Combined Procedure Research Articles

A Comparative Study of Planned and Unplanned Manual Small Incision Cataract Surgery (MSICS) Outcomes at Nan Hospital, Thailand: A Retrospective Study

Objective: To compare the visual outcomes and complications of planned and unplanned manual small incision cataract surgery (MSICS) using Ruit technique in cataract patients. Materials and Methods: The medical records of 3,107 eyes for 2,642 patients with cataracts who underwent MSICS using the Ruit technique at Nan Hospital between January 2016 and April 2023 were retrospectively reviewed. MSICS used a temporal scleral tunnel incision. All 3,107 surgeries were performed by a single surgeon. Out of these 908 eyes of 719 patients, 411 eyes missed the six-week follow-up, the data were incomplete on 195 eyes, 58 eyes underwent combined ocular procedures, and 244 eyes had preoperative vision impairing pathology or previous ocular surgeries. Medical records of 2,199 eyes from 1,923 patients were analyzed, including data on preoperative and postoperative uncorrected visual acuity (UCVA), operative time, intra- and postoperative complications, and astigmatism at the second and sixth weeks after surgery. Results: MSICS using Ruit technique was performed on 2,199 eyes of 1,923 patients. Both groups achieved excellent surgical outcomes with low complication. The postoperative UCVA at the sixth-week follow-up was 20/70 or better in 96.2% (1,467 out of 1,526 patients) in the planned group and 94.7% (637 out of 673 patients) in the unplanned group. At the sixth week after treatment, the median postoperative astigmatism of both groups were –1.0 (IQR –1.5 to –0.5) D. Hyphema was the most frequent intraoperative complication found in both groups, equating to 5.9% (90 out of 1,526 patients) in the planned group and 8.2% (55 out of 673 patients) in the unplanned group. There was no significant difference in the visual results and complication rates between the groups (p<0.05). Conclusion: The present study demonstrates that cataract surgery in the unplanned group was safe, and the outcomes in terms of visual results and complications were comparable to those of the planned group. The findings revealed that favorable visual outcomes could be achieved with Ruit technique MSICS. Keywords: Ruit technique; Manual small incision cataract surgery

Preserflo MicroShunt Implantation: A Narrative Review of Its Standalone Benefits vs. Combined Use with Phacoemulsification in Managing Open-Angle Glaucoma.

Glaucoma and cataract often coexist. Patients with both conditions who qualify for surgical treatment may undergo either a combined surgical procedure or sequential treatments such as cataract surgery followed by an antiglaucoma procedure. A combined procedure with phacoemulsification is related to an increased risk of fibrosis of the filtering bleb; however, it is a rational approach for patients with high intraocular pressure and clinically significant lens opacification. Trabeculectomy has been a traditional filtration procedure for decades, effectively lowering intraocular pressure. It is highly effective; however, it may cause sight-threatening complications. The Preserflo MicroShunt, introduced less than a decade ago in the field of glaucoma surgery, has shown similar hypotensive efficacy to trabeculectomy, and is a less invasive procedure with a better safety profile. Despite their shared mechanism of action to reduce intraocular pressure, the two procedures differ in the extent of scleral incision and filtration bleb morphology, which may influence the extent of the post-surgery inflammation process. This review evaluated and compared reports on the efficacy and safety of Preserflo MicroShunt implantation as a standalone procedure versus combined with cataract removal in surgical treatment for patients with open-angle glaucoma and concomitant cataract.

Safety of Simultaneous Laparoscopic Cholecystectomy and Inguinal Hernia Repair: A Systematic Review.

Background: Cholelithiasis and inguinal hernias are common surgical conditions that often coexist. Laparoscopic techniques are increasingly used for both cholecystectomy and inguinal hernia repair. This study aimed to systematically review the available evidence on the safety and efficacy of simultaneous laparoscopic cholecystectomy (LC) and laparoscopic inguinal hernia repair (LIHR). Methods: A systematic search of the PubMed/MEDLINE and Google Scholar databases was performed for articles published until March 2024 using specific keywords. Studies meeting predetermined inclusion and exclusion criteria were analyzed. Results: Ten studies comprising 199 patients were included in the review. The mean operative time for combined LC and LIHR ranged from 55 to 157 minutes, with an average hospital stay between 1 and 4 days. The overall complication rate was 22%, with seroma/hematoma formation (6.5%) being most common. There were no reported mortalities or cases of mesh infection. Discussion: This review suggested that simultaneous LC and LIHR is a safe and effective option for patients with both conditions. The combined procedure offers potential benefits such as reduced hospital stay, faster recovery, and cost savings. Although the optimal sequence of surgical procedures for LIHR and LC remains debatable, the risk of mesh infection appears to be minimal.

Long-term Results of Lymphedema Treatment with combined Lymph Node Transfer and Collagen Scaffolds: An observational study

Aim: Vascularized lymph node transfer (VLNT) accelerates growth factor secretion, lymphatic endothelial-cell migration towards the interstitial flow and lymphagiogenesis in a multidirectional pattern. Our observational study aims to examine the hypothesis that nanofibrillar collagen scaffolds (NCS) combined with VLNT can provide guided lymphagiogenesis creating long-lasting lymphatic pathways.Methods: Twenty-four patients (21 female, 3 male) who had undergone a lymphatic microsurgery for upper (n=11) or lower (n=13) limb secondary lymphedema and completed at least 18months follow up were selected and equally divided in two groups; Group-A underwent a VLNT, Group-B a combined VLNT and NCS procedure. Lymph-node flap sizes, harvesting procedure and implantation location were resembling in both groups. Demographics, lymphedema etiology and staging, limb volumetry, and somatometric data were recorded. Pre- and postoperative data for limb-volume difference, infection episodes/year, and indocyanine-green (ICG) lymphography changes were documented in all patients.Results: Mean follow-up was 42 months24-60 in Group-A, and 27 months18-48 in Group-B patients. Demographic data, lymphedema etiology, and staging were comparable in both groups. Pre- and postoperative edema volume difference for Group-A was 36% and 25% (p<0.001), while in Group-B 33% and 14% (p=0.001) respectively. The mean number of infection episodes decreased in Group-A and B from 1.75 to 0.33 and from 2.17 to 0.42 per patient/year, respectively. ICG mean stage in Group-A was 3.58 pre- and 3 postoperatively (p=0.045), and 3.67 pre- and 2.08 postoperatively in Group-B (p=0.506). A statistically significant difference was found in postoperative volume difference between the two groups (p=0.008) as well as the postoperative ICG changes (p<0.001). ICG-lymphography demonstrated new lymphatic vessel formation at the location of NCS implantation.Conclusions: Long-term follow-up of the patients treated with a combined VLNT-NCS approach revealed a statistically significant improvement regarding volume reduction, infection episodes per year, ICG downstaging and new lymphatic vessel formation, compared to VLNT alone.

Combined one-step hybrid treatment for a paediatric giant internal carotid artery aneurysm: a case report.

Background Giant intracranial aneurysms (GIAs) require complex treatment strategies including clipping, coiling, stenting, parent artery occlusion, bypass, or combined procedures. Neurovascular hybrid operating rooms (h-OR) combine a conventional operating theatre with high-resolution digital subtraction angiography (DSA). We describe a one-step combined surgical and endovascular treatment in a h-OR for a paediatric internal carotid artery giant aneurysm that can be an optimal solution to manage challenging cases, such as giant aneurysms. Case Description An 11-year-old boy presented with rapid onset right hemiparesis and left eyelid ptosis. A three months history of headache associated with sporadic vomit was reported. A giant, unruptured, left internal carotid artery aneurysm (ICA) was detected on imaging. The patient underwent surgical trapping of the aneurysm. Intraoperative DSA showed residual backflow from the posterior communicating artery (PComA) and coils were placed to completely exclude the aneurysm. At 18 months follow up, the patient showed a complete recovery and MRI showed a progressive reduction of the sac aneurysm. Conclusions Due to their morphologic variability, intracranial giant aneurysms may require a different procedural strategy instead of direct clipping or coiling. The introduction of h-OR allows combined treatments to be performed simultaneously in the same room setting. The present case shows that combined treatment in a neurovascular h-OR can be an optimal solution to manage challenging cases, such as giant aneurysms, reducing operative time with the added benefit of selecting an appropriate strategy adjustment in a multidisciplinary effort.

Acute treatment of elderly patients with acetabular fractures by open reduction, internal fixation, and total hip arthroplasty: a 1-10-year follow-up of 48 patients.

Acetabular fractures in osteoporotic bone are associated with substantial joint impaction and comminution, previously shown to be prognostic for a poor result. A combined procedure of open reduction, internal fixation (ORIF), and total hip arthroplasty (THA) can be a good option, allowing for immediate weightbearing as tolerated. We report short- to medium-term outcome and complications of the results of patients treated with this combined procedure. 48 cases treated with ORIF and acute THA from 2000 to 2019 were identified from our local pelvic fracture registry, from which follow-up data was extracted. Descriptive statistics were used and Kaplan-Meier survival curves were calculated. Primary outcome was HHS at 1 year. Secondary outcomes were implant survival, complications requiring surgery, and mortality at 3 months. There were 37 men and 11 women treated in the study period. Mean age was 68 (37-87) years. 6 patients died within 3 months of surgery, leaving 42 cases available for follow-up. Mean follow-up (FU) was 2.8 (1-16) years. The most common mechanism of injury was fall from standing height (n = 36). Medical comorbidities were common. Mean Harris Hip Score (HHS) was 83 (51-100) at 1-year follow-up. There were 7 reoperations: 6 for postoperative infection and 1 closed reduction of implant dislocation. 38 had their implant intact at latest FU. At the latest FU, 28 patients were ambulatory without a walking aid. Our results indicate that ORIF and acute THA can be performed with good functional results in patients with unreconstructable displaced acetabular fractures, but with a significant risk of infection and revision.

Usefulness of Suture-Tape Augmentation Based on Intraoperative Ankle Stress Radiographs During Anatomical Ligament Repair for Chronic Lateral Ankle Instability.

During the modified Broström procedure for chronic ankle instability, surgeons often experience cases with insufficiently restored mechanical stability even after anatomical ligament repair. In these cases, longer postoperative immobilization and delayed rehabilitation can be required, and a risk for recurrence of instability may persist. This study aimed to evaluate the clinical usefulness of suture-tape augmentation based on intraoperative stress radiographs during anatomical ligament repair for chronic ankle instability. Twenty-four patients who underwent additional suture-tape reinforcement because of residual mechanical instability on intraoperative stress radiographs were followed up ≥3 years. Clinical assessment was performed using the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM). Changes in mechanical stability were analyzed through periodic stress radiographs, and postural control ability was evaluated with the modified Romberg test. FAOS and FAAM scores improved significantly from preoperative mean 55.1 and 52.4 points to 92.3 and 90.2 points at final follow-up, respectively (P < .001). Talar tilt angle and anterior talar translation improved significantly from preoperative mean 15.8 degrees and 13.6 mm to 2.9 degrees and 4.2 mm, respectively (P < .001). Balance retention time improved significantly from preoperative mean 3.6 to 6.4 seconds (P < .001). Although 9 patients experienced sprain injury after surgery, no patient showed recurrence of mechanical and subjective instability, and 21 patients (87.5%) were able to return to preinjury level of sports activity. Evaluation of residual mechanical instability through intraoperative stress view and additional suture-tape augmentation showed satisfactory clinical outcomes at midterm follow-up. Suture-tape augmentation based on intraoperative stress radiographs seems to be a useful surgical option for patients with insufficiently restored mechanical stability even after anatomical ligament repair. This combined procedure can provide a reliable mechanical stability that can be performed after recognition of residual instability during the index surgery.

The Efficacy of Combined Decompression of Carpal and Cubital Tunnel in the Setting of Cervical Spine Stenosis: A Retrospective Analysis.

Background and objective Hand numbness, often associated with carpal tunnel syndrome (CTS) and cubital tunnel syndrome (CuTS), significantly impacts the quality of life. This study aimed to evaluatethe effectiveness of combined carpal and cubital tunnel decompression(CCTD) in patients with concurrent mild to moderate cervical spine stenosis when compared tosingle decompression procedures. Methods We retrospectively reviewed the records of 100 patients who underwent decompression surgery for hand numbness and concurrent cervical spine stenosis, with positive electromyography (EMG) results in some cases, between January 1, 2023, and January 1, 2024. Surgical interventions included carpal tunnel decompression (CTD, n=91), cubital tunnel decompression (CuTD, n=4), and combined procedures (n=5). Results Of the 100 patients (aged range: 32-92 years), 11 with coexisting cervical stenosis reported neck pain. Those who underwent CCTD reported significantly lower pain severity and interference scores, as well as better functional outcomes, compared to single decompression groups. Despite the small number of patients (n=5) in the combined decompression group, preliminary findings suggest potential benefits related to this approach. Conclusions Simultaneous decompression of the carpal and cubital tunnels may offer superior symptom relief and functional improvement in patients with mild to moderate cervical spine stenosis, highlighting the importance of addressing cervical spine pathology in cases of hand numbness. However, further research with larger sample sizes is warranted to validate these preliminary results and better understand the efficacy of combined decompression for complex cases.

Strategy Optimization for a Combined Procedure in Patients With Atrial Fibrillation

The optimal strategy of combining left atrial appendage occlusion (LAAO) with catheter ablation (CA) in patients with atrial fibrillation (AF) during a single procedure remains unclear. To determine the effects of ablation-first vs occlusion-first strategies on long-term clinical outcomes among patients with atrial fibrillation undergoing a combined LAAO and CA procedure. The prospective, multicenter COMBINATION randomized clinical trial was conducted in 14 high-volume centers in China. Enrollment of patients with nonvalvular AF referred for the combined procedure began on July 24, 2020, and concluded on January 20, 2022. Patients were randomly assigned to either the ablation-first group or the occlusion-first group. Outcomes of LAAO using an occlusion device and CA using a contact force-sensing catheter following different combination strategies during long-term follow-up were evaluated. The primary end point was a composite of thromboembolic events including stroke or transient ischemic attack, device-related thrombus (DRT), clinically relevant bleeding, and cardiovascular rehospitalization or death. Freedom from AF or atrial tachyarrhythmia (ATA) after a single procedure without antiarrhythmic drugs, at both 1 year and long-term follow-up, was also evaluated. Of the 202 patients enrolled, 194 (96.0%) completed the trial (97 in the ablation-first group and 97 in the occlusion-first group). The mean (SD) age of the cohort was 67.3 (9.2) years, and 110 patients (56.7%) were male. All procedures achieved acute successful LAAO and restoration of sinus rhythm, with similar incidences of periprocedural complications. Compared with the ablation-first group, the occlusion-first group exhibited significantly higher event-free survival of the primary end point (83.5% vs 71.1%; hazard ratio [HR], 0.53 [95% CI, 0.29-0.95]; log-rank P = .04) during the median 2.5 (IQR, 2.3-2.8) years of follow-up. Subgroup analysis indicated that male patients and those with higher CHA2DS2-VASc scores (a composite of factors associated with stroke risk; higher scores indicate higher risk) were at lower risk of thromboembolic events. Rates of long-term freedom from AF (77.3% vs 63.5%; HR, 0.58 [95% CI, 0.34-0.97]; log-rank P = .04) and from ATA (70.1% vs 55.7%; HR, 0.62 [95% CI, 0.39-0.99]; log-rank P = .04) were higher in the occlusion-first group vs the ablation-first group. Additionally, a higher incidence of chronic peridevice leak (15 [15.5%] vs 5 [5.2%]; P = .03) and DRT (8 [8.2%] vs 1 [1.0%]; P = .04) was observed in the ablation-first group vs the occlusion-first group. In this randomized clinical trial, the occlusion-first approach was superior due to its higher event-free survival of the primary end point and long-term freedom from ATA. These findings suggest that the occlusion-first approach should be recommended for combined procedures with plug-like device implantation. Chinese Clinical Trial Registry Identifier: ChiCTR2000031486.

Long-term surgical outcomes of combined Ahmed glaucoma valve implantation and phacoemulsification with intraocular lens implantation for patients with glaucoma secondary to iridocorneal endothelial syndrome

BackgroundTo assess the long-term outcomes of patients with glaucoma secondary to iridocorneal endothelial syndrome (GS-ICE) who underwent Ahmed glaucoma valve (AGV) implantation combined with phacoemulsification and intraocular lens (IOL) implantation surgery.MethodsIn this non-comparative retrospective case series study, twelve patients with uncontrolled GS-ICE and cataract underwent Ahmed aqueous shunt combined with phacoemulsification and IOL implantation surgery at Beijing Tongren Eye Center between June 2014 and June 2022. Main medical records included best-corrected visual acuity (BCVA), intraocular pressure (IOP), number of antiglaucoma medications (AGM), corneal status and further surgical interventions. Surgical success was defined as a postoperative IOP ≥ 6mmHg and ≤ 21mmHg without (complete success) or with/without (qualified success) topical AGM and vision of at least light perception during the follow-up period.ResultsTwelve eyes of twelve patients were reviewed. Preoperative IOP was decreased from a mean of 38.5 ± 6.7 mmHg on 3.3 ± 0.9 AGM to a mean of 16.3 ± 4.3 mmHg (P<0.001) on 0.6 ± 1.1 medications (P<0.001) at the last follow-up (47.0 ± 24.7 months). Eight eyes (66.7%) had stable vision or at least one line improvement than that before surgery. Eight eyes (66.7%) achieved qualified success and six eyes (50.0%) achieved complete success after surgery. The surgical procedure had a qualified survival of 91.7% at 1 year, 82.5% at 3 years, 72.2% at 5 years, and 48.1% at 7 years.ConclusionAGV implantation combined with phacoemulsification and IOL implantation seems to be an effective method in IOP control and vision maintain for patients with GS-ICE. The combined surgical procedure may be a reliable option for those GS-ICE patients with coexisting cataract.

Assessing the Nursing Workload in the Cardiothoracic Intensive Care Unit: Comparative Study.

This study aimed to assess nursing workload in Cardiac Intensive Care Unit (CICU) after three cardiothoracic surgery procedures during first four postoperative days using Nursing Activities Score (NAS) and Nine Equivalents of Nursing Manpower Use Score (NEMS) systems, to compare their performance for that purpose and to investigate association between nursing workload and type of surgery. A comparative study. The research environment includes CICU of the University Hospital for Cardiovascular Diseases in Serbia. A total of 808 patients who underwent coronary, valvular, or combined surgery, resulting in 2282 filled NAS and NEMS pairs chart. Statistical analysis was performed using SPSS-19. The correlation between NAS and NEMS was tested by Spearman's correlation coefficient. Differences were considered statistically significant at p < 0.05. The lowest median of cumulative NAS 176 (175-257) and NEMS 76 (64-91) had coronary surgery patients, the highest NAS 224.5 (178-334.5) and NEMS 83 (69-121) had those with combined surgery; this difference was statistically significant (p < 0.001). The median of both scores decreased after surgery, with the following values from the first to the fourth postoperative day: NAS from 104 (102-105) to 81 (74-85) and NEMS from 46 (42-46) to 30 (30-37). The difference in mean values of both scores between the first and the fourth postoperative day was statistically significant (p < 0.001). NAS and NEMS were in a positive, strong correlation (r = 0.913; p < 0.005). Both scores can be used to measure nursing workload, identify the required number of nurses in CICU, and support task allocation. NAS may have an advantage because it better describes extensive postoperative monitoring and care needed for cardiac surgery patients. Nursing workload is associated with type of surgery, with the highest workload measured in patients who underwent combined surgery procedure and on the first postoperative day.

Trends in glaucoma surgery in a tertiary hospital in Spain: 2010-2022.

This study aims to conduct an analysis glaucoma surgeries performed over a 13-year period at a tertiary hospital affiliated with the Spanish National Health System, with the goal of assessing temporal trends. This retrospective observational study scrutinized surgeries undertaken in the glaucoma unit of a tertiary center in Spain between 2010 and 2022. Data collected included surgical dates, procedure performed, whether it was standalone or combined, as well as patient demographics including age, sex, and type of underlying glaucoma. Surgeries on individuals under 18 years of age were excluded. An annual comparative analysis was performed to ascertain the evolving trends in glaucoma surgical interventions. A total of 12,944 surgeries were included in the analysis, comprising 9428 isolated cataract surgeries and 2975 glaucoma procedures. Trabeculectomy, glaucoma drainage devices (GDD), and cyclodestruction, collectively referred to as traditional surgery, demonstrated a decline from 93.2% to 23.6% over the study duration. Minimally invasive glaucoma surgery (MIGS) and minimally invasive bleb surgery (MIBS) demonstrated a significant increase from 3.8% in 2010 to 74.7% in 2022, relative to the total glaucoma surgeries. Furthermore, combined surgeries manifested a noteworthy increase from 39.0% in 2010 to 44.2% in 2022, with 86.4% of combined procedures in 2022 being MIGS or MIBS. In recent years, there has been a noticeable change in the trend of glaucoma surgeries, with MIGS and MIBS procedures experiencing a significant increase and becoming the most commonly performed glaucoma procedures. Consequently, traditional glaucoma surgeries have decreased in frequency.

Combined PVI and LAAC is feasible using RFA or PFA in a canine model despite acute tissue edema in PFA versus RFA

Abstract Background Combined procedure with pulmonary vein isolation (PVI) using thermal energy followed by left atrial appendage closure (LAAC) has been used in select patient populations with positive results. Pulsed field ablation (PFA) is a novel non-thermal ablation modality that ablates cardiac tissue by irreversible electroporation. The effect of PFA on cardiac tissue and its interaction with a LAAC device in a single procedure has not been studied. Purpose To evaluate using transesophageal echo (TEE) imaging the acute tissue response following ablation by PFA compared to radiofrequency ablation (RFA) and its interaction with the WATCHMAN FLX Pro LAAC device when used in a combined procedure in a healthy canine model. Methods Nine mongrel canines underwent PVI using either circumferential PFA (FARAPULSE) energy application (n=6) or RFA energy (n=3). TEE imaging was obtained at the time of the procedure before and immediately after ablation energy application. The general appearance and echogenicity of the left lateral ridge was assessed and the os of the left atrial appendage (LAA) was measured in the four standard TEE views (0, 45, 90, and 135 degrees). Decisions about device sizing were made accordingly. PVI was evaluated by entry and exit block in all veins except the right inferior pulmonary vein (RIPV), which was not ablated. Following ablation, the LAAC device was implanted using TEE and fluoroscopic guidance in all animals and the percentage of compression measured. PASS criteria were assessed before the release of each device. All animals received dual antiplatelet therapy post implant. Results PVI was confirmed in all animals (except RIPV which was not targeted for ablation) using PFA and RFA. LAA dimensions (at device landing site) did not change substantially after RF ablation. With PFA, there was evidence of more diffuse edema and decrease in LAA diameter (Table). The LAAC device was implanted successfully after meeting PASS criteria in all animals within 30 minutes post ablation. The device size was decreased following PFA in two (2/6) animals, whereas there was no deviation from baseline measurements in device size for any of the RFA animals. Average LAAC device compression was higher for PFA versus RFA animals (Table). TEE post implant confirmed absence of any peri-device leaks in all animals. Conclusion Concomitant PVI using PFA (FARAPULSE) and LAAC (WATCHMAN FLX Pro) is feasible with 100% success and no residual acute peri-device leak. In the canine model, PFA is associated with more diffuse edema compared to RFA, which might affect device sizing. Long term consequences of this acute edema need to be evaluated in serial imaging and future larger clinical trials.Table

Mortality rates by therapeutic approaches for isolated severe tricuspid regurgitation: a systematic review

Abstract Background Managing isolated severe tricuspid regurgitation (TR) poses significant challenges, with questions recently arising about the efficacy of surgical and percutaneous therapies compared to conservative approaches in improving survival. Purpose This systematic review aims to evaluate the mortality associated with various treatment modalities for isolated severe TR. Methods A comprehensive search of medical databases was conducted. Studies reporting mortality of isolated TR at 1-year follow-up, with TR severity classified as moderate-to-severe or worse, were included. Exclusion criteria were TR associated with left-heart disease and combined procedures (treating other valves). The primary endpoint was all-cause mortality at 1-year, with secondary outcomes including in-hospital, 2 and 5 years mortality. Patients with isolated severe TR were categorized by management type: medical, percutaneous, or surgical. Percutaneous treatment included all types of transcatheter therapy (repair or replacement), and surgical interventions encompassed both repair and replacement procedures. Results Twenty-nine studies met the inclusion criteria. Mean age was 72 years among the 5970 patients managed medically, 77 years among the 1205 patients treated percutaneously, and 60 years among the 1754 patients managed surgically. In medically managed patients, 1-year, 2-year, and 5-year mortality rates were 23.6%, 32.5%, and 45.9% respectively. Among percutaneously managed patients, there was an in-hospital mortality of 2.5% and a 1-year mortality rate of 16.9%, which increased to 27.9% at 2 years. Surgically managed patients experienced an in-hospital mortality of 8.6% (p&amp;lt;0.001 compared to percutaneous treatment), with 1-year, 2-year, and 5-year mortality rates of 19.8%, 21.7% and 33.5%, respectively. Compared to medical management, both transcatheter therapy and surgical management demonstrated significantly lower mortality rates at 1 year (p&amp;lt;0.001 vs. percutaneous treatment; p=0.02 vs. surgery), with no significant differences between surgical and percutaneous treatment (p=0.16). At 2-year follow-up, patients undergoing surgical management exhibited significantly lower mortality compared to the other groups (p&amp;lt;0.001 vs. medical treatment; p=0.02 vs. percutaneous treatment), while mortality rates between medical and percutaneous treatment was not different (p=0.11). Conclusion The findings underscore the significant long-term mortality associated with isolated severe TR. While selection bias should be considered, invasive management, through either percutaneous or surgical interventions, demonstrates superior 1-year survival rates compared to medical management. Surgical therapy appears to offer the lowest long-term mortality in selected, operable patients, potentially due to their younger age. Further research is warranted to refine patient selection criteria and optimize therapeutic strategies to improve outcomes in the management of isolated TR.

Strategy optimization for the combined procedure of left atrial appendage occlusion plus catheter ablation in patients with atrial fibrillation (COMBINATION): a multi-center, randomized study

Abstract Background The long-term efficacy and safety of combining left atrial appendage closure (LAAC) plus catheter ablation (CA) in patients with atrial fibrillation (AF) in a single procedure have been established. However, the optimal combining strategy has not been well elucidated. Objective To determine the impact of different combining strategies on long-term clinical outcomes. Methods In this prospective multicenter study, patients with non-valvular AF referred for the combining procedure were randomly assigned to the ablation-first or occlusion-first groups at a 1:1 ratio. We evaluated the outcomes of LAAC with a Watchman device and CA using a contact-force sensing catheter during long-term follow-up. Results Of the 202 randomized patients, 194(96.0%) completed the trial with 97 patients in each group. Baseline characteristics were comparable between groups. All procedures were accomplished with acute successful LAAC and restoration of sinus rhythm. Incidences of periprocedural complications were similar. Higher chronic peri-device leak (PDL, 15.5% vs 5.2%, P=0.031) and device-related thrombus (DRT, 8.2% vs 1.0%, P=0.035) rates were observed in the ablation-first group. The event-free survival rate of the primary endpoint (composite of stroke/transient ischemic attack, thromboembolism, clinically-relevant bleeding, cardiovascular rehospitalization/death) was significantly higher in the occlusion-first group (83.5% vs 71.1%, log-rank P=0.036, HR 0.53, 95%CI 0.29-0.95) during a median 2.5-year follow-up. Patients with male gender and higher CHA2DS2-VASc score were at lower risk in the subgroup analysis. Long-term freedoms from AF (77.3% vs 63.5%, log-rank P=0.039) and atrial tachyarrhythmias (70.1% vs 55.7%, log-rank P=0.044) were higher in the occlusion-first group, respectively. Conclusions The occlusion-first approach is recommended for combined procedures where a plug-like device is implanted due to its superior long-term clinical benefits.Flowchart of the COMBINATION trialIncidences of primary endpoint

An early analysis of polyetheretherketone (PEEK) plates for the surgical stabilization of rib fractures: A pilot study

BackgroundSurgical stabilization of rib fractures (SSRF) is a viable treatment option for rib fracture patients. Polyetheretherketone (PEEK) plates have become available for SSRF. The objective of this pilot study was to examine the use of PEEK plates for SSRF. MethodsA prospective, observational, multi-center study of patients undergoing SSRF with PEEK plates from 4/23 through 2/24. Standard indications for SSRF were followed and the decision to use PEEK plates was left to the discretion of the treating surgeon. Basic demographics were obtained. Outcomes included the number of rib fractures stabilized with PEEK plates, complications related to SSRF, and 6-month follow-up with chest computed tomography (CT) to assess healing of PEEK repaired fracture sites, identified as complete or incomplete union. Patients also answered a five-question quality-of-life survey regarding mobility, self-care, usual activities, chest pain/discomfort, and anxiety/depression. Answers were scaled 1 to 5 (1=worse condition possible; 5=best possible condition). Patients rated their health on a scale of 0 to 100 (100=closet to their health preinjury). All data was reported as descriptive. ResultsForty-six patients were included. Average age was 57(±16) years; 82.6 % were male. Median ISS was 18 (IQR 14,29) and median chest-AIS was 4 (IQR 3,4). 219 rib fractures were stabilized with PEEK plates. Sixteen (34.8 %) had a combination (PEEK + titanium) procedure. Three patients had a complication: one required a second surgery for additional SSRF, and two patients were readmitted. Twenty-seven patients were surveyed at 6 months, and 19 agreed to CT scan. Eighty PEEK repaired rib fractures were assessed for healing. 80 % of fractures had complete union and no hardware failure. Quality-of-life survey averaged >4.5/category and mean overall health was 89. ConclusionPEEK plates for SSRF are safe and effective, allowing for adequate rib fracture healing and are associated with positive patient reported outcomes.

Abdominal Lymphatic Malformations: A Novel Approach in Management

Aim of the studyAbdominal lymphatic malformations (LM) are a challenging clinical entity. Complete excision can be impossible due to the infiltrative nature of some lesions and high rate of complications. Sclerotherapy may require multiple episodes of general anaesthesia and an inability to be definitive in terms of diagnosis and treatment. Subsequently we have adopted a newer algorithm of treatment involving a joint procedure with interventional radiology to enable an intra-operative treatment plan based on the findings. We present our early results. MethodA retrospective observational study in a single tertiary paediatric centre from January 2019 to December 2023. The details of each patient were recorded along with their treatment pathway and outcome. Results12 children underwent treatment for abdominal LM. Under GA and laparoscopic vision, pigtail catheters were inserted into the lesion to effect maximal drainage and assessment of surgical anatomy. If resection was feasible this was undertaken through a laparotomy and if not, the drains were retained and sclerotherapy was started.Three underwent drainage with sclerotherapy without resection and 9 underwent drainage with resection. Of the 3 who underwent sclerotherapy 2 have had further treatment and remain under review at a mean follow up of 7.6 months. Of the other 9 there were no signs of recurrence of the LM at a mean follow up of 29 (range 6–56) months. ConclusionWe have found a combined procedure involving IR-guided drainage under laparoscopic vision enabling curative surgical resection to be undertaken, where feasible, with currently no significant morbidity. For those in whom this is not possible then direct intralesional sclerotherapy is the next most useful treatment modality for longer term control of symptoms. Level of evidenceII.

Laparoscopic central hepatectomy: Feasibility and safety.

Anatomical liver resection is the gold standard for hepatocellular carcinoma (HCC), enhancing survival and disease-free outcomes. For centrally located tumors, major resections are necessary but risky, especially for patients with liver disease. Central hepatectomy (CH) offers a parenchymal-sparing alternative to extended or hemihepatectomy (HH), reducing postoperative liver failure risk. However, its complexity and the large transection area make it challenging, especially with laparoscopic techniques. This study evaluates the feasibility and safety of laparoscopic CH for centrally located HCC, comparing surgical outcomes with those of the HH group. A total of 1592 laparoscopic hepatectomy cases from January 2011 to April 2023 were reviewed in a single institution. Patients undergoing laparoscopic CH were compared to those receiving HH during the same period. Exclusion criteria included non-HCC diagnosis, non-central tumors, and cases involving combined procedures. 70 cases of laparoscopic CH and 32 cases of laparoscopic HH were included. The CH and HH groups showed similar estimated blood loss (median 400ml vs. 290ml, p = 0.187) and intraoperative blood transfusion rates (10% vs. 15%, p = 0.413). Operation time did not significantly differ (median 330min vs. 360min, p = 0.862). Postoperative hospital stay was shorter in CH (median 6days vs. 9days, p = 0.018), with fewer ICU transfers (19% vs. 44%, p = 0.014) and lower 90-day mortality (1% vs. 9%, p = 0.055) compared to HH. Complication rates were similar overall (26% vs. 41%, p = 0.069), but HH had more Clavien-Dindo class I and II complications (13% vs. 19%, p = 0.040). Long-term survival did not significantly differ, but tended to favor the CH group. Despite the complexity, laparoscopic CH offers comparable perioperative outcomes and favorable long-term survival compared to HH. It can be considered a viable option for centrally located HCC, preserving liver function.

Patient-Initiated Communication After Parotidectomy.

We sought to study the incidence of patient-initiated communication after parotidectomy, identify patient and surgical factors associated with patient-initiated communication, and evaluate trends and possible areas for improvement. A retrospective cohort study of patients who underwent parotidectomy without combined procedures from 2018 to 2022 in a single tertiary-care institution was performed. We reviewed all patient communications documented within the electronic medical record within 30 days of discharge. We categorized patient communications as requiring an action by the surgeon, instruction by support staff, or reassurance. A total of 363 patients were included. Most patients were women (55.4%), Caucasian (78.8%), and had an average age of 56 years ± 16. We found 123 (33.9%) patients initiated postoperative communications. Swelling (47.2%) was the most common concern followed by wound concerns (15.4%). Switching from planned inpatient to outpatient surgery increased (OR = 2.635; 95% CI = 1.200-6.146, p = 0.026) propensity for postoperative communication. We found 31 (25.2%) postoperative communications required an action by the surgeon, 40 (32.5%) required instruction by the support staff, and the other 52 (42.3%) required reassurance or clarification. Multivariate analysis showed swelling (OR = 6.5, CI = 2.2-19, p < 0.001), male sex (OR = 3.27, CI = 1.127-9.459, p = 0.029), previous smoking (OR = 3.468, CI = 1.181-10.185, p = 0.024), and cancer (OR = 6.862, CI = 1.757-26.804, p = 0.006) were predictive of requiring an action by the surgeon. This is the first study to evaluate patient-initiated communication after parotidectomy and found it occurred 33.4% of the time. We found significant opportunities to improve perioperative care, enhance patient satisfaction, and reduce the overall burden on medical personnel. Level IV Laryngoscope, 2024.

Refractive outcomes following simultaneous silicone oil removal and ciliary sulcus intraocular lens implantation.

This study aimed to assess the refractive outcomes following the combined intervention of silicon oil (SO) removal and ciliary sulcus intraocular lens (IOL) implantation in aphakic eyes after phacovitrectomy. A retrospective examination of medical records from patients who underwent a combined procedure of SO removal and ciliary sulcus IOL implantation from 2019 to 2022 was performed. The primary outcomes of interest included uncorrected distance visual acuity (UDVA), predictive error (PE) and mean absolute predictive error (MAE). Subgroup analyses were performed to compare outcomes between patients with and without intraoperative posterior capsulotomy. The cohort comprised 40 eyes from 40 patients, with a mean duration of SO tamponade of 5.17 ± 1.48 months. A significant improvement in UDVA was observed from 1.58 ± 0.31 logMAR to 0.99 ± 0.31 logMAR one month postoperatively (P < 0.01). The PE was -0.73 ± 0.86 diopters (D), and the MAE was 0.90 ± 0.67 D, with 37.50% and 57.50% of cases achieving PE within ±0.5 D and ±1.0 D, respectively. No significant differences in UDVA, PE, or MAE were found between the capsulotomy and non-capsulotomy subgroups (all P > 0.05). However, a lower proportion of eyes in the capsulotomy group achieved PE within ±1.0 D compared to the non-capsulotomy group one month postoperatively (38.90% vs. 72.70%, P = 0.03). The combined procedure of SO removal and sulcus IOL implantation resulted in a mild myopic shift in postoperative refraction. Intraoperative posterior capsulotomy seems to increase the lability of postoperative refractive outcomes.