Meticulous Perioperative Care Research Articles

Comparison of syndromic and non-syndromic craniosynostosis cases followed in a tertiary pediatric intensive care unit: a case control study.

Craniosynostosis, marked by premature skull suture closure, manifests as isolated or syndromic cases. While isolated cases are more common, syndromic craniosynostoses are associated with a range of complications. This study aims to compare postoperative outcomes in isolated and syndromic craniosynostosis, hypothesizing greater complications in the latter. A case-control study was conducted with 30 pediatric patients with isolated (Group C) and syndromic (Group S) craniosynostosis undergoing surgery. Data on demographics, operative details, blood product transfusions, and postoperative complications were analyzed. Statistical analysis employed Chi-square, Fisher exact tests, and Mann-Whitney U tests. Perioperative bleeding and postoperative packed red blood cell (PRBC) transfusions were significantly higher in isolated cases. Morbidity analysis, including reoperation, massive bleeding, infection, hydrocephalus, and seizures indicated higher rates in syndromic cases. The rates of postoperative morbidities were 30% in syndromic and 10% in isolated cases (p = 0.053). Correlations revealed a low positive association between body weight and both PICU and hospital stays. Additionally, a low positive correlation was found between perioperative PRBC transfusion amount and PICU length of stay. The total number of morbidities showed a moderate positive correlation with PICU length of stay and a low positive correlation with hospital length of stay. Isolated craniosynostosis cases exhibited higher perioperative bleeding and PRBC transfusions, potentially influenced by surgery at an earlier age. Although complications tended to be elevated in syndromic cases, no significant differences were observed. This study underscores the necessity for meticulous perioperative care, emphasizing individualized approaches considering age-related factors and associated complications in managing craniosynostosis cases.

Pushing the Limits: Aesthetic Surgery Breakthrough in a High-Dose Cortisone Dermatomyositis Patient

Dermatomyositis is a rare autoimmune disease characterized by muscle weakness and skin rashes. Management typically involves high-dose cortisone treatment, which raises concerns about the feasibility and safety of aesthetic surgeries for affected individuals. This case report presents a successful outcome of an aesthetic surgery conducted on a dermatomyositis patient undergoing high-dose cortisone therapy. The patient, a 39-year-old female with a history of juvenile dermatomyositis, expressed a desire for aesthetic improvement, first in the periocular area and then in terms of the appearance of her breasts. Despite the challenges posed by the underlying condition and ongoing corticosteroid treatment, the patient underwent elective aesthetic surgeries with meticulous perioperative care and close collaboration between the surgical, anesthetic, and rheumatology teams. The successful outcome of the procedures enhanced the patient’s self-esteem and quality of life. This case underscores the importance of individualized treatment planning, interdisciplinary collaboration, and careful perioperative management for achieving favorable aesthetic outcomes for patients with dermatomyositis undergoing corticosteroid therapy for more than 20 years. Further research and awareness are warranted to guide the safe performance of aesthetic surgeries on this unique patient population.

Comparative analysis of long-term outcomes in thoracoabdominal aortic aneurysm repair between Marfan syndrome patients and non–Marfan syndrome patients

BackgroundA consensus on the management of thoracoabdominal aortic aneurysm (TAAA) in patients with Marfan syndrome (MFS) has not yet been established. This study aimed to compare the long-term outcomes after open TAAA repair in patients with and without MFS. MethodsThis retrospective study examined 230 consecutive patients who underwent TAAA repair between 2012 and 2022, including of 69 MFS patients and 161 non-MFS patients. The primary endpoint was long-term mortality. The secondary endpoint was a composite of early adverse events, including early mortality, permanent stroke, permanent paraplegia, permanent renal failure, and reoperation. Univariable and multivariable logistic regression analyses were used to assess the impact of MFS on early composite adverse events, and univariable and multivariable Cox proportional hazards models were constructed to evaluate the association between MFS and overall mortality. ResultsCompared with non-MFS patients, MFS patients were younger (mean, 31.9 ± 8.5 years vs 44.8 ± 12.3 years; P < .001), had less comorbid coronary artery disease (0 vs 8.1%; P = .034), more frequently underwent Crawford extent III repair (56.5% vs 34.8%; P = .002) and applied normothermic iliac perfusion (91.3% vs 81.4%; P = .057). There was no significant difference in the rate of early composite adverse events between the MFS and non-MFS groups (23.2% vs 14.3%; P = .099), which was verified by multivariable logistic regression analyses with multiple models. Overall mortality was significantly lower in the MFS group compared to the non-MFS group (P = .026, log-rank test), with 1-, 5-, and 10-year cumulative mortality of 4.4% versus 8.7%, 8.1% versus 17.2%, and 20.9% versus 36.4%, respectively. Multivariable Cox regression analyses across different models further confirmed MFS as a significant protective factor for overall mortality (model 1: hazard ratio [HR], 0.31; 95% confidence interval [CI] 0.13-0.73; P = .007; model 2: HR, 0.32, 95% CI, 0.13-0.75; P = .009; model 3: HR, 0.38; 95% CI, 0.15-0.95; P = .039). ConclusionsDespite varying risk profiles, MFS patients undergoing open TAAA repair can achieve comparable or even superior outcomes to non-MFS patients with tailored surgical strategies, meticulous perioperative care, and close follow-up surveillance, especially in the long term.

An Update of Neuroanesthesia for Intraoperative Brain Mapping Craniotomy.

The perioperative multidisciplinary team approach has probably been best exemplified by the care of awake craniotomy patients. Advancement in anesthesia and meticulous perioperative care has supported the safety and complexity of the surgical and mapping efforts in glioma resection. The discussions in this review will emphasize on anesthetic and perioperative management strategies to prevent complications and minimize their effects if they occur, including current practice guidelines in anesthesia, updates on the applications of anesthetic medications, and emerging devices. Planning the anesthetic and perioperative management is based on understanding the pharmacology of the medications, the goals of different stages of the surgery and mapping, and anticipating potential problems.

Analysis of Morbidity, Mortality and Survival Pattern Following Surgery for Borderline Ovarian and Malignant Ovarian Tumour in Tertiary Care Centre.

To analyse the morbidity, mortality and survival pattern following surgery for borderline ovarian and malignant ovarian tumours. The medical records of 57 consecutive patients with invasive and borderline epithelial ovarian cancer patients registered and operated in our tertiary centre between 2015 to 2017 were reviewed. Patients were followed up for a minimum of 18months to maximum of 42months at an interval of 3months with CA125 values. Various prognostic factors were analysed. The data descriptive statistics of frequency and percentage analysis were used for categorical variables and mean and standard deviation were used for continuous variables. The most common age group was 51years and above with the majority (56.2%) of women belonging to postmenopausal age group (32/57). In our study, 30 out of 57 women (52.6%) had stage III disease, 17 women had stage I disease (29.8%) and 7 women had stage 2 disease (12.3%). Majority of the women had serous epithelial ovarian tumour (47 out of 57 patients), which contributed to 82.4%. Grade 1 and 2 morbidity was encountered in 8 patients. Six patients had wound infection (grade 1), and 2 patients required blood transfusions (grade 2). One patient had grade 3 morbidity requiring re-laparotomy. Borderline tumours and early-stage epithelial ovarian tumours had good prognosis, less morbidity and good survival. The overall median survival was 25months. With meticulous perioperative care, surgery for ovarian cancer in the primary and interval setting can be done with minimal morbidity and no postoperative mortality, especially in patients with co-morbidities. Grade is an important prognostic factor affecting the survival of patients with epithelial ovarian cancers undergoing surgery. Lymph node dissection helps achieve local control but may not improve the survival.

The Importance of Meticulous Peri-operative Care in Managing High-Risk Patients Undergoing Bariatric Procedures

The Importance of Meticulous Peri-operative Care in Managing High-Risk Patients Undergoing Bariatric Procedures

Surgical management of neuromuscular scoliosis: approaches, pitfalls and outcomes

Background. Scoliosis is a common problem among neuromuscular disorders with increased incidence of morbidity and mortality. The management of neuromuscular scoliosis (NMS) is complex and requires a cooperative multi-disciplinary team to provide meticulous perioperative care. Conservative treatment, such as bracing, can delay but not replace surgical correction. However, surgery has the risk of higher perioperative complication rates in this patient population.&#x0D; Aim. It is a retrospective study to evaluate clinical outcome, approaches, pitfalls in management of NMS patients undergoing surgical correction.&#x0D; Materials and methods. We retrospectively evaluated patients with NMS who underwent surgery for scoliosis from 2004 to 2018. Sixty-eight patients were included in the study after meticulous preoperative checkup. In most cases an single-pedicle screw construct was used, but in a few others a hybrid construct was used. A follow up was performed to make a clinical and radiological assessment and recorded all measurements and any complications. A telephone questionnaire was used for functional evaluation and patient/parent satisfaction with surgery. Only 52 patients could participate in the questionnaire.&#x0D; Results. The mean follow up period was 43.28 months, and the mean age at the time of surgery was 14.29 years. The mean preoperative Cobbs angle was 71.7, while that of final follow-up was 34.6. The mean Cobbs correction percentage was 53.25%. For correction of fixed pelvic obliquity 15, a sacropelvic extension was done in 60.29% of cases. Complications occurred in 39.71% of operated cases; chest related in 36.11% (of all complications), hardware-related 16.67%, visceral complications (as paralytic ileus) in 13.89%, decubitus ulcer and delayed wound healing in 13.89%, deep wound infection in 8.33%, CNS complications (as status epilepticus) in 8.33%, and death in 2.78% (one case). The results of the questionnaire indicated favorable functional outcomes and patient/family satisfaction with surgery.&#x0D; Conclusion. Despite the perioperative difficulties seen in patients with NMS, patients who had relatively higher postoperative morbidity and mortality, most patients/parents were satisfied with the results of the spinal deformity surgery. The patients/parents would recommend surgery to other patients with similar disorders.

What Is the Best Approach to Prevent Advanced-Stage Pressure Injuries After Pediatric Tracheotomy?

What Is the Best Approach to Prevent Advanced-Stage Pressure Injuries After Pediatric Tracheotomy?

Survival After Uncomplicated EVAR in Octogenarians is Similar to the General Population of Octogenarians Without an Abdominal Aortic Aneurysm

Long term survival after endovascular aortic aneurysm repair (EVAR) in octogenarians remains unclear. This was evaluated by comparing octogenarians after EVAR with a matched group of octogenarians without an abdominal aortic aneurysm (AAA) from the Rotterdam Study (RS). The influence of complications after EVAR on survival was also studied with the aim of identifying risk factors for the development of complications in octogenarians. Using propensity score matching (PSM), 83 EVAR octogenarians were matched for comorbidities with 83 octogenarians from the RS, and survival was compared between these two groups using Cox proportional hazard analysis. Then, complications were studied, defined as cardiac or pulmonary, renal deterioration, access site bleeding, acute limb ischaemia or bowel ischaemia, within 30 days of surgery between 83 EVAR octogenarians and 475 EVAR non-octogenarians. Also, the difference in baseline characteristics between the octogenarians with and without complications after EVAR were studied, and survival was compared between the RS controls and the complicated and uncomplicated EVAR octogenarians separately. The total EVAR octogenarian population did not show an increased mortality risk compared with RS octogenarian controls (hazard ratio [HR] 1.28, 95% confidence interval [CI] 0.84-1.97). Post-operative complications occurred in 22 octogenarians (27%) and 59 non-octogenarians (12.4%, p<.001), mainly cardiac, pulmonary, and bleeding complications. All baseline characteristics were similar in the complicated EVAR octogenarians compared with the uncomplicated EVAR octogenarians. After uncomplicated EVAR, octogenarians had a similar survival compared with the RS controls (HR 1.09, 95% CI 0.68-1.77), but after complicated EVAR their mortality risk increased significantly (HR 1.93, 95% CI 1.06-3.54). After standard EVAR, the life expectancy of octogenarians is the same as that of a matched group from the general population without an AAA, provided they do not develop early post-operative complications. Patient selection and meticulous peri-operative care are key.

Laparoscopic cholecystectomy in patients with liver cirrhosis: 8 years experience in a tertiary center. A retrospective cohort study.

BackgroundWith improved laparoscopic techniques, experience, and availability of newer tools and instruments like ultrasonic shears; laparoscopic cholecystectomy (LC) became a feasible option in cirrhotic patients, the aim of this study was to analyze the outcome of LC in cirrhotic patients. Methods: We retrospectively analyzed 213 cirrhotic patients underwent LC, in the period from 2011 to 2019; the overall male/female ratio was 114/99. Results: The most frequent Child-Turcotte-Pugh (CTP) score was A, The most frequent cause of cirrhosis was hepatitis C virus (HCV), while biliary colic was the most frequent presentation. The harmonic device was used in 39.9% of patients, with a significant correlation between it and lower operative bleeding, lower blood and plasma transfusion rates, higher operative adhesions rates, lower conversion to open surgery and 30-day complication rates, shorter operative time and post-operative hospital stays where operative adhesions and times were independently correlated. The 30-day morbidity and mortality were 22.1% and 2.3% respectively while overall survival was 91.5%, higher CTP, and model for end-stage liver disease (MELD) scores, higher mean international normalization ratio (INR) value, lower mean platelet count, higher operative bleeding, higher blood, and plasma transfusion rates, longer mean operative time and postoperative hospital stays were significantly correlated with all conversion to open surgery, 30-day morbidities and mortalities. Conclusion: LC can be safely performed in cirrhotic patients. However, higher CTP and MELD scores, operative bleeding, more blood and plasma transfusion units, longer operative time, lower platelet count, and higher INR values are predictors of poor outcome that can be improved by proper patient selection and meticulous peri-operative care and by using Harmonic scalpel shears.

Outcomes of Cataract Surgery Following Glaucoma Filtering Surgery at the University College Hospital, Ibadan

Objective: To evaluate the outcomes of cataract surgery following glaucoma filtering surgeries carried out at the University College Hospital, Ibadan. Methods: This study was a retrospective review of the records of patients who had cataract surgery following glaucoma filtering surgery. Outcomes of interest include change in visual acuity with cataract surgery following glaucoma filtering surgery, time from glaucoma filtering surgery to cataract surgery, change in intraocular pressure control with cataract surgery and glaucoma filtering surgery complications. Paired t-test and Chi-squared tests were carried out for differences in means and categorical data respectively. Results: Thirty-one eyes of 27 patients were evaluated. Mean (SD) age was 56.7 years (15.4). Sixteen (59.3%) patients were males. The median time from glaucoma surgery to cataract surgery was 21 months (6-180 months). The number of eyes with visual acuity > 6/18 increased from four (13%) pre-operatively to 19 (61.3%) post-cataract surgery. There was no statistically significant difference (P = 0.295) between mean intraocular pressure before surgery (15 mmHg, SD = 5.5) and at last follow-up visit (16.6 mmHg, SD = 7.4). Conclusion: Outcomes of cataract surgery following glaucoma filtering surgery can be optimized with careful patient selection and meticulous perioperative care.

Age - Does it really count? A study of the Perioperative Morbidity and Long-Term Outcome in Patients Above 70 Years of Age Undergoing Spine surgery for Lumbar Degenerative Disorders.

Objective To assess the long-term outcome and perioperative morbidity in spine surgeries for lumbar degenerative disorders and, thereby, to evaluate the safety of surgery in the aging population. Methods Retrospective study of patients aged > 70 years, operated for degenerative lumbar disorders between 2011 and 2015. We evaluated patient demographic, clinical and surgical data; comorbidities, perioperative complications, pre & postoperative pain scores and Oswestry disability index (ODI) scores, patient satisfaction and overall mortality. Results A total of 103 patients (Males: Females55:48) with mean age 74.6 years (70–85yrs) were studied. 60 patients (58.2%) had decompression alone, while 43 (41.8%) had decompression & fusion. Mean hospital stay was 5.7days. Mean follow-up was 47.6months (24–73mnths). Patients reported significant improvement in backpain (Numerical pain score 7.7 vs 1.6; p < 0.001), leg pain (Numerical pain score 7.4 vs 1.7; p < 0.001), disability (ODI 82.3 vs 19.1; p < 0.001) and walking distance ( p < 0.001). 76% patients were satisfied with the results at the time of final follow-up. 26 patients (25.24%) had perioperative complications which were all minor, without mortality. Most common intraoperative & postoperative complications were dural tear (6.79%) & urinary tract infection (6.79%) respectively. Conclusions With meticulous perioperative care lumbar spine surgery is safe and effective in elderly population. Patients had longer mean hospital stay in view of the gradual and comprehensive rehabilitation program. Presence of comorbidities or minor perioperative complications did not increase the overall morbidity or affect the clinical outcomes of surgery in our study.

Survival After EVAR in Octogenarians is Similar to the General Population of Octogenarians Without an Abdominal Aortic Aneurysm

Introduction: Long-term survival after endovascular aortic aneurysm repair (EVAR) in octogenarians remains unclear. We evaluated this by comparing octogenarians after EVAR with a matched group of octogenarians without an abdominal aortic aneurysm (AAA) from the Rotterdam Study (RS). We also studied the influence of complications after EVAR on survival and aimed to identify risk factors for the development of complications in octogenarians. Methods: Using propensity score matching (PSM), we matched 83 EVAR octogenarians on comorbidities with 83 octogenarians from the RS and compared survival between these two groups using Cox proportional hazard analysis. Then, we studied complications, defined as cardiac or pulmonary, renal deterioration, access site bleeding, acute limb ischemia or bowel ischemia, within 30 days of surgery between 83 EVAR octogenarians and 475 EVAR nonoctogenarians. Also, we studied the difference in baseline characteristics between the octogenarians with and without complications after EVAR and compared survival between the RS controls and the complicated and uncomplicated EVAR octogenarians separately. Results: The total EVAR octogenarian population did not show an increased mortality risk compared to RS octogenarian controls (hazard ratio (HR) 1.18, 95% confidence interval (CI): 0.78- 1.78). Postoperative complications occurred in 23 octogenarians (27.7%) and 59 nonoctogenarians (12.5%, p < 0.0001), mainly due to the occurrence of cardiac (15.7% versus 4.9%, p< 0.0001), pulmonary (4.8% versus 1.3%, p=0.03) and bleeding (6.0% versus 1.9%, p=0.03) complications. Peripheral artery disease (PAD) was the only baseline characteristic that was significantly more prevalent in the complicated EVAR octogenarians compared to the uncomplicated EVAR octogenarians (26.1% versus 8.5%, p=0.04). After uncomplicated EVAR, octogenarians had a similar survival compared to the RS controls (HR 0.99, 95% CI: 0.62-1.58), but after complicated EVAR their mortality risk increased significantly (HR 1.86, 95% CI: 1.02- 3.39). Conclusion: After standard EVAR, the life expectancy of octogenarians equals that of a matched group from the general population without an AAA, provided that they do not develop early postoperative complications. Patient selection and meticulous peri-operative care is key. Disclosure: Nothing to disclose

Bisoprolol transdermal patch for perioperative care of non-cardiac surgery in patients with hypertrophic obstructive cardiomyopathy

BackgroundNon-cardiac surgery for hypertrophic obstructive cardiomyopathy (HOCM) is considered to require meticulous perioperative care. β-blockers are considered the first-line drugs for patients with HOCM, and they play a key role in preventing cardiovascular complications in perioperative care. The bisoprolol transdermal patch has recently become available in Japan, and it is useful for patients who are unable to take oral medication during perioperative care. The aim of this case series was to assess the hemodynamic features of patients with HOCM who used the bisoprolol transdermal patch during perioperative care for non-cardiac surgery.MethodsBetween August 2016 and August 2018, we retrospectively analyzed 10 consecutive cases of HOCM with the patients using the bisoprolol transdermal patch during perioperative care. Hemodynamic and echocardiographic features were evaluated before and after patients were switched from oral bisoprolol to transdermal patch therapy or started transdermal patch therapy as a new β-blocker medication. In addition, cardiovascular complications (all-cause death, cardiac death, heart failure, ventricular tachycardia, and ventricular fibrillation) during the perioperative period were evaluated.ResultsThere was no significant change in the patients’ heart rate, blood pressure, ejection fraction, and pressure gradient in the left ventricle after switching from oral bisoprolol to the transdermal patch therapy. On the other hand, patients who started using the bisoprolol transdermal patch as a new ß-blocker medication tended to have a decreased heart rate and pressure gradient thereafter, but there was no significant difference in blood pressure or ejection fraction. No cardiovascular complications occurred during the perioperative period.ConclusionsWe described the utilization of the bisoprolol transdermal patch during perioperative care for non-cardiac surgery in patients with HOCM. We determined that the hemodynamic features of these patients did not change significantly after switching to patch therapy. Further, initiation of the bisoprolol transdermal patch as a new ß-blocker medication sufficiently tended to decrease the pressure gradient. This unique approach can be an alternate treatment option for HOCM.Trial registrationThe registry was registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN000036703). The date of registration was 10/5/2019 and it was “Retrospectively registered”.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P22. Single-center, matched-pair comparative study of spine surgery in patients with solid organ transplantation: short- and long-term clinical outcomes

BACKGROUND CONTEXT Solid organ transplant is the mainstay of treatment for a wide variety of several end-stage organ diseases. The number of patients who will benefit from it is expected to increase due to improvement in distribution system for organs from donors, the discovery of novel immunosuppressive treatment/regimens, and better per- and post-operative management of these patients in general. Hence, an increasing number of these patients are becoming reasonable candidates for subsequent, elective surgeries such as spine surgery. Even though these patients are considered to be a high-risk group for surgery generally, clinical outcomes of spine surgery in patients with solid organ transplantation are not well-documented in the current literature partly due to its substantially rare incidence. Furthermore, prolonged use of steroids as well as immunosuppressant such as cyclosporine is associated with a decrease in bone mineral density. Thus, these outcome data might be of particular importance to consider surgical options for this high-risk cohort and inform them of specific risks and complications associated with spinal surgery after organ transplantation. PURPOSE Summarize clinical outcomes of spine surgery in solid organ recipients, such as readmission rate, infectious complications, and mortality, to facilitate clinical decision-making processes for this specific cohort. STUDY DESIGN/SETTING Retrospective, single-center, propensity-matched cohort. PATIENT SAMPLE Patients who underwent spine surgery at a single institution with previous history of solid organ transplantation were included and compared with a matched-cohort without solid organ transplantation. OUTCOME MEASURES Thirty-day readmission rate, 90-day medical complication rate, one-year infectious complication rate, one-year mortality, and functional outcomes such as ambulatory status, which was rated on a four-point scale (4, independently ambulatory; 3, requiring a cane; 2, requiring a walker; and 1, wheelchair bound). METHODS Single-center, retrospective data review from 2010 to 2016 yielded a total of 4,968 patients who underwent spine surgery. Amongst those, 28 patients had a previous history of solid organ transplantation. Patients from the database were propensity-matched for age, sex, body mass index (BMI), smoking status, diagnoses, procedures, co-morbidities other than diseases which had prompted organ transplantation at 1:2 ratio, which yielded 56 matched-patients. Clinical outcomes of (A) 28 patients with organ transplantation and (B) 56 matched-patients were compared and statistically analyzed. Intergroup comparison of binary variables was performed via Fisher's exact test. Intergroup comparison of continuous variables was achieved using unpaired t-tests. All reported p values are 2-sided and p values RESULTS Baseline characteristics including age, sex, BMI, smoking, diagnoses, procedures, and co-morbidities (ASA scale) were similar between the two groups with no statistically significant difference, which validated our matching methods. There were no statistically significant intergroup differences in operative data such as operative time, estimated blood loss, operated levels, and use of bone morphogenetic protein-2. In terms of functional outcomes, postoperative improvement in ambulatory status was comparable between the two groups (A) 16.7% vs. (B) 18.1%, p>.99). However, the organ-recipient group resulted in longer hospital stays (A) 7.2days vs. (B) 4.3days, p CONCLUSIONS Spinal surgery after solid organ transplantation resulted in substantially increased complication rates when compared with the matched-control group, while other variables such as baseline characteristics, operative data, and functional outcomes were similar between the two groups. Careful patient selection, meticulous perioperative care, and thorough informed consent of potential complications would be imperative when performing spine surgery on this cohort.

Paediatric liver transplantation: an overview

Abstract The only definitive treatment for end stage liver disease is transplantation. This has been made possible by advances in vascular surgery and immunosuppression. In the paediatric population, liver transplantation is most commonly performed for liver failure secondary to biliary atresia. Successful transplantation depends on patient preparation by a dedicated multidisciplinary team and meticulous peri-operative care. Improvements in timing of transplantation, immunosuppression advances and peri-operative intensive care have all contributed to improvements in patient survival. Currently the survival rates for children undergoing deceased donor liver transplant in the UK is 95.7% at 1 year and 91.8% at 5 years. These outcomes are reliant on multi-disciplinary care, which is best provided in centres that provide the expertise in each of the specialist fields required to care for these children. This article provides an overview of the entire process. It describes the selection process, the surgery undertaken and early and late post-operative complications.

Single-Stage Combined Craniofacial Repair for Frontoethmoidal Meningoencephalocele.

Frontoethmoidal meningoencephalocele (FMEC) is a rare congenital anomaly characterized by herniation of brain tissue and meninges through a defect in the cranium and associated with facial dysmorphism. Treatment modalities include extra cranial, transcranial, or combined craniofacial approaches. The combined approach is considered the best treatment choice. Twelve patients with FMEC aging from 6 months to 4 years were treated by single-stage combined craniofacial approach between July 2011 and July 2015. They were followed up for evaluation of outcome and detection of complications. Seven patients (58.3%) were males and 5 patients (41.7%) were females. Eight patients (66.7%) were less than 2 years while 4 patients (33.3%) were between 2 and 4 years. The main presentations were external mass, telecanthus and hypertelorbitism, radiologically, frontobasal bone defect and herniated dural sac with brain tissue were detected in all patients. Excision of the mass with dural repair, craniofacial reconstruction, and medial canthopexy were done for all patients. Orbital translocation was done for 8 patients (75%), nasal reconstruction for 7 patients (58.3%), while dacryocystorhinostomy in 3 patients (25%). Venticuloperitoneal shunt was done before correction of FMEC in one patient (8.3%). The follow-up period ranged from 6 to 48 months with mean 29.2 months. The esthetic results were satisfactory in 9 patients (75%). Ugly facial scars were recorded in 3 patients (25%). Early surgical management for FMEC is advisable to avoid deleterious effects on facial growth. Meticulous perioperative care is important for successful surgery. The authors recommend combined craniofacial approach to achieve good outcome and decrease the incidence of complications.

P1.08-068 Salvage Surgical Resection after Curative-Intent Concurrent Chemoradiothrapy for N2-Stage III Lung Cancer

A concurrent chemoradiotherapy (CRT) is thought to be the curative treatment for N2 Stage IIIA locally advanced lung cancer (LALC). However, after the CRT the cancer sometimes remained the treatment field. The radical pulmonary resection of residual cancer after CRT is one of the options for the treatment. We retrospectively evaluated 20 patients who received curative-intent CRT and radical surgical resection for LALC from January 2003 to April 2016. The initial treatment for LALC consisted of platinum based 2-drugs with concurrent curative thoracic radiotherapy (60Gy.). The mean age at the surgery was 62.8 years (range 46∼ 80 years), two women and 18 men. The mean interval from CRT to the surgery was 25 months (range 3-96 months). All patients except two cases underwent complete surgical resection with mediastinal nodal dissection including lobectomy in 15 cases, lobectomy with bronchoplasty in 2 cases, pneumonectomy in 2 cases and 1 wedge resection. The bronchial stump was covered with pericardial fat tissue or intercostal muscle. Histological type was adenocarcinoma in 11 cases, squamous carcinoma in 6 cases, large-cell-carcinoma in 2 cases, and combined cell type small-cell carcinoma in one case. The mean operation time was 320 minutes (range 163-649 minutes), and mean blood loss was 868g (range 90-6000g). There was no operative mortality and 8 cases post-operative morbidity such as arrhythmia in 4 cases, atelectasis in 2 cases, pneumonia, ileus and heart failure in each. There was no broncho-pleural fistula or bronchial dehiscence. The 3 and 5 years survival after surgical resection was 70% and 60 % with 43 months median follow-up period. The radical pulmonary resection after curative-intent concurrent chemoradiotherapy is feasible with careful patient selection, operative procedure and meticulous perioperative care.

The effect of periorbital cooling on pain, edema and ecchymosis after rhinoplasty: a randomized, controlled, observer-blinded study

Success and satisfactory results in rhinoplasty are established not only with flawless surgery but also with meticulous perioperative care. Pain stays at the centre of these circumstances. Besides, several contributing perioperative factors such as periorbital edema and ecchymosis play key role on the patients' comfort. Septorhinoplasty was carried out in 50 patients between February and May 2014 under general anesthesia. Local anesthesia with lidocaine and adrenaline combination was done prior to incision. Following the procedure, silicone gel packs were applied. One periorbital region was cooled after surgery whereas the opposite site was left uncooled. Periorbital edema-ecchmosis and pain intensity were graded and noted 1 hour, 1 day, 3 days, 1 week and 1 month after surgery. Cold application seriously reduced postoperative edema and ecchymosis at the first week (p=0.001 for the first 3 days and p=0.006 at first week). Pain was reduced with cooling not on the first hour (p&gt;0.05), but on the forthcoming days throughout the first week (p<0.005). Operation time revealed that primary cases were carried out quicker than revisional surgery. Moreover, pain scores were found lower in primary cases than revisions, especially in the first 3 days. These finding were approved statistically. Cooling of the periorbital region reduces edema and ecchymosis as well as pain; however 3 days of use is enough after rhinoplasty. One hour after surgery, cooling does not affect the pain but reduce edema and ecchymosis.

The effect of periorbital cooling on pain, edema and ecchymosis after rhinoplasty: a randomized, controlled, observer-blinded study.

Success and satisfactory results in rhinoplasty are established not only with flawless surgery but also with meticulous perioperative care. Pain stays at the centre of these circumstances. Besides, several contributing perioperative factors such as periorbital edema and ecchymosis play key role on the patients' comfort. Septorhinoplasty was carried out in 50 patients between February and May 2014 under general anesthesia. Local anesthesia with lidocaine and adrenaline combination was done prior to incision. Following the procedure, silicone gel packs were applied. One periorbital region was cooled after surgery whereas the opposite site was left uncooled. Periorbital edema-ecchmosis and pain intensity were graded and noted 1 hour, 1 day, 3 days, 1 week and 1 month after surgery. Cold application seriously reduced postoperative edema and ecchymosis at the first week (p=0.001 for the first 3 days and p=0.006 at first week). Pain was reduced with cooling not on the first hour (p&gt;0.05), but on the forthcoming days throughout the first week (p<0.005). Operation time revealed that primary cases were carried out quicker than revisional surgery. Moreover, pain scores were found lower in primary cases than revisions, especially in the first 3 days. These finding were approved statistically. Cooling of the periorbital region reduces edema and ecchymosis as well as pain; however 3 days of use is enough after rhinoplasty. One hour after surgery, cooling does not affect the pain but reduce edema and ecchymosis.