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1.	Amini, Mahdi, et al. (författare) Sublingual misoprostol vs. oral misoprostol solution for induction of labor : A retrospective study 2022 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 9 Tidskriftsartikel (refereegranskat)abstract Introduction: Induction of labor (IOL) is one of the most common obstetrical procedures, with an increasing rate. The prostaglandin E1 analogue misoprostol is frequently used as a primary method of labor induction. The optimal dose and route of administration is yet to be ascertained. Aim: To compare efficiacy and safety between a regimen of sublingually administered misoprostol and a regimen of orally administered misoprostol, with cesarean delivery as primary outcome. Methods: A retrospective study was conducted including women carrying a live, singleton fetus in a cephalic position with labor induced at >37 + 0 gestational weeks at Skåne University hospital, Lund, between January 1st 2013 to December 31st 2017. Data was obtained from computerized obstetrical charts. Results: Totally 2,404 women were included; 974 induced with sublingual misoprostol and 1,430 with oral solution. In primiparous women the cesarean delivery rate was lower in primiparous women induced with oral compared to sublingual misoprostol (20.5% vs. 28.6%, p < 0.001), whereas in parous women the rates did not differ significantly 4.9% vs. 7.5%; NS). The increased risk of caesarean remained after controlling for potential confounding factors (adjusted odds ratio 1.49 (1.14–1.95). Women induced with sublingual misoprostol had a shorter time to vaginal delivery when compared to oral solution (primiparous median 16.7 h vs. 21.7 h; p < 0.001, parous median 9.9 h vs. 13.3 h; p = 0.01), and a higher rate of vaginal delivery within 24 h (primiparas 77.7% vs. 63.3%, p < 0.001, parous 93.2% vs. 84.2%; p = 0.01). Conclusion: IOL with oral misoprostol solution was associated with a significantly higher vaginal delivery rate when compared to sublingual misoprostol, whereas sublingual misoprostol was associated with a significantly shorter time from induction to vaginal delivery. Oral administration is considered the most safe and efficient administration of misoprostol, although more studies are needed to find the optimal route and dosage of misoprostol for IOL.
2.	Arzola, Luis H., et al. (författare) Outcome of a dedicated complex aortic surgery fellowship program 2024 Ingår i: Frontiers in Surgery. - : Frontiers Media S.A.. - 2296-875X. ; 11 Tidskriftsartikel (refereegranskat)abstract Introduction: Advancements in endovascular therapy, especially in complex aortic procedures, underscore the need for additional post-certification training. Dedicated post-residency vascular fellowship programs offer exposure to diverse cases, research opportunities, and professional networking. The study aims to describe and present outcomes from the complex aortic fellowship program at the Vascular Surgery Department of the Uppsala University Hospital.Methods: Nine former fellows who completed the aortic fellowship program at the Uppsala University Hospital from 2018 to 2023 were invited to take part in an anonymous 29-question survey through email. Demographic data, information about the existence of local aortic programs as well as on the types of aortic procedures performed were gained. The overall experience and impact of the fellowship were assessed using multiple interval scale questions, with a rating scale (1 excellent to 5 very poor). Finally, we provided the option to the participants to share additional feedback.Results: Median age of participants was 34 years (IQR, 30.5-36), with 44.4% being women (4/9). There was a significant variation in the number of publications produced during the fellowship, with an overall mean of 4 papers (IQR, 2-10). Regarding the long-term impact of the fellowship, 5/9 (55.6%) of the fellows have contributed to the implementation of a complex aortic program after finishing the fellowship, providing a broad range of complex aortic procedures. All fellows (9/9, 100%) stated that the quality of the fellowship was excellent. The clinical experience 7/9 (77.8%), the academic environment 7/9 (77.8%) and the research opportunities 7/9 (77.8%) together with the mentorship 9/9 (100%) and the work environment 8/9 (88.9%), were considered of most value among the fellows. In general, the survey participants agreed that the fellowship atmosphere was suitable for learning, 9/9 (100%), and that it had a positive impact on their current practice, 7/9 (77.8%). Currently, 5/9 (55.5%) of the fellows hold a position including academic involvement.Conclusions: There is a universal need for additional post-certification training. The current study showed that a balanced clinical and scientific exposure to complex aortic diseases is broadly welcomed among young vascular surgeons. The extension of the fellowship to cover other disciplines dealing with complex aortic procedures can be of value.
3.	Ayoubi, Jean Marc, et al. (författare) Case Report: Post-Partum SARS-CoV-2 Infection After the First French Uterus Transplantation 2022 Ingår i: Frontiers in Surgery. - : Frontiers Media SA. - 2296-875X. ; 9 Tidskriftsartikel (refereegranskat)abstract Absolute uterus factor infertility, whether congenital or acquired, renders the woman unable to carry a child. Although uterus transplantation (UTx) is being increasingly performed as a non-vital procedure to address this unfortunate condition, the immunosuppression required presents risks that are further compounded by pregnancy and during the puerperium period. These vulnerabilities require avoidance of SARS-CoV-2 infection in pregnant UTx recipients especially during the third trimester, as accumulating evidence reveals increased risks of morbidity and mortality. Here we describe a successful UTx case with delivery of a healthy child, but in which both mother and neonate developed asymptomatic SARS-CoV-2 infection seven days after RNA vaccination, on day 35 post-partum. Although the patient was successfully treated with a combination therapy comprised of two monoclonal antibodies, this case highlights the challenges associated with performing UTx in the era of Covid-19. More broadly, the risks of performing non-vital organ transplantation during a pandemic should be discussed among team members and prospective patients, weighing the risks against the benefits in improving the quality of life, which were considerable for our patient who achieved motherhood with the birth of a healthy child.
4.	Azer, Amanda, et al. (författare) Outcomes of humeral osteotomies versus soft-tissue procedures in secondary surgical procedures for neonatal brachial plexus palsy : a meta-analysis 2023 Ingår i: Frontiers in Surgery. - : Frontiers Media S.A.. - 2296-875X. ; 10 Tidskriftsartikel (refereegranskat)abstract Secondary surgical procedures can be used in brachial plexus birth injury to correct shoulder movement imbalances. This study compares outcomes of the two secondary surgical procedure types: humeral osteotomies and soft tissue procedures. Outcome measures assessed included active and passive internal and external rotation, active and passive abduction and adduction, active and passive flexion and extension, percentage of the humeral head anterior to the middle glenoid fossa, glenoid version, and Mallet Score. Nineteen full-text articles were included in the analysis. Humeral osteotomies resulted in a loss of internal rotation postoperatively (-15.94 degrees). Active internal rotation was not evaluated for soft tissue procedures. All other assessed outcomes were improved postoperatively for bony and soft tissue procedures. Bony procedures exhibited a greater degree of active external rotation postoperatively when compared to soft tissue procedures (+67 degrees vs. +40 degrees). Both bony and soft tissue procedures Improve shoulder function in children with neonatal brachial plexus palsy, however, soft tissue procedures showed greater consistency in outcomes.Level of Evidence: IV
5.	Bittersohl, Bernd, et al. (författare) Advanced Imaging in Femoroacetabular Impingement: Current State and Future Prospects. 2015 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 2, s. 34-34 Forskningsöversikt (refereegranskat)abstract Symptomatic femoroacetabular impingement (FAI) is now a known precursor of early osteoarthritis (OA) of the hip. In terms of clinical intervention, the decision between joint preservation and joint replacement hinges on the severity of articular cartilage degeneration. The exact threshold during the course of disease progression when the cartilage damage is irreparable remains elusive. The intention behind radiographic imaging is to accurately identify the morphology of osseous structural abnormalities and to accurately characterize the chondrolabral damage as much as possible. However, both plain radiographs and computed tomography (CT) are insensitive for articular cartilage anatomy and pathology. Advanced magnetic resonance imaging (MRI) techniques include magnetic resonance arthrography and biochemically sensitive techniques of delayed gadolinium-enhanced MRI of cartilage (dGEMRIC), T1rho (T1ρ), T2/T2* mapping, and several others. The diagnostic performance of these techniques to evaluate cartilage degeneration could improve the ability to predict an individual patient-specific outcome with non-surgical and surgical care. This review discusses the facts and current applications of biochemical MRI for hip joint cartilage assessment covering the roles of dGEMRIC, T2/T2*, and T1ρ mapping. The basics of each technique and their specific role in FAI assessment are outlined. Current limitations and potential pitfalls as well as future directions of biochemical imaging are also outlined.
6.	Buondonno, A., et al. (författare) A Hub and Spoke Learning Program in Bariatric Surgery in a Small Region of Italy 2022 Ingår i: Frontiers in Surgery. - : Frontiers Media SA. - 2296-875X. ; 9 Tidskriftsartikel (refereegranskat)abstract BackgroundMetabolic and bariatric surgery (BS) are considered life-changing and life-saving treatments for obese patients. The Italian Society of Obesity Surgery (SICOB) requires at least 25 operations per year to achieve the standard of care in the field. Despite the increasing need to treat obese patients, some small southern regions of Italy, such as Molise, do not have enough experience in bariatric procedures to be allowed to perform them. Therefore, our aim was to run a Hub and Spoke Program with a referral center in BS to treat obese patients and provide a proper learning curve in BS in Molise. MethodsIn 2020, the "A. Cardarelli Hospital" in Campobasso, Molise, started a formal "Learning Model of Hub and Spoke Collaboration" with the Hub center "Ospedale Del Mare", Naples. A multidisciplinary approach was achieved. Patients were supervised and operated under the supervision and tutoring of the referral center. We retrospectively reviewed our prospectively collected database from February 2020 to August 2021 in order to analyze the safety and effectiveness of our learning program. ResultsIn total, 13 (3 men and 10 women) patients underwent BS with the mean age of 47.08 years and a presurgery BMI of 41.79. Seven (53.84%) patients were the American Society of Anesthesiologist (ASA) II, and 6 (46.16%) patients were ASA III. Twelve (92.31%) procedures were laparoscopic sleeve gastrectomies, 1 (7.69%) patient underwent endoscopic BioEnterics Intragastric Balloon (BIB) placement. One (8.33%) sleeve gastrectomy was associated to gastric band removal. Mean surgical time was 110.14 +/- 23.54 min. The mean length of stay was 4.07 +/- 2.40 days. No Clavien-Dindo >= III and mortality were reported. The follow-up program showed a mean decrease of 11.82 in terms of body mass index (BMI) value. The last 5 procedures were performed by the whole equips from "A. Cardarelli" under external tutoring without any impact on complication rate. ConclusionThe setup of a proper Hub and Spoke Program may allow to perform BS to provide the standard of care. This approach may reduce health costs and related patient migration.
7.	Bydén, Moa, et al. (författare) Cerebrovascular Reserve Capacity as a Predictor of Postoperative Delirium : A Pilot Study 2021 Ingår i: Frontiers in Surgery. - : Frontiers Media S.A.. - 2296-875X. ; 8 Tidskriftsartikel (refereegranskat)abstract Introduction: Postoperative delirium is a common complication after cardiac surgery with cardiopulmonary bypass (CPB). Compromised regulation of the cerebral circulation may be a predisposing factor for delirium. However, the potential relationship between cerebrovascular reserve capacity and delirium is unknown. The aim of this study was to investigate if impaired cerebrovascular reserve capacity was associated with postoperative delirium.Methods: Forty-two patients scheduled for cardiac surgery with CPB were recruited consecutively. All patients underwent preoperative transcranial Doppler (TCD) ultrasound with calculation of breath-hold index (BHI). BHI < 0.69 indicated impaired cerebrovascular reserve capacity. In addition, patients were examined with preoperative neuropsychological tests such as MMSE (Mini Mental State Examination) and AQT (A Quick Test of cognitive speed). Postoperative delirium was assessed using Nursing Delirium Screening Scale (Nu-DESC) in which a score of >= 2 was considered as delirium.Results: Six patients (14%) scored high for postoperative delirium and all demonstrated impaired preoperative cerebrovascular reserve capacity. Median (25th-75th percentile) BHI in patients with postoperative delirium was significantly lower compared to the non-delirium group [0.26 (-0.08-0.44) vs. 0.83 (0.57-1.08), p = 0.002]. Preoperative MMSE score was lower in patients who developed postoperative delirium (median, 25th-75th percentile; 26.5, 24-28 vs. 28.5, 27-29, p = 0.024). Similarly, patients with postoperative delirium also displayed a slower performance during the preoperative cognitive speed test AQT color and form (mean +/- SD; 85.8 s +/- 19.3 vs. 69.6 s +/- 15.8, p = 0.043).Conclusion: The present findings suggest that an extended preoperative ultrasound protocol with TCD evaluation of cerebrovascular reserve capacity and neuropsychological tests may be valuable in identifying patients with increased risk of developing delirium after cardiac surgery.
8.	Calon, T. G. A., et al. (författare) The Use of cone Beam computed Tomography in Assessing the Insertion of Bone conduction hearing Implants 2017 Ingår i: Frontiers in Surgery. - : Frontiers Media SA. - 2296-875X. ; 4 Tidskriftsartikel (refereegranskat)abstract Objective: This study aimed to compare postoperative cone beam CT (CBCT) imaging to implant stability quotient (ISO) measurement and direct caliper measurements as a suitable technique to assess bone conduction hearing implant (BCHI) seating and insertion depth. Methods: in vitro, BCHIs were completely (n = 9) and partially inserted (n = 9) in bone blocks of different densities and subsequently scanned. Scans were processed using 3DSlicer 4.3.1 and Mathematica 10.3. ISO measurements were obtained for all BCHIs mounted with different abutment lengths (9, 12, and 14 mm). CBCT imaging was performed for patients with a clinical indication. Results: In vitro, 95% prediction intervals for partially inserted and completely inserted BCHIs were determined. ISO values significantly decreased with partial insertion, low -density artificial bone, and longer abutment lengths. Evaluation of in vitro and in vivo 3D models allowed for assessment of insertion depth and inclination. Conclusion: CBCT imaging allows to study implant seating and insertion depth after BCHI surgery. This can be useful when visual confirmation is limited. It is possible to distinguish a partial BCHI insertion from a complete insertion in artificial bone blocks. This technique could prove to be a valuable research tool. In vitro, ISO values for Ponto BCHIs relate to abutment length, insertion depth, and artificial bone density.
9.	Cruz, L. D., et al. (författare) Minimally invasive surgery as a new clinical standard for bone anchored hearing implants-real-world data from 10 years of follow-up and 228 surgeries 2023 Ingår i: Frontiers in Surgery. - 2296-875X. ; 10 Tidskriftsartikel (refereegranskat)abstract PurposeTo explore the clinical practice development of different surgical techniques when installing bone-anchored hearing implants and their associated trends in outcomes. DesignRetrospective study of 228 bone-anchored hearing implants in 200 patients, performed over a 10-year period between 2012 and 2022 in a referral hospital. MethodReal-world data of demography, etiology, surgical setup, complications, and audiological outcomes were collected. Eligibility criteria from clinical practice were applied. ResultsThe minimally invasive technique is associated with shorter surgery duration, 20 vs. 44 min as compared to a linear incision technique. The minimally invasive technique was also associated with a lower occurrence of complications when compared to linear incision techniques (intraoperative; 1.8% vs. 4.9%, postoperative; 49% vs. 66%). Most differences were seen in complications relating to skin and wound healing. ConclusionAdoption of a minimally invasive surgical technique for the installations of bone-anchored hearing implants can reduce surgical complexity without compromising safety aspects or clinical benefits.
10.	Darkahi, B, et al. (författare) Laparoscopic Common Bile Duct Exploration: 9 Years Experience from a Single Center 2016 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 3, s. 23- Tidskriftsartikel (refereegranskat)
11.	Fekete, Boglarka, et al. (författare) What predicts survival in glioblastoma? A population-based study of changes in clinical management and outcome. 2023 Ingår i: Frontiers in surgery. - 2296-875X. ; 10 Tidskriftsartikel (refereegranskat)abstract Glioblastoma is the most common and most aggressive primary brain tumor in adults. Despite multimodal treatment, the median survival time is 15-16 months and 5-year survival rate 5%-10%. The primary goal of this study was to identify prognostic factors for survival in an unselected population of patients operated for glioblastoma. The secondary goal was to explore changes in outcome and the clinical management of this patient group over time.We identified 222 consecutive adults operated for glioblastoma between November 2012 and June 2016 at the Department of Neurosurgery, Sahlgrenska University Hospital in Gothenburg, serving a health care region in the western part of Sweden with 1.900.000 inhabitants. Clinical variables were identified and tested as predictors for prognosis in extended Poisson regression models. The results were compared with a previously published cohort from 2004 to 2008, before current standard of care based on molecular tumor diagnosis was fully implemented.Median overall survival was 1.07 years, which was significantly longer than in the 2004-2008 cohort (1.07 vs. 0.73 y, age- and sex adjusted HR=1.89, p<0.0001). Variables associated with longer survival in the multivariable model were MGMT promoter hypermethylation, non-central tumor location, complete resection of enhancing tumor, WHO performance status 0-1, unilateral tumor location, fewer lobes involved, younger age and no comorbidities.The median survival for patients with glioblastoma treated according to current standard treatment has moderately but significantly increased, with MGMT promoter hypermethylation as the strongest predictor for survival.
12.	Forssten, Maximilian Peter, 1996-, et al. (författare) Prioritizing patients for hip fracture surgery : the role of frailty and cardiac risk 2024 Ingår i: Frontiers in Surgery. - : Frontiers Media S.A.. - 2296-875X. ; 11 Tidskriftsartikel (refereegranskat)abstract INTRODUCTION: The number of patients with hip fractures continues to rise as the average age of the population increases. Optimizing outcomes in this cohort is predicated on timely operative repair. The aim of this study was to determine if patients with hip fractures who are frail or have a higher cardiac risk suffer from an increased risk of in-hospital mortality when surgery is postponed >24 h.METHODS: All patients registered in the 2013-2021 TQIP dataset who were ≥65 years old and underwent surgical fixation of an isolated hip fracture caused by a ground-level fall were included. Adjustment for confounding was performed using inverse probability weighting (IPW) while stratifying for frailty with the Orthopedic Frailty Score (OFS) and cardiac risk using the Revised Cardiac Risk Index (RCRI). The outcome was presented as the absolute risk difference in in-hospital mortality.RESULTS: A total of 254,400 patients were included. After IPW, all confounders were balanced. A delay in surgery was associated with an increased risk of in-hospital mortality across all strata, and, as the degree of frailty and cardiac risk increased, so too did the risk of mortality. In patients with OFS ≥4, delaying surgery >24 h was associated with a 2.33 percentage point increase in the absolute mortality rate (95% CI: 0.57-4.09, p = 0.010), resulting in a number needed to harm (NNH) of 43. Furthermore, the absolute risk of mortality increased by 4.65 percentage points in patients with RCRI ≥4 who had their surgery delayed >24 h (95% CI: 0.90-8.40, p = 0.015), resulting in a NNH of 22. For patients with OFS 0 and RCRI 0, the corresponding NNHs when delaying surgery >24 h were 345 and 333, respectively.CONCLUSION: Delaying surgery beyond 24 h from admission increases the risk of mortality for all geriatric hip fracture patients. The magnitude of the negative impact increases with the patient's level of cardiac risk and frailty. Operative intervention should not be delayed based on frailty or cardiac risk.
13.	Georgiou, Konstantinos, et al. (författare) Saliva stress biomarkers in ERCP trainees before and after familiarisation with ERCP on a virtual simulator 2024 Ingår i: Frontiers in Surgery. - : Frontiers Media S.A.. - 2296-875X. ; 11 Tidskriftsartikel (refereegranskat)abstract Background: Stress during the early ERCP learning curve may interfere with acquisition of skills during training. The purpose of this study was to compare stress biomarkers in the saliva of trainees before and after familiarisation with ERCP exercises on a virtual simulator.Methods: Altogether 26 endoscopists under training, 14 women and 12 men, completed the three phases of this study: Phase 1. Three different ERCP procedures were performed on the simulator. Saliva for α-amylase (sAA), Chromogranin A (sCgA), and Cortisol (sC) were collected before (baseline), halfway through the exercise (ex.), and 10 min after completion of the exercise (comp.); Phase 2. A three-week familiarisation period where at least 30 different cases were performed on the virtual ERCP simulator; and Phase 3. Identical to Phase 1 where saliva samples were once again collected at baseline, during, and after the exercise. Percentage differences in biomarker levels between baseline and exercise (Diffex) and between baseline and completion (Diffcomp) during Phase 1 and Phase 3 were calculated for each stress marker.Results: Mean % changes, Diffex and Diffcomp, were significantly positive (p < 0.05) for all markers in both Phase 1 and Phase 3. Diffex in Phase 1 was significantly greater than Diffex in Phase 3 (p < 0.05) for sAA and sCgA. Diffcomp for sAA in Phase 1 was significantly greater than Diffcomp in Phase 3 (p < 0.05). No significant differences were found in sC concentration between Phases 1 and 3.Conclusion: This study shows that familiarisation with the ERCP simulator greatly reduced stress as measured by the three saliva stress biomarkers used with sAA being the best. It also suggests that familiarisation with an ERCP simulator might reduce stress in the clinical setting.
14.	Georgiou, Konstantinos, et al. (författare) Validity of a virtual reality endoscopic retrograde cholangiopancreatography simulator : can it distinguish experts from novices? 2023 Ingår i: Frontiers in Surgery. - : Frontiers Media S.A.. - 2296-875X. ; 10 Tidskriftsartikel (refereegranskat)abstract Background: There is a lack of evidence regarding the effectiveness of virtual simulators as a means to acquire hands-on exposure to endoscopic retrograde cholangiopancreatography (ERCP). The present study aimed to assess the outcome and construct validity of virtual ERCP when training on the GI II Mentor simulator.Methods: A group of seven experienced endoscopists were compared with 31 novices. After a short introduction, they were requested to carry out three virtual ERCP procedures: diagnosing and removing a common bile duct (CBD) stone; diagnosing and taking brush cytology from a hilar stenosis; and, finally, diagnosing and treating a cystic leakage with a BD stent. For each task, the total time required to complete the task, time required to correctly view the papilla, total time of irradiation, time to deep cannulation, time to define diagnosis, time to complete sphincterotomy, and time to complete the respective intervention were measured. Cannulation of the BD, correct diagnosis, sphincterotomy, and time to complete intervention were assessed by an assessor blinded to the status of the endoscopist who performed the virtual ERCP.Results: The time required to visualize the papilla and to cannulate deeply when removing the BD stone was significantly shorter for the experts (both p < 0.05). The time to visualize the papilla, cannulate deeply, reach a diagnosis, complete sphincterotomy, and complete the intervention was significantly shorter for the experts when managing cystic leakage (all p < 0.05). In diagnosing and taking brush cytology from a hilar stenosis, there was only a trend toward the experts needing less time for the deep cannulation of the BD (p = 0.077).Conclusion: The performance differed between experts and novices, especially in the management of cystic leakage. This corroborates the construct validity of the GI II Mentor simulator.
15.	Guntinas-Lichius, O, et al. (författare) Treatment of recurrent acute tonsillitis-a systematic review and clinical practice recommendations 2023 Ingår i: Frontiers in surgery. - 2296-875X. ; 10, s. 1221932- Tidskriftsartikel (refereegranskat)
16.	Gutlic, Nihad, et al. (författare) The Relevance of Sexual Dysfunction Related to Groin Pain After Inguinal Hernia Repair : The SexIHQ Short Form Questionnaire Assessment 2018 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 5, s. 1-8 Tidskriftsartikel (refereegranskat)abstract Background: Chronic postoperative pain after inguinal hernia surgery can affect sexual function. A new short form questionnaire for inguinal hernia pain related sexual dysfunction (SexIHQ) was introduced and applied to a register based cohort of total extra-peritoneal hernioplasty (TEP) operated patients. Methods: Sexually active men, 30–60 years old, recorded in the Swedish Hernia Register for a primary inguinal hernia TEP operation were included. Two initial questions of the SexIHQ identify patients with pain at sexual activity. Only these patients proceeded to answer the specific questions on pain-induced impairment of sexual activity, pain frequency and intensity, physical functions (erection and ejaculation), and symptoms of depression. SexIHQ, the Short Form-36 (SF-36), the Inguinal Pain Questionnaire (IPQ) were mailed to participants for long term follow up. Results: In 538 included patients, 44 (8.2%) reported pain during sexual activity at mean 33 months after surgery. Sexual dysfunction was seen in 33 of these patients. A postoperative complication was a risk factor for pain during sexual activity; OR 4.89 (95% CI 1.92–12.43; p < 0.001). Quality-of-life was reduced in almost all SF-36 domains in patients with pain during sexual activity. Conclusions: A short form questionnaire, suitable for large cohorts, was developed to assess sexual dysfunction due to groin pain after inguinal hernia repair in male patients. Sexual dysfunction due to groin pain after hernia surgery by TEP is surprisingly common. Patients should preoperatively be informed of the risk of having pain during sexual activity following groin hernia surgery.
17.	Hellgren, Johan, 1965, et al. (författare) Unmet challenges in septoplasty-nordic studies from a uniform healthcare and geographical area 2022 Ingår i: Frontiers in Surgery. - : Frontiers Media SA. - 2296-875X. ; 9 Forskningsöversikt (refereegranskat)abstract PurposeNasal septoplasty is one of the most common surgical procedures in otorhinolaryngology and optimising both patient selection and the surgery is a challenge. The Nordic countries have similar public healthcare systems and comparable populations in terms of size. MethodsThis is a review of studies of outcome and predictors related to septoplasty from Denmark, Finland, Norway and Sweden, published during the last decade. The aim of this review was to identify areas in need of further research to meet the challenges of septoplasty in the Nordic countries with reference to international data. ResultsPostoperative patient satisfaction at 6-12 months was reported in around 2/3 of the patients and well in line with international data. Patients with more severe symptoms had a higher chance of improvement. Lack of standardisation in patient selection, surgical methods and skills, and follow up procedures, still makes it difficult to explain the 25% failure rate in septoplasty surgery. ConclusionThis review of the Nordic studies from the last decade shows that septoplasty in general is effective in relieving nasal obstruction. There is a need for studies addressing the standardisation of diagnostic tools and algorithms and the systematic and continuous implementation of follow-up of the surgical results at both departmental and personal level. This includes an awareness of how surgical skills in septoplasty are obtained and maintained.
18.	Holmdahl, Viktor, 1990-, et al. (författare) Autologous full-thickness skin in the repair of complex ventral hernias : an innovative step into the future of complex hernia repair? 2023 Ingår i: Frontiers in Surgery. - : Frontiers Media S.A.. - 2296-875X. ; 10 Forskningsöversikt (refereegranskat)abstract The repair of complex ventral hernias, such as giant incisional or parastomal hernia, is associated with a high risk for complications and recurrence. Some serious complications are related to implantation of synthetic mesh as reinforcement material. Autologous full-thickness skin graft (FTSG) as reinforcement material in the repair of these complex hernias may offer a safe alternative. This is a review of the history of FTSG use in hernia surgery and the experiences of our research group regarding its application over the last decade. The results of FTSG used in the repair of giant ventral hernias are promising, and this method may already be recommended in selected cases. We have also conducted a translational chain of preclinical studies, based on a murine model, to gain a greater understanding of the behaviour of FTSG implanted in various positions in the abdominal wall. The use of intraperitoneal FTSG as reinforcement material in parastomal hernia repair is currently being evaluated in a randomised, controlled, multicentre study.
19.	Holmdahl, Viktor, et al. (författare) The Tensile Strength of Full-Thickness Skin : A Laboratory Study Prior to Its Use as Reinforcement in Parastomal Hernia Repair 2019 Ingår i: Frontiers in Surgery. - : Frontiers Media S.A.. - 2296-875X. ; 6 Tidskriftsartikel (refereegranskat)abstract Purpose: Parastomal hernia is a common complication of an enterostoma. Current methods of repair have high recurrence rates and are associated with severe complications. Autologous full-thickness skin as reinforcement may reduce the recurrence and complication rates. This study aims to investigates the tensile strength of full-thickness skin; information that is essential if we are to proceed with clinical trials on humans.Methods: Full-thickness skin samples from 12 donors were tested for tensile strength, as well as the load tolerated by a suture through the skin. Strips of skin were cut out and stretched until breaking point. Sutures were made through skin samples and traction applied until either the tissue or the suture gave way. All done while recording the forces applied using a dynamometer. Identical tests were carried out on commercially available synthetic and biologic graft material for comparison.Results: The full-thickness skin strips had a median tensile strength of 604 N/cm. This tensile strength was significantly higher than that of the compared materials evaluated in this study. In full-thickness skin, the suture, or tissue endured a median force of 67 N before giving way, which was as high as, or higher than similar sutures through the compared materials.Conclusions: The tensile strength of full-thickness skin vastly exceeds the physiological forces affecting the abdominal wall, and sutures through skin endure high loads before giving way. The tensile strength of a full-thickness skin graft and the strength of sutures through this material will not limit its use for reinforcement in parastomal hernia repair.
20.	Johansson, Martin L, et al. (författare) Long-term osseointegration of laser-ablated hearing implants in sheep cranial bone 2022 Ingår i: Frontiers in Surgery. - : Frontiers Media SA. - 2296-875X. ; 9 Tidskriftsartikel (refereegranskat)abstract Osseointegration, the ability for an implant to be anchored in bone tissue with direct bone-implant contact and allowing for continuous adaptive remodelling, is clinically used in different reconstructive fields, such as dentistry, orthopedics and otology. The latter uses a bone conducting sound processor connected to a skin-penetrating abutment that is mounted on a titanium implant placed in the temporal bone, thereby acting as a path for transmission of the vibrations generated by the sound processor. The success of the treatment relies on bone healing and osseointegration, which could be improved by surface modifications. The aim of this study was to evaluate the long-term osseointegration in a sheep skull model and compare a laser-ablated implant surface with a machined implant. Commercially available 4mm titanium implants, either with a machined (Wide Ponto) or a laser-ablated surface (Ponto BHX, Oticon Medical, Sweden), were used in the current study. The surfaces were evaluated by scanning electron microscopy. The implantation was performed with a full soft tissue flap and the osteotomy was prepared using the MIPS drill kit (Oticon Medical, Sweden) prior to installation of the implants in the frontal bone of eight female sheep. After five months, biopsies including the implant and surrounding bone tissue obtained, processed and analysed using histology, histomorphometry, scanning electron microscopy and Raman spectroscopy. The animals healed well, without signs of adverse events. Histomorphometry showed a large amount of bone tissue around both implant types, with 75% of the threaded area occupied by bone for both implant types. A large amount of bone-implant contact was observed for both implant types, with 67%–71% of the surface covered by bone. Both implant types were surrounded by mature remodelled lamellar bone with high mineral content, corroborating the histological observations. The current results show that the laser-ablated surface induces healing similar to the well-known clinically used machined surface in ovine cranial bone. In conclusion, the present long-term experimental results indicate that a laser-ablated implant performs equally well as a clinically used implant with a machined surface. This, together with previously reported, improved early biomechanical anchorage, suggests future, safe and efficient clinical potential.
21.	Kallinowski, F, et al. (författare) Editorial: Mesh Complications in Hernia Surgery 2022 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 9, s. 841672- Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)
22.	Karonen, Emil, et al. (författare) Risk Factors for Fasciotomy After Revascularization for Acute Lower Limb Ischaemia 2021 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 8 Tidskriftsartikel (refereegranskat)abstract Background: Acute lower limb ischaemia (ALI) is a life and limb threatening vascular emergency. Acute compartment syndrome (ACS) may develop upon revascularization. The risk of fasciotomy was hypothesized to be decreased in women due to their lower calf muscle mass. The main aim was to evaluate risk factors for fasciotomy after revascularization for ALI. Methods: This is a retrospective observational study of patients undergoing revascularization for ALI between 2001 and 2018. Factors associated with outcome at 1 year in univariable analysis (p < 0.1) were chosen for multi-variable analysis and expressed in Odds Ratios (OR) with 95% confidence intervals (CI). Results: The median age for women (n = 394) was 75 years and men (n = 449) was 70 years (p < 0.001). The frequency of fasciotomy was 10.0% (84/843). The median in-hospital stay was 28 vs. 6 days for patients undergoing fasciotomy and not, respectively (p < 0.001). In adjusted analysis, renal insufficiency (OR 1.77, 95% CI 1.04–3.01), motor deficit (OR 4.40, 95% CI 2.45–7.92), popliteal artery aneurysm thromboembolism (OR 2.26, 95% CI 1.06–4.80), and open vascular surgery (OR 3.43, 95% CI 1.97–5.98) were associated with an increased risk of fasciotomy. Female patients (OR 0.49, 95% CI 0.28–0.84) and anemia (OR 0.52, 95% CI 0.28–0.84) had a lower risk. The major amputation/mortality rate at 1-year was 27.7%; fasciotomy (OR 1.94, 95% CI 1.11–3.40), anemia (OR 1.84, 95% CI 1.24–2.73) and female gender (OR 1.44, 95% CI 1.00–2.08) were independently associated with an increased risk. Conclusions: Female patients had lower rates of fasciotomies, but subsequent higher risk of major amputation/mortality, which may be attributed to inferior results of revascularization. Lower muscle mass and underdiagnosis of ACS could also explain the lower frequency of fasciotomy for female patients. Further studies are needed to better understand gender differences in presentation of ALI, revascularization results and diagnosis of ACS.
23.	Li, Hao, 1984-, et al. (författare) A Synchrotron and Micro-CT Study of the Human Endolymphatic Duct System : Is Meniere's Disease Caused by an Acute Endolymph Backflow? 2021 Ingår i: Frontiers in Surgery. - : Frontiers Media S.A.. - 2296-875X. ; 8 Tidskriftsartikel (refereegranskat)abstract Background: The etiology of Meniere's disease (MD) and endolymphatic hydrops believed to underlie its symptoms remain unknown. One reason may be the exceptional complexity of the human inner ear, its vulnerability, and surrounding hard bone. The vestibular organ contains an endolymphatic duct system (EDS) bridging the different fluid reservoirs. It may be essential for monitoring hydraulic equilibrium, and a dysregulation may result in distension of the fluid spaces or endolymphatic hydrops. Material and Methods: We studied the EDS using high-resolution synchrotron phase contrast non-invasive imaging (SR-PCI), and micro-computed tomography (micro-CT). Ten fresh human temporal bones underwent SR-PCI. One bone underwent micro-CT after fixation and staining with Lugol's iodine solution (I2KI) to increase tissue resolution. Data were processed using volume-rendering software to create 3D reconstructions allowing orthogonal sectioning, cropping, and tissue segmentation. Results: Combined imaging techniques with segmentation and tissue modeling demonstrated the 3D anatomy of the human saccule, utricle, endolymphatic duct, and sac together with connecting pathways. The utricular duct (UD) and utriculo-endolymphatic valve (UEV or Bast's valve) were demonstrated three-dimensionally for the first time. The reunion duct was displayed with micro-CT. It may serve as a safety valve to maintain cochlear endolymph homeostasis under certain conditions. Discussion: The thin reunion duct seems to play a minor role in the exchange of endolymph between the cochlea and vestibule under normal conditions. The saccule wall appears highly flexible, which may explain occult hydrops occasionally preceding symptoms in MD on magnetic resonance imaging (MRI). The design of the UEV and connecting ducts suggests that there is a reciprocal exchange of fluid among the utricle, semicircular canals, and the EDS. Based on the anatomic framework and previous experimental data, we speculate that precipitous vestibular symptoms in MD arise from a sudden increase in endolymph pressure caused by an uncontrolled endolymphatic sac secretion. A rapid rise in UD pressure, mediated along the fairly wide UEV, may underlie the acute vertigo attack, refuting the rupture/K+-intoxication theory.
24.	Lindstrom, P, et al. (författare) Postoperative Pain After Robot-Assisted Laparoscopic Ventral Hernia Repair 2021 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 8, s. 724026- Tidskriftsartikel (refereegranskat)abstract Background: Robot-assisted ventral hernia repair, when performed correctly, may reduce the risk for pain and discomfort in the postoperative period thus enabling shorter hospital stay. The aim of the present study was to evaluate postoperative pain following robot-assisted laparoscopic repair. The approach was selected after an intraoperative decision to complete the repair as: (1). Transabdominal Preperitoneal Repair (TAPP); (2). Trans-Abdominal RetroMuscular (TARM) repair; or (3). Intraperitoneal Onlay Mesh (IPOM) repair depending on anatomical conditions.Methods: Twenty ventral hernia repairs, 8 primary and 12 incisional, were included between 18th Dec 2017 and 11th Nov 2019. There were 8 women, mean age was 60.3 years, and mean diameter of the defect was 3.8 cm. The repairs were performed at Södersjukhuset (Southern General Hospital, Stockholm) using the Da Vinci Si Surgical System®. Sixteen repairs were completed with the TAPP technique, 2 with the TARM technique, and 2 as IPOM repair.Results: Mean hospital stay was 1.05 days. No postoperative infection was seen, and no recurrence was seen at 1 year. At the 30-day follow-up, fifteen patients (75%) rated their pain as zero or pain that was easily ignored, according to the Ventral Hernia Pain Questionnaire. After 1 year no one had pain that was not easily ignored.Conclusion: The present study shows that robot-assisted laparoscopic ventral hernia is feasible and safe. More randomized controlled trials are needed to show that the potential benefits in terms of shorter operation times, earlier discharge, and less postoperative pain motivate the extra costs associated with the robot technique.
25.	Liu, YP, et al. (författare) Consensus on MR Imaging of Endolymphatic Hydrops in Patients With Suspected Hydropic Ear Disease (Meniere) 2022 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 9, s. 874971- Tidskriftsartikel (refereegranskat)abstract Endolymphatic hydrops (EH) is considered the histological hallmark of Meniere's disease. Visualization of EH has been achieved by special sequences of inner ear magnetic resonance imaging (MRI) with a gadolinium-based contrast agent via intravenous or intratympanic administration. Although it has been applied for more than 10 years since 2007, a unified view on this technique has not yet been achieved. This paper presents an expert consensus on MRI of endolymphatic hydrops in the following aspects: indications and contra-indications for patient selection, methods of contrast-agent administration (intravenous or intratympanic), MRI sequence selection, the specific scanning parameter settings, and standard image evaluation methods and their advantages and disadvantages. For each part of this consensus, a comment is attached to elucidate the reasons for the recommendation.
26.	Liu, YP, et al. (författare) Vestibular Endolymphatic Hydrops Visualized by Magnetic Resonance Imaging and Its Correlation With Vestibular Functional Test in Patients With Unilateral Meniere's Disease 2021 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 8, s. 673811- Tidskriftsartikel (refereegranskat)abstract Background:Currently, 3 Tesla-MRI following intratympanic gadolinium injection has made it possible to assess the existence and the severity of hydrops in each compartment of the endolymphatic spacesin vivo. However, the relationship between vestibular endolymphatic hydrops (EH) visualized by MRI and vestibular functional tests, especially the correlation between caloric test, video-head impulse test, and semicircular canal hydrops, has not been well-investigated.Objective:The purpose of this study is to investigate the relationship between the severity of EH in each compartment of otoliths and semicircular canal and the results of vestibular functional tests.Methods:In this retrospective study, we performed three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) sequences following intratympanic gadolinium injection in 69 unilateral patients with definite Menière's disease. Vestibular and lateral semicircular canal hydrops was graded on MRI using a four grade criterion. All patients underwent pure-tone audiometry, cervical vestibular evoked myogenic potential (cVEMP), ocular vestibular evoked myogenic potential (oVEMP), caloric test and video head impulse test (vHIT). The latency, amplitude and asymmetry ratio of VEMP, canal paresis (CP) and vestibulo-ocular reflex (VOR) gain of lateral semicircular canal of vHIT were collected. The correlation analysis were performed between the parameters of function test and EH.Results:Vestibular EH showed correlations with the duration of disease (r= 0.360) and pure tone average (r= 0.326). AR of cVEMP showed correlations with Vestibular EH (r= 0.407). CP (r= 0.367) and VOR gain of lateral semicircular canal at 60 ms (r= 0.311) showed correlations with lateral semicircular canal hydrops.Conclusion:EH in different compartments is readily visualized by using 3D-FLAIR MRI techniques. The degree of vestibular EH correlated with AR of cVEMP and EH in the semicircular canal ampullar affects the caloric and vHIT response in patients with unilateral Meniere‘s disease.
27.	Montgomery, Agneta, et al. (författare) Evidence for Replacement of an Infected Synthetic by a Biological Mesh in Abdominal Wall Hernia Repair. 2015 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 2, s. 67-67 Forskningsöversikt (refereegranskat)abstract The incidence of deep infection using a synthetic mesh in inguinal hernia repair is low and reported to be well below 1%. This is in contrast to incisional hernia surgery where the reported incidence is 3% respective 13% comparing laparoscopic to open mesh repair reported in a Cochrane review. Main risk factors were long operation time, surgical site contamination, and early wound complications. An infected mesh can be preserved using conservative treatment were negative pressure wound therapy (VAC(®)) could play an important role. If strategy fails, the mesh needs to be removed. This review aims to look at evidence for situations were a biological mesh would work as a replacement of a removed infected synthetic mesh.
28.	Myrelid, Pär, et al. (författare) Surgical Planning in Penetrating Abdominal Crohns Disease 2022 Ingår i: Frontiers in Surgery. - : Frontiers Media SA. - 2296-875X. ; 9 Forskningsöversikt (refereegranskat)abstract Crohns disease (CD) is increasing globally, and the disease location and behavior are changing toward more colonic as well as inflammatory behavior. Surgery was previously mainly performed due to ileal/ileocaecal location and stricturing behavior, why many anticipate the surgical load to decrease. There are, however, the same time data showing an increasing complexity among patients at the time of surgery with an increasing number of patients with the abdominal perforating disease, induced by the disease itself, at the time of surgery and thus a more complex surgery as well as the post-operative outcome. The other major cause of abdominal penetrating CD is secondary to surgical complications, e.g., anastomotic dehiscence or inadvertent enterotomies. To improve the care for patients with penetrating abdominal CD in general, and in the peri-operative phase in particular, the use of multidisciplinary team discussions is essential. In this study, we will try to give an overview of penetrating abdominal CD today and how this situation may be handled. Proper surgical planning will decrease the risk of surgically induced penetrating disease and improve the outcome when penetrating disease is already established. It is important to evaluate patients prior to surgery and optimize them with enteral nutrition (or parenteral if enteral nutrition is ineffective) and treat abdominal sepsis with drainage and antibiotics.
29.	Noorani, A, et al. (författare) Delayed Gastric Emptying after Pancreatic Surgery: Analysis of Factors Determinant for the Short-term Outcome 2016 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 3, s. 25- Tidskriftsartikel (refereegranskat)
30.	Nyman, Erika, et al. (författare) Patients having surgery for ulnar nerve compression at the elbow rarely have affection of the spinal nerve root at C8-Th1 levels 2022 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 9 Tidskriftsartikel (refereegranskat)abstract Cervical pathology may contribute to residual problems after surgery for ulnar nerve compression. We aimed to evaluate the presence of pathological conditions in spinal cord and cervical spinal nerve roots in patients surgically treated for ulnar nerve compression at elbow. In a cohort of patients, surgically treated for ulnar nerve compression at elbow, magnetic resonance images (MRI; performed 3 years pre/postoperatively) were evaluated by a neuroradiologist blinded to patient characteristics and outcome of surgery. Cervical conditions were assessed and related to patient characteristics, preoperative McGowan grade, and outcome. Among 62 patients (45 unilaterally and 17 bilaterally), only one had spinal nerve root affection of nerve roots contributing to the ulnar nerve (C8-Th1). About half of the patients, mainly those at higher age, had alterations affecting C3–C7 spinal nerve roots at both surgically treated and contralateral, non-surgically treated, sides. Only few other changes were observed at cervical levels. A high McGowan grading was related to a high frequency of spinal nerve root affection. Smokers were more frequently observed among those with spinal nerve root affection at C3–C7 levels at surgically treated side. Residual problems, expressed as patient dissatisfaction and DASH score ≥40, were common. Spinal nerve roots, contributing to the ulnar nerve, are rarely affected in surgically treated patients with ulnar nerve compression at elbow even though pathology is often observed at other cervical levels. Pathology is often detected at other cervical spinal nerve root levels at surgically treated and contralateral sides, particularly among older patients, smokers, and in conjunction with worse preoperative McGowan grade. No relation between cervical pathology and outcome of ulnar nerve surgery is seen.
31.	Odhagen, Erik, 1977, et al. (författare) Long-term complications after tonsil surgery : an analysis of 54,462 patients from the Swedish Quality Register for Tonsil Surgery 2023 Ingår i: Frontiers in Surgery. - : Frontiers Media S.A.. - 2296-875X. ; 10 Tidskriftsartikel (refereegranskat)abstract Objective: This study aims to evaluate long-term complications after tonsil surgery using an exploratory retrospective cohort study design based on data from the Swedish Quality Register for Tonsil Surgery (SQTS).Methods: All patients registered in the SQTS between 1 January 2009 and 31 May 2021 were eligible for the study. In this study, a long-term complication is defined as any complication persisting for a minimum of 6 months after surgery. The definition of a complication was based on individual patient reports, provided in a free text format, of any remaining issues 6 months after tonsil surgery. Complications were categorized as follows: disturbed taste or sense of smell, dysphagia, miscellaneous and general symptoms and signs, miscellaneous throat problems, pain or discomfort in the mouth or throat, problems with jaws or teeth, problems with the ears or hearing, problems with the nose or sinuses, problems with throat secretions or throat clearing, problems with voice or speech, and sensory symptoms. A multivariable logistic regression analysis was used to identify independent predictors of long-term complications.Results: In total, 54,462 patients were included in the study. A total of 3,780 patients (6.9%) reported one or more long-term complications. The most frequent long-term complications, with a plausible connection to the surgery, were found in the following categories: pain or discomfort in the mouth or throat (1.9%), problems with throat secretions or throat clearing (0.8%), dysphagia (0.6%), and problems with voice or speech (0.6%). Tonsillotomy was associated with a lower risk of long-term complications than tonsillectomy.Conclusion: This study suggests that subjective long-term complications after tonsil surgery, in general, are relatively common (6.9%). However, complications with a plausible connection to the surgery were less common (4.0%), and specific complications seemed to be relatively rare, with no single specific problem reaching a prevalence of ≥0.6%.
32.	Pedersen, Lars, et al. (författare) A comparison of men and women undergoing septoplasty-the Swedish national septoplasty register 2023 Ingår i: Frontiers in Surgery. - 2296-875X. ; 10 Tidskriftsartikel (refereegranskat)abstract ObjectiveMen represent more than two-thirds of septoplasty patients in many studies, but differences between men and women in terms of patient selection or outcome are seldom reported. This study aims to investigate whether women undergoing septoplasty differ from men in critical variables before and after surgery, in a large national sample of septoplasties. DesignCross-sectional register study. ParticipantsThe study includes 2,532 patients from the National Swedish Septoplasty Register undergoing septoplasty with or without additional turbinoplasty on the indication of nasal obstruction in 2014-2019. Patients in the register have not been preselected. Main outcome measuresPreoperative variables and postoperative outcome were compared between men and women. ResultsMen accounted for 1,829 (72%) of the patients. There was no significant difference between men and women in severity of self-reported nasal obstruction or type of surgery performed (septoplasty with or without turbinoplasty). Mean postoperative nasal obstruction 12 months after surgery and overall satisfaction with the result were similar. Women, however, reported more complications 12 months postoperatively, while men reported more problems with snoring and obstructive sleep apnea preoperatively. ConclusionIn this large national patient cohort undergoing septoplasty, we found no differences in preoperative nasal obstruction or postoperative patient-rated outcome in men and women undergoing septoplasty, despite the fact that 72% of the patients were men. It thus remains unclear why women are under-represented in septoplasty surgery in this and many other cohorts.
33.	Petersson, Patrik, et al. (författare) Dynamic Fascial Closure With Vacuum-Assisted Wound Closure and Mesh-Mediated Fascial Traction (VAWCM) Treatment of the Open Abdomen—An Updated Systematic Review 2020 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 7 Forskningsöversikt (refereegranskat)abstract Introduction: Several different temporary abdominal closure techniques are described in the context of open abdomen treatment. Techniques based on dynamic fascial closure combined with negative pressure therapy have gained popularity and seem to result in the highest fascial closure rates without increased complications and are highlighted in recent guidelines and recommendations. One dynamic closure technique is the vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) technique, first described in 2007. The aim of this systematic review was to evaluate the VAWCM technique regarding a number of short- and long-term results. Materials and Methods: A systematic literature search was performed in PubMed, EMBASE, and Cochrane Library databases for articles published between January 1, 2006 and May 8, 2020. The review was independently performed by the two authors according to the PRISMA statements for reporting systematic reviews and meta-analyses. Results were pooled for presentation of weighted means when applicable. Results: A total of 220 articles were screened by title and abstract. Thirty-two articles were assessed for eligibility by full-text review and 15 articles finally remained for review. A total of 600 patients treated with VAWCM were included. The pooled weighted means were as follows: fascial closure, 83.5%; enteroatmospheric fistula, 5.6%; planned ventral hernia, 6.2%; in-hospital survival, 72%; and incisional hernia incidence, 40.5%. Long-term survival ranged between 22 and 72%. Quality of life (SF-36) was reported in two studies showing lower scores than the population mean especially in physical domains. Incisional hernia resulted in lower scores in one but not in the other study. Discussion: The results of 600 VAWCM-treated patients from 15 studies were evaluated in this systematic review. Earlier findings with high fascial closure rates, low enteroatmospheric fistula, and planned ventral hernia rates as well as high incisional hernia incidences were underlined. Permanent mesh for efficient fascial traction and reinforcement at fascial closure seem to be the next step in evolving an optimal temporary closure technique in open abdomen treatment.
34.	Popowicz, A, et al. (författare) Management of Common Bile Duct Stones Encountered During Cholecystectomy in Patients With Previous Gastric Bypass 2021 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 8, s. 789231- Tidskriftsartikel (refereegranskat)abstract Background: Rapid weight loss following gastric bypass (GBP) predisposes to the development of gallstones, and in those who develop gallstone disease there is a high prevalence of common bile duct stones (CBDS). Furthermore, in these patients, CBDS are difficult to extract due to the altered upper gastrointestinal anatomy following GBP. The aim of the present study was to assess outcome after various management methods applied in the counties of Stockholm and Uppsala, Sweden.Methods: Data from the Swedish Register for Gallstone Surgery and ERCP (GallRiks) and the Swedish Obesity Surgery Register (SoReg) were crossmatched to identify all patients who had undergone gallstone surgery after GBP, where CBDS were found at intraoperative cholangiography, in the Stockholm and Uppsala counties 2009–2013. A retrospective review of patient records was performed for all patients identified.Results: In all, 55 patients were identified. These were managed as follows: expectancy (N = 11); transgastric ERCP (N = 2); laparoscopic choledochotomy (N = 3); open choledochotomy (N = 5); transcystic stone extraction (N = 12); and other approach (N = 13). In nine cases, data on management could not be found. There were nine cases of minor postoperative complication. No retained stones were registered. The operation time was longer for transgastric ERCP (p = 0.002), and the postoperative stay was longer following open and laparoscopic choledochotomy (p < 0.001). There was no statistically significant difference between any of the methods regarding the incidence of postoperative complications (p = 0.098).Discussion: Further development of techniques for managing CBDS discovered in patients undergoing cholecystectomy after previous GBP are needed, as well as more comparative studies with greater statistical power.
35.	Qiang, Yongjia, et al. (författare) Atypical location of primary cardiac lymphoma in the left heart with atypical clinical presentation: A case report and literature review 2023 Ingår i: Frontiers in Surgery. - : FRONTIERS MEDIA SA. - 2296-875X. ; 9 Forskningsöversikt (refereegranskat)abstract BackgroundPrimary cardiac lymphoma (PCL) is a rare and aggressive cardiac tumor with very poor prognosis that occurs mostly in the right cardiac cavity. Early diagnosis and treatment may improve its prognosis. In the present report, we describe the diagnosis and treatment of a primary cardiac diffuse large B-cell lymphoma (PC-DLBCL) with atypical location and clinical presentation. Additionally, a literature review was conducted to summarize the current knowledge of the disease. Case PresentationA 71-year-old man visited his local hospital because of syncope, recurrent chest tightness, shortness of breath, palpitations, and profuse sweating for more than 20 days. Chest radiography revealed a mediastinal mass. Cardiac computed tomography (CT) showed multiple enlarged mediastinal lymph nodes. Transthoracic echocardiography (TTE) showed a cardiac mass in the posterior-inferior wall of the left atrium. He was then transferred to our hospital for positron emission tomography-CT (PET-CT) which showed active uptake of fluorodeoxyglucose both in the cardiac mass and in the multiple enlarged mediastinal lymph nodes. Biopsy of the enlarged mediastinal lymph nodes was carried out by using video-assisted thoracic surgery (VATS) technique, and pathological examination confirmed the subtype of PC-DLBCL, Stage IV, NCCN IPI 3. Therefore, the patient received a combination of chemotherapy and immunotherapy with R-CDOP (rituximab, cyclophosphamide, liposome doxorubicin, vincristine, and prednisone). After four courses of treatment in 4 months, the cardiac lymphoma and the enlarged mediastinal lymph nodes achieved complete remission with mild side effects of the chemotherapy. ConclusionEarly diagnosis and a precise choice of chemotherapy and immunotherapy based on cardiac imaging and pathological examination may improve the prognosis of PC-DLBCL in an atypical location.
36.	Qin, H, et al. (författare) Visualization of Endolymphatic Hydrops in Patients With Unilateral Idiopathic Sudden Sensorineural Hearing Loss With Four Types According to Chinese Criterion 2021 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 8, s. 682245- Tidskriftsartikel (refereegranskat)abstract Objective: The aim of this study is to evaluate the possible value of endolymphatic hydrops (EH) in patients with unilateral idiopathic sudden sensorineural hearing loss (UISSNHL) with four types according to audiometry.Methods: Seventy-two patients (40 men and 32 women; age range, 28–78 years; mean age: 50.0 ± 12.9 years) with UISSNHL were admitted retrospectively into this study. Based on the pure tone audiometry before treatment, the hearing loss of all these patients were categorized into four types: low-frequency group (LF-G), high-frequency group (HF-G), flat group (F-G), and total deafness group (TD-G). The average time from symptom onset to the first examination was 6.9 ± 4.4 days (1–20 days). 3D-FLAIR MRI was performed 24 h after intratympanic injection of gadolinium (Gd) within 1 week after the UISSNHL onset. The incidence of EH in the affected ears based on four types of hearing loss were analyzed using the Chi-square test, and the possible relationship with vertigo and prognosis were also assessed.Results: Eleven of 21 patients (52.4%) in LF-G had the highest EH-positive rate, followed by 18.2% in HF-G, 11.8% in F-G, and 17.4% in TD-G. The significant difference was found in the four groups (P = 0.018). The EH rate of LF-G was statistically significantly higher than that of F-G and TD-G (P = 0.009, P =0.014), respectively. After being valued by the volume-referencing grading system (VR scores), the EH level was represented by the sum scores of EH. In LF-G, no statistically significant difference was found in the prognosis of ISSNHL patients between with the EH group and the no EH group (P = 0.586). The symptom “vertigo” did not correlate with EH and prognosis.Conclusions: EH was observed in UISSNHL patients by 3D-FLAIR MRI. EH may be responsible for the pathology of LF-G but not related to prognosis. It might be meaningless to assess EH in other hearing loss types, which might be more related to the blood-labyrinth dysfunction.
37.	Sandblom, G (författare) Editorial: Case Reports in Visceral Surgery: Tumors of the Liver 2022 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 9, s. 841783- Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)
38.	Sandblom, G (författare) Editorial: Incisional and Stomal Hernia Prevention 2018 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 5, s. 46- Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)
39.	Sandblom, G (författare) Editorial: New endoscopic techniques for ventral hernia repair 2023 Ingår i: Frontiers in surgery. - 2296-875X. ; 10, s. 1245620- Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)
40.	Sandblom, G (författare) Grand challenges in visceral surgery 2022 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 9, s. 1005046- Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)
41.	Saphir, Ebba, et al. (författare) Performance of Computed Tomography Angiography Before Revascularization Is Associated With Higher Amputation-Free Survival in Rutherford IIb Acute Lower Limb Ischaemia 2021 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 8 Tidskriftsartikel (refereegranskat)abstract Background: Acute lower limb ischemia with a motor deficit (Rutherford IIb) needs urgent revascularization to avoid major amputation and mortality. It is unclear whether immediate revascularization without performing CT angiography (CTA) prior to revascularization in Rutherford IIb acute lower limb ischemia (ALI) is associated with better outcomes. Methods: Retrospective observational study of Rutherford IIb ALI patients treated between 2006 and 2018. A propensity score adjusted analysis was performed to compare outcomes after the performance of CTA examination or not. Results: Among 681 patients, 260 had Rutherford IIb ALI. CTA prior to revascularization was performed in 131 (50.4%) and increased (p < 0.001) throughout the study period. Open vascular and endovascular surgery was first performed in 147 (56.5%) and 113 (43.5%) patients, respectively. The proportion of endovascular treatment increased while the open vascular surgery decreased during the study period (p = 0.031). In the propensity score adjusted analysis, the performance of CTA was associated with decreased risk of combined major amputation /mortality (odds ratio 0.52, 95% confidence interval 0.27-0.99; p = 0.046) at 1 year. Conclusion: Performance of CTA was associated with a higher amputation-free survival in revascularized patients with Rutherford IIb ALI. CTA seem to provide guidance in selecting the most appropriate candidates for revascularization and choice of technique.
42.	Shadbolt, Cade, et al. (författare) The Surgeon's Role in the Opioid Crisis : A Narrative Review and Call to Action 2020 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 7 Forskningsöversikt (refereegranskat)abstract Over the past two decades, there has been a sharp rise in the use of prescription opioids. In several countries, most notably the United States, opioid-related harm has been deemed a public health crisis. As surgeons are among the most prolific prescribers of opioids, growing attention is now being paid to the role that opioids play in surgical care. While opioids may sometimes be necessary to provide patients with adequate relief from acute pain after major surgery, the impact of opioids on the quality and safety of surgical care calls for greater scrutiny. This narrative review summarizes the available evidence on rates of persistent postsurgical opioid use and highlights the need to target known risk factors for persistent postoperative use before patients present for surgery. We draw attention to the mounting evidence that preoperative opioid exposure places patients at risk of persistent postoperative use, while also contributing to an increased risk of several other adverse clinical outcomes. By discussing the prevalence of excess opioid prescribing following surgery and highlighting significant variations in prescribing practices between countries, we note that there is a pressing need to optimize postoperative prescribing practices. Guided by the available evidence, we call for specific actions to be taken to address important research gaps and alleviate the harms associated with opioid use among surgical patients.
43.	Soltanzadeh-Naderi, Yasmin, et al. (författare) Trends in population-based incidence, diagnostics, and mortality of acute superior mesenteric artery occlusion 2024 Ingår i: Frontiers in surgery. - 2296-875X. ; 10, s. 01-08 Tidskriftsartikel (refereegranskat)abstract Acute occlusion of the superior mesenteric artery (SMA) results in lethal intestinal ischemia. Results from two previous population-based studies in Malmö, Sweden, suggest a decreasing incidence of acute SMA occlusion. This study aimed to evaluate trends in the epidemiology of acute SMA occlusion in Malmö. The report was a retrospective population-based study conducted from 2014 to 2019 on patients with acute SMA occlusion residing in Malmö municipality. Patient data were retrieved from Skåne University Hospital and postmortem examinations. Epidemiological data were compared to those of the two earlier studies, in particular to the one conducted from 2000 to 2006. Sixteen patients with acute SMA occlusion resided in Malmö municipality. The incidence of acute SMA occlusion significantly decreased from 5.4/100,000 person-years to 0.8/100,000 person-years. The ratio of acute SMA occlusion to non-occlusive mesenteric ischemia (NOMI) decreased from 12.5:1 to 0.9:1 (p < 0.0001), the proportion of inhabitants aged 80 years or above in the population decreased from 6.0% to 4.3% (p < 0.0001), and the autopsy rate decreased from 25% to 14% (p < 0.0001). The in-hospital mortality rate decreased from 63% to 44% (p = 0.14). The incidence of acute SMA occlusion seems to have decreased significantly in Malmö, probably due to high-resolution computed tomography angiographies being available around the clock to distinguish acute SMA occlusion from NOMI, a reduced proportion of elderly individuals, improved control of medical risk factors, and a decrease in autopsy rates.
44.	Song, Amy X., et al. (författare) A PRISMA-IPD systematic review and meta-analysis : does age and follow-up improve active range of motion of the wrist and forearm following pediatric upper extremity cerebral palsy surgery? 2024 Ingår i: Frontiers in Surgery. - : Frontiers Media S.A.. - 2296-875X. ; 11 Forskningsöversikt (refereegranskat)abstract Purpose: Surgical treatments such as tendon transfers and muscle lengthening play a significant role in cerebral palsy management,but timing of upper extremity cerebral palsy surgery remains controversial. This study systematically reviews the current literature and investigates the correlation between age at surgery and follow-up time with surgical outcomes in pediatric upper extremity cerebral palsy patients.Methods: A comprehensive search of PubMed, Cochrane, Web of Science, and CINAHL databases was performed from inception to July 2020 and articles were screened using PRISMA guidelines to include full-text, English papers. Data analysis was performed using itemized data points for age at surgery, follow-up length, and surgery outcomes, reported as changes in active forearm and wrist motion. A 3D linear model was performed, to analyze the relationship between age, follow-up length, and surgery outcomes.Results: A total of 3,855 papers were identified using the search terms and a total of 8 studies with itemized patient data (n=126) were included in the study. The studies overall possessed moderate bias according to the ROBINS-I scale. Regression analysis showed that age is a significant predictor of change (\|t\| > 2) in active forearm supination (Estimate = -2.3465, Std. Error = 1.0938, t-value= -2.145) and wrist flexion (Estimate = -2.8474, Std. Error = 1.0771, t-value = -2.643) post-intervention, with older individuals showing lesser improvements. The duration of follow-up is a significant predictor of improvement in forearm supination (Estimate = 0.3664, Std. Error = 0.1797, t-value = 2.039) and wrist extension (Estimate = 0.7747, Std. Error = 0.2750, t-value = 2.817). In contrast, forearm pronation (Estimate = -0.23756, Std. Error = 0.09648, t-value = -2.462) and wrist flexion (Estimate = -0.4243, Std. Error=0.1859, t-value = -2.282) have a significant negative association with follow-up time.Conclusion: These results suggest that there is significant correlation between the age and follow up after surgery with range of motion gains. Most notably, increased age at surgery had a significant negative correlation with select active range of motion postoperative outcomes. Future research should focus on identifying other factors that could affect results of surgical treatment in upper extremity.
45.	Strijbos, R. M., et al. (författare) Ex vivo Evaluation of a New Drill System for Placement of Percutaneous Bone Conduction Devices 2022 Ingår i: Frontiers in Surgery. - : Frontiers Media SA. - 2296-875X. ; 9 Tidskriftsartikel (refereegranskat)abstract The procedure for installation of a percutaneous bone-conducting device has undergone significant improvements since its introduction 40 years ago. Today, the linear incision technique with tissue preservation (LITT-P) and the minimally invasive procedure (MIPS) are the most commonly used approaches. In both these techniques, a gradual increase of the osteotomy using a three-step drilling sequence is utilized, as this approach can allow a stepwise deepening and widening of the osteotomy in the mastoid and can prevent bone overheating. A new minimally invasive procedure (MONO) has been developed that allows an osteotomy to be performed and enables complete removal of the bone volume in one single drill step for a 4 mm implant using a novel parabolic twist drill. Here, the feasibility of the MONO procedure was qualitatively and quantitatively evaluated in terms of the dura response to drill trauma in comparison with the outcomes achieved with guide drills used for the LITT-P and MIPS techniques. Fresh frozen temporal bone from a human cadaver was subjected to penetration by three drills beyond the base of the mastoid bone to different depths. The sites were evaluated, and the damage to and possible penetration of the dura were determined. The results showed that for a drill depth exceeding mastoid bone thickness by not more than 1 mm, damage to the dura was limited or nonexistent, whereas for a drill depth exceeding bone thickness by 2 mm, damage increased, or the dura was penetrated. There was a trend toward more damage and penetration for both the round burr and MIPS guide drill compared with the MONO drill bit. From this experimental ex vivo study, it can be concluded that if the dura is encountered, the MONO system is not more inclined to penetrate the dura than the conventional LITT-P and MIPS systems.
46.	Söderbäck, Harald, et al. (författare) Prophylactic Resorbable Synthetic Mesh to Prevent Wound Dehiscence and Incisional Hernia in High High-risk Laparotomy : A Pilot Study of Using TIGR Matrix Mesh 2016 Ingår i: Frontiers in Surgery. - : Frontiers Media SA. - 2296-875X. ; 3 Tidskriftsartikel (refereegranskat)abstract Background: Wound dehiscence and incisional hernia are potentially serious complications following abdominal surgery, especially if performed through a midline incision. Although prophylactic reinforcement with on-lay mesh has been shown to reduce this risk, a permanent mesh carries the risk of seroma formation, infection, and persistent pain. The aim of this study was to assess the safety of a reabsorbable on-lay mesh to reinforce the midline suture in patients with high risk for wound dehiscence or incisional hernia.Method: Sixteen patients with three or more risk factors for wound dehiscence or incisional hernia were included. A TIGR® Matrix mesh, composed of a mixture of 40% copolymer fibers of polyglycolide, polylactide, and polytrimethylene carbonate and 60% copolymer fibers of polylactide and polytrimethylene carbonate, was placed on the aponeurosis with an overlap of five on either side and fixated with continuous monofilament polydioxanone suture. All postoperative complications were registered at clinical follow-up.Results: Mean follow-up was 9 months. One patient developed a seroma that needed drainage and antibiotic treatment. One patient had a wound infection that needed antibiotic treatment. There was no complication requiring a reoperation. No wound dehiscence or incisional hernia was seen.Conclusion: On-lay placement of TIGR® Matrix is safe and may provide a feasible way of reinforcing the suture line in patients with high risk for postoperative wound dehiscence or incisional hernia. Larger samples are required, however, if one is to draw any conclusion regarding the safety and effectiveness of this technique.
47.	Taube, Magdalena, et al. (författare) Commentary: The impact of bariatric and metabolic surgery on cancer development. 2022 Ingår i: Frontiers in surgery. - : Frontiers Media SA. - 2296-875X. ; 9 Tidskriftsartikel (refereegranskat)
48.	Tsoposidis, Alexandros, et al. (författare) The value of "diaphragmatic relaxing incision" for the durability of the crural repair in patients with paraesophageal hernia: a double blind randomized clinical trial 2023 Ingår i: FRONTIERS IN SURGERY. - 2296-875X. ; 10 Tidskriftsartikel (refereegranskat)abstract Surgical repair of paraesophageal hernias (PEHs) is burdened with high recurrence rates, and hitherto various techniques explored to enforce the traditional crural repair have not been successful. The hiatal reconstruction in PEH is exposed to significant tension, which may be minimized by adding a diaphragmatic relaxing incision to enhance the durability of the crural repair.Patients and methodsAll individuals undergoing elective laparoscopic repair of a large PEH, irrespective of age, were considered eligible. PEHs were classified into types II-IV. The preoperative work-up program included multidetector computed tomography and symptom assessment questionnaires, which will be repeated during the postoperative follow-up. Patients were randomly divided into a control group with crural repair alone and an intervention group with the addition of a left-sided diaphragmatic relaxing incision at the edge of the upper pole of the spleen. The diaphragmatic defect was then covered by a synthetic mesh.ResultsThe primary endpoint of this trial was the rate of anatomical PEH recurrence at 1 year. Secondary endpoints included symptomatic gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular and pulmonary symptoms, and patient satisfaction in the immediate postoperative course (3 months) and at 1 year. Postoperative complications, morbidity, and disease burden were recorded for each patient. This was a double-blind study, meaning that the operation report was filed in a locked archive to keep the patient, staff, and clinical assessors blinded to the study group allocation. Blinding must not be broken during the follow-up unless required by any emergencies in the clinical management of the patient. Likewise, the patients must not be informed about the details of the operation.
49.	van Hoof, M., et al. (författare) Clinical Outcomes of Soft Tissue Preservation Surgery With Hydroxyapatite-Coated Abutments Compared to Traditional Percutaneous Bone Conduction Hearing Implant Surgery-A Pragmatic Multi-Center Randomized Controlled Trial 2020 Ingår i: Frontiers in Surgery. - : Frontiers Media SA. - 2296-875X. ; 7 Tidskriftsartikel (refereegranskat)abstract Background: Soft tissue preservation using a hydroxyapatite-coated abutment in bone conduction hearing implant surgery may lead to improved clinical outcomes over the short (1 year) and long term (3 years). Methods: In this open multi-center, randomized (1:1), controlled clinical trial, subjects with conductive, mixed hearing loss or single-sided sensorineural deafness were randomly assigned to receive the conventional intervention, a titanium abutment with soft tissue reduction surgery (control), or a new intervention, a hydroxyapatite-coated abutment with soft tissue preservation surgery (test). The primary efficacy outcome was the combined endpoint of numbness, pain, peri-abutment dermatitis, and soft tissue thickening/overgrowth after 1 and 3 years. Results: The Intention-to-treat (ITT) population consisted of 52 control subjects and 51 test subjects. The difference between the groups after 1 year of follow-up as measured by the primary efficacy outcome was not statistically significant (p = 0.12) in the ITT population (n = 103), but did reach statistical significance (p = 0.03) in the per-protocol (PP) population (n = 96). It showed an advantage for the test group, with over twice as many subjects (29%) without these medical events during the first year compared to the control group (13%). After 3 years, the difference between the two groups had declined and did not reach statistical significance (24 vs. 10%, ITT p = 0.45). Secondary outcome measures which showed a statistical significant difference during the first year, such as surgical time (15 vs. 25 minutes, p < 0.0001), numbness (90 vs. 69% of subjects experienced no numbness at 1 year, p < 0.01), neuropathic pain at 3 months (p = 0.0087) and the overall opinion of the esthetic outcome (observer POSAS scale at 3 months, p < 0.01) were favorable for the test group. More soft tissue thickening/overgrowth was observed at 3 weeks for the test group (p = 0.016). Similar results were achieved for the long term follow up. Conclusions: Soft tissue preservation with a hydroxyapatite-coated abutment leads to a reduction in the combined occurrence of complications over the first year which is not statistically significant in the ITT population but is in the PP population. This effect decreased for the long-term study follow up of 3 years and did also not reach statistical significance.
50.	Wade, Ryckie G., et al. (författare) Diffusion Tensor Imaging for Diagnosing Root Avulsions in Traumatic Adult Brachial Plexus Injuries : A Proof-of-Concept Study 2020 Ingår i: Frontiers in Surgery. - : Frontiers Media S.A.. - 2296-875X. ; 7 Tidskriftsartikel (refereegranskat)abstract Cross-sectional MRI has modest diagnostic accuracy for diagnosing traumatic brachial plexus root avulsions. Consequently, patients either undergo major exploratory surgery or months of surveillance to determine if and what nerve reconstruction is needed. This study aimed to develop a diffusion tensor imaging (DTI) protocol at 3 Tesla to visualize normal roots and identify traumatic root avulsions of the brachial plexus. Seven healthy adults and 12 adults with known (operatively explored) unilateral traumatic brachial plexus root avulsions were scanned. DTI was acquired using a single-shot echo-planar imaging sequence at 3 Tesla. The brachial plexus was visualized by deterministic tractography. Fractional anisotropy (FA) and mean diffusivity (MD) were calculated for injured and avulsed roots in the lateral recesses of the vertebral foramen. Compared to healthy nerves roots, the FA of avulsed nerve roots was lower (mean difference 0.1 [95% CI 0.07, 0.13]; p < 0.001) and the MD was greater (mean difference 0.32 × 10−3 mm2/s [95% CI 0.11, 0.53]; p < 0.001). Deterministic tractography reconstructed both normal roots and root avulsions of the brachial plexus; the negative-predictive value for at least one root avulsion was 100% (95% CI 78, 100). Therefore, DTI might help visualize both normal and injured roots of the brachial plexus aided by tractography. The precision of this technique and how it relates to neural microstructure will be further investigated in a prospective diagnostic accuracy study of patients with acute brachial plexus injuries.

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