Microinvasive Carpal Tunnel Release Using a Retractable Needle-Mounted Blade.

We report 166 microinvasive ultrasound-guided carpal tunnel releases using the MICROi-Blade (Summit Medical Products, Inc, Sandy, UT), a needle-based tool for cutting under ultrasound guidance. The 6-month follow-up of the first 21 cases, including 5 bilateral releases, showed a progressive reduction in median pain scores, Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale scores, and BCTQ Functional Status Scale scores. The median return to work was 7 days. The 3-month follow-up of 62 subsequent cases showed similar improvement in the BCTQ scores and return to work. There were no complications. This report supports the effectiveness of the technique.

Ex vivo dissection increases lymph node yield in oesophagogastric cancer.

BACKGROUND: Retrieval and analysis of an adequate number of lymph nodes is critical for accurate staging of oesophageal and gastric cancer. Higher total node counts reported by pathologists are associated with improved survival. A prospective study was undertaken to understand the factors contributing to variability in lymph node counts after oesophagogastric cancer resections and to determine whether a novel strategy of ex vivo dissection of resected specimens into nodal stations improves node counts reported by pathologists. METHODS: The study involved 88 patients with potentially curable oesophagogastric cancer undergoing radical resection. Lymph node counts were obtained from pathology reports and analysed in relation to multiple variables including the introduction of ex vivo dissection of nodal stations in theatre. RESULTS: Higher lymph node counts were obtained with ex vivo dissection of nodal stations (median 19 versus 8, P < 0.01). Node counts also varied significantly with the reporting pathologist (median range 4 to 48, P = 0.02) which was independent of the level of experience of the pathologist (P = 0.67). Node counts were not affected by patient age (P = 0.26), gender (P = 0.50), operative approach (P = 0.50) or neoadjuvant therapy (P = 0.83). CONCLUSIONS: Specimen handling is a significant factor in determining lymph node yield following radical oesophageal and gastric cancer resections. Ex vivo dissection of resected specimens into nodal stations improves node counts without alterations to surgical techniques. Ex vivo dissection should be considered routine.

Torsion of Wandering Gallbladder following Colonoscopy.

Torsion of the gallbladder is an uncommon condition that may present as an acute abdomen. Its preoperative diagnosis can often be challenging due to its variable presentation, with specific sonographic signs seen infrequently. We describe, to our knowledge, the first case of torsion of a wandering gallbladder following a colonoscopy in a 69-year-old female who presented with acute abdominal pain after procedure. This was discovered intraoperatively, and after a subsequent cholecystectomy, she had an uncomplicated recovery.

The heel: anatomy, blood supply, and the pathophysiology of pressure ulcers.

There remains much confusion regarding the pathophysiology of pressure ulcers. Data indicate that the prevalence of pressure ulcers is increasing. The heel is unique in structure and well adapted to the task of shock absorption. However, it is often subject to prolonged pressure, which predisposes it to tissue breakdown, with attempts at reconstruction prone to failure. Four dissections were carried out of the heel region, which included removing each heel pad en bloc for histology. Seventeen arterial injection studies, 12 venous studies, and a combined arterial and venous study of the foot were performed. The results were correlated with clinical cases and previous research. The heel was found to be richly vascularized by a subdermal plexus and periosteal plexus with vessels traveling between the 2 within fibrous septa that connect the reticular dermis and periosteum of the calcaneus. These septa effectively create isolated compartments containing relatively avascular fat. A layer of panniculus carnosus muscle was observed in the subcutaneous tissue. It is likely that the metabolically active panniculus carnosus muscle is involved early in the course of pressure ulcers. Extensive pressure damage can be concealed by intact skin. Friction and shear are additional factors important in skin breakdown.

Comparative anatomical study of the gracilis and coracobrachialis muscles: implications for facial reanimation.

Since the introduction of cross-facial nerve grafting and free vascularized muscle transfer for the treatment of longstanding facial paralysis, substantial progress has been made toward restoration of facial expression that is as normal as possible. Much of the focus has remained on the gracilis as a donor muscle. However, its inherent anatomical characteristics may preclude it from ever being more than simply a mass of contractile tissue in the face. The coracobrachialis muscle, which is the analogue in the arm of the lower limb adductor mass, was proposed as an alternative donor muscle because it was thought that certain features would allow it to improve on the overall results that are currently possible with the gracilis. A comparative anatomical study was conducted to gauge this potential. A total of 133 muscles were analyzed, including 96 dissected specimens, 16 arterial and 14 venous study specimens, and seven neurovascular study specimens. Anatomical parameters were recorded for each muscle and later tabulated. Histological analysis of the nerves to 10 gracilis and 10 coracobrachialis muscles was performed, and the findings were confirmed with intraneural dissection of an additional 20 nerves under an operating microscope. The coracobrachialis was observed to be a practical alternative to the gracilis. Indeed, it has many of the attributes that initially drew attention to the gracilis as a possible donor muscle, including a reliable neurovascular supply, minimal donor-site morbidity, and the option of having two teams operate simultaneously. In addition, it has a size, shape, and form that make it an excellent choice for transfer to the face. It could be easily attached in the face to provide static support as well as animation, because of its long proximal tendon, the thick intermuscular septum along its lateral surface, and, when present, the ligament of Struthers.

Neurovascular congruence results from a shared patterning mechanism that utilizes Semaphorin3A and Neuropilin-1.

Peripheral nerves and blood vessels have similar patterns in quail forelimb development. Usually, nerves extend adjacent to existing blood vessels, but in a few cases, vessels follow nerves. Nerves have been proposed to follow vascular smooth muscle, endothelium, or their basal laminae. Focusing on the major axial blood vessels and nerves, we found that when nerves grow into forelimbs at E3.5-E5, vascular smooth muscle was not detectable by smooth muscle actin immunoreactivity. Additionally, transmission electron microscopy at E5.5 confirmed that early blood vessels lacked smooth muscle and showed that the endothelial cell layer lacks a basal lamina, and we did not observe physical contact between peripheral nerves and these endothelial cells. To test more generally whether lack of nerves affected blood vessel patterns, forelimb-level neural tube ablations were performed at E2 to produce aneural limbs; these had completely normal vascular patterns up to at least E10. To test more generally whether vascular perturbation affected nerve patterns, VEGF(165), VEGF(121), Ang-1, and soluble Flt-1/Fc proteins singly and in combination were focally introduced via beads implanted into E4.5 forelimbs. These produced significant alterations to the vascular patterns, which included the formation of neo-vessels and the creation of ectopic avascular spaces at E6, but in both under- and overvascularized forelimbs, the peripheral nerve pattern was normal. The spatial distribution of semaphorin3A protein immunoreactivity was consistent with a negative regulation of neural and/or vascular patterning. Semaphorin3A bead implantations into E4.5 forelimbs caused failure of nerves and blood vessels to form and to deviate away from the bead. Conversely, semaphorin3A antibody bead implantation was associated with a local increase in capillary formation. Furthermore, neural tube electroporation at E2 with a construct for the soluble form of neuropilin-1 caused vascular malformations and hemorrhage as well as altered nerve trajectories and peripheral nerve defasciculation at E5-E6. These results suggest that neurovascular congruency does not arise from interdependence between peripheral nerves and blood vessels, but supports the hypothesis that it arises by a shared patterning mechanism that utilizes semaphorin3A.