Intraoperative Features Research Articles

OS10.3.A Predicting delirium after craniotomy in neuro-oncology

Abstract BACKGROUND Post-operative delirium (POD) is a frequent and severe complication after neurosurgical operations. Good prediction of POD after craniotomy in neuro-oncologic patients is important to install prophylactic measures, increase recognition and apply early treatment. Hence, we compared logistic regression with machine learning to build an accurate predictive model in a large dataset. MATERIAL AND METHODS POD was defined in case of a Delirium Observation Scale (DOS) ≥ 3 or start of antipsychotic treatment for delirium within 10 days after surgery. Adult patients undergoing a craniotomy for a neuro-oncologic disease in the Erasmus Medical Centre in Rotterdam were retrospectively included. The cohort was split into a training (75%), after three-fold cross validation, and test set (25%). Logistic regression and Lasso Elastic-Net Regularized Generalized Linear Models (GLMNet) were trained based on 19 pre- and intra-operative features and risk factors were identified based on the superior model. RESULTS We included 1025 neuro-oncologic craniotomies between June 2017 and September 2020. Overall incidence of POD was 18.6% (95%CI 17.4–19.8). Compared to logistic regression, Lasso GLMNet performed superior (AUC 0.73 vs. 0.76) based on the optimal tuning parameters (α=1, λ=0.014). Several non-modifiable risk factors such as age (OR1.01), prior delirium (OR1.04), memory problems (OR1.12), surgery duration (OR1.01) and modifiable risk factors, such as low potassium (OR0.97) levels and opioid administration (OR1.03), were identified. CONCLUSION POD is a frequent complication after craniotomy in neuro-oncologic patients. Lasso GLMNet was useful in predicting POD in this cohort. Validation in a prospective cohort of this model should be applied to further evaluate its value in diminishing POD.

Primary Extra-axial Glioblastoma: Case Report and Literature Review

AbstractGlioblastoma multiforme (GBM) is the most frequent and most aggressive primary brain tumor in adults, mainly located in the cerebral hemispheres. In the literature, few cases of primary GBM have been reported to have radiographic and intraoperative features of extra-axial lesions, leading to a diagnostic dilemma. Despite the advances in imaging modalities, the diagnosis of GBM can be challenging, and it is mainly based on the histopathologic confirmation of the excised tumor. We describe the case of a 76-year-old previously healthy female patient who presented to our hospital due to speech disturbances and cognitive impairment. The diagnosis of the tumor type on magnetic resonance imaging (MRI) was difficult, as the findings were suggestive of a malignant meningioma due to the heterogeneous enhancement of a dural-based mass with a dural tail sign. Moreover, the intraoperative findings revealed an extra-axial mass attached to the dura. A histological examination confirmed the diagnosis of glioblastoma with arachnoid infiltration. The patient underwent adjuvant radiotherapy and concomitant temozolomide treatment, she had clinical improvement postoperatively, and was stable during the six months of follow-up. Glioblastoma should be considered in the differential diagnosis of primary extra-axial mass with atypical and malignant features, especially in elderly patients.

Differential Diagnoses of Pediatric Upper Limb Masses

Upper limb masses are one of the most common presentations in the outpatient setting. However, there is a paucity of information in the literature regarding the epidemiology of upper-extremity masses in the pediatric population. The aim of this study was to determine the differential diagnoses and clinical characteristics in children aged ≤18 years presenting with upper limb masses. A retrospective review of patients aged ≤18 years managed at our institution over a 5-year period was performed. We obtained information on patient demographics, clinical features, radiological investigations, intraoperative features, and histology. We also evaluated the correlation between the clinical and histopathological diagnoses in patients who underwent surgery. There were 141 upper limb masses in our series. The mean age at presentation was 12 years (SD, 5 years). The most common presenting complaints were asymptomatic swelling, pain, and paresthesia. The majority (128; 91%) of tumors were benign; there were 5 locally aggressive tumors and 6 malignant tumors. The dominant hand was involved in 60 patients. Of 140 patients, 43 (31%) patients had surgery. The procedures included incisional biopsy, excisional biopsy, wide resection, and reconstruction. One patient required a below elbow amputation for an osteosarcoma. Ten percent of cases represented malignant or locally aggressive disease. We have used our observations to develop a clinical algorithm that can assist clinicians in evaluating and managing children and adolescents presenting with upper-extremity masses. Prognostic IV.

Probability of severe postpartum hemorrhage in repeat cesarean deliveries: a multicenter retrospective study in China

To determine the factors predicting the probability of severe postpartum hemorrhage (SPPH) in women undergoing repeat cesarean delivery (RCD). This multicenter, retrospective cohort study involved women who underwent RCD from January 2017 to December 2017, in 11 public tertiary hospitals within 7 provinces of China. The all-variables model and the multivariable logistic regression model (pre-operative, operative and simple model) were developed to estimate the probability of SPPH in development data and external validated in validation data. Discrimination and calibration were evaluated and clinical impact was determined by decision curve analysis. The study consisted of 11,074 women undergoing RCD. 278 (2.5%) women experienced SPPH. The pre-operative simple model including 9 pre-operative features, the operative simple model including 4 pre-operative and 2 intraoperative features and simple model including only 4 closely related pre-operative features showed AUC 0.888, 0.864 and 0.858 in development data and 0.921, 0.928 and 0.925 in validation data, respectively. Nomograms were developed based on predictive models for SPPH. Predictive tools based on clinical characteristics can be used to estimate the probability of SPPH in patients undergoing RCD and help to allow better preparation and management of these patients by using a multidisciplinary approach of cesarean delivery for obstetrician.

Pancreatoduodenectomy at the Verona Pancreas Institute: the Evolution of Indications, Surgical Techniques, and Outcomes: A Retrospective Analysis of 3000 Consecutive Cases.

The aim of the present study was to critically reappraise the experience at our high-volume institution to obtain new insights for future directions. The indications, surgical techniques, and perioperative management of pancreatoduodenectomy (PD) have profoundly evolved over the last 20 years. All consecutive PDs performed during the last 20 years at the Verona Pancreas Institute were divided into four 5-year timeframes and retrospectively analyzed in terms of indications, intraoperative features, and surgical outcomes. Significant milestones were provided to understand practice changes using a before-after analysis method. The study population consisted of 3000 patients. The median age, ASA ≥ 3 and number of nonbenchmark cases significantly increased over time ( P < 0.005). Pancreatic cancer was the leading indication, representing 60% of patients/year in the last timeframe, 40% of whom received neoadjuvant treatment. Conversely, after the development of International Guidelines, the proportion of resected cystic neoplasms progressively and thoroughly decreased. Given the increased complexity of surgery for pancreatic cancer, the evolution of technologies, surgical techniques, and postoperative management allowed the maintenance of favorable surgical outcomes over time, with a stable 20.0% of patients with a Clavien-Dindo grade ≥ 3, an 11.7% failure to rescue and a 2.3% in-hospital mortality rate. The incidence of postoperative pancreatic fistula, hemorrhage, and delayed gastric emptying was 22.4%, 13.4%, and 12.4%, respectively. PD significantly evolved in Verona over the past 2 decades. Surgeries of greater complexity are currently performed on increasingly frailer patients, mostly for pancreatic cancer and often after neoadjuvant chemotherapy. However, the progression of all fields of pancreatic surgery, including the expanding use of postoperative pancreatic fistula mitigation strategies, has allowed satisfactory outcomes to be maintained.

Clinical analysis of 21 cases of cholesteatoma recidivism after canal-wall-up mastoidectomy with tympanoplasty

Objective:To discuss the possible reasons for cholesteatoma recidivism after canal-wall-up mastoidectomy with tympanoplasty by analyzing clinical characteristics of patients. Methods:Data of 21 cases who suffered from cholesteatoma recidivism after canal-wall-up surgery were retrospectively reviewed, including preoperative examination, high resolution temporal bone CT, and intraoperative findings. Results:90.5%（19/21） cases had recurrent cholesteatoma with retraction pockets. Among 12 cases with previous operative notes, 66.7%（8/12） had extensive cholesteatoma which was not limited to attic in the original surgery. The intraoperative features of revision surgery in 21 patients including the destruction of reconstructive lateral attic wall and scutumwere found in 19.0%（4/21） cases, the head of malleus left in 19.0%（4/21） cases, the cholesteatoma found in hidden part in 14.3%（3/21） cases, the hadeustachian tube dysfunction in 38.1%（8/21）cases. the sclerotic mastoid in 42.9%（9/21） cases. hadanatomic variations of the temporal bone in 14.3%（3/21） cases and atresia of external auditory canal in 4.8%（1/21） cases. Conclusion:In this group of recidivism cases, most patients had extensive cholesteatoma, which may lead to excessive mucosa loss during lesion clearance, poor ventilation of tympanic isthmus after surgery, and promote the formation of retraction pocket. In addition, some cases had eustachian tube dysfunction, unstable reconstruction of attic lateral wall, and improper selection of the indications, which may also increase the risk of recurrence. Therefore, in order to reduce cholesteatoma recidivism after canal-wall-up surgery, attention should be paid to the striction of surgical indications, comprehensive preoperative evaluation, thorough clearance of lesions and firm reconstruction.

Pancreatoduodenectomy at the Verona Pancreas Institute: The Evolution of Indications, Surgical Techniques and Outcomesanalysis of 3000 Consecutive Cases

View Large Image Figure ViewerDownload Hi-res image Download (PPT) View Large Image Figure ViewerDownload Hi-res image Download (PPT) Purpose: The indications, surgical techniques, and perioperative management of pancreatoduodenectomy (PD) have profoundly evolved during the last 20 years. Aim of the present study was to critical reappraise the experience at our high-volume Institution to obtain new insights for future directions. Methods: All consecutive PDs performed during the last 20 years at the Verona Pancreas Institute were divided into four 5-year timeframes and retrospectively analyzed in terms of indications, intraoperative features and surgical outcomes. Significant milestones were provided to understand practice changes using a before-after analysis method. Results: The study population consisted of 3000 patients. The median age, ASA ³ 3 and non-benchmark cases significantly increased over time (p < 0.005). Pancreatic cancer was the leading indication, representing the 60% of cases/year in the last timeframe, 40% of which after receiving neoadjuvant treatments. Conversely, after the development of International Guidelines, the proportion of resected cystic neoplasms has progressively while thoroughly decreased. In the setting of augmented complexity of surgery for pancreatic cancer, the evolution of technology, surgical technique and postoperative management allowed to maintain favorable surgical outcomes over time, with a stable 20.0% Clavien-Dindo grade ³ 3, 11.7% failure to rescue and 2.3% in-hospital mortality rates. Postoperative pancreatic fistula, hemorrhage and delayed gastric emptying incidence were 22.4%, 13.4% and 12.4%, respectively. Conclusion: Pancreatoduodenectomy significantly evolved in Verona during the past two decades. Surgeries of greater complexity are currently performed on increasingly frailer patients, mostly for pancreatic cancer and often after neoadjuvant chemotherapy. However, the progression of all fields of pancreatic surgery, including the expanding use of POPF mitigation strategies, has allowed to maintain satisfactory outcomes.

Lateral Interbody Fusion at L4/5: Management of the Transitional Psoas

Managing retraction of the lumbar plexus is critical to safely perform lateral lumbar interbody fusion (LLIF) via the transpsoas approach. Occasionally, a transitional psoas is encountered at L4/5 and has been postulated to be a contraindication to transpsoas LLIF. A case series of patients with transitional psoas who underwent L4/5 LLIFs is presented. This retrospective review assessed 79 consecutive patients who underwent L4/5 LLIF during a 24-month period. Preoperative imaging was reviewed, and patients were classified into 2 groups: normal psoas or transitional psoas. Intraoperative features and outcomes were compared between groups. Seventy-nine patients underwent L4/5 LLIFs, of whom 23 had transitional psoas anatomy and 56 had normal psoas anatomy. Among patients with transitional psoas, the center of the psoas was a mean (range) of 11.2 (5.2-26.6) mm in front of the center of the vertebral body compared with 2.0 (0-4) mm in the normal psoas group. The mean (range) retraction time was similar between groups (10.8 [6.7-14.9] minutes in the transitional psoas group vs. 11.0 [7.8-15.0] minutes in the normal psoas group). No permanent motor injuries occurred in either group, and no differences in length of stay or preoperative or postoperative Oswestry Disability Index scores were found between the groups. The protocol for L4/5 LLIF in patients with transitional psoas anatomy is described. Transitional psoas anatomy is frequently encountered in surgical candidates for L4/5 LLIF. Through careful identification of the lumbar plexus and judicious retraction, the transpsoas LLIF can safely be performed in these patients.

Transcanal Endoscopic Management of Glomus Tympanicum: Multicentric Case Series.

The aim of this study was to report a multicentric surgical experience in the exclusive endoscopic management of glomus tympanicum (GT). Retrospective case series review at two institutions. Tertiary referral centers. The study included 30 patients who underwent exclusive transcanal excision of GT between 2010 and 2017 at the two referral centers. Exclusive endoscopic transcanal excision of GT type A1, A2, and B1 (modified Fisch-Mattox classification). All surgical procedures were performed by two senior surgeons (L.P.; M.B.). For each procedure, intraoperative features of the disease, postoperative complications, and functional outcomes were evaluated. Recurrent or residual diseases were clinically and radiologically assessed during the follow-up period. None of the patients treated with transcanal endoscopic approach (TEA) experienced intraoperative complications, nor required conversion to microscopic approach. Gross total resection (GTR) was obtained in 90% of the cases, while a near total resection was advocated when the residual pathology had a close relationship with the internal carotid artery. Mean hospitalization time was 1.6 (±0.8 SD) days and no postoperative complications were reported. No recurrences were reported in the GTR group after a mean follow-up period of 38.1 (±28.7 SD) months. Middle ear paragangliomas with no mastoid involvement (Class A1, A2, and B1) can be safely managed by means of a transcanal endoscopic approach. Low rate of postoperative complications, short hospitalization, and high rate of gross total resection demonstrate that TEA is a safe and effective procedure.

Hematological factors predicting mortality in patients with traumatic epidural or subdural hematoma undergoing emergency surgical evacuation: A retrospective cohort study.

Hematological abnormalities at admission are common after traumatic brain injuries and are associated with poor outcomes. The objective of this study was to identify the predictive factors of mortality among patients who underwent emergency surgery for the evacuation of epidural hematoma (EDH) or subdural hematoma (SDH).This was a single-center retrospective cohort study of 200 patients who underwent emergency surgical evacuation of EDH or SDH between September 2010 and December 2018. Data on hematological parameters and clinical and intraoperative features were collected. The primary end-point was 1-year mortality after surgery. Univariate and multivariate analysis were performed, and the receiver operating characteristic (ROC) curves were assessed.Of the 200 patients included in this study, 102 (51%) patients died within 1 year of emergency surgery. Lymphocyte count at admission, creatinine levels, activated partial thromboplastin time (aPTT), age, intraoperative epinephrine use, and Glasgow Coma Scale (GCS) score were significantly associated with mortality in the multivariate analysis. The areas under the ROC curve for the GCS score, aPTT, and lymphocyte counts were 0.677 (95% confidence interval [CI] 0.602–0.753), 0.644 (95% CI 0.567–0.721), and 0.576 (95% CI 0.496–0.656), respectively.Patients with elevated lymphocyte counts on admission showed a higher rate of 1-year mortality following emergency craniectomy for EDH or SDH. In addition, prolonged aPTT and a lower GCS score were also related to poor survival.

Results of Carotid Endarterectomy in Patients With Asymptomatic Carotid Artery Stenosis With or Without Criteria for Surgery on the Basis of the Recent European Guidelines

The objective was to retrospectively compare perioperative outcomes of carotid endarterectomy (CEA) performed for >60% asymptomatic stenosis in patients with or without preoperative clinical and imaging features suggesting the need for intervention on the basis of the 2018 European Society of Cardiology-European Society for Vascular Surgery guidelines. From January 2008 to December 2018, there were 2501 consecutive CEAs performed in a single academic institution. Data concerning these interventions were prospectively collected in a dedicated database. A retrospective analysis of the database was performed, and 1956 interventions performed in asymptomatic patients were found. Those patients were divided in two subgroups: patients not candidates for intervention on the basis of the 2018 European Society of Cardiology-European Society for Vascular Surgery guidelines (life expectancy <5 years, predominantly hyperechoic plaques on preoperative duplex ultrasound, absence of silent brain infarction at preoperative computed tomography scan; 876 interventions, group 1) and patients fulfilling the suggested indications (1080 interventions, group 2). The two groups were compared in terms of clinical, anatomic, and surgical characteristics and perioperative (<30 days) outcomes with the χ2 test. There were no differences between the two groups in terms of demographics, risk factors, and comorbidities and preoperative features, except for the cited characteristics. Intraoperative features were also similar in the two groups, with >85% of the interventions performed under clinical monitoring of the neurologic status and about 95% of polyurethane patch angioplasty closures in both groups. Shunt insertion rate was significantly higher in group 1 (19.7%) than in group 2 (16%; P = .03). Perioperative mortality was 0.3% in group 1 (three patients) and 0.3% in group 2 (three cases; P = .7). At 30 days, there were seven neurologic events in group 1 (0.8%) and eight events in group 2 (0.7%; P = .8), of which six and five were strokes, respectively. Thirty-day stroke and death rates were 1% in group 1 and 0.75% in group 2 (P = .5). There were no differences between the two groups in terms of neck hematoma requiring surgical revision, cranial nerve injuries, and perioperative myocardial infarction. Patients in group 1 more frequently experienced a perioperative atrial fibrillation (13 cases [1.4%]) than patients in group 2 (5 cases [0.4%]; P = .02). CEA performed in patients who should not undergo intervention on the basis of the recent guidelines provided excellent perioperative results, similar to those of patients inside the suggested indications. A long-term comparison is necessary.

Early Detection of Heart Failure With Reduced Ejection Fraction Using Perioperative Data Among Noncardiac Surgical Patients: A Machine-Learning Approach.

Heart failure with reduced ejection fraction (HFrEF) is a condition imposing significant health care burden. Given its syndromic nature and often insidious onset, the diagnosis may not be made until clinical manifestations prompt further evaluation. Detecting HFrEF in precursor stages could allow for early initiation of treatments to modify disease progression. Granular data collected during the perioperative period may represent an underutilized method for improving the diagnosis of HFrEF. We hypothesized that patients ultimately diagnosed with HFrEF following surgery can be identified via machine-learning approaches using pre- and intraoperative data. Perioperative data were reviewed from adult patients undergoing general anesthesia for major surgical procedures at an academic quaternary care center between 2010 and 2016. Patients with known HFrEF, heart failure with preserved ejection fraction, preoperative critical illness, or undergoing cardiac, cardiology, or electrophysiologic procedures were excluded. Patients were classified as healthy controls or undiagnosed HFrEF. Undiagnosed HFrEF was defined as lacking a HFrEF diagnosis preoperatively but establishing a diagnosis within 730 days postoperatively. Undiagnosed HFrEF patients were adjudicated by expert clinician review, excluding cases for which HFrEF was secondary to a perioperative triggering event, or any event not associated with HFrEF natural disease progression. Machine-learning models, including L1 regularized logistic regression, random forest, and extreme gradient boosting were developed to detect undiagnosed HFrEF, using perioperative data including 628 preoperative and 1195 intraoperative features. Training/validation and test datasets were used with parameter tuning. Test set model performance was evaluated using area under the receiver operating characteristic curve (AUROC), positive predictive value, and other standard metrics. Among 67,697 cases analyzed, 279 (0.41%) patients had undiagnosed HFrEF. The AUROC for the logistic regression model was 0.869 (95% confidence interval, 0.829-0.911), 0.872 (0.836-0.909) for the random forest model, and 0.873 (0.833-0.913) for the extreme gradient boosting model. The corresponding positive predictive values were 1.69% (1.06%-2.32%), 1.42% (0.85%-1.98%), and 1.78% (1.15%-2.40%), respectively. Machine-learning models leveraging perioperative data can detect undiagnosed HFrEF with good performance. However, the low prevalence of the disease results in a low positive predictive value, and for clinically meaningful sensitivity thresholds to be actionable, confirmatory testing with high specificity (eg, echocardiography or cardiac biomarkers) would be required following model detection. Future studies are necessary to externally validate algorithm performance at additional centers and explore the feasibility of embedding algorithms into the perioperative electronic health record for clinician use in real time.

Clinical experience with the Clareon® IOL and the AutonoMe® implantation system

The AutonoMe® implantation system with a preloaded, monofocal, aspherical, hydrophobic Clareon® intraocular lens (IOL) has recently become available. The aim of this analysis was the most comprehensive review of intraoperative and postoperative outcomes to date. Prospective evaluation of intraoperative features in all eyes scheduled to have cataract surgery with Clareon® IOL implantation using the AutonoMe® implantation system between December 2017 and September 2018 with follow-up at 4-6weeks. Inclusion of all patients, regardless of comorbidities and accompanying ocular surgery. A total of 391 eyes were evaluated for the intraoperative analysis and 144 eyes were evaluated for postoperative follow-up. There was one IOL-associated intraoperative complication in which the posterior haptic was not correctly loaded and should not have been implanted. The best corrected distance visual acuity (BCDVA) increased from a mean of 0.33 logMAR (SD 0.21) preoperatively to 0.09 logMAR (SD 0.21) postoperatively, independent of ocular comorbidities. The BCDVA in patients without ocular comorbidities increased from 0.27 logMAR (SD 0.13) preoperatively to 0.03 logMAR (SD 0.05) postoperatively. Using the SRK®/T formula 87.5% of all eyes had arefractive error of ≤0.5 D and 98.0% had arefractive error of ≤1 D 4-6weeks after surgery. This study showed that using the recommended safety guidelines, the AutonoMe® system enables safe implantation of the IOL. The Clareon® IOL showed good postoperative visual outcomes and refraction results using the SRK®/T formula.

Efficacy of Sialendoscopy in the Management of Noncalculi-Related Sialadenitis

Sialendoscopy has effectively changed the paradigm for the treatment of sialolithiasis. Its effect on noncalculi-related recurrent sialadenitis is, however, unclear, especially regarding the long-term outcomes. The objectives of the present study were to evaluate the long-term efficacy of sialendoscopy for noncalculi-related recurrent sialadenitis and determine the clinical and intraoperative features that might be prognosticate outcomes. We performed a prospective cohort study of 33 consecutive patients who had undergone sialendoscopy for recurrent noncalculi-related sialadenitis by a single surgeon in a tertiary institution from January 2010 to December 2016. The patient-reported outcome measures were used as the primary determinant of treatment efficacy. The clinical features and endoscopic findings were evaluated as variables that might predict the treatment outcomes. The Fischer exact test was used to analyze the descriptive data, and a P value of<.05 was considered to indicate statistical significance. Of the 33 patients with recurrent noncalculi-related sialadenitis, 1 was lost to follow-up and thus excluded from the analysis. The mean and median follow-up period for the 32 patients was 27 and 21.5months, respectively. Of the 33 patients, 28 (87.5%) reported symptom improvement, and 19 patients (59.4%) were symptom free after a single sialendoscopic treatment. The chronicity of symptoms, younger patient age, and concurrent autoimmune disease were predictive of recurrent symptoms despite sialendoscopy. The use of sialendoscopy achieved sustained long-term improvements or resolution of symptoms for most patients with recurrent noncalculi-related sialadenitis. The data from our study support the benefits of sialendoscopy for patients with recurrent noncalculi-related sialadenitis.

Primary pigmented meningeal melanocytoma originating in Meckel cave in a patient with carney complex

Rationale:Primary melanin-producing tumors are rare extra-axial neoplasms OPEN of the central nervous system. In the literature, few case reports have discussed neoplasms involving the cavernous sinus; of these, only 4 have reported on neoplasms originating in Meckel cave. The diagnostic approach, including clinical and radiological analysis, is challenging, and cytopathological assessment with a molecular basis is the best approach to discriminate between these lesions. Herein, we discuss the pathophysiology, diagnostic approach, intraoperative features, and postoperative management in a unique case of primary pigmented meningeal melanocytoma originating in Meckel cave in a patient who was diagnosed with Carney complex (CCx) and sickle cell disease (SCD).Patient concerns:A 23-year-old man diagnosed with SCD had also been diagnosed previously with CCx, without any familial history or neurocutaneous melanosis. He had experienced headaches accompanied by left facial pain and paresthesia for 2 months.Diagnosis:The initial computed tomography scan and magnetic resonance imaging (MRI) revealed a mass arising from the left Meckel cave. On MRI, it followed the signal intensity of melanin. He underwent subtotal resection of the mass. Considering the patient's history of CCx, melanocytic schwannoma was the most relevant diagnosis. A postoperative histopathological examination was suggestive of benign pigmented meningeal melanocytoma.Interventions:The patient underwent an uneventful subtotal resection of the mass through a left temporal linear incision.Outcomes:The patient showed progressive improvement of neurologic deficits, and after 2 years of follow-up, he did not present with any new complaints.Lessons:To the best of our knowledge, this is the first report of the unusual presentation of both SCD, as well as of primary pigmented meningeal melanocytoma in a patient with CCx. Complete surgical resection can be curative in most cases of melanocytoma. The presence of CCx with SCD suggests potential shared genetic contributions that will require further exploration.

Hybrid aortic repair in patients with type III aortic dissection and concomitant proximal aortic lesion

To report our own experience of hybrid treatment using FET technique in patients with type A aortic dissection and concomitant lesion of aortic arch and ascending aorta. There were 90 (28,3%) FET procedures for the period from January 2010 to August 2019. Type B aortic dissection was diagnosed in 19 (45,2%) patients. Type B aortic dissection combined with aortic arch aneurysm occurred in 11 (58%) cases, ascending aorta aneurysm - 15 (79%) cases. Patients underwent total arch and ascending aorta replacement via median sternotomy (upper partial J-shaped sternotomy in 3 cases). Valve-sparing interventions were performed in 58% of cases (aortic root repair - 6 (32%) patients, David procedure - 5 (26%) cases). Intraoperative features, early postoperative morbidity and in-hospital mortality were retrospectively analyzed. In long-term period, distal aortic remodeling, survival rate and incidence of redo interventions were evaluated. Mean CPB time was 166±27 min, aortic cross-clamping time - 93±23 min, duration of circulatory arrest - 43±11 min. Neurological complications and paraplegia were absent. In-hospital mortality was absent. Reversible acute renal failure without need for hemodialysis developed in 2 cases (11%). Two patients underwent repeated intervention (TEVAR) due to dSINE and negative aortic remodeling. Annual survival rate was 100%. Freedom from redo aortic surgery was 89,5%. FET surgery is an adequate alternative treatment for type B aortic dissection combined with lesion of aortic arch and ascending aorta. This approach ensures a one-stage repair in patients with contraindications to TEVAR. Unlike thoracotomy, FET procedure is valuable for simultaneous correction of cardiac and proximal aortic lesion, stabilizing the distal segments of dissected aorta. This is obvious advantage of this technique.

Risk factors, prevention measures and diagnostics postoperative stermediastinitis

Median sternotomy remains the most frequent access in cardiac surgery, while postoperative sternomediastinitis is one of the most serious complications of transsternal access. The article analyzes the preoperative factors for the development of complications, including concomitant pathology, constitutional features, bad habits, length of hospital stay, and urgency of the operation. It was also noted that intraoperative factors consist of technical errors in the operation, intraoperative features of the course of surgical intervention, the nature of the choice of shunt during myocardial vascularization and the completion of the operation. Postoperative risk factors include the management of the postoperative period in cardiac patients, that can lead to complications. The analysis of preventive measures taken by cardiac surgeons in the development of complications is presented.

Anomalous superior oblique muscles and tendons in congenital fibrosis of the extraocular muscles

To evaluate the finding of anomalous superior oblique muscles in congenital fibrosis of the extraocular muscles (CFEOM), a feature not previously emphasized in this condition. The medical records of all patients clinically or genetically diagnosed with CFEOM at Boston Children's Hospital between 2010 and 2018 were reviewed retrospectively. Those who underwent strabismus surgery during the study period were included in the analysis. Baseline patient characteristics, type of CFEOM, results of genetic testing, and intraoperative features of the superior oblique muscle or tendon were recorded. Of 24 patients identified (age range, 1month to 62years), 10 (42%) had genetically confirmed CFEOM, and 22 underwent strabismus surgery, 14 (64%) involving the superior oblique muscle. Of these, 7 (50%) had anomalously inserted tendons (most commonly attached nasal to the superior rectus muscle), whereas 7 (50%) had increased superior oblique muscle tension. Half of CFEOM patients who underwent superior oblique surgery had abnormally inserted superior oblique tendons, and 50% had tight muscles or abnormally thin tendons, findings that have not been well-characterized in this condition. The findings suggest that abnormal insertion of the superior oblique muscles and tendons are additional features of the disease process in CFEOM that have not been described previously. These features may contribute to the severe upgaze limitation in CFEOM and highlight the importance of superior oblique tenotomy in surgical management.

Safety and effectiveness of a new valvulotome: insights from the LIMBSAVE registry.

In the endovascular era peripheral bypass surgery still plays a key role. In situ saphenous vein bypass is a standardized technique. The main limitation of this procedure is the vein diameter. A new hydrophylic valvulotome (HYDRO LeMaitre® Valvulotome; LeMaitre Vascular, Burlington, MA, USA) allows even to disrupt the valves in smaller veins. The aim of this study was to analyze the intraprocedural and technical successes of this new valvulotome. In January 2018 in Italy a national, multicenter, observational, prospective registry based on the examination of treatment of critical limb ischemia with infragenicular bypass adopting in situ saphenous vein technique (LIMBSAVE registry) started the enrollment. Until December 2018 216 patients have been enrolled in the registry. All data concerning the procedures were prospectively collected in a dedicated database. The information included demographics, preoperative risk factors, clinical and diagnostic preoperative assessments, intraoperative features, and discharge outcomes, including the safety and effectiveness of the valvulotome during the surgical procedure. Patients were predominantly male (160, 74.1%) with a mean age of 74.1 years (range 49-95). The mean diameter of the great saphenous vein was 3.7 mm (range 1.7-10) in the proximal part of the thigh, 3.4 mm (range 1.6-7) in the distal part of the thigh, and 3.1 mm in the proximal part of the leg (range 1.6-5). The technical success was obtained in all cases (the bypass pulsed after the utilization of the valvulotome). The valvulotome was able to reach the proximal anastomosis in all cases. The mean number of utilizations was 2.6 (range 1-5). No vein perforation has been detected. In 6 cases (2.8%) a vein adventitial damage occurred. In one case with uncontrolled bleeding (0.5%) the substitution of the deleted vein segment was necessary. Preliminary intraprocedural outcomes of LIMBSAVE registry showed that HYDRO LeMaitre® Valvulotome was safe and effective in disrupting the valves and obtaining the pulsatility of the saphenous vein. The rate of complications related to the utilization of the valvulotome was low. Further examinations are needed to evaluate the long-term outcomes of the bypass in terms of patency, reinterventions, and limb salvage.

Acute pancreatitis with Cullen's sign presentation in a case of mixed type I and II choledochal cyst

A 3 year old girl presented initially with acute severe hemorrhagic pancreatitis diagnosed by clinical features including a positive Cullen's sign and raised serum amylase. A contrast enhanced computed tomography (CECT) scan corroborated the same and also reported a type I choledochal cyst. Magnetic resonance cholangiopancreatography (MRCP) 2 months later reported a type II choledochal cyst and a persistent pseudo pancreatic cyst. Intraoperative features and close perusal of the CECT and MRCP films showed the presence of mixed type I and II choledochal cyst. The case is reported for the presence of Cullen's sign, CECT and MRCP features of a mixed type I and II choledochal cyst and successful surgical outcome. It appears to be only the fifth case of mixed type I and II choledochal cyst in world literature in the pediatric age group, following the 4 previous cases in children reported from Japan.