Comparison of Clinical Outcomes of Robot-Assisted, Video-Assisted, and Open Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-analysis.

Importance: The utilization of robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer is increasing, despite limited data comparing RAMIE with other surgical approaches. Objective: To evaluate the literature for clinical outcomes of RAMIE compared with video-assisted minimally invasive esophagectomy (VAMIE) and open esophagectomy (OE). Data Sources: A systematic search of PubMed, Cochrane, Ovid Medline, and Embase databases from January 1, 2013, to May 6, 2020, was performed. Study Selection: Studies that compared RAMIE with VAMIE and/or OE for cancer were included. Data Extraction and Synthesis: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline, data were extracted by independent reviewers. A random-effects meta-analysis of 9 propensity-matched studies was performed for the RAMIE vs VAMIE comparison only. A narrative synthesis of RAMIE vs VAMIE and OE was performed. Main Outcomes and Measures: The outcomes of interest were intraoperative outcomes (ie, estimated blood loss [EBL], operative time, lymph node [LN] harvest), short-term outcomes (anastomotic leak, recurrent laryngeal nerve [RLN] palsy, pulmonary and total complications, and 90-day mortality), and long-term oncologic outcomes. Results: Overall, 21 studies (2 randomized clinical trials, 11 propensity-matched studies, and 8 unmatched studies) with 9355 patients were included. A meta-analysis was performed with 9 propensity-matched studies comparing RAMIE with VAMIE. The random-effects pooled estimate found an adjusted risk difference (RD) of -0.06 (95% CI, -0.11 to -0.01) favoring fewer pulmonary complications with RAMIE. There was no evidence of differences between RAMIE and VAMIE in LN harvest (mean difference [MD], -1.1 LN; 95% CI, -2.45 to 0.25 LNs), anastomotic leak (RD, 0.0; 95% CI, -0.03 to 0.03), EBL (MD, -6.25 mL; 95% CI, -18.26 to 5.77 mL), RLN palsy (RD, 0.01; 95% CI, -0.08 to 0.10), total complications (RD, 0.05; 95% CI, -0.01 to 0.11), or 90-day mortality (RD, -0.01; 95% CI, -0.02 to 0.0). There was low certainty of evidence that RAMIE was associated with a longer disease-free survival compared with VAMIE. For OE comparisons (data not pooled), RAMIE was associated with a longer operative time, decreased EBL, and less pulmonary and total complications. Conclusions and Relevance: In this study, RAMIE had similar outcomes as VAMIE but was associated with fewer pulmonary complications compared with VAMIE and OE. Studies on long-term functional and cancer outcomes are needed.

Comparison of the C-MAC D-Blade videolaryngoscope and direct laryngoscope in pediatric patients: Randomized controlled trial.

BACKGROUND: Endotracheal intubation is a key skill for clinicians and may be challenging in some patients due to various reasons. Nowadays, various kinds of videolaryngoscopes are available and usually used as a rescue device when direct laryngoscopy failed. Pediatric airway has some differences when compared with adults and may be challenging. This study aims to compare and evaluate C Mac D-Blade and commonly used Macintosh laryngoscope in pediatric patients. METHODS: In this study, 56 pediatric patients, 5-10 years old (10-40 kgs) who had undergone elective surgery and need endotracheal intubation were included after obtaining ethical board approval and informed consent from parents. The patients were randomized into two equal groups for laryngoscopy and intubation by either with Macintosh laryngoscope or C Mac D-Blade videolaryngoscope. Glottic view, number of attempts, intubation time, any complications and hemodynamic variables were recorded. A value of p<0.05 was considered significant. RESULTS: In pediatric patients with unanticipated difficult airway, the mean intubation time was significantly shorter with C Mac D-Blade (21±9 and 41±7 seconds, respectively (p<0.001). The results of the two groups were similar concerning the remaining parameters. CONCLUSION: C Mac D-Blade videolaryngoscope shortened intubation time about twice when compared to Macintosh blade C Mac D-Blade videolaryngoscope, Videolaryngoscopes may be a good alternative for routine intubation, education and a rescue device for difficult intubation.

Video-assisted minimal access surgery for complicated mitral valve endocarditis, tricuspid valve insufficiency and progressive coronary disease after previous CABG - in the time of COVID-19: a case report.

BACKGROUND: The timing for heart surgery following cerebral embolization after cardiac valve vegetation is vital to postoperative recovery being uneventful, additionally Covid-19 may negatively affect the outcome. Minimally invasive methods and upgraded surgical instruments maximize the benefits of surgery also in complex cardiac revision cases with substantial perioperative risk. CASE PRESENTATION: A 68 y.o. patient, 10 years after previous sternotomy for OPCAB was referred to cardiac surgery on the 10th postoperative day after neurosurgical intervention for intracerebral bleeding with suspected mitral valve endocarditis. Mitral valve vegetation, tricuspid valve insufficiency and coronary stenosis were diagnosed and treated by minimally invasive revision cardiac surgery on the 14th postoperative day after neurosurgery. CONCLUSION: The present clinical case demonstrates for the first time that the minimally invasive approach via right anterior mini-thoracotomy can be safely used for concomitant complex mitral valve reconstruction, tricuspid valve repair and aorto-coronary bypass surgery, even as a revision procedure in the presence of florid endocarditis after recent neurosurgical intervention. The Covid-19 pandemic and prophylactic patient isolation slow down the efficacy of pulmonary weaning and mobilisation and prolong the need for ICU treatment, without adversely affecting long-term outcome.

Office-Based Lower Airway Endoscopy: Feasibility and Safety.

OBJECTIVES: The primary aim of this study was to identify the ease and safety of office-based lower airway endoscopy (OLAE) in patients with and without comorbidities. In addition, we identified the most common indications for OLAE and the associated diagnosis. METHODS: A retrospective review on 567 patients and 706 in-office flexible fiberoptic procedures was performed. Using a previously established grading system, the ease of visualization of the subglottis, trachea, and carina was assessed, in addition to the overall ease of the exam. RESULTS: Four hundred and eighty-eight videos were available for review. Of those, 105 videos included an OLAE, accounting for 21.5% of all procedures. Laryngomalacia was the most common diagnosis in 35 of 105 (36%) OLAE. For all laryngomalacia cases, the overall ease was found to be on average 2.15 (standard error 0.12). Fisher exact testing showed a statistical significance in the ability to visualize the trachea between the types of Laryngomalacia (LM) (P = .035). Fisher exact testing was performed comparing LM types I, II, or III, and combined types of LM; no statistical difference was found between groups. In 4.76% of OLAE procedures, a subglottic pathology was diagnosed. Comorbidities were found in OLAE 26 of 105 patients. There were no complications identified. CONCLUSION: We found OLAE more challenging than previously reported. OLAE of combined types of laryngomalacia was subjectively more difficult, but this difference did not reach statistical significance. OLAE continues to be a safe alternative to operative laryngoscopy in pediatric patients and appears safe in those with comorbidities when precautions are taken. LEVEL OF EVIDENCE: 4. Laryngoscope, 131:E649-E652, 2021.

First Experiences with MANTA Vascular Closure Device in Minimally Invasive Valve Surgery.

BACKGROUND: To more minimize the minimally invasive valve surgeries, percutaneous vascular access and closure has been used for the establishment of extracorporeal circulation. This study investigates early clinical outcomes of patients who received MANTA for femoral artery closure as first experiences in minimally invasive valve surgery. METHODS: Between January 2019 and July 2019, 103 consecutive patients (mean age: 58 ± 11 years) underwent video-assisted minimally invasive valve surgery through right anterior minithoracotomy at two cardiac surgery referral centers in Germany. Percutaneous cannulation for cardiopulmonary bypass and femoral artery closure with MANTA were performed in all patients: 18-F and 14-F MANTA were used in 88 (85.4%) and 15 (14.6%) patient, respectively. Mitral, aortic, tricuspid, and double valve surgeries were performed in 51 (49.5%), 39 (37.9%), 7 (6.8%), and 6 (5.8%), patients, respectively. Clinical data were prospectively entered into our institutional database. RESULTS: Cardiopulmonary bypass time and cross-clamping time were 69 ± 23 and 38 ± 14 minutes, respectively. Except for two patients with late pseudoaneurysm on 15th and 23th postoperative day, neither major nor minor vascular complications nor vascular closure device failure according to the Valve Academic Research Consortium-2 definition criteria was observed. Additionally, no wound healing disorders or conversion to surgical closure was observed. CONCLUSIONS: MANTA as percutaneous femoral artery closure after decannulation of cardiopulmonary bypass is a safe, feasible, and effective approach and yields excellent early outcomes. Larger size studies are needed to evaluate more the efficacy and safety of MANTA.

Left Cardiac Sympathetic Denervation Monotherapy in Patients With Congenital Long QT Syndrome.

BACKGROUND: Videoscopic left cardiac sympathetic denervation (LCSD) is an effective antifibrillatory, minimally invasive therapy for patients with potentially life-threatening arrhythmia syndromes like long QT syndrome (LQTS). Although initially used primarily for treatment intensification following documented LQTS-associated breakthrough cardiac events while on beta-blockers, LCSD as 1-time monotherapy for certain patients with LQTS requires further evaluation. We are presenting our early experience with LCSD monotherapy for carefully selected patients with LQTS. METHODS: Among the 1400 patients evaluated and treated for LQTS, a retrospective review was performed on the 204 patients with LQTS who underwent LCSD at our institution since 2005 to identify the patients where the LCSD served as stand-alone, monotherapy. Clinical data on symptomatic status before diagnosis, clinical, and genetic diagnosis, and breakthrough cardiac events after diagnosis were analyzed to determine efficacy of LCSD monotherapy. RESULT: Overall, 64 of 204 patients (31%) were treated with LCSD alone (37 [58%] female, mean QTc 466±30 ms, 16 [25%] patients were symptomatic before diagnosis with a mean age at diagnosis 17.3±11.8 years, 5 had [8%] ≥1 breakthrough cardiac event after diagnosis, and mean age at LCSD was 21.1±11.4 years). The primary motivation for LCSD monotherapy was an unacceptable quality of life stemming from beta-blocker related side effects (ie, beta-blocker intolerance) in 56/64 patients (88%). The underlying LQTS genotype was LQT1 in 36 (56%) and LQT2 in 20 (31%). There were no significant LCSD-related surgical complications. With a mean follow-up of 2.7±2.4 years so far, only 3 patients have experienced a nonlethal, post-LCSD breakthrough cardiac event in 180 patient-years. CONCLUSIONS: LCSD may be a safe and effective stand-alone therapy for select patients who do not tolerate beta-blockers. However, LCSD is not curative and patient selection will be critical when potentially considering LCSD as monotherapy.

Video-Assisted Ligation of Intersphincteric Fistula Tract for Complex Anal Fistula: Technique and Preliminary Outcomes.

BACKGROUND: Sphincter-preserving operations have been increasingly used for treating anal fistula. However, their success rates remain modest in complex anal fistulas. OBJECTIVE: This study aimed to report outcomes of video-assisted ligation of intersphincteric fistula tract (a procedure combining video-assisted anal fistula treatment and ligation of intersphincteric fistula tract) for treating complex anal fistulas and to compare its results with conventional ligation of intersphincteric fistula tract. DESIGN: A review of prospectively collected data from October 2014 to December 2017 was performed. SETTINGS: The study was conducted at a large tertiary hospital in Thailand. PATIENTS: All patients with primary or recurrent complex anal fistulas undergoing video-assisted ligation of intersphincteric fistula tract were included. Patients with anal fistula related to malignancy, Crohn's disease, tuberculosis, or acute abscess were excluded. MAIN OUTCOME MEASURES: Healing as defined by an absence of fistula or drainage from an external opening and complete epithelialization of the external opening were measured. RESULTS: This study included 103 patients with a median age of 47 years. The primary healing rate was 84.5% at a median follow-up of 28 months (range, 15-38 mo). Primary healing rates of anterior high transsphincteric fistula, semi-horseshoe fistula, and horseshoe fistula were 88% (44 of 50 cases), 77% (30 of 39 cases), and 93% (13 of 14 cases). Median time to healing was 4 weeks (range, 4-8 wk). Accordingly, the overall failure rate was 15.5%. None reported worse fecal incontinence postoperatively. Video-assisted ligation of intersphincteric fistula tract had a higher rate of primary healing for complex anal fistula than ligation of intersphincteric fistula tract (84.5% vs 63.4%; p < 0.001). LIMITATIONS: This study is limited by its small sample size. CONCLUSIONS: The outcomes of video-assisted ligation of intersphincteric fistula tract for complex anal fistulas are quite good. This technique has the potential to become another viable option of sphincter-preserving operation for complex anal fistulas. See Video Abstract at http://links.lww.com/DCR/B373. LIGADURA ASISTIDA POR VIDEO DEL TRACTO DE LA FÍSTULA INTERESFINTÉRICA PARA LA FÍSTULA ANAL COMPLEJA: TÉCNICA Y RESULTADOS PRELIMINARIES: Las operaciones de preservación del esfínter se han utilizado cada vez más para tratar la fístula anal. Sin embargo, sus tasas de éxito siguen siendo modestas en las fístulas anales complejas.Este estudio tuvo como objetivo informar los resultados de la ligadura asistida por video del tracto de la fístula interesfintérica (un procedimiento que combina el tratamiento de la fístula anal asistida por video y la ligadura del tracto de la fístula interesfintérica) para el tratamiento de las fístulas anales complejas y comparar sus resultados con la ligadura convencional de la fístula interesfintérica tracto.Se realizó una revisión de los datos recolectados prospectivamente desde Octubre de 2014 hasta Diciembre de 2017.El estudio se realizó en un gran hospital terciario en Tailandia.Se incluyeron todos los pacientes con fístulas anales complejas primarias o recurrentes sometidas a ligadura asistida por video del tracto de la fístula interesfintérica. Se excluyeron los pacientes con fístula anal relacionada con malignidad, enfermedad de Crohn, tuberculosis o absceso agudo.Curación definida por la ausencia de fístula o drenaje de la abertura externa y la epitelización completa de la abertura externa.Este estudio incluyó 103 pacientes con una mediana de edad de 47 años. La tasa de curación primaria fue del 84,5% con una mediana de seguimiento de 28 meses (rango 15-38). La tasa de curación primaria de la fístula transesfintérica alta anterior, la fístula semi-herradura y la fístula de herradura fue del 88% (44 de 50 casos), 77% (30 de 39 casos) y 93% (13 de 14 casos), respectivamente. El tiempo mediano hasta la curación fue de 4 semanas (rango 4-8). En consecuencia, la tasa de fracaso general fue del 15,5%. Ninguno informó peor incontinencia fecal después de la operación. La ligadura asistida por video del tracto de la fístula interesfintérica tuvo una mayor tasa de curación primaria para la fístula anal compleja que la ligadura del tracto de la fístula interesfintérica (84.5% vs 63.4%; p <0.001).Este estudio está limitado por su pequeño tamaño de muestra.Los resultados de la ligadura asistida por video del tracto de la fístula interesfintérica para fístulas anales complejas son bastante buenos. Esta técnica tiene el potencial de convertirse en otra opción viable de operación de preservación del esfínter para fístulas anales complejas. Consulte Video Resumen en http://links.lww.com/DCR/B373. (Traducción-Dr Yesenia Rojas-Khalil).

Comparison of surgical outcomes between video-assisted anal fistula treatment and fistulotomy plus seton for complex anal fistula: A propensity score matching analysis - Retrospective cohort study.

BACKGROUND: Video-assisted anal fistula treatment (VAAFT) is a new minimally invasive technique for treating complex anal fistula (CAF). This study aimed to compare the efficacy and safety of VAAFT with fistulotomy plus seton (FPS) for treatment of CAF. MATERIALS AND METHODS: We included 148 patients with CAF receiving surgical treatment at our hospital between January 2017 and December 2018. Propensity score matching (PSM) analysis was conducted with patients' baseline characteristics, and surgical outcomes were compared between the matched groups. Logistic analysis was performed to identify the risk factors for fistula recurrence after VAAFT. RESULTS: Among the study population, 68 and 80 patients underwent VAAFT and FPS, respectively. After PSM, 64 matched pairs of patients were created with no significant differences in baseline characteristics. Compared with FPS, VAAFT had greater efficiency of locating internal openings (90.6% vs. 100%), less intraoperative blood loss (26 ± 15 vs. 12 ± 5 mL), lower incidence of postoperative bleeding (10.9% vs. 1.5%), shorter postoperative hospital stay (6.8 ± 5.1 vs. 5.0 ± 3.3 days), reduced postoperative pain, and decreased wound secretion (all P < 0.05). VAAFT showed a significantly lower Wexner incontinence score than FPS (0.9 ± 1.7 vs. 1.9 ± 2.6, P = 0.003) at 3 months postoperatively, but no significant difference in the healing rate was observed either at 3-month or 1-year (P = 1.000) follow-up. A total of 12 patients (17.6%) developed fistula recurrence after VAAFT, and logistic analysis revealed that multiple fistula tracts, prolonged operating time and severe postoperative wound secretion were independent risk factors (odds risk = 2.18, 3.25 and 3.04, respectively, all adjusted P < 0.05). CONCLUSION: Compared with FPS, VAAFT offers some advantages for treatment of CAF, including minimal damage, less pain, rapid recovery, fewer complications and better sphincter preservation.

Drug-induced sleep endoscopy in children. / Exploración videoendoscópica bajo sueño inducido en niños.

This document is intended as a guide for Spanish ENT specialists who want to perform drug-induced sleep endoscopy. Indications, sedation method and important findings are discussed to unify criteria and methodology.

Drug-induced sleep endoscopy. / La endoscopia del sueño inducido.

This document introduces drug-induced sleep endoscopy to the specialist treating sleep breathing disorders and is intended as a guide for those willing to perform the procedure so that it can be reproducible.

Surgical training in video-assisted neck surgery-based thyroidectomy using fresh frozen human cadavers.

Endoscopic surgery has been introduced in various surgical fields. Endoscopic surgery requires different skills from open surgery due to the restricted surgical field and difficulty in identifying anatomical structures from certain viewpoints. Therefore, surgeons need to undergo sufficient surgical training before performing such surgery in the clinical setting. We examined the utility of fresh frozen human cadavers for surgical training aimed at introducing video-assisted neck surgery (VANS) at our department. First, we performed surgical training using fresh human cadavers four times. Next, we performed hemi-thyroidectomy with VANS in 5 clinical patients. After the cadaver training and the actual surgery, the surgeons evaluated each step of the surgical procedure using a 3-point scale. In the cadaver training, the scores for steps : creation of a subcutaneous tunnel and lifting up the skin flap and pre-thyroid muscles were higher than other steps. And a tracheal injury occurred as a complication. However, we were able to recognize anatomical structures under the endoscopic view. And it was also useful for confirming the role of surgical staff and simulating the placement of surgical equipment. Surgical training using fresh frozen human cadavers was effective at introducing a new surgical method. J. Med. Invest. 66 : 293-296, August, 2019.

[Evaluation of experience acquisition in video-assisted hemithyroidectomy]. / Sposoby otsenki priobreteniya opyta pri osvoenii videoassistirovannykh gemitireoidektomii.

OBJECTIVE: To determine validity and adequacy of the assessment of experience acquisition in video-assisted hemithyroidectomy, to compare surgical outcomes at the learning stage and in delayed period. MATERIAL AND METHODS: Experience acquisition was studied via assessment of the duration of video-assisted hemithyroidectomy in 67 patients who were operated by the same surgeon. Time of surgery was analyzed through between-group comparison of surgical outcomes. These groups were defined arbitrarily, in exponential fashion, using the logarithm method and moving average. Risks of failure regarding duration of surgery and postoperative complications were investigated using CUSUM analysis. RESULTS: Minimum period of experience accumulation in video-assisted hemithyroidectomy (26 procedures) was determined using logarithmic analysis, maximum period (66 interventions) - using CUSUM analysis. Other approaches also showed sharp nature of the learning curve.CUSUM analysis of failures at the learning stage showed 2-fold decrease of their probability after 66 operations. However, even experience acquisitiondoes not exclude risk of failures in hemithyroidectomy. CONCLUSION: Arbitrary division of the cohort of patients seems to be unreasonable because clear number of operations necessary to achieve sustainable results does not follow it.Mathematical methods adequately reflect experience accumulation and allow determining the required number of interventions for stable results and minimum complication rate.

Application of indocyanine green-enhanced near-infrared fluorescence-guided imaging in laparoscopic lateral pelvic lymph node dissection for middle-low rectal cancer.

BACKGROUND: As one effective treatment for lateral pelvic lymph node (LPLN) metastasis (LPNM), laparoscopic LPLN dissection (LPND) is limited due to the complicated anatomy of the pelvic sidewall and various complications after surgery. With regard to improving the accuracy and completeness of LPND as well as safety, we tried an innovative method using indocyanine green (ICG) visualized with a near-infrared (NIR) camera system to guide the detection of LPLNs in patients with middle-low rectal cancer. AIM: To investigate whether ICG-enhanced NIR fluorescence-guided imaging is a better technique for LPND in patients with rectal cancer. METHODS: A total of 42 middle-low rectal cancer patients with clinical LPNM who underwent total mesorectal excision (TME) and LPND between October 2017 and March 2019 at our institution were assessed and divided into an ICG group and a non-ICG group. Clinical characteristics, operative outcomes, pathological outcomes, and postoperative complication information were compared and analysed between the two groups. RESULTS: Compared to the non-ICG group, the ICG group had significantly lower intraoperative blood loss (55.8 ± 37.5 mL vs 108.0 ± 52.7 mL, P = 0.003) and a significantly larger number of LPLNs harvested (11.5 ± 5.9 vs 7.1 ± 4.8, P = 0.017). The LPLNs of two patients in the non-IVG group were residual during LPND. In addition, no significant difference was found in terms of LPND, LPNM, operative time, conversion to laparotomy, preoperative complication, or hospital stay (P > 0.05). CONCLUSION: ICG-enhanced NIR fluorescence-guided imaging could be a feasible and convenient technique to guide LPND because it could bring specific advantages regarding the accuracy and completeness of surgery as well as safety.

Post-surgical atypical mycobacteriosis in 125 patients in Rio de Janeiro.

INTRODUCTION: The growing incidence of post-surgical atypical mycobacteriosis (PSAM) may be related to the increased use of low- and medium-complexity video-assisted surgery. METHODS: Between April 2007 and June 2009, 125 patients were referred from the State Health Department of Rio de Janeiro for the treatment of confirmed, probable, or suspected PSAM. RESULTS: Laparoscopic cholecystectomy was the most frequent surgical procedure (48.8%) among patients. Clarithromycin, ethambutol, and terizidone were used to treat 113 patients for a mean duration of 226 days. CONCLUSIONS: Despite the need for multidrug therapy and long treatment duration, most included patients adhered to treatment and experienced cure without relapse.

10-mm Laparo-Endoscopic Single-Site Cholecystectomy Using Multiple Magnetically Anchored and Controlled Instruments.

BACKGROUND: To study the feasibility of laparo-endoscopic single-site (LESS) cholecystectomy through a 10-mm incision using a miniature magnetically anchored and controlled laparoscopy system and a grasper system. METHODS: The miniature magnetically anchored and controlled laparoscopy system consisted of a miniature magnetically anchored camera (MMAC), an external magnetic anchoring unit, and a vision output device. The camera weighed 9.8 g and measured Φ10 mm × 50 mm. The magnetically anchored and controlled grasper system consisted of a magnetically anchored grasper (MAG), an external magnetic anchoring unit, and a push-pull device. The MAG had a titanium alloy clip head and a magnetic tail. The laparoscopy system and grasper system were used simultaneously to perform LESS cholecystectomy through a single 10-mm incision in model canines. RESULTS: LESS cholecystectomy through a 10-mm incision using the MMAC and MAG was attempted in six dogs. The mean operative time was 85.75 ± 7.14 min. The operation was completed successfully in four cases, with failure occurring in one case due to gallbladder rupture and in another due to bile duct injury. The MMAC provided clear imaging, and the MAG provided sufficient exposure to perform the cholecystectomy. The use of multiple magnetically anchored and controlled instruments did not result in notable collisions. CONCLUSIONS: The designed MMAC and MAG system could be easily maneuvered. LESS cholecystectomy may be feasible through a single 10-mm incision with the simultaneous use of multiple magnetically anchored and controlled instruments.

Strategy-specific durability of mitral valve repair through the video-assisted right minithoracotomy approach.

AIMS: We sought to analyze the early and follow-up results of minimally invasive video-assisted mitral valve repair. With particular focus on degenerative disease, results were stratified according to type of lesion, strategy of repair and surgical technique. METHODS: We retrospectively built a database over 241 patients who received mitral repair for severe regurgitation through right minithoracotomy in the 2009-17 period. Cause was degenerative in 92.1%, restrictive in 5.8% and mixed in the remainders. Clinical and echocardiographic follow-up (98.7% complete, average duration 2.9 years ±â€Š1.4) was obtained through contact of in-house and territorial cardiologists. Recurrent mitral regurgitation at follow-up was defined as being at least mild-to-moderate (2+). RESULTS: Operative mortality was 1.7%, and related to the technique in one case. Five-year actuarial survival was 95% ±â€Š2; there was no valve-related death and one reoperation. At follow-up, we observed eight cases of 2+ regurgitation and one instance of 4+ regurgitation (4-year actuarial freedom: 92% ±â€Š4). Freedom from recurrent regurgitation was significantly lower in the 'restrictive' subgroup vs. the 'degenerative' subgroup (P = 0.02); no statistically significant difference in freedom from recurrence was observed among patients who received mitral repair using a 'resect' vs. 'nonresection' strategy (P = 0.46), and in those who received the Totally Endoscopic technique (endoaortic balloon occlusion, no costal spreading) vs. controls (external aortic clamp, costal spreading) (P = 0.98). CONCLUSION: Durability of minimally invasive mitral repair is optimal. Nonresection repair techniques are at least noninferior to previous approaches based on leaflet resection.

Invasive EEG-electrodes in presurgical evaluation of epilepsies: Systematic analysis of implantation-, video-EEG-monitoring- and explantation-related complications, and review of literature.

INTRODUCTION: Stereoelectroencephalography (sEEG) is a diagnostic procedure for patients with refractory focal epilepsies that is performed to localize and define the epileptogenic zone. In contrast to grid electrodes, sEEG electrodes are implanted using minimal invasive operation techniques without large craniotomies. Previous studies provided good evidence that sEEG implantation is a safe and effective procedure; however, complications in asymptomatic patients after explantation may be underreported. The aim of this analysis was to systematically analyze clinical and imaging data following implantation and explantation. RESULTS: We analyzed 18 consecutive patients (mean age: 30.5 years, range: 12-46; 61% female) undergoing invasive presurgical video-EEG monitoring via sEEG electrodes (n = 167 implanted electrodes) over a period of 2.5 years with robot-assisted implantation. There were no neurological deficits reported after implantation or explantation in any of the enrolled patients. Postimplantation imaging showed a minimal subclinical subarachnoid hemorrhage in one patient and further workup revealed a previously unknown factor VII deficiency. No injuries or status epilepticus occurred during video-EEG monitoring. In one patient, a seizure-related asymptomatic cross break of two fixation screws was found and led to revision surgery. Unspecific symptoms like headaches or low-grade fever were present in 10 of 18 (56%) patients during the first days of video-EEG monitoring and were transient. Postexplantation imaging showed asymptomatic and small bleedings close to four electrodes (2.8%). CONCLUSION: Overall, sEEG is a safe and well-tolerated procedure. Systematic imaging after implantation and explantation helps to identify clinically silent complications of sEEG. In the literature, complication rates of up to 4.4% in sEEG and in 49.9% of subdural EEG are reported; however, systematic imaging after explantation was not performed throughout the studies, which may have led to underreporting of associated complications.