Augmented Reality-Assisted Spine Surgery: An Early Experience Demonstrating Safety and Accuracy with 218 Screws

Study Design Prospective cohort study. Objectives In spine surgery, accurate screw guidance is critical to achieving satisfactory fixation. Augmented reality (AR) is a novel technology to assist in screw placement and has shown promising results in early studies. This study aims to provide our early experience evaluating safety and efficacy with an Food and Drug Administration-approved head-mounted (head-mounted device augmented reality (HMD-AR)) device. Methods Consecutive adult patients undergoing AR-assisted thoracolumbar fusion between October 2020 and August 2021 with 2 -week follow-up were included. Preoperative, intraoperative, and postoperative data were collected to include demographics, complications, revision surgeries, and AR performance. Intraoperative 3D imaging was used to assess screw accuracy using the Gertzbein-Robbins (G-R) grading scale. Results Thirty-two patients (40.6% male) were included with a total of 222 screws executed using HMD-AR. Intraoperatively, 4 (1.8%) were deemed misplaced and revised using AR or freehand. The remaining 218 (98.2%) screws were placed accurately. There were no intraoperative adverse events or complications, and AR was not abandoned in any case. Of the 208 AR-placed screws with 3D imaging confirmation, 97.1% were considered clinically accurate (91.8% Grade A, 5.3% Grade B). There were no early postoperative surgical complications or revision surgeries during the 2 -week follow-up. Conclusions This early experience study reports an overall G-R accuracy of 97.1% across 218 AR-guided screws with no intra or early postoperative complications. This shows that HMD-AR-assisted spine surgery is a safe and accurate tool for pedicle, cortical, and pelvic fixation. Larger studies are needed to continue to support this compelling evolution in spine surgery.

Geriatric approach to the treatment of senile patients with colorectal cancer

Introduction. The lack of consensus guidelines for the treatment of colorectal cancer (CRC) in senile patients, the high incidence of early postoperative complications after radical surgery caused the search for the most optimal approach to the management of this category of patients.The aim is to introduce a geriatric approach to the treatment of colorectal cancer in senile patients, reduce the incidence of Clavien–Dindo grade 4 early postoperative complications.Materials and methods. 190 senile patients who underwent radical surgery with D3 lymphadenectomy with stage II and III colorectal cancer were enrolled in the study. They were divided into two groups: the control group included 100 patients who underwent standard treatment, the study group included 90 patients, to whom the geriatric approach with a comprehensive geriatric assessment (CGA) and subsequent pre-rehabilitation was applied. A comparative intergroup analysis was performed on the basis of obtained data.Results. The study group differed from the control group in higher polymorbidity and high operational and anesthetic risk (p <0.001). Implementation of geriatric pre-rehabilitation with due account for CGA results and correction of polymorbidity improved chances of providing surgical care using laparoscopic and robotic technologies. The frequency of intraoperative blood transfusion and prolonged mechanical ventilation in the study group was reduced (p <0.001 and p = 0.009, respectively). Predictors that increase the chances of developing acute postoperative myocardial infarction were identified. They included the patient’s male gender (p = 0.004), redo surgery after development of early postoperative complications (p = 0.043), prolonged mechanical ventilation (p = 0.052), increased length of stay in the intensive care unit (p = 0.011), and comorbidity (p = 0.022). The introduction of the geriatric approach made it possible to reduce the risk of postoperative myocardial infarction by 17.86 times (p = 0.007).Conclusion. The geriatric approach to the senile patients with colorectal cancer makes it possible to expand the indications for radical treatment in severe polymorbidity and senile asthenia, as well as to reduce the incidence of early postoperative complications.

Results obtained after the surgical treatment of Graves’ disease depending on the levels of anti-thyroid antibodies

Graves' disease (GD) is a hereditary autoimmune disease which is characterized by persistent abnormal hypersecretion of thyroid hormones and thyrotoxicosis syndrome development. GD affects from 0.5 % to 2.0 % of population in different regions. 46 % of these patients develop ophthalmopathy. GD is a common cause of disabilities in patients under 60 years of age. In recent years, the incidence of GD in Ukraine has increased by 9.9 % — from 106.2 to 117.9 per 100,000 individuals. This can be connected with the improved diagnostic possibilities and active disease detection as well as with the increased number of autoimmune thyroid disorders. The recent studies focus on prevention of specific complications and recurrences of GD after surgery. Objective — to compare the levels of antibodies to the thyroid‑stimulating hormone receptors (TSHR‑Ab) during different postoperative periods as well as the incidence of early and late complications depending on the surgical technique used for the treatment of GD. Materials and methods. The results of surgical treatment of 130 patients, with GD were compared. 29 male patients and 101 female patients aged from 19 to 76 (average — 44.1 ± 3.2 years), receiving their treatment for GD in Kyiv Center of Endocrine Surgery during 2010—2018, were randomly selected and divided into two groups. At the time of operation the duration of disease was from 1 to 30 years (average — 4.6 ± 1.2 years). Group 1 included 65 patients that underwent total thyreoidectomy (TT) and group 2 included 65 patients that underwent subtotal thyreoidectomy (ST). The following parameters were compared: surgery duration, the incidence of early postoperative complications, including bleedings and damage to the recurrent laryngeal nerves, and late outcomes of surgical treatment (persistent hypoparathyreoidism disorder and disorder recurrences) depending on the method of surgery (ST or TT). Furthermore, the patterns of the TSHR‑Ab level reduction were studied for different postoperative periods. Results. The comparison of surgical outcomes following TТ and ST didn’t reveal any statistically significant differences in such evaluation criteria as the average surgery duration, the average volume of intraoperative blood loss and the average duration of the postoperative inpatient treatment. The comparative assessment of the thyroid stump volume and the average amount of drained discharge showed statistically significant differences for TТ. It allows considering TТ as a surgery which causes less complications than ST. The studied parameters of early postoperative complications had no significant differences for ST and TТ. The long‑term (5 years) postoperative level of TSHR‑Ab was statistically significantly lower in patients after TT and made up 1.15 ± 0.13 IU/L (thus corresponding to the normal level). Conclusions. Total thyroidectomy is an optimal surgical technique and is more appropriate compared with subtotal thyroid gland resection. It should be noted that TT provides lower risk of complications due to significantly lower level of TSHR‑Ab in late postoperative period.

Longer Diagnosis-surgery Duration Is Associated With an Increased Risk of Early Postoperative Complications for Crohn's Disease: A Retrospective Study

Background: Early postoperative complications(ePOCs) frequently occur in Crohn’s patients after surgery. The risk factors of ePOCs for Crohn’s disease (CD), however, remain controversial. We aimed to assess the incidence and risk factors of ePOCs in CD patients after surgical resection.Methods: The retrospective study was conducted on 97 patients undergoing surgeries between January 2010 and September 2019 for Crohn’s disease in a tertiary hospital in China. Results: In total, 33 patients (34.0%) experienced ePOCs, including 11 intra-abdominal septic complications (11.3%) and 1 postoperative death (1.0%). Severe complications (Dindo–Clavien III–IV) were seen in 8 patients (8.2%). In multivariate analysis, diagnosis-surgery duration exceeding 6 months(odds-ratio [OR]=4.07; confidence interval [CI] 95%[1.10-15.09], P=0.036), serum platelet count <300*1000/mm3(odds-ratio [OR]=6.74; confidence interval [CI] 95%[1.58-28.71], P=0.01) and serum gamma-glutamyl transpeptidase(GGT) level >10U/L(odds-ratio [OR]=9.22; confidence interval [CI] 95%[1.23-68.99], P=0.031)were identified as independent risk factors for ePOCs. Preoperative exposure to anti-tumor necrosis factor (TNF) agents (P=1.00) were not associated with a higher risk of ePOCs. 34.0% of CD patients developed ePOCs after surgical resection.Conclusions: Diagnosis-surgery duration exceeding 6 months, serum platelet count <300*1000/mm3, and serum GGT level >10U/L were associated with an increased risk of ePOCs. Preoperative exposure to anti-TNF agents were not associated with a higher risk of ePOCs.

Stroke Volume Variation-Guided Goal-Directed Fluid Therapy Did Not Significantly Reduce the Incidence of Early Postoperative Complications in Elderly Patients Undergoing Minimally Invasive Esophagectomy: A Randomized Controlled Trial

Study Objective: This study aimed to investigate whether stroke volume variation (SVV)-guided goal-directed therapy (GDT) can improve postoperative outcomes in elderly patients undergoing minimally invasive esophagectomy (MIE) compared with conventional care.Design: A prospective, randomized, controlled study.Setting: A single tertiary care center with a study period from November 2017 to December 2018.Patients: Patients over 65 years old who were scheduled for elective MIE.Interventions: The GDT protocol included a baseline fluid supplement of 7 ml/kg/h Ringer's lactate solution and SVV optimization using colloid boluses assessed by pulse-contour analysis (PiCCO™). When SVV exceeded 11%, colloid was infused at a rate of 50 ml per minute; if SVV returned below 9% for at least 2 minutes, then colloid was stopped.Measurements: The primary outcome was the incidence of postoperative complications before discharge, as assessed using a predefined list, including postoperative anastomotic leakage, postoperative hoarseness, postoperative pulmonary complications, chylothorax, myocardial injury, and all-cause mortality.Main Results: Sixty-five patients were included in the analysis. The incidence of postoperative complications between groups was similar (GDT 36.4% vs. control 37.5%, P = 0.92). The total fluid volume was not significantly different between the two groups (2,192 ± 469 vs. 2,201 ± 337 ml, P = 0.92). Compared with those in the control group (n = 32), patients in the GDT group (n = 33) received more colloids intraoperatively (874 ± 369 vs. 270 ± 67 ml, P &lt;0.05) and less crystalloid fluid (1,318 ± 386 vs. 1,937 ± 334 ml, P &lt;0.05).Conclusion: The colloid-based SVV optimization during GDT did not significantly reduce the incidence of early postoperative complications after minimally invasive esophagectomy in elderly patients.Clinical Trial Number and Registry URL: ChiCTR-INR-17013352; http://www.chictr.org.cn/showproj.aspx?proj=22883

Mid-Term Outcomes of Veno-Venous Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplantation: Comparison with Non-Bridged Recipients

Objectives: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is increasingly being used in acutely deteriorating patients with end-stage lung disease as a bridge to transplantation (BTT). It can allow critically ill recipients to remain eligible for lung transplant (LTx) while reducing pretransplant deconditioning. We analyzed early and mid-term postoperative outcomes of patients on VV-ECMO as a BTT and the impact of preoperative VV-ECMO on posttransplant survival outcomes. Methods: All consecutive LTx performed at our institution between January 2012 and December 2018 were analyzed. After matching, BTT patients were compared with non-bridged LTx recipients. Results: Out of 297 transplanted patients, 21 (7.1%) were placed on VV-ECMO as a BTT. After matching, we observed a similar 30-day mortality between BTT and non-BTT patients (4.6% vs. 6.6%, p=0.083) despite a higher incidence of early postoperative complications (need for ECMO, delayed chest closure, acute kidney injury). Furthermore, preoperative VV-ECMO did not appear associated with 30-day or 1-year mortality in both frequentist and Bayesian analysis (OR 0.35, 95%CI 0.03-3.49, p=0.369; OR 0.27, 95%CrI 0.01-3.82, P=84.7%, respectively). In sensitivity analysis, both subgroups were similar in respect to 30-day (7.8% vs. 6.5%, p=0.048) and 1-year mortality (12.5% vs. 18%, p=0.154). Conclusions: Patients with acute refractory respiratory failure while waiting for LTx represent a high-risk cohort of patients. We observed that these patients can be successfully bridged to LTx with VV-ECMO with post-transplant mortality comparable to non-BTT patients.