Bone marrow aspiration and biopsy: techniques and practice implications

Bone marrow aspiration and biopsy (BMAB) is a valuable diagnostic procedure commonly performed for evaluation of a wide spectrum of diseases including hematologic abnormalities, nonhematologic malignancies, metabolic abnormalities, and tumor treatment response such as chemotherapy and bone marrow transplantation, hematologic tumor staging, and suspected infection in patients with fever of unknown origin. This minimally invasive intervention offers excellent safety profile and a high diagnostic yield. Radiologists should be familiar with clinical implications of BMAB for patient care and be able to implement various technical armamentarium available to achieve a safe intervention while maximizing procedure yield.

Field-scale monitoring of nitrate leaching in agriculture: assessment of three methods

Deterioration of groundwater quality due to nitrate loss from intensive agricultural systems can only be mitigated if methods for in-situ monitoring of nitrate leaching under active farmers' fields are available. In this study, three methods were used in parallel to evaluate their spatial and temporal differences, namely ion-exchange resin-based Self-Integrating Accumulators (SIA), soil coring for extraction of mineral N (Nmin) from 0 to 90 cm in Mid-October (pre-winter) and Mid-February (post-winter), and Suction Cups (SCs) complemented by a HYDRUS 1D model. The monitoring, conducted from 2017 to 2020 in the Gäu Valley in the Swiss Central Plateau, covered four agricultural fields. The crop rotations included grass-clover leys, canola, silage maize and winter cereals. The monthly resolution of SC samples allowed identifying a seasonal pattern, with a nitrate concentration build-up during autumn and peaks in winter, caused by elevated water percolation to deeper soil layers in this period. Using simulated water percolation values, SC concentrations were converted into fluxes. SCs sampled 30% less N-losses on average compared to SIA, which collect also the wide macropore and preferential flows. The difference between Nmin content in autumn and spring was greater than nitrate leaching measured with either SIA or SCs. This observation indicates that autumn Nmin was depleted not only by leaching but also by plant and microbial N uptake and gaseous losses. The positive correlation between autumn Nmin content and leaching fluxes determined by either SCs or SIA suggests autumn Nmin as a useful relative but not absolute indicator for nitrate leaching. In conclusion, all three monitoring techniques are suited to indicate N leaching but represent different transport and cycling processes and vary in spatio-temporal resolution. The choice of monitoring method mainly depends (1) on the project's goals and financial budget and (2) on the soil conditions. Long-term data, and especially the combination of methods, increase process understanding and generate knowledge beyond a pure methodological comparison.

Update on chronic total occlusion percutaneous coronary intervention

Chronic total occlusion (CTO) percutaneous coronary interventions (PCI) can be challenging to perform. The main indication for CTO PCI is to improve symptoms. Several contemporary studies have reported high CTO PCI success rates at experienced centers but success rates in all-comer registries remain low. Several scores can estimate the difficulty and the likelihood of success of CTO PCI. Dual arterial access and use of CTO crossing algorithms can improve the success and safety of CTO PCI. Intracoronary imaging can optimize stent expansion and minimize adverse cardiovascular events. While complications are more common in CTO PCI, careful planning and prompt diagnosis and treatment can prevent them or minimize their adverse consequences. In this article, we review contemporary data on the indications, safety and efficacy of CTO PCI.

Laboratory methods to decipher epigenetic signatures: a comparative review

Epigenetics refers to nucleotide sequence-independent events, and heritable changes, including DNA methylation and histone modification (as the two main processes), contributing to the phenotypic features of the cell. Both genetics and epigenetics contribute to determining the outcome of regulatory gene expression systems. Indeed, the flexibility of epigenetic effects and stability of genetic coding lead to gene regulation complexity in response signals. Since some epigenetic changes are significant in abnormalities such as cancers and neurodegenerative diseases, the initial changes, dynamic and reversible properties, and diagnostic potential of epigenomic phenomena are subject to epigenome-wide association studies (EWAS) for therapeutic aims. Based on recent studies, methodological developments are necessary to improve epigenetic research. As a result, several methods have been developed to explore epigenetic alterations at low, medium, and high scales, focusing on DNA methylation and histone modification detection. In this research field, bisulfite-, enzyme sensitivity- and antibody specificity-based techniques are used for DNA methylation, whereas histone modifications are gained based on antibody recognition. This review provides a mechanism-based understanding and comparative overview of the most common techniques for detecting the status of epigenetic effects, including DNA methylation and histone modifications, for applicable approaches from low- to high-throughput scales.

Review of dexamethasone administration for management of complications in postoperative third molar surgery

Dexamethasone has been used in oral and maxillofacial surgery for postoperative pain, swelling, and trismus following third molar surgeries. It is a potent and powerful drug that can alleviate the aforementioned postoperative sequelae. Dexamethasone is responsible for inhibiting the release of inflammatory mediators in the inflammation process to improve patient quality of life after surgical intervention. There are several available routes of administering dexamethasone. This article will help determine the suggested routes of administration, dosage, parameters, and dexamethasone timing for third molar surgeries.

A Review of Techniques for Biodelivery of Nerve Growth Factor (NGF) to the Brain in Relation to Alzheimer's Disease

Age-dependent progressive neurodegeneration and associated cognitive dysfunction represent a serious concern worldwide. Currently, dementia accounts for the fifth highest cause of death, among which Alzheimer's disease (AD) represents more than 60% of the cases. AD is associated with progressive cognitive dysfunction which affects daily life of the affected individual and associated family. The cognitive dysfunctions are at least partially due to the degeneration of a specific set of neurons (cholinergic neurons) whose cell bodies are situated in the basal forebrain region (basal forebrain cholinergic neurons, BFCNs) but innervate wide areas of the brain. It has been explicitly shown that the delivery of the neurotrophic protein nerve growth factor (NGF) can rescue BFCNs and restore cognitive dysfunction, making NGF interesting as a potential therapeutic substance for AD. Unfortunately, NGF cannot pass through the blood-brain barrier (BBB) and thus peripheral administration of NGF protein is not viable therapeutically. NGF must be delivered in a way which will allow its brain penetration and availability to the BFCNs to modulate BFCN activity and viability. Over the past few decades, various methodologies have been developed to deliver NGF to the brain tissue. In this chapter, NGF delivery methods are discussed in the context of AD.

Helicobacter pylori

Helicobacter pylori (H. pylori) is an important human pathogen etiologically associated with peptic ulcers and gastric cancer. The infection is present in approximately one-half of the world's population. Population-based H. pylori eradiation has confirmed that cure or prevention of the infection produces a marked reduction in gastric cancer and peptic ulcer disease. Antimicrobial therapy has become increasingly ineffective, and complexity and costs of antimicrobial therapy for infected individuals residing in and, immigrating from, the developing world combined with the cost of treatment for cancer make vaccine development a cost-effective alternative. Challenge studies allowed making a "go-no go" decision regarding vaccine effectiveness. We provide detailed protocols regarding challenge strain selection and administration as well as guidance regarding the clinical and laboratory tests used to confirm and monitor experimental infection. Experience shows that reliance of noninvasive methods led to the erroneous conclusion that some subjects were not infected. The current data suggests that histologic assessment of gastric mucosal biopsies may be one of the most sensitive and specific means of assessment of the presence of experimental infection as well as of successful H. pylori eradication. We recommend detailed recommendations for acquiring, processing, embedding, sectioning, and examining the gastric biopsies.

African indigenous contraception: A review

In Africa, indigenous methods of contraception continue to play a significant role in preventing unwanted pregnancies despite the introduction and popularity of modern contraceptives. The current review identified the common techniques and practices of African indigenous contraception, and examined their mechanisms and reasons for use. We searched data bases such as Google Scholar, Scopus, Web of Science, EBSCohost, African Journals, Science Direct, textbooks, thesis and dissertations for research articles on African indigenous contraception. The six common techniques of African indigenous contraception included periodic abstinence, withdrawal, breastfeeding, use of herbs, postpartum abstinence and waist bands, whilst practices relate to child (birth) spacing, postponement of first birth (virginity), stopping of reproduction and indigenous emergency contraception. Mother and infant health was stated as one of the reasons for using African indigenous contraception. African indigenous contraception continues to play a critical reproductive role in preventing unwanted pregnancies. However, there is lack of clarity regarding mechanisms, the safety, and efficacy of some techniques.

Interstitial multi-catheter breast brachytherapy: Technical aspects and experience feedback in a comprehensive cancer center

PURPOSE

To focus on technical aspects of the implementation of interstitial high dose rate brachytherapy, with a step-by-step approach.

MATERIALS AND METHODS

Patients were selected during multidisciplinary tumor boards, according to inclusion criteria adapted from GEC-ESTRO guidelines. A CT scan was performed a few days before implantation. On pre-implant CT, using surgical scar and clips, surgical and pathological reports, and preoperative images, we delineated the tumor bed to be included in the Clinical Target Volume (CTV), according to GEC ESTRO Recommendations. A 3D virtual implant simulation of the best catheter positions was performed in order to cover the target volume. Implantation was then carried out under local anaesthetic using 3D projections of the catheter inlets and outlets. Dosimetry was performed on post-implantation CT scan. A dose of 34Gy was delivered in 10 fractions. Acute and late side effects, and local control were evaluated 2 and 8 months after treatment.

RESULTS

Between July 2017 and January 2020, 20 patients were treated with accelerated partial breast irradiation. Dose constraints regarding target volume coverage, overdose, dose homogeneity, conformation index and organs at risk were met in 94.7%, 100%, 63.2%, 0% and 89.5% of the treatment plans, respectively. Grade 1-2 acute adverse events were observed in 21% of patients, with no grade 3-4 events.

CONCLUSION

The first dosimetric results and early clinical tolerance and efficacy achieved by the implementation of breast interstitial multicatheter brachytherapy in routine clinical practice are very encouraging, and confirm the interest of extending this practice.

[Resection arthoplasty of the trapezium with ligament reconstruction and tendon interposition and variations]

OBJECTIVE

Creation of a pain-free, flexible and stable (pseudo) joint between the carpus and the base of the 1st metacarpal bone.

INDICATIONS

Painful carpometacarpal (CMC)‑I joint due to primary or secondary osteoarthritis, CMC‑I instability.

CONTRAINDICATIONS

Carpal instability, local infection, tumors.

SURGICAL TECHNIQUE

Resection of the trapezium (and of the arthritic joint surfaces in CMC‑I and STT [scaphoid-trapezium-trapezoid-joint]), stabilization of the base of the 1st metacarpal bone by suspension with a distally pedicled strip of the flexor carpi radialis tendon or variants thereof.

POSTOPERATIVE MANAGEMENT

Immobilization in a splint for 3-5 weeks, followed by hand therapy.

RESULTS

Worldwide for almost 40 years, regardless of the exact technique, almost always (90%) significant pain reduction, increased strength in the grip and slightly less in the pinch grip, very good mobility, 85-95% very satisfied patients and very good long-term results.

The Asian Federation of Societies for Ultrasound in Medicine and Biology (AFSUMB) Guidelines for Contrast-Enhanced Endoscopic Ultrasound

The Asian Federation of Societies for Ultrasound in Medicine and Biology aimed to provide information on techniques and indications for contrast-enhanced harmonic endoscopic ultrasound (CH-EUS), and to create statements including the level of recommendation. These statements are based on current scientific evidence reviewed by a Consensus Panel of 15 internationally renowned experts. The reliability of clinical questions was measured by agreement rates after voting. Six statements were made on techniques, including suitable contrast agents for CH-EUS, differences between contrast agents, setting of mechanical index, dual imaging and duration and phases for observation. Thirteen statements were made on indications, including pancreatic solid masses, pancreatic cancer staging, pancreatic cystic lesions and mural nodules, detection of subtle pancreatic lesions, gallbladder sludge and polyps, hepatic lesions, lymph nodes, subepithelial lesions, visceral vascular diseases, guidance of fine needle aspiration and evaluation for local therapy. These international expert consensus guidelines will assist endosonographers in conducting CH-EUS according to evidence-based information.

Looking for a way forward for the cryopreservation of orchid diversity

The family Orchidaceae, with over 25,000 species, includes five subfamilies and nearly 700 genera. Loss of plants in the wild has resulted from clearing of forests and excessive collection for various purposes. Moreover, the requirement of symbiotic association during seed germination under natural conditions adds a certain level of difficulty in retaining the orchid resources in the wild. Cryopreservation is an important arena in conservation science due to its potential of storing genetic resources without altering the genetic makeup. Cryopreserved orchids are a very small percentage of the species, and are also not representative of most genera. Finding effective protocols for the various explant types is of prime importance in conserving orchid diversity. Seed is the most commonly stored and directly useful explant, and direct plunging in liquid nitrogen or PVS2 vitrification appear to be suitable for most tested species. The myriad of other species should be screened as they become available, with special emphasis on seed maturity and moisture content. Studies of protocorms and protocorm-like bodies mostly employ desiccation, PVS2 vitrification or encapsulation-dehydration. Pollinia are generally stored successfully following desiccation or slow cooling. There are too few examples of shoot tip cryopreservation to make a determination, however vitrification techniques are likely the most useful for a range of genera. A systematic and coordinated effort is needed to screen all available species in as many taxa as possible, initially with seed, protocorms and pollinia. It is a charge to the orchid research community to organize this effort and fill in the required data for the large number of untested taxa. In addition, providing stored samples to established orchid cryo collections would greatly increase preservation of these endangered treasures.

Methods of Ovarian Tissue Cryopreservation: Is Vitrification Superior to Slow Freezing?-Ovarian Tissue Freezing Methods

After cancer treatment, female survivors often develop ovarian insufficiency or failure. Oocyte and embryo freezing are well-established fertility preservation options, but cannot be applied in pre-pubescent girls, in women with hormone-sensitive malignancies, or when gonadotoxic treatment cannot be delayed. Although ovarian tissue cryopreservation (OTC) has been used to restore fertility and endocrine function, the relative efficacy of its two major protocols, slow freezing and vitrification, remains controversial. This literature review evaluates clinical and lab-based studies published between January 2012 and June 2020 to determine whether vitrification, the optimal technique for oocyte and embryo cryopreservation, preserves ovarian tissue more effectively than slow freezing. Due to limited clinical data involving ovarian tissue vitrification, most clinical studies focus on slow freezing. Only 9 biochemical studies that directly compare the effects of slow freezing and vitrification of human ovarian tissue were noted. Most studies report no significant difference in follicular morphology and distribution between cryopreservation methods, but these findings must be interpreted in the context of high methodological variability. Discrepant findings regarding the effects of cryopreservation method on follicle viability, gene expression, and hormone production require further evaluation. Early clinical outcomes appear favorable for vitrification, but additional studies and longer term follow-up are needed to establish its efficacy. Sharing data through national or international registries would expedite this analysis. However, even if research corroborates conclusions of no clinical or biochemical difference between cryopreservation methods, the decreased costs and increased efficiency associated with vitrification make this method more accessible and cost-effective.

A review of technical progression in the robot-assisted radical prostatectomy

Since the advent of the robotic surgery, its implementation in urology has been both wide and rapid. Particularly in extirpative surgery for prostate cancer, techniques in robotic-assisted radical prostatectomy have—and continue to—evolve to maximize functional and oncologic outcomes. In this review, we briefly present a historical perspective of the evolution of various robotic techniques, allowing us to contextualize contemporary robotic approaches to radical prostatectomy.

A systematic review on the application of the hybrid operating room in surgery: experiences and challenges

The hybrid operating room has been widely applied in different surgery sub-specialties. We aim to identify the advantages of hybrid operating rooms by focusing on intraoperative imaging and explore what to do for further improving its application. We searched related literature in websites including Pubmed, MEDLINE, Web of science, using the keywords ("hybrid operating room" or "integrated operating room" or "multifunctional operating room") and ("surgery" or "technique" or "intervention" or "radiology"). All the searched papers were screened and underwent quality evaluation. A total of 30 literature was eventually identified after full-text screening. These articles covered 10 countries and presented data for 15,558 individuals. The median sample size was 536 (range 8-12,804). Application of the hybrid operating room in general surgery, neurosurgery, thoracic surgery, urology, gynaecologic and obstetrics surgery, cardiovascular surgery, was summarized. Four different operative indicators were applied (operative duration, mortality rate, operation success rate and complication rate). A hybrid OR could significantly increase the operation success rate and reduce operative duration, mortality rates, and complication rates. Further efforts could be made to reduce radiation exposure in the hybrid operating room and increase its cost-effectiveness ratio.

Topical Oxygen Jet Therapy (TOJT) for treating infected chronic surgical wounds

OBJECTIVES

To evaluate the effectiveness of Topical Oxygen Jet Therapy (TOJT) in the treatment of surgical wounds in adult patients who has clinical signs of infection for over 30 days; and to identify the pathogens causing complicated skin and soft tissue infections.

METHOD

Parallel, randomized clinical trials randomly divided into "Control Group" (CG) and "Treatment Group" (TG), which were followed up for 10 consecutive days. Venous antibiotics and dressings were used in both groups. In addition, TOJT were used on the wounds in the TG. The outcome criteria were based on clinical indicators: Pressure Ulcer Scale for Healing (PUSH) and Visual Analog Scale Pain (VAS). The paired t-test or Wilcoxon, chi-squared or Fisher's exact test, and Student's t-test or Mann-Whitney tests were used with a significance level of 5%.

RESULTS

73 inpatients were included and followed up: 39 in TG and 34, CG. There were no significant differences in socio-demographic variables or of initial laboratory tests, except for blood glucose that was higher in TG than in CG (p = 0.044). Ten days into treatment, both the area of PUSH wounds (p < 0.001) and the pain scale (p = 0.029) were significantly reduced in TG. Staphylococcus aureus was the most prevalent pathogen (40%) with no significant difference between the two groups.

DISCUSSION

Although the follow-up time was of only ten days, a significant improvement was observed in TG. As a limitation of the study, the small sample size precluded the comparison of S. aureus infections between the two groups.

CONCLUSION

TOJT accelerated the healing process, reduced pain and contributed to an improvement in the clinical status of the wounds when compared to CG. These findings demonstrate the effectiveness and relevance of the employed technique. It can be easily incorporated as a routine procedure in hospitals without extra investment.

Changing behaviour, 'more or less': do implementation and de-implementation interventions include different behaviour change techniques?

BACKGROUND

Decreasing ineffective or harmful healthcare practices (de-implementation) may require different approaches than those used to promote uptake of effective practices (implementation). Few psychological theories differentiate between processes involved in decreasing, versus increasing, behaviour. However, it is unknown whether implementation and de-implementation interventions already use different approaches. We used the behaviour change technique (BCT) taxonomy (version 1) (which includes 93 BCTs organised into 12 groupings) to investigate whether implementation and de-implementation interventions for clinician behaviour change use different BCTs.

METHODS

Intervention descriptions in 181 articles from three systematic reviews in the Cochrane Library were coded for (a) implementation versus de-implementation and (b) intervention content (BCTs) using the BCT taxonomy (v1). BCT frequencies were calculated and compared using Pearson's chi-squared (χ²), Yates' continuity correction and Fisher's exact test, where appropriate. Identified BCTs were ranked according to frequency and rankings for de-implementation versus implementation interventions were compared and described.

RESULTS

Twenty-nine and 25 BCTs were identified in implementation and de-implementation interventions respectively. Feedback on behaviour was identified more frequently in implementation than de-implementation (Χ²(2, n=178) = 15.693, p = .000057). Three BCTs were identified more frequently in de-implementation than implementation: Behaviour substitution (Χ²(2, n=178) = 14.561, p = .0001; Yates' continuity correction); Monitoring of behaviour by others without feedback (Χ²(2, n=178) = 16.187, p = .000057; Yates' continuity correction); and Restructuring social environment (p = .000273; Fisher's 2-sided exact test).

CONCLUSIONS

There were some significant differences between BCTs reported in implementation and de-implementation interventions suggesting that researchers may have implicit theories about different BCTs required for de-implementation and implementation. These findings do not imply that the BCTs identified as targeting implementation or de-implementation are effective, rather simply that they were more frequently used. These findings require replication for a wider range of clinical behaviours. The continued accumulation of additional knowledge and evidence into whether implementation and de-implementation is different will serve to better inform researchers and, subsequently, improve methods for intervention design.

Robotic Complete Mesocolic Excision (CME) is a safe and feasible option for right colonic cancers: short and midterm results from a single-centre experience

BACKGROUND

Complete mesocolic excision (CME) for right colon cancers has traditionally been an open procedure. Surgical adoption of minimal access CME remains limited due to the technical challenges, training gaps and lack of level-1 data for proven benefits. Currently there is limited published data regarding the clinical results with the use of robotic CME surgery. Aim To report our experience, results and techniques, highlighting a clinical and oncological results and midterm oncological outcomes for robotic CME.

AIM

To report our experience, results and techniques, highlighting a clinical and oncological results and midterm oncological outcomes for robotic CME.

METHODS

All patients undergoing standardised robotic CME technique with SMV first approach between January 2015 and September 2019 were included in this retrospective review of a prospectively collected database. Patient demographics, operative data and clinical and oncological outcomes were recorded.

RESULTS

Seventy-seven robotic CME resections for right colonic cancers were performed over a 4-year period. Median operative time was 180 (128-454) min and perioperative blood loss was 10 (10-50) ml. There were 25 patients who had previous abdominal surgery. Median postoperative hospital stay was 5 (3-18) days. There was no conversion to open surgery in this series. Median lymph node count was 30 (10-60). Three (4%) patients had R1 resection. There was one (1%) local recurrence in stage III disease and 4(5%) distal recurrence in stage II and stage III. There was no 30- or 90-day mortality. Three-year disease-free survival was 100%, 91.7% and 92% for stages I, II and III, respectively. Overall survival was 94%.

CONCLUSIONS

Robotic CME is feasible, effective and safe. Good oncological results and improved survival are seen in this cohort of patients with a standardised approach to robotic CME.

A comprehensive review on incredible renewable carriers as promising platforms for enzyme immobilization & thereof strategies

Enzymes are the highly versatile bio-catalysts having the potential for being employed in biotechnological and industrial sectors to catalyze biosynthetic reactions over a commercial point of view. Immobilization of enzymes has improved catalytic properties, retention activities, thermal and storage stabilities as well as reusabilities of enzymes in synthetic environments that have enthralled significant attention over the past few years. Dreadful efforts have been emphasized on the renewable and synthetic supports/composite materials to reserve their inherent characteristics such as biocompatibility, non-toxicity, accessibility of numerous reactive sites for profitable immobilization of biological molecules that often serve diverse applications in the pharmaceutical, environmental, and energy sectors. Supports should be endowed with unique physicochemical properties including high specific surface area, hydrophobicity, hydrophilicity, enantioselectivities, multivalent functionalization which professed them as competent carriers for enzyme immobilization. Organic, inorganic, and nano-based platforms are more potent, stable, highly recovered even after used for continuous catalytic processes, broadly renders the enzymes to get efficiently immobilized to develop an inherent bio-catalytic system that displays higher activities as compared to free-counter parts. This review highlights the recent advances or developments on renewable and synthetic matrices that are utilized for the immobilization of enzymes to deliver emerging applications around the globe.

Approaches combining methods of Operational Research with Business Process Model and Notation: A systematic review

BACKGROUND

Business process modelling is increasingly used not only by the companies' management but also by scientists dealing with process models. Process modeling is seldom done without decision-making nodes, which is why operational research methods are increasingly included in the process analyses.

OBJECTIVE

This systematic literature review aimed to provide a detailed and comprehensive description of the relevant aspects of used operational research techniques in Business Process Model and Notation (BPMN) model.

METHODS

The Web Of Science of Clarivate Analytics was searched for 128 studies of that used operation research techniques and business process model and notation, published in English between 1 January 2004 and 18 May 2020. The inclusion criteria were as follows: Use of Operational Research methods in conjunction with the BPMN, and is available in full-text format. Articles were not excluded based on methodological quality. The background information of the included studies, as well as specific information on the used approaches, were extracted.

RESULTS

In this research, thirty-six studies were included and considered. A total of 11 specific methods falling into the field of Operations Research have been identified, and their use in connection with the process model was described.

CONCLUSION

Operational research methods are a useful complement to BPMN process analysis. It serves not only to analyze the probability of the process, its economic and personnel demands but also for process reengineering.

Lights and colours: Science, Techniques and Surveillance for the Future - 4th IC3EM 2020, Caparica, Portugal

•Special Issue on 4th IC³EM 2020.•Science, Techniques, Surveillance.•The importance of Science.•Fluorescent dyes.

Surgical treatment of symmastia: A systematic review of techniques, outcomes and complications

BACKGROUND

The term "symmastia" defines a confluence across the mid-sternal line of the breast mounds and subsequent loss of adhesion between sternum and pre-sternal skin. This condition can be congenital or, more frequently, iatrogenic. Despite the number of different treatments published in literature, no systematic review or surgical techniques classification has been attempted in literature. There is, therefore, a concrete need to elucidate surgical options and propose a treatment algorithm, improving surgical practice and patient's care.

OBJECTIVE

This systematic review aims to collect and evaluate the published evidence on surgical procedures to correct symmastia deformities (both congenital and acquired) in order to clearly overview possible treatments and outcomes related to this surgery, providing a surgical classification guide as well.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, PubMed database was queried for papers describing symmastia surgical treatment, along with operative indications, outcomes, and complications.

RESULTS

In this review, 23 articles and 118 patients were finally included. Four main categories of treatment were identified: dermo-sternal adhesions, capsulorrhaphy, neopocket creation, and muscle repair. Symmastia correction was achieved and satisfactory in 108 of patients, despite varying techniques. Globally, recurrence was the most frequent complication, reported in the 8.5% of cases.

CONCLUSION

Symmastia represent a difficult condition to treat and recurrence is a common problem. Because of the low number of patients involved in the studies, it is difficult to make conclusions as to the superiority of one technique over another. However, this review, collecting comprehensively for the first time the surgical knowledge over this topic, could guide the surgeon to choose the best surgical treatment based on nowadays evidence.

Spinal Tumor Ablation: Indications, Techniques, and Clinical Management

Percutaneous thermal ablation has proven to be safe and effective in the management of patients with spinal tumors. Such treatment is currently proposed following the decision of a multidisciplinary tumor board to patients with small painful benign tumors such as osteoid osteoma or osteoblastoma, as well as carefully selected patients presenting with spinal metastases. In both scenarios, in order to provide a clinically effective procedure, ablation is often tailored to the specific patients' clinical needs and features of the target tumor. In this review, we present the most common clinical contexts in which spine ablation may be proposed. We scrutinize technical aspects and challenges that may be encountered during the procedure, as well as offering insight on follow-up and expected outcomes.

Left Main Coronary Interventions: A Practical Guide

Coronary artery bypass surgery has been the accepted treatment for left main coronary artery disease for over 50 years. Balloon angioplasty was later used then abandoned because of deaths likely due to restenosis or thrombotic occlusion. However, rapid innovations in drug-eluting stent designs leading to more biocompatible thin strut platforms with optimal drug elution profiles and further advances in modern pharmacotherapy involving potent P2Y₁₂ inhibitors combined with utilization of intracoronary imaging and physiologic assessment for procedural planning and optimization have transformed percutaneous interventions into successful alternatives to coronary artery bypass graft surgery (CABG) in selected LM anatomic territories. Herein, we provide an evidence-based practical guide on how to approach and perform LM percutaneous interventions (PCI).

Shoulder MR Imaging and MR Arthrography Techniques: New Advances

MR imaging is the standard diagnostic modality that provides a comprehensive and accurate assessment for both osseous and soft-tissue pathologic conditions of the shoulder. This article discusses standard MR imaging and arthrography protocols used routinely in clinical practice, as well as more innovative sequences and reconstruction techniques, facilitated by the increasing availability of high-field-strength magnets and multichannel phased array surface coils and incorporation of artificial intelligence. These exciting innovations allow for a more detailed and diagnostic imaging assessment, improvements in image quality, and more rapid image acquisition.

Complexities of spine surgery in obese patient populations: a narrative review

The obese population is particularly challenging to the spine surgeon in all phases of care. A narrative literature review was performed to review difficulties in spine surgery on the obese patient population and techniques for mitigation. We specifically aimed to assess several topics with regard to this population: patient selection and preoperative care; intraoperative and surgical techniques; and postoperative care, outcomes, and complications. The literature review demonstrated that obese patients are at increased surgical risk with spine surgery due to a variety of factors at all stages of intervention. Preoperatively, obese patients have worse outcomes with physical therapy and present technical difficulties for injections. Transport to a hospital, imaging, resuscitation, and intubation are all challenged by increased body habitus. Intraoperatively, obese patients have increased operative times, blood loss, surgical site infections, and nerve palsies. Patient positioning and intraoperative imaging may be limited. Surgery itself may be technically challenging due to body habitus and minimally invasive techniques are becoming more prevalent in this population. Postoperatively, several studies demonstrate that obese patients have inferior outcomes compared with nonobese counterparts. Patient selection is a key for elective interventions, and appropriate infrastructure aids in the ultimate outcomes for both elective and nonelective surgical treatments. Overall, obese patients present several challenges to the spine surgeon, and certain precautions can be undertaken preoperatively, intraoperatively, and postoperatively to mitigate the associated risks to optimize outcomes.

Evolution of Minimally Invasive Surgery in Hallux Valgus

Minimally invasive (MIS) or percutaneous surgery has evolved rapidly through the development of novel techniques with precise description, correct indications, and the incorporation of modifications of safe and effective techniques described in open surgery. The correct term to describe these procedures should be percutaneous and MIS should be reserved for procedures between percutaneous and open surgery (eg, osteosynthesis). According to results, third-generation techniques are useful, effective, and easier than open procedures. It seems that MIS surgery has an extensive learning curve, and therefore it may be difficult to duplicate the results shown on already-published data.

First national survey of the diagnosis of Helicobacter pylori infection in Clinical Microbiology Laboratories in Spain

INTRODUCTION

The aim of this study was to know, through a national survey, the methods and techniques used for the diagnosis of Helicobacter pylori (Hp) in the different Clinical Microbiology Services/Laboratories in Spain, as well as antibiotic resistance data.

METHODS

The survey requested information about the diagnostic methods performed for Hp detection in Clinical Microbiology laboratories, including serology, stool antigen, culture from gastric biopsies, and PCR. In addition, the performance of antibiotic susceptibility was collected. Data on the number of samples processed in 2016, positivity of each technique and resistance data were requested. The survey was sent by email (October-December 2017) to the heads of 198 Clinical Microbiology Laboratories in Spain.

RESULTS

Overall, 51 centers from 29 regions answered the survey and 48/51 provided Hp microbiological diagnostic testing. Concerning the microbiological methods used to diagnose Hp infection, the culture of gastric biopsies was the most frequent (37/48), followed by stool antigen detection (35/48), serology (19/48) and biopsy PCR (5/48). Regarding antibiotic resistance, high resistance rates were observed, especially in metronidazole and clarithromycin (over 33%).

CONCLUSION

Culture of gastric biopsies was the most frequent method for detection of Hp, but the immunochromatographic stool antigen test was the one with which the largest number of samples were analyzed. Nowadays, in Spain, it concerns the problem of increased antibiotic resistance to 'first-line' antibiotics.

Experimental and Simulation Efforts in the Astrobiological Exploration of Exooceans

The icy satellites of Jupiter and Saturn are perhaps the most promising places in the Solar System regarding habitability. However, the potential habitable environments are hidden underneath km-thick ice shells. The discovery of Enceladus' plume by the Cassini mission has provided vital clues in our understanding of the processes occurring within the interior of exooceans. To interpret these data and to help configure instruments for future missions, controlled laboratory experiments and simulations are needed. This review aims to bring together studies and experimental designs from various scientific fields currently investigating the icy moons, including planetary sciences, chemistry, (micro-)biology, geology, glaciology, etc. This chapter provides an overview of successful in situ, in silico, and in vitro experiments, which explore different regions of interest on icy moons, i.e. a potential plume, surface, icy shell, water and brines, hydrothermal vents, and the rocky core.

Interaction of Copper-Based Nanoparticles to Soil, Terrestrial, and Aquatic Systems: Critical Review of the State of the Science and Future Perspectives

In the past two decades, increased production and usage of metallic nanoparticles (NPs) have inevitably increased their discharge into the different compartments of the environment, which ultimately paved the way for their uptake and accumulation in various trophic levels of the food chain. Due to these issues, several questions have been raised on the usage of NPs in everyday life and have become a matter of public health concern. Among the metallic NPs, Cu-based NPs have gained popularity due to their cost-effectiveness and multifarious promising uses. Several studies in the past represented the phytotoxicity of Cu-based NPs on plants. However, comprehensive knowledge is still lacking. Additionally, the impact of Cu-based NPs on soil organisms such as agriculturally important microbes, fungi, mycorrhiza, nematode, and earthworms is poorly studied. This review article critically analyses the literature data to achieve a more comprehensive knowledge on the toxicological profile of Cu-based NPs and increase our understanding of the effects of Cu-based NPs on aquatic and terrestrial plants as well as on soil microbial communities. The underlying mechanism of biotransformation of Cu-based NPs and the process of their penetration into plants have also been discussed herein. Overall, this review could provide valuable information to design rules and regulations for the safe disposal of Cu-based NPs into a sustainable environment.

Optimized Training in the Use of Endoscopic Closure Devices

Successful closure of gastrointestinal defects is one of the most important goals for therapeutic endoscopy. Historically, surgical repair was the mainstay of treatment for any gastrointestinal defect; however, surgery is associated with high morbidity and mortality. Endoscopic management of gastrointestinal defects has developed rapidly in recent years and has become more effective, reducing the morbidity and mortality rates, and avoiding surgical interventions. Appropriate use of endoscopic techniques requires extensive knowledge of the devices and their advantages and limitations during practical applications.

Pulsed and Fractionated Techniques for Helium Plasma Energy Skin Resurfacing

Energy-based skin rejuvenation has, like other forms of aesthetic treatments, the capability of achieving desirable end results. These end results must be balanced with the degree and duration of morbidity, which affect recovery from treatment. Renuvion skin resurfacing protocols include a free hand approach and we describe our preferred approach of pulsing and fractionating the helium plasma resurfacing energy.

Strategies for measuring airway mucus and mucins

Mucus secretion and mucociliary transport are essential defense mechanisms of the airways. Deviations in mucus composition and secretion can impede mucociliary transport and elicit airway obstruction. As such, mucus abnormalities are hallmark features of many respiratory diseases, including asthma, cystic fibrosis and chronic obstructive pulmonary disease (COPD). Studying mucus composition and its physical properties has therefore been of significant interest both clinically and scientifically. Yet, measuring mucus production, output, composition and transport presents several challenges. Here we summarize and discuss the advantages and limitations of several techniques from five broadly characterized strategies used to measure mucus secretion, composition and mucociliary transport, with an emphasis on the gel-forming mucins. Further, we summarize advances in the field, as well as suggest potential areas of improvement moving forward.

A novel, rapid, and low cost method for preparing tissues with metallic stents for routine histology

BACKGROUND

Coronary artery stenting has become a common procedure and cardiovascular pathology specimens containing these metallic stents are accordingly becoming common. Histologic examination of stented vessels is imperative, but special techniques are needed due to the presence of metal within the tissue. We describe a rapid and inexpensive method for preparing stented vascular specimens for routine histology suitable for use in almost any histology laboratory.

DESIGN

After formalin fixation and decalcification, stented vascular segments were freeze-embedded and sectioned using a handheld power micro cutoff wheel tool into ~1 mm slices. Sections were allowed to thaw and the strut shards removed with fine forceps. No longer containing metal, the sections were processed for routine paraffin embedding, microtomy and staining.

RESULTS

Histologic sections showed only minor tissue disruption around the stent struts. In our experience with 25 stented arteries (mean interval from implantation 5.6 years), the mean subjective section quality score was 4.1 out of 5. The position of each strut could easily be determined, along with neointimal in-stent restenosis and thrombosis. Local reaction to each strut could be surmised even if minor tissue disruption occurred. The entire process was completed in 2-3 days. The incremental cost over that of routine histology is nominal.

CONCLUSION

This method for examining stented vascular segments histologically could readily be applied in most pathology laboratories and serves as a highly practical solution to dilemma of examining stents histologically.

Giant pedunculated oesophageal liposarcomas: A review of literature and resection techniques

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Giant oesophageal liposarcomas, a rare but important cause of oesophageal tumours.

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A review of the current literature focusing on resection techniques.

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Shift in the treatment paradigm in recent years to endoscopic resection techniques.

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Decision on type of resection technique depends on tumour characteristics and location.

Introduction and presentation of case

Liposarcomas are rare causes of oesophageal tumours, accounting for <1% of tumours. We present a case of a dedifferentiated oesophageal liposarcoma arising from a giant fibrovascular polyp for which resection was performed via a left cervical oesophagostomy with transgastric retrieval of tumour. We also review the existing literature focusing on discussion of resection techniques.

Discussion

To date, 62 cases of oesophageal liposarcoma have been reported in the literature. They usually occur in males (74.2%), with a median age of 66 years (range 38–84 years). Such tumours present most commonly with dysphagia (69.4%); usually arise from the cervical oesophagus (79%), and are well-differentiated. Treatment options include surgery and recently, endoscopic resection techniques such as submucosal dissection (ESD).

Conclusion

Giant oesophageal liposarcomas are very rare tumours. Such tumours are usually polypoid, arising from a pedicle. As such, resection techniques have shifted away from oesophagectomy to less invasive means such as endoscopic resection or oesophagostomy. Decision on type of resection technique depends on tumour characteristics and location; with the guiding principle being resection with clear margins in order to prevent local recurrence.

Better clinical and post mortem photography: A crash course in ten technical tips

For forensic clinicians and pathologists, photography of bodily regions, injuries and skin lesions present a number of technical challenges including proper framing, avoidance of distortion, choice of background and inclusion of a properly orientated scale. Photography of internal organs at autopsy presents further difficulties with regard to correct exposure, light reflections and limited depth of field. Situations commonly arise in clinical forensic and autopsy practice which require photographic documentation but which may not warrant calling upon the clinical photographer or police Scenes of Crime Officer. This article provides a brief explanation of various technical considerations which will allow forensic practitioners and technicians to take their own high quality external and internal photographs. Technical aspects discussed include aperture, shutter speed, ISO, depth of field, camera shake, and use of flash, scales, focal planes and backgrounds. The possible pitfalls encountered in several common photographic situations are illustrated and discussed, together with suggested workarounds and camera settings. Whilst the photographic examples presented here mostly relate to autopsy practice, the general principles and technical discussion also apply to wider clinical forensic photography practice.

Enacting Homebirth Bodies: Midwifery Techniques in Germany

Building on insights from science and technology studies-inspired anthropological research on reproduction, this paper uses a praxiographic approach to analyze homebirth midwifery practices in Germany. I show that such practices are syncretic, and that techniques of routinizing and multiplying obstetrical interventions are combined in more or less coherent ways to configure pregnancies and births as physical, emotional, and social becomings. In the process of attending, homebirth bodies learn to co-respond to each other, to the midwifery techniques, and to the homebirth environment. Understanding how and with which aims midwives and women invest in those longterm engagements specific to homebirth surroundings may inform clinical practices.

Identification of a unique VUV photoabsorption band of carbonic acid for its identification in radiation and thermally processed water-carbon dioxide ices

Carbonic acid was synthesized within an ice containing water and carbon dioxide by irradiation of ~9 eV photons. Vacuum UltraViolet (VUV)/UltraViolet (UV) photoabsorption spectra of the irradiated ice revealed absorption features from carbon dioxide, ozone, water, carbon monoxide and oxygen in addition to a band peaking at ~200 nm which is identified to be characteristic of carbonic acid. After thermal processing of the irradiated ice leading to desorption of the lower volatile ices, a pure carbonic acid spectrum is identified starting from 170 K until sublimation above 230 K. Therefore the ~200 nm band in the VUV region corresponding to carbonic acid is proposed to be a unique identifier in mixed ices, rich in water and carbon dioxide typically encountered on planetary and satellite surfaces.

The Use of Navigation in Osteotomies Around the Knee

Osteotomies around the knee for treating osteoarthritis or knee instability are currently well-established procedures. Success of these realignment procedures is based on the accuracy and the reliability of correction angles in the coronal and sagittal alignment. In this context of improving precision and adapting the correction to each patient, navigation is currently being widely used. The rationale for its use is based on understanding the advantages and limitations, technical principles, and potential pitfalls. This article describes these areas and the overall clinical outcomes of this system for knee osteotomies.

Robot-assisted Partial Nephrectomy for Complex (PADUA Score ≥10) Tumors: Techniques and Results from a Multicenter Experience at Four High-volume Centers

BACKGROUND

Robot-assisted partial nephrectomy (RAPN) represents a widely accepted minimally invasive alternative to open and laparoscopic surgery for the treatment of clinically localized renal tumors.

OBJECTIVE

To assess the feasibility of RAPN in a contemporary series of patients with highly complex tumors (PADUA score ≥10) treated at four high-volume robotic surgery institutions.

DESIGN, SETTING, AND PARTICIPANTS

Data from a prospectively maintained multi-institutional database on patients subjected to RAPN between 2010 and 2017 were reviewed. For the scope of this analysis, only patients with highly complex renal tumors, defined as a PADUA score between 10 and 14, were included.

SURGICAL PROCEDURE

RAPN was performed with the da Vinci Si or Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) using novel technologies such as TilePro and near-infrared fluorescence imaging.

MEASUREMENTS

Intraoperative, postoperative, surgical, and oncological outcomes were collected. Predictors of optimal surgical outcomes defined according to the Margin Ischemia and Complications binary system (absence of Clavien-Dindo >2 complications, warm ischemia time [WIT] <20min, and absence of positive surgical margins) were determined using logistic regression models (LRMs).

RESULTS AND LIMITATIONS

Overall, 255 patients with complex renal tumors were included. The mean operative time was 165min and mean WIT was 18.6min. Overall, WIT was longer than 20min in 86 (33.7%) individuals, while a Clavien-Dindo >2 complication and positive surgical margins were observed in 13 (5.1%) and four (out of 211 patients with malignant histotypes; 1.9%) individuals, respectively. Optimal surgical outcomes were achieved in 158 (62.0%) patients. At a median follow-up of 28mo, one (0.4%) local and two (0.8%) distant recurrences of the disease were observed. In multivariable LRMs, extremely complex tumors (PADUA score 12-13) were associated with an increased likelihood of not achieving optimal outcomes (odds ratio: 2.31; p=0.024). Besides tumor complexity, male gender was also associated with a two-fold higher risk of not achieving optimal surgical outcomes (p=0.029).

CONCLUSIONS

In experienced hands, RAPN can be considered as an effective treatment option even in cases of complex renal lesions. However, increasing tumor complexity may affect the surgical outcomes in this highly selected patient population.

PATIENT SUMMARY

We reported our multicentric experience with robot-assisted partial nephrectomy (RAPN) in patients with complex renal tumors. We demonstrated that, in experienced hands, RAPN is a feasible and safe treatment option even in such patients. Novel technologies applied to RAPN may further extend the indications without compromising the outcomes.

A simple method for bone graft insertion during Schatzker II and III plateau fixation

Insertion of bone graft to fill metaphyseal defects and supply subchondral support when fixing Schatzker type II and III tibial plateau fractures can be difficult and tedious. Accurately directing the placement of bone graft through a small entry portal and against gravity can be challenging. Using a modified 3-mL syringe and bone tamps with application of the Seldinger technique can make this tedious task simple and more accurate.Level of evidence V.

Early-Onset Scoliosis: Updated Treatment Techniques and Results

STUDY DESIGN

This is a review of the current literature on early-onset scoliosis (EOS) techniques and treatment written by the Growing Spine Committee of the Scoliosis Research Society.

OBJECTIVES

The Growing Spine Committee of the Scoliosis Research Society sought to update the information available on the definition and treatment of EOS, including new information about existing techniques.

SUMMARY OF BACKGROUND DATA

EOS represents a diverse, heterogeneous, and clinically challenging group of spinal disorders occurring in children under the age of 10. Our understanding of EOS has changed dramatically in the last 15 years, and management of EOS has changed even more rapidly in the last five years.

METHODS

The Growing Spine Committee of the Scoliosis Research Society has embarked upon a review of the most current literature on EOS techniques and treatment.

RESULTS

This white paper provides recent updates on current techniques, including a summary of new modalities, indications, contraindications, and clinical results.

CONCLUSIONS

Although treatment of EOS is still challenging and complicated, the evolution of options and knowledge presents hope for better understanding and management in the future.

LEVEL OF EVIDENCE

Level V.

The Evolution of Selective Dorsal Rhizotomy for the Management of Spasticity

Selective dorsal rhizotomy is a key technique in the surgical management of spasticity in patients with cerebral palsy. The technique evolved from the late 1800s when pioneers like Dana and Abbe performed dorsal rhizotomy in their treatment of refractory pain. These surgeons noted a reduction in muscle tone associated with the operation. When Sherrington then published his Nobel prize-winning work on the corticospinal tract and its role in the neuromuscular system in the 1890s, the course was set for modifying spasticity by aiming surgery at the dorsal roots. This procedure underwent multiple modifications through the next century and today it is, arguably, the most commonly performed operation to treat cerebral palsy children with spasticity. Selective dorsal rhizotomy is a technique that still teaches us a great deal about neurophysiology on a daily basis and it is thanks to the pioneers, described in this article, that we have this tool in our armamentarium.

Surgical Treatment of Chiari Malformation in Adults: Comparison of Surgical Techniques Described in the Literature and Our Experience

This paper has been edited for clarity, correctness and consistency with our house style. Please check it carefully to make sure the intended meaning has been preserved. If the intended meaning has been inadvertently altered by the editing changes, please make any corrections needed.

Cut or Do Not Cut? Assessing Perceptions of Safety During Laparoscopic Cholecystectomy Using Surgical Videos

OBJECTIVE

Bile duct injury remains a serious complication of laparoscopic cholecystectomy despite established criteria for the critical view of safety (CVS). Using surgical videos, we compared surgeons' willingness to divide critical structures based on their assessment of the CVS dissection.

DESIGN

Participants reviewed 20 operative videos lasting 1 minute each, edited at various points of the CVS dissection. Participants stated whether the structures were safe to divide, and if not, what steps they would take to achieve an adequate dissection. Videos were independently scored using a validated scale and categorized as an "adequate" or "inadequate" dissection based on the score. Participants were blinded to CVS score and adequacy. Cohen's kappa statistic was used to evaluate inter-rater agreement and responses were compared by univariate analysis.

SETTING

University of Michigan, Ann Arbor, Michigan. Tertiary care university hospital.

PARTICIPANTS

General surgery residents (n = 13) and faculty (n = 13) at the study institution.

RESULTS

There was minimal agreement on willingness to divide critical structures among all participants (κ = 0.25), among faculty (κ = 0.30), and among residents (κ = 0.21). Participants were more willing to divide critical structures when videos showed an adequate CVS dissection (CVS score ≥ 4) than an inadequate dissection (CVS score ≤ 3) (60.4% vs. 16.3%, p = 0.043). For inadequate dissections, participants most commonly recommended further dissection of the hepatocystic triangle (30.8%). There was no significant difference in the rate of unsafe practices (choosing to divide critical structures for videos with an "inadequate" dissection) between faculty and residents (14.2% vs. 18.3%, p = 0.781).

CONCLUSIONS

There was minimal agreement on what constituted a safe CVS dissection and there was no difference in the rate of unsafe practices between trainees and faculty. Education may play a more important role than experience when building a culture of safety for laparoscopic cholecystectomy.

Chronic Total Occlusion Interventions: Update on Current Tips and Tricks

PURPOSE OF REVIEW

To summarize novel techniques and developments in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

RECENT FINDINGS

Using an algorithmic, step-by-step approach can help overcome several complex CTO lesions subsets, such as proximal cap ambiguity, ostial location, in-stent occlusion, bifurcations, balloon uncrossable and undilatable lesions. Similarly, an algorithmic approach can help prevent and optimally treat CTO PCI-related complication, such as perforation, radiation, and contrast-induced nephropathy. Continual update and reassessment of each operator's algorithm for performing CTO PCI can lead to improved outcomes.

[Pilon fractures-considerations for treatment strategies and surgical approaches]

The majority of pilon or tibial plafond fractures are complex articular fractures and the treatment strategy, including the choice of the ideal surgical approach, is essential for a good functional outcome. In this paper, we discuss the considerations for dealing with such fractures as well as the pro and cons of the different approaches. The standard protocol consists of a two-staged procedure following the slogan span-scan-plan. After applying an ankle-spanning external fixator (span), the diagnostic work-up is completed by a CT scan with axial views, two-dimensional and three-dimensional reconstruction (scan) to fully understand the fracture pattern. Using this information, in coordination with the soft tissue situation, the ideal approaches, type and position of implants are planned in detail. This article, supported by clinical cases, describes different surgical approaches and the areas of interest which can be seen through these approaches as well as the implant position.

[Clinical and morphological indications for delayed breast reconstruction]

A full range of breast reconstructions procedures exists and had to be proposed within a surgical team, from the simplest to the most complex. The choice of the technique is simply based on the discussion between the surgeon and the patient during a consultation. A computed tomographic angiography might be required in the case of DIEP flap reconstruction. The surgeon bases his decision on a clinical exam of the breast area, the quality of the tissues and looks for potential flaps or fat donor sites. The patient expresses her expectations in terms of breast volume, form and is clearly informed about potential risks and follow-up. Thus the surgeon could propose the most adequate procedure in the case of the patient, who will take the final decision. The surgeon should ensure to find the most adapted procedure to each individual. A well-determined indication will lead to a truly satisfied patient, which is the main goal of breast reconstruction. We decided to present this dialogue and the path towards the final choice in a fun and original format.