Successful minimally invasive surgery for primary hyperparathyroidism: influence of preoperative imaging and intraoperative parathyroid hormone levels.

PURPOSE: Adenoma is the main parathyroid disorder leading to primary hyperparathyroidism (PHP). Minimally invasive parathyroidectomy (MIP) is recognized as a valid procedure for adenoma-related PHP. It requires precise preoperative localization combining Tc-99m-MIBI (methoxy-isobutyl-isonitrile) scintigraphy and single-photon emission computed tomography (SPECT) with x-ray computed tomography (CT) and intraoperative confirmation of successful excision by change in intact parathormone (iPTH) levels. The study aim was to assess the surgery success in relation to these two parameters. METHODS: All patients operated on for PHP from 2005 to mid-2014 at our institution were retrospectively reviewed. MIP was performed in case of precise preoperative adenoma localization on scintigraphy, absence of past cervical surgery, and absence of concomitant thyroid resection necessity. In these patients, iPTH levels were monitored intraoperatively. Confirmation criteria for iPTH values were a return to normal level or a decrease >50 % of basal iPTH level. RESULTS: There were 197 PHP operations during the study period: 118 MIP and 79 bilateral neck explorations (BNEs). The MIP success rate was 95 % (112/118) with a preoperative MIBI scan ± CT accurate in 94 % (111/118) of the patients and with correct iPTH in 90 % (106/118) of the cases. Among the 12 iPTH levels that did not meet the confirmation criteria, 10 returned to normal range by postoperative day 2. Treatment failure appeared in three patients (one BNE, two MIPs). CONCLUSIONS: Tc-99m-MIBI dual-phase scintigraphy with SPECT/CT is the key examination for functional and morphological parathyroid adenoma localization. If preoperative scintigraphy is obvious and intraoperative assessment is clear, one could possibly safely omit iPTH, as it may lead to unnecessary BNE in primary PHP.

Long-term professional performance of minimally invasive surgery post-graduates

OBJECTIVE: to evaluate the contribution of a post-graduation program in surgeons professional careers. METHODS: participants were asked to answer a questionnaire with questions related to possible changes in their professional performance after the end of the course. RESULTS: forty-three (76.7%) of the 56 participants eligible for the study responded to the questionnaires. Most participants, 32 (74.4%), had previous contact with laparoscopic surgery; however, only 14 (32.5%) reported the experience as primary surgeon. The expectations on the course were reached or exceeded for 36 (83.7%) participants. Thirty-seven (86%) incorporated minimally invasive procedures in their daily surgical practice, 37 (86%) reported improvements in their income above 10% and 12% reported income increase of over 100%, directly related to their increase of laparoscopic activity. CONCLUSION: the program in minimally invasive surgery provides a high level of satisfaction to its participants, enables them to perform more complex technical procedures, such as sutures, and improves their professional economic performance.

Video assisted resections. Increasing access to minimally invasive liver surgery?

Objective: To evaluate perioperative outcomes, safety and feasibility of video-assisted resection for primary and secondary liver lesions. Methods : From a prospective database, we analyzed the perioperative results (up to 90 days) of 25 consecutive patients undergoing video-assisted resections in the period between June 2007 and June 2013. Results : The mean age was 53.4 years (23-73) and 16 (64%) patients were female. Of the total, 84% were suffering from malignant diseases. We performed 33 resections (1 to 4 nodules per patient). The procedures performed were non-anatomical resections (n = 26), segmentectomy (n = 1), 2/3 bisegmentectomy (n = 1), 6/7 bisegmentectomy (n = 1), left hepatectomy (n = 2) and right hepatectomy (n = 2). The procedures contemplated postero-superior segments in 66.7%, requiring multiple or larger resections. The average operating time was 226 minutes (80-420), and anesthesia time, 360 minutes (200-630). The average size of resected nodes was 3.2 cm (0.8 to 10) and the surgical margins were free in all the analyzed specimens. Eight percent of patients needed blood transfusion and no case was converted to open surgery. The length of stay was 6.5 days (3-16). Postoperative complications occurred in 20% of patients, with no perioperative mortality. Conclusion : The video-assisted liver resection is feasible and safe and should be part of the liver surgeon armamentarium for resection of primary and secondary liver lesions.

Experimental myocardial hypertrophy induced by a minimally invasive ascending aorta coarctation

Ascending aorta coarctation was produced by a minimally invasive technique in rabbits. Animal mortality was 5%. Morphometric and hemodynamic parameters were evaluated. A parabiotically isolated heart model was used to assess the hemodynamic parameters. Left ventricular weight/body weight ratio and muscle area showed clear evidence of hypertrophy when compared to control. The hemodynamic changes in the isolated heart model suggested decreased diastolic and systolic function in the coarcted group. The present model produced hypertrophy with low mortality rates as a result of its less invasive nature.

Highly efficient neural differentiation of human somatic stem cells, isolated by minimally invasive periodontal surgery

Neural stem cells (NSCs) are potential sources for cell therapy of neurodegenerative diseases and for drug screening. Despite their potential benefits, ethical and practical considerations limit the application of NSCs derived from human embryonic stem cells (ES) or adult brain tissue. Thus, alternative sources are required to satisfy the criteria of ready accessibility, rapid expansion in chemically defined media and reliable induction to a neuronal fate. We isolated somatic stem cells from the human periodontium that were collected during minimally invasive periodontal access flap surgery as part of guided tissue regeneration therapy. These cells could be propagated as neurospheres in serum-free medium, which underscores their cranial neural crest cell origin. Culture in the presence of epidermal growth factor (EGF) and fibroblast growth factor-2 (FGF-2) under serum-free conditions resulted in large numbers of nestin-positive/Sox-2-positive NSCs. These periodontium-derived (pd) NSCs are highly proliferative and migrate in response to chemokines that have been described as inducing NSC migration. We used immunocytochemical techniques and RT-PCR analysis to assess neural differentiation after treatment of the expanded cells with a novel induction medium. Adherence to substrate, growth factor deprivation, and retinoic acid treatment led to the acquisition of neuronal morphology and stable expression of markers of neuronal differentiation by more than 90% of the cells. Thus, our novel method might provide nearly limitless numbers of neuronal precursors from a readily accessible autologous adult human source, which could be used as a platform for further experimental studies and has potential therapeutic implications.

DNA damage in patients who underwent minimally invasive surgery under inhalation or intravenous anesthesia

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Cytokine Profile in Patients Undergoing Minimally Invasive Surgery with Balanced Anesthesia

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Experimental myocardial hypertrophy induced by a minimally invasive ascending aorta coarctation

Ascending aorta coarctation was produced by a minimally invasive technique in rabbits. Animal mortality was 5%. Morphometric and hemodynamic parameters were evaluated. A parabiotically isolated heart model was used to assess the hemodynamic parameters. Left ventricular weight/body weight ratio and muscle area showed clear evidence of hypertrophy when compared to control. The hemodynamic changes in the isolated heart model suggested decreased diastolic and systolic function in the coarcted group. The present model produced hypertrophy with low mortality rates as a result of its less invasive nature.

Electrical and mechanical effects of hyoscine butylbromide on the human stomach: a non-invasive approach

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Clinical and microbiological changes after minimally invasive therapeutic approaches in intrabony defects: a 12-month follow-up

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Comparison of oxidative stress in ASA physical status I patients scheduled for minimally invasive surgery under balanced or intravenous anesthesia

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Minimally invasive mastectomy: minimal incisions for better aesthetic quality of breast reconstruction

Background: Women with a family history of breast cancer who develop this disease are confronted with important situations regarding the increased risk for development of a second cancer in the contralateral breast. Prophylactic contralateral mastectomy (PCM) reduces by approximately 95% the risk for contralateral breast cancer. In spite of an increase in indications for PCM, the technical difficulties are many regarding the accomplishment of these procedures. The aim of this study is to describe the technique of mastectomy with preservation of the nipple-areola complex and a small incision, reducing surgical difficulties and complications attributed to this technique, thus allowing better aesthetic results in breast reconstruction. Methods: Forty-six patients with indications for PCM (28 bilateral) were submitted to minimally invasive mastectomy from March 2005 to November 2007. A small incision in the superior pole of the areola, sufficient to pass a liposuction 4 mm cannula is made. With the help of this cannula, detachment of the skin from the gland tissue is performed. Then a 3.5 to 4.5-cm long incision in the inframammary fold is made. Glandular detachment is completed using cautery in the sub,glandular portion and scissors in the upper breast portion cutting the restraints left by the cannula. The mammary gland tissue is removed through this incision. Results: Seventy-four breasts were operated on. The resected breast mass ranged from 285 g to 475 g. All 43 patients were reconstructed with prostheses. There was no necrosis of the nipple-areola complex or of the skin. Conclusions: This technique is an option for cases of patients with indications for PCM.

Design and fabrication of MOMS-based ultrasonic probes for minimally invasive endoscopic applications

A Micro-opto-mechanical systems (MOMS) based technology for the fabrication of ultrasonic probes on optical fiber is presented. Thanks to the high miniaturization level reached, the realization of an ultrasonic system constituted by ultrasonic generating and detecting elements, suitable for minimally invasive applications or Non Destructive Evaluation (NDE) of materials at high resolution, is demonstrated. The ultrasonic generation is realized by irradiating a highly absorbing carbon film patterned on silicon micromachined structures with a nanosecond pulsed laser source, generating a mechanical shock wave due to the thermal expansion of the film induced by optical energy conversion into heat. The short duration of the pulsed laser, together with an appropriate emitter design, assure high frequency and wide band ultrasonic generation. The acoustic detection is also realized on a MOMS device using an interferometric receiver, fabricated with a Fabry-Perot optical cavity realized by means of a patterned SU-8 and two Al metallization levels. In order to detect the ultrasonic waves, the cavity is interrogated by a laser beam measuring the reflected power with a photodiode. Various issues related to the design and fabrication of these acoustic probes are investigated in this thesis. First, theoretical models are developed to characterize the opto-acoustic behavior of the devices and estimate their expected acoustic performances. Tests structures are realized to derive the relevant physical parameters of the materials constituting the MOMS devices and determine the conditions theoretically assuring the best acoustic emission and detection performances. Moreover, by exploiting the models and the theoretical results, prototypes of acoustic probes are designed and their fabrication process developed by means of an extended experimental activity.

Minimally invasive post-mortem CT-angiography in a case involving a gunshot wound

Non-contrast post-mortem computed tomography (pm-CT) is useful in the evaluation of bony pathologies, whereas minimally invasive pm-CT-angiography allows for the detection of subtle vascular lesions. We present a case of an accidentally self-inflicted fatal bullet wound to the chest where pm-CT-angiography revealed a small laceration of the anterior interventricular branch of the left coronary artery and a tiny disruption of the right ventricle with pericardial and pleural effusion. Subsequent autopsy confirmed our radiological findings. Post-mortem CT-angiography has a great potential for the detection of vascular lesions and can be considered equivalent to autopsy for selected cases in forensic medicine.