Post Repair Research Articles

Safety and efficacy of tranexamic acid in major non-cardiac vascular surgery: a systematic review and meta-analysis

Background: Tranexamic acid (TXA) is a synthetic lysine analogue that inhibits fibrinolysis. The effectiveness of TXA in obstetrics, trauma and orthopaedic and cardiac surgery is well established. However, concerns regarding its prothrombotic potential remain, which is an important consideration for vascular surgery. We aimed to evaluate the safety and efficacy of TXA in adults undergoing major non-cardiac vascular surgery. Methods: A pre-specified protocol (PROSPERO CRD42023427282) was followed. Relevant databases (PubMed, MEDLINE, EMBASE) were searched for randomised controlled trials (RCTs). Data extraction and risk of bias assessments were performed in duplicate. A random effects model was used to synthesise data from RCTs. Measures of effect were reported as relative risk (RR) with 95% confidence intervals (CIs). The primary safety outcome was a composite of arterial and venous thromboembolic events (composite of myocardial infarction, non-haemorrhagic stroke, peripheral arterial thrombosis and symptomatic proximal venous thromboembolism). Certainty of evidence was assessed using the GRADE approach. Results: After screening 1989 records, three RCTs were included, cumulatively enrolling 1,560 participants. In all trials, patients received either TXA (intravenously or orally) compared with placebo. There was no evidence of the effect of intravenous TXA on thromboembolic events (RR 1.10, 95% CI 0.89 to 1.36, two RCTs, 1460 participants, low certainty of evidence) or on critical bleeding (composite of life-threatening, critical and major organ bleed) (RR 0.85, 95% CI 0.65 to 1.11, two RCTs, 1460 participants, low certainty of evidence). TXA may reduce postoperative blood loss, especially at 0–4 hours (Cliff’s delta −0.41, 95% CI −0.19 to −0.59) and 0–24 hours (Cliff’s delta −0.37, 95% CI −0.14 to −0.55) after surgery. There was no evidence of an effect of TXA on reducing perioperative red blood cell (RBC) transfusion requirements (RR 0.66, 95% CI 0.11 to 3.95, one RCT, 100 participants). One RCT assessed oral TXA and found no evidence of an effect on type II endoleak post endovascular aneurysm repair. No thrombotic complications were reported in this RCT during the study period. Conclusions: We found no evidence of an effect of TXA on thromboembolic complications. While TXA appears to reduce early postoperative bleeding, the clinical relevance of this is uncertain. Due to limitations of study design and the variety of vascular procedures, the role of TXA in vascular surgery is still unclear. Ongoing trials may reduce this uncertainty. Registration: Prospectively registered on PROSPERO (CRD42023427282)

Upper Esophageal Sphincter Dysfunction in Children with Type 1 Laryngeal Cleft after Failed Primary Cleft Repair.

Changes in pharyngeal and upper-esophageal-sphincter (UES) motor dynamics contribute to swallowing dysfunction. Children with type 1 laryngeal clefts can present with swallowing dysfunction and associated symptoms which may persist even after the initial endoscopic intervention. This study sought to characterize pharyngeal and esophageal motor function in children with type 1 laryngeal clefts who had persistent presenting symptoms after their initial therapeutic intervention. We retrospectively analyzed high-resolution esophageal manometry studies of children ≤ 18 years old with type 1 laryngeal clefts who had an esophageal manometry study performed for persistent symptoms after an initial repair. A total of 16 children were found to have significantly increased UES resting pressure, UES pre- and post-swallow maximum pressures, and duration of UES contraction during swallows in comparison to nine age-matched controls of children without pharyngeal anatomical abnormalities. There was no difference between UES residual pressures or pharyngeal dynamics between the two groups. UES resting and residual pressures did not correlate with VFFS in penetration and aspiration scores of children with type 1 laryngeal clefts status post repair. Our study is the first to identify specific changes in UES motor function in patients with type 1 laryngeal cleft post initial repair.

Ultrasound Coded-Excitation Imaging for Endoleak Detection After Complex Endovascular Aortic Repair.

Several imaging modalities have been suggested for surveillance after fenestrated endovascular aortic repair in general and endoleak detection in specific. In the present project a coded excitation-based ultrasound (B-Flow) was investigated for endoleak detection after complex endovascular aortic repair. Patients post complex endovascular aortic repair (FEVAR or T/FEVAR) undergoing follow-up appointments including ultrasonography of the aorta at a vascular and endovascular surgery outpatient center were included in the study. B-Flow was compared with computed tomography angiography (CTA), Duplex ultrasound (DUS), and contrast-enhanced ultrasound (CEUS) regarding agreement and reliability for endoleak detection and characterization. In total, 47 follow-ups were included. They accumulated in a total of 149 imaging investigations. Endoleaks were discovered in 44.7% of B-Flow studies and a majority of these endoleaks were classified as type II. Agreement between B-Flow and other imaging modalities was good (>80.0%) in general. However, with B-Flow 6 and 2 endoleaks would have been missed compared with CEUS and CTA, respectively. Regarding endoleak classification, B-Flow had a strong agreement (94.5%) with CEUS in detected cases. Furthermore, in a limited subset analysis, imaging findings were externally validated using findings from angiography. Ultrasonography allows for endoleak detection and characterization without an invasive procedure or the use of potentially nephrotoxic contrast medium and can reduce radiation exposure. While CEUS mitigates issues of radiation and nephrotoxicity it still requires the intravenous application of contrast enhancers. Ultrasound coded-excitation imaging such as B-Flow could therefore further simplify endoleak surveillance after fenestrated endovascular aortic repair.

An assessment of factors associated with early postoperative stiffness in arthroscopic rotator cuff repair.

Postoperative stiffness affects up to 20% of patients following arthroscopic rotator cuff repair. Recent evidence indicates that early postoperative stiffness may associated with lower retear rates. This study aimed to identify the independent predictors of early postoperative stiffness. A retrospective cohort study of 1526 rotator cuff repairs was performed. Range of motion at 6-week postop was used to identify stiff patients. Stiffness was defined as external rotation <27.5o or forward flexion <145o . Multiple logistic regression analysis was used to identify the independent predictors of 6-week stiffness. The independent predictors for external rotation stiffness at 6-week postop were more recent cases (Wald = 60), restricted preoperative external rotation (Wald = 36), younger age (Wald = 21) and poorer surgeon-ranked tissue quality (Wald = 15). The independent predictors for forward flexion stiffness were more recent cases (Wald = 101), restricted preoperative forward flexion (Wald = 16) and external rotation (Wald = 13) and female patients (Wald = 12). All patients that developed early postoperative stiffness had recovered range of motion by 6 months to preoperative levels (P < 0.0001). A significantly greater proportion of younger patients (40-49) developed postoperative stiffness when compared to older patients aged 50-59 (P < 0.0062), 70-79 (P < 0.0126) and 80-89 (P < 0.004). Patients that retore had significantly greater average 6-week postoperative range of motion. Patients earlier in the study were found to have greater postoperative range of motion, which coincided with a more aggressive rehabilitation program with less immobilization. Thus, the data supports the hypothesis that a temporary period of shoulder stiffness facilitates tendon repair and ultimately a better outcome post rotator cuff repair.

Abstract 13830: Pheochromocytoma in a Patient With Tetralogy of Fallot and Chromosome 17p12 Duplication

Description of Case: A 22-year-old male with Tetralogy of Fallot (TOF) status post transannular patch repair, hypothyroidism, and known partial duplication of chromosome 17p12 concerning for Charcot-Marie-Tooth disease (CMT), presented to his cardiologist with exertional angina and dyspnea, difficulty gaining weight, and diaphoresis. Cardiac MRI demonstrated moderate to severe pulmonic regurgitation with regurgitation fraction of 35% and RV end-diastolic volume index of 150 cc/m 2 . He was referred for pulmonic valve replacement surgery. While awaiting surgical evaluation, he presented to an ER with new hypertension with blood pressure to 240/140 and tachycardia to 107. A CT scan demonstrated a 4.3 x 5.0 x 4.4 cm mass in the right adrenal gland. On admission he was started on phenoxybenzamine and carvedilol. Workup revealed elevated catecholamines and metanephrines ( Table ). He underwent surgical adrenalectomy without complications. Immunohistochemical staining was consistent with pheochromocytoma. Post-procedurally, he was normotensive off medications. He was seen in clinic three weeks after surgery with significant improvement in symptoms. Discussion: We report on a novel genetic association of chromosome 17p12 duplication and pheochromocytoma. The region transcribes peripheral myelin protein-22, which has associations with CMT. Overlap has been demonstrated in other CMT-associated mutations and pheochromocytoma syndromes (e.g. kinesin family member 1B). In congenital heart disease, risk for pheochromocytoma is felt to be driven by hypoxia causing catecholamine secretion, adrenal hyperplasia, and eventual neoplasia. Further study is needed to characterize genetic associations between pheochromocytoma, neuropathy, and congenital heart disease. This patient’s presentation is a lesson in maintaining a high index of suspicion for pheochromocytoma in congenital heart disease, especially with associated genetic syndromes.

Abstract 12267: Timing and Mode of Death Following Treatment of Neonatal Symptomatic Tetralogy of Fallot

Introduction: Neonates with tetralogy of Fallot and symptomatic cyanosis (sTOF) require early intervention, using a staged (SR) or primary repair (PR) strategy. Independent of management, the risk of post-procedural mortality is considerable. Although risk factors for late mortality after TOF repair have been established, the modes of death and associated factors have not been defined in early childhood following treatment of sTOF. Methods: Neonates with sTOF who had an initial intervention from 2005-2017 at 9 centers of the Congenital Cardiac Research Collaborative were reviewed. Among the patients who died, additional details related to timing and cause of death, and last clinical follow-up, were obtained and described. Comparisons of patient characteristics between survivors and non-survivors were performed. Results: Of 572 sTOF patients (230 PR, 342 SR), there were 52 (9%) deaths at a median age of 82 (25 th - 75 th %ile: 28, 246) days . Timing of mortality included: inpatient post-palliation (n=9), interstage in SR pathway (n=11), inpatient post complete repair (CR) (SR, n=5; PR, n=11) and post-CR following hospital discharge (n=16). Death occurred within 30 days of palliation or repair in 52% of cases. Most deaths were due to cardiac etiologies, with only 6 including ≥1 non-cardiac cause of death (NEC (n=2), sepsis (n=1), CNS bleed (n=2), trauma (n=1)). Risk factors for mortality included presence of genetic syndrome, non-cardiac anomaly, prematurity, low birth weight, and need for ventilation prior to initial intervention (p&lt;0.05 for all). Modes and timing of death in the 16 patients who died after CR discharge are shown (Figure). In these, RV dysfunction at last echo was present in 50%. Conclusions: When death occurs after interventions for sTOF, it frequently occurs early, and relates to traditional risk factors. Amongst patients with childhood mortality following discharge from CR, sudden death and reintervention-related events predominate known causes.

Causes and Outcome of Central Venous Catheter Repair in Children with Intestinal Failure on Home Parenteral Nutrition.

Children requiring a central venous catheter (CVC) for long-term parenteral nutrition (PN) are at risk of CVC breakage. Modern intestinal failure (IF) management aims to preserve vascular access sites. CVC repair rather than removal is hence attempted for broken catheters. The aim of this study was to describe causes and outcomes of CVC repairs in home PN dependent children. All patients (ages 0-17 years) with CVC dependency enrolled in the IF rehabilitation program of a pediatric referral center were identified, and those who underwent a CVC repair between January 2019 and November 2020 included. Data on associated cause for breakage and incidence of central line-associated bloodstream infections (CLABSIs) post repair were documented retrospectively. Descriptive statistics including medians, percentages, and frequencies were used. Forty children, 15 males (37%) and 25 females (63%), were identified. Fifteen of 40 (37.5%) patients underwent a total of 29 CVC repairs (0.1 repairs per 1000 catheter days); 8 of 15 (53%; 33% females) were <5 years of age. The most common reason for repair was CVC fracture by biting (41%) followed by catheter occlusion with intraluminal PN deposition (13.2%). Repair was successful in 100% cases. Only 1 patient had a confirmed CLABSI post repair (1/29 repairs; 3%) who presented 3 days late after the initial catheter breakage. Catheter salvage was successful with antibiotics. CVC repair in our cohort was very successful and infection rate after repair minimal. CVC repair rather than removal is recommended to preserve central venous access.

Case Study: An Analysis of a Sidewalk Trip and Fall after Repair Utilizing Photograph Scaling

Often, forensic human factors consultants are hired to work on a case after the incident area is altered, repaired, or destroyed. Photographs documenting the original incident area are critical in determining the causes of the injured parties’ fall. The case presented in this paper involves a trip and fall that occurred on the sidewalk of a large apartment complex. A human factors consultant analyzed the incident sidewalk post repair and was able to estimate the original condition of the sidewalk through the use of photograph scaling. In addition to an analysis of the human factors surrounding an incident, photograph scaling can be a useful tool in estimating elevation changes and determining the causes in a post repair trip and fall incident.

Developing balloon dilatation sizing guidance for anastomotic stricture dilatation following oesophageal atresia repair.

To develop guidance for the selection of balloon catheter size when performing an oesophageal dilatation for a stricture post oesophageal atresia repair. This was a single centre retrospective study at a paediatric tertiary centre. Dilatations were performed between 2015 and 2020. All dilatations were performed under general anaesthesia using balloon catheters under fluoroscopic guidance. Outliers were excluded using ROUT method and descriptive analysis was calculated to 1SD or IQR depending on the normality of data distribution. 97 patients underwent 341 dilatations. Median age was 19 months (37 weeks corrected gestation-17 years), median weight was 10.7 kg (2.6-72 kg). Balloon catheter sizes ranged from 6-8 mm to 18-20 mm. There was strong correlation between weight and balloon size (r = 0.8, p < 0.0001). There were 2 perforations (0.6%), both diagnosed intra-operatively and treated conservatively. From the results, weight recommendations were created for each balloon size. Fluoroscopic balloon dilatation is a safe and effective method to treat anastomotic stricture following oesophageal atresia repair. Previous studies have shown correlation between patient weight and oesophageal diameter. We propose guidance for using an appropriate balloon size based on patient's weight with the aim to reduce complication.

Management of systemic to pulmonary shunts and elevated pulmonary vascular resistance.

Repair of systemic to pulmonary shunts is timed to prevent the development of irreversible pulmonary vascular disease, including in patients with other factors contributing to pulmonary hypertension. This study assessed outcomes of an individualised strategy for managing patients with mild-moderately elevated pulmonary vascular resistance (PVR) deemed borderline eligible for repair. A retrospective chart review was conducted of patients with systemic to pulmonary shunts and baseline indexed PVR (PVRi) ≥3 WU·m2 treated at a single centre from 1 January 2005 to 30 September 2019. Data included demographics, World Health Organization functional class (WHO FC), medications and haemodynamic data at baseline and serial follow-up. 30 patients (18 females) met criteria for inclusion. Median age at diagnosis of pulmonary arterial hypertension was 1.3 years (range 0.03-54 years) and at surgery was 4.1 years (range 0.73-56 years). Median follow-up time was 5.8 years (range 0.2-14.6 years) after repair. Most patients received at least one targeted pulmonary arterial therapy prior to repair and the majority (80%) underwent fenestrated shunt closure. There was a significant decrease in mean pulmonary arterial pressure (mPAP) (p<0.01), PVRi (p=0.0001) and PVR/systemic vascular resistance (p<0.01) between baseline and preoperative catheterisation and a decrease in PVRi (p<0.005), mPAP (p=0.0001) and pulmonary to systemic flow ratio (p<0.03) from baseline to most recent catheterisation. WHO FC improved from FC II-III at baseline to FC I post repair in most patients (p<0.003). In carefully selected patients with systemic to pulmonary shunts and elevated PVR considered borderline for operability, the use of preoperative targeted therapy in conjunction with fenestrated or partial closure of intracardiac shunts is associated with improvement in WHO FC and clinical outcomes.

Predictors of the Need for Cerebrospinal Fluid Diversion in Patients with Myelomeningocele

Background There is no consensus about the optimal timing and the criteria for cerebrospinal fluid diversion in children with myelomeningocele (MM). The aim of this work is to assess the predictors of the need for cerebrospinal fluid diversion in patients with myelomeningocele to avoid the unnecessary shunting with its complications. Patients and Methods This prospective study included fifty infants with myelomeningocele that were managed in the Neurosurgical department in Ain shams University hospital and October health insurance hospital from August 2016 till December 2018. Results In this study, 22 (44%) patients needed a shunt surgery after repair of the myelomeningocele. The age at presentation was highly significant (HS) for the need for shunt (P-value 0.006), with median age of 4.25 months. There were 22 cases (44%) that crossed the head circumference percentile for age while 28 cases (56%) matched; This was statistically highly significant (P-value 0.000). All patients with lax anterior fontanel (AF) or with mild bulge didn’t need a shunt, while all patients with tense AF needed a shunt (P-value 0.000). It was noticed that persistent vomiting was a sensitive indicator of the increased intracranial pressure since it occurred in all the cases who required shunt, this was statistically highly significant (P-vale 0.000). Four cases (8% of the cases) suffered from cerebrospinal fluid leak from the myelomeningocele wound within the first week post MM repair. Conclusion AF status &amp; HC percentile for age represent the most reliable clinical signs to identify those who will need &amp; benefit from a CSF diversion. The VP shunt should be preserved for cases exhibiting progressive signs of increased ICP (moderate to severe AF bulge- HC crossing percentile for age), while cases showing ventriculomegaly on imaging without signs of increased ICP should be followed up.

Haemodynamic changes in visceral hybrid repairs of type III and type V thoracoabdominal aortic aneurysms

The visceral hybrid procedure combining retrograde visceral bypass grafting and completion endovascular stent grafting is a feasible alternative to conventional open surgical or wholly endovascular repairs of thoracoabdominal aneurysms (TAAA). However, the wide variability in visceral hybrid configurations means that a priori prediction of surgical outcome based on haemodynamic flow profiles such as velocity pattern and wall shear stress post repair remain challenging. We sought to appraise the clinical relevance of computational fluid dynamics (CFD) analyses in the setting of visceral hybrid TAAA repairs. Two patients, one with a type III and the other with a type V TAAA, underwent successful elective and emergency visceral hybrid repairs, respectively. Flow patterns and haemodynamic parameters were analysed using reconstructed pre- and post-operative CT scans. Both type III and type V TAAAs showed highly disturbed flow patterns with varying helicity values preoperatively within their respective aneurysms. Low time-averaged wall shear stress (TAWSS) and high endothelial cell action potential (ECAP) and relative residence time (RRT) associated with thrombogenic susceptibility was observed in the posterior aspect of both TAAAs preoperatively. Despite differing bypass configurations in the elective and emergency repairs, both treatment options appear to improve haemodynamic performance compared to preoperative study. However, we observed reduced TAWSS in the right iliac artery (portending a theoretical risk of future graft and possibly limb thrombosis), after the elective type III visceral hybrid repair, but not the emergency type V repair. We surmise that this difference may be attributed to the higher neo-bifurcation of the aortic stent graft in the type III as compared to the type V repair. Our results demonstrate that CFD can be used in complicated visceral hybrid repair to yield potentially actionable predictive insights with implications on surveillance and enhanced post-operative management, even in patients with complicated geometrical bypass configurations.

Abstract P1080: Periostin Is Induced During Cell-based Repair In The Sheep Model Of Myocardial Infarction

Cardiac disease is the leading cause of death worldwide. Stem cell-based therapy may improve patient outcomes following a myocardial infarction. Our laboratory is studying the mechanistic basis by which neonatal Islet-1 positive cardiovascular progenitor cells (CPC) facilitate post infarct repair in the sheep model of myocardial infarction. Here, we addressed the hypothesis that periostin (POSTN) is induced in the cardiovascular repair zone following neonatal Islet-1+ cell-based repair. POSTN promotes cardiomyocyte proliferation, recruitment of M2 macrophages, epithelial-mesenchymal transition (EMT), migration, and angiogenesis. We examined human neonatal Islet-1+ cardiovascular progenitor cell clones isolated from several patients to initially determine whether or not POSTN was expressed in these cells. All clones expressed POSTN as shown by RT-PCR. The size of the amplified transcripts was confirmed by gel electrophoresis and POSTN expression in these clones was further confirmed by RNA sequencing. We then examined POSTN expression in the cardiovascular repair zone following myocardial infarction and cell transplantation in sheep. Sheep neonatal Islet-1+ CPC clones were used in this model of allogeneic cell-based repair. A myocardial infarction was induced in three Western sheep by left anterior descending coronary artery ligation. Ten million neonatal sheep Islet1+ cardiac progenitor cell clones isolated from 9 day old sheep were injected into the area surrounding the infarct site 3-4 weeks post infarction. RNA was isolated from the cardiovascular repair zone two months after cell injection. The non-infarcted region of the left ventricle and the left ventricle of normal, non-infarcted sheep were used as controls. POSTN transcripts were significantly elevated in the cell-treated cardiovascular repair zone of all three sheep, as identified by qRT-PCR relative to controls. Periostin levels were elevated between 6 and 255 fold in the repair zone relative to the non-infarcted region of the heart. Our data shows that POSTN is expressed in human Islet-1+ neonatal cardiovascular progenitor cells and that POSTN levels are induced during cell-based cardiovascular repair in the sheep model of myocardial infarction.

Three-dimensional reconstruction reveals the correlation between the extent of alveolar clefts and secondary nasal deformity in adults.

This study aimed to explore the relationship between alveolar cleft and secondary nasal deformity post unilateral cleft lip repair in adults. A total of 27 patients aged 16-30 years old with unilateral secondary nasal deformity and alveolar cleft were included, 13 of whom underwent bone grafting. Spiral CT data of all preoperative and postoperative patients who had alveolar bone grafting were collected. Then, Mimics software was used for three-dimensional reconstruction to evaluate the correlation between the width, height, and volume of the alveolar cleft and those of the nasal deformity. The difference in nasal deformity before and after alveolar bone grafting was also explored. The width of the alveolar cleft was positively correlated with the difference in bilateral nostril floor width (P<0.05). As the effective depth of the alveolar cleft increased, the sub-alare inclination angle largened (P<0.05). However, no significant difference was found in the nasal deformity between before and after alveolar bone grafting. Alveolar cleft is closely related to secondary nasal deformities post unilateral cleft lip repair, especially nasal floor deformities. Alveolar bone grafting benefits adult patients for the improvement of secondary nasal deformities post unilateral cleft lip repair.

Patterns of Esophageal Motility and Bolus Transit in Children With Repaired Esophageal Atresia

Background: Esophageal dysmotility is common after esophageal atresia (EA) repair. Esophageal manometry (HRM) is the gold standard to investigate motility. We aim to characterize esophageal dysmotility and bolus transit for liquid and solids in children with repaired EA. Method: Retrospective analysis of HRM from children with repaired EA. Five liquid and 5 solid swallows per child were assessed for the standard manometric measurement and peristalsis pattern. Impedance tracings were used to assess bolus transit. Results: Ninety measurements were assessed from 9 patients, 44% Females. Mean age was 10.5 (±4.6) years. All children had dysphagia and anastomotic strictures were excluded. None of the children had intact peristalsis, 44.4% of the liquid swallows were failed, 33.3% fragmented and 22.2% ineffective. 44.4% of the solid swallows were failed, 44.4% fragmented and 11.1% ineffective. 33.3% had incomplete bolus transit in the whole esophagus, 44.4% in the upper and 11% in the lower esophagus. Mean peristalsis break for liquid was 7 cm (±2.1) and for solid was 5.9 cm (±3.2) P .025. Conclusion: Impaired esophageal motility is universal post EA repair. Failed and ineffective peristalsis predominate with incomplete bolus transit and large peristalsis breaks after liquid and solid swallows. HRM can provide clinical guidance, diagnostic and prognostic information post EA repair.

Neonatal Carotid Artery and Internal Jugular Vein Management Practices at Extracorporeal Membrane Oxygenation Decannulation: No Standard Approach

BackgroundThere are currently no commonly accepted standardized guidelines for management of cervical vessels at neonatal extracorporeal membrane oxygenation (ECMO) decannulation. This study investigates neonatal ECMO decannulation practices regarding management of the carotid artery and internal jugular vein, use of post-repair anticoagulation, and follow-up imaging. MethodsA survey was distributed to the 37 institutions in the Children's Hospitals Neonatal Consortium. Respondents reported their standard approach to carotid artery and internal jugular vein management (ligation or repair) at ECMO decannulation by their pediatric surgery and cardiothoracic (CT) surgery teams as well as post-repair anticoagulation practices and follow-up imaging protocols. ResultsThe response rate was 95%. Pediatric surgeons performed most neonatal respiratory ECMO cannulations (88%) and decannulations (85%), while all neonatal cardiac ECMO cannulations and decannulations were performed by CT surgeons. Pediatric surgeons overwhelmingly ligate both vessels (90%) while CT surgeons typically repair both vessels at decannulation (83%). Of the responding centers that repair, 28% (7) have a standard anticoagulation protocol after neck vessel repair. While 52% (13) of centers routinely image cervical vessel patency at least once post repair, most do not subsequently repeat neck vessel imaging. ConclusionsSignificant practice differences exist between pediatric and CT surgeons regarding the approach to cervical vessels at neonatal ECMO decannulation. For those centers that do repair the vessels there is little uniformity in post-repair anticoagulation or imaging protocols. There is a need to develop standardized cervical vessel management guidelines for neonatal ECMO patients and to study their impact on both short- and long-term outcomes. Level of EvidenceIV.

Median to Radial Nerve Transfer: An 8-Year Experience From a Lower-Middle Income Country

IntroductionWith an incidence of 2-16%, radial nerve palsy is one of the common forms of nerve injuries globally. Radial nerve palsy causes debilitating effects including loss of elbow extension, wrist drop and loss of finger extension. Reparative surgical pathways range from primary repair and neurolysis, to nerve grafting, nerve transfers, and tendon transfers. Due to ease of performance and acceptability and reproducibility of outcomes, tendon transfers are considered the gold standard of radial nerve palsy repair. However, independent finger function cannot be achieved and as such may not give truly desirable results. In lower-middle income countries, the question of nerve transfer versus tendon transfer for patients who are keen to get back to work is key. While tendon transfer recovery is faster, the functional loss is often considered devastating for fine hand function due to loss of grip secondary to lack of wrist and finger extension. In this study, we present our experience of performing median nerve transfers for radial nerve palsy in Pakistan. MethodsWe performed a retrospective case-series of patients undergoing median to radial nerve transfer for radial nerve palsy over a period of 6 y, from 2012 to 2019. Patients with radial nerve palsy were diagnosed via electromyography and nerve conduction studies. The procedure involved coapting the branches of the flexor carpi radialis and flexor digitorum superficialis (long and ring finger) nerves to the posterior interosseous nerve and extensor carpi radialis brevis, respectively. Patients were assessed using the Medical Research Council scale for muscle strength of wrist, finger and thumb extension separately at 1 y time. Our results were then compared to results from similar nerve transfer studies. ResultsWe operated on 10 right-hand dominant patients, eight males and two females with a median age of 33 y (6-63 y). four sustained injury to the right hand and six to the left. Causes of the injuries included road traffic accident (n = 3), firearm injury (n = 4), shrapnel (n = 1), iatrogenic injury (injection in deltoid region (n = 1) and fall (n = 1). Types of fracture included mid humerus fracture, fracture of the surgical neck of the humerus, and supracondylar fracture of the humerus. Median time to surgery since injury was 4 mo (1-8 mo). Independent wrist extension was M4+ in all patients and independent finger extension was M4+ in seven and M4-in two patients. However, a patient who presented late at 8 mo had poorer finger outcomes with extension at M2-. All patients had independent movement of fingers. ConclusionsNerve transfer is a reliable method of post traumatic nerve repair and reinnervation, particularly in lower-middle income countries, even in cases where the nerve damage is severe and extensive and up to 6 mo may have elapsed between injury and presentation. Timely median to radial nerve transfer is a highly recommended option for radial nerve palsy, with regular follow-ups and physical therapy added to ensure positive outcomes.

Surgical treatment of high-grade acute intramuscular hamstring tendon injuries in athletes leads to predictable return to sports and no re-injuries.

The purpose of this study was to assess the post-operative return to sport and re-injury rates following surgical repair of acute, first-time, high-grade intramuscular hamstring tendon injuries in high level athletes. Patients were identified using the databases of two sports surgeons. Once patients were identified their clinical notes and imaging were reviewed to confirm that all patients had injuries to the intramuscular portion of the distal aspect of the proximal biceps femoris tendon. All imaging was reviewed by an experienced musculoskeletal radiologist to confirm diagnosis. Surgery for such injuries was indicated in high-level athletes presenting with acute hamstring injuries. All patients were operated on within 4weeks. Outcomes included Tegner scores, return to sport, Lower Extremity Functional Score (LEFS), current hamstring symptoms and complications including re-injury. Eleven injuries (10 patients) were included in the study. All patients were male and Australian Rules Football players. Six patients were professional athletes and 4 semi-professional athletes. Median age was 24.5 (range 21-29) and median follow-up period was 33.7months (range; 16-65). 91% were British Athletic Muscle Injury Classification (BAMIC) 3c and 9% were BAMIC 4c. 91% were classed as MR2 and 9% as MR3 on the simplified four-grade injury classification. Athletes achieved return to play (RTP) at an average of 3.1months (SD 1.0) post repair. All but one patient achieved a Tegner score equal to pre-injury levels. Maximum LEFS was achieved by all patients. Minor pain scores (all with VAS < 1/10) on sciatic and functional stretch were recorded in 36% and 27% of patients respectively, with subtle neural symptoms (9%) and subjective tightness (36%) also noted. There were no surgical complications in our patient cohort. No patients had a re-injury or re-operation. Surgical repair of high-grade intramuscular tendon injuries of the biceps femoris hamstring muscle in athletes resulted in high levels of return to pre-injury sporting levels and no re-injuries. The intra-muscular tendon should be scrutinized when assessing hamstring injuries in elite sport and offer surgery in high-grade cases. IV.

Preoperative factors affecting the quality of life after arthroscopic rotator cuff repair: a prospective study

Rotator cuff tears are well known to cause significant pain and disability, having a marked impact on an individual's quality of life. This prospective study aimed to analyze the various patient factors and their impact on health-related quality of life (HrQoL) post arthroscopic rotator cuff repair (RCR). We prospectively analyzed 95 patients at one year and 81 patients at two years, with complete rotator cuff tear, who underwent arthroscopic repair of the same. The 36-Item Short Form Survey (physical and mental component score), visual analog scale (pain, function), and QuickDASH questionnaires were administered to all the patients preoperatively and at one- and two-year follow-ups. Relationships between various patient factors (age, gender, side, duration of symptoms, pseudoparalysis, diabetes mellitus [DM], type, and size of tear) and outcome measures were analyzed. All outcome parameters showed significant improvement at one- and two-year follow-ups. Patient factors, such as gender, tear type (traumatic vs degenerative), and DM, affected all outcome parameters and were significant even in the regression analysis model at a 2-year follow-up. Factors such as age and symptoms duration were significant only at 1-year follow-up, with older age and patients with symptoms > 6 weeks showing more disability. Side (dominant or nondominant), tear size, and pseudoparalysis do not affect outcomes. This study showed that arthroscopic RCR significantly improved HrQoL post arthroscopic RCRs. Factors independently affecting HrQoL were noted as gender, tear type, and DM. On the other hand, age, side involved, duration of symptoms, pseudoparalysis, and tear size had no independent effect on HrQoL at a two-year follow-up.

O-054 Live Births following Laparoscopic Caesarean Scar Niche Repair in patients with Secondary Infertility: A Self-Controlled Case Series and Literature Review.

Abstract Study question Does laparoscopic repair of caesarean scar niches as a treatment for secondary infertility improve live birth rates? Summary answer In our self-controlled case series, the laparoscopic repair of caesarean section niches in patients with secondary infertility has improved pregnancy and live birth rates. What is known already A niche is an iatrogenic myometrial defect due to abnormal tissue healing at a previous caesarean section scar site. Patients with a niche present with symptoms of vaginal discharge, abnormal uterine bleeding, chronic pelvic pain, dyspareunia and secondary infertility. As a niche is secondary to caesarean sections, rising caesarean section rates will lead to an increase in the rate of niche presentation and diagnosis. Study design, size, duration A retrospective review was performed of all women undergoing a hysteroscopy assisted laparoscopic niche repair between 2016 and 2023 at Guy’s and St Thomas’ Hospital in London. The primary outcome measure was live births. A literature review was performed to interrogate the currently available evidence on live birth rate following niche repair. Ultrasound images of the niche prior to and post repair, as well as intra-operative laparoscopic and hysteroscopic images and videos, are also presented. Participants/materials, setting, methods The cases were identified from the Assisted Conception Unit database. Only women who presented with secondary infertility with a diagnosis and repair of a niche were reported. Niche diagnosis was made in patients presenting with abnormal discharge, bleeding and fluid in the uterine cavity. Any incidental myometrial defect found on transvaginal ultrasound was also a diagnostic characteristic. Main results and the role of chance There are some reports in the literature on pregnancy outcome following niche repair. A scarcity of studies reporting specifically on live birth rates following repair, suggests this case series as unique. Eleven patients underwent caesarean section niche repair by two surgeons at our unit. The mean age at repair of the patients was 36. All patients had two or more years of subfertility on presentation, with a proportion having several failed in-vitro fertilisation (IVF) cycles prior to repair. The pregnancy rate, clinical pregnancy rate and live birth rate were 73% (8/11), 64% (7/11) and 45% (5/11) respectively. One patient had an early miscarriage at age 48 following repair and has not conceived again since. One patient underwent a second repair and is awaiting further investigations. Two patients have not yet conceived following repair, one of which had sickle cell disease, age factor and endometriosis. Our findings suggest a positive correlation between surgical repair of the niche and live births. However, this could be due to a strict selection criteria in a small sample size. In the two patients that did not have live births following repair, other factors of subfertility such as age, male factor and comorbidities could also play a role. Limitations, reasons for caution The small sample size can lead to selection bias and impairs the external validity of our findings. The likelihood of random error is high. Lack of a control group prevents any comparisons. Furthermore, all repairs were performed by the two surgeons which introduces operator bias. Outcome assessors were not blinded. Wider implications of the findings Subfertility secondary to niches is likely to be a growing challenge as caesarean section rates continue to increase. Our study suggests that surgical repair may improve live birth rates. We present our findings to augment the current international data on live birth rates following niche repair. Trial registration number not applicable