Longer Surgical Duration Research Articles

Digital tools in primary total knee arthroplasty-Prevalence in the German-speaking region

Digital tools are being increasingly used worldwide in primary knee arthroplasty. This study aimed to analyze the utilization density of digital tools, the preferred alignment strategies, and the obstacles and benefits of implementing these technologies in German-speaking countries. An online survey with 57questions about digital tools in primary knee arthroplasty and their usage was conducted among members of the Arthroplasty Working Group (AE). The survey included questions on navigation, robotics, patient-specific instruments, individualized implants, and augmented reality. The survey revealed that 18% of hospitals use navigation and 17% use robotic systems in primary total knee arthroplasty surgery. The main reasons for not implementing supportive technologies were high acquisition and ongoing costs, as well as longer surgical duration. Patient-specific instruments and individualized implants currently play aminor role. Patient-specific alignment strategies, such as kinematic (navigation: 35%; robotics: 44%) and functional alignment (navigation: 15%; robotics: 35%), are preferred in this context. With conventional instrumentation predominantly mechanical alignment was applied (79%). The results indicate arelatively high utilization density of digital tools, which are mainly used to perform personalized alignment strategies in primary knee arthroplasty in German-speaking countries. This was particularly evident in high-volume hospitals. Economic aspects were the main reasons for not using these technologies. Future developments should aim to simplify the systems and thus achieve improved cost efficiency.

Risk Factors for Postoperative Urinary Tract Infections in Paediatric Hydronephrosis: A Retrospective Analysis.

Paediatric hydronephrosis frequently necessitates surgical intervention. However, postoperative urinary tract infections (UTIs) are common and challenging. This retrospective cohort study aimed to identify UTI risk factors following an operation for paediatric hydronephrosis. Paediatric patients with hydronephrosis who underwent operation from January to December 2023 were studied. Patients were categorised into no UTI and UTI groups. Demographics, surgical history, pre/postoperative factors, imaging, and lab values were compared. A total of 111 patients were enrolled, with 98 in the no-UTI group and 13 in the UTI group. The UTI group had significantly more previous surgeries and longer surgical duration (p < 0.05). Preoperative factors associated with UTI occurrence included higher hydronephrosis grade, absence of antibiotic prophylaxis, presence of vesicoureteral reflux (VUR), abnormal preoperative urine cultures, and ureteral stent placement (p < 0.05). The UTI group exhibited more extended hospital stays, higher rates of postoperative fever, reoperation, and readmission within 30 days (p < 0.05). Postoperative imaging and laboratory findings were also significantly different (p < 0.05). The UTI group had elevated white blood cell count, C-reactive protein levels, serum creatinine, and urine white blood cell count (p < 0.05). Other potential risk factors included constipation, family history of UTI, bladder dysfunction, history of recurrent UTI, and use of prophylactic antibiotics. Multivariate logistic regression analysis indicated that while antibiotic prophylaxis and preoperative urine culture results negatively correlated with UTI occurrence, other factors were positively correlated, with the number of previous surgeries having the most significant impact on UTI occurrence (odds ratio (OR) = 20.617; 95% confidence interval (CI): [0.718, 0.802]; p < 0.001). Multiple factors contribute to the risk of postoperative UTI for paediatric hydronephrosis, highlighting the need for tailored interventions to mitigate risks and improve outcomes.

Perioperative complications in patients aged ≥85 years undergoing spinal surgery: a retrospective comparative study of pre-old and old patients in Japan.

A retrospective comparative study. To compare the characteristics of perioperative complications in patients aged ≥85 years with those of younger patients undergoing similar spine surgery and examine factors associated with perioperative complications and clinical outcomes among patients aged ≥85 years. The risk factors for perioperative complications and their effect on outcomes in patients aged ≥85 years remain unclear. Furthermore, no study has compared younger patients with similar surgeries and condition with those aged ≥85 years. The study included patients aged ≥65 years who underwent spinal surgeries. The patients aged ≥85, 75-84, and 65-74 years were categorized into the super-old, old, and pre-old groups, respectively. The differences in perioperative age-related complications were compared among the three groups while matching for surgical procedures and general conditions (study 1). Furthermore, preoperative and intraoperative factors were examined for perioperative complications in the super-old group (study 2). Complications were categorized into surgical site and systemic complications. The analysis included 44 patients from each group. In study 1, the total complication rates were 40.9%, 25%, and 18.2% of the super-old, old, and pre-old groups, respectively. Differences in complication rates were observed between the super-old and pre-old groups (p=0.011). In study 2, 58 patients from the super-old group were analyzed. Surgical site complications were significantly associated with longer surgical duration (p=0.02) and more estimated blood loss (p=0.003). Systemic complications were significantly associated with previous cerebrovascular disease (p=0.014), preoperative motor deficit (p=0.023), and emergency case (p=0.006) and negatively associated with diabetes mellitus (p=0.048). Perioperative complications increased with advancing age in the super-old, old, and pre-old groups. The complication type is associated with specific background factors; therefore, determining them may help prevent perioperative complications.

Feasibility of lung lobectomy through a transdiaphragmatic approach in dogs.

Different pulmonary pathologies may require a partial or total lung lobectomy as treatment. This study compared two techniques for performing a caudal pulmonary lobectomy: a traditional lateral thoracotomy (LT) and a novel transdiaphragmatic (TD) approach. TD and LT approaches were performed on each of 18 canine cadavers. The operator and order of intervention were randomised at the beginning of the study. To compare both techniques, surgical time, percentage of area of lobe removed, incision length and iatrogenic damage were recorded. The mean length of surgery for the TD approach (1155±232.8 seconds) was non-inferior to the LT approach (1126.8±180.6 seconds) (p=0.6131). The mean percentage of the area of caudal lobe that was successfully removed during the TD approach was 25.83±8.95% (range 10.55‒40.72%) of the lobe surface, while 100% of the caudal lobe was removed during the LT approach. There was no statistical difference in iatrogenic damage between the procedures. This is a non-inferiority ex vivo study carried out by three different surgeons, and no leak test was performed after lobectomies. Partial caudal lung lobectomy can be performed in dogs by the TD approach without greater iatrogenic damage or longer surgical duration than the traditional LT approach.

Comparison of Extracorporeal and Intracorporeal Urinary Diversion after Robot-Assisted Radical Cystectomy for Bladder Cancer: A Meta-Analysis.

To explore the therapeutic efficacy of intracorporeal urinary diversion (ICUD) and extracorporeal urinary diversion (ECUD) after robot-assisted radical cystectomy for bladder cancer through systematic review. This study systematically retrieved electronic databases of PubMed, Web of Science, Cochrane Library, CNKI, and Wanfang to include peer-reviewed studies comparing ICUD and ECUD after robot-assisted radical cystectomy for bladder cancer. Relative risk (RR) and mean difference (MD) were used to represent the pooled effect size and estimate its 95% confidence interval (CI). This study included 15 studies with good quality, involving 5,370 patients undergoing robot-assisted radical cystectomy for bladder cancer. Meta-analysis showed that ICUD reduced intraoperative bleeding volume by 64.12 ml (95% confidence interval [CI]: [-100.95, -27.29]), significantly decreased the risk of blood transfusion (RR: 0.40; 95% CI: [0.24, 0.68]) and gastrointestinal complications (odds ratio [OR]: 0.61; 95% CI: [0.47, 0.80]), with shorter postoperative time of exhaust (MD: -9.27; 95% CI: [-18.47, -0.08]) and oral intake (MD: -0.92; 95% CI: [-1.30, -0.54]). However, ICUD had a relatively longer surgical duration (MD: 30.84 min, 95% CI: [5.03, 56.66]). In addition, there was no statistically significant difference concerning the impact of ICUD and ECUD on the length of stay in the hospital (MD: -0.68d; 95% CI: [-1.79, 0.42]), overall complications (30-day: RR: 1.16; 95% CI: [0.93, 1.46]; and 90-day, RR: 0.85; 95% CI: [0.69, 1.04]) and readmission rate (30-day: RR: 0.96; 95% CI: [0.72, 1.27]; and 90-day: RR: 1.15; 95% CI: [0.80, 1.64]). ICUD after robot-assisted laparoscopic radical cystectomy for bladder cancer exhibits obvious positive effects, especially in reducing the risk of blood transfusion and gastrointestinal complications, and shortening postoperative time of exhaust and oral intake. The findings in this meta-analysis should be confirmed by multiple high-quality studies in the future.

294. LEARNING CURVE OF MINIMALLY INVASIVE ESOPHAGECTOMY: OUR SERIES, SYSTEMATIC REVIEW OF THE LITERATURE AND META-ANALYSIS

Abstract Background Minimally invasive esophagectomy has demonstrated non-inferiority in terms of surgical and oncologic outcomes compared with open esophagectomy, with better short-term outcomes. The learning curve of this procedure is protracted before a plateau of ideal results is reached. The purpose of this study is to evaluate the safety and efficacy of implementing a totally minimally invasive esophagectomy program for cancer in a high-volume center and the impact of the learning curve on perioperative and oncologic outcomes. Methods This is a retrospective non-randomized control study. The study includes 199 patients who underwent surgery from June 2018 to October 2022. Patients undergoing MIE were assigned to the “MIE group” (n=61), while those undergoing Open Esophagectomy to the “OE group” (n=138). By comparing the perioperative and oncological outcomes between the two groups, we assessed the safety and efficacy of the MIE. Subsequently, the MIE group was divided into two subgroups: Early Experience (“EE”) and Late Experience (“LE”) group. By comparing the perioperative surgical outcomes between these two groups we evaluated the presence and the impact of a learning curve. Results Although longer surgical duration (p&amp;lt;0.001), MIE did not compromise surgical radicality (same rate of R0, p=0.345 and higher number of lymph node yields p&amp;lt;0.001). We observed a learning curve effect on postoperative outcomes, with decreasing complication rates (61% vs. 36.7%, p=0.054), and shorter ICU stay (1.6 ± 2.4 vs. 0.6 ± 1.5, p=0.049) and faster recovery in the LE group (19.6 ± 19.8 vs. 12.2 ± 5.9, p=0.055). Analysis of CUSUM plots reveals a decrease in total ICU and recovery starting with patient number 25. A meta-analysis confirms a trend towards lower anastomotic leak rates as the learning curve progresses. Conclusion The findings of this study support the safety and efficacy of implementing a totally MIE program for cancer in a high-volume center. The outcomes are not impaired by the learning curve effect and meet current standards. Comparing the outcomes of the early experience with those of the late experience, we discovered improving trends in postoperative complication and recovery rates. In our high-volume center's experience, improving these outcomes has required 25 to 30 cases.

Evaluating the surgical trainee ergonomic experience during minimally invasive abdominal surgery (ESTEEMA study)

Minimally invasive abdominal surgery (MAS) can exert a physical cost. Surgical trainees spend years assisting minimally-invasive surgeries, increasing the risk of workplace injury. This prospective questionnaire-based cohort study was conducted amongst general surgery residents in Singapore. Residents assisting major MAS surgery were invited to complete anonymous online survey forms after surgery. The Phase 1 survey assessed physical discomfort scores and risk factors. Intraoperative measures to improve ergonomics were administered and evaluated in Phase 2. During Phase 1 (October 2021 to April 2022), physical discomfort was reported in at least one body part in 82.6% (n = 38) of respondents. Over a third of respondents reported severe discomfort in at least one body part (n = 17, 37.0%). Extremes of height, training seniority, longer surgical duration and operative complexity were significant risk factors for greater physical discomfort. In Phase 2 (October 2022 to February 2023), the overall rate of physical symptoms and severe discomfort improved to 81.3% (n = 52) and 34.4% (n = 22) respectively. The ergonomic measure most found useful was having separate television monitors for the primary surgeon and assistants, followed by intraoperative feedback on television monitor angle or position. Close to 20% of survey respondents felt that surgeon education was likely to improve physical discomfort.

Is young adult idiopathic scoliosis a distinct clinical entity from adolescent idiopathic scoliosis? a Systematic Review and Meta-analysis comparing pre-operative characteristics and operative outcomes.

This study aims to conduct a systematic review of the literature comparing pre-operative, intraoperative, and post-operative characteristics between adolescent idiopathic scoliosis (AIS) and young adult idiopathic scoliosis (YAdIS) patients. Following PRISMA guidelines, we conducted a search of the PubMed/Medline, EMBASE, and Cochrane Central databases to identify full-text articles in the English-language literature. Our inclusion criteria were studies that compared preoperative, intraoperative, and postoperative characteristics between AIS and YAdIS patients. We performed a meta-analysis reporting mean difference (MD) for continuous variables and Odds ratios (ORs) to assess differences in postoperative complications. Seven studies consisting of 1562 patients were included in the meta-analysis. The AIS group exhibited less intraoperative bleeding and shorter surgical procedures, with a mean difference between groups of 122.3ml (95% CI 46.2-198.4, p = 0.002) and 28.7min (95% CI 6.5-50.8, p = 0.01), respectively. Although the preoperative Cobb angle did not differ between groups (p = 0.65), patients with AIS achieved superior postoperative deformity correction, with a mean difference of 7.3% between groups, MD -7.3 (95% CI -9.7, -4.8, p < 0.00001), and lower postoperative Cobb angles of the major curve, MD 4.2 (95% CI 3.1, 5.3, p < 0.00001). YAdIS patients were fused, on average, 0.2 more vertebral levels than AIS patients, MD 0.2 (95% CI 0.01, 0.5, p = 0.04). AIS patients experienced a significantly shorter length of stay after the surgical procedure, with an MD of 0.8days (95% CI 0.1, 1.6, p = 0.02). No significant difference was found between groups in terms of complications (p = 0.19). YAdIS should be regarded as a distinct surgical entity, characterized by increased bleeding, longer surgical duration, greater deformity correction challenges, and the need for fusion of additional vertebral levels compared to AIS. Surgeons should be mindful of these differences and discuss them with patients and their families, especially in cases where the correction of the AIS deformity is delayed and there is a high risk of progression after skeletal maturity. Further research is needed to explore alternative surgical techniques and enhance outcomes for YAdIS patients.

Pain during cesarean delivery: A patient-related prospective observational study assessing the incidence and risk factors for intraoperative pain and intravenous medication administration

IntroductionThe incidence of pain during cesarean delivery (PDCD) remains unclear. Most studies evaluated PDCD using interventions suggesting inadequate analgesia: neuraxial replacement, unplanned intravenous medication (IVM), or conversion to general anesthesia. Few assess self-reported pain. This study evaluates the incidence of and risk factors for self-reported PDCD and IVM administration. MethodsBetween May and September 2022, English-speaking women undergoing cesarean delivery under neuraxial anesthesia were approached within the first 48 h. Participants answered a 16-question survey about intraoperative anesthesia care. Clinical characteristics were extracted from electronic medical records. The primary outcome was PDCD. Secondary outcomes were analgesic IVM (opioids alone or in combination with ketamine, midazolam, or dexmedetomidine) and conversion to general anesthesia. Risk factors for PDCD and analgesic IVM were identified using multivariable logistic regression models. ResultsPain was reported by 46/399 (11.5%; 95% CI: 8.6, 15.1) participants. Analgesic IVM was administered to 16 (34.8%) women with PDCD and 45 (12.6%) without. Conversion to general anesthesia occurred in 3 (6.5%) women with and 4 (1.1%) without PDCD. Risk factors associated with PDCD were substance use disorder and intrapartum epidural extension. Risk factors associated with analgesic IVM were PDCD, intrapartum epidural extension when ≥2 epidural top-ups were given for labor analgesia, and longer surgical duration. DiscussionIn our cohort of scheduled and unplanned cesarean deliveries, the incidence of PDCD was 11.5%. A significant proportion of women (15.1%) received analgesic IVM, of which some but not all reported pain, which requires further evaluation to identify triggers for IVM administration and strategies optimizing shared decision-making.

Surgical Site Infections in Open and Laparoscopic Operations in Rooms With Open-floor Drainage Systems.

Surgical site infections are common postoperative complications. Some operating rooms have open-floor drainage systems for fluid disposal during endourologic cases, although nonendoscopy cases are not always allowed in these rooms. We hypothesized that operating rooms with open-floor drainage systems would not materially affect risk of surgical site infections for patients undergoing open and laparoscopic procedures. Patients who had surgical site infections from 2016 through 2020 were identified from data of the National Surgical Quality Improvement Program. Patients without surgical incisions, with open wounds, and with surgical site infections at surgery were excluded. The primary outcome was surgical site infection occurrence within 30 days of surgery. Multilevel multivariable logistic regression was used to estimate the observed-to-expected surgical site infection ratio for each operating room (2 with and 23 without open-floor drainage systems). We identified 8,419 surgical cases, of which 802 (9.5%) were performed in operating rooms with open-floor drainage systems; 166 patients (2.0%) had surgical site infections. Of the surgical site infections, 7 (4.2%) occurred in operating rooms with open-floor drainage systems. Surgical specialty, American Society of Anesthesiologists physical status, higher case acuity, dyspnea, immunosuppression, longer surgical duration, and wound classification were associated with surgical site infections (P < .05 for all). The observed-to-expected ratios of surgical site infections occurring in the 2 operating rooms with open-floor drainage systems were 0.85 and 1.15. The odds ratio of surgical site infections for urologic cases performed in room with vs without open-floor drainage systems was 1.30 (P = .65). Urology operating room designs often include open-floor drainage systems for water-based cases. These drainage systems were not associated with an increased risk of surgical site infections.

A novel auxiliary fixation technique of meshes in intraperitoneal onlay mesh procedures for incisional hernia repair.

Mesh fixation is an important step in incisional hernia repair. Weak fixation possibly results in postoperative pain, and even hernia recurrence. We innovated an auxiliary fixation approach, the magnet attraction technique (MAT), to achieve better mesh fixation. The purpose of this study was to evaluate the effect of MAT in intraperitoneal onlay mesh (IPOM) procedures for incisional hernia repair. Historical patient records were analyzed according to the clinical data of 16 patients with incisional hernias. Among them, 5 patients have undergone IPOM repair procedures in combination with MAT to assist in mesh fixation. As a control, 11 patients treated with IPOM and mesh fixation via conventional suspension were included. The clinical data collected include patients' basic characteristics, intraoperative and postoperative conditions, and follow-up results in both groups. Compared with patients in the control group, patients in the MAT group were found to suffer from a larger hernia ring diameter and longer surgical duration, but shorter hospitalization length on average. And most importantly, no complication has been reported in the MAT group. MAT in IPOM operation was regarded as a feasible and safe technique for patients suffering from incisional hernias.

Machine learning prediction of venous thromboembolism after surgeries of major sellar region tumors

PurposeTo describe and predict the risk of venous thromboembolism (VTE) after surgical resection of major sellar region tumors. MethodPatients with sellar region tumors were identified from a database. The outcome was VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE) within 60 days after surgery. We trained regression and machine learning models to predict the outcome using baseline characteristics, surgical findings and postoperative laboratory tests. ResultsAmong 3818 patients included, 124 patients developed VTE after surgery. The total 60-day VTE incidence was 3.2 %, with incidence peak within ten days after the surgery. The risk increased in patients >65 years old (OR 2.96, p < 0.001), in patients with chordoma (OR 3.40, p = 0.006) or craniopharyngioma (OR 1.86, p = 0.036), in patients underwent craniotomy approach (OR 2.78, p = 0.017), in patients with high volume CSF leakage (OR 4.24, p < 0.001), and in patients with longer surgical duration (OR 1.78, p = 0.029). The linear discriminant analysis algorithm had the highest AUC (0.869, 95%CI, 0.840–0.898) in predicting the outcome. The specificity, accuracy, and sensitivity of the best model were 61.8 %, 93.6 %, and 92.8 %, respectively. Risk stratification using our best model suggested that 1.3 % and 24.5 % of the patient developed VTE in the low-risk group and in the high-risk group, respectively. We developed an online decision-support tool available on https://deepvep.shinyapps.io/VTEpred/. ConclusionThe overall incidence of VTE after surgical resection of major sellar region tumors was clinically significant, especially in older patients with chordoma or craniopharyngioma.

Ultrasound assessment of gastric contents and volume in patients undergoing endoscopic endonasal transsphenoidal surgery: a prospective observational study

Intraoperative ingestion of blood, cerebrospinal fluid, and irrigation fluid can lead to an increase in gastric volume, resulting in the potential risk of aspiration in patients after endoscopic endonasal transsphenoidal surgery (EETS). In this prospective observational study, we aimed to assess the volume of gastric contents in patients undergoing this neurosurgical procedure using ultrasound, and to determine the factors associated with volume change. Eighty-two patients diagnosed with pituitary adenoma were recruited consecutively. Semi-quantitative (Perlas scores: 0, 1 and 2) and quantitative (cross-sectional area, CSA) ultrasound assessments of the gastric antrum were performed immediately before and after surgery in the semi-recumbent and semi-recumbent right-lateral positions. Seven (8.5%) patients had antrum scores from preoperative grade 0 to postoperative grade 2; nine (11%) patients had antrum scores from preoperative grade 0 to postoperative grade 1. The mean ± standard deviation (SD) of increased gastric volume was 71.0 ± 33.1 mL and 236.5 ± 32.4 mL in postoperative grade 1 and 2 groups, respectively. Subgroup analysis showed that 11 (13.4%) patients (4 in grade 1 and all in grade 2) had postoperative estimated gastric volume > 1.5 mL kg−1 (mean ± SD 3.08 ± 1.67, range 1.51–5.01 mL kg−1). Logistic regression analysis revealed that older age, diabetes mellitus, and long surgical duration were independent risk factors for significant volume change (all P < 0.05). Our results showed a significant increase in gastric volume in some patients who underwent EETS. Bedside ultrasound measurements of gastric volume can be used to assess the postoperative aspiration risk, particularly in older diabetic patients with a longer surgical duration.

Reconstruction of nasal airway in patients of class IIId maxillary defect with vastus lateralis muscle-chimeric double skin paddle ALT flap

A reconstructive challenge in patients with class IIId maxillary defect is how to obliterate the defect and restore a patent nasal airway. The current strategy using the single anterolateral thigh (ALT) fasciocutaneous flap for reconstruction may result in permanent mouth breathing. As the ALT flap was a common option in reconstruction processes, this study aimed to evaluate the benefits of vastus lateralis (VL) muscle-chimeric double skin paddle ALT flap in simultaneous defect and nasal airway reconstruction. This study included 21 patients with class IIId maxillary defect who underwent free ALT flap reconstruction (n = 11, single ALT flap group; n = 10, VL muscle-chimeric double skin paddle ALT flap (chimeric ALT flap) group) at the China Medical University Hospital from August 2015 to September 2019. Associated parameters collected for analysis included gender, age, body mass index (BMI), operative time, hospitalization, clinical stage, preoperative treatment, flap/defect size, comorbidities, postoperative RT, mouth breathing and short/long term complications. No significant differences were observed in age, BMI, hospitalization, clinical stage, preoperative treatment, defect size, comorbidities, and postoperative RT between the two groups; however, the chimeric ALT flap group as dominated by male patients (p = 0.009), and had longer operative times (12.1h vs. 10.1h, p = 0.002) and larger flap sizes (180 cm2 vs. 96.7 cm2, p = 0.013). Compared with the chimeric ALT flap group, the single ALT flap group suffered from permanent mouth breathing. Nasal airway reconstruction should be considered in patients with class IIId maxillary defect. Compared to the single ALT flap, the chimeric ALT flap is a superior reconstructive option for patients with class IIId maxillary defect, although a longer surgical duration and larger flap size are required.

Trans-arterial positive ICG staining-guided laparoscopic liver watershed resection for hepatocellular carcinoma.

IntroductionAnatomical liver resection is the optimal treatment for patients with resectable hepatocellular carcinoma (HCC). Laparoscopic Couinaud liver segment resection could be performed easily as liver segments could be stained by ultrasound-guided indocyanine green (ICG) injection into the corresponding segment portal vein. Several smaller liver anatomical units (liver watersheds) have been identified (such as S8v, S8d, S4a, and S4b). However, since portal veins of liver watersheds are too thin to be identified under ultrasound, the boundaries of these liver watersheds could not be stained intraoperatively, making laparoscopic resection of these liver watersheds demanding. Digital subtraction angiography (DSA) could identify arteries of liver watersheds with a diameter of less than 2 mm. Yet, its usage for liver watershed staining has not been explored so far.PurposeThe aim of this study is to explore the possibility of positive liver watershed staining via trans-arterial ICG injection under DSA examination for navigating laparoscopic watershed-oriented hepatic resection.MethodsWe describe, in a step-by-step approach, the application of trans-arterial ICG injection to stain aimed liver watershed during laparoscopic anatomical hepatectomy. The efficiency and safety of the technique are illustrated and discussed in comparison with the laparoscopic anatomical liver resection via ultrasound-guided liver segment staining.ResultsEight of 10 HCC patients received successful trans-arterial liver watershed staining. The success rate of the trans-artery staining approach was 80%, higher than that of the ultrasound-guided portal vein staining approach (60%). Longer surgical duration was found in patients who underwent the trans-artery staining approach (305.3 ± 23.2 min vs. 268.4 ± 34.7 min in patients who underwent the ultrasound-guided portal vein staining approach, p = 0.004). No significant difference was found in major morbidity, reoperation rate, hospital stay duration, and 30-day and 90-day mortality between the 2 groups.ConclusionsTrans-arterial ICG staining is safe and feasible for staining the aimed liver watershed, navigating watershed-oriented hepatic resection under fluorescence laparoscopy for surgeons.

12. Sleep Disturbance in the First Year After Mastectomy Among Patients With or Without Reconstruction

Purpose: Reconstruction following mastectomy has become increasingly popular. Sleep disturbances following surgery have the potential to adversely impact quality of life. It is important for breast and reconstructive surgeons to understand how surgical extent, including reconstruction, may impact sleep habits of their patients. In this prospective longitudinal study, we aimed to examine sleep disturbance in patients who underwent mastectomy with and without reconstruction throughout the first year following surgery. Methods: Patients completed the PROMIS Sleep Disturbance short form preoperatively and then at 2 weeks, 6 months, and 12 months post-operatively. Independent sample t-test or Mann-Whitney U tests were used to compare groups who did or did not receive reconstruction. Association of factors with sleep disturbance over time was investigated using GEE linear regression. Results: This subset (n=123) of a larger cohort of postoperative patients included women who had a mastectomy with and without reconstruction; 34 (28%) had no reconstruction and 89 (72%) had reconstruction. Patients in the group receiving reconstruction were younger (49 vs 58 years, p=0.001) and had longer surgical duration (257 vs 132 minutes, p<0.001), but were not more likely to receive chemotherapy, radiation, or nodal surgery. Baseline anxiety, depression, or Pain Catastrophizing Score (PCS) was not different between groups. Sleep disturbance was higher in the reconstruction group at some later timepoints (6 and 12 months postoperatively (PROMIS sleep disturbance at 6 months:17.5 vs 22, p=0.003; PROMIS sleep disturbance at 6 months:18.7 vs 22.5, p=0.046). However, an overall model assessing sleep disturbance over the first year after surgery which concurrently took both age and surgical type into account, revealed that (younger) age (beta=-0.142, p=0.027), but not surgical type (beta=-2.704, p=0.113) was associated with greater sleep disturbance. Conclusion: Overall, this study suggests that younger age, rather than surgical types, is associated with greater sleep disturbance in the first year after surgery.

Perioperative Outcomes for Radical Nephrectomy and Level III-IV Inferior Vena Cava Tumor Thrombectomy in Patients with Renal Cell Carcinoma

This study examined the characteristics, intraoperative, and postoperative course of patients undergoing inferior vena cava tumor thrombectomy for metastatic renal cell carcinoma. A single-center case series that reported demographic data and intraoperative and postoperative outcomes for patients with renal cell carcinoma undergoing inferior vena cava thrombectomy. This investigation was performed at a large quaternary referral center. Adult patients (age ≥18) admitted to the authors' hospital from January 1, 2005, to March 10, 2017, undergoing inferior vena cava thrombectomy for level III and IV renal cell carcinoma. No interventions were performed. Sixty-five patients who met the inclusion criteria were identified, with 31 patients diagnosed with level III and 34 with level IV renal cell carcinoma. Patients with level IV tumors were significantly more likely to have greater intraoperative blood loss, had longer surgical duration and hospital stays, and had more frequently required blood products, pressors, and cardiopulmonary bypass intraoperatively. Intraoperative transesophageal echo was more frequently used in level IV thrombectomy compared to level III (91.2% v 67.7%). Of patients with level IV thrombus, 41.2% developed postoperative atrial fibrillation compared to only 3.2% with level III thrombus. The 30-day mortality was 4.6% for both groups. Patients undergoing inferior vena cava tumor thrombectomy for renal cell carcinoma had more complex intraoperative and postoperative courses with level IV compared to level III tumor thrombus.

Surgical Techniques for Abdominoperineal Resection for Rectal Cancer: One Size Does Not Fit All.

Abdominoperineal resection (APR) of rectal cancer is associated with poorer oncological outcomes than anterior resection. This may be due to higher rates of intra-operative perforation (IOP) and circumferential resection margin (CRM) involvement causing higher recurrence rates and surgical complications. To address these concerns, several centers advocated a change in technique from a standard APR to a more radical extra-levator abdominoperineal excision (ELAPE). Initial reports showed that ELAPE reduced IOP rates and CRM involvement but increased wound complications and longer surgical duration. However, many of these studies had unacceptable rates of IOP and CRM before retraining in ELAPE. This may indicate that it was a sub-optimal surgical technique, which improved upon training, that had influenced the high CRM and IOP rates rather than the technique itself. Subsequent studies demonstrated that the CRM involvement rate for ELAPE was not always lower than for standard APR and, in some cases, significantly higher. The morbidity of ELAPE can be high, with studies reporting higher adverse events than APR, especially in terms of wound complications from the larger perineal incision required in ELAPE. Whether ELAPE improves short- or long-term oncological outcomes for patients has not been clearly demonstrated. The authors propose that all centers performing rectal cancer surgery audit surgical outcomes of patients undergoing APR or ELAPE and examine CRM involvement, IOP rates, and local recurrence rates, preferably through a national body. If rates of adverse technical or oncological outcomes exceed acceptable levels, then retraining in the appropriate surgical techniques may be indicated.

Psychologic Status and Influence of Surgery Techniques on Acute Nonneuropathic Pain After Dental Implant Surgery: Systematic Review and Meta-analyses.

Dental implant placement is often followed by acute pain, which is one of the most important patient-centered matters of treatment. However, this pain is often not adequately appreciated by clinicians, and knowledge about risk factors associated with acute pain is scant. An understanding of these factors is important to help clinicians deliver efficient pain control advice based on individual demand. A systematic review of the literature was carried out to identify published risk factors for acute pain after dental implant surgery. PubMed, Cochrane Central Register of Controlled Trials, Embase, and Google Scholar databases were searched to find pertinent studies up to August 2019. Cohorts and randomized controlled trials (RCTs; including split-mouth trials) were included. The criteria used were those described in the PRISMA statement for performing systematic reviews. Nine hundred twenty-five papers were identified through the initial searching. After three stages of screening, 38 articles were included in the qualitative analysis but only 8 in the quantitative analysis. Despite the heterogeneity of the included articles, these data showed that flapped (vs flapless) surgery, anxiety, longer surgical duration, anticipation of more pain before surgery, and higher pain levels at earlier time points play a key role in the intensity of acute pain after dental implant surgery. There is strong evidence to suggest that the place of insertion (maxilla/mandible) is not a risk factor for pain. The results for the effect of immediate loading (vs delayed loading), number of implants inserted, sex, age, and smoking on pain were inconclusive.

Application of clockwise modularized laparoscopic lymphadenectomy in the suprapancreatic area, a propensity score matching study and comparison with open gastrectomy

BackgroundSuprapancreatic lymphadenectomy is the essence of D2 radical gastric cancer surgery. The present study aimed to describe clockwise modularized laparoscopic lymphadenectomy in the suprapancreatic area.MethodsThe data from gastric cancer patients who underwent surgical treatment from September 2016 to December 2018 were collected. Patients were divided into clockwise modularized lymphadenectomy (CML) and traditional open gastrectomy (OG) groups according to the surgical treatment strategy. The propensity score matching method was utilized to balance the baseline characteristics between the two groups.ResultsFinally, 551 gastric cancer patients were included in the present study. Following propensity score matching, 106 pairs of patients in the CML group and OG group were included in the final analysis. The CML group had more total examined lymph nodes (36, IQR 28–44.74 vs. 29, IQR 29–39.5, p = 0.002) and no. 9 station nodes (2, IQR 1–5 vs. 2, IQR 1–3, p = 0.007) than the OG group. There was less intraoperative blood loss (30, IQR 20–80 ml vs. 80, IQR 50–80 ml, p < 0.001) and a longer surgical duration (262.5 min, IQR 220–303.25 min vs. 232, IQR 220–255 min, p < 0.001) in the CML group than in the OG group. The incidence of postoperative complications (19.8% vs. 16.0%, p = 0.591) and postoperative hospital stay (8, IQR 7–9 days vs. 8, IQR 7–9 days, p = 0.452) were comparable between the CML and OG groups.ConclusionLaparoscopic lymphadenectomy for gastric cancer surgery is technically demanding. Clockwise modularized laparoscopic lymphadenectomy in the suprapancreatic area can attain similar effects as traditional open surgery and without an increase in postoperative adverse events.