Rates Of Other Complications Research Articles

P42. Similar readmission and complications with minimally invasive versus open anterior and lateral lumbar interbody fusion, a national study

P42. Similar readmission and complications with minimally invasive versus open anterior and lateral lumbar interbody fusion, a national study

Outcomes of laparoscopic versus open total gastrectomy with D2 lymphadenectomy for gastric cancer: a systematic review and meta-analysis

BackgroundThe effectiveness of laparoscopic total gastrectomy with D2 lymphadenectomy (LTGD2) remains controversial. This meta-analysis compares surgical and survival outcomes of LTGD2 and open total gastrectomy with D2 lymphadenectomy (OTGD2) for gastric cancer.MethodsControlled studies comparing LTGD2 and OTGD2 published before November 2021 were retrieved via database searches. We compared intraoperative outcomes, pathological data, postoperative outcomes, 5-year disease-free survival (DFS), and overall survival (OS).Results17 studies were included, containing 4742 patients. Compared with OTGD2, the LTGD2 group had less blood loss (mean difference [MD] = − 122.48; 95% CI: − 187.60, − 57.37; P = 0.0002), fewer analgesic medication (MD = -2.48; 95% CI: − 2.69, − 2.27; P < 0.00001), earlier first flatus (MD = − 1.03; 95% CI: − 1.80, − 0.26; P = 0.009), earlier initial food intake (MD = − 0.89; 95% CI: − 1.09, − 0.68; P < 0.00001) and shorter hospital stay (MD = − 3.24; 95% CI: − 3.75, − 2.73; P < 0.00001). The LTGD2 group had lower postoperative total complication ratio (OR = 0.76; 95% CI: 0.62, 0.92; P = 0.006), incision (OR = 0.50; 95% CI:0.31, 0.79; P = 0.003) and pulmonary (OR = 0.57; 95% CI: 0.34, 0.96; P = 0.03) complication rates, but similar rates of other complications and mortality. Total number of dissected lymph nodes were similar, but the number of No. 10 dissected nodes was less with LTGD2 (MD = − 0.31; 95% CI: − 0.46, − 0.16; P < 0.0001). There was no difference in 5-year OS (P = 0.19) and DFS (P = 0.34) between LTGD2 and OTGD2 groups.ConclusionsLTGD2 produces small trauma, fast postoperative recovery and small length of hospital stays than OTGD2, and had similar long-term clinical efficacy as OTGD2. However, these results still need further high-quality prospective randomized controlled trials confirmation.

Post-mastectomy adjuvant radiotherapy for direct-to-implant and two-stage implant-based breast reconstruction: A meta-analysis

In recent years, immediate replacement with a prosthesis (direct-to-implant, DTI) is gaining more popularity than two-staged methods (tissue expander followed by an implant, TEI). The safety of immediate implant-based breast reconstruction (IBR) is debatable when postmastectomy radiotherapy (PMRT) is indicated. This meta-analysis aims to evaluate the outcomes of DTI and TEI procedures followed by PMRT. Studies searched in the PubMed/Embase/The Cochrane Library databases (1995-2021) were filtered by exclusion criteria. Cases were divided into PMRT and non-irradiated groups, PMRT with a permanent implant or tissue expander. The outcomes were capsular contracture and other complications. A total of 22 studies with 6964 patients were included. PMRT increased the risk of capsular contracture in DTI patients and caused other complications in TEI patients. In PMRT and non-irradiated groups, the mean rates of capsular contracture were 17.01% versus 3.30% (p<0.01) in IBR and 15.49% versus 5.70% (p<0.01) in DTI. The mean rates of other complications were 22.59% versus 11.29% (p<0.01) in IBR, 31.88% versus 27.87% (p=0.35) in DTI, and 22.11% versus 9.90% (p<0.01) in TEI. Implants and tissue expanders caused a similar rate of capsular contracture and other complications. PMRT is related to a higher risk of complication and capsular contracture in IBR, including DTI procedure. This negative effect may not be related to the type of breast contents during radiotherapy.

Preoperative Lumbar Epidural Steroid Injection Increases the Risk of a Dural Tear During Minimally Invasive Lumbar Discectomy.

Preoperative lumbar epidural steroid injections (LESI) are known to be a risk factor for intraoperative dural tears in traditional spine surgery. However, whether the same holds true after minimally invasive surgery is debatable. The authors decided to investigate the incidence of complications in patients undergoing minimally invasive lumbar discectomy after a preoperative LESI. A retrospective analysis was carried out on patients ages 21 to 65 years who underwent minimally invasive lumbar discectomy over 3 years between November 2017 and October 2020. These were classified into 2 groups based on the administration of an LESI within a year of surgery. Those receiving LESI were further subdivided on the basis of the proximity of the injection to the surgery. The complications encountered during and up to 6 months after the surgery were recorded. Various demographic variables were also noted. A total of 315 patients were included in the study, of which 129 were in the LESI group and 186 were in the non-LESI group. The overall complication rate was 13.65%, with 17.83% in the LESI group and 10.75% in the non-LESI group (P = 0.07). Patients receiving an LESI were 2.49 times more likely to suffer from intraoperative dural tears compared to the other group (95% CI: 1.00-6.20, P = 0.049). This was more prevalent in those who were administered an LESI within 3 months of the surgery (OR: 3.24, 95% CI: 1.12-9.40, P = 0.03). However, the rates of other complications including infections were comparable. A history of LESI within 3 months of the surgery is a risk factor of intraoperative dural tears. However, other complications, including infections, are not affected by a preoperative LESI. A history of an LESI within 3 months of a proposed minimally invasive discectomy should make the surgeon extra-cautious of the risk of a dural tear.

Endoscopic approach for giant pituitary adenoma: clinical outcomes of 205 patients and comparison of two proposed classification systems for preoperative prediction of extent of resection.

Giant pituitary adenoma is considered a challenging pathology for surgery owing to its complications and low resection rate. In this study, the authors present their experience of using the endoscopic endonasal approach to treat patients with giant pituitary adenoma, and they aimed to develop a classification system for prediction of extent of resection. The institutional medical records of patients diagnosed with giant pituitary adenoma who underwent endoscopic endonasal transsphenoidal surgery between August 1997 and December 2019 were retrospectively reviewed. Surgical and clinical outcomes were evaluated in detail. The effects of tumor characteristics on extent of resection were analyzed. The findings were used to develop two classification systems that could preoperatively predict extent of resection. Morphological score was based on tumor characteristics, and landmark-based classification was defined according to surgical zones based on neurovascular landmarks. The effects of change in surgical strategy, which aimed to maximize tumor resection and capsule dissection, on rates of resection and complications were evaluated before and after 2017. This study included 205 patients, with a mean patient age of 46.95 years and mean preoperative tumor diameter of 46.56 mm. Gross-total resection (GTR) was achieved in 35.12% of patients, near-total resection (NTR) in 39.51%, and subtotal resection (STR) in 25.36%. Extent of resection differed significantly between the grades and zones of the classification systems (p < 0.001 for both). Among patients with grade 3 tumor, 75.75% of patients achieved STR, 21.21% achieved NTR, and 3.03% achieved GTR. Among patients with zone 3 tumor, 65.75% achieved STR, 32.87% achieved NTR, and 1.36% achieved GTR. Both grade 3 and zone 3 indicated limited extent of resection. The mean (range) follow-up duration was 50.16 (9-247) months. Postoperative recovery of at least one hormone axis was seen in 15.24% of patients with pituitary deficiency, and development of new hormonal deficiency was observed in 22.43% of patients. Complications included permanent diabetes insipidus (7.80%), cerebrospinal fluid leakage (3.90%), postoperative apoplexy (3.90%), meningitis (3.41%), and epistaxis (3.41%). The surgical mortality rate was 1.46%. Among 85 patients treated before 2017, 27.05% of patients achieved GTR, 37.64% achieved NTR, and 35.29% achieved STR; among 120 patients treated after 2017, 40.83% achieved GTR, 40.83% achieved NTR, and 18.33% achieved STR. Seven patients in the pre-2017 cohort had postoperative apoplexy versus only 1 patient in the post-2017 cohort. There were no statistically significant differences between the two periods in terms of the incidence rates of other complications. Capsule dissection and GTR are valuable for preventing serious complications and reducing recurrence of giant adenoma. Treatment of giant pituitary adenoma may be better managed with the help of a classification system that provides information about extent of resection that can be achieved with an endoscopic approach.

Efficacy of side-to-end anastomosis to prevent anastomotic leakage after anterior resection for rectal cancer.

The present study aimed to investigate whether side-to-end anastomosis could provide an improved surgical outcome, such as lower anastomotic leakage rate, compared with end-to-end anastomosis, following anterior resection for rectal and rectosigmoid cancer. This retrospective study included 162 patients with rectal cancer who underwent elective anterior resection between January 2012 and October 2019 at a single institution. Patients with double cancers or colonic J-pouch were excluded. Anastomotic leakage was defined clinically and radiologically. Side-to-end anastomosis was introduced in the International University of Health and Welfare Mita Hospital in January 2017. Side-to-end anastomosis was performed in 63 patients, while end-to-end anastomosis was performed in 99 patients. Tumors tended to be located lower in the rectum in the side-to-end anastomosis group than in the end-to-end anastomosis group. No significant differences were observed in other patient characteristics. The incidence of anastomotic leakage was significantly lower in the side-to-end anastomosis group than in the end-to-end anastomosis group (3/63, 4.8% vs. 18/99, 18.2%, respectively, P=0.02). No significant differences were observed in the incidence rates of other complications. Univariate and multivariate analyses revealed that a smoking habit (P=0.04) and side-to-end anastomosis (P=0.02) were significantly associated with anastomotic leakage. In conclusion, side-to-end anastomosis using a double-stapling technique following anterior resection for rectal cancer may prevent anastomotic leakage.

How the Choice of Osteosynthesis Affects the Complication Rate of Intercalary Allograft Reconstruction? A Systematic Review and Meta-analysis.

There is no clear consensus on the optimal type of fixation in intercalary allograft reconstruction. In this study, we aimed to compare the rate of most common complications following the plate and nail fixation of the intercalary allograft. We searched PubMed, EMBASE, Web of Science, Scopus, and Cochrane Library. Studies in which the complication rate of the single bridging plate and intramedullary nail fixation was extractable were included. Studies that used extra procedures such as cementation and fibular vascular graft augmentation were excluded. The primary outcome was the fixation-specific rate of nonunion. Secondary outcomes were the fixation-specific rate of fracture, infection, and local recurrence. In total, 13 studies with 431 reconstructions (352 reconstructions in the plate group and 79 reconstructions in the intramedullary nailing group) were included in this study. In the plate fixation, the rate of nonunion, fracture, infection and local recurrence was 12%, 11%, 11%, and 3%, respectively. In the intramedullary nail fixation, the rate of nonunion, fracture, infection, and local recurrence was 37%, 5%, 4%, and 0%, respectively. The rate of nonunion was significantly higher in the intramedullary nail group (OR = 6.34; 95% CI 2.98-13.49, P < 0.001). The rate of fracture, infection, and local recurrence was not significantly different between the two fixation methods. Intramedullary nail is associated with a significantly higher rate of nonunion. Since the rate of other complications was not significantly different between the two osteosynthesis types, plate fixation could be considered as a better type of fixation. The online version contains supplementary material available at 10.1007/s43465-021-00563-7.

Pediatric endothelial keratoplasty: a systematic review and individual participant data meta-analysis.

Recently, endothelial keratoplasty (EK) has been increasingly considered the first intervention in pediatrics with isolated corneal endothelial dysfunction. This systematic review aims to investigate the current evidence about the advantages, disadvantages, technical challenges, and clinical outcomes of EK in the pediatric group. All the English literature relevant to pediatric EK was searched in PubMed, Embase, Scopus, and Cochrane databases with appropriate keywords. Relevant data were pooled to conduct an individual participant data meta-analysis. Of 1646 articles found initially, 35 articles were finally eligible to be included in our study. A total of 154 eyes of 107 patients underwent Descemet's stripping automated endothelial keratoplasty (DSAEK). Congenital hereditary endothelial dystrophy (CHED) was the most reported indication for pediatric DSAEK (108 eyes). Descemet's membrane endothelial keratoplasty (DMEK) was performed in 2 eyes of 2 cases, one with PPCD and another one in a patient with Kearns-Sayre syndrome. Owing to some specific anatomical and physiological pediatric characteristics, some modifications in a standard procedure were suggested. The average follow-up period was 23.80 ± 20.18months (3months to 8.5years). Seventy-six eyes who had a mean best-corrected visual acuity (BCVA) of 1.36 ± 0.70 (0.49 to 3) logMAR preoperatively found mean BCVA of 0.51 ± 0.33 (0.04 to 2) logMAR postoperatively. Graft dislocation was the most reported complication (26 eyes). The rate of other complications was low. Endothelial cell loss was reported from 8.3 to 63.7% after pediatric EK with follow-up duration from 3months to 8.3years. EK procedures, despite some technical challenges, are feasible surgical techniques with acceptable visual and anatomical outcomes in the management of pediatrics with corneal endothelial dysfunction and minimal stromal involvement.

Shunt complications and revisions in children: A retrospective single institution study.

IntroductionShunt surgery in children is associated with high revision and complication rates. We investigated revision rates and postoperative complications to specify current challenges associated with pediatric shunt surgery.MethodsAll patients aged < 18 years admitted to St. Olavs University Hospital, Norway, from January 2008 through December 2017, who underwent primary shunt insertions, were reviewed. Follow‐up ranged from 1 to 10 years. Ventriculoperitoneal, cystoperitoneal, and ventriculoatrial shunts were included. All subsequent shunt revisions and 30‐day postoperative complication rates were registered.Results81 patients underwent 206 surgeries in the study period. 47 patients (58%) required minimum one revision during follow‐up. In 14 (29.8%), the first revision was due to the misplacement of hardware. Proximal occlusion was the most common cause of revision (30.4%), followed by misplacement (18.5%) and infection (9.6%). Young age and MMC were associated with revision surgery in a univariable analysis, but were not significant in multivariable analyses. Congenital hydrocephalus was associated with infection (p = .028). In approximately 30% of procedures, complications occurred within 30 days postoperatively, the most common being revision surgery. In approximately 5% of the procedures, medical complications occurred.ConclusionChildren are prone to high revision and complication rates, and in this study, misplacement of hardware and proximal occlusion were the most common. Complication rates should not be limited to revision rates only, as 30‐day complication rates indicate a significant rate of other complications as well. Multi‐targeted approaches, perhaps focusing on measures to reduce misplacement, may be key to reducing revision rates.

Long-term mortality in women with myocardial infarction who underwent PCI using radial versus femoral access

Abstract Background Radial artery approach (RA) has become the recommended vascular access for percutaneous coronary intervention (PCI). In particular, women are at higher risk of bleeding after PCI. RA reduces the risk of bleeding. However, data on the association between RA and mortality after MI in women undergoing PCI are sparse and long-term data are lacking. Purpose The aim of our study was to assess whether RA per se is associated with long-term mortality in women with MI who underwent PCI at our center. Methods We retrospectively studied 1528 consecutive female patients with MI who underwent PCI between January 2011 and December 2017. RA was performed in 573 (37.5%) patients. Long-term all-cause mortality was observed in the RA and femoral access (FA) groups. The median follow-up time was 3.0 (25th, 75th percentile; 1, 5) years. Data were analyzed using descriptive statistics. Results RA patients had significantly lower long-term unadjusted mortality [107 (18.7%) patients died in the RA group compared to 311 (32.6%) patients in the FA group; p&amp;lt;0.0001] (Figure 1). After adjusting for confounders, the RA patients still had more than a 20% lower mortality risk than the FA patients (adjusted HR: 0.78; 95% CI: 0.62 to 0.99; p=0.042) (Figure 2). Age, diabetes, hypertension, renal function, ST-elevation MI, TIMI flow after PCI, dual antiplatelet therapy, and bleeding additionally predicted mortality. Conclusion RA independently provided a lower long-term all-cause mortality risk in women with MI (ST-elevation MI and non-ST-elevation MI) who underwent PCI. This finding suggests that RA should be preferred in daily practice whenever possible. From a clinical perspective, it is irrelevant whether RA per se is associated with a better outcome or whether the better outcome is related to fewer bleeding events and lower rates of other complications due to RA. This is especially true for patients at higher risk of bleeding (women, elderly patients, underweight patients, and patients with renal dysfunction). Funding Acknowledgement Type of funding sources: None. Figure 1. Unadjusted long-term mortalityFigure 2. Adjusted long-term mortality

Harris Hip Score and SF-36 following metal-on-metal total hip arthroplasty and hip resurfacing - a randomized controlled trial with 5-years follow up including 75 patients

BackgroundThe metal-on-metal large-diameter-head (MoM-LDH) hip replacements increased in popularity during the start of the twenty-first century. Subsequently reports raised concerns regarding adverse reactions due to elevated chromium (Cr) and cobalt (Co) concentrations as well as high rates of other complications and revisions.The purpose was to compare Harris Hip Score and SF-36 at 5-years follow up following MoM-LDH total hip arthroplasty (MoM-LDH-THA) or MoM hip resurfacing (MoM-HR).MethodsThe study was conducted between November 2006 to January 2012 in a tertiary health care center in Denmark. Patients with primary or secondary osteoarthritis were randomly assigned to receive a Magnum (MoM-LDH-THA) or a Recap (MoM-HR) prosthesis. Randomization was computer generated and allocation was concealed in an opaque envelope. Neither patients nor care provider were blinded. Primary outcome was Harris Hip Score at 5-years follow up.ResultsSeventy-five were included and allocated to the MoM-LDH-THA (n = 39) and MoM-HR (n = 36) group. The study was prematurely stopped due to numerous reports of adverse events in patients with MoM hip replacements. Thirty-three in the MoM-LDH-THA and 25 in the MoM-HR group were available for primary outcome analysis.Median Harris Hip Score was 100 (IQR: 98–100) for MoM-LDH-THA and 100 (IQR: 93–100) for MoM-HR (p = 0.486). SF-36 score was high in both groups with no significant difference between groups.ConclusionHarris Hip Score and SF-36 score was excellent in both groups with no significant difference at 5-years follow up. Our findings suggest that there is no clinical important difference between the two prostheses implanted 5 years after implantation.Trial registrationClinicalTrials.gov, NCT04585022, Registered 23 September 2020 – Retrospectively registered.This study was not prospectively registered in a clinical trial database since it was not an entirely implemented standard procedure in the international orthopedic society when the study was planned.

Implementation of a perioperative-enhanced recovery protocol in patients undergoing open gastrectomy for gastric cancer.

The purpose of this study was to compare surgical outcomes before and after implementation of an enhanced recovery protocol (ERP) in gastrectomy for gastric cancer. We included patients who underwent open gastrectomy for gastric cancer before (January 2016 to September 2018) or after (October 2018 to September 2020) ERP implementation. The primary outcome was the postoperative length of stay (LOS). Secondary outcomes included 90-day readmission rates and Clavien-Dindo grade ≥ 3 complications. One hundred patients underwent gastrectomy before (pre-ERP group) and 52 underwent gastrectomy after (ERP group) protocol implementation. Demographic and clinicopathologic characteristics were similar. The median (interquartile range) postoperative LOS was shorter in the ERP group (7.0 days [6.0-8.0] vs. 8.0 days [7.0-11.0];p < 0.001). The ERP group had similar rates of readmission (33% vs. 24%; p = 0.34) and grade ≥ 3 complications (19% vs. 19%; p = 1.0) compared to the pre-ERP group, but experienced lower rates of surgical wound complications (0% vs. 19%; p < 0.001). Rates of other complications were similar. Implementation of an ERP in patients undergoing open gastrectomy for gastric cancer is feasible and safe and has the potential to decrease postoperative LOS without increasing complication rates.

Cardiogenic shock without hypotension in acute myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cardiogenic Shock(CS)complicates 10%of Acute Myocardial Infarction(AMI), being the main cause for intra-hospital death in these patients.Although early revascularization has contributed to increase survival,mortality still presents high, being 40-50%.CS usually presents with inadequate cardiac output and persistent hypotension.However,after large AMI,peripheral hypoperfusion can occur with sustained or borderline systolic blood pressure(SBP). Purpose Characterize patients(pts)with CS after AMI in the absence of hypotension(defined as SBP &amp;lt; 90mmHg),and assess impact in mortality. Methods We evaluated 528pts presenting with CS in context of AMI.We considered 2groups:Group 1-Pts who had SBP ≥90mmHg,without any inotropic drug or assist device and 2-Pts with SBP &amp;lt; 90mmHg.We registered age,gender,co-morbidities,presentation,coronary anatomy and treatment strategies.We evaluated in-hospital mortality and complications:re-infarction,mechanical complications,high-grade atrioventricular block(AVB),sustained ventricular tachycardia,atrial fibrillation,resuscitated cardiac arrest and stroke. Results AMI presenting as Cardiogenic Shock without hypotension(CSWH)was found in 51%of pts(n = 272),of whom 69%were male.They were younger(between age of 45-64years old in 34%of cases vs 25%,p = 0.040)and had higher body mass index (27.3 ± 4.5vs 26 ± 4.1,p = 0.001).Hypertension was a similarly distributed comorbidity.In group 1,pts were previously more frequently under beta blocker medication (25.2%vs 17.7%,p = 0.047).In this group,mean left ventricular (LV)ejection fraction was 39 ± 13%,a quarter having severely depressed LV function(&amp;lt;30%).Although STEMI was the most common presentation in both sets(73.5% vs 87.1%,p &amp;lt; 0.001),NSTEMI was more prevalent in CSWH(23.9%vs12.1%,p &amp;lt; 0.001).Those pts presented more,at admission,with dyspnea(14.9%vs5.5%,p &amp;lt; 0.001)and in sinus rhythm(81.9%vs69%,p &amp;lt; 0.001).In this group,ICU admission was less frequent(19.4%vs27.2%,p = 0.036),and only about half of pts were medicated with inotropic drugs(vs 78.1%,p &amp;lt; 0.001).However,difference in intra-aortic balloon use wasn’t found.CSWH presented with multivessel disease in 63.8%of pts,being LAD more frequently the culprit vessel(42.4% vs 30.7%,p = 0.030),but fewer left main artery(LM)(4.2%vs14.0%,p = 0.003).Group 1 had fewer prevalence of vessel occlusion,which was particularly true for LM(3.8%vs11.5%,p = 0.015) and circumflex(12.4%vs20.7%,p = 0.047),and were less often submitted to revascularization.Group 1 had fewer AVB(9.8%vs22.4%,p &amp;lt; 0.001).Rates of other complications were similar.In-hospital mortality was higher in classic CS(33.1% vs 43.8%, p= 0.012). Conclusion Cardiogenic Shock without hypotension was found in about half of pts with CS due to AMI.A majority of these were younger and globally had a less severe event and complications.Even though CSWH was associated with one third of in-hospital mortality,it was lower than in pts with hypotension.

Safety and efficacy of Angio-Seal device for transfemoral neuroendovascular procedures: A systematic review and meta-analysis.

Angio-Seal is a commonly used device for femoral hemostasis in neuroendovascular procedures. This meta-analysis investigates of the safety and efficacy of Angio-Seal in patients undergoing endovascular neurointerventional procedures. A systematic review and meta-analysis on all studies evaluating the Angio-Seal device in neurointerventional procedures from inception through 2020 were performed. We studied rates of groin hematoma, retroperitoneal hematoma, pseudoaneurysm, ipsilateral DVT, and ischemic complications. Meta-analysis was performed using the random-effects model. 13 studies were included in our analysis. 2250 patients with 104 complications were found {4.5% (95% CI, 2.7%-6.3%)}. Of these complications, groin hematoma was the most common with a rate of 2.4% (95% CI, 1.1%-3.6%). Retroperitoneal hematoma {0.3% (95% CI, 0%-0.5%)}, pseudo-aneurysm {0.5% (95% CI, 0.2%-0.8%), and ipsilateral DVT {0.3% (95% CI, 0.1%-0.7%) were also not in negligible rate. The rate of other complications were as follows: vessel occlusion/stenosis; 0.2% (95% CI, 0%-0.4%), vascular surgery; 0.2% (95% CI, 0%-0.5%), and infection; 0.2% (95% CI, 0%-0.5%). One patient died as result of hemorrhagic complications {0.1% (95% CI, 0%-0.3%)}. Use of anticoagulant/antiplatelet therapy was found to be positively correlated with high risk of any groin complication and groin hematoma (p ≤ .05). Female gender was associated with high risk of ipsilateral DVT (p ≤ .05). Interestingly, large sheath size was associated with low risk of groin hematoma (p ≤ .05). The safety and efficacy rate of Angio-Seal was approximately 95%. The most common complication was groin hematoma. Serious complications including retroperitoneal hematoma and femoral artery occlusion were rare.

Effect of Enteral Lipid Supplement on Severe Retinopathy of Prematurity

Lack of arachidonic acid (AA) and docosahexaenoic acid (DHA) after extremely preterm birth may contribute to preterm morbidity, including retinopathy of prematurity (ROP). To determine whether enteral supplementation with fatty acids from birth to 40 weeks' postmenstrual age reduces ROP in extremely preterm infants. The Mega Donna Mega trial, a randomized clinical trial, was a multicenter study performed at 3 university hospitals in Sweden from December 15, 2016, to December 15, 2019. The screening pediatric ophthalmologists were masked to patient groupings. A total of 209 infants born at less than 28 weeks' gestation were tested for eligibility, and 206 infants were included. Efficacy analyses were performed on as-randomized groups on the intention-to-treat population and on the per-protocol population using as-treated groups. Statistical analyses were performed from February to April 2020. Infants received either supplementation with an enteral oil providing AA (100 mg/kg/d) and DHA (50 mg/kg/d) (AA:DHA group) or no supplementation within 3 days after birth until 40 weeks' postmenstrual age. The primary outcome was severe ROP (stage 3 and/or type 1). The secondary outcomes were AA and DHA serum levels and rates of other complications of preterm birth. A total of 101 infants (58 boys [57.4%]; mean [SD] gestational age, 25.5 [1.5] weeks) were included in the AA:DHA group, and 105 infants (59 boys [56.2%]; mean [SD] gestational age, 25.5 [1.4] weeks) were included in the control group. Treatment with AA and DHA reduced severe ROP compared with the standard of care (16 of 101 [15.8%] in the AA:DHA group vs 35 of 105 [33.3%] in the control group; adjusted relative risk, 0.50 [95% CI, 0.28-0.91]; P = .02). The AA:DHA group had significantly higher fractions of AA and DHA in serum phospholipids compared with controls (overall mean difference in AA:DHA group, 0.82 mol% [95% CI, 0.46-1.18 mol%]; P < .001; overall mean difference in control group, 0.13 mol% [95% CI, 0.01-0.24 mol%]; P = .03). There were no significant differences between the AA:DHA group and the control group in the rates of bronchopulmonary dysplasia (48 of 101 [47.5%] vs 48 of 105 [45.7%]) and of any grade of intraventricular hemorrhage (43 of 101 [42.6%] vs 42 of 105 [40.0%]). In the AA:DHA group and control group, respectively, sepsis occurred in 42 of 101 infants (41.6%) and 53 of 105 infants (50.5%), serious adverse events occurred in 26 of 101 infants (25.7%) and 26 of 105 infants (24.8%), and 16 of 101 infants (15.8%) and 13 of 106 infants (12.3%) died. This study found that, compared with standard of care, enteral AA:DHA supplementation lowered the risk of severe ROP by 50% and showed overall higher serum levels of both AA and DHA. Enteral lipid supplementation with AA:DHA is a novel preventive strategy to decrease severe ROP in extremely preterm infants. ClinicalTrials.gov Identifier: NCT03201588.

Outcomes and complications of the INFIX technique for unstable pelvic ring injuries with high-velocity trauma: a systematic review and meta-analysis.

The pelvic INFIX technique has been proposed as a useful alternative to symphyseal plating for management of unstable pelvic ring injuries. The minimally invasive nature of the procedure, shorter operative time and less perioperative blood loss have been purported as potential advantages. This systematic review and meta-analysis were conducted to determine the outcomes and complications of the INFIX technique for unstable pelvic ring injuries. A systematic review of literature was performed on the PubMed, EMBASE and Scopus databases. Prospective and retrospective studies in all languages, whether comparative or non-comparative, pertaining to the use of INFIX in pelvic fractures were included. Studies which did not evaluate INFIX, case reports, conference abstracts and those with less than 10 cases were excluded. Cadaveric studies, technique papers and studies that did not describe the prespecified outcome measures were also excluded. Meta-analysis consisted of two different arms: a comparative arm, to compare INFIX to symphyseal plating, and a non-comparative meta-analysis arm, to determine pooled rates of outcomes and complications. Risk of bias was determined by the Methodological Index for Non-Randomised Studies (MINORS) tool. A total of 22 studies were included in the systematic review, of which 7 were comparative and 15 were non-comparative. 746 patients were included for qualitative analysis and pooled analysis done for 589 patients. The average follow-up of these studies ranged from a minimum of 5.4months to a maximum of 54months. Comparative meta-analysis (n = 3 studies) of plating and INFIX showed significantly lesser blood loss (mean difference = 176.46mL; 95% CI -207.54 to -145.38) and shorter operative time (mean difference = 26.43min, 95% CI -31.79 to -21.07) with INFIX, but no significant difference in the overall complication rates (OR 1.59, 95% CI 0.83-3.05) and functional outcome scores (mean difference = -2.51, 95% CI -5.73 to 0.71). Pooled analysis showed overall good radiological (mean percentage of excellent to good reduction = 91.4%, 95% CI 0.860-0.969) and functional outcomes (mean Majeed score = 86.48, 95% CI 83.34-89.61) with INFIX. The most common complications were lateral femoral cutaneous nerve (LFCN) injury (overall rate 28%, 95% CI 15.1-41%) and heterotopic ossification (HO) (overall rate 9.4%, 95% CI 5.5-13.3%); rates of other complications were low. Significant heterogeneity was noted in the pooled analysis of blood loss, operative time, functional outcome, HO and LFCN injury. The overall strength of evidence was found to be weak. The INFIX technique can be considered as a viable alternative to symphyseal plating for unstable pelvic ring injuries. It has the advantages of shorter operative times and less blood loss, along with comparable functional outcomes, when compared to plating. Overall, good functional outcomes can be expected. However, well-designed, multi-center randomized controlled trials are needed to conclusively prove the benefit of this technique.

Comparison of single-step renal dilatation and serial renal dilatation in percutaneous nephrolithotomy: A retrospective case-control study.

Background:Access to the pelvi-calyceal system and subsequent dilatation of the tract are among the initial important steps in percutaneous nephrolithotomy (PCNL). In this study, we share our experience with single-step renal dilatation when compared to multiple serial renal dilatation in PCNL.Materials and Methods:This is a retrospective study wherein 35 patients who underwent PCNL by single-step renal dilatation by appropriate size Amplatz Dilator were compared with 35 patients who underwent multi-step serial renal dilatation using serial metallic Alken dilators. These patients were analyzed on the basis of demographic profile, total intra-operative time, fluoroscopic time, intra-operative and postoperative complications, stone clearance, requirement of blood transfusion, duration of hospital stay, and follow-up.Results:There were no significant differences in the demographic profile among the patients in these two groups. The mean total operative duration and fluoroscopic duration were less in single step renal dilatation group, and these have been found to be statistically significant (P < 0.05). There were no statistically significant differences in the rates of other complications – incomplete stone clearance, bleeding and hematoma formation, requirement of blood transfusion, duration of hospital stay, and follow-up.Conclusion:Operative duration and rate of radiation exposure are significantly less in PCNL by single-step renal dilatation; however, there is no statistically significant difference in the rates of other complications.

Comparison of outcomes between endoscopic and microscopic transsphenoidal surgery for the treatment of pituitary adenoma: a meta-analysis.

Pituitary tumors are among the most common intracranial tumors. Surgical resection is the most effective treatment for patients with pituitary tumors. Microscopic transsphenoidal surgery has become the first-choice surgical approach to treating this malignancy, although it has certain limitations. Neuroendoscopy has also been widely used for pituitary tumor surgery in recent years. This study aimed to compare the efficacy and safety of these two surgical options for the treatment of pituitary tumors. We conducted a literature search of the PubMed, Embase, Cochrane Controlled Center Register of Controlled Trials (CENTRAL), Web of Science database, Google Scholar, and Baidu Scholar. Relevant articles published up to September 25, 2020 were retrieved and then meta-analyzed using RevMan software 5.1. A total of 29 case-control studies involving 7,774 patients were included in the meta-analysis. There was no significant difference in gross tumor removal (GTR) (RR =1.11, 95% CI: 0.97-1.26, P=0.12) or hormone excess secretion (HES) remission (RR =1.08, 95% CI: 0.97-1.21, P=0.16) between the two groups. Endoscopic transsphenoidal surgery was associated with a lower incidence of diabetes insipidus (DI) than was microscopic transsphenoidal surgery (RR =0.76, 95% CI: 0.60-0.97, P=0.03). Endoscopic transsphenoidal surgery does not significantly improve GTR or HES remission, but it can reduce the incidence of DI without increasing the rates of other complications.

Endoscopic endonasal surgery for anterior cranial fossa meningiomas.

Meningiomas along the anterior skull base arise from the midline but have historically been resected via open cranial approaches with lateral to medial trajectories. The endoscopic endonasal approach (EEA) offers a direct, inferomedial approach which has demonstrated several superior qualities for their resection. These meningiomas include tuberculum sellae, planum sphenoidale, and olfactory groove meningiomas. While early gross total resection (GTR) was lower than open approaches, EEA has currently achieved comparable rates of GTR and significantly improved postoperative visual outcomes. Rate of cerebrospinal fluid (CSF) leak was one of the early complicating features preventing widespread use of EEA. However, CSF leak rates have dramatically fallen into a tolerable range with introduction of the vascularized nasoseptal flap. Olfactory groove meningiomas often present with anosmia which is persistent after endonasal approach. Rates of other complications have proven similar between EEA and open approaches and include: vascular injury, infection, morbidity, and mortality. With the appropriate team and experience, EEA for anterior skull base meningiomas is increasingly becoming the standard for resection of these lesions. However, there are certain anatomic considerations, patient features, and other aspects which may favor the open approach over EEA, and vice versa; these must be carefully and judiciously evaluated preoperatively. Overall, resection and recurrence rates are comparable, complication rates fall within a very acceptable range, and patients experience superior cosmesis and improved visual outcome with this approach.

Parathyroidectomy for Tertiary Hyperparathyroidism: A Multi-Institutional Analysis of Outcomes

BackgroundPatients with tertiary hyperparathyroidism (HPT) often experience delays between diagnosis and referral for surgical treatment. We hypothesized that patients with tertiary HPT experience similarly high cure rates and low complication rates after parathyroidectomy compared with patients with primary HPT. MethodsWe retrospectively identified patients undergoing parathyroidectomy from the Collaborative Endocrine Surgery Quality Improvement Program for primary or tertiary HPT from January 2014 to April 2019. Patients were categorized according to their primary diagnosis and compared for cure rates and surgical complications. ResultsThe study included 9030 patients, with 334 (3.7%) being treated for tertiary HPT. Parathyroidectomy provided a high cure rate (93.7%) in patients with tertiary HPT. However, adjusting for age, sex, and prior thyroid or parathyroid surgery, tertiary HPT was associated with a greater chance of persistent disease than was primary HPT (odds ratio: 2.3, 95% confidence interval: 1.3-4.0). Overall, complications were low for patients across both groups. However, patients with tertiary HPT were more likely to present to the emergency department (7.5% versus 3.3%; P < 0.001), be readmitted (5.1% versus 1.1%; P < 0.001), and develop a hematoma (1.5% versus 0.2%; P = 0.002). Both groups of patients shared similarly low rates of other complications, including mortality, vocal cord dysfunction, and surgical site infections (P < 0.5% for all). ConclusionsPatients undergoing parathyroidectomy for tertiary HPT experience high cure rates and low complication rates. However, tertiary HPT is associated with a greater chance of persistent disease and select complications. Nevertheless, the low rates of persistent disease and complications should not deter early referral for the treatment of tertiary HPT.