Reason For Reoperation Research Articles

P-259 Laparoscopic gastrectomy: our technique, complications and long-term oncological results

Introduction: Although laparoscopic gastrectomy (LGE) has become a standard treatment of early gastric cancer (GC) in Japan and South Korea, it doesn't have wide spread in other World. We want to represent our experience in performing LGE with analysis of short postoperative and long oncological results. Methods: Since 2011 we have done 87 LGE with D1+ or D2 lymphadenectomy (according to Japanese Gastric Cancer Treatment Guidelines 2010 (version 3)). There were 64 total and 23 subtotal LGE among them. Distribution for stages was: IA – 2 (2.3%), IB – 7 (8.1%), IIA – 16 (18.4%), IIB – 43 (49.4%), IIIA – 8 (9.2%), IIIB – 6 (6.9%), IIIC – 5 (5.7%). Thus 79 (90.8%) of patients had advanced stage (cT3-4, N0-2) and 82 (94.3%) received perioperative chemotherapy. In 10 cases extended resections were done: splenectomy (4), colon resection (2), hepatic (3), distal pancreatic (1). We used 5-6 trocars and 5-6 cm laparotomy for specimen extraction. In 6 cases transvaginal route for specimen retrieval were used. Anastomoses after Roux-an-Y reconstruction were performed using circular staplers (37), linear (45) and intracorporeal manual suture (5) for BI-reconstruction after distal LG. Results: Mean age was 57.8 (37-78) years. Mean operating time - 245 (160-550) minutes for total LGE and 235 (155-420) – for subtotal. Mean intraoperative blood loss - 95 (50-1100) ml. Mean postoperative hospital stay - 7.9 (4-24) days. Mean number of resected lymph nodes - 24.3 (8-60). All patients had R0 resection margins. There were no conversions to laparotomy. 30-day postoperative complications were registered in 28 (32.2%) patients. Among them grade IIIB-IV complications (according to Clavien-Dindo, 2004 classification) were in 12 (13.8%). Anastomotic leaks occurred in 5 (5.7%). Reoperations were done in 8 (9.2%). Reasons for reoperation were: anastomotic leak (4), bleeding (3) and anastomotic stricture (1). Mortality rate was 2.3% (2 patients died). Long-term oncologic results were assessed in 72 cases. One-year overall survival rate was 80.1%, 2-year – 64.3%, 3-year – 62.7% and 4-year – 55.6%. One-year progression-free survival (PFS) rate was 64.4%. PFS rates for 2, 3 and 4-years were 53.6, 52.9 and 50.3% respectively. Conclusion: Laparoscopic gastrectomy is feasible and safe method for patients even with advanced stage of gastric cancer. It has acceptable postoperative and long-term oncological outcomes in compare with open procedure.

Current Trends and Controversies in Breast Augmentation.

A survey was conducted to study current attitudes and common practices in breast augmentation. A 35-item electronic questionnaire was sent to the entire active American Society of Plastic Surgeons membership. It was divided into current controversies, new technologies, common practices, secondary procedures, and member demographics. There were 1067 respondents. Fifty percent of surgeons never use anatomically shaped implants and another 42 percent do so less than half the time. Autologous fat is used infrequently as a primary technique but more often as a supplemental technique. Approximately 7 percent report a case of anaplastic large cell lymphoma. Eighty-five percent do not use preoperative three-dimensional imaging. More than half of surgeons use acellular dermal matrix in secondary procedures. Approximately half do not use insertion funnels. Preoperative sizing with silicone implants, inframammary incisions, partial submuscular pockets, and smooth silicone implants larger than 300 cc are dominant practice preferences. Postoperative massage is still popular with over half of respondents. Just over half do not use pharmacologic agents for capsular contracture. Capsular contracture and size change were the most frequent reasons for reoperation. Capsular contracture is typically treated with anterior capsulectomy the first time, and either total capsulectomy or anterior capsulectomy with acellular dermal matrix use when recurrent. Almost half of respondents perform fewer than 50 breast augmentations yearly. There is an established most common approach to breast augmentation among respondents. Most surgeons are slow to embrace controversial practices and to adopt new technologies, although acellular dermal matrix use is becoming more popular. The 7 percent incidence of anaplastic large cell lymphoma was noteworthy.

The Incidence of Subsequent Surgery After Outpatient Arthroscopic Rotator Cuff Repair

To quantify the incidence and risk factors associated with subsequent shoulder procedures in individuals undergoing outpatient arthroscopic rotator cuff repair (ARCR). We examined the New York Statewide Planning and Research Cooperative Systems outpatient database from 2003 through 2014 to identify patients undergoing isolated ARCR with or without concomitant acromioplasty. Patients were longitudinally followed up for a minimum of 2 years to determine the incidence of subsequent ipsilateral shoulder surgery. The impact of age, sex, insurance, concomitant acromioplasty, and tobacco use on reoperation was explored. Between 2003 and 2012, 30,430 patients underwent isolated ARCR. The mean age was 56.6 ± 11.5 years, and 55.1% were male patients. A total of 1,826 patients (6.0%) underwent subsequent ipsilateral outpatient shoulder surgery a mean of 24.3 ± 27.1 months after the initial ARCR. Of patients who underwent repeat surgery, 57.3% underwent a revision cuff repair. Patients who underwent additional outpatient shoulder surgery were significantly younger (53.7 ± 10.9 years v 56.8 ± 11.5years, P < .001). Tobacco use was associated with an increased rate of subsequent surgery (7.3% v 5.9%, P= .044) and accelerated time to reoperation (16.9 months v 24.7 months, P < .001). Independent risk factors for subsequent ipsilateral surgery after initialARCR were presence of a Workers' Compensation claim (odds ratio, 2.11; 95% confidence interval, 1.89-2.36; P<.001) and initial ARCR without acromioplasty (odds ratio, 1.20; 95% confidence interval, 1.09-1.34; P < .001). We identified a 6.0% incidence of repeat ipsilateral surgery after isolated ARCR. Although reasons for reoperation are likely multifactorial, younger age, Workers' Compensation claim, and absence of acromioplasty at the time of initial ARCR remained independent predictors of subsequent outpatient procedures, whereas a history of tobacco use was associated with accelerated time to subsequent surgery. Level III, retrospective comparative study.

Reoperation rates in minimally invasive, hybrid and open surgical treatment for adult spinal deformity with minimum 2-year follow-up.

Minimally invasive surgical (MIS) techniques are gaining popularity in the treatment of adult spinal deformity (ASD). The premise is that MIS techniques will lead to equivalent outcomes and a reduction in perioperative complications when compared with open techniques. Potential issues with MIS techniques are a limited capacity to correct lumbar lordosis, unknown long-term efficacy, and the potential need for revision surgery. This study compares reoperation rates and reasons for reoperation following MIS, hybrid, and open surgery for ASD through multicenter database analysis. We retrospectively analyzed a prospective multicenter ASD database comparing open and MIS correction techniques. Inclusion criteria were: age>18years with minimum 20° coronal lumbar Cobb angle, a minimum of three levels fused, and minimum 2-year follow-up. Patients were propensity matched for preoperative sagittal vertebral axis (SVA), pelvic incidence-lumbar lordosis (PI-LL), and number of levels fused. We included 189 patients from three propensity-matched subgroups of 63 patients each: (1) MIS: lateral or transforaminal lumbar interbody fusion (LIF) and percutaneous pedicle instrumentation, (2) Hybrid: MIS LIF with open posterior segmental fixation (PSF), and (3) OPEN: open posterior fixation±osteotomies. With propensity matching, there were significant differences between groups in pre-op SVA or PI-LL (p>0.05). The MIS group had significantly fewer levels fused (5.4) (0-14) than the OPEN group (7.4) (p=0.002) (0-17). The rate of revision surgery was significantly different between the groups with a higher rate of revision (27%) amongst the HYB group versus MIS=11.1%, and OPEN=12.0%. The most common reason for reoperation in the OPEN and HYB groups was a postoperative neurological deficit (7.9 and 11.1%), respectively. The most common reason for reoperation in the MIS group was pseudoarthrosis (7.9%). Reoperation rates were not statistically different among the MIS, and OPEN surgical groups, but differed significantly on multivariate analysis with HYB group. The incidence of reoperations was twice as high in the Hybrid group compared to OPEN and MIS.

Meniscal Allograft Transplantation in the Adolescent Population

To report the results of meniscal allograft transplantation (MAT) with minimum 2-year follow-up in an active adolescent population. After institutional review board approval, all patients aged 16years or younger who underwent MAT and had more than 2years' clinical follow-up were identified from a prospectively collected database. Demographic data were collected and summary statistics calculated. Functional outcome scores were collected preoperatively and at 6months, 1year, 2years, and final follow-up. Differences between scores at each time point were calculated using a mixed-model repeated-measures analysis of variance. All prior procedures and reoperations were documented. Thirty-seven MAT procedures were performed in 36 children (84% lateral and 16% medial). For 32 of these procedures (86%), the patients met the inclusion criteria with minimum 2-year follow-up. The mean age was 15.4 ± 1.04years (range, 13 to 16years). All patients had undergone prior knee surgery. Of the 32 patients, 23 (72%) were girls and 9 (28%) were boys. Eleven patients had open physes. Forty-eight percent of patients underwent concomitant procedures, mainly for chondral defects. The mean length of clinical follow-up was 7.2 ± 3.2years (range, 2 to 15years). MAT resulted in significant improvements in the Knee Injury and Osteoarthritis Outcome Score, Lysholm score, International Knee Documentation Committee subjective score, Western Ontario and McMaster Universities Osteoarthritis Index pain score, Western Ontario and McMaster Universities Osteoarthritis Index function score, and Short Form 12 physical score. After MAT, 7 patients (22%) underwent 8 surgical procedures, most of which were for chondral disease. The meniscal reoperation rate was 6%. No revision MAT procedures were required. No angular deformities or limb-length inequalities were reported. MAT resulted in predictable improvements in functional outcomes in the adolescent population. The meniscal reoperation rate was low (6%), no revision MAT procedures were required, and no growth complications were reported. Chondral disease remains the primary reason for reoperation after MAT. Level IV, therapeutic case series.

The Adult With Repaired Coarctation: Need for Lifelong Surveillance

Because surgical repair for coarctation of the aorta has been performed since 1945, growing numbers of patients with repaired coarctation are reaching adulthood. Primary transcatheter intervention for coarctation emerged as an alternative to surgery after 1983, and it provides comparable relief of the aortic gradient with few complications at a cost of an increased need for reintervention and a higher risk of aneurysm after repair. Although short-term outcomes are good after coarctation repair, alterations of vascular form and function persist. Mortality is increased after coarctation repair compared with that in the general population, which is related to several predictable complications. Hypertension mediates much of the late morbidity with increased rates of stroke, coronary artery disease, and heart failure after coarctation repair. Prevalence of hypertension in patients with coarctation increases over time, with a majority of patients being affected by middle age. Other late complications include recoarctation, which can usually be addressed with percutaneous balloon dilation and stenting with covered stents. Aneurysms at the coarctation repair site and the ascending aorta require surveillance with imaging and timely treatment. Intracranial aneurysms occur 5 times more commonly in patients with coarctation than in the general population. Finally, bicuspid aortic valve disease, which is present in at least half of these patients, requires surveillance and ultimately becomes the most common reason for reoperation. Awareness, identification, and appropriate treatment of long-term complications after coarctation repair are paramount to reducing long-term morbidity and mortality.

Predictors of reoperation after sacral neuromodulation: A single institution evaluation of over 400 patients.

To explore factors that may predispose patients to reoperation after sacral neuromodulation (SNM). Patients enrolled in our longitudinal neuromodulation database were reviewed. Medical records data, and voiding diaries, Interstitial Cystitis Symptom-Problem Indices (ICSI-PI), and Overactive Bladder Questionnaires (OAB-q) at baseline and 3 months were analyzed with Pearson's χ2 , Fisher's Exact test, Wilcoxon rank tests, and multivariable logistic regression. Of 407 patients, 134 (33%) had at least one reoperation over median 28.9 months follow-up (range 1.6-121.7); 78/407 (19%) were revised, and 56/407 (14%) were explanted. The most common reason for reoperation was lack of efficacy/worsening symptoms (n = 87). The reoperations group had a higher proportion of women (P = 0.049), lower mean body mass index (BMI; P = 0.010), more reprogramming events (P < 0.0001), longer median follow-up (P = 0.0008), and higher proportions with interstitial cystitis (P = 0.013), using hormone replacement therapy (P = 0.0004), and complications (P < 0.0001). Both reoperations/no reoperations groups had similar improvements in ICSI-PI (P < 0.0001 for both), OAB-q severity (P < 0.0001 for both) and quality of life (P < 0.0001 for both). On multivariate analysis, only longer follow-up (P = 0.0011; OR 1.048; CI 1.019, 1.078) and having a complication (P < 0.0001; OR 23.2; CI 11.47, 46.75) were significant predictors of reoperations. In women only, using HRT at time of implant was also predictive of reoperation (P = 0.0027; OR 3.09; CI 1.48, 6.46). In this largest known series to date, one third of the patients required reoperation and the most common reason was lack of efficacy/worsening symptoms. Ongoing study is needed as the technology continues to evolve. Neurourol. Urodynam. 36:354-359, 2017. © 2015 Wiley Periodicals, Inc.

The clinical outcome of minimally invasive Phase 3 Oxford unicompartmental knee arthroplasty: a 15-year follow-up of 1000 UKAs.

There have been concerns about the long-term survival of unicompartmental knee arthroplasty (UKA). This prospective study reports the 15-year survival and ten-year functional outcome of a consecutive series of 1000 minimally invasive Phase 3 Oxford medial UKAs (818 patients, 393 men, 48%, 425 women, 52%, mean age 66 years; 32 to 88). These were implanted by two surgeons involved with the design of the prosthesis to treat anteromedial osteoarthritis and spontaneous osteonecrosis of the knee, which are recommended indications. Patients were prospectively identified and followed up independently for a mean of 10.3 years (5.3 to 16.6). At ten years, the mean Oxford Knee Score was 40 (standard deviation (sd) 9; 2 to 48): 79% of knees (349) had an excellent or good outcome. There were 52 implant-related re-operations at a mean of 5.5 years (0.2 to 14.7). The most common reasons for re-operation were arthritis in the lateral compartment (2.5%, 25 knees), bearing dislocation (0.7%, seven knees) and unexplained pain (0.7%, seven knees). When all implant-related re-operations were considered as failures, the ten-year rate of survival was 94% (95% confidence interval (CI) 92 to 96) and the 15-year survival rate 91% (CI 83 to 98). When failure of the implant was the endpoint the 15-year survival was 99% (CI 96 to 100). This is the only large series of minimally invasive UKAs with 15-year survival data. The results support the continued use of minimally invasive UKA for the recommended indications.

P44. Capsular contracture after breast augmentation: an update for clinical practice

Capsular contracture is the one the most common complications following implant based breast augmentation and remains a common reason for reoperation. Despite this, there is still uncertainty regarding the pathogenesis and the best way to treat capsular contracture, as well as what can be done to reduce its incidence. There is a consensus that contracture occurs due to an excessive fibrotic reaction to a foreign body (the implant) and risk factors include the use of a smooth (vs. textured) implant, a silicone (vs. saline filled) implant, a subglandular (vs. submuscular) placement and previous radiotherapy. Current management involves a capsulectomy or capsulotomy usually, and medical management using the off-label leukotriene antagonist Zafirlukast has been reported to reduce severity and help prevent contracture. However, both approaches are associated with a significant recurrence rate. Recent research has focussed on ways to prevent capsular contracture from developing in the first instance, or novel treatment strategies such as autologous fat transfer.

Natrelle 410 Extra-Full Projection Silicone Breast Implants

Background:The safety and effectiveness of the Natrelle Style 410 highly cohesive silicone gel breast implant (Allergan, Inc., Irvine, Calif.) in full or moderate height and projection have been shown in a 10-year study. Extra-full projection implants may be an appropriate option for some women undergoing breast reconstruction.Methods:A total of 2795 women received at least one Natrelle 410 extra-full projection implant (X-style) for breast reconstruction in two similarly designed, prospective, multicenter studies. Data collected for 2 years after implantation in these studies were pooled to evaluate complication rates and subject and physician satisfaction.Results:Most subjects (76.0 percent) underwent bilateral reconstruction; a total of 4912 devices were implanted. Complication rates at 2 years were low. The most common complications were asymmetry (4.8 percent) and capsular contracture (3.3 percent). The cumulative risk of reoperation was 21.6 percent by subject and 16.6 percent by device; the most common reasons for reoperation were scarring (n = 97), asymmetry (n = 89), implant malposition (n = 78), and infection (n = 71). Subject and physician satisfaction rates exceeded 90 percent. At 2 years, 97 percent of physicians reported that the shape of the breast reflected the shape of the implant, and that the breast implant had maintained its original position.Conclusions:The safety profile of the Natrelle 410 extra-full projection implant mirrors that of its moderate projection and full projection counterparts. Both physicians and subjects were highly satisfied with the implants 2 years after surgery.CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.

Capsular Contracture after Breast Augmentation: An Update for Clinical Practice.

Capsular contracture is the most common complication following implant based breast surgery and is one of the most common reasons for reoperation. Therefore, it is important to try and understand why this happens, and what can be done to reduce its incidence. A literature search using the MEDLINE database was conducted including search terms 'capsular contracture breast augmentation', 'capsular contracture pathogenesis', 'capsular contracture incidence', and 'capsular contracture management', which yielded 82 results which met inclusion criteria. Capsular contracture is caused by an excessive fibrotic reaction to a foreign body (the implant) and has an overall incidence of 10.6%. Risk factors that were identified included the use of smooth (vs. textured) implants, a subglandular (vs. submuscular) placement, use of a silicone (vs. saline) filled implant and previous radiotherapy to the breast. The standard management of capsular contracture is surgical via a capsulectomy or capsulotomy. Medical treatment using the off-label leukotriene receptor antagonist Zafirlukast has been reported to reduce severity and help prevent capsular contracture from forming, as has the use of acellular dermal matrices, botox and neopocket formation. However, nearly all therapeutic approaches are associated with a significant rate of recurrence. Capsular contracture is a multifactorial fibrotic process the precise cause of which is still unknown. The incidence of contracture developing is lower with the use of textured implants, submuscular placement and the use of polyurethane coated implants. Symptomatic capsular contracture is usually managed surgically, however recent research has focussed on preventing capsular contracture from occurring, or treating it with autologous fat transfer.

Reoperation for anastomotic complications of esophageal atresia and tracheoesophageal fistula

Background/PurposeThe purpose of the study was to review our experience in the re-operative management of anastomotic complications (ACs) following primary repair of esophageal atresia (EA) and tracheoesophageal fistula (TEF) and to assess the outcomes after reoperation. MethodsWe retrospectively reviewed 21 EA patients who underwent reoperation from 2005 to 2014. Clinical features, reasons for reoperation, diagnosis of ACs, re-operative procedures and outcomes, as well as long-term follow-up of reoperation were analyzed. ResultsReoperation occurred in 16 recurrent TEF (RTEF) cases (76.2%), 4 severe anastomotic strictures (AS), and 1 anastomotic leakage (AL) cases (19% and 4.8%, respectively). All of AS and AL were confirmed by esophagography. RTEF were confirmed by esophagoscopy and bronchoscopy. All of the cases underwent reoperation successfully. The average operative time and length of post-operative hospital stay were 2.7 ± 0.8 hours and 15.4 ± 3.3 days, respectively. The mortality rate was 4.8%. All of the cases were followed up from 1 to 107 months after reoperation. No patients experienced respiratory or feeding issues. No severe postoperative complications were shown in all re-operative cases. ConclusionsACs including severe AS and AL as well as RTEF are the significant indications for reoperation after EA repair. The reoperation was effective to treat multiple anastomotic complications.

Long-Term Follow-Up of Gastric Banding 10 Years and Beyond.

This investigation assessed the long-term outcome of patients with gastric banding implanted more than 10 years ago. A total of 73 patients undergoing laparoscopic gastric banding between 1997 and 2003 were identified. Patients who had their band removed were converted to a laparoscopic gastric bypass procedure. The mean preoperative body mass index (BMI) was 44.4 (SD 5.3). The mean follow-up was 11.6 (SD 2.1) years. The reasons for reoperation were leakage (N = 16, 21.9 %), slipping (N = 15, 20.5 %), and insufficient weight loss (N = 9, 12.3 %). The band was left in situ in 33 patients (45.2 %). The 5- and 10-year survival rates for the banding were 82.2 % (95 %CI 73.9-91.5 %) and 53.4 % (95 %CI 43.1-66.2 %). Best results were observed in male patients (10-year survival rate 76.5 %, 95 %CI 58.7-99.5 %, HR = 0.44, P = 0.043) and patients older than 50 years (10-year survival rate 63.8 %, 95 %CI 51.5-79.2 %, HR = 0.41, P = 0.006). Overall, the BMI was 31.0 (SD 6.3) at follow-up, excess weight loss was 68.1 % (SD 26.4), and the score for the Moorehead-Ardelt Questionnaire was 1.6 (SD 1.0). Similar results were obtained for patients with and without banding failure. The present investigation provides evidence that gastric banding remains effective after more than 10 years in less than 50 % of initially operated patients. Older (>50 years) and male patients seemed to maintain the banding as long-time carriers with good results, and these patients subjectively profited from this method. Good results can be achieved if patients are followed thoroughly, and alternative surgical options for patients who fail may be offered with longstanding success.

Remodeling Characteristics and Collagen Distributions of Biologic Scaffold Materials Biopsied From Postmastectomy Breast Reconstruction Sites.

The study purpose was to evaluate the associations between patient characteristics and the histologic remodeling scores of acellular dermal matrices (ADMs) biopsied from breast reconstruction sites in the first attempt to generate a multivariable risk prediction model of nonconstructive remodeling. It was hypothesized that host characteristics and surgical site assessments predict the degree of graft remodeling for ADMs used during breast reconstruction. The ADMs were biopsied from the breast reconstruction sites of n = 62 patients during a subsequent breast procedure, stained with hematoxylin-eosin, and evaluated according to a semi-quantitative scoring system for remodeling characteristics (cell types, cell infiltration, extracellular matrix deposition, scaffold degradation, fibrous encapsulation, and neovascularization) and a mean composite score. Biopsies were stained with Sirius Red and Fast Green, and analyzed to determine the collagen I:III ratio. Based on univariate analyses between subject clinical characteristics and the histologic remodeling scores, cohort variables were selected for multivariable regression models using a P value of 0.20 or less. The composite score model yielded 3 variables: pack-year history, corticosteroid use, and radiation timing (r pseudo = 0.81). The model for collagen I yielded 2 variables: corticosteroid use and reason for reoperation (r pseudo = 0.78). The model for collagen III yielded 1 variable: reason for reoperation (r pseudo = 0.35). These preliminary results constitute the first steps in generating a risk prediction model that predicts the patients and clinical circumstances most likely to experience nonconstructive remodeling of biologic grafts used to reconstruct the breast.

Risk Factors for Early Conversion to Total Hip Arthroplasty following Hip Arthroscopy

Objectives:The most common reason for reoperation following arthroscopic hip surgery is conversion to total hip arthroplasty (THA). The purpose of this study was to identify clinical and radiographic risk factors for early conversion to THA.Methods:Data were prospectively collected on all hip arthroscopy patients from January 2009 through December 2011. Inclusion criteria for the study group were patients undergoing hip arthroscopy for a labral tear who eventually converted to THA. Patients were then compared to a control group of patients who underwent hip arthroscopy for a labral tear and did not convert to THA during the same period. Exclusion criteria were patients with previous hip conditions such as Legg-Calves-Perthes, slipped capital femoral epiphysis, pigmented villonodular synovitis, and avascular necrosis. A bivariate analysis of 41 preoperative and intraoperative variables was performed.Results:A total of 792 patients met inclusion and exclusion criteria. A total of 72 (9%) converted to THA. The control group consisted of 720 patients who did not convert to THA. Bivariate analysis demonstrated that the study group had significantly higher means or frequencies than the control group for the following variables: male gender, age at time of surgery, BMI, back pain, previous back surgery, Tönnis grade above 0, acetabular inclination angle, alpha angle, Seldes combined-type labral tear, labral tear size, chondral injury, traction time, labral debridement (versus repair), number of anchors used repair or reconstruction, and capsular release (versus repair). The study group had significantly lower means or frequencies than the control group for the following variables: preoperative patient reported outcome scores, crossover sign, lateral center edge angle, and psoas release. A statistically significant difference in average joint space was not observed.Conclusion:Multiple risk factors are possible preoperative and intraoperative risk factors for conversion to THA following hip arthroscopy. The clinician and patient should be aware of these variables.

Analysis the reasons of emergency reoperation after skull base surgery: report of 14 cases

Objective To report the clinical features of the patients who underwent emergent re-craniotomy after skull base operation. Methods A serial of 14 cases of reoperation after elective surgery in the Department of Neurosurgery, Beijing Tiantan Hospital between October 2008 and October 2013 were reviewed. Six cases were skull basal meningioma, 3 schwannoma, 1 pituitary adenoma, 1 craniopharyngioma, 1 chondroma, 1 angioleiomyoma, and 1 glomus jugular tumor. The mean length of first operation time was 9.2 h, and the mean amount of bleeding was 2 750 ml. The reason of reoperation was evaluated by the surgeons and experts, and then approved by all doctors. Results The clinical features of these reoperation patients included altered level of consciousness in 9 cases, unrecovered from anesthesia in two, abnormal CT scan in two and one sudden bleeding in wound. The mean time of abnormal CT scan was 17 h. As for the reason for reoperation, the tumor cavity bleeding was found in 4 cases, intracerebral hematoma and brain contusion in 4, massive brain infarction in 2, intracerebral hematoma and subdural hematoma in 1, epidural hematoma in 2, and vertebral artery dissection in 1. Six patients lived a normal life after the second operation, 2 moderate disability, 2 severe disability, 1 persistent vegetative state, and 3 died. Conclusion For skull base surgery, the perioperative management should be reinforced to decrease the emergency reoperation. Key words: Neurosurgical procedures; Skull base neoplasms; Reoperation

The treatment of perilunate injuries.

Perilunate dislocations and fracture-dislocations (PLD-PLFD) continue to both fascinate and puzzle wrist surgeons. There are several reasons for this. This acute, high-energy injury, which often occurs in young, active males, results in one of the most complex combinations of osseous and/or ligamentous lesions that can be encountered at the wrist. The late sequelae of this injury can be devastating and include carpal instability, arthritis, pain, and functional impairment. A PLD-PLFD is never exactly the same from one patient to another in terms of pathology and displacement, which is why investigators have striven to develop a classification that can aid in understanding the pathology specific to each case and in planning treatment. No displaced variants of this injury, or PLIND, have recently been recognized. The number of cases that are seen even at specialized centers is small, which makes it difficult to study the outcomes of the different treatment protocols. Toward the end of the last century, it became apparent that the results following an early open reduction and pinning combined with ligament repair were far superior to a closed reduction and casting alone in terms of long-term carpal stability and scaphoid healing. A closed reduction in the emergency room, followed by early surgery within 48 hours of injury, has thus become the gold standard. Despite the maintenance of an anatomic alignment, however, the development of long-term, post-traumatic midcarpal arthrosis is the rule, although it may be asymptomatic. Since 2000, a variety of investigators have attempted to apply mini-invasive techniques, including wrist arthroscopy, to the treatment of acute PLD-PLFDs, with the goal of improving wrist motion and reducing the incidence of late arthrosis. Arthroscopy has allowed the surgeon to visualize the pathology without the need for extensile incisions and has expanded the options for percutaneous fixation. The reader must remember, however, that not all PLD-PLFDs such as scapho-capitate syndrome, are amenable to these techniques. Any mini-invasive technique must also match the outcomes seen following open surgery. In some cases, an immediate salvage procedure may be indicated. The special focus session for this issue hones in on the treatment of perilunate injuries. It includes an innovative paper by Dr. Ring and colleagues that examines the reasons for reoperation after surgical treatment of PLD-PLFD, a paper on the use of temporary external fixation and adjuvant pinning for polytraumatized patients by Dr. Olga Savvidou and colleages, as well as three papers on arthroscopic management by Drs. Park et al, Dr. Bo, and myself that highlight the use of arthroscopy or the combination of arthroscopy and mini-open techniques.

Diagnosis and therapy of particle disease in total hip arthroplasty

Particle disease is caused by periarticular accumulation of attrition particles and the inflammatory reaction of the body's tissue. This process may result in osteolysis or soft tissue transformation which presents itself symptomless in the beginning and can proceed to aseptic implant loosening, fracture, implant breaking as a result of the inappropriate osseous support and to algetic and destructive soft tissue reactions as well. Attrition particles originate from tribological pairing, and the extent of the attrition or the particle concentration depend on different factors as there are the tribological pairing's material, the head size, the patient's level of activity, and the implant position. Attrition particles can also be found in the range of any modular connection. Particle disease and its resulting morphological alterations of the tribological pairing is one of the most frequent reasons for re-operation in hip endoprosthetics.

Does endoscopic retrograde cholangiopancreatography have a negative effect on laparoscopic cholecystectomy?

We have observed that patients who had undergone endoscopic retrograde cholangiopancreatography (ERCP) had some difficulties with laparoscopic cholecystectomy procedures. Through a retrospective study, we planned to compare the surgical procedures between patients who had undergone ERCP and those who had not in order to clarify this. The results of 122 patients who had undergone ERCP because of choledocholithiasis before undergoing laparoscopic cholecystectomy procedures between 2008 and 2011 were compared to the values of 2140 patients operated because of cholelithiasis only within the same period. Among the patients who underwent surgical procedures following ERCP, 80 (65%) were female and 42 (35%) were male. The average age of the patients was 51.9 years (range: 20-83 years). The operation period after the procedure was 30.14 days (range: 1-93 days). Although the hospitalization period was 4.67 days (range: 1-22 days), the postoperative hospitalization period was 2.68 days (range: 1-15 days). Regarding the difficulty of operation, adhesion in 58 (47.5%) patients, bleeding in two (1.6%) patients, and conversion to open procedure in 12 (9.8) patients were observed. In two (1.6%) patients, bleeding and biliary fistula were the reasons for re-operation. Laparoscopic cholecystectomy is more complicated in patients who underwent ERCP.

MP89-03 THE IMPACT OF PRIOR BACK SURGERY ON UROLOGIC DIAGNOSES AND NEUROMODULATION OUTCOMES

INTRODUCTION AND OBJECTIVES: Many patients benefit from sacral neuromodulation (SNM) yet some do not achieve significant clinical improvements. Patients that fail SNM may benefit from increased afferent stimulation via tined lead placement at the pudendal nerve. We evaluated 2-year outcomes in patients that had a pudendal lead placed after failed sacral neuromodulation (SNM). METHODS: Adults enrolled in our prospective observational neuromodulation study that had a pudendal lead placed were evaluated. Medical records were reviewed. Outcomes were measured at 3, 6, 12 and 24 months with Interstitial Cystitis Symptom/Problem Indices (ICSI-PI), Overactive Bladder Questionnaire (OABq) symptom and quality of life (QOL) domains, voiding diaries, and Global Response Assessments (GRA). Data were examined with Pearson’s Chi-square, Fisher’s Exact, and Wilcoxon rank sum tests. RESULTS: Of 103 patients that had a pudendal lead placed, 48 (46.6%) had prior SNM (mean age 54 18 years; 85% female). Primary urologic diagnoses were urinary urgency/frequency with urge incontinence (18/48; 37.5%), interstitial cystitis/bladder pain syndrome (11/48; 22.9%), urgency/frequency (8/48: 16.7%), urinary retention (8/48; 16.7%), and pelvic pain (3/48; 6.3%). Mean operative time for lead placement was 48 19 minutes and 45/48 (93.8%) underwent generator implantation. Overall, 11 patients required 12 reoperations after lead implant; 5 of these occurred within the first 2 years. 4 were explanted at median 42 months (25th, 75th: 21.9, 50.9 months). 10/11 patients had symptom worsening as a reason for reoperation. Lead migration was identified in 2 patients. On average, 45% (range 31 to 50%) of survey responders that had prior SNM reported moderate or marked improvement in urgency, frequency, and urge incontinence at 3, 6, 12, and 24 months on the GRA. Significant improvements were seen over 2 years in ICSI PI composite score (p<0.0001), OABq symptom severity (p<0.0001), and QOL improved (p<0.0001). When compared to pudendal patients that had not had prior SNM, urologic diagnoses, operative time, generator implant rate, reoperations, lead migration, and GRA responses were similar; ICSI-PI and OABq scores also improved significantly over time (p<0.0001 and p<0.0001 respectively). CONCLUSIONS: Pudendal neuromodulation is a reasonable alternative for patients regardless of prior sacral failure.