Surgeries

Background/Objectives: Patient acceptable symptom state (PASS) thresholds have been used as a marker of good functional outcome following total knee arthroplasty (TKA) but have not been applied to pre-operative subjective function. This study aimed to compare the outcomes of patients above and below PASS thresholds prior to TKA. Methods: A secondary analysis of a multicenter prospective observational study was used, including 1182 patients prescribed a smartphone-based care management platform following TKA with pre-operative and 1-year KOOS JR scores available. Patient demographics, pain, satisfaction, and KOOS JR were compared between those above and below PASS pre-operatively by student t-test. Logistic regression was used to quantify the odds of decline or no improvement at 1 year. Results: In this cohort, 191 (16.2%) KOOS JR scores were above PASS thresholds prior to TKA. Those above PASS reported lower pain pre-operatively (3.7 ± 1.9 vs. 6.0 ± 1.9, p < 0.0001) and less pain reduction at 90 days (−1.4 ± 2.5 vs. −3.2 ± 2.6, p < 0.0001). Patients above PASS also demonstrated higher KSS satisfaction scores pre-operatively (20.7 ± 7.9 vs. 12.1 ± 6.7, p < 0.0001) with less improvement (9.9 ± 10.6 vs. 16.5 ± 11.2, p < 0.0001) at 90 days. In logistic regression, those above PASS pre-operatively were 5.1 times more likely to report a decline or no improvement in KOOS JR at 1 year (5.10 95% CI 2.73–9.53, p < 0.0001). Conclusions: Patients above previously defined PASS thresholds who presented for TKA appreciated less improvement in pain and satisfaction and were more likely to experience functional decline or no improvement in KOOS JR post-operatively. The application of PASS thresholds pre-operatively may be useful for patient selection or guidance of patient expectations. Full article

Background: Adrenal cortical carcinoma (ACC) is a rare and aggressive malignant tumor with an estimated prevalence of 0.5–2 cases per million people. For patients with advanced or metastatic disease, the prognosis is very poor, and death usually occurs in the first 24 months after diagnosis. Some cases of ACC with invasion of the inferior vena cava (IVC) and the right atrium (RA) have been reported. Methods: We herein report an additional case of IVC and RA involvement in ACC in a 61-year-old woman with no relevant past medical history. Results: The patient underwent heart surgery to remove neoplastic thrombi in the IVC and RA; abdominal surgery to remove the adrenal mass was performed one month later, when the patient’s clinical condition was stable. Conclusions: The histologic and immunohistochemical features, as well as the differential diagnosis, are highlighted herein. Full article

Background/Objectives: Malpractice in cardiovascular surgery was addressed from the forensic pathology perspective, offering reflections on risk prevention in the Italian context. Litigation and risk management in healthcare, following the Italian law on safety of care, clinical risk management and professional liability, should be viewed in an integrated manner. Methods: We conducted a narrative review on litigation data and the principal areas of complaint in Italy regarding the cardiovascular field. The aim is to discuss human, communicative, organisational, technological and regulatory factors that may play a role in this phenomenon. Results: We discuss the importance of information and consent and the management and monitoring of competences, particularly in specialised activities, given the current human capital deficit. Furthermore, we focus on the centrality of the surgical indication focusing on benefit-risk balance in light of clinical guidelines and team-based evaluation, such as by an emergency heart team, to better tailor care to patients. At the facility level, the minimum volume of activity and the requirements for human resources, specialisations, technologies and organisation standards needed for health activity authorisation are highlighted as foundational to risk prevention. Furthermore, we discussed the availability of the minimum diagnostic and care tools in compliance with guidelines and the role of company clinical and organisational protocols. Conclusions: In the surgical, time-sensitive, highly specialised and technologically advanced sector, the importance of enterprise risk prevention and broad, value-based governance to ensure healthcare quality and safety is emphasised. Full article

Background: The increasing incidence of cerebrovascular accidents represents an emerging problem. The rise in risk factors such as lifestyle choices—smoking, poor nutrition, and metabolic diseases—poses a significant challenge for the global healthcare system. The female population, due to physiological conditions and iatrogenic risks, may be at a greater risk of developing ischemic accidents. In addition to these acquired conditions, life phases such as pregnancy or puerperium, and medical conditions like surgical treatments and hormone therapy, may elevate this risk. Methods: This narrative aims to assess the various risk factors specific to the female population and evaluate the appropriate management strategies, including anesthetic support. Anesthesia plays a crucial role in enabling pharmacological procedures, such as thrombolysis, or surgical procedures like thrombectomy, in the management of ischemic cerebrovascular events. Results: The review emphasizes the importance of early recognition of risk factors to ensure prompt diagnosis and the most appropriate treatment options for ischemic events. Anesthesia support has become essential for carrying out necessary medical interventions effectively. Choosing the right anesthesia technique for endovascular thrombectomy is particularly significant, requiring consideration of the patient’s characteristics, the timing of diagnosis, and the preferences of the interventional neuroradiologists. Conclusions: It is vital to identify risk factors in the female population early to facilitate timely diagnosis and optimize treatment outcomes. Anesthetic support plays a key role in ensuring that critical procedures, such as thrombolysis and thrombectomy, are carried out effectively. Tailoring anesthesia choices to the patient’s individual needs is critical for a successful intervention. Full article

Background: Crown lengthening (CL) in esthetic areas has become a versatile procedure with applications in many clinical situations. Knowledge concerning different periodontal phenotypes, and the supracrestal tissue attachment (STA)—former biological width—has allowed for a better understanding of surgical management, allowing for the individualization of surgical therapy. This review presented an individualized surgical approach to CL in esthetic areas based on evaluating the phenotype and current considerations about the STA, correlating them to suggestive surgical techniques. Methods: For an individualized surgical approach, it is primarily necessary to understand STA, including the relationship and distance between the cementoenamel junction (CEJ) and the bone crest (BC) and the position of the free gingival margin (FGM); secondarily, it is necessary to verify the periodontal phenotype to prepare surgical planning (gingivectomy or osseous resection/contouring). Three periodontal phenotypes are recognized, presenting different biological behaviors due to specific characteristics implicitly correlated to soft tissue management. Results: Then, after assessing the distance from the CEJ to the BC, the position of the FGM, and the periodontal phenotype, it is possible to individualize the treatment according to the phenotype. In cases of a thin and scalloped periodontium with delicate gingiva, there might be the presence of bone dehiscence, fenestration, and instability in the healing of the gingival margin, bringing extra attention to tissue manipulation and suggesting a minimally invasive technique (no flap). A partial-thickness flap is recommended for a thick and scalloped periodontium, keeping the periosteum adhered to the bone. For periodontium B (fibrous and dense gingiva and tissue resistant to injuries), the surgical approach recommended is an open full-thickness flap with osteotomy for horizontal and vertical bone volume removal. Then, observing first the specific parameters, such as the STA, CEJ, BC, FGM, and KTW, and then the characteristics of periodontal phenotypes, it is possible to determine the individualized surgical strategy and a reasonable surgical approach to tissue manipulation in clinical CL surgeries. Conclusions: The surgical approach must be defined according to individualized planning since several variables can influence the dynamics of the periodontal tissues. Full article

Background: Mandibular condylar fractures are among the most common fractures of the facial skeleton, and their surgical management remains a topic of considerable debate in maxillofacial trauma surgery. Numerous studies in the literature internationally have explored optimal treatment approaches, with a growing preference for open reduction and internal fixation (ORIF). While conservative treatment has traditionally been the standard for intra-articular fractures, recent research suggests that ORIF may also be appropriate for selected cases of these fractures. Methods: This study presents a 14-year review (2009–2023) of the authors’ experience in the surgical management of intra-articular condylar fractures. Data were collected on surgical techniques, early and late complications, clinical and radiological outcomes, and comparisons with conservative treatment. Results: The analysis included evaluations of both short-term and long-term outcomes following ORIF, identifying specific scenarios where ORIF demonstrated advantages over conservative management. Clinical and radiographic assessments provided valuable insights into patient recovery and functional outcomes, while complication rates were documented for both treatment methods. Conclusions: Findings indicate that ORIF can be a beneficial treatment option for intra-articular condylar fractures in select patient groups, offering improved outcomes in cases where conservative treatment may be insufficient. However, conservative management remains a valid approach when surgical risks exceed potential benefits. This study adds to the ongoing discussion, supporting a tailored approach that considers individual patient factors when choosing between ORIF and conservative treatment. Full article

Background: The gold standard treatment of acute cholecystitis is early laparoscopic cholecystectomy (LC), as indicated in the Tokyo Guidelines (TG). However, the definition of “early” is still unclear. In 2013, TG suggested surgical intervention within 72 h from the onset of the symptoms; however, according to the 2018 revision, LC must be performed as soon as possible, regardless of symptom onset. Therefore, the optimal timing for surgery is still debated. In order to avoid any complications, surgeons need to know all the surgical strategies for safety in case of a difficult cholecystectomy. Methods and Materials: Starting from January 2023 at Cittiglio Hospital (Italy), the following strategies were implemented: LC within 72 h from the onset of symptoms, systematic intraoperative use of indocyanine green fluorescence cholangiography, systematic identification of the Critical View of Safety (CVS), and subtotal cholecystectomy when the CVS was impossible to identify. We retrospectively analyzed a cohort of patients who underwent LC in our surgical department, subdividing them into two groups: Group 1 (G1) included patients operated on in 2022, and Group 2 (G2) included patients operated on in 2023. End points were length of stay and in-hospital postoperative complications, with particular interest in biliary duct injury. Results: Overall, 210 LC have been performed (97 in G1 and 113 in G2). After the introduction of the new safety strategy, the median length of stay (3 days in G1 vs. 2 in G2), BDI rate (2 in G1 vs. 0 in G2), and conversion rate to open procedure (5 in G1 vs. 1 in G2) were decreased. Conclusions: Our data are promising, highlighting that LC with the standardization of new safety strategies, especially in case of acute cholecystitis, immediately improves surgical outcomes in terms of length of stay and complications. Full article

Objective: to study the effectiveness of type II pectoral nerve block (PEC II) for breast augmentation with submuscular implants by assessing opioid consumption and pain scale in the immediate postoperative period, from the post-anesthesia care unit (PACU) to 24 h postoperatively. Methods: A prospective, controlled, randomized, and double-blind study. Thirty-four patients were analyzed during the perioperative period and in the PACU, with one group receiving bilateral PEC II combined with general anesthesia and the control group receiving only general anesthesia. Results: There was no difference between the groups regarding demographic data, surgical and anesthetic times, or intraoperative opioid use. Opioid consumption in the control group was consistently higher at all the time intervals studied, with an average morphine consumption 38.7% greater. The largest variation in morphine consumption occurred at the fourth and sixth hours postoperatively. The greatest difference in postoperative pain was 36% higher in the control group compared to the intervention group. Conclusions: patients who underwent general anesthesia combined with PEC II had lower opioid consumption and a lower postoperative pain score without associated complications, confirming the effectiveness of the procedure. Full article

Introduction: Peripheral arterial disease (PAD) impedes the ability to recover from lower extremity arthroplasties (LEA) while simultaneously increasing risks of peri- and postoperative complications, morbidity, and mortality. Despite the known risks that PAD presents, there are currently no standards outlining how practitioners should screen patients prior to undergoing LEA. The purpose of this manuscript is to facilitate the improved diagnosis of PAD, leading to appropriate vascular surgery consultation prior to undergoing orthopedic surgeries. Recommendations for Preoperative Assessment: Screening begins with a succinct history and physical exam, looking for signs and symptoms of diminished vascular integrity. A heightened suspicion for PAD should prompt the immediate enactment of an ankle brachial index, or alternatively, a pressure volume recording or the skin perfusion pressure technique. Full article

Background: Breast reconstruction after mastectomy may improve psychological sequelae for patients. The objective of this study is to characterize differences in depression and anxiety rates for mastectomy and breast reconstruction (BR) patients by race. Methods: The All of Us database was utilized for patients who underwent mastectomy and BR post-mastectomy. Anxiety and depression rates and self-identified race were extracted from DatasetV7. Results: Of mastectomy patients, 2398 were White and 472 were Black. Black patients had the greatest difference in depression rates between mastectomy (44.5%) and BR patients (28.8%) (OR = 0.46, 95% CI 0.26–0.82). White patients had lower depression rates (40.4%) for mastectomy than Black patients. Asian patients had the lowest rates of depression for mastectomy (OR = 0.43, 95% CI 0.22–0.84) and for mastectomy and BR (OR = 0.35). Black patients had a decrease in anxiety rates from mastectomy (49.4%) to BR (40.9%) (OR = 0.67). Conclusions: Anxiety and depression varied significantly by race for mastectomy and BR patients. Black mastectomy patients had the highest rates of depression and anxiety, which decreased after receiving BR. Lower rates of anxiety and depression were found amongst Asian mastectomy patients. These data highlight the need to identify and treat races vulnerable to depression and anxiety before and after mastectomy/BR. Full article

Open total cranial vault reconstruction (CVR) is the common procedure in managing craniosynostosis, yet more techniques have been introduced as alternatives, namely endoscopic suturectomy (ES), endoscopy-assisted craniectomy (EC), spring-assisted surgery (SAS), strip craniectomy with helmet (SC), Pi craniectomy (PiC), Pi plasty (PiP), and Renier’s “H” technique (RH). The aim of this study was to compare the effectiveness of craniosynostosis surgeries in improving the cephalic index of the patients. Studies published until 7 March 2024 reporting CVR, ES, SAS, SC, RH, and PiP as definitive craniosynostosis management with the cephalic index as the outcome were included. Bayesian network meta-analysis and pair-wise meta-analysis were performed using a random-effects model based on standardized mean difference (SMD) and 95% confidence interval (CI). Nine studies published in 2008–2024 recruiting a total of 464 craniosynostosis patients (age: 18–61 months) were included in this meta-analysis. EC (SMD = 0.23 [95%CI: −5.47 to 5.63]; p = 0.935), PiP (SMD = −0.07 [95%CI: −9.27 to 8.79]; p = 0.988), ES (SMD = −0.59 [95%CI: −6.07 to 4.94]; p = 0.834), PiC (SMD = −1.16 [95%CI: −8.89 to 6.35]; p = 0.765), RH (SMD = −0.96 [95%CI: −6.62 to 4.53]; p = 0.736), SAS (SMD = −0.86 [95%CI: −8.25 to 6.18]; p = 0.815), and SC (SMD = −1.79 [95%CI: −9.05 to 5.28]; p = 0.624) were found to be as effective as CVR in improving the cephalic index. Network meta-analysis suggests that PiP is the most effective among these techniques (rank 1 probability = 0.273). According to the rank probabilities of our model the order of techniques from the most to the least effective is as follows: EC > CVR > PiP > ES > SAS > RH > PiC > SC. Full article

Background: Oral wound healing in the aging population is a multifaceted issue requiring a comprehensive approach, considering the physiological changes that come with aging and the frequent presence of comorbidities. Methods: This descriptive review summarizes the factors influencing oral wound healing in aging patients, including age-related physiological changes, hormonal modifications, multimorbidities, polypharmacy, oralome alterations, and nutritional status. Results: The aging population encounters numerous challenges in oral wound healing due to intrinsic factors, such as biological aging and hormonal changes, and extrinsic factors, such as medication use and lifestyle. Conclusion: Understanding these factors and their combined impact is essential for effective clinical management and improved outcomes in older adults. Full article

Background: We use vessel dilators to assess the diameter of the target vein during surgery for arteriovenous fistula (AVF) creation in hemodialysis patients. This study investigates the efficacy of using vein diameter as measured using dilators (surgical diameter; SD) versus that as measured by preoperative ultrasonography (ultrasonographic diameter; UD) to predict postoperative complications and patency. Methods: Sixty-three patients who underwent radiocephalic AVF creation and had measurements of UD and SD were retrospectively analyzed. Cutoff values for UD and SD regarding complications were used to dichotomize the patients into high and low groups for comparisons. Results: The 2-year primary and secondary patency rates overall were 66.5% and 88.9%, respectively. The optimal UD and SD cutoff values were 2.4 and 3.5 mm, respectively. The 2-year primary patency rate was higher in the high-SD group than the low-SD group (88.2% vs. 58.6%; p = 0.0426). The 2-year secondary patency rate was significantly higher in the high-UD/high-SD group than the low-UD/low-SD group (91.7% vs. 68.4%; p = 0.0067). Conclusions: Intraoperative measurement of vein diameter using dilators during AVF creation might be a useful method of predicting patency, particularly when SD is used in combination with UD. Full article

Objective: This review evaluated the use of autogenous tooth as a bone graft material in guided bone regeneration (GBR). Moreover, it compared the results of GBR using autogenous demineralized dentin, partially demineralized dentin, and mineralized dentin with or without membrane to verify its clinical advantage, effectiveness, and safety. Methods: A search was conducted in PubMed/MEDLINE, Lilacs, Embase, Cochrane, and Scopus databases. Specific criteria were established for the inclusion and exclusion of studies, including types of studies considered, target population (clinical studies: humans), evaluated intervention (studies assessing and comparing autologous demineralized dentin, partially demineralized dentin, and mineralized dentin in GBR with or without resorbable membrane), and language and publication period of articles (English and published in the last 11 years). A detailed assessment of the methodological quality of the selected studies was conducted using the JBI critical appraisal tool. Results: Based on the analysis conducted, out of 174 potentially relevant articles obtained, only 19 publications met the inclusion criteria, with three papers showing medium quality/moderate risk of bias and the rest with high quality/low risk of bias. Comparison between groups revealed stability of the newly formed bone, low marginal bone loss, clinically acceptable primary and secondary implant stability quotient (ISQ) values, and high implant survival rates after using autogenous tooth biomaterial. Conclusions: The results of this review on the use of autogenous teeth as a bone graft material in guided bone regeneration indicated that the technique has the potential to be an effective and safe treatment option. Analysis of selected studies showed favorable evidence for the use of autogenous teeth in bone regeneration, suggesting clinical benefits, most for socket preservation. These results are relevant for guiding clinical practice and assisting dental professionals in having options for biomaterials for bone regeneration. Full article

Tumors of the spine are rare, with an incidence of 1.0 and 1.5 per 100,000 individuals. A 44-year-old female patient underwent emergency surgery for posterior decompression and tumor resection. A 3-level laminectomy was performed from T6 to T8 using the Medtronic Midas Rex drill and a 5 mm diamond drill, with microsurgical resection of the lesion. A new resection was performed one week later to address a residual tumor located towards the rostral and cephalic levels. A sample of the extradural lesion was obtained and was sent to the Pathology Department of the Hospital Regional de Alta Especialidad de Ixtapaluca (HRAEI) for histopathological diagnosis, reporting Grade 1 psammomatous meningioma according to the WHO’s criteria. Our patient’s rehabilitation treatment consisted of two parts. The first part occurred during her hospital stay, before and after surgery, and upon her discharge. At the first outpatient consultation three weeks after surgery, the patient showed improved strength in the lower extremities, scoring 4/5 on the Daniel’s scale muscle strength test. After one year of follow-up, our patient has recovered muscle strength. This allows her to move freely, scoring 5/5 on the Daniel’s scale muscle strength test. Full article

Background: Evidence on return to sport (RTS) criteria and timelines for pediatric patients with osteochondral (OCD) lesions of the foot and ankle is limited. Methods: This systematic review evaluated RTS criteria and outcomes in this population by querying PubMed, Embase, Web of Science, CINAHL, and SPORTDiscus up to 30 May 2024. Inclusion criteria were retrospective or prospective studies that examined pediatric patients with osteochondral lesions of the foot and ankle and gave outcomes or criteria regarding RTS. Results: Five observational studies (n = 168 patients; n = 180 OCD lesions; mean age: 14.19 ± 0.47 years; mean follow-up: 42 ± 174 months) were included. Two studies (40%) used time-based criteria for RTS, two studies (40%) used mixed criteria, and the final study (20%) used milestone-based criteria. Across the mixed and milestone criteria, physical therapy (n = 3) and minimal partial weight-bearing prior to RTS (n = 4) were most frequently seen as the milestones used for assessing RTS readiness. RTS from the postoperative period ranged from 3 months to 6 months. At the final follow-up, 61.45% of patients (n = 110) were available to provide information regarding their ability to RTS. Of these patients, 80% (n = 88) achieved RTS. Conclusions: Results showed variability in RTS criteria, ranging from three to six months, with no clear patterns. Most patients returned to sport, suggesting that such individualized criteria may be effective to an extent. Future research should focus on larger, high-quality studies to develop consistent RTS protocols. Full article

Background: Robotic systems have the potential to significantly enhance the accuracy and outcomes of spinal surgery. Adopting this new technology requires an examination of its learning curve and influencing factors. This study analyzes the learning curve associated with using the Mazor X Stealth Edition system for pedicle screw placement and performs a matched-pair analysis to compare operative durations between robot-assisted and navigation-based surgeries, evaluating the efficiency of the robotic system. Methods: We collected retrospective operative data from patients who underwent robot-assisted pedicle screw placements between December 2020 and June 2024 and conducted a cumulative sum (CuSUM) analysis to assess the learning curve, focusing on the robotic system’s setup duration. Additionally, we compared a group of patients who underwent robot-assisted pedicle screw placements with a pair-matched group who underwent O-arm-based navigation-assisted pedicle screw placements. Results: There was a notable decrease in the robotic setup duration, with a significant shift in trend observed after the first 20 cases. While the initial setup time was 24 minutes, it reduced to 17 minutes in later cases, reflecting a marked improvement in efficiency as the surgeon gained more experience with the robot. Conclusion: Our findings indicate there were no added difficulties using the robotic system compared to the navigation system. Moreover, the learning curve for the robotic system can be quickly surmounted, and it offers clear advantages over previous systems, making it a valuable tool for pedicle screw application. Full article

Background: After pancreatic surgery, the development of postoperative pancreatic fistula (POPF) is a serious concern. POPF involves the leakage of pancreatic fluids from the surgical site, which can lead to complications and even death. Preventing POPF is essential for enhancing patient recovery and lessening the impact on healthcare resources. This systematic review and meta-analysis evaluated medical methods and surgical techniques to prevent POPF. Methods: This study was registered under the International Prospective Register of Systematic Reviews (PROSPERO) with the registration number CRD42024500938. An electronic search was conducted through the PubMed, Google Scholar, Web of Science, and ScienceDirect databases for all relevant articles published in English from 2018 to 2023. The following search terms were used: ((Whipple procedure OR Pancreaticojejunal OR Pancreaticogastrostomy) AND (Prevention of postoperative pancreatic fistula) AND (Prevention OR Octreotide OR Sealant agent OR Stent OR Postoperative drain)). Results: Of 260 papers, 28 articles extracted through the database search were considered suitable for the systematic review. The included studies investigated a variety of surgical approaches for pancreatic resection. Pancreaticoduodenectomy (PD) was the most prevalent intervention. The incidence rates for POPF varied widely across the studies, ranging from as low as 11.6% to as high as 100%. The incidence rate of clinically relevant POPF (CR-POPF) ranged from 11.7% to 33.3%. The length of postoperative hospital stays also varied significantly. Discussion: Postoperative pancreatic fistula (POPF) affects 13–41% of patients post-pancreatic surgery. Despite its high incidence, mortality rates are low. Postoperative hospital stay varies, with higher rates in older patients and overweight individuals. Advancements in surgical techniques and perioperative management have reduced mortality rates to <5%. Conclusions: This study provides insights into the outcomes of pancreatectomy, including the incidence of POPF, postoperative hospital stays, and mortality rate. The findings suggest that the incidence of POPF is similar to that suggested in the literature and is influenced by various factors. Full article

Background: Low-dose computed tomography-based lung cancer screening (LCS) has demonstrated efficacy in reducing lung cancer mortality. However, concerns about overdiagnosis and overtreatment hinder global LCS implementation. Methods: Here, we report the unique case of a slow-growing 1 cm pure ground-glass opacity (GGO) of the lung, known for 15 years, which unexpectedly developed into a 5 cm mixed GGO within 1 year, with an increased solid component and FDG-PET uptake. Results: The patient, asymptomatic, underwent right upper lobectomy and lymphadenectomy, even complicated with postoperative chylothorax, later revealing to be affected by only an unchanged adenocarcinoma in situ (AIS). Conclusions: This case serves as a reminder of the potential behavior of pre-invasive lesions, which can mimic invasive neoplasia and may lead to overtreatment, and underscores the challenge of distinguishing indolent lesions from potentially aggressive malignancies in LCS, highlighting the need for the ongoing refinement of LCS protocols to mitigate this risk. Full article