Grade IIIb Research Articles

Laparoscopic radical nephroureterectomy with only three trocars: Results of a prospective single centre study.

Radical nephroureterectomy (RNU) with full bladder cuff excision is the gold standard for treatment of non-metastatic upper tract urothelial cancer (UTUC). We describe our technique of laparoscopic nephroureterectomy (LNU) with bladder cuff excision technique with modified port placement, reporting our long-term follow-up outcomes. Patients affected by UTUC were prospectively enrolled and undergone to LNU. Perioperative outcomes, oncological data at 6, 12, 24 and 36 months after surgery, and all the surgical complications according to Clavien-Dindo classification were evaluated in all subjects. A total of 50 patients with UTUC underwent LNU, using this new technique without patient and port repositioning. The mean operative time was 168 minutes, estimated blood loss was 75 mL, mean length of hospital stay was 3 days. There were no intraoperative complications while four late complications occurred (two grade IIIb and two grade II according to Clavien-Dindo classification, incisional hernias and fever, respectively). Postoperative pathology was T1 in 12 patients, T2 in 17 patients, and T3 in 21 patients. Tumor grade was low in 12 patients and high in 38 patients. In our study the described LNU technique was related to a significant reduction in terms of operative time and length of hospital stay, with a faster patients' recovery and no peri and postoperative complications. The long-term oncological outcomes were similar to data reported in literature.

APPLICATION OF PROBLEM-BASED LEARNING MODEL ON MULTIPLICATION AND DIVISION MATERIAL TO IMPROVE STUDENT LEARNING OUTCOMES IN GRADE III SD NEGERI 4 BANDA ACEH

Based on observations, one of the problems in SD Negeri 4 Kota Banda Aceh is the low learning outcomes of students in mathematics subjects. The application of the Problem Based Learning model can provide a pleasant atmosphere for students in learning multiplication and division material. This study used the type of Classroom Action Research (PTK). The subjects of this study amounted to 23 students of grade III-B SD Negeri 4 Banda Aceh City, data collection techniques were carried out by observation, documentation, and learning outcomes tests. The technique of analyzing data from observations of student activities is with percentage descriptive statistics and individual student learning outcomes data. Based on the results of research in cycles I, II, and III obtained the following data: (1) the results of observations on student activities in learning observed for three cycles, increased in each cycle, namely: student activity in cycle I reached 82% of the good category, cycle II reached 84% of the good category, and cycle III reached 98% of the very good category. (2) the learning outcomes of students in multiplication and division material increased in cycle I of classical completeness criteria reaching 34% with an average value of 57.39, in cycle II classical completeness criteria of 69% with an average value of 71.37, while cycle III of classical completeness criteria 91% with an average value of 84.34. It was concluded that the Problem Based Learning learning model on multiplication and division material can improve the learning outcomes of grade III-B students of SD Negeri 4 Banda Aceh City.

Real-world study of surgical treatment of pancreatic cancer in China: annual report of China Pancreas Data Center (2016–2020)

Abstract Objective: In 2015, the Chinese Pancreatic Association of the Chinese Society of Surgery of the Chinese Medical Association launched a national multicenter online system for registration of surgical treatment of pancreatic cancer in China, called China Pancreas Data Center (CPDC). With continued effort, the CPDC has developed over time. Herein, we report the general results of the CPDC from January 2016 to January 2020 to present the real-world situation of surgical treatment of pancreatic cancer in China. Methods: The data of the CPDC from January 2016 to January 2020 were retrieved and analyzed in this real-world study, including the data on patient demographics, comorbidities, diagnostic modalities, neoadjuvant treatment, surgical procedures, postoperative complications and treatment, pathological examinations, postoperative adjuvant treatment, survival, and risk factors. Results: A total of 13,595 cases from 70 centers in 28 provinces were retrieved for analysis. This study reported the largest cohort of patients who underwent surgical treatment for pancreatic cancer in China to date. More cases were derived from the Eastern regions, among which Shanghai, Beijing, and Zhejiang ranked in the top three. The peak age of the patients ranged from 60 to 69 years. The ratio of males to females was 1.5:1. Overall, 64.3% of the tumors were located in the head and neck of the pancreas, and 35.7% in the body and tail of the pancreas. Of the patients, 23.0% underwent positron-emission tomography-computed tomography, 21.6% underwent endoscopic ultrasound, and 4.8% underwent preoperative biopsy. Two percent of the patients underwent neoadjuvant treatment, while 68.9% underwent R0 surgical resection (margin free of tumor cells). Of the latter, 78.6% of the operations were open procedures, 12.6% were laparoscopic procedures, 2.9% were robotic procedures, and 3.7% were converted to open procedures. The in-hospital mortality rate after surgery was 0.4%. The incidence of grade 2 and grade 3 postoperative pancreatic fistulas was 25.5% and 2.5%, respectively. The incidence of complications based on the Clavien-Dindo classification was 17.9% of grade II, 4.3% of grade IIIa, 1% of grade IIIb, and 0.6% of grade IV. Of the patients, 28.9% underwent postoperative adjuvant chemotherapy. The 1-year, 2-year, and 3-year overall survival of these patients were 77%, 51%, and 38%, respectively. In the 8542 patients who underwent R0 resection, the 1-year, 2-year, and 3-year overall survival and disease-free survival were 77%, 54%, and 43%, and 68%, 49%, and 41%, respectively. The factors related to the prognosis of these patients were also identified after uni- and multi-variate analyses. Conclusion: The surgical quality, safety, and long-term survival of the patients in CPDC are similar to those of international high-volume pancreatic centers. However, neoadjuvant and postoperative adjuvant chemotherapy should be improved.

Assessment of ESGO Quality Indicators in Cervical Cancer Surgery: A Real-World Study in a High-Volume Chinese Hospital.

The ESGO developed a list of fifteen quality indicators for cervical cancer surgery in order to audit and improve clinical practice in 2020. However, data from the developing countries with high incidence rates of cervical cancer is still lacking. Therefore, we conducted a retrospective study of 7081 cases diagnosed as cervical cancer between 2014 and 2019 in a Chinese single center according to the quality indicators proposed by ESGO. A total of 5952 patients underwent radical procedures, with an average of 992.0 per year. All surgeries were performed or supervised by a certified gynecologic oncologist as surgical qualification grading system has been established. Compared with the low-volume group, patients in the high-volume group (≥15 cases/year) had a shorter hospital stay (P<0.001), more free surgical margins (P=0.031), and less complications (P<0.001), but the 5-year recurrence-free survival and overall survival rates were similar (P>0.05). Treatment was not planned at a multidisciplinary team meeting but with the consultation system. The required preoperative workup was incomplete in 19.7% of patients with pelvic MRI and 45.7% of patients with PET-CT. A total of 1459 (20.6%) patients experienced at least one complication after surgery. The CDC grade IIIb or higher complications occurred in 80 patients, accounting for 5.5% complications. The urological fistula rate within 30 postoperative days were 0.3%. After primary surgical treatment, 97.4% patients had clear vaginal and parametrial margins. After restaging FIGO 2009 to FIGO 2018 system, 14.7% patients with a stage T1b disease were T-upstaged. After a median follow-up of 42 months, recurrence occurred in 448 patients, and 82.1% patients recurred within 2 years. The 2-year RFS rate of patients with pT1b1N0 was 97.3% in 2009 FIGO staging system. Lymph node staging was performed in 99.0% patients with a stage T1 disease. After a primary surgical treatment for a stage pT1b1N0 disease, 28.3% patients received adjuvant chemoradiotherapy. Above all, most of quality indicators reached the targets, except four quality indicators. The quality indicators of ESGO should be popularized and applied in China to guarantee quality of surgery.

The decision in severe upper-limb injuries: amputation or reconstruction? A retrospective case series

Background: Large bone defects in the humerus that are associated with severe soft-tissue loss are a challenge. The aim of this study was to share the authors’ experience with the use of an Ilizarov apparatus in treating patients with severe open humeral fractures with large bone defects and soft-tissue compromise. The authors propose important prognostic factors for surgeons to consider when deciding on treating such cases. Methods: Sixteen patients with severely injured upper extremities with open humeral fractures associated with bone loss were treated with Ilizarov distraction osteogenesis in an attempt to salvage the limb. Trauma etiology were motor vehicle accidents in 12 patients and machine crushing injuries in four. All patients had open fracture Gustilo-Anderson grade IIIB. The mean bone loss was 10.67 cm (average, 5 cm to 19.5 cm). The radial nerve was completely lost at the site of injury or cut in all patients, the ulnar nerve was found in six patients, and the median nerves and brachial arteries were intact in all patients. Results: The mean age of patients was 31.1 yr (range, 21 to 42 yr). Twelve patients were men (75%). The left limb was injured in seven patients (43.75%), and all patients were right-hand dominant Average time of fixator use was 256.87 days, (range, 220 to 355). The mean follow-up period was 4.02 yr (range, 3 to 5 yr). At the end of the follow-up period, all sixteen limbs were salvaged, and bony union was achieved in all patients. Conclusions: In severely injured upper limbs, regardless of severity scores, the authors believe that reconstructive vascular impairment is the only reasons to carry out an amputation. Level of Evidence: Level IV.

Superior mesenteric venous thrombosis: Endovascular management and outcomes.

BACKGROUNDSuperior mesenteric venous thrombosis (SMVT) is a rare but fatal condition that is typically treated initially with anticoagulation therapy, and if this fails, with endovascular interventions. However, due to its rarity, there are not many studies that have explored the effectiveness of anticoagulation and endovascular therapies in treating SMVT.AIMTo evaluate patients diagnosed with SMVT who received endovascular therapy in addition to anticoagulation and report technical and clinical outcomes.METHODSA retrospective analysis of the patients who underwent endovascular treatment for SMVT at Mayo Clinic from 2000-2019 was performed. Technical success was defined as angiographic improvement in SMV flow after intervention. Primary patency was defined as the interval from reestablishing mesenteric venous flow until the first repeat thrombotic event or need for additional intervention. Secondary patency was defined as successful restoration of flow after repeat intervention until rethrombosis or last follow-up. The adverse events were reported through Clavien-Dindo classification.RESULTSTwenty-four patients were included for analysis. The median age at intervention was 60 years (35-74 years) and 16 (67%) were men. Nineteen patients presented with acute thrombosis (79.2%) and 5 with chronic thrombosis with acute manifestations (20.8%). The most commonly used endovascular modalities were thrombectomy in 12 patients (50.0%) and catheter-directed thrombolysis in 10 patients (41.7%). Technical success was achieved in 18 patients (75%). The 14-d and 30-d primary patency rates were 88.9% and 83.3%, respectively. Adverse events were reported in two patients (8.3%), one marked as grade IIIB, and 1 death marked as grade V. Five-year overall survival rate was 82% (58%-100%).CONCLUSIONEndovascular intervention with anticoagulation appears to be effective for managing SMVT. This treatment combination may be considered as first-line therapy for SMVT management in select patients.

Pancreas Transplantation with Duodeno-Duodenal Anastomosis: A Single-Center Experience

Introduction: Techniques such as retroperitoneal graft placement have further improved the ability to reproduce the physiology of the “native” pancreas. We herein present our experience of a technique for pancreatic transplant, with the organ placed into a fully retroperitoneal position with systemic venous and enteric drainage of the graft by duodenoduodenostomy. Methods: All pancreas transplantations performed between May 2016 and July 2021 were prospectively entered into our transplant database and retrospectively analyzed. Results: A total of 81 transplants were performed using the duodenoduodenostomy (43 men: median age of 42 years [IQR 36-50]). Median cold ischemia times was 9 hours [IQR 7-10.4]. The preservation solution used was Celsior (n=19), IGL-1 (n=49), and UW (n=13). Regarding morbidity, 43.2% of patients presented pancreas related complications: abdominal hemorrhage (n=8, 9.9%); graft pancreatitis (n=5, 6.2%); fluid collections (n=9, 11.1%); and vascular thrombosis (n=20, 24.7%). Intestinal complications (n=7, 8.6%) were: intestinal obstruction (n=2); paralytic ileus (n=2); dehiscence in duodenum after pancreas transplantectomy (n=1); dehiscence of duodeno-duodenostomy (n=2). Of these, four cases required relaparotomy: adhesiolysis (n=2); transplantectomy (n=1); primary leak closure (n=1). According to the Clavien-Dindo classification, pancreas complications were: Grade I: 3.7 %, Grade-II: 13.6 %, and Grade IIIa:4.9%, Grade IIIb: 21%. The median hospital stay was 13.5 days. After a median follow-up of 30.7 months [IQR 18.1-44], the 1 and 3-year graft survival was 89.5%, respectively, with no patient mortality. Conclusions: Retroperitoneal graft placement with duodenoduodenostomy is safe and feasible, with a low rate of intra-abdominal complications, providing competitive results in terms of graft/patient survival.

Total parietal peritonectomy for 61 patients: a retrospective study

Objective: To evaluate the morbidity of total parietal peritonectomy (TPP) during cytoreduction surgery, and its impact on the site of recurrence of different peritoneal surface malignancies (PSM). Methods: We led a retrospective study in a French tertiary cancer institution (Centre Oscar Lambret - Lille) experienced in treating PSM over a 6-year period from 2012 to 2018. All patients underwent a total parietal peritonectomy during a debulking surgery for PSM including ovarian cancer, appendiceal pseudomyxoma peritonei or peritoneal mesothelioma. Results: Among the 61 patients included in this study, 49 patients(80.3%) had an ovarian cancer. The rate of complete tumor resection reached 86.9% with almost 69% of surgeries being highly complex. 73.8% were transfused during the surgical procedure. The median length of hospital stay was 10 days including 7 days in Intensive Care Unit. Overall, 19 patients (31.1%) had an early postoperative complication, including 3 with a grade IIIB complication of Clavien Dindo classification. With a median follow-up of 30 months, the estimated disease-free survival in the ovarian cancer subgroup who had an initial peritonectomy (n = 42) was 84.7% at 1 year and 12.0% at 3 year. The main site of first and second recurrence was peritoneal (42% and 14%). Conclusion: TPP is a safe surgical procedure to treat peritoneal surface malignancies and their recurrences with a low rate of grade IIIB morbidity and no treatment-related death and allow optimal surgery. In this study there is no atypical recurrence site, such as abdominal muscle involvement.

Mango-shaped Bi-paddled pectoralis major myocutaneous flap reconstruction for large full-thickness defects post resection of squamous cell carcinoma of oral cavity: An analysis of 232 cases.

Objectives:The objective of the study was to examine the feasibility of bi-paddled pectoralis major myocutaneous (PMMC) flap reconstruction in patient undergoing full thickness composite resection.Materials and Methods:Inclusion criteria: The subjects chosen were patients with clinically T4A squamous cell carcinoma of buccal mucosa, lower alveolus, and maxilla in with skin involvement. Patients required a full-thickness composite resection of intraoral lesion, bone (mandibular segment and/or maxilla), and overlying involved skin and had modified radical neck dissection. Exclusion criteria: Patients not requiring full thickness composite resection including skin. Patients were observed postoperatively for early and late postoperative complications, starting of oral feeding, post-operative trismus, and dysphagia during subsequent follow-up and cosmetic outcome.Results:Overall, the complication rate was 33.8% out of which only 7.8% required major re-surgery with second flap reconstruction. This is comparable with other large series of PMMC flap. Clavien-Dindo Grade I complications were seen in 9.5%, Grade II in 69.7%, Grade IIIA in 13.4%, and Grade IIIB in 7.45% of patients. Full-thickness partial flap necrosis included necrosis of either the external or the internal skin paddle. There were 15 cases – 6.5% of full thickness external paddle necrosis. These were mostly in patients with bite composite resections and having a larger random fasciocutaneous distal component of the flap without underlying muscle. Furthermore, 40% of these patients were females. In females, the flap necrosis comprised 4 of the 12 patients (33.33%).Conclusion:Pectoralis major mycocutaneous flap has been a boon to reconstruction of the oral cavity post its inception. In case of locally advanced squamous cell carcinomas of the oral cavity, in many instances, there is a clinically significant cervical lymph nodal spread vessels post mandating a comprehensive lymph node dissection. PMMC flap provides a robust well vascularized muscular cover to the cervical vessels poststernocleidomastoid excision.

Diagnosis and treatment status of perioperative anemia in patients with gastrointestinal neoplasms: a multi-center study in Hubei Province

Objective: To investigate the incidence and treatment of perioperative anemia in patients with gastrointestinal neoplasms in Hubei Province. Methods: The clinicopathological data of 7 474 patients with gastrointestinal neoplasms in 62 hospitals in 15 cities (state) of Hubei Province in 2019 were collected in the form of network database. There were 4 749 males and 2 725 females. The median age of the patients was 62 years (range: 17 to 96 years). The hemoglobin value of the first time in hospital and the first day after operation was used as the criterion of preoperative anemia and postoperative anemia. Anemia was defined as male hemoglobin <120 g/L and female hemoglobin <110.0 g/L, mild anemia as 90 to normal, moderate anemia as 60 to <90 g/L, severe anemia as <60 g/L. The t test and χ2 test were used for inter-group comparison. Results: The overall incidence of preoperative anemia was 38.60%(2 885/7 474), and the incidences of mild anemia, moderate anemia and severe anemia were 25.09%(1 875/7 474), 11.37%(850/7 474) and 2.14%(160/7 474), respectively. The overall incidence of postoperative anemia was 61.40%(4 589/7 474). The incidence of mild anemia, moderate anemia and severe anemia were 48.73%(3 642/7 474), 12.20%(912/7 474) and 0.47%(35/7 474), respectively. The proportion of preoperative anemia patients receiving treatment was 26.86% (775/2 885), and the proportion of postoperative anemia patients receiving treatment was 14.93% (685/4 589). The proportions of preoperative anemia patients in grade ⅢA, grade ⅢB, and grade ⅡA hospitals receiving treatment were 26.12% (649/2 485), 32.32% (85/263), and 29.93% (41/137), and the proportions of postoperative anemia patients receiving treatment were 14.61% (592/4 052), 22.05% (73/331), and 9.71% (20/206). The proportion of intraoperative blood transfusion (16.74% (483/2 885) vs. 3.05% (140/4 589), χ²=434.555, P<0.01) and the incidence of postoperative complications (17.78% (513/2 885) vs. 14.08% (646/4 589), χ²=18.553, P<0.01) in the preoperative anemia group were higher than those in the non-anemia group, and the postoperative hospital stay in the preoperative anemia group was longer than that in the non-anemia group ((14.1±7.3) days vs. (13.3±6.2) days, t=5.202, P<0.01). Conclusions: The incidence of perioperative anemia in patients with gastrointestinal neoplasms is high. Preoperative anemia can increase the demand for intraoperative blood transfusion and affect the short-term prognosis of patients. At present, the concept of standardized treatment of perioperative anemia among gastrointestinal surgeons in Hubei Province needs to be improved.

Learning curve for single-port robot-assisted rectal cancer surgery.

PurposeWe analyzed the learning curve of single-port robotic (SPR)-assisted rectal cancer surgery.MethodsFifty-seven consecutive SPR-assisted rectal cancer surgery cases performed by the same surgeon were considered in surgical interventions for rectal cancer. Total operation time (OT), docking time (DT), and surgeon console time (SCT) measured during surgery were used to parametrize the learning curve. The parameters representing the learning curve were evaluated using the cumulative sum (CUSUM).ResultsThe mean value of total OT was 241.8 ± 91.7 minutes, the mean value of DT was 20.6 ± 19.1 minutes, and the mean value of SCT was 135.9 ± 66.7 minutes. The learning curve was divided into phase 1 (initial 16 cases), phase 2 (second 16 cases), and phase 3 (subsequent 25 cases). The peak on the CUSUM graph occurred in the 21st case. The longest OT among phases was in phase 2. Complications were most frequent in phase 2. However, complications of Clavien-Dindo (CD) grade IIIb were most frequent in phase 3 with 2 patients. The most common complications were fluid collection and urinary retention (7 patients each). Complications of CD grade IIIb required one stomal revision due to stoma obstruction and one irrigation and loop ileostomy due to anastomosis leakage.ConclusionImprovement in surgical performance of SPR assisted rectal cancer operation was achieved after 21 cases. The three phases identified in the cumulative sum analysis showed a significant decrease in operative time after the middle stage of the learning curve without an increase in the complication rate.

Early Diagnosis of Postpancreatectomy Acute Pancreatitis after Pancreaticoduodenectomy: A Study Using Biomarkers and Diffusion-Weighted Magnetic Resonance Imaging

Introduction: Early phases of postpancreatectomy acute pancreatitis (PPAP) are poorly characterized but might represent novel therapeutic opportunities. This study aims to investigate the radiologic, biochemical, and clinical spectrum associated with PPAP. Method: 65 patients undergoing pancreaticoduodenectomy prospectively collected. IVIM magnetic resonance imaging (MRI) at 1.5T scanner was performed on a postoperative day (POD) 3. Serum pancreatic amylase and lipase were assessed after surgery and daily until POD 5. PPAP was defined based on radiologic findings. Results: PPAP incidence was 9.2%. All patients with PPAP had a sustained increased serum enzyme activity persisting at least 48 hours (POH–postoperative serum hyper-amylasemia, -lipasemia) and lead to the worst postoperative outcome with (all p<0.05) high incidence of local (postoperative pancreatic fistula: 83%) and systemic morbidity (Clavien Dindo≥grade IIIb: 67%). Still, 21.5% and 24.6% of cases with no radiologic features of PPAP showed POH, without significant differences in median serum activity. Patients with POH-PPAP had significantly lower values of true diffusion coefficient (D) and higher heterogeneity of perfusion parameters: D* and F on IVIM MRI. No macroscopic changes consistent with PPAP were identified at any MRI. 21 patients subsequently underwent computer tomography imaging for clinical worsening, and 6 have PPAP confirmed. Conclusions: PPAP is characterized by early biochemical alteration, without correlation between severity and enzymes elevation. Macroscopic radiologic changes appear later and correlate with the most severe clinical pictures. This paper paves the ground for future prospective series validating correlations between biochemical and radiological features, eventually leading to changes in clinical practice management.

Results of reconstructive surgery with formation of low colorectal anastomoses after previous Hartmann's procedure

To evaluate the efficacy and safety of original access to short rectal stump compared to traditional direct one. A retrospective-prospective cohort comparative study was conducted between 2012 and 2018. Inclusion criterion was previous Hartmann's procedure with formation of a short rectal stump. Short stump was determined by its length from anal-skin line to the cupola <7 cm. There were 93 patients who were divided into 2 groups: the main group - new approach (n=38), the control group - traditional direct approach (n=55). We analyzed surgery time, blood loss, intraoperative, early and late postoperative morbidity. Surgery time and blood loss were similar in both groups (299.9 vs. 288.3 min, p=0.82; 204.5 vs. 112.4 ml, p=0.94, respectively). Intraoperative complications occurred in 7 patients of the control group (0 vs. 12.7% (7/55), p=0.02). Incidence of early postoperative complications was similar (28.9% (11/38) vs. 25.5% (14/55), p=0.71). Adverse events Clavien-Dindo grade I and IIIa were more common in the main group, grade IIIb and IVa - in the control group. Incidence of delayed postoperative complications were similar (10.5% (4/38) vs. 7.3% (4/55), p=0.58). Colorectal anastomosis stricture prevailed in the control group, ureteral stricture - in the main group. Neurophysiological and complex urodynamic examinations revealed no between-group differences. The new method ensures access to the rectal stump and formation of colorectal anastomosis under direct visual control. Postoperative outcomes demonstrated safety and effectiveness of this technique.

Impaction Bone Grafting for Severe Femoral Bone Loss: Surgical Technique in Revision Total Hip Arthroplasty.

The specific steps to perform this procedure include (1) preoperative planning; (2) positioning of the patient and surgical approach; (3) cautious removal of the previous components; (4) preparation of the bone graft; (5) implantation of the appropriate IBG revision system, restoring bone loss from distal to proximal and utilizing metal mesh as needed; (6) implantation of the new stem, bypassing the defect; and (7) aftercare with protected weight-bearing in order to avoid subsidence of the stem and periprosthetic fracture. There are several alternatives to the IBG technique in the setting of revision total hip arthroplasty with extensive femoral bone loss. These alternatives include distal cementless fixation (either modular or nonmodular), a megaprosthesis, or an allograft-prosthesis composite. The rationale for use of the IBG technique is restoration of bone stock. Although this issue may be irrelevant in low-demand elderly patients, we believe it is of the utmost importance among young (i.e., <60 years old) and active patients. This technique is versatile enough to be utilized in different scenarios such as periprosthetic fracture, periprosthetic joint infection (2-stage protocols), and aseptic loosening. We have reported favorable clinical and radiographic outcomes for the treatment of both aseptic and septic femoral component loosening. In all cases, we utilized vancomycin-supplemented impacted cancellous allograft without evidence of secondary effects with regard to bone incorporation, nephrotoxicity, or allergic reactions. Although it was initially contraindicated, we further extended the indication for this reconstruction alternative to cases of circumferential proximal bone loss with non-neoplastic bone defects of ≤15 cm, utilizing encompassing metal mesh and a bypassing long stem. Recently, we reported on poorer outcomes following IBG compared with the use of uncemented modular stems for the treatment of type B3 periprosthetic femoral fractures, with a significantly higher rate of infection and implant breakage for the former treatment. Nowadays, we advocate the use of this technique in young, active patients (i.e., <60 years old) with a femoral bone defect Paprosky grade IIIB or IV, in which reconstitution of bone stock is crucial to avoid an eventual implant failure in the long term. This technique requires an experienced team. This procedure should be avoided in the presence of active periprosthetic joint infection.The gluteus maximus tendon should be detached to avoid tensioning the sciatic nerve and to decrease the chance of periprosthetic femoral fracture.Massive bone loss can jeopardize correct implant orientation and restoration of biomechanics. In this scenario, surgeons might consider the intercondylar axis as a guide for femoral version.Try to avoid (if possible) trochanteric or extended trochanteric osteotomy because proximal bone stock is necessary to contain the bone grafts. In some cases, such as those in which the removal of the stem is difficult, especially with certain uncemented stem designs, an extended trochanteric osteotomy must be performed. Whether or not a cemented stem is removed, it is mandatory to remove all remaining cement in the femoral canal.Preoperative templating is a necessity to reconstruct leg length. Accurately determining the length of the mesh is the most important step to avoid shortening or overlengthening of the lower extremity.Approximately 10 cm of circumferential metal mesh should be fixed with 3 to 5 double cerclage metal wires to the remaining bone. The new femoral stem should bypass extend beyond the mesh for approximately 5 cm. If the stem does not bypass the mesh, there is an increased risk of postoperative fracture.In order to decrease the risk of intraoperative femoral fracture, the distal aspect of the femur should be secured with cerclage wires, and the proximal aspect of the femur should also be protected with cerclage wires over the mesh. As in any other complex femoral revision procedure, torsional forces in the supracondylar zone should be avoided, especially during trial or stem reduction maneuvers.Always utilize a bone graft mixed with antibiotic powder.Retrograde cementation must be done with cement that is in a more liquid state than in primary total hip arthroplasty. PO = postoperativePMMA = polymethyl methacrylateIV = intravenousLMWH = low molecular weight heparinDVT/EP = deep vein thrombosis and extended prophylaxis.

A Case of Pediatric Grade IIIb Pancreatic Trauma: Considerations for Endoscopic and Surgical Procedures

A Case of Pediatric Grade IIIb Pancreatic Trauma: Considerations for Endoscopic and Surgical Procedures

Extracorporeal Hand-Sewn vs. Intracorporeal Mechanic Anastomosis During Laparoscopic Right Colectomy.

Background and Objectives:To compare the outcomes of extracorporeal hand-sewn side-to-side isoperistaltic ileocolic anastomosis (EHSIA) versus intracorporeal mechanic side-to-side isoperistaltic ileocolic anastomosis (IMSIA) during laparoscopic right hemicolectomy for adenocarcinoma.Methods:This is a retrospective propensity score-matched analysis of prospectively collected data. Fifty-four patients who underwent surgery with EHSIA (intervention group) were paired with 54 patients who underwent surgery with IMSIA (control group) based on patients’ demographics and type of surgery (standard right hemicolectomy or extended right hemicolectomy).Results:Fifty-four patients were included for each group. Statistically significant differences between groups were not observed in patients’ demographics and type of surgery. Conversion occurred in three patients of the intervention group due to intra-abdominal adhesions for previous surgery (5.6%) (p = 0.079). Median operative time was statistically significant shorter in the control group in comparison to the intervention group (85 and 117.5 minutes, respectively, p ≤ 0.0001). In both groups one anastomotic leakage was observed (1.9%) (Clavien-Dindo grade III-a). In the control group one patient (1.9%) underwent reintervention for acute postoperative anemia (Clavien-Dindo grade III-b). Median number of harvested lymph-nodes was 17 and 12 (p ≤ 0.0001), in the intervention and the control group, respectively. Median hospital stay was statistically significant lower in the control group in comparison to the intervention group (5 and 6.5 days, respectively, p ≤ 0.013).Conclusion:IMSIA showed lower operative time and hospital stay in comparison to EHSIA. Further randomized studies are required to draw definitive conclusions about the best anastomotic technique during laparoscopic right hemicolectomy.

Purposive bone shortening––a technique which aided soft-tissue coverage in a Grade III Gustillo–Anderson Open Distal Third Leg Fracture: A case report and treatment strategy

Problems faced in open fractures of the distal third tibia are usually associated with soft-tissue coverage, infection control, and union of the bone. Tibia is commonly associated with impaired healing if soft tissues are severely damaged. Not all cases can be treated with flaps due to its unavailability in acute settings, high learning curve, and cost. We present the outcomes of a case of an open Grade III-B Gustillo–Anderson distal tibia fracture treated with debridement and deliberate bony shortening which helped in primary closure of the wound. A 61-year-old gentleman, a known hypothyroid, had an alleged history of accidental cut injury over right lower limb by a machine used for cutting trees. He sustained a 7 cm × 4 cm laceration over the anteromedial aspect of the distal tibia with blown-out soft tissues and bone exposed. Wound debridement and stabilization with ankle spanning external fixation were immediately done. Wound could be primarily closed because the tibia and fibula were deliberately shortened during the external fixation. Many free bone fragments were removed during debridement leaving a bony void. One week later bone graft was used to fill the void after redebridement of the wound and wound could be primarily closed. Negative wound therapy was used as an adjuvant. One month later the external fixator was converted to Ilizarov fixator, which was removed at the end of 5 months, showing a fully healed fracture without soft-tissue complications at the end of 6 months follow-up. Debridement and shortening of the open tibia is a powerful technique to provide bony apposition and allow primary wound closure without tension, averting the need for any secondary reconstructive procedures.

P-OGC93 Weight Loss and Complications in Oesophagectomy and Gastrectomy Patients

Abstract Background Oesophagectomy and gastrectomy are major surgeries which often involve patients fasting for prolonged periods of time post operatively thus requiring alternative nutrition regimens. In addition, patients often suffer dysphagia, anorexia, chemotherapy side effects and significant weight loss prior to surgery. Post-operative concerns include delayed gastric emptying, refeeding syndrome and dumping syndrome. Whilst placement of enteral feeding tubes aids the transition back to normal diet there are often still social, physical and dietary challenges that hinder nutrition. The aim of this study was to review weight loss in patients post operatively and to optimise post-operative nutrition. Methods The records of 113 patients who had undergone an oesophagectomy (43) or gastrectomy (64) between June 2018 and November 2019 at a single regional cancer centre were retrospectively examined. These patients’ contemporaneous weights had been recorded at set peri operative timelines and the greatest percentage weight loss calculated. The percentage weight loss was matched to the highest Clavien-Dindo post-operative complication. Results 89 patients had weights routinely reviewed post operatively, with the remainder not having regular post operative weights documented. The median weight loss was 7.53. For patients undergoing a total gastrectomy (27) weight loss ranged from 7.36-29.2%. Median weight loss was 11.45%. Patients who underwent subtotal gastrectomy (26) had between 0.37-18.5% with a median of 7.83% weight loss. Those who underwent an oesophagectomy (36) had between 0 - 28.67% weight loss with the median being 7.21%. 6 patients had their operations abandoned. Post-operative complications, inclusive of Grade II and above, occurred in 16.8% of cases. Majority of complications occurred in those undergoing an oesophagectomy (64%), however complications did not correlate with percentage weight loss. The most common complication was grade IIIb (Grade I: 8, Grade II: 1, Grade IIIa: 1, Grade IIIb: 14, Grade IVa: 2, Grade V: 2). Conclusions Significant post-operative weight loss is common after oesophagectomy or gastrectomy surgery. Postoperative weight loss did not correlate with complications. Furthermore, there did not appear to be a correlation with weight loss and type of procedure. Nutritional status plays an important prognostic role in patients undergoing oesophagectomy or gastrectomy. Optimising nutrition perioperatively and post operatively is important to enhance post-operative recovery and reduce post operative risk. Reviewing a larger cohort of patients would improve the robustness of this study.

Validity of vetrivel trauma score in predicting salvage of limb in gustilo anderson grade III B and grade III C open fractures

There have been many classification systems developed for open fractures like Gustilo Anderson grading system, Mangled extremity severity score, Ganga hospital open injury severity score. But the gray zone still exists in many open fractures whether the limb has to be salvaged or amputated. The above-mentioned scores have poor sensitivity and specificity in evaluating open fractures. This led to the development of a novel scoring system known as Vetrivel trauma score.This study aims to assess the validity of this novel scoring system in predicting the outcome of limbs in Gustilo Anderson Grade IIIB and Grade IIIC open fractures.One hundred and forty-four open fracture cases were taken for this study. 82 patients sustained Grade III injuries according to the Gustilo Anderson classification. Of these, 35 patients were of Grade IIIB and above. These 35 patients were scored using Vetrivel Trauma score, Ganga hospital open injury severity score, and Mangled extremity severity score.Vetrivel trauma score was compared with Ganga hospital open injury severity score, and Mangled extremity severity score. Analysis indicated Vetrivel trauma scoring system is more accurate than others. The area under the curve of the receiver operating characteristic curve for Vetrivel Trauma score (0.983) is found to be significantly higher than other scoring systems compared.Vetrivel trauma score is a better predictor of injury severity in Grade IIIB and Grade IIIC open fractures with the highest sensitivity and specificity in deciding amputation versus salvage. A score of 39 or more has the highest predictability for amputation.

Ureteral Reimplantation for Primary Obstructive Megaureter in Pediatric Patients: Is It Time for Robot-Assisted Approach?

Objective: To compare open and robotic approach for treatment of Primary Obstructive Megaureter (POM) in a series of pediatric patients. Materials and Methods: Medical records of all patients who had undergone ureteral reimplantation for POM at our institution, between January 2016 and December 2019, were retrospectively collected and analyzed. Open (Group B) and robotic (Group A) approach were compared. Success was defined as reduction of anteroposterior diameter of pelvis and ureter on postoperative ultrasound scan. Surgical complications were reported according to the Clavien-Dindo Classification. Esthetic results were compared through the Vancouver Scar Scale. Results: Out of 23 patients, 11 belonged to Group A (5M and 6F) and 12 to Group B (9M and 3F). Median age at diagnosis was 38 months in Group A and 46 months in Group B (P = .69). Operative times were comparable (150' Group A and 140' Group B; P = .35), but the hospital stay was significantly shorter in the robotic group (P < .01). Success rate was comparable: 90.9% in Group A and 91.7% in Group B, respectively (P = .95). Incidence of early complications was 9.1% in Group A (grade IIIB) and 8.3% in Group B (grade II) (P = .95). Esthetic evaluation obtained a median score of 1 in Group A and 3 in Group B (P < .01). Conclusions: Our preliminary experience shows that robotic reimplantation can be a safe option in the treatment of POM in pediatric patients with clinical outcomes comparable to the open technique.