[Philosophy and technque in everyday practice of robotic surgery]. / Filozófia és technika a robotsebészet mindennapjaiban.

A modern, betegközpontú sebészet alapja a pácienst ért mutéti stressz minimalizálása. E tekintetben jelentett forradalmi újítást a minimálisan invazív sebésztechnikák megjelenése. A laparoscopos kulcslyuksebészet mára számos kórkép kezelésében "gold standard" megoldássá vált. A párhuzamosan megjeleno robotsebészeti rendszerek a sebészi beavatkozások invazivitásának további csökkenését eredményezték. A laparoscopos beavatkozások elonyei mellett a robotsebészet alkalmazása során a még precízebb technikai megvalósítás jelentos javulást hozott egyes mutatókban, úm. onkológiai, funkcionális eredmények. A szöveti szintu preparálás, a képletek speciális szögekbol való megközelítése a sebészet határait újra kijjebb tolta. A kezdeti lépések után a robotasszisztált beavatkozások körében, az urológiai és nogyógyászati területek után, egyre nagyobb teret kaptak az emésztoszervi megbetegedések is. Jelen összefoglaló tanulmány célja a robotasszisztált mutétek sajátosságainak bemutatása, valamint a robotsebészet szerepének, eredményeinek összefoglalása gastrointestinalis tumorok tekintetében.

Physical prehabilitation improves the postoperative outcome of associating liver partition and portal vein ligation for staged hepatectomy in experimental model.

Aiming to improve the postoperative outcome of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), the effect of physical prehabilitation (PP) was investigated in experimental model. Male Wistar rats (n = 106) divided to PP and sedentary (S) groups underwent ALPPS. Changes in liver weight, Ki67 index and liver volume by magnetic resonance imaging (MRI) were evaluated. Liver function was assessed by laboratory parameters and 99mTc-mebrofenin single-photon emission computed tomography (SPECT) hepatobiliary scintigraphy (HBS). Utilizing endotoxemia model mortality and septic parameters were investigated. Liver mass (p < 0.001), Ki67 index (p < 0.001) and MRI liver volume (p < 0.05) increased in the PP group compared to the S group. Both standard laboratory parameters (p < 0.001) and HBS (p < 0.05) showed enhanced liver function in the PP group compared to the S group. The vulnerability of animals improved in the PP group, as mortality decreased (p < 0.001), while septic laboratory parameters improved (p < 0.05) compared to the S group in the endotoxemia model. Our study demonstrated for the first time the beneficial role of PP on not only volumetric but also functional liver regeneration and postoperative vulnerability after ALLPS.

Case report of actinomycotic liver abscess following COVID-19 infection.

Introduction and importance: In the last few years, the novel coronavirus, named severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), generated a large health care problem worldwide. Due to the immunomodulation effect of the virus the number of opportunistic infections has also increased. Case presentation: We present the unique case of a patient who was diagnosed with an actinomycotic liver abscess after coronavirus disease 2019 (COVID-19) without the presence of any chronic disease or mucosal injury. Clinical discussion: According to the results of the computer tomography (CT scan) and the liver biopsy, the patient was treated with antibiotics and ultrasound-guided drainage. Conclusion: With this case we would like to draw attention to the possible occurrence of liver abscesses caused by an opportunistic pathogen following COVID-19.

The effect of Cyclophilin D depletion on liver regeneration following associating liver partition and portal vein ligation for staged hepatectomy.

AIM: Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is a modification of two-stage hepatectomy profitable for patients with inoperable hepatic tumors by standard techniques. Unfortunately, initially poor postoperative outcome was associated with ALPPS, in which mitochondrial dysfunction played an essential role. Inhibition of cyclophilins has been already proposed to be efficient as a mitochondrial therapy in liver diseases. To investigate the effect of Cyclophilin D (CypD) depletion on mitochondrial function, biogenesis and liver regeneration following ALPPS a CypD knockout (KO) mice model was created. METHODS: Male wild type (WT) (n = 30) and CypD KO (n = 30) mice underwent ALPPS procedure. Animals were terminated pre-operatively and 24, 48, 72 or 168 h after the operation. Mitochondrial functional studies and proteomic analysis were performed. Regeneration rate and mitotic activity were assessed. RESULTS: The CypD KO group displayed improved mitochondrial function, as both ATP production (P < 0.001) and oxygen consumption (P < 0.05) were increased compared to the WT group. The level of mitochondrial biogenesis coordinator peroxisome proliferator-activated receptor γ co-activator 1-α (PGC1-α) was also elevated in the CypD KO group (P < 0.001), which resulted in the induction of the mitochondrial oxidative phosphorylation system. Liver growth increased in the CypD KO group compared to the WT group (P < 0.001). CONCLUSIONS: Our study demonstrates the beneficial effect of CypD depletion on the mitochondrial vulnerability following ALPPS. Based on our results we propose that CypD inhibition should be further investigated as a possible mitochondrial therapy following ALPPS.

Drug Delivery through the Psoriatic Epidermal Barrier-A "Skin-On-A-Chip" Permeability Study and Ex Vivo Optical Imaging.

Psoriasis is a chronic inflammatory disease with unmet medical needs. To clarify potential therapeutic targets, different animal models have been developed. In the current study, imiquimod-induced psoriasiform dermatitis was used for monitoring the changes in skin thickness, transepidermal water loss, body weight, blood perfusion and drug permeability for a topical cream formulation of caffeine, both in wild type and in knock out mice. Morphological characterization of control and diseased tissues was performed by scanning electron microscopy and two-photon microscopy. The chemically induced psoriatic group showed increased skin permeability for the model drug during disease progression. In wild type and TRPA1 KO mice, however, enhanced skin thickness and hyperkeratosis blocked further increase of drug penetration at the late phase (96 h). These results indicate that topical drug therapy can be more effective in early phases of plaque development, when skin thickness is lower. Although paracellular connections (tight junctions) are looser in the advanced phase, hyperkeratosis blocks drug delivery through the transappendageal routes. Novel drug formulations may have the potency for effective drug delivery across the epidermal barrier even in the advanced phase. For development of more effective topical drugs, further research is proposed to explore drug penetration both in healthy and diseased conditions.

Multimodality management of focal nodular hyperplasia / A focalis nodularis hyperplasia multimodális kezelése

Focal nodular hyperplasia (FNH) is the second most common benign mass of the liver. According to the current recommendations, removal makes relative indication. Several different treatment methods are known. The purpose of the paper is to provide a summary of FNH care and to present alternative treatment options in two cases. A 40-year old woman was investigated for abdominal complaints; CT scan confirmed FNH of the liver. Given the localization of the lesion, we chose transarterial embolization (TAE) due to the high risk of surgical resection. After multiple treatments, regression was achieved, and the patient became asymptomatic. Painful FNH in a 25-year-old female was confirmed by MRI. The lesion was dominantly seen in segment 1, causing vena cava compression and collaptiform episodes. As a definitive solution, liver resection was performed, after which her complaints ceased. Long-term follow-up of patients may be sufficient when asymptomatic FNH is detected. In the case of symptoms or high risk of surgery, TAE can be used effectively by FNH either alone or in combination with surgical treatment. For lower-risk patients, primary laparoscopic resection is the most appropriate choice.

The Role of Farnesoid X Receptor in Accelerated Liver Regeneration in Rats Subjected to ALPPS.

BACKGROUND: the role of bile acid (BA)-induced farnesoid X receptor (Fxr) signaling in liver regeneration following associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) was investigated in a rat model. METHODS: Male Wistar rats underwent portal vein ligation (PVL) (n = 30) or ALPPS (n = 30). Animals were sacrificed pre-operatively and at 24, 48, 72, or 168 h after intervention. Regeneration rate, Ki67 index, hemodynamic changes in the hepatic circulation, and BA levels were assessed. Transcriptome analysis of molecular regulators involved in the Fxr signaling pathway, BA transport, and BA production was performed. RESULTS: ALLPS induced more extensive liver regeneration (p < 0.001) and elevation of systemic and portal BA levels (p < 0.05) than PVL. The mRNA levels of proteins participating in hepatic Fxr signaling were comparable between the intervention groups. More profound activation of the intestinal Fxr pathway was observed 24 h after ALPPS compared to PVL. CONCLUSION: Our study elaborates on a possible linkage between BA-induced Fxr signaling and accelerated liver regeneration induced by ALPPS in rats. ALPPS could trigger liver regeneration via intestinal Fxr signaling cascades instead of hepatic Fxr signaling, thereby deviating from the mechanism of BA-mediated regeneration following one-stage hepatectomy.

Treatment of vena cava inferior leiomyosarcoma with cavotomy and right renal vein neoimplantation / Vena cava inferior leiomyosarcoma kezelése cavotomiával és a jobb vena renalis neoimplantatiójával

Leiomyosacroma of the inferior vena cava is an extremely rare malignancy originating from the tunica media of the venous wall. Its symptoms and radiomorphological signs do not always lead to an accurate diagnosis. Histological sampling can be dangerous due to its location. Therefore the diagnosis is often a challenge for clinicians. Its treatment is primarily surgical, supplemented by radiotherapy and chemotherapy applied together or in monotherapy. In our case, an asymptomatic 74-year-old female patient was diagnosed with a tumor of the inferior caval vein located just above the right renal vein and involving the right adrenal gland. As serum cortisol, epinephrine, norepinephrine, adrenocorticotropic hormone (ACTH), total and free testosterone, dehydroepiandrosterone sulfate (DHEA-S), sex hormone binding globulin (SHBG) was at normal level, the tumor showed no hormone secretion. Primary surgical resection was planned. Preoperative biopsy was not performed due to its high risk of complications. During operation, tumor resection was performed by resection of the venous wall, removal of the right adrenal gland and neoimplantation of the right renal vein. For better exposure, cholecystectomy was also performed at the beginning of surgery. There were no postoperative complications. The patient received adjuvant radiation therapy. Thanks to the early diagnosis of the tumor and the complete resection, we significantly increased the patient's chances of total recovery. With the radiotherapy performed, we reduced the likelihood of tumor recurrence.

The effects of physical prehabilitation: Improved liver regeneration and mitochondrial function after ALPPS operation in a rodent model.

BACKGROUND: To identify the role of physical prehabilitation (PP) in liver regeneration, mitochondrial function, biogenesis, and inflammatory response was investigated after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in a rodent model. METHODS: Male Wistar rats (n = 60) underwent ALPPS. Animals were divided (n = 30) to the physical prehabilitation group (PP) and sedentary group (S). The animals were exsanguinated before (0 hour) and 24, 48, 72, or 168 hours after the operation. Regeneration rate and proliferation index were assessed. Mitochondrial function, biogenesis, and inflammatory response were evaluated. RESULTS: Regeneration rate and Ki67 index were significantly increased in the PP group compared to the S group (P < .001). Due to the changes in oxidative capacity and ATP production rate, the P/O ratio of PP group compared to the S group was significantly increased (P < .05). PP group was characterized by accelerated mitochondrial biogenesis and less intense inflammatory response compared to the S group. CONCLUSIONS: To our knowledge, this is the first demonstration of the beneficial effects of PP on liver regeneration, mitochondrial function, biogenesis, and the inflammatory response after ALPPS.

The Effects of Whole-Body Photobiomodulation Light-Bed Therapy on Creatine Kinase and Salivary Interleukin-6 in a Sample of Trained Males: A Randomized, Crossover Study.

Photobiomodulation therapy (PBMT) can be applied to the whole body as compared to the application of using single hand-held devices that isolate a smaller muscle area. The purpose of this study was to examine the effects of an acute dose of whole-body PBMT pre- and post-high-intensity resistance training on creatine kinase (CK) and salivary interleukin-6 (IL-6) in a sample of trained males. Twelve males (31 ± 8.3 years, 177.2 ± 5.4 cm, and 86.0 ± 7.5 kg) were part of a randomized, counterbalanced, cross-over design, whereby each participant performed a high-intensity resistance training session that consisted of the bench press, chin-up, and repeated sprints on two separate occasions. Each participant was assigned to either the PBMT or control condition on two separate weeks, with a 10-days washout period between the weeks. Creatine kinase was measured at baseline, 24, 48, and 72 h post-exercise. Salivary IL-6 was measured at baseline, 60, 90, and 120 min. A paired t-test showed no significant difference (p = 0.669) in the area under the curve (AUC) for CK during the PBMT (191.7 ± 48.3) and control conditions (200.2 ± 68.0). A Wilcoxon signed-rank test also showed no significant median difference (p = 0.155) in the AUC for salivary IL-6 during the PBMT (Mdn = 347.7) and control conditions (Mdn = 305.8). An additional Wilcoxon signed-rank test for CK percentage change from 24 to 72 h showed the PBMT condition (Mdn = -45%) to have a -18% median difference as compared to the control condition (Mdn = -41%). As such, whole-body PBMT does not significantly reduce the activity of salivary IL-6 or CK concentration during the 24 to 72-h recovery post-high-intensity resistance training.

Treatment of bile duct injuries during cholecystectomy / Cholecystectomia során bekövetkezo epeútsérülések ellátása

Biliary injury is a rare but a very serious complication of laparoscopic cholecystectomy (LC). Our aim was to analyse the incidence of the biliary injuries and its therapeutic outcome on patients who underwent LC or converted LC. Our research was conducted at the 1st Department of Surgery, Semmelweis University, Budapest between 2006 and 2016, retrospectively. We analysed the LCs and converted LCs performed at our Department and as well as cases where the primary operations were conducted at other institutions but they were unable to provide the adequate therapy for the injury, thus the patients were transferred to our institution. At the 1st Department of Surgery complications occurred in 0,66% (30/4885) of all LCs. 327 converted LCs were done, complications occurred in 26 (7.95%) times. 22 patients were transferred to the 1st Department of Surgery from other institutions. Bilio-vascular injuries occurred in 61% (41/78). ERCP was performed in 25 cases with a 92% success rate. Reoperation was needed in 41% (28/41). Biliary reconstruction during the reoperation was performed via hepaticojejunostomy in 82% of all reoperations. The therapeutic solutions of LC's complications are complex. Therefore, the treatment is recommended only in institutions with appropriate experience.

[Decreasing morbidity after Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) with technical modification and patient selection]. / Speciális májmutét (Associating Liver Partition and Portal vein ligation for Staged hepatectomy, ALPPS) morbiditásának csökkentése átértékelt betegkiválasztási elvek és mutéttechnikai módosítás révén.

Introduction: Resecability of liver tumors is exclusively depending on the future liver remnant (FLR). The remnant can be hypertrophised using portal vein occlusion techniques. The latest hypertrophising method is Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS), which provides the most significant induced hypertrophy in the shortest time. Morbidity and mortality of this procedure were initially unacceptably high. Aim: Reducing complications by better patient selection and modified surgical technique. Method: The First Department of Surgery, Semmelweis University, Budapest, prefers the 'no touch' technique, instead of 'complete mobilization'. For optimizing patient selection, an international registry (including our patients' data) was established. In addition to the surgical, we collected demographic, disease, liver function, histology, morbidity (Clavien-Dindo) and mortality parameters. Volume and function measurements were performed by using CT-volumetry and 99mtechnecium-mebrofenin SPECT/CT. Data were analyzed by multivariate analysis (significance: p<0.05). Results: We performed 20 ALPPS procedures from 2012 to 2018. The relative volume increment and resectability in our department and among the 320 registry patients were 96% vs. 86% and 95% vs. 98%. Using 'no touch' technique, the Clavien-Dindo III-IV morbidity and mortality rates were significantly lower (22%-0%) than with 'complete mobilization' (63%-36%) (p<0.05). Based on the multivariate analysis of the registry patients, age over 60 years, liver macrosteatosis, non-colorectal liver tumor, >300 minutes operation time, >2 units of red blood cell transfusion, or insufficient FLR function before stage 2 were identified as independent factors influencing mortality (p<0.05). Conclusion: Mortality and morbidity of ALPPS can be reduced by proper patient selection and 'no touch' surgical technique. Orv Hetil. 2019; 160(32): 1260-1269.

Systematic Review on Characteristics and Reporting Quality of Animal Studies in Liver Regeneration Triggered by Portal Vein Occlusion and Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy: Adherence to the ARRIVE Guidelines.

BACKGROUND: Portal vein occlusion and associating liver partition and portal vein ligation for staged hepatectomy techniques are in the spotlight of oncological liver surgery. Research involving animal models is indispensable to study the mechanisms of liver regeneration. Inaccurate reporting acts as a significant barrier during the correct interpretation of preclinical findings. Hence, we performed a systematic review to evaluate the status quo of the reporting standards and to assess the potential factors influencing reporting in animal studies, which are focusing on portal vein occlusion and/or associating liver partition and portal vein ligation for staged hepatectomy techniques. MATERIALS AND METHODS: A systematic review was performed in the PubMed and Ovid MEDLINE databases. Baseline study characteristics were recorded, and quality assessment was performed using the Animals in Research: Reporting in vivo Experiments (ARRIVE) checklist. RESULTS: A total of 107 research articles were included for the comprehensive assessment. In the subgroup analysis, newer reports and studies from the post-ARRIVE era, and reports from Europe were all associated with significantly higher ARRIVE scores (P < 0.05). Univariable regression analysis confirmed these factors as predictors of higher reporting quality. However, in the multivariable analysis, only publishing in the post-ARRIVE era has been found as single independent predictor of higher reporting standards (P = 0.028 post-ARRIVE total score 75th percentile; P = 0.000 post-ARRIVE total score median). CONCLUSIONS: Although an improving trend has been observed in reporting quality over the past years, this effect was clearly insufficient. Our results emphasize the need for further measures to improve the methodical quality at all levels of planning, execution, and reporting of preclinical studies in liver regeneration research.

Isoform-Dependent Changes in Cytochrome P450-Mediated Drug Metabolism after Portal Vein Ligation in the Rat.

BACKGROUND: Surgical removal of complicated liver tumors may be realized in two stages via selective portal vein ligation, inducing the atrophy of portally ligated lobes and the compensatory hypertrophy of nonligated liver lobes. Unlike morphological changes, functional aspects such as hepatic cytochrome P450 (CYP)-mediated drug metabolism remain vaguely understood, despite its critical role in both drug biotransformation and hepatic functional analysis. Our goal was the multilevel characterization of hepatic CYP-mediated drug metabolism after portal vein ligation in the rat. METHODS: Male Wistar rats (n = 24, 210-230 g) were analyzed either untreated (controls; n = 4) or 24/48/72/168/336 h (n = 4 each) following portal vein ligation affecting approximately 80% of the liver parenchyma. Besides the weights of ligated and nonligated lobes, pentobarbital (30 mg/kg)-induced sleeping time, CYP1A(2), CYP 2B(1/2), CYP2C(6/11/13), CYP3A(1) enzyme activities, and corresponding isoform mRNA expressions, as well as CYP3A1 protein expression were determined by in vivo sleeping test, CYP isoform-selective assays, polymerase chain reaction, and immunohistochemistry, respectively. RESULTS: Portal vein ligation triggered atrophy in ligated lobes and hypertrophy nonligated lobes. Sleeping time was transiently elevated (p = 0.0451). After an initial rise, CYP1A, CYP2B, and CYP3A enzyme activities dropped until 72 h, followed by a potent increase only in the nonligated lobes, paralleled by an early (24-48 h) transcriptional activation only in nonligated lobes. CYP2C enzyme activities and mRNA levels were bilaterally rapidly decreased, showing a late reconvergence only in nonligated lobes. CYP3A1 immunohistochemistry indicated substantial differences in positivity in the early period. CONCLUSIONS: Beyond the atrophy-hypertrophy complex, portal vein ligation generated a transient suppression of global and regional drug metabolism, re-established by an adaptive, CYP isoform-dependent transcriptional response of the nonligated lobes.

Limb remote ischemic conditioning of the recipient protects the liver in a rat model of arterialized orthotopic liver transplantation.

BACKGROUND: Ischemic-reperfusion (IR) injury still represents a major concern in clinical transplantation, especially in the era of extreme organ shortage and extended criteria donor organs. In the present study we aimed to investigate the hepatoprotective effects of remote ischemic conditioning (RIC) in a rat model of arterialized orthotopic liver transplantation (OLT). METHODS: Male Lewis rats were used (n = 144 / 72 OLT cases; 240-340g) as donors and recipients. Livers were flushed and stored in 4°C HTK-solution for 8h before implantation. Recipients were randomly allocated into three experimental groups: RIC 1, RIC 2, Control. In RIC 1, RIC 2 groups, RIC was applied in the recipient before hepatectomy or after reperfusion (4x5-5min IR via clamping the infrarenal aorta), respectively. Animals were sacrificed at 1, 3, 24, 168h post-reperfusion (n = 6 recipient/group/time point). Hepatocellular injury, graft circulation, serum cytokines, tissue redox-stress and adenosine-triphosphate (ATP) levels have been assessed. Additional markers were analyzed, using Western blotting and reverse-transcription polymerase chain reaction. RESULTS: RIC 1 group showed significantly (p<0.05) improved portal venous and microcirculation flow as well as velocity. RIC has significantly reduced tissue injury according to the serum levels of transaminases and results of histopathological evaluation. Reduced TUNEL-staining (p<0.01 RIC 1-2 vs. Control) and elevated pBAD/BAD ratio was detected in the RIC groups (p<0.01 RIC 1 vs. Control). Supporting findings were obtained from measurements of serum IL-10 as well as tissue malondialdehyde and ATP levels. Hemoxygenase-1 (HO-1) mRNA-expression was significantly higher in RIC 1 compared to Control (p<0.05 RIC 1 vs. Control). CONCLUSION: These results suggest that RIC might confer potent protection against the detrimental effects of IR injury including tissue damage, apoptosis, graft circulation, inflammation, tissue energetic status in OLT. HO-1 overexpression might play an orchestrating role in RIC mediated organ protection. An earlier intervention (RIC 1 protocol) was more effective than remote conditioning after graft reperfusion.

[Surgical treatment of primary liver malignancies]. / A máj primer rosszindulatú daganatainak sebészeti kezelése.

The incidence of primary malignant liver tumours is globally rising. Hepatocellular carcinoma constitutes 75-85% of primary liver malignancies. Owing to advancements of oncological therapies, several methods are available to combat the tumour. Upon the complexity of the disease and the wide spectrum of therapeutical regimens, therapy of HCC is debated, with several undecided issues. Noteworthy, however, is that in early tumour stages, as a de facto curative approach, surgical therapy remains the most effective, allowing long-term survival. Intrahepatic cholangiocellular carcinoma (iCCC) is the second most frequent primary malignant liver tumour. Despite technical developments, prognosis of iCCC patients remains dismal. Unfortunately, as the sole curative approach, surgery (nearing 40% 5-year survival) is mostly contraindicated because of a late diagnosis. In these cases, median survival remains below 7-12 months despite parallel palliative therapies. The present review focuses on the surgical management of primary malignant liver tumours.

Effects of a 6-Week Bench Press Program Using the Freak Bar in a Sample of Collegiate Club Powerlifters.

Ghigiarelli, JJ, Pelton, LM, Gonzalez, AM, Fulop, AM, Gee, JY, and Sell, KM. Effects of a 6-week bench press program using the freak bar in a sample of collegiate club powerlifters. J Strength Cond Res 32(4): 938-949, 2018-Powerlifters train using specialty bars for unstable load (UL) training. For the bench press, the acute effects of UL are mixed, with few studies that examine training interventions. The purpose of this study was to examine the effects of a 6-week bench press training program that uses the Freak Bar (FB) as compared to a traditional barbell (TB) on maximum bench press, peak force, and peak impulse. Seven men and 3 women (21 ± 2.0 years, 172.2 ± 2.9 cm, and 95.3 ± 20.3 kg) were required to bench press 2 days per week as part of a structured program. On the second bench press day, the FB and TB groups performed 3-position pause bench presses at 60-70% one repetition maximum (1RM). One repetition maximum, peak force, and peak impulse were measured before test and after test after the 6-week program. Peak force and peak impulse were tested at 3 bench positions, including the presticking, sticking, and poststicking points, defined by the distance of the barbell from the chest. Posttraining 1RM for the FB group and TB group increased 6.7% (6.78 ± 1.6 kg, p = 0.006) and 4.3% (4.5 ± 2.7 kg, p = 0.23), respectively, with no significant differences between the groups (p = 0.589, ηp = 0.044). There were no significant differences between the groups at each bench position for peak force (p = 0.606) or peak impulse (p = 0.542). Freak Bar can be an alternative for improving maximum strength and peak force but is not significantly better than TB training when performing the 3-position pause bench press.