Surgeries, Volume 6, Issue 4 (December 2025) – 34 articles

Background: Tight blood pressure control is a cornerstone of postoperative cardiac surgery patients. In addition, plasma lactate levels are frequently monitored in this setting as it is a marker for malperfusion, with early elevated levels being associated with increased morbidity and mortality. Elevations from malperfusion may be due to decreased cardiac output, hypovolemia, or persistent post-bypass vasoplegic response. Here, we investigate whether lower blood pressures, significant changes from baseline, and cardiac perfusion pressures delay the clearance of lactate after cardiac surgery. Methods: This is a retrospective cohort observational study of patients who have undergone coronary artery bypass graft (CABG) and valve replacement or repair surgeries at NYU Langone Long Island Hospital over a 6-month period. Postoperative blood pressures and lactate levels were examined over the first 16 h of care. Primary outcome: The relationship between blood pressure parameters and lactate clearance. Secondary outcomes: ICU length of stay, hospital length of stay, and mortality. Results: A total of 81 patients met inclusion criteria. The average pre-operative mean arterial blood pressure (MAP) was 95.4 mmHg and the average MAP in the first 6 h post-operatively was 78.4 mmHg. The average change in MAP from baseline was a decrease of 16.7%. The average cleared lactate fraction by 16 h postoperatively was 85.9%. Lactate clearance was associated in a statistically significant way only with the need for inotropic support on postoperative day 1, p = 0.03. There was a slight trend toward a delay in lactate clearance in those with lower early systolic blood pressures, p = 0.14. Conclusions: Lactate clearance appears to occur largely independently of postoperative blood pressures in the first 16 h after surgery but may be delayed in those requiring inotropic support through the morning or postoperative day one. Full article

Objective: To demonstrate that PerClot’s efficacy is non-inferior to other hemostatic treatments and its safety is non-inferior to the standard of care (SoC) during surgery. Methods: Applying keywords and inclusion criteria, we queried electronic databases to conduct a systematic (e.g., Embase and Cochrane Library, etc.) and manual search (e.g., Google Scholar, etc.) for studies from 1 January 2008 (first CE marked date) to 30 March 2024. Results: Five published studies were included in this systematic review. From the included studies, 691 patients received either PerClot (n = 315) or other hemostatic agents/SoC/control (n = 376) in different surgical specialties. All five studies had comparable outcome measures, interventions, and control groups, allowing for the pooling of the study data. The primary outcomes were the achievement of hemostasis and time to hemostasis. At 7 min post-application, PerClot demonstrated non-inferior hemostasis performance as compared to Arista (absolute difference: −1.4%; 95% CI: −7.54, 4.74; p = 0.65). The time to achieve hemostasis was comparable between PerClot and other hemostatic agents (mean difference: 0.00 min; 95% CI: 0.00, 0.00; p = 1.00). No statistically significant difference in adverse event occurrence was observed between PerClot and other hemostatic agents/SoC groups (absolute difference: 0.02; 95% CI: −0.30, 0.35; p = 0.2691) and the absence of new unknown adverse events indicates the safety profile of PerClot. The results of all outcome measures are statistically insignificant. Conclusions: Our systematic review demonstrated that PerClot achieved comparable hemostasis with no new safety concerns and a statistically significant reduction in postoperative drainage volume, indicating its safety, efficacy, and performance as an alternative for hemostasis across multiple surgical specialties. Full article

Background: The development of CAD, FEA, and biomechanical models of the shoulder is challenging due to the joint’s complexity. The spatial relationships between bones, muscles and ligaments are difficult to parameterize, both statically and dynamically, because these structures move three-dimensionally and synergistically. Methods: An assembly of the shoulder joint was developed, including parameterisation of the positional relationships among the rotator cuff structures, with particular focus on the bone components: Humerus, Scapula, Clavicle, and Sternum. Discussion: The abundance of existing CAD models of the shoulder makes it difficult to compare numerical results. Variability in reference frames, positioning assumptions and geometric relationships often hinders reproducibility and cross-study interpretation. Conclusions: The presented methodology supports standardised assembly of a shoulder joint model, ensuring consistent assumptions about the relative positioning of the bony structures. This standardization enables more accurate numerical comparisons across studies and improves the reliability of biomechanical research on the shoulder. Full article

Background: Trapeziometacarpal osteoarthritis (TMC OA) is a prevalent degenerative disorder that causes considerable pain and functional limitations, especially in older individuals, whose ideal treatment is still debated in the literature. Various treatments are described to restore a good functional outcome of the thumb; over the past 50 years, biological arthroplasties have been considered the gold standard for treating advanced stages of TMC OA. However, in the last decade, the use of dual mobility cup prostheses has significantly increased, with numerous studies reporting excellent clinical outcomes. In this case report, we show the results of a patient treated on the left hand with suspension arthroplasty and on his right hand with dual mobility arthroplasty in one-stage surgery. The aim of this case report is to directly compare outcomes between trapeziometacarpal prosthesis and suspension arthroplasty performed simultaneously in the same patient. Case Presentation: The present case reports a 71-year-old male patient with bilateral TMC osteoarthritis, referred to our clinic in May 2024. His medical history included hypertension, hypertriglyceridemia, paroxysmal atrial fibrillation, and benign prostatic hyperplasia. On examination, the right hand showed grade 3 osteoarthritis according to the Eaton–Littler classification, with the trapezium maintaining adequate bone stock, making the patient eligible for trapeziometacarpal prosthesis implantation. Conversely, the left hand demonstrated scaphotrapezoid arthritis with a slight reduction in trapezial bone stock, indicating the need for trapeziectomy followed by suspension arthroplasty. Both procedures were performed during the same surgical session by the same experienced hand surgeon using a lateral approach. On the right side, the trapeziometacarpal joint surfaces were resected and replaced with a dual mobility prosthesis, while on the left side, the trapezium was excised, and suspension arthroplasty was performed using a slip of the flexor carpi radialis (FCR) tendon. Methods: The patient underwent simultaneous treatment with a dual mobility trapeziometacarpal prosthesis on the right hand and trapeziectomy with suspension arthroplasty on the left hand. Clinical outcomes (grip and pinch strength, pain, QuickDASH, satisfaction, and range of motion) were evaluated at 1, 3, 6, and 12 months. Paired comparative statistics were applied with significance set at p < 0.05. Results: At all follow-up intervals (1, 3, 6, and 12 months), the hand treated with a trapeziometacarpal prosthesis demonstrated superior grip and pinch strength compared to the hand treated with trapeziectomy and suspension arthroplasty, with the greatest difference observed at 3 months. At 12 months, grip strength increased from 28 kg to 40 kg in the prosthesis-treated hand and from 25 kg to 33 kg in the suspension arthroplasty hand. Paired comparisons were performed at each follow-up interval up to 12 months, confirming a significant difference for grip strength. Pain levels (VAS, Visual Analogue Scale) decreased progressively in both hands, with a more rapid reduction in the hand treated with a trapeziometacarpal prosthesis, reaching statistical significance. QuickDASH scores indicated an earlier return to daily activities in the hand treated with the prosthesis, although this difference was not statistically significant. Patient satisfaction was consistently higher for the hand treated with a trapeziometacarpal prosthesis, with the patient reporting a ‘very satisfied’ rating at all timepoints. Range of motion recovery, assessed through the Kapandji score and measurements of thumb abduction and extension, also favored the hand treated with the prosthesis, with statistically significant differences for abduction and extension, whereas the hand treated with trapeziectomy and suspension arthroplasty demonstrated more gradual improvement over time. Conclusions: This case highlights the functional efficacy of both surgical approaches—biological arthroplasty and trapeziometacarpal prosthesis—in the treatment of TMC osteoarthritis. Both procedures resulted in a good clinical outcome and high patient satisfaction. However, recovery was noticeably faster in the hand treated with a trapeziometacarpal prosthesis, which is consistent with findings previously reported in the literature. These observations suggest that, while both techniques are valid and effective, trapeziometacarpal prosthetic replacement may offer a quicker return to function in appropriately selected patients. Full article

Introduction: Chest drainage is central to thoracic surgery, pleural medicine, and emergency care, yet practice remains heterogeneous in tube caliber, access, suction, device selection, and removal thresholds. This narrative review aims to synthesize evidence and translate it into guidance. Materials and Methods: We performed a narrative review with PRISMA-modeled transparency. Using backward citation from recent comprehensive overviews, we included randomized trials, meta-analyses, guidelines/consensus statements, and high-quality observational studies. We extracted data on indications, technique, tube size, analog versus digital drainage, suction versus water-seal drainage, removal criteria, and key pleural conditions. Due to heterogeneity in device generations, suction targets, and outcomes, we synthesized the findings qualitatively according to converged evidence. Results: After lung resection, single-drain strategies, early use of water-seal, and standardized removal at ≤300–500 mL/day reduce pain and length of stay without increasing the need for reintervention; digital systems support objective removal using sustained low-flow thresholds (approximately 20–40 mL/min). Small-bore (≤14 Fr) Seldinger catheters perform comparably to larger tubes for secondary and primary pneumothorax and enable ambulatory pathways. In trauma, small-bore approaches can match large-bore drainage in stable patients when paired with surveillance and early escalation of care. For pleural infection, image-guided drainage, combined with fibrinolytics or surgery, is key. Indwelling pleural catheters provide relief comparable to talc in dyspnea associated with malignant effusions in patients with non-expandable lungs. Complications are mitigated by ultrasound guidance and avoiding abrupt high suction after chronic collapse; however, these strategies must be balanced against risks of malposition, occlusion or retained collections, prolonged air leaks, and device complexity, which demand protocolized escalation and team training. Conclusions: Practice coalesces around three pillars—right tube, right system, proper criteria. Adopt standardized pathways, device-agnostic thresholds, and volume or airflow criteria. Trials should harmonize “seal” definitions and validate telemetry-informed removal strategies. Full article

The study reports a diagnostic challenge involving an inflammatory lesion mimicking a brown tumor. A 23-year-old male patient was referred for treatment of a cystic lesion in the left frontal process of the maxilla and ethmoid region. The leading symptoms were hemoptysis and chronic sinus inflammation. Endoscopic surgery was performed under general anesthesia, including curettage and drainage of the lesion into the middle nasal meatus. Histopathological examination revealed chronic inflammatory and fibrotic changes with hemosiderin deposits and CD68(+) histiocytes, findings that could suggest a brown tumor. However, subsequent laboratory investigations excluded this diagnosis. Postoperative healing was uneventful, with complete resolution of symptoms. This report highlights the importance of distinguishing inflammatory from metabolic bone lesions in the paranasal sinuses and underscores the critical role of histopathological evaluation in differentiating true neoplasms from inflammatory pseudotumors. Full article

Background/Objectives: Adipose tissue (AT) plays significant roles in energy storage, metabolite signaling, and immunomodulation. The understanding of its underlying mechanisms of dysregulation can provide insight into complex disease processes through analysis with histology, flow cytometry, metabolomics, and proteomics. Tissue sampling in the clinical setting has largely shifted towards minimally invasive approaches to improve factors such as patient satisfaction, post-operative recovery, and procedure length. In contrast, preclinical animal models continue to rely on more invasive methods until refined, minimally invasive techniques are developed and systematically assessed. To improve animal welfare and enhance clinical translatability, there is a critical need to reverse translate these approaches into animal models. Methods: Our study evaluated the feasibility and performance of a commercially available vacuum-assisted biopsy (VAB) device for AT sampling in a preclinical nonhuman primate (NHP) model. Six rhesus NHPs successfully underwent three serial AT biopsies with a VAB device (n = 18). Results: All animals recovered without any serious or unexpected adverse events. The amount of adipose tissue collected per biopsy (0.5–2.7 g) was proportional to the number of individual tracks. Isolation of the stromal vascular fraction (SVF) from a subset of samples (n = 6) yielded 0.41 ± 0.12 × 10⁶ cells/g of tissue. Conclusions: The minimally invasive VAB technique is a safe and reliable method of AT collection in NHPs. This feasibility study demonstrated adequate volumes of tissue cores that are suitable for typical, downstream research applications including immunologic studies and pathology, while improving animal welfare. Full article

Introduction: Lateral epicondylitis (LE) typically affects the extensor carpi radialis brevis (ECRB) tendon, while isolated degeneration of the extensor digitorum communis (EDC) origin is rare and poorly characterized. Surgical debridement of these lesions may result in capsular exposure requiring soft-tissue coverage, which can be achieved through a vascularized muscle flap to enhance tendon healing potential and reduce recurrence. This study aimed to describe a modification of the anconeus rotation flap as originally described by Almquist in 1998, and to evaluate its clinical and functional outcomes in patients with isolated EDC tendinopathy. The modified technique consists of a simpler muscle advancement (AMA) that preserves the distal vascular pedicle and reduces soft-tissue dissection. Methods: A retrospective study was conducted on 12 consecutive patients with lateral epicondylitis with isolated EDC tendon involvement (10.71% of all operative cases at our Institution between 2019 and 2022), who were surgically treated with the anconeus muscle advancement modification. Clinical outcomes, including the visual analog pain scale (VAS), grip strength and patient-reported outcome measures (PROMs), which include the QuickDASH score, the Mayo Elbow Performance Score (MEPS) and the Patient-Rated Tennis Elbow Evaluation (PRTEE) score were assessed. Paired statistical tests with 95% confidence intervals and minimal clinically important difference (MCID) thresholds were applied. Results: At a mean follow-up of 38 months, all outcomes demonstrated statistically significant and clinically meaningful improvements (p < 0.05). Reductions in pain/disability (VAS, QuickDASH, PRTEE scores) and functional gains (Grip strength, MEPS) far exceeded their respective MCID thresholds, with 100% attainment for each outcome. Conclusions: This modified anconeus muscle advancement appears to be a technically feasible option for managing isolated EDC-related lateral epicondylitis, preserving vascular integrity while limiting dissection. Although favorable results were obtained, the small retrospective cohort precludes definitive conclusions regarding efficacy. The findings support the technical feasibility of the proposed modification and warrant further prospective comparative investigations. Full article

Background: The Orbay approach to volar distal radius described a volar zig-zag incision across the wrist crease, allowing a more distal exposure than traditional approaches. This adaptation enhances mobilization of the proximal radial fragment and improves visualization of both the articular surface and dorsally displaced distal radius fractures. Methods: In the present paper, we propose a further modification of the volar zig-zag approach, positioning the apex of the incision at the level of the radial styloid. Results: This modification aims to improve visualization of the radial styloid, the articular comminution, and the dorsal aspect of the distal radius, thereby optimizing fracture exposure and reduction. Conclusions: The principal advantage lies in the reduced need for traction along the radial margin of the incision to achieve adequate visualization and the avoidance of crossing the wrist crease, thereby preventing the formation of unsightly or adherent scars. Full article

Background: Open phalangeal fractures raise timing questions that may not mirror long-bone protocols. We aimed to test whether time-to-surgery is associated with infection, time to union, and return to work. Methods: A single-centre retrospective cohort study was conducted between October 2023 and January 2025. Adults with open phalangeal fractures were grouped by time-to-surgery: ≤24 h (A), 24–72 h (B), and ≥72 h (C). Primary outcome was infection while secondary outcomes were time to radiographic union and time to return to work. Results: Ninetypatients were finally included. Baseline demographics and injury characteristics did not differ significantly among groups (all p >0.05). Infection occurred in 10/90 patients (11%); rates were similar across the three windows—10%, 10%, and 12%—with no association between timing and infection (χ² = 0.09; p =0.96). Mean time to union was 48.4 ± 16.2, 56.0 ± 2.9, and 47.8 ± 14.4 days for the ≤24 h, 24–72 h, and ≥72 h groups, respectively, without significant between-group differences (p = 0.61). Return to work occurred at 92.0 ± 25.5, 70.0 ± 17.3, and 74.0 ± 46.0 days, again with no significant difference by timing (p = 0.53). Overall, no clinically meaningful trend favoured earlier surgery within the studied windows. Conclusions: In this heterogeneous yet clinically representative cohort of open phalangeal fractures, surgical timing up to and beyond 72 h was not associated with infection, time to union, or time to return to work. These findings support individualized decision-making, while larger prospective studies are needed to refine timing thresholds. Full article

Background: Odontogenic myxoma (OM) is a rare, benign, but locally aggressive tumor of odontogenic mesenchymal origin. This study aims to expand current knowledge by integrating a concise literature review with a detailed case report of a surgically complex pediatric OM, treated using a biologically advantageous reconstructive technique. Methods: In this study, we report the case of an eight-year-old girl presenting with a large OM that caused complete disruption of the architecture of the left hemimandible. Due to the tumor’s size and bone involvement, radical resection was necessary. A modified extraoral facelift approach was employed to ensure adequate surgical access while avoiding intraoral incisions and minimizing visible scarring. Immediate mandibular reconstruction was performed using an autologous costochondral graft. Discussion: Although infrequently used in modern surgical practice, the costochondral graft offers unique advantages in pediatric patients due to its inherent growth potential and capacity for long-term biological integration. In this case, the graft allowed restoration of mandibular continuity and form with minimal donor site morbidity, demonstrating its viability even today. Conclusions: This case underlines the importance of tailored reconstructive strategies in pediatric OM. The costochondral graft provided excellent functional and esthetic results, with four-year follow-up confirming stable anatomical remodeling and bone regeneration. Full article

Background: Total knee arthroplasty (TKA) is the gold standard for advanced hemophilic arthropathy. However, surgical management in hemophilic patients is complex due to joint deformities, bleeding risk, and systemic comorbidities. This study aimed to compare the surgical outcomes and cost-effectiveness of TKA in hemophilic versus non-hemophilic patients. Methods: This prospective study included 50 patients treated between 2010 and 2024 at Elias University Hospital, Romania. Group 1 included 20 male patients with severe hemophilia (2 with inhibitors); Group 2 included 30 non-hemophilic male patients. Data collection was standardized and conducted preoperatively, at 6 and 12 months postoperatively, and annually thereafter for up to 14 years following surgery. The mean follow-up duration across the cohort was 7.3 ± 3.9 years (range: 0.5–14 years), allowing for consistent long-term evaluation of clinical and functional outcomes. Study included operative time, transfusion requirements, hospitalization length, perioperative complications, functional outcomes (Knee Society Score—KSS), quality of life (EQ-5D), and cost per quality-adjusted life year (QALY). Results: Hemophilic patients had significantly longer operative times (154.5 vs. 88.7 min; p < 0.001), higher transfusion rates (45% vs. 20%, p < 0.047), and longer hospital stays (mean 12.3 vs. 6.6 days). Perioperative complications occurred in 90% of hemophilic patients (anemia requiring transfusion: 45%; compressive hematomas: 10%; wound dehiscence: 15%) compared to 10% in controls. Non-hemophilic patients achieved superior postoperative functional scores. Mean preoperative KSS was 32.25 ± 11.24 and postoperatively, the mean score increased to 98 ± 1.34. The mean preoperative KSS in the hemophilic group was 31 ± 13.93 and postoperative KSS was 74.5 ± 19.92. The cost per QALY was €2506 in the hemophilic group versus €1258 in controls. The economic assessment was conducted from the hospital perspective, focusing on direct medical costs incurred during hospitalization and the perioperative period. Cost components included factor replacement therapy, surgical and anesthesia costs, hospital stay, laboratory investigations, blood transfusions, and management of postoperative complications. Conclusion: Although TKA improves quality of life and function in hemophilic patients, it is associated with higher complication rates and costs. These findings highlight the need for careful patient selection and informed consent when considering TKA in hemophilic patients. Full article

Background: Hospitals generate large volumes of single-use plastic waste, which are predominantly incinerated. To improve sustainability, standardized procedure-specific surgical trays have been implemented, reducing waste and setup time. This early feasibility study investigated whether all residual plastics from surgical procedures could be recycled via pyrolysis into high-quality oil for circular reuse in medical supply production. Methods: All residual plastics from five transurethral resection (TUR) trays were subjected to pyrolysis at 430–460 °C in a batch reactor. Condensable fractions were separated into heavy (HF) and light (LF) oils, while non-condensable gases and coke were quantified. Chemical analyses included the density, water content, heating value, and elemental composition. Results: From 1.102 kg of input material, the process yielded 78 weight percent (wt%) oil (HF 59.1%, LF 40.9%), 20.5 wt% gas, and 1.5 wt% coke. HF solidified at room temperature, whereas LF remained liquid, reflecting distinct hydrocarbon chain distributions. The oils exhibited densities of 767.0 kg/m³ (HF) and 748.9 kg/m³ (LF), heating values of 46.39–46.80 MJ/kg, low water contents (<0.05 wt%), and minimal contamination (silicone ≤ 193 mg/kg; chlorine ≤ 110 mg/kg). Conclusions: Pyrolysis of surgical tray plastics produces decontaminated high-energy oils comparable in quality to fossil fuels, with a material recovery rate exceeding 75% and potential CO₂ savings of ~ 2.9 ton per t plastic compared with incineration. This process provides a technically and ecologically viable pathway toward a scalable circular economy in healthcare. Full article

Background: Peritoneal metastasis (PM) from colorectal cancer (CRC) carries a poor prognosis. The Peritoneal Cancer Index (PCI) is among the principal prognostic stratification tools, yet the prognostic value of the anatomical distribution of disease beyond total PCI is underexplored. This pilot study evaluated whether quadrant-specific involvement adds prognostic information in patients undergoing cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC), with a focused analysis of oligometastatic disease (PCI ≤ 6). Methods: A single-institution cohort of 48 CRC-PM patients treated with CRS + HIPEC was analyzed. Primary endpoints were OS, DFS, and PRFS, with a focused evaluation of the oligometastatic subset (PCI ≤ 6). Comparative statistics used Student’s two-sample t test for continuous variables and chi-square or two-sided Fisher’s exact tests for categorical variables. Survival was estimated by Kaplan–Meier with log-rank tests, and prognostic factors were evaluated using Cox regression. Results: Median follow-up was 177 months (IQR 87–224). Outcomes favored PCI ≤ 6: 5-year OS and DFS were 54% and 37.5% versus 6.6% and 0% for PCI > 6, and median OS 64 vs. 29 months (log-rank p = 0.007), median DFS 30 vs. 7 months (p = 0.0002), and median PRFS 26 vs. 8 months (p = 0.0002). In the PCI ≤ 6 subset (n = 27), quadrant 3 (left upper quadrant) was associated with higher recurrence risk and shorter DFS, remaining independently prognostic for DFS (p = 0.005) and PRFS (p = 0.005). For PRFS, quadrants 7 and 8 also showed associations on univariable analysis; Q7 remained independent (p = 0.047), whereas Q8 was borderline (p = 0.077). A histology-related signal at Q8 (p = 0.011) was exploratory due to very small mucinous and signet-ring strata. Sidedness and synchronicity yielded no significant differences in quadrant involvement within PCI ≤ 6. No quadrant effects were observed in PCI > 6. Conclusions: PCI remains the dominant prognostic determinant after CRS + HIPEC, yet in oligometastatic disease, the anatomical distribution adds complementary prognostic information, particularly involvement of Q3 and Q7. These findings are hypothesis-generating and warrant validation in larger, preferably multicenter cohorts with standardized quadrant mapping. If confirmed, quadrant-directed operative planning, including consideration of prophylactic resection in selected high-risk regions, could be prospectively evaluated. Full article

Background/Objectives: To identify independent predictors of free peritoneal cancer cells (FPCC), and to investigate survival outcomes relative to peritoneal cytology status among patients who underwent intended curative gastrectomy for adenocarcinoma of the stomach or esophagogastric junction. Methods: Medical records of patients who underwent radical surgery between January 2005 and December 2020 were retrospectively reviewed. Clinical data and cytology results were evaluated. Multivariate Cox regression analysis was used to identify independent predictors of FPCC. Kaplan–Meier survival analysis was used to estimate disease recurrence and survival outcomes. Results: Out of the 349 enrolled patients, 188 (53.8%) had negative cytology, 32 (9.2%) were positive, and 129 (36.9%) showed atypical cells in peritoneal cytology. Poor differentiation (adjusted odds ratio [aOR]: 2.63, 95% confidence interval [95%CI]: 1.04–6.82; p = 0.015), pT4 (aOR: 4.62, 95%CI: 1.28–14.34; p = 0.018), pN3 (aOR: 4.13, 95%CI: 1.14–15.03; p = 0.031), and metastatic lymph node ratio >0.40 (aOR: 6.49, 95%CI: 1.44–29.14; p = 0.015) were independent predictors of FPCC. Median overall survival was 34.1 months in the negative group, 13.1 months in the positive group, and 28.7 months in the atypical cell group (p < 0.001). Median time to disease recurrence was 20.5, 4.9, and 11.3 months, respectively (p < 0.001). Survival and recurrence outcomes in the atypical cell group were comparable to those with negative cytology. Conclusions: Poorly differentiated histology, pT4, pN3, and metastatic lymph node ratio >0.40 are independent predictors of FPCC, which is significantly associated with poor survival and disease recurrence outcomes. These findings suggest that high-risk patients may benefit from routine peritoneal cytologic screening during surgery to improve risk stratification and guide postoperative treatment planning. Full article

Herniation of the transplanted ureter into the inguinal canal is an exceptionally rare complication following renal transplantation. Most cases present as delayed-onset obstructions, typically occurring more than one year post-transplant and often involving the ipsilateral inguinal canal. We presented the case of a 49-year-old male kidney transplant recipient who developed obstructive uropathy due to herniation of the graft ureter into the ipsilateral inguinal canal. Diagnosis was confirmed by computed tomography (CT), which proved superior to ultrasonography in delineating the ureteral course. A JJ ureteral stent was successfully placed, followed by inguinal hernia repair using the Lichtenstein technique. The postoperative course was uneventful, with complete resolution of symptoms and preservation of graft function. Transplanted ureteral herniation is a rare but important cause of late post-transplant obstruction. Cross-sectional imaging, particularly CT, offers greater diagnostic accuracy than ultrasound alone in identifying ureteral displacement. When feasible, primary ureteral stenting may obviate the need for nephrostomy, thereby reducing patient morbidity. Full article

Background: Pulmonary hypertension is common in left-sided heart valve disease, with historical studies reporting mortality rates up to 31% in severe cases undergoing mitral valve surgery. This study evaluates the impact of severe pulmonary hypertension on outcomes of mechanical mitral valve replacement with posterior leaflet preservation by comparing results with patients having mild-to-moderate pulmonary hypertension. Methods: Prospective analysis of 86 patients with mitral valve disease undergoing mechanical valve replacement with posterior leaflet preservation from March 2015 to September 2016 was conducted. Patients were stratified by pulmonary artery pressure: severe (≥60 mmHg, n = 19) versus mild–moderate (35–59 mmHg, n = 67). Primary outcomes included mortality, complications, and functional recovery at 1, 6, and 12 months. Results: The cohort included 67 patients (77.9%) with mild–moderate pulmonary hypertension and 19 patients (22.1%) with severe pulmonary hypertension. Severe pulmonary hypertension patients demonstrated higher NYHA functional class (73.7% class III vs. 46.2%, p = 0.03), larger left atrial diameter (56.3 ± 9.8 vs. 49.5 ± 6.7 mm, p = 0.01), and higher mean pressure gradients (14.4 ± 5.3 vs. 11.3 ± 5.0 mmHg, p = 0.025). Mortality was 5.3% in the severe group versus 0% in the mild–moderate group (p = 0.331). Patients with severe pulmonary hypertension required longer ICU stays (6.3 ± 3.7 vs. 4.7 ± 2.2 days, p = 0.024) but showed no significant differences in ventilation time, reoperation rates, or major complications. At the 12-month follow-up, both groups achieved equivalent outcomes in pulmonary artery pressures, left ventricular function, and cardiac dimensions. Conclusion: In this study with a relatively small sample size, severe pulmonary hypertension was associated with significantly longer intensive care unit stay but not with higher mortality compared to mild–moderate pulmonary hypertension, with both groups attaining comparable functional and hemodynamic parameters at 12 months after mechanical mitral valve replacement with posterior leaflet preservation. Full article

Background: THA is a gold-standard intervention for end-stage hip osteoarthritis, historically performed in older adults. However, the growing global obesity epidemic is reshaping this landscape. Emerging evidence suggests that elevated body mass index (BMI) may not only worsen perioperative outcomes but also accelerate the need for surgery at a younger age. Understanding how BMI influences both the timing and safety of THA is crucial to optimizing care in this evolving patient population. Methods: We conducted a retrospective analysis of 1,626,965 elective THA hospitalizations from the Nationwide Inpatient Sample. Patients were stratified by BMI into three categories: <29.9, 30–34.9, and ≥35. Fracture- and oncology-related cases were excluded. ICD-10 codes identified comorbidities and complications. Primary outcomes included age at surgery, in-hospital mortality, length of stay (LOS), complications, and hospitalization costs. Statistical analysis used Pearson correlation, linear regression, chi-square tests, and t-tests via SPSS version 26.0.0.0. Results: Higher BMI was significantly associated with younger age at THA (r = −0.187, p < 0.001). Each 5-unit BMI increase corresponded to a ~2-year decrease in age at surgery. Obese patients had higher rates of hypertension, diabetes, dyslipidemia, and sleep apnea. Complications including blood loss anemia, acute kidney injury, venous thromboembolism, and postoperative infections were more common in higher BMI groups. LOS increased with BMI, though total hospital charges showed minimal clinical variation. Conclusions: Obesity is a key driver of earlier THA and elevated perioperative risk. These findings underscore the need for BMI-tailored surgical planning and risk stratification. As younger, high-BMI patients increasingly undergo THA, future strategies must focus on preoperative optimization, complication prevention, and long-term implant durability. Full article

Background: Pelvic autonomic nerve injury during colorectal surgery causes debilitating urinary, bowel, and sexual dysfunction. This review synthesizes contemporary evidence on neuroanatomy, nerve-sparing techniques, and functional outcomes to minimize iatrogenic injury while maintaining oncologic efficacy. Methods: Systematic analysis of cadaveric studies, clinical trials, and imaging advancements focused on the superior hypogastric plexus, hypogastric nerves, pelvic splanchnic nerves (S2–S4), and inferior hypogastric plexus. Surgical innovations evaluated included robotic-assisted dissection, fluorescence-guided visualization, and intraoperative neuromonitoring. We distinguished evidence for nerve identification from evidence for functional protection and graded study designs accordingly. Results: Anatomical variability (e.g., superior hypogastric plexus leftward deviation 58.8%; hypogastric nerve median width 3.5 mm) necessitates precision techniques. Nerve-sparing approaches reduce urinary dysfunction from 30–70% to 10–30% and sexual dysfunction from 40–80% to 15–30%. However, the functional benefit of specific technical steps is often derived from anatomical rationale and cohort studies, with limited randomized trials for individual maneuvers. While technique refinements such as Denonvilliers’ fascia preservation may offer early sexual function benefits, randomized evidence shows no 12-month urinary advantage and uncertainty regarding longer-term durability; routine adoption should be individualized. Advanced imaging (3 T MRI, diffusion tensor imaging) and fluorescence guidance improve pre-/intraoperative visualization, but randomized evidence for improved postoperative urinary or sexual function is limited. Randomized data support pelvic intraoperative neuromonitoring in reducing urinary deterioration; most adjuncts have observational or feasibility-level support. Conclusions: Integrating neuroanatomical knowledge with advanced technologies enhances identification and may support nerve-sparing execution; however, robust randomized evidence for durable functional protection of novel technologies and specific technical steps remains limited. Priorities include standardizing preservation protocols, conducting randomized trials that validate the efficacy of individual surgical maneuvers, linking identification to functional outcomes, and validating long-term patient-reported outcomes. Full article

Background: Upper eyelid blepharoplasty is one of the most common aesthetic surgeries performed worldwide. The procedure consists of removing excess skin with or without muscle and/or fat from the upper eyelid by a transcutaneous approach and placement of a supratarsal crease. The surgery is performed in a cosmetically sensitive area and every attempt to avoid poor scar formation should be made. Methods: This review presents a conspectus of the existing medical literature regarding scar-avoiding strategies in upper blepharoplasty with the aim of contributing to the reduction in postoperative scar formation. The Medline, Embase, and Cochrane databases were searched on 2 September 2025. Results: The search yielded a total of 562 records, and, following screening, eleven publications were included. Conclusions: A systematic approach to pre-, intra-, and postoperative measures to minimize scarring are presented. There is a need to standardize scar assessment and reporting to facilitate inter-study comparison of effects, as well as prospective, randomized studies comparing suture materials and techniques. Full article

Background/Objectives: Ultrasound-guided carpal tunnel release (UGCTR) has emerged as a minimally invasive alternative to open surgery for the treatment of carpal tunnel syndrome (CTS). This study aimed to evaluate the clinical outcomes, complication rates, and recovery profiles associated with UGCTR in a large multicenter cohort. Methods: A retrospective observational study was conducted across Italian hand surgery centers, including 735 patients who underwent UGCTR between January 2012 and April 2025. Data were collected on demographics, comorbidities, ultrasound measurements, and surgical outcomes. Primary endpoints included pain (measured using the Visual Analog Scale [VAS]), symptom severity and function (assessed via the Boston Carpal Tunnel Questionnaire [BCTQ]), complication rates, time to return to daily activities (RDA), and return to work (RTW). Follow-up assessments were performed at 1, 4, and 12 weeks postoperatively. Results: A significant improvement in pain was observed, with mean VAS scores decreasing from 6.37 preoperatively to 0.58 at 12 weeks. The mean cross-sectional area (CSA) of the median nerve decreased from 12.81 mm² to 8.83 mm² at 4 weeks. Both the BCTQ Symptom Severity Scale (BCTQ-SS) and Functional Status Scale (BCTQ-FS) scores showed significant improvement by week 1. The mean RDA was 5.7 days, and RTW was 14.5 days. Complication rates were low and decreasing over time, from 8.7% at 1 week to 3.4% at 12 weeks. Conclusions: UGCTR is a safe and effective technique for the treatment of CTS, offering rapid functional recovery and a favorable complication profile. Its feasibility in outpatient settings and potential for cost-effectiveness support its role as a viable alternative to open surgery and as a model of image-guided, minimally invasive intervention. Full article

Background: Lumbar foraminal stenosis (LFS) is a prevalent degenerative condition associated with significant radicular pain and impaired quality of life. Advances in minimally invasive and fusion-based surgical techniques have introduced new strategies for decompressing the neural elements. However, comparative data correlating volumetric foraminal expansion with functional outcomes remain limited. Methods: This retrospective cohort study analyzed 256 patients treated surgically for symptomatic LFS between December 2017 and December 2023. Patients were categorized into four surgical subgroups: endoscopic decompression, anterior lumbar interbody fusion (ALIF), microsurgical decompression, and transforaminal lumbar interbody fusion (TLIF). Preoperative and postoperative assessments included magnetic resonance imaging (MRI) to calculate foraminal volume and standardized clinical scales: the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) for back and leg pain, and SF-36 health-related quality-of-life scores. Statistical significance was determined using p-values, and inter-observer agreement was evaluated via κ-statistics. Results: Postoperative imaging demonstrated a significant increase in foraminal canal volume across all surgical groups: endoscopy (29.9%), ALIF (71.8%), microsurgery (48.06%), and TLIF (67.0%). ODI scores improved from a preoperative mean of 55.25 to 18.27 at 24 months post-surgery (p < 0.001). VAS scores for back pain decreased from 6.37 to 2.1 (p < 0.001), while leg pain scores declined from 6.85 to 2.05 (p < 0.001). Functional improvement reached or exceeded the minimal clinically important difference (MCID) threshold in over 66% of patients. Conclusions: Modern surgical strategies for LFS, particularly fusion-based techniques, yield significant volumetric decompression and durable clinical improvement. Volumetric gain in the foraminal canal is closely associated with pain reduction and enhanced functional outcomes. These findings support a tailored surgical approach based on anatomical pathology and segmental stability. Full article

Background and Objectives: Effective pain management is essential for optimizing recovery after laparoscopic cholecystectomy (LC). Ultrasound-guided erector spinae plane (ESP) and transversus abdominis plane (TAP) blocks are validated techniques, but may be limited by equipment requirements and technical complexity. This study aimed to evaluate whether surgeon-delivered local anesthetic infiltration provides comparable analgesic efficacy. Materials and Methods: This prospective, randomized, controlled, single-center trial enrolled 172 patients undergoing elective LC between November 2020 and June 2022. Patients were randomized into four groups: Group A—surgeon-delivered port-site and intraperitoneal bupivacaine infiltration; Group B—ESP block; Group C—TAP block; and Group D—control. Primary outcomes were postoperative pain assessed by Visual Analog Scale (VAS) scores at 1, 3, 6, 12, and 24 h, and Behavioral Pain Scale (BPS) scores at 1 and 3 h. Secondary outcomes included 24 h tramadol consumption, patient satisfaction, additional rescue analgesia requirement, and procedure duration. Results: All intervention groups (A–C) demonstrated significantly lower VAS and BPS scores compared to controls (VAS at 24 h: 1.8 ± 0.9 vs. 2.8 ± 1.3, p < 0.001). Tramadol use was also reduced (≈82 mg vs. 97 mg, p < 0.001), with fewer opioid-related adverse effects. No significant differences were observed among Groups A–C. Patient satisfaction was higher in the intervention groups, and no major complications were reported. Conclusions: Surgeon-delivered local infiltration achieved analgesic efficacy equivalent to ESP and TAP blocks. Considering its simplicity, safety, and minimal resource demands, this method may represent a practical alternative for enhanced recovery pathways following LC. Full article

Background/Objectives: The use of vaginal mesh for pelvic organ prolapse (POP) repair remains controversial following global restrictions due to safety concerns. This study evaluated intra- and perioperative morbidity following a standardized single-incision, six-point fixation approach using an ultralight vaginal mesh in primary surgery for anterior/central POP. Methods: We conducted a retrospective multicenter study including 426 women who underwent primary POP repair with the InGYNious mesh system between May 2016 and February 2024. All surgeries followed a uniform technique across seven Italian centers. Data were collected on perioperative complications, urinary function, postoperative pain, and catheter duration. Results: The overall morbidity rate was 7.3% (31/426), primarily due to hematomas (4.5%), bladder injuries (1.4%), and ureteral injuries (0.7%). Median surgery duration was 40 min with minimal blood loss. Early postoperative pain was associated with higher POP-Q scores, longer surgical duration, and lower BMI. No cases of de novo urinary incontinence or urinary tract infection were reported in the perioperative period. Conclusions: This large multicenter case series suggests that, in experienced hands, this standardized vaginal mesh approach is associated with a low perioperative complication rate. However, the absence of a control group and the short follow-up are major limitations. Long-term outcome data, particularly regarding mesh-related complications, are essential before drawing firm conclusions on the broader safety or role of vaginal mesh in POP repair. Full article

Background/Objectives: Surgical site infections (SSIs) following pancreaticoduodenectomy contribute to significant morbidity and healthcare costs. Negative pressure wound therapy (NPWT) has emerged as a potential preventive intervention; however, evidence regarding its efficacy in pancreatic surgery remains limited. This systematic review and meta-analysis aimed to evaluate the efficacy of NPWT compared to conventional dressings in preventing SSI following pancreaticoduodenectomy. Methods: PubMed, Scopus, BASE, Cochrane CENTRAL, and ClinicalTrials.gov were systematically searched from their inception to 2 April 2025. Randomized clinical trials and observational studies comparing NPWT with conventional dressings in patients undergoing pancreaticoduodenectomy were included. Two independent reviewers extracted the data and assessed the methodological quality. Random-effects meta-analysis was performed to calculate the pooled relative risks (RRs) with 95% CIs. The primary outcome was the incidence of SSI. The secondary outcomes included pancreatic fistula, seroma formation, incisional hernia, and readmission rates. Results: Nine studies (three randomized clinical trials and six observational studies) comprising 1247 patients were included. NPWT was associated with a significant reduction in SSI compared with conventional dressings (RR, 0.61; 95% CI, 0.41–0.90). Subgroup analysis revealed varying effects by study design: retrospective cohort studies showed a nonsignificant trend toward SSI reduction (RR, 0.53; 95% CI, 0.19–1.48), randomized clinical trials demonstrated a nonsignificant trend favoring NPWT (RR, 0.67; 95% CI, 0.37–1.23), and the single prospective cohort study showed significant SSI reduction (RR, 0.48; 95% CI, 0.28–0.84). No significant differences were observed in pancreatic fistula rates between the NPWT and conventional dressing groups. Prophylactic NPWT application, longer duration (≥5 days), and higher negative pressure settings (−125 mmHg) appeared more effective than therapeutic application, shorter duration, and lower-pressure settings, respectively. Conclusions: This systematic review and meta-analysis suggests that NPWT is associated with a reduced SSI risk following pancreaticoduodenectomy. The greatest benefit may be achieved with prophylactic application in high-risk patients, longer therapy duration, and higher negative pressure settings. These findings support the consideration of NPWT as part of SSI prevention strategies in pancreatic surgery, particularly for patients with identified risk factors. Full article

Background/Objectives: Machine learning has been suggested as a way to improve how we predict anesthesia-related complications after surgery. However, many studies report overly optimistic results due to issues like data leakage and not fully using information from clinical notes. This study provides a transparent comparison of different machine learning models using both structured data and preoperative notes, with a focus on avoiding data leakage and involving clinicians throughout. We show how high reported metrics in the literature can result from methodological pitfalls and may not be clinically meaningful. Methods: We used a dataset containing both structured patient and surgery information and preoperative clinical notes. To avoid data leakage, we excluded any variables that could directly reveal the outcome. The data was cleaned and processed, and information from clinical notes was summarized into features suitable for modeling. We tested a range of machine learning methods, including simple, tree-based, and modern language-based models. Models were evaluated using a standard split of the data and cross-validation, and we addressed class imbalance with sampling techniques. Results: All models showed only modest ability to distinguish between patients with and without complications. The best performance was achieved by a simple model using both structured and summarized text features, with an area under the curve of 0.644 and accuracy of 60%. Other models, including those using advanced language techniques, performed similarly or slightly worse. Adding information from clinical notes gave small improvements, but no single type of data dominated. Overall, the results did not reach the high levels reported in some previous studies. Conclusions: In this analysis, machine learning models using both structured and unstructured preoperative data achieved only modest predictive performance for postoperative complications. These findings highlight the importance of transparent methodology and clinical oversight to avoid data leakage and inflated results. Future progress will require better control of data leakage, richer data sources, and external validation to develop clinically useful prediction tools. Full article

(1) Background: trays are surgery-specific sets of required materials and medical devices, assembled in consultation between manufacturer and user, and provided in a sterile package. (2) Methods: in a high-volume urological center performing 11,920 operations/procedures annually (2023), we prospectively evaluated the effect of trays compared with the standard approach in a comparative study of 64 operations conducted between 29 October and 30 November 2024. The primary endpoints were the amount of operating room (OR) waste (volume/cm³, weight/g) and setup time (minutes). The secondary endpoint was the workflow assessment by nursing staff, rated on a numerical score (0–10) across seven relevant domains. (3) Results: for endourological procedures, setup time was reduced by 35%, operating room (OR) waste by 34%, and waste volume by 19.0%. Workflow was positively rated with a mean score of 9.75/10. For major open procedures, setup time was reduced by 43%, waste weight by 24.8%, and waste volume by 32%. Workflow was positively rated with a mean score of 8.9/10. (4) Conclusions: Trays have a sustainable and significant impact on reducing OR waste, save nursing staff preparation time, and facilitate improved workflow in the operating room. Full article

Background: Hemorrhoids and anal fissure are among the most common benign anorectal conditions. The incidence of synchronous symptomatic hemorrhoids and chronic anal fissure is unknown. In this study we evaluated the outcomes of our experience with concomitant surgical treatment for both these conditions. Methods: In this retrospective study we included consecutive patients who underwent surgical treatment for symptomatic hemorrhoids combined with lateral internal sphincterotomy for chronic anal fissure, during a time period of over 5 years. Eligible patients were contacted by phone and were asked to answer a questionnaire to evaluate recurrent symptoms, fecal incontinence, satisfaction, and improvement in quality-of-life. Results: A total of 56 patients were included, and 29 (51.8%) were female; the mean age was 46.9 ± 13.7 years, and the median follow-up time was 45.4 months. The median self-assessed improvement in quality-of-life on a scale of 0–10 was 10 [IQR 8, 10]. No significant differences were observed in satisfaction or self-assessed improvement in quality-of-life between genders or across different surgical procedures for hemorrhoids. Conclusions: Patients who underwent concomitant surgical treatment for hemorrhoids and chronic anal fissure were satisfied. This study supports our approach for synchronous treatment for different anorectal pathologies given the right patient selection, being safe and feasible. Full article

Background: Pulmonary lobectomy remains the gold standard for early-stage non-small cell lung cancer, with the primary goal of complete tumor removal. Postoperative imaging is critical for evaluating recovery and identifying complications, yet systematic descriptions of radiologic patterns after lobectomy are limited. Methods: We conducted a retrospective analysis of 125 patients who underwent pulmonary lobectomy between 2019 and 2024 at a tertiary thoracic surgery center. Preoperative and postoperative imaging findings were coded and compared using a standardized classification system. Modalities included chest radiography, thoracic CT, ultrasound, PET-CT and MRI. Results: Postoperative imaging demonstrated a clear reduction in pathological findings. Emphysema decreased from 29.6% to 21.6%, pleural effusion from 12.8% to 3.2%, atelectasis/pleural thickening from 15.2% to 8.8%, and ground-glass infiltrates from 12.0% to 8.0%. The proportion of patients without abnormalities increased from 18.5% to 24.8%. Chest radiography (92%) and CT (89.6%) were the most frequently employed modalities. Patients treated with VATS lobectomy showed slightly fewer postoperative abnormalities compared with those undergoing open surgery. Conclusions: Pulmonary lobectomy is associated with measurable radiologic improvement, reflecting favorable structural recovery. Routine imaging follow-up, particularly chest radiography, remains essential for early detection of complications and guiding postoperative care. However, the retrospective single-center design and limited generalizability represent important limitations that should be considered when interpreting these findings. Full article

Background/Objectives: Surgical ward rounds are central to trainee education but are often associated with stress, cognitive overload, and inconsistent learning. Advances in artificial intelligence (AI), particularly large language models (LLMs), offer new ways to support trainees by simulating ward-round questioning, enhancing preparedness, and reducing anxiety. This study explores the role of generative AI in surgical ward-round education. Methods: Hypothetical plastic and reconstructive surgery ward-round scenarios were developed, including flexor tenosynovitis, DIEP flap monitoring, acute burns, and abscess management. Using de-identified vignettes, AI platforms (ChatGPT-4.5 and Gemini 2.0) generated consultant-level questions and structured responses. Outputs were assessed qualitatively for relevance, educational value, and alignment with surgical competencies. Results: ChatGPT-4.5 showed a strong ability to anticipate consultant-style questions and deliver concise, accurate answers across multiple surgical domains. ChatGPT-4.5 consistently outperformed Gemini 2.0 across all domains, with higher expert Likert ratings for accuracy, clarity, and educational value. It was particularly effective in pre-ward round preparation, enabling simulated questioning that mirrored consultant expectations. AI also aided post-round consolidation by providing tailored summaries and revision materials. Limitations included occasional inaccuracies, risk of over-reliance, and privacy considerations. Conclusions: Generative AI, particularly ChatGPT-4.5, shows promise as a supplementary tool in surgical ward-round education. While both models demonstrated utility, ChatGPT-4.5 was superior in replicating consultant-level questioning and providing structured responses. Pilot programs with ethical oversight are needed to evaluate their impact on trainee confidence, performance, and outcomes. Although plastic surgery cases were used for proof of concept, the findings are relevant to surgical education across subspecialties. Full article