Early Surgery Group Research Articles

Research in brief

Early pancreatic drainage surgery could be recommended for patients with chronic pancreatitis, according to results of the ESCAPE trial. Yama Issa and colleagues randomly assigned patients with chronic pancreatitis, a dilated main pancreatic duct, and who had recently started using prescribed opioids for severe pain to receive pancreatic drainage surgery within 6 weeks (n=44) or to the standard endoscopy-first approach, including lithotripsy if required, and surgery if required (n=44). At 18 months, a lower Izbicki pain score was observed in the early surgery group compared to the endoscopy-first group (37 vs 49; between-group difference −12 points [95% CI −22 to −2]; p=0·02). In the early surgery group, complete or partial pain relief was achieved in 23 (58%) of 40 patients compared with 16 (39%) of 41 in the endoscopy-first group (p=0·10). Adverse events were similar between groups.

Efficacy of Early Decompression Surgery Versus Epidural Injection in Management of Sciatica Due to Lumbar Disc Herniation–A Randomised Control Trial

Introduction: Sciatica is one of the most excruciating type of pain resulting due to irritation of the sciatic nerve in the lower back. Pain radiates along the distribution of the sciatic nerve in the lower limb. Lumbar disc herniation is commonly implicated as a cause of sciatica. Treatment options include initial conservative approach with epidural injection and analgesics and in patients with no relief decompression surgery performed. The short-term efficacy of the epidural injections is well established but the long-term outcome remains controversial. Even, spinal decompression surgeries have shown significant relief of symptoms at short term but in long term remain doubtful. This study attempts to compare both these treatment options in people with disabling chronic sciatic pain. Materials and Method: This prospective randomized controlled trial conducted on 25 patients for duration of 1 year with sciatica symptoms lasting for more than 6 weeks. Complete history and examination with imaging studies was carried out with pain assessment done by using a Roland Disability Questionnaire (RDQ) and Visual Analogue Scale (VAS). Follow up Assessment of the patient’s were done at regular interval of 0, 2, 4, 12, 26, 52 weeks post intervention. Results: Of the 25 patients 12 were assigned randomly to early surgery group and 13 to epidural injection group. Immediate post-op and follow up assessment showed significant improvement in pain and disability scores for patients randomized to early surgery group with a significant difference between areas under the curve. The short-term benefit of early surgery was no longer significant by 6 months and by the end of 1 year outcomes were similar between the two groups. Conclusion: Early surgery achieved more rapid relief of sciatica than conservative care, but outcomes were similar by one year in patients of both groups.

Timing of conversion surgery in stage IV gastric cancer

Background: Conversion surgery is performed when unresectable gastric cancer is changed to be resectable by chemotherapy. There are the unresectable factors of tumor invasion of adjacent structure (T4b), peritoneal metastasis (P1), hepatic metastasis (H1), distant metastasis (M1), positive peritoneal cytology (CY1). This study was aimed to define the optimal time for operation in conversion therapy by comparing the difference of survival rate between the early conversion surgery group and the late conversion surgery group in the patients with stage IV gastric cancer which was equally down-staged by initial palliative chemotherapy and fulfill the criteria for surgical resection.

Effect of Early Surgery vs Endoscopy-First Approach on Pain in Patients With Chronic Pancreatitis

For patients with painful chronic pancreatitis, surgical treatment is postponed until medical and endoscopic treatment have failed. Observational studies have suggested that earlier surgery could mitigate disease progression, providing better pain control and preserving pancreatic function. To determine whether early surgery is more effective than the endoscopy-first approach in terms of clinical outcomes. The ESCAPE trial was an unblinded, multicenter, randomized clinical superiority trial involving 30 Dutch hospitals participating in the Dutch Pancreatitis Study Group. From April 2011 until September 2016, a total of 88 patients with chronic pancreatitis, a dilated main pancreatic duct, and who only recently started using prescribed opioids for severe pain (strong opioids for ≤2 months or weak opioids for ≤6 months) were included. The 18-month follow-up period ended in March 2018. There were 44 patients randomized to the early surgery group who underwent pancreatic drainage surgery within 6 weeks after randomization and 44 patients randomized to the endoscopy-first approach group who underwent medical treatment, endoscopy including lithotripsy if needed, and surgery if needed. The primary outcome was pain, measured on the Izbicki pain score and integrated over 18 months (range, 0-100 [increasing score indicates more pain severity]). Secondary outcomes were pain relief at the end of follow-up; number of interventions, complications, hospital admissions; pancreatic function; quality of life (measured on the 36-Item Short Form Health Survey [SF-36]); and mortality. Among 88 patients who were randomized (mean age, 52 years; 21 (24%) women), 85 (97%) completed the trial. During 18 months of follow-up, patients in the early surgery group had a lower Izbicki pain score than patients in the group randomized to receive the endoscopy-first approach group (37 vs 49; between-group difference, -12 points [95% CI, -22 to -2]; P = .02). Complete or partial pain relief at end of follow-up was achieved in 23 of 40 patients (58%) in the early surgery vs 16 of 41 (39%)in the endoscopy-first approach group (P = .10). The total number of interventions was lower in the early surgery group (median, 1 vs 3; P < .001). Treatment complications (27% vs 25%), mortality (0% vs 0%), hospital admissions, pancreatic function, and quality of life were not significantly different between early surgery and the endoscopy-first approach. Among patients with chronic pancreatitis, early surgery compared with an endoscopy-first approach resulted in lower pain scores when integrated over 18 months. However, further research is needed to assess persistence of differences over time and to replicate the study findings. ISRCTN Identifier: ISRCTN45877994.

Optimal Timing of Extracranial-Intracranial Bypass with Microsurgical Trapping for Ruptured Blister Aneurysms of the Internal Carotid Artery

Ruptured blister aneurysms of the internal carotid artery are challenging to treat because of their difficult diagnosis and the fragility of the wall structure. Here, we sought to clarify the efficacy of extracranial-intracranial bypass followed by trapping (bypass/trapping) for ruptured blister aneurysms. A retrospective study identified 45 patients with ruptured blister aneurysms between 1998 and 2017. Our principle was to attempt bypass/trapping as early as possible after diagnosis (early surgery). If early diagnosis was difficult, patients underwent elective surgery in the later stage when aneurysms were detected (elective surgery). Patient characteristics, radiologic findings, clinical course, and outcomes were analyzed. Forty-three patients were treated by bypass/trapping. Twenty-eight patients were classified as early surgery and 15 as elective surgery. Two patients experienced fatal rebleeding and did not undergo surgery. All 15 patients in the elective surgery group showed rebleeding and/or aneurysmal growth while awaiting surgery. In the elective surgery group, 10 aneurysms were missed initially by catheter angiography. In the early surgery group, 9 patients were assessed by vessel wall magnetic resonance imaging, which showed circumferential enhancement along the aneurysm wall, most of which was shown as only a small bulge in the angiography. Postoperative rebleeding did not occur in any of the patients. Bypass/trapping is effective to prevent rebleeding. Early surgery may be beneficial, because most patients in the elective surgery group showed rebleeding or aneurysmal growth. Vessel wall magnetic resonance imaging is a useful adjunct for early diagnosis and may contribute to prompt early surgery.

Early Surgery or Conservative Care for Asymptomatic Aortic Stenosis

BackgroundThe timing and indications for surgical intervention in asymptomatic patients with severe aortic stenosis remain controversial.MethodsIn a multicenter trial, we randomly assigned 145 asymptomatic patients with very severe aortic stenosis (defined as an aortic-valve area of ≤0.75 cm2 with either an aortic jet velocity of ≥4.5 m per second or a mean transaortic gradient of ≥50 mm Hg) to early surgery or to conservative care according to the recommendations of current guidelines. The primary end point was a composite of death during or within 30 days after surgery (often called operative mortality) or death from cardiovascular causes during the entire follow-up period. The major secondary end point was death from any cause during follow-up.ResultsIn the early-surgery group, 69 of 73 patients (95%) underwent surgery within 2 months after randomization, and there was no operative mortality. In an intention-to-treat analysis, a primary end-point event occurred in 1 patient in the early-surgery group (1%) and in 11 of 72 patients in the conservative-care group (15%) (hazard ratio, 0.09; 95% confidence interval [CI], 0.01 to 0.67; P=0.003). Death from any cause occurred in 5 patients in the early-surgery group (7%) and in 15 patients in the conservative-care group (21%) (hazard ratio, 0.33; 95% CI, 0.12 to 0.90). In the conservative-care group, the cumulative incidence of sudden death was 4% at 4 years and 14% at 8 years.ConclusionsAmong asymptomatic patients with very severe aortic stenosis, the incidence of the composite of operative mortality or death from cardiovascular causes during the follow-up period was significantly lower among those who underwent early aortic-valve replacement surgery than among those who received conservative care. (Funded by the Korean Institute of Medicine; RECOVERY ClinicalTrials.gov number, NCT01161732.)

Early surgical intervention among patients with acute central cord syndrome is not associated with higher mortality and morbidity

Conflicting reports exist regarding mortality and morbidity of early surgical decompression in the setting of acute central cord syndrome (ACS) in multisystem trauma despite evidence of improved neurological outcomes. Consequently, optimal decompression timing in ACS in multisystem trauma patients remains controversial. This study aims to determine the association between early surgery for acute traumatic central cord and all-cause mortality among multisystem trauma patients in the National Trauma Data Bank (NTDB) using propensity score matching. We used the NTDB (years 2011-2014) to perform a retrospective cohort study, which included patients >18 years, with ACS (identified using ICD-9 coding). Collected patient data included demographics, surgery timing (≤24 hours, >24 hours), injury mechanism, Charlson comorbidity index (CCI), injury severity score (ISS), serious adverse events (SAE). Logistic regression and propensity matching were used to investigate the relationship between surgery timing and subsequent inpatient mortality. We identified 2,379 traumatic ACS patients. This group was 79.3% male with an average age of 56.3±15.2. They had an average ISS of 19.5±9.0 and mortality rate of 3.0% (n=72). A total of 731 (30.7%) patients underwent surgery for ACS within 24 hours. Univariate analysis did not show a significantly higher mortality rate in the early versus late surgery groups (3.8% vs. 2.7%, P=0.127). In unadjusted models, early surgery was not predictive of death or SAE + death in full (P=0.129, P=0.140) or matched samples (P=0.137, P=0.280). In models adjusted for age, ISS, and CCI, early surgery was predictive of death and SAE + death using the full sample (P=0.013, P=0.027), but not when using the propensity matched sample (P=0.107, P=0.255). Early surgical intervention does not appear to be associated with increased mortality among ACS patients unlike previously suggested. We theorize that survival noted within the NTDB is confounded by factors including existing comorbidities and multisystem trauma, rather than surgical timing. Delaying definitive surgical care may predispose patients to worsened greater neurological morbidity.

Microsurgery for Brachial Plexus Injury Before Versus After 6 Months of Age: Results of the Multicenter Treatment and Outcomes of Brachial Plexus Injury (TOBI) Study.

Infants with more severe brachial plexus birth injury (BPBI) benefit from primary nerve surgery to improve function. The timing of the surgery, however, is controversial. The Treatment and Outcomes of Brachial Plexus Injury (TOBI) study is a multicenter prospective study with the primary aim of determining the optimal timing of this surgical intervention. This study compared outcomes evaluated 18 to 36 months after "early" microsurgery (at <6 months of age) with the outcomes of "late" microsurgery (at >6 months of age). Of 216 patients who had undergone microsurgery, 118 were eligible for inclusion because they had had a nerve graft and/or transfer followed by at least 1 physical examination during the 18 to 36-month interval after the microsurgery but before any secondary surgery. Patients were grouped according to whether the surgery had been performed before or after 6 months of age. Postoperative outcomes were measured using the total Active Movement Scale (AMS) score as well as the change in the AMS score. To address hand reinnervation, we calculated a hand function subscore from the AMS hand items and repeated the analysis only for the subjects with a Narakas grade of 3 or 4. Our hypothesis was that microsurgery done before 6 months of age would lead to better clinical outcomes than microsurgery performed after 6 months of age. Eighty subjects (68%) had early surgery (at a mean age of 4.2 months), and 38 (32%) had late surgery (at a mean age of 10.7 months and a maximum age of 22.0 months). Infants who underwent early surgery presented earlier in life, had more severe injuries at baseline, and had a significantly lower postoperative AMS scores in the unadjusted analysis. However, when we controlled for the severity of the injury, the difference in the AMS scores between the early and late surgery groups was not significant. Similarly, when we restricted our multivariable analysis to patients with a Narakas grade-3 or 4 injury, there was no significant difference in the postoperative AMS hand subscore between the early and late groups. This study suggests that surgery earlier in infancy (at a mean age of 4.2 months) does not lead to better postoperative outcomes of BPBI nerve surgery than when the surgery is performed later in infancy (mean age of 10.7 months). Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Impact of Surgical Timing and Approaches to Health Care Utilization in Patients Undergoing Surgery for Acute Traumatic Cervical Spinal Cord Injury.

ObjectiveAcute traumatic cervical spinal cord injury (AcSCI) causes significant morbidity and has an impact on health care utilization. The aim of our study was to analyze health care utilization in patients undergoing surgical decompression and fusion for AcSCI based on timing and type of surgical approaches. Patient and methodsData were extracted using ICD9/10 and CPT codes from MarketScan (IBM Corp. Armonk, New York [v. 2000-2015]). We defined the comparative groups based on the timing of surgery (early <24 hours and late >24 hours) and surgical approaches: anterior, posterior and circumferential. Outcomes of interest were: length of hospital stay, discharge disposition and health care utilization in the index hospitalization, within 30 days after discharge and 12 months following injury.ResultsOf 1604 patients, 80.9% had early procedures and 55.7% of these had anterior-only procedures. Overall, the median age was 46 years in the early surgery group and 47 years in the late surgery group. Patients in the early surgical group incurred higher outpatient services and there was no difference in cumulative median payments (index + 12 months) across the cohorts (early: $127,379, late: $121,049). The incidence of repeat surgery at the index level did not differ based on the timing of surgery (early 5% vs. late 7%). Complications were higher in the circumferential surgery cohort irrespective of the timing of surgery. Overall, combined median payment (index hospitalization + 12 months) was significantly higher for early circumferential cohorts compared to the anterior or posterior-only cohort ($195,990 and $109,977 vs. $121,236 respectively).ConclusionLate (>24 hours) surgeries were associated with a higher likelihood to be discharged home, lower utilization of outpatient services, higher hospital readmissions and no differences in payments (index and cumulative) compared to early surgeries. Circumferential approaches were associated with higher complication rates, lesser likelihood to be discharged home, higher utilization of outpatient services compared to anterior-only approaches.

Gender differences and temporal trends over two decades in acromegaly: a single center study in 112 patients.

To evaluate the impact of gender and year at surgery on clinical presentation and postoperative outcomes in acromegaly. Retrospective review of patients operated between 1994 and 2016 to compare presentation and outcomes in groups defined by gender and year of surgery. Kaplan-Meier survival analyses with a composite endpoint (recurrence, reoperation, and radiation) were used for gender comparison and Youden indices for biochemical remission rates changes during study period. Primary indications for evaluation were phenotype, neurological symptoms, incidentaloma, hypogonadism, and galactorrhea. At surgery, men (N = 54) were younger (43.6 ± 12.7 years) than women (N = 58, 48.7 ± 12.3, P = 0.04). Male:female ratios before and after age 50 were 1.4 and 0.6 respectively. Men had higher mean IGF-1 levels (874 ± 328 vs 716 ± 296, P < 0.01) and smaller tumors (1.8 ± 1.3 cm vs 2.3 ± 1.5, P = 0.04). Postoperative remission rates were comparable (51% men, 56% women) and inversely associated with cavernous sinus invasion and GH levels. Women had longer mean follow-up (5.2 ± 3.4 years vs 3.6 ± 3.6 men, P = 0.02) and longer endpoint-free survival (P < 0.01). At last follow-up, 89.6% women and 70% men had normal IGF-1 levels (P = 0.03). Postoperative remission rates were higher in patients operated after February 15, 2011 (67.35 vs 43.5% previously, P = 0.01). In late vs early surgery group, physical changes as main indication for screening decreased (54 vs 30%, P < 0.01), while incidentaloma and hypogonadism increased. Median GH levels were lower in late vs early surgery group (P = 0.03). We demonstrate gender-specific characteristics and an evolving spectrum of clinical presentation with implications for earlier diagnosis and personalized management of acromegaly.

Extended time interval between diagnosis and surgery does not improve the outcome in patients operated for resection or ablation of breast cancer liver metastases

BackgroundBreast cancer liver metastases (BCLM) is considered a systemic disease with poorly defined selection criteria for surgery and little evidence for the appropriate timing of surgery. MethodsPostoperative outcomes of patients operated for BCLM were retrospectively reviewed and compared based on the timing of surgery, with the early surgery (ES) group treated ≤12 months after BCLM diagnosis, and late surgery (LS) group operated >12 months after diagnosis. ResultsSeventy-two patients with BCLM underwent liver surgery, including 37 and 35 in the ES and LS groups, respectively. Demographic and preoperative characteristics were similar between the groups, except that multifocal liver disease was more frequent in the LS group (p = 0.008). The LS group had a morbidity rate of 38%, compared to 11% in the ES group (p = 0.015). No postoperative deaths occurred. In the whole cohort, median progression-free (PFS) and overall survival (OS) were 19 and 50 months, respectively, and 1-, 3- and 5-year PFS and OS were 63%, 41%, 24% and 93%, 66%, 43%, respectively, with no significant difference observed between the ES and LS groups. Multivariate analysis revealed that breast cancer progesterone receptor negativity (HR = 3.34, p = 0.03) and a size of LM > 40 mm (HR = 3.11, p = 0.01) were significant negative prognostic factors for PFS. Only a size of LM > 40 mm (HR = 2.79, p = 0.008) was significantly associated with shorter OS. ConclusionA prolonged preoperative observational period does not improve long-term outcomes after liver surgery in patients with resectable BCLM, suggesting that early management can safely be proposed to those patients, with good oncological outcomes.

The Efficacy of Hyaluronidase in Early Surgery of Nasal Bone Fracture.

A nasal bone fracture is one of the most common facial injuries and is often treated by closed reduction. Typically, 2 to 3 weeks are needed for patients to return to daily life because the operation is performed after swelling around the fracture site is reduced. This study aimed to investigate that hyaluronidase injection could reduce swelling, perform early operation and return to daily life accelerated.From January 2017 to December 2017, 181 patients with nasal bone fracture were analyzed. 60 patients underwent hyaluronidase injection and massage to reduce edema, then performed surgery within 2 to 4 days. The remaining patients were treated conservatively (massage alone); they then underwent surgery. Ultrasonography was used to measure changes in skin thickness, and the treatment duration, outcome, and patient satisfaction were compared.The duration from injury to surgery was short in the early operation group, and the period of recovery and return to ordinary life was significantly shorter than in the conventional group. The difference in skin thickness after hyaluronidase injection and massage was 0.8 mm in the early operation group; there was no significant difference in the conventional group. There was no statistically significant difference in satisfaction between the 2 groups, but the mean satisfaction was higher in the early operation group.In patients with nasal bone fracture after facial trauma, hyaluronidase injection, and massage led to reduced edema. This might improve patient satisfaction by allowing earlier operation and earlier return to daily life.

Early Versus Late Surgical Decompression for Acute Spinal Cord Injury: An Individual Patient Data Meta-Analysis of 1548 Patients

Abstract INTRODUCTION We sought to leverage the statistical power derived from pooling 4 high-quality prospective datasets to compare sensorimotor recovery with early (&lt; 24 hr) vs late (≥ 24 hr) surgical decompression for acute traumatic spinal cord injury (SCI). METHODS Patients with acute SCI who underwent surgical decompression were identified from 4 prospective, multi-center SCI datasets (NACTN, STASCIS, Sygen, and NASCIS III). Patients were dichotomized into early (&lt; 24 hr) and late (≥ 24 hr) surgery groups. The primary end point was change in ASIA motor score (AMS) at 1-yr. Secondary outcomes included AIS grade and change in ASIA light touch and pin prick scores at 1-yr. One-stage meta-analyses for each outcome were performed by hierarchical mixed-effects regression using a stratified intercept to account for clustering of patients within studies. Fixed-effect covariates were specified for baseline score, age, injury mechanism, AIS grade, neurological level, and steroids. The treatment (early vs late surgery) was specified as a random-effect. RESULTS A total of 1548 patients were eligible. The early surgery group experienced greater improvement than the late surgery group at 1-yr for AMS (MD 4.0, 95% CI 1.7-6.2, P = .001), light touch score (MD 4.6, 95% CI 1.9-7.2, P = .001), and pin prick score (MD 4.2, 95% CI 1.5-6.9, P = .003). Further, on ‘shift analysis’, the early surgery group achieved a more favorable distribution of AIS grades at 1-yr compared to the late surgery group (cOR 1.46, 95% CI 1.14-1.87, P = .003). The effect of early surgery was strongest for cervical SCI (P = .003); however, we observed a trend toward improved recovery with early versus late surgery for thoracic SCI as well (MD 5.2, 95% CI -0.8-11.2, P = .088). CONCLUSION In an individual patient data meta-analysis adjusting for potential confounders, we found early surgery, within 24 hr of injury, to be associated with superior sensorimotor recovery at 1-yr following acute SCI, as compared to late surgery.

Early Versus Late Surgical Decompression for Central Cord Syndrome: A Propensity Score-Matched Analysis

Abstract INTRODUCTION The optimal timing of surgical decompression for central cord syndrome (CCS) remains unclear. We sought to perform a head-to-head comparison of the neurological and functional outcomes of early (&lt;24 h) vs late (≥24 h) surgical decompression in patients with CCS. METHODS Patients who underwent surgery for CCS (AIS grade C or D; LEMS UEMS ≥ 5) were identified from 3 prospective, multi-center SCI datasets (NACTN SCI Registry; STASCIS; NASCIS III). Propensity scores were calculated as the probability of undergoing early (&lt;24 h) versus late (≥24 h) surgery using the logit method with age, injury mechanism, data source, and initial ASIA motor score, AIS grade, and neurological level as covariates. Propensity score matching (nearest neighbor) was performed in a 1:1 ratio. The primary outcome was ASIA motor score at 1 yr. Secondary outcomes included Functional Independence Measure (FIM) motor score at 1 yr. Outcomes were compared between study groups by t-test. Effect sizes for each outcome measure were summarized by mean differences (MDs). RESULTS A total of 300 patients were eligible. Propensity score matching produced a final cohort of 186 patients (N = 93 early surgery; N = 93 late surgery). Patient demographic, injury, and treatment characteristics at baseline were balanced between matched early and late surgery groups. ASIA motor score at 1 yr was significantly higher in the early surgery (mean: 91.8) compared to late surgery (mean: 87.1) group (MD 4.64, 95% CI 0.19 to 9.09, P = .04). Similarly, patients who underwent early (mean: 84.2) as opposed to late (mean: 77.2) surgery achieved better functional status at 1 yr, as measured by the FIM motor score (MD 7.04, 95% CI 0.59 to 13.49, P = .03). CONCLUSION In patients with CCS, we found early surgery, within 24 h of injury, to result in improved neurological and functional outcomes at 1 yr, as compared to late surgery, after adjusting for key potential confounders by a propensity score matching technique.

When Does an Incidental Chiari I Malformation Require Surgery? A 10-Year Prospective Study on the Evolution and Natural History

Abstract INTRODUCTION The optimal management of incidental CM-I remains elusive, in part, due to a lack of understanding of its natural history. Despite recent efforts, most studies are limited by their retrospective design, small sample size, and variable follow-up as well as indication for surgery. We present a large-scale, long-term, prospective study of the natural history of incidental CM-I in pediatric patients. METHODS A single-institution, prospective review of patients with incidental CM-I was performed from 2008 to 2018. CM-I was defined as “incidental” when it was discovered during workup for an unrelated indication in an otherwise asymptomatic individual. Patients were stratified into observation only, early surgery (&lt;6 mo from initial diagnosis) or delayed surgery (&gt;6 mo) groups. To observe the evolution of CM-I, a minimum follow-up of 1-yr was set as the inclusion criteria for patients in the observation only cohort. Demographics, radiographic features, clinical presentation and indications for surgery were analyzed to define parameters for conservative management and determine predictors of surgery. RESULTS From 777 CM-I patients, 433 (55.73%) were diagnosed incidentally. A total of 390 (90.1%)were managed conservatively while 43 (9.93%) eventually required surgery at an average duration of 10.6 m from diagnosis.Among the surgical cohort, there was a trend toward early surgery with 90.7% undergoing surgery within 3 yr of initial diagnosis (see Kaplan-Meier analysis). Most patients (76%) in the early surgery group presented with a syrinx at initial presentation compared to only 2 (15%) in the delayed surgery group. The remaining patients manifested progressive symptoms.Predictive factors significantly associated with surgery included syrinx, cervicomedullary kinking and gait abnormality (P &lt; .05). CONCLUSION Incidental CM-I has a relatively benign natural history and can be managed in a conservative fashion in majority of pediatric patients. However, careful and longterm follow-up, particularly during the first 3 yr after diagnosis is critical since 9.9% of patients are likely to experience a change in clinical or radiographic status necessitating surgical intervention.

Efficacy and learning curve of holmium laser enucleation of prostate on patients with benign prostatic hyperplasia

Objective To evalutate the efficacy and learning curve of holmium laser enucleation of prostate on patients with benign prostatic hyperplasia (BPH). Methods We retrospectively analyzed the first 60 surgical cases of a surgeon who was experienced on transurethral resection of prostate (TURP) and newly using holmium laser enucleation of prostate (HoLEP). Participants were divided into three groups (the early surgery group, middle group and late stage group), based on surgical time. There were 20 patients in each group, while the operative duration time, postoperative hemoglobin, urethral catheterization duration time, postoperative hospitalization duration, enucleation efficacy, and the change of hemoglobin were compared. The learning curve was evaluated by enucleation efficacy. Results The early group, middle group and late surgical enucleation of the prostate enucleation time gradually shortened, the efficiency gradually increased, there were statistically significant differences (P 0.05). Conclusions It is available for experienced TURP surgeon to use HoLEP on patients with BPH. As the surgeon become experienced, the enucleation efficacy is satisfied. Key words: Prostatic Hyperplasia; Lasers, Solid-State; Prostatectomy

Surgical Outcome between Early and Delayed Surgery of Extradural Haematoma (EDH) in Closed Head Injury

Background: Surgical management of Extradural Haematoma (EDH) in Closed Head Injury is an essential issue.&#x0D; Objective: The purpose of the present study was to compare the surgical outcome between early and delayed surgery of extradural haematoma (EDH) in closed head injury.&#x0D; Methodology: This comparative cross-sectional study was carried out from January 2010 to June 2011 for a period of one year and six months in the Department of Neurosurgery, Dhaka medical College Hospital, Dhaka, Bangladesh. All patients presented with traumatic head injury having extradural haematoma in any age with both sexes who were underwent surgical management were selected as study population. The patients were categorized into groups designated as group A or early surgery group where operation was done within 24 hours of head injury and group B or delayed surgery group where operation was done after 24 hours to 3 days of head injury. Inclusion of patients in group B was not intentional but due to delayed referral from primary and secondary hospitals of` different parts of' the country. Glasgow coma scale (GCS) was used for initial assessment and Glasgow outcome scale (GOS) was applied to assess outcome in terms of neurological recovery in all patients. General and neurological examinations and findings were recorded. Surgical outcome was noted and recorded in the data collection sheet.&#x0D; Result: Eighty (80) patients of traumatic head injury with EDH operation (EDH operated within 24 hours and after 24 hours of head injury) were enrolled in this study. Mean (±SD) age of the patients of group A and group B was 32.66±16.65 and 33.23±13.38 respectively. In this study the patient's age ranged from 3 years to 64 years. In group A, 6 patients were admitted with GCS (14-15) and 01 patient in group B. With GCS (9~13), 19 patients in group A and 22 patients in group B. With GCS (3-8), 15 patients were admitted in group A and 17 patients in group B. Out of all patients’ good recovery occurred in 80.0% in group A and 45.0% in group B. Moderate disability and severe disability in both group A and group B was 12.5% vs 30% and 7.5% vs 12.5% respectively. Furthermore 5.0% persistent vegetative state and 7.5% death occurred only among the patients of group B (p&lt;0.05). Out of all patients good recovery occurred in 82.6% in group A and 54.0% in group B. Moderate disability and severe disability in both group A and group B was 10.0% vs 27.5% and 7.5% vs 13.51% respectively. 5.41% persistent vegetative state occurred only in patients of group B (p&lt;0.05).&#x0D; Conclusion: In conclusion morbidity and mortality rate can be reduced in patients with EDH by early surgical intervention in better GCS score.&#x0D; Journal of National Institute of Neurosciences Bangladesh, 2019;5(1): 24-28

Early Versus Delayed Surgery Results In Similar Outcomes Following Multiligament Knee Injury; A Prospective Cohort

Objectives: Multiligament knee injuries (MLKI’s) are rare, but life-altering injuries that have significant implications on patients’ functional status, quality of life and return to work and sport. While the treatment of these injuries is far from standardized, there exists good evidence to support operative intervention. Unfortunately there are no guidelines to indicate the ideal timing of surgery after injury to optimize clinical outcomes and patient satisfaction. With that in mind, the aim of this study was to assess injury specific functional outcomes following surgery for MKLIs and identify advantages to early versus delayed surgery. Methods: Between 2006-2017, adults with MLKIs were identified at an academic level 1-trauma center. Patients were enrolled in prospective data collection and followed routinely after surgery. Study participants were stratified into early (&lt;45 days from injury) and delayed surgical intervention (&gt;45 days from injury). The primary analysis was patient reported outcomes in the form of a specific and validated score (MLQOL) to compare early vs delayed surgical intervention. We secondarily analyzed associations between age, gender, BMI, injury severity (Schenck classification), associated nerve injuries, and reoperation rates to our primary outcome measure. Results: A total of 152 patients were identified, with 85 patients in the early group and 67 in the delayed. The mean time to surgery was 16.7 ± 7.9 days in the early group versus 253 ± 132.6 days in the delayed. Average follow-up was 46.7 months. There was no significant difference between groups with respect to age, gender distribution, BMI, injury mechanism, nor severity. The early surgery group was found to include more patients with lateral sided injuries (p=0.010) as well as nerve injuries at initial presentation (p=0.002). The delayed group was found to have more patients with PCL involvement compared to early surgery (P=0.003). We did not identify a significant difference in pain, stiffness, or instability patient reported outcome scores between the early and delayed surgical groups. 49 of the 152 patients underwent a repeat operation (32%) including manipulation under anesthesia, arthroscopic debridement, removal of hardware, revision and/or conversion to total knee arthroplasty. No significant difference was found in reoperation rates between the two groups. In our primary outcome, we did not identify any relationship between early or late surgery and MLQOL scores. In our secondary analysis, using a linear regression model, we determined older age to be independently predictive of poor outcomes with respect to pain (p=0.018), stiffness (p=0.048) and instability (p=0.004) as assessed through MLQOL questionnaire. Conclusion: In our analysis, stratifying patients to early vs delayed surgery had no effect patient reported outcomes following MLKI reconstruction. In the secondary outcome measures, we identified that regardless of time from injury to surgical intervention, older age was independently predictive of poor pain, stiffness, and instability scores in the MLQOL questionnaire. To our knowledge this is the largest prospectively collected dataset of injury specific outcomes in MLKIs. This analysis will allow for an evidence based approach to guide discussion, manage expectations, and predict outcomes of MLKI patients as well as provide the framework for how surgeons manage these significant injuries.

Early or delayed anterior cruciate ligament reconstruction: Is one superior? A systematic review and meta-analysis

BackgroundAnterior cruciate ligament (ACL) reconstruction is a rapidly developing orthopaedic field and an area of notable clinical equipoise. The optimal timing of surgery in an acute (< 3 weeks) or delayed (≥ 3 weeks) time frame remains unresolved with a 2010 meta-analysis concluding no difference between these two groups across multiple outcomes. In an era of evidence-based medicine, surgeons are still basing their decisions on when to operate on little more than anecdotal evidence and personal preference. Clear guidance is required to determine whether the timing of surgery can optimise outcomes in this largely young and active patient cohort.MethodsA systematic literature search was performed in January 2018 of Embase, Medline and OpenGrey in accordance with (PRISMA) guidelines. A total of 658 articles were retrieved, with 6 suitable for inclusion, covering 576 ACL reconstructions. Four meta-analyses were performed assessing subjective measures of Tegner activity scale and Lysholm score, and objective measures of arthroscopically identified meniscal and chondral injury. Additional relevant outcome measures underwent narrative review. Study bias was assessed and reported using the Downs and Black checklist.ResultsA statistically significant difference of 0.39 points was found on the Tegner activity scale in favour of early surgery within 3 weeks (RR 0.39, CI 0.10, 0.67, p = 0.008). No statistically difference was found between groups for the patient-reported Lysholm score (RR − 0.18, CI − 2.40, 2.05, p = 0.17). There was no statistically significant difference between groups for intra-operative findings of meniscal lesions (RR 0.84, CI 0.66, 1.08, p = 0.17). A trend towards significance was observed for the incidence of chondral lesions in the early surgery group (RR 0.56, CI 0.31, 1.02, p = 0.06). All the studies were rated either fair or good on the Downs and Black checklist with no study excluded due to bias.ConclusionsAlthough there was a statistically significant result for the Tegner activity scale in favour of early surgery, the magnitude of the effect is unlikely to translate into any clinically meaningful difference. At present, there remains no clear evidence to determine superiority of acute/early or delayed reconstruction of a ruptured anterior cruciate ligament. Further research through methodologically robust randomised controlled trials or through the UK National Ligament Registry may help to provide clearer guidance.

Long-term impact of pediatric endoscopic endonasal skull base surgery on midface growth.

Cranial base development plays a large role in anterior and vertical maxillary growth through 7 years of age, and the effect of early endonasal cranial base surgery on midface growth is unknown. The authors present their experience with pediatric endoscopic endonasal surgery (EES) and long-term midface growth. This is a retrospective review of cases where EES was performed from 2000 to 2016. Patients who underwent their first EES of the skull base before age 7 (prior to cranial suture fusion) and had a complete set of pre- and postoperative imaging studies (CT or MRI) with at least 1 year of follow-up were included. A radiologist performed measurements (sella-nasion [S-N] distance and angles between the sella, nasion, and the most concave points of the anterior maxilla [A point] or anterior mandibular synthesis [B point], the SNA, SNB, and ANB angles), which were compared to age- and sex-matched Bolton standards. A Z-score test was used; significance was set at p < 0.05. The early surgery group had 11 patients, with an average follow-up of 5 years; the late surgery group had 33 patients. Most tumors were benign; 1 patient with a panclival arteriovenous malformation was a significant outlier for all measurements. Comparing the measurements obtained in the early surgery group to Bolton standard norms, the authors found no significant difference in postoperative SNA (p = 0.10), SNB (p = 0.14), or ANB (0.67) angles. The S-N distance was reduced both pre- and postoperatively (SD 1.5, p = 0.01 and p = 0.009). Sex had no significant effect. Compared to patients who had surgery after the age of 7 years, the early surgery group demonstrated no significant difference in pre- to postoperative changes with regard to S-N distance (p = 0.87), SNA angle (p = 0.89), or ANB angle (p = 0.14). Lesion type (craniopharyngioma, angiofibroma, and other types) had no significant effect in either age group. Though our cohort of patients with skull base lesions demonstrated some abnormal measurements in the maxillary-mandibular relationship before their operation, their postoperative cephalometrics fell within the normal range and showed no significant difference from those of patients who underwent operations at an older age. Therefore, there appears to be no evidence of impact of endoscopic endonasal skull base surgery on craniofacial development within the growth period studied.