Surgical Cases Research Articles

Significance and Priority of Surgical Resection as Therapeutic Strategy Based on Clinical Characteristics of Brain Metastases from Renal Cell Carcinoma

To clarify a rational surgical priority, clinical characteristics were compared between brain metastases (BM) from renal cell carcinoma (RCC) and other cancers. We reviewed 425 consecutive patients with BM who underwent treatments including surgery between January 2014 and December 2022. Primary cancers included lung (n= 220), breast (n= 46), digestive (n= 65), RCC (n= 25), and others (n= 69). Tumor volume (T), edema volume (E), and edema volume/tumor volume ratio (E/T ratio) were compared between RCC and other primary cancers. Cutoff T values for identifying both symptomatic tumors and tumors suitable for surgery were determined by receiver operating characteristic curves. Factors including E/T ratio, age, Karnofsky Performance Scale score, and tumor characteristicswere statistically analyzed. Cutoff values of T and E to determine surgical suitability were 4.973 cm3 (sensitivity, 0.848; specificity, 0.74) and 23.088 cm3 (sensitivity, 0.894; specificity, 0.623), respectively. E/T ratio was significantly higher for RCC than for other cancers (P < 0.01). These results remained consistent after propensity score matching. RCC tended to show a significantly lower frequency of posterior fossa tumor (16%, P < 0.01) and higher rates of single lesions (72%, P= 0.03) and intratumoral hemorrhage (24%, P=0.02). Subgroup analysis limited to surgical cases showed that E was consistent across tumors, T tended to be smaller, and E/T ratio was significantly higher in RCC. Generally, symptomatic BM were indicated for surgery. BM from RCC were characteristically single, low-volume lesions with expanding edema and intratumoral hemorrhage, causing symptoms. These results suggest that surgery should be a high priority for BM from RCC.

Modernizing Surgical Quality: A Novel Approach to Improving Detection of Surgical Site Infections in the Veteran Population.

Introduction: Surgical site infections (SSIs) are an important quality measure. Identifying SSIs often relies upon a time-intensive manual review of a sample of common surgical cases. In this study, we sought to develop a predictive model for SSI identification using antibiotic pharmacy data extracted from the electronic medical record (EMR). Methods: A retrospective analysis was performed on all surgeries at a Veteran Affair's Medical Center between January 9, 2020 and January 9, 2022. Patients receiving outpatient antibiotics within 30 days of their surgery were identified, and chart review was performed to detect instances of SSI as defined by VA Surgery Quality Improvement Program criteria. Binomial logistic regression was used to select variables to include in the model, which was trained using k-fold cross validation. Results: Of the 8,253 surgeries performed during the study period, patients in 793 (9.6%) cases were prescribed outpatient antibiotics within 30 days of their procedure; SSI was diagnosed in 128 (1.6%) patients. Logistic regression identified time from surgery to antibiotic prescription, ordering location of the prescription, length of prescription, type of antibiotic, and operating service as important variables to include in the model. On testing, the final model demonstrated good predictive value with c-statistic of 0.81 (confidence interval: 0.71-0.90). Hosmer-Lemeshow testing demonstrated good fit of the model with p value of 0.97. Conclusion: We propose a model that uses readily attainable data from the EMR to identify SSI occurrences. In conjunction with local case-by-case reporting, this tool can improve the accuracy and efficiency of SSI identification.

Mediastinal lymph node dissection in segmentectomy for peripheral c-stage IA (≤2 cm) non–small-cell lung cancer

ObjectiveAlthough recent trials on intentional segmentectomy have made mediastinal lymph node dissection (MLND) mandatory, the necessity of MLND in segmentectomy remains uncertain. We conducted a retrospective study to evaluate the necessity of MLND in segmentectomy for patients with peripheral stage IA (≤2 cm) non–small cell lung cancer. MethodsOf the 5222 surgical cases for non–small cell lung cancer from 3 institutions between 2010 and 2021, 1457 patients met the JCOG0802 trial eligibility criteria. Initially, we analyzed 574 patients who underwent lobectomy with MLND to identify preoperative risk factors for cN0-pN2 occurrence (cohort 1). Subsequently, we evaluated the relationship between these factors and the cumulative postoperative recurrence in 390 patients who underwent segmentectomy (cohort 2). ResultsIn cohort 1, risk factors for cN0-pN2 occurrence were consolidation-to-tumor ratio = 1.0 and maximum standardized uptake value ≥2.0. When classifying patients into 3 groups (group A, without any factors, group B, with either factor, and group C, with both factors), the occurrence of cN0-pN2 was significantly greater in group C than in the other groups (0.9%, 3.4%, and 8.4%, respectively, P = .005). When classifying patients in cohort 2 using the classification identified in cohort 1 (117, 131, and 142 were categorized into group A, group B, and group C, respectively), the 5-year cumulative incidence of recurrence rate was significantly greater in group C than in others (2.0%, 2.0%, and 15.9%, respectively, P < .001). ConclusionsMLND is unlikely to be beneficial in intentional segmentectomy for patients with tumors showing consolidation-to-tumor ratio <1.0 and maximum standardized uptake value <2.0.

Intra-operative and post-operative complications of endometriosis excision using the SOSURE approach - A single- surgeon retrospective series of 1116 procedures over 8 years.

Endometriosis surgery outcomes have been widely studied, yet heterogeneity in terminology and techniques persist. This study focuses on the perioperative outcomes of a single surgeon using the same structured approach (SOSURE: Survey & Sigmoid mobilisation, Ovarian mobilisation, Suspension of uterus and ovaries, Ureterolysis, Rectovaginal and pararectal space development, Excision of all visible disease) and adheres to the recent standardised terminology proposed by international gynaecological and endometriosis societies. A quality improvement study was conducted retrospectively from January 2015 to January 2023. Data collection involved two databases: the National British Society for Gynaecological Endoscopy (BSGE) database and a more comprehensive locally kept database. The methodology also integrated four endometriosis staging systems. Intra-operative and post-operative complication rates. Between 2015 and 2023, 1047 women underwent 1116 endometriosis procedures in various UK hospitals with S.K. as primary surgeon. Exclusions totalled 20 due to missing records and specific surgical criteria. The rate of major post-operative complications (Clavien-Dindo grade 3a and 3b) was 1.5% and minor post-operative complications (Clavien-Dindo grade 1 and 2) were seen in 13.8%. No Clavien-Dindo grade 4 or 5 complications were noted. Our study has shown a low complication rate in endometriosis surgery, despite increasing complexity of surgical cases. This is likely attributed to the surgeon's learning curve, high surgical volume and adherence to a structured approach. Our study demonstrates the learning curve of a surgeon over the course of 8 years. This series involved more than 1000 patients and to our knowledge, is the first to report the complexity of the casemix using four different endometriosis staging systems.

Pregnancy Associated with Gallstones Disease

Background: Gallstone disease during pregnancy can lead to significant maternal and fetal complications. This study aims to evaluate the prevalence, symptomatology, management strategies, and pregnancy outcomes associated with gallstones in pregnant women at Ashulia Women and Children Hospital (AWCH), Dhaka, Bangladesh. Methods: This prospective observational study included 100 pregnant women diagnosed with gallstones between July 2022 and June 2024 at AWCH. Data were collected on demographic characteristics, symptoms, management approaches, and pregnancy outcomes. Descriptive statistics were used for analysis. Result: The study population had a mean age of 30 years, with the majority being multiparous (60%) and in the 25-34 year age group (50%). Abdominal pain was the most common symptom (83%), followed by nausea and vomiting (50%) and indigestion (40%). Conservative management was the primary approach (60%), with 25% receiving medication and 15% undergoing surgical intervention. Successful outcomes were achieved in 14 of 15 surgical cases, including laparoscopic and open cholecystectomy. Pregnancy outcomes were generally favorable, with 85% of pregnancies resulting in full-term births. Preterm births occurred in 10% of cases, and stillbirths were reported in 5%. Maternal complications included postoperative infections (6%) and hepatitis (3%). Conclusion: Gallstone disease during pregnancy predominantly presents with abdominal pain and is managed effectively with conservative or surgical approaches. While the majority of pregnancies resulted in full-term births, there were notable complications, emphasizing the need for careful management and follow-up.

Trends and outcomes in colorectal cancer surgery: a multicenter cross-sectional study of minimally invasive versus open techniques in Germany

BackgroundThe objective of this study was to assess the trend from open to modern minimally invasive (laparoscopic and robot-assisted) surgical techniques for colorectal cancer (CRC) in Germany, with a particular focus on hospital mortality, postoperative complications, and length of hospital stay.MethodsA multicenter cross-sectional study was conducted using data from 36 German hospitals, encompassing 1,250,029 cases from January 2019 to December 2023. The study included all hospitalized patients aged ≥ 18 with CRC who underwent surgery. Surgical cases were categorized as open or minimally invasive. Outcomes assessed included in-hospital mortality, morbidity, and hospital length of stay. Statistical analyses involved multivariable logistic and linear regression models adjusted for main diagnosis, metastasis presence, age, sex, and comorbidities.ResultsThe study included 4525 CRC cases: 2767 underwent open surgery and 1758 underwent minimally invasive surgery (173 robotic). In-hospital mortality was significantly higher in open surgery (6.1% vs. 1.7%). Open surgery was also significantly associated with higher rates of acute post-hemorrhagic anemia (OR: 2.38; 95% CI: 1.87–3.02), respiratory failure (OR: 1.71; 95% CI: 1.34–2.18), and intraoperative and postprocedural complications (OR: 3.64; 95% CI: 2.83–4.70). Average hospital stay was longer for open surgery (19.5 days vs. 11.0 days).ConclusionDespite the advantages of minimally invasive surgery, including reduced mortality, morbidity, and shorter hospital stays, open surgery remains the predominant approach for CRC in Germany. These findings underscore the need for increased adoption of minimally invasive techniques and highlight the potential benefits of shifting toward minimally invasive methods to enhance the overall quality of CRC care.Graphical abstract

Primary adrenal sarcomas: A national analysis of epidemiological trends, treatment patterns, and outcomes.

Primary adrenal sarcoma (PAS) is an exceedingly rare malignancy with limited data available on its epidemiology, management, and outcomes. This study aimed to characterize the national incidence, treatment patterns, and survival of PAS utilizing a National Cancer Database. The National Cancer Database was queried for patients diagnosed with primary adrenal tumors from 2004 to 2019. Cases with sarcoma histology were identified as PAS. Annual incidence trends, histological distribution, treatment modalities (surgery, chemotherapy, radiation therapy), perioperative outcomes, and overall survival (OS) were analyzed. Of 7213 primary adrenal tumor cases, 332 (4.6%) were PAS. The most common histological subtypes were leiomyosarcoma (37.3%), hemangiosarcoma (27.1%), and sarcoma not otherwise specified (6.0%). Most cases (71.7%) presented as locoregional disease. Treatment included surgery alone (47.8%), surgery plus chemotherapy and/or radiation (27.1%), chemotherapy/radiation alone (13.3%), or no treatment (13.9%). For surgical cases, the median length of stay was 5 days, the 30-day readmission rate was 3.36%, and the 30/90-day mortality rates were 3.65% and 9.90%, respectively. The 5-year OS rate for surgery alone was 43%, with a median OS of 34.6 months. For surgery with radiation/chemotherapy, the 5-year OS rate was 37.3%, with a median OS of 35.4 months. This largest analysis of PAS to date demonstrates that most cases present as locoregional disease amenable to surgical resection, with favorable outcomes. The role of adjuvant therapy remains unclear, as no significant survival difference was observed between surgery alone and multimodal treatment.

Surgical and irradiated case of early breast cancer in a patient with Ehlers–Danlos syndrome

BackgroundEhlers–Danlos syndrome (EDS) is a rare inherited connective tissue disease characterized by hyperextensibility of the skin and joints and tissue fragility of the skin and blood vessels, Vascular EDS is the most severe form of EDS, with abnormal arterial fragility. There have been no reports of breast cancer occurring in patients with vascular EDS. Here, we report here a very rare case of breast cancer in a patient with vascular EDS.Case presentationA 46-year-old woman with vascular EDS underwent partial left mastectomy and sentinel lymph node biopsy for left breast cancer (cStage 0) detected by medical examination. The final pathological diagnosis was invasive ductal carcinoma of the breast (pStage IA) [hormone receptor-positive, HER2 score 2 equivocal (FISH-positive), Ki-67LI 18%, luminal-HER2 type]. BluePrint was submitted as an aid in determining the postoperative treatment strategy, BluePrint Molecular Subtype HER2-type. However, the 10-year breast cancer mortality risk using Predict was low (5%). After consultation with the patient, the decision was made to administer postoperative radiation to the preserved breast along with hormone therapy only. There was no delay in postoperative wound healing, and the patient was free of metastatic recurrence for 9 months after surgery.ConclusionWe performed surgery, postoperative radiotherapy, and hormonal therapy in a breast cancer patient with vascular EDS without major complications.

Educating for success: ambulatory anesthesia training.

This article explores the unique intersection of the challenges confronting ambulatory anesthesiology education and charts a trajectory forward. The proportion of ambulatory, nonoperating room (NORA), and office-based surgical cases continues to rise; however, the requirements for trainees in these settings have remained static. The rapid evolution of the field combined with a limited workforce also makes continuing education essential, and we discuss the current and future states of ambulatory anesthesia education. Although numerous resources are available across an array of platforms to foster both trainee education and continuing education for practicing anesthesiologists, there is a paucity of current literature evaluating the impact of new curricula developed specifically for ambulatory, NORA, or office-based anesthesiology (OBA). We begin with an appraisal of the current state of ambulatory anesthesiology training and evaluate the gap between current graduate medical education and trends in ambulatory surgery. We then develop a vision for an ideal state of future ambulatory education for residents as well as anesthesiologists in practice and highlight the priorities necessary to reach this vision.

Challenging Conventional Treatment: Retrograde Implantation of a Covered Stent in Superior Mensenteric Artery Occlusion Case.

Background: This case report describes a novel endovascular technique for treating superior mesenteric artery (SMA) occlusion, a condition leading to chronic mesenteric ischemia (CMI). Traditional treatment methods for CMI, primarily due to SMA stenosis, are often complex and risky, particularly for patients unsuitable for conventional surgery. Objective: This study details the application of retrograde recanalization followed by the deployment of a VIABAHN covered stent in a patient with complete SMA ostium occlusion. Methods: The procedure's success in re-establishing mesenteric blood flow demonstrates its potential as a less invasive, safer alternative to traditional surgical approaches. This technique's innovation lies in its retrograde approach, allowing for effective treatment in cases where antegrade access is unfeasible. Results: The patient showed significant symptom improvement without procedural complications, underscoring the method's efficacy and safety. Conclusion: These findings suggest that retrograde stent implantation can be a viable option for managing SMA occlusions, especially in high-risk surgical cases. The successful application of this technique in this case contributes to the evolving landscape of endovascular interventions in vascular surgery and offers a promising direction for future research and clinical practice in treating SMA-related conditions.

Management of bilateral head and neck paragangliomas at a single-institution across four decades.

Bilateral head and neck paragangliomas (HNPGLs) require nuanced management to balance tumor control with functional preservation. All patients seen at a single-institution for bilateral paraganglioma between 1983 and 2023 were retrospectively reviewed. Demographics, genetic testing results, and tumor characteristics were analyzed and compared to treatment modality and cranial nerve outcomes. There were 49 patients with 116 tumors (90 carotid body tumors [CBTs], 15 vagal paragangliomas [VPs], and 11 jugular paragangliomas [JPs]). Twenty-six patients had SDH pathologic variants (PV). Surgical management was more commonly utilized in younger patients (OR: 0.97, 95% CI: 0.950-0.992) and for JPs (OR: 9, 95% CI: 1.386-58.443). In surgical cases, CBTs had a lower risk of postoperative cranial nerve deficits compared to JPs and VPs (OR: 0.095, 95% CI: 0.013-0.692). Younger patients with bilateral HNPGLs, especially those with JP and CBT, are more often treated with surgery. CBTs have lowest risk of cranial nerve deficits after surgery.

Opioid Dose Variation in Cardiac Surgery: A Multicenter Study of Practice.

Although high-opioid anesthesia was long the standard for cardiac surgery, some anesthesiologists now favor multimodal analgesia and low-opioid anesthetic techniques. The typical cardiac surgery opioid dose is unclear, and the degree to which patients, anesthesiologists, and institutions influence this opioid dose is unknown. We reviewed data from nonemergency adult cardiac surgeries requiring cardiopulmonary bypass performed at 30 academic and community hospitals within the Multicenter Perioperative Outcomes Group registry from 2014 through 2021. Intraoperative opioid administration was measured in fentanyl equivalents. We used hierarchical linear modeling to attribute opioid dose variation to the institution where each surgery took place, the primary attending anesthesiologist, and the specifics of the surgical patient and case. Across 30 hospitals, 794 anesthesiologists, and 59,463 cardiac cases, patients received a mean of 1139 (95% confidence interval [CI], 1132-1146) fentanyl mcg equivalents of opioid, and doses varied widely (standard deviation [SD], 872 µg). The most frequently used opioids were fentanyl (86% of cases), sufentanil (16% of cases), hydromorphone (12% of cases), and morphine (3% of cases). 0.6% of cases were opioid-free. 60% of dose variation was explainable by institution and anesthesiologist. The median difference in opioid dose between 2 randomly selected anesthesiologists across all institutions was 600 µg of fentanyl (interquartile range [IQR], 283-1023 µg). An anesthesiologist's intraoperative opioid dose was strongly correlated with their frequency of using a sufentanil infusion (r = 0.81), but largely uncorrelated with their use of nonopioid analgesic techniques (|r| < 0.3). High-dose opioids predominate in cardiac surgery, with substantial dose variation from case to case. Much of this variation is attributable to practice variability rather than patient or surgical differences. This suggests an opportunity to optimize opioid use in cardiac surgery.

Quality Assessment of TikTok as a Source of Information About Mitral Valve Regurgitation in China: Cross-Sectional Study.

In China, mitral valve regurgitation (MR) is the most common cardiovascular valve disease. However, patients in China typically experience a high incidence of this condition, coupled with a low level of health knowledge and a relatively low rate of surgical treatment. TikTok hosts a vast amount of content related to diseases and health knowledge, providing viewers with access to relevant information. However, there has been no investigation or evaluation of the quality of videos specifically addressing MR. This study aims to assess the quality of videos about MR on TikTok in China. A cross-sectional study was conducted on the Chinese version of TikTok on September 9, 2023. The top 100 videos on MR were included and evaluated using quantitative scoring tools such as the modified DISCERN (mDISCERN), the Journal of the American Medical Association (JAMA) benchmark criteria, the Global Quality Score (GQS), and the Patient Education Materials Assessment Tool for Audio-Visual Content (PEMAT-A/V). Correlation and stepwise regression analyses were performed to examine the relationships between video quality and various characteristics. We obtained 88 valid video files, of which most (n=81, 92%) were uploaded by certified physicians, primarily cardiac surgeons, and cardiologists. News agencies/organizations and physicians had higher GQS scores compared with individuals (news agencies/organizations vs individuals, P=.001; physicians vs individuals, P=.03). Additionally, news agencies/organizations had higher PEMAT understandability scores than individuals (P=.01). Videos focused on disease knowledge scored higher in GQS (P<.001), PEMAT understandability (P<.001), and PEMAT actionability (P<.001) compared with videos covering surgical cases. PEMAT actionability scores were higher for outpatient cases compared with surgical cases (P<.001). Additionally, videos focused on surgical techniques had lower PEMAT actionability scores than those about disease knowledge (P=.04). The strongest correlations observed were between thumbs up and comments (r=0.92, P<.001), thumbs up and favorites (r=0.89, P<.001), thumbs up and shares (r=0.87, P<.001), comments and favorites (r=0.81, P<.001), comments and shares (r=0.87, P<.001), and favorites and shares (r=0.83, P<.001). Stepwise regression analysis identified "length (P<.001)," "content (P<.001)," and "physicians (P=.004)" as significant predictors of GQS. The final model (model 3) explained 50.1% of the variance in GQSs. The predictive equation for GQS is as follows: GQS = 3.230 - 0.294 × content - 0.274 × physicians + 0.005 × length. This model was statistically significant (P=.004) and showed no issues with multicollinearity or autocorrelation. Our study reveals that while most MR-related videos on TikTok were uploaded by certified physicians, ensuring professional and scientific content, the overall quality scores were suboptimal. Despite the educational value of these videos, the guidance provided was often insufficient. The predictive equation for GQS developed from our analysis offers valuable insights but should be applied with caution beyond the study context. It suggests that creators should focus on improving both the content and presentation of their videos to enhance the quality of health information shared on social media.

Cytologic Findings and Ancillary Tests Results of Sclerosing Pneumocytoma: Our Institutional Experience.

Sclerosing pneumocytoma (SP) is a rare benign tumor and a potential diagnostic pitfall. Our aim was to review the cytologic features of our surgically diagnosed SP cases including the clinical, immunohistochemical and available molecular findings. A computerized search from 2013 to 2020 for surgical cases with corresponding cytology specimens diagnosed as SP was performed. The clinical data, cytology, and surgical specimens were collated for analysis. Six cytology specimens were collected. All were female (mean age = 35). Three have incidental lung nodules and three with cough. Cytologic findings showed variable architectural pattern (papillary, solid, singly scattered, acinar/rosette-like) and cellular heterogeneity (surface, stromal, epithelioid, plasmacytoid cells). Atypia was identified in 4/6 cases. The original cytology diagnoses were negative = 1, SP = 2 and adenocarcinoma = 3. The latter diagnoses were amended to SP after review of the surgical specimens. The three false positive cases on review have cytologic features mimicking adenocarcinoma. Immunohistochemical stains showed tumor cells (surface and stromal) were positive for TTF-1, and EMA with only the surface cells positive for pancytokeratin and Napsin A. Though two cases sent for molecular testing were negative for AKT1 or CTNNB1 exon 3 mutation, our panel did not evaluate AKT1 exon 4. SP is a diagnostic pitfall with 50% initially misdiagnosed as adenocarcinoma. Integrating the clinical/radiologic findings, cytologic features, and performance of immunohistochemistry on cell block are helpful in avoiding misdiagnosis. Molecular testing for recurrent mutations, if present, could be helpful for diagnosis and possible therapy options. However, routinely used molecular testing may not always capture relevant molecular markers for SP.

Minimally invasive far lateral tubular microdiscectomy: surgical technique and case series of 176 patients.

Far lateral (extraforaminal) disc herniations comprise approximately 10% of symptomatic lumbar disc herniations. They represent operative challenges due to accessibility and surgical unfamiliarity. Surgical strategies in the past have included open discectomy and posterior lumbar interbody fusion. Tubular microdiscectomies have gained traction due to their minimally invasive advantages, including reduced morbidity, pain and length of hospital stay. We report our retrospective single institution consecutive case series of tubular far lateral microdiscectomies. One hundred and seventy-six patients were operated on over an eight-year period. Clinical outcomes were assessed after institutional ethics approval. We additionally describe our surgical technique with an illustrative video case. Over a mean follow-up of 21 weeks, 77% of patients had good or excellent clinical outcomes according to the MacNab criteria. 12% of patients underwent reoperation at the index level for symptom recurrence or persistence. Mean length of hospital stay was 1.3 days. There was a 1% rate of both postoperative haematoma and infection. Mean operation duration was 86minutes. This case series represents the largest currently reported in the literature. Minimally invasive microdiscectomies performed through tubes allow for precise localisation, reduced tissue disruption and favourable clinical outcomes. Our results appear consistent with a review of the literature, demonstrating the safety and efficacy of this approach.

Is It Time for a Paradigm Shift in the Surgical Management of Trigeminal Schwannomas? Evaluating the Role of the Transorbital Approach: An Anatomo-Clinical Study and Systematic Literature Review

BackgroundEndoscopic transorbital approach emerged in recent years as an effective, minimally invasive route to access Meckel’s cave area. Several case series proved its effectiveness in the surgical treatment of trigeminal schwannomas. Nonetheless, this route provides the advantages of a minimally invasive approach associated with low morbidity rates. In this anatomo-clinical study we illustrate the usefulness of the superior eyelid transorbital approach for the surgical treatment of trigeminal schwannoma guiding the clinical applicability of the anatomical findings into the real surgical practice. MethodsSuperior eyelid transorbital endoscopic approach was performed on eight cadaveric specimens, and the surgical results were confirmed in a retrospective review of all the surgical cases of transorbital surgery performed by the senior authors providing an illustrative case. Finally, we performed a literature review of all the case series of trigeminal schwannomas operated through an endoscopic transorbital approach. ResultsStepwise dissection was divided in 3 phases: skin, endo-orbital and endocranial. The illustrative case provided demonstrate gross total resection of a cavernous sinus type trigeminal schwannomas treated through this route. Literature review revealed 68 cases of trigeminal schwannomas that were successfully treated using the transorbital approach. ConclusionsThe endoscopic transorbital approach may offer a valuable alternative for the surgical treatment of trigeminal schwannomas. This technique provides a minimally invasive, direct and natural “interdural” route to the lateral wall of the cavernous sinus and Meckel's cave.

Endoscopic Transsphenoidal Drainage for Rathke Cleft Cyst With Sellar Xanthogranuloma - Successful Cyst Drainage and Prevention of Postoperative Cerebrospinal Fluid Leakage: 2-Dimensional Operative Video.

The etiology of sellar xanthogranuloma (SXG) remains unclear,1-5 and the surgical strategy for treating SXG is debatable. In this study, we present the surgical case of a symptomatic SXG associated with Rathke cleft cyst. The intraoperative decision to prevent postoperative cerebrospinal fluid (CSF) leakage and secure the drainage route is discussed. A 72-year-old woman presented with severe headaches, visual loss, and gradual enlargement of a cystic lesion on magnetic resonance imaging. The cyst compressed the chiasm upward. The cyst wall was partially thickened and contained a solid mass that was weakly enhanced after gadolinium administration. The endoscopic transsphenoidal cyst was drained, the solid tumor was partially removed for histological diagnosis, and the wide drainage orifice was secured. Intraoperatively, the cyst wall was widely open, but CSF leaked during manipulation of the solid tumor. The sellar floor was partially reconstructed by a multilayer technique to prevent postoperative CSF leakage. The wide cyst drainage route to the sphenoid sinus was also secured. Histologic diagnosis revealed SXG with ciliated columnar epithelium. No postoperative CSF leakage occurred, and the cyst continued to shrink. The patient's visual acuity improved, and pituitary function was preserved. If a CSF leak is identified intraoperatively in a case of secondary SXG associated with Rathke cleft cyst, a cystic fenestration with partial sellar reconstruction may reduce the likelihood of postoperative CSF leakage and ensure continuous drainage. Institutional Review Board approval was not required; The patient consented to the surgery and the publication of her images and surgical video.

Leaks after laparoscopic sleeve gastrectomy: 2024 update on risk factors.

Leaks after sleeve gastrectomy remain a deadly complication significantly affecting outcomes and medical costs. The aim of the present review is to provide an updated decalogue on leak prevention. Risk factors of leakage after LSG were examined based on an extensive review of literature (in period time 2016-2024) and summary of evidence was provided using Oxford levels of evidence scale. Pathogenesis of leakage after LSG still remain related to ischemic and mechanical factors and, therefore, no new evidence has been reported. Conversely, some technical aspect of the procedure has changed: bougie size, antrum resection, staple line reinforcement, and intraoperative leak testing. Bougie size 36F is effective and safe achieving similar leakage rate compared to larger bougie sizes (EL:2) 2024 UPDATE; There is no significant difference in the leak rate between restrictive (< 6cm) and conservative (6cm) antrum resection (EL: 1) 2024 UPDATE; Surgical experience and case volume affect the leak rate more consistently than every kind of SLR (EL: 2) 2024 UPDATE; Intraoperative leak test after LSG represents a decision based on surgeon preference in absence of standardization (endoscopy, bubble test, methylene blue, indocyanine green.) and strong detection/prevention rate (EL: 3) 2024 UPDATE.

CADS as a Decision-making Tool: Developing an Oculoplastic Management Algorithm for Facial Nerve Palsy.

The Cornea, Asymmetry, Dynamic, Synkinesis (CADS) score is a validated grading score for periocular involvement in facial nerve palsy (FNP). We conducted a retrospective review of FNP cases, including initial CADS scores and subsequent ophthalmic interventions. The results were used to inform the development of an oculoplastic management algorithm for FNP. Single-center retrospective cohort study of patients with FNP referred to a tertiary unit between 2016 and 2022. Data collected included demographic data, etiology of FNP, treatment initiated, and CADS grading at each visit. Adult patients with ≥6 months of follow-up were included, and cases were excluded if ocular surface or oculoplastic procedures were performed elsewhere prior to the initial review by the unit. Of 408 consecutive new patients with FNP, 80 fulfilled inclusion criteria (mean age 57 years, range 21-83 years). Presentations of FNP were unilateral in 98.8% (79/80), with an underlying preganglionic etiology in 75.0% (60/80). At the initial review, surgery was recommended for 61.3% (49/80) of cases. Subgroup analysis of surgical cases for each CADS domain showed 46.9% (23/49) had C-score ≥2, which was predictive of upper lid surgery requirement (e.g., upper lid platinum segment chain; levator recession). About 63.2% (31/49) had an A-score ≥1 which predicted for lower lid surgery requirement (e.g., retractor recession, lower lid sling, medial canthal tendon plication, and lower lid full thickness skin graft) as well as a brow lift. Almost 79.6% (39/49) had a D-score ≥2, which was associated with both upper lid and lower lid surgery requirements. Also, 59.2% (29/49) had an S-score of ≥1 however, this was not associated with the surgical requirement, highlighting a different approach compared with the other CADS domains. This study represents a large cohort of patients followed up with a validated ophthalmic-specific FNP grading scale. This was utilized to develop a CADS-based management algorithm to help guide decision-making for surgical intervention versus medical management in FNP.

Annual record on the number of general urological surgeries registered in the National Clinical Database system between April 2018 and December 2021 in Japan.

The Japanese National Clinical Database (NCD) is a large-scale, nationwide, web-based data entry system that covers the majority of surgical cases performed in Japan. An NCD specializing in urological surgery was launched based on the NCD system in 2018. All urological surgeries performed at more than 1000 institutions were registered from 2018. We herein report the number of surgeries conducted as stipulated in the "Certified Urology Surgeon Training Curriculum" between April 2018 and December 2021. A total of 1 377 677 cases were registered from 1185 facilities nationwide under the initiative of the Japanese Urological Association. We examined the number of procedures performed every year for each of the 10 categories. The NCD system sustainably provides important information relating to the preoperative status, operational outcome, and best practice for urological surgery in Japan.