Treatment tactics and outcomes of complications of intrastromal MyoRing implantation and corneal crosslinking in keratoconus

Purpose. To analyze the nature and frequency of intra - and postoperative complications during MyoRing implantation and corneal crosslinking in patients with keratoconus and to develop methods for their treatment and prevention. Material and methods. We conducted a study of the results of MyoRing implantation in 131 patients (147 eyes) with keratoconus II-III. Corneal rings with a diameter of 5-6 mm and a thickness of 280-320 µm were implanted. PocketMaker microkeratome (Dioptex GmbH, Austria) was used to create a stromal pocket during the implantation of the ICR. The patients were divided into the control group (32 patients, 34 eyes) – using the standard ICR implantation technology and the main group (38 patients, 42 eyes) – ICR implantation using the developed tools. Results. Among the complications, intraoperatively, the eruption of the stromal pocket was noted due to the loss of vacuum during the application of the applicator in 4 cases. In the long term, after 10 and 12 months, patients underwent ICR reimplantation with a positive result. In 2 cases, the surface location of the implant led to ring extrusion, which may have been due to the thinning of the surface layers, and subsequently keratoplasty was performed on the patients. In 1 case, the patient's pronounced deposition of lamellar deposits caused dissatisfaction of a cosmetic nature. At the request of the patients, the rings were removed, and in the following terms, the patient made up for the visual defect by wearing hard contact lenses. Conclusion. A moderate number of complications indicates the relative safety of the method of intrastromal keratoplasty. The use of the proposed instruments during the operation provides a significant reduction in the frequency of complications compared to the results with the standard technique of forming a corneal tunnel. Thus, it was found that the optimized method of implantation of MyoRing intrastromal rings reduces corneal trauma, simplifies the manipulation of the ring and reduces the total operation time by 1.4 times. Key words: keratoconus, intrastromal corneal rings, MyoRing, corneal crosslinking, complications.

The Learning Curve of Computer-Assisted Free Flap Jaw Reconstruction Surgery Using 3D-Printed Patient-Specific Plates: A Cumulative Sum Analysis

BackgroundComputer-assisted jaw reconstruction (CAJR) has benefits in reducing operation time and improving reconstruction accuracy, compared to conventional freehand jaw reconstruction. However, no information is available regarding learning curves in CAJR with the use of 3D-printed patient-specific surgical plates (PSSP). The purpose of this study was to assess surgical outcomes and learning curve for the first 58 consecutive CAJR using 3D-printed PSSP performed by a single surgical team in a single institution.MethodsIn a prospective study, consecutive patients who underwent free flap CAJR using 3D-printed PSSP were included. The determination of proficiency, based on the cumulative sum of surgical success (no major adjustment of 3D-printed PSSP, flap survival) passing the acceptable boundary line of cumulative sum analysis, was the primary outcome. To find out any potential factors influencing the learning curve, baseline characteristics of patients were compared before and after proficiency achievement. Secondary outcomes included inflexion points of the total operation time, blood loss, length of hospital stay, and bone graft deviation, measured by the cumulative sum analysis.ResultsFrom December 2016 to November 2020, 58 consecutive cases underwent surgery performed by a single surgical team. The overall surgical success rate was 94.8% (55/58). A three-stage learning curve of primary outcome was observed. The proficiency was achieved after 23 cases. The proportions of advanced tumor staging and concomitant surgery after obtaining proficiency were significantly higher than those before achieving proficiency (p = 0.046 and p < 0.001, respectively). Mean values of operation time, intraoperative blood loss, length of hospital stay, and bone graft deviation were 532.5 ± 119.2 min, 1,006.8 ± 547.2 ml, 16.1 ± 6.3 days, and 0.9 ± 1.2 mm, respectively. Two trends of learning curve were observed in the CUSUM analyses of total operation time, length of hospital stay, and bone graft deviation, in which the first and second inflexion points occurred between 8 and 17 cases and between 43 and 46 cases, respectively.ConclusionOur results revealed a three-stage learning curve of CAJR with the use of PSSP, including initial learning, plateau, and overlearning. Based on CUSUM analysis, the surgical proficiency was achieved after 23 cases, and total operation time, length of hospital stay, and bone graft deviation stabilized after 8–17 cases.

Comparison of different approaches to combined spinal epidural anesthesia (CSEA) under the guidance of ultrasound in cesarean delivery of obese patients: a randomized controlled trial

Background Combined spinal epidural anesthesia (CSEA) is commonly performed in cesarean deliveries. However, it is difficult to perform in obese parturients because of positioning challenges. The aim of this study was to compare the effect of different approaches to CSEA under the guidance of ultrasound. Methods One hundred obese patients (BMI ≥ 30 kg/m2) who underwent elective cesarean section were randomly enrolled. Patients were assigned to a median approach group and a paramedian approach group randomly. Clinical characteristics were compared between groups. First-attempt success rate, the median positioning time and total operation time, ultrasonic predicted anesthesia puncture depth, actual puncture depth, anesthesia adverse reactions, complications after anesthesia, and patients’ satisfaction with the epidural puncture were recorded. Results The first-attempt success rate was significantly different between the two groups [92% (46/50) vs. 76% (38/50), P = 0.029]. The median positioning time and total operation time in the paramedian approach group were higher than those in the median approach group (227.7 s vs. 201.6 s, P = 0.037; 251.3 s vs. 247.4 s, P = 0.145). The incidence of postanesthesia complications in the paramedian approach group was significantly lower than that in the median approach group (2% vs. 12%, P = 0.026), and patient satisfaction was higher in the paramedian approach group than in the median approach group (P = 0.032). Conclusion The ultrasound-guided paramedian approach for CSEA is time-consuming, but it can effectively improve the success rate of the first puncture, reduce the incidence of anesthesia-related adverse reactions, and improve patient satisfaction. Trial registration: This study was registered with the Chinese Clinical Trial Registry (ChiCTR1900024722) on July 24, 2019

Comparison of Effects of Radiofrequency Ablation of Liver Cancer Guided by CT Images Based on Deep Learning Algorithm

Objective. To investigate the paper radiofrequency ablation (RFA) CT-guided feasibility of hepatocellular carcinoma (primary liver cancer) treatment, safety, and clinical efficacy of the use of deep learning algorithms. Method. A total of 47 cases of primary liver cancer patients were included: 21 cases of CT-guided liver lesions in line with RFA (C-CT group) and, in the same period, 26 cases of spiral CT-guided liver lesions in line with RFA (S-CT group). Two groups of patients were recorded immediately after the total operation time and ablation time, the acceptable radiation dose was observed in the incidence of postoperative complications of 7d, and the postoperative hospital stay was recorded to evaluate the efficacy of the treatment of lesions in 1, 3, and 6 months after RFA. Results. All 47 patients were successful; two technical success rates were 100%. There was a significant difference ( P < 0.05) in the total operation time groups, ablation time, and acceptable radiation dose. And there was no significant difference ( P < 0.05) in postoperative complications of 7d groups, postoperative hospital stay, and local disease control. There was a significant difference ( P < 0.05) in the S-CT group, seven ablation residual or recurrent lesions during the follow-up ratio of 26.9%, and C-CT groups compared with only 14.3%. Conclusion. CT-guided RFA treatment of primary liver cancer patients is safe, effective, and superior to the conventional spiral CT-guided ablation lesion site-specific terms.

A novel “three-dimensional-printed individual guide template-assisted percutaneous vertebroplasty” for osteoporotic vertebral compression fracture: a prospective, controlled study

Background Conventional percutaneous vertebroplasty (PVP) are mainly guided by C-arm fluoroscopy, and it usually leads to excessive X-ray radiation exposure to patients, surgeons, and anesthetists. Moreover, multi-time fluoroscope may prolong the operation time. 3D-printed template could help minimize fluoroscopy shot times and fluoroscopy dosage during operation, and shorten operation time. We perform this study to compare the efficacy and accuracy of PVP assisted by “three-dimensional printed individual guide template” versus conventional PVP. Method Patients who suffered acute painful single segment osteoporotic vertebral compression fracture(OVCF) needed operative treatment were randomly assigned into three-dimensional printing individual guide template-assisted percutaneous vertebroplasty group (group A) or conventional PVP guided by C-arm fluoroscopy group (group B) at a 1:1 ratio. Fluoroscopy times for puncture points (FTPP), total radiation dosages (TRD), total fluoroscopy time (TFT), and total operation time (TOT) were recorded as the main evaluation factors to evaluate the two operation procedures. Results A total of 36 acute painful single segment OVCF patients were successfully operated on, and each group has 18 patients. None of the patients presented symptomatic complications. The surgical success rate in group A was 94.4%(17/18), one patient in the group A was failed and then operated by conventional procedure. FTPP (1.8 ± 0.8 in group A vs 5.2 ± 1.9 in group B, P < 0.05), TRD (4.9 ± 0.9 mGy vs 7.9 ± 1.6 mGy, P < 0.05), TFT (16.7 ± 2.9 vs 26.6 ± 5.3, P < 0.05), and total operation time (19.4 ± 2.4 min vs 27.8 ± 4.0 min, P < 0.05) were presented statistically difference in the two groups. The incidence of cement leakage occurred in group A (3/18, 16.7%) was less than that occurred in group B (7/18, 38.9%) (P > 0.05). Conclusions Compared with the conventional PVP, “three-dimensional-printed individual guide template-assisted PVP” could minimize fluoroscopy shot times during operation and fluoroscopy dosage, shorten operation time, and is a more precise and feasible operation method. Trial registration The present study was registered with the Chinese Clinical Trial Registry (ChiCTR) (http://www.chictr.org.cn), and its registration no. is ChiCTR1900024283.

A Modified Technique of Thulium Laser Enucleation for Benign Prostatic Hyperplasia With Non-morcellator Approach

Background: Until recently, most enucleation techniques of the prostate were performed with the application of morcellator. We introduce a modified enucleation technique of thulium laser with non-morcellator approach, which is about incising and vaporizing remaining prostate tissue instead of a morcellator.Methods: A retrospective evaluation of 223 patients undergoing ThuLEP from January 2014 to December 2015 was performed in our institution. One hundred five of the patients used morcellator while the other 118 used non-morcellator approach. All patients were assessed with the International Prostate Symptom Score (IPSS), quality of life (Qol), ultrasonography, serum prostate-specific antigen (PSA), maximal urine flow rate (Qmax), and postvoid residual urine volume (PVR). We reassessed these parameters at 1-, 3-, 6-, and 12-months after operation. Operative time, perioperative, and postoperative complications were also recorded.Results: Significant improvement was noted in the IPSS, QoL, Qmax, and PVR in both groups at the 12-month follow-up, and assessment showed no differences in these parameters between the two groups. Comparisons of the total operation time and enucleation time demonstrated no significant differences between the two groups. Our non-morcellator approach needed more time to incise and vaporize the enucleated tissue compared to morcellation when the prostate volume was about 40–80 ml (p &lt; 0.05), while it showed a significant lower rate of superficial bladder injury than using morcellator (p &lt; 0.05). There were no significant differences in other complications between the two groups (p &gt; 0.05).Conclusions: Our modified technique is a safe and effective procedure for the treatment of BPH avoiding the potential complications caused by morcellator.

Bilateral cochlear implantation in children: simultaneously or in consecutive sessions?

Objective This study aimed to evaluate and compare cases of simultaneous and consecutive bilateral cochlear implantation from the perspective of the duration of anaesthesia, surgical complications and hospitalisation. Method Fifty patients with simultaneous bilateral cochlear implantation (group 1) and 47 patients with consecutive bilateral cochlear implantation (group 2) were included in this study. The two groups were compared in terms of the duration of anaesthesia, the duration of surgery, radiological findings, the complications and the post-operative hospitalisation time. Results Group 1 had a significantly shorter operation time than group 2 (p < 0.01). The mean total operation time was 189 minutes in group 1. In group 2, the mean operation times for the first and second surgery were 134 minutes and 136 minutes, respectively, and the total operation time for both surgical procedures in group 2 was 270 minutes. The duration of post-operative hospitalisation of the patients in group 1 was significantly shorter than the total post-operative hospitalisation after both operations for the patients in group 2 (p < 0.01). Conclusion In conclusion, if there is no anatomical problem that may lead to a prolonged operation time or any risk regarding anaesthesia, simultaneous bilateral cochlear implantation can be performed safely.

Hysterectomy and Adnexal Procedures by Vaginal Natural Orifice Transluminal Endoscopic Surgery (VNH): Initial Findings From a Korean Surgeon

Objective: To evaluate feasibility and safety of hysterectomy and adnexal procedures by vaginal natural orifice transluminal endoscopic surgery (vNOTES).Study Design: This is a prospective observational study at a tertiary center and teaching University hospital. We enrolled prospectively 34 patients with benign diseases sequentially.Results: We measured baseline characteristics, surgical data, and pain score (VAS) after surgery. We surveyed before/after surgery. The time of port installation and each stage of surgery was measured. The learning curve was assessed through the graph according to the number of operations using linear and logarithmic regression curve estimation. The complications of surgery were investigated. The median age of the patients was 47.5 years (38–73). Median BMI was 22.4 (18.2–30.0). 20 cases of leiomyoma, four cases of adenomyosis, three cases of uterine prolapse, four cases of endometrial hyperplasia, and three cases of CIN were diagnosed. The median uterine weight was 180.0 g. The median port-installation time was 15.0 min (range, 4–35 min) and median total operation time was 85.5 min (range 43.0–132.0). Complications occurred in three patients. Two cases of bladder injury happened during vesicovaginal space dissection before the installation of the Wound Retractor (WR). One patient underwent transumbilical single-port surgery because of late-onset postoperative bleeding on the 13th postoperative day. The mean postoperative VAS scores were 3.36 immediately after surgery and 3.06, 2.79, and 2.45 at 6, 12, and 24 h after surgery, respectively. In continuous variable analysis, we detected a correlation between port-installation time and postoperative VAS ≥4 (pain score as need for medication). Based on a learning curve, port-installation time and total operation time appeared to reach the proficiency level by the 10th case.Conclusions: Although there were three complications, vNOTES offers advantages to patients and surgeons. More surgical techniques will be developed in vNOTES.

Fifteen-Year Survival Of Hepatocellular Carcinoma Extending Into The Right Atrium Treated By Multidisciplinary Therapies Including Surgical Resection Under Cardiopulmonary Bypass: A Case Report And Literature Review

Background: Hepatocellular carcinoma (HCC) with tumor thrombus (TT) extending into the right atrium (RA) is rare, and most cases are at an advanced stage with a poor prognosis. We report a case of HCC with TT in the RA (RATT) with 15-year survival.Case presentation: The patient was a 67-year-old man with a huge HCC with RATT. He developed edema of the lower extremities in November 2002. Then, a liver tumor 6.5 cm in diameter in hepatic segments 7 and 8 was identified by ultrasonography and computed tomography. Cavo-atrial thrombectomy was performed successfully using cardiopulmonary bypass (CPB) with heparinization and cardiac arrest. After the thrombectomy, right hepatectomy was performed using the hanging maneuver. The right hepatic vein was transected, and the stump was closed with a running suture. The total operation time was 10 h 48 min, and the total blood loss was 7267 mL. The patient recovered uneventfully except for right pleural effusion, and he experienced no side effects related to CPB, such as immunosuppression or cerebral infarction. He was cancer-free for approximately 9 years after the surgery. A new lesion in the remnant liver was detected by magnetic resonance imaging in March 2012. He underwent six rounds of transcatheter arterial chemoembolization, followed by sequential administration of sorafenib and sunitinib. Radiation therapy was administered to the remnant liver twice and to the spine after he was diagnosed with bone metastasis. Finally, the patient died 6 years after the recurrence. Conclusions: Cavo-atrial thrombectomy under CPB prior to hepatectomy for HCC with RATT can be performed safely to prevent major complications related to CPB. Our patient’s postoperative clinical course followed by multidisciplinary therapies led to an approximately 15-year survival.

Suspension arthroplasty in the treatment of thumb carpometacarpal osteoarthritis

Literature presents several examples of surgical techniques for the treatment of carpometacarpal osteoarthritis. In our study we used a modified Ceruso’s suspended arthroplasty technique. In this study, 53 patients from 2011 to 2017 underwent arthroplasty with trapezius excision and suture suspension between abductor pollicis longus and flexor carpi radialis. The average age at surgery was 69, the participants were 43 women and 10 men. The average total operation time was 59 minutes. The modified CMC suspension arthroplasty technique provides excellent results compared with those in the literature.