Surgical Visualization Research Articles

Multispectral Imaging for Automated Tissue Identification of Normal Human Surgical Specimens.

Safe surgery requires the accurate discrimination of tissue intraoperatively. We assess the feasibility of using multispectral imaging and deep learning to enhance surgical vision by automated identification of normal human head and neck tissues. Construction and feasibility testing of novel multispectral imaging system for surgery. Academic university hospital. Multispectral images of fresh-preserved human cadaveric tissues were captured with our adapted digital operating microscope. Eleven tissue types were sampled, each sequentially exposed to 6 lighting conditions. Two convolutional neural network machine learning models were developed to classify tissues based on multispectral and white-light color images (ARRInet-M and ARRInet-W, respectively). Blinded otolaryngology residents were asked to identify tissue specimens from white-light color images, and their performance was compared with that of the ARRInet models. A novel multispectral imaging system was developed with minimal adaptation to an existing digital operating microscope. With 81.8% accuracy in tissue identification of full-size images, the multispectral ARRInet-M classifier outperformed the white-light-only ARRInet-W model (45.5%) and surgical residents (69.7%). Challenges with discrimination occurred with parotid vs fat and blood vessels vs nerve. A deep learning model using multispectral imaging outperformed a similar model and surgical residents using traditional white-light imaging at the task of classifying normal human head and neck tissue ex vivo. These results suggest that multispectral imaging can enhance surgical vision and augment surgeons' ability to identify tissues during a procedure.

Clinical Evaluation of a Novel Preloaded Intraocular Lens Delivery System During Routine Cataract Surgery.

PurposeTo evaluate the clinical handleability and acceptability of a novel preloaded intraocular lens (IOL) delivery system for implantation of the TECNIS ZCB00 IOL (Johnson & Johnson Surgical Vision, Inc., Santa Ana, CA, USA) during routine small-incision cataract surgery.Subjects and MethodsIn this prospective, open-label, noncomparative, unilateral or bilateral, multicenter study, adult subjects with unilateral or bilateral cataracts scheduled for IOL implantation were enrolled. Surgeons and surgical technicians completed per-eye day-of-surgery and end-of-surgical-day questionnaires. The primary endpoint of the study was the rate of acceptable overall clinical performance of the preloaded IOL delivery system. Other endpoints included additional responses from the questionnaires, preimplantation incision size, and safety.ResultsThe study included 91 eyes that underwent cataract surgery and IOL implantation using the preloaded delivery system and were available for the 1-day postoperative visit. Five surgeons and 14 surgical technicians from four investigational sites participated in the study. The rate of acceptable overall clinical performance was 100% (91/91) of eyes, with most responses (78/91; 85.7%) being the highest possible rating of 5 (very satisfied). Favorable responses by most surgeons and surgical technicians regarding additional endpoints further highlighted the handleability and acceptability of the preloaded delivery system. No ocular adverse events or lens findings (ie, no cases of IOL instability, haptic breakage, IOL marking, or crimping) were reported.ConclusionThe results of this study demonstrated that this preloaded IOL delivery system was safe and effective during routine small-incision cataract surgery.Trial RegistrationGerman Clinical Trials Register identifier, DRKS00014757.

Use of Transthoracic Echocardiogram to Detect Left Ventricular Thrombi

The presence of a left ventricular thrombus (LVT) poses a risk of thromboembolic complications and excludes patients from undergoing left ventricular assist device (LVAD) implantation without the aid of cardiopulmonary bypass (CPB). Transthoracic echocardiography (TTE) and transesophageal echocardiography are used to detect LVT in patients with heart disease; however, the detection validity of these imaging studies has not been definitively elucidated. A retrospective analysis of patients with end-stage heart failure who underwent LVAD implantation from May 2012 to August 2018 in a single center was completed. To be included, patients' medical records had to have presurgical TTE and transesophageal echocardiographic images, as well as intraoperative digital and visual exploration observations. A total of 301 patients underwent LVAD implantation; 239 of these patients had an LVAD implanted with the use of CPB. A total of 230 patients had complete data sets and were included in the analysis. Preoperative TTE identified LVT in 23 of the 230 patients (10%); 15 patients (6.5%) had LVT confirmed by surgical intraventricular visualization. Of the patients with visual LVT confirmation, preoperative TTE identified an LVT in all but 1 case (93%; 14 of 15). Preoperative TTE of LVT had a high sensitivity (94%) and specificity (96%), as well as high negative predictive value (99%). The results of this study show that preoperative TTE is highly accurate for LVT detection. The high negative predictive value could have significant implications for the choice of surgical procedure because with TTE, surgeons can reasonably determine whether LVAD placement procedure can be attempted without CPB support.

History of endoscopic and keyhole spinal surgery

Development of endoscopic and keyhole surgery is often considered among the greatest scientific advancements in medicine alongside other scientific breakthroughs such as the discovery of antibiotics and the deciphering of DNA structure. The earliest concept of laparoscopy or endoscopy dates back to the use of instruments to visualize various body orifices as recorded in the notes of Hippocrates dating between 460 and 375 B.C. Adequate exposure of the surgical field which is key to safe surgical procedures required large incisions to identify the anatomical structures in the traditional open surgical approaches, and in an attempt to reduce the iatrogenic tissue trauma, smaller corridors were developed to utilize the technological advancements in magnification and illumination, and more recently navigation. As expected, perioperative morbidity is directly proportional to the extent of tissue trauma and surgical dissection, and the shift toward minimizing tissue dissection and prolonged retraction has been generally associated with earlier mobilization, reduced bleeding, and generally reduced morbidity in comparison to traditional open techniques. The advances in surgical technology, particularly in the light source and smaller cameras allowed the use of smaller incisions and adoption of minimal access surgery in the various surgical disciplines, laparoscopic cholecystectomy evolved as a cultural changing procedure and highlighted the focus on minimizing the surgical morbidity experienced by the patient. In spinal surgery, the evolution of surgical loupes, operating microscope, fiber optic light source, and minimal access surgical tools and retractors, allowed for improved surgical field visualization, resulting in smaller incisions and approaches. The initial adoption started with Lumbar discectomy and spinal stenosis decompression and evolved in other aspects of percutaneous fixation and minimal access fusion techniques applicable to trauma, degenerative disease, and tumors. This brief outline of the development of endoscopic and microscopic keyhole techniques in spinal surgery attempts to touch upon the major developments that paved the way for the large plethora of keyhole spinal surgical techniques currently available from the authors’ perspective.

Diferencias en la visión intermedia: lente intraocular monofocal vs. lente intraocular monofocal de rango extendido

PurposeThe purpose of this study was to analyse whether an extended depth of focus (EDOF) monofocal intraocular lens (IOL) (TECNIS Eyhance™, Johnson&Johnson Surgical Vision, Inc., Santa Ana, CA) provides better intermediate visual acuity (VA) than another monofocal IOL (TECNIS 1-piece™, Johnson&Johnson Surgical Vision, Inc., Santa Ana, CA) from the same platform. MethodsRandomised prospective observational study. Patients who required cataract surgery in both eyes were included. Patients in one group were implanted with Tecnis 1-piece IOL and those in the other group with Eyhance EDOF monofocal IOL. One month after surgery in the second eye, we assessed the corrected intermediate VA (66 cm) and obtained defocus curves. We also explored the correlation of: high-order and spherical aberrations with intermediate VA, pupil size with intermediate VA and age with intermediate VA. ResultsWe analysed 30 patients (60 eyes), 15 patients in the TECNIS 1-piece group and 15 in the Eyhance group.Both groups achieved a far VA of 0.00 logMAR. In contrast, for intermediate vision, VA was better with the Eyhance EDOF monofocal IOLs (0.16 ± 0.12 LogMAR), the difference being statistically significant (p < 0.001). In addition, binocular intermediate VA was found to be significantly correlated with corneal (6 mm) RMS high-order aberrations (ρ 0.476) and Z40 (ρ 0.483) with the Eyhance IOL. ConclusionsThe new EDOF monofocal IOL (Eyhance) offers sufficient depth of focus to provide patients with comfortable vision without impairing far vision.

Evaluating the didactic value of 3D visualization in otosurgery

IntroductionImprovements of surgical visualization add value to the quality of clinical routine and offer the opportunity to improve surgical education of medical staff. The aim of this study was to determine whether otorhinolaryngology trainees gain additional comprehension of the anatomical structures and the surgical site when 3D visualization is used.MethodsData were collected from ENT trainees of microsurgical courses of the middle ear, inner ear and lateral skull base at four university ENT departments (Charité (Berlin), Martin Luther University Halle-Wittenberg (Halle/Saale), Ludwig Maximilian University (Munich) and Rostock University Medical Center). Participants were asked to complete a questionnaire assessing the subjective value of identical surgical field visualization in 3D for surgeon and observer.ResultsA total of 112 participants completed the questionnaire. The majority of participants stated a high additional value of 3D visualization compared to 2D visualization, with 75% fully agreeing to the statement that 3D visualization of the surgical field is superior to perceive the anatomical topography and structures compared to 2D representation. Participants encouraged the storage of data in online learning platforms.ConclusionThe results show that 3D visualization with identical imaging for surgeon and observer is a useful tool in teaching of microsurgery. It addresses perception of anatomical topography and structures as well as conception of the surgical workflow.

Types of refractive errors and methods for their diagnosis

Refraction of the eye means its ability to bend (refract) light in its own optical system. In a normal state, which is called emmetropia, light rays passing through the optical system of the eye focus on the retina, from where the impulse is transmitted to the visual cortex of the brain and is analyzed there. A person sees equally well both in the distance and near in this situation. However, very often, refractive errors develop as a result of various types of influences. Myopia, or short-sightedness, occurs when the light rays are focused in front of the retina as a result of passing through the optical system of the eye. In this case, a person will clearly distinguish close objects and have difficulties in seeing distant objects. On the opposite side is development of farsightedness (hypermetropia), in which the focusing of light rays occurs behind the retina — such a person sees distant objects clearly, but outlines of closer objects are out of focus. Near vision impairment in old age is a natural process called presbyopia, it develops due to the lens thickening. Both myopia and hypermetropia can have different degrees of severity. The variant, when different refractive errors are observed in different eyes, is called anisometropia. In the same case, if different types of refraction are observed in the same eye, it is astigmatism, and most often it is a congenital pathology. Almost all of the above mentioned refractive errors require correction with spectacles or use of contact lenses. Recently, people are increasingly resorting to the methods of surgical vision correction.

Negative-Pressure Ureteroscopic Holmium-YAG Laser Lithotripsy for Ureteral Stones

Objectives: The aim of this study was to describe a novel negative-pressure laser lithotripsy device to overcome the deficiencies of the conventional procedure. Patients and Methods: Between August 2018 and March 2019, 78 patients with a single ureteral stone underwent retrograde ureteroscopy with a Wolf 8F/9.8F rigid ureteroscope and a 200-μm holmium-YAG laser. The mean stone size was 11.8 mm, measured for the maximum length. The negative-pressure laser lithotripsy device consists of an F5 ureter catheter and a T joint. The closed tip of an F5 ureter catheter is cut off, and it is then inserted within one opening of the T joint. The 200-μm laser fiber is introduced into the ureteral catheter through the other opening of the T joint. The third opening of the T joint is connected to the negative-pressure pipe. The valve end of the Foley catheter is used for sealing the cap. Continuous suction and active irrigation throughout the lithotripsy could maintain adequate visibility. Results: All ureteroscopic procedures were successful. The negative-pressure device showed good stone retention capabilities, with no observed stone migration. We did not observe any major complications. The stone-free rate was 97.44% (76/78), demonstrated on plain radiography of the kidney-ureter-bladder on the first postoperative day. The stone-free rate after 1 month was 100%. Conclusions: The negative-pressure ureteroscopic lithotripsy is easy and safe management for the ureteral stones. It might reduce the risk of stone fragment retropulsion, improve surgical vision, shorten the operative time, and decrease the renal pelvic pressure.

Near Infrared Fluorescent Nanoplatform for Targeted Intraoperative Resection and Chemotherapeutic Treatment of Glioblastoma

Despite significant efforts to improve glioblastoma multiforme (GBM) treatment, GBM remains one of the most lethal cancers. Effective GBM treatments require sensitive intraoperative tumor visualization and effective postoperative chemotherapeutic delivery. Unfortunately, the diffusive and infiltrating nature of GBM limits the detection of GBM tumors, and current intraoperative visualization methods limit complete tumor resection. In addition, although chemotherapy is often used to eliminate any cancerous tissue remaining after surgery, most chemotherapeutic drugs do not effectively cross the brain-blood barrier (BBB) or enter GBM tumors. As a result, GBM has limited treatment options with high recurrence rates, and methods that improve its complete visualization during surgery and treatment are needed. Herein, we report a fluorescent nanoparticle platform for the near-infrared fluorescence (NIRF)-based tumor boundary visualization and image-guided drug delivery into GBM tumors. Our nanoplatform is based on ferumoxytol (FMX), an FDA-approved magnetic resonance imaging-sensitive superparamagnetic iron oxide nanoparticle, which is conjugated with hepthamethine cyanine (HMC), a NIRF ligand that specifically targets the organic anion transporter polypeptides that are overexpressed in GBM. We have shown that HMC-FMX nanoparticles cross the BBB and selectively accumulate in the tumor using orthotopic GBM mouse models, enabling NIRF-based visualization of infiltrating tumor tissue. In addition, HMC-FMX can encapsulate chemotherapeutic drugs, such as paclitaxel or cisplatin, and deliver these agents into GBM tumors, reducing tumor size and increasing survival. Taken together, these observations indicate that HMC-FMX is a promising nanoprobe for GBM surgical visualization and drug delivery.

Mobilization of the Vertebral Artery-Surgical Option for C2 Screw Fixation in Cases With "High Riding" Vertebral Artery.

Mobilization of intraosseous course of vertebral artery for safe screw insertion into pedicle of axis in cases with high riding vertebral artery is discussed. To show drilling, exposure, and mobilization of the "high-riding" vertebral artery loop during its course in relationship with superior facet/pedicle of C2 vertebra can provide safety to techniques of atlantoaxial fixation that involve insertion of screws in the pars/pedicle/facet of C2. During the period June 2016 to April 2018, 15 patients operated for atlantoaxial stabilization underwent vertebral artery exposure and mobilization using the technique discussed. The ages of the patients ranged from 6 to 48 yrs. Four patients had mobile and reducible atlantoaxial dislocation. Seven patients had basilar invagination. Four patients had os-odontoideum. Gentle and precise drilling of bone that covers the "high-riding" vertebral artery can lead to its safe and wide surgical exposure. The arterial loop can then be either completely or partially mobilized out of the vertebral artery groove such that C2 screw insertion can be conducted under direct surgical visualization of the vertebral artery. During the average follow-up period of 14 mo, there have been no complications related to the surgical procedure, metal implant, or vertebral artery. Vertebral artery exposure and mobilization is rather simple and safe procedure and is remarkably effective in providing a space for C2 screw implantation.

Obesity does not alter endometrial gene expression in women with endometriosis.

Does obesity affect endometrial gene expression in women with endometriosis, specifically women with stage I disease? Differential gene expression analysis was conducted on endometrium from women with and without endometriosis (n = 169). Women were diagnosed after surgical visualization and staged according to the revised American Society for Reproductive Medicine (stage I-IV). Women were grouped by body mass index (BMI) (kg/m2) as underweight, normal, pre-obese or obese. After accounting for menstrual cycle stage, endometrial gene expression was analysed by BMI (continuous and grouped) in women with endometriosis, and in non-endometriosis controls. No significant interaction effect was found between BMI and endometriosis status on endometrial gene expression. We have previously reported that obese women with endometriosis have a reduced incidence of stage I disease; however, stratifying our analysis into stage I endometriosis versus combined II, III and IV endometriosis failed to reveal any differentially expressed endometrial genes between normal, pre-obese and obese patients. Despite obesity having deleterious effects on endometrial gene expression in other gynaecological pathologies, e.g. endometrial cancer and polycystic ovary syndrome, our results do not support an association between BMI and altered endometrial gene expression in women with or without endometriosis.

Video Standards for Rhinoplasty Education: A Review and Recommended Guidelines.

Importance: Intraoperative videography is widely used to record rhinoplasty procedures, yet little is known about the optimal surgical vantage points at critical procedural steps. Objective: To assess commonly used camera angles in public and proprietary intraoperative rhinoplasty videos and discuss approaches to obtaining these viewing angles. Design: Public and propriety rhinoplasty videos were reviewed and categorized based on procedure type, specific area(s) of focus, and camera angles utilized at a series of critical operative steps. The most commonly used camera angles were recorded and assessed based on surgical field visualization and the authors' personal recording experiences. Results: Of the 114 videos that met inclusion criteria, 49 were full-length open rhinoplasty procedures, 20 full-length endonasal rhinoplasty procedures, 17 tip techniques, 8 opening techniques, 7 fashioning grafts, 7 osteotomies, and 6 cartilage harvests. With respective to footage acquisition, the upward camera angle was most frequently used for recording, and endoscopic view was least frequently used. Conclusions and Relevance: These findings demonstrate that there is extensive variability in camera angles between surgical films. Moreover, many of these camera angles are insufficient due to obstruction by surgical staff, inability to visualize deep structures, and difficulty capturing the three-dimensional nasal framework. A guide indicating the best viewing angles for different aspects of the procedure would be useful to optimize educational videos.

Impact of 4K ultra-high-definition endoscope in pituitary surgery: analysis of a comparative institutional case series.

Trans-sphenoidal endoscopic surgery has drawn huge benefits from advances in surgical visualization. The Ultra-HD "4K" endoscope has improved 4-fold image resolution compared with HD, but its actual advantages are unclear. Aim of the present study was to assess its usefulness in the early outcome of trans-sphenoidal surgery. We analyzed a series of 199 trans-sphenoidal pituitary adenoma procedures performed by an experienced team using alternatively HD (N.=102) or 4K (N.=97) endoscopes. We evaluated extent of resection both subjectively, based on intraoperative surgeon's impression, and objectively based on postoperative MR scan. Baseline patients' characteristics were balanced. Objective near-total and total resection rates were comparable between 4K and HD groups (91.5% vs. 86.3% and 64.9% vs. 56.9%, respectively). 4K endoscope slightly improved resection rate in recurrent adenoma. At multivariate analysis, the only independent prognosticator of total resection was cavernous sinus invasion. Importantly, 4K endoscope enhanced the reliability of intraoperative judgement on extent of resection, significantly reducing unexpected residuals (12.8% vs. 33.3% for HD). Operative features and clinical outcomes were similar. The HD endoscope remains the standard-of-care for pituitary surgery. The 4K enhanced, "immersive" visualization significantly improved the reliability of surgeon's judgment on resection and might be useful in surgically difficult cases.

Use of an Iris Speculum for Retrolental Membrane Dissection for Stage 5 Prematurity of Retinopathy Complicated With Pupillary Adhesion.

To report a novel use of an iris speculum to assist with membrane dissection and trough separation for stage 5 retinopathy of prematurity-related funnel-shaped tractional retinal detachment complicated with pupillary adhesion. Limbus-based closed vitrectomy and membrane dissection were performed in 10 eyes (9 patients) with stage 5 retinopathy of prematurity-related tractional retinal detachment and pupillary adhesion. After synechiolysis, an iris speculum was positioned to enlarge the pupil for surgical visualization and maintain a neutral iris plane. The retrolental membrane was dissected bimanually and circumferentially along the peripheral trough and then toward the central retina with vertical scissors and end-gripping forceps. In all 10 eyes, retrolental membranes were entirely removed and troughs were circumferentially unraveled. Follow-up examinations performed 6 to 18 months postoperatively showed reattachment of the retina in 3 eyes with an open-narrow funnel and 6 of 7 eyes with a narrow-narrow funnel. A near-circular pupil without recurrent pupillary adhesion was preserved in all nine eyes showing retinal reattachment. This use of the iris speculum effectively exposes the surgical field for the entire removal of retrolental tissue and interruption of the peripheral trough in stage 5 retinopathy of prematurity-related tractional retinal detachment complicated with pupillary adhesion. The pupil's configuration is well preserved postoperatively.

COMBINED REGIONAL NASAL BLOCK AND GENERAL ANESTHESIA VERSUS GENERAL ANESTHESIA WITH INDUCED HYPOTENSION TECHNIQUE DURING ENDOSCOPIC SINUS SURGERY

Background: Since the early development of functional endoscopic sinus surgery (FESS) in the 1970s, this technique has gained increasing popularity. Objective: To compare the efficacy of combined regional nasal anesthesia and general anesthesia -in a group of patients undergoing FESS versus the efficacy of general anesthesia. Patients and Methods: A double blinded study was carried out, in Al-Azhar University Hospitals on 40 adult patients undergoing endoscopic sinus surgery, Physical status (ASA I&II), after approval of the ethical committee of Al-Azhar University. Written consent was obtained from all patients. Every patient received an explanation to the purpose of the study and given a code number. The SPSS program was used for data handling. Results: After analysis of the data, the results have shown that the regional anesthesia in Group B could achieve better surgical fields, less blood loss, a stable hemodynamic profile with no need for the use of risky multimodal drugs, less anesthesia time, and better postoperative analgesia. Conclusion: Regional anesthesia of the nose after induction of general anesthesia in patients undergoing FESS is an effective method that can provide better surgical field visualization with fewer bleeding, more stable hemodynamic profile without the use of multimodal drugs, less anesthesia time, and better postoperative analgesia when compared to the induced hypotension technique.

COMBINED REGIONAL NASAL BLOCK AND GENERAL ANESTHESIA VERSUS GENERAL ANESTHESIA WITH INDUCED HYPOTENSION TECHNIQUE DURING ENDOSCOPIC SINUS SURGERY

Background: Since the early development of functional endoscopic sinus surgery (FESS) in the 1970s, this technique has gained increasing popularity. Objective: To compare the efficacy of combined regional nasal anesthesia and general anesthesia -in a group of patients undergoing FESS versus the efficacy of general anesthesia. Patients and Methods: A double blinded study was carried out, in Al-Azhar University Hospitals on 40 adult patients undergoing endoscopic sinus surgery, Physical status (ASA I&II), after approval of the ethical committee of Al-Azhar University. Written consent was obtained from all patients. Every patient received an explanation to the purpose of the study and given a code number. The SPSS program was used for data handling. Results: After analysis of the data, the results have shown that the regional anesthesia in Group B could achieve better surgical fields, less blood loss, a stable hemodynamic profile with no need for the use of risky multimodal drugs, less anesthesia time, and better postoperative analgesia. Conclusion: Regional anesthesia of the nose after induction of general anesthesia in patients undergoing FESS is an effective method that can provide better surgical field visualization with fewer bleeding, more stable hemodynamic profile without the use of multimodal drugs, less anesthesia time, and better postoperative analgesia when compared to the induced hypotension technique.

Anatomical Assessment of the Endoscopic Assisted Lateral Supraorbital Approach and Endoscopic Endonasal Transclival Approach to Basilar Apex Aneurysms.

To assess the feasibility of using an endoscopic-assisted lateral supraorbital (LSO) approach and an endoscopic endonasal transclival approach (EETA) for basilar apex (BAX) aneurysms. Ten cases with LSO approaches, with or without posterior clinoidectomy and endoscopic assistance, and 10 cases with EETA, with or without drilling of the dorsum sellae, were performed on 20 cadaveric heads. Anatomical exposure and surgical freedom at the BAX were evaluated. Anatomical exposure provided by the LSO approach was limited to the BAX and ipsilateral posterior cerebral artery (PCA) and increased with a mean value of 5.0 mm after posterior clinoidectomy; the basilar artery, contralateral PCA, and superior cerebellar arteries (SCAs) were visualized in all cases. Accordingly, surgical freedom was larger. Endoscopic assistance provided a significant increase in basilar artery exposure; however, surgical freedom did not increase markedly. The main advantage of EETA was the greatest exposure of the basilar artery. With drilling of the dorsum sellae, anatomical exposure increased by a mean value of 3.4 mm, and provided the greatest amount of surgical freedom and visualization of the basilar artery terminal bifurcation and of the SCAs in all cases. The endoscopic-assisted LSO approach and the EETA may represent a feasible approach for treatment of BAX aneurysms lying within 5.0 mm below and within 3.4 mm above the dorsum sellae.

Effects of tourniquet application on enhanced recovery after surgery (ERAS) and ischemia-reperfusion post-total knee arthroplasty: Full- versus second half-course application.

Pneumatic tourniquets are used in total knee arthroplasty (TKA) for surgical field visualization and improved cementation; however, their use is controversial. This study aimed to assess the effects of tourniquet application on enhanced recovery post-TKA. A prospective randomized single-blinded trial assessed tourniquet's effects on postoperative pain, swelling, and early outcome in TKA. One-hundred and two patients with knee osteoarthritis were randomized to full-course (FC) and second half-course (SHC) application (n = 51/group). Tumor necrosis factor-alpha (TNF-α), C-C motif chemokine ligand 2(CCL-2), pentraxin-3 (PTX-3), prostaglandin E-2 (PGE-2), superoxide dismutase-1 (SOD-1), and myoglobin (Mb) were assessed by enzyme-linked immunosorbent assay, while the visual analog scale (VAS), range of motion (ROM), and thigh circumference growth rate were recorded. Average tourniquet duration significantly differed between the SHC (37.5 ± 5.1 min) and FC (66.4 ± 7.2 min) groups (p < 0.01); VAS and thigh circumference growth rate in the SHC group were much lower compared with the FC group, while ROM was higher within 48 h of tourniquet removal (p < 0.01). Blood TNF-α, PTX3, CCL2, PGE2, SOD-1, and Mb were lower in the SHC group than the FC group (p < 0.01). Additionally, intraoperative blood loss was significantly elevated in the SHC group than the FC group (p < 0.01), with lower postoperative blood loss in the drain (p = 0.001). Postoperative drainage volume was reduced in the SHC group compared with the FC group (p < 0.01); five and two patients in the FC and SHC groups required blood transfusion, respectively (p = 0.025). Hospital stay tended to be shorter in the SHC group (p = 0.023), and no tourniquet-related complications were recorded. Improved therapeutic outcome was observed in the SHC group, indicating patients should routinely undergo TKA with SHC tourniquet application.

Efficacy and prognosis of transforaminal endoscopy in the treatment of lumbar disc herniation in patients infected with human immunodeficiency virus: a nonrandomized, controlled, 2-year follow-up clinical study

Background and objective: Transforaminal endoscopy has certain advantages over traditional surgeries (e.g., intervertebral disc fusion) in the treatment of lumbar disc herniation, as it is associated with minimal trauma, clear surgical vision, and lower degree of bleeding. However, the therapeutic effects of transforaminal endoscopy on lumbar disc herniation in human immunodeficiency virus (HIV)-infected patients are poorly understood. The purposes of this study are to indicate the efficacy of transforaminal endoscopy in the treatment of lumber disc herniation in HIV-infected patients and compare the efficacy between transforaminal endoscopy and conventional lumbar disc fusion based on 2-year follow-up and prognosis turnover. Subjects and Methods: This is a prospective, single-center, non-randomized, controlled, 2-year follow-up clinical study. Sixty HIV-infected patients with lumbar disc herniation who will receive treatment in the Shanghai Public Health Clinical Center will be included in this study. These patients will be divided into two groups according to the surgical treatment. Patients in the experimental group (n = 30) will undergo nucleus pulposus enucleation under an intervertebral foramen endoscope, while patients in the control group (n = 30) will undergo intervertebral disc fusion. All patients will be followed up postoperatively at 6, 12, and 24 months. This study was approved by the Institutional Ethics Committee of Shanghai Public Health Clinical Center of China (approval No. [2020]2020-S122-02) on July 28, 2020. All participants will be informed about the study protocol and will be asked to provide written informed consent. This study was designed on November 30, 2018. Patient recruitment will be performed in the period between October 30, 2020 and April 30, 2021. The study outcomes will be analyzed between May 1, 2023 and May 30, 2023. The study will be terminated on June 30, 2023. The primary outcome measure of this study is the change in the symptom improvement rate evaluated by the Japanese Orthopedic Association score at 24 months after the surgery. The secondary outcome measures include the changes in the symptom improvement rate evaluated by the Japanese Orthopedic Association score at 6 and 12 months after the surgery; pain improvement rate evaluated by the Visual Analogue Scale, and improvement in the quality of life evaluated by 36-Item Short Form Health Survey (SF-36) at 6, 12, and 24 months, as well as the recurrence rate of lumbar disc herniation and the incidence of postoperative adverse reactions at 6, 12, and 24 months after the surgery. Results: In our preliminary study ongoing between January 2016 and January 2018, 86 patients were included and divided into two groups, i.e., the experimental group (n = 48; nucleus pulposus enucleation under intervertebral foramen endoscope) and the control group (n = 38; intervertebral disc fusion). Six-month follow-up results revealed that the mortality of the experimental and control groups was 0 during and 6 months after the surgery, and no deaths occurred due to intervertebral foramen endoscope surgery or postoperative adverse reactions. Six-month follow-up results revealed that the improvement rate of the Japanese Orthopedic Association score and recurrence rate were comparable between the experimental and control groups, and no adverse reactions occurred. However, the improvement rate of the Visual Analogue Scale in the experimental group was higher than that in the control group (P Conclusion: The results of this study can be used to indicate whether transforaminal endoscopy with minimal trauma in the treatment of lumbar disc herniation in HIV-infected patients is associated with better medium- and long-term surgical effects and prognosis as well as turnover than intervertebral disc fusion. The innovation of this study lies in a fact that the subjects are HIV-infected patients with lumbar disc herniation. Trial registration: This study was registered in the Chinese Clinical Trial Registry (registration number: ChiCTR2000037464) on August 28, 2020. Study protocol: 1.0.

Survey of anesthesiologists on anesthetic maintenance techniques and total intravenous anesthesia for endoscopic sinus surgery.

Inhalational anesthesia and total intravenous anesthesia (TIVA) are techniques used for maintenance of general anesthesia for endoscopic sinus surgery (ESS). Growing evidence exists that TIVA may be associated with decreased bleeding and improved surgical fields, yet data suggest it is used in a minority of sinus surgery cases. The objective of this study was to investigate perceptions and approaches to anesthetic maintenance techniques in ESS among anesthesia providers. A total of 719 anesthesiology residents, faculty, and certified registered nurse anesthetists (CRNAs) at 3 tertiary academic centers in the United States were invited to participate in a survey of considerations and practice patterns for inhalational anesthesia and TIVA for ESS. Responses were received from 200 participants (28%). Sixty-five percent of respondents reported a lack of familiarity with current literature on TIVA for ESS. Many considered factors other than surgical field visualization when choosing a maintenance technique. Most were comfortable with performing TIVA but stated they would participate in additional training. The majority of anesthesiology providers were unaware of the existing literature demonstrating advantage in improved surgical visualization with TIVA. Many used a combination of inhaled and intravenous anesthetics for maintenance. These findings suggest that future opportunities may exist to develop education, training, and practice approaches specific to anesthetic techniques for ESS.