Outcomes Of Reoperation Research Articles

Clinical Indications for and Outcomes of Reoperation in Adult Tetralogy of Fallot Patients in Japan: A Nationwide Retrospective Study

Clinical Indications for and Outcomes of Reoperation in Adult Tetralogy of Fallot Patients in Japan: A Nationwide Retrospective Study

217 Outcomes of Reoperation for Residual or Recurrent Obstruction After Previous Myectomy in Patients with Hypertrophic Cardiomyopathy

Abstract Aim Describe the mechanism(s) of residual or recurrent obstruction in patients who have previously undergone septal myectomy for hypertrophic cardiomyopathy and assess early outcomes of reoperation. Method From January 1989 to March 2022, we performed 73 repeat myectomies at our institution. Patients’ demographics, operative details, echocardiographic parameters, and postoperative complications were retrieved from a prospectively maintained surgical database and electronic healthrecords. Results Median age at reoperation was 48.3 years (IQR 38.6-58.6); 51 patients were women (69.9%). 90.4% presented with NYHA class III/IV symptoms. Median interval between previous myectomy and reoperation was 2.7 years (IQR 1.2-4.5). Mechanism of obstruction was an inadequate length of previous septectomy in 41 patients (56.2%), a combination of inadequate length and midventricular obstruction in 30 (41.1%), and isolated midventricular obstruction in 2 patients (2.7%). There were no instances of recurrent LVOT obstruction due to muscle regrowth at the site of previous resection. All patients had an extended transaortic septal myectomy; 14 patients (19.2%) had concomitant transapical myectomy. Preoperatively, the median LVOT gradient was 83 mmHg (IQR 60-122), which reduced to 2 mmHg (IQR 0-7) following repeat myectomy. There were no perioperative deaths. Postoperatively, 4 patients (5.5%) developed a new CHB, necessitating PPM implantation. The 5-,10-, and 20-year survival after reoperation were 100%, 91%, and 76%, respectively. Conclusions Inadequate resection at the time of primary septal myectomy is the commonest cause of residual or recurrent obstruction in oHCM patients. However, repeat myectomy, including a combined transaortic and transapical approach has minimal risk with excellent hemodynamic and long-term survival outcomes.

Long-term durability of bioprosthetic aortic valve replacement in young patients with bicuspid aortic stenosis

ObjectiveTo examine long-term surgical aortic valve replacement (SAVR) outcomes for young (ie, younger than age 65 years) patients with bicuspid aortic valve and aortic stenosis (AS) with or without concomitant aneurysm. BackgroundThere are few studies evaluating the early and late outcomes of SAVR in young patients (younger than age 65 years) with bicuspid aortic valve and AS. MethodsUsing institutional data from 2004 through 2022, 498 patients with bicuspid aortic valve younger than age 65 years underwent SAVR for AS with bioprosthetic valves. We examined operative outcomes, long-term valve durability, and reintervention. ResultsThe total cohort comprised 281 patients undergoing isolated SAVR and 217 with concomitant aneurysm repair (SAVR/aneurysm). The average age was 55 ± 8 years, with Society of Thoracic Surgeons predicted risk of mortality score of median 0.7 (IQR 0.5, 1.0) and mean valve size of 25 mm. Operative mortality (0.7% vs 1.4%; P = .77) was similar between SAVR and SAVR/aneurysm patients. Predischarge permanent pacemaker implantation occurred in 1.6% (8 out of 498) patients. During overall follow-up of 5.0 years (IQR 1.8-9.9; range, 0.2-18.2 years), the cumulative incidence of reintervention at 10 years for structural valve degeneration (n = 33), including valve-in-valve (n = 15) was 6.6% (8.1% SAVR vs 4.5% SAVR/aneurysm; P = .66). No mortality was observed for valve-in-valve or redo-SAVR. Moderate or greater aortic regurgitation and paravalvular leak were observed in 6.5% and 0.3%, respectively, at most recent follow-up. ConclusionsBicuspid AS is common in patients younger than 65 years and management includes consideration of future valve intervention. SAVR confers excellent operative and reoperative outcomes, 10-year durability, and valve function. These results may support initial SAVR when considering lifetime management of AS.

External aortic annuloplasty with a dedicated expansible ring improves outcomes in remodeling root repair compared with homemade Dacron ring

ObjectivesIn remodeling valve-sparing root replacement with external annuloplasty, we compare long-term outcomes of a calibrated expansible extra-aortic ring with a homemade Dacron ring. MethodsAll patients (2003-2020) operated for root aneurysm with/without aortic insufficiency (AI) were included. The standardized CAVIAAR (conservation aortique valvulaire dans les insuffisances aortiques et anévrysmes de la racine-Valve sparing in aortic insufficiencies and root aneurysms) technique was root remodeling and external annuloplasty ring with the EXTRA-AORTIC Ring or homemade Dacron ring. ResultsAmong 486 patients (age 52.3 ± 14.0 years) operated for root aneurysm, 375 (repair rate: 77.1%) underwent root remodeling with annuloplasty (extra-aortic ring, n = 289, vs Dacron ring, n = 86). At 10 years (median follow-up, 4.08 years’ interquartile range, 1.95-7.61), unmatched and matched analysis showed that patients with extra-aortic ring had greater survival, similar to the general population (93.3% vs 79.9%, P = .097), lower reoperation incidence (2.0% vs 9.7%, P = .0098), and lower AI grade >2 recurrence (1.9% vs 11.2%, P = .0042), compared with patients with a Dacron ring. Mixed-effect model showed that with extra-aortic ring annuloplasty, annular dilation over time (P = .0033) was prevented and, compared with the homemade Dacron ring, root expansibility was better preserved (3.22% vs 2.12%, P = .002) and mean transvalvular gradient was lower (6.58 mm Hg vs 7.94 mm Hg, P = .001). Tricuspid and bicuspid valves with extra-aortic ring had similar reoperation (4.3% vs 0.85%, P = .65) and AI grade >2 incidence (2.7% vs 1.2%, P = .61), expansibility (P = .29), and diameter (P = .47), whereas mean transvalvular gradient was lower for tricuspid valves (5.58 mm Hg vs 7.60 mm Hg, P = .004). ConclusionsValve-sparing root remodeling with calibrated expansible extra-aortic ring annuloplasty improves the outcomes of reoperation and recurrent AI compared with a homemade Dacron ring. It prevents dilation and maintains physiological root dynamics for durable valve repair.

Nationwide Trends in Utilization of Minimally Invasive Techniques for Blunt Abdominal Trauma.

Despite increasing use of minimally invasive surgical (MIS) techniques for trauma, limited large-scale studies have evaluated trends, outcomes, and resource utilization at centers that utilize MIS modalities for blunt abdominal trauma. Operative adult admissions after blunt assault, falls, or vehicular collisions were tabulated from the 2016-2020 National Inpatient Sample. Patients who received diagnostic laparoscopy or other laparoscopic and robotic intervention were classified as MIS. Institutions with at least one MIS trauma operation in a year were defined as an MIS Performing Institution (MPI; rest: non-MPI). The primary endpoint was mortality, with secondary outcomes of reoperation, complication, postoperative length of stay (LOS), and hospitalization costs. Mixed regression models were used to determine the association of MPI status on the outcomes of interest. Throughout the study period, the proportion of MIS operations and MPI significantly increased from 22.6 to 29.8% and 45.9 to 58.8%, respectively. Of an estimated 77,480 patients, 66.7% underwent care at MPI. After adjustment, MPI status was not associated with increased odds of mortality (adjusted odds ratio [AOR] 1.09, 95% confidence interval [CI] [.96,1.24]), reoperation (AOR 1.02, CI [.87,1.19]), or any of the tabulated complications. There was additionally no difference in adjusted LOS (β-.18, CI [-.85, +.49]) or costs (β+$1600, CI [-1600, +4800]), between MPI and non-MPI. The use of MIS operations in blunt abdominal trauma has significantly increased, with performing centers experiencing no difference in mortality or resource utilization. Prospectively collected data on outcomes following MIS trauma surgery is necessary to elucidate appropriate applications.

Reoperation Following Primary Greater Occipital Nerve Decompression Surgery: Incidence, Risk Factors and Outcomes.

Although nerve decompression surgery is an effective treatment for refractory occipital neuralgia (ON), a proportion of patients experience recurrence of pain and undergo reoperation. This study analyzes the incidence, risk factors, and outcomes of reoperation following primary greater occipital nerve (GON) decompression. 215 patients who underwent 399 primary GON decompressions were prospectively enrolled. Data included patient demographics, past medical and surgical history, reoperation rates, intraoperative findings, surgical technique, and postoperative outcomes in terms of pain frequency (days/month), duration (hours/day), intensity (scale 0-10), and migraine headache index (MHI). Bivariate analyses, univariable and multivariable logistic regression analysis was performed. 27 (6.8%) GON decompressions required reoperation with neurectomy at a median follow-up time of 15.5 months (9.8-40.5). Cervical spine disorders on imaging that did not warrant surgical intervention (OR, 4.88; 95% 1.61-14.79; p<0.01) and radiofrequency ablation (RFA) (OR, 4.20; 95% CI, 1.45-15.2; p<0.05) were significantly associated with higher rates of reoperation. At 12 months postoperatively, patients who underwent reoperation achieved similar mean reductions in pain frequency, duration, intensity and MHI, as compared to patients who underwent only primary decompression (p>0.05). Patients with ON who have a history of cervical spine disorders or RFA should be counseled that primary decompression has a higher risk of reoperation, but outcomes are ultimately comparable.

Contemporary trends in choledochal cyst excision: An analysis of the pediatric national surgical quality improvement program.

Choledochal cysts are rare congenital anomalies of the biliary tree that may lead to obstruction, chronic inflammation, infection, and malignancy. There is wide variation in the timing of resection, operative approach, and reconstructive techniques. Outcomes have rarely been compared on a national level. We queried the Pediatric National Surgical Quality Improvement Program (NSQIP) to identify patients who underwent choledochal cyst excision from 2015 to 2020. Patients were stratified by hepaticoduodenostomy (HD) versus Roux-en-Y hepaticojejunostomy (RNYHJ), use of minimally invasive surgery (MIS), and age at surgery. We collected several outcomes, including length of stay (LOS), reoperation, complications, blood transfusions, and readmission rate. We compared outcomes between cohorts using nonparametric tests and multivariate regression. Altogether, 407 patients met the study criteria, 150 (36.8%) underwent RNYHJ reconstruction, 100 (24.6%) underwent MIS only, and 111 (27.3%) were less than one year old. Patients who underwent open surgery were younger (median age 2.31 vs. 4.25years, p=0.002) and more likely underwent RNYHJ reconstruction (42.7% vs. 19%, p=0.001). On adjusted analysis, the outcomes of LOS, reoperation, transfusion, and complications were similar between the type of reconstruction, operative approach, and age. Patients undergoing RNYHJ had lower rates of readmission than patients undergoing HD (4.0% vs. 10.5%, OR 0.34, CI [0.12, 0.79], p=0.02). In children with choledochal cysts, most short-term outcomes were similar between reconstructive techniques, operative approach, and age at resection, although HD reconstruction was associated with a higher readmission rate in this study. Clinical decision-making should be driven by long-term and biliary-specific outcomes.

Forced eruption in impacted teeth: analysis of failed cases and outcome of re-operation

BackgroundForced eruption of an impacted tooth usually requires surgical and orthodontic interventions to successfully bring the tooth into the dental arch. The clinical time required for a forced eruption is difficult to predict before treatment begins and success rates are affected by several factors before and after an eruption. This study was conducted to identify factors that affect the success of forced eruption, the duration of orthodontic treatment of impacted teeth, and the reasons for re-operation and forced eruption failure in a various teeth and cases.MethodsIn this retrospective study, the records regarding the forced eruption of 468 teeth in 371 patients from June 2006 to May 2020 at the Advanced General Dentistry Department of Yonsei University Dental Hospital were initially examined. The records of 214 teeth in 178 patients who completed orthodontic treatment were included in the analysis. Data on patient demographics, tooth characteristics, orthodontic treatment duration, re-operations, and failures were collected from electronic medical records.ResultsThere was a significant difference in age between the success and failure forced eruption. Factors significantly affecting treatment duration were apex formation, position, rotation, and re-operation. Re-operation had a 96% success rate. The average orthodontic treatment duration was 29.99 ± 16.93 months, but the average orthodontic treatment duration for teeth that undergone re-operation was 20.36 ± 11.05 months, which was approximately 9 months shorter. Additionally, there was an interaction effect between rotation and re-operation on the duration of orthodontic treatment. The causes for failure of forced eruption in 6 cases were ankyloses (3 cases), incomplete alignment with the normal dental arch (2 cases), and a significant deviation in the impacted tooth’s location (1 case).ConclusionsTo increase the success rate of forced eruption, age should be considered as a priority, and in order to predict the treatment period, the apex formation status, position in the arch, and rotation should be considered in addition to age. When determining re-operation, considering factors such as ankylosis, root curvature, and apex formation can help in the success of orthodontic treatment.

Machine learning clustering of adult spinal deformity patients identifies four prognostic phenotypes: a multicenter prospective cohort analysis with single surgeon external validation

BACKGROUND CONTEXTAmong adult spinal deformity (ASD) patients, heterogeneity in patient pathology, surgical expectations, baseline impairments, and frailty complicates comparisons in clinical outcomes and research. This study aims to qualitatively segment ASD patients using machine learning-based clustering on a large, multicenter, prospectively gathered ASD cohort. PURPOSETo qualitatively segment adult spinal deformity patients using machine learning-based clustering on a large, multicenter, prospectively gathered cohort. STUDY DESIGN/SETTINGMachine learning algorithm using patients from a prospective multicenter study and a validation cohort from a retrospective single center, single surgeon cohort with complete 2-year follow up. PATIENT SAMPLEAbout 805 ASD patients; 563 patients from a prospective multicenter study and 242 from a single center to be used as a validation cohort. OUTCOME MEASURESTo validate and extend the Ames-ISSG/ESSG classification using machine learning-based clustering analysis on a large, complex, multicenter, prospectively gathered ASD cohort. METHODSWe analyzed a training cohort of 563 ASD patients from a prospective multicenter study and a validation cohort of 242 ASD patients from a retrospective single center/surgeon cohort with complete two-year patient-reported outcomes (PROs) and clinical/radiographic follow-up. Using k-means clustering, a machine learning algorithm, we clustered patients based on baseline PROs, Edmonton frailty, age, surgical history, and overall health. Baseline differences in clusters identified using the training cohort were assessed using Chi-Squared and ANOVA with pairwise comparisons. To evaluate the classification system's ability to discern postoperative trajectories, a second machine learning algorithm assigned the single-center/surgeon patients to the same 4 clusters, and we compared the clusters' two-year PROs and clinical outcomes. RESULTSK-means clustering revealed four distinct phenotypes from the multicenter training cohort based on age, frailty, and mental health: Old/Frail/Content (OFC, 27.7%), Old/Frail/Distressed (OFD, 33.2%), Old/Resilient/Content (ORC, 27.2%), and Young/Resilient/Content (YRC, 11.9%). OFC and OFD clusters had the highest frailty scores (OFC: 3.76, OFD: 4.72) and a higher proportion of patients with prior thoracolumbar fusion (OFC: 47.4%, OFD: 49.2%). ORC and YRC clusters exhibited lower frailty scores and fewest patients with prior thoracolumbar procedures (ORC: 2.10, 36.6%; YRC: 0.84, 19.4%). OFC had 69.9% of patients with global sagittal deformity and the highest T1PA (29.0), while YRC had 70.2% exhibiting coronal deformity, the highest mean coronal Cobb Angle (54.0), and the lowest T1PA (11.9). OFD and ORC had similar alignment phenotypes with intermediate values for Coronal Cobb Angle (OFD: 33.7; ORC: 40.0) and T1PA (OFD: 24.9; ORC: 24.6) between OFC (worst sagittal alignment) and YRC (worst coronal alignment). In the single surgeon validation cohort, the OFC cluster experienced the greatest increase in SRS Function scores (1.34 points, 95%CI 1.01–1.67) compared to OFD (0.5 points, 95%CI 0.245–0.755), ORC (0.7 points, 95%CI 0.415–0.985), and YRC (0.24 points, 95%CI -0.024–0.504) clusters. OFD cluster patients improved the least over 2 years. Multivariable Cox regression analysis demonstrated that the OFD cohort had significantly worse reoperation outcomes compared to other clusters (HR: 3.303, 95%CI: 1.085–8.390). CONCLUSIONMachine-learning clustering found four different ASD patient qualitative phenotypes, defined by their age, frailty, physical functioning, and mental health upon presentation, which primarily determines their ability to improve their PROs following surgery. This reaffirms that these qualitative measures must be assessed in addition to the radiographic variables when counseling ASD patients regarding their expected surgical outcomes.

Knee flexion compensation in postoperative adult spinal deformity patients: implications for sagittal balance and clinical outcomes.

To determine whether maintaining good sagittal balance with significant knee flexion (KF) constitutes a suboptimal outcome after adult spinal deformity (ASD) correction. This single-center, single-surgeon retrospective study, assessed ASD patients who underwent posterior spinal fusion between 2014 and 2020. Inclusion criteria included meeting at least one of the following: PI-LL ≥ 25°, T1PA ≥ 20°, or CrSVA-H ≥ 2cm. Those with lower-extremity contractures were excluded. Patients were classified into four groups based on their 6-week postoperative cranio-hip balance and KF angle, and followed for at least 2 years: Malaligned with Knee Flexion (MKF+) (CrSVA-H > 20mm + KFA > 10), Malaligned without Knee Flexion (MKF-) (CrSVA-H > 20mm + KFA < 10), Aligned without Knee Flexion (AKF-) (CrSVA-H < 20mm + KFA < 10), and Aligned with Knee Flexion (AKF+) (CrSVA-H < 20mm + KFA > 10). The primary outcomes of this study included one and two year reoperation rates. Secondy outcomes included clinical and patient reported outcomes. 263 patients (mean age 60.0 ± 0.9 years, 74.5% female, and mean Edmonton Frailty Score 3.3 ± 0.2) were included. 60.8% (160/263 patients) exhibited good sagittal alignment at 6-week postop without KF. Significant differences were observed in 1-year (p = 0.0482) and 2-year reoperation rates (p = 0.0374) across sub-cohorts, with the lowest and highest rates in the AKF- cohort (5%, n = 8) and MKF + cohort (16.7%, n = 4), respectively. Multivariable Cox regression demonstrated the AKF- cohort exhibited significantly better reoperation outcomes compared to other groups: AKF + (HR: 5.24, p = 0.025), MKF + (HR: 31.7, p < 0.0001), and MKF- (HR: 11.8, p < 0.0001). Our findings demonstrate that patients relying on knee flexion compensation in the early postoperative period have inferior outcomes compared to those achieving sagittal balance without knee flexion. When compared to malaligned patients, those with CrSVA-H < 20mm and KFA > 10 degrees experience fewer early reoperations but similar delayed reoperation rates. This insight emphasizes the importance of considering knee compensation perioperatively when managing sagittal imbalance in clinical practice.

Impact of explanted valve type on aortic valve reoperations: nationwide UK experience.

This nationwide retrospective cohort study assessed the impact of the explanted valve type on reoperative outcomes in aortic valve surgery within the UK over a 23-year period. Data were sourced from the National Institute for Cardiovascular Outcomes Research (NICOR) database. All patients undergoing first-time isolated reoperative aortic valve replacement between 1996 and 2019 in the UK were included. Concomitant procedures, homograft implantation or aortic root enlargement were excluded. Propensity score matching was utilized to compare outcomes and risk factors for in-hospital mortality was evaluated through multivariable logistic regression. Final model selection was conducted using Akaike Information Criterion through bootstrapping. The primary end point was in-hospital mortality, and secondary end points included postoperative morbidities. Out of 2371 patients, 24.9% had mechanical and 75% had bioprosthetic valves implanted during the primary procedure. Propensity matched groups of 324 patients each, were compared. In-hospital mortality for mechanical and bioprosthetic valve explants was 7.1% and 5.9%, respectively (P = 0.632). On multivariable logistic regression analysis, valve type was not a risk factor for mortality [odds ratio (OR) 0.62, 95% confidence interval (CI) 0.37-1.05; P = 0.1]. Age (OR 1.03, 95% CI 1.01-1.05; P < 0.05), left ventricular ejection fraction (OR 1.62, 95% CI 1.08-2.42; P < 0.05), creatinine ≥ 200 mg/dl (OR 2.21, 95% CI 1.17-4.04; P < 0.05) and endocarditis (OR 2.66, 95% CI 1.71-4.14; P < 0.05) emerged as risk factors for mortality. The type of valve initially implanted (mechanical or bioprosthetic) did not determine mortality. Instead, age, left ventricular ejection fraction, renal impairment and endocarditis were significant risk factors for in-hospital mortality.

Concomitant Tricuspid Valve Surgery With Mitral Valve Surgery for Moderate Tricuspid Regurgitation

BackgroundTricuspid valve surgical procedures (TVS) concomitant with mitral valve (MV) surgical procedures for less than severe tricuspid regurgitation (TR) remains controversial. This study examined the long-term outcomes of patients with moderate or mild to moderate TR undergoing MV surgical procedures with or without TVS. MethodsPatients with moderate or mild to moderate TR undergoing MV replacement or repair between January 2002 and June 2021 were included. Primary outcomes of reoperation and long-term survival were compared for patients undergoing MV replacement or repair with or without TVS before and after stratifying by mitral disease cause. ResultsThe study included 505 patients. Mean age was 69 ± 12.7 years. The Society of Thoracic Surgeons Predicted Risk of Mortality for MV replacement (3.71 vs 4.39; P = .34) and repair (1.73 vs 1.67; P = .84) was similar for patients who did and did not undergo TVS. Operative mortality was similar for replacement (4.2% vs 6.1%; P = .77) or repair (0% vs 0%) with or without TVS. Patients undergoing MV replacement or repair with or without TVS had similar 10-year survival (67.1% vs 73.2% [P = .37]; 68.7% vs 78.8% [P = .052]) and rates of reoperation (2.1% vs 0.8% [P = .69]; 4.9% vs 4.6% [P = .99]). Cox proportional hazards modeling confirmed that TVS did not decrease the risk of death after MV replacement (hazard ratio, 0.839 [0.479-1.467]) or repair (hazard ratio, 0.852 [0.516-1.408]). The findings were unchanged after stratifying by MV disease cause or restricting the analysis to patients with moderate TR only, with no differences in survival or reoperation (all P > .05). ConclusionsConcomitant TVS for moderate or mild to moderate TR did not improve survival or decrease reoperation. Parameters beyond the degree of TR may aid in surgical decision-making.

Ceramic-on-Ceramic or Metal-on-Polyethylene: The Bearing of Choice after Ceramic Component Fracture in Total Hip Arthroplasty along with Concise Follow-Up of the Previous Cohort.

We previously reported the questionable result of reoperation using metal-on-polyethylene (MoP) bearing after the fracture of the ceramic component. After the report, we abandoned the use of MoP; instead, we used ceramic-on-ceramic (CoC) bearing. This report aimed to present the outcome of reoperation to CoC bearing after ceramic component failures along with the longer-term outcome of the previously reported cohort with an MoP bearing. The mean follow-up of the MoP cohort was extended from 4.3 years to 8.8 years. Metallosis had occurred in three of nine patients of the previous cohort, which all required re-reoperations. Two hips from 11 patients with revision to CoC had re-reoperations due to ceramic liner fracture and non-union of the osteotomized fragment, respectively. No metallosis and wear occurred in the cohort revised with CoC articulation. Otherwise, there were no adverse changes in radiographs and no impairment in functions. We conducted an extended prospective evaluation of a previous cohort consisting of six head fractures and three liner fractures. In this cohort, the patients underwent a bearing change to metal-on-polyethylene. Additionally, we retrospectively analyzed 11 cases of third-generation ceramic bearing fractures, comprising nine head fractures and two liner fractures. These cases were subsequently treated with a bearing change to fourth-generation CoC. We assessed clinical and radiological outcomes, including complication rates, in both groups. We recommend the latest CoC as the bearing of choice in reoperation after the fracture of ceramic components. In the case of an MoP bearing after the ceramic component fracture, the risk of metallosis seemed high in the early postoperative period.

Increasing surgeon experience and cumulative institutional experience drive decreasing hospital mortality after reoperative cardiac surgery

ObjectiveThe study objective was to identify the effects of surgeon experience and age, in the context of cumulative institutional experience, on risk-adjusted hospital mortality after cardiac reoperations. MethodsFrom 1951 to 2020, 36 surgeons performed 160,338 cardiac operations, including 32,871 reoperations. Hospital death was modeled using a novel tree-bagged, generalized varying-coefficient method with 6 variables reflecting cumulative surgeon and institutional experience up to each cardiac operation: (1) number of total and (2) reoperative cardiac operations performed by a surgeon, (3) cumulative institutional number of total and (4) reoperative cardiac operations, (5) year of surgery, and (6) surgeon age at each operation. These were adjusted for 46 patient characteristics and surgical components. ResultsThere were 1470 hospital deaths after cardiac reoperations (4.5%). At the institutional level, hospital death decreased exponentially and became less variable, leveling at 1.2% after approximately 14,000 cardiac reoperations. For all surgeons as a group, hospital death decreased rapidly over the first 750 reoperations and then gradually decreased with increasing experience to less than 1% after approximately 4000 reoperations. Surgeon age up to 75 years was associated with ever-decreasing hospital death. ConclusionsSurgeon age and experience have been implicated in adverse surgical outcomes, particularly after complex cardiac operations, with young surgeons being novices and older surgeons having declining ability. However, at Cleveland Clinic, outcomes of cardiac reoperations improved with increasing primary surgeon experience, without any suggestion to mid-70s of an age cutoff. Patients were protected by the cumulative background of institutional experience that created a culture of safety and teamwork that mitigated adverse events after cardiac surgery.

The Fate of Reoperation After Proximal Femur Fracture Surgery in Elderly Population.

The overall complication rate after proximal femur fracture surgery is high. This study aims to define the reoperation reasons and outcomes of reoperations after proximal femur fracture surgery in elderly patients. This retrospective cohort study included patients over 75 years of age who underwent surgery for an intertrochanteric femur fracture and femoral neck fracture between 2014 and 2021. The minimum follow-up was 12 months, or until the patient was deceased. The primary outcome measure was the success of reoperation with regard to fracture type and implant. Results: A total of 89 patients required reoperation for an overall rate of 9.3% during follow-up. Infection was the leading reason for reoperation. Hemiarthroplasty (HA) for intertrochanteric fracture is associated with a high rate of infection compared with HA for femoral neck fracture. The success rate of reoperation due to postoperative infection was poor (46.3%) whereas the success rate for other implant-related complications was favorable (91.6%). Conclusion: The risk of postoperative infection after HA is significantly higher for intertrochanteric femur fractures compared to neck fractures in the elderly population. The limited success after postoperative infection should be taken into consideration in decision-making.

Patient-reported Outcome After Surgical Evacuation of Postoperative Spinal Epidural Hematomas at One-year Follow-up.

Retrospective analysis of prospectively collected data from the National Swedish Spine Register (Swespine). The objective of this study was to evaluate the effects of symptomatic spinal epidural hematoma (SSEH) requiring reoperation on one-year patient-reported outcome measures (PROMs) in a large cohort of patients treated surgically for lumbar spinal stenosis. Studies exploring the outcomes of reoperations after SSEH are scarce and often lack validated outcome measures. As SSEH is considered a serious complication, understanding of the outcome after hematoma evacuation is important. After retrieving data from 2007 to 2017 from Swespine, we included all patients with lumbar spinal stenosis without concomitant spondylolisthesis who were treated surgically with decompression without fusion. Patients with evacuated SSEH were identified in the registry. Back/leg pain numerical rating scales (NRSs), the Oswestry Disability Index (ODI), and EuroQol Visual Analogue Scale were used for the outcome assessment. PROMs before and one year after decompression surgery were compared between evacuated patients and all other patients. Multivariate linear regression was performed to determine whether hematoma evacuation predicted inferior one-year PROM scores. A total of 113 patients with an evacuated SSEH were compared with 19527 patients with no evacuation. One-year after decompression surgery, both groups showed significant improvement in all PROMs. When comparing the two groups' one-year improvement, there were no significant differences in any PROM. The proportion of patients achieving the minimum important change was not significantly different for any PROM. Multivariate linear regression found that hematoma evacuation significantly predicted inferior one-year ODI (β=4.35, P =0.043), but it was not a significant predictor of inferior NRS Back (β=0.50, P =0.105), NRS Leg (β=0.41, P =0.221), or EuroQol Visual Analogue Scale (β=-1.97, P =0.470). A surgically evacuated SSEH does not affect the outcome in terms of back/leg pain or health-related quality of life. Commonly used PROM surveys may not capture neurological deficits associated with SSEH.

Outcomes of Glaucoma Reoperations in the Primary Tube Versus Trabeculectomy Study

To describe the incidence and outcomes of reoperations for glaucoma in the Primary Tube VersusTrabeculectomy (PTVT) Study. Cohort study of patients in a multicenter randomized clinical trial. The PTVT Study enrolled 242 patients with medically uncontrolled glaucoma and no previous incisional ocular surgery. Randomization assigned 125 patients to placement of a tube shunt (350-mm2 Baerveldt glaucoma implant) and 117 patients to trabeculectomy with mitomycin C (MMC, 0.4 mg/ml for 2 minutes). Data were analyzed from patients who underwent additional glaucoma surgery. Outcome measures included intraocular pressure (IOP), use of glaucoma medications, visual acuity, surgical complications, and failure (IOP > 21 mmHg or reduced by <20%, IOP ≤ 5 mmHg, additional glaucoma surgery, or loss of light perception vision). Additional glaucoma surgery was performed in 21 patients in the tube group and 12 patients in the trabeculectomy group in the PTVT Study, and the 5-year cumulative reoperation rate for glaucoma was 18.0% in the tube group and 10.4% in the trabeculectomy group (P= 0.15). Follow-up (mean ± standard deviation [SD]) after additional glaucoma surgery was 35.1 ± 17.7 months in the tube group and 30.1 ± 17.6 months in the trabeculectomy group (P= 0.44). At 3 years after glaucoma reoperation, IOP (mean ± SD) was 15.5 ± 4.8 mmHg in the tube group and 16.6 ± 7.3 mmHg in the trabeculectomy group (P= 0.71). The number of glaucoma medications (mean ± SD) after 3 years of follow-up was 2.1 ± 1.7 in the tube group and 1.7 ± 1.0 in the trabeculectomy group (P= 0.58). The cumulative probability of failure at 3 years after a glaucoma reoperation was 37.8% in the tube group and 21.3% in the trabeculectomy group (P= 0.47). No significant difference in the rate of reoperation for glaucoma was observed after tube shunt implantation and trabeculectomy with MMC in the PTVT Study. Similar surgical outcomes were observed after additional glaucoma surgery, irrespective of the initial procedure to which the patient was randomized. Proprietary or commercial disclosure may be found after the references.

Favorable long-term outcomes in hospital survivors of a neonatal arterial switch operation

ObjectivesTo assess long-term survival and reoperation-free survival after the arterial switch operation (ASO) and analyze the outcomes of reoperations after hospital discharge. MethodsThis was a single-institution retrospective study of 476 hospital survivors of ASO since August 1982. Preoperative diagnoses included 286 transpositions of the great arteries with intact septum, 143 transpositions with ventricular septal defect, and 47 double outlet right ventricles. There were 236 neonatal ASOs, 30 aortic arch repairs, 22 concomitant left ventricular outflow tract obstruction reliefs, 16 preoperative mild pulmonary regurgitations, and 13 intramural coronary arteries. ResultsDuring a median follow-up of 21.1 years (range, 0.1-39.2 years), 25 late deaths (5.3%) and 91 reoperations in 69 patients (14.5%) were noted. The reoperations included 44 left-sided reoperations in 34 patients (7.1%), 35 right-sided reoperations in 30 patients (6.3%), and 12 other reoperations in 12 patients (2.5%). Among the 69 patients who underwent reoperation, those with left-sided reoperations had lower survival at 15 years after reoperation compared to those with non–left-sided reoperations (91.2% vs 100%; P = .015; log-rank, 5.9). Multivariable analysis identified non-neonatal ASO, preoperative pulmonary regurgitation, intramural coronary artery, aortic arch repair, and concomitant left ventricular outflow tract obstruction relief as risk factors for left-sided reoperations. Reoperation-free survival was significantly higher in neonatal ASO compared with non-neonatal ASO (89.2% vs 75.2% at 20 years; P < .001; log-rank, 13.4). ConclusionsHospital survivors of neonatal ASO had favorable long-term outcomes. Video Abstract [Display omitted]

Comparative analysis between radioactive seed localization and wire-guided for non-palpable breast cancer surgery

The conservative surgery for impalpable breast cancer requires an intraoperative localization method that guides the identification and correct excision of the lesion. The aim of this study is to comparatively analyze two intraoperative breast localization technologies, wire guided localization (WGL) and radioactive seed localization (RSL), regarding their surgical efficacy through the outcomes of surgical margins, intraoperative re-excision, reoperation and recurrence. To this end, a systematic search was realized in databases for clinical trials that match with the study eligibility criteria. The selected studies were evaluated for their methodological quality; the data were then collected and quantitatively synthesized. The results comprised thirty-eight studies that match the eligibility criteria. The main outcomes reported demonstrating that the RSL is at least equivalent to the WGL in efficiency rates. These results confirm the method applicability for impalpable breast lesions surgery in an effective way, in addition to presenting organizational optimization of radiology and surgery services by allowing the surgery to be performed up to two months after seed implantation.

A Nationwide Analysis Evaluating the Safety of Using Acellular Dermal Matrix with Tissue Expander-Based Breast Reconstruction.

Background In March 2021, the United States Food and Drug Administration (FDA) safety communication cautioned against the use of acellular dermal matrix (ADM) products in breast reconstruction and reiterated that the FDA does not approve ADM use in breast surgery. This study aims to assess the safety of ADM use in breast reconstruction. Methods Women who underwent ADM and non-ADM assisted tissue expander (TE)-based breast reconstruction were identified using the National Surgical Quality Improvement Program database (2012-2019). Trends of ADM use over time, and 30-day outcomes of surgical site infection (SSI), dehiscence, and unplanned reoperation were assessed. Results Of the 49,049 TE-based breast reconstructive cases, 42.4% were ADM assisted and 57.6% non-ADM assisted. From 2012 to 2019, the use of ADM increased from 26.1 to 55.6% (relative risk [RR] =1.10; p < 0.01). Higher rates of SSI (3.9 vs. 3.4%; p = 0.003) and reoperation (7.4 vs. 6.0%; p < 0.001) were seen in the ADM cohort. There was no significant difference seen in dehiscence rates (0.7 vs. 0.7%; p = 0.73). The most common reoperation within 30 days for the ADM group (17.6%) was removal of TE without insertion of implant (current procedural terminology: 11,971). ADM-assisted breast reconstruction was associated with increased relative risk of SSI by 10% (RR = 1.10, confidence interval [CI]: 1.01-1.21; p = 0.03) and reoperation by 15% (RR = 1.15, CI: 1.08-1.23; p < 0.001). Conclusions ADM-assisted breast reconstruction more than doubled from 2012 to 2019. There are statistically higher complication rates of SSI (0.5%) and reoperation (1.4%) with ADM use in TE-based breast reconstruction, suggesting that reconstruction without ADM is safe when comparing immediate postoperative outcomes.