저자는 임상 종양 절제 프로그램으로 자신의 리더십에 대한 프레드 리 주니어를 감사하고 싶습니다, 그리고 리사 샘슨, 월 Ketzler 및 위스콘신 매디슨 대학에서 연구와 임상 프로그램을 자신의 지원 마르 센터.

1. 소개 / 사례 발표 : 예 케이스 : retroperitoneal leiomyosarcoma S / P 기본 절제술과 함께 50 YR 된 여성. 화학 요법에 반응을 간과 폐에 전이성 질병의 증거를했다. 단일 화학 내화물 간장 병변을했다. 종합 토론 환자의 젊은 나이, comorbidities 부족 및 대체 chemotherapeutic 치료 옵션의 소수 주어진, 가능한 치료 옵션으로 절제되었다. 병변은 전이성 질병을 확인하기 전에 치료를 biopsied했다. 초음파를 계획하는 것은 왼쪽 간장 엽의 하부 및 후부 측면에서 병변을 보여주었다. 췌장 및 대장들의 서식지 감안할 때, hydrodissection의 필요성은 상담 시간에 환자를 검토했다. 2. 환자 선택 <ol><li> 절차의 가장 중요한 측면 중 하나는 환자가 적절한 후보 있는지 확인하는 것입니다. 이것은 포함하는 종양과 환자 모두 관련 요인 여러 요소 평가를 포함 : <ol><li> 종양 종류, 크기, 위치 및 focality (그림 1). </li><li> 환자 공동 morbidities 및 전반적인 건강. </li></ol></li><li> 환자는 가능한 치료 대안을 결정하고 가장 효과 및 적절한 옵션을 선택하는 여러 학문 종양 보드에서 논의해야합니다. </li><li> 기관 내에서 종양의 위치, 인접 구조물의 근접 및 정확도에 대한 관련 필요 운영자의 경험, 기본 간질환의 존재 또는 출혈 : 가장 적절한 절제 양상은 변수와 같은뿐만 아니라 여러 요인에 따라 달라집니다 diatheses. 이러한 요소의 모든 이상이 가장 적절한 절제 양상을 결정하고 선택하는 것으로 간주합니다. </li><li> 환자가 잘 절차, 예상 위험, 완전한 치료 가능성, 그리고 가능성이 혜택에 관한 정보를하셔야합니다. 따라서, 우리는 일반적으로 아래와 초음파 계획시 사전 절차로 모든 환자와 상담. </li><li> 환자 및 절차의 전반적인 평가는 사건에 대한 안전하고 효과 모두는 진정 작용 / 마취에 노출된 정도를 확인하는 것입니다. </li></ol> 3. 사전 치료 계획 <ol><li> 우리는 최적의 환자 위치 및 approach.This을 결정하기 위해 사전 절제 계획 초음파 또한 우리는 다른 이미징 modalities이지도보다 특히, 모니터링해야합니다 여부를 결정하는 데 도움을 수행합니다. 그것은 대상 종양 절제 구역 및 인접 구조물의 개요 평가에 대한 절제 절차의 시간에서 구할 중부 표준시를하는 것이 도움이됩니다. </li><li> 우리는 또한 안전성과 효능 (그림 2)에 중점을두고 이번에 도움이되는 기술에 대한 필요성을 평가. </li><li> 이 기간 동안 우리는 치료뿐만 아니라 최적의 배치를 완료하는 데 필요한 가능성이 applicators의 수를 결정합니다. </li></ol> 4. 절제 절차 <ol><li> 환자 준비 <ol><li> 고려 / 평가하는 요인은 다음과 같습니다 장 준비, 사전 / periprocedural 항생제, 간 기능 / 신장, IV 액세스,이 결정은 건별로 만든 혈압 모니터링을위한 동맥 라인 등이 필요하지만,이 다음 수 있으며, 이들이 논의 될 몇 가지 일반적인 원칙은있다. </li><li> 전신 마취는 일반적이지만, 절제는 종종 어떤 시나리오에 깊은 진정 작용, 또는 의식 진정 작용과 함께 수행할 수 있습니다. 개별 환자에게 최적화할 수 있습니다. </li></ol></li><li> 장비 설치 (설치의 여러 측면은 공급 업체에 의존됩니다) <ol><li> RF, cryoablation 및 MW 박리 장비 및 접지 패드 배치, 연결 및 테스트를 포함하여 설치의 예를 보여줍니다. 이 경우 들면, radiofrequency 박리가 활용됩니다. </li></ol></li><li> 절제 세션 <ol><li> 지도 <ol><li> 정확하고 적절한 이미지 작은 주걱 가이드의 위치가 중요합니다. 이것은 종종 특히 큰 종양에 대해 여러 개의 작은 주걱 게재 위치를 포함 이래, 고려하는 많은 요인이되며 고용 수있는 몇 가지 &#39;트릭&#39;은 (그림 3)가 있습니다. </li></ol></li><li> 도움이되는 기술 <ol><li> percutaneous 박리를 수행할 때, 열 손상에 취약할 수 있습니다 인접 구조가 종종 있습니다. 이것은 hydrodissection 적절하게 적용하면 물리적, 열적, 전기 보호 수 있도록 다른 변위 기술의 발전되었다. 우리는이 기술의 사용을 검토할 것입니다. </li><li> 우리는 또한 다른 트리 트먼트 /로 표시되었습니다, 또는 이론적으로 치료의 효능 및 안전성을 높일 수있는 기술에 대해 설명합니다. </li></ol></li><li> 모니터링 <ol><li> 미국, CT, MRI 및 모든 효과적이고 정확하게 성장 박리 영역을 모니터하는 능력에 관한 구체적인 강점과 약점을 가지고. 이 때문에, 우리는 종종 미국 중부 표준시 모두 여러 양상의 접근 방식을 사용합니다. 이것은 우리가 안전하고 효과적으로 절차를 수행할 수 있습니다. </li><li> 포스트 절제 평가 <ol><li> 이후 절제 평가는 치료의 효능을 결정하실 수 있습니다. 언제, 어떻게 그것이 수행하는 변수이며, 치료의 기술적인 성공 (그림 4)에 관한 자료, 미국이나 중부 표준시 대비를 관리의 실용성, 그리고 불확실성의 가용성에 따라 달라집니다. 절제 세션이 체결되어 즉시 저희 기관에서, 우리는 적절한 환자에 대비 향상된 CT를 수행합니다. 이것은 우리가 (다시 치료 즉시와 환자가 마취 필요한 경우 아래에있는 동안) 완벽하게 치료를 평가할 수 있도록, 사후 절차 기준을 수립하고 조기 합병증을 식별합니다. 그러나 많은 기관은 초기 평가 절제 세션 후 한 달 이상을 수행합니다. </li></ol></li></ol></li></ol></li><li> 추적 조사 <ol><li> 평가를 수행에 대한 간격 및 최적의 양상은 종양 유형과 환자 요인에 따라 다릅니다. 우리는이 결정에 영향을 미칠 및 접수 프로토콜 (그림 5)를 설명하는 다양한 요소를 설명합니다. </li></ol></li></ol> 5. 결과 : 절차가 성공적으로 중부 표준시와 초음파 모니터링과 초음파지도의 조합을 사용하여 실시되었다. 물에 5 % 덱스 트로 오스 (D5W)의 직접 분사는 hydrodissection (그림 2)에 사용되었다. 초음파는 종양이 초음파 영상에 의해 쉽게 시각 이후지도 활용 아니라 함께 비 대비 CT (주로 간 병변의 경우와 같이).했습니다 우리의 경험에서 초음파지도와 applicators을 배치하는 것은 중부 표준시보다 빠릅니다. 초음파는 이온화 방사선을 사용하고 따라서 환자와 직원 모두에게 안전하고, 종양과 정확하고 일관된 배치를 허용하는 작은 주걱 위치의 실시간 피드백을 제공하지 않습니다. 정확한 타겟팅이 절차의 성공에 정말 중요하다 때문에, 작은 주걱지도는 종종 절차가 완료 치료의 결과 여부를 결정합니다. 초음파 및 중부 표준시 모니터링의 조합이 활용되었다. 중부 표준시가 있으므로, 인접 구조물에 작은 주걱 배치의 안전과 가까운 구조에 부수적인 피해의 가능성의 우수한 평가를 작은 주걱 배치 및 근접의 글로벌 개요를 제공하면서 초음파 개발 절제의 실시간 평가하실 수 있습니다. 따라서, 안전한 치료에 초음파 및 중부 표준시 이미징 결과의 조합. D5W는 두 가지 이유로 hydrodissection 활용되었다 : 그것이 이후의 절차 고통을 감소 보여왔다 물리적 전기적 가열에 장벽하고, 따라서, 인접 구조물에 손상 (예 : 췌장 및 대장) 방지하고, intraperitoneal D5W 모두의 역할 간 종양의 RF 절제를 겪고 환자. 따라서,이 개입은 절차 모두 안전하고 환자에 대한 더 편안합니다. 절차없이 관련 합병증에만 최소한의 환자 불편이 있었있는 종양의 완전한 치료에 이어진 영상 쇼를 따르십시오. 간 종양의 절제는 cirrhotic 환자에서 간세포암에 가장 일반적으로 적용하고, 제한 간장 전이성 질병에 결장, 유방 또는 neuroendocrine 종양 환자에 있습니다. 간장 전이성 질환을 가지고 다른 종양 유형의 환자는 종종 체계적 질병을 가지고 절제 혜택을 누릴 수 없습니다,이 환자는 건별로 간주됩니다. 전이성 육종 환자에서 장기적인 데이터의 상대적으로 소수가 있습니다. 이 경우에는 절제와 함께 진행하는 결정이 젊은 환자에있는 질병의 다른 모든 사이트가 하나의 내화물 간장 병변과 화학 요법에 반응 것을 주어 만들어졌다. 이것은 단기 그녀의 질병을 제어하고 이러한 종류의 종양과 함께, 그녀의 화학 요법에서 집행 유예를 줄 수 있지만, 치료하지 않을 수 있습니다. 환자는 나중에 추가로 간 병변 두 폐 nodules을 개발했습니다. 모두 절제로 치료했다. 환자는 계속 감시 중입니다. 6. 대표 결과 : <img src="/files/ftp_upload/2596/2596fig1.jpg" alt="그림 1" /> 그림 1. 사전 절차 중부 표준시 그냥 열등 위에 그냥 측면에있는 십이지장과 췌장 (P)을 인접 왼쪽 간장 엽 (화살표)에 낮은 감쇄 병변을 보여주는. <img src="/files/ftp_upload/2596/2596fig2.jpg" alt="그림 2" /> 그림 2. 부정사 위치에 환자와 함께 계획 초음파는 밀접하게 인접 위 (별)과 췌장을 (표시되지 않음) 인접 hypoechoic 병변 (화살표)를 보여줍니다. 따라서, 결정 절차 동안 감압 NG 튜브를 삽입되었다ND는 사후 구조를 보호하기 위해 hydrodissection를 사용합니다. <img src="/files/ftp_upload/2596/2596fig3.jpg" alt="그림 3" /> 그림 3. 초음파 이미지 (왼쪽) 간 및 유체의 주입과 췌장 사이의 공간에 왼쪽 간장 엽을 통해 확장 hydrodissection 바늘 (화살표)를 보여줍니다. 복부 CT도 (오른쪽) 복부의 사후 변위 (별표)로 간, 췌장 (P) 사이의 액체의 축적과 장소에 바늘 (화살표)를 보여줍니다. <img src="/files/ftp_upload/2596/2596fig4.jpg" alt="그림 4" /> 절제하는 동안 얻은 그림 4. 초음파 이미지는 측면 왼쪽 엽 (화살표)의 가스 구름을 보여줍니다. 유체의 얇은 계층은 간 및 췌장 (P) 사이에 볼 수 있습니다. <img src="/files/ftp_upload/2596/2596fig5.jpg" alt="그림 5" /> 그림 5. 신속한 사후 절차 CT (왼쪽)은 절제 영역 (화살표)를 보여줍니다. 절제 영역은 한 달 후속 CT (오른쪽 화살표)에 계약을 체결했다.

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A., Liu, Z., Lobo, S. M., Ahmed, M., Hines-Peralta, A. U., Lenkinski, R. E., Goldberg, S. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Radiofrequency+ablation:+importance+of+background+tissue+electrical+conductivity--an+agar+phantom+and+computer+modeling+study.">Radiofrequency ablation: importance of background tissue electrical conductivity--an agar phantom and computer modeling study.</a> Radiology. 236, 495-502 (2005).</li><li>Lu, D. S. K., Raman, S. S., Vodopich, D. J., Wang, M., Sayre, J., Lassman, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+vessel+size+on+creation+of+hepatic+radiofrequency+lesions+in+pigs:+assessment+of+the+"heat+sink"+effect.">Effect of vessel size on creation of hepatic radiofrequency lesions in pigs: assessment of the "heat sink" effect.</a> AJR Am J Roentgenol. 178, 47-51 (2002).</li><li>Lubner, M. G., Brace, C. L., Hinshaw, J. L., Lee, F. T. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microwave+tumor+ablation:+mechanism+of+action,+clinical+results,+and+devices.">Microwave tumor ablation: mechanism of action, clinical results, and devices.</a> J Vasc Interv Radiol. 21, 192-203 (2010).</li><li>Andreano, A., Huang, Y., Meloni, M. F., Lee, F. T. J., Brace, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microwaves+create+larger+ablations+than+radiofrequency+when+controlled+for+power+in+ex+vivo+tissue.">Microwaves create larger ablations than radiofrequency when controlled for power in ex vivo tissue.</a> Med Phys. 37, 2967-2973 (2010).</li><li>Simon, C. J., Dupuy, D. E., Mayo-Smith, W. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microwave+ablation:+principles+and+applications.">Microwave ablation: principles and applications.</a> Radiographics. 25, S69-S83 (2005).</li><li>Shibata, T., Iimuro, Y., Yamamoto, Y., Maetani, Y., Ametani, F., Itoh, K., Konishi, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Small+hepatocellular+carcinoma:+comparison+of+radio-frequency+ablation+and+percutaneous+microwave+coagulation+therapy.">Small hepatocellular carcinoma: comparison of radio-frequency ablation and percutaneous microwave coagulation therapy.</a> Radiology. 223, 331-337 (2002).</li><li>Ong, S. L., Gravante, G., Metcalfe, M. S., Strickland, A. D., Dennison, A. R., Lloyd, D. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+and+safety+of+microwave+ablation+for+primary+and+secondary+liver+malignancies:+a+systematic+review.">Efficacy and safety of microwave ablation for primary and secondary liver malignancies: a systematic review.</a> Eur J Gastroenterol Hepatol. 21, 599-605 (2009).</li><li>Liang, P., Wang, Y., Zhang, D., Yu, X., Gao, Y., Ni, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound+guided+percutaneous+microwave+ablation+for+small+renal+cancer:+initial+experience.">Ultrasound guided percutaneous microwave ablation for small renal cancer: initial experience.</a> J. Urol. 180, 844-848 (2008).</li><li>Hinshaw, J. L., Shadid, A. M., Nakada, S. Y., Hedican, S. P., Winter, T. C., Lee, F. T. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+percutaneous+and+laparoscopic+cryoablation+for+the+treatment+of+solid+renal+masses.">Comparison of percutaneous and laparoscopic cryoablation for the treatment of solid renal masses.</a> AJR Am J Roentgenol. 191, 1159-1168 (2008).</li><li>Atwell, T. D., Farrell, M. A., Callstrom, M. R., Charboneau, J. W., Leibovich, B. C., Frank, I., Patterson, D. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+cryoablation+of+large+renal+masses:+technical+feasibility+and+short-term+outcome.">Percutaneous cryoablation of large renal masses: technical feasibility and short-term outcome.</a> AJR Am J Roentgenol. 188, 1195-1200 (2007).</li><li>Sheen, A. J., Poston, G. J., Sherlock, D. 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 : 절제 기술을 개발 NeuWave 의료, 병원에 대한 주주 및 컨설턴트. Triagenics, LLC에 대한 컨설턴트.

열 종양 절제 수술을하는 내화물, 또는 방사선 치료 / 화학 요법과 함께 치료를 실패한 많은 복부 종양에 대한 안전하고 효과적인 치료입니다. 또한, 그것은 빠른 일부 환자 접수 첫 선 치료를지고 있습니다. 이점은 다음과 같습니다 뛰어난 안전성 프로파일, 적절하게 triaged 환자에서 전통적인 수술 치료, 감소 비용, 우수한 지역 제어 속도보다 빠른 convalescence합니다. Percutaneous 절차는 안전을 향상시키기 위해 같은 hydrodissection 같은 기술을 사용하기 때문에 더욱 병적 상태를 제한, 종양 타겟팅 특히, 일반적으로 가능합니다. 이 기술은 지금 몇 수십 년 동안 연습에 활용되었으며, 장기적인 결과에 종양학의 효능에 관한 질문에 많은 격려 결과와 답변을하고 있습니다. 열 절제 분명 앞으로 몇 년간 종양학 환자의 관리에 중요한 성장 역할을 담당할 것입니다.

볼더, (주)에 Covidien / Valleylab에서 쿨 팁 RF 박리 시스템

thermal ablation for the treatment of abdominal tumors

Percutaneous 열 절제는 종래의 치료 의무가 아닌 복부의 많은 종양에 대한 새로운 치료 옵션입니다. 열 절제 절차 동안 얇은 작은 주걱은 영상지도하에 대상 종양으로 안내합니다. 온도가 세포 독성 수준 (50-60 ° C)에 상승까지 에너지는 다음 조직에 적용됩니다. 다양한 에너지 소스 radiofrequency (RF) 전류, 전자 레인지, 레이저 빛과 초음파를 포함하여 생물 학적 조직을 열을 사용할 수 있습니다. 이들 중, RF 및 마이크로 웨이브 절제가 가장 일반적으로 전세계적으로 사용됩니다. RF 절제하는 동안, 전류를 교류하는 것은 (~ 500 kHz에서) 중간 전극 주위에 저항 가열을 생산하고 있습니다. 피부 표면 전극 (접지 패드)는 전기 회로를 완료하는 데 사용됩니다. RF 절제는 로컬 종양 제어, 확장 생존과 낮은 합병증 요금 1,2에 대한 좋은 결과와 함께 거의 20 년 동안 사용되었습니다. 최근 연구의 RF 절제 작은 간세포암 및 신장 세포 암종 3-5를위한 첫 선 치료 옵션이있을 수 있습니다 제안합니다. 그러나, RF 가열 현지 혈액 흐름과 높은 전기 임피던스 조직 (예, 조직을 desiccated하거나 버린 폐, 뼈,) 6,7에 의해 방해합니다. 전자 레인지 빠른, 판매량 가열 80-10을 제작하여 이러한 문제의 일부를 완화 있습니다. RF 전극들이 효율성을 제한 순차 작업을 필요로하는 동안 크거나 등각 ablations을 만들려면 여러 개의 마이크 로파 안테나가 동시에 사용할 수 있습니다. 마이크 로파 시스템과 초기 경험이 효능 및 유사한, 또는 11-13 RF 장치의보다 나은 안전을 제안한다. 또는 cryoablation은 치명적인 수준 (-20 -40 ° C)에 대상 조직을 버립니다. Percutaneous의 cryoablation은 간장 14-16에서, 특히 대장암 RCC 많은 전이성 종양에 대한 효과적인 것으로 표시되었습니다. Cryoablation도 적은 후 절차 고통과 몇 가지 징후 17 빠른 회복에 연결되어있을 수 있습니다. Cryoablation은 종종 기본 coagulopathy 자주 cirrhotic 환자에서 볼 관련된 출혈 위험으로 인해 기본 간암에 대한 금기이다. 또한, 종양 세포 내용 갑자기 릴리스 때 냉동 조직 녹아서는 cryoshock 16로 알려진 잠재적으로 심각한 상태로 이어질 수 있습니다. 열 종양의 절제가 열린 수술, laparoscopy에서 수행하거나 percutaneous의 접근법을 사용하실 수 있습니다. percutaneously 수행하면, 절제 절차는 진단, 계획, 작은 주걱지도, 치료 모니터링 및 후속에 대한 이미지에 의존합니다. 초음파지도 및 치료 모니터링 전세계 가장 인기있는 양상이지만, 계산된 tomography (CT)과 자기 공명 영상 (MRI)은 일반적으로 잘 사용하고 있습니다. 대비 향상된 중부 표준시 또는 MRI는 일반적으로 진단 및 후속 영상에 대한 고용 수 있습니다.

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

열 종양의 절제 절차가 설명되어 있습니다. 전체 절차는 percutaneous 접근, 이미징 종양, 열 치료, 사후 치료 치료에 절제 장치의 지침과 후속을 촉진하기위한 전처리 계획 및 이미징 연구, 마취, 도움이되는 기술을 포함한 상세한 수 있습니다.

복부 종양의 치료를위한 열 절제

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 조회수.  University of Wisconsin-Madison. 열 종양의 절제 절차가 설명되어 있습니다. 전체 절차는 percutaneous 접근, 이미징 종양, 열 치료, 사후 치료 치료에 절제 장치의 지침과 후속을 촉진하기위한 전처리 계획 및 이미징 연구, 마취, 도움이되는 기술을 포함한 상세한 수 있습니다.

비디오: 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 - 인감 : 누출에서 잘라 대장암 문합 보호 Biofragmentable 드레인

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

연구

의학

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.

양적 시각화 및 동적 써멀 이미징을 사용하여 피부암의 감지

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.

심방 세동에 대한 왼쪽 심방 부위 요 폐쇄와 함께 카테 테르 박리

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.

심한 건선에 중간의 치료를위한 Goeckerman 처방

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.

기본 종양 및 / 또는 전임상에 대한 관련 전이 및 치료제의 임상 개발의 전 생체 치료 응답

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.

마우스의 복부 유착의 창조

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.

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.

신경 외과에서 복잡한 두개내 종양의 다색 3D 프린팅

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.

심방 세동 의 치료에 왼쪽 심방 절제 동안 식도 부상을 줄이기 위해 식도를 냉각 또는 온난화

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.

위장 기질 종양의 치료를위한 복강경 내시경 검사 협동 수술

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

Methods Article

복부 종양의 치료를위한 열 절제