Open Surgical Treatment Research Articles

Hybrid and open repair for patients with acute limb ischemia of the lower extremities.

Hybrid revascularization procedures for acute limb ischemia (ALI) are becoming increasingly common, bibliographic data on outcomes is however sparse. Single-center, retrospective study of consecutive patients with ALI that underwent either surgical treatment (ST) or hybrid treatment (HT) between January 2015 and December 2021. The composite outcome of amputation-free survival (AFS) was the primary endpoint. Technical success, overall survival, amputation, and re-intervention rates were the secondary endpoints. During the study period 266 patients (mean age 70.2±14.5 years; 49.6% males) were treated for ALI, 67.3% undergoing ST and 32.7% HT. HT was more frequently used in patients with a previous vascular intervention in the index limb (38/87; 43.7% HT vs. 40/179; 22.3% ST, P=0.001), a stent- or stent graft-occlusion (16/87; 18.4% HT vs. 10/179; 5.6% ST, P=0.002) and/or a bypass occlusion (16/87; 18.4% HT vs. 16/179; 8.9% ST, P=0.043). Technical success was higher in the OR group (75/87; 86.2% HT vs. 173/179; 96.6% ST, P=0.003). Amputation-free survival rate during follow-up (43/87; 49.4% HT vs. 94/179; 52.5% ST, HR 0.76, 95% CI: 0.49 to 1.18, P=0.22) and overall survival (32/87; 36.8% HT vs. 84/179; 46.9% ST, HR 0.81, 95% CI: 0.49 to 1.34, P=0.41) were comparable between the two groups. No statistical differences were observed between the groups regarding major amputation (19/87; 21.8% HT vs. 15/179; 8.4% ST, HR 0.85, 95% CI: 0.33 to 2.23, P=0.74) or reintervention during follow-up (45/87; 51.7% HT vs. 65/179; 36.3% ST, HR 0.92, 95% CI: 0.56 to 1.51, P=0.73). Hybrid and open surgical treatments showed comparable results in our cohort, even though significantly more patients undergoing HT presented with stent and bypass occlusions rather than de-novo lesions.

기도폐쇄를 동반한 흉골하 갑상선종 1예

Open surgical treatment is the traditional approach and management of retrosternal goiter presenting airway obstruction. Tracheal repair is primarily considered in cases of significant airway narrowing. An 88-year-old female presented with worsening dyspnea and was diagnosed with a huge retrosternal goiter. Preoperative imaging revealed airway compression, and thus a thyroidectomy with possible tracheal repair was planned. However, conventional electromyography tube cannot be used due to narrow airway. We performed intraoperative neural monitoring successfully with needle electrode. Tracheal repair was not necessary after removal of the goiter because tracheal wall recovered from compression by thyroid gland. Here we report this case with a review of literature.

Ultrasound-guided tenotomy for lateral epicondylitis with TenJet improves physical functional and decreased pain outcomes at 1 year: a case series review

Common extensor tendinopathy is a common cause of lateral elbow pain. Ultrasound-guided minimally invasive tenotomy (MIT) has been utilized successfully as a treatment for several years, but the use of TenJet device has not been well described. To evaluate the effectiveness and safety of MIT with TenJet who failed nonsurgical management of common extensor tendinopathy in an outpatient setting. A total of 100 patients with common extensor tendinopathy who failed conservative treatment underwent ultrasound-guided MIT with TenJet device in the outpatient setting at a single institution. All 100 patients prior to MIT underwent diagnostic musculoskeletal ultrasound showing common extensor tendinosis. The findings were interpreted by a fellowship-trained and board-certified musculoskeletal radiologist. Patients were evaluated with the Oxford Elbow Score prior to the procedure and at 1-year follow-up. Exclusion criteria included prior corticosteroid injection within the past 6 weeks of the MIT intervention, active local or systemic infection, complete full thickness tear of the common extensor tendon, and pregnancy. Oxford Elbow Score had a statistically significant difference in baseline to 1 year (P<.001). No complications were reported and zero patients went on to require open surgical intervention. MIT with TenJet is a safe, effective, and well-tolerated treatment for common extensor tendinopathy.

BACTERIAL TRANSMISSION AND ANTIBIOTIC SENSITIVITY OF CAUSATIVE AGENTS IN PURULENT-SEPTIC COMPLICATIONS IN PATIENTS WITH A SEVERE COURSE OF ACUTE PANCREATITIS

Introduction: Acute pancreatitis has emerged as a leading urgent abdominal condition, with a high mortality rate of up to 70% in cases of purulent-septic complications. The identification of specific causative agents during the infection stage of acute severe pancreatitis is challenging due to the various mechanisms by which pathogens can infiltrate parapancreatic fluid collections. However, early antibiotic prophylaxis is essential in the management of this patient population, considering the potential need for prolonged treatment involving multiple antibiotic rotations. This study aims at analyzing the changes in the microbial species spectrum responsible for purulent-septic complications in acute severe pancreatitis during the course of treatment.&#x0D; Methods: We investigated 174 bacterial cultures obtained from patients diagnosed with acute severe pancreatitis who were treated at the Surgical Department of M.V. Sklifosovsky Poltava Regional Hospital between 2015 and 2018. Among these cultures, 87 were obtained during the initial surgical intervention (39 after initial ultrasound-guided drainage and 38 during the initial open surgical intervention), and 87 were obtained during the course of treatment.&#x0D; Results: Among patients who underwent primary drainage of parapancreatic fluid collections, no aerobic flora was detected in 71.4% of cases, but subsequent bacterial cultures revealed microbial growth in 77.6% of patients. In patients who underwent open surgical intervention, pathological flora was detected in nearly all cases, both during the primary bacterial passage and in subsequent cultures. The species spectrum differed significantly between the primary and repeated bacterial passages. The initial cultures showed a predominance of gram-positive flora (S. epidermidis, Streptococcus spp., Enterococcus spp.), while repeated cultures demonstrated a notable increase in hospital-acquired strains and gram-negative flora (E. coli, Proteus spp., Acinetobacter spp.), along with a nearly three-fold increase in S. aureus. These findings have significant implications for selecting appropriate antibacterial agents throughout the treatment course. Notably, a substantial decrease in the sensitivity of multidrug-resistant strains to reserve antibiotics such as meropenem and trigecycline, by approximately 20%, was observed in subsequent bacterial studies.&#x0D; Conclusion: The microbial spectrum and antibiotic sensitivity of pathogens causing purulent-septic complications in acute severe pancreatitis undergo dynamic changes during the course of treatment. These findings underscore the importance of conducting repeated bacterial cultures and adjusting antibiotic therapy accordingly to optimize treatment outcomes.

The Significant Burden of Iatrogenic Vascular Injury on the Vascular Surgery Workforce at an Academic Medical Center

The treatment of iatrogenic vascular injury remains a critical role of the vascular surgeon, especially in the context of the increasing adoption of percutaneous procedures by other inpatient services. Vascular surgeons are called upon to provide emergent surgical assistance to other specialties for iatrogenic complications, both intraoperatively and at the bedside. This study aims to characterize consultation timing, management, and outcomes for iatrogenic vascular injuries. This study identified patients for whom vascular surgery was consulted for iatrogenic vascular complications from February 1, 2022, to January 8, 2023. Patient information, including demographic information, injury details, and details of any operative intervention, were retrospectively collected from February 1 to October 13 and prospectively collected for the remainder of the study period. Analyses were performed with R version 2022.02.03. There were 63 patients with consultations related to iatrogenic vascular injury. Of these, 29 (46%) were female and the mean age was 59 ± 18 years. The most common consulting services were cardiology (32%), cardiothoracic surgery (27%), and neurointerventional radiology (10%). Reasons for consultation included hemorrhage (38%), limb ischemia (32%), and treatment for pseudoaneurysm (27%). Of the consults, 25% were intraoperative, 19% related to ECMO cannulation, and 19% related to ventricular assist devices including left ventricular assist devices and intra-aortic balloon pumps. The majority of consult requests occurred during evening and night hours (5 pm to 7 am) (60%) (Figure). Emergent intervention was required in 75% of cases and consisted of: primary open surgical repair of arterial injury (50%), endovascular intervention (15%), and open thromboembolectomy (13%). Overall, in-hospital mortality for the patient cohort was 18% and the reintervention rate was 21%, reflecting the underlying complexity of the illness and nature of the vascular injury in this patient group. Vascular surgery plays an essential role in managing emergent life-threatening hemorrhagic and ischemic iatrogenic vascular complications in the hospitalized setting. These consults and complications require immediate bedside or intraoperative consultation and often emergent open surgical or endovascular intervention. Furthermore, many of these require urgent management in the evening or overnight hours, and therefore the high frequency of these events represents a potential significant resource utilization and workforce issue to vascular surgeons.

Assessing the Robustness of Positive Vascular Surgery Randomized Controlled Trials Using Their Fragility Index

The fragility index (FI) measures the robustness of statistically significant findings in randomized controlled trials (RCTs) calculated as the minimum number of event conversions required to alter the result’s statistical significance. In vascular surgery, many clinical guidelines and critical decision-making points are informed by a handful of key RCTs, especially regarding open surgical vs endovascular treatment. The objective of this study is to evaluate the FI of RCTs with statistically significant primary outcomes that compared open vs endovascular surgery. MEDLINE, Embase, and CENTRAL were searched for RCTs comparing open vs endovascular treatments for abdominal aortic aneurysms, carotid artery stenosis, and peripheral arterial disease to December 2022. RCTs with statistically significant primary dichotomous outcomes were included. Data screening and extraction were conducted in duplicate. The FI was calculated by adding an event to the group with the smaller number of events while subtracting a nonevent to the same group until the Fisher exact test produced a non-statistically significant result (P > .05, Table I). The primary outcome measures were FI and proportion of outcomes where loss to follow-up was greater than FI. Secondary analyses were performed to determine whether FI varied by study disease state, presence of commercial funding, and study design. Overall, 5133 articles were captured in the initial search with 21 RCTs reporting 23 primary outcomes being included in the final analysis. The median FI [first quartile, third quartile] was 3 [3, 20] with 16 outcomes (70%) reporting loss to follow-up greater than its FI. The Mann-Whitney U test revealed that commercially funded RCTs and composite outcomes had greater FIs (20 vs 3, P = .035; 21 vs 3, P = .01, respectively). The FI did not vary between disease states (P = .285) or between index trials vs follow-up analyses (P = .147, Table II). There were significant correlations between FI and P value (Pearson r = 0.901, P < .001) and number of events (r = 0.832, P < .001). A small number of event conversions (median 3) are needed to alter the statistical significance of primary outcomes in vascular surgery RCTs evaluating open surgical and endovascular treatments. Most studies had loss to follow-up greater than its FI, which can call into question trial results, and commercially funded studies had a greater FI. The FI and these findings should be considered in future trial design in vascular surgery.Table ITwo-by-two contingency tables highlighting the calculation of the fragility index (FI), with the FI calculated (FI = 70) for the BEST-CLI trial as an exampleTrial 2 × 2 contingency tableCalculation of the FIEventNo eventEventNo eventOpen surgical treatmentABOpen surgical treatmentA + FIB − FIEndovascular treatmentCDEndovascular treatmentCDFisher exact test: P < .05Fisher exact test: P ≥ .05BEST-CLI 2 × 2 contingency tableCalculation of the FI in the BEST-CLI trialMajor adverse limb event or deathNo eventMajor adverse limb event or deathNo eventBypass with single segment great saphenous vein302416Open surgical treatment372 (302 + 70)346 (416 − 70)Endovascular treatment408308Endovascular treatment408308Fisher exact test: P < .05 (P = .00000002)Fisher exact test: P ≥ .05 (P = .05002)BEST-CLI, Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia. Open table in a new tab Table IICharacteristics of the fragility index (FI) of primary outcomes of statistically significant RCTs evaluating open vs endovascular treatment in vascular surgeryCategoryOutcomes, nMedian FI [Q1, Q3]Disease state AAA103 [3, 3] CAS910 [3, 20] PAD415 [5, 46]Study design Index trial133 [3, 4] Follow-up study1014 [3, 21]Funding Commerciala920 [5, 25] Noncommercial143 [2, 6]Outcome Single163 [2, 9] Compositea721 [8, 38]Loss to follow-up <FI73 [3, 8] ≥FI1616 [6, 2, 21]AAA, Abdominal aortic aneurysm; CAS, carotid artery stenting; PAD, peripheral arterial disease.aP < .05. Open table in a new tab

Predicting Outcomes Following Open Aortoiliac Revascularization Using Machine Learning

Open surgical treatment options for aortoiliac occlusive disease carry significant perioperative risks; however, outcome prediction tools remain limited. Using machine learning (ML), we developed automated algorithms that predict 30-day outcomes following open aortoiliac revascularization. In this multicenter retrospective cohort study, the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) targeted database was used to identify patients who underwent open aortoiliac revascularization for atherosclerotic disease between 2011 and 2021. Patients treated for aneurysmal disease, acute limb ischemia, trauma, dissection, or malignancy were excluded. Input features included 38 preoperative demographic/clinical variables. The primary outcome was 30-day major adverse limb event (MALE; composite of untreated loss of patency, major reintervention, or major amputation) or death. The 30-day secondary outcomes were individual components of the primary outcome, major adverse cardiovascular event, wound complication, bleeding, other morbidity, non-home discharge, and unplanned readmission. Our data were split into training (70%) and test (30%) sets. Using 10-fold cross-validation, we trained 6 ML models using preoperative features. The primary model evaluation metric was area under the receiver operating characteristic curve (AUROC). Model robustness was evaluated with calibration plot and Brier score. Variable importance scores were calculated to determine the top 10 predictive features. Performance was assessed on subgroups based on age, sex, race, ethnicity, symptom status, procedure type, and urgency. Overall, 9649 patients were included. Thirty-day MALE or death occurred in 1021 patients (10.6%). Those with a primary outcome were older with more comorbidities, had poorer functional status, and were more likely to have high-risk physiologic and anatomic features, yet a lower proportion were on antiplatelets/statins. Our best performing prediction model for 30-day MALE or death was XGBoost, achieving an AUROC of 0.95 (95% confidence interval [CI], 0.94-0.96) (Fig 1). In comparison, logistic regression had an AUROC of 0.79 (95% CI, 0.77-0.81). For 30-day secondary outcomes, XGBoost achieved AUROCs between 0.87 and0.97. The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.05 (Fig 2). The strongest predictive feature in our algorithm was symptom status (chronic limb-threatening ischemia). Model performance remained robust on all subgroup analyses of specific demographic and clinical populations. Our ML models accurately predict 30-day outcomes following open aortoiliac revascularization using preoperative data, performing better than logistic regression. They have potential for important utility in guiding risk mitigation strategies for patients being considered for open aortoiliac revascularization to improve outcomes and reduce costs.Fig 2Calibration plot with Brier score for predicting 30-day major adverse limb event (MALE) or death following open aortoiliac revascularization using Extreme Gradient Boosting (XGBoost) model.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Wide Awake Local Anesthesia No Tourniquet Surgery of Carpal Tunnel Syndrome: Patients' Experience and Recall Bias in a Day-Care Setting.

Background and Objective: Wide-Awake Local Anesthesia No Tourniquet (WALANT) is a technique of local anesthesia commonly used in the surgical treatment of a wide variety of conditions affecting the upper extremity, including Carpal Tunnel Syndrome (CTS). The recent retrospective studies investigated patient experiences in a wide variety of hand disorder-related cases. The aim of our study is to evaluate patient satisfaction regarding open surgical treatment for CTS using the WALANT technique. Material and Methods: we enrolled 82 patients with CTS without medical record of surgical treatment for CTS. For WALANT, a hand surgeon used a combination of 1:200,000 epinephrine, 1% lidocaine, and 1 mL 8.4% sodium bicarbonate solution without tourniquet application and sedating the patient. All patients were treated in a day-care setting. For assessment of patient experience, Lalonde's questionnaire was adapted. Participants completed survey twice: one month and six months after the surgical treatment was performed. Results: the median pre-operative pain score for all patients was 4 (range 0-8) after one month and 3 (range 1-8) after six months. The median intraoperative pain score for all patients was 1 (range 0-8) after one month and 1 (range 1-7) after six months. The median post-operative pain score for all patients was 3 (range 0-9) after one month and 1 (range 0-8) after six months. More than half (61% after one month and 73% after six months) of the patients responded by stating that their real experience of WALANT was better than their initial expectations. An absolute majority of patients (95% after one month and 90% after six months) would recommend WALANT treatment to their relatives. Conclusions: overall, patient satisfaction with treatment for CTS using WALANT is high. Furthermore, complications related to the performed treatment and persistent post-operative pain could be associated with more reliable patient recall of this healthcare intervention. A longer period of time between intervention and assessment of patient experience could possibly be a reason for recall bias.

Endoscopic resection of gastric glomus tumor: a case report and literature review

Abstract Objectives Gastric glomus tumor (GGT) is a rare mesenchymal tumor, mostly located in the gastric antrum region, and occasionally displays malignant behavior. Due to the lack of typical endoscopic or clinical features that distinguish GGT from other gastric submucosal tumors, the diagnosis is based primarily on postoperative histopathological and immunohistochemical findings. The first-line treatment is either local laparoscopic resection or open surgical intervention. Endoscopic resection techniques can also be used to successfully treat such lesions. Case presentation This case report presented a 39-year-old woman suffering from anorexia for the past 15 days. Barium upper gastrointestinal radiography suggested a benign space-occupying lesion in the antrum region. Endoscopically, a non-ulcerative, smooth submucosal lesion was observed in the greater curvature of the antrum. Endoscopic ultrasound (EUS) examination revealed a hypoechoic lesion with an anechoic zone in the center, originating from the muscularis propria layer of the stomach wall, which could be a gastrointestinal stromal tumor (GIST). Conclusions The lesion was successfully removed via submucosal tunneling endoscopic resection (STER). Based on histopathological and immunohistochemical findings, the patient was diagnosed with GGT.

A clinical case of successful palliative endovascular treatment of a patient with a single ventricle, mitral valve atresia, an intact atrial septum and persistent cardinal vein

BackgroundTreatment of newborns with univentricular hemodynamics in combination with an anomaly of pulmonary venous return has the worst correction results in modern cardiac surgical papers. According to the data obtained by different authors, postoperative mortality in this cohort of patients varies from 41.7 to 53%. The presence of the venous outflow tract obstruction, as well as the serious condition of a newborn, is one of the main factors that increase the risk of death in the postoperative period.Case presentationThis article reveals a clinical case of a patient with a combined heart disease prenatally diagnosed in the form of a functionally single ventricle with a double outlet of the main vessels from it, mitral valve atresia, an intact atrial septum and an anomaly of venous return, when the blood outflow from the left atrium was carried out through a single fetal communication such as stenotic cardinal vein. In order to stabilize the patient's condition, the newborn urgently underwent stenting of the stenotic section of the cardinal vein. However, due to the lack of positive dynamics in the postoperative period, the child underwent repeated endovascular intervention and stenting of the intraoperatively created interatrial communication was performed. Taking into account the absence of obstruction of the outflow tract to the pulmonary artery, it was necessary to perform an open surgical intervention in a short time such as pulmonary artery banding.ConclusionsThus, palliative endovascular intervention in critically ill neonates with univentricular hemodynamics and anomalous pulmonary venous return can be considered as a method of choice that can become a new safer strategy for managing infants in order to stabilize the condition before the main stage of surgical intervention comes.

Congenital Portosystemic Shunts in Dogs and Cats: Treatment, Complications and Prognosis.

Congenital portosystemic shunts (CPSS) are a common vascular anomaly of the liver in dogs and cats. Clinical signs of CPSS are non-specific and may wax and wane, while laboratory findings can raise the clinical suspicion for CPSS, but they are also not specific. Definitive diagnosis will be established by evaluation of liver function tests and diagnostic imaging. The aim of this article is to review the management, both medical and surgical, complications, and prognosis of CPSS in dogs and cats. Attenuation of the CPSS is the treatment of choice and may be performed by open surgical intervention using ameroid ring constrictors, thin film banding, and partial or complete suture ligation or by percutaneous transvenous coil embolization. There is no strong evidence to recommend one surgical technique over another. Medical treatment strategies include administration of non-absorbable disaccharides (i.e., lactulose), antibiotics, and dietary changes, and are indicated for pre-surgical stabilization or when surgical intervention is not feasible. After CPSS attenuation, short- and long-term post-surgical complications may be seen, such as post-operative seizures and recurrence of clinical signs, respectively. Prognosis after surgical attenuation of CPSS is generally favorable for dogs and fair for cats.

Laparoscopic and Open Liver Resections for Colorectal Cancer Liver Metastasis in the Ukrainian State Center.

Background Minimally invasive liver resections for metastatic colorectal cancer have been increasingly performed all over the world with promising results. We planned the current studyto review our experience on this matter and compare short- and long-term outcomes of laparoscopicliver resection (LLR) and open liver resection(OLR) in patients with colorectal cancer liver metastasis (CRLM). Materials and methods This is a single-center retrospective analysis of patients with CRLM who underwent laparoscopic (n=86) and open (n=96) surgical treatment for metastatic liver lesions between March 2016 and November 2022. Tumor characteristics, intra- and postoperative results, overall survival (OS), and disease-free survival (DFS)were analyzed and compared. Results LLR was associated with significantly shorter surgery duration (180 minutes versus 295 minutes, p=0.03). There was no significant difference in blood loss between the two groups (100 mL versus 350 mL, p=0.061). Additionally, the laparoscopic approach was associated with significantly shorter hospital stays (6 days versus 9 days, p=0.004). The rate of major complications (Clavien-Dindo classification ≥ 3) was lower in the LLR group (5.8% versus 16.6%, p=0.037). There was no mortality in the LLR group, and in the OLR group, one lethal case was induced by mesenteric thrombosis on the fifth postoperative day. We did not find a statistically significant difference in the OS rate between the two groups at one, three, and five years: 97.3%, 74.7%, and 43.4%, respectively,in the OLR group and 95.1%, 70.3%, and 49.5%,respectively,in the LLR group (p=0.53). DFS at one, three, and five years were 88.7%, 52.3%, and 25.5%,respectively, in the LLR group and 71.9%, 53.1%, and 19.3%, respectively, in the OLR group(p=0.66). Conclusions This study showed that laparoscopic liver surgery is a safe and effective method of CRLM treatment in our center. LLR was associated with a decrease in major morbidity, shorter surgery duration, and reduced postoperative hospital stay. Minimally invasive liver resections showed similar oncological outcomes to the open approach in terms of overall and disease-free survival.

Staged Repair of Primary Aortoesophageal Fistula.

Primary aortoenteric fistulas are rare with an incidence reported up to .07% at autopsy. Literature review yields few reported cases, and rarer still is a fistula between a normal thoracic aorta and the esophagus. Rather, 83% of cases are associated with an aneurysmal aorta and 54% involve the duodenum. Patients with aortoesophageal fistula (AEF) usually present with a triad of chest pain, dysphasia, and a herald bleed. Without treatment, AEFs will result in exsanguination and are universally fatal; even with traditional open surgical treatment, mortality is reported over 55%. The complex pathology of AEFs makes repair more challenging, given an infected field, friable tissue, and patients who are often hemodynamically unstable. Staged repair using endografts as initial treatment with the primary goal of controlling bleeding and preventing fatal exsanguination has been reported. We present a case where a descending thoracic aorta to esophageal fistula was repaired, and this strategy was utilized.

Endoscopic treatment of diastasis recti: Training method and literature review

Endoscopic treatment of diastasis rectus abdominis offers the possibility of correcting the condition without complete abdominoplasty. The purpose of this study was to develop a training method on fresh cadavers models based on a literature review on this surgery. The endoscopic procedure considered involved the insertion of a 10mm suprapubic trocar and of 5mm trocars in each iliac fossae. The muscle suture is done using running barbed suture. The surgery was performed on eight fresh cadavers to estimate the learning curve for this intervention, which was estimated with the CUSUM method. A systematic literature review in the PubMed database was performed, and 20 articles that met the inclusion criteria were analyzed. The learning curve threshold was reached after 6 operations and can be separated into two phases. The most common complication of this surgery is seroma, it is encountered in 3 to 27% of cases according to the studies. Diastasis recurrence is rare, occurring in less than 2% of cases. In comparison, open surgical treatment of diastasis recti is associated with a higher risk of hematoma, skin necrosis and longer operating times. Recurrence rates are similarly low after open and endoscopic repair. Mesh reinforcement is indicated in cases of diastasis wider than 5cm, diastasis recurrence, severe musculoaponeurotic laxity, or hernia larger than 1cm. The data in the literature indicate that laparoscopic surgery is an efficient and safe approach to correct diastasis of the rectus muscles and can be offered by plastic surgeons to selected patients.

History of endoscopic treatment of vesicoureteral reflux.

Since its first clinical application in 1984, the endoscopic subureteral injection of bulking agents has become an alternative to long-term antibiotic prophylaxis and open surgical intervention in the treatment of VUR in children. The 15min day care endoscopic procedure has gained worldwide popularity in the management of VUR in children. Over the years, multiple studies have demonstrated safety and long-term efficacy of this minimally invasive outpatient procedure. Nowadays almost 90% of the surgical treatment of VUR in Sweden is done by endoscopic procedure. In the current article, our aim was to review how the endoscopic treatment of VUR developed.

Epikondylopathie des Ellenbogens

Epicondylosis of the elbow are common pathologies, with ahigher incidence for radial epicondylosis. Approximately 90% are self-limiting under conservative treatment. Multiple surgical procedures exist for the treatment of refractory cases. Arthroscopic treatment has been described for both radial and medial pathologies. Open and arthroscopic procedures show equivalent results in the surgical treatment of radial epicondylosis. This paper describes the most common open surgical procedures for the treatment of radial epicondylosis. Furthermore, the pros and cons of the arthroscopic versus the open approach are discussed, and the indications for an open surgical procedure for radial pathologies are highlighted. The authors believe that the open technique represents the standard treatment in the surgical treatment of ulnar epicondylosis. Arthroscopic procedures have been described, but studies comparing the clinical outcome versus open surgical treatment are lacking. The anatomic proximity of the flexor origin to the ulnar nerve with the risk of iatrogenic damage is another limiting factor. In addition, concomitant pathologies on the ulnar side can better be ruled out preoperatively, so that arthroscopy has arather low significance in the treatment of ulnar epicondylosis.

Nutcracker Syndrome: Challenges in Diagnosis and Surgical Treatment

Nutcracker syndrome (NCS) is an uncommon syndrome that presents with signs and symptoms caused by compression of the left renal vein (LRV), whereas 'nutcracker phenomenon' is solely used to refer to the anatomical configuration without clinical symptoms. Treatment for NCS may include nonoperative management, open surgical intervention, and in some instances endovascular stenting. We present a single-center retrospective case series of patients who presented with NCS managed with open surgical interventions. A single-center, retrospective review of patients managed from 2010-2021. We diagnosed NCS via a thorough clinical examination and additional cross-sectional imaging studies including magnetic resonance venography and/or computed tomography venography. For further confirmation of the diagnosis, duplex ultrasound was frequently combined with contrast venography. Thirty eight patients were included in our study from 2010-2021. Twenty one (55.3%) patients presented with symptoms including flank pain, abdominal pain, hematuria, and fatigue. The remaining 17 (44.7%) patients had nutcracker phenomenon. Within the group of patients diagnosed with NCS, 11 patients underwent LRV transposition. Symptoms related to NCS improved in 10 patients. Hematuria in 1 patient did not improve. Transposition of the LRV is an effective treatment for NCS. Nonoperative management is an option for those patients experiencing less severe or nonspecific clinical symptoms.

172 Health Inequities in Access to Treatment for Unruptured Intracranial Aneurysms in the United States over 20 Years

INTRODUCTION: Literature suggests that minority racial and ethnic groups have lower treatment rates for unruptured intracranial aneurysms (UIA). It is uncertain how these disparities have changed across time. METHODS: The National Inpatient Sample (NIS) database was queried using diagnostic and procedural codes for adult patients who underwent open surgical or endovascular treatment for UIA. Aneurysmal SAH patients were used as a substitute control for patients with intracranial aneurysms that progressed to hemorrhage before intervention. A multivariable logistic regression model was constructed using patient factors and hospital factors to identify predictors of treatment. RESULTS: A total of 213,350 UIA patients and 173,375 aSAH patients from 2000-2019 were included in the final analysis. After adjusting for covariates, Black patients (0.715, 95% CI 0.699-0.730), Hispanic patients (0.734, 95% CI 0.717-0.751) and other racial/ethnic minority patients (0.633, 95% CI 0.617-0.651) had lower odds of intervention for UIA compared to White patients with UIA. Medicare patients had higher odds of treatment than private insurance patients while Medicaid and the uninsured patients had lower odds. Non-White/Hispanic females (0.697, 95% CI 0.646-0.752) and males (0.602, 95%CI 0.556-0.651) had lower treatment odds than their white counterparts, irrespective of insurance status. Multivariable regression analysis revealed that the treatment odds of Black patients improved over time, while other minority group patients had variable treatment odds over time. CONCLUSIONS: This analysis of NIS data from 2000 to 2019 demonstrates disparities in treatment for UIA across race, sex, insurance status, and hospital factors. The persistence of inequalities over time requires attention in order to target improvement.

Features of Surgical Treatment of Symptomatic Patients with Isolated Superior Mesenteric Artery Dissection (Clinical Cases and Literature Review)

Introduction. Isolated superior mesenteric artery dissection (ISMAD) is a rare disease with high variability of clinical manifestations: from incidental findings to the development of acute or chronic mesenteric ischemia and the formation of aneurysms with the probability of their rupture. Despite significant world experience, surgical and conservative treatment of patients with ISMAD remains debatable.&#x0D; The aim. Improvement of the diagnosis and surgical treatment of patients with ISMAD.&#x0D; Clinical cases.&#x0D; In the first clinical observation, a 78-year-old patient with chronic visceral ischemia was diagnosed with an aneurysm of the upper mesenteric artery with signs of dissection and malperfusion. Previous unsuccessful attempts of endovascular treatment at another hospital caused the need for open surgical intervention – resection of the aneurysm and upper mesenteric artery reconstruction.&#x0D; &#x0D; In the second clinical case, a 61-year-old patient had acute abdominal pain syndrome, and based on clinical examination, laboratory and instrumental examination, the diagnosis of acute mesenteric ischemia with signs of dissection of the superior mesenteric artery was confirmed, which determined immediate indications for surgical treatment – resection of the affected segment of superior mesenteric artery and aorta-superior mesenteric bypass.&#x0D; &#x0D; The surgical interventions contributed to complete regression of clinical symptoms. Follow-up of the patients showed promising long-term results.&#x0D; &#x0D; Conclusion. Computed tomography angiography is the method of choice in the diagnosis of ISMAD and makes it possible to provide prompt diagnosis, determine treatment tactics and prevent the development of fatal complications. Open surgical intervention in some cases remains the method of choice in the treatment of ISMAD.

Endoscopic retrograde contact electro-impulse lithotripsy and lithotomy

The paper presents clinical observation of a patient with cholelithiasis and so-called “difficult” choledocholithiasis. Considering the developed complications – mechanical jaundice and purulent cholangitis, as well as large operative risk, it was decided to refrain from open surgical intervention. Traditionally-performed endoscopic stone extraction did not provide any success. Contact electro-impulse lithotripsy and lithotomy were performed. This enabled choledocholithiasis and cholangitis to be eliminated, bile ducts patency to be restored, and ensured the possibility of safe elective surgical intervention for chronic calculous cholecystitis.