Durability Of Repair Research Articles

OC-061 IMAGE-BASED DEEP LEARNING MODELS (DLMS) IDENTIFY ABDOMINAL WALL RECONSTRUCTION (AWR) PATIENTS RECEIVING PREOPERATIVE BOTULINUM TOXIN A (BTA) WHO REQUIRE COMPONENT SEPARATION TECHNIQUE (CST)

Abstract Aim Preoperative BTA facilitates muscle/fascia elongation and fascial closure, which increases the durability of hernia repair and may reduce requirement for CST. The aim of this study was to develop image-based DLMs that predict whether patient will require CST if injected with BTA prior to surgery. Methods An institutional database was used to identify AWR patients who received preoperative BTA and had preoperative CT imaging. Axial CT cuts of the hernias were rendered to train and develop a DLM. The primary outcome was a ROC for predicting CST. The DLM was tested on CT scans from a pre-identified subset of patients who underwent CST and did not receive preoperative BTA. Results There were 116 patients who met criteria (4,580 CT images). Of these patients, 69 (59.5%) required CST (2884 images); 47 patients (40.5%) did not undergo CST (1,696 images). The DLM ROC was 0.78 (Figure 1); accuracy, sensitivity, and specificity were 0.79, 0.86, and 0.68, respectively. There were 98 patients in the test set; 57 (58.1%) were predicted to require CST and 41 (41.9%) were not. For patients with an M1 hernia component, 21.1% were predicted to be spared CST versus 46.8% those with an M2-M5 hernia component (p=0.04). Figure 1 Model Performance for CST Prediction Conclusions Image-based DLMs accurately predicted which patients receiving preoperative BTA may require CST. When the DLM was applied to a test set, patients with an M1 hernias were very likely to require CST, which is consistent with previously reported data, further validating the model.

P-121 RETROSPECTIVE REVIEW OF PRACTICE AND OUTCOMES USING A SINGLE BRAND BIOLOGIC MESH AT A DISTRICT GENERAL HOSPITAL

Abstract Aim A retrospective review of all operated hernia patients in which a single brand of Biologic mesh was used, since it's first introduction in our Trust and to date, has been conducted. During last almost 5 years, twelve patients were identified and included. All patients operated with any other type of Biologic mesh and all patients operated with synthetic meshes were excluded, as the aim of the study was to look at the efficiency of a particular product, which was the cheapest biologic mesh at the time of contract with our Hospital. Material and Methods Retrospective review of patient's notes and outcomes, including post-op follow-up and long-term follow-up. The study looked at the following criteria: indication of use as per VHWG (ventral hernia working group) classification of the patients, LOS (length of stay) compared with patients operated with synthetic mesh, any post-op complications including SSO/SSI (surgical site occurrence and/or infection) and outcome at follow-up to date, including recurrence, chronic pain or mesh infection. Results The biologic mesh studied proved itself as a reliable product and provided a durable repair in the cases where it was used. It was noticed that majority of the cases were emergency presentations for complicated ventral or inguinal hernias, the complexity of the cases compared with elective cases being higher (higher ASA grade patients, non-optimised etc). Conclusions The outcome of the study recommends to continue utilising this product, as efficient and financially competitive.

Too big to fail?-An aggressive strategy for a dire problem.

Tracheo-innominate fistula (TIF) is a reported complication of tracheostomy that typically presents with a herald bleed. The phenomenon of an aortotracheal fistula has similar pathology and presentation to TIF, but no standard surgical repair. In the manuscript by Musgrove et al. in the Journal of Cardiac Surgery, the authors propose a surgical treatment that is reproducible for the correct anatomic configuration-an ascending and aortic arch replacement, pericardial patch of the tracheal defect, and omental flap coverage. While this intervention is a large undertaking for a small defect, it is a safe and durable repair.

Clinical and echocardiographic predictors of the anterior mitral leaflet repair failure

Anterior mitral leaflet prolapse repair is a highly effective procedure, but despite excellent operative results still has an inferior long-term durability when compared to posterior leaflet repair. We analysed mitral repair durability in 74 consecutive patients operated for anterior leaflet prolapse between 2010 and 2021. Their pre- and postoperative clinical, echocardiographic data and repair durability as well, were compared with74 randomly assigned posterior leaflet prolapse patients who underwent valve repair during the same period. While groups were of similar age, patients with anterior leaflet prolapse had an inferior preoperative status in terms of functional reserve, atrial fibrillation, operative risk, ejection fraction and had more dilated left heart chambers as well. 1, 5, and 10-year freedom from repair failure was 87.1 ± 4.6%, 79.8 ± 6.5% and 50.7 ± 12.5% in the anterior, and 98.5 ± 1.5% respectively in the posterior leaflet group. Atrial fibrilation (hazard ratio [HR]5.365; 95%; confidence interval[CI] 1.093-26.324 p = .038) and left ventricle end-systolic diameter (HR 1.160 95%; CI 1.037-1.299 p = .010) independently predicted anterior leaflet repair failure. Receiver Operating Curve analysis established left ventricle end-systolic diameter ≤42 mm as a cut-off value associated with improved anterior leaflet repair durability. Accordingly, 10-year repair durability in a subset of patients, with preserved left ventricle end-systolic diameter (≤42 mm) was 86.4 ± 7.8%. Better long-term repair durability in patients with anterior mitral leaflet prolapse and preserved sinus rhytm and left-ventricle diameters justifies early reconstructive approach.

Artificial chordae for mitral valve repair.

Mitral valve repair using expanded polytetrafluoroethylene sutures to replace mitral chordae tendineae is a well-established procedure. However, the incidence of neo-chordae failure causing recurrent mitral regurgitation is not well defined. We have reviewed the reported cases of complications after mitral valve repair related to the use of neo-chordae. This study was mainly carried out through PubMed, Medline, and Google Chrome websites. We have identified a total of 26 patients presenting with rupture of polytetrafluoroethylene neo-chordae, mostly being described as isolated cases. Few other cases of recurrent mitral regurgitation with hemolysis were found, where reoperation was not caused by neo-chordal failure but most likely by technical errors. At pathological investigation the findings were substantially similar in all reported cases. The neo-chordae retained their length and pliability, became covered with host tissue and rupture was mainly related to suture size. Mild calcification was observed not interfering with chordal function; chordal infection did never occur. The use of artificial neo-chordae provides excellent late results with durable mitral valve repair stability. Chordal rupture may occur late postoperatively leading to reoperation because of recurrent mitral regurgitation. Despite its rarity, this potential complication should not be overlooked during follow-up of patients after mitral valve repair using artificial neo-chordae.

Fifteen-Year Outcomes After Valve-Sparing Aortic Root Remodelling or Exclusion of the Non-Coronary Sinus: When to Preserve the Sinuses of Valsalva?

Isolated exclusion of the non-coronary sinus (NCS) is an attractive strategy in valve-sparing aortic root surgery, which avoids the mobilisation and re-implantation of coronary ostia. However, the long-term durability of aortic valve repair and the fate of remnant sinuses of Valsalva remain unclear. From January 2006 to December 2013, 29 patients underwent replacement of the ascending aorta extending to the NCS (group NCS) and 56 patients underwent a modified Yacoub procedure (group MY) in our centre by a single surgeon. Significant difference of preoperative parameters was observed between two groups in the presence of bicuspid aortic valve (41.4% vs 12.5%, p=0.002) and the diameter of the sinus of Valsalva (47.3±4.7 mm vs 51.5±4.9 mm, p=0.01). The group NCS, as compared to the group MY, was associated with significantly shorter cardiopulmonary bypass time (106.6±40.5 min vs 138.4±37.5 min, p=0.001) and aortic cross clamping time (69.0±21.8 min vs 105.4±27.8 min, p<0.01). The mean follow-up was 11.5±2.8 years. No surgical re-intervention was performed for aortopathies of the aortic root; the neo-sinus were not dilated in either groups (38.2±4.2 mm vs 34.0±4.0 mm, p<0.01). The 10-year freedom from aortic valve-related re-operation was estimated to be 96.6±3.4% and 94.5±3.1% (p=0.58), and the cumulative 10-year survival rates were 95.2±4.6% and 85.6±4.7% (p=0.61) in the group NCS and the group MY, respectively. Aortic valve-sparing isolated NCS replacement can be safely performed in selected patients; its early outcomes, overall survival and long-term freedom from aortic valve-related or aortopathy-related re-intervention were comparable to those obtained with the Yacoub procedure.

The Role of Suture Tape Augmentation in Lateral Ankle Ligament Reconstruction

The Broström lateral ankle ligament repair is the gold standard for treatment of ankle instability, but there is always the concern that without augmentation the repair might fail over time. There is growing evidence, both from cadaver studies and clinical research, that augmentation with a suture tape construct significantly add to the strength and durability of a standard repair. Not only does it increase the time zero strength, but it also allows for a more aggressive rehabilitation program and earlier return to sports without compromising the primary repair. This chapter will highlight the technique and pointers to improve results while avoiding pitfalls.

Treatment of Secondary Aortoenteric Fistulas Following AORTIC Aneurysm Repair in a Tertiary Reference Center.

Objectives: To present our experience with various therapeutic approaches for the treatment of secondary aortoenteric fistulas following open and endovascular aortic aneurysm repair. Methods and Materials: A retrospective data analysis of patients treated for secondary aortoenteric fistulas in a single vascular institution between January 2005 and December 2018 was performed. Analyzed parameters included patients’ demographics, clinical presentation, diagnostic work-up, perioperative data and repair durability during follow-up. Results: Twenty-three patients with aortoenteric fistulas were treated in the target period. The fistulous connection was located in 21 cases (91.3%) in the duodenum and in two cases (8.7%) in the small intestine. Average time between the initial procedure and detection of the aortoenteric fistula was 69.4 ± 72.5 months. The most common presenting symptom was gastrointestinal bleeding (n = 12, 52.2%), followed by symptoms suggestive of chronic infection (n = 11, 47.8%). Open surgical repair was performed in 19 patients (bridging in 3 patients), and endovascular repair was carried out in two cases and one patient underwent a hybrid operation. One patient underwent abscess drainage due to significant comorbidities. Mean follow-up was 35.1 ± 35.5 months. In-hospital mortality and overall mortality were 43.5% (10/23) and 65.2% (15/23), respectively. Patients presenting with bleeding had a significantly higher perioperative mortality rate in comparison to patients presenting with chronic infection (66.7% (8/12) and 18.2% (2/11), respectively, p = 0.019). Patients who underwent stent-graft implantation for control of acute life-threatening bleeding showed significantly better perioperative survival in comparison to patients that were acutely treated with an open procedure (66.6%, (4/6) and 0% (0/6), respectively, p = 0.014). Perioperative mortality was also higher for ASA IV patients (71.4%, 5/7), when compared to ASA III Patients (31.2%, 5/16), although this did not reach statistical significance (p = 0.074). Conclusion: Treatment of secondary aortoenteric fistulas is associated with a high perioperative mortality rate. Patients who survive the perioperative period following open surgical repair in the absence of hemorrhagic shock show acceptable midterm results during follow-up. Stent-graft implantation for bleeding control in patients presenting with life-threatening bleeding seems to be associated with lower perioperative mortality rates.

Relación entre el volumen quirúrgico y la calidad de la reparación de la insuficiencia mitral severa en centros de referencia

During the last decade, several findings have significantly changed the understanding, prognosis, and management of mitral valve regurgitation including genetic and arrhythmogenic characterization of mitral valve prolapse, new advanced imaging techniques that allow precise quantification and flow analysis, and the adoption and spread of repair techniques. Without doubt, the development of mitral valve repair in reference centers has radically changed the clinical prognosis of patients with severe mitral regurgitation. The key role of these centers is already a reality in every expert consensus, and of course, in every cardiovascular guideline. Particularly if we talk about asymptomatic mitral valve regurgitation. However, the clinical philosophy and structure of reference centers still remain unknown for many physicians. The following aims to clarify and establish every requirement to have a reference center and also demonstrates the strong link between surgical volume and repair durability.

Repair of Bulk-Fill and Nanohybrid Resin Composites: Effect of Surface Conditioning, Adhesive Promoters, and Long-Term Aging.

The aim of the study was to investigate the effect of different repair procedures on the repair bond strength of bulk-fill and nanohybrid resin composites after different aging periods. The resin composite blocks (8 × 8 × 4 mm3) were prepared from a bulk-fill (reliaFIL Bulk) and a nanohybrid (reliaFIL LC) resin composite and grouped according to aging duration (6 months, 1 year, and 2 years). Following aging, the blocks were assigned to different surface treatments; air-abrasion with aluminum oxide powder, roughening with a diamond bur, and no treatment. After cleansing with phosphoric acid, a silane layer (Porcelain Primer) was applied on the surface of half of the specimens in each group. The specimens were subdivided into two groups (n = 5): Scotchbond Universal (3M Oral Care) and All-Bond Universal (Bisco). The blocks were repaired with the nanohybrid composite (8 × 8 × 8 mm 3). The repaired specimens were stored in distilled water (37 °C/24 h) and segmented into beams. Half of the beams were immediately subjected to microtensile μTBS testing (1 mm/min), while the other half was stored in distilled water (37 °C) for 6 months before testing. Failure modes were analyzed using stereomicroscope and SEM. Statistical analyses were performed with ANOVA and least significant difference tests (LSD) tests (p = 0.05). The extension of aging periods (6 months, 1 year, and 2 years) reduced the repair bond strength in some groups for both resin composites (p < 0.05). The air-abrasion and bur roughening improved the repair bond strength (p < 0.05). The silane application did not influence the repair bond strength and durability (p > 0.05). There was no difference among the universal adhesives in the same surface treatment groups (p > 0.05). The mechanical roughening treatments are necessary for the repair of resin composite. The universal adhesives might be used for the repair of resin composites regardless of silane content without prior silane application.

Reply to Jasinski M et al.: “Indeed, there is still room for improvement in long‐term durability of BAV repair”

We read the letter to the editor by Dr Jasinski et al. entitled "Long-term durability of valve-sparing or repair procedures in BAV-Is there room for improvement?" with great interest.

ETEP-RS for incisional hernias in a non-robotic center. Is laparoscopy enough to perform a durable MIS repair of the abdominal wall defect?

IntroductionIncisional hernias can complicate up to 25% of laparotomies, and successful repair remains a significant clinical challenge for surgeons. Recently, the surgical technique of ventral hernia repair (eTEP-RS) has been introduced. The method was presented relatively recently and continues to evolve. The use of a robotic platform in eTEP-RS resulted in a significant improvement in ergonomics. Therefore, the questions arise as to whether the laparoscopic technique might still be feasible for such long procedures. The objective of this study is to present our early results in the treatment of patients with incisional ventral hernias using eTEP-RS and to discuss key technical aspects.Patients and methodsA prospective case-controlled study was conducted for all incisional ventral hernia patients (hernia orifice between 4 and 10 cm) who underwent eTEP-RS between March 2019 and December 2021. Demographic data were recorded; and perioperative and postoperative results were analyzed.ResultsWe performed 34 eTEP-RS procedures. The mean duration of the surgery was 211 min (145–295). The mean width of the defect was 6.8 cm and the defect area was 42.5 cm2. The mean mesh size was 498 cm2 (270–625). After an average follow-up of 16 months (2–30), there was no recurrence or major complication.ConclusionsThe eTEP-RS is a safe alternative to open ventral hernia repair in selected cases and allows for the placement of a large piece of mesh in accordance with current recommendations, even in non-robotic centers. Excellent knowledge of the detailed anatomy of the abdominal wall is essential for safe and effective hernia repair. Compliance with certain rules of the laparoscopic eTEP-RS facilitates improved ergonomics for this procedure even in non-robotic centers.

Tracheobronchoplasty yields long-term anatomy, function, and quality of life improvement for patients with severe excessive central airway collapse

ObjectivesThis study examines the long-term anatomic and clinical effects of tracheobronchoplasty in severe excessive central airway collapse. MethodsIncluded patients underwent tracheobronchoplasty for excessive central airway collapse (2002-2016). The cross-sectional area of main airways on dynamic airway computed tomography was measured before and after tracheobronchoplasty. Expiratory collapse was calculated as the difference between inspiratory and expiratory cross-sectional area divided by inspiratory cross-sectional area ×100. The primary outcome was improvement in the percentage of expiratory collapse in years 1, 2, and 5 post-tracheobronchoplasty. Secondary outcomes included mean response profile for the 6-minute walk test, Cough-Specific Quality of Life Questionnaire, Karnofsky Performance Status score, and St George Respiratory Questionnaire. Repeated-measures analysis of variance was used for statistical analyses. ResultsThe cohort included 61 patients with complete radiological follow-up at years 1, 2, and 5 post-tracheobronchoplasty. A significant linear decrease in the percentage of expiratory collapsibility of the central airways after tracheobronchoplasty was present. Anatomic repair durability was preserved 5 years after tracheobronchoplasty, with decrease in percentage of expiratory airway collapse up to 40% and 30% at years 1 and 2, respectively. The St George Respiratory Questionnaire (74.7 vs 41.8%, P < .001) and Cough-Specific Quality of Life Questionnaire (78 vs 47, P < .001) demonstrated significant improvement at year 5 compared with baseline. Similar results were observed in the 6-minute walk test (1079 vs 1268 ft, P < .001) and Karnofsky score (57 vs 82, P < .001). ConclusionsTracheobronchoplasty has durable effects on airway anatomy, functional status, and quality of life in carefully selected patients with severe excessive central airway collapse.

Angiogenesis in Wound Repair: Too Much of a Good Thing?

Angiogenesis, or the growth of new blood vessels from the preexisting vasculature, is a visible and important component of wound repair. When tissue damage occurs, disruption of the vasculature structure leads to hypoxia. The restoration of normoxia is essential for appropriate and durable tissue repair. Angiogenesis in wounds is regulated by endogenous proangiogenic mediators, which cause rapid growth of a new vascular bed that is much denser than that of normal tissue. Such rapid growth of the capillary bed results in capillaries that are abnormal, and the newly formed vessels are tortuous, dilated, and immature. During wound resolution, this substantial neocapillary bed is pruned back to normal density with attendant maturation. Many poorly healing wounds, including nonhealing ulcers and scars, exhibit an aberrant angiogenic response. The fine-tuning of capillary regrowth in wounds is an area of significant therapeutic potential.

Osteochondral lesions of the talar dome in the athlete: what evidence leads to which treatment

Osteochondral lesions of the talar dome in the athlete: what evidence leads to which treatment

Transoral endoscopic repair of Zenker diverticulum by a thoracic surgical service.

Zenker diverticulum (ZD), a pulsion diverticulum of the esophagus, has been traditionally managed with an open surgical approach, but endoscopic transoral stapling has been reported with increasing frequency. The objective of this study was to evaluate the results of endoscopic repair of ZD by a thoracic surgery service. We conducted a retrospective review of patients who underwent transoral stapling repair of ZD at our institution by the thoracic surgery service. We evaluated perioperative outcomes including dysphagia (1, no dysphagia to 5, unable to swallow saliva) and failure of repair requiring surgical intervention. A total of 151 patients (median age, 78years; 75 men, 76 women) underwent evaluation for endoscopic repair of ZD. Endoscopic stapled repair of the ZD was completed in 135. Sixteen patients underwent conversion to open repair. The perioperative mortality was 0.6% (1 patient). The median hospital stay was 2days (range, 0-18days). Complications occurred in 5 patients who underwent endoscopic repair. The mean preoperative dysphagia score was 2.8 and improved to 1.2 during follow-up (median, 16months; P<.001). During further follow-up (median, 52months), 8 patients (5.3%) had failure of the endoscopic repair requiring open surgery (n=5) or redo transoral stapling (n=3). Endoscopic stapling repair of ZD can be performed safely with good results in experienced centers by thoracic surgeons with significant esophageal experience. Long-term follow-up is required to evaluate the durability of endoscopic repair of ZD.

Study on relative shrinkage of cement-based micro-concrete for durable concrete repair

This paper presents the investigation into the crack formation in micro-concrete due to their bond strength and drying shrinkage under normal and accelerated drying conditions at the interface between the substrate and micro concrete in a concrete repair. Investigated six different cement-based micro-concretes about their grain size, compressive strength, bond strength, and relative shrinkage values due to normal and raised drying temperature. Finite element analysis and microscopic study of crack development at the interface were investigated to strengthen the analysis of the crack developments. It was observed that the bond strength and drying shrinkage of the micro concretes influence the formation of cracks at the interface due to the relative shrinkage of the substrate and the micro concrete. The micro-concrete having high bond strength as compared to low bond strength micro-concrete, exhibits low crack width even though free drying shrinkage values are high in both case. Early detection of cracks at the interface in 3 days due to the combined effect of bond strength and drying shrinkage under accelerated drying conditions can be a helpful tool for selecting the micro concretes for concrete repair.

Debonding of Thin Bonded Rubberised Fibre-Reinforced Cement-Based Repairs under Monotonic Loading: Experimental and Numerical Investigation.

In this study, the durability of cement-based repairs was observed, especially at the interface of debonding initiation and propagation between the substrate–overlay of thin-bonded cement-based material, using monotonic tests experimentally and numerically. Overlay or repair material (OM) is a cement-based mortar with the addition of metallic fibres (30 kg/m3) and rubber particles (30% as a replacement for sand), while the substrate is a plain mortar without any addition, known as control. Direct tension tests were conducted on OM in order to obtain the relationship between residual stress-crack openings (σ-w law). Similarly, tensile tests were conducted on the substrate–overlay interface to draw the relationship between residual stress and opening of the substrate–overlay interface. Three-point monotonic bending tests were performed on the composite beam of the substrate–overlay in order to observe the structural response of the repaired beam. The digital image correlation (DIC) method was utilized to examine the debonding propagation along the interface. Based on the different parameters obtained through the above-mentioned experiments, a three-point bending monotonic test was modelled through finite elements using a software package developed in France called CAST3M. Structural behaviour of repaired beams observed by experimental results and that analysed by numerical simulation are in coherence. It is concluded from the results that the hybrid use of fibres and rubber particles in repaired material provides a synergetic effect by improving its strain capacity, restricting crack openings by the transfer of stress from the crack. This enhances the durability of repair by controlling propagation of the interface debonding.

Renal Complications Following Juxtarenal Aortic Aneurysm Repair Affect Late Survival and Repair Durability

Renal complications following open and endovascular repair of juxtarenal aortic aneurysms are associated with increased postoperative mortality and morbidity. Our objective was to assess the effect of postoperative renal complications on late outcomes following juxtarenal aortic aneurysm repair.

Outcomes Following Urgent Fenestrated-Branched Endovascular Repair for Pararenal and Thoracoabdominal Aortic Aneurysms

To evaluate outcomes following urgent or emergent fenestrated-branched endovascular aortic repair (F-BEVAR) for pararenal (PRA) and thoracoabdominal aortic aneurysms (TAAA) in patients who are considered high-risk for open repair. A retrospective, single institution evaluation of outcomes following F-BEVAR of symptomatic, rapidly enlarging, or ruptured PRA or TAAA treated with physician modified endograft (PMEG) and company manufactured devices (CMD). Outcomes were technical success, 30-day morbidity and mortality, and 1 year aortic related outcomes. Thirty-two patients (23 male, mean age, 74±9years) underwent F-BEVAR using PMEG or CMD over a 12-year period. Fourteen patients underwent emergent repair for contained rupture and 18 patients underwent urgent repair for symptomatic, mycotic, or rapidly growing aneurysms. Aneurysm classification was PRA in 10 patients and TAAA in 22 (9 extent IV and 13 extent I-III). Twenty-three patients (72%) were repaired with PMEG and 8 patients (26%) with CMD. Technical success was 97% with a total of 98 renal-mesenteric arteries incorporated using 67 fenestrations (68%), 29 directional branches (29%), and 2 double-wide scallops (2%). A 30-day mortality was 6%, with 1 patient expiring from unclear causes after hospital discharge and the other from mesenteric ischemia. Mortality and major adverse events MAEs otherwise occurred in 16 patients (50%), including minor stroke in 3 patients, transient paraparesis and heart failure in 1 patient each, and early return to the operating room in 6 patients. Mean follow-up was 24±22months. At 1-year, overall survival, freedom from aortic-related mortality and freedom from secondary intervention were 70%±8%, 94%±3 and 83%±7, respectively. Urgent F-BEVAR of selected patients with PRA and TAAA is a feasible and potentially safe treatment in patients with suitable anatomy, with low rates of early mortality and spinal cord complications. Long-term follow-up is needed to assess the durability of repair and device-related complications.