Low Risk Of Surgical Complications Research Articles

Long-term Visual Acuity Outcomes of Deep Sclerectomy in Pediatric Glaucoma.

This study provides evidence of the long-term efficacy and safety of Deep Sclerectomy as a successful surgical intervention option in cases with childhood glaucoma. The primary objective was to evaluate the long-term visual acuity outcomes of Deep Sclerectomy in pediatric glaucoma and identify factors predicting poor prognosis. The secondary objective was to evaluate the long-term success rate of Deep Sclerectomy in controlling intraocular pressure. A retrospective review was conducted of all pediatric patients who underwent deep sclerectomy at King Abdulaziz University Hospital (KAUH) between 2001 and 2016. We included all patients who had valid visual acuity tests. The preoperative findings and long-term visual and intraocular pressure outcomes were analyzed. A total of 83 eyes of 68 patients were included. The mean (SD) age of participants was 11.1 (4.0) years (range: 5-25 years). The mean age at surgery was 5.9 months, and the mean follow-up period was 10.75 years. The majority of cases (83.1%) were primary congenital glaucoma. Visual acuity was ≥ 20/40 in 56.6% of cases, ranged between 20/40 and 20/200 in 18.1%, and was ≤ 20/200 in 25.3% of the operated eyes. Complete success rate (IOP ≤ 21mmHg without medications) after one surgery was achieved in 53 eyes (63.86%). Qualified success rate (IOP ≤ 21 mmHg with medications) was achieved in 8 eyes (9.6%), while 22 eyes (26.5%) failed to achieve target IOP of ≤ 21 mmHg or needed additional surgery to achieve it. Nine eyes (10.74%) had post-operative complications. Deep sclerectomy is a reasonable option for pediatric glaucoma that can provide good long-term visual outcomes and IOP control with a lower risk of surgical complications.

Unformed conglomerate debilitating jejunal fistulas and their two-stage surgical treatment via posterolateral laparotomy

To create a method of two-stage repair of high unformed conglomerate delimited debilitating jejunal fistulas via posterolateral laparotomy with low risk of surgical complications. Methodology and treatment outcomes were analyzed in 37 patients with unformed conglomerate high debilitating delimited jejunal fistulas. Of these, 22 patients underwent one-stage treatment through 2 converging incisions and/or two-stage treatment through anterolateral access. They made up a control group. Fifteen patients in the main group underwent two-stage treatment via posterolateral left-sided laparotomy with unilateral disconnection of jejunum with fistula. In most patients of both groups, fistulas complicated surgery for acute adhesive intestinal obstruction. Topography of adhesions that caused acute intestinal obstruction in both groups was studied in 172 other patients. Identical jejunal fistulas and two different surgical approaches made it possible to consider our groups representative. Two-stage treatment via posterolateral left-sided laparotomy reduced mortality from 63.6±10.2% to 20.0±10.3% (t=11.8; p<0.001). This approach simplified intraoperative diagnostics that became more informative. Posterolateral access increased the quality of anastomosis and safety of viscerolysis. A new two-stage approach with posterolateral left-sided laparotomy allowed atraumatic imposing of inter-intestinal anastomosis with proximal disconnection of jejunal fistula. This exclusion turns the fistula into analogue of the definitive Meidl's jejunostomy, unloads the intestinal anastomosis and increases the quality of suture. New strategy reduced the risk of complications and mortality.

Gynecologic Surgical Subspecialty Training Decreases Surgical Complications in Benign Minimally Invasive Hysterectomy

Study ObjectiveTo evaluate the impact of gynecologic subspecialty training on surgical outcomes in benign minimally invasive hysterectomies (MIH) while accounting for surgeon volume. DesignRetrospective cohort study of patients who underwent a MIH between 2014 and 2017. SettingSingle community hospital system. PatientsPatients were identified via CPT (Current Procedural Terminology) codes for MIH: vaginal, laparoscopic or robotic. Exclusion criteria included a gynecologic cancer diagnosis or concomitant major procedure at the time of hysterectomy. One thousand six hundred and thirty-one patients underwent a benign MIH performed by a gynecologic generalist or a subspecialist in Minimally-Invasive Gynecologic Surgery (MIGS), Urogynecology and Pelvic Reconstructive Surgery (URPS), or Gynecologic Oncology. 125 hysterectomies were vaginal, 539 were conventional laparoscopic, and 967 were robotic. InterventionsN/A Measurements and Main ResultsSurgical outcomes including intraoperative complications, operative outcomes, and postoperative readmissions and reoperations, were compared between generalists and subspecialists and stratified by surgeon volume status, with “high-volume” defined as performing 12 or more hysterectomies annually. Odds ratios for the primary outcome, Clavien-Dindo Grade III complications (which included visceral injuries, conversions, and reoperations within 90 days), were calculated to evaluate the impact of subspecialty training while accounting for surgeon volume status. 855/1631 (52.4%) MIH were performed by generalists and 776/1631 (47.6%) by subspecialists. High-volume generalists performed 618/1631 (37.9%) of MIH, 14.5% (237/1631) were performed by low-volume generalists. All subspecialists were high-volume surgeons; 38.1% of generalists were high-volume.The odds of a Clavien-Dindo Grade III complication was 0.39 (0.25-0.62) for hysterectomies performed by subspecialists compared to high-volume generalists after adjusting for potential confounding variables (p < .001). Subspecialists and high-volume surgeons had significantly lower incidence of visceral injuries, transfusions, blood loss over 500 mL, and conversions compared to generalists and low-volume surgeons, respectively. ConclusionBoth subspecialty training and high surgeon volume status are associated with a lower risk of surgical complications in benign MIH. Subspecialty training is associated with a reduction in surgical complications even after accounting for surgeon volume.

Risk Factors in Patients Who Had Prior Renal or Liver Transplant Undergoing Primary Total Knee Arthroplasty

BackgroundMore solid organ transplant (SOT) patients are undergoing total knee arthroplasty (TKA). This study identifies risk factors for complications, implant survivorship, and mortality in TKA patients who had prior SOT. MethodsWe identified 176 TKAs in patients who had prior SOT. Of these, 77 had a prior renal (RT), 77 had a prior liver (LT) transplant, and 22 had multiple prior transplants (MT). Median survival was estimated using Kaplan-Meier. Univariate analyses were assessed with mixed-effects logistic regressions for complications and Cox-regressions for mortality. Median follow-up was 63 months (range, 24 to 109). ResultsAt least one acute medical complication occurred in 25, 13, and 27% of cases with prior RT, LT, and MT, respectively (P = .12). None of the variables were significantly associated with acute medical complications. At least one surgical complication occurred in 14, 13 and 14% of cases with prior RT, LT, and MT, respectively (P = 1). Vitamin D supplementation (Odds Ratio [OR] = 0.38, P < .03) was associated with lower risk of surgical complications. Reoperation and revision rates were 5 and 3%, respectively. Older age at time of transplantation and greater level of serum creatinine at time of TKA were associated with lower risk (OR = 0.96, P = .01), and higher risk of reoperation (OR = 4.9, P = .01), respectively. Coronary artery disease was associated with higher mortality (Hazard Ratio = 2.35, P = .01). ConclusionsVitamin D was associated with lower surgical complications, whereas a younger age at time of transplantation increased the risk of reoperation. Additionally, SOT patients with coronary artery disease demonstrated higher mortality after TKA.

P47 MITRAL VALVE RE–REPAIR THROUGH A RIGHT MINITHORACOTOMY

Abstract Objective Recurrent mitral valve regurgitation after prior repair is usually treated with re–repair or replacement through a median sternotomy. We report our small initial experience with mitral valve re–repair through a repeated minimally invasive approach. Methods From July 2018 to November 2021, 10 patients (median age 52 years IQR 49–68; male 90%) underwent isolated mitral valve re–repair with a right mini–thoracotomy approach with peripheral arterial and venous cannulation. Median Euroscore II was 2.05 (IQR 2.03–2.54). Results The median time from the original operation to redo surgery was 4.7 (3.5–8.1) years. Median cardiopulmonary bypass and cross–clamp times were 128 (IQR 109–134) and 99.5 (IQR 81–112) minutes, respectively. Failure of previous mitral valve repair was mainly due to Gore–Tex chordal rupture (3 patients), annular detachment (3 patients), native chordal rupture (2 patients), and posterior leaflet prolapse (2 patients). Concerning the surgical terchnique, a complete mitral valve ring Corcym Memo 3D or 4D was used in 8 patients while additional repair techniques were needed 5 patients (PTFE neochords implantation, cleft or commissure closure). No conversion to full sternotomy and no reoperation for bleeding was necessary. Median ICU and hospital stay were 2.0 (IQR 2.0–2.0) and 7.5 (7.0–9.0) days respectively. Median follow up time was 3.5 (2.8–3.9) years. Neither deaths nor major postoperative complications occurred in the follow–up period. Conclusions In our experience, mitral valve re–repair can be an attractive option for patients with failure of previous mitral valve surgery and can be safely performed through a minimally invasive approach with good outcomes. Main advantages seem to be the avoidance of extensive surgical dissection, optimal valve exposure, and low risk of surgical complications.

Readmissions after emergent incisional ventral hernia repair: a retrospective review of the nationwide readmissions database.

Emergent ventral hernia repair (eVHR) is associated with significant morbidity, yet there is no consensus regarding optimal surgical approach. We hypothesized that eVHR with synthetic mesh would have a higher readmission rate compared to primary eVHR or biologic mesh repair. Retrospective analysis of the Nationwide Readmissions Database (NRD) was conducted for patient entries between 2016 and 2018. Adult patients who underwent eVHR were included. Patient demographics, comorbidities, and surgical techniques were compared between readmitted and non-readmitted patients. Predictors of readmission were assessed using multivariate analysis with propensity weighting for various eVHR techniques. Secondary outcomes included hospital length of stay and readmission diagnoses. 43,819 patients underwent eVHR; of the 22,732 with 6 months of follow-up, 6382 (28.1%) were readmitted. The majority of readmissions occurred within the first 30days (51.8%). Over half of the readmissions were related to surgical complications (50.6%), the most common being superficial surgical site infection (30.1%) and bowel obstruction/ileus (12.2%). In the multivariate analysis, predictors of 30-day readmission included use of synthetic mesh (OR 1.07, 95% CI 1.00-1.14), biologic mesh (OR 1.26, 95% CI 1.06-1.49), and need for concomitant large bowel resection (OR 1.46, 95% CI 1.30-1.65). eVHR is associated with high rates of readmission. Primary repair had favorable odds for readmission and lower risk of surgical complications compared to synthetic and biologic mesh repairs. Synthetic repair had lower odds of readmission than biologic repair. Given the inherent limitations of the NRD, further institutional prospective studies are required to confirm these findings.

PARAGANGLIOMA OF NECK IN MIDDLE AGED MALE: A CASE REPORT

Aim: To present a rare case of Paraganglioma of neck in an adult. Introduction: Paragangliomas of the head and neck represent rare benign tumors of neural crest origin that comprises of &lt;0.5% of all head and neck tumors. A schwannoma, also referred to as neurilemmoma, is relatively uncommon slowly growing benign lesion which originates from peripheral neural sheath of any myelinated nerve. Parapharyngeal space tumours are very rare and account for only 1 % of all head and neck tumours. The clinical presentation of schwannoma varies with the anatomical area involved. Surgical excision has been the treatment of choice and recurrence is very rare. Methodology: A 24-year, male presented in ENT OPD with the complaints of swelling on the right side of neck since 2 years. On Examination, the patient had a swelling on right side of neck, extending from angle of mandible upto supraclavicular region, 10 x 6 cm in size, ovoid in shape, non-tender, smooth surface, well defined rounded margins &amp; firm in consistency. On CECT Neck, a well circumscribed hypodense mass with poor enhancement not invading surrounding tissue was seen. On MRI-NECK study, a well-defined heterogenous mass on the right-side posterior to carotid vessels, suggestive of neoplastic lesion, mostly neurogenic stroma. Results: Surgical excision of swelling approximately 9 X 6 cm was performed under general anaesthesia. Conclusions: Schwannoma of the parapharyngeal tumor, should be included in the differential diagnosis of well circumscribed neck mass MRI &amp;CT are highly informative and definitive diagnosis requires histopathological evaluation. From the literature review and experience in our patient, we conclude that in early-stage Cervical paraganglioma with a low risk of surgical complications, primary resection for cure is recommended.

Single-port hidden incision endoscopic (HIdES) pediatric nephrectomy via pfannenstiel incision

Laparoendoscopic single-site surgery (LESS) and hidden incision endoscopic surgery techniques are increasingly used in pediatric urology. For pediatric nephrectomy, access through a single Pfannenstiel incision is novel and may offer cosmetic benefit. In this retrospective study, we describe this approach and assess operative outcomes associated with this technique. Patients who underwent LESS nephrectomy through a single Pfannenstiel incision had minimal blood loss, short length of stay, low risk of surgical complications, and satisfactory wound healing. The Pfannenstiel approach to LESS nephrectomy is feasible, versatile, and achieves excellent operative and cosmetic outcomes, although direct comparison to other approaches is warranted.

Posterior quadrant epilepsy surgery: case series of a South American hospital

BackgroundPosterior quadrant epilepsy (PCE) is a type of focal epilepsy that originates in the parietal lobe, occipital lobe, and the parietal-occipital border of the temporal lobe, or in any combination of these regions. PCE has a low incidence, but it can cause a great burden in disability-adjusted life years. In this retrospective cohort, patients of all ages with a diagnosis of PCE between 2006 and 2019 were evaluated in a referral center in Bogotá, Colombia. A descriptive analysis of demographic data, clinical history, imaging findings, type of surgery, histopathological diagnosis, outcome, and follow-up was performed using the Engel scale.MethodsThis study included refractory PCE patients of all ages who were evaluated by the epilepsy surgery group of the Hospital Universitario San Ignacio from 2006 to 2019. Clinical, imaging and surgical variables were obtained from the medical records and analyzed. ResultsThirteen patients were included in the study, including 8 males and 5 females. The mean age of diagnosis was 8.8 years, while the mean age of surgery was 25 years. The most frequent clinical finding was intellectual disability. The most common findings on magnetic resonance imaging were encephalomalacia and gliosis. In 61.5% of the patients, the lateralization of video-EEG matched with brain magnetic resonance imaging alteration. The most frequent types of surgery performed were lobectomies, lesionectomies and cortical resections. Seizure-freedom was achieved in approximately one third of the patients; however, more than half of the patients were free of disabling seizures or had significant improvement after surgery.ConclusionsPCE surgery is scarcely performed worldwide, therefore the effectiveness and outcomes are quite variable in the reported literature. In this study, we show that patients with PCE can obtain great benefits in terms of reduction of seizures with a low risk of surgical complications, encouraging the use of this type of procedure in carefully selected patients.

Cementless primary or revision stem in revision hip arthroplasty for aseptic stem loosening with Paprosky type I/II femoral defect?

The use of primary or revision stem during revision total hip arthroplasty (THA) for aseptic stem loosening with Paprosky type I/II femoral defect remains controversial. The aim of this study was to compare the outcomes of patients who underwent revision THA with a primary or revision stem. We retrospectively reviewed 78 patients who received revision THA for aseptic stem loosening using primary (N = 28) or revision stems (N = 50). The bone defects were classified as Paprosky type I or II. The mean follow-up duration was 72.3 ± 34.7 months. The primary outcome domains included surgical complications and implant failures. The secondary outcome domains included medical complications, 30- and 90-day readmission, and Harris hip score (HHS). The use of revision stem was associated with a higher incidence than primary stem of patient complications (60.0% vs. 32.1%, p = 0.018), including intraoperative femur fracture (28.0% vs. 7.1%, p = 0.029) and greater trochanter fracture (16.0% vs. 0%, p = 0.045). The implant survival rate was comparable between groups. HHS at the final follow-up was similar. With a lower risk of surgical complications and a similar rate of mid-term implant survival, cementless primary stem appears superior to revision stem in revision THA for aseptic stem loosening with Paprosky type I/II femoral defect.

Benefits and harms of hemithyroidectomy, total or near-total thyroidectomy in 1-4 cm differentiated thyroid cancer.

For 1-4cm differentiated thyroid cancer (DTC), current ATA guideline recommended hemithyroidectomy (HT) as an acceptable alternative initial procedure to total or near-total thyroidectomy (TT). The aim of this study was to evaluate benefits and harms of HT, TT in 1-4cm DTC. Retrospective cohort study. DTC patients aged 18 years or older who underwent initial thyroidectomyin a tertiary medical centre were included from January 2008 to July 2018. The structural persistent/recurrent disease, reoperation rates and surgicalcomplications were compared using Cox proportional regression and logistic regression. Propensity score matching was performed to adjust for related clinicopathological variables. Among 1824 DTC patients, 795 patients sized 1-4cm were included. A total of 286 patients underwent HT and 509 patients underwent TT. In the matched analysis, no significant difference in disease-free survival (DFS) between HT and TT was observed during the median follow-up period of 56.5 months (hazard ratio [HR] 0.86; 95% CI, 0.37-2.00; p=.733). The difference in DFS between two groups was consistent regardless of age, sex, tumour size, follow-up duration. Meanwhile, HT was associated with a decreased risk of surgicalcomplications (odds ratio [OR] 0.47, 95% CI 0.31-0.71, p<.001), as well as lower proportion of levothyroxine replacement (p=.007). Two cases in HT group received reoperation. Further multivariate analysis showed surgical procedure was not associated with structural persistence/recurrence (HR 0.68; 95%CI, 0.29-1.58, p=.367). For patients with 1-4cm DTC without clinical evidence of lymph node metastasis or extrathyroidal extension, HT was associated with lower risk of surgical complications than TT while provided similar benefits as TT.

Pregnancy outcomes following different types of bariatric surgery: A national cohort study

ObjectiveTo assess the impact of type of bariatric surgery on pregnancy outcomes. Study designThis is a national prospective observational study using the UK Obstetric Surveillance System (UKOSS). Data collection was undertaken in 200 consultant-led NHS maternity units between November 2011 and October 2012 (gastric banding), and April 2014 and March 2016 (gastric bypass and sleeve gastrectomy). Participants were pregnant women following gastric banding (n = 127), gastric bypass (n = 134) and sleeve gastrectomy (n = 29).Maternal and perinatal outcomes were compared using generalised linear and linear mixed models. Maternal outcomes included gestational weight gain, pre-eclampsia, gestational diabetes, anaemia, surgical complications. Perinatal outcomes included birthweight, small/large for gestational age (SGA/LGA), preterm birth, stillbirth. ResultsMaternal: Women pregnant after gastric banding and sleeve gastrectomy had a lower risk of anaemia compared with gastric bypass (banding (16 %) vs bypass (39 %): p = 0.002, sleeve (21 %) vs bypass: p = 0.04). Gestational diabetes risk was lower after gastric banding compared with gastric bypass (7 % vs 16 %, p = 0.03) despite women with banding having significantly greater weight at booking as well as gestational weight gain. Women pregnant after gastric banding and sleeve gastrectomy had a lower risk of surgical complications than after gastric bypass (banding (0.9 %) vs bypass (11.4 %): p = 0.03, sleeve (0.0 %) vs bypass: p = 0.06).Perinatal: Infants born to mothers after gastric banding had a higher birthweight than those born to mothers after gastric bypass (mean difference = 260 g (125–395), p < 0.001). Infants were more likely to be LGA if their mothers had gastric banding compared with gastric bypass or sleeve gastrectomy (banding (21 %) vs bypass (5 %): p = 0.006; banding vs sleeve (3 %): p = 0.03). Risk of preterm birth was higher in women with gastric banding compared with gastric bypass (13 % vs 8 %, p = 0.04). ConclusionsWomen planning bariatric surgery should be counselled regarding the differing impacts of different types of procedure on any future pregnancy. Pre-existing gastric bypass is associated with higher rates of potentially serious surgical complications during pregnancy.

Laparoscopic Conversion of Sleeve Gastrectomy to One Anastomosis Gastric Bypass for Weight Loss Failure: Mid-Term Results.

Laparoscopic sleeve gastrectomy (SG) became the most performed surgical intervention for treating population with morbid obesity. However, revisional surgery after SG has been increasingly performed due to weight loss failure. We describe the results of a single surgeon's experience with conversion of SG to one anastomosis gastric bypass (OAGB) in patients with previous SG and weight loss failure. The aim of the study is to analyze the short- and mid-term results of conversion of SG to OAGB for failure of weight loss. Conversion of SG to OAGB was performed in 77 patients from May 2010 to June 2018. Vertical resleeving of the gastric tube was done in all patients. A chart review was conducted to determine the weight loss mid-term results and the occurrence of postoperative complications. Revisional surgery was completed by laparoscopy in all cases. The mean operative time was 42.0 ± 8.0min, and mean blood loss was 56.8 ± 56.7mL. A total complication rate of 3.9% was observed. Ninety-day mortality rate was 0%. Patients mean %EWL was 80.2 (36-128) at 12-month follow-up, mean percent total weight loss (%TWL) was 0.74 (range 0.03-1.8), and mean percent excess BMI loss (%EBMIL) was 70.7%. At 24-month follow-up, mean %EWL was 84.1 (41-128), mean %TWL 0.79 (range 0.32-1.6), and mean %EBMIL 79.9%. In patients with history of SG and weight loss failure, conversion from SG to OAGB is effective in terms of weight loss and has a low risk of surgical complications.

Complications of Open Appendectomy Versus Laparoscopic Appendectomy in Children. Comparative Assessment

Abstract Laparoscopic pediatric surgery (LA) is becoming a good alternative in many centres of the entire world, being associated with low risk of surgical complications and it offers a better alternative for the management of the appendectomy than open surgery. The goal of the study was to evaluate a comparative LA versus open appendectomy (OA) through the prism of the clinical results as they were reflected in specialty literature in the last two decades. In general, pediatric laparoscopic surgery has become acceptable in centres of the whole world. Many studies and meta-analyses have proven that laparoscopic surgery is a feasible and secure procedure, with many clinical benefits. Because laparoscopic appendectomy (LA) was associated with low risk of surgical complications, it may be a better alternative for appendectomy than OA.

Comparison of anterior transthoracic debridement and fusion with posterior transpedicular debridement and fusion in the treatment of mid-thoracic spinal tuberculosis in adults

BackgroundThe surgical procedures for mid-thoracic spinal tuberculosis mainly include anterior transthoracic debridement and fusion and posterior transpedicular debridement and fusion. Until now, the surgical choice is still controversial. This study aims to compare the clinical efficacy of anterior transthoracic debridement and fusion with posterior transpedicular debridement and fusion in the treatment of mid-thoracic (T5–9) spinal tuberculosis in adult patients.MethodsEighty-seven cases with mid-thoracic spinal tuberculosis were treated with anterior transthoracic debridement and fusion (Group A, n = 39) and posterior transpedicular debridement and fusion (Group B, n = 48) from January 2007 to June 2014. Parameters including the operation time, blood loss, time of ESR and CRP decreasing to the normal level, time of abscess disappearance, time of bone graft fusion, rate of surgical complications, Visual Analog Scale (VAS) score, kyphosis angle and SF-36 scale were compared between two groups to evaluate their therapeutic effects.ResultsAll patients were followed up for 5–10 years with the mean of 6.2 ± 1.1 years. No significant differences were observed regarding the gender composition ratio, age, course of disease, number of lesion segments, and preoperative indexes of ESR, CRP, VAS score, kyphosis angle and SF-36 scale between the two groups. Besides, no significant differences were observed regarding VAS score, kyphosis angle and SF-36 scale between the two groups in the 5th postoperative year (P > 0.05). However, the operation time (158.2 ± 10.7 min vs. 183.7 ± 14.1 min), blood loss (517.9 ± 76.5 ml vs.714.6 ± 57.4 ml), time of ESR (2.3 ± 1.1 months vs.3.1 ± 1.4 months) and CRP (1.1 ± 0.3 months vs.1.2 ± 0.6 months) decreasing to the normal level, time of abscess disappearance (2.7 ± 1.6 months vs.4.9 ± 1.9 months), and time of bone graft fusion (6.6 ± 0.8 months vs.8.0 ± 9.6 months) in Group A were less than those in Group B (P < 0.05).ConclusionsBoth anterior transthoracic debridement and fusion and posterior transpedicular debridement and fusion have a low risk of surgical complications and provide good quality of life for the patients with mid-thoracic (T5–9) spinal tuberculosis followed up in the mid-term. Moreover, the anterior procedure leads to early resolution of the disease and faster fusion.

Increased Fetal Chromosome Detection with the Use of Operative Hysteroscopy During Evacuation of Products of Conception for Diagnosed Miscarriage

To determine whether incorporation of operative hysteroscopy with biopsy of products of conception, in conjunction with a suction curettage for a first trimester missed abortion, affected the rate of maternal cell contamination when chromosomal analysis was performed on the products of conception, and to determine the rates of retained products of conception with incorporation of hysteroscopy after suction curettage. Retrospective chart study. Private, minimally invasive surgery and infertility practice with academic-community hospital affiliation. Infertility patients undergoing evacuation of products of conception for documented first trimester miscarriages between 2006 and 2017. Suction curettage or hysteroscopic biopsy and suction curettage, followed by chromosomal analysis of products of conception for determination of fetal genetics. A total of 264 charts were analyzed. Patients were categorized into 2 groups based on surgical collection of products of conception: group 1 (N = 174), suction curettage only, and group 2 (N = 90), a single procedure consisting of operative hysteroscopy with biopsy of products of conception followed by suction curettage and then diagnostic hysteroscopy to look for retained products. Data for chromosome detection and retained products of conception were available for 246 and 239 patients, respectively. No significant differences were detected between the groups for age, body mass index, ethnicity, gravida, parity, primary infertility, secondary infertility, spontaneous conception, single or multiple gestation, and surgical complications. Fetal chromosome detection was significantly higher without maternal contamination in group 2 (88.5%) compared with group 1 (64.8%) (p < .001). There was no significant between-group difference in postoperative retained products of conception. Obtaining fetal genetics can be useful when planning for a future successful pregnancy. The addition of operative hysteroscopy to biopsy the gestational sac, chorionic villi, and/or fetus significantly decreases the risk of maternal contamination and increases the ability to detect fetal chromosomes for genetic analysis without an increased risk of surgical complications. Despite the low risk of surgical complications, immediate second-look hysteroscopy after the completion of suction evacuation does not reduce the risk of postoperative retained products of conception.

Active surveillance for very low-risk papillary thyroid carcinoma: experience and perspectives from Japan

Low-risk papillary thyroid carcinoma (PTC) has been treated using lobectomy in Japan. This represents a very different approach to that used in Western countries, where the majority of patients have been treated with total thyroidectomy followed by radioactive iodine (RAI). Given the excellent survival and lower risk of surgical complications, Western guidelines have recently adopted a limited surgical approach for low-risk PTC. The treatment paradigm has shifted from a one-size-fits-all approach to more individualized protocols under the concept of risk-adapted management and treatment policies in the East and West have become increasingly integrated. The incidence of thyroid cancer has continued increasing around the world, mainly thanks to the increased detection of small PTCs, and debate is now emerging regarding the potential for overdiagnosis and overtreatment of subclinical thyroid cancers. Countermeasures to the phenomenon have been explored. Guidelines have been establishing new standards for cancer screening and clinical diagnosis. Pathologists have proposed changing the diagnostic criteria and terminology for indolent thyroid tumors. Since the 1990s, two Japanese institutions have initiated prospective trials of active surveillance for asymptomatic papillary microcarcinoma (PMC). These trials verified that the vast majority of tumors did not progress during active surveillance and outcomes were unaffected by delaying surgery. The Japanese guidelines adopted active surveillance management for asymptomatic PMC in 2010. The 2015 American Thyroid Association (ATA) guidelines have accepted the policy as an alternative to immediate surgery in patients with very low-risk tumors. Further studies have revealed that PMC was less progressive in older patients than in younger patients. Strong calcification and poor vascularity were indicators of stable disease. Several clinical issues remain unsolved in terms of active surveillance options for very low-risk PTC. Studies on patient-reported outcomes are still lacking and more specific predictors for the progression of low-risk PTC at the time of diagnosis are in demand.

Type of Blunt Expansion of the Low Transverse Uterine Incision During Caesarean Section and the Risk of Postoperative Complications: A Prospective Randomized Controlled Trial

ObjectiveTo evaluate two techniques of uterine incision expansion (cephalad-caudad vs. transverse) during Caesarean section (CS). MethodsA total of 839 patients were randomized to either a cephalad-caudad blunt expansion of uterine incision during CS versus a transverse (lateral-lateral) expansion. The primary outcome was blood loss, measured with the descent of hemoglobin level. Secondary outcomes were the need for blood transfusion and the number of surgical or postoperative complications presented in both groups. ResultsThere was no statistical difference with regard to decrease in hemoglobin level, but there was a higher number of surgical complications in the transverse expansion group (Cephalad-caudad: 11.53% vs. transverse: 16.42%; odds ratio [OR] 0.66; 95% confidence interval [CI] 0.45–0.98; P = 0.04). There were more cases of unintended extensions of uterine incision (10.35% vs. 16.18%; OR 0.6; 95% CI 0.4–0.9; P = 0.01) but no statistical difference in the number of hematomas, uterine vessel injury, or the need to transfuse. ConclusionThe cephalad-caudad blunt expansion technique of the low transverse uterine incision is safer than the transverse expansion. There was no difference in regard to decrease in hemoglobin level, but there is a lower risk of surgical complications not associated with an increased need for blood transfusions when compared with the transverse expansion.

Evidence Based Tailored Parotidectomy in Treating External Auditory Canal Carcinoma

Carcinoma of the external auditory canal (EAC) is a rare tumor and little information is available regarding parotid gland in surgically treating EAC carcinomas. This study aimed to investigate the mode of parotid involvement in EAC carcinoma through staging and histopathological analysis, and to establish surgical guidelines for the parotid gland management when there is no clinical evidence of parotid involvement. Sixty-five patients with EAC carcinoma who underwent temporal bone resection and any type of parotidectomy simultaneously were retrospectively reviewed. The rate of direct parotid invasion and parotid nodal involvement was analyzed according to the stage and histopathological findings. Among the 65 patients, 39 were confirmed to have squamous cell carcinoma (SCC) and 26 were confirmed to have adenoid cystic carcinoma (ACC). Direct parotid invasion occurred in 7 of 39 patients with SCC, only in the advanced stages, and in 15 of 26 patients with ACC, regardless of stage. Metastasis to the parotid node was noted in 6 patients with advanced-stage SCC, whereas no patient with ACC showed parotid nodal metastasis. For adequate tumor control with low risk of surgical complications, evidence based tailored parotidectomy should be applied. With no evidence of parotid involvement, an elective parotidectomy can be excluded in early SCC, whereas a total parotidectomy is recommended for advanced SCC. In ACC, basal resection of the parotid gland rather than a superficial or total parotidectomy should be performed at all disease stages.

Novel rabbit model of moderate knee contracture induced by direct capsular damage.

The treatment of joint contracture continues to represent a challenging problem in orthopedic surgery and rehabilitation medicine. Existing animal models of knee contracture for evaluating new treatments are mostly created by extensive joint tissue damage with Kirschner-wire immobilization which requires a second surgery to remove Kirschner-wires. This study aimed to develop a less invasive rabbit model of moderate knee contracture through a single surgery. Skeletally mature New Zealand White rabbits had their right knee operated to create surgical damage to the posterior capsule under direct visualization. Operated knees were then held in a flexed position by suturing the superficial flexion muscles with absorbable sutures. The flexion contracture (net extension loss) was determined by comparing the extension angles between the operated and non-operated knees from 8 to 24 weeks post-surgery. The flexion contracture of the operated knees was significantly greater (p < 0.01/0.001) than the non-operated knees at each weekly measurement. The mean flexion contractures were 22° at 8 weeks, 19° at 16 weeks, and 18° at 24 weeks. No significant differences in the severity of flexion contracture were observed between 8-week and each of the following weeks, suggesting that the flexion contracture was essentially stabilized by 8 weeks post-surgery. Histopathologic analyses demonstrated intra-articular and peri-articular scar formation. This less invasive rabbit model of moderate knee contracture is more quickly established through a single surgery with lower risk of surgical complications compared to the previously reported invasive models, and could be an alternative animal model for joint contracture research. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2687-2695, 2018.