Abstract Background and Aims There is little evidence that structures targeted during EUS-guided celiac ganglia neurolysis (EUS-CGN) are celiac ganglia and that selective ethanol injection into ...ganglia is feasible. We aimed to visualize celiac ganglia, confirm that these structures are ganglia, and visualize ethanol spread after EUS-CGN and EUS-guided celiac plexus neurolysis (EUS-CPN). Methods First, celiac ganglia were sought during 97 consecutive EUS procedures. Second, ganglia were identified in a prosected human cadaver by placing a linear echo-endoscope next to the celiac trunk and the underlying tissue was removed for histology. Finally, various EUS-CGN and EUS-CPN techniques were performed in human cadavers; EUS-CGN was performed with 1 mL ethanol in one ganglion, 1 mL per ganglion (both “low volume”), and 4 mL per ganglion (“high volume”). EUS-CPN was performed with a central (20 mL) and a bilateral (2*10 mL) approach. Transverse sections (75 μm) were obtained and photographed to visualize the spread of ethanol. Results 204 ganglia were detected in 83 patients. Mean size of the long axis was 8.1 (±7.4) mm. Histology of the removed region in the cadaver showed only nerve cell bodies. After low volume EUS-CGN in cadavers, ethanol spread well beyond the targeted ganglion. After high-volume EUS-CGN in cadavers, a larger ethanol spread was seen, which also reached unidentified ganglia; the spread was comparable with spread after EUS-CPN. Conclusions Specific EUS-CGN is not feasible because ethanol spreads well beyond the targeted ganglion. Unidentified celiac ganglia are better reached with high-volume EUS-CGN, and this would likely result in a more thorough neurolysis. High-volume EUS-CGN should be preferred to low-volume EUS-CGN.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Background Occasionally incurable cancer is encountered after completion of the thoracic (first) phase of a three-phase esophagectomy. The outcome of aborting the operation at this stage, leaving the ...mobilized thoracic esophagus in situ, is unknown. Methods A multicenter retrospective analysis was performed of patients in whom a completely mobilized thoracic esophagus was left in situ when incurable disease was discovered intraoperatively. The occurrence of esophageal necrosis or perforation, mortality, and all other adverse events were recorded and graded by severity. Results Some 18 patients were included. The median admission time was 9 days. All patients had resumed oral intake at discharge, except for 1 patient who was fed through a nasojejunal tube. After the operation, the median overall survival was 2.9 months. Postoperatively, 7 patients (39%) experienced major surgical adverse events, and 11 patients (61%) had no or only minor adverse events. Major adverse events were associated with the patient’s death in 6 patients (33%), within 5 to 34 days postoperatively. Esophageal perforation or ischemia developed in 4 patients (22%) and 1 patient (6%), respectively. No predictive factors could be identified. Conclusions Leaving a completely mobilized thoracic esophagus in situ when incurable cancer was discovered intraoperatively was a successful strategy in more than half of the patients. However, one third experienced major adverse events leading to mortality.
Decreased smile dynamics is reported as an unwanted side effect after Le Fort I osteotomies. It is assumed that this negative sequela might be caused by postoperative changes in the anatomy of ...peri-oral mimic muscles. Due to a lack of specific anatomical knowledge, the exact mechanism is not yet clarified. This makes prevention of the undesired changes in smile dynamics difficult. The first aim of this study is to increase basic anatomical and radiological MRI knowledge of the peri-oral mimic muscles. The second aim is to investigate if 7 Tesla MRI scans are better suited to identify these muscles than 3 Tesla MRI scans.
Eleven peri-oral mimic muscles were chosen as subjects of the present study. Three and 7 Tesla MRI scans of a cadaver head were made. The same head was cut in axial slices using a cryomacrotome. Every second slice was digitally photographed. A three-dimensional model was created utilizing EMAC software, which served as gold standard for the identification and comparison of the chosen peri-oral mimic muscles on both MRI scans.
All predetermined peri-oral mimic muscles could be identified in the cadaver head, and a detailed radiological atlas was created. The ease of identification and separation of the peri-oral mimic muscles was significantly higher on the 7 Tesla MRI than on the 3 Tesla MRI scan (
< 0.001).
A 7 Tesla MRI scanner offers great improvement in the identification of peri-oral mimic muscles compared with a 3 Tesla scanner.
Facial expressions are ubiquitous in communication. Therefore, assessment of mimic function is essential in facial surgery, but no reference standards are currently available. This prospective study ...aims to create reference values of three-dimensional landmark displacement for different sex and age groups.
Three-dimensional photographs were taken from healthy subjects in rest, maximum closed smile, and pouting. Displacement for both exercises of perioral landmarks was analyzed with MATLAB as absolute displacement and as the ratio of mouth width. Additionally, displacement in three planes was analyzed for each landmark. Averages were calculated for both genders in four age groups: 4-8, 8-12, 12-16, and >16 years.
In total, 328 subjects were included. Oral landmarks predominantly moved forward and backward for both exercises. Nasal landmarks predominantly moved vertically. Growing up, oral landmark displacement decreased for smiling, whereas nasal landmark displacement increased. For pouting, oral landmark displacement increased while growing up, whereas nasal landmark displacement decreased.
The present study creates reference values for movement of perioral structures for different sex and age groups, for two facial expressions. These data are of great value for the assessment of mimic function and give insight into the development of facial animation over time.
Radiology practice has become increasingly based on volumetric images (VIs), but tests in medical education still mainly involve two-dimensional (2D) images. We created a novel, digital, VI test and ...hypothesized that scores on this test would better reflect radiological anatomy skills than scores on a traditional 2D image test. To evaluate external validity we correlated VI and 2D image test scores with anatomy cadaver-based test scores.
In 2012, 246 medical students completed one of two comparable versions (A and B) of a digital radiology test, each containing 20 2D image and 20 VI questions. Thirty-three of these participants also took a human cadaver anatomy test. Mean scores and reliabilities of the 2D image and VI subtests were compared and correlated with human cadaver anatomy test scores. Participants received a questionnaire about perceived representativeness and difficulty of the radiology test.
Human cadaver test scores were not correlated with 2D image scores, but significantly correlated with VI scores (r = 0.44, P < .05). Cronbach's α reliability was 0.49 (A) and 0.65 (B) for the 2D image subtests and 0.65 (A) and 0.71 (B) for VI subtests. Mean VI scores (74.4%, standard deviation 2.9) were significantly lower than 2D image scores (83.8%, standard deviation 2.4) in version A (P < .001). VI questions were considered more representative of clinical practice and education than 2D image questions and less difficult (both P < .001).
VI tests show higher reliability, a significant correlation with human cadaver test scores, and are considered more representative for clinical practice than tests with 2D images.
Ulnar nerve injury is the most common neurologic complication of elbow arthroscopy. The purpose of this cadaveric study was to quantify the ability of surgeons to locate the ulnar nerve behind the ...posteromedial capsule during elbow arthroscopy using sole arthroscopic vision.
Twenty-one surgeons were asked to pin the ulnar nerve at the medial gutter and the posteromedial compartment using arthroscopic visualization of the medial capsule only. Pinning of the ulnar nerve was performed from extra-articular. Then, the cadaveric specimens were dissected and the shortest distances between the pins and ulnar nerve measured.
Median pin-to-nerve distances at the medial gutter and posteromedial compartment were 0 mm (interquartile range IQR, 0-3 mm) and 2 mm (IQR, 0-6 mm), respectively. The ulnar nerve was pinned by 11/21 surgeons (52%) at the medial gutter, and 7/21 surgeons (33%) at the posteromedial compartment. Three of 21 surgeons (14%) pinned the ulnar nerve at both the medial gutter and the posteromedial compartment. Surgeon's experience and operation volume did not affect these outcomes (P > .05).
Surgeons' ability to locate the ulnar nerve behind the posteromedial capsule using sole arthroscopic visualization, without external palpation, is poor. We recommend to proceed carefully when performing arthroscopic procedures in the posteromedial elbow, and identify and mobilize the ulnar nerve prior to any posteromedial capsular procedures.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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