Postoperative Day Research Articles

An Experimental and Clinical Study of Flap Monitoring with an Analysis of the Clinical Course of the Flap Using an Infrared Thermal Camera

Flap surgery is a common method used to cover defects following tumor ablation, trauma, or infection. However, insufficient vascularity in the transferred flap can lead to flap necrosis and failure. Proper postoperative monitoring is essential to prevent these complications. Recently, research has explored the use of infrared thermal imaging in plastic surgery, leading to its clinical application. This study comprises two separate parts: an in vivo experimental study and a clinical study. In this study, 28 rats underwent reverse McFarlane flap surgery, and their flaps were analyzed using a FLIR thermal imaging camera seven days post-surgery. Additionally, thermal images of flaps were taken on postoperative days 0, 1, 2, 3, and 7 in 22 patients. This study focused on temperature differences between normal skin and the perforator compared to the average flap temperature. Results showed that the temperature difference was higher in the necrosis group and increased over time in cases of total necrosis. A lower perforator temperature compared to the flap’s average indicated vascular compromise, potentially leading to flap failure. The FLIR camera, being contact-free and convenient, shows promise for understanding and inferring the clinical progression of flaps in postoperative monitoring.

An Experimental and Clinical Study of Flap Monitoring with an Analysis of the Clinical Course of the Flap Using an Infrared Thermal Camera

Flap surgery is a common method used to cover defects following tumor ablation, trauma, or infection. However, insufficient vascularity in the transferred flap can lead to flap necrosis and failure. Proper postoperative monitoring is essential to prevent these complications. Recently, research has explored the use of infrared thermal imaging in plastic surgery, leading to its clinical application. This study comprises two separate parts: an in vivo experimental study and a clinical study. In this study, 28 rats underwent reverse McFarlane flap surgery, and their flaps were analyzed using a FLIR thermal imaging camera seven days post-surgery. Additionally, thermal images of flaps were taken on postoperative days 0, 1, 2, 3, and 7 in 22 patients. This study focused on temperature differences between normal skin and the perforator compared to the average flap temperature. Results showed that the temperature difference was higher in the necrosis group and increased over time in cases of total necrosis. A lower perforator temperature compared to the flap’s average indicated vascular compromise, potentially leading to flap failure. The FLIR camera, being contact-free and convenient, shows promise for understanding and inferring the clinical progression of flaps in postoperative monitoring.

Robotic Left Pancreatectomy with Perirenal Tissue Excision and Left Adrenalectomy (Posterior Ramps) for Pancreatic Ductal Adenocarcinoma Abutting the Adrenal Gland.

Radical antegrade modular pancreato-splenectomy (RAMPS) has been largely described in left-sided pancreatic cancers.1.J Hepato-Biliary-Pancreat Sci 29:1156-1165 Its prognostic advantage is not clear, although a theoretical improvement in R0 resection rate has been shown.2.J Am Coll Surg 204:244-249 Furthermore, RAMPS is usually carried out without adrenal gland removal, the so-called anterior RAMPS, while extending the resection to the adrenal plane could impair perioperative outcomes.3.HPB 25:311-319 METHODS: A 40mm pancreatic ductal adenocarcinoma (PDAC) was found in a 70-year-old patient. Tumor infiltrates the adrenal gland and a robotic posterior RAMPS was indicated. After sectioning the splenic vessels and the pancreatic neck, the dissection was directed vertically in a sagittal plane along the left border of the superior mesenteric artery to identify the left renal vein. Our dissection plane was then directed on a caudo-cranial axis, after identification of the left renal artery and below the adrenal gland. The resection was also delimitated medially by the left borders of the superior mesenteric artery and the aorta, and posteriorly by the renal parenchyma. Postoperative course was marked by a biochemical leak. The patient was discharged on postoperative day (POD)5 and the drain removed at POD18. Pathological examination confirmed a pT2N2 PDAC with negative margins, with 4/18 positive nodes. The robotic platform is routinely employed in pancreatic surgery. Thanks to its increased degree of movement, its dexterity, and the magnification, this approach can help surgeons with vascular identification and control, in performing extended lymphadenectomies, and finding the correct planes of dissection. All these elements are crucial in a well-performed posterior RAMPS.

Open and Endoscopic Endonasal Optic Nerve Decompression for Craniofacial Fibrous Dysplasia in an Adolescent: 2-Dimensional Operative Video.

Craniofacial fibrous dysplasia (CFFD) is a benign, bony disease that may affect the skull base.1,2 Most cases are asymptomatic and observed; however, advanced disease can present with cranial neuropathy or craniofacial deformity requiring intervention.3-5 A 16-year-old adolescent girl with known CFFD involving the sphenoid and frontal bones with severe bilateral optic canal narrowing developed progressive right eye visual decline and frontal cosmetic deformity. Visual acuity worsened oculus dextrus (OD) to 20/30 with a new superior nasal scotoma and 20% loss in the retinal nerve fiber layer and remained oculus sinister (OS) 20/20. The patient was recommended a staged subfrontal craniotomy for right optic decompression and simultaneous correction cosmetic deformity followed by endonasal right optic decompression. On postoperative day one, visual acuity OD improved to 20/20; however, she developed OS visual decline to 20/800. Curiously, there were no episodes of intraoperative hypotension or additional iatrogenic compression. Use of methylprednisolone led to improvement OS 20/400. Given persistent visual decline, urgent second stage endonasal bilateral optic nerve decompression, rather than unilateral, was performed. Postoperatively, vision improved to OS 20/200. At one month, her vision improved to OD 20/15 and OS returned to 20/20 with a paracentral scotoma and 29% decline in left retinal nerve fiber layer with further improvement anticipated. This video describes a multidisciplinary, multistaged approach in treatment of optic nerve compression due to CFFD in addition to the management of unanticipated contralateral visual decline. The patient consented to the procedure and publication of her image. No Institutional Review Board/ethics committee approval was necessary for this case report.

Preoperative Acetaminophen For Microsuspension Laryngoscopy Reduces Postoperative Opioid Use.

The opioid crisis has prompted consideration of analgesic prescriptions. This study explored the value of preoperative acetaminophen for pain control following microsuspension laryngoscopy (MSL) and compared the results with a previous study of pain and opioid use following MSL (Tsang et al.). A prospective open-label clinical trial was conducted in patients undergoing MSL. All patients were administered preoperative acetaminophen. Short-form McGill Pain Questionnaire (SF-MPQ), pain visual analogue scale (VAS), and present pain intensity (PPI) scores were collected preoperatively and on postoperative days (PODs) 1, 3, 7, and 14. Statistical analysis identified variables associated with opioid use or increased pain scores, and compared outcomes with Tsang et al. RESULTS: Eighty-nine patients were included (mean age 52.8 ± 17.3 years, 40 males). All patients received preoperative 1 g acetaminophen (77 (86.5%) orally) with no adverse effects. On POD1, opioid usage was 10%. Median [IQR] pain scores were 5 [2-11], 21 [12.3-56.8], and 3 [2-3.3] on SF-MPQ, VAS, and PPI, respectively. Post-Anesthesia Care Unit (PACU) opioid requirements significantly correlated with POD1 opioid consumption (τb = 0.214; p ≤ 0.05), and significant associations with PACU opioid administration were found for total anesthesia time (OR (95%CI) = 1.271 (1.043-1.548), p = 0.017) and total laryngoscope suspension time (OR (95%CI) = 0.791 (0.651-0.962, p = 0.019)). This cohort demonstrated reduced opioid usage on POD1 compared with Tsang et al (23%). Preoperative acetaminophen is a safe intervention, resulting in decreased postoperative opioid use following MSL. Anesthesia time correlated with need for postoperative opioids. Level 4 Laryngoscope, 2024.

Practical use of transanal decompression tube following the repair of fourth-degree perineal tears associated with vaginal delivery

BackgroundFourth-degree perineal tears associated with vaginal delivery (PTAVD) occur in approximately 0.25 to 6% of vaginal deliveries. A persistent challenge in treating fourth-degree PTAVD is the high incidence of anastomotic leakage, leading to impaired quality of life, marked by incontinence, rectovaginal fistula, and painful sexual intercourse. Thus, effective interventions are necessary. Herein, we report our successful approach in repairing a fourth-degree PTAVD, involving the placement of a transanal decompression tube (TDT) during the early postoperative period.Case presentationFive patients underwent the repair of fourth-degree PTAVD by suturing the mucosal and muscular layers of the rectum, and the vaginal wall in layers. Subsequently, a TDT was placed in the rectum, positioned 10–15 cm from the anal verge. The TDT was allowed to drain spontaneously without suction. Gastrografin enema examination was performed through a TDT, followed by a computed tomographic scan on postoperative days 3–4. After unfavorable complications were ruled out, the TDT was removed and the patients were transitioned to a normal diet.ResultAll patients showed favorable outcomes with no occurrence of vaginal fistula or incontinence.ConclusionThis simple intervention demonstrates potential efficacy in reducing anastomotic leakage following the repair of fourth-degree PTAVD.

Who Do We Fail to Rescue after Pancreatoduodenectomy? Outcomes Among >4000 Procedures Expose Windows of Opportunity.

Our investigation on in-hospital mortality after 4474 pancreatoduodenectomies aimed to identify time-dependent risks as well as windows of opportunity to rescue patients from complications. Pancreatoduodenectomy is generally considered a safe procedure with a 1-10% perioperative mortality based on complexity and surgical volume. Yet, patients are susceptible for life-threatening complications particularly with extended resections. Recognition of distinct vulnerabilities over time while patients recover is required to permit focused monitoring, sophisticated resource allocation, and greatest surgical safety. Patients who deceased in-hospital after pancreatoduodenectomy between 2003-2021 were retrieved from the institutional pancreatectomy registry and analyzed in detail with respect to their postoperative course. Among 4474 pancreatoduodenectomies, 156 patients deceased in-hospital (3.5%). When assessing root causes of mortality, we observed 3 different clusters of complications which were postpancreatectomy-specific (47.4%), visceral vasculature-associated (25.6%), or cardiopulmonary in origin (23.7%). The median times of root cause onset in the 3 categories were postoperative day (POD) 9, POD 4.5 (P=0.008) and POD 3 (P<0.001), and medians of in-hospital mortality were POD 31, POD 18 (P=0.009) and POD 8 (P<0.001), respectively. Intervals between root cause onset and mortality varied with medians of 23 days, 11 days (P=0.017), and 1 days (P<0.001). The 3 categories were similarly distributed between different types of surgical complexity. Postpancreatectomy-specific complications prompt almost half of in-hospital mortalities after pancreatoduodenectomy, with rather long intervals for interventions to prevent failure to rescue. In contrast, visceral vasculature-related events and cardiopulmonary complications dominate early in-hospital mortalities with short intervals until mortality, demanding rigorous management of such events or preoperative conditioning. These data externally validate a previous high-volume initiative and highlight distinct windows of opportunity to optimize perioperative safety.

Stress Response and Analgesia During and after Robotic-Assisted Pelvic Exenteration

Introduction. Thoracic epidural analgesia or thoracic epidural anaesthesia (TEA) and opioid-based intravenous multimodal analgesia (MMA) provide adequate control of perioperative pain, however, comparative data are still to be gathered. Aim. To compare both anesthesia techniques in terms of stress response during and after robotic-assisted pelvic exenteration (PE). Materials and methods. 112 patients were divided into 2 equal groups A level of serum cortisol was measured at induction of anesthesia and in 2, 24, and 48 hours. The efficacy of analgesia was compared using a 10-point numeric pain scale. Analgesic administration and side effects were reported for 1–3 postoperative days. Results. Cortisol levels increased 2 hours after skin incision in the MMA group and only in 24 hours in the TEA group (p &lt; 0.050). Postoperative cortisol levels were significantly lower in the TEA group (p = 0.001). Numeric pain scores were significantly lower in the TEA group (1.7 [1.0–3.2] vs. 2.7 [2.1–4.2]; 1.9 [1.0–3.3] vs. 3.5 [3.5–5.0]; 3.7 [3.0–4.8] vs. 4.2 [3.7–4.7], respectively; p &lt; 0.050). Patients in the TEA group received less opioid administration (4.3 mg vs. 13.9 mg; 7.0 mg vs. 19.9 mg; 10.9 mg vs. 16.5 mg, respectively; p &lt; 0.050). The two groups of patients were detected with no significant difference in the incidence of respiratory depression. Discussion. According to the study results, perioperative stress response was reduced with TEA being added to the anesthesia protocol. Patients in the TEA group received lower doses of analgesics. Both groups produced similar short-term postoperative outcomes. Conclusion. As compared to opioid-based MMA, TEA provided more effective analgesia and similar side effect profiles. Therefore, TEA appears to be an acceptable method for stress response suppression and pain management in patients undergoing robotic-assisted PE.

Multicentric short term and safety study of ineffective esophageal motility patients treated with RefluxStop device

Gastroesophageal reflux disease (GERD) presents a general health problem with a variety of symptoms and an impairment of life quality. Conservative therapies do not offer sufficient symptom relief in up to 30% of patients. Patients who suffer from ineffective esophageal motility (IEM) and also GERD may exhibit symptoms ranging from mild to severe. In cases where surgical intervention becomes necessary for this diverse group of patients, it is important to consider the potential occurrence of postoperative dysphagia. RefluxStop is a new alternative anti-reflux surgery potentially reducing postoperative dysphagia rates. In this bicentric tertiary hospital observational study consecutive patients diagnosed with PPI refractory GERD and IEM that received RefluxStop implantation were included. A first safety and efficacy evaluation including clinical examination and GERD-HRQL questionnaire was conducted. 40 patients (25 male and 15 female) were included. 31 patients (77.5%) were on PPI at time of surgery, with mean acid exposure time of 8.14% ± 2.53. The median hospital stay was 3 days. Postoperative QoL improved significantly measured by GERD HRQL total score from 32.83 ± 5.08 to 6.6 ± 3.71 (p < 0.001). A 84% reduction of PPI usage (p < 0.001) was noted. 36 patients (90%) showed gone or improved symptoms and were satisfied at first follow-up. Two severe adverse events need mentioning: one postoperative slipping of the RefluxStop with need of immediate revisional operation on the first postoperative day (Clavien–Dindo Score 3b) and one device migration with no necessary further intervention. RefluxStop device implantation is safe and efficient in the short term follow up in patients with GERD and IEM. Further studies and longer follow-up are necessary to prove long-lasting positive effects.

Stress Response and Analgesia During and after Robotic-Assisted Pelvic Exenteration

Introduction. Thoracic epidural analgesia or thoracic epidural anaesthesia (TEA) and opioid-based intravenous multimodal analgesia (MMA) provide adequate control of perioperative pain, however, comparative data are still to be gathered. Aim. To compare both anesthesia techniques in terms of stress response during and after robotic-assisted pelvic exenteration (PE). Materials and methods. 112 patients were divided into 2 equal groups A level of serum cortisol was measured at induction of anesthesia and in 2, 24, and 48 hours. The efficacy of analgesia was compared using a 10-point numeric pain scale. Analgesic administration and side effects were reported for 1–3 postoperative days. Results. Cortisol levels increased 2 hours after skin incision in the MMA group and only in 24 hours in the TEA group (p &lt; 0.050). Postoperative cortisol levels were significantly lower in the TEA group (p = 0.001). Numeric pain scores were significantly lower in the TEA group (1.7 [1.0–3.2] vs. 2.7 [2.1–4.2]; 1.9 [1.0–3.3] vs. 3.5 [3.5–5.0]; 3.7 [3.0–4.8] vs. 4.2 [3.7–4.7], respectively; p &lt; 0.050). Patients in the TEA group received less opioid administration (4.3 mg vs. 13.9 mg; 7.0 mg vs. 19.9 mg; 10.9 mg vs. 16.5 mg, respectively; p &lt; 0.050). The two groups of patients were detected with no significant difference in the incidence of respiratory depression. Discussion. According to the study results, perioperative stress response was reduced with TEA being added to the anesthesia protocol. Patients in the TEA group received lower doses of analgesics. Both groups produced similar short-term postoperative outcomes. Conclusion. As compared to opioid-based MMA, TEA provided more effective analgesia and similar side effect profiles. Therefore, TEA appears to be an acceptable method for stress response suppression and pain management in patients undergoing robotic-assisted PE.

A novel technique for NO.253 lymph node dissection and left colic artery preservation to avoid potential postoperative internal hernia in laparoscopic radical resection for rectal cancer

BackgroundThe preservation of the left colic artery (LCA) has emerged as a preferred approach in laparoscopic radical resection for rectal cancer. However, preserving the LCA while simultaneously dissecting the NO.253 lymph node can create a mesenteric defect between the inferior mesenteric artery (IMA), the LCA, and the inferior mesenteric vein (IMV). This defect could act as a potential “hernia ring,” increasing the risk of developing an internal hernia after surgery. The objective of this study was to introduce a novel technique designed to mitigate the risk of internal hernia by filling mesenteric defects with autologous tissue.MethodsThis new technique was performed on eighteen patients with rectal cancer between January 2022 and June 2022. First of all, dissected the lymphatic fatty tissue on the main trunk of IMA from its origin until the LCA and sigmoid artery (SA) or superior rectal artery (SRA) were exposed and then NO.253 lymph node was dissected between the IMA, LCA and IMV. Next, the SRA or SRA and IMV were sequentially ligated and cut off at an appropriate location away from the “hernia ring” to preserve the connective tissue between the “hernia ring” and retroperitoneum. Finally, after mobilization of distal sigmoid, on the lateral side of IMV, the descending colon was mobilized cephalad. Patients’preoperative baseline characteristics and intraoperative, postoperative complications were examined.ResultsAll patients’ potential “hernia rings” were closed successfully with our new technique. The median operative time was 195 min, and the median intraoperative blood loss was 55 ml (interquartile range 30–90). The total harvested lymph nodes was 13.0(range12−19). The median times to first flatus and liquid diet intake were both 3.0 days. The median number of postoperative hospital days was 8.0 days. One patient had an injury to marginal arterial arch, and after mobolization of splenic region, tension-free anastomosis was achieved. No other severe postoperative complications such as abdominal infection, anastomotic leakage, or bleeding were observed.ConclusionsThis technique is both safe and effective for filling the mesenteric defect, potentially reducing the risk of internal hernia following laparoscopic NO.253 lymph node dissection and preservation of the left colic artery in rectal cancer surgeries.

Early Postoperative Prediction of Complications and Readmission After Colorectal Cancer Surgery Using an Artificial Neural Network.

Early predictors of postoperative complications can risk-stratify patients undergoing colorectal cancer surgery. However, conventional regression models have limited power to identify complex nonlinear relationships among a large set of variables. We developed artificial neural network models to optimize the prediction of major postoperative complications and risk of readmission in patients undergoing colorectal cancer surgery. The aim of this study was to develop an artificial neural network model to predict postoperative complications using postoperative laboratory values, and compare these models' accuracy to standard regression methods. This retrospective study included patients who underwent elective colorectal cancer resection between January 1, 2016, and July 31, 2021. Clinical data, cancer stage, and laboratory data from postoperative day 1 to 3 were collected. Models of complications and readmission risk were created using multivariable logistic regression and single-layer neural networks. National Cancer Institute-Designated Comprehensive Cancer Center. Adult colorectal cancer patients. Accuracy of predicting postoperative major complication, readmission and anastomotic leak using the area under the receiver-operating characteristic curve. Neural networks had larger areas under the curve for predicting major complications compared to regression models (neural network 0.811; regression model 0.724, p < 0.001). Neural networks also showed an advantage in predicting anastomotic leak (p = 0.036) and readmission using postoperative day 1-2 values (p = 0.014). Single-center, retrospective design limited to cancer operations. In this study, we generated a set of models for early prediction of complications after colorectal surgery. The neural network models provided greater discrimination than the models based on traditional logistic regression. These models may allow for early detection of postoperative complications as soon as postoperative day 2. See Video Abstract.

Propofol/Dexmedetomidine versus Desflaurane Effects on Post Hepatectomy Hepatocellular Injury

Abstract Objective The Pringle maneuver used during hepatectomy causes ischemic reperfusion injury to the liver remnant. In this study, we compared the effect of maintenance of general anesthesia with propofol dexmedetomidine intravenous infusion versus desflurane inhalational anesthesia on post hepatectomy hepatocellular injury in patients undergoing partial hepatectomy during the first six postoperative days. Method Group A (15 patients) received total intravenous anesthesia with a combination of propofol and dexmedetomidine for anesthesia maintenance. and Group B (15 patients) received desflurane for anesthesia maintenance. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), serum albumin, serum bilirubin, prothrombin time and international normalized ratio (INR) were measured before surgery and at 1, 3, and 6 days after surgery. Results Transaminase levels, which were comparable in both groups, peaked between the first and the third postoperative days. Peak alanine aminotransferase was 224.27±29.7 and 318.20±52.5 U/L in the group A and group B, respectively (P &amp;lt; 0.001). Peak aspartate aminotransferase was 265.60±22.3 U/L in group A and 349.27±56.1 U/L in group B (P &amp;lt; 0.001). Albumin levels at day one showed no significant differences between both groups but at days 3 and 6, group A showed significantly higher albumin levels than group B. Other liver function tests including serum albumin, total and direct bilirubin, PT and INR showed lower values in propofol/dexmedetomidine group. Conclusion The main finding of this study is that propofol/dexmedetomidine as a technique for maintenance of anesthesia resulted in less hepatocellular injury and better hepatic functions than desflurane in patients undergoing partial hepatectomy during the first 6 postoperative days.

"What really matters to the patients?": assessing the impact of wound healing on the quality of life in patients undergoing incisional hernia repair.

We aim to evaluate the impact of surgical wound complications in the first 30 postoperative days after incisional hernia repair on the long-term quality of life of patients. In addition, the impact of the surgical technique and preoperative comorbidities on the quality of life of patients will also be evaluated. Prospective cohort study, which evaluates 115 patients who underwent incisional hernioplasty between 2019 and 2020, using the onlay and retromuscular techniques. These patients were initially assessed with regard to surgical wound outcomes in the first 30 postoperative days (surgical site infection (SSI) or surgical site occurrence (SSO)), and then, assessed after three years, through a specific quality of life questionnaire, the Hernia Related Quality of Life Survey (HerQLes). After some patients were lost to follow-up during the study period, due to death, difficulty in contact, refusal to respond to the questionnaire, eighty patients were evaluated. Of these, 11 patients (13.8%) had SSI in the first 30 postoperative days and 37 (46.3%) had some type of SSO. The impact of both SSI and SSO on quality of life indices was not identified. When analyzing others variables, we observed that the Body Mass Index (BMI) had a significant impact on the patients' quality of life. Likewise, hernia size and mesh size were identified as variables related to a worse quality of life outcome. No difference was observed regarding the surgical techniques used. In the present study, no relationship was identified between surgical wound outcomes (SSO and SSI) and worse quality of life results using the HerQLes score. We observed that both BMI and the size of meshes and hernias showed an inversely proportional relationship with quality of life indices. However, more studies evaluating preoperative quality of life indices and comparing them with postoperative indices should be carried out to evaluate these correlations.

Study of heart rate and corticosterone variability in the simulation of rhino-surgical interventions in biological objects.

Aims: to assess changes in the time range of heart rate variability (HRV) and plasma corticosterone concentration in rats after simulating septoplasty. Materials and methods: a septoplasty was simulated in 30 mature male Wistar rats weighing 210-290 g. An ECG was recorded with subsequent analysis of the time domain of HRV, as well as blood sampling for changes in the concentration of corticosterone in the blood plasma. Results: SDNN significantly increased in comparison with the control on days 2 and 3 (p &lt;0.001), but decreased on days 4-5 (p &lt;0.001) and 6 days (p &lt;0.01 ). rMSSD changed in waves with two irregular peaks on days 1 and 6. SDNN / rMSSD, in comparison with the 1st day of the postoperative period, increased on the 2nd day and continued to grow (p &lt;0.05), and on the 4th day it began to decrease (p &lt;0.01). The total power of HRV was low throughout the postoperative period (p &lt;0.001), except for the 3rd day, when it was equal to the control data. The increase in the total power indicator fell on the 3rd day after the operation (p &lt;0.01), after which its decline occurred again. The concentration of corticosterone in the blood plasma in rats was significantly higher than before (p &lt;0.001). From the 2nd to the 4th postoperative day, its plateau was determined. Conclusion: Simulation of septoplasty leads to changes in the time range of HRV, an increase in the concentration of corticosterone in the blood plasma in rats with its maximum at the time of surgery and after 24 hours, the formation of a "plateau" from the 2nd to the 4th postoperative days, which coincides with changes of HRV.

Evaluating a Methodical Approach to Lingual Nerve Protection during Third Molar Surgery Using a Standardized Step-by-Step Procedure: A Retrospective Analysis

The aim of this study was to assess the methodical protection of the lingual nerve via the use of a standardized step-by-step procedure in the surgical extraction of the lower third molar. A 5-year retrospective analysis of surgical third molar surgery conducted by third-year oral surgery specialty program students was performed in the oral surgery department of Policlinico Umberto I in Rome, from 2017 to 2022. All surgeries were carried out using a standardized step-by-step procedure to protect the lingual flap during the surgery. Every patient underwent a review on the initial postoperative day, and subsequently, one week after the surgery, coinciding with the removal of the sutures. During each postoperative visit, thorough examinations were conducted to assess any sensory nerve impairment of the inferior alveolar, lingual, or mylohyoid nerves. None of the cases reported postsurgical lingual nerve injury; there was zero incidence of lingual nerve paresthesia or dysesthesia. The systematic application of lingual flap protection proved to be an effective and reproducible approach for the surgical removal of lower third molars without raising the risk of lingual nerve sensory impairment, regardless of the operator’s experience.

Long-term outcomes following mitral valve replacement in children at heart center Leipzig: a 20-year analysis

BackgroundAlthough mitral valve repair is the preferred surgical strategy in children with mitral valve disease, there are cases of irreparable severe dysplastic valves that require mitral valve replacement. The aim of this study is to analyze long-term outcomes following mitral valve replacement in children in a tertiary referral center.MethodsA total of 41 consecutive patients underwent mitral valve replacement between February 2001 and February 2021. The study data was prospectively collected and retrospectively analyzed. Primary outcomes were in-hospital mortality, long-term survival, and long-term freedom from reoperation.ResultsMedian age at operation was 23 months (IQR 5–93), median weight was 11.3 kg (IQR 4.8–19.4 kg). One (2.4%) patient died within the first 30 postoperative days. In-hospital mortality was 4.9%. Four (9.8%) patients required re-exploration for bleeding, and 2 (4.9%) patients needed extracorporeal life support. Median follow-up was 11 years (IQR 11 months − 16 years). Long-term freedom from re-operation after 1, 5, 10 and 15 years was 97.1%, 93.7%, 61.8% and 42.5%, respectively. Long-term survival after 1, 5, 10 and 15 years was 89.9%, 87%, 87% and 80.8%, respectively.ConclusionIf MV repair is not feasible, MV replacement offers a good surgical alternative for pediatric patients with MV disease. It provides good early- and long-term outcomes.

The efficacy of simple oral nutritional supplements versus usual care in postoperative patients with gastric cancer: study protocol for a multicenter, open-label, parallel, randomized controlled trial

BackgroundBody weight loss (BWL) after gastrectomy impact on the short- and long-term outcomes. Oral nutritional supplement (ONS) has potential to prevent BWL in patients after gastrectomy. However, there is no consistent evidence supporting the beneficial effects of ONS on BWL, muscle strength and health-related quality of life (HRQoL). This study aimed to evaluate the effects of ONS formulated primarily with carbohydrate and protein on BWL, muscle strength, and HRQoL.MethodsThis will be a multicenter, open-label, parallel, randomized controlled trial in patients with gastric cancer who will undergo gastrectomy. A total of 120 patients who will undergo gastrectomy will be randomly assigned to the ONS group or usual care (control) group in a 1:1 ratio. The stratification factors will be the clinical stage (I or ≥ II) and surgical procedures (total gastrectomy or other procedure). In the ONS group, the patients will receive 400 kcal (400 ml)/day of ONS from postoperative day 5 to 7, and the intervention will continue postoperatively for 8 weeks. The control group patients will be given a regular diet. The primary outcome will be the percentage of BWL (%BWL) from baseline to 8 weeks postoperatively. The secondary outcomes will be muscle strength (handgrip strength), HRQoL (EORTC QLQ-C30, QLQ-OG25, EQ-5D-5L), nutritional status (hemoglobin, lymphocyte count, albumin), and dietary intake. All analyses will be performed on an intention-to-treat basis.DiscussionThis study will provide evidence showing whether or not ONS with simple nutritional ingredients can improve patient adherence and HRQoL by reducing BWL after gastrectomy. If supported by the study results, nutritional support with simple nutrients will be recommended to patients after gastrectomy for gastric cancer.Trial registrationjRCTs051230012; Japan Registry of Clinical Trails. Registered on Apr. 13, 2023.

682 Impact of Regionalisation of Major Trauma Services on Hip Fracture Care in England: A Comparative Study

Abstract Aim Following the establishment of Major Trauma Networks in England in 2012, there were concerns that pressures regarding resource allocation in Major Trauma Centres (MTCs) may negatively impact their care of hip fracture patients. This study aimed to compare outcomes in hip fracture care between MTCs and trauma units (TUs). Method National Hip Fracture Database data was extracted from 01/01/2015 to 31/12/2022 for all hospitals in England. Outcome measures included perioperative medical and physiotherapy assessments, time to surgery, Best Practice Tariff (BPT) compliance, discharge to original residence, and mortality. Data was pooled and weighted for MTCs and remaining hospitals (TUs). Results 487,089 patients were included from 167 hospitals (23 MTCs, 144 TUs). MTCs achieved marginally higher rates of orthogeriatrician assessment within 72 hours of admission (91.1% vs 90.4%, p&amp;lt;0.001) and mobilisation by first postoperative day (81.9% vs 79.7%, p&amp;lt;0.001). Fewer patients underwent surgery by the day after admission in MTCs (65.2% vs 69.7%, p&amp;lt;0.001). There was poorer compliance with BPT criteria in MTCs (57.3% vs 60.4%, p&amp;lt;0.001), and fewer MTC patients were discharged to their original residence (60.4% vs 63.5%, p&amp;lt;0.001). There was no difference between MTCs and TUs in 30-day mortality (6.8% vs 6.8%, p=0.825). Conclusions This study demonstrates that MTCs have greater difficulty in providing prompt surgery to hip fracture patients. However, their marginally superior perioperative care outcomes appear to compensate for this, with similar mortality rates compared to TUs. These findings suggest that the regionalisation of major trauma in England has not significantly compromised the overall care of hip fracture patients.

Trans-Disc Aspiration of Anterior Cervical Cysts

Abstract Background Spinal arachnoid cysts are rare entities occurring mainly in the cervical and thoracic spine. The majority of these lesions are treated through posterior approaches with laminectomy or laminotomy. We present trans-disc and trans-vertebral aspiration of anterior cervical arachnoid cysts as an alternative therapeutic approach. Methods We present three cases and four procedures where anterior cervical arachnoid cysts were treated through an anterior trans-discal or trans-vertebral approach. A standard Smith–Robertson approach was used to expose the appropriate level in the cervical spine. A 22-gauge spinal needle is passed through the intervertebral disc or a 3-mm channel created in the midline of the vertebral body. This is performed under fluoroscopic guidance. Results Three out of the four procedures resulted in complete clinical resolution at a 6-month follow-up. One patient required a repeat aspiration for a recurrent cyst at a level lower than the previous procedure. One patient had an initial improvement post-procedure followed by a functional decline within the first 5 postoperative days. Our assessment was that the cyst was re-filled and this was confirmed on magnetic resonance imaging (MRI). A standard posterior approach was used to excise the cyst with a good clinical result. Overall, no morbidity was suffered from the anterior approach. Conclusion We believe this approach is a safe alternative to posterior intradural approaches. MRI scanning is advised at 6 months or earlier if clinical improvement is not demonstrated.