Delay In Surgical Treatment Research Articles

Management of Terson Syndrome: Long-Term Experience in a Single Center.

Terson Syndrome (TS) is a rare entity consisting of an intraocular hemorrhage secondary to subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (IH). This study aimed to retrospectively describe the experience of the Ophthalmology Unit of Policlinico Gemelli, Rome, in the management of TS. Twenty-four eyes of 19 patients (10 males-53%; 9 females-47%; mean age of 44.73 ± 12.49 years) with TS who had pars plana vitrectomy between 2011 and 2024 were included. The primary outcome was the mean change in best-corrected visual acuity (BCVA) 1-3 months after surgery. The secondary outcome was the correlation of post-operative BCVA with the timing of vitrectomy (early vs. late, ≤100 or >100 days). The time between diagnosis and surgery ranged from 33 to 284 days (median = 102 days, interquartile range IQR = 74-161). Baseline BCVA ranged from 6 to 50 ETDRS letters with a median of 17 letters (IQR = 15-25) and significantly increased after surgery, with a median value of 80 (IQR = 70-85). The BCVA percentage improvement had a median of 325% (IQR = 300-431%). No differences in post-operative BCVA were found between patients who underwent early or late vitrectomy. One vitrectomy was complicated by an endophthalmitis. Although no clear guidelines exist on managing TS, vitrectomy significantly improves BCVA, and a delay in surgical intervention does not necessarily worsen the functional outcome. However, an early vitrectomy could improve the stimuli perception, facilitating the rehabilitation process.

Propensity score matching analysis of early vs. delayed surgery for intertrochanteric fracture in older patients: a retrospective multicenter cohort study of 7414 patients with a mean 4-year follow up

BackgroundThe widespread acceptance of early surgery as a treatment for acute intertrochanteric fracture (ITF) has been accompanied by ongoing controversy due to conflicting conclusions presented in previous studies. This study aims to compare the occurrence of perioperative complications and mortality, as well as functional outcomes in older patients with ITF who underwent either early or delayed surgery.MethodsA retrospective multicenter cohort study involving 7414 patients with ITF between Jan. 2017 and Dec. 2021 was conducted. After predefined participants selection inclusion and exclusion criteria, 2323 surgically treated ITF patients were included and analyzed utilizing propensity score matching (PSM) method. Their demographics, injury-related data, surgery-related data, and perioperative adverse outcomes during hospitalization were collected and compared between the early or delayed surgery groups by PSM with a 1:4 ratio. All participants received a minimum of two-year follow-up and perioperative outcomes, functional outcomes, and survival analyses were conducted and compared.ResultsAfter adjustment for potential confounders, there were no significant difference in surgery duration, intraoperative blood loss, transfusion rate, mortality rates, functional outcomes, and perioperative complications rates including severe complications, cardiac complications, pulmonary complications, and neurological complications regardless of whether the patient was treated with early or delayed surgery (all P > 0.05). Although length of hospital stay (mean, 11.5 versus 14.4 days, P < 0.001), total hospital costs (mean, 39305 versus 42048 yuan, P < 0.001), and minor complications rates including hematological complications (31.7% versus 41.2%, P = 0.007) and nutritional/metabolic complications (59.3% versus 66.4%, P = 0.039) were lower in the early surgery group, our result indicated patients with early surgery were more inclined to receive more blood transfusion (mean, 2.8 versus 2.2 units, P = 0.004).ConclusionsOur findings suggest that a 48-hour delay in surgical intervention for older patients with an ITF does not result in a higher mortality rate, worse functional outcomes, and increased incidence of major perioperative complications when compared to early surgery. While expedited surgery is undoubtedly necessary for suitable patients, a reasonable preoperative delay of 48 h may be justified and safe for those with severe conditions, rather than strictly adhering to the current guidelines.

Abstract B128: Underlying factors influencing kidney cancer surgical treatment disparities: Patients, non-patient community members and urologists’ perspectives

Abstract Background: Racial and ethnic minority patients often delay or forgo kidney cancer (KCa) surgical treatment and have an invasive surgical treatment. This study aimed to understand the underlying factors of KCa surgical treatment disparities through interviews with KCa patients and non-patients from racial and ethnic minority communities in Arizona and online surveys with urologists who practice in the U.S. Methods: We conducted phone interviews with KCa patients (n=13) and interviews at health events with community members without KCa (n=61). Online surveys were conducted with urologists (n=54). Results: Many interview participants had healthcare access issues with 22% reporting not having a primary care doctor and 12% reporting that there was a time when they could not see a doctor because of cost. Almost 50% reported that they had delayed care because they could not get an appointment soon enough. Among 10 patients who responded to a question about diagnosis delay, 4 answered that they waited over a year to see their doctor when they had health issues before their diagnosis. A quarter of community participants (25%) and about a third of patients (31%) reported that cultural values or religious beliefs influenced their choice of treatment. When community participants were asked what they knew about KCa symptoms and treatments, many did not provide relevant or correct information. Only 51% of non-patients reported that they trusted their doctor’s judgements about their medical care, but 92% of patients reported that they trusted their doctor’s judgement. About 30% of urologists reported that patients from racial and ethnic minority backgrounds often have healthcare access challenges, but only 9% responded that NHW patients often have challenges. They did not report that racial and ethnic differences in treatment exist. About 10% of urologists reported socioeconomic backgrounds of patients affect treatment decision and timeliness often or all the time. Only 46% reported that they refer patients to necessary services all the time, when patients express concerns of finance and healthcare access challenges. Many urologists strongly or slightly agreed that treatment decisions should be made by the treating clinicians (82%) and based on clinical information (87%). Many also strongly or slightly agreed that patients and their family members should contribute to decision-making (98%), while 46% strongly or slightly agreed that patients’ cultural and religious backgrounds often affect their treatment choices. In open-ended questions, urologists responded that work and family obligations, healthcare access, and health literacy rather than race and ethnicity are factors influencing treatment, while mistrust was identified as one of factors influencing treatment delay. Conclusions: Barriers to healthcare access, lack of knowledge, and mistrust before diagnosis may be underlying factors among patients, while urologists view healthcare access, social and economic factors, and mistrust influence KCa surgical treatment decision and delay. Citation Format: Ken Batai, Alex Cruz, Juan Adrover, Daphne Larose, D'Andre Gomez, Francine C. Gachupin, Jacquanette R. Slowtalker, Benjamin R. Lee, Juan Chipollini. Underlying factors influencing kidney cancer surgical treatment disparities: Patients, non-patient community members and urologists’ perspectives [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr B128.

Surgical treatment delay in patients with headache disorders and neuralgia correlates with poor postoperative outcome

Although nerve decompression surgery has proven to be effective in reducing symptoms in patients with head and neck neuralgia and headache disorders, it is currently not part of the treatment algorithms for headache disorders. Therefore, patients wait an average of 20 years from the onset of symptoms to surgery, resulting in high conservative treatment costs ($989,275.65 per patient) and patient morbidity. This study evaluated the clinical impact of treatment delays on surgical outcomes. Overall, 282 patients who underwent nerve decompression surgery at Weill Cornell Medicine and Massachusetts General Hospital between September 2012 and January 2024 were enrolled. Information regarding demographics, onset of symptoms, and headache characteristics was collected using patient surveys. The treatment outcome was evaluated by the percentage of symptom reduction in terms of frequency, duration, and pain intensity. An area under the receiver operating characteristic analysis was performed to determine the optimal timepoint to undergo surgery. Postoperative symptom reduction and time between the onset of symptoms and surgery were negatively correlated (r=-0.22; p<0.001). The most significant difference in outcome was found at 2.9 years from symptom onset; patients who underwent surgery before this timepoint reported an average improvement of 79±23% versus 67±35% in those who were treated after the timepoint (p=0.021). Our results indicate that delays in undergoing nerve decompression surgery beyond 2.9 years from symptom onset leads to less favorable postoperative outcomes, underscoring the need for timely referral to peripheral nerve surgeons when conservative management fails. Nonetheless, even with delays in surgical intervention, patients continued to experience significant symptom reduction.

Practice patterns and clinical outcomes in acute appendicitis differ in the elderly patient.

Appendicitis is the most frequent global abdominal surgical emergency. An ageing population, who often exhibit atypical symptoms and delayed presentations, challenge conventional diagnostic and treatment paradigms. This study aims to delineate disparities in presentation, management, and outcomes between elderly patients and younger adults suffering from acute appendicitis. This subgroup analysis forms part of ESTES SnapAppy, a time-bound multi-center prospective, observational cohort study. It includes patients aged 15years and above who underwent laparoscopic appendectomy during a defined 90-day observational period across multiple centers. Statistical comparisons were performed using appropriate tests with significance set at p < 0.05. The study cohort comprised 521 elderly patients (≥65years) and 4,092 younger adults (18-64years). Elderly patients presented later (mean duration of symptoms: 7.88 vs. 3.56days; p < 0.001) and frequently required computed tomography (CT) scans for diagnosis (86.1% vs. 54.0%; p < 0.001). The incidence of complicated appendicitis was higher in the elderly (46.7% vs. 20.7%; p < 0.001). Delays in surgical intervention were notable in the elderly (85.0% operated within 24h vs. 88.7%; p = 0.018), with longer operative times (71.1 vs. 60.3min; p < 0.001). Postoperative complications were significantly higher in the elderly (27.9% vs. 12.9%; p < 0.001), including severe complications (6.9% vs. 2.4%; p < 0.001) and prolonged hospital stays (7.9 vs. 3.6days; p < 0.001). Our findings highlight significant differences in the clinical course and outcomes of acute appendicitis in the elderly compared to younger patients, suggesting a need for age-adapted diagnostic pathways and treatment strategies to improve outcomes in this vulnerable population.

How does trauma secondary to unexpected extreme weather affect orthopaedic surgery departments? : An epidemiological study on the Filomena snowstorm

Trauma secondary to extreme weather events may heavily impact the normal activity of orthopaedic surgery departments, especially in places not prepared to deal with them. The Filomena snowstorm, which happened in January 2021, was one of the greatest snowstorms ever in Spain. During it, the constant influx of trauma patients caused Orthopaedic Emergencies Department (OED) to collapse. The primary objective of this study was to describe the orthopaedic injuries and changes in fracture's epidemiology observed during this exceptional period. Secondary objectives were to analyse the collected variables in order to minimize the future impact of these unexpected extreme weather events. A retrospective cohort study between patients that came to the OED during the snowstorm (Filomena group) and those who came on the same period of the previous year (Control group) was made. The following data were collected: age, sex, injury location, injury mechanism, diagnosis, AO/OTA fracture classification, treatment type (conservative vs surgical) and delay of surgical treatment. Atotal of 1237 patients were included, 655 patients from the Filomena group and 582 from the Control group. One in two patients in the Filomena group sustained afracture (50.7% vs 23.2%). The most frequent diagnosis on the Filomena group was distal radius fracture (16.2%), which was five times more frequent than in the Control group (3.4%). Asignificant increment was also observed in the incidence of ankle (21.7%) and proximal humerus (33%) fractures. In the Filomena group, surgically treated fractures increased by 168%, being more severe, as C‑type fractures were more prevalent (23% vs 13%). Mean delay to surgery was 6.78 days during the snowstorm. Unexpected snowstorms entail an exponential rise in orthopaedic care demand and OED pressures. Asignificant increment in orthopaedic trauma surgery, up to 168% more, particularly distal radius, proximal humerus and ankle fractures, is to be expected, which will imply elective surgery cancellation, hurting patients and increasing costs.

Surgical Management of Headache Disorders - A Systematic Review of the Literature.

This review article critically evaluates the latest advances in the surgical treatment of headache disorders. Studies have demonstrated the effectiveness of innovative screening tools, such as doppler ultrasound, pain drawings, magnetic resonance neurography, and nerve blocks to help identify candidates for surgery. Machine learning has emerged as a powerful tool to predict surgical outcomes. In addition, advances in surgical techniques, including minimally invasive incisions, fat injections, and novel strategies to treat injured nerves (neuromas) have demonstrated promising results. Lastly, improved patient-reported outcome measures are evolving to provide a framework for comparison of conservative and invasive treatment outcomes. Despite these developments, challenges persist, particularly related to appropriate patient selection, insurance coverage, delays in diagnosis and surgical treatment, and the absence of standardized measures to assess and compare treatment impact. Collaboration between medical/procedural and surgical specialties is required to overcome these obstacles.

THE NATURAL HISTORY OF UNDISPLACED LISFRANC-TYPE INJURIES INITIALLY TREATED CONSERVATIVELY

BackgroundUndisplaced Lisfranc-type injuries are subtle but potentially unstable fracture-dislocations with little known about the natural history. These injuries are often initially managed conservatively due to lack of initial displacement and uncertainty regarding subsequent instability at the tarsometatarsal joints (TMTJ). The aim of this study was to determine the secondary displacement rate and the need for delayed operative intervention in undisplaced Lisfranc injuries that were managed conservatively at initial presentation.MethodsOver a 6-year period (2011 to 2017), we identified 24 consecutive patients presenting to a university teaching hospital with a diagnosis of an undisplaced Lisfranc-type injury that was initially managed conservatively. Pre-operative radiographs were reviewed to confirm the undisplaced nature of the injury (defined as a diastasis&lt; 2mm at the second TMTJ). The presence of a ‘fleck’ sign (small bony avulsion of the second metatarsal) was also noted. Electronic patient records and sequential imaging (plain radiographs/CT/MRI) were scrutinized for demographics, mechanism of injury and eventual outcome.ResultsThe mean age of the patients at the time of injury was 42 years (19 Female). 96% (23/24) were low energy injuries and 88% (21/24) had a positive ‘fleck sign’. The secondary displacement rate in this group of patients was 62.5% (15/24) over a median interval of 14 days (range 0 to 482 days). 12 patients underwent open reduction internal fixation after a median interval of 29 days (range 1 to 294 days) from their initial injury. One patient required TMTJ fusion at 19 months and two patients were managed non-operatively. The injury remained undisplaced in 37.5% patients (9/24) with only one patient requiring subsequent TMTJ fusion at 5 months.ConclusionUndisplaced Lisfranc injuries have a high rate of secondary displacement and warrant close follow-up. Early primary stabilisation of undisplaced Lisfranc injuries should be considered to prevent unnecessary delays in surgical treatment.

Incomes to Outcomes: A Global Assessment of Disparities in Cleft and Craniofacial Treatment.

Recent investigations focused on health equity have enumerated widespread disparities in cleft and craniofacial care. This review introduces a structured framework to aggregate findings and direct future research. Systematic review was performed to identify studies assessing health disparities based on race/ethnicity, payor type, income, geography, and education in cleft and craniofacial surgery in high-income countries (HICs) and low/middle-income countries (LMICs). Case reports and systematic reviews were excluded. Meta-analysis was conducted using fixed-effect models for disparities described in three or more studies. N/A. Patients with cleft lip/palate, craniosynostosis, craniofacial syndromes, and craniofacial trauma. N/A. One hundred forty-seven articles were included (80% cleft, 20% craniofacial; 48% HIC-based). Studies in HICs predominantly described disparities (77%,) and in LMICs focused on reducing disparities (42%). Level II-IV evidence replicated delays in cleft repair, alveolar bone grafting, and cranial vault remodeling for non-White and publicly insured patients in HICs (Grades A-B). Grade B-D evidence from LMICs suggested efficacy of community-based speech therapy and remote patient navigation programs. Meta-analysis demonstrated that Black patients underwent craniosynostosis surgery 2.8 months later than White patients (P < .001) and were less likely to undergo minimally-invasive surgery (OR 0.36, P = .002). Delays in cleft and craniofacial surgical treatment are consistently identified with high-level evidence among non-White and publicly-insured families in HICs. Multiple tactics to facilitate patient access and adapt multi-disciplinary case in austere settings are reported from LMICs. Future efforts including those sharing tactics among HICs and LMICs hold promise to help mitigate barriers to care.

39. Costs Associated With Surgical Treatment Delay In Patients With Occipital Neuralgia: A Prospective Cohort Study

39. Costs Associated With Surgical Treatment Delay In Patients With Occipital Neuralgia: A Prospective Cohort Study

Boston carpal tunnel syndrome questionnaire clinical function assessment outcomes of carpal tunnel injection for carpal tunnel syndrome

Carpal tunnel syndrome is the most common compressive neuropathy. Risk factors include hereditary, obesity, pregnancy, hypothyroidism, rheumatoid arthritis, and work related. With treatment ranging from simple lifestyle changes, up until surgery. Studies have shown that local steroid injection improve symptoms by at least one month and up to one year after injection, which allows for the delay of surgical treatment. In this study, BCTQ was chosen as a measuring tool because it can objectively assess functional improvement in functional status and disease severity. An analytical study design with a quasi-experimental pretest post-test one group only design approach was used in this study. Primary data and secondary data were used to measure the symptom severity scale and functional status based on the BCTQ. The research subjects were taken from populations that fulfilled the inclusion and exclusion criteria. Based on the Friedman test analysis of differences in the severity scale of symptoms of clinical function assessment outcome data and functional status on the BCTQ from the action of carpal tunnel injection on carpal tunnel syndrome, the results of the BCTQ value show that there is a significant difference before and after injection at one month and three months assessment post injection with a P-value of 0.00 (p&lt;0.05) on both. Carpal tunnel injection with Triamcinolone acetonide 20 mg can provide good clinical outcomes in cases of carpal tunnel syndrome and can reduce the severity of symptoms and provide a good functional status scale of the hand.

DEVELOPMENT OF ULTRASTRUCTURAL CHANGES IN DIAPHRAGM MUSCLE FIBERS DURING PARTIAL TRACHEAL STENOSIS IN YOUNG SEXUALLY IMMATURE RATS

Introduction. The study of congenital pathology of the respiratory tract in children is of great importance for theoretical and clinical pediatric otolaryngology. Currently, in the scientific literature there are single works concerning the study of the pathogenesis and clinic of laryngomalacia. First of all, this concerns the effect of acute and chronic hypoxia on the muscles of the respiratory system, in particular, the diaphragm. The aim of thіs work is to reveal the effect of hypoxia on the development of pronounced structural and functional changes in the diaphragm muscles of sexually immature animals when modeling partial tracheal occlusion. Materials and methods. Surgical partial occlusion of the trachea was performed on in sexually immature Wistar rats; we applied electron microscopy, morphometric and statistical research methods.&#x0D; Results. The obtained data demonstrated that the muscle fibers of the diaphragm are characterized by significant structural, functional and metabolic resistance to the development of acute or chronic hypoxia due to limited lung ventilation in rats. The density of muscle fibers did not change in any of the used terms of the experiment (7 and 21 days). On the 7th day of hypoxic exposure, a change in the state of the matrix of mitochondria of muscle fibers was observed, which was accompanied by partial ultrastructural rearrangements of the organization of these organelles. At the same time, no significant changes were observed during histological studies. Electrongrams demonstrated the ultrastructural damages were mainly limited to focal reduction of myofibrils and an increase in the mitochondria's diameter and found as especially pronounced on day 21 (a state of chronic hypoxia) on the muscular component of the respiratory system in rats. These changes are accompanied by the development of dystrophic disorders in the diaphragm myofibrils. On day 21 changes in the transendothelial transport of substance molecules were also detected. This was based on establishing the fact of a significant reduction in the number of pinocytosis vesicles in the cytoplasm of endothelial cells of diaphragm hemocapillaries in animals with partial tracheal occlusion. Disruption of the structural organization of actomyosin complexes was revealed in muscle fibers due to pathological changes in the mitochondria of myofibrils. It should be noted the development of destruction or complete loss of an important ultrastructural component of muscle fibers, Z-lines. These changes were completely absent on the 7th day following the influence of partial tracheal occlusion and the development of acute hypoxia. Moreover, on day 21, partial lysis of a significant amount of myofilaments of muscle fibers was observed. In addition, the development of the process of fiber swelling was detected against the background of which the above-mentioned ultrastructural destruction of the muscular component in the diaphragm was observed. These changes indicate the need for earlier treatment of laryngomalacia in children. The delay in surgical intervention leads to the development of severe or irreversible structural changes not only in the respiratory organs, but also in their muscular system.&#x0D; Conclusion. The muscular elements of the diaphragm have the pronounced and significant resistance to the state of hypoxia under conditions of limited ventilation of the respiratory tract. Ultrastructural and morphometric data, found on the 21st day after the modeling of partial tracheal stenosis, are not only of a compensatory and adaptive in nature, but also signs of pronounced disorders in the muscle fibers of the central part of the diaphragm in test animals.

Decision for Carpal Tunnel Surgery: High-deductible Health Plans versus Traditional Health Plans.

Delay in surgical treatment for carpal tunnel syndrome (CTS) may result in long-term decreased functional outcomes. Few investigators have examined the relationship between type of health insurance plan and time to definitive treatment of CTS following diagnosis. We investigated the relationship between insurance type, treatment decision, and the time between diagnosis and surgery across groups. This was a retrospective cohort study using the MarketScan Commercial Claims and Encounters Database 2011-2020. We used χ2 tests, linear regression, and logistic regression models to analyze demographic data and the time lag interval between CTS diagnosis and treatment. Overall, 28% of high-deductible health plan (HDHP) patients underwent carpal tunnel release, compared with 20% of traditional insurance patients (P < 0.001). HDHPs are defined by the internal revenue service as a deductible of $1400 for an individual or $2800 for a family per year. The odds of undergoing surgery versus no treatment for HDHP patients were 47% higher than traditional patients (P < 0.001). Among the patients who underwent surgery, HDHP patients underwent surgery 65 days earlier on average following diagnosis compared with traditional patients (P < 0.001). Patients with HDHPs who receive a diagnosis of CTS are more likely to undergo surgery, with a shorter time lag between diagnosis and surgery. The results from this study call attention to differences in surgical decision-making between patients enrolled in different insurance plans.

Presentation, diagnosis, management and outcome of complicated hydatid cyst of the lung

Introduction: Introduction: The complicated hydatid cyst of the lung is defined as any cyst ruptured in the bronchi tree or in the pleural cavity, infected, and rarely in the pericardial cavity. The aim of this study was to evaluate the problems of complicated pulmonary hydatid cyst, including presentation, diagnosis choice of surgical methods. and complication of delay in surgical treatment of pulmonary hydatid cysts. Methods: Between 2016 and 2021, 192 operations operated for pulmonary hydatid cysts, 42 of these patients were complicated hydatid cyst. Presentations were cough, chest pain and dyspnea.Diagnosis tools were CXR and CT-scan of chest. surgical approach was a posterolateral thoracotomy and anterolateral thoracotomyin all patients; a phrenotomy in eight patients and one-stage bilateral thoracotomy in six patients. Results: In 18 patients (67.5%), there were single hydatid cysts; whereas 4 patients (32.5%) had multiple cysts.12 patients had bilateral cyst and 8 had both lung and liver and others organs, 6 patients had preoperative hydatid cyst history. Iatrogenic rupture of an intact hydatid cyst occurred in 4 patients. Extrathoracic involvement was apparent in 6 patients (27%). Intrathoracic but extrapulmonary involvement was apparent in 4 patients (16%). Conclusion: Complicated hydatid cyst may present with different clinical and radiologically manifestations as a primary lung tumor , pleural effusion ,empyema hydropneumothorax. In patients with suspicious lung masses in endemic area or history of a hydatid cyst in patients a complicated pulmonary hydatid cyst may be in differential diagnosis.

Systematic Lymphatic Repair for Reduction of Postoperative Lymphatic Leak Following Neuroblastoma Resection

BackgroundGross total resection of neuroblastoma is associated with lymphatic leaks that can delay postoperative resumption of treatment. To prevent postoperative lymphatic leak, we introduced systematic lymphatic repair (SLR), which involved oversewing the entire edge of the disrupted lymphatic plane after neuroblastoma resection. We sought to study the impact of SLR on postoperative lymphatic leak and time to return to treatment. MethodsWe reviewed 60 neuroblastoma patients who underwent gross total resection at KK Women's and Children's Hospital. Patient, disease, and operative factors were correlated with surgical drainage, treatment delay and length of stay (LOS). Among patients with sufficient records, the interaction between variables associated with drainage, delay and LOS outcomes were compared in 14 patients who had SLR versus 35 historical controls who had targeted lymphatic repair (TLR). ResultsPostoperative drain duration and volume were significantly higher in tumors with ≥2 image-derived risk factors (IDRFs, P = 0.005 and P = 0.013, respectively) or vessel encasement (P = 0.031 and P = 0.024, respectively). Longer LOS was significantly associated with ≥2 IDRFs (P = 0.006). All forms of suture repair of lymphatics and use of Tachosil™ were associated with significantly longer postoperative drain duration (P < 0.05); the former was also associated with significantly higher total drain volume (P < 0.05) – indicating appropriate use of these adjuncts in patients at risk of chyle leak. In patients who had suture repair of lymphatics, SLR was significantly associated with reduced postoperative interval to chemotherapy resumption (P = 0.014, two-way ANOVA). ConclusionA systematic approach to repair of lymphatic channels following neuroblastoma resection can significantly reduce time to postoperative resumption of treatment. Type of StudyClinical Research. Level of EvidenceIII.

Exploratory prospective, randomized phaseII study of neoadjuvant transcatheter arterial chemoembolization plus surgery versus surgery alone for large hepatocellular carcinoma (CSGO-HBP-005): Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group.

Neoadjuvant transcatheter arterial chemoembolization (TACE) for large tumors is controversial, especially in the minimally invasive surgery era. The aim of this study was to compare features between groups treated with neoadjuvant TACE followed by surgery (TACE+surgery) or upfront surgery for hepatocellular carcinoma >5cm. In this exploratory, multicenter, randomized phaseI study, the primary measure was 2-year disease-free survival (DFS). Secondary measures were resection rate, necrosis rate by TACE, 2-year overall survival, and site of recurrence. A total of 30 patients were randomly allocated to each arm. The two arms did not differ in patient characteristics. The median time to surgery from randomization was 48days for TACE+surgery and 29 for surgery only (p<0.001). Postoperative morbidities did not differ between arms. The 2-year DFS, overall survival, and resection rates were 56.7%, 80.0%, and 93.3%, respectively, in the TACE+surgery arm, and 56.1%, 89.9%, and 90.0% in the upfront surgery arm. Minimally invasive surgery was carried out in 35.7% in the TACE+surgery arm and in 29.6% in the upfront surgery arm. The median necrosis rate by TACE was 90.0%. In resected specimens, invasion to the hepatic vein was less with TACE+surgery (3.6% vs. 22.2%, p=0.0380). In cases of 100% necrosis with TACE, 2-year DFS was 100%. Site of recurrence did not differ between groups. Neoadjuvant TACE did not improve 2-year DFS, and neoadjuvant TACE allowed delay of surgical treatment without increased morbidity and cancer progress. UMIN: 000005241.

Treatment tactics for gastric erosive-ulcerative bleeding on the background of liver cirrhosis

Analysing the polymorphism of etiological factors that contribute to the development of erosive‑ulcerative gastric lesions in patients with liver cirrhosis (acid‑peptic factors, transformation of venous blood flow, immune complexes, etc.), it should be noted that portal hypertension is the most important cause of these lesions. Bleeding from erosive‑ulcerative gastric lesions is a direct cause of death, occupying the first place in the structure of mortality and far exceeding ulcer perforations in this regard. Mortality in the first massive acute gastric bleeding reaches 50%, after the second — 70%, in hepatic coma — 80% or more. Objective — to improve the treatment outcomes for patients with erosive and ulcerative bleeding in the stomach due to liver cirrhosis. Materials and methods. The treatment outcomes of 192 patients with the hepatic form of portal hypertension (liver cirrhosis) who were hospitalised in the therapeutic and surgical departments, which are the clinical bases of the Department of Surgery No. 2 at Bogomolets National Medical University, were studied for the period from 2005 to 2023. During upper endoscopy, degenerative changes in the gastric mucosa were detected in 94 (48.9%) patients. Specifically, gastric erosions were observed in 31 (33.0%) patients, gastric ulcers in 34 (36.2%), and portal gastropathy in 29 (30.8%) patients. A total of 88 (46.6%) patients with liver cirrhosis and acute gastric bleeding were admitted to the surgical department as an emergency. According to the Child‑Pugh scale, the vast majority of patients were at the stage of sub‑ and decompensation (71 patients, or 89.1%). In 41 (45.2%) patients, gastric cancer was attributed to gastric erosive and ulcerative lesions: erosive gastritis — in 20 (48.8%) patients and gastric ulcer — in 21 (51.2%) patients. Results. Enhancing the protective properties of the mucous‑bicarbonate barrier of the gastric mucosa as part of pathogenetic conservative treatment schemes can reduce the influence of this mechanism on the development of hemorrhagic complications in 89.4% of patients. The risk of bleeding in this group of patients with liver cirrhosis is 15.1%, which requires the search for new methods of conservative treatment. In 79.6% of cases, primary endoscopic hemostasis of bleeding erosive‑ulcerative gastric lesions was effective when combined with drug therapy. For 53.1% of patients, it proved to be the final treatment. This enabled a reduction in overall mortality to 22.4% from 50% (p &lt;0.05) and, if necessary, a delay in surgical intervention. Out of the total number of patients, 19 (38.8%) patients required surgical intervention, with 73.7% of them undergoing urgent surgery and 26.3% undergoing delayed surgery. When considering operative methods for peptic ulcers complicated by hemorrhage, preference should be given to organ‑ and function‑preserving interventions. They yield more favourable immediate outcomes for this extremely challenging group of patients (postoperative mortality was reduced to 26.3% vs. 50.0% (p &lt;0.05). Conclusions. Acute gastric bleeding resulting from erosive‑ulcerative gastric lesions, which are complications of liver cirrhosis, can significantly impair the health of patients. However, by implementing modern treatment technologies, such as surgical procedures, it is feasible to achieve a 50% reduction in both overall and postoperative mortality.

A clinical case of hydatid echinococcosis in Perm Krai

The objective of the study was to analyze the clinical picture of hydatid echinococcosis with combined damage of the liver and lungs as well as tactics of management and treatment. A clinical observation of a patient with echinococcosis is presented. Information from the medical record of an inpatient with the results of clinical examination, instrumental and laboratory diagnostic methods was used. The clinical case is characterized by a delay in surgical intervention and a severe course of infection. The need for increased attention of practitioners to echinococcosis is indicated; an individual work with each patient to prevent a severe course, possible complications and a favorable outcome of the disease is required.

Anticoagulation management in elderly patients with proximal femur fractures- overview of current concepts.

Proximal femur fractures (PFF) are common injuries in elderly patients and can have considerable effects on their quality of life, morbidity, and mortality. Due to pre-existing comorbidities, the prevalence of anticoagulated patients is increasing. The right timing for surgery and perioperative anticoagulation treatment remains controversial. This overview aims to summarize current practices in the pre- and postoperative anticoagulation management and the recommended time to surgery in elderly patients with PFF. Time to surgery for anticoagulated patients is often prolonged due to worries about serious perioperative bleeding and higher transfusion demands. But the delay of surgical PFF treatment increases the risk for perioperative complications like pulmonary embolism, pneumonia, deep vein thrombosis and urinary tract infections. Early surgery can be achieved with a consistent and interdisciplinary perioperative anticoagulation management. Antiplatelets do not have to be discontinued and surgery should be performed early without delay. For patients taking vitamin K antagonists (VKA) an INR less than 1.5 is recommended prior to surgery, which can be achieved by pausing VKA intake or by administering vitamin K, prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP). For the treatment with direct oral anticoagulants (DOAC) a plasma drug level of under 50 pg/mL is considered safe for surgery. If the plasma level can not be determined, a gap of 24 h between the last DOAC dose and surgery is recommended. The systemic administration of tranexamic acid can reduce overall blood loss and transfusion rates in anticoagulated patients with PFF. Surgical treatment of PFF should be performed within 24 h, as delayed surgery increases the risk for perioperative complications. This also applies to anticoagulated patients, when clinically appropriate. International and interdisciplinary guidelines are necessary to ensure early and appropriate treatment of anticoagulated elderly patients with PFF.

Factores relacionados a la demora del tratamiento quirúrgico de fractura de cadera en adultos mayores de 50 años

Introduction: Hip fracture rates increase with age, due to loss of bone density. According to international guidelines it is recommended that the surgical treatment for this pathology is of choice and should be established during the first 48 hours. Objective: To identify and describe the factors related to the delay of surgical treatment of hip fracture in patients over 50 years of the Regional Hospital of Lambayeque during March - September 2019. Material and methods: Quantitative, descriptive, prospective, observational study, with a census-type sample of 52 patients, diagnosed with hip fracture and submitted to surgical treatment, data collection carried out through a clinical history review and personal interview, a data collection sheet was prepared. data that evaluated delay time; clinical features; and administrative factors. Results: The median delay time was 127 hours, the median age was 81 years, the most frequent characteristics were female sex (67.3 %), intertrochanteric fracture (59.6 %), internal fixation surgery (72 %), urinary tract infection (23.1 %) as complication and arterial hypertension (50 %) as comorbidity. Significant difference was found with urinary tract infection, non-specific disorientation, bed availability, type of surgery and times until the application of surgical risk. Conclusions: The delay time of the surgical treatment of the Hospital Regional Lambayeque is 127 hours, the related characteristics were urinary tract infection, non-specific disorientation, bed availability, type of surgery and the time until the application of surgical risk.