Interstage Interval Research Articles

A Multicenter Exploration of the APRI/ALBI Score in Associating Liver Partition and Portal Vein Ligation for Staged hepatectomy’ (ALPPS)

Abstract Background Perioperative morbidity and mortality remain a point of concern for the Associating Liver Partition and Portal Vein Ligation for Staged hepatectomy (ALPPS) procedure. Post-hepatectomy liver failure (PHLF) after the second step poses the most significant risk factor for futile outcome. Recovery of liver function after the first step of ALPPS is critically important to allow for sufficient liver function after this surgery. The APRI+ALBI score has been proposed as an easily assessable score to monitor liver function and its dynamic recovery. Aims We explored if the APRI+ALBI score was able to assess liver function recovery after the first step of ALPPS and allow for optimal timing of the 2nd step. Methods Based on the ALPPS registry, patients from 2012 to 2020 with available APRI+ALBI score were included. Postoperative outcomes (PHLF A – C, PHLF B + C, 90-day mortality and severe morbidity) were defined as per standard definitions. The APRI/ALBI score was monitored perioperatively. Results Overall, 464 patients from 16 international participating centers in the ALPPS registry were included. Clinically relevant PHLF (B + C) was observed in 7.5 % and of these 63 % of patients ultimately died due to liver failure. The APRI+ALBI score immediately increased after each surgical intervention and continuously decrease thereafter. Failure of the APRI+ALBI score to decrease until the 2nd step of ALPPS predicted PHLF B+C (p = 0.001; AUC 0.78). Particularly patients with high APRI+ALBI scores and short interstage intervals were at risk to develop PHLF B+C. Conclusion The APRI+ALBI score objectifies liver function recovery after the 1st step of ALPPS and failure to sufficiently decreased is associated with a higher risk for PHLF B+C. This might allow for optimized planning of the 2nd step of ALPPS to allow for sufficient liver function recovery to minimize the risk for PHLF B+C and associated futile outcome.

Climatic drivers and ecological implications of variation in the time interval between leaf-out and flowering

Leaf-out and flowering in any given species have evolved to occur in a predetermined sequence, with the inter-stage time interval optimized to maximize plant fitness. Although warming-induced advances of both leaf-out and flowering are well documented, it remains unclear whether shifts in these phenological phases differ in magnitudes and whether changes have occurred in the length of the inter-stage intervals. Here, we present an extensive synthesis of warming effects on flower-leaf time intervals, using long-term (1963-2014) and in situ data consisting of 11,858 leaf-out and flowering records for 183 species across China. We found that the timing of both spring phenological events was generally advanced, indicating a dominant impact of forcing conditions compared with chilling. Stable time intervals between leaf-out and flowering prevailed for most of the time series despite increasing temperatures; however, some of the investigated cases featured significant changes in the time intervals. The latter could be explained by differences in the temperature sensitivity (ST) between leaf and flower phenology. Greater ST for flowering than for leaf-out caused flowering times to advance faster than leaf emergence. This shortened the inter-stage intervals in leaf-first species and lengthened them in flower-first species. Variation in the time intervals between leaf-out and flowering events may have far-reaching ecological and evolutionary consequences, with implications for species fitness, intra/inter-species interactions, and ecosystem structure, function, and stability.

Revival of associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma: An international multicenter study with promising outcomes

BackgroundAssociating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma has been considered to be contraindicated due to the initial poor results. Given the recent reports of improved outcomes, we aimed to collect the recent experiences of different centers performing associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma to analyze factors related to improved outcomes. MethodsThis proof-of-concept study collected contemporary cases of associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma and analyzed for morbidity, short and long-term survival, and factors associated with outcomes. ResultsIn total, 39 patients from 8 centers underwent associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma from 2010 to 2020. The median preoperative future liver remnant volume was 323 mL (155–460 mL). The median future liver remnant increase was 58.7% (8.9% -264.5%) with a median interstage interval of 13 days (6–60 days). Post–stage 1 and post–stage 2 biliary leaks occurred in 2 (7.7%) and 4 (15%) patients. Six patients (23%) after stage 1 and 6 (23%) after stage 2 experienced grade 3 or higher complications. Two patients (7.7%) died within 90 days after stage 2. The 1-, 3-, and 5-year survival was 92%, 69%, and 55%, respectively. A subgroup analysis revealed poor survival for patients undergoing additional vascular resection and lymph node positivity. Lymph node–negative patients showed excellent survival demonstrated by 1-, 3-, and 5-year survival of 86%, 86%, and 86%. ConclusionThis study highlights that the critical attitude toward associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma needs to be revised. In selected patients with perihilar cholangiocarcinoma, associating liver partition and portal vein ligation for staged hepatectomy can achieve favorable survival that compares to the outcome of established surgical treatment strategies reported in benchmark studies for perihilar cholangiocarcinoma including 1-stage hepatectomy and liver transplantation.

Efficacy of Technical Modifications to the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Procedure: A Systematic Review and Meta-Analysis.

ALPPS is an established technique for treating advanced liver tumors. PubMed, Web of Science, and Cochrane databases were searched. The outcomes were assessed by single-arm and 2-arm analyses. Seventeen studies containing 335 modified-ALPPS patients were included in single-arm meta-analysis. The estimated blood loss was 267 ± 29 mL (95% confidence interval [CI], 210-324 mL) during the first and 662 ± 51 mL (95% CI, 562-762 mL) during the second stage. The operation time was 166 ± 18 minutes (95% CI, 131-202 minutes) during the first and 225 ± 19 minutes (95% CI, 188-263 minutes) during the second stage. The major morbidity rate was 14% (95% CI, 9%-22%) after the first stage. The future liver remnant hypertrophy rate was 65.2% ± 5% (95% CI, 55%-75%) and the interstage interval was 16 ± 1 days (95% CI, 14-17 days). The dropout rate was 9% (95% CI, 5%-15%). The overall complication rate was 46% (95% CI, 37%-56%) and the major complication rate was 20% (95% CI, 14%-26%). The postoperative mortality rate was 7% (95% CI, 4%-11%). Seven studies containing 215 patients were included in comparative analysis. The hypertrophy rate was not different between 2 methods (mean difference [MD], -5.01; 95% CI, -19.16 to 9.14; P = 0.49). The interstage interval was shorter for partial-ALPPS (MD, 9.43; 95% CI, 3.29-15.58; P = 0.003). The overall complication rate (odds ratio [OR], 10.10; 95% CI, 2.11-48.35; P = 0.004) and mortality rate (OR, 3.74; 95% CI, 1.36-10.26; P = 0.01) were higher in the conventional-ALPPS. The hypertrophy rate in partial-ALPPS was similar to conventional-ALPPS. This shows that minimizing the first stage of the operation does not affect hypertrophy. Moreover, the postoperative overall morbidity and mortality rates were lower following partial-ALPPS.

СПЕЦИФИЧЕСКАЯ ПРОФИЛАКТИКА НОВОЙ КОРОНАВИРУСНОЙ ИНФЕКЦИИ У ДЕТЕЙ И ПОДРОСТКОВ: КЛИНИЧЕСКИЕ АСПЕКТЫ ВАКЦИНАЦИИ

The new coronavirus infection pandemic has had a major impact on public health. In order to decrease the volume of severe cases the mass vaccination is needed. The purpose of the study was to analyze the results of immunization of children against COVID-19. Materials and methods of the research: a single-center cohort prospective continuous study of the results of the COVID-19 vaccination in children and adolescents was carried out in Feb. - Mar. 2022. The research included 385 children and adolescents aged 12 to 17 years old divided into 2 groups: children aged 12 to 14 and adolescents aged 15 to 17 y/o. The combined vector-based vaccine “Gam-COVID-Vac-M” with two stages and 21 days interstage interval was used. The general and local reactions were studied for 42 days in both groups. Results: the impaired health and local reactions after the 1st stage of vaccination were statistically significantly more common in girls aged 12 to 14 y/o: 8 (16.0%) compared to 2 (2.9%) boys (p=0.0012). Among adolescents aged 15 to 17 y/o statistically significant differences between boys and girls were recorded after the 2nd stage of vaccination in the forms of: violation of well-being: in 36 (20.5%) boys and 37 (40.6%) girls (p=0.007); subfebrile condition in the 1st day after the vaccination in 33 (18.7%) boys and 36 (39.5%) girls (p=0.004). Conclusion: despite the insufficient number of cases studied and the impossibility for the researcher to control all the key parameters that contribute to the assessment of the tolerability of the 1st and the 2nd stages of vaccination, the results indicate the good tolerability and safety of vaccination against COVID-19 in children and adolescents. The results obtained indicate the statistically significant differences between the group of children aged 12 to 14 y/o, in whom 98 (83.1%) vaccinated had an uncomplicated course of the early post-vaccination period, compared to adolescents aged 15 to 17 y/o, where only 194 (72.7%) had an uncomplicated course of the early post-vaccination period (p=0.029).

Sex Disparities in Outcomes Following Major Liver Surgery: New Powers of Estrogen?

To explore potential sex differences in outcomes and regenerative parameters post major hepatectomies. Although controversial, sex differences in liver regeneration have been reported for animals. Whether sex disparity exists in human liver regeneration is unknown. Data from consecutive hepatectomy patients (55 females, 67 males) and from the international ALPPS (Associating-Liver-Partition-and-Portal-vein-ligation-for-Staged-hepatectomy, a two stage hepatectomy) registry (449 females, 729 males) were analyzed. Endpoints were severe morbidity (≥3b Clavien-Dindo grades), Model for End-stage Liver Disease (MELD) scores, and ALPPS interstage intervals. For validation and mechanistic insight, female-male ALPSS mouse models were established. t , χ 2 , or Mann-Whitney tests were used for comparisons. Univariate/multivariate analyses were performed with sensitivity inclusion. Following major hepatectomy (Hx), males had more severe complications ( P =0.03) and higher liver dysfunction (MELD) P =0.0001) than females. Multivariate analysis established male sex as a predictor of complications after ALPPS stage 1 (odds ratio=1.78; 95% confidence interval: 1.126-2.89; P =0.01), and of enhanced liver dysfunction after stage 2 (odds ratio=1.93; 95% confidence interval: 1.01-3.69; P =0.045). Female patients displayed shorter interstage intervals (<2 weeks, 64% females versus 56% males, P =0.01), however, not in postmenopausal subgroups. In mice, females regenerated faster than males after ALPPS stage 1, an effect that was lost upon estrogen antagonism. Poorer outcomes after major surgery in males and shorter ALPPS interstage intervals in females not necessarily suggest a superior regenerative capacity of female liver. The loss of interstage advantages in postmenopausal women and the mouse experiments point to estrogen as the driver behind these sex disparities. Estrogen's benefits call for an assessment in postmenopausal women, and perhaps men, undergoing major liver surgery.

Parenchyma Sparing ALPPS - Ultrasound Guided Partition Through Segment 4 to Maximize Resectability (with video)

Background: Associating liver partition and portal vein ligation (ALPPS) has evolved as a treatment strategy for patients with liver tumors who are not amenable for upfront hepatectomy because of an insufficient future liver remnant (FLR). Aim of this study was to test the applicability of ultrasound guided parenchyma sparing surgery to ALPPS concept, by non-anatomically shifting the plane of transection in favor of FLR, resulting in a new technical variant of ALPPS, entitled parenchyma sparing ALPPS (psALPPS). Materials and Methods: Patients who could not safely undergo right trisectionectomy ALPPS because of insufficient FLR were considered eligible for psALPPS, consisting in liver partition through segment 4 using ultrasound guidance. Results: Between April 2017 and April 2021, five patients with median age of 68 years (range: 66-78), four male and one female, underwent psALPPS for colorectal liver metastases (N=2), intrahepatic cholangiocarcinoma (N=2), and hepatocellular carcinoma (N=1). Standardized FLR (sFLR) for segments 2-3 before stage 1 surgery would have been a median of 11.6%. PsALPPS could double the sFLR at stage 1 resulting in an increase of ps-sFLR from a median of 22.7% (at stage 1) to 34.0% (at stage 2) after a median interstage interval of 15 days. All patients tolerated surgery well and no major complications were recorded. Conclusions: Applying the principles of parenchyma sparing surgery to ALPPS offers the advantage to maximize FLR and simultaneously reduce ischemic injury of segment 4 compared to conventional ALPPS. In this way, psALPPS may markedly increase resectability while reducing morbidity.

Robotic liver partition and portal vein embolization for staged hepatectomy for perihilar cholangiocarcinoma

Perihilar cholangiocarcinoma (pCCA) is one of the most complex challenges for hepatobiliary surgeons. Poor results and high incidence of morbidity after Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) for pCCA discouraged this indication. It has been proposed that minimally invasive approach for ALPPS first stage, as well as combination of surgical liver partition and radiologic portal vein embolization (PVE), may improve outcomes reducing interstage morbidity. We report a case of right trisectionectomy with enbloc caudatectomy ALPPS scheduled for pCCA with robotic approach at stage-1, the full video is provided as supplementary material. Due to intraoperative presence of portal vein tumor infiltration during hilar dissection (no evidence in the pre-operative work-up), a radiologic right PVE was performed after stage-1 instead of portal vein ligation, followed by portal vein resection and biductal hepatico-jejunostomy at stage-2 with open approach. The patient was a 74-year-old female diagnosed with 3-cm mass-forming pCCA. The total clean liver volume was 1231 cc, with future liver remnant (FLR) volume of 25.1% (segments II and III). She was discharged in the interstage interval on postoperative day (POD) 4; CT scan on POD 12 showed that FLR increased up to 33% (369 cc) (Fig. 1). ALPPS was completed on POD 17, the postoperative course was uneventful, and the patient was discharged in good general condition on POD 19 after stage-2. Besides the already demonstrated advantages in terms of reduced interstage morbidity, robotic ALPPS represents a promising strategy to expand surgical indication in patients with pCCA. The combination of liver partition and PVE may increase the opportunities to perform radical resections in selected patients with pCCA and portal vein infiltration.Supplementary InformationThe online version contains supplementary material available at 10.1007/s13304-021-01209-x.

Interstage mortality in two‐stage elephant trunk surgery

Diffuse mega-aorta is challenging. Prior studies have raised concerns regarding the safety of the open two-stage elephant trunk (ET) approach for extensive thoracic aortic aneurysm (TAA), specifically in regard to interstage mortality. This study evaluates the safety of the two-stage ET approach for management of extensive TAA. Between 2003 and 2018, 152 patients underwent a Stage I ET procedure by a single surgeon (mean age 64.5 ± 14.8). Second stage ET procedure was planned in 60 patients (39.4%) and to-date has been performed in 54 patients (90%). (in the remaining patients, the ET was prophylactic for the long-term, with no plan for near-term utilization). In-hospital mortality after the Stage I procedure was 3.3% (5/152). In patients planned for Stage II, the median interstage interval was 5 weeks (range: 0-14). Of the remaining six patients with planned, but uncompleted Stage II procedures, five patients expired from various causes in the interval period (interstage mortality of 8.3%). There were no cases of aortic rupture in the interstage interval. Stage II was completed in 58 patients (including four unplanned) with a 30-day mortality of 10.3% (6/58). Seven patients developed strokes after Stage II (12%), and three patients (5.1%) developed paraplegia. The overall mortality, including Stage I, interstage interval, and Stage II was 18.6%. This substantial cumulative mortality for the open two-staged ET approach for the treatment of extensive TAA appears commensurate with the severity of the widespread aortic disease in this patient group. Fear of interstage rupture should not preclude the aggressive Two-Stage approach to the management of extensive TAA.

First Analysis of d-ALPPS, a Safe Alternative to ALPPS

Purpose: The “ideal” length of the inter-stage interval of Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) has not yet been investigated but many centres suggest that progression to the second stage within two weeks is crucial to achieve resection rates >95%, a key feature of ALPPS. However, without accurate volumetric and functional assessment of the future liver remnant (FLR), completion hepatectomy after one week might be too early, contributing to high morbidity and mortality.

Parenchyma Sparing ALPPS Ultrasound Guided Partition Through Segment 4 to Maximize Resectability (with video).

Associating liver partition and portal vein ligation (ALPPS) has evolved as a treatment strategy for patients with liver tumors who are not amenable for upfront hepatectomy because of an insufficient future liver remnant (FLR). Aim of this study was to test the applicability of ultrasound guided parenchyma sparing surgery to ALPPS concept, by non-anatomically shifting the plane of transection in favor of FLR, resulting in a new technical variant of ALPPS, entitled parenchyma sparing ALPPS (psALPPS). Patients who could not safely undergo right trisectionectomy ALPPS because of insufficient FLR were considered eligible for psALPPS, consisting in liver partition through segment 4 using ultrasound guidance. Between April 2017 and April 2021, five patients with median age of 68 years (range: 66-78), four male and one female, underwent psALPPS for colorectal liver metastases (N=2), intrahepatic cholangiocarcinoma (N=2), and hepatocellular carcinoma (N=1). Standardized FLR (sFLR) for segments 2-3 before stage 1 surgery would have been a median of 11.6%. PsALPPS could double the sFLR at stage 1 resulting in an increase of ps-sFLR from a median of 22.7% (at stage 1) to 34.0% (at stage 2) after a median interstage interval of 15 days. All patients tolerated surgery well and no major complications were recorded. Applying the principles of parenchyma sparing surgery to ALPPS offers the advantage to maximize FLR and simultaneously reduce ischemic injury of segment 4 compared to conventional ALPPS. In this way, psALPPS may markedly increase resectability while reducing morbidity. https://www.revistachirurgia.ro/pdfs/?EntryID=922974&art=2021-parenchyma-sparing-ALPPS-ultrasound-guided-partition.pdf

Temporary new implant spacers increase post-reimplantation total knee prosthesis survival after periprosthetic joint infection

Two-stage exchange arthroplasty is considered the gold standard for treatment of periprosthetic joint infection (PJI) following total knee arthroplasty (TKA). Antibiotic cement spacers can include cement-based spacers (CBS), new components (NEW), and autoclaved components (ACL). The factors that most influence post-reimplantation prosthesis (PRP) survival were determined. A retrospective database review of patients undergoing two-stage exchange arthroplasty from 2008 to 2014 was performed. There were 85 patients, 25 patients and 30 patients in CBS, NEW and ACL groups, respectively. Patient, disease and surgical characteristics were collected and analyzed. Post-reimplantation prosthesis (PRP) survival was modeled using the Kaplan-Meier method. Cox proportional hazard modeling was then performed to identify risk factors associated with implant failure. Overall PRP survival was 82% in 140 unilateral TKAs. PRP survival between groups was 81%, 96% and 73% within the minimum 2-year follow-up period, respectively. There was a difference in median interval-to-reimplantation between groups (CBS, 72.0days; NEW, 111.0days; ACL, 84.0days, p = 0.003). Adjusting for time-to-reimplantation, NEW spacers demonstrated greater PRP survival compared with ACL spacers (p = 0.044), and a trend towards greater survival compared with CBS spacers (p = 0.086). Excluding early failures (< 90days), NEW spacers still demonstrated greater survival than ACL spacers (p = 0.046). Lower volume (≤ 10 within this series) surgeons tended to use more CBS spacers, while higher volume surgeons were comfortable with ACL spacers. There was greater PRP survival with NEW spacers. NEW spacers also demonstrated an increased inter-stage interval, likely because of increased comfort and motion. There were spacer choice differences between low- and high-volume surgeons. III.

Renal Impairment Is Associated with Reduced Outcome After Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy

BackgroundImpaired postoperative renal function is associated with increased morbidity and mortality after liver resection. The role of impaired renal function in the two-stage hepatectomy setting of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is unknown. MethodsAn international multicenter cohort of ALPPS patients captured in the ALPPS Registry was analyzed. Particular attention was drawn to the renal function in the interstage interval to determine outcome after stage 2 surgery. Interstage renal impairment (RI) was defined as an increase of serum creatinine of ≥ 0.3 mg/dl referring to a preoperative value or an increase of serum creatinine of ≥ 1.5× of the preoperative value on the fifth postoperative day after stage 1. ResultsA total of 705 patients were identified of which 7.5% had an interstage RI. Patients developing an interstage RI were significantly older. During stage 1, a longer operation time, higher rate of intraoperative transfusions, and additional procedures were observed in patients that developed interstage RI. After stage 1, interstage RI patients had more major complications and higher interstage mortality (1% vs. 8%, p < 0.001). Furthermore, these patients developed more and severe complications after completion of stage 2. Mortality of patients with interstage RI was 38% vs. 8% without interstage RI. In 41% of patients with interstage RI, the renal function recovered before stage 2; however, the mortality after stage 2 remained 28% in those patients. Risk factors for the development of an interstage RI were age over 67 years, prolonged operative time, and additional procedure during stage 1. ConclusionThis study shows that interstage RI is a predictor for interstage and post-stage 2 morbidity and perioperative mortality. The causality of impaired renal function on outcome, however, remains unknown. Interstage RI may directly cause adverse outcome but may also be a surrogate marker for major complications.

P1 cortical auditory evoked potential in children with unilateral or bilateral cochlear implants; implication for the timing of second cochlear implantation.

To examine maturation of the central auditory pathway, using P1 cortical auditory evoked potential (CAEP), in children who had received unilateral or bilateral cochlear implantation (CI). Prospective study. Tertiary referral hospital. Twenty children who had received CI due to congenital, or prelingual, deafness participated in the study. Participants had received the 1st implant at a mean age of 3.4 ± 0.7years; 16 had also received a 2nd CI for the contralateral ear, at a mean age of 11.1 ± 2.1years. P1 CAEP was recorded while using the 1st implant and, for those who received contralateral CI, within 2weeks of switching on the 2nd implant. Relations between P1 latency and duration with the 1st implant, and between age at 1st CI and P1 latency, were investigated. Relations between P1 latency with the 1st and 2nd implants, and between the interstage interval and difference between P1 latencies with the 1st and 2nd implants, were also examined. P1 CAEP with the 1st implant was present in 16 of the 20 children. Mean P1 latency was shorter in the early CI group compared with the late CI group, but this difference was not statistically significant (p = 0.154). There was a significant negative correlation between the duration with the 1st implant and P1 latency (r = - 0.783, p < 0.001). Among the 16 children with sequential bilateral CI, P1 CAEP with the 2nd implant was present in 10. There was a significant negative correlation between the duration with the 1st implant before receiving the 2nd implant and P1 latency with the 2nd implant (r = - 0.710, p = 0.021); there was also a significant positive correlation between P1 latency with the 1st and 2nd implants (r = 0.722, p = 0.018). There was not a significant correlation between interstage interval and the difference between the two P1 latencies (r = - 0.430, p = 0.248). Longer cochlear implant use is associated with shorter P1 latency. Unilateral hearing with the 1st implant may positively affect P1 latency with the 2nd CI ear. These findings imply that increased auditory experience may influence central auditory pathway maturation and that the degree of central auditory pathway maturation before the 2nd CI, rather than the timing when the surgery is received, may influence 2nd CI outcome in children with sequential bilateral cochlear implants.

Time to Reimplantation: Waiting Longer Confers No Added Benefit

BackgroundWhile the preferred surgical treatment for chronic periprosthetic joint infection (PJI) in North America is a 2-stage exchange arthroplasty, the optimal time between first-stage and reimplantation surgery remains unknown. This study was conceived to examine the association between time to reimplantation and treatment failure. MethodsUsing an institutional database, we identified PJI cases treated with 2-stage exchange arthroplasty between 2000 and 2016. Musculoskeletal Infection Society criteria were used to define PJI, and treatment failure was defined using Delphi criteria. The interstage interval between first-stage and reimplantation surgery for each case was collected, alongside demographics, patient-related and organism-specific data. Multivariate logistic regression analyses were used to examine association with treatment failure. ResultsOur final analysis consisted of 282 patients with an average time to reimplantation of 100.2 days (range, 20-648). Sixty-three patients (22.3%) failed at 1 year based on Delphi criteria. Time to reimplantation was not significantly associated with failure in both univariate (P = .598) and multivariate (P = .397) models. However, patients reimplanted at >26 weeks were twice as likely to fail in comparison to those reimplanted within <26 weeks (43.8% vs 21.1%), and this finding reached marginal significance (P = .057). Patients who failed had significantly more comorbidities (P = .008). Charlson comorbidity index was the only variable significantly associated with treatment failure in regression analysis (odds ratio, 1.40; 95% confidence interval, 1.06-1.86; P = .019). ConclusionThe length of the interstage interval was not a statistically significant predictor of failure in patients undergoing 2-stage exchange arthroplasty for PJI.

Sequential pediatric bilateral cochlear implantation: The effect of time interval between implants

ObjectiveTo examine speech intelligibility in children subjected to sequential bilateral cochlear implants (CI) surgery and to assess the influence of the inter-stage interval duration. IntroductionBinaural hearing recovery can have additional benefits, especially in speech and language development in patients with congenital profound sensorineural hearing loss; so recently there has been an increase in the number of children receiving bilateral CI. MethodsTwenty-seven children who underwent sequential bilateral cochlear implant (SBCI) with a short (1–3 yrs), medium (4–6 yrs) and long (7–12 yrs) range interval between both implantations, respectively, were evaluated. All patients underwent periodic speech perception test in quiet and noise after second implant activation in three conditions: with the first or second implant alone and with both implants. Results were examined according to the inter-stage interval. ResultsSpeech intelligibility in noise was significantly better under bilateral conditions than either ear alone, in all three groups. Small improvements were seen in quiet, especially in the third group (6–12 yrs). ConclusionBenefits of second implant in the early-implanted children and after a short inter-implant delay are more evident. However our study support that, even after a long period of deafness and despite a prolonged inter-stage interval, sequential bilateral cochlear implantation should be considered.Level of Evidence: Level 4.

Feasibility Accuracy of Three-Dimensional Echocardiography Colour Flow Measurement on Duct Pulmonary Dependent Circulation

The assessment for patient with duct-dependent pulmonary circulation (DDPC) during the inter-stage intervals before first stage palliation commonly includes imaging of the heart with multiple imaging modalities. Recently, three-dimensional echocardiography (3DE) was found with the ability to delineate cardiac structure that is able to do 360o rotation. Therefore, this study aimed at identifying the accuracy of 3DE colour flow in measuring PDA size compared to computer tomography angiography (CTA). This study involves randomly selected 26 patients with DDPC undergoing CTA for palliation treatment in one year. The mean patient age is 1.6 ± 0.261 months with mean weight of 3.65 ± 0.82 kg. The full-volume 3DE colour flow acquisition was performed and analysed offline using Q-lab software. The PDA diameters at the origin as well as the insertion site were measured. The data obtained by 3DE colour flow data were compared to the CTA, which was taken as the gold standard. Results showed that the offline analysis of PDA size was feasible in all patients (100%) with the mean diameter of PDA at the origin on 3DE colour flow and CTA of 0.51 mm ± 0.14 and 0.52 mm ± 0.11, respectively (p = 0.92) . The PDA diameter at insertion site on 3DE colour flow and CTA was 0.29 mm ± 0.08 and 0.27 mm ± 0.97 respectively (p = 0.5). Meanwhile, the measurement of 3DE colour flow is comparable to CTA in measurement PDA size. However, the use of 3DE colour flow in infants with rapid heart rate is yet challenging to 3DE colour flow acquisitions. DOI : http://dx.doi.org./10.17576/JSKM-2017-1502-17

Short Chemotherapy-Free Interval Improves Oncological Outcome in Patients Undergoing Two-Stage Hepatectomy for Colorectal Liver Metastases.

In patients undergoing two-stage hepatectomy (TSH) for colorectal liver metastases (CRLM), chemotherapy is discontinued before portal vein occlusion and restarted after curative resection. Long chemotherapy-free intervals (CFI) may lead to tumor progression and poor oncological outcomes. The aim of this study was to investigate the impact of the length of CFI on oncological outcome in patients undergoing TSH for CRLM. Overall, 74 patients suffering from bilobar CRLM who underwent ALPPS (associating liver partition with portal vein ligation for staged hepatectomy; n=43) or conventional TSH (n=31) at two tertiary centers were investigated. The impact of CFI on long-term outcomes was analyzed by univariable and multivariable analysis. Preoperative chemotherapy was administered in 91% (67/74) of patients, and chemotherapy was resumed postoperatively in 69% (44/64) of patients who completed TSH. The use of postoperative chemotherapy was significantly associated with improved mean overall survival (36±3 vs. 13±3months; p<0.001). Overall, the median CFI from surgery to postoperative chemotherapy was 16weeks (interquartile range 11-31) and was significantly shorter in the ALPPS group when compared with the conventional TSH group (10 vs. 21weeks; p<0.001). Multivariable analysis revealed a CFI≤10weeks as an independent factor associated with improved overall survival (p=0.006) and disease-free survival (p=0.010). A short CFI is associated with improved oncological outcome in patients undergoing TSH for CRLM. Decreased interstage intervals after ALPPS may facilitate the timely resumption of chemotherapy.

Doppler Flow Patterns in the Right Ventricle–to–Pulmonary Artery Shunt and Neo-Aorta in Infants with Single Right Ventricle Anomalies: Impact on Outcome after Initial Staged Palliations

A Pediatric Heart Network trial compared outcomes in infants with single right ventricle anomalies undergoing Norwood procedures randomized to modified Blalock-Taussig shunt (MBTS) or right ventricle-to-pulmonary artery shunt (RVPAS). Doppler patterns in the neo-aorta and RVPAS may characterize physiologic changes after staged palliations that affect outcomes and right ventricular (RV) function. Neo-aortic cardiac index (CI), retrograde fraction (RF) in the descending aorta and RVPAS conduit, RVPAS/neo-aortic systolic ejection time ratio, and systolic/diastolic (S/D) ratio were measured early after Norwood, before stage II palliation, and at 14 months. These parameters were compared with transplantation-free survival, length of hospital stay, and RV functional indices. In 529 subjects (mean follow-up period, 3.0 ± 2.1 years), neo-aortic CI and descending aortic RF were significantly higher in the MBTS cohort after Norwood. The RVPAS RF averaged <25% at both interstage intervals. Higher pre-stage II descending aortic RF was correlated with lower RV ejection fraction (R= -0.24; P=.032) at 14 months for the MBTS cohort. Higher post-Norwood CI (5.6 vs 4.4 L/min/m(2), P= .04) and lower S/D ratio (1.40 vs 1.68, P= .01) were correlated with better interstage transplantation-free survival for the RVPAS cohort. No other Doppler flow patterns were correlated with outcomes. After the Norwood procedure, infants tolerated significant descending aortic RF (MBTS) and conduit RF (RVPAS), with little correlation with clinical outcomes or RV function. Neo-aortic CI, ejection time, and S/D ratios also had limited correlations with outcomes or RV function, but higher post-Norwood neo-aortic CI and lower S/D ratio were correlated with better interstage survival in those with RVPAS.

Functional benefits of sequential bilateral cochlear implantation in children with long inter-stage interval between two implants

ObjectivesOlder children are increasingly deriving binaural benefits from sequential bilateral cochlear implantation, and this procedure should be considered by experienced cochlear implant centers. This study aimed to identify the influence of a long inter-stage interval between two implants in older children. Speech perception and everyday listening performance were investigated and analyzed according to the length of the inter-stage interval. Study design and settingsForty-two children who received sequential bilateral cochlear implantation participated in this study. Their average ages at the first and second implantation were 4.2 and 9.7years, respectively. All subjects acquired excellent speech performance from their first implant, and the mean inter-stage interval was 5.5years. Speech perception in quiet was assessed by formal speech measures, and postoperative performance using the second implant only was compared with the preoperative performance. Speech perception in noise test was administered using three noise directions with noise (+10dB signal-to-noise ratio) from front and 90° to each side, and the change in performance using the first implant only and both implants were analyzed across the three noise directions. Subjects were divided into three groups according to their inter-stage interval (group I, 3–4.9years; group II, 5–6.9years; and group III, 7–9.9years), and the test results were compared between the groups. Functional hearing benefits in daily life were measured by a questionnaire before and after bilateral cochlear implantation. ResultsThe speech perception abilities in quiet using the second implant only improved quickly and were similar to those using the first implant only within 1year after the second implantation. The scores for the monosyllabic word test (phoneme: p=0.052; word: p=0.125) and common phrases sentence test (p=0.062) 6month after the second implantation, and the Categories of Auditory Performance score (p=1.000) 1year after the second implantation using the second implant only did not differ significantly from those using the first implant only. Speech perception was significantly better using both implants than using the first implant in all three noise conditions (speech and noise in front: p=0.004; speech in front and noise to the first implant: p=0.003; speech in front and noise to the second implant: p<0.001), and the effect of noise direction was negligibly small. No salient influence of inter-stage interval was observed in both quiet and noise tests. The second and third groups with longer inter-stage intervals (>5years) achieved performance close to the level of the first group with a shorter interval. These subjects obtained significantly better functional hearing benefits in the everyday environment with bilateral implants compared with the first implant (p=0.018). ConclusionThe subjects in this study showed rapid postoperative progression within 6months after the second implantation, and more listening benefits in noise and daily life with bilateral implants. This group of older children, who were good performers with the first implant, developed auditory perceptual competence in the second ear and achieved functional binaural benefits with their two implants. Sequential bilateral cochlear implantation should be recommended to this group of older children despite a long inter-stage interval between two implants.