Operative Indications Research Articles

Delayed vs single-staged abdominal wall reconstruction in contaminated ventral hernia.

When faced with contaminated ventral hernia repairs, surgeons must decide to repair the defect in a single-stage or delay the definitive repair until a clean scenario has been achieved. We sought to compare wound complications, long-term hernia recurrence and quality of life for patients who underwent delayed versus single-staged abdominal wall reconstruction (AWR) in the setting of clean-contaminated and contaminated wounds. The Abdominal Core Health Quality Collaborative was used to identify adult patients at our institution who underwent open AWR with retromuscular synthetic mesh placement between January 2014 and August 2023. The delayed group included patients who underwent clean-contaminated or contaminated abdominal operation in the setting of a ventral hernia without placement of permanent synthetic mesh, then underwent AWR with permanent synthetic mesh placement in a separate operation. The single-staged group had clean-contaminated or contaminated wounds concomitant with AWR. Outcomes of the AWR were compared. 63 patients underwent a delayed AWR and 375 patients underwent a single-staged AWR with a median(IQR) follow-up of 3(2,5)years. Most common concomitant procedures involved small intestine(30%) or hepatobiliary(30%). Most common index operations in delayed AWR were ileostomy(52.4%) and colostomy(14.2%) reversals. Median(IQR) time between initial operation and definitive AWR was 1.0 (0.7, 1.9)years. Median(IQR) hernia width was 11.35(8.4, 15.0)cm at initial operation and 16.0(15.0,20.0)cm at AWR for the delayed group(p < 0.001). Three patients (19%) in the delayed group and 14(12%) in the single-staged underwent wound debridement within 30-days(p = 0.46); a single patient in each required partial mesh excision within 30-days(p = 0.098). Wound morbidity, reoperation and hernia recurrence were similar (p > 0.05). In patients with a ventral hernia and separate indication for abdominal operation with a clean-contaminated or contaminated wound, either delayed or single-stage approaches to AWR may be viable.

Prophylactic closed-incisional negative pressure wound therapy following posterior instrumented spinal fusion: a single surgeon's experience and cost-benefit analysis.

Surgical site infections (SSIs) following spine surgery are associated with morbidity and resource utilization. Applying prophylactic closed-incisional negative pressure wound therapy (ciNPWT) during posterior instrumented fusion has mixed results in reducing rates of wound complications and SSI. We evaluated the clinical efficacy and potential cost-savings associated with ciNPWT in high-risk patients receiving posterior instrumented spinal fusion. We retrospectively reviewed patients receiving posterior instrumented spinal fusion for any surgical indication between July 1, 2017 and December 31, 2019, and compared rates of wound dehiscence, SSI, and reoperation for wound complications between standard surgical dressings and ciNPWT. Surgical dressing selection was based on the senior author's assessment of infection risk factors. A total of 229 patients (n = 85 standard surgical dressings, n = 144 ciNPWT) were included. The ciNPWT group had significantly more risk factors for wound-related complications, including older age (61.8 vs. 58.5 years, p = 0.042), diabetes mellitus (36.8% vs. 23.5%, p = 0.037), more instrumented levels (5.6 vs. 3.9, p < 0.0001), estimated blood loss (1298 vs. 998 mL, p = 0.036), and deformity was the predominant operative indication (29.9% vs. 17.7%, p = 0.040). Prophylactic ciNPWT was associated with significantly lower rates of wound dehiscence (21.5% vs. 34.1%, p = 0.036) and SSI (8.3% vs. 21.2%, p = 0.005). Number needed to treat with ciNPWT to prevent one SSI was 8 patients. The cost of preventing one SSI was $4,560. Cost-benefit analysis demonstrated a potential mean savings of $21,662 per operative SSI prevented and $270,775 per 100 patients undergoing posterior instrumented fusion with ciNPWT. Prophylactic ciNPWT use is a cost-effective means of reducing rates of wound dehiscence and SSI following posterior instrumented fusion.

HPB SO77 - Effects of Patient and Operative Variables on Isolation of Primary Human Hepatocytes

Abstract Background Isolation of human primary hepatocytes from tissue samples derived from therapeutic hepatectomy offers an important resource for a range of pharmacological and toxicology based experimental platforms, whilst simultaneously providing an opportunity to reduce the use of animal models. This study analysed the impact of a range of patient and operative derived variables on the yield and viability of isolated human primary hepatocytes. Method Excess hepatic tissue from resected liver parenchyma was sampled from consented patients undergoing major and minor hepatectomy for a range of oncological and non-oncological indications. Tissue dissociation and hepatocyte isolation was performed using a two-step collagenase perfusion procedure. Hepatocyte viability was calculated using the Trypan blue exclusion test while hepatocyte yield was calculated by the number of cells isolated divided by the tissue mass isolated from. Patient and operative variables were collected retrospectively from 25 patients in a prospectively maintained database. Results Samples from normal liver parenchyma achieved high hepatocyte viability and yields in all patients. Improved hepatoctye viability was associated with female sex, with a 2.9% increase in viability in samples from women (P&amp;lt;0.05). Patient age, BMI, operative indication, neo-adjuvant chemotherapy, as well as prolonged intra-operative Pringle time and blood loss did not significantly affect hepatocyte yield or viability, allowing use of primary human hepatocytes from a wide range of patients in a plethora of translational research experiments. Conclusion High levels of hepatocyte viability and yield are achievable across a broad range of patients, even in instances patients with high burdens of disease, prolonged Pringle time or higher levels of intra-operative blood loss. Tissue samples from consenting patients undergoing therapeutic liver resection provide an invaluable resource for various translational experimental platforms, including primary human hepatocytes. To date, more than 400 patients have donated tissue used in a range of basic science techniques, significantly reducing reliance on animal models.

The fallacy of a roadmap computed tomography after an abdominal gunshot wound: A road that leads to nowhere.

The 2019 Western Trauma Association guidelines recommend an abdominopelvic computed tomography (CTAP) in patients with a question of abdominal penetration after a gunshot wound. However, it is common practice to obtain a CTAP to provide a roadmap for an operation or to potentially alter management even in patients with classic indications for a laparotomy. The hypothesis for this study was that a CTAP for preoperative planning has no value in patients with an abdominal gunshot wound. This was a retrospective study from 2017 to 2022 of patients with an abdominal gunshot wound who had a preoperative CTAP. Data collection included clinical characteristics and CTAP and operative findings. Admission hypotension, abdominal pain and/or peritonitis, evisceration, and a transabdominal trajectory were considered clear indications for laparotomy. Computed tomography and operative findings were compared to determine concordance and if computed tomography altered management. There were 149 patients included in the study, of which 72.5% had a clear indication for laparotomy. The CTAP findings were concordant with operative findings in 57.0% of patients, while additional injuries were found at laparotomy in 36.2% of patients. Based on CTAP, a negative diagnostic angiogram was performed in three patients (2.0%). Three patients (2.0%) underwent a trial of nonoperative management based on CTAP findings. All underwent laparotomy after a clinical change. Six patients (4.0%) had a nontherapeutic operation; all patients had findings suspicious for either a hollow viscous injury or a vascular injury on preoperative imaging. While a CTAP scan may help to define an intra-abdominal trajectory when the trajectory is unclear, it does not alter management in those with indications for operation. In addition, CTAP missed injuries in a third of patients and contributed to all six nontherapeutic laparotomies. A preoperative CTAP has minimal value in patients who have indications for an operation. Diagnostic Test/Criteria; Level IV.

Long-Term Efficacy of Posterior Neurectomy in Anterior Cutaneous Nerve Entrapment Syndrome.

To analyze long-term treatment outcomes of a posterior neurectomy in a large cohort of patients with anterior cutaneous nerve entrapment syndrome (ACNES). The current step-up treatment approach for ACNES involves abdominal wall tender point injections, pulsed radiofrequency, and neurectomy. If an anterior neurectomy fails or pain reoccurs, a posterior neurectomy is considered as a final surgical option. Data on posterior neurectomy treatment outcomes are scarce. ACNES patients who underwent a unilateral posterior neurectomy between 2012 and 2022 in a single institution completed a questionnaire regarding their current pain status. Primary outcomes were short- and long-term treatment success, defined as ≥50% pain relief. Patients were stratified whether the operative indication was recurrent pain (>3months) after an initially successful anterior neurectomy or ongoing pain after an anterior neurectomy. Data from 260 of 379 patients (77% female, mean age 42years) were analyzed (68.6% response rate). Sensitivity analysis found that short-term outcomes were similar between responders and non-responders. The recurrent pain group demonstrated significantly better treatment outcomes compared to the ongoing pain group, both in the short-term (7weeks; treatment success 79.2% vs. 53.2%, p < 0.001) and long-term (58months; treatment success 61.1% vs. 42.0%, p = 0.001). Sixteen (minor) complications (6.2%) were reported, resulting in three surgical re-interventions (1.2%). A posterior neurectomy is long-term beneficial in approximately half of patients although treatment success is better for recurrent pain than ongoing pain. These findings aid in optimizing preoperative patient counseling.

Does two dimensional templating allow for the use of reduced-size ancillaries in total hip arthroplasty?

Rising costs in healthcare for total hip arthroplasty (THA) mean that new solutions must be considered, such as the use of single-use ancillaries (SUA). The goal of this study was to assess the accuracy of 2D templating in primary THA for the use of reduced-size SUA. Our hypothesis was that the accuracy of 2D templating in primary THA would be higher than 95%, give or take two sizes. This single-centre prospective study included all primary THAs performed over two years. Templating was carried out using 2D templating on anteroposterior pelvic X-rays. The template sizes were compared to the implant sizes. The primary endpoint was the rate of coincidence between digitally templated estimates and the actual implant sizes. The secondary endpoint was the difference of accuracy based on patient parameters. We analysed 512 cases of THA. Accuracy within two sizes was 96.9% for acetabular implants and 98.5% for femoral implants. Accuracy was below the 95% threshold only in patients under 55 and over 85 years old. A BMI above 30.0kg/m2 significantly reduced accuracy but did not fall below the 95% threshold. The operated hip, the type of implant, and the operative indication did not significantly influence templating accuracy. Using reduced-size SUA with five rasps and five reamers depending on template sizes means that THA can be performed in more than 95% of cases allowing the use of compact single use ancillaries.

Impact of multidisciplinary Endocarditis Team on management of infective endocarditis

Infective Endocarditis (IE) is a complex, life-threatening disease. The aim of the present study was to evaluate the impact of the Endocarditis-Team on management of IE. This observational study conducted at a university hospital (2015‒22), included adult patients with IE. The study period was divided in two periods: before (pre-Endocarditis-Team; pre-ET) and after the establishment of the Endocarditis-Team (post-Endocarditis-Team; post-ET) on January 2018. Among 505 IE episodes (187 in pre-Endocarditis-Team, 318 in post-ET period), 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography was more commonly used in post-ET period (14 % vs. 28 %; p < 0.001). Overall, thirty-day and one-year mortality were 14 % and 27 %, respectively; no difference was observed between the two periods. In post-ET period, the administration of 4-weeks, rather than 6-weeks, of intravenous antimicrobial treatment was higher than in the post-ET period (15 % vs. 45 %; p < 0.001). Indication for surgery was present in 115 (61 %) patients in pre-ET and in 153 (48 %) in the post-ET period. In post-ET period, among patients with indication, valve surgery was more frequently performed (66 % vs. 78 %; p = 0.038). Such difference was due to a higher acceptance of operative indication by the cardiac surgeon (69 % vs. 94 %; p = 0.013). The observed increase in number of patients benefiting from cardiac surgery in the post-ET period led to a decrease of subsequent embolic events, since among patients with operative indication (n = 268), new embolic events after the establishment of the indication were more common in the pre-ET period compared to post-ET (23 % vs. 12 %; p = 0.033). After the implementation of the multidisciplinary Endocarditis-Team we observed several improvements in the general management of IE patients.

Thermal desorption technique to speciate mercury in carbonate, silicate, and organic-rich soils

Thermal desorption is a well-assessed technique to speciate mercury (Hg) in soils and sediments. However, the effects related to the different matrices are still not properly assessed. In this study, thermal desorption was applied to Hg-free calcite mixed with Hg standard and soils rich in carbonate and silicate minerals, as well as organic matter. Hg0, HgCl2, HgO, α-HgS, β-HgS and organo-mercuric compounds were recognized, pointing out that the soil matrix operates notable differences in terms of breakdown temperatures of the Hg-compounds and suggesting that the mineralogical composition of soil has to be investigated before applying the thermal desorption technique. Furthermore, the presence of Hg0 was carefully evaluated since, as already observed, it forms Hg2+, which increases mercury mobility in the pedological cover with important consequences for those soils contaminated and located close to decommissioned or active mining areas and/or industrial sites (e.g. chloro-alkali industries). Experimental runs were thus carried out by using carbonate-, silicate- and organic-rich soils doped with liquid Hg. It was observed that Hg0 tends to be oxidized to form Hg+ and then Hg2+ as a function of soil matrix and reaction time. Surprisingly, the oxidation rate is rather fast, since after 42 days the initial content of Hg0 is halved, thus following an exponential decay. This implies that in Hg0-polluted areas, the fate of the resulting Hg2+ can be that to: i) be adsorbed by organic matter and/or Fe–Mn–Al oxides and/or ii) feed shallow aquifers. This study is a further step ahead to understand the behavior of Hg in contaminated soils from industrial and mining areas where liquid Hg is occurring in different soil matrices and may provide useful indications for remediation operations.

Re-evaluation and operative indications after induction therapy for thymic epithelial tumors.

Thymic epithelial tumors (TETs), encompassing thymoma and thymic carcinoma, represent a rare and heterogeneous group of thoracic malignancies with varying prognoses and treatment strategies. Surgical resection is the cornerstone of therapy for localized stages, but the management of locally advanced or unresectable TETs often involves induction therapy, including chemotherapy and/or radiation therapy, as a neoadjuvant approach aimed at downstaging the tumor to facilitate subsequent resection. This review synthesizes current knowledge on the re-evaluation process and operative indications following induction therapy for TETs, highlighting the pivotal role of accurate assessment in guiding surgical decisions and optimizing patient outcomes. Induction therapy's efficacy is contingent upon precise re-evaluation methods to accurately gauge treatment response and assess resectability post-therapy. This review discusses the various modalities employed in re-evaluation, including computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography-CT (PET-CT), and the significance of tumor markers, underlining their strengths and limitations. The adoption of modified RECIST criteria for TETs by the International Thymic Malignancy Interest Group (ITMIG) underscores the necessity for standardized assessment guidelines to ensure consistency and reliability across studies and clinical practices. Furthermore, we explore the implications of induction therapy on surgical decision-making, emphasizing the criteria for determining the suitability of patients for surgical intervention post-therapy. The review addresses the challenges and future perspectives associated with the re-evaluation process, including the potential for advanced imaging techniques and the integration of molecular and genetic markers to enhance the precision of treatment response assessment. In conclusion, the re-evaluation of TETs post-induction therapy is a complex but critical component of the multidisciplinary management approach for these patients. Standardizing re-evaluation methodologies and incorporating novel diagnostic tools could significantly improve the prognostication and treatment stratification, ultimately enhancing the therapeutic outcomes for patients with advanced TETs.

Outcomes of a Novel Single Branched Aortic Stent Graft for Treatment of Type B Aortic Dissection

Intervention on Type B dissection frequently requires landing the proximal edge of the stent graft between the left common carotid artery and left subclavian artery (LSA). The Gore® TAG® Thoracic Branch Endoprosthesis (TBE) is a technology which allows LSA preservation with a single internal branch. This study was a prospective non-randomized single-arm clinical trial of patients with type B aortic dissection that were treated with the single branched device. Patients with operative indications for acute, chronic or residual Type B dissections that originated distal to the origin of a left subclavian artery suitable for branch graft placement were eligible for the study. Native aortic and surgical graft proximal landing zones were eligible. Among the 132 patients, there were 25 (18.9%) acute type B dissections, 79 (59.8%) of chronic type B dissections and 28 (21.1%) of residual dissections after previous open Type A repair. Percutaneous access was used in 105 (79.5%) patients. Overall, 30-day mortality occurred in 6 patients (4.5%). The overall 30 day stroke rate was 2/132(1.5%) and the one-year freedom from stroke was 96.8%. Device Technical Success and Procedural Success was achieved in 129/132(97.7%) and 110/132(83.3%) of subjects, respectively and there was one instance of loss of side branch patency. There was no persistent antegrade false lumen flow observed. In this study of a novel branched endograft device to preserve the LSA in patients with type B dissection undergoing TEVAR, we demonstrate acceptable safety and efficacy outcomes at one year.

Ross Confers More Favorable Left Ventricular Remodeling Compared With Mechanical Aortic Valve Replacement.

Background: Aortic valve disease results in left ventricular (LV) dilation and/or hypertrophy. Valve intervention may improve, but not normalize flow dynamics. We hypothesized that LV remodeling would be more favorable following the Ross procedure versus mechanical aortic valve replacement (mAVR). Methods: Patients who were 18 to 50 years of age and underwent Ross or mAVR from 2000 to 2016 at a single institution were retrospectively reviewed. Propensity score matching was performed and yielded 27 well-matched pairs. Demographics and echocardiographic variables of LV morphology and wall thickness were collected. Those with > mild residual valve disease were excluded. Primary endpoints included LV morphology. T test and Fisher exact test analysis were used for statistical comparison. Results: Average age at operation (Ross 35.3 ± 10.2 vs mAVR 37.3 ± 8.9 years) did not differ. Indication for operation was similar between groups. Preoperative echocardiographic variables did not differ. At average follow-up duration (Ross 7.9 ± 2.4 vs mAVR 7.3 ± 2.4 years), wall thickness was significantly smaller for Ross compared with mAVR (P = .00715). Only 4/27 (15%) of mAVR patients had normalized LV parameters compared with 16/27 (59%) of Ross patients (P = .000813). Residual hypertrophy was the most common long-term abnormality for mAVR. Conclusion: Following aortic valve replacement with the Ross procedure or mechanical aortic valve prosthesis, the Ross conferred more favorable LV remodeling compared with mAVR. Future directions include analyzing longer follow-up to determine if patterns persist and the impact on cardiac morbidity and mortality.

Impact of frailty on outcomes following emergency laparotomy: a retrospective analysis across diverse clinical conditions.

Emergency laparotomy (EL) encompasses procedures of varying complexity and urgency, undertaken in different clinical scenarios, leading to different risks of morbidity and mortality. We hypothesized that the increased mortality and longer postoperative length of stay (LoS) observed in frail patients are related to differences in indication for operation, a higher rate of sepsis, worse intraperitoneal soiling, and more advanced malignancy in this group. This retrospective cohort study analysed patients entered into the National Emergency Laparotomy Audit database between January 1, 2018, and June 15, 2021, in Oxford. The primary outcome was 180-day survival analysed using multivariable Cox regression. The secondary outcomes, delay to surgery (DtS) and postoperative LoS, were analysed using logarithmically transformed multivariable linear regression. Of the 803 patients analysed, 396 (49.3%) were male. The median age was 66, and 337 (42%) were living with at least very mild frailty. Mortality hazard ratios for Clinical Frailty Scale grades 4 (3.93, 95% CI 1.89-8.20), 5 (5.86, 95% CI 2.87-11.97), and 6-7 (14.17, 95% CI 7.33-27.40) were not confounded by indication, sepsis, intraperitoneal soiling, or malignancy status. Frail patients experienced a 1.38-fold longer DtS and a 1.24-fold longer postoperative LoS, even after adjusting for indication, sepsis, intraperitoneal soiling, malignancy status, and DtS. Our results indicate that frail patients have a poorer prognosis and longer postoperative LoS, independent of DtS, indication, sepsis, intraperitoneal soiling, and malignancy status. Patient frailty is also associated with longer DtS.

Landscape of peripheral immunity in patients with upper urinary tract urolithiasis and the underlying correlations with renal function

IntroductionInflammatory and immunological responses are reported involved in the pathogenesis and progression of obstructive nephropathy (ON). This study was designed to investigate the characteristics of peripheral immunity in patients with upper urinary tract urolithiasis and analyze the underlying associations with renal function.MethodsPatients with unilateral upper urinary tract urolithiasis meeting the operation indications were prospectively enrolled. Preoperative circulating immune cells and inflammatory cytokines were detected in our clinical laboratory, and the indicators of renal function and calculi related parameters were particularly recorded. Patients were sectionalized into subgroups on the basis of the lesion of calculi. Characteristics of peripheral immunity in each subgroup were investigated by statistical approaches, and the underlying correlations with the degree of hydronephrosis (HN) and renal function were discussed in corresponding group.ResultsPatients with ureteral calculi presented severer HN compared with renal calculi, especial middle ureteral calculi, acting as the chief culprit of ON, exhibiting the highest serum creatine and blood urea nitrogen, most impaired estimated glomerular filtration rate, and severest HN. In addition, serum interleukin-8 (IL-8) and IL-6 were demonstrated presenting statistical differences between ureteral calculi and renal calculi patients, exhibiting underlying values in comprehending ON. However, circulating immune cells were demonstrated no obvious differences among groups.ConclusionsCirculating inflammatory cytokines, referred in particular to serum IL-8 and IL-6 were partially associated with kidney injury in patients with upper urinary tract urolithiasis. But the specific influences and mechanisms between them needed to be investigated furthermore.

Warfarin, not direct oral anticoagulants or antiplatelet therapy, is associated with increased bleeding risk in emergency general surgery patients: Implications in this new era of novel anticoagulants: An EAST multicenter study.

This study aimed to assess perioperative bleeding complications and in-hospital mortality in patients requiring emergency general surgery presenting with a history of antiplatelet (AP) versus direct oral anticoagulant (DOAC) versus warfarin use. A prospective observational study across 21 centers between 2019 and 2022 was conducted. Inclusion criteria were age 18 years or older, and DOAC, warfarin, or AP use within 24 hours of an emergency general surgery procedure. Outcomes included perioperative bleeding and in-hospital mortality. The study was conducted using analysis of variance, χ 2 , and multivariable regression models. Of the 413 patients, 221 (53.5%) reported AP use, 152 (36.8%) DOAC use, and 40 (9.7%) warfarin use. The most common indications for surgery were obstruction (23% [AP], 45% [DOAC], and 28% [warfarin]), intestinal ischemia (13%, 17%, and 23%), and diverticulitis/peptic ulcers (7%, 7%, and 15%). Compared with DOAC use, warfarin use was associated with significantly higher perioperative bleeding complication (odds ratio [OR], 4.4 [95% confidence interval (CI), 2.0-9.9]). There was no significant difference in perioperative bleeding complication between DOAC and AP use (OR, 0.7 [95% CI, 0.4-1.1]). Compared with DOAC use, there was no significant difference in mortality between warfarin use (OR, 0.7 [95% CI, 0.2-2.5]) or AP use (OR, 0.5 [95% CI, 0.2-1.2]). After adjusting for confounders, warfarin use (OR, 6.3 [95% CI, 2.8-13.9]), medical history, and operative indication were associated with an increase in perioperative bleeding complications. However, warfarin was not independently associated with risk of mortality (OR, 1.3 [95% CI, 0.39-4.7]), whereas intraoperative vasopressor use (OR, 4.7 [95% CI, 1.7-12.8]), medical history, and postoperative bleeding (OR, 5.5 [95% CI, 2.4-12.8]) were. Despite ongoing concerns about the increase in DOAC use and lack of readily available reversal agents, this study suggests that warfarin, rather than DOACs, is associated with higher perioperative bleeding complications. However, that risk does not result in an increase in mortality, suggesting that perioperative decisions should be dictated by patient disease and comorbidities rather than type of AP or anticoagulant use. Prognostic and Epidemiological; Level III.

Current Practice of Laparoscopic Surgery for Choledochal Cyst in Children -a Survey on Opinion and Experience Among IPEG Members

PurposeLaparoscopic resection of choledochal cyst (CC) has become a popular approach. As the discussion about optimal treatment and technical strategies continues, we aimed to investigate perspectives of IPEG members. MethodsAn online survey was conducted in 2023 on behalf of the IPEG Research Committee. IPEG members were asked to complete an anonymous questionnaire that included 36 items on the management of CC. Result148 members responded to the survey (North America:49/Asia:44/Europe:23/South America:21/Others:11) and 116 completed all questions. Most surgeons (92.5%) operate on less than 5 cases annually. Diagnostic tools of choice were Magnetic Resonance Imaging (MRI, 95.9%) and ultrasonography (US, 74.5%). Regarding fusiform-type CC, operative indications were cyst size greater than 10 mm (68.9%), typical symptoms (78.5%), or anomalous pancreatico-biliary junction (63.8%). In unilateral intrahepatic biliary cysts (type IVa) cases, 81.3% of respondents do not perform a simultaneous liver resection with the initial cyst resection. While 22.0% resect the CC at diagnosis, even if asymptomatic, a larger group of surgeons (41%; 49/118) wait until the infant reaches six months. Intraoperative cholangiography and choledochoscopy are performed routinely by 38.9% and 13.7%, respectively. The majority (52.5%) ligates the common bile duct stump just below the CC. Laparoscopic reconstructions are performed by retrocolic hepatico-jejunostomy (48.3%) or hepatico-duodenostomy (45.8%) at similar rates, but when done open, 71.2% of respondents prefer retrocolic hepatico-jejunostomy. For the laparoscopic anastomosis, interrupted sutures with intracorporeal knot tying were most often utilized (48.3%). ConclusionInidividual pediatric surgeons treat a small number of patients with CC each year. Laparosopic and open reconstruction techniques vary, likely due to technical challenges. Level of EvidenceIII.

Advances in Surgery for Metastatic Disease of the Spine: An Update for Oncologists.

Narrative review. Metastatic spine disease is an increasingly common clinical challenge that requires individualised multidisciplinary care from spine surgeons and oncologists. In this article, the authors describe the recent surgical advances in patients presenting with spinal metastases. We present an overview of the presentation, assessment, and management of spinal metastases from the perspective of the spine surgeon, highlighting advances in surgical technology and techniques, to facilitate multidisciplinary care for this complex patient group. Neither institutional review board approval nor patient consent was needed for this review. Advances in radiotherapy delivery and systemic therapy (including immunotherapy and targeted therapy) have refined operative indications for decompression of neural structures and spinal stabilisation, while advances in surgical technology and technique enable these goals to be achieved with reduced morbidity. Formulating individualised management strategies that optimise outcome, while meeting patient goals and expectations, requires a comprehensive understanding of the factors important to patient management. Spinal metastases require prompt diagnosis and expert management by a multidisciplinary team. Improvements in systemic, radiation, and surgical therapies have broadened operative indications and increased operative candidacy, and future advances are likely to continue this trend.

Neurological Outcomes Following Craniotomy for Extracorporeal Membrane Oxygenation-Associated Intracranial Hemorrhage: Case Series and Literature Review

BackgroundIntracranial hemorrhage (ICH) is a potential complication associated with extracorporeal membrane oxygenation (ECMO), which has been increasingly utilized in recent years. A paucity of data exists describing patient outcomes following invasive neurosurgical interventions in patients receiving ECMO therapy. The purpose of this study was to assess the clinical and functional outcomes in patients who underwent cranial neurosurgery for the management of an ECMO-associated intracranial complication. MethodsThis was a single-institution retrospective review of adult patients who underwent craniotomy or craniectomy after sustaining an intracranial hemorrhagic complication of ECMO therapy from 2008-2023. Anticoagulation status, operative indication, surgical details, post-operative course, and functional outcome were recorded. A systematic review of the prior literature was performed to contextualize our institutional results within previous reports. ResultsFour adult patients were identified at our institution who underwent craniotomy or craniectomy for the neurosurgical management of an ECMO-associated ICH. One patient (25%) ultimately made a satisfactory recovery (mRS 3 at one year). The surviving patient had a notably higher GCS (7T vs 3T), had not received anticoagulation at the time of surgery, and did not experience post-operative re-accumulation or expansion of their hemorrhage, distinguishing factors from the other three included. Review of the existing literature identified 15 adult patients who underwent craniotomy while receiving ECMO therapy, of which four (26.7%) had a long-term favorable neurologic outcome. ConclusionsThe overall prognosis following neurosurgical intervention for the management of ECMO-associated intracranial complications was poor in our case series, which was corroborated by our literature review.

Disparities in outpatient rural cholecystectomy outcomes

BackgroundPrevious studies showed comparable outcomes for common in-patient general surgery operations, but it is unknown if this extends to outpatient operations. Our aim was to compare outpatient cholecystectomy outcomes between rural and urban hospitals. MethodsA retrospective cohort analysis was done using the Nationwide Ambulatory Surgery Sample for patients 20-years-and-older undergoing cholecystectomy between 2016 and 2018 ​at rural and urban hospitals. Survey-weighted multivariable regression analysis was performed with primary outcomes including use-of-laparoscopy, complications, and patient discharge disposition. ResultsThe most common indication for operation was cholecystitis in both hospital settings. On multivariable analysis, rural hospitals were associated with higher transfers to short-term hospitals (adjusted odds ratio [aOR] 2.40, 95%CI 1.61-3.58, p ​< ​0.01) and complications (aOR 1.39, 95%CI 1.11-1.75, p ​< ​0.01). No difference was detected with laparoscopy (aOR 1.93, 95%CI 0.73-5.13, p ​= ​0.19), routine discharge (aOR 1.50, 95%C I0.91-2.45, p ​= ​0.11), or mortality (aOR 3.23, 95%CI 0.10–100.0, p ​= ​0.51). ConclusionsPatients cared for at rural hospitals were more likely to be transferred to short-term hospitals and have higher complications. No differences were detected in laparoscopy, routine discharge or mortality.

Determinants of Pre- and Post-Procedural Neurological Assessment, and Outcome of Carotid Endarterectomy or Stenting.

Background: The German-Austrian guideline on the treatment of carotid stenosis recommends specialist neurological assessment (NA) before and after carotid endarterectomy (CEA) or carotid artery stenting (CAS). This study analyzes the determinants of NA and the association of NA with the perioperative rate of stroke or death. Materials and Methods: This study is a pre-planned sub-study of the ISAR-IQ project, which analyzes data from the nationwide German statutory quality assurance carotid database. Patients were classified as asymptomatic (group A), elective symptomatic (group B), and others (group C: emergency (C1), simultaneous operation (C2), and other indications (C3)). The primary outcome event (POE) of this study was any in-hospital stroke or death. Adjusted odds ratios for pre- and post-NA and the POE were calculated using multivariable regression analyses. Results: We analyzed 228,133 patients (54% asymptomatic, 68% male, mean age 72 years) undergoing CEA or CAS between 2012 and 2018. Age and sex were not associated with the likelihood of pre-NA or post-NA. The multivariable regression analysis showed an inverse association between pre-NA and POE (adjusted odds ratio (aOR) 0.47; 95% CI 0.44-0.51, p < 0.001), and a direct association of post-NA and POE (aOR 4.39; 95% CI 4.04-4.78, p < 0.001). Conclusions: Pre- and postinterventional specialist NA is strongly associated with the risk of any in-hospital stroke or death after CEA or CAS in Germany. A relevant confounding by indication or reversed causation cannot be ruled out. Nevertheless, to improve the quality assurance of treatment, the NA recommended in the guideline should be carried out consistently.

Inpatient Hospital Costs, Emergency Department Visits, and Readmissions for Revision Hip and Knee Arthroplasty

BackgroundRevision total hip arthroplasty (THA) and total knee arthroplasty (TKA) tremendously burden hospital resources. This study evaluated factors influencing perioperative costs, including emergency department (ED) visits, readmissions, and total costs-of-care within 90 days following revision surgery. MethodsA retrospective analysis of 772 revision TKAs and THAs performed on 630 subjects at a single center between January 2007 and December 2019 was conducted. Cost data were available from January 2015 to December 2019 for 277 patients. Factors examined included comorbidities, demographic information, preoperative Anesthesia Society of Anesthesiologists score, implant selection, and operative indication using mixed-effects linear regression models. ResultsAmong 772 revisions (425 THAs and 347 TKAs), 213 patients required an ED visit, and 90 required hospital readmission within 90 days. There were 22.6% of patients who underwent a second procedure after their initial revision. Liver disease was a significant predictor of ED readmission for THA patients (multivariable odds ratio [OR]: 3.473, P = .001), while aseptic loosening, osteolysis, or instability significantly reduced the odds of readmission for TKA patients (OR: 0.368, P = .014). In terms of ED visits, liver disease increased the odds for THA patients (OR: 1.845, P = .100), and aseptic loosening, osteolysis, or instability decreased the odds for TKA patients (OR: 0.223, P < .001). Increased age was associated with increased costs in both THA and TKA patients, with significant cost factors including congestive heart failure for TKA patients (OR: $7,308.17, P = .004) and kidney disease for THA patients. Revision surgeries took longer than primary ones, with TKA averaging 3.0 hours (1.6 times longer) and THA 2.8 hours (1.5 times longer). ConclusionsLiver disease increases ED readmission risk in revision THA, while aseptic loosening, osteolysis, or instability decreases it in revision TKA. Increased age and congestive heart failure are associated with increased costs. These findings inform postoperative care and resource allocation in revision arthroplasty. Level of EvidenceEconomic and Decision Analysis, Level IV.