Optimal Timing Of Surgical Treatment Research Articles

Aortic Regurgitation: From Valvular to Myocardial Dysfunction.

Chronic aortic regurgitation (AR) leads to volume overload in the left ventricle (LV), which is well tolerated for years. In this condition, the LV usually dilates with minimal reduction in the ejection fraction (EF), even in the absence of symptoms. Echocardiography is the primary imaging test used to quantify AR. However, no single assessment of Doppler measures is accurate and precise in individual patients; therefore, the integration of multiple parameters is necessary. Recent guidelines recommend surgical treatment for severe AR in patients who are symptomatic or have an LVEF < 55% and an end-systolic diameter > 50 mm. Nevertheless, advances in imaging technology have improved the quantification of AR and the assessment of LV subclinical dysfunction. It is widely recognized that patients who undergo aortic valve replacement/repair (AVR) due to symptoms or a low LVEF experience worse outcomes than those undergoing AVR for non-Class I indications. In fact, subclinical irreversible myocardial damage may occur in clinically well-compensated and closely monitored patients while awaiting formal surgical indications. This condition could be prevented by the use of multimodal imaging parameters, in particular longitudinal LV strain and magnetic resonance imaging. In addition, better cut-off values for mortality predictors should be established. This review aims to identify simple models that integrate several echocardiographic and cardiac magnetic resonance-derived parameters to predict the optimal timing of surgical treatment in asymptomatic patients with chronic severe AR.

309. SURGICAL TREATMENT FOR THE RECURRENT SITE OF ESOPHAGEAL CANCER AFTER ESOPHAGECTOMY

Abstract Background Although the outcome of patients with recurrent esophageal cancer following radical esophagectomy is extremely poor, long-term survival can be achieved with multimodal therapy, including surgical resection of the recurrent lesion. Developing a treatment strategy is a critical issue; therefore, we examined the indications and optimal timing for surgical treatment in patients with recurrence. Methods A total of 184 patients with recurrent esophageal cancer after radical esophagectomy were studied between 2001 and 2015, with a focus on surgical resection. Results The first recurrence site was the lymph nodes (124 cases; 67%) [neck (35; 19%), mediastinum (82; 45%), abdomen (35; 19%)], lung (36; 20%), liver (32; 17%), pleura (18; 10%), bone (13; 7%), etc. Second-line treatment following recurrence was surgery (8 cases), chemoradiotherapy (89 cases), chemotherapy (64 cases), and best supportive care (23 cases). Patients with single organ or solitary recurrence and recurrence more than 8 months after surgery had better prognoses. All the surgical cases had single-site recurrence (lung-3, cervical lymph nodes-3, colon-1, and brain-1). Good prognosis was expected for the patients with lung or cervical lymph node recurrence. Conclusion Surgical treatment for recurrent esophageal cancer following radical esophagectomy was considered beneficial for the recurrence of cervical lymph node or lung metastasis of solitary lesions at least 8 months after esophagectomy. Immune checkpoint inhibitors have recently been indicated for esophageal cancer and expected for improving prognosis, and the role of surgery in multidisciplinary treatment for metastatic recurrence needs repeated investigation.

Technical evolution of pediatric neurosurgery: moyamoya disease.

Moyamoya disease (MMD) is a rare steno-occlusive disease of the bilateral internal carotid arteries that predominantly occurs in East Asia. Since the first description of the MMD by Suzuki and Takaku in 1969, significant advances have been made in both basic and clinical understanding of the disease. The incidence and prevalence of pediatric MMD have increased, potentially due to improved detection rates. The advancement of neuroimaging techniques has enabled MRI-based diagnostics and detailed visualization of the vessel wall. Various methods of surgical treatments are successful in pediatric MMD patients, and recent studies emphasize the importance of reducing postoperative complications since the goal of MMD surgery is to prevent future cerebral infarction and hemorrhage. Long-term outcomes following appropriate surgical treatment in pediatric MMD patients have shown promising results, including favorable outcomes in very young patients. Further studies with a large patient cohort are needed to establish individualized risk group stratification for determining the optimal timing of surgical treatment and to conduct multidisciplinary outcome assessments.

Cascade of decisions meet personal preferences in sciatica treatment decisions

Study designAn in-depth interview study including patients, general practitioners, neurologists and neurosurgeons.ObjectiveTo gain insight in decision-making in sciatica care, by identifying patients’ and physicians’ preferences for treatment options, and the...

Optimal Terms of Surgical Treatment of Adhesive Capsulitis (Retrospective Study)

Summary. Relevance. Surgical treatment of adhesive capsulitis is infrequent, as the doctor is convinced that this pathology has a staged course and the 'thawing stage' is inevitable in 12-24 months. Unfortunately, this is not always the case.&#x0D; Objective: to determine the optimal timing for surgical treatment of adhesive capsulitis.&#x0D; Materials and Methods. From 2015 to 2019, we performed 175 arthroscopic surgeries in patients with adhesive capsulitis of the shoulder joint, of which 59 (33.7%) patients were diagnosed with type 2 diabetes. The age of patients ranged from 40 to 70 years. The average age was 55.9±17.2 years. All patients were divided into 2 groups (group 1 – adhesive capsulitis and a history of diabetes, group 2 – adhesive capsulitis). In our study, we retrospectively assessed the function of the shoulder joint on the Constant Shoulder Score and VAS scales before surgery and 12 months after surgery.&#x0D; Results. The surgery performed within 100 days in patients with adhesive capsulitis and diabetes mellitus (group 1) when evaluated on the Constant Shoulder Score demonstrates worse results than the surgery performed at a later date (r=0.6; p&lt;0.05); similar results were obtained on the VAS scale (r=0.62; p&lt;0.05). The surgery performed within 100 days in patients with adhesive capsulitis (group 2) shows worse results on the Constant Shoulder Score than the surgery performed at a later date (r=0.775; p&lt;0.05); similar results were obtained on the VAS scale (r=0.57; p&lt;0.05). There is a tendency of less effective results of treatment on the Constant Shoulder Score and the VAS scale in patients of group 2 when performing surgery more than 350 days after the onset of the disease.&#x0D; Conclusions. Despite a number of conservative methods of treatment of adhesive capsulitis, timely surgery allows to obtain good treatment results. The optimal period for surgical intervention in adhesive capsulitis ranges from 100 to 350 days from the onset of the disease.

Magnetic resonance derived regurgitant fraction, 3D vena contracta area, and B-natriuretic peptide: the most accurate prognostic markers in patients with chronic asymptomatic aortic regurgitation

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health of the Czech Republic 17-28265A. Background The optimal timing of surgical treatment is challenging in asymptomatic patients with severe aortic regurgitation (AR). A significant number of patients undergoing aortic valve surgery as per current guidelines have irreversible left ventricular (LV) myocardial damage with a negative impact on their long-term postoperative outcome. Purpose We aimed to determine the value of magnetic resonance-, advanced echocardiography–derived indices and serum B-natriuretic peptide level (BNP) to identify patients with chronic asymptomatic AR who are at risk of early disease progression. Methods We prospectively enrolled a group of asymptomatic patients with pure chronic severe AR, without an indication for surgical treatment as per the current guidelines, in a multicenter study. Baseline examination consisted of serum BNP level analysis, comprehensive echocardiography including 3D vena contracta area (VCA) and 2D global longitudinal strain (GLS), and a comprehensive MRI including regurgitant fraction (RF) measurement; all imaging data were analyzed in Corelab. Patient follow-up was every 6 months. The primary endpoint was a new guideline-directed indication for surgical treatment. Results In total, 129 patients were enrolled between 2015 and 2019, the endpoint occurred in 43 patients during a median follow-up of 1375 (IQR 1041-1783) days. Baseline clinical data did not differ between patients with the endpoint (surgical group) and stable patients (medical group). Baseline BNP levels were significantly higher in the surgical group (55 vs. 21 ng/L, P = 0.008). MRI-derived LV ejection fraction was not different (61 vs 61 %, P = 0.815) at baseline while both CMR-derived end-systolic and end-diastolic LV volumes were significantly higher in the surgical group (all P &amp;lt; 0.01). Both baseline 3D VCA and 2D GLS were different between the surgical and medical groups (33 vs. 25 mm2, P = 0.006 and 18 vs 19 %, P = 0.07). Magnetic resonance derived RF was significantly higher in the surgical group (46 vs 32 %) with P &amp;lt; 0.01. A combined model including independent markers such as BNP (cut-off &amp;gt; 31 ng/L), MRI RF (cut-off value &amp;gt; 34 %), 3D VCA (cut-off value 36 mm2) or 2D GLS (cut-off value &amp;lt; 17 %) showed the highest predictive accuracy (P = 0.002) to predict the primary endpoint. (Figure 1). Conclusion A combination of baseline parameters of AR severity (3D VCA, MRI-derived RF) and myocardial impairment (2D GLS, serum BNP level) present an accurate tool for the identification of patients with chronic asymptomatic AR who are at risk of early disease progression. Abstract Figure 1

Surgery for Degenerative Cervical Myelopathy: A Nationwide Registry-Based Observational Study With Patient-Reported Outcomes.

BACKGROUNDIndications and optimal timing for surgical treatment of degenerative cervical myelopathy (DCM) remain unclear, and data from daily clinical practice are warranted.OBJECTIVETo investigate clinical outcomes following decompressive surgery for DCM.METHODSData were obtained from the Norwegian Registry for Spine Surgery. The primary outcome was change in the neck disability index (NDI) 1 yr after surgery. Secondary endpoints were the European myelopathy score (EMS), quality of life (EuroQoL 5D [EQ-5D]), numeric rating scales (NRS) for headache, neck pain, and arm pain, complications, and perceived benefit of surgery assessed by the Global Perceived Effect (GPE) scale.RESULTSWe included 905 patients operated between January 2012 and June 2018. There were significant improvements in all patient-reported outcome measures (PROMs) including NDI (mean −10.0, 95% CI −11.5 to −8.4, P < .001), EMS (mean 1.0, 95% CI 0.8-1.1, P < .001), EQ-5D index score (mean 0.16, 95% CI 0.13-0.19, P < .001), EQ-5D visual analogue scale (mean 13.8, 95% CI 11.7-15.9, P < .001), headache NRS (mean −1.1, 95% CI −1.4 to −0.8, P < .001), neck pain NRS (mean −1.8, 95% CI −2.0 to −1.5, P < .001), and arm pain NRS (mean −1.7, 95% CI −1.9 to −1.4, P < .001). According to GPE scale assessments, 229/513 patients (44.6%) experienced “complete recovery” or felt “much better” at 1 yr. There were significant improvements in all PROMs for both mild and moderate-to-severe DCM. A total of 251 patients (27.7%) experienced adverse effects within 3 mo.CONCLUSIONSurgery for DCM is associated with significant and clinically meaningful improvement across a wide range of PROMs.

Is there an optimal timing for surgical treatment of pediatric supracondylar humerus fractures in the first 24 hours?

BackgroundWe aimed to determine the ideal surgical timing in the first 24 hours after admission to the hospital of pediatric supracondylar humerus fractures (SHF) that do not require emergent intervention.Materials and MethodsPatients who underwent surgery in our institution between January 2011 and January 2019 due to pediatric Gartland type 3 SHFs were evaluated retrospectively. Open fractures, fractures associated with vascular injury and compartment syndrome, flexion type fractures were excluded. A total of 150 Gartland type 3 were included. The effect of early (<12 hours) or late (>12 hours) surgical interventions, daytime or night-time surgeries, working or non-working hour surgeries on operative parameters (operative duration and open reduction rate, reduction quality on postoperative early radiographs) were evaluated in pediatric SHFs.ResultsEarly (<12 hours) or late (>12 hours), daytime or nighttime, working or non-working hour surgeries were found to be similar in Gartland type 3 patients regarding early postoperative reduction quality, duration of surgery, open reduction rate (p>0.05). Mean times passed from first admission to hospital until surgery were longer in working hour, late (>12 hours) and daytime surgery groups than non-working hour, early (<12 hours) and night-time surgery groups (p<0.001).ConclusionAlthough delaying the operation to the working hours seems to prolong the time until surgery in pediatric Gartland type 3 SHF patients who do not require emergent intervention such as open fractures, neurovascular impairment and compartment syndrome, there may not be a time interval that makes a difference for the patients if surgery is performed within the first 24 hours, thus the surgery could be scheduled according to the surgeons’ preference.Level of Evidence: Level 3, Retrospective cohort study

Surgery for Degenerative Cervical Myelopathy: What Really Counts?

Retrospective study (data analysis). The purpose of this study was to assess the role of different factors on postoperative outcome of patients with degenerative cervical myelopathy (DCM). Ongoing degenerative changes of DCM lead to progressive neurological deficits. The optimal timing of surgical treatment is still unclear, especially in patients with mild DCM. Patients with DCM treated in our clinic between 2007 and 2016 were retrospectively analyzed. Pre- and postoperative neurological function was assessed by the modified Japanese Orthopaedic Association Score (mJOA Score) at different stages. The minimum clinically important difference (MCID) was used to evaluate the improvement after surgery. The comorbidities were recorded using the Charlson Comorbidity Index (CCI). Possible associations between age, sex, CCI, preoperative symptoms duration, high signal intensity (SI) on T2-weighted magnetic resonance imaging (MRI) with mJOA Score and MCID were analyzed using univariate analysis and multivariate regression models. Additionally, subgroup analysis was performed according to the severity of DCM (mild: mJOA Score ≥15 points; moderate: mJOA Score of 12-14 points; and severe: mJOA Score <12 points). The mean age of the final cohort (n = 411) was 62.6 years (range: 31-96 years), 36.0% were females. High SI on T2-weighted MRI was detected in 60.3% of the cases. In the multivariate analysis, patients' age (P = 0.005), higher CCI (P = 0.001), and presence of high SI on T2-weighted MRI (P = 0.0005) were associated independently with lower pre- and postoperative mJOA Score and postoperative MCID. Subgroup analysis revealed age and high SI on T2-weighted MRI as predictors of pre- and postoperative mJOA. However, symptom duration did not influence neurological outcome according to the severity of DCM. Surgery for DCM leads to significant functional improvement. However, better outcome was observed in younger individuals with lower CCI and absence of radiographic myelopathy signs. Therefore, DCM surgery, particularly before occurrence of high SI on MRI, seems to be essential for postoperative functional improvement regardless the above-mentioned confounders.Level of Evidence: 3.

The optimal timing of surgical treatment of acute cholecystitis according to evidence-based studies

Aim . To analyze of the optimal time of surgical treatment of acute cholecystitis based on the results of evidence-based studies of domestic and foreign clinical guidelines. Materials and methods . A review has been conducted based on an analysis of the clinical recommendations of the Russian Federation and other countries and meta-analyzes of clinical trial, published since 2015. Results . The surgical method is the main treatment approach of acute cholecystitis both in our country and abroad. Possible differences in assessing the results of surgical interventions are due to different ways of determining the time to perform the surgery (report from the onset of the disease, from the diagnosis, and also taking into account the time of hospitalization). In the majority of the world evidence-based studies early cholecystectomy have been defined as a surgery within 3-7 days after onset. The expediency of performing early operations with a persistent attack of acute cholecystitis is due to the inability to control the course of gallbladder's inflammation, the shorter duration of hospitalization and cost-effectiveness advantages. Conclusion . In clinical practice, taking into account the heterogeneity of the patient population with acute cholecystitis and various conditions for the provision of surgical care, early operations within the first three days from the onset of symptoms remains preferred.

Does increasing time to surgery affect survival in stage I renal cell carcinoma? Analysis of the national cancer database.

635 Background: Optimal timing for surgical treatment of localized renal cell carcinoma (RCC) remains undefined. We sought to determine the survival impact of time to definitive surgical treatment for Stage 1 RCC and elucidate factors associated with a delay in surgical care utilizing the National Cancer Database (NCDB). Methods: The NCDB was queried for Stage 1 RCC cases (cT1N0M0) from 2004-2013 treated with partial or radical nephrectomy. Quartiles were formed from the range of time to surgery of the entire cohort in days: early defined as the first two quartiles and delayed as the fourth. Descriptive analyses were conducted between early and delayed groups. Overall survival (OS) between early and delayed groups was calculated with Kaplan-Meier analysis. Multivariable analysis was performed to determine factors associated with delay in surgical care. Results: 38,859 patients were analyzed. Median time to treatment was 40 days (IQR 22-68). Early (≤40 days, n = 23,712) and delayed ( &gt; 68 days, n = 15,147) groups had a median follow-up of 44.8 and 41 months, respectively (p &lt; 0.001). Delayed surgery was more frequent with African-Americans (14.8% vs. 9.1%, p &lt; 0.001), patients with government or no insurance (53.7% vs. 45.1%, p &lt; 0.001), males (60.7% vs. 58.3%, p = 0.001), and Charlson Comorbidity Index (CCI) ≥2 (9.7% vs. 6.7%, p &lt; 0.001). Kaplan-Meier analysis demonstrated survival benefit to the earlier treatment group, with 5 year OS of 85.5% and 80.9% (p &lt; 0.001; Figure). On multivariable analysis, increasing age (OR = 1.001, p = 0.015), African-American race (OR = 1.5, p &lt; 0.001), increasing distance from treatment center (OR = 1.005, p = 0.001), residence in areas with low high school graduation rates (OR = 1.42, p &lt; 0.001), residence in an area of &gt; 1 million population (OR = 1.6, p &lt; 0.001), and CCI ≥2 (OR = 1.4, p &lt; 0.001) were independently associated with increasing time to surgery. Conclusions: Surgery of T1 RCC carried out beyond 9 weeks after diagnosis is associated with reduced overall survival compared to patients treated within 6 weeks. Time to definitive surgical treatment should be a quality of care metric, with special attention given to populations most at risk for delays in care.

Forecasting postoperative complications of transurethral resection of prostate in patients with benign prostatic hyperplasia

The work focuses on unfavorable factors with well-grounded features that influence the development of postoperative complications of transurethral resection of the prostate (TURP). 266 patients with benign prostatic hyperplasia (BPH) were analyzed, including 141 cases in urgent and 125 planned procedures, which had undergone TURP in the Urological departments of the Oleksandrivka Clinical Hospital in Kyiv in 2015–2016. There was determined informative value (in points) of each sign (27, included in 13 factors), as well as the significance of relative risk. Based on their analytical and synthetic analysis, the prognostic cards for outpatient-polyclinic and in-patient stages of providing medical care to contingents are compiled. The principle of distribution of patients with BPH is proposed for two groups of risk (minimum and maximum). Thus, for clinical urology, a convenient, cost-effective tool for taking appropriate action at certain stages of medical care and choosing the optimal timing for surgical treatment is offered. The essence of the unified approach is in summarizing the existing features in the patient at the time of the survey, the magnitude of which correlates with the objectified limit values for each group, while an algorithm of action is presented.

An analysis of surgical treatment for IPNBs based on the carcinoma case in myasthenia gravis and IgG4 related sclerosing cholangitis with autoimmune pancreatitis patient

Intraductal papillary neoplasm of the bile duct (IPNB) of the liver is a rare tumor whose long term clinical behavior is still unknown. IPNBs were known as precancerous lesion like IPMNs of the pancreas pathologically, but clinically, an optimal timing of surgical treatment has not been discussed different from IPMNs. In this study, we experienced a unique case of IPNB involving myasthenia gravis (MG) and IgG-4 related sclerosing cholangitis (IgG4-SC) with autoimmune pancreatitis in a 65-year-old male patient. An initial 3cm simple cystic lesion in S3 liver had become aberrant with peripheral biliary dilatation in 2 years. The impact of IgG4-SC gave some difficulty in deciding how to treat it. Finally, a left hepatectomy was completed with R0 resection. The resected specimen revealed a gastric type IPNB with carcinoma in situ. Steroids treatment was inevitable for IgG4-SC and MG. Then IgG4-SC became exacerbated in a year and high dose steroid administration was critical. Intra- or extrahepatic bile duct cancer has not been detected in 2 years after surgery. IPNBs are biliary disorders with similar pathological features to IPMNs. About 60% of IPNBs have developed in the left lobe of liver similar to our case, and the 5-year survival rate has been reported as 83.9%, 75.4% and 46.8% in gastric type, intestinal type and pancreaticobiliary type, respectively. However, the clinical behavior remains unclear. This case suggested the critical gist of IPNB's biological behavior and optimal timing of surgery. Further analysis will be needed to clarify clinical essentials of IPNBs.

Reconstructive valve surgery within 10 days of stroke in endocarditis.

The optimal timing of surgical treatment for infective endocarditis complicated by cerebrovascular events is controversial, largely due to the perceived risk of perioperative intracranial bleeding. Current guidelines suggest waiting 2 weeks between the diagnosis of stroke and surgery. The aim of this study was to investigate the clinical and neurological outcomes of early surgery following a stroke. This was a single-center retrospective analysis of 12 consecutive patients requiring surgery for infective endocarditis between 2011 and 2014 at Rush University Medical Center, with either ischemic (n = 6) and/or hemorrhagic (n = 6) cerebrovascular complications. All underwent computed tomographic angiography prior to early valve reconstructive surgery to identify potentially actionable neurological findings. Early valve surgery was performed for ongoing sepsis or persistent emboli. Neurologic risk and outcome were assessed pre- and postoperatively using the National Institutes of Health Stroke Scale and the Glasgow Outcome Scale, respectively. All 12 patients underwent surgical treatment within 10 days of the diagnosis of stroke. Mortality in the immediate postoperative period was 8%. Eleven of the 12 patients exhibited good neurological recovery in the immediate postoperative period, with a Glasgow Outcome Scale score ≥ 3. There was no correlation between duration of cardiopulmonary bypass and neurological outcomes. Early cardiac surgery in patients with infective endocarditis and stroke maybe lifesaving with a low neurological risk. Comprehensive neurovascular imaging may help in identifying patient-related risk factors.

"Ultra-rapid" sequential treatment in cholecystocholedocholithiasis: alternative same-day approach to laparoendoscopic rendezvous.

There is still no consensus about timing of laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography in the treatment of cholecystocholedocholithiasis. The aim of our retrospective study is to analyze the optimal timing of surgical treatment in patients presenting concurrent choledocholithiasis, choosing to perform a sequential endoscopic plus surgical approach, introducing a same-day two-stage alternative. All cases of cholecystocholedocholithiasis occurred between January 2007 and December 2014 in "Gradenigo" Hospital (Turin-Italy) were reviewed. Patients were divided into three groups, based on the timing of cholecystectomy after endoscopic retrograde cholangiopancreatography, and compared. Out of 2233 cholecystectomies performed in the mentioned time interval, have been identified 93 patients that fulfill the selection criteria. 36 patients were treated with a same-day approach, while 29 within first 72 h and 28 with delayed surgery. The overall length of stay was significantly lower in patients that were treated with a same-day approach (4.7 days), compared with other groups (p = 0.001), while no significant differences were found in terms of length of surgical intervention, intraoperative complications and conversions to open procedure, postoperative stay, morbidity and mortality. Patients treated with delayed surgery had a 18 % recurrency rate of biliary events, with an odds ratio of 14.13 (p = 0.018). Same-day two-stage approach should be performed in suitable patients at the index admission, reducing overall risks, improving the patients' quality-of-life, preventing recurrency, leading to a significant cost abatement; furthermore, this approach allows same outcomes of laparoendoscopic rendezvous, avoiding technical and organizational troubles.

Are PEGJs a Risk Factor for the Buried Bumper Syndrome?

AimPercutaneous endoscopic gastrostomies (PEGs) with or without a jejunal extension (PEGJs) are a well-accepted method of enteral feeding. They are associated with a number of complications, including the buried bumper syndrome (BBS). We aimed to identify risk factors for BBS, our current management strategies, and optimal timing for surgical treatment. MethodsHospital coding and a database compiled by our specialist nutrition nurse were used to identify all cases of buried bumpers from January 2012 to December 2014 as well as all PEG/PEGJ devices inserted during this time. A retrospective case note review was performed for each patient with BBS to identify risk factors, management strategies, and outcomes. ResultsTwo hundred twelve PEGs and 22 PEGJs were inserted. Nine patients were identified with BBS. Patients with PEGJ tubes were significantly more likely to develop BBS (7/22, 32%) than those with PEG tubes (2/212, 0.9%) P<0.01. There was one death in the study group because of abdominal sepsis associated with an intraperitoneal PEG bumper 33days after BBS was diagnosed and before removal was attempted. All other patients underwent laparotomy to remove the bumper. Mean hospital stay was 22days postoperatively. ConclusionsBuried bumper syndrome is a serious condition which warrants urgent intervention. We have demonstrated a higher than expected rate of BBS associated with PEGJ tubes. We hypothesize that this may be related to the jejunal extensions leading to difficulty in the usual maintenance regimen that all carers are taught after PEG/PEGJ insertion.

Tricuspid regurgitation following left-sided valve surgery: echocardiographic evaluation and optimal timing of surgical treatment.

Severe tricuspid regurgitation may often appear and progress late after left-sided valve surgery without left-sided valve dysfunction, significant left heart failure, and pulmonary hypertension. The clinical features, echocardiographic evaluation, treatment, and prognosis of this disease entity have been discussed, but data is limited compared with left-sided valve diseases. Tricuspid annular dilatation associated with atrial fibrillation and right ventricular dysfunction strongly relate to development of isolated tricuspid regurgitation late after left-sided valve surgery. Three-dimensional evaluation may be useful in evaluating tricuspid valve anatomy in more detail. Better prognosis in patients undergoing surgical treatment for severe isolated tricuspid regurgitation than those who were treated medically has been reported; however, the timing of isolated tricuspid valve surgery is often too late. Right ventricular function is a key word for determining the timing of isolated tricuspid valve surgery; however, it is difficult to evaluate by conventional echocardiography. One of the serious issues in the future will be how to accurately evaluate right ventricular function.

Surgical Management of Tricuspid Valve Endocarditis in Systemically Infected Patients

BACKGROUND AND AIM OF THE STUDY Isolated bacterial tricuspid valve (TV) endocarditis is usually managed medically. Whilst the indications and optimal timing for surgical treatment of the condition have not been clearly defined, it is hypothesized that early surgery in patients who are bacteremic and/or have evidence of systemic seeding is superior to medical treatment. METHODS All cases of isolated TV endocarditis reported between 2006 and 2011 at the authors' institution were reviewed. Patients with bacteremia and/or systemic seeding who were treated surgically after short-term medical therapy were compared to an equivalent group of patients who remained under long-term medical treatment only. RESULTS A total of 45 patients with isolated TV endocarditis showed evidence of bacteremia and/or systemic seeding. Of these patients, 10 (22.2%) were treated surgically with valve repair or replacement, and 35 (77.8%) received long-term medical therapy only. The 30-day and one-year survival rates in both groups were comparable (100% versus 88.6%, p = 0.27). Patients treated surgically had clear blood cultures sooner (2.0 versus 6.7 days, p = 0.04), defervesced earlier (0 versus 9.0 days, p = 0.02), and demonstrated a complete resolution of TV vegetations (100% versus 30.0%, p = 0.003). Change in creatinine clearance (+22.1 versus +11.6 ml/min, p = 0.40) and durations of vasopressor support (6.8 versus 8.9 h, p = 0.86), mechanical ventilation (8.5 versus 32.2 h, p = 0.44), ICU stay (148.1 versus 53.8 h, p = 0.14) and total hospital stay (32.1 versus 24.6 days, p = 0.22) were not different between groups. Long-term echocardiogram surveillance demonstrated a higher prevalence of moderate-severe tricuspid regurgitation in the medically treated patients (75.0 versus 0.0%, p < 0.001). None of the patients treated surgically was readmitted with prosthetic valve endocarditis. CONCLUSION Early surgery is warranted in patients with isolated TV endocarditis who are bacteremic and/or systemically infected despite optimal medical therapy.

Posterior cervical foraminotomy for the treatment of cervical radiculopathy

Cervical radiculopathy remains a potentially disabling disease with a significant impact on patients’ quality of life. Despite conservative nonoperative treatment a large number of patients will end up needing surgical treatment. The most prevalent surgical options in this setting include anterior cervical discectomy and fusion (ACDF), posterior cervical foraminotomy, and cervical arthroplasty.2 Importantly, posterior cervical foraminotomy is an attractive option that may maintain cervical range of motion and minimize adjacent-segment degeneration. There are, however, no good data to guide the optimal timing of surgical treatment. Surgery is generally recommended when cervical-root–related dysfunction persists for more than 6–12 weeks despite nonsurgical treatment.12 A comparison of medical and surgical treatment published in Spine in 1999,12 showed that surgically treated patients had better outcomes with greater degrees of improvement, even though they had more neurological and nonneurological symptoms and more functional disability before treatment. In the current issue of Journal of Neurosurgery: Spine, Jagannathan et al.8 have reviewed a series of 162 cases involving patients with cervical radiculopathy who were treated with a posterior cervical foraminotomy, with a mean follow-up of 77.3 months (range 60–177). This review has addressed not only the clinical outcome but also and more importantly the long-term radiological outcome of cervical spinal alignment following posterior cervical foraminotomy. In this current series, 92% of patients showed an improvement of their Neck Disability Index scores from 18 (range 2–39) preoperatively to 8 (range 0–39) postoperatively. Ninety-five percent of patients with cervical radiculopathy experienced improvement of their symptoms. Loss of cervical lordosis (defined as segmental Cobb angle < 10°) was seen in 30 (18.5%) of patients. The overall cohort did not show any statistically significant progression of the focal or segmental kyphosis with time. Age over 60 years at the time of surgery and preoperative lordosis of less than 10° have been identified as risk factors of worsening sagittal alignment. Since the original description in the late 1940s, the surgical approaches to cervical radiculopathy secondary to laterally based discoligamentous and osseous pathology have been a choice between ACDF and posterior foraminal decompression. Many anatomical, pathophysiological, and patient factors influence the choice between these treatment approaches. Multiple studies have shown that in matched cohorts the clinical outcomes of ACDF and posterior foraminotomy are similar. The most important factor that influences the approach to treatment of unilateral single-level radiculopathy is surgeon bias. There has been a resurgence of interest in posterior foraminotomy, especially with recent popularization of minimally invasive surgery (MIS) techniques using tubular access.1,6,7,11 The 2 concerns with posterior foraminotomies are same-level degeneration/kyphosis secondary to partial resection of the facet joint and persistent neck and shoulder pain secondary to muscle stripping with the open procedure. In vitro studies have shown that segmental hypermobility of the cervical spine results if a foraminotomy involves resection of more than 50% of the facet.13 In another cadaveric in vitro study Onan et al.9 demonstrated that isolated cervical facet joints are highly mobile in comparison with facet joints within the constraints of intact motion segments. This has prompted surgeons to be more conservative with the amount of facet joint resected when performing a posterior foraminotomy. The surgical technique reported by John Jane’s team in this issue of Journal of Neurosurgery: Spine, which involves resecting the medial half of the facet joint to enable excellent nerve root decompression, importantly does not seem to have a deleterious effect on segmental stability or sagittal plane alignment. Jane’s team also identified the risk factors for delayed instability based on observations in a small subset of patients with worsening sagittal balance following surgery. These observations made by Jagannathan et al. in the current review, which were lackJ Neurosurg Spine 10:343–346, 2009 See the corresponding article in this issue, pp 347–356.

Congenital tracheal stenosis: the prognostic significance of associated cardiovascular anomalies and the optimal timing of surgical treatment

Background/Purpose Cardiovascular anomalies (CA) are frequently associated with congenital tracheal stenosis (CTS), but their prognostic impact on CTS and the optimal timing of surgical treatment remain uncertain. The aim of this study was to explore the prognostic factors and the optimal timing of surgical treatment in CTS patients with CA. Methods After obtaining institutional review board approval, a retrospective review of 42 patients who underwent surgical repair of CTS between 1996 and 2006 was conducted. The patients were divided into 3 groups: CTS without CA (n = 10, group A), CTS with CA repaired simultaneously (n = 27, group B), and CTS with CA repaired in stages (n = 5, group C). Seven clinical characteristics, including gestational week and weight at birth, the age and body weight at operation, the length of tracheal stenosis (%), the duration of cardiopulmonary bypass (CPB) during surgery, and operation time were compared among the groups using analysis of variance, Fisher's Exact test, and Student's t test. Results Although no operative mortalities occurred in groups A and C, there were 3 early deaths and 1 late death in group B. The deaths occurred in cases with associated complex CA (critical pulmonary stenosis, tetralogy of Fallot with an absent pulmonary valve, right ventricular outflow block, and cor triatrium). The duration of CPB was significantly different between groups A and B ( P = .017), and furthermore, CPB time was significantly longer in early death cases than in surviving cases in group B (318.3 ± .71.1 vs 204.0 ± 67.8 minutes; P = .012). Conclusions Complex CA and long CPB duration would be prognostic factors for the outcome of surgical management for CTS and CA. Simultaneous reconstruction of CTS and simple CA appears to be a reasonable method of surgical intervention, but patients with long segment CTS with complex CA may still be difficult to cure using this strategy, and staged correction may be considered.