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Background Cage subsidence (CS) was previously reported as one of the most common complications following oblique lumbar interbody fusion (OLIF). We aimed to assess the impacts of CS on surgical results following OLIF combined with anterolateral fixation, and determine its radiological characteristics as well as related risk factors. Methods Two hundred and forty-two patients who underwent OLIF at L4-5 and with a minimum 12 months follow-up were reviewed. Patients were divided into three groups according to the extent of disk height (DH) decrease during follow-up: no CS (DH decrease ≤ 2 mm), mild CS (2 mm < DH decrease ≤ 4 mm) and severe CS (DH decrease > 4 mm). The clinical and radiological results were compared between groups to evaluate radiological features, clinical effects and risk factors of CS. Results CS was identified in 79 (32.6%) patients, including 48 (19.8%) with mild CS and 31 (11.8%) with severe CS. CS was mainly identified within 1 month postoperatively, it did not progress after 3 months postoperatively, and more noted in the caudal endplate (44, 55.7%). In terms of clinical results, patients in the mild CS group were significantly worse than those in the no CS group, and patients in the severe CS group were significantly worse than those in the mild CS group. There was no significant difference in fusion rate between no CS (92.6%, 151/163) and mild CS (83.3%, 40/48) groups. However, significant lower fusion rate was observed in severe CS group (64.5%, 20/31) compared to no CS group. CS related risk factors included osteoporosis (OR = 5.976), DH overdistraction (OR = 1.175), flat disk space (OR = 3.309) and endplate injury (OR = 6.135). Conclusion CS following OLIF was an early postoperative complication. Higher magnitudes of CS were associated with worse clinical improvements and lower intervertebral fusion. Osteoporosis and endplate injury were significant risk factors for CS. Additionally, flat disk space and DH over-distraction were also correlated with an increased probability of CS.

Background The unilateral biportal endoscopic (UBE) technique is a minimally invasive procedure for spinal surgery, while open microscopic discectomy is the most common surgical treatment for ruptured or herniated discs of the lumbar spine. A new endoscopic technique that uses a UBE approach has been applied to conventional arthroscopic systems for the treatment of spinal disease. In this study, we aimed to compare and evaluate the perioperative parameters and clinical outcomes, including recovery from surgery, pain and life quality modification, patient’s satisfaction, and complications, between UBE and open lumbar microdiscectomy (OLM) for single-level discectomy procedures. Methods This study included 141 patients with degenerative disc disease requiring discectomy at a single level from L2–L3 to L5–S1. A total of 60 and 81 patients underwent UBE and OLM, respectively. Analysis was based on comparison of perioperative metrics, operation time (OT); estimated blood loss (EBL); length of hospital stay (HS); clinical outcomes, including assessment using the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI); patient satisfaction (the MacNab score); and the incidence of reoperation and complications. Results The study cohort was 56.7% women, and the mean patient age was 50.98 ± 18.23 years. The mean VAS (the back and leg), MacNab score, and ODI improved significantly from the preoperative period to the last follow-up (12.92 ± 3.92) in both groups ( p  < 0.001). One week after operation, the back VAS score in the UBE group showed significantly more improvement than that in the OLM group. However, the 1-week, 3-month, and 12-month VAS (the back and leg), ODI improvement, modified MacNab score, and OT were not significantly different between the two groups. In the UBE group, EBL (34.67 ± 16.92) was smaller and HS (2.77 ± 1.2) was shorter than that of the OLM group (140.05 ± 57.8, 6.37 ± 1.39). However, OT (70.15 ± 22.0) was longer in the UBE group than in the OLM group (60.38 ± 15.5), and the difference was statistically significant. Meanwhile, the differences in the rate of surgical conversion and complications between the two groups were not statistically significant. Conclusions The UBE for single-level discectomy yielded similar clinical outcomes to OLM, including pain control, functional disability, and patient satisfaction, but incurred minimal EBL, HS, and postoperative back pain. Trial registration Not applicable.

BackgroundPostoperative hypocalcemia is a common complication of thyroidectomy. This problem is most often associated with accidental devascularization or excision of the parathyroid glands (PG).AimAim was to study near-infrared (NIR) fluorescent imaging with intraoperative PG indocyanine green (ICG) angiography to help identify and preserve PG during total thyroidectomy in order to avoid postoperative hypocalcemia.Material and methodsFrom 2017 to 2022, a total of 92 patients underwent total thyroidectomy at Odessa Regional Hospital. Indications for surgery were multinodular goiter (n = 42), thyroid cancer (n = 43), and Graves’ disease (n = 7). By randomization all patients were divided into two groups: in the control group, 48 patients underwent standard total thyroidectomy, and in the main group, 44 patients underwent NIR-assisted total thyroidectomy with ICG angiography. Serum calcium and parathyroid hormone levels were compared between the two groups of patients in 1, 7–15 days after surgery and then 3, 6 months later.ResultsIn the control group, based on a visual assessment of the PG, autotransplantation of the PG was conducted in only five cases. In the second group, autotransplantation was performed in 16 patients. The transient postoperative hypocalcemia was observed in 8 patients of the control group (16, 70%) and in the 2 patients of ICG group (4, 50%) on 5–10 postoperative days. In the first group, 2 patients at 3 months after surgery had permanent hypocalcaemia.ConclusionNIR fluorescent imaging with intraoperative PG ICG angiography is a safe and an easily repeatable method. This technique provides improved detecting and assessment of the perfusion of the PG. The need for autotransplantation of the PG can be determined more objectively using ICG imaging than simple visualization.

Purpose It was our hypothesis that patient-specific instrumentation (PSI) can improve the accuracy of the rotational alignment in TKA based on the concept of the system and on the potential to clearly identify pre-operatively during planning the classical anatomical landmarks that serve as references to set-up the rotation both for the femur and tibia. Materials and methods In this prospective comparative randomized study, 40 patients (20 in each group) operated in our institution between September 2012 and January 2013 by the 2 senior authors were included. Randomization of patients into one of the two groups was done by the Hospital Informatics Department with the use of a systematic sampling method. All patients received the same cemented high-flex mobile bearing TKA. In the PSI group, implant position was compared to the planed position using previously validated dedicated software. The position of the implants (frontal and sagittal) was compared in the 2 groups on standard X-rays, and the rotational position was analysed on post-operative CT-scan. Results 90 % of the patients add <2° or mm of difference between the planned position of the implants and the obtained position, except for the tibial rotation where the variations were much higher. Mean HKA was 179° (171–185) in the PSI group with 4 outliers (2 varus: 171° and 172°:184° and 185°) and 178.3° with 2 outliers (171° and 176°) in the control group. No difference was observed between the two groups concerning the frontal and sagittal position of the implants on the ML and AP X-rays. No significant difference of femoral rotation was observed between the two groups with a mean of 0.4° in the PSI group and 0.2° in the control group ( p : n.s). Mean tibial rotation was 8° of internal rotation in the PSI group and 15° of internal rotation in the standard group ( p : n.s). Conclusion Based on our results, we were unable to confirm our hypothesis as PSI cannot improve rotation in TKA. More work needs to be done to more clearly define the place of PSI in TKA, to keep on improving the accuracy of the system and to better define the individual targets in TKA in terms of frontal, sagittal and rotational positioning of the implant for each patient. Level of evidence Prospective comparative randomized study, Level II.

Purpose This prospective, double-blind, randomised controlled trial was designed to address the following research questions: firstly, is there a significant difference in outliers in alignment in the frontal and sagittal plane between PSG TKA and conventional TKA. Secondly, is there a significant difference in operation time, blood loss and length of hospital stay between the two techniques. We hypothesise that there will be fewer outliers with PSG TKA and that operation time, blood loss and length of hospital stay can be significantly reduced with PSG. Methods A total of 180 patients were randomised for PSG TKA (group 1) or conventional TKA (group 2) in two centres. Patients were stratified per hospital. Alignment of the mechanical axis of the leg and flexion/extension and varus/valgus of the individual prosthesis components were measured on digital, standing, long-leg and standard lateral radiographs by two independent outcome assessors in both centres. Percentages of outliers (>3°) were determined. We compared blood loss, operation time and length of hospital stay. Results There was no statistically significant difference in mean mechanical axis or outliers in mechanical axis between groups. No statistically significant difference was found for the alignment of the individual components in the frontal plane nor for the percentages of outliers. There was a statistically significant difference in outliers for the femoral component in the sagittal plane, with a higher percentage of outliers in the group 1 ( p  = 0.017). No such significant result was found for the tibial component in that plane. All interclass correlation coefficients were good. Blood loss was 100 mL less in group 1 ( p  < 0.001). Operation time was 5 min shorter in group 1 ( p  < 0.001). Length of hospital stay was identical with a mean of 3.6 days ( p  = 0.657). Conclusions The results in terms of obtaining a neutral mechanical axis and a correct position of the prosthesis components did not differ between groups. A small reduction in operation time and blood loss was found with the PSG system. Future research should especially focus on cost-effectiveness analysis and functional outcome of PSG TKA. Level of evidence I.

Background Ventilator-induced lung injury caused by mechanical ventilation under general anesthesia as well as CO 2 pneumoperitoneum and special positions for laparoscopy may increase the risk of postoperative pulmonary complications (PPCs). Lung protective ventilation under general anesthesia is advised by the guidelines to lower the risk of PPCs in surgical patients. However, there is considerable controversy about the optimal level of positive end-expiratory pressure (PEEP) and how to set it. Driving pressure reflects the overall respiratory stress and high driving pressure is an independent risk factor for PPCs. The purpose of this study is to explore whether driving pressure-guided individualized PEEP ventilation can lower the incidence of postoperative atelectasis by improving respiratory mechanics during laparoscopic surgery consequently lowering the incidence of PPCs compared with the traditional fixed PEEP ventilation strategy. Methods The study will be a single-center, prospective, randomized controlled clinical study. A total of 106 adult patients with medium-to-high-risk PPCs undergoing laparoscopic surgery for more than 2 h will be randomly assigned in a 1:1 ratio to receive an individualized PEEP guided by minimum driving pressure (group D) or a fixed PEEP of 5 cmH 2 O (group C). Patients in group C will maintain a PEEP of 5 cmH 2 O throughout the whole process, and patients in group D will be administered individualized PEEP after the start of pneumoperitoneum to achieve minimum driving pressure until the end of the operation. The primary outcome is the LUS score at 24 h postoperatively. The secondary outcomes are the LUS scores at other time points, intraoperative respiratory mechanics and oxygenation index, incidence and specific types of PPCs at 7 days postoperatively. Discussion This study will better evaluate the effect of individualized PEEP application guided by driving pressure on the incidence of postoperative atelectasis based on ultrasound assessment consequently the incidence of PPCs in patients undergoing prolonged laparoscopic surgery. The results may provide a clinical evidence for optimizing perioperative lung protection strategies. Trial registration www.chictr.org.cn ChiCTR2300079041. Registered on December 25, 2023.

BACKGROUND AND OBJECTIVEHemidiaphragmatic paresis is common after supraclavicular brachial plexus block (SCBPB). In this randomized trial, we compared the incidence of hemidiaphragmatic paresis in patients who had local anesthetic injected primarily in the corner pocket (defined as the intersection of the first rib and subclavian artery) during SCBPB with that of patients who underwent injection primarily inside the neural cluster. METHODSThirty-six patients scheduled for right elbow, forearm, wrist, or hand surgery under SCBPB (using 12.5 mL of 0.75% ropivacaine and 12.5 mL of 2% lidocaine with 1:200,000 epinephrine) were randomly assigned to 1 of 2 groups. In group CP, local anesthetic was injected primarily in the corner pocket (20 mL) and secondarily inside the neural cluster (5 mL). In group NC, local anesthetic was deposited primarily inside the neural cluster (20 mL) and secondarily in the corner pocket (5 mL). The primary outcome was the incidence of hemidiaphragmatic paresis, as measured by M-mode ultrasonography 30 minutes after SCBPB. RESULTSThe incidence of hemidiaphragmatic paresis was significantly lower in group CP than in group NC (27.8% vs 66.7%, P = 0.019). The median decreases in forced expiratory volume at 1 second (7.5% [interquartile range, 3.3%–17.1%] vs 24.4% [interquartile range, 10.2%–31.2%]; P = 0.010) and forced vital capacity (6.4% [interquartile range, 3.3%–11.1%] vs 19.3% [interquartile range, 13.7%–33.2%]; P = 0.001) were also lower in group CP than in group NC. CONCLUSIONSThe incidence of hemidiaphragmatic paresis was effectively reduced when local anesthetic was injected primarily in the corner pocket during right-sided SCBPB. However, the 28% incidence of hemidiaphragmatic paresis associated with the corner pocket technique may still represent a prohibitive risk for patients with preexisting pulmonary compromise. CLINICAL TRIAL REGISTRATIONThis study was registered at Clinical Trial Registry of Korea, identifier KCT0001769.

IntroductionPostsurgical hypoparathyroidism (PoSH) is an iatrogenic condition that occurs as a complication of several different procedures with thyroid surgery being the most common. PoSH has significant short- and long-term morbidities. The volume of thyroid surgery is increasing, and PoSH is therefore likely to increase. Some studies have shown promising results using near-infrared fluorescence (NIRF) imaging in reducing the risk of PoSH which has the potential to significantly reduce morbidity and costs associated with monitoring and treatment.Methods and analysisNIFTy is an unblinded, parallel group, multicentre, seamless phase II/III randomised controlled trial in patients undergoing total or completion thyroidectomy. The trial incorporates a process evaluation (IDEAL (Idea, Development, Exploration, Assessment and Long-term follow-up framework) 2a) to inform the trial protocol, a phase II (IDEAL 2b) analysis using a surrogate primary outcome of 1 day transient hypocalcaemia to determine early futility and phase III (IDEAL 3) assessment of the primary outcome of PoSH at 6 months after surgery. 454 participants will be randomised on a 1:1 basis to evaluate thyroid surgery with NIRF and indocyanine green against standard thyroid surgery in reducing PoSH at 6 months after surgery, with the phase II analysis occurring once data are available for 200 participants. Analysis in both phases will be using multilevel logistic regression incorporating random effects with respect to surgeon and adjusting for minimisation factors. Phase III secondary outcomes include protracted hypoparathyroidism, hypercalcaemia, complications, length of stay, readmissions and patient reported quality of life using the Short Form 36 Health Survey Questionnaire and Hypoparathyroid Patient Questionnaire instruments.Ethics and disseminationNIFTy is funded by National Institute for Health and Care Research Efficacy and Mechanism Evaluation Programme (Grant Ref: 17/11/27) and approved by a Research Ethics Committee (reference: 21/WA/0375) and Health Research Authority (HRA). Trial results will be disseminated through conference presentations, peer-reviewed publication and through relevant patient groups.Trial registration numberISRCTN59074092.

Background. Symptomatic postoperative spinal epidural hematoma (PSEH) is a devastating complication that could develop after lumbar decompression surgery. PSEH can also develop after biportal endoscopic spine surgery (BESS), one of the recently introduced minimally invasive spine surgery techniques. Gelatin-thrombin matrix sealant (GTMS) is commonly used to prevent PSEH. This study aimed at analyzing the clinical and radiological effects of GTMS use during BESS. Methods. A total of 206 patients with spinal stenosis who underwent decompression by BESS through a posterior interlaminar approach from October 2015 to September 2018 were enrolled in this study. Postoperative magnetic resonance imaging (MRI) was performed in all patients for evaluation of PSEH. Patients in whom GTMS was not used during surgery were assigned to Group A, and those in whom GTMS was used were classified as Group B. In the clinical evaluation, the visual analog scale (VAS) of the leg and back, Oswestry Disability Index (ODI), and modified MacNab criteria were used. The incidence rate and degree of dural compression of PSEH on postoperative MRI were measured. Results. The average age of the patients was 68.1±11.2 (42–89) years. The overall incidence rate of PSEH was 20.9% (43/206). The incidence rates in Groups A and B were 26.4% and 13.6%, respectively, showing a significant difference (p=0.023). The VAS-leg and ODI improvement was significantly different depending on the intraoperative use of GTMS. However, there was no statistically significant difference between the two groups in terms of the VAS-back improvement. Groups A and B showed “good” and “excellent” rates according to the modified MacNab criteria in 79.4% and 87.6% of patients, respectively, showing statistically significant difference (p=0.049). In Group A, two patients underwent revision surgery due to PSEH, while none in Group B had such event. Conclusion. Intraoperative use of GTMS during BESS may be related to reduction in the occurrence rate of PSEH. Specifically, patients with GTMS appliance showed marked decrease in the occurrence of PSEH and had better clinical outcomes.

PurposeThe use of ursodeoxycholic acid (UDCA) to prevent gallstone formation after sleeve gastrectomy (SG) is still debated. Furthermore, no study has assessed the effectiveness of UDCA on gallstone formation after the first postoperative year. Our aim was to compare the incidence of cholelithiasis (CL) at 1 and 3 years after SG between patients treated or not treated with UDCA.Materials and MethodsFrom January 2008, a postoperative ultrasound monitoring was scheduled for all patients who underwent SG in our institution. Patients with a preoperative intact gallbladder who performed at least one ultrasound at 1 year after SG were included. We compared the incidence of CL between patients operated before October 2013 who did not receive UDCA and those operated from October 2013 who received UDCA 500 mg once daily for 6 months postoperatively.ResultsThe incidence of CL at 1 year after SG was 28% in the 46 non-treated and 3.5% in the 143 treated patients (p < 0.001). UDCA reduced the proportion of cholecystectomies from 11% to 1.4% (p = 0.012). Thus, the number of patients needed to treat to avoid a cholecystectomy was about 10. Only 2 patients (1.4%) stopped UDCA for adverse effects. No gallstone appeared at 3 postoperative years in the 61 patients who performed an ultrasound at this time.ConclusionUDCA 500 mg once daily for 6 months postoperatively is effective and well tolerated to prevent CL at midterm after SG. We recommend UDCA treatment in all patients after SG with an intact preoperative gallbladder. However, large randomized studies are needed to establish guidelines for prevention of gallstone formation after SG.