Lower Risk Of Reoperation Research Articles

Surgical Treatment of Symptomatic Chiari I Malformation

Background: There is lack of consensus on the most appropriate surgical management for Chiari malformation type I (CM I), the extent of decompression, and on the management of patients with Chiari I who also have associated scoliosis or syringomyelia, and the signs and symptoms can be attributed to these but not to compression on the posterior fossa. We present our surgical results with CM I and compare outcomes on the basis of clinical presentation, surgical approaches, and types of graft materials used. Methods: We retrospectively reviewed the charts of 37 consecutive patients. Presenting complaints, imaging studies, and different patient management strategies were analyzed with respect to outcomes and complications. Results: There were 27 male and 10 female patients with a mean age of 25.7±13.9 years at the time of admission. Comparisons based on age, sex, and extent of laminectomy were found to be statistically insignificant. There was also no significant difference between posterior fossa decompression with duraplasty and posterior fossa decompression in symptomatic improvement of the patients. Posterior fossa decompression with duraplasty was found to be associated with a higher risk of developing CSF leaks but a lower risk of reoperation. Conclusions: CM I should be considered in the list of differentials in patients with nonspecific headaches and neck pains. Timely surgical intervention for symptomatic CM I patients can lead to significant clinical improvement. However, the extent of decompression, the need for duraplasty, and the choice of graft material lack general consensus. In CM I patients with associated scoliosis and syringomyelia, decompressive surgery may halt further progression of the spinal abnormalities.

Hemiarthroplasty versus total hip arthroplasty for displaced femoral neck fractures: a meta-analysis of the literature

Background: Hemiarthroplasty and total hip arthroplasty are the two most common methods for displaced femoral neck fracture. However, the efficacy of the two methods is still controversial and needs a comprehensive analysis. Objective: This meta-analysis was to investigate whether total hip arthroplasty (THA) is associated with lower reoperation rate, mortality, complications, better function and quality of life than hemiarthroplasty (HA) for patients with displaced femoral neck fractures. Materials and Methods: Thirty-one trials involving a total of 4324 patients were included. Six randomized controlled trials, 8 lower-quality randomized trials, and 17 retrospective cohort studies comparing HA with THA for displaced femoral neck fractures were assessed for eligibility. Incidence rate and risk ratios (RR) were pooled using random-effects or fixed-effects models depending on the heterogeneity of included studies. Results: Meta-analysis showed that THA was associated with a lower risk of reoperation (incidence rate 2.8%, 95%CI 1.8%-3.8%) compared with HA (incidence rate 7.4%, 95%CI 5.3%-9.6%) (RR = 0.42, 95%CI 0.30-0.58, P Conclusion: THA can benefit patients of displaced femoral neck fractures with a reduced reoperation rate and better hip function, though it can result a higher incidence of postoperative dislocation. The impact of different hip arthroplasty on prognosis need further studies. Keywords: Displaced femoral neck fractures, hemiarthroplasty, total hip arthroplasty

Repair of anomalous origin of the left coronary artery from the pulmonary artery in infants

Anatomical repair seems an ideal method for the surgical treatment of the anomalous left coronary artery arising from the pulmonary artery (ALCAPA) in infancy. The medium-term outcome has been investigated for infants with ALCAPA following the restoration of a dual-coronary arterial circulation. Between April 1995 and July 2012, 23 infants with a median age of 4 months underwent surgical repair of ALCAPA in our department. Direct implantation of the anomalous coronary artery into the ascending aorta was feasible in 16 patients. A trap door flap method was used in 5 cases and a tubular extension technique in 2. No infant underwent mitral valve repair at the time of ALCAPA surgery. Left ventricular function and the degree of mitral valve regurgitation were assessed during a 10-year follow-up. Four patients died in the early postoperative period, without independent predictors associated with this mortality. During follow-up, improvement in myocardial function occurred in all patients both early and late. There was only one improvement in severe mitral valve regurgitation. Subsequently, 2 children needed mitral valve replacement. There were no early or late reoperations of the reimplanted coronary arteries. Aortic reimplantation is an effective surgical treatment for ALCAPA in infants burdened with a low risk of reoperation due to coronary artery stenosis. There was good potential for myocardial recovery within the first year after surgery. Restoration of the anatomical coronary circulation did not improve mitral valve function in infants with severe preoperative mitral incompetence.

Incidence and risk factors for reoperation of surgically treated urinary incontinence

The objective of our study was to estimate the incidence and to identify the risk factors for reoperation of surgically treated stress urinary incontinence (SUI). We conducted a nested case-control study among 1,132 women who underwent SUI surgery from January 1988 to June 2007. Cases (n=35) were women who required reoperation for SUI following the first intervention up to December 2008. Controls (n=89) were women randomly selected from the same cohort who did not require reoperation. The cumulative incidence of SUI reoperation was 3.1 % with a mean follow-up of 10.9 years (range 1.7-21.0). The main risk factor was the history of more than one vaginal delivery [adjusted odds ratio (OR) 3.5; 95 % confidence interval (CI) 1.0-12.6]. The use of synthetic midurethral slings was a protective factor compared to other surgical procedures for urinary incontinence (adjusted OR 0.1; 95 % CI 0.0-0.6). The risk of reoperation after SUI surgery appears to be low and associated with multiple vaginal deliveries. Synthetic slings at index surgery are associated with a lower risk of reoperation.

Photoselective Vaporization Versus Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia: A Meta-Analysis

To determine whether photoselective vaporization has advantages over transurethral resection of the prostate (TURP) in terms of effectiveness and safety for treatment of patients with benign prostatic hyperplasia. MEDLINE, EMBASE, and the Cochrane Controlled Trial Register were searched for randomized controlled trials. The risk ratio, mean difference, and their corresponding 95% confidence intervals were calculated for dichotomous and continuous outcomes, respectively. Risk of bias of enrolled trials was assessed according to Cochrane Handbook. A total of five trials were enrolled. There was no significant difference in the International Prostate Symptom Score and maximum flow rate between photoselective vaporization and TURP at 6-, 12-, and 24-month follow-up. Photoselective vaporization was associated with significantly lower risk of capsule perforation, transurethral resection syndrome, and clot retention, significantly lower transfusion requirements, a shorter catheterization time, and a shorter length of hospital stay. TURP was associated with a shorter operative time and a lower risk of reoperation. In addition, there was no difference in risk of acute urinary retention and urethral/bladder neck sclerosis between photoselective vaporization and TURP. Photoselective vaporization and TURP provide comparable improvements in functional results, including International Prostate Symptom Score and maximum flow rate at 6-, 12-, and 24-month follow-up. Photoselective vaporization offers advantages over TURP in terms of intraoperative safety; however, TURP is found to have a shorter operative time and lower reoperative risk.

Clinical outcome after undisplaced femoral neck fractures

Background and purpose Little attention has been paid to undisplaced femoral neck fractures. By using data from the Norwegian Hip Fracture Register, we investigated the risk of reoperation and the clinical outcome after treatment of these fractures in patients over 60 years of age.Methods Data on 4,468 patients with undisplaced femoral neck fractures who were operated with screw osteosynthesis were compared to those from 10,289 patients with displaced femoral neck fractures treated with screw osteosynthesis (n = 3,389) or bipolar hemiarthroplasty (n = 6,900). The evaluation was based on number of reoperations and patient assessment at 4 and 12 months of follow-up.Results The 1-year implant survival was 89% after screw fixation for undisplaced fractures, 79% after screw fixation for displaced fractures, and 97% after hemiarthroplasty for displaced fractures. Patients with displaced fractures who were operated with internal fixation had a higher risk of reoperation (RR = 1.9, CI: 1.7–2.2), reported more pain, were less satisfied, and had lower quality of life than patients with undisplaced fractures treated with internal fixation (p < 0.05). Patients with displaced fractures who were operated with hemiarthroplasty had a lower risk of reoperation than patients with undisplaced fractures who were operated with internal fixation (RR = 0.32, CI: 0.27–0.38). Furthermore, they had the lowest degree of pain, were most satisfied, and reported the highest quality of life.Interpretation The differences in clinical outcome found were less than what is considered to be of clinical importance. The results support the use of screw osteosynthesis for undisplaced femoral neck fractures in elderly patients, although even better results were obtained in the hemiarthroplasty group in patients with displaced fractures.

Recurrent groin hernia surgery

The reoperation rate after recurrent groin hernia surgery is more than twice that recorded for primary groin hernia procedures. The aim was to define the outcome from routine redo hernia surgery by analysing a large population-based cohort from a national hernia register. All recurrent groin hernia operations registered in the Swedish Hernia Register from 1992 to 2008 were analysed using multivariable analysis with stratification for preceding repair. Altogether 174,527 hernia operations were recorded in the Swedish Hernia Register between 1992 and 2008, including 19 582 reoperations. The preceding repair was included in the register for 5565 of these recurrent repairs. With laparoscopic repair as reference standard, the hazard ratio for recurrence was 2·55 (95 per cent confidence interval 1·66 to 3·93) after sutured repair, 1·53 (1·20 to 1·95) after Lichtenstein repair, 2·31 (1·76 to 3·03) after plug repair, 1·36 (0·95 to 1·94) after open preperitoneal mesh and 3·08 (2·22 to 4·29) after other repairs. Laparoscopic and open preperitoneal repair were associated with a lower risk of reoperation following a preceding open repair (P < 0·001), but no technique differed significantly from the others following a preceding preperitoneal repair. The laparoscopic and the open preperitoneal mesh methods of repair for recurrent groin hernias were associated with the lowest risk of reoperation. Although the method of repair in previous surgery must be considered, these techniques are the preferred methods for recurrent groin hernia surgery.

La correction anatomique de la transposition des gros vaisseaux : un modèle de « guérison » en chirurgie cardiaque pédiatrique ?

Transposition of the great arteries (TGA) is a common congenital heart malformation, involving inversion of the two great vessels (aorta and pulmonary artery). Without surgical treatment, TGA is not compatible with life. The prognosis of this malformation has been dramatically changed by the development of neonatal cardiac surgery. "Anatomic" repair was introduced in the 1980s, with the goal of providing near-normal cardiac anatomy. It is carried out in neonates with isolated TGA (so-called simple TGA), as well as in those with associated anomalies (ventricular septal defect, aortic coarctation). Since January 1987, 1020 neonates have undergone anatomic repair of TGA in the pediatric cardiac surgery department of Groupe Hospitalier Laennec-Necker-Enfants Malades in Paris. The overall mortality rate was 4.8% (49 patients), and all deaths occurred within the first postoperative year. Among the 966 survivors who could be monitored (mean follow-up 6.2 years), 52 children (5.4%) underwent reoperation, with no additional mortality. Nearly all the survivors have normal cardiac function and quality of life. Despite significant mortality (albeit currently low) anda low risk of reoperation, the mid-term results of anatomic repair of TGA are excellent and represent a surgical "cure" in most cases. Very-long-term outcome remains to be determined.

Arthroplasty versus internal fixation for femoral neck fractures in the elderly

We studied 140 patients with femoral neck fractures treated from January 1999 to December 2006. There were 68 men and 72 women with a mean age of 72 years (range 60–80 years). Seventy patients were treated with closed reduction and internal fixation (group A), and 70 patients with hip arthroplasty (group B). The duration of surgery, length of hospitalization, complications, postoperative Harris hip score, and need for reoperation were recorded. Group B had significantly higher blood loss, increased surgical time and length of hospitalization compared to group A patients. The Harris hip score was significantly higher in group B at the 3, 6, and 12-month follow-up evaluations; however, the differences were no longer significant at the 24-month evaluation. The overall complications rate was 18.6% (13 patients) in group A compared to 25.7% (18 patients) in group B; this was not statistically significant (P = 0.309). A statistically significant difference was found regarding reoperation rate in group A (11.4%, eight patients) compared to group B (1.4%, one patient) (P = 0.016). Arthroplasty compared to internal fixation for displaced femoral neck fractures is associated with a significantly higher functional score and lower risk of reoperation at the cost of greater infection rates, blood loss, and operative time.

Comparison of posterior fossa decompression with and without duraplasty for the surgical treatment of Chiari malformation Type I in pediatric patients: a meta-analysis

Surgery for Chiari malformation Type I (CM-I) is one of the most common neurosurgical procedures performed in children, although there is clearly no consensus among practitioners about which surgical method is preferred. The objective of this meta-analysis was to compare the outcome of posterior fossa decompression with duraplasty (PFDD) and posterior fossa decompression without duraplasty (PFD) for the treatment of CM-I in children. The authors searched Medline-Ovid, The Cochrane Library, and the conference proceedings of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons (2000-2007) for studies meeting the following inclusion criteria: 1) surgical treatment of CM-I; 2) surgical techniques of PFD and PFDD being reported in a single cohort; and 3) patient age < 18 years. Five retrospective and 2 prospective cohort studies involving a total of 582 patients met the criteria for inclusion in the meta-analysis. Of the 582 patients, 316 were treated with PFDD and 266 were treated with PFD alone. Patient age ranged from 6 months to 18 years. Patients undergoing PFDD had a significantly lower reoperation rate (2.1 vs 12.6%, risk ratio [RR] 0.23, 95% confidence interval [CI] 0.08-0.69) and a higher rate of cerebrospinal fluid-related complications (18.5 vs 1.8%, RR 7.64, 95% CI 2.53-23.09) than those undergoing PFD. No significant differences in either clinical improvement (78.6 vs 64.6%, RR 1.23, 95% CI 0.95-1.59) or syringomyelia decrease (87.0 vs 56.3%, RR 1.43, 95% CI 0.91-2.25) were noted between PFDD and PFD. Posterior fossa decompression with duraplasty is associated with a lower risk of reoperation than PFD but a greater risk for cerebrospinal fluid-related complications. There was no significant difference between the 2 operative techniques with respect to clinical improvement or decrease in syringomyelia.

Editorial Comment on: Complication Rates of Tension-Free Midurethral Slings in the Treatment of Female Stress Urinary Incontinence: A Systematic Review and Meta-Analysis of Randomized Controlled Trials Comparing Tension-Free Midurethral Tapes to Other Surgical Procedures and Different Devices

Objectives: To evaluate the complication rates of tension-free midurethral slings compared with other surgical treatments for stress urinary incontinence, including other tension-free midurethral slings. Methods: A systematic review of the literature using MEDLINE, EMBASE, and Web of Science was performed in January 2007. Meta-analysis was conducted by using the Review Manager software 4.2. Results: Our search identified 33 randomized controlled trials reporting data on complication rates. Our meta-analysis showed that complication rates were similar after tension-free vaginal tape (TVT) and Burch colposuspension, with the exclusion of bladder perforation, which was more common after TVT (p = 0.0001), and reoperation rate, which was significantly higher after Burch colposuspension (p = 0.02). TVT and pubovaginal sling were followed by similar complication rates. With regards to the comparisons among retropubic tapes, TVT and intravaginal slingplasty had similar complication rates, whereas suprapubic arc sling (SPARC) was complicated by higher rates of voiding lower urinary tract symptoms (LUTS) (p = 0.02) and reoperations (p = 0.04). Comparing retropubic and transobturator tapes, the occurrence of bladder perforations (p = 0.007), pelvic haematoma (p = 0.03), and storage LUTS (p = 0.01) was significantly less common in patients treated by transobturator tapes. Conclusions: Tension-free slings were followed by lower risk of reoperation compared with Burch colposuspension, whereas pubovaginal sling and tension-free midurethral slings had similar complication rates. With regards to different tension-free tapes, voiding LUTS and reoperations were more common after SPARC, whereas bladder perforations, pelvic haematoma, and storage LUTS were less common after transobturator tapes. The quality of many evaluated studies was limited.

Valve repair surgery for incompetent bicuspid aortic valves

Surgical valve repair is a good alternative for correction of incompetent bicuspid aortic valve. To report the early and late surgical, clinical and ecochardiographic results of surgical repair of incompetent bicuspid aortic valves. Retrospective review of medical records of 18 patients aged 19 to 61 years, with incompetent bicuspid aortic valve in whom a valve repair was performed. Four patients had infectious endocarditis and 17 were in functional class I or II. Follow up ranged from 3 to 113 months after surgery. A triangular resection of the prolapsing larger cusp, which included the middle raphe, was performed in 17 cases; in 13 of these, a complementary subcommisural annuloplasty was performed. In the remaining case, with a perforation of the non-coronary cusp, a pericardial patch was implanted; this procedure was also performed in 2 other cases. In 3 cases large vegetations were removed. Postoperative transesophageal echocardiography showed no regurgitation in 11 patients (62%) and mild regurgitation in 7 (38%). There was no operative morbidity or mortality. There were no deaths during the follow-up period. In 3 patients (17%) the aortic valve was replaced with a mechanical prosthesis, 8 to 108 months after the first operation. Reoperation was not needed in 93%+/-6,4% at 1 year and 85%+/-9,5% at 5 years, these patients were all in functional class I at the end of the follow-up period. 60% had no aortic regurgitation, 20% had mild and 20% moderate aortic regurgitation on echocardiographic examination. A significant reduction of the diastolic diameter of the left ventricle was observed, but there were no significant changes in systolic diameter or shortening fraction. Surgical repair of incompetent bicuspid aortic valves has low operative morbidity and mortality and has a low risk of reoperation.

Ciruguía reparadora de la válvula aórtica bicúspide insuficiente

Surgical valve repair is a good alternative for correction of incompetent bicuspid aortic valve.To report the early and late surgical, clinical and ecochardiographic results of surgical repair of incompetent bicuspid aortic valves.Retrospective review of medical records of 18 patients aged 19 to 61 years, with incompetent bicuspid aortic valve in whom a valve repair was performed. Four patients had infectious endocarditis and 17 were in functional class I or II. Follow up ranged from 3 to 113 months after surgery.A triangular resection of the prolapsing larger cusp, which included the middle raphe, was performed in 17 cases; in 13 of these, a complementary subcommisural annuloplasty was performed. In the remaining case, with a perforation of the non-coronary cusp, a pericardial patch was implanted; this procedure was also performed in 2 other cases. In 3 cases large vegetations were removed. Postoperative transesophageal echocardiography showed no regurgitation in 11 patients (62%) and mild regurgitation in 7 (38%). There was no operative morbidity or mortality. There were no deaths during the follow-up period. In 3 patients (17%) the aortic valve was replaced with a mechanical prosthesis, 8 to 108 months after the first operation. Reoperation was not needed in 93%+/-6,4% at 1 year and 85%+/-9,5% at 5 years, these patients were all in functional class I at the end of the follow-up period. 60% had no aortic regurgitation, 20% had mild and 20% moderate aortic regurgitation on echocardiographic examination. A significant reduction of the diastolic diameter of the left ventricle was observed, but there were no significant changes in systolic diameter or shortening fraction.Surgical repair of incompetent bicuspid aortic valves has low operative morbidity and mortality and has a low risk of reoperation.

Long Term Clinical and Echocardiographic Results of Isolated Aortic Valve Replacement in Elderly Patients

Results after isolated aortic valve replacement with bileaflet prostheses in patients over 70 years old were reviewed. One-hundred-twenty-eight elderly patients were operated on between January 1988 and January 2000. Patients with associated heart disease were excluded from the study. Preoperative data, early and late postoperative mortality, all valve related complications and data concerning anticoagulation status were recorded. Hospital mortality was 9.3%. Mean follow-up time was 60.98 +/- 2.23 months. Twelve-year actuarial survival was 69.6 +/- 0.08%. Valve related and anticoagulation related complication rates (0.8% and 1.6% respectively) and actuarial freedom (99 +/- 0.009 both) were low, as well as the mean interval between consecutive INR checks (18.39 +/- 1.90 days) and the mean INR value (2.17 +/- 0.135). Late echocardiographic results showed low postoperative mean transprosthetic gradients (15.48 +/- 0.94). Bileaftlet prostheses in the elderly can achieve excellent results with a low incidence of anticoagulation related complications and low risk of reoperation. Older age can no longer be considered a contraindication to bileaftlet prosthesis implant.

Incidence and risk of reintervention after coarctation repair

We examined the need for intervention after coarctation repair in a retrospective study of 197 procedures performed between 1967 and 1989. Reintervcntion was required in 23 patients. No technique of coarctation repair was free from complications. Although there were only two stenoses in the group receiving Dacron patch angioplasty, only seven of these procedures were performed in children under the age of 1 year. The risk of stenosis was inversely correlated to the age at primary repair, with children less than 1 year old being at greater risk than those more than 1 year of age ( p < 0.05). Subclavian flap angioplasty had a lower risk of reoperation than end-to-end anastomosis ( p < 0.02). Formation of true aneurysms was confined to the Dacron patch angioplasty group. The morbidity and mortality for reintervention was low in all groups, with only one procedure-related death and no incidence of paraplegia. Although no technique is free from risk, subclavian flap angioplasty leads to fewer reinterventioas in younger patients.