How I Do It: New Dissector Device Allows for Effective Operative Field in Transoral Endoscopic Thyroid Surgery Using Vestibular Approach.

BACKGROUND: Minimally invasive thyroid and parathyroid resections are rarely performed. Promising new endoscopic transoral approaches to the anterior neck (transoral endoscopic thyroidectomy vestibular approach [TOETVA]) have been described with good results and few complications. This study evaluates a new device to allow the safe entrance of trocars in the subplatysmal space for TOETVA in a cadaver model. METHODS: The technique was performed in 4 unilateral thyroidectomies in female cadavers. The technical steps consisted of a 10-mm incision made at the center of the oral vestibule followed by subplatysmal hydrodissection. The blunt dissector is a metallic stick with an olive at the end and promotes progressive gain in subplatysmal space enlarging the operative field. The instrument was inserted creating a space below the platysma to the anterior neck and the strap muscles. Three trocars were inserted in the vestibular area. The dissection begins by cutting the linea alba cervicalis. The isthmus was dissected and transected. Anatomical structures as the superior thyroid artery, parathyroid glands, and the recurrent laryngeal nerve could be safely identified with magnified vision. RESULTS: Optimal operative field due to subplatysmal dissection by the device allowed for exposition of thyroid and parathyroid glands in all cases. Unilateral thyroidectomy was performed in a mean of 54 minutes with excellent aesthetic results. CONCLUSIONS: The new device is a promising feature to allow safe transoral thyroid surgery in a cadaver model. Further studies in clinical series are needed to evaluate the broad application of the device.

Concerted down-regulation of immune-system related genes predicts metastasis in colorectal carcinoma.

BACKGROUND: This study aimed at the identification of prognostic gene expression markers in early primary colorectal carcinomas without metastasis at the time point of surgery by analyzing genome-wide gene expression profiles using oligonucleotide microarrays. METHODS: Cryo-conserved tumor specimens from 45 patients with early colorectal cancers were examined, with the majority of them being UICC stage II or earlier and with a follow-up time of 41-115 months. Gene expression profiling was performed using Whole Human Genome 4x44K Oligonucleotide Microarrays. Validation of microarray data was performed on five of the genes in a smaller cohort. RESULTS: Using a novel algorithm based on the recursive application of support vector machines (SVMs), we selected a signature of 44 probes that discriminated between patients developing later metastasis and patients with a good prognosis. Interestingly, almost half of the genes was related to the patients' immune response and showed reduced expression in the metastatic cases. CONCLUSIONS: Whereas up to now gene signatures containing genes with various biological functions have been described for prediction of metastasis in CRC, in this study metastasis could be well predicted by a set of gene expression markers consisting exclusively of genes related to the MHC class II complex involved in immune response. Thus, our data emphasize that the proper function of a comprehensive network of immune response genes is of vital importance for the survival of colorectal cancer patients.

Inside-Out Surgical Anatomy of Superior Laryngeal Artery Endoscopic Dissection and Proposal for Nomenclature of Branches.

Objectives: To describe the inside out surgical anatomy of the superior laryngeal artery and to resolve the ambiguities in the nomenclature of its main branches. Study Design: Endoscopic dissection of the superior laryngeal artery in the paraglottic space of larynges of fresh frozen cadavers and a review of the literature. Setting: A center for anatomy encompassing facilities for latex injection into the cervical arteries of human donor bodies and a laryngeal dissection station equipped with a video-guided endoscope and a 3-dimensional camera. Methods: Video-guided endoscopic dissection of 12 hemilarynges in fresh frozen cadavers whose cervical arteries were injected with red latex. Description of the inside-out surgical anatomy of the superior laryngeal artery and its main branches. Review of the previous reports describing the anatomy of the superior laryngeal artery. Results: From inside the larynx, the artery was exposed upon its entry through the thyrohyoid membrane or through the foramen thyroideum. It was traced ventrocaudally in the paraglottic space exposing its branches to the epiglottis, the arytenoid, and the laryngeal muscles and mucosa. Its terminal branch was followed until it left the larynx through the cricothyroid membrane. Branches of the artery, previously described under different names, appeared to supply the same anatomical domains. Conclusion: Mastering the inside out anatomy of the superior laryngeal artery is mandatory to control any intraoperative or postoperative hemorrhage during transoral laryngeal microsurgery or during transoral robotic surgery. Naming the artery's main branches according to their domain of supply would resolve the ambiguities resulting from various nomenclatures.

The inside-out surgical anatomy of the paraglottic space a video-guided endoscopic dissection.

Objectives: The paraglottic space is an essential anatomic compartment of the larynx. It is central to the spread of laryngeal cancer and to the choice of conservative laryngeal surgery and many phonosurgical procedures. Since its description, 60 years ago, the surgical anatomy of the paraglottic space was sparsely revisited. Amid the era of endoscopic and transoral microscopic functional surgery of the larynx, we provide here a long-awaited description of the inside-out anatomy of the paraglottic space. Methodology: Using an endoscope equipped with a 3D camera, we dissected 10 hemilarynges from 5 fresh frozen cadavers from the inside out. Before dissection, we labeled the vessels through injecting them with colored latex. We explored the paraglottic space emphasizing its shape, boundaries, and contents. We documented our findings through endoscopic photography and video recordings. Results: The paraglottic space is a spacious tetrahedral space located parallel not only to the glottic, but also to the subglottic and the supraglottic compartments of the laryngeal lumen. It has musculo-cartilaginous, musculo-fibrous, and mucosal boundaries. It is separated from the pyriform sinus only by mucosa. A cushion of fat surrounds its vascular and to a lesser extent its neural contents. Harbored intrinsic laryngeal muscles are endoscopically identifiable within the space, namely the thyroarytenoid, the lateral, and posterior cricoarytenoid muscles. Conclusion: The endoscopic description of the paraglottic space partly fills the knowledge gap on the laryngeal anatomy from the inside out. It opens the door for novel diagnostic methods and for ultraconservative functional laryngeal interventions under endoscopic control. Level of Evidence: N/A.

Understanding the Interplay Between Paraspinal Muscle Atrophy and Lumbar Endplate Degeneration: A 3-Year Longitudinal Study.

STUDY DESIGN: Retrospective analysis of longitudinal data. OBJECTIVE: To assess the association between the paraspinal musculature (PM) and lumbar endplate degeneration. BACKGROUND: The PM is essential for spinal stability, while the vertebral endplate is pivotal for nutrient transport and force distribution. The clinical importance of both has been highlighted in recent literature, though little is known about their interaction. METHODS: We identified patients with lumbar MRI scans due to low back pain, with a 3-year interval between MRI scans. Endplate damage was assessed by the total endplate score (TEPS) at each lumbar level. The PM was evaluated for its functional cross-sectional area and fatty infiltration (FI) at the L4 level. We used a generalized mixed model to analyze the association between PM parameters and TEPS at timepoint one, adjusting for age, sex, BMI, diabetes, hypertension, and smoking status. The association with the progression of endplate damage was analyzed through an ordinal regression model, additionally adjusted for TEPS at baseline. RESULTS: In all, 329 patients were included, with a median follow-up time of 3.4 years. Participants had a median age of 59 and a BMI of 25.8 kg/m 2 . In the univariate analysis, FI of the posterior PM was significantly associated with TEPS at baseline (ß: 0.08, P <0.001) and progression of TEPS [Odds Ratio (OR): 1.03, P =0.020] after adjustment for confounders. The ß and OR in this analysis are per percent of FI. In a binary analysis, patients with FI≥40% had an OR of 1.92 ( P =0.006) for the progression of TEPS. CONCLUSIONS: This is the first longitudinal study assessing the relationship between PM and endplate degeneration, demonstrating the association between PM atrophy and the progression of endplate degeneration. This insight may aid in identifying patients at risk for degenerative lumbar conditions and guide research into preventive measures.

THBS4, a novel stromal molecule of diffuse-type gastric adenocarcinomas, identified by transcriptome-wide expression profiling.

Gastric adenocarcinomas can be divided into two major histological types, the diffuse and intestinal type (Laurén classification). Since they diverge in many clinical and molecular characteristics, it is widely accepted that they represent distinct disease entities that may benefit from different therapeutic approaches. Gene expression profiling studies have identified numerous genes that are differentially expressed between them. However, none of these studies covered the whole transcriptome and the published gene lists reveal little overlap, raising the need for further, more comprehensive analyses. Here, we present the first transcriptome-wide expression profiling study comparing the two types (diffuse n=19, intestinal n=24), which identified >1000 genes that are differentially expressed. Among them, thrombospondin 4 (THBS4) showed the strongest correlation to histological type, with vast overexpression in the diffuse type. Quantitative real-time PCR validated this strong overexpression and revealed that intestinal tumors generally lack THBS4 expression. Immunohistochemistry demonstrated THBS4 overexpression on the protein level (n=10) and localized THBS4 to the stromal aspect. Its expression was primarily observed within the extracellular matrix surrounding the tumor cells, with the highest intensities found in regions of high tumor cell density and invasion. Intestinal tumors and matched non-neoplastic gastric epithelium and stroma did not feature any relevant THBS4 expression in a preliminary selection of analyzed cases (n=5). Immunohistochemical colocalization and in vitro studies revealed that THBS4 is expressed and secreted by cancer-associated fibroblasts. Furthermore, we show that THBS4 transcription in fibroblasts is stimulated by tumor cells. This study is the first to identify THBS4 as a powerful marker for diffuse-type gastric adenocarcinomas and to provide an initial characterization of its expression in the course of this disease.

Middle trapezius transfer for treatment of irreparable supraspinatus tendon tears- anatomical feasibility study.

PURPOSE: The purpose of this study was to investigate the anatomical feasibility of a middle trapezius transfer below the acromion for treatment of irreparable supraspinatus tendon tears. METHODS: This study involved 20 human cadaveric shoulders in 10 full-body specimens. One shoulder in each specimen was dissected and assessed for muscle and tendon extent, force vectors, and distance to the neurovascular structures. The opposite shoulder was used to evaluate the surgical feasibility of the middle trapezius transfer via limited skin incisions along with an assessment of range of motion and risk of neurovascular injury following transfer. RESULTS: The harvested acromial insertion of the middle trapezius tendon showed an average muscle length of 11.7 ± 3.0 cm, tendon length of 2.7 ± 0.9 cm, footprint length of 4.3 ± 0.7 cm and footprint width of 1.4 ± 0.5 cm. The average angle between the non-transferred middle trapezius transfer and the supraspinatus was 33 ± 10° in the transversal plane and 34 ± 14° in the coronal plane. The mean distance from the acromion to the neurovascular bundle was 6.3 ± 1.3 cm (minimum: 4.0 cm). During surgical simulation there was sufficient excursion of the MTT without limitation of range of motion in a retracted scapular position but not in a protracted position. No injuries to the neurovascular structures were noted. CONCLUSION: Transfer of the acromial portion of the middle trapezius for replacement of an irreparable supraspinatus seems to be feasible in terms of size, vector, excursion, mobility and safety. However, some concern regarding sufficiency of transfer excursion remains as scapula protraction can increase the pathway length of the transfer. LEVEL OF EVIDENCE: Basic Science Study/Anatomical Study.

Nerve-Sparing Systematic Lymph Node Dissection in Gynaecological Oncology: An Innovative Neuro-Anatomical and Surgical Protocol for Enhanced Functional Outcomes.

Whilst systematic lymph node dissection has been less prevalent in gynaecological cancer cases in the last few years, there is still a good number of cases that mandate a systematic lymph node dissection for diagnostic and therapeutic purposes. In all of these cases, it is crucial to perform the procedure as a nerve-sparing technique with utmost exactitude, which can be achieved optimally only by isolating and sparing all components of the aortic plexus and superior hypogastric plexus. To meet this purpose, it is essential to provide a comprehensive characterization of the specific anatomy of the human female aortic plexus and its variations. The anatomic dissections of two fresh and 17 formalin-fixed female cadavers were utilized to study, understand, and decipher the hitherto ambiguously annotated anatomy of the autonomic nervous system in the retroperitoneal para-aortic region. This study describes the precise anatomy of aortic and superior hypogastric plexus and provides the surgical maneuvers to dissect, highlight, and spare them during systematic lymph node dissection for gynaecological malignancies. The study also confirms the utility and feasibility of this surgery in gynaecological oncology.

A Concise Paradigm on Radical Hysterectomy: The Comprehensive Anatomy of Parametrium, Paracolpium and the Pelvic Autonomic Nerve System and Its Surgical Implication.

The current understanding of radical hysterectomy is more centered on the uterus and little is discussed regarding the resection of the vaginal cuff and the paracolpium as an essential part of this procedure. The anatomic dissections of two fresh and 17 formalin-fixed female pelvis cadavers were utilized to understand and decipher the anatomy of the pelvic autonomic nerve system (PANS) and its connections to the surrounding anatomical structures, especially the paracolpium. The study mandates the recognition of the three-dimensional (3D) anatomic template of the parametrium and paracolpium and provides herewith an enhanced scope during a nerve-sparing radical hysterectomy procedure by precise description of the paracolpium and its close anatomical relationships to the components of the PANS. This enables the medical fraternity to distinguish between direct infiltration of the paracolpium, where the nerve sparing technique is no longer possible, and the affected lymph node in the paracolpium, where nerve sparing is still an option. This study gives rise to a tailored surgical option that allows for abandoning the resection of the paracolpium by FIGO stage IB1, where less than 2 cm vaginal vault resection is demanded.

REG1A expression is a prognostic marker in colorectal cancer and associated with peritoneal carcinomatosis.

By expression profiling of early staged colon carcinomas, we found regenerating islet-derived 1 alpha (REG1A) to be upregulated in patients with an unfavorable clinical outcome. For validation, REG1A expression was quantified in another colorectal cancer (CRC) patient cohort by Taqman PCR. Aside from tumor and normal tissue from 63 nonpretreated CRC patients, 31 mucosa biopsies from healthy individuals as well as 22 adenomas were included in the investigation. REG1A was significantly upregulated in tumor specimens (p < 0.001) and adenoma (p < 0.01) as compared to normal colorectal tissue. REG1A expression in normal peritumoral tissue in turn proved to be significantly elevated compared to mucosa from healthy individuals (p < 0.01). Determination of REG1A expression might be useful for early tumor diagnosis with a sensitivity of 90.6%, and a specificity of 77.9%. REG1A expression was significantly increased in tumors with peritoneal carcinomatosis (p < 0.01). Moreover, REG1A turned out to be a significant predictor of disease-free survival (p < 0.05). In conclusion, we present evidence that REG1A is a molecular marker of prognostic value and is associated with peritoneal carcinomatosis in CRC. REG1A turned out to be already significantly raised in peritumoral normal tissue compared to mucosa from healthy individuals, suggesting a molecular field effect of secreted REG1A.

Helicobacter pylori stimulates host vascular endothelial growth factor-A (vegf-A) gene expression via MEK/ERK-dependent activation of Sp1 and Sp3.

VEGF-A is a key regulator of inflammatory and tumor-associated angiogenesis. H. pylori plays a critical role in the pathogenesis of benign and malignant gastric diseases. It has been suggested that H. pylori infection is associated with activation of host angiogenesis, however, underlying mechanisms as well as angiogenic growth factors activated by the bacterium have not yet been identified. Therefore, we investigated the influence of the bacterium on VEGF-A as a candidate host target gene in vivo and in vitro. We show that H. pylori potently up-regulates production and release of VEGF-A protein as well as vegf-A mRNA levels, and we provide strong evidence that enhanced recruitment of Sp1 and Sp3 transcription factors to two proximal GC-rich vegf-A promoter elements mediates H. pylori-triggered vegf-A gene expression. In addition, H. pylori infection increased the transactivating capacity of both Sp1 and Sp3, which suggests additional mechanism(s) of vegf-A gene regulation by the bacterium. Signaling studies identified the MEK>ERK1/-2 kinase cascade as principal host signaling pathway mediating H. pylori-stimulated vegf-A transcription. By identifying H. pylori as potent activator of vegf-A gene expression and characterization of underlying molecular mechanisms, our results provide novel insights into pathways linking the bacterium to host angiogenesis and may help to develop strategies to influence vegf-A gene expression in the setting of H. pylori infection.

The maintenance of the permeability barrier of bladder facet cells requires a continuous fusion of discoid vesicles with the apical plasma membrane.

The luminal surface of the bladder epithelium is continuously exposed to urine that differs from blood in its ionic composition and osmolality. The apical plasma membrane of facet or umbrella cells, facing the urine, is covered with rigid-looking plaques consisting of hexagonal uroplakin particles. Together with tight junctions these plaques form a specialized membrane compartment that represents one of the tightest and most impermeable barriers in the body. Plaques also occur in the membrane of cytoplasmic discoid vesicles. Here it is shown shown that synaptobrevin, SNAP23 and syntaxin are perfectly colocalized with uroplakin III at the apical plasma membrane as well as with membranes of discoid vesicles. Such a distribution suggests that discoid vesicles in facet cells may gain access to the apical plasma membrane probably by combination of homotypic and heterotypic fusion events. Furthermore, we detected uroplakin III-containing membranes of different sizes in the urine of healthy humans and rats. Probably facet cells maintain their permeability barrier by a process of continuous membrane regeneration that includes the cutting off of areas of the apical membrane and its replacement by newly fused discoid vesicles.

K+-ATP-channel-related protein complexes: potential transducers in the regulation of epithelial tight junction permeability.

K(+)-ATP channels are composed of an inwardly rectifying Kir6 subunit and an auxiliary sulfonylurea receptor (SUR) protein. The SUR subunits of Kir6 channels have been recognized as an ATPase, which appears to work as a mechanochemical device like other members of the ABC protein family. Thus, in spite of just gating ions, Kir6/Sur might, in addition, regulate completely different cellular systems. However, so far no model system was available to directly investigate this possibility. Using highly specific antibodies against Kir6.1-SUR2A and an in vitro model system of the rat small intestine, we describe a new function of the Kir6.1-SUR2A complex, namely the regulation of paracellular permeability. The Kir6.1-SUR2A complex localizes to regulated tight junctions in a variety of gastrointestinal, renal and liver tissues of rat, pig and human, whereas it is absent in the urothelium. Changes in paracellular permeability following food intake was investigated by incubating the lumen of morphological well-defined segments of rat small intestine with various amounts of glucose. Variations in the lumenal glucose concentrations and regulators of Kir6.1/SUR2A activity, such as tolbutamide or diazoxide, specifically modulate paracellular permeability. The data presented here shed new light on the physiological and pathophysiological role K(+)-ATP channels might have for the regulation of tight junctions.

Vascular endothelial growth factor-D and its receptor VEGFR-3: two novel independent prognostic markers in gastric adenocarcinoma.

PURPOSE: Vascular endothelial growth factor (VEGF)-D and its homolog VEGF-C influence lymphangiogenesis through activation of VEGF receptor 3 (VEGFR-3), and have been implicated in lymphatic tumor spread. Nodal dissemination of gastric adenocarcinomas critically determines clinical outcome and therapeutic options of affected patients. Therefore, we analyzed expression and prognostic significance of VEGF-D along with VEGF-C, and VEGFR-3 in gastric adenocarcinomas. MATERIALS AND METHODS: VEGF-C, VEGF-D, and VEGFR-3 were analyzed in 91 R(0)-resected primary gastric adenocarcinomas, corresponding noncancerous gastric mucosa, and lymph node metastases employing immunohistochemistry and/or in situ hybridization. Blood and lymph vessel densities were assessed after staining with CD31 and LYVE-1-specific antibodies. RESULTS: VEGF-D and VEGF-C were detected in 67.0% and 50.5% of gastric cancers, respectively. Healthy gastric mucosa was negative for VEGF-C and in 12.5% positive for VEGF-D. Presence of VEGF-D (P = .005) or VEGF-C (P = .006) was correlated with lymphatic metastases and decreased survival (VEGF-D, P < .05; VEGF-C, P < .05). VEGFR-3 was correlated with reduced carcinoma-specific survival (P < .05), and Cox multivariate regression analysis qualified VEGF-D and VEGFR-3, but not VEGF-C, as independent prognostic parameters. In lymph node-positive gastric cancers, presence of VEGF-D/VEGFR-3 was associated with poor survival, whereas absence of VEGF-D/VEGFR-3 defined a subgroup of patients with clearly favorable prognosis. CONCLUSION: VEGF-D and VEGFR-3 are novel independent prognostic marker molecules aiding to identify patients with poor prognosis after curative resection of gastric adenocarcinomas. Combined analysis of the VEGF-C/VEGF-D/VEGFR-3 system can be useful to identify patients with unfavorable clinical outcome and thereby may help to refine therapeutic decisions in gastric cancer.

Macrophage/microglia activation factor expression is restricted to lesion-associated microglial cells after brain trauma.

After traumatic brain lesion, microglial cells are rapidly activated, migrate toward the sites of injury, and cause secondary damage that accounts for most of the loss of brain function. In the present study, we have characterized a new macrophage/microglia activation factor (MAF). Using the monocytic cell line U937, we were able to demonstrate that MAF is upregulated after TPA-induced differentiation into macrophages. We have generated a specific antibody against MAF. In BV-2 microglial cells, MAF is partially co-localized with IB4, a classical microglial marker. In addition, we have analyzed the in vivo expression patterns of MAF after entorhinal cortex lesion. We were able to show a substantial upregulation of MAF on selected CD11b(+) and IB4(+) macrophages/microglial cells in the deafferented hippocampus and in the perilesional region, while no MAF expression was detectable on the contralateral side. Confocal microscopy revealed a lysosome-like expression pattern in BV-2 cells, as well as in ECL-associated macrophages/microglial cells in vivo. Furthermore, we were able to demonstrate that U937 cells with downregulated MAF converted slower and to a significantly reduced extent to the macrophageal phenotype after TPA treatment. In addition, MAF downregulation in BV-2 microglial cells substantially reduced the phagocytotic uptake of dextran beads. Our data indicate that MAF is expressed in selected macrophages/microglial cells around the lesion and in the degenerating hippocampus after ECL. Furthermore, MAF expression in monocytic cells seems to play a functional role in the differentiation to a phagocytosing phenotype and may be, at least partially, required for phagocytotic activity, specifically in lesioned tissue after brain trauma.