Nucleolus vs nucleus count for identifying spiral ganglion in human temporal bone

OBJECTIVES: Spiral ganglion (SG) counting is used in experimental studies conducted on age-, noise-, and drug-induced sensorineural hearing loss, as well as in the assessment of cochlear implant performances. Different methods of counting have been reported, but no definite standardization of such procedure has been published. The aim of our study is to identify the best method to count human spiral ganglions (SGs). MATERIAL and METHODS: By identification of nuclei or nucleoli as described by Schucknect, seven researchers with different experience levels counted SGs in 123 human temporal bones (TBs). Data on time of post-mortem bone removal post-mortem, methods of specimen’s fixation, decalcification, and coloration were collected to test their possible influence on human tissue. Percentage, two-tailed t-test, Spearman’s test, and one-way ANOVA were used to analyze the data. RESULTS: Nucleoli were identified in 61% of cases, whereas nuclei were recognized in 100% of cases (p<0.005). Nucleoli presence in all four segments in the same temporal bone (TB) was observed in 69 cases (92%), whereas nuclei were identified in all four segments in 103 cases (83.7%) (p<0.001). The junior investigators requested a double check by the seniors in 25 (20.3%) cases for identifying and counting nucleoli, whereas the senior researchers showed no doubts in their identification and count. The only parameter positively affecting nucleoli identification in tissue preparation was bone removal for <12 h with respect to longer post-mortem time (p<0.001). CONCLUSION: We suggest counting nuclei, rather than nucleoli, for spiral ganglion computation because of easier recognition of nuclei, especially in case of investigator’s limited experience

Augmented reality in open surgery

Augmented reality (AR) has been successfully providing surgeons an extensive visual information of surgical anatomy to assist them throughout the procedure. AR allows surgeons to view surgical field through the superimposed 3D virtual model of anatomical details. However, open surgery presents new challenges. This study provides a comprehensive overview of the available literature regarding the use of AR in open surgery, both in clinical and simulated settings. In this way, we aim to analyze the current trends and solutions to help developers and end/users discuss and understand benefits and shortcomings of these systems in open surgery. We performed a PubMed search of the available literature updated to January 2018 using the terms (1) “augmented reality” AND “open surgery”, (2) “augmented reality” AND “surgery” NOT “laparoscopic” NOT “laparoscope” NOT “robotic”, (3) “mixed reality” AND “open surgery”, (4) “mixed reality” AND “surgery” NOT “laparoscopic” NOT “laparoscope” NOT “robotic”. The aspects evaluated were the following: real data source, virtual data source, visualization processing modality, tracking modality, registration technique, and AR display type. The initial search yielded 502 studies. After removing the duplicates and by reading abstracts, a total of 13 relevant studies were chosen. In 1 out of 13 studies, in vitro experiments were performed, while the rest of the studies were carried out in a clinical setting including pancreatic, hepatobiliary, and urogenital surgeries. AR system in open surgery appears as a versatile and reliable tool in the operating room. However, some technological limitations need to be addressed before implementing it into the routine practice

A Case-Control Comparison of Surgical and Functional Outcomes of Robotic-Assisted Spleen-Preserving Left Side Pancreatectomy versus Pure Laparoscopy

Aim During left-sided spleen-preserving pancreatectomy (SPLP), limitations of laparoscopy may require spleen sacrifice or conversion to maintain patient safety. The objective of our study is to compare surgical and functional outcomes of robot-assisted and pure laparoscopic SPLP in patients with benign or borderline lesions of the body/tail of the pancreas. Patients and methods This was a case-matched study: fifteen patients who had robotic SPLP (R-SPLP) were matched with 15 comparable patients who had pure laparoscopic SPLP (L-SPLP). The peri-operative variables (conversion rate, amount of bleeding, operation time, length of hospital stay, complications, mortality and readmission) as well as the spleen preservation rate were compared between the two groups, The European Organisation for Research and Treatment of Cancer QLQ-C30 (EORTC QLQ-C30) specific questionnaires were used in each arm after at least 1 year of follow up in order to evaluate quality of life (QoL). Results No R-SPLP was converted to conventional laparoscopy, hand-assisted laparoscopy, or open surgery whereas L-SPLP had a conversion rate of 13.3% (p=n.s.); also fistula formation (20% vs. 46%; p=n.s.) was higher in the laparoscopic group although not statistically significant. Mean operative time (220 vs. 279 min; p=0.027) was shorter and the spleen-preserving rate (fail/ success, 0/15 vs. 4/11; p=0.03) of R-SPLP was significantly better compared to L-SPLP. Moreover, length of hospital stay was significantly shorter in the R-SPLP group compared to the L-SPLP group (6.5 vs. 8.8 days; p=0.04). Post-operative high grade surgical complications occurred only in one L-SPLP patient (0% vs. 6.6%; p=n.s.). Quality of life scores were not significantly different between the two groups. Conclusions R-SPLP could provide an increased chance for spleen preservation and faster surgical procedure. Furthermore, fistula formation and conversion rate seem to be lower, reducing the length of the hospital stay. Our case matched study confirmed the potential peri-operative benefits of robotic assistance in this setting, however these benefits did not translate into a better quality of life at least one year post-operatively

Short-term clinical outcomes of robot-assisted intersphincteric resection and low rectal resection with double-stapling technique for cancer: a case-matched study

Background: Intersphincteric resection (ISR) with total mesorectal excision (TME) is an accepted technique for the surgical treatment of very low rectal cancer. Historically it is associated with a higher functional complication rate than the Double Stapling (DS) technique when performed with open or laparoscopic approach. The aim of this study was to compare the surgical, short-term oncologic and functional outcomes of robotic ISR TME (R-ISR-TME) with those of robotic low anterior resection TME with a double stapling technique (R-DS-TME). Methods: Between April 2010 and December 2013, 42 patients underwent robot-assisted rectal resection with TME at our General Surgery Unit, including 10 R-ISR-TME. The outcomes of the R-ISR-TME group were compared with a R-DS-TME group selected using a case-matched methodology. We evaluated the operative, pathological, short-term oncologic results and postoperative sexual, urinary and defecation functions using specific questionnaires. Results: The analyses of the data showed similar results for R-ISR-TME and R-DS-TME regarding the operative, pathological and oncologic results. Focusing on urinary and sexual function, no score values were significantly different at any time between the two groups. The daily frequency of defecation 1 year after surgery was 1.9±0.9 for RISR-TME and 1.8±0.3 for RDS-TME indicating no difference between the two groups. Moreover, there were no significant differences between the two groups in other defecation functions. The mean Wexner score 1 year after surgery was 3.0±1.1 in R-ISR-TME and 2.2±1.0 in R-DS-TME group (p=0.2) and defecation-related quality of life for R-ISR-TME and R-DS-TME was not significantly different (modified fecal incontinence quality of life score: 30.3±19.1 vs 27.5±14.5, respectively; p=0.2). Conclusions: These clinical and functional results suggest that R-ISR-TME could be a good sphincter-preserving surgery for patients with very low rectal cancer. Robotic assistance may overcome some intrinsic limitations of the ISR technique flattening the difference with the DS-TME procedure

Robot-assisted surgery for the radical treatment of deep infiltrating endometriosis with colorectal involvement: short- and mid-term surgical and functional outcomes.

Sexual and urinary dysfunctions are complications in radical treatment of deep infiltrating endometriosis (DIE) with colorectal involvement. The aim of this article is to report the preliminary results of our single-institution experience with robotic treatment of DIE, evaluating intraoperative and postoperative surgical outcomes and focusing on the impact of this surgical approach on autonomic functions such as urogenital preservation and sexual well-being. METHODS: From January 2011 through December 2013, a case series of 10 patients underwent robotic radical treatment of DIE with colorectal resection using the da Vinci System. Surgical data were evaluated, together with perioperative urinary and sexual function as assessed by means of self-administered validated questionnaires. RESULTS: None of the patients reported significant postoperative complications. Questionnaires concerning sexual well-being, urinary function, and impact of symptoms on quality of life demonstrated a slight worsening of all parameters 1 month after surgery, while data were comparable to the preoperative period 1 year after surgery. Dyspareunia was the only exception, as it was significantly improved 12 months after surgery. CONCLUSIONS: Robot-assisted surgery seems to be advantageous in highly complicated procedures where extensive dissection and proper anatomy re-establishment is required, as in DIE with colorectal involvement. Our preliminary results show that robot-assisted surgery could be associated with a low risk of complications and provide good preservation of urinary function and sexual well-being

Sexual and urinary functions after robot-assisted versus pure laparoscopic total mesorectal excision for rectal cancer

Background Laparoscopic total mesorectal excision (LapTME) is a validated technique for the treatment of rectal cancer. However, the ergonomic limitations of pure laparoscopy could lead to high conversion rates and a high rate of autonomic disorders. For these reasons the robot-assisted TME (RobTME) has been proposed to overcome the limitations of LapTME. The aim of this study is to compare surgical outcomes, medium-term oncologic results, and postoperative autonomic function of LapTME versus RobTME, in a single surgeon experience. Patients and Methods The first 26 LapTME were compared with the first 26 RobTME performed by a single surgeon between January 2009 and May 2013. Perioperative outcomes were prospectively collected and compared. The impact of minimally invasive TME on autonomic function and quality of life (QOL) was analyzed with the ICIQ-FLUTS and the ICIQ-MLUTS (International Consultation on Incontinence–Male/Female Lower Urinary Tract Symptoms) and IIEF (International Index of Erectile Function)/FSFI (Female Sexual Function Index) questionnaires. Pathological aspects and oncological outcomes were also collected. Results Of the 26 LapTME, 22 were anterior resections (ARR), 2 intersphincteric resections (ISR), and 2 abdominoperineal resections (APR), while of the 26 RobTME, 17 were ARR, 5 ISR, and 4 APR. Mean operative time was significantly higher (p<0.001) while conversion rate to hand-assisted or open surgery was significantly lower in the robTME group (p<0.05). There were no significant differences in sexual and urinary scores between the two groups before surgery and at 1 year after surgery. There were no differences in 3 year overall survival, disease free survival, and recurrence rate as well as the other parameters analysed. Conclusion RobTME is a safe and effective technique and the results compare favourably to the results obtained with laparoscopic procedures. It seems a promising alternative to preserve autonomic function and results in a low conversion rate even when used for more high risk procedures such as ISR or APR

A Plea for Surgery in Pancreatic Metastases from Renal Cell Carcinoma: Indications and Outcome from a Multicenter Surgical Experience

Pancreatic metastases from renal-cell carcinoma (RCC-PMs) are rare. Surgery may play a role in improving overall (OS) and disease-free survival (DFS)

Subclinical Atrial Fibrillation on Prolonged ECG Holter Monitoring: Results from the Multicenter Real-World SAFARI (Silent Atrial Fibrillation ANCE-Sicily Research Initiative) Study

Background: The detection of subclinical/silent atrial fibrillation (SAF) in the general population is of the utmost importance, given its potential adverse consequences. Incident AF has been observed in 30% to 70% of patients with implanted devices, but its prevalence may indeed be lower in the general population. The prospective, multicentric, observational Silent Atrial Fibrillation ANCE Research Initiative (SAFARI) study aimed at assessing the SAF prevalence in a real-world outpatient setting by the means of a small, wearable, prolonged ECG Holter monitoring (&gt;5 days) device (CGM HI 3-Lead ECG; CGM TELEMEDICINE, Piacenza, Italy). Methods: Patients = 55 years of age at risk for AF were screened according to the inclusion criteria to undergo prolonged 3-lead ECG Holter monitoring. SAF episodes were classified as follows: Class A, &lt;30 s; Class B, 30 to 299 s; and Class C, =300 s. Results: In total, 119 patients were enrolled (64 men; median age 71 (IQR 55-85) years). At a median of 13.5 (IQR 5-21) days of monitoring, SAF episodes were found in 19 patients (16%). A total of 10,552 arrhythmic episodes were registered, 6901 in Class A (n = 7 patients), 2927 in Class B (n = 3), and 724 in Class C (n = 9), (Class A vs. B and C, p &lt; 0.001). This latter group had multiple (all-class) episodes, and two patients had &gt;1000 episodes. There were no clinical, echocardiographic, or laboratory findings able to discriminate patients with SAF from those in sinus rhythm in univariate and multivariable analyses; of note is that the Class C patients showed a higher diastolic blood pressure, resting heart rate, and indexed LA volume. Conclusions. Over a median of 13 days of Holter monitoring, the SAFARI study confirmed the usefulness of small wearable devices in detecting SAF episodes in real-world outpatients at risk for, but with no prior history of, AF

Pancreatoduodenectomy without vascular resection in patients with primary resectable adenocarcinoma and unilateral venous contact:A matched case study

Purpose. To investigate the oncological outcome and survival of patients following a conservative approach on the portal- mesenteric axis, in an intraoperative ultrasound-selected group of pancreatoduodenectomy (PD), performed on patients with primary resectable with vascular contact (prVC) pancreatic ductal adenocarcinoma (PDAC). Methods. A consecutive series of patients who underwent PD for PDAC at our tertiary care center, between 2008 and 2017, were reviewed. A total of 156 PDs and 88 total pancreatectomies were performed during the study period, including 35 vascular resections. We identified a group of 40 (25.6%) patients with prVC-PDAC in whom after checking the feasibility with intraoperative ultrasound, we were able to perform PD by separation of the tumor from the portomesenteric axis avoiding vascular resection, without residual macroscopic disease (no vascular resection, nvrPD), and compared this group, using case-matched methodology, with the standard PD (sPD) group of primary resectable without vascular contact- (prwVC-) PDAC. Results. The median follow-up was 28.5 ± 23.2 months in the sPD group and 23.8 ± 20.8 months in the nvrPD group (p = 0 35). Isolated local recurrence rate was 2/40 (5%) in both groups. Additionally, there were no statistical differences in the systemic progression of the disease (42.5% sPD vs. 45% nvrPD, p = 0 82) or local plus synchronous systemic disease rates (2.5% sPD vs. 7.5% nvrPD, p = 0 30). The median survival was 22 months for the sPD group and 23 months for the nvrPD group, p = 0 86. The overall survival was similar in the two groups (1 y: 76.3% sPD vs. 70.0% nvrPD; 3 y: 35.6% vs. 31.6%; and 5 y: 28.5% vs. 25.3%; p = 0 80). Conclusions. PD without vascular resection can be considered safe and oncologically acceptable in selected patients with preoperative diagnosis of prVC-PDAC. The poor prognosis of PDAC is related to the aggressive biology and systemic spread of the tumor, rather than the local control of the disease

Impact of acute changes of left ventricular contractility on the transvalvular impedance: validation study by pressure-volume loop analysis in healthy pigs

BACKGROUND: The real-time and continuous assessment of left ventricular (LV) myocardial contractility through an implanted device is a clinically relevant goal. Transvalvular impedance (TVI) is an impedentiometric signal detected in the right cardiac chambers that changes during stroke volume fluctuations in patients. However, the relationship between TVI signals and LV contractility has not been proven. We investigated whether TVI signals predict changes of LV inotropic state during clinically relevant loading and inotropic conditions in swine normal heart. METHODS: The assessment of RVTVI signals was performed in anesthetized adult healthy anesthetized pigs (n = 6) instrumented for measurement of aortic and LV pressure, dP/dtmax and LV volumes. Myocardial contractility was assessed with the slope (Ees) of the LV end systolic pressure-volume relationship. Effective arterial elastance (Ea) and stroke work (SW) were determined from the LV pressure-volume loops. Pigs were studied at rest (baseline), after transient mechanical preload reduction and afterload increase, after 10-min of low dose dobutamine infusion (LDDS, 10 ug/kg/min, i.v), and esmolol administration (ESMO, bolus of 500 µg and continuous infusion of 100 µg·kg-1·min-1). RESULTS: We detected a significant relationship between ESTVI and dP/dtmax during LDDS and ESMO administration. In addition, the fluctuations of ESTVI were significantly related to changes of the Ees during afterload increase, LDDS and ESMO infusion. CONCLUSIONS: ESTVI signal detected in right cardiac chamber is significantly affected by acute changes in cardiac mechanical activity and is able to predict acute changes of LV inotropic state in normal heart