Successful Rescue Ventilation of an Infant With a Laryngeal Mask Airway After Accidental Extubation in the Prone Position During Open Calvarial Reconstruction of a Craniosynostosis: A Case Report.

In this case report, we present a critical situation during an open calvarial reconstruction involving an 11-month-old infant. The patient experienced accidental extubation, requiring immediate intervention while in the prone position. Approximately two hours post-incision, ventilation became increasingly difficult due to a significant leak detected in the system. On closer inspection, it was observed that both the rubber tourniquet responsible for securing the anesthesia circuit and the tape that held the endotracheal tube in place had become loosened. In response to this emergency, the decision was made to remove the displaced endotracheal tube. We successfully introduced a 1.5 laryngeal mask airway (LMA; Unique™, Teleflex Incorporated, Wayne, PA), which restored ventilation. The patient maintained stable oxygen levels throughout this emergency period, displaying no signs of desaturation. An hour post-intervention, the surgical procedure was completed. The process of removing the LMA was uneventful without any complications. In the setting of emergent airway management, especially for patients in the prone position during surgical procedures, accidental extubation presents a challenge for healthcare providers. This case highlights the importance of prompt decision-making and having alternative airway devices on hand, such as an LMA.

Preoperative Frailty Risk in Cranioplasty Patients: Risk Analysis Index Predicts Adverse Outcomes.

Cranioplasty is a common surgical procedure used to repair cranial defects, and it is associated with significant morbidity and mortality. Although frailty is a strong predictor of poor postoperative outcomes across surgical specialties, little is known about frailty's impact on cranioplasty outcomes. This study examined the association between frailty and cranioplasty by comparing the effect of the Risk Analysis Index-Administrative (RAI-A) and the Modified Frailty Index-5 (mFI-5) on cranioplasty outcomes. Methods: The National Surgical Quality Improvement Program was queried for patients undergoing cranioplasty between 2012 and 2020. Receiver operating characteristics and multivariable analyses were used to assess the relationship of postoperative outcomes and the RAI-A, mFI-5, and increasing patient age. Results: There were 2864 included study patients with a median age of 57 years (IQR, 44-67), and a higher proportion of patients were women (57.0%) and White (68.5%). The RAI-A had a more robust predictive ability for 30-day mortality (C-Statistic, 0.741; 95% confidence interval (CI), 0.678-0.804) compared with mFI-5 (C-Statistic, 0.574; 95% CI, 0.489-0.659) and increasing patient age (C-Statistic, 0.671; 95% CI, 0.610-0.732). On multivariable analyses, frailty was independently associated with mortality and other poor postoperative outcomes (P < 0.05). Conclusions: The RAI-A demonstrated superior discrimination than the mFI-5 and increasing patient age in predicting mortality. Additionally, the RAI-A showed independent associations with nonhome discharge and postoperative complications (CDII, CDIIIb, and CDIV). The high rates of operative morbidity (5.0%-36.5%) and mortality (0.4%-3.2%) after cranioplasty highlight the importance of identifying independent risk factors for poor cranioplasty outcomes.

Preclinical evaluation of sentinel node localization in the stomach via mannose-labelled magnetic nanoparticles and indocyanine green.

BACKGROUND: Gastrectomy with extended (D2) lymphadenectomy is considered standard of care for gastric cancer to provide the best possible outcomes and pathologic staging. However, D2 gastrectomy is a technically demanding operation and reported to be associated with increased complications and mortality. Application of sentinel lymph node (SLN) concept in gastric cancer has the potential to reduce patient morbidity; however, SLN techniques are not established for gastrectomy, in part due to lack of practical tracers. An effective and convenient tracer with enhanced SLN accumulation is critically needed. METHODS: Mannose-labelled magnetic tracer 'FerroTrace' and fluorescent dye indocyanine green (ICG) were injected laparoscopically into the stomach submucosa of 8 healthy swine under general anaesthesia. Intraoperative fluorescence imaging was used to highlight draining lymphatic pathways containing ICG, while preoperative T2-weighted MRI and ex vivo magnetometer probe measurements were used to identify nodes containing FerroTrace. Lymphadenectomy was performed either robotically (n = 2) or via laparotomy (n = 6). RESULTS: Mixing ICG and FerroTrace ensured concurrence of fluorescent and magnetic signals in SLNs. An initial trial with robotic dissection removed all magnetic LNs (n = 4). In the subsequent laparotomy study that targeted all ICG-LNs based on intraoperative fluorescence imaging, dissection removed an average of 4.7 ± 1.2 fluorescent, and 2.0 ± 1.3 magnetic LNs per animal. Both MRI and magnetometer detected 100% of SLNs (n = 7). FerroTrace demonstrated high specificity to SLNs, which contained 76 ± 30% of total lymphotropic iron, and 88 ± 20 % of the overall magnetometer signal. CONCLUSIONS: Through utilisation of this dual tracer approach, SLNs were identified via preoperative MRI, visualised intraoperatively with fluorescence imaging, and confirmed with a magnetometer. This combination pairs the sensitivity of ICG with SLN-specific FerroTrace and can be used for reliable SLN detection in gastric cancer, with potential applications in neoadjuvant therapy.

Successful Administration of Preoperative Botox for Giant Omphalocele Repair With Ultrasound Guidance.

We present a case of a four-year-old male with a history of giant omphalocele who underwent ultrasound-guided Botox injection to bilateral anterior abdominal wall musculature in preparation for definitive repair. Botox administration was successfully combined with preoperative subfascial tissue expanders to achieve definitive midline closure of the anterior abdominal wall defect. Our experience suggests that Botox can be safely used as part of the treatment plan for giant omphalocele repair.

The utility of machine learning for predicting donor discard in abdominal transplantation.

BACKGROUND: Increasing access and better allocation of organs in the field of transplantation is a critical problem in clinical care. Limitations exist in accurately predicting allograft discard. Potential exists for machine learning to provide a balanced assessment of the potential for an organ to be used in a transplantation procedure. METHODS: We accessed and utilized all available deceased donor United Network for Organ Sharing data from 1987 to 2020. With these data, we evaluated the performance of multiple machine learning methods for predicting organ use. The machine learning methods trialed included XGBoost, random forest, Naïve Bayes (NB), logistic regression, and fully connected feedforward neural network classifier methods. The top two methods, XGBoost and random forest, were fully developed using 10-fold cross-validation and Bayesian optimization of hyperparameters. RESULTS: The top performing model at predicting liver organ use was an XGBoost model which achieved an AUC-ROC of .925, an AUC-PR of .868, and an F1 statistic of .756. The top performing model for predicting kidney organ use classification was an XGBoost model which achieved an AUC-ROC of .952, and AUC-PR of .883, and an F1 statistic of .786. CONCLUSIONS: The XGBoost method demonstrated a significant improvement in predicting donor allograft discard for both kidney and livers in solid organ transplantation procedures. Machine learning methods are well suited to be incorporated into the clinical workflow; they can provide robust quantitative predictions and meaningful data insights for clinician consideration and transplantation decision-making.

Nanoparticles Targeted to Fibroblast Activation Protein Outperform PSMA for MRI Delineation of Primary Prostate Tumors.

Accurate delineation of gross tumor volumes remains a barrier to radiotherapy dose escalation and boost dosing in the treatment of solid tumors, such as prostate cancer. Magnetic resonance imaging (MRI) of tumor targets has the power to enable focal dose boosting, particularly when combined with technological advances such as MRI-linear accelerator. Fibroblast activation protein (FAP) is overexpressed in stromal components of >90% of epithelial carcinomas. Herein, the authors compare targeted MRI of prostate specific membrane antigen (PSMA) with FAP in the delineation of orthotopic prostate tumors. Control, FAP, and PSMA-targeting iron oxide nanoparticles were prepared with modification of a lymphotropic MRI agent (FerroTrace, Ferronova). Mice with orthotopic LNCaP tumors underwent MRI 24 h after intravenous injection of nanoparticles. FAP and PSMA nanoparticles produced contrast enhancement on MRI when compared to control nanoparticles. FAP-targeted MRI increased the proportion of tumor contrast-enhancing black pixels by 13%, compared to PSMA. Analysis of changes in R2 values between healthy prostates and LNCaP tumors indicated an increase in contrast-enhancing pixels in the tumor border of 15% when targeting FAP, compared to PSMA. This study demonstrates the preclinical feasibility of PSMA and FAP-targeted MRI which can enable targeted image-guided focal therapy of localized prostate cancer.

Successful upper extremity limb salvage using cellular- and tissue-based products in a patient with uncontrolled diabetes.

INTRODUCTION: Uncontrolled diabetes causes dysfunction in all stages of wound healing, including greatly delayed wound closure owing to impaired angiogenesis. CTPs play an important role in advanced wound care, especially in complex diabetic wounds. The 3 categories of CTP are ECMs, amniotic tissues, and composite products that combine living cells and a collagen matrix. These products are available as xenografts or allografts, or as bioengineered products. ECMs provide a biological scaffold to facilitate wound healing, and these tend to modulate the wound environment and become incorporated into the wound bed. CASE REPORT: A right-hand dominant female with uncontrolled type 2 diabetes presented with a complex nonhealing wound of the right upper extremity; the patient was treated with CTPs after surgical intervention (incision and drainage of the abscess, open carpal tunnel release, forearm fasciotomy, and excisional debridement) for a deep forearm abscess. Exposed critical structures included flexor tendons and the median nerve. The patient received a single application of a meshed dermal regeneration template, an application of minimally processed human umbilical cord membrane, and an application of acellular fish skin, resulting in successful wound reconstruction and improved function of the right upper extremity. CONCLUSION: To the authors' knowledge, this is the first described use of acellular fish skin in the setting of upper extremity reconstruction.

Preclinical feasibility of robot-assisted sentinel lymph node biopsy using multi-modality magnetic and fluorescence guidance in the head and neck.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is a staging procedure dependent on accurate mapping of draining lymphatics via tracers. Robot-assisted SLNB enables access to multiple neck levels with a single incision and intraoperative fluorescence guidance to the SLN. METHODS: Lymphatic mapping in swine was done using a magnetic tracer and fluorescent dye, injected into the tongue. MRI preoperatively mapped lymphatic spread of the magnetic tracer. Dissection was performed using a da Vinci Xi robot guided by fluorescence-imaging of the dye. RESULTS: Robot-assisted SLNB was successfully performed in all animals (n = 5). A novel MRI protocol differentiated SLNs (n = 6) from lower echelon nodes (n = 11) based on flow progression. Fluorescence imaging provided valuable intraoperative guidance and correlated with magnetic-positive nodes. CONCLUSIONS: This study demonstrates preclinical feasibility of a robot-assisted approach to SLNB using magnetic and fluorescent tracers in the head and neck, enabling both preoperative mapping and intraoperative guidance.

Preclinical evaluation of a mannose-labeled magnetic tracer for enhanced sentinel lymph node retention in the head and neck.

Sentinel lymph node biopsy in cancers of the head and neck offers demonstrated clinical and diagnostic value, but adoption is limited by concerns about the detrimental consequence to survival of false negative results in a highly curable setting. The aim of this study was to demonstrate potential to overcome this via application of a novel mannose-labeled magnetic iron oxide tracer. In a large animal model, preoperative imaging and intraoperative magnetometer detection were used to identify magnetic lymph nodes. Iron quantification mapped the distribution of tracer within lymphatic levels. Over a 4-week test period, uptake of magnetic tracer in lymph nodes increased in a linear-like fashion, with a substantial percentage of accumulated iron (83%) being retained in the sentinel node. This result indicates a high affinity of mannose-labeled particles to the sentinel node, while providing a means for the magnetometer probe to indicate node status based on intraoperative signal.

Anomalous Presentation of Venous Malformations in an Adolescent Male.

Venous malformations (VMs) may manifest clinically in a broad spectrum. Most VMs are sporadic with previous studies reporting less than 1.2% to be inherited. Conversely, multifocal lesions, such as glomuvenous malformations (GVMs), which have glomus cells in their vascular walls, have been reported to have a frequency of inheritance of 63.8%. Both VMs and GVMs may occur due to sporadic mutation and must be differentiated clinically because this will dictate their proper treatment. Sporadic GVMs involve skin and subcutis, with bluish-purple coloration, are painful to compression, and have no radiographic evidence of phleboliths. Previous studies have demonstrated that VMs are almost always associated with a single lesion that is nontender to compression and are often able to be diagnosed by the presence of phleboliths on radiographic imaging. We present a case of a 14-year-old right-hand-dominant male who presented with two distinct VMs on the dorsum of the right index finger at the proximal and middle phalanges. A previously biopsied lesion overlying the ipsilateral olecranon, which was reported as a possible glomus tumor versus vascular malformation, was present as well. Based on history, physical examination, multicentric presentation, and radiographic findings, the presumptive diagnosis was that the lesions were GVMs. However, after surgical excision and histopathologic examination, the lesions were determined to be VMs because of the absence of glomus cells. Due to the difference in treatment modalities for VMs and GVMs, the ability to accurately diagnose these lesions clinically is essential. This case represents an anomalous presentation of multiple venous malformations occurring in two distinct locations in a 14-year-old boy.

Correction: The Preferred Treatment of Sternoclavicular Joint Infections: A Systematic Review.

[This corrects the article DOI: 10.7759/cureus.9963.].

Is ventriculomegaly and hindbrain herniation seen before and after prenatal neural tube defect repair associated with a worse functional level than anatomical level at birth?

OBJECTIVE: To determine if the evaluation of the fetal ventricular system and hindbrain herniation (HBH) is associated with motor outcome at birth in prenatally repaired open neural tube defect (NTD). METHODS: Retrospective cohort study of 47 patients with NTD who underwent prenatal repair (17 fetoscopic; 30 open-hysterotomy). At referral and 6 weeks postoperatively, the degree of HBH, ventricular atrial widths and ventricular volume were evaluated by MRI. Head circumference and ventricular atrial widths were measured on ultrasound at referral and during the last ultrasound before delivery. Anatomic level of the lesion (LL) was determined based on the upper bony spinal defect detected by ultrasound. We considered the functional level as worse than anatomical level at birth when the motor level was equal or worse than the anatomical LL. RESULTS: 26% (12/47) of the cases showed worse functional level than anatomical level at birth. Having a HBH below C1 at the time of referral was associated with a worse functional level than anatomical level at birth (OR = 9.7, CI95 [2.2-42.8], p < 0.01). None of the other brain parameters showed a significant association with motor outcomes at birth. CONCLUSIONS: HBH below C1 before surgery was associated with a worse functional level than anatomical level at birth.

Cost-effective fetal lung volumetry for assessment of congenital diaphragmatic hernia.

OBJECTIVES: (1) To investigate the reproducibility of total fetal lung volume (TFLV) measurements using a free 3D modeling software (3DSlicer); (2) To correlate these measurements with lung-to-head ratio (LHR) or TFLV measured using PACS and; (3) To determine the role of 3DSlicer in predicting perinatal outcomes in cases with congenital diaphragmatic hernia (CDH) who had fetal tracheal occlusion (FETO). METHODS: Retrospective cohort study between 2012 and 2017 at Texas Children's Hospital (2011-2017), including all patients who underwent FETO for CDH. LHR was measured by ultrasound and TFLV was measured by MRI at the time of referral and 6 weeks after FETO using 3DSlicer and PACS. We evaluated intra- and inter-rater reliability of TFLV measurement using 3DSlicer, infant survival to 1 year, need for ECMO and pulmonary hypertension. RESULTS: The intra- and inter-rater reliability of TFLV measured with 3DSlicer was excellent before and after FETO (Intra-class correlation coefficient: 0.98-0.99 and 0.94-0.99, respectively). There was a good correlation between TFLV measured with PACS and with 3DSlicer before and after FETO (r = 0.78 and r = 0.99, respectively). Similarly, there was a good correlation between TFLV measurements using PACS or 3DSlicer and LHR after FETO (r = 0.86 and r = 0.88, respectively). Infants who survived to 1 year had a significantly higher TFLV evaluated with 3DSlicer before FETO compared to non-surviving infants (OR = 1.16[1.1-1.3], p = 0.03) as well as a significantly higher TFLV evaluated by 3DSlicer after FETO (OR = 1.2[1-1.4], p = 0.04). CONCLUSION: Lung volume measurements using free 3DSlicer in infants with severe CDH who underwent FETO are reproducible and reliable, and have comparable predictive capability for survival as those measured using conventional software.

Morbidity Associated With Structural Graft Use in Paramedian Forehead Flap.

INTRODUCTION: Paramedian forehead flap for nasal reconstruction may involve the use of a structural graft. The authors hypothesized that the use of structural grafts with paramedian forehead flap is associated with an increased risk of 30-day complications. METHODS: This is a retrospective study of the American College of Surgeon (ACS) National Surgical Quality Improvement Program (NSQIP). We identified all patients undergoing paramedian forehead flap reconstruction from 2007 through 2018 using Current Procedural Terminology code 15731. Patients who had structural graft harvested at the time of paramedian forehead flap were identified using Current Procedural Terminology codes. Groups were defined based on the use of structural grafts. Propensity score matching was performed using preoperative and intraoperative characteristics to produce matched cohorts. The authors further stratified individual graft types to identify differential risks associated with each. Logistic regression was then used to determine whether the use of structural grafts was associated with increased risk for 30-day complications. RESULTS: The authors identified 1198 patients with paramedian forehead flap reconstruction, of whom 325 (27.1%) required structural grafts. Propensity score matching 1:1 yielded 247 patients in each of the matched cohorts. Overall 30-day complications (4.5% versus 5.3%), wound related complications (3.2% versus 4.1%), systemic complications (1.2% versus 2%), unplanned reoperation (6.5% versus 3.2%), and unplanned readmission (6.6% versus 10.2%) were similar between the 2 groups (P > 0.05). Subgroup analysis of different graft types showed that costochondral graft was associated with increased wound related complications (0.9% versus 8.3%, P = 0.03). The odds of having wound related complications with the use of costochondral graft was OR = 5.3, CI = 1.5-18.8, P = 0.02. CONCLUSIONS: Although the use of structural grafts does not increase risk of overall 30-day complications, there is an increased risk of wound related complications associated with the use of costochondral and rib grafts.

Muscle flaps for sternoclavicular joint septic arthritis.

Septic arthritis of the sternoclavicular joint (SC) is rare. The most accepted technique for reconstruction of the defect after SC joint resection is the use of muscle flaps. We hypothesized that resection of ribs with the SC joint impacts timing, type and outcomes of reconstruction. This is a retrospective review of 44 patients who underwent wound closure with muscle flap following resection of the SC joint for septic arthritis over 14 years period from a single institution. Patients were divided into two groups based on the resection of the adjacent ribs with the SC joint. We found 18 (40.9%) patients with SC joint resection only and 26 (59.1%) with concomitant resection of the adjacent ribs. Patients in the rib resection group were younger, did not need SC joint fluid aspiration, and had higher tissue culture positivity (p < .05). Rib resection with the SC joint was found to be associated with delayed reconstruction (57.7% vs 22.2%, p = .030), need for serial debridement's (2 vs 1, p = .009), increased days from debridement to reconstruction for a subset of patients (75% percentile of 8 days vs. 0 days, p = .024), and longer hospital stay (18 vs 9, p = .006). Flap complications were higher in rib resection group (26.9% vs 5.6%, p = .67). Reconstruction following resection of the SC joint for septic arthritis is guided by the surgeon's impression regarding source control of infection. Rib resection concomitantly with joint resection appears to be a useful indicator of disease extent and may help guide clinical decision making in this challenging scenario.

Safety of neonatal sternal wound reconstruction after open heart surgery.

An open sternal wound is a dreaded complication after open heart surgery for neonatal congenital cardiac anomalies. Vascularised muscle flap reconstruction of sternal wound defects, to prevent life-threatening mediastinal infections, is the standard of care in adults and children. However, there is paucity of published literature regarding the safety of this technique in neonates. We describe a successful operative technique for complex reconstruction of an open heart sternal defect on a neonatal male patient. On 6 months postoperative follow-up, we identified an issue with sternal instability. Patient underwent a subsequent operation for reinforcement of the sternal wound repair with Vicryl mesh. The authors report safety of using three separate vascularised muscle flaps in a single neonatal operation. Long-term follow-up of the sternal wound reconstruction is warranted to determine need for secondary procedures.

The Preferred Treatment of Sternoclavicular Joint Infections: A Systematic Review.

The treatment of sternoclavicular joint infection is a topic of controversy. This systematic review aims to evaluate the preferred treatment of sternoclavicular joint infections. A literature search using PubMed/MEDLINE®/Embase databases was conducted to identify publications on the surgical management of sternoclavicular joint infections. Case reports and studies without surgical management were excluded. The outcomes of interest included patient demographics, comorbidities, infectious etiologies, radiographic features, surgical management, and complications. Sixteen articles met the inclusion criteria. The mean age of the subjects was 53.4 years; there was a predominance of males (65%), and a minority of the subjects were obese (15%). The most common infectious etiology was methicillin-susceptible Staphylococcus aureus (MSSA) (48%). CT scan was reported in 46% of cases. The most common treatment was surgical resection of the joints (85%), followed by muscle flap closure of the wounds (54.2%). The complication rate ranged from 0-40%. Specifically, recurrence of infection was low with resection of the joint, followed by muscle flap closure. Given the heterogeneity of the methodology and inconsistency in the outcomes, a meta-analysis could not be performed. Overall, the current literature favors the resection of the sternoclavicular joint as the gold standard treatment. Closure of the wound using muscle flap seems to adequately treat this problem without any major untoward events.

Tenosynovial Giant Cell Tumor in an Infant.

In this report, the authors describe a child presenting at 6 months old with a rapidly expanding extracranial left temporal mass concerning for malignancy. The mass was successfully treated at 16 months with radical surgical excision. The patient was found to have a tenosynovial giant cell tumor, diffuse type, completely encased by the temporalis muscle. To our knowledge, this is the first report of a case of diffuse type tenosynovial giant cell tumor in the temporalis muscle, without articular involvement, presenting in an infant.

Successful management of sternomanubrial joint septic arthritis with pectoralis muscle flap closure: a case series.

Primary infection of the sternomanubrial joint (SMJ) is extremely rare. We present four consecutive cases who were all treated with SMJ resection (partial sternectomy), bilateral partial 2nd rib resection and immediate placement of temporary wound vacuum therapy followed by pectoralis major muscle flap closure. Average patient age was 35.5 years with male predominance (75%). All patients had intravenous drug use as underlying risk factor along with concomitant viral infections Hep C (75%) and HIV (25%). MSSA was identified in resection cultures in 75% of the patients. Delayed bilateral PMFC was achieved in all patients (average post-resection day 5). Response to treatment was excellent with no recurrent infections, no complications and zero 30-day mortalities. Our experience represents the largest reported case series in adults and would suggest that aggressive surgical resection followed by PMFC would appear to be the preferred treatment for all patients with SMJ infection.