Intraoperative Observations Research Articles

Impact of pancreatic tumour biomechanics on diagnosis and post-operative complications.

756 Background: Around 600 people are diagnosed with pancreatic cancer in Ireland each year, with 90% of these having pancreatic ductal adenocarcinoma (PDAC). Five-year survival for PDAC is around 10%. PDAC upregulates stromal collagen formation which contributes to tissue stiffness. Stiffer pancreatic tumours have worse oncological outcomes due to faster progression and increased chemoresistance. Softer pancreata, conversely, are more likely to develop post-operative pancreatic fistulae (POPF), a significant post-pancreatectomy complication. While incorporated in risk scores, softness is currently determined by subjective intra-operative observation. Methods: Atomic force microscopy (AFM) is the gold standard technique used to measure biomechanics at a cellular length scale. We obtained fine needle biopsies (FNBs) of pancreatic tumours during diagnostic endoscopic ultrasound. This is the first time tissue biomechanics have been measured from pancreatic biopsies. Separately, we applied this technique to pancreatic tumours and adjacent normal tissue following resection. We also assessed collagen organisation in these pancreatic tumours to understand its contribution to the observed mechanical properties. Results: Of the patients with PDAC who underwent FNB, those presenting with metastatic disease had significantly stiffer tumours than those without, 1,490 Pa (SD 2,048.03 Pa) vs 250 Pa (SD 555.06 Pa) (p<0.0001). Neuroendocrine tumours exhibited larger variance compared to PDAC (p < 0.0001), SD 5,885.97 Pa vs SD 1,797.23 Pa. Regarding tumours which have undergone curative resection, tumour stroma is significantly stiffer than both cancer and benign epithelium. The collagen strands in this stroma are straighter, more numerous, and more packed than epithelial tissues. Pancreata which develop post-operative pancreatic fistulae (POPF) are softer than those which do not 96.42 Pa (SD 691.14 Pa) vs 343.99 Pa (SD 1,678.37 Pa). Conclusions: We describe a novel technique to measure the biomechanical properties of pancreatic biopsies. Using this technique, we now have the opportunity to measure these properties for the first time on all pancreatic tumours, including those presenting with unresectable disease. It is possible to distinguish between different types of tumour based on the biomechanical profile of biopsies. Previous ex vivo studies have linked stiffer tumours to a higher metastatic potential, and our results are the first to suggest that this may be true in a human population. In resected tumours, we confirm the anecdotal belief that softer pancreata are associated with POPF. Overall, this research demonstrates that tissue biomechanics has potential diagnostic and prognostic applications in pancreatic cancer.

Role of Sulcal Hyperintensity and Web/Net Appearance on MRI in Patients With Chronic Subdural Hematoma Presenting With Transient Neurological Deficits.

Transient neurological deficits (TNDs) in patients with chronic subdural hematoma (CSDH), such as fluctuating aphasia, hemiparesis, or sensory disturbances, present diagnostic and treatment challenges as their pathophysiology remains unclear. The aim of this study was to investigate the association between specific MRI findings and TNDs in patients with CSDH and explored their relationship through intraoperative observation. We retrospectively evaluated 72 patients with CSDH who underwent preoperative MRI among 251 CSDH patients treated from January 2020 to December 2023. Sulcal hyperintensity (SHI) on fluid-attenuated inversion recovery images and web/net appearance (W/N) on T2*-weighted images were assessed and their association with TNDs was analyzed. Flexible neuroendoscopic surgery (FNS) was performed on 8 patients with TNDs exhibiting these MRI findings, allowing intraoperative observation of intrahematoma conditions. Histopathological examination was performed on hematoma samples. Thirteen patients (5.2%) presented with preoperative TNDs. Diffuse SHI and W/N were strongly associated with preoperative TNDs (odds ratio = 150.0, P < .001). FNS revealed organized hematomas with inflammatory changes corresponding to the SHI and W/N seen on MRI. Patients who underwent FNS experienced complete resolution of TNDs postprocedure, with diffuse SHI disappearing by one month. No recurrence was observed at a mean follow-up of 5.9 months. This study provided the first evidence that the combination of diffuse SHI and W/N on MRI strongly correlates with TNDs in patients with CSDH, serving as valuable diagnostic indicators. These findings will aid in guiding surgical approach selection and facilitate more personalized treatment strategies for patients with CSDH presenting with TNDs.

Use of Magnetic Resonance Neurography for Sensory Nerve Injuries of the Head and Neck.

Identification of peripheral nerve injuries of the head and neck can be challenging due to a broad spectrum of symptoms from neuropathic pain to headaches and migraine. This article aimed to present the clinical features and diagnostic workup of patients with acute and chronic peripheral nerve injuries of the head and neck using magnetic resonance neurography (MRN), to demonstrate potential advantages compared with conventional magnetic resonance imaging (MRI). Patients who presented with suspected peripheral nerve injury were either referred for a conventional MRI or MRN. Patients who underwent nerve exploration for suspected nerve transection and/or neuroma formation on imaging were included in this study. Imaging findings were correlated with intraoperative observations. Four patients (3 women, 1 man, age range: 34-70 years) were included. Three subjects had a history of head and neck surgery and 1 experienced direct trauma to the medial eyebrow. Clinical symptoms included numbness, allodynia, positive Tinel sign, and pain relief following nerve blocks. Two patients underwent conventional MRI and 2 underwent MRN. MRI provided a vague indication of potential neuromas and failed to accurately depict their locations. MRN offered a comprehensive visualization of the entire nerve path, identifying nerve transection and neuromas, as well as precise location, dimensions, and relation to adjacent bones and muscles. High-resolution 3-dimensional MRN provides clear visualization of acute and chronic peripheral nerve injuries of the head and neck region, facilitating early diagnosis of nerve injuries in this region and improving diagnostic accuracy, as well as surgical planning and execution.

Identification of a T2-hyperintense Perivascular Space in Brain Arteriovenous Malformations.

Brain arteriovenous malformations (AVMs) are vascular malformations characterized by dysmorphic, aberrant vasculature. During previous surgeries of compact nidus brain AVMs (representing the majority of cases), we have observed a "shiny" plane between nidal and perinidal AVM vessels and the surrounding grey and white matter and hypothesized that preoperative neuroimaging of brain AVMs may show a neuroradiological correlate of these intraoperative observations. We retrospectively reviewed and analyzed multiplanar and multisequence 3-Tesla magnetic resonance (3T MR) imaging in five consecutive brain AVMs with special attention on imaging characteristics of the brain-AVM interface, i.e., the perivascular and perinidal regions. In all five patients, we identified T2-hypertinense perivascular perinidal spaces, which were predominantly observed around the AVM nidus and less prominently around the feeding arteries or draining veins. The identification of T2-hypertinense perivascular spaces surrounding brain AVMs on neuroradiological imaging may provide insights into the anatomico-radiological relationships of brain AVMs and the surrounding grey and white matter parenchyma. These findings could have future implications for our understanding of brain AVM biology and may influence neurosurgical approaches to these lesions.

A Study of the Comparison Between Preoperative Ultrasonography Findings With Intraoperative Observations in Laparoscopic Cholecystectomy.

This study aims to evaluate the accuracy of ultrasonography (US) by comparingpreoperative ultrasonographic findings with intraoperative observations during laparoscopic cholecystectomy (LC). An observational analytical study was conducted at a tertiary hospital in Pune over two years and included 98 patients aged 20-80 with symptomatic cholelithiasis confirmed by US. Preoperative parameters assessed included gallstone number, gallbladder volume, wall thickness, and pericholecystic fluid. These were compared to intraoperative findings during LC. Data were analyzed using SPSS Statistics for Windows, Version 16 (Released 2007; SPSS Inc., Chicago, Ill), with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) calculated for the US parameters. The mean patient age was 44.14±15.06 years, with a female predominance (70%). US showed high sensitivity (78.13%) but low specificity (35.29%) for detecting the number of stones, and showed high specificity (100%) but low sensitivity (21%) in the assessment of gallbladder wall thickness. For detecting gallbladder distension, UShad a sensitivity of 69.7% and a specificity of 11.1%, while itachieved perfect sensitivity and NPV (100%) for evaluation of pericholecystic fluid. Preoperative US provides valuable insights for surgical planning, with high sensitivity and specificity for gallbladder wall thickness and pericholecystic fluid. However, its accuracy in detecting the number of stones and gallbladder distension is moderate. US can be considered a useful investigation for diagnosing cholelithiasis. It may be used topredict the fate of LC, but further studies need to be carried out to confirm its surgical importance.

Radiological and Surgical Assessment of Proximity of Roots of Mandibular Third Molar to the Inferior Alveolar Canal in Impacted Teeth

ABSTRACT Background and Objective: A mandibular canal around the lower third molar roots house the inferior alveolar nerve (IAN). There is a risk of nerve injury during surgical tooth extraction. Methods: The College of Dental Sciences at Davangere’s Department of Oral and Maxillofacial Surgery served as the outpatient setting for this investigation. The study comprised one hundred participants who were going to have their mandibular third molars surgically extracted. The risk of IAN injury was evaluated by comparing the radiographic findings from preoperative orthopantomography and intraoral periapical radiographs with intraoperative observations. Results: The study revealed that the patient’s age did not have a significant correlation with the risk of nerve injury. However, cases involving bony impactions were found to have a higher risk of IAN damage. Additionally, mesioangular impactions and radiographic indicators, such as root deflection, were associated with an elevated risk of nerve injury. Conclusion: To reduce the risk of IAN injury during the extraction of mandibular third molars, it is essential to have a detailed understanding of the relevant anatomical features and to plan the surgical procedure meticulously.

Computational hemodynamic pathophysiology of internal carotid artery blister aneurysms

ObjectiveBlister aneurysms of the internal carotid artery (ICA) are rare and are primarily documented in the literature through small series and case reports. The intraoperative observation of a hemorrhage in the artery wall proximal to the aneurysmal bulge led to the hypothesis that some of these aneurysms might develop in a retrograde manner.MethodsWe developed software to reconstruct the ICA with and without Type I and II blister aneurysms using patients’ imagery as input to simulate hemodynamic conditions before and after their formation. Kinematic blood flow data before and after aneurysm formation were obtained using a finite volume solver. We compared the wall shear stress (WSS) distribution of the arterial wall prior to aneurysm formation.ResultsIn two out of four cases, WSS was significantly elevated on the dorsal wall of the supraclinoid segment of the ICA at the distal part of the future site of the aneurysm sac, suggesting that the aneurysm sac may ultimately develop in a retrograde fashion. Once the structural changes have been initiated, WSS gradient (WSSG) was significantly elevated at the proximal and distal boundaries of the bulging aneurysmal pouch. Low WSS and high WSSG at the proximal part of the aneurysm sac seem to contribute to the extension of the proximal intramural hematoma observed during blister aneurysm surgery.ConclusionsBy enabling assessment of the impact of elevated WSS and its gradient, our computational pipeline supports the hypothesis that the development of blister aneurysms may occur either in a retrograde or anterograde fashion.

Window Coverage and Liquid Biopsy in the First-Line Therapy of Severe Sudden Sensorineural Hearing Loss.

Based on clinical practice guidelines, the application of corticosteroids as a first-line therapy is common. Although sudden sensorineural hearing loss (SSHL) etiology is primarily idiopathic, hearing loss can result from a perilymphatic fistula (PLF). Recent findings show evidence of a specific rate of PLF based on a cochlin-tomoprotein (CTP) detection test. Based on this rate of PLF treatment, the concepts of SSNHL need to be re-evaluated. The present study aimed to evaluate CTP in SSNHL patients and compare pre-surgical and post-surgical pure tone hearing thresholds after round and oval window sealing as first-line treatment. A total of 30 patients with unilateral SSNHL with a pure tone average (PTA) (4 Freq. of 60 dB or more were enrolled in a prospective study. All patients underwent tympanoscopy for middle ear exploration as a first-line treatment. After intraoperative observation of a possible PLF, all patients obtained middle ear lavage to gain CTP samples for following ELISA-based CTP detection tests. All patients received round window and oval window sealing with fascia. PTA hearing thresholds were analyzed post-surgically 3 weeks after treatment based on 4-frequency bone conduction (BC). The average preoperative pure tone BC threshold was 97.7 dB compared with the 69 dB postoperative BC threshold. Mean BC improved by 20.3 dB after middle ear exploration and window sealing. A total of 56% (17 of 30) of patients recovered at least 10 dB. The middle ear cochlin-tomoprotein detection rate was 70% positive. The combination of early tympanoscopy and inner ear-specific cochlin-tomoprotein as a detection tool for suspected PLF showed evidence of PLF as a key causative in SSNHL.

Endoscopic revision surgery for ossicular chain reconstruction: intraoperative findings and functional outcomes.

To report the intraoperative observations and hearing outcomes in patients undergoing endoscopic revision ossiculoplasty. A retrospective cohort of patients who had undergone revision ossiculoplasty were enrolled in this study. Intraoperative findings were documented. Follow-up visits were scheduled from 3 to 12 months post-surgery to assess hearing levels and record any potential complications. Between April 2020 and May 2023, a total of 26 cases were enrolled, with 11 male patients represented. The mean age of the patients was 40.5 ± 9.4 years, ranging from 18 to 66 years. During the revision surgeries, various intraoperative findings were noted, including adhesive tissues affecting the activity of ossicular chain (observed in 37.0% of cases), tympanosclerosis of the ossicular chain (also in 37.0% of cases), dislocation of ossicular prosthesis (33.3%), erosion of the ossicular chain (33.3%), and identified cholesteatoma (11.1%). In terms of hearing outcomes, a significant improvement was observed. Overall, only 37.0% of patients achieved an air-bone gap of 20 dB or less, indicating the inferior outcome in revision ossiculoplasty. This study highlight the role of inflammatory responses (adhesion, tympanosclerosis), stapes erosion, and prosthesis dislocation, as contributing factors to the failure of primary tympanoplasty. Endoscopic revision ossiculoplasty emerges as a reliable and effective approach.

HPB SO68 - Evaluating the Outcome of Laparoscopic Cholecystectomy Against Key Performance Indicator (KPI) of the British Benign Upper GI Surgical Society (BBUGSS)

Abstract Background Laparoscopic cholecystectomy (LC) presents inherent challenges and potential for significant complications, influenced by both patient factors and surgical expertise. Recognizing this variability, the British Benign Upper GI Surgical Society (BBUGSS) has established Key Performance Indicators (KPIs) aimed at enhancing LC outcomes. This study conducts an audit of LC outcomes in a single centre district general hospital (DGH) in accordance with BBUGSS KPIs and thus aims to determine if quality LC by modern standards is achievable in a DGH. Method The present retrospective observational study examined all adult LC conducted between August 2022 and June 2024 by two specialized biliary surgeons at a single surgical unit within a DGH, which also serves as a referral center of biliary cases from affiliated hospitals. The analysis encompassed preoperative assessments, intraoperative observations, and postoperative outcomes, with a focus on aligning these findings against the benchmarks established by the BBUGSS KPIs. Results 141 patients were included; median age was 54 years (IQR 41-64) and 59.6% were female. 37.6% were emergency cases, 44.2% were for acute cholecystitis, 22.7% for gallstone pancreatitis and 63.1% underwent intra-operative cholangiogram. KPIsBBUGSS StandardOur resultDay case for elective cases50%42%Readmission (within 30 days)&amp;lt;10%4.3%Laparoscopic cholecystectomy for acute cholecystitis (within 7 days)&amp;gt;35%97%Laparoscopic cholecystectomy for gallstone pancreatitis (within 2 weeks)&amp;gt;95%100%Conversion to open&amp;lt;5%0.7%Morbidity&amp;lt;10%1.4%Bile leak after elective surgery&amp;lt;1.5%0%Retained bile duct stones&amp;lt;2.5%0%Bile duct injury&amp;lt;0.3%0%Mortality&amp;lt;0.1%0% Conclusion This study shows that with the exception of day-case rate in elective LC, all KPIs were satisfactorily achieved, indicating that high quality LC is achievable within a DGH. The majority of readmissions within 30 days were related to inadequate postoperative analgesia. We have since enhanced pain management pathways. It is hoped that this will also improve same day discharge for elective cases to achieve BBGUGS standard. We are committed to conducting annual audits to monitor and optimize surgical outcomes and would encourage other centers to consider adopting the same approach.

HPB SO70 - Evaluating the Outcome of Laparoscopic Common Bile Duct Exploration Against Key Performance Indicator (KPI) of the British Benign Upper GI Surgical Society (BBUGSS)

Abstract Background Treatment of common bile duct (CBD) stone(s) can be challenging with a risk of significant complications. Laparoscopic common bile duct exploration (LCBDE) displays superior outcomes when compared to endoscopic retrograde cholangiopancreatography (ERCP). Acknowledging the impact of patient variables and surgical proficiency, the British Benign Upper GI Surgical Society (BBUGSS) developed Key Performance Indicators (KPIs) to optimize LCBDE outcomes. The present study comprises an audit of LCBDE outcomes with respect to the BBUGSS KPIs and aims to determine the feasibility and quality of LCBDE that can be achieved in a district general hospital (DGH) with a recently developed LCBDE service. Method This retrospective observational study examined all adult patients who underwent LCBDE between August 2022 and June 2024 by two specialized biliary surgeons at a single surgical unit within a DGH. This DGH also serves as a referral center for biliary cases from affiliated hospitals. The preference in our surgical unit is single stage management (laparoscopic cholecystectomy and simultaneous LCBDE) of CBD stones in surgically fit patients. The analysis included preoperative assessments, intraoperative observations, and postoperative outcomes, with respect to the published BBUGSS KPIs for LCBDE. Results 60 patients were eligible for inclusion; median age was 56 years (IQR 40-67) and 40 (66.7%) were female. 33 (55%) were emergency cases. 52 (86.7%) were transcystic exploration; of these 8 (15.4%) utilised basket-in-catheter and 44 (84.6%) utilised choledochoscopes. Median post-operative stay for transcystic exploration was 1 day (IQR 0-2) and for cholechodotomy 8 days (IQR 5-9). Key Performance IndicatorBBUGSS StandardOur outcomeConversion rates&amp;lt;10%0%Bile duct clearance rates&amp;gt;85%91.7%Bile Leak Rates&amp;lt;5%0%Returns to theatre&amp;lt;5%0%Readmission rates (within 30 days)&amp;lt;15%6.7%Overall Morbidity&amp;lt;15%3.3%Overall Mortality&amp;lt;1%0% Conclusion This study indicates that the BBUGSS KPIs for LCBDE are satisfactorily achieved in our centre. Adequate ductal clearance with minimal morbidity was achieved. Our outcomes are likely attributed to the recent commencement of a specialist biliary service and utilisation of predominantly transcystic approach, with the aid of electrohydraulic lithotripsy where needed, as opposed to choledochotomy. Furthermore, the present study suggests a high quality LCBDE service is feasible in a DGH setting if there is sufficient clinical and managerial motivation. We suggest that single stage management of bile duct stones model should be considered in other similar centres.

Ultrasonographic liver nodules are more often benign lesions in dogs with hemoperitoneum secondary to splenic tumor rupture.

To evaluate the reliability of preoperative abdominal ultrasonography as a staging tool for dogs with hemoperitoneum due to presumed splenic tumor rupture, focusing on the detection of metastatic lesions in the liver. 99 dogs from 20 emergency and specialty hospitals across the US. Dogs with nontraumatic hemoperitoneum secondary to splenic tumor rupture were included. A post hoc analysis was conducted on data from a nationwide prospective trial investigating novel treatments for canine hemangiosarcoma. The accuracy of preoperative staging was assessed by comparing ultrasonographic findings with intraoperative observations and histologic findings. On preoperative ultrasonography, there was a 20% incidence of liver lesions identified, with no association to liver lesions seen during operation. Notably, 22% of liver lesions observed during operation were missed on preoperative ultrasonography. The presence of liver lesions on preoperative ultrasonography was associated with a higher likelihood of a benign splenic tumor diagnosis. There was no association between the identification of liver lesions on preoperative ultrasonography and the presence of metastatic disease on liver biopsy, with a sensitivity and specificity of 19% and 82%, respectively. Additionally, ultrasound had low sensitivity in detecting intra-abdominal lesions beyond the liver and spleen, with 82% of these lesions missed preoperatively. This study challenges conventional perceptions around the approach to staging in dogs with hemoperitoneum. These findings advocate for a reevaluation of the staging approach, with more comprehensive modalities like whole-body CT or MRI potentially being more warranted.

Evaluation of fundus first laparoscopic cholecystectomy in an obscured calot triangle: outcomes

Background: A fundus first laparoscopic cholecystectomy when performed by an experienced surgeon, provides the same level of safety and durability as an open cholecystectomy. When Calot's triangle cannot be safely dissected during laparoscopic cholecystectomy a rescue treatment is advised. Current revisions stress the importance of intraoperative observations in helping surgeons make a rescue decision and minimize additional harm. Objective: To examines the fundus-first strategy in laparoscopic cholecystectomy in an indistinct Calot's triangle and the patient's clinical outcome. Patients and Methods: This is a prospective study that was done in Rizgary Teaching Hospital from January 1st, 2020 to December 31st, 2022, on 68 cases who underwent laparoscopic cholecystectomy where Calot’s triangle was difficult to distinguish during the operation. Fundus: first dissection of the gall bladder down to the infundibulum and after safe ligation of the gall bladder stump and good hemostasis of the liver bed, the gallbladder is removed via a 10-mm port. This research looked at the duration of operation, postoperative pain, rate of conversion to open surgery and duration of the hospital stay. Results: Among 68 cases of fundus first laparoscopic cholecystectomy most of the patients were female 45(66.17%) and 23(33.82%) were male, majority of cases were between 31 and 50 years old, with a mean age of 39±10.44, and the majority of patients were complaining of inflammation with fibrosis at the site of the cystic duct. The duration of operation ranged from 45-60 minutes in 16(23.52%) and 60-80 minutes in 20(29.41%) cases and 130-140 minutes in 2(2.94%) cases. The majority of our cases remained in the hospital and ambulated on day 3-5, and the main hospital stay was 4.68±1.8 days. There was statistical significance in the age distribution with a P-value 0.04. Conclusion: Fundus first laparoscopic cholecystectomy remains a feasible and safe procedure. Surgeon experience and judgement affects the operative time, conversion rate, morbidity and hospital stay in difficult and obscured Calot’s triangle.

Incidence of Concurrent Cerebral Desaturation and Electroencephalographic Burst Suppression in Cardiac Surgery Patients.

Increased intraoperative electroencephalographic (EEG) burst suppression is associated with postoperative delirium. Cerebral desaturation is considered as one of the factors associated with burst suppression. Our study investigates the association between cerebral desaturation and burst suppression by analyzing their concurrence. Additionally, we aim to examine their association with cardiac surgical phases to identify potential for targeted interventions. We retrospectively analyzed intraoperative 1-minute interval observations in 51 patients undergoing cardiac surgery. Processed EEG and cerebral oximetry were collected, with the anesthesiologists blinded to the information. The associations between cerebral desaturation (defined as a 10% decrease from baseline) and burst suppression, as well as with phase of cardiac surgery, were analyzed using the Generalized Logistic Mixed Effect Model. The results were presented as odds ratio and 95% confidence intervals (CIs). A value of P < .05 was considered statistically significant. The odds of burst suppression increased 1.5 times with cerebral desaturation (odds ratio [OR], 1.52, 95% CI, 1.11-2.07; P = .009). Compared to precardiopulmonary bypass (pre-CPB), the odds of cerebral desaturation were notably higher during CPB (OR, 22.1, 95% CI, 12.4-39.2; P < .001) and post-CPB (OR, 18.2, 95% CI, 12.2-27.3; P < .001). However, the odds of burst suppression were lower during post-CPB (OR, 0.69, 95% CI, 0.59-0.81; P < .001) compared to pre-CPB. Compared to pre-CPB, the odds of concurrent cerebral desaturation and burst suppression were notably higher during CPB (OR, 52.3, 95% CI, 19.5-140; P < .001) and post-CPB (OR, 12.7, 95% CI, 6.39-25.2; P < .001). During CPB, the odds of cerebral desaturation (OR, 6.59, 95% CI, 3.62-12; P < .001) and concurrent cerebral desaturation and burst suppression (OR, 10, 95% CI, 4.01-25.1; P < .001) were higher in the period between removal of aortic cross-clamp and end of CPB. During the entire surgery, the odds of burst suppression increased 8 times with higher inhalational anesthesia concentration (OR, 7.81, 95% CI, 6.26-9.74; P < .001 per 0.1% increase). Cerebral desaturation is associated with intraoperative burst suppression during cardiac surgery, most significantly during CPB, especially during the period between the removal of the aortic cross-clamp and end of CPB. Further exploration with simultaneous cerebral oximetry and EEG monitoring is required to determine the causes of burst suppression. Targeted interventions to address cerebral desaturation may assist in mitigating burst suppression and consequently enhance postoperative cognitive function.

The characteristics of sinonasal inverted papilloma and recurrence factors: An analysis of 207 cases

AbstractObjectivesSinonasal inverted papilloma (IP) is a rare and benign tumor that affects the nose and sinuses. This tumor has a recurring nature and can be associated with malignancy or transform into a malignant lesion. Various factors have been proposed as potential recurrent and malignancy risk factors in sinonasal IP. This study examines some of these factors and the relationship between tumor location and recurrence and malignancy.MethodsA retrospective analysis was conducted on patients diagnosed with IP for 10 years or more, assessing the patients’ demographic statistics and intraoperative observations. Additionally, CT scan results of the patients were investigated.ResultsFinally, 207 patients with an average age of (52.0 ± 13.8) years were included in the study. A hundred and fifty‐five (74.9%) of patients were male and the most substance abuse was tobacco (72, 34.8%). Fifty‐five (26.6%) patients had a recurrence and 21 (10.2%) patients showed malignancy or dysplastic changes. The most common site of the tumor was the maxillary sinus (131, 63.3%).ConclusionsLong‐term follow‐up of IP patients is necessary due to the risk of recurrence and malignancy. The probability of recurrence was higher in cases where the tumor involved the frontal sinus or multisite attachment. Therefore, for accurate diagnosis of this tumor and complete resection of the lesion, especially in cases where achieving a free margin may be challenging, the intraoperative frozen section seems necessary.

The Role of Pretarsal Fascia in Upper Eyelid Crease Formation and its Implications in East Asians.

This study aims to investigate the role of pretarsal fascia in the formation of upper eyelid crease in East Asians. Through intraoperative fascia retraction observation, fascia-stretching test, histological examination, and anatomical analysis of pretarsal fascia and surrounding tissues, we explored the mechanical consequences and their impact on upper eyelid crease formation. The levator aponeurosis extension comprises three parts to impact sub-orbicularis fat pad mechanically. The pretarsal fascia is anatomically distinct from the aponeurosis extension but is influenced by its mechanic forces. Differential distribution of collagen fiber bundles within the pretarsal fascia can buffer and transmit the forces of aponeurosis extension, leading to diverse upper eyelid crease patterns. The factors determining upper eyelid crease are multifaceted, and the buffering-conduction theory of pretarsal fascia can explain both physiological and postoperative crease in East Asians. It determines the presence, depth, and stability of crease, laying the foundation for the formation of upper eyelid crease in East Asians. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

L’utilisation de la caméra thermique smartphone compatible (FLIR One) pour le repérage préopératoire des perforantes de DIEP

The success of surgeries involving free flaps largely depends on accurate preoperative mapping of perforator arteries. Various imaging techniques, such as Doppler ultrasound and CT angiography, are typically used, each having its advantages and disadvantages in terms of cost, accuracy, and patient risk. The main objective of our study is to compare the effectiveness of the FLIR One device for detecting these arteries compared with traditional methods. Thermal imaging appears to be a simpler, less expensive, and less invasive alternative for surgical planning. The study, conducted at the Regional Hospital Center of Nancy, included 25 free flaps (DIEP) on an exclusively female cohort of 22 patients, with follow-up from 2022 to 2023. Before the procedure, an abdominal-pelvic CT angiography was performed, followed by additional evaluation with thermal imaging using FLIR One and acoustic Doppler examination on the eve of the operation. This approach aimed to provide precise mapping of vascular perforators for each patient. Three different operators performed these markings, and the results were then compared with intraoperative observations. The imaging protocol also included a Doppler examination to validate the results of the thermal imaging. Statistical analyses with intraclass correlation coefficients (ICC) were performed to evaluate the correlation between different preoperative localization methods of perforating vessels. In 22 patients undergoing 25 DIEP flaps for breast reconstructions, three imaging techniques were used to identify vascular perforators: thermal imaging with FLIR, acoustic Doppler, and CT angiography. FLIR identified the most perforators (n=137), followed by acoustic Doppler (n=128) and CT angiography (n=126). Comparing these with intraoperative results, 66% of perforators identified by FLIR were confirmed, 70% for acoustic Doppler, and 95% for CT angiography. The ICCs shows a significant correlation between these imaging techniques and intraoperative results. FLIR demonstrated a strong correlation with intraoperative observations (ICC of 0.74, P<0.001), followed by a moderate correlation with acoustic Doppler (ICC of 0.56, P<0.03) and CT angiography (ICC of 0.52, P<0.006). The study concludes that thermal imaging with FLIR is a reliable and effective tool for locating vascular perforators. Although the study and FLIR have their own limitations, the tool presents several advantages such as ease of use, speed, and affordability. These characteristics make FLIR particularly attractive as a complement to traditional detection methods, such as acoustic Doppler and CT angiography.

Acute peritumoral brainstem hemorrhage of a clival chondrosarcoma successfully treated via endoscopic endonasal surgery: illustrative case.

Chondrosarcoma is typically a slow-growing tumor, and intratumoral hemorrhage is rare. Acute brainstem hemorrhage due to chondrosarcoma has rarely been reported. A 77-year-old man presented with the sudden onset of headache and vomiting followed by a declining level of consciousness, progressive right hemiparesis, and left ophthalmoplegia. Magnetic resonance imaging showed pontine hemorrhage and a mass in the retroclival space compressing the brainstem. Emergency endoscopic endonasal surgery was performed. Intraoperative observation revealed that a hematoma was located in the pons and subdural space around the tumor mass, suggesting that the hematoma had likely been caused by the rupture of small vessels around the pons, not by intratumoral hemorrhage. The pathological diagnosis was chondrosarcoma. The patient recovered well and underwent radiotherapy. This report describes a case of sudden neurological deterioration due to hemorrhage in a patient with chondrosarcoma of the skull base. An emergency endoscopic endonasal approach for mass reduction and hematoma removal was effective in the acute setting. This approach revealed the suspected etiology of peritumoral hemorrhage, not intratumoral hemorrhage. https://thejns.org/doi/10.3171/CASE2460.

Optimizing strategies for lymphaticovenular anastomosis in lower secondary extremity lymphedema

BackgroundLymphovenous anastomosis (LVA) has become an increasingly common treatment for patients with secondary extremity lymphedema. The objective of this study was to optimize strategies for lower secondary extremity lymphedema using LVA techniques, with the aim of enhancing patient outcomes. MethodsWe conducted a retrospective analysis of 121 patients who underwent LVA at Taizhou Hospital of Zhejiang Province from January 2020 to December 2023. Preoperative and postoperative assessments included intraoperative observations, functional parameters, and clinical outcomes. The efficacy of LVA was evaluated based on circumferential reduction, quality of life improvements (Lymphoedema Quality of Life Questionnaire), and postoperative complications. ResultsThis study enrolled 121 patients with lower secondary extremity lymphedema, with an average age of 58.19 years. The results revealed significant associations between incision depth, lymphatic vessel size, the number of LVAs performed, and the number of incisions per patient, all of which correlated with postoperative volume reduction. The resulted analysis that identified optimal incision depths of 10 to 15 mm, lymphatic vessel size of 0.4 to 0.6 mm, and a recommended number of 6 to 8 LVAs. After LVA, there was a marked improvement in patient quality of life, with particularly notable enhancements in functionality and appearance. ConclusionsThis study’s findings optimizing the strategy for LVA surgery recommend the depth of incision, the size of lymphatic vessels, and the number of anastomoses to improve the quality of life and limb volume in patients with secondary lymphedema of the lower limbs.

Can Ultrasound Spot the Culprit - Evaluating the Effectiveness of Ultrasonography in Precisely Diagnosing Acute Appendicitis in Children.

Acute appendicitis is a common surgical emergency in children, often requiring imaging for confirmation due to diverse presentations. While computed tomography scan is favored in many centers for its sensitivity, it comes with radiation exposure and higher costs. Ultrasonography, being radiation-free and cost-effective, is gaining popularity, especially in pediatric cases. However, its reported accuracy varies in the literature. This study aims to evaluate the diagnostic accuracy of ultrasonography in pediatric appendicitis cases and to determine its precision in distinguishing between simple and complicated cases of appendicitis. A retrospective analysis was conducted on children with suspected appendicitis who presented to the department of pediatric surgery. All patients underwent ultrasonography followed by appendicectomy based on considered clinical decision. Ultrasonography findings were compared with intraoperative observations categorized as uncomplicated or complicated appendicitis. Among 152 patients, ultrasonography accurately diagnosed appendicitis in 94.6% of cases, with 5.38% having nonvisualized appendices. In our group, the sensitivity and specificity of ultrasound to detect appendicitis were 94.62% and 95.65%, respectively. The diagnostic accuracy of the test is 95.63%. However, in our study, the sensitivity of the ultrasonography to correctly identify if it is a simple or complicated appendicitis was only 54.9% but had a specificity of 98.7%. Thus, ultrasonography showed a much lower sensitivity (54.9%) in distinguishing between simple and complicated appendicitis. Ultrasonography demonstrates high sensitivity and specificity in diagnosing pediatric appendicitis, making it a promising preoperative investigation. However, it may not accurately differentiate between simple and complicated cases. A comprehensive approach involving clinical and laboratory parameters alongside secondary imaging may be necessary for accurate diagnosis, especially in cases of perforated appendicitis.