Longer Duration Of Surgery Research Articles

Long-term Outcomes After Emergency Laparotomy: a Retrospective Study

BackgroundEmergency laparotomy (EL) is a common surgical operation with poor outcomes. Patients undergoing EL are often frail and have chronic comorbidities, but studies focused on the long-term outcomes after EL are lacking. The aim of the present study was to examine the long-term mortality after EL. MethodsWe conducted a retrospective single-center cohort study of 674 adults undergoing midline EL between May 2015 and December 2017. The follow-up lasted until September 2020. The primary outcome was 2-year mortality after surgery. The secondary outcome was factors associated with mortality during follow-up. ResultsA total of 554 (82%) patients survived > 90 days after EL and were included in the analysis. Of these patients, 120 (18%) died during the follow-up. The survivors were younger than the non-survivors (median [IQR] 64 [49–74] vs. 71 [63–80] years, p < 0.001). In a Cox regression model, death during follow-up was associated with longer duration of operation (OR 2.21 [95% CI 1.27–3.83]), higher ASA classification (OR 2.37 [1.15–4.88]), higher CCI score (OR 4.74 [3.15–7.14]), and postoperative medical complications (OR 1.61 [1.05–2.47]). ConclusionsPatient-related factors, such as higher ASA classification and CCI score, were the most remarkable factors associated with poor long-term outcome and mortality after EL.

Progress in the treatment of refractory macular hole by human amniotic membrane

The surgery of refractory macular hole is often very tough for its uncertain prognosis. There is no unified definition for refractory macular hole, which usually refers to macular hole with a long duration, large diameter, or failure of initial operation. Treatment success can be achieved in some cases by expanding the range of internal limiting membrane peeling or filling with autologous tissue. Human amniotic membrane is a kind of tissue with strong anti-inflammatory and anti-fibrosis effects, and has been widely used in the treatment of ocular surface diseases. In recent years, amniotic membrane has been used in treating refractory macular hole. Some positive results have been achieved, including improvement of postoperative macular structure and increase of visual function. This review focuses on the mechanism, efficacy and prospect of human amniotic membrane in the treatment of refractory macular hole, providing reference for clinical practice and research.

Perioperative Risk Factors Associated with Unplanned Neurological Intensive Care Unit Events Following Elective Infratentorial Brain Tumor Resection

Our aim of this study was to identify risk factors and develop a prediction model for unplanned neurological intensive care unit (NICU) events after elective infratentorial brain tumor resection in order to propose an individualized admission to the NICU tailored to patient needs. Patients admitted to our NICU between September 2018 and May 2021 after elective infratentorial brain tumor resection were reviewed. Prolonged NICU stays and unplanned NICU admissions were defined as unplanned NICU events. The prognostic model of unplanned NICU events was developed using a forward stepwise logistic regression analysis, and external validation was evaluated. The C-statistic was used to assess discrimination, and a smooth, nonparametric calibration line was used to assess calibration graphically in the model. Of the 1,710 patients in the development cohort, unplanned NICU events occurred in 162 (9.5%). Based on the lesion type, a Karnofsky Performance Status score <70 at admission, longer duration of surgery, bleeding in the operative area evident on postoperative computed tomography, higher fibrinogen and blood glucose levels at admission, and more intraoperative blood loss were independently associated with unplanned NICU events. The external validation test showed good discrimination (C-statistic= 0.811) and calibration (Hosmer-Lemeshow P= 0.141) for unplanned NICU events. Several patient and operative characteristics are associated with a greater likelihood of the occurrence of unplanned NICU events. In the future, we may be able to provide better help for the resource allocation of NICUs according to these risk factors and prediction models.

Comparison of early outcomes associated with coronary artery bypass grafting for multi-vessel disease conducted using minimally invasive or conventional off-pump techniques: a propensity-matched study based on SYNTAX score

BackgroundThis study was designed to compare early outcomes associated with coronary artery bypass grafting for multi-vessel disease conducted using either minimally invasive or conventional off-pump techniques.MethodsFrom January 2017 through January 2021, 582 patients with multi-vessel lesion coronary artery disease underwent either minimally invasive cardiac surgery coronary artery bypass grafting (MICS CABG) or conventional off-pump coronary artery bypass grafting (OPCABG) treatment by our team at Anzhen Hospital. Patients in the MICS CABG group were propensity score-matched with those in the OPCABG at a 1:1 ratio (MICS CABG = 172; OPCABG = 172), using epidemiological data, preoperative clinical characteristics, and SYNTAX score as covariates. Perioperative outcomes and 6-month computed tomography angiography findings were compared between these groups.ResultsNo significant differences between groups were observed with respect to 30-day postoperative mortality, myocardial infarction, and stroke incidence. Surgical data indicated that the MICS CABG procedure was able to cover all three main arterial territories with a relatively low need for circulatory assistance. The MICS CABG procedure was associated with a longer operative duration, but was also associated with higher postoperative hemoglobin and activities of daily living index values as well as a shorter duration of postoperative hospitalization (P < 0.05). No differences in 6-month graft patency were observed between groups.ConclusionsMICS CABG is a safe, less invasive alternative to OPCABG when performing complete revascularization provided patients are properly selected, yielding similar in-hospital outcomes and 6-month graft patency rates together with an earlier return of physical function.

Meta-analysis of randomized controlled trials comparing minimal-invasive versus open pancreatic surgery

Abstract Objective To compare perioperative outcomes of minimal-invasive pancreatic surgery (MIPS) to open pancreatic surgery (OPS) using data obtained from randomised controlled trials (RCTs). Methods Literature search was done in CENTRAL, Medline and Web of Science; all currently available RCTs comparing MIPS and OPS in adult patients requiring elective distal pancreatectomy (DP) or partial pancreatoduodenectomy (PD) were included in the analysis. Outcomes were mortality, general and pancreatic surgery specific morbidity and length of hospital stay (LOS). Subgroup analysis between PD and DP was performed. A random-effects model for Mantel-Haenzsel and inverse variance analysis was used. Cochrane RoB 2.0 tool and GRADE approach was used for assessment of risk of bias and certainty of evidence. Results A total of 166 patients for DP (80 MIPS vs. 86 OPS) in two RCTs and 856 for PD (429 MIPS vs. 427 OPS) in five RCTs were analysed. Meta-analysis showed a reduction of LOS by 1.2 days (-2 to -0.3, p&amp;lt;0.01) and intraoperative blood loss by 143 ml (-186 to -101, p&amp;lt;0.01) in MIPS. In the subgroup analysis reduction of LOS was only present for minimal-invasive DP (-2 days, -2.3 to -1.7, p&amp;lt;0.01). A minimal-invasive approach showed reduction of surgical site infections (odds ratio 0.4, 0.1 to 0.96, p=0.04) and intraoperative blood loss (-141 ml, -181 to -101, p&amp;lt;0.01) only in PD. Duration of surgery was about 96 min longer in minimal-invasive PD (56 to 137 min, p&amp;lt;0.01), but not in DP. Analysis showed no significant difference between MIPS and OPS, as well as between subgroups, in mortality, complications according to Clavien-Dindo &amp;gt;=3 and pancreatic surgery specific complications like postoperative pancreatic fistula and delayed gastric emptying. Certainty of evidence according to the GRADE approach was moderate to low. Conclusion This meta-analysis of level 1 evidence shows reduced LOS and intraoperative blood loss in MIPS compared to OPS. Morbidity and mortality did not differ between MIPS and OPS. Longer duration of surgery in minimal-invasive PD hints that minimal-invasive technique in PD is more challenging than in DP. However, patients undergoing minimal-invasive PD seem to benefit from lower surgical site infections and less intraoperative blood loss.

Effect of local anaesthetic infiltration on postoperative pain after laparoscopic cholecystectomy: randomized clinical trial.

BackgroundLocal anaesthetic infiltration is widely used to reduce pain after laparoscopic cholecystectomy (LC). This trial evaluated the effect of depth of local anaesthetic infiltration on postoperative pain reduction after LC.MethodsPatients undergoing elective LC between March 2018 and February 2019 were randomized into no infiltration, subcutaneous infiltration, and rectus sheath infiltration using bupivacaine. The primary outcome was 24-h postoperative cumulative morphine use, and the secondary outcomes were mean 24-h Numerical Rating Scale (NRS) for pain, and nausea, and vomiting. Subgroups were compared and multivariable analyses were performed.ResultsOut of 170 eligible patients, 162 were selected and 150 patients were analysed: 48 in the no-infiltration group, 50 in the subcutaneous infiltration group, and 52 in the rectus sheath infiltration group. The groups had similar clinical features, although mean BMI was higher in the subcutaneous infiltration group (P = 0.001). The 24-h cumulative morphine use in the rectus sheath infiltration group was significantly lower than in the no-infiltration group (P = 0.043), but no difference was observed between the subcutaneous infiltration and no-infiltration groups (P = 0.999). One hour after surgery, the rectus sheath infiltration group had a significantly lower NRS score than the no-infiltration and subcutaneous infiltration groups respectively (P = 0.006 and P = 0.031); however, the score did not differ among the three groups at any of the time points from 2 h after the surgery. The incidence of nausea or vomiting was comparable among the three groups. Multivariable analysis documented that a lower dose of morphine use was associated with rectus sheath infiltration (P = 0.004) and diabetes (P = 0.001); whereas, increased morphine use was associate with age (P = 0.040) and a longer duration of surgery (P = 0.007).ConclusionsLocal anaesthetic infiltration into the rectus sheath reduced postoperative cumulative morphine use and the immediate NRS score in patients undergoing LC; however, the pain scores were comparable 2 h after surgery.Registration numberTCTR20201103002 (http://www.thaiclinicaltrials.org).

Assessment of Mastectomy Skin Flaps for Immediate Reconstruction with Implants via Thermal Imaging-A Suitable, Personalized Approach?

Background: Impaired perfusion of the remaining skin flap after subcutaneous mastectomy can cause wound-healing disorders and consecutive necrosis. Personalized intraoperative imaging, possibly performed via the FLIR ONE thermal-imaging device, may assist in flap assessment and detect areas at risk for postoperative complications. Methods: Fifteen female patients undergoing elective subcutaneous mastectomy and immediate breast reconstruction with implants were enrolled. Pre-, intra- and postoperative thermal imaging was performed via FLIR ONE. Potential patient-, surgery- and environment-related risk factors were acquired and correlated with the occurrence of postoperative complications. Results: Wound-healing disorders and mastectomy-skin-flap necrosis occurred in 26.7%, whereby areas expressing intraoperative temperatures less than 26 °C were mainly affected. These complications were associated with a statistically significantly higher BMI, longer surgery duration, lower body and room temperature and a trend towards larger implant sizes. Conclusion: Impaired skin-flap perfusion may be multifactorially conditioned. Preoperative screening for risk factors and intraoperative skin-perfusion assessment via FLIR ONE thermal-imaging device is recommendable to reduce postoperative complications. Intraoperative detectable areas with a temperature of lower than 26 °C are highly likely to develop mastectomy-skin-flap necrosis and early detection allows individual treatment concept adaption, ultimately improving the patient’s outcome.

Case controlled study for determination of risk factors in abdominal wall endometriosis following a cesarean section

Introduction: Abdominal wall endometriosis (AWE) is the presence of ectopic endometrial tissue in abdominal wall and is most frequently encountered in women with previous cesarean section (CS). The aim of this study is to evaluate the possible risk factors of AWE development. Methods: Women with previous CS and pathologically confirmed AWE were included into the study ( n = 33). Controls ( n = 127) were randomly selected among women who had previous CS and absence of AWE were confirmed by physical examination. Clinical characteristics of the patient and the CS operation preceding AWE were recorded. Results: CS was performed before onset of labor in 87.9% in AWE and in 59.1% of control group ( p = 0.002). The antenatal BMI and weight gain during pregnancy were significantly higher in AWE patients ( p &lt; 0.0001; p = 0.002, respectively). In logistic regression model procedure duration ( p = 0.039; OR = 1083), antenatal BMI ( p = 0.003; OR = 1254), weight gain ( p = 0.002; OR = 1171), and CS before spontaneous labor ( p = 0.021; OR = 5169) were significant parameters for predicting AWE. Discussion: High antenatal BMI, weight gain during pregnancy, and longer duration of operation are all factors effecting subsequent AWE development. However, CS before spontaneous labor is by far the most powerful risk factor for AWE development.

A study on the microbial profile at surgical site with orthopedic implant in traumatic injuries and its associated risk factors at tertiary care hospital

Introduction: Study was conducted to identify the etiological agents of orthopedic implant infections in posttraumatic postoperative period. To identify the risk factors for orthopedic implant infection. To study the Antimicrobial susceptibility patterns of the isolates with a view to formulate an empiric antibiotic regimen.Material and Methods: The study period was prospective study conducted January 2020 to December 2021. One hundred and fifty patients were investigated for early, intermediate and late post-operative infections of orthopedic bone implants using conventional microbiological procedures. Antimicrobial susceptibility testing was then performed for the isolated bacteria according to the standard guidelines.Results: Out of 150 orthopedic post traumatic, postoperative implant infections, a total of 140 isolates had positive culture (138 aerobes and 2 anaerobes). Of the total 150 cases 80.66 % was mono microbial infection whereas 12.6% had poly microbial. Staphylococcus aureus is the most common organism isolated followed by Pseudomonas and E.coli. 60.2 % of Staphylococcus aureus and 73.52% of Staphylococcus epidermidis were found to be methicillin resistant. 85 % Proteus and 67.2% of Escherichia coli were found to be Extended Spectrum Beta-Lactamases (ESBL) producers. 60% of staphylococcus showed sensitivity to Vancomycin and Rifampin, 76.78 %, 66.96%, 49.10%, 42.84%, 46.42% to Linid, Tiecoplanin, Clindamycin, Meropenum and to Imipenum respectively. Whereas 68.7% of Pseudomonas showed sensitivity to collistin, 56.25% and 53.12 to Piptaz/Tazobactum and tobramycin respectively. 70.2% of staphylococcus, 40% of Pseudomonas was sensitive to cephalosporins. Diabetes mellitus, compound injuries and longer duration of surgery were the important risk factors noted in our study. Diabetes was associated more with methicillin resistant Staphylococcus aureus. There was no difference found in sensitivity pattern in stainless steel and titanium implant.Conclusion: Prophylactic antibiotics should be started as per locally commonly observed organism and their sensitivity pattern to prevent infection.

Сравнительный анализ периоперационных результатов открытой и лапароскопической радикальной цистэктомии с формированием илеокондуита

Introduction. Minimally invasive radical cystectomy replicates principles of open surgery and has similar oncological outcomes. In addition, it may reduce the incidence of early postoperative complications and confer earlier patients’ recovery. Materials and methods. We prospectively selected 44 cases, 40 men (90,9%) and 4 women (9,1%), from of 148 patients who undergone radical cystectomy (RCE) with urine derivation into the Briсker’s ileum-conduit during the period from 2017 to 2020. The average age of patients was 62.8± 10,1 years. All the patients included in our study were assigned into 2 groups. Group I consisted from 22 (50%) patients who underwent open RCE and 22 (50%) patients who underwent laparoscopic RCE were included in group II. Results. Median of surgery time was 257 (200-360) min in group I and 290 (160-470) min in group II, р=0,04. Median of estimated blood loss was 218 (50-700) ml in group I and 193 (100-500) ml in group II, р=0,04. Blood transfusions were required in 3 (13,6%) patients of group I. Median length of stay was 16 days in group I and 14 days in group II, р=0,05. There were 25 (56,8%) complications recorded over the 30-day’s period. Eight (36,1%) patients of group I and in 6 (27,2%) patients of group II (р=0,33) had a complications grade I-II according to Clavien-Dindo classification. Grade III-IV ClavienDindo had 7 (31,8%) patients from group I and 4 (18,2%) patients from group II (p=0,04). There were 13 (29,5%) complications within 31-90 days after surgery. The grade I-II Clavien-Dindo were registered in 5(22,7%) patients from group I and in 4 (18,1 %) patients from group II (p=0,47). Grade III-IV Clavien-Dindo observed in 2 (9,1%) patients from group I and 2 (9.1%) patients from group II (р=0,68). Readmission rate within the 90 days after surgery was 10.4% among the patients of group I and 7,7% among patients of group II. General 90-day mortality rate was 6.9%: 1 (4,8%) patient from group I and 2 (9,0%) patients from group II (p=0,48). Conclusion. The laparoscopic approach for RCE has a longer surgery duration but provides a lower blood loss and of Clavien-Dindo grade III-IV complications rate during the 30 days after surgery in comparison with open surgery.

Göğüs cerrahisi ameliyatı geçiren torakal epidural kateter takılan hastalarda postoperatif bulantı/kusmayı öngörmedeki parametreler

Aim: In thoracic surgery, many factors; such as long duration of surgery and the use of volatile anesthetics may increase the frequency of postoperative nausea/ vomiting (PONV). Recent studies suggests that inflammatory markers such as neutrophils lymphocytes ratio (NLR) can predict PONV. The aim of this study is to postoperatively examine the role of demographic, laboratory, and clinical data in predicting PONV in patients who underwent thoracotomy and received thoracic epidural analgesia (TEA).&#x0D; Material and Methods:Data were collected for patients who underwent elective thoracic surgery and were administered TEA between March 2017 and December 2020. Patients' demographic data, laboratory parameters, and clinical characteristics; such as American Association of Anesthesiologists (ASA) I-II-III, erythrocyte distribution width (RDW), NLR, postoperative visual analog scale (VAS), were scanned. All patients who developed PONV were included in Group 1. Hospital records were used to select Group 2 patients who did not develop PONV.&#x0D; Results: The incidence of PONV was determined as 14.77%. There was a statistically significant difference between the groups in terms of ASA and 24-hour VAS scores (p &lt; 0.05). Patients with PONV had statistically significantly higher 24-hour VAS scores(p &lt; 0.05). PONV was statistically significantly higher in patients with ASA III compared to other ASA groups (p &lt; 0.05). Multivariate analysis suggests that ASA, RDW and 24-hour VAS are significant in predicting PONV. Lower RDW, higher ASA and 24-hour VAS increase the risk of PONV.&#x0D; Conclusion: Demographic data, laboratory parameters, and clinical characteristics were evaluated concerning their correlation with PONV in this study. It was observed that the frequency of PONV might increase in patients with low RDW levels. In addition, higher VAS values and ASA physical score were also found to increase the risk of PONV in patients who underwent thoracotomy and administered TEA

Outcomes for Adults with Metabolic Syndrome Undergoing Elective Carotid Endarterectomy

Metabolic syndrome (MetS) is a disorder characterized by a constellation of cardiometabolic risk factors including abdominal obesity, dyslipidemia, hypertension, and glucose intolerance that has been associated with adverse perioperative outcomes. We evaluated outcomes for patients with MetS after carotid endarterectomy (CEA) in the largest population to date. We performed a matched cohort analysis using clinical data from 2012 to 2018 in the American College of Surgeons National Surgical Quality Improvement Program. We used propensity scores to match patients to attain covariate balance and used logistic regression to assess odds of unfavorable outcomes, including a predefined primary outcome of composite cardiovascular incident. We identified 50,423 eligible adult patients, of whom 14.2% qualified for MetS (n= 7156). Patients with MetS tended to have CEA at an earlier age, more functional dependence, and longer operative durations. After matching, MetS remained associated with the primary outcome of combined cardiovascular incident (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.18-1.72; P < 0.001), stroke (OR, 1.44; 95% CI, 1.12-1.85; P= 0.004), prolonged length of stay (OR, 1.31; 95% CI, 1.18-1.44; P < 0.001), and discharge to facility (OR, 1.32; 95% CI, 1.08-1.61; P= 0.007). We also found that obesity alone is protective against combined cardiovascular incident, whereas hypertension with diabetes and MetS increase odds of a cardiovascular complication. Metabolic syndrome is associated with adverse outcomes for adult patients undergoing elective CEA.

Impact of previous upper/lower abdominal surgery on pancreatic surgical outcomes and complications: a propensity score matching study.

Pancreatic surgery is a complex operation that has been associated with severe intraoperative and postoperative complications, especially in patients with previous abdominal surgery (PAS). Our study aimed to assess the impact of PAS on pancreatic surgery. A total of 1430 patients who underwent pancreatic surgery were included in this retrospective study and classified into the following 3 groups: previous upper abdominal surgery (PUAS) (n = 135); previous lower abdominal surgery (PLAS) (n = 161), and no history of abdominal surgery (non-PAS) (n = 1134). Using propensity score matching (PSM), patients were matched to one another at a 1:1:1 ratio with balanced baseline characteristics. Intraoperative factors, surgical complications, hospital costs, and postoperative hospitalization were collected and compared. A longer operative duration was observed in the PUAS group compared to the non-PAS group (187.54 vs. 150.50min, p = 0.016). The intraoperative blood loss in the PUAS group was significantly higher (193.68 vs. 150.51 and 156.81mL, p < 0.05), while the intraoperative plasma transfusion volume was higher in PLAS patients than in non-PAS patients (183.8 vs. 102.7mL, p = 0.008). Intra-abdominal adhesions in PUAS patients were most severe, and non-PAS patients exhibited significantly lower intra-abdominal adhesion grading (p < 0.001). No significant differences were observed in postoperative complications, postoperative histopathology, postoperative hospitalization, or hospital cost. PAS has no significant influences on surgical outcomes, and pancreatic surgery is relatively safe in this patient population. A patient history of PAS may prolong operation duration and increase intraoperative blood loss but has no impact on postoperative complications and does not increase the economic burden.

The impact of age in acute type A aortic dissection: a retrospective study

BackgroundAcute type A aortic dissection (aTAAD) is a lethal disease and age is an important risk factor for outcomes. This retrospective study was to analyze the impact of age stratification in aTAAD, and to provide clues for surgeons when they make choices of therapy strategies.MethodsFrom January 2011 to December 2019, 1092 aTAAD patients from Nanjing Drum Tower Hospital received surgical therapy. Patients were divided into 7 groups according to every ten-year interval (20–80 s). The differences between the groups were analyzed in terms of the baseline preoperative conditions, surgical methods and postoperative outcomes of patients of different age groups. During a median follow-up term of 17 months, the survival rates were compared among 7 groups through Kaplan–Meier analysis.ResultsThe median age was 52.0 years old in whole cohort. The multiple comorbidities were more common in old age groups (60 s, 70 s, 80 s), while the 20 s group patients had the highest proportion of Marfan syndrome (28.1%). Preoperative hypotension was highest in 80 s (16.7%, P = 0.038). Young age groups (20–60 s) had a higher rate of root replacement and total arch replacement, which led to a longer duration of operation and hypothermic circulation arrest. The overall mortality was 14.1%, the tendency of mortality was increased with age except 20 s group (33.3% in 80 s, P = 0.016). The postoperative morbidity of gastrointestinal bleeding and bowel ischemia were 16.7% and 11.1% in 80 s group.ConclusionsAge is a major impact factor for aTAAD surgery. Old patients presented more comorbidities before surgery, the mortality and complications rate were significantly higher even with less invasive and conservative surgical therapy. But the favorable long-term survival indicated that the simple or less extensive arch repair is the preferred surgery for patients over 70 years old.

Factors Affecting Residual Stone Rate, Operative Duration, and Complications in Patients Undergoing Minimally Invasive Percutaneous Nephrolithotomy.

Background and objectives: Although minimally invasive percutaneous nephrolithotomy (MPCNL) has demonstrated its efficacy, complete stone clearance was not always achieved, necessitating a second procedure. The purpose of this study was to evaluate factors associated with residual stone rate, operative duration, complications, and hospital stay, in order to develop algorithms for pre-operative prognosis and planning. Materials and Methods: This retrospective study involved 163 Bulgarian patients who underwent MPCNL with Holmium: YAG lithotripsy for the treatment of kidney stones. Patients were considered stone-free if no visible fragments (<3 mm) were found on nephroscopy at the end of the procedure, as well as on postoperative X-ray and abdominal ultrasound on the first postoperative day. Results: Immediate postoperative stone-free outcome was attained for 83.43% of the patients (136/163). Residuals were associated with staghorn stones (OR = 72.48, 95% CI: 5.76 to 91.81); stones in two locations (OR = 21.91, 95% CI: 4.15 to 137.56); larger stone size (OR = 1.12, 95% CI: 1.006 to 1.25); and higher density (OR = 1.03, 95% CI:1.005 to 1.06). The overall categorization accuracy for these factors was 93.80%, AUC = 0.971 (95% CI: 0.932 to 0.991), 89.71% sensitivity, and 96.30% specificity. Predictors of prolonged operative duration were staghorn stones and volume, R-square (adj.) = 39.00%, p < 0.001. Longer hospitalization was predicted for patients with hydronephrosis and staghorn stones, R-square (adj.) = 6.82%, p = 0.003. Post-operative complications were rare, predominantly of Clavien-Dindo Grade 1, and were more frequent in patients with hydronephrosis. We did not find a link between their occurrence and the outcome of MPCNL. Conclusions: Staghorn stones and stones in more than one location showed the strongest association with residual stone rate. Staghorn stones and larger volume were linked with a longer operative duration. Hydronephrosis increased the risk of complications and longer hospitalization.

Impact of perioperative antithrombotic strategies on clinical events in non-cardiac surgery.

Antithrombotic therapy including antiplatelet agents and anticoagulants are prescribed for secondary prevention in patients with established cardiovascular disease. Although antithrombotic therapy is often interrupted before non-cardiac surgery with or without perioperative bridging anticoagulation, the impact on thrombotic and bleeding events remains uncertain. A total of 360 patients chronically treated with antithrombotic therapy for secondary prevention underwent elective non-cardiac surgery under general anesthesia, with the complete interruption of antithrombotic agents. The study endpoints included all-cause death, thrombotic events, and major bleeding complications after surgical procedures. Of 360 patients, 190 (52.8%) and 200 (55.6%) received antiplatelet and anticoagulation perioperatively. Atrial fibrillation (32.8%) and coronary artery disease (22.5%) were the major indications for antithrombotic regimens. Antithrombotic therapy was interrupted from 5 [2, 7] days before the surgery to 4 [2, 7] days postoperatively. Perioperative bridging therapy with unfractionated heparin was employed in 113 (31.4%) patients. During the hospitalization, one (0.3%) patient died due to non-cardiovascular causes. Thrombotic events and major bleeding occurred in two (0.6%) and eight (2.2%) patients. Bridging therapy with heparin was significantly associated with an increased risk of bleeding events (5.3% vs. 0.8%, p = 0.02). Pre-operative bridging therapy with heparin and operative duration were significantly associated with bleeding complications. In the present study, complete interruption of antithrombotic therapy resulted in a few thrombotic events in patients undergoing elective non-cardiac surgery. Bridging therapy with heparin and longer operative duration were significantly associated with post-operative bleeding complications.

Identification of the preoperative and perioperative factors that predict postoperative endothelial cell density after Descemet membrane endothelial keratoplasty: A retrospective cohort study.

Low postoperative endothelial-cell density (ECD) plays a key role in graft failure after Descemet-membrane endothelial keratoplasty (DMEK). Identifying pre/perioperative factors that predict postoperative ECD could help improve DMEK outcomes. This retrospective study was conducted with consecutive adult patients with Fuchs-endothelial corneal dystrophy who underwent DMEK in 2015-2019 and were followed for 12 months. Patients underwent concomitant cataract surgery (triple-DMEK) or had previously undergone cataract surgery (pseudophakic-DMEK). Multivariate analyses assessed whether: patient age/sex; graft-donor age; preoperative ECD, mean keratometry, or visual acuity; triple DMEK; surgery duration; surgical difficulties; and need for rebubbling predicted 6- or 12-month ECD in the whole cohort or in subgroups with high/low ECD at 6 or 12 months. The subgroups were generated with the clinically relevant threshold of 1000 cells/mm2. Surgeries were defined as difficult if any part was not standard. In total, 103 eyes (95 patients; average age, 71 years; 62% women) were included. Eighteen eyes involved difficult surgery (14 difficult graft preparation or unfolding cases and four others). Regardless of how the study group was defined, the only pre/perioperative variable that associated significantly with 6- and 12-month ECD was difficult surgery (p = 0.01, 0.02, 0.05, and 0.0009). Difficult surgery also associated with longer surgery duration (p = 0.002). Difficult-surgery subgroup analysis showed that difficult graft dissection associated with lower postoperative ECD (p = 0.03). This association may reflect endothelial cell loss due to excessive graft handling and/or an intrinsic unhealthiness of the endothelial cells in the graft that conferred unwanted physical properties onto the graft that complicated its preparation/unfolding.

Outcomes of Arthroscopic-Assisted Distal Radius Fracture Volar Plating: A Meta-Analysis

The use of wrist arthroscopy to assist fixation of distal radius fractures with volar locking plates (VLPs) has been gaining popularity in recent years; however, there is no consensus on its benefits. This meta-analysis compares outcomes of arthroscopic-assisted VLP to fluoroscopic-assisted VLP in distal radius fractures through a systematic review of the published literature. A systematic search of publications from databases (Medline, EMBASE, Scopus, and Cochrane) was obtained from inception to May 2020. A random-effects meta-analysis was used to calculate effect sizes. Outcomes included postoperative radiographic reduction (gap, stepoff, radial inclination, volar tilt, and ulnar variance), procedural outcomes (operative time, additional soft tissue injuries and complications), and functional outcomes (range of motion; visual analog scale score; Disabilities of the Arm, Shoulder, and Hand score; Patient-Rated Wrist Evaluation score; Mayo clinic score; and grip strength). Six studies, involving 280 patients, met the final inclusion criteria. The meta-analysis for postoperative stepoff was statistically significant, favoring arthroscopic-assisted VLP. In addition, there was greater identification of associated soft tissue injuries, increased wrist extension, and a longer operative duration when performing arthroscopic-assisted VLP fixation. There were no differences in other postoperative radiographic outcomes, complications, or functional outcomes. The current literature suggests that arthroscopic-assisted VLP is a useful adjunct to intra-articular reduction and treatment of associated soft tissue injuries in distal radius fractures. Considerations should include operative time, costs, and the additional training required. Further studies are needed to assess functional outcomes. Therapeutic II.

Long-Term Follow-Up of Corneal Endothelial Cell Changes After Iris-Fixated Phakic Intraocular Lens Explantation.

The purpose of this study was to evaluate long-term corneal endothelial cell changes and visual outcomes after iris-fixated phakic intraocular lens (pIOL) explantation in patients with endothelial damage and to investigate potential predictors of endothelial injury. Consecutive patients undergoing pIOL explantation with corneal endothelial cell density (ECD) <2000 cells/mm 2 at the time of the procedure were retrospectively reviewed in a single tertiary center. All patients were treated between April 2016 and October 2020 at a high-volume referral-based tertiary hospital. The primary outcome was the change in corneal endothelial parameters, including ECD, over long-term follow-up. Secondary outcomes included changes in corrected distance visual acuity and analysis of prognostic factors. This study included 44 eyes from 28 patients with an average age of 42.5 ± 7.8 years (range: 27-63). Mean ECD before explantation was 1375.4 ± 468.2 cells/mm 2 (range: 622-1996), and the average duration of follow-up after explantation was 20.5 months (6-58.2). Two years after explantation, ECD had significantly decreased by more than 25% to 1019.6 ± 368.6 (608-1689; P < 0.01). However, there was no significant change in corrected distance visual acuity (20/23-20/22, P = 0.59). Longer operation duration (odds ratio, 1.004; P = 0.04) was the only significant factor weakly associated with postoperative decreases in ECD. Although ECD continuously decreased despite pIOL explantation on a long-term follow-up, patients did not experience any discomfort or showed decreases in visual acuity. Therefore, a careful follow-up is required for possible endothelial injury after pIOL explantation.

Pedicle flap reconstruction for treatment of infected median sternotomy wounds after cardiac surgery in overweight and obese patients: proposal of a management algorithm based on a case series analysis

BackgroundA relationship between obesity and adverse outcomes in patients with post-sternotomy wounds undergoing pedicle flap reconstruction is not well-documented. In this study, we present a single-centre retrospective case series analysis of early postoperative outcomes of patients with infected post-sternotomy wounds undergoing pedicle flap reconstruction. We also propose a management algorithm for such patients, based on BMI and wound width.MethodsWe retrospectively analyzed all patients, who underwent pedicle flap reconstruction for major sternal wound infections after sternotomy for cardiac surgery in a tertiary hospital in Germany during a 5-year period. Exclusion criteria included patients younger than 18 years of age and patients with BMI < 18.5 kg/m2. Patients were divided into 2 groups according to BMI: normal-weight (NW; BMI < 25 kg/m2) and overweight/obese (OB/OW; BMI > 25 kg/m2). Both groups were compared in terms of preoperative parameters and early postoperative outcomes. Preoperative parameters included demographics, wound bacteria and comorbidities. Postoperative outcomes included duration of surgery time (from incision to skin closure), transfusion requirement (during surgery and entire hospital stay), onset of flap and donor-site complications, length of stay and 30-day mortality. We employed the two-tailed t-test to compare continuous variables and the two-sided Fischer’s exact test to compare categorical variables. Statistical significance was set at p < 0.05.ResultsThe total sample consisted of 48 patients. Overall mean BMI was 28.4 (6.1) kg/m2. Mean age was 67 (12) years. The study group consisted of 28 patients with BMI > 25 kg/m2, who were compared with 20 normal-weight patients. There was a significant difference amongst both groups regarding duration of surgery (120 vs. 174 min, p < 0.05). Donor-site complications requiring intervention were observed in 30% of patients in both groups. Flap-related complications were recorded in 16 (57%) cases in the study group and 7 cases in the control group (35%, p = 0.15).ConclusionsWe conclude that wound width and BMI can aid the decision-making process for patients with infected sternal wounds after cardiac surgery requiring pedicle flap reconstruction. However, in our case series analysis, OB/OW patients were not found to be at statistically significantly increased risk for worse postoperative outcomes, but were associated with a longer duration of surgery.