Optimal Surgical Approach Research Articles

Acromioplasty combined with arthroscopic rotator cuff repair can reduce the risk of reoperation: a systematic review and meta-analysis

ABSTRACT Background Whether to perform acromioplasty in arthroscopic rotator cuff repair (ARCR) is controversial, and the optimal surgical approach for rotator cuff tear repair is unknown. The purpose of this study was to compare the reoperation rate, retear rate and patient-reported outcomes (PROs) of ARCR with those of ARCR combined with acromioplasty (ARCR-A). Methods PubMed, Embase and Cochrane Library were searched for relevant literature dated between database inception and 4 December 2023. The primary outcomes of this study were the reoperation rate and the retear rate. The secondary outcomes were PROs, including the visual analogue scale (VAS) pain score, the American Shoulder and Elbow Surgeons (ASES) score, the University of California-Los Angeles (UCLA) score, the Constant score and the Western Ontario Rotator Cuff (WORC) score. The quality of the included studies was evaluated by using the risk of bias assessment tool. RevMan 5.3 software was used for meta-analysis. Fixed (I2 <50%) or random (I2 ≥50%) effects models were applied to calculate the effect size. Results Meta-analysis revealed that ARCR-A had a lower reoperation rate (OR = 0.35, 95%CI: 0.15-0.85, p = 0.02), but the difference in the retear rate between ARCR-A and ARCR was not significant (p = 0.25). In type 2 acromion patients, the reoperation rate was not significantly different between ARCR and ARCR-A (p = 0.12), but, for type 3 acromion patients, the retear rate was lower for ARCR-A than for ARCR (OR = 0.12, 95%CI: 0.01-0.94, p = 0.04). There were statistically significant differences in the 6-month postoperative Constant scores (p < 0.001), VAS pain scores (p = 0.003) 12-month postoperative ASES scores (p = 0.02) and 24-month postoperative WORC scores (p = 0.04), but these differences were not clinically significant. Conclusions Combining ARCR with acromioplasty can reduce the rate of reoperation, especially in patients with type 3 acromion, but it provides no clinically important change in the retear rate and postoperative PRO compared with ARCR.

Surgical outcomes of trigonal intraventricular meningiomas: a single-centre study.

Trigonal meningiomas are rare intraventricular tumours that present a surgical challenge. There is no consensus on the optimal surgical approach to these lesions, though the transtemporal and transparietal approaches are most frequently employed. We aimed to examine the approach-related morbidity and surgical nuances in treating trigonal meningiomas. This retrospective review assimilated data from 64 trigonal meningiomas operated over 15 years. Details of clinicoradiological presentation, surgical approach and intraoperative impression, pathology and incidence of various postoperative deficits were recorded. In our study, Trigonal meningiomas most frequently presented with headache and visual deterioration. The median volume of tumours was 63.6cc. Thirty-one meningiomas each (48.4%) were WHO Grade 1 and WHO Grade 2, while 2 were WHO Grade 3. The most frequent approach employed was transtemporal (38 patients, 59.4%), followed by transparietal (22 patients, 34.4%). After surgery features of raised ICP and altered mental status resolved in all patients, while contralateral limb weakness resolved in 80%, aphasia in 60%, seizures in 70%, and vision loss in 46.2%. Eighteen patients (28.13%) developed transient postoperative neurological deficits, with one patient (1.5%) developing permanent morbidity. Surgery for IVMs results in rapid improvement of neurological status, though visual outcomes are poorer in patients with low vision prior to surgery, longer duration of complaints and optic atrophy. The new postoperative deficits in some patients tend to improve on follow up. Transtemporal and transparietal approaches may be employed, based on multiple factors like tumour extension, loculation of temporal horn, size of lesion with no significant difference in their safety profile.

Intramedullary Screw versus Locking Plate Fixation for Traumatic Displaced Proximal Fifth Metatarsal Fractures: A Systematic Review.

Background/Objectives: Intramedullary screw fixation (IMS) and locking plate fixation (LPF) are currently recommended treatments for proximal fifth metatarsal fractures (PFMF). However, treating comminuted or small displaced avulsion PFMF with IMS poses challenges due to complications. A novel alternative fixation method, the locking compression plate for distal ulna hook plate fixation (LPF), has been introduced recently for distal ulna fractures and has shown improved clinical results. This scoping review aims to assess whether LPF yields superior outcomes, such as postoperative AOFAS scores and rate of postoperative complications, compared to IMS in PFMF treatment. Methods: This review included randomized controlled trials (RCTs), prospective cohort studies, retrospective cohort studies, or case series involving patients with PFMF who underwent plate fixation or screw fixation. The primary outcome was the postoperative American Orthopedic Foot and Ankle Society (AOFAS) score. Studies were sourced from databases including PubMed, Embase, and Scopus, with the search conducted up to February 2024. The Systematic Review protocol was registered in the CRD PROSPERO database (CRD42024532593). Results: Ten studies were included, comprising 3 cohort studies, 1 case-control study, and 6 case series, with a total of 309 patients (158 with LPF and 142 with IMS). The postoperative AOFAS scores showed no significant difference between LPF and IMS in treating PFMF. However, LPF demonstrated efficient surgical procedures and enhanced functional outcomes. Complications were minimal in both groups, with no significant difference in the rate of postoperative complications. Conclusions: Although there was no significant difference in AOFAS scores between LPF and IMS, LPF demonstrated efficient surgical procedures and enhanced functional outcomes, making it a reasonable alternative method for PFMF. Effective shared decision-making (SDM) with patients becomes paramount in choosing the optimal surgical approach. In the surgical landscape, thoughtful deliberation, patient engagement, and adherence to biomechanical principles are crucial for achieving successful outcomes in the treatment of PFMF.

Tacker Fixation versus Suturing of Mesh in Laparoscopic Inguinal Hernia Repair

Abstract Background Laparoscopic hernia repair is more difficult technically than open surgery and there is evidence of learning curve in its performance and many complications which reported from laparoscopic procedure is due to learning curve lead to operative complications. Objective To compare the outcome results of the fixation of mesh by intracorporeal sutures and by tackers in TAPP hernia repair. Patients and Methods In our study, 30 patients were included divided on two groups, 15 for each. Group A; fixation mesh with tackers, Group B; fixation mesh with intracorporeal sutures. Both groups were compared in terms of operative technique, operative time, mesh device fixation cost, intra &amp; post operative complications, early post operative pain within two weeks and in first month, hospital stay, restriction of physical activity and incidence of recurrence and chronic pain. Results We found that using Intracorporeal sutures for fixation mesh is available, cheaper and more handle than using the Tackers which are expensive and less available so it makes a laparoscopic hernia more practical and decrease need for open surgery so we avoid the complication of open surgery. Both techniques are considered safe and effective with similar rates of recurrence and chronic pain although further wider scale studies are recommended. Conclusion TAPP hernia is considered safe as all perioperative complications are well tolerated by patients and mostly there was no need for a second operative intervention. Mesh fixation technique did not affect long-term persistent pain. A large number of patients reported persistent pain regardless of mesh fixation technique, which emphasizes the need for preoperative information. Preoperative pain was a risk factor for persistent pain. The optimal surgical approach must be selected individually for the patient, taking into account patient age, hernia size, unilateral or bilateral, primary or recurrent status, strangulation and type of anesthesia, occupation, and leisure activities. Both techniques are effective in the management of inguinal hernia and were associated with same recurrence rate. However, due to small sample size and short follow up duration, longer- term studies are also recommended.

P-743 Laparoscopic radical excision of deep endometriosis: A positive impact of fertility outcome

Abstract Study question Does laparoscopic radical excision of deep endometriosis (DE) and endometrioma enucleation impact fertility outcomes and recurrence rates when compared to partial excision group? Summary answer In stage IV endometriosis, laparoscopic radical surgery significantly reduced the recurrence rates.The laparoscopic radical excision group tended to have a higher rate of natural conception. What is known already Endometriosis-related symptoms can be significantly improved through surgery, leading to better pregnancy rates. However, the optimal surgical approach can vary due to the complexity of DE. As a result, the recurrence of postoperative symptoms and pregnancy rates can differ due to the lack of randomized trials comparing primary surgery with first-line IVF studies. Thus, the ESHRE stated that there was no evidence supporting surgical management of DE prior to ART to improve pregnancy rates. However, the higher probability of postoperative spontaneous conception in patients undergoing radical resection versus conservative treatment of DE has been reported. Study design, size, duration study design: Retrospective cohort study in a tertiary referral center. size: 77 patients diagnosed with moderate or severe endometriosis and DE. duration: between 2018 and 2020 Participants/materials, setting, methods 77 patients underwent laparoscopic surgery for dysmenorrhea or infertility. Group 1 (n = 22) underwent conservative treatment through partial excision of endometriosis, indicating incomplete resection. Group 2 (n = 55) underwent radical excision of endometriosis and restoration of pelvic anatomy, indicating complete resection. We compared the baseline characteristics, peri-operative data, and follow-up outcomes, aiming to investigate whether radical excision yields superior results in terms of recurrence rate, re-intervention, and pregnancy rate. Main results and the role of chance Main results: Group 2 showed significantly higher surgical complexity with higher revised American Fertility Society classification scores, a greater proportion of severe endometriosis, multiple sites with endometriotic lesions, and longer operation times. Both groups had comparable pregnancy, recurrence, and re-intervention outcomes during the follow-up period of 28.2±16.4 months. While Group 2 tended to have a higher pregnancy rate (84% versus 67%, p = 0.56) and higher live birth rates (80% versus 67%, p = 0.59) when compared with group 1. In the population with stage IV endometriosis, group 2 significantly reduced the recurrence rates (9% versus 50%, p = 0.04) when compared to group 1. Conclusions: The group that underwent laparoscopic endometrioma enucleation with radical excision of extra-ovarian endometriosis exhibited significantly higher surgical complexity. In the population with stage IV endometriosis, radical surgery significantly reduced the recurrence rates. Surgical excision of ovarian endometriosis and extra-ovarian disease is advisable to limit disease progression and ensure complete symptom resolution. Additionally, the laparoscopic radical excision group tended to have a higher rate of natural conception, indicating potential benefits for fertility in patients who have moderate and severe endometriosis with DE. Limitations, reasons for caution The main limitations were the small sample size and recall bias. But, additionally, the limited cases in the research group might have influenced the results and restricted the extrapolation of related conclusions. Further studies with larger sample sizes are needed in the future. Wider implications of the findings We believe that a standardized surgical technique outlining a step-by-step method to delineate all important structures and address altered planes as in endometriosis, with the aim of restoring normal pelvic anatomy, ensures the avoidance of high complication rates, leads to lower recurrence rates and positive impact on fertility outcomes. Trial registration number not applicable

ОЦЕНКА РЕЗУЛЬТАТОВ ПРИМЕНЕНИЯ АЛГОРИТМА ВЫБОРА ОПТИМАЛЬНОГО ХИРУРГИЧЕСКОГО ДОСТУПА К ЗАБРЮШИННОМУ ПРОСТРАНСТВУ У ПАЦИЕНТОВ С РАЗЛИЧНЫМИ ПАРАМЕТРАМИ КОНСТИТУЦИИ.

Relevance. Despite the rapid development and predominance of endovideosurgical techniques in the treatment of pathologies of organs and structures of the retroperitoneal space, the implementation of transperitoneal or retroperitoneal approaches for open surgical interventions remains a routine activity. Surgical treatment of various pathologies of retroperitoneal localization leads to the development of nonspecific life-threatening complications in 23.8% - 30% of clinical observations, and associated mortality - 7.2% - 11% of cases. Previously, our works presented the results of comparing the number of this type of complications when using laparotomy or retroperitoneal access, depending on the constitutional parameters of the patient. An assessment was made of the significance of the influence of constitutional parameters on the development of nonspecific life-threatening complications, on the basis of which an algorithm for choosing the optimal surgical access to the structures of the retroperitoneal space was developed [patent application No. 2024113445 dated May 17, 2024]. Purpose of the study. To evaluate the effectiveness of using an algorithm for selecting the optimal surgical approach in the surgical treatment of pathologies of organs and structures of retroperitoneal localization. Materials and methods. Comparative analysis of the results of surgical treatment of patients with various surgical pathologies of the retroperitoneal space. Group I (n = 167), where the choice of surgical approach was determined using the “optimal surgical approach selection algorithm.” Group II (n = 284), in which the choice of access to the structures of the retroperitoneal space was not unified and was chosen without taking into account the constitutional parameters of the patient. In the perioperative period, the duration of surgical intervention, the volume of intraoperative blood loss, the number of days of stay in the intensive care unit, the time of postoperative respiratory support, the duration of postoperative intestinal paresis and the number of postoperative bed days were assessed. Criteria assessed in the postoperative period: development of myocardial infarction, acute cardiovascular failure, ARDS with the development of respiratory failure, acute kidney injury; cases of development of ischemic colitis and small intestinal obstruction, requiring repeated interventions, as well as the phenomenon of multiple organ failure. Wound complications included failure of retroperitoneal and laparotomy wounds, including eventration. To calculate quantitative characteristics, the median (Me) and percentiles (Q0.25 - Q0.75) were determined. Calculation of statistical significance between groups was performed using the Mann-Whitney U test**, for comparison of qualitative indicators - the Chi-square test* in IBM SPSS Statistics 25 software. Results. In group I, compared with group II, there was a shorter surgical intervention time [140.8 vs 179.5] min, p = 0.031**, a smaller volume of intraoperative blood loss [280.4 vs 413.3] ml, p = 0.024* *; postoperative respiratory support [4.5 vs 8.5] hours, p = 0.041**; length of stay in the intensive care unit [1.8 vs 3.4] days, p = 0.021**; postoperative intestinal paresis [1.2 vs 4.8] days p = 0.024**; and duration of total postoperative hospital stay [9.1 vs 16.4] days p = 0.003**. The number of postoperative nonspecific life-threatening and wound complications in group I was 24 (14.4%), and in group II - 64 (22.5%) cases (p = 0.023*). The number of complications-related deaths in group I was 9 (5.4%); in group II - 32 (11.26%) cases (p = 0.037*). Conclusion. The use of an algorithm for selecting the optimal surgical approach for surgical treatment of pathologies of organs and structures of the retroperitoneal localization of the access leads to a reduction in the number of nonspecific life-threatening complications to 14.4%, and associated deaths to 5.4%.

Surgical Management of a Non-Obstetric Vulvar Hematoma

Purpose: To describe the successful management of a rare non-obstetric vulvar hematoma. Background: While vulvar hematomas are common in obstetric cases, vulvar hematomas due to non-obstetric trauma are rare, representing only 0.8% of all gynecological emergencies. The vulva is made primarily of loose connective tissue richly supplied by branches of the pudendal artery, so it is susceptible to injury by multiple different types of trauma. Because non-obstetric vulvar hematomas are so rare, there is no established consensus for management. In this article, we shall present a patient who, after sustaining multiple injuries from a motor vehicle collision, developed a large vulvar hematoma that was successfully treated with surgical evacuation. Case Description: A healthy 26-year-old female presented to the emergency department following a broadside motor vehicle collision. CT with contrast described multiple pelvic fractures as well as a small volume retroperitoneal hemorrhage anterior to the bladder. There was no evidence of bladder injury or other areas of extravasation. On hospital day 1, she underwent uncomplicated open reduction and internal fixation of pelvic and sacral ring fractures. On hospital day 3, the patient began noticing a painful, rapidly expanding labial hematoma, and OBGYN services were consulted. Despite conservative management with ice and analgesics, the patient described the pain as 10 out of 10. On physical exam the right vulva was found to have a 14 cm hematoma expanding down to the perineum and extending to include the labia majora and labia minora. The area was extremely edematous and tender to light palpation. Swelling distorted the anatomy, occluding the vaginal introitus and obscuring the left labia. A Foley catheter was draining clear urine from the bladder. The following morning, the hematoma had continued to expand and Hgb significantly decreased, so the decision was made to proceed with surgical management. Pre-operative antibiotics were given, and the patient was prepped and draped according to hospital protocol. Hart’s line was injected with a marcaine/lidocaine/epinephrine premixed solution for hemostasis. A 3 cm vertical incision was created along Hart’s line, and the space was bluntly entered using a hemostat. Clotted blood was evacuated from the labial space, and active bleeding was ligated with using Vicryl. Once hemostasis was noted, the incision was loosely closed with interrupted stitches placed widely apart to allow for drainage. The vagina and left labia were examined and found to be normal. The right labial space was packed using kerlix, and the patient was prescribed a 7-day course of oral antibiotics. The patient tolerated the procedure well and reported no vulvar pain on post-op day 1. The vulvar packing was removed without incident, and no bleeding was noted from the incision site. The patient was reevaluated by the OBGYN team on post-op day 8 and was healing very well. She reported very little pain and had no issues with spontaneous urination. On physical exam, the hematoma was nontender to palpation and measured approximately 10 x 5 x 2.5 cm with decreased bruising and areas of discoloration. The patient was discharged with no further issues. Despite multiple attempts to schedule an outpatient appointment, the patient was unfortunately lost to follow-up. Discussion: Non-obstetric vulvar hematomas due to non-obstetric trauma are rare, and with improper management, may lead to significant morbidity. However, there is no established consensus for management, and little literature is available for guidance. Some small studies have reported success with conservative management. Benrubi et al, however, observed that conservative management of vulvar hematomas may be associated with longer hospital stays and increased need for antibiotics and blood transfusions10. A recent retrospective analysis also suggests a preference for surgical management, as a significantly reduced mortality rate was observed in patients who underwent surgical intervention for non-obstetric vulvar trauma. The same study found that while the surgical cohort tended to require a slightly longer hospital stay, there were no differences in ICU days, ventilator days, or rates of UTI between cohorts who had undergone surgical management and those who had undergone conservative management1. Arterial embolization has also been described as an alternative to surgical intervention in select patients, but this approach requires equipment and specialized personnel that may not be readily available to all institutions. Some case studies suggest using rate of expansion or hemodynamic instability as indications for surgical management. Size of the hematoma may also be considered as evidence suggests vulvar hematomas with a diameter greater than 4 cm have a higher potential for skin necrosis. Even when surgical management is clearly indicated there is little data regarding an optimal surgical approach. Conclusion: In this article, we discuss the successful surgical management and short-term follow up of a very large non-obstetric vulvar hematoma. We hope that our surgical approach can add to the small pool of literature available on these rare gynecological cases and help guide future research into developing standardized management guidelines.

Surgical Management of a Non-Obstetric Vulvar Hematoma

Purpose: To describe the successful management of a rare non-obstetric vulvar hematoma. Background: While vulvar hematomas are common in obstetric cases, vulvar hematomas due to non-obstetric trauma are rare, representing only 0.8% of all gynecological emergencies. The vulva is made primarily of loose connective tissue richly supplied by branches of the pudendal artery, so it is susceptible to injury by multiple different types of trauma. Because non-obstetric vulvar hematomas are so rare, there is no established consensus for management. In this article, we shall present a patient who, after sustaining multiple injuries from a motor vehicle collision, developed a large vulvar hematoma that was successfully treated with surgical evacuation. Case Description: A healthy 26-year-old female presented to the emergency department following a broadside motor vehicle collision. CT with contrast described multiple pelvic fractures as well as a small volume retroperitoneal hemorrhage anterior to the bladder. There was no evidence of bladder injury or other areas of extravasation. On hospital day 1, she underwent uncomplicated open reduction and internal fixation of pelvic and sacral ring fractures. On hospital day 3, the patient began noticing a painful, rapidly expanding labial hematoma, and OBGYN services were consulted. Despite conservative management with ice and analgesics, the patient described the pain as 10 out of 10. On physical exam the right vulva was found to have a 14 cm hematoma expanding down to the perineum and extending to include the labia majora and labia minora. The area was extremely edematous and tender to light palpation. Swelling distorted the anatomy, occluding the vaginal introitus and obscuring the left labia. A Foley catheter was draining clear urine from the bladder. The following morning, the hematoma had continued to expand and Hgb significantly decreased, so the decision was made to proceed with surgical management. Pre-operative antibiotics were given, and the patient was prepped and draped according to hospital protocol. Hart’s line was injected with a marcaine/lidocaine/epinephrine premixed solution for hemostasis. A 3 cm vertical incision was created along Hart’s line, and the space was bluntly entered using a hemostat. Clotted blood was evacuated from the labial space, and active bleeding was ligated with using Vicryl. Once hemostasis was noted, the incision was loosely closed with interrupted stitches placed widely apart to allow for drainage. The vagina and left labia were examined and found to be normal. The right labial space was packed using kerlix, and the patient was prescribed a 7-day course of oral antibiotics. The patient tolerated the procedure well and reported no vulvar pain on post-op day 1. The vulvar packing was removed without incident, and no bleeding was noted from the incision site. The patient was reevaluated by the OBGYN team on post-op day 8 and was healing very well. She reported very little pain and had no issues with spontaneous urination. On physical exam, the hematoma was nontender to palpation and measured approximately 10 x 5 x 2.5 cm with decreased bruising and areas of discoloration. The patient was discharged with no further issues. Despite multiple attempts to schedule an outpatient appointment, the patient was unfortunately lost to follow-up. Discussion: Non-obstetric vulvar hematomas due to non-obstetric trauma are rare, and with improper management, may lead to significant morbidity. However, there is no established consensus for management, and little literature is available for guidance. Some small studies have reported success with conservative management. Benrubi et al, however, observed that conservative management of vulvar hematomas may be associated with longer hospital stays and increased need for antibiotics and blood transfusions10. A recent retrospective analysis also suggests a preference for surgical management, as a significantly reduced mortality rate was observed in patients who underwent surgical intervention for non-obstetric vulvar trauma. The same study found that while the surgical cohort tended to require a slightly longer hospital stay, there were no differences in ICU days, ventilator days, or rates of UTI between cohorts who had undergone surgical management and those who had undergone conservative management1. Arterial embolization has also been described as an alternative to surgical intervention in select patients, but this approach requires equipment and specialized personnel that may not be readily available to all institutions. Some case studies suggest using rate of expansion or hemodynamic instability as indications for surgical management. Size of the hematoma may also be considered as evidence suggests vulvar hematomas with a diameter greater than 4 cm have a higher potential for skin necrosis. Even when surgical management is clearly indicated there is little data regarding an optimal surgical approach. Conclusion: In this article, we discuss the successful surgical management and short-term follow up of a very large non-obstetric vulvar hematoma. We hope that our surgical approach can add to the small pool of literature available on these rare gynecological cases and help guide future research into developing standardized management guidelines.

A Meta-analysis of the Efficacy of Different Surgical Methods in the Treatment of Uterine Prolapse.

The management of uterine prolapse poses a significant clinical challenge, with surgical intervention often necessary for symptom relief and restoration of pelvic floor function. However, the optimal surgical approach for uterine prolapse remains uncertain, prompting a comprehensive meta-analysis to compare the efficacy of various surgical methods. This study aims to assess the effectiveness of different surgical methods for treating uterine prolapse. We used computer search to retrieve relevant literature to compare the therapeutic effects of different surgical methods for treating uterine prolapse. The search was conducted in the Web of Science and PubMed databases, and articles published until October 2023 were obtained. We employed random effects and fixed effects models and performed a meta-analysis using the R software. This study included 40 standard papers covering 25,896 patients with uterine prolapse. We used random and fixed effects models to conduct a meta-analysis of hysterectomy and uterine fixation procedures. The findings indicated that different surgical approaches had no significant impact on surgical success rates (I2 = 69%, p < 0.01; risk ratio (RR) (95% confidence intervals (CI)): 1.00 [0.98; 1.03]) or postoperative adverse reactions (I2 = 54%, p < 0.01; RR (95% CI), 1.10 [0.83; 1.45]). However, the durations of the surgical procedure for hysterectomy (I2 = 91%, p < 0.01; standardized mean difference (SMD) (95% CI), 0.78 [0.49; 1.07]), surgical blood loss (I2 = 97%, p < 0.01, SMD (95% CI): 1.14 [0.21; 2.07]), and intraoperative adverse reactions (I2 = 0%, p = 0.61, RR (95% CI): 1.37 [1.10; 1.71]) were statistically significant between hysterectomy and uterine fixation procedures. Additionally, publication bias and sensitivity tests showed no publication bias in this meta-analysis and no literature causing significant sensitivity. In the treatment of uterine prolapse, both hysterectomy and uterine fixation are similar in terms of surgical success rates and postoperative adverse reactions. However, hysterectomy is associated with longer duration of the surgical procedure, increased blood loss and higher incidence of intraoperative adverse reactions compared to uterine fixation.

Transvaginal resection of a gastrointestinal stromal tumor of the rectum: a case report

BackgroundThe most common curative treatment for gastrointestinal stromal tumors (GISTs) is local excision. For rectal GISTs, however, local excision is difficult because of the anatomical features of the rectum. The optimal surgical approach is still under debate, and less invasive methods are desired. We herein report a case of transvaginal resection of a rectal GIST in a young woman.Case presentationA 21-year-old woman was diagnosed with a resectable GIST in the anterior rectal wall and underwent transvaginal tumor resection. The posterior vaginal wall was incised, revealing the tumor fully covered by the rectal mucosa. The rectal adventitia and muscular layer were incised, and the tumor was resected en bloc without rupture. The postoperative course was favorable, and the patient was discharged on postoperative day 12. No findings consistent with recurrence were present 6 months postoperatively.ConclusionTransvaginal tumor resection is a treatment option as a minimally invasive procedure for GISTs in the anterior rectal wall in female patients.

Initial versus Staged Thyroidectomy for Differentiated Thyroid Cancer: A Retrospective Multi-Dimensional Cohort Analysis of Effectiveness and Safety.

The optimal surgical approach for differentiated thyroid cancer remains controversial, with debate regarding the comparative risks of upfront total thyroidectomy versus staged completion thyroidectomy following the initial lobectomy. This study aimed to assess the complication rates associated with these two strategies and identify the optimal timing for completion thyroidectomy using a multi-dimensional analysis of four cohorts: an institutional series (n = 148), the National Surgical Quality Improvement Program (NSQIP) database (n = 39,992), the TriNetX repository (n > 30,000), and a pooled literature review (10 studies, n = 6015). Institutional data revealed higher overall complication rates with total thyroidectomy (18.3%) compared to completion thyroidectomy (6.8%), primarily due to increased temporary hypocalcemia (10% vs. 0%, p = 0.004). The NSQIP analysis demonstrated that total thyroidectomy was associated with a 72% increased risk of transient hypocalcemia (p < 0.001) and a 25% increased risk of permanent hypocalcemia (p < 0.001). TriNetX data confirmed these findings and identified obesity and concurrent neck dissection as risk factors for complications. A meta-analysis showed that total thyroidectomy increased the rates of transient (RR = 1.63) and permanent (RR = 1.23) hypocalcemia (p < 0.001). Institutional and TriNetX data suggested that performing completion thyroidectomy between 1 and 6 months after the initial lobectomy minimized permanent complication rates compared to delays beyond 6 months. In conclusion, for differentiated thyroid cancer, total thyroidectomy is associated with higher risks of transient and permanent hypocalcemia compared to staged completion thyroidectomy. However, performing completion thyroidectomy within 1-6 months of the initial lobectomy may mitigate the risk of permanent complications. These findings can inform personalized surgical decision-making for patients with differentiated thyroid cancer.

Primary Versus Revisional Bariatric and Metabolic Surgery in Patients with a Body Mass Index ≥ 50kg/m2-90-Day Outcomes and Risk of Perioperative Mortality.

Bariatric and metabolic surgery (BMS) is an effective treatment for patients with severe obesity. Patients with higher body mass index (BMI) and patients undergoing revisional surgery have a higher rate of major complications. This study purpose is to evaluate perioperative outcomes of patients with BMI ≥ 50kg/m2. A retrospective analysis of patients with a BMI ≥ 50kg/m2 undergoing BMS between 2015 and 2023 was conducted. A comparative analysis was performed between patients undergoing primary versus revisional surgery. A total of 263 patients were included in the study. Primary procedures were performed in 220 patients (83.7%) and revisional procedures in 43 patients (16.3%). BMS included one anastomosis gastric bypass (n = 183), sleeve gastrectomy (n = 63), and other procedures (n = 17). Mean BMI was 54.6 with no difference between groups. There was no difference in baseline characteristics except the revisional group was older (44.8 ± 9.6 versus 39 ± 13years; p = 0.006), had higher rates of gastroesophageal reflux disease (21% vs 7.3%; p = 0.005), and fatty liver disease (74% vs 55%; p = 0.02). There was perioperative mortality in three cases (1.1%) with no significant difference between groups. Leak rates were higher, and length of stay (LOS) was longer in the revisional group (4.6% vs 0.45%; p = 0.018 and 2.9 vs 3.7; p = 0.006, respectively). Revisional BMS in patients with a BMI ≥ 50kg/m2 is associated with increased leak rates and LOS. Mortality rate is 1.1% and is insignificantly different between groups. Further prospective and large-scale studies are needed to clarify the optimal surgical approach to patients with extreme BMI including revisional surgery.

Comparison of open and endovascular left subclavian artery revascularization for zone 2 thoracic endovascular aortic repair

ObjectiveIn patients undergoing elective thoracic endovascular aortic repair (TEVAR) and left subclavian artery (LSA) coverage, routine preoperative LSA revascularization is recommended. However, in the current endovascular era, the optimal surgical approach is debated. We compared baseline characteristics, procedural details, and perioperative outcomes of patients undergoing open or endovascular LSA revascularization in the setting of TEVAR. MethodsAdult patients undergoing TEVAR with zone 2 proximal landing and LSA revascularization between 2013 and 2023 were identified in the Vascular Quality Initiative. We excluded patients with traumatic aortic injury, aortic thrombus, or ruptured presentations, and stratified based on revascularization type (open vs any endovascular). Open LSA revascularization included surgical bypass or transposition. Endovascular LSA revascularization included single-branch, fenestration, or parallel stent grafting. Primary outcomes were stroke, spinal cord ischemia (SCI), and perioperative mortality (Pearson's χ2 test). Multivariable logistic regression was used to evaluate associations between revascularization type and primary outcomes. Secondarily, we studied other in-hospital complications and 5-year mortality (Kaplan-Meier, multivariable Cox regression). Sensitivity analyses were performed in patients undergoing concomitant LSA revascularization to TEVAR. ResultsOf 2489 patients, 1842 (74%) underwent open and 647 (26%) endovascular LSA revascularization. Demographics and comorbidities were similar between open and endovascular cohorts. Compared with open, endovascular revascularization had shorter procedure times (median, 135 minutes vs 174 minutes; P < .001), longer fluoroscopy times (median, 23 minutes vs 16 minutes; P < .001), lower estimated blood loss (median, 100 mL vs 123 mL; P < .001), and less preoperative spinal drain use (40% vs 49%; P < .001). Patients undergoing endovascular revascularization were more likely to present urgently (24% vs 19%) or emergently (7.4% vs 3.4%) (P < .001). Compared with open, endovascular patients experienced lower stroke rates (2.6% vs 4.8%; P = .026; adjusted odds ratio [aOR], 0.50 [95% confidence interval (CI), 0.25-0.90]), but had comparable SCI (2.9% vs 3.5%; P = .60; aOR, 0.64 [95% CI, 0.31-1.22]) and perioperative mortality (3.1% vs 3.3%; P = .94; aOR, 0.71 [95% CI, 0.34-1.37]). Compared with open, endovascular LSA revascularization had lower rates of overall composite in-hospital complications (20% vs 27%; P < .001; aOR, 0.64 [95% CI, 0.49-0.83]) and shorter overall hospital stay (7 vs 8 days; P < .001). After adjustment, 5-year mortality was similar among groups (adjusted hazard ratio, 0.85; 95% CI, 0.64-1.13). Sensitivity analyses supported the primary analysis with similar outcomes. ConclusionsIn patients undergoing TEVAR starting in zone 2, endovascular LSA revascularization had lower rates of postoperative stroke and overall composite in-hospital complications, but similar SCI, perioperative mortality, and 5-year mortality rates compared with open LSA revascularization. Future comparative studies are needed to evaluate the mid- to long-term safety of endovascular LSA revascularization and assess differences between specific endovascular techniques.

Association of Surgical Approaches and Outcomes in Total Mesorectal Excision and Margin Status for Rectal Cancer

IntroductionDespite being a key metric with a significant correlation with the outcomes of patients with rectal cancer, the optimal surgical approach for total mesorectal excision (TME) has not yet been identified. The aim of this study was to assess the association of the surgical approach on the quality of TME and surgical margins and to characterize the surgical and long-term oncologic outcomes in patients undergoing robotic, laparoscopic, and open TME for rectal cancer. MethodsPatients with primary, nonmetastatic rectal adenocarcinoma who underwent either lower anterior resection or abdominoperineal resection via robotic (Rob), laparoscopic (Lap), or open approaches were selected from the US Rectal Cancer Consortium database (2007-2017). Quasi-Poisson regression analysis with backward selection was used to investigate the relationship between the surgical approach and outcomes of interest. ResultsAmong the 664 patients included in the study, the distribution of surgical approaches was as follows: 351 (52.9%) underwent TME via the open approach, 159 (23.9%) via the robotic approach, and 154 (23.2%) via the laparoscopic approach. There were no significant differences in baseline demographics among the three cohorts. The laparoscopic cohort had fewer patients with low rectal cancer (<6 cm from the anal verge) than the robotic and open cohorts (Lap 28.6% versus Rob 59.1% versus Open 45.6%, P = 0.015). Patients who underwent Rob and Lap TME had lower intraoperative blood loss compared with the Open approach (Rob 200 mL [Q1, Q3: 100.0, 300.0] versus Lap 150 mL [Q1, Q3: 75.0, 250.0] versus Open 300 mL [Q1, Q3: 150.0, 600.0], P < 0.001). There was no difference in the operative time (Rob 243 min [Q1, Q3: 203.8, 300.2] versus Lap 241 min [Q1, Q3: 186, 336] versus Open 226 min [Q1, Q3: 178, 315.8], P = 0.309) between the three approaches. Postoperative length of stay was shorter with robotic and laparoscopic approach compared to open approach (Rob 5.0 d [Q1, Q3: 4, 8.2] versus Lap 5 d [Q1, Q3: 4, 8] versus Open 7.0 d [Q1, Q3: 5, 9], P < 0.001). There was no statistically significant difference in the quality of TME between the robotic, laparoscopic, and open approaches (79.2%, 64.9%, and 64.7%, respectively; P = 0.46). The margin positivity rate, a composite of circumferential margin and distal margin, was higher with the robotic and open approaches than with the laparoscopic approach (Rob 8.2% versus Open 6.6% versus Lap 1.9%, P = 0.17), Rob versus Lap (odds ratio 0.21; 95% confidence interval 0.05, 0.83) and Rob versus Open (odds ratio 0.5; 95% confidence interval 0.22, 1.12). There was no difference in long-term survival, including overall survival and recurrence-free survival, between patients who underwent robotic, laparoscopic, or open TME (Figure 1). ConclusionsIn patients undergoing surgery with curative intent for rectal cancer, we did not observe a difference in the quality of TME between the robotic, laparoscopic, or open approaches. Robotic and open TME compared to laparoscopic TME were associated with higher margin positivity rates in our study. This was likely due to the higher percentage of low rectal cancers in the robotic and open cohorts. We also reported no significant differences in overall survival and recurrence-free survival between the aforementioned surgical techniques.

Minimally invasive approach for retrorectal tumors above and below S3: a multicentric tertiary center retrospective study (MiaRT study)

BackgroundRetrorectal tumors are uncommon lesions developed in the retrorectal space. Data on their minimally invasive resection are scarce and the optimal surgical approach for tumors below S3 remains debated.MethodsWe performed a retrospective review of consecutive patients who underwent minimally invasive resection of retrorectal tumors between 2005 and 2022 at two tertiary university hospital centers, by comparing the results obtained for lesions located above or below S3.ResultsOf over 41 patients identified with retrorectal tumors, surgical approach was minimally invasive for 23 patients, with laparoscopy alone in 19, with transanal excision in 2, and with combined approach in 2. Retrorectal tumor was above S3 in 11 patients (> S3 group) and below S3 in 12 patients (< S3 group). Patient characteristics and median tumor size were not significantly different between the two groups (60 vs 67 mm; p = 0.975). Overall median operative time was 131.5 min and conversion rate was 13% without significant difference between the two groups (126 vs 197 min and 18% vs 8%, respectively; p > 0.05). Final pathology was tailgut cyst (48%), schwannoma (22%), neural origin tumor (17%), gastrointestinal stromal tumor (4%), and other (19%). The 90-day complication rates were 27% and 58% in the > S3 and < S3 groups, respectively, without severe morbidity or mortality. After a median follow-up of 3.3 years, no recurrence was observed in both groups. Three patients presented chronic pain, three anal dysfunction, and three urinary dysfunction. All were successfully managed without reintervention.ConclusionsMinimally invasive surgery for retrorectal tumors can be performed safely and effectively with low morbidity and no mortality. Laparoscopic and transanal techniques alone or in combination may be recommended as the treatment of choice of benign retrorectal tumors, even for lesions below S3, in centers experienced with minimally invasive surgery.

Neuroanatomy of cerebellar mutism syndrome: the role of lesion location.

Approximately 25% of paediatric patients who undergo cerebellar tumour resection develop cerebellar mutism syndrome. Our group recently showed that damage to the cerebellar deep nuclei and superior cerebellar peduncles, which we refer to as the cerebellar outflow pathway, is associated with an increased risk of cerebellar mutism syndrome. Here, we tested whether these findings replicate in an independent cohort. We evaluated the relationship between lesion location and the development of cerebellar mutism syndrome in an observational study of 56 paediatric patients ranging from five months to 14 years of age who underwent cerebellar tumour resection. We hypothesized that individuals who developed cerebellar mutism syndrome after surgery, relative to those who did not, would have lesions that preferentially intersect with: (i) the cerebellar outflow pathway and (ii) a previously generated 'lesion-symptom map' of cerebellar mutism syndrome. Analyses were conducted in accordance with pre-registered hypotheses and analytic methods (https://osf.io/r8yjv/). We found supporting evidence for both hypotheses. Compared to patients who did not develop cerebellar mutism syndrome, patients with cerebellar mutism syndrome (n = 10) had lesions with greater overlap with the cerebellar outflow pathway (Cohen's d = 0.73, P = 0.05), and the cerebellar mutism syndrome lesion-symptom map (Cohen's d = 1.1, P = 0.004). These results strengthen the association of lesion location with the risk of developing cerebellar mutism syndrome and demonstrate generalizability across cohorts. These findings may help to inform the optimal surgical approach to paediatric cerebellar tumours.

Optimal Surgical Approaches for Thyroid Cancer: A Comparative Analysis of Efficacy and Complications.

BACKGROUND Completion thyroidectomy (CTx) is performed following hemithyroidectomy (HTx) when the risk of malignancy persists or is discovered postoperatively. Different surgical approaches, including CTx after HTx (CTx-HTx), total thyroidectomy (TTx), and revision surgery after TTx (RTx-TTx), offer varying risks and benefits, including pathological outcomes and complication rates. Understanding the predictors and rates of malignancy in these procedures is crucial for optimizing surgical management of thyroid disorders. MATERIAL AND METHODS This retrospective study analyzed data from January 2014 to October 2019, including 60 patients each in the CTx-HTx and TTx groups, and 47 in the RTx-TTx group. The CTx-HTx group was subdivided based on benign or malignant findings in CTx specimens. Clinicodemographic data and pathological features such as tumor type, size, side, capsular and vascular invasion, extrathyroidal spread, multifocality, and lymph node metastasis were reviewed. RESULTS Age and sex distributions were similar across groups. In the CTx-HTx group, 76.7% of specimens were benign and 23.3% malignant. No significant predictors of malignancy were found between the benign and malignant subgroups in univariate and multivariable analyses. In the TTx group, 75.0% of initial lobes and 13.3% of contralateral lobes were malignant. TTx was associated with a significant postoperative decrease in calcium and longer hospital stays. Multivariable analysis identified TTx as an independent risk factor for hypocalcemia. CONCLUSIONS Reducing overtreatment in thyroid cancer may involve limiting CTx after HTx and considering more conservative initial surgeries, particularly when indications for TTx are not definitive.

Comparison of the post-operative outcomes between different surgical techniques for inferior turbinate reduction surgery: A cross sectional study.

To compare and measure post-operative outcomes among various surgical techniques for reducing inferior turbinate hypertrophy (ITH), and to identify the factors associated with the clinical outcomes of turbinoplasty in patients with this condition. A cross-sectional study was carried out from January 2021 to December 2022 at the Otorhinolaryngology Department of King Abdulaziz Medical City in Riyadh, Saudi Arabia. A total of 301 adult patients with ITH were included and were divided into different groups. Postoperative follow-up assessments were completed after one week, one month, and 6 months to evaluate outcomes and complications associated with each surgical technique; descriptive analysis, cross-tabulation, and exact logistic regression were utilized as data analysis methods. Most patients in both groups experienced partial or complete improvement after surgery, with 92% showing positive outcomes. Common clinical signs included deviated nasal septum deviation and external nasal deformity, while nasal obstruction was most frequently reported as the primary symptom. Post-surgery bleeding occurred in 3.7% of cases; no adhesions were noted. Microdebrider, medial flap, out-fracture, and submucosal diathermy techniques all demonstrated significantly higher improvement rates than others. The identified techniques with higher improvement rates offer evidence-based guidance for selecting optimal surgical approaches, while the study's limitations warrant further prospective research to validate these findings. Ultimately, it contributes valuable knowledge to the field of otorhinolaryngology, aiming to enhance patient outcomes and improve the management of ITH worldwide.

Surgical access to the mediastinum-all roads lead to Rome: a literature review.

The mediastinum is a complex, heterogeneous area, which leads vertically across the thoracic cavity between the bilateral mediastinal pleurae, connecting the head and neck region with the thoracic cavity. Different classifications have been published to differentiate between the so-called mediastinal compartments while the most used classification surely is the 4-compartments Gray`s classification, dividing it into the superior, anterior, middle and posterior mediastinum. Mediastinal abnormalities include infections (mediastinitis) and solid or cystic mediastinal masses. These masses can be divided into benign and malignant lesions originating from mediastinal structures/organs or represent manifestations of metastatic disease, often metastatic non-small cell lung cancer (NSCLC). This review aims to explore the different mediastinal pathologies along with indications and surgical approaches. We performed literature research in PubMed, MEDLINE, Embase, CENTRAL, and CINAHL databases. Only papers written in English were included. Depending on the indication for surgical intervention and the localization of the pathology, surgical approach may differ immensely. Mediastinal staging of lung cancer, primary lesions of the mediastinum, mediastinitis and traumatic mediastinal injuries display the most frequent indications for mediastinal surgery. Surgical approaches trend towards minimally invasive, video- or robotic-assisted techniques and are becoming increasingly refined to adapt to the special characteristics of the mediastinum. However, certain indications still require open access for best possible mediastinal exposure or oncological reasons. To guide optimal surgical approach selection to the mediastinum, the following overview will present all published surgical approaches to the mediastinum and discuss their practical relevance and indications aiming to help surgeons in the management of patients with mediastinal pathologies who should undergo surgery.

Functional Mitral Valve Regurgitation: Mitral Valve Repair or Replacement? Our "Road Map" for the Appropriate Strategy.

Objectives: The optimal surgical approach for the treatment of functional mitral regurgitation (FMR) remains controversial. Current guidelines suggest that the surgical approach has to be tailored to the individual patient. The aim of the present study was to clarify further aspects of this tailored treatment. Methods: From 01/2006 to 12/2015, 390 patients underwent mitral valve (MV) surgery for FMR (ischemic n = 241, non-ischemic n = 149) at our institution. A regression analysis was used to determine the effect of MV repair or replacement on survival. The patients were analyzed according to the etiology of the MR (ischemic or non-ischemic), different age groups (<65 years, 65-75 years, and >75 years), LV function, and LV dimensions, as well as the underlying heart rhythm. Results: The overall survival rates for the repair group at 1, 5, and 8 years were 86.1 ± 1.9%, 70.6 ± 2.6%, and 55.1 ± 3.1%, respectively. For the same intervals, the survival rates in patients who underwent MV replacement were 75.9 ± 4.5%, 58.6 ± 5.4%, and 40.9 ± 6.4%, respectively (p = 0.003). Patients younger than 65 years, with an ischemic etiology of FMR, poor ejection fraction (<30%), severe dilatation of left ventricle (LVEDD > 60mm), and presence of atrial fibrillation had significantly higher mortality rates after MV replacement (HR, 3.0; CI, 1.3-6.9; p = 0.007). Patients between 65 and 75 years of age had a higher risk of death when undergoing mitral valve replacement (HR, 1.7; CI, 1.0-2.8; p = 0.04). In patients older than 75 years, the surgical approach (MV repair or replacement) had no effect on postoperative survival (HR, 0.8; CI, 0.4-1.3; p = 0.003). Conclusions: Our data demonstrate that, in patients younger than 65 years, the treatment of choice for FMR should be MV repair. This advantage was even more evident in patients with an ischemic origin of MR, a poor ejection fraction, a severe LV dilatation, and atrial fibrillation.