Intraoperative Assessment Research Articles

Flowmetry and spectrophotometry can detect reduced intestinal microperfusion in nonsurvivors during equine colic surgery for large intestinal strangulation.

To evaluate the use of laser Doppler flowmetry and spectrophotometry (LDFS) for large intestinal viability assessment in horses with naturally occurring large intestinal strangulations. By use of LDFS, intestinal microperfusion was quantified as tissue oxygen saturation (tSo2), hemoglobin (tHB), and blood flow (tBF) in cases with large colon volvulus and small colon strangulations undergoing colic surgery (n = 17). Intestinal biopsies were taken from the pelvic flexure in all large colon cases and in small colon cases that underwent intraoperative euthanasia. Measurements were compared between survivors and nonsurvivors, and the correlation between LDFS and (immuno)histology was tested (P < .05). The tSo2 and tBF were clearly lower and tHB was higher than previously reported in healthy horses. Following correction of the lesion, pelvic flexure tBF was significantly lower than that of the left ventral colon. Prior to correction of the lesion, microperfusion did not differ between survivors and nonsurvivors, but following release of the strangulation the survivors had a significantly higher tSo2 and tBF compared to the nonsurvivors. There was a negative correlation between tBF and interstitium-to-crypt ratio and a positive correlation between tHB and the histological hemorrhage score. There were no significant correlations between LDFS measurements and inflammatory cell counts or hypoxia-inducible factor-1α immunoreactivity. Large intestinal microperfusion was decreased in nonsurvivors compared to survivors and was correlated with histological injury, suggesting that LDFS has the potential to predict tissue injury and postoperative survival. The use of LDFS as an ancillary diagnostic aid may improve intraoperative viability assessment during colic surgery.

Centralized prostatectomy with intraoperative NeuroSAFE margin assessment improves surgical margin control.

To investigate the surgical margin status in patients with prostate cancer who underwent robot-assisted radical prostatectomy (RARP) with intraoperative neurovascular structure-adjacent frozen-section analysis (NeuroSAFE) and evaluate differences compared to patients who underwent radical prostatectomy without NeuroSAFE. Between September 2018 and January 2021, 962 patients underwent centralized RARP with NeuroSAFE. A secondary resection was performed in case of a positive surgical margin (PSM) on intraoperative frozen section (IFS) analysis to convert a PSM into a negative surgical margin (NSM). A retrospective cohort consisted of 835 patients who had undergone radical prostatectomy in a tertiary centre without NeuroSAFE between January 2000 and December 2017. We performed multivariable logistic regression to evaluate differences in risk of PSM between cohorts after controlling for clinicopathological variables. Patients operated with NeuroSAFE in the centralized clinic had 29% PSM at a definitive pathological RP examination. The median cumulative length of definitive PSM was 1.1 mm (interquartile range: 0.4-3.8). Among 275 men with PSM, 136 (49%) had a cumulative length ≤1 mm and 198 (72%) ≤3 mm. After controlling for PSA, Grade group, cribriform pattern, pT-stage, and pN-stage, patients treated in the centralized clinic with NeuroSAFE had significantly lower odds on PSM (odds ratio [OR]: 0.70, 95% confidence interval [CI]: 0.56-0.88; P = 0.002), PSM length >1 mm (OR: 0.14, 95% CI: 0.09-0.22; P < 0.001), and >3 mm (OR: 0.21, 95% CI: 0.14-0.30; P < 0.001). This study provides a detailed overview of surgical margin status in a centralized RP NeuroSAFE cohort. Centralization with NeuroSAFE was associated with lower PSM rates and significantly shorter PSM cumulative lengths, indicating improved control of surgical margin status.

Open versus laparoscopic completion cholecystectomy in patients with previous open partial cholecystectomy; a retrospective comparative study

Background: Some patients report recurrence or persistence of their manifestations after cholecystectomy, and retained gallstones may be a relevant etiology for their complaint. Completion cholecystectomy is advised for these cases to alleviate their manifestations. No previous studies have compared the outcomes of open versus laparoscopic outcomes in these patients, especially in patients who had initial open partial procedures. That is why we performed this study to report the perioperative outcomes of the two approaches in such patients. Methodology: This is a retrospective analysis of 80 patients who had a completion cholecystectomy in our center (40 open and 40 laparoscopic cases) after initial open partial cholecystectomy. Results: The duration elapsed since the primary procedure had an average of 18 months in the open group and 21 months in the laparoscopic group. Abdominal pain and dyspepsia were the most common presentations. Some patients had stump cholecystitis or jaundice. The intraoperative assessment revealed either the residual gallbladder or a long cystic duct stump. Laparoscopy yielded shorter operative time, earlier oral intake, and shorter hospitalization periods compared to the open approach (P&lt;0.05). The latter was associated with a 20% wound infection rate that was never encountered after laparoscopy (P =0.003). Conclusion: Previous open partial cholecystectomy does not hinder subsequent laparoscopic completion cholecystectomy. Additionally, laparoscopy is associated with better perioperative outcomes than the open approach.

Intraoperative margin assessment during radical prostatectomy: is microscopy frozen in time or ready for digital defrost?

Intraoperative frozen section (IFS) is used with the intention to improve functional and oncological outcomes for patients undergoing radical prostatectomy (RP). High resource requirements of IFS techniques such as NeuroSAFE may preclude widespread adoption, even if there are benefits to patients. Recent advances in fresh-tissue microscopic digital imaging technologies may offer an attractive alternative, and there is a growing body of evidence regarding these technologies. In this narrative review, we discuss some of the familiar limitations of IFS and compare these to the attractive counterpoints of modern digital imaging technologies such as the speed and ease of image generation, the locality of equipment within (or near) the operating room, the ability to maintain tissue integrity, and digital transfer of images. Confocal laser microscopy (CLM) is the modality most frequently reported in the literature for margin assessment during RP. We discuss several imitations and obstacles to widespread dissemination of digital imaging technologies. Among these, we consider how the 'en-face' margin perspective will challenge urologists and pathologists to understand afresh the meaning of positive margin significance. As a part of this, discussions on how to describe, categorize, react to, and evaluate these technologies are needed to improve patient outcomes. Limitations of this review include its narrative structure and that the evidence base in this field is relatively immature but developing at pace.

Intraoperative Cytological Assessment of Bone Marrow from Resected Mandible in Analyzing the Surgical Bone Margins in Oral Squamous Cell Carcinoma: A Promising Tool

Intraoperative Cytological Assessment of Bone Marrow from Resected Mandible in Analyzing the Surgical Bone Margins in Oral Squamous Cell Carcinoma: A Promising Tool

Evaluating the Effect of MarginProbe® Use on Re-excisions After Partial Mastectomy: A Single-Institution Analysis.

Breast conservation therapy is a widely accepted approach in treating breast cancer, yet the average re-excision rates are approximately 25% despite surgical advancements. The Food and Drug Administration (FDA)-approved MarginProbe® device uses radiofrequency spectroscopy for intraoperative margin assessment, potentially reducing re-excision rates. This study evaluated the effectiveness of MarginProbe® in reducing re-excisions compared with standard of care (SOC). A prospective cohort with MarginProbe® usage during partial mastectomies from June 2019 to July 2023 (153 patients) was compared with a retrospective control group without the device from January 2015 to May 2019 (300 patients). Both groups underwent partial mastectomies performed by two breast surgeons. Positive margins were defined as tumor on ink for invasive cancers and within 2 mm for ductal carcinoma in situ. When control was used for patient demographics and tumor characteristics, the findings showed that MarginProbe® significantly decreased the probability of re-excision by 58% (p<0.001), although it led to a higher shave volume, with an average of 9.8cc additional tissue removed compared with SOC (p < 0.001). Human epidermal growth factor 2 (HER2) positivity was significantly associated with increased odds of re-excision (p = 0.036). MarginProbe® demonstrated a sensitivity of 70.1% and a specificity of 47.5%. MarginProbe® is an effective adjunct for intraoperative margin assessment to decrease re-excision rates. However, patient selection is paramount. Given its significant increase in shave volume, women with small breasts may be at higher risk for poor cosmesis. Surgeons should exercise clinical judgement when determining the suitability of MarginProbe® use for patients undergoing breast conservation. Further research is necessary to refine MarginProbe®'s specificity and to optimize its clinical application.

Comparison of preoperative aortic valve imaging techniques for patients with aortic insufficiency undergoing aortic valve repair surgery

ObjectiveTo report the accuracy of preoperative 4-dimensinal cardiac computed tomography angiogram (CTA), real-time 3-dimensional transesophageal echocardiography (TEE) and intraoperative techniques in aortic valve (AV) measurement and phenotype determination in patients undergoing surgery for aortic insufficiency and/or root aneurysm. MethodsThis is a prospective, observational study of preoperative AV imaging for AV repair surgery. Twenty-two patients were accrued over 12 months. Preoperative TEE and CTA were obtained and measurements provided by dedicated imaging cardiologists. Intraoperative measurements were obtained from the arrested heart and reported by the surgeon before repair. Intraoperative assessment was considered the gold standard of height measurements, with CTA being the standard assessment for commissural orientation. Correlation coefficients were used to describe agreement of measurements. ResultsBaseline characteristics and assessment of phenotype and measurement of commissural orientation, geometric height and commissural heights are reported. TEE (κ = 0.833; P < .01) and CTA (κ = 0.729; P < .01) both agreed with intraoperative assessment of AV phenotype. TEE appeared more accurate than intraoperative measurement at predicting commissural orientation (rs = 0.79; P < .01 vs rs = 0.58; P = .01). CTA and TEE were unlikely to predict and measured shorter than intraoperative geometric height measurement. Measurements of commissural heights by CTA did not agree with and were shorter than intraoperative measurement. ConclusionsTEE and CTA both appear accurate in predicting the AV phenotype identified intraoperatively. CTA and TEE predicted shorter heights than intraoperative measurement.

The evolution and future directions of bypass surgery.

Cerebral bypass surgery is one of the most complex and elegant procedures in neurosurgery. It involves several meticulous steps that test the skills of even the most prepared neurosurgeons. This surgery has transcended its traditional role in arterial stenosis and atherosclerosis, expanding its applications to include flow preservation techniques for complex conditions such as aneurysms, tumors, and vascular malformations. The decreased number of procedures performed across many hospitals reflects the development of newer endovascular therapies but is also due to the results of the extracranial-intracranial bypass study, the Carotid Occlusion Surgery Study, and the Carotid and Middle Cerebral Artery Occlusion Surgery Study, which have raised questions about the efficacy of cerebral bypass surgery for individuals with carotid artery occlusion who are prone to ischemic stroke. Despite this, there is still a potential benefit of bypass surgery for patients with hemodynamic impairment refractory to medical management. Also, revascularization in moyamoya vasculopathy is an effective strategy for preventing ischemic and hemorrhagic events in both children and adults. Additionally, innovations in the technique, such as the flow-regulated bypass and intraoperative flow assessment, aim to minimize perioperative morbidity. Despite bypass surgery being less performed in this current era, the teaching and development of these skills are still encouraged for future neurosurgeons, as a role for bypass will exist for the foreseeable future.

Feasibility of a Novel 3D Ultrasound Imaging Technique for Intraoperative Margin Assessment during Tongue Cancer Surgery.

Squamous cell carcinoma (SCC) of the tongue is the most prevalent form of oral cavity cancer, with surgical intervention as the preferred method of treatment. Achieving negative or free resection margins of at least 5 mm is associated with improved local control and prolonged survival. Nonetheless, margins that are close (1-5 mm) or positive (less than 1 mm) are often observed in practice, especially for the deep margins. Ultrasound is a promising tool for assessing the depth of invasion, providing non-invasive, real-time imaging for accurate evaluation. We conducted a clinical trial using a novel portable 3D ultrasound imaging technique to assess ex vivo surgical margin assessment in the operating room. During the operation, resected surgical specimens underwent 3D ultrasound scanning. Four head and neck surgeons measured the surgical margins (deep, medial, and lateral) and tumor area on the 3D ultrasound volume. These results were then compared with the histopathology findings evaluated by two head and neck pathologists. Six patients diagnosed with tongue SCC (three T1 stage and three T2 stage) were enrolled for a consecutive cohort. The margin status was correctly categorized as free by 3D ultrasound in five cases, and one case with a "free" margin status was incorrectly categorized by 3D ultrasound as a "close" margin. The Pearson correlation between ultrasound and histopathology was 0.7 (p < 0.001), 0.6 (p < 0.001), and 0.3 (p < 0.05) for deep, medial, and lateral margin measurements, respectively. Bland-Altman analysis compared the mean difference and 95% limits of agreement (LOA) for deep margin measurement by 3D ultrasound and histopathology, with a mean difference of 0.7 mm (SD 1.15 mm). This clinical trial found that 3D ultrasound is accurate in deep margin measurements. The implementation of intraoperative 3D ultrasound imaging of surgical specimens may improve the number of free margins after tongue cancer treatment.

The utility of intraoperative marrow margin frozen section in extremity bone sarcoma resection.

Intraoperative frozen section analysis is commonly used to evaluate marrow margins during extremity bone sarcoma resections, but its efficacy in the era of magnetic resonance imaging is debated. This study aimed to compare the accuracy of intraoperative frozen section assessment with final pathology, assess its correlation with gross intraoperative margin assessment, and evaluate its impact on surgical decision making. Consecutive patients undergoing extremity bone sarcoma resections from 2010 to 2022 at a single sarcoma center were included. Intraoperative frozen section and gross margin assessments were compared to final pathology using positive predictive values (PPV) and negative predictive values (NPV). Changes in surgical decisions due to positive intraoperative margins were recorded. Of 166 intraoperative frozen section marrow margins, four were indeterminant/positive, with two false positive/indeterminant findings and two false negatives compared to final pathology. Gross intraoperative assessment had no false positives and two false negatives. Frozen section analysis yielded a PPV of 50% (95% confidence interval [CI]: 16%-84%) and NPV of 98.8% (95% CI: 97%-100%), while gross assessment had a PPV of 100% (95% CI: 16%-100%) and NPV of 98.8% (95% CI: 97%-100%). Positive frozen section margins led to additional resections in three of four cases. Intraoperative frozen section analysis did not offer added clinical value beyond gross margin assessment in extremity bone sarcoma resections. It exhibited a low PPV and led to unnecessary additional resections. Gross intraoperative assessment proved adequate for margin evaluation, potentially saving time and resources.

Simplifying vasectomy reversal without compromising outcomes: a single-surgeon series.

In vasovasostomy (VV) surgery, the micro-surgical technique has consistently been shown to provide superior outcomes to both macroscopic and loupe-assisted techniques, with large studies showing overall patency rates of ~86% and pregnancy rates of ~52%. However, the question of whether a single- or double-layer anastomosis offers the best outcomes remains contentious, and despite the popularity of the two-layer technique, a meta-analysis suggests little difference in outcomes. This study records the outcomes of a single-surgeon series of a simplified single-layer technique, along with the comparative outcomes and predictive factors. A retrospective analysis of 237 consecutive patients undergoing microsurgical vasectomy reversal between 2010 and 2022 in a single institution was performed. A microsurgical, single-layer, six-point, 8-0 nylon anastomosis was performed with macroscopic intra-operative assessment of vasal fluid. An ipsilateral vasoepididymostomy (VE) was only performed in cases of complete absence of vasal fluid or the presence of toothpaste-like discharge (bilateral VE were excluded from this series). Semen analysis was performed 3 months postoperatively to assess for the presence of motile sperm. A total of 237 men underwent microsurgical vasectomy reversal over a 12-year period. The median age of men at vasectomy was 34 years. The median age at vasectomy reversal was 42 years. The median obstructive interval was 7.3 years. An overall patency rate of 85.8% was achieved (motile sperm present), with 53.8% having a sperm count greater than 15 million/mL on initial 3-month assessment. For obstructive intervals of <3, 3-8, 9-14, and ≥15 years, there were declining patency rates of 96.3%, 90.5%, 80.0%, and 74.1%, respectively (P=0.04). These are the equivalent outcomes to published high-volume two-layer studies. We found no difference between patency rates of VV performed on the straight vas vs. the convoluted vas, and no difference when only one side could be re-anastomosed (20 patients). Using a micro-surgical technique in high volume, similar outcomes can be achieved from a simplified single-layer VV technique with fewer sutures, as compared to the more complex two-layer techniques described. We postulate that this may be due to reduced ischaemia relating to fewer sutures and less tissue-handling. Given the associated time and cost savings, as well as the easier learning curve involved, we would advocate the use of this technique in routine VV practise.

Through Different Lenses: A Retrospective Analysis of the Agreement Between Laparoscopic and Histopathological Evaluations of the Appendix.

Appendicectomy is the most frequently performed emergency general surgical procedure. Previous research has highlighted discrepancies between initial intraoperative laparoscopic diagnoses and subsequent histopathology reports following appendicectomy. In the United Kingdom (UK), routine histopathological examination is the established practice, ensuring precise diagnosis of appendiceal specimens. This retrospective analysis aims to compare intraoperative laparoscopic assessments of the appendix with corresponding histopathology findings. We conducted a retrospective analysis of 418 consecutive emergency laparoscopic appendectomies at Peterborough City Hospital in the UK between April 2018 and June 2019 for suspected appendicitis. Intraoperative findings were compared with histopathological examination outcomes using kappa statistics. Of the 418 appendectomies analysed, we found a substantial agreement between surgeons and pathologists (kappa = 0.71, P < 0.001) in detecting overall abnormalities of appendices. This agreement was also high for detecting inflamed appendices (kappa = 0.72, P< 0.001). However, of the six neoplastic lesions confirmed in the pathologists' final report, only two were suspected during laparoscopy. While laparoscopic assessments of the appendix demonstrate a statistically significant and improved agreement with histopathological findings in detecting abnormal and inflamed appendices, the ability of surgeons to identify neoplasia appears suboptimal based on our small sample of neoplasia cases. The data strongly support the continued practice of routine histopathological examination following appendicectomy due to its crucial role in avoiding missed diagnoses and ensuring better patient outcomes.

Spectral characterization of intraoperative renal perfusion using hyperspectral imaging and artificial intelligence

Accurate intraoperative assessment of organ perfusion is a pivotal determinant in preserving organ function e.g. during kidney surgery including partial nephrectomy or kidney transplantation. Hyperspectral imaging (HSI) has great potential to objectively describe and quantify this perfusion as opposed to conventional surrogate techniques such as ultrasound flowmeter, indocyanine green or the subjective eye of the surgeon. An established live porcine model under general anesthesia received median laparotomy and renal mobilization. Different scenarios that were measured using HSI were (1) complete, (2) gradual and (3) partial malperfusion. The differences in spectral reflectance as well as HSI oxygenation (StO2) between different perfusion states were compelling and as high as 56.9% with 70.3% (± 11.0%) for “physiological” vs. 13.4% (± 3.1%) for “venous congestion”. A machine learning (ML) algorithm was able to distinguish between these perfusion states with a balanced prediction accuracy of 97.8%. Data from this porcine study including 1300 recordings across 57 individuals was compared to a human dataset of 104 recordings across 17 individuals suggesting clinical transferability. Therefore, HSI is a highly promising tool for intraoperative microvascular evaluation of perfusion states with great advantages over existing surrogate techniques. Clinical trials are required to prove patient benefit.

How to increase the success rate in microsurgical free and pedicled flap reconstructions with intraoperative multistep ICG imaging: A case series with 400 consecutive cases

BackgroundOver the last decade, microsurgical soft tissue transfer became the gold standard for a wide variety of reconstructions throughout the body. Continued improvement of instruments and surgical techniques allowed reaching a very high success rate, like the employment of intra-operative indocyanine green angiography (ICG-A). This study aims to assess and validate the role of a standard intraoperative ICG-A in free flap and pedicled flap surgery to improve the overall outcomes. Patients and MethodsFrom April 2018 and April 2023, four hundreds consecutive patients who underwent reconstruction using free flap and pedicled flap were enrolled. The ICG-A was always performed in free flap after elevation of the flap, after microsurgical anastomosis, immediately after the flap inset and after wound closure; in pedicled flap the sequential procedure was performed after elevation of the flap, after flap inset and after wound closure. ResultsAll four hundred patients who underwent flap reconstruction using intraoperative ICG angiography had an extremely low incidence of necrosis (0.75% partial necrosis among free flaps and pedicled flaps) and reoperation for perfusion-related complications (0.75% due to acute ischemia and 0.50% due to flap congestion). Minor complications like hematoma, seroma, wound dehiscence, and wound infections were managed with a second operation. No flaps were lost and all the patients were successfully treated. ConclusionsThe present report shows how the employment of systematic multiple-steps ICG angiography for intra-operative assessment of both free and pedicled flap’s perfusion can significantly reduce the complications rate, including flap loss and re-exploration surgeries, in a time- and cost-effective manner.

Performance of Intraoperative Contrast-Enhanced Ultrasound (Io-CEUS) in the Diagnosis of Primary Lung Cancer.

Suspicious tumors of the lung require specific staging, intraoperative detection, and histological confirmation. We performed an intrathoracic, intraoperative contrast-enhanced ultrasound (Io-CEUS) for characterization of lung cancer. Retrospective analysis of prospectively collected data on the application of Io-CEUS in thoracic surgery for patients with operable lung cancer. Analysis of the preoperative chest CT scan and FDG-PET/CT findings regarding criteria of malignancy. Immediately before lung resection, the intrathoracic Io-CEUS was performed with a contrast-enabled T-probe (6-9 MHz-L3-9i-D) on a high-performance ultrasound machine (Loqic E9, GE). In addition to intraoperative B-mode, color-coded Doppler sonography (CCDS), or power Doppler (macrovascularization) of the lung tumor, contrast enhancement (Io-CEUS) was used after venous application of 2.4-5 mL sulfur hexafluoride (SonoVue, Bracco, Italy) for dynamic recording of microvascularization. The primary endpoint was the characterization of operable lung cancer with Io-CEUS. Secondly, the results of Io-CEUS were compared with the preoperative staging. The study included 18 patients with operable lung cancer, who received Io-CEUS during minimally invasive thoracic surgery immediately prior to lung resection. In the chest CT scan, the mean size of the lung tumors was 2.54 cm (extension of 0.7-4.5 cm). The mean SUV in the FDG-PET/CT was 7.6 (1.2-16.9). All lung cancers were detected using B-mode and power Doppler confirmed macrovascularization (100%) of the tumors. In addition, Io-CEUS showed an early wash-in with marginal and mostly simultaneous central contrast enhancement. The intrathoracic application of Io-CEUS demonstrated a peripheral and simultaneous central contrast enhancement in the early phase, which seems to be characteristic of lung cancer. In comparison to preoperative imaging, Io-CEUS was on par with the detection of malignancy and offers an additional tool for the intraoperative assessment of lung cancer before resection.

Intraoperative technologies to assess margin status during radical prostatectomy - a narrative review.

Positive surgical margin (PSM) is a frequent concern for surgeons performing radical prostatectomy for prostate cancer (PCa). PSM are recognized as risk factors for earlier biochemical recurrence and expose patients to adjuvant or salvage treatments such as external radiotherapy and hormonotherapy. Several strategies have been established to reduce PSM rate, while still allowing safe nerve-sparing surgery. Precise preoperative staging by multiparametric magnetic resonance imaging (mpMRI) and fusion biopsy is recommended to identify suspicious areas of extracapsular extension (ECE) that warrant special attention during dissection. However, even with optimal imaging, ECE can be missed, some cancers are not well defined or visible, and capsular incision during surgery remains an issue. Hence, intraoperative frozen section techniques, such as the neurovascular structure-adjacent frozen section examination (NeuroSAFE) have been developed and lately widely disseminated. The NeuroSAFE technique reduces PSM rate while allowing higher rate of nerve-sparing surgery. However, its use is limited to high volume or expert center because of its high barrier-to-entry in terms of logistics, human resources and expertise, as well as cost. Also, NeuroSAFE is a time-consuming process, even in expert hands. To address these issues, several technologies have been developed for an ex vivo and in vivo use. Ex vivo technology such as fluorescent confocal microscopy and intraoperative PET-CT require the extraction of the specimen for preparation, and digital images acquisition. In vivo technology, such as augmented reality based on mpMRI images and PSMA-fluorescent guided surgery have the advantage to provide an intracorporeal analysis of the completeness of the resection. The current manuscript provides a narrative review of established techniques, and details several new and promising techniques for intraoperative PSM assessment.

Near-Infrared Autofluorescence Signature: A New Parameter for Intraoperative Assessment of Parathyroid Glands in Primary Hyperparathyroidism.

The success of parathyroidectomy in primary hyperparathyroidism depends on the intraoperative differentiation of diseased from normal glands. Deep learning can potentially be applied to digitalize this subjective interpretation process that relies heavily on surgeon expertise. In this study, we aimed to investigate whether diseased versus normal parathyroid glands have different near-infrared autofluorescence (NIRAF) signatures and whether related deep learning models can predict normal versus diseased parathyroid glands based on intraoperative in-vivo images. This prospective study included patients who underwent parathyroidectomy for primary hyperparathyroidism or thyroidectomy using intraoperative NIRAF imaging at a single tertiary referral center from November 2019 to March 2024. Autofluorescence intensity and heterogeneity index of normal versus diseased parathyroid glands were compared, and a deep learning model was developed. NIRAF images of a total of 1,506 normal and 597 diseased parathyroid glands from 797 patients were analyzed. Normal versus diseased glands exhibited a higher median normalized NIRAF intensity [2.68 (2.19-3.23) vs 2.09 (1.68-2.56) pixels, p<.0001] and lower heterogeneity index [0.11 (0.08-0.15) vs 0.18 (0.13-0.23), p<.0001]. On receiver operating characteristics analysis, optimal thresholds to predict a diseased gland were 2.22 in pixel intensity and 0.14 in heterogeneity index. On deep learning, precision and recall of the model were 83.3% each, and area under the precision-recall curve (AUPRC) was 0.908. Normal and diseased parathyroid glands in primary hyperparathyroidism have different intraoperative NIRAF patterns that could be quantified with intensity and heterogeneity analyses. Visual deep learning models relying on these NIRAF signatures could be built to assist surgeons in differentiating normal from diseased parathyroid glands.

Prophylactic Venous Supercharging in Deep Inferior Epigastric Artery Perforator Flap Surgery: A Retrospective Dual-Center Study.

Deep inferior epigastric artery perforator (DIEP) flap is nowadays considered the gold standard in breast reconstruction. However, venous congestion is still a leading cause of free flap failure. Despite the conspicuous articles regarding the use of a secondary venous anastomosis, there is a lack in the literature regarding the prophylactic use of a secondary venous route to reduce the incidence of complications during breast reconstruction. A double-center retrospective study based on women undergoing DIEP breast reconstruction was conducted, dividing patients into case group (DIEP flaps with double venous anastomosis) and control group (DIEP flaps with single venous anastomosis). Demographic and surgical data and complications were compared and statistically analyzed, and a reconstructive algorithm was proposed to improve the flap insetting. In total, 154 patients were included in the study, divided into case group (74 patients) and control group (80 patients). The median age at the time of surgery was 49.09 years (range: 29-68 years), slightly lower in group 1 when compared with group 2. The mean body mass index (BMI) was 25.52 kg/m2 (range: 21.09-29.37 kg/m2), in particular 25.47 kg/m2 (range: 23.44-28.63 kg/m2) in group 1 and 25.58 kg/m2 (range: 21.09-29.37 kg/m2) in group 2. No statistical differences were found between groups in terms of BMI and smoking and comorbidities history. The average operative times were 272.16 minutes (range: 221-328 minutes) in group 1 and 272.34 minutes (range: 221-327 minutes) in group 2, with no significant difference between groups, as well as ischemia time (44.4 minutes in group 1 [range: 38-56 minutes] and 49.12 minutes in group 2 [range: 41-67 minutes]). Statistical analysis showed a reduction in short-term complications and a statistically significant reduction for take-backs in the two groups. Our study suggests that venous supercharging of DIEP flap by performing dual venous anastomosis can be routinely and safely done prophylactically, and thus not only after intraoperative assessment of venous congestion, to avoid flap venous congestion and decrease the rates of re-exploration.

The methods of bronchial stump buttressing in post-pneumonectomy bronchopleural fistula prevention: a systematic review

Introduction The bronchopleural fistula remains one of the most severe complications after pneumonectomy. Several surgical methods may enhance bronchial stump healing and reduce the occurrence of BFP. Usually, surgeons use tissue buttressing, such as intercostal muscle flap, parietal pleura, pericardium fat pad, or mediastinal fat, to reinforce the bronchial stump. This paper reviews the literature describing the impact of different buttressing tissues on the occurrence of early post-pneumonectomy bronchopleural fistula.Material and methods We included all studies that described the use of bronchial stump buttressing in patients after pneumonectomy. Studies written in languages other than English were excluded. The search was performed using PubMed, Google Scholar, Embase, COCHRANE databases, and the clinical trial registry (www.clinicaltrials.gov) on December 1, 2023. We used the following search input: "lung cancer" AND "pneumonectomy" AND ("bronchopleural fistula" OR "BPF") AND ("tissue buttressing" OR "intercostal muscle flap" OR "mediastinal fat pad"). We analyzed the types of studies, the numbers of patients, and the most important conclusions. We performed descriptive statistics.Results Twenty-seven articles on the use of bronchial tissue buttressing were identified. Nine papers were rejected due to small sample size (&lt;20 patients), surgical operation other than pneumonectomy or lobectomy, or papers older than 30 years. Ultimately, sixteen articles were included in the analysis. Among them, three papers highlighted the statistically significant influence of bronchial stump buttressing in reducing the risk of bronchopleural fistula (BPF) formation. Descriptive statistics were reported in nine studies, and two papers included the assessment of the blood perfusion in the buttressing tissue. Only one study was a randomized trial featuring a control group for comparison.Discussion Buttressing the bronchial stump remains a controversial issue in thoracic surgery. It could be beneficial for high-risk patients. Among different tissues, the ideal one has still not been identified. Future research should incorporate control groups and intraoperative assessments of the blood supply to the tissue employed for bronchial buttressing.

Intraoperative Assessment of Noninvasive Left Ventricular Myocardial Work Indices in Patients Undergoing Aortic Valve Replacement

ObjectivesEvaluation of noninvasive left ventricular (LV) myocardial work (MW) enables insights into cardiac contractility and efficacy beyond conventional echocardiography. However, there is limited intraoperative data on patients undergoing surgical aortic valve replacement (AVR). The aim of this study was to describe the feasibility and the intraoperative course of this technique of ventricular function assessment in these patients and compare it to conventional two- and three-dimensional echocardiographic measurements and strain analysis. DesignProspective observational study SettingAt single university hospital Participants25 patients scheduled for isolated AVR with preoperative preserved left and right ventricular function, sinus rhythm, without significant other heart valve disease or pulmonary hypertension, and an uneventful intraoperative course. InterventionsTransesophageal echocardiography (TEE) was performed after induction of anesthesia (T1), after termination of cardiopulmonary bypass (T2), and after sternal closure (T3). Evaluation was performed in stable hemodynamics, in sinus rhythm or atrial pacing and vasopressor support with norepinephrine ≤ 0.1 µg/kg/min. Measurements and Main ResultsEchoPAC v206 software (GE Vingmed Ultrasound AS, Norway) was used for analysis of 2D- and 3D LV ejection fraction (EF), LV global longitudinal strain (GLS), LV global work index (GWI), LV global constructive work (GCW), LV global wasted work (GWW), and LV global work efficiency (GWE). Estimation of myocardial work was feasible in all patients. Although there was no significant difference in the values of 2D- and 3D-EF, GWI and GCW decreased significantly after AVR [T1 v T2, 1647 ± 380 mmHg% v 1021 ± 233 mmHg%, p<0.001; T1 v T2, 2095 ± 433 mmHg% v 1402 ± 242 mmHg%, p<0.001, respectively], while GWW remained unchanged [T1 v T2, 296 mmHg% (IQR 178-452) v 309 mmHg% (IQR 255-438), p=0.97]. This resulted in a decreased GWE directly after bypass [T1 v T2, 84 ± 6 % v 78 ± 5 %, p<0.001], but GWE already improved at the end of surgery [T2 v T3, 78 ± 5 % v 81 ± 5 %, p=0.003]. There was no significant change in the values of GWI, GCW, 2D- and 3D-LVEF before and after sternal closure [T2 v T3]. ConclusionLV MW analysis showed a reduction of LV work load after bypass in our group of patients, which was not detected by conventional echocardiographic measures. This evolving technique provides deeper insights into cardiac energetics and efficiency in the perioperative course of aortic valve replacement surgery.