Intraoperative Testing Research Articles

Unstable jefferson burst fractures (JBF): Intraoperative stability testing after posterior atlas ring osteosynthesis (C1-RO) allows determination of surgical procedure extent

IntroductionMotion preserving atlas ring osteosynthesis (C1-RO) for unstable Jefferson burst fractures (JBF) with insufficiency of the transverse atlantal ligament (TAL) is under debate. There is controversy about when to apply C1-RO and when further stabilization is needed. Research question:Is intraoperative stability testing after C1-RO with restoration of secondary stabilizers feasible, and what are mid-to long-term results of posterior C1-RO vs. C1–C2 ORIF in unstable Jefferson burst fractures with Dickman type I or II transverse atlantal ligament lesions based on intraoperative decision using this stability testing? Material and methodsFive consecutive patients with unstable JBF were treated with posterior C1-RO or C1–C2 ORIF based on the findings after intraoperative reduction and posterior C1-RO and stability testing. This newly developed intraoperative stability test based on the findings of biomechanical studies is a fluoroscopically controlled manual C1–C2 test with a force of approximately 50 ​N posterior-anterior stress and a tilting maneuver after C1-RO with repositioning. Clinical and radiological results of the cases with C1-RO were analyzed 3.5–21 months postoperatively. ResultsPosterior C1-RO was performed in four patients. One case required C1–C2 fixation due to significant instability. In cases of C1-RO, stable bony fusions of the atlas ring were observed within a year. In flexion-extension views, the anterior atlanto-dental interval (AADI) did not increase until the latest follow-up. No complications were observed. Discussion and conclusionThe described intraoperative stability test after posterior C1-RO in unstable JBF enables the determination if C1-RO is sufficient or C1–C2 ORIF is necessary for treatment.

Comparison Between Cotton Test and Tap Test for the Assessment of Coronal Syndesmotic Instability: A Cadaveric Study

Category:Ankle; Basic Sciences/Biologics; Sports; TraumaIntroduction/Purpose:Diagnosis of subtle instability of the distal tibiofibular syndesmosis is challenging. In surgically treated rotational malleolar fractures, instability is typically assessed with the intraoperative Cotton test. However, this test can be unreliable due to its dynamic nature and uncontrolled distraction force. The Tap test is an alternative test where a cortical tap is advanced through the fibula with a progressive, stable, and unidirectional distraction force. The objective of this cadaveric study was to compare the DTFS widening when using the Cotton and Tap tests as diagnostic tools for coronal plane syndesmotic instability.Methods:Ten below-knee cadaveric specimens were tested in intact non-stressed, intact stressed, injured non-stressed, and injured stressed conditions, with stressed conditions utilizing both Cotton and Tap tests. In injured conditions, the syndesmotic ligamentous complex was sectioned (anterolateral longitudinal approach). Perfect fluoroscopic Mortise images were acquired for all conditions. For the Tap test, a 2.5 drill bit was used to drill a hole through both distal fibular cortices. A blunt-edged 3.5mm cortical tap was advanced toward the tibia. For the Cotton test, a lateral distraction force was applied to the distal fibula with a towel clamp. Two observers measured Tibiofibular Clear Space (TFCS) 1cm proximal to the ankle joint line. Intra and interobserver reliabilities were assessed by Intraclass Correlation Coefficient (ICC). Syndesmotic TFCS values for all conditions were compared by paired Wilcoxon. Diagnostic performance of the Cotton and Tap tests was assessed (a relative increase of TFCS>2mm). P-values <0.05 were considered significant.Results:The intraclass correlation coefficient (ICC) for intraobserver and interobserver reliability was respectively, 0.96 and 0.78.TFCS measurements were similar in intact non-stressed, intact stressed (both Cotton and Tap tests) and injured non- stressed conditions: intact non-stressed, 3.5mm (CI, 3.0 to 3.9mm); intact stressed, 3.6mm (CI, 3.1 to 4.1mm) (Cotton test) and 4.0mm (CI, 3.5 to 4.5mm) (Tap test); injured non-stressed, 3.8mm (CI, 3.3 to 4.3mm). TFCS was significantly increased (p<0.0001) in injured and stressed ankles for both Cotton and Tap tests, with values of respectively, 6.2mm (CI, 5.8 to 6.7mm) and 6.1mm (CI, 5.7 to 6.6mm). The Cotton test had 73.3% sensitivity, 100% specificity, and 86.7% diagnostic accuracy. The Tap test had 70% sensitivity, 90% specificity, and 80% diagnostic accuracy.Conclusion:Our cadaveric study compared the Cotton and Tap tests for detection of coronal plane syndesmotic instability. Both tests demonstrated similar increases in TFCS measurements in stressed injured conditions when compared to intact and injured non-stressed conditions. Additionally, both tests demonstrated similar diagnostic accuracy for coronal plane syndesmotic instability, with slight favor for the Cotton test. In our experience, the Cotton test can be unreliable due to the difficulty in applying a steady distraction force while maintaining a perfect Mortise view. We recommend the Tap test as a more stable, controlled, and reproducible intraoperative diagnostic test for coronal plane syndesmotic instability.

Intraoperative Chertsey Test, is it a Reliable Alternative to Computed Tomography Scan for Diagnosing Syndesmotic Injuries of the Ankle?

Background:The present study aims to evaluate the diagnostic exactitude of the intraoperative Chertsey test in tibiofibular syndesmotic injuries in patients with malleolar fractures, in comparison with a computed tomography (CT) scan.Materials and Methods:In this study, patients with malleolar fractures operated between 2018 and 2020 were examined. Thirty-nine patients were enrolled in the study. A three-dimensional preoperative CT scan was obtained. The opposite unfractured ankle was also scanned and considered as the control group. The Chertsey test was performed during the operation to assess the syndesmosis injury. Then, patients were partitioned into two distinct groups, considering the condition of their ankle, namely the Chertsey positive (unstable syndesmosis) group and the Chertsey negative (stable syndesmosis) group.Results:The outcomes of the present survey illustrated that the Chertsey test was positive in 16 patients (41.03%) and negative in 23 patients (59.07%). The median of all CT scan parameters (anterior tibiofibular distances (TFD), middle TFD, posterior TFD, and maximal TFD and volume) before surgery in the group of patients with a positive Chertsey test was significantly higher, measured against the unfractured control group (P < 0.001 for all parameters). Furthermore, a comparison of CT scan parameters and syndesmosis space volume before surgery between the two groups of patients with positive and negative Chertsey test results showed that the measurement of parameters in Chertsey-positive patients was significantly higher than the Chertsey-negative patients (P < 0.001).Conclusion:Chertsey test could be used to diagnose syndesmosis injuries in patients with malleolar fractures due to its high importance in the outcome of patients.

A prospective study on radiological functional outcome of syndesmotic screw fixation in distal tibiofibular syndesmotic injuries associated with ankle injuries

Introduction and Purpose: Improper alignment, malreduction and neglecting to foresee syndesmotic injuries in ankle trauma led to persistent post-operative ankle pain, delay in recovery and early arthritic changes of ankle joint. The treatment of distal tibiofibular syndesmotic injuries is a major concern in ankle injuries. The objectives of this study are to have Preoperative suspicious, assessment of mode of injury, stress x-rays and intraoperative test for all ankle injuries to avoid missing syndesmotic injuries and thereby the treatment. Materials and Methods: This is a prospective study of 28 ankle injuries diagnosed to have a syndesmotic injury. All cases are due to RTA or falls while walking. Mostly of Weber type b and c. Compound grades I, II & III A were also included. After clinical and radiological investigations, the diagnosis was confirmed and intraoperative test was done and bimalleolar fracture was fixed first then syndesmotic injury fixed with either single or double cortical screws and with 3 or 4 cortex purchase. Postoperative check x-rays taken for checking the proper reduction of the syndesmotic joint and level of screw placement. Postoperative outcome were measured using the AOFAS score chart. Results and Discussion: Results of our study show excellent (AOFAS 90-100) in 17 cases, good (AOFAS 80-89) in 9 cases, fair (AOFAS 70-79) in 1 case and poor (AOFAS less than 70) in 1 case. With this, we come to the conclusion that (1) pronation external rotation injury is the common type. (2) Diagnosis of distal syndesmotic injuries and fixing it is very much important for having a pain-free stable ankle joint, early mobilization and preventing ankle joint arthritis. (3) Three cortical or four cortical purchase of syndesmotic screw is not significant in postoperative maintenance of reduction. (4) There is no definitive disadvantage if the syndesmotic screws were not removed.

Quadrimalleolar Fractures of the Ankle: Principles and Medium-Term Results of Surgical Fixation

Category:Ankle; TraumaIntroduction/Purpose:Over the last decade, much attention has been paid to the fractures of the posterior malleolus as it became obvious that the mere presence of a posterior tibial fragment is associated with a less favorable prognosis in malleolar fractures. It seems logical to pay the anterior restraints of the ankle joint a similar attention as to the posterior ones. The anteriolateral distal tibia may be considered a 'fourth' or anterior malleolus. Here, we present a technique of fixation of trimalleolar fractures with additional fracture of the anterior tibial tubercle ('quadrimalleolar') or anterior fibular rim ('quadrimalleolar equivalent').Methods:Twenty-four patients with a mean age of 60 years were treated with open reduction and internal fixation of all 4 malleoli. There were 17 quadrimalleolar and 6 quadrimalleolar equivalent fractures. One patient had both anterior tibial and fibular avulsion fractures in addition to a trimalleolar ankle fracture. Surgical approaches and internal fixation were tailored individually. Twenty patients were operated in prone position with direct fixation of the posterior malleolus and 4 patients in supine position with indirect anterior to posterior screw fixation of the posterior malleolus under transfibular control of reduction.Results:After fixation of al 4 malleoli, only one patient (4%) required a syndesmotic screw for residual syndesmotic instability on intraoperative testing. There were no infections, and no wound healing problems. All patients went on to solid union. No late fusions were needed. Nineteen patients (79%) could be reevaluated after a mean of 77 months (range, 15 to 156 months) follow- up. The Foot Function Index averaged 15 (range, 50 to 0), the Olerud and Molander Score averaged 79 (range, 45 to 100) and the AOFAS Ankle and Hindfoot Scale averaged 87 (range, 39 to 100).Conclusion:Fixation of the anterior and posterior tibial fragments increases syndesmotic stability by providing a bone-to-bone fixation. Reduction of displaced anterior and posterior tibial rim fractures restores the physiological shape of the tibial incisura and therefore facilitates fibular reduction. In the majority of cases, this also restores articular congruity of the lateral tibial plafond.Anatomic reduction of the anterior and posterior malleolus in addition to medial and lateral malleolar fixation leads to favourable functional results despite a complex (quadrimalleolar) fracture pattern.

Pelviureteric Junction Obstruction Due to Vascular Anomalies in Children - Simple Surgical Options.

ABSTRACTAims:Pelviureteric junction obstruction (PUJO) due to aberrant lower polar artery is conventionally managed with pyeloplasty. We present our experience of managing PUJO due to “vascular” anomalies-aberrant lower polar artery and vascular adhesions with simpler surgical options.Subjects and Methods:This is a protocol based, retrospective study of PUJO. Preoperative investigations included ultrasonography (USG) and diuretic renogram. An intraoperative methylene blue test (MBT) assessed transit across the Pelviureteric junction (PUJ) after release of vascular compression. Surgical management included adhesiolysis for vascular adhesions and pyelopyelostomy anterior to the aberrant polar artery. Postoperative studies were repeated after 3 and 6 months.Results:Fourteen of 144 PUJO (9.7%) were “vascular” obstructions. Those with vascular adhesions (six) were largely infants with antenatal hydronephrosis. Children with aberrant lower polar artery (eight) were older, had fleeting symptoms, minimally increased pelvic diameter and subtle impairment on diuretic renogram. Majority were term males with urinary tract infection. The MBT showed normal transit across the PUJ in all. Postoperatively, there was progressive improvement on USG and diuretic renogram after 3 and 6 months. None had any complication or redosurgeries. At a mean follow-up of 41.2 months, all are asymptomatic.Conclusions:PUJO due to extrinsic vascular anomalies is rare. Intraoperative evaluation with the MBT ruled out associated intrinsic pathology. We describe two simple surgical alternatives preserving the normal PUJ - adhesiolysis for vascular adhesions and pyelopyelostomy for aberrant lower polar artery. The preliminary outcomes are comparable to conventional pyeloplasty.

Leaks after sleeve gastrectomy – A narrative review

Background: Laparoscopic sleeve gastrectomy has become a standalone procedure for the treatment of severe obesity with excellent short- and mid-term outcome. Staple-line leak is one of the most dreaded complications of this procedure. Following a standardized sequence of critical steps can help decrease the incidence of leaks. In this review, we examine the etiopathogenesis of leaks after laparoscopic sleeve gastrectomy and important implicated technical considerations. Materials and Methods: A comprehensive literature search of various databases was performed with relevant keywords. The published scientific literature was critically appraised. Results: Patient-, surgery-, and surgeon-related risk factors should be recognized and modifiable risk factors should be addressed. There are anatomical, physiological, and technical considerations that contribute to the pathogenesis of leaks, based on which a multitude of precautions need to be taken to prevent staple-line leak. Conclusion: The correct bougie size, distance from the pylorus, stapler size, orientation of staple line, and distance from angle of His and an intraoperative leak test are some of the crucial aspects for a successful outcome after sleeve gastrectomy. Staple size less than that of 1.5 mm should not be used on the stomach, stapling should be initiated at least 5 cm from pylorus and calibrated on a bougie that should not be <32 Fr size. Reinforcing the staple line reduces the incidence of hemorrhage, and current evidence indicates the incidence of leak. Performing a leak test, though offers less sensitivity to predict a leak, does help in detecting the immediate mechanical failure of staple line.

Positive SARS-CoV-2 Detection on Intraoperative Nasopharyngeal Viral Testing is Not Associated with Worse Outcomes for Asymptomatic Elective Surgical Patients

Positive SARS-CoV-2 Detection on Intraoperative Nasopharyngeal Viral Testing is Not Associated with Worse Outcomes for Asymptomatic Elective Surgical Patients

Evaluation of Ischemic Tolerance during Cavernous Carotid Aneurysm Surgery: Initial Experience with “Intraoperative Test Occlusion”

Evaluation of Ischemic Tolerance during Cavernous Carotid Aneurysm Surgery: Initial Experience with “Intraoperative Test Occlusion”

Intraoperative vs. Postoperative Side-Effects-Thresholds During Pallidal and Thalamic DBS.

Background: It is currently unknown whether results from intraoperative test stimulation of two types of Deep Brain Stimulation (DBS), either during awake pallidal (GPi) or thalamic (Vim), are comparable to the results generated by chronic stimulation through the definitive lead.Objective: To determine whether side-effects-thresholds from intraoperative test stimulation are indicative of postoperative stimulation findings.Methods: Records of consecutive patients who received GPi or Vim were analyzed. Thresholds for the induction of either capsular or non-capsular side-effects were compared at matched depths and at group-level.Results: Records of fifty-two patients were analyzed (20 GPis, 75 Vims). The induction of side-effects was not significantly different between intraoperative and postoperative assessments at matched depths, although a large variability was observed (capsular: GPi DBS: p = 0.79; Vim DBS: p = 0.68); non-capsular: GPi DBS: p = 0.20; and Vim DBS: p = 0.35). Linear mixed-effect models revealed no differences between intraoperative and postoperative assessments, although the Vim had significantly lower thresholds (capsular side-effects p = 0.01, non-capsular side-effects p < 0.01). Unpaired survival analyses demonstrated lower intraoperative than postoperative thresholds for capsular side-effects in patients under GPi DBS (p = 0.01), while higher intraoperative thresholds for non-capsular side-effects in patients under Vim DBS (p = 0.01).Conclusion: There were no significant differences between intraoperative and postoperative assessments of GPi and Vim DBS, although thresholds cannot be directly extrapolated at an individual level due to high variability.

Anatomically Fixed Posterior Malleolar Fractures in Syndesmosis Injuries without Transsyndesmotic Screw Fixation.

The stability of the syndesmosis is extremely important in terms of syndesmosis injury, ankle instability, and posttraumatic osteoarthritis development following ankle fractures. The aim of this study is to evaluate 1-year radiographic outcomes after posterior malleolar fixation in lateral and posterior malleolar fractures and trimalleolar fractures without transsyndesmotic screw fixation. Ninety-four patients who underwent posterior malleolar fixation with posterolateral approach between January 2017 and June 2019 were evaluated retrospectively. The patients were evaluated with parameters such as demographic characteristics, fracture type, injury mechanism, physical examination, and radiographic measurements. The stability of the syndesmosis was evaluated by an intraoperative Cotton test and by measuring the tibiofibular overlap, tibiofibular clear space, and medial clear space parameters preoperatively on the immediate postoperative, first-year weightbearing ankle anteroposterior radiographs. In immediate postoperative measurements on radiographs, although the mean tibiofibular overlap (P < .001) increased, the mean tibiofibular clear space (P < .001) and mean medial clear space (P < .001) decreased compared with preoperative radiographs. Immediate postoperative mean tibiofibular overlap, tibiofibular clear space, and medial clear space compared with postoperative first-year mean tibiofibular overlap (P = .39), tibiofibular clear space (P = .23), and medial clear space (P = .43) were not statistically significant. Bone union was completed radiographically at a median of 3.4 ± 1.8 months after surgery. After posterior malleolar fractures, anatomic reduction of the posterior malleolus and posterior inferior tibiofibular ligament complex provides strong syndesmosis stability as measured radiographically at 1 year. Patients may not need additional transsyndesmotic screw fixation. Level IV, case series.

A Novel Cell Morphology Analyzer Application in Head and Neck Cancer

PurposeRapid and accurate diagnosis of the pathological characteristics of head and neck cancer and tumor resection margins is important. The DiveScope cell morphology analyzer (DiveScope) is a new endomicroscope that can rapidly image living tissues and cells. In this study, we preliminarily examined the accuracy of the DiveScope for determining the malignancy of head and neck cancers and the positivity/negativity of tumor resection margins and determined the consistency between diagnostic results with the DiveScope and those of frozen section pathology to provide a foundation for further clinical trials in pathological diagnosis of head and neck cancers and tumor resection margins.MethodsHead and neck cancer samples and resection margin samples were rapidly stained ex vivo before observation under the DiveScope cell morphology analyzer. Experienced pathologists distinguished the benignity and malignancy of the tumors based on images obtained by the DiveScope in a double-blind manner to validate the diagnostic performance of the analyzer.ResultsWe found that the cell morphology, cell nucleus morphology, karyoplasmic ratio, and even the nucleolus could be clearly distinguished. The positive likelihood ratio (PLR) and negative likelihood ratio (NLR) of benign and malignant head and neck cancer according to DiveScope results were 10.55 and 0.04, respectively. The PLR and NLR of the head and neck cancer resection margins according to the DiveScope were 19.01 and 0, respectively.ConclusionThe DiveScope showed high accuracy in determining the benignity and malignancy of head and neck cancer and the positivity/negativity of resection margins, and its results were highly consistent with those of intraoperative frozen section pathology tests.

A Data-Based Approach for Selecting Pre- and Intra-Operative Language Mapping Tasks.

Background: Pre- and intra-operative language mapping in neurosurgery patients frequently involves an object naming task. The choice of the optimal object naming paradigm remains challenging due to lack of normative data and standardization in mapping practices. The aim of this study was to identify object naming paradigms that robustly and consistently activate classical language regions and could therefore be used to improve the sensitivity of language mapping in brain tumor and epilepsy patients.Methods: Functional magnetic resonance imaging (fMRI) data from two independent groups of healthy controls (total = 79) were used to generate threshold-weighted voxel-based consistency maps. This novel approach allowed us to compare inter-subject consistency of activation for naming single objects in the visual and auditory modality and naming two objects in a phrase or a sentence.Results: We found that the consistency of activation in language regions was greater for naming two objects per picture than one object per picture, even when controlling for the number of names produced in 5 s.Conclusion: More consistent activation in language areas for naming two objects compared to one object suggests that two-object naming tasks may be more suitable for delimiting language eloquent regions with pre- and intra-operative language testing. More broadly, we propose that the functional specificity of brain mapping paradigms for a whole range of different linguistic and non-linguistic functions could be enhanced by referring to databased models of inter-subject consistency and variability in typical and atypical brain responses.

BRMP-02. Feasibility and evaluation of a novel language paradigm for intraoperative language testing

Abstract INTRODUCTION Mapping language during direct cortical stimulation (DCS) in the stetting of awake craniotomy might be challenging without using more than one language paradigm. Applying several language tasks leads to increasing surgery times and to patient’s exhaustion. Additionally, a single language trial must be performed in less than 4 seconds to avoid DCS-induced seizures. Therefore, we aimed to design a single language paradigm which pictures highly relevant language functions and simultaneously restrains the assessment time of single language trials up to 4 seconds. METHOD The intraoperative language task comprised a combination of picture naming and verb generation. During DCS patients should generate correct sentences according to the language stimulus by not exceeding 4 seconds. To assess the intraoperative feasibility of the language task we included 30 healthy subjects in a pilot study to measure subjects’ speed of performing a single language task trial and to evaluate the language paradigm according to its language sensitivity by using the paradigm as a task for functional MRI. Intraoperatively, 21 patients with brain tumors in language associated brain areas were included. Patients received neuropsychological testing before and after surgery. RESULTS The pilot study showed in healthy subjects that by applying the novel paradigm during fMRI there is activation in a left accentuated network of inferior frontal and parietal regions and the superior and middle temporal gyrus (p&amp;lt;.05, FEW). It was feasible to conduct a single language trial of the novel paradigm in a time frame of 4s (performance speed 2.53 s; SD=.32s). Intraoperatively, tumor patients showed DCS-associated language errors while conducting the language task. Postoperatively, mild language but no other neuropsychological deteriorations compared to presurgical assessment were observed (p&amp;lt;.05). CONCLUSION We present a novel language paradigm which safely pictures and monitors highly relevant language functions and consequently can minimize postoperative language deficits.

Successful umbilicus salvage following concurrent infraumbilical single-port myomectomy and free transverse rectus abdominis myocutaneous flap elevation: a case report

Performing a concurrent gynecologic operation and mastectomy with immediate breast reconstruction using a free transverse rectus abdominis myocutaneous flap may increase the risk of complications such as umbilical necrosis due to vascular compromise. Imaging studies such as preoperative computed tomography angiography and intraoperative indocyanine green testing can provide information regarding the umbilical blood supply, facilitating decision-making for pedicle selection. Therefore, in situations where a coordinated operation is unavoidable, a thorough preoperative and intraoperative evaluation of the umbilical blood supply is recommended to avoid complications.

Comparison of cognitive performance between patients with Parkinson\u2019s disease and dystonia using an intraoperative recognition memory test

Neuroscientific studies on the function of the basal ganglia often examine the behavioral performance of patients with movement disorders, such as Parkinson’s disease (PD) and dystonia (DT), while simultaneously examining the underlying electrophysiological activity during deep brain stimulation surgery. Nevertheless, to date, there have been no studies comparing the cognitive performance of PD and DT patients during surgery. In this study, we assessed the memory function of PD and DT patients with the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE). We also tested their cognitive performance during the surgery using a continuous recognition memory test. The results of the MoCA and MMSE failed to reveal significant differences between the PD and DT patients. Additionally, no significant difference was detected by the intraoperative memory test between the PD and DT patients. The intraoperative memory test scores were highly correlated with the MMSE scores and MoCA scores. Our data suggest that DT patients perform similarly to PD patients in cognitive tests during surgery, and intraoperative memory tests can be used as a quick memory assessment tool during surgery.

White test versus conventional saline test in detecting intra-operative bile leakage in liver resection

Abstract Background Hepatic surgery will be always one of the most challenging surgical procedures due to its anatomical and pathophysiologic varieties. Various problems may complicate the post-operative course. Bile leak remains a serious complication after hepatectomy. Bile leaks can significantly impact morbidity, mortality, and cost of treatment. Bile leak increases risk of sepsis, need for further intervention, either radiological or return to theatre, prolongs duration of intensive care unit and hospital stay, and can precipitate liver failure and death. Objective To assess the post-operative bile leak complication after using white test versus conventional saline test Patients and Methods A prospective study on 50 Hepatectomy cases divided into two groups, the first group consist of 25 cases using white test and the second group consist of 25 cases using conventional saline test from January 2019 to January 2020, at Hepatobiliary unit of the general surgery department of Ain Shams university hospitals. Results The White test has clear advantages in comparison with other bile leakage tests: it precisely detects bile leakages, regardless of size; it does not stain the resection surface, allowing it to be washed off and repeated ad infinitum; and it is safe, quick, and inexpensive. The white test is a feasible and sensitive bile leakage test with no obvious disadvantages. It could be a possible standardized method to prevent bile leakage in major liver resection. Conclusion Now after we discussed our study and reviewed other opinions discussing the optimal methods for intraoperative bile leakage testing, we have now settled on White test using fat emulsion solution to be best of all tests.

Thermal Neuromodulation With Focused Ultrasound: Implications for the Technique of Subthreshold Testing.

During focused ultrasound ablation (FUSA), the presumed stereotactic target is tested with subthreshold sonications before permanent ablation. This testing relies on ultrasound-induced reversible clinical effects (thermal neuromodulation, TN). However, the thermal dose and spot size thresholds to induce TN are not yet defined. To define the thermal dose and spot size thresholds associated with TN. We performed a retrospective analysis of intraoperative FUSA data of essential tremor patients. Sonications with a thermal dose of less than 25 cumulative equivalent minutes (CEM) were classified as subthreshold. The intraoperative writing samples were independently rated by 2 raters using the clinical rating scale for tremor. The association between thermal dose and tremor scores was statistically analyzed, and the thermal dose and spot size thresholds for TN were computed using leave-one-out cross-validation analysis. A total of 331 pairs of sonications and writing samples were analyzed; 97 were classified as subthreshold sonications. TN was observed in 23 (24%) subthreshold sonications. The median tremor improvement during TN was 20% (interquartile range=41.6). The thermal dose threshold for TN was 0.67 CEM (equivalent to 30 s thermal exposure at 43°C). The spot size threshold for TN was 2.46mm. Ventral intermediate medial nucleus was exposed to TN thermal dose during subablative and ablative sonications. The TN thermal dose and spot size thresholds are significantly higher than the current FUSA standard of care. We recommend long duration (>30 s), subthreshold sonications for intraoperative testing during FUSA. Future investigations should test whether the thermal dose threshold is tissue-specific and determine the mechanisms underlying focused ultrasound TN.

Feasibility and Short-Term Outcomes of Three-Dimensional Hand-Sewn Esophago-Jejunal Anastomosis in Completely Laparoscopic Total Gastrectomy for Cancer.

Simple SummaryLaparoscopic total gastrectomy for the treatment of gastric and esophago-gastric junction cancer is on the rise. The procedure’s rate-limiting step is the construction of the esophago-jejunal anastomosis. Most surgeons are performing the anastomosis laparoscopically by utilizing an endoscopic linear or circular stapler; scarce evidence exists regarding laparoscopic hand-sewn esophago-jejunal anastomosis. Herein, we present our technique and results of laparoscopic manual esophago-jejunal anastomosis during totally laparoscopic total gastrectomy for gastric and esophago-gastric junction cancer. Anastomosis was performed in a two-layer fashion. Overall implementation provided excellent surgical outcomes in our cohort of patients; median anastomotic time was 55 min, while median operating time was 240 min. Intra-operative methylene blue leak test was negative in all cases. No anastomotic leak or anastomotic stricture were noted postoperatively. The 30-day and 90-day mortality rates were zero.Laparoscopic total gastrectomy is on the rise. One of the most technically demanding steps of the approach is the construction of esophago-jejunal anastomosis. Several laparoscopic anastomotic techniques have been described, like linear stapler side-to-side or circular stapler end-to-side anastomosis; limited data exist regarding hand-sewn esophago-jejunal anastomosis. The study took place between January 2018 and June 2021. Patients enrolled in this study were adults with proximal gastric or esophago-gastric junction Siewert type III tumors that underwent 3D-assisted laparoscopic total gastrectomy. A hand-sewn esophago-jejunal anastomosis was performed in all cases laparoscopically. Forty consecutive cases were performed during the study period. Median anastomotic suturing time was 55 min, with intra-operative methylene blue leak test being negative in all cases. Median operating time was 240 min, and there were no conversions to open. The anastomotic leak rate and postoperative stricture rate were zero. The 30- and 90-day mortality rates were zero. Laparoscopic manual esophago-jejunal anastomosis utilizing a 3D platform in total gastrectomy for cancer can be performed with excellent outcomes regarding anastomotic leak and stricture rate. This anastomotic approach, although technically challenging, is safe and reproducible, with prominent results that can be disseminated in the surgical community.

Intraoperative Indocyanine Green Retention Test of Left Hemiliver in Decision-Making for Patients With Hepatocellular Carcinoma Undergoing Right Hepatectomy

Introduction: The aim of this study was to select qualified patients with hepatocellular carcinoma (HCC) who underwent right hepatectomy (RH) via intraoperative indocyanine green retention test at 15 min (ICG-R15) of the left hemiliver, which prevents severe posthepatectomy liver failure (PHLF).Methods: Twenty HCC patients who were preoperatively planned to undergo RH were enrolled. Intraoperative ICG-R15 of left hemiliver was measured after the right Glissonean pedicle was completely blocked. Patients then underwent RH if intraoperative ICG-R15 was ≤ 10%. Otherwise, patients underwent staged RH (SRH), either associating liver partitioning and portal vein ligation for staged hepatectomy (ALPPS) or portal vein ligation (PVL), followed by stage-2 RH. The comparison group consisted of patients with a ratio of standard left liver volume (SLLV) of > 40% and preoperative ICG-R15 ≤ 10% who underwent RH. The clinical outcomes of these two groups were compared.Results: Of the 20 patients, six underwent stage-1 RH, six underwent ALPPS, five underwent PVL followed by stage-2 RH, and three failed to proceed to stage-2 RH after PVL. No significant differences were found among the 17 patients who underwent stage-1 or stage-2 RH in the study group, the 19 patients in the comparison group, the 11 patients in the stage-2 RH group, and the six patients in the stage-1 RH group in incidences of PHLF, postoperative complications, hospital stay, and HCC recurrence within 1 year after RH. Compared with the stage-1 ALPPS group, the mean operative time and blood loss of the stage-1 PVL group were significantly less (p <0.001 and p = 0.022, respectively). The stage-1 PVL group had a significantly longer waiting-time (43.4 vs. 14.0 days, p = 0.016) than the stage-1 ALPPS group to proceed to stage-2 RH. After stage-2 RH, tumor recurrence within 1 year was 20% (1/5) in patients after PVL and 50% (3/6) after stage-1 ALPPS.Conclusions: Intraoperative ICG-R15 ≤ 10% of left hemiliver was valuable in intraoperative decision-making for patients who were planned to undergo RH. There is a possibility that stage-1 PVL might help to select patients with more favorable biological behavior to undergo stage-2 RH.