Surgeries, Volume 4, Issue 3 (September 2023) – 17 articles

Introduction: Patients receiving bariatric surgery are at risk for sleep apnea (OSA) and need extensive surveillance in the postoperative period. There is evidence of respiratory events (RE) several hours after leaving PACU. We analyzed the late onset of RE in patients recovering from bariatric surgery and their opiate requirements through the first night after surgery. Methods: We studied 52 patients with OSA and 38 non-OSA patients. Preoperative studies comprised meticulous OSA evaluation for all patients and computing the predictive score PRODIGY to stratify for the risk of RE. All patients received intraoperative multimodal non-opioid anesthesia. After PACU recovery, patients were admitted to a ward and continuously monitored for pulse oximetry, heart rate, and acoustic respiratory rate for up to 18 h using MASIMO RAD-97 and TRACE software (Masimo, USA). Results: All patients showed a progressing reduction in the frequency of RE after admission to the floor. Desaturations and bradypnea, however, increased significantly for a second peak between 14 and 16 h in the OSA group. The opiate doses administered to OSA and non-OSA patients were not different and remained low during the increases in RE. Discussion: After bariatric surgery, patients with OSA show significant late-desaturation and bradypnea events. Opiate administration cannot be invoked as the cause. Full article

The understanding of mediastinal anatomy represents a real challenge because of the vital structures inside it and due to its complex relationships with surrounding anatomical regions. Human anatomical specimens are always used both for the teaching of anatomy and the training of young surgeons, thus providing a deep understanding of the most complex anatomical regions and allowing less experienced surgeons to become familiar with surgical instruments and their use on actual human tissues. Despite the spread of these learning practices, there are no principles of dissection to follow for a young physician interested in the anatomy of the mediastinum. Therefore, the main objective of this study is to define a reliable and reproducible protocol for the dissection of the mediastinum. A stratigraphic anatomical dissection on three embalmed human specimens was performed. All steps were documented by high-quality photographs, taken with a professional digital reflex camera, and subsequently edited. A step-by-step anatomical dissection guide was created, detailing every phase, guiding the dissection of the mediastinal anatomy, and leading to the correct identification of its main anatomical structures. We present a step-by-step dissection guide to the mediastinal anatomy with point-by-point explanations and dedicated images, providing an additional tool for the comprehension of this complex anatomical area. Full article

The implementation of barbed sutures appears to enhance the process of suturing and knot tying, particularly in the field of bariatric surgery, where they can offer significant advantages. The objective of this study is to evaluate the safety and effectiveness of utilising barbed sutures for gastric pouch-jejunal anastomosis (GPJA) and jejuno-jejunal anastomosis (JJA) anastomosis in Roux-en-Y Gastric Bypass (RYGB). Data from patients who underwent primary RYGB between January 2012 and October 2018 were retrospectively collected using Propensity Score Matching (PSM) to randomise groups (barbed sutures—BS-G and conventional sutures—CS-G). The primary outcome was postoperative early complications. The secondary outcomes were late complications (internal hernias and small bowel obstructions), operative time and postoperative hospital stay. A total of 969 patients were included. After PSM, 322 (161 in BS-G vs. 161 in CS-G) patients were compared (chi-square 0.287, p = 0.862). Postoperative early and late complications were comparable between the two groups. BS-G had a significantly shorter median operative time (65 vs. 95 min p < 0.001). Median postoperative hospital stay was significantly shorter for BS-G (2 vs. 5 days, p < 0.001). Barbed sutures effectively reduce the operation duration and are as safe as conventional sutures for closing anastomotic defects during RYGB. Full article

Animals in the veterinary and experimental settings, including nonhuman primates (NHPs), often require repeated and prolonged vascular access for indications including blood sampling or administration of fluids, blood products, medication, or other therapies. A vascular access approach should be tailored to experimental or clinical use meeting the needs of the individual animal such that benefits outweigh risks. The optimal device and placement technique is based on the inherent advantages and disadvantages of specific anatomic sites and planned use. Totally implanted vascular access ports (VAPs) enable reliable central venous access for frequent sample collection and/or intravenous therapies. VAPs minimize discomfort with IV access to facilitate cooperation with handling and minimize stress-induced physiologic changes which can confound biologic data and drug responses. VAPs do not limit species-typical behavior and social group activities and are compatible with animal enrichment programs that include play and swim because there are no externalized components. VAPs are typically used long-term and demonstrate excellent durability with high patency and low complication rates over time, presenting a safe and dependable vascular access approach. Full article

Background: The aim of this study is to compare the mid-term outcomes of primary tear of the anterior cruciate ligament (ACL) reconstruction via the use of peroneus longus tendon (PLT) and bone–patellar tendon–bone (BPTB) autografts. Methods: 53 patients (group 1) received ACL reconstruction via BPTB, whereas 55 patients (group 2) received arthroscopic ACL reconstruction using PLT autograft. Results: In group 1, the mean preoperative and postoperative scores on the Lysholm Knee Questionnaire (LKQ) scale resulted in 69.2 ± 10.7 points and −92.2 ± 6.4 points, respectively. The average preoperative and postoperative value on the International Knee Documentation Committee (IKDC) scale was 68.2 ± 10.6% and −90.1 ± 9.5%, respectively. For KT-1000, according to the results of surgical treatment, it is −3.7 ± 1.4 mm, and for the American Orthopaedic Foot & Ankle Society (AOSAF) it is −95.3 ± 4.5%. The autograft ruptured within 2 years after operation in 4 of 50 patients. In group 2, the mean score on the LKQ scale before the operation was 70.2 ± 11.6 points, after −94.3 ± 0.5 points. The average value on the IKDC scale before surgery was 68.6 ± 8.7%, after −91.5 ± 8.2%. KT-1000 −3.4 ± 1.2 mm. Conclusion: The results in both groups can be assessed as good; peroneus longus muscle tendon autograft is an alternative graft for the primary reconstruction of ACL, preserving the dynamic stabilizers of the knee and has no effect on the formation of flat feet and other disease in the postoperative period. Full article

Background: The craniovertebral junction is a complex region, connecting the occiput, the atlas, the axis, and the containing vital neural and vascular structures. There is a great variability in diseases involving the craniovertebral junction, of different nature, each rare in frequency. Methods: We conducted a retrospective chart review of the patients diagnosed with extremely rare pathologies of the craniovertebral junction that we have operated in the last 5 years. Results: After excluding the relatively more frequent pathologies, we identified nine cases of rare craniovertebral junction pathologies. Six were operated using an endoscopic endonasal approach, two using a far lateral transcranial approach, and one underwent a C1 hemilaminectomy. Conclusions: Diagnosis and management of the rare pathologies of the craniovertebral junction are challenging. A multidisciplinary approach is recommended for the proper management of these patients. Full article

Smooth muscle tumors of unknown malignant potential (STUMP) represent a group of heterogeneous uterine neoplasms showing worrisome histological features, raising concerns for a malignant behavior, but do not satisfy the diagnostic criteria for leiomyosarcoma. The existing literature remains scarce due to its rarity; therefore, there is no consensus regarding diagnostic criteria, malignant potential, treatment of choice, and follow-up. The authors report their case series to analyze the heterogeneous features of this poorly understood neoplasm. A retrospective, monocentric cohort study of all patients who underwent surgery diagnosed with STUMP at the Garibaldi-Nesima Hospital in Catania from February 2018 to August 2021 was conducted. Each patient’s age at diagnosis, symptoms, surgical treatment, tumor features, postoperative management, and follow-up were recorded. Nine STUMP cases were included. All patients reported menometrorrhagia and pelvic pain. In all women, the tumor lesion was single and intramural, and the mean diameter was 7.5 cm. Four women underwent laparotomic conservative surgery. The mean postoperative follow-up time was 36 months, and recurrences were observed in two patients. In conclusion, STUMP cases should be systematically discussed by tumor boards, pathologists with good expertise in gynecological diseases should examine the histological samples, and close surveillance is mandatory because of the possibility of recurrence or metastasis. Full article

The 38th Annual Meeting of the Academy of Surgical Research took place in La Jolla, CA, USA, on 14–16 September 2022. For more than 40 years, the Academy has promoted the advancement of professional and academic standards in education and research in the arts and sciences of experimental surgery. The diverse membership includes technicians, veterinarians, medical doctors, and biomedical researchers from industry, academia, and complementary disciplines supporting discovery and translational research. At the annual meeting, this experimental surgery community shared the latest in research and surgical techniques, along with professional development that included cutting-edge lectures, hands-on training, and qualification exams for certifications. Over 130 participants from 26 different states and 3 countries were in attendance for the scientific program and social events. Two scientific tracks featuring three keynotes were presented together with a poster session. Participants could practice hands-on surgical techniques in dry and wet labs that ranged from applied surgical anesthesia to minimally invasive surgical skills, followed by in-depth discussion roundtables focused on improving study design and best practices in anesthesia and analgesia. The social program provided participants the opportunity to connect in person with potential mentors and collaborators. We present the highlights from this meeting in this report, together with selected abstracts that illustrate the diverse scientific expertise of the Academy and promising new surgical research. Full article

The expected rate and timing of return to work (RTW) following hip arthroscopy is an important consideration for patients. The purpose of this study was to evaluate the rates of RTW following hip arthroscopy, the time required to RTW, and factors correlated with successful RTW. A retrospective review was performed of patients who underwent hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) from 2018–2021. Data were collected regarding pre-injury employment, work activity level, workers’ compensation (WC) status, ability to return to work, the pre- and postoperative pain visual analog score (VAS), and the Nonarthritic Hip Score (NAHS). Overall, 76 patients (90.5%) returned to their pre-surgical occupation at an average of 9.3 weeks (range: 0.14–56 weeks) postoperatively. Of those who returned, 62 patients (81.6%) returned to full work duties. The NAHSs improved significantly from the preoperative period to follow-up at 1 year (64.7 vs. 83.7, p < 0.001). A linear regression found elevated BMI to be associated with an increased time to return (β = 0.757, p = 0.012). On average, patients with WC status returned to work 9 weeks later than non-WC patients, though this difference did not reach statistical significance (18.4 vs. 9.9 weeks, p = 0.130). There is a high rate of return to full work duties at an average of 9.3 weeks following hip arthroscopy for FAIS. Full article

Angiosarcoma is a rare and aggressive neoplasia of endothelial cells which represents only 2% of all soft-tissue tumors and frequently occurs in the skin and subcutaneous tissues. It is classified in two groups: the first is represented by primary angiosarcoma, which includes cutaneous and breast angiosarcoma; the second is constituted by secondary angiosarcoma, which is related to radiation therapy, lymphedema, exposure to some chemical toxins, and familiar syndromes. Post-radiation intestinal angiosarcoma is a special type of secondary angiosarcoma, and only a few cases have been reported in the literature. We present a case of radiation-induced small bowel angiosarcoma in an 88-year-old female patient who was admitted to our department for abdominal pain and signs of intestinal obstruction. Her clinical history included previous radiotherapy treatments after a hysterectomy for uterine fibroids, excision of the vaginal stump for squamous cell carcinoma, and the surgical removal of a left-leg cutaneous angiosarcoma. She underwent emergency surgery, and features of peritoneal carcinomatosis were detected. A histological examination showed the presence of a small intestinal angiosarcoma. At the histochemical analysis, MYC amplification was detected, suggesting that her small bowel angiosarcoma was related to past radiation treatments. Full article

Understanding the optimal time, length, intensity, and type of exercise program for bariatric surgery patients is crucial due to increased obesity prevalence and the number of performed bariatric procedures. Our aim for this review is to identify the effects of exercise on all aspects of health regarding the most recent and randomized studies. A total of 120 articles were reviewed through PubMed. As a result of the research, 11 studies that met the inclusion criteria were included. A quality analysis and a risk of bias assessment of the trials included in this systematic review were performed using the Physiotherapy Evidence Database (PEDro) scoring and classification system. Narrative syntheses were given for this systematic review. The articles’ intervention description, outcomes, and results are given in detail in the Results Section. Most exercise interventions were carried out in the post-op stage in bariatric surgery patients. Only two studies were conducted before the scheduled procedure. Overall, aerobic training (AT) and resistance training (RT) combined exercise programs effectively improved clinical parameters, including cardiac function, lower extremity function, muscle strength and endurance, cardiovascular parameters, and functionality. Exercise training caused no additional effects on inflammation and endothelial dysfunction biomarkers. In the literature, no research identifies the effects of only AT on bariatric surgery patients. Therefore, this aspect should be considered when interpreting all the studies’ results. In conclusion, there is a need for research to examine only AT in bariatric surgery patients and for general exercise training studies, including better randomization and quality. Full article

Mixed reality (MR) platforms for neurosurgical education, training, and clinical use have gained popularity in recent years. However, their use in pediatric neurosurgery is comparatively unexplored. We designed a study to explore the use of an MR-based application for pediatric brain tumors. The primary aim is to determine if the use of MR provides the neurosurgical team with a better understanding of the visuospatial anatomy of neoplasms in pediatric craniums and to guide operative planning. Secondary aims include exploring its use as an educational tool for junior doctors and medical students. Methods: Three-dimensional anatomical models of selected pediatric brain tumors are created and uploaded to an MR application. The processed data is transferred into designated MR head-mounted devices. At the end of the trial, users are required to fill in an evaluation form. Results: A total of 30 participants took part in this study. Based on the collated feedback data, all of them agreed that the MR platform was useful as a tool in different aspects of understanding the selected pediatric brain tumors. Conclusions: This study demonstrates a proof of concept of the feasibility of MR platforms for a better understanding of pediatric brain tumors. Further development is needed to refine the current setup to be more versatile. Full article

COVID-19 resulted in dramatic changes to the delivery of bariatric surgery; however, the lasting effect on current and future delivery remains uncharacterized. We sought to characterize differences and trends in bariatric surgery care and outcomes between 2020 and 2021. The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) collects data from 902 centers in North America. The MBSAQIP database was evaluated, including patients undergoing sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) with two cohorts described: those receiving surgery in 2020 and those in 2021. Patient selection, operative techniques, and outcomes were compared using bivariate analysis. Multivariable modelling evaluated factors including operative year, independently associated with serious complications and mortality. We evaluated 349,209 patients, with 154,960 (44.4% undergoing bariatric surgery during 2020 compared to 194,249 (55.6%) in 2021. This represents a 20.2% year-to-year increase in total cases, and a 20.7% increase in cases per center (178.5 cases/center in 2020 vs. 215.4 cases/center in 2021). Patients receiving bariatric surgery during 2021 were statistically younger with fewer comorbidities compared to 2020; however, differences were small and groups appeared clinically similar. Length of stay continued to decrease (1.4 ± 1.1 days 2020 vs. 1.3 ± 1.2 days 2021, p < 0.001), yet post-operative outcomes remained similar. Bariatric surgical volumes have increased but may still remain inadequate to meet demand, while trends towards selecting younger, healthier patients for bariatric surgery continue. Efforts to recover from the effects of COVID-19 are ongoing, and long-term evaluation of outcomes following these changes will remain important. Full article

Adhesive capsulitis is a pathology that affects the shoulder and can have a particularly long and disabling course. The usual therapies are treatment with non-steroidal anti-inflammatory drugs (NSAID) and painkillers, steroid injections, physiotherapy, and surgical treatment. This case report describes the effect of a single treatment with pulsed radiofrequency of the suprascapular nerve in a diabetic patient affected by this pathology, for whom steroid injections were contraindicated. Three weeks after the treatment, the reduction of pain and the improvement of ROM (range of movement) allowed the patient to start an adequate physiotherapy treatment, which was not feasible until that moment due to the severe pain despite NSAIDS therapy. The peculiarity of this work consists in the accurate measure of the impact of the analgesic treatment alone in improving the ROM and muscular activation in the patient. The patient was able to correctly perform physiotherapy only once the pain was reduced, after PRF (pulsed radio frequency) treatment. This study has two limitations: being a case report and not a prospective randomized study, and observing the kinematic and pain aspects for a limited period of time. Finally, the case report draws attention to the importance of cooperation between the various health figures involved in the treatment of patients suffering from adhesive capsules. Full article

In the last decades, a digital revolution has transformed several aspects of people’s lives worldwide. Consequently, many substantial changes have concerned numerous professional environments, including medical ones. Among all the different new instruments available in this field, the metaverse is the most futuristic one and seems to be likewise promising. The metaverse is an emerging resource in healthcare, resulting from the integration of virtual and physical reality. It is particularly valuable in surgical operations, since it allows surgeons to perfectly visualize patients’ anatomy. Metaverse applications even include the pediatric field—in particular, the implementation of children and parents’ shared decision-making processes, as well as prenatal diagnosis and fetal surgery. This resource further represents a rising opportunity in pediatric urology: the development of 3D virtual models and robotic surgery will allow surgeons to explore surgical fields, perfectionating their own professional skills. The metaverse will empower pediatric urologists, patients and their families in many ways, and each one of them deserves to be explored to the fullest. In this work, we aim to discuss the current applications of the metaverse in pediatric urology and its future perspectives. Full article

Paranasal sinus osteomas are the most common benign fibro-osseous lesions that occur in the paranasal sinuses, having potential serious complications. With a prevalence ratio of 2:1 towards males, in 95% of the cases, the osteomas are situated most commonly in the frontoethmoidal region. However, osteomas of the maxillary sinus account for less than 5% of cases. The management of symptomatic paranasal sinus osteomas is surgical and is decided based on tumor size and location, patient symptoms, and experience of the surgeon. The Caldwell–Luc procedure, lateral rhinotomy, or craniotomy as external standard procedures remain mandatory if endonasal endoscopic surgery fails. In most reported cases, large tumors are excised by an external approach or in conjunction with an endoscopic technique. Endoscopic treatment of such tumors is a huge challenge for the operator. We report on a 42-year-old male patient presenting with a giant calcified mass in the right maxillary sinus. In this case, an endonasal approach was the most appropriate management even with the large size of the tumor. No recurrence at 24 months follow-up was reported. Full article

Objective: Persistent pain is a common complication after breast cancer surgery. We sought to determine the characteristics of persistent pain after breast cancer surgery and identify perioperative risk factors associated with its development. Methods: This prospective cohort study uses data from a prior randomized controlled trial of 100 patients undergoing breast cancer surgery. Patients were assessed on the presence and characteristics of pain at 3 months after surgery. Baseline and perioperative data were explored for potential associations with persistent pain in univariate and multivariate logistic regression models. Results: Fifty-three percent of patients reported persistent pain 3-months after surgery. Pain was primarily located in the axilla, chest, and shoulder, with the vast majority of patients with pain (96.2%) reporting a neuropathic pain feature. The mean intensity of pain was 2.5 (standard deviation [SD] 2.4, on a 0 to 10 pain scale) and persistent pain was associated with worse quality of life scores (p = 0.004) and increased use of analgesics (p = 0.015). Variables found to be associated with persistent pain in our univariable and multivariable-adjusted analyses were preoperative employment (OR 2.70, 95% CI 1.04–9.66, p = 0.042), acute postoperative pain during movement (OR 1.63, 95% CI 1.06–2.51, p = 0.027), and adjuvant chemotherapy (OR 3.30, 95% CI 1.19 to 9.15, p = 0.022). Conclusions: Persistent pain after breast cancer surgery is neuropathic and is associated with reduced quality of life and increased analgesic need. Future research should focus on perioperative interventions to reduce acute postoperative pain and consideration of modified adjuvant chemotherapy regimens to address modifiable risk factors and potentially reduce the incidence of persistent pain after breast cancer surgery. Full article