Intraoperative Lesion Research Articles

Association between preoperative appendiceal histology grade and Pseudomyxoma peritonei grade offer a solution to avoid right hemicolectomy during cytoreductive surgery and HIPEC

Introduction& objectives: Treatment of PMP consists of appendectomy, cytoreductive surgery (CRS) and HIPEC. Right-sided hemicolectomy is necessary only when PMP is high grade, given the lymphatic invasion risk. To date, no single preoperative factor was identified as predictive of PMP grade.Materials & methods: Preoperative factors of a prospective cohort study on PMP were retrospectively analysed, in order to identify situations linked with high or low grade appendiceal PMP. The main outcome was PMP grade on definitive histology after CRS. Resultsn=105. In univariate analysis, the grade of the appendiceal tumor, systematically reviewed in an expert center, showed an OR of 25.00 (95% CI: 3.30–189.27; p = 0.001) and an NPV of 93.75 [85.36, 100]. Peritoneal biopsy demonstrated an OR of 19.80 (95% CI: 2.30–170.71; p = 0.002) and a PPV of 90 [71.41, 100]. In multivariate analysis, these two factors remained significantly associated with PMP grade. ConclusionWhenever appendiceal tumor is low grade on preoperative histology, the colon has to be spared unless completeness of CRS is compromised, which is a high-grade feature in fact. In case of high grade appendiceal tumor and/or peritoneal biopsy, right-sided hemicolectomy is warranted. If no histology is available preoperatively, adapt to intraoperative lesions as no preoperative factors seem to be predictive.

More negative sagittal tibial tuberosity-trochlear groove distances are correlated with larger patellofemoral chondral lesion size.

The purpose of this study is to assess the association between sagittal tibial tuberosity-trochlear groove (sTT-TG) distance and patellofemoral chondral lesion size in patients undergoing cartilage restoration procedures. A retrospective cohort analysis of patients who underwent an osteochondral allograft transplantation or matrix-induced autologous chondrocyte implantation in the patellofemoral compartment, from 2010 to 2020, were included if they had patellofemoral high-grade lesions, magnetic resonance imaging (MRI) and minimum 2-year follow-up. The preoperative sTT-TG distance was measured independently on axial T2-weighted MRI sequences by two authors, each at least two weeks apart. Intraoperative lesion size was reported according to operative report measurements by the attending surgeon. An interclass correlation coefficient (ICC) was calculated to assess intra- and inter-rater reliability, and categorical data analysis and linear regression models were used to assess the relationship between sTT-TG and lesion size. A total of 80 patients (50 females) with a mean age of 31.5 ± 10.4 years, body mass index of 27.0 ± 5.9 kg/m2 and follow-up of 61.5 ± 21.4 months were included. A total of 107 lesions were present: 63 patients with unipolar (patella = 41, trochlea = 22) and 22 with bipolar lesions. The mean MRI defect size was 1.6 ± 1.0 cm2 and the mean intraoperative defect size was 3.8 ± 2.4cm2. Intra- (ICC: 0.99,0.98) and inter-rater reliability (ICC: 0.96) were excellent for both MRI defect size and sTT-TG measurements. The mean sTT-TG was -4.8 ± 4.9 mm and was significantly inversely related to MRI defect size (-0.45, p < 0.01), intraoperative patellar lesion size (-0.32, p = 0.01), total lesion area (-0.22, p = 0.04), but not trochlear lesion size (-0.09, p = 0.56). Multivariable regression demonstrated a more negative sTT-TG remained an independent variable correlated with larger MRI-measured patellofemoral defect sizes and intraoperative patellar lesions. A more negative sTT-TG was an independent variable correlated with larger patellofemoral lesions in patients undergoing patellofemoral cartilage restoration. Level III, Diagnostic.

Configurational changes of ruptured intracranial aneurysms at the window between pre-operative CTA and the definite clipping surgery

Background: Ruptured intracranial aneurysms may face configurational changes in size and shape resulting from extreme weakness in their wall. These configurational changes are associated with an amplified risk of rupture and surgical challenges as these aneurysms have proven to be unstable. However, to our knowledge, no previous studies have addressed the issue of configurational aneurysmal changes between the patient’s presentation (radiological images) and intraoperative findings. This paper aims to compare aneurysmal size and shape between pre-operative Computed tomography angiography and intraoperative lesion characteristics in a cohort of patients presented to our centre. Methods: A retrospective analysis was performed on cases admitted to the Neurosurgery Teaching Hospital in Baghdad, Iraq, and underwent microsurgical clipping of ruptured aneurysms. Their records were checked for aneurysmal configurational changes by comparing pre-operative radiological images and intra-operative findings. Results: Of the 275 patients, 5 cases were enrolled with aneurysmal configurational changes. Three of them were females, and two were males. The pre-operative aneurysmal shapes based on Computed tomography angiography were (3 unicyst and two conical shapes) and the range of aneurysmal size was (7-11 mm) with a mean of 9 mm. Compared to intra-operative findings, there were total aneurysmal shape changes (connected cyst in 4 patients and spherical aneurysm in one patient). The range of aneurysmal size was (7-11 mm) with a mean of 9 mm. Conclusion: Intracranial aneurysms may undergo configurational changes through the time between pre-op imaging and surgery; early detection of these changes may ensure optimal management of such cases.

Radar localization of breast and axillary lesions with SCOUT: a prospective single institution pilot study.

Wire-guided localization has been the mainstay of localization techniques for non-palpable breast and axillary lesions prior to excision. Evidence is still growing for relatively newer localization technologies. This study evaluated the efficacy of the wireless localization technology, SCOUT®, for both breast and axillary surgery. Data were extracted from a prospective database (2021-2023) of consecutive patients undergoing wide local excision, excisional biopsy, targeted axillary dissection, or axillary lymph node dissection with SCOUT at a high-volume tertiary centre. Rates of successful reflector placement, intraoperative lesion localization, and reflector retrieval were evaluated. A survey of surgeon-reported ease of lesion localization and reflector retrieval was also evaluated. ACTRN386751. One-hundred-ninety-five reflectors were deployed in 172 patients. Median interval between deployment and surgery was 3 days (range 1-20) and mean distance from reflector to lesion was 3.2 mm (standard deviation, SD 3.1). Rate of successful localization and reflector retrieval was 100% for both breast and axillary procedures. Mean operating time was 65.8 min (SD 33). None of the reflectors migrated. No reflector deployment or localization-related complications occurred. Ninety-eight percent of surgeons were satisfied with ease of localization for the first half of cases. SCOUT is an accurate and reliable method to localize and excise both breast and axillary lesions, and it may overcome some of the limitations of wire-guided localization.

Hemorrhagic cerebral venous infarction after vein injury during intraoperative lesion resection: incidence, hemorrhagic stages, risk factors and prognosis.

Cerebral venous infarction (CVI) after vein injury during intraoperative lesion resection is associated with intracranial hemorrhage. We conducted this study to identify the incidence, clinical and imaging features, and prognosis of hemorrhage CVI. We performed a retrospective analysis of patients with confirmed CVI after vein injury who underwent craniotomy in our hospital. Postoperative clinical symptoms were observed, and imaging features were compared between patients with and without intracranial hemorrhages through CT examination. Variables were analyzed using univariate and multivariate regression analyses. Among 2,767 patients who underwent craniotomy, 93 cases of injured veins were identified intraoperatively. Hemorrhagic CVI was found in 38% (35/93). Multivariate analysis revealed that midline approach, meningioma, postoperative seizures, disorders of consciousness and interval in hours < 72 h were identified as predictors of hemorrhagic CVI. After 3 months of follow-up, the prognosis was poor in 15 cases (16%, 15/93), including death (two cases), vegetative survival (four cases), and severe disability (nine cases). Hemorrhagic CVI, as a critical complication after venous injury, can have disastrous consequences. Do not injure known veins intraoperatively. In case of injury, requisite remedial measures should be adopted during and after surgery.

Hybrid operating room with ceiling mounted imaging system assisted pre-operative and intra-operative lung nodule localization for thoracoscopic resections: a 5-year case series

BackgroundVideo-assisted thoracoscopic (VATS) lung resections are increasingly popular and localization techniques are necessary to aid resection. We describe our experience with hybrid operating room (OR) cone-beam computed tomography (CT) assisted pre-operative and intra-operative lesion localization of lung nodules for VATS wedge resections, including our novel workflow using the hybrid OR cone-beam CT to re-evaluate patients who have undergone pre-operative localization for those who are unsuitable for intra-operative localization.MethodsRetrospective analysis of all consecutive patients with small (≤ 20 mm), deep (≥ 10 mm distance from pleura) and/or predominantly ground-glass nodules selected for lesion localization in the Interventional Radiology suite followed by re-evaluation with cone-beam CT in the hybrid OR (pre-operative), or in the hybrid OR alone (intra-operative), prior to intentional VATS wedge performed by a single surgeon at our centre from January 2017 to December 2021.Results30 patients with 36 nodules underwent localization. All nodules were successfully resected with a VATS wedge resection, although 10% of localizations had hookwire or coil dislodgement. The median effective radiation dose in the pre-operative group was 10.4 mSV including a median additional radiation exposure of 0.9 mSV in the hybrid OR for reconfirmation of hookwire or coil position prior to surgery (p = 0.87). The median effective radiation dose in the intra-operative group was 3.2 mSV with a higher mean rank than the intra-operative group, suggesting a higher radiation dose (p = 0.01).ConclusionsWe demonstrate that our multidisciplinary approach utilizing the hybrid OR is safe and effective. Intra-operative localization is associated with lower radiation doses. Routine use of cone-beam CT to confirm the position of the physical marker prior to surgery in the hybrid OR helps mitigate consequences of localization failure with only a modest increase in radiation exposure.

Vagus Nerve Stimulation in the Carotid Triangle: An Effective Method for Monitoring the Recurrent Laryngeal Nerve in Thyroid and Parathyroid Surgery.

Our objective is the description of the technique of vagus nerve stimulation in carotid triangle in order to monitor the recurrent laryngeal nerve (RLN) during thyroid and parathyroid surgery. We stimulated the vagus nerve in the carotid triangle during 150 thyroid or parathyroid surgeries using a monopolar electromyography electrode inserted under the mastoid process towards the jugular foramen as a cathode, and using another subdermal electrode in the mastoid as an anode. Another complementary method of vagus stimulation was achieved with a pair of subdermal electrodes, placing the cathode at the mandibular angle and the anode at the mastoid. In all patients, compound muscle action potential (CMAP) was recorded in the vocal cords with both stimulation techniques, allowing semi-continuous monitoring to be carried out. Intraoperative lesions were detected in 16 of the cases; 9 of them were transient with CMAP recovery achieved when modifying surgical maneuvers. Vagus nerve stimulation in the carotid triangle is a reliable technique for monitoring the RLN in thyroid surgery. Vagus nerve stimulation in the carotid triangle is effective and safe for RLN monitoring, and it is a clear alternative to direct continuous stimulation of the nerve that by contrast requires its dissection in the carotid sheath.

INTRA- AND EARLY POSTOPERATIVE RESULTS OF BIOPSY OF SIGNAL LYMPH NODE UNDER CONTROL OF ICG MAPPING IN PATIENTS WITH ENDOMETRIAL CANCER OF INITIAL STAGES

Biopsy of sentinel lymph nodes (SNL) with the use of indocyanine green (ICG) as an indicator is becoming a standard method for evaluating the lymphatic reservoir in endometrial cancer in patients in the early stages.&#x0D; The purpose of the study. To conduct a comparative assessment of іntra- and early postoperative results in patients with endometrial cancer of initial stages when performing systemic lymphadenectomy and ICG mapping for the detection of SLNs.&#x0D; Materials and methods. The study included 98 patients (2017-2022) with morphologically verified endometrial cancer with low and mediumintermediate risks of metastasis. Removal of lymph nodes was carried out in two ways: 1)systemic lymphadenectomy (group 1); 2) ICG mapping for detection of SLN in the pelvic area (group 2).&#x0D; Results. The time of the operation for 1 group is longer - (63.7 ± 14.8) min. than for the second - (36.4 ± 8.9) min. In group 1, intraoperative lesions of the obturator nerve were detected in 2 patients (4.5%), postoperative complications also were observed: lymphocysts 3 (7.5%), lymphostasis 2 (5.5%), prolonged lymphorrhea 4 (9.5%) and. There were no complications in group 2. In both groups, there were no bleedings and intraoperative injuries of the pelvic organs. In group 1, the average number of extracted LVs was 8.5±2 on each side; positive LNs were found in 3 (8%) patients, the remaining 38 (92%) were negative. Identification of the localization of LN was not carried out; since their evacuation from the abdominal cavity was carried out in a single block - 32 (80%), in 8 (20%) - fragmentary (which still does not allow identification of the position of the LN). No metastases were detected in group 2; in 40 (70 %) patients, SLN was detected on both sides, 11 (20 %) - on one side, and 6 (10 %) - not detected. In these 10% of patients, systemic lymph node dissection was performed. The most common localizations of LN are the external iliac vessels and the obturator area on both sides.&#x0D; Conclusions. SLN biopsy should be used more often in early-stage endometrial cancer. The SLN technique can be used in patients with low and intermediate risk of lymphatic metastases to reduce the frequency of complications associated with systemic lymph node dissection. This technique can be used for patients with a higher risk of metastasis (in particular, average and high-average) in the presence of concomitant comorbid pathology. Its advantages are: reducing the trauma of the procedure, surgical comorbidity (lymphorrhea, lymphocysts, vascular and nerve injury), reducing the time of surgical intervention (which reduces the risk of infectious complications), reduction of blood loss, shortening of hospitalization, faster recovery, improvement of cosmetic effect and equivalence of oncological results.

Heterogeneity of prostate-specific membrane antigen (PSMA) and PSMA-ligand uptake detection combining autoradiography and postoperative pathology in primary prostate cancer

BackgroundTargeting prostate-specific membrane antigen (PSMA) has been highly successful for imaging and treatment of prostate cancer. However, heterogeneity in immunohistochemistry indicates limitations in the effect of imaging and radionuclide therapy of multifocal disease. 99mTc-PSMA-I&S is a γ-emitting probe, which can be used for intraoperative lesion detection and postsurgical autoradiography (ARG). We aimed to study its intraprostatic distribution and compared it with (immuno)-histopathology.ResultsSeventeen patients who underwent RGS between 11/2018 and 01/2020 with a total of 4660 grids were included in the preliminary analysis. Marked intratumor and intra-patient heterogeneity of PSMA expression was detected, and PSMA negative foci were observed in all samples (100%). Heterogeneous intra-patient PSMA-ligand uptake was observed, and no significant correlation was present between the degree of heterogeneity of PSMA expression and PSMA-ligand uptake. Higher PSMA-ligand uptake was observed in GS ≥ 8 than GS < 8 (p < 0.001). The appearance of Gleason Pattern (GP) 4 was strongly associated with higher uptake (coefficient: 0.43, p < 0.001), while GP 5 also affected the uptake (coefficient: 0.07, p < 0.001).ConclusionPSMA expression and PSMA-ligand uptake show marked heterogeneity. Prostate carcinoma with GP 4 showed significantly higher uptake compared with non-neoplastic prostate tissue. Our analyses extend the scope of applications of radiolabeled PSMA-ligands to ARG for identifying high-grade disease and using its signal as a noninvasive biomarker in prostate cancer.

Short-term effectiveness of orthopedic robot-assisted resection for osteoid osteoma

To investigate short-term effectiveness and clinical application advantages of orthopedic robot-assisted resection for osteoid osteoma compared with traditional open surgery. A retrospective analysis was conducted on clinical data of 48 osteoid osteoma patients who met the selection criteria between July 2022 and April 2023. Among them, 23 patients underwent orthopedic robot-assisted resection (robot-assisted surgery group), and 25 patients received traditional open surgery (traditional surgery group). There was no significant difference ( P>0.05) in gender, age, disease duration, lesion location and size, and preoperative visual analogue scale (VAS) score, and musculoskeletal tumor society (MSTS) score between the two groups. The surgical time, intraoperative blood loss, intraoperative lesion localization time, initial localization success rate, infection, and recurrence were recorded and compared. VAS scores before surgery and at 24 hours, 1, 3, 6, and 9 months after surgery and MSTS score before surgery and at 3 months after surgery were assessed. All patients completed the surgery successfully, with no significant difference in surgical time between the two groups ( P>0.05). Compared to the traditional surgery group, the robot-assisted surgery group had less intraoperative blood loss, shorter lesion localization time, and shorter hospitalization time, with significant differences ( P<0.05). The initial localization success rate was higher in the robot-assisted surgery group than in the traditional surgery group, but the difference between the two groups was not significant ( P>0.05). All patients in both groups were followed up, with the follow-up time of 3-12 months in the robot-assisted surgery group (median, 6 months) and 3-14 months in the traditional surgery group (median, 6 months). The postoperative MSTS scores of both groups improved significantly when compared to those before surgery ( P<0.05), but there was no significant difference in the changes in MSTS scores between the two groups ( P>0.05). The postoperative VAS scores of both groups showed a gradually decreasing trend over time ( P<0.05), but there was no significant difference between the two groups after surgery ( P>0.05). During follow-up, except for 1 case of postoperative infection in the traditional surgery group, there was no infections or recurrences in other cases. There was no significant difference in the incidence of postoperative infection between the two groups ( P>0.05). Orthopedic robot-assisted osteoid osteoma resection achieves similar short-term effectiveness when compared to traditional open surgery, with shorter lesion localization time.

Endoscopic release of the carpal tunnel using the Agee technique modified by Neumann

Decompression of the median nerve by complete endoscopic release of the transverse carpal ligament (TCL) and the distal antebrachial fascia. Minimization of surgical trauma results in decreased postoperative morbidity and earlier return to work and daily activities. Symptomatic carpal tunnel syndrome. Revision surgery after open or endoscopic procedure, rheumatic diseases. Small transverse incision at the ulnar border of the palmaris longus tendon, and proximal to the distal wrist flexion crease. Exposure and incision of the antebrachial fascia, dilatation of the carpal tunnel and dissection of synovial tissue from the undersurface of the TCL. With the wrist in extension, the endoscopic blade assembly with integrated camera is inserted into the canal. Exposure of TCL and short incision in the middle portion. Gradually, dissection of the distal portion of the TCL then completion by retraction of the blade distally to proximally. Slightly compressive dressing, selfcare on day1 after procedure. More than 25years of experience, more than 8000 treated patients, and 3 documented cases with intraoperative lesions of the median nerve requiring revision. High acceptance and patient satisfaction in AQS1patient-reported surveillance.

Morphological and Metrical Relationships Between Sphenoid Sinus and Sella Turcica: Possible Applications in Transnasal Transsphenoidal Surgery.

Transsphenoidal surgeries imply the risk of intraoperative lesions to the neurovascular structures surrounding the sphenoid sinus (SS). Aim of the present study is to assess the metrical and morphologic relationships existing between SS and sella turcica (ST). Two hundred computed tomography-scans of patients were selected. For each patient volumes of SS were calculated from their 3-dimensional models segmented through ITK-SNAP program. Variants of SS in pneumatisation and sellar diameters [antero-posterior (AP) diameter, depth, and length] were evaluated on each computed tomography-scan. Correlations among different measurements were assessed through Spearman test ( P <0.01), whereas associations between sellar parameters and presence of pneumatisation variants were assessed through Mann-Whitney test ( P <0.01). In males, pneumatization of the greater wings was related to smaller AP diameter ( P <0.01) and depth of ST ( P <0.01), whereas in females lower values of depth were found in patients with pneumatization of the pterygoid processes ( P <0.01). In both sexes, a positive correlation was found between AP diameter and, respectively, length and depth of ST ( P <0.01), together with a negative correlation between volume of SS and depth of ST ( P <0.01). Lastly, in females a positive correlation was found between age and, respectively, length and depth of ST ( P <0.01). The present study highlighted new metrical and morphologic relationships between volume and pneumatisation of SS and diameters of ST. Knowledge of these correlations allows to understand more clearly, in the preoperative setting, the surgical working space. Further studies are needed, especially for what concerns the relationship between sellar measurements and age in females.

Computational Imaging to Compensate for Soft-Tissue Deformations in Image-Guided Breast Conserving Surgery.

During breast conserving surgery (BCS), magnetic resonance (MR) images aligned to accurately display intraoperative lesion locations can offer improved understanding of tumor extent and position relative to breast anatomy. Unfortunately, even under consistent supine conditions, soft tissue deformation compromises image-to-physical alignment and results in positional errors. A finite element inverse modeling technique has been developed to nonrigidly register preoperative supine MR imaging data to the surgical scene for improved localization accuracy during surgery. Registration is driven using sparse data compatible with acquisition during BCS, including corresponding surface fiducials, sparse chest wall contours, and the intra-fiducial skin surface. Deformation predictions were evaluated at surface fiducial locations and subsurface tissue features that were expertly identified and tracked. Among n = 7 different human subjects, an average of 22 ± 3 distributed subsurface targets were analyzed in each breast volume. The average target registration error (TRE) decreased significantly when comparing rigid registration to this nonrigid approach (10.4 ± 2.3 mm vs 6.3 ± 1.4 mm TRE, respectively). When including a single subsurface feature as additional input data, the TRE significantly improved further (4.2 ± 1.0 mm TRE), and in a region of interest within 15 mm of a mock biopsy clip TRE was 3.9 ± 0.9 mm. These results demonstrate accurate breast deformation estimates based on sparse-data-driven model predictions. The data suggest that a computational imaging approach can account for image-to-surgery shape changes to enhance surgical guidance during BCS.

Adolescent Athletes Achieve High Levels of Athletic and Daily Function After Arthroscopic Marrow Stimulation for Elbow Capitellar Osteochondritis Dissecans

To determine the functional outcomes of adolescent athletes treated with arthroscopic marrow stimulation/microfracture for elbow capitellar osteochondritis dissecans (OCD). The medical records for all patients younger than 18 years of age with capitellar OCD who underwent arthroscopic treatment at a single institution were retrospectively reviewed. The variables examined included patient characteristics, bone age, pre- and postoperative lesion grade/size and range of motion (ROM), intraoperative lesion grade/size, time to postoperative return to sport, and validated outcome scores. Twenty patients with 21 treated elbows met the study's inclusion criteria. Three patients were not available for follow-up, leaving 18 of 21 (85.7%) elbows in the final cohort. Mean age and follow-up was 14.1 and 4.4 years, respectively. All 18 elbows were treated with diagnostic arthroscopy, arthroscopic debridement with loose body removal as indicated, and marrow stimulation. Sixteen of 18 (88.9%) elbows returned to sports postoperatively, with 12 of 18 (66.7%) elbows returning to their primary sport at the same level or higher. Overall, there were significant improvements in elbow ROM (132.8°, range 120°-140° postoperatively, compared with 122.1°, range 80°-140° preoperatively) (P= .002) and excellent Quick Disabilities of the Arm, Shoulder and Hand scores (mean 2.3 ± 5.1), as well as Kerlan-Jobe Orthopaedic Clinic Overhead Athlete Shoulder and Elbow scores (mean 94.1 ± 8.7) in those who returned to sports. There was no correlation with outcome or return to sport for preoperative lesion grade/size, bone age, physeal status or open versus arthroscopic treatment. Arthroscopic debridement and marrow stimulation for capitellar OCD in adolescent athletes leads to improvements in ROM, as well as a high rate of return to sport, and high levels of athletic and daily functional activity during follow-up, regardless of bone age and lesion grade/size at time of surgery. Level IV, therapeutic case series.

Generation of DNA-aptamers targeting galectin-7 for the identification of cholesteatoma residue

PurposeAiming at complete excision of cholesteatoma during trympanomastoidectomy and therefore reducing the risk of recurrence, intraoperative imaging techniques are required to assist the visualization of cholesteatoma residue. Galectin-7 has been demonstrated to be a biomarker for cholesteatoma matrix and used for intraoperatively identifying the excision margins. MethodsA galectin-7-targeted DNA-aptamer library was generated for labeling the cholesteatoma matrix using cell-systematic evolution of ligands by an exponential enrichment technique. The binding characteristics of the identified aptamers were analyzed, and structure optimization of the identified aptamers was carried out both in silico and in vitro. FindingsA fluorophore-labeled structure-optimized DNA fragment was commercially synthesized as a non-invasive aptamer-based probe for intraoperative lesion detection. Using galectin-7-aptamer-guided molecular imaging, the excision margins of cholesteatoma matrix and surrounding normal tissue were successfully achieved within 15–20 min. ConclusionsGalectin-7-targeted aptamers could benefit molecular imaging-guided surgical treatment, which would enable clinicians to not only intraoperatively detect the locations of cholesteatoma matrix in the middle ear, but also assess the postoperative response of the expression profile to therapy. It is highly expected that further efforts for rational design and development should be directed towards the development of clinically translatable aptamer-based imaging agents.

Intraoperative lesion characterization after focused ultrasound thalamotomy.

Outcomes after focused ultrasound ablation (FUSA) for essential tremor remain heterogeneous, despite therapeutic promise. Clinical outcomes are directly related to the volume and location of the therapeutic lesions, consistent with CNS ablative therapies. Recent data demonstrate that postoperative diffusion MRI, specifically the quantification of intracellular diffusion by restricted diffusion imaging (RDI), can accurately characterize focused ultrasound lesions. However, it is unclear whether RDI can reliably detect focused ultrasound lesions intraoperatively (i.e., within a few minutes of lesioning) and whether the intraoperative lesions predict delayed clinical outcomes. An intraoperative imaging protocol was implemented that included RDI and T2-weighted imaging in addition to intraoperative MR thermography. Lesion characteristics were defined with each sequence and then compared. An imaging-outcomes analysis was performed to determine lesion characteristics associated with delayed clinical outcomes. Intraoperative RDI accurately identified the volume and location of focused ultrasound lesions. Intraoperative T2-weighted imaging underestimated the lesion volume but accurately identified the location. Intraoperative RDI revealed that lesions of the ventral border of the ventral intermediate nucleus were significantly associated with postoperative tremor improvement. In contrast, the lesions extending into the inferolateral white matter were associated with postoperative ataxia. These data support the acquisition of intraoperative RDI to characterize focused ultrasound lesions. Future research should test the histological correlates of intraoperative RDI and test whether it can be developed as feedback to optimize the current technique of FUSA.

A Novel Surgical Method for Congenital Lung Malformations: A Pilot Study

Thoracoscopic surgery for congenital lung malformations (CLMs) has been widely used. However, there are still many shortcomings in the current surgical methods, such as the removal of some normal lung tissue and residual lesions. Thoracoscopic anatomical lesion resection (TALR) may be an effective and safe method to resolve these problems. This retrospective study was conducted to estimate the safety and efficiency of TALR. A retrospective review of clinical data involving patients who underwent TALR in our hospital from October 2019 to January 2021 was performed. Clinical data, including patients' demographic characteristics, manipulative details, and postoperative complications, were extracted and analyzed. A total of 95 cases were included in this study. All cases were operated on under thoracoscope, with no conversion to open surgery. The average operation time was 63.2 ± 15.2 min (range 36-142 min). The average bleeding volume during the operation was 5.8 ± 2.1 mL (range 2-10 mL). The mean diameter of the lesion was 4.4 ± 1.9 cm (range 3-7 cm). All cases had no complications, such as bronchopleurothelial fistula, hemorrhage, atelectasis, or pulmonary infection. Two patients developed pneumothorax 1 month after the operation and were cured by closed thoracic drainage. One month after the operation, chest CT showed regular cysts in 2 cases. The other patients were followed up for over 1 year by chest CT after the operation, and all recovered well without residual lesions or recurrence. Combined with the preoperative thin slice CT and intraoperative lesion boundary, anatomical intrapulmonary dissociation based on the pulmonary vein system, TALR, as a lung-sparing surgery of completely removing the lesion and retaining all normal lung tissue, has high safety and effectiveness in the treatment of CLMs.

Machine-Learning Analysis of Serum Proteomics in Neuropathic Pain after Nerve Injury in Breast Cancer Surgery Points at Chemokine Signaling via SIRT2 Regulation.

Background: Persistent postsurgical neuropathic pain (PPSNP) can occur after intraoperative damage to somatosensory nerves, with a prevalence of 29–57% in breast cancer surgery. Proteomics is an active research field in neuropathic pain and the first results support its utility for establishing diagnoses or finding therapy strategies. Methods: 57 women (30 non-PPSNP/27 PPSNP) who had experienced a surgeon-verified intercostobrachial nerve injury during breast cancer surgery, were examined for patterns in 74 serum proteomic markers that allowed discrimination between subgroups with or without PPSNP. Serum samples were obtained both before and after surgery. Results: Unsupervised data analyses, including principal component analysis and self-organizing maps of artificial neurons, revealed patterns that supported a data structure consistent with pain-related subgroup (non-PPSPN vs. PPSNP) separation. Subsequent supervised machine learning-based analyses revealed 19 proteins (CD244, SIRT2, CCL28, CXCL9, CCL20, CCL3, IL.10RA, MCP.1, TRAIL, CCL25, IL10, uPA, CCL4, DNER, STAMPB, CCL23, CST5, CCL11, FGF.23) that were informative for subgroup separation. In cross-validated training and testing of six different machine-learned algorithms, subgroup assignment was significantly better than chance, whereas this was not possible when training the algorithms with randomly permuted data or with the protein markers not selected. In particular, sirtuin 2 emerged as a key protein, presenting both before and after breast cancer treatments in the PPSNP compared with the non-PPSNP subgroup. Conclusions: The identified proteins play important roles in immune processes such as cell migration, chemotaxis, and cytokine-signaling. They also have considerable overlap with currently known targets of approved or investigational drugs. Taken together, several lines of unsupervised and supervised analyses pointed to structures in serum proteomics data, obtained before and after breast cancer surgery, that relate to neuroinflammatory processes associated with the development of neuropathic pain after an intraoperative nerve lesion.

A multicenter prospective cohort study to evaluate feasibility of radio-frequency identification surgical guidance for nonpalpable breast lesions: design and rationale of the RFID Localizer 1 Trial

BackgroundBreast cancer screening and improving imaging techniques have led to an increase in the detection rate of early, nonpalpable breast cancers. For early breast cancer, breast conserving surgery is an effective and safe treatment. Accurate intraoperative lesion localization during breast conserving surgery is essential for adequate surgical margins while sparing surrounding healthy tissue to achieve optimal cosmesis. Preoperative wire localization and radioactive seed localization are accepted standard methods to guide surgical excision of nonpalpable breast lesions. However, these techniques present significant limitations. Radiofrequency identification (RFID) technology offers a new, nonradioactive method for localizing nonpalpable breast lesions in patients undergoing breast conserving surgery. This study aims to evaluate the feasibility of RFID surgical guidance for nonpalpable breast lesions.MethodsThis multicenter prospective cohort study was approved by the Institutional Review Board of the University Medical Center Utrecht. Written informed consent is obtained from all participants. Women with nonpalpable, histologically proven in situ or invasive breast cancer, who can undergo breast conserving surgery with RFID localization are considered eligible for participation. An RFID tag is placed under ultrasound guidance, up to 30 days preoperatively. The surgeon localizes the RFID tag with a radiofrequency reader that provides audible and visual real-time surgical guidance.The primary study outcome is the percentage of irradical excisions and reexcision rate, which will be compared to standards of the National Breast Cancer Organisation Netherlands (NABON)(≤ 15% irradical excisions of invasive carcinomas). Secondary outcomes include user acceptability/experiences, learning curve, duration and ease of the placement- and surgical procedure and adverse events.DiscussionThis study evaluates the feasibility of RFID surgical guidance for nonpalpable breast lesions. Results may have implications for the future localization techniques in women with nonpalpable breast cancer undergoing breast conserving surgery.Trial registrationNetherlands National Trial Register, NL8019, registered on September 12th 2019.

Intradural Lumbar Disc Herniation: Updated Report of a Case with Literature Review

Intradural lumbar disc herniation is a rare complication of disc disease. The mechanism by which a herniated disc tears the dura matter remains unknown. The preoperative diagnosis of an intradural lumbar disc herniation is still difficult. We report our experience dealing with a case of intradural lumbar disc herniation at level L3/4 in a 34-year-old man. Based on current experience, we found that attachment of the ventral dura to the posterior longitudinal ligament can be a favorable factor indicating intradural lumbar disc herniation. One should pay attention to those with cauda equina syndrome, as it can thereby promptly suggest a preoperative diagnosis of intradural lumbar disc herniation. Surgeons need to avoid omitting intraoperative lesions by palpating the dura mater during surgery for suspected tumor cases.