Search Results (143)

Background/Objectives: The uniform application of total neoadjuvant therapy (TNT) for locally advanced rectal cancer (LARC) risks overtreatment and surgical complications. We evaluated a novel tailor-made therapy that personalizes radiotherapy and chemotherapy to balance oncological safety with organ preservation. Methods: We retrospectively analyzed 38 patients with cStage II–III LARC treated between 2023 and 2025. Patients were stratified by sphincter preservation feasibility and high systemic risk (cN2, extramural vascular invasion, lateral lymph node enlargement). Group A (sphincter-preserving, n = 20) received induction chemotherapy; long-course chemoradiotherapy (LCCRT) was omitted in favorable responders but added if MRF-positive or to aim for non-operative management (NOM) in exceptional responders. Group B (non-sphincter-preserving, low systemic risk, n = 8) received LCCRT plus consolidation chemotherapy. Group C (non-sphincter-preserving, high systemic risk, n = 10) received short-course radiotherapy plus consolidation chemotherapy. Results: Over a median observation period of 20 months (range, 6–37), NOM was initiated in 7 patients (18% overall; Group A: 10%, Group B: 50%, Group C: 10%), with one local regrowth observed to date, resulting in 6 of 7 patients (85.7%) successfully maintaining NOM. Preoperative radiotherapy was safely omitted in 32% of the total cohort, and notably in 60% of patients in Group A. Surgery was performed in 28 patients (74%), achieving an R0 resection rate of 100% across all groups. Distant metastasis recurrence during preoperative treatment occurred in 5 patients (13%). Risk-stratified, tailor-made therapy for LARC facilitates the highly customized application or omission of radiotherapy. Conclusions: Risk-stratified, tailor-made therapy facilitates the safe omission or targeted application of radiotherapy in LARC. This personalized approach prevents overtreatment, maintains complete surgical curability, and achieves successful organ preservation in appropriately selected patients. Full article

Ports combine clusters of operational buildings, shared energy infrastructure, and structurally critical assets requiring coordinated management to ensure safety and efficiency. Nevertheless, existing Digital Twin (DT) frameworks for building energy management rarely integrate Structural Health Monitoring (SHM) with energy performance assessment, while port-specific implementations remain scarce. This paper presents a pre-operational energy-aware DT architecture for port building clusters, structured in a unified five-layer framework integrating three capabilities: (i) EGMS/InSAR-based SHM screening with planned in situ sensing and computer-vision inspection workflows; (ii) smart metering and measurement and verification (M&V) protocols aligned with ISO 50001/50015 and IPMVP standards; and (iii) weighted multi-criteria prioritization considering structural condition, energy saving potential, service continuity, and cost. The framework is applied to the Port of Formia (Italy), a brownfield district comprising nine buildings (3371 m²), 16 high-mast lighting towers, shore power infrastructure, and 90 kWp of planned photovoltaics. In the absence of operational metering, energy and carbon values are reported as bounded ex-ante scenario estimates, not as verified performance outcomes. The analysis estimates photovoltaic generation of 116–137 MWh/year and lighting retrofit savings of 31.5–36.8 MWh/year; the related carbon values are treated as gross grid-displacement upper bounds pending measured self-consumption and export data. A four-phase validation roadmap with quantitative acceptance criteria supports the transition from feasibility assessment to verified performance. Full article

The surgical management of extremity bone defects, particularly post-traumatic nonunion wounds, remains a challenge. Vascularized bone flaps (VBFs), widely used for mandibular reconstruction in head and neck oncologic surgery, are less established in extremity reconstruction and are typically performed freehand, which has several limitations. In the past decade, virtual surgical planning (VSP) and computer-aided design and modeling (CAD-CAM) technology have enabled patient-specific 3D-printed models to guide reconstruction. While this technology has been used extensively in head and neck reconstructive surgery, its application to extremity reconstruction is less well-documented. This case series evaluates the feasibility, safety, and surgical utility of VSP and in-house CAD-CAM manufacture of 3D-printed models and cutting guides for post-traumatic non-healing extremity reconstructions using VBFs. Eight patients at a single tertiary academic center underwent VBF reconstruction guided by patient-specific models and cutting guides, with cases grouped into categories (humerus, femur, and tibia). The multi-disciplinary workflow supported preoperative visualization, osteotomy planning, and intraoperative execution. All vascularized flaps survived, and radiographic union was documented in patients with adequate follow-up. These findings suggest that integrating VSP and CAD-CAM into trauma-associated VBF extremity reconstruction is feasible and safe and may improve reconstructive accuracy and enhance multi-disciplinary team workflow, potentially contributing to improved clinical outcomes. Full article

Objective: The aim of this study was to evaluate the safety and efficacy of robot-assisted laparoscopic ureteroureterostomy (RALUU) and laparoscopic ureteroureterostomy (LUU) for duplicated kidney malformations in infants. Methods: This retrospective comparative cohort included infants with duplicated kidney malformations who underwent RALUU or LUU between May 2021 and April 2025. Perioperative variables assessed included operative duration, blood loss, oral feeding time, FLACC pain score, hospital stay, and complications. Follow-up outcomes included changes in anteroposterior pelvic diameter (APD), ureteral diameter (UD), and renal function (RF) of the affected upper moiety, assessed using renal ultrasonography and radionuclide imaging, with preoperative measurements serving as the baseline reference. The minimum follow-up duration was 12 months. Surgical success was determined based on fulfillment of all three criteria: resolution or alleviation of clinical symptoms, a reduction in APD and UD, and preserved or improved upper-moiety renal function compared with baseline. Results: The final cohort consisted of 52 infants (RALUU, n = 28; LUU, n = 24). Demographic and clinical profiles were comparable between groups. RALUU was associated with a shorter operative duration than LUU (139.6 ± 16.6 vs. 151.8 ± 21.6 min, p = 0.029). Estimated blood loss, time to oral feeding, FLACC pain score, and hospital stay were comparable. Postoperative complications were observed in 2 RALUU patients and 3 LUU patients. One patient in the LUU group developed urine leakage, which was managed conservatively. Postoperative urinary tract infection occurred in 2 patients in each group. No patient required secondary surgery. At a mean follow-up of 26.8 ± 10.4 and 28.1 ± 11.7 months in the RALUU and LUU groups, both groups showed significant reductions in APD and UD, with preserved RF and a modest postoperative increase. Conclusions: Both RALUU and LUU were safe and effective for duplicated kidney malformations in infants. RALUU was associated with a shorter operative time, while postoperative recovery, complication rates, and follow-up outcomes were comparable. Full article

Introduction: Sediment flushing is widely used to recover storage capacity and maintain outlet functionality in Mediterranean reservoirs, but it can also generate short downstream pulses of suspended sediment, oxygen depletion, and ammonia that may threaten fish and fish habitats. Despite this, operation-specific environmental criteria explicitly oriented to reducing acute fish risk during flushing remain poorly defined. Objective: This study aimed to develop and validate a practical operational protocol for sediment flushing in southern Spain, with emphasis on reducing acute downstream risk to fish through field-applicable thresholds, decision rules, and stop criteria. We also evaluated whether water density could serve as a rapid surrogate for total suspended matter (TSM) during operations. Methodology: The protocol was applied to 14 flushing events conducted at seven reservoirs and weirs in Andalusia, southern Spain. Monitoring included upstream and downstream stations, pre-operation baseline surveys, 15-minute measurements during flushing, and post-operation recovery checks. Operational control was based on pre-alert and alert thresholds for dissolved oxygen, ammonium/ammonia, conductivity, suspended matter, and a density-based surrogate for TSM. Protocol validation considered operational safety during flushing, the relationship between field density and laboratory-measured TSM, and before–after multivariate changes in downstream environmental conditions. Results: Threshold exceedances occurred in 5 of the 14 events, comprising 4 pre-alerts and 1 alert. Pre-alerts were mainly driven by ammonium/ammonia or dissolved oxygen, and exceedance durations were generally short (30–120 min). The only alert-level event combined severe oxygen depletion with high sediment concentrations and triggered suspension of the operation, showing the usefulness of the stop rule. Density was significantly related to laboratory TSM in all reservoirs retained for calibration (R² = 0.365–0.934), supporting its use as a rapid field proxy when calibrated at the reservoir scale. Before–after multivariate analysis detected no consistent overall downstream shift, although event-level responses were heterogeneous. Conclusions: The protocol proved operationally feasible as a science-based framework for managing sediment flushing while reducing acute risk to downstream fish in Mediterranean reservoirs. Its combination of fish-relevant thresholds, real-time monitoring, site-specific density calibration, and explicit stop rules can support safer operations, improve transparency, and strengthen environmental permitting. Full article

Background/Objectives: Pelvic organ prolapse (POP) management requires precise patient selection for surgical techniques to balance clinical efficacy and safety. The primary aim of this study was to evaluate the role of preoperative 3D/4D transperineal ultrasound in the risk stratification of POP recurrence. We analyzed the impact of levator ani muscle (LAM) injuries, specifically avulsion and ballooning, as identified by ultrasound, on both anatomical and subjective success rates, comparing native tissue repair versus mesh-augmented surgery. Methods: A prospective, multicenter observational study was conducted over a five-year period, January 2021 to December 2024 (recruitment), with follow-up completed in December 2025, ensuring a minimum follow-up of 12 months for all participants. The cohort included 276 women scheduled for primary surgery for symptomatic POP stage ≥ 2. Prior to intervention (116 underwent native tissue repair and 160 received mesh), all patients underwent 3D/4D transperineal ultrasound for standardized volume acquisition. Using this preoperative functional imaging technique, we measured the hiatal area and diagnosed the presence of hiatal ballooning (≥25.0 cm²) or levator muscle avulsion. Results: Ultrasound assessment revealed significant differences in surgical success based on the diagnosed baseline site-specific defects. Hiatal ballooning was the sonographic finding that demonstrated the greatest impact on risk stratification. Among patients with preoperative ballooning, mesh use significantly reduced both subjective recurrence (5.7% vs. 21.4%, p = 0.001) and objective recurrence (21.4% vs. 35.7%, p = 0.040) compared to native tissue repair. Furthermore, in women without ultrasound-documented avulsion, mesh also decreased objective recurrence (17.9% vs. 33.0%, p = 0.024). Multivariate analysis, adjusted for age, BMI, menopausal status, and parity, confirmed that, after stratifying by these preoperative ultrasound findings, a native tissue approach remains the primary independent predictor of surgical failure (OR 1.752 for objective recurrence; p = 0.041). Conclusions: In conclusion, native tissue repair was identified as the primary independent predictor of surgical failure. While 3D/4D transperineal ultrasound helps identify high-risk phenotypes such as hiatal ballooning, these sonographic findings did not maintain independent significance in the multivariate model. Therefore, ultrasound should be considered a complementary tool for surgical planning rather than a definitive predictor of recurrence. Full article

Background/Objectives: Unanticipated difficult airway remains a critical patient safety concern in perioperative care. Despite routine preoperative assessment, difficult intubation may still occur in patients without obvious high-risk findings. This study aimed to evaluate perioperative factors associated with unanticipated difficult intubation and to examine the relationship between preoperative assessment and intraoperative intubation difficulty in routine clinical practice. Methods: This retrospective case–control study included adult patients undergoing general anesthesia with tracheal intubation between 2015 and 2020 at a tertiary care hospital. Unanticipated difficult intubation was defined as requiring ≥3 intubation attempts without documented preoperative suspicion of difficult airway. Patients with anticipated difficult airway or preoperative mechanical ventilation were excluded. A total of 95 cases and 429 controls were analyzed. Associations were explored using multivariable logistic regression. Results: Among 524 patients, cases more frequently had ASA physical status III and airway/neck/oral deformity. Notably, intubation difficulty became evident only at laryngoscopy, characterized by poorer visualization, increased intubation attempts (median 4 vs. 1), and frequent escalation to video laryngoscopy. Severe laryngoscopic views (Cormack–Lehane grade III–IV: 74.8% vs. 3.0%) were markedly overrepresented among cases. In multivariable analysis, ASA III and airway deformity remained independently associated with unanticipated difficult intubation. The model demonstrated modest discrimination (AUC 0.685). Conclusions: Unanticipated difficult intubation was uncommon but clinically important and frequently became apparent only during airway management. Although several associated factors were identified, routine bedside airway assessment alone may not reliably predict all cases of intraoperative difficult intubation. These findings highlight the limitations of routine bedside airway assessment in identifying all patients who subsequently experience difficult intubation and support the need for improved strategies to identify patients at risk. Full article

Background and Objectives: Preoperative anaemia represents a key modifiable risk factor in obstetrics. Within the framework of Patient Blood Management (PBM), establishing precise hemoglobin (Hb) thresholds is essential for optimal clinical decision-making. This study aimed to assess the predictive value of preoperative hemoglobin levels and to determine the optimal cutoff associated with transfusion risk. Materials and Methods: A retrospective analysis was performed on 932 pregnant women. The association between preoperative hemoglobin, anticoagulant therapy, mode of delivery and maternal age with the need for red blood cell transfusion was evaluated using binary logistic regression and Receiver Operating Characteristic (ROC) curve analysis with the Youden index. Results: Red blood cell transfusion was required in 5.2% (n = 48) of the study population. Logistic regression identified preoperative hemoglobin as the strongest independent predictor (p < 0.001, OR = 0.216, 95% CI: 0.153–0.306), indicating that each 1 g/dL increase in Hb reduced the likelihood of transfusion by 78.4%. Anticoagulant therapy and age were not significant independent predictors (p > 0.05). ROC analysis demonstrated excellent predictive performance, with an Area Under the Curve (AUC) of 0.875 (95% CI: 0.823–0.927, p < 0.001). The optimal threshold for predicting transfusion risk was 10.9 g/dL (sensitivity: 89.6%, specificity: 60.5%). Conclusions: Preoperative hemoglobin concentration is the primary determinant of transfusion risk, outweighing the influence of clinical comorbidities. The integration of PBM protocols designed to sustain hemoglobin levels above 10.9 g/dL is essential to reduce perioperative transfusion requirements and to promote improved maternal safety and clinical outcomes. Full article

Background/Objectives: Early thrombosis of systemic-to-pulmonary artery shunts (SPS) remains a major cause of morbidity and mortality in neonates with duct-dependent pulmonary circulation. Despite advances in surgical technique, no universally accepted perioperative thrombosis-prevention protocol exists. We evaluated the early outcomes of a standardized perioperative thrombosis-prevention protocol applied in neonates undergoing SPS placement. Methods: This single-center case series included nine consecutive neonates undergoing primary modified Blalock–Taussig shunt placement between January 2024 and July 2025. A predefined and standardized perioperative thrombosis-prevention protocol was uniformly applied, incorporating preoperative aspirin when feasible, intraoperative systemic heparinization targeting activated clotting time (ACT) > 300 s, meticulous shunt flushing and de-airing, preferential distal anastomosis to the main pulmonary artery when anatomically suitable, and early postoperative continuous heparin infusion followed by enteral aspirin. The primary endpoint was early shunt thrombosis within 30 days. Results: Median age at surgery was 28 days (range 14–35), and median operative weight was 3.2 kg (range 2.8–3.6). Cardiopulmonary bypass was required in 33.3% of patients. Delayed sternal closure was performed in 22.2%. Despite recognized prothrombotic risk factors—including complex anatomy, hypoplastic pulmonary arteries, and low cardiac output syndrome (33.3%)—no early shunt thrombosis occurred (0/9). There were no reinterventions, no early mortality, and no major bleeding or intracranial hemorrhage. Conclusions: In this single-center neonatal series, implementation of a standardized perioperative thrombosis-prevention protocol was associated with preserved early shunt patency without increased bleeding risk. Although limited by a small sample size, these findings support the feasibility and short-term safety of a standardized perioperative management strategy in neonatal systemic-to-pulmonary shunt surgery. These findings should be considered hypothesis-generating and not evidence of definitive effectiveness. Full article

Backgrounds/Objectives: Malignant pleural effusion (MPE) is a frequent complication of advanced cancer, and talc pleurodesis via video-assisted thoracoscopic surgery (VATS) represents a standard palliative treatment with high efficacy. However, evidence regarding synchronous bilateral pleurodesis in patients with bilateral MPE is limited. This study evaluates the feasibility, safety, and outcomes of a single-stage bilateral VATS talc pleurodesis approach. Materials and Methods: We retrospectively analyzed patients undergoing synchronous bilateral VATS talc poudrage between 2000 and 2025 at a single tertiary cancer center. Inclusion criteria included adult patients with bilateral MPE, expandable lungs, and suitability for surgery. Preoperative assessment involved imaging and multidisciplinary evaluation. Perioperative data, complications, mortality, and recurrence rates at 30 days and 3 months were collected. Survival and pleural effusion-free survival were estimated using the Kaplan–Meier method. Results: Thirty patients were included (median age 63.2 years). The most common primary tumors were breast (43%), lung (30%), and ovarian cancer (17%). Mean operative time was 78.6 min, with no intraoperative complications. Mean hospital stay was 6 days. Postoperative morbidity included atrial fibrillation (13%) and respiratory failure (6.6%), both managed conservatively. Thirty-day mortality was 3%. Pleural effusion recurrence occurred in 6.6% at 3 months and 10% at 7 months. Mean follow-up was 9.7 months. Conclusions: Synchronous bilateral VATS talc pleurodesis is a feasible and safe procedure in selected patients with bilateral MPE with acceptable morbidity. Further prospective studies are needed to confirm these findings and refine patient selection. Full article

Introduction: Effective perioperative management in cesarean section remains essential to optimize maternal outcomes. Melatonin (M) has been proposed as a potential adjunct due to its analgesic, anxiolytic, and antiemetic properties; however, evidence from randomized controlled trials (RCTs) remains inconsistent. This meta-analysis aimed to evaluate the efficacy and safety of preoperative melatonin compared with placebo in women undergoing cesarean section. Methods: A systematic search was conducted in PubMed, Scopus, and Cochrane from inception to 15 March 2026 for studies evaluating pregnant women undergoing elective cesarean section receiving preoperative melatonin versus placebo (P) (PROSPERO “CRD420261355468”). Heterogeneity was assessed using the I² statistic and Cochrane Q test. Risk ratios (RRs) and standardized mean differences (SMDs) were computed using a restricted maximum-likelihood estimator random-effects method. Trial Sequential Analysis (TSA) was performed to assess the robustness and sufficiency of the evidence. Results: Seven RCTs were included with 552 patients (melatonin: 278; placebo: 274). Preoperative melatonin significantly reduced opioid consumption in the overall pooled analysis (RR 0.31, 95% CI 0.12 to 0.80; p = 0.030; I² = 50%), and TSA supported the robustness of this opioid-sparing finding under the selected assumptions. Postoperative pain scores were also significantly lower in the melatonin group (SMD −2.10, 95% CI −2.43 to −1.78; p < 0.01; I² = 22%). The incidence of postoperative nausea showed a trend toward reduction in the conventional meta-analysis (RR 0.49, 95% CI 0.23–1.04; p = 0.057; I² = 34%); although TSA suggested a possible benefit, this finding should be considered exploratory. No significant difference was observed in intraoperative blood loss (SMD −0.33, 95% CI −1.53 to 0.88; p = 0.60; I² = 94%). Conclusions: Preoperative melatonin may be a promising adjunct in cesarean section, particularly for reducing postoperative pain and overall opioid consumption. TSA findings support the opioid-sparing result under selected assumptions, while the possible effect on postoperative nausea remains exploratory. Further high-quality trials are warranted before routine clinical implementation can be recommended. Full article

Background: Carpal tunnel syndrome (CTS) is the most prevalent peripheral nerve entrapment neuropathy, with rising incidence in aging populations. Uncertainty persists regarding the efficacy and safety of carpal tunnel release (CTR) in patients aged ≥ 70 years. Objectives: To systematically evaluate the indications, clinical outcomes, and utility of CTR in elderly patients (≥70 years), with comparison to younger cohorts. Methods: Following PRISMA 2020 guidelines, PubMed/MEDLINE, Scopus, CENTRAL, Embase, Web of Science, and grey literature sources were searched from inception through September 2025. Two independent reviewers extracted data; inter-rater agreement was strong (κ = 0.81–0.86). The primary outcome was the Boston Carpal Tunnel Questionnaire (BCTQ). Weighted mean differences (WMDs) with 95% confidence intervals (CIs) were calculated using DerSimonian–Laird random-effects models. Certainty of evidence was assessed using the GRADE framework. Results: A total of 20 studies encompassing 3841 operated hands, including 1139 hands in elderly patients and 2702 hands in younger comparators across comparative studies, were analyzed. Mean SS-BCTQ improvement was 1.8 points (95%CI: 1.6–2.0; exceeding the established MCID of 1.04–1.05 points). FS-BCTQ improvement was 1.1 points (95%CI: 0.9–1.3; marginally below the pooled MCID of 1.13 points). Elderly patients demonstrated SS-BCTQ improvement of 1.7 points and satisfaction rates of 72–94%, comparable to younger cohorts (75–95%; p = 0.38). Grip strength improved 15–25% in younger patients but remained unchanged in elderly patients (p < 0.001). Sensory recovery reached 42% in elderly versus 58% in younger patients (p < 0.01). Complication rates were low and age-independent (3.1%; RR 1.08; 95%CI: 0.86–1.35; p = 0.52). GRADE certainty was as follows: low for symptom and functional improvement; very low for surgery versus conservative management. Conclusions: CTR is associated with significant symptomatic benefit in elderly patients when conservative treatment fails, with complication rates comparable to younger populations. Age alone should not constitute a surgical contraindication. Preoperative counseling must establish realistic expectations regarding grip strength and functional recovery. High-quality randomized trials in elderly populations remain an urgent research priority. Full article

Background: Endobronchial hamartoma (EBH) is an exceptionally rare benign neoplasm frequently misdiagnosed as an obstructive malignancy. The therapeutic paradigm is shifting from traditional anatomical resection toward parenchyma-preserving interventional techniques. This study evaluates the efficacy and safety profiles of contemporary bronchoscopic interventions versus surgical management for EBH. Methods: A retrospective analysis was conducted on a clinical cohort of 17 patients treated between 2013 and 2026, alongside a comprehensive systematic review of 31 contemporary studies (2013–2025). The primary endpoint was the treatment success rate at 3 months, while secondary outcomes included perioperative complications, re-intervention rates, and successful lung parenchyma preservation. Results: Within the analyzed cohort (median age, 58 years), lesions exhibited a significant right-sided predilection (70.6%). Preoperative imaging uniformly revealed non-specific masses, with 41.2% displaying secondary obstructive manifestations. Definitive interventions comprised bronchoscopic management (n = 11, 64.7%) and surgical resection (n = 6, 35.3%). The technical success rate was 100%, with zero major perioperative complications and only minimal-to-scant intraoperative bleeding reported. Over a median follow-up of 3 months, local recurrence was observed in three cases (17.6%)—notably spanning both surgical (n = 2) and bronchoscopic (n = 1) modalities. The systematic review corroborated these findings, underscoring the exemplary safety profile and superior lung-sparing capacity of bronchoscopic interventions. Conclusions: Within the limits of this retrospective cohort and literature review, interventional bronchoscopy appears to be a safe and lung-sparing approach. It may be considered as a preferable initial treatment option for anatomically suitable EBHs. Traditional surgical resection remains necessary for anatomically complex lesions or cases with irreversible distal parenchymal destruction. Vigilant longitudinal surveillance is advised across all modalities. Full article

Background and Objectives: Atrial fibrillation (AF) is the most common cardiac arrhythmia, present in up to 14–20% of patients undergoing cardiac surgery, with the number of patients expected to double within the next decade. Despite a Class I recommendation for concomitant surgical ablation and a Class I-B recommendation for left atrial appendage (LAA) occlusion in patients with AF undergoing cardiac surgery (Class IIa for endoscopic or hybrid AF ablation), both procedures remain substantially underutilized in clinical practice. The design of the Mapping atrial fibrillation after Epicardial Surgical Ablation plus AtriClip to Guide Endocardial ablation (MESAGE) prospective study is presented. Materials and Methods: A narrative literature review was conducted using PubMed through March 2025. Randomized controlled trials, multicenter registries, meta-analyses and current clinical guidelines were prioritized. The MESAGE study protocol is presented in accordance with the SPIRIT recommendations. Results: Randomized evidence demonstrates that hybrid ablation achieves 32–48% greater arrhythmia freedom than catheter ablation (CA) alone in persistent and long-standing persistent AF, with comparable safety and significantly fewer interventions at two-year follow-up. Epicardial LAA occlusion with the AtriClip device achieves complete occlusion in all patients with an 87.5% relative reduction in ischemic stroke risk in anticoagulation-free follow-up. Continuous implantable loop recorder (ILR)-based monitoring reveals AF recurrence in substantially more patients than conventional monitoring, with AF burden emerging as a more meaningful endpoint than arrhythmia freedom. The MESAGE study enrolls 40 patients undergoing cardiac surgery who have pre-existing AF, pre-randomized 1:1 to pulmonary vein isolation (PVI) alone versus PVI-BOX, with mandatory pre-operative ILR implantation, intra-operative AtriClip LAA exclusion, and systematic Day-60 endocardial mapping and supplementary ablation using the Affera dual-energy system. Conclusions: Hybrid epicardial–endocardial ablation combined with LAA exclusion and continuous ILR monitoring represents a comprehensive, mechanistically rational and evidence-informed approach to AF management in patients undergoing cardiac surgery, although current evidence remains heterogeneous, and the benefits depend on the AF phenotype and monitoring strategy. The MESAGE pilot study will generate hypothesis-generating prospective comparative data on epicardial PVI versus PVI-BOX in the concomitant surgical setting, assessed through systematic post-surgical endocardial mapping and continuous rhythm monitoring. Full article

Patient Blood Management (PBM) has evolved from a transfusion-centered practice to a structured, patient-focused perioperative strategy aimed at improving surgical outcomes while preserving blood resources. In the operating room, where bleeding risk is anticipated and modifiable, PBM requires proactive intervention rather than reactive transfusion. This review synthesizes current evidence on perioperative blood conservation strategies specifically relevant to surgeons and anesthesiologists. Preoperative optimization begins with systematic identification and correction of anemia, most commonly iron deficiency, using appropriately timed oral or intravenous iron therapy and, in selected cases, erythropoiesis-stimulating agents. Careful management of anticoagulant and antiplatelet therapies, early recognition of acquired or inherited coagulopathies, and protocol-driven reversal strategies further reduce perioperative hemorrhagic risk. Intraoperatively, blood conservation depends on meticulous surgical technique, respect for anatomical planes, minimally invasive approaches, and the judicious use of advanced energy devices and topical hemostatic agents. Pharmacologic interventions—particularly tranexamic acid administered with appropriate timing and dosing—have demonstrated consistent reductions in blood loss and transfusion requirements across multiple surgical disciplines. Goal-directed coagulation management guided by viscoelastic testing allows targeted correction of specific hemostatic deficits while minimizing unnecessary blood product exposure. Acute normovolemic hemodilution and intraoperative cell salvage provide additional benefit in selected high-blood-loss procedures. Collectively, these multimodal strategies shift perioperative care from product-driven transfusion toward physiology-based blood conservation. When embedded within institutional protocols and supported by multidisciplinary collaboration, perioperative PBM reduces transfusion exposure, decreases morbidity, shortens hospital stay, and promotes sustainable stewardship of blood resources without compromising patient safety. Full article