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Introduction: The impact of medical student involvement in anesthetic procedures on operating room (OR) efficiency and patient outcomes remains understudied, despite its importance in medical education. This study aimed to quantify the effects of fifth-year medical students' participation in anesthetic procedures on key time metrics, perceived difficulty, procedural success, and postoperative complications and to compare these effects with those of anesthetic residents and student nurse anesthetists. Methods: This prospective observational study was conducted between April and July 2022 in the OR of a tertiary university hospital in southern Thailand. We analyzed 111 elective obstetric-gynecologic and general surgery procedures under subarachnoid block or general anesthesia, equally distributed among three groups: fifth-year medical students, anesthetic residents, and student nurse anesthetists. Key time intervals, perceived difficulty, number of attempts, success rates, and postoperative complications were recorded and compared across groups. Results: Fifth-year medical students exhibited significantly prolonged anesthesia release time, anesthesia-controlled time, anesthetic preparation time, and anesthetic procedure time compared to anesthetic residents and student nurse anesthetists (p < 0.05). Medical students perceived case inductions as more challenging than the other groups did (p < 0.001), but procedural success rates were comparable across groups. Immediate postoperative airway complications were more frequent among medical students than anesthetic residents, but no significant differences were found in intraoperative or 24-h postoperative complications. Discussion: While the involvement of medical students in anesthetic procedures extends specific time metrics, it does not significantly impact overall case duration or major patient outcomes. These findings support the continued integration of medical student training in the OR, with appropriate supervision to manage the slightly increased risk of immediate postoperative complications. Further research is needed to optimize the balance between educational opportunities and OR efficiency. [ABSTRACT FROM AUTHOR]

Introduction: The impact of medical student involvement in anesthetic procedures on operating room (OR) efficiency and patient outcomes remains understudied, despite its importance in medical education. This study aimed to quantify the effects of fifth-year medical students' participation in anesthetic procedures on key time metrics, perceived difficulty, procedural success, and postoperative complications and to compare these effects with those of anesthetic residents and student nurse anesthetists. Methods: This prospective observational study was conducted between April and July 2022 in the OR of a tertiary university hospital in southern Thailand. We analyzed 111 elective obstetric-gynecologic and general surgery procedures under subarachnoid block or general anesthesia, equally distributed among three groups: fifth-year medical students, anesthetic residents, and student nurse anesthetists. Key time intervals, perceived difficulty, number of attempts, success rates, and postoperative complications were recorded and compared across groups. Results: Fifth-year medical students exhibited significantly prolonged anesthesia release time, anesthesia-controlled time, anesthetic preparation time, and anesthetic procedure time compared to anesthetic residents and student nurse anesthetists (p<0.05). Medical students perceived case inductions as more challenging than the other groups did (p< 0.001), but procedural success rates were comparable across groups. Immediate postoperative airway complications were more frequent among medical students than anesthetic residents, but no significant differences were found in intraoperative or 24-h postoperative complications. Discussion: While the involvement of medical students in anesthetic procedures extends specific time metrics, it does not significantly impact overall case duration or major patient outcomes. These findings support the continued integration of medical student training in the OR, with appropriate supervision to manage the slightly increased risk of immediate postoperative complications. Further research is needed to optimize the balance between educational opportunities and OR efficiency. Clinical trial registration: https://www.thaiclinicaltrials.org/show/ TCTR20220418006, identifier TCTR20220418006. [ABSTRACT FROM AUTHOR]

Intraoperative ultrasound is described widely in multiple pathological scenarios in adult practice and in image-guided interventions in children. We aim to describe the technique and range of potential uses of intraoperative ultrasound in paediatric urological surgery, from outlining the process of case selection, preparation, and logistics to demonstrating the ranging benefits of real-time, high spatial resolution ultrasound during resection. At our centre, we use intraoperative ultrasound to assist in a variety of operations. These include guiding excision margins in nephron-sparing surgery, assessing for vascular infiltration in renal tumours, and identifying salvageable testicular tissue in orchidectomy. By exhibiting these scenarios, we hope to display the unique value that intraoperative ultrasound can have to the paediatric surgeon and inspire additional uses further afield. [ABSTRACT FROM AUTHOR]

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. [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.

• 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]

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

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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.

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]

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.

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.

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.

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]

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.

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.

Background. One of the most frequent and severe complications in the early postoperative period in lung transplantation is primary graft dysfunction resulting from ischemia-reperfusion injury. There is evidence of the effectiveness of using inhaled nitric oxide in order to prevent such injury.Objective. To assess the effectiveness of nitric oxide in the intra- and early postoperative period in bilateral lung transplantation.Material and methods. We examined 43 patients who underwent bilateral lung transplantation at the N.V. Sklifosovsky Research Institute for Emergency Medicine in the period from 2012-2021. The patients were divided into two groups. The study group consisted of 23 patients, whose complex of treatment included the use of inhaled nitric oxide. Patients in the comparison group (n=20) received a standard therapy. The end points of the study were: the mechanical ventilation duration, the frequency of using extracorporeal membrane oxygenation and its duration, mortality, dynamics of oxygenation index, blood lactate level, pH, base deficiency.Results. The use of inhaled nitric oxide therapy in patients in the intra- and early postoperative period during lung transplantation improved the ventilation-perfusion ratio, as evidenced by an increase in the oxygenation index by 1.1 times (p=0.128) and 1.3 times (p=0.026) at 48 and 72 hours after surgery, respectively. Meanwhile, the frequency of using extracorporeal membrane oxygenation during surgery was found to decrease by 1.2 times (p=0.033), and that after surgery decreased by 1.4 times (p=0.474); the mechanical ventilation duration decreased by 1.4 times (p=0.042); the duration of extracorporeal membrane oxygenation decreased by 1.6 times (p=0.028); mortality reduced by 8%.Conclusion. The use of inhaled nitric oxide therapy for lung transplantation had a positive effect on the intra- and early postoperative period, as indicated by an improvement in blood gas parameters, a reduction in the frequency and duration of veno-arterial extracorporeal membrane oxygenation, and the duration of mechanical ventilation.

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

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]

Objective: To map perioperative nurses' main activities in the Brazilian scenario, explained in the current literature. Methods: This is a scoping review prepared in accordance with current JBI guidelines, using the checklist for conducting and reporting the study. The search was carried out by two independent researchers, between August and December 2021, in six databases in the health area, using the descriptors nurses, nurse role, intraoperative period, perioperative nursing, surgical centers. Articles published between January 2011 and October 2022, in English, Portuguese or Spanish, were part of the sample. The information was extracted, classified, synthesized and presented descriptively. Results: Eighteen were included in the research synthesis. The analysis of results made it possible to highlight the implementation of surgical safety measures as prevalent activities in care (50%); in management, material, input and equipment (72%) and room preparation (39%) management; in teaching, permanent nursing education (50%). No studies related to researcher activity were identified. Conclusion: In the Brazilian scenario, perioperative nurses' activities range from management to assistance with a smaller proportion in teaching, highlighting their strategic position in mobilizing actions that promote safety and quality in perioperative processes. Protocol registration on the Open Science Framework platform: https://osf.io/8jmq6/ [ABSTRACT FROM AUTHOR]

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]

Purpose: The purpose is to study the change in the contact of the IOL with the posterior capsule using intraoperative SD-OCT before and after implantation of the CTR post implantation of the IOL in the capsular bag., Methods: A total of 51 eyes of 51 patients with senile immature cataract underwent topical phacoemulsification procedure with implantation of an extended depth of focus intraocular lens by a single experienced surgeon. The Rescan 700 SD-OCT system was used for intraoperative imaging. These patients were imaged using intraoperative SD-OCT after implantation of the IOL and before and after implantation of appropriate size of CTR. The vertical height between posterior surface of the lens capsule and the posterior surface of the IOL was measured and compared across 3 CTR sizes., Results: The vertical height between the posterior surface of the lens capsule and the posterior surface of the IOL reduced significantly post CTR implantation (P value < 0.001) in all three groups. The change in height after CTR implantation was seen highest with the CTR size 13 mm and lowest with CTR size 11 mm., Conclusion: Significant improvement of contact between the IOL and the posterior capsule was shown after implantation of the CTR. Larger the size CTR, more the contact of the IOL with the bag was shown., (Copyright © 2025 Indian Journal of Ophthalmology.)

Introduction: This study was designed to examine the capacity of intraoperative optical coherence tomography (OCT) to predict the postimplant position of the glaucoma drainage device PreserfloTM., Methods: 13 eyes (mean age 65.42 (14.89) years) underwent PreserfloTM (Santen, Osaka, Japan) placement. Before surgery, participants were subjected to a comprehensive ophthalmic examination (intraocular pressure (IOP), cup to disk ratio (C/D), visual field, OCT, endothelial cell count). Anterior segment OCT scans were obtained intraoperatively using a Rescan 700 OCT system (Carl Zeiss Meditec, Inc., Oberkochen, Germany). One day postsurgery, anterior segment OCT using the Spectralis OCT (Heidelberg Engineering GmbH) was performed in a sitting position to capture the same chamber cross-section as before. The main outcome variables were tube-endothelium distance (T-E) and tube length (TL) in the anterior chamber measured using both OCT systems. Correlation between intraoperative and office measurements was examined through Pearson correlation (r) and intraclass correlation coefficients (ICC)., Results: Mean intraoperative and in-office T-E were 625.26 (SD 366.60) versus 561.16 (SD 364.62) µm respectively ( p  = 0.540). Intraoperative and in-office anterior chamber TL were 1386 (SD 701.82) and 1433.91 (SD 713.55) µm, respectively ( p  = 0.029). Excellent correlation was observed between both sets of T-E ( r  = 0.992; p  = 0.008) and TL ( r  = 0.984; p  = 0.016) values. Both OCT systems showed good agreement yielding ICCs of 0.992 ( p  < 0.001) for T-E and 0.995 ( p  = 0.001) for TL., Discussion: Excellent correlation was observed between our intraoperative and postoperative OCT measurements. These results support the usefulness of intraoperative OCT to confirm the correct position of an implanted PreserfloTM microshunt., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Positive surgical margin (PSM) is a frequent concern for surgeons performing radical prostatectomy for prostate cancer (PCa). PSM are recognized as risk factors for earlier biochemical recurrence and expose patients to adjuvant or salvage treatments such as external radiotherapy and hormonotherapy. Several strategies have been established to reduce PSM rate, while still allowing safe nerve-sparing surgery. Precise preoperative staging by multiparametric magnetic resonance imaging (mpMRI) and fusion biopsy is recommended to identify suspicious areas of extracapsular extension (ECE) that warrant special attention during dissection. However, even with optimal imaging, ECE can be missed, some cancers are not well defined or visible, and capsular incision during surgery remains an issue. Hence, intraoperative frozen section techniques, such as the neurovascular structure-adjacent frozen section examination (NeuroSAFE) have been developed and lately widely disseminated. The NeuroSAFE technique reduces PSM rate while allowing higher rate of nerve-sparing surgery. However, its use is limited to high volume or expert center because of its high barrier-to-entry in terms of logistics, human resources and expertise, as well as cost. Also, NeuroSAFE is a time-consuming process, even in expert hands. To address these issues, several technologies have been developed for an ex vivo and in vivo use. Ex vivo technology such as fluorescent confocal microscopy and intraoperative PET-CT require the extraction of the specimen for preparation, and digital images acquisition. In vivo technology, such as augmented reality based on mpMRI images and PSMA-fluorescent guided surgery have the advantage to provide an intracorporeal analysis of the completeness of the resection. The current manuscript provides a narrative review of established techniques, and details several new and promising techniques for intraoperative PSM assessment., Competing Interests: Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Purpose: To study the utility of integrated intraoperative OCT (i 2 OCT) in pediatric patients with cataracts in the real world., Methods: It was a retrospective case series. We included patients aged 0-12 years with unilateral or bilateral cataracts who underwent cataract surgery or membranectomy for visual axis opacification between July 2022 and December 2023, where intraoperative OCT was used. We matched the clinical data with i 2 OCT images and tried to identify any useful information i 2 OCT provided. Intraoperative notes were reviewed to analyze any changes in the surgical plan or steps after doing i 2 OCT., Results: The mean age of the children undergoing surgery was 5.9 ± 2.4 years (range: 6 months-9 years). OCT provided valuable insights into the anterior, posterior capsule, and vitreolental surface morphology. The surgical decision was modified in 10 cases after doing the intraoperative OCT (31.3%)., Conclusions: The study adds to the database of pediatric patients imaged using i 2 OCT in the real world. i 2 OCT complements the preoperative examination and aids intraoperative decision-making in cases of white cataracts with excellent real-time delineation of the vitreolental interface in children., (Copyright © 2024 Indian Journal of Ophthalmology.)

Purpose: To study change in the contact of intraocular lens (IOL) with the posterior capsule with respect to the vertical versus horizontal orientation of the haptic-optic junction of the IOL using intraoperative spectral domain optical coherence tomography (SD-OCT)., Methods: Fifty eyes of 50 patients with senile immature cataract underwent topical phacoemulsification procedure with implantation of a monofocal IOL by a single experienced surgeon. The Rescan 700 SD-OCT system was used for intraoperative imaging. These patients were imaged using intraoperative SD-OCT after implantation of IOL, with the haptics oriented horizontally and then vertically., Results: The vertical height between the posterior surface of the lens capsule and the posterior surface of IOL reduced significantly when the haptics were oriented vertically compared to horizontal orientation. This difference was found on analyzing both vertical as well as horizontal axis scans., Conclusion: We found a greater contact between the posterior capsule and the posterior surface of IOL, with the haptic optic junction of the IOL oriented vertically. This study also suggests the need for newer toric IOL designs which allow vertical orientation of haptics, leading to better contact between IOL and the bag., (Copyright © 2024 Indian Journal of Ophthalmology.)

Background: The clinical challenge of unexpected positive intraoperative cultures (UPICs) persists in 2-stage resection arthroplasty for managing periprosthetic joint infections (PJIs) following total knee arthroplasty.(TKA). This study aimed to investigate the incidence of UPICs during the definitive reimplantation phase of 2-stage resection arthroplasty of the knee and to assess both the infection-free and revision-free survivorship of the implanted prosthesis., Methods: This retrospective study included 450 2-stage resection arthroplasties of primary knee prostheses performed between January 2012 and April 2017. Patients were excluded if they: (1) underwent three or more staged resections, (2) had ambiguous clinical documentation or deviated from the 2-stage protocol, or (3) underwent revision arthroplasty prior to the PJI. Additionally, patients presumed aseptic before the second-stage reimplantation were excluded if they lacked joint aspiration or met the 2011 Musculoskeletal Infection Society criteria for PJI before implantation., Results: After exclusions, 300 patients were analyzed. Among them, 14% had UPIC during the second-stage reimplantation. The follow-up time was 2,316 (range, 1,888 to 3,737) days and 2,531 (range, 1,947 to 3,349) days for UPIC and negative intraoperative culture (NIC) groups, respectively. Rerevision due to subsequent PJI occurred in 26.2% of UPIC patients and 15.1% of NIC patients. The 2-year infection-free survival rates for the NIC, one UPIC, and ≥ two UPIC cohorts were 99.5, 98.2, and 94.3%, respectively, while the 5-year survival rates were 92.1, 91.1, and 54.3%, respectively. The unfavorable survivorship was significantly different in multiple UPIC cases (P < 0.001). Multiple UPICs with pathogens consistent with the first-stage findings were strongly associated with the risk of reinfection (P < 0.001)., Conclusions: An UPIC was identified in 14% of second-stage reimplantations. Patients who had multiple UPICs demonstrated truncated survivorship and suboptimal outcomes relative to the NIC and single UPIC cohorts, especially with pathogen consistency to the first-stage surgery., Level of Evidence: III., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Context.—: Frozen sections are essential in the surgical management of patients, especially those with pancreatic masses, because frozen sections can provide answers intraoperatively and aid in treatment decisions. Pancreas frozen sections are challenging because of the small tissue size, processing artifacts, neoadjuvant treatment effects, and concurrent pancreatitis-like obstructive changes. The authors present a review of intraoperative evaluation of pancreatic specimens., Objective.—: To provide an approach to the diagnosis of pancreatic adenocarcinoma on frozen sections and to discuss commonly encountered pitfalls. Indications for pancreas frozen sections and specific margin evaluation will be discussed. We will also review frozen section diagnosis of subcapsular liver lesions and tumors other than metastases of pancreatic ductal adenocarcinoma., Data Sources.—: Data sources included a literature review and the personal experiences of the authors., Conclusions.—: The features for diagnosis of pancreatic adenocarcinoma include disordered architecture, glands at abnormal locations, and atypical cytology. It is important to be aware of the pitfalls and clues on frozen section. The evaluation of resection margins can be challenging, and in the setting of the resection of cystic tumors, the key is the diagnosis of high-grade dysplasia or cancer. Finally, it is vital to remember the differential diagnosis for subcapsular liver lesions because not all lesions will be metastases of adenocarcinomas or bile duct adenomas. Frozen sections remain a useful tool for the intraoperative management of patients with pancreatic tumors., Competing Interests: The authors have no relevant financial interest in the products or companies described in this article., (© 2025 College of American Pathologists.)

We conducted a retrospective analysis of the impact of indocyanine green (ICG) on perioperative outcomes in partial nephrectomy. The utility of ICG in partial nephrectomy remains unclear. We performed a retrospective cohort study of all patients at a single institution who underwent laparoscopic or robotic partial nephrectomy in 2014-2019. Some surgeons used ICG while others did not. Outcomes of interest were estimated blood loss, positive surgical margins, ischemia time, and postoperative kidney function. We used multivariate regression to assess ICG use and outcomes. We identified 150 patients meeting inclusion criteria. The majority of cases (58%) used ICG. Patients who did and did not receive ICG were similar in age, sex, and histologic subtype. Median estimated blood loss was 100 mL (IQR 50-200), 9% had a positive surgical margin, and median ischemia time was 21 min (IQR 16-26). Of those with renal function follow-up, 17% had increased chronic kidney disease stage and mean percent creatinine change was + 4.7 ± 14.9%. On multivariate analysis, ICG use was associated with change in CKD stage (OR 9.9, 95% CI 1.0-93.9, p = 0.05). It was not associated with positive surgical margin status (OR 1.20, 95% CI 0.38-3.85, p = 0.755), percent change creatinine (beta 5.18, 95% CI -1.87-12.23, p = 0.155), ischemia time (beta 0.86, 95% CI - 1.38-3.09, p = 0.45), or EBL (beta - 0.13, 95% CI - 0.53-0.28, p = 0.53). We observed a difference in CKD change according to ICG in partial nephrectomy, but not other perioperative outcomes. ICG may have impacted surgical decision-making in unmeasured ways but did not significantly affect perioperative outcomes., Competing Interests: Declarations. Conflict of interest: The authors declare no competing interests. Ethical approval: Approval was granted by the Ethics Committee of Columbia University under IRB AAAA9967., (© 2025. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Radiation therapy is actively utilized for superficial lesions. External beam radiotherapy for cutaneous lesions utilizes electrons with low transmittance. Conventional electron beam therapy uses Cerrobend blocks for field shaping; however, the Intraoperative Radiotherapy (IORT) applicator offers superior dosimetric characteristics. The dosimetric parameters were measured using 4 and 6 MeV electron beams delivered by a Trilogy linear accelerator, and percent depth dose and lateral dose profiles were compared under the presence of the IORT applicator and Cerrobend block. The dose calculations under various IORT applicator conditions and planning studies were performed using Monte Carlo simulation. Treatment plans for three sites were evaluated in terms of coverage of the planning target volume, dose to the surrounding normal tissue, and beam-on time for two treatment modalities. The results of the measured and calculated dosimetric parameters correspond. Scattered electrons along the IORT applicators resulted in shorter d max and R 50 and sharper penumbras compared to the blocks. Oblique IORT applicators also maintained sharp penumbras. Treatment-plan analysis indicated significant reductions in normal tissue dose using the IORT applicator. Implementing IORT in clinical practice requires deliberation of extended beam-on times and associated patient safety protocols; however, the potential benefits regarding dose distribution warrant further optimization in clinical use., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Fluorescence-guided surgeries, including tumor resection and tissue soldering, are advancing the frontiers of surgical precision by offering enhanced control that minimizes tissue damage, improving recovery and outcomes. However, integrating fluorescence visualization with real-time temperature monitoring remains a challenge, limiting broader clinical use. We address this issue with an augmented reality (AR) visor that combines nanomaterial excitation, fluorescence detection, and temperature monitoring. Using advanced fluorescent nanoparticles like indocyanine green-doped particles and carbon nanotubes, the visor provides a comprehensive view of both the surgical field and sub-surface conditions invisible to the naked eye. This integration improves the safety and efficacy of fluorescence-guided surgeries, including laser tissue soldering, by ensuring optimal temperatures and laser guidance in real time. The presented technology enhances existing surgical techniques and supports the development of new strategies and sensing technologies in areas where traditional methods fall short, marking significant progress in precision surgery and potentially improving patient care., (© 2024 The Author(s). Journal of Biophotonics published by Wiley‐VCH GmbH.)

A visible-near infrared (VIS-NIR) projected multispectral imaging (Proj-MSI) system consisting of an MSI subsystem and a compact projector for intraoperative breast tumor margin assessment was developed. MSI with an average spectral resolution of 24 nm was realized through sequential illumination of 26 sets of VIS-NIR light-emitting diodes and synchronized single NIR-sensitive camera image capture. Rapid (~1 min) tumor margin delineation revealed significantly (p < 0.01, Student's t-test) reduced reflectivity associated with breast tumor. Speeded-up robust features algorithm-based field of view calibration allowed the MSI identified tumor margins to be projected directly onto the breast-conserving surgery (BCS) surgical cavity with a projection error of < 1 mm. Besides, the projected tumor margin boundaries were outlined using Indian ink to simulate breast tumor removal, demonstrating the potential of the Proj-MSI system developed for intraoperative tumor margin assessment during BCS., (© 2024 Wiley‐VCH GmbH.)

Solid tissue biopsy is fundamental in guiding surgeons during intraoperative and peri-operative management of cancer patients. However, conventional histopathologic methods depend heavily on the expertise of trained pathologists, facing challenges in accuracy and efficiency. Methods: Here, we show that unbiased labeling of proteins within tissue sections using tumor-selective dyes enhances tumor-specific signals, enabling robust and accurate differentiation of tumors from normal tissues in less than 45 min. This diagnostic approach combines a tumor-selective dye labeling strategy and a three-dimensional (3D) histological electrophoresis separation strategy to visualize protein differences between tissues and exclude off-target interference. Results: We successfully diagnose and delineate malignant tissue from frozen and fresh surgical specimens from 34 patients across six types of cancer (mean AUC = 0.93). Furthermore, we apply this method to distinguish different histological characteristics in liver cancer surgical specimens, as well as identify and quantify the degree of inflammation in tumor-surrounding tissues. Conclusion: This rapid, accurate, unbiased, and marker-free approach may enhance intraoperative detection of multiple types of tumor specimens., Competing Interests: Competing Interests: The authors have declared that no competing interest exists., (© The author(s).)

Intraoperative femur fractures are a complication of hip arthroplasty, strongly related to the cementless stem design; this kind of fracture is not always recognised during surgery, and revision surgery may be necessary. The present study aimed to simulate intraoperative crack propagation during stem implantation using subject-specific quasi-static finite element models. Eleven subject-specific finite element femur models were built starting from CT data, and the implant pose and size of a non-commercial cementless stem were identified. The model boundary conditions were set with a compressive load from 1000 N to 10 000 N, to simulate the surgeon's hammering, and element deactivation was used to model the crack propagation. Two damage quantifiers were analysed to identify a threshold value that would allow us to assess if a fracture occurred. A methodology to assess the primary stability of the stem during insertion was also proposed, based on a push-out test. Crack propagation up to the surface was obtained in six patients; in two cases there was no crack generation, while in three patients the crack did not reach the external surface. This study demonstrates the possibility to simulate the propagation of the fracture intraoperatively during hip replacement surgery and generate quantitative information about the bone damage using a virtual cohort of simulated patients with anatomical and physiological variability., Competing Interests: Declaration of competing interest The authors declare that they do not have any financial or personal relationships with other people or organisations that could have inappropriately influenced this study., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Our aim was to evaluate the prevalence and impact of unexpected positive intraoperative cultures (UPICs) on the outcome of presumed aseptic total knee and hip revision surgery., Methods: Data regarding patients who underwent elective total hip or knee revision surgery from January 2003 to July 2017 due to preoperatively presumed aseptic reasons was retrospectively reviewed. Partial revisions and patients who had follow-ups below 60 months were excluded from the study. In all surgeries, at least 3 intraoperative samples were taken for microbial culture. Failure was defined as the need for rerevision due to any cause at 5 years and/or the need for antibiotic suppressive therapy. Overall, 123 total hip and 431 total knee revisions were eligible for the study. All cases had at least a 5 years follow-up., Results: There were 420 cases (75.8%) that had all cultures negative, 108 (19.5%) had a single UPIC, and 26 (4.7%) had either ≥2 UPICs for the same microorganism or 1 UPIC for a virulent microorganism. This latter group was not associated with a significantly higher failure rate (2 of 26, 7.7%) compared to those in the aseptic group (54 of 528, 10.2%). Revisions performed within the first 24 months after primary implantation had a higher 5-years rerevision rate (19.3 versus 8.4%, P = .01), mainly attributable to aseptic causes., Conclusions: Total hip and knee revisions with UPICs were not significantly associated with a higher rerevision risk at 5 years. Those revisions performed within the first 24 months after primary arthroplasty had a higher rate of any-cause failure., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Whole-slide imaging (WSI) is a promising tool in pathology. However, the use of WSI in cytopathology has lagged behind that in histology. We aimed to evaluate the utility of WSI for the intraoperative touch imprint cytological diagnosis of axillary sentinel lymph nodes (SLNs) in breast cancer patients., Methods: Glass slides from touch imprint cytology of 480 axillary SLNs were scanned using two different WSI scanners. The intra- and interobserver concordance, accuracy, possible reasons for misdiagnosis, scanning time, and review time for three cytopathologists were compared between WSI and light microscopy (LM)., Results: A total of 4320 diagnoses were obtained. There was substantial to strong intraobserver concordance when comparing reads among paired LM slides and WSI digital slides (κ coefficient ranged from 0.63 to 0.88, and concordance rates ranged from 94.58% to 98.33%). Substantial to strong interobserver agreement was also observed among the three cytopathologists (κ coefficient ranged from 0.67 to 0.85, and concordance rates ranged from 95.42% to 97.92%). The accuracy of LM was slightly higher (average of 98.06%) than that of WSI (averages of 96.81% and 97.78%). The majority of misdiagnoses were false negative diagnoses due to the following top three causes: few cancer cells, confusing cancer cells with histiocytes, and confusing cancer cells with lymphocytes., Conclusions: This study is the first to address the feasibility of WSI in touch imprint cytology. The use of WSI for intraoperative touch imprint cytological diagnosis of SLNs is a practical option when experienced staff are not available on-site., (© 2024 The Author(s). Diagnostic Cytopathology published by Wiley Periodicals LLC.)

Objective: One of the most difficult areas in a surgical pathology practice is intraoperative consultation. In a previous study, we proposed an algorithm that provides a systematic approach to intraoperative consultation for central nervous system tumors. Our aim was to demonstrate the effectiveness of this algorithm., Material and Methods: 102 cases were selected from intraoperative consultation procedures performed at our institution between 2012 and 2020. The algorithm was tested by five observers. The observers examined the smears and frozen sections without the algorithm, and then with the algorithm., Results: The percentage change in the rate of correct diagnoses made by the four observers (O) increased after using the algorithm (O2: 8%, O3: 5%, O4: 8% and O5: 13%), but decreased for only one observer (O1) (5%). The most common error made by the four observers was `grading of glial tumors` (O1: 40%; O2: 23%; O4: 40% and O5: 27.5%), and this group of errors was mostly corrected by using the algorithm (O1: 33%; O2: 3.8%; O4: 23% and O5: 10%). For two observers (O2 and O5), a statistically significant change in diagnostic levels was observed after using the algorithm (p=0.024 and p=0.040; respectively). In addition, thanks to the use of the algorithm, a high degree of agreement was found between the observers` diagnoses (77.7%, p < 0.001)., Conclusion: In the intraoperative consultation of central nervous system lesions, algorithms can help to increase the accuracy of the diagnosis and reduce interobserver variability. This study demonstrates that an algorithmic approach is an effective method for pathologists in intraoperative consultation procedures.

Background: Precise fluid therapy is extremely important during surgeries, as enough circulating blood volume ensures tissue perfusion and cell oxygenation. Yet, extra fluid volume could cause other adverse events, such as heart failure, intestinal swelling, etc. Thus, precise evaluation of the circulating blood volume is essential for maintaining sufficient circulating blood volume and avoiding excessive fluid infusion., Objective: This study aimed to evaluate the relationship between SVV and circulating blood volume during intraoperative fluid therapy., Methods: SVV was measured by FloTrac/Vigileo in the study. A prospective cohort study was conducted. 103 patients aged from 20 to 60 years old with an ASA Grade I-II and a diagnosis of meningioma less than 3 centimeters planning for selective neurosurgery were randomly divided into the Crystalloid Group and the Colloid Group. After induction, each Patient received 15 ml/kg of Plasma-Lyte-A or 6% hydroxyethyl starch in 30 min followed by continuous infusion at the speed of 0.1 ml/kg during the next 60 min. Hb concentration, Hct, Delta-BV/kg, and Delta-SVV were recorded every 5 minutes., Results: The delta-SVV and Delta-bv/kg were significantly higher in the Crystalloid Group than that of the Colloid Group. There was a strong linear correlation between Delta-SVV and Delta-bv/kg in both Crystalloid Group (Delta-bv / kg = 1.108 Delta-SVV + 0.0712, P < .001) and Colloid Group (Delta-bv / kg = 1.047 Delta-SVV + 0.4153, P < .001). An equation between Delta-bv/kg and Delta-SVV was established (Delta-bv / kg = 1.099 Delta-SVV + 0.1139, P < .001)., Conclusion: In conclusion, SVV measured by FloTrac / Vigileo could guile fluid therapy precisely by predicting the blood volume of patients during the intraoperative period, as it has a strong linear correlation with the blood volume of patients who underwent general anesthesia, meaning anesthesiologist could calculate the exact fluid volume for patients' infusion. Further studies with large cohorts and centers would be needed to validate its efficiency.

Study Objective: To evaluate the associations between high and low intraoperative time-weighted average mean arterial pressures before, during and after cardiopulmonary bypass on postoperative delirium., Design: Single center retrospective cohort study., Setting: Operating rooms and postoperative care units., Patients: 11,382 patients, 18 years of age or older who had cardiac surgery requiring cardiopulmonary bypass between January 2017 and December 2020 at the Cleveland Clinic Main Campus., Interventions: All cardiac surgery requiring bypass except procedures requiring deep hypothermic circulatory arrest., Measurements: Post operative delirium was assessed from 12 to 96 h postoperatively, using the Confusion Assessment Method and brief Confusion Assessment Methods. Hypotension and hypertension were defined as time-weighted average mean arterial pressure < 60 and > 80 mmHg., Main Results: Postoperative delirium occurred in 678 (6.0 %) of 11,382 patients. Confounder-adjusted associations, using multivariable logistic regression models, between hypotension (time-weighted average mean arterial pressure < 60 mmHg) and hypertension (time-weighted average mean arterial pressure > 80 mmHg) and postoperative delirium were not statistically significant or clinically meaningful before, during, or after the cardiopulmonary bypass., Conclusions: This large single-center cohort analysis found no evidence that exposure to high or low blood pressures during various intraoperative phases of cardiac surgery are associated with postoperative delirium., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Daniel I Sessler reports a relationship with Pacira BioSciences Inc. that includes: consulting or advisory. If there are other authors, they 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 Elsevier Inc. All rights reserved.)

Scleral-fixated intraocular lens (SFIOL) is a widely used technique for IOL implantation in patients where capsular support is insufficient. Most surgeons have shifted away from sutured to sutureless SFIOL techniques where haptics of a multifocal IOL are inserted in scleral tunnels/flaps. Large-scale publications have shown wide variation in the refractive status of eyes post-SFIOL even in the best of the hands. This is because even slight variations in the site of scleral flap/tunnel formation and tension on haptics due to the variable length of haptics placed in scleral flaps/tunnels can alter the effective lens position and induce significant residual refractive error, especially cylindrical astigmatism due to IOL tilt. Our technique aims to reduce residual refractive error after SFIOL implantation. This is achieved by using intraoperative aberrometry and adjusting haptics accordingly to achieve minimal refractive error intraoperatively., (Copyright © 2024 Indian Journal of Ophthalmology.)

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