Robotic Surgery: An Effective Treatment Option for Epiphrenic Diverticulum Associated with Nutcracker Esophagus

Background: Epiphrenic Diverticulum is frequently associated with esophageal motility disorders, such as nutcrackers esophagus. The diagnosis is usually made using imaging studies such as a Barium esophagogram, and esophageal manometry. Surgical treatment options for epiphrenic diverticulum and EN include diverticulectomy and wide myotomy. Aim: The resection of three epiphrenic diverticula and extensive myotomy were performed by robotic thoracoscopy uneventfully. Case presentation: A 65-year-old female complaining of dysphagia for solid foods, Chest pain and regurgitation. Esophagogastroduodenoscopy (EDG) with difficulty in advancing the endoscope at 25 cm and demonstrating an ED, no hiatal hernia and normal stomach and duodenum. Barium Esophagogram showed multiple diverticula and tortuosity throughout the esophagus. Conclusion: With robotic surgery, surgeons can perform highly precise operations with enhanced 3D vision and control. Through this cutting-edge approach, the treatment of ED associated with EN can be drastically changed, promising better outcomes for patients.

Treatment of nutcracker syndrome with spermatic vein ligation and iliac vein anastomosis:Case report of three cases

Three patients with nutcracker syndrome(NCS) were enrolled in the study.Their clinical symptoms mainly included proteinuria and serious varicocele.Color Doppler ultrasound and computed tomography showed that the patients had constricted abdominal aortas,reduced superior mesenteric artery angles,and thinned left renal veins.Patients then underwent left spermatic vein ligation and iliac vein anastomosis.They were checked tliree months after their operation,and results showed that their sperms were improved and their proteinuria disappeared. The color Doppler ultrasound showed new cycle pathways.NCS clinical manifestations are complicated,and need combination diagnosis of symptoms and auxiliary examination to detennine surgical indications.Ligation of spermatic vein and vein anastomosis can be used to treat NCS.

Nutcracker syndrome

The nutcracker phenomenon [left renal vein(LRV) entrapment syndrome] refers to compression of the LRV most commonly between abdominal aorta and superior mesenteric artery.Term of nutcracker syndrome(NCS) is used for patients with clinical symptoms associated with nutcracker anatomy.LRV entrapment divided into 2 types:anterior and posterior.Posterior and right-sided NCSs are rare conditions.The symptoms vary from asymptomatic hematuria to severe pelvic congestion.Symptoms include hematuria,orthostatic proteinuria,flank pain,abdominal pain,varicocele,dyspareunia,dysmenorrhea,fatigue and orthostatic intolerance.Existence of the clinical features constitutes a basis for the diagnosis.Several imaging methods such as Doppler ultrasonography,computed tomography angiography,magnetic resonance angiography and retrograde venography are used to diagnose NCS.The management of NCS depends upon the clinical presentation and the severity of the LRV hypertension.The treatment options are ranged from surveillance to nephrectomy.Treatment decision should be based on the severity of symptoms and their expected reversibility with regard to patient's age and the stage of the syndrome.

Nutcracker现象与反复性肉眼血尿

Nutcracker现象引起的反复性肉眼血尿最近为放射科、泌尿科及小儿科医生所重视。该病为非肾小球性血尿,根据尿中红细胞形态可与肾小球性血尿鉴别。数字减影血管造影术已广泛用于血管病变的筛查。定义 Nutcracker现象是左肾静脉受压出现类似肠系膜上动脉压迫综合征的病态,即左肾静脉(LRV)走行于腹主动和肠系膜上动脉(SMA)间,受其压迫,变窄,瘀血引起反复性肉眼血尿。病因正常时SMA起始于主动脉成45～60°角,被肠系膜脂肪、淋巴结及腹膜等包绕,防止压迫LRV及十二指肠。到青春期身高速增,椎体过度伸展,体型急剧变化引起LRV机械受压。Pastershank等报告因纤维性条索物的绞窄,Wendel报告因肾的后方(背侧)下垂也是发病机理之一。

Flavonoid scutellarin positively regulates root length through NUTCRACKER

Exploring approaches to regulate meristem is of special importance and broad interest.In this study,we found that the flavonoid scutellarin,which has a 6-hydroxyl and a 7-glucoside,increased root length through the transcription factor NUTCRACKER(NUC).This root lengthening disappeared in NUCknockout and reappeared in NUC-rescue plants.Scutellarin induced NUC expression and promoted the division of cortex/endodermal initials.In contrast,naringenin,which has same chemical backbone but without 6-hydroxyl and with 7-hydroxyl group,showed the opposite or no effects.Our results demonstrate that scutellarin promotes root length through NUC-mediated regulatory pathways and reveal that flavonoids with and without the 6-hydroxyl and 7-glucoside have positive and negative effects on meristem size,respectively。

An Incidental Detection of Nutcracker Phenomenon in an Adolescent with Transient High Blood Pressure: A Case Report

Nutcracker phenomenon (NCP) is caused by a compression of left renal vein between aorta and superior mesenteric artery. The traditional clinical manifestations of nutcracker syndrome is usually accompanied with abdominal pain, hematuria, orthostatic proteinuria, and varicocele formation, however, hypertension is rarely reported as main clinical feature. We describe a male adolescent with manifestation of hypertension who was identified as NCP. Renal ultrasound and computed tomography angiography have provided evidences of left renal vein dilatation, probably due to the compression through the decreased angle between aorta and superior mesenteric artery. There were no other signs for secondary hypertension for the blood levels of renin and aldosterone being between normal limits and urinalysis being negative of hematuria and proteinuria. This patient was conservatively observed without any anti-hypertensive drugs and was asked for appropriately putting on weight. Three months later, the hypertension symptom was alleviated. In conclusion, although there were no established direct pathogenetic links between hypertension and NCP, no other definite etiology was shown to be the cause of this main manifestation. Thus we speculate that the NCP might be the main cause of hypertension in this patient.

A minimally invasive alternative for the treatment of nutcracker syndrome using individualized three-dimensional printed extravascular titanium stents

Background: This study was designed to evaluate the clinical and radiographic outcomes of patients with nutcracker syndrome (NCS) who were treated with three-dimensional printing (3DP) extravascular titanium stents (EVTSs). The 3DP EVTS was expected to release the hypertension of the left renal vein (LRV) produced by its compression between the superior mesenteric artery (SMA) and the aorta without causing any complications. Method: The pre-operative kidney model of each patient was printed out to enable surgical planning. After that, the EVTS was designed based on the LRV’s primitive physiologic structure using computer-aided design software, and each stent was printed out with a precision setting of 20 μm. Seventeen patients who had been suffering from NCS underwent laparoscopic 3DP EVTS placement. The surgical procedure was designed for the placement of EVTS, taking great care in positioning and fixing the stent. Surgical data, which included patient demographic characteristics as well as pre- and post-operative test results, were collected and analyzed. Results: The mean duration of surgery was 75 ± 9 min, and the mean blood loss was 20 ± 5 mL. Computed tomography examinations revealed that the pre- and post-operative angle between the SMA and the aorta ranged from 18.7°± 4.3° to 48.0°± 8.8°(P < 0.05);in patients with left varicocele, the mean diameter of the left spermatic vein ranged from 3.7 ± 0.5 to 1.3 ± 0.2 mm (P < 0.05). Moreover, Doppler ultrasound examinations showed that the peak velocity of blood flow at the hilar area ranged from 12.4 ± 3.3 to 18.5 ± 3.4 cm/s (P < 0.05). No side effects were observed in the 24 to 42 months following surgery. Conclusion: The findings after 2 years of follow-up suggest that the 3DP EVTS is a safe and effective minimally invasive alternative for the treatment of NCS.

Two-Year Follow-up on Laparoscopic Three-Dimensional Printed Extravascular Stent Placement for Posterior Nutcracker Syndrome

To the Editor:Posterior nutcracker syndrome (PNS)is a condition caused by compression of the left renal vein (LRV)between the vertebral column and the aorta (AO).Open surgery with LRV transposition has usually been recommended for patients with PNS.[1,4]However,existing surgical means of treatment are not sufficiently safe,effective,or minimally invasive.Here,we present one case of PNS treated with three-dimensional (3D)printed extravascular stent placement using laparoscopy.

Treatment of six cases of left renal nutcracker phenomenon: surgery and endografting

Objective A retrospective study was undertaken to examine therapeutic strategies used in 6 patients with left renal venal nutcracker phenomenon.Methods Three patients underwent surgical transposition of the superior mesenteric artery. Three patients underwent endograft stent implantations with intervention.Results All 6 cases were completely relieved of left renal vein compression after the operations, leading to improved clinical symptoms and normal urine tests.Conclusions Transposition of the superior mesenteric artery is a feasible method, but leads to complications and great trauma. Treating left renal venal nutcracker phenomenon with endografting techniques is minimally invasive in certain cases, and seems to have a prospective future.

Quantum nutcracker for near-room-temperature H_2 dissociation

Solid surfaces are well known to mediate the dissociation of molecules via electronic interactions (heterogeneous catalysis).In particular,H2 dissociation on metal surfaces has been widely studied for several decades because it is an important step in hydrogenation reactions.The efficiency of the process depends on both the electronic properties of the metal surface and the surface microstructures [1].Enhanced efficiency and reduced cost are usually achieved by using nanoparticles,which have increased the surface-to-volume ratio and low-coordination atoms [2].Another approach is to optimize the local electronic states of the metal surface by doping [3],alloying with other elements [4],or by taking advantage of strong interactions between metal nanoparticles and the supporting substrate [5].These methods often work together to tailor the adsorption properties on surfaces and show major efficiency enhancement.

Effects of sun compass error on spatial search by Clark’s nutcrackers

Animals employ compasses during navigation,but little attention has been paid to how accuracy is maintained in the face of compass error,which is inevitable in biological systems.The use of multiple landmarks may min­imize the effect of compass error.We allowed Clark’s nutcrackers to cache seeds in an outdoor aviary with ei­ther one or four landmarks present,and subsequently subjected them to small clock-shifts mimicking the effects of compass error.As predicted,the results showed a significant decrease in search accuracy following the clock-shift when one landmark was present but not when four landmarks were present.These results support that nut­crackers encode information from the sun as well as terrestrial landmarks,and these spatial cues are used in a flexible manner.Overall,our results are important as they support the hypothesis that multiple landmarks may be used during situations where the sun compass has even a small amount of error.

Renal venous hypertension

Renal venous hypertension usually seen in young, otherwise healthy individuals and can lead to significant overall morbidity. Aside from clinical findings and physicalexamination, diagnosis can be made with ultrasound, computed tomography, or magnetic resonance conventional venography. Symptoms and haemodynamic significance of the compression determine the ideal treatment method. This review of the literature discusses normal and pathological developmental aspects of renocaval venous segment and related circulatory disorders, summarizes congenital and acquired changes in left renal vein and their impact on development of renal venous hypertension. Also will be discussed surgical tactics of portosystemic shunting and their potential effects on renal hemodynamics.