Less-invasive Surgical Procedures Research Articles

Comparing Orthopaedic Randomized Control Trials Published in High-Impact Medical and Orthopaedic Journals.

Orthopaedic studies published in high-impact medical journals are often believed to have a high prevalence of negative or neutral results and possess methodological characteristics that may bias toward nonsurgical treatments. The purpose of this study was to compare study characteristics, methodologic quality, exposure, and outcome direction among orthopaedic randomized control trials (RCTs) published in high-impact medical and orthopaedic journals and to identify study attributes associated with greater impact. RCTs published between January 2010 and December 2020 in the five medical journals and 10 orthopaedic journals with the highest 5-year impact factors were analyzed. Inclusion criteria were RCTs reporting on orthopaedic surgical intervention compared with nonsurgical or less-invasive surgical procedures. Study characteristics, methodologic quality (Jadad scale), outcomes, and altmetric data were collected. Primary outcomes were categorized as positive (favoring surgical/more-extensive surgery), negative (favoring nonsurgical/less-extensive surgery), or neutral. One hundred twenty-eight RCTs were analyzed; 26 from medical and 102 from orthopaedic journals. Studies published in medical journals included more authors ( P < 0.001), larger sample sizes ( P < 0.001), more institutions ( P < 0.001), and more often received funding ( P < 0.001). The average Jadad scale did not significantly differ between journals ( P = 0.14). The direction of the primary study outcome did not differ between journals ( P = 0.22). Average AAS and annual citation rates were higher in RCTs published in medical journals ( P < 0.001). Publication in a medical journal was the only covariate associated with higher annual citation rates ( P < 0.001) and AAS ( P < 0.001) on multivariable analyses. High-impact medical journals do not publish orthopaedic RCTs with negative or neutral findings at a rate that significantly differs from orthopaedic journals. However, the higher impact and digital coverage of the studies published in medical journals may disproportionally influence the practices of nonorthopaedic providers. Raising awareness of critical findings published in orthopaedic journals may be particularly important for improving healthcare policies and orthopaedic referral patterns for musculoskeletal problems.

A Novel Craniocervical Junction Compression Severity Index-Based Grading System for Multidirectional Quantification of the Biomechanics at Foramen Magnum of Chiari Malformation Type I.

Objective This study aimed to establish a novel grading system, based on the craniovertebral junction compression severity index (CVJCSI) for multidirectional quantification at the foramen magnum plane for Chiari malformation type I (CMI). Methods The CVJCSI grading system was established to stratify patients based on the ventral (modified clivoaxial angle < 138°), dorsal (tonsil herniation), and central (brainstem herniation) CVJ (craniovertebral junction) compression, the CVJCSI grading system was established to stratify patients. The optimal surgical method for each grade was recommended by intragroup comparisons regarding the efficacy of the three operations. Finally, according to the CVJCSI grading system, a prospective validation trial was performed and surgically treated for internal validation. Results Based on the retrospective study ( n = 310), the CVJCSI included six grades: I: syrinx alone without compression; II: dorsal compression; III: dorsal and central compression; IV: ventral compression; V: dorsal and ventral compression; and VI: ventral, dorsal, and central compression. Among all available variables, only the CVJCSI and surgical methods significantly affected the CCOS. The CCOS scores, overall and for each CVJCSI grade, increased in the prospective cohort ( n = 42) compared with that in the retrospective analysis. Conclusions The CVJCSI can be used to stratify CMI patients. The higher the CVJCSI grade, the more severe the CVJ compression and the worse posterior fossa deformity. Meanwhile, the CVJCSI was negatively correlated with the CCOS. The lower the CVJCSI grade, the better the response to surgery, and the less-invasive surgical procedures were warranted. Finally, the prospective cohort study validated the proposed CVJCSI-based surgical protocols.

P37 LIMITED MEDIASTINAL LYMPHADENECTOMY FOR ELDERLY PATIENTS OVER 75 YEARS OLD WITH THORACIC ESOPHAGEAL CARCINOMA IS PERMISSIBLE

Abstract Aim The aim of this study is to investigate the influence on postoperative complications and survival rate by the difference in the number of mediastinal lymph node dissection for elderly patients over 75 years old with thoracic esophageal carcinoma. Background &amp; Methods In esophagectomy for thoracic esophageal carcinoma, mediastinal lymphadenectomy is an essential procedure for the radical cure and also an invasive procedure. In elderly patients, especially, the postoperative complications are likely to be serious, and less-invasive surgical procedure is preferred. We sometimes perform limited mediastinal lymphadenectomy for elderly patients with thoracic esophageal carcinoma depending on the case, but the influence on survival rate is controversial. 55 patients who underwent esophagectomy for thoracic esophageal carcinoma over 75 years old between 2007 and 2015 were included in this study. Patients were divided into two groups by number of mediastinal lymph node dissection: normal group (15 or more: n=28) and limited group (less than 15: n=27). The short- and long-term outcomes were retrospectively examined to those groups. Results The median age of the normal and limited group were 76.5 and 79, respectively. No significant differences were demonstrated in clinical stage, operation time and estimated blood loss between these groups. The incidences of postoperative circulatory complications were 37.0% in the normal group and 25.0% in the limited group, but there was no statistically significant difference (P = 0.43). In the normal group, the postoperative respiratory complications (46.4 vs. 14.8%, P = 0.011) and recurrent laryngeal nerve paralysis (21.4 vs. 3.7%, P = 0.049) were significantly higher than that of the limited group. The 5-year overall survival rate (OS) and the 5-year relapse free survival rate (RFS) did not show statistical differences between the normal and limited group (OS: 45.0 vs. 46.0%, P = 0.44; RFS: 39.7 vs. 37.7%, P = 0.57). Conclusion In the limited mediastinal lymphadenectomy group, the postoperative respiratory complications and recurrent laryngeal nerve paralysis have a low occurrence rate. There was no difference in the survival rate between these groups. It was considered that limited mediastinal lymphadenectomy for elderly patients with thoracic esophageal carcinoma is permissible to prevent postoperative complications.

Surgical management of sternoclavicular joint septic arthritis

IntroductionInfections of the sternoclavicular joint (SCJ) account for less than 1% of all joint infections. There are no standardized diagnostic and therapeutic algorithms defined in literature. This study intended to report the risk factors, the bacterial spectrum, the extent and localization and the clinical outcome of SCJ infections. Patients and methodsWe retrospectively reviewed the medical charts of 13 patients (8 men, five women, mean age 37.6 years) with SCJ infections between Januray 1st 2008 and October 30th 2015 for clinical parameters and radiological studies. All patients were interviewed during their follow-up along with clinical examination and assessing the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). ResultsNine patients presented with local chest pain and swelling; in 4 patients, the prevalent symptom was pain without local signs of inflammation. Full blood count revealed a mean leukocytosis of 15 × 109 L and a mean CRP of 21.0 mg/dl. Approximately 61.5% reported known diabetes mellitus. 10 patients presented an involvement of surrounding structures. All patients received a preoperativ CT scan. Each patient was treated via SCJ resection without intraoperative complications. Primary wound closure was possible in all cases. The mean follow-up was 95 days. Wound culture revealed Staphylococcus aureus in all patients. Pathological examination affirmed acute osteomyelitis in 7 patients. Four patients required the intensive care of which 2 patients died from septic shock. Recurrent infection was encountered in 3 patients who underwent revision surgery. Mean DASH Score was 18.7. ConclusionCT should be routinely obtained to recognize the possible extends to the surrounding structures. SCJ resection can result in satisfactory clinical results and should be considered in cases of extended infections including the surrounding structures. Empiric antibiotic coverage should contain cephalosporin or extended-spectrum penicillin. Inappropriate or less-invasive surgical procedures may cause recurrencent infections, especially in cases of osteomyelitis.

Laparoscopy-Assisted Spleen-Preserving Distal Pancreatectomy for Living-Donor Pancreas Transplantation

BackgroundLiving pancreas transplantation plays an important role in the treatment of patients with severe type 1 diabetes. However, pancreatectomy is very invasive for the donor, and less-invasive surgical procedures are needed. Although some reports have described hand-assisted laparoscopic surgery for distal pancreatectomy in living-donor operations, less-invasive laparoscopy-assisted (LA) procedures are expected to increase the donor pool. We herein report the outcomes of four cases of LA spleen-preserving distal pancreatectomy (Warshaw technique [WT]) in living pancreas donors. Patients and MethodsFour living pancreas donors underwent LA-WT at our institution from September 2010 to January 2013. All donors fulfilled the donor criteria established by the Japan Society for Pancreas and Islet Transplantation. ResultsThe median donor age was 54 years. Two donors underwent left nephrectomy in addition to LA-WT for simultaneous pancreas–kidney transplantation. The median donor operation time for pancreatectomy was 340.5 minutes. The median pancreas warm ischemic time was 3 minutes. The median donor blood loss was 246 g. All recipients immediately achieved insulin independence. One donor required reoperation because of obstructive ileus resulting from a port-site hernia. Another donor developed a pancreatic fistula (International Study Group of Pancreatic Fistula grade B), which was controlled with conservative management. After a maximum follow-up of 73 months, no clinically relevant adverse events had occurred. These results were comparable with those of previous studies concerning living-donor pancreas transplantation. ConclusionThe LA-WT is a safe and acceptable operation for living-donor pancreas transplantation.

Early, Prophylactic Thyroidectomy in Hereditary Medullary Thyroid Carcinoma

Prophylactic thyroidectomy has been encouraged for children with REarranged during Transfection (RET) germline mutations to prevent the onset, persistence, or recurrence of medullary thyroid carcinoma (MTC). The American Thyroid Association (ATA) recently published guidelines on the timing of prophylactic thyroidectomy. Our aim here was to seek information on the optimal timing of surgery for carriers of RET gene mutations with no clinical evidence of disease, bearing in mind the ATA recommendations. From 1986 to 2012, total thyroidectomy was performed at our institute on 31 carriers of RET gene mutations, 28 of them found on family screening in the post-RET era, and the other 3 under 20 years of age and classified as "early cases" in the pre-RET era. The following parameters were studied: age at surgery, MTC risk, basal calcitonin (bCT) and pentagastrin-stimulated calcitonin (sCT), surgery outcomes, and persistence of disease. By family, the most prevalent mutation was codon 634 (30%) RET mutation. The youngest MTC patient was 5 years old. Overall, MTC was found in 68% of cases; 52% of the sample had a normal bCT and 25% had an sCT unresponsive to pentagastrin. The only factor predicting the risk of MTC at final histology was an ATA-RET risk level C. On receiver oparating curves analysis, a cutoff at age over 24 years predicted (P=0.06) a yield of MTC in the resected specimen. Interestingly, none of the patients with MTC had nodal involvement (0/21 patients with MTC). Yet, none of the patients had permanent nerve palsy, and only 1 patient had permanent hypocalcemia. bCT was normal postoperatively and during the follow-up in all but 3 patients. It is noteworthy that the yield of cancer in removed thyroid was 100% for codon 634 (9/9 patients, 5 families) and for codons 891 and 768 (2/2 patients in each of the 2 families with those codon mutations), followed by 67% for codon 609 (4/6 patients, 1 family), and 60% for codon 618 (3/5 patients in 4 families) RET mutation. In cases of ATA-RET levels B and C, waiting for an increase in bCT and/or sCT may not guarantee that prophylactic surgery is performed before MTC develops (which would assure patients a life free of diseases and a less-invasive surgical procedure, without any need for central lymph-node dissection).

Laparoscopic spleen-preserving distal pancreatectomy: Our techniques and outcomes

Living pancreas transplantation plays an important role in the treatment of patients with severe type 1 diabetes. However, pancreatectomy is very invasive for the donor, and less-invasive surgical procedures are needed. Although some reports have described hand-assisted laparoscopic surgery for distal pancreatectomy in living-donor operations, less-invasive laparoscopy-assisted (LA) procedures are expected to increase the donor pool. We herein report the outcomes of four cases of LA spleen-preserving distal pancreatectomy (Warshaw technique [WT]) in living pancreas donors.Four living pancreas donors underwent LA-WT at our institution from September 2010 to January 2013. All donors fulfilled the donor criteria established by the Japan Society for Pancreas and Islet Transplantation.The median donor age was 54 years. Two donors underwent left nephrectomy in addition to LA-WT for simultaneous pancreas–kidney transplantation. The median donor operation time for pancreatectomy was 340.5 minutes. The median pancreas warm ischemic time was 3 minutes. The median donor blood loss was 246 g. All recipients immediately achieved insulin independence. One donor required reoperation because of obstructive ileus resulting from a port-site hernia. Another donor developed a pancreatic fistula (International Study Group of Pancreatic Fistula grade B), which was controlled with conservative management. After a maximum follow-up of 73 months, no clinically relevant adverse events had occurred. These results were comparable with those of previous studies concerning living-donor pancreas transplantation.The LA-WT is a safe and acceptable operation for living-donor pancreas transplantation.

Low-grade periprosthetic knee infection: diagnosis and management.

Diagnosis and management of low-grade periprosthetic knee infection are still controversial and debatable. The diagnosis of low-grade infection after total knee arthroplasty is often complex, as clinical symptomatology and diagnostic studies are highly conflicting and knees often exhibit well-fixed components. Although the criterion standard for staged reimplantation is interim placement of an antibiotic-loaded spacer, less-invasive surgical procedures have been advocated for managing infections caused by low-virulence bacteria. Debridement with polyethylene exchange and single-stage reimplantation could offer advantages, such as fewer surgeries, reduced potential for intraoperative complications, and lower direct social costs. The aim of this narrative review was to analyze the literature to evaluate the effectiveness of different surgical procedures in managing low-grade periprosthetic knee infections. Additionally, the most reliable investigations for diagnosing total knee infection caused by low-virulence bacteria were reviewed.Level of evidence Level V.

Update on management of vertebral column tumors.

Treatment options for metastatic and primary spinal tumors have expanded in recent years, in part due to the advances made in stereotactic radiosurgery. For metastatic spinal tumors, our institution utilizes the neurologic, oncologic, mechanical, and systemic (NOMS) decision framework, which provides a treatment paradigm based on the neurologic, oncologic, mechanical and systemic status of the patient. Radiosurgery as a supplement to surgical decompression has allowed for less-invasive surgical procedures carrying minimal morbidity while still providing effective local tumor control. Although wide en bloc excision has traditionally been the goal for the treatment of high-grade primary spine tumors, recent studies have shown promise for radiosurgery in providing control in tumors such as chordomas and high-grade sarcomas. Despite advances in radiosurgery, there continues to be limitations in providing effective conformational doses with minimal toxicity to critical structures. One of the ways to circumvent this and supplement external beam radiation is through the use of brachytherapy delivered by radioactive plaque or seeds.

Chylothorax after surgery for congenital heart disease

Postoperative chylothorax is a frequently encountered pathology in the cardiac intensive care unit. The continuous loss of chyle is a challenging problem to treat and is associated with increased morbidity and mortality. The purpose of this article is to review the pathophysiology of chylothorax in patients after surgery for congenital heart disease, its implications and the current therapies available. The incidence of chylothorax has been increasing over the last two decades. Multiple uncontrolled case series describe octreotide as an effective treatment, and octreotide usage is increasing around the world for patients nonresponsive to dietary modifications. Most centers reserve surgical treatment for patients nonresponsive after 4 weeks of medical treatment. Less-invasive surgical procedures such as thoracic duct ligation by video-assisted thoracoscopy are gaining popularity. Chylothorax is commonly seen in children after surgery for congenital heart disease. The multiple and serious complications associated with chylous effusions are well known. Conservative therapy with diet modification and octreotide remain the standard initial approach. Thoracic duct ligation has been reported as a highly successful treatment but has considerable risk. Thus, this procedure should be reserved for patients nonresponsive to conservative therapy.

Sexual Activity and Cardiovascular Disease

Sexual activity is an important component of patient and partner quality of life for men and women with cardiovascular disease (CVD), including many elderly patients.1 Decreased sexual activity and function are common in patients with CVD and are often interrelated to anxiety and depression.2,3 The intent of this American Heart Association Scientific Statement is to synthesize and summarize data relevant to sexual activity and heart disease in order to provide recommendations and foster physician and other healthcare professional communication with patients about sexual activity. Recommendations in this document are based on published studies, the Princeton Consensus Panel,4,5 the 36th Bethesda Conference,6–10 European Society of Cardiology recommendations on physical activity and sports participation for patients with CVD,11–13 practice guidelines from the American College of Cardiology/American Heart Association14–16 and other organizations,17 and the multidisciplinary expertise of the writing group. The classification of recommendations in this document are based on established ACCF/AHA criteria (Table). View this table: Table. Applying Classification of Recommendation and Level of Evidence Numerous studies have examined the cardiovascular and neuroendocrine response to sexual arousal and intercourse, with most assessing male physiological responses during heterosexual vaginal intercourse.18–24 During foreplay, systolic and diastolic systemic arterial blood pressure and heart rate increase mildly, with more modest increases occurring transiently during sexual arousal. The greatest increases occur during the 10 to 15 seconds of orgasm, with a rapid return to baseline systemic blood pressure and heart rate thereafter. Men and women have similar neuroendocrine, blood pressure, and heart rate responses to sexual activity.24,25 Studies conducted primarily in young married men showed that sexual activity with a person's usual partner is comparable to mild to moderate physical activity in the range of 3 to …

Right Diaphragm Injury

Laparoscopic cholecystectomy (LC) is nowadays the standard method for cholecystectomy. Recently, surgeons attempt to introduce even less-invasive surgical procedures, such as single-port LC or LC through natural orifice transluminal endoscopic surgery (NOTES). The number of studies showing the feasibility of these techniques increased during the last years, but specific complications that correlated with these new techniques are still not apparent. Here, we report on a case with an unusual complication, iatrogenic right diaphragm injury in single-port LC. A 72-year-old man underwent single-port LC because of symptomatic cholecystolithiasis. During the operation, the long rigid straight forceps holding the fundus of the gallbladder slipped off toward the right diaphragm and caused a 1-cm full-thickness diaphragmatic tear. Laparoscopic suture repair was performed, and the patient recovered uneventfully. In using long forceps in single-port LC or transvaginal NOTES-LC, reticulating and bent instruments may avoid this unusual but possible complication in these operations.

Robotic cardiac surgery

To outline current techniques in robotic cardiac surgery and to report the recent results. Robot-assisted surgery is the latest iteration toward less-invasive surgical procedures. Cardiac surgeons have slowly adopted robotic techniques into their armamentarium. In particular, robotic mitral valve surgery has evolved over the last decade and become the preferred method of mitral valve repair and replacement at certain specialized centers worldwide because of excellent results. Robotic single-vessel and double-vessel total endoscopic coronary artery bypass grafting procedures have likewise been standardized on the beating and arrested heart. Other cardiac procedures are in various stages of evolution. Results to date have matched the outcomes of major trials for sternotomy-based procedures. In addition, patients may benefit from shorter hospital stays and experience faster return to full activity. Stepwise progression of robotic technology and procedure development will continue to make robotic operations simpler and more efficient, which will encourage more surgeons to take up this technology and extend the benefits of robotic surgery to a larger patient population. Long-term results are needed to determine whether robotic techniques could become the new standard in cardiac surgery.

NOTES-Assisted Transvaginal Splenectomy: The Next Step in the Minimally Invasive Approach to the Spleen

Natural orifice transluminal endoscopic surgery (NOTES) has marked yet another step forward in less-invasive surgical procedures. Access to solid organs located deep in the left hypochondrium can be difficult using this technique but the transvaginal approach with the patient positioned in full lateral decubitus may be an option. We present the case of a 60-year-old woman with a symptomatic splenic polycystic tumor. The procedure was carried out by a multidisciplinary team using a standard flexible videogastroscope and endoscopic instruments. Transvaginal visualization of the spleen and standard dissection of attachments were feasible, and splenectomy was completed using transvaginal stapling of the splenic hilum. The organ was extracted transvaginally. The postoperative course was uneventful. The patient had minimal postoperative pain and minimal scars, and was discharged on the second postoperative day. Transvaginal access can be safely used for operative visualization, hilum transection, and spleen removal with conventional instrumentation, reducing parietal wall trauma to a minimum. The clinical, esthetic, and functional advantages require further analysis.

Ghrelin as an Acute-phase Reactant during Postoperative Stress Response

Ghrelin is a growth hormone-releasing peptide, discovered in 1999 by Kojima et al. Its potential role in inflammation and stress response is not yet clear. The purpose of this study was to characterize perioperative levels of circulating ghrelin in relation to different surgical procedures. The authors compared plasma ghrelin changes with cortisol, cytokines, and acute-phase proteins. The prospective study was performed on 22 patients with resection for colon cancer (group 1). Group 2, functioning as a comparative group, consisted of 22 patients with elective laparotomic cholecystectomy. Plasma concentrations of ghrelin, cortisol, tumor necrosis factor-alpha (TNF-alpha), interleukin-1beta, IL-6, IL-8, soluble IL-2 receptor, C reactive protein, and alpha1-antitrypsin were estimated repeatedly during a 72-hour postoperative period. Data revealed significant elevation of plasma ghrelin 24 hours after resection of coli (median 508.0 ng/l, interquartile range 398.2-633.7 ng/l) in relation to both preoperative levels (317.6 ng/l, 253.4-355.1 ng/l, p<0.01) and group 2 maximal postoperative levels (386.2 ng/l, 324-432 ng/l, p<0.05). Ghrelin levels returned to initial status 36-48 hours after surgery with subsequent decline to subnormal levels. The regression coefficient was the highest for ghrelin and TNF-alpha 24 hours after laparotomy (r=0.64, p<0.05) and for ghrelin and IL-6 24 hours after surgery (r=0.56, p<0.05). Maximal postoperative levels of all tested parameters except for cortisol and IL-1beta differed significantly between both patient groups at p<0.05. After large abdominal surgery, ghrelin shows itself as an acute-phase reactant. The significant correlation between ghrelin and inflammatory cytokines supposes their regulatory role in this period. Our comparison of more- and less-invasive surgical procedures with similar nutritional restrictions argues for a dominant role of inflammatory factors in postoperative ghrelin elevation.

Surgery for Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained disturbance of cardiac rhythm, affecting an estimated 2.3 million people in North America and 4.5 million people in the European Union. Although af is associated with significant morbidity, mortality, and increased health care costs, more-precise and less-invasive surgical ablation procedures have been developed. Specific cardiac sites emitting the aberrant, premature electrical signals that induce AF are ablated, which results in excellent cure rates and allows normal sinus rhythm to resume. These procedures can be performed with or without the use of cardiopulmonary bypass, through either traditional sternotomy or minimally invasive thoracotomy incisions.

Laparoscopic gastrectomy for early gastric cancer targeting as a less invasive procedure

Since only a few extensive reports are available on the less invasive nature of laparoscopic gastrectomy, we compared postoperative changes over time in vital signs and hematological parameters between this surgery and laparotomic gastrectomy. Of 188 patients who underwent distal gastrectomy for preoperatively diagnosed early gastric cancer between January 2004 and September 2006, 87 underwent laparoscopy-assisted distal gastrectomy (LADG) and 101 underwent laparotomic distal gastrectomy (DG). The invasiveness of the two procedures was evaluated in 164 patients with no postoperative complications (82 cases of LADG and 82 cases of DG by measuing vital signs daily and performing hematological examination on postoperative days (POD) 1, 4, 7, and 10. For body temperature, heart rate, and blood pressure, significantly lower values were obtained with LADG on 3 and 4 POD, 4 POD, and 3 and 4 POD, respectively. For white blood cell counts (WBC) and C-reactive protein (CRP), significantly lower values were obtained with LADG on 7 and 10 POD, and 10 POD, respectively. For serum protein levels and lymphocyte counts, significantly higher values were obtained with LADG on 1, 4, 7, and 10 POD, and 4 and 10 POD, respectively. Body temperature, WBC, and CRP showed no significant difference immediately after surgery but earlier recovery occurred with LADG. For protein levels and lymphocyte counts, higher values were obtained immediately after surgery. There seemed to be two patterns of less invasiveness in the parameters: the early recovery found for body temperature, WBC and CRP, and the smaller shift immediately after surgery in protein level and lymphocyte count, and probably, heart rate and blood pressure. The complication rate was 18.8% for DG and 5.7% for LADG. LADG is a less-invasive surgical procedure as it produces early normalization or smaller shifts in various parameters and exhibits a low prevalence of complications.