One-stage Procedure Research Articles

Arnica montana and Bellis perennis for seroma reduction following mastectomy and immediate breast reconstruction: randomized, double-blind, placebo- controlled trial

Seroma is a common surgical complication created by the inflammatory process that follows mastectomy and reconstruction [9–15]. It is, therefore, common practice to insert surgical drains, which often remain in place for long periods and delay recovery [26, 27]. In light of the many advantages of homeopathic treatment, there has been a global trend of integrating this with conventional medicine [29]. In this study, we examined the effect of Arnica montana and Bellis perennis on seroma prevention after mastectomy and breast reconstruction. This was a prospective double-blinded randomized analysis of 55 consecutive patients (78 breasts), who underwent mastectomy and immediate breast reconstruction between January 2016 and August 2017. Patients were randomly assigned and treated with Arnica montana and Bellis perennis or placebo from surgery and up to the time of drain removal. The mean patient age was 47.9 years. Comorbidities included obesity, diabetes mellitus, essential hypertension, fibromyalgia, and hypothyroidism (1, 4, 6, 2, and 4 patients respectively). Age, body mass index, mastectomy type, and lymph node dissection were similar among groups. Forty-two breasts underwent one-stage procedure, and the remaining were two-stage. Arnica montana and Bellis perennis significantly reduced drain removal time (discharge < 30 ml) by 18% (2.4 days, p < 0.05), 11.1 (6.1) days in the study groups compared with 13.5 (6.4) days in the placebo group. Patient opioid intake was lower (p < 0.057) in the study group. Quality of life, postoperative pain, hemoglobin and cortisol levels, and complications were not associated with any treatment. Arnica montana and Bellis perennis have been shown to reduce seroma formation and opioid intake following mastectomy and reconstruction. As this treatment lacks side effects and is inexpensive, it should serve as a valuable treatment adjunct in patients undergoing mastectomy and reconstruction. Level of evidence: Level I, therapeutic study.

Metoidioplasty as a one-stage phallic reconstruction in transmen

Gender dysphoria is a condition where there is a discrepancy between the gender assigned at birth and the desired gender, leading the patient to pursue surgical intervention. Reconstruction of the neophallus for transmen is still challenging, even though there are many surgical techniques with satisfying results. The aim of neophallic reconstruction in gender affirmation surgery (GAS) for transmen is to provide stand-up voiding, erotic sensation, orgasm and penetration ability, and acceptable donor site morbidity with minimal scarring and complications. Metoidioplasty as a variant of phalloplasty for transmen is a one-stage procedure that results in male-like external genitals, with minimal scarring, ability of standing micturition, and full erogenous sensation with the ability to achieve orgasm during sexual intercourse. Metoidioplasty is a method of choice for those transmen who wish to have GAS in one procedure without multi-staged procedures to create the adult-male-sized neophallus.

Revisiting the Rintala advancement flap for nasal tip reconstruction

The approach to nasal reconstruction is based on the nature of the defect and the donor tissue. The Rintala flap, first described by Rintala and Asko-Slejavaara, is a surgical technique used to close midline nasal defects. It is a simple, one-stage procedure and is most effective for defects ranging from 1.5 to 2.5 centimeters. In addition, the Rintala flap is an excellent tissue match and maintains the natural contour of the nose. Other flaps employed in nasal defect closure include the paramedian forehead flap and the Rieger flap. The authors discuss the Rintala flap technique and utility with comparison to alternative flaps used for nasal reconstruction.

Immediately Loaded Single Unit Dental Implants: A Clinical Study.

ABSTRACTBackground:Immediate loading of dental implants is an obvious advantage. A long treatment period that involves the wearing of a temporary prosthesis may be of great inconvenience, and is sometimes the reason for not choosing implant-supported restorations at all.Aim:In our study, an attempt was made to immediately load single tooth implants in the aesthetic zone of the dentition.Materials and Methods:Patients were selected from Government Dental College, Patna. Twenty-four single tooth implants were placed in 24 patients; 12 male and 12 female patients desiring replacement of one or more missing teeth in anterior region were selected. Surgery for the placement of the implant was carried out, and implants of the Uniti Implant System were placed. The abutment was then attached and the flap was sutured. A temporary acrylic resin crown was fabricated and cemented on the same day. Permanent prosthesis was inserted on sixth month after implant placement.Results:A clinical study was performed to evaluate the treatment outcomes of dental implants installed according to a one-stage surgical procedure followed by immediate loading with prosthesis. Of the 24 implants, 23 showed signs of successful osseointegration over a 1-year follow-up.Conclusion:Within limits of the evaluated data, it was observed that immediately loaded implants osseointegrate, so this alternative was used over conventional procedures that take 6 months for osseointegration. This has advantages, both for patient and practitioner.

Decreasing complication rates for one-stage conversion band to laparoscopic sleeve gastrectomy: A retrospective cohort study.

Background:Laparoscopic adjustable gastric banding (LAGB) revision surgery is often necessary because of its high failure rate. The objective of this study was to demonstrate that better patient selection, when converting a failed LAGB to a laparoscopic sleeve gastrectomy (LSG) as a one-stage revision procedure, is safe, feasible and improves the complication rate.Patients and Methods:A retrospective chart review was performed on patients who underwent a one-stage conversion of failed gastric banding to a LSG. Collected data included age, sex, body mass index (BMI), intraoperative complications, length of stay and post-operative complications. The results were compared to a previous study of 90 cases of LSG as a revision procedure for failed LAGB.Results:There were 75 patients in the current study, 61 women and 14 men, aged 25–67 (average: 46), with a mean BMI of 45 kg/m2 (32–66). Seventy patients (93.3%) were operated for insufficient weight loss and 5 patients (6.7%) for intolerance to the band. In our previous study, 35 patients (39%) were operated for slippage, erosion or obstruction and 14 (15.6%) had post-operative complications as opposed to only 4 patients (5.3%) in this series (P = 0.0359). Gastric leak also improved to 1.3% compared to 5.5% previously. Average hospitalisation time was 2.5 days (1–40).Conclusions:Rigorous patient selection, without band complications such as slippage, erosion or obstruction, allows for a significantly lower rate of operative complications for a one-stage conversion of failed gastric banding to a LSG.

Sex-specific effects of nutritional supplements in infants born early or small: protocol for an individual participant data meta-analysis (ESSENCE IPD-MA)

IntroductionPreterm and small for gestational age (SGA) infants are at increased risk of poor growth, disability and delayed development. While growing up they are also at increased risk of obesity,...

CORR Synthesis: What Is the Evidence for the Clinical Use of Stem Cell-based Therapy in the Treatment of Osteoarthritis of the Knee?

CORR Synthesis: What Is the Evidence for the Clinical Use of Stem Cell-based Therapy in the Treatment of Osteoarthritis of the Knee?

Peri-Prosthetic Joint Infection after Finger Joint Arthroplasty.

Background: Endoprosthetic treatment of finger joints is an established procedure. However, data on peri-prosthetic finger joint infections (PJI) are rare. The goal of this retrospective study was to assess infection rates and treatment outcomes after PJI of the finger joints. Methods: Between 1984 and 2014, 1,195 finger joints (978 metacarpal and 217 proximal interphalangeal [PIP] joints) in 518 patients were treated. A retrospective record analysis was conducted. Besides demographic data, infection rates, types of revision surgery, and treatment outcomes were evaluated. Treatment strategies changed during the treatment period. Routinely assessed patient-reported outcome measures, namely the QuickDASH score, visual analogue scale (VAS), an everyday function score (activities of daily living; ADL), and an adapted Clayton score, were compared. Results: In 36 finger joints of 30 patients, a post-operative peri-prosthetic infection could be identified (3%). Infections occurred on average 3.8 years after arthroplasty. For meta-carpal phalangeal (MCP) joints, the best clinical outcomes could be observed after a two-stage revision procedure (QuickDASH score 86). Arthrodesis performed in a one-stage procedure achieved favorable outcomes in PIP joints (QuickDASH score 89). Re-infection mandating revision surgery occurred in seven joints in five patients (7/36; 19.4%). In 25 patients with 29 finger joints, there was no re-infection and no need for revision. Conclusion: Peri-prosthetic infection of finger joint prostheses occurs in approximately 3% of all cases, which is a higher rate than in the more common hip and knee procedures. For MCP joint revision surgery, a two-stage procedure seems to be the best treatment choice. For PIP joint revision, a single-stage revision with arthrodesis in a functional position achieves a good outcome.

Transumbilical enterostomy for Hirschsprung's disease with a two-stage laparoscopy-assisted pull-through procedure.

BACKGROUNDA one-stage laparoscopic operation has recently been considered a favorable option for the management of patients with Hirschsprung's disease (HD) due to its superior cosmetic results. One-stage transanal endorectal pull-through for the treatment of rectosigmoid HD has been widely used in newborns without complications. However, enterostomy is required in some HD cases for enterocolitis and dilated colon. Our transumbilical enterostomy (TUE) and two-stage laparoscopy-assisted anorectoplasty were effective and achieved a similar cosmetic effect to one-stage laparoscopy on the abdominal wall in patients with anorectal malformation, but the effect in patients with HD is unclear.AIMTo evaluate the safety, efficacy and cosmetic results of TUE in two-stage laparoscopy-assisted pull-through for HD.METHODSFrom June 2013 to June 2018, 53 patients (40 boys, 13 girls; mean age at enterostomy: 5.5 ± 2.2 mo) who underwent enterostomy and two-stage laparoscopy-assisted pull-through for HD with stoma closure were reviewed at our institution. Two enterostomy approaches were used: TUE in 24 patients, and conventional abdominal enterostomy (CAE) in 29 patients. Eleven patients with rectosigmoid HD had severe preoperative enterocolitis or a dilated colon. 26 patients had long-segment HD, and 16 patients had total colonic aganglionosis (TCA). The patients with left-sided HD underwent the two-stage laparoscopic Soave procedure, and the patients with right-sided HD and TCA underwent the laparoscopic Duhamel procedure. Demographics, enterostomy operative time, complications and cosmetic results were respectively evaluated.RESULTSThere were no differences between the groups with respect to gender, age at enterostomy, weight and clinical type (P > 0.05). No conversion to open technique was required. Two patients experienced episodes of stomal mucosal prolapse in the TUE group and 1 patient in the CAE group (8.33% vs 3.45%, P > 0.05). No parastomal hernia was observed in either of the two groups. Wound infection at the stoma was seen in 1 case in the TUE group, and 2 cases in the CAE group (4.17% vs 6.90%, P > 0.05). No obstruction was noted in any of the patients in the TUE group, whereas obstruction was found in 1 patient in the CAE group. Enterocolitis was observed in 3 and 5 patients in the TUE and CAE group, respectively (12.50% vs 17.24%, P > 0.05). There was no significant difference between the TUE group and CAE group in terms of the incidence of soiling and constipation (P > 0.05). The cosmetic result using the scar score in the TUE group was better than that in the CAE group (6.83 ± 0.96 vs 13.32 ± 1.57, P < 0.05).CONCLUSIONTUE is a safe and feasible method for the treatment of HD, and the staged enterostomy and two-stage laparoscopy-assisted pull-through achieved a similar cosmetic effect to the one-stage laparoscopic procedure.

Controlled Release of Vancomycin and Tigecycline from an Orthopaedic Implant Coating Prevents Staphylococcus aureus Infection in an Open Fracture Animal Model

Introduction Treatment of open fractures routinely involves multiple surgeries and delayed definitive fracture fixation because of concern for infection. If implants were made less susceptible to infection, a one-stage procedure with intramedullary nailing would be more feasible, which would reduce morbidity and improve outcomes. Methods In this study, a novel open fracture mouse model was developed using Staphylococcus aureus (S. aureus) and single-stage intramedullary fixation. The model was used to evaluate whether implants coated with a novel “smart” polymer coating containing vancomycin or tigecycline would be colonized by bacteria in an open fracture model infected with S. aureus. In vivo bioluminescence, ex vivo CFUs, and X-ray images were evaluated over a 42-day postoperative period. Results We found evidence of a markedly decreased bacterial burden with the local release of vancomycin and tigecycline from the PEG-PPS polymer compared to polymer alone. Vancomycin was released in a controlled fashion and maintained local drug concentrations above the minimum inhibition concentration for S. aureus for greater than 7 days postoperatively. Bacteria were reduced 139-fold from implants containing vancomycin and undetected from the bone and soft tissue. Tigecycline coatings led to a 5991-fold reduction in bacteria isolated from bone and soft tissue and 15-fold reduction on the implants compared to polymer alone. Antibiotic coatings also prevented osteomyelitis and implant loosening as observed on X-ray. Conclusion Vancomycin and tigecycline can be encapsulated in a polymer coating and released over time to maintain therapeutic levels during the perioperative period. Our results suggest that antibiotic coatings can be used to prevent implant infection and osteomyelitis in the setting of open fracture. This novel open fracture mouse model can be used as a powerful in vivo preclinical tool to evaluate and optimize the treatment of open fractures before further studies in humans.

One-stage treatment of hip dislocation with cerebral palsy via soft tissue release, hip reduction and osteotomy

Objective To investigate the methods and outcomes of surgical treatment for hip dislocation with cerebral palsy (CP) via soft tissue release, hip reduction and osteotomy. Methods Nineteen CP patients (male: 9, female: 10; total 23 hips) with hip dislocation underwent reconstructive surgery between April 2010 and December 2016. The average age was 12.5±2.4 years. There were 17 diplegic, 1 hemiplegic and 1 quadriplegic patient. Gross motor function classification system distribution were type I in 2 patients, type II in 10 patients, type III in 5 patients, type IV in 2 patients. Combine one-stage surgical procedures included soft tissue release, close or open reduction of hip joint and femoral varus shortening or de-rotational osteotomy and pelvic osteotomy. During the follow-up period, the clinical symptom and radiological parameters including Sharp angle and acetabular index were recorded. Results The average follow-up duration was 2.1 years (1-4.5 years). The radiological parameters were evaluated at one year postoperatively. The migration percentage corrected to 6%±8% from 68%±21% with statistically significant different (t=12.760, P<0.001). The mean Sharp angle was 42°±8.9°, which was statistically significant reduced compared with the pre-operative value 59°±6.1° (t=9.058, P<0.001). In 15 patients with triradiate cartilage open, the acetabular index also improved from 34°±8.7° pre-operatively to 18°±10° with statistical significance (t=5.598, P<0.001). Total of 15 patients had gained hip stability and improved functional status. Hip pain, which happened in 11 patients preoperatively, all had relieved after operation. Four patients had dissatisfied results and re-subluxation happened in 3 hips. All of them had CE angle <20° immediately after operation (average, 17°±2.6°), which was significantly different compared with average CE angle 32°± 8.0° in non-recurrence hips (t=3.143, P=0.005). One patient, who underwent proximal hamstring release, had decline of function status and contralateral hip dislocation. Conclusion Dislocation hips in CP patients can be effectively treated with one stage soft tissue release, hip reduction and femoral and pelvic osteotomy. The selection of osteotomy method is based on the age and pathological changes of patients. Key words: Cerebral palsy; Hip dislocation; Osteotomy

Lateral-Expansion Pharyngoplasty: Combined Technique for the Treatment of Obstructive Sleep Apnea Syndrome.

Introduction Obstructive sleep apnea syndrome (OSAS) is a multifactorial disease characterized by episodes of partial or complete collapse during sleep of different regions of the upper airway. Surgery for OSAS evolved with the introduction of different techniques, considering new surgical concept of reconstruction of the upper airway. Objective To retrospectively evaluate the effectiveness of a new approach aimed at reducing pharyngeal collapse by combining two surgical techniques: lateral and expansion pharyngoplasty. Methods We reviewed the medical records of 38 patients with OSAS undergoing lateral/expansion pharyngoplasty from January 2012 to December 2016. The following data were collected: patient age, gender, and pre- and postoperative body mass index (BMI), Epworth sleepiness scale (ESS) scores, snoring visual analogue scale (VAS) scores, and polysomnography (PSG) results. Results The PSG results showed a significant reduction in the apnea/hypopnea index (AHI) from 22.4 ± 27.3 events/h preoperatively to 13.6 ± 17.9 events/h postoperatively ( p = 0.009), with postoperative AHI reduction greater than 50% in 63.2% of the patients. There was also a significant reduction in the microarousal index (19.5 ± 22.6 vs 11.0 ± 13.4 events/h; p = 0.001) and in the minimum oxygen saturation (82.6 ± 10.3 vs 86.9 ± 11.1; p = 0.007). Conclusions Lateral-expansion pharyngoplasty represents a new surgical strategy for the treatment of OSAS in patients with palatal collapse by combining two different techniques: lateral and expansion pharyngoplasty. The two techniques, performed as a one-stage procedure, led to improvements in excessive daytime sleepiness, snoring, and PSG respiratory parameters by acting on lateral and retropalatal collapse, producing favorable results with good applicability in otolaryngology clinical practice.

Acellular dermal matrices as an adjunct to implant breast reconstruction: Analysis of outcomes and complications

PurposeAcellular dermal matrices (ADM) are increasingly used in implant-based breast reconstruction (IBR). Uncertainty remains with regard to their efficacy and complications. The aim of this study was to evaluate the outcomes and complication rates associated with the use of ADMs in IBR. MethodsRetrospective cohort study of patients undergoing ADM-assisted IBR between 2008 and 2013. Cases were identified from a prospectively collected database. Simple descriptive statistics and logistic regression analysis were performed. ResultsA total of 110 patients (175 mastectomies) were included in the analysis. The median age was 46 (19–75) years and the median BMI was 22.2 (16.2–41.5). Seventy nine mastectomies were performed for therapeutic purposes. The median mastectomy weight was 244 (185–335) gr. The majority of reconstructions were performed with fixed volume (n = 115, 66%) or permanent expandable implants (n = 53, 30%) as one-stage procedures. Forty mastectomies were associated with at least one complication. The infection rate was 2.3% (n = 4). Post-operative haematoma developed in 5 cases (2.9%), but only 2 required surgical interventions. Three mastectomies were complicated by nipple necrosis (3.6%), 3 with skin necrosis (1.7%) and 9 with wound dehiscence (5.1%). The capsule formation rate was 2.3% (n = 4). Reconstruction failure with implant loss occurred in 3 cases (1.7%). ConclusionsThe complication rates following ADM-assisted IBR can be very low with appropriate patient selection and meticulous surgical technique. This supports the safety of using ADM in carefully selected patients. Further research is warranted to assess the health economics of ADM use in IBR.

An automated method for segmentation and quantification of blood vessels in histology images

Alzheimer's disease (AD) is a chronic neuro-degenerative disease that adversely affect many people on a global scale. Despite different diagnostic and therapeutic treatment, there is no cure for AD. The brain is one of the most complex organ and researchers are still trying to understand so as to find a cure. Objective: To complement the efforts of clinical researchers engaged in research in alzheimer's disease, accurate segmentation and quantification of blood vessels in brain images is required. Method: For robust segmentation of blood vessels even in the presence of colour variation, we introduce a fully automated morphological tool that can extract and quantify vessels from haematoxylin and diaminobenzidine stained histology brain image. The method, exploits saturation channel of stained image slides, ISODATA threshold method is applied to obtain a binary image. This helps in eliminating background and remaining with only blood vessels. A one-stage procedure that includes eliminating small artefacts is performed on the binary mask. The intensity of the image is transformed. Joining is performed to deal with fragmentation of intact blood vessels on the images, and artefactual appearance of the blood vessel structures. The artefactual fragments based on measured incoherence with neighbouring tissue are removed. The vessels are then labelled to facilitate quantification. Morphometric measurements are used during the vessel quantification assess both vessels with lumen and vessels without lumen. We have quantified the diameter of blood vessels. Results: The image processing technique is developed in close collaboration with neuroscientist experts to help clinician. We have evaluated our proposed approach qualitatively. The method was validated against their manual quantification results. Qualitative results show that the method can indeed segment the blood vessels in the presence of colour variations and artefacts. The quantitative method produces fairly better results.

Prevalence, assessment and surgical correction of penile curvature in hypospadias patients treated at one European Referral Center: description of the technique and surgical outcomes.

Penile curvature (PC) is a common component of hypospadias, but its presence is inconstantly assessed. We aim to report prevalence of PC in hypospadias patients, as well as to report our method to assess and correct PC, with the associated postoperative outcomes. We scrutinized 303 pediatric hypospadias patients operated (2013-2018) at our referral center. PC was routinely assessed and eventually corrected with dorsal plications (DP) as one-stage procedure, or ventral tunica attenuations ± DP as two-stage repair. PC severity and surgical treatment of PC were compared between primary and failed hypospadias. Finally, PC severity, failed repair and PC treatment were tested as predictors of perioperative complications. PC (> 10°) was identified in 274/303 (90.4%) patients, 86.1% with distal, 91.8% with midshaft, and 100% with proximal hypospadias, respectively. PC was found in 51/64 (79.7%) of failed hypospadias. One-stage and two-stage procedures were adopted in 211/274 (77%) and 63/274 (23%) children, respectively. PC severity (p = 0.1) and PC treatment (p = 0.4) did not differ between primary and failed hypospadias. PC severity (all p > 0.2), failed repair (p = 0.8), and PC treatment (all p > 0.09) were not predictors of perioperative complications. 95.6% of patients achieved a straight penis. Less than 1/10 patients did not require PC correction. High rate of residual PC in failed hypospadias and similar severity between failed and primary suggest that PC was usually under-corrected. It is possible to correct PC completely and the resulting complication would not be associated with PC severity, failed repair or treatment adopted.

Foot salvage using microsurgical free muscle flaps in severely crushed foot with soft tissue defects

ObjectiveManagement of complex foot injuries including skin, tendons, vessels, bone, with soft tissue defects is considered as an orthopedic challenge. Microsurgical free muscle flaps provide the best solution in such cases. Patients and methodsThirty two consecutive cases of complex ankle and foot injuries were treated by skin grafted muscle free flap in one stage procedure after radical debridement. Twenty four were males and 8 were females. Right foot was affected in 26 and left was involved in 6 patients. The average age was 22 years (range 6–33 years). The most common cause of injury was motor car accident. All cases had complex soft tissue defect with bone exposure. All cases were candidate for amputation. Gracilis muscle transfer was done in 26 cases and latissimus dorsi free flap in 6 cases. The average follow up was 38 months. ResultsAll the free muscle flaps survived. The involved bone fracture was united at an average 3 months. No evidence of osteomyelitis was noted. Full weight bearing was restored 3 months post-operatively. All patients were satisfied with the cosmetic appearance and functional capacity of their operated limbs. ConclusionSkin-grafted free muscle flap as one-stage procedure is a good solution for reconstruction of complex ankle and foot injuries.

401. Predictors of Treatment Failure for Hip and Knee Prosthetic Joint Infections in the Setting of Prosthesis Removal: A Multi-Center Retrospective Cohort

BackgroundProsthetic hip and knee joint infections (PJIs) are challenging to eradicate despite prosthesis removal and long courses of antibiotics. We aimed to describe the risk factors for PJI treatment failure in a multicenter retrospective cohort.MethodsA retrospective cohort of individuals who underwent prosthetic joint removal for a PJI at one of five hospitals in Toronto, Ontario, Canada from 2010–2014. Individuals eligible for the cohort were obtained by searching operative listings and PJIs were defined according to the criteria of the Musculoskeletal Infection Society. Treatment failure was defined as recurrent PJI, amputation, death or chronic antibiotic suppression. Potential risk factors for treatment failure were abstracted by chart review and assessed using a Cox proportional hazards model.Results533 PJIs were analyzed over a median follow-up duration of 1102 days with 21 surgeons performing more than 5 revision arthroplasties for a PJI. Two-stage procedures were performed in 81% (430/533) and the most common organism was coagulase negative staphylococci (32%). Treatment failure occurred in 28% (150/533) over 1443 patient-years and was caused by a different bacterial species in 53% (56/105). On multivariate analysis the characteristics associated with PJI treatment failure included liver disease (adjusted hazard ratio (aHR) 3.12, 95% confidence interval (95% CI) 2.09–4.66), the presence of a sinus tract (aHR 1.53, 94% CI (1.12–2.10), preceding debridement with prosthesis retention (aHR 1.68, 95% CI 1.13–2.51), a one-stage procedure (aHR 1.72, 95% CI (1.28–2.32), and infection due to Gram-negative bacilli (aHR 1.35, 95% CI 1.04–1.76).ConclusionPJI treatment failure remains high despite prosthesis removal and the patient risk factors identified are non-modifiable. Novel treatment paradigms are urgently needed along with efforts to reduce orthopedic surgical site infections.Disclosures All authors: No reported disclosures.

Clinico-pathological Features of Colon Cancer Patients Undergoing Emergency Surgery: A Comparison Between Elderly and Non-elderly Patients.

BackgroundColorectal cancer (CRC) is one of the most common cancers in patients older than 65 years. Emergency presentation represents about 30% of cases, with increased morbidity and mortality rates. The aim of this study is to compare the perioperative outcome between elderly and non-elderly patients undergoing emergency surgery.MethodWe retrospectively analysed CRC patients that underwent emergency surgery at the Departments of Surgery of the Sapienza University Sant’Andrea Hospital in Rome, and at San Donato Hospital in Arezzo, between June 2012 and June 2017. Patients were divided into two groups: non-elderly (< 65 years) and elderly (≥ 65 years). Variables analysed were sex, onset symptoms, associated disease, ASA score, tumor site and TNM stage, surgical procedures and approach, and morbidity and mortality.ResultsOf a total of 123 patients, 29 patients were non-elderly and 94 patients were elderly. No significant differences were observed in sex, onset symptoms and tumor site between the two groups. Comorbidities were significantly higher in elderly patients (73.4% vs 41.4%, p<0.001). No significant differences were observed between the two groups in surgical approach and the rate of one-stage procedures. Elderly patients were more frequently treated by Hartmann’s procedure compared to non-elderly patients (20.2% vs 6.9%). Left colorectal resection with protective ileostomy was most frequent in the non-elderly group (27.6% vs 11.7%). No significant differences were found in the pT and pN categories of the TNM system between the two groups. However, a higher number of T3 in non-elderly patients was observed. A consistent number of non-oncologically adequate resections were observed in the elderly (21.3% vs 3.5%; p<0.03). The morbidity rate was significantly higher in the elderly group (31.9 % vs 3.4%, p<0.001). No significant difference was found in the mortality rate between the two groups, being 13.8% in the elderly and 6.9% in the non-elderly.ConclusionsEmergency colorectal surgery for cancer still presents significant morbidity and mortality rates, especially in elderly patients. More aggressive tumors and advanced stages were more frequent in the non-elderly group and as a matter it should be taken into account when treating such patients in the emergency setting in order to perform a radical procedure as much as possible.

Staged Revision with Antibiotic Spacers for Infected Hindfeet vs One-Stage Revision Using an Ilizarov Ringfixator: What’s Better?

Category:HindfootIntroduction/Purpose:The treatment of hindfeet infections with a two-stage revision surgery using an antibiotic-loaded cement spacer is an established treatment strategy. If the soft tissue situation is critical or if patients do have severe comorbidities, the use of a one-stage procedure, using an Ilizarov ringfixator to perform the arthrodesis is also an option. We wanted to compare the outcome of patients who either received the two-stage revision or the one-stage procedure.The purpose of the study was to determine the likelihood of infection control and radiological consolidation of the arthrodesis after either two-stage or one-stage revision in patients with hindfoot infection, as defined by the Musculoskeletal Infection Society PJI criteria. The postoperative AOFAS score was used to measure the clinical outcome.Methods:Between 1995 and 2015, we treated 12 patients with a two-stage procedure using an antibiotic-loaded cement spacer, followed by antibiotic therapy. The second stage consisted of a hindfoot arthrodesis. Of those, 7 were available for review at a minimum of 24 months. 3 were excluded because they were deceased (due to old age). Two moved abroad, leaving 7 patients for analysis.During the same time period we treated 13 patients with a one-stage hindfoot arthrodesis using an Ilizarov ringfixator. Of those, 10 were available for review at a minimum of 24 months. 2 were excluded because they were deceased due to old age, leaving 10 patients for analysis.The primary outcome included the proportion of patients achieving infection control, defined as the absence of the Musculoskeletal Infection Society PJI criteria. Radiological consolidation on standard foot X-rays was also determined. The clinical outcome was assessed with the AOFAS hindfoot score.Results:Successful infection control in the two-stage revision group was achieved in 6 out of 7 patients (86%). One patient achieved infection control only after a below-knee amputation. The mean AOFAS score at the latest follow-up was 75.Radiological consolidation was achieved in 70% (5 out of 7, with one patient needing an amputation for infection control).In the Ilizarov-group, successful infection control was achieved in 9 out of 10 patients (90%). One patient achieved infection control only after a below-knee amputation. The mean AOFAS score at the latest follow-up was 70. Radiological consolidation was achieved in 80% (8 out of 10, with one patient needing an amputation for infection control).Conclusion:A one-stage arthrodesis using an Ilizarov ringfixator for infection control in infected hindfeet leads to comparable infection control and radiological consolidation as the established two-stage procedure with an antibiotic-loaded cement spacer. The clinical outcome, measured by the AOFAS hindfoot score, is also comparable in both groups. The one-stage procedure using an Ilizarov ringfixator should therefore be considered as a treatment option, when soft tissues or comorbidities do not allow a two-stage procedure. It is an option to avoid a below-knee amputation in those patients.

Two-year follow-up of one-stage left unilateral thoracoscopic epicardial and transcatheter endocardial ablation for persistent and long-standing persistent atrial fibrillation.

The purpose of this study was to analyze the efficacy and complication rates of a one-stage left unilateral thoracoscopic hybrid procedure in a series of patients with persistent and long-standing persistent atrial fibrillation (AF) in a 2-year follow-up. Fifty-one consecutive patients (34 males, 65.7 ± 8years) having undergone hybrid isolation of pulmonary veins (PVs) and posterior wall of left atrium (LA) by means of left unilateral hybrid thoracoscopic ablation for symptomatic persistent (n = 22, 43%) and long-standing persistent atrial fibrillation (AF) (n = 29, 57%) were analyzed. At a mean follow-up of 24.9 ± 11.8months (median 24), the success rate without antiarrhythmic therapy was achieved in 68.6% of patients. Procedure-related major complications were observed in 2 patients (4%) including diaphragmatic perforation and late pericardial tamponade requiring mini left-sided thoracotomy and pericardial drainage, respectively. The success rate did not significantly differ between persistent and long-standing persistent AF (respectively, 68.2 and 69%; P =0.89). Patients with AF relapse during the blanking period were 3.8 times more likely to have AF recurrence after 3months from the ablation procedure. The hybrid one-stage left unilateral thoracoscopic procedure exhibits encouraging results in the setting of both persistent and long-standing persistent AF after a 2-year follow-up, at a low rate of adverse events.