Surgical Invasiveness Research Articles

Pedicle screw insertion into infected vertebrae reduces operative time and range of fixation in minimally invasive posterior fixation for thoracolumbar pyogenic spondylitis: a multicenter retrospective cohort study

BackgroundMinimally invasive posterior fixation surgery for pyogenic spondylitis is known to reduce invasiveness and complication rates; however, the outcomes of concomitant insertion of pedicle screws (PS) into the infected vertebrae via the posterior approach are undetermined. This study aimed to assess the safety and efficacy of PS insertion into infected vertebrae in minimally invasive posterior fixation for thoracolumbar pyogenic spondylitis.MethodsThis multicenter retrospective cohort study included 70 patients undergoing minimally invasive posterior fixation for thoracolumbar pyogenic spondylitis across nine institutions. Patients were categorized into insertion and skip groups based on PS insertion into infected vertebrae, and surgical data and postoperative outcomes, particularly unplanned reoperations due to complications, were compared.ResultsThe mean age of the 70 patients was 72.8 years. The insertion group (n = 36) had shorter operative times (146 versus 195 min, p = 0.032) and a reduced range of fixation (5.4 versus 6.9 vertebrae, p = 0.0009) compared to the skip group (n = 34). Unplanned reoperations occurred in 24% (n = 17) due to surgical site infections (SSI) or implant failure; the incidence was comparable between the groups. Poor infection control necessitating additional anterior surgery was reported in four patients in the skip group.ConclusionsPS insertion into infected vertebrae during minimally invasive posterior fixation reduces the operative time and range of fixation without increasing the occurrence of unplanned reoperations due to SSI or implant failure. Judicious PS insertion in patients with minimal bone destruction in thoracolumbar pyogenic spondylitis can minimize surgical invasiveness.

Associations of body composition parameters with postoperative outcome and perineural tumour invasion after oncological pancreatic resection

BackgroundPancreatic cancer is often accompanied by wasting conditions. While surgery is the primary curative approach, it poses a substantial risk of postoperative complications, hindering subsequent treatments. Therefore, identifying patients at high risk for complications and optimizing their perioperative general condition is crucial. Sarcopenia and other body composition abnormalities have shown to adversely affect surgical and oncological outcomes in various cancer patients. As most pancreatic tumours are located close to the neuronal control centre for the digestive tract, it is possible that neural infiltration in this area deranges bowel functions and contributes to malabsorption and malnutrition and ultimately worsen sarcopenia and weight loss.MethodsA retrospective analysis of CT scans was performed for pancreatic cancer patients who underwent surgical tumour resection at a single high-volume centre from 2007 to 2023. Sarcopenia prevalence was assessed by skeletal muscle index (SMI), and visceral obesity was determined by the visceral adipose tissue area (VAT). Obesity and malnutrition were determined by the GLIM criteria. Sarcopenic obesity was defined as simultaneous sarcopenia and obesity. Postoperative complications, mortality and perineural tumour invasion, were compared among patients with body composition abnormalities.ResultsOf 437 patients studied, 46% were female, the median age was 69 (61;74) years. CT analysis revealed 54.9% of patients with sarcopenia, 23.7% with sarcopenic obesity and 45.9% with visceral obesity. Sarcopenia and sarcopenic obesity were more prevalent in elderly and male patients. Postoperative surgical complications occurred in 67.7% of patients, most of which were mild (41.6%). Severe complications occurred in 22.7% of cases and the mortality rate was 3.4%. Severe postoperative complications were significantly more common in patients with sarcopenia or sarcopenic obesity. Visceral obesity or malnutrition based on BMI alone, did not significantly impact complications. Perineural invasion was found in 80.1% of patients and was unrelated to malnutrition or body composition parameters.ConclusionsThis is the first and largest study evaluating the associations of CT-based body mass analysis with surgical outcome and histopathological perineural tumour invasion in pancreatic cancer patients. The results suggest that elderly and male patients are at high risk for sarcopenia and should be routinely evaluated by CT before undergoing pancreatic surgery, irrespective of their BMI. Confirmation of the results in prospective studies is needed to assess if pancreatic cancer patients with radiographic sarcopenia benefit from preoperative amelioration of muscle mass and function by exercise and nutritional interventions.

Correlation between Peripheric Blood Markers and Surgical Invasiveness during Humeral Shaft Fracture Osteosynthesis in Young and Middle-Aged Patients.

The treatment for humeral shaft fractures (HSFs) is still controversial, consisting of a wide variety of orthopedic osteosynthesis materials that imply different grades of invasiveness. The aim of this study is to investigate the correlation between inflammatory blood-derived markers and the magnitude of the surgical procedure in young and middle-aged patients who sustained these fractures. Observational, retrospective research was conducted between January 2018 and December 2023. It followed patients diagnosed with recent HFSs (AO/OTA 12-A and B) and followed operative treatment. They were split in two groups, depending on the surgical protocol: group A, operated by closed reduction and internal fixation (CRIF) with intramedullary nails (IMNs), and group B, operated by open reduction and internal fixation (ORIF) with dynamic compression plates (DCPs). Statistically significant differences (p < 0.05) between the two groups could be observed in injury on the basis of surgery durations, surgical times, pre- and postoperative neutrophil-per-lymphocyte ratio (NLR), postoperative platelet-per-lymphocyte ratio (PLR), monocyte-per-lymphocyte ratio (MLR), systemic inflammatory index (SII), systemic inflammatory response index (SIRI) and aggregate inflammatory systemic index (AISI). The multivariate regression model proposed revealed that NLR > 7.99 (p = 0.007), AISI > 1668.58 (p = 0.008), and the surgical times (p < 0.0001) are strongly correlated to the magnitude of the surgical protocol followed. Using receiver operating characteristic (ROC) curve analysis, a balanced reliability was determined for both postoperative NLR > 7.99 (sensitivity 75.0% and specificity 75.6) and AISI > 1668.58 (sensitivity 70.6% and specificity 82.2%). Postoperative NLR and AISI as inflammatory markers are highly associated with the magnitude of surgical trauma sustained during humeral shaft fracture osteosynthesis in a younger population.

Assessing the Economic Benefits of Enhanced Recovery After Surgery (ERAS) Protocols in Adult Cervical Deformity Patients: Is the Initial Additive Cost of Protocols Offset by Clinical Gains?

To assess the financial impact of Enhanced Recovery After Surgery (ERAS) protocols and cost-effectiveness in cervical deformity corrective surgery. Retrospective review of prospective CD database. Enhanced Recovery After Surgery (ERAS) can help accelerate patient recovery and assist hospitals in maximizing the incentives of bundled payment models while maintaining high-quality patient care. However, the economic benefit of ERAS protocols, nor the heterogeneous components that make up such protocols, has not been established. Operative CD patients ≥18 y with complete pre-(BL) and up to 2-year(2Y) postop radiographic/HRQL data were stratified by enrollment in Standard-of-Care ERAS beginning in 2020. Differences in demographics, clinical outcomes, radiographic alignment targets, perioperative factors, and complication rates were assessed through means comparison analysis. Costs were calculated using PearlDiver database estimates from Medicare pay scales. QALY was calculated using NDI mapped to SF6D using validated methodology with a 3% discount rate to account for a residual decline in life expectancy. In all, 127 patients were included (59.07±11.16y, 54% female, 29.08±6.43kg/m 2 ) in the analysis. Of these patients, 54 (20.0%) received the ERAS protocol. Per cost analysis, ERAS+ patients reported a lower mean total 2Y cost of 35049 USD compared with ERAS- patients at 37553 ( P <0.001). Furthermore, ERAS+ patients demonstrated lower cost of reoperation by 2Y ( P <0.001). Controlling for age, surgical invasiveness, and deformity per BL TS-CL, ERAS+ patients below 70 years old were significantly more likely to achieve a cost-effective outcome by 2Y compared with their ERAS- counterparts (OR: 1.011 [1.001-1.999, P =0.048]. Patients undergoing ERAS protocols experience improved cost-effectiveness and reduced total cost by 2Y post-operatively. Due to the potential economic benefit of ERAS for patients incorporation of ERAS into practice for eligible patients should be considered.

Outpatient Surgery Center - Modern Capabilities

Outpatient surgery is a rapidly developing independent area of surgery with its specific ideology, features and perspectives. It increases the availability of planned surgical care, allows to expand the number of surgical invasions on early disease stages, significantly reduces the rehabilitation time for patients, while treating patients is much cheaper than in a hospital and increases the competence of medical personnel. Providing outpatient surgical care in a multidisciplinary hospital makes it possible to solve a number of medical, economic and social problems: rationally use the bed capacity of inpatient departments, reduce the risk of purulent complications, minimize the psycho-emotional trauma from hospital stay, increase the income of the institution and develop medical tourism.

Impact of Self-Reported Loss of Balance and Gait Disturbance on Outcomes following Adult Spinal Deformity Surgery.

Background: The objective of this study was to evaluate if imbalance influences complication rates, radiological outcomes, and patient-reported outcomes (PROMs) following adult spinal deformity (ASD) surgery. Methods: ASD patients with baseline and 2-year radiographic and PROMs were included. Patients were grouped according to whether they answered yes or no to a recent history of pre-operative loss of balance. The groups were propensity-matched by age, pelvic incidence-lumbar lordosis (PI-LL), and surgical invasiveness score. Results: In total, 212 patients were examined (106 in each group). Patients with gait imbalance had worse baseline PROM measures, including Oswestry disability index (45.2 vs. 36.6), SF-36 mental component score (44 vs. 51.8), and SF-36 physical component score (p < 0.001 for all). After 2 years, patients with gait imbalance had less pelvic tilt correction (-1.2 vs. -3.6°, p = 0.039) for a comparable PI-LL correction (-11.9 vs. -15.1°, p = 0.144). Gait imbalance patients had higher rates of radiographic proximal junctional kyphosis (PJK) (26.4% vs. 14.2%) and implant-related complications (47.2% vs. 34.0%). After controlling for age, baseline sagittal parameters, PI-LL correction, and comorbidities, patients with imbalance had 2.2-times-increased odds of PJK after 2 years. Conclusions: Patients with a self-reported loss of balance/unsteady gait have significantly worse PROMs and higher risk of PJK.

Exoscopic Minimally Invasive Open-Door Laminoplasty for Cervical Myelopathy: A Technical Note and Preliminary Analysis of Clinical Outcomes during the Acute Postoperative Period.

Background/Objectives: Expansive open-door laminoplasty results in favorable clinical outcomes for cervical myelopathy. However, some postoperative complications associated with surgical invasiveness, such as axial neck pain and kyphosis, have not been resolved. The use of an exoscope, which is a recently introduced novel magnification tool, allows for traditional open-door laminoplasty with minimal invasiveness. Therefore, we propose the use of exoscopic minimally invasive open-door laminoplasty (exLAP) and present its clinical outcomes during the acute postoperative period. Methods: A total of 28 patients who underwent open-door laminoplasty at C3-C6 were reviewed. Of these patients, 17 underwent exLAP (group M) and 11 underwent conventional Hirabayashi open-door laminoplasty (group H). Outcomes were evaluated using numerical rating scale (NRS) scores for neck pain and the frequency of oral analgesic use from postoperative day 1 to 7. Results: The NRS score for neck pain was significantly lower for patients in group M than for those in group H. Conclusions: ExLAP is a novel, practical, and minimally invasive surgical technique that may alleviate the postoperative axial pain of patients with cervical myelopathy.

163 Assessing the Economic Benefit of Enhanced Recovery After Surgery (ERAS) Protocols in Adult Cervical Deformity Patients: Is the Initial Additive Cost of Protocols Offset by Clinical Gains

INTRODUCTION: The economic benefit of ERAS protocols, nor the heterogeneous components that make up such protocols, has not been established. METHODS: CD patients =18 yrs with pre-(BL) and up to 2-year (2Y) postop data were stratified by enrollment in Standard-of-Care ERAS beginning in 2020. Differences in pre, peri-, and post-operative factors were assessed via means comparison analysis. Costs were calculated using PearlDiver database estimates from Medicare pay-scales. QALY was calculated using NDI mapped to SF6D using validated methodology with 3% discount rate to account for residual decline to life expectancy. RESULTS: 270 patients were included (58.11 ± 11.97 years, 48% female). 54 (20.0%) received ERAS protocol recovery treatment post-operatively. Peri-operatively, ERAS+ patients also reported lower mean LOS overall (4.33 vs 5.84, p = .393), and were more likely to be discharged directly to home (χ2(1) = 4.974, p = .028). Per cost analysis, ERAS+ patients reported a lower mean total 2Y cost of 33,829 USD compared to ERAS- patients at 36,951 (p &lt; .001). Furthermore, ERAS+ patients trended towards greater life-expectancy 2Y QALYs gained versus ERAS- patients (.423 vs .368, p = .051), and demonstrated lower costs at reoperation by 2Y (7050 USD vs 8110, p &lt; .001). Controlling for age, surgical invasiveness, and deformity per BL TS-CL, ERAS+ patients below 70 years old were more likely to achieve a cost-effective outcome by 2Y compared to their ERAS- counterparts (OR: 1.011 [1.001 – 1.999, p = .048]. CONCLUSIONS: Patients undergoing Enhanced Recovery After Surgery (ERAS) protocols experience lower operative times, length of stay, and rates of peri-and and post-operative complications. Subsequently, this study demonstrates that ERAS programs in ACD surgery demonstrate improved cost-effectiveness and reduced total cost by 2Y post-operatively. Due to the potential economic benefit of ERAS for patients, physicians and instutions should consider incorporation of ERAS into practice for eligible patients.

1071 Initial Experience Using an Augmented Reality Head-Mounted Display System During Surgical Management of Thoracolumbar Spinal Trauma

INTRODUCTION: Advancements in trauma medicine can improve the speed and accuracy of care response with a major impact on downstream operative outcomes. Augmented reality using a head-mounted-display (AR-HMD) is a novel technology that may be applied to spine surgery to provide surgeons with a real-time CT-guided 3-dimensional reconstruction of a patient’s spinal anatomy. METHODS: We retrospectively reviewed trauma patients who underwent pedicle screw placement guided by AR-HMD or robotic-assisted platforms at an academic tertiary care center between January 1, 2021 and December 31, 2022. Demographic, clinical, cost, and perioperative outcome information was analyzed and outcome profiles were compared using a U test. RESULTS: The AR cohort (4 females, 5 males) had a mean age of 66.0 years, BMI of 29.4 kg/m2, Charlson Comorbidity Index (CCI) of 4.11, and Surgical Invasiveness Index (SII) of 8.78. Pedicle screws (77) were placed in the thoracic (51%), lumbar (39%), and sacral spine (10%). Intraoperatively, there was a mean blood loss of 377.78 ml, 0.78 units transfused, 398.33 minutes spent in the operating room, and a 20.00 day LOS. The average 3-month, 6-month, and 12-month ODI scores were 14.25 (n = 8), 15.40 (n = 5), and 12.66 (n = 3). The robotic cohort (5 females, 8 males) had a mean age of 55.6 years, BMI of 27.1 kg/m2, CCI of 3.77, and SII of 14.23. Pedicle screws (128) were placed in the thoracic (59%), lumbar (37%), sacral spine (2%), iliac spine (2%), and pelvis (2%). Intra-operatively, there was a mean blood loss of 431.54 ml, 0.46 units transfused, 330.61 minutes spent in the operating room, and a 10.38 day LOS. The average 3-month, 6-month, and 12-month ODI scores were 22.67 (n = 9), 18.60 (n = 5), and 29.50 (n = 2). CONCLUSIONS: This case series demonstrates the utility of AR-HMD in surgical spinal trauma cases by showing operative outcomes comparable to those observed in robotic-assisted surgery.

Definitive internal fracture fixation followed by staged free flap coverage (“fix followed by flap” protocol) for open Gustilo type IIIB fractures

BackgroundAlthough the concept of the “fix and flap” approach, in which definitive fracture fixation and flap coverage are completed in a single procedure at the earliest opportunity may seem ideal for the treatment of Gustilo type IIIB open fractures, the individual circumstances of patients, such as polytrauma or multiple fracture cases may not allow for the immediate fracture fixation and flap coverage (“fix and flap” approach). In our hospital, patients with Gustilo type IIIB open fractures are treated with definitive internal fixation of the fracture followed by staged flap coverage (“fix followed by flap” protocol) when the “fix and flap” approach was not feasible due to the patient's condition or difficulty in coordinating surgery schedules. The “fix followed by flap” protocol provides benefits in terms of flexibility in adjusting the surgical timetable, simplifying the planning of flap coverage following fracture fixation, and minimizing individual surgical invasion. MethodsWe reviewed 10 cases of severe open fractures treated with the “fix followed by flap” protocol and evaluated their outcomes. All surgical procedures, including wound debridement, fracture fixation, and flap coverage, were performed by orthoplastic surgeons specializing in both fracture surgery and microsurgery including soft tissue reconstruction. ResultsAll free flaps survived, and no partial necrosis was observed. None of the patients developed postoperative deep infection up to the last follow-up. Fracture union was achieved in all patients with or without autologous bone grafts. The median time for union was 9.4 months (range, 4–12 months). ConclusionsThis study presents favorable outcomes of treatment for Gustilo type IIIB open fractures with fracture fixation followed by staged flap coverage (“fix followed by flap” protocol). Despite a delay in flap coverage, the consistency of treatment provided by orthoplastic surgeons may have contributed to the favorable outcomes in this study.

Extremely Rare Complications in Uniportal Spinal Endoscopy: A Systematic Review with Unique Case Analyses.

Background: Endoscopic spine surgery represents a significant advancement in the minimally invasive treatment of spinal disorders, promising reduced surgical invasiveness while aiming to maintain or improve clinical outcomes. This study undertakes a comprehensive review of the literature on endoscopic spine surgery, with a particular focus on cataloging and analyzing the range of complications, from common postoperative issues to more severe, casuistic outcomes like dural tears and nerve damage. Methods: Our methodology encompassed a detailed review of meta-analyses, prospective randomized trials, cohort studies, and case reports to capture a broad spectrum of complications associated with endoscopic spine techniques. The emphasis was on identifying both the frequency and severity of these complications to understand better the procedural risks. Results: The findings suggest that endoscopic spine surgery generally exhibits a lower complication rate compared to traditional surgical approaches. Nonetheless, the identification of specific, rare complications peculiar to endoscopic methods underscores the critical need for surgeons' advanced skills, continuous learning, and awareness of potential risks. Conclusions: Recognizing and preparing for the potential complications associated with the rapid adoption of endoscopic techniques is paramount to ensuring patient safety and improving surgical outcomes in minimally invasive spine surgery.

Successful multidisciplinary treatment for synchronous advanced esophageal and cecal cancers after total gastrectomy with reconstruction by jejunal interposition

BackgroundEsophageal squamous cell carcinoma is characterized by field cancerization, wherein multiple cancers occur in the esophagus, head and neck, and stomach. Synchronous esophageal and colorectal cancers are also encountered with a certain frequency. A good prognosis can be expected if the tumors in both locations can be safely and completely removed. For patients with multiple cancers that occur simultaneously with esophageal cancer, it is necessary to perform a staged operation, taking into consideration the associated surgical invasiveness. It is also necessary to select multidisciplinary treatment depending on the degree of progression of the multiple lesions. We report our rare experience with a staged operation for a patient with synchronous advanced cancers of the esophagus and cecum who had previously undergone total gastrectomy with reconstruction by jejunal interposition for gastric cancer.Case presentationA 71-year-old man with a history of reconstruction by jejunal interposition after total gastrectomy was diagnosed as having multiple synchronous esophageal and cecal cancers. After neoadjuvant chemotherapy, we performed a planned two-stage operation, with esophagectomy and jejunostomy in the first stage and ileocecal resection and jejunal reconstruction with vascular anastomosis in the second. Postoperatively, the patient was relieved without major complications, and both tumors were amenable to curative pathologic resection.ConclusionsOur procedure reported here may be recommended as an option for staged resection and reconstruction in patients with simultaneous advanced esophageal and cecal cancer after total gastrectomy.

The factors impacting on Gleason score upgrading in prostate cancer with initial low Gleason scores

BackgroundThis study aims to investigate the factors contributing to the discrepancy in between biopsy Gleason score (GS) and radical prostatectomy GS in patients diagnosed with prostate cancer. Methods341 patients who underwent radical prostatectomy from 2011/04 to 2020/12 were identified. 102 Patients with initial GS of six after biopsy were enrolled. Preoperative clinical variables and pathological variables were also obtained and assessed. The optimal cut-off points for significant continuous variables were identified by the area under the receiver operating characteristic curve. ResultsUpgrading was observed in 63 patients and non-upgrading in 39 patients. In the multiple variables assessed, smaller prostate volume (PV) (p value = 0.0007), prostate specific antigen density (PSAD) (p value = 0.0055), positive surgical margins (p value = 0.0062) and pathological perineural invasion (p value = 0.0038) were significant predictors of GS upgrading. To further explore preclinical variables, a cut-off value for PV (≤ 38 ml, p value = 0.0017) and PSAD (≥ 0.26 ng/ml2, p value = 0.0013) were identified to be associated with GS upgrading. ConclusionsSmaller PV and elevated PSAD are associated with increased risk of GS upgrading, whereas lead-time bias is not. A cut-off value of PV < 38 ml and PSAD > 0.26 ng/ml2 were further identified to be associated with pathological GS upgrading.

Utilization of Augmented Reality Head-Mounted Display for the Surgical Management of Thoracolumbar Spinal Trauma.

Background and Objectives: Augmented reality head-mounted display (AR-HMD) is a novel technology that provides surgeons with a real-time CT-guided 3-dimensional recapitulation of a patient's spinal anatomy. In this case series, we explore the use of AR-HMD alongside more traditional robotic assistance in surgical spine trauma cases to determine their effect on operative costs and perioperative outcomes. Materials and Methods: We retrospectively reviewed trauma patients who underwent pedicle screw placement surgery guided by AR-HMD or robotic-assisted platforms at an academic tertiary care center between 1 January 2021 and 31 December 2022. Outcome distributions were compared using the Mann-Whitney U test. Results: The AR cohort (n = 9) had a mean age of 66 years, BMI of 29.4 kg/m2, Charlson Comorbidity Index (CCI) of 4.1, and Surgical Invasiveness Index (SII) of 8.8. In total, 77 pedicle screws were placed in this cohort. Intra-operatively, there was a mean blood loss of 378 mL, 0.78 units transfused, 398 min spent in the operating room, and a 20-day LOS. The robotic cohort (n = 13) had a mean age of 56 years, BMI of 27.1 kg/m2, CCI of 3.8, and SII of 14.2. In total, 128 pedicle screws were placed in this cohort. Intra-operatively, there was a mean blood loss of 432 mL, 0.46 units transfused units used, 331 min spent in the operating room, and a 10.4-day LOS. No significant difference was found between the two cohorts in any outcome metrics. Conclusions: Although the need to address urgent spinal conditions poses a significant challenge to the implementation of innovative technologies in spine surgery, this study represents an initial effort to show that AR-HMD can yield comparable outcomes to traditional robotic surgical techniques. Moreover, it highlights the potential for AR-HMD to be readily integrated into Level 1 trauma centers without requiring extensive modifications or adjustments.

Age-related changes in intraoperative mean values of nociceptive response in patients undergoing non-cardiac surgery under general anesthesia: A retrospective cohort study.

Intraoperative nociception is affected by preoperative factors, surgical invasiveness, and anesthesia. Although age-related changes in nociception in conscious humans have been well examined, those in intraoperative nociception in unconscious patients under general anesthesia are unknown. To clarify associations between age and intraoperative nociception under general anesthesia, we performed a retrospective cohort study in consecutive patients of all ages undergoing non-cardiac surgery under general anesthesia from January 2019 to July 2023. The intraoperative nociception value in each surgery was assessed by the averaged value of nociceptive response (mean NR) index during surgery. Patient characteristics, including age, sex, body mass index (BMI), emergent surgery, preoperative serum C-reactive protein (CRP) level, and comorbidities were also collected. After excluding patients with missing data of CRP and mean NR index, 22,061 patients were enrolled, and were divided into low, intermediate, and high surgical risk groups. Multivariable regression analysis showed a significant association between age and mean NR index in all three surgical procedure risk groups. The preoperative variables of CRP levels, BMI, emergent surgery, atrial fibrillation, renal failure, and long-term steroid use also showed significant associations with mean NR index in all three groups. Sensitivity analysis showed that intraoperative mean NR index was higher in younger children than that in both older children and younger adults, and it gradually increased again in older adults to the same level as in younger children. In conclusion, there is likely an association between age and intraoperative mean NR index in patients under general anesthesia.

Trouillas’s Grading and Post-Surgical Tumor Residue Assessment in Pituitary Adenomas: The Importance of the Multidisciplinary Approach

Background: We aim to assess the role of a multidisciplinary approach in pituitary adenomas (PitNETs) classification, evaluate criteria concordance, and compare intraoperative assessments with post-operative MRIs for tumor remnants. Methods: Clinical, radiological, histological, and intra- and post-operative data of the treated PitNETs were extracted from prospectively created records. PitNETs were graded according to Trouillas, and the evaluation of the tumor remnants was recorded. Results: Of 362 PitNETs, 306 underwent surgery, with Trouillas grading assigned to 296. Eight-nine radiologically non-invasive PitNETs progressed to grades 1b (27), 2a (42), or 2b (20) due to proliferative or surgical invasiveness criteria. Twenty-six radiologically invasive tumors were graded 2b due to proliferative criteria. Surgical resection details and post-surgical MRI findings revealed that residual tumors were more common in grades 2a and 2b. During surgery, small tumor remnants were documented in 14 patients which were not visible on post-surgical MRI. Post-surgical MRIs identified remnants in 19 PitNETs not seen during surgery, located in lateral recesses of the sella (4), retrosellar (2), or suprasellar regions (7), along the medial wall of the cavernous sinus (6). Conclusions: The Pituitary Board allows for the correct grading of PitNETs to be obtained and an accurate identification of high-risk patients who should undergo closer surveillance due to tumor remnants.

Fixation of Posterior Malleolus in Trimalleolar Ankle Fractures: Anteroposterior Screw or Posterolateral Plate?

Background: The treatment of the third malleolus has evolved in recent years, and surgical treatment can be carried out with traditional percutaneous osteosynthesis using anteroposterior screws or ORIF with a posterolateral plate. Methods: Our study included 54 patients divided into two groups based on the intervention type (screw or plate). Instrumental assessments comprised pre- and post-operative X-rays and pre-operative CT scans to evaluate joint step-off. The mean follow-up duration was 1 year and 9 months. Results: Radiographic control revealed no loss of reduction or mobilization of the synthesis devices, and all patients achieved fracture healing. Articular step-off &gt; 2 mm was observed in 21 patients (38.9%), including 4 in the plate group and 17 in the screw group, with a statistically significant likelihood of step-off presence in the latter. The mean AOFAS score was 90 points, negatively correlated with age, and lower in patients with joint step-off and a 15° reduction in ROM. Conclusions: The management of posterior malleolus fractures has changed with anatomical studies and an understanding of ankle stability through CT scans. ORIF with a posterior plate is advantageous for anatomical reduction of the tibial plafond but is disadvantageous in terms of surgical invasiveness and technical difficulty.

Pulmonary miRNA expression after polytrauma depends on the surgical invasiveness and displays an anti-inflammatory pattern by the combined inhibition of C5 and CD14.

Respiratory failure can be a severe complication after polytrauma. Extensive systemic inflammation due to surgical interventions, as well as exacerbated post-traumatic immune responses influence the occurrence and progression of respiratory failure. This study investigated the effect of different surgical treatment modalities as well as combined inhibition of the complement component C5 and the toll-like receptor molecule CD14 (C5/CD14 inhibition) on the pulmonary microRNA (miRNA) signature after polytrauma, using a translational porcine polytrauma model. After induction of general anesthesia, animals were subjected to polytrauma, consisting of blunt chest trauma, bilateral femur fractures, hemorrhagic shock, and liver laceration. One sham group (n=6) and three treatment groups were defined; Early Total Care (ETC, n=8), Damage Control Orthopedics (DCO, n=8), and ETC + C5/CD14 inhibition (n=4). Animals were medically and operatively stabilized, and treated in an ICU setting for 72 h. Lung tissue was sampled, miRNAs were isolated, transcribed, and pooled for qPCR array analyses, followed by validation in the individual animal population. Lastly, mRNA target prediction was performed followed by functional enrichment analyses. The miRNA arrays identified six significantly deregulated miRNAs in lung tissue. In the DCO group, miR-129, miR-192, miR-194, miR-382, and miR-503 were significantly upregulated compared to the ETC group. The miRNA expression profiles in the ETC + C5/CD14 inhibition group approximated those of the DCO group. Bioinformatic analysis revealed mRNA targets and signaling pathways related to alveolar edema, pulmonary fibrosis, inflammation response, and leukocytes recruitment. Collectively, the DCO group, as well as the ETC + C5/CD14 inhibition group, revealed more anti-inflammatory and regenerative miRNA expression profiles. This study showed that reduced surgical invasiveness and combining ETC with C5/CD14 inhibition can contribute to the reduction of pulmonary complications.

Advancements in medical research using fetal sheep: Implications for human health and treatment methods.

Sheep are typically considered as industrial animals that provide wool and meals. However, they play a significant role in medical research in addition to their conventional use. Notably, sheep fetuses are resistant to surgical invasions and can endure numerous manipulations, such as needle puncture and cell transplantation, and surgical operations requiring exposure beyond the uterus. Based on these distinguishing characteristics, we established a chimeric sheep model capable of producing human/monkey pluripotent cell-derived blood cells via the fetal liver. Furthermore, sheep have become crucial as human fetal models, acting as platforms for developing and improving techniques for intrauterine surgery to address congenital disorders and clarifying the complex pharmacokinetic interactions between mothers and their fetuses. This study emphasizes the significant contributions of fetal sheep to advancing human disease understanding and treatment strategies, highlighting their unique characteristics that are not present in other animals.

Current Issues in Reduced-Port Gastrectomy: A Comprehensive Review.

Reduced-port gastrectomy (RPG) includes all procedures derived from various efforts to minimize surgical invasiveness, with single-incision laparoscopic gastrectomy (SILG) being the ultimate reduced-port technique. However, there are challenges related to its feasibility, oncological validity, training, and education. This review describes the current issues and challenges, as well as the future prospects of RPG for gastric cancer. Gastrectomy, which started as an open surgery, has evolved into a laparoscopic surgery. With the advancements in laparoscopic technology, SILG has been used to minimize surgical scarring. However, owing to the technical difficulties of SILG, cases involving the addition of 1 trocar or needle grasper alongside the multichannel port have also been reported. Additionally, 3-port laparoscopic gastrectomy (3PLG) using only 3 trocars is also being performed. RPG, as a concept, includes a range of approaches such as SILG, 2-port laparoscopic gastrectomy, and 3PLG. These techniques aimed to reduce the number of ports or incisions required for laparoscopic gastrectomy. Despite technical difficulties, RPGs offer numerous advantages, including minimal invasiveness, excellent cosmetic outcomes, and the potential for improved post-operative recovery, such as reduced length of hospital stay and post-operative pain. It could be considered similar to conventional laparoscopic gastrectomy, and may not be oncologically inferior. Ongoing studies, such as the KLASS 12, are required to gain further insights.