Intraoperative Revision Research Articles

The damages of processus vermicularis and Meckel’s diverticulum in gun–shoot abdominal woundings

Objective. Determination of the damages peculiarities in processus vermicularis and Meckel’s diverticulum in a gun–shot abdominal woundings and tactics of their surgical treatment.
 Materials and methods. Analysis of the gun–shot abdominal woundings has been witnessed the presence of isolated and combined damages of processus vermicularis and Meckel’s diverticulum in 0.18 and 0.06% patients, accordingly. All the wounded persons were the men, their average age have constituted (32±0.3) yrs old. The shrapnel woundings have occurred in 92.4% patients, and the bullet – in 7.6%. Damages of the processus vermicularis base have dominated in its descendent localization, the damages of processus vermicularis and Meckel’s diverticulum were combined with such intestinal affections.
 Results. All the damages of Meckel’s diverticulum and processus vermicularis were revealed intraoperatively. All the hospitalized patients have had the pain syndrome, the peritonitis signs and free liquid in a small pelvis. Surgical tactics consisted of resection of processus vermicularis (in 2 patients using laparoscopic approach), and in the Meckel’s diverticulum woundings the operative intervention volume have included a wedge–like resection of the small intestine part with diverticulum or segmental intestinal resection with formation of the side to side ileo–ileoanastomosis.
 Conclusion. The damages of processus vermicularis and Meckel’s diverticulum constitute a rare combat woundings, which occurs in combined intestinal trauma, what constitute the need for its detailed intraoperative revision. Operative tactics in damages of processus vermicularis and Meckel’s diverticulum constitutes their resection and restoration of intestinal integrity and may be realized through laparoscopic access.

The Importance of Perioperative Flow Evaluation and Prevention of Steal Syndrome in Arteriovenous Fistula Surgery Using Transit-Time Flow Measurement

Aim: Our aim is to evaluate the relationship between the survival time of arteriovenous (AV) fistula whose flows are measured with flow meter in patients with chronic renal failure who were operated for AV fistula (AVF) and present the results. Materials and Methods: In our clinic, we evaluated the flow meter measurement results with patency rates and usability after 6 months of AVF in 100 patients who underwent AVF operation due to chronic renal failure. Findings: In February 2012, transit-time flow measurement was put into use in our clinic. The last 50 consecutive patients with the same characteristics before this date constituted the control group (Group A) and the first 50 consecutive patients after this date constituted the study group. Radiocephalic fistula was made the most common (Group A, n = 50; Group B, n = 50). Nondominant upper extremity was selected when planning AVF for patients. First radiocephalic, then brachiocephalic AVF was performed. Fistulas flow was measured with an intraoperative flow meter. Those with bad flow were revised during the operation. Embolectomy was performed in one patient at the 2nd month due to fistula thrombosis, but it was not successful in one patient, and an AVF was opened with a graft. Results: While creating AVF, our aim is to use it effectively for a long time. By evaluating the fistula flows with the flow meter and make an intraoperative revision if necessary we ensure to extend the lifespan of a fistula.

The one-stop-shop approach: Navigating lumbar 360-degree instrumentation in a single position.

Treatment strategies of patients suffering from pyogenic spondylodiscitis are a controverse topic. Percutaneous dorsal instrumentation followed by surgical debridement and fusion of the infectious vertebral disc spaces is a common approach for surgical treatment. Technical advances enable spinal navigation for dorsal and lateral instrumentation. This report investigates combined navigated dorsal and lateral instrumentation in a single surgery and positioning for lumbar spondylodiscitis in a pilot series. Patients diagnosed with 1- or 2-level discitis were prospectively enrolled. To enable posterior navigated pedicle screw placement and lateral interbody fusion (LLIF) patients were positioned semi-prone in 45-degree fashion. For spinal referencing, a registration array was attached to the pelvic or spinal process. 3D scans were acquired intraoperatively for registration and implant control. 27 patients suffering from 1- or 2-level spondylodiscitis with a median ASA of 3 (1-4) and a mean BMI of 27.9 ± 4.9 kg/m2 were included. Mean duration of surgery was 146 ± 49 min. Mean blood loss was 367 ± 307 ml. A median of 4 (4-8) pedicle screws were placed for dorsal percutaneous instrumentation with an intraoperative revision rate of 4.0%. LLIF was performed on 31 levels with an intraoperative cage revision rate of 9.7%. Navigated lumbar dorsal and lateral instrumentation in a single operation and positioning is feasible and safe. It enables rapid 360-degree instrumentation in these critically ill patients and potentially reduces overall intraoperative radiation exposure for patient and staff. Compared to purely dorsal approaches it allows for optimal discectomy and fusion while overall incisions and wound size are minimized. Compared to prone LLIF procedures, semi-prone in 45-degree positioning allows for a steep learning curve due to minor changes of familiar anatomy.

Splenectomy for hemangiosarcoma in dogs

A retrospective study was conducted on 20 dogs with histologically verified hemangiosarcoma of the spleen after splenectomy. The average age of the dogs was above average - over 10 years old. Breed predisposition was revealed in German Shepherds and Yorkshire Terriers. All patients underwent splenectomy and intraoperative revision. According to the results of intraoperative revision, the study was divided into 2 groups - with the presence of the gemabdomen and without the gemabdomen. The gemabdomen was diagnosed in 70% of patients during the initial diagnosis. Intraoperative revision revealed metastatic lesions in 64.2% of cases, with 55.5% in the liver and 44.4% in the omentum in dogs with haemobdomain. In the group with haemobdomain, progression of the disease was detected in 42.8% of patients, and metastasis was noted exclusively in the abdominal organs. In the group without haemobdomen, metastasis was recorded only in one patient on day 32, also only in the abdominal organs. The duration of the relapse-free period and the average life expectancy in animals with hemobdomena after splenectomy was 57.2% and 75 days, respectively. Animals without hemobdomain at primary diagnosis had an average life expectancy of 135 days.

Chronic obstruction of the stomach as a result of congenital malformation in a child of 1 year 10 months. Case report

Congenital malformation of the gastrointestinal tract in a rare case can cause partial obstruction and masquerade as functional disorders of the intestine for a long time. Atypical clinic of membranous gastric obstruction causes difficulties in diagnosis and determination of treatment tactics. The aim to determine and present to the surgical community the features of diagnosis, surgical treatment, possible complications of a rare malformation of the stomach in children in the form of a stomach membrane.
 The paper presents a clinical case of the stomach membrane in a child 1 year 10 months old with complaints of vomiting after each meal, bloating, lethargy for one month. The results of ultrasonography, X-ray examination with the passage of a contrast agent through the gastrointestinal tract, fibrogastroduodenoscopy established anatomical changes in the stomach in the form of pyloric stenosis up to 0.40.5 cm in diameter. Intraoperative revision of the stomach, supplemented by intraluminal endoscopic support, made it possible to reliably establish the presence of a perforated pyloric membrane. The membrane is radically cut along the entire circumference at the level of its base. The next postoperative period was uneventful. After 1.5 months, the child was again admitted to the pediatric surgical department on an emergency basis with a clinic of intestinal obstruction, including the childs anxiety, repeated vomiting, and bloating. X-ray and endoscopic picture corresponded to the diagnosis of cicatricial stenosis of the pyloric part of the stomach. Taking into account the presence of cicatricial deformity, due to the high risk of complications during resection of the stenotic part of the stomach and the imposition of gastroduodenoanastomosis, a bypass retrocolic gastrojejunoanastomosis with Brown fistula was formed. When examining a child of a child in the late postoperative period, no complications were identified.
 The presented clinical case confirms that congenital malformations of the gastrointestinal tract in the form of stenoses and membranes can have a long stage of compensation, their diagnosis is based on a comprehensive examination of the child using radiopaque and endoscopic studies.

Robot-assisted pedicle screw placement

Pedicle screw-based posterior instrumentation of the spine. Instability of the spine due to trauma, infection, degenerative spinal disease or tumor. None. Robot-assisted navigated pedicle screw placement. Early functional mobilization starting on the first postoperative day. Astudy by Lee etal. analyzed the clinical application of the system MazorX Stealth Edition (Medtronic Navigation, Louisville, CO, USA; Medtronic Spine, Memphis, TN, USA) in 186cases with atotal of 1445 pedicle screws [1]. Correct screw positioning was achieved in 1432 pedicle screws (99.1%); six pedicle screws (0.4%) were revised intraoperatively. The mean duration of pedicle screw placement was 6.1 ± 2.3 min. Pojskić etal. published acase series regarding the application of the system Cirq (Brainlab, Munich, Germany) in 13cases with atotal number of 70pedicle screws implanted [2]. Intraoperative imaging showed screw positioning according to the Gertzbein Robbins classification (GR) categoryA in 65screws (92.9%) and GRB in one screw (1.4%). Screw positioning GRD with intraoperative revision was reported in two screws (2.9%). Mean duration of pedicle screw placement was 08:27 ± 06:54 min.

Intraoperative revision rates due to three-dimensional imaging in orthopedic trauma surgery: results of a case series of 4721 patients

PurposeIntraoperative 3D imaging has become a valued tool in assessing the quality of reduction and implant placement in orthopedic trauma surgery. In our institution, 3D imaging is used routinely since 2001. To evaluate the intraoperative findings and consequences of this technique, intraoperative revision rates in cases with 3D imaging were analyzed.MethodsAll operative procedures carried out with intraoperative 3D imaging between August 2001 and December 2016 were included. The scans were assessed intraoperatively and documented thereafter. In case of malreduction or misplaced implants, an immediate revision was performed. The number of scans per case as well as the findings and consequences drawn regarding the anatomical region were analyzed.Results4721 cases with 7201 3D scans were included in this study. The most common anatomical regions were the ankle (22.3%), the calcaneus (14.8%) and the tibial head (9.5%).In 19.1% of all cases, an intraoperative revision was performed. The highest revision rates were found with 36.0% in calcaneal fractures, 24.8% in fractures of the tibial plateau, 22.3% in injuries of the ankle.In 52.0% of revisions, the reduction was improved regarding intra-articular steps or joint congruency. In 30.5% an implant was corrected.ConclusionIntraoperative revision due to results of 3D imaging was performed in almost one-fifth of cases. This illustrates the improved possibilities to detect malreduction and implant misplacements intraoperatively and thus the abilities to improve surgical outcome.Level of evidenceIII.

Robotic degenerative mitral repair: Factors associated with intraoperative revision and impact of mild residual regurgitation

ObjectivesNational registry data show wide variability in degenerative mitral repair rates and infrequent use of intraoperative repair revision to eliminate residual mitral regurgitation (MR). The consequence of uncorrected mild residual MR is also not clear. We identified factors associated with intraoperative revision of degenerative mitral repair and evaluated long-term effects of intraoperative mild residual MR. MethodsA prospective institutional registry of 858 patients with degenerative MR undergoing robotic mitral surgery was linked to statewide databases. Univariate logistic regression identified factors associated with intraoperative repair revision. Survival was estimated using the Kaplan-Meier method and adjusted with Cox regression. Late freedom from more-than-moderate MR or reintervention was estimated with death as a competing risk. ResultsRepair rate was 99.3%. Repair was revised intraoperatively in 19 patients and was associated with anterior or bileaflet prolapse, adjunctive repair techniques, and annuloplasty band size (all P < .05). Intraoperative repair revision did not result in increased postoperative complications. Intraoperative mild residual MR (n = 111) was independently associated with inferior 8-year survival (hazard ratio, 2.97; 95% CI, 1.33-6.23), worse freedom from more than moderate MR (hazard ratio, 3.35; 95% CI, 1.60-7.00), and worse freedom from mitral reintervention (hazard ratio, 6.40; 95% CI, 2.19-18.72) (all P < .01). ConclusionsA near 100% repair rate with acceptable durability may be achieved safely with intraoperative revision of postrepair residual MR. Mild residual MR was independently associated with reduced survival, worse freedom from more-than-moderate MR, and worse freedom from mitral reintervention at 8-year follow-up.

Combined complications of duodenal ulcer: classification and some aspects of pathogenesis and tactics of surgical treatment

Aim. To improve the existing classifications as the basis for the development of a pathogenetically substantiated treatment and diagnostic tactics that meets the modern requirements of surgical gastroenterology. Material and methods. The material is based on the results of diagnosis and surgical treatment of 658 patients with duodenal ulcerative colitis with combined complications. A combination of two or more complications occurred: stenosis + penetration - in 368 (55.9 %) patients, penetration + stenosis + bleeding - in 105 (16.0 %), penetration + stenosis + perforation - in 58 (8.8 %) ), perforation + bleeding - in 52 (7.9 %), perforation + penetration - in 18 (2.7 %), penetration + bleeding - in 51 (7.8 %) patients, a combination of multiple and rare complications - in 6 (0.9 %) patients, including penetration + stenosis + perforation + bleeding - in 1 (0.15 %) patient, a combination of penetration, stenosis and duodenocholedochal fistula - in 3 (0.45 %), a combination of penetration + bleeding + stenosis + chronic pancreatitis - in 1 (0.15%), a combination of penetration + choledochal stricture + obstructive jaundice - in 1 (0.15%) patient. Results and discussion. In the classification of each variant of combined complications, the main factors influencing the choice of treatment tactics are identified. The choice of the method of surgical treatment with a simultaneous combination of several complications, first of all, depends on the general condition of the patients, due to the severity of bleeding, the prevalence of peritonitis, and the stage of stenosis of the gastroduodenal junction. In emergencies, only intraoperative revision makes it possible to clarify the nature of the pathological process and the possibility of its elimination by radical or palliative methods. Conclusion. The proposed classification can become a new platform for conducting a pathogenetically substantiated diagnostic and therapeutic strategy with the possibility of improving the results of surgical treatment of patients with duodenal ulcerative colitis with combined complications.

Accuracy of pedicle screw placement using neuronavigation based on intraoperative 3D rotational fluoroscopy in the thoracic and lumbar spine

IntroductionIn spinal surgery, precise instrumentation is essential. This study aims to evaluate the accuracy of navigated, O-arm-controlled screw positioning in thoracic and lumbar spine instabilities.Materials and methodsPosterior instrumentation procedures between 2010 and 2015 were retrospectively analyzed. Pedicle screws were placed using 3D rotational fluoroscopy and neuronavigation. Accuracy of screw placement was assessed using a 6-grade scoring system. In addition, screw length was analyzed in relation to the vertebral body diameter. Intra- and postoperative revision rates were recorded.ResultsThoracic and lumbar spine surgery was performed in 285 patients. Of 1704 pedicle screws, 1621 (95.1%) showed excellent positioning in 3D rotational fluoroscopy imaging. The lateral rim of either pedicle or vertebral body was protruded in 25 (1.5%) and 28 screws (1.6%), while the midline of the vertebral body was crossed in 8 screws (0.5%). Furthermore, 11 screws each (0.6%) fulfilled the criteria of full lateral and medial displacement. The median relative screw length was 92.6%. Intraoperative revision resulted in excellent positioning in 58 of 71 screws. Follow-up surgery due to missed primary malposition had to be performed for two screws in the same patient. Postsurgical symptom relief was reported in 82.1% of patients, whereas neurological deterioration occurred in 8.9% of cases with neurological follow-up.ConclusionsCombination of neuronavigation and 3D rotational fluoroscopy control ensures excellent accuracy in pedicle screw positioning. As misplaced screws can be detected reliably and revised intraoperatively, repeated surgery for screw malposition is rarely required.

Does Intraoperative Frozen Section and Revision of Margins Lead to Improved Survival in Patients Undergoing Resection of Perihilar Cholangiocarcinoma? A Systematic Review and Meta-analysis.

Perihilar cholangiocarcinoma (PHC) is a rare malignancy that arises at the biliary confluence. Achieving a margin-negative resection (R0) is challenging given the anatomic location of tumors and remains the most important prognostic indicator of long-term survival. The objective of this study is to review the impact of intraoperative revision of positive biliary margins in PHC on oncologic outcomes. Electronic databases were searched from inception to October 2021. Studies comparing three types of patients undergoing resection of PHC with intraoperative frozen section of the proximal and/or distal bile ducts were identified: those who were margin-negative (R0), those with an initially positive margin who had revised negative margins (R1R0), and those with a persistently positive margin with or without revision of a positive margin (R1). The primary outcome was overall survival (OS). Secondary outcomes included risk of postoperative complication. A total of 449 studies were screened. Ten retrospective observational studies reporting on 1955 patients were included. Patients undergoing successful revision of a positive proximal and/or distal bile duct margin (R1R0) had similar OS to those with a primary margin-negative resection (R0) [hazard ratio (HR) 0.93, 95% confidence interval (CI) 0.72-1.19, p = 0.56, I2 = 84%], and significantly better OS than patients with a positive final bile duct margin (R1) (HR 0.52, 95% CI 0.34-0.79, p = 0.002, I2 = 0%). There was no increase in the risk of postoperative complications associated with additional resection, although postoperative morbidity was inconsistently reported. This review supports routine intraoperative biliary margin evaluation during resection of PHC with revision if technically feasible.

Real-time intraoperative computed tomography can accurize virtual surgical planning on the double-barrel fibular flap for mandibular reconstruction

Real-time intraoperative computed tomography created the accuracy of less than 1 mm deviation in virtual surgical planning double barrel fibular flap for mandibular reconstruction-the symbiosis of intelligent technology in a digital OR. BackgroundWith the intelligent technology of virtual surgical planning, CAD/CAM, and intraoperative CT(iCT) in a digital OR, the secondary mandibular defect or primary amelobalstoma mandibulectomy can be restored using double barrel fibula and be achieved precision medicine purpose. Material and MethodA series of 7 patients underwent free flap for oral cancers who sustained 5 osteoradionecrosis, 2 segmental mandibular defect, and 2 ameloblastoma. They received 9 double barrel fibula flap and 2 free skin flaptransfers. The fibula flap were reconstructed using a virtual surgical planning including CAD/CAM for simulation 3D model, cutting guides for recipient sites and fibulas osteotomy, and iCT for image fusion in a digital OR. ResultThe mandibular defect was 5–16 cm (average: 9.56 cm), and 2–5 fibular struts for double barrel fibula (average: 3.67 struts) image fusion. One vein graft for artery was required and all 11 flaps were transferred successfully without reexploration. Six patients had intraoperative revision of the fibula and plate to improve the onlay image fusion volume from 74.71 to 82.57%. The postoperative inter-incisor midline deviation was less than 2 mm in 5 patients, and well reduction image in 4 edentulous patients. Five landmarks including bilateral condyles, bilateral gonions, and gnathion demonstrated deviation less than 1 mm in average. ConclusionCAD/CAM can allow a practical virtual surgery to restore mandibular defect reconstruction using a double barrel fibula. The symbiosis of intelligent technology in a digital OR, the iCT can promote the accuracy of mandibular spatialframework and occlusion plain.

Leiomyosarcoma of the inferior vena cava. Clinical observation

Leiomyosarcoma of the inferior vena cava (IVC) is a rare malignant tumor observed in 2 % of all leiomyosarcomas. Less than 400 cases are described in the literature, in Russian publications not more than 30. Computed tomography is the most accurate diagnostic method for determination of tumor location, presence or absence of thrombosis and its severity, evaluation of resectability. We present a case of a patient with leiomyosarcoma of the IVC with preoperative diagnosis of adrenocortical carcinoma of the right adrenal gland with tumor thrombosis of the IVC and tumor advancement into the right kidney. During intraoperative revision the tumor was evaluated as primary leiomyosarcoma of the IVC with thrombosis of the iliac veins up to the retrohepatic segment of the IVC and advancement into the right adrenal gland and vascular structures of the right kidney and its pole which was confirmed by histological examination. Surgery is the main method of treatment of leiomyosarcoma of the IVC. Long-term results depend on the volume and radicality of operation. Reconstruction of the IVC is not always necessary. Despite high recurrence rate, there is no consensus on adjuvant treatment. The best results are achieved through interdisciplinary approach involving an oncological surgeon, chemotherapist, vascular surgeon, anesthesiologist. Perioperative planning, coordination, and adherence to oncological methods are crucial for recovery.

ТЕРАТОМА ПОДЖЕЛУДОЧНОЙ ЖЕЛЕЗЫ

Pancreatic teratoma is an infrequent entity. Only a few cases have been reported in the world literature. The primary treatment for mature teratoma is radical surgery. The article presents a case of pancreatic teratoma in a 3-year-old patient. Teratoma was diagnosed preoperatively with an intravenous contrast-enhanced CT scan, which revealed that the common hepatic and splenic arteries enter the tumour walls. Intraoperative revision confirmed the CT data, and corporocaudal pancreatectomy with celiac axis resection (modified Appleby procedure) was performed to achieve R0 resection. In this case, the blood supply to the liver and stomach was derived from the superior mesenteric artery via the pancreaticoduodenal arcades and then through the gastroduodenal artery. The postoperative period was uneventful. The patient was discharged on the eighth day in satisfactory condition. Keywords: Teratoma, mature teratoma, pancreas, corporocaudal resection, celiac trunk.

Initial Intraoperative Experience with Robotic-Assisted Pedicle Screw Placement with Cirq® Robotic Alignment: An Evaluation of the First 70 Screws.

Background: Robot-guided spine surgery is based on a preoperatively planned trajectory that is reproduced in the operating room by the robotic device. This study presents our initial experience with thoracolumbar pedicle screw placement using Brainlab’s Cirq® surgeon-controlled robotic arm (BrainLab, Munich, Germany). Methods: All patients who underwent robotic-assisted implantation of pedicle screws in the thoracolumbar spine were included in the study. Our workflow, consisting of preoperative imagining, screw planning, intraoperative imaging with automatic registration, fusion of the preoperative and intraoperative imaging with a review of the preplanned screw trajectories, robotic-assisted insertion of K-wires, followed by a fluoroscopy-assisted insertion of pedicle screws and control iCT scan, is described. Results: A total of 12 patients (5 male and 7 females, mean age 67.4 years) underwent 13 surgeries using the Cirq® Robotic Alignment Module for thoracolumbar pedicle screw implantation. Spondylodiscitis, metastases, osteoporotic fracture, and spinal canal stenosis were detected. A total of 70 screws were implanted. The mean time per screw was 08:27 ± 06:54 min. The mean time per screw for the first 7 surgeries (first 36 screws) was 16:03 ± 09:32 min and for the latter 6 surgeries (34 screws) the mean time per screw was 04:35 ± 02:11 min (p < 0.05). Mean entry point deviation was 1.9 ± 1.23 mm, mean deviation from the tip of the screw was 2.61 ± 1.6 mm and mean angular deviation was 3.5° ± 2°. For screw-placement accuracy we used the CT-based Gertzbein and Robbins System (GRS). Of the total screws, 65 screws were GRS A screws (92.85%), one screw was a GRS B screw, and two further screws were grade C. Two screws were D screws (2.85%) and underwent intraoperative revision. There were no perioperative deficits. Conclusion: Brainlab’s Cirq® Robotic Alignment surgeon-controlled robotic arm is a safe and beneficial method for accurate thoracolumbar pedicle screw placement with high accuracy.

Intraoperative 3D imaging with cone-beam computed tomography leads to revision of pedicle screws in dorsal instrumentation: a retrospective analysis

BackgroundCorrect positioning of pedicle screws can be challenging. Intraoperative imaging may be helpful. The purpose of this study was to evaluate the use of intraoperative 3D imaging with a cone-beam CT. The hypotheses were that intraoperative 3D imaging (1) will lead to an intraoperative revision of pedicle screws and (2) may diminish the rate of perforated screws on postoperative imaging.MethodsTotally, 351 patients (age 60.9 ± 20.3 a (15–96); m/f 203/148) underwent dorsal instrumentation with intraoperative 3D imaging with 2215 pedicle screws at a trauma center level one. This study first evaluates intraoperative imaging. After this, 501 screws in 73 patients (age 62.5 ± 19.7 a; m/f 47/26) of this collective were included in the study group (SG) and their postoperative computed tomography was evaluated with regard to screw position. Then, 500 screws in 82 patients (age 64.8 ± 14.4 a; m/f 51/31) as control group (CG), who received the screws with conventional 2D fluoroscopy but without 3D imaging, were evaluated with regard to screw position.ResultsDuring the placement of the 2215 pedicle screws, 158 (7.0%) intraoperative revisions occurred as a result of 3D imaging. Postoperative computed tomography of the SG showed 445 (88.8%) screws without relevant perforation (type A + B), of which 410 (81.8%) could be classified as type A and 35 (7.0%) could be classified as type B. Fifty-six (11.2%) screws in SG showed relevant perforation (type C–E). In contrast, 384 (76.8%) screws in the CG were without relevant perforation (type A + B), of which 282 (56.4%) could be classified as type A and 102 (20.4%) as type B. One hundred and sixteen (23.2%) screws in the CG showed relevant perforation (type C–E).ConclusionThis study shows that correct placement of pedicle screws in spine surgery with conventional 2D fluoroscopy is challenging. Misplacement of screws cannot always be prevented. Intraoperative 3D imaging with a CBCT can be helpful to detect and revise misplaced pedicle screws intraoperatively. The use of intraoperative 3D imaging will probably minimize the number of revision procedures due to perforating pedicle screws.

Completion Arteriogram Following Carotid Endarterectomy Yields Lower Perioperative Stroke Rate.

Introduction: Completion imaging following carotid endarterectomy (CEA) remains controversial. We present our experience performing routine completion arteriography (CA). Methods: A retrospective review of our prospectively maintained institutional database was performed for patients undergoing isolated CEA. Results: 1439 isolated CEAs with CA were performed on 1297 patients. CEA was for asymptomatic lesions in 70% (1003) of cases. There were no complications related to arteriography. An abnormal arteriogram documented significant abnormalities in the internal carotid artery (ICA) and prompted revision in 1.7% (24/1439) of cases: 20 unsatisfactory distal endpoints of the endarterectomy (12 residual stenoses, 7 intimal flaps, and 1 dissection), 3 kinks or stenoses within the body of the patch, and 1 thrombus. Of the 20 distal endpoint lesions, stent deployment was used in 17 cases and patch revision in 3 cases. The other 4 cases were treated by patch angioplasty (3) or thrombectomy (1). None suffered a perioperative stroke. The overall 30-day stroke, death, and combined stroke/death rate for the 1439 patients in our series was 1.5% (22), .5% (7), and 1.9% (27), respectively. The combined stroke/death rate for asymptomatic lesions was 1.1% (11/1003) and for symptomatic lesions was 2.5% (11/436). Of the 22 strokes in the entire series (all with normal CA), 15 were non-hemorrhagic strokes ipsilateral to the CEA; 14 were confirmed to have widely patent endarterectomy sites by CT-A (13) or re-exploration and repeat arteriography (1). The occluded site was re-explored and underwent thrombectomy, but no technical problems were identified. The remaining strokes were hemorrhagic (4 reperfusion syndrome and 1 surgical site bleeding) or contralateral to the CEA (2). Conclusion: Although not all patients in this series who underwent intraoperative revision due to abnormal CA might have suffered a stroke, performing this simple and safe study may have halved our overall perioperative stroke rate from 3.2% to 1.5%.

CARDIOPULMONARY BYPASS RE-INSTITUTION AND INTRAOPERATIVE REVISIONS ARE ASSOCIATED WITH INCREASED PERIOPERATIVE RISK IN CONGENITAL CARDIAC SURGERY

CARDIOPULMONARY BYPASS RE-INSTITUTION AND INTRAOPERATIVE REVISIONS ARE ASSOCIATED WITH INCREASED PERIOPERATIVE RISK IN CONGENITAL CARDIAC SURGERY

Zygomaticomaxillary complex fracture repair with intraoperative CBCT imaging. A prospective cohort study

The aim of this study was to evaluate the value of intraoperative conebeam computed tomography (CBCT) imaging in the treatment of zygomaticomaxillary complex (ZMC) fractures.A prospective single center cohort study was performed. Included were consecutive patients who underwent surgery for a unilateral ZMC fracture. An intraoperative CBCT scan was performed after reduction of the ZMC fracture. Revision reduction was performed of the ZMC and/or orbital floor (OF) on indication. The preoperative and postoperative asymmetry of the outer surface of the ZMC was measured on digital 3D-models of CBCT scans, using a mirroring and surface-based matching technique. The postoperative asymmetry of the ZMC in the study group was compared to the asymmetry of the ZMC in the control group with healthy individuals.A total of 38 patients with a unilateral ZMC fracture were included. The mean postoperative asymmetry in the study group (1.67 mm, SD 0.89) was less than the mean preoperative asymmetry (2.69 mm, SD 0.95) (paired samples T-test p < 0.01) but showed no statistically significant difference with the mean asymmetry in the healthy control group (1.40 mm, SD 0.54) (independent samples T-test p = 0.31). Revision reduction of the ZMC and/or OF fracture had been performed in 11 cases after malalignment was noted on the intraoperative CBCT. The indication for intraoperative revision reduction was associated with comminuted ZMC fractures and/or fractures with indication for OF reduction (Pearson Chi Square p < 0.01).Within the limitations of the study, intraoperative CBCT imaging seemed to have a positive influence on ZMC fracture treatment, especially in the case of comminuted ZMC fractures and/or fractures with indication for OF treatment.

Intraoperative completion studies in carotid endarterectomy: systematic review and meta-analysis of techniques and outcomes.

BackgroundDeclining perioperative stroke and death rates over the past 3 decades have been paralleled by an increasing use of intraoperative completion studies (ICS) following carotid endarterectomy (CEA). Techniques applied include angiography, intraoperative duplex ultrasound (IDUS), flowmetry, and angioscopy. This systematic review and meta-analysis is aiming on providing an overview of techniques and corresponding outcomes.MethodsA PubMed based systematic literature review comprising the years 1980 through 2020 was performed using predefined keywords to identify articles on different ICS techniques. Pooled analyses and meta-analyses estimating risk ratios (RR) and 95% confidence intervals (CI) were performed to compare outcomes of different ICS modes to nonapplication of any ICS. I2 values were assessed to quantify study heterogeneities.ResultsIdentification of 34 studies including patients undergoing CEA with angiography (n=53,218), IDUS (n=20,030), flowmetry (n=16,812), and angioscopy (n=2,291). Corresponding rates of perioperative stroke were 1.5%, 1.8%, 3.6%, and 1.5%, perioperative stroke or death occurred in 1.7%, 1.9%, 2.2%, and 2.0%. Intraoperative surgical revision rates were 6.2%, 5.9%, and 7.9% after CEA with angiography, IDUS, and angioscopy, respectively. Compared to nonapplication of any ICS, the pooled analysis revealed angiography to be significantly associated with lower rates of stroke (RR 0.47; 95% CI, 0.36–0.62; P<0.0001) and stroke or death (RR 0.76; 95% CI, 0.70–0.83; P<0.0001). IDUS was significantly associated with lower rates of stroke (RR 0.56; 95% CI, 0.43–0.73; P<0.0001) and stroke or death (RR 0.83; 95% CI, 0.74–0.93; P=0.0018), whereas angioscopy showed a significant association with a lower stroke rate (RR 0.48; 95% CI, 0.033–0.68; P=0.0001), but no effect on the combined stroke or death rate. Angioscopy was associated with a higher intraoperative revision rate compared to angiography (RR 1.29; 95% CI, 1.07–1.54; P=0.006). The meta-analyses confirmed lower perioperative stroke or death rates for angiography (RR 0.83; 95% CI, 0.76–0.91) and IDUS (RR 0.86; 95% CI, 0.76–0.98) compared to non-application of any ICS, whereas flowmetry showed no significant association.ConclusionsThis study represents the first systematic literature review and meta-analysis on usage of ICSs in CEA. Data strongly indicate a significant beneficial effect of angiography, IDUS, and angioscopy on perioperative CEA outcomes. Any carotid surgeon should consider implementation of ICSs in his routine armamentarium.