Minor Complication Rate Research Articles

Use of computer-assisted hexapod external fixators for complex foot and ankle reconstructions – An analysis of functional outcomes and complications

IntroductionFoot and ankle pathology can often require complex surgical reconstruction. Until recently, circular external fixators such as the Ilizarov frame have proven to be useful, yet they fall short when progressive, precise corrections are required. Computer-assisted hexapod external fixators seek to address many of the shortfalls of traditional circular fixators. However, evidence for their use is scarce. The objective of this work was to evaluate the functional and quality of life outcomes and post-operative complications of patients treated with computer-assisted hexapod external fixation. MethodsA retrospective, observational study was conducted. All cases were treated with either a TrueLok hex (TL-HEX) or a Taylor Spatial Frame (TSF) fixator. Primary outcomes were post-operative improvement in 12-Item Short Form Survey (SF12) and American Orthopaedic Foot and Ankle Score (AOFAS) scores, and complications following Paley’s classification. ResultsA total of 59 patients with complex foot and ankle conditions using 64 external fixation frames were included. The median sum of both SF12 score domains improved from a preoperative score of 63.6 to 91.3 at last follow-up (p < 0.001). Median AOFAS improved from a preoperative score of 35 to 75.5 at last follow up (p < 0.001). Functional improvement was not affected by the choice of external fixator. Complications occurred in 49 cases (77 %). The most common post-operative complications included pin tract complications in 37 (58 %) cases, joint rigidity in 24 (38 %) and axial deviation in 9 (14 %). ConclusionsComputer-assisted hexapod external fixation is an effective technique to correct complex foot and ankle deformities and leads to a marked improvement in post-operative functional and quality-of-life outcomes with a high minor complication rate.

Trans-catheter procedures in the management of renal artery aneurysm

Background The endovascular approach has emerged as the preferred method for managing renal artery aneurysms (RAAs), particularly in cases with intricate anatomical features, as a viable alternative to surgical intervention. Aim The objective of this research was to assess the significance of trans-catheter operations in the treatment of RAAs, with a particular focus on the management of symptoms. Patients and methods This prospective minimally invasive was carried out on 30 patients with RAA aged from 6 to 67 years old, diagnosed by various radiological modalities (ultrasonography, computed tomography, or MRI) and underwent 30 arteriographies for RAA who were managed by Trans-catheter procedures (especially selective embolization with coils). All patients undergo follow-up by clinical assessment, medical imaging, and laboratory investigations. Results Out of the total 28 RAAs that were treated, a significant majority of 93.3% were effectively embolized and showed no symptoms of recurrence during the subsequent follow-up period. One case (3.3%) of RAA did not achieve effective embolization, resulting in failed embolization. Additionally, another case (3.3%) of RAA had recurrence during follow-up despite initial successful closure. Minor issues occurred in seven instances, accounting for 23.3% of the total occurrences, while significant complications were observed in only one instance, representing 3.3% of the total occurrences. Conclusions The endovascular approach is a very safe and successful method for managing RAAs, whether in planned or emergent medical scenarios. This approach preserves renal function and minimizes invasiveness, while also demonstrating low rates of both severe and minor complications.

National Trends in Inpatient Hospital Outcomes of Children with Osteogenesis Imperfecta and the Importance of Extraskeletal Manifestations: A Kids’ Inpatient Database Study

ObjectiveTo investigate the extent of extra-skeletal manifestations along with inpatient outcomes and complications associated with osteogenesis imperfecta (OI). Study designThis cross-sectional study utilized the Kids’ Inpatient Database (KID) as part of the Healthcare Cost and Utilization Project (HCUP) to investigate inpatient hospital outcomes and management in patients with OI from 1997 through 2016. Data regarding hospital characteristics, cost of treatment, inpatient outcomes, and procedures were collected and analyzed. ResultsThere were 7,291 admissions that listed OI as a diagnosis in the KID database from 1997 through 2016. Unexpectedly, over one third of all admissions in these children with OI presented with an extra-skeletal manifestation. The rate of major complications was 3.85%. The rate of minor complications was 19.4%, most commonly respiratory problems. Mortality rate was 18.2 % in the neonatal period and 1.0% in all other admissions. Total charges of hospital stay increased over the years. ConclusionWe identified a striking prevalence of extra-skeletal manifestations in OI along with inpatient outcomes and complications associated with OI, of which respiratory complications were predominant. We observed a significant financial burden for patients with OI and identified additional risks for financial crisis, in addition to disparities in care identified among socioeconomic groups. These data contribute to a more holistic understanding of OI from diagnosis to management.

Optimizing Morbidity in Unplanned Soft Tissue Sarcoma Excisions: Should We Skip the Reconstructive Ladder?

Soft tissue sarcomas (STSs) are rare and diverse primary malignant tumors that comprise approximately 1% of all malignancies. Misdiagnoses and unplanned excisions of STSs are common due to the tumor's rarity, leading to secondary tumor bed excisions (TBEs). Reconstructive outcomes for TBEs remain poorly understood, prompting this study to address the knowledge gap and inform preoperative discussions. This was a retrospective cohort study of patients who underwent STS excisions at a quaternary cancer center. Patients were categorized into mass excision (ME) and TBE groups. Reconstructive approaches were divided into simple (primary closure, complex repair, skin grafts, local flaps) and advanced (pedicled or free flaps). The groups were compared for postoperative outcomes, including complications, recurrence, and death. When simple reconstructive techniques were used, TBEs exhibited higher rates of overall and major complications, whereas MEs had higher rates of overall and minor complications. Intergroup analysis revealed that with simple reconstruction, rates of overall and major complications were higher in TBEs than in MEs, and rates of minor complications were higher in MEs than in TBEs. Regression analyses revealed that simple reconstruction of TBEs had 90% and 180% higher odds of major complications and reoperation compared to simple reconstruction of MEs (P < 0.05). TBEs, despite their smaller size, exhibited a heightened susceptibility to overall and major complications, challenging the notion that simpler techniques suffice in these cases. Our findings encourage the consideration of advanced reconstructive techniques for TBEs that may seem amenable to simple reconstructive techniques.

Left ventricular unloading via percutaneous assist device during extracorporeal membrane oxygenation in acute myocardial infarction and cardiac arrest.

A feared complication of an acute myocardial infarction (AMI) is cardiac arrest (CA). Even if return of spontaneous circulation is achieved, cardiogenic shock (CS) is common. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) supports patients with CS and is often used in conjunction with an Impella device (2.5 and CP) to off-load the left ventricle, although limited evidence supports this approach. The goal of this study was to determine whether a mortality difference was observed in VA-ECMO alone versus VA-ECMO with Impella (ECPELLA) in patients with CS from AMI and CA. A retrospective chart review of 50 patients with AMI-CS and CA and were supported with VA-ECMO (n = 34) or ECPELLA (n = 16) was performed. The primary outcome was all-cause mortality at 6-months from VA-ECMO or Impella implantation. Secondary outcomes included in-hospital mortality and complication rates between both cohorts and intensive care unit data. Baseline characteristics were similar, except patients with ST-elevation myocardial infarction were more likely to be in the VA-ECMO group (p = 0.044). The ECPELLA cohort had significantly worse survival after VA-ECMO (SAVE) score (p = 0.032). Six-month all-cause mortality was not significantly different between the cohorts, even when adjusting for SAVE score. Secondary outcomes were notable for an increased rate of minor complications without an increased rate of major complications in the ECPELLA group. Randomized trials are needed to determine if a mortality difference exists between VA-ECMO and ECPELLA platforms in patients with AMI complicated by CA and CS.

Utilization and Surgical Outcomes of Sentinel Lymph Node Biopsy for Endometrial Intraepithelial Neoplasia.

To describe the rate and surgical outcomes of sentinel lymph node (SLN) biopsy in patients with endometrial intraepithelial neoplasia (EIN). We conducted a cohort study that used the prospective American College of Surgeons National Surgical Quality Improvement Program database. Women with EIN on postoperative pathology who underwent minimally invasive hysterectomy from 2012 to 2020 were included. The cohort was dichotomized based on the performance of SLN biopsy. Patients' characteristics, perioperative morbidity, and mortality were compared between patients who underwent SLN biopsy and those who did not. Postoperative complications were defined using the Clavien-Dindo classification system. Overall, 4,447 patients were included; of those, 586 (13.2%) underwent SLN biopsy. The proportion of SLN biopsy has increased steadily from 0.6% in 2012 to 26.1% in 2020 ( P <.001), with a rate of 16% increase per year. In a multivariable regression that included age, body mass index (BMI), and year of surgery, a more recent year of surgery was independently associated with an increased adjusted odds ratio of undergoing SLN biopsy (1.51, 95% CI, 1.43-1.59). The mean total operative time was longer in the SLN biopsy group (139.50±50.34 minutes vs 131.64±55.95 minutes, P =.001). The rate of any complication was 5.9% compared with 6.7%, the rate of major complications was 2.3% compared with 2.4%, and the rate of minor complications was 4.1% compared with 4.9% for no SLN biopsy and SLN biopsy, respectively. In a single complications analysis, the rate of venous thromboembolism was higher in the SLN biopsy group (four [0.7%] vs four [0.1%], P =.013). In a multivariable regression analysis adjusted for age, BMI, American Society of Anesthesiologists classification, uterus weight, and preoperative hematocrit, the performance of SLN biopsy was not associated with any complications, major complications, or minor complications. The performance of SLN biopsy in EIN is increasing. Sentinel lymph node biopsy for EIN is associated with an increased risk of venous thromboembolism and a negligible increased surgical time.

Low Hartmann’s procedure versus abdominoperineal resection for rectal cancer, a propensity score matching cohort study

BackgroundThis study aimed to compare low Hartmann’s procedure (LHP) with abdominoperineal resection (APR) for rectal cancer (RC) regarding postoperative complications.MethodRC patients receiving radical LHP or APR from 2015 to 2019 in our center were retrospectively enrolled. Patients’ demographic and surgical information was collected and analyzed. Propensity score matching (PSM) was used to balance the baseline information. The primary outcome was the incidence of major complications. All the statistical analysis was performed by SPSS 22.0 and R.Results342 individuals were primarily included and 134 remained after PSM with a 1:2 ratio (50 in LHP and 84 in APR). Patients in the LHP group were associated with higher tumor height (P < 0.001). No significant difference was observed between the two groups for the incidence of major complications (6.0% vs. 1.2%, P = 0.290), and severe pelvic abscess (2% vs. 0%, P = 0.373). However, the occurrence rate of minor complications was significantly higher in the LHP group (52% vs. 21.4%, P < 0.001), and the difference mainly lay in abdominal wound infection (10% vs. 0%, P = 0.006) and bowel obstruction (16% vs. 4.8%, P = 0.028). LHP was not the independent risk factor of pelvic abscess in the multivariate analysis.ConclusionOur data demonstrated a comparable incidence of major complications between LHP and APR. LHP was still a reliable alternative in selected RC patients when primary anastomosis was not recommended.

Surgical Correction of Abdomen Irregularities after Liposuction: Case Series.

The occurrence of surface irregularities in the abdomen after liposuction is frequent and can be due to the fact that more liposuctions are being done nowadays, and perhaps, the fact that more noncore surgeons are doing it could be an important factor. These superficial changes compromise the aesthetic results of surgery, and their correction is a major technical challenge. The author presents a systematized approach for surgical treatment of fibrosis and post liposuction irregularities. Twenty-three patients underwent liposuction and abdominoplasty or mini abdominoplasty by a single surgeon (G.B.B.) over a period of 24 months to correct superficial abdominal wall irregularities after previous liposuction. All patients underwent evaluation through digital photography by two independent senior plastic surgeons according to an objective aesthetic outcome scale, 12 months after the operation. All 23 patients showed an improvement in the appearance of the abdominal wall according to the aesthetic outcome scale used. Eighty-seven percent of the patients operated on in this series had previously undergone liposuction using technologies and 4.3% underwent liposuction alone. The overall minor complication rate was 26%. No major complications were noted. The combination of liposuction, direct fibrosis removal, and flap tensioning (abdominoplasty or mini abdominoplasty) could correct in this series the multiple factors (fibrosis, skin laxity, residual fat deposits post liposuction) related to abdominal wall surface irregularities in a safe, effective, and reproducible manner.

Does The Lengthening Frequency Affect The Outcome of Distraction Osteogenesis? Comparing Two Times a Day with Four Times a Day Lengthening Protocol

Objective: Distraction osteogenesis (DO) is a well-known technique. The traditional method utilized the lengthening frequency of four times a day (QID). Many mechanical factors may affect the DO outcome. However, the effect of distraction frequency has not been proven clinically. Therefore, we aim to investigate whether the BID and QID lengthening frequency affect the healing index and complications of the DO. Materials and Methods: We retrospectively reviewed patients who had undergone DO from 2010 – 2021. The patient was divided into BID and QID groups. Demographics, lengthening outcomes, and complications between the two groups were compared. We used the inverse probability of treatment weighting (IPTW) to determine the effect of treatment. Results: The median healing index (HI) of the patients whose lengthening was done QID is 41.36 (IQR 32.72 - 67.68) days/cm, and BID is 49.12 (IQR 35.28 - 62.54) days/cm, which did not differ significantly. The Odds ratio of achieving HI &lt; 45 days/cm for patients receiving QID lengthening compare to BID is 1.12 (95% CI 0.31-3.99, p = 0.862 ). The IPTW did not show a difference in average treatment effects between QID and BID lengthening. The rates of minor and major complications were not significantly different between the two groups (26.1% in QID group and 32.1% in BID group). Conclusion: The frequency of QID and BID lengthening results in comparable HI and complications for patients who undergo DO. However, prospective research is needed to evaluate the effect of frequency differences in a clinical setting.

Clinical efficacy of mini-percutaneous nephrolithotomy versus retrograde intrarenal surgery for the management of upper urinary tract calculus (1–2.5 cm) in children ≤10 years of age

With improvements in endoscopic surgery, open surgical procedures for urinary system stones have cleared the path for the use of less invasive treatment modalities in patients with pediatric kidney stone disease. Extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), and retrograde intrarenal surgery (RIRS) are among the treatment options available. To prospectively evaluate the outcomes of mini-percutaneous nephrolithotomy and retrograde intrarenal surgery (RIRS) for children ≤10 years of age with upper urinary tract calculus (1-2.5cm). Sixty pediatric patients with single or multiple renal stones (1-2.5cm in diameter) were collected prospectively and equally divided into two groups to undergo RIRS or mini-PCNL. The operative and postoperative outcomes of both groups were analyzed. The groups' mean ages and genders were comparable. The mean stone size for the RIRS group was 1.86cm and 1.69cm for the PCNL group (P=0.449). The PCNL group had statistically longer mean fluoroscopy and hospitalization times. The stone-free rates (SFRs) after a single procedure were 27 (90%) in the PCNL group and 25 (83.33%) in the RIRS group (P=0.706). The UAS was placed in 13 (43.33%) patients in the RIRS group. In the RIRS group, 14 (46.67%) children required preoperative DJ stent application to passively dilate the ureteric orifice. As regard post DJ stenting, 13 (46%) cases applied DJ in the mini PCNL group. major complications were observed in either group. Minor complication (Clavien 1-3) rates were 16.66% and 13.33% for the PCNL and RIRS groups, respectively. There were no differences found between the RIRS and mini-PCNL groups regarding operative time. The mean cost of RIRS was $703.96 and $537.03 for the mini-PCNL. According to the results of this study, mini-PCNL and RIRS are effective procedures for treating renal stones in children up to 2.5cm with comparable success and complication rates. Hospital stay, radiation exposure, and fluoroscopy time are significantly lower in RIRS than in the mini PCNL technique. Although RIRS is effective, a major disadvantage is the greater requirement for JJ stent insertion either before or after the procedure and the consequent need for a second procedure for removal.

Left atrial appendage closure in patients with atrial fibrillation and haemodialysis: outcomes from an international, multicentric registry

Abstract Background Atrial fibrillation (AF) patients receiving haemodialysis (HD) face increased bleeding risks, so the net benefit of stroke prophylaxis by oral anticoagulation (OAC) is ill defined. Left atrial appendage closure (LAAC) might serve as a suitable alternative to OAC for stroke prevention in this high-risk cohort. Objective To determine the safety and clinical efficacy of LAAC in HD patients with AF. Methods In an international multi-center (n=9) registry, the clinical details were compiled from all HD+AF patients who underwent LAAC. Results The cohort included 147 patients: age 72.6 ± 10.4 yrs, 73% male, CHA2DS2-VASc 4.5 ± 1.5, HAS-BLED 4.7 ± 1.2, prior stroke/TIA 22,5%, prior major bleed 57,8%. The pre-LAAC anticoagulation regimen was heterogeneous with a wide array of at least 12 different combinations of medications utilized. A total of 149 procedures were performed and LAAC was successful in 98% (146 of 149), with a median procedure time of 43 (30-66) minutes. The most common device was Watchman (61%), followed by Amulet (23,3%). The rate of major complications was 5,4% (8), same as the rate of minor complications (5,4%), leading to an overall complication rate of 10,7% (16/149) including one fatal bleed the day after implantation, 4 (2.7%) cardiac tamponades of which 3 were treated with pericardiocentesis and one surgery, and 2 device dislodgements requiring percutaneous retrieval followed by successful reimplantation. Most patients were discharged on DAPT (61,6%). At a median of 61 days follow-up, imaging was performed in 83% of patients, revealing: only 2 (1.7%) peri-device leaks ≥5 mm, and no DRT. Subsequently, anticoagulation was shifted to SAPT so that SAPT emerged as the predominant anticoagulation regimen representing 165,9 patient years (py) of usage followed by DAPT (41,8 py). Over the follow-up of 222,9 py, the incidence of ischemic stroke was 0,9% per year (2 strokes in total), reflecting an 88% relative risk reduction (p&amp;lt;0,001) compared with the calculated stroke rate of 7,4% for patients with a similar CHA2DS2VASc score and no anticoagulation. Similarly, the rate of major bleeding events (defined as BARC score ≥3) was 4,5% per year, signifying a 55% relative risk reduction (p=0,023) compared to the expected rate of patients on VKA therapy, based on a comparable HAS-BLED score. Event tough time on SAPT was nearly four times longer than on DAPT, the number of major bleeding events was similar (SAPT: 5; DAPT: 4). Conclusion In light of these findings LAAO emerges as a promising solution for this unique patient cohort. By mitigating the risks of both bleeding complications associated with anticoagulation and the threat of stroke in the absence of anticoagulation, LAAO represents a well-balanced and effective therapeutic strategy for these individuals. However, the procedural complication rate was elevated compared to that observed in other LAAC cohorts, and requires further study.

Comparative Analysis of Transpedal and Transfemoral Access During Genicular Artery Embolization for Knee Osteoarthritis.

This retrospective study aimed to compare the efficacy and safety of transpedal access (TPA) with transfemoral access (TFA) in Genicular Artery Embolization (GAE). 60 patients who underwent GAE between January and June 2023, were recruited and outcomes were compared between the TFA (n = 37) and TPA (n = 23) groups. Technical and clinical success rates, complications, and patient-reported outcomes were assessed. All patients attained a 100% technical success rate, which was defined as the successful selective catheterization and embolization of at least one feeding artery to the knee joint, without encountering any major complications. Minor complications, observed in 12/60 patients (20%), were predominantly manifested as a transient skin discoloration. The TPA group had a comparatively higher (p = 0.008) rate of minor complication than the TFA group. Notably, TPA was associated with a longer duration of the procedure (p = 0.013), duration of fluoroscopy (p = 0.004), increased total air kerma (p = 0.037), dose-area product values (p = 0.021), and a greater incidence of vasospasm (p = 0.018) than TFA. However, TPA patients reported shorter recovery times and less post-procedural discomfort, especially reduced back pain due to postinterventional bedrest (p < 0.001). At the 3-month follow-up, the clinical success rate was similar between the two groups (p = 0.905). TFA is the safer and faster method for GAE, offering fewer complications and reduced radiation exposure. For patients with challenging groin anatomies, however, TPA may provide a valuable alternative.

Ultrasound-guided venipuncture of femoral veins vs standard palpation approach in patients undergoing pulmonary veins isolation

Abstract Introduction Complications related to vascular access frequently arise during transcatheter atrial fibrillation (AF) ablation. Vascular access related complications remain the main cause of procedure related adverse events. In the literature, there is no clear evidence supporting the benefit of ultrasound-guided (USG) vascular access. Purpose We hypothesized that USG venipuncture could reduce vascular complication rates and reduce the need for additional interventions due to complications related to vascular access. Methods We conducted a single-center retrospective study. The primary endpoint was the rate of major complications, defined as arteriovenous fistula, pseudoaneurysm, and groin hematoma with Bleeding Academic Research Consortium (BARC) classification ≥ 2 requiring interventions such as transfusions or surgical/percutaneous repair and/or resulting in hospital prolongation or readmission). The secondary endpoints were the rate of minor complications, defined as groin hematoma with BARC classification = 1 or bleeding without sequelae, and the composite rate of additional non-scheduled exams and procedures due to vascular complications. The study included all patients who underwent atrial fibrillation ablation with radiofrequency (RF) between January 2020 and December 2022 in our center, performed by two expert operators: one utilizing a classic palpation (BLIND) approach and the second one employing the USG approach. Identical materials were used for access in both groups, and the choice of protamine administration or closure method was decided by the operator on a case by case basis. In total, there were 946 patients, 352 in USG group and 594 in BLIND group. For patients in both groups who were on vitamin K antagonists (VKAs), uninterrupted administration with an international normalized ratio (INR) ratio between 2.0 and 3.0 was required. Results Major complications were significantly reduced in the USG group compared to the BLIND group (0 (0%) in USG vs. 9 (1.5%) in BLIND, P = 0.02). No significant difference was observed in minor complications between the two groups (3 (0.8%) in USG vs. 6 (1.0%) in BLIND, P = 0.809). During hospitalization or readmission, 3 additional non-scheduled exams/procedures were required (3 vascular echos) in the USG group, while 33 were needed in the BLIND group (23 vascular echos, 6 thrombin injections, 2 surgical procedures and 2 CT-Angio) with a significative reduction (P 0.034). Conclusions USG venipuncture was associated with a reduction in major complication rates and a decrease in additional exams required during hospitalization or readmission. However, it did not lead to a reduction in minor complications. These findings support the use of ultrasound in AF ablation procedures to avoid access related complications requiring intervention.Baseline CharacteristicsSummary

Catheter ablation of premature ventricle complex from multiples site of origin guided by an ultra-high density mapping system in a single-center

Abstract Background Frequent premature ventricle complex (PVC) could induce cardiomyopathy in some patient. PVC ablation by radiofrequency (RF) is a well-stablished procedure in high density PVC patients and results are consistent and robust in literature, with somewhat differing success rates reported. Catheter ablation of radiofrequency guided by ultra-high density mapping systems (UHDMS), enable a much more accurate reconstruction of the site of origin (SOO). Furthermore, we obtained this anatomic recreation with the analysis of a few number of beats. The UHDMS have demonstrated to be feasible and safe in a wide range / large spectrum of arrhythmic substrates, however, there is lack of evidence of its usefulness in the ablation of PVC. Purpose To determine the safety and utility, both in the acute phase and in the short-medium term, of employing a UHDMS in PVC catheter ablation in a retrospective cohort of patients treated at a single centre. Methods Catheter ablation procedures guided by an UHDMS carried out from July 2015 to January 2021 in a single-center of Spain were retrospectively included. The primary outcomes analyzed were: acute success rate, short-medium success rate (6-month efficacy after ablation), and complication rate related to the procedure. Results One hundred and two procedures, corresponding to 92 patients (mean age 59 ± 14 years, 63% male, 74% without cardiomyopathy, mean LVEF of 60%), were analyzed. The acute success rate was 93%. According the SOO, the lowest acute success rate was PVC from epicardial level (LV Summit) (75%). At 6-month follow-up after the first procedure, the short-medium success rate was up to 84% (no recurrence of the PVC ablated). There were three acute complications related to the procedure (complication rate 2,94%). In 19% (21 out 102) of the procedures, at least two arrhythmic substrates were successfully ablated in a single intervention. Conclusion Catheter ablation guided by an UHDMS showed an excellent safety profile in PVC ablation procedures. Beyond this minor complication rate, this type of technique has improved acute and short-term success rates. This allows us to assert that this type of technique grants a very high success rate and improves previously results. Last but not least, this new approach was useful and accurate in complex patients, providing good results in ablation procedures of two or more arrhythmic substrates without altering the safety profile.

Pulsed field ablation versus very high-power short-duration radiofrequency ablation in persistent atrial fibrillation: a single-centre experience

Abstract Background Pulsed Field ablation (PFA) has recently emerged as a treatment strategy for patients with atrial fibrillation (AF) and early studies showed promising procedural data and durable pulmonary vein isolation (PVI). However, Very High-Power Short-Duration ablation (VHPSD) has previously reported good efficiency and mid-term outcomes, and only a few works compared these two procedures, especially in patients with persistent AF. Objective Our aim is to compare these different modalities of transcatheter ablation in patients with persistent AF, focusing mainly on some procedural aspects, safety and efficacy. Methods We performed a retrospective observational study enrolling all consecutive patients with persistent AF from September 2021 to May 2023 undergoing transcatheter ablation with PFA or VHPSD. In the first group, PVI was achieved by 2kV pulses with eight applications to each vein using both catheter configurations, while isolation of the posterior wall of the left atrium was achieved by applications through the only "flower" configuration; additional lesions were then added at the operator's discretion. In the second group, PVI was achieved by delivering 90W radiofrequency pulses for 4 seconds in the posterior portions of the left atrium and 50W pulses in the anterior region of the pulmonary veins; additional lesions were occasionally applied. All patients received general anaesthesia or deep sedation with fentanyl and dexmedetomidine. Results A total of 79 patients were included, n = 24 (30%) in the PFA group and N = 55 (70%) in the VHPSD one: early persistent AF (n= 2 [8,3%]; N = 7 [12,7%]), persistent AF (n= 17 [70,8%]; N = 36 [65,5%]), long-standing persistent AF (n= 5 [20,8%]; N = 12 [21,8%]). The two populations showed similar clinical features: CHA2DS2-VASc (median value 3 [0-6] in PFA vs 2 [0-6] in VHPSD, p = 0,10), indexed left atrial volume (mean value 42,6 ml/m² in PFA vs 42,4 ml/m² in VHPSD, p = 0,07) and EF (mean value 55,4% in PFA vs 54,8% in VHPSD, p = 0,33). PVI was successfully achieved in all patients. Nevertheless, the PFA group was associated with shorter procedural duration (92,1 ± 36,9 vs 134,2 ± 36,1 minutes, p = 0,00001) but longer fluoroscopy time (25,5 ± 9,3 vs 17,4 ± 11,5 minutes, p = 0,001); it also showed a lower rate of minor complications (n = 1 [4,2%] vs N = 3 [5,5%], p = 0,057), even though serious complications were not observed in either group. After a median follow-up of 14 (9-26) months, n = 19 [79.2%] in the PFA and N = 43 [78.2%] in the VHPSD population were free of any atrial arrhythmia (p = 0,92). Conclusion PFA allows faster procedures, representing a major advantage for the operator and the patient, who is at lower risk of peri-procedural complications. On the other hand, VHPSD correlates with shorter fluoroscopy times, reducing exposure to ionizing radiation. Finally, the two procedures show similar mid-term efficacy in terms of recurrence-free time.

Comparison between catheter ablation versus permanent pacemaker implantation as an initial treatment for tachycardia–bradycardia syndrome patients: a prospective, randomized trial

BackgroundClinical outcomes after catheter ablation (CA) or pacemaker (PM) implantation for the tachycardia–bradycardia syndrome (TBS) has not been evaluated adequately. We tried to compare the efficacy and safety outcomes of CA and PM implantation as an initial treatment option for TBS in paroxysmal atrial fibrillation (AF) patients.MethodsSixty-eight patients with paroxysmal AF and TBS (mean 63.7 years, 63.2% male) were randomized, and received CA (n = 35) or PM (n = 33) as initial treatments. The primary outcomes were unexpected emergency room visits or hospitalizations attributed to cardiovascular causes.ResultsIn the intention-to-treatment analysis, the rates of primary outcomes were not significantly different between the two groups at the 2-year follow-up (19.8% vs. 25.9%; hazard ratio (HR) 0.73, 95% confidence interval (CI) 0.25–2.20, P = 0.584), irrespective of whether the results were adjusted for age (HR 1.12, 95% CI 0.34–3.64, P = 0.852). The 2-year rate of recurrent AF was significantly lower in the CA group compared to the PM group (33.9% vs. 56.8%, P = 0.038). Four patients (11.4%) in the CA group finally received PMs after CA owing to recurrent syncope episodes. The rate of major or minor procedure related complications was not significantly different between the two groups.ConclusionCA had a similar efficacy and safety profile with that of PM and a higher sinus rhythm maintenance rate. CA could be considered as a preferable initial treatment option over PM implantation in patients with paroxysmal AF and TBS.Trial registrationKCT0000155.

Robotic transanal minimally invasive surgery (r-TAMIS): perioperative and short-term outcomes for local excision of rectal cancers

BackgroundTransanal minimally invasive surgery (TAMIS) is an advanced technique for excision of early rectal cancers. Robotic TAMIS (r-TAMIS) has been introduced as technical improvement and potential alternative to total mesorectal excision (TME) in early rectal cancers and in frail patients. This study reports the perioperative and short-term oncological outcomes of r-TAMIS for local excision of early-stage rectal cancers.MethodsRetrospective analysis of a prospectively collected r-TAMIS database (July 2021–July 2023). Demographics, clinicopathological features, short-term outcomes, recurrences, and survival were investigated.ResultsTwenty patients were included. Median age and body mass index were 69.5 (62.0–77.7) years and 31.0 (21.0–36.5) kg/m2. Male sex was prevalent (n = 12, 60.0%). ASA III accounted for 66.7%. Median distance from anal verge was 7.5 (5.0–11.7) cm. Median operation time was 90.0 (60.0–112.5) minutes. Blood loss was minimal. There were no conversions. Median postoperative stay was 2.0 (1.0–3.0) days. Minor and major complication rates were 25.0% and 0%, respectively. Seventeen (85.0%) patients had an adenocarcinoma whilst three patients had an adenoma. R0 rate was 90.0%. Most tumours were pT1 (55.0%), followed by pT2 (25.0%). One patient (5.0%) had a pT3 tumour. Specimen and tumour maximal median diameter were 51.0 (41.0–62.0) mm and 21.5 (17.2–42.0) mm, respectively. Median specimen area was 193.1 (134.3–323.3) cm2. Median follow-up was 15.5 (10.0–24.0) months. One patient developed local recurrence (5.0%).Conclusionsr-TAMIS, with strict postoperative surveillance, is a safe and feasible approach for local excision of early rectal cancer and may have a role in surgically unfit and elderly patients who refuse or cannot undergo TME surgery. Future prospective multicentre large-scale studies are needed to report the long-term oncological outcomes.

Operative Time and Accrual of Postoperative Complications in Minimally Invasive Versus Open Myomectomy

Study ObjectiveTo compare the prevalence and accrual of 30-day postoperative complications by operative time for open myomectomy (OM) and minimally invasive myomectomy (MIM). DesignRetrospective cohort study SettingHospitals participating in the National Surgical Quality Improvement Program database from January 2015 to December 2021. PatientsFemale patients aged ≥18 years undergoing OM or MIM. InterventionsPatients were categorized into OM and MIM cohorts. Covariates associated with operative time and composite complications were identified using general linear model and chi-square or Fisher's exact test as appropriate. Adjusted spline regression was performed as a test of linearity between operative time and composite complications. Adjusted risk ratios of 30-day postoperative individual, minor, major, and composite complications by 60-minute operative time increments were estimated using Poisson regression with robust error variance. Measurements and Main ResultsOf 27 728 patients, 11 071 underwent MIM and 16 657 underwent OM. Mean operative times (SD) were 164.6 (82.0) for MIM and 129.2 (67.0) for OM. Raw composite complication rates were 5.5% for MIM and 15.8% for OM. Adjusted spline regression demonstrated linearity between operative time and relative risk of composite postoperative complications for both MIM and OM. MIM had higher adjusted relative risk (aRR, 95% CI) compared to OM of blood transfusion (1.55, 1.45–1.64 versus 1.29, 1.25–1.34), overall minor complications (1.13, 1.03–1.23 versus 1.01, 0.92–1.10), and overall major complications (1.43, 1.35–1.51 versus 1.27, 1.12–1.32). Operative time had greater impact on risk of composite complications for MIM than OM, reaching aRR 2.0 at 296 minutes versus 461 minutes for OM. ConclusionOM has a higher overall rate of composite, minor, and major complications compared to MIM. While operative time is independently and linearly associated with postoperative complications with myomectomy regardless of approach, optimizing surgical efficiency for MIM may be more critical than for OM.

Soft Tissue Reconstruction After Sacral Neoplasm Resection: The University of California San Francisco Experience.

Resection of sacral neoplasms such as chordoma and chondrosarcoma with subsequent reconstruction of large soft tissue defects is a complex multidisciplinary process. Radiotherapy and prior abdominal surgery play a role in reconstructive planning; however, there is no consensus on how to maximize outcomes. In this study, we present our institution's experience with the reconstructive surgical management of this unique patient population. We conducted a retrospective review of patients who underwent reconstruction after resection of primary or recurrent pelvic chordoma or chondrosarcoma between 2002 and 2019. Surgical details, hospital stay, and postoperative outcomes were assessed. Patients were divided into 3 groups for comparison based on reconstruction technique: gluteal-based flaps, vertical rectus abdominus myocutaneous (VRAM) flaps, and locoregional fasciocutaneous flaps. Twenty-eight patients (17 males, 11 females), with mean age of 62 years (range, 34-86 years), were reviewed. Twenty-two patients (78.6%) received gluteal-based flaps, 3 patients (10.7%) received VRAM flaps, and 3 patients (10.7%) were reconstructed with locoregional fasciocutaneous flaps. Patients in the VRAM group were significantly more likely to have undergone total sacrectomy (P < 0.01) in a 2-stage operation (P < 0.01) compared with patients in the other 2 groups. Patients in the VRAM group also had a significantly greater average number of reoperations (2 ± 3.5, P = 0.04) and length of stay (29.7 ± 20.4 days, P = 0.01) compared with the 2 other groups. The overall minor and major wound complication rates were 17.9% and 42.9%, respectively, with 17.9% of patients experiencing at least 1 infection or seroma. There was no association between prior abdominal surgery, surgical stages, or radiation therapy and an increased risk of wound complications. Vertical rectus abdominus myocutaneous flaps are a more suitable option for patients with larger defects after total sacrectomy via 2-staged anteroposterior resections, whereas gluteal myocutaneous flaps are effective options for posterior-only resections. For patients with small- to moderate-sized defects, local fasciocutaneous flaps are a less invasive and effective option. Paraspinous flaps may be used in combination with other techniques to provide additional bulk and coverage for especially long postresection wounds. Furthermore, mesh is a useful adjunct for any reconstruction aimed at protecting against intra-abdominal complications.

Complications of pediatric enteral nutrition at home: a systematic review of quantitative research

Objective: Identifying complications related to enteral nutrition at home in children is important in terms of establishing standard discharge education and training programs to support parents in managing complications. The study aimed to synthesize current evidence on the complications of pediatric enteral nutrition at home. Methods: The study was conducted according to PRISMA recommendations. Eight databases were reviewed between 2012 and 2022 in Turkish, German, and English languages. Articles were assessed in three stages: title, abstract, and full text. The review included 18 studies that met all the inclusion criteria. The Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instruments were used to assess the quality appraisal of the studies. Results: A total of 18 studies with 19,531 children were included from 14 countries. The outcome measures were major and minor complications with pediatric enteral nutrition at home. 11 of the 18 papers included were retrospective studies on complications of PEG. In studies reporting the overall rate of major complications ranged from 0% to 14.3%, and the most common complications were reoperation (2.64%-12.4%), and gastrocolic fistula/perforation (0.9%-3.8%). In studies reporting the overall rate of minor complications, the rate ranged from 16.4%-73.6% and the most common complications were infection (8.2%-31.9%), dislodgement (1.6%-21%), skin granulation (4%-50.4%), and vomiting (1%-49.89%). Conclusion: This systematic review reveals that the rate of complications in pediatric enteral nutrition at home cannot be underestimated. Healthcare providers should plan their practice considering these complications to support parents in managing complications of pediatric enteral nutrition at home.