Robotic-Assisted Anastomosis in Orthoplastic Surgery: Preliminary Data

BACKGROUND

The evolution of microsurgery has relied on advancements in operating microscopes and surgical instruments. Pioneering advancements, however, especially within the domain of "super-microsurgery", challenge the limits of human dexterity by dealing with anastomoses between vessels smaller than 0.8 mm. Based on these premises, the Symani robotic system was designed and developed. This platform utilizes teleoperation and motion-scaled movement to provide surgeons with precision and accuracy in manipulating millimetre and submillimetre-sized anatomical structures. In this study, we present our experience in performing robotic-assisted anastomoses using the Symani Surgical System in free flap reconstruction.

METHODS

We present a comprehensive analysis of all reconstructive procedures involving microsurgical free flaps performed using the Symani robotic platform at the orthoplastic unit of the Rizzoli Orthopaedic Institute from 1 October 2022 to 1 May 2023.

RESULTS

Sixteen microsurgical reconstructions using free flaps were performed, involving a total of 40 anastomoses on vessel calibres ranging from 0.6 mm to 2.5 mm. In each case, the anastomosis was executed with the assistance of the robotic platform, achieving a 100+% success rate in patent anastomoses, and no major complications occurred.Conclusion The Symani system has proven to be safe and reliable in performing microsurgical anastomoses. While this platform demonstrated successful in various vessel calibres, its most promising potential lies in anastomoses below the size of a millimetre. Larger patient cohorts and extended investigation periods will be essential to explore whether robotics in microsurgery offers advantages across all microsurgical procedures or should be reserved for selected cases.

Rhino-oropharingeal osteoradionecrotic soft-tissue and bony defect reconstruction with submental artery island flap: a case report

BACKGROUND

The submental artery island flap is widely used in head and neck reconstruction, since it is easy and quick to harvest, and it can be successfully used for the coverage of perioral, intraoral and facial defects. We used this technique for the reconstruction of a complex soft-tissue and bony defect of rhino-oropharinx.

CASE REPORT

Osteoradionecrosis of rhino-oropharingeal posterior wall with C2 necrotic body exposure occurred in a 77-year-old woman. After the failure of reconstruction with a Hadad-Bassagasteguy flap, a submental island flap with cervical spine stabilization was planned to be performed in a one-stage operation. The anterior arc of C1 and odontoid process of C2 were removed and, according to the defect size, a submental island flap was designed in an elliptical fashion. The flap was rotated 180° and tunnelized under the left parapharingeal-prevertebral space, then it was positioned in the rhino-oropharinx and fixed with reabsorbable sutures. The donor site was closed primarily. No peri- or post-operative complications occurred, neither in the recipient nor in the donor-site. At the latest follow-up, 15 months postoperatively, the patient was able to speak without any impairment and started swallowing rehabilitation with good results and an aesthetically satisfactory outcome.

CONCLUSION

The submental island flap may be a reliable and versatile flap for reconstruction of head and neck defects, even though in the rhino-oropharingeal posterior wall.

Microsurgical robotic system enables the performance of microvascular anastomoses: a randomized in vivo preclinical trial

Technical advances in microsurgery have enabled complex oncological reconstructions by performing free tissue transfers, nerve and lymphatic reconstructions. However, the manual abilities required to perform microsurgery can be affected by human fatigue and physiological tremor resulting in tissue damage and compromised outcomes. Robotic assistance has the potential to overcome issues of manual microsurgery by improving clinical value and anastomoses' outcomes. The Symani Surgical System, a robotic platform designed for microsurgery, was used in this in-vivo preclinical study using a rat animal model. The tests included anastomoses on veins and arteries performed by microsurgeons manually and robotically, with the latter approach using Symani. The anastomoses were assessed for patency, histopathology, and execution time. Patency results confirmed that the robotic and manual techniques for venous and arterial anastomoses were equivalent after anastomosis, however, the time to perform the anastomosis was longer with the use of the robot (p < 0.0001). Histological analysis showed less total average host reaction score at the anastomotic site in robotic anastomosis for both veins and arteries. This study demonstrates the equivalence of vessel patency after microsurgical anastomoses with the robotic system and with manual technique. Furthermore, robotic anastomosis has proven to be slightly superior to manual anastomosis in terms of decreased tissue damage, as shown by histological analysis.

First-in-Human Free Flap Tissue Reconstruction Using a Dedicated Microsurgical Robotic Platform

BACKGROUND

Microsurgery has become standard of care for increasingly complex techniques in tissue harvest, replantation, reconstruction, allotransplantation, and supermicrosurgery on submillimetric vessels. As techniques become more challenging and are performed at smaller and smaller scale, there is greater potential application for robotic assistance in extreme motion scaling and tremor reduction.

METHODS

The Symani Surgical System (Medical Microinstruments, S.p.A, Calci, Pisa, Italy), a robotic platform designed for microsurgery, was used in a robot-assisted microsurgical free flap reconstruction using a perforator-to-perforator flap technique. This procedure utilized robot-assisted anastomosis of an artery and vein.

RESULTS

The procedure was completed successfully, with vessels fully patent immediately following and 20 minutes after anastomosis. The flap was viable, no re-exploration of the anastomosis was necessary postoperatively, and no flap loss occurred.

CONCLUSIONS

This novel, dedicated robotic platform with wristed microsurgical instruments was shown to be feasible for carrying out robot-assisted anastomosis of veins and arteries less than 0.8 mm in diameter, in the domain of supermicrosurgery. The system has the potential to open the field of microsurgery to new clinicians and to facilitate new microsurgical applications that were previously rendered inaccessible by the limits of manual precision and physiological tremor.

New Robotic System with Wristed Microinstruments Allows Precise Reconstructive Microsurgery: Preclinical Study

BACKGROUND

Microsurgery allows complex reconstruction of tissue defects after oncological resections or severe trauma. Performing these procedures may be limited by human tremor, precision, and manual dexterity. A new robot designed specifically for microsurgery with wristed microinstruments and motion scaling may reduce human tremor and thus enhance precision. This randomized controlled preclinical trial investigated whether this new robotic system can successfully perform microsurgical needle driving, suturing, and anastomosis.

METHODS

Expert microsurgeons and novices completed six needle passage exercises and performed six anastomoses by hand and six with the new robot. Experienced microsurgeons blindly assessed the quality of the procedures. Precision in microneedle driving and stitch placement was assessed by calculating suturing distances and angulation. Performance of microsurgical anastomoses was assessed by time, learning curves, and the Anastomosis Lapse Index score for objective performance assessment.

RESULTS

Refined precision in suturing was achieved with the robot when compared with the manual technique regarding suture distances (p = 0.02) and angulation (p < 0.01). The time required to perform microsurgical anastomoses was longer with the robot, however, both expert and novice microsurgeons reduced times with practice. The objective evaluation of the anastomoses performed by novices showed better results with the robot.

CONCLUSIONS

This study demonstrated the feasibility of performing precise microsutures and anastomoses using a new robotic system. Compared to standard manual techniques, robotic procedures were longer in time, but showed greater precision.

Reconstruction after complete mandibular avulsion with double-paddle fibular free flap. A case report

Reconstruction after maxillofacial trauma is extremely challenging. During the past several decades, the chimeric fibular-free flap has emerged as a leading reconstructive option for head and neck compound defects. This report describes a unique case of total mandibular reconstruction using a double-paddle osteocutaneous fibular free flap after facial traumatic injury. A 45-year-old man presented a severe maxillofacial trauma with complete mandibular avulsion. The shortest segment of a 24-cm fibular flap was used to reconstruct the symphysis while the longest segments were placed to rebuild the mandibular body. Microvascular anastomoses were performed with the external jugular vein and facial artery. The distal skin island (10 × 5 cm) was sutured to cover the endo-oral defect while the proximal one (12 × 6 cm) to restore the external tissues continuity of the facial lower third. The postoperative course was uneventful. One year after flap reconstruction, a first commissuroplasty was performed. After 3 months, secondary commissuroplasty was performed with an Estlander flap to rebuild the right lower lip. At latest follow-up, 60 months postoperatively, the patient was able to tolerate soft diet with maximal mouth opening of more than 4 cm; no impairment to mastication, deglutition, or phonation was observed. Speech was normal and the aesthetic outcome was judged good. Double-paddle fibular free flap allows reconstruction of extremely challenging defects, such in case of complete mandibular avulsion. The proximal perforator can provide extended soft-tissue coverage and greater volume than traditional osteocutaneous flaps, avoiding two flaps simultaneous harvest.

Pelvic ring reconstruction with double-barreled fibular free flap: A systematic review

INTRODUCTION

Pelvic ring reconstruction after internal hemipelvectomy is an extremely challenging surgical procedure, and mandatory reconstruction is to provide a durable and pain-free functional outcome, especially for young, active patients. One of the most widely employed techniques is reconstruction with a double-barreled fibular free flap (DBF). The aim of our work was an in-depth analysis of the outcome of pelvic ring reconstruction performed using the above-mentioned method, in particular looking for a correlation between the fixation technique and either ambulation status or complications.

MATERIALS AND METHODS

A systematic review was performed in November 2020 using PubMed and MedLine Ovid databases according to the PRISMA guidelines and the results were statistically analyzed.

RESULTS

Studies were published between 1994 and 2015. A DBF was used in each case, with a total of 30 patients. Reconstruction was performed with screws in 13 cases, Cotrel-Dubousset rod fixation in 6, screws and plate in 5, screws with external fixation in 4, and ISOLA in 2. Follow-up time ranged from 3 to 131 months. Functional outcome was excellent in 4 patients and good in 26 patients. Statistical analysis showed no statistical evidence of existing correlation between fixation technique and complications (p = .873), while statistical correlation between age and fixation technique was found (p < .001).

CONCLUSION

Reconstruction of pelvic ring with DBF provides an overall good functional outcome. Our data indicate that there is no statistical evidence of existing correlation between the fixation technique and either complications or ambulation status.

Six-years experience in major scalp defect reconstruction with free flap: analysis of the results

Introduction The purposes of this study were to report 10-years experiences in microsurgical reconstruction of major scalp defects, comparing outcomes, evaluating complications.  Materials and methods From November to July 2015, 10 consecutive patients underwent microsurgical procedures for severe scalp defects. Results The average age was 55,1 years ranging from 6 to 87 years. The mean follow-up was 16.7 months ranging from 12 to 24 months. The size of the lesions ranged from 9x10 to 16x20cm. The average hospital stay was 20 days ranging from 8 to 43 days. Mean operative times was 5.3 h ranging from 5 to 6.45 h. Free flaps included 8 Latissimus Dorsi flaps (LD) and 2 anterolateral thigh flaps (ALT). The superficial temporal vessels were used as recipient vessels in 9 cases while the superior Thyroid artery was used in remaining case. Discussion For large or complex lesions, the use of free flaps is mandatory. Nowadays LD and ALT flaps are among the most common reconstructive choices for scalp defects reconstructions. Older age does not contraindicate the operation procedure nevertheless in younger patients the size of vessels is proportionately larger and pristine.   Conclusion Microvascular free tissue transfer is the mainstay of scalp defects coverage. In our series early complications are less common and concerning than late complications and in fact reoperations are mainly required to manage these latter. Advanced age should be not consider a contraindication for free flap surgery and the procedure can be considered safe and reliable in both old and young population.

Free perforator flaps vs propeller flaps in lower limb reconstruction: A cost/effectiveness analysis on a series of 179 cases

PURPOSE

The aim of this report is to compare free perforator flaps and propeller flaps in the coverage of lower limb soft tissue defects.

PATIENTS AND METHODS

179 patients (age between 5 and 92 years old), underwent soft tissue reconstruction of the lower limb between January 2009 and January 2015, either by free flap or propeller flap. The two groups were retrospectively evaluated in order to assess the outcome, complications and potential risk factors. Correlations between risk factors and presence/absence of failure or complications have been evaluated with descriptive statistical analysis and a set of logistic regression models. Finally, an economic analysis was conducted to evaluate the different tecniques.

RESULTS

In a simple descriptive statistical analysis, the overall failure rate is 6% for free flaps and 3.7% for propeller flaps; the complication rates are 14% vs 21.5% and it increases as dimension increases. The logistic models relating failure and complications with potential risk factors do not show significant differences, whereas the economic analysis show that the average expense of free flaps is 5077.5€ per patient, 1595.6€ per patient for propeller flaps.

CONCLUSIONS

Our results do not demonstrate significant differences between the two groups about correlation of risk factors or flap size with complication or failure. The surgical option choice should be taken only after accurate evaluation of the soft tissue surrounding the defect. Propeller flaps should be preferred in case of small/medium size defects in otherwise healthy extremities. Free perforator flaps should be the choice in large defects due to trauma or vascular diseases. The economic analysis suggests that propeller flap should be considered when possible.

Extensor hallucis longus tendon and soft-tissue reconstruction with palmaris longus tendon included in a radial forearm free flap: A case report

Reconstruction of foot structures is challenging because of the need to restore both anatomy and function. Extensor hallucis longus (EHL) excision without reconstruction could result in a flexion deformity of the toe at the interphalangeal joint. In this report, we present a case of the use of a palmaris longus tendon included in a fasciocutaneous radial forearm free flap to reconstruct EHL tendon and soft tissues of the distal foot dorsum. A 41-year-old woman presented with a recurrence of myxoinflammatory fibroblastic sarcoma on the medial part of the left foot dorsum. The EHL tendon was sacrificed, leaving a soft-tissue defect of 14 × 5 cm and 14-cm tendon gap. A 14 × 5 cm radial forearm flap with a 16-cm section of palmaris longus tendon was harvested from the left forearm. Radial artery and its comitant vein were anastomosed with dorsalis pedis artery and vein. EHL tendon repair was performed from the composite mass to the proximal and distal stumps. No complication in the postoperative period occurred. At latest follow-up, 12 months postoperatively, the patient showed a normal joint function and was satisfied with the treatment. Palmaris longus tendon included in a radial forearm free flap could be recommended for combined soft tissue and tendon defects, particularly on the foot dorsum.

Long-Term Functional Outcome After Surgical Treatment of Peroneal Intraneural Ganglion Cyst

BACKGROUND

Intraneural ganglia are benign mucinous cystic formations that originate within the epineurium of peripheral nerves. Different treatments have been recommended, with an overall satisfactory outcome. In this paper, we aim to evaluate the long-term outcomes of surgical treatment of peroneal intraneural ganglia by reviewing our local institutional experience.

METHODS

We performed a case series review of peroneal intraneural ganglia surgical treatment performed by the senior author. Demographic and surgical details were abstracted from the medical record for each patient. Electrodiagnostic studies and magnetic resonance imaging (MRI) were performed in all patients pre- and postoperatively.

RESULTS

Eight men were enrolled, with an average age at time of surgery of 47.5 years (range 28-68 years). Motor testing revealed a preoperative deficit of dorsiflexion, eversion, and toe extension in 7 patients, with a median preoperative Medical Research Council (MRC) score of 0/5. Sensory loss in the distribution of the common peroneal nerve was present in 7 patients. Mean clinical follow-up time was 113 months (range 32-189 months). Significant pain relief was achieved in all patients. Overall neurologic function was improved, more so for motor function. The median postoperative dorsiflexion, eversion, and toe extension at last follow-up were MRC score of 5/5. No complications occurred postoperatively. There was no clinical evidence of intraneural recurrence, as confirmed in postoperative MRI. In 2 patients, an extraneural cystic formation was visible in the anterior muscular compartment.

CONCLUSIONS

The data from our series support excellent long-term postoperative motor outcomes with a low recurrence rate. To avoid extraneural recurrence, resection of the superior tibiofibular joint is necessary.

Calcaneal reconstruction after total calcanectomy with iliac crest free flap

INTRODUCTION

Calcaneal tumors being a rare occurrence, surgical options and outcomes are not well-known. Extensive defects following wide resection, especially in weight-bearing areas, still remain a challenge and different reconstructive techniques have been proposed. The aim of this report was to analyze the clinical and functional long-term outcomes of heel reconstruction using an iliac crest free flap.

PATIENTS AND METHODS

Four patients who underwent calcaneal reconstruction between 1999 and 2012 were included. Two were females and mean age was 27 years, ranging 18-42 years. Each patient underwent total calcanectomy, for two osteoblastomas, one osteosarcoma, and one Ewing's sarcoma. An iliac crest flap was harvested and shaped to fit the residual space. After the articular cartilage at recipient site was debrided, the flap was fixed to the talus and the cuboid.

RESULTS

The average size of the flaps was 2 x 7 x 5 cm. Postoperatively wound dehiscence, screw breaking, and graft fracture healed conservatively. All the arthrodesis healed successfully and no donor site complication occurred. At an average follow-up of 13 years (range 6-19 years) any patient claimed pain, evident limp or limitation of daily activities. Computerized pedobarographic examination and gait analysis revealed a satisfactory result and an acceptable weight-bearing area in the reconstructed limb in each patient.

CONCLUSIONS

Calcaneal reconstruction with iliac crest free flap is likely to provide good chances of a long-lasting result, especially in young patients. Particularly, it provides the possibility to adequately shape the graft to fit the bone loss while using the crest as the weight-bearing surface.

Short and long-term results of sternectomy for sternal tumours

Background

We analyzed our experience in sternal resections (SRs) for primary or secondary neoplasm focusing on technical aspects of reconstruction, post-operative outcomes and long term survival.

Methods

From January 2005 to December 2015, 36 patients (24 males, 67%) underwent surgical excision of primary (chondrosarcoma n=18 patients, 50%; osteosarcoma n=2, 6%; Ewing sarcoma n=1, 3%; other n=2, 6%) or secondary (breast cancer n=7, 19%; kidney carcinoma n=2, 6%) sternal tumour. We performed n=30 partial sternectomy and n=6 total sternectomy with en-bloc resection of the sternocostal cartilages in all patient and extended resection in 7 patients. Stability was obtained with prosthetic material, rigid and non-rigid and a muscular flap: rigid material [Strasbourg Thoracic Osteosynthesis System (STRATOS), MedXpert GmbH] and muscle flap n=11 (30.6%); polytetrafluoroethylene patch and muscle flap n=6 (16.7%); muscle flap alone n=19 (52.8%).

Results

The 30-day mortality rate was 0, overall complication rate was 19%. The median ICU stay was 1.5 days and mean hospital stay was 10.6±5.9 days. We obtained a complete (R0) resection in all patients. Overall survival (OS) at 5 and 10 years were 59% and 40%; in the group of primary neoplasm OS rate at 5 and 10 years was 79% and 54%. Disease free survival (DFS) rate at 5 years was 61%. Higher grading was identified as negative prognostic factor.

Conclusions

Wide radical resections of anterior chest wall are basilar in a multimodality treatment for primary or metastatic neoplasm of the sternum. Stabilization with titanium bars and clips provides rigidity of chest wall with good functional results.

BAG3 promotes pancreatic ductal adenocarcinoma growth by activating stromal macrophages

The incidence and death rate of pancreatic ductal adenocarcinoma (PDAC) have increased in recent years, therefore the identification of novel targets for treatment is extremely important. Interactions between cancer and stromal cells are critically involved in tumour formation and development of metastasis. Here we report that PDAC cells secrete BAG3, which binds and activates macrophages, inducing their activation and the secretion of PDAC supporting factors. We also identify IFITM-2 as a BAG3 receptor and show that it signals through PI3K and the p38 MAPK pathways. Finally, we show that the use of an anti-BAG3 antibody results in reduced tumour growth and prevents metastasis formation in three different mouse models. In conclusion, we identify a paracrine loop involved in PDAC growth and metastatic spreading, and show that an anti-BAG3 antibody has therapeutic potential.

Abstract 2393: PDAC cells release BAG3 that activates a paracrine loop with stromal macrophages

Interactions between cancer cells and stromal cells are critically involved in tumor formation, progression and development of metastasis. Here we report for the first time that human pancreatic adenocarcinoma (PDAC) cells secrete BAG3 that binds and activates macrophages, inducing their activation and the secretion of pancreatic cancer- supporting factors. We also identify IFITM-2 as a BAG3 receptor, by its co-precipitation with BAG3 from macrophage cell membrane and by impairment of BAG3- induced activation in IFITM-2- silenced macrophages. Finally we show the importance of this pathway in vivo since in nu/nu mice carrying orthotopic xenografts of human PDAC (MIA PaCa-2) cells, BAG3 sequestration by an anti-BAG3 antibody results in reduced tumor growth and prevents metastastasis formation. In conclusion we have identified a novel paracrine loop involved in PDAC growth and metastatic spreading and shown that its pharmacological blockage with an anti-BAG3 antibody has therapeutic potential.

Citation Format: Alessandra Rosati, Anna Basile, Raffaella D'Auria, Morena d'Avenia, Margot De Marco, Antonia Falco, Michelina Festa, Luana Guerriero, Vittoria Iorio, Maria Pascale, Renato Franco, Claudio Arra, Antonio Barbieri, Domenica Rea, Giulio Menichini, Michael Hahne, Marteen Bijlsma, Daniela Barcaroli, David A. Tuveson, Jelena Todoric, Michael Karin, Vincenzo De Laurenzi, Maria Caterina Turco. PDAC cells release BAG3 that activates a paracrine loop with stromal macrophages. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2393. doi:10.1158/1538-7445.AM2015-2393

Applications of natural compounds in the photodynamic therapy of skin cancer

Despite significant advances in early diagnosis and treatment, skin cancer is one of the leading causes of death. Photodynamic therapy (PDT) is a new therapeutic modality that is emerging as an important resource against malignant tumors. This strategy is based on the action of photosensitizers, i.e. of molecules which may accumulate preferentially inside tumor cells where they exert a cytotoxic effect after excitation by light at appropriate wavelengths. Some forms of skin cancers and also some non-tumor pathologies are now treated with PDT. Several compounds with photosensitizing activity have been identified, and some of these molecules are commercially available. Many photoactive principles are natural compounds. Numerous reviews in the last decade have focused on photodynamic therapy, its effects and applications, but less attention has been paid to plant extracts or molecules of natural origin studied for their phototoxic activity to date.This review critically examines the potential role of various plant extracts and naturally occurring compounds in the treatment of skin cancer. Both in vitro and in vivo effects of these agents, together with their known related cellular and molecular mechanisms, are presented and discussed.

Hypericum perforatum L. subsp. perforatum induces inhibition of free radicals and enhanced phototoxicity in human melanoma cells under ultraviolet light

OBJECTIVES

Our interest continues in discovering phytocomplexes from medicinal plants with phototoxic activity against human melanoma cells; thus the aim of the present study was to assess antioxidant, anti-inflammatory and phototoxic activity of Hypericum perforatum L. subsp. perforatum, and relate these properties to the plant's chemical composition.

MATERIALS AND METHODS

Components of H. perforatum subsp. perforatum were extracted by hydroalcoholic solution and chemical profiles of preparations (HyTE-3) performed by HPTLC. Linoleic acid peroxidation and DPPH tests were used to assess antioxidant activity, while MTT assay allowed evaluation of anti-proliferative activity with respect to A375 human melanoma cells after irradiation with UVA dose, 1.8 J/cm(2) . Inhibition of nitric oxide production of macrophages was also investigated.

RESULTS

HyTE-3 indicated better antioxidant activity with β-carotene bleaching test in comparison to DPPH assay (IC50 = 0.89 μg/ml); significant phototoxicity in A375 cells at 78 μg/ml concentration resulted in cell destruction of 50%. HyTE-3 caused significant dose-related inhibition of nitric oxide production in murine monocytic macrophage cell line RAW 264.7 with IC50 value of 342 μg/ml.

CONCLUSIONS

The H. perforatum subsp. perforatum-derived product was able to suppress proliferation of human malignant melanoma A375 cells; extract together with UVA irradiation enhanced phototoxicity. This biological activity of antioxidant effects was combined with inhibition of nitric oxide production.

Evaluation of phototoxic potential of aerial components of the fig tree against human melanoma

OBJECTIVES

To date, Ficus carica L. cultivar Dottato (F. carica) has not been studied from a phototoxic point of view. In the present work, aerial components of F. carica from Italy, were examined to assess their antioxidant and phototoxic activity on human melanoma cells. A relationship between antioxidant, phototoxic activities and chemical composition has also been investigated.

MATERIALS AND METHODS

Coumarin and fatty acid content in F. carica leaves, bark and woody parts were examined and compared by capillary GC and GC/MS. Polyphenolic content was also determined. Linoleic acid peroxidation and DPPH test were used to assess antioxidant activities, and MTT assay was used to evaluate anti-proliferative activity, on C32 human melanoma cells, after irradiation with a UVA dose of 1.08 J/cm(2).

RESULTS

Leaves demonstrated the best antioxidant and anti-proliferative activity in comparison to bark and wood. In particular, leaves were shown to possess the highest anti-radical activity and inhibition of peroxidation, with IC(50) values of 64 and 1.48 μg/ml respectively. The leaves had highest anti-proliferative activity with IC(50) value of 3.92 μg/ml. The phytochemical investigation revealed different composition between the coumarins, psoralen and bergapten, fatty acids, polyphenols and flavonoid content among plant parts.

CONCLUSIONS

Data obtained indicate that this type of fig tree may constitute an excellent source of bioactive compounds, such as phenolics, coumarins and fatty acids. This study offers a new perspective in developing others formulations potentially useful in photodynamic therapy for treatment of non-melanoma skin cancers.

Cachrys pungens Jan inhibits human melanoma cell proliferation through photo-induced cytotoxic activity

OBJECTIVE

To date, plants belonging to the genus Cachrys have not been amply studied. In the present study, aerial components of Cachrys pungens Jan from Italy, were examined to assess their free radical-scavenging and antioxidant activity, and their phototoxicity on A375 melanoma cells. In view of potential pharmaceutical applications, a relationship between antioxidant, phototoxic activities and polyphenolic composition has also been investigated.

MATERIALS AND METHODS

Content of sterols, terpenes, fatty acids and coumarins was assessed by gas chromatography-mass spectrometry and GC. Total phenolic content was also determined. Antioxidant activity of the methanol extract and fractions of C. pungens Jan was assessed using DPPH scavenging assay and β-carotene bleaching test. Plant phototoxicity was also investigated in this human tumour cell line (amelanotic melanoma).

RESULTS

  Analysis of the chloroform extract was particularly interesting, as it led to identification of many coumarins, of which five were linear and one angular furanocoumarins. Methanol and ethyl acetate fractions exhibited substantial antioxidant activity. Moreover, chloroform extract and isolated coumarin fraction had strong phototoxic activity on UVA-induced A375 cells after irradiation at UVA dose of 1.08 J/cm.

CONCLUSIONS

Plant-derived natural compounds are an important source for development of cancer-fighting drugs. This study has demonstrated strong phototoxic activity of the coumarin fraction of C. pungens, a plant which, to our knowledge, has never been studied before. This investigation offers a new perspective for developing other formulations potentially useful in photodynamic therapy for treatment of non-melanoma skin cancers as well as melanomas.

Scrotal calcinosis: a very rare multiple clinical presentation

Scrotal calcinosis (SC) is a rare benign disease that affects patients in childhood or early adulthood. It is characterized by slow-growing yellowish-white nodules consisting of deposits of calcium and phosphates, within the scrotal skin. The nodules vary in number, and can be solitary or grouped. Owing to the age of onset and anatomical location, SC may be a source of embarrassment and lead to social isolation. Because of its rarity, the aetiology of SC is still controversial. We report a very rare case of an SC in a 59-year-old white man who presented with multiple nodules with different clinical patterns in the scrotum, which had been present for > 42 years. Despite the rarity and the multiple long-lasting lesions, surgical excision of the scrotal nodules can offer a very good aesthetic outcome in a single procedure even under local anaesthesia.

Thyroid tissue remnants after "total thyroidectomy"

Total Thyroidectomy (TT) is a gold standard for benign bilateral pathologies and malignant pathologies of the thyroid. TT has numerous advantages over less radical approaches, such as the resolution of the thyroid pathology, avoidance of recurrences, and improved response to life-long substitutive organotherapy. TT has a negligible rate of recurrence. Near Total Thyroidectomy (NTT) is associated with a low rate of recurrence. Subtotal Thyroidectomy (ST), in which a portion of the thyroid gland is deliberately left in the thyroid lodge, has a considerably higher rate of recurrence. The incidence of complications with TT is similar to that with other techniques of thyroid exeresis. However, despite the radical intent of surgeons, a real TT is not always carried out. The complete removal of all the thyroid tissue employing TT is not the norm and micro/macroscopic remnants almost always remain. The literature on these tissue remnants is often based on techniques that are not very accurate in terms of determining the diameters of the tissue remaining. In our study, conducted by colour echo-doppler of the thyroid lodge in 102 patients who had undergone TT for benign thyroid pathologies, we demonstrated significant thyroid tissue remnants after TT in 34 cases of 102 (33,3%). Therefore, out of a total of 102 so-called "total thyroidectomies", only 68 (66,7%) were really total, whereas 12 patients (11,76%) had near total thyroidectomy, leaving tissue remnants < 1 cm, and 22 patients (21,57%) had subtotal thyroidectomy, with tissue remnants > or = 1 cm.

An approach to managing non-melanoma skin cancer of the nose with mucosal invasion: our experience

CONCLUSIONS

The absence of recurrences after final nasal reconstruction demonstrates the reliability of our three-stage strategy and the necessity to delay nasal reconstruction, focusing attention on oncological safety for nasal non-melanoma skin cancer (NMSC) with mucosal invasion.

OBJECTIVES

To validate a therapeutic strategy aimed at oncological safety and minimization of possible recurrences after full-thickness excision of nasal NMSC with mucosal invasion. The strategy was divided into three stages: surgical excision with clinically safe perilesional skin margins and extemporary frozen section histological control; 8-15 months follow-up leaving the nasal defect unreconstructed with a 'wait and see' strategy; new extemporary histological control of defect margins and, if negative, definitive reconstruction.

PATIENTS AND METHODS

Twenty patients affected by nasal NMSC with mucosal invasion were treated and followed up.

RESULTS

Basal cell carcinoma was the most common lesion (75%), followed by squamous cell carcinoma (25%). Ultrasonography excluded lymphatic involvement for SCC. Before final reconstruction, extemporary histological examination revealed the presence of tumour cells in three patients. After tumour extirpation, these patients were resubmitted to a new follow-up period before reconstruction. No recurrences were observed after definitive nasal reconstruction in all patients during the 5-year follow-up.

Nonsurgical tightening of skin laxity: a new radiofrequency approach

BACKGROUND

Improvement in skin laxity can be difficult to achieve without invasive surgical procedures. Monopolar radiofrequency (RF) treatment is used by physicians to heat skin and promote tissue tightening and contouring. RF technology produces an electric current that generates heat through resistance in the dermis and subcutaneous tissue. The thermal effect depends on the conductivity features of the treated tissue. When heated, collagen fibrils will denature and contract, which is believed to lead to the observed tissue tightening.

METHODS

Ninety-three consecutive patients with mild to moderate laxity were included in the study. The Surgitron Dual Frequency RF (Radiowave technology, Ellman International) was used to treat skin laxity. The application of RF energy took place in an ambulatory setting with no need for skin sterilization or anesthesia.

RESULTS

Patients immediately noticed a microlifting retraction in the treated tissues according to the vectors mapped in the area. There were no significant complications and the majority of patients were satisfied with the procedure and able to return to their daily routine after leaving the office, thereby substantiating the popularity of noninvasive rejuvenating procedures.

[Risk factors for cardiovascular diseases: what is the role for homocysteine?]

Cardiovascular diseases are commonly related to classical risk factors, but other risk markers have been identified, including homocysteine. Homocysteine is a sulphurated amino acid which derives from methionine. The causes of hyperhomocysteinemia are multifactorial, such as genetic defects, pathophysiological conditions, lifestyle and drugs-related. Hyperhomocysteinemia favors atherothrombosis through endothelial dysfunction, enhancement of inflammation and thrombophilic profile. A number of clinical and laboratory trials exist regarding the association between homocysteine levels and an increased risk of cardiovascular disease. However, the lack of homogeneity in the data, together with the high number of factors capable of influencing homocysteine plasma levels, and the disappointing results of therapeutic trials do not permit us at present to consider homocysteine as an independent and major risk factor for cardiovascular disease.

Is color-Doppler US a reliable method in the follow-up of transjugular intrahepatic portosystemic shunt (TIPS)?

Transjugular intrahepatic portosystemic shunt (TIPS) has become a widely accepted treatment for complications of portal hypertension. Shunt or hepatic vein stenoses or occlusions are common short- and mid-term complications of the procedure, with a one-year primary patency ranging from 25% to 66%. When promptly identified, shunt stenosis or occlusion may be treated before the recurrence of gastrointestinal bleeding or ascites. The revision is usually successful and the primary-assisted patency of TIPS is approximately 85% at one year.Doppler sonography is a widely accepted screening modality for TIPS patients, both as a routine follow-up in asymptomatic patients and in those cases with clinically suspected TIPS malfunction.In a routine US follow-up, a TIPS patient is scheduled for a control 24 h after the procedure, and then after one week, 1 month, 3 months, and at 3-month intervals thereafter. Venography is at present performed solely on the basis of a suspected shunt dysfunction during the sonographic examination.Color-Doppler sonography is the most reliable method for monitoring the shunt function after TIPS implantation. Several studies have shown that Doppler sonography is a sensitive and relatively specific way to detect shunt malfunction, particularly when multiple parameters are examined. Achieving high sensitivity is optimal so that malfunctioning shunts can be identified and shunt revision can be performed before symptomatic deterioration. Venous angiography is at present indicated only on the basis of US suspicion of shunt compromise. Power-Doppler US and US contrast media can be useful in particular conditions, but are not really fundamental.

A new type of magnification system in free microvascular tissue transfer: Varioscope M5

Free microvascular tissue transfers have become today a key instrument for the surgical treatment of wide loss of tissue. These procedures can provide definitive treatment in a single operation but they are expensive and require specialized practitioners. The operating microscope traditionally has provided this requirement; our study is focusing on the prospect of using a new visual system-Varioscope M5-in the reconstructive microsurgery field. Varioscope M5 (Life Optics, Vienna, Austria) has been employed in 21 microvascular anastomoses, where different free flaps were used in head and neck reconstruction. The necessity to operate in a different department, not provided with an operating microscope, brought along the idea of exploring an alternative procedure to classical visualization systems. Specific advantages such as reduced cost, freedom of movement, autofocus, minimal upkeep, a variable range of magnification from 2x to 9x are some of the reasons that convinced the authors to use this new type of magnification system. Increasing interest in microsurgery magnification highlights the need for further technical development in that field. We consider Varioscope M5 a future mean of anastomotic magnification in most free-tissue transfers with specific characteristics that combine the microscope and loupe philosophies.

Histologic, microradiographic and electron microscopic investigations of bone tissue in a case of craniodiaphyseal dysplasia

The results of histologic, microradiographic and electron microscopic investigations carried out on two bone biopsies pertaining to a case of craniodiaphyseal dysplasia are reported. They show that the affected skeletal segments are chiefly characterized by enhancement of bone volume, and defective calcification of the bone matrix. Moreover, interstitial calcification of skeletal muscle has been found.