは、TOSでトラップされた神経血管構造の減圧に使用されています。他の外科的処置の中で、TFRRの利点は、再発率が最も低く、美容上の結果が優れていることです。TFRRの欠点は、狭くて深い作業廊下を提供し、血管制御の取得を困難にすることです。

臨床転帰 この研究には合計15人の患者が含まれていました。.3人の患者(20%)が男性で、12人(80%)が女性でした。.患者の平均年齢は30.6±8.98歳でした。.男性参加者全員、女性参加者5名は肉体労働者であった。NTOS群の最も一般的な訴えは、腕と前腕の痛みとしびれ、握力の低下と歯茎下部萎縮でした。術後の臨床フォローアップでは、患者は感覚異常と痛みの重症度、全体的な満足?...

Watch this Scientific Journal Video about Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome at JoVE.com

Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

ここでは、腕神経叢、鎖骨下静脈および動脈の圧迫によって引き起こされる胸郭出口症候群の治療のための第一肋骨の経腋窩切除のプロトコルを提示する。

胸郭出口症候群の治療のための経腋窩第一肋骨切除術

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol ...

transaxillary-first-rib-resection-for-treatment-thoracic-outlet

Research

JoVE Journal

Medicine

2.7K ビュー.  Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital. ここでは、腕神経叢、鎖骨下静脈および動脈の圧迫によって引き起こされる胸郭出口症候群の治療のための第一肋骨の経腋窩切除のプロトコルを提示する。

ビデオ: Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

Isolated Hepatic Perfusion as a Treatment for Liver Metastases of Uveal Melanoma

Isolated hepatic perfusion (IHP) is a procedure where the liver is surgically isolated and perfused with a high concentration of the chemotherapeutic agent melphalan. Briefly, the procedure starts with the setup of a percutaneous veno-venous bypass from the femoral vein to the external jugular vein. Via a laparotomy, catheters are then inserted into the proper hepatic artery and the caval vein. The portal vein and the caval vein, both supra- and infrahepatically, are then clamped. The arterial and venous catheters are connected to a heart lung machine and the liver is perfused with melphalan (1 mg/kg body weight) for 60 min. This way it is possible to locally perfuse the liver with a high dose of a chemotherapeutic agent, without leakage to the systemic circulation.
In previous studies including patients with isolated liver metastases of uveal melanoma, an overall response rate of 33-100% and a median survival between 9 and 13 months, have been reported. The aim of this protocol is to give a clear description of how to perform the procedure and to discuss IHP as a treatment option for liver metastases of uveal melanoma.

Here, we present a protocol how to perform an isolated liver perfusion (IHP) with melphalan and we also discuss IHP as a treatment option for liver metastases of uveal melanoma.

ブドウ膜黒色腫の肝転移の治療として単離した肝灌流

Isolated hepatic perfusion (IHP) is a procedure where the liver is surgically isolated and perfused with a high concentration of the chemotherapeutic ...

医学

Surgical Models of Gastroesophageal Reflux with Mice

Multiple surgical procedures have been reported to induce gastroesophageal reflux in animals. Herein, we report three surgical models with mice aiming to induce reflux of gastric contents, duodenal contents or mixed contents. Surgical procedures and general principles have been described in detail. A researcher with surgical experience should be able to grasp the technique after a short period of practice. After surgery, most mice can survive and develop reflux esophagitis similar to that in humans. However, it should be noted that histological differences between mouse and human esophagus are the inherent limitations of these surgical models. If used for research on Barrett&#8217;s esophagus and adenocarcinoma, these procedures may need to be combined with genetic modifications.

This article demonstrates surgical procedures of gastroesophageal reflux with mice. These models are useful tools for research on mechanisms and treatment of gastroesophageal reflux disease and potentially Barrett&#8217;s esophagus and esophageal adenocarcinoma.

マウスを用いた胃食道逆流の外科モデル

Multiple surgical procedures have been reported to induce gastroesophageal reflux in animals. Herein, we report three surgical models with mice aiming to ...

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 ...

Oleic Acid-Injection in Pigs As a Model for Acute Respiratory Distress Syndrome

The acute respiratory distress syndrome is a relevant intensive care disease with an incidence ranging between 2.2% and 19% of intensive care unit patients. Despite treatment advances over the last decades, ARDS patients still suffer mortality rates between 35 and 40%. There is still a need for further research to improve the outcome of patients suffering from ARDS. One problem is that no single animal model can mimic the complex pathomechanism of the acute respiratory distress syndrome, but several models exist to study different parts of it. Oleic acid injection (OAI)-induced lung injury is a well-established model for studying ventilation strategies, lung mechanics and ventilation/perfusion distribution in animals. OAI leads to severely impaired gas exchange, deterioration of lung mechanics and disruption of the alveolo-capillary barrier. The disadvantage of this model is the controversial mechanistic relevance of this model and the necessity for central venous access, which is challenging especially in smaller animal models. In summary, OAI-induced lung injury leads to reproducible results in small and large animals and hence represents a well-suited model for studying ARDS. Nevertheless, further research is necessary to find a model that mimics all parts of ARDS and lacks the problems associated with the different models existing today.

In this article, we present a protocol to induce acute lung injury in pigs by central-venous injection of oleic acid. This is an established animal model for studying the acute respiratory distress syndrome (ARDS).

急性呼吸窮迫症候群のためのモデルとして豚のオレイン酸注入

The acute respiratory distress syndrome is a relevant intensive care disease with an incidence ranging between 2.2% and 19% of intensive care unit ...

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex procedures. The high-quality 3-D visual, multijoint arm and natural tremor filtration allow the surgeon to expose and dissect more accurately with minimal invasion. Total mesorectal excision is the standard surgical technique for the treatment of resectable rectal cancer. To reduce the lateral recurrence rate, lateral pelvic lymph node dissection can be performed, as it is a safe and feasible procedure for locally advanced middle-low rectal cancer with a high possibility of metastasis to the lateral lymph nodes. However, the complexity of the anatomic structures and the high postoperative complication rate limit its application. Recently, several surgeons have increasingly used robotic techniques for total mesorectal excision and lateral pelvic lymph node dissection. Compared with open and laparoscopic surgery, the robotic technique has several advantages, such as less blood loss, fewer blood transfusions, minimal trauma, shorter postoperative hospitalization, and quicker recovery. A robotic approach is generally regarded as a reasonable alternative for complicated procedures such as lateral pelvic lymph node dissection, although there are a limited number of high-quality prospective randomized controlled studies reporting direct evidence. Here, we provide the detailed steps of robot-assisted total mesorectal excision and lateral pelvic lymph node dissection performed at the First Affiliated Hospital of Xi&#39;an Jiaotong University.

The robotic technique described herein aims to detail a stepwise approach to robot-assisted total mesorectal excision and lateral pelvic lymph node dissection for locally advanced (T3/T4) rectal cancer located below the peritoneal reflection.

局所進行中低直腸癌に対するロボット支援全中腸切除および横骨盤リンパ節切断

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex ...

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 ...

Laparoscopic Oocyte Retrieval and Cryopreservation during Vaginoplasty for Treatment of Mayer-Rokitansky-Kuster-Hauser Syndrome

In Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS) patients who are scheduled for laparoscopic vaginoplasty and have a desire for biological motherhood, we propose that a concomitant laparoscopic oocyte retrieval for cryopreservation is performed. Oocyte retrieval is pursued at the beginning of the laparoscopy. Right and left 5 mm trocars are positioned, through which a 17 G ovum aspiration needle is used for puncture of the right and left ovaries, respectively. To facilitate exposure of the follicles, the ovaries are mobilized and held with laparoscopic forceps.
When aspirating multiple follicles near each other, the needle tip is retained in the ovary to reduce the number of times that the ovarian cortex is transfixed and due to the inherent risk of bleeding. Subsequent steps are unchanged compared to the Davydov laparoscopic modified technique for vaginoplasty. Prior to surgery, controlled ovarian stimulation is performed with a gonadotropin hormone-releasing hormone (Gn-RH) antagonist protocol, and the concomitant procedure of oocyte retrieval and vaginoplasty is scheduled 36 h after the final follicular maturation trigger. Follicular fluid is collected in the same 10 mL sterile tubes used during transvaginal oocyte retrieval and transferred in a warming block (37 &#176;C) to the assisted reproduction laboratory, where mature (metaphase II) oocytes are vitrified.
In this case, a series of 23 women with MRKH, oocytes were successfully retrieved and cryopreserved in all patients; vaginoplasty was subsequently conducted without modifications, and the inpatient and outpatient postoperative care (day of urinary catheter removal, day of hospital discharge, dilator use, and comfort at follow-up) remained unaffected. One postoperative complication occurred in one patient (fever developing on day 5 post surgery and intraperitoneal fluid detection on transabdominal ultrasound) and resolved after conservative treatment. Rather than performing surgical vaginoplasty and delaying oocyte retrieval in MRKH patients, this approach combines both procedures in a single laparoscopy, thereby minimizing surgical invasiveness and anesthesiologic risks.

A dedicated team can offer Mayer-Rokitansky-Kuster-Hauser patients the option to perform controlled ovarian stimulation and oocyte cryopreservation at the time of laparoscopic vaginoplasty.

マイヤー・ロキタンスキー・クスター・ハウザー症候群の治療のための膣形成術中の腹腔鏡下卵母細胞回収と凍結保存

In Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS) patients who are scheduled for laparoscopic vaginoplasty and have a desire for biological motherhood, ...

Modified Posterior Vertebral Column Resection for Patients with Thoracolumbar Kyphotic Deformity

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may cause severe thoracolumbar kyphotic deformity, often accompanied by intractable low back pain or compression of the spinal cord, leading to severe neurological symptoms or even paralysis. If conservative treatment cannot relieve the symptoms or correct the deformities, surgical treatment is usually needed. For severe kyphotic deformity, reconstruction of the physiological curvature and rigid fixation determine the prognosis of the patients. Osteotomy and orthopedics are the standard procedure for deformities with severe compression of the front and middle column, but the trauma to the patients is high, with a long operation time and massive blood loss. To avoid these disadvantages, we have developed a modified technique to remove the diseased vertebra unilaterally. In this technique, we use a modified trephine to resect the vertebral columns like in the pedicle screw technique by adding a locking instrument that can restrict the trephine to lower the risk of osteotomy and shorten the surgery time and blood loss.

We describe a modified technique for resecting the posterior vertebral column unilaterally based on a modified trephine for patients with thoracolumbar kyphotic deformity.

胸腰椎後弯変形症に対する修正後脊柱切除術

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may ...

A Modified Technique for Arteriovenous Fistula Construction in Rabbits

Juxta-anastomotic stenosis is a challenging problem that often causes non-maturation and decreases the patency of an arteriovenous fistula (AVF). Injury to the veins and arteries during the operation and hemodynamic changes can lead to intimal hyperplasia, leading to juxta-anastomotic stenosis. To reduce injury to the veins and arteries during the operation, this study proposes a new modified no-touch technique (MNTT) for AVF construction that can decrease the rate of juxta-anastomotic stenosis and improve the AVF patency. To unravel the hemodynamic changes and mechanisms of the MNTT, this study presented an AVF procedure using this technique. Although this procedure is technically challenging, 94.4% procedural success was achieved after adequate training. Ultimately, 13 out of 34 rabbits had a functional AVF 4 weeks after the surgery, leading to a 38.2% AVF patency rate. However, at 4 weeks, the survival rate was 86.1%. Ultrasonography showed active blood flow through AVF anastomosis. Furthermore, the spiral laminar flow was observed in the vein and artery near the anastomosis, suggesting that this technique may improve the hemodynamics of the AVF. On histological observation, significant venous intimal hyperplasia was observed at the AVF anastomosis, whereas no significant intimal hyperplasia was observed at the proximal external jugular vein (EJV) of the anastomosis. This technique will improve the understanding of the mechanisms underlying the use of MNTT for AVF construction and provide technical support for the further optimization of the surgical approach in AVF construction.

The present protocol proposes the creation of an arteriovenous fistula in rabbits using a modified no-touch technique. The technique involves the side-to-side anastomosis of the common carotid artery and external jugular vein without the dissection of the perivenous tissues or cutting off the artery.

ウサギの動静脈瘻構築のための改良技術

Juxta-anastomotic stenosis is a challenging problem that often causes non-maturation and decreases the patency of an arteriovenous fistula (AVF). Injury ...

Use of the Scissor-Type Knife During the Peroral Endoscopy Myotomy Procedure for the Treatment of Achalasia

Peroral endoscopic myotomy (POEM) is one of the first-line treatment modalities along with pneumatic dilation and Heller myotomy for patients with achalasia. Endoscopists, especially trainees during the learning phase, commonly face difficulty in tissue plane dissection and selective myotomy while working near the esophagogastric junction, with increased risks of inadvertent injury, unexpected bleeding, and inadequate myotomy. To minimize the technical difficulty and improve the safety of POEM, we describe a protocol for using a scissor-type knife for the main steps of POEM, including mucosal incision, submucosal tunneling, myotomy, and hemostasis. The standard techniques used with the scissor-type knife involve grasping the target tissue, and then dissection or coagulation. The confirmation of the cutting line after grasping improves the accuracy and reliability of dissection, which is particularly useful for the selective myotomy of the internal circular muscle. Meanwhile, the scissor-type knife provides enhanced hemostatic capability and enables hemostasis and pre-coagulation without the device exchange for hemostatic forceps. Evaluation of the clinical outcomes in three patients who successfully received POEM using the scissor-type knife revealed no perioperative adverse events. At the 3-month follow-up, all patients achieved clinical success with postoperative Eckardt scores ranging from 0 to 1. In conclusion, the use of a scissor-type knife could minimize the technical difficulty and improve the safety of the POEM procedures, which may be suitable for trainees during the learning phase.

To minimize the technical difficulty and improve the safety of peroral endoscopic myotomy (POEM), we describe a protocol for using a scissor-type knife for the main steps of POEM, including mucosal incision, submucosal tunneling, myotomy, and hemostasis.