Failure Of Surgical Treatment Research Articles

Endovascular transcatheter embolization of recurrent postsurgical varicocele: anatomic reasons for surgical failure

Formation or pre-existence of collateral gonadal veins in varicocele patients has been reported as the main cause of surgical treatment failure. To describe venographic findings in patients with postsurgical recurrent varicoceles and to assess the efficacy of the following minimally invasive endovascular treatment. Thirty-three men with failed surgical treatment of left-sided varicocele were examined between 2006 and 2013, using retrograde venography to assess the anatomy of varicocele draining veins before the attempted transcatheter embolization. Anatomic variants of gonadal veins were categorized according to the classification modified for the purpose of the present study. 3% polidocanol was used as an embolic agent together with pushable fibered coils. In 31 (93%) out of 33 patients venography demonstrated incompetence of the gonadal vein or veins draining varicoceles after failed surgical treatment. The most frequent venographic finding was gonadal vein duplication - 66% of cases (39% in its mid-portion). Technical success of embolization was achieved in all 31 patients. No major complications were observed. Retrograde varicocele embolization may be superior to surgery because of its ability to detect gonadal vein variants. In our study group, transcatheter embolization with 3% polidocanol and fibered coils allowed successful, minimally invasive treatment of postsurgical varicoceles.

Does the nature of chondrolabral injury affect the results of open surgery for femoroacetabular impingement?

The degree to which patient characteristics, clinical outcomes, and the nature, severity, and corresponding treatment of chondrolabral injury in femoroacetabular impingement (FAI) is associated with failure after surgery is incompletely understood. (1) Are patient factors associated with failure (age, sex, body mass index, and preoperative modified Harris hip score [mHHS]) in the open surgical treatment of FAI? (2) Is the nature of chondrolabral injury associated with failure? (3) Are any specific chondrolabral injury treatment methods superior? Between 2000 and 2008, 172 open surgical procedures in 167 patients were performed for the treatment of FAI by two surgeons at two separate academic medical centers. Ultimately, 142 patients were included in this retrospective study. Mean followup was 3 years (range, 1-12 years). Patient and clinical factors along with the nature, severity, and treatment of chondrolabral injuries were assessed for an association with failure, defined as conversion to THA or the inability to achieve the minimum clinically important difference of the mHHS. Thirty-two percent (45 of 142) of patients failed open surgical treatment of FAI. Patient factors associated with failure included age (odds ratio [OR], 1.04; p = 0.036) and preoperative mHHS (OR, 4.42; p = 0.033). Neither the nature of the labral lesion nor the severity of the chondral lesion demonstrated a relationship with failure (p > 0.05). Surgically, labral refixation was associated with a decrease in the risk of failure (OR, 0.31; p = 0.039). We were unable to identify an increased risk of poor outcomes based on sex, body mass index, or severity of chondrolabral lesions. We did find an increased risk of poorer outcomes associated with age. Labral refixation was associated with a decrease in the risk of failure indicating that treatment methodology, rather than the nature of the chondrolabral injury, may be associated with clinical failure. Future studies will be needed to help determine optimal treatment strategies for chondrolabral injuries.

The use of early postoperative prostate-specific antigen to stratify risk in patients with positive surgical margins after radical prostatectomy.

BackgroundIt is well recognized that the presence of positive surgical margins (PSM) after radical prostatectomy (RP) adversely affects cancer specific outcomes and recent evidence from randomized trials supports the use of adjuvant radiotherapy in these cases. However, not all of the patients with PSM develop disease recurrence and the policy of adjuvant radiation could result in considerable over-treatment. We investigated the ability of early postoperative prostate specific antigen (PSA) and PSA decline rates to stratify the risk of disease progression during the first weeks after the surgery thereby allowing adequate time for planning eventual adjuvant therapy.MethodsWe studied 116 consecutive patients with the finding of PSM after RP for localized prostate cancer between 2001 and 2012. No patients were treated with radiation or hormonal therapy. An intensive postoperative PSA monitoring using ultrasensitive assay started first at day 14 after the surgery, then at day 30, 60, 90 and 180, and subsequently in 3 monthly intervals. Biochemical recurrence (BCR) presented the failure of surgical treatment and it was defined as PSA ≥0.2 ng/ml. The ability of PSA decline parameters to predict BCR was assessed using Cox regression model and area under the curve (AUC) calculation.ResultsOverall 55 (47%) patients experienced BCR during median follow-up of 31.4 months (range 6–69). Preoperative PSA, pathologic Gleason sum and pathologic grade failed to reveal any association with observation of BCR. Postoperative PSA levels achieved significant predictive accuracy already on day 30 (AUC 0.74). PSA >0.073 ng/ml at day 30 increased significantly the risk of BCR (HR 4.35, p < 0.001). Predictive accuracy was significantly exceeded on day 60 (AUC 0.84; p < 0.001), while further enhancements on day 90 (AUC 0.84) and 180 (AUC 0.91) were not significant.ConclusionsThe level of ultrasensitive PSA yields valuable information about the prostatectomy outcome already at the first month after the surgery and should aid risk stratification in patients with PSM. Patients not likely to experience subsequent disease progression may be spared the toxicity of immediate adjuvant radiotherapy.

The Use of HemiCAP for the Treatment of Osteochondral Lesions

Osteochondral defects of the talus are located on the medial talar dome in most cases. Arthroscopic debridement and microfracture is the preferred primary treatment for defects up to 15 mm. The optimal secondary treatment for osteochondral defects of the talus after failed primary surgical treatment has yet to be determined. Current methods such as osteochondral autograft transfer have disadvantages including donor site morbidity. A metal resurfacing inlay implant with a diameter of 15 mm (HemiCAP) was developed for treatment of osteochondral defects of the medial talar dome. The operative approach by means of a medial malleolar osteotomy and the implantation technique is reproducible. Intra-articular contact stresses are acceptable with proper implantation, that is, recessed relative to the adjacent cartilage level. A prospective study evaluated the clinical effectiveness. Overall, 20 consecutive patients were studied for a mean period of 3 years (range: 2-5 years). There was statistically significant reduction of pain and improvement of validated ankle outcome scores and quality of life scores. One patient required a reoperation for the osteochondral defect. The promising clinical outcomes indicate that the metal implantation technique is a reasonable alternative to current secondary treatment methods for osteochondral defects of the medial talar dome after failed previous treatment.

Role of Bladder Dysfunction in Vesicoureteral Reflux

Lower urinary tract dysfunction (LUTD) is associated with vesicoureteral reflux (VUR) as well as urinary tract infections (UTIs), particularly when micturition abnormalities occur in the voiding phase. The most common presenting symptoms are urinary urgency and frequency, UTI, incontinence, holding behaviors, and dysuria; many children will also have concurrent constipation. Since LUTD is associated with lower VUR resolution rates, increased rates of breakthrough UTI, and increased rates of surgical treatment failure, successful management of VUR in the setting of LUTD requires therapy for the VUR as well as concomitant management of the LUTD to maximize treatment success. LUTD treatment should be applied sequentially, beginning with behavioral modification and progressing to pharmacologic agents, biofeedback, and neuromodulation in refractory patients.

Reverse arthroplasty for osteoarthritis and rotator cuff deficiency after previous surgery for recurrent anterior shoulder instability

Osteoarthritis in combination with rotator cuff deficiency following previous shoulder stabilisation surgery and after failed surgical treatment for chronic anterior shoulder dislocation is a challenging condition. The aim of this study was to analyse the results of reverse shoulder arthroplasty in such patients. Thirteen patients with a median follow-up of 3.5 (range two to eight) years and a median age of 70 (range 48-82) years were included. In all shoulders a tear of at least one rotator cuff tendon in combination with osteoarthritis was present at the time of arthroplasty. The Constant score, shoulder flexion and external and internal rotation with the elbow at the side were documented pre-operatively and at the final follow-up. Pre-operative, immediate post-operative and final follow-up radiographs were analysed. All complications and revisions were documented. Twelve patients were either satisfied or very satisfied with the procedure. The median Constant score increased from 26 points pre-operatively to 67 points at the final follow-up (p = 0.001). The median shoulder flexion increased significantly from 70° to 130° and internal rotation from two to four points (p = 0.002). External rotation did not change significantly (p = 0.55). Glenoid notching was present in five cases and was graded as mild in three cases and moderate in two. One complication occurred leading to revision surgery. Reverse arthroplasty leads to high satisfaction rates for patients with osteoarthritis and rotator cuff deficiency who had undergone previous shoulder stabilisation procedures. The improvements in clinical outcome as well as the radiographic results seem to be comparable with those of other studies reporting on the outcome of reverse shoulder arthroplasty for other conditions.

Are hip hemiarthroplasty and total hip arthroplasty infections different entities? The importance of hip fractures

Hip hemiarthroplasty (HHA) and total hip arthroplasty (THA) infections are usually considered as one entity; however, they may show important differences. We analyze these differences, as well as predictors of treatment failure (TF) and poor functional status among patients with prosthetic hip infections (PHIs). A multicenter cohort study of consecutive patients with PHIs was performed. The main outcome variable was TF after the first surgical treatment performed to treat the infection. Multivariate analysis was used to identify predictors of TF. A total of 127 patients with PHI were included (43 HHA, 84 THA). Patients with HHA infections were more frequently women (88% vs. 54%; p < 0.001), had comorbidities (86% vs. 67%, p = 0.02), and were older (median age 79 vs. 65 years, p < 0.001), and the reason for arthroplasty was more frequently a fracture (100% vs. 18%, p < 0.001). Failure of initial treatment and crude mortality were more frequent among HHA patients (44% vs. 23%, p = 0.01 and 28% vs. 7%, p = 0.001, respectively). However, HHA was not associated with TF in the multivariate analysis when hip fracture was considered; thus, variables independently associated with TF were hip fracture, inadequate surgical management, prosthesis retention, and higher C-reactive protein level. Failure of the first surgical treatment was associated with poorer functional status. HHA and THA infections showed significant differences in epidemiology, clinical features, and outcome. Although patients with HHA infections had a higher risk of TF, this was related to the reason for hip implant: a hip fracture. Success of the initial management of infection is a predictor of better clinical and functional outcome.

Treatment of Pilonidal Disease Using the Bascom ‘Cleft-Lift’ Procedure

Introduction Treating pilonidal disease can be an unrewarding and frustrating experience for a general surgeon. It is not unusual for a busy surgeon to have several young people coming to the office each week for wound evaluations and dressing changes for failed surgical treatment of pilonidal disease, or for treatment of intentionally created open wounds. These patients are uniformly unhappy, and the situation is frustrating and stressful for the patient, the office staff, and the surgeon.

Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding

Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding

Transcorporal artificial urinary sphincter implantation as a salvage surgical procedure for challenging cases of male stress urinary incontinence: surgical technique and functional outcomes in a contemporary series

To describe the surgical technique of transcorporal artificial urinary sphincter (AUS) implantation. To assess the efficacy of the AUS on continence and erectile function. A prospective evaluation was conducted between December 2007 and October 2012 at a tertiary referral centre of all male patients treated by transcorporal AUS (AMS800™, AmericanMedicalSystems, Minnetonka, MN, USA) implantation for stress urinary incontinence (SUI) recurrence, after failure of previous anti-incontinence surgery. Functional urinary outcomes were assessed according to daily pad use, the Urinary Symptom Profile questionnaire, and International Consultation on Incontinence Questionnaire - Short-Form. Erectile function was evaluated using the five-item International Index of Erectile Function (IIEF-5) questionnaire and patient satisfaction was assessed by Patient Global Impression of Improvement questionnaire. Data were collected by telephone interview. A total of 23 patients were included. Their mean (sd; range) age was 70 (7; 60-85) years. Of these, 18 patients had urethral atrophy and/or erosion after placement of AUS (11 patients), male sling (four patients) or both (three patients), and five patients had severe urethral atrophy after pelvic radiation therapy. The implantation of the AUS with transcorporal cuff placement was successful in all patients, with no peri-operative complications. Follow-up data over 1 year were available for 17 patients. After a median (sd; range) follow-up of 20 (15; 2-59) months, eight patients were perfectly dry (no pad use and no symptoms), five achieved social continence (less than one pad/day), and four still had SUI (required two or more pads/day). Among six patients who had good preoperative erectile function and were sexually active, four had no decrease in their IIEF-5 score. Transcorporal AUS cuff placement is a useful alternative for challenging cases of male SUI after failure of previous surgical treatment, urethral atrophy or erosion. Erectile function can be maintained despite dissection of the corporal body.

Infected primary knee arthroplasty: Risk factors for surgical treatment failure

ObjectiveTo present epidemiological data and risk factors associated with surgical outcomes favorable or unfavorable for the treatment of infection in infected total knee arthroplasty. MethodsWe reviewed medical records of 48 patients who underwent treatment of primary total knee arthroplasty for infection between January 1994 and December 2008, in the Orthopedics and Traumatology Department of the Santa Casa de Misericórdia de São Paulo. The variables associated with favorable outcome of surgical treatment (debridement and retention or exchange arthroplasty in two days) or unfavorable (arthrodesis or death) infection. ResultsA total of 39 cases of infection after primary total knee arthroplasty, 22 progressed to 17 for a favorable outcome and unfavorable outcome. Early infections (OR: 14.0, 95% CI 1.5–133.2, p=0.016) and diabetes (OR: 11.3, 95% CI 1.4–89.3, p=0.032) were associated with arthrodesis joint and death respectively. ConclusionPatients with early infection had a higher risk of developing surgical procedure with unfavorable outcome (arthrodesis) and diabetics had higher odds of death after infection of primary knee arthroplasties.

Factors Associated With the Failure of Surgical Treatment for Femoroacetabular Impingement

Background: With the recent increased recognition of femoroacetabular impingement (FAI) as a cause of hip pain and early osteoarthritis, surgical treatment has proliferated. There is a growing body of literature on outcomes of surgical intervention for FAI, but factors associated with inferior surgical outcomes have not been reviewed systematically. Purpose: To review the available literature and identify factors associated with the failure of open or arthroscopic surgery for FAI. Study Design: Systematic review. Methods: Using the PubMed database, we searched for relevant English-language articles published from January 1966 through August 2012. Inclusion criteria were a primary focus on the surgical treatment of FAI, measurement of functional or pain outcomes, identification of treatment failures, and statistical analysis of factors leading to failure. Exclusion criteria were review articles, technique-only articles, and studies of nonoperative management. Two definitions of failure were considered: (1) a lack of statistically significant improvement in validated measures of pain, function, or satisfaction postoperatively; and (2) revision surgery or conversion to hip arthroplasty because of persistent symptoms. The consistency of association between preoperative variables and clinical outcomes was reported across all studies. Results: Thirteen studies were included. Three were retrospective; there were no randomized controlled trials. Many studies had important methodological limitations. Preoperative cartilage damage or osteoarthritis had the strongest and most consistent relationship with conversion to hip arthroplasty and with a lack of improvement in pain or function. Greater age at the index operation, worse preoperative modified Harris Hip Score, and longer duration of symptoms preoperatively (>1.5 years) were associated with conversion to hip arthroplasty. Conclusion: Older age, presence of arthritic changes, longer duration of symptoms, and worse preoperative pain and functional scores are associated with poor outcomes of surgery for FAI. Incorporation of these data into discussions with patients may facilitate informed, shared decision making about the surgical treatment of FAI.

A systematic review of the treatment for female stress urinary incontinence by ACT® balloon placement (Uromedica, Irvine, CA, USA)

(1) To describe the minimally invasive adjustable continence therapy (ACT)(®) balloon placement surgical technique. (2) To analyse the results of ACT(®) balloon in the treatment for female stress urinary incontinence (SUI). A review of the literature was performed by searching the PubMed database using the following search terms: ACT balloons, female urinary incontinence, and female continence. Eight studies were published between 2007 and 2013. The mean follow-up of these studies was 1-6 years. The mean age of the patients ranged between 62 and 73 years; 40-100 % of patients had already been treated surgically for their SUI. A significant reduction in the number of pads used per day was observed after ACT(®) balloon placement, with improvement of short pad tests from 49.6 to 77.3 g preoperatively to 11.2-25.7 g after ACT(®) balloon placement. Fifteen to 44 % of patients considered that their SUI had been cured and 66-78.4 % were satisfied with the result. The explantation rate ranged between 18.7 and 30.8 %. Quality of life was significantly improved, and no major complication was reported. ACT(®) balloons constitute a reasonable, minimally invasive alternative for the treatment for female SUI due to intrinsic sphincter disorder, especially in patients who have already experienced failure of standard surgical treatment and in clinical settings incompatible with invasive surgical placement of an artificial urinary sphincter (especially women over the age of 80 years). Long-term results are essential to evaluate the efficacy of this treatment.

Sacral neuromodulation for bowel dysfunction

Bowel dysfunction generally refers to a variety of clinical conditions including fecal incontinence, constipation, and chronic pelvic pain. Fecal incontinence is the uncontrolled loss of stool, either liquid or solid. Its true prevalence in the adult population is unknown, but might be as high as 5 % if based on a Cleveland Clinic score above 5/20 [1]. The resulting handicap is responsible for social isolation and reduced quality of life. First treatment should be dietary measures, medication, and biofeedback physiotherapy. Surgery is indicated when conservative treatment fails. Direct sphincter repair is suggested in the case of limited total sphincter rupture, but results deteriorate over time, with only around 50 % of patients still continent at long-term follow-up. Sphincter substitution is indicated in patients with large sphincter defects or a severely disrupted sphincter and in the case of failure of other surgical treatment. Non-stimulated graciloplasty (the so-called Pickrell’s procedure) has been abandoned because of the fatigability of the transposed muscle [2]. Dynamic graciloplasty is nowadays very rarely proposed in the treatment of fecal incontinence because the technique is complex, expensive and has a high morbidity rate [3]. Despite a certain level of expertise, our results with the artificial bowel sphincter, like other authors have recently shown, are less promising than those previously published in the literature [4]. Sacral nerve modulation, first developed for the treatment of urinary dysfunction, is another option that has proved to be effective in the treatment of fecal incontinence in patients with an intact or nearly intact sphincter complex [5]. Some authors have demonstrated that sacral neuromodulation could also be beneficial in patients with sphincter defects, in patients presenting with fecal incontinence following anterior resection and chemoradiation for rectal cancer, and in patients suffering from systemic sclerosis or Crohn’s disease. After implantation, 41–75 % of patients achieve complete fecal continence and 75–100 % experience improvement in episodes of incontinence [5]. A few studies have also reported efficacy of sacral neuromodulation in patients suffering from double incontinence, the urinary incontinence being due to either urge incontinence (involuntary urine leakage following urgency), stress incontinence (involuntary urine leakage during efforts), or mixed (associating both urge and stress incontinence) [6, 7]. These functional results are obtained with a reasonable, moderate level of complications [8, 9]. We published the number and causes of reoperation from a series of 87 consecutive patients operated on in a single institution. Among these patients, 36 had surgical revision of the device for the following reasons: device-related failure due to infection in 4 (successful reimplant in 4), electrode displacement in 2, electrode breakage in 2 (reimplantation of electrode in 4), and dysfunction owing to impedance increase in the system in 4; adverse stimulation with pain in 7 (stimulator repositioning in 4 and explantation in 3); battery depletion either spontaneously (n = 6) or owing to an MRI examination (n = 2); total or partial loss of clinical efficacy in 9 (removal of the generator and electrode). In total, nearly 40 % of patients needed a revision of their stimulator, but some of the reoperations were due to the learning curve, the patients in question having been the very first patients being included in the study. A position statement, based on a collective experience of French J.-L. Faucheron (&) G. Martin Colorectal Unit, Department of Surgery, University Hospital, CS 10217, B.P. 217, 38043 Grenoble Cedex, France e-mail: JLFaucheron@chu-grenoble.fr

Results of revision after failed surgical treatment for traumatic anterior shoulder instability

Introduction and objectivesPersistent or recurrent glenohumeral instability after a previous operative stabilization can be a complex problem.Our aim is to establish the incidence of recurrence and its revision surgery, and to analyze the functional results of the revision instability surgery, as well as to determine surgical protocols to perform it. Materials and methodsA retrospective analysis was conducted on 16 patients with recurrent instability out of 164 patients operated on between 1999 and 2011. The mean follow-up was 57 months and the mean age was 29 years. To evaluate functional outcome we employed Constant, Rowe, UCLA scores and the visual analog scale. ResultsOf the 12 patients who failed the initial arthroscopic surgery, 6 patients underwent an arthroscopic antero-inferior labrum repair technique, 4 using open labrum repair techniques, and 2 coracoid transfer. The two cases of open surgery with recurrences underwent surgery for coracoid transfer. Results of the Constant score were excellent or good in 64% of patients. ConclusionsSurgical revision of instability is a complex surgery essentially for two reasons: the difficulty in recognizing the problem, and the technical demand (greater variety and the increasingly complex techniques).

Weight Loss Outcome After Roux-en-Y Gastric Bypass: 10 Years of Follow-up

By submitting obese people to surgical treatment, we hope they lose weight and stay slim. Long-term monitoring is essential to assess effectiveness of surgery. This study aims to evaluate weight loss over 10years in an obese population undergoing banded Roux-en-Y gastric bypass (B-RYGBP). The surgery was performed in 211 obese between May 1999 and December 2000. This prospective study evaluated excess weight loss (%EWL) and body mass index (BMI) during the period. We considered surgical treatment failure if %EWL was less than 50%. We followed 54.9% of the population (116 patients). Patients' %EWL was 67.6 ± 14.9% 1year after surgery, 72.6 ± 14.9% after 2years, 69.7 ± 15.1% after 5years, 66.8 ± 7.6% after 8years, and 67.1 ± 11.9% after 10years postoperatively. Surgical treatment failure occurred in 16 patients (14.6%) over 10years. B-RYGBP is a good technique to promote and maintain weight loss 10years after surgery with low failure rate.

Efficacité et tolérance de la toxine botulique dans l’hémispasme facial

Given the failure of pharmacologic and surgical treatment in the management of hemifacial spasm, the use of botulinum toxin as first line therapy is interesting. To evaluate the safety and efficacy of type A botulinum toxin in the treatment of hemifacial spasm. We conducted a retrospective, descriptive and comparative study of 25 patients with hemifacial spasm followed in the ophthalmology department of Habib Thameur hospital in Tunis over the period from June 2003 to June 2009. All patients received injections of botulinum toxin type A (Botox). We carried out 168 Botulinum A toxin injections (Botox) with an average of 6.85 ± 4.32 injections per patient. Doses varied between 12.5 U and 28 U Botox. A good response to treatment was observed in 92% of patients with a satisfactory return to daily activities and work. Based on a subjective scale from 1 to 3, the average total functional benefit was 2.55 ± 0.56. Average total duration of therapeutic response was 9.35 ± 3.64 weeks. Local side effects observed were comparable to those described in the literature: ptosis (32.4%), diplopia (8.2%), drooping of the labial commissure (11.2%), lagophthalmos (21.3%), tearing (7%), dry eye (4%). No systemic complication was noted. Botulinum toxin type A provides effective short-term and medium-term results in the treatment of hemifacial spasm. It is well tolerated locally and systemically. This safety and efficacy make it a valuable therapeutic alternative in the management of hemifacial spasm.

Endocarditis infecciosa: características clínicas, complicaciones y mortalidad en 506 pacientes y factores pronósticos de sobrevida a 10 años (1998-2008). Estudio cooperativo nacional en endocarditis infecciosa en Chile (ECNEI-2)

Rates of morbidity and mortality in Infective Endocarditis (IE) remain high and prognosis in this disease is still difficult and uncertain. To study IE in Chile in its active phase during inpatient hospital stay and long term survival rates. Observational prospective national cohort study of 506 consecutive patients included between June 1,1998 and July 31, 2008, from 37 Chilean hospitals (secondary and tertiary centers) nationwide. The main findings were the presence of Rheumatic valve disease in 22.1 % of patients, a history of intravenous drug abuse (IVDA) only in 0.7%, the presence of Staphylococcus aureus in 29.2% of blood cultures, negative blood cultures in 33.2%, heart failure in 51.7% and native valve involvement in 86% of patients. Echocardiographic diagnosis was achieved in 94% of patients. Hospital mortality was 26.1% and its prognostics factors were persisting infection (Odds ratio (OR) 6.43, Confidence Interval (CI) 1.45-28.33%), failure of medical treatment and no surgical intervention (OR 48.8; CI 6.67-349.9). Five and 10 years survival rates were 75.6 and 48.6%, respectively. The significant prognostic factors for long term mortality, determined by multivariate analysis were the presence of diabetes, Staphylococcus aureus infection, sepsis, heart failure, renal failure and lack of surgical treatment during the IE episode. The microbiologic diagnosis of IE must be urgently improved in Chile. Mortality rates are still high (26.1%) partly because of a high incidence of negative blood cultures and the need for more surgical valve interventions during in-hospital period. Long term prognostic factors for mortality should be identified early to improve outcome.

Reasons and Prevalence of Reoperations After Esophagomyotomy for Achalasia

Surgical esophagomyotomy has been shown to provide superior long-term symptom relief as compared with nonsurgical interventions. Failure of surgical treatment remains the center of controversy regarding this topic. A retrospective review was conducted of all patients who underwent surgical treatment of achalasia from January 2005 to July 2009 at Cleveland Clinic Florida. A total of 66 patients (41 women and 25 men), with a mean age of 51 years (range, 24 to 86 y). Fifty-nine patients (89%) underwent laparoscopic surgery, including 2 (3%) with recurrent achalasia. One patient was converted to laparotomy. Twelve patients required a reintervention because of failure or complications (18%). Six cases were confirmed intraoperatively to be recurrent achalasia that necessitated redo Heller myotomy. Early reoperations after Heller's Dor esophagomyotomy are mostly related to technical errors, whereas most late reoperations are related to recurrent disease. Laparoscopy seems to be safe and the preferred approach for primary as well as redo procedures.

The role of autologous bone graft in surgical treatment of hypertrophic nonunion of midshaft clavicle fractures

BackgroundThis study was conducted to evaluate the results of treating hypertrophic nonunion of mid-shaft clavicle fracture with a limited contact dynamic compression plate (LC-DCP) without autologous cancellous bone graft. MethodsFrom 1995 to 2008, 51 cases of hypertrophic nonunion of mid-shaft clavicle fracture were managed with open reduction and internal fixation by LC-DCP without bone graft involvement. Of these 51 cases, 30 had nonunion after failure of initial surgical treatment (Group 1), and 21 had nonunion after failure of conservative treatment (Group 2). Preoperative and postoperative case management were the same for both groups, with the average follow-up period being 20.4 months (range 18–36). Our study evaluated the radiographic results and functional outcomes of these cases according to the quick disability of arm, shoulder, and hand score. ResultsAll 51 cases resulted in uneventful unions. There was no statistically significant difference between the two groups regarding patient demography, cause of injury, preoperative and postoperative functional scores, length of operation, union time, and duration of hospitalization (p>0.05). ConclusionLC-DCP fixation is an effective method for treating hypertrophic nonunion of mid-shaft clavicle fracture. Local bone graft is sufficient to achieve necessary union, and autologous bone graft from other sites of the body appears unnecessary.