Risk assessment for pancreatic fistula by intraoperative image analysis of laparoscopic and robotic gastrectomy.

BACKGROUND: Pancreatic fistula (PF) is one of the most serious postoperative complications of gastrectomy. Misidentification of the boundary between the pancreas and the dissected fat is a primary concern. In this study, we focused on differences in the appearance of the pancreas and the dissected fat in actual surgical images and statistically analyzed the relationship between the pancreas and the dissected fat. METHODS: We analyzed data from 109 gastric cancer patients who underwent curative gastrectomy between November 2018 and March 2023. Intraoperative images were taken from videos of lymph node dissections of Nos.6 and 8a regions, and the mean gray value of the areas was measured using ImageJ software for analysis. The visceral fat area (VFA) was evaluated by preoperative axial CT at the umbilical level using Ziostation software. RESULTS: A significant correlation was observed between the fat/pancreas gray value ratio in the No.8a lymph node region and the drain/serum amylase ratio (P < 0.001). The fat/pancreas gray value ratio in the No.6 lymph node region correlated with VFA (P < 0.001). The VFA and drain/serum amylase ratio were significantly higher in the group with intra-abdominal complications (P = 0.004). CONCLUSIONS: We revealed significant relationships between the fat/pancreas gray value ratio with drain/serum amylase and VFA. Detecting differences in gray values between the pancreas and the dissected fat may lead to a decrease in the drain/serum amylase ratio and PF.

Clinical application of computed tomographic volumetric imaging in postoperative lung function assessment in patients with lung cancer.

BACKGROUND: To evaluate the effectiveness of the computed tomographic (CT) volumetric analysis in postoperative lung function assessment and the predicting value for postoperative complications in patients who had segmentectomy for lung cancer. METHODS: CT scanning and pulmonary function examination were performed for 100 patients with lung cancer. CT volumetric analyses were performed by specific software, for the volume of the inspiratory phase (Vin), the mean inspiratory lung density (MLDin), the volume of expiratory phase (Vex), and the mean lung density at expiratory phase (MLDex). Pulmonary function examination results and CT volumetric analysis results were used to predict postoperative lung function. The concordance and correlations of these values were assessed by Bland-Altman analysis and Pearson correlation analysis, respectively. Multivariate binomial logistic regression analysis was executed to assess the associations of CT data with complication occurrence. RESULTS: Correlations between CT scanning data and pulmonary function examination results were significant in both pre- and post-operation (0.8083 ≤ r ≤ 0.9390). Forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and the ratio of FVC and FEV1 estimated by CT volumetric analyses showed high concordance with those detected by pulmonary function examination. Preoperative (Vin-Vex) and (MLDex- MLDin) values were identified as predictors for post-surgery complications, with hazard ratios of 5.378 and 6.524, respectively. CONCLUSIONS: CT volumetric imaging analysis has the potential to determine the pre- and post-operative lung function, as well as to predict post-surgery complication occurrence in lung cancer patients with pulmonary lobectomy.

The Value of Coagulation-Related Indicators Combined with Vascular Ultrasound Parameters in the Risk Assessment of Deep Vein Thrombosis after Secondary Traumatic Fracture Surgery.

OBJECTIVE: The incidence of deep vein thrombosis (DVT) after traumatic fracture is high, and DVT causes serious adverse effects on the postoperative recovery of patients. The purpose of this study was to explore the effect of coagulation-related indicators combined with vascular ultrasound measurements for the risk assessment of DVT after secondary traumatic fracture, and to provide a new method for predicting the occurrence of DVT. METHODS: The clinical data of patients with secondary traumatic fracture surgery in our hospital from January 2019 to January 2022 were retrospectively analyzed. The patients were divided into a non-DVT group and a DVT group according to whether DVT was indicated in the medical record system. The coagulation-related indices and vascular ultrasound measurements of the two groups were compared, and the risk factors for postoperative DVT were analyzed by bivariate correlation and multivariate logistic regression. RESULTS: According to the medical record system, 55 patients (47.41%) had DVT, and 61 patients (52.59%) did not have DVT. There was no significant difference in prothrombin time (PT) or activated partial thromboplastin time (APTT) between the two groups (p > 0.05). The thrombin time (TT) in the DVT group was lower than that in the non-DVT group. The levels of fibrinogen (FIB) and D-dimer (D-D) in the DVT group were higher than those in the non-DVT group (t = 2.766, 3.242, 2.649, p = 0.007, 0.002, 0.009). Spearman correlation analysis showed that peak systolic velocity (Vs), end-diastolic velocity (Vd), pulsatility index (PI), resistance index (RI), FIB, and D-D were positively correlated with the risk of DVT after secondary traumatic fracture surgery (r = 0.264, 0.656, 0.293, 0.276, 0.287, 0.251, p < 0.05). TT was negatively correlated with DVT risk after secondary traumatic fracture surgery (r = -0.249, p < 0.05). The measurements of peak systolic velocity (Vs), end diastolic velocity (Vd), pulsatility index (PI) and resistance index (RI) in the DVT group were higher than those in the non-DVT group (t = 2.663, 2.998, 3.135, 2.953, p = 0.009, 0.003, 0.002, 0.004). FIB, D-D, Vs, Vd, PI, and RI were independent risk factors for DVT after secondary traumatic fracture surgery (Odds Ratio (OR) = 1.483, 2.026, 2.208, 1.893, 1.820, 1.644, p < 0.05). TT index was an independent protective factor for DVT after secondary traumatic fracture surgery (OR = 0.868, p < 0.05). The sensitivity and specificity for prediction of DVT based on combined coagulation-related indicators and vascular ultrasound imaging measurements were higher than those of individual measurements (p < 0.05). CONCLUSIONS: Coagulation-related indicators and vascular ultrasound parameters can effectively predict the formation of DVT. Through the analysis of factors related to DVT formation, screening of high-risk patients for effective intervention may help to reduce the risk of DVT. Further verification in additional, large-scale clinical trials is advocated.

Assessment of pre-extubating recurrent laryngeal nerve palsy using ultrasound in postoperative patients with esophageal cancer: a prospective observational study.

PURPOSE: Ultrasound performed after extubation has been suggested to be useful for the diagnosis of recurrent laryngeal nerve (RLN) paralysis. However, the use of ultrasound for this purpose before extubation has not been examined. The aim of this study was to examine the versatility (interrater reliability) and usefulness of ultrasound for evaluating the movement of vocal cords before extubation. METHODS: The subjects were 30 patients who underwent radical surgery for esophageal cancer from August 2020 to December 2021. An experienced examiner performed an ultrasound examination before and after elective extubation on the day after surgery to evaluate RLN paralysis and record videos. Bronchoscopy was then performed to make a definite diagnosis. Three anesthetists blinded to the diagnosis also evaluated the cases using the videos, and the versatility of the examination was determined using a kappa test. RESULTS: The diagnostic accuracies of the examiner and three anesthetists were 76.7%, 50.0%, 53.3%, and 46.7%, respectively, and the kappa coefficients for the examiner with the anesthetists were 0.310, 0.502, and 0.169, respectively. The sensitivity, specificity, positive predictive value and negative predictive value for diagnosis of RLN paralysis by the examiner using ultrasound before extubation were 0.57, 0.95, 0.80, and 0.87, respectively. CONCLUSION: These results indicate a lack of versatility of the ultrasound examination based on the low kappa coefficients. However, with an experienced examiner, ultrasound can serve as a non-invasive examination that can be performed before extubation with high accuracy and specificity for diagnosis of postoperative RLN paralysis.

Role of Radiology in Assessment of Postoperative Complications of Heart Transplantation.

Heart transplantation is a pivotal treatment of end-stage heart failure, and recent advancements have extended median posttransplant life expectancy. However, despite the progress in surgical techniques and medical treatment, heart transplant patients still face complications such as rejection, infections, and drug toxicity. CT is a reliable tool for detecting most of these complications, whereas MR imaging is particularly adept at identifying pericardial pathologies and signs of rejection. Awareness of these nuances by radiologists, cardiologists, and surgeons is desired to optimize care, reduce morbidities, and enhance survival.

Radiomics for the prediction of a postoperative pancreatic fistula following a pancreatoduodenectomy: A systematic review and radiomic score quality assessment.

BACKGROUND: Postoperative pancreatic fistula (POPF) is a severe complication following a pancreatoduodenectomy. An accurate prediction of POPF could assist the surgeon in offering tailor-made treatment decisions. The use of radiomic features has been introduced to predict POPF. A systematic review was conducted to evaluate the performance of models predicting POPF using radiomic features and to systematically evaluate the methodological quality. METHODS: Studies with patients undergoing a pancreatoduodenectomy and radiomics analysis on computed tomography or magnetic resonance imaging were included. Methodological quality was assessed using the Radiomics Quality Score (RQS) and Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis (TRIPOD) statement. RESULTS: Seven studies were included in this systematic review, comprising 1300 patients, of whom 364 patients (28 %) developed POPF. The area under the curve (AUC) of the included studies ranged from 0.76 to 0.95. Only one study externally validated the model, showing an AUC of 0.89 on this dataset. Overall adherence to the RQS (31 %) and TRIPOD guidelines (54 %) was poor. CONCLUSION: This systematic review showed that high predictive power was reported of studies using radiomic features to predict POPF. However, the quality of most studies was poor. Future studies need to standardize the methodology. REGISTRATION: not registered.

Radiological assessment of skeletal muscle index and myosteatosis and their impact postoperative outcomes after liver transplantation.

BACKGROUND: Liver transplantation offers curative treatment to patients with acute and chronic end-stage liver disease. The impact of nutritional status on postoperative outcomes after liver transplantation remains poorly understood. The present study investigated the predictive value of radiologically assessed skeletal muscle index (SMI) and myosteatosis (MI) on postoperative outcomes. PATIENTS AND METHODS: Data of 138 adult patients who underwent their first orthotopic liver transplantation were retrospectively analysed. SMI and MI in computer tomography (CT) scan at the third lumbar vertebra level were calculated. Results were analyzed for the length of hospitalisation and postoperative outcomes. RESULTS: In 63% of male and 28.9% of female recipients, low SMI was found. High MI was found in 45(32.6%) patients. Male patients with high SMI had longer intensive care unit (ICU) stay (P < 0.025). Low SMI had no influence on ICU stay in female patients (P = 0.544), length of hospitalisation (male, P > 0.05; female, P = 0.843), postoperative complication rates (males, P = 0.883; females, P = 0.113), infection rate (males, P = 0.293, females, P = 0.285) and graft rejection (males, P = 0.875; females, P = 0.135). The presence of MI did not influence ICU stay (P = 0.161), hospitalization (P = 0.771), postoperative complication rates (P = 0.467), infection rate (P = 0.173) or graft rejection rate (P = 0.173). CONCLUSIONS: In our study, changes in body composition of liver transplant recipients observed with SMI and MI had no impact on postoperative course after liver transplantation. CT body composition analysis of recipients and uniformly accepted cut-off points are crucial to producing reliable data in the future.

Postoperative stroke assessment inconsistencies in cardiac surgery: Contributors to higher stroke-related mortality?

OBJECTIVES: In-hospital stroke mortality is surprisingly much worse than for strokes occurring outside of the hospital. Cardiac surgery patients are amongst the highest risk groups for in-hospital stroke and experience high stroke-related mortality. Variability in institutional practices appears to play an important role in the diagnosis, management, and outcome of postoperative stroke. We therefore tested the hypothesis that variability in postoperative stroke management of cardiac surgical patients exists across institutions. MATERIALS AND METHODS: A 13 item survey was employed to determine postoperative stroke practice patterns for cardiac surgical patients across 45 academic institutions. RESULTS: Less than half (44%) reported any formal clinical effort to preoperatively identify patients at high risk for postoperative stroke. Epiaortic ultrasonography for the detection of aortic atheroma, a proven preventative measure, was routinely practiced in only 16% of institutions. Forty-four percent (44%) reported not knowing whether a validated stroke assessment tool was utilized for the detection of postoperative stroke, and 20% reported that validated tools were not routinely used. All responders, however, confirmed the availability of stroke intervention teams. CONCLUSIONS: Adoption of a best practices approach to the management of postoperative stroke is highly variable and may improve outcomes in postoperative stroke after cardiac surgery.

Lung ultrasound score-based assessment of postoperative atelectasis in obese patients according to inspired oxygen concentration: A prospective, randomized-controlled study.

BACKGROUND: According to a recent meta-analysis, in patients with a body mass index (BMI) ≥ 30, a high fraction of inhaled oxygen (FiO2) did not increase postoperative atelectasis. However, a high FiO2 generally increases the risk of postoperative atelectasis. Therefore, this study aimed to evaluate the effect of FiO2 on the development of atelectasis in obese patients using the modified lung ultrasound score (LUSS). METHODS: Patients were assigned to 4 groups: BMI ≥ 30: group A (n = 21) and group B (n = 20) and normal BMI: group C (n = 22) and group D (n = 21). Groups A and C were administered 100% O2 during preinduction and emergence and 50% O2 during anesthesia. Groups B and D received 40% O2 for anesthesia. The modified LUSS was assessed before and 20 min after arrival to the postanesthesia care unit (PACU). RESULTS: The difference between the modified LUSS preinduction and PACU was significantly higher in group A with a BMI ≥ 30 (P = .006); however, there was an insignificant difference between groups C and D in the normal BMI group (P = .076). CONCLUSION: High FiO2 had a greater effect on the development of atelectasis in obese patients than did low FiO2; however, in normal-weight individuals, FiO2 did not have a significant effect on postoperative atelectasis.

Assessment of pyloric sphincter physiology after Ivor-Lewis esophagectomy using an endoluminal functional lumen imaging probe.

OBJECTIVE OF THE STUDY: The most common functional complication after Ivor-Lewis esophagectomy is the delayed emptying of the gastric conduit (DGCE) for which several diagnostic tools are available, e.g. chest X-ray, upper esophagogastroduodenoscopy (EGD) and water-soluble contrast radiogram. However, none of these diagnostic tools evaluate the pylorus itself. Our study demonstrates the successful measurement of pyloric distensibility in patients with DGCE after esophagectomy and in those without it. METHODS AND PROCEDURES: Between May 2021 and October 2021, we performed a retrospective single-centre study of all patients who had an oncological Ivor-Lewis esophagectomy and underwent our post-surgery follow-up programme with surveillance endoscopies and computed tomography scans. EndoFlip™ was used to perform measurements of the pylorus under endoscopic control, and distensibility was measured at 40 ml, 45 ml and 50 ml balloon filling. RESULTS: We included 70 patients, and EndoFlip™ measurement was feasible in all patients. Successful application of EndoFlip™ was achieved in all interventions (n = 70, 100%). 51 patients showed a normal postoperative course, whereas 19 patients suffered from DGCE. Distensibility proved to be smaller in patients with symptoms of DGCE compared to asymptomatic patients. For 40 ml, 45 ml and 50 ml, the mean distensibility was 6.4 vs 10.1, 5.7 vs 7.9 and 4.5 vs 6.3 mm2/mmHg. The differences were significant for all three balloon fillings. No severe EndoFlip™ treatment-related adverse events occurred. CONCLUSION: Measurement with EndoFlip™ is a safe and technically feasible endoscopic option for measuring the distensibility of the pylorus. Our study shows that the distensibility in asymptomatic patients after esophagectomy is significantly higher than that in patients suffering from DGCE. However, more studies need to be conducted to demonstrate the general use of EndoFlip™ measurement of the pylorus after esophagectomy.

Intraoperative evaluation of renal resistive index with transesophageal echocardiography for the assessment of acute renal injury in patients undergoing coronary artery bypass grafting surgery: A prospective observational study.

Background: Acute kidney injury (AKI) is a common complication after on pump coronary artery bypass grafting (CABG) surgery and is associated with a poor prognosis. Postoperative AKI is associated with morbidity, mortality, and increase in length of intensive care unit (ICU) stay and increases the financial burden. Identifying individuals at risk for developing AKI in postoperative period is extremely important to optimize outcomes. The aim of the study is to evaluate the association between the intraoperative transesophageal echocardiography (TEE) derived renal resistive index (RRI) and AKI in patients undergoing on-pump CABG surgery. Methods: This prospective observational study was conducted in patients more than 18 years of age undergoing elective on pump CABG surgery between July 1, 2018, and December 31, 2019, at a tertiary care center. All preoperative, intraoperative, and postoperative parameters were recorded. TEE measurement was performed in hemodynamically stable patients before the sternum was opened. Postoperative AKI was diagnosed based on the serial measurement of serum creatinine and the monitoring of urine output. Results: A total of 115 patients were included in our study. Thirty-nine (33.91%) patients had RRI >0.7 while remaining seventy-six (66.08%) patients had RRI <0.7. AKI was diagnosed in 26% (30/115) patients. AKI rates were significantly higher in patients with RRI values exceeding 0.7 with 46.15% (18/39) compared to 15.75% (12/76) in RRI values of less than 0.7. Multivariate analysis revealed that AKI was associated with an increase in RRI and diabetes mellitus. The RRI assessed by receiver operating characteristic (ROC) curve and the area under the curve (AUC) to distinguish between non-AKI and AKI groups were 0.705 (95% CI: 0.588-0.826) for preoperative RRI. The most accurate cut-off value to distinguish non-AKI and AKI groups was a preoperative RRI of 0.68 with a sensitivity of 70% and specificity of 67%. Conclusions: An increased intraoperative RRI is an independent predictor of AKI in the postoperative period in patients undergoing CABG surgery. The cutoff value of TEE-derived RRI in the intraoperative period should be >0.68 to predict AKI in the postoperative period.

Prognostic significance of the skeletal muscle index and systemic inflammatory index in patients with lymph node-positive breast cancer after radical mastectomy.

BACKGROUND: The role of skeletal muscle index (SMI) and systemic inflammation index (SII) for patients with lymph node-positive breast cancer remain controversial. This retrospective study aims to evaluate the individual and synergistic value of SMI and SII in outcomes prediction in this population. METHODS: Lymph node-positive breast cancer patients who received mastectomy between January 2011 and February 2013 were included in this retrospective study. We used abdominal computed tomography (CT) to measure skeletal muscle mass at the third lumbar (L3) level. The optimal cut-off values of SMI and SII were determined through maximizing the Youden index on the receiver operating characteristic (ROC) curves. Kaplan-Meier method was used to assess the correlation between SMI, SII, and overall survival (OS). The prognostic value of SMI and SII were analyzed with the multivariable Cox proportional hazards model. RESULTS: Of 97 patients included in our study (mean age: 46 [range: 27-73] years; median follow-up: 62.5 months), 71 had low SMI (sarcopenia), 59 had low SII, and 56 had low SMI + SII. Kaplan-Meier survival curves showed that both high SMI (P = 0.021, 5-year OS: 84.0% vs. 94.1%) and high SII (P = 0.043, 5-year OS: 81.0% vs. 97.3%) were associated with worse OS. Additionally, patients with either low SMI or low SII had significantly better OS (P = 0.0059, 5-year OS: 100.0% vs. 84.6%) than those with high SMI + SII. Multivariable analysis confirmed the predictive values of high SMI (P = 0.024, hazard ratio [HR]: 9.87) and high SII (P = 0.048, HR: 6.87) for poor OS. Moreover, high SMI + SII was significantly associated with poor survival (P = 0.016, HR: 16.36). CONCLUSIONS: In this retrospective analysis, both SMI and SII independently predicted the prognosis of patients with lymph node-positive breast cancer. SMI + SII might be a stronger prognostic factor than either alone based on our findings, but should be further verified in a larger study.

Assessment of deep vein thrombosis using routine pre- and postoperative duplex Doppler ultrasound in patients with pelvic trauma : a prospective study.

AIMS: The aims of this study were to assess the pre- and postoperative incidence of deep vein thrombosis (DVT) using routine duplex Doppler ultrasound (DUS), to assess the incidence of pulmonary embolism (PE) using CT angiography, and to identify the factors that predict postoperative DVT in patients with a pelvic and/or acetabular fracture. METHODS: All patients treated surgically for a pelvic and/or acetabular fracture between October 2016 and January 2020 were enrolled into this prospective single-centre study. The demographic, medical, and surgical details of the patients were recorded. DVT screening of the lower limbs was routinely performed using DUS before and at six to ten days after surgery. CT angiography was used in patients who were suspected of having PE. Age-adjusted univariate and stepwise multiple logistic regression analysis were used to determine the association between explanatory variables and postoperative DVT. RESULTS: A total of 191 patients were included. A DVT was found preoperatively in 12 patients (6.3%), of which six were proximal. A postoperative DVT was found in 42 patients (22%), of which 27 were proximal. Eight patients (4.2%) had a PE, which was secondary to a DVT in three. None of the 12 patients in whom a vena cava filter was implanted prophylactically had a PE. Multivariate logistic regression analysis indicated that the association with the need for spinal surgery (odds ratio (OR) 19.78 (95% confidence interval (CI) 1.12 to 348.08); p = 0.041), intramedullary nailing of a long bone fracture (OR 4.44 (95% CI 1.05 to 18.86); p = 0.043), an operating time > two hours (OR 3.28 (95% CI 1.09 to 9.88); p = 0.035), and additional trauma surgery (OR 3.1 (95% CI 1.03 to 9.45); p = 0.045) were statistically the most relevant independent predictors of a postoperative DVT. CONCLUSION: The acknowledgement of the risk factors for the development of a DVT and their weight is crucial to set a threshold for the index of suspicion for this diagnosis by medical staff. We suggest the routine use of the DUS screening for DVT in patients with a pelvic and/or acetabular fracture before and six to ten days after surgery. Cite this article: Bone Joint J 2022;104-B(2):283-289.

Routine Radiologic Assessment for Anastomotic Leak Is Not Necessary in Asymptomatic Patients After Esophagectomy for Esophageal Cancer.

BACKGROUND: Anastomotic leaks (AL) are a major source of post-esophagectomy morbidity and patients are often initially asymptomatic. Debate exists on timing and utility of imaging to detect AL post-esophagectomy. We sought to evaluate the efficacy and timing of radiographic AL evaluation in esophageal cancer patients post-esophagectomy. METHODS: A retrospective database of esophageal cancer patients who underwent esophagectomy at a single institution from 2004 to 2020 was used to determine the utilization, timing, and sensitivity of radiologic testing for AL post-esophagectomy. RESULTS: Seventy-six patients were identified of which 37 (49%) had a cervical anastomosis. Sixty-four (84%) underwent 71 "asymptomatic radiographic leak tests" (ARLT), 7 of which had 2 different tests, including: 41 fluoroscopic esophagrams (58%), 18 CT-esophagrams (25%), and 12 upper GI studies (17%). Seventeen patients (22%) developed clinical signs of AL (hemodynamic instability, leukocytosis) and underwent "symptomatic radiographic leak tests" (SRLT) with fluoroscopic esophagram (n = 9, 12%), CT-esophagram (n = 7, 9%), or upper GI study (n = 1, 1%). ARLT and SRLT were positive in 2/64 (3%) and 17/17 (100%) patients, respectively, for 19 total ALs (25%). Among the 17 SRLT( +) patients, 1 was also ARLT( +), 13 were initially ARLT( -), and 3 were not evaluated by ARLT. The median postoperative day for ARLT and SRLT was 4.0 (IQR 3.0-5.5) and 9.0 days (IQR 6.0-13.0), respectively, with a statistically significant difference (p < 0.005). The sensitivity and specificity of ARLT for detecting AL were 13.3% and 100.0%, respectively. CONCLUSIONS: Based on the low ARLT sensitivity, routine use of imaging to detect asymptomatic ALs post-esophagectomy may be limited. Symptomatic ALs were often present in a delayed fashion, even after initial negative imaging.

Volumetry and Surgical Grading Systems for Vestibular Schwannoma Size Assessment and their Relationship to Postoperative Facial Nerve Function.

BACKGROUND AND STUDY AIMS: Treatment modalities in vestibular schwannoma (VS) are difficult to compare since different techniques for size measurements are used. The purpose of this study was to evaluate the relation between different tumor size grading systems regarding their compatibility as well as the relationship to facial nerve outcome facilitating comparisons of different studies. MATERIAL AND METHODS: In this retrospective study, preoperative magnetic resonance imaging of 100 patients with surgically treated VS was evaluated regarding total tumor volume and anatomical extension based on the Koos and Samii classification, as well as volumetric and maximal diameter measures. Three-dimensional constructive interference in steady state (3D-CISS) and T1 postcontrast volumetric interpolated breath-hold examination (VIBE) sequences were used. Facial nerve function was evaluated according to the House-Brackmann (HB) scale 6 months following complete tumor removal via the retrosigmoid approach. RESULTS: Tumor size showed a moderate influence on postsurgical facial nerve function with correlations not exceeding 0.4. Severe palsy was observed mainly in patients with large tumors with Koos grade 4, Samii grade 4b, respectively a volume of at least 6 cm3 or a maximum diameter of 2.4 cm for HB ≥ 3 and a volume of 7.5 cm3 and maximum diameter of 3.2 cm for HB ≥ 4. In regard to volumetry, the Koos and Samii grading systems were highly comparable, whereas the maximal diameter showed consistently lower correlation values. CONCLUSIONS: The results of our study allow direct comparison of studies on surgery versus radiotherapy of VS. The data allow for translation of tumor sizes based on different grading systems. Comparison of microsurgical, radiotherapeutic and radiosurgical approaches should concentrate on patients with large tumors. Whereas smaller tumors were rarely associated with severe facial palsy, large tumors did not exclude the possibility of weak or no palsy 6 months after surgery.

Relation Between Early Disturbance of lymphatic transport Visualized With Lymphofluoroscopy and Other Clinical Assessment Methods in Patients With Breast Cancer.

INTRODUCTION: Lymphedema of the upper extremity is one of the most feared complications following breast cancer treatment. Lymphofluoroscopy is a sensitive instrument for detection of lymphedema and visualization of superficial lymphatic transport, thus suitable for early detection. Early detection of lymphedema is important as it can prevent lymphedema to progress into more severe stages and minimalize impact on quality of life and medical costs. OBJECTIVE: To determine agreement between the presence of early disturbance of the lymphatic transport and outcome of clinical measurement tools evaluating the development of lymphedema. METHODS: A prospective study was conducted in 128 breast cancer patients scheduled for breast cancer surgery. Patients were evaluated before surgery and 1, 3-, 6-, 9-, and 12-months' post-surgery. Cohen's Kappa was used to determine agreement between presence of early disturbance in lymphatic transport and presence of pitting/increased skinfold thickness/increased Percentage Water Content ratio (PWC)/increased arm-hand volume (circumference measures and water displacement). RESULTS: For pitting status (Kappa 0.23), for skinfold thickness (Kappa 0.29) and the PWC ratio (Kappa 0.21) a minimal agreement was found. The circumference measurement had a minimal agreement for 5% volume difference (Kappa 0.22) and no agreement for 3% volume difference (Kappa 0.19). Sensitivity was weak for all clinical assessments. The specificity was excellent for pitting status, skinfold thickness, PWC ratio, and for 5% volume difference. For 3% a high specificity was found. CONCLUSION: The clinical tools assessed in this study were not able to predict an early disturbance of the lymphatic transport seen on lymphofluoroscopy.

Reducing the risk of postoperative pancreatic fistula in radical gastrectomy: pre-assessment with computed tomography for the diagnosis of pancreatic steatosis.

PURPOSE: To determine whether pancreatic steatosis (PS) is associated with the risk of postoperative pancreatic fistula (POPF) after radical gastrectomy, and if so, to investigate whether pre-assessment by diagnostic imaging can mitigate the risk. METHODS: The clinical records of 276 patients with cStage I gastric cancer who underwent laparoscopic gastrectomy with D1 + lymphadenectomy between 2012 and 2015 were reviewed. In the first phase up to July 2013 (n = 138), PS was classified from computed tomography (CT) findings into type S (superficial fat deposition) or type D (diffuse fatty replacement) and examined for association with POPF. In the second phase (n = 138), the preoperative CT assessment of PS was routinized. Separate samples from pancreatoduodenectomy consistent with each type were histologically examined. RESULTS: In the first phase, the incidence of POPF was significantly higher in group S, but not in group D, compared with normal pancreas (16.3% and 9.1% vs. 3.6%, respectively; P = 0.03). The drain amylase level was lowest in group D, reflecting exocrine insufficiency. Histologically, the loose connective-tissue space between the fat infiltrating the pancreas and the peripancreatic fat containing the lymph nodes was unclear in type D but conserved in type S. In the second phase, surgery was performed with more intention on accurately tracing the dissection plane and significantly lowered incidence of POPF in Group S (16.3% to 2.1%; P = 0.047). CONCLUSION: Peripancreatic lymphadenectomy is more challenging and likely to cause POPF in patients with PS. However, the risk may be reduced using appropriate dissection techniques based on the CT pre-assessment findings.

Determination of the segmental hepatic clearance rate of 99mTc-mebrofenin and its application in the functional assessment of future liver remnant after liver resection.

99mTc-mebrofenin hepatobiliary scintigraphy with SPECT/CT (HBS-M) has become an important quantitative method to evaluate global liver function and future liver remnant (FLR) function in patients who are candidates for resective liver surgery. The purpose of this work was to describe the method in the prediction of post-surgical liver failure. The overall liver function and that of the FLR are obtained by analysis of the initial dynamic phase of the scan. Liver volume to be preserved is expressed as a percentage of the total liver volume measured in both CT sections. HBS-M is able to accurately gauge regional liver function abnormalities that could be represented as normal liver tissue parenchyma in the CT study. This technique can provide very valuable prognostic information for the estimation of the postoperative risk of liver failure in all patients who are candidates for resective liver surgery.

Computed tomography assessment of the aortic root morphology in predicting the development of paravalvular leak following transcatheter aortic valve implantation.

Introduction: Transcatheter aortic valve implantation (TAVI) is an effective treatment of significant aortic stenosis. Paravalvular leaks (PVLs) are one of the most common complications after the procedure. Objectives: The aim of this study was to assess whether the aortic root morphology affects the occurrence of PVL after TAVI. Patients and methods: We enrolled 50 patients with bicuspid and 50 patients with tricuspid aortic valve who underwent multislice computed tomography (MSCT) and transthoracic echocardiography prior to TAVI. The dimensions of the aortic root were assessed by MSCT. PVL after TAVI was assessed by transthoracic echocardiography. Patients were divided in 2 groups according to the PVL severity: less than moderate PVL (n = 80) and moderate or worse PVL (n = 20), and comparisons between the groups were performed. Results: Patients with at least moderate PVL, compared with those with less than moderate PVL, had greater mean (SD) area (5.2 [1.1] cm2 vs 4.7 [0.8] cm2; P = 0.02), perimeter (8.4 [0.9] cm vs 7.9 [0.7] cm; P = 0.01), and long axis (29.5 [2.7] mm vs 28 [2.7] mm; P = 0.04) of the aortic annulus and greater mean (SD) area (5.3 [1.3] cm2 vs 4.7 [1.1] cm2; P = 0.04) and perimeter (8.6 [1.1] cm vs 8.1 [0.9] cm; P = 0.02) of the left ventricular outflow tract. In multivariable analysis, bicuspid aortic valve disease, interventricular septum hypertrophy, greater left ventricular outflow tract, and postdilatation were significant predictors of moderate PVL following TAVI. Conclusions: The assessment of the aortic root morphology with MSCT can be helpful in predicting PVL after TAVI.

Radiographs assessment of changes in the psoas muscle at L4-L5 level after single-level lateral lumbar interbody fusion in patients with postoperative motor weakness.

The purposes of this study were (1) to investigate postoperative changes in cross-sectional area (CSA) and signal intensity (SI) of the psoas muscle (PS) using magnetic resonance imaging (MRI) and (2) to compare the CSA and SI of the PS between patients with and without motor weakness after single-level lateral lumbar interbody fusion (LLIF) at level L4-L5. Sixty patients were divided into two groups-those with postoperative motor weakness and those without-and the two groups were compared. Baseline demographics and clinical characteristics, such as operation time and blood loss, length of hospital stay, and postoperative complications, were recorded. The CSA and SI of the PS were obtained from the MRI regions of interest defined by manual tracing. Patients who developed motor weakness after surgery were significantly older (p = 0.040). The operation time (p = 0.868), LLIF operative time (p = 0.476), and estimated bleeding loss (p = 0.168) did not differ significantly between groups. In both groups, the CSA and SI of the left and right PS increased after surgery. The change in the CSA of the left PS was significantly higher in patients with weakness (247.6 ± 155.2 mm2) than without weakness (152.2 ± 133.1 mm2) (p = 0.036). The change in SI of the left PS did not differ between the two groups (p = 0.530). To prevent postoperative motor weakness regardless of the operation time, surgeons should be aware of the potential for surgical invasive of the PS during LLIF in older people.