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With improvement in arthroscopic techniques, partial meniscectomy with repair for symptomatic discoid lateral meniscus (DLM) has been the preferred treatment to restore meniscal function. It was reported that DLM exhibited deformation and extrusion shortly after saucerization with repair. Therefore it is desirable to minimize removal of the DLM. The anterior zone of the DLM is often tighter than that of the normal meniscus and anatomic variant. It is considered that the anterior and anterocentral dislocation types in the majority of symptomatic DLM can be related to both peripheral instability and anterior tightness. We present a technique that, first, the inside-out repair technique is applied from the posterior to middle segment of the DLM; next, the tension of the anterior zone during knee flexion–extension is confirmed to determine the released amount of that part; and, finally, all sutures are tied to reproduce the normal meniscus movement. Meniscus repair with anterior cord release without any meniscectomy could resolve peripheral instability of DLM and prevent degeneration of the articular cartilage., Technique Video Video 1 We present a technique that meniscus repair with anterior cord release for peripheral tear type of discoid lateral meniscus. First, diagnostic arthroscopy is performed. Left knee view from the anterolateral portal in a 9-year-old girl. We identify the tear site and instability by careful probing, and then locking, popping, and abnormal movement of discoid lateral meniscus during knee flexion–extension are examined. In addition, meniscus tear or peripheral instability are analyzed according to their location, type, and size. A probe from the anteromedial portal is inserted, and the thick fibers posterior to the anterior horn of the discoid lateral meniscus are identified. View from the anteromedial portal. The probe shows the border of thick fibers of the free edge of the meniscus and the fiber with straight arrangement to attachment on the tibia. First, vertical divergent suturing was performed on the superior and inferior surfaces of the discoid lateral meniscus from the posterior segment using suture with a Henning needle. At this time, the suture is not tied but left so that the tension of suture can be subsequently adjusted. A scalpel is inserted from the anterolateral portal to gradually release the free end of the meniscus, and tension is applied to the suture. There is instability in the midbody of the meniscus, a far anteromedial portal is created and sutured in the same way without knot tying. When the meniscus is reduced posteriorly and laterally, the released part is opened, and a smooth line is drawn The degree of release is determined by observing meniscus movement while applying tension to the untied suture. Tension in each suture and meniscus movement is confirmed arthroscopically; then, the sutures are tied. We confirm that normal movement of the lateral meniscus during knee flexion–extension can be reproduced and that dislocation does not occur. Repaired discoid lateral meniscus move posterior in knee flexion and anterior in knee extension. View from the anteromedial portal: the repaired discoid lateral meniscus looks like a normal meniscus with a crescent shape.

Yakimenko V. V. Clinical and prognostic value of TAMX index of interlobar arteries of the middle segment in patients after allograph kidney transplantation in the late postoperative period. Journal of Education, Health and Sport. 2020;10(11):171-181. eISSN 2391-8306. DOI http://dx.doi.org/10.12775/JEHS.2020.10.11.016 https://apcz.umk.pl/czasopisma/index.php/JEHS/article/view/JEHS.2020.10.11.016 https://zenodo.org/record/4282981 The journal has had 5 points in Ministry of Science and Higher Education parametric evaluation. § 8. 2) and § 12. 1. 2) 22.02.2019. © The Authors 2020; This article is published with open access at Licensee Open Journal Systems of Nicolaus Copernicus University in Torun, Poland Open Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author (s) and source are credited. This is an open access article licensed under the terms of the Creative Commons Attribution Non commercial license Share alike. (http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, provided the work is properly cited. The authors declare that there is no conflict of interests regarding the publication of this paper. Received: 16.10.2020. Revised: 30.10.2020. Accepted: 20.11.2020. CLINICAL AND PROGNOSTIC VALUE OF TAMX INDEX OF INTERLOBAR ARTERIES OF THE MIDDLE SEGMENT IN PATIENTS AFTER ALLOGRAPH KIDNEY TRANSPLANTATION IN THE LATE POSTOPERATIVE PERIOD V. V. Yakimenko State Institution "Zaporozhye Medical Academy of Postgraduate Education of the Ministry of Health of Ukraine", Vintera blvd., Zaporozhye, Ukraine, 69096 ORCID: 0000-0002-8867-6501 diagnostica@mail.ua Abstract Introduction. Kidney transplantation has become the best treatment for patients with end-stage of chronic renal failure. The issues of studying the causes and mechanisms of the development of renal transplant dysfunction in the late postoperative period, the search for high-precision minimally invasive methods for early diagnosis of renal transplant dysfunction remain relevant, since this largely determines the further normal functioning of the organ and prognosis for the patient. The aim of the study was to investigate the clinical and prognostic value of the time-averaged peak velocity (TAMX) index of the interlobar arteries of the middle segment in patients after allograft transplantation in the long-term postoperative period. Material and research methods. For the period 2014-2015 ultrasound scan of renal grafts were performed in 26 patients with creatinine levels within the normative values. The average age of recipients in this group was 31.4 ± 1.67 years. Among the recipients there were 15 men (57.7%), 11 women (42.3%). Living related kidney transplantation (LRKT) were performed in 61.54% of patients, in 38.46% – cadaveric kidney transplantation (CKT). In all patients, the plasma creatinine level met the standard value or exceeded them by no more than 25%, fluctuating on average from 94 to 130 μmol / L, averaging 114.5 ± 3.85 μmol / L. The second study is based on the results of ultrasound scan of renal transplants in 26 patients with creatinine levels exceeding the standard values for the period 2015-2016. The average age of recipients in this group was 38.99 ± 2.32 (34.35-43.62) years. There were 14 men (53.84%) among the recipients, and 12 women (46.16%). LRKT were performed in 6 patients, in 20 – CKT. In all patients the plasma creatinine level was above normal values, fluctuating on average from 155 to 629 μmol / L, averaging 259.46 ± 35.33 μmol / L. The groups were comparable in terms of the main clinical and demographic parameters. Results. The method for predicting complications by the level of TAMX of the interlobar arteries of the middle segment of the kidneys during Doppler ultrasonography of the renal blood flow ( The interdependence between the TAMX of the interlobar arteries of the middle segment and serum creatinine, which is gradually regressing in a parabola, shows that more than half of the entire variance of the creatininemia sign can be associated with a change in the TAMX indicator (as a sign of deterioration in the renal blood flow of the graft), and the largest "failure" of the function were observed in the range from 12 to 15 cm / s TAMX, where in the overwhelming majority of cases (about 80%) there were impaired renal hemodynamics and the available laboratory markers of impaired renal function (creatinine above 200 μmol / l). Conclusions. A reliable prognostic value of TAMX of interlobar arteries (middle segment) was shown in spectral Doppler ultrasonography of renal blood flow in a priori assessment of the risk of developing post-transplant nephropathy, which allows us to consider it as a cumulative predictor of an unfavorable prognosis and a potential factor not only for the formation of graft dysfunction, but also for rejection in the late postoperative period. Key words: logistic regression; late graft dysfunction; pulsation index; Wald test; Doppler ultrasound.

The coronary artery aneurysm (CAA) is not a frequent condition in the catheterization laboratory. The management is uncertain. Most of the cases, the treatment is surgical with good results. In smaller aneurysm, the use of covered stents is an alternative. This is an anterograde approach CTO (chronic total occlusion) case of a middle segment RCA (right coronary artery) with a thrombosed coronary aneurysm. This was occluded due to thrombus as a result of a STEMI five months ago. In this case, we used a covered stent with good results in follow up to five months.

Purpose This article aims to present all aspects regarding patient selection, planning, and implantation technique for a new off-the-shelf pre-cannulated multi-inner branch stent graft. The stent graft comes in 4 different versions with proximal diameters of 33 and 38 mm and distal diameters of 26 and 30 mm. The 4 inner branches are located in the middle segment, which has a diameter of 24 mm. Technique With inner branch technology, the field of application for the treatment of thoracoabdominal aortic aneurysms (TAAA) has been further extended. In addition to routine use in elective cases the pre-cannulation of the inner branches predisposes especially for emergencies. Pre-cannulation is intended to reduce the time to cannulation and the radiation dose. All steps of planning, stent-graft deployment, and cannulation of the inner branches are described in detail. Conclusion The E-nside stent graft represents a promising new endovascular therapy in the treatment of acute and elective TAAA. By using inner branch technology, this endograft combines the advantages of fenestrated and branched stent grafts. Indication, planning, and implantation require experience in branched and fenestrated stent graft technology.

Introduction There was little information about the isolated medial meniscal tears in the anterior–middle segment. This study aimed to report the infrequent cases of the isolated medial meniscal tears in the anterior–middle segment related to kicking motion among young soccer players with a short-term postoperative outcome. Presentation of case In the retrospective review of the surgical records from 2000 to 2018, there were 15 cases with the corresponding tear. They were all young male soccer players with a mean age of 16.7 years (range: 10–23 years). The cause of injury was kicking motion during playing soccer in all the patients. The most frequent symptom was locking in 80% of the cases. In the arthroscopic evaluation, all the cases presented with a longitudinal (bucket-handle) tear in the anterior–middle segment in the peripheral zone with a length of 25 to 30 mm, while the posterior segment and the cruciate ligaments were intact. Meniscal repair was performed for all the cases. At one year, all the patients could return to play soccer with a pre-injury level without any symptoms. In the second-look arthroscopy at six months among four cases, all meniscal tears healed completely. Discussion and conclusion Clinicians should be aware of the possibility of isolated peripheral longitudinal tear in the anterior–middle segment of the medial meniscus, which is related to the kicking motion among young soccer players and mainly causes locking., Highlights • Isolated medial meniscal tears in anterior–middle segment are relatively infrequent. • These tears cause after kicking motion among young soccer players. • Longitudinal (bucket-handle) tears are observed in the periphery. • Clinical outcomes after repair are good.

The present study aimed to explore the variability of the arm-stroke temporal descriptors between and within laps during middle-distance swimming event using IMMUs. Eight male swimmers performed a 200-m maximum front-crawl in which the inter-lap and intra-lap variability of velocity, stroke rate, stroke-phases duration and arm-coordination index were measured through five units of IMMU. An algorithm computes the 3D coordinates of the wrist by means the IMMU orientation and the kinematic chain of upper arm biomechanical model, and it recognizes the start events of the four arm-stroke phases. Velocity and stroke rate had a mean value of 1.47 &plusmn, 0.10 m&middot, s&minus, 1 and 32.94 &plusmn, 4.84 cycles&middot, min&minus, 1, respectively, and a significant decrease along the 200-m (p &lt, 0.001, &eta, 2 = 0.80 and 0.47). The end of each lap showed significantly lower stroke rate compared to the start and the middle segment (p &lt, 0.05, 2 = 0.55). No other significant inter-lap and intra-lap differences were detected. The two main findings are: (i) IMMUs technology can be an effective solution to continuously monitor the temporal descriptors during the swimming trial, (ii) swimmers are able to keep stable their temporal technique descriptors in a middle-distance event, despite the decrease of velocity and stroke rate.

Involvement of the heart in Behcet's disease (BD) is rare. We retrospectively analyzed these three patients with interventricular septal (IVS) dissection in BD and discussed the echocardiographic manifestations of IVS dissections. In our patients, the echocardiographic characteristics of IVS dissection were echo-free space in the IVS basal segment or basal to middle segment, dilatation in the diastole and contraction in systole, and abnormal turbulent blood flow in the heart.

INTRODUCTION: Debridement of the root canal system is essential for endodontic success. Traditional instruments alone cannot sufficiently clean root canals. There must be an effective delivery system. OBJECTIVES: was to compare the cleaning efficiency of XP-endo Finisher and the EndoActivator using the scanning electron microscope. MATERIALS AND METHODS Sixty human mandibular first premolars with single oval canals were used in this study. Teeth were instrumented using One-Shape file. Teeth were then randomly divided into three parallel groups (n=20) according to the agitation method used; Group I: XP-endo Finisher. Group II: EndoActivator. Group III: both XP-endo Finisher and EndoActivator. Teeth were sectioned longitudinally and assessed by the scanning electron microscope using the five-score debris and smear layer indices. Data were analyzed using Kruskal-Wallis, Friedman, and Dunn-Bonferroni tests. RESULTS: No significant differences were found between XP- endo Finisher and EndoActivator in debris and smear layer removal. In the middle segment, each of the XP-endo Finisher and EndoActivator revealed significantly lower debris scores than both together (P 0.05). In smear layer removal, significant differences were found in both the coronal and apical segments between each one of the XP-endo Finisher and EndoActivator compared to both together (P 0.05). The apical segment was more efficiently cleaned from debris and smear layer than the other segments in all groups. CONCLUSIONS: Irrigation of root canals using XP-endo Finisher and EndoActivator solely was more effective in the removal of debris and smear layer than both used together. The apical third was more efficiently cleaned from debris and smear layer than the other segments.

A coronary artery aneurysm is a challenging cli-nical situation due to the lack of sufficient evidence from randomized controlled studies and the lack of consensus on a management strategy. The present case is a description of the exclusion of a middle segment aneurysm of the left circumflex coronary artery using a PK Papyrus covered stent (Biotronik, AG, Bulach, Switzerland). The final images were favorable.

Leiomyosarcoma of inferior venacava is a rare tumor. Female are most commonly affected and middle segment of inferior vena cava is the commonest site. The diagnosis can sometimes be challenging as patients present with non-specific symptoms. We present a case of a 65-year-old female who presented with pain in right hypochondrium and epigastric region since 4 months along with weight loss, anorexia and vomiting. Histopathological examination revealed a capsulated, multilobated tumor arising from muscle layer of inferior venacava with extraluminal growth pattern and tumor cells showing cytoplasmic positivity for immuno-histochemical stain smooth muscle actin. With the diagnosis of leiomyosarcoma of inferior venacava, excision of tumor was done with tangential excision of 4 cm length of inferior venacava with primary repair. Keywords: inferior venacava; leiomyosarcoma; smooth muscle actin.

We report surgical treatment of a 65-year-old patient with recurrent hemangioendothelioma of inferior and middle segment of inferior vena cava with spread to previously established prosthesis. Advanced resection of inferior vena cava and right-sided nephrectomy were not followed by complications and resulted R0 resection. Surgery time was 180 min. Inferior vena cava cross-clamping time was 30 min. Total blood loss was 300 ml. Hemangioendothelioma is a rare tumor with unpredictable potential for malignant transformation and obligatory indications for surgical treatment. Resection and reconstruction of inferior vena cava and renal veins with a synthetic conduit is effective and safe procedure.Представлен клинический случай оперативного лечения больной в возрасте 65 лет по поводу рецидивной гемангиоэндотелиомы нижнего и среднего сегмента нижней полой вены с распространением на ранее установленный протез. Выполнение протяженной резекции нижней полой вены и нефрэктомии справа не привело к развитию каких-либо осложнений и позволило добиться R0-резекции. Время операции составило 180 мин, пережатия нижней полой вены — 30 мин. Объем кровопотери 300 мл. Гемангиоэндотелиома — редкая опухоль с непредсказуемым потенциалом злокачественности, единственный радикальный метод лечения гемангиоэндотелиомы нижней полой вены — хирургическое лечение. Резекция и реконструкция нижней полой вены синтетическим кондуитом с реконструкцией почечных вен при необходимости является эффективной и безопасной операцией.

Solid serous cystadenoma of the pancreas is the rarest subtype of serous cystadenoma. Cystic structures are difficult to recognize by imaging studies. In the clinical setting, it is crucial to discriminate a solid serious cystadenoma from other solid pancreatic tumors. The present study reported a case of solid serous cystadenoma in which the magnetic resonance cholangiopancreatography (MRCP) findings were useful for diagnosis and decision-making regarding the surgical strategy, with a review of the previous reports of solid serous cystadenoma. A 50-year-old woman was referred to our hospital for investigation of a pancreatic body mass. A 2-cm hypervascular solid tumor was revealed by computed tomography. No typical radiological imaging findings of small cysts were detected, such as a honeycomb structure, and an adequate specimen could not be gained by biopsy under endoscopic ultrasonography. However, the tumor showed high intensity on MRCP, suggesting its cystic nature. A solid serous cystadenoma was suspected based on these radiological findings, and middle segment pancreatectomy was performed as a function-preserving surgery. The histological findings were compatible with a solid serous cystadenoma. In conclusion, MRCP imaging may be helpful for diagnosis and decision-making regarding the most appropriate surgical method for solid serous cystadenomas.

Background Submandibular gland (SMG) transplantation is a successful treatment approach for patients with severe dry eye. However, duct obstruction can occur post-transplant. Methods We studied nineteen patients with duct obstruction of transplanted SMGs, including five interventional modalities: stone removal; secretory stimulation (to mimic "internal irrigation" with substantial secretory flow); irrigation; surgical opening of stenosis and orifice reconstruction; cephalic vein bypass and Wharton's duct reconstruction. Results A solitary stone was found and removed in one patient. Duct blockages like mucus plug were cleared by secretory stimulation in three patients, and by normal saline irrigation in two grafts. In the remaining 13 patients, irrigation failed and surgical opening was performed. Orifice reconstruction succeeded in six of the eight patients, whose stenosis was near the orifice. Wharton's duct reconstruction was successful in two of the five cases where stenosis was located in the middle segment of the duct. Conclusion Transplanted SMGs obstruct for various reasons. Stone, which is easy to diagnose and treat, should be excluded first. Non-organic blockage and stenosis were semblable in clinic. Therefore, subsequent steps should be a diagnostic/therapeutic trial of secretory stimulation, followed by irrigation; failure of these interventions suggests the diagnosis of duct stenosis, necessitating surgical recanalization.

For multiple low-grade malignant tumors located in the pancreatic head and tail, middle-segment-preserving pancreatectomy (MSPP) is sometimes indicated. However, MSPP has rarely been performed laparoscopically. Here we report the first case of laparoscopic MSPP for multiple pancreatic neuroendocrine tumors diagnosed preoperatively under an endoscopic ultrasound-guided fine-needle aspiration biopsy. A 70-year-old man had multiple small tumors located in the pancreatic head, body and tail. Endoscopic ultrasound-guided fine-needle aspiration biopsy with immunohistochemical staining made a definitive diagnosis of a pancreatic neuroendocrine tumor (G1). To preserve the 5-cm pancreas body, we successfully performed laparoscopic MSPP: subtotal stomach-preserving pancreaticoduodenectomy followed by distal pancreatosplenectomy. Pathological examination revealed negative surgical margin after resection. Postoperative course was uneventful, and at 14 months after the operation, the patient remains tumor-free. The patient has discontinued insulin supplement therapy but does use an oral hypoglycemic agent. Laparoscopy-assisted MSPP, with reconstruction through a 6-cm transverse incision, can be safely performed for selected cases of borderline and malignant lesions.

Introduction: Several techniques have been used for arthroscopic repair of middle segment, posteromedial or posterolateral corner tears of the meniscus. One of the commonly used methods is the inside-out double arm needle technique. Surgical Technique: We have developed a vertical mattress absorbable suture technique. It is easy to perform with a small sized skin incision for knot tying. This technique just necessitates 1 or 2 spinal needles for repair. Materials and Methods: Between March 2010 and February 2012, 20 menisci were treated by this technique, a modified method of the outside-in vertical meniscal repair using a spinal needle and No. 2 PDS absorbable suture material. Evaluation of clinical results was done using the Lysholm score. Results: The mean preoperative Lysholm score was 63.9 and the mean postoperative score was 97.3. A second look arthroscopy was performed in 13 knees (65%) and the repair sites were well healed. Conclusions: We recommend this method as an alternative technique for repair of the middle segment, posteromedial or posterolateral corner of the meniscus.

Background Defects sustained at the distal forearm are common and pedicled perforator flaps have unique advantages in resurfacing it. The purpose of this study is to reappraise the anatomy of the perforator in the posterolateral aspect of the mid-forearm and present our clinical experience on using perforator flaps based on it for reconstruction of defects in the distal forearm. Methods: This study was divided into anatomical study and clinical application. In the anatomical study, 30 preserved upper limbs were used. Clinically, 11 patients with defects at the forearm underwent reconstruction with the posterolateral mid-forearm perforator flaps. The defects, ranging from 4.5 × 2.5 cm to 10.5 × 4.5 cm, were located at the dorsal aspect of the distal forearm in 6 cases and at the volar aspect of the distal forearm in 5 cases. Results Three patterns of the perforator were observed in the posterolateral aspect of the mid-forearm, which originated from the posterior interosseous artery, the proximal segment of the radial artery or the radial recurrent artery, and the middle segment of the radial artery, respectively. The perforator was located 11.8 ± 0.2 cm to 15.8 ± 0.4 cm inferior to the lateral humeral epicondyle. Clinically, flaps in 8 cases survived uneventfully, while the other 3 cases suffered mild marginal epidermal necrosis, which was cured with continuous dress changing. Conclusion The location of the perforator at the posterolateral aspect of the mid-forearm is consistent; the posterolateral mid-forearm perforator flap is particularly suitable to cover defects in the distal one-third of the forearm. © 2013 Wiley Periodicals, Inc. Microsurgery 33:638–645, 2013.

Open segmental fractures of both bones of the forearm with the loss of the middle segment of the radius is a rare injury in children. An eight-year-old boy presented to our clinic four days following a road traffic accident. The child’s mother was carrying a 12-cm long extruded and soiled segment of the radius bone. The extruded bone segment seemed necrotic, and we decided not to use it for replantation. The wound over the forearm fracture was infected. It was debrided and regularly dressed until it became healthy. We planned to use a fibular graft for the gap and to fix the graft with a Kirschner wire (K-wire). The operation was delayed due to the poor wound condition. At the four-week follow-up, we noticed unexpected signs of bone regeneration in the bone defect of the radius. After eight weeks, a complete spontaneous reconstruction of the bone was noted. This case highlights the excellent healing potential of the bones in children, where even if a long segment of the bone is lost, we can expect spontaneous complete regeneration of the bone if the periosteum is intact and continuous.

The midpalatal suture has bone margins with thick connective tissue interposed between them, and it does not represent the fusion of maxillary palatal processes only, but also the fusion of palatal processes of the jaws and horizontal osseous laminae of palatal bones. Changing it implies affecting neighboring areas. It has got three segments that should be considered by all clinical analyses, whether therapeutic or experimental: the anterior segment (before the incisive foramen, or intermaxillary segment), the middle segment (from the incisive foramen to the suture transversal to the palatal bone ) and the posterior segment (after the suture transversal to the palatal bone ). Rapid palatal expansion might be recommended for patients at the final pubertal growth stage, in addition to adult patients with maxillary constriction. It represents a treatment solution that can potentially avoid surgical intervention. When performed in association with rapid palatal expanders, it might enhance the skeletal effects of the latter. Of the various designs of expansion appliances, MARPE (miniscrew-assisted rapid palatal expander) has been modified in order to allow its operational advantages and outcomes to become familiar in the clinical practice. RESUMO A sutura palatina mediana tem margens ósseas interpostas por tecido conjuntivo denso e não representa apenas a união dos processos palatinos da maxila, mas também a dos processos alveolares das maxilas e das lâminas horizontais dos ossos palatinos. Modificá-la implica em influenciar outras áreas vizinhas. Ela tem três segmentos a serem considerados em todas as análises clínicas, terapêuticas e experimentais: anterior (antes do forame incisivo, ou intermaxilar), médio (do forame incisivo até a sutura transversa com o osso palatino) e posterior (após a sutura transversa com o osso palatino). A expansão rápida da maxila pode ser indicada para pacientes que se encontram no final da fase de crescimento da puberdade, além de pacientes adultos com atresia maxilar, representando uma solução de tratamento, possivelmente evitando uma intervenção cirúrgica. Quando associada a aparelhos de protração maxilar, pode maximizar os efeitos esqueléticos desses. Entre os vários designs de aparelhos disjuntores, ultimamente encontra-se o MARPE (Miniscrew-Assisted Rapid Palatal Expander), que tem sido modificado para que ocorra, na rotina clínica, uma familiarização com suas vantagens operatórias e resultados obtidos.

Spontaneous haemothorax is a subcategory of haemothorax that occurs in the absence of trauma or other causes. It is a rare emergency that can progress rapidly with massive blood loss leading to haemorrhagic shock and death. We describe a patient with massive spontaneous haemothorax caused by the disruption of an oesophageal artery from the middle segment of descending thoracic aorta. We sutured the bleeding artery in an emergency thoracotomy after the failure of interventional procedure.

Middle segment pancreatectomy (MSP) is a new operation where the advantages of parenchymal preservation are counterbalanced by a high postoperative complication rate and unease among surgeons with adopting a new technique. This study reviews our experience incorporating MSP into our clinical practice focusing on the initial 34 consecutive patients operated on by one surgeon at a single institution between 1998 and 2007. Patients were divided into early (initial 17 operations) and late (subsequent 17 operations) groups for analysis. Thirty-one reconstructions were by Roux-en-y pancreaticojejunostomy and three were by pancreaticogastrostomy. Using multiple linear regression and logistic regression, we found no significant differences in performance outcomes (operative time, blood loss, tumor size, margin negative resection rate, pancreatic fistula rate, hospital length of stay, postoperative complications, and hospital readmission rate) between our early and late experience even after adjusting for potential confounding variables (patient demographics, co-morbidities, neoplasm, pancreatitis). The pancreatic fistula rate in this series was 29.4% (10/34) and they were all International Study Group on Pancreatic Fistula (ISGPF) Grade A (60%) or B (40%). In summary, MSP is an operation with a flat learning curve and acceptable morbidity rate that can be safely incorporated as a parenchymal preserving option by pancreatic surgeons in their clinical practice.

Lodging of foreign bodies in the esophagus is not frequent in adults. The cases are often diagnosed within the first 24 hours. We present herein a case who had swallowed a chicken bone 10 days before that had become embedded in the middle segment of the esophagus. Successful removal of the bone was achieved with the aid of an endoscope., Erişkinlerde özofagusa yabancı cisim takılması sık karşılaşılan bir durum değildir. Vakalar çoğunlukla ilk 24 saatte tanı alır. Tavuk kemiği yuttuktan sonra özofagus orta kesime impakte olan ve 10 gün sonra geç dönemde tanı alan, endoskop yardımı ile başarılı bir şekilde çıkarılan bir vakayı sunuyoruz.

Background: Conventional distal pancreatectomy is used for the removal of lesions located at the body and tail of the pancreas. Generally, the spleen is sacrificed. But for benign and low malignant potential tumours in the pancreatic neck and body, this incurs notable loss of normal pancreatic tissue and the unnecessary risk of diabetes mellitus as well as splenic loss. Methods: We report three cases of middle segment pancreatectomy in an effort to avoid the unnecessary loss of normal pancreatic tissue and the spleen. Two patients were males with a mucinous cystadenoma and non-cystic mucinous cystadenocarcinoma. The other was a female with a serous cystadenoma. Middle segment pancreatectomy was performed. Two patients were reconstructed with double pancreaticojejunostomy and the third with a pancreaticogastrostomy. Results: No major complications were observed. Comnclusions: Middle segment pancreatectomy is a safe and effective procedure for the resection of benign and low malignant potential tumours in the pancreatic neck and body with preservation of normal pancreatic tissue and the spleen in selected patients. This is the first report of middle segment pancreatectomy for pancreatic tumour in China.

Evaluation of: Balin M, Celik A, Kobat MA. Circulating soluble lectin-like oxidized low-density lipoprotein receptor-1 levels are associated with proximal/middle segment of the LAD lesions in patients with stable coronary artery disease. Clin. Res. Cardiol. 101(4), 247–253 (2011). In search of developing therapeutic agents to attenuate the process of atherogenesis and finding a novel biomarker of coronary artery disease, the study of soluble LOX-1 (s-LOX-1) has gained a great attention. The contributory role of LOX-1 in atherogenesis is now supported by several lines of evidence. In this context, a recent paper by Balin et al. presents new information on the possible role of s-LOX-1 in the identification of proximal/middle segment left anterior descending lesions. We have attempted to summarize the role of s-LOX-1 in atherosclerotic coronary artery disease and discuss the impact of the aforementioned paper in current arena of research on s-LOX-1.

Introduction: This video shows the submucosal tunneling endoscopic resection (STER). Today, endoscopic submucosal dissection (ESD) is increasingly used for superficial esophageal cancers and esophageal submucosal tumors (SMTs),1,2 but the surgical area in the esophagus is limited and the esophageal adventitia is very thin. As improved ESD technology, STER can reduce risk of postoperative gastrointestinal (GI) tract leakage and secondary infection.3 Method: This was a 56-year-old patient who found it difficult to swallow since November 23rd 2013. Then, she went to hospital and had a computer tomography (CT) scan and endoscopic ultrasonography; both of them showed there was an SMT in the middle segment of the esophagus. The patient had no other symptoms besides dysphagia, and the blood routine examination is regular. On December 4th 2013, we decided to use STER to treat this lesion. After a short anesthesia induction, we found there had been a lesion of about 1.5×1.5 cm with smooth surface in the m...

Dear Sir, We describe two modifications to simplify cannulation and passage of fine feeding catheter through flexor sheath for closed irrigation of infective flexor tenosynovitis. Cannulating the flexor sheath and controlled passage of fine feeding catheter through the retinacular system can be difficult due to its pliability, often requiring multiple attempts and causing additional trauma to flexor tendons. Conventionally, irrigation solution is pumped out through the tip of the catheter and intrathecal lavage is dependent on the pressure jet and continuous flow [2]. The potential drawbacks of the latter are incomplete evacuation of infected material and tedious dressings. Other authors have described single and multiple fenestrations along catheter in human and veterinary patients [1, 4]. The advantage of side fenestration is the delivery of irrigation solution to sanctuaries such as the sub-chiasms and intertendinous interfaces. Based on the above techniques, we have modified the closed irrigation technique in two ways to ease cannulation and intrathecal lavage. In all cases, the flexor sheath is visualized and accessed through hemi-Brunner incision centered over A4/5 or A3/4, and a palmar crease incision centered on the A1. The first modification introduces an intraluminal 24-gauge wire to stiffen the tube for cannulation at either A3/4 or A4/5 and retrograde passage to the A1 window (Fig. 1). The second modification involves fenestrating the catheter along its middle portion to increase turbulence of intrathecal flow. During irrigation, the catheter is drawn back and forth, while an assistant flushes the tube after clamping its tip. The end point is the evacuation of clear fluid from the A1 window. Fig. 1 Middle segment of a feeding catheter is marked (black arrows) and fenestrated with a no. 11 blade. Intraluminal 24-gauge wire to increase stiffness of catheter to ease cannulation and manipulation of catheter We believe that the combination of mechanical lavage and fluid flow through the fenestrations increases direct clearance of intrathecal material as opposed to indirect methods that rely on continuous flow (Fig. 2). The catheter is removed after irrigation and postoperative irrigation is not practiced due to the lack of perceived benefits [3]. Fig. 2 Left to right. Direct irrigation—tip of catheter clamped to facilitate intrathecal flow of irrigation fluid (blue arrows), and oscillating motion (thick black arrows) to promote mechanical lavage. Indirect irrigation—flexor sheath is ...

Many cases of surgical resection of metastatic pancreatic tumors originating from renal cell carcinoma have been reported; however, cases of reresection of recurrent pancreatic metastasis of renal cell carcinoma in the remnant pancreas are rare. We performed a second resection for recurrent pancreatic metastasis of renal cell carcinoma six years after pancreatoduodenectomy with pancreaticogastrostomy reconstruction. By performing middle segment-preserving pancreatectomy, we were able to successfully spare the exocrine and endocrine pancreatic function compared to that observed after total pancreatectomy, with no signs of recurrence for two years after the surgery.

Magnetic-resonance imaging techniques use different imaging planes than does conventional coronary angiography to acquire longer segments of a coronary artery in a single tomographic slice. At first sight, these planes appear rather puzzling, because the coronary arteries are displayed in unfamiliar orientations. In this article we will review the existing methodology for obtaining the orientations for the proximal coronary arteries and describe the associated anatomical landmarks that can be seen. Additional orientations for the middle segment of the circumflex and distal right coronary artery are introduced. These orientations are used both in various acquisition techniques and for evaluation of three-dimensional data when using multiplanar reformatting.

Selective embolization of coronary vein of stomach was employed for the treatment of 222 patients with bleeding from esophageal varices due to portal hypertension. The coronary vein was separated at middle segment and tube was inserted and clamped 5 cm below and above the cardia. The gamma-octyl-cyanoacrylate was used for embolization. 19 patients received preventive operation, 106 was subject to emergency surgery and 98 patients was treated by elective operation. The bleeding of all patients receiving emergency procedure was stopped. 3 died of liver failure after operation. 219 survived. 189 cases were followed up for 1-2 years and on varices was found. 182 cases followed up for 6 years revealed no relapse of bleeding. This technique could achieve good curative effect, which provides a new approach for the treatment of bleeding from esophageal varices of portal hypertension.

A case of a thirty-nine-year-old woman with leiomyosarcoma of the inferior vena cava (IVC) is described. The tumor arose from the middle segment of the IVC, and liver metastasis of the tumor was found. The tissue of the tumor obtained at laparotomy was positive for estrogen receptor and progesterone receptor. The patient has been treated with combined multimodal therapy including resection of the main tumor, intrahepato-arterial chemotherapy, and hormonal manipulation. To the authors' knowledge, this is the first case of leiomyosarcoma of the IVC in which the presence of steroid receptors was determined.

BACKGROUND The 180-degree propeller flaps allow closure of soft-tissue defects of the distal lower extremity. In addition to twist, the pedicle is often subject to additional kinking which increases proportionally to the angle at which the perforator pierces through the fascia. This study evaluates the directionality of the perforators at the fascial level to guide in the selection process of the best perforator. MATERIAL AND METHODS Perforators were identified in the lower extremities of 16 fresh cadavers. The angle of fascial perforation was measured. Perforators were grouped according to source vessel and location. Results were analyzed statistically regarding angle of fascial perforation along the source vessel and region. RESULTS A total of 324 perforators were identified. Distal perforators pierced the fascia at a significantly greater angle than in the proximal and middle segment of the peroneal and anterior tibial vessels (P < 0.005). Perforators originating from the posterior tibial artery pierced the fascia at less acute angles distally. When grouped according to the region of the perforators, no significant difference was found between perforators from all source vessels in the proximal region of the distal lower extremity. Even distally, perforators from the posterior tibial artery traveled almost perpendicular (P < 0.005). CONCLUSION Perforators traveling in a near perpendicular manner are ideal to serve as a pedicle for 180-degree propeller flaps as solely the twist has to be distributed along the vessel. The posterior tibial artery was the source to perforators with the most constant, near-perpendicular course, predisposing them for use in 180-degree propeller flaps.

Imaging techniques try to identify patients who may respond to cardiac resynchronization therapy (CRT). However, it may be clinically more useful to identify patients for whom CRT would not be beneficial as the procedure would not be indicated for this group. We developed a novel, clinically feasible and technically-simple echocardiographic dyssynchrony index and tested its negative predictive value. Subjects with standard indications for CRT had echo preand post-device implantation. Atrial-ventricular dyssynchrony was defined as a left ventricular (LV) filling time of

Purpose: To evaluate the effect of a real-time adaptive trigger delay on image quality to correct for heart rate variability in 3D whole-heart coronary MR angiography (MRA). Materials and Methods: Twelve healthy adults underwent 3D whole-heart coronary MRA with and without the use of an adaptive trigger delay. The moment of minimal coronary artery motion was visually determined on a high temporal resolution MRI. Throughout the scan performed without adaptive trigger delay, trigger delay was kept constant, whereas during the scan performed with adaptive trigger delay, trigger delay was continuously updated after each RR-interval using physiological modeling. Signal-to-noise, contrast-to-noise, vessel length, vessel sharpness, and subjective image quality were compared in a blinded manner. Results: Vessel sharpness improved significantly for the middle segment of the right coronary artery (RCA) with the use of the adaptive trigger delay (52.3 7.1% versus 48.9 7.9%, P 0.026). Subjective image quality was significantly better in the middle segments of the RCA and left anterior descending artery (LAD) when the scan was performed with adaptive trigger delay compared to constant trigger delay. Conclusion: Our results demonstrate that the use of an adaptive trigger delay to correct for heart rate variability improves image quality mainly in the middle segments of the RCA and LAD.

Small, benign, or low-grade malignant tumors located in the neck of the pancreas are usually treated with enucleation. However, if enucleation is too risky because of possible damage of the main pancreatic duct, standard pancreatic resections are performed. Such operations can lead to impaired long-term exocrine–endocrine function. Middle segment pancreatectomy consists of a limited resection of the midportion of the pancreas and can be performed in selected patients affected by tumors of the pancreatic neck. Middle segment pancreatectomy is a safe and feasible procedure for treating tumors of the pancreatic neck; in experienced hands it is associated with no mortality but with high morbidity, even if the rate of “clinical” pancreatic fistula is about 20%. Moreover, it allows a surgeon to preserve pancreatic parenchyma and consequently long-term endocrine and exocrine pancreatic function.

Mitral valve (MV) repair is the procedure of choice for MV prolapse or flail. However, valve repair is more technically demanding and requires a precise definition of MV morphology to determine the timing, complexity, and feasibility of repair. We prospectively examined 170 consecutive patients with MV prolapse or flail referred for MV repair. The MV valve was systematically assessed by intraoperative transesophageal echocardiography. MV anatomy was independently assessed at the time of operation. Accuracy of transesophageal echocardiography in identifying MV segments ranged from 90% to 97%, and was best for the middle segment/scallop of either anterior or posterior leaflet. MV repair was successful in 91% of patients. Success rate was the lowest (78%) in the presence of extensive bileaflet disease involving at least 2 segments of each leaflet. Independent predictors of unsuccessful repair were central jet of mitral regurgitation, calcification or severe dilatation of the mitral annulus, and extensive leaflet disease with involvement of at least 3 segments.

Background: Myocardial bridges (MBs) are a congenital abnormality in which a part of the coronary artery is tunneled or immersed in the myocardium, most commonly found in the left anterior descending (LAD) artery. In the artery proximal to the bridge, there is formation of atherosclerosis causing stenosis. However, the tunneled and distal part of the artery is free from atherosclerosis. Objective: This study will investigate the relationship between MB type and proximal stenosis in hypertensive patients. Methods: A total of 140 MB patients were selected form Nanjing Hospital database, all aged between 31 and 91 years. A total of 33 were further excluded from the study. The data of the remaining 107 patients, including the type of bridge, length, depth, blood pressure, cholesterol level, and artery involved, were all taken. The Pearson's Chi-square test was done to compare the relationship between the bridge type and degree of stenosis in the artery proximal to the bridge in hypertensive patients. Results: Among those 107 patients, 69 (64.4%) had a superficial bridge and 38 (35.5%) had a deep bridge. The P value of the superficial bridge group was (0.993), while that of the deep bridge group was (0.580). Conclusion: In this study, superficial bridges were the most common form of MB and the most common artery involved was the (middle segment of) LAD. There were no signs of atherosclerosis in the MB (or tunneled) arteries or the distal parts. This study found no link between MB type and proximal stenosis in hypertensive patients.

In this study, we examined the effects of age and growth hormone replacement on both coronary blood flow and capillary density. Blood flow was measured by using [(14)C]-iodoantipyrine in three groups of anesthetized Brown Norway x Fischer 344 rats: young vehicle-treated animals (6 months; n = 13), old vehicle treated animals (30 months; n = 9), and old animals treated with bovine growth hormone (200 microg/kg) twice a day for 30 days (30 months; n = 7). Capillary density was measured by color segmentation analysis of sections stained for platelet endothelial cell adhesion molecule-1. In all regions examined, coronary blood flow decreased with age, and growth hormone administration resulted in an increase in flow compared to vehicle-treated animals. Capillary density decreased with age in the apex and the left ventricular middle segment. In response to growth hormone administration, capillary density increased significantly in the apex but not in other regions of the heart. Our results demonstrate that growth hormone enhances regional myocardial blood flow in the aged heart and suggest that part of this effect could be due to an increase in capillary density.

Indigenous Sabi rams of Southern Africa were experimentally infected with Trypanosoma congolense for 8 and 16 weeks. Testes weights (g) were significantly (P

A 60-year-old man, 4 years after an anterior myocardial infarction at the middle segment of the left anterior descending coronary artery (LAD), underwent coronary angiography (CAG) because of severe continuous chest pain for >3 hours 3 weeks earlier. CAG revealed no significant stenosis but showed a wall fissure with a double-contrast opacification at the proximal segment of the LAD (short arrow on CAG in the Figure⇓), which had not been detected by …

In 1997, a 55-year-old man underwent percutaneous coronary angioplasty (PTCA) of a lesion in the middle segment of the left anterior descending coronary artery (LAD) (Figure⇓, A). He subsequently informed his cardiologist that his twin brother had also been treated successfully with PTCA at another hospital for stenosis of the LAD. The cineangiographic film of the twin brother was retrieved (Jackson Heart Clinic, Jackson, …