Fiber Optic RealShape (FORS) Technology for Endovascular Navigation in Severe Tortuous Vessels

Purpose: The purpose of this study was to describe the use of a wire and catheters embedded with optical fiber (Fiber Optic RealShape [FORS]) to catheterize tortuous target vessels avoiding radiation. Technique: A virtual biplane vies was simulated coupling traditional x-ray system, preoperative CT scan, and FORS system to treat an isolated hypogastric aneurysm. Despite the complex anatomy, catheterization of all target vessels was possible in 12 minutes with 19 seconds of fluoroscopy time (Radiation Exposure 3.8 mGy×cm2). A minimal invasive endovascular exclusion of the aneurysm was achieved through selective coil-embolization of the iliolumbar artery and implantation of balloon expandable covered stents, thus preserving the perfusion of the superior gluteal artery. Conclusion: FORS guidance allowed catheterization of a target vessel with challenging anatomy with a low radiation exposure.

Should Preoperative Computed Tomography Be Routine Examination For Cervicofacial Space Infections?

Background: Cervicofacial space infections are potentially life-threatening, which require accurate diagnosis, early incision, and adequate drainage. The utilization of computed tomography (CT) in cervicofacial space infections has significantly increased. However, the clinical value of preoperative CT imaging in cervicofacial space infections remains controversial. We, therefore, investigated whether CT examination should be used as a routine examination in the treatment of patients with cervicofacial space infections.Methods: A retrospective study of all patients affected by cervicofacial space infections that received incision and drainage surgery from Jan 2016 to Dec 2020 was performed. Patients were divided into 2 groups: the group with preoperative CT and the group without preoperative CT. Outcomes, including re-operation rate, missed diagnosis rate, days of symptom relief, length of stay, duration of surgery, and total cost of hospitalization, were analyzed.Results: Of 153 patients, 108 patients underwent surgery with preoperative CT and 45 patients without preoperative CT. The re-operation rate in the preoperative CT group (6/108, 5.6%) was significantly lower (P<0.05) than that in the group without preoperative CT (10/45, 22.2%). Significant reduction of missed diagnosis rate, days of symptom relief, length of stay, and duration of surgery (P<0.05) were detected in the preoperative CT group. Conclusions: Preoperative CT examination should be recommended as a routine examination in the treatment of cervicofacial space infections for its usefulness in reducing the missed diagnosis rate and repeated surgery complication.

Mesenteric occlusive disease of the inferior mesenteric artery is associated with anastomotic leak after left-sided colon and rectal cancer surgery: a retrospective cohort study

Purpose Anastomotic leak (AL) is a serious complication following colorectal surgery. Atherosclerosis causes inadequate anastomotic perfusion and is suggested to be a risk factor for AL. The aim of this study was to investigate the association of mesenteric occlusive disease on preoperative computed tomography (CT) scan with AL after left-sided colon or rectal cancer surgery. Methods This was a retrospective, multicenter cohort study including 1273 patients that underwent left-sided or rectal cancer resection between 2009 and 2018 from three hospitals in the Netherlands. AL patients were 1:1 matched with non-leak patients and preoperative contrast-enhanced CT-scans were retrospectively analyzed for mesenteric atherosclerotic lesions. The main outcome measure was the presence of mesenteric occlusive disease on the preoperative CT-scan. Results Anastomotic leak developed in 6% of 1273 patients (N = 76). Low anterior resection and stage I–III disease were statistically significant associated with AL (p = 0.01, p = 0.04). No other statistically significant differences in patient characteristics between AL and non-leak patients were found. A clinically significant stenosis (≥ 70–100%) of the inferior mesenteric artery was statistically significant more frequent present in AL patients, compared to non-leak patients (p < 0.01). No statistically significant differences in the presence of mesenteric occlusive disease of the celiac artery and superior mesenteric artery between AL patients and non-leak patients were found. Conclusion Mesenteric occlusive disease of the IMA on preoperative CT-scan is associated with AL after left-sided colon or rectal resection for cancer. Preoperative identification of high-risk patients with a preoperative CT-scan of the mesenteric vasculature might be useful to reduce the risk of AL.

Association between CT-Based Preoperative Sarcopenia and Outcomes in Patients That Underwent Liver Resections

This retrospective observational study aimed to evaluate whether preoperative sarcopenia, assessed by CT imaging, was associated with postoperative clinical outcomes and overall survival in patients that underwent liver resections. Patients operated on between January 2014 and February 2020 were included. The skeletal muscle index (SMI) was measured at the level of the third lumbar vertebra on preoperative CT scans. Preoperative sarcopenia was defined based on pre-established SMI cut-off values. The outcomes were postoperative morbidity, length of hospital stay (LOS), and overall survival. Among 355 patients, 212 (59.7%) had preoperative sarcopenia. Patients with sarcopenia were significantly older (63.5 years) and had significantly lower BMIs (23.9 kg/m2) than patients without sarcopenia (59.3 years, p < 0.01, and 27.7 kg/m2, p < 0.01, respectively). There was no difference in LOS (8 vs. 8 days, p = 0.75), and the major complication rates were comparable between the two groups (11.2% vs. 11.3%, p = 1.00). The median overall survival times were comparable between patients with sarcopenia and those without sarcopenia (15 vs. 16 months, p = 0.87). Based on CT assessment alone, preoperative sarcopenia appeared to have no impact on postoperative clinical outcomes or overall survival in patients that underwent liver resections. Future efforts should also consider muscle strength and physical performance, in addition to imaging, for preoperative risk stratification.

Surgical and Anatomic Consideration in Endoscopic Dacryocystorhinostomy of a Patient with Damaged Sinonasal Anatomy Post–Caldwell-Luc Surgery: A Case Report

Background: The Caldwell-Luc (CL) procedure, an outdated operative procedure that is used to treat inflammatory sinus diseases, is rarely performed presently. However, physicians may encounter patients with a history of CL surgery who develop considerable postoperative changes that may lead to diagnostic confusion in imaging evaluation; increase the difficulty of future surgery, such as sinonasal surgery; and increase the incidence of future intraoperative complications. Case summary: A 67-year-old man with a surgical history of chronic sinusitis reported epiphora of the left eye for five years. Balloon dacryocystoplasty was attempted but failed. Endo-DCR (Endoscopic dacryocystorhinostomy) was indicated; however, preoperative CT (computed tomography) imaging and nasal endoscopic examination showed sinonasal anomalies and the loss of internal landmarks for localizing the lacrimal sac. Preoperative CT results indicated previous CL surgery. Endo-DCR was performed with the aid of nasal forceps and a 20-gauge vitreoretinal fiberoptic endoilluminator. A six-month follow-up revealed the complete resolution of symptoms and no signs of recurrence. Conclusions: Epiphora might be a delayed complication of the CL procedure. Before performing endo-DCR, ophthalmologists should be familiar with the sinonasal anatomy and carefully assess preoperative imaging to identify anatomical variations. Nasal forceps and transcanalicular illumination can assist in determining the precise location of the lacrimal sac during endo-DCR.

Are we mindful of nasal dorsal integrity during septal surgery? An imaging study of nasal keystone area

Objectives: Review of radiological images of the keystone area to assess risk of disruption to the nasal dorsum when separating the osseo-cartilaginous junction in septoplasty. Methods: A Cross sectional radiological study of adults who underwent CT scan of paranasal sinuses. Outcome measures included were: The Length of the keystone area (shorter length implies a higher risk of disruption) and a high-risk shape (high risk shape implies shorter keystone area) that can predispose to disruption of nasal dorsal integrity during septoplasty surgery. Certain nasal dimensions were evaluated to determine if they add risk to the dorsum. Results: CT scans of 343 patients were reviewed. The mean keystone area length was initially 10.42 mm that came down to 7.43 mm after adjustment in patients with high-risk shape. 31.5% of subjects were at risk of disruption to the dorsum due to short keystone area length <5 mm. Relatively shorter nasal bones (nasal bone length: overall dorsal length <0.49%) were associated with a shorter keystone area length (P = 0.004). Age, gender, septal deviation are not risk factors as they did not significantly influence keystone area length. Conclusions: One third of our patients (31.5%) had short KSA length < 5mm which carries higher risk of disruption to the dorsum integrity upon complete detachment of osseo-cartilaginous junction. We recommend preoperative CT imaging for thorough evaluation and precise measurement of KSA. Patients with relatively shorter nasal bones detected on examination (and confirmed radiologically), need to be recognized as they are more likely to have shorter KSA

Perfusion Strategy for Minimally Invasive Cardiac Surgery

Minimally invasive cardiac surgery (MICS) has a number of proven advantages compared to median sternotomy. Safe cannulation and perfusion are some of the main components of the success of MICS. The aim. To present our perfusion strategy and describe the methods of cannulation, technical features, contraindications and potential complications. Materials and methods. We examined the results of 1088 adult patients who underwent primary cardiac surgery in our hospital (coronary artery bypass grafting, valve surgery, aortic surgery, left ventricle repair, congenital cardiac surgery and combined procedures) from July 2017 to May 2021. Of these, 851 patients were qualified for MICS. To select a safe cannulation strategy, we performed contrast enhanced computed tomography (CT) of the aorta and main branches for all the patients, also we calculated the body surface area according to the DuBois and DuBois formula. Results. We performed 838 minimally invasive on-pump procedures, which is 98.5% of all patients qualified for MICS. According to the results of the preoperative CT scan, 13 (1.5%) patients were not operated with the minimally invasive approach due to the hazards related to the provision of cardiopulmonary bypass. Peripheral cannulation was performed in 754 (90%) patients and an alternative cannulation site was selected in 62 (8.2%) patients based on preoperative CT data. There were 10 (1.32%) patients who developed major complications (stroke, acute aortic dissection, acute renal failure requiring hemodialysis) after peripheral cannulation. Conclusions. Preoperative CT scan is mandatory for planning a perfusion strategy in minimally invasive cardiac surgery. The required surgical techniques should include cannulation of the right and left femoral and right axillary arteries.

Preoperative CT Simulation of Iliosacral Screws for Treating Unstable Posterior Pelvic Ring Injury

BackgroundPercutaneous iliosacral screw placement is an important surgical method for the treatment of pelvic unstable fractures, but either intraoperative X-ray screws or navigational screws may be misplaced. This study aimed to demonstrate a safe, effective, and rapid medthod for placing iliosacral screws for the treatment of unstable posterior pelvic ring injury according to preoperative computed tomography (CT) planning using simulated screws. MethodsAfter preoperative CT simulation of iliosacral screws planning screw insertion point and trajectory, intraoperative percutaneous iliosacral screws were used to treat unstable pelvic posterior ring injury.The mechanism of injury, Tile classification, number of screw implants, operative time of each screw implantation, radiation exposure time of each screw implantation screw position, complications, and postoperative follow-up time were collected.Screw position grading was evaluated by Smith grading. ResultsA total of 24 screws were implanted in 21 patients (9 men and 12 women;mean age 41.3 years:range 14-71 years). Tile classification included:Tile B:15 patients;Tile C:6 patients. The mean placement time of each screw was 19.5 minutes (range 14-32min); Radiation exposure time: 0.6 min (range 0.5-0.9min); Two screws were inserted in 3 patients; One screw was inserted in 18 patients; According to Smith grading standard, grade0:20 cases; and Grade1:1 case; Mean postoperative follow-up time was 17.1months (range12-25 months); None of the patients showed nonunion. ConclusionsPreoperative CT simulation of iliosacral screws for placement planning, screw trajectory, and intraoperative placement of screws is a safe method that can be used to reduce surgical time, radiation exposure, and accurate screw placement.