Surgeries

Background: Fibrinogen is a substrate for blood clots formation. In cardiac surgery, a number of different mechanisms lead to a decrease in fibrinogen levels and consequent impaired haemostasis. Patients undergoing cardiac surgery are therefore frequently exposed to blood loss and allogeneic blood transfusion, which are risk factors associated with morbidity and mortality. Thus, particular efforts in fibrinogen management should be made to decrease bleeding and the need for blood transfusion. Therefore, fibrinogen remains an active focus of investigations from basic science to clinical practice. This review aims to summarise the latest evidence regarding the role of fibrinogen and current practices in fibrinogen management in adult cardiac surgery. Methods: The PubMed database was systematically searched for literature investigating the role and disorders of fibrinogen in cardiac surgery and diagnostic and therapeutic procedures related to fibrinogen deficiency aimed at reducing blood loss and transfusion requirements. Clinical trials and reviews from the last 10 years were included. Results: In total, 146 articles were analysed. Conclusion: The early diagnosis and treatment of fibrinogen deficiency is crucial in maintaining haemostasis in bleeding patients. Further studies are needed to better understand the association between fibrinogen levels, bleeding, and fibrinogen supplementation and their impacts on patient outcomes in different clinical settings. Full article

The physiological behavior of paranasal sinuses depends on the potency of the ostiomeatal complex and on normal mucociliary function. The interruption of this delicate equilibrium can lead to pathological conditions such as sinusitis. Anywhere between 10% and over 25% of cases of maxillary sinusitis have an odontogenic origin, such as: dental infection; alveolar dental trauma; or iatrogenic causes, such as extractions, endodontic therapies, maxillary osteotomies or placement of endosseous implants. The resolution of sinus pathology is related to the resolution of odontogenic pathology. Aim: to evaluate the therapeutic efficacy of a combined oral and endoscopic approach in the treatment of chronic odontogenic sinusitis vs. oral dental management through a case control study. Materials and Methods: all patients showing signs and symptoms of odontogenic sinusitis with obliteration (appreciable radiopacity in CT) of unilateral maxillary sinus between January 2018 and September 2019 at Padua University Hospital were enrolled in this retrospective study. The exclusion criteria were: maxillary sinusitis without odontogenic origin, or resolution with a systemic antibiotic therapy; and presence of anatomical abnormalities that promote the onset of rhinosinusitis. The patients were divided into two groups: one group was treated with a combined surgical approach under general anesthesia (Functional Endoscopic Sinus Surgery-FESS and simultaneous closure of oroantral communication with Bichat’s fat pad advancement); while the other group was treated only with an intraoral approach under local anesthesia and conscious sedation (closure of oroantral communication with Bichat’s fat pad advancement). The variable “success of the surgical procedure” in the two groups was compared by a Student test (with p < 0.05). Results: among the patients enrolled, 10 patients (aged between 42 and 70) made up the case group and the other 10 patients (aged between 51 and 74) constituted the control group. There was no statistically significant difference in success between the two groups (p < 0.025). Conclusions: according to this case study, an exclusive annotation invasive intraoral approach seemed to be comparable to the transoral endoscopic combined method. However, during diagnosis it is necessary and fundamental to distinguish between odontogenic and rhinogenic sinusitis in order for the resolution of odontogenic sinusitis to be achieved. Full article

(1) Background: The COVID-19 pandemic tested the public health system’s readiness for crises and highlighted the importance of knowing the demand for blood products and the maintenance of the blood supply chain. The aim of this study was to evaluate blood product usage in a series of patients that were hospitalized due to COVID-19 and to analyze their demographics and clinical characteristics. (2) Methods: In this retrospective cohort study, we analyzed data from transfused COVID-19 patients that were treated in the University Hospital Medical Center Bezanijska Kosa in Belgrade, Serbia during the second wave of the epidemic. (3) Results: This study included 90 patients. The median age of the patients was 72 (range 23–95) years. The median time of hospitalization was 23 days (range 3–73 days). In intensive care units (ICUs) the median time of hospitalization was 9 days (range 0–73). One or more comorbidities were observed in 86 individuals (95.6%). The total number of transfused red blood cell concetrates (RBC) was 304 (139 in ICU, 165 in other wards), with a mean of 3 units/patient (range 1–14). Comorbidities, severity of illness and hospital duration in the ICU were statistically significant predictors of higher RBC use. (4) Conclusion: Knowledge of the transfusion profile of COVID-19 patients allowed better management of the hospital’s blood stocks during the COVID-19 pandemic. Full article

We report two cases of ectopic bone formation in the head and neck following treatment with recombinant human bone morphogenetic protein-2 (rhBMP-2). Surgical pathologic data, laryngoscopy imaging, CT imaging, and patient medical history were obtained. First, we report osseous metaplasia in the vocal fold in a 67-year-old male following mandibular dental implants with rhBMP-2; second, a case of severe bony overgrowth of the larynx and fusion to the anterior cervical spine (ACS) in a 73-year-old male following multiple anterior cervical discectomies and fusions with rhBMP-2. Ectopic bone formation following rhBMP-2 has been previously reported. Adverse events like local swelling and edema leading to dysphagia and even airway obstruction after cervical spine application of rhBMP-2 have also been widely reported. Due to the uncommon nature of abnormal bony growth in soft tissue areas of the head and neck and the previously documented adverse effects of rhBMP-2 use, especially in the cervical spine, we consider the two unusual case presentations of ectopic bony formation highly likely to be linked with rhBMP-2. We urge awareness of the adverse effects caused by rhBMP-2, and urge caution in dosing. Full article

Gastric leak is a serious complication of sleeve gastrectomy with a well-documented morbidity and mortality. Depending on the series the leak rate ranges between 1 and 5%. The treatment of sleeve gastrectomy leak is still challenging. Different procedures have been described in management of gastric leak, both surgical and endoscopic. The treatment of gastric leaks depends on the extent of the staple-line leak, the site of the leak and its association with stenosis. As published data are limited, there are no still standardized guidelines on best treatment. One of the most commonly used option in the treatment of gastric leak is esophageal stent. Its success rate reaches 70–80% but it is burdened by some complications. Stent migration is the most common complication in the placement of esophageal stent.We present a challenging surgical in which case the use of an esophageal stent for the treatment of a sleeve gastrectomy leak gained the resolution of the leak but was complicated by bowel obstruction due to migration of the stent. Full article

Decompressive craniotomy is a neurosurgical emergency procedure in which a large skull bone is removed and the dura matter is extensively opened. Duraplasty is required to avoid cerebrospinal fluid (CSF) leakage during the decompressive craniotomy. DuraGen^® is a safe and effective type I collagen matrix graft, which is frequently used in decompressive craniotomy procedures. Since DuraGen^® does not require labor-intensive suturing, the operative time is shortened by DuraGen^® closure with sufficient tightness preventing CSF leakage. Recently, early cranioplasty is preferred to achieve efficient rehabilitation after decompressive craniotomy. Although evidence of efficacy and safety of DuraGen^® has been increasing in the management of duraplasty, no reports have previously discussed the condition of DuraGen^® during the second surgery (cranioplasty) at this early timing. DuraGen^®-derived neodura develops a mature dura 1 year post its placement, and the neodura remain fragile at this early time point. A deconstructed fragile neodura may result in postoperative CSF leakage. Here, we illustrated a multilayered dural repair technique with DuraGen^® to avoid disruption of the fragile neodura during early cranioplasty. Full article

Introduction: Colorectal cancer (CRC) is the third most common cancer in the world. The liver is the most common site of metastasis with 15 to 25% of patients presenting with synchronous colorectal liver metastasis (CRLM). This study is aimed at evaluating the long- and short-term outcomes of laparoscopic and robotic CRLM surgery, and directly comparing their respective effectiveness. Methodology: A literature search was performed and all studies that reported on operative characteristics, oncological outcomes for CRLM, morbidity or mortality and cost-effectiveness on robotic or laparoscopic surgery were included. The study design was in keeping with the PRISMA guidelines. Results: From the initial 606 manuscripts identified, 19 studies were included in the final qualitative analysis. A total of 1340 patients with 1194 LLR (Laparoscopic Liver Resection) and 146 RLR (Robotic Liver Resection) cases were analysed. Within the LLR group, the average tumour size excised was 32.1 mm compared to the RLR group of 33.8 mm. The average operative time in the LLR was 193 min, CI of 95% (147.4 min to 238.6 min) compared to RLR 257 min, CI of 95% (201.5 min to 313.8 min) with a p-value < 0.0001. Estimated blood loss was lower in the RLR group (210 mL) compared with the LLR group (246 mL). Conclusion: Despite the higher operative cost, RLRs do not result in statistically better treatment outcomes, with the exception of lower estimated blood loss and excision of larger CRLMs. Operative time and total complication rate are significantly more favourable with LLRs. Our study has shown that robotic liver surgery is safe and feasible in well-selected patients. Full article

(1) Background: We tested Capstesia against a reference system, Vigileo FloTrac, in patients undergoing major vascular surgery procedures. (2) Methods: Twenty-two adult patients (236 data pairs) were enrolled. Cardiac output (CO), stroke volume (SV), systemic vascular resistance (SVR), and related indexed parameters from the two monitoring systems were collected and compared at eleven time points during surgery. Intraclass correlation coefficients with 95% confidence intervals (CIs) and Bland–Altman plots with percentages of error were used. (3) Results: The interclass correlation coefficients for CO, SV, and SVR were 0.527 (95%CI 0.387 to 0.634), 0.580 (95%CI 0.454 to 0.676), and 0.609 (95%CI 0.495 to 0.698), respectively. In the Bland–Altman analysis, bias (and limits of agreement) of CO was 0.33 L min⁻¹ (−2.44; 3.10), resulting in a percentage error of 61.91% for CO. For SV, it was 5.02 mL (−36.42; 46.45), with 57.19% of error. Finally, the bias (and limit of agreement) of SVR was −75.99 dyne sec cm⁻⁵ (−870.04; 718.06), resulting in an error of 69.94%. (4) Conclusions: Although promising, cost-effective, and easy to use, the moderate level of agreement with Vigileo and the high level of error make Capstesia unsuitable for use in the intraoperative setting of vascular surgery. Critical errors in acquisition or digitalization of the snap might have a strong impact on the accuracy and performance. Further standardization of the acquisition technique and improvements in the processing algorithm are needed. Full article

Punch incision is an alternative to elliptical excision for treating epidermal inclusion cysts, but its efficacy has not been systematically reviewed. This study assessed the efficacy and safety of punch incision versus elliptical excision for epidermal inclusion cysts. Randomized controlled trials published through January 2021 that evaluated the performance of punch incision versus elliptical excision on epidermal inclusion cysts were identified through electronic databases and clinical registries. Version 2 of the Cochrane risk-of-bias tool for randomized trials tool was used. Review Manager software was used for the meta-analysis. Two trials (100 participants) were identified. The primary outcomes were recurrence rate (risk ratio, 2.40; 95% confidence interval [CI], 0.37–15.60 [favoring elliptical excision]), mean operative time (mean difference [MD], −5.28; 95% CI, −12.72 to 2.16 [favoring punch incision]), and mean postoperative wound length (MD, −11.67; 95% CI, −20.59 to −2.76 [favoring punch incision]). The evidence was low to moderate due to the small sample size and its considerable heterogeneity. The use of punch incision shortened the mean postoperative wound length and had comparable safety to that of elliptical excision. Full article

Compressive neuropathies of the forearm are common and involve structures innervated by the median, ulnar, and radial nerves. A thorough patient history, occupational history, and physical examination can aid diagnosis. Electromyography, X-ray, and Magnetic Resonance Imaging may prove useful in select syndromes. Generally, first line therapy of all compressive neuropathies consists of activity modification, rest, splinting, and non-steroidal anti-inflammatory drugs. Many patients experience improvement with conservative measures. For those lacking adequate response, steroid injections may improve symptoms. Surgical release is the last line therapy and has varied outcomes depending on the compression. Carpal Tunnel syndrome (CTS) is the most common, followed by ulnar tunnel syndrome. Open and endoscopic CTS release appear to have similar outcomes. Endoscopic release appears to incur decreased cost baring a low rate of complications, although this is debated in the literature. Additional syndromes of median nerve compression include pronator syndrome (PS), anterior interosseous syndrome, and ligament of Struthers syndrome. Ulnar nerve compressive neuropathies include cubital tunnel syndrome and Guyon’s canal. Radial nerve compressive neuropathies include radial tunnel syndrome and Wartenberg’s syndrome. The goal of this review is to provide all clinicians with guidance on diagnosis and treatment of commonly encountered compressive neuropathies of the forearm. Full article

(1) Background: The purpose of this study was to investigate intraoperative pharmacological and nonpharmacological methods and techniques in reducing blood loss in patients following total hip or knee arthroplasty. (2) Methods: A retrospective cross-sectional study was conducted in patients undergoing TKA or THA surgery, electively performed at the General Hospital Valjevo, Valjevo, Serbia, in 2014 when the principles of patient blood management (PBM) were not applied at all or in part, and in 2019 when PBM principles were applied as standard. (3) Results: This study includes 197 patients, of whom 83.8% developed postoperative anemia (PA defined by haemoglobin < 12 g/dL in both sexes). Using multivariate logistic regression and ROC curve analysis, it was shown that the use of tranexamic acid (TXA) with intraoperative cell salvage (ICS) in patients without preoperative anemia reduced the incidence of PA (odds ratio = 0.081). (4) Conclusions: Preoperative diagnosis and treatment of anemia are necessary in orthopedic patients since the use of TXA with ICS strongly reduces PA in patients without preoperative anemia. Full article

(1) Background: spinal tumors not only causes structural problem but also it affects body functionality, too. Surgery has a key role in management of patients with spinal tumor. The aim of this study is that to observe their clinical profile, functional outcomes and prognostic factors. (2) Methods: 20 retrospectively consecutive patients with spinal tumors operated over a period of 2 years were analyzed. (3) Results: nine (45%) were intradural and 11(55%) were extradural. Mean age at surgery was 45.05 years (range 20–80 years). The common clinical features were pain, limb weakness and autonomic involvement. Schwannoma was common in intradural extramedullary group whereas astrocytoma and ependymoma was common in intramedullary group. In this case, 16 (80%) patients had improvement following surgery and 4 (20%) remained the same, none had deterioration. Common complications were persistent pain (1 case) and autonomic involvement (1 case). (4) Conclusion: spinal tumors need early exploration and excision and usually patients recover well without any residual effect. Full article

A range of surgical techniques have been developed for the repair or regeneration of lesioned cartilage in the human knee and a corresponding array of scoring systems have been created to assess their outcomes. The published literature displays a wide range of opinions regarding the factors that influence the success of surgical cartilage repair and which parameters are the most useful for measuring the quality of the repair at follow-up. Our objective was to provide some clarity to the field by collating items that were agreed upon by a panel of experts to be important in these areas. A modified, three-round Delphi consensus study was carried out consisting of one idea-generating focus-group and two subsequent, self-completed questionnaire rounds. In each round, items were assessed for their importance and level of consensus against pre-determined threshold levels. In total, 31 items reached consensus, including a hierarchy of tissues in the joint based on their importance in cartilage repair, markers of repair cartilage quality and the implications of environmental and patient-related factors. Items were stratified into those that can be employed for predicting the success of cartilage repair and those that could be used for assessing the structural quality of the resulting repair cartilage. Items that did not reach consensus represent areas where dissent remains and could, therefore, be used to guide future clinical and fundamental scientific research. Full article

Post-operative analgesic management is challenging in infants and opioids have been the standard of care. However, they are associated with adverse effects which may negatively impact infants. In this retrospective cohort study, we sought to explore the postoperative analgesic efficacy of quadratus lumborum (QL) block in the infant population undergoing dorsal lumbotomy pyeloplasty. Chart review of 34 infants (≤12 months) who underwent dorsal lumbotomy pyeloplasty between 2016–2020 was performed. Post-operative pain was assessed using externally validated pain scales (CRIES & FLACC) and monitored hemodynamics (pulse and blood pressure). Opioid doses were standardized by using morphine milligram equivalency (MME). The Prescription Database Monitoring Program (PDMP) was utilized to determine if discharge opioid prescriptions were filled. Of 34 patients, 13 received the QL block. Mean age at the time of surgery was 6.2 months ± 3.2 months. The QL group received 0.8 MME postoperatively, whereas the non-QL group received 0.9 MME (p = 0.82). The QL group (20%) filled their discharge opioid prescription less frequently compared to non-QL group (100%) (p = 0.002). There were no observed differences between pain scale or hemodynamic variables. Further studies are warranted to explore QL block’s efficacy for post-operative infant pain management. Full article

Introduction: This systematic review aims to summarize the existing evidence relating to preoperative anemia and clinical outcomes in peripheral vascular surgery patients. Methods: The following databases were searched—PubMed, COCHRANE, LILACS, and Science Research—from 1 January 2010 up to 8 May 2020, with the last search performed on 1 January 2021. An additional manual search for potential primary studies was conducted on major journals (e.g., Anesthesiology, the British Journal of Anesthesia and the European Journal of Anaesthesiology) and reference lists of included studies. Google Scholar was also checked for additional eligible studies. Reviewers independently screened potentially eligible articles and extracted data from included studies on populations, interventions, comparisons, and outcomes. This review was registered at PROSPERO as CRD 180954. Results: In total, 6 observational studies with a combined total of 87,327 participants were analyzed. Data collected in this review suggest that preoperative anemia, especially when hemoglobin is <10 g/dL, is associated with an increased risk of red blood cell transfusions (OR: 7.5; 95% CI 6.3–8.9, p < 0.0001), limb amputation (OR: 5.2; 95% CI 3.1–8.6, p < 0.0001), and death (p < 0.0031). Conclusions: These data suggest an association between preoperative anemia, blood transfusion requirements, and other adverse clinical outcomes among patients subjected to peripheral vascular interventions. However, further investigations, particularly randomized controlled trials, are warranted to better understand the association between preoperative anemia and patients’ prognosis. Full article

In about 20% of all cases, the fine needle aspiration cytology (FNAC) results are equivocal, delivering the two common categories of indeterminate cytology, Bethesda III and IV. The observed rates of malignancy vary widely among institutions, with the urgent need for a more precise risk stratification. 99mcTc methoxyisobutylisonitrile scintigraphy (MIBI) is less expensive than molecular testing and has been shown to have a high negative predictive value. For this reason, the results of MIBI scintigraphy in adult patients with indeterminate FNAC were collected, and correlated with the final pathology reports of surgical specimens. Patients receiving FNAC, MIBI scintigraphy and surgery for sonographic suspicious hypofunctional thyroid nodules between 2015 and 2019 at the University Hospital of Cologne, Germany were identified. Sensitivity, specificity, positive predictive and negative predictive value of MIBI scintigraphy were calculated. Seventy-eight patients with sonographic suspicious hypofunctional thyroid nodules underwent surgery after interdisciplinary case discussion of both FNAC and MIBI results. In 49 (62.5%) cases, FNAC consisted of Bethesda III and IV results. In 39 (79.6%) of these cases, MIBI scintigraphy resulted in mismatch and intermediary results, but in only 4 (10.2%) of these cases was a carcinoma diagnosed. The negative predictive value of MIBI scintigraphy was 90–100%, respectively. Relying on the negative predictive value of MIBI match results might have obviated the need for surgery in 20.4% cases; one papillary microcarcinoma, however, would have been missed. MIBI scintigraphy has an underused potential for improving the diagnostic precision of hypofunctional thyroid nodules. Full article

The coronavirus SARS-CoV-2 pandemic has affected over one hundred million people worldwide and has resulted in over two million deaths. In addition to the toll that coronavirus takes on the health of humans infected with the virus and the potential long term effects of infection, the repercussions of the pandemic on the economy as well as on the healthcare system have been enormous. The global supply of equipment necessary for dealing with the pandemic experienced extreme stress as healthcare systems around the world attempted to acquire personal protective equipment for their workers and medical devices for treating COVID-19. This review describes how 3D printing is currently being used in life saving surgeries such as heart and lung surgery and how 3D printing can address some of the worldwide shortage of personal protective equipment, by examining recent trends of the use of 3D printing and how these technologies can be applied during and after the pandemic. We review the use of 3D printed models for treating the long term effects of COVID-19. We then focus on methods for generating face shields and different types of respirators. We conclude with areas for future investigation and application of 3D printing technology. Full article

Tracheobronchial injuries are rare but potentially high-impact events with significant morbidity and mortality. Common etiologies include blunt or penetrating trauma, often combined with various complex injuries, while iatrogenic injury usually occurs during operation, intubation, or bronchoscopy. An early and accurate diagnosis and a multidisciplinary approach in a center experienced in treating airway lesions are essential to obtain favorable results. For a long time, surgery has been considered the treatment of choice for post-traumatic airway lesions. However, recent reports have shown a paradigm shift in the management of tracheal injury towards a conservative approach, especially in treating iatrogenic lesions. In our experience of 11 consecutive patients, although there are still definitive indications for surgery, we demonstrated the effectiveness of conservative treatment in patients with mixed varieties of tracheal injury by etiology, extension, and complications. Full article

18F-fluorodeoxyglucose ([18F]-FDG) positron emission tomography/computed tomography (PET/CT) is a useful functional image technique to evaluate the disease extent in many cancers, as well as differentiate benign disease from malignant metastasis. We report the case of a 49-year-old woman with breast cancer and suspected lung metastasis by conventional images. After FDG-PET/CT demonstrating faint, or even no FDG uptake in bilateral pulmonary nodules, accompanied with obvious uterine fibroids, benign metastasizing leiomyoma (BML) of the lung was included in a differential diagnosis and finally confirmed by surgical pathology. FDG PET/CT showed its value in the diagnosis of BML in the breast cancer patient who was misleading as lung metastasis during outpatient follow-up. Full article