Optimal Surgical Option Research Articles

Outcomes of retropupillary iris claw lens implantation in patients with intraocular lens dislocation and low (less than 1000 cells/mm2) corneal endothelial cell density

BackgroundPosterior chamber intraocular lens (IOL) dislocation is a common complication of cataract surgery. Dislocated IOLs often require surgical intervention due to the potentially severe risks of leaving this condition untreated. If a patient with extremely low corneal endothelial cell density (ECD) presents with IOL dislocation, the surgeon faces a crucial dilemma of choosing the most optimal surgical treatment option. We sought to investigate the efficacy and safety of retropupillary iris claw intraocular lens (R-IOL) implantation in patients with IOL dislocation and extremely low (< 1000 cells/mm2) ECD.MethodsWe retrospectively reviewed the medical records of nine patients (all men) whose pre-operative ECD was < 1000 cells/mm2 and who underwent R-IOL implantation due to intraocular subluxation or total dislocation into the vitreous cavity between 2014 and 2020. We evaluated corneal endothelial function and visual outcomes after surgery.ResultsNine patients were included in this study. The mean age at diagnosis was 64.89 ± 7.15 years (range 57–76 years), and the follow-up duration was 37.93 ± 23.72 months (range 18.07–89.07 months). No patients developed bullous keratopathy during follow-up. Compared to the initial ECD, corneal thickness (CT), coefficient variation of cell area (CV) and percentage of hexagonal cells (HEX), there was no statistically significant decrease in the ECD, CV, and HEX at last follow-up (P = 0.944, 0.778, 0.445, 0.443). There was significant improvement in the mean uncorrected distance visual acuity (UDVA) at the last follow-up (average 0.13 logMAR, 20/27 Snellen) compared to the pre-operative mean UDVA (average 1.09 logMAR, 20/250 Snellen) (P < 0.01).ConclusionsR-IOL implantation did not result in a statistically significant decline in corneal endothelial function in patients with preoperatively low ECD, and it significantly improved the mean UDVA postoperatively. R-IOL implantation appears to be a safe and effective treatment modality for intraocular lens dislocation in patients with low ECD (< 1000 cells/mm²); however, long-term follow-up studies are warranted to corroborate these findings.

Current aspects of surgical treatment of pelvic organ prolapse

Objective: comparative analysis of the used methods of surgical treatment of pelvic organ prolapse. Methodology for writing a review. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search and analysis of articles published in the scientific databases e-Library, PubMed, Google Scholar for the period from 2015 to 2023 was carried out. After excluding publications that did not correspond to the search, 50 articles were selected for analysis. Conclusion. According to the study, each of the currently used methods of surgical treatment of pelvic organ prolapse has its own advantages and disadvantages, which makes it possible to select the optimal surgical option in each specific case. The determining factors when choosing a surgical intervention are the following factors: the patient's age, the presence of comorbid pathologies, including benign neoplasms, planning or not planning a pregnancy in the future.

Liver transplant versus liver resection in patients with multifocal hepatocellular carcinoma

BackgroundThe optimal surgical option in patients with multifocal hepatocellular carcinoma (MHCC) is an area of active research. The preference varies based on geographic variations and institutional policies. We sought to determine long-term outcomes in patients with MHCC based on surgical treatment—liver transplant (LT) vs resection (LR). MethodsWe performed a retrospective analysis of the National Cancer Database (2004–2015) and identified patients with MHCC within Milan criteria. Patients with α-fetoprotein ≥ 1000 ng/mL and those who underwent ablation were excluded. The primary outcome measure was long-term survival in patients undergoing LT vs LR. The secondary aim of our study was to determine clinicodemographic factors associated with the receipt of LT and LR. ResultsA total of 1546 patients were included, of whom 1211 received LT and 335 underwent LR. Patients who were non-Hispanic White (70.8% vs 54.9%; P < .01), privately insured (53.7% vs 36.7%; P < .01), and treated at academic centers (85.4% vs 71.6%; P < .01) were more likely to receive an LT. Multivariable Cox analysis revealed LT was associated with improved survival compared with LR (hazard ratio, 0.34; 95% CI, 0.28–0.42). ConclusionWe described clinical and sociodemographic differences in LT and LR patients and found LT to be associated with a decreased mortality risk compared with LR. The study’s findings should be interpreted in the context of several limitations, including the selection of MHCC criteria within Milan criteria.

МНОГОЭТАПНОЕ ЛЕЧЕНИЕ ТЕТРАДЫ ФАЛЛО: ОТ ПАЛЛИАТИВНЫХ ВМЕШАТЕЛЬСТВ ДО ГИБРИДНОГО БИФУРКАЦИОННОГО Y-СТЕНТИРОВАНИЯ ЛЁГОЧНОЙ АРТЕРИИ И РАДИКАЛЬНОЙ КОРРЕКЦИИ (КЛИНИЧЕСКИЙ СЛУЧАЙ)

Primary radical correction of tetralogy of Fallot (ToF) is an optimal surgical option; however, in some conditions, in particular with concomitant extracardiac pathology and hypoplasia of the pulmonary artery (PA) branches, this intervention is not possible. Obstruction and/or hypoplasia of the PA is one of the risk factors for primary radical correction of this congenital heart defect (CHD). In world practice, there are several methods of palliative approach for PA growth with the possibility of further radical correction. However, in some cases, palliative approaches do not give the desired result. In this regard, we present a clinical case of a successful hybrid bifurcation Y-stenting of the PA and radical correction of ToF. Keywords: Tetralogy of Fallot, radical correction, branches of the pulmonary artery, hypoplasia, stenting of the branches of the pulmonary artery, bifurcation Y-stenting, clinical case.

Surgical management of giant pituitary adenomas: institutional experience and clinical outcomes of 94 patients

BackgroundGiant (with a diameter of at least 40 mm and a volume of at least 10 cm3) pituitary adenomas (GPAs) are intricate tumors that pose considerable difficulty for surgical removal. While endoscopic transsphenoidal surgery (ETS) is a commonly employed technique for these destructive tumors, its effectiveness may be restricted in cases where invasion into multiple compartments is present, leading to limited resection.MethodsA retrospective review was conducted on the clinical records of 94 patients diagnosed with GPAs who had undergone surgical resection from 2014 to 2022. An analysis was conducted on the outcomes of the surgical and clinical procedures.ResultsIn this group, the average size of the tumor before surgery was 44.6 ± 5.6 mm (range, 40–73 mm), and the volume was 25. 5± 16.6 cm3 (range, 10–20.67 cm3). Of the total number of patients, 72 (76.6%) underwent a single ETS, 12 (12.8%) opted for transcranial surgery (TCS), and 10 (10.6%) chose a combined method. Gross total resection (GTR) was successfully performed in 49 (68.1%), 3 (25.0%), and 8 (80.0%) patients who underwent each surgical approach. Seventy-four (78.7%) patients had improved vision, 20 (21.3%) were unchanged, and none had deterioration. Twenty-two patients (23.4%) experienced a total of 43 complications, which comprised hormonal insufficiency (11/94, 11.7%), diabetic insipidus (6/88, 6.8%), electrolyte disorders (7/94, 7.4%), cerebrospinal fluid leakage (5/94, 5.3%), meningitis (8/94, 8.5%), and hydrocephalus (6/94, 6.4%). The GTR, subtotal resection (STR), and partial resection (PTR) rates were 63.8% (60/94), 21.3% (20/94), and 14.9% (14/94), respectively. Throughout the follow-up duration, 18.1% (17/94) of patients required reoperation and/or adjuvant radiation treatment as a result of tumor regrowth or inadequate biochemical remission of functioning GPAs.ConclusionETS remains the optimal surgical option for most GPAs and generally offers safe and efficient tumor resection. However, a combined approach with TCS remains a requirement in cases that are not suitable for treatment with a single ETS. To achieve optimal tumor removal and minimize the occurrence of surgical complications, a flexible combination of ETS and TCS is recommended based on the characteristics of the tumor.

SEEG-based epileptic seizure network modeling and analysis for pre-surgery evaluation

Stereo-electroencephalography is a minimally invasive technique for patients with refractory epilepsy pursuing surgery to reduce or control seizures. Electrodes are implanted based on pre-surgery evaluations and can collect deep brain activities for surgery decisions. This paper presents a methodology to analyze stereo-electroencephalography and assist clinicians by recommending the optimal surgical option and target areas for focal epilepsy patients. A seizure network (graph) model is proposed to characterize the spatial distribution and temporal changes of ictal events. The network nodes and edges correspond to specific epileptogenic regions and propagation/impact pathways (weighted by directed transfer function), respectively. We then employ a K-means clustering strategy to group nodes into a few clusters, from which the target surgical areas can be identified. Ten patients with different types of focal seizures were thoroughly analyzed. Promising consistency between results of our method’s recommendations, clinical decisions and surgery outcomes were observed.

A Randomized Trial of Total Drain Volume in Post-Modified Radical Mastectomy (MRM) Breast Cancer Patient Using Songket Incision Compare to Stewart Incision plus Axillary Anchor at Dr. Mohammad Hoesin Hospital Palembang

Background: Breast cancer is the most common malignancy in women globally. In Indonesia, a total of 65,858 new cases with a 22,530 mortality rate were reported in 2020. To overcome this health condition, surgery serves as the primary treatment, with post-mastectomy complications frequently involving seroma formation, exacerbating post-operative problems. Therefore, this study aimed to assess the total drain volume in post-MRM breast cancer patients using Songket incision compared to Stewart incision plus axillary anchor. This experiment was conducted to determine the optimal surgical option for breast cancer patients.Methods: A two-arm randomized controlled trial was conducted in female patients with breast cancer treated at the Surgical Oncology Division of Mohammad Hoesin Hospital Palembang between April to May 2022. Patients were blindly assigned to one of the two arms, namely the Songket incision and Stewart incision plus an axillary anchor. The eligible sample consisted of patients diagnosed with breast cancer who were slated for Modified Radical Mastectomy (MRM) surgery, willing to participate, and signed informed consent. The primary outcome of this study was total drain volume, while the secondary objective encompassed the length of treatment selected.Results: A total of 26 patients participated in this study (n=13 in each arm). The total drain volume using the Stewart incision was 378.07 ± 219.57, compared to 174.23 ± 97.44 ml for the Songket design (p&lt; 0.001). The mean length of treatment was 4.46 ± 0.77 days in the Stewart incision plus axillary anchor group and 3.23 ± 0.43 days in the Songket incision design (p &lt; 0.001). Conclusions: Songket incision was the best surgical option for breast cancer patients.

Syndromic Assessment of Degenerative Disorders of the Lumbar Spine in Elderly Patients

Background. The choice of the method and options for surgical treatment of degenerative pathology of the lumbar spine is difficult due to the lack of clear clinical and radiological criteria for diagnosis and a direct correlation between the severity of the radiological manifestations of the disease and clinical symptoms.&#x0D; The aim of this study was to analyze the clinical and neurological characteristics of elderly patients with degenerative disorders of the lumbar spine and to identify the dominant clinical and radiologic syndromes.&#x0D; Methods. Сohort of 1013 patients were operated using MIS technologies (decompression alone, TLIF, LLIF, ALIF) in the period 20132017 (367 male/646 female). The age range is 60-89 years (mean 66 years). The criteria for identifying the leading syndromes: leg pain/back pain with a threshold value of 5 points according to VAS, X-ray criteria for clinical instability by A.A. White and M.M. Panjabi (value 5 points), Cobb angle 10, markers of sagittal imbalance: Index Barrey (II and III), PT increase above target values, L4-S1 and LL deficiency.&#x0D; Results. Symptoms of compression were identified in 97% of patients. Radiculopathy syndrome was detected in 665 (66%) patients with mean leg pain 7 points, neurogenic intermittent claudication in 319 (31%) patients. Degenerative spondylolisthesis according to radiological criteria was detected in 428 (42%) patients. Degenerative scoliotic deformity had 91 (9%) patients. In accordance with the proposed criteria, the dominant compression syndrome was determined in 624 patients (62%), clinical instability syndrome in 338 (33%), deformity syndrome with sagittal imbalance in 51 (5%).&#x0D; Conclusion. Syndromic assessment of clinical, neurological and radiological manifestations of degenerative disorders provides the possibility of identifying the dominant syndrome requiring operative surgical treatment and a differentiated approach to choosing the optimal surgical option.

A deep learning model for automatic segmentation of intraparenchymal and intraventricular hemorrhage for catheter puncture path planning.

Intracerebral hemorrhage is the subtype of stroke with the highest mortality rate, especially when it also causes secondary intraventricular hemorrhage. The optimal surgical option for intracerebral hemorrhage remains one of the most controversial areas of neurosurgery. We aim to develop a deep learning model for the automatic segmentation of intraparenchymal and intraventricular hemorrhage for clinical catheter puncture path planning. First, we develop a 3D U-Net embedded with a multi-scale boundary aware module and a consistency loss for segmenting two types of hematoma in computed tomography images. The multi-scale boundary aware module can improve the model's ability to understand the two types of hematoma boundaries. The consistency loss can reduce the probability of classifying a pixel into two categories at the same time. Since different hematoma volumes and locations have different treatments. We also measure hematoma volume, estimate centroid deviation, and compare with clinical methods. Finally, we plan the puncture path and conduct clinical validation. We collected a total of 351 cases, and the test set contained 103 cases. For intraparenchymal hematomas, the accuracy can reach 96 % when the proposed method is applied for path planning. For intraventricular hematomas, the proposed model's segmentation efficiency and centroid prediction are superior to other comparable models. Experimental results and clinical practice show that the proposed model has potential for clinical application. In addition, our proposed method has no complicated modules and improves efficiency, with generalization ability. Network files can be accessed through https://github.com/LL19920928/Segmentation-of-IPH-and-IVH.

Cesarean Scar Ectopic Pregnancy Clinical Classification System With Recommended Surgical Strategy.

To establish a new cesarean scar ectopic pregnancy clinical classification system with recommended individual surgical strategy and to evaluate its clinical efficacy in treatment of cesarean scar ectopic pregnancy. This retrospective cohort study included patients with cesarean scar ectopic pregnancy in Qilu Hospital in Shandong, China. From 2008 to 2015, patients with cesarean scar ectopic pregnancy were included to determine risk factors for intraoperative hemorrhage during cesarean scar ectopic pregnancy treatment. Univariable analysis and multivariable logistic regression analyses were used to explore the independent risk factors for hemorrhage (300 mL or greater) during a cesarean scar ectopic pregnancy surgical procedure. The model was internally validated with a separate cohort. Receiver operating characteristic curve methodology was used to identify optimal thresholds for the identified risk factors to further classify cesarean scar ectopic pregnancy risk, and the recommended operative treatment was established for each classification group by expert consensus. A final cohort of patients from 2014 to 2022 were classified according to the new classification system, and the recommended surgical procedure and clinical outcomes were abstracted from the medical record. Overall, 955 patients with first-trimester cesarean scar ectopic pregnancy were included; 273 were used to develop a model to predict intraoperative hemorrhage with cesarean scar ectopic pregnancy, and 118 served as an internal validation group for the model. Anterior myometrium thickness at the scar (adjusted odds ratio [aOR] 0.51, 95% CI 0.36-0.73) and average diameter of the gestational sac or mass (aOR 1.10, 95% CI 1.07-1.14) were independent risk factors for intraoperative hemorrhage of cesarean scar ectopic pregnancy. Five clinical classifications of cesarean scar ectopic pregnancy were established on the basis of the thickness and gestational sac diameter, and the optimal surgical option for each type was recommended by clinical experts. When the classification system was applied to a separate cohort of 564 patients with cesarean scar ectopic pregnancy, the overall success rate of recommended first-line treatment with the new classification grouping was 97.5% (550/564). No patients needed to undergo hysterectomy. Eighty-five percent of patients had a negative serum β-hCG level within 3 weeks after the surgical procedure; 95.2% of patients resumed their menstrual cycles within 8 weeks. Anterior myometrium thickness at the scar and the diameter of the gestational sac were confirmed to be independent risk factors for intraoperative hemorrhage during cesarean scar ectopic pregnancy treatment. A new clinical classification system based on these factors with recommended surgical strategy resulted in high treatment success rates with minimal complications.

Evaluation of the advantages of robotic versus laparoscopic surgery in elderly patients with colorectal cancer

BackgroundThe incidence of colorectal cancer increases with aging. Curative-intent surgery based on a minimally invasive concept is expected to bring survival benefits to elderly patients (aged over 80 years) with colorectal cancer who are frequently with fragile health status and advanced tumors. The study explored survival outcomes in this patient population who received robotic or laparoscopic surgery and aimed to identify an optimal surgical option for those patients.MethodsWe retrieved the clinical materials and follow-up data on elderly patients with colorectal carcinoma who received robotic or laparoscopic surgery in our institution. The pathological and surgical outcomes were compared to examine the efficacy and safety of the two approaches. The DFS (disease-free survival) and OS (overall survival) results at 3 years after surgery were assessed to explore the survival benefits.ResultsA total of 111 patients were screened for the study, including 55 in the robotic group and 56 in the laparoscopic group. The demographic details were generally similar between the two groups. No statistically significant difference in the number of removed lymph nodes was observed between the two approaches, with a median of 15 versus 14 (P = 0.053). The intraoperative blood loss was significantly reduced by robotic technique when compared to the laparoscopic approach, with a mean of 76.9 ml versus 161.6 ml (P = 0.025). There were no significant differences in operation time, conversion, postoperative complications and recovery, and long-term outcomes between the two groups.ConclusionRobotic surgery was prized for elderly patients with colorectal cancer who developed anemia and/or hematological conditions.

Enhanced recovery after surgery (ERAS) protocol in geriatric patients underwent unicompartmental knee arthroplasty: A retrospective cohort study.

The enhanced recovery after surgery (ERAS) pathway was formulated with the aim to reduce surgical stress response, alleviate pain and guarantee the best-fit experience of patients' perioperative period. However, the application of ERAS in geriatric patients who underwent unicompartmental knee arthroplasty (UKA) was relatively lacking. We hypothesize that UKA patients can benefit from the ERAS protocol. A total of 238 patients were recruited in this retrospective study from August 2018 to December 2021, and Oxford phase III UKA was applied to all patients. ERAS pathway included nutrition support, anesthesia mode, interoperative temperature, and blood pressure control, application of tranexamic acid, early initiation of oral intake and mobilization, and pain management. Demographic data, operation-relative variables, and postoperative complications were analyzed. Forgotten Joint Scores, Oxford Knee Score, Lysholm score, numerical rating scale, and knee range of motion were introduced to estimate the activity function and pain of surgical knee, and these variables were compared between the 2 groups. There were 117 patients in the ERAS group and 121 patients in the traditional group, respectively. The ERAS group had a shorter length of surgical incision and less intraoperative blood loss. Postoperative hemoglobin and albumin of patients in the ERAS group were better than those in the traditional group (P < .05), after 17.0 ± 10.8 months follow-up, the numerical rating scale, Lysholm, Oxford Knee Score, Forgotten Joint Scores, and knee range of motion of patients in the ERAS group were significantly better than the traditional group. The length of hospital stay for patients who underwent ERAS was 11.7 ± 3.8 days and the postoperative complication rate was lower for the ERAS group patients (P = .000 and 0.031). ERAS can reduce the length of hospital stay, and patients can achieve excellent postoperative knee function. The formulation and implementation of the ERAS protocol require good collaboration across multiple disciplines, as well as a deep understanding of the existing clinical evidence and the concept of the ERAS program.

CT-based preoperative risk assessment of prolonged urine leak in patients undergoing partial nephrectomy.

This study aims to evaluate risk factors of prolonged urine leak following partial nephrectomy (PN) to identify objective imaging characteristics on preoperative CT. A total of 865 patients who underwent PN and had preoperative CT and postoperative imaging were included. We set a twofold size-matched control group without urine leak, with all tumors located ≤ 4 mm to the collecting system to identify imaging parameters that increase the risk of urine leak other than tumor size and location. Four CT parameters that show the relationship of the tumor and collecting system, namely, curvilinear border length, protruding distance, margin at the interface, and pelvicalyceal contact, were analyzed. Multivariate logistic regression analyses were performed to identify significant predictors of urine leak. The diagnostic performance of the significant parameters was evaluated using the area under the receiver operating characteristic curve (AUC). Fifty-three of 865 patients (6.1%) demonstrated urine leak. Compared with the control group, urine leak group showed longer curvilinear border length, longer protruding distance, frequent non-smooth contact interface, and frequent direct pelvicalyceal contact (p < 0.05 for all). In the multivariate analysis, pelvicalyceal contact was the independent predictor of urine leak (OR = 2.62; 95% C.I 1.02-6.63). Combining four CT parameters, an AUC of 0.70 with a sensitivity of 58.5% and a specificity of 79.2% for identifying urine leak after PN could be obtained. The four CT features that describe the relationship between the tumor and collecting system might be useful for evaluating the risk of urine leak before PN. • Four CT parameters (curvilinear border length, protruding distance, margin at the interface, and pelvicalyceal contact) were significantly associated with postoperative urine leak after partial nephrectomy. • A comprehensive preoperative imaging evaluation of the relationship between the tumor and renal sinus may help in selecting the optimal surgical options and afford better patient counseling of complication risk.

Molecular Testing for Thyroid Nodules: The Experience at McGill University Teaching Hospitals in Canada.

Simple SummaryThe aim of this review is to provide a general overview about the molecular markers (mutations and alterations) of thyroid cancers, present several molecular tests, and discuss the clinical applications of identifying these markers supported by the clinical experience of several high-volume thyroid cancer specialists at the McGill university teaching hospitals in Montreal, Canada.In the past few decades, molecular characterization of thyroid cancer has made significant progress and is able to identify thyroid-cancer-related molecular markers that can then be applied clinically for improved decision making. The aim of this review is to provide a general overview about the molecular markers (mutations and alterations) of thyroid cancers, present several molecular tests, and discuss the clinical applications of identifying these markers supported by the clinical experience of several high-volume thyroid cancer specialists at the McGill university hospitals in Montreal, Canada. Our group experience showed that molecular testing can reclassify more than half of the patients with indeterminate thyroid nodules (Bethesda III and IV) into benign and spare these patients from unnecessary diagnostic surgery. Furthermore, it can help optimize the initial management in thyroid cancers with no evidence of high risk of recurrence of disease preoperatively. While routine molecular testing is not firmly established for thyroid FNA specimens that are suspicious or positive for malignancy (Bethesda V and VI), knowledge of a thyroid nodule’s molecular risk group profile in such cases, together with its clinical and radiologic features, can help select the optimal surgical options (lobectomy versus upfront total thyroidectomy and central neck dissection), as demonstrated by our studies.

Retrograde Intramedullary Kirschner Wire Fixation as an Alternative for Treating Distal Fibular Shaft Fractures Combined with Distal Tibial Pilon Fractures.

Treatment or management techniques for pilon fractures are associated with high complication rates and poor outcomes. No consensus exists regarding the optimal surgical option for pilon fractures, especially for pilon fractures combined with distal fibular fractures. Accordingly, we explored the use of fibular fixation for treating pilon fractures involving distal fibular shaft fractures. We hypothesized that retrograde intramedullary Kirschner wire (K-wire) fixation is a suitable alternative technique for distal fibular fixation. We retrospectively reviewed the data of 156 patients who underwent surgery for pilon fractures at our hospital from May 2013 to May 2021. The radiographic and functional outcomes were comparable between the fibular intramedullary nailing (Group A; n = 80) and the fibular plating (Group B; n = 76) groups. Groups A and B differed significantly in total hospitalization time (11.4 vs. 18.2 days, p = 0.024), length of postoperative admission (6.8 vs. 11.4 days, p = 0.012), and total admission cost (USD 3624 vs. USD 6145, p = 0.004). We also noted that poor Olerud and Molander ankle scores were significantly associated with age (p = 0.008), smoking (p = 0.012), and preoperative admission length (p = 0.018). Retrograde intramedullary K-wire fixation produced a comparable 12-month functional outcome to plate fixation for distal fibular shaft fractures, rendering it a viable alternative method based on soft tissue condition.

An Evidence-Based Approach to Multi-Ligamentous Knee Injuries.

Multi ligament knee injuries (MLKIs) are highly complex injuries with associated complications and often present with difficult management strategies. MLKIs may affect the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (or posteromedial corner (PMC)), and lateral collateral ligament (or posterolateral corner (PLC)) in addition to other structures including the menisci, common peroneal nerve, and popliteal artery. MLKIs are highly associated with the male sex and are commonly seen in high-velocity motor vehicle accidents and low-velocity sports injuries. Given the multiple planes of movement in the knee and various primary and secondary stabilizers throughout those planes, there is great heterogeneity in an injury pattern and most involve the ACL and PCL. Initial evaluation of this injury includes assessment of lower extremity sensation, distal pulses, and ankle-brachial index (ABI). If vascular compromise is suspected, computed tomography angiography (CTA) or magnetic resonance angiography (MRA) are indicated to evaluate the vasculature. As opposed to CTA, MRA offers visualization of the soft-tissue structures that are commonly damaged in MLKIs. Initial management typically includes closed reduction of the knee with subsequent external fixation. Classification systems guide initial assessments; however, further management is unclear and leads the surgical team to decide the best, individualized management option for each patient. As a result, optimal surgical and postoperative treatment options remain complicated, and clinical outcomes remain difficult to predict. The purpose of this review is to consolidate the most up-to-date practices of the diagnostic workup, management, and treatment of MLKIs.

Off-pump versus on-pump coronary artery bypass grafting for octogenarians: A meta-analysis involving 146 372 patients.

There is an ongoing debate concerning the optimal surgical option of myocardial revascularization for octogenarians. The current meta‐analysis aimed to compare clinical outcomes following off‐pump coronary artery bypass grafting (OPCABG) or conventional coronary artery bypass grafting (CCABG) in octogenarians. PubMed, Cochrane, Web of Science, and EMBASE databases were searched to identify eligible studies from inception to March 2021. The analysis was performed using STATA 15.1. A literature search yielded 18 retrospective studies involving 146 372 patients (OPCABG = 44 522 vs. CCABG = 101 850). Pooled analysis showed a strong trend toward reducing mortality risk in the OPCABG group (odds ratio: 0.75, 95% confidence interval: 0.56–1.00, p = .05). However, it did not reach statistical significance. The sensitive analysis demonstrated that OPCABG was less likely to cause death than CCABG. There were comparable data in myocardial infarction, renal failure, deep sternal wound infection, and hospital stays between the two groups, although the incidence of stroke, atrial fibrillation, prolonged ventilation, and reoperation for bleeding was significantly lower in the OPCAGB group. OPCABG may be an effective surgical strategy for myocardial revascularization, especially in reducing the incidence of postoperative stroke, atrial fibrillation, prolonged ventilation, and reoperation for bleeding.

Pelvic ring injuries: classification and treatment

This review article will focus on the classification and treatment options for pelvic ring fractures. The pelvic ring can be split into anterior and posterior supporting structures. Injury can result in mechanical pelvic instability, the significance of which is determined by the magnitude and direction of forces applied during injury. The typical fracture patterns of anteroposterior compression, lateral compression and vertical shear form the basis of the Young and Burgess classification. However, the logic of the Tile classification system is useful in determining the degree of pelvic instability and the optimal surgical stabilization options. Posterior pelvic ring stabilization is often performed percutaneous after closed fracture reduction with sacro-iliac screws. This avoids the soft tissue complications often associated with open posterior approaches. Alternative reduction techniques can be performed through an open anterior approach using the first ilio-inguinal window to approach sacro-iliac joint disruptions as well as crescent fractures of the posterior iliac wing. The anterior pelvic ring, traditionally stabilized with external fixation, can be well accessed with the open ‘STOPPA’ approach. This allows access to an area extending from the pubic symphysis around the pelvic brim to the anterior aspect of the sacro-iliac joint where plates can be applied. Other options for anterior ring stabilization include column screws and the use of the ‘In-fix’ (Internal Fixator).

Preoperative prediction for lymph node metastasis in early gastric cancer by interpretable machine learning models: A multicenter study

BackgroundThe presence of lymph node metastasis plays a decisive role in the selection of treatment options in patients with early gastric cancer. However, there is currently no established protocol to predict the risk of lymph node metastasis before/after endoscopic resection. The aim of this study was to develop and validate several machine learning algorithms for clinical practice. MethodsA total of 2,348 patients with early gastric cancer were selected from 5 major tertiary medical centers. We applied 6 machine learning algorithms to develop lymph node metastasis prediction models for clinical feature variables. The partial dependence plots were used to explain the prediction of the models. The area under the receiver operating characteristic curve and area under the precision recall curve were measured to assess the detection performance. The R shiny interactive web application was used to translate the prediction model in a clinical setting. ResultsThe incidence of lymph node metastasis in patients with early gastric cancer was 13.63% (320/2348) and significantly higher in young women, in the lower third of the stomach, with a size >2 cm, depressed type, poorly/nondifferentiated, lymphovascular invasion, nerve invasion, and submucosal infiltration. In terms of age, there is a nonlinear and younger trend. XGBOOST displayed the best predictive performance at the initial and postendoscopy evaluation. In addition, the machine learning algorithm was converted to a user-friendly web tool for patients and clinicians. ConclusionXGBOOST can predict the risk of lymph node metastasis with best accuracy in patients with early gastric cancer. Our online web application may help determine the optimal best surgical option for patients with early gastric cancer.

Ankle/Hindfoot Arthrodesis as a Salvage Procedure for Failed Total Ankle Arthroplasty

Category:Ankle; HindfootIntroduction/Purpose:High failure rate after total ankle arthroplasty (TAA) in 10-year follow-up has been reported, ranging from 10 to 20%. Massive bony destruction after TAA often caused by periprosthetic osteolysis, implant subsidence or loosening, or periprosthetic infection, and it would be considerable challenge to many orthopedic surgeons. In some cases, it is difficult to perform revision arthroplasty. For failed TAA, ankle/hindfoot arthrodesis can be performed as a salvage procedure. In this study, we evaluate the clinical and radiologic outcomes of the ankle/hindfoot arthrodesis in patients with failed TAA.Methods:Ankle/hindfoot arthrodesis was performed in 10 ankles with failed TAA from October 2003 to March 2019 (at least 6- month follow-up). As for the clinical evaluation, visual analogue scale (VAS) pain scores, and American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores were assessed. Postoperative complications such as skin necrosis, surgical site infection (SSI), or non-union were reviewed through medical records. Radiographs including CT images at last follow-up were assessed to confirm bone union.Results:The average follow-up was 49.1 months (range, 7-89). There were 6 cases performed with tibiotalocalcaneal (TTC) arthrodesis, and 4 cases with ankle arthrodesis. The operations were performed at mean postoperative 46.6 months (range, 8- 178) from index TAA. Allo-femoral head structural bone graft was used in 9 cases, and auto proximal tibia cancellous bone graft was used in 5 cases. Mean VAS pain score decreased from 7.6 pre-operatively to 2.2. AOFAS score increased from 15.6 to 42.0 (subjective assessment only; maximum score=68). 3 revision surgeries had been performed after initial arthrodesis (1 case for SSI, 2 cases for non-union), and bone union was obtained in 2 cases (1 case of SSI, 1 case of non-union).Conclusion:Ankle/hindfoot arthrodesis after failed TAA can be optimal surgical option for the patients with massive bony destruction which compromises revision arthroplasty. It acts as a salvage procedure for failed TAA and could yield favorable outcome.