The PROCESS 2020 Guideline: Updating Consensus Preferred Reporting Of CasESeries in Surgery (PROCESS) Guidelines

Comprehensive Surgical Management of Thoracic Schwannomas: A Retrospective Multicenter Study on 98 Lesions

BACKGROUND AND OBJECTIVES

The optimal surgical management of thoracic schwannomas (TSs) remains contentious, with various approaches proposed. Video-assisted thoracoscopic surgery (VATS) and combined VATS with neurosurgical procedures have shown promise, particularly for Eden type IV and III lesions. However, unanimous consent on the most effective surgical intervention and understanding of prognostic factors for tumor recurrence needs to be improved. The aim of this study was to elucidate the optimal surgical approach according to the Eden type and investigate predictive factors for TS recurrence.

METHODS

This retrospective, multicentric, observational study analyzed 98 surgically treated patients with TS from 2011 to 2023, assessing preoperative and 6-month follow-up clinical (recurrences, pain, and myelopathy recovery) and surgical parameters (operative time, intraoperative blood loss, extent of resection). Surgical procedures included thoracic laminectomy or hemilaminectomy for type I, laminectomy or thoracic transpedicular (TPD) approach for type II, laminectomy alone or combined laminectomy with VATS for type III, and VATS or thoracotomy (open thoracotomy [OT]) for type IV. Descriptive and deductive analyses were conducted between and within the 4 cohorts, with multivariate analysis assessing the contribution of predictor variables.

RESULTS

No significant differences were found between hemilaminectomy and laminectomy for all analyzed parameters for type I. Type II lesions treated with TPD exhibited similar outcomes to laminectomy, albeit with longer procedure times. Type III lesions benefited from combined approaches compared with neurosurgical-only approaches. Video-assisted thoracoscopic surgery emerged as more favorable than OT for type IV lesions. Multivariate analysis revealed that patient sex, tumor location, extent of resection, and pathology significantly influenced recurrence rates.

CONCLUSION

For Eden type III TSs, neurosurgical and VATS combined surgery achieved better outcomes than neurosurgery alone; for Eden type IV TSs, VATS achieved better results than OT. For Eden types I and II, hemilaminectomy and bilateral laminectomy and laminectomy and TPD achieved similar outcomes, respectively.

Early Outcomes on Triple-Branch Arch Device With Retrograde Left Common Carotid Branch: A Case Series

INTRODUCTION

Endovascular aortic arch repair using multibranch devices has been applied in patients considered at high risk for open repair. The aim of this case series was to report the early outcomes in patients managed with a new design 3 branch arch custom-made device, including a retrograde left common carotid artery (LCCA) branch.

METHODS

The Preferred Reporting Of CaSe Series in Surgery (PROCESS) guidelines were followed. All consecutive patients undergoing endovascular repair of an aortic arch lesion with a custom-made triple-branch device, including a retrograde LCCA branch (Cook Medical, Bloomington, IN, USA), between October 27, 2022, and February 28, 2023, were included. The presence of an arch aneurysm (degenerative or post-dissection) with diameter ≥55 mm and high risk for a conventional open repair set the indication for treatment. The primary outcomes were technical success and mortality at 30 days. Early morbidity and reinterventions were considered as secondary outcomes.

RESULTS

Eight elective patients (87.5% men, mean age 72.3±27.0 years) were included. Five of them (62.5%) had undergone a previous ascending aorta repair of an acute type A aortic dissection. All patients were asymptomatic, except one, with left recurrent laryngeal nerve compression. The mean maximum aortic diameter was 70.4±21.0 mm. Percutaneous femoral and axillary access was used in all cases except three in which a cut down for right carotid access was performed. Technical success was 100%. Femoral access to the LCCA and implantation of the bridging stent was performed without technical challenges. No death nor cerebrovascular event was recorded during the 30 day follow-up. Five patients (62.5%) presented major complications, 3 related to access needing reintervention and the remaining related to congestive heart failure (CHF), which were managed successfully with medical treatment. Follow-up (range 1-4 month) was uneventful, except for one patient who presented a secondary type Ia endoleak.

CONCLUSIONS

According to our early experience, the presence of a retrograde branch facilitated the revascularization of the LCCA through femoral access, decreasing the risk of cerebrovascular morbidity. Further analyses with longer follow-up are needed to evaluate the safety and efficacy of the device.Clinical ImpactData arising mainly from the retrograde branch for the revascularization of the LSA are encouraging from a variety of devices. The premiminary experience with a triple-branched arch device, with a retrograde branche for the LSA but also for the LCCA, was associated with no 30 day mortality and 100% technical success.The device's design allowed swift catheterization and completion of the LCCA revascularization using femoral access exclusively.

Impact of Tumor Characteristics on Endoscopic Endonasal Approach to Tuberculum Sellae and Planum Sphenoidale Meningiomas: Single Center Experience

BACKGROUND AND OBJECTIVES

The expanded endoscopic endonasal approach (EEA) has emerged as a viable alternative technique for the removal of tuberculum sellae meningioma (TSM) and planum sphenoidale meningioma (PSM), offering early tumor devascularization, wide optic canal decompression, while avoiding brain manipulation. The authors present 13-year experience with retrospective analysis evaluating the impact of tumor characteristics on the outcomes of TSM and PSM resections using the expanded EEA.

METHODS

Patients who underwent expanded EEA for TSMs or PSMs from 2010 to 2022 were analyzed. Patient's demographics, preoperative evaluations, tumor features, previous treatments, surgical outcomes, complications, follow-up, and recurrence rates were reviewed. Meningiomas were classified using the Sekhar-Mortazavi classification.

RESULTS

The study included 52 patients (32 with TSMs and 20 with PSMs). Visual impairment was the most common presenting symptom, occurring in 41 patients (78.8%). Gross-total resection (GTR) was achieved in 42 patients (80.7%), reaching 92% for Sekhar-Mortazavi class I tumors. GTR rates decreased with larger tumor size, optic pathway involvement, and vascular encasement. Fibrous and fibroelastic tumors had lower resection rates. The postoperative cerebrospinal fluid leak rate decreased from 23.3% (2010-2017) to 9% (2018-2022), and 34 patients (79%) experienced visual improvement after surgery.

CONCLUSION

The expanded EEA is a safe and effective technique for the resection of TSM and PSM, facilitating GTR and improving visual outcomes.

Surgical outcomes of isolated coronary artery bypass grafting for acute and chronic coronary artery syndromes: based on Sulaimani cardiac registry

Background

The leading cause of death worldwide is coronary artery disease. Globally, coronary artery bypass grafting is among the most frequently carried out procedures. A number of factors, including but not limited to gender, age, comorbidities, duration of cardiopulmonary bypass time, and surgical urgency, influence the short-term mortality following Coronary Artery Bypass Grafting (CABG).

Patients and methods

220 consecutive CABG patients who underwent surgery between January 2022 and December 2022 were included in a prospective comparative analysis carried out at a single location. Convenience sampling was the approach used to obtain the data.

Results

60.4 ± 9.4 CI (95% 36-81) years was the average age of all patients. Just 32.3% of participants were smokers. In 15.5% of cases, patients had emergent surgery. There was no discernible correlation between the pre-operative and intraoperative composite score and early morbidities. However, emergency surgery had a significant value of (P = 0.018) in relation to hospital mortality. Additionally, there was a strong correlation between in-hospital mortality and the cross-clamp time and CPB (P = 0.000 and 0.05). Our subjects underwent survival analysis using Kaplan-Meier, with a mean follow-up duration of 50.43 ± 12.36 weeks. Eleven deaths were reported in the first year's results.

Conclusion

Survival is significantly impacted by CABG. If at all possible, it is preferable to improve a patient's condition before surgery in order to reduce mortality. The patient's chance of survival is impacted by complications including stroke and extended intubation. In some patients, re-examination should be allowed with a low barrier because the alternative might be fatal.

The Relationship Between Jugular Foramen Schwannoma and Surrounding Membrane Structures and Its Surgical Application

BACKGROUND AND OBJECTIVES

Surgical resection of jugular foramen (JF) schwannomas with minimal neurological complications is challenging because of their difficult-to-access location and complex relationships with surrounding neurovascular structures, even for experienced neurosurgeons. In this article, we elucidate the membranous anatomy of JF schwannomas, with the aim of reducing iatrogenic injury to the lower cranial nerves (LCNs) during surgery.

METHODS

The clinical data of 31 consecutive patients with JF schwannomas were reviewed. The relationship between the tumor and the surrounding membranous structures was observed during dissection. Samples were analyzed using Masson's trichrome and immunofluorescence staining to study the membranous characteristics. Histological-radiographic correlations were also summarized.

RESULTS

In this series, we found that all 3 type B, 2 type C, and 8 type D tumors (according to the Kaye-Pellet grading system) were entirely extradural in location, whereas the 18 type A tumors could be subdural (9 cases) or extradural (9 cases), which frequently could not be predicted preoperatively based on whether the tumor had intraforaminal extension. The dural capsule, when present, could be used as an insulating layer to protect LCNs. With this subcapsular dissection technique, postoperative LCN dysfunction occurred in 10 patients (32.3%), which was usually temporary and mild.

CONCLUSION

The different relationships between the tumor and membranous structures of the JF is related to the distinct point of tumor origin and the complex anatomy of the meningeal dura within the JF. Subcapsular dissection technique is recommended for better preservation of LCNs when the dural capsule is identified.

Assessing the feasibility of near infrared autofluorescence imaging in minimally-invasive video assisted parathyroidectomy and the autofluorescence signature of parathyroid adenomas. A single center surgical case series

BACKGROUND

The role of near-infrared autofluorescence (NIRAF)-imaging in thyroid surgery is well-established. However, its role in hyperparathyroidism surgery is yet to be defined due to the lack of consensus regarding the autofluorescence (AF) pattern of parathyroid adenomas (PAs). Furthermore, its utility in minimally invasive video-assisted parathyroidectomy (MIVAP) has yet to be assessed.

OBJECTIVE

To assess the feasibility of utilizing NIRAF-imaging via the limited-access of MIVAP and whether PAs demonstrate a unique AF signature allowing NIRAF-imaging to serve as an intraoperative diagnostic tool.

METHODS

The clinical records of patients who underwent MIVAP for hyperparathyroidism between February and October 2024 were retrospectively reviewed. The primary endpoint was to assess the feasibility of NIRAF-imaging in MIVAP and whether PAs demonstrate a defining AF pattern. Secondary endpoints included whether certain AF patterns of PAs correlated with specific PA features including cell type, size, and/or location. Furthermore, operative-time and cost implications were assessed.

RESULTS

24 consecutive patients underwent MIVAP for hyperparathyroidism. NIRAF-imaging was feasible via the limited-access with no technical difficulties reported. AF patterns included high-intensity AF in 10 (38.5%), low-intensity AF in 10 (38.5%), and cap AF in 6 (23%). A new AF pattern was also described and referred to as "double cap AF". No significant differences in the patterns of AF were observed (p = 0.2). The pattern of AF did not considerably correlate with the predominant cell type, size or location of the PA. However, mediastinal PAs demonstrated a significantly higher tendency for cap AF. The additional time added to the procedure applying the technology was only a few minutes. However, it conferred a considerable additional cost.

CONCLUSION

In experienced hands, a direct minimal-access did not preclude utilizing NIRAF-imaging. PAs seem to lack a uniform characteristic AF signature implying a limited diagnostic role of NIRAF-imaging in parathyroid surgery apart from confirming normal parathyroid tissue. The study has been registered in ClinicalTrials.gov; registration number: NCT06779760.

Paraquat poisoning: a case series of 15 survivors and narrative review

Background

Paraquat (PQ) poisoning is a grave concern in developing countries due to its wide availability. Acute paraquat poisoning can have both systemic and local manifestations, with mortality rates that can reach as high as 90%; pulmonary complications and multiple organ dysfunction syndromes being major causes. This case series is a unique retrospective observational study of 15 survivors from South India.

Case presentation

The case series consists of 15 cases, with a mean age of 24.6 years (excluding outliers), that were alleged to have taken varying amounts of paraquat dichloride. Patients exhibited a diverse range of symptoms affecting multiple organ systems, with particular emphasis on kidney, liver, and lung function. Treatments included a combination of hemodialysis, targeted drug therapy in the form of N-acetyl cysteine, anti-inflammatory therapy with corticosteriods and symptomatic therapy. The case descriptions also include the details of the amount of paraquat allegedly ingested, the ingestion to hospitalization time, demographics, etc, that further help in determination of prognosis.

Overview

PQ can cause a variety of clinical signs and symptoms, including gastrointestinal, renal, hepatic, and pulmonary problems. Less commonly, it can also affect the neurological and cardiac systems. Treatment is mainly focused on reducing the effective PQ concentration in blood, as no antidote has been named till date. The paper also discusses the various treatments available, drugs and procedures, and their mechanisms. Also prognostic factors like age, amount, ingestion to hospitalization time, etc.

Conclusion

The study underlines the need for defined treatment protocols, prognostic factors, and enforcing restrictions on availability of this deadly poison.

Prediction of MRI in intra-operative findings for spinal meningeal diseases

BACKGROUND

A large variety of spinal meningeal diseases have been described in the literature, and differential diagnosis is often complex, requiring a good knowledge of the different entities and accurate neuroimaging. The purpose of this article was to depict the most relevant diagnostic features on the commonly utilized MRI sequences for the main and most frequent pathologies of the spinal arachnoid and to correlate them with intraoperative findings.

MATERIAL AND METHODS

Five cases harboring each different spinal meningeal diseases were analyzed, illustrated, extensively described, and discussed: arachnoid web, arachnoiditis, idiopathic spinal cord herniation, intradural arachnoid cyst, extradural arachnoid cyst. All the cases were surgically treated in the same institution (Neurological Hospital, Lyon, France). We underlined imaging clues for differential diagnosis to help physicians to elaborate the right diagnosis and guide the surgical management.

RESULTS

MRI was efficient to determine the nature of the arachnoid or/and dural disease as well as to predict precisely the intra-operative findings. Six key-radiological features were selected, helping differential diagnosis: localization (intra/extradural/both), aspect of the spinal cord (compressive effect/displacement/scalpel sign), arachnoid bride, CSF turbulent flow, vertebral scalloping, absence of gadolinium-enhancement.

CONCLUSION

MRI demonstrated excellent correlation with intra-operative findings for all the five spinal meningeal diseases analyzed. Although rare, these pathologies must be recognized by clinicians considering that appropriate treatment most often permit to relieve the symptoms.

Predictive Factors for Converting Endoscopic to Open Carpal Tunnel Release

Introduction: Both open and endoscopic methods of carpal tunnel release are accepted treatments for carpal tunnel syndrome. The objective was to determine the endoscopic to open conversion rate of all carpal tunnel surgeries. We evaluated potential predictive factors for an increased rate of conversion. Methods: The IRB/IRBnet approved (#20210613/1639264) a retrospective chart review of all attempted endoscopic carpal tunnel surgeries performed from July 1, 2012 through June 30, 2021. Charts were reviewed for procedure, age, sex, body mass index (BMI), electromyograph (EMG) reading, wrist arthritis on x-ray, preoperative steroid injections, trainee as surgeon, diabetes, hand dominance, and operated side. Conversion rate was noted. A chi-square test using a P-value of <0.05 was used to determine the statistical significance of the patients' age, sex, BMI, EMG severity, the presence of wrist arthritis, preoperative steroid injections, resident as surgeon, diabetic status, and operated hand dominance as predictive factors for conversion. Results: The plastic surgery service attempted 1053 endoscopic carpal tunnel releases using the Chow dual port technique over a 9-year period. Forty-five cases converted to an open release. Median age (P = 0.54), sex (P = 0.43), median BMI (P = 0.76), EMG severity (P = 0.20), wrist arthritis (P = 1.0), preoperative steroid injections (P = 0.65), resident surgeon (P = 0.53), diabetes (P = 0.50), and operated hand dominance (P = 0.36) were not statistically significant predictive risk factors. Nineteen of 45 converted cases had a future successful contralateral endoscopic release. Conclusion: Our study found a 4.27% endoscopic to open conversion rate. No identifiable risk factors could predict conversion. Prior conversion does not determine a future contralateral conversion.

"Floating Island" Technique: Case Series of a Novel Technique for Surgical Management of Interdigitating Calcified Thoracic Disc Herniations

OBJECTIVE

The objective of this study was to describe the use of a novel approach, the "floating island" technique, to surgically address calcified thoracic disc herniation (cTDH) that interdigitates with adjacent dura and to report clinical and radiographic outcomes of patients.

METHODS

A retrospective case series was conducted by examining the electronic medical records of consecutive patients who underwent thoracic discectomy from August 2017 to December 2022. Of 65 patients treated for thoracic disc herniation, 37 had cTDHs. Five of these 37 patients underwent treatment with the floating island technique, which involves osseous separation, debulking, and ligamentous separation.

RESULTS

The floating island technique was applied using the posterolateral approach in 3 patients and the anterolateral approach in 2 patients. One patient experienced a cerebrospinal fluid leak, which was managed without a lumbar drain. All patients showed radiographic improvement of spinal cord compression postoperatively and were admitted to an intensive care unit for 1 night. Hospital stays ranged from 2 to 6 nights, with 4 patients discharged home and 1 to a rehabilitation facility. Neurological improvement or baseline status was observed in all patients at discharge, with follow-up ranging from 9 to 24 months. Nurick grade improved in all patients by at least 1 point, with no progression of symptoms.

CONCLUSIONS

The floating island technique offers a promising option for the surgical management of interdigitating cTDH, demonstrating excellent immediate radiographic and long-term clinical outcomes. Further studies are needed to validate these findings and determine the technique's generalizability.

Utilising intraoperative hand-held cryoneurolysis for enhanced post-thoracotomy pain control

Post-thoracotomy pain (PTP) is a challenging complication following thoracic surgery, often leading to chronic, debilitating symptoms. However, little is known about the potential of intraoperative cryoneurolysis (IC) as a solution for managing PTP. This retrospective case series reports the application of IC in three patients undergoing thoracic surgery for chest wall tumors. Under direct visualisation of the intercostal nerves, temporary inhibition of nerve signalling was achieved without disrupting the surrounding tissue using a handheld device. All three patients experienced decreased pain and reduced reliance on opioids during the 6 week postoperative period. These outcomes highlight the potential of IC to improve post-thoracotomy pain management.

Technical Considerations for Optimizing Flow in Superficial Temporal Artery to Middle Cerebral Artery Bypass: Case Series

BACKGROUND AND OBJECTIVES

Cerebral bypass can provide flow augmentation for select patients with moyamoya disease (MMD) and steno-occlusive cerebrovascular disease (SOCD). Earlier work has suggested that sacrificing the nondonor branch of the superficial temporal artery (STA) can optimize direct flow, which we assessed in real time.

METHODS

This was a single-institution observational study of consecutive patients undergoing direct STA-middle cerebral artery (MCA) bypass with indirect encephalo-duro-myo-synangiosis for MMD and SOCD over 1 year. Excluding patients with significant STA-intracranial collateralization, the intraoperative effect of nondonor STA branch temporary occlusion on direct STA-MCA bypass flow was assessed using a Charbel flow probe. Patient characteristics and perioperative and postoperative data were reviewed.

RESULTS

Eleven patients (5 MMD, 6 SOCD; mean age 53.5 ± 15.3 years) underwent combined revascularization (4 left, 7 right). The mean donor STA branch flow increased from 4.91 ± 2.79 (baseline) to 16.63 ± 11.92 mL/min after anastomosis (95% CI 1.25-17.50; P = .015), and to 20.94 ± 10.63 mL/min after nondonor STA branch test occlusion (95% CI 1.71-6.90; P = .002). The parietal STA branch was used as the donor in 8 cases (72%). In 9 patients, the nondonor STA branch was sacrificed. Perioperatively, 1 patient experienced transient dysarthria/paresthesias (9.1%); there were no strokes or other major complications. The median hospital stay was 5.0 (IQR 4.0, 7.0) days, with 81% of patients discharged home. Over a mean follow-up of 6.2 ± 3.0 months, no patients had significant wound-healing issues, and the median modified Rankin Scale score improved from 2 (IQR 1.0, 2.5) preoperatively to 0 (IQR 0.0, 0.0) (95% CI 0.11-1.69; P < .015). Six-month angiography (available in 9 patients) demonstrated 100% direct bypass patency and a median direct bypass flow grade of 2.0 (IQR 2.0, 3.0).

CONCLUSION

In patients without STA-intracranial anastomoses, STA-MCA direct bypass flow may be optimized safely by nondonor STA branch sacrifice.

Synchronous management of urethral stricture disease and penile prosthesis implantation: a case series

There is currently limited data to describe managing a urethral stricture identified while attempting penile prosthesis placement. This study reports our management of urethral strictures during penile prosthesis placement and proposes a guideline for this event. A retrospective analysis was performed on patients who underwent penile prosthesis implantation and had incidentally found urethral stricture disease from 2009 to 2023. Cases that proceeded to the placement of penile implant were classified as "completed," while cases that could not proceed were classified as "aborted." Successful management was defined as the absence of complications requiring explantation within 90 days of the procedure. Twenty-four cases were identified. Of these twenty-four patients, eighteen had completed procedures, while six had their procedures aborted. Within 90 days after the procedure, one patient presented with urinary retention. No patients had penile prosthesis infections within 90 days. Of the six "aborted" patients, five had strictures greater than 2 cm in length with urethral lumens between 8-10F. One patient had an obliterated urethra; three patients underwent urethroplasty; one patient underwent urethral dilation and suprapubic tube placement; and two patients underwent a direct vision internal urethrotomy. This retrospective study surrounding synchronous penile prosthesis implantation and urethral stricture disease management yielded high success and low complication rates.

Yellow enhance mode is useful for distinguishing tissues in endoscopic transnasal surgery: case series with preliminary results

Precise tissue differentiation is vital in neurosurgery, especially during endoscopic endonasal surgery (ETS), where visual information is critical. The Yellow Enhance (YE) mode, a novel image-enhanced endoscopy technology, emphasizes yellow pigments to potentially improve tissue differentiation. This study retrospectively evaluated the efficacy of YE mode in five cases (two primary pituitary neuroendocrine tumors, one recurrent skull base-invasive pituitary neuroendocrine tumor, one pituitary apoplexy, and one recurrent craniopharyngioma) using the Olympus VISERA ELITE III endoscope. Eight experienced neurosurgeons reviewed surgical videos and provided 40 structured evaluations. Statistical analyses (Kruskal-Wallis and Mann-Whitney U tests) compared scores among cases. Gross or near-total resection was achieved in all cases without neurological complications. YE mode improved differentiation between normal pituitary tissue and tumors in 80% of cases, but was less effective in cases like pituitary apoplexy with degenerative changes. Across 40 evaluations, 68% rated YE mode as "useful" or "somewhat useful," while 20% noted limited utility in complex cases, such as recurrent craniopharyngiomas. YE mode shows promise in enhancing visual differentiation during ETS, particularly for normal pituitary tissue, but its utility depends on tissue characteristics. Larger prospective studies are needed to validate these findings and explore broader applications in neurosurgery.

Long-Term Risk of Adjacent-Segment Disease in Isthmic Spondylolisthesis Treated with Posterior Interbody Fusion

OBJECTIVE

Posterior interbody fusion can be associated with adjacent-segment disease (ASD) some years after surgery. The aim of this study is to confirm the rate of ASD in isthmic spondylolisthesis treated by posterior fusion.

METHODS

The records of patients treated by posterior lumbar fusion between January 2014 and June 2022 were collected. Inclusion criteria encompassed adults diagnosed with isthmic spondylolisthesis and available preoperative, postoperative, and follow-up radiologic images.

RESULTS

Of the 140 patients included in the study, the majority were female (53.6%) with a mean age of 48.5 years. In 111 (79.3%) patients the spondylolisthesis was located at L5-S1; in 20 (14.3%) patients at L4-L5; 5 (3.6%) cases presented the defect at L4-L5-S1, and in 4 (2.8%) cases at L3-L4. In 75 (53.6%) patients, the listhesis was classified as grade I (Meyerding); in 50 (35.7%) cases as grade II; in 12 (8.6%) cases as grade III; and in 3 (2.1%) cases as grade IV. The average follow-up of this study was 67 (10-111) months. Two cases (1.43%, 95% confidence interval 0.17%-5.07%) of ASD were observed. Evaluations of clinical symptoms revealed a notable reduction in the average Numeric Rating Scale score from 8 to 1.9 at the last follow-up. Postoperative pelvic incidence-lumbar lordosis mismatch <10 correlating with a favorable outcome (Numerical Rating Scale ≤3).

CONCLUSIONS

This study confirms data already present in the literature regarding the low incidence of ASD in patients who underwent surgery for isthmic spondylolisthesis. The posterior approach seems to remain a safe and effective technique in these patients.

Incidence of intraoperative morbidities in anterior lumbar interbody fusion (ALIF): a comprehensive study of 5,299 levels

CONTEXT

Anterior Lumbar Interbody Fusion (ALIF) is performed via an abdominal approach to remove the intervertebral disc. Although academic reports suggest low intraoperative complication rates, the available data show significant variability. There is a lack of large-scale, robust studies that consistently evaluate the morbidity rates associated with this procedure.

OBJECTIVE

This study evaluates the operative parameters of this procedure based on a substantial number of cases.

STUDY DESIGN

A retrospective case series.

METHODS

Patient data were retrospectively collected from the database of the Instituto de Acessos à coluna Aécio Dias (IAAD). All patients aged 18 years or older who underwent ALIF surgery were included in the study. Patients who underwent other surgical approaches were excluded. Data on intraoperative morbidity (vascular injuries, injuries to intra- and extraperitoneal organs, dural sac injuries, and nerve root injuries), operative time, and blood loss were collected and analyzed.

RESULTS

A total of 3,438 patients were evaluated. 1,671 (48.6%) were male, and 1,767 (51.4%) were female. The mean age was 47.87 ± 12.10 years, ranging from 18 to 88 years. The reported incidence of complications was as follows: vascular injuries (3.25%), nerve root injuries (0.09%), dural sac injuries (0.06%), and injuries to intra- and extraperitoneal organs (0.03%).

CONCLUSIONS

ALIF surgery demonstrated safety and low morbidity. A multidisciplinary team, including access surgeons, played a pivotal role in reducing vascular complications, optimizing surgical times, and minimizing blood loss, aligning with the standards reported in the literature.

Anterior rotation of the temporalis muscle for prevention of temporal hollowing in cranial surgeries: Esthetic and patient-reported outcomes

Background

Temporal hollowing is a common cosmetic complication following pterional craniotomies. To address this issue, we evaluated the efficacy of anterior rotation of the temporalis muscle at closure. Although this technique is not new and has been generally reported, no research studies have been conducted to evaluate its objective and patient-reported outcomes in the long term.

Methods

We retrospectively reviewed 22 patients treated with pterional, fronto-orbitozygomatic, or frontotemporo-zygomatic craniotomies from March 2021 to 2023. A 12-month postoperative magnetic resonance imaging was used to evaluate the degree of temporal hollowing. To quantify temporal hollowing, we measured the distance of depression at the level of the temporal fossa. This distance, or "temporal thickness," was defined as the widest distance between the skull's outer cortical bone and skin surfaces at the level of the anterior clinoid process (D1) and foramen of Monro (D2). Furthermore, pre and postoperative cosmetic results were evaluated using the Rostock Functional and Cosmetic Cranioplasty (RFCC) Score. For reasons of objectivity, RFCC was tested by two independent plastic surgeons against the patient's rating.

Results

After a year or more follow-up, 54.5% of patients exhibited no hollowing, while 31.8% had mild or moderate hollowing. Moreover, 91% reported good esthetic outcomes. No cases of severe hollowing were observed. Importantly, temporomandibular joint dysfunction was not observed.

Conclusion

These results suggest that anterior rotation of the temporalis muscle is an effective primary strategy to mitigate cosmetic deformities without compromising masticatory function. Further studies with larger sample sizes are warranted to confirm these findings.

Surgical Resection of Vascular Anomalies of the Upper Extremity-An Observational Study

Background/Objectives: This study aimed to investigate surgical resections of vascular malformations and haemangiomas of the upper extremity, pre- and postoperative symptoms, complications and recurrences. Methods: A total of 82 patients with vascular malformations and haemangiomas treated by surgical resection from 2010 to 2020 were included in this observational study. Pre- and postoperative symptoms, including pain and swelling, as well as complications and recurrence rates, were assessed. Descriptive statistics were provided for all reported data. Parametric and non-parametric tests were used for group comparisons. Alterations of reported pain were assessed. A two-sided alpha of 5% determined statistical significance. Results: A total of 88 procedures were performed in 82 patients. The most common vascular malformation was a venous malformation, followed by arterio-venous malformations. More than 50% of the patients reported pain prior to the surgery, while 14.6% of patients experienced pain postoperatively, which indicated significant improvement (p = 0.001). Minor postoperative complications occurred in 31.7% of patients. Overall, a recurrence rate of 17.1% was recorded during postoperative follow-up, mostly occurring in diffuse and infiltrating types of vascular malformations. Conclusions: Surgical resections of vascular anomalies of the upper extremity led to symptom improvement and are an important part of the multidisciplinary treatment algorithm.

Case report: Free autologous costal cartilage transplantation for osteochondral lesions of the talus: three cases with 2-5 years follow-up

Background

Osteochondral lesions of the talus (OLT) is a common and clinically challenging condition with no consensus on the optimal treatment. The prospective case series aim to evaluate the feasibility and clinical outcomes of free autologous costal cartilage transplantation (ACCT) for OLT.

Methods

From April 2018 to October 2022, three patients who were diagnosed with OLT underwent free ACCT. Demographic characteristics, including age, gender, lesion size and location were collected at baseline. Functional and imaging outcomes were evaluated at 1 year, 2 years, and 5 years postoperatively. The primary outcomes were American Orthopedic Foot and Ankle Society (AOFAS) score and Foot and Ankle Ability Measure (FAAM) score. Secondary outcomes included Numeric Rating Scale (NRS), Tegner Activity Scale, and evaluations of images. A paired t-test was used for preoperative and postoperative comparison of the paired-design dataset.

Results

Three patients (37.33 ± 16.50 years old) were included in the study with 2-5 years follow-up. AOFAS score improved from 60 ± 11 at baseline to 96 ± 6.93 at 2 years (p < 0.01) and 94 ± 8.49 at 5 years. FAAM/ADL improved from 60.97 ± 6.58 at baseline to 98 ± 1.83 at 2 years (p < 0.01) and 97 ± 0.85 at 5 years. FAAM/Sports improved from 56.4 ± 11.95 at baseline to 88.23 ± 11.34 at 2 years (p < 0.01) and 89 ± 4.67 at 5 years. Other functional scores in patient reported outcomes also showed significant improvements. Postoperative CT and MRI showed complete defect filling and robust tissue integration after ACCT. Arthroscopic evaluations further confirmed solid integration of costal cartilage into the underlying subchondral bone with a smooth surface over the repair site.

Conclusion

Free ACCT is a feasible method for improving ankle function and quality of life for at least 2 years in patients with OLT. Promising long-term outcomes may be possible because of the good integration between the recipient talus and the implanted ACCT.

Evaluation of adherence to the Preferred Reporting of CasE Series in Surgery (PROCESS) 2020 guideline in case series describing endovascular management of vein of Galen malformation demonstrates suboptimal reporting practices

BACKGROUND

Interventional neuroradiology is a dynamic field with technological advancements constantly driving evolution in clinical practice. Case series provide interventional neuroradiologists the opportunity to describe the clinical implications of novel equipment and techniques almost in real-time, informing broader adoption and directing future research. Complete reporting in case series is vital in enabling readers to detect bias, determine the generalizability of results and replicate study methodology. The aim of this study was to assess the quality of reporting in case series describing endovascular management of vein of Galen malformations.

METHODS

A systematic search for case series describing endovascular management of vein of Galen malformations in paediatric patients was conducted using a previously published search strategy in Medline, Embase and Web of Science in February 2024. Screening and data extraction were performed by two independent reviewers with disagreements resolved by consensus discussion. Quality of reporting was assessed using adherence to the Preferred Reporting of CasE Series in Surgery (PROCESS) 2020 checklist.

RESULTS

We included 19 case series representing a broad range of approaches and endovascular techniques for management of vein of Galen malformations. Overall adherence to the PROCESS 2020 guideline was moderate with a mean of 7.0/13 (54%; range 5.2 - 9.7/13; SD 1.1) items reported. The most consistently reported items related to characteristics of the clinical cohort and details regarding the specific image-guided intervention(s) provided. Items relating to study design, source of funding, pre-intervention patient optimisation, clinical follow-up and potential complications and alternatives for novel techniques/devices were less frequently reported.

CONCLUSIONS

The quality of reporting in case series describing endovascular management of vein of Galen malformation is suboptimal. Measures to improve the quality of reporting in neurointerventional case series include mandating adherence to reporting guidelines in journal instructions for authors and requiring submission of completed copies of relevant reporting guidelines alongside manuscripts.

A novel technique for rapid localization of pulmonary nodules on-site in operating room followed by lung resection: a case series

BACKGROUND

The localization of pulmonary nodules is crucial for surgical intervention. However, a safe, simple, and efficient method remains elusive. This study aims to evaluate the safety and feasibility of a newly developed preoperative localization method for pulmonary nodules called Rapid Localization of Pulmonary Nodules On-Site (RLPN-OS).

METHODS

This study is a single-center, single-arm prospective investigation that collects and analyses the clinical data of patients who underwent RLPN-OS and lung resection, primarily evaluating the safety and feasibility of this technique.

RESULTS

A total of 200 lung nodules from 190 patients who underwent RLPN-OS and partial lobectomy were included in this study. The success rate of localization was 98.0%, and minor intercostal bleeding was observed in 3 (1.5%) cases. All targeted lesions were located and resected successfully. No patients reported experiencing anxiety or pain during or after the procedure.

CONCLUSIONS

This novel RLPN-OS technology represents a safe, feasible, patient-friendly, and cost-effective method for lung nodule localization. It has the potential to serve as an alternative to traditional CT-guided percutaneous localization techniques.

Predictors of Postoperative Segmental and Overall Lumbar Lordosis in Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Consecutive Case Series

STUDY DESIGN

Retrospective Case-Series.

OBJECTIVES

Due to heterogeneity in previous studies, the effect of MI-TLIF on postoperative segmental lordosis (SL) and lumbar lordosis (LL) remains unclear. Therefore, we aim to identify radiographic factors associated with lordosis after surgery in a homogenous series of MI-TLIF patients.

METHODS

A single-center retrospective review identified consecutive patients who underwent single-level MI-TLIF for grade 1 degenerative spondylolisthesis from 2015-2020. All surgeries underwent unilateral facetectomies and a contralateral facet release with expandable interbody cages. PROs included the ODI and NRS-BP for low-back pain. Radiographic measures included SL, disc height, percent spondylolisthesis, cage positioning, LL, PI-LL mismatch, sacral-slope, and pelvic-tilt. Surgeries were considered "lordosing" if the change in postoperative SL was ≥ +4° and "kyphosing" if ≤ -4°. Predictors of change in SL/LL were evaluated using Pearson's correlation and multivariable regression.

RESULTS

A total of 73 patients with an average follow-up of 22.5 (range 12-61) months were included. Patients experienced significant improvements in ODI (29% ± 22% improvement, P < .001) and NRS-BP (3.3 ± 3 point improvement, P < .001). There was a significant increase in mean SL (Δ3.43° ± 4.37°, P < .001) while LL (Δ0.17° ± 6.98°, P > .05) remained stable. Thirty-eight (52%) patients experienced lordosing MI-TLIFs, compared to 4 (5%) kyphosing and 31 (43%) neutral MI-TLIFs. A lower preoperative SL and more anterior cage placement were associated with the greatest improvement in SL (β = -.45° P = .001, β = 15.06° P < .001, respectively).

CONCLUSIONS

In our series, the majority of patients experienced lordosing or neutral MI-TLIFs (n = 69, 95%). Preoperative radiographic alignment and anterior cage placement were significantly associated with target SL following MI-TLIF.

Enhancing root coverage and esthetic outcomes in isolated gingival recession using orthodontic intervention and lateral closed tunnel technique: An interdisciplinary prospective case series

BACKGROUND

Gingival recession (GR) in malposed tooth in association with bone dehiscence and/or fenestration poses a challenge for successful root coverage treatment. Lateral closed tunnel (LCT) technique is particularly useful in isolated GR in mandibular anterior region, where the shallow vestibular depth prevents tension-free coronal mobilization of tissues.

METHODS

Twenty patients with GR associated with tooth malposition were treated using a combined orthodontic-periodontic approach with a torquing auxiliary spring followed by LCT technique.

RESULTS

The two techniques resulted in a combined recession depth reduction from 3.75 ± 1.14 mm to 0.40 ± 0.50 mm at the end of 6-month study period. The orthodontic intervention led to an increase in labial marginal bone levels, as assessed through cone beam computed tomography (CBCT), while the LCT achieved closure of residual recession defect. Also, an increase of keratinized tissue width from 0.81 ± 0.88 mm at baseline to 3.30 ± 0.67 mm at 6 months was achieved. Mean root coverage percentage (MRC%) of 91.40% + 10.25% was seen, with 11 out of 20 sites (55%) showing complete root coverage (CRC).

CONCLUSIONS

Single tooth orthodontic repositioning followed by LCT technique proved effective in successfully managing isolated recession defects in the mandibular anterior gingival region, which often presents challenging mucogingival conditions. The precise single tooth repositioning resulted in labial marginal bone augmentation, while the LCT surgical approach allowed residual defect closure.

KEY POINTS

Why are these cases new information? Correction of single tooth malposition is achieved before recession coverage treatment to achieve a favorable environment for graft uptake. The reduction in denuded root surface along with the bone remodeling results in increasing the ratio of vascular to avascular region, thus improving the overall prognosis of the treatment. What are the keys to successful management of these cases? The lateral closed tunnel technique involves creating a mucoperiosteal tunnel to close the recession site. Precision is crucial to avoid damage to surrounding tissues. The recipient site should be wider than the width of recession to improve graft vascularity. What are the primary limitations to success in these cases? Limitations may arise when dealing with complex cases, such as multiple teeth involvement or teeth with significant vertical or horizontal bone loss.

Maxillary sinus augmentation via the bone lid technique: A prospective, radiographic case series

BACKGROUND

Maxillary sinus augmentation is one of the most performed procedures to increase the bone quantity of the atrophic maxilla to allow implant placement. The aim of the present case series was to describe a surgical protocol to perform maxillary sinus augmentation with the "bone lid technique," and its outcomes in a cohort of patients eligible for the procedure.

METHODS

After the initial clinical evaluation, a cone-beam computed tomography (CBCT) examination was performed for preoperative assessment. Patients were then scheduled for surgical intervention. At 6-9 months follow-up, patients underwent a second CBCT scan to evaluate bone height following bone graft and to schedule implant placement.

RESULTS

A total of 11 patients were enrolled in the study with a total of 13 sinus lift procedures. Membrane perforation was registered in 4 cases (30.76%). Mean surgical time was 67.69 min (SD 6.51). Postoperative period was uneventful in all patients, in the absence of complications. The mean graft volume increase was 2.46 cm3 (SD 0.85), and the mean height increase was 14.27 mm (SD 3.18). Mean membrane thickness was 1.40 mm (SD 0.75). In all the 4 cases with sinus membrane perforation, the membrane had a thickness lower than 1 mm.

CONCLUSIONS

The present study highlights that the maxillary sinus augmentation with bone lid repositioning could provide repeatable results in terms of bone height increase. The technique appears reliable both in terms of bone gain and absence of complications.

KEY POINTS

The bone lid technique for maxillary sinus augmentation provides repeatable results in terms of bone height increase. The favorable clinical outcomes can be related to an enhancement of bone formation due to the unique osteoconductive and osteoinductive properties of autogenous bone, along with a reduction of soft tissue ingrowth. Complications were not observed in any of the patients following the surgical procedures. The risk of Schneiderian membrane perforation is inversely proportional to membrane thickness; the thinner the membrane is, the higher the risk to perforate it.

Minimally Invasive Anterolateral Cervical Cordotomy for Intractable Cancer Pain Using Microtubular Retractors: A Single Institution Case Series

BACKGROUND AND OBJECTIVES

As advancements in cancer treatments have allowed patients with a high burden of disease to live longer, the number of patients who present with debilitating refractory pain has increased. Anterolateral cordotomy has long been used for the treatment of intractable unilateral cancer pain using either an imaging-guided percutaneous approach or an open surgical approach. In this report, we describe a novel minimally invasive modification to the open surgical approach. It combines the benefits of both approaches by providing direct visualization for lesioning without the collateral tissue damage of an open approach.

METHODS

This retrospective study evaluated medical records, operative reports, and imaging studies of patients who underwent a minimally invasive cordotomy at a single institute between 2018 and 2022. The surgical technique involved a microscope-assisted C2 hemilaminectomy using microtubular retractors followed by dural opening and anterolateral cordotomy under direct visualization and with intraoperative neurophysiological monitoring.

RESULTS

Eleven patients were included in the study. None were converted to an open approach, and no wound-related postoperative complications were observed. A clinically significant decrease in pain was observed after the procedure, and 10 of the 11 patients (91%) were ambulatory by the time of analysis.

CONCLUSION

Compared with image-guided percutaneous cordotomy, anterolateral cervical cordotomy with microtubular retractors potentially improves the safety of the procedure through direct visualization while being less invasive than a conventional open approach. Our preliminary experience with this technique demonstrates the feasibility of the approach, as it was both safe and effective.

Cost outcomes of pituitary adenoma resection: The use of a hybrid microscopic/endoscopic surgery

Background

The pathogenesis, surgical techniques, and outcomes of pituitary adenomas (PAs) remain variable. We compared our surgical techniques and perioperative/long-term PA outcomes to highlight the hybrid microscopic/endoscopic technique used to optimize efficiency, cost savings, and outcomes in PA surgery.

Methods

Consecutive PA cases performed from January 2017 through February 2020 were evaluated retrospectively. A cost analysis by surgical approach was performed combining this primarily microscopic series, with endoscopic visual assist, and a separate cohort of consecutive intra-institutional endoscopic-only PA resections.

Results

Among 160 patients included in the main cohort analysis (mean age 51.5 ± 16.2; 89 females [55.6%]), a microscope was used in 81.9% of cases, with endoscopic assistance (hybrid) or the endoscope alone used in the remaining cases. Surgical complications occurred in 5 cases (3.1%): postoperative diabetes insipidus in 3 (1.9%), electrolyte imbalances requiring additional drug treatment in 3 (1.9%), and syndrome of inappropriate anti-diuretic hormone release in 2 (1.2%). Thirty-three additional patients were included in the cost analysis (193 total). Patients treated with a microscopic-only approach had the lowest operating time (mean normalized operating room costs 1.00 [95% confidence interval (CI) 0.95, 1.04], P < 0.001; mean normalized total direct costs 5.00 [95%CI 4.69, 5.31], P = 0.008), with hybrid and endoscopic-only approaches having higher comparable operating times and costs.

Conclusion

PA surgery using a primarily microscopic approach (with endoscopic assistance for complex cases) remains a safe, efficient, and cost-effective strategy and results in shorter anesthesia time to reduce patient complications while maintaining excellent endocrinologic outcomes.

Keywords

Endoscope, Hybrid approach, Microscope, Pituitary adenoma, Transnasal surgery, Transsphenoidal surgery.

Total active range of movement after treatment using a traction orthotic for extra-articular phalangeal fractures: A case series

BACKGROUND

The use of traction orthoses for complex finger fractures is not a common intervention though some research purports its efficacy as an alternative treatment approach to surgery in some scenarios.

PURPOSE

This study examined total active of range of movement (TAROM) outcomes achieved by patients on discharge from hand therapy after being treated using a traction orthotic following an extra-articular displaced proximal or middle phalangeal fracture.

STUDY DESIGN

A retrospective, consecutive longitudinal case series.

METHODS

Data was collected on the time from injury to traction, duration of traction, injury location (hand, digit, phalanx), fracture classification, age, sex, hand dominance, number of therapy sessions (mobilization phase of rehabilitation), duration from injury to discharge from hand therapy and TAROM at discharge. TAROM outcomes are categorized using the criteria recommended by the American Society of Surgery of the Hand. Categorical variables are summarized using frequency and percentages. Continuous data is summarized as mean and standard deviation or median and interquartile range. Any potential correlations between TAROM and time from injury to discharge were analyzed using Pearson's correlation (two-tailed).

RESULTS

Twenty-three patients were referred for traction (14 male: nine female). Three people went on to have surgery and two patients were lost to follow-up. Mean TAROM was 230.9º (SD 22.6º) indicating a good outcome using the American Society of Surgery of the Hand criteria. Mean time from injury to discharge was 65.6 (SD 30.4) days. There was no correlation observed between time from injury to discharge and TAROM on discharge (r = -0.18, p = 0.48).

CONCLUSIONS

Good and excellent TAROM was achieved following treatment using traction orthoses for extra-articular phalangeal fractures though further studies are necessary. Larger sample sizes will allow for more granular analysis of different fracture classifications.

Risk factors and significance of post-operative edema in Parkinson Disease patients submitted to deep brain stimulation. A ten-year case series

BACKGROUND

Peri-electrode edema after deep brain stimulation (DBS) surgery for Parkinson Disease (PD) has been reported in up to 100% of cases. The clinical significance of this finding is unclear, with most papers suggesting a benign course. The risk factors are also poorly defined. We aimed at defining the incidence rate, the clinical significance and the predictive factors of peri-electrode edema in patients undergoing DBS for PD.

METHODS

We reviewed data of 119 patients treated with frameless stereotactic DBS for PD between 2012 and 2022 at our Institution. A mixed-technique targeting was adopted. Awake surgery was used in 64.7% cases; in most cases, microelectrode recording (MER) was adopted. The target was the subthalamic nucleus (STN) in 91.2% cases.

RESULTS

Ninety patients were included. Postoperative edema related to lead placement was noticed in 40% patients after a median time of 2 days since surgery; in 88.9% of these cases, it was limited to subcortical white matter. Symptomatic edema was registered only in one case (1.1%), confirming previous reports on the benign clinical course. The only independent predictive factor for edema onset was asleep surgery (p = 0.0451). Notably, the use of directional electrodes was not associated with an increased risk of edema at multivariable analysis. Clinical parameters including age, and timing of CT scanning, did not affect edema onset.

CONCLUSIONS

We confirmed the very low rate of symptomatic edema in DBS for PD. When feasible, awake DBS using MER is the ideal technique to reduce the risk of radiologic postoperative edema.

Percutaneous and endoscopic transpapillary cholecystoduodenal stenting in acute cholecystitis-A viable long-term option in high-risk patients?

BACKGROUND

The prolonged use of percutaneous cholecystostomy tubes (PCTs) in patients with acute cholecystitis, deemed inoperable, is fraught with complications. Transpapillary cholecystoduodenal stenting (TCDS) is an alternative technique that restores the physiologic outflow of bile, avoiding the need for an external drain. However, the long-term safety and efficacy of this approach remain unclear. We sought to prospectively assess the safety and efficacy of this procedure, performed via percutaneous or endoscopic approach, in high-risk patients presenting with acute cholecystitis.

METHODS

This prospective study included consecutive patients with acute cholecystitis and long-lasting, prohibitive surgical risk, in whom TCDS was offered at two partnering tertiary care centers between August 1, 2018, and December 31, 2022. Patients with a need for endoscopic retrograde cholangiopancreatography (ERCP) underwent ERCP-guided TCDS. In patients without a need for ERCP, a temporary PCT was followed by fluoroscopic-guided TCDS 4 weeks to 6 weeks later. Interval cholecystectomy was performed in patients who became surgical candidates later. All patients were followed up until January 1, 2023.

RESULTS

Transpapillary cholecystoduodenal stenting was successful in 67 (percutaneous in 45/50; endoscopic in 22/23) of 73 patients (92%) attempted. Over a median follow-up period of 17 months (7, 26), 10 patients (15%) developed stent blockage or migration; all but two had their stent successfully replaced. Five patients (7%) developed mild, self-limited pancreatitis. Five (7%) patients underwent interval cholecystectomy at a median time of 7 months.

CONCLUSION

Transpapillary cholecystoduodenal stenting is a safe and promising definitive alternative to chronic PCT in high-risk patients with acute cholecystitis that eliminates the discomfort and complications of long-term external drainage.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level II.

Surgical outcomes from robotic-assisted adrenalectomy: a case series on experience in a large tertiary referral centre

BACKGROUND

Robotic-assisted surgery is gaining wider acceptance in most surgical specialties. However, in the United Kingdom, endocrine surgery has not fully adopted robotics. This paper aims to present the early experience and outcomes of patients who underwent robotic-assisted adrenalectomy at a tertiary referral endocrine surgery department. Outcomes were compared to national and international performance measures.

METHODS

Seventy-two elective robotic adrenalectomies were performed over a 24-month period. Data collected included patient demographics, co-morbidities, indication for surgery and tumour size. Outcomes assessed were console time, conversion rates, complications, length of stay and excision margin.

RESULTS

Seventy-two cases were included for analysis. Sixty-six percent (n = 48) of the patients were female with a median age of 60 years. Median BMI was 28. Functional tumours accounted for 76% (n = 55) of cases with the most common being phaeochromocytomas and cortisol producing adenomas. Median docking time was 5 min with a median intraoperative time on the console of 45.5 min. Tumour size ranged from 1 to 14 cm. Median length of stay postoperatively was 1 day. There was only one conversion to open procedure. Two patients reported post-op superficial surgical site infections and there were no mortalities.

CONCLUSION

This case series demonstrates robotic-assisted adrenalectomies performed in a tertiary care centre were safe and feasible in a selected cohort of patients with functional and non-functional tumours. Large randomised controlled trials with long-term follow-up are required to establish the benefits of robotic adrenal surgery over conventional laparoscopic adrenalectomy.

3D printed customized facemask for early treatment of Class III malocclusion: a two-center case series feasibility study

BACKGROUND

This prospective two-center case series feasibility study aimed to investigate the potential of a novel maxillary protraction facemask customized to the patients' anatomy recorded with 3D face scanning and then produced by digital design and additive manufacturing.

METHODS

Ten subjects (5 females and 5 males, average age 7.7±1.0 years) with Class III malocclusion were treated with a rapid maxillary expander (RME) and a Petit-type facemask (FM), whose components were digitally designed on a 3D scan of the patient's face. Subjects' face scans were obtained either with a tablet or with face scanner. FM components were modelled with a 3D software. The pads were 3D printed in biocompatible resin, and the bar was printed in stainless steel. A questionnaire investigating the patients' experience was filled in after the first week of treatment and after 3, 6, and 9 months.

RESULTS

The customized FM showed an excellent adaptation to the anatomy of the face. No severe complications were reported during the 9 months of appliance wearing. Some reversible episodes of skin irritation were reported below the pads, mainly in the chin area. The reported time wearing ranged between 8.2±2.3 and 9.5±1.2 hours per day, mainly at night. Reported pain was overall low (maximum after 1 week with an average value of 1.9±1.7 on a visual analog scale [VAS] 0-10) and patients' satisfaction was adequate at the end of the facemask wear after 9 months (8.7±1.4 on a VAS 0-10).

CONCLUSIONS

The customized FM was overall well accepted by the patients and represents a valid alternative to conventional ones.

Mad (wild) honey poisoning: a case series of eleven cases

Introduction

Mad (Wild) honey, used as alternative medicine in some countries where cases of poisoning are reported, got its name due to its intoxicating effects. Poisoning due to mad honey mostly presents as bradycardia and hypotension.

Case reports

We report 11 cases involving 6 females and 5 males, of mad honey poisoning used for medicinal purposes. All patients were young adults (average age 43.9 years) except for one. Lightheadedness, dizziness and nausea were the most common complaints. All presented in bradycardia ranging from 35 to 60 beats per minute. All cases were managed conservatively while one required vasopressors support. All patients improved with a couple of days of supportive care.

Discussion

Mad honey poisoning seems to be a geographically restricted entity as the majority of cases are reported from a particular region. Because of its use as an alternative medicine for various purposes, cases of intoxication occur year around. Although the signs and symptoms of mad honey can be life threatening including nausea, dizziness, bradycardia, and hypotension, the prognosis is generally good.

Conclusion

Although the prognosis is fairly good, mad honey intoxication has significant morbidity. Lack of awareness about the potential complications of consuming mad honey seems to be the cause of cases of poisoning seen annually.

Indocyanine Green as a Marker for Tissue Ischemia in Spinal Tumor Resections and Extended Revisions: A Technical Note

Background/Objectives: The increasing complexity of spinal oncology procedures, particularly in en-bloc tumor resections, creates challenges in tissue perfusion assessment due to extended operative times and extensive surgical dissection. Real-time visualization of tissue perfusion can be achieved with ICG using commercially available handheld imaging systems, offering potential advantages in spinal oncology cases. This study assessed the utility of ICG in analyzing soft-tissue viability during complex spine procedures extending beyond 7.5 h, with a particular focus on oncologic resections. Methods: Three cases that required over 7.5 h of operative time were chosen for ICG utilization. These cases included an en-bloc malignant peripheral nerve sheath tumor resection, an en-bloc resection of a malignant epithelioid neoplasm, and a long-segment fusion revision for pseudoarthrosis. At the conclusion of the critical portion of the procedure, a handheld intraoperative fluorescence camera was utilized to visualize the tissue penetration of intravenous ICG. Results: Prior to injecting ICG, devascularized tissue was not clearly visible. Injecting ICG allowed clear separation of vascularized (fluorescing) and devascularized (non-fluorescing) tissues. One region of non-florescent tissue was later confirmed to be devascularized with MRI and experienced postoperative infection. Conclusions: As the complexity of spinal oncology procedures increases, ICG fluorescence imaging offers a novel method for real-time assessment of tissue perfusion. This technique may be particularly valuable in extensive tumor resections, post-radiation cases, and revision surgeries where tissue viability is at risk. Further investigation in the spinal oncology population could help establish whether early identification of poorly perfused tissues impacts wound healing outcomes.

Preoperative Diffusion Tensor Imaging and Neurite Dispersion and Density Imaging in Isocitrate Dehydrogenase-Mutant Grade 2 and 3 Gliomas: Definition of Tumor-Related Epilepsy and Predictive Factors of Seizure Outcomes Based on a Single-Center Retrospective Case Series

BACKGROUND AND OBJECTIVES

Understanding and managing seizure activity is crucial in neuro-oncology, especially for highly epileptogenic lesions like isocitrate dehydrogenase (IDH)-mutant gliomas. Advanced MRI techniques such as diffusion tensor imaging (DTI) and neurite orientation dispersion and density imaging (NODDI) have been used to describe microstructural changes associated with epilepsy. However, their role in tumor-related epilepsy (TRE) remains unclear. This study aims to investigate the role of DTI and NODDI tumor-derived metrics in defining TRE and predicting postoperative seizure outcomes in patients undergoing surgical resection for IDH-mutant grade 2 and 3 gliomas.

METHODS

This was a single-center retrospective study. Preoperative DTI parameters included fractional anisotropy and mean diffusivity. NODDI parameters included neurite density index (NDI), orientation dispersion index, and free-water fraction (FWF). These metrics were calculated within three volumes of interest (fluid-attenuated inversion recovery [FLAIR] tumor volume, FLAIR peripheral zone, and FLAIR central zone [Fcz]) and correlated with seizure presentation, type, and postoperative control, which was reported according to the Engel classification system.

RESULTS

Fifty-seven patients were included in this study. Increased NODDI-derived FWF-Fcz (P = .031) and NDI-Fcz (P = .046) values correlated with preoperative generalized seizure presentation, although only the FWF-Fcz confirmed its statistical significance (P = .047) in the multivariate analysis. Lower mean diffusivity-FLAIR tumor volume correlated with poor postoperative seizure control both in the univariate (P = .015, P = .026) and multivariate analyses (P = .024, P = .036), while a trend toward significance was found between higher NDI-FLAIR peripheral zone and worse seizure control (P = .055).

CONCLUSION

DTI and NODDI tumor-derived quantitative parameters may define TRE and predict postoperative seizure outcomes in patients with IDH-mutant gliomas. Notably, DTI metrics were found to be independent predictors of postoperative seizure outcomes, while preoperative NODDI parameters correlated with seizure presentation. Further research is warranted to validate our findings and to better understand the underlying mechanisms driving TRE.

Adjunctive intravascular lithotripsy for heavily calcified carotid stenosis: a dual-center experience and technical case series

BACKGROUND

Heavily calcified carotid stenosis (HCCS) is considered an exclusion for carotid angioplasty and/or stenting (CAS), amenable only to carotid endarterectomy. This study presents preliminary retrospective dual-center experience utilizing the Shockwave S4 intravascular lithotripsy (IVL) system (Shockwave Medical) as an adjunct to CAS for HCCS.

METHODS

Patients with symptomatic or asymptomatic HCCS (de novo stenosis or in-stent restenosis (ISR)) undergoing IVL+CAS were included. Charts were reviewed for demographic, imaging, procedural, and outcome data. The primary endpoint was composite major adverse event (MAE) rate: death, ipsilateral stroke, or myocardial infarction (MI) within 30 days of IVL+CAS. Secondary endpoints included technical and procedural success, residual stenosis, and ISR postprocedure.

RESULTS

Fifteen patients underwent 17 IVL+CAS procedures: de novo HCCS=13, heavily calcified ISR=4; symptomatic disease was addressed in seven cases. Procedures were performed transfemorally under conscious sedation with dual protection; flow reversal through a balloon guide catheter, and distal embolic protection system (EPS) use. Median pre-IVL+CAS stenosis was 73% (IQR 60-80%). Technical success (IVL+CAS+ EPS use) was achieved in all cases. Median post-IVL+CAS residual stenosis was 27% (IQR 12-33%), achieving <50% residual stenosis and procedural success in all. Five patients required dopamine infusion for postprocedural hypotension. No periprocedural ipsilateral strokes occurred. MAE rate was 6.7% (95% CI 0.2% to 32%), including one MI resulting in death. Additionally, one ISR (6.3%; 95% CI 0.2% to 30.2%) identified 160 days after IVL+CAS was retreated with angioplasty.

CONCLUSIONS

IVL+CAS was safe and effective for treating symptomatic and asymptomatic HCCS, achieving high rates of freedom from MAE. IVL has potential to expand the role of CAS in difficult to treat HCCS.

Multimodal treatment combining neoadjuvant therapy, laparoscopic subtotal distal pancreatectomy and adjuvant therapy for pancreatic neck-body cancer: Case series

BACKGROUND

Pancreatic cancer involving the pancreas neck and body often invades the retroperitoneal vessels, making its radical resection challenging. Multimodal treatment strategies, including neoadjuvant therapy, surgery, and postoperative adjuvant therapy, are contributing to a paradigm shift in the treatment of pancreatic cancer. This strategy is also promising in the treatment of pancreatic neck-body cancer.

AIM

To evaluate the feasibility and effectiveness of a multimodal strategy for the treatment of borderline/locally advanced pancreatic neck-body cancer.

METHODS

From January 2019 to December 2021, we reviewed the demographic characteristics, neoadjuvant and adjuvant treatment data, intraoperative and postoperative variables, and follow-up outcomes of patients who underwent multimodal treatment for pancreatic neck-body cancer in a prospectively collected database of our hospital. This investigation was reported in line with the Preferred Reporting of Case Series in Surgery criteria.

RESULTS

A total of 11 patients with pancreatic neck-body cancer were included in this study, of whom 6 patients were borderline resectable and 5 were locally advanced. Through multidisciplinary team discussion, all patients received neoadjuvant therapy, of whom 8 (73%) patients achieved a partial response and 3 patients maintained stable disease. After multidisciplinary team reassessment, all patients underwent laparoscopic subtotal distal pancreatectomy and portal vein reconstruction and achieved R0 resection. Postoperatively, two patients (18%) developed ascites, and two patients (18%) developed pancreatic fistulae. The median length of stay of the patients was 11 days (range: 10-15 days). All patients received postoperative adjuvant therapy. During the follow-up, three patients experienced tumor recurrence, with a median disease-free survival time of 13.3 months and a median overall survival time of 20.5 months.

CONCLUSION

A multimodal treatment strategy combining neoadjuvant therapy, laparoscopic subtotal distal pancreatectomy, and adjuvant therapy is safe and feasible in patients with pancreatic neck-body cancer.

Clinical application of 3D slicer reconstruction and 3D printing localization combined with neuroendoscopy technology in VPS surgery

To explore techniques, advantages and disadvantages of 3D Slicer reconstruction and 3D printing localization technology combined with transcranial neuroendoscopy in ventriculoperitoneal shunt surgery. Retrospective analysis of clinical data of patients with hydrocephalus treated by ventriculoperitoneal shunt surgery using 3D Slicer reconstruction and 3D printing positioning technology combined with transcranial neuroendoscopy in our hospital from October 2021 to March 2023. A total of 33 patients with complete data were collected, including 19 males and 14 females, aged 10-81 years. Pre operative use of 3D Slicer reconstruction and 3D printing localization, and intraoperative use of neuroendoscopy assisted catheterization to complete ventriculoperitoneal shunt surgery. The drainage tube position was confirmed by brain CT and 3D Slicer reconstruction after operation, of which 30 cases were located in the frontal horn or center of the ipsilateral lateral ventricle, and 3 cases were located in the frontal horn or center of the contralateral lateral ventricle. All patients were successfully catheterized and well positioned. According to the unique ventricular system characteristics of each hydrocephalus patient, the 3D Slicer reconstruction technology was used to determine the individualized puncture point and direction, measure the puncture depth, accurately locate the puncture through the 3D printing guide plate, and accurately send the tip of the ventricular catheter into the frontal or central part of the lateral ventricle with the assistance of neuroendoscopic visualization, which improved the success rate of the operation and reduced the risk of tube blockage. At the same time, our team has newly developed a puncture point ("Cai's point"), which has a puncture path in a non-vascular area and can reduce the risk of puncture bleeding. However, further prospective clinical research is needed to determine its routine location.

Bilateral synchronous UBE for unilateral laminotomy and bilateral decompression as a potentially effective minimally Invasive approach for two-level lumbar spinal stenosis

Currently, Unilateral biportal endoscopy is widely used in the surgical treatment of lumbar spinal stenosis. To investigate the feasibility of bilateral synchronous UBE to unilateral laminotomy and bilateral decompression(BS-UBE-ULBD) for treating two-level lumbar spinal stenosis (LSS). Sixty-four patients with two-level lumbar spinal stenosis (LSS) treated with BS-UBE-ULBD from October 2022 to January 2024 were retrospectively analyzed. All patients were treated with BS-UBE-ULBD. All 64 patients successfully underwent surgery, and the duration of surgery was 95-180 min, with an average of 119.92 ± 14.79 min. The average number of fluoroscopy was 3.02 ± 0.92. The average blood loss during the surgery was 73. 44 ± 36.70 ml. Postoperative lumbar CT showed that the spinal canal and bilateral nerve roots were fully decompressed. There were no postoperative complications, such as infection, severe nerve root injury, and lumbar instability. Complete follow-up data were obtained for all 64 cases. The VAS score of low back and leg pain and the ODI of lumbar function significantly (P < 0.05) improved at each follow-up time point. MacNab evaluation at 6 months after the surgery showed that the results were excellent in 48 cases, good in 14 cases, and fair in 2 cases. The excellent and good rate was 96. 88% (62/64). So BS-UBE-ULBD is a minimally invasive, highly effective, and safe procedure for 2-level LSS.Degenerative lumbar spinal stenosis (LSS) refers to clinical symptoms caused by the compression of the cauda equina, nerve root, and vascular complex. LSS can occur due to the abnormal shape and volume of the bony or fibrous structure after degenerative changes and the stenosis of the inner diameter of one or more lumens at a single level or multiple levels. It is a common cause of lumbago or lumbago and leg pain, which is common among middle-aged and elderly people1. LSS has become the most common cause of lumbar surgery among patients over 60 years of age2. However, traditional surgery necessitates extensive stripping of paraspinal muscles, which can easily lead to the ischemic injury of paraspinal muscles and atrophy after denervation. Therefore, traditional surgery may result in intractable back pain, stiffness, and discomfort after surgery3,4. Furthermore, as the posterior bone and soft tissue structures need to be extensively resected during the surgery, epidural scar and nerve compression are highly likely after the surgery. The high risk of general anesthesia cannot be ignored among elderly and weak patients2,5.Recently, with the rapid development of minimally invasive spine surgery, endoscopic surgery has been applied in the treatment of LSS6. Unilateral biportal endoscopy (UBE ) is more popular in treating LSS and is a more flexible operation, with small trauma, quick recovery, and a gentle learning curve. In addition, many studies have proven the good clinical efficacy of unilateral biportal endoscopy7. Multilevel spinal stenosis can be done simultaneously. Previously, the same operator decompressed multiple segments in turn8,9, but the operation lasted longer, and the corresponding problems, such as bleeding, high risk of anesthesia, and fluoroscopy frequency, increased.From October 2022 to June 2024, our hospital pioneered the use of Bilateral Synchronous UBE-unilateral Laminotomy and Bilateral Decompression (BS-UBE-ULBD) for two-level degenerative LSS. Sixty-four patients with two-segment LSS were treated with BS-UBE-ULBD, and the results were satisfactory.

Endoscope-assisted transcranial surgery for complex pituitary adenoma: a retrospective case series study with propensity score matching

Surgical treatment of complex pituitary adenomas (PAs) presents a significant challenge. Here in, we compared the surgical outcomes between patients undergoing endoscope-assisted transcranial surgery and microscopic regimens to assess the safety and efficacy of endoscope-assisted transcranial surgery in treating complex PA. This retrospective case-control study was conducted at the First Affiliated Hospital of Soochow University, China. Clinical data were retrospectively analysed between January 2018 and January 2023. The primary outcome was gross total resection (GTR), and the secondary outcomes included recurrence, residual tumour volume, and patient status. Propensity score matching was used to account for group differences. We enrolled 73 patients, of whom 29 underwent endoscope-assisted transcranial surgery, and 44 underwent transcranial microscopic surgery. Compared with the microscopic regimen group, the endoscope-assistedgroup had higher postoperative Karnofsky Performance Scale (KPS) scores (p = 0.031), higher GTR rates (GTR: 79.3% vs. 50%, p = 0.023), and smaller tumour residual volume (residual tumour volume: 0.15 vs. 0.94, p = 0.029). After propensity score matching, the endoscope-assistedregimen was associated with increased odds of GTR rate, compared with the microscopic regimen (odds ratio: 3.65, 95% confidence interval: 1.06-12.54, p = 0.040). KPS score improvement at discharge was more evident in the endoscope-assisted group than in non-combined group. The endoscope-assisted transcranial surgery regimen offered increased GTR rates, higher postoperative KPS score, and less residual tumour than the non-combined regimen did, highlighting endoscope-assistedtherapy as the more favourable treatment approach for patients with complex PA.

Novel triangle papilla access approach for interdental bone defect regeneration: A case study

BACKGROUND

Successful periodontal regeneration depends on primary wound closure and interdental papilla preservation. In this case study, we introduce a novel triangle papilla access approach (T-PAA) performed under a surgical microscope for treating interdental bone defects. In this novel approach, buccal incisions were used to access root surfaces and bone defects, avoiding interdental papilla incisions and preventing papillary collapse and necrosis.

METHODS

Nine patients with a mean age of 56 years were enrolled in this study. Incisions were made to create a triangular flap, which was reflected using a micro-periosteal elevator to expose the bone defect and granulation tissue. Subsequently, the granulation tissue was removed from the bone defect using a microsurgical blade, followed by root debridement using ultrasonic and micro-hand scalers and root conditioning. Thereafter, a mixture of fibroblast growth factor-2 and carbonated apatite granules was applied to the bone defect. The triangular flap was repositioned to ensure that the apex was not lifted by the graft material, and from the flap apex, 7-0 nylon sutures were used, followed by the addition of mesial and distal sutures. Adjacent teeth were splinted using wire and resin cement.

RESULTS

Postoperatively, clinical and radiographic evaluations at 6 months and 1 year showed significant improvements in periodontal parameters and bone filling. All patients achieved primary wound closure with no postoperative complications.

CONCLUSIONS

T-PAA is a promising approach for periodontal regeneration, providing adequate surgical access under a surgical microscope while preserving the papilla and potentially improving clinical outcomes in patients with interdental bone defects.

KEY POINTS

Triangle papilla access approach (T-PAA) provides adequate surgical access, preserves the interdental papillae, and improves clinical outcomes in cases of interdental bone defects. Triangular incisions made in areas with abundant blood flow and thicker gingiva at the base of the papilla are less likely to impair blood supply to the interdental papillae. T-PAA facilitates effective debridement, precise placement of regenerative materials, and accurate flap repositioning regardless of the defect morphology in localized interdental areas.

PLAIN LANGUAGE SUMMARY

Successful periodontal treatment often requires surgical procedures for bone regeneration in patients with bone defects. However, traditional surgical approaches may damage the interdental papillae, leading to esthetic concerns and compromised healing. In this study, we introduced a new surgical technique called the triangle papilla access approach, which uses a specially designed triangular incision to access and treat bone defects under a surgical microscope while preserving the interdental papillae. Our results from nine patients demonstrated that this technique effectively maintained tissue health and promoted bone regeneration. Therefore, it could become a more efficient approach for treating interdental bone defects.

A Case of Successful Explantation of an Infected Fenestrated Aortic Endograft Using a Composite Xeno/Biosynthetic In Situ Reconstruction

Introduction

Graft infections after open or endovascular repair can be devastating, and their treatment is always challenging. For thoraco-abdominal and abdominal aortic aneurysms, fenestrated and branched endografts are used increasingly. Because of the involved materials and anatomy, infective complications can be even more complex.

Report

One year after double fenestrated endovascular endorepair for a type Ia endoleak after standard endovascular repair, a 77 year old patient developed clinical signs for sepsis at an external clinic. As his clinical situation deteriorated, he was then referred to the centre, where an infection focus search revealed a Staphylococcus aureus bacteraemia, and computed tomography (CT), and fludeoxyglucose positron emission tomography CT showed signs of endograft infection. Trestment by endograft explantation followed, and in situ reconstruction with a composite xeno/biosynthetic graft was performed. Through a median laparotomy, endograft explantation as well as in situ reconstruction were technically successful, and sepsis control was achieved under concomitant anti-infective therapy. After a 48 day hospital stay (22 days in the intensive care unit), the patient was discharged to a rehabilitation clinic. After three months of uneventful follow up, precision dual antibiotic therapy with ciprofloxacin and rifampicin was stopped. Four year follow up confirmed freedom from infection and a properly functioning aortic reconstruction.

Discussion

After fenestrated stent graft procedures, successful late conversion is challenging and is known to correlate with high morbidity and mortality. The present case confirms the feasibility of this approach, even in patients with sepsis, with good results.

Case Report: Winkelmann hip rotationplasty as a last-resort solution

Background

Rotationplasty, an invasive surgery, serves as an alternative to amputation in pediatric orthopedic oncology. It is currently applied in broader cases (e.g., infection, trauma, or malignant tumors). Winkelmann Type BII rotationplasty is a rare procedure with limited literature. Furthermore, no description of rotationplasties where the femur is attached to the sacroiliac joint has been published to date.

Methods

Between September 2022 and March 2023, three patients underwent Type BII rotationplasty. We used the Clavien-Dindo classification to describe postoperative complications and the musculoskeletal tumor society score (MSTS) for functional result assessments.

Results

One patient suffered from multiple complications during the first 6 months postoperatively, one presented a single complication, and one had no complications after 4 and 3 months postoperatively, respectively. Two patients could walk pain-free with the help of crutches. One patient developed a crack on the femur, which did not require surgical revision. They all achieved satisfactory joint amplitudes of at least 50° in passive hip flexion. Unfortunately, one of the patients suffered from lung metastases.

Conclusions

Winkelmann's Type BII rotationplasty is a reliable alternative to hindquarter amputation. Furthermore, we demonstrated that complete resection of the iliac wing and femur fixation through the sacroiliac joint is feasible.

Mapping the scientific landscape and evolution of the International Journal of Surgery : a scientometric analysis (2004-2024)

AIM

The purpose of this study was to analyze the publication characteristics and development of the International Journal of Surgery (IJS) over its 20-year history.

METHODS

This study included articles published in IJS during the 20 years from 2004 to 2024. The data were analyzed using the Citespace, VOS viewer, and the 'Bibliometrix' package in R software. The authors studied the dynamics and trend patterns of IJS literature production through descriptive bibliometrics and identified the most prolific authors, publications, institutions, and countries. Bibliometric maps were utilized to visualize published articles' content and identify the most prolific research terms and topics in IJS , as well as their evolution over time.

RESULTS

A total of 5964 publications in the IJS from 2004 to 2023 and 356 publications in 2024 were included in the analysis. The study revealed a positive trend in literature production, although the number of articles published in IJS has slightly decreased recently. The most productive country was China ( n =1211), the most productive institution was Sichuan University ( n =151), and the most prolific author was Wang Yang ( n =87). The top 15 most cited articles focus primarily on research reporting standard guidelines for surgical studies. Research published in IJS mainly targeted middle-aged and older adults, emphasizing postoperative complications and treatment outcomes. The future research focus in IJS might center on integrating artificial intelligence and deep learning technologies to revolutionize surgical research and practice.

CONCLUSIONS

The International Journal of Surgery significantly contributes to advances in surgical research. IJS prioritized enhancing patient outcomes and advancing surgical techniques, focusing on middle-aged and older adults, postoperative complications, and treatment outcomes. The journal emphasized robust evidence through retrospective, controlled, and cohort surgical studies. Integrating artificial intelligence and deep learning represented a significant frontier poised to revolutionize surgical care, shaping the future landscape of research and practice.

Personalized Rehabilitation of Atrophic Customized Subperiosteal Implants

Severe maxillary atrophy and edentulism can pose a range of challenges in implant planning and oral rehabilitation. Modern dentistry has allowed for a review of the concepts and surgical protocols of subperiosteal implants, presenting them as a solution for the rehabilitation of atrophic maxillary and mandibular bone deficiencies. This study aims to address a series of 3 patients with severe maxillary atrophy, as evidenced by presurgical and postsurgical radiographic images, as well as computer-assisted planning and analysis of patient anatomy for rehabilitation with custom sintered subperiosteal implants. Promising results these clinical cases, highlighting the precise technique, biocompatibility, and durability of these materials. The absence of postoperative complications was evident, with high success rates in procedures and patient reports. Importantly, periodic follow-up is needed to assess the longevity and effectiveness of the technique used.

The Use of Front Plateau in the Treatment of Temporomandibular Disorders: A Case Series and Literature Review

Temporomandibular disorders (TMDs) are conditions with multifactorial etiology and complex treatment. Among the non-invasive therapeutic possibilities for these conditions is the Front Plateau, a partial anterior plate made from colourless self-curing acrylic resin. It is a simple procedure that can be carried out in a single clinical section promoting muscle relaxation to reduce symptoms associated with TMDs. This study aims to report a prospective, consecutive, single-centric case series to evaluate the Front Plateau's effectiveness in patients with temporomandibular disorders. A questionnaire adapted from the Research Diagnostic Criteria for TMDs was used and 4 patients were treated with the Front Plateau plaque. Patients were monitored after 5 and 9 months, respectively, after starting to use the Front Plateau. Of the 4 cases listed, 2 showed significant improvement in initial signs and symptoms. Front Plateau may be a favourable treatment option for patients with TMD, if the guidelines are followed. Clinical trials on this modality should seek to minimize possible biases and limitations associated with the design of this type of research.

Using DaSilva Cone Operation to Establish 1.5 or 2 Ventricle Circulation After Initial Single Ventricle Palliation with Starnes Procedure

Ebstein anomaly (EA) is a congenital dysplasia of the tricuspid valve resulting in reduced right ventricular (RV) volume and tricuspid regurgitation. Severe EA in the neonatal period is associated with high mortality. The Starnes procedure (fenestrated RV exclusion) is reserved for EA patients with cardiogenic shock and has previously committed patients to single ventricle (SV) palliation. In this report, we present the results of a strategy to redirect patients utilizing the Da Silva Cone operation to achieve a 2 or 1.5 ventricle circulation. Single-center retrospective study including all consecutive cases of Da Silva Cone operation after Starnes procedure. Between 2019 and 2023, six conversions from Starnes procedure to Cone reconstruction were performed. All were critically ill before their Starnes procedure; four on extracorporeal membrane oxygenation. Two patients were successfully rerouted to a two-ventricle repair; the remainder to 1.5 ventricle circulation. RV pressure estimates showed no correlation with success. Post-Cone intensive care and hospital stays were brief, median 5 and 6 days, respectively. All are between 2.5 and 6 years old, without indications for SV palliation. There were no deaths, with follow up ranging 1 month-4 years. No repeat interventions were performed on the tricuspid valves. One subject had a surgical pulmonary valve replacement. Tricuspid regurgitation was mild in all. The Da Silva Cone operation offers successful redirection of EA patients from a SV pathway to a 1.5 or 2 ventricle pathway after Starnes procedure. The approach is feasible and durable in midterm follow-up. The decision to initially proceed with Starnes need not be an irrevocable decision to continue down a SV palliation pathway.

Analysis of 73 Cases of Percutaneous Cholecystostomy for Acute Cholecystitis: Patient Selection is Key

Background: Percutaneous cholecystostomy (PC) rates have substantially increased in England over the past two decades. However, its utilization and clinical outcomes at a local level are not well documented or understood. This study aimed to characterize the cohort of patients who underwent PC and resulting clinical outcomes at a tertiary center for hepatobiliary and emergency general surgery. Methods: This is a retrospective cohort study of patients treated between 2012 and 2020 at a single center. A subgroup analysis was conducted to compare outcomes between Tokyo grade 2 and Tokyo grade 3 patients. Results: In the 73-patient cohort, a 57.1% increase in PC was observed between 2012 and 2020. Compared to the gold-standard Tokyo guidelines, 36 patients (49.3%) met the criteria for PC. Postprocedural complications occurred in 50 patients (68.5%), including PC tube dysfunction (27.4%), intra-abdominal abscess (20.5%), external bile leak (8.2%), and biloma (5.5%). Recurrent biliary infection developed in 30 patients (41.1%). Twenty-seven patients (37%) underwent emergency reinterventions due to acute cholecystitis recurrence. Twenty patients (27.4%) required radiological reintervention. Seven patients (9.6%) required emergency cholecystectomy, and ten patients (13.7%) underwent an elective cholecystectomy. Overall, 36 patients (49.3%) died during the follow-up period. Five patients (6.8%) died during index admission. Subgroup analysis demonstrated a higher rate of complications in the Tokyo grade 3 subgroup of 82.8% vs. 59.1% (P = .04). Patients from this subgroup were also more likely to require emergency additional abscess drainage (17.2% vs. 2.3%, P = .034). There was no significant difference in the number of emergency cholecystectomies performed between groups. Patients from the Tokyo grade 2 subgroup were more likely to have an elective cholecystectomy in the future (20.5% vs. 3.4%, P = .044). Conclusions: PC was overperformed in our patient cohort, and was associated with high postprocedure morbidity and mortality. Clinicians should be discerning in patient selection criteria for PC.

Comparing Management Strategies for Thoracolumbar Injury Classification and Severity Score of 4 (TLICS = 4) in the Pediatric Population: A Single-Institutional Experience

BACKGROUND

Thoracolumbar (TL) fractures are uncommon injuries in the pediatric population. Surgery is recommended for TL fractures with significant deformity, posterior ligamentous complex disruption, or neurological compromise. The Thoracolumbar Injury Classification and Severity Scale (TLICS) has been validated in pediatric populations and serves as a valuable tool for guiding treatment decisions. However, there remains a lack of clarity regarding the appropriate treatment for patients with a TLICS of 4. While conservative and surgical techniques have been described, most studies focused on adult populations, and there is no consensus on the appropriate management in the pediatric population. We reviewed our institutional experience of TL fractures in young children with TLICS of 4, managed both non-operatively and operatively.

METHODS

A retrospective review of a single institution's experience managing pediatric patients (<18 years old) with TL fractures receiving a TLICS of 4 from 2015 to 2023 was conducted to determine the clinical outcomes following non-operative and operative treatment.

RESULTS

Among 11 pediatric patients, 4 were managed with bracing alone, primarily for posterior column fractures, using a thoracolumbar sacral orthosis (TLSO). Four patients underwent minimally invasive screw fixation (MISF), for Chance or posterior column fractures, with an average operative time of 143 min, blood loss of 29 cc, length of stay (LOS) of 9.8 days, and a follow-up interval of 6 months. Three patients received open posterior screw fixation (OPSF), most commonly for Chance fractures, with averages of 129 min operative time, 225 cc blood loss, 9.7 days LOS, and 4 months follow-up. Both MISF and OPSF utilized intra-operative imaging, with lower radiation exposure in the MISF group. One MISF patients had hardware failure evident by screw lucency on follow-up imaging.

CONCLUSIONS

Bracing and surgery are safe management options for pediatric TL fractures receiving a TLICS of 4. MISF is an effective alternative treatment strategy, comparable to OPSF, with the advantage of reduced blood loss and radiation exposure. Further studies with age-matched cohorts and long-term outcomes may help determine the optimal management course.

Unilateral nerve preservation during parametrectomy is not sufficient to prevent persistent urinary retention after cytoreductive endometriosis surgery

OBJECTIVES

This study sought to quantify the risks of urinary retention following different levels or degrees of nerve preservation during parametrectomies for deep endometriosis (DE).

METHODS

Women undergoing laparoscopic and robotic nerve-sparing DE surgeries were studied. The cases were divided into 6 groups according to the degree of preservation of parasympathetic parametrium fibers on each side: P1 (P1 left /P1 right-Excellent preservation: presacral and pararectal fascia bilateral preservation), P2 (P1/P2 or P2/P1, P2/P2-Regular preservation: fascia violation with local fat visualization-either of both sides; and P3 (P1/P3 or P3/P1, P2/P3 or P3/P2, P3/P3)-Poor preservation: musculature and pelvic floor exposure-even if only unilateral.

RESULTS

Of a total of 151 women eligible for the study, 110 (72.8%) had excellent nerve preservation; 24 (15.8%) had regular nerve preservation, and 17 (11.2%) had poor-nerve preservation. The incidence of elevated PVR was higher in the P3 group. Thirty-five patients were catheterized post-operatively, more common in the P3 group. In four cases from the P3 group, prolonged intermittent self-catheterization after discharge was necessary. The calculated risk of needing intermittent catheterization in the P3 group was 23.1% up to 8 weeks and 7.7% up to 8 months post-surgery.

CONCLUSION

Parametrectomy with poor-nerve preservation can lead to urinary retention, even with excellent contralateral preservation.