Neoadjuvant chemotherapy with capecitabine combined with oxaliplatin for mid-low locally advanced rectal cancer with negative mesorectal fascia:Long-term outcomes of a prospective trial(PKUCH-R03 trial)

Objective:To evaluate the safety and efficacy of neoadjuvant chemotherapy(NCT)in mid-low locally advanced rectal cancer with negative mesorectal fascia(MRF).Methods:This prospective,single-arm phaseⅡtrial was designed and conducted at Peking University Cancer Hospital.The patients who provided consent received 3 months of NCT(capecitabine and oxaliplatin,CapOX)followed by total mesorectal excision(TME).The primary endpoint was the rate of pathological complete response(pCR).Results:From January 2019 through December 2021,a total of 53 patients were enrolled,7.5%of whom experienced grade 3-4 adverse events during NCT.The pCR rate was 17.0%for the entire cohort,and the overall rate of postoperative complications was 37.7%(1.9%of gradeⅢa patients).The 3-year disease-free survival rate was 91.4%,and 23.5%(12/51)of the patients suffered from major low anterior resection syndrome(LARS).Postoperative complications were independently associated with major LARS.Conclusions:For patients with mid-low rectal cancer with negative MRF,3 months of NCT were found to yield a favorable tumor response with acceptable toxicity.With fair long-term survival,the NCT regimen could be associated with low rates of perioperative complications as well as acceptable anal function.

Symmetry of upper eyelid after unilateral blepharoptosis repair with minimally invasive conjoint fascial sheath suspension technique

AIM:To investigate the symmetry of upper eyelid in patients with unilateral mild and moderate blepharoptosis who underwent unilateral minimally invasive combined fascia sheath(CFS)suspension.METHODS:A retrospective study of patients who underwent unilateral minimally invasive CFS suspension surgery between January 2018 and December 2021.Inclusion criteria included unilateral mild and moderate ptosis,good levator muscle function(>9 mm)and follow-up of at least 6mo.Pre-and post-operative symmetry was graded subjectively for marginal reflex distance 1(MRD1),tarsal platform show(TPS)and eyebrow fat span(BFS).A t-test was used to evaluate MRD1,TPS and BFS asymmetry by calculating delta values.The Bézier curve tool of the Image J software was used to extract the upper eyelid contours,where the symmetry was measured by the percentage of overlapping curvatures(POC).RESULTS:Totally 105 patients(105 eyelids)were included(mild group,n=84;moderate group,n=21).Postoperatively,all patients increased MRD1 and decreased TPS in the ptotic eye while maintaining unchanged BFS.The asymmetric delta value for MRD1 was measured to be 1.48±0.86 preoperatively,and it decreased to 0.58±0.67 postoperatively in all cases(P=0.0004).In patients with mild ptosis,the asymmetry value of TPS fell significantly from 1.15±0.62 to 0.68±0.38(P=0.0187).The symmetry of the upper eyelid contour increased in all subgroups of patients,with a POC of 59.39%±13.45%preoperatively and POC of 78.29%±13.80%postoperatively.CONCLUSION:Minimally invasive CFS suspension is proved to be an effective means of improving the symmetry of unilateral ptosis in terms of MRD1(all subgroups),POC(all subgroups)and TPS(only mild group),whereas BFS is unaffected.

A new technique for correction of iatrogenic upper eyelid retraction by using a composite flap of the orbicularis muscle and fascia on the anterior surface of the tarsal plate

Background:Upper eyelid retraction is a challenging complication of cosmetic upper eyelid blepharoplasty.To avoid extra trauma,we developed a new technique for correcting iatrogenic upper eyelid retraction by postmigrating a compound flap of the orbicularis muscle and fascia(OFC)on the anterior surface of the tarsal plate.This method extends the aponeurosis of the levator palpebrae superioris muscle(LPS),which can achieve a good correction for post-blepharoplasty retraction.Methods:We collected data from 15 patients with mild to moderate iatrogenic upper eyelid retraction who were treated at our hospital between February 2017 and December 2019.The OFC was used to replace the missing part of the LPS,and post-migration of the LPS and fixation of the OFC to the tarsal margin were conducted.Postoperative outcome measurements included postoperative binocular symmetry,double eyelid smoothness,eyelid fullness,margin reflex distance(MRD1),degree of eyelid closure,and exposure keratitis.The patients were followed-up at seven days,one month,and six months postoperatively.Results:One patient with moderate eyelid retraction showed undercorrection 6 months postoperatively,with the upper eyelid margin located at the upper edge of the pupil.The remaining patients had the upper eyelid margin stabilized at 1.0–2.0 mm below the upper corneal margin.Other observational indicators were satisfactory,including binocular symmetry,double eyelid fluency,and eyelid fullness.During the follow-up,no exposure keratitis was identified.The MRD1 indexes after the operation were significantly different(P<0.001)from those before the procedure.Conclusions:Extension and post-migration of the LPS using the orbicularis muscle and OFC structure can effectively correct mild iatrogenic eyelid retraction after ptosis with less damage and good postoperative eyelid morphology and closure function.

Optimizing Recovery Following Mihata Superior Capsular Reconstruction Surgery with Tensor Fascia Lata Auto Graft: A Comprehensive Rehabilitation Protocol

Objective: Superior Capsular Reconstruction (SCR) using a Tensor Fascia Lata (TFL) autograft is an evolving technique for treating irreparable rotator cuff tears. The Mihata technique, initially developed in Japan, has shown promising long-term results. However, a standardized post-operative rehabilitation protocol for this procedure in the USA is lacking. Purpose: This study aims to evaluate the outcomes of a comprehensive rehabilitation protocol following SCR with TFL autograft in a cohort of nine patients. Participants and Methods: A prospective observational study was conducted at Concentra Urgent Care, San Francisco. Nine patients, aged 55 - 65 years, underwent SCR with TFL autograft performed by a specialized orthopedic surgeon. Post-operative rehabilitation was managed using a structured protocol, divided into three phases focusing on passive exercises, progressive range of motion, and strengthening. Outcomes were measured using the Visual Analogue Scale (VAS) for pain, forward flexion range of motion (FF-ROM), and Single Assessment Numeric Evaluation (SANE) scores over a six-month period. Results: Significant improvements were observed in pain reduction (mean VAS decrease of −3.67 points, p = 0.01), ROM (mean FF increase of 41.11 degrees, p = 0.014), and SANE scores (mean improvement of 42.11%, p = 0.009), indicating the efficacy of the rehabilitation protocol. Conclusion: The comprehensive rehabilitation protocol following SCR with TFL autograft significantly improved pain, range of motion, and shoulder function in patients, suggesting its potential utility in clinical practice.

Laparoscopic lateral lymph node dissection in two fascial spaces for locally advanced lower rectal cancer

BACKGROUND The procedure for lateral lymph node(LLN)dissection(LLND)is complicated and can result in complications.We developed a technique for laparoscopic LLND based on two fascial spaces to simplify the procedure.AIM To clarify the anatomical basis of laparoscopic LLND in two fascial spaces and to evaluate its efficacy and safety in treating locally advanced low rectal cancer(LALRC).METHODS Cadaveric dissection was performed on 24 pelvises,and the fascial composition related to LLND was observed and described.Three dimensional-laparoscopic total mesorectal excision with LLND was performed in 20 patients with LALRC,and their clinical data were analyzed.RESULTS The cadaver study showed that the fascia propria of the rectum,urogenital fascia,vesicohypogastric fascia and parietal fascia lie side by side in a medial-lateral direction constituting the dissection plane for curative rectal cancer surgery,and the last three fasciae formed two spaces(Latzko's pararectal space and paravesical space)which were the surgical area for LLND.Laparoscopic LLND in two fascial spaces was performed successfully in all 20 patients.The median operating time,blood loss and postoperative hospitalization were 178(152-243)min,55(25-150)mL and 10(7-20)d,respectively.The median number of harvested LLNs was 8.6(6-12),and pathologically positive LLN metastasis was confirmed in 7(35.0%)cases.Postoperative complications included lower limb pain in 1 case and lymph leakage in 1 case.CONCLUSION Our preliminary surgical experience suggests that laparoscopic LLND based on fascial spaces is a feasible,effective and safe procedure for treating LALRC.

Preservation of Parotid Masseter Fascia in Preventing Frey's Syndrome

Objective: To compare the functional outcomes of patients who had parotid masseter fascia reserved and unreserved flap elevating scheme in parotidectomy, especially the morbidity of Frey's syndrome. Methods: Twenty-three patients (group A) had parotid masseter fascia reserved in the parotidectomy, 32 patients (group B) had parotid masseter fascia unreserved in the operation. Compare the morbidity of gustatory sweating syndrome of the two groups. Results: Follow-up after 6 months to 2.5 years, gustatory sweating syndrome occurred in 4 patients of group A (17%), 17 patients in group B (57%). Conclusion: Reservation technic of the parotid masseter fascial in parotidectomy could prevent regeneration of parasympathetic nerve and thus prevent Frey's syndrome post-operation.

Assessment of T staging and mesorectal fascia status using high-resolution MRI in rectal cancer with rectal distention

AIM： To determine the accuracy of high-resolution magnetic resonance imaging （MRI） using phasedarray coil for preoperative assessment of T staging and mesorectal fascia infiltration in rectal cancer with rectal distention.METHODS： In a prospective study of 67 patients with primary rectal cancer, high-resolution magnetic resonance imaging （in-plane resolution, 0.66 × 0.56） with phased-array coil were performed for T-staging and measurement of distance between the tumor and the mesorectal fascia. The assessment of MRI was compared with postoperative histopathologic findings. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were evaluated.RESULTS： The overall magnetic resonance accuracy was 85.1% for Tstaging and 88% for predicting mesorectal fascia involvement. Magnetic resonance sensitivity, specificity, accuracy, positive predictive value, and negative predictive value was 70%, 97.9%, 89.6%, 93.3% and 88.5% for ≤ T2 tumors, 90.5% , 76% , 85.1%, 86.4% and 82.6% for T3 tumors, 100%, 95.2%, 95.5% , 62.5% and 100% for T4 tumors, and 80% , 90.4%, 88%, 70.6% and 9d% for predicting mesorectal fascia involvement, respectively.CONCLUSION： High-resolution MRI enables accurate preoperative assessment for T staging and mesorectal fascia infiltration in rectal cancer with rectal distention.

Rectal cancer staging: Multidetector-row computed tomography diagnostic accuracy in assessment of mesorectal fascia invasion

AIM: To assess the diagnostic accuracy of multidetectorrow computed tomography(MDCT) as compared with conventional magnetic resonance imaging(MRI), in identifying mesorectal fascia(MRF) invasion in rectal cancer patients.METHODS: Ninety-one patients with biopsy proven rectal adenocarcinoma referred for thoracic and abdominal CT staging were enrolled in this study. The contrast-enhanced MDCT scans were performed on a 256 row scanner(ICT, Philips) with the following acquisition parameters: tube voltage 120 KV, tube current 150-300 m As. Imaging data were reviewed as axial and as multiplanar reconstructions(MPRs) images along the rectal tumor axis. MRI study, performed on 1.5 T with dedicated phased array multicoil, included multiplanar T2 and axial T1 sequences and diffusion weighted images(DWI). Axial and MPR CT images independently were compared to MRI and MRF involvement was determined. Diagnostic accuracy of both modalities was compared and statistically analyzed.RESULTS: According to MRI, the MRF was involved in 51 patients and not involved in 40 patients. DWI allowed to recognize the tumor as a focal mass with high signal intensity on high b-value images, compared with the signal of the normal adjacent rectal wall or with the lower tissue signal intensity background. The number of patients correctly staged by the native axial CT images was 71 out of 91(41 with involved MRF; 30 with not involved MRF), while by using the MPR 80 patients were correctly staged(45 with involved MRF; 35 with not involved MRF). Local tumor staging suggested by MDCT agreed with those of MRI, obtaining for CT axial images sensitivity and specificity of 80.4% and 75%, positive predictive value(PPV) 80.4%, negative predictive value(NPV) 75% and accuracy 78%; while performing MPR the sensitivity and specificity increased to 88% and 87.5%, PPV was 90%, NPV 85.36% and accuracy 88%. MPR images showed higher diagnostic accuracy, in terms of MRF involvement, than native axial images, as compared to the reference magnetic resonance images. The difference in accuracy was statistically significant(P = 0.02). CONCLUSION: New generation CT scanner, using high resolution MPR images, represents a reliable diagnostic tool in assessment of loco-regional and whole body staging of advanced rectal cancer, especially in patients with MRI contraindications.

Efficacy of fascia iliaca compartment nerve block as part of multimodal analgesia after surgery for femoral bone fracture

BACKGROUND: Fascia iliaca compartment nerve block(FICNB) has been an established technique for postoperative analgesia after surgery for femoral bone fracture. FICNB is technically easy, effective for postoperative pain control after operation for femoral bone fracture and decreases the complications induced by systemic analgesic drugs. The severity of postoperative pain is affected by genetics, cultural and social factors across the world. In this study we assessed the efficacy of fascia iliaca compartment nerve block when it is used as part of multimodal analgesia after surgery for femoral bone fracture.METHODS: An institution-based case control study was conducted from September, 2013 to May, 2014. All patients who had been operated on under spinal anesthesia for femoral bone fracture were included. The patients divided into a FICNB group(n=20) and a control group(n=20). The FICNB group was given 30 mL of 0.25% bupivacaine at the end of the operation. Postoperative pain was assessed within the f irst 24 hours, i.e. at 15 minutes, 2 hours, 6 hours, 12 hours and 24 hours using 100 mm visual analogue scale(VAS), total analgesic consumption, and the time for the f irst analgesic request.RESULTS: VAS pain scores were reduced within the f irst 24 hours after operation in the FICNB group compared wtih the control group. VAS scores at 2 hours were taken as median values(IQR) 0.00(0.00) vs.18.00(30.00), P=0.001; at 6 hours 0.00(0.00) vs. 34.00(20.75), P=0.000; at 24 hours 12.50(10.00) vs. 31.50(20.75), P=0.004; and at 12 hours(17.80±12.45) vs.(29.95±12.40), P=0.004, respectively. The total analgesic consumption of diclofenac at 12 and 24 hours was reduced in the FICNB group, and the time for the fi rst analgesic request was signifi cantly prolonged(417.50 vs. 139.25 minutes, P=0.000).CONCLUSIONS: A single injection for FICNB could lead to postoperative pain relief, reduction of total analgesic consumption and prolonged time for the fi rst analgesic request in the FICNB group after surgery for femoral bone fracture. We recommend FICNB for analgesia after surgery for femoral bone fracture and for patients with femoral bone fracture at the emergency department.

Reconstruction of the urethral defects with autologous fascial tube graft in a rabbit model

Aim： To investigate the feasibility of the autologous fascia graft in urethra defect reconstruction. Methods： In 24 adult male rabbits, a standardized defect （17 mm） was created within the midportion of each urethra. Two-cm long fascial tube grafts were interposed between the cut ends of the urethra. Twenty-four rabbits were divided into 12 groups. At 0, 3, 10, 15, 21, 30, 45, 60, 90, 120, 150, and 180 days postoperatively, one group was killed. In the first four groups, rabbits were killed and specimens were obtained for histological examination. After 21 postoperative days, in the subsequent eight groups, retrograde urethrograms were carried out to evaluate urethral patency and caliber, then rabbits were killed and specimens were obtained. Results： In the histological study, advancement of the urethral transitional epithelium along scaffold provided by the fascial graft was determined. At the 30th day, the new urethra was completely covered with the transitional epithelium. Fistula formation was observed in two of 24 rabbits. In urethrograms, narrowing was determined in three of 16 rabbits. Conclusion： For segmental urethral reconstruction, fascial graft is a good urethral substitute because of its rapid epithelization capacity, low contraction degree and thinness. We therefore propose the use of fascial grafts for reconstruction of male-urethra defects in humans.

Ultrasound-guided fascia iliaca compartment block combined with general anesthesia for amputation in an acute myocardial infarction patient after percutaneous coronary intervention: A case report

BACKGROUND Fascia iliaca compartment block is a technique that blocks three nerves,similar to a 3-in-1 nerve block.This block provides analgesia for patients undergoing lower limb surgery,and is a simple technique that is easy to implement.Here,we report a case of fascia iliaca compartment block in a patient with myocardial infarction who underwent emergency middle thigh amputation.CASE SUMMARY A 78-year-old female patient weighing 38 kg with gangrene and occlusive peripheral atherosclerosis of the right leg underwent an emergency middle thigh amputation.The patient had a history of hypertension,coronary heart disease,cerebral infarction,anterior wall myocardial infarction,and had recently undergone percutaneous coronary intervention consisting of coronary angiography and right coronary artery stent implantation.Considering the patient's condition,an ultrasound-guided fascia iliaca compartment block combined with general anesthesia was implemented for amputation.The fascia iliaca compartment block provided analgesia for the operation,and reduced the dosage of general anesthetics.It also alleviated adverse cardiovascular effects caused by pain stress,and ensured the safety of the patient during the perioperative period.This block also provided postoperative analgesia.The patient had a good prognosis,and was subsequently discharged from hospital.CONCLUSION Fascia iliaca compartment block provides surgical analgesia.It also alleviates adverse cardiovascular effects,and ensures patient safety during the perioperative period.

Ultrasound-guided,direct suprainguinal injection for fascia iliaca block for total hip arthroplasty:A retrospective study

BACKGROUND Peripheral regional block combined with general anesthesia might be a preferable anesthetic regimen for elderly patients undergoing total hip arthroplasty.AIM To investigate whether ultrasound-guided,direct suprainguinal injection for fascia iliaca block accelerated recovery after general anesthesia and relieved postoperative pain after total hip arthroplasty.METHODS Patients who underwent total hip arthroplasty under general anesthesia in 2015 or 2019 at The Second Affiliated Hospital of Xuzhou Medical University were retrospectively analyzed.The patients were grouped based on whether preoperative suprainguinal fascia iliaca block was performed or not.The time to tracheal extubation and time spent in the post-anesthesia care unit(PACU),intraoperative remifentanil dosage,fentanyl consumption in the PACU,postoperative cumulative fentanyl consumption within 48 h after operation,visual analogue scale at rest and during movement on the first and second days after surgery,and adverse reactions were compared.RESULTS Thirty-one elderly patients who underwent total hip arthroplasty were included in the study(block group,n=16;no-block group,n=15).The visual analog scale scores at rest and during movement on the first and second days were significantly lower in the block group than in the no-block group(all P<0.05).Compared with the no-block group,the intraoperative remifentanil dosage was lower,the time to tracheal extubation and the time spent in the PACU were shorter in the block group(all P<0.01).Fentanyl consumption in the PACU and postoperative cumulative fentanyl consumption in 48 h after operation were lower in the block group(all P<0.01).The incidence of dizziness was higher in the no-block group than in the block group(P=0.037).CONCLUSION Ultrasound-guided,direct suprainguinal injection for fascia iliaca block led to faster recovery after general anesthesia and early postoperative pain relief in elderly patients undergoing total hip arthroplasty.

Fascia- vs vessel-oriented lateral lymph node dissection for rectal cancer: Short-term outcomes and prognosis in a single-center experience

BACKGROUND For the management of lateral lymph node(LLN)metastasis in patients with rectal cancer,selective LLN dissection(LLND)is gradually being accepted by Chinese scholars.Theoretically,fascia-oriented LLND allows radical tumor resection and protects of organ function.However,there is a lack of studies comparing the efficacy of fascia-oriented and traditional vessel-oriented LLND.Through a preliminary study with a small sample size,we found that fasciaoriented LLND was associated with a lower incidence of postoperative urinary and male sexual dysfunction and a higher number of examined LLNs.In this study,we increased the sample size and refined the postoperative functional outcomes.AIM To compare the effects of fascia-and vessel-oriented LLND regarding short-term outcomes and prognosis.METHODS We conducted a retrospective cohort study on data from 196 patients with rectal cancer who underwent total mesorectal excision and LLND from July 2014 to August 2021.The short-term outcomes included perioperative outcomes and postoperative functional outcomes.The prognosis was measured based on overall survival(OS)and progression-free survival(PFS).RESULTS A total of 105 patients were included in the final analysis and were divided into fascia-and vesseloriented groups that included 41 and 64 patients,respectively.Regarding the short-term outcomes,the median number of examined LLNs was significantly higher in the fascia-oriented group than in the vessel-oriented group.There were no significant differences in the other short-term outcomes.The incidence of postoperative urinary and male sexual dysfunction was significantly lower in the fascia-oriented group than in the vessel-oriented group.In addition,there was no significant difference in the incidence of postoperative lower limb dysfunction between the two groups.In terms of prognosis,there was no significant difference in PFS or OS between the two groups.CONCLUSION It is safe and feasible to perform fascia-oriented LLND.Compared with vessel-oriented LLND,fascia-oriented LLND allows the examination of more LLNs and may better protect postoperative urinary function and male sexual function.

From basic to clinical:Anatomy of Denonvilliers’fascia and its application in laparoscopic radical resection of rectal cancer

The total mesorectal excision(TME)approach has been established as the gold standard for the surgical treatment of middle and lower rectal cancer.This approach is widely accepted to minimize the risk of local recurrence and increase the long-term survival rate of patients undergoing surgery.However,standardized TME causes urogenital dysfunction in more than half of patients,thus lowering the quality of life of patients.Of note,pelvic autonomic nerve damage during TME is the most pivotal cause of postoperative urogenital dysfunction.The anatomy of the Denonvilliers’fascia(DVF)and its application in surgery have been investigated both nationally and internationally.Nevertheless,controversy exists regarding the basic to clinical anatomy of DVF and its application in surgery.Currently,it is a hotspot of concern and research to improve the postoperative quality of life of patients with rectal cancer through the protection of their urinary and reproductive functions after radical resection.Herein,this study systematically describes the anatomy of DVF and its appli-cation in surgery,thus providing a reference for the selection of surgical treatment modalities and the enhancement of postoperative quality of life in patients with middle and low rectal cancer.

Better prognostic determination of cT3 rectal cancer through measurement of distance to mesorectal fascia:A multicenter study

Objective:To forward the magnetic resonance imaging(MRI)based distance between the deepest tumor invasion and mesorectal fascia(DMRF),and to explore its prognosis differentiation value in cT3 stage rectal cancer with comparison of cT3 substage.Methods:This was a retrospective,multicenter cohort study including cT3 rectal cancer patients undergoing neoadjuvant chemoradiotherapy followed by radical surgery from January 2013 to September 2014.DMRF and cT3 substage were evaluated from baseline MRI.The cutoff of DMRF was determined by disease progression.Multivariate cox regression was used to test the prognostic values of baseline variables.Results:A total of 804 patients were included,of which 226(28.1%)developed progression.A DMRF cutoff of7 mm was chosen.DMRF category,the clock position of the deepest position of tumor invasion(CDTI)and extramural venous invasion(EMVI)were independent predictors for disease progression,and hazard ratios(HRs)were 0.26[95%confidence interval(95%CI),0.13-0.56],1.88(95%CI,1.33-2.65)and 1.57(95%CI,1.13-2.18),respectively.cT3 substage was not a predictor for disease progression.Conclusions:The measurement of DMRF value on baseline MRI can better distinguish cT3 rectal cancer prognosis rather than cT3 substage,and was recommended in clinical evaluation.

Combined fascia iliaca compartment block and monitored anesthesia care for geriatric patients with hip fracture: Two case reports

BACKGROUND Major hip surgery usually requires neuraxial or general anesthesia with tracheal intubation and may be supplemented with a nerve block to provide intraoperative and postoperative pain relief.CASE SUMMARY This report established that hip surgical procedures can be performed with a fascia iliaca compartment block(FICB)and monitored anesthesia care(MAC)while avoiding neuraxial or general anesthesia.This was a preliminary experience with two geriatric patients with hip fracture,American Society of Anesthesiologists status III,and with many comorbidities.Neither patient could be operated on within 48 h after admission.Both general anesthesia and neuraxial anesthesia were high-risk procedures and had contraindications.Hence,we chose nerve block combined with a small amount of sedation.Intraoperative analgesia was provided by single-injection ultrasound-guided FICB.Light intravenous sedation was added.Surgical exposure was satisfactory,and neither patient complained of any symptoms during the procedure.CONCLUSION This report showed that hip surgery for geriatric patients can be performed with FICB and MAC,although complications and contraindications are common.The anesthetic program was accompanied by stable respiratory and circulatory system responses and satisfactory analgesia while avoiding the adverse effects and problems associated with either neuraxial or general anesthesia.

Enhanced recovery after surgery pathway: The use of fascia iliaca blocks causes delayed ambulation after total hip arthroplasty

BACKGROUND Fascia iliaca compartment blocks(FIBs) have been used to provide postoperative analgesia after total hip arthroplasty(THA). However, evidence of their efficacy remains limited. While pain control appears to be satisfactory, quadriceps weakness may be an untoward consequence of the block. Prior studies have shown femoral nerve blocks and fascia iliaca blocks as being superior for pain control and ambulation following THA when compared to standard therapy of parenteral pain control. However, most studies allowed patients to ambulate on post-operative day(POD) 2-3, whereas new guidelines suggest ambulation on POD 0 is beneficial.AIM To determine the effect of FIB after THA in patients participating in an enhanced recovery after surgery(ERAS) program.METHODS We conducted a retrospective analysis of patients undergoing THA with or without FICBs and their ability to ambulate on POD 0 in accordance with ERAS protocol. Perioperative data was collected on 39 patients who underwent THA.Demographic data, anesthesia data, and ambulatory outcomes were compared.RESULTS Twenty patients had FIBs placed at the conclusion of the procedure, while 19 did not receive a block. Of the 20 patients with FIB, only 1 patient was able to ambulate. Of the 19 patients without FIB blocks, 17 were able to ambulate. All patients worked with physical therapy 2 h after arriving in the post-anesthesia care unit on POD 0.CONCLUSION Our data suggests an association between FIB and delayed ambulation in the immediate post-operative period.

Mesorectal excision: Surgical anatomy of the rectum, mesorectum, and pelvic fascia and nerves and clinical relevance

Biologic behavior and management of rectal cancer differ significantly from that of colon cancer. The surgical treatment is challenging since the rectum has dual arterial blood supply and venous drainage, extensive lymphatic drainage and is located in a bony pelvic in close proximity to urogenital and neurovascular structures that are invested with intricate fascial covering. The rectum is encased byfatty lymphovascular tissue(mesorectum) that is surrounded by perirectal fascia that act as barrier to the spread of the cancer and constitute the surgical circumferential margin. Locoregional recurrence after rectal cancer surgery is influenced by tumor-related factors and adequacy of the resection. Local recurrence is associated with incomplete excision of circumferential margin, violation of perirectal fascia, transmesorectal dissection, presence of isolated deposits in the mesorectum and tumor in regional lymph nodes and incomplete lymph node clearance. Hence to eradicate the primary rectal tumor and control regional disease, the rectum, first area of lymph node drainage and surrounding tissue must be completely excised while maintaining an intact fascial envelope around the rectum and preserving surrounding structures. This is achieved with extrafascial dissection and removal of the entire mesorectum including the portion distal to the tumor(total mesorectal excision) within its enveloping fascia as an intact unit. Total mesorectal excision is the standard of care surgical treatment of mid and low rectal cancer and can be performed in conjunction with low anterior resection,abdominoperineal resection, extralevator abdominoperineal resection, and extraregional dissection. To accomplish such a resection, thorough knowledge of the surgical anatomy of the rectum and pelvic structures and fascial planes is paramount.

Fascial pedicle artificial nerve tissue compared with silicone tube bridging to repair sciatic nerve defects in rats

BACKGROUND： Silicone tube bridging for peripheral nerve defects has been shown to be successful in guiding neural regeneration. However, this method is accompanied by complications. Because materials for bridging nerve fibers should exhibit biocompatibility, the development of novel artificial tissues to bridge nerve grafts has become important in the field of nerve tissue engineering for the repair of peripheral nerve defects. OBJECTIVE： To investigate effectiveness and feasibility of fascial pedicle artificial nerve tissue to repair peripheral nerve defects, and to compare to autologous nerve grafts and silicone tube bridging methods. DESIGN, TIME AND SETTING： Randomized, controlled, neural tissue engineering-based, animal experiments were performed at the Laboratory of Human Anatomy in Qingdao University Medical College from March 2006 to March 2007. MATERIALS： Medical absorbable collagen sponge was purchased from Henan Province Tiangong BJo-Material, China. Cantata 2-track 4-trace EMG-evoked potential instrument was purchased from Dantec, Denmark. Medical silicone tube was purchased from Shenzhen Legend Technology, China. METHODS： Forty healthy, adult, male, Sprague Dawley rats were randomly assigned to four groups fascial pedicle nerve, autologous nerve, silicone tube, and normal, with 10 rats in each group. A 10-mm defective sciatic nerve section was produced in rats following the removal of the fascial pedicle. The fascial flap surrounding the defect was harvested; one side of the nerve pedicle was maintained and then sutured into a tube with the fascia surface as the pipe inner wail. The tube was filled with a medical absorbable collagen （Bodyin） to construct a bridge between the artificial tissue nerve graft and the damaged sciatic nerve. The sciatic nerve defects in the autologous nerve and silicone tube groups were bridged using autologous nerve grafts and a medical silicone tube with matched specifications. MAIN OUTCOME MEASURES： At 4 months after transplantation, electromyogram was used to detect sciatic nerve conduction velocity and action potential amplitude. Hematoxylin-eosin and Nissl staining were used to determine the number of spinal cord anterior horn motor neurons and neurites Osmium tetroxide staining of the sciatic nerve bridge section was performed to detect the number and diameter of nerve fibers. RESULTS： There were no differences in sciatic nerve conduction velocity, action potential amplitude, the number of spinal cord anterior horn motor neurons and neurites, sciatic nerve fiber number, and diameter between the autologous nerve graft and normal groups （P 〉 0.05）. However, these values were significantly greater than in the silicone tube group （P 〈 0.05）. CONCLUSION： Quantitative results suggested that artificial nerve tissue, with an autologous tissue fascia flap as a nerve conduit, could be used to repair peripheral nerve defects. The regenerated fascial pedicle artificial nerve tissue was similar to an autologous nerve graft in terms of morphology and functional recovery and was superior to results from silicone tube bridging transplants.

Long-term results of type I tympanoplasty with perichondrium reinforced cartilage palisade vs temporalis fascia for large perforations:A retrospective study

Objective:To compare the rate of graft uptake and postoperative hearing outcomes of Type I tympanoplasty with perichondrium reinforced cartilage palisade to temporalis fascia for large tympanic membrane(TM)perforations over 5 years follow-up period.Materials and methods:This was a retrospective comparative study involving patients with chronic otitis media with large TM perforations.The patients underwent type I tympanoplasty using either perichondrium reinforced cartilage palisade(CP group)or temporalis fascia(TF group)as the graft via a transmeatal approach and under local anesthesia.Morphological and functional results were recorded at three-and five years follow-up.Demographic profiles including age and sex,surgery side,contralateral disease and graft uptake rate,as well as hearing outcomes,were compared between the two groups.Results:At three years follow-up,graft uptake was 94.87%for perichondrium reinforced cartilage palisade and 80.7%for fascia,respectively,(p¼0.67).At five years follow-up,the uptake rate dropped to 87.17%in the CP group,but to 66.6%in the TF group(p¼0.019).Hearing improved after surgery in both groups,and showed no significant difference between the two groups.Conclusion:Over long-term,perichondrium reinforced palisade showed a statistically significant better outcome regarding graft uptake than temporalis fascia in type Itympanoplasty for large TM perforations with comparable audiometric results.