Minimally invasive surgical approaches for spontaneous intracranial hemorrhage in neonates aged 0-3 months

OBJECTIVE

The aim of this study is to assess the clinical efficacy of minimally invasive surgical interventions in addressing spontaneous intracranial hemorrhage among neonates aged 0-3 months.

METHODS

A retrospective analysis was conducted on a cohort of 30 neonates diagnosed with spontaneous intracranial hemorrhage, who underwent minimally invasive cranial trepanation and drainage procedures at our department between 2011 and 2015.

RESULTS

A comprehensive follow-up, spanning a duration of 1-5 years, was conducted for all 30 neonates, revealing a 100% survival rate among the pediatric cohort.

CONCLUSION

The findings suggest that minimally invasive cranial trepanation and drainage exhibit efficacy in neonates aged 0-3 months experiencing spontaneous intracranial hemorrhage, leading to a reduction in both mortality and disability rates. It is recommended that surgery be promptly performed upon definitive diagnosis and identification of operation indications to prevent severe brain damage resulting from prolonged intracranial hypertension and potential fatal outcomes in neonates. Furthermore, the surgical procedure is characterized by its simplicity, involving minimal trauma.

Intraoral Microscopic Versus Robot-Assisted Sialolithotomy and Sialendoscopy for Submandibular Stones

OBJECTIVE

Sialendoscopy has remained the standard of treatment for sialolithiasis; however, large stones impacted in the submandibular gland hilum often require an intra-oral combined approach.

METHODS

Patients treated for submandibular hilar sialolithiasis from 2015 to 2021 at two tertiary centers were stratified into two groups based on the surgical technique: Intraoral Microscopic-Assisted Sialolithotomy (IMAS) versus Robot-Assisted Sialolithotomy and Sialendoscopy (RASS). We compared the characteristics of retrieved stones, surgical success rate, operative time, and post-operative complications in both techniques. True surgical success was defined as successful stone extraction without reoccurrence within 12 months.

RESULTS

The RASS technique was attempted in 60 patients and successful in 56 (93.3%) cases whereas the IMAS technique was performed in 52 patients and successful in 48 (92.3%) cases. The longest dimension of the predominant retrieved calculi was 9.6 ± 3.1 mm (range, 5-18 mm) for the robotic technique and 10 ± 4.8 mm (range, 5-30 mm) for the microscopic technique. The operative time for the robotic technique excluding robot setup time was 70.6 ± 24.8 min compared to 61.9 ± 42.4 min for microscopic technique (p = 0.018). No major adverse outcomes were reported; however, temporary lingual paresthesia was found in ten robotic (16.7%) and five microscopic (9.6%) cases.

CONCLUSION

The two techniques were comparable in terms of efficacy and safety for large stones. The robot has the advantage of intraoral high dynamic maneuverability and improved surgeon posture while the microscopic technique has the advantage of intraoral tactile feedback. The procedure was significantly shorter in duration with the microscope.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2170-2176, 2024.

Ultrasonography is an effective tool for breast cancer screening in individuals with severe motor and intellectual disabilities

BACKGROUND

Individuals with severe motor and intellectual disabilities have become an aging population, and high cancer morbidity and mortality are critical issues affecting their survival. Cancer screening is a crucial method of resolving this issue; however, a suitable screening method for them has not been established.

METHODS

We used ultrasonography alone and performed breast cancer screening for women over 30 years old in our facility from 2016 to 2023. We observed the outcomes and calculated the recall/detection rate in this screening.

RESULTS

Three cases among 379 tested positive in this screening, all of which underwent radical surgery. They are alive and well without relapse present. We detected these breast cancer cases with a low recall rate.

CONCLUSION

We were able to successfully detect breast cancer cases using ultrasonography alone. Ultrasonography is an effective and feasible tool for breast cancer screening in individuals with severe motor and intellectual disabilities.

Thoracoscopic resection of lung masses is associated with excellent survival to discharge and good long-term outcomes

OBJECTIVE

To report and evaluate risk factors for conversion and perioperative and long-term outcomes in dogs undergoing thoracoscopic lung lobectomy for resection of lung masses.

ANIMALS

61 client-owned dogs.

METHODS

This retrospective cohort study (June 11, 2008, to February 14, 2020) of data collected from medical records included signalment, results of diagnostic imaging, surgical technique, surgical and anesthesia time, mass location and size, hospitalization time, histopathologic findings, and long-term outcome. Follow-up was obtained from medical records and telephone contact with owners or referring veterinarians.

RESULTS

Histopathology results were available for 60 of 61 tumors. Fifty-seven (95%) were considered primary lung tumors, of which 46 (81%) were carcinomas. Clean surgical margins were achieved in 46 of 52 (88%) dogs. Conversion from thoracoscopy to thoracoscopic-assisted or open surgery occurred in 16 of 61 (26%) dogs. Larger tumor diameter (≥ 5 cm) and lymphadenopathy detected by preoperative CT scan were significantly associated with increased risk of conversion. There was no association between conversion and patient weight, body condition score, and tumor location. All 61 dogs survived to discharge, and 56 of 57 were alive 1 month postoperatively. Median overall survival time was 311 days (95% CI, 224 to 570 days). Tracheobronchial lymphadenopathy on preoperative CT scans was associated with shorter postoperative survival (P < .001). Patient age, tumor diameter, adjuvant chemotherapy following surgery, and incomplete margins were not associated with survival time.

CLINICAL RELEVANCE

Dogs had high survival to discharge and good long-term prognosis following thoracoscopic lung lobectomy. However, larger tumor size and tracheobronchial lymphadenopathy may increase the likelihood of conversion.

Microsurgical clipping of multiple intracranial aneurysms via the keyhole approach

BACKGROUND

Keyhole surgery has been widely used to clip various intracranial aneurysms. Here, the feasibility of microsurgical clipping of multiple intracranial aneurysms via the keyhole approach was further investigated.

METHODS

The clinical data of 80 patients with multiple intracranial aneurysms treated with keyhole surgery were retrospectively analyzed. The patients included 25 males and 55 females, with an average age of 57.5 years. There were 13 patients with unruptured aneurysms, 67 patients with ruptured aneurysms (small aneurysms accounted for 52.2% of ruptured aneurysms), and a total of 198 aneurysms. A 4 cm incision and a bone hole of approximately 2.5 cm were used, per craniotomy standards. Forty-eight cases were treated via the supraorbital keyhole approach, 45 cases via the pterional keyhole approach, and three cases via the interhemispheric keyhole approach.

RESULTS

A bilateral and unilateral keyhole approach was applied in 18 and 62 cases, respectively. A total of 170 ipsilateral and 7 contralateral aneurysms were clipped. The complete clipping rate was 98.9%. During the follow-up period of 6-12 months after surgery, the Glasgow outcome scale score was 5 points in 74 cases, 4 points in five cases, and 3 points in one case. The prognosis was associated with the preoperative Hunt-Hess classification but not with the number of operative sides, the operation opportunity, or the number of clipped aneurysms.

CONCLUSION

Early keyhole surgical clipping of multiple intracranial aneurysms is an effective treatment. Among ruptured aneurysms, small aneurysms are common and need attention and timely treatment.

Arthroscopic Treatment of Popliteal Cyst Through the Posterior Portal: A Comprehensive Clinical Study

BACKGROUND A popliteal cyst, often perceived as benign, poses potential harm and symptoms. This study focused on arthroscopic treatment through the posterior knee portal at our medical center, aiming to assess its efficacy, safety, and long-term outcomes compared to traditional methods. MATERIAL AND METHODS A retrospective analysis of 20 patients (9 males and 11 females) with symptomatic popliteal cysts (January 2020 to December 2022) undergoing arthroscopic treatment via the posterior knee portal was conducted. Data on demographics, clinical presentation, preoperative imaging, surgical techniques, intraoperative findings, and postoperative Rauschning and Lindgren scores were collected and analyzed. RESULTS With a mean follow-up of 13.6 months (range: 12 to 36 months), all patients had associated intra-articular lesions and were treated. Degenerative cartilage damage was most common (65.0% of cases). The Rauschning and Lindgren score significantly improved after surgery (P<0.05), with no recurrence evident on MRI in any patients. CONCLUSIONS Arthroscopic treatment through the posterior knee portal has good potential for popliteal cyst management. This minimally invasive approach offers benefits such as direct visualization, precise cyst excision, and concurrent treatment of intra-articular pathologies.

All-inside endoscopic semiautomatic running locked stitch technique shows favourable outcomes for acute Achilles tendon ruptures

PURPOSE

The safety and reliability of endoscopic Achilles tendon rupture repair are still concerning aspects. This study's aim is to evaluate an all-inside endoscopic semiautomatic running locked stitch (Endo-SARLS) technique.

METHODS

Forty cases with acute Achilles tendon rupture were treated with the all-inside Endo-SARLS technique between 2020 and 2021. Under endoscopic control, the proximal tendon stumps were stitched with the running locked method using a semiautomatic flexible suture passer. The threads of the high-strength suture were grasped through the paratenon subspace and then fixed into calcaneal insertion with a knotless anchor. Magnetic resonance imaging (MRI), surgical time and complications were assessed. Achilles Tendon Total Rupture Score (ATRS), Achilles Tendon Resting Angle (ATRA) and Heel Rise Height Scale (HRHS) were utilised to evaluate final outcomes.

RESULTS

The average follow-up time was 25.4 ± 0.4 (range: 24-32) months. Appropriate tendon regeneration was observed on MRI after 12 months. At the final follow-up, the median value of ATRS score was 95 (interquartile range: 94, 98). Furthermore, there is no significant difference between the injured and contralateral side in the average ATRA (18.2 ± 1.8 vs. 18.3 ± 1.9°, ns) and median value of HRHS [14.5 (13.3, 15.5) vs. 14.8 (13.5, 15.6) cm, ns]. No infection and nerve injuries were encountered. Thirty-nine patients reported that they resumed casual sports activity after 6 months. One patient had a slight anchor cut-out, due to an addition injury, which was removed after 5 months.

CONCLUSIONS

An all-inside Endo-SARLS technique showed promising clinical results for acute Achilles tendon ruptures. This procedure reduces the risk of sural nerve injuries while establishing a reliable connection between the tendon stumps.

LEVEL OF EVIDENCE

Level IV.

Insights from Seoul National University Hospital's experience: a systematic review of pure laparoscopic donor hepatectomy progression

Following its initial execution in November 2015, pure laparoscopic donor hepatectomy (PLDH) has gained acceptance as a conventional practice at Seoul National University Hospital (SNUH). It is noteworthy that a significant proportion of cases entail full right hepatectomies, which are acknowledged to be technically demanding. As expertise and knowledge have been accrued, the pure laparoscopic technique has been extended to encompass liver recipients as a viable option in SNUH. The aim of this review is to present the developmental progression of PLDH, with a focus on pure laparoscopic donor right hepatectomy (PLDRH), at SNUH. This includes the standardization process, which can be achieved by sharing the hospital's accumulated experience and previous reports. Various types of graft, including full right, left, left lateral section, and monosegment, were procured by pure laparoscopic technique. The criteria for selection were expanded to include donors with variations in the anatomy of the portal vein and bile duct. Additionally, the procedure of PLDRH was determined to be safe and viable for donors with high body mass index and larger graft weight. In conclusion, this review demonstrates the alterations implemented throughout our evolution from restricted to inclusive criteria for donor selection, leading to a complete shift from open surgery to pure laparoscopic procedures in donor hepatectomy and eventually pure laparoscopic living donor liver transplantation (LDLT) in recipient.

The Minimally Invasive Approach Confers Improved Outcomes in Frail Cancer Patients Undergoing Hepatectomy: An ACS NSQIP Analysis

BACKGROUND

Morbidity for liver resection has decreased and frail patients are undergoing surgery. The impact of the minimally invasive approach (MILR) is unknown. This study aims to evaluate the impact of approach on outcomes in frail patients.

METHODS

Elective hepatectomies from the 2014-2020 ACS-NSQIP Hepatectomy-specific PUF were reviewed. The five-factor modified frailty index (mFI-5) was used. It includes diabetes, hypertension, functional status, heart failure and dyspnea. Patients were considered frail if their mFI-5 was >2.

RESULTS

3,116 patients were included: 2117 (67.9%) minor and 999 (32%) major. There were 2, 254 open cases and 862 MILR. Postoperatively (minor) MILR conferred lower risk of prolonged LOS, discharge not-to-home, transfusion, major complications, and minor complications (P<0.05). Postoperatively (major) MILR had lower incidence of prolonged LOS and any complication (P<0.05). In the minor group, MILR remained independently predictive of lower rates of prolonged LOS (OR: 0.34, 95% CI: 0.28-0.42), discharge not-to-home (0.58, 0.41-0.84), transfusion (0.72, 0.54-0.96), major complication (0.78, 0.62-1) and any complication (0.73, 0.58-0.92). In the major group, MILR remained independently predictive of prolonged LOS (0.60, 0.40-0.89).

CONCLUSION

MILR conferred lower rates of complications in minor as well as shorter LOS in major hepatectomy. The minimally invasive approach to hepatectomy may benefit frail cancer patients.

Intrapericardial liver herniation after coronary artery bypass grafting: a case report of minimally invasive repair with 20-year follow-up

BACKGROUND

Transdiaphragmatic intrapericardial herniation (DIPH) of intra-abdominal organs is a rare but potentially life-threatening phenomenon often requiring urgent repair. There are currently no guidelines on the preferred repair technique in this situation.

METHODS

Retrospective case report with long-term follow-up. We describe a case in which the left liver herniated into the pericardium after coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA).

RESULTS

Urgent laparoscopic reduction of the liver herniation and repair of the large diaphragmatic defect was performed using an expanded polytetrafluoroethylene (ePTFE) mesh in a 50 year old male patient. Hemodynamic instability normalized after the hernia reduction. The postoperative course was uneventful. CT-scan evaluation after 9 and 20 years of follow-up showed perfect integrity of the mesh.

CONCLUSION

A laparoscopic approach for DIPH is feasible in emergency situations provided sufficient hemodynamic stability of the patient. On-lay ePTFE mesh repair is a valid option for such repairs. We illustrate the long-term durability and safety of ePTFE for DIPH repair in what seems to be by far the longest documented follow-up after laparoscopic ePTFE mesh repair for DIPH.

Postoperative Outcomes and Analgesic Requirements of Single-Port vs Multiport Robotic-Assisted Radical Cystectomy

Objective: To compare outcomes in patients undergoing robotic-assisted radical cystectomy (RARC) with urinary diversion for bladder cancer with either the single-port (SP) or multiport (MP) robotic platform. Methods: All patients who underwent SP and MP RARC at our institution between January 2018 and January 2023 were retrospectively reviewed. Postoperative analgesia was administered by a departmentwide narcotic stewardship protocol, and inpatient and outpatient narcotic use was tracked. The available preoperative clinical, operative, and postoperative outcomes were analyzed using t-test, chi-square, and Fischer exact statistical measures. Kaplan-Meier analysis with log-rank testing was used to determine the freedom from high-grade (Clavien-Dindo grade ≥3) postoperative complications stratified by SP or MP robotic use. Results: Overall, 96 patients underwent RARC with urinary diversion at our institution, with 49 MP and 47 SP procedures performed. Preoperative clinical parameters including age, body mass index, prior abdominal surgery, and use of neoadjuvant chemotherapy were similar between the two groups. Patients undergoing SP RARC had a shorter operative time (386.0 ± 90.9 minutes vs 453.6 ± 94.8 minutes, p < 0.01) and faster return of bowel function (3.4 ± 1.4 days vs 4.5 ± 2.2 days, p < 0.01). However, both cohorts had similar length of hospitalization, postoperative narcotic use, pathologic staging, and rate of positive surgical margin. Within 3 months postoperatively, both cohorts had a similar high-grade complication, hospital readmission, and cancer recurrence rate. Conclusions: The SP robot allows a safe alternative surgical approach for RARC and offers similar postoperative outcomes compared to the MP robot.

Endoscopy for T10 nerve sheath tumor

Minimally invasive surgery (MIS) is increasingly being adopted for spinal intradural tumors. Through the use of conventional microscopy or exoscopy for large lobulated nerve sheath tumors, the posterior root attachment is often visualized only after mobilizing the tumor. Here, the authors describe the utility of angled endoscopy with its panoramic view for a T10 nerve sheath tumor. Gross-total extracapsular excision was achieved utilizing a minimally invasive right paraspinous approach, fenestration, lateral durotomy, sliding delivery of the tumor, sharp dissection of radicular attachments under neuromonitoring, and dural closure with oblique clips. Angled endoscopes help visualize the attachments behind large multilobulated tumors and confirm the totality of excision. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23214.

Minimally invasive anterior cervical foraminotomy for unilateral radiculopathy

Anterior cervical foraminotomy (ACF) is an alternative surgical option for the treatment of refractory unilateral radiculopathy due to disc herniation or spondylosis. The efficacy and adverse event rate in experienced practitioners are comparable to those of anterior cervical discectomy and fusion, total disc arthroplasty, and posterior foraminotomy. However, this technique has not been widely adopted, likely because of the proximity of the working zone and the vertebral artery. The authors present a detailed operative video of a patient successfully treated with an ACF. They also present a review of the ACF literature. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23196.

Minimally invasive keyhole approach for supramaximal frontal glioma resections: technical note

OBJECTIVE

The authors aimed to review the frontal lobe's surgical anatomy, describe their keyhole frontal lobectomy technique, and analyze the surgical results.

METHODS

Patients with newly diagnosed frontal gliomas treated using a keyhole approach with supramaximal resection (SMR) from 2016 to 2022 were retrospectively reviewed. Surgeries were performed on patients asleep and awake. A human donor head was dissected to demonstrate the surgical anatomy. Kaplan-Meier curves were used for survival analysis.

RESULTS

Of the 790 craniotomies performed during the study period, those in 47 patients met our inclusion criteria. The minimally invasive approach involved four steps: 1) debulking the frontal pole; 2) subpial dissection identifying the sphenoid ridge, olfactory nerve, and optic nerve; 3) medial dissection to expose the falx cerebri and interhemispheric structures; and 4) posterior dissection guided by motor mapping, avoiding crossing the inferior plane defined by the corpus callosum. A fifth step could be added for nondominant lesions by resecting the inferior frontal gyrus. Perioperative complications were recorded in 5 cases (10.6%). The average hospital length of stay was 3.3 days. High-grade gliomas had a median progression-free survival of 14.8 months and overall survival of 23.9 months.

CONCLUSIONS

Keyhole approaches enabled successful SMR of frontal gliomas without added risks. Robust anatomical knowledge and meticulous surgical technique are paramount for obtaining successful resections.

Radiological and Clinical Outcomes comparing 2-level MIS Lateral and MIS Transforaminal Lumbar Interbody Fusion in Degenerative Lumbar Spinal Stenosis

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

To compare early postoperative radiological and clinical outcomes between 2-level minimally invasive (MIS) trans-psoas lateral lumbar interbody fusion (LLIF) and MIS transforaminal lumbar interbody fusion (TLIF) for degenerative lumbar spinal stenosis.

METHODS

Fifty three consecutive patients undergoing 2-level lumbar interbody fusion from L3-L5 for degenerative lumbar spinal stenosis were enrolled. Twenty four patients underwent LLIF and 29 underwent TLIF.

RESULTS

Operative time and length of stay were similar between LLIF and TLIF (272.8 ± 82.4 vs 256.1 ± 59.4 minutes; 5.5 ± 2.8 vs 4.7 ± 3.3 days, P > .05), whereas blood loss was lower for LLIF (229.0 ± 125.6 vs 302.4 ± 97.1mls, P = .026). Neurological deficits were more common in LLIF (9 vs 3, P = .025), whereas persistent deficits were rare for both (1 vs 1, P = 1). For both groups, all patient reported outcomes visual analogue scale (VAS back pain, VAS leg pain, ODI, SF-36 physical) improved from preoperative to 2-years postoperative (P < .05), with both groups showing no significant differences in extent of improvement for any outcome. Lateral lumbar interbody fusion demonstrated superior restoration of disc height (L3-L4: 4.1 ± 2.4 vs 1.2 ± 1.9 mm, P < .001; L4-L5: 4.6 ± 2.4 vs .8 ± 2.8 mm, P < .001), foraminal height (FH) (L3-L4: 3.5 ± 3.6 vs 1.0 ± 3.6 mm, P = .014; L4-L5: 3.0 ± 3.5 vs -.1 ± 4.4 mm, P = .0080), segmental lordosis (4.1 ± 6.4 vs -2.1 ± 8.1°, P = .005), lumbar lordosis (LL) (4.1 ± 7.0 vs -2.3 ± 12.6°, P = .026) and pelvic incidence-lumbar lordosis (PI-LL) mismatch (-4.1 ± 7.0 vs 2.3 ± 12.6°, P = .019) at 2-years follow-up.

CONCLUSION

The superior radiological outcomes demonstrated by 2-level trans-psoas LLIF did not translate into difference in clinical outcomes compared to 2-level TLIF at the 2-years follow-up, suggesting both approaches are reasonable for 2-level lumbar interbody fusion in degenerative lumbar spinal stenosis.

Patient and physician radiation exposure during minimally invasive lumbar decompression: A prospective assessment of X-ray exposure risks

INTRODUCTION

Minimally invasive lumbar decompression (mild®) is becoming a popular procedure for treating lumbar spinal stenosis (LSS) secondary to hypertrophic ligamentum flavum (LF). The mild® procedure is commonly performed under live fluoroscopic guidance and carries a risk of radiation exposure to the patient and healthcare.

METHODS

One physician performed mild® on 41 patients at the Cleveland Clinic Department of Pain Management from October 2019 to December 2021, while wearing a radiation exposure monitor (Mirion Technologies). Mean fluoroscopy time, mean exposure per case, and mean exposure per unilateral level decompressed were the primary outcomes measured. The secondary outcome was to provide a comparison of radiation exposure during similar fluoroscopically guided procedures.

RESULTS

Mean patient fluoroscopy exposure time was 2.1 min ±0.9 (range: 1.1-5.6) fluoroscopy time per unilateral level decompressed. The mean patient radiation skin exposure from mild® was 1.1 ± 0.9 mGym2, and the mean total dose was 142.3 ± 108.6 mGy per procedure. On average, the physician was exposed to an average deep tissue exposure of 4.1 ± 3.2 mRem, 2.9 ± 2.2 mRem estimated eye exposure, and 14.7 ± 11.0 mRem shallow tissue exposure per unilateral level decompressed. An individual physician would exceed the annual exposure limit of 5 Rem after approximately 610 mild® procedures per year.

CONCLUSIONS

This study is an attempt to quantify the radiation exposure to the physician and patient during the mild® procedure. Compared with other fluoroscopically guided pain management procedures, patient and physician radiation exposure during mild® was low.

Comparison of the Outcomes of Microendoscopic Discectomy Versus Full-Endoscopic Discectomy for the Treatment of L4/5 Lumbar Disc Herniation

STUDY DESIGN

Retrospective Comparative Study.

OBJECTIVES

To compare the outcomes of microendoscopic discectomy (MED) versus full-endoscopic discectomy (FED) for treating L4/5 lumbar disc herniation (LDH).

METHODS

A retrospective study was performed on patients with L4/5 LDH treated using MED (n = 249) or FED (n = 124). A 16-mm tubular retractor and endoscope was used for MED, while a 4.1-mm working channel endoscope was used for FED. Patient background and operative data were collected. The Oswestry Disability Index (ODI) and European Quality of Life-5 Dimensions (EQ-5D) scores were recorded preoperatively and at 1 and 2 years postsurgery.

RESULTS

The background data of the two groups were similar. The mean operation times for MED and FED were 59.3 and 47.7 min (respectively), and the mean volumes of removed nucleus pulposus were .65 and 1.03 g, respectively. These differences were significant (P < .001). Six dural tears and one postoperative hematoma were observed in the MED group; none were observed in the FED group. During the follow-up period, 16 MED and 7 FED patients required re-operation due to recurrence (P = 1.00). Although the ODI and EQ-5D scores significantly improved at 1 and 2 years postsurgery in both groups, the differences were not statistically significant.

CONCLUSIONS

Operative outcomes were almost identical in both groups. We did not observe any operative or postoperative complications in FED. We, therefore, recommend FED as the first option for the treatment of L4/5 LDH since it has a better safety profile and is minimally invasive.

Minimally Invasive Surgical Therapies for Ureteral Polyps: A Systematic Review

Background: Ureteral polyps are rare benign ureteral tumor. No guideline recommends that open or minimally invasive surgery is best for treating ureteral polyps. This article aims to provide a comprehensive review of the minimally invasive techniques currently available for treating ureteral polyps. Materials and Methods: We performed a comprehensive search of articles published in PubMed, using the keywords "ureteral" and "polyp," or "polyps." Results: A total of 275 studies were obtained from the literature search but 96 articles were excluded. Conclusions: Several minimally invasive approaches were developed with the advancement of medical technology, including endoscopic, laparoscopic, and robotic approaches; however, the best surgical technique was yet to be decided. Due to the advantages and disadvantages of these approaches, the best surgical approach should be tailored to each patient's needs and the surgeon's preferences and experience.

Sequential surgery for the treatment of type I knee ankylosis: a series of 62 cases

BACKGROUNDS

The lack of systematic classification and standard treatment principles for knee ankylosis prevents optimal treatments. This study explored treatments for type I (mild) knee joint ankylosis.

METHOD

This retrospective study analysed patients with knee joint ankylosis admitted from March 2013 to January 2018 who underwent sequential arthroscopic release.

RESULT

The 62 patients had 12-36 (average, 18) months of follow-up. Thirty-eight patients were released; of these, 18 were assisted by limited incision with partial quadriceps femoris expansion myotomy and released according to arthroscopy. Six patients underwent lengthening and release of the quadriceps femoris. All surgeries combined with full-course rehabilitation resulted in improved joint mobility. The range of motion (ROM) of the knee joint recovered to a range of 0° to 85°-140° (mean: 118.32 ± 9.42°) from the preoperative range of 30°-70° (mean: 45° ± 15.50°). The clinical effect was evaluated according to the Judet criteria at the final follow-up. The outcomes at the last follow-up (at least for 1 year) were excellent in 55 cases, good in six cases, and fair in one case.

CONCLUSION

Sequential arthroscopic release, minimal selective invasion of limited incision of partial quadriceps femoris expansion myotomy, assisted by pie-crusting technique to release, or quadriceps femoris lengthening, and release surgery for type I knee joint ankylosis, accompanied by early rehabilitation training provided satisfactory results without significant complications.

Detection and Classification of Hysteroscopic Images Using Deep Learning

BACKGROUND

Although hysteroscopy with endometrial biopsy is the gold standard in the diagnosis of endometrial pathology, the gynecologist experience is crucial for a correct diagnosis. Deep learning (DL), as an artificial intelligence method, might help to overcome this limitation. Unfortunately, only preliminary findings are available, with the absence of studies evaluating the performance of DL models in identifying intrauterine lesions and the possible aid related to the inclusion of clinical factors in the model.

AIM

To develop a DL model as an automated tool for detecting and classifying endometrial pathologies from hysteroscopic images.

METHODS

A monocentric observational retrospective cohort study was performed by reviewing clinical records, electronic databases, and stored videos of hysteroscopies from consecutive patients with pathologically confirmed intrauterine lesions at our Center from January 2021 to May 2021. Retrieved hysteroscopic images were used to build a DL model for the classification and identification of intracavitary uterine lesions with or without the aid of clinical factors. Study outcomes were DL model diagnostic metrics in the classification and identification of intracavitary uterine lesions with and without the aid of clinical factors.

RESULTS

We reviewed 1500 images from 266 patients: 186 patients had benign focal lesions, 25 benign diffuse lesions, and 55 preneoplastic/neoplastic lesions. For both the classification and identification tasks, the best performance was achieved with the aid of clinical factors, with an overall precision of 80.11%, recall of 80.11%, specificity of 90.06%, F1 score of 80.11%, and accuracy of 86.74 for the classification task, and overall detection of 85.82%, precision of 93.12%, recall of 91.63%, and an F1 score of 92.37% for the identification task.

CONCLUSION

Our DL model achieved a low diagnostic performance in the detection and classification of intracavitary uterine lesions from hysteroscopic images. Although the best diagnostic performance was obtained with the aid of clinical data, such an improvement was slight.

Efficacy and safety analysis of AcoStream thrombus aspiration device in the treatment of acute superior mesenteric artery embolism

OBJECTIVE

Acute superior mesenteric artery embolism is a life-threatening disease caused by the abrupt interruption of mesenteric blood circulation, and the prognosis is very poor. Several studies have confirmed the efficacy and safety of percutaneous mechanical thrombectomy in acute superior mesenteric artery embolism, however, there are currently no literature reports on the latest percutaneous mechanical thrombectomy device-AcoStream™. In the present report, we summarize a series of cases and share our surgical experiences.

METHODS

The clinical data of 10 patients (six men and four women, mean age 77.6 ± 7.4 years) with acute superior mesenteric artery embolism treated by AcoStream™ in our center from December 2022 to December 2023 were retrospectively analyzed. Based on the literature, we summarized the diagnosis, therapy, and surgical experience of acute superior mesenteric artery embolism.

RESULTS

Percutaneous mechanical thrombectomy was performed for all the patients. The success rate of surgery reached 100% and no perioperative complications occurred. Abdominal pain was significantly relieved and the abdominal signs gradually disappeared in eight patients, while the other two patients still complained of abdominal pain during hospitalization, and eventually, they underwent resection of necrotic bowel. All the patients' symptoms were significantly relieved and they were smoothly discharged from the hospital.

CONCLUSIONS

As shown in the present study, percutaneous mechanical thrombectomy using AcoStream™ is minimally invasive, safe, and efficient in the initial stage of acute superior mesenteric artery embolism. We believe that percutaneous mechanical thrombectomy can be a promising alternative in selected cases.

Minimally Invasive vs Open Approach for First Metatarsophalangeal Joint Arthrodesis: Short Report of Early Results

BACKGROUND

We aim to compare early surgical results between groups who underwent minimally invasive surgery (MIS) vs open first metatarsophalangeal (MTP) arthrodesis to treat end-stage hallux rigidus.

METHODS

We conducted a retrospective cohort review of 65 patients who underwent a first MTP fusion procedure at an academic medical center between 2015 and 2023. Success of fusion was determined radiographically. Postoperative complications were identified through medical record review.

RESULTS

Sixty-seven first MTP fusion surgeries (41 open and 26 MIS) were performed on 65 patients with a primary diagnosis of hallux rigidus. Open surgery and MIS groups had similarly high fusion rates: 95% (39/41) and 96% (25/26), respectively (P = .84). We identified no difference in overall complication rates: 20% for open surgery and 23% for MIS (P = .73).

CONCLUSION

This retrospective analysis of 67 first MTP arthrodesis procedures showed no significant differences in fusion success or complications in the short term when comparing MIS to open surgery. Further studies are needed to elucidate potential differences between MIS vs open surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

[Effectiveness of unilateral biportal endoscopy combined with percutaneous pedicle screw fixation in treatment of lumbar burst fractures with neurological symptoms]

Objective

To evaluate the effectiveness of spinal canal decompression assisted by unilateral biportal endoscopy (UBE) and percutaneous uniplanar pedicle screw internal fixation in the treatment of lumbar burst fractures with neurological symptoms.

Methods

Between June 2021 and December 2022, 10 patients with single level lumbar burst fracture with neurological symptoms were treated with spinal canal decompression assisted by UBE and percutaneous uniplanar pedicle screw internal fixation. There were 7 males and 3 females with an average age of 43.1 years (range, 21-57 years). The injured vertebrae located at L 1 in 2 cases, L 2 in 4 cases, L 3 in 3 cases, and L 4 in 1 case. There were 7 cases of AO type A3 fractures and 3 cases of AO type A4 fractures. The total operation time, the time of operation under endoscopy, and complications were recorded. Pre- and post-operative visual analogue scale (VAS) score and American Spinal Injury Association (ASIA) scale (grading A-E corresponding to assigning 1-5 points for statistical analysis) were used to evaluate effectiveness. X-ray film and CT were performed to observe the fracture healing, and the ratio of anterior vertebral body height, Cobb angle, and rate of spinal canal invasion were measured to evaluate the reduction of fracture.

Results

All operations was successfully completed, and the spinal canal decompression and the bone fragment in spinal canal reduction completed under the endoscopy. Total operation time was 119 minutes on average (range, 95-150 minutes), and the time of operation under endoscopy was 46 minutes on average (range, 35-55 minutes). There was no complication such as dural sac, nerve root, or blood vessel injury during operation. All incisions healed by first intention. All patients were followed up 18.7 months on average (range, 10-28 months). The VAS score after operation significantly decreased when compared with that before operation ( P<0.05), and further improved at last follow-up ( P<0.05). The ASIA scale after operation significantly improved when compared with that before operation ( P<0.05), and there was no significant difference ( P>0.05) in the ASIA scale between at 1 week after operation and at last follow-up. The imaging examination showed that the screw position was good and the articular process joint was preserved. During follow-up, there was no loosening, fracture, or fixation failure of the internal fixation. The ratio of anterior vertebral body height and Cobb angle significantly improved, the rate of spinal canal invasion significantly decreased after operation ( P<0.05), and without significant loss of correction during the follow-up ( P>0.05).

Conclusion

Spinal canal decompression assisted by UBE and percutaneous uniplanar pedicle screw fixation is a feasible minimally invasive treatment for lumbar burst fractures with neurological symptoms, which can effectively restore the vertebral body sequence, as well as relieve the compression of spinal canal, and improve the neurological function.

A systematic review and meta-analysis of minimally invasive versus conventional open proctectomy for locally advanced colon cancer

BACKGROUND

Locally advanced colon cancer is considered a relative contraindication for minimally invasive proctectomy (MIP), and minimally invasive versus conventional open proctectomy (COP) for locally advanced colon cancer has not been studied.

METHODS

We have searched the Embase, Cochrane Library, PubMed, Medline, and Web of Science for articles on minimally invasive (robotic and laparoscopic) and COP. We calculated pooled standard mean difference (SMD), relative risk (RR), and 95% confidence intervals (CIs). The protocol for this review has been registered on PROSPERO (CRD42023407029).

RESULTS

There are 10132 participants including 21 articles. Compared with COP, patients who underwent MIP had less operation time (SMD 0.48; CI 0.32 to 0.65; I2 = 0%, P = .000), estimated blood loss (MD -1.23; CI -1.90 to -0.56; I2 = 95%, P < .0001), the median time to semi-liquid diet (SMD -0.43; CI -0.70 to -0.15; I2 = 0%, P = .002), time to the first flatus (SMD -0.97; CI -1.30 to -0.63; I2 = 7%, P < .0001), intraoperative blood transfusion (RR 0.33; CI 0.24 to 0.46; I2 = 0%, P < .0001) in perioperative outcomes. Compared with COP, patients who underwent MIP had fewer overall complications (RR 0.85; CI 0.73 to 0.98; I2 = 22.4%, P = .023), postoperative complications (RR 0.79; CI 0.69 to 0.90; I2 = 0%, P = .001), and urinary retention (RR 0.63; CI 0.44 to 0.90; I2 = 0%, P = .011) in perioperative outcomes.

CONCLUSION

This study comprehensively and systematically evaluated the difference between the safety and effectiveness of minimally invasive and open treatment of locally advanced colon cancer through meta-analysis. Minimally invasive proctectomy is better than COP in postoperative and perioperative outcomes. However, there is no difference in oncological outcomes. This also provides an evidence-based reference for clinical practice. Of course, multi-center RCT research is also needed to draw more scientific and rigorous conclusions in the future.

Minimally Invasive Delivery of Percutaneous Ablation Agent via Magnetic Colloidal Hydrogel Injection for Treatment of Hepatocellular Carcinoma

Percutaneous thermotherapy, a minimally invasive operational procedure, is employed in the ablation of deep tumor lesions by means of target-delivering heat. Conventional thermal ablation methods, such as radiofrequency or microwave ablation, to a certain extent, are subjected to extended ablation time as well as biosafety risks of unwanted overheating. Given its effectiveness and safety, percutaneous thermotherapy gains a fresh perspective, thanks to magnetic hyperthermia. In this respect, an injectable- and magnetic-hydrogel-construct-based thermal ablation agent is likely to be a candidate for the aforementioned clinical translation. Adopting a simple and environment-friendly strategy, a magnetic colloidal hydrogel injection is introduced by a binary system comprising super-paramagnetic Fe3O4 nanoparticles and gelatin nanoparticles. The colloidal hydrogel constructs, unlike conventional bulk hydrogel, can be easily extruded through a percutaneous needle and then self-heal in a reversible manner owing to the unique electrostatic cross-linking. The introduction of magnetic building blocks is exhibited with a rapid magnetothermal response to an alternating magnetic field. Such hydrogel injection is capable of generating heat without limitation of deep penetration. The materials achieve outstanding therapeutic results in mouse and rabbit models. These findings constitute a new class of locoregional interventional thermal therapies with minimal collateral damages.

Robotic mitral valve surgery

Totally endoscopic robotic mitral valve repair is the least invasive surgical therapy for mitral valve disease. Robotic mitral valve surgery demonstrates faster recovery with shorter hospital stays, less morbidity, and equivalent mortality and mid-term durability compared to sternotomy. In this review, we will explore the advantages and disadvantages of robotic mitral valve surgery and consider important technical details of both operative set-up and mitral valve repair techniques. The number of robotic cardiac surgical procedures being performed globally is expected to continue to rise as experience grows with robotic techniques and increasing numbers of cardiac surgeons become proficient with this innovative technology. This will be facilitated by the introduction of newer robotic systems and increasing patient demand.

Study International Multicentric Pancreatic Left Resections (SIMPLR): Does Surgical Approach Matter?

BACKGROUND

Minimally invasive surgery is increasingly preferred for left-sided pancreatic resections. The SIMPLR study aims to compare open, laparoscopic, and robotic approaches using propensity score matching analysis.

METHODS

This study included 258 patients with tumors of the left side of the pancreas who underwent surgery between 2016 and 2020 at three high-volume centers. The patients were divided into three groups based on their surgical approach and matched in a 1:1 ratio.

RESULTS

The open group had significantly higher estimated blood loss (620 mL vs. 320 mL, p < 0.001), longer operative time (273 vs. 216 min, p = 0.003), and longer hospital stays (16.9 vs. 6.81 days, p < 0.001) compared to the laparoscopic group. There was no difference in lymph node yield or resection status. When comparing open and robotic groups, the robotic procedures yielded a higher number of lymph nodes (24.9 vs. 15.2, p = 0.011) without being significantly longer. The laparoscopic group had a shorter operative time (210 vs. 340 min, p < 0.001), shorter ICU stays (0.63 vs. 1.64 days, p < 0.001), and shorter hospital stays (6.61 vs. 11.8 days, p < 0.001) when compared to the robotic group. There was no difference in morbidity or mortality between the three techniques.

CONCLUSION

The laparoscopic approach exhibits short-term benefits. The three techniques are equivalent in terms of oncological safety, morbidity, and mortality.

Blubber biopsy in common bottlenose dolphins using a novel biopsy puncher: Evaluation of the impact on living individuals and possibility of applications in cetacean research

Biopsy has recently become a preferred protocol for sampling the skin and blubber of many cetacean species, although it is desirable to collect as minimally invasive as possible. Here, the effect of biopsy sampling on the captive common bottlenose dolphins was evaluated by analyzing the process of wound healing and changes in hematological and blood biochemical parameters after biopsy using a puncher developed to collect up to the inner layer of the dolphin blubber. Results showed that the wounds caused by biopsy were closed in as early as 1 day and completely covered with the epidermis within 5-11 days. Blood fibrinogen, which generally increases due to a wound-induced inflammatory response or activation of the coagulation system, was significantly elevated after the biopsy indicating ongoing tissue repair, while other parameters did not exhibit significant differences. Furthermore, histological observation and RNA extraction of samples were performed to investigate the versatility of this method to cetacean research. Histological examination revealed three distinct layers of the blubber in the biopsy samples. Moreover, total RNA extracted from biopsy samples exhibited sufficient quality and quantity for gene expression analyses. Overall, the puncher utilized in our study represents a valuable and minimally invasive tool for investigating various aspects of small cetacean studies.

A Minimally Invasive Endoscopic Transnasal and Transorbital Approach to Sinonasal Tumor Resection

A 35-year-old female with an extensive biphenotypic sinonasal sarcoma (BSNS) eroding through the left frontal sinus into the orbit required gross total resection of the tumor. We wanted to forgo an open approach and provide a less invasive alternative via combined endonasal and transorbital endoscopic techniques to allow for tumor removal through small, well-disguised incisions. We utilized three portals-nasal, transorbital, and anterior table window-to create interconnected orbit-sinonasal corridors, thus generating alternate pathways for visualization and manipulation of this extensive tumor. Laryngoscope, 134:1308-1312, 2024.

Comparing robotic with laparoscopic beyond total mesorectal excision for advanced rectal cancer-a propensity-matched analysis

AIM

Robotic surgery is increasingly being used for rectal resection, with short-term benefits such as reduced hospital stay, faster bowel recovery and fewer complications. However, its utility for advanced rectal cancers requiring beyond total mesorectal excision has not been adequately evaluated. The aim of this study was to compare robotic and laparoscopic approaches for extended rectal resection, with postoperative and short-term oncological outcomes as endpoints.

METHOD

A retrospective, single-centre study of patients with advanced rectal cancer requiring extended rectal resection between January 2017 and December 2022 was carried out. Beyond total mesorectal excisions included pelvic exenteration, en bloc soft tissue or partial organ resection with the rectum, and lateral pelvic node dissection. Propensity score matching in a 4:1 ratio of laparoscopic to robotic was performed with age, sex, comorbidities, body mass index, organs involved, clinical T stage and colonoscopic obstruction.

RESULTS

A total of 425 beyond total mesorectal excisions were performed by minimally invasive approaches during the study period, and after propensity matching 228 laparoscopic operations were compared with 57 robotic resections. All baseline characteristics were balanced. No difference in blood loss, postoperative complications, length of hospital stay, positive resection margin or nodal yield was found, but there was a somewhat longer operating duration in robotics. The 2-year disease-free and overall survival were also similar.

CONCLUSIONS

No differences in postoperative or short-term oncological outcomes were found between robotic and laparoscopic beyond total mesorectal excisions for advanced tumours when performed by teams experienced in both robotics and laparoscopy.

Lower Limb Malrotation following Minimally Invasive Plating in Distal Tibia Fractures

Introduction

Minimally invasive percutaneousosteosynthesis (MIPO) plating techniques havedemonstrated good outcomes in the treatment of distal tibia fractures. Early arthritis and functional impairment mayoccur if length and rotation are not restored. This study aims to determine the incidence and severity of tibia malrotation following MIPO plating of isolated unilateral distal tibia fractures, defined as torsional difference of greater than 10° as compared to the contralateral limb and whether the degree of malrotation affects functional outcomes scores.

Materials and methods

This was a level 2 prospective cohort study. All patients with fractures of the distal tibia who underwent surgical fixation with the exclusion ofpatients with polytrauma, neurovascular injuries or pre-existing disabilities were recruited. Patients underwent MIPO plating followed by a post-operative ComputedTomography (CT) scan of bilateral lower limbs. AOFAS ankle-hindfoot score was recorded at six months and one year follow-up.

Results

A total of 24 patients (28 to 83 years old) were recruited. Nineteen patients obtained CT scans. Nine of the 19 patients (47.3%) had tibia malrotation. The mean tibia malrotation angle was 10.3° (0° - 45°). The average AOFAS scores was 82.4 and 84.3 at 6 months and 1 year follow-up. Degree of CT malrotation was not significantly associated with AOFAS scores at 6 month (spearman rho -0.386) and 1 year (spearman rho -0.343).

Conclusions

Tibia malrotation following MIPO plating of distal tibia fractures is common, with an incidence of 47.3% and an average malrotation angle of 10.3°. The degree of malrotation does not appear to have significant mid-term functional impact on the patient.

The lateral transorbital approach to the medial sphenoid wing, anterior clinoid, middle fossa, cavernous sinus, and Meckel's cave: target-based classification, approach-related complications, and intermediate-term ocular outcomes

OBJECTIVE

The lateral transorbital approach (LTOA) is a relatively new minimal access skull base approach suited for addressing paramedian pathology of the anterior and middle fossa. The authors define target zones for this approach and describe a series of cases with detailed measurements of visual outcomes, including those obtained with exophthalmometry.

METHODS

The authors performed a retrospective analysis of a consecutive series of LTOA patients. Seven target zones were identified: 1) the orbit, 2) the lesser sphenoid wing and anterior clinoid, 3) the middle fossa, 4) the lateral wall of the cavernous sinus and Meckel's cave, 5) the infratemporal fossa, 6) the petrous apex, and 7) the anterior fossa. The authors used volumetric analyses of preoperative and postoperative MR and CT imaging data to calculate the volume of bone and tumor removed and to provide detailed ophthalmological, neurological, and cosmetic outcomes.

RESULTS

Of the 20 patients in this cohort, pathology was in zone 2 (n = 10), zone 4 (n = 6), zone 3 (n = 2), zone 1 (n = 1), and zone 5 (n = 1). Pathology was meningioma (n = 10), schwannoma (n = 2), metastasis (n = 2), epidermoid (n = 1), dermoid (n = 1), encephalocele (n = 1), adenoma (n = 1), glioblastoma (n = 1), and inflammatory lesion (n = 1). The goal was gross-total resection (GTR) in 9 patients, all of whom achieved GTR. Subtotal resection (STR) was the goal in 8 patients (5 spheno-orbital meningiomas, 1 giant cavernous sinus/Meckel's cave schwannoma, 1 cavernous sinus prolactinoma, and 1 cavernous sinus dermoid), 7 of whom achieved STR and 1 of whom achieved GTR. The goal was biopsy in 2 patient and repair of encephalocele in 1. Visual acuity was stable or improved in 18 patients and worse in 2. Transient early postoperative diplopia, ptosis, eyelid swelling, and peri-orbital numbness were common. All 9 patients with preoperative diplopia improved at their last follow-up. Seven of 8 patients with preoperative exophthalmos improved after surgery (average correction of 64%). There were no cases of clinically significant (> 2 mm) postoperative enophthalmos. The most frequent postoperative complaint was peri-orbital numbness (40%). There was 1 CSF leak. Most patients were satisfied with their ocular (84%-100% of patients provided positive satisfaction-related responses) and cosmetic (75%-100%) outcomes.

CONCLUSIONS

The LTOA is a safe minimal access approach to a variety of paramedian anterior skull base pathologies in several locations. Early follow-up revealed excellent resolution of exophthalmos with little risk of clinically significant enophthalmos. Transient diplopia, ptosis, and peri-orbital numbness were common but improved. Careful case selection is critical to ensure good outcome.

A new minimally invasive, nonexcisional, surgical browlift technique with minimal scarring: a protocol for a prospective observational study

Background

The aim of this study is to prospectively evaluate the new minimal invasive (MINE) browlift technique with possibly superior results and minimal visible scarring.

Study design

A prospective observational study will be performed on all available data from patients who will undergo a browlift procedure in the HMC from 1 June 2021 till 31 May 2024. Our goal is to include at least 50 patients. Inclusion criteria are: patients with medical (i.e. brow ptosis and facial paralysis) or cosmetic indication, patients with sufficient understanding of the Dutch or English language and willingness to participate in extra study specific follow-up moments and filling in of questionnaires. Exclusion criteria are: less than 18 years of age and patients with previous brow or eyelid surgery. Patients will be photographed preoperatively and postoperatively using the VECTRA camera.

Outcome measurements

Scarring after procedure; functionality of eyebrow movement; amount of correction in brow ptosis, measured in VECTRA; longevity of procedure in months; aesthetic result as assessed by questionnaires and adverse effects of procedure will be measured.

Ethics and dissemination

The database management software 'Castor' will be used to store and collect the data from the questionnaire. The Medical Research Ethics Committee found this study not eligible to be submitted to the Dutch Medical Research Involving Human Subjects Acts (WMO). Written consent will be obtained from all patients.

Reconsidering the role of prophylactic pancreaticojejunostomy in pancreatic enucleation: balancing the benefits and risks

BACKGROUND

The incidence of postoperative pancreatic fistula (POPF) following enucleation is high, and prophylactic pancreaticojejunostomy (PPJ) is frequently performed. Minimally invasive enucleation (MEN) has been demonstrated to be safe and feasible, leaving most enucleation wounds exposed.

METHODS

The clinical data of 40 patients who underwent open enucleation with PPJ at our center between 2012 and 2021 were compared with those of 80 patients who underwent MEN.

RESULTS

The MEN group had better outcomes than the PPJ group in terms of intraoperative bleeding (50.0 versus 100.0 mL), postoperative semi-liquid diet recovery (2.0 versus 5.0 days), and postoperative length of stay (7.7 versus 12.5 days). While the MEN group had higher rates of complex enucleation (60.0% versus 40.0%), main pancreatic duct repair (32.5% versus 10.0%), discharge with drains (48.8% versus 25.0%), and grade B POPFs (47.5% versus 17.5%). Both surgical methods effectively preserved pancreatic function; however, two patients in the PPJ group experienced severe haemorrhaging and died. Additionally, during the follow-up period, gastrointestinal bleeding was found and discomfort in the surgical area was reported.

CONCLUSION

Pancreatic enucleation combined with PPJ should be avoided, and although a biochemical or grade B POPF may develop after MEN, it can be compensated for by preserving pancreatic function and ensuring a good long-term quality of life in the patients.

Biomechanical evaluation of Percutaneous endoscopic posterior lumbar interbody fusion and minimally invasive transforaminal lumbar interbody fusion: a biomechanical analysis

In order to analyze and evaluate the stability of lumbar spine and the risk of cage subsidence after different minimally invasive fusion operations, two finite element models Percutaneous endoscopic posterior lumbar interbody fusion (PE-PLIF) and minimally invasive transforaminal lumbar interbody Fusion (MIS-TLIF) were established. The results showed that compared with MIS-TLIF, PE-PLIF had better segmental stability, lower pedicle screw rod system stress, and lower risk of cage subsidence. The results suggest that the cage with appropriate height should be selected to ensure the segmental stability and avoid the risk of the subsidence caused by the cage with large height.

Laser-assisted dacryocystorhinostomy of acquired dacryops in a dog

OBJECTIVE

To describe a novel minimally invasive surgical approach to treatment of a nasolacrimal duct cyst in a dog and outcome.

ANIMAL STUDIED

A 10-year-old, male entire, Springer Spaniel with a chronic right-sided maxillary swelling and associated right eye epiphora and sneezing.

PROCEDURE

Computed tomography with dacryocystography confirmed a cystic structure and destruction of the right maxilla and zygomatic bone with invasion of the nasal cavity. Obstruction of the nasolacrimal duct was confirmed. Rhinoscopy was performed allowing visualization of the ventromedial wall of the cyst. Under direct visualization, dacryocystorhinostomy was performed and the wall of the cyst was ablated with the aid of a thulium laser fiber.

RESULTS

No intraoperative complications occurred during the procedure. Full resolution of clinical signs was noted within 2 weeks of treatment. No recurrence had occurred on long-term follow-up at 32 months.

CONCLUSIONS

Laser-assisted dacrocystorhinostomy under direct visualization was successful in the treatment and resolution of a nasolacrimal duct cyst (dacryops) in this case.

Case Report: Totally endoscopic minimally invasive mitral valve surgery during pregnancy: a case series

A totally endoscopic minimally invasive approach is widely used for cardiac valve surgery in normal adults. However, minimally invasive cardiac surgery during pregnancy is rarely reported. In addition to traditional median thoracotomy, totally endoscopic minimally invasive approaches can now be used for pregnant patients. We describe our experience with totally endoscopic cardiac valve surgery (TECVS) during pregnancy, which is safe for both mothers and fetuses.

Navigated simultaneous lateral minimally invasive tubular and posterior mini-open access for removal and revision of triangular sacroiliac joint implants: Technical note

BACKGROUND

Sacroiliac joint (SIJ) fusion, to treat back pain caused by SIJ dysfunction, can employ open or minimally invasive surgery (MIS) techniques and either cylindrical (screw-shaped) or triangular (wedge-shaped) implants. Fusion nonunion sometimes explains recurrent SIJ pain following fusion and occasionally requires hardware revision. MIS revision minimizes patient pain, infection, and disability, but due to the triangular implant size and form factor, implant removal can present challenges for MIS access during the explantation and achieving good bony purchase for re-instrumentation. Here, we report a prone single-position lateral MIS/posterior mini-open procedure for triangular-implant SIJ fusion revision.

METHODS

The patient is a 72-year-old female who underwent right SIJ fusion for lower back and leg pain sustained after a fall two years prior but experienced recurrent pain over the subsequent two years, with imaging findings of right SIJ peri-hardware lucencies and diagnostic injections confirming persistent right-sided sacroiliitis.

RESULTS

The patient underwent hardware removal using the lateral MIS incision with table-mounted tubular access and image-guided navigation to maintain exposure, plus simultaneous re-instrumentation using a navigated S2-ilioalar screw and iliac bolt construct with connecting rod through the posterior mini-open incision made for the navigation reference frame spinous process clamp.

CONCLUSION

The use of navigation and MIS access can significantly decrease the complexity of lateral hardware removal, and mini-open navigated screw-and-rod constructs offer re-instrumentation options accessible to surgeons unfamiliar with specialized posterior SIJ systems.

Ventricular Assist Device using a Thoracotomybased Implant Technique: Multi-center HeartMate 3 SWIFT Study

OBJECTIVES

The HeartMate 3 (HM3) left ventricular assist device (LVAD) provides substantial improvement in long-term morbidity and mortality in advanced heart failure patients. The SWIFT study compares thoracotomy-based implantation clinical outcomes with standard median sternotomy.

METHODS

We conducted a prospective, multicenter, single-arm study in patients eligible for HM3 implantation with thoracotomy-based surgical technique (bilateral thoracotomy or partial upper sternotomy with left thoracotomy). The composite primary endpoint was survival free of disabling stroke (Modified Rankin Score > 3), or reoperation to remove or replace a malfunctioning device, or conversion to median sternotomy at 6-months post-implant (elective transplants were treated as a success). The primary end point (non-inferiority, -15% margin) was assessed with >90% power compared to a propensity-matched cohort (ratio 1:2) derived from MOMENTUM 3 Continued Access Protocol (CAP).

RESULTS

The study enrolled 102 patients between December 2020 and July 2022 in the thoracotomy-based arm at 23 North American Centers. Follow-up concluded in December 2022. In the SWIFT group non-inferiority criteria was met (absolute between-group difference, -1.2%; Farrington Manning lower, one-sided 95%CI: -9.3%, P<0.0025) and event-free survival was not different (85.0% versus 86.2%; HR 1.01, 95%CI 0.58-2.10). Length of stay with thoracotomy-based implant was longer (median 20 versus 17 days, p=0.03). No differences were observed for blood product utilization, adverse events (including right heart failure), functional status, and quality of life between cohorts.

CONCLUSION

Thoracotomy-based implantation of the HM3 LVAD is non-inferior to implantation via standard full sternotomy. This study supports thoracotomy-based implantation as an additional standard for surgical implantation of the HM3 LVAD.

[Binocular loupe assisted mini-lateral and medial incisions in lateral position for release of elbow stiffness]

Objective

To analyze the effectiveness of binocular loupe assisted mini-lateral and medial incisions in lateral position for the release of elbow stiffness.

Methods

The clinical data of 16 patients with elbow stiffness treated with binocular loupe assisted mini-internal and external incisions in lateral position release between January 2021 and December 2022 were retrospectively analyzed. There were 9 males and 7 females, aged from 19 to 57 years, with a median age of 33.5 years. Etiologies included olecranon fracture in 6 cases, elbow dislocation in 4 cases, medial epicondyle fracture in 2 cases, radial head fracture in 4 cases, terrible triad of elbow joint in 2 cases, supracondylar fracture of humerus in 1 case, coronoid process fracture of ulna in 1 case, and humerus fracture in 1 case, with 5 cases presenting a combination of two etiologies. The duration of symptoms ranged from 5 to 60 months, with a median of 8 months. Preoperatively, 12 cases had concomitant ulnar nerve numbness, and 6 cases exhibited ectopic ossification. The preoperative range of motion for elbow flexion and extension was (58.63±22.30)°, the visual analogue scale (VAS) score was 4.3±1.6, and the Mayo score was 71.9±7.5. Incision lengths for both lateral and medial approaches were recorded, as well as the occurrence of complications. Clinical outcomes were evaluated using Mayo scores, VAS scores, and elbow range of motion both preoperatively and postoperatively.

Results

The lateral incision lengths for all patients ranged from 3.0 to 4.8 cm, with an average of 4.1 cm. The medial incision lengths ranged from 2.4 to 4.2 cm, with an average of 3.0 cm. The follow-up duration ranged from 6 to 19 months and a mean of 9.2 months. At last follow-up, 1 patient reported moderate elbow joint pain, and 3 cases exhibited residual mild ulnar nerve numbness. The other patients had no complications such as new heterotopic ossification and ulnar nerve paralysis, which hindered the movement of elbow joint. At last follow-up, the elbow range of motion was (130.44±9.75)°, the VAS score was 1.1±1.0, and the Mayo score was 99.1±3.8, which significantly improved when compared to the preoperative ones ( t=-12.418, P<0.001; t=6.419, P<0.001; t=-13.330, P<0.001).

Conclusion

The binocular loupe assisted mini-lateral and medial incisions in lateral position integrated the advantages of traditional open and arthroscopic technique, which demonstrated satisfying safety and effectivity for the release of elbow contracture, but it is not indicated for patients with posterior medial heterolateral heterotopic ossification.

Thoracoscopic Excision of Mediastinal Bronchogenic Cysts in Children: A Case Series

Background: Bronchogenic cysts result from a congenital anomalous budding of the tracheobronchial tree. Resection is usually recommended to avoid complications. Mediastinal bronchogenic cysts present a unique challenge due to their proximity to vital structures. The purpose of this study is to review our experience with mediastinal bronchogenic cysts. Methods: A single-institution retrospective review evaluated all mediastinal bronchogenic cyst excisions between January 2012 and November 2022. Patient demographics were assessed, including age at diagnosis, presenting symptoms, imaging workup, and cyst characteristics. Operative approach, complications, and surgical pathology were reported. Results: Five patients were identified. Age at diagnosis ranged from 18 to 27 months. No patient was diagnosed prenatally. All patients had symptoms at the time of diagnosis, including cough, wheezing, and respiratory distress. Three cysts were paratracheal, and two were paraesophageal. Age at surgery ranged from 26 to 30 months. All bronchogenic cysts were successfully resected thoracoscopically. Individual technical challenges included narrowing of the mainstem bronchus preventing lung isolation, significant mediastinal inflammation, the necessity for cyst evacuation to delineate the extent of the cyst, adherence of cyst wall to bronchus or trachea requiring cold dissection, and a stalk of tissue with an intimate connection to the carina that was amputated. No intraoperative or postoperative complication occurred. Surgical pathology was consistent with a bronchogenic cyst in all cases. Median length of hospital stay was two days. Conclusion: Thoracoscopy is a safe and effective procedure for mediastinal bronchogenic cyst excision in children. Certain technical maneuvers are highlighted, which may facilitate resection.

Efficacy and Safety of the Extreme Lateral Interbody Fusion (XLIF) Technique in Spine Surgery: Meta-Analysis of 1409 Patients

(1) Objectives: The objective of this study was to quantify the exact clinical-radiological efficacy and safety of the extreme lateral interbody fusion (XLIF) technique in spinal surgery; (2) Methods: A meta-analysis was performed using PubMed, Embase, Scopus, and Cochrane Collaboration Library. Studies focusing on patients surgically treated with XLIF were included. The outcomes were as follows: visual analog scale (VAS) and Oswestry disability index (ODI), radiological outcomes, and adverse events. Cohort studies and case series were also included. Clinical outcomes were assessed at 12 months of age. Data were combined using Review Manager 5.4 and WebPlotDigitizer 13.1.4; (3) Results: Nineteen studies with a pool of 1409 patients were included in this meta-analysis. Leg pain VAS and back pain VAS significantly improved at 12 months (SMD 2.75, 95% CI 0.59-4.90; SMD 4.54, 95% CI 1.39-7.69). ODI showed significant improvement (MD 32.51, 95% CI 24.01-41.00) at 12 months. Disc height increased significantly (SMD -2.73, 95% CI -3.58 to -1.88). Lumbar lordosis and segmental lordosis were significantly corrected postoperatively (MD -2.44, 95% CI -3.45 to -1.43; MD -2.55, 95% CI -3.61 to -1.48). The fusion rates at 12 months ranged from 85.0% to 93.3%. The most frequent complications were transient neurological conditions (2.2%), hardware failure (1.9%), and transient pain (1.8%). The most frequent serious complications were nerve root injury (1.0%), gastrointestinal impairment (0.7%), and vertebral fractures (0.6%); (4) Conclusions: This is the first meta-analysis of the specific use of XLIF in spinal surgery. This study demonstrates that the XLIF technique in spine surgery is associated with good clinical and radiological results and a low complication rate.

Impact of minimally invasive lung transplantation on early outcomes and analgesia use: A matched cohort study

INTRODUCTION

Minimally invasive (MI) approaches to lung transplantation (LTx) offer the prospect of faster recovery compared to traditional incisions, however, little data exist describing the impact of surgical technique on early outcomes and analgesia use.

METHODS

A prospectively maintained institutional registry identified 170 patients who underwent LTx between 01/2017 and 06/2022. Post-COVID acute respiratory distress syndrome, repeat, and multiorgan transplants were excluded (n=27) leaving 37 MILTx and 106 traditional LTx patients. Propensity score matching by age, sex, body mass index, diagnosis, lung allocation score, double vs. single lung, hypertension, diabetes, and hospitalization status created 37 pairs.

RESULTS

Before matching, MILTx patients were more often male (70% vs 43%) and more likely to receive grafts from younger (31 vs 42 years), circulatory death donors (19% vs 6%) compared with traditional LTx patients (all p<0.05). After matching, there were no differences in graft warm ischemia or operative duration (both p>0.05). Postoperatively, MILTx experienced shorter ICU (4.3 [IQR 3.1-5.5] vs 8.2 [IQR 3.7-10.8] days) and hospital lengths of stay (LOS) (13 [IQR 11-15] vs 17 [IQR 12-25] days) (both p<0.05). Among patients surviving to discharge, MILTx patients required fewer opioid prescriptions at discharge (38% vs 66%, p=0.008) and had improved pulmonary function at 3-months (FEV1 82 [IQR 72-102] vs 77 [IQR 52-88] % predicted; FVC 78 [IQR 65-92] vs 70 [IQR 62-80] % predicted] (both p<0.05).

CONCLUSION

Minimally invasive LTx techniques demonstrate potential advantages over traditional approaches, including reduced ICU and hospital LOS, lower opioid use on discharge, and improved early pulmonary function. Word count: 250/250.

Robotic repair for Barlow mitral regurgitation: Repairability, safety, and durability

OBJECTIVE

In Barlow disease, increased repair complexity drives decreased repair rates. We evaluated outcomes of a simplified approach to robotic mitral repair in Barlow disease.

METHODS

A prospective institutional registry with vital-statistics, statewide admissions and echocardiographic follow-up was used to identify 924 consecutive patients undergoing robotic surgery for degenerative mitral regurgitation (MR) between 2005 and 2020, including 12% (n = 111) with Barlow disease. Freedom from >moderate (>2+) MR was analyzed with death as a competing risk and predictors of failure were analyzed using multivariable Cox regression. Median follow-up was 5.5 years (range, 0-15 years).

RESULTS

Patients with Barlow disease were younger (median, age 59 years; interquartile range [IQR], 51-67 vs 62; IQR, 54-70 years, P = .05) than patients without Barlow disease. Replacements were performed in 0.9% (n = 1) of patients with Barlow disease and 0.8% (n = 6) of patients without Barlow disease (P = 1). Repairs comprised simple leaflet resection and annuloplasty band in 73.9% (n = 546) of non-Barlow valves versus 12.7% (n = 14) of patients with Barlow disease who required neochordae (53.6%, n = 59), chordal transfer (20%, n = 22), and commissural sutures (37.3%, n = 41), with longer cardiopulmonary bypass time (median 133; IQR, 117-149 minutes vs 119; IQR, 106-142 minutes, P < .01). Survival free from greater than moderate MR at 5 years was 92.0% (95% confidence interval [CI], 80.2%-98.1%) in patients with Barlow disease versus 96.0% (95% CI, 93.3%-98.0%) in patients without Barlow disease (P = .40). Predictors of late failure included Barlow disease (hazard ratio, 3.9; 95% CI, 1.7-9.0) and non-Barlow isolated anterior leaflet prolapse (hazard ratio, 5.6; 95% CI, 2.3-13.4).

CONCLUSIONS

Barlow disease may be reliably and safely repaired with acceptable long-term durability by experienced robotic mitral surgery programs.

Midterm outcomes of aortic valve replacement using a rapid-deployment valve for aortic stenosis: TRANSFORM trial

Background

The use of rapid-deployment valves (RDVs) has been shown to reduce the operative time for surgical aortic valve replacement (AVR). Long-term core laboratory-adjudicated data are scarce, however. Here we report final 7-year data on RDV use.

Methods

TRANSFORM was a prospective, nonrandomized, multicenter, single-arm trial implanting a stented bovine pericardial valve with an incorporated balloon-expandable sealing frame. A prior published 1-year analysis included 839 patients from 29 centers. An additional 46 patients were enrolled and implanted, for a total of 885 patients. Annual clinical and core laboratory-adjudicated echocardiographic outcomes were collected through 8 years. Primary endpoints were structural valve deterioration (SVD), all-cause reintervention, all-cause valve explantation, and all-cause mortality. Secondary endpoints included hemodynamic performance assessed by echocardiography. The mean duration of follow-up was 5.0 ± 2.0 years.

Results

The mean patient age was 73.3 ± 8.2 years. Isolated AVR was performed in 62.1% of the patients, and AVR with concomitant procedures was performed in 37.9%. Freedom from all-cause mortality at 7 years was 76.0% for isolated AVR and 68.2% for concomitant AVR. Freedom from SVD, all-cause reintervention, and valve explantation at 7 years was 97.5%, 95.7%, and 97.8%, respectively. The mean gradient and effective orifice area at 7 years were 11.1 ± 5.3 mm Hg and 1.6 ± 0.3 cm2, respectively. Paravalvular leak at 7 years was none/trace in 88.6% and mild in 11.4%. In patients undergoing isolated AVR, the cumulative probability of pacemaker implantation was 13.9% at 30 days, 15.5% at 1 year, and 21.8% at 7 years.

Conclusions

AVR for aortic stenosis using an RDV is associated with low rates of late adverse events. This surgical pericardial tissue platform provides excellent and stable hemodynamic performance through 7 years.

Outcomes of minimally invasive isolated tricuspid valve repair and replacement through right mini-thoracotomy

Objective

Isolated tricuspid valve surgery is uncommon and associated with high perioperative morbidity and mortality. We aimed to study the overall outcomes of patients who underwent minimally invasive right thoracotomy tricuspid valve surgery (Mini-TVS), consisting of either tricuspid valve repair (TVre) or replacement (TVR).

Methods

We performed a retrospective analysis of all Mini-TVS procedures (2017-2022), through which we identified isolated tricuspid valve surgeries. We examined in-hospital outcomes, survival analysis over a 4-year period, and competing risk analysis for reoperative surgery.

Results

Among a total of 51 patients, the average age was 60 ± 16 years, and 67% (n = 34) were female. Severe tricuspid regurgitation was present in all cases. Infective endocarditis was noted in 7.8% (n = 4), and 24% (n = 12) had preexisting pacemakers. Mini-TVS included TVre in 18 patients (35%) and TVR in 33 patients (65%). The in-hospital and 30-day mortality rates were 4% (n = 2) and 6% (n = 3), respectively. At 4 years, the overall TVS survival was 76% (confidence interval, 62-93%), with no significant difference between TVre and TVR (91% vs 69%, P = .16). At follow-up, 3 patients required repeat surgery for recurrent regurgitation after 2.6, 3.3, and 11 months, with a reoperation rate of 7.3% (confidence interval, 2.4-22%) at 2 years. Factors associated with worse overall survival included nonelective surgery, right ventricular dysfunction, serum creatinine >2 g/dL, and concomitant left-sided valve disease.

Conclusions

A nonsternotomy minimally invasive approach is a feasible option for high-risk patients. Midterm outcomes were similar in repair or replacement. Patients with right ventricular dysfunction and left-sided disease had worse outcomes.

A multi-center comparison of surgical techniques for corpus Callosotomy in pediatric drug-resistant epilepsy

OBJECTIVES

Corpus callosotomy (CC) is used to reduce seizures, primarily in patients with generalized drug-resistant epilepsy (DRE). The invasive nature of the procedure contributes to underutilization despite its potential superiority to other palliative procedures. The goal of this study was to use a multi-institutional epilepsy surgery database to characterize the use of CC across participating centers.

METHODS

Data were acquired from the Pediatric Epilepsy Research Consortium (PERC) Surgery Database, a prospective observational study collecting data on children 0-18 years referred for surgical evaluation of DRE across 22 U.S. pediatric epilepsy centers. Patient, epilepsy, and surgical characteristics were collected across multiple CC modalities. Outcomes and complications were recorded and analyzed statistically.

RESULTS

Eighty-three patients undergoing 85 CC procedures at 14 participating epilepsy centers met inclusion criteria. Mean age at seizure onset was 2.3 years (0-9.4); mean age for Phase I evaluation and surgical intervention were 9.45 (.1-20) and 10.46 (.2-20.6) years, respectively. Generalized seizure types were the most common (59%). Complete CC was performed in 88%. The majority of CC procedures (57%) were via open craniotomy, followed by laser interstitial thermal therapy (LiTT) (20%) and mini-craniotomy/endoscopic (mc/e) (22%). Mean operative times were significantly longer for LiTT, whereas mean estimated blood loss was greater in open cases. Complications occurred in 11 cases (13%) and differed significantly between surgical techniques (p < .001). There was no statistically significant difference in length of postoperative stay across approaches. Mean follow-up was 12.8 months (range 1-39). Favorable Engel outcomes were experienced by 37 (78.7%) of the patients who underwent craniotomy, 10 (58.8%) with LiTT, and 12 (63.2%) with mc/e; these differences were not statistically significant.

SIGNIFICANCE

CC is an effective surgical modality for children with DRE. Regardless of surgical modality, complication rates are acceptable and seizure outcomes generally favorable. Newer, less-invasive, surgical approaches may lead to increased adoption of this efficacious therapeutic option for pediatric DRE.

Bronchoscopic Laser Resection as a Monotherapy for Bronchial Carcinoid

Lung carcinoid tumors are rare neuroendocrine cancers that primarily affect younger individuals and exhibit unique epidemiological characteristics unrelated to smoking or environmental factors. Symptoms may include coughing and wheezing. Bronchoscopic biopsy is the standard for diagnosis, with surgical resection as the gold standard treatment. Recent advances, such as laser resection, offer alternative options. We present a case of a 46-year-old female with bronchial carcinoid successfully treated using bronchoscopic diode laser therapy, highlighting its minimally invasive benefits. The success of this approach depends on tumor location, underscoring the importance of considering tumor characteristics in treatment decisions. Our report contributes to the evolving landscape of bronchogenic tumor management, emphasizing the need for continued research.

Horizontal versus vertical direction of posterior vaginal wall suture after eradication of rectovaginal endometriosis: A multicenter study

OBJECTIVE

To compare safety and effectiveness of two-different directions of suturing the posterior vaginal breach (horizontal [Ho] vs vertical [Ve]) in women undergoing recto-vaginal endometriosis (RVE) nodule resection.

METHODS

A multicenter, retrospective, observational, cohort study was performed including all women of reproductive age undergoing RVE nodule resection between March 2013 and December 2018 at our tertiary centers. Patients included in the present study were divided into two groups based on the direction in suturing the posterior vaginal fornix defect, for comparisons in terms of rate of postoperative complications, pain relief, pain and anatomical recurrence, and length of hospital stay. Univariate comparisons were performed adopting the t test or the Mann-Whitney test for continuous data and the chi-square test or the Fisher exact test for categorical data, with a significant P value set to <0.05.

RESULTS

A total of 101 women were included: 67 in the Ho-group and 34 in the Ve-group. The two groups did not significantly differ in length of hospital stay (6.7 ± 6.9 vs 6.6 ± 3.3 days; P = 0.95), overall postoperative complications (32.8% vs 14.7%; P = 0.05), pain recurrence (35.8% vs 26.5%; P = 0.34) and anatomical recurrence rate (19.4% vs 23.5%; P = 0.62). Conversely, grade III complications were significantly more common in the Ho-group than in the Ve-group (22.7% vs 20%, P = 0.009), while pain relief in terms of deep dyspareunia, dyschezia, dysuria and chronic pelvic pain was more consistent in the Ve-group patients (P = 0.04, 0.04, 0.05, 0.004, respectively).

CONCLUSION

In symptomatic women undergoing RVE nodule resection, Ho suturing of the vaginal breach appears more commonly associated with severe postoperative complications and a worse pain control.

As simple as it sounds? The treatment of simple bone cysts in the proximal femur in children and adolescents: Retrospective multicenter EPOS study of 74 patients

Purpose

Simple bone cysts are among the most prevalent benign cystic tumor-like lesions in children. Proximal femoral simple bone cysts may require specific treatment because of increased fracture risk. With limited literature available on this specific localization, consensus regarding optimal treatment is lacking. We present a large international multicenter retrospective cohort study on proximal femoral simple bone cysts.

Methods

All consecutive pediatric patients with proximal femoral simple bone cyst from 10 tertiary referral centers for musculoskeletal oncology were included (2000-2021). Demographics, primary treatment, complications, and re-operations were evaluated. Primary outcomes were time until full weight-bearing and failure-free survival.

Results

Overall, 74 simple bone cyst patients were included (median age 9 years (range = 2-16), 56 (76%) male). Median follow-up was 2.9 years (range = 0.5-21). Index procedure was watchful waiting (n = 6), percutaneous procedure (n = 12), open procedure (n = 50), or osteosynthesis alone (n = 6). Median time until full weight-bearing was 8 weeks (95% confidence interval = 0.1-15.9) for watchful waiting, 9.5 (95% confidence interval = 3.7-15.3) for percutaneous procedure, 11 (95% confidence interval = -0.7 to 13.7) for open procedure, and 6.5 (95% confidence interval = 5.9-16.1) for osteosynthesis alone (p = 0.58). Failure rates were 33%, 58%, 29%, and 0%, respectively (p = 0.069). Overall failure-free survival at 1, 2, and 5 years was 77.8% (95% confidence interval = 68.2-87.4), 69.5% (95% confidence interval = 58.5-80.5), and 62.0% (95% confidence interval = 47.9-76.1), respectively.

Conclusion

A preferred treatment for proximal femoral simple bone cysts remains unclear, with comparable failure rates and times until full weight-bearing. Watchful waiting may be successful in certain cases. If not feasible, osteosynthesis alone can be considered. Treatment goals should be cyst control, minimizing complications and swift return to normal activities. Therefore, an individualized balance should be made between undertreatment, with potentially higher complication risks versus overtreatment, resulting in possible larger interventions and accompanying complications.

Level of evidence

Level IV, retrospective multicentre study.