Search Results (23)

Background: Perioperative fluid therapy plays a critical role in the outcome of microvascular free-flap surgery. While both inadequate and excessive fluid administration may impair flap perfusion and systemic recovery, the impact of fluid balance and crystalloid volume—normalized to body weight and operative time—on postoperative complications remains underexplored. This study investigates the dose-dependent effects of intraoperative fluid and crystalloid administration on flap-related and systemic outcomes. Methods: This retrospective, single-centre cohort study included 495 adult patients who underwent microvascular free-flap transplantation between 2009 and 2020. Intraoperative fluid balance and crystalloid volumes were normalized to patient weight and operative duration (mL/kg/h) and stratified into pre-defined thresholds. The primary endpoint was the incidence of flap-related complications (partial/total flap loss, thrombosis, revision surgery). Secondary endpoints included flap loss, suture insufficiency, pneumonia, ICU length of stay (LOS-ICU), and in-hospital mortality. Results: Higher intraoperative fluid rates were significantly associated with higher complication rates. Flap-related complications occurred in 54.8% of patients receiving >10 mL/kg/h versus 37.1% in the ≤5 mL/kg/h group (p < 0.01) and reached 100% in patients receiving >20 mL/kg/h, although this category comprised only seven patients (p < 0.01). Suture insufficiency increased from 3.1% (≤5 mL/kg/h) to 57.1% (>20 mL/kg/h; p < 0.01). Pneumonia incidence rose from 8.8% (≤5 mL/kg/h) to 31.9% (>10 mL/kg/h; p < 0.01). A U-shaped trend was observed for flap loss, with the highest rate (24.6%) at >10 mL/kg/h. Crystalloid volume > 3000 mL was significantly associated with higher flap loss (20.2% vs. 0.2%; p < 0.01) and suture insufficiency (7.0% vs. 0.2%; p = 0.02). Red blood-cell (RBC) transfusions were associated with higher overall complication rates (45.6% vs. 34.2%; p < 0.01) and suture insufficiency (9.9% vs. 3.4%; p < 0.01). Gelatin-based colloids showed no negative impact. Operative time was the only strong independent predictor of total flap loss; each additional operative hour increased the odds of flap loss by 34% (p < 0.001). Intraoperative noradrenaline use and a history of neoadjuvant radiotherapy were not independently associated with flap-related complications or flap loss. Median LOS-ICU increased from 2 days to 10 days in patients receiving >20 mL/kg/h (p < 0.01). In-hospital mortality increased significantly with higher fluid volumes (0.3% for ≤10 mL/kg/h vs. 28.6% for > 20 mL/kg/h; p < 0.01). Conclusions: In 495 microvascular free-flap reconstructions, diagnosis, flap type, defect localization and operative time emerged as key determinants of postoperative outcomes, while defect type itself showed no predictive value. Intraoperative fluid overload—particularly crystalloid rates exceeding 10 mL/kg/h—is associated with a significantly higher risk of flap-related complications, pneumonia, prolonged ICU stay and mortality. These findings support the implementation of individualized or goal-directed fluid strategies in microvascular reconstructive surgery to optimize outcomes. Full article

Lipomyelomeningocele (LMMC) is one of the most common forms of occult spinal dysraphism, with an estimated incidence of 3–6 per 100,000 live births, and microsurgical untethering remains the cornerstone of management for symptomatic and selected at-risk children. The operation is technically demanding: reported rates of long-term symptomatic re-tethering after partial resection still reach 15–25%, and the surgeon must balance adequate untethering against preservation of the placode and lumbosacral nerve roots. In this technical note, we present a stepwise, illustrated description of our institutional 14-step microsurgical technique for pediatric LMMC. Each step is anchored to a defined anatomical landmark, beginning with a midline skin incision planned away from the anal verge and proceeding through subtotal subcutaneous lipoma resection, identification of the dural penetration site, a limited rostral laminectomy over normal anatomy, dural opening with circumferential dissection of lipoma–dura–cord adhesions, exploitation of the arachnoid–dura plane, electrophysiologically guided debulking of the intradural lipoma, stimulation-controlled division of the fatty filum, pia-to-pia reconstruction of the placode with 8-0 monofilament suture, expansile duraplasty with an artificial dural substitute, and reinforced multilayered watertight closure. Technical pearls aimed at minimizing the risks of cord injury, cerebrospinal fluid leak, and postoperative re-tethering are highlighted at each stage, and the role of multimodal intraoperative neurophysiological monitoring is emphasized. This note is intended as a practical, image-anchored operative reference for pediatric neurosurgeons and trainees managing this challenging closed neural tube defect. Full article

Infra-hepatic inferior vena cava (IVC) balloon occlusion is an effective strategy for reducing intraoperative bleeding during precision liver surgery, yet rapid balloon inflation can produce abrupt transient deviations in downstream venous pressure that are not yet quantitatively characterized. Current practice relies on operator experience, with no quantitative framework to balance occlusion efficacy against downstream pressure safety. A computational fluid dynamics (CFD) model of the balloon-occluded IVC was developed in ANSYS 2025 R2 with two-way fluid–structure interaction (FSI), Carreau–Yasuda blood rheology, and a balloon described by an Ogden hyperelastic model; the flow regime was laminar (Re ≈ 254). Reduced-order ARX models of four input–output subsystems were identified from CFD-generated data, and a model predictive control (MPC) strategy was formulated to penalize downstream pressure overshoot through a weighted cost function. The identified models achieved training normalized root-mean-square errors of 0.0363 to 0.1164 and out-of-sample validation errors of 0.1224 to 0.2381. Conventional sigmoid inflation induced a 45.82% overshoot in downstream pressure (P_aft); the optimal input signal (q = [0, 1, 0, 0], λ = 0.1) reduced this to 6.05%, a reduction of 39.77 percentage points, while preserving >90% flow occlusion at U_F = 3 × 10⁴ Pa. The proposed framework offers a quantitative basis for balloon-occlusion device design that limits downstream pressure overshoot, motivating subsequent benchtop, ex vivo, and in vivo validation. Full article

Liver transplantation (LT) is the definitive treatment for patients with end-stage liver disease. Since its inception in the 1960s, transplant medicine has undergone substantial advances in surgical technique, immunosuppression, organ preservation, and organ allocation policies. According to the 2023 WHO census, approximately 47,180 LT procedures occur worldwide each year, with living donors contributing to up to 23% of cases. Additional milestones include the expansion of transplant eligibility to patients with hilar cholangiocarcinoma and advanced colorectal liver metastasis, the incorporation of viscoelastic testing into perioperative blood management algorithms, and the increasing use of mechanical circulatory support for pre-transplant optimization. In parallel, medical training has evolved to meet the complexities associated with these high-risk procedures. Structured fellowship programs now provide focused expertise, and guide investigations to resolve complex clinical dilemmas. Experience accumulated over decades has improved clinicians’ ability to manage the expanding spectrum of comorbidities seen in contemporary transplant candidates. Key perioperative challenges include accurate assessment of fluid status, optimization of intravascular volume, management of vasoplegia, intraoperative renal replacement therapy, treatment of right-ventricular failure, and the mitigation of severe lactic acidosis. As transplant recipients increasingly present at older ages and with multiple comorbidities, perioperative management has become more demanding. One emerging strategy for select high-risk patients involves performing concurrent surgical procedures within a single operative session. This narrative review focuses on the intraoperative management of five variables that proved challenging during the first case of concurrent liver transplantation and off-pump coronary artery bypass surgery in our institution. Full article

Background: Focal chondral and osteochondral knee defects have limited intrinsic healing capacity and may progress toward post-traumatic osteoarthritis. Early post-operative inflammatory signaling may influence clinical recovery after cartilage repair. This prospective, single-center observational cohort study aimed to characterize short-term post-operative inflammatory biomarker profiles in synovial fluid and serum after AMIC and to assess associations with patient-reported outcomes over 12 months. Methods: Fifteen patients undergoing autologous matrix-induced chondrogenesis (AMIC) for focal knee chondral/osteochondral defects were prospectively enrolled. International Knee Documentation Committee (IKDC) and Lysholm scores were recorded pre-operatively and at 6 and 12 months. Synovial fluid and serum were collected intraoperatively, at 6 and 12 weeks post-operatively. Interleukin (IL)-1β, IL-1 receptor antagonist (IL-1RA), and IL-6 were quantified using multiplex flow luminescence immunoassay, and the total synovial fluid protein level was measured. Non-parametric repeated-measures testing and Spearman’s rank correlation were applied (p < 0.05). Results: IKDC and Lysholm scores improved from (30.6 ± 9.4) to (58.8 ± 15.0) and from (57.5 ± 18.6) to (78.2 ± 14.7), respectively, exceeding established minimal clinically important difference (MCID) thresholds. Synovial fluid IL-1β and IL-1RA increased significantly over time ((p = 0.01357) and (p = 0.03953), respectively); IL-1β remained elevated, whereas IL-1RA tended to decline after 6 weeks. IL-6 levels remained low throughout. Total synovial fluid protein increased significantly (p = 0.00043). No significant correlations were observed between corresponding biomarker levels in synovial fluid and serum. Higher IL-6 and a higher IL-1β/IL-1RA ratio were associated with poorer clinical improvement (ρ = −0.80, p < 0.05 and ρ = −0.580, p < 0.05, respectively). Conclusions: AMIC was associated with a sustained intra-articular inflammatory response despite favorable 12-month outcomes. Exploratory analyses suggest that inflammatory dysregulation—particularly involving IL-6 and IL-1β/IL-1RA balance—may be linked to less favourable clinical recovery. Synovial fluid measurements provided more relevant information on local joint biology than serum sampling. Full article

Background/Objectives: Various pathophysiological mechanisms play a role in the development of cardiovascular diseases (CVDs). There is a need for new biomarkers that can complement existing clinical findings, particularly in the early diagnosis and prognostic assessment of coronary artery disease (CAD) and that can also contribute to more effective management of the diagnosis and treatment process. Therefore, both blood and pericardial fluid samples can provide important diagnostic information. This study aims to investigate Stromal Cell-Derived Factor 4 (SDF4) levels and thiol/disulfide homeostasis in the blood and pericardial fluid of patients with established CAD undergoing open-heart surgery with cardiopulmonary bypass (CPB), in order to better characterize oxidative stress-related and redox-mediated pathophysiological processes associated with the development and progression of coronary heart disease. Comparisons with a healthy control group were performed to elucidate disease-related biochemical alterations rather than to propose these markers as diagnostic tools for CAD. Methods: In this study, intraoperatively collected venous blood and pericardial fluid samples from 45 patients undergoing on-pump coronary artery bypass grafting were analyzed. SDF4 levels were measured using enzyme-linked immunosorbent assay (ELISA), while thiol–disulfide homeostasis was assessed via spectrophotometric analysis. Results: The study revealed statistically significant differences in parameters such as SDF-4, native thiol, total thiol, disulfide, and disulfide/total thiol ratio among the control, patient serum, and pericardial fluid groups (p < 0.05). Notably, SDF-4 and disulfide levels were elevated, while thiol levels were reduced in the pericardial fluid group, suggesting increased oxidative stress and disrupted redox balance. Principal Component Analysis (PCA) and Variable Importance in Projection (VIP) analyses successfully demonstrated the discriminative power of these parameters among the groups. Conclusions: The increased SDF-4 levels and disturbances in the thiol–disulfide balance observed in this study indicate elevated oxidative stress and impaired cellular redox homeostasis in CAD. These findings suggest that SDF-4 and thiol–disulfide parameters may serve as important biochemical markers in the pathophysiology of CVD and hold potential as diagnostic and prognostic biomarkers. Full article

Background and Objectives: The endothelial glycocalyx (EG) maintains vascular barrier and homeostasis, but is vulnerable to perioperative stress and ischemia/reperfusion. We evaluated whether central venous pressure (CVP) strategy—low (LCVP, <5 mmHg) versus normal (NCVP, 5–12 mmHg)—and hepatic ischemia/reperfusion during hepatectomy influence perioperative EG shedding in hepatic or pancreatic resections. Materials and Methods: A total of 37 adults, out of 40 screened, (18–80 years) scheduled for elective hepatic or pancreatic resection under propofol–remifentanil anesthesia with invasive hemodynamic monitoring, were allocated by initial CVP to LCVP or NCVP protocols and further stratified by ischemia versus no ischemia. Plasma syndecan-1 and heparan sulfate were quantified by ELISA at predefined timepoints (baseline after induction; intraoperative and 2 h post-op). Statistical analyses included nonparametric tests, Friedman with Bonferroni, and ANCOVA adjusted for baseline; p < 0.05 significant. Results: Thirty-six patients completed analysis (NCVP n = 23; LCVP n = 13). In procedures without ischemia (n = 24; NCVP 16, LCVP 8), heparan sulfate increased over time in both groups; between-group differences in absolute/percentage change were not significant. Syndecan-1 was similar between groups except at 2 h post-op (T3), where LCVP was higher than NCVP (median 9 [11.5] vs. 1.4 [4.5]; p = 0.027). In procedures with ischemia (n = 12; NCVP 7, LCVP 5), neither biomarker differed between CVP groups at any timepoint. A weak negative CVP–stroke volume variation (SVV) correlation was seen at one timepoint (T1: r = −0.363; p = 0.030). Conclusions: Major hepatic/pancreatic surgery is associated with measurable EG shedding. Overall, shedding appeared largely independent of CVP strategy and ischemia/reperfusion status, with a late postoperative rise in syndecan-1 under LCVP in non-ischemia cases suggesting potential endothelial cost of aggressive fluid restriction/vasopressor use. These findings highlight the need to refine hemodynamic targets that balance minimizing bleeding with preserving endothelial integrity and suggest that perioperative fluid and vasopressor management may directly influence glycocalyx preservation. Full article

Background/Objectives: 3-Hydroxy-3-methylglutaryl-CoA lyase deficiency (HMGCLD) is an extremely rare autosomal recessive metabolic disorder caused by mutations in the HMGCL gene. HMGCLD disrupts ketogenesis and β-oxidation, leading to energy failure during fasting or stress, with clinical episodes characterized by hypoglycemia, hyperammonemia, lactic acidosis, and encephalopathy. Only 211 cases have been reported worldwide, with no prior reports on anesthetic management in these patients. Methods: We report a 14.5-year-old girl with known HMGCLD who was admitted with abdominal pain and nausea following a fatty meal. Imaging confirmed acute cholecystitis. Initial conservative management failed due to persistent vomiting and inability to tolerate feeding. Deviation from the metabolic protocol led to lactic acidosis and hypoglycemia, requiring intensive care with bicarbonate, carnitine, and glucose infusion. Once optimized, she underwent emergency laparoscopic cholecystectomy under sevoflurane-based anesthesia. Propofol was avoided, given the patient’s compromised lipid metabolism. Intraoperative glucose and acid-base status were closely monitored, with balanced dextrose-based fluids. Results: The patient remained hemodynamically stable throughout and was discharged three days postoperatively. Conclusions: This case highlights the anesthetic challenges of HMGCLD, where system-level miscommunication can trigger severe metabolic decompensation. A review of the literature emphasizes fasting avoidance, continuous glucose supplementation, careful drug and fluid selection, and multidisciplinary coordination. This report provides the first anesthetic roadmap for HMGCLD, underscoring the need for individualized care and meticulous perioperative metabolic control. Full article

Background/Objectives: Perioperative organ injury (POI) is frequently observed following hepatectomy as acute kidney injury (AKI), perioperative myocardial injury (PMI), or both. We aimed to determine the incidences of POI, PMI, and AKI, reveal the risk factors and predictive tools for POI occurrence, and evaluate the relationship between POI and patient outcomes. Methods: This was a single-center historical cohort study of consecutive patients. The primary endpoint was the occurrence of POI within 3 days following hepatectomy. Results: Out of 128 patients, POI, PMI, and AKI occurred in 48 (37.5%), 36 (28.1%), and 23 (18%) patients, respectively. Ten (7.8%) patients suffered from both PMI and AKI. The presence of chronic kidney disease or systolic/valvular heart disease, fluid balance more than 365 mL/h, and intraoperative bleeding more than 950 mL were the risk factors for POI. A tool created by using the intraoperative decline of central venous oxygen saturation and lactate value during skin closure performed well in predicting POI (area under the ROC curve: 0.79, p < 0.001). In patients with POI, the number of those who needed intensive care unit (ICU) follow-up for more than 1 day was significantly higher (21% vs. 6%, p: 0.01). The length of hospital stay for these patients was significantly longer as well (11 (8–18) vs. 9 (7–13) days, p: 0.02). Two patients (20% of 10 patients who suffered from both AKI and PMI) died in the 90-day follow-up. Conclusions: POI is a common complication following hepatectomy and is associated with longer hospital and ICU stays. Patients who suffer from both AKI and PMI have a higher risk of mortality. Full article

Cardiac disease remains a leading cause of maternal morbidity and mortality, particularly in developed countries where improved survival has increased the number of pregnant patients with congenital heart disease. The physiological changes of pregnancy, such as increased blood volume, cardiac output, and hypercoagulability, can exacerbate preexisting cardiac conditions, posing significant anesthetic challenges during cesarean delivery. This review outlines anesthetic strategies for parturients with structural or functional cardiac disease, emphasizing individualized, multidisciplinary care. We examine general and regional anesthesia approaches, intraoperative monitoring, and hemodynamic goals, including fluid balance, venous return optimization, and myocardial oxygen demand reduction. Preoperative risk stratification and coordination with cardiology and obstetric teams are essential. Future efforts should aim to standardize protocols and improve maternal–fetal outcomes through evidence-based anesthetic planning. Full article

(1) Background: Pituitary adenomas are benign tumors comprising about 18% of all intracranial tumors, and they often require surgical intervention. Differentiating pituitary tissue from adenoma during surgery is crucial to minimize complications. We hypothesized that using ICG dye would reduce the hormonal complication rates. (2) Methods: A prospective randomized study (February 2019–October 2023) included 34 patients with non-functional macroadenomas of the pituitary gland randomly assigned to receive intraoperative ICG or be in the control group. All underwent endoscopic endonasal transsphenoidal surgery. Pituitary function was assessed preoperatively, immediately postoperatively, and 3–6 months postoperatively. Adenohypophysis function was evaluated with hormonal tests (Cosyntropin stimulation test, TSH, fT3, fT4, prolactin, IGF-1, FSH, LH, and testosterone in men) and neurohypophysis function with fluid balance, plasma and urine osmolality, and serum and urinary sodium. (3) Results: Of the 34 patients (23 men, 11 women; average age 60.9 years), 5.9% in the ICG group developed diabetes insipidus postoperatively, compared to 23.5% in the control group. Adenohypophysis function worsened in 52.9% of the ICG group and in 35.3% of the control group. (4) Conclusions: Our study did not confirm the benefits of using ICG in these surgeries. Further research with a larger sample is needed. Full article

During the perioperative period of transplantation, patients experience hypotension secondary to the side effects of anesthesia, surgical stress, inflammatory triggering, and intraoperative fluid shifts, among others causes. Vasopressor support, in this context, must reverse systemic hypotension, but ideally, the agents used should benefit allograft function and avoid the adverse events commonly seen after transplantation. Traditional therapies to reverse hypotension include catecholamine vasopressors (norepinephrine, epinephrine, dopamine, and phenylephrine), but their utility is limited when considering allograft complications and adverse events such as arrhythmias with agents with beta-adrenergic properties. Synthetic angiotensin II (AT2S–[Giapreza]) is a novel vasopressor indicated for distributive shock with a unique mechanism of action as an angiotensin receptor agonist restoring balance to an often-disrupted renin angiotensin aldosterone system. Additionally, AT2S provides a balanced afferent and efferent arteriole vasoconstriction at the level of the kidney and could avoid the arrhythmic complications of a beta-adrenergic agonist. While the data, to date, are limited, AT2S has demonstrated safety in case reports, pilot studies, and small series in the kidney, liver, heart, and lung transplant populations. There are physiologic and hemodynamic reasons why AT2S could be a more utilized agent in these populations, but further investigation is warranted. Full article

Background: The surgical treatment of advanced ovarian cancer is associated with extensive tissue trauma, prolonged operating times and a considerable volume shift. It, therefore, represents a challenge for anaesthesiological management. Aim: The aim of this single-centre, retrospective, observational study was to investigate whether intraoperative extensive volume supply influences postoperative outcomes and long-term survival. Methods: The study included 73 patients with a mean (SD) age of 63 (13) years who underwent extensive tumour-reducing surgery for ovarian cancer between 2012 and 2015. The effect of the intraoperative fluid balance on postoperative complications, such as anastomotic insufficiency or pleural effusions, was investigated using logistic regression. Further, the influence of fluid balance, lactate and creatinine levels on 5-year survival was analysed in a Cox regression model. Associations between anaesthesia time and the intraoperative fluid balance were examined using Spearman’s rank correlation coefficients. Results: The mean (SD) postoperative fluid balance in the considered patient cohort was 9.1 (3.4) litres (l) at a mean (SD) anaesthesia time of 529 (106) minutes. Cox regression did not reveal a statistically significant effect of the fluid balance, but it did reveal a statistically significant association between the lactate level 24 h following surgery and the 5-year survival (HR [95%-CI] fluid balance: 0.97 [0.85, 1.11]; HR [95%-CI] lactate: 1.79 [1.24, 2.58]). According to logistic regression, the intraoperative fluid balance was associated with an increased chance of postoperative complications in the considered patient cohort (OR [95%-CI] 1.28 [1.1, 1.54]). Conclusions: We could not detect a negative impact of an increased fluid balance on 5-year survival, but a negative impact on postoperative complications was found in our patient cohort. Full article

Background: In head and neck reconstructive surgery, postoperative complications are a well-known concern. Methods: We examined 46 patients who underwent ablative surgery and received fibula free flap reconstruction. The main focus was to assess the influence of intraoperative blood pressure fluctuations and the administration of inotropic drugs on complications, either related to the flap or systemic, serving as the primary endpoint. Results: Utilizing logistic regression models, we identified that intraoperative mean arterial blood pressure (MAP) drops did not correlate with the occurrence of either flap-related complications (MAP < 70, p = 0.79; MAP < 65, p = 0.865; MAP < 60, p = 0.803; MAP < 55, p = 0.937) or systemic medical complications (MAP < 70, p = 0.559; MAP < 65, p = 0.396; MAP < 60, p = 0.211; MAP < 55, p = 0.936). The occurrence of flap-related complications significantly increased if a higher dosage of dobutamine was administered (median 27.5 (IQR 0–47.5) vs. 62 (38–109) mg, p = 0.019) but not if norepinephrine was administered (p = 0.493). This correlation was especially noticeable given the uptick in complications associated with fluid overload (3692 (3101–4388) vs. 4859 (3555–6216) mL, p = 0.026). Conclusion: Intraoperative and immediate postoperative blood pressure fluctuations are common but are not directly associated with flap-related complications; however, dobutamine application as well as fluid overload may impact flap-specific complications. Full article

The use of norepinephrine and the restriction of intraoperative hydration have gained increasing acceptance over the last few decades. Recently, there have been concerns regarding the impact of this approach on renal function. The objective of this study was to examine the influence of norepinephrine, intraoperative fluid administration and their interaction on acute kidney injury (AKI) after cystectomy. In our cohort of 1488 consecutive patients scheduled for cystectomies and urinary diversions, the overall incidence of AKI was 21.6% (95%—CI: 19.6% to 23.8%) and increased by an average of 0.6% (95%—CI: 0.1% to 1.1%, p = 0.025) per year since 2000. The fluid and vasopressor regimes were characterized by an annual decrease in fluid balance (−0.24 mL·kg⁻¹·h⁻¹, 95%—CI: −0.26 to −0.22, p < 0.001) and an annual increase in the amount of norepinephrine of 0.002 µg·kg⁻¹·min⁻¹ (95%—CI: 0.0016 to 0.0024, p < 0.001). The interaction between the fluid balance and norepinephrine levels resulted in a U-shaped association with the risk of AKI; however, the magnitude and shape depended on the reference categories of confounders (age and BMI). We conclude that decreased intraoperative fluid balance combined with increased norepinephrine administration was associated with an increased risk of AKI. However, other potential drivers of the observed increase in AKI incidence need to be further investigated in the future. Full article