Late Repair Research Articles

Outcome Prospective of Late Duodenal Perforation Repairs in Elderly

Introduction: Perforated duodenal ulcer is the communal emergency seen in surgical department, and postoperative complications of this emergency surgeries are very high which requires the related factors identification with this incidence. Aim: This study was designed to evaluate duodenal ulcer in older patients by revealing the patient's health status, early and late repair, choice of surgical procedure, and differences between older and younger duodenal ulcer patients. Study Design: A Retrospective study. Place and duration: In the Surgical Unit 2 of, Sheikh Zayed Medical College/ Hospital Rahim Yar Khan for two-year duration from January 2020 to December 2021. Methods: This study included 140 patients were alienated into 2 age groups as geriatric patients’ group (A) and adult age group (B). Patient age, gender, co-morbidities, drug use, presence of Helicobacter pylori infection, medical conditions that may have been affected by perforation, such as characteristic pain (severe upper abdominal pain or vague abdominal pain), extent of symptoms at presentation, smoking, outcomes of late repair versus early repair was recorded. Results: 140 patients were registered in the analysis. Group I (n = 70) consisted of geriatric patients (age> 65) and Group-II (n = 70) adults’ patients (age <65). Both groups have male dominance in this study. In both groups, the most common comorbidities were diabetes (25.7% and 8.6%, respectively) and arterial hypertension (42.8% and 41.4%, respectively), hypertension (p = 0.002) and coronary artery disease (p = 0.035) was much high in group I, while morbidity and mortality were higher in the group of elderly patients. Conclusion: Duodenal perforation is a serious disease that requires urgent surgical intervention, especially in the geriatric age. Keywords: Duodenal ulcer perforation, acute abdomen, geriatric surgery.

Vascular injury during cholecystectomy: A multicenter critical analysis behind the drama

BackgroundThe management of a vascular injury during cholecystectomy is still very complicated, especially in centers not specialized in complex hepatobiliary surgery. MethodsThis was a multi-institutional retrospective study in patients with vascular injuries during cholecystectomy from 18 centers in 4 countries. The aim of the study was to analyze the management of vascular injuries focusing on referral, time to perform the repair, and different treatments options outcomes. ResultsA total of 104 patients were included. Twenty-nine patients underwent vascular repair (27.9%), 13 (12.5%) liver resection, and 1 liver transplant as a first treatment. Eighty-four (80.4%) vascular and biliary injuries occurred in nonspecialized centers and 45 (53.6%) were immediately transferred. Intraoperative diagnosed injuries were rare in referred patients (18% vs 84%, P = .001). The patients managed at the hospital where the injury occurred had a higher number of reoperations (64% vs 20%, P ˂ .001). The need for vascular reconstruction was associated with higher mortality (P = .04). Two of the 4 patients transplanted died. ConclusionVascular lesions during cholecystectomy are a potentially life-threatening complication. Management of referral to specialized centers to perform multiple complex multidisciplinary procedures should be mandatory. Late vascular repair has not shown to be associated with worse results.

Outcome of humanitarian patients with late complete repair of tetralogy of Fallot: A 13-year long single-center experience

BackgroundSurgical repair of tetralogy of Fallot is usually performed between 3 and 6 months of age with pulmonary valve-sparing repair promoted for the best long-term result. Through a humanitarian program from developing countries, late complete surgical repair of tetralogy of Fallot has been performed at our institution for many years. MethodsRetrospective analysis of pre- and perioperative data, as well as 30-days outcome of patients older than one year with a confirmed diagnosis of tetralogy of Fallot who had a complete surgical repair between 2005 and 2018 at our institution. ResultsOne hundred sixty-five patients were included with a median age of 4.5 years [3.0–6.3], median weight of 13.5 kg [10.9 to 16.5], median transcutaneous oximetry of 78% [70 to 85] and median pulmonary valve annulus Z-score of −1.8 [-3.4 to −0.8]. There was no early surgical mortality. By multivariate analysis, only severe right ventricular hypertrophy, severe right ventricle outflow tract obstruction, and hypoplasia of the main pulmonary artery were independent predictors of failure to preserve the pulmonary annulus at surgical repair. ConclusionsLate complete surgical repair of tetralogy of Fallot has low mortality and morbidity even when pulmonary valve-sparing repair cannot be successfully performed. The preservation of the pulmonary valve function is significantly associated with shorter ventilation time, ICU and hospital lengths of stay. In the analyzed group of patients, a pulmonary valve-sparing repair cannot be predicted exclusively based on the dimension of the pulmonary valve annulus.

Mitral valve repair: Regulatory or ethical problem?

The long-term outcome of patients undergoing mitral valve repair (MVr) is based on what happens during the more or less 60 min of aortic cross-clamping necessary to transform a leaking valve into a well-functioning one. As a consequence, the experience of the surgeon performing the procedure is the only determinant of the success rate that deserves to be taken into account. It is clear from the literature that the number of cases/year is inversely related to the number of early and late deaths, repair failures, and reoperations. However, there is no agreement on the minimum caseload/year that represents the threshold to identify surgeons that can perform or not MVr. This problem then cannot be regulated by specific guidelines of Scientific Societies, but only by the ethical perception, we have of our profession.

Cleft Rhinoplasty: Does Timing and Utilization of Cartilage Grafts Affect Perioperative Outcomes?

The purpose of this study was to evaluate the epidemiology and perioperative complications of different reconstructive strategies to correct cleft nasal deformity, with particular attention paid to type and timing of cartilage grafting. Retrospective cohort study was conducted of cleft rhinoplasty performed between 2012 and 2017 in North America utilizing the American College of Surgeons National Surgical Quality Improvement Program- Pediatric hospital network. Medical/surgical complications, reoperations, and readmissions within 30 days postoperatively were analyzed with appropriate statistics. During the study interval, 3317 pediatric patients underwent cleft rhinoplasty, with 8.0% involving the use of cartilage grafts. Ear cartilage was significantly more commonly used for intermediate repair, whereas rib cartilage was more commonly used for late repair (P=0.006). Overall, rhinoplasties with ear cartilage grafts had shorter procedure durations than those without cartilage grafts (P=0.005), whereas those with rib cartilage grafts had increased procedure duration (P<0.001). The use of cartilage grafts was not associated with increased complications in either intermediate or late cleft rhinoplasty. Patients with bilateral clefts were more likely to undergo rhinoplasty with cartilage grafts overall (P=0.047) and with cartilage grafts for late reconstruction (P=0.039). Ear cartilage is most frequently utilized for intermediate repair, whereas rib cartilage is most frequently utilized for late repair during cleft rhinoplasty. Ear cartilage grafts are associated with significantly decreased procedure duration, whereas rib cartilage grafts are associated with significantly increased procedure duration. Not surprisingly, cleft rhinoplasty is relatively safe, with a 2% overall short-term complication rate.

Early results of geometric ring annuloplasty for bicuspid aortic valve repair during aortic aneurysm surgery.

ObjectivesGeometric ring annuloplasty has shown promise during bicuspid aortic valve repair for aortic insufficiency. This study examined early outcomes of bicuspid aortic valve repair associated with proximal aortic aneurysm replacement.MethodsFrom September 2017 to November, 2021, 127 patients underwent bicuspid aortic valve repair with concomitant proximal aneurysm reconstruction. Patient age was 50.6 ± 12.7 years (mean ± standard deviation), male gender was 83%, New York Heart Association Class was 2 (1-2) (median [interquartile range]), and preoperative aortic insufficiency grade was 3 (2-4). Ascending aortic diameter was 50 (46-54) mm, and all patients had ascending aortic replacement. Forty patients had sinus diameters greater than 45 mm, prompting remodeling root procedures. A total of 105 patients had Sievers type 1 valves, 3 patients had type 0, and 7 patients had type 2. A total of 118 patients had primarily right/left fusion, 8 patients had right/nonfusion, and 1 patient had left/nonfusion. Leaflet reconstruction used central leaflet plication and cleft closure, with limited ultrasonic decalcification in 31 patients.ResultsRing size was 23 (21-23) mm, and 26 of 40 root procedures were selective nonfused sinus replacements. Aortic clamp time was 139 (112-170) minutes, and bypass time was 178 (138-217) minutes. Postrepair aortic insufficiency grade was 0 (0-0) (P < .0001), and mean valve gradient was 10 (7-14) mm Hg. No early and 1 late mortality occurred. Four patients required reoperation for bleeding, and 4 patients required pacemakers. At a mean follow-up of 20 months (maximal 93), there were no valve-related complications, 5 late repair failures prompting valve replacement, and 1 death due to Coronavirus Disease 2019.ConclusionsGeometric ring annuloplasty for bicuspid aortic valve repair with proximal aortic aneurysm reconstruction is safe and associated with good early outcomes. Further experience and follow-up will help inform long-term durability.

Renal Complications Following Juxtarenal Aortic Aneurysm Repair Affect Late Survival and Repair Durability

Renal complications following open and endovascular repair of juxtarenal aortic aneurysms are associated with increased postoperative mortality and morbidity. Our objective was to assess the effect of postoperative renal complications on late outcomes following juxtarenal aortic aneurysm repair.

Late Repairs of Right-Sided Partial Anomalous Pulmonary Veins

In this issue of The Annals of Thoracic Surgery, Griffeth and colleagues1 at the Mayo Clinic describe their results of the surgical repair of right-sided partial anomalous pulmonary veins. In contrast to the typical patient seen in pediatric heart practices, their patients were older children and adults. Unlike school age children undergoing early repair, for the most part, these patients have been subjected to decades of chronic volume loading with resultant adverse atrial and ventricular remodeling.

Effect of surgical timing in 23-g pars plana vitrectomy for primary repair of macula-off rhegmatogenous retinal detachment, a retrospective study

BackgroundRhegmatogenous retinal detachment (RRD) is a common, potentially blinding ocular pathology that is considered a surgical emergency. Macular involvement has been identified as a major negative prognostic indicator for visual recovery after RRD correction. It is not currently clear whether early intervention improves visual outcomes, and in practice, there are potential disadvantages to performing early surgery for fovea-involving RRD. Such disadvantages include inadequate assessment of coexisting comorbidities, increased rate of complications related to poorly trained staff or tired surgeons, and anesthetic risk.MethodsA single-center, retrospective, cohort study of patients who underwent repair of macula-involving rhegmatogenous retinal detachment at the University of Virginia was performed. Variables collected included patient demographics, ocular history, clinical characteristics, and post-operative complications. Patients were excluded if they had a history of congenital or acquired pathology with an effect on visual function, bilateral or repeat rhegmatogenous detachment, age less than 18 years, follow up duration less than 6 months, or if they were repaired using scleral buckle, pneumatic retinopexy, 25- or 27-gauge pars plana vitrectomy, or any combination of these techniques. A multivariate regression model was used to compare overall outcomes such as post-operative visual acuity, intra-ocular pressure, retina attachment status, and complications among patients of differing timing of surgical repair. These analyses were adjusted for clinical factors known or considered to be associated with worse prognosis in rhegmatogenous retinal detachment.ResultsA total of 104 patients undergoing 23-gauge vitrectomy for repair of macula involving rhegmatogenous retinal detachments were included in this study with mean follow up period 17.9 ± 14.1 months. Early surgical repair (< 48 h) was pursued in 26 patients, moderately delayed surgical repair (3–7 days), was performed in 29 patients and late surgical repair (> 7 days) in 49 patients. Our analysis showed no difference in post-operative visual acuity between patients with detachments undergoing early versus moderately delayed repair of RRD. However, mean visual acuity differed between patients undergoing early versus late repair at 3, 6, and 12 months. No significant difference was observed in post-operative complications between the three surgical timepoints including cataract formation, development of glaucoma and re-detachment rate. Use of 360 laser was found to be protective against re-detachment overall (OR 6.70 95% CI 1.93–23.2).ConclusionsThese findings indicate that a moderate delay of 3–7 days from symptom onset for repair of macula-involving retinal detachment may be a safe approach as there are no differences in terms of visual acuity or post-operative complications compared to early repair within 48 h. Delaying surgery for > 7 days however is not recommended due to the loss of recovery of visual acuity observed in this study. Use of 360 laser may prevent risk of re-detachment after primary repair.

Aortic valve repair for isolated right coronary leaflet prolapse.

ObjectivesIsolated right coronary leaflet prolapse is a common cause of nonaneurysmal aortic insufficiency, but can rarely occur in patients with proximal aortic aneurysms. Standardized techniques for routine autologous repair of this disorder are presented.MethodsMost aortic valve leaflet prolapse is isolated to the right coronary leaflet, with hypertension and annular dilatation being contributory. Echocardiographically, a posteriorly eccentric aortic insufficiency jet together with “fracture” of the right leaflet tip are diagnostic. Primary repair includes internal geometric ring annuloplasty to downsize and reshape the annulus, together with central plication of the prolapsing leaflet. Thickened, scarred, or retracted noduli are released using an ultrasonic aspirator. The goal is to achieve equivalent coaptation heights of ≥8 mm for all 3 leaflets.ResultsThree videos of 6 cases are provided to illustrate these techniques. In the first, 3 patients are shown with classic isolated right leaflet prolapse. In the second and third videos, alternative pathologies are presented for contrast. Applying the reconstructive approaches of geometric ring annuloplasty, leaflet plication, and ultrasonic nodular release, excellent early and late repair outcomes are obtainable in most patients.ConclusionsThe combination of aortic ring annuloplasty, central leaflet plication, and ultrasonic nodular release allows routine and standardized repair of right coronary leaflet prolapse, either isolated or concomitant with aneurysm surgery.

Timing of surgical repair of bile duct injuries after laparoscopic cholecystectomy: A systematic review.

BACKGROUNDThe surgical management of bile duct injuries (BDIs) after laparoscopic cholecystectomy (LC) is challenging and the optimal timing of surgery remains unclear. The primary aim of this study was to systematically evaluate the evidence behind the timing of BDI repair after LC in the literature.AIMTo assess timing of surgical repair of BDI and postoperative complications.METHODSThe MEDLINE, EMBASE, and The Cochrane Library databases were systematically screened up to August 2021. Risk of bias was assessed via the Newcastle Ottawa scale. The primary outcomes of this review included the timing of BDI repair and postoperative complications.RESULTSA total of 439 abstracts were screened, and 24 studies were included with 15609 patients included in this review. Of the 5229 BDIs reported, 4934 (94%) were classified as major injury. Timing of bile duct repair was immediate (14%, n = 705), early (28%, n = 1367), delayed (28%, n = 1367), or late (26%, n = 1286). Standardization of definition for timing of repair was remarkably poor among studies. Definitions for immediate repair ranged from < 24 h to 6 wk after LC while early repair ranged from < 24 h to 12 wk. Likewise, delayed (> 24 h to > 12 wk after LC) and late repair (> 6 wk after LC) showed a broad overlap.CONCLUSIONThe lack of standardization among studies precludes any conclusive recommendation on optimal timing of BDI repair after LC. This finding indicates an urgent need for a standardized reporting system of BDI repair.

Outcomes of late open fetal surgery for intrauterine spina bifida repair after 26weeks. Should we extend the Management of Myelomeningocele Study time window?

To evaluate maternal and perinatal outcomes of late open fetal repair for open spina bifida (OSB) between 26+0 -27+6 weeks. A cohort of fetuses with OSB who underwent open surgery in two fetal surgery centers (Argentina and Mexico). Two groups were defined based on the gestational age (GA) at intervention: Management of Myelomeningocele Study (MOMS) time window group: GA 19+0 -25+6 , and late intervention group: GA 26+0 -27+6 . Intrauterine OSB repair was successfully performed in 140 cases, either before (n=57) or after (n=83) 26weeks, at on average 25+0 (22+6 -25+6 ) and 26+5 (26+0 -27+6 ) weeks + days, respectively. There were no significant differences in the rate of premature rupture of membranes, chorioamnionitis, oligohydramnios, preterm delivery, perinatal death and maternal complications. The late intervention group showed a significantly lower surgical times (112.6 vs. 124.2min, p=0.01), lower interval between fetal surgery and delivery (7.9 vs. 9.2weeks, p<0.01) and similar rate of hydrocephalus requiring treatment (30.6% vs. 23.3%, p=0.44) than the MOMS time window group. Late fetal surgery for OSB repair between 26+0 -27+6 weeks is feasible and was associated with similar outcomes than that performed before 26weeks. These findings may allow an extension of the proposed time window for cases with late diagnosis or referral.

Reduction in blood product transfusion requirements with early on-ECMO repair of congenital diaphragmatic hernia

BackgroundFor infants with severe congenital diaphragmatic hernia (CDH) stabilized with extracorporeal membrane oxygenation (ECMO), early repair on ECMO improves outcome; however when compared to operative repair after ECMO, repair on ECMO is associated with increase bleeding risk and need for blood product transfusions.MethodsA retrospective review of 54 patients with CDH placed on ECMO prior to CDH repair was performed. For the subset of patients repaired on ECMO, analysis comparing those repaired early (within 48 h of cannulation) and late (beyond 48 h) on ECMO was performed. Outcomes of interest included survival to discharge, days on ECMO, and postoperative blood product utilization.ResultsWhen compared to those patients repaired prior to 48 h of ECMO initiation, 57.7% of patients survived versus 40.9% of late repair patients. For those repaired early, blood product utilization was significantly less. Early repair patients received a median of 72 mL/kg packed red blood cells (PRBC) and 75 mL/kg platelets compared to 151.9 mL/kg and 98.7 mL/kg, respectively (p < 0.05 respectively). There was no difference in median days on ECMO (p = 0.38).ConclusionOur data supports prior reports of improved outcome with repair with 48 h of ECMO initiation and suggests early repair on ECMO is associated with less bleeding and decreased blood product requirement in the postoperative period.

Abstract 9363: Ascending Aorta Dilation is Less Frequent in Bicuspid Aortic Valve With Coarctation of Aorta Compared to Isolated Bicuspid Aortic Valve

Introduction: Bicuspid aortic valve (BAV) is known to be associated with aortopathy and aortic valve dysfunction. There is paucity of data in the pediatric population comparing ascending aorta (AA) dilation related to BAV in patients with and without coarctation of aorta (CoA). Hypothesis: We assess the hypothesis that BAV is associated with decrease in incidence of AA dilation in patients with CoA when compared to patients with isolated BAV. Methods: A retrospective cross-sectional study was done for all BAV patients 0-26 years of age seen from 2012 through 2021 in the outpatient pediatric cardiology clinic. The patients were subdivided into two groups: associated CoA (cBAV) and isolated BAV (iBAV) . Exclusion criteria were pregnancy, connective tissue disorders and/or aortic valve interventions. Patients with late repair of CoA ( ≥ 9 years) were excluded from the analysis of AA diameters because persistent hypertension, associated with late repair, could be a risk factor for AA dilation. Aortic insufficiency and aortic stenosis were defined by color Doppler and Doppler velocity by echocardiogram. Aortic dilation was defined by Z-score above 2.0. 95% score confidence intervals were used to compare the proportion of patients with an outcome in the two groups. Results: 345 patients with bicuspid aortic valve were included (67.5% male, median age 13). CoA history was present in 32 patients (9.3%). Of the 27 patients with CoA included to assess AA dilation, two patients did not need intervention for CoA. Incidence of AA dilation was 11.1% in cBAV and 28.7% in iBAV (CI: [-26.5%, 0%]; p= 0.05). AS was noted in 63 (18.3%) and AI in 184 (53.3%) of the 345 patients. AI was less common in cBAV at 34.4% than in iBAV at 55.3% (CI: [-35.9%, -2.7%]; p= 0.024). Incidence of AS was 9.4% in cBAV and 19.2% in iBAV (CI: [-17.5%, 5.6%]; p= 0.17). Conclusions: In conclusion, our study suggests that the ascending aorta in pediatric patients with BAV and CoA (who underwent early repair or did not meet criteria for intervention) may have less frequent dilation than in those with isolated BAV. Patients with BAV and CoA also have lower risk for aortic insufficiency and may have lower risk for aortic stenosis. The results are limited by the small sample size of patients with CoA and further study is recommended.

Late Type 1A Endoleaks: Associated Factors, Prognosis and Management Strategies

Unlike periprocedural Type 1A endoleaks, late appearing proximal endoleaks have been poorly described. We studied all elective EVAR from 2010 -2018 in a single institution. Late endoleaks were defined as those appearing after 1 year. We used Cox regression to study factors associated with late Type 1A endoleaks and survival. Of 477 EVAR during the study period, 411 (86%) had follow-up imaging, revealing 24 Type 1A endoleaks; 4 early and 20 late. Freedom from Type 1A endoleaks was 99%, 92-81% at 1, 5 and 8 years with a median time to occurrence of 2.5 years (.01-8.2 years). On completion angiogram, only 10% of patients with a late Type 1A had a proximal endoleak, and 60% had no endoleak. Only 21% of late Type 1As were diagnosed on routine 1-year CT angiogram, but 79% had stable or expanding sacs. Two thirds (65%) of the patients eventually diagnosed with late Type 1A endoleaks had previously been treated for other endoleaks, mostly Type 2 (10/13). Age (HR 1.07/year [1.02-1.12], P=0.01), neck diameter >28mm (HR 3.5 [1.2-10.3], P=0.02), neck length <20mm (HR 3.0 [1.1-8.6], P=0.04), and neck angle>60 degrees (HR 3.4 [1.5-7.9], P=0.004) were associated with higher rates of Type 1A endoleak, but not female sex, endograft, or the use of suprarenal fixation. 2 patients had proximal degeneration and 5 experienced graft migration. There were 2 ruptures (10%), and 13 patients underwent repair with 5 open conversions. Median survival after late Type 1A repair was 6.6 years (0-8.4 years). Late appearing Type 1A endoleaks have a high rate of rupture and present significant diagnostic and management challenges. Careful surveillance is needed in patients with hostile neck anatomy and those who undergo intervention for other endoleaks. Adverse neck anatomy may be better suited for open repair or fenestrated/branched devices rather than conventional EVAR.

Outcome of truncus arteriosus repair: 20 years of single-center experience comparing early versus late surgical repair.

Truncus arteriosus is a rare CHD. Neonatal and early infancy repair is recommended though some cases may present late. The aim of our study is to investigate the current results of truncus arteriosus repair and to analyse the differences in outcome and reintervention need between early versus late truncus arteriosus surgical repair. In this cohort study, we reviewed all children who underwent truncus arteriosus repair from 2001 till 2021. We divided patients into two groups; early repair group including patients repaired at age less than 3 months and late repair group including patients who had repair at 3 months of age and later. We compared both groups for outcome variables. Sixty-four children had truncus arteriosus repair including 48(75%) patients in early repair and 16(25%) patients in late repair groups. Peri-operative course was comparable between both groups. Post-surgery, we observed pulmonary hypertension in 6(12%) patients in early repair group comparing with 11(69%) patients in late repair group (p = 0.0001). In the last follow-up visit, pulmonary hypertension resolved in all early repair group patients while 6(37.5%) patients in late repair group continued to have pulmonary hypertension (p = 0.0001). Twenty-three(36%) patients required reintervention including 22(48%) in early repair group versus 1(6%) in late repair group (p = 0.007). In general, the outcome of early truncus arteriosus repair is excellent with resolution of pulmonary hypertension following early repair. Late repair caries higher risk of persistent pulmonary hypertension (37.5%). About one-third of the patients who had truncus arteriosus repair will require re-intervention within 38±38.4 months after initial surgery.

Beyond Repair: Reflections on Late Medieval Parchment Scarf-Joined Repairs

ABSTRACT The permanence of parchment, its salvage-ability and persistence, is demonstrated by the centuries-long tradition of medieval parchment repair. Some conservators of rare books and manuscripts, including Anthony Cains, have recommended parchment be repaired with parchment, paper with paper. This contribution contrasts Cains’s method for parchment repair with late medieval parchment repair techniques. Medieval scarf-joinery, a technique not recommended as modern conservation practice for reasons outlined, ought to be better recognized in medieval manuscripts as interventions that go well beyond repair. With examples ranging in date from the thirteenth to the fifteenth centuries, medieval scarf-joined parchment repairs are appreciated for their invisibility and as sites for embellishment and concealment. By revealing the presence of these repairs, we might better recognize issues affecting a manuscript’s condition while understanding the purposes to which scarf-joinery methods were deployed. As expressions of craft refinement and as evident ‘workmanship of risk’, late medieval scarf-joined parchment repair techniques are appreciated not as ancillary to a manuscript’s production, but as sometimes even central to its original construction.

TRAUMATIC CHEST WALL INJURY WITH DIAPHRAGMATIC RUPTURE AND LUNG HERNIATION

TOPIC: Cardiothoracic Surgery TYPE: Medical Student/Resident Case Reports INTRODUCTION: Traumatic diaphragmatic injuries are a rare injury that can occur after chest wall trauma. Injury to the diaphragm and its surrounding structures can easily be missed as the patients often have polytrauma. We present a case of a penetrating injury with blunt traumatic chest wall injury with diaphragm rupture and herniation of the left lung through the chest wall after a motorcycle collision. CASE PRESENTATION: A 24-year-old male presented to the hospital as a trauma alert after a motorcycle crash. The patient was found to have a large open chest wound with exposed lung and diaphragm. He was taken for CT imaging and found to have a left apical pneumothorax, left lung contusion, left rib fractures 2-10, and a grade 2 spleen laceration. The patient was taken for emergent exploration of his left chest wound. The patient was found to have disruption of his left chest wall and diaphragmatic attachments with rupture of the lateral aspect of his diaphragm at the level of rib 5-6. The wound was explored with evidence of injury to the left inferior lateral lobe of his lung. The lung did not require any resection. The entire left diaphragm was examined with the central tendon of the left diaphragm found to be intact, the diaphragm was repaired along the lateral edge and reattached to the costal cartilage laterally along the chest wall. The left chest was washed out and a chest tube was placed. The patients remaining hospital course was uneventful, and his chest tube was removed with no signs of air leaks. DISCUSSION: There are no specific signs of diaphragmatic injury or rupture on physical exam. Missed diaphragmatic injuries can result in major morbidity or mortality for the patient. All diaphragmatic injuries should be examined along with all surrounding structures at the time of diagnosis. Most diaphragmatic injuries occur on the left side as the right side is protected by the liver. We highly recommend CT imaging to examine the upper abdomen and chest. In the case of our patient which is rare, we were able to visualize his chest wall injury with his diaphragmatic injury on physical exam. When diagnosed early we recommend repair through the abdomen, but if found late repair through the chest is a better approach. In our case we were able to re-approximate the diaphragm to the chest wall. CONCLUSIONS: Traumatic injuries to the diaphragm can be tough to diagnose at times when there is not obvious injury noted to the diaphragm. We recommend full exposure of the diaphragmatic surface and examination of the surrounding organs and structures to rule out further injury that is not obvious on first examination. The diaphragm should be repaired and then reattached to the chest wall along its costal cartilage laterally. Complete repair with reattachment will allow the patient to avoid morbidity and mortality of a chronic diaphragmatic injury that could lead to impaired respiratory or chest wall function. REFERENCE #1: DeBarros, M., Martin, M.J. Penetrating Traumatic Diaphragm Injuries. Curr Trauma Rep 1, 91-101 DISCLOSURES: No relevant relationships by Michael Bishop, source=Web Response No relevant relationships by Alyssa Ritchie, source=Web Response

What Is the Importance of Electrocardiography in the Routine Screening of Patients with Repaired Tetralogy of Fallot?

Background: In patients following complete repair of the tetralogy of Fallot, the duration of the QRS complex is associated with the size and mechanical function of the right ventricle, which are contemporarily assessed by cardiac magnetic resonance (CMR). Methods: 38 patients aged 18.0–54.9 years (median age 24.9 years) who had undergone complete repair of the tetralogy of Fallot were examined using CMR and concomitant 24 h ambulatory electrocardiography monitoring. We used statistical analysis to investigate the correlations between electrocardiographic parameters (heart rate, HR; PQ interval, PQ; QRS duration, QRS; and corrected QT interval, QTc) and CMR results (right ventricular ejection fraction, RVEF; right ventricular end-diastolic volume index, RVEDVI; and right ventricular end-systolic volume index, RVESVI) for patients after early and late repair. Results: The ECG-based parameters were not correlated with time since repair. There were significant correlations between QRS duration and RVEF (r = −0.61), RVEDVI (r = 0.56), and RVESVI (r = 0.54) for early operated patients but not for late-operated patients. No other substantial correlations were reported. Conclusion: Despite its role in screening for arrhythmias, electrocardiography has a limited role as a predictor of morphology and function of the right ventricle in patients after repair of the tetralogy of Fallot.

PD35-06 IATROGENIC URETERAL INJURY REPAIR: COMPARISON BETWEEN EARLY AND DELAYED REPAIR

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion I (PD35)1 Sep 2021PD35-06 IATROGENIC URETERAL INJURY REPAIR: COMPARISON BETWEEN EARLY AND DELAYED REPAIR Tarek Taha, Ben Sionov, Ami Sidi, and Alexander Tsivian Tarek TahaTarek Taha More articles by this author , Ben SionovBen Sionov More articles by this author , Ami SidiAmi Sidi More articles by this author , and Alexander TsivianAlexander Tsivian More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002039.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Iatrogenic injury of the ureter during various surgeries is a potential risk for late complications and poses therapeutic challenges. Repairing of the ureteral injury may reduce the risk of future complications and restore early functioning of the affected organ. The timing for repair is not yet agreed upon by most surgeons, some tend to perform urinary diversion using nephrostomy or JJ stent insertion, and some recommend immediate repair of the injury. In our study we aim to compare perioperative and postoperative outcomes between early and late repair of iatrogenic ureteral injury METHODS: Between January 2006 and August 2019, 44 patients with iatrogenic ureteral injuries were gathered retrospectively. Patients were divided into two groups: Group A (n=28) patients who had an early repair injury (<1 week) and Group B (n=16) patients who underwent late repair of ureteral injury (>2 weeks). The comparison between the two groups was performed using operative parameters and events that were recorded postoperatively and during the follow-up period RESULTS: Median follow-up period was similar between both groups (18.8 vs 21.3-month, p=0.35), median age in group A was higher than group B (51.3 vs 42.6, p=0.28). Median operative time was shorter in group A compared to group B but is statistically insignificant (152.7 vs 165.7 min, p=0.15). Median estimated blood loss intraoperatively was slightly higher in group A compared to group B (88.1 vs 41.8, p=0.16). The median length stay was similar between both groups (3.6 vs 4, p=0.21). The median time to urethral catheter removal was shorter in group B (5.8 vs 7 days, p=0.01) and the median time to ureteral stent removal was similar between both groups (4.8 vs 4.6 week, P = 0.33), no complications occurred during surgery in either group. During the postoperative and follow-up period, 6 complications (21.4%) were recorded in group-A versus 3 (18.75%) in group-B. All complications were Clavien I, II. There was no difference in creatinine value in both groups at 1 month (0.84 vs 0.94, p=0.214),6 month (0.82 vs 0.82, p=031) and 12 months (0.91 vs 0.94, p=0.31) postoperatively During follow-up, two patients from group A (7.1%) and two patients from Group B (12.5%) underwent re-repair due to re-stenosis in the anastomotic area CONCLUSIONS: In our study, there were no differences in the outcomes between early and delayed repair. Early repair is recommended to reduce the suffering and the frustration of the patients due to the complication after their primary surgery or because of the using of PCN and JJ stent until the definitive repairing surgery of the ureteral injury Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e590-e591 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tarek Taha More articles by this author Ben Sionov More articles by this author Ami Sidi More articles by this author Alexander Tsivian More articles by this author Expand All Advertisement Loading ...