Recovery and immune function after low pressure pneumoperitoneum during robot-assisted radical prostatectomy: a randomised controlled trial.

OBJECTIVE: To compare the effectiveness of low intra-abdominal pressure (IAP) facilitated by deep neuromuscular block (NMB) to standard practice in improving the quality of recovery, preserving immune function, and enhancing parietal perfusion during robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: In this blinded, randomised controlled trial, 96 patients were randomised to the experimental group with low IAP (8 mmHg) facilitated by deep NMB (post-tetanic count 1-2) or the control group with standard IAP (14 mmHg) and moderate NMB (train-of-four 1-2). Recovery was measured using the 40-item Quality of Recovery questionnaire and 36-item Short-Form Health survey. Immune function was evaluated by plasma damage-associated molecular patterns, cytokines, and ex vivo lipopolysaccharide-stimulated cytokine production. Parietal peritoneum perfusion was measured by analysing the recordings of indocyanine-green injection. RESULTS: Quality of recovery was not superior in the experimental group (n = 46) compared to the control group (n = 50). All clinical outcomes, including pain scores, postoperative nausea and vomiting, and hospital stay were similar. There were no significant differences in postoperative plasma concentrations of damage-associated molecular patterns, cytokines, and ex vivo cytokine production capacity. The use of low IAP resulted in better parietal peritoneum perfusion. CONCLUSION: Despite better perfusion of the parietal peritoneum, low IAP facilitated by deep NMB did not improve the quality of recovery or preserve immune function compared to standard practice in patients undergoing RARP.

Three Dimensional Printing as a Tool For Anatomical Training in Lung Surgery.

Objective: Pulmonary anatomy is challenging, due to the high variability and its three-dimensional (3D) shape. While demands in thoracic oncologic surgery are increasing, the transition from open to thoracoscopic surgery is hampering anatomical understanding. This study analyzed the value of a 3D printed lung model in understanding and teaching anatomy. Methods: A 3D pulmonary model was created and tested among different levels of proficiency: 10 experienced surgeons, 10 fellow surgeons and 10 junior residents. They were tested in interpretation of anatomy based on thoracic CT-scans, either using the 3D model or a 2D anatomical atlas. Accuracy of the given answers, time to complete the task and the self-reported level of certainty were scored in each group. Results: In the experienced surgeons group there was no difference in between the 2D-model or 3D-model with a high rate of correct answers in both groups, and no differences in time or certainty. Fellow surgeons highly benefitted from the 3D-model with an improved accuracy from 26.6% to 70.0% (p = 0.001). Time to complete the task was shorter (207 versus 122 s, p < 0.0001) and participants were more secure (median of 4 versus 3, p = 0.007). For junior residents time to complete the task was shorter, the level of certainty was higher, but there was no improvement in accuracy. Conclusions: 3D printing may benefit in understanding anatomical relations in the complex anatomy of the bronchiopulmonary tree, especially for surgeons in training and could benefit in teaching anatomy. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01807-x.

Development and validation of the patient-reported "Facial Function Scale" for facioscapulohumeral muscular dystrophy.

PURPOSE: Facial weakness and its functional consequences are an often underappreciated clinical feature of facioscapulohumeral muscular dystrophy (FSHD) by healthcare professionals and researchers. This is at least in part due to the fact that there are few adequate clinical outcome measures available. METHODS: We developed the Facial Function Scale, a Rasch-built questionnaire on the functional disabilities relating to facial weakness in FSHD. A preliminary 33-item questionnaire was created based on semi-structured interviews with 16 FSHD patients and completed by 119 patients. For reliability studies, 73 patients completed it again after a two-week interval. Data were subjected to semi-automated Rasch analysis to select the most appropriate item set to fit model expectations. RESULTS: This resulted in a 25-item unidimensional, linear-weighted questionnaire with high internal consistency (person separation index = 0.92) and test-retest reliability (patients' locations ICC = 0.98 and items' locations ICC = 0.99). Good external construct validity scores were obtained through correlation with the Communicative Participation Item Bank questionnaire, examiner-reported Facial Weakness Score and facial weakness subscale of the FSHD evaluation score (respectively r = 0.733, r = -0.566, and r = 0.441, all p < 0.001). CONCLUSIONS: This study provides a linear-weighted, clinimetrically sound, patient-reported outcome measure on the functional disabilities relating to facial weakness in FSHD, to enable further research on this relevant topic.Implications for rehabilitationFacial weakness and its functional consequences are an often underappreciated clinical feature of facioscapulohumeral muscular dystrophy (FSHD), both in symptomatic treatment and in research.To enable the development and testing of therapeutic symptomatic interventions for facial weakness, clinical outcome measures are required.This study provides a linear-weighted, clinimetrically sound, patient-reported outcome measure on the functional disabilities relating to facial weakness in FSHD patients.

A semi-automatic three-dimensional technique using a regionalized facial template enables facial growth assessment in healthy children from 1.5 to 5.0 years of age.

Objectives: To develop a semi-automatic technique to evaluate normative facial growth in healthy children between the age of 1.5 and 5.0 years using three-dimensional stereophotogrammetric images. Materials and Methods: Three-dimensional facial images of healthy children at 1.5, 2.0, 2.5, 3.0, 4.0 and 5.0 years of age were collected and positioned based on a reference frame. A general face template was used to extract the face and its separate regions from the full stereophotogrammetric image. Furthermore, this template was used to create a uniform distributed mesh, which could be directly compared to other meshes. Average faces were created for each age group and mean growth was determined between consecutive groups for the full face and its separate regions. Finally, the results were tested for intra- and inter-operator performance. Results: The highest growth velocity was present in the first period between 1.5 and 2.0 years of age with an average of 1.50 mm (±0.54 mm) per six months. After 2.0 years, facial growth velocity declined to only a third at the age of 5.0 years. Intra- and inter-operator variability was small and not significant. Conclusions: The results show that this technique can be used for objective clinical evaluation of facial growth. Example normative facial averages and the corresponding facial growth between the age 1.5 and 5.0 years are shown. Clinical Relevance: This technique can be used to collect and process facial data for objective clinical evaluation of facial growth in the individual patient. Furthermore, these data can be used as normative data in future comparative studies.

The Automatic Quantification of Morphological Features of Pectus Excavatum Based on Three-Dimensional Images.

Visual examination and quantification of severity are essential for clinical decision making in patients with pectus excavatum. Yet, visual assessment is prone to inter- and intra-observer variability and current quantitative methods are inadequate. This study aims to develop and evaluate a novel, automatic and non-invasive method to objectively quantify pectus excavatum morphology based on three-dimensional images. Key steps of the automatic analysis are normalization of image orientation, slicing, and computation of the morphological features encompassing pectus depth, width, length, volume, position, steepness, flaring, asymmetry and mean cross-sectional area. A digital phantom mimicking a patient with pectus excavatum was used to verify the analysis method. Prospective three-dimensional imaging and subsequent surface analysis in patients with pectus excavatum was performed to assess clinical feasibility. Verification of the developed analysis tool demonstrated 100% reproducibility of all morphological feature values. Calculated parameters compared to the predetermined phantom dimensions were accurate for all but four features. The pectus width, length, volume and steepness showed an error of 4 mm (4%), 2 mm (2%), 12 mL (5%) and 1 degree (3%), respectively. Prospective imaging of 52 patients (88% males) demonstrated the feasibility of the developed tool to quantify morphological features of pectus excavatum in the clinical setting. Mean duration to calculate all features in one patient was 7.6 seconds. We have developed and presented a non-invasive pectus excavatum surface analysis tool, that is feasible to automatically quantify morphological features based on three-dimensional images with promising accuracy and reproducibility.

Three-dimensional virtual planning in mandibular advancement surgery: Soft tissue prediction based on deep learning.

The study aimed at developing a deep-learning (DL)-based algorithm to predict the virtual soft tissue profile after mandibular advancement surgery, and to compare its accuracy with the mass tensor model (MTM). Subjects who underwent mandibular advancement surgery were enrolled and divided into a training group and a test group. The DL model was trained using 3D photographs and CBCT data based on surgically achieved mandibular displacements (training group). Soft tissue simulations generated by DL and MTM based on the actual surgical jaw movements (test group) were compared with soft-tissue profiles on postoperative 3D photographs using distance mapping in terms of mean absolute error in the lower face, lower lip, and chin regions. 133 subjects were included - 119 in the training group and 14 in the test group. The mean absolute error for DL-based simulations of the lower face region was 1.0 ± 0.6 mm and was significantly lower (p = 0.02) compared with MTM-based simulations (1.5 ± 0.5 mm). CONCLUSION: The DL-based algorithm can predict 3D soft tissue profiles following mandibular advancement surgery. With a clinically acceptable mean absolute error. Therefore, it seems to be a relevant option for soft tissue prediction in orthognathic surgery. Therefore, it seems to be a relevant options.

Three-Dimensional Imaging of the Chest Wall: A Comparison Between Three Different Imaging Systems.

BACKGROUND: Three-dimensional (3D) imaging is being used progressively to create models of patients with anterior chest wall deformities. Resulting models are used for clinical decision-making, surgical planning, and analysis. However, given the broad range of 3D imaging systems available and the fact that planning and analysis techniques are often only validated for a single system, it is important to analyze potential intrasystem and intersystem differences. The objective of this study was to investigate the accuracy and reproducibility of three commercially available 3D imaging systems that are used to obtain images of the anterior chest wall. METHODS: Among 15 healthy volunteers, 3D images of the anterior chest wall were acquired twice per imaging device. Reproducibility was determined by comparison of consecutive images acquired per device while the true accuracy was calculated by comparison of 3D image derived and calipered anthropometric measurements. A maximum difference of 1.00 mm. was considered clinically acceptable. RESULTS: All devices demonstrated statistically comparable (P = 0.21) reproducibility with a mean absolute difference of 0.59 mm. (SD: 1.05), 0.54 mm. (SD: 2.08), and 0.48 mm. (SD: 0.60) for the 3dMD, EinScan Pro 2X Plus, and Artec Leo, respectively. The true accuracy was, respectively, 0.89 mm. (SD: 0.66), 1.27 mm. (SD: 0.94), and 0.81 mm. (SD: 0.71) for the 3dMD, EinScan, and Artec device and did not statistically differ (P = 0.085). CONCLUSIONS: Three-dimensional imaging of the anterior chest wall utilizing the 3dMD and Artec Leo is feasible with comparable reproducibility and accuracy, whereas the EinScan Pro 2X Plus is reproducible but not clinically accurate.

Photographic documentation and severity quantification of pectus excavatum through three-dimensional optical surface imaging.

Conventional photography is commonly used to visually document pectus excavatum and objectively assess chest wall changes over time without repeated exposure to ionising radiation, as in our centre since 2008. However, as conventional photography is labour-intensive and lacks three-dimensional (3D) information that is essential in 3D deformities like pectus excavatum, we developed a novel imaging and processing protocol based on 3D optical surface imaging. The objective of this study was to report our developed protocol to visually document pectus excavatum through 3D imaging. We also investigated the absolute agreement of the 3D image- and conventional photography-derived pectus excavatum depth to investigate whether both techniques could be used interchangeably to measure pectus excavatum depth and assess its evolution. The protocol consisted of three consecutive steps: patient positioning and instructions, data acquisition, and data processing. Three-dimensional imaging through the developed protocol was feasible for all 19 participants. The 3D image- and photography-derived pectus excavatum depth demonstrated good to excellent agreement (intraclass correlation coefficient: 0.97; 95%-confidence interval: 0.88 to 0.99; p < 0.001). In conclusion, 3D imaging through the developed protocol is a feasible and attractive alternative to document the surface geometry of pectus excavatum and can be used interchangeably with conventional photography to determine pectus severity. Clinical registration number: NCT04185870.

Optical imaging versus CT and plain radiography to quantify pectus severity: a systematic review and meta-analysis.

BACKGROUND: Computed tomography (CT) and two-view chest radiographies are the most commonly used imaging techniques to quantify the severity of pectus excavatum (PE) and pectus carinatum (PC). Both modalities expose patients to ionizing radiation that should ideally be avoided, especially in pediatric patients. In an effort to diminish this exposure, three-dimensional (3D) optical surface imaging has recently been proposed as an alternative method. To assess its clinical value as a tool to determine pectus severity we conducted a systematic review in which we assessed all studies that compared 3D scan-based pectus severity measurements with those derived from CT-scans and radiographies. METHODS: Six scientific databases and three registries were searched through April 30th, 2019. Data regarding the correlation between severity measures was extracted and submitted to meta-analysis using the random-effects model and I2-test for heterogeneity. RESULTS: Five observational studies were included, enrolling 75 participants in total. Pooled analysis of participants with PE demonstrated a high positive correlation coefficient of 0.89 [95% confidence interval (CI): 0.81 to 0.93; P<0.001] between the CT-derived Haller index (HI) and its 3D scan equivalent based on external measures. No heterogeneity was detected (I2=0.00%; P=0.834). CONCLUSIONS: 3D optical surface scanning is an attractive and promising imaging technique to determine the severity of PE without exposure to ionizing radiation. However, further research is needed to determine novel cut-off values for 3D scans to facilitate clinical decision making and help determine surgical candidacy. No evidence was found that supports nor discards the use of 3D scans to determine PC severity.

Electrocardiography-gated computed tomography angiography analysis of cardiac pulsatility-induced motion and deformation after endovascular aneurysm sealing with chimney grafts.

OBJECTIVE: To evaluate the proximal stability of the chimney endovascular aneurysm sealing configuration (chEVAS) during the cardiac cycle by investigating the cardiac pulsatility-induced movement and deformation. METHODS: We retrospectively analyzed postoperative electrocardiogram-gated computed tomography angiography scans of 11 chEVAS cases (9 primary chEVAS plus 2 chEVAS-in-chEVAS). ChEVAS procedures were conducted between September 2013 and June 2016. Motion and deformation of the EVAS stents, the chimney grafts, and the stented branch vessels were evaluated during the cardiac cycle using an established combination of image registration and segmentation techniques. RESULTS: Electrocardiogram-gated computed tomography angiography scans of 11 chEVAS configurations including 22 EVAS stents and 20 chimney grafts were analyzed. The three-dimensional displacement was at most 1.7 mm for both the EVAS stents and the chimney grafts. The maximum change in distance between components was no more than 0.4 mm and did not differ between EVAS-to-EVAS stent and EVAS stent-to-chimney stent (0.2 ± 0.1 mm vs 0.2 ± 0.1 mm; P = .823). The mean change in chimney deflection angle was 1.2 ± 0.7°; the maximum change was greatest for the superior mesenteric artery (SMA) (2.6°). The EVAS stent-to-chimney angles for the left renal artery, right renal artery, and SMA varied on average by 0.7 ± 0.3° (range, 0.4°-1.3°), 1.0 ± 0.3° (range, 0.5°-1.7°), and 0.8 ± 0.4° (range, 0.3°-1.3°), respectively, during the cardiac cycle. The end-stent angles for the left renal artery, right renal artery, and SMA varied on average by 1.7 ± 0.9° (range, 0.5°-3.3°), 1.9 ± 0.8° (range, 0.7°-3.3°), and 1.3 ± 0.4° (range, 0.7°-1.6°), respectively, during the cardiac cycle. Overall, the end-stent angles varied on average by 1.7 ± 0.8° (range, 0.5°-3.3°). CONCLUSIONS: The chEVAS configuration proved to be stable during the cardiac cycle, as demonstrated by minimal cyclical changes in distance between device components and angulation between the EVAS stents and the chimney grafts. The limited deflection angles of the chimney grafts decrease the risk of bending fatigue, but the more apparent change in end-stent angle distal to the chimney graft may raise concerns regarding late branch occlusion or stenosis.

Visualising improved peritoneal perfusion at lower intra-abdominal pressure by fluorescent imaging during laparoscopic surgery: A randomised controlled study.

BACKGROUND: Laparoscopy is the gold standard for many surgical procedures and is embraced as minimally invasive surgery in the enhanced recovery after surgery programme. Lowering intra-abdominal pressure during laparoscopy may decrease the degree of surgical injury and further enhance patient outcomes. This study aims to assess the effect of low pressure pneumoperitoneum on peritoneal perfusion during laparoscopic surgery. MATERIALS AND METHODS: We performed a prospective randomized intervention study in 30 adults undergoing colorectal robot assisted laparoscopic surgery at a secondary care medical center in the Netherlands between June and December 2018. A 3 min video recording of the parietal peritoneum was made with the Da Vinci® Firefly mode following intravenous injection of 0.2 mg/kg indocyanine green at a pneumoperitoneum pressure of 8, 12 or 16 mmHg. Observers were blinded for the level of intra-abdominal pressure that was used. Fluorescent intensity in [-] over time was extracted from each video in MATLAB. Time to reach maximal fluorescent intensity (TMFI) and maximum fluorescent intensity (MFI) were compared among groups. The study was registered at clinicaltrials.gov (NCT03928171). RESULTS: Mean TMFI was shorter at low pressure (8 mmHg) than standard pressure (12 and 16 mmHg): 44 ± 12 versus 58 ± 18 s (p = 0.032), respectively. Mean MFI was higher at 8 mmHg than 12 and 16 mmHg (222 ± 25 versus 188 ± 54, p = 0.033). Regression analysis identified intra-abdominal pressure, mean arterial pressure and female gender as significant predictors of peritoneal perfusion. CONCLUSION: Low pressure pneumoperitoneum was associated with improved perfusion of the parietal peritoneum. Current available evidence supported feasibility and enhanced postoperative recovery. Future investigations should focus on optimizing factors that facilitate lower intra-abdominal pressure and explore effects on other clinically relevant patient outcomes such as anastomotic leakage and immune homeostasis.

Three-dimensional facial volume analysis using algorithm-based personalized aesthetic templates.

Three-dimensional stereophotogrammetry is commonly used to assess volumetric changes after facial procedures. A lack of clear landmarks in aesthetic regions complicates the reproduction of selected areas in sequential images. A three-dimensional volumetric analysis was developed based on a personalized aesthetic template. The accuracy and reproducibility of this method were assessed. Six female volunteers were photographed using the 3dMDtrio system according to a clinical protocol, twice at baseline (T1) and twice after 1year (T2). A styrofoam head was used as control. A standardized aesthetic template was morphed over the baseline images of the volunteers using a coherent point drift algorithm. The resulting personalized template was projected over all sequential images to assess surface area differences, volume differences, and root mean square errors. In 12 well-defined aesthetic areas, mean average surface area and volume differences between the two T1 images ranged from -7.6mm2 to 10.1mm2 and -0.11cm3 to 0.13cm3, respectively. T1 root mean square errors ranged between 0.24mm and 0.62mm (standard deviation 0.18-0.73mm). Comparable differences were found between the T2 images. An increase in volume between T1 and T2 was only observed for volunteers who gained in body weight. Personalized aesthetic templates are an accurate and reproducible method to assess changes in aesthetic areas.

Three-dimensional facial development of children with unilateral cleft lip and palate during the first year of life in comparison with normative average faces.

BACKGROUND: Stereophotogrammetry can be used to study facial morphology in both healthy individuals as well as subjects with orofacial clefts because it shows good reliability, ability to capture images rapidly, archival capabilities, and high resolution, and does not require ionizing radiation. This study aimed to compare the three-dimensional (3D) facial morphology of infants born with unilateral cleft lip and palate (UCLP) with an age-matched normative 3D average face before and after primary closure of the lip and soft palate. METHODS: Thirty infants with a non-syndromic complete unilateral cleft lip, alveolus, and palate participated in the study. Three-dimensional images were acquired at 3, 6, 9, and 12 months of age. All subjects were treated according to the primary surgical protocol consisting of surgical closure of the lip and the soft palate at 6 months of age. Three-dimensional images of UCLP patients at 3, 6 (pre-treatment), 9, and 12 months of age were superimposed on normative datasets of average facial morphology using the children's reference frame. Distance maps of the complete 3D facial surface and the nose, upper lip, chin, forehead, and cheek regions were developed. RESULTS: Assessments of the facial morphology of UCLP and control subjects by using color-distance maps showed large differences in the upper lip region at the location of the cleft defect and an asymmetry at the nostrils at 3 and 6 months of age. At 9 months of age, the labial symmetry was completely restored although the tip of the nose towards the unaffected side showed some remnant asymmetry. At 12 months of age, the symmetry of the nose improved, with only some remnant asymmetry noted on both sides of the nasal tip. At all ages, the mandibular and chin regions of the UCLP patients were 2.5-5 mm posterior to those in the average controls. CONCLUSION: In patients with UCLP deviations from the normative average 3D facial morphology of age-matched control subjects existed for the upper lip, nose, and even the forehead before lip and soft palate closure was performed. Compared to the controls symmetry in the upper lip was restored, and the shape of the upper lip showed less variation after primary lip and soft palate closure. At this early age, retrusion of the soft-tissue mandible and chin, however, seems to be developing already.