Search Results (780)

Background and Objectives: Effective perioperative pain management remains a key goal of enhanced recovery protocols, especially in minimally invasive urologic surgery, where optimizing comfort while limiting opioid exposure is essential. Intravenous lidocaine has gained attention for its multimodal analgesic and anti-inflammatory properties, yet evidence in robotic prostatectomy remains limited. This study evaluated whether intraoperative lidocaine infusion was associated with lower early postoperative pain scores and reduced opioid use in patients undergoing robotic-assisted radical prostatectomy. Materials and Methods: A retrospective, single-center analysis was conducted at Pelican Clinical Hospital, Oradea, Romania, including 112 patients operated on between January 2020 and December 2023. All procedures were performed by the same surgical and anesthetic teams using standardized ERAS-based protocols. Patients were divided into two groups: the Lidocaine Group (LG, n = 51), who received a bolus of 1.5 mg/kg lidocaine followed by an infusion of 1.5 mg/kg/h during surgery, and the Control Group (CG, n = 61), who received standard anesthesia without lidocaine. Postoperative pain was measured using the visual analog scale (VAS) at 0, 4, 12, and 24 h, and opioid use was converted into morphine milligram equivalents (MME). Secondary outcomes included time to ambulation, gastrointestinal recovery, oral intake, hospital stay, and complications. Results: Pain intensity was significantly lower in the lidocaine group at 4 h postoperatively (VAS 3.5 ± 1.1 vs. 4.3 ± 1.3; p = 0.01), with similar scores later. Total opioid use was reduced by about 18% in the lidocaine group (25.7 ± 9.4 vs. 31.2 ± 10.5 MME; p = 0.03). Recovery parameters and complication rates were comparable between groups, and no lidocaine-related adverse events were recorded. Conclusions: Intraoperative intravenous lidocaine was associated with lower early postoperative pain scores and reduced opioid requirements after robotic-assisted radical prostatectomy without affecting recovery or safety. Its favorable profile and low cost support its inclusion as a practical adjunct in multimodal analgesia within ERAS pathways. Full article

Background/Objectives: Fetoscopic repair of open spinal dysraphism (OSD) is a rare intrauterine procedure performed in specialized fetal surgery centers. Conducted under restrictive fluid management and continuous tocolysis, it poses substantial challenges to maternal hemodynamic stability. Blood pressure optimization with vasopressor boluses is often required, yet intraoperative hemodynamic data remain limited. Methods: This prospective observational study was conducted between December 2023 and January 2025 during fetoscopic repair of OSD at Marburg University Hospital, Germany. Maternal hemodynamics were continuously monitored using pulse contour analysis with the Acumen IQ sensor and HemoSphere platform (Edwards Lifesciences, Irvine, CA, USA). To stabilize arterial pressure, cafedrine/theodrenaline (Akrinor, Ratiopharm, Ulm, Germany) was administered as intravenous boluses. Hemodynamic parameters were analyzed immediately before and after each bolus. Fetal heart rate was assessed as a secondary parameter at predefined intraoperative time points when available. Results: A total of 13 patients and 110 vasopressor boluses were analyzed. Reported values reflect median percent changes; parentheses indicate the total range. Following maternal blood pressure optimization, mean arterial pressure increased by 13.7% (5.9–21.6), systemic vascular resistance index by 23.1% (8.3–36.7), and dP/dtmax by 21.7% (6.3–29.9): p < 0.001 for all. Cardiac index and stroke volume index decreased by −6.7% (−11.8 to −0.6), p < 0.001, and −4.3% (−9.8 to 1.8), p = 0.048, respectively. Fetal heart rate remained stable (+0.4% (−0.8 to 1.5); p = 0.470). A total of 38 HPI alerts were followed by hypotension, with a median latency of 120 s (80–235); 73 alerts were not followed by hypotension during the observation period. Conclusions: Intermittent cafedrine/theodrenaline boluses significantly increased arterial pressure, dP/dtmax, and systemic vascular resistance under conditions of fluid restriction and tocolysis-induced vasodilation. Maternal heart rate remained stable, and cardiac output showed only minor reductions. Fetal heart rate was unchanged following maternal blood pressure treatment, indicating no adverse fetal response to C/T within the observed intraoperative period. Full article

Spinal vascular malformations (SVMs) are rare and heterogeneous lesions that may lead to progressive neurological decline or hemorrhage, posing significant challenges for management due to their complex angioarchitecture and proximity to critical neural structures. This review examines the role of angiographic imaging modalities used intraoperatively and postoperatively in guiding treatment, confirming therapeutic success, and informing follow-up strategies. We summarize evidence on two-dimensional digital subtraction angiography (2D DSA), indocyanine green videoangiography (ICG–VAG), and emerging adjunctive techniques. 2D DSA remains the reference standard, offering superior temporal and spatial resolution for real-time visualization of vascular anatomy, catheter navigation, and embolic delivery, though its invasive nature, radiation exposure, and two-dimensional projection limit long-term applicability. ICG–VAG provides a complementary, non-ionizing method for intraoperative fluorescence imaging, aiding in shunt localization and venous preservation, although its restricted field of view and limited capacity for quantitative analysis reduce its standalone value. Advances in quantitative angiographic metrics, patient-specific hemodynamic modeling, and artificial intelligence-driven image analysis are anticipated to enhance diagnostic accuracy and reproducibility. The development of standardized multimodal protocols will be crucial for optimizing patient-centered treatment of these complex and rare lesions. Full article

A 60-year-old woman with hypertension and hyperlipidemia was referred for an incidentally detected gastric subepithelial mass during screening endoscopy. Esophagogastroduodenoscopy revealed a 10 mm dimple in the antrum, and contrast-enhanced CT showed a 2.5 cm enhancing oval lesion. Laparoscopic partial gastrectomy with intraoperative endoscopic guidance was performed. Gross examination revealed a 3.0 × 2.0 × 1.0 cm pale, firm nodule. Histology showed small round cells arranged in nests and trabeculae within the muscularis propria, with numerous vessels and focal calcification. Immunohistochemistry was negative for CD117, HMB45, and chromogranin A, but demonstrated strong smooth muscle actin positivity, weak synaptophysin reactivity, and focal CD56 staining. The findings confirmed a gastric glomus tumor with neuroendocrine features. Smooth muscle actin immunostaining is essential to distinguish gastric glomus tumors from neuroendocrine tumors when biopsy material is limited, ensuring accurate diagnosis and appropriate management. Full article

Background and Objectives: This study aims to comparatively evaluate the outcomes of glaucoma surgeries performed by a single surgeon during the non-pandemic period (2019, 2021, and the first quarter of 2022) versus the pandemic year (2020). The analysis focuses on key surgical outcomes, including intraocular pressure (IOP) reduction, intraoperative and postoperative complications, surgical success and failure rates, and their broader clinical implications. Materials and Methods: Out of a total of 66 patients admitted between November 2019 and March 2022, 45 met the inclusion and exclusion criteria and were enrolled in the study. All patients underwent glaucoma surgery conducted by the same surgeon employing a standardized technique (trabeculectomy ± iridectomy ± mitomycin C). The evaluated clinical parameters included preoperative and postoperative IOP values (with specific assessment on the first postoperative day), early and late intraoperative and postoperative complications, as well as postoperative success and failure rates. Results: The majority of glaucoma cases—particularly those of primary open-angle glaucoma—were recorded in 2021 and 2022, in contrast to 2019 and 2020, when pseudoexfoliative and secondary closed-angle glaucomas predominated. Over the observation period, retrobulbar anesthesia was more frequently utilized in 2019. Statistical analysis indicated that the surgical failure rate was not significantly influenced by the presence of complications, patient age, associated comorbidities, or the specific surgical variant performed. Conclusions: The conduct of glaucoma surgery during the pandemic period was marked by substantial operational and clinical constraints when compared to non-pandemic years, primarily as a consequence of decreased patient accessibility and the reprioritization of healthcare resources, despite the acknowledged emergency status of these procedures. Nonetheless, the overall incidence of early intraoperative and postoperative complications remained minimal, with transient intraocular hypotony emerging as the predominant adverse event, observed in ten cases. Across all study cohorts, more than 80% of patients achieved qualified surgical success, while only 18% exhibited surgical failure, underscoring the robustness of standardized operative protocols under variable healthcare conditions. Consistent with the directives of the American Academy of Ophthalmology (AAO) and the European Glaucoma Society (EGS), glaucoma must be regarded as a genuine ophthalmic emergency necessitating prompt surgical intervention when intraocular pressure cannot be adequately managed through pharmacological or laser-based therapies. The current findings reinforce the imperative of timely glaucoma surgery, irrespective of pandemic or non-pandemic circumstances, as a critical measure for averting irreversible optic nerve damage, mitigating functional visual loss, and sustaining long-term ocular integrity. Full article

Background and Objectives: Odontogenic infections are common emergencies in oral and maxillofacial surgery. They are typically polymicrobial, with aerobes guiding initial empirical therapy. However, regional data on their microbiology and resistance patterns in Romania are limited. This study aimed to characterize the aerobic microbial profile of odontogenic infections in Southwestern Romania and assess the antimicrobial susceptibility of isolated pathogens. Materials and Methods: A prospective observational study was conducted over 12 months at a tertiary referral hospital. Pus samples collected intraoperatively were cultured aerobically. Bacterial identification used biochemical methods and the VITEK 2 system. Antimicrobial susceptibility was determined by disk diffusion and automated MIC testing, interpreted according to EUCAST v13.0 (2023). Results: Of 110 patients, 96 (87.3%) yielded positive aerobic cultures, producing 97 isolates. Streptococcus spp. were predominant (49.5%), followed by coagulase-negative staphylococci (24.7%), Staphylococcus aureus (14.4%), Enterobacterales (7.2%), and Pseudomonas aeruginosa (3.1%). Streptococcus spp. remained susceptible to penicillin G (82.3%), amoxicillin–clavulanate (76.4%), and clindamycin (70.5%), but only 55.0% to erythromycin. Most S. aureus isolates were methicillin-susceptible (92.9%), while coagulase-negative staphylococci showed high methicillin resistance (59.3%) yet full susceptibility to linezolid, vancomycin, and teicoplanin. Enterobacterales were resistant to ampicillin (90%) and amoxicillin–clavulanate (65%) but remained susceptible to ceftriaxone (80%) and ciprofloxacin (85%). P. aeruginosa isolates were fully susceptible to piperacillin–tazobactam, ceftazidime, cefepime, and meropenem. Conclusions: This study provides regional data on aerobic pathogens in odontogenic infections. High resistance to penicillin and macrolides limits empirical use. Amoxicillin–clavulanate and clindamycin retain moderate activity, while glycopeptides, linezolid, and carbapenems preserved full efficacy. Surgical drainage remains central to management, and antibiotic therapy should be guided by local susceptibility patterns. These data provide baseline information to inform empirical therapy and stewardship efforts and highlight the need for multicenter studies including anaerobic and molecular analyses. Full article

Intraoperative ultrasound (IOUS) is an increasingly adopted adjunctive intraoperative visualization method in spinal tumor surgery, offering real-time imaging that improves lesion localization, exposure planning, and resection control. This paper focuses on IOUS findings in rare intradural entities (neuroenteric/respiratory cysts, chronic spinal subdural hematoma, tethered cord/scarring, intradural extramedullary hemangioblastomas, and arachnoid cysts) where evidence remains limited. Across these lesions, IOUS typically depicts cysts as anechoic or hypoechoic cavities with definable walls and occasional septations; CSSDH is also delimited by hypoechoic subdural collections bounded by echogenic membranes; hemangioblastomas, as well as circumscribed, homogeneous nodules often with cystic components; and arachnoid webs/cysts with their boundaries and subtle subarachnoid communications. Doppler and micro-Doppler can delineate feeding and draining vessels in highly vascular tumors, while shear wave elastography provides quantitative stiffness changes that support effective detethering. IOUS complements preoperative MRI, shortens exposure, helps tailor bone and dural openings, and allows immediate assessment of residual disease. Taken together, current data and our experience support IOUS as a safe, cost-effective, and versatile intraoperative tool for rare intradural spinal pathology, while underscoring the need for prospective studies to refine sonographic criteria and validate outcome benefits. Full article

Background/Objectives: Artificial intelligence (AI) is increasingly applied across the perioperative continuum, with potential benefits in efficiency, personalization, and patient safety. Unfortunately, most such tools are developed in isolation, limiting their clinical utility. Multi-Agent Systems for Healthcare (MASH), in which autonomous AI agents coordinate tasks across multiple domains, may provide the necessary framework for integrated perioperative care. This critical review synthesizes current AI applications in anesthesiology and considers their integration within a MASH architecture. This is the first review to advance MASH as a conceptual and practical framework for anesthesiology, uniquely contributing to the AI discourse by proposing its potential to unify isolated innovations into adaptive and collaborative systems. Methods: A critical review was conducted using PubMed and Google Search to identify peer-reviewed studies published between 2015 and 2025. The search strategy combined controlled vocabulary and free-text terms for AI, anesthesiology, perioperative care, critical care, and pain management. Results were filtered for randomized controlled trials and clinical trials. Data were extracted and organized by perioperative phase. Results: The 16 studies (6 from database search, 10 from prior work) included in this review demonstrated AI applications across the perioperative timeline. Preoperatively, predictive models such as POTTER improved surgical risk stratification. Intraoperative trials evaluated systems like SmartPilot and Navigator, enhancing anesthetic dosing and physiologic stability. In critical care, algorithms including NAVOY Sepsis and VentAI supported early detection of sepsis and optimized ventilatory management. In pain medicine, AI assisted with opioid risk assessment and individualized pain-control regimens. While these trials demonstrated clinical utility, most applications remain domain-specific and unconnected from one another. Conclusions: AI has broad potential to improve perioperative care, but its impact depends on coordinated deployment. MASH offers a unifying framework to integrate diverse agents into adaptive networks, enabling more personalized anesthetic care that is safer and more efficient. Full article

Previous evidence indicates that the endoscopic approach is the gold standard treatment for sinonasal inverted papillomata (IP). Our objectives were to evaluate the rate of complications and recurrence of IP after management using image-guided endoscopic techniques. This retrospective cohort included patients who underwent tumour resection between 2011 and 2022 in a single sinus-surgery-dedicated centre. In total, 40 patients were treated for IP using endoscopic techniques. The most common site for IP was the maxillary sinus (35%). Cases were managed endoscopically, with 30% having a medial maxillectomy and 15% managed by Draf IIb/III. The rate of complications was 5%, which included 1 case of intra-operative cerebrospinal fluid leak and 1 case with facial numbness. A total of 21 cases had a recurrence—6 (27%) out of the total of 22 primary cases and 15 (83%) out of the total of 18 secondary cases. The difference between the two groups was statistically significant c2(1) = 12.48 and p = 0.0004. The odds ratio was 13.33 (confidence interval, CI 95%: 2.82 to 63.12) with a relative risk of 3.06 (CI 95%: 1.50–6.24). This highlights that the risk and rate of recurrence are higher in secondary cases. As a possible explanation for the results could be that secondary cases were operated by a non-rhinologist ENT (Ears, Nose, and Throat) surgeon. Our results demonstrate that cases operated by a non-rhinologist at first presentation have higher recurrence rates even once a rhinologist was able to manage them. Therefore, IPs managed by a fellowship-trained rhinologist may have superior outcomes in terms of recurrence. Full article

Anesthesiologic management of Transcatheter Aortic Valve Implantation (TAVI) is a key factor in procedural success and effectiveness. Although general anesthesia was the main anesthesiologic approach during the early years of the development of TAVI, over the last decade, there has been a shift towards sedation. Hemodynamic stability is the main concern of intraoperative anesthesiologic management. Preprocedural, multidisciplinary assessment of the patient is essential prior to TAVI and should include a full anesthesiologic evaluation. TAVI offers a number of advantages to patients and medical teams, but important accompanying complications and anesthesiologic risks remain. In this narrative review, all aspects of sedation in TAVI are presented and analyzed, including methods, patient selection, contraindications, drug administration, intraprocedural parameters, outcomes, and future developments in this field. Full article

Introduction: Odontogenic keratocyst (OKC) is a locally aggressive cystic lesion derived from remnants of the dental lamina. It is most commonly located in the posterior mandible, while maxillary involvement is rare and poses diagnostic and surgical challenges due to its proximity to critical anatomical structures. This case report describes the surgical management of a maxillary OKC with an uncommon localisation. Methods: A 50-year-old male presented with an asymptomatic swelling in the posterior maxilla. Cone beam computed tomography (CBCT) revealed a well-defined unilocular radiolucency extending toward the maxillary sinus floor. Surgical management included complete enucleation and peripheral curettage, followed by histopathological confirmation. The defect was left to heal naturally through bone regeneration without the need for grafting. Results: Intraoperatively, a thin pearly white cystic capsule and buccal cortical thinning were observed, consistent with OKC. The lesion was enucleated intact, without rupture or sinus perforation. Histology confirmed the diagnosis. Postoperative healing was uneventful, with radiographic follow-up at one month showing favourable healing changes. Conclusions: Careful surgical planning combined with advanced imaging facilitates safe and effective management of OKCs in uncommon maxillary sites. Enucleation with peripheral curettage provided satisfactory short-term outcomes. Long-term follow-up remains essential due to the risk of recurrence. Full article

Background/Objectives: Scoliosis surgery in pediatric patients, particularly those with neuromuscular disorders, is associated with increased perioperative risk due to respiratory insufficiency, cardiovascular comorbidities, and nutritional deficiencies. This review aims to summarize current evidence-based approaches to anesthetic management in this vulnerable population. Methods: A comprehensive literature review was conducted focusing on anesthetic strategies and multidisciplinary protocols used in the perioperative care of children with neuromuscular conditions undergoing scoliosis surgery. Emphasis was placed on intraoperative neurophysiological monitoring (IONM), blood conservation techniques, and Enhanced Recovery After Surgery (ERAS) principles. Results: Key management strategies include individualized preoperative risk assessment, use of total intravenous anesthesia (TIVA) to preserve IONM signal integrity, and the implementation of blood conservation methods such as antifibrinolytic therapy and intraoperative cell salvage. Additional perioperative considerations include maintaining normothermia, careful positioning, and multimodal analgesia. Postoperative care should incorporate structured respiratory support and early mobilization within the ERAS pathway to promote recovery and reduce complications. Conclusions: The perioperative care of pediatric patients with neuromuscular scoliosis undergoing spinal surgery requires a multidisciplinary and individualized anesthetic approach. Adherence to evidence-based protocols, including TIVA, blood management strategies, and ERAS principles, is essential for minimizing perioperative complications and improving outcomes in this high-risk group. Full article

Background and Clinical Significance: Effective postoperative pain management is crucial in patients undergoing extensive thoracoabdominal surgery, such as esophageal reconstruction, where both thoracic and abdominal incisions are involved. In such cases, a single epidural catheter may not provide sufficient analgesic coverage. Dual epidural analgesia (DEA) offers a potential solution, allowing segmental, targeted pain control while minimizing systemic opioid exposure. Case Presentation: A 64-year-old male underwent esophageal reconstruction using a combined thoracoabdominal approach. Two epidural catheters were placed at Th5/6 and Th11/12 levels. Intraoperatively, segmental bupivacaine boluses and multimodal non-opioid intravenous analgesia were administered. Postoperatively, continuous epidural bupivacaine infusion was maintained, supplemented with morphine boluses when the numeric rating scale (NRS) was ≥5. Mean NRS scores were 2 at rest and 5 on movement on postoperative day 1 (POD1); 1 and 4 on POD2; and 3 and 5 on POD3. Total epidural morphine consumption was 36 mg over 340 h, and the 24-h bupivacaine dose was 180 mg (2.77 mg/kg/24 h). No complications were observed. Conclusions: Dual epidural analgesia provided effective, opioid-sparing multimodal pain control in complex thoracoabdominal surgery. This case highlights DEA as a safe and feasible approach when single-catheter coverage is inadequate, supporting enhanced recovery and reduced opioid use after esophageal reconstruction. Full article

Background: Endometrioma recurrence after laparoscopic cystectomy remains a clinical challenge in the long-term management of endometriosis. The Empressin Injection Technique (EIT), which involves the use of a vasopressin analog during surgery, may reduce recurrence by improving the completeness of cyst removal. This study aimed to evaluate the impact of the EIT on recurrence rates compared to standard cystectomy without Empressin. Methods: We conducted a retrospective case–control study of 263 patients who underwent laparoscopic cystectomy for unilateral or bilateral endometriomas between 2014 and 2024 at a tertiary endometriosis referral center. The patients were divided into two groups: EIT (n = 110) and control (n = 153). In the EIT group, 10 mL of diluted Empressin (1 mL in 100 mL NaCl 0.9%) was injected at the cyst capsule–ovarian cortex interface prior to stripping. Demographic and clinical variables were analyzed using descriptive statistics (chi-square test and the Mann–Whitney t-test) and logistic regression to identify factors associated with recurrence between the two groups. Results: No significant differences were found between the groups regarding age, BMI, #ENZIAN O score, or r-ASRM stage. No intraoperative or postoperative complications were reported. Recurrence was significantly lower in the EIT group (5.5%) compared to the control group (19.6%) (p = 0.001; OR 0.2, 95% CI: 0.08–0.55). Hormonal therapy was administered postoperatively in 69.1% of EIT patients and 62.5% of controls. Pregnancy rates were comparable between the groups. Repeat surgery for recurrence was required only in the control group (4.2%, p = 0.004). Conclusions: Use of Empressin during laparoscopic cystectomy significantly reduces endometrioma recurrence without adverse effects, particularly when combined with postoperative hormonal therapy. Full article

Proximal humerus fractures are common and complex; despite advances, malunion, nonunion, and osteonecrosis remain concerns. Three-dimensional (3D) imaging/printing has emerged to improve classification, planning, and execution, especially in displaced patterns. Methods: Multiple databases have been searched using predefined terms (“proximal humerus fractures/sequelae”, “three-dimensional”, and “3D printing”). Inclusion criteria targeted human longitudinal studies (retrospective/prospective) on 3D-assisted fracture or sequela management; expert opinion, prior reviews, and letters to editors were excluded. Data extracted included the design, the level of evidence (LoE), the sample size, 3D application (diagnostic, planning, intraoperative, and combined), outcomes, follow-up, and complications. Results: Nineteen studies were included (fourteen fractures and five sequelae; 636 and 28 patients, respectively). In fractures, 3D imaging was used chiefly for preoperative planning (57.1%) and diagnostic support (35.7%); no intraoperative PSI was reported. In sequelae, intraoperative/PSI dominated (100%), with planning in 80% and combined uses in 80%. Fracture studies were mostly retrospective (50.0%; LoE III 78.6%), while all sequelae were LoE IV–V (60% of case reports). Standardized outcomes were reported in 42.1% of studies; follow-up was available in 42.1% (means ≈ 18 months). Complications occurred in 14.3% of fracture studies and in none of the sequelae. Conclusions: Three-dimensional printing is primarily applied for planning in fractures and intraoperative guidance in sequelae. While feasibility and potential perioperative benefits are evident, small heterogeneous cohorts and limited outcome reporting warrant larger prospective studies with standardized endpoints. Full article