First-stage Operation Research Articles

Classification of Microtia With Unusable Remnant Ear and Techniques in the First Stage of Two-Stage Auricular Reconstruction.

The remnant ear is a very important material in auricular reconstruction surgery; its dimension, position, and shape determine how it is used. However, the local conditions of microtia patients are complex and variable. Situations may be encountered where a series of abnormal remnant ears cannot be utilized in clinical practice. Currently, there are no literature that elaborates on this type of microtia and provides systematic treatment methods. The purpose of this article is to systematically classify them and optimize the two-stage method auricular reconstruction, to provide an effective surgical method for these patients. Based on the size, shape, and relative position of the residual ears, the unusable remnant ears were classified into three types: tiny size, abnormal shape, and relative position anomaly (over 1-cm higher than the contralateral earlobe). Fifty-three microtia patients with unusable remnant ear (54 ears) who underwent two-stage auricular reconstruction from August 2020 to August 2023 were reviewed. All patients had experienced earlobe reconstruction by using autologous rib cartilage during the first stage of surgery. Aesthetic assessments were evaluated from the naturalness of the earlobe reconstructed with autologous rib cartilage and the connection with the overall framework. The data on any complications that occurred during the follow-up period and patient satisfaction were collected. Among all patients, 31 had tiny size, 14 had abnormal shape, and 8 had excessively high positions. Patients were followed up for an average period of 9.2 months (6 to 12 months). No complex complications such as infection, skin necrosis, or cartilage exposure occurred. Fifty patients (94.3%) achieved excellent or good aesthetic outcomes. Fifty-one patients (96.2%) were satisfied with the reconstruction outcomes. An accurate assessment of the residual ear preoperatively is essential. Reconstructing and splicing the earlobe with autologous rib cartilage in cases where the residual ear cannot be utilized compensate for the defect that the soft tissue cannot provide the earlobe flap. This is an effective surgical method for the ear reconstruction in such patients.

Modified Ex Vivo Renal Reconstruction to Facilitate Fenestrated-Branched Endovascular Repair of a Thoracoabdominal Aortic Aneurysm.

To report the use of modified ex vivo renal artery (RA) reconstruction in a patient with 2 small right RAs (RRAs) in anticipation of planned fenestrated-branched endovascular aortic repair (FB-EVAR) of thoracoabdominal aortic aneurysm (TAAA). A staged hybrid repair was utilized in a patient with Extent II TAAA involving celiac axis (CA), superior mesenteric artery (SMA), single left RA (LRA), and 2 small (<3 mm) RRAs. The first-stage operation consisted of hepato-renal bypass using modified ex vivo renal reconstruction with single end-to-end anastomosis to both RAs using a saphenous vein graft. A second stage FB-EVAR was performed using patient-specific manufactured stent-graft with 3 fenestrations for the CA, SMA, and LRA 6 weeks later. The patient recovered with no complications. At 4 years, the patient had widely patent hepato-renal bypass and target vessels with normal renal function. The use of adjunctive hybrid procedures may optimize or facilitate FB-EVAR. In this patient, salvage of 2 small RAs was not ideally suited for branch stenting but was possible using modified ex vivo RA reconstruction with preservation of kidney parenchyma and function. This case report illustrates a hybrid approach to overcome one of the most frequent limitations to total endovascular incorporation of renal arteries, eg small diameter, early bifurcation and multiple vessels. The modified ex vivo technique allows meticulous renal artery reconstruction without the deleterious effect of warm ischemia and without the cumbersome reconstruction of ureter and vein that is needed with traditional on table ex vivo auto transplantation. The technique is used in a minority of cases and adds the morbidity of open approach. Case selection is of paramount importance.

Staged urethroplasty with groin full-thickness skin graft for managing complex anterior urethral strictures: surgical outcomes and predictive factors.

To describe outcomes of staged-urethroplasty in complex anterior urethral strictures using full-thickness-skin-graft (FTSG) harvested from the hairless groin area, and to identify factors influencing successful outcomes. Through retrospective chart review, we identified a total of 67 men who underwent the first-stage operation (grafting) using groin-FTSG for staged-urethroplasty to treat complex anterior urethral strictures unsuitable for one-stage urethroplasty. Among these, 59 underwent the second-stage operation (tubularization) at a median duration of 5.1-months after grafting. Patients were assessed for outcomes as scheduled after tubularization outcomes were analyzed only for 48 patients for whom ≥ 1-year follow-up data after tubularization were available. Their mean follow-up duration was 27.1months. Success was defined as achieving physiologic voiding without requiring further procedures. Median stricture-length was 5.5cm in all 67 patients. After grafting, neourethral-opening-narrowing occurred in 18. Partial graft-loss occurred in 8, of whom only 3 underwent re-grafting. The percentage of patients who achieved successful outcomes was 81.3%. Improvements in maximum-urine-flow-rate and post-void-residual-urine-volume were maintained until the last follow-up visit. A urethrocutaneous-fistula occurred in one patient, while meatal-stenosis occurred in two. On multivariate-regression-analysis, the presence of neourethral-opening-narrowing was the only predictor of non-success after tubularization. Furthermore, the presence of hypertension, longer stricture-length, and a history of prior direct-vision-internal-urethrotomy were predictors of the occurrence of neourethral-opening-narrowing. Staged-urethroplasty using groin-FTSG is well worth considering as a useful therapeutic option for complex anterior urethral strictures, with an acceptable success rate and low morbidity. The absence of neourethral-opening-narrowing after the first-stage operation leads to success.

Comparison between staged laparoscopic technique in children with high intra-abdominal undescended testis: a systematic review and meta-analysis.

This study performed a systematic review and meta-analysis to compare the outcomes of the staged laparoscopic Fowler-Stephens Laparoscopic Orchiopexy (FSLO) and Staged Laparoscopic Traction Orchiopexy (SLTO) in patients with intra-abdominal testes (IAT). This study reviewed literature published from 2016 to 2024. A systematic literature search was conducted on three databases: PubMed, ScienceDirect, and Google Scholar, using keywords (High intra abdominal testis) AND (("Fowler Stephens laparoscopic orchiopexy" OR (FSLO)) OR (Staged Laparoscopic traction orchiopexy OR (SLTO)). Non-randomized trials and observational studies comparing staged laparoscopic FSLO and SLTO, without any time range restriction are included. Studies without FLSO orchidopexy as a control, case reports, case studies, duplicate publication, no full text and non-English studies are excluded. This study used the PRISMA protocol, the Jadad Scale, and the Newcastle Ottawa Scale (NOS) to evaluate the included studies. To analyze statistical data, the Review Manager (RevMan) software was used. The Chi-squared test was used to calculate statistical heterogeneity in the meta-analysis. There were 240 patients from 5 studies (109 in the SLTO group and 131 FSLO in group). The primary outcome of this study is testicular descent and atrophy. There were no significant differences in testicular descent (RR:1.08[0.96 - 1.23],p<0.20,I 2:0%) and atrophy rate (RR:0.45[0.19 - 1.09],p<0.08,I 2:0%). Secondary outcomes are the duration of operation in both the first and second stages. Statistical analysis reveals a significantly lower first-stage operation time in the FSLO group (MD:9.31[7.08,11.55], p<0.05;I 2:94%). At the same time, lower second-stage operation times are significantly reported in the SLTO group (MD:-4.05[-7.99,-0.12],p<0.05; I 2:60%). In terms of testicular descent and testicular atrophy the SLTO technique yields similar results to the FSLO technique. Both techniques have advantages and disadvantages, and we recommend SLTO as the first choice in children with a high IAT of <4 cm. CRD42023412407.

Parents’ Journeys of Mastery and Knowledge Construction After Their Infant’s First Stage of Surgery for Complex Congenital Heart Disease

ABSTRACT Background A growing body of conceptual evidence over the last decade has increased our understanding of parents’ experiences of having an infant with complex congenital heart disease. These concepts include parents’ feelings of uncertainty, fear, excitement, and mastery. However, little is known about parents’ experiences, confidence, and knowledge acquisition during transition from hospital to home with their infant after the first stage of complex cardiac surgery. A theoretical framework to assess, plan and implement child and family centered care would assist children’s cardiac nurses responsible for parental education, discharge planning and coordination. Aim To explore parents’ experiences of the transition from hospital to home with their infant, following the first stage of cardiac surgery. Design A prospective mixed methods longitudinal design. Semi-structured interviews were undertaken, including administration of the Maternal Confidence Questionnaire at four timepoints: before discharge following stage one cardiac surgery (T0), 2 weeks’ post discharge (T1), 8 weeks’ post discharge (T2) and after stage two surgery (T3). Qualitative data were thematically analyzed. Descriptive statistics were used to characterize the sample and non-parametric repeated measures analysis of variance was used to analyze changes over time in maternal confidence scores. Results Sixteen parents of 12 infants participated. Four “patterns of transition experience” emerged, the fourth “Mastery”, is discussed in this paper. Mastery can be contextualized in terms of the parents’ journeys of knowledge construction, gaining confidence and reflection. Learning was dynamic and transformational, but successful learning and acquisition of knowledge was also dependent upon the parents’ ability to absorb, integrate and adjust at any given time. Confidence at T0 was significantly lower than at T1 (p = .011), T2 (p = .018) and T3 (p = .012). There were no significant differences between scores at T1, T2 and T3. Liminality, as a concept, described the between and betwixt time that parents experienced as they were preparing for discharge from hospital; excitement to be going home balanced with the fear of being alone and confidence in looking after their fragile infant. Conclusion Parents of infants with complex congenital heart disease obtain knowledge, confidence, and mastery dependent upon their transition experience and their personal journey through pre-liminal, liminal, and post-liminal phases of discharge from hospital to home. A conceptual framework “Parenting through Transitions – hospital to home” emerged that could assist in structuring assessment of parents’ knowledge and support needs within a coordinated discharge process. Identifying individualized support would promote adaptation and adjustment during transition from the pre to post liminal phase, following their infant’s first stage of complex cardiac surgery.

Outcomes after surgical repair of pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries: a series of 104 cases

Objective: To examine the early and midterm surgical outcome of pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (PA/VSD/MAPCA) using revised surgical strategies. Methods: A retrospective analysis of clinical data, surgical methods, and follow-up results was performed of 104 cases of PA/VSD/MAPCA in Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center from January 2017 to September 2022. There were 55 males and 49 females, aged (M(IQR)) 33.9(84.0) months (range: 0.5 to 209.6 months) at the first surgical procedures. The anatomical classification included 89 cases of type B and 15 cases of type C. The number of major aortopulmonary collateral arteries was 4.2 (3.0) (range: 1 to 8). The Kaplan-Meier method was used for survival estimation. Results: In the first stage of surgery, 50 patients underwent a complete primary repair, 12 patients underwent partial repair, 32 patients underwent palliative right ventricular-pulmonary artery connection, and only 10 patients chose the Blalock-Taussig shunt. There were 10 cases of early death. In the second stage, 14 patients underwent complete repair and 4 patients underwent partial repair with no early death. The interval between the two surgeries was 19 (10) months (range: 9 to 48 months). Finally, during the 40 (34) months follow-up period, a total of 64 patients were complete repair and the right/left ventricular pressure ratio after complete repair was 0.63±0.16 (range: 0.36 to 1.00). Survival analysis showed that survival rates at 1 and 5 years after first-stage surgery were both 89.4% (95%CI: 83.5% to 95.3%). At 28 (34) months (range: 1 to 67 months) of follow-up after complete repair, the survival analysis showed that the survival rates at 1 and 5 years were both 95.2% (95%CI: 89.9% to 100%). Conclusions: Using combined approaches tailored to individual patients and optimized unifocalization strategy, the complete repair rate at one stage and the cumulative complete repair rate at 5 years improved significantly with a lower right/left ventricular pressure ratio and satisfactory early and intermediate survival.

Comparison between staged laparoscopic technique in children with high intra-abdominal undescended testis: a systematic review and meta-analysis

Background: This study performed a systematic review and meta-analysis to compare the outcomes of the staged laparoscopic Fowler-Stephens Laparoscopic Orchiopexy (FSLO) and Staged Laparoscopic Traction Orchiopexy (SLTO) in patients with intra-abdominal testes (IAT). Methods: This study reviewed literature published from 2016 to 2023. A systematic literature search was conducted on three databases: PubMed, ScienceDirect, and Google Scholar, using keywords (High intra abdominal testis) AND (("Fowler Stephens laparoscopic orchiopexy" OR (FSLO)) OR (Staged Laparoscopic traction orchiopexy OR (SLTO)). Non-randomized trials and observational studies comparing staged laparoscopic FSLO and SLTO, without any time range restriction are included. Studies without FLSO orchidopexy as a control, case reports, case studies, duplicate publication, no full text and non-English studies are excluded. This study used the PRISMA protocol, the Jadad Scale, and the Newcastle Ottawa Scale (NOS) to evaluate the included studies. To analyze statistical data, the Review Manager (RevMan) software was used. The Chi-squared test was used to calculate statistical heterogeneity in the meta-analysis. Results: This study included four studies of 151 patients (72 SLTO group and 79 FSLO group). There was no significant difference between the two groups in terms of testicular descent (p=0.08), and there was no testicular atrophy in the SLTO group compared to the FSLO group (p=0.04). Statistical analysis revealed a significantly shorter first-stage operation time in the FSLO group (p 0.0001), whereas the SLTO group reported a significantly shorter second-stage operation time (p = 0.04). Conclusions: In terms of testicular descent, the SLTO technique yields similar results to the FSLO technique. The SLTO position is preferable to the FSLO position. Both techniques have advantages and disadvantages, and we recommend SLTO as the first choice in children with a high IAT of 4 cm. PROSPERO registration: CRD42023412407

Morphometric analysis and outcomes following posterior cranial vault distraction in syndromic and multisuture craniosynostosis

Turribrachycephaly is a common feature in many syndromic and multisuture craniosynostoses and is traditionally treated with total cranial vault reshaping and fronto-orbital advancement. A staged approach with posterior cranial vault distraction as a primary procedure followed by anterior cranial vault reshaping has the advantage of reducing the vertical dimension of the skull in a controlled and gradual manner while expanding the cranial volume. The purpose of this study was to evaluate outcomes following posterior cranial vault expansion using distraction osteogenesis at a single tertiary pediatric center. This retrospective review included all cases of posterior cranial vault distraction at a single institution from 2008 to 2022 performed by one surgeon. Morphometric outcomes such as Turricephaly Index (TI) and posterior cranial volume (PCV) were assessed from pre- and postoperative computerized tomography scans for patients who underwent posterior cranial vault distraction as a primary first-stage operation. Clinical outcomes and complications were collated. A total of 41 patients (25 females, 16 males; mean age 11 months) with syndromic craniosynostosis (n=32) and nonsyndromic craniosynostosis (n=9) were included. The main indication for posterior cranial vault distraction in this cohort was turricephaly (63%). The mean distraction distance was 25.9mm and the mean decrease in TI was 18%. The estimated increase in PCV from distraction in this cohort was 19.7%. In this cohort of patients, 13 patients (32%) experienced complications but there were no mortalities. Posterior cranial vault distraction osteogenesis is an effective surgical procedure to increase intracranial volume and correct turricephaly in children with syndromic and nonsyndromic craniosynostosis. This procedure is considered a safe and effective first-stage cranial operation in children with syndromic craniosynostosis with increased intracranial pressure and or turricephaly.

The role of planned two-stage surgery in the management of congenital cholesteatoma.

The purpose of this study is to verify the role of "planned two-stage surgery" in the management of advanced congenital cholesteatoma regarding disease recurrence rates, complications and the need for salvage surgery. Retrospective review of all congenital cholesteatoma under the age of 18 years underwent surgery from October 2007 to December 2021 in a single tertiary referral center. Patients with Potsic stage I/II who had closed-type congenital cholesteatoma received one-stage surgery. Advanced cases or those with open-type infiltrative congenital cholesteatomas underwent planned two-stage surgery. The second stage of surgery was performed 6-10 months after the first stage of surgery. Ossiculoplasty would be performed in the second operation if a significant air-bone gap was detected in the preoperative pure-tone audiometry test. Twenty-four patients were included in the series. Six patients received one-stage surgery and no recurrence was noted in this group. The remaining 18 underwent planned two-stage surgery. Residual lesions found in the second operative phase were observed in 39% of patients who received planned two-stage surgery. Except for one patient whose ossicular replacement prosthesis protruded and two patients who had perforated tympanic membranes, none of the 24 patients required salvage surgery during follow-up (mean, 77 months after surgery), and no major complications occurred. Planned two-stage surgery for advanced-stage or open infiltrative congenital cholesteatoma could timely detect residual lesions to avoid extensive surgery and reduce complications.

Two-Stage Operations in Patients with Acute Right-sided Colonic Obstruction: a 15-year Single Institution Experience

Objective The aim of the study was to review the characteristics, surgical outcomes, complications, and long-term outcomes of two-stage operations for acute right-sided colonic obstruction (RSCO) in a single institution. Summary background data Although patients with acute RSCO can be treated by resection of the tumor with a primary anastomosis, longer procedure times and bigger wounds can result in more mortality and complications. A two-stage operation by diverting loop ileostomy was another surgical option. However, the outcomes of two-stage operations are lacking. Methods The retrospective study reviewed the patients who underwent emergency surgery for acute RSCO in a tertiary center from 2004-2018. First-stage operations other than diverting loop ileostomy, incomplete obstructions that could be treated medically, or pathologies other than adenocarcinomas were excluded. Perioperative data such as first and second operations, operative times, lengths of stay, harvested lymph nodes, and any complications were included. We assessed overall survival (OS) and disease-free survival (DFS) for the oncologic outcomes. Results Sixty-nine patients were included. Seven patients had surgical complications related to ileostomy. Three of them died within 30 days of first admission. Thirty-one patients received a second-stage operation by right hemicolectomy. None had anastomosis leakage or 30-day mortality. Only 9.7% of patients had fewer than 12 harvested lymph nodes. One-year OS was 34% in the patients who received only ileostomy, and 89% in those who received two-stage operations (P &lt; 0.001). Among 26 patients who underwent curative resection of tumor, 3-year DFS was 61.5%. Conclusions A two-stage operation is associated with low mortality and morbidity rates in an emergency setting. The subsequent right hemicolectomy can harvest more lymph nodes than emergency resection. Long-term survival benefits can be expected.

Mitral homograft in tricuspid position: indications for implantation and surgical technique

HighlightsThe article presents the latest data on the techniques of implantation of the mitral homograft in the tricuspid position, and identifies groups of patients who are best suited for this method. Moreover, the article describes the evolution of this type of replacement, and highlights that many surgical techniques, although justified, require further study to show demonstrate their advantages. AbstractDespite the general trend in cardiac surgery towards valve-preserving interventions, valve replacements remain relevant, and the search for the perfect prosthetic valve continues. Many believe that tricuspid valve replacement using a mitral homograft can be the method of choice in certain situations. The analysis of the studies found in the PubMed database led the authors to the following conclusions: most of the data on the use of this technique in patients with infective endocarditis (IE), other indications are congenital heart disease (CHD) and rheumatic heart disease. Patients with IE who have undergone tricuspid valve replacement using a mitral homograft have good medium-term prospects, and respond well to medical treatment of recurrent IE. The mitral homograft in the tricuspid position remains intact even after prosthetic endocarditis. In this regard, it is possible to perform reconstructive intervention in case of prosthetic valve dysfunction without the need for repeated replacement. Such interventions are relevant for patients with growing heart for whom annuloplasty at the first stage of surgery is undesirable. Moreover, it is also cost-effective due to the high cost and low availability of homografts. The possibility of repeated tricuspid valve-in-valve replacement is important for patients who may not survive open surgery. To date, there are not enough long-term and short-term data on using a mitral homograft for tricuspid valve replacement, however, it can be assumed that the results of this technique will be positive provided that the appropriate implantation technique and strict patient selection are ensured. Many authors have come to the conclusion that the optimal homograft implantation technique includes sewing of the graft`s papillary muscles into the wall of the myocardium of the right ventricle (RV), fixating them on the outer surface of the RV, anatomical positioning of the homograft (anterior leaflet faces towards the IVS), and the use of an annuloplasty ring.

Staged osteotomy in lateral position for the treatment of severe kyphotic deformity secondary to ankylosing spondylitis: a retrospective study

BackgroundPatients with severe kyphotic deformity (Cobb > 100°) secondary to ankylosing spondylitis (AS) occasionally cannot undergo corrective surgery in the prone position. Osteotomy in the lateral position might provide a possible solution. In this study, we aim to evaluate the clinical efficacy and safety of staged osteotomy in the lateral position for the treatment of AS-related severe kyphosis with a minimum of 2-year follow-up.MethodsIn total, 23 patients who underwent staged osteotomy in the lateral position from October 2015 to June 2017 were analyzed. In the first stage of surgery, all but one patient underwent a single-level Ponte osteotomy, which was followed by a pedicle subtraction osteotomy in the second stage. Mean follow-up was 30.8 ± 4.6 months. Global kyphosis (GK), thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), osteotomized vertebra intervertebral angle (OVI), chin-brow vertical angle (CBVA), Oswestry Disability Index (ODI) score and Scoliosis Research Society-22 Patient Questionnaire (SRS-22) were all compared pre- and postoperation.ResultsAll kyphosis parameters were significantly improved (all P < 0.05). GK was corrected from 115.0 ± 13.4° to 46.5 ± 9.0° postoperatively, with a mean correction of 68.5°. SVA was improved from 21.2 ± 5.1 cm to 5.1 ± 1.8 cm postoperatively. After surgery, CBVA was adjusted from 64.1 ± 23.2° to 5.7 ± 10.6° and OVI was changed from 9.0 ± 2.7° to − 20.1 ± 5.6°. Both the ODI and SRS-22 showed substantial improvements (all P < 0.05). Four patients with mild complications were observed perioperatively.ConclusionIn AS patients with severe kyphosis, satisfactory correction can be safely achieved with staged osteotomy in the lateral position, which can not only correct the sagittal imbalance of the spine with acceptable complications but also facilitate the placement of the intraoperative position.

Surgical outcomes of percutaneous endoscopic thoracic decompression in the treatment of multi-segment thoracic ossification of the ligamentum flavum.

Previous studies have demonstrated satisfactory outcomes of percutaneous endoscopic thoracic decompression (PETD) for single-segment thoracic ossification of the ligamentum flavum (TOLF). However, the clinical outcomes of PETD in patients with multi-segment TOLF (mTOLF) remain unclear. The aim of the present study was to evaluate the efficacy and safety of PETD for patients with multi-segment mTOLF. Eighteen consecutive patients (41 segments) with mTOLF were treated with PETD between January 2020 and December 2021. The clinical outcomes were evaluated using the modified Japanese Orthopaedic Association (mJOA) score and Visual Analog Scale (VAS), whereas radiographic parameters were measured by cross-section area of the spinal canal and anteroposterior diameter of the spinal cord. The follow-up period ranged from 14 to 34months. The mean operation time and blood loss were 154.06 ± 32.14min and 61.72 ± 12.72ml, respectively. Hospital stay after first-stage operation was 10.89 ± 2.42days. The mJOA score and VAS score significantly improved at the final follow-up, with a mean mJOA recovery rate of 63.3 ± 21.90%. The incidence of complications was 12.2% per level. The radiographic outcomes showed adequate decompression of the spinal cord. The present study demonstrates that PETD is effective and safe as a minimally invasive procedure to treat patients with mTOLF. All patients showed relief of their symptoms and improvement in neurological function.

Autologous myocutaneous flap implantation for chronic refractory chest wall sinus with infection: a case report

BackgroundChest wall sinus with infection is a refractory disease caused by a variety of susceptible factors, and the treatment is still challenging. For clinically complex cases, although there are various surgical methods to choose from, it is still very difficult to achieve clinical cure, especially for patients with older age and many underlying diseases. Complete resection of chest wall sinus and application of repair and reconstruction technology may bring hope to refractory cases.Case presentationHerein, we report a case of a 67 year-old woman who had undergone breast cancer surgery and a history of multiple cycles of radiotherapy and chemotherapy. One year ago, she had a fistula in the left chest wall with yellow purulent fluid. After admission to our hospital, chest computed tomography (CT) showed the formation of the left chest wall sinus, accompanied by high-density images of the left clavicle, part of the ribs and part of the sternu. According to the patient's symptoms, signs and imaging examination, we preliminarily diagnosed the patient as chest wall sinus with infection and chronic osteomyelitis. Therefore, in the first-stage operation, the patient underwent left chest wall sinus resection, left partial rib resection, left partial clavicular resection and left partial sternal resection, After surgery, the wound surface was changed with gauze dressing with sensitive antibiotic solution every day until the wound surface was clean and new granulation was formed. In the second-stage operation, the wound surface was appropriately expanded, and the pedicled latissimus dorsi myocutaneous flap was transferred to the chest wall defect. Finally, the skin paddle was sutured without tension to the normal skin around the chest, and two drainage tubes were placed. Anti-infection, anti-spasm, anti-coagulation and other treatments were given after operation, and the survival of myocutaneous flap, wound healing and sinus disappearance were observed.ConclusionThe application of pedicled latissimus dorsi myocutaneous flap in the treatment of intractable chronic chest wall sinus is an effective method. It does not change the shape of the thorax. The clinical effect is satisfactory in the near and medium term, which is worthy of clinical promotion.

Emergent Subtotal Colectomies Have Higher Leak Rates in Subsequent J-Pouch Stages

PurposeThe most common surgery for ulcerative colitis (UC) is the staged restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). On occasion, an emergent first-stage subtotal colectomy must be performed. The purpose of this study was to compare rates of postoperative complications in three-stage IPAA patients who underwent emergent vs non-emergent first-stage subtotal colectomies in the subsequent staged procedures. MethodsThis was a retrospective chart review conducted at a single tertiary care inflammatory bowel disease (IBD) center. All UC or IBD-Unspecified patients who underwent a three-stage IPAA between 2008 and 2017 were identified. Emergent surgery was defined as that performed on an inpatient who had perforation, toxic megacolon, uncontrolled hemorrhage, or septic shock. The primary outcomes were the presence of anastomotic leak, obstruction, bleeding, and the need for reoperation for each within a 6-month postoperative period of the second (RPC with IPAA and DLI) and third surgical stages (ileostomy reversal). ResultsA total of 342 patients underwent a three-stage IPAA, of which 30 (9.4%) had emergent first-stage operations. Patients who underwent an emergent STC were more likely to have a post-operative anastomotic leak and need an additional procedure following the subsequent second and third-staged operations on both univariate and multivariate analysis (p < 0.05). No difference was found for obstruction, wound infection, intra-abdominal abscess, or bleeding (p > 0.05). ConclusionThree-stage IPAA patients with emergent first-stage subtotal colectomies were more likely to have a post-operative anastomotic leak and need an additional procedure for a leak following the subsequent second- and third-stage operations.

Outcomes of surgical treatment of congenital cataract with microphthalmia in infancy

Objective: To examine the outcomes of surgical treatment for infants with congenital cataract and microphthalmia (CATM). Methods: It was a retrospective case series study. Data of 28 (55 eyes) CATM children who underwent cataract surgery at the Qingdao Eye Hospital of Shandong First Medical University and were followed up for more than 5 years between January 2010 and December 2014 under the age of 6 months. There were 15 male and 13 female children. The age at the time of surgery was (3.2±1.3) months, and the follow-up time was (8.2±1.7) years. The data included the basic information of the children, the ocular biological parameters before and after surgery and intraocular lens (IOL) implantation, and the occurrence of complications. Paired t-tests or Wilcoxon signed rank tests were used to compare groups, and logistic regression analysis was used to identify factors related to IOL implantation, secondary glaucoma, and visual axis opacification (VAO). Results: The mean preoperative axial length was (16.6±1.0) mm, and the mean horizontal corneal diameter was (9.5±0.9) mm. The axial growth rate within 2 years after the first stage of surgery was (1.4±0.8) mm/year. None of the children had an IOL implanted before the age of 2. Sixty percent of the eyes (33/55) received IOL implantation within 2 to 4 years after the first stage of surgery, while the remaining 40% (22/55) did not receive IOL implantation at the last follow-up. The axial growth rate was (0.9±0.7) mm/year within two years after the second stage of surgery. Postoperative secondary glaucoma occurred in 7 eyes (12.7%), and VAO occurred in 15 eyes (27.3%). IOL implantation was associated with preoperative axial length (OR=0.072, P<0.001) and age at the first stage of surgery (OR=7.270, P<0.001), but not with preoperative corneal diameter (P=0.735). The incidence of VAO was associated with preoperative corneal diameter (OR=4.124, P=0.011), but not with age at the first stage of surgery (P=0.489) or preoperative axial length (P=0.489). No factors related to the occurrence of secondary glaucoma were found. The best corrected visual acuity at the last follow-up after IOL implantation was (0.37±0.28) logMAR, which was better than that of children without IOL implantation (0.67±0.19) logMAR (U=49.50, P=0.003). Conclusions: Children with CATM can obtain the opportunity for IOL implantation through early surgery and ultimately achieve good visual outcomes. Properly selecting the timing for implanting IOL can keep the incidence of secondary glaucoma at an acceptable level.

Clinical, histological, and histomorphometrical comparison of CenoBone® with and without plasma rich in growth factor for edentulous ridge preservation in the dental sockets.

The aim of this study was to compare the clinical, histological, and histomorphometrical outcomes of CenoBone® allograft with and without plasma rich in growth factor (PRGF) for the preservation of edentulous ridge in the dental sockets. This study is experimental clinical trial that 14 dental sockets were included the sockets required ridge preservation followed by implant placement in the premolar and molar of the mandible. After extraction of the teeth, the CenoBone® allograft and PRGF were used in the test group and CenoBone® allograft was used alone in the control group. During the first stage of surgery and 5 months later, in the second stage of surgery (implant placement), the vertical changes of the ridge were measured. Furthermore, using Core-Biopsy in the second stage of surgery, criteria of histologic and histomorphometric were determined. Data were analyzed with t-test, Mann-Whitney U-test, and Fisher's exact test at the level of significance of P < 0.05. The mean trabecular thickness in the test group (52.18 ± 5.53) was significantly higher than that in the control group (41.53 ± 10.40) (P = 0.344). However, there were no significant differences in the mean values of vertical bone absorption, bone percentage, remaining biomaterials, inflammation, and blood vessels between the two groups. There was no case of foreign body reaction and the bone was vital in all the cases and in direct contact with the biomaterial. Although CenoBone® allograft with PRGF was effective in some histomorphometric factors such as trabecular thickness, it did not lead to significant clinical changes.

Antibiotic artificial bone implantation for the treatment of infection after internal fixation of tibial plateau fractures

ObjectiveTo explore the clinical effect of antibiotic artificial bone (Calcium phosphate) in the treatment of infection after internal fixation of tibial plateau fractures.MethodsWe retrospectively reviewed the clinical data of 32 patients with infection after internal fixation of tibial plateau fractures treating from March 2010 to October 2021. There were 18 males and 14 females, aged from 23 to 70 (average 49.66 ± 10.49), 19 cases of the left side and 13 cases of the right side. Among them, 7 cases were open fractures with initial injury and 25 cases were closed fractures. On the basis of thorough debridement and implanting antibiotic artificial bone, the internal fixation of 18 patients were tried to be preserved and the internal fixation of 14 patients were removed completely. In order to provide effective fixation, 14 patients also received external fixation. Postoperative wound healing, infection control, Hospital for Special Surgery knee scores (HSS), related inflammatory indicators and bone healing time were recorded and followed up.ResultsThirty-two patients were followed up for 12 ~ 82 months (average 36.09 ± 19.47 months). The redness, swelling and pain of pin site occurred in 2 patients, which returned to normal after applying antibiotics and continuous dressing change. One patient retained the internal fixation during the first-stage operation. Redness and swelling of incision, subcutaneous undulation occurred after two months. In order to avoid the recurrence of infection, the internal fixation was removed completely and antibiotic artificial bone was filled again. The infection was controlled and fracture healed. Four patients’ wounds could not be closed directly due to soft tissue defect and was covered with skin flap. After the first-stage operation, 12 patients received second-stage autologous iliac bone grafting due to residual bone defects and poor healing of the fracture end. The bone healing time was 4 ~ 16 months (average 7.31 ± 2.79 months). Inflammatory indicators including CRP, ESR, and WBC returned to normal levels within 2 ~ 10 weeks (average 4.97 ± 2.58 weeks). The HSS of all patients were 54 ~ 86 points (average 73.06 ± 8.44 points) at the last follow-up.ConclusionImplantation of antibiotic artificial bone, retention or removal of internal fixation according to infection and fracture healing, application of external fixation timely is an effective method to treat infection after internal fixation of tibial plateau fractures, which can control infection effectively and promote functional recovery.

Two stages of salvaging an extensively necrotic foot with chronic limb‐threatening ischemia by arterialization of great saphenous vein and free latissimus dorsi musculocutaneous flap transfer for wound coverage with the arterialized vein as the recipient vessel: A case report

Patients with chronic limb-threatening ischemia (CLTI) without other options for adequate arterial revascularization could undergo deep (or distal) venous arterialization for limb salvage. Additionally, patients with extensive foot wound with CLTI sometimes require free flap transfer for limb salvage. We herein report a case of successful reconstructive limb-salvage surgery for an extensively necrotic foot with CLTI, using a two-stage operation involving venous arterialization using foot-perforating veins and subsequent free flap transfer (with preservation of the arterialized vein). The patient was a 59-year-old man with CLTI. The patient's right foot had dry necrotic tissue after Lisfranc joint amputation. Only one straight-line to the posterior tibial artery was achieved after endovascular therapies (four times). At the first stage of surgery, an arterial-venous shunt bypass from the superficial femoral artery to the distal great saphenous vein (GSV) (near the foot-perforating vein) was created. Arterial blood supply reached the necrotic area via the foot venous circulation system. At the second stage of surgery, free latissimus dorsi musculocutaneous flap (8 × 27 cm) transfer with preservation of the arterialized vein was performed. The pedicle artery was anastomosed to the bypass graft (end-to-side). The pedicle vein was anastomosed to the proximal stump of the GSV (end-to-end). The flap and residual foot survived completely, at a one-year follow-up postoperatively. An indocyanine green bypass-through angiography revealed the angiosome through the venous arterialization bypass graft, which included the flap; entire forefoot; and partial regions of the midfoot and heel. This two-stage operation might be considered a useful option for limb-salvage and complete wound-healing in patients with severe non-healing wound with CLTI. The two methods could compensate and overcome the problems of either method: incomplete wound-healing after venous arterialization, and the absence of a recipient artery for free flap transfer.

The effect of staged TIP urethroplasty on proximal hypospadias with severe chordee

BackgroundProximal hypospadias with severe chordee is still a formidable challenge for most pediatric urologists, and the treatment approach remains controversial. Here, we describe a modified two-stage technique to repair proximal hypospadias with severe chordee.MethodsWe retrospectively identified 53 children referred for proximal hypospadias with severe chordee from July 2016 to July 2019, who underwent a two-stage urethroplasty. In group 1, the children were repaired with staged tubularized incised plate (TIP) urethroplasty, while Byars’ two-stage urethroplasty was attempted in group 2. We corrected chordee by releasing all remaining attachments to the corpora after degloving the penis, transceting the urethral plate, and dorsal plication. The mean age of patients in the first stage of surgery was 26.6 months in group 1 and 24.8 months in group 2. Postoperative complications in the two groups included: fistula, urethral stricture, urethral diverticulum, and glanular dehiscence.ResultsA total of 20 cases were repaired with staged TIP urethroplasty (group 1), and 33 cases were repaired with Byars’ two-stage urethroplasty (group 2). The length of follow-up in group 1 was 39.8 ± 10.1 months, and in group 2, it was 38.1 ± 8.7 months (P > 0.05). After the second stage of surgery, 1 case (5%) in group 1 and 11 cases (33.3%) in group 2 developed a urinary fistula (P < 0.05). One case (5%) in group 1 and three cases (9.1%) in group 2 had urethral stricture (P > 0.05). All strictures were cured by repeated dilation, and no patient required reoperation. No cases in group 1 and one case (3%) in group 2 had urethral diverticulum (P > 0.05). There was no residual chordee in both groups. Two cases (10%) in group 1 and 13 cases (39.3%) in group 2 required reoperation (P < 0.05).ConclusionsStaged urethroplasty is appropriate to repair proximal hypospadias with severe chordee. Particularly, staged TIP urethroplasty is a good choice for patients with proximal hypospadias and severe chordee, especially those with better penile development, wider urethral plate, larger glans, and deeper navicular fossa of the urethra.