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• Significant Transfusion Rates: 25.44% of patients undergoing elective surgeries required intraoperative or immediate postoperative blood transfusions, indicating a critical need for blood reserve management in surgical settings. • Pre-Surgical Hemoglobin as a Predictor: Patients with higher pre-surgical hemoglobin levels were less likely to need transfusions, underscoring the importance of pre-operative anemia management. • Diverse Surgical Needs: The study found a higher prevalence of transfusions in oncological surgeries compared to other types, highlighting varying blood component needs across surgical categories. • Blood Utilization Efficiency: The research revealed inefficiencies in blood utilization, with a high ratio of requested to transfused blood units, particularly in red blood cell concentrates. • Trend Towards Restrictive Transfusion Practices: The study aligns with global trends towards more restrictive blood transfusion practices, especially in cancer surgeries where transfusion probabilities are higher. The transfusion practice by surgery blood reserve, varied among services, must be performed through the rational and restrictive use of blood components because it is a scarce and expensive resource for health care services. Analyze the use of blood products for surgery blood reserve by means of the study of the clinical-hematological profile of patients submitted to intraoperative and immediate postoperative transfusions. This was an observational, cross-sectional, and retrospective study, conducted by collecting biological, operational, and laboratory variables, involving 680 patients at a university hospital who had elective surgery with surgery blood reserve request sent during the period from October 2021 to October 2022. The overall transfusion rate was 25.44%, and the mean preoperative hemoglobin level of transfused patients was 9.74 ± 2.50 g/dL, with the mean number of transfusions packed red blood cell units was 1.58 ± 0.77. Patients with higher preoperative hemoglobin levels were less likely to have transfusion (p < 0.001) and patients who had surgical oncologic were more likely to require transfusion (p = 0.048). The transfusion rate of packed red blood cells and platelets concentrates, compared to what was requested, was 15.86% and 5.82%. There is a tendency of transfusions to follow restrictive models, with higher transfusion probability in surgical oncologic. Furthermore, there should be more a conscise use of the surgery blood reserves request. [ABSTRACT FROM AUTHOR]

This systematic review and meta-analysis investigates the objective evidence regarding outcomes in head and neck free flap surgeries using vasoactive agents in the perioperative period. A search was performed in PubMed, Cochrane, Web of Science, and Scopus databases. Inclusion criteria were clinical studies in which vasopressors were used in head and neck free flap surgery during the intraoperative and perioperative period. Eighteen studies (n = 5397) were included in the qualitative analysis and nine (n = 4381) in the meta-analysis. There was no difference in flap failure outcomes with perioperative vasopressor use in head and neck free flap surgery (n = 4015, OR = 0.93, 95% CI [0.60, 1.44]). When patients received vasopressors perioperatively, there was an associated decrease in flap-specific complications (n = 3881, OR = 0.69, 95% CI [0.55, 0.87]). Intraoperative vasopressor use does not negatively impact free tissue transfer outcomes in head and neck surgery and may reduce overall free flap complications.

Introduction: Spinal anaesthesia is an extensively used anaesthetic technique for infraumbilical surgeries. Despite its many advantages, hypotension and bradycardia are two common complications. The incidence of bradycardia following spinal anaesthesia is higher in young adults. Although a few previous studies have observed that intramuscular glycopyrrolate is effective in preventing spinal-induced bradycardia and hypotension in elderly and parturient patients, there is a lack of reported studies in the young population. Aim: To evaluate the role of intramuscular glycopyrrolate in the prevention of bradycardia and hypotension in adult patients undergoing lower limb surgeries. Materials and Methods: A randomised, parallel-group, doubleblind, placebo-controlled study was conducted in the Department of Anaesthesiology at Calcutta National Medical College, Kolkata, West Bengal, India. The duration of the study was 15 months, from July 2021 to September 2022. A total of 60 patients aged 18-45 years, of either sex, with American Society of Anaesthesiologists (ASA) physical status I and II, undergoing elective lower limb surgeries under spinal anaesthesia. The patients were randomised into two groups: group G received intramuscular glycopyrrolate 1 mL (0.2 mg) and group N received intramuscular normal saline 1 mL 15 minutes prior to spinal anaesthesia. Hyperbaric bupivacaine (0.5%) 3 mL and fentanyl (25 mcg) 0.5 mL were injected intrathecally. Haemodynamic parameters were monitored. All data were analysed using appropriate statistical tests. A p-value of

Objective: The optimal target for blood glucose concentration in critically ill patients is unclear. We will perform a systematic review and meta-analysis with aggregated and individual patient data from randomized controlled trials, comparing intensive glucose control with liberal glucose control in critically ill adults. Data sources: MEDLINE®, Embase, the Cochrane Central Register of Clinical Trials, and clinical trials registries (World Health Organization, clinical trials.gov). The authors of eligible trials will be invited to provide individual patient data. Published triallevel data from eligible trials that are not at high risk of bias will be included in an aggregated data meta-analysis if individual patient data are not available. Methods: Inclusion criteria: randomized controlled trials that recruited adult patients, targeting a blood glucose of = 120mg/dL (= 6.6mmol/L) compared to a higher blood glucose concentration target using intravenous insulin in both groups. Excluded studies: those with an upper limit blood glucose target in the intervention group of > 120mg/dL (> 6.6mmol/L), or where intensive glucose control was only performed in the intraoperative period, and those where loss to follow-up exceeded 10% by hospital discharge. Primary endpoint: In-hospital mortality during index hospital admission. Secondary endpoints: mortality and survival at other timepoints, duration of invasive mechanical ventilation, vasoactive agents, and renal replacement therapy. A random effect Bayesian meta-analysis and hierarchical Bayesian models for individual patient data will be used. Discussion: This systematic review with aggregate and individual patient data will address the clinical question, 'what is the best blood glucose target for critically ill patients overall?'. [ABSTRACT FROM AUTHOR]

Introduction: Spinal anaesthesia is an extensively used anaesthetic technique for infraumbilical surgeries. Despite its many advantages, hypotension and bradycardia are two common complications. The incidence of bradycardia following spinal anaesthesia is higher in young adults. Although a few previous studies have observed that intramuscular glycopyrrolate is effective in preventing spinal-induced bradycardia and hypotension in elderly and parturient patients, there is a lack of reported studies in the young population. Aim: To evaluate the role of intramuscular glycopyrrolate in the prevention of bradycardia and hypotension in adult patients undergoing lower limb surgeries. Materials and Methods: A randomised, parallel-group, doubleblind, placebo-controlled study was conducted in the Department of Anaesthesiology at Calcutta National Medical College, Kolkata, West Bengal, India. The duration of the study was 15 months, from July 2021 to September 2022. A total of 60 patients aged 18-45 years, of either sex, with American Society of Anaesthesiologists (ASA) physical status I and II, undergoing elective lower limb surgeries under spinal anaesthesia. The patients were randomised into two groups: group G received intramuscular glycopyrrolate 1 mL (0.2 mg) and group N received intramuscular normal saline 1 mL 15 minutes prior to spinal anaesthesia. Hyperbaric bupivacaine (0.5%) 3 mL and fentanyl (25 mcg) 0.5 mL were injected intrathecally. Haemodynamic parameters were monitored. All data were analysed using appropriate statistical tests. A p-value of <0.05 was considered statistically significant. Changes in Heart Rate (HR) were considered the primary outcome variable. The secondary outcome variables were changes in Mean Arterial Pressure (MAP), incidence of bradycardia and hypotension, phenylephrine requirement, and incidence of dry mouth. Results: The mean age of the study participants of group G and group N was 34.17 years and 33.63 years. The two groups were comparable in terms of demographic profile. In comparison to group N, patients in group G showed a significantly higher HR throughout the intraoperative period (p<0.001) and at 60 minutes in the postoperative period. The incidence of hypotension was significantly higher in group N (53.33%) compared to group G (3.33%, p<0.001), and the MAP was lower in group N compared to group G in the intraoperative period. The number of patients requiring phenylephrine was also higher in group N (53.33%) compared to those in group G (3.33%). Conclusion: Prophylactic use of intramuscular glycopyrrolate can maintain stable haemodynamics in patients undergoing lower limb surgeries under spinal anaesthesia. It can maintain a higher HR and reduces the incidence of hypotension following spinal anaesthesia. [ABSTRACT FROM AUTHOR]

Background: Unplanned intraoperative extubation is a rare but potentially catastrophic safety event. Inadvertent extubation in the neonatal and pediatric critical care setting is a recognized quality improvement metric whereas literature for intraoperative extubation is scarce. The aim of this study was to identify risk factors and outcomes associated with unplanned intraoperative extubation. Methods: We queried the National Surgical Quality Improvement Program—Pediatric database from 2019 to 2020 for patients <18 years of age. A total of 253 673 patients were included in the analysis. Associations between demographics, clinical variables, and unplanned intraoperative extubation were evaluated with univariable and multivariable logistic regression models. The primary outcome was unplanned intraoperative extubation. Secondary outcomes were postoperative pulmonary complication, unplanned reintubation within 24 h, cardiac arrest on day of surgery, and surgical site infection. Results: Unplanned intraoperative extubation occurred in 163 (0.06%) patients. Specific procedures experienced unplanned intraoperative extubation at a higher rate such as bilateral cleft lip repair (1.31% of procedure type) and thoracic repair of tracheoesophageal fistula (1.11% of procedure type). Age, operative time (z‐score), American Society of Anesthesiologists Classification 3 and 4, neurosurgery, plastic surgery, thoracic surgery, otolaryngology, and structural pulmonary/airway abnormalities were independent risk factors. Unplanned intraoperative extubation was associated with an increased unadjusted risk for postoperative pulmonary complication (p <.005; OR, 6.05; 95% confidence interval [CI]: 1.93–14.44), unplanned reintubation within 24 h (p <.005; OR, 8.41; 95% CI: 2.08–34.03), cardiac arrest on day of surgery (p <.05; OR, 22.67; 95% CI: 0.56–132.35), and surgical site infection (p <.0005; OR, 3.27; 95% CI 1.74–5.67). Conclusions: Unplanned intraoperative extubation occurs at a higher frequency in a subset of procedures and patient types. Identifying and targeting at‐risk patients with preventative measures may decrease the incidence of unplanned intraoperative extubation and its associated outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Surgical care has been a vital part of healthcare services worldwide. Several patient safety measures have been adopted universally in the operating room (OR) before, during, and following surgical procedures. Despite this, errors or near misses still occur. Nurses in the OR have a pivotal role in the identification of factors that may impact patient safety and quality of care. Therefore, exploring the OR nurses' understanding of their roles and responsibilities for patient care and safety in the intraoperative practice, which could lead to optimal patient safety, is essential. Objective: This study explored the understanding of OR nurses regarding their roles and responsibilities for patient care and safety measures in the intraoperative practice. Methods: The study was conducted in one of the tertiary care hospitals in the United Arab Emirates. Qualitative, descriptive, exploratory research design was utilized. The data were collected using semi-structured face to face interviews. Purposive sampling included eight nurses. Data analysis was performed following Colaizzi's seven-step strategy. Results: Seven emerging themes were identified. The main themes are: patient safety, preoperative preparation, standardization of practice, time management, staffing appropriateness, staff education and communication, and support to the patient in the OR. Conclusion: OR nurse leaders may take into consideration the current findings as a reference for quality improvement projects in the hospital, considering the specific characteristics of each local setting. Although the participants consider that the environment is safe and the quality of care is high in the study setting, there is still room for improvement on workflows and processes. OR workflow should be improved especially by addressing the potential patient safety issues. [ABSTRACT FROM AUTHOR]

Background: Despite the widespread use of intraoperative steroids in various neurological surgeries to reduce cerebral edema and other adverse symptoms, there is sparse evidence in the literature for the optimal and safe usage of intraoperative steroid administration in patients undergoing craniotomy for brain tumors. We aimed to investigate the effects of intraoperative steroid administration on postoperative 30-day mortality in patients undergoing craniotomy for brain tumors. Methods: Adult patients who underwent craniotomy for brain tumors between January 2011 to January 2020 were included at West China Hospital, Sichuan University in this retrospective cohort study. Stratified analysis based on the type of brain tumor was conducted to explore the potential interaction. Results: This study included 8,663 patients undergoing craniotomy for brain tumors. In patients with benign brain tumors, intraoperative administration of steroids was associated with a higher risk of postoperative 30-day mortality (adjusted OR 1.98, 95% CI 1.09-3.57). However, in patients with malignant brain tumors, no significant association was found between intraoperative steroid administration and postoperative 30-day mortality (adjusted OR 0.86, 95% CI 0.55-1.35). Additionally, administration of intraoperative steroids was not associated with acute kidney injury (adjusted OR 1.11, 95% CI 0.71-1.73), pneumonia (adjusted OR 0.89, 95% CI 0.74-1.07), surgical site infection (adjusted OR 0.78, 95% CI 0.50-1.22) within 30 days, and stress hyperglycemia (adjusted OR 1.05, 95% CI 0.81-1.38) within 24 h after craniotomy for brain tumor. Conclusion: In patients undergoing craniotomy for benign brain tumors, intraoperative steroids were associated with 30-day mortality, but this association was not significant in patients with malignant brain tumors. [ABSTRACT FROM AUTHOR]

BackgroundClean Cut is an adaptive, multimodal programme to identify improvement opportunities and safety changes in surgery by enhancing outcomes surveillance, closing gaps in surgical infection prevention standards, and strengthening underlying processes of care. Surgical-site infections (SSIs) are common in low-income countries, so this study assessed a simple intervention to improve perioperative infection prevention practices in one.MethodsClean Cut was implemented in five hospitals in Ethiopia from August 2016 to October 2018. Compliance data were collected from the operating room focused on six key perioperative infection prevention standards. Process-mapping exercises were employed to understand barriers to compliance and identify locally driven improvement opportunities. Thirty-day outcomes were recorded on patients for whom intraoperative compliance information had been collected.ResultsCompliance data were collected from 2213 operations (374 at baseline and 1839 following process improvements) in 2202 patients. Follow-up was completed in 2159 patients (98·0 per cent). At baseline, perioperative teams complied with a mean of only 2·9 of the six critical perioperative infection prevention standards; following process improvement changes, compliance rose to a mean of 4·5 (P

BackgroundReduced creatinine clearance is an indication for surgery in asymptomatic primary hyperparathyroidism, and a significant proportion of patients undergoing parathyroidectomy have chronic kidney disease. The purpose of this study was to evaluate the kinetics of intraoperative parathyroid hormone decline during parathyroidectomy in patients who have chronic kidney disease compared with those with who have normal renal function.MethodsThis is a single-center, retrospective study of patients with primary hyperparathyroidism undergoing parathyroidectomy (n = 646). Patients were grouped based on estimated glomerular filtration rate greater than (normal renal function) or less than (chronic kidney disease) 60 mL/min/1.73m2. All patients had intraoperative parathyroid hormone monitoring and ≥6-month postoperative serum studies to confirm surgical cure. Intraoperative parathyroid hormone kinetic curves were analyzed using a linear mixed model.ResultsDespite similar pre-excision values, patients with chronic kidney disease had significantly higher intraoperative parathyroid hormone values at 5 minutes (76 vs 58 pg/mL, P = .02) and 10 minutes (54 vs 37 pg/mL, P = .004) postexcision. No significant difference was observed in whether patients met Miami criterion by 5 minutes (chronic kidney disease 71%, normal renal function 78%, P = .255) or by 10 minutes (chronic kidney disease 95%, normal renal function 96%, P = .751) postexcision. Using a linear mixed model, glomerular filtration rate did not have a significant effect on the change in intraoperative parathyroid hormone over time.ConclusionPatients with chronic kidney disease had significantly higher postexcision intraoperative parathyroid hormone levels. However, renal function did not affect the change in intraoperative parathyroid hormone over time, nor did renal function ultimately affect the likelihood of meeting the Miami criterion. Intraoperative parathyroid hormone monitoring remains useful in this population, although additional time points may be needed to observe normalization of values.

Background For patients with acute ischemic stroke undergoing endovascular mechanical thrombectomy with x-ray angiography, the use of adjuncts to maintain vessel patency, such as stents or antiplatelet medications, can increase risk of periprocedural complications. Criteria for using these adjuncts are not well defined. Purpose To evaluate use of MRI to guide critical decision making by using a combined biplane x-ray neuroangiography 3.0-T MRI suite during acute ischemic stroke intervention. Materials and Methods This retrospective observational study evaluated consecutive patients undergoing endovascular intervention for acute ischemic stroke between July 2019 and May 2020 who underwent either angiography with MRI or angiography alone. Cerebral tissue viability was assessed by using MRI as the reference standard. For statistical analysis, Fisher exact test and Student t test were used to compare groups. Results Of 47 patients undergoing acute stroke intervention, 12 patients (median age, 69 years; interquartile range, 60-77 years; nine men) underwent x-ray angiography with MRI whereas the remaining 35 patients (median age, 80 years; interquartile range, 68-86 years; 22 men) underwent angiography alone. MRI results influenced clinical decision making in one of three ways: whether or not to perform initial or additional mechanical thrombectomy, whether or not to place an intracranial stent, and administration of antithrombotic or blood pressure medications. In this initial experience, decision making during endovascular acute stroke intervention in the combined angiography-MRI suite was better informed at MRI, such that therapy was guided in real time by the viability of the at-risk cerebral tissue. Conclusion Integrating intraprocedural 3.0-T MRI into acute ischemic stroke treatment was feasible and guided decisions of whether or not to continue thrombectomy, to place stents, or to administer antithrombotic medication or provide blood pressure medications. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Lev and Leslie-Mazwi in this issue.

Intraoperative hypertension (IOHTA) during neck surgery is undesirable because this type of surgery has a propensity to bleed profoundly even in normotensive anesthesia. The purpose of our study was to detect predictors of IOHTA in patients undergoing neck surgery. This single center retrospective study included 880 adult patients who underwent neck surgery under general anesthesia. The impact of gender, age, comorbidity, difficult tracheal intubation, anesthesia duration, and induced hypotension on IOHTA was studied. IOHTA was present in 57 (6.7%) patients. The highest incidence of IOHTA was recorded in patients with ASA 4 status and those with Cormack-Lehane grade 4,: (22.2% and 21.4%, respectively). Significantly more patients with hypertension, hyperlipoproteinemia and ventricular extrasystoles had IOHTA compared with patients without these comorbidities. Statistically significant predictors of IOHTA were age (OR 1.438; 95% CI 1.144-1.808; p=0.002), cardiac arrhythmia (OR 1.702; 95% CI 1.129-2.566; p=0.011), Cormack-Lehane grade (OR 1.407; 95% CI 1.054-1.878; p=0.020), and duration of anesthesia (OR 1.005; 95% CI 1.001-1.008; p=0.005). The risk of IOHTA occurrence was lower in patients with induced hypotension (OR 0.024; 95% CI 0.003-0.185; p=0.000). During neck surgery, special attention is needed in patients of older age, those with cardiac arrhythmia, difficult intubation, and longer anesthesia duration because they are at risk of IOHTA.

PurposeTo compare the efficacy of intraoperative scleral application with subconjunctival injection of mitomycin C (MMC) in trabeculectomy.DesignProspective, randomized, interventional study.MethodsThis study took place in a single clinical practice in an academic setting. Patients had medically uncontrolled glaucoma as indicated by high intraocular pressure (IOP), worsening visual field, or optic nerve head changes in whom primary trabeculectomy was indicated. Patients were older than 18 years with medically uncontrolled glaucoma and no history of incisional glaucoma surgery. Patients were randomized to MMC delivered by preoperative subconjunctival injection or by intraoperative direct scleral application using surgical sponges during trabeculectomy. Comprehensive eye examinations were conducted at 1 day, 1 week, 6 weeks, 3 months, and 6 months postoperatively. Subconjunctival 5-fluorouracil injections were given postoperatively, as needed. The primary outcome was the proportion of patients who demonstrated IOP of

PurposeTo compare patients from a large multicenter cohort with a history of seizure and those without a history of seizure regarding preoperative and intraoperative findings and surgical procedures performed.MethodsPatients undergoing shoulder stabilization from 2011 to 2018 at 11 orthopaedic centers were prospectively enrolled. Those with a history of seizure were identified and compared with non-seizure controls. Preoperative demographic, history, physical examination, and imaging findings were collected. Intraoperative findings and surgical procedures performed were recorded. The Mann-Whitney test, χ2 test, and logistic regression analysis were used to examine differences between the groups and define independent risk factors. Owing to the number of statistical tests performed, the false discovery method was used to determine adjusted P values to achieve α < .05.ResultsDuring enrollment, 25 of 1,298 shoulder stabilization patients (1.9%) had a history of seizure. The sex ratio and age were similar between groups, as was posterior instability incidence (23.2% in control group vs 28.0% in seizure group). Seizure patients more frequently had more than 5 dislocations in the year preceding surgery (P = .016) and had increased preoperative radiographic evidence of bone loss (P < .001). Intraoperatively, seizure patients had a higher prevalence of reverse Hill-Sachs lesions (P < .001) and large (>30% of glenoid fossa) bony Bankart lesions (P < .001). Arthroscopic Bankart repair was the most common procedure in both groups. However, open procedures were performed in 15.6% of controls and 40.0% of seizure patients (P = .001). These procedures were most commonly bony procedures.ConclusionsSeizure patients had more prior dislocations, had more preoperative bone loss, and underwent more open stabilization procedures than controls because of bone loss. Studies examining recurrence after stabilization will help establish appropriate management practices in this population.Level of evidenceLevel III, retrospective review of prospectively collected cohort.

Objective: To investigate the association involving site, concentrations and dosing of local anaesthetics used intraoperatively on postoperative pain scores, motor block and need for rescue analgesia. Method: The observational study was conducted June 1, 2020, to May 31, 2021, at the Aga Khan University Hospital, Karachi, and comprised patients planned for major abdominal surgeries with epidurals as primary analgesic modality. They were followed prospectively from placement of epidurals to 24h postoperatively. Data was collected from anaesthesia chart and pain management notes. Data was analysed using SPSS 19. Results: Of the 170 patients, 96(56.4%) were females and 74(43.5%) were males. The overall mean age was 54.1±12.6 years and mean body mass index was 26.7±5.5Kg/m2. More than half of the patients 110(64.7%) had thoracic epidural, while 60(35.3%) had lumber epidural. Requirement of opioid co-analgesia intraoperatively was significantly high with higher compared to lower concentration of local anaesthetics (p=0.004). The difference in frequencies of motor block was significantly associated with catheter length (p=0.006). Conclusions: Intraoperative management of epidurals is an essential but overlooked component of perioperative pain management. Guidelines should be formulated for intraoperative epidural analgesic regimens to improve postoperative outcomes. Key Words: Epidural management, Pain management, Local anaesthetics, Intraoperative period, Thoracic epidural, Practice trends.

BackgroundAlthough clinical factors related to intraoperative opioid administration have been described, there is little research evaluating whether administration is influenced by drug formulation and, specifically, the unit dose of the drug. The authors hypothesized that the unit dose of hydromorphone is an independent determinant of the quantity of hydromorphone administered to patients intraoperatively.MethodsThis observational cohort study included 15,010 patients who received intraoperative hydromorphone as part of an anesthetic at the University of California, Los Angeles hospitals from February 2016 to March 2018. Before July 2017, hydromorphone was available as a 2-mg unit dose. From July 1, 2017 to November 20, 2017, hydromorphone was only available in a 1-mg unit dose. On November 21, 2017, hydromorphone was reintroduced in the 2-mg unit dose. An interrupted time series analysis was performed using segmented Poisson regression with two change-points, the first representing the switch from a 2-mg to 1-mg unit dose, and the second representing the reintroduction of the 2-mg dose.ResultsThe 2-mg to 1-mg unit dose change was associated with a 49% relative decrease in the probability of receiving a hydromorphone dose greater than 1 mg (risk ratio, 0.51; 95% CI, 0.40-0.66; P < 0.0001). The reintroduction of a 2-mg unit dose was associated with a 48% relative increase in the probability of administering a dose greater than 1 mg (risk ratio, 1.48; 95% CI, 1.11-1.98; P = 0.008).ConclusionsThis observational study using an interrupted time series analysis demonstrates that unit dose of hydromorphone (2 mg vs. 1 mg) is an independent determinant of the quantity of hydromorphone administered to patients in the intraoperative period.

Objective: to demonstrate the experience of using complex hemodynamic monitoring by means of prepulmonary thermodilution (PPTD) and transpulmonary thermodilution (TPTD) – PiCCO – in lung transplantation (LTx). Materials and methods. Presented is a clinical case study of a 51-year-old patient with the following diagnosis: severe bronchiectasis and type 3 respiratory failure. Bilateral lung transplantation was performed at Sklifosovsky Research Institute for Emergency Medicine, Moscow. Intraoperative hemodynamic monitoring was performed using PPTD and TPTD techniques. Conclusion. The case study presented shows that simultaneous use of PPTD and TPTD for hemodynamic monitoring during lung transplantation achieves better treatment outcomes. This hemodynamics monitoring strategy is highly informative, allows for continuous measurement of necessary hemodynamic parameters and for timely and targeted correction of identified disorders by influencing the basic pathogenesis links of cardiovascular disease.

Intraoperative adverse events (iAEs) impact the outcomes of surgery, and yet are not routinely collected, graded, and reported. Advancements in artificial intelligence (AI) have the potential to power real-time, automatic detection of these events and disrupt the landscape of surgical safety through the prediction and mitigation of iAEs. We sought to understand the current implementation of AI in this space. A literature review was performed to PRISMA-DTA standards. Included articles were from all surgical specialties and reported the automatic identification of iAEs in real-time. Details on surgical specialty, adverse events, technology used for detecting iAEs, AI algorithm/validation, and reference standards/conventional parameters were extracted. A meta-analysis of algorithms with available data was conducted using a hierarchical summary receiver operating characteristic curve (ROC). The QUADAS-2 tool was used to assess the article risk of bias and clinical applicability. A total of 2982 studies were identified by searching PubMed, Scopus, Web of Science, and IEEE Xplore, with 13 articles included for data extraction. The AI algorithms detected bleeding (n = 7), vessel injury (n = 1), perfusion deficiencies (n = 1), thermal damage (n = 1), and EMG abnormalities (n = 1), among other iAEs. Nine of the thirteen articles described at least one validation method for the detection system; five explained using cross-validation and seven divided the dataset into training and validation cohorts. Meta-analysis showed the algorithms were both sensitive and specific across included iAEs (detection OR 14.74, CI 4.7–46.2). There was heterogeneity in reported outcome statistics and article bias risk. There is a need for standardization of iAE definitions, detection, and reporting to enhance surgical care for all patients. The heterogeneous applications of AI in the literature highlights the pluripotent nature of this technology. Applications of these algorithms across a breadth of urologic procedures should be investigated to assess the generalizability of these data. [ABSTRACT FROM AUTHOR]

Objective To explore the influence of opioid-free general anesthesia on the perioperative period and short-term prognosis of patients undergoing ileostomy resection.Methods A total of 60 patients who underwent ileostomy reduction in this hospital from August 2020 to May 2021 were selected and divided into the opioid-free group and the traditional group according to the corresponding randomly generated numbers, with 30 patients in each group, and one case in the opioid-free group was excluded because of the change of the operation mode during the operation.During the perioperative period, the two groups of patients were given different anesthetic drug management strategies.The vital signs during the perioperative period, postoperative pain, nausea and vomiting, and postoperative short-term prognosis of the two groups were compared.Results Compared with the traditional group, the first sitting time, the first time of getting out of bed for activity, the recovery time of peristalsis and the first exhausting time of patients in the opioid-free group were significantly shortened after operation; The mean arterial pressure and heart rate at each time point during the perioperative period were significantly higher than those in the conventional group; The visual analog scale scores at 4 and 8 hours after the operation, as well as the number and degree of nausea and vomiting occurred were significantly lower, and the differences were all statistically significant（P<0.05）. The comparison of EEG dual frequency index between the two groups at the beginning and the end of the operation also had statistical significance（P<0.05）.Conclusion The use of opioid-free drugs can make the hemodynamics of patients in the perioperative period more stable, have a good analgesic effect, and can reduce the incidence of postoperative anesthesia-related complications, accelerate the recovery of postoperative gastrointestinal function, and be in an advantageous position to improve the short-term prognosis of patients. [ABSTRACT FROM AUTHOR]

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Purpose: Neurosurgical interventions are long and complex, and additional difficulties are encountered in positioning in the operating room. The aim of the study is to determine the risk of pressure injury development in the intraoperative period of patients undergoing elective cranial surgery. Material and Methods: This descriptive cross-sectional study was conducted with 127 patients who met the inclusion criteria and underwent elective cranial surgery in a city hospital between September and October 2021. 3S Operating Room Pressure Injury Risk Diagnostic Scale were used to collect data. Results: It was determined that 55.1% of the patients were female, their mean age was 53.22±13.47 years, and 61.4% had at least one chronic disease. It was determined that 71.7% of the patients were operated with the diagnosis of cerebellar tumor. Stage 1 pressure injuries were observed in 37% of the patients. It was determined that the total score obtained from the scale was 14.87±2.83 and the patients were at low risk for pressure injury. Age, body mass index and duration of the surgical procedure were found to be independent factors affecting the patients' operating room pressure injuries risk assessment scale score. Conclusion: It was determined that the risk of pressure injury in patients who underwent cranial surgery was low level. [ABSTRACT FROM AUTHOR]

IntroductionMany patients who undergo coronary artery bypass surgery have a prior history of cancer and potentially chest radiation which is a known risk factor for coronary atherosclerosis. Prior radiation increases fibrosis and can make the dissection of the left internal mammary artery (LIMA) more challenging.Case reportA 72-year-old woman with a history of stage IIA pT2N0M0 left breast intraductal carcinoma treated with lumpectomy, adjuvant chemotherapy and radiation therapy 11 years prior presented to the emergency room with a non-ST elevation myocardial infarction and was taken for cardiac catheterization followed by three-vessel coronary artery bypass grafting. The LIMA was found to be encased in scar tissue and was deemed unsuitable as a conduit, and a saphenous vein graft was bypassed to the left anterior descending artery in its place. Pathologic review of the LIMA showed nests of tumor cells infiltrating within dense fibrous tissue with areas of necrosis and calcifications consistent with recurrent breast cancer. Interestingly the patients original breast cancer was positive for estrogen receptors (ER) and progesterone receptors (PR) ER and PR and negative for HER2 and she had therefore been treated with 5 years of hormonal therapy. The recurrent cancer found in the LIMA dissection bed at the time of bypass surgery was ER, PR, and HER2 negative, suggesting hormonal therapy driven clonal selection of these metastatic tumor cells.Discussion and conclusionsScarring in the LIMA dissection bed in patients with a history of cancer and prior chest radiation should be carefully evaluated for the possibility of recurrent cancer. The gross appearance of tissue can be misleading and sending a biopsy for a formal frozen section histologic evaluation should be considered if there is any question of recurrent malignancy.

Through a multicenter study, we collected seven cases of gastric plexiform fibromyxoma including four females and three males, 21 to 79 y old (46.1 ± 10.1). All cases showed a unilocular lesion measuring 0.3 to 17 cm (5.3 ± 2.4), arising from antrum (5/7) or body (2/7). Six of the seven cases had intraoperative frozen sections and/or endoscopic ultrasound fine needle aspiration (EUS-FNA), and all of them were preoperatively or intraoperatively diagnosed as gastrointestinal stromal tumor (GIST). EUS-FNA material showed markedly elongated spindle cells with streaming oval to elongated nuclei with rounded ends. Histologically, the tumors exhibited a plexiform growth pattern and were composed of a rich myxoid stroma and cytologically bland uniform spindle cells without mitotic figures, with the exception of one case which displayed nuclear pleomorphism and increased mitosis. Immunostains showed the tumor cells to be focally positive for SMA (6/6), focally and weakly positive for desmin (3/6) and caldesmon (2/3), negative for CD117 (0/7), CD34 (0/7), DOG1 (0/4), and S100 (0/5). No mutations were identified on Next-Generation Sequencing test, and no loss of SDHB immunoreactivity was identified in the tumor with nuclear pleomorphism. One case was treated with Gleevec because of the initial diagnosis of GIST. All patients had a follow-up for up to 11 y, with no tumor recurrence or metastasis reported. Our results suggest that gastric plexiform fibromyxoma is rare and may be underrecognized and misinterpreted as GIST during intraoperative frozen section or preoperative EUS-FNA diagnosis without immunostains leading to inappropriate treatment.

BackgroundPreoperative breast and lung markers have significant drawbacks, including migration, patient discomfort, and scheduling difficulties. SignalMark is a novel localizer device with a unique signal on Doppler ultrasound.ObjectiveWe aimed to evaluate intraoperative identification of SignalMark microspheres compared with HydroMARK® clips. We also assessed the safety and efficacy of SignalMark in the lung.MethodsTwelve breasts of lactating pigs were injected with SignalMark or HydroMARK® by a breast radiologist, and subsequently identified using a standard ultrasound machine by three surgeons blinded to marker location. Time to identification of each marker was recorded, with a maximum allotted time of 300 s. To further demonstrate efficacy in lung parenchyma, a second cohort of pigs underwent lung injections.ResultsA total of eight SignalMark markers and four HydroMARK® clips were placed in pig breasts. Overall, the surgeons correctly identified SignalMark 95.8% of the time (n = 23/24) and HydroMARK® clips 41.7% of the time (n = 5/12) within 300 s (p

Background: Peritoneal carcinomatosis in ovarian cancer is frequent and generally associated with higher stage and poorer outcome. The clinical features of peritoneal carcinomatosis are diverse and their relevance for surgical and long-term outcome remains unclear. We conducted this prospective study to describe intraoperatively the different features of peritoneal carcinomatosis(PC) and correlate them with clinicopathological features, progression-free(PFS) and overall survival (OS),. Methods: We performed a systematic analysis of all patients with documented intraoperative PC and a primary diagnosis of epithelial ovarian, tubal, or peritoneal cancer from January 2001 to September 2018. All data were evaluated by using the systematic tumor bank tool. Specific PC features included texture(soft-hard), consistency(coarse-fine or both), wet vs dry(PC with ascites vs. PC without ascites), and localization(diffuse-local). PC characteristics were then evaluated for correlation with age, FIGO-stage, histology, lymph-node involvement, grade, and presence of residual tumor at primary surgery. Moreover, the influence of PC characteristics on OS and PFS was analyzed. Results: A total of 1686 patients with PC and primary epithelial ovarian cancer were included. Majority of the patients were characterized by diffuse PC(73.9%). The majority of peritoneal nodules were fine in texture (55.3%) and hard in consistency (87.4%). Moreover, 27.6% of patients had dry PC. Diffuse PC localization was significantly associated with higher FIGO-stage (p<0.001), high-grade (p=0.003) and serous tumors (p=0.006) as well as residual tumor as compared to local PC (p<0.001). Wet PC also significantly correlated with diffuse localization (p <0.001) and residual tumor as compared to dry PC (p<0.001). Coarse PC was significantly associated with residual tumor as compared to fine PC (p=0.044). All other PC features didn't correlate with clinicopathological features. As for survival outcomes, diffuse peritoneal localization (p<0.001), wet PC (p<0.001), and additional lymph node involvement (p<0.001) were associated with lower OS and PFS rates. Other PC features did not significantly impact survival. Conclusion: Diffuse localization of peritoneal carcinomatosis was significant predictor of recurrence. Lower OS and PFS were associated with diffuse peritoneal localization, wet PC, and additional lymph node involvement. Further prospective trials are warranted with the inclusion of translational research aspects to better understand the different peritoneal carcinomatosis patterns. [ABSTRACT FROM AUTHOR]

A high-flow nasal cannula is commonly used to manage hypoxic respiratory failure. High-flow nasal cannula not only reduces respiratory effort and work of breathing but also provides better patient comfort. It lowers mortality compared to standard oxygen therapy or non-invasive ventilation and is associated with more ventilator-free days. A 60-year-old female presented for the correction of ankle fracture with pneumonia and successfully underwent lower limb orthopaedic surgery under the subarachnoid block with the use of high-flow nasal oxygen therapy. High-flow nasal cannula may be considered as one of the useful options for intraoperative management of pneumonia in patients undergoing lower limb surgery under regional anaesthesia. [ABSTRACT FROM AUTHOR]

Background and Aims: The effect of a single intraoperative dose of steroids on perioperative blood sugar levels is uncertain. We hypothesised that a single dose of dexamethasone would not unfavourably alter the glucose levels of non-diabetic patients. This study aimed to evaluate the post-operative glycaemic profile after a single dose of intraoperative dexamethasone in non-diabetic patients. The presence of post-operative nausea and vomiting (PONV), pain, surgical site infection (SSI) and length of hospital stay were also evaluated. Methods: This randomised, double-blind, controlled study was done by recruiting 150 non-diabetic adult patients of the American Society of Anesthesiologists physical status I/II undergoing elective surgery. Patients in the study group were administered a single dose of dexamethasone (0.15 mg/kg). Blood glucose levels were assessed at various time points for up to 72 hours post-operatively using point-of-care testing. Secondary outcomes such as PONV, pain, fever and SSI were also documented. Data were compared and analysed using Student's t-test, Chi-square test, Mann-Whitney test and analysis of variance test. Results: There was an earlier, higher and prolonged elevation in blood glucose levels in patients receiving dexamethasone. The mean (standard deviation) of fasting/postprandial blood sugars on the first, second and third postoperative days respectively was significantly higher in the study group 98.04 (21.89)/139.16 (20.59), 96.64 (19.20)/138.17 (18.05), 96.60 (17.40)/138.32 (15.10) mg/dl as compared to control group 86.9 6 (10.28)/128.95 (10.53), 88.81 (8.87)/131.97 (9.68), 88.16 (8.50)/130.88 (9.48) mg/dl. About 10.7% of the patients who received dexamethasone had blood glucose levels greater than 180 mg/dl. There were no significant differences in the secondary outcomes. Conclusion: Even a single dose of dexamethasone in non-diabetic adults causes significant and prolonged postoperative hyperglycaemia. [ABSTRACT FROM AUTHOR]

This study aimed to determine the risk and development of pressure ulcers in operating rooms. The sample of the study included a total of 250 patients. In the study, the risk of pressure ulcers was assessed before the operation, and the development of pressure ulcers was evaluated within 24 h after the operation. The risk of pressure ulcers was low before the operation, and Stage I pressure ulcer developed in 12.8% of the patients within 24 h after the operation. The patients had pressure ulcers mostly in their sacrum. Their mean 3S Intraoperative Risk Assessment Scale of Pressure Sore score was 15.68 ± 4.84, suggesting that they were not at risk of developing pressure ulcers. Having a chronic disease (OR = 8.986; 95% CI = 3.697–21.845), undergoing general anesthesia (OR = 3.084; 95% CI = 1.323–7.194), and orthopedic surgery (OR = 10.172; 95% CI = 3.121–33.155) were statistically significant risk factors for pressure ulcers (p < 0.001). Additionally, moderately edematous skin (OR = 3.838; 95% CI = 1.024–14.386), overweight/underweight (OR = 16.333; 95% CI = 3.779–70.602), intraoperative bleeding greater than 800 ml (OR = 13.000; 95% CI = 3.451–48.969), operation time longer than 5 h (OR = 21.667; 95% CI = 2.122–221.223), moderate intraoperative stress (OR = 4.917; 95% CI = 0.425–56.916), body temperature higher than 38.3 °C or lower than 36.1 °C (OR = 5.462; 95% CI = 2.161–13.805), and intraoperative prone position (OR = 3.354; 95% CI = 1.386–8.115) were statistically significant risk factors for the development of pressure ulcers. According to our preoperative pressure ulcer risk assessment, it is very important to take additional protective measures both during and after surgical operations to prevent pressure ulcers. • The risk of pressure ulcers was low before the operation, and Stage 1 pressure ulcer developed in 12.8% of the patients within 24 h after the operation. • Chronic disease, general anesthesia, type of surgical intervention were statistically significant risk factors for pressure ulcers. • It is very important to take additional protective measures both during and after surgical operations to prevent pressure ulcers. [ABSTRACT FROM AUTHOR]

Aims This study aimed to describe a new method of plastic surgery for deformities of the cranial vault. The focus of the study was an analysis of the results of conventional and developed by authors techniques for the plastic surgery of post-burn scars and defects of the cranial vault. Material & Methods The patients were divided into two groups: the main group, which used the newly developed method of plastic surgery (n=36), and the compared group - the conventional method of local plastic surgery (n=33). The investigation presented the surgical technique using a clinical case study. Findings The authors developed a technique, which includes intraoperative balloon dermotension of the tissues surrounding the defect and an improved method of wound closure ("figure-of-eight suture"). Conclusion The advantages of the new technique are the relative simplicity of the procedure, the option of using local anesthesia, a low rate of postoperative complications, and a short postoperative period. In addition, the method used allows for good aesthetic results in the long term. [ABSTRACT FROM AUTHOR]

Background and Aims: The effect of a single intraoperative dose of steroids on perioperative blood sugar levels is uncertain. We hypothesised that a single dose of dexamethasone would not unfavourably alter the glucose levels of non-diabetic patients. This study aimed to evaluate the post-operative glycaemic profile after a single dose of intraoperative dexamethasone in non-diabetic patients. The presence of post-operative nausea and vomiting (PONV), pain, surgical site infection (SSI) and length of hospital stay were also evaluated. Methods: This randomised, double-blind, controlled study was done by recruiting 150 non-diabetic adult patients of the American Society of Anesthesiologists physical status I/II undergoing elective surgery. Patients in the study group were administered a single dose of dexamethasone (0.15 mg/kg). Blood glucose levels were assessed at various time points for up to 72 hours post-operatively using point-of-care testing. Secondary outcomes such as PONV, pain, fever and SSI were also documented. Data were compared and analysed using Student's t-test, Chi-square test, Mann-Whitney test and analysis of variance test. Results: There was an earlier, higher and prolonged elevation in blood glucose levels in patients receiving dexamethasone. The mean (standard deviation) of fasting/postprandial blood sugars on the first, second and third postoperative days respectively was significantly higher in the study group 98.04 (21.89)/139.16 (20.59), 96.64 (19.20)/138.17 (18.05), 96.60 (17.40)/138.32 (15.10) mg/dl as compared to control group 86.9 6 (10.28)/128.95 (10.53), 88.81 (8.87)/131.97 (9.68), 88.16 (8.50)/130.88 (9.48) mg/dl. About 10.7% of the patients who received dexamethasone had blood glucose levels greater than 180 mg/dl. There were no significant differences in the secondary outcomes. Conclusion: Even a single dose of dexamethasone in non-diabetic adults causes significant and prolonged postoperative hyperglycaemia.

Background/Aim. Cephalomedullary and extramedullary methods are used for the internal fixation of trochanteric fractures. The usage of the third generation Gamma Nail (GN) is a gold standard in this kind of treatments. Self-dynamisable Internal Fixator (SIF) is an extramedullary implant for trochanteric fractures’ treatment. The aim of this study was to compare these two methods regarding operation time and intraoperative fluoroscopy time. Methods. A total of 89 patients with a surgical treatment of a trochanteric fracture were included in this study. There were two groups of patients – GN group (43 patients) and SIF group (46 patients). Results. Average operation times were 67.5 min (GN group) and 56.0 min (SIF group). Average intraoperative fluoroscopy times were 84.8 s (GN group) and 36.7 s (SIF group). The difference between the groups was statistically significant for both of the given parameters (p < 0.05). The correlation between operation time and intraoperative fluoroscopy time was confirmed in the SIF group (p < 0.05; r = 0.405), while it was not confirmed in the GN group (p > 0.05). There was a higher variability in the GN method than in the SIF method regarding the duration and type of repeated surgical maneuvers followed by X-ray checks. Conclusion. The number of planned surgical interventions per day could depend on the type of trochanteric fracture internal fixation (intramedullary or extramedullary). Certain additional analyses including radiation dose assessment are desirable to clarify if shorter intraoperative fluoroscopy time in the SIF method can have the influence regarding intraoperative X-ray protection clothing. If there is the need to activate dynamization in long femoral axis after initial static fixation in that axis, the SIF method provides its spontaneous activation several weeks after the surgery without the need neither for additional surgery nor for additional intraoperative fluoroscopy

Background: Fluid administration in children undergoing surgery requires precision, however, determining fluid responsiveness can be challenging. Ultrasound has been used widely in the emergency department and intensive care units as a noninvasive, bedside manner of determining volume status, but the intraoperative period presents unique challenges as often the chest and abdomen are inaccessible for ultrasound. We investigate whether carotid artery ultrasound, specifically carotid flow time, can be used to determine fluid responsiveness in children under general anesthesia. Methods: Prospective observational study of 87 children ages 1–12 years who were scheduled for elective noncardiac surgery. Ultrasound of the carotid artery and heart was performed at three time points: (1) after inhalational induction of anesthesia with the subject spontaneously breathing, (2) during positive pressure ventilation through endotracheal tube or supraglottic airway with tidal volume set at 8 ml/kg with PEEP of 10 cmH2O, and (3) after a 10 ml/kg fluid bolus. Carotid flow time and cardiac output were measured from saved images. Results: Corrected carotid flow time (FTc) increased with initiation of positive pressure ventilation in both fluid responders and nonresponders (352.7 vs. 365.3 msec, p =.005 in fluid responders; 348.3 vs. 365.2 msec, p =.001 in nonresponders). FTc increased after fluid bolus in both responders and nonresponders (365.3 vs. 397.6 msec, p <.001 in fluid responders; 365.2 vs. 397.2 msec, p <.001 in nonresponders). However, baseline FTc during spontaneous ventilation or positive pressure ventilation prior to fluid bolus was not associated with fluid responsiveness. Discussion: Flow time increases with initiation of positive pressure ventilation and after administration of a fluid bolus. FTc may serve as an indicator of fluid status but does not predict fluid responsiveness in children under general anesthesia. [ABSTRACT FROM AUTHOR]

TOPIC: To assess the role and utility of intraoperative optical coherence tomography (iOCT) guidance during pars plana vitrectomy with chorioretinal biopsy for patients with suspicious chorioretinal lesions. CLINICAL RELEVANCE: Chorioretinal lesions suspicious for malignancy sometimes require surgical biopsy for diagnosis and treatment guidance. Biopsy site selection is currently guided by presurgical imaging, and clinical assessment. We sought to determine whether iOCT provides useful information for biopsy site selection to ensure a diagnostic specimen and assessment of wound repair after biopsy. MATERIALS AND METHODS: DISCOVER is a prospective study examining microscope-integrated iOCT systems in ophthalmic surgery. In this report, we examine all eyes in the DISCOVER study that underwent chorioretinal biopsy. Clinical characteristics, surgical technique, and imaging findings were reviewed. In addition, surgeon feedback data on iOCT utility and value to the procedure was also evaluated. RESULTS: Six eyes were identified within the DISCOVER study that underwent chorioretinal biopsy. iOCT was used to assess retinal and choroidal lesions prior to chorioretinal incision. Following biopsy, iOCT was utilized to assess retinal attachment and wound margin integrity. Additionally, iOCT was performed in real-time during biopsy to ensure proper biopsy depth and position. In 2 cases, preoperative OCT evaluation of retinal lesions was not possible. Utilizing iOCT, comprehensive evaluation of anatomic features was successfully performed prior to biopsy. This facilitated identification of biopsy sites most likely to provide a diagnostic sample based on lesion morphology on iOCT. After completion of chorioretinal biopsy, iOCT verified completeness of biopsy site and the retinal-RPE relationship (e.g., complete apposition, partial detachment). CONCLUSION: Microscope-integrated iOCT provides real-time guidance of biopsy site selection and verification of biopsy site stability following specimen collection.

Competing Interests: Conflicts of interest None disclosed.

Background: Clinical prediction modeling plays a pivotal part in modern clinical care, particularly in predicting the risk of in-hospital mortality. Recent modeling efforts have focused on leveraging intraoperative data sources to improve model performance. However, the individual and collective benefit of pre- and intraoperative data for clinical decision-making remains unknown. We hypothesized that pre- and intraoperative predictors contribute equally to the net benefit in a decision curve analysis (DCA) of in-hospital mortality prediction models that include pre- and intraoperative predictors., Methods: Data from the VitalDB database featuring a subcohort of 6043 patients were used. A total of 141 predictors for in-hospital mortality were grouped into preoperative (demographics, intervention characteristics, and laboratory measurements) and intraoperative (laboratory and monitor data, drugs, and fluids) data. Prediction models using either preoperative, intraoperative, or all data were developed with multiple methods (logistic regression, neural network, random forest, gradient boosting machine, and a stacked learner). Predictive performance was evaluated by the area under the receiver-operating characteristic curve (AUROC) and under the precision-recall curve (AUPRC). Clinical utility was examined with a DCA in the predefined risk preference range (denoted by so-called treatment threshold probabilities) between 0% and 20%., Results: AUROC performance of the prediction models ranged from 0.53 to 0.78. AUPRC values ranged from 0.02 to 0.25 (compared to the incidence of 0.09 in our dataset) and high AUPRC values resulted from prediction models based on preoperative laboratory values. A DCA of pre- and intraoperative prediction models highlighted that preoperative data provide the largest overall benefit for decision-making, whereas intraoperative values provide only limited benefit for decision-making compared to preoperative data. While preoperative demographics, comorbidities, and surgery-related data provide the largest benefit for low treatment thresholds up to 5% to 10%, preoperative laboratory measurements become the dominant source for decision support for higher thresholds., Conclusions: When it comes to predicting in-hospital mortality and subsequent decision-making, preoperative demographics, comorbidities, and surgery-related data provide the largest benefit for clinicians with risk-averse preferences, whereas preoperative laboratory values provide the largest benefit for decision-makers with more moderate risk preferences. Our decision-analytic investigation of different predictor categories moves beyond the question of whether certain predictors provide a benefit in traditional performance metrics (eg, AUROC). It offers a nuanced perspective on for whom these predictors might be beneficial in clinical decision-making. Follow-up studies requiring larger datasets and dedicated deep-learning models to handle continuous intraoperative data are essential to examine the robustness of our results., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 International Anesthesia Research Society.)

Background: Thyroid cancer is a common thyroid malignancy. The majority of thyroid lesion needs intraoperative frozen pathology diagnosis, which provides important information for precision operation. As digital whole slide images (WSIs) develop, deep learning methods for histopathological classification of the thyroid gland (paraffin sections) have achieved outstanding results. Our current study is to clarify whether deep learning assists pathology diagnosis for intraoperative frozen thyroid lesions or not., Methods: We propose an artificial intelligence-assisted diagnostic system for frozen thyroid lesions that applies prior knowledge in tandem with a dichotomous judgment of whether the lesion is cancerous or not and a quadratic judgment of the type of cancerous lesion to categorize the frozen thyroid lesions into five categories: papillary thyroid carcinoma, medullary thyroid carcinoma, anaplastic thyroid carcinoma, follicular thyroid tumor, and non-cancerous lesion. We obtained 4409 frozen digital pathology sections (WSI) of thyroid from the First Affiliated Hospital of Sun Yat-sen University (SYSUFH) to train and test the model, and the performance was validated by a six-fold cross validation, 101 papillary microcarcinoma sections of thyroid were used to validate the system's sensitivity, and 1388 WSIs of thyroid were used for the evaluation of the external dataset. The deep learning models were compared in terms of several metrics such as accuracy, F1 score, recall, precision and AUC (Area Under Curve)., Results: We developed the first deep learning-based frozen thyroid diagnostic classifier for histopathological WSI classification of papillary carcinoma, medullary carcinoma, follicular tumor, anaplastic carcinoma, and non-carcinoma lesion. On test slides, the system had an accuracy of 0.9459, a precision of 0.9475, and an AUC of 0.9955. In the papillary carcinoma test slides, the system was able to accurately predict even lesions as small as 2 mm in diameter. Tested with the acceleration component, the cut processing can be performed in 346.12 s and the visual inference prediction results can be obtained in 98.61 s, thus meeting the time requirements for intraoperative diagnosis. Our study employs a deep learning approach for high-precision classification of intraoperative frozen thyroid lesion distribution in the clinical setting, which has potential clinical implications for assisting pathologists and precision surgery of thyroid lesions., (© 2024. The Author(s).)

With the development of chest CT screening, surgically resected lung tumors have shifted from predominantly large masses to predominantly small nodules. The intraoperative frozen diagnosis of pulmonary small nodules faces many challenges, such as the accurate understanding about the concepts of adenocarcinoma in situ, minimally invasive adenocarcinoma and lepidic adenocarcinoma, as well as their differential diagnosis with small size invasive adenocarcinoma, benign tumors (such as bronchiolar adenoma, sclerosing pneumocytoma, etc.), metastatic tumors and so on. This study summarizes some common problems encountered in the intraoperative frozen diagnosis of small pulmonary nodules in daily practice, focusing on the diagnosis and differential diagnosis of adenocarcinoma, in order to make the accurate intraoperative frozen diagnosis of small pulmonary nodules and diminish misdiagnosis.

Objectives: To evaluate the feasibility of intraoperative transurethral contrast-enhanced ultrasound for the assessment of male urethral fistulas., Methods: Patients in a prospective database who underwent intraoperative two-dimensional ultrasound, transurethral saline-enhanced ultrasound, and contrast-enhanced ultrasound between January 2017 and July 2022 were included. All patients were clinically diagnosed with urethral fistulae (UF) in the outpatient setting based on clinical presentations, traditional two-dimensional ultrasound, and/or other imaging modalities and confirmed during surgical repair. Dynamic videos of the scans were independently analyzed by two experienced ultrasonologists., Results: Thirty-nine patients with an average age of 51 years were included. The UF were located in the anterior urethra in 22 (56.4%) patients and in the bulbar urethra in 14 (63.6%) patients. UF were located in the posterior urethra in 17 (436%) patients and in the prostatic urethra in 13 (76.5%) patients. Contrast-enhanced ultrasonography revealed UF in all patients. In patients with anterior UF, saline-enhanced ultrasound images did not show a UF in 15 (68.2%, 15/22) patients, 13 (86.7%, 13/15) of whom had fistulae with diameters <3 mm. Saline-enhanced ultrasound images did not reveal posterior UF in 13 (76.5%, 13/17) patients. The fistula diameters in eight (61.5%, 8/13) patients were <3 mm. The duration for contrast-enhanced ultrasonography was approximately 3 minutes. The duration for surgical repair was approximately 2 hours., Conclusions: Transurethral contrast-enhanced ultrasound is a real-time, noninvasive, and radiation-free method that allows intraoperative imaging and accurate assessment of male UF. Its sensitivity is higher than that of both two-dimensional ultrasound and transurethral saline-enhanced ultrasound. The location, size, and course of the fistulae can be clearly seen due to greater contrast during contrast-enhanced ultrasound., (© 2024 American Institute of Ultrasound in Medicine.)

Purpose: This study aimed to analyze variations in intraoperative corneal thickness during corneal cross-linking in patients with keratoconus and to investigate its possible correlation with presurgical maximal keratometry (Kmax) and pachymetry., Methods: This was a prospective case series. We used a method similar to the Dresden protocol, with the application of hydroxypropyl methylcellulose 0.1% hypo-osmolar riboflavin in corneas between 330 and 400 µm after epithelium removal. Corneal thickness was measured using portable calipers before and immediately after epithelium removal, and 30 and 60 min after the procedure., Results: The 30 patients in this study were followed up for one year. A statistically significant difference was observed in pachymetry values during the intraoperative period (p<0.0001) and an increase of 3.05 µm (95%C1: 0.56-5.54) for each diopter was seen after epithelium removal (p0.019). We found an average Kmax difference of -2.12 D between men and women (p0.013). One year after treatment, there was a statistically significant reduction in pachymetry (p<0.0001) and Kmax (p0.0170) values., Conclusions: A significant increase in pachymetry measurements was seen during the procedure, and most patients showed a regression in Kmax and pachymetry values one year after surgery.

Purpose: To analyze the image quality of a novel, state-of-the art platform for CBCT image-guided spine surgery, focusing particularly on the dose-effectiveness compared with conventional CT (the gold standard for postoperative assessment)., Methods: The ClarifEye platform (Philips Healthcare) with integrated augmented-reality surgical navigation, has been compared with a GE Revolution CT (GE Healthcare). The 3D spatial resolution (TTF) and noise (NPS) were evaluated considering relevant feature contrasts (200-900 HU) and background noise for differently sized patients (200-300 mm water-equivalent diameter). These measures were used to determine the noise equivalent quanta (NEQ) and observer model detectability., Results: The CBCT system exhibited a linear response with 50% TTF at 5.7 cycles/cm (10% TTF at 9.2 cycles/cm), and the axial noise power peaking at about 3.6 cycles/cm (average frequency of 4.1 cycles/cm). The noise magnitude and texture differed markedly compared to iteratively reconstructed CT images (GE ASiR-V). The CBCT system had 26% lower detectability for a high-frequency task (related to edge detection) compared with CT images reconstructed using the Bone kernel combined with ASiR-V 50%. Likewise, it had 18% lower detectability for low- and mid-frequency tasks compared with CT images reconstructed using the Standard kernel. This difference translates to 50%-80% higher CBCT imaging doses required to match the CT image quality., Conclusions: The ClarifEye platform demonstrates intraoperative CBCT-imaging capabilities that under certain circumstances are comparable with conventional CT. However, due to limited dose-effectiveness, a trade-off between timeliness and radiation exposure must be considered if end-of-procedure CBCT is to replace postoperative CT., 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 Associazione Italiana di Fisica Medica e Sanitaria. Published by Elsevier Ltd. All rights reserved.)

Purpose: Prostate-specific membrane antigen (PSMA) is increasingly used to image prostate cancer in clinical practice. We sought to develop and test a humanised PSMA minibody IAB2M conjugated to the fluorophore IRDye 800CW-NHS ester in men undergoing robot-assisted laparoscopic radical prostatectomy (RARP) to image prostate cancer cells during surgery., Methods: The minibody was evaluated pre-clinically using PSMA positive/negative xenograft models, following which 23 men undergoing RARP between 2018 and 2020 received between 2.5 mg and 20 mg of IR800-IAB2M intravenously, at intervals between 24 h and 17 days prior to surgery. At every step of the procedure, the prostate, pelvic lymph node chains and extra-prostatic surrounding tissue were imaged with a dual Near-infrared (NIR) and white light optical platform for fluorescence in vivo and ex vivo. Histopathological evaluation of intraoperative and postoperative microscopic fluorescence imaging was undertaken for verification., Results: Twenty-three patients were evaluated to optimise both the dose of the reagent and the interval between injection and surgery and secure the best possible specificity of fluorescence images. Six cases are presented in detail as exemplars. Overall sensitivity and specificity in detecting non-lymph-node extra-prostatic cancer tissue were 100% and 65%, and 64% and 64% respectively for lymph node positivity. There were no side-effects associated with administration of the reagent., Conclusion: Intraoperative imaging of prostate cancer tissue is feasible and safe using IR800-IAB2M. Further evaluation is underway to assess the benefit of using the technique in improving completion of surgical excision during RARP., Registration: ISCRCTN10046036: https://www.isrctn.com/ISRCTN10046036 ., (© 2024. The Author(s).)

Background: Cerenkov luminescence imaging (CLI) is a new emerging technology that can be used for optical imaging of approved radiotracers, both in a preclinical, and even more recently, in a clinical context with rapid imaging times, low costs, and detection in real-time (Grootendorst et al. Clin Transl Imaging 4(5):353-66, 2016); Wang et al. Photonics 9(6):390, 2022). This brief review provides an overview of clinical applications of CLI with a focus on intraoperative margin assessment (IMA) to address shortcomings and provide insight for future work in this application., Methods: A literature review was performed using PubMed using the search words Cerenkov luminescence imaging (CLI), intraoperative margin assessment (IMA), and image-guided surgery. Articles were selected based on title, abstract, content, and application., Results: Original research was summarized to examine advantages and limitations of CLI compared to other modalities for IMA. The characteristics of Cerenkov luminescence (CL) are defined, and results from relevant clinical trials are discussed. Prospects of ongoing clinical trials are reviewed, along with technological advancements related to CLI., Conclusion: CLI is a proven method for molecular imaging and shows feasibility for determining intraoperative margins if future work involves establishing quantitative approaches for attenuation and scattering, depth analysis, and radiation safety for CLI at a larger scale., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Acute kidney injury (AKI) is a common complication after on-pump cardiac surgery, and previous studies have suggested that blood glucose is associated with postoperative AKI. However, limited evidence is available regarding intraoperative glycemic thresholds in cardiac surgery. The aim of this study was to explore the association between peak intraoperative blood glucose and postoperative AKI, and determine the cut-off values for intraoperative glucose concentration associated with an increased risk of AKI., Methods: The study was retrospective and single-centered. Adult patients in West China Hospital of Sichuan University who underwent on-pump cardiac surgery (n = 3375) were included. The primary outcome was the incidence of AKI. Multivariable logistic analysis using restricted cubic spline was performed to explore the association between intraoperative blood glucose and postoperative AKI., Results: The incidence of AKI in the study population was 18.0% (607 of 3375). Patients who developed AKI had a significantly higher peak intraoperative glucose during the surgery compared to those without AKI. After adjustment for confounders, the incidence of AKI increased with peak intraoperative blood glucose (adjusted odds ratio, 1.08, 95% confidence interval 1.03, 1.12). Furthermore, it was demonstrated that the possibility of AKI was relatively flat till 127.8 mg/dL (7.1 mmol/L) glucose levels which started to rapidly increase afterward., Conclusions: Increased intraoperative blood glucose was associated with an increased risk of AKI. Among patients undergoing on-pump cardiac surgery, avoiding a high glucose peak (i.e., below 127.8 mg/dL [7.1 mmol/L]) may reduce the risk of postoperative AKI., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: There are a wide variety of intraoperative techniques available in breast surgery to achieve low rates for positive margins of excision. The objective of this systematic review was to determine the pooled diagnostic accuracy of intraoperative breast margin assessment techniques that have been evaluated in clinical practice., Methods: This study was performed in accordance with PRISMA guidelines. A systematic search of the literature was conducted to identify studies assessing the diagnostic accuracy of intraoperative margin assessment techniques. Only clinical studies with raw diagnostic accuracy data as compared with final permanent section histopathology were included in the meta-analysis. A bivariate model for diagnostic meta-analysis was used to determine overall pooled sensitivity and specificity., Results: Sixty-one studies were eligible for inclusion in this systematic review and meta-analysis. Cytology demonstrated the best diagnostic accuracy, with pooled sensitivity of 0.92 (95 % CI 0.77-0.98) and a pooled specificity of 0.95 (95 % CI 0.90-0.97). The findings also indicate good diagnostic accuracy for optical spectroscopy, with a pooled sensitivity of 0.86 (95 % CI 0.76-0.93) and a pooled specificity of 0.92 (95 % CI 0.82-0.97)., Conclusion: Pooled data indicate that optical spectroscopy, cytology and frozen section have the greatest diagnostic accuracy of currently available intraoperative margin assessment techniques. However, long turnaround time for results and their resource intensive nature has prevented widespread adoption of these methods. The aim of emerging technologies is to compete with the diagnostic accuracy of these established techniques, while improving speed and usability., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to declare., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Colorectal cancer remains a major cause of cancer death and morbidity worldwide. Surgery is a major treatment modality for primary and, increasingly, secondary curative therapy. However, with more patients being diagnosed with early stage and premalignant disease manifesting as large polyps, greater accuracy in diagnostic and therapeutic precision is needed right from the time of first endoscopic encounter. Rapid advancements in the field of artificial intelligence (AI), coupled with widespread availability of near infrared imaging (currently based around indocyanine green (ICG)) can enable colonoscopic tissue classification and prognostic stratification for significant polyps, in a similar manner to contemporary dynamic radiological perfusion imaging but with the advantage of being able to do so directly within interventional procedural time frames. It can provide an explainable method for immediate digital biopsies that could guide or even replace traditional forceps biopsies and provide guidance re margins (both areas where current practice is only approximately 80% accurate prior to definitive excision). Here, we discuss the concept and practice of AI enhanced ICG perfusion analysis for rectal cancer surgery while highlighting recent and essential near-future advancements. These include breakthrough developments in computer vision and time series analysis that allow for real-time quantification and classification of fluorescent perfusion signals of rectal cancer tissue intraoperatively that accurately distinguish between normal, benign, and malignant tissues in situ endoscopically, which are now undergoing international prospective validation (the Horizon Europe CLASSICA study). Next stage advancements may include detailed digital characterisation of small rectal malignancy based on intraoperative assessment of specific intratumoral fluorescent signal pattern. This could include T staging and intratumoral molecular process profiling (e.g. regarding angiogenesis, differentiation, inflammatory component, and tumour to stroma ratio) with the potential to accurately predict the microscopic local response to nonsurgical treatment enabling personalised therapy via decision support tools. Such advancements are also applicable to the next generation fluorophores and imaging agents currently emerging from clinical trials. In addition, by providing an understandable, applicable method for detailed tissue characterisation visually, such technology paves the way for acceptance of other AI methodology during surgery including, potentially, deep learning methods based on whole screen/video detailing., (© 2024. The Author(s).)

Background: To date, the benefit of image guidance during robot-assisted surgery (IGS) is an object of debate. The current study aims to address the quality of the contemporary body of literature concerning IGS in robotic surgery throughout different surgical specialties., Methods: A systematic review of all English-language articles on IGS, from January 2013 to March 2023, was conducted using PubMed, Cochrane library's Central, EMBASE, MEDLINE, and Scopus databases. Comparative studies that tested performance of IGS vs control were included for the quantitative synthesis, which addressed outcomes analyzed in at least three studies: operative time, length of stay, blood loss, surgical margins, complications, number of nodal retrievals, metastatic nodes, ischemia time, and renal function loss. Bias-corrected ratio of means (ROM) and bias-corrected odds ratio (OR) compared continuous and dichotomous variables, respectively. Subgroup analyses according to guidance type (i.e., 3D virtual reality vs ultrasound vs near-infrared fluoresce) were performed., Results: Twenty-nine studies, based on 11 surgical procedures of three specialties (general surgery, gynecology, urology), were included in the quantitative synthesis. IGS was associated with 12% reduction in length of stay (ROM 0.88; p = 0.03) and 13% reduction in blood loss (ROM 0.87; p = 0.03) but did not affect operative time (ROM 1.00; p = 0.9), or complications (OR 0.93; p = 0.4). IGS was associated with an estimated 44% increase in mean number of removed nodes (ROM 1.44; p < 0.001), and a significantly higher rate of metastatic nodal disease (OR 1.82; p < 0.001), as well as a significantly lower rate of positive surgical margins (OR 0.62; p < 0.001). In nephron sparing surgery, IGS significantly decreased renal function loss (ROM 0.37; p = 0.002)., Conclusions: Robot-assisted surgery benefits from image guidance, especially in terms of pathologic outcomes, namely higher detection of metastatic nodes and lower surgical margins. Moreover, IGS enhances renal function preservation and lowers surgical blood loss., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Metastasectomy is a common treatment option for patients with colorectal lung metastases (CLM). Challenges exist with margin assessment and identification of small nodules, especially during minimally invasive surgery. Intraoperative fluorescence imaging has the potential to overcome these challenges. The aim of this study was to assess feasibility of targeting CLM with the carcinoembryonic antigen (CEA) specific fluorescent tracer SGM-101., Methods: This was a prospective, open-label feasibility study. The primary outcome was the number of CLM that showed a true positive fluorescence signal with SGM-101. Fluorescence positive signal was defined as a signal-to-background ratio (SBR) ≥ 1.5. A secondary endpoint was the CEA expression in the colorectal lung metastases, assessed with the immunohistochemistry, and scored by the total immunostaining score., Results: Thirteen patients were included in this study. Positive fluorescence signal with in vivo, back table, and closed-field bread loaf imaging was observed in 31%, 45%, and 94% of the tumors respectively. Median SBRs for the three imaging modalities were 1.00 (IQR: 1.00-1.53), 1.45 (IQR: 1.00-1.89), and 4.81 (IQR: 2.70-7.41). All tumor lesions had a maximum total immunostaining score for CEA expression of 12/12., Conclusion: This study demonstrated the potential of fluorescence imaging of CLM with SGM-101. CEA expression was observed in all tumors, and closed-field imaging showed excellent CEA specific targeting of the tracer to the tumor nodules. The full potential of SGM-101 for in vivo detection of the tracer can be achieved with improved minimal invasive imaging systems and optimal patient selection., Trial Registration: The study was registered in ClinicalTrial.gov under identifier NCT04737213 at February 2021., (© 2023. The Author(s).)

Background: The current expansion of image-guided surgery is closely related to the role played by radio-guided surgery in supporting the sentinel node (SN) procedure during more than three decades. The so-called triple approach (lymphoscintigraphy, gamma probe detection and blue dye) was not only essential in the seminal validation of the SN procedure but also a first collective learning effort based on skill transfer and outcome-related evaluation which laid the fundaments to delineate the field of intraoperative molecular imaging (IMI) based on a similar multimodality approach and multidisciplinary practice., Methods: These elements are also becoming valid in the current incorporation of SPECT/CT and PET/CT to existing and new protocols of IMI procedures and SN mapping concerning other clinical applications. On the other hand, there is a growing tendency to combine novel modern technologies in an allied role with gamma guidance in the operating room following the development of hybrid tracers and multimodal detection approaches. Against this background, learning initiatives are required for professionals working in this area., Results: This objective has led to a group of European practitioners with large experience in SN mapping and IMI applications to give shape to a programme made up out of specific learning modules aimed to be used as a conductive thread in peripherical or centralised training instances concerning the topic., Conclusion: The presented work, written as a tutorial review, is placed in an available prior-art context and is primarily aimed at medical and paramedical practitioners as well as at hardware and software developers., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)