Operative Indications Research Articles

Open Hamstring Tendon Excision Following a Distal Semitendinosus Avulsion Tear: A Technique Video

Background: Hamstring injuries are commonly considered the number one reason for delayed return to play and return to sport (RTS) across several sport disciplines. Traditionally, they are treated conservatively. However, recent literature has shown surgical intervention to improve recovery and expedite RTS. One potential explanation behind this phenomenon is conservative treatment does not address the disrupted length-tendon relationship, which can cause hamstring re-injury. Indications: Operative indications for tendon excision include patients with distal semitendinosus avulsions tear with retraction, especially patients who had already failed conservative management. Elite athletes with distal hamstring tears who have experienced a delayed RTS or desired activity level should also be considered for distal hamstring excision. Technique Description: A distal 4-cm incision, which was longitudinal in line with the semitendinosus, was made over the posterior knee at the measured level of the avulsed tendon stump, 2 cm proximal to the knee flexion crease. Blunt dissection was used for the subcutaneous layers, and the overlying hypertrophic and fibrotic tendon sheath was sharply incised. The torn and retracted tendon tissue was exteriorized. An allis clamp was used to provide tension on the distal semitendinosus, and mobilization of the avulsed tendon was performed. Sheath tissue surrounding the injured tendon was removed. The stump was whipstitched to provide further traction, and the hypertrophied portion of the tendon was excised. An open tendon stripper was implemented to exercise both limbs of the semitendinosus. The subcutaneous tissue and skin were closed, and an incisional wound vac was placed. Discussion/Conclusion: Distal avulsion tears of semitendinosus tendons can lead to unsatisfactory results with conservative treatment, with delayed RTS and recurrence of symptoms. Resection of hamstring tendon tissue may eliminate the recurrence of injury, along with inflammation, fibrosis, and hemorrhage associated with retraction reinjuries. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Therapeutic Prediction of Osteoporotic Vertebral Compression Fracture Using the AO Spine-DGOU Osteoporotic Fracture Classification and Classification-Based Score: A Single-Center Retrospective Observational Study.

The treatment of osteoporotic vertebral compression fractures (OVCFs) is based on their severity; however, an efficient prediction tool is lacking. We aimed to evaluate the validity of the osteoporotic fracture classification (OF classification) and scoring system (OF score) in predicting the treatment strategy for patients with OVCF, defined according to the Japanese criteria. We retrospectively investigated 487 consecutive patients diagnosed with vertebral body fractures between January 2018 and December 2022. Only patients with their fresh vertebral fracture episode during the study period were included. Patients were classified into 3 groups: conservative treatment, balloon kyphoplasty (BKP), and open surgery. OF classification and OF scores were assessed for each patient. A total of 237 patients with OVCF were included. There were 127, 81, and 29 patients in the conservative, BKP, and open surgery groups, respectively. The OF score was significantly higher in the BKP and open surgery groups than in the conservative group (p < 0.001). Multivariate logistic regression analysis showed that antiosteoporotic drug use, OF classification, progressive deformity, neurological symptoms and mobilization were independent risk factors for operative treatment (all p < 0.001). Receiver operating characteristic analysis showed that the cutoff OF score for operative indication was 5.5, with a sensitivity of 91.9%, specificity of 56.5%, and area under the curve of 0.820 (95% confidence interval, 0.769-0.871). The OF score identified patients who required operative treatment with a high degree of accuracy. This is especially important for ruling out patients who definitely require operative treatment.

Comparative analysis of transabdominal and retroperitoneal approaches in adrenalectomy

Laparoscopic adrenalectomy has been recognised as the «gold standard» approach for benign adrenal tumours. The majority of surgeons opt for transabdominal laparoscopic adrenalectomies, while retroperitoneoscopic adrenalectomies in the prone position, which were pioneered by Waltz, offer certain advantages for patients. Objective — to compare the effectiveness and complication rates of transabdominal and retroperitoneoscopic laparoscopic adrenalectomies. Materials and methods. Between 2000 and 2021, our clinic performed 472 laparoscopic adrenalectomies. The age of the patients ranged from 19 to 79 years, with a mean age of 50.5±10.2 years. The patient pool consisted of 315 women and 157 men. The primary indications for operation were as follows: incidentaloma (32.5%), pheochromocytoma (30.2%), aldosteronoma (19%), corticosteroma (10.3%), myelolipoma (3.0%), and metastatic cancer (5.0%). Tumour sizes ranged from 1 to 10 cm. Results. A total of 316 patients underwent transabdominal adrenalectomies: 206 patients had right adrenalectomies and 110 patients had left adrenalectomies. A total of 156 patients underwent retroperitoneoscopic adrenalectomies. Seven patients required a conversion to a transabdominal approach, including three patients with tumours exceeding 6 cm in size and four patients with tumours ranging from 4 to 6 cm. The conversion rate amounted to 4.9%. The retroperitoneoscopic approach showed certain advantages for patients with small tumours, including shorter surgery duration, lower operative blood loss, diminished postoperative pain intensity, a lower incidence of shoulder‑tip pain, a faster transition to oral intake, and shorter hospital stays. Conclusions. Both approaches were equally safe. In patients with small tumours, retroperitoneoscopic adrenalectomies outperformed the transabdominal approach in terms of shorter surgery duration, lower blood loss, lower postoperative pain, faster recovery, and favourable cosmetic results. In patients with large tumours, the transabdominal approach demonstrated better outcomes, with lower complication and conversion rates.

Effects of Upright and Supine Radiograph on Shortening and Displacement of Middle Clavicle Fracture

Objective: To compare the difference in degree of shortening and displacement in middle clavicle fracture between upright and supine radiograph. Materials and Methods: Two hundred fifty-nine patients with a median age of 36 years old and between 18 to 80 years with acute displaced clavicular fractures that occurred within two weeks were included in the present study. Standardized upright and supine AP radiograph of bilateral clavicles were obtained. The fractures were classified into three subtypes, simple for 85 patients, wedge for 123 patients, and complex for 51 patients. Shortening and displacement were measured and compared between the two positions. Results: Shortening was higher in upright radiograph at 10.00 mm (–7.60 to 33.20) compared to supine radiograph at 6.90 mm (–11.80 to 21.40). Median difference of shortening was significant at 2.60 mm (–8.30 to 21.10) (p&lt;0.001). The differences of shortening were also significant, in the three subtypes with simple at 2.40 mm (–5.60 to 11.70) (p&lt;0.001), wedge at 2.20 mm (–8.30 to 21.10) (p&lt;0.001), and complex at 4.60 mm (–7.40 to 13.80) (p&lt;0.001). Displacement was greater when measured on upright radiograph at 18.30 mm (4.40 to 36.40) compared to supin radiograph at 8.20 mm (2.00 to 29.30). Median difference of displacement was significant at 8.10 mm (0.10 to 23.50) (p&lt;0.001). The differences of displacement were significant also the three subtypes with simple at 7.20 mm (0.10 to 20.40) (p&lt;0.001), wedge at 8.70 mm (0.50 to 21.70) (p&lt;0.001), and complex at 12.20 mm (2.90 to 23.50) (p&lt;0.001). The intraclass correlation was 0.91 (95% CI 0.88 to 0.93) for shortening, 0.86 (95% CI 0.75 to 0.92) for displacement, and 0.88 (95% CI 0.84 to 0.93) for OTA fracture classification, all indicating excellent agreement. The number of patients who met operative indication, which was a shortening or displacement greater than 20 mm, in upright position were greater than those in supine position. Conclusion: Significant discrepancies in shortening and displacement of middle clavicle fracture among the positions were obtained in all fracture subtypes. The ability of upright radiograph to demonstrate maximal shortening and displacement may influence the decision on the treatment courses. Keywords: Clavicle fracture; Displacement; Shortening; Upright radiograph; Supine radiograph

Morphology of the inferior laryngeal nerve (recurrent nerve) in the anterior cervical region: A report of 30 thyroidectomies

Objective: To study the morphological peculiarities of the left and right Inferior Laryngeal Nerves (ILN) in the anterior cervical region and their variations induced by thyroid pathology. Materials and methods: The study concerned 30 patients who underwent thyroidectomy at the ENT and cervico-facial surgery department of Idrissa POUYE general hospital (HOGIP) from June 1st, 2018 to June 30, 2019. Age, sex, morphotype, operative indication, type of thyroidectomy, route, morphometry, and mode of termination of the ILN were studied. Results: The mean age was 42 years. There were 29 women and one man. Eleven patients (36.7%) were brevilinear, 8 patients (26.6%) were longilinear and 11 patients (36.7%) were of intermediate morphotype. Multinodular goiter was the indication for surgery in 18 cases. A total of 53 ILNs were studied (29 left and 24 right). Path variations concerned 8 left recurrent nerves (28%). The mean diameter of the ILN was 2mm. Longilinear patients and those with intermediate morphotypes had the longest recurrent nerves, while brevilinear patients had the thickest nerves. On the right, the ILN was bifid in 10 cases (41.6%), trifurcated in 3 cases (12.5%), and fan-shaped in 1 case (4.1%). On the left, it was bifid in 23 cases (79.3%) and trifurcated in 2 cases (6.8%). Conclusion: The caliber of the recurrent nerve is relatively large, and can sometimes be spindly, especially on the right. Morphotype may predict ILN dimensions. Extra-laryngeal division of the ILN is a common situation.

A Retrospective Cohort Study on One-Year Mortality Following Emergency Laparotomy: A Tertiary Centre Experience From Western Australia.

Background Emergency laparotomy is a common general surgical procedure associated with a high mortality and morbidity profile. While short-term outcomes following emergency laparotomy have been increasingly described, there remains a paucity of literature on long-term outcomes in Australia. We report our one-year mortality following emergency laparotomy at Royal Perth Hospital, Australia. Methodology A retrospective observational series of emergency laparotomies performed during 2019 and 2020 at Royal Perth Hospital was collected. The primary endpoint is the one-year mortality, and the secondary endpoints are patient demography, COVID-19 status, ASA classification, surgical category, operative indication, primary surgical pathology, procedure and surgical duration, ICU stay, post-operative destination, length of stay, 30-day mortality, and 90-day mortality. Subgroup analysis was performed for years 2019 and 2020. Results A total of 272 emergency laparotomies were performed during the two-year study period. The average age was 61 years (range 18- 98, SD ± 18.32). The majority of patients were in the ASA classification III (n= 134, 49.26%). The average length of patients' stay was 14.17 days (median 10, IQR 11). Moreover, 31.98% of patients were admitted directly to the ICU following emergency laparotomy. One year mortality was 16.6%. However, a significant difference in the long-term mortality rates was observed between the two calendar years, 24.6% in 2019 and 8.66% in 2020. The one-month mortality rate was 7.33%, and the three-month mortality rate was 10.85%. Conclusion The one-year mortality rate observed is high and considerable and similar to experiences published elsewhere. The significant reduction in mortality during the study period warrants further investigation and may reflect improved planning and attitudes around these high-risk surgeries.

The Delta III and Delta Xtend reverse shoulder arthroplasty—risk of revision and failure mechanisms: a report on 3650 cases from the Norwegian Arthroplasty Register 1994-2021

The Delta reverse shoulder arthroplasty (RSA) is commonly used worldwide and is the most frequently used RSA in Norway. The aim of this registry-based study was to report 10- and 20-year implant survival, risk of revision, and reasons for revision in 2 consecutive time periods for Delta III (1994-2010) and Delta Xtend (2007-2021) prostheses. We included 3650 primary RSAs reported to the Norwegian Arthroplasty Register: 315 Delta III (42% cemented stems) and 3335 Delta Xtend (88% cemented stems). We used Kaplan-Meier analyses to investigate implant survival. The reasons for revision were compared for the 2 designs and fixation technique. Factors that could influence the risk of revision, such as implant design, fixation technique, and patient factors, were investigated using Cox regression analyses with adjustments for age, sex, and diagnosis. Patients operated with Delta III were more likely to be diagnosed with inflammatory disease or fracture sequela, whereas acute fracture, osteoarthritis, and cuff arthropathy were the most frequent indications for Delta Xtend. Ten-year survival was 93.0% (95% confidence interval [CI]: 87.0-99.0) (cemented stem) and 81.6% (95% CI: 75.3-87.9) (uncemented stem) for Delta III and 94.7% (95% CI: 93.3-96.1) (cemented stem) and 95.7% (95% CI: 88.3-100) (uncemented stem) for Delta Xtend. Twenty-year survival for Delta III (uncemented stem) was 68.2% (95% CI: 58.8-77.6). Compared with DeltaXtend (cemented stem) at 10-year follow-up, we found a higher risk of revision for Delta III (uncemented stem) (hazard ratio [HR]: 2.9, 95% CI: 1.7-5.0), whereas no significant difference was found for Delta III (cemented stem) and Delta Xtend (uncemented stem). The most common reason for revision of Delta III (uncemented stem) was glenoid loosening followed by deep infection and instability. Instability was the most frequent revision cause for Delta Xtend (both cemented and uncemented stem). Men had an overall higher revision risk than women (HR: 2.8 [95% CI: 2.0-3.9]), and patients with fracture sequela had increased risk for revision (HR: 2.8, 95% CI: 1.7-4.7) compared with patients with osteoarthritis. We found that Delta III (uncemented stem) had a higher risk of revision compared with Delta Xtend (cemented stem). The risk of revision for glenoid component loosening was lower for Delta Xtend, but revisions due to instability/dislocation are still a concern. This register study cannot determine whether the differences found were caused by differences in implant design or other factors that changed during the study period. Risk of revision may have been affected by the indication for primary operation.

Long-term results of oncological endoprosthetics of the ankle joint: multicenter study

Introduction. The distal tibia and fibula are rare sites of involvement by primary and metastatic tumors. For a long time, amputation remained the standard surgical intervention for this location. Oncological ankle replacement is associated with a number of difficulties, including a lack of soft tissue necessary to cover the implant, close proximity of anatomical structures, a high probability of vascular and infectious complications, and difficulties in restoring the biomechanics of the lost joint. Currently, due to the small number of analyzed groups and short-term observations, there is no generalized data on primary and revision oncological ankle replacement, and there is no developed approach to treatment and prevention of complications.Aim. To generalize the analysis of long-term results, the structure of complications, and functional results in a group of patients after primary and revision oncological ankle replacement in a statistically significant group of patients.Materials and methods. The study included 40 patients with benign bone tumors, primary localized sarcomas of bone and soft tissue, and metastatic lesions, which, since 2008, until 2023 56 primary and revision endoprosthetics of postresection defect of the distal tibia were performed. Over a period of 15 years, the study group included 40 (71.4 %) surgeries in the scope of primary endoprosthetics and 16 (28.6 %) surgeries in the scope of revision oncological endoprosthetics of the ankle joint.Results. Over a 15-year follow-up period, the overall incidence of complications, structured according to the International Society of limb Salvage (ISOLS) 2013 classification, after primary and revision arthroplasty was 50 %. The average time until detection of oncological and non-oncological complications was 16.1 months. The leading complication after endoprosthetics was aseptic instability (Type II; 21.4 %) and tumor recurrence (Type V) – 20 %. The average functional outcome after primary and revision ankle replacement was assessed using the MSTS scale and was 72 % after 6 months and ranged from 43 to 97 %. After 12 months, this figure was 78 % and ranged from 49 to 97 %.Conclusion. An objective assessment and increase in the statistical reliability of the results of oncological ankle replacement requires a larger number of surgeries, a longer observation period and joint consolidation of data from various clinics. Development of indications for such reconstructive operations, careful selection of patients taking into account the effect of conservative treatment allows to reduce the total number of complications, the number of local relapses and achieve a good functional result.

Obstetrical and perinatal consequences of childbirth in women with antenatally undiagnosed fetal growth restriction

Fetal growth restriction (FGR) is one of the most studied topics in the medicine of the mother and fetus. However, not identified antenatally FGR can have an increased risk of both perinatal morbidity and mortality, as well as adverse long-term consequences. The identification of FGR during pregnancy will contribute to the reduction of both perinatal morbidity and perinatal mortality.&#x0D; Aim. Based on a retrospective analysis, assess the obstetric and perinatal consequences of childbirth in women with antenatally undiagnosed fetal growth restriction.&#x0D; Materials and methods. An analysis of 488 cases of childbirth in women with singleton pregnancy, who gave birth to a live child, was conducted. In all cases, the gestational age was ≥22 weeks with a fetal weight less than the 10th percentile for the corresponding gestational age. Depending on the antenatally established diagnosis of FGR, two study groups were formed: group I consisted of 204 (41.8 %) cases with antenatally diagnosed FGR, group II – 284 (58.2 %) cases in which signs of FGR were identified after the birth of the child. Maternal characteristics, neonatal outcomes, and evaluation of short-term infant outcomes were analyzed.&#x0D; Results. Both groups were dominated by women with first births, the number of which was almost the same. Somatic pathology was almost 2 times more common in women of group I, 17.2 %, compared to 9.2 % of women in group II (p &lt; 0.01), this indicates that the majority of women who were not diagnosed with FGR during pregnancy belong to the low-risk group. Fetuses with impaired blood flow in the umbilical cord arteries were twice as common in group I, 49.5 % versus 23.9 % in group II (p &lt; 0.0001), and the frequency of absent/reversible end flow in the umbilical arteries in group I compared to group II, prevailed 3 times (p &lt; 0.0001), indicating more serious lesions of the placenta and, as a result, early manifestation of the fetal condition disorder. The frequency of premature abdominal delivery was 3.75 times higher in group I compared to group II. The most frequent indication for cesarean delivery in both groups was signs of fetal distress syndrome. Analysis of neonatal outcomes showed that the average birth weight was significantly lower in group I and was 2180 ± 55 g against 2420 ± 61 g in group II (p &lt; 0.0001). The need for hospitalization of newborns in the intensive care unit had no statistical difference between the groups (p &gt; 0.05). However, the complications of the early neonatal period and the total length of stay in the hospital were greater in children of the I group, compared to the II group (p &lt; 0.0001).&#x0D; Conclusions. The results of the conducted research indicate a low level of prenatal diagnosis of fetal growth restriction. Most pregnant women with antenatally undiagnosed fetal growth restriction belong to the group of low perinatal risk. The most frequent indication for cesarean section operation, regardless of the date of delivery, in both groups were signs of fetal distress, the frequency of which was 1.5 times higher in the antenatally diagnosed fetal growth retardation group. Newborns with an undetected growth anomaly before delivery have an increased risk of fetal distress, the severity of which is determined by the degree of deterioration of fetal oxygenation, and not by weight percentile, which requires more careful observation of fetuses with signs of growth restriction.

Retrospective analysis of decision-making in post-traumatic posterior shoulder instability

PurposeThis study aims to assess the clinical outcomes in the management of post-traumatic posterior shoulder instability (PSI) with a focus on the decision-making process for operative and conservative treatments.IntroductionPSI can result from traumatic events, impacting a patient’s quality of life. This study delves to better indicate decision-making for operative indication of post-traumatic PSI patients.MethodsPatients who sustained posterior shoulder dislocations were selected from a single surgeon’s database within a five-year period. Cases of degenerative or genetically caused PSI were excluded, resulting in a cohort of 28. Patients were initially managed conservatively but indicated for surgery if they were unable to actively stabilize the shoulder or exhibited bony or cartilage defects confirmed through imaging. If conservative treatment did not yield significant improvements, it was classified as a failure, and operative intervention was recommended. The WOSI Score, ROM, and X-ray were employed to evaluate the success of treatment.ResultsOut of the 28 patients, 11 received conservative, seven immediate surgeries, and ten transitioned from conservative to operative treatment. The overall success rate showed 25 good to excellent results. In the persistent conservative treatment group, the initial WOSI score was significantly lower compared to the operative group.ConclusionThis study suggests that post-traumatic PSI can be successfully managed conservatively with initial low clinical symptoms (low WOSI score) and in the absence of absolute indications for operative treatment. When surgery is necessary, arthroscopic procedures proved effective in achieving good to excellent results in 16 out of 17 cases.

Current status of pre- or subpectoral breast reconstruction in Japan.

Breast reconstruction using silicone breast implants (SBIs) has been performed for many patients in Japan under the initiative of the Japan Oncoplastic Breast Surgery Society (JOBSS) since SBIs were first covered by insurance in 2013. A change in the lineup of available SBIs owing to the Allergan crisis caused a decrease in the availability of SBIs appropriate to Japanese breast contours. Recently, the number of immediate implant-based breast reconstructions (IBRs) was approximately 4,000 in one year and was slightly decreasing. The SBI is generally placed under the pectoralis major muscle. Because the number of patients with one-stage, implant-based operative indications is small, an acellular dermal matrix is not available in Japan, and the complication rate in one-stage, IBR is high, most immediate, IBRs are performed in two stages. The prevalence of immediate, one-stage, IBRs is approximately 10%. Fat grafting by injection using Coleman's technique is performed in many hospitals under the JOBSS initiative as a surgery combined with SBI insertion. Complications after SBI placement may be less common in Japan than those in other countries. Japanese breast reconstructive surgeons undertake preventive measures to lessen these complications according to guidelines and experts' opinions, which may contribute to the low complication rate after SBI placement. The total reported number of patients with breast implant-associated anaplastic large cell lymphoma is four, and no patients have died because of this disease. In Japan, procuring informed consent and diagnosing and treating this disease are performed according to the JOBSS guidelines.

Strategy and technique for surgical treatment of Ebstein's anomaly.

Ebstein's anomaly (EA) is a rare and complex congenital heart anomaly, and the effect of surgical treatment is not ideal. This study aims to introduce our experience in management strategies, surgical techniques, and operative indications for patients with Ebstein's anomaly. A retrospective study of 258 operations was performed in 253 patients by the same cardiac surgeon in The First Hospital of Tsinghua University between March 2004 and January 2020. 32 patients had previously received cardiac surgery in other hospitals. The clinical data including diagnosis, operative indications, techniques, pathological changes, and survival rates were collected and analyzed. Anatomical correction was performed in 203 (78.7%) operations, 1½ ventricle repair in 38 (14.7%) operations, tricuspid valve repair only in four operations (1.6%), tricuspid valve replacement in ten (3.9%), total cavopulmonary connection (TCPC) in two (0.8%), and Glenn operation in one operation (0.4%). Reoperation was performed in five patients (2.0%) during hospitalization. Among them, tricuspid valve replacement was performed in one patient, 1½ ventricle repair in two patients, and tricuspid valve annulus reinforcement in two patients. Five patients died with an early mortality rate of 2.0%. Complete atrioventricular conduction block was complicated in one patient (0.4%). A total of 244 patients was followed up (four in the 253 patients lost) with a duration of 3.0-168.0 (87.6 ± 38.4) months. Cardiac function of 244 patients improved significantly with mean New York Heart Association (NYHA) functional class recovery from 3.5 to 1.1. The mean grade of tricuspid valve regurgitation improved from 3.6 to 1.5. Three late deaths (1.2%) occurred. The survival rates at five and ten years after surgery were 98.6% and 98.2%, respectively. Reoperation was performed in five patients (2.0%) during the follow-up period. Based on our management strategies and operative principles and techniques, anatomical correction of EA is capable of achieving excellent long-term results, and low rates of TCPC, 1½ ventricle repair and valvular replacement.

Indocyanine green (ICG)-GUIDED lymphatic sparing laparoscopic varicocelectomy in children and adolescents. Is intratesticular injection of the dye safe? A mid-term follow-up study

Laparoscopic Palomo varicocelectomy using indocyanine green (ICG) fluorescent lymphography (FL) is standardized technique to perform lymphatic sparing and avoid post-operative hydrocele. No data regarding the safety of intratesticular injection of ICG are currently available. The study aimed to assess the safety and efficacy of this procedure at mid-term follow-up. Seventy-two patients (median age 14.5 years) undergoing laparoscopic Palomo varicocelectomy using ICG-FL from January 2019 to July 2022, were enrolled. Operative indication was high-grade varicocele in all patients, associated symptoms in 30/72 (41.7%) and left testicular hypotrophy in 42/72 (58.3%). Follow-up included clinical examination at 1, 6, 12 months and scrotal Doppler ultrasonography (US) at 12 months postoperatively to assess varicocele persistence, hydrocele, and injections-related complications. Lymphatic sparing was achieved using ICG-FL in all cases. No intra-operative complications or adverse reactions secondary to ICG occurred. The median follow-up was 22.8 months (range 11-49). Self-limited scrotal hematoma at the injection site occurred in 1/72 (1.4%). Intratesticular hypoechoic millimetric area was detected at the injection site in3/72 (4.2%) on US. This finding disappeared after 1-year observation in 2/3 cases (66.7%) (Figure). Persistent grade II varicocele was observed in 4/72 (5.5%), not requiring re-intervention. No hydrocele occurred and 14/22 (63.6%) with pre-operative hypotrophy showed catch-up growth. ICG-FL was clinically safe, with no allergy or systemic adverse reactions to the dye reported in this series. No injury directly related to the injection of the dye was clinically observed, except for self-limiting scrotal hematoma in one patient. A millimetric hypoechoic and avascular area in the body of the left testicle at the injection site was found on scrotal US at 1-year follow-up in 3 patients of our series. This finding does not seem to be clinically relevant as patients were asymptomatic and serum tumor markerswere normal in all cases. Furthermore, the hypoechoic area with calcifications resolved 1 year later in 2/3 patients. The absence of evolution of this finding seems to exclude the heteroplastic nature. We hypothesized that this finding may be linked to elevated volume and/or pressure of intratesticular injection. Future prospective study with larger series and longer follow-up is needed to assess long-term testicular outcomes. Laparoscopic Palomo varicocelectomy using ICG-FL reported excellent outcomes with low incidence ofvaricocele persistence and no post-operativehydrocele. These preliminary data also confirmed safety of intratesticular injection of ICG at mid-term follow-up, without specific risks for both testis and patient.

Predicting wound complications following lower extremity revascularization

ObjectiveThe aim of this study was to create a simple risk score to identify factors associated with wound complications after infrainguinal revascularization. MethodsThe Veterans Affairs Surgical Quality Improvement Program national data set was queried from 2005 to 2021 to identify 22,114 patients undergoing elective open revascularization for peripheral arterial disease (claudication, rest pain, tissue loss) or peripheral aneurysm. Emergency and trauma cases were excluded. The data set was divided into a two-thirds derivation set and one-third validation set to create a risk prediction model. The primary end point was wound complication (wound dehiscence, superficial/deep wound surgical site infection). Eight independent risk factors for wound complications resulted from the model and were assigned whole number integer risk scores. Summary risk scores were collapsed into categories and defined as low (0-3 points), moderate (4-7 points), high (8-11 points), and very high (>12 points). ResultsThe wound complication rate in the derivation data set was 9.7% (n = 1428). Predictors of wound complication included age ≤73 (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.08-1.46), body mass index ≥35 kg/m2 (OR, 1.99; 95% CI, 1.68-2.36), non-Hispanic White (vs others: OR, 1.48; 95% CI, 1.30-1.69), diabetes (OR, 1.23; 95% CI, 1.10-1.37), white blood cell count >9900/mm3 (OR, 1.18; 95% CI, 1.03-1.35), absence of coronary artery disease (OR, 1.27; 95% CI, 1.03-1.35), operative time >6 hours (OR, 1.20; 95% CI, 1.05-1.37), and undergoing a femoral endarterectomy in conjunction with bypass (OR, 1.34; 95% CI, 1.14-1.57). In both the derivation and validation sets, wound complications correlated with risk category. Among the defined categories in the derivation set, wound complication rates were 4.5% for low-risk patients, 8.5% for moderate-risk patients, 13.8% for high-risk patients, and 23.8% for very high-risk patients, with similar results for the internal validation data set. Operative indication did not independently associate with wound complications. Patients with wound complications had higher rates of reoperation and graft failure. ConclusionsThis risk prediction model uses easily obtainable clinical metrics that allow for informed discussion of wound complication risk for patients undergoing open infrainguinal revascularization.

The Role of Transvesical Adenomectomy in the Era of Endourology (TURP, PVP, Holmium Laser) at the Mohammed V Military Training Hospital, Rabat, Urology Department: A Case Report and Literature Review

Transvesical adenomectomy according to Fuller-Freyer- Hryntschak, although challenged by other endoscopic techniques, is one of the surgical options validated and recommended by the majority of urology societies for managing and operating on large prostate adenomas with volumes greater than 100 cc, such as the one described in this case report with an ultrasound-measured prostate volume of 238g. Long-term results are excellent, but it is important to note marked perioperative morbidity, including bleeding, and a significant complication that should be explained to the patient prior to the procedure: retrograde ejaculation. We present a case of a 60-year-old patient with a prostate volume of 238g with failure of dual alpha-blocker and 5-alpha reductase therapy, who underwent urodynamic assessment revealing a Qmax of 9ml and a post-void residual volume of 180ml, acute urinary retention requiring Foley catheterization with unsuccessful trial of voiding after Foley catheter removal. A comprehensive report of his evaluation is provided, including clinical history, physical examination, and para-clinical findings. We discuss the operative indication and review the relevant literature.

USE of IMplanting the Biotronik PassEo-18 Lux drug coated balloon to treat failing haemodialysis arteRiovenous FIstulas and grafts (SEMPER FI Study)

Background: Plain old balloon angioplasty has been the mainstay of treatment for arteriovenous fistula (AVF) stenoses. Recent studies suggest that drug coated balloons (DCB) may significantly reduce re-intervention rates on native and recurrent lesions. The Passeo-18 Lux DCB (Biotronik AG, Buelach, Switzerland) is packaged with a 3.0 µg/mm2 dose of paclitaxel. The hypothesis is that its use provides better target lesion primary patency (TLPP), primary assisted patency (PP), secondary patency (SP) rates and reduces the number of visits for re-intervention in a cohort of patients with stenotic AVF and arteriovenous grafts (AVGs). Methods: The USE of IMplanting the Biotronik PassEo-18 Lux DCB to treat failing haemodialysis arteRiovenous FIstulas and grafts trial (SEMPER FI) was a prospective double-centre, multi-investigator, non-consecutive, non-blinded single-arm study investigating the efficacy and safety of the Passeo-18 Lux DCB in patients with stenotic AVF/AVG lesions between January 2021 and January 2022. Patient demographics, clinical characteristics, vascular access history, operative indications, details and outcomes were collected prospectively. TLPP, circuit access primary patency (CAP), PP, SP and deaths 6- and 12-months post-intervention were studied. Results: Ninety-one patients with 110 lesions were recruited across the two centres. 62.6% ( n = 57) were male with a median age of 63.5 years (SD = 10.5). 62.6% ( n = 57) were taking anti-platelets. Eighty-five AVFs and six AVGs were treated. 60% ( n = 54) of AVFs intervened were radiocephalic. 52.7% ( n = 58) of targeted lesions were juxta-anastomotic stenosis (JAS) and one-third ( n = 33) at the AVF/AVG outflow. 70.9% ( n = 78) of lesions were recurrent. Median time from last intervention was 219 days. 78% of target lesions ( n = 85) and circuits ( n = 70) were patent at 6-months, of which 96.7% ( n = 87) of those requiring assisted intervention were patent. Conclusion: This study shows that the Passeo-18 Lux DCB can be an effective and safe tool in the treatment of failing haemodialysis AVFs/AVGs.

The mid-term outcomes of aortic root replacement after surgical repair for CHD.

The purpose of this study is to assess the mid-term outcomes of aortic root replacement after repair of CHDs. This is a single-institutional retrospective, cohort study with consecutive patients undergoing aortic root replacement after surgical repair of CHDs between 1999 and 2022. Operative indications included aortic root dilatation with/without aortic insufficiency, sinus of Valsalva rupture, or aortic dissection involving the root. Forty-four patients (36 male and 8 female) were enrolled. Mean age at the root replacement was 36.6 ± 11.9 years. The most frequent primary diagnosis was congenital aortic stenosis (n = 10) and ventricular septal defect (n = 10). Mean time from the surgical repair to aortic root replacement was 26.6 ± 13.0 years. Operative indications were aortic root enlargement with or without aortic valve aetiology (n = 40), sinus of Valsalva rupture (n = 2), and aortic dissection (n = 2). Forty-two patients underwent valve-replacing aortic root replacement, and two patients underwent valve-sparing, with 40 concomitant procedures. The median follow-up was 3.5 (1.3-7.6) years. There were one early and five late mortalities and five cardiovascular-related reoperations. Actuarial survival at 5-10 years after root replacement was 81.0 ± 6.6%. The cumulative incidence of cardiovascular-related reoperation and aortic root or valve-related reoperation at 5 years after root replacement was 11.9% and 5.6%, respectively. The early and mid-term outcomes of aortic root replacement for patients with a history of repair of CHDs were favourable in terms of survival and aortic root or valve-related reoperation.

Abstract 14916: Clinical and Socioeconomic Factors Associated With Time to Surgery and Preoperative Mortality in Surgery-Eligible Patients With Rheumatic Valvular Heart Disease in Uganda

Background: There is a considerable gap between those needing and receiving surgery among people with rheumatic heart disease (RHD) in Uganda. Nevertheless, risk factors associated with time to surgery and preoperative mortality among those in need of surgery remain poorly understood. Methods: A cohort of patients with RHD who met criteria for valve surgery was assembled using the Uganda National RHD Registry (Jan. 2009- Aug. 2022). Kaplan-Meier estimates and multivariable Cox proportional hazards models were constructed to estimate time to surgery and death for those awaiting surgery. Results: 1,452 patients met surgical indication for valvular RHD. Median age was 20 years (interquartile range [IQR] 13-36), and 30.4% were male. 29.4% had multiple concurrent valve indications. During a median follow-up of 357 days (IQR 21-1029), 30.6% died while awaiting surgery and 13.5% obtained surgery. Median time to surgery was 9.3 years. Multivariable time to surgery model adjusted for age, socioeconomic factors, and HIV status revealed significantly increased likelihood of surgery in men vs. women (hazard ratio [HR] 1.78; 95% CI 1.21-2.64), college/university vs. none/primary school education (HR 3.60; 95% CI 1.88-6.89), and history of atrial fibrillation (HR 2.78; 95% CI 1.63-4.76), but decreased likelihood of surgery in age ≥18 years (HR 0.49; 95% CI 0.32-0.77) and NYHA class III/IV vs. I/II (HR 0.51; 95% CI 0.32-0.83). Median preoperative time to death was 4.6 years. Following stratification by NYHA class I/II and III/IV and adjustment for age, sex, and socioeconomic class, the following predictors were associated with increased mortality in both models: history of infective endocarditis (HR 2.38; 95% CI 1.05-5.39), RV dysfunction (HR 2.44; 95% CI 1.13-5.27), pericardial effusion (HR 1.68; 95% CI 1.27-2.21), surgical indication for multiple valves (HR 1.77; 95% CI 1.41-2.21), and atrial fibrillation (HR 1.47; 95% CI 1.03-2.10). Conclusions: Our analysis revealed a low rate of surgical intervention and high mortality rate in a high-risk population of Ugandans living with advanced RHD and operative indication. Unsurprisingly, sex and socioeconomic status remain barriers to receipt of surgery that must be addressed to achieve equity in this neglected disease.

Abstract 042: Cognitive outcomes in patients with carotid insufficiency after undergoing direct extracranial‐intracranial bypass

Introduction Extracranial‐intracranial (EC‐IC) bypass is a niche procedure that has been selectively used for flow augmentation or flow restoration in patients with intracranial carotid insufficiency.1 The underlying etiology varies but is most commonly related to Moya Moya disease (MMD) or intracranial carotid atherosclerotic disease (ICAD).2 Patients are often managed non‐operatively until they begin to develop symptoms such as transient ischemic attacks (TIAs) or strokes that are recalcitrant to maximal medical management, at which point bypass is pursued.1 This lag period, however, could put patients at risk for long term deficit, not only in the form of focal neurological deficits but also in terms of overall neurocognitive capability.3 Several reports have previously demonstrated some level of association between EC‐IC bypass and neurocognitive outcomes, though in isolated populations of either MMD or ICAD.4,5 We therefore aim to further assess the relationship between EC‐IC bypass and neurocognitive outcomes in patients with intracranial carotid insufficiency. Methods Patients ages 18 years and up undergoing EC‐IC bypass were identified from a single institution database between January 2020 and December 2021. Patient records were reviewed for demographic data including age and sex, as well as preoperative clinical information including comorbidities, operative indication, anticoagulation/antiplatelet therapy usage, prior ischemic stroke, modified Rankin score (mRS), and Montreal Cognitive Assessment (MOCA) score. Radiographic data was also collected including Suzuki grade, collateralization, and perfusion. Post‐operative clinical information including complications, discharge mRS, and discharge MOCA scores were identified. Follow‐up duration, MOCA scores, and mRS were also identified and recorded. Results Of the forty‐four patients that underwent EC‐IC bypass during the specified period, ten had cognitive assessments before and after surgery available for review. The indications for bypass in these cases were ICA steno‐occlusive disease resulting in strokes despite maximal medical management in 9 cases, and MMD in one case. Suzuki grade was IV in the MMD case. Pial collaterals were present in 7 cases, and ECA collaterals were present in 5. Prior ischemic strokes were present in 8 cases, with a preoperative mRS range from 1‐4 (median 1), and average MOCA of 20. Perfusion imaging demonstrated a Tmax mismatch in eight cases, with an average volume of 73.6 cc at risk. All patients underwent direct superficial temporal artery to middle cerebral artery bypass, with additional encephaloduroarteriomyosynangiosis (EDAMS). Follow up MOCA score was improved in 8 cases, unchanged in one case, and worsened in one case (average MOCA increased from 20 to 23). Follow up mRS ranged from 0‐2. Additionally, CT perfusion demonstrated notable improvements in Tmax &gt;4 seconds (decrease from 176 cc to 110 cc), Tmax &gt;6 seconds (decrease from 59 cc to 29 cc), and mismatch (decrease from 59 cc to 17 cc) at 6 month follow up. Conclusion Patients with carotid insufficiency from MMD or ICAD undergoing EC‐IC bypass demonstrate well below normal preoperative MOCA scores. This is suggestive of ongoing neurocognitive decline, which is an often overlooked issue in patients with these pathologies. MOCA and mRS both appear to improve in patients after bypass at longer term follow‐up, suggesting that bypass may be an effective method of addressing the issue of neurocognitive decline in patients with carotid insufficiency.

Intraoperative angiography in neurosurgery: temporal trend, access site, and operative indication considerations from a 6-year institutional experience.

Historically, the transfemoral approach (TFA) has been the most common access site for cerebral intraoperative angiography (IOA). However, in line with trends in cardiac interventional vascular access preferences, the transradial approach (TRA) and transulnar approach (TUA) have been gaining popularity owing to favorable safety and patient satisfaction outcomes. To compare the efficacy and safety of TRA/TUA and TFA for cerebral and spinal IOA at an institutional level over a 6-year period. Between July 2016 and December 2022, 317 angiograms were included in our analysis, comprising 60 TRA, 10 TUA, 243 TFA, and 4 transpopliteal approach cases. Fluoroscopy time, contrast dose, reference air kerma, and dose-area products per target vessel catheterized were primary endpoints. Multivariate regression analyses were conducted to evaluate predictors of elevated contrast dose and radiation exposure and to assess time trends in access site selection. Contrast dose and radiation exposure metrics per vessel catheterized were not significantly different between access site groups when controlling for patient position, operative region, 3D rotational angiography use, and different operators. Access site was not a significant independent predictor of elevated radiation exposure or contrast dose. There was a significant relationship between case number and operative indication over the study period (P<0.001), with a decrease in the proportion of cases for aneurysm treatment offset by increases in total cases for the management of arteriovenous malformation, AVF, and moyamoya disease. TRA and TUA are safe and effective access site options for neurointerventional procedures that are increasingly used for IOA.