Optimal Timing Of Repair Research Articles

Timing of Surgical Repair After Bile Duct Injury Impacts Postoperative Complications but Not Anastomotic Patency.

Our goal was to determine the optimal timing for repair of bile duct injuries sustained during cholecystectomy. Bile duct injury during cholecystectomy is a serious complication that often requires surgical repair. There is heterogeneity in the literature regarding the optimal timing of surgical repair, and it remains unclear to what extent timing determines postoperative morbidity and long-term anastomotic function. A single institution prospective database was queried for all E1 to E4 injuries from 1989 to 2014 using a standardized tabular reporting format. Timing was stratified into 3 groups [early (<7 days), intermediate (8 days until 6 weeks), and late (>6 weeks) after injury]. Analysis was stratified between those who had a previous bile duct repair or not, including postoperative complications and anastomotic failure as outcome variables in 2 separate multivariate logistic regression models. There were 614 patients included in the study. The mean age was 41 years (range, 15-85 yrs), and the majority were female (80%). The mean follow-up time was 40.5 months. Side-to-side hepaticojejunostomy was performed in 94% of repairs. Intermediate repair was associated with a higher risk of postoperative complications [odd ratio = 3.7, 95% confidence interval (1.3-10.2), P = 0.01] when compared with early and late in those with a previous repair attempt. Sepsis control and avoidance of biliary stents were protective factors against anastomotic failure. Adequate sepsis control and delayed repair of biliary injuries should be considered for patients presenting between 8 days and 6 weeks after injury to prevent complications, if a previous bile duct repair was attempted.

Resilience-Based Component Importance Measures for Critical Infrastructure Network Systems

In this paper, we propose two metrics, i.e., the optimal repair time and the resilience reduction worth, to measure the criticality of the components of a network system from the perspective of their contribution to system resilience. Specifically, the two metrics quantify: 1) the priority with which a failed component should be repaired and re-installed into the network and 2) the potential loss in the optimal system resilience due to a time delay in the recovery of a failed component, respectively. Given the stochastic nature of disruptive events on infrastructure networks, a Monte Carlo-based method is proposed to generate probability distributions of the two metrics for all of the components of the network; then, a stochastic ranking approach based on the Copeland's pairwise aggregation is used to rank components importance. Numerical results are obtained for the IEEE 30-bus test network and a comparison is made with three classical centrality measures.

P19 Is the requirement for long term antihypertensive therapy after primary coarctation repair related to age at surgery?

Introduction Systemic hypertension manifesting after surgical coarctation repair is a known long term sequela and affects about two thirds of subjects. Previous studies suggest the risk of developing hypertension is reduced if the coarctation repair is performed at a younger age with the optimal time for repair between the first year of life up to 9 years of age. Objective Using our experience of patients operated on since the opening of the new Evelina London Children’s Hospital in 2005, we sought to further clarify the optimal age at which coarctation repair is most effective in reducing the risk of systemic hypertension. Risk of developing re-coarctation related to the age of primary surgical repair was also examined. Methods Retrospective analysis of patients with coarctation undergoing primary surgical repair from October 2005 to October 2014, identified from the institutional database (Heartsuite, Systeria, Glasgow, UK). Included patients were all Results Eighty seven patients were included: 58 neonates ( 2 9.83, P = 0.0073). The relative risk of requiring long term anti-hypertension medication if repaired during the neonatal period versus during infancy was 0.26 (95% CI 0.078 to 0.88, P = 00.03), 0.65 (95% CI 0.23 to 1.92, P = 00.44) for repair during infancy versus over 1 year of age, and 0.17 (95% CI 0.051 to 0.58, P = 00.0045) for repair during the neonatal period versus being over 1 year of age. There was no significant difference in the proportion of those developing re-coarctation depending on the age they were first operated, though the prevalence was lowest in the infant age group, 5.3%, versus 22.4% in the neonatal group and 20% in those over 1 year of age. Conclusion We have demonstrated that the risk of being on long term anti-hypertensive medication if operated on during neonatal period was 74% less compared to being operated on during infancy and 83% less if operated in the neonatal period compared to surgery after the first year of life. Therefore primary surgical repair of coarctation of the aorta to reduce the future risk of hypertension is optimal in the neonatal period. We were unable to demonstrate a significant difference in the prevalence of re-coarctation depending on age of first coarctation repair.

Giant omphaloceles: surgical management and perinatal outcomes

BackgroundThe purpose of this study was to describe the current management and outcomes of infants with omphalocele. MethodsThe medical records of all patients treated for omphalocele at a large children's hospital from January, 2003–February, 2014 were reviewed. Patients were classified as having an isolated omphalocele or omphalocele with minor or major associated anomalies. Prenatal data collected included fetal magnetic resonance imaging-based observed-to-expected total fetal lung volumes. Giant omphalocele (GO) was defined as >50% of liver in the omphalocele sac. ResultsOf 95 patients, 59 presented prenatally and had comprehensive fetal center evaluation. Of 82 live-born infants, 21 had chromosomal and 25 had major associated anomalies. No live-born baby with an isolated defect (n = 19) died, whereas mortality was 41% and 17% for those with major and minor anomalies, respectively (P = 0.006). Infants with major anomalies had significantly longer median length of intubation (36 versus 0 versus 0 d; P = 0.04) and hospital stay (157 versus 28.5 versus 18 d; P < 0.001) compared with those with minor or no anomalies. Of 40 infants with GO, the majority (85%) were managed surgically by delayed closure with a median age at repair of 10 mo (range, 3.4–23.6 mo). Six-month survival was 80%. None of the delayed repair patients required a later operative revision, whereas 2 of 5 with early repair did. ConclusionsThe presence of associated anomalies is the strongest predictor of morbidity and mortality in fetuses or neonates with omphalocele. In patients with GO, delayed closure is associated with good outcomes, but larger, prospective studies comparing delayed to early closure are needed to determine the optimal timing of repair.

Timing of repair of congenital diaphragmatic hernia in patients supported by extracorporeal membrane oxygenation (ECMO)

PurposeThe optimal timing of repair for congenital diaphragmatic hernia (CDH) in patients requiring extracorporeal membrane oxygenation (ECMO) is controversial. Repair during ECMO may improve respiratory function by restoring normal anatomy. However, there is increased risk of complications including surgical bleeding. The purpose of this study was to examine the impact of timing of CDH repair on outcomes in a large cohort of patients treated at a single institution. MethodsWe retrospectively reviewed charts of all CDH patients in our Pulmonary Hypoplasia Program from 2004 to 2013. Categorical variables were analyzed by Fisher’s exact test and continuous variables by Mann–Whitney t-test (p<0.05). ResultsA total of 77 CDH patients required ECMO support during the study dates. Of these, 16 patients did not survive to repair, 3 patients were repaired prior to cannulation, 41 patients were repaired during ECMO, and 17 patients were repaired after decannulation. Survival was 67%, 43.9%, and 100% for those repaired prior to, during, or post ECMO, respectively, with statistical significance associated with repair after decannulation (P<0.0001). Operative bleeding requiring transfusion occurred in 12 patients repaired on ECMO, while no significant bleeding occurred in patients repaired after decannulation (P=0.003). ConclusionOutcomes were improved in CDH patients undergoing surgical repair following ECMO with significantly increased survival, lower rates of surgical bleeding, and decreased total duration of ECMO therapy compared to patients repaired on ECMO. In patients who can be successfully weaned from ECMO, our study supports a role for delayed repair off ECMO with reduced operative morbidity and increased survival.

A new aortic injury score predicts early rupture more accurately than clinical assessment

The optimal timing for repair of a high-grade blunt thoracic aortic injury (BTAI) is uncertain. Delayed repair is common and associated with improved outcomes, but some lesions may rupture during observation. To determine optimal patient selection for appropriate management, we developed a pilot clinical risk score to evaluate aortic stability and predict rupture. Patients presenting in stable condition with Society for Vascular Surgery grade III or IV BTAI diagnosed on computed tomography (CT) were retrospectively reviewed. To determine clinical and radiographic factors associated with aortic rupture, patients progressing to aortic rupture (defined by contrast extravasation on CT or on operative or autopsy findings) were compared with those who had no intervention ≤48 hours of admission. A model targeting 100% sensitivity for rupture was generated and internally validated by bootstrap analysis. Clinical utility was tested by comparison with clinical assessment by surgeons experienced in BTAI management who were provided with CT images and clinical data but were blinded to outcome. The derivation cohort included 18 patients whose aorta ruptured and 31 with stable BTAI. There was no difference in age, gender, injury mechanism, nonchest injury severity, blood pressure, or Glasgow Coma Scale on admission between patient groups. As dichotomous factors, admission lactate >4 mM, posterior mediastinal hematoma >10 mm, and lesion/normal aortic diameter ratio >1.4 on the admission CT were independently associated with aortic rupture. The model had an area under the receiver operator curve of .97, and in the presence of any two factors, was 100% sensitive and 84% specific for predicting aortic rupture. No aortic lesions ruptured in patients with fewer than two factors. In contrast, clinical assessment had lower accuracy (65% vs 90% total accuracy, P < .01). This novel risk score can be applied on admission using clinically relevant factors that incorporate patient physiology, size of the aortic lesion, and extent of the mediastinal hematoma. The model reliably identifies and distinguishes patients with high-grade BTAI who are at risk for early rupture from those with stable lesions. Although preliminary, because it is more accurate than clinical assessment alone, the score may improve patient selection for emergency or delayed intervention.

A risk-stratified analysis of delayed congenital diaphragmatic hernia repair: Does timing of operation matter?

Congenital diaphragmatic hernia (CDH) remains a significant cause of death in newborns and, despite improved outcomes with multimodality therapies, optimal timing of repair remains undefined. We sought to evaluate the influence of surgical timing on patient outcomes and hypothesized that delayed repair does not improve survival in CDH. Prospectively collected data from 1,385 CDH Registry infants without preoperative extracorporeal membrane oxygen therapy (ECMO) were evaluated. Patients were stratified by timing of repair: Day of life (DOL) 0-3 (group 1), 4-7 (group 2), or >8 (group 3), and the effect of surgical timing on mortality was determined by logistic regression and risk-adjusted for severity of illness. The unadjusted odds ratio (OR) for mortality increased significantly with delayed repair (group 2, 1.73 [95% CI, 1.00-2.98; group 3, 3.42 [95% CI, 1.97-5.96]). However, when adjusted for severity of illness, delay in repair did not predict increased mortality (group 2, 1.2 [95% CI, 0.7-2.2]; group 3, 1.4 [95% CI, 0.8-2.6]), nor did it portend an increased need for postoperative ECMO (group 2, 1.1 [95% CI, 0.5-2.4]; group 3, 0.5 [95% CI, 0.2-1.4]). After adjustment for known risk factors, the timing of CDH repair in low-risk infants does not seem to influence mortality. However, specific clinical parameters guiding timing of elective CDH repair remain unknown.

Outcomes of repair of complete atrioventricular septal defect in the current era

We sought to evaluate the surgical outcomes of the repair of complete atrioventricular septal defects (cAVSDs) in our institution in the current era. From 2000 to 2011, 138 patients underwent definitive repair of cAVSD. Repair was performed using a two-patch technique in 92.0% of patients and one-patch technique in 2.2%, and the ventricular septal component was closed directly in 5.8% of patients. Operative mortality was 1.4% (2 of 138). Overall mortality was 5.8% (8 of 138). Follow-up was 96% complete. Freedom from reoperation was 84.3% (95% CI 77.1-91.5%) at 8 years. Age >6 months at repair was associated with higher rates of reoperation (P = 0.001; HR 6.85; 95% CI 2.30-20.44). However, operating at <6 months of age was associated with longer intensive care unit stay (P = 0.019; median 2.7 vs 1.4 days), mechanical ventilation (P = 0.001; median 1.7 vs 0.9 days) and postoperative hospital stay (P = 0.016; median 8 vs 5 days). Moderate or greater left atrioventricular valvular regurgitation (LAVVR) at discharge was a risk factor for reoperation (P < 0.001; HR 10.85; 95% CI 3.75-31.40). Repair of cAVSD carries low mortality, but a moderate reoperation rate. An optimal time for repair of the cAVSD is between 3 and 6 months of age. Repair prior to 3 months of age and the need for cleft closure were associated with a higher degree of LAVVR at discharge. Greater LAVVR at discharge is a risk factor for reoperation regardless of age at initial repair. In the current era, Down's syndrome is not a risk factor for reoperation.

불완전 수리에서의 수리시간한계를 가진 교체모형

This article concerns a profit model in a repair limit replacement problem with imperfect repair. If a system fails, we should decide whether we repair the failed system (repair option) or replace it by new one (replacement option with a lead time). We assume that repair times are random variables and can be estimated before repair with estimation error. If the estimated repair time is less than the specified limit (repair time limit), the failed unit is repaired but the unit after repair is different from the new one (imperfect repair). Otherwise, we order a new unit to replace the failed unit. The long run average profit (expected profit rate) is used as an optimization criterion and the optimal repair time limit maximizes the expected profit rate. Some special cases are derived.

Repair of congenital diaphragmatic hernias on Extracorporeal Membrane Oxygenation (ECMO): Does early repair improve patient survival?

IntroductionThe optimal timing of repair for congenital diaphragmatic hernia (CDH) patients that require ECMO is controversial. Early repair on ECMO theoretically allows for restoration of normal thoracic anatomy but entails significant bleeding risks. The purpose of this study was to examine the institutional outcomes of early CDH repair on ECMO. MethodsThe records of infants with CDH placed on ECMO from 2001 to 2011 were reviewed. Since 2009, a protocol was instituted for early repair while on ECMO. For this study, three cohorts were analyzed: early repair (<72h), late repair (>72h), and post-decannulation. These groups were compared for outcomes regarding morbidity and survival. ResultsForty-six CDH patients received ECMO support with an overall survival of 53%. Twenty-nine patients (11 early/18 late) were repaired on ECMO, while 17 patients had repair post-decannulation. Survival was 73%, 50%, and 64% for those repaired early, late, or post-decannulation, respectively. Despite significantly worse prenatal factors, patients repaired early on ECMO had a similar survival. When comparing patients repaired on ECMO, the early group patients were decannulated 6days earlier (p-value=0.009) and had significantly lower circuit complications (p=0.03). ConclusionIn conclusion, early repair on ECMO was associated with decreased ECMO duration, decreased circuit complications, and a trend towards improved survival.

Laparoscopic inguinal hernia repair in premature neonates: is it safe?

With advances in clinical medicine, many premature babies nowadays can have excellent survival outcomes. As the incidence of inguinal hernias in this group is high and there is scarce data in the literature regarding the optimal timing for repair, this study aims to review our experience in laparoscopic repair in premature infants. In our centre, premature neonates with inguinal hernia noted during hospitalization were offered laparoscopic repair when the body weights reached 2.5kg unless there is contraindication for laparoscopy. A retrospective review was carried out for all premature neonates who underwent laparoscopic inguinal hernia repair from 2001 to 2011. The operative results, complications, incarceration risk and postoperative apnea risk were recorded. A total of 79 premature neonates received laparoscopic inguinal hernia repair during this period. The mean gestational age at birth was 31.9weeks (27-36weeks) and the mean gestational age at operation was 46.5weeks (33-92weeks). One patient had incarceration and required emergency operation while waiting for the elective repair. The mean operative time was 44.9min (25-93min). One patient (1.3%) had recurrence. No postoperative apnea was noted in any patient. Laparoscopic hernia repair is safe and feasible in premature neonates when they attain reasonable body size, as long as there is excellent anaesthesia support. Low risk of incarceration was noted in this study and it is worth waiting for the body weight to build up and hence facilitate laparoscopic repair.

Reliability and optimised maintenance for sea defences

Sea defence structures are valuable assets hence requiring viable and diligent asset management and maintenance strategies in order to ensure their integrity and functionality. It has been well documented that rising sea levels due to climate change together with the aggressive environment to which coastal defence structures are subjected can lead to serious defects compromising the integrity of the structures. This paper presents a method for quantitatively assessing the risk of wave overtopping of sea defences, analysing the probability of failure of the structures under future hydraulic and structural conditions and providing cost-effective maintenance planning during the service life. Typical failure mechanisms in an earth sea defence are considered for reliability analyses, namely erosion of dyke crest and landside slope by wave overtopping, piping in the underlain water-conductive layer and uplifting of impermeable layer behind the structure. The stochastic deterioration model based on the gamma process is adopted to represent the settlement of dyke crest height and the deterioration of seepage resistance. The time-dependent reliability of the earth dyke is analysed by using a Monte Carlo simulation method to give probability of failure over time. Optimal repair planning during the service life is determined by optimising the balance between the risk of failure and the costs for maintenance. The numerical results for the example typical earth dyke section show that overtopping is a dominant failure mechanism with significantly increasing failure probability over time. The optimal repair time largely depends on the deterioration rate of structural resistance and the relative cost of preventive maintenance.

A Cost-Effectiveness Analysis of Early vs Late Reconstruction of Iatrogenic Bile Duct Injuries

Controversy exists regarding the optimal timing of repair after iatrogenic bile duct injuries (BDI). Several studies advocate late repair (≥6 weeks after injury) with mandatory drainage and resolution of inflammation. Others indicate that early repair (<6 weeks after injury) produces comparable or superior clinical outcomes. Additionally, although most studies have reported inferior outcomes with primary surgeon repair, this practice continues. With disparate published recommendations and rising health care costs, decision analysis was used to examine the cost-effectiveness of BDI repair. A Markov model was developed to evaluate primary surgeon repair (PSR), late repair by a hepatobiliary surgeon (LHBS), and early repair by a hepatobiliary surgeon (EHBS). Baseline values and ranges were collected from the literature. Sensitivity analsyses were conducted to test the strength of the model and variability of parameters. The model demonstrated that EHBS was associated with lower costs, earlier return to normal activity, and better quality of life. Specifically, 1 year after repair, PSR yielded 0.53 quality adjusted life years (QALYs) ($120,000/QALY) and LHBS yielded 0.74 QALYs ($74,000/QALY); EHBS yielded 0.82 QALYs ($48,000/QALY). Sensitivity analyses supported these findings at clinically meaningful probabilities. This cost-effectiveness model demonstrates that early repair by a hepatobiliary surgeon is the superior strategy for the treatment of BDI in properly selected patients. Although there is little clinical difference between early and late repair, there is a great difference in cost and quality of life. Ideally, costs and quality of life should be considered in decisions regarding strategies of repair of injured bile ducts.

Does Timing of Laparoscopic Bile Duct Injury Repair affect Long-term Outcome?

Results: The reported incidence of bile duct injury after laparoscopic cholecystectomy varies widely due to the inclusion or exclusion of minor or self-limited events, such as bile leak from intrahepatic radicles or leak from a cystic stump. Once a major bile duct injury occurs, early recognition is paramount to minimize morbidity and potential mortality. Once recognized, appropriate measures are instituted to address the damage. However, controversy surrounds as to the optimal time for repair of the injury. The literature gives conflicting assessment and interpretation of when such injuries should be repaired. Patients cared for in facilities that lack the expertise to perform immediate repair may inherently end up at a tertiary referral center in a delayed manner. Some recognized institutions and individual surgeons with the expertise and resources to perform immediate repair opt for repair without delay claiming good outcomes while others delay the repair to intermediate and late repairs with claims of equally good outcomes reported. Conclusion: While immediate recognition of any injury is mandatory for improved patient outcome, the timing of repair remains controversial with convincing arguments on both sides of the issue. However, there seems to be more evidence to support either immediate repair in experienced hands or delayed repair beyond six weeks. Intermediate repair (within 3 to 14 days) is more likely to lead to failures and long-term complications.

A critical review of premature infants with inguinal hernias: optimal timing of repair, incarceration risk, and postoperative apnea

Background/purpose This study evaluated the optimal timing for repair, incarceration risk, and postoperative apnea rate in premature infants with inguinal hernias. Methods This was a retrospective review of premature infants undergoing inguinal hernia repairs from 2006 to 2008. Results One hundred seventy-two patients were identified. Mean gestational age was 30.7 weeks, and mean birth weight was 1428 g. At repair, mean postconceptional age was 46.6 weeks with mean weight of 3688 g. Elective repairs were performed on 127 patients. Thirty-five patients were discharged with a known hernia, and none developed incarceration. No postoperative apnea episodes occurred in any of these 127 patients. Forty-five patients had herniorrhaphy before discharge from the neonatal intensive care unit (NICU) with a median postoperative hospitalization of 8 days (2-51 days). Thirteen percent required prolonged (>48 hours) intubation after repair. Of 172 patients, 8 (4.6%) developed incarcerated hernia. Five incarcerations occurred in the NICU before discharge, and 3 patients had incarceration as their initial presentation. Conclusions There is minimal risk of postoperative apnea for premature infants undergoing elective inguinal hernia repair. The risk of incarceration in premature infants discharged from the NICU with a known hernia is low. Herniorrhaphy before discharge from the NICU was associated with a prolonged hospital stay.

A critical review of premature infants with inguinal hernias: optimal timing of repair, incarceration risk, and postoperative apnea

A critical review of premature infants with inguinal hernias: optimal timing of repair, incarceration risk, and postoperative apnea

Optimal timing for repair of an inguinal hernia in premature infants

The aim of this study was to determine the optimal timing for inguinal herniotomy in premature infants treated in the neonatal intensive care unit. A two-institutional-center retrospective study was performed including 41 prematures at gestational age 28-35 weeks who underwent herniotomy within 1 week of diagnosis [short-waiting group (SWG), median 5 days, n = 25] or more than 1 week after diagnosis [long-waiting group (LWG), median 30.55 days, n = 16]. Gestational age, birthweight, post-conceptional age at diagnosis, age at diagnosis, post-conceptional age at surgery, age at surgery, weight at surgery, timing of surgery, operative time, and occurrence of incarceration, postoperative apnea, hernia recurrence, testicular atrophy, and hospital stay were compared between the two groups. Statistical analysis was performed using one-way ANOVA. Twelve preoperative episodes of incarceration occurred: three in the SWG and nine in the LWG (P < 0.05). Six infants had apnea postoperatively: four in the SWG and two in the LWG (P > 0.05). Follow-up revealed five hernia recurrences, one in the SWG and four in the LWG (P < 0.05); four testicular atrophies were found, one in the SWG and three in the LWG (P > 0.05). Early elective herniotomy should be considered in prematures in order to avoid perioperative morbidity and to reduce the risk of incarceration and subsequent testicular ischemia, and hernia recurrence.

Invited Commentary

Invited Commentary

Echocardiographic Prediction of Left Ventricular Dysfunction After Mitral Valve Repair for Mitral Regurgitation as an Indicator to Decide the Optimal Timing of Repair

Echocardiographic Prediction of Left Ventricular Dysfunction After Mitral Valve Repair for Mitral Regurgitation as an Indicator to Decide the Optimal Timing of Repair

Echocardiographic prediction of left ventricular dysfunction after mitral valve repair for mitral regurgitation as an indicator to decide the optimal timing of repair

Echocardiographic prediction of left ventricular dysfunction after mitral valve repair for mitral regurgitation as an indicator to decide the optimal timing of repair