Higher Incidence Of Reoperation Research Articles

A Risk Prediction Model for Prolonged Length of Stay After Minimally Invasive Valve Surgery.

Minimally invasive surgery determines shorter postoperative hospital length of stay (LOS) even in cardiac surgery. Potential preoperative factors affecting LOS are still not known in minimally invasive heart valve surgery (MIVS). We aimed to identify preoperative variables influencing prolonged LOS in MIVS. We reviewed 189 patients who underwent MIVS via minithoracotomy at our institution. Prolonged LOS was defined as more than 7 postoperative days. Poisson and logistic regression were used to screen the predictors. The mean postoperative LOS was 9.13 days, and 64 patients (33.9%) experienced a prolonged LOS. These patients were older, more frequently in New York Heart Association (NYHA) class III or IV, showed worse left ventricular ejection function (LVEF), and had a higher incidence of reoperation and chronic kidney disease (CKD). At univariate analysis, the most significant preoperative factors affecting prolonged LOS were age (odds ratio [OR] = 1.04), NYHA class III or IV (OR = 3.03), reduced LVEF (OR = 3.22), CKD (OR = 2.7), and redo surgery (OR = 3.6). After adjustment, the most significant preoperative factors predicting prolonged LOS were age (OR = 1.03, 95% CI: 1.01 to 1.06, P = 0.02) and redo surgery (OR = 3.33, 95% CI: 1.29 to 8.9, P = 0.01). The most important factors affecting prolonged LOS after MIVS were represented by age and redo surgery, although other preoperative characteristics such as reduced LVEF, NYHA class III or IV, and CKD play a significant role in delaying recovery after MIVS. Further larger studies are needed to better identify potential preoperative predictors of prolonged LOS after MIVS.

Atrioventricular valve surgery in patients with univentricular heart and two separate atrioventricular valves.

Atrioventricular valve regurgitation in patients with univentricular heart is a well-known risk factor for adverse outcomes and atrioventricular valve repair remains a particular surgical challenge. We reviewed all surgical atrioventricular valve procedures in patients with univentricular heart and two separate atrioventricular valves who underwent surgical palliation. Endpoints of the study were reoperation-free survival and cumulative incidence of reoperation. Between 1994 and 2021, 202 patients with univentricular heart and two separate atrioventricular valve morphology underwent surgical palliation, with 15.8% (32/202) requiring atrioventricular valve surgery. Primary diagnoses were double inlet left ventricle (n = 14, 43.8%), double outlet right ventricle (n = 7, 21.9%), and congenitally corrected transposition of the great arteries (n = 7, 21.9%). Median weight at valve surgery was 10.6 kg (interquartile range, 7.9-18.9). Isolated left or right atrioventricular valve surgery was required in nine (28.1%) and 22 patients (68.8%), respectively. Concomitant left and right atrioventricular valve surgery was performed in one patient (3.1%). Closure of the left valve was conducted in four patients (12.5%) and closure of the right valve in three (9.4%). Operative and late mortality were 3.1% and 9.7%, respectively. Reoperation-free survival and cumulative incidence of reoperation at 10 years after surgery were 62.3% (standard error of the mean: 6.9) and 30.9% (standard error of the mean: 9.6), respectively. In patients with univentricular heart and two separate atrioventricular valves, surgical intervention on these valves is required in a minority of patients and is associated with low mortality but high incidence of reoperation.

Outcomes after Bipolar Osteochondral Allograft Transplantation in the Ankle

Category: Ankle Arthritis; Ankle Introduction/Purpose: Surgical treatment options for symptomatic, full-thickness articular cartilage loss in the ankle are not consistently effective in restoring ankle function. Osteochondral allograft transplantation provides a standard-of-care alternative for patients, however, outcomes reported to date have been only fair, with a high incidence of reoperation and revision. However, recent cartilage storage and preservation techniques have significantly improved the percent viable chondrocytes at the time of implantation in OCAs. These high-chondrocyte-viability allografts should lead to improved survivability of OCAs and improved outcome measures. This study aimed to document the initial outcomes for patients undergoing bipolar OCA transplantation in the ankle after advances in tissue preservation, transplantation techniques, and patient management strategies. Methods: Patients with symptomatic tibiotalar arthritis were prospectively enrolled into a registry designed to follow outcomes after OCA surgeries in the ankle. All patients underwent complete OCA replacement of their tibial plafond and talar dome, with most undergoing fibular articular resurfacing. All OCA were size and side matched and preserved in Missouri Osteochondral Allograft Preservation System (MOPS). Patients followed a standardized, procedure-specific rehabilitation protocol after surgery, including remaining non-weight bearing for 8 weeks, weekly therapy visits, limited step count during recovery, and avoidance of high impact activities until 1 year after surgery. Patients followed-up with their physician at regular post-operative timepoints. Radiographs and patient reported outcome measures (VAS, AAOS Foot and Ankle, PROMIS PF, PROMIS Mobility) were obtained at each follow-up visit. Demographic and operative data were collected from the electronic medical record. All reported complications, reoperations, revisions, and failures were recorded in the EMR. Results: 14 patients were included for analyses with 12 undergoing primary OCA transplantation, and 2 undergoing revision OCA transplantation. Mean age and follow up was 36 and 44.1 months, respectively. All patients underwent tibia and talus OCA transplantation, with 10/14 including a fibula OCA transplantation. Initial success was 92.9% with one documented failure (tibial OCA collapse). Radiographic assessments indicated OCA integration and maintenance of joint space in 12 patients (85.7%). AAOS and VAS pain scores improved significantly from preoperative measures at each timepoint (p=.002, p=.03), while postoperative improvements in PROMIS Mobility and PROMIS Physical Function scores did not reach significance (p>0.15) (Table 1). Patients that were non-adherent to postoperative restriction and rehabilitation protocols, all 1-year postoperative PROs were significantly lower than for patients who were adherent. Conclusion: Ankle osteoarthritis in young patients continues to present a challenging dilemma. Previous attempts at large bipolar OCAs in the ankle have yielded fair, to poor, results. However, recent advances in bulk osteochondral allograft preservation has improved chondrocyte viability. Based on the results of our study, the use of high-chondrocyte-viability allografts for OCA transplantation is a viable option for the treatment of symptomatic bipolar osteochondral defects in the ankle joint. However, post operative rehab protocols are equally important in determining outcomes, and patient selection and education is key to ensuring successful outcomes. Longer term follow up is ongoing.

Focal-occult placenta accreta: a clandestine source of maternal morbidity

Focal-occult placenta accreta spectrum is known to cause adverse obstetrical morbidity outcomes, however, direct comparisons with previa-associated placenta accreta spectrum morbidity are lacking. We sought to compare the baseline characteristics, surgical and obstetrical morbidity, and subsequent pregnancy outcomes of patients with focal-occult placenta accreta spectrum with those of patients with previa-associated accreta. A retrospective review was conducted of all pathologically confirmed placenta accreta spectrum cases from 2018 to 2022 at a tertiary care center. The baseline characteristics, surgical, obstetrical, and subsequent pregnancy outcomes were recorded. Cases of focal-occult placenta accreta spectrum was compared with cases of previa-associated placenta accreta spectrum across a range of morbidity characteristics including hemorrhagic factors, interventions, postdelivery reoperations, infections, and intensive care unit admission. Statistical comparison was performed using Kruskal-Wallis or chi-square tests, and a P value of <.05 was considered significant. A total of 74 cases were identified with 43 focal-occult and 31 previa-associated placenta accreta spectrum cases. Of those, 25.6% of the patients with focal-occult placenta accreta spectrum and 100% of the patients with previa-associated placenta accreta spectrum underwent a hysterectomy. One case of focal-occult placenta accreta spectrum and 29 cases of previa-associated placenta accreta spectrum were diagnosed antenatally. Patients with focal-occult placenta accreta spectrum did not differ from those with previa-associated placenta accreta spectrum in mean maternal age (33.0 vs 33.1 years), body mass index, or the incidence of previous dilation and curettage procedures (16.3% vs 25.8%). Patients with focal-occult placenta accreta spectrum were significantly more likely to have a lower mean parity (1.5 vs 3.6 gestations), higher gestational age at delivery (36.1 vs 33.9 weeks' gestation), and were less likely to have had a previous cesarean delivery (12/43, 27.9% vs 30/31, 96.8%). In addition, patients with focal-occult placenta accreta spectrum had less previous cesarean deliveries (mean, 0.5 vs 2.3), were more likely to have undergone in vitro fertilization (20.9% vs 3.2%), and less likely to have anterior placentation. When contrasting the clinical outcomes of patients with focal-occult placenta accreta spectrum with those with previa-associated placenta accreta spectrum, the postpartum hemorrhage rates (71.0% vs 67.4%), mean quantitative blood loss (2099 mL; range, 500-9516 mL vs 2119 mL; range 350-12,220 mL), mean units of red blood cells transfused (1.4 vs 1.7), massive transfusion rate (9.3% vs 3.2%), and intensive care unit admission rates (11.6% vs 6.5%) were not significantly different, but there was a nonsignificant trend toward higher morbidity among patients with focal-occult accreta. Patients with focal-occult accreta had a higher incidence of reoperations or return to the operating room (30.2 vs 6.5%; P=.01). When comparing focal-occult with previa-associated placenta accreta spectrum, the composite outcomes, including hemorrhagic morbidity (77.4% vs 74.4%), any maternal morbidity (83.9% vs 76.7%), and severe maternal morbidity (64.5% vs 65.1%), were not significantly different between the groups. Nine focal-occult placenta accreta spectrum patients had a subsequent pregnancy, and 3 of those had recurrent placenta accreta spectrum. Focal-occult placenta accreta spectrum presents with fewer identifiable risk factors than placenta previa-associated placenta accreta spectrum but may be associated with an in vitro fertilization pregnancy. Patients with focal-occult placenta accreta spectrum was observed to have a higher incidence of reoperation when compared with patients previa-associated placenta accreta spectrum, and no other statistically significant differences in morbidity outcomes were observed. The absence of differences in morbidity outcomes may be attributable to a lack of antenatal detection of focal-occult accreta and merits further investigation.

Comparison of discover cervical disc arthroplasty and anterior cervical discectomy and fusion for the treatment of cervical degenerative disc diseases: A meta-analysis of prospective, randomized controlled trials.

This study aims to evaluate the clinical efficacy and safety between Discover cervical disc arthroplasty (DCDA) and anterior cervical discectomy and fusion (ACDF) in Cervical degenerative disc diseases. Two researchers independently conducted a search of PubMed, EMBASE, and Cochrane Central Register of Controlled Trails (CENTRAL) for randomized controlled trials (RCTs) following the Cochrane methodology guidelines. A fixed-effects or random-effects model was applied based on different heterogeneity. Review Manager (Version 5.4.1) software was used to perform data analysis. A total of 8 RCT studies were included in this meta-analysis. The results indicate that the DCDA group had a higher incidence of reoperation (P = 0.03) and a lower incidence of ASD (P = 0.04) than the CDA group. There was no significant difference between two groups regarding NDI score (P = 0.36), VAS ARM score (P = 0.73), VAS NECK score (P = 0.63), EQ-5D score (P = 0.61) and dysphagia incidence (0.18). DCDA and ACDF have similar results in terms of NDI scores, VAS scores, EQ-5D scores, and dysphagia. In addition, DCDA can reduce the risk of ASD but increases the risk of reoperation.

Demographic and physiological factors associated with clinically significant eyelid edema in patients following upper eyelid surgery

To investigate demographic and physiological variables associated with clinically significant edema after upper eyelid surgery. A retrospective chart review was performed on patients who underwent blepharoplasty or external levator advancement with or without lid crease formation between January 2018 and January 2021 at the University of Southern California. Age, sex, pertinent medical history (medications causing edema and comorbidities), and pertinent surgical procedures were all collected. Postoperative photos were graded by two independent physician graders on a newly developed photographic scale ranging from 0 (no edema) to 3 (severe edema). Clinically significant edema of the eyelids was defined as Grade 3 edema at any postoperative point or ≥ Grade 1 edema after 90 days post operation. Patients without postoperative photos were excluded. Mann-Whitney U test, Fisher's exact test, and χ2 test were used to compare groups with and without significant edema. All analyses were conducted using SAS version 9.4 (SAS Institute Inc.) with α=0.05. Out of 217 patients, East Asian participants had higher odds of developing edema than White participants (odds ratio, 7.92; CI, 3.15-19.93, p < 0.0001) and Hispanic participants (odds ratio, 3.47; CI, 1.51-7.97, p=0.003). Southeast Asian participants also had higher odds of developing CSEE than White participants (odds ratio, 6.19; CI, 1.71-22.43, p=0.006). Fifty-four (24.9%) patients had clinically significant edema. Although BMI, medical comorbidities, medication use, and age did not affect edema, there was a statistically significant relationship between race and incidence of edema (p=0.0001). Those in the CSEE group were also more likely to require reoperation (p=0.0143). There is a statistically significant relationship between Asian race and the incidence of clinically significant eyelid edema. CSEE is associated with a higher incidence of reoperation.

Contemporary Use of Trochanteric Plates in Periprosthetic Femur Fractures: A Displaced Trochanter Will Not Be Tamed

BackgroundThe objective of this study was to evaluate the reoperation and complication rate following trochanteric plate fixation of greater trochanter (GT) periprosthetic femur fractures associated with total hip arthroplasty and to identify risk factors for subsequent reoperation, nonunion, and hardware failure (plate/cable breakage or migration). MethodsBetween 2010 and 2020, 44 patients who had 44 periprosthetic greater trochanter fractures at mean follow up of 2 years were retrospectively reviewed. Initial injury radiographs as well as immediate and final follow-up radiographs were evaluated. Subsequent reoperations, nonunion, and cases of hardware failure were identified. There were 22 (50%) Vancouver B2 fractures and 22 (50%) Vancouver A fractures. ResultsThe 2-year cumulative probability of any subsequent reoperation was 20%. There were 9 total subsequent reoperations. The trochanteric fracture went on to nonunion in 14 patients (39%), and hardware failure occurred in 10 (28%) patients. A trochanteric bolt was used in addition to the trochanteric plate in 6 patients (14%), of which 4 (67%) patients had trochanteric plate displacement and 3 (50%) patients had trochanteric nonunion. Displacement of the greater trochanter prior to fixation was a predictor of subsequent nonunion (77% versus 23%, P = .02). ConclusionIn this large contemporary series, there was a high incidence of reoperation (20%) with in the first 2-years following plating of periprosthetic GT fractures, as well as a high rate of nonunion (39%), and hardware failure (28%). Displacement of the GT prior to plating predicted nonunion. Level of EvidenceLevel IV, retrospective observational study.

Common atrioventricular valve surgery in children with functional single ventricle.

A common atrioventricular valve (CAVV) is considered to be a risk factor for early and late deaths in patients with functional single ventricle (FSV). CAVV surgery in patients with FSV is challenging and there is limited knowledge of the outcomes of CAVV repair with univentricular physiology. We reviewed all CAVV surgical procedures in patients with FSV who underwent univentricular palliation. End points of the study were survival after CAVV surgery and cumulative incidence of reoperation. Between 1984 and 2019, 66 children with CAVV and FSV underwent single-ventricle palliation, of whom 45.5% (30/66) required CAVV surgery. Indication for surgery was moderate CAVV regurgitation in 40% (12/30) and severe CAVV regurgitation in 60% (18/30). CAVV repair was performed in 93.3% (28/30) and CAVV replacement in 6.7% (2/30). The median age and weight at surgery were 0.9 years (interquartile range 0.3-1.8) and 6.5 kg (interquartile range 3.9-8.7), respectively. Operative and late mortality were 23.3% and 8.7%, respectively. Survival and cumulative incidence of reoperation at 4 years after CAVV surgery were 68.9% [standard deviation (SD): 8.7] and 35.8% (SD: 9.1), respectively. Fontan completion was achieved in 60% (18/30). Survival at 4 years after birth was 69.7% (SD: 8.5) in 30 patients with CAVV surgery, whereas it was 83% (SD: 6.3) in 36 patients without CAVV surgery (P = 0.32). CAVV surgery in patients with FSV is associated with substantial mortality and a high incidence of reoperation.

Comparative analysis of Grade I vs Grade II intracranial Meningiomas in a retrospective series of 63 patients

ResumenIntroducción:Los meningiomas Grado II tienen un comportamiento biológico más agresivo que los Grado I. A partir del año 2007, con los nuevos criterios de clasificación, la incidencia de meningiomas atípicos reportada aumentó hasta un 35%.Objetivo:Establecer diferencias entre los Meningiomas Grado I y II de la clasificación de la OMS, en lo que respecta a: grados de resección de Simpson, localización tumoral, necesidad de reintervención, tratamiento adyuvante, evolución y mortalidad.Métodos:Estudio retrospectivo de 63 pacientes operados entre el periodo 2009-2015.Variables analizadas:sexo, edad, grado histológico, localización, grado de resección quirúrgica, radioterapia adyuvante, mortalidad y evolución.Resultados:Se analizaron 63 pacientes: 51 Grado I y 12 Grado II de la clasificación de la OMS. La distribución por sexo no mostró diferencias entre meningiomas benignos y atípicos. Tampoco el grupo etario de presentación; mediana de 57 años. Un 55% de los meningiomas benignos se localizaron fuera de la base del cráneo versus el 91,6% de los meningiomas atípicos (P = 0.02). En el 74,5% de los meningiomas benignos se logró una resección total (Simpson I-II-III) versus el 58.3% para los atípicos (P = 0.3). Se reintervinieron el 33,3% de meningiomas atípicos en comparación con el 9.8% de los benignos (P = 0.03). Tuvieron una buena evolución el 86,2% de los benignos vs el 53,8% de los GII (P = 0.01). Realizaron radioterapia adyuvante el 33,3% de los meningiomas Grado II vs el 1,9% de los Grado I.Conclusiones:Los meningiomas atípicos cerebrales tienen peor pronóstico evolutivo que los Grado I de la OMS. Presentan una mayor tasa de reintervención y se localizan más frecuentemente fuera de la base del cráneo. La localización pareciera ser un factor de riesgo para el desarrollo de meningiomas atípicos.

Is subvalvular repair worthwhile in severe ischemic mitral regurgitation? Subanalysis of the Papillary Muscle Approximation trial

ObjectiveThe symmetry of mitral valve tethering and regional left ventricle wall dysfunction are reported to play a fundamental role in the outcomes and long-term durability of surgical repair in ischemic mitral regurgitation (IMR). We recently demonstrated in a randomized clinical trial (the Papillary Muscle Approximation trial) the superiority of papillary muscle approximation (PMA) in combination with standard restrictive annuloplasty (RA) in severe IMR over annuloplasty alone in terms of adverse left ventricular remodeling and mitral regurgitation (MR) recurrence. This approach, however, failed to produce a survival advantage and was still plagued by a high incidence of reoperation. We therefore performed a subanalysis of the PMA trial on the basis of preoperative parameters to elucidate the value of subvalvular surgery in certain subcategories of patients with the aim of creating a decisional algorithm on the best operative strategy. MethodsWe performed a subanalysis of PMA trial, evaluating 96 patients with severe IMR and eligible for myocardial revascularization randomized to PMA + RA (n = 48) versus RA alone (n = 48) in association with coronary artery bypass grafting. Endpoints included left ventricular remodeling, MR recurrence, overall mortality, reoperation, and a composite cardiac endpoint (cardiac death, stroke, reintervention, hospitalization for heart failure, or New York Heart Association class worsening). Stratification variables were preoperative symmetry of mitral valve tethering and regional wall motion abnormality. ResultsPMA improved ventricular remodeling and recurrence of MR in both preoperative symmetric and asymmetric tethering and in case of inferior wall dyskinesia but did not produce an additional benefit in anterolateral wall dysfunction. ConclusionsPreoperative symmetric and asymmetric tethering and isolated inferior wall dyskinesia are an indication for subvalvular apparatus surgery in IMR.

Clinical Characteristics and Outcomes of Patients With Myocardial Infarction and Cardiogenic Shock Undergoing Coronary Artery Bypass Surgery: Data From The Society of Thoracic Surgeons National Database

Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is associated with substantial mortality. We evaluated outcomes of patients in The Society of Thoracic Surgeons Adult Cardiac Surgery Database who underwent coronary artery bypass graft surgery (CABG) in the setting of AMI-CS. All patients with AMI-CS who underwent nonelective CABG or CABG with ventricular assist device implantation within 7 days after myocardial infarction were enrolled. The primary analysis sample consisted of patients who underwent surgery between June 2011 and December 2013. Baseline characteristics, operative findings, outcomes, and the utilization of mechanical circulatory support (MCS) were assessed in detail in this population. We also evaluated trends in unadjusted mortality for all patients undergoing CABG or CABG with ventricular assist device for AMI-CS from January 2005 to December2013. A total of 5,496 patients met study criteria, comprising 1.5% of all patients undergoing CABG during the study period. Overall operative mortality was 18.7%, decreasing from 19.3% in 2005 to 18.1% in 2013 (p< 0.001). Use of MCS increased from 5.8% in 2011 to 8.8% in 2013 (p= 0.008). Patients receiving MCS had a high proportion of cardiovascular risk factors or high clinical acuity. Patients requiring preoperative and patients requiring intraoperative or postoperative MCS had operative mortality of 37.2% and 58.4%, respectively. Patients undergoing CABG as a salvage procedure had an operative mortality of 53.3%, and a high incidence of reoperation (21.8%), postoperative respiratory failure requiring prolonged ventilation (59.7%), and renal failure (18.5%). Most patients undergoing CABG for AMI-CS have a sizeable but not prohibitive risk. Patients who require MCS and those undergoing operation as a salvage procedure reflect higher risk populations.

Congenital heart disease in the older adult: a scientific statement from the American Heart Association.

The population of adults with congenital heart disease (ACHD) has increased dramatically over the past few decades, with many people who are now middle-aged and some in the geriatric age range. This improved longevity is leading to increased use of the medical system for both routine and episodic care, and caregivers need to be prepared to diagnose, follow up, and treat the older adult with congenital heart disease (CHD). The predictable natural progression of CHD entities and sequelae of previous interventions must now be treated in the setting of late complications, acquired cardiac disease, multiorgan effects of lifelong processes, and the unrelenting process of aging. Despite the advances in this field, death rates in the population from 20 to >70 years of age may be twice to 7 times higher for the ACHD population than for their peers.1 This American Heart Association (AHA) scientific statement will focus on the older adult (>40 years old) with CHD. It is meant to be complementary to the 2008 American College of Cardiology (ACC)/AHA guidelines for ACHD and orient the reader to the natural history, ramifications of childhood repair, and late initial diagnosis of CHD in the older adult. This population with CHD is unique and distinct from both the pediatric and young adult populations with CHD. Much of the information we provide is from scientific research combined with clinical experience from longitudinal care. We emphasize that this is the beginning of a discussion regarding this rapidly growing population, and continued research aimed at the progression of disease and complications reviewed here is necessary to advance the field of ACHD with the scientific rigor it deserves. ACHD encompass a broad range of presentations. There are people who are diagnosed for the first time in adulthood, as well as those with prior palliative repair …

Interspinous spacer versus traditional decompressive surgery for lumbar spinal stenosis: a systematic review and meta-analysis.

BackgroundDynamic interspinous spacers, such as X-stop, Coflex, DIAM, and Aperius, are widely used for the treatment of lumbar spinal stenosis. However, controversy remains as to whether dynamic interspinous spacer use is superior to traditional decompressive surgery.MethodsMedline, Embase, Cochrane Library, and the Cochrane Controlled Trials Register were searched during August 2013. A track search was performed on February 27, 2014. Study was included in this review if it was: (1) a randomized controlled trial (RCT) or non-randomized prospective comparison study, (2) comparing the clinical outcomes for interspinous spacer use versus traditional decompressive surgery, (3) in a minimum of 30 patients, (4) with a follow-up duration of at least 12 months.ResultsTwo RCTs and three non-randomized prospective studies were included, with 204 patients in the interspinous spacer (IS) group and 217 patients in the traditional decompressive surgery (TDS) group. Pooled analysis showed no significant difference between the IS and TDS groups for low back pain (WMD: 1.2; 95% CI: −10.12, 12.53; P = 0.03; I2 = 66%), leg pain (WMD: 7.12; 95% CI: −3.88, 18.12; P = 0.02; I2 = 70%), ODI (WMD: 6.88; 95% CI: −14.92, 28.68; P = 0.03; I2 = 79%), RDQ (WMD: −1.30, 95% CI: −3.07, 0.47; P = 0.00; I2 = 0%), or complications (RR: 1.39; 95% CI: 0.61, 3.14; P = 0.23; I2 = 28%). The TDS group had a significantly lower incidence of reoperation (RR: 3.34; 95% CI: 1.77, 6.31; P = 0.60; I2 = 0%).ConclusionAlthough patients may obtain some benefits from interspinous spacers implanted through a minimally invasive technique, interspinous spacer use is associated with a higher incidence of reoperation and higher cost. The indications, risks, and benefits of using an interspinous process device should be carefully considered before surgery.

Revisional weight loss surgery after failed laparoscopic gastric banding: an institutional experience

Increasing experience with laparoscopic adjustable gastric banding (LAGB) has demonstrated a high rate of complications and inadequate weight loss. Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) have been reported to be safe and effective in selected patients. The purpose of our study was to evaluate the incidence and outcomes of revisional weight loss surgery (RWLS) after laparoscopic gastric banding at our institution. From June 2006 to February 2013, all patients who underwent LAGB and those who required revision were retrospectively analyzed. All procedures were performed by two surgeons with extensive experience in bariatric surgery. Parametric data are presented as mean ± SD; nonparametric data are presented as median and interquartile range (IQR). During the study period, 256 patients underwent LAGB. A total of 111 patients (43 %) required reoperation. Sixty-one patients (56 women, age = 43.7 ± 12 years) with a BMI of 45.4 ± 6 kg/m(2) successfully underwent RWLS (53 RYGB, 8 LSG). Indications for RWLS included dysphagia (40 patients, 63 %), inadequate weight loss (17 patients, 27 %), GERD (2 patients, 3 %), gastric prolapse (2 patients, 3 %), and needle phobia (1 patient, 2 %). Two required conversion to an open RYGB due to extensive adhesions. RWLS was undertaken approximately 36.3 [25-45] months after LAGB. Removal of the gastric band and the RWLS were performed in 15 patients with an interval of 3 [1.5-7] months between procedures. Median operative time was 165 [142-184] min. Median hospital length of stay was 2 [2-3] days. Early complications occurred in 11 patients (18 %), including 4 anastomotic leaks. Twelve patients (20 %) presented with late complications requiring intervention. There was one death. At a median follow-up of 12.4 months, excess weight loss was 47.5 ± 27 %, and 48 % of patients achieved a BMI < 33. LAGB is associated with a high incidence of reoperation. Reoperative weight loss surgery can be performed in selected patients with a higher rate of complications than primary surgery. Good short-term weight loss outcomes can be achieved.

The use of cell saver system in cardiac surgery with cardiopulmonary bypass

The use of cell saver (CS) in cardiac surgery is proposed to reduce the use of units of packed red blood cells stored (URBC), which increases morbidity, mortality and causes inflammatory reactions. The objective is to evaluate whether the use of CS decreases the use URBC, is cost /effective and beneficial to the patient. In a prospective study, between November 2009 and October 2011, 100 consecutive patients who underwent cardiovascular surgery with CPB, hemodilution and hemofiltration, were enrolled. Patients were divided into group 1 (no CS) and 2 (CS). The criteria for the replacement of RBC were hemodynamic instability and hemoglobin (Hb) <7-8g/dl. Demographic data, as well as Hb and hematocrit, mediastinal drainage, number of URBC and CPB, ICU and hospital time, were analysed. In groups 1 and 2 the average age was 64.1 and 60.6 years; predominantly male; the logistic EuroSCORE 10.3 and 9.4; mortality 2% and 4%. Group 2 had a higher incidence of reoperations (12% versus 6%), but the average of URBC used (4.31 versus 1.25) and mean length of hospital stay (10.8 versus 7.4 days) was lower. Univariate and multivariate analysis, were performed, which showed no statistically significant values, except in the use of URBC. The relationship between the CS and the cost of RBC was not cost /effective and length of stay was shorter. The use of CS decreases the number of used URBC, is not cost /effective but has shown benefits for patients.

Patellar Resurfacing in Total Knee Arthroplasty: Does Design Matter?

Patellar resurfacing in total knee arthroplasty remains controversial. The aim of this study was to compare outcomes following total knee arthroplasty with patellar resurfacing with those following total knee arthroplasty without patellar resurfacing. We also sought to identify any correlation between outcomes and prosthetic design. Eighteen Level-I randomized controlled trials with a cumulative sample size of 7075 knees (3463 in the resurfacing group and 3612 in the non-resurfacing group) satisfied the inclusion criteria. In the primary analysis, patellar resurfacing total knee arthroplasty was compared with non-resurfacing total knee arthroplasty, with use of reoperation rates, incidence of anterior knee pain, and functional scores as outcome measures. The secondary analysis focused on comparing patella-friendly and non-patella-friendly total knee arthroplasty designs with regard to the same three outcome measures. No significant differences were found between the resurfacing and non-resurfacing groups with regard to the incidence of anterior knee pain. A higher rate of reoperations was observed in the non-resurfacing group. Analysis of homogeneous data comparing patella-friendly with non-patella-friendly total knee arthroplasty designs demonstrated no differences in the incidence of reoperations. No evidence was found to suggest that either patellar resurfacing or the prosthetic design affects the clinical outcome of a total knee arthroplasty. The higher incidence of reoperations in the non-resurfacing group may be attributed to the fact that secondary patellar resurfacing adds a surgical option for the treatment of anterior knee pain following total knee arthroplasty, thus artificially increasing the rate of reoperations in the non-resurfacing group.

Reoperation for Left Atrioventricular Valve Regurgitation After Atrioventricular Septal Defect Repair

Left atrioventricular valve regurgitation (LAVVR) is a major cause of morbidity after atrioventricular septal defect (AVSD) repair. This study evaluates the outcomes of repair and replacement of the left atrioventricular valve after AVSD correction, as well as factors predictive of durability of valve repair. Between January 1983 and March 2007, 31 patients underwent reoperation for LAVVR after AVSD repair (23 valve repairs and 8 valve replacements). Median age at primary repair was 5.0 months and time to reoperation was 5.0 months. The distribution of AVSD morphology was 9 primum, 5 transitional, and 17 complete. Early postoperative mortality was 6.4% (2 of 31). Survival at 10 years was 88.1%. At a mean follow-up of 8.2 years, 86% of hospital survivors were in New York Heart Association class I. Overall freedom from reintervention at 10 years was 67.2%. Among patients undergoing primary repair, 6 of 23 underwent subsequent replacement. Follow-up LAVVR in those who did not require subsequent valve replacement was mild or less in 92.8%. Factors that demonstrated a trend toward durable repair included the use of patch augmentation rather than primary cleft closure (p = 0.02) and earlier timing to repair (less than 2 months; p = 0.03). Significant cardiomyopathy developed in 21.4% of patients after prosthetic valve replacement (3 of 14). Surgical management of LAVVR after AVSD repair can be performed with excellent midterm outcomes. However, both repair and replacement are associated with a high incidence of reoperation. Nonetheless, an aggressive reparative approach should be pursued to avoid the morbidity of pediatric left atrioventricular valve replacement that includes anticoagulation, inevitable reoperation, and cardiomyopathy.

Single centre experience on primary correction of common arterial trunk: overall survival and freedom from reoperation after more than 15 years.

To identify predictors of early and late outcomes of common arterial trunk (CAT) after primary surgical correction, such as clinical state prior to surgery, age and weight at presentation, implications of truncal valve abnormalities and associated anomalies of this complex congenital malformation. A consecutive series of 106 patients, operated between 1976 and 1998, were reviewed retrospectively. Using the 'Van Praagh' classification, 59 patients presented as A1, 33 as A2, six as A3, and eight as A4. The mean age at operation was 8.6 months (range, 14 days-8.9 years; median, 4.4 months), and the mean weight was 5.2 kg (range, 2.5-30.8 kg; median, 4.4 kg). At the time of operation, 32 patients had congestive heart failure, five were on ventilator support for less than 1 week, and 21 for more than 1 week. Between 1976 and 1989, the early mortality was 21%, and between 1990 and 1998, it dropped to 13%. After 1, 10 and 15 years, the overall survival was 66, 61 and 59%. The 1, 5, 10 and 15 year freedom from reoperation was 82, 60, 22 and 10%, respectively. Clinical condition prior to intervention, truncal valvar dysfunction, and coronary anomalies were significantly associated with poor surgical outcome, whereas weight and age at presentation in our series were not. In the current era of paediatric cardiac surgery, primary surgical repair of CAT can be carried out with reasonable early and late mortality. However, our data suggest that a high incidence of reoperation, mainly due to the outgrowth and failure of the conduit, has to be expected. The patient's clinical state after diagnosis is decisive for the timing of intervention.

Total Hip Arthroplasty

A series of 507 consecutive, unselected cementless hip arthroplasties performed by one surgeon was reviewed to address specifically potential concerns with the use of extensively coated femoral components, including the frequency and nature of reoperation, thigh pain, component stability, osteolysis, and stress shielding. Excluding hips in patients who had died or were lost to followup, there were 426 hips with minimum 5-year followup. The overall femoral reoperation rate of 2.6% (13 cases) included seven for failure of fixation and six for osteolysis. Of the unrevised cases, 96% of the femoral components showed radiographic bone ingrowth, and 3.7% showed a stable fibrous pattern. Fixation did not deteriorate with time. A 2.9% incidence of activity limiting thigh pain did affect clinical outcome (limp, ambulation tolerance, support), but there were no clinical or radiographic predisposing variables. There was no detectable femoral osteolysis in 88.3% of cases. The remainder had lesions confined to Gruen Zones 1 and 7, suggesting that circumferential extensive coating was protective against distal osteolysis. Although osteolysis did not affect component stability, in six cases it did result in pathologic trochanteric fracture, contributing to the frequency of reoperation. Stress shielding was common (25%) and was related to older patients and the use of larger diameter stems (> 15 mm), but did not predispose to thigh pain, loosening, osteolysis, or an inferior clinical result. These results documented the clinical and radiographic success in the use of extensively coated cementless femoral components. Debris generation from wear and resulting osteolysis remain significant concerns in a hip arthroplasty with this design as with many others. However, concerns about the high incidence of reoperation, thigh pain, component instability, or stress shielding are not supported by this study.

Perioperative Blood Loss Is a Major Risk Factor for Nonshunt Celiotomies in Patients with Liver Cirrhosis - Clinical and Experimental Evidence

The records of 76 consecutive cirrhotic patients undergoing nonshunt celiotomy were reviewed. Hospital mortality was 14.5%, and emergent operations were more frequent in nonsurvivors than survivors (p < 0.001). Nonsurvivors also had a higher incidence of reoperation and greater perioperative blood loss: 783 and 1,722 ml in survivors and nonsurvivors, respectively (p < 0.001). Major postoperative complications, such as intra-abdominal hemorrhage, gastrointestinal bleeding and/or severe infection occurred in all nonsurvivors and were significantly less frequent in survivors (p < 0.001). Hypotension for 1 h was induced by exsanguination in thioacetamide-induced liver cirrhosis in rats. After subsequent blood transfusion, both liver and kidney tissue blood flow, tissue ATP concentration and energy charge remained depressed in cirrhotic rats, despite normalized arterial pressure (p < 0.01). Perioperative hemorrhage is a major risk factor for subsequent hepatic and renal failure.