Operative Technique Research Articles

Laparoscopic Roux-Y-gastric bypass versus laparoscopic one-anastomosis gastric bypass for obesity: clinical & metabolic results of a prospective randomized controlled trial.

One anastomosis gastric bypass (OAGB) has been proposed as an effective alternative to the current standard procedure in Switzerland, Roux-en-Y gastric bypass (RYGB). Prospective data comparing both procedures are scarce. Therefore, we performed a non-inferiority randomized controlled trial assessing the effectiveness and safety of these 2 operative techniques. Eighty patients were randomized 1:1. OAGB consisted of a very long gastric pouch with a 200cm biliopancreatic limb, RYGB of a 150cm ante-colic alimentary and a 60cm biliopancreatic limb, respectively. Primary endpoint was the percent excess weight loss (%EWL) at 12months after surgery. Mean %EWL at 12months was 87.9% (SD24.4) in the RYGB group and 104.1% (SD24.6) in the OAGB group (p = 0.006). There was no mortality. The rate of marginal ulcers was higher in patients with OAGB compared to those with RYGB (p = 0.011), while the total number of late complications did not statistically differ between the two groups. Except for the remission of GERD, which was higher in the RYGB group compared to OAGB, there was no difference between the groups regarding the remission of comorbidities. OAGB showed improved glucose control compared to the RYGB after 1 year (p = 0.001). Furthermore, glucagon-like peptide-1 increase was significantly higher in OAGB at 6 weeks (p = 0.041) and 1 year after surgery (p = 0.029). Quality of life improved after both surgeries, without differences between the groups. %EWL 1 year after surgery was higher in OAGB than in RYGB. A better glycemic control with a higher increase in GLP-1 was observed after OAGB compared to RYGB. This trial is registered on ClinicalTrials.gov under the identifier NCT02601092.

Minimal learning curve for minimally invasive aortic valve replacement.

Minimally invasive aortic valve replacement (MiAVR) is an established technique for surgical aortic valve replacement (AVR). Although MiAVR was first described in 1993 and has shown good results compared to full sternotomy AVR (FSAVR) only a minority of patients undergo MiAVR. We recently started using MiAVR via an upper hemisternotomy. We aimed to examine the early results of our initial experience with this technique. We compared 55 MiAVR to a historical cohort of 142 isolated FSAVR (12.2016-12.2022). The primary outcome was in-hospital mortality. Secondary outcomes included cardiopulmonary bypass (CPB) and cross clamp times, blood product intake, in hospital morbidity, and length of ICU and hospital stay. There was no significant difference in preoperative characteristics, including age, laboratory values and co-morbidities. There was no significant difference between the groups regarding in-hospital mortality (FSAVR 3.52% vs MiAVR 1.82%). There was no significant difference in CPB time (FSAVR 103.5 min [IQR 82-119.5] vs MiAVR 107 min [92.5-120]), aortic cross-clamp time (FSAVR 81 min [66-92] vs MiAVR 90 min [73-99]), and valve size (FSAVR 23 [21-25] vs MiAVR 23 [21-25]). The incidence of intraoperative blood products transfusion was significantly lower in the MiAVR group (10.91%) compared to the FSAVR group (25.35%, P=0.03). Our findings further establish the possibility of reducing invasiveness of AVR without compromising patient safety and clinical outcomes. This is true even in the learning curve period and without requiring any significant change in the operative technique and dedicated equipment.

Modern Trends in Surgical Site Infection Rates for Colorectal Surgery: A National Surgical Quality Improvement Project Study 2013-2020.

There are few studies investigating trends in global surgical site infection rates in colorectal surgery in the last decade. This study seeks to describe changes in rates of different surgical site infections from 2013-2020, identify risk factors for SSI occurrence and evaluate the association of minimally invasive surgery and infection rates in colorectal resections. A retrospective analysis of the National Surgical Quality Improvement Program database 2013-2020 identifying patients undergoing open or laparoscopic colorectal resections by procedure codes was performed. Patient demographic information, comorbidities, procedures, and complications data were obtained. Univariable and multivariable logistic regression were performed. This was a retrospective study. A total of 279,730 patients received colorectal resection from 2013 - 2020. Primary outcome measure was rate of surgical site infection, divided into superficial, deep incisional and organ space infections. There was a significant decrease in rates of superficial infections (p < 0.01) and deep incisional infections (p < 0.01) from 5.9% in 2013 to 3.3% in 2020 and from 1.4% in 2013 to 0.6% in 2020, respectively, but a rise in organ space infections (p < 0.01) from 5.2% in 2013 to 7.1% in 2020. Use of minimally invasive techniques was associated with decreased odds of all surgical site infections compared to open techniques (p < 0.01) in multivariate analysis and adoption of minimally invasive techniques increased from 59% in 2013 to 66% in 2020. Study is limited by retrospective nature and variables available for analysis. Superficial and deep infection rates have significantly decreased, likely secondary to improved adoption of minimally invasive techniques and infection prevention bundles. Organ space infection rates continue to increase. Additional research is warranted to clarify current recommendations for mechanical bowel prep and oral antibiotic use as well as to study novel interventions to decrease postoperative infection occurrence. See Video Abstract.

Ridge Preservation Combined With Open Barrier Membrane Technique in Case of Postextractive Oroantral Communication: A Case Series Retrospective Study.

After dental extraction, a physiological phenomenon of reabsorption of the dentoalveolar process is triggered, especially if periradicular lesions are present, which can sometimes be associated with oroantral communication in the upper posterior maxilla. To investigate a minimally invasive approach, 19 patients undergoing tooth extraction in the posterosuperior maxilla were recruited. All cases presented an oroantral communication with a diameter of 2-5 mm after tooth extraction and the alveolar process and, in some cases, with a partial defect of 1 or more bony walls. In these cases, a single surgical procedure was used to preserve the alveolar ridge using an open barrier technique with an exposed dense polytetrafluoroethylene membrane. The bottom of the extraction socket was filled with a collagen fleece. The residual bone process was reconstructed using a biomaterial based on carbonate-apatite derived from porcine cancellous bone. After 6 months, all patients were recalled and subjected to radiographic control associated with an implant-prosthetic rehabilitation plan. Data relating to the sinus health status and the average height and thickness of the regenerated bone were collected. Radiographic evaluation verified the integrity of the maxillary sinus floor with new bone formation, detecting a vertical bone dimension between 3.1 mm and 7.4 mm (average 5.13 ± 1.15 mm) and a horizontal thickness between 4.2 mm and 9.6 mm (average 6.86 ± 1.55 mm). The goal of this study was to highlight the advantage of managing an oroantral communication and, simultaneously, obtain the preservation and regeneration of the alveolar bone crest. The open barrier technique appears to be effective for the minimally invasive management of oroantral communication up to 5 mm in diameter in postextraction sites, with a good regeneration of hard and soft tissue.

Evaluating Patient-reported Outcomes after Bilateral Reduction Mammoplasty: A Comparison of Reduction Techniques at a University Hospital.

Macromastia, defined as the abnormal enlargement of breasts, burdens individuals physically and psychologically, impacting their daily lives beyond aesthetics. Reduction mammoplasty offers relief by restoring proportional breast volume and appropriate contour. Surgical success relies on choosing a suitable individualized operative technique tailored to the patient's presentation and postoperative goals. This study examines postoperative, patient-reported outcomes across different reduction techniques to gauge the impact of reduction technique on overall patient perspective of aesthetic and functional satisfaction. A retrospective review identified reduction mammoplasty patients by a single surgeon between 2018 and 2022. Exclusion criteria included augmentation-related or cancer reconstructive procedures. Phone interviews were conducted using a survey adapted from BREAST-Q to assess postoperative outcomes in patients. Data analysis included Pearson chi-square test in STATA 16.1. Among 155 patients identified, 64 completed the survey. Average postsurgical interval was 24 months postoperative. After stratifying patients by operative technique, there was no significant difference in postoperative satisfaction among the cohorts with regard to nipple and breast appearance, sensation, symmetry, or shape. This study highlights no significant disparity in perceived aesthetic or functional outcomes among different reduction mammoplasty techniques. Personalized considerations, such as patient factors, surgical expertise, and anatomical specifics, should guide technique selection, emphasizing individualized approaches over presumed superior methods for optimal results.

Impact of Persistent Versus Paroxysmal Preoperative Atrial Fibrillation on In-Hospital, One-Year, and Late Clinical Outcomes Following Transcatheter Aortic Valve Implantation

Previous reports on the impact of preexisting atrial fibrillation (AF) on clinical outcomes after transcatheter aortic valve implantation (TAVI) have presented limited data on the relative impact of paroxysmal versus persistent AF subtypes. We compared in-hospital, 1-year, and late clinical outcomes in 1,098 patients who underwent TAVI with preoperative AF (556 paroxysmal, 542 persistent) versus 1,787 patients without AF. The propensity-matched cohorts with AF (n = 643) and without AF (n = 686) did not differ with respect to baseline clinical characteristics, operative technique, or in-hospital TAVI complications. At 1-year, patients with AF had higher all-cause mortality (9.0% vs 6.1%, p = 0.046) and readmission rates (13.1 vs 8.8%, p = 0.014), with lower Kansas City cardiomyopathy questionnaire scores (77.8 ± 21.8 vs 84.3 ± 17.1, p <0.001). Echocardiographic follow-up (mean time 455 ± 285 days) demonstrated no significant intergroup differences in hemodynamic findings other than a progressive increase in left atrial volume index in patient subgroups (without AF: 37.4 ± 14.7 ml/m2 vs paroxysmal AF: 46.4 ± 21.4 ml/m2 vs persistent AF: 60.5 ± 26.3 ml/m2, p <0.001). On late follow-up (mean time 49.0 [45.1 to 52.9] months), patients with persistent AF had worse all-cause mortality than patients without AF (hazard ratio 1.55, 95% confidence interval 1.17 to 2.06, p = 0.003), with no significant survival differences between the paroxysmal AF and without AF subgroups. In conclusion, patients with preexisting AF and patients without AF who underwent TAVI had similar in-hospital outcomes but worse 1-year mortality, hospital readmission, and quality of life outcomes. Compared with patients without AF, patients with persistent but not paroxysmal preexisting AF have higher late all-cause mortality at a mean follow-up of 49 months. Patients with persistent AF have higher levels of left atrial volume index than patients with paroxysmal AF and patients without AF on intermediate echocardiographic follow-up.

Role of alkyl chain length on aggregation enhanced two-photon absorption and thermal diffusivity of Carbazole-Barbituric acid D-π-A systems

Aggregation Induced Emission (AIE) luminogens exhibit no or faint emission in dilute solution and are induced to emit when aggregated with restriction of intramolecular motion as the principle mechanism. We investigated the role of hydrophobic interaction in AIE effect by varying the alkyl chain length of Carbazole-Barbituric acid (CBA) D-π-A system. We synthesized six CBA conjugates, studied their photophysical properties and morphological changes upon aggregation by varying water: tetrahydrofuran ratio. We performed thermal lens experiment in all CBA conjugates to understand the variation in radiative and non-radiative decays upon aggregation. Both aggregation and hydrophobic interaction is found to play significant role in tuning thermal diffusivity of CBA conjugates. The knowledge about their energy levels was gained by using DFT in Gaussian 09 program package. Perturbation of energy levels associated with molecular aggregation open up the possibility of such D-π-A system in nonlinear optics. The open aperture Z-scan technique with Nd:YAG laser at 1064 nm was utilized to measure the change in two-photon absorption (TPA) coefficient at different stages of aggregation and as a function of alkyl chain lengths. We observed an aggregation enhanced TPA and could tune the TPA in aqueous solution by changing the alkyl chain length. Experimentally observed TPA coefficient showed the same trend as obtained in DFT calculation for hyperpolarizability. Furthermore, for practical utility we fabricated CBA conjugate doped PMMA thin films for low threshold optical limiting applications.

Three-point Method Nerve Block for Relieving Pain of Microbotox Injection in Middle and Upper Face.

With the popularity of microbotox, pain caused by multiple microdroplets and subcutaneous injection of botulinum toxin is increasing. This study presents a new, refined, three-point nerve block technique that provides effective pain relief during minimally invasive injection therapy targeting the middle and upper face. Fifty volunteers underwent facial ultrasonography to measure the locations of the supraorbital and infraorbital foramen. Following microdrop Botox injection of the middle and upper face, 100 patients underwent a self-controlled study to analyze whether a three-point nerve block surpasses topical anesthesia for reducing injection pain. The visual analog scale pain score, the time of the three-point method and botulinum toxin injection, and side effects were recorded. Among the volunteers, the location of the supraorbital and infraorbital foramen showed no statistical difference between the left and right sides. For the 100 patients (13 men, 87 women) who underwent the three-point nerve block, the visual analog scale pain scores on the experimental side were significantly lower than those on the control side, except in the frontotemporal region (2.46 ± 0.50, 2.42 ± 0.47, P > 0.05). The duration of the unilateral three-point nerve block was 74.8 ± 5.64 seconds. The total injection time was 189.86 ± 26.79 seconds (range 148-286 s). The three-point method exerted prominent analgesic effects during middle and upper facial treatments, with benefits including a precise block region, high satisfaction, and simple operation technique. Therefore, clinicians can easily master and apply this method.

Identifying modifiable factors and their joint effect on brain health: an exposome-wide association study.

Considerable uncertainty remains regarding the associations of multiple factors with brain health. We aimed to conduct an exposome-wide association study on neurodegenerative disease and neuropsychiatry disorders using data of participants from the UK Biobank. Multivariable Cox regression models with the least absolute shrinkage and selection operator technique as well as principal component analyses were used to evaluate the exposures in relation to common disorders of central nervous system (CNS). Restricted cubic splines were conducted to explore potential nonlinear correlations. Then, weighted standardized scores were generated based on the coefficients to calculate the joint effects of risk factors. We also estimated the potential impact of eliminating the unfavorable profiles of risk domains on CNS disorders using population attributable fraction (PAF). Finally, sensitivity analyses were performed to reduce the risk of reverse causality. The current study discovered the significantly associated exposures fell into six primary exposome categories. The joint effects of identified risk factors demonstrated higher risks for common disorders of CNS (HR = 1.278 ~ 3.743, p < 2e-16). The PAF varied by exposome categories, with lifestyle and medical history contributing to majority of disease cases. In total, we estimated that up to 3.7 ~ 64.1% of disease cases could be prevented.This study yielded modifiable variables of different categories and assessed their joint effects on common disorders of CNS. Targeting the identified exposures might help formulate effective strategies for maintaining brain health.

Deep Peroneal Neurectomy for Midfoot Arthritis: A Comprehensive Review, Surgical Technique, and Case Series

Patients with painful midfoot arthritis unsuccessfully treated with conservative measures have been historically left with the surgical option of midfoot arthrodesis as a definitive treatment. In recent years, excision of the deep peroneal nerve has been offered as a potential alternative. Existing literature on the outcomes of patients undergoing deep peroneal neurectomy for the treatment of midfoot arthritis is limited and piecemeal. In this comprehensive review, technique guide, and retrospective case series, we consolidate the evidence around deep peroneal neurectomy for midfoot arthritis, review operative technique, and determine the outcomes of 4 patients who underwent deep peroneal neurectomy from February 2021 to December 2022 using Patient-Reported Outcome Measurement Information System Physical Function and Pain Interference scores. Four original articles from National Center for Biotechnology Information Medline, published through May 2023, were included. The outcomes of patients treated with deep peroneal neurectomy for midfoot arthritis are discussed. In our case series, the average amount of time between surgery and final postoperative Patient-Reported Outcome Measurement Information System scores was 289 days. The average preoperative physical function score was 36.8. Three patients showed a minimal clinically important difference in physical function; postoperative average was 41.3. Three patients had a minimally clinical important reduction in pain levels (average preoperative pain interference score was 65.8; average postoperative pain interference score was 59.3). One patient underwent a revision neurectomy for inadequate pain relief, and another sought additional treatment for inadequate pain relief. All patients returned to walking in a shoe within 1 month. The outcomes of our case series are similar to those of previously published case series, which demonstrate satisfactory results and acceptable complication rates. For patients with symptomatic midfoot arthritis, deep peroneal neurectomy can be an effective treatment option to reduce pain and improve physical function while requiring minimal postoperative recovery time.

Secondary Achilles Tendon Repair After Calcaneal Exostectomy for Haglund Deformity Using a Unique Surgical Technique

Calcaneal exostectomy with Achilles tendon reattachment and repair is a common procedure used to treat insertional Achilles tendonitis and Haglund deformity. This was first described by Haglund in the early 1900s. Calcaneal exostectomy with Achilles tendon reattachment and repair reduces pain by removing the spur on the back of the heel. We describe a less common operative technique utilizing a Krackow suture technique to create another failure point during the repair of the Achilles tendon. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Laparoscopic versus open pancreatoduodenectomy for periampullary tumors: An updated systematic review and meta-analysis.

e16362 Background: Laparoscopic pancreatoduodenectomy (LPD) has emerged as an alternative to open technique in treating periampullary tumors, particularly pancreatic ductal adenocarcinoma (PDAC). However, the evidence regarding safety and efficacy of LPD compared to open pancreatoduodenectomy (OPD) remains unclear. Methods: According to PRISMA guidelines, we searched PubMed, Embase, and Cochrane Library in December 2023 for randomized controlled trials (RCTs) that directly compare LPD versus OPD in patients with periampullary tumors. Outcomes were stratified as intraoperative outcomes, postoperative complications, in-hospital and short-term, and prespecified subanalysis was performed in patients with PDAC. All statistical analysis was performed using R software version 4.3.1 with a random-effects model. Results: Five RCTs yielding 1,018 patients with periampullary tumors were included, of whom 511 (50.2%) were randomized to LPD group. The total follow-up time was 90 days. LPD was associated with a longer operation time (MD 66.75; 95% CI 26.59 to 106.92; p = 0.001; I2= 87%; Figure 1A), lower intraoperative blood loss (MD -124.05; 95% CI -178.56 to -69.53; p &lt; 0.001; I2= 86%; Figure 1B), and shorter length of stay (MD -1.37; 95% IC -2.31 to -0.43; p = 0.004; I2= 14%; Figure 1C) as compared to OPD. In terms of 90-day mortality rates and number of lymph nodes yield, no significant differences were found between both groups. Subgroup analysis for PDAC consistently aligned with the overall results and provided relatively lower heterogeneity compared to the primary analysis. Conclusions: Our meta-analysis of RCTs suggests that LPD is an effective and safe alternative for patients with periampullary tumors, with lower intraoperative blood loss and shorter length of stay.

Laparoscopic versus open pancreatoduodenectomy for periampullary tumors: An updated systematic review and meta-analysis.

e16362 Background: Laparoscopic pancreatoduodenectomy (LPD) has emerged as an alternative to open technique in treating periampullary tumors, particularly pancreatic ductal adenocarcinoma (PDAC). However, the evidence regarding safety and efficacy of LPD compared to open pancreatoduodenectomy (OPD) remains unclear. Methods: According to PRISMA guidelines, we searched PubMed, Embase, and Cochrane Library in December 2023 for randomized controlled trials (RCTs) that directly compare LPD versus OPD in patients with periampullary tumors. Outcomes were stratified as intraoperative outcomes, postoperative complications, in-hospital and short-term, and prespecified subanalysis was performed in patients with PDAC. All statistical analysis was performed using R software version 4.3.1 with a random-effects model. Results: Five RCTs yielding 1,018 patients with periampullary tumors were included, of whom 511 (50.2%) were randomized to LPD group. The total follow-up time was 90 days. LPD was associated with a longer operation time (MD 66.75; 95% CI 26.59 to 106.92; p = 0.001; I2= 87%; Figure 1A), lower intraoperative blood loss (MD -124.05; 95% CI -178.56 to -69.53; p &lt; 0.001; I2= 86%; Figure 1B), and shorter length of stay (MD -1.37; 95% IC -2.31 to -0.43; p = 0.004; I2= 14%; Figure 1C) as compared to OPD. In terms of 90-day mortality rates and number of lymph nodes yield, no significant differences were found between both groups. Subgroup analysis for PDAC consistently aligned with the overall results and provided relatively lower heterogeneity compared to the primary analysis. Conclusions: Our meta-analysis of RCTs suggests that LPD is an effective and safe alternative for patients with periampullary tumors, with lower intraoperative blood loss and shorter length of stay.

Anatomical Reduction of Spondylolisthesis Through Lateral Lumbar Interbody Fusion With Percutaneous Pedicle Screw Fixation: An Intraoperative Technical Note

Surgical management of lumbar spondylolisthesis requires neural decompression, stabilization, and alignment restoration. Minimally invasive spine approaches offer a wide variety of advantages for spondylolisthesis management. This intraoperative note describes the treatment of L4-L5 lumbar spondylolisthesis with lateral lumbar interbody fusion (LLIF) and percutaneous pedicle screw fixation (PSF). The surgical technique for treating L4-L5 lumbar spondylolisthesis using a minimal invasive approach with LLIF and percutaneous PSF is described. This operative technique is illustrated with figures, and an intraoperative case example of its application is described. LLIF with percutaneous PSF can be a safe, effective, and reliable option for treating lumbar spondylolisthesis when applied with appropriate surgical technique in a selected patient population. This technique is a valuable addition to the range of available spine surgical options. LLIF with percutaneous PSF can be an effective technique for treating lumbar L4-L5 spondylolisthesis.

Digital Evaluation of Trueness and Precision of Modern Impression Materials in Implant- Retained Mandibular Overdentures.

The purpose of this in vitro study was to evaluate the dimensional accuracy, trueness, and precision of vinyl siloxane ether (VSXE) and polyvinylsiloxane (PVS) impression materials using different impression techniques. A three-dimensional (3D) printed mandibular model with implants and metal rods served as the reference model. Impressions were taken in custom trays, resulting in four groups: PVS-closed-tray, VSXE-closed-tray, PVS-open-tray, and VSXE-open-tray. The reference model and impressions were scanned and analyzed using 3D analysis software to assess the trueness and precision within each group. There was significant difference in trueness between the groups, with PVS closed tray showing a higher deviation than VSXE-closed-tray and PVS-open-tray. VSXE-open-tray had the lowest deviation, which was statistically significant. In terms of precision, PVS-closed-tray showed the highest deviation, while no significant differences were found among the other groups. VSXE impression material with an open tray technique consistently demonstrated the highest levels of accuracy and precision. Conversely, PVS impression material with a closed tray technique yielded less favorable results. Better understanding of trueness and precision of new impression materials with new impression techniques will increase their clinical effectiveness.

The Effects of Upper-Ocean Sea Temperatures and Salinity on the Intensity Change of Tropical Cyclones over the Western North Pacific and the South China Sea: An Observational Study

With increasing air and sea temperatures, the thermodynamic environments over the oceans are becoming more favourable for the development of intense tropical cyclones (TCs) with rapid intensification (RI). The South China coastal region consists of highly densely populated cities, especially over the Pearl River Delta (PRD) region. Intense TCs maintaining their strength or the RI of TCs close to the coastal region can present substantial forecasting challenges and have significant potential impacts on the coastal population. This study investigates the effect of sea-surface and sub-surface temperatures and salinity on the intensification of five TCs, namely Super Typhoon Hato in 2017, Super Typhoon Mangkhut in 2018, and Typhoon Talim, Super Typhoon Saola, and Severe Typhoon Koinu in 2023, which have significantly affected the South China coastal region and triggered high TC warning signals in Hong Kong in the past few years. This analysis utilised the Hong Kong Observatory’s TC best-track and intensity data, along with sea temperature and salinity profiles generated using the China Ocean ReAnalysis version 2 (CORA2) product from the National Marine Data and Information Service of China. It was found that high sea-surface temperatures (SST) of 30 °C or above for a depth of about 20 m, low sea-surface salinity (SSS) levels of 33.8 psu or below for a depth of at least 20 m, and strong salinity stratification of at least 0.6 psu per 100 m depth might offer useful hints for predicting the RI of TCs over the western North Pacific and the South China Sea (SCS) in operational forecasting, while noting other contributing environmental factors and synoptic flow patterns conducive to RI. This study represents the first documentation of sub-surface salinity’s impact on some intense TCs traversing the SCS during 2017–2023 based on an observational study. Our aim is to supplement operational techniques for forecasting RI with some quantitative guidance based on upper-level ocean observations of temperatures and salinity, on top of well-known but more rapidly changing dynamical factors like low-level convergence, weak vertical wind shear, and upper-level divergent outflow, as forecasted with numerical weather prediction models. This study will also encourage further research to refine the analysis of quantitative contributions from different RI factors and the identification of essential features for developing AI models as one way to improve the forecasting of TC RI before the TC makes landfall near the PRD, with due consideration given to the effect of freshwater river discharge from the Pearl River.

Early postoperative complications in open heart surgery patients: A review

Over the past few decades, open heart surgery has undergone significant progress in terms of technologies used, operative techniques and resuscitation care. This has led to a significant increase in patient survival and quality of life after discharge. However, there are still a number of challenges to be addressed, one of which is reducing the incidence of early postoperative complications. They are directly and primarily determined by patients’ demographic and clinical characteristics, as well as by the characteristics of the surgical intervention itself and are a major factor in the outcome of the surgery performed. This review presents the most important and frequent early complications, their epidemiological and clinical features. Their good knowledge is the key to achieving an optimal treatment approach and seeking effective opportunities for their prediction and incidence reduction.

Influence of distal insertion technique, valve selection, and patient demographics on shunt survival in ventriculoperitoneal shunt insertion: A retrospective analysis of an Australian case series

BackgroundVentriculoperitoneal (VP) shunt insertion is a means of diverting cerebrospinal fluid (CSF) for management of hydrocephalus. Revision rates, operating time, and length of stay (LOS) following laparoscopic insertion of the distal catheter have been mixed. There are limited data on the role of adhesiolysis during VP shunt insertion. Valve characteristics have also been shown to influence patient outcomes. There is a paucity of Australian data reporting on the effect of these variables on shunt outcomes. We aimed to study patient demographics, indications, and surgical and instrument variables in the Australian context. MethodsWe performed a retrospective, multi-surgeon, single-centre analysis of VP shunts inserted in adults via an open or laparoscopic technique. Data on patient demographics and surgery characteristics were collected from the hospital medical records and the Australasian Shunt Registry. The primary outcome was shunt revision rate and secondary outcomes were postoperative complications, operating time and LOS, and shunt survivability. ResultsFifty-six participants were eligible for analysis. The overall revision rate was 14.3 %, which was lower than the national average. The distal catheter revision rate was 0 %. Laparoscopic insertion of the distal catheter was shown to significantly reduce operating time (70.4 min in the open group and 50.7 min in the laparoscopic group, p < 0.001). This was demonstrated across different aetiologies, and when controlling for age and valve-type (p < 0.05). The revision rate of non-programmable was higher than programmable valves (42.9 % versus 2.9 %, respectively). There were no differences between previous abdominal surgery, LOS, complication, or revision rate between open and laparoscopic insertion. VP shunt survivability was greater in the laparoscopic group (90-day shunt survival of 96.7 % and 92 % in the laparoscopy and open groups, respectively; p > 0.05). We did not find any significant difference in operating time or length of stay for age, sex, or previous abdominal surgery, even when accounting for surgical technique. Indication and shunt survivability varied widely between age groups. The use of laparoscopic insertion increased over time, though surgeons did not crossover techniques. ConclusionsThe overall distal revision rate of VP shunts is low. Laparoscopic insertion of the distal catheter reduces operating time and may improve shunt survivability. Larger studies are needed to confirm differences in shunt survivability in open versus laparoscopic distal catheter insertion, between age groups, clinical indications, and valve type on patient outcomes.

Dorsal root entry zone lesioning for brachial plexus avulsion - technical evolution and long-term follow-up.

Brachial plexus avulsion (BPA) injuries can cause severe deafferentation pain. This has been successfully treated with dorsal root entry zone (DREZ) lesioning. Distortions in anatomy following a BPA injury can make identifying neural structures challenging. We describe a modification to the operative technique that improves the surgical view and the advanced intraoperative neuromonitoring (IONM) employed to identify DREZ. We have analysed the long-term outcomes for pain, quality of life, and complications in patients undergoing DREZ lesioning. This is a single-centre retrospective case series including patients who underwent DREZ lesioning with IONM for brachial plexus avulsion between 2012 and 2022. Analysed data included pre- and postoperative pain (VAS), quality of life score for chronic pain, and complications. The evolution of the surgical approach is discussed. 44 consecutive patients underwent a DREZ lesioning procedure with intraoperative monitoring and mapping. In these patients the mean VAS score improved from 8.9 (7-10) to 1.87 (0-6) (p < 0.0001) at the time of discharge. 31 patients were followed-up for more than 12 months with a mean duration of follow-up of 41 months and their results were as follows: the mean VAS improved from 9.0 (7-10) to 4.1 (0-9) (p < 0.0001) at the last follow-up and the mean QOL values improved from 3.7 (2-6) to 7.4 (4-10) (p < 0.0001). The long-term outcomes were 'good' in 39%, 'fair' in 29% and 'poor' in 32% of patients. 55% of the patients were able to stop or reduce pain medications. Modifications of surgical technique provide better exposure of DREZ, and IONM aids in identifying DREZ in the presence of severe intra-dural changes. Long-term outcomes of DREZ lesioning indicate not only a reduction in pain but also a significant improvement in quality of life.

Robotic-assisted treatment of paraesophageal hernias in the emergency setting: a retrospective study.

Emergency treatment of paraesophageal hernias can be carried out through laparotomy or minimally invasive approaches, however, evidence in this regard is weak. The aim of our study was to assess safety and feasibility of the robotic-assisted treatment of paraesophageal hernias in the emergency setting. At the Bellinzona e Valli Regional Hospital, Switzerland, we conducted a retrospective analysis of patients operated on from January 2020 to January 2024 with robotic surgery for emergency presentation of paraesophageal hernias. Demographic and clinical details, operative techniques, and postoperative outcomes were collected and analyzed. Out of 82 patients who underwent robotic-assisted paraesophageal hernia repair, 17 were treated in the emergency setting. Median age was 79years (IQR 77-85), 3 (17.6%) patients were male, and median BMI was 23.9kg/m2 (IQR 21.0-26.0). Most frequent presentation symptoms were pain (100%), regurgitation (88.2%), and dyspnea (17.6%). No intraoperative complication, conversion to open surgery or stomach resections were recorded. Two complications of grade 3 according to the Clavien-Dindo classification and one of grade 2 occurred; all were successfully treated until resolution. The median length of hospital stay was 8days (IQR 5-16). After a mean follow-up of 15.9months (IQR 6.5-25.6) only two small axial asymptomatic recurrences that required no treatment. Despite limitations, our study demonstrated a very low rate of intra- and postoperative complications, likely supporting the safety and feasibility of robotic-assisted treatment for paraesophageal hernias in emergency settings. Larger studies with a control arm are needed to validate our initial findings.