Need For Surgical Revision Research Articles

Outcome differences and device performance of the subcutaneous ICD in patients with and without structural heart disease.

The performance of the subcutaneous ICD (S-ICD™) has been described in different kinds of heart disease and has been proven to be an important advance in prevention of sudden cardiac death (SCD). While positive experiences with the S-ICD™ initially came from collectives of patients without structural heart diseases, positive results have also been collected from cohorts with structural heart disease. All S-ICD™ patients with either ischemic cardiomyopathy (ICM), dilated cardiomyopathy (DCM) or hypertrophic cardiomyopathy (HCM) as the main indication for ICD implantation (n = 144 patients) or electrical heart disease/idiopathic ventricular fibrillation (n = 83 patients) in our large-scaled single-center S-ICD™ registry were included in this study. Baseline characteristics, appropriate and inappropriate shocks, and complications were documented in a mean follow-up of 18 ± 15months. Baseline characteristics were significantly different between the two groups in most categories. In contrast, there was no difference concerning neither appropriate nor inappropriate shock delivery between the two groups. Also other outcome parameters such as need for surgical revisions and all-cause mortality did not differ. There was a significant difference between the first- and second-generation S-ICDs™ in inadequate shocks mainly driven by patients with HCM. In our study, S-ICD™ performance was similar in patients with and without structural heart disease. Decision pro- or contra-S-ICD™ should be made rather on the basis of expected shock rate and probability of the need for future anti-tachycardia or anti-bradycardia pacing than in dependence of the underlying heart disease.

Epidemiology of intra-abdominal infection and sepsis in critically ill patients: \u201cAbSeS\u201d, a multinational observational cohort study and ESICM Trials Group Project

PurposeTo describe the epidemiology of intra-abdominal infection in an international cohort of ICU patients according to a new system that classifies cases according to setting of infection acquisition (community-acquired, early onset hospital-acquired, and late-onset hospital-acquired), anatomical disruption (absent or present with localized or diffuse peritonitis), and severity of disease expression (infection, sepsis, and septic shock).MethodsWe performed a multicenter (n = 309), observational, epidemiological study including adult ICU patients diagnosed with intra-abdominal infection. Risk factors for mortality were assessed by logistic regression analysis.ResultsThe cohort included 2621 patients. Setting of infection acquisition was community-acquired in 31.6%, early onset hospital-acquired in 25%, and late-onset hospital-acquired in 43.4% of patients. Overall prevalence of antimicrobial resistance was 26.3% and difficult-to-treat resistant Gram-negative bacteria 4.3%, with great variation according to geographic region. No difference in prevalence of antimicrobial resistance was observed according to setting of infection acquisition. Overall mortality was 29.1%. Independent risk factors for mortality included late-onset hospital-acquired infection, diffuse peritonitis, sepsis, septic shock, older age, malnutrition, liver failure, congestive heart failure, antimicrobial resistance (either methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, extended-spectrum beta-lactamase-producing Gram-negative bacteria, or carbapenem-resistant Gram-negative bacteria) and source control failure evidenced by either the need for surgical revision or persistent inflammation.ConclusionThis multinational, heterogeneous cohort of ICU patients with intra-abdominal infection revealed that setting of infection acquisition, anatomical disruption, and severity of disease expression are disease-specific phenotypic characteristics associated with outcome, irrespective of the type of infection. Antimicrobial resistance is equally common in community-acquired as in hospital-acquired infection.

A qualitative study of parental preferences for postcircumcision care education

Although uncommon, complications associated with newborn male circumcision may require costly and emotionally upsetting surgical revisions. Improvements in parental education regarding postcircumcision care may reduce preventable complications; however, little is known about parents' preferences for education of this type. The authors sought to describe parents' preferences regarding the content and delivery of education on postcircumcision care as a first step toward improving parental education and ultimately reducing the need for surgical revisions. The authors conducted a qualitative, descriptive study, collecting data from 14 parents during two separate focus group discussions. The authors applied thematic analysis techniques to analyze the transcribed content of both groups. Parents indicated that postcircumcision care instructions should be detailed and include clear images and/or an actual demonstration of care processes. Despite being aware of the low likelihood of complications, parents expressed a preference for providers who took education seriously rather than those approaching it with a 'cavalier attitude.' There was widespread support for delivering education at a time that met each family's unique circumstances and needs. Consistent with prior research, parents in this study identified gaps in understanding postprocedure care instructions. However, this study adds to the literature in highlighting the specific concerns and preferences of parents with regard to the content and delivery of postcircumcision care education. Based on these findings, the authors conclude that healthcare teams should ensure that parents have access to detailed instructions for postcircumcision care. Education of parents should occur at times when they are able to pay attention and should be supplemented with materials that they can easily access from home. Pediatric urologists can play a leading role in the development and dissemination of high-quality, family-centered educational materials to both parents and providers in other specialty areas that perform high volumes of newborn circumcision. Future research would benefit from larger, more diverse samples. In addition, future studies investigating the effect of parental education on potentially avoidable complications are needed to maximize clinical impact. Parents readily provided detailed input into what they perceived as much-needed improvements in postcircumcision care education. Future research is needed to determine what effect, if any, such changes would have on the incidence of preventable complications, particularly those requiring surgical intervention.

2958 Robotic Ureteral Reimplantation for Posthysterectomy Injury: Is Laparotomy Necessary

Study Objective There is limited data on robotic ureteral reimplantation for ureteral injury following hysterectomy. The aim of this study is to demonstrate the use of robotic ureteral reimplantation in a setting of ureteral injury sustained during hysterectomy. Design Retrospective case series Setting Hospital Patients or Participants Patients who developed ureteral obstruction as a result of hysterectomy Interventions Robotic ureteral implantation Measurements and Main Results This case series exhibited a 100% rate of success of robotic ureteral reimplantation without conversion from robotic to an open procedure. Two patients presented with injury in bilateral ureters (unilateral ureteral reimplantation with contralateral stenting), 4 with injury on the left, and 3 with injury on the right, 1 bilateral. 2 of the 8 procedures had a history of concurrent bladder injury during the initial surgery. The mean days to the recognition of ureteral injury was 6.5 days. 37.5% underwent concomitant lysis of adhesions during the robotic ureteroneocystostomy. The Jackson-Pratt drain, ureteral stents, and foley catheters remained upon discharge and were removed in the office post-operatively. JP drains were removed on ave 8.5 (8-10) days. Foley catheters were removed on 10.8 average (6-18) days. Ureteral stents were removed mean 34 (28-47) days. All patient underwent serial outpatient Renal US post-operatively with only 25% of patients exhibiting mild hydronephrosis following ureteral reimplantation and ureteral stent removal. 0% of patient required surgical revision of the ureteroneocystostomy. Mean duration of post-operative follow up was 110.75 (22-270) days. Conclusion The use of robotic ureteral reimplantation is effective and safe and is underutilized. This case series demonstrates effective utilization of robotics in ureteroneocystostomy following ureteral injury sustained during hysterectomy without the need of surgical revision of the ureteroneocystostomy post-operatively, no loss of renal units, and no significant hydronephrosis.

Risk factors and complications after body-contouring surgery and the amount of stromal vascular fraction cells found in subcutaneous tissue.

Body contouring surgery following massive weight loss is often prone to complications. Subcutaneous adipose tissue is a rich source of stromal vascular fraction (SVF) cells, and moreover it plays an important role in the pathophysiology of obesity, metabolic syndrome, and wound healing. In this retrospective, single-centred appraisal, complications are examined and correlated with individual SVF numbers in abdominal subcutaneous fat tissue. We analysed whether the weight loss method affected complications. Eighty seven massive weight loss patients undergoing body contouring surgery between 2010 and 2017 were included in the study. In total, 57 cases with at least one complication were recorded (65.5%). Maximum lifetime weight was 109.6 kg (range 48-184 kg). Half of the complications (50.8%) were minor complications without the need for surgical revision. The mean number of SVF found in the resected tissue was 714 997.63 cells/g fat tissue. We found no statistical difference in complication rates dependent on cell numbers. Smoking (P = .049) and a high BMI at the time point of surgery (P = .031) led to significantly more complications. Also, a high resection weight (P = .057) showed a tendency for impaired wound healing. However, there was no difference in complication rates following body contouring procedures attributable to the method of weight loss in this study.

Postoperative Bioresorbable Chitosan-Based Dressing for Endoscopic Middle Meatal Dacryocystorhinostomy With Balloon Dilation.

To evaluate the improvement in epiphora and need for surgical revision in patients with acquired nasolacrimal duct obstruction following balloon-assisted, middle meatal endoscopic dacryocystorhinostomy with chitosan-based dressing versus bioresorbable polyurethane packing versus no packing. This was a retrospective study of consecutive adult patients seen from 2015 to 2018 with follow-up evaluation of epiphora at least 3 months after balloon-assisted, middle meatal endoscopic dacryocystorhinostomy. Patients with a history of prior punctoplasty, septoplasty, sinus surgery, or dacryocystorhinostomy of any kind were excluded. Those meeting criteria were stratified by postoperative hemostatic intervention: no packing, bioresorbable packing, and chitosan-based dressing (groups 1, 2, and 3, respectively). Procedural outcomes were graded as successes or failures based on subjective report and anatomical findings at most recent visit within an 18-month postoperative window. Instances of recommendation for revision surgery were also recorded. Forty-three cases (36 patients) met the abovementioned criteria. Groups 1, 2, and 3 comprised 12, 17, and 14 cases each, respectively. Average patient age was 55.3 years old, and average duration of follow-up was 6.7 months. Significant variation in outcomes was detected across the 3 groups (P = .0495), particularly between groups 1 and 3 (P = .033). Use of chitosan-based dressing trended toward reduced rates of recommendation for surgical revision (P = .203, P = .113). Use of chitosan-based dressing after endoscopic dacryocystorhinostomy was associated with improved subjective and anatomical outcomes. It may also contribute to less frequent need for revision surgery. Further study in a larger prospective trial is recommended.

243. The effect of sacroiliac fusion and pelvic fixation on rod strain in thoracolumbar fusion constructs: a biomechanical investigation

BACKGROUND CONTEXT Hardware failure is a multifactorial and challenging problem frequently encountered by spinal surgeons. A common cause of construct failure is the mechanical strain that results from excessive force placed on the spine. In implanted hardware, increased rod strain can lead to construct failure and rod fracture. Clinically significant rod fractures are associated with loss of correction as well as new onset radiculopathy, pain, radiographic signs of pseudarthrosis, and the need for surgical revision. PURPOSE To investigate the effect of sacroiliac joint (SIJ) fusion and iliac fixation on distal rod strain in thoracolumbar fusions. STUDY DESIGN/SETTING In vitro biomechanical study METHODS Seven fresh-frozen human cadaveric specimens (T9–Pelvis) were used. Six operative constructs were tested to investigate changes in rod strain at L5–S1 and S1–Ilium rods: posterior pedicle screws and rods from T10–S1 (PS); PS+bilateral iliac screw fixation; PS+unilateral iliac screw fixation; PS+UIS+3 unilateral SIJ screws; PS+3 unilateral SIJ screws; and PS+6 bilateral SIJ screws. Uniaxial strain gauges were used to measure surface strain of rods during flexion-extension motion. RESULTS In flexion-extension, bilateral iliac screws added significant strain to L5–S1 when compared to long fusion constructs that ended at S1 (PS) (p CONCLUSIONS This biomechanical study examined the effect of pelvic fixation and SIJ fusion on distal rod strain in thoracolumbar fusions. Results showed that additional fixation below S1 to the pelvis significantly increased rod strain. Unilateral pelvic screws had the highest rod strain while SIJF did not affect rod strain. The authors believe these findings can help guide surgeons when associated risk of rod failure needs to be considered. FDA DEVICE/DRUG STATUS SI-LOK Screws (Approved for this indication).

Outcomes of endoscopic treatment of leaks and fistulae after sleeve gastrectomy: results from a large multicenter U.S. cohort

BackgroundSleeve gastrectomy is the most commonly performed bariatric surgery in the United States. Leaks after sleeve gastrectomy (SGL) occur in 1% to 3% of patients. Endoscopic therapies are increasingly used for treatment of SGLs, but few data exist on their outcomes. ObjectivesThe aim of this study was to assess technical success, leak resolution, and reoperation rates of patients undergoing endoscopic therapy for repair SGLs. SettingEight high-volume academic endoscopy centers. MethodsPatients undergoing endoscopic therapy for SGLs from 2007 to 2017 were identified. Patients were excluded if the index endoscopic therapy for SGL was performed elsewhere or if no follow-up data were available. Leaks were classified as acute (≤7 d of SG), early (1–6 wk), late (7–12 wk), and chronic (>12 wk). Leak resolution was defined as lack of extraluminal air, extravasation on oral contrast radiography, cross-sectional imaging, or resolution of percutaneous drain output. Demographic and procedural data were recorded as rates of additional therapy, adverse events, and surgical revision. ResultsA total of 85 patients met criteria for analysis (70 women, age 42.6 ± 10.8 yr). A total of 295 endoscopic sessions (median 3, range 1–14) were performed across the cohort. SGLs resolved after index endoscopic therapy in 43 (50.1%) patients. The primary outcome of endoscopic resolution of SGL was observed in 62 patients (72.9%). There were 34 (11.5%) PRAE (the majority occurring with self-expandable metal stents), all but 1 of which were managed endoscopically. Surgical revision was required in 23 (21.7%) patients. On univariate analyses independent variables associated with the need for surgical revision included both acute and chronic SGLs (P = .028), loculated subphrenic collections/abscesses (P = .03), and intraabdominal sepsis (P = .03). On multivariable logistic regression using statistically significant predictors from the univariate analyses, acute SGLs were significantly associated with a need for surgical revision (odds ratio 4.8, 95% confidence interval 1.2–18.9, P = .025). ConclusionEndoscopic therapy for SGLs is associated with good clinical success, avoiding the need for surgical revision in 73% of patients, with an acceptable adverse event profile. Patients with acute or chronic SGLs and those with loculated abscesses or intraabdominal sepsis are more likely to undergo surgical revision. Endoscopic therapy is an appropriate first-line modality for the management of SGLs, especially those not classified as acute or chronic.

Surgical treatment of type II odontoid fractures in elderly patients: a comparison of anterior odontoid screw fixation and posterior atlantoaxial fusion using the Magerl-Gallie technique.

This single-centre retrospective study compared anterior odontoid screw fixation and posterior atlantoaxial fusion in the surgical treatment of type II B odontoid fractures according to Grauer in elderly patients. Between 1994 and 2014, 133 consecutive patients above 60years presenting with type II B odontoid fracture were treated surgically in our department. They were divided retrospectively into two groups. Group A included 47 patients in whom anterior odontoid screw fixation was performed. Group B with 86 patients underwent posterior atlantoaxial fusion. The clinical and radiological data were analysed. Any reoperation during the follow-up was recorded and evaluated. The mean age in group A (74.19years) was significantly less than in group B (78.16years). The mean operative time in group A (64.5min) was significantly shorter than in group B (116min). Again, the mean amount of blood loss in group A (79ml) was significantly less than in group B (379ml). The mean postoperative hospital stay was significantly shorter in group A (17.4days) than in group B (30days). The mean follow-up was 29.3months in group A and 32months in group B. The rate of pseudoarthrosis was significantly higher in group A (25.5%) than in group B (3.5%). Furthermore, the need for revision surgery was significantly increased in group A (23.4%) than in group B (10.47%). Odontoid screw fixation is a less invasive surgery for type II B odontoid fractures in elderly patients. However, posterior atlantoaxial fusion provides a superior surgical outcome regarding fracture healing and the need for surgical revisions. These slides can be retrieved under Electronic Supplementary Material.

Managing Postoperative Infection following Breast Reconstruction with the Sientra AlloX2 Tissue Expander.

Implant-based breast reconstruction is the most common reconstructive modality in the United States. Significant advances in surgical technique and technology have resulted in improvement of clinical outcomes. A recent innovation has been the introduction of a tissue expander with an integral drain that permits access to the periprosthetic space. A new use for this drain port is presented in patients with postoperative surgical-site infection. Patients who underwent staged implant-based breast reconstruction with the Sientra AlloX2 tissue expander and experienced postoperative infection that warranted inpatient management with intravenous antibiotics were included in the study. The integral drain port was used in these patients to perform washout of the periprosthetic space at the bedside. The ability to salvage the tissue expander in the setting of infection without the need for surgical revision in the operating room was determined. Of 31 patients who underwent a total of 52 staged breast reconstructions with the Sientra AlloX2 tissue expander, 3 patients (8.7%) with a mean age of 50.3 years (range, 34-76 years) and mean body mass index of 23.3 kg/m2 (range, 22.3-24.1 kg/m2) met inclusion criteria. Salvage of the device with successful progression through expansion and eventual expander-implant exchange was achieved in 2 patients. One patient failed the salvage attempt and required removal of the device. Using the integral drain port of the AlloX2 tissue expander has the potential for device salvage in a subset of patients with surgical-site infection without the need for surgical revision.

Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap

The aim of this study was to analyze our technique of intraoperative venous compromise management based on conservation of the superficial inferior epigastric vein (SIEV), and to undertake a retrospective review of our series of breast reconstructions by deep inferior epigastric perforator (DIEP) flap, followed by a review of other techniques reported in the literature. This retrospective study involves 198 breast reconstructions by DIEP flap performed between January 2010 and September 2017. Our surgical technique is related in detail, with a focus on venous compromise management. Operative time, re-intervention rate, hospital stay, and complications were all noted and analyzed, and a literature review dealt with other techniques of prevention and management of flap venous congestion. Among breast reconstructions by DIEP, 7.5% contained an episode of intraoperative venous compromise, as opposed to 6.5% postoperatively. The SIEV was used in 65% of cases of venous congestion. In our series, 15.1% of cases presented postoperative complications, and we observed a 2.5% flap failure rate (2%: venous thrombosis; 0.5%: arterial thrombosis). In all patients for whom venous drainage augmentation was performed, the flaps survived without partial loss. While average length of hospital stay in the group having undergone intraoperative secondary anastomosis was 7.5 days, in the group having undergone postoperative secondary anastomosis, it was 13.5 days. In cases of intraoperative venous congestion, while a second venous anastomosis may immediately increase duration of an initial intervention by 1hour and 45minutes, it is nonetheless likely to pronouncedly decrease need for surgical revision, cases of failure, rate of partial necrosis and overall hospital stay.

Phrenic Nerve Simulation for Central Sleep Apnea is Effective and Safe in the Presence of Concomitant Cardiac Devices

Introduction Central sleep apnea (CSA) is common in patients with heart failure. Many of these patients also have cardiac implantable electronic devices (CIED). The remedē® System is an implantable neurostimulator for CSA which transvenously stimulates the phrenic nerve to contract the diaphragm, restoring a normal breathing pattern and improving sleep, oxygenation and quality of life. In the remedē System Pivotal Trial, 44% (64/151) of patients had a prior CIED at the time of phrenic nerve stimulation (PNS) implant. Interaction testing was conducted at implant and therapy initiation (1 month post implant). Hypothesis PNS for the treatment of CSA is effective and safe in patients with a prior CIED. Methods Implant metrics, sleep metrics and related serious adverse events (AE) were compared based on the presence or absence of a CIED in patients enrolled in the remedē System Pivotal Trial. Results Of 64 subjects with a CIED, 33 (52%) had an ICD, 20 (31%) CRT-D, 10 (16%) PM, and 1 (2%) CRT-P. Implant metrics: remedē System implant time (2.7 ± 0.8 hours with vs 2.7 ± 0.9 hours without), fluoroscopy time (42 ± 22 min with vs 44 ± 23 min without) and contrast used (57 ± 51 cc with vs. 59 ± 59 cc without) were similar with or without CIED. Successful placement of a left-sided lead for PNS was similar with and without CIED (60% (38/64) vs. 67% (58/87)) as were improvements in central apnea index (-25.7 ± 18.0 events/hour with vs -19.8 ± 17.9 events/hour without) and oxygen desaturation ≥4% index (-23.4 ± 15.7 events/hour with vs -20.9 ± 19.2 events/hour without). Related serious AE through 24 months were lower in the CIED group overall with 8 events reported in 6 (9%) patients compared to 13 events in 11 (13%) patients in the group without CIED. The only event more prevalent in the CIED group was concomitant device interaction, with 4 CIED oversensing events reported in 3 patients resulting in the delivery of ICD therapy in 2 patients (1 shock, 1 anti-tachycardia pacing). Device interactions could be resolved by re-programming the PNS System in all patients without need for surgical revision. Improved concomitant device interaction testing procedures are part of device training and product labeling. Conclusion Phrenic nerve stimulation can effectively and safely treat CSA in patient with a CIED. Rare device interactions could be handled by reprogramming.

Sacral neuromodulation for treatment of overactive bladder: a review

Sacral neuromodulation (SNM) therapy is an established third line therapeutic option for the treatment of urgency urinary incontinence, urgency-frequency and chronic non-obstructive urinary retention. The continuous stimulation of the sacral root S3 with an electrode connected to an implanted pulse generator (IPG) may influence detrusor and sphincter activity and improve lower urinary tract symptoms. The mechanism of action is not completely understood and seems to be based on the modulation of spinal cord reflexes and brain centers involved in lower urinary tract function. It is implanted with a minimally invasive technique that can be performed under local anesthesia and includes a test phase that precedes the definitive implantation of the pulse generator. When compared to the standard pharmacological therapy, neuromodulation promoted better results both in the partial improvement of overactive bladder (OAB) symptoms and total continence. Moreover, sexual function, quality of life and depressive symptoms may also improve in patients with OAB that undergo SNM. However, SNM is associated with significant rates of adverse events and need for surgical revisions, requiring continuous medical attention.

Pulsed electromagnetic fields and platelet rich plasma alone and combined for the treatment of wear-mediated periprosthetic osteolysis: An in vivo study

Wear-mediated osteolysis is a common complication occurring around implanted prosthesis, which ultimately leads to bone loss with mechanical instability and the need for surgical revision. At the moment, revision surgery is the only effective treatment. The aim of this study was to assess the efficacy of pulsed electromagnetic fields (PEMFs) and platelet rich plasma (PRP), alone and in association, in a clinically relevant in vivo model of periprosthetic osteolysis. Titanium alloy pins were implanted intramedullary in distal femurs of male inbred rats and, after osseointegration, polyethylene particles were injected intra-articularly to induce osteolysis. Animals were divided in four groups of treatment: PEMFs, PRP, PEMFs + PRP and no treatment. Microtomography was performed during the course of experiments to monitor bone stock and microarchitecture. Histology, histomorphometry, immunohistochemistry and biomechanics were evaluated after treatments. Biophysical and biological stimulations significantly enhanced bone to implant contact, bone volume and bone microhardness and reduced fibrous capsule formation and the number of osteoclasts around implants. Among treatments, PEMFs alone and in association with PRP exerted better results than PRP alone. Present data suggest that biophysical stimulation, with or without the enrichment with platelet derived growth factors, might be a safe, mini-invasive and conservative therapy for counteracting osteolysis and prompting bone formation around implants. Statement of significancePulsed electromagnetic fields (PEMFs) and platelet rich plasma (PRP) show anabolic and anti-inflammatory effects and they are already been used in clinical practice, but separately. To date, there are no preclinical in vivo studies evaluating their combined efficacy in periprosthetic osteolysis, in bone tissue microarchitecture and in biomechanics. The aim of the present study was to evaluate the effects of PEMFs and PRP in vivo, when administered individually and in combination in the treatment of periprosthetic wear mediated ostelysis, and in restoring the osteogenetic properties of perimplant bone tissue and its biomechanical competence. The combination of PEMFs and PRP could be employed for counteracting the ostelysis process in a conservative and non surgical manner.

Endoscopic biliary stent placement for anastomotic stricture following esophageal atresia repair in infant

Abstract Esophageal atresia is the most common congenital anomaly of the esophagus. Treatment optimally includes primary tension-free anastomosis of the upper and lower aspects of the esophagus. Distance between the upper and lower esophagus predisposes the anastomosis to tension, increasing the risk of anastomotic stricture. Esophageal stricture has historically been managed with repeated endoscopic balloon dilations. Multiple failed attempts at endoscopic balloon dilation requires surgical revision of the anastomosis. Stenting of esophageal stricture has been used in the adult population but has not been described for children. This case report demonstrates the placement of biliary stents in a 2-month-old infant with esophageal stricture following repair of a long gap Type C tracheoesophageal fistula. Successful stenting procedure averted the need for surgical revision.

Abstract No. 573 Outcomes of ureteroplasty and stenting of anastomotic ureteral strictures occurring after urinary diversion and renal transplantation

To report outcomes of percutaneous ureteroplasty and stenting of anastomotic ureteral strictures which occurred within 1 year of urinary diversion (ureteroenteric anastomosis -UEA) or renal transplantation (ureterovesical anastomosis-UVA). We retrospectively identified patients who underwent ureteroplasty with percutaneous nephroureteral (PCNU) or double pigtail ureteral stent placement (stent) for benign anastomotic strictures occurring within one year of urinary diversion or renal transplantation from March 2004 to July 2016 (N = 54). 31 patients had UEA strictures (25 men and 6 women; mean age 65, 19 ileal conduits and 12 continent diversions) and 23 renal transplant patients had UVA strictures (15 men and 8 women; mean age 53). Mean follow-up was 31 months (range, 1.107 months). Primary endpoint was freedom from ureteral stent or nephrostomy without the need for surgical revision (i.e., tube free). Mean balloon diameter used for ureteroplasty in the urinary diversion and renal transplant cohorts was 7.7 mm and 6 mm, respectively (p < 0.01). Mean French size of PCNU or stent placed after ureteroplasty was 10 French. In the UEA group, 8/31 (25%) patients underwent surgical revision and 18/31 (58%) required chronic ureteral stents after failed ureteroplasty. Only 5/31(16%) were tube free without surgery. In the UVA cohort, 2/23 (8%) patients underwent surgical revision and 9/23 (39%) required chronic indwelling ureteral stents after failed ureteroplasty. 12/23 (52%) renal transplant patients were tube free without surgery. By Kaplan Meier analysis, the actuarial mean time to PCNU or stent removal was 81 ± 10 months and 41 ± 11 months for UEA and UVA respectively (p = 0.01). Ureteroplasty had greater success in achieving the primary endpoint of freedom from PCNU or ureteral stent in patients after renal transplantation as compared with patients after urinary diversion.

Cochlear implant revision surgeries in children

IntroductionThe surgery during which the cochlear implant internal device is implanted is not entirely free of risks and may produce problems that will require revision surgeries. ObjectiveTo verify the indications for cochlear implantation revision surgery for the cochlear implant internal device, its effectiveness and its correlation with certain variables related to language and hearing. MethodsA retrospective study of patients under 18 years submitted to cochlear implant surgery from 2004 to 2015 in a public hospital in Brazil. Data collected were: age at the time of implantation, gender, etiology of the hearing loss, audiological and oral language characteristics of each patient before and after cochlear implant surgery and any need for surgical revision and the reason for it. ResultsTwo hundred and sixty-five surgeries were performed in 236 patients. Eight patients received a bilateral cochlear implant and 10 patients required revision surgery. Thirty-two surgeries were necessary for these 10 children (1 bilateral cochlear implant), of which 21 were revision surgeries. In 2 children, cochlear implant removal was necessary, without reimplantation, one with cochlear malformation due to incomplete partition type I and another due to trauma. With respect to the cause for revision surgery, of the 8 children who were successfully reimplanted, four had cochlear calcification following meningitis, one followed trauma, one exhibited a facial nerve malformation, one experienced a failure of the cochlear implant internal device and one revision surgery was necessary because the electrode was twisted. ConclusionThe incidence of the cochlear implant revision surgery was 4.23%. The period following the revision surgeries revealed an improvement in the subject's hearing and language performance, indicating that these surgeries are valid in most cases.

The Utility of a Benign Biliary Stricture Protocol in Preventing Symptomatic Recurrence and Surgical Revision

PurposeTo determine whether treating benign biliary strictures via a stricture protocol reduced the probability of developing symptomatic recurrence and requiring surgical revision compared to nonprotocol treatment. Materials and MethodsA stricture protocol was designed to include serial upsizing of internal/external biliary drainage catheters to a target maximum dilation of 18-French, optional cholangioplasty at each upsizing, and maintenance of the largest catheter for at least 6 months. Patients were included in this retrospective analysis if they underwent biliary ductal dilation at a single institution from 2005 to 2016. Forty-two patients were included, 25 women and 17 men, with an average age of 51.9 years (standard deviation ± 14.6). Logistic regression models were used to determine the probability of symptomatic recurrence and surgical revision by stricture treatment type. ResultsTwenty-two patients received nonprotocol treatment, while 20 received treatment on a stricture protocol. After treatment, 7 (32%) patients in the nonprotocol group experienced clinical or laboratory recurrence of a benign stricture, whereas only 1 patient in the stricture protocol group experienced symptom recurrence. Patients in the protocol group were 8.9 times (95% confidence interval [CI] = 1.4–175.3) more likely to remain symptom free than patients in the nonprotocol group. Moreover, patients in the protocol group had an estimated 89% reduction in the probability of undergoing surgical revision compared to patients receiving nonprotocol treatment (odds ratio = .11, 95% CI = .01–.73). ConclusionsEstablishing a stricture protocol may decrease the risk of stricture recurrence and the need for surgical revision when compared to a nonprotocol treatment approach.

Biceps Augmentation Using Solid Silicone Implants.

Biceps augmentation using solid silicone implants has been increasingly requested in recent years despite a paucity of literature evaluating the safety and efficacy of this procedure. The purpose of this study was to provide information about complications, surgical planning, and aesthetic outcomes of biceps augmentation. A retrospective chart review was conducted for patients undergoing solid silicone biceps augmentation in the author's practice from April 2011 through May 2016. Collected data were analyzed to assess the indications for surgery, quantity of complications, and need for surgical revision, and to evaluate aesthetic outcome. Twenty-one male patients were included in the study. The mean age was 42.6 years and the mean follow up was 7.1 months. Indications for surgery include a desire to increase biceps size (n = 16), and correction of biceps deformity after biceps tendon rupture (n = 5). Eight patients underwent subfascial implant placement and 13 submuscular implant placement. Complications occurred in 10 patients (48%) including asymmetry (n = 4), seroma (n = 3), surgical site infection (SSI) (n = 1), cellulitis (n = 1), and hematoma (n = 1). The overall reoperation rate was 23.8%. Implant malposition occurred in 3 of the 8 (38%) of subfascial implant placement patients. Complications requiring revision surgery were higher for subfascial implants 37.5% vs 15.4% for submuscular. Biceps augmentation with a solid silicone implant can increase upper arm volume and correct asymmetry and deformity resulting from muscle injury. Submuscular biceps implant placement is recommended over subfascial insertion to avoid implant malposition.

Spinal or general anaesthesia for lower‐limb amputation in peripheral artery disease – a retrospective cohort study

The present study aimed to determine which method of anaesthesia (spinal anaesthesia or general anaesthesia) is better in reducing post-operative analgesic requirements in patients undergoing major limb amputation for lower-limb ischaemia. Another aim was to find out if anaesthesiologists use neuraxial anaesthesia in high-risk patients despite abnormal coagulation profile or use of anticoagulation. The study was a retrospective cohort study. All patients undergone above-the-knee amputation or below-the-knee amputation due to peripheral artery disease between 1996 and 2010 were reviewed to evaluate post-operative opioid consumption and complications. A total of 434 amputations in 323 patients were included in the study. The number of surgical complications, the need for surgical revision and the number of intensive care unit admissions were significantly higher in the general anaesthesia group. The need for post-operative opioid medication was significantly lower in patients with above-the-knee amputation and spinal anaesthesia. The use of post-operative epidural analgesia did not reduce analgesic requirements. In the present study, there were patients who received neuraxial anaesthesia despite abnormal coagulation profile or uninterrupted warfarin or clopidogrel. There were no reported cases of spinal or epidural haematoma. Patients with spinal anaesthesia had a lower rate of surgical complications, re-operations and intensive care unit admissions. Patients with above-the-knee amputation and spinal anaesthesia had a lesser need for opioid medication in the post-operative period than patients with general anaesthesia. Anaesthesiologists performed neuraxial anaesthesia and/or analgesia in high-risk patients despite abnormal coagulation profile or ongoing anticoagulation, but no adverse outcomes were reported.