Oral squamous cell carcinoma (OSCC) is a common malignancy that can develop from precancerous conditions such as oral lichen planus (OLP). This case report describes the clinical management and complication reporting of a patient with OLP who developed an exophytic lesion on the anterior maxillary gingiva, diagnosed as well-differentiated OSCC (cT1N0M0). Surgical treatment included anterior maxillectomy and reconstruction using an iliac crest bone graft housed in a customized CAD-CAM titanium mesh, covered by a facial artery musculomucosal (FAMM) flap. Postoperatively, the patient experienced significant surgical complications, including FAMM flap dehiscence and subsequent necrosis of the underlying bone graft, leading to total graft failure. Management of these adverse events required aggressive wound care, hyperbaric oxygen therapy, and complete removal of the exposed titanium mesh under local anesthesia, classified as a Grade IIIad complication according to the Clavien–Dindo system. To address the functional and aesthetic deficits resulting from the surgical failure, the patient was successfully rehabilitated using a removable partial prosthesis. This report highlights the novel clinical lesson that while CAD-CAM mesh reconstruction is innovative, high soft-tissue tension in dynamic maxillary regions represents a critical failure risk; it demonstrates that conventional removable prosthetics served as a successful, low-morbidity rescue strategy in this patient when complex surgical reconstructions failed.
Background: Low Cardiac Output Syndrome (LCOS) remains a common and clinically significant complication after cardiac surgery, characterized by impaired myocardial performance and inadequate systemic oxygen delivery despite optimized preload, afterload, and rhythm control. Although LCOS has traditionally been attributed to ischemia–reperfusion injury, myocardial stunning, inflammation, and neurohormonal dysregulation, accumulating evidence suggests that subcellular energetic impairment may contribute to postoperative myocardial dysfunction. Objective: This review evaluates mitochondrial dysfunction as a potential pathophysiological substrate that may underlie or exacerbate postoperative LCOS, integrating experimental, translational, and clinical findings relevant to adult cardiac surgery. Methods: A focused narrative review of preclinical and clinical literature was performed, emphasizing mitochondrial bioenergetics, calcium handling, redox signaling, and mitochondrial quality control in the context of cardiopulmonary bypass, ischemia–reperfusion, and postoperative myocardial injury. Results: Cardiomyocytes rely predominantly on mitochondrial oxidative phosphorylation, which supplies approximately 95% of myocardial ATP under physiological conditions. Surgical ischemia–reperfusion, cardioplegia, and systemic inflammatory activation are associated with transient mitochondrial disturbances, including impaired electron transport, increased reactive oxygen species generation, calcium overload, and mitochondrial permeability transition pore opening. These changes may contribute to reduced ATP availability, delayed myocardial recovery, contractile inefficiency, and increased susceptibility to arrhythmias. Emerging evidence suggests that circulating mitochondrial biomarkers, such as cell-free mitochondrial DNA, correlate with postoperative organ dysfunction, supporting the presence of systemic mitochondrial stress after cardiac surgery. Conclusions: Postoperative LCOS may partially reflect a reversible state of myocardial energetic failure. Recognition of mitochondrial involvement complements established hemodynamic and inflammatory models and offers a biologically plausible framework for variability in postoperative cardiac recovery.
Background: Coronary artery perforation is a potentially life-threatening complication in 0.2–0.6% of all patients undergoing percutaneous coronary intervention. Despite the ongoing development of technical skills and coronary devices, severe recalcitrant calcified coronary lesions remain a challenge for interventional cardiologists and can carry a potential risk for life-threatening complications, including coronary perforation. Discussion and Conclusion: The algorithm for cardiac vessel perforation could be more comprehensive and cover preventive and predictive measures. It is necessary to take into consideration prompt recognition, implement actions to restabilize the hemodynamic status, understand the source and mechanism of bleeding, and classify the cause of bleeding into proximal, distal, coronary artery bypass graft and collateral vessel, pericardial, myocardial extravasation, and vessel-chamber perforation, as each causality would necessitate a different management strategy for a successful outcome. Imaging information about cardiac vessel injury is useful for a better understanding of the spatial orientation of the coronary vessels. It also helps to detect a hematoma that deteriorates the hemodynamic status without effusion “dry tamponade” and could have a particular role in cardiac interventions to predict and prevent this complication.
The introduction of adjuvant immunotherapy with immune checkpoint inhibitors (ICIs) has significantly changed the management of high-risk urological cancers, particularly clear cell renal cell carcinoma and muscle-invasive urothelial carcinoma. This review provides a comprehensive narrative overview of immune-related adverse events (irAEs) associated with adjuvant ICIs, integrating evidence from pivotal registrational trials and real-world clinical experience. Clinical studies and reports were reviewed to characterize the incidence, type, severity, and management of irAEs. Across registrational trials, endocrine, cutaneous, and gastrointestinal toxicities were the most frequently reported irAEs and were predominantly mild to moderate in severity. Severe events were less common and required early recognition and structured management, often including corticosteroids and targeted immunomodulatory therapies. In our real-world cohort, irAEs occurred in 5 of 13 patients (38.5%) receiving adjuvant anti-PD-1 therapy, mainly involving endocrine and cutaneous systems, with a frequency and severity profile consistent with that reported in the KEYNOTE-564 and CheckMate-274 trials. Most irAEs were grades 1–2 according to CTCAE criteria and were manageable with standard treatments; permanent discontinuation of immunotherapy was required in a single case. Overall, the integration of clinical trial data and real-world evidence supports a favourable and manageable safety profile of adjuvant ICIs in high-risk urological cancers. Multidisciplinary management remains essential to optimise patient outcomes.
Postoperative respiratory failure (PRF) remains a pervasive clinical challenge that substantially contributes to perioperative morbidity, mortality, and prolonged ICU stay. Although conventional oxygen therapy is often sufficient, a significant subset of high-risk patients requires escalation to advanced non-invasive support to avoid reintubation and invasive mechanical ventilation. Evidence from recent randomized trials, including the 2025 RENOVATE and Goret et al. studies, indicates that both non-invasive ventilation (NIV) and high-flow nasal oxygen (HFNO) reduce postoperative pulmonary complications and reintubation in selected high-risk populations. While NIV is preferred for hypercapnic ventilatory failure and is commonly used in selected high-risk cardiac surgery patients, HFNO offers comparable outcomes in pure hypoxemic failure with the added benefits of superior patient tolerance and a lower incidence of interface-related complications. Effective PRF management necessitates an individualized, physiology-based approach. By implementing a phenotype-driven algorithm that aligns device mechanics with the dominant pathophysiology, such as atelectasis versus pump failure, clinicians can optimize patient outcomes while minimizing the specific risks associated with delayed intubation.
Intravenous fluids are integral to pediatric perioperative care, yet optimal fluid volumes during adenotonsillectomy remain debated. In 2024, Hurricane Helene disrupted IV fluid supply chains, necessitating an involuntary shift to restrictive intraoperative fluid administration. This event created an opportunity to evaluate whether reduced intraoperative fluids affected postoperative pain or complication rates in pediatric adenotonsillectomies. We conducted a retrospective cohort study of children under 12 years who underwent adenotonsillectomy between 1 October 2024, and 31 January 2025. Patients were stratified into a restrictive fluid group (<10 mL/kg) and a non-restrictive group (≥10 mL/kg). Collected data included demographics, intraoperative fluid volumes, postoperative FLACC pain scores, and documented complications. Pain scores were compared using Mann–Whitney U tests, due to non-normal data distribution with descriptive analysis. A total of 133 patients were included (63 restrictive, 70 non-restrictive). Mean postoperative FLACC scores were similar between groups (4.53 ± 2.62 vs. 4.57 ± 3.44; p = 0.50), with comparable operative times. Complications occurred in both groups without a consistent association with fluid strategy. These findings suggest that intraoperative fluid restriction below 10 mL/kg does not significantly affect postoperative pain or overall complication rates in pediatric adenotonsillectomy. Short-term fluid restriction may be safe in resource-limited settings, though prospective studies are warranted.
We report the case of a 68-year-old man presenting with rapidly progressive left cervical swelling, sialorrhea, and dysphagia. Imaging revealed a cervical fluid collection extending into the anterior mediastinum, initially suggestive of descending mediastinitis. Broad-spectrum antibiotic therapy was initiated, and surgical drainage was planned. Intraoperative exploration, however, revealed opalescent, milky fluid consistent with chyle, leading to a revised diagnosis of spontaneous chylocervical collection associated with chylothorax. Cultures were negative, and biochemical analysis confirmed markedly elevated triglyceride levels. Conservative management with total parenteral nutrition and a nil per os regimen achieved rapid resolution. Lymphangiography demonstrated normal thoracic duct anatomy without leakage. The patient was discharged in good condition, and follow-up imaging showed complete recovery. This case highlights the diagnostic challenge of differentiating chylous from infectious mediastinal collections, particularly when clinical presentation mimics descending mediastinitis. Accurate intraoperative assessment and multidisciplinary management are essential to avoid unnecessary invasive procedures. Rare etiologies such as idiopathic chylothorax should be considered in atypical presentations of cervical and mediastinal fluid collections.
Background: Maxillary sinus floor elevation is a predictable procedure for implant rehabilitation in the posterior maxilla with reduced residual bone height. Schneiderian membrane perforation is the most frequent intraoperative complication during sinus lift surgery and may compromise graft stability and treatment outcomes. Stabilized collagen membrane techniques have been proposed to manage extensive perforations. Objective: The aim of this study was to describe the management of a large Schneiderian membrane perforation (>10 mm) using a stabilized collagen membrane technique and to evaluate the clinical outcome. Case Description: A 67-year-old male patient (ASA I, non-smoker) with insufficient posterior maxillary bone height underwent lateral window sinus augmentation. During membrane elevation, a large perforation (>10 mm) occurred. A resorbable collagen membrane was adapted and stabilized to isolate the defect and create a contained compartment for graft placement. A xenograft was inserted, and an additional collagen membrane was used to cover the lateral window and stabilized with fixation pins. Primary closure was achieved with tension-free sutures. Results: Healing was uneventful, without sinus pathology or postoperative complications. Radiographic evaluation confirmed graft stability and adequate volume maintenance. Implant placement was successfully performed after 6 months, achieving satisfactory primary stability and favorable clinical outcomes after one year of loading. Conclusion: In this case, the stabilized collagen membrane technique allowed successful management of a large Schneiderian membrane perforation, enabling continuation of sinus augmentation, successful graft containment, and favorable implant rehabilitation outcomes.
Robotic retroperitoneal lymph node dissection (R-RPLND) represents an evolution in the surgical management of testicular germ cell tumors, offering reduced morbidity compared with open approaches. However, this procedure remains technically challenging, particularly after chemotherapy, due to dense fibrosis and distortion of the retroperitoneal anatomy. We report a case of an unrecognized intraoperative thermal injury causing a partial transection of the proximal ureter presenting postoperatively as a urinary fistula following R-RPLND for residual mass resection, along with a focused review of the contemporary literature on procedure-related complications. A review of large series highlights severe complications (Clavien–Dindo ≥ III) occurring in 6–12% of cases, with ureteral injuries occurring in up to 6%, often identified after surgery. This case underscores the importance of meticulous dissection, awareness of altered anatomy, and prompt intervention when unexpected events arise during R-RPLND.
Gallstone ileus is a rare but serious complication of gallstone disease, often requiring surgical intervention. While enterolithotomy remains the standard treatment, the role of additional biliary surgery, particularly subtotal cholecystectomy, remains controversial. This study examines the management of gallstone ileus in a rural setting, where limited surgical resources and access to specialized biliary interventions pose unique challenges. We present a case series of four patients diagnosed with gallstone ileus in a rural healthcare facility. All patients underwent initial enterolithotomy for bowel obstruction relief. Surgical outcomes, complications, and the necessity for a second intervention, including subtotal cholecystectomy, were evaluated. Ever patient had a successful recovery. Of the four cases, two patients underwent a subtotal cholecystectomy. No perioperative mortality was observed, but limited access to advanced imaging and specialized biliary surgery influenced clinical decision-making. The rural setting in which these series occurred comes with its unique challenges regarding resource management and technological demands.
Carotid paragangliomas are rare neuroendocrine tumors that, despite being typically benign, present significant surgical and anesthetic challenges. This manuscript outlines the anesthetic management for surgical resection, highlighting preoperative assessment, intraoperative monitoring, and postoperative care. A multidisciplinary approach is essential, particularly for functional tumors, requiring preoperative screening and pharmacologic preparation. Intraoperatively, cerebral perfusion monitoring is critical to prevent ischemic events. Postoperative vigilance is necessary to detect complications such as bleeding, cranial nerve deficits, and hemodynamic instability. A multidisciplinary team skilled in these surgical procedures is essential to improve safety in carotid paraganglioma surgery.
Introduction: Chordomas are rare, locally aggressive tumors of the spine and skull base typically managed with maximal surgical resection followed by adjuvant radiotherapy. Although postoperative radiotherapy improves local control, the optimal interval for initiation remains uncertain, as early delivery may exacerbate wound-related complications while delayed initiation may allow tumor progression. Methods: We performed a retrospective cohort analysis using the multi-center, national TriNetX Research Network. Adults with histologically confirmed skull base and/or spinal chordoma who underwent surgical resection followed by radiotherapy were stratified into ultraearly (≤2 weeks), standard (4–6 weeks), or delayed (≥10 weeks) radiotherapy initiation groups. Propensity score matching was used to adjust for demographic and clinical covariates. The primary outcome was all-cause mortality at 1, 3, and 5-years. Secondary outcomes included wound dehiscence, surgical site infection, and neurologic complications. Results: A total of 378 patients met the inclusion criteria. Ultraearly radiotherapy was not associated with significant differences in mortality at 1 year (RR 1.338; 95% CI 0.833–2.15; p = 0.22), 3 years (RR 1.233; 95% CI 0.858–1.772; p = 0.25), or 5 years (RR 1.196; 95% CI 0.876–1.633; p = 0.25) compared with standard timing. Delayed radiotherapy, however, demonstrated significantly reduced mortality at 1 year (RR: 0.53; 95% CI: 0.331–0.851; p = 0.01), 3 years (RR 0.641; 95% CI 0.449–0.914; p = 0.01), and 5 years (RR 0.654; 95% CI 0.473–0.905; p = 0.01) compared with standard timing. Event counts for secondary outcomes were insufficient for robust statistical comparison. Conclusions: Radiotherapy timing following surgical resection of chordoma did not impact short-term survival, but delayed radiotherapy significantly decreased 1, 3 and 5-year mortality. Rare secondary complications were seen. These findings suggest that the delayed initiation of radiotherapy may be helpful for patients with chordoma, supporting the need for prospective, long-term studies to clarify the balance between oncologic efficacy and perioperative morbidity.
Chronic subdural hematoma (CSDH) in frail older adults is increasingly recognized as a sentinel event, with mortality often driven by medical complications rather than neurosurgical factors. We report a failure-to-rescue case in which rapid postoperative deterioration occurred after burr-hole drainage for bilateral CSDH in a frail older adult with diabetes. A clinical picture consistent with sepsis was suspected, and a gastrointestinal source was considered, but the infectious focus could not be confirmed due to limited diagnostic work-up. On admission, chest-computed tomography showed mild right lower-lobe pneumonia, and incidental transverse colonic dilatation was also visible. Burr-hole drainage was uneventful and oxygenation rapidly normalized on room air. On postoperative day (POD) 3, the patient developed a high fever (39 °C), rising C-reactive protein (CRP; 14 mg/dL), abrupt leukopenia (15,300 → 3300/µL), and, several hours later, profuse watery diarrhea. At that time, an evaluation for an infectious source and escalation of therapy (e.g., blood cultures, serum lactate, and abdominal imaging) were not performed. In the early hours of POD 4, he suffered sudden desaturation, shock, and cardiac arrest, and died despite resuscitation. A portable radiograph after intubation showed no new diffuse pulmonary infiltrates but marked colonic gas distension. This case highlights the need to reassess diagnostic framing when discordant postoperative “red flags” emerge and proposes practical triggers for early sepsis evaluation and escalation—prioritizing early recognition and timely rescue rather than a definitive determination of the cause of death—in high-risk CSDH patients.
Spinal sarcomas are rare, aggressive tumors requiring wide resection that creates large, challenging defects. Conventional reconstruction using allografts or metallic implants is prone to failure in compromised settings like irradiated or infected tissue. This narrative review synthesizes the literature on biologic reconstruction strategies, focusing on vascularized bone grafts (VBGs) and the ‘spinoplastic’ reconstruction approach, to provide a clinical framework for their application. We performed a narrative literature review using PubMed and Scopus to synthesize clinical studies describing biologic spinal reconstruction in compromised host beds. The main findings show that pedicled VBGs (e.g., rib, iliac crest) and free VBGs (e.g., fibula) function as living structural components. ‘Spinoplastic’ reconstruction leverages these grafts to promote biologic fusion, with clinical series reporting high union rates, even in irradiated or revision settings, offering a durable alternative to avascular constructs. Biologic reconstruction using VBGs is a critical strategy for achieving durable spinal stability in these challenging scenarios, and future directions point toward hybrid strategies combining 3D-printed implants with the biologic power of VBGs.
Introduction: Rerouting urine flow is often required following radical cystectomy (RC). In this context, the ileal conduit (IC) has become the most common technique for urinary diversion, primarily due to its technical simplicity and suitability for patients with compromised renal function, elderly individuals, and those unable to perform self-catheterization. Objective: This review aims to highlight the complications of IC and categorize them into metabolic and surgical complications, further subdivided by timing (intraoperative, short-term, intermediate-term, and long-term) and anatomical location (uretero-ileal anastomosis, stoma, and ileal segment). Methods: A comprehensive narrative review was conducted to summarize the most common complications of IC, their clinical presentation, and management using Google Scholar, PubMed, and Embase databases to identify studies published from 1950 to 2024. Results: The morbidity associated with IC, especially when compared to continent diversions, remains a subject of debate. Notably, IC-related complications have been described with an incidence rate ranging from 39% to 67%. Conclusions: Providing a comprehensive overview of IC complications and management strategies can enhance clinical practice and improve patient outcomes.
Ankle fractures are extremely common and often require surgical management, historically with open reduction and internal fixation (ORIF), although fibular intramedullary nailing (IMN) has demonstrated promising results in recent years. The purpose of this study is to report on risk factors, quality of reduction, and complications in a series of patients undergoing fibular IMN for management of ankle fractures using a novel device via a retrospective case series. Patients undergoing locked fibular IMN with the Flex-Thread nail (Conventus Flower Orthopedics, Horsham, PA, USA) by a single surgeon from January 2023 to March 2025 were included, with at least 6 months of follow-up. Demographics, comorbidities, injury characteristics, reduction quality, and post-operative complications were recorded. Descriptive analyses were reported for categorical variables. A total of 15 patients were included, with a mean age of 58.9 ± 22.0 (range 18–91) and mean BMI of 31.5 ± 5.7 kg/m2. All patients experienced a fall as their mechanism of injury, with 12 Weber B and 3 Weber C fractures. The mean time to surgery from the date of injury was 9.5 ± 5.5 days. Of 15 patients, 66.7% had good reduction quality, 26.7% had fair, and 1 patient experienced poor reduction quality requiring subsequent hardware removal. There was one patient who experienced delayed wound healing. Patients undergoing fibular fixation using the novel Flex-Thread nail experience a fair to good quality of reduction, with limited complications. Both young and elderly patients have relatively positive early post-operative outcomes. Additional research with longer-term follow-up will be required to confirm its efficacy.
This study analyzed complication rates, perioperative metrics, and hospital readmissions across BMI cohorts in patients undergoing direct anterior approach (DAA) total hip arthroplasty (THA) in a mature hip practice. Currently, the precise BMI cutoff points for risk in THA are not fully understood. A retrospective review was conducted of patients who underwent DAA THA by a single, highly experienced, fellowship-trained surgeon between January 2021 and January 2023. The use of single-surgeon cases allows for control of many potentially confounding variables but may limit the generalizability of the findings. Data collected included patient demographics, hospital readmissions, 12-month complication rates, and intraoperative metrics. Patients with Class II obesity (BMI 35–39.9) kg/m2 and Class I obesity (BMI 30–34.9) kg/m2 had significantly higher intraoperative blood loss and longer operative times compared to the control group (BMI 20–24.9 kg/m2). No statistically significant differences in hospital readmission rates or complication rates were observed between BMI cohorts. Higher BMI was associated with increased intraoperative blood loss and longer operation time; however, no differences were found in hospital readmissions or complication rates between BMI cohorts.
Diabetic foot ulcers drive non-traumatic lower-limb amputation; limb salvage surgery is often pursued to preserve function and survival. Predictors of adverse outcomes remain incompletely defined, and evidence for multidisciplinary team (MDT) care is heterogeneous. We aimed to clarify risk factors for major amputation and death after diabetic limb salvage and evaluate MDT impact. We systematically reviewed 49 studies (2020–2025) reporting major amputation or mortality after limb salvage in diabetes (PROSPERO CRD420251044859). Risk factors spanned demographic, clinical, and surgical domains (e.g., older age, male sex, renal/cardiovascular disease, ischemia, osteomyelitis, advanced ulcer classification). MDT models generally showed lower amputation rates and improved wound healing, with occasional survival benefits; heterogeneity precluded meta-analysis. As a real-world comparator, the Mid Essex Diabetes Amputation Reduction Plan (MEDARP) treated 72 high-risk patients using a “toe and flow” MDT. Major amputation occurred in 6.9% and mortality in 12.5%, both at or below published ranges, with gains in patient-reported outcomes. Findings support MDT-based strategies, but conclusions should be interpreted cautiously given the predominantly observational evidence, and highlight the need for standardized outcome definitions and reporting.
Introduction: Tobacco smoking is a known risk factor for adverse surgical outcomes, including delayed wound healing and an increased risk of infection and nonunion. The rising use of cannabis products and alternative nicotine products, such as smokeless tobacco and electronic cigarette devices present new challenges for perioperative management, yet their influence in foot and ankle surgery is not well studied. Objectives: This scoping review aims to synthesize the existing literature on tobacco use, cannabis, and electronic cigarettes and their influence on postoperative outcomes in foot and ankle surgery. Methods: A comprehensive search of PubMed was performed using PRISMA-ScR guidelines. Eligible studies included observational studies and reviews that focus on the relationship between perioperative substance use and foot and ankle surgery complications. Results: There is a wide range of evidence that supports increased wound and bone healing complications with use of combustible tobacco. Data on the effects of smokeless tobacco, electronic cigarettes, and cannabis on this patient population is limited, with most evidence drawn from animal studies or broader orthopaedic literature. Conclusions: The existing data raises potential concern for adverse effects with use of these products. By identifying existing findings and gaps in the literature, this review highlights the need for further research on the perioperative effects of these substances in foot and ankle surgery.
Background: Despite advances in surgical techniques and perioperative care, pancreatic resections such as pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) remain high-risk procedures. Postoperative complications significantly impact morbidity, mortality, and patient quality of life. Methods: This narrative review summarizes recent literature on major complications following pancreatic surgery, including postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), and post-pancreatectomy hemorrhage (PPH), with an emphasis on incidence, risk factors, outcomes, and current preventive strategies. Results: POPF is a leading complication, occurring in 5–22% of cases and often linked with sepsis and hemorrhage. Key risk factors include high BMI, soft pancreatic texture, and small duct size. Preventive measures like Pasireotide, modified anastomosis techniques, and neoadjuvant therapy show variable success. DGE affects up to 57% of PD patients and is associated with prolonged recovery; antecolic reconstruction and erythromycin may reduce incidence. PPH, though less frequent (3–13%), can be life-threatening, particularly when secondary to POPF. Endovascular approaches are now favored for late arterial bleeding. Other complications include wound infections, abscesses, bile leaks, and pulmonary issues, all contributing to extended hospital stays and diminished quality of life. Conclusions: Pancreatic surgery continues to carry significant risks, with POPF, DGE, and PPH being the most impactful complications. While multiple interventions have shown promise, standardized protocols and predictive tools are still needed. Surgery should be performed in high-volume centers with experienced multidisciplinary teams to optimize outcomes.
