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Thyroid cancer is a common malignancy that requires comprehensive clinical evaluation prior to adequate surgical management. Over the last three decades thyroid surgery has tripled and is considered one of the most commonly performed procedures in general surgery. These procedures are associated with potential postoperative complications with significant deterioration in the patient's quality of life. While the current rates of recurrent laryngeal nerve injury following thyroidectomy have decreased secondary to intraoperative neuromonitoring, thyroid surgery remains the leading cause of iatrogenic injury. The authors herein present a case of a thyroid nodule with cervical lymph node involvement undergoing total thyroidectomy guided by near-ultraviolet (NUV) imaging nerve auto-fluorescent technology to visualize, identify and protect vital structures. [ABSTRACT FROM AUTHOR]

Intracranial pressure (ICP) is a well-established measure in managing not only traumatic brain injury but also nontraumatic intracranial bleeding or edema. When ICP increases despite nursing or medical management, ICP may be reduced via surgical measures. Deciding whether to perform a craniotomy vs. craniectomy (whether the bone flap is replaced or not, respectively) is commonly made intraoperatively following preoperative planning. While ICP monitoring (ICPm) is standard pre- and postoperatively, its intraoperative utility remains understudied. We conducted a study utilizing prospectively gathered and retrospectively analyzed data from 25 traumatic brain injury surgical decompression cases at a single center. All cases had intraoperative ICPm throughout surgery. Our findings indicate that ICPm significantly influenced real-time intraoperative decision-making, diverging from preoperative. These results bring forward the potential pivotal role of intraoperative ICPm in guiding surgical strategies for elevated ICP, suggesting a novel data-driven approach to intraoperative management of decompression surgery. [ABSTRACT FROM AUTHOR]

Background: Studies show that the two peak heights of electroencephalographic bicoherence (pBIC-high, pBIC-low) decrease after incision and are restored by fentanyl administration. We investigated whether pBICs are good indicators for adequacy of analgesia during surgery. Methods: After local ethical committee approval, we enrolled 50 patients (27–65 years, ASA-PS I or II) who were scheduled elective surgery. Besides standard anesthesia monitors, to assess pBICs, we used a BIS monitor and freeware Bispectrum Analyzer for A2000. Fentanyl 5 µg/kg was completely administered before incision, and anesthesia was maintained with sevoflurane. After skin incision, when the peak of pBIC-high or pBIC-low decreased by 10% in absolute value (named LT10-high and LT10-low groups in order) or when either peak decreased to below 20% (BL20-high and BL20-low groups), an additional 1 g/kg of fentanyl was administered to examine its effect on the peak that showed a decrease. Results: The mean values and standard deviation for pBIC-high 5 min before fentanyl administration, at the time of fentanyl administration, and 5 min after fentanyl administration for LT10-high group were 39.8% (10.9%), 26.9% (10.5%), and 35.7% (12.5%). And those for pBIC-low for LT10-low group were 39.5% (6.0%), 26.8% (6.4%) and 35.0% (7.0%). Those for pBIC-high for BL20-high group were 26.3% (5.6%), 16.5% (2.6%), and 25.7% (7.0%). And those for pBIC-low for BL20-low group were 26.7% (4.8%), 17.4% (1.8%) and 26.9% (5.7%), respectively. Meanwhile, at these trigger points, hemodynamic parameters didn't show significant changes. Conclusion: Superior to standard anesthesia monitoring, pBICs are better indicators of analgesia during surgery. Trial registry: Clinical trial Number and registry URL: UMIN ID: UMIN000042843 https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr%5fview.cgi?recptno = R000048907 [ABSTRACT FROM AUTHOR]

Minimally invasive parathyroidectomy is the treatment of choice in patients with primary hyperparathyroidism (PHP), but it needs a reliable preoperative localization method to detect hyperfunctioning parathyroid tissue. Higher sensitivity and lower radiation exposure was demonstrated for [18F]fluorocholine PET/CT (FCh-PET/CT) in comparison to [99mTc]sestamibi (MIBI) scintigraphy. However, data of its efficiency in resource use and patient outcomes is lacking. The aim of our study was to determine the resource efficiency and patient outcomes of FCh-PET/CT in comparison to conventional MIBI scintigraphy. A group of 234 patients who underwent surgery after MIBI scintigraphy was compared to a group of 163 patients who underwent surgery after FCh-PET/CT. The whole working process from the implementation of imaging to the completion of surgical treatment was analyzed. The economic burden was expressed in the time needed for the required procedures. The time needed to perform imaging was reduced by 83% after FCh-PET/CT in comparison to MIBI scintigraphy. The time needed to perform surgery was reduced by 41% when intraoperative parathyroid hormone monitoring was not used. There was no significant difference in the time of surgery between FCh-PET/CT and MIBI scintigraphy. FCh-PET/CT reduces the time of imaging, the time of surgery and potentially reduces the number of reoperations for persistent disease. [ABSTRACT FROM AUTHOR]

Background: Literature regarding the application of traditional growing rod (TGR) instrumentation in patients with early-onset congenital scoliosis with type-I split cord malformation is scarce. The purpose of the present study was to assess the safety and effectiveness of TGR surgery and repeated lengthening procedures in patients with congenital scoliosis with type-I split cord malformation not treated with prophylactic osseous spur excision. Methods: Thirteen patients with early-onset congenital scoliosis associated with type-I split cord malformation and a stable neurologic status between March 2009 and July 2020 were recruited. All patients underwent primary TGR surgery and subsequent repeated lengthening procedures without osseous spur excision by the same surgical team. Clinical information and radiographic data from the preoperative, postoperative, and latest follow-up periods were collected. Results: The mean preoperative Cobb angle of the major coronal curve was 74.62° ± 25.59°, the mean early postoperative angle was 40.23° ± 17.89°, and the mean latest follow-up angle was 40.62° ± 16.60°. The scoliotic deformity correction percentage was 46.81% ± 12.26% after the initial operation and 45.08% ± 15.53% at the latest follow-up. Compared with the preoperative values, significant improvements were observed in the coronal and sagittal balance early postoperatively and at the latest follow-up (p < 0.05 for all). The average annual amounts of spinal height gained were 15.73 ± 5.95 mm at T1-S1, 8.94 ± 3.94 mm at T1-T12, and 12.02 ± 6.70 mm between the instrumented segments. The total height gained at T1-S1 and T1-T12 was 72.18 ± 28.74 mm and 37.62 ± 12.53 mm, respectively. No intraoperative neurophysiological monitoring events were observed, and no case of neurological deficit was observed postoperatively or during follow-up. Conclusions: Patients without neurologic deficit and having a stable neurologic exam who have early-onset congenital scoliosis associated with type-I split cord malformation can safely and effectively undergo TGR surgery, followed by repeated lengthening procedures, without prophylactic osseous spur excision. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Intraoperative hypotension is a common perioperative complication in pediatric anesthesia. Oscillometric blood pressure measurement is therefore an essential part of standard perioperative monitoring in pediatric anesthesia. The optimum measurement site is the upper arm. Attention must be paid to the correct cuff size. Blood pressure should be measured before induction. In children undergoing major surgery or in critically ill children, invasive blood pressure measurement is still the gold standard. Continuous noninvasive measurement methods could be an alternative in the future. Threshold values to define hypotension remain unknown, even in awake children. There are also little data on hypotension thresholds in the perioperative setting. The most reliable measurement parameter for estimating hypotension is the mean arterial pressure. The threshold values for intraoperative hypotension are 40 mm Hg in newborns, 45 mm Hg in infants, 50 mm Hg in young children and 65 mm Hg in adolescents. Treatment should be initiated at a deviation of 10% and intensified at a deviation of 20%. Bolus administration of isotonic balanced crystalloid solutions, vasopressors and/or catecholamines are used as treatment options. Consistent and rapid intervention in the event of hypotension appears to be crucial. So far there is no evidence as to whether this leads to an improvement in outcome parameters. [ABSTRACT FROM AUTHOR]

Background: To investigate if intraoperative very short-term variability in blood pressure measured by sample entropy improves discrimination of postoperative acute kidney injury after noncardiac surgery. Methods: Adult surgical patients undergoing general, thoracic, urological, or gynecological surgery between August 2016 to June 2017 at Seoul National University Hospital were included. The primary outcome was acute kidney injury stage 1, defined by the Kidney Disease: Improving Global Outcomes guidelines. Exploratory and explanatory variables included sample entropy of the mean arterial pressure and standard demographic, surgical, anesthesia and hypotension over time indices known to be associated with acute kidney injury respectively. Random forest classification and L1 logistic regression were used to assess four models for discriminating acute kidney injury: (1) Standard risk factors which included demographic, anesthetic, and surgical variables (2) Standard risk factors and cumulative hypotension over time (3) Standard risk factors and sample entropy (4) Standard risk factors, cumulative hypotension over time and sample entropy. Results: Two hundred and thirteen (7.4%) cases developed postoperative acute kidney injury. The median and interquartile range for sample entropy of mean arterial pressure was 0.34 and [0.26, 0.42] respectively. C-statistics were identical between the random forest and L1 logistic regression models. Results demonstrated no improvement in discrimination of postoperative acute kidney injury with the addition of the sample entropy of mean arterial pressure: Standard risk factors: 0.81 [0.76, 0.85], Standard risk factors and hypotension over time indices: 0.80 [0.75, 0.85], Standard risk factors and sample entropy of mean arterial pressure: 0.81 [0.76, 0.85] and Standard risk factors, sample entropy of mean arterial pressure and hypotension over time indices: 0.81 [0.76, 0.86]. Conclusion: Assessment of very short-term blood pressure variability does not improve the discrimination of postoperative acute kidney injury in patients undergoing non-cardiac surgery in this sample. [ABSTRACT FROM AUTHOR]

Background: A combination of remimazolam and propofol could produce more stable sedation. A good medication regimen should consider not only efficacy but also safety, especially hypotension. The aim of the current study was to compare the incidence and amount of hypotension by propofol versus remimazolam-propofol combinations in day-surgery hysteroscopy. Methods: Patients were randomly assigned to receive either propofol (Group P, n = 125) or remimazolam-propofol combinations (Group RP, n = 125) at a 1:1 ratio. Intravenous injection of sufentanil 0.1ug/kg were administered before sedative medication. In group P, a bolus of 2.5 mg/kg propofol was administered. In group RP, intravenous anesthesia was commenced with 0.125 mg/kg remimazolam and 1 mg/kg propofol. After loss of consciousness, propofol was maintained at 6 mg/kg/h. The primary outcomes were the incidence and amount of hypotension during surgery. Hypotension was defined as a MAP less than 65mmHg for at least 1 min. The amount of hypotension was assessed by time-weighted average intraoperative MAP under a threshold of 65 mmHg. The secondary outcomes were various anesthesia related parameters and some adverse events. Results: In group P, 25 patients (20.0%) experienced hypotension during hysteroscopy compared with 9 patients (7.2%) in group RP, for a difference of 12.8% (RR 2.778, 95%CI [1.352–5.709]). The combination of remimazolam and propofol resulted in significantly lower TWA (Time Weighted Average) threshold 0.14 (0.10–0.56) mmHg in group RP compared to 0.31 (0.15–0.67) mmHg in group P. The total dose of propofol was nearly double in group P compared to group RP. A significantly higher frequency of injection pain and low oxygen saturation was observed in the group P than that of the group RP. Hiccup was observed only in group RP. The incidences of body movement, bradycardia and vomiting were no significant difference between groups. Conclusion: The incidence and amount of hypotension by remimazolam-propofol combinations was significantly less than that by propofol sedation in day-surgery hysteroscopy. The optimization of medication regimen would attenuate the harm of hypotension and contribute to patients' rapid recovery in day surgery. Trial registration : Chinese Clinical Trial Registry, ChiCTR2400079888 (date: 15/01/2024), [ABSTRACT FROM AUTHOR]

Pediatric low-grade gliomas (pLGGs) in the cerebellar vermis present unique challenges due to their intricate anatomical location and potential impact on critical neurological functions. Surgical intervention remains a cornerstone in the management of these tumors, aiming to achieve maximal tumor resection while preserving neurological function. In this review, the authors will discuss anatomical consideration and will explore current surgical techniques and strategies employed in the treatment of cerebellar vermis pLGGs such as the midline and lateral suboccipital approaches, as well as endoscopic-assisted technique. Additionally, we will emphasize the importance of intraoperative neurophysiological monitoring (IONM) in ensuring safe and effective tumor resection. Overall, this review provides insights into the neurosurgical approach of pLGGs in the cerebellar vermis. [ABSTRACT FROM AUTHOR]

Purpose: The significance of dental status and oral hygiene on a range of medical conditions is well-recognised. However, the correlation between periodontitis, oral bacterial dysbiosis and visceral surgical outcomes is less well established. To this end, we study sought to determine the influence of dental health and oral hygiene on the rates of postoperative complications following major visceral and transplant surgery in an exploratory, single-center, retrospective, non-interventional study. Methods: Our retrospective non-interventional study was conducted at the Department of General, Visceral, and Transplant Surgery, University Hospital Heidelberg, Germany. Patients operated on between January 2018 and December 2019 were retrospectively enrolled in the study based on inclusion (minimum age of 18 years, surgery at our Department, intensive care / IMC treatment after major surgery, availability of patient-specific preoperative dental status assessment, documentation of postoperative complications) and exclusion criteria (minor patients or legally incapacitated patients, lack of intensive care or intermediate care (IMC) monitoring, incomplete documentation of preoperative dental status, intestinal surgery with potential intraoperative contamination of the site by intestinal microbes, pre-existing preoperative infection, absence of data regarding the primary endpoints of the study). The primary study endpoint was the incidence of postoperative complications. Secondary study endpoints were: 30-day mortality, length of hospital stay, duration of intensive care stay, Incidence of infectious complications, the microbial spectrum of infectious complication. A bacteriology examination was added whenever possible (if and only if the examination was safe for the patient)for infectious complications. Results: The final patient cohort consisted of 417 patients. While dental status did not show an influence (p = 0.73) on postoperative complications, BMI (p = 0.035), age (p = 0.049) and quick (p = 0.033) were shown to be significant prognostic factors. There was significant association between oral health and the rate of infectious complications for all surgical procedures (p = 0.034), excluding transplant surgery. However, this did not result in increased 30-day mortality rates, prolonged intensive care unit treatment or an increase in the length of hospital stay (LOS) for the cohort as a whole. In contrast there was a significant correlation between the presence of oral pathogens and postoperative complications for a group as a whole (p < 0.001) and the visceral surgery subgroup (p < 0.001). Whilst this was not the case in the cohort who underwent transplant surgery, there was a correlation between oral health and LOS in this subgroup (p = 0.040). Bacterial swabs supports the link between poor oral health and infectious morbidity. Conclusions: Dental status was a significant predictor of postoperative infectious complications in this visceral surgery cohort. This study highlights the importance preoperative dental assessment and treatment prior to major surgery, particularly in the case of elective surgical procedures. Further research is required to determine the effect of oral health on surgical outcomes in order to inform future practice. Trial registration: Trial registered under the ethics-number S-082/2022 (Ethic Committee of the University Heidelberg). [ABSTRACT FROM AUTHOR]

Purpose: Femur shaft fractures commonly occur due to high velocity trauma and most of them are fixed with nailing. Malrotation is common after fixation. A rotational malalignment more than 30° is a deformity which requires correction. Various techniques described for rotational deformities are: the 'cable techniques' for the determination of varus-valgus malalignment; the 'hyperextension test', 'radiographic recurvatum sign', 'tibial plateau sign', and 'meterstick technique' for length analysis; and the 'hip rotation test', 'lesser trochanter shape sign', 'cortical step sign', and 'diameter difference sign' for rotational analysis. We describe integration sign at the medial or lateral aspect of notch of femur in fixed internal or external rotation due to condensation of trabeculae. Methods: This is a prospective observational study. Informed consent was taken, and this study was approved by institutional review board. C arm imaging study of 50 knees was done at our institution in which rotational profile of distal femur was analyzed In 3 different views –AP , Internal and external rotation views. The rotation views were taken sequentially and each observer was asked to identify the sign at its appearance and at rotation when it was best seen. All the observers were asked to draw the sign on linear line diagram of distal femur. The data was analysed statistically. Results: Sign of integral (∫) for rotational deformity was seen at Mean external rotation of 22±1.71 with a range of 19 degree to 25 degree and Mean internal rotation of 15.78±1.21 with a range of 14 degree to 18 degree. Conclusion: The integration sign can be used as intraoperative C arm sign to understand the rotational deformity of distal fragment of femur. This helps the surgeon to understand the alignment and revise if needed intraoperatively. If combined with position of lesser trochanter, this will give alignment for both proximal as well as distal fragment of femur. [ABSTRACT FROM AUTHOR]

The current S1 guidelines on the intraoperative clinical application of hemodynamic monitoring in patients scheduled for noncardiac surgery are presented based on a case report under the aspect of an optimized intraoperative anesthesiological management. The S1 guidelines were developed with the aim of identifying the questions on the intraoperative hemodynamic monitoring and management which are important for the routine daily clinical practice, to discuss them in a guideline group and to answer them based on the current state of scientific knowledge. The guidelines were written under the auspices of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and published by the AWMF in 2023 under the register number 001/049. [ABSTRACT FROM AUTHOR]

Anterior approach surgeons who utilize intraoperative fluoroscopy often try to match a preoperative radiograph as a reference for intraoperative cup position. Every degree of inaccuracy in tilt leads to a roughly 0.7° change in anteversion. This study aimed to determine how closely pelvic tilt (PT) is approximated intraoperatively when compared to preoperative anteroposterior (AP) radiographs. This was a retrospective review of 193 primary THA's done by 2 surgeons at an academic tertiary referral center between September 2021–January 2023. There were 24 patients excluded for distorted anatomy, post-traumatic arthritis, insufficient x-rays, or a sacroiliac joint that could not be visualized on film. Data collected included age and BMI. PT was calculated using the formula, Tilt = -(ln((B/A) x (1/0.483)))/0.051. Value A is the distance from the base of the SI joint to the superior margin of the obturator foramen; value B is the height of the obturator foramen. Mean preoperative PT was 0.2° versus intraoperative PT was 3.4° (p < 0.001). Mean absolute difference was 6.5°. 48% of patients (n = 81) had an absolute difference less than 5°, 31% (n = 52) between 5° and 10°, 14% (n = 24) between 10° and 15°, and 7% (n = 12) greater than 15°. There was no correlation between BMI or age and PT discrepancy. Of the patients, 21% had a discrepancy of 10° or greater between their preoperative radiographs and intraoperative fluoroscopic images. Surgeons should be aware of potential errors in cup positioning and be particularly diligent in high-risk cases. [ABSTRACT FROM AUTHOR]

The introduction of new technologies in current digestive surgical practice is progressively reshaping the operating room, defining the fourth surgical revolution. The implementation of black boxes and control towers aims at streamlining workflow and reducing surgical error by early identification and analysis, while augmented reality and artificial intelligence augment surgeons' perceptual and technical skills by superimposing three-dimensional models to real-time surgical images. Moreover, the operating room architecture is transitioning toward an integrated digital environment to improve efficiency and, ultimately, patients' outcomes. This narrative review describes the most recent evidence regarding the role of these technologies in transforming the current digestive surgical practice, underlining their potential benefits and drawbacks in terms of efficiency and patients' outcomes, as an attempt to foresee the digestive surgical practice of tomorrow. [ABSTRACT FROM AUTHOR]

Background: In this study, we observed the frequency of side effects encountered when the neural integrity monitor electromyogram endotracheal tube (NIM-EMG-ETT) was used in thyroidectomy and parathyroidectomy surgeries. Methods: After obtaining hospital ethics committee approval, 239 cases affiliated with the American Society of Anesthesiologists (ASA II-IV) who used NIM EMG tubes in thyroid and parathyroid surgery were included in the prospective observational study. Tube and patient-related complications encountered with two different NIM EMG-ETT (silicone and polyvinyl chloride-PVC) were recorded. Results: The average age of the patients is 49.50 ± 13.44 years, the average BMI is 28.25 ± 4.91 kg/m2, the median surgery time is 115 (32–475) minutes, 75.7% are women, 97.5% are ASA II. Additional diseases other than thyroid and parathyroid problems were present in 77.3%. Thyroidectomy was performed in 73.2% of the patients. In our study, only 0.8% of patients with transient recurrent laryngeal nerve RLN paralysis were observed in thyroid and parathyroid surgeries performed using NIM-EMG tubes, 3 patient already had nerve involvement in the preoperative period. The most common complication was loss of stimulation response related to tubes and patient-related ventilation failure. There was no difference between the complications of silicone and PVC tubes except for irregular EMG response. Conclusions: There was no significant difference in side effects other than irregular EMG response in the two different tubes we used in our study. It was observed that prolonging the surgical time increased the risk of irregular EMG response. It should not be forgotten that no matter which NIM-EMG tube is used, additional risks are encountered during the intubation and extubation process. In order to avoid negative consequences, it is necessary to follow the usage rules recommended by the manufacturer when using NIM-EMG tubes. [ABSTRACT FROM AUTHOR]

Background: Most intraoperative adverse events (iAEs) result from surgeons' errors, and bleeding is the majority of iAEs. Recognizing active bleeding timely is important to ensure safe surgery, and artificial intelligence (AI) has great potential for detecting active bleeding and providing real-time surgical support. This study aimed to develop a real-time AI model to detect active intraoperative bleeding. Methods: We extracted 27 surgical videos from a nationwide multi-institutional surgical video database in Japan and divided them at the patient level into three sets: training (n = 21), validation (n = 3), and testing (n = 3). We subsequently extracted the bleeding scenes and labeled distinctively active bleeding and blood pooling frame by frame. We used pre-trained YOLOv7_6w and developed a model to learn both active bleeding and blood pooling. The Average Precision at an Intersection over Union threshold of 0.5 (AP.50) for active bleeding and frames per second (FPS) were quantified. In addition, we conducted two 5-point Likert scales (5 = Excellent, 4 = Good, 3 = Fair, 2 = Poor, and 1 = Fail) questionnaires about sensitivity (the sensitivity score) and number of overdetection areas (the overdetection score) to investigate the surgeons' assessment. Results: We annotated 34,117 images of 254 bleeding events. The AP.50 for active bleeding in the developed model was 0.574 and the FPS was 48.5. Twenty surgeons answered two questionnaires, indicating a sensitivity score of 4.92 and an overdetection score of 4.62 for the model. Conclusions: We developed an AI model to detect active bleeding, achieving real-time processing speed. Our AI model can be used to provide real-time surgical support. [ABSTRACT FROM AUTHOR]

Introduction: The introduction of the functional lumen imaging probe (FLIP) has provided objective, real-time feedback on the geometric variations with each component of a hiatal hernia repair (HHR). The utility of this technology in altering intraoperative decision-making has been scarcely reported. Herein, we report a single-center series of intraoperative FLIP during HHR. Methods: A retrospective review of electronic medical records between 2020 and 2022 was conducted and all patients undergoing non-recurrent HHR with FLIP were queried. Patient and hernia characteristics, intraoperative FLIP values and changes in decision-making, as well as early post-operative outcomes were reported. Both diameter and distensibility index (DI) were measured at 40 ml and 50 ml balloon inflation after hiatal dissection, after hiatal closure, and after fundoplication when indicated. Results: Thirty-three patients met inclusion criteria. Mean age was 62 ± 14 years and mean BMI was 28 ± 6 kg/m2. The majority (53%) were type I hiatal hernias. The largest drop in DI occurred after hiatal closure, with minimal change seen after fundoplication (mean DI of 4.3 ± 2. after completion of HH dissection, vs 2.7 ± 1.2 after hiatal closure and 2.3 ± 1 after fundoplication when performed). In 13 (39%) of cases, FLIP values directly impacted intraoperative decision-making. Fundoplication was deferred in 4/13 (31%) patients, the wrap was loosened in 2/13 (15%); the type of fundoplication was altered to achieve adequate anti-reflux values in 2/13 (15%) patients, and in 1/13 (3%) the wrap was tightened. Conclusion: FLIP measurements can be used intraoperatively to guide decision-making and alter management plan based on objective values. Long-term outcomes and further prospective studies are required to better delineate the value of this technology. [ABSTRACT FROM AUTHOR]

Postoperative cognitive dysfunction (POCD) is a neurological complication associated with surgery and anesthesia that is commonly observed in older patients, and it can significantly affect patient prognosis and survival. Therefore, predicting and preventing POCD is important. Regional cerebral oxygen saturation (rSO2) reflects cerebral perfusion and oxygenation, and decreased intraoperative cerebral oxygen saturation has been reported to increase the risk of POCD. In this review, we elucidated the important relationship between the decline in rSO2 and risk of POCD in older patients. We also emphasized the importance of monitoring rSO2 during surgery to predict and prevent adverse perioperative cognitive outcomes. The findings reveal that incorporating intraoperative rSO2 monitoring into clinical practice has potential benefits, such as protecting cognitive function, reducing perioperative adverse outcomes, and ultimately improving the overall quality of life of older adults. [ABSTRACT FROM AUTHOR]

Background: Postoperative delirium (POD) significantly affects patient outcomes after surgery, leading to increased morbidity, extended hospital stays, and potential long-term cognitive decline. This study assessed the predictive value of intraoperative electroencephalography (EEG) patterns for POD in adults. Methods: This systematic review and meta-analysis followed the PRISMA and Cochrane Handbook guidelines. A thorough literature search was conducted using PubMed, Medline, and CENTRAL databases focusing on intraoperative native EEG signal analysis in adult patients. The primary outcome was the relationship between the burst suppression EEG pattern and POD development. Results: From the initial 435 articles identified, 19 studies with a total of 7,229 patients were included in the systematic review, with 10 included in the meta-analysis (3,705 patients). In patients exhibiting burst suppression, the POD incidence was 22.1% vs. 13.4% in those without this EEG pattern (p=0.015). Furthermore, an extended burst suppression duration associated with a higher likelihood of POD occurrence (p = 0.016). Interestingly, the burst suppression ratio showed no significant association with POD. Conclusions: This study revealed a 41% increase in the relative risk of developing POD in cases where a burst suppression pattern was present. These results underscore the clinical relevance of intraoperative EEG monitoring in predicting POD in older patients, suggesting its potential role in preventive strategies. [ABSTRACT FROM AUTHOR]

Background: Dynamic fluctuations of arterial blood pressure known as blood pressure variability (BPV) may have short and long-term undesirable consequences. During surgical procedures blood pressure is usually measured in equal intervals allowing to assess its intraoperative variability, which significance for peri and post-operative period is still under debate. Lidocaine has positive cardiovascular effects, which may go beyond its antiarrhythmic activity. The aim of the study was to verify whether the use of intravenous lidocaine may affect intraoperative BPV in patients undergoing major vascular procedures. Methods: We performed a post-hoc analysis of the data collected during the previous randomized clinical trial by Gajniak et al. In the original study patients undergoing elective abdominal aorta and/or iliac arteries open surgery were randomized into two groups to receive intravenous infusion of 1% lidocaine or placebo at the same infusion rate based on ideal body weight, in concomitance with general anesthesia. We analyzed systolic (SBP), diastolic (DBP) and mean arterial blood (MAP) pressure recorded in 5-minute intervals (from the first measurement before induction of general anaesthesia until the last after emergence from anaesthesia). Blood pressure variability was then calculated for SBP and MAP, and expressed as: standard deviation (SD), coefficient of variation (CV), average real variability (ARV) and coefficient of hemodynamic stability (C10%), and compared between both groups. Results: All calculated indexes were comparable between groups. In the lidocaine and placebo groups systolic blood pressure SD, CV, AVR and C10% were 20.17 vs. 19.28, 16.40 vs. 15.64, 14.74 vs. 14.08 and 0.45 vs. 0.45 respectively. No differences were observed regarding type of surgery, operating and anaesthetic time, administration of vasoactive agents and intravenous fluids, including blood products. Conclusion: In high-risk vascular surgery performed under general anesthesia, lidocaine infusion had no effect on arterial blood pressure variability. Trial registration: ClinicalTrials.gov; NCT04691726 post-hoc analysis; date of registration 31/12/2020. [ABSTRACT FROM AUTHOR]

Gliomas adjacent to the corticospinal tract (CST) should be carefully resected to preserve motor function while achieving maximal surgical resection. Modern high-field intraoperative magnetic resonance imaging (iMRI) enables precise visualization of the residual tumor and intraoperative tractography. We prospectively evaluated the extent of resection and distance between the tumor resection cavity and CST using 3-T iMRI combined with motor evoked potentials (MEP) in glioma surgery. Participants comprised patients who underwent surgery for solitary supratentorial glioma located within 10 mm of the CST. All cases underwent surgery using neuronavigation with overlaid CST under MEP monitoring. The correlation between distance from CST and transcortical MEP amplitude was calculated using Spearman rank correlation. Among the 63 patients who underwent surgery, 27 patients were enrolled in the study. Gross total resections were achieved in 26 of the 27 cases. Volumetric analysis showed the extent of resection was 98.6%. Motor function was stable or improved in 24 patients (Stable/Improved group) and deteriorated in 3 patients (Deteriorated group). All patients in the Deteriorated group showed motor deficit before surgery. Mean intraoperative minimal distance was significantly longer in the Stable/Improved group (7.3 mm) than in the Deteriorated group (1.1 mm; P < 0.05). MEP amplitude correlated with minimal distance between the resection cavity and CST (R = 0.64). Resection of gliomas adjacent to CST with a navigation system using 3-T iMRI could result in an ultimate EOR >98%. The combination of intraoperative tractography and MEP contributes to maximal removal of motor-eloquent gliomas. [ABSTRACT FROM AUTHOR]

With the growing number of patients undergoing left ventricular assist device (LVAD) implantation and improved survival in this population, more patients with LVADs are presenting for various types of non-cardiac surgery. Therefore, anesthesiologists need to understand the physiology and adequately prepare for the perioperative management of this unique patient population. This review addresses perioperative considerations and intraoperative management for the safe and successful management of patients with an LVAD undergoing non-cardiac surgery. Understanding the basic physiology of preload dependency and afterload sensitivity in these patients is essential. The main considerations include a collaborative preoperative multidisciplinary approach, perioperative care aimed at optimizing the intravascular volume and right ventricular function, and maintaining the afterload within recommended ranges for optimal LVAD function. [ABSTRACT FROM AUTHOR]

Pulmonary hypertension (PH) is a complex disease of the cardiopulmonary system. Perioperative management of PH is one of the most challenging issues for the anesthetists. Morbidity and mortality are significantly high in PH patients undergoing surgery due to right heart failure, arrhythmia, atrial fibrillation, ischemia, hemodynamic unstability, hypoxia, respiratory failure, renal failure, sepsis, and stroke. In PH patients, it is important that more than one physician, including anesthesiologist, intensivist, pulmonologist, cardiologist, and surgeon, discuss the patient's possible difficulties and complications with a multidisciplinary approach and make a decision. In order to optimize the management of PH patients, it is necessary to comprehensively evaluate the underlying cause, pathophysiology, risk factors, course, and treatment of the disease. A balanced anesthesia technique, including inhalation or intravenous agents, appropriate regional anesthesia (RA), opioids, and α-2-adrenoceptor agonists, may provide the most uniform hemodynamic profile in these patients. The basis of anesthesia management should be to prevent and treat triggering factors, provide perfusion pressures, and optimize right ventricular functions. Advanced monitoring, pulmonary vasodilator therapies, adequate anesthesia and analgesia, and appropriate ventilator settings should be performed for patients with PH. Patients with PH should be followed in the intensive care unit in the first 48–72 h postoperatively. Our review aims to focus on appropriate preoperative preparation, perioperative monitoring, anesthesia and ventilator management, pain control, preventive methods, and treatment in patients with PH in light of the literature. [ABSTRACT FROM AUTHOR]

Thyroid surgery rates have tripled over the past three decades, making it one of the most frequently performed procedures within general surgery. Thyroid surgery is associated with the possibility of serious postoperative complications which have a significant impact on the patient's quality of life. Recurrent laryngeal nerve (RLN) palsy and external branch of the superior laryngeal nerve (EBSLN) palsy are, next to hypoparathyroidism and postoperative bleeding, some of the most common complications. The introduction of neuromonitoring into thyroid surgery, which enabled both the confirmation of anatomical integrity and the assessment of laryngeal nerve function, was a milestone that began a new era in thyroid surgery. The International Neural Monitoring Study Group has produced a standardization of the technique of RLN and EBSLN monitoring during thyroid and parathyroid surgery, which in turn increased the prevalence of neural monitoring during thyroidectomy. The current status of IONM and the benefits of its use have been presented in this publication. [ABSTRACT FROM AUTHOR]

Objectives: To compare subjective voice outcomes and postoperative laryngoscopic examination findings of patients with subjective voice complaints between surgeon-monitored and certified technician–monitored thyroidectomies. Methods: Patients who underwent hemithyroidectomy, total thyroidectomy, and completion thyroidectomy using a nerve monitoring system between November 2015 and June 2018 were included in the study. Retrospective chart review was carried out to assess how often patients reported voice changes and to record postoperative flexible laryngoscopic findings of patients when that examination was performed. Data were analyzed using the χ2 test to identify significant differences in outcomes for the 2 groups. Results: A total of 293 procedures was performed among 3 surgeons. Surgeons monitored the nerves in 147 cases and a certified technician monitored the nerves in 146 cases. Subjective voice changes were identified in 11 (7.48%) cases in the surgeon-monitored group and in 20 (13.70%) cases in the technician-monitored group (P =.084). Among the patients who expressed subjective voice changes, 7 patients were identified with vocal cord hypomobility or immobility in the surgeon-monitored group and 13 patients had an abnormal examination in the technician-monitored group (P =.234). Conclusions: Subjective voice changes or proven vocal cord mobility problems were not different between surgeon-monitored patients and technician-monitored patients in thyroidectomies. [ABSTRACT FROM AUTHOR]

Surgical pleth index (SPI) monitoring is a representative, objective nociception-monitoring device that measures nociception using photoplethysmographic signals. It is easy to apply to patients and the numerical calculation formula is intuitively easy to understand; therefore, its clinical interpretation is simple. Several studies have demonstrated its efficacy and utility. Compared with hemodynamic parameters, the SPI can detect the degree of nociception during surgery under general anesthesia with greater accuracy, and therefore can provide better guidance for the administration of various opioids, including remifentanil, fentanyl, and sufentanil. Indeed, SPI-guided analgesia is associated with lower intraoperative opioid consumption, faster patient recovery, and comparable or lower levels of postoperative pain and rates of adverse events compared with conventional analgesia. In addition, SPI monitoring allows for the degree of postoperative pain and analgesic requirements to be predicted through the SPI values immediately before patient arousal. However, because patient age, effective circulating volume, position, concomitant medication and anesthetic regimen and level of consciousness may be confounding factors in SPI monitoring, clinicians must be careful when interpreting SPI values. In addition, as SPI values can differ depending on anesthetic and analgesic regimens and the underlying disease, an awareness of the effects of these variables with an understanding of the advantages and disadvantages of SPI monitoring compared to other nociception monitoring devices is essential. Therefore, this review aimed to help clinicians perform optimal SPI-guided analgesia and to assist with the establishment of future research designs through clarifying current usefulness and limitations of SPI monitoring in perioperative pain management. [ABSTRACT FROM AUTHOR]

Introduction: The proper visualisation of the larynx is required for the diagnostic assessment and therapeutic intervention. The most significant challenges for surgeon is to visualise the anterior commissure of the glottis region. The aim of this study is to record the preoperative laryngoscore in patients posted for endolaryngeal surgery and to assess preoperative predictors for intraoperative difficult laryngeal exposure by correlating with preoperative laryngoscore. Design: Prospective, Cross-sectional, Observational study. Setting: Department of Otorhinolaryngology in a tertiary care teaching facility. Subjects: 150 patients were included with an endolaryngeal disease who were planned for surgery with age > 18yrs. Methodology: In 150 subjects preoperative laryngoscore was calculated, which comprised 11 parameters including thyromental distance, mandibular prognathism, macroglossia, micrognathia, trismus, inter incisor gap, degree of neck flexion-extension, history of prior open-neck surgery or radiotherapy, upper jaw dental status, modified Mallampati score and body mass index in order to produce a total score out of a possible maximum score of 17. According to the anterior commissure visualisation all patients were categorised into five classes, ranging from class 0 to class IV during surgery. The laryngoscore parameters were assessed and compared statistically with five classes of intraoperative anterior commissure visualisation. Result: Out of 150 patients 70 (46.6%) were having 3–4 laryngoscore, followed by 45 (30%) patients with 5–6 laryngoscore. Total 123 (82%) patient had class 0,1 and 2 intraoperative anterior commissure visualisation while 27 (18%) had class 3 and 4 visualisation. If laryngoscore was either less or equal to 5, 90% of the patients had excellent laryngeal exposure whereas only 10% of the patients had challenging laryngeal exposure. At univariate analysis, thyromental distance, degree of neck flexion/extension, and modified Mallampati classification were found statistically significant for difficulty of anterior commissure visualisation independently. Conclusion: A sound, easy and valid preoperative laryngoscore may be significantly helpful in identifying intraoperative difficult laryngeal exposure. This may prevent inadequacy of surgery, abandon of surgery, intra operative complication, and medico-legal cases for laryngologist. [ABSTRACT FROM AUTHOR]

Simple Summary: Despite advances in surgical and imaging techniques, intramedullary spinal cord tumors (IMSCTs) still represent a challenge. Surgical removal of IMCTs carries a substantial risk of spinal cord injury and neurologic morbidity. This study aimed to assess the predictive potential of multimodal intraoperative neurophysiological monitoring (IONM) for functional outcomes in IMSCTs. Clinical data were collected from 64 patients who underwent surgery between 2011 and 2020. Monitoring of motor evoked potentials (MEPs) and somatosensory evoked potentials (SSEPs) was conducted for all patients, while a D-waves recording was obtained in 57 patients. Postoperative neurologic outcomes were measured with Frankel and modified McCormick scales. D-wave monitoring provided valuable insights into motor outcomes, enabling us to proceed with surgery even in cases where MEPs/SSEPs were lost. D-wave monitoring demonstrated superior accuracy and predictive ability compared to MEPs and SSEPs alone. Multimodal IONM has the potential to significantly enhance the extent of tumor resection while minimizing the risk of neurological morbidity in IMSCT surgery. Objective: The study aimed at evaluating the efficacy and the ability of D-wave monitoring combined with somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) to predict functional outcomes in intramedullary spinal cord tumor (IMSCT) surgery. Methods: Between December 2011 and December 2020, all patients harboring IMSCT who underwent surgery at our institution were prospectively collected in a surgical spinal registry and retrospectively analyzed. Patient charts and surgical and histological reports were analyzed. The multimodal IONM included SSEPs, MEPs, and—whenever possible—D-waves. All patients were evaluated using the modified McCormick and Frankel grade at admission and 3, 6, and 12 months of follow-up. Results: Sixty-four patients were enrolled in the study. SSEP and MEP monitoring was performed in all patients. The D-wave was not recordable in seven patients (11%). Significant IONM changes (at least one evoked potential modality) were registered in 26 (41%) of the 64 patients. In five cases (8%) where the SSEPs and MEPs lost and the D-wave permanently dropped by about 50%, patients experienced a permanent deterioration of their neurological status. Multimodal IONM (SSEP, MEP, and D-wave neuromonitoring) significantly predicted postoperative deficits (p = 0.0001), with a sensitivity of 100.00% and a specificity of 95.65%. However, D-waves demonstrated significantly higher sensitivity (100%) than MEPs (62.5%) and SSEPs (71.42%) alone. These tests' specificities were 85.10%, 13.89%, and 17.39%, respectively. Comparing the area under ROC curves (AUCs) of these evoked potentials in 53 patients (where all three modalities of IONM were registered) using the pairwise t-test, D-wave monitoring appeared to have higher accuracy and ability to predict postoperative deficits with strong statistical significance compared with MEP and SSEP alone (0.992 vs. 0.798 vs. 0.542; p = 0.018 and p < 0.001). Conclusion: The use of multimodal IONM showed a statistically significant greater ability to predict postoperative deficits compared with SSEP, MEP, and D-wave monitoring alone. D-wave recording significantly increased the accuracy and clinical value of neurophysiological monitoring in IMSCT tumor resection. [ABSTRACT FROM AUTHOR]

A technique called arch-clamping was used at our institute to ensure perfusion of the lower body and brain during total arch replacement with frozen elephant trunk (TAR and FET). The aortic arch clamp is inserted between the left common carotid artery and the left subclavian artery after inserting the stented elephant trunk into the true lumen of the descending aorta during the procedure, and then clamps the aorta and graft together as the distal anastomotic edge of the aorta. After the arch clamp was in place, lower body perfusion was resumed through the femoral artery was resumed and time to circulatory arrest was reduced to approximately 4 min. Cardiopulmonary bypass (CPB) flow was gradually restored to full rate. Thereafter, the left carotid artery anastomosis was completed and rewarming began. Finally, during the rewarming period, other branches of the aortic arch and ascending aorta were reconstructed. In this paper, we describe the perfusion management strategy, discuss intraoperative monitoring parameters, and examine the feasibility of the technique from a perfusion perspective. [ABSTRACT FROM AUTHOR]

• Surgical decisions for degenerative cervical myelopathy (DCM) primarily depend on clinical symptoms and radiological examinations. Preoperative evoked potential testing is a functional diagnostic tool that can indicate the severity of myelopathic symptoms in patients with DCM. Additionally, preoperative tibial nerve-somatosensory evoked potential has significant prognostic value in predicting postoperative clinical outcomes. Thus, preoperative evoked potential tests are significantly helpful in determining suitable surgical treatment and forecasting postoperative prognosis. Decompression surgery is a treatment option for patients with degenerative cervical myelopathy (DCM). Surgical decisions primarily depend on clinical symptoms and radiological examinations. The diagnostic and prognostic significance of evoked potential tests for surgical outcomes in patients with DCM has not been thoroughly examined. To identify the diagnostic and prognostic significance of preoperative evoked potential tests in patients with DCM who underwent decompression surgery. This was a retrospective observational study. One hundred two consecutive patients who underwent evoked potential tests and surgical treatment between January 2016 and December 2020 in a single spine center and had a minimum follow-up of 6 months. Japanese Orthopedic Association (JOA) scores obtained preoperatively and 6 months after surgery. This study evaluated the preoperative central motor conduction time (CMCT), somatosensory evoked potentials, and Japanese Orthopedic Association (JOA) scores obtained preoperatively and 6 months after surgery. Abnormal CMCT findings were observed in 94 patients (92.2%). Abnormal somatosensory evoked potentials were observed in 77 patients (75.5%). There was a statistically significant correlation between preoperative JOA score and abductor pollicis brevis (APB)-CMCT (r=−0.546, p =.001), tibialis anterior (TA)-CMCT (r=−0.517, p <.001), median nerve (MN)-SSEP (r=−0.353, p =.001), and tibial nerve (TN)-SSEP (r=−0.349, p =.003). There were significant differences in recovery rates associated with diabetes mellitus (DM), preoperative severity of myelopathy, TA-CMCT, MN-SSEP, and TN-SSEP. Stepwise multiple regression analysis showed that the major factors affecting the clinical outcomes were TN-SSEP (β=0.327, p=.004), preoperative JOA score (β=0.278, p=.012), and DM (β=0.241, p=.025). Evoked potential testing is a functional diagnostic tool that can indicate the severity of myelopathic symptoms in patients with DCM. Additionally, preoperative TN-SSEP may have significant prognostic value in predicting postoperative clinical outcomes. Thus, preoperative evoked potential tests could be helpful for determining suitable surgical treatment candidates and forecasting postoperative prognosis. [ABSTRACT FROM AUTHOR]

Background & Objective: Studies have shown contradictory results regarding the use of pregabalin and melatonin as analgesic agents. Because the analgesic effects of these drugs as preemptive have not been compared in abdominal hysterectomy, one of the most common surgical procedures in women with moderate to severe pain, under general anesthesia. The aim of this study was to compare the pretreatment effects of melatonin and pregabalin on postoperative pain intensity in total abdominal hysterectomy (TAH). Materials & Methods: Ninety Patients were randomly divided into three groups (N=30): the first group received oral melatonin (6 mg), the second group received pregabalin (50 mg), and the third one who took no drug. Serum melatonin and betaendorphin levels were measured before and after the surgery. Pain intensity was assessed by the Numerical Rating Scale at 1,6,12, and 24 hours after the surgeries. Results: At 12 hrs after the surgery, mean pain intensity in the melatonin group was significantly lower than the pregabalin group, and in the pregabalin group was significantly lower than the third group (P<0.05). At 24 hrs after the TAH, the mean pain intensity in the melatonin group was significantly lower than the third group (P<0.05). Conclusion: injection preventive melatonin is more effective than pregabalin to reduce pain throughout the first 24 hrs after the TAH. [ABSTRACT FROM AUTHOR]

Prolonged operation times should be avoided due to the associated complications and negative effects on the efficiency of the use of operating room resources. Surgical treatment of mandibular condylar head fractures is a well-established routine procedure at our department, nevertheless, we recognized fluctuating operating times. This study aims to pinpoint the influencing factors, in particular the hypothesis whether the efficiency of intraoperative muscle relaxation may decisively affect the duration of surgery. It analyses 168 mandibular condylar head fractures that were surgically treated in the period from 2007 to 2022 regarding the duration of the surgery and potential factors affecting it. The potential predictors' influence on the dependent variable operation time was mainly calculated as a bivariate analysis or linear regression. Efficiency of relaxation (p ≤ 0.001), fragmentation type (p = 0.031), and fracture age (p = 0.003) could be identified as decisive factors affecting the duration of surgery, as the first surgeon was a constant. In conclusion, surgical intervention should start as soon as possible after a traumatic incident. In addition, a dosage regimen to optimize the efficiency of relaxation should be established in future studies. Fragmentation type and concomitant fractures should also be considered for a more accurate estimation of the operating time. [ABSTRACT FROM AUTHOR]

Single dose prophylaxis is good enough for general surgery with low risk patients. However, the evidence for the effectiveness of single dose anti-microbial prophylaxis (AMP) is not conclusive in high risk patients and spinal surgeries requiring instrumentation or the use of implants in particular. No studies have explored the various concentration of ceftriaxone in plasma and tissue as well during an ongoing spinal surgery. Therefore, the objective of study was to correlate the serum and tissue concentrations of ceftriaxone with the SSI and identify patients with increased risk of SSI. It was an open label prospective study in 50 consecutive patients who underwent elective spine surgery under prophylactic cover of ceftriaxone. Serum and tissue concentration were estimated by high pressure liquid chromatography during the ongoing surgery. Subjects were observed for any post-operative complications including SSI. Serum (p=0.002) and tissue (p=0.012) concentrations of ceftriaxone at the closure of spinal surgery were associated with SSI. Duration of the surgery (p=0.04) and use of implants (p=0.02) were also important surgery related risk factors. Serum and tissue concentrations of ceftriaxone at the closure and duration of surgery and instrumentation or use of implants in the spinal surgery are good predictors of SSI. [ABSTRACT FROM AUTHOR]

Background: EEG monitoring techniques are receiving increasing clinical attention as a common method of reflecting the depth of sedation in the perioperative period. The influence of depth of sedation indices such as the bispectral index (BIS) generated by the processed electroencephalogram (pEEG) machine to guide the management of anesthetic depth of sedation on postoperative outcome remains controversial. This research was designed to decide whether an anesthetic agent exposure determined by raw electroencephalogram (rEEG) can influence anesthetic management and cause different EEG patterns and affect various patient outcomes. Methods: A total of 141 participants aged ≥ 60 years undergoing abdominal major surgery were randomized to rEEG-guided anesthesia or routine care group. The rEEG-guided anesthesia group had propofol titrated to keep the rEEG waveform at the C-D sedation depth during surgery, while in the routine care group the anesthetist was masked to the patient's rEEG waveform and guided the anesthetic management only through clinical experience. The primary outcome was the presence of postoperative complications, the secondary outcomes included intraoperative anesthetic management and different EEG patterns. Results: There were no statistically significant differences in the occurrence of postoperative respiratory, circulatory, neurological and gastrointestinal complications. Further EEG analysis revealed that lower frontal alpha power was significantly associated with a higher incidence of POD, and that rEEG-guidance not only reduced the duration of deeper anesthesia in patients with lower frontal alpha power, but also allowed patients with higher frontal alpha power to receive deeper and more appropriate depths of anesthesia than in the routine care group. Conclusions: In elderly patients undergoing major abdominal surgery, rEEG-guided anesthesia did not reduce the incidence of postoperative respiratory, circulatory, neurological and gastrointestinal complications. rEEG-guided anesthesia management reduced the duration of intraoperative BS in patients and the duration of over-deep sedation in patients with lower frontal alpha waves under anesthesia, and there was a strong association between lower frontal alpha power under anesthesia and the development of POD. rEEG-guided anesthesia may improve the prognosis of patients with vulnerable brains by improving the early identification of frail elderly patients and providing them with a more effective individualized anesthetic managements. [ABSTRACT FROM AUTHOR]

The technical evolution of the surgery for spina bifida occulta (SBO) over the course of a half-century was reviewed with special foci placed on the spinal lipoma and tethered spinal cord. Looking back through history, SBO had been included in spina bifida (SB). Since the first surgery for spinal lipoma in the mid-nineteenth century, SBO has come to be recognized as an independent pathology in the early twentieth century. A half-century ago, the only option available for SB diagnosis was the plain X-ray, and pioneers of the time persevered in the field of surgery. The classification of spinal lipoma was first described in the early 1970s, and the concept of tethered spinal cord (TSC) was proposed in 1976. Surgical management of spinal lipoma with partial resection was the most widely practiced approach and was indicated only for symptomatic patients. After understanding TSC and tethered cord syndrome (TCS), more aggressive approaches became preferred. A PubMed search suggested that there was a dramatic increase of publications on the topic beginning around 1980. There have been immense academic achievements and technical evolutions since then. From the authors' viewpoint, landmark achievements in this field are listed as follows: (1) establishment of the concept of TSC and the understanding of TCS; (2) unraveling the process of secondary and junctional neurulation; (3) introduction of modern intraoperative neurophysiological mapping and monitoring (IONM) for surgery of spinal lipomas, especially the introduction of bulbocavernosus reflex (BCR) monitoring; (4) introduction of radical resection as a surgical technique; and (5) proposal of a new classification system of spinal lipomas based on embryonic stage. Understanding the embryonic background seems critical because different embryonic stages bring different clinical features and of course different spinal lipomas. Surgical indications and selection of surgical technique should be judged based on the background embryonic stage of the spinal lipoma. As time flows forward, technology continues to advance. Further accumulation of clinical experience and research will open the new horizon in the management of spinal lipomas and other SBO in the next half-century. [ABSTRACT FROM AUTHOR]

Electroencephalogram (EEG)-guided anesthesia is indispensable in modern operating rooms and has become established as the standard form of monitoring. Many anesthesiologists rely on processed EEG indices in the hope of averting anesthesia-related complications, such as intraoperative awareness, postoperative delirium and other cognitive complications in their patients. This educational review aims to provide information on the five most prevalent monitors used to guide depth of sedation during general anesthesia. This article elucidates the principles underpinning the application of these monitors where known, which are generally based on power in various EEG frequency bands and on the burst suppression pattern. Convinced that EEG-guided anesthesia has the potential of benefitting many surgical patients, it is felt that many basic principles and shortcomings of processed EEG indices need to be better understood in the clinical practice. After discussing the different monitors and clinically relevant data from the literature, the article gives a short practical guidance on how to critically interpret processed EEG information and troubleshooting of confounded indices in the context of clinical situations. [ABSTRACT FROM AUTHOR]

The basic principle of head and neck surgery is based on the identification and preservation of important structures, rather than avoidance. Thyroid surgeries are the most frequently performed endocrine procedures worldwide. Recurrent laryngeal nerve (RLN) palsy after thyroid surgery is a serious postoperative complication that can diminish the quality of life. While it is generally accepted that direct visualisation of the nerve is the gold standard, intraoperative nerve monitoring (IONM) is being used increasingly as an adjuvant to help identify the nerve. This study was carried out in Mahatma Gandhi medical college and hospital, Jaipur, Rajasthan from June 2018 to March 2020. 100 patients were enrolled in the study. RLN is identified & visualized in Beahr's triangle or in Lore's triangle. We have randomly selected the patient and use IONM as an adjunct to standard visual identification of the recurrent laryngeal nerve (RLN) to prevent nerve lesion. 8 out of 108 nerves which were at risk during thyroid surgery were found injured. 2 of 50 (4%) nerves at risk were injured with IONM that caused temporary paresis. Without IONM, 5 of 58 (8.6%) nerves at risk suffered temporary paresis and 1of 58(1.72%) had paralysis. Visual nerve identification alone remains the gold standard of recurrent laryngeal nerve management in thyroid surgery and one can use operating microscope for magnification. Neuromonitoring helps to identify the RLN particularly in difficult cases, but it does not decrease the injury to RLN as compared to visualization alone. [ABSTRACT FROM AUTHOR]

Introduction: Patients with spinal deformities undergoing corrective surgery are at risk for iatrogenic spinal cord injury (SCI) and subsequent neurological deficit. Intraoperative neurophysiological monitoring (IONM) allows early detection of SCI which enables early intervention resulting in a better prognosis. The primary aim of this literature review was to search if there are threshold values of TcMEP and SSEP in the literature that are widely accepted as alert during IONM. The secondary aim was to update knowledge concerning IONM during scoliosis surgery. Method: PubMed/MEDLINE and Cochrane library electronic databases were used to search publication from 2012 to 2022. The following keywords were used: evoked potential, scoliosis, surgery, intraoperative monitoring and neurophysiological. We included all studies dealing with SSEP and TcMEP monitoring during scoliosis surgery. Two authors reviewed all titles and abstracts to identify studies that met the inclusion criteria. Results: We included 43 papers. Rates of IONM alert and neurological deficit varied from 0.56 to 64% and from 0.15 to 8.3%, respectively. Threshold values varied from a loss of 50 to 90% for TcMEP amplitude, whereas it seems that a loss of 50% in amplitude and/or an increase of 10% of latency is widely accepted for SSEP. Causes of IONM changes most frequently reported were surgical maneuver. Conclusion: Concerning SSEP, a loss of 50% in amplitude and/or an increase of 10% of latency is widely accepted as an alert. For TcMEP, it seems that the use of highest threshold values can avoid unnecessary surgical procedure for the patient without increasing risk of neurological deficit. [ABSTRACT FROM AUTHOR]

Backgroud: Recurrent laryngeal nerve (RLN) injury is one of the serious complications of thyroid tumour surgery, surgical treatment of thyroid cancer requires careful consideration of the RLN and its impact on glottis function. There has been no unified standard for precise neuromuscular block monitoring to guide the monitoring of RLN in thyroid surgery. This study aimed to investigate the correlation between Train-of-four stabilization ratio (TOFr) and neural signal values of intraoperative neurophysiological monitoring (INOM) during thyroid operation, and further to determine the optimal timing for INOM during thyroid operation. Methods: Patients scheduled for thyroid tumour resection with INOM and RLN monitoring from April 2018 to July 2018 in our center were recruited. Electromyography (EMG) signals and corresponding TOFr were collected. All nerve stimulation data were included in group VR. Vagus nerve stimulation data were included in Subgroup V. RLN stimulation data were included in Subgroup R. The timing of recording was as follows: Vagus nerve EMG amplitude after opening the lateral space between the thyroid and carotid sheath and before the initiation of thyroid dissection, RLN EMG amplitude at first recognition, RLN EMG amplitude after complete thyroid dissection (Repeat three times), and Vagus nerve EMG amplitude after resection of the thyroid (Repeat three times). Correlation analysis of continuous variables was described by a scatter diagram. Pearson correlation analysis or Spearman correlation analysis was used for the two groups of variables. Results: Finally, 134 vagus nerve signals and 143 RLN signals were analysed after matching with TOFr. The EMG amplitude in the VR group and subgroups after nerve stimulation was positively correlated with TOFr (p < 0.05). In the VR, V and R group, the incidence of EMG ≥ 500 µV in the 0.75 < TOFr ≤ 0.85 interval was significantly higher than the 0 < TOFr ≤ 0.75 interval (P = 0.002, P = 0.013 and P = 0.029), and has no statistical difference compared to 0.85 < TOFr ≤ 0.95 interval (P > 0.05). Conclusions: The EMG signals of the RLN and vagus nerve stimulation during thyroid surgery were positively correlated with TOFr. TOFr > 0.75 could reflect more than 50% of the effective nerve electrophysiological signals, 0.75 < TOFr ≤ 0.85 interval was the optimal timing for IONM during thyroid surgery. Trial registration: Chinese Clinical Trial Registry (ChiCTR1800015797) Registered on 20/04/2018. https://www.chictr.org.cn. [ABSTRACT FROM AUTHOR]

Syringomyelia can be associated with multiple etiologies. The treatment of the underlying causes is first-line therapy; however, a direct approach to the syrinx is accepted as rescue treatment. Any direct intervention on the syrinx requires a myelotomy, posing a significant risk of iatrogenic spinal cord (SC) injury. Intraoperative neurophysiological monitoring (IONM) is crucial to detect and prevent surgically induced damage in neural SC pathways. We retrospectively reviewed the perioperative and intraoperative neurophysiological data and perioperative neurological examinations in ten cases of syringomyelia surgery. All the monitored modalities remained stable throughout the surgery in six cases, correlating with no new postoperative neurological deficits. In two patients, significant transitory attenuation, or loss of motor evoked potentials (MEPs), were observed and recovered after a corrective surgical maneuver, with no new postoperative deficits. In two cases, a significant MEP decrement was noted, which lasted until the end of the surgery and was associated with postoperative weakness. A transitory train of neurotonic electromyography (EMG) discharges was reported in one case. The surgical plan was adjusted, and the patient showed no postoperative deficits. The dorsal nerve roots were stimulated and identified in the seven cases where the myelotomy was performed via the dorsal root entry zone. Dorsal column mapping guided the myelotomy entry zone in four of the cases. In conclusion, multimodal IONM is feasible and reliable and may help prevent iatrogenic SC injury during syringomyelia surgery. [ABSTRACT FROM AUTHOR]

Background: The positioning of implant components for total hip arthroplasty (THA) is essential for joint stability, polyethylene liner wear, and range of motion. One potential benefit of the direct anterior approach (DAA) for THA is the ability to use intraoperative fluoroscopy for acetabular cup positioning and limb-length evaluation. Previous studies comparing intraoperative fluoroscopy with no fluoroscopy during DAA have reported conflicting results. This meta-analysis aimed to evaluate whether intraoperative fluoroscopy improves component positioning compared to no fluoroscopy during direct anterior total hip arthroplasty. Methods: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. We searched Web of Science, EMBASE, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, CNKI, VIP, and Wanfang database in May 2023 to identify studies involving intraoperative fluoroscopy versus no fluoroscopy during direct anterior total hip arthroplasty. Finally, we identified 1262 hips assessed in seven studies. Results: There were no significant differences in terms of acetabular cup inclination angle (ACIA, P = 0.21), ACIA within safe zone rate (P = 0.97), acetabular cup anteversion angle (ACAA, P = 0.26); ACAA within safe zone rate (P = 0.07), combined safe zone rate (P = 0.33), and limb-length discrepancy (LLD, P = 0.21) between two groups. Conclusion: Even though intraoperative fluoroscopy was not related to an improvement in cup location or LDD. With fewer experienced surgeons, the benefit of intraoperative fluoroscopy might become more evident. More adequately powered and well-designed long-term follow-up studies were required to determine whether the application of the intraoperative fluoroscopy for direct anterior total hip arthroplasty will have clinical benefits and improve the survival of prostheses. [ABSTRACT FROM AUTHOR]

Objectives: To investigate a method for predicting postoperative facial nerve paralysis (POFNP) during parotid surgery using intraoperative nerve monitoring (IONM). Methods: We assessed prediction for POFNP by using IONM, comparing between stimulation in the facial nerve trunk and each branch by using facial nerve monitoring. The amplitude response ratio (ARR) was calculated for the trunk/periphery. In addition, we then examined the correlation between ARR and time to recovery of paralyzed branches. Results: 372 branches of 93 patients did not develop POFNP and were classified as group A. Among 20 patients who developed POFNP, 51 branches without POFNP were classified as group B, and 29 branches with POFNP were classified as group C. The ARR was approximately 1 in group A and B. but less than 0.5 in all branches in Group C. When the cut off value of ARR was set at 0.55, the sensitivity, specificity, and accuracy of POFNP diagnosis by ARR were 96.5%, 93.1%, and 96.8%, respectively. Conclusion: Using IONM during parotid surgery enables easy prediction of POFNP. [ABSTRACT FROM AUTHOR]

Background: Understanding the patterns of IONM use and training among resident otolaryngologists is essential to ensure that the IONM skills and knowledge gained in residency are optimized for successful future practice of IONM. Method: An electronic survey was distributed to US‐based OHNS residents. Questions evaluated resident experience, implementation, knowledge and understanding of IONM for endocrine surgeries. Results: One hundred and seven OHNS residents participated, spanning all training levels and US geographic locations. The majority of residents received no didactic teaching on IONM (74.5%) nor had a clear troubleshooting algorithm in the event of a loss of signal (69.8%). The majority of residents were uncertain regarding the advantages/disadvantages of continuous versus intermittent IONM. Conclusion: The knowledge gap found in our survey study suggests that greater teaching of IONM principles for endocrine head and neck surgeries in OHNS residency programs would help to ensure successful utilization in future practice. [ABSTRACT FROM AUTHOR]

Cholangioscopy remains a key tool for the assessment of clearance of the biliary system in the management of hepatolithiasis either in laparoscopic or open common bile duct exploration. A fiber optic bronchoscope (Ambu® aScope™ 2, Ambu UK Ltd, Cambridgeshire, UK), from the anesthesia cart, can be utilized in place of a specific choledochoscope for the same. A middle-aged male patient was planned for open common bile duct exploration and bilioenteric anastomosis for choledocholithiasis and hepatolithiasis, not amenable for endoscopic clearance. After choledochotomy and stone clearance, a sterile pediatric fiber optic bronchoscope, selected from the anesthesia cart, was utilized as a choledochoscope for intraoperative cholangioscopy and complete stone clearance was assured. The biliary system was explored up to tertiary biliary radicals as well as distal common bile duct up to the duodenum. Bilioenteric anastomosis was done after assurance of complete stone clearance. The patient was discharged on postoperative day 4. Fiber optic bronchoscope can be used for intraoperative cholangioscopy as a makeshift choledochoscope as good resource utilization with minimal logistic issues. [ABSTRACT FROM AUTHOR]

Vasovagal reflex may cause benign self-limiting syncope triggered by factors such as pain and emotional stress. However, rarely, it may cause cardiac arrest requiring urgent resuscitation, which has heretofore not been reported during blepharoplasty. In this report, the case of a 28-year-old man who underwent blepharoplasty under local anesthesia is presented. He suddenly experienced bradycardia and subsequent cardiac arrest during resection of the orbicularis oculi. He was fearful after smelling the unpleasant odor of burned tissue and fainted. He recovered consciousness within 1 min following prompt chest compression. Based on intraoperative conditions and cardiological examinations, vasovagal reflex was considered to be the cause of the cardiac arrest. Blepharoplasty involves multiple factors that can lead to neurocardiogenic syncope, thus increasing the risk for intraoperative syncope and circulatory collapse. Hence, the procedure should be performed under close monitoring with the preparation of staff, intravenous access, drugs, and resuscitation cart to manage possible cardiac arrest.

CNS invasion has been included as an independent criterion for the diagnosis of a high-grade (WHO and CNS grade 2 and 3) meningioma in the 2016 and more recently in the 2021 WHO classification. However, the prognostic role of brain invasion has recently been questioned. Also, surgical treatment for brain invasive meningiomas may pose specific challenges. We conducted a systematic review of the 2016–2022 literature on brain invasive meningiomas in Pubmed, Scopus, Web of Science and the Cochrane Library. The prognostic relevance of brain invasion as a stand-alone criterion is still unclear. Additional and larger studies using robust definitions of histological brain invasion and addressing the issue of sampling errors are clearly warranted. Although the necessity of molecular profiling in meningioma grading, prognostication and decision making in the future is obvious, specific markers for brain invasion are lacking for the time being. Advanced neuroimaging may predict CNS invasion preoperatively. The extent of resection (e.g., the Simpson grading) is an important predictor of tumor recurrence especially in higher grade meningiomas, but also – although likely to a lesser degree – in benign tumors, and therefore also in brain invasive meningiomas with and without other histological features of atypia or malignancy. Hence, surgery for brain invasive meningiomas should follow the principles of maximal but safe resections. There are some data to suggest that safety and functional outcomes in such cases may benefit from the armamentarium of surgical adjuncts commonly used for surgery of eloquent gliomas such as intraoperative monitoring, awake craniotomy, DTI tractography and further advanced intraoperative brain tumor visualization. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES While open surgical repair remains the gold standard for thoracoabdominal aortic aneurysm (TAAA) treatment, there is still no consensus regarding perioperative neuromonitoring technique for prevention of spinal cord ischaemia. METHODS In this systematic review, we aimed to explore the effects and practices of neuromonitoring during the open TAAA repair. A systematic literature search in PubMed, Embase via Ovid, Cochrane library and ClinicalTrialsGov until December 2022 was performed. RESULTS A total of 535 studies were identified from the literature search, of which 27 studies including a total of 3130 patients met the eligibility criteria. Most studies (21 out of 27, 78%) investigated the feasibility of motor-evoked potentials (MEP), while 15 analysed somatosensory-evoked potentials (SSEP) and 2 studies analysed near-infrared spectroscopy during open TAAA repair. CONCLUSIONS Current literature suggest that rates of postoperative spinal cord ischaemia can be kept at low levels after open TAAA repair with the adequate precautions and perioperative manoeuvres. Neuromonitoring with MEP provides the surgeon objective criteria to direct selective intercostal reconstruction or other protective anaesthetic and surgical manoeuvres. Simultaneous monitoring of MEP and SSEP is a reliable method that can rapidly detect important findings and direct adequate protective manoeuvres during open TAAA repair. [ABSTRACT FROM AUTHOR]

BACKGROUND: Enhanced recovery protocols have been developed to improve perioperative outcomes; however, there is ongoing concern for aspiration with recent oral intake in patients with obesity, who may be predisposed to impaired gastrointestinal motility and greater gastric volumes. We aim to study the safety of a 300-mL preoperative carbohydrate-loading drink preceding bariatric surgery. STUDY DESIGN: Data were collected prospectively from patients undergoing primary bariatric surgery. All bariatric patients at our institution are prescribed a proton pump inhibitor for 4 weeks before surgery and undergo a screening preoperative esophagogastroduodenoscopy (EGD) before surgery with a traditional 8-hour fast (NOCARB), followed by an intraoperative day-of-operation EGD with carbohydrate loading (CARB) 2 to 4 hours before incision. Gastric volumes and pH are measured after being endoscopically suctioned via direct visualization during both settings. RESULTS: We identified 203 patients: 94 patients (46.3%) in the CARB group and 109 patients (53.7%) in the NOCARB group. The patients were 82.3% female with a mean age of 42.8 years and average BMI of 41.7 kg/m². There was no difference in gastric volume between NOCARB and CARB (17.0 vs 16.1 mL, p = 0.59). The NOCARB group had lower pH values than the CARB group (2.8 vs 3.8, p = 0.001). Subset analysis of 23 patients who had measurements on both screening and intraoperative EGD revealed lower gastric volumes in CARB patients (13.3 vs 18.3, p < 0.0001). CONCLUSIONS: When included in an enhanced recovery protocol, proton pump inhibitor use and preoperative carbohydrate loading 2 to 4 hours before bariatric surgery does not increase aspiration risk based on gastric volumes and pH and should be strongly considered in all eligible bariatric patients. [ABSTRACT FROM AUTHOR]

Abstract Background Primary hyperparathyroidism is a disease caused by the secretion of excess parathyroid hormone (PTH) owing to the enlargement of the parathyroid gland. Ectopic parathyroid glands exist in the mediastinum in approximately 1–2% of cases, which is relatively rare. Intraoperative monitoring of serum PTH level is important to assess whether the source of hyperparathyroidism has been eliminated. Case presentation A 53-year-old asymptomatic woman was diagnosed with ectopic mediastinal parathyroid adenoma. A three-port robotic partial resection of the thymus containing the tumor was attempted, but bleeding from a swollen pericardial diaphragmatic vein led to the addition of an assist port along the way. The PTH level was measured intraoperatively. After confirming that the 15-min PTH level after removal of the tumor was less than 50% of the baseline value, the operation was completed. The tumor was positive for PTH and was diagnosed as an ectopic mediastinal parathyroid adenoma. Some small ectopic parathyroid gland tissues were observed in other parts of the thymic tissue. Serum calcium and PTH levels decreased and normalized. Conclusions We report the usefulness of robotic resection for ectopic mediastinal parathyroid adenoma with PTH monitoring. However, histopathologically, small parathyroid gland tissues may remain in the surrounding thymus. Hence, we believe that a strict follow-up is required for parathyroid function in the future.