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Study Objective: To assess the association of intraoperative hypotension with long-term survivals in older patients after major noncardiac surgery mainly for cancer., Design: A secondary analysis of databases from three randomized trials with long-term follow-up., Setting: The underlying trials were conducted in 17 tertiary hospitals in China., Patients: Patients aged 60 to 90 years who underwent major noncardiac thoracic or abdominal surgeries (≥ 2 h) in a single center were included in this analysis., Exposures: Restricted cubic spline models were employed to determine the lowest mean arterial pressure (MAP) threshold that was potentially harmful for long-term survivals. Patients were arbitrarily divided into three groups according to the cumulative duration or area under the MAP threshold. The association between intraoperative hypotension exposure and long-term survivals were analyzed with the Cox proportional hazard regression models., Measurements: Our primary endpoint was overall survival. Secondary endpoints included recurrence-free and event-free survivals., Main Results: A total of 2664 patients (mean age 69.0 years, 34.9% female sex, 92.5% cancer surgery) were included in the final analysis. MAP < 60 mmHg was adopted as the threshold of intraoperative hypotension. Patients were divided into three groups according to duration under MAP < 60 mmHg (<1 min, 1-10 min, and > 10 min) or area under MAP <60 mmHg (< 1 mmHg⋅min, 1-30 mmHg⋅min, and > 30 mmHg⋅min). After adjusting confounders, duration under MAP < 60 mmHg for > 10 min was associated with a shortened overall survival when compared with the < 1 min patients (adjusted hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.09 to 1.57, P = 0.004); area under MAP < 60 mmHg for > 30 mmHg⋅min was associated with a shortened overall survival when compared with the < 1 mmHg⋅min patients (adjusted HR 1.40, 95% CI 1.16 to 1.68, P < 0.001). Similar associations exist between duration under MAP < 60 mmHg for > 10 min or area under MAP < 60 mmHg for > 30 mmHg⋅min and recurrence-free or event-free survivals., Conclusions: In older patients who underwent major noncardiac surgery mainly for cancer, intraoperative hypotension was associated with worse overall, recurrence-free, and event-free survivals., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

This retrospective study aimed to assess the effects of the use of intraoperative three-dimensional (3D) imaging on outcomes in surgical treatment of nasal fractures. Furthermore, we investigated whether the use of intraoperative imaging improves outcomes and decreases the frequency of corrective surgeries compared to published literature. This retrospective descriptive study included patients who underwent operative treatment for nasal fractures with the use of intraoperative 3D imaging between January 2015 and January 2020 at a University Hospital. The primary outcome measure was patient satisfaction, which was assessed through patient charts about subjective esthetic problems and nasal obstruction. The secondary outcome measures were the number of intraoperative images and necessity of intra- and postoperative revisions. All the outcomes were evaluated using regression analysis. Of the 172 patients, secondary rhinoplasty and intraoperative revision were performed in 10 (6 %) and 93 (54 %) patients, respectively. Postoperatively, 19 (11 %) and 12 (7 %) patients complained of subjective esthetic problems and nasal obstruction, respectively. The intraoperative revision rate in patients undergoing surgical treatment of nasal fractures with intraoperative 3D imaging was >50 %. However, the incidence of postoperative secondary revision, nasal obstruction, and subjective esthetic problems was lower than that reported in the literature not having an intraoperative imaging. Our findings suggest that prompt quality control of the operative result enables immediate correction and prevents postoperative revision., Competing Interests: Declaration of competing interest None., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objectives: The aim of this study was to evaluate testing turnaround time (TAT) and incision to close time in parathyroid surgeries before and after switching intraoperative parathyroid hormone (PTH) testing from a near point of care location to a central clinical laboratory. Design and Methods: This retrospective study covered a ten-year period. Both testing locations used the same Roche Diagnostics PTH immunoassay but on different analyzers. The predominant site for surgeries was the main operating rooms (ORs) in an adjacent building, with a limited number of parathyroid surgeries performed at a more distant ambulatory surgery center (ASC). Under ideal conditions, TAT for near point-of-care testing was 20 ​min, although multiple factors could increase TAT. Incision to close time from the electronic health record was used to define time of surgery. Results: A total of 897 unique patients were identified for which 3031 orders for intraoperative PTH were placed (383 unique patients and 1244 orders after switch in testing site). The average total TAT times for testing (mean ​± ​SD) in the central laboratory were 23.9 ​± ​16.0 ​min (median, 22 ​min) for all specimens, 22.8 ​± ​7.9 ​min (median, 21 ​min) for main OR specimens, and 26.4 ​± ​7.1 ​min (median, 25 ​min) for ASC specimens. Incision to close time for parathyroidectomies showed decreases in mean, median, and standard deviation following testing change. Conclusions: Surgery time for parathyroidectomies may remain consistent or decrease if intraoperative PTH testing is moved from a near point of care to a central laboratory.

Intraoperative monitoring of parathyroid hormone (PTH) is commonly used during parathyroidectomies. There are a number of practical challenges in achieving rapid turnaround time (TAT) for intraoperative PTH testing, whether the testing is performed point-of-care, near point-of-care, or in a central clinical laboratory. In the related research article, we analyzed a decade of data from 3025 intraoperative PTH tests on 897 unique patients. Of these, 1787 tests on 514 unique patients (375 female, 139 male) occurred while intraoperative PTH measurement was done as near point-of-care testing; the remaining 1238 tests on 383 unique patients (282 female, 101 male) occurred after a switch to intraoperative PTH measurement by the hospital central laboratory. The data in this article provides the patient age, gender, location of surgery (main operating rooms vs. ambulatory surgery center), incision to close time for surgery, and operation start to end times. For the central laboratory testing, additional data are provided for the intraoperative PTH TAT. The analyzed data is provided in the supplementary tables included in this article. Plots of operation start and end times are also included. The dataset reported is related to the research article entitled “Evaluation of Switch from Satellite Laboratory to Central Laboratory for Testing of Intraoperative Parathyroid Hormone” [D. Jacob, G. Lal, D.R. Voss, T. Bebber, S.R. David, J. Kulhavy, S.L. Sugg, A.E. Merrill, M.D. Krasowski, Evaluation of Switch from Satellite Laboratory to Central Laboratory for Testing of Intraoperative Parathyroid Hormone, Pract. Lab. Med. (2020) 22: e00176] [1]

Purpose/objective(s): Accelerated partial breast irradiation (PBI) delivered in 5 fractions with intensity modulated radiation therapy (IMRT) has been shown to have comparable clinical outcomes to whole breast irradiation with reduced toxicity profiles. In contrast, intraoperative radiation therapy (IORT) offers patients the potential to complete adjuvant radiation therapy in a single treatment. While early data were promising, concerns exist regarding long-term rates of local recurrence after IORT. We present a comparison of 5 fraction PBI versus IORT., Materials/methods: We performed a retrospective review of 473 patients with early-stage breast cancer treated at a single institution from 2011 to 2021 with 258 receiving PBI and 215 receiving IORT. PBI patients received 30 Gy in 5 fractions delivered with IMRT. IORT patients received 20 Gy in 1 fraction prescribed to the applicator surface at surgery using the low-energy TARGIT technique., Results: Mean age was 71 years old (IQR:67-74) for IORT patients and 67 years old (IQR:62-72) for PBI patients. Median follow up was 5.7 years (IQR:4.2-7.0) for IORT patients and 2.4 years (IQR:1.8-3.3) for PBI patients (P < .001). Recurrence at any time (locoregional and distant) was seen in 7.9% (n = 17) of patients receiving IORT as compared to 0.8% (n = 2) of patients receiving PBI. IORT was associated with reduced rates of locoregional relapse free survival at 5 years (93.6% vs. 99.4%, P = .05) with no difference in overall survival(92.8% vs. 95.1%, P = .99)., Conclusion: Low-energy TARGIT IORT was associated with higher rates of locoregional recurrence compared to PBI. These outcomes, consistent with other series and current guidelines, suggest a limited role for low-energy IORT as monotherapy., Competing Interests: Disclosure Chirag Shah, MD- Consultant ImpediMed, Consultant PreludeDX, Consultant Videra Surgical, Grants- Varian Medical Systems, VisionRT, PreludeDx;; Stephanie Valente, DO- Advisory Board Impedimed, Consultant AxoGen, (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: In the overall surgical population, inadvertent perioperative hypothermia has been associated with an increased incidence of surgical site infection (SSI). However, recent clinical trials did not validate this notion. This study aimed to investigate the potential correlation between inadvertent perioperative hypothermia and SSIs following liver resection., Methods: This retrospective cohort study included all consecutive patients who underwent liver resection between January 2019 and December 2021 at the First Affiliated Hospital, Zhejiang University School of Medicine. Perioperative temperature managements were implemented for all patients included in the analysis. Estimated propensity score matching (PSM) was performed to reduce the baseline imbalances between the normothermia and hypothermia groups. Before and after PSM, univariate analyses were performed to evaluate the correlation between hypothermia and SSI. Multivariate regression analysis was performed to determine whether hypothermia was an independent risk factor for postoperative transfusion and major complications. Subgroup analyses were performed for diabetes mellitus, age > 65 years, and major liver resection., Results: Among 4000 patients, 2206 had hypothermia (55.2%), of which 150 developed SSI (6.8%). PSM yielded 1434 individuals in each group. After PSM, the hypothermia and normothermia groups demonstrated similar incidence rates of SSI (6.3% vs. 7.0%, P = 0.453), postoperative transfusion (13.3% vs. 13.7%, P = 0.743), and major complications (9.0% vs. 10.1%, P = 0.309). Univariate regression analysis revealed no significant effects of hypothermia on the incidence of SSI in the group with the highest hypothermia exposure [odds ratio (OR) = 1.25, 95% confidence interval (CI): 0.84-1.87, P = 0.266], the group with moderate exposure (OR = 1.00, 95% CI: 0.65-1.53, P = 0.999), or the group with the lowest exposure (OR = 1.11, 95% CI: 0.73-1.65, P = 0.628). The subgroup analysis revealed similar results. Regarding liver function, patients in the hypothermia group demonstrated lower γ-glutamyl transpeptidase (37 vs. 43 U/L, P = 0.001) and alkaline phosphatase (69 vs. 72 U/L, P = 0.016). However, patients in the hypothermia group exhibited prolonged activated partial thromboplastin time (29.2 vs. 28.6 s, P < 0.01)., Conclusions: In our study of patients undergoing liver resection, we found no significant association between mild perioperative hypothermia and SSI. It might be due to the perioperative temperature managements, especially active warming measures, which limited the impact of perioperative hypothermia on the occurrence of SSI., (Copyright © 2024 First Affiliated Hospital, Zhejiang University School of Medicine in China. Published by Elsevier B.V. All rights reserved.)

Background: We report our long-term experience with high dose rate intraoperative radiotherapy (HDR-IORT) in a single, quaternary institution., Patients/methods: From 2004 to 2020, 60 HDR-IORT procedures for locally advanced colorectal cancer (LACC) and 81 for locally recurrent colorectal cancer (LRCC) were done in our institution. Preoperative radiotherapy was done prior to majority of the resections (89%, 125/141). Sixty-nine percent (58/84) of the resections involving pelvic exenterations had >3 en bloc organs resected. HDR-IORT was delivered using a Freiburg applicator. A single 10 Gy fraction was delivered. Margin status was R0 and R1 in 54% (76/141) and 46% (65/141) of the resections, respectively., Results: With a median follow-up time of 4 years, 3-, 5-, and 7- year, overall survival (OS) rates were 84%, 58%, and 58% for LACC and 68%, 41%, and 37% for LRCC, respectively. Local progression-free survival (LPFS) rates were 97%, 93%, and 93% for LACC and 80%, 80%, 80% for LRCC, respectively. For the LRCC group, an R1 resection was associated with worse OS, LPFS, and progression-free survival (PFS), preoperative EBRT was associated with improved LPFS and PFS, and ≥2 years disease-free interval was associated with improved PFS. The most common severe adverse events were postoperative abscess (n = 25) and bowel obstruction (n = 11). There were 68 grade 3 to 4 and no grade 5 adverse events., Conclusions: Favorable OS and LPFS can be achieved for LACC and LRCC with intensive local therapy. In patients with risk factors for poorer outcomes, optimization of EBRT and IORT, surgical resection, and systemic therapy are required., Competing Interests: Disclosure The authors have stated that they have no conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Although breast surgeons can request frozen section biopsies to evaluate margin status in breast-conserving surgery (BCS), specimen imaging is also a useful assessment tool. Intraoperative digital specimen mammography (IDSM) has recently been introduced in Korea. To estimate the clinical role of IDSM, this study compared the clinicopathologic factors of patients whose specimen was assessed with IDSM with those assessed using conventional specimen mammography (CSM)., Methods: From October to December 2021, 78 breast cancer patients who underwent BCS were included in this study. The obtained specimens were assessed using IDSM (n = 44) and CSM (n = 34). Clinicopathologic factors included margin involvement status in specimen mammography and the results of frozen section biopsies. The radiation dose emitted from the specimen after mammography was measured using a portable device., Results: There were no significant differences in clinicopathological factors between the two groups, except the type of surgery for axillary lymph nodes. The closest distance from the margin to tumor was longer in the CSM group than in the IDSM group, although the difference was not statistically significant (p = 0.894). Margin involvement was accurately detected using IDSM due to the absence of compression (p < 0.001). In addition, the sensitivity and accuracy of IDSM were higher, and the false-negative rate was lower., Conclusion: Both specimen mammography methods were highly accurate in evaluating the margin involvement status. However, the margin status could be examined more precisely using IDSM because the specimen was not compressed to perform the examination. Because the IDSM system was installed in the operating room, it not only shortened performing routes but also reduced the operating time by providing immediate results., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2023 Asian Surgical Association and Taiwan Robotic Surgery Association. Published by Elsevier B.V. All rights reserved.)

Background: To investigate the cerebral protective effect of intraoperative dexmedetomidine infusion on patients with chronic cerebral vascular stenosis receiving endovascular interventional therapy., Methods: Sixty patients with carotid artery or cerebral artery stenosis or occlusion stenting under elective general anesthesia were divided into dexmedetomidine group (group D) and normal saline group (group N). Group D was given dexmedetomidine loading dose 1.0 μg/kg after peripheral vein opening for 10 min, and then adjusted infusion rate to 0.5 μg/kg/h until stopped 30 min before end., Results: At 7 days after operation, the contents of S100β, neuron-specific enolase (NSE) and interleukin-6 (IL-6) in group D were apparently lower than those in group N (P < 0.05), while the contents of IL-1β and tumor necrosis factor-α in 2 groups showed no statistical significance (P > 0.05). Additionally, at 4 days and 7 days after operation, the scores of Mini-Mental State Scale (MMSE) and Wechsler Memory Scale (WMS) in group D were significantly higher than those in group N (P < 0.05). Thirty days after surgery, the cerebral hemodynamic indexes (relative mean transit time, relative time to peak) in group D were significantly improved, and obviously better than those in group N (P < 0.05)., Conclusions: The S-100β, NSE, and inflammatory mediator IL-6 in group D were significantly decreased compared with group N, the MMSE and WMS cognitive function scores, and the cerebral blood perfusion were apparently improved in group D, clarifying dexmedetomidine has protective effect on nerve tissue injury by inhibiting inflammation., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: There are few randomized controlled trials with sufficient statistical power to assess the effectiveness of intraoperative cholangiography (IOC) in the detection and treatment of common bile duct injury (BDI) or retained stones during cholecystectomy. The best evidence so far regarding IOC and reduced morbidity related to BDI and retained common bile duct stones was derived from large population-based cohort studies. Population-based studies also have the advantage of reflecting the outcome of the procedure as it is practiced in the community at large. However, the outcomes of these population-based studies are conflicting., Data Sources: A systematic literature search was conducted in 2020 to search for articles that contained the terms "bile duct injury", "critical view of safety", "bile duct imaging" or "retained stones" in combination with IOC. All identified references were screened to select population-based studies and observational studies from large centers where socioeconomic or geographical selections were assumed not to cause selection bias., Results: The search revealed 273 references. A total of 30 articles fulfilled the criteria for a large observational study with minimal risk for selection bias. The majority suggested that IOC reduces morbidity associated with BDI and retained common bile duct stones. In the short term, IOC increases the cost of surgery. However, this is offset by reduced costs in the long run since BDI or retained stones detected during surgery are managed immediately., Conclusions: IOC reduces morbidity associated with BDI and retained common bile duct stones. The reports reviewed are derived from large, unselected populations, thereby providing a high external validity. However, more studies on routine and selective IOC with well-defined outcome measures and sufficient statistical power are needed., (Copyright © 2022 First Affiliated Hospital, Zhejiang University School of Medicine in China. Published by Elsevier B.V. All rights reserved.)

Objective: We evaluated whether a combination of intraoperative contrast-enhanced cone beam computed tomography (ceCBCT) and postoperative contrast-enhanced ultrasound (CEUS) after infrarenal endovascular abdominal aortic aneurysm repair (EVAR) could reduce late stent graft-related complications and, consequently, reintervention., Methods: All consecutive patients who had received infrarenal bifurcated stent grafts in our hybrid room (IGS 730; GE Healthcare, Île-de-France, France) during two discrete periods were included in the present study. From November 2012 to September 2013, two-dimensional completion angiography was performed after each EVAR, followed by computed tomography angiography (CTA) before discharge (group 1). From October 2013 to January 2015, intraoperative ceCBCT was performed, followed by CEUS within the first postoperative days (group 2). Comparative analyses of the outcomes were performed. The primary endpoint was late stent graft-related complications, a composite factor incorporating aneurysm-related death, type I or III endoleaks, kink or occlusion of the iliac limb, and aortic sac enlargement after the first 30 postoperative days. The secondary endpoint was all stent graft-related reinterventions. All-cause and aneurysm-related deaths were also recorded., Results: Overall, 100 consecutive patients (50 each in groups 1 and 2) were enrolled, with a median follow-up of 60 months (interquartile range, 41-69 months). At 60 months after the index procedure, the freedom from late stent graft-related complications in each group was 61.6% (95% confidence interval [CI], 47.0%-80.6%) for group 1 and 81.7% (95% CI, 70.1%-95.2%) for group 2 (P = .033). The use of intraoperative ceCBCT was independently associated with a reduced rate of late stent graft-related complications on multivariate analysis (hazard ratio, 0.39; 95% CI, 0.16-0.95; P = .038) but did not appear to significantly protect against stent graft-related reinterventions (hazard ratio, 0.53; 95% CI, 0.20-1.39; P = .198) or all-cause death (P = .47)., Conclusions: To the best of our knowledge, the present study is the first to report the influence of routine ceCBCT on late outcomes after EVAR. The use of ceCBCT shows the potential for reducing late stent graft-related complications associated., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

We demonstrate a simple, intraoperative modification to a 65 cm Beacon Tip Kumpe catheter (Cook Medical) using readily-available components in order to increase its functionality during endovascular procedures. The steerable endovascular catheter has near-spherical range, improving accessibility to challenging anatomy over conventional catheters as demonstrated by our qualitative modeling. In addition, the modification provides structural reinforcement at the catheter tip leading to precise wire advancement. Use of the steerable catheter was demonstrated in vivo during contralateral gate cannulation of an endovascular aneurysm repair, however it holds broad applications in visceral, branched and fenestrated cannulations. Physician-modified devices offer the potential to improve endovascular techniques and reduce additional procedure costs while avoiding regulatory board approval required of novel steerable endovascular devices., (Copyright © 2021. Published by Elsevier Inc.)

Anomalies of the inferior vena cava pose a great challenge to surgeons. Although uncommon, these congenital vascular malformations may have significant surgical implications. Awareness of their presence is essential to avoid inadvertent injury and major bleeding during retroperitoneal procedures. An accurate preoperative diagnosis and detailed planning play a crucial role to obtain successful outcomes when confronted with them. Several surgical techniques have been recommended to protect these anomalous venous structures. The aim of this review is to contribute to the knowledge of the most common types of anomalies of inferior vena cava encountered during retroperitoneal procedures. With this purpose, a summary of their anatomy, embryology, incidence, diagnosis and intra-operative management is presented., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Using indocyanine green (ICG) fluorescence imaging and tissue marking dyes (TMDs), perigastric lymphatic mapping and their pathological correlation were examined to see whether ICG staining covers all metastatic lymph nodes (LNs) in advanced gastric cancer (AGC)., Methods: Patients with AGC who underwent open distal or total gastrectomy were enrolled. ICG was serially injected intraoperatively into the subserosa along the greater and lesser curvatures. Stomach specimens were examined under a near-infrared camera. ICG-stained LNs were named, excised, and tattooed with different colored TMDs to retrace the exact location after pathological examinations., Results: A total of 687 LNs and 69 LN stations were examined from 11 patients. The map of the perigastric lymphatic network showing the topography of ICG-stained and ICG-unstained LNs, including metastatic information, was successfully reconstructed. The average number of ICG-stained and ICG-unstained LNs were 23.6 ± 12.3 (37.8%) and 38.8 ± 17.1 (62.2%), respectively. LN metastases were present in 28 LN stations of 8 patients. Of 8 cases with LN metastases, 40% (11.1-75% per case) of metastatic LNs were stained by ICG. Of 28 metastatic LN stations, 21 (75.0%) were covered by ICG, and actual metastatic LNs were stained in 16 LN stations (57.1%). In 4/8 cases (50%), all metastatic LN stations showed ICG signals., Conclusions: ICG fluorescence imaging and TMD are useful tools for visualizing the perigastric lymphatic network and retracing the exact location of ICG-stained LNs in AGC. However, ICG imaging is still not recommended for selective LN dissection in AGC because of the limited staining of perigastric LNs., Competing Interests: Declaration of competing interest None of the authors have any conflicts of interest to declare. The paper is not based on a previous communication to a society or meeting., (Copyright © 2021 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: Intraoperative molecular imaging (IMI) may improve surgical outcomes during pulmonary resection for lung cancer. A multiinstitutional phase 2 IMI clinical trial was conducted using a near-infrared, folate receptor-targeted contrast agent for lung adenocarcinomas, OTL38. The primary goal was to determine whether OTL38 improved surgeons' ability to identify difficult to find nodules, occult cancers, and positive margins., Methods: Patients with lung nodules received OTL38 (0.025 mg/kg) preoperatively. Patients had IMI sequentially during lung inspection, tumor resection, and margin check. Efficacy was evaluated by occurrence of clinically significant events, occurrences that caused the surgeon to modify the operation or upstage the patient's cancer. Safety was assessed for a single intravenous dose of OTL38., Results: Of 110 patients recruited, 92 were eligible for analysis. During lung inspection, IMI found 24 additional nodules, 9 (10%) of which were cancers that had not been known preoperatively. During tumor resection, IMI located 11 (12%) lesions that the surgeon could not find. During the margin check, IMI revealed 8 positive margins (9%) that the surgeon thought were negative. Benefits of IMI were pronounced in patients undergoing sublobar pulmonary resections and in patients with ground-glass opacities. There were no serious adverse events. All surgeons felt comfortable with the procedures by 10 cases., Conclusions: In this phase 2 clinical trial, IMI improved outcomes for 26% of patients. A randomized, multiinstitutional phase 3 clinical trial is underway., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: For successful lymphaticovenous anastomosis (LVA), it is important to create anastomoses with high flow to maintain patency. To ensure that this can be achieved, we compared the efficacy of a modified intraoperative distal compression (IDC) technique with the conventional no compression (NC) method for lower limb lymphedema., Patients and Methods: In the IDC group, compression was applied to an area of the foot distal to the first LVA site. After completion of the first LVA, the distal compression was extended over the first LVA site to the distal end of the second LVA site., Results: There was no significant difference between the IDC (n = 25) and NC (n = 25) groups in detection rate. However, significant differences were observed in lymphatic vessel diameter and LVA success rate. No intraoperative anastomotic obstruction was seen at the conclusion of surgery. Intraoperative congestion with blood was detected in lymphatic vessels in 8 of 79 anastomoses (10.1%) in the NC group, but not in any cases in the IDC group (p = 0.002). There was a significant between-group difference in the rate of improvement in lymphedema between the IDC (16.1±3.6) and NC groups (14.0±3.4; p = 0.03)., Discussion: IDC during LVA is thought to increase lymph flow in larger caliber lymphatics, leading to a high success rate and a low rate of venous reflux. IDC is beneficial when performing LVA., Competing Interests: Declaration of Competing Interest None declared, (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: Burn injury and reconstructive operations often result in severe pain, particularly at skin graft donor sites. Traditional local anesthetics administered intraoperatively control pain at donor sites, but the duration of action is short. Liposomal bupivacaine, a novel local anesthetic, can provide sustained-release analgesia for 72h. The primary aim of this study was to describe the efficacy of liposomal bupivacaine for postoperative donor site pain control for patients undergoing skin graft procedures., Methods: A retrospective cohort study was performed on patients who received a donor site liposomal bupivacaine field block and was compared to a matched control. Patients rated donor site pain on post-operative day 0 and 1, and stated whether the donor or graft site was more painful., Results: Fifty-eight patients were included. Twenty-nine patients received liposomal bupivacaine. Eighty-six percent of patients in the treatment group rated donor site pain as three or less on postoperative day 0 and 1, compared to 3.4% in the control (p<0.0001). Also, 76% of patients in the treatment group stated donor site pain was less than graft site pain, compared to 3.4% in the control (p<0.0001)., Conclusion: Patients who received liposomal bupivacaine reported less postoperative donor site pain and found the donor site to be less bothersome without major complications. Liposomal bupivacaine may be a safe and promising agent for prolonging postoperative analgesia and minimizing donor site pain., (Copyright © 2020. Published by Elsevier Ltd.)

Background: The relationship between the femoral component design in total knee arthroplasty (TKA) and the patellofemoral contact force, as well as the soft tissue balance, has not been well reported thus far., Methods: Twenty-eight mobile-bearing posterior-stabilized (PS) TKAs using the traditional model (PFC Sigma) and 27 mobile-bearing PS TKAs using the latest model (Attune) were included. Surgeries were performed using the measured resection technique assisted with the computed tomography (CT)-based free-hand navigation system. After all the trial components were placed, patellar contact forces on the medial and lateral sides were measured using two uniaxial ultrathin force transducers with the knee at 0°, 10°, 30°, 60°, 90°, 120°, and 135° of flexion. The joint component gap and the varus ligament balance of the femorotibial joint were also measured. The non-paired Student's t-test was conducted to compare the values of the two groups., Results: The medial patellar contact force was significantly lower for Attune group than for PFC Sigma group at 120° of knee flexion (P = 0.0058). The lateral patellar contact force was also significantly lower for Attune group than PFC Sigma group at 120° and 135° of knee flexion (P = 0.0068 and P = 0.036). The joint component gap, as well as the varus ligament balance, showed no statistically significant difference between the two groups., Conclusions: Reduced thickness and width of the anterior flange of the femoral component in the Attune may play a role in low patellar contact force., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: No data have demonstrated how joint gap measured under a distraction force is actually associated with mediolateral laxity evaluated under a varus-valgus force during total knee arthroplasty (TKA). This study aimed to investigate the correlations between them using a navigation system., Methods: A total of 113 primary navigated TKAs were included. After bone resection and soft-tissue balancing, the component gap was measured with a distraction force of 60 N and 80 N for both the medial and lateral compartment (i.e. a total of 120 N and 160 N) at 0°, 10°, 30°, 60°, 90°, and 120° knee flexion. After the final prosthetic implantation and capsule closure, mediolateral laxity under a maximum varus-valgus stress was recorded with image-free navigation at each knee flexion angle. The correlation between joint gap laxity (total differences between component gap and insert thickness in the medial and lateral compartment) and mediolateral laxity was analyzed using Spearman's rank correlation coefficient., Results: The joint gap laxity under both distraction forces showed significant positive correlations with mediolateral laxity at 10°, 30°, 60°, and 90° flexion, whereas no correlation was observed at extension and 120° flexion. The correlations were stronger in gap measurement under 80 N than 60 N at all examined ranges. In patients with body mass indexes (BMIs) ≥ 30 kg/m 2 , the correlation became non-significant., Conclusion: Intraoperative joint gap laxity was associated with mediolateral laxity after TKA, especially at mid-flexion angles. The factors weakening the correlations were a lower applied distraction force for gap measurement and a larger BMI., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

The Enhanced Recovery After Surgery (ERAS) is a pathway designed to achieve early recovery for patients undergoing major surgery. The ERAS pathway included three important components preoperative, intraoperative, postoperative program. Pre-habilitation and re-habilitation are of paramount importance to improve patients' care. The ERAS is based on evidence-based medicine. Accumulating evidence highlighted that adopting ERAS resulted in lower complication rate, and shorter length of hospital stay in comparison to standard protocols of care. The adoption of the ERAS resulted in a significant improvement of patients' outcomes and a reduction of the overall cost of care. In the present review, we summarized current evidence on ERAS, focusing on the steps useful for its adoption into clinical practice., Competing Interests: Declaration of competing interest The Authors declare no conflicts of interest. No funding sources supported this investigation., (Copyright © 2020 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: Blunt thoracic aortic injuries (BTAIs) are the second most common cause of death due to blunt-force trauma in the United States. Patients with minimal injuries do not typically require surgical repair, whereas patients with severe injuries are treated emergently. Moderate aortic injuries are repaired in a semielective fashion, but the optimal management of patients with moderate BTAI with associated intracranial hemorrhage (ICH) is unknown. We sought to analyze the management and outcomes of patients presenting with concomitant moderate BTAI and ICH., Methods: Consecutive patients who received a thoracic endovascular aortic repair (TEVAR) at our institution for treatment of moderate BTAI between January 2014 and December 2017 were retrospectively reviewed as part of an institutional review board-approved protocol. Patients were classified by our BTAI classification into "minimal", "moderate", or "severe". ICH was identified on computed tomography scan and its severity determined by the neurosurgical team. Outcome measures included surgical timing and surgical outcomes., Results: Fifty-two patients had a moderate BTAI and underwent TEVAR, 20 (38 %) of whom presented with ICH. Median time from admission to surgery was 58.5 hr for patients with ICH and 26.5 hr for non-ICH patients. Intraoperative heparin was administered in all patients without ICH and in 19 of 20 (95%) patients with ICH after the ICH met criteria for stability. Protamine reversal was utilized in 80% of patients with ICH and 75% of non-ICH patients. No patient developed ischemic stroke or spinal cord ischemia. Worsening ICH was seen in only one patient, who also received heparin infusion for pulmonary embolus 24 hr before TEVAR. There were no aortic-related mortalities in either group. Thirty-day all-cause mortality was 5% for patients with ICH and 3% for non-ICH patients., Conclusions: Patients with moderate BTAI and stable ICH are not at increased risk of TEVAR-related complications. Administration of intraoperative heparin during TEVAR appears to be safe and does not worsen ICH., (Copyright © 2020. Published by Elsevier Inc.)

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure performed to remove bile duct stones. Intraoperative cholangiography (IOC) is often performed at the time of cholecystectomy to determine the presence of intraductal stones. However, many of the ERCP procedures performed for this indication fail to find any intraductal stones. Given that ERCP carries significant patient morbidity, we investigated whether there are features on IOC that can guide ERCP patient selection., Methods: A retrospective analysis of 152 patients who had an IOC filing defect and a subsequent ERCP was performed., Results: Small single stones greater than or equal to 4.5 mm on IOC can be used to predict the presence of stones on a subsequent ERCP. Furthermore, ERCPs performed for single filling defects smaller than 4.5 mm are more likely to be negative if performed later rather than earlier, suggesting that small stones can pass over time. We show that 80% of these stones will pass by 11 days after the IOC., Conclusion: Single small stones on IOC should be given adequate time to pass into the intestine. Imaging should be performed to determine if the stone has passed into the intestine after day 11 prior to performing a therapeutic ERCP., (Copyright © 2020 International Hepato-Pancreato-Biliary Association Inc. All rights reserved.)

Older patients represent a growing proportion of the general surgical caseload. This includes those undergoing liver resection, with figures rising faster than the rate of population ageing. The physiology of ageing leads to changes in all body systems which may render the provision of safe anaesthesia more challenging than in younger patients. Anaesthesia for liver surgery has specific principles, largely aimed at reducing venous bleeding from the liver, and those related to complex major surgery. This review explores the principles of anaesthesia for liver resection and describes how they may require modification in the older patient. The traditional approach of low central venous pressure anaesthesia in order to reduce bleeding may need to be altered in the presence of a cardiovascular system less able to tolerate hypotension and hypoperfusion. These changes in physiology should also lower the threshold for invasive monitoring. The provision of effective analgesia perioperatively should be tailored to minimise the surgical stress response and opiate use. Careful consideration of general principles of intra-operative care for older patients, such as positioning, drug dosing, avoidance of excessively deep anaesthesia, and maintenance of normothermia are also important given the prolonged, complex nature of liver surgery. This individualised approach, with careful attention to changes in physiology allows liver resections to be undertaken in older patients without increases in mortality., Competing Interests: Declaration of interest All authors are either employed as Consultant Anaesthetists at University Hospital Aintree, or as Anaesthetic trainees at Health Education North West., (Copyright © 2020 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: This RCT investigated the effect of opioid titration by three different nociception monitoring devices or clinical signs during general anaesthesia., Methods: Ninety-six patients undergoing radical retropubic prostatectomy with propofol/remifentanil anaesthesia were randomised into one of four groups to receive remifentanil guided by one of three nociception monitoring devices (surgical pleth index [SPI], pupillary pain index [PPI], or nociception level [NOL]) or by clinical judgement (control). Intraoperative remifentanil requirement was the primary endpoint, whereas recovery parameters and stress hormone levels were secondary endpoints., Results: The mean [95% confidence interval {CI}] remifentanil administration rate differed between the groups: control 0.34 (0.32-0.37), SPI 0.46 (0.38-0.55), PPI 0.07 (0.06-0.08), and NOL 0.16 (0.12-0.21) μg kg -1 min -1 (P<0.001). Intraoperative cessation of remifentanil administration occurred in different numbers (%) of patients: control 0 (0%), SPI 1 (4.3%), PPI 18 (75.0%), and NOL 11 (47.8%); P=0.002. The area under the curve analyses indicated differences in cumulative cortisol levels (mg L -1 min -1 ) amongst the groups: control 37.9 (33.3-43.1), SPI 38.6 (33.8-44.2), PPI 72.1 (63.1-82.3), and NOL 54.4 (47.6-62.1) (mean [95% CI]). Pairwise group comparison results were as follows: control vs SPI, P=0.830; control vs PPI, P<0.001; control vs NOL, P=0.001; SPI vs PPI, P<0.001; SPI vs NOL, P=0.002; and PPI vs NOL, P=0.009., Conclusions: The nociception monitoring devices and clinical signs reflect the extent of nociception differently, leading to dissimilar doses of remifentanil. Very low remifentanil doses were associated with an increase and higher remifentanil doses were accompanied by a decrease in serum cortisol concentrations. Use of nociception monitoring devices for guiding intra-operative opioid dosing needs further validation., Clinical Trial Registration: NCT03380949., (Copyright © 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: The consistency of meningioma is a factor that may influence surgical planning and the extent of resection. The aim of our study is to develop a predictive model of tumor consistency using the radiomic features of preoperative magnetic resonance imaging and the tumor elasticity measured by intraoperative ultrasound elastography (IOUS-E) as a reference parameter., Methods: A retrospective analysis was performed on supratentorial meningiomas that were operated on between March 2018 and July 2020. Cases with IOUS-E studies were included. A semiquantitative analysis of elastograms was used to define the meningioma consistency. MRIs were preprocessed before extracting radiomic features. Predictive models were built using a combination of feature selection filters and machine learning algorithms: logistic regression, Naive Bayes, k-nearest neighbors, Random Forest, Support Vector Machine, and Neural Network. A stratified 5-fold cross-validation was performed. Then, models were evaluated using the area under the curve and classification accuracy., Results: Eighteen patients were available for analysis. Meningiomas were classified as hard or soft according to a mean tissue elasticity threshold of 120. The best-ranked radiomic features were obtained from T1-weighted post-contrast, apparent diffusion coefficient map, and T2-weighted images. The combination of Information Gain and ReliefF filters with the Naive Bayes algorithm resulted in an area under the curve of 0.961 and classification accuracy of 94%., Conclusions: We have developed a high-precision classification model that is capable of predicting consistency of meningiomas based on the radiomic features in preoperative magnetic resonance imaging (T2-weighted, T1-weighted post-contrast, and apparent diffusion coefficient map)., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Study Objective: To evaluate the feasibility, safety, and potential usefulness of near-infrared imaging (NIR) with indocyanine green (ICG) to assess ureteral perfusion after conservative surgery (ureterolysis or nodule removal) for ureteral endometriosis. Any changes to the surgical plan regarding intraoperative ureteral stent placement after NIR-ICG evaluation and early postoperative outcomes were recorded., Design: Prospective case series study., Setting: Tertiary level referral center for endometriosis and minimally invasive gynecology., Patients: Consecutive symptomatic women scheduled for laparoscopic conservative ureteral surgery for ureteral endometriosis., Interventions: After ureterolysis or nodule removal, residual perfusion of the ureters with regular caliber and peristalsis was evaluated through NIR-ICG imaging. Ureteral perfusion grade was defined as absent, irregular, or regular. Time required for NIR-ICG assessment, interoperator agreement regarding ureteral perfusion grade, any changes to the surgical plan after NIR-ICG evaluation, perioperative complications, and clinical-radiologic outcomes at early follow-up were recorded., Measurements and Main Results: A total of 31 ureters were examined with NIR-ICG imaging after conservative ureteral procedures. ICG assessment required 5.4 + 2.3 minutes. No complications related to fluorescence imaging were observed. Local ischemia supporting ureteral stent placement was suspected in 5 ureters (16.1%) at white light. Of these, 2 (40.0%) presented regular fluorescence; thus, ureteral stent placement was avoided. In the remaining 3 (60.0%), NIR-ICG confirmed irregular or absent fluorescence, requiring ureteral stent placement. Interoperator agreement regarding NIR-ICG evaluation was high. At a 3-month follow-up, all procedures were clinically and radiologically successful., Conclusion: NIR-ICG imaging after conservative surgery for ureteral endometriosis seems to be a feasible, safe, and useful tool to assess ureteral perfusion and guide surgical decision, together with other visual cues at white light. However, this approach needs to be validated by further larger and controlled studies., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Background: Although massive bleeding following transbronchial lung biopsies (TBLB) is rare, even minor hemorrhage may prolong the procedure and result in inadequate sampling. Tranexamic acid (TXA) is an antifibrinolytic agent, which reduces bleeding in numerous scenarios, however, its prophylactic use in mitigating post-TBLB bleeding has not been investigated. We conducted a prospective, randomized, double-blind, placebo-controlled trial to determine whether topical infusion of TXA prior to TBLB would reduce bleeding, shorten procedure duration and increase the number of biopsies obtained., Methods: We blindly randomized patients undergoing TBLB to receive topical TXA or placebo in the lobar bronchus prior to biopsies. Vital signs, procedure length, fluid balance (as a measure of the amount of bleeding), operator's assessment of bleeding, and number of biopsies obtained were measured. Data was analyzed using the two-tailed Student's T-Test, Chi-square or Mann-Whitney tests as appropriate., Results: Fifty patients were randomized, 26 to the TXA arm. The bleeding in the TXA group was significantly lower (P = 0.0037), with more specimens being obtained (placebo 7 (6, 9) (median and interquartile range) vs. TXA 9 (8, 10), P = 0.023) and no difference in procedure length (placebo 30 min (29.3, 34.3) vs. TXA 30 (24.8, 36), P = 0.90). There were no clinically significant adverse events in any of the groups up to one month of follow up., Conclusion: Endobronchial installation of TXA prior to obtaining TBLB results in less bleeding and allows more biopsies to be obtained with no additional adverse events. The prophylactic use of TXA during TBLB may be considered as standard., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: The effect of intraoperative fluid balance on postoperative acute kidney injury (AKI) in cardiac surgical patients is poorly defined., Methods: In this retrospective study of patients undergoing aortic valve replacement for aortic stenosis, the primary outcome of interest was postoperative AKI. Secondary outcomes were postoperative fluid balance, cardiac index, vasopressor use, hospital-free days, stroke, myocardial infarction, hospital readmission, and 30- and 90-day mortality., Results: A total of 2327 patients were analyzed. Positive intraoperative fluid balance was associated with lower odds of AKI; the lowest odds were in the 20- to 39-mL/kg group (odds ratio, 0.56; 95% confidence interval, 0.38-0.81; P = .002). Positive intraoperative fluid balance was associated with a lower postoperative fluid balance. Increased ultrafiltration volume was associated with increased postoperative fluid resuscitation and vasopressor use. AKI was associated with increased 30- and 90-day mortality. Increased fluid balance was associated with increased odds of myocardial infarction and 30-day mortality. Increased ultrafiltration volume was associated with increased odds of 30- and 90-day mortality., Conclusions: In patients who underwent aortic valve replacement for aortic stenosis, positive intraoperative fluid balance was associated with decreased odds of AKI. Patients developing AKI had increased 30- and 90-day mortality. Although the overall incidence was low, increased intraoperative fluid balance was associated with myocardial infarction and 30-day mortality, whereas increased ultrafiltration volume was associated with 30- and 90-day morality. Prospective studies are needed to better define proper intraoperative fluid management in patients undergoing cardiac surgery., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to find out if intra-arterial intraoperative iloprost administration, in selected patients undergoing endovascular revascularization procedures, could lead to better results compared with a control group of patients with similar clinical background and risk factors., Methods: We prospectively collected data of consecutive patients undergoing endovascular or hybrid revascularization in the period from June 2017 to August 2019, which were then retrospectively analyzed. Those patients were divided into 2 groups: iloprost and control groups. Inclusion criteria were as follows: the presence of an arteriography that included the foot; Rutherford class 4-6; and Rutherford class 3 with at least 2 cardiovascular risk factors or previous revascularization procedures on the same limb. The intraoperative intra-arterial administration of iloprost was the inclusion criterion for the iloprost group. Patients with a compromised cardiological condition were excluded, as this was a contraindication for iloprost administration. Patients from the 2 groups were matched using the propensity score matching (PSM) methodology of Rosenbaum and Rubin. The primary outcome was freedom from target lesion revascularization (TLR). The secondary outcomes were limb salvage and overall survival., Results: During the mentioned period, we treated 190 consecutive limbs. The mean follow-up was 11.73 months (median, 10; interquartile range, 5-19). After PSM, the freedom from TLR was significantly better in the iloprost group (78 ± 7%, 74 ± 8%, and 63 ± 9% vs. 67 ± 8%, 50 ± 9%, and 38 ± 10% at 3, 6, and 12 months, respectively; P = 0.043). No significant difference was found in terms of limb salvage (92 ± 5%, 88 ± 6%, and 88 ± 6% vs. 92 ± 4%, 85 ± 6%, and 81 ± 7% at 3, 6, and 12 months, respectively; P = 0.52) and survival (95 ± 3%, 95 ± 3%, and 95 ± 3% vs. 95 ± 4%, 92 ± 5%, and 71 ± 9% at 3, 6, and 12 months, respectively; P = 0.14) between the 2 groups., Conclusions: These results seem to encourage considering intraoperative use of this adjunct, at least in endovascular revascularization procedures, to improve distal outflow., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Intraoperative magnetic resonance imaging (iMRI) has been shown to optimize the extent of resection of parenchymal brain tumors. To facilitate the use of preoperative treatment plans after an intraoperative navigation update via iMRI, an elastic image fusion (EIF) algorithm was developed., Methods: Ten MRI-iMRI data pairs of patients with brain tumor were evaluated and typical anatomic landmarks were assessed. The pre- and iMRI scans were elastically fused by using a prototype EIF software (Elements Virtual iMRI [Brainlab AG]). For each landmark pair, the Euclidean distance was calculated for rigidly and elastically fused image data., Results: The Euclidean distance was 2.67 ± 2.62 mm using standard rigid image fusion and 1.8 ± 1.57 mm using our EIF algorithm (P = 0.005). For landmarks near the resected lesion, which were subject to higher anatomic distortion, the Euclidian distances were 4.38 ± 2.51 and 2.52 ± 1.9 mm (P = 0.003)., Conclusions: This feasibility study shows that EIF can compensate for surgery-related brain shift in a highly significant manner even in this small number of cases. The establishment of an easy applicable and reliable EIF tool integrated in the clinical workflow could open a large variety of new options for image-guided tumor surgery., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background and Objectives: A previous pilot study proved the feasibility, safety and efficacy of electrochemotherapy in the treatment of colorectal liver metastases. The aim of this study was to evaluate long-term effectiveness and safety of electrochemotherapy in the treatment of unresectable colorectal liver metastases., Patients and Methods: In this prospective phase II study, patients with metachronous colorectal liver metastases were included. In all patients, at least one metastasis was unresectable due to its central location or a too-small future remnant liver volume. Patients were treated by electrochemotherapy using intravenously administered bleomycin during open surgery. Treated were 84 metastases in 39 patients. Local tumor control, progression-free survival and overall survival were evaluated., Results: The objective response was 75% (63% CR, 12% PR). The median duration of the response was 20.8 months for metastases in CR and 9.8 months for metastases in PR. The therapy was significantly more effective for metastases smaller than 3 cm in diameter than for larger ones. There was no difference in response according to the metastatic location, i.e., metastases in central vs. peripheral locations. Progression-free survival was better in patients who responded well to electrochemotherapy compared to those metastases that had a partial response or progressive disease. However, there was no difference in overall survival, with a median of 29.0 months., Conclusions: Electrochemotherapy has proven to be safe and effective in the treatment of colorectal liver metastases, with a durable response. It provides local tumor control that enables patients with unresectable metastases to receive further treatments., Competing Interests: Declaration of competing interest Damijan Miklavčič holds patents on electrochemotherapy that have been licensed to IGEA S. p.a (Carpi, Italy) and is also a consultant to various companies with an interest in electroporation-based technologies and treatments. The other authors have no competing interests., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: Many studies have suggested the anti-nociceptive role for magnesium either as an adjunct for postoperative pain. Although several studies have been carried out to evaluate the anti-nociceptive effect of magnesium, there is still considerable uncertainty., Patients and Methods: Eighty patients who underwent posterior spinal fusion were randomly divided into two groups (magnesium and saline). Changes in cell count, magnesium concentration and coagulation status were assessed one hour after operation at both group and compared to baseline. At recovery room, their pain score was assessed according to 10 points visual analogue scale (VAS). Morphine consumption was evaluated at regular times after the surgery by patient controlled analgesia (PCA) device., Results: VAS scores were significantly lower in the magnesium group. Cumulative PCA morphine consumption after the surgery was significantly lower in the magnesium group. Pre and postoperative values for haemoglobin, platelet count, Prothrombin Time (PT), fibrinogen were not significantly different. There was a significant increase in activated Partial Thromboplastin Time (aPTT), International Normalized Ratio (INR), and bleeding time (BT), one hour after the operation in the magnesium group but intraoperative blood loss was similar in both groups., Conclusions: Perioperative magnesium sulfate infusion improves the postoperative analgesia, decreases the amount of morphine consumption after the operation and does not change the intraoperative bleeding in patients undergoing posterior spinal fusion surgery., (Copyright © 2020. Published by Elsevier B.V.)