Primary Surgical Indication Research Articles

Mechanical Thromboprophylaxis and Hospital-Acquired Venous Thromboembolism Among Critically Ill Adolescents: A U.S. Pediatric Health Information Systems Registry Study, 2016-2023.

To estimate the rate of mechanical thromboprophylaxis (mTP) prescription among critically ill adolescents using a multicenter administrative database and determine whether mTP prescription is inversely associated with hospital-acquired venous thromboembolism. Multicenter, observational, retrospective study of the Pediatric Health Information Systems (PHIS) Registry cohort, January 2016 to December 2023. Thirty PICUs located within quaternary pediatric referral centers in the United States. Critically ill children 12-17 years old, excluding encounters with a principal diagnosis at admission of venous thromboembolism. mTP prescription within the first 24 hours of hospitalization. A total of 107,804 children met the study criteria, of which 21,124 (19.6%) were prescribed mTP. Hospital center prescribing rates ranged from 1.4% to 65.4% and decreased by 1.6% per year from 28.2% in 2016 to 17.1% in 2023. As compared with those without mTP, those with mTP more frequently had a concurrent central venous catheter (17.2% vs. 9.4%, p < 0.001), underwent invasive mechanical ventilation (37.4% vs. 24.8%, p < 0.001), were admitted for a primary surgical indication (30.9% vs. 12.7%, p < 0.001), and experienced a longer median duration of hospitalization (7 [interquartile range (IQR): 4-15] vs. 4 [IQR: 2-9] d, p < 0.001). Hospital-acquired venous thromboembolism occurred in 2.7% of the study sample and was more common among those with, as compared with without, prescription of mTP (4% vs. 2.4%, p < 0.001). In multivariable logistic regression models for hospital-acquired venous thromboembolism adjusting for salient prothrombotic risk factors, we failed to identify an association between mTP and greater odds of hospital-acquired venous thromboembolism (HA-VTE) among low-, moderate-, and high-risk tiers. However, we cannot exclude the possibility of 17-50% greater odds of HA-VTE in this population. In the multicenter PHIS cohort, 2016-2023, the prescribing patterns for mTP among critically ill adolescents showed a low rate of mTP prescription (19.6%) that varied widely across institutions, decreased annually over the study period by 1.6%/year, and was not independently associated with HA-VTE risk reduction.

Open Approach for Repair of Tibial PCL Avulsion

Background: Tibial avulsion of the posterior cruciate ligament (PCL) often requires operative fixation, which frequently results in successful outcomes if identified acutely. Open or arthroscopic techniques are most commonly used. Indications: Primary surgical indications for open fixation include acute tibial avulsion of the PCL. Secondary indications include grade 2 to grade 3 posterior drawer test and radiographic posterior subluxation of the tibia. Ideally, the joint space and articular cartilage should be well preserved. Technique Description: In the simplified approach initially described by Burks and Schaffer, the patient is placed prone, and an inverted L-shaped incision is made over the posteromedial corner of the knee. A plane is developed between the medial head of the gastrocnemius and the semimembranosus down to the knee joint capsule. The gastrocnemius is retracted laterally to protect neurovascular structures and a vertical capsulotomy is performed. The tibial attachment of the PCL is reduced and held with K (Kirschner) wires and then fixated with screw and washer. Results: Six months post operation, our patient achieved full active and passive range of motion with a stable posterior drawer test. He returned to work without difficulty. Multiple studies have shown success with open PCL fixation and decreased rates of arthrofibrosis when compared with arthroscopic approach. In this case, the patient did not develop arthrofibrosis. Discussion/Conclusion: PCL tibial avulsions can be safely treated with an open approach. Contrary to other ligaments that favor reconstruction over repair, PCL avulsions may be better treated with early repair, so it is important to avoid delay in intervention. The most common complication in both open and arthroscopic approaches is arthrofibrosis, which is less common in the open approach. Early range of motion is encouraged to prevent arthrofibrosis. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Determination of Lesion Localization with Intraoperative Gamma Probe in the Presence of a Primary Parathyroid Lesion with Early Wash-Out in Radionuclide

Objective: In this research, we aimed to evaluate the success of the minimally invasive surgical method performed with intraoperative gamma-probe despite early wash-out in solitary primary parathyroid lesions and to contribute to the literature on this subject. Methods: This retrospective study included 48 adult patients diagnosed with hyperparathyroidism, with an average parathormone value of 105 pg/mL (range: 82-127 pg/mL). Radionuclide imaging was conducted using Tc-99m sestamibi and Tc-99m-pertechnetate. Minimally invasive surgery with an intraoperative gamma probe was planned for patients with primary parathyroid lesions and surgical indications. At the conclusion of the operation, count equalization was observed in all four quadrants. Results: Minimally invasive surgery was performed on 42 patients with the assistance of an intraoperative gamma probe. In 6 patients, the procedure was extended to conduct a four-gland exploration due to early wash-out. Each patient had one pathological lesion removed, all of which were histopathologically confirmed as parathyroid adenomas. Among the 6 patients with extended surgeries, 4 experienced early wash-out, and all 6 had been diagnosed with multinodular goiter. Conclusion: In cases with primary hyperparathyroidism, it is aimed to remove the pathological lesion with minimally invasive surgery and leave the glands that continue their normal function in place. Preoperative localization methods help the surgeon in this regard, but pathologies in the surrounding tissue can reduce the success of minimally invasive surgery.

Bovine Acellular Dermal Matrix-Based Breast Reconstruction in Previously Irradiated Breasts: Complications and Outcomes From a Single-Center Experience.

Radiation therapy is considered today an integral part of the management of breast cancer. However, radiotherapy significantly increases the incidence of total complications in breast reconstruction. Several procedures have been adopted to reduce complication rates in irradiated fields, including the use of acellular dermal matrices (ADMs). We conducted a retrospective analysis of our single-center experience with ADM-assisted implant-based reconstruction or revision surgeries for capsular contracture treatment in irradiated breasts. We divided our population into 4 groups based on prior surgical history: group A (previous quadrantectomy), group B (previous mastectomy and expander reconstruction), group C (previous mastectomy and implant reconstruction), and group D (prior quadrantectomy followed by mastectomy and implant reconstruction). At the European Oncology Institute in Milan, Italy, between June 2017 and April 2019, we identified 84 patients for a total of 86 irradiated breasts reconstructed with implant and ADM. We observed a total of 12 reconstructive failure, with the highest rate of failure in group B (16.6%) and in group D (15.38%). Overall, we recorded 22 total complications (24.4%): 12 major complications and 10 minor complications. The most common complication was infection, with 9 cases (10.4%), 6 of which were classified as severe and required implant removal. In group B, we observed the highest complication rate, both major and minor, with 7 of 42 patients (16.6%) experiencing each. Before reconstruction with ADM, the Baker grade ranged from 3 to 4, with a mean of 3.25. At the 2-year follow-up, the Baker grade ranged from 1 to 4, with a mean of 1.9. Surgeons were highly satisfied with the aesthetic result in 72.1% of cases, moderately in 8.1% and unsatisfied in 5.81%, and in 13.9%, the outcome was not assessable because of reconstructive failure. The worst aesthetic result was in group B. We observed significant reduction in capsular contracture in revision surgeries despite a moderately high rate of complications in previous quadrantectomy and radiotherapy. In our experience, breast reconstruction with implant and ADM is not the primary surgical indication in case of prior irradiation, but it can be considered as a valid alternative with reasonable safety profile, to be used in selected cases.

Understanding Herpes Simplex Virus Type 1 Versus Herpes Simplex Virus Type 2 Encephalitis After Neurosurgery: A Case Series and Literature Review.

Abstract Background: Herpes simplex virus encephalitis (HSVE) is a rare post-operative infection that can be fatal if treatment is delayed. Herpes simplex virus type 1 (HSV-1) is a more common cause of encephalitis than herpes simplex virus type 2 (HSV-2), however, a significant overlap exists. The goal of this project was to understand the frequency and trend of HSVE after neurosurgery through a case series at our institution and in the literature with a focus on comparing HSV-1 versus HSV-2. Patients and Methods: A literature review of all published cases and case series of HSVE after neurosurgery was performed. Descriptive statistics comparing HSV-1 and HSV-2 encephalitis were computed. Data on demographics, symptoms, surgery, treatment, immunosuppression, imaging findings, steroids, and mortality were collected. Results: We identified 55 total cases of HSVE post-neurosurgery. These included 28 cases of HSV-1, 10 cases of HSV-2, and 17 cases of HSV-unspecified encephalitis. There were no differences in age, gender, symptoms, surgery, or latency between surgery and symptom onset between HSV-1 and HSV-2. Mortality was higher with HSV-1 versus HSV-2 although not statistically significant. The primary surgical indication varied substantially between HSV-1 and HSV-2. Conclusions: Herpes simplex virus encephalitis is often overlooked in the setting of encephalitis after surgery. A high index of suspicion is needed to prevent a delay in treatment.

Gastro-Intestinal Disorders and Micronutrient Deficiencies following Oncologic Esophagectomy and Gastrectomy.

Primary surgical indications for the esophagus and stomach mainly involve cancer surgeries. In recent years, significant progress has been made in the field of esogastric surgery, driven by advancements in surgical techniques and improvements in perioperative care. The rate of resectability has increased, and surgical strategies have evolved to encompass a broader patient population. However, despite a reduction in postoperative mortality and morbidity, malnutrition remains a significant challenge after surgery, leading to weight loss, muscle mass reduction, and deficiencies in essential nutrients due to digestive complications. Malnutrition worsens quality of life and increases the risk of tumor recurrence, significantly affecting prognosis. Nevertheless, the nutritional consequences following surgery are frequently overlooked, mainly due to a lack of awareness regarding their long-term effects on patients who have undergone digestive surgery, extending beyond six months. Micronutrient deficiencies are frequently observed following both partial and total gastrectomy, as anticipated. Surprisingly, these deficiencies appear to be similarly prevalent in patients who have undergone esophagectomy with iron, vitamins A, B1, B12, D, and E deficiencies commonly observed in up to 78.3% of the patients. Recognizing the distinct consequences associated with each type of intervention underscores the importance of implementing preventive measures, early detection, and prompt management.

Functional outcomes correlate with sagittal spinal balance in degenerative lumbar spondylolisthesis surgery

BACKGROUND CONTEXTDegenerative lumbar spondylolisthesis (DLS) is a debilitating condition associated with poor preoperative functional status. Surgical intervention has been shown to improve functional outcomes in this population though the optimal surgical procedure remains controversial. The importance of maintaining and/or improving sagittal and pelvic spinal balance parameters has received increasing interest in the recent DLS literature. However, little is known about the radiographic parameters most associated with improved functional outcomes among patients undergoing surgery for DLS. PURPOSETo identify the effect of postoperative sagittal spinal alignment on functional outcome after DLS surgery. STUDY DESIGNRetrospective cohort study. PATIENT SAMPLETwo-hundred forty-three patients in the Canadian Spine Outcomes and Research Network (CSORN) prospective DLS study database. OUTCOME MEASURESBaseline and 1-year postoperative leg and back pain on the 10-point Numeric Rating Scale and baseline and 1-year postoperative disability on the Oswestry Disability Index (ODI). METHODSAll enrolled study patients had a DLS diagnosis and underwent decompression in isolation or with posterolateral or interbody fusion. Global and regional radiographic alignment parameters were measured at baseline and 1-year postoperatively including sagittal vertical axis (SVA), pelvic incidence and lumbar lordosis (LL). Both univariate and multiple linear regression was used to assess for the association between radiographic parameters and patient-reported functional outcomes with adjustment for possible confounding baseline patient factors. RESULTSTwo-hundred forty-three patients were available for analysis. Among participants, the mean age was 66 with 63% (153/243) female with the primary surgical indication of neurogenic claudication in 197/243 (81%) of patients. Worse pelvic incidence-LL mismatch was correlated with more severe disability [ODI, 0.134, p<.05), worse leg pain (0.143, p<.05) and worse back pain (0.189, p<.001) 1-year postoperatively. These associations were maintained after adjusting for age, BMI, gender, and preoperative presence of depression (ODI, R2 0.179, β, 0.25, 95% CI 0.08, 0.42, p=.004; back pain R2 0.152 (β, 0.05, 95% CI 0.022, 0.07, p<.001; leg pain score R2 0.059, β, 0.04, 95% CI 0.008, 0.07, p=.014). Likewise, reduction of LL was associated with worse disability (ODI, R2 0.168, β, 0.04, 95% CI -0.39, -0.02, p=.027) and worse back pain (R2 0.135, β, -0.04, 95% CI -0.06, -0.01, p=.007). Worsened SVA correlated with worse patient reported functional outcomes (ODI, R2 0.236, β, 0.12, 95% CI 0.05, 0.20, p=.001). Similarly, an increase (worsening) in SVA resulted in a worse NRS back pain (R2 0.136, β, 0.01, 95% CI .001, 0.02, p=.029) and worse NRS leg pain (R2 0.065, β, 0.02, 95% CI 0.002, 0.02, p=.018) scores regardless of surgery type. CONCLUSIONSPreoperative emphasis on regional and global spinal alignment parameters should be considered in order to optimize functional outcome in lumbar degenerative spondylolisthesis treatment.

Intraoperative Complications With Vitreous Biopsy for Molecular Proteomics.

To study the incidence of intraoperative complications while collecting a vitreous sample for proteomic biomarker analyses during small-gauge pars plana vitrectomy (PPV). A retrospective case series was assembled from the surgical logs and charts of patients who underwent 23-, 25-, and 27-gauge PPV along with an undiluted vitreous biopsy. Primary surgical indication and detailed operative reports were reviewed. Complications specific to vitreous biopsy were assessed while complications related to vitrectomy in general without biopsy were not tabulated. In 1190 eyes that underwent vitreous biopsy, the most common indications for PPV were rhegmatogenous retinal detachment (24.2%), epiretinal membrane (ERM) (21.7%), vitreous hemorrhage (11.0%), uveitis (8.3%), and macular hole (7.5%). An adequate sample of 0.5 cc to 1.0 cc was obtained in all cases. There was one sclerotomy break associated with biopsy, but no instances of lens touch, retinal contusion, retinal detachment, or intraocular hemorrhage. Undiluted vitreous biopsy obtained at the time of small-gauge vitrectomy is a generally safe procedure and may be considered for collection of samples for proteomic analysis. [Ophthalmic Surg Lasers Imaging Retina 2023;54:32-36.].

Jehovah's witness head and neck free flap reconstruction patient outcomes

BackgroundJehovah's Witnesses are members of a Christian religious denomination that rejects the transfusion of whole blood and component blood products. Given new transfusion-free strategies, Jehovah's Witness patients are undergoing free flap reconstructions with increased regularity. However, outcome data remains limited. With this study, we sought to examine post-operative outcomes in Jehovah's Witness patients undergoing free flap reconstruction of the head and neck, compare their outcomes to non-Jehovah's Witness patients, and enumerate strategies to enhance the safety of transfusion-free surgery. MethodsA retrospective chart review was carried out on 10 patients who identified as Jehovah's Witness and 63 patients who did not. Demographic information, pre-operative laboratory values, peri-operative resuscitative interventions, and peri-operative outcome measures were compiled. Descriptive data analysis, Mann-Whitney, Chi-square tests, and multivariate analysis were used. ResultsJehovah's Witness patients were significantly older than non-Jehovah's Witness patients (p = 0.03) and had significantly higher ASA scores (p = 0.009). Head and neck cancer was the primary surgical indication in both groups (p = 0.71). Jehovah's witness patients have significantly less intraoperative blood loss (p = 0.011) and lower post-operative hemoglobin (p = 0.002) compared to non-Jehovah's Witness patients. While Jehovah's Witness patients had significantly higher rates of severe anemia (p = 0.014), there was no significant difference between the two groups in other post-operative complications and readmission rates even in a multivariate analysis accounting for age and ASA score. ConclusionsFree flap microvascular reconstruction can be reliably performed on Jehovah's Witness head and neck patients without an increased risk of complication. Policies such as the use of non-blood volume expanders, albumin, Epogen, perioperative iron supplementation, cell saver and acute normovolemic hemodilution are key to ensuring good outcomes.

Endoscopic Endonasal Transsphenoidal Surgery for Patients with Prolactinomas: Indications and Outcomes

Clinical paradigms and consensus recommend dopamine agonists (DAs) as the primary treatment for prolactinomas. However, medically treated patients also encounter challenges such as DA resistance, intolerable side effects, and recurrence of hyperprolactinemia after DA withdrawal. Technical advances in transsphenoidal resection, with an endoscopic endonasal approach, have led to improved visualization of tumor, decreased postoperative morbidity, and shortened length of stay. We examined the indications and outcomes in patients with prolactinomas who underwent surgical resection at our center. A retrospective analysis was performed of 60 consecutive patients with prolactinomas who underwent endoscopic endonasal transsphenoidal resection between August 2010 and July 2019 and were followed by the same multidisciplinary team. Women comprised 73% of surgical cases, and 60% of the tumors were macroadenomas. The most common primary surgical indication was patient preference (26.6%) followed by DA intolerance (25%) and DA failure (18.3% inadequate shrinkage, 15% persistent hyperprolactinemia, 11.7% both). Gross total resection was noted in 83% and length of stay was 1 day in 92% of patients. Early remission (postoperative day 1 normalization of prolactin off DA therapy) was seen in 71% of all patients, 91% of microadenomas, 56% of macroadenomas, 65% of Knosp grade 0-2 macroadenomas, and 75% of macroadenomas operated on with expectation of a cure. Only 3 patients had recurrence, at 4.3, 3.3, and 1.6 years of follow-up, respectively. Endoscopic endonasal resection is a viable option for management of patients with prolactinomas in the setting of a high-volume pituitary center, with minimal postoperative complications.

Computed Tomography Intraoperative Navigation in Spinal Surgery: Assessment of Patient Radiation Exposure in Current Practices.

Patient radiation exposure associated with the use of computed tomography (CT) navigation during spinal surgeries was widely compared with other intraoperative imaging techniques. The aim of this study is to explore the use of navigation with regard to current spinal surgery practices and the technical limitations of such imaging systems. Dosimetric data from 101 patients who underwent intraoperative, CT-navigated spine surgery were retrospectively collected. The study population was divided into 3 groups according to the primary surgical indication. The number of CT image acquisitions per patient, the field length, and the time of exposure per acquisition during a single surgery were compared as well as the radiation dose emitted to patients. Dose-length products (DLP) per acquisition were 678.52, 656.8, and 649.36 mGy·cm with no significant difference for spinal deformity (SD), degenerative disease (DD), and vertebral fracture (VF) procedures, respectively. Analyzing the number of CT image acquisitions per patient revealed that repeated intraoperative scans were often performed for patients who were suffering from an SD due to technical limitations of the navigation. As a consequence, the cumulative dose was higher in the SD group (DLP total = 1175 mGy·cm) than in the DD (DLP total = 762.74 mGy·cm) and VF (DLP total = 649.36 mGy·cm) groups. CT navigation is an efficient intraoperative imaging technique that reduces the rate of surgical complications, but its technical limitations lead to an increased risk of patient radiation exposure, especially for complex surgeries where multiple scanning acquisitions are needed. To avoid patient's overexposure, spine surgeons should minimize the number of intraoperative acquisitions while considering the complexity of the surgery and the limitations of the guidance system. The use of dual guidance systems has also to be considered according to the benefit-risk balance between patient's outcomes and radiation dose exposure.

Predicting mortality in nonsurgical patients beforecannulation for veno-arterial extracorporeal life support: Development and validation of the LACT-8 score.

We sought to derive and validate a model to predict inpatient mortality after veno-arterial extracorporeal life support (VA-ECLS) based on readily available, precannulation clinical data. Refractory cardiogenic shock supported by VA-ECLSis associated with high morbidity and mortality. VA-ECLS cases at our institution from January 2014 through July 2019 were retrospectively reviewed. Exclusion criteria were cannulation: (1) at another institution; (2) for primary surgical indication; or (3) for extracorporeal cardiopulmonary resuscitation. Multivariable logistic regression compared those with and without inpatient mortality. Multiple imputation was performed and optimism-adjusted area under the curve (oAUC) values were computed. VA-ECLS cases from August 2019 through November 2020 were identified as a validation cohort. In the derivation cohort (n = 135), the final model included Lactate (mmol/L), hemoglobin (g/dl; Anemia), Coma (Glasgow Coma Scale [GCS] < 8) and resusciTATEd cardiac arrest (LACTATE score; oAUC = 0.760). In the validation cohort (n = 30, LACTATE showed similar predictability [AUC = 0.710]). A simplified (LACT-8) score was derived by dichotomizing lactate (>8) and hemoglobin (<8) and summing together the number of components for each patient. LACT-8 performed similarly (derivation, oAUC = 0.724; validation, AUC = 0.725). In the derivation cohort, both scores outperformed SAVE (oAUC = 0.568) and SOFA (oAUC = 0.699) scores. A LACT-8 ≥ 3 had a specificity for mortality of 97.9% and 92.9%, in the derivation and validation cohorts, respectively. The LACT-8 score can predict inpatient mortality prior to before cannulation for VA-ECLS. LACT-8 can be implemented utilizing clinical data without the need for an online calculator.

Pre-Operative Risk Factors for Anastomotic Leak after Bowel Resection for Endometriosis

Study Objective Determine the preoperative risk factors for anastomotic leak after bowel resection during non-emergent endometriosis related surgery. Design Retrospective population level case-control study. Setting Analysis of American College of Surgeons National Surgical Quality Improvement Program (NSQIP) dataset. Patients or Participants Patients undergoing a bowel resection for endometriosis related surgery from 2014-2019 at a NSQIP participating site. International Classification of Diseases codes (ICD 9/10) were utilized to identify bowel resection cases with a primary surgical indication for endometriosis. Interventions Evaluation of patient demographics, perioperative management strategies and surgical technique that were associated with the occurrence of an anastomotic leak following bowel resection for endometriosis. Measurements and Main Results 289 bowel resection cases (non-emergent, benign) for endometriosis were identified. Anastomotic leak occurred in 9 cases (3.11%). There were no baseline patient demographics, perioperative management strategies (mechanical bowel preparation, preoperative oral antibiotics) or differences in surgical technique (laparoscopic vs open) that demonstrated a statistically significant association with an anastomotic leak. Multivariable logistic analysis identified that an increased preoperative albumin level was associated with a reduced risk of anastomotic leak with an adjusted odds ratio of 0.11 (95% CI 0.01-0.95). Conclusion The majority of population level data for anastomotic leak after bowel resection has included mainly data involving surgery for cancer. Data on complications after bowel resection for endometriosis has primarily been published form single site, single surgeon case series. This study using multicenter national data identified decreased preoperative albumin level as a risk factor for anastomotic leak after bowel resection for endometriosis. Further prospective studies are warranted to identify possible optimization strategies before bowel resection for endometriosis, with a particular focus on nutritional status atop perioperative management strategies and surgical techniques. Determine the preoperative risk factors for anastomotic leak after bowel resection during non-emergent endometriosis related surgery. Retrospective population level case-control study. Analysis of American College of Surgeons National Surgical Quality Improvement Program (NSQIP) dataset. Patients undergoing a bowel resection for endometriosis related surgery from 2014-2019 at a NSQIP participating site. International Classification of Diseases codes (ICD 9/10) were utilized to identify bowel resection cases with a primary surgical indication for endometriosis. Evaluation of patient demographics, perioperative management strategies and surgical technique that were associated with the occurrence of an anastomotic leak following bowel resection for endometriosis. 289 bowel resection cases (non-emergent, benign) for endometriosis were identified. Anastomotic leak occurred in 9 cases (3.11%). There were no baseline patient demographics, perioperative management strategies (mechanical bowel preparation, preoperative oral antibiotics) or differences in surgical technique (laparoscopic vs open) that demonstrated a statistically significant association with an anastomotic leak. Multivariable logistic analysis identified that an increased preoperative albumin level was associated with a reduced risk of anastomotic leak with an adjusted odds ratio of 0.11 (95% CI 0.01-0.95). The majority of population level data for anastomotic leak after bowel resection has included mainly data involving surgery for cancer. Data on complications after bowel resection for endometriosis has primarily been published form single site, single surgeon case series. This study using multicenter national data identified decreased preoperative albumin level as a risk factor for anastomotic leak after bowel resection for endometriosis. Further prospective studies are warranted to identify possible optimization strategies before bowel resection for endometriosis, with a particular focus on nutritional status atop perioperative management strategies and surgical techniques.

A NEWLY ESTABLISHED SURGICAL SEPTAL MYECTOMY PROGRAM FOR OBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY IN BRITISH COLUMBIA: EARLY CLINICAL AND ECHOCARDIOGRAPHIC RESULTS

<h3>BACKGROUND</h3> Surgical septal myectomy is an effective treatment for drug-refractory heart failure symptoms in patients with obstructive hypertrophic cardiomyopathy (HCM). Given the low case volume, current practice guidelines recommend HCM surgery to be performed at experienced HCM centres for optimal outcomes. To meet the growing need for septal reduction therapy in British Columbia, a dedicated septal myectomy program was established in September 2019 as part of the provincial HCM referral centre at St. Paul's Hospital in Vancouver. Concerted efforts were made to centralize the case volume and develop standardized perioperative protocols. In this study, we report the early clinical and echocardiographic results of our initial case series. <h3>METHODS AND RESULTS</h3> We retrospectively reviewed our initial experience with septal myectomy performed for symptomatic obstructive HCM at our institution between September 2019 and December 2020. Patients whose primary surgical indication was unrelated to obstructive HCM were excluded. Among 45 patients (62±10 years of age; 49% male) reviewed, 69% had isolated septal myectomy while 31% had planned concomitant procedures (CABG, AVR, and/or MV repair/replacement). Intraoperative provocation with inducible PVCs and isoproterenol infusion, with simultaneous direct needle measurement of LVOT gradient, was performed before and after cardiopulmonary bypass. All operations were performed by one surgeon (JMK) with support of another senior surgeon (JA). All patients underwent comprehensive preoperative assessment by a dedicated HCM cardiologist (KO). Preoperatively, 85% of patients were in NYHA class III or IV while 15% were in NYHA class II. Preoperative echocardiography demonstrated resting LVOT gradient of 65±39 mmHg and Valsalva-provoked gradient of 94±38 mmHg. Five patients had SAM-related 3 or 4+ mitral regurgitation (MR). First postoperative echocardiography at 1-3 months showed significant reduction of resting LVOT gradient to 8±6 mmHg and Valsalva-provoked gradient to 11±8 mmHg. None of the patients had significant SAM or residual 3 or 4+ MR. At time of postoperative follow-up at 3-4 months, 98% of patients had improvement in NYHA functional class, with 76% in class I and 24% in class II. There was no mortality. There was no iatrogenic ventricular septal defect, and none of the patients required unplanned mitral valve repair/replacement. There was no postoperative CVA, AKI requiring dialysis, or complete heart block requiring permanent pacemaker. One patient required mediastinal re-exploration for bleeding in immediate postoperative period. <h3>CONCLUSION</h3> Our experience demonstrates that, with appropriate planning and support, it is feasible for new HCM surgical programs to achieve safe and desired operative results comparable with those of experienced high-volume centres.

Patients with infective endocarditis referred to Division of Cardiovascular and Pulmonary Diseases at Oslo University Hospital between 2014 and 2017

Objectives. Infective endocarditis has potential for severe complications and high mortality. The number of patients with prosthetic valves has risen, and an increase in incidence of infective endocarditis has been suggested. We aimed to examine the epidemiology, etiology, treatment and outcome of patients admitted to Division of Cardiovascular and Pulmonary Diseases at Oslo University Hospital, and explore changes in incidence over the last four years. Design. We conducted a retrospective study including all patients admitted to a tertiary hospital in Oslo, Norway, and diagnosed with infective endocarditis according to ICD-10 between 2014 and 2017. Results. Two hundred and ninety-one patients ≥18 years were included (61.3 ± 13.8 years, 75.6% men). 36.4% had previous valve surgery and this proportion decreased during the period. The aortic valve was most commonly affected (51.9%). Streptococci were the most frequent microorganisms (35.1%), while staphylococci accounted for 26.8%. 81.8% were treated surgically, at a median of 6.5 (0–120) days after admission. Hemodynamic changes or instability was the primary surgical indication (51.5%). One-year mortality was 20.6%. Surgery within a week after admission resulted in poorer 1-year prognosis than surgery after one week. Also, surgically treated patients who died were significantly older than those who survived. Conclusions. In this cohort, streptococci were the most common causative microorganism. Approximately, one-third of the patients had prosthetic valves. Mortality remains high, underscoring the need for continuous medical awareness. A high number of streptococcus infections in this cohort suggest dental origin.

Decreased early complication rates associated with rheumatoid arthritis compared to alternate indications for total elbow arthroplasty

Abstract: Background Rheumatoid arthritis is currently seen as the primary surgical indication for total elbow arthroplasty (TEA). Nevertheless, surgical indications continue to expand accounting for greater TEA case volumes. Despite evolving trends, very few data describes complications associated with specific surgical indication of TEA. Methods We analyzed The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for individuals that received a TEA from 2006 to 2015. Surgical indications and 30-day postoperative complication data for patients treated as inpatients at participating hospitals was obtained. Results 317 patients were identified for analysis. 22.1% of individuals received TEA for rheumatoid arthritis. 52 total adverse events were reported for all patients undergoing TEA. Rheumatoid arthritis patients experienced significantly lower rates of overall adverse events (8.57% versus 18.62%, p= 0.045). Conclusion Rheumatoid arthritis patients that undergo TEA are significantly less likely to develop a 30 day post-operative complication than patients who receive TEA for other reasons.

Comparison of Parkinson’s Disease Patients’ Characteristics by Indication for Deep Brain Stimulation: Men Are More Likely to Have DBS for Tremor

<strong>Background:</strong> We investigated whether the characteristics of Parkinson’s disease (PD) patients differ based on the primary indication for deep brain stimulation (DBS). <strong>Methods:</strong> We reviewed data for 149 consecutive PD patients who underwent DBS at the University of Virginia. Patients were categorized based on primary surgical indication, and clinical characteristics were compared between groups. <strong>Results:</strong> Twenty-nine (93.5%) of 31 PD patients who underwent DBS for medication refractory tremor were men, and 66 (62.3%) of 106 PD patients who underwent DBS for motor fluctuations were men (p = 0.001). Other primary indications for DBS were tremor and fluctuations (<em>n</em> = 5), medication intolerance (<em>n</em> = 5), and dystonia (<em>n</em> = 2). <strong>Discussion:</strong> Patients who underwent DBS for medication refractory tremor were predominantly men, while patients who had DBS for motor fluctuations approximated the gender distribution of PD. Possible explanations are that men with PD are more likely to develop medication refractory tremor or undergo surgery for medication refractory tremor in PD compared to women.

Outcomes of Using Sutureless, Scleral-Fixated Posterior Chamber Intraocular Lenses

ABSTRACTBackground. Implantation of sutureless, scleral-fixated posterior chamber intraocular lenses (SSFIOL) is a promising option in the surgical management of patients unable to undergo standard cataract surgery due to insufficient capsular support. The purpose of this study was to describe the indications, visual outcomes and complications of SSFIOL implantation.Methods. Retrospective, investigational cohort study of 112 consecutive SSFIOL implantations between July 2013 and August 2017. Pre-operative ocular morbidity, operative indications, postoperative outcomes, complications, and reinterventions were summarized. Visual and refractive outcomes were compared between the pre- and latest postoperative visit using Wilcoxon signed-ranked test.Results. Mean follow-up: 13.0 ± 10.4 months. Primary surgical indication was dislocated IOL due to zonular weakness (77 eyes (68.8%)). At latest follow-up, there was improvement in uncorrected visual acuity (1.3 ± 0.8 to 0.64 ± 0.60 logMAR, p < .01), best-corrected visual acuity (BCVA) (0.6 ± 0.5 logMAR to 0.36 ± 0.40 logMAR, p < .01). Postoperative complications included transient IOP elevation >30 mmHg (26.8%), cystoid macular edema (CME) (14.3%), transient hypotony (13.4%), iris capture (12.5%), uveitis-glaucoma-hyphema (UGH) syndrome (11.6%), vitreous hemorrhage (VH) (6.3%). Operative reinterventions included SSFIOL exchange (3.6%), SSFIOL repositioning (5.4%), SSFIOL removal (2.7%). Ten (8.9%) patients required multiple re-interventions.Conclusion. SSFIOL implantation is a reasonable option for eyes with inadequate capsular support, resulting in visual improvement in most patients. Many of the surgical complications were related to a floppy iris-lens diaphragm (UGH syndrome, iris capture), which were predisposed in eyes with complex pathology. Surgical modifications can be made to minimize the iris-related complications.

Current Trends in Management of Nonsyndromic Unilateral Coronal Craniosynostosis: A Cross-sectional Survey.

Background:Although the natural history of nonsyndromic unilateral coronal craniosynostosis has been extensively described, optimal management remains controversial due to lack of Level 1 evidence. This study aims to assess the current state of practice among craniofacial surgeons.Methods:Ninety-four craniofacial surgeons were approached to complete a survey consisting of 15 questions. Data were collected assessing surgeons’ primary surgical indication, timing of intervention, preoperative imaging, and choice of technique for patients presenting with nonsyndromic unilateral coronal craniosynostosis. Choice of technique and timing of intervention in case of recurrence were also investigated.Results:After 5 mailings, the response rate was 61%. The combination of both appearance and raised intracranial pressure was the primary indication for treatment for 73.2% of surgeons. Preoperative CT scan of the skull was “always” performed by 70.1% of respondents. Open surgical management was most commonly performed at 8–10 months of age (38.6%). Bilateral frontal craniectomy with remodeling of the supraorbital bandeau and frontal bone was the most common choice of procedure (84.2%). In case of mild to moderate and moderate to severe recurrences at 1 year of age, 89.5% and 47.4% of surgeons opted for conservative management, respectively. Optimal timing for repeat cranioplasty was after 4 years of age (65.5%). Overall, 43.4% quoted lack of evidence as the greatest obstacle to clinical decision-making when dealing with unilateral synostosis.Conclusion:This survey exposes the lack of consensus and the disparity of opinion among craniofacial surgeons regarding the management of nonsyndromic coronal synostosis, particularly in the setting of recurrence.

Oblique Lateral Closing-Wedge Osteotomy for Cubitus Varus in Skeletally Immature Patients.

We perform an oblique lateral closing-wedge osteotomy of the distal end of the humerus to correct cubitus varus deformity in children. This deformity is often the consequence of undertreatment, malreduction, or malunion of supracondylar humeral fractures1. Although standard arcs of motion may be altered, cosmesis was traditionally considered a primary surgical indication. However, uncorrected cubitus varus leads to posterolateral rotatory instability of the elbow (PLRI)2, lateral condylar fractures3, snapping medial triceps, and ulnar nerve instability4. A contemporary understanding of these delayed sequelae has expanded our current indications. Detailed parameters predictive of late sequelae are needed to further specify surgical indications. We remove an oblique lateral closing wedge from the distal end of the humerus via a standard lateral approach. The osteotomy is angled away from the varus joint line such that lateral cortices after reduction lack prominence. Kirschner wires provide adequate fixation in young patients. In older children, extension is simultaneously corrected, and fragments are stabilized via plate osteosynthesis. Patients who decline surgery are counseled regarding risks of delaying treatment until symptoms are present. PLRI manifests as lateral elbow pain or instability while rising from a chair. Once symptomatic, the lateral ulnar collateral ligament (LUCL) is irreversibly attenuated and morphologic changes in the ulnohumeral joint necessitate more extensive surgery to include distal humeral osteotomy, LUCL reconstruction, and possibly ulnar nerve transposition5. Alternative osteotomy techniques are described and categorized as simple lateral closing wedge, step-cut6-9, dome, 3-dimensional10, or distraction osteogenesis. Simple closing-wedge osteotomies include a distal cut parallel to the joint line and retain a problematic lateral prominence (if the medial cortex is intact or the distal end of the humerus is not translated medially)11,12. Step-cut osteotomies theoretically minimize this lateral prominence while enhancing inherent stability. However, these additional cuts mandate wide surgical exposure despite similar outcomes13. Three-dimensional planning employs computed tomography to create expensive anatomic cutting guides that address varus, extension, and internal rotation. However, residual internal rotation is generally well tolerated, derotation is associated with loss of fixation, and the extension deformity will successfully remodel in patients who are <10 years old14. We employ 3-dimensional planning in skeletally mature patients with complex deformity and no remodeling potential. The oblique lateral closing wedge is ideal for skeletally immature patients because it is simple, reproducible, and efficient. It avoids the lateral prominence without increasing complexity or complications.