Microsurgery for management of primary and secondary lymphedema.

OBJECTIVE: The objective of this study was to evaluate the efficacy and safety of lymphaticovenular anastomosis (LVA) in patients with lymphedema. METHODS: A retrospective analysis was conducted of 70 patients suffering from primary or secondary lymphedema who underwent LVA surgery with indocyanine green fluorescence lymphangiography. Postoperative evaluation included qualitative and quantitative volumetric assessment and analysis. Limb volume was measured by circumferential tape measurement volumetric method, in which the limb is subdivided into five segments and each segment's circumference is measured. RESULTS: LVA was performed in 70 patients, 22 with primary lymphedema and 48 with secondary lymphedema. The difference in preoperative upper limb volume was 35% with mean postoperative follow-up of 9 months. The mean number of lymphovenous bypasses was 3.9. The reduction in limb volume at 3, 6, and 12 months was 40.4%, 41%, and 45%, respectively. Patients with early-stage lymphedema had significantly higher volume reductions than patients with late-stage lymphedema at 3, 6, and 12 months (48% vs 18%, 49% vs 22%, and 65% vs 31%; P < .001). For lower extremity lymphedema, the preoperative volume differential was 25.5%. The mean postoperative follow-up was 9 months. The reduction in limb volume at 3, 6, and 12 months was 28%, 37%, and 39%, respectively. CONCLUSIONS: LVA surgery is a safe and effective method of reducing lymphedema severity, especially in upper extremity lymphedema at an earlier disease stage.

Robotic inguinal hernia repair: Is it a new era in the management of inguinal hernia?

OBJECTIVE: We compared outcomes of elective inguinal hernia repair performed at one institution by three approaches: robotic-assistance, laparoscopic, and open. METHODS: Characteristics of the patients, the hernia and the procedures performed during 2014-2016 were accessed from patient electronic medical files of 137 elective inguinal hernia repairs. 24 surgeries were robotic-assisted, 16 laparoscopic and 97 open repairs. RESULTS: Distributions of age, sex and BMI did not differ between the groups. Bilateral repair was more common in the robotic (70.8%) than the laparoscopic (50.0%) and open groups (12.4%) (p < 0.001). Direct hernias were more common in the open (45.4%) than the robotic (20.8%) and laparoscopic (12.5%) groups (p < 0.001). Only 3 hernias were inguinoscrotal, all in the robotic group. The median operation times were 44.0, 79.0 and 92.5 min for the open, laparoscopic and robotic methods, respectively (p < 0.001). Among the unilateral repairs, the median operative times were the same for the robotic and laparoscopic procedures, 73 min, and less for the open procedures, 40 min. The proportion of patients hospitalized for 2-3 days was higher for open repair (13.4% vs. 6.2% and 0% for laparoscopic and robotic), but this difference was not statistically significant. The median maximal postoperative pain according to a 0-10-point visual analogue score was 5.0, 2.0 and 0 for open, laparoscopic and robotic procedures, respectively (p < 0.001). CONCLUSIONS: This report demonstrated the safety and feasibility of robotic-assisted inguinal hernia repair.

Resection of an axillary macrocystic lymphatic malformation in a 14-year-old girl using intraoperative indocyanine green lymphography.

Lymphangioma is a malformation of the lymphatic system for which surgical excision is a possible treatment. However, complete excision may be hindered by the lesion's size, anatomic location, unclear borders, and invasion into adjacent tissues. We describe a 14-year-old girl who presented with a rapidly progressing axillary swelling. Magnetic resonance imaging and ultrasound revealed a lymphatic macrocystic multilocular lesion. After preoperative and intraoperative indocyanine green lymphography, a complete surgical excision was achieved without damage to collateral lymphatic channels or surrounding tissues. Intraoperative indocyanine green lymphography may be useful in achieving efficient and safe resection of lymphangioma without damaging unconnected lymphatics.

MicroRNA regulation of progesterone receptor in breast cancer.

Hormone receptor status is of significant value when deciding on anti-estrogenic adjuvant therapy for breast cancer tumors. However, while estrogen receptor (ER) regulation was intensively studied, the regulation of progesterone receptor (PR) levels has not been extensively investigated. MicroRNAs (miRNAs, miRs) are post-transcriptional negative regulators of gene expression involved in diverse cellular processes. The aim of this study was to identify miRNAs that regulate PR in breast cancer.We mapped potential miRNA binding sites for miR-181a, miR-23a and miR-26b on PR mRNA and demonstrated a direct regulation of PR by these three miRNAs by in-vitro Luciferase binding assays. Over-expression of each miRNA in MCF-7 cells resulted in a reduction in the expression levels of PR mRNA. Then, expression levels of these miRNAs were measured in Formalin-Fixed, Paraffin-Embedded (FFPE) samples of 29 ER-positive breast cancer tumors and adjacent normal breast tissues. A significant reciprocal correlation between PR mRNA and the miRNA levels were identified suggesting a role for miR-181a, miR-23a and miR-26b in PR regulation in breast cancer. Moreover, the average expression fold-changes of the three miRNAs between cancerous and normal tissues displayed an opposite trend when analyzing according to Immuno-histochemistry(IHC) status. Furthermore, miR-181a and miR-26b were found to be over-expressed in most tumor tissues supporting their role in ER-positive breast cancer development. We conclude that miR-181a, miR-23a and miR-26b act as negative regulators of PR expression in ER-positive breast cancer. The diagnostic and prognostic potential of these miRNAs in breast cancer should be further evaluated.

Validation and reduction of the oxidative stress following laparoscopic operations: a prospective randomized controlled study.

OBJECTIVE: To validate ischemia-reperfusion mechanism during laparoscopic cholecystectomy, and to assess the reduction of oxidative stress by an intermittent sequential pneumatic compression (ISPC) device. SUMMARY BACKGROUND: Increased intraperitoneal pressure during laparoscopic operations may lead to decreased cardiac output and visceral perfusion, and possible ischemia-reperfusion effects. Using the ISPC device was shown to improve cardiac output and visceral perfusion during pneumoperitoneum (PP). METHODS: Twenty patients undergoing elective laparoscopic cholecystectomy were enrolled in a randomized prospective controlled study and divided into 2 groups: 1) study group (10 patients), activation of ISPC together with creation of PP; and 2) control group, without ISPC. Lipid peroxidation and glutathione levels (as indicators of oxidative stress) as well as liver and renal function tests, were measured before and at the end of PP, and again at 30 minutes, 4 hours, and 24 hours afterward, together with hemodynamic and respiratory parameters. RESULTS: There was no significant difference between both groups concerning liver enzymes and bilirubin, nor in hemodynamic parameters. In the control group, increased lipid peroxide levels were noted 4 hours after PP termination, in comparison to pre-PP levels (590.4-649.2 mmol/L, P = 0.002). In the study group (ISPC), such changes were not inspected. Decreased total glutathione levels were noted in the control group, 30 minutes following CO2 evacuation. CONCLUSIONS: Our study validates the ischemia-reperfusion mechanism following laparoscopic surgery. The use of an ISPC device decreased the oxidative stress (secondary to relative ischemia-reperfusion insult) following PP, probably due to improved cardiac output and visceral perfusion.

An unusual presacral mass: extramedullary hematopoiesis.

Presacral masses are a rare finding in the adult patient, confronting the physician with diagnostic and therapeutic challenges. We present an unusual case of a symptomatic presacral mass caused by extramedullary hematopoietic tissue in a thalassemic patient and review the unique aspects of this entity.