Intraoperative radiotherapy after neurosurgical resection of brain metastases as institutional standard treatment- update of the oncological outcome form a single center cohort after 117 procedures.

PURPOSE: Stereotactic radiotherapy (SRT) is the predominant method for the irradiation of resection cavities after resection of brain metastases (BM). Intraoperative radiotherapy (IORT) with 50 kV x-rays is an alternative way to irradiate the resection cavity focally. We have already reported the outcome of our first 40 IORT patients treated until 2020. Since then, IORT has become the predominant cavity treatment in our center due to patients´ choice. METHODS: We retrospectively analyzed the outcomes of all patients who underwent resection of BM and IORT between 2013 and August 2023 at Augsburg University Medical Center (UKA). RESULTS: We identified 105 patients with 117 resected BM treated with 50 kV x-ray IORT. Median diameter of the resected metastases was 3.1 cm (range 1.3 - 7.0 cm). Median applied dose was 20 Gy. All patients received standardized follow-up (FU) including three-monthly MRI of the brain. Mean FU was 14 months, with a median MRI FU for patients alive of nine months. Median overall survival (OS) of all treated patients was 18.2 months (estimated 1-year OS 57.7%). The observed local control (LC) rate of the resection cavity was 90.5% (estimated 1-year LC 84.2%). Distant brain control (DC) was 61.9% (estimated 1-year DC 47.9%). Only 16.2% of all patients needed WBI in the further course of disease. The observed radio necrosis rate was 2.6%. CONCLUSION: After 117 procedures IORT still appears to be a safe and appealing way to perform cavity RT after neurosurgical resection of BM with low toxicity and excellent LC.

Routine intraoperative ureteric stenting for kidney transplant recipients.

BACKGROUND: Major urological complications (MUCs) after kidney transplantation contribute to patient morbidity and compromise graft function. The majority arise from vesicoureteric anastomosis and present early after transplantation. Ureteric stents have been successfully used to treat such complications. A number of centres have adopted a policy of universal prophylactic stenting at the time of graft implantation to reduce the incidence of urine leaks and ureteric stenosis. Stents are associated with specific complications, and some centres advocate a policy of only stenting selected anastomoses. This is an update of our review, first published in 2005 and last updated in 2013. OBJECTIVES: To examine the benefits and harms of routine ureteric stenting to prevent MUCs in kidney transplant recipients. SEARCH METHODS: We contacted the Information Specialist and searched the Cochrane Kidney and Transplant's Specialised Register (up to 19 June 2024) using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA: Our meta-analysis included all randomised controlled trials (RCTs) and quasi-RCTs designed to examine the impact of using stents for kidney transplant recipients. We aimed to include studies regardless of the type of graft, the technique of ureteric implantation, or the patient group. DATA COLLECTION AND ANALYSIS: Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: Twelve studies (1960 patients) were identified. One study was deemed to be at low risk of bias across all domains. The remaining 11 studies were of low or medium quality, with a high or unclear risk of bias in at least one domain. Universal prophylactic ureteric stenting versus control probably reduces major urological complications (11 studies: 1834 participants: RR 0.30, 95% CI 0.16 to 0.55; P < 0.0001; I2 = 16%; moderate certainty evidence; number needed to treat (17)); this benefit was confirmed in the only study deemed to be at low risk of bias across all domains. This benefit was also seen for the individual components of urine leak and ureteric obstruction. Universal prophylactic ureteric stent insertion reduces the risk of MUC in the subgroup of studies with short duration (≤ 14 days) of stenting (2 studies, 480 participants: RR 0.39, 95% CI CI 0.21 to 0.72; P = 0.003; I2 = 0%) and where stenting was continued for > 14 days (8 studies, 124 participants: RR 0.22, 95% CI 0.08 to 0.61; P = 0.004; I2 = 29%). It is uncertain whether stenting has an impact on the development of urinary tract infection (UTI) (10 studies, 1726 participants: RR 1.32, 95% CI 0.97 to 1.80; P = 0.07; I² = 60%; very low certainty evidence due to risk of bias, heterogeneity and imprecision). Subgroup analysis showed that the risk of UTI did not increase if short-duration stenting was used (9 days) and that there was no impact on UTI risk when the prophylactic antibiotic regime co-trimoxazole 480 mg/day was used. Stents appear generally well tolerated, although studies using longer stents (≥ 20 cm) for longer periods (> 6 weeks) had more problems with encrustation and migration. There was no evidence that the presence of a stent resulted in recurrent or severe haematuria (8 studies, 1546 participants: RR 1.09, 95% CI 0.59 to 2.00; P = 0.79; I2 = 33%). The impact of stents on graft and patient survival and other stent-related complications remains unclear as these outcomes were either poorly reported or not reported at all. AUTHORS' CONCLUSIONS: Routine prophylactic stenting probably reduces the incidence of MUCs, even when the duration of stenting is short (≤ 14 days). Further high-quality studies are required to assess optimal stent duration. Studies comparing selective stenting and universal prophylactic stenting, whilst difficult to design and analyse, would address the unresolved quality of life and economic issues.

Intraoperative Dexmedetomidine Use for Enhanced Recovery after Surgery (ERAS) in Cardiac Surgery-Single Center Retrospective Observational Cohort Study.

Background and Objectives: Dexmedetomidine, an alpha-2 agonist, is used as an adjunct to anesthesia in enhanced recovery after surgery (ERAS) programs. One of its advantages is the opioid-sparing effect which can facilitate early extubation and recovery. When the ERAS cardiac society was set in 2017, our facility was already using the ERAS program, in which the "fast-track Anesthesia" was facilitated by the intraoperative infusion of dexmedetomidine. Our objective is to share our experience and investigate the potential impact of intraoperative dexmedetomidine use as a part of the ERAS program on patient outcomes in elective cardiac surgery. Materials and Methods: An observational retrospective cohort study was conducted at a university hospital in Switzerland. The patients who underwent elective cardiac surgery with cardiopulmonary bypass between 1 June 2017 and 31 August 2018 were included in this analysis (n = 327). Regardless of the surgery type, all the patients received a standardized fast-track anesthesia protocol inclusive of dexmedetomidine infusion, reduced opioid dose, and parasternal nerve block. The primary outcome was the postoperative time when the criteria for extubation were met. Three groups were identified: group 0-(extubated in the operating room), group < 6 (extubated in less than 6 h), and group > 6 (extubated in >6 h). The secondary outcomes were adverse events, length of stay in ICU and in hospital, and total hospitalization costs. Results: Dexmedetomidine was well-tolerated, with no significant adverse events reported. Early extubation was performed in 187 patients (57%). Group 3 had a significantly longer length of stay in the ICU (median: 70 h vs. 25 h) and in hospital (17 vs. 12 days), and consequently higher total hospitalization costs (CHF 62,551 vs. 38,433) compared to the net data from the other two groups (p < 0.0001). Conclusions: Our findings suggest that dexmedetomidine can be safely used as part of the opioid-sparing anesthesia protocol in patients undergoing elective cardiac surgery with cardiopulmonary bypass with the potential to facilitate early extubation, shorter ICU and hospital stays, and reduced hospitalization costs.

Effect of intraoperative cold solution irrigation to reduce postoperative pain in knee osteoarthritis patients who underwent unilateral primary total knee arthroplasty: a double-blinded randomized controlled trial.

PURPOSE: To compare the postoperative pain score, opioid consumption, and blood loss in knee osteoarthritis patients who underwent unilateral primary total knee arthroplasty with and without intraoperative cold solution irrigation. METHOD: In total, 70 knee osteoarthritis patients were randomly included in the study and allocated into 2 groups. The first group was irrigated intraoperatively with a cold solution and the second group was irrigated intraoperatively with a room-temperature solution. RESULTS: The cold solution group showed significantly lower pain scores (numerical rating scale, NRS) at 28 h postoperatively (p = 0.047). There were no significant differences in opioid consumption or blood loss between the groups. CONCLUSIONS: Intraoperative cold solution irrigation in unilateral primary total knee arthroplasty patients may provide the benefit of early postoperative pain reduction for up to 28 h but has no effect in terms of reducing opioid consumption or blood loss. TRIAL REGISTRATION: The trial was registered in the Thai Clinical Trials Registry (TCTR) Trial registration number ID: TCTR20200706001 on 06/07/2020.

Timing of Intraoperative Transitions of Care Among Anesthesiologists Is Not Associated With Postoperative Adverse Outcomes: Retrospective Cohort Study.

BACKGROUND: The majority of published research suggests that anesthesia handovers during major surgical procedures are associated with unintended harmful consequences. It is still unclear if the number or quality of the transition of care is the main driver of the adverse outcomes. There is even less data if the timing of the anesthesiologist handovers during the critical portion of the anesthetic continuum (induction or emergence versus surgical period) plays a role in patient outcomes. Therefore, we investigated if the anesthesiologist handovers during induction and emergence are associated with adverse patient outcomes. METHODS: This retrospective investigation included noncardiac surgical procedures occurring between January 1, 2012 and December 31, 2019 that had exactly 1 attending anesthesiologist handover. We categorized transitions of care between attending anesthesiologists as being before incision, between incision and closing, and after closing. Our primary outcome was a composite of 6 categories of surgical complications and in-hospital mortality. We created logistic generalized estimating equation models to estimate the average relative effect odds ratio between each pair of the 3 transition timing groups across the components of the composite outcome. Inverse probability of treatment weights were used to mitigate confounding on a host of baseline variables. We used Bonferroni correction to adjust for multiple comparisons between the transition groups. RESULTS: In total, we studied 36,937 procedures with exactly 1 attending anesthesiologist handover. Of these records, 4370 had the transition during induction, 24,999 between incision and closure, and 7568 during emergence. No differences were found between the transition periods and the composite outcome. The estimated average relative effect odds ratio (98.3% confidence interval [CI]) across the components of the composite outcome was as follows: (1.0002 [0.81-1.24], P = .99) between the induction and surgical period; (1.10 [0.87-1.40], P = .32) between the induction and emergence periods; and (0.91 [0.79-1.04], P = .08) between the emergence and surgical periods. CONCLUSIONS: Timing of intraoperative handover among attending anesthesiologists during noncardiac surgery is not associated with adverse patient outcomes.

The Intermalleolar Method for Intraoperative Rotational Assessment of the Tibia-A Prospective Clinical Validation Study.

OBJECTIVES: To determine the accuracy of the intermalleolar method, an intraoperative fluoroscopic method for assessing tibial rotation in patients undergoing intramedullary nail fixation for tibial shaft fractures, by comparing it with the gold standard computed tomography (CT). DESIGN: Prospective cohort study. SETTING: Academic Level 1 trauma center. PATIENT SELECTION CRITERIA: Consecutive patients, aged 18 years and older, with unilateral tibial shaft fractures who underwent intramedullary fixation from September 2021 to January 2023. OUTCOME MEASURES AND COMPARISONS: Intraoperatively, tibial rotation measurements were obtained using the intermalleolar method on both the uninjured and injured limbs. Postoperatively, patients underwent bilateral low-dose lower extremity rotational CT scans. CT measurements were made by 4 blinded observers. Mean absolute rotational differences and standard errors were calculated to compare the injured and uninjured limbs. Subgroup analysis was performed assessing accuracy relating to injured versus uninjured limbs, body mass index, OTA/AO fracture pattern, tibial and fibular fracture location, and distal articular fracture extension requiring fixation. RESULTS: Of the 20 tibia fractures, the mean patient age was 43.4 years. The intermalleolar method had a mean absolute rotational difference of 5.1 degrees (standard error 0.6, range 0-13.7) compared with CT. Sixty percent (24/40) of the measurements were within 5 degrees, 90% (36/40) of the measurements were within 10 degrees, and 100% (40/40) were within 15 degrees of the CT. No patients were revised for malrotation postoperatively. CONCLUSIONS: The intermalleolar method is accurate and consistently provides intraoperative tibial rotation measurements within 10 degrees of the mean CT measurement for adult patients undergoing intramedullary nail fixation for unilateral tibial shaft fractures. This method may be employed in the operating room to accurately quantify tibial rotation and assist with intraoperative rotational corrections. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Intraoperative Methadone Use Is Associated With Reduced Postoperative Pain and More Rapid Opioid Weaning After Coronary Artery Bypass Grafting.

OBJECTIVE: To explore the association between intraoperative methadone use, postoperative pain, and opioid consumption after coronary artery bypass grafting (CABG) surgery. DESIGN: Retrospective cohort study. SETTING: Single academic medical center. PARTICIPANTS: Patients undergoing isolated CABG over a 5-year period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic data, comorbidities, and intraoperative anesthetic medications were recorded. Primary study outcomes were average and maximum pain scores and morphine milligram equivalent consumption on the first 2 postoperative days (PODs). Linear mixed-effects regression models were used to examine the effect of intraoperative methadone use on study outcomes. Among 1,338 patients, 78.6% received intraoperative methadone (0.2 mg/kg). Patients who did not receive methadone had higher average (estimated [Est], 0.48; 95% confidence interval [CI], 0.22-0.73; p < 0.001) and maximum postoperative (Est, 0.49; 95% CI, 0.23-0.75; p < 0.001) pain scores over PODs 0 to 2. For postoperative opioid consumption, there was a significant intraoperative methadone use-time interaction effect on postoperative opioid use (odds ratio [OR], 2.21; 95% CI, 1.74-2.80; p < 0.001). Across PODs 0 to 2, patients who received intraoperative methadone had a faster decline in postoperative opioid use than those who did not receive intraoperative methadone. Patients who did not receive intraoperative methadone were extubated slightly faster (OR, 0.82; 95% CI, 0.72-0.93; p < 0.01). CONCLUSIONS: Our data suggest that the use of intraoperative methadone is safe, reduces postoperative pain, and expedites weaning from postoperative opioids after CABG surgery.

Effects of Soothing Music on the Intraoperative Management of Patients Undergoing Tension-Free Herniorrhaphy: A Retrospective Study.

BACKGROUND: Noise pollution in the operating room can have adverse effects on the physical and mental well-being of patients. Since the mid-20th century, music therapy has been increasingly used in clinical practice. Soothing music has a beneficial effect in maintaining the efficacy of intraoperative sedation and regulating patients' emotions. OBJECTIVE: To investigate the effects of soothing music on the intraoperative management of patients undergoing tension-free herniorrhaphy. METHODS: We retrospectively analyzed the clinical data of 244 patients who underwent open tension-free herniorrhaphy under local anesthesia at the Fourth Affiliated Hospital of Nanchang University from June 2019 to May 2021. According to the different included time periods, the hospital implemented soothing music management from June 2020 to May 2021, and 110 patients admitted during this period were classified as the study group. One hundred thirty-four patients who underwent clinical routine management from June 2019 to May 2020 were classified as the control group. The patients in the two groups received corresponding management modes during surgery. The perioperative indicators, stress response, anxiety, depression, and clinical efficacy of the two groups were analyzed. RESULTS: No significant differences in the operative time, intraoperative blood loss, postoperative off-bed activity time, and hospitalization time between the two groups (P > 0.05). The study group exhibited lower postoperative cortisol (213.30 (203.40, 229.00) nmol/L) and anxiety (9.00 (7.00, 12.00) points) levels than the control group (246.85 (230.50, 258.40) nmol/L; 14.00 (12.00, 15.00) points) (P < 0.001). Moreover, no significant differences were noted in the norepinephrine and depression levels and the severity of illness, global improvement, and efficacy index scores between the two groups (P > 0.05). CONCLUSION: Soothing music therapy, as a clinical auxiliary method, has a positive impact on the intraoperative management of patients undergoing open tension-free herniorrhaphy, leading to reduced cortisol levels and alleviation of anxiety.

Dynamic parameters of fluid responsiveness in the operating room : An analysis of intraoperative ventilation framework conditions.

BACKGROUND: Reliable assessment of fluid responsiveness with pulse pressure variation (PPV) depends on certain ventilation-related preconditions; however, some of these requirements are in contrast with recommendations for protective ventilation. OBJECTIVE: The aim of this study was to evaluate the applicability of PPV in patients undergoing non-cardiac surgery by retrospectively analyzing intraoperative ventilation data. MATERIAL AND METHODS: Intraoperative ventilation data from three large medical centers in Germany and Switzerland from January to December 2018 were extracted from electronic patient records and pseudonymized; 10,334 complete data sets were analyzed with respect to the ventilation parameters set as well as demographic and medical data. RESULTS: In 6.3% of the 3398 included anesthesia records, patients were ventilated with mean tidal volumes (mTV) > 8 ml/kg predicted body weight (PBW). These would qualify for PPV-based hemodynamic assessment, but the majority were ventilated with lower mTVs. In patients who underwent abdominal surgery (75.5% of analyzed cases), mTVs > 8 ml/kg PBW were used in 5.5% of cases, which did not differ between laparoscopic (44.9%) and open (55.1%) approaches. Other obstacles to the use of PPV, such as elevated positive end-expiratory pressure (PEEP) or increased respiratory rate, were also identified. Of all the cases 6.0% were ventilated with a mTV of > 8 ml/kg PBW and a PEEP of 5-10 cmH2O and 0.3% were ventilated with a mTV > 8 ml/kg PBW and a PEEP of > 10 cmH2O. CONCLUSION: The data suggest that only few patients meet the currently defined TV (of > 8 ml/kg PBW) for assessment of fluid responsiveness using PPV during surgery.

Intraoperative hemodialysis with supra- and infradiaphragmatic catheters for liver transplantation.

PURPOSE: The benefits of intraoperative dialysis during orthotopic liver transplantation remain controversial. In patients with anuric renal failure and portopulmonary hypertension, maintaining venous return during caval clamping and unclamping along with minimizing fluid overload is critical to avoiding right ventricular strain and failure. CLINICAL FEATURES: We present the case of a 54-yr-old female who underwent orthotopic liver transplantation for alcohol-related liver disease with acute decompensation including severe hepatorenal syndrome (anuric requiring dialysis), probable hepatopulmonary syndrome, moderate pulmonary hypertension (right ventricular systolic pressure, 44 mm Hg), hepatic encephalopathy (grade 2), and esophageal varices. Prior to incision, pulmonary arterial pressures were 48/28 (mean, 35) mm Hg with a central venous pressure of 30 mm Hg, cardiac output of 7.4 L·min-1, and pulmonary vascular resistance of 98 dynes·sec·cm-5. In the context of right ventricular strain and volume overload observed on transthoracic echocardiography, we inserted an additional dialysis catheter into the right femoral vein. We initiated dialysis using the two catheters as a circuit (femoral line to the dialysis machine; blood was reinjected via the subclavian line) acting as a limited venovenous bypass, allowing right ventricular offloading and hemodialysis throughout the case. We removed 4.5 L via hemodialysis during the surgery, while avoiding acidosis, hyperkalemia, and sodium shifts. The patient tolerated reperfusion adequately despite pre-existing right ventricular dilation and dysfunction. CONCLUSION: We report on the use two hemodialysis catheters in a patient undergoing orthotopic liver transplantation as a circuit for simultaneous anuric hepatorenal syndrome and moderate pulmonary hypertension with right ventricular dilation and dysfunction. We believe this technique was instrumental in the patient's successful transplant.

RéSUMé: OBJECTIF: Les avantages de la dialyse peropératoire pendant une transplantation hépatique orthotopique demeurent controversés. Chez la patientèle atteinte d'insuffisance rénale anurique et d'hypertension portopulmonaire, il est essentiel de maintenir le retour veineux pendant le clampage et le déclampage de la veine cave ainsi que de minimiser la surcharge hydrique, afin d'éviter la déformation et l'insuffisance ventriculaires droites. CARACTéRISTIQUES CLINIQUES : Nous présentons le cas d'une femme de 54 ans qui a bénéficié d'une transplantation hépatique orthotopique pour une maladie hépatique liée à l'alcool avec une décompensation aiguë comprenant un syndrome hépatorénal sévère (anurie nécessitant une dialyse), un syndrome hépatopulmonaire probable, une hypertension pulmonaire modérée (pression systolique ventriculaire droite, 44 mm Hg), une encéphalopathie hépatique (grade 2) et des varices œsophagiennes. Avant l'incision, les pressions artérielles pulmonaires étaient de 48/28 (moyenne, 35) mm Hg avec une pression veineuse centrale de 30 mm Hg, un débit cardiaque de 7,4 L·min−1 et une résistance vasculaire pulmonaire de 98 dynes·sec·cm−5. Dans le contexte de la déformation ventriculaire et de la surcharge volémique droites observées à l'échocardiographie transthoracique, nous avons inséré un cathéter de dialyse supplémentaire dans la veine fémorale droite. Nous avons amorcé la dialyse en créant un circuit avec les deux cathéters (ligne fémorale en direction de l'appareil de dialyse; sang réinjecté via la ligne sous-clavière) agissant comme un pontage veino-veineux limité, permettant la décharge du ventricule droit et l'hémodialyse tout au long du cas. Nous avons retiré 4,5 L par hémodialyse pendant la chirurgie, tout en évitant l'acidose, l'hyperkaliémie et les changements en sodium plasmatique. La patiente a toléré la reperfusion de manière adéquate malgré la dilatation et le dysfonctionnement préexistants du ventricule droit. CONCLUSION: Nous rapportons l'utilisation de deux cathéters d'hémodialyse pour créer un circuit chez une patiente bénéficiant d'une transplantation hépatique orthotopique pour le traitement d'un syndrome hépatorénal anurique simultané à une hypertension pulmonaire modérée avec dilatation et dysfonctionnement du ventricule droit. Nous pensons que cette technique a joué un rôle déterminant dans la réussite de la greffe chez la patiente.

A multi-country survey on the availability of intraoperative use of echocardiography for noncardiac surgery

BACKGROUND: This survey aimed to explore the availability and accessibility of echocardiography during noncardiac surgery worldwide. METHODS: An internet-based 45-item survey was sent, followed by reminders from August 30, 2021, to August 20, 2022. RESULTS: 1189 responses were received from 62 countries. Nearly seventy-one percent of respondents had intraoperatively used transesophageal or transthoracic echocardiography (TEE and TTE, respectively) for monitoring or examination. The unavailability of echocardiography machines (30.3%), lack of trained personnel (30.2%), and absence of clinical indications (22.6%) were the top 3 reasons for not using intraoperative echocardiography in noncardiac surgery. About 61.5% of participants had access to at least one echocardiography machine. About 41% had access to at least 1 TEE probe, and 62.2% had access to at least 1 TTE probe. Seventy-four percent of centers had a procedure to request intraoperative echocardiography if needed for noncardiac cases. Intraoperative echocardiography service was immediately available in 58% of centers. CONCLUSIONS: Echocardiography machines and skilled echocardiographers are still unavailable at many centers worldwide. National societies should aim to train a critical mass of certified TEE/TTE anesthesiologists and provide all anesthesiologists access to perioperative TEE/TTE machines in anesthesiology departments, considering the increasing number of older and sicker surgical patients scheduled for noncardiac surgery.

Fine-tuning the needle: analysis of acupuncturist response to alarming events during gynecological oncology surgery.

OBJECTIVE: Examining an intra-operative acupuncture/acupressure setting, with real-time "fine-tuning" in response to alarming events (AEvs) during gynecological oncology surgery. METHODS: Narratives of acupuncturists providing intraoperative acupuncture during gynecological oncology surgery were qualitatively analyzed. These described real time "fine-tuning" in response to AEvs during surgery, identified through hemodynamic changes (e.g., systolic/diastolic arterial pressure); bispectral index (BIS) elevation; and feedback from surgeons and anesthesiologists. Documentation of acupuncturist responses to AEvs was addressed as well. RESULTS: Of the 48 patients in the cohort, 33 had at least one intraoperative AEv (69%), of which 30 were undergoing laparoscopic surgery and 18 laparotomies. A total of 77 AEvs were documented throughout surgery (range 1-7; mean: 2.3 events per patient), identified through increased (63 events) or decreased (8) mean arterial pressure (MAP); increased BIS levels (2), or other hemodynamic parameters (4). Integrative oncology interventions implemented in response to AEs included acupressure alone (59); combining acupressure with acupuncture (10); or acupuncture alone (4). In 54 (70%) events, documentation was provided from beginning to conclusion of the AEv, with a mean duration of 9.7 min, with 32 events including a documented anesthesiologist intervention. CONCLUSION: The present study demonstrated the feasibility of intraoperative acupuncture with acupressure, with ongoing "fine-tuning" to AEvs identified through objective pain-related parameters (MAP, heart rate and BIS) and real-time input from surgeons and anesthesiologists. Documentation of the intraoperative IO practitioner's response to these AEvs is important, and should be addressed in future research of the innovative integrative model of care. TRIAL REGISTRATION NUMBER: CMC-18-0037 (Carmel Medical Center, June 11, 2018).

Surgical treatment of nasal fractures may benefit from intraoperative 3D imaging.

This retrospective study aimed to assess the effects of the use of intraoperative three-dimensional (3D) imaging on outcomes in surgical treatment of nasal fractures. Furthermore, we investigated whether the use of intraoperative imaging improves outcomes and decreases the frequency of corrective surgeries compared to published literature. This retrospective descriptive study included patients who underwent operative treatment for nasal fractures with the use of intraoperative 3D imaging between January 2015 and January 2020 at a University Hospital. The primary outcome measure was patient satisfaction, which was assessed through patient charts about subjective esthetic problems and nasal obstruction. The secondary outcome measures were the number of intraoperative images and necessity of intra- and postoperative revisions. All the outcomes were evaluated using regression analysis. Of the 172 patients, secondary rhinoplasty and intraoperative revision were performed in 10 (6 %) and 93 (54 %) patients, respectively. Postoperatively, 19 (11 %) and 12 (7 %) patients complained of subjective esthetic problems and nasal obstruction, respectively. The intraoperative revision rate in patients undergoing surgical treatment of nasal fractures with intraoperative 3D imaging was >50 %. However, the incidence of postoperative secondary revision, nasal obstruction, and subjective esthetic problems was lower than that reported in the literature not having an intraoperative imaging. Our findings suggest that prompt quality control of the operative result enables immediate correction and prevents postoperative revision.