Repair Attempts Research Articles

Calpastatin Overexpression Preserves Cognitive Function Following Seizures, While Maintaining Post-Injury Neurogenesis.

In the adult mammalian brain, new neurons continue to be produced throughout life in two main regions in the brain, the subgranular zone (SGZ) in the hippocampus and the subventricular zone in the walls of the lateral ventricles. Neural stem cells (NSCs) proliferate in these niches, and migrate as neuroblasts, to further differentiate in locations where new neurons are needed, either in normal or pathological conditions. However, the endogenous attempt of brain repair is not very efficient. Calpains are proteases known to be involved in neuronal damage and in cell proliferation, migration and differentiation of several cell types, though their effects on neurogenesis are not well known. Previous work by our group has shown that the absence of calpastatin (CAST), the endogenous inhibitor of calpains, impairs early stages of neurogenesis. Since the hippocampus is highly associated with learning and memory, we aimed to evaluate whether calpain inhibition would help improve cognitive recovery after lesion and efficiency of post-injury neurogenesis in this region. For that purpose, we used the kainic acid (KA) model of seizure-induced hippocampal lesion and mice overexpressing CAST. Selected cognitive tests were performed on the 3rd and 8th week after KA-induced lesion, and cell proliferation, migration and differentiation in the dentate gyrus (DG) of the hippocampus of adult mice were analyzed using specific markers. Cognitive recovery was evaluated by testing the animals for recognition, spatial and associative learning and memory. Cognitive function was preserved by CAST overexpression following seizures, while modulation of post-injury neurogenesis was similar to wild type (WT) mice. Calpain inhibition could still be potentially able to prevent the impairment in the formation of new neurons, given that the levels of calpain activity could be reduced under a certain threshold and other harmful effects from the pathological environment could also be controlled.

Tried in the Court of Public Opinion

This study expands the empirical study of Benoit’s image repair theory by serving two purposes using a sports context. First, this study will specifically examine criminal transgressions by comparing the effectiveness of image repair attempts by athletes facing domestic violence charges compared to other crimes. Second, this study will look at the effectiveness of using the mortification (apology) strategy in combination with other predominant strategies used by athletes in order to repair one’s image. Using a 3 × 8 factorial experiment involving 490 participants, results showed that athletes facing domestic violence charges are perceived more negatively regardless of their response to the transgression. In addition, results also showed that using mortification in combination with corrective action is the best response for athletes, regardless of the crime. Finally, using the mortification strategy in combination with other strategies is more effective to repair an athlete’s image, suggesting that it may be better to use combination strategies to respond to transgressions.

Permanent knee sensorimotor system changes following ACL injury and surgery.

The cruciate ligaments are components of the knee capsuloligamentous system providing vital neurosensory and biomechanical function. Since most historical primary ACL repair attempts were unsuccessful, reconstruction has become the preferred surgery. However, an increased understanding of the efficacy of lesion-site scaffolding, innovative suturing methods and materials, and evolving use of biological healing mediators such as platelet-rich plasma and stem cells has prompted reconsideration of what was once believed to be impossible. A growing number of in vivo animal studies and prospective clinical studies are providing increasing support for this intervention. The significance of ACL repair rather than reconstruction is that it more likely preserves the native neurosensory system, entheses, and ACL footprints. Tissue preservation combined with restored biomechanical function increases the likelihood for premorbid neuromuscular control system and dynamic knee stability recovery. This recovery should increase the potential for more patients to safely return to sports at their desired intensity and frequency. This current concepts paper revisits cruciate ligament neurosensory and neurovascular anatomy from the perspective of knee capsuloligamentous system function. Peripheral and central nerve pathways and central cortical representation mapping are also discussed. Surgical restoration of a more physiologically sound knee joint may be essential to solving the osteoarthritis dilemma. Innovative rehabilitative strategies and outcome measurement methodologies using more holistic and clinically relevant measurements that closely link biomechanical and neurosensory characteristics of physiological ACL functionare discussed. Greater consideration oftask-specific patient physical function and psychobehavioral links should better delineate the true efficacy of all ACL surgical and non-surgical interventions. Level of evidence IV.

Timing of Surgical Repair After Bile Duct Injury Impacts Postoperative Complications but Not Anastomotic Patency.

Our goal was to determine the optimal timing for repair of bile duct injuries sustained during cholecystectomy. Bile duct injury during cholecystectomy is a serious complication that often requires surgical repair. There is heterogeneity in the literature regarding the optimal timing of surgical repair, and it remains unclear to what extent timing determines postoperative morbidity and long-term anastomotic function. A single institution prospective database was queried for all E1 to E4 injuries from 1989 to 2014 using a standardized tabular reporting format. Timing was stratified into 3 groups [early (<7 days), intermediate (8 days until 6 weeks), and late (>6 weeks) after injury]. Analysis was stratified between those who had a previous bile duct repair or not, including postoperative complications and anastomotic failure as outcome variables in 2 separate multivariate logistic regression models. There were 614 patients included in the study. The mean age was 41 years (range, 15-85 yrs), and the majority were female (80%). The mean follow-up time was 40.5 months. Side-to-side hepaticojejunostomy was performed in 94% of repairs. Intermediate repair was associated with a higher risk of postoperative complications [odd ratio = 3.7, 95% confidence interval (1.3-10.2), P = 0.01] when compared with early and late in those with a previous repair attempt. Sepsis control and avoidance of biliary stents were protective factors against anastomotic failure. Adequate sepsis control and delayed repair of biliary injuries should be considered for patients presenting between 8 days and 6 weeks after injury to prevent complications, if a previous bile duct repair was attempted.

The cervicosternolaparotomy approach for the treatment of graft dysfunction after retrosternal esophageal reconstruction for caustic injuries

ObjectiveThe study purpose was to report the indications, technical aspects, and outcomes of cervicosternolaparotomy during revision surgery after esophageal reconstruction for caustic injuries. MethodsPatients who underwent cervicosternolaparotomy during revision surgery for graft dysfunction between 1999 and 2015 were included. Cervicosternolaparotomy was performed to mobilize and pull up the primary conduit during surgery for strictures (rescue cervicosternolaparotomy) or to allow retrosternal access for management of other graft-related complications (exposure cervicosternolaparotomy). Statistical tests were performed to identify factors associated with primary conduit preservation during rescue cervicosternolaparotomy. ResultsFifty-five patients were included (28 men; median age, 43 years). Median delay between primary reconstruction and cervicosternolaparotomy was 15 months. Exposure cervicosternolaparotomy was performed in 12 patients (22%) for redundancy (n = 8), spontaneous perforation (n = 2), and caustic reingestion (n = 2). Rescue cervicosternolaparotomy was performed in 43 patients (78%) to treat supra-anastomotic (n = 11), anastomotic (n = 23), and diffuse (n = 9) stenosis. During rescue cervicosternolaparotomy, the primary conduit was preserved in 32 patients; median length gain obtained by transplant release was 8 cm. Failure to preserve the primary conduit was associated with previous surgical repair attempts (P = .003) and lack of initial concomitant pharyngeal reconstruction (P = .039). Two patients died (4%), and 35 patients (64%) experienced operative complications. Operative outcomes were similar after rescue and exposure cervicosternolaparotomy. With a median follow-up of 4.4 years, the functional success rate was 85%. ConclusionsCervicosternolaparotomy during revision surgery for graft dysfunction is reliable, is associated with low morbidity and mortality, and has good results.

The role of ICP monitoring in patients with persistent cerebrospinal fluid leak following spinal surgery: a case series.

Cerebrospinal fluid (CSF) leak following spinal surgery is a relatively common surgical complication. A disturbance in the underlying CSF dynamics could be the causative factor in a small group of patients with refractory CSF leaks that require multiple surgical repairs and prolonged hospital admission. A retrospective case series of patients with persistent post spinal surgery CSF leak referred to the hydrocephalus service for continuous intracranial pressure (ICP) monitoring. Patients' notes were reviewed for medical history, ICP data, radiological data, and subsequent management and outcome. Five patients (two males/three females, mean age, 35.4years) were referred for ICP monitoring over a 12-month period. These patients had prolonged CSF leak despite multiple repair attempts 252 ± 454 days (mean ± SD). On ICP monitoring, all five patients had abnormal results, with the mean ICP 8.95 ± 4.41mmHg. Four had abnormal pulse amplitudes, mean 6.15mmHg ± 1.22mmHg. All five patients underwent an intervention. Three patients underwent insertion of ventriculoperitoneal (VP) shunts. One patient had venous sinus stent insertion and one patient underwent medical management with acetazolamide. All five of the patients' CSF leak resolved post intervention. The mean time to resolution of CSF leak post intervention was 10.8 ± 12.9days. Abnormal cerebrospinal fluid dynamics could be the underlying factor in patients with a persistent and treatment-refractory CSF leak post spinal surgery. Treatments aimed at lowering ICP may be beneficial in this group of patients. Whether abnormal pressure and dynamics represent a pre-existing abnormality or is induced by spinal surgery should be a subject of further study.

Long-term results of ligation of intersphincteric fistula tract (LIFT) for management of anal fistula

BackgroundLigation of intersphincteric fistula tract technique is a new sphincter saving method with good results in management of anal fistula, but few studies report long-term follow-up data. Material and methodsThis study investigated the use of ligation of intersphincteric fistula tract as a sphincter saving method based on long term results. This was a retrospective review of prospectively collected data. The study was conducted at two tertiary care university medical centers. 36 patients with complex fistula from January 2010 to January 2014 treated with classic ligation of intersphincteric fistula tract were retrospectively followed. Demographic data, previous repair attempts, the type of the fistula and score of fecal continence were collected. The procedure was performed by colorectal surgeons. Primary healing rate, failures and fecal incontinence score of patients were followed for 6–48 months. ResultsA total of 36 patients underwent ligation of intersphincteric fistula tract during 24 months. The mean age of the patients was 35 years and 50% had two previous attempts at surgery. A total of 25 patients (69/5%) had high transsphincteric fistula. The mean follow up was 27 months. Successful fistula closure was achieved in 63/8% of the patients (23 of 36). The mean time of recurrence was 4.5 weeks. Only one (2/77%) patient reported gas incontinence (score: 3) after the procedure. ConclusionThe recurrence rate and fecal incontinence were measured. The ligation of intersphincteric fistula is a promising sphincter-preserving procedure that is simple and safe. Our study demonstrates favorable long-term results of ligation of intersphincteric fistula tract for management of complex anal fistulas.

Endoscopic repair of cerebrospinal fluid rhinorrhea

IntroductionNasal liquorrhea indicates a cerebrospinal fluid fistula, an open communication between the intracranial cerebrospinal fluid and the nasal cavity. It can be traumatic and spontaneous. ObjectiveThe aim of this study was to assess the outcome of endoscopic repair of cerebrospinal fluid fistula using fluorescein. MethodsThis retrospective study included 30 patients of both sexes, with a mean age of 48.7 years, treated in the period from 2007 to 2015. All patients underwent lumbar administration of 5% sodium fluorescein solution preoperatively. Fistula was closed using three-layer graft and fibrin glue. ResultsCerebrospinal fluid fistulas were commonly located in the ethmoid (37%) and sphenoid sinus (33%). Most patients presented with traumatic cerebrospinal fluid fistulas (2/3 of patients). The reported success rate for the first repair attempt was 97%. Complications occurred in three patients: one patient presented with acute hydrocephalus, one with reversible encephalopathy syndrome on the fifth postoperative day with bilateral loss of vision, and one patient was diagnosed with hydrocephalus two years after the repair of cerebrospinal fluid fistula. ConclusionEndoscopic diagnosis and repair of cerebrospinal fluid fistulas using fluorescein intrathecally has high success rate and low complication rate.

Widespread transcriptional gene inactivation initiated by a repair intermediate of 8-oxoguanine.

DNA damage can significantly modulate expression of the affected genes either by direct structural interference with transcription components or as a collateral outcome of cellular repair attempts. Thus, DNA glycosylases of the base excision repair (BER) pathway have been implicated in negative transcriptional response to several spontaneously generated DNA base modifications, including a common oxidative DNA base modification 8-oxoguanine (8-oxoG). Here, we report that single 8-oxoG situated in the non-transcribed DNA strand of a reporter gene has a pronounced negative effect on transcription, driven by promoters of various strength and with different structural properties, including viral, human, and artificial promoters. We further show that the magnitude of the negative effect on the gene expression correlates with excision of the modified base by OGG1 in all promoter constructs tested. Moreover, by using expression vectors with nuclease resistant backbone modifications, we demonstrate that OGG1 does not catalyse DNA strand cleavage in vivo. Rather, cleavage of the phosphate bond 5′ to 8-oxodG (catalysed by APE1) is essential and universally required for the onset of transcriptional silencing, regardless of the promoter structure. Hence, induction of transcriptional silencing emerges as a ubiquitous mode of biological response to 8-oxoG in DNA.

Deutsche Telekom’s spying scandal: An international application of the image repair discourse

This analysis expands on the image restoration discourse and adapts it to the German business environment. It takes into account the cultural dimensions of uncertainty ambiguity and long-term orientation (Hofstede, 2011) to analyze Deutsche Telekom’s image repair attempts in the aftermath of a spying scandal. The results reveal that the strategies of mortification and reduce offensiveness emerged within the frame of corrective action while denial was present in the overarching theme of transcendence. The use of corrective action and transcendence as larger frames for crisis communication meets the stakeholders’ expectations in terms of a systematic overview of details and a focus on the crisis's context. The results reveal the need for continued research that ascertains ways of adapting the image repair discourse to international business environments. Finally, the results of this study can be used by companies that operate in Germany in their attempt to reduce the negative impact of a crisis on their reputation.

Revision Arthroscopic Repair Versus Latarjet Procedure in Patients With Recurrent Instability After Initial Repair Attempt: A Cost-Effectiveness Model

To compare the cost-effectiveness of arthroscopic revision instability repair and Latarjet procedure in treating patients with recurrent instability after initial arthroscopic instability repair. An expected-value decision analysis of revision arthroscopic instability repair compared with Latarjet procedure for recurrent instability followed by failed repair attempt was modeled. Inputs regarding procedure cost, clinical outcomes, and health utilities were derived from the literature. Compared with revision arthroscopic repair, Latarjet was less expensive ($13,672 v $15,287) with improved clinical outcomes (43.78 v 36.76 quality-adjusted life-years). Both arthroscopic repair and Latarjet were cost-effective compared with nonoperative treatment (incremental cost-effectiveness ratios of 3,082 and 1,141, respectively). Results from sensitivity analyses indicate that under scenarios of high rates of stability postoperatively, along with improved clinical outcome scores, revision arthroscopic repair becomes increasingly cost-effective. Latarjet procedure for failed instability repair is a cost-effective treatment option, with lower costs and improved clinical outcomes compared with revision arthroscopic instability repair. However, surgeons must still incorporate clinical judgment into treatment algorithm formation. Level IV, expected value decision analysis.

Limb Replantation in Air-Transported Patients: A 4-Year Study

ObjectivePatients who require extremity reimplantation represent a population in whom rapid transport could provide potential benefit. Only 1 previous report has described the use of air transport in patients with these injuries. We describe our experience in air medical transport of limb reimplantation candidates. MethodsA retrospective chart review for all patients with amputation or near-amputation extremity injuries who were transported by helicopter to a regional reimplantation center over a 4-year period was conducted. The primary outcome measure was patients who were taken to the operating room (OR) for a definitive repair attempt by the surgical team. ResultsOf the 115 patients, 104 were taken to the OR (90%), and 84 (80%) had a repair attempted. Similar results were found between those patients who were transported from the scene or another hospital with regard to the number of candidates taken to the OR and the number of patients in who definitive repair was attempted. ConclusionAir medical transport can play an important role in a regional reimplantation program.

P11 Intraoperative management of paravalvular leak of the melody valve in mitral position

Introduction A male infant was diagnosed and treated for Group B Streptococcus meningitis from day 10 of life after uncomplicated pregnancy and delivery. During this intravenous antibiotic treatment he presented with symptoms of heart failure. The diagnosis of infective endocarditis of the mitral valve with mixed pathology and impaired LV function was established on day 26 of life. His weight was 4kg at that time. On day 34 of life attempt of valve repair failed and 17mm mechanical prosthesis was implanted into mitral position. 2 subsequent bypass surgeries followed this initial operation on day 79 and 82 due to partially blocked prosthesis including re-do mitral valve replacement. Despite otherwise good clinical progression conversion from iv Heparin to Warfarin remained unsuccessful requiring several courses of thrombolysis due to repeated blockage of one leaflet of the prosthesis. Treatment and Complication: The mechanical prosthesis was replaced with Melody valve 6 months after the initial and 4 months after the last surgery at a body weight of 7.4kg. The Melody valve was implanted by dilating it to 14mm under direct vision. Post bypass transoesophageal echocardiography showed a 4mm significant paravalvular leak (figure 1). Result No significant leak after repeat balloon dilatation of the valve was detected (figure 2).

Robotic repair of vesicovaginal fistula - initial experience.

ABSTRACTObjective The most common acquired fistula of the urinary tract is Vesicovaginal fistulae (VVF) (1) posing social stigmata for the patient as well as a surgical challenge for the urologist. Here we present our initial experience with Robotic assisted laparoscopic repair of VVF, its safety and efficacy.Materials and Methods Seven out of eight fistulas were post hysterectomy; five had undergone abdominal while two had laparoscopic hysterectomy while one was due to prolonged labour. Two had associated ureteric injury. All underwent robotic assisted laparoscopic trans abdominal extravesical approach. Three 8 mm ports for robotic arms, one 12 mm port for camera and another 12 mm for assistant were used in a fan shaped manner. All had preoperative ureteric catheter placed. Bladder was closed in two layers and vagina in one layer. Omental flap placed in all cases except two where it was not possible. Drain and per urethral catheter placed in all cases. Double J stents were placed in two cases requiring ureteric implantation additionally.Results The mean age of presentation was 39.25 years (26-47 range) with mean BMI being 26.25 kg/m2 (21-32 range). Mean duration between insult and repair was 9.37 months (3-24 months). Only in single case there was history of previous repair attempt. On cystoscopy four had supratrigonal VVF and four were trigonal with mean size of 13.37 mm (7-20 mm). Mean operative time was 117.5 minutes (90-150). There were no intraoperative/postoperative complications or need for open conversion. Mean haemoglobin drop was 1.4 gm/dL (0.3-2 gm). Drain was removed once 24-48 hours output is negligible. One patient had post-operative urinary leak at 2 weeks which ceased with continuation of catheterisation for another 2 weeks. Catheter was removed after voiding cystourethrogram showed no leak at 2-3 weeks postoperatively. Mean duration of drain was 3.75 days (3-5) and per urethral catheterisation (which was removed after voiding cystourethrography) was 15.75 days (9-28). Mean hospital stay was 6.62 days (4-14). Post-operative bladder capacity was 324.28 cc (280-350) on voiding diary. Follow up ranged from 3-9 months. At 3 months of follow-up, these patients continued to void normally and there was no evidence of recurrence of VVF.Conclusion Robotic repair of VVF is safe and feasible and has additional advantages in the form of precise suturing under 3D vision and certainly a more striking and effective option especially in complex VVF repair associated with ureteric injuries (2).

Developing a Simple Proof of Concept Clinical Decision-Making Tool for Predicting Surgical Outcomes after Obstetric Fistula Repair in a Developing Country

Introduction: Obstetric fistula is a serious injury resulting from obstructed labor causing significant maternal morbidity in women in developing countries. In order to maximize probability of successful surgical repair, it is important to identify women at-risk for poor surgical outcomes so that they can be given appropriate care. The goal of this study is to explore additional factors associated with fistula repair outcomes, as well as determine whether statistical modeling can be used to create a clinical decision-making tool for predicting a successful repair. Methods: Medical records for 82 patients surgically treated for obstetric fistula in Benin were retrospectively reviewed to collect demographic and clinical information related to their condition and procedure. Individuals were grouped into 3 main outcomes: successful closure with continence, successful closure with residual incontinence, and failed repair. A backwards stepwise selection methodology and logistic regression were used to select factors and examine their associations with the surgical outcomes. Structural equation modelling was used to develop a prediction tool for successful repair. Results: Location of fistula (vesicovaginal, vesicouterine, ureteroalvaginal, ureterouterine, and rectovaginal) (OR=7.6 (2.39, 24.36)), being married (OR=3.45 (1.09, 10.90)), parity of 1 to 3 (OR=2.99 (0.94, 9.49)), duration of fistula less than 10 years (OR=2.07 (0.88, 8.25)), and no previous repair attempt (OR=2.40 (0.79, 7.25)) were found to favor a successful closure with continence. We developed a prediction tool to sort women with obstetric fistula into 5 different categories based on probability of success. Our model suggests that marital status affects successful repair through a mediating factor not yet identified. Conclusion: This study classified fistulous women into clinically relevant categories based on the probability of a successful repair. The results from the present study may inspire further research on identifying fistulas with poor prospect of success, which might benefit from more specialized care.

The microenvironment and cell behavior

Event Abstract Back to Event The microenvironment and cell behavior Vasif Hasirci1 1 Middle East Technical University, Biological Sciences, Türkiye Extracellular matrix and its organization are very critical for the function and viability of the tissues. Tissues are organized in a variety of complex forms and the current approach in design for biomaterials and tissue engineering takes this into account in order to understand the cell and material interactions and also to produce successful products. The nerves are organized in the form of fiber bundles and most of the current treatments of severed peripheral and central nervous system elements aim to provide a form of guiding element[1]. This could be a simple empty tube into which severed proximal and the distal nerve ends are introduced in order to support aligning and healing (Fig 1A). Another tissue consisting of highly aligned elements is the muscle[2]. An example of repair attempt to damaged muscle tissue after a heart attack is to employ a muscle patch with stem cells aligned on electrospun polymeric fibers prepared in the form of a mesh, a mat or a bundle (Fig 1B). When a systematic attempt is made to determine the factors that make a surface attractive or repulsive for cells, planned creation of surfaces highly decorated with topographical and chemical/biological features using micro- and nanotechnology methods. Topographical features such as micro and nano-sized posts/pillars and wells are designed for increasing attachment on the surface and also for forcing conformational changes in the cell and in their nuclei. Physical patterns might convince cells to adhere preferentially on certain regions or constrain them in voids or gaps much smaller than their normal sizes (Figs 1C , 1D)[3],[4]. There are also chemical and biological patterning approaches that are used to create adhesive and repulsive regions or islands and posts with tips modified with cell adhesive molecules such as fibronectin or cell repulsive molecules such as PEG. The results of these intense activities find application in other fields such as biosensors. Thus the design of the microenvironment of the cells is becoming a very important area in the field of biomaterials and tissue engineering and the newly evolving techniques contribute significantly to the advances made in these fields. Figure 1. Various extracellular surfaces designed and used in guidance of various tissues. A) Nerve guide[1], B) Cardiac patch[2], C) Selective attachment of cells on micropillared surfaces[3], D) Micropatterned surface with cells arranging their cytoskeleton to fit the pillar dimensions for bone tissue studies[4]. BIOMATEN for the Ministry of Development funds; METU Grants

Large Dumbbell Shaped Vesicovaginal Calculus Managed with Holmium Laser Cystolithotripsy Followed by Staged Repair of Vesicovaginal Fistula

Complicated Vesicovaginal Fistulae (VVF) is prevalent in developing countries following obstetric injury. We report a rare case of a large dumbbell shaped vesicovaginal calculus measuring 7x 4.6cm in a patient with recurrent, complicated VVF managed successfully in two stages 6 weeks apart. Holmium laser (30 Watt) cystolithotripsy was used to break the vesical portion of the stone at the waist of the dumbbell, followed by delivery of vaginal part of the stone. Trans-abdominal VVF repair (O'Connor method) with omental interposition flap with right side ureteric reimplant was done after six weeks. Our case was unique because of occurrence of a larger sized fistula after a gynaecological surgery. She had developed larger stone (weight more than190gm- vaginal component) into the fistula tract. Also she had undergone multiple failed VVF repair attempts before. Use of holmium laser energy to break the stone was unique which minimized the morbidity of the first procedure leading to early recovery followed by staged repair of fistula after six weeks.

Transperineal approach to complex rectourinary fistulae

We sought to present our experience and outcomes in patients with complex rectourethral fistulae (RUF) treated using the transperineal approach with gracilis muscle flap interposition. Complex RUF was defined as having prior radiation, failed repair attempts, and large size (>2 cm). A retrospective review identified 10 patients presenting with complex RUF between July 2009 and November 2013. Three were excluded due to large fistula defects managed with urinary diversion. Seven patients met inclusion criteria and underwent reconstruction. Six of 7 patients had prostate cancer, and one patient had colon cancer treated with low anterior resection with adjuvant radiation. The primary modality of prostate cancer therapy was brachytherapy (n=3), external beam radiotherapy (n=2) and radical retropubic prostatectomy (RRP) (n=1). Three patients had salvage cancer therapy, including RRP (n=1), cystoprostatectomy with ileal conduit (n=1), and cryotherapy (n=1). One patient developed RUF post-primary RRP without radiation. Mean fistula size was 2.8cm (2-4 cm). No fistulas recurred at mean follow-up 11.4 months (6-20 months). Three patients have had colostomy reversal, one is pending reversal and three have permanent colostomies. Five patients have stress urinary incontinence, with two managed with one to four pads per day, one managed with a condom catheter, and two waiting for artificial urinary sphincter (AUS). One patient developed a perineal wound infection and one developed a pulmonary embolus treated medically. Complex RUF defects are effectively treated with transperineal repair using gracilis muscle interposition. The procedure has low morbidity and high success. Concomitant stress incontinence and bladder outlet contracture are prevalent in this population and may require ongoing management.

Obstetric fistula management and predictors of successful closure among women attending a public tertiary hospital in Rwanda: a retrospective review of records.

BackgroundGlobally, 50,000–100,000 women develop obstetric fistula annually. At least 33,000 of these women live in Sub-Saharan Africa where limitations in quality obstetric care and fistula corrective repairs are prevalent. Among women with fistula seeking care at public health facilities in resource-limited settings, there is paucity of data on quality of care received. The aim of this study was to characterize obstetric fistula among Rwandan women managed at a public tertiary hospital and evaluate for predictors of successful fistula closures.MethodsA retrospective review of records for all obstetric fistula women managed at a public referral health facility between 2007 and 2013 was performed. Patient socio-demographics, obstetric characteristics and fistula repair outcomes data were reviewed. A multivariate logistic regression model was used to analyse for predictors of successful fistula repair outcomes.ResultsA total of 272 women aged between 16 to 78 years and with a mean age of 34.6 years were included. Of these, 93 (34.2 %), 48 (17.6 %), 65 (24 %) and 64 (23 %) women had vesico-vaginal fistula, recto-vaginal fistula, urethro-vaginal fistula and vesico-uteral fistula types, respectively. Successful fistula closure was achieved among 86.3 %. Women with fistula who reported being in labour for ≥3 days, having ≥1 previous fistula repair attempt, and having lived with the fistula for >1 year, had significantly lower odds of successful repair outcomes.ConclusionsAmong 272 women with obstetric fistula managed in this study, 69.5 and 26.5 % of their fistula were causally associated with obstructed labour complications and iatrogenic factors, respectively. Successful fistula closure rates of about 89 % among women of index repair attempt were achieved. Conversely, reported histories of ≥3 days in labour, ≥1 previous failed attempts at repair and a fistula duration of >1 year, were significant determinants of failed fistula closures. To effectively mitigate obstetric fistula burden in Rwanda, a comprehensive package of services including quality emergency obstetric care, increased availability of and access to quality fistula repair, active surveillance to identify community-based women with fistula and a strong political will towards effective fistula care, are recommended.

Long-term outcome after treatment of pulmonary atresia with ventricular septal defect: nationwide study of 109 patients born in 1970-2007.

Treatment of pulmonary atresia with ventricular septal defect (PA + VSD) has evolved during recent decades, but it still remains challenging. This study evaluated 41-year experience of outcome, survival and treatment of PA + VSD patients. Patient records and angiograms of 109 patients with PA + VSD born in Finland between 1970 and 2007, and treated at the Children's Hospital, Helsinki University Central Hospital, were retrospectively analysed in this nationwide study. Of the 109 patients, 66 (61%) had simple PA + VSD without major aortopulmonary collateral arteries (MAPCAs). Although we observed no difference in overall survival between those with or without MAPCAs, the patients without MAPCAs had better probability to achieve repair (64 vs 28%, P < 0.0003). Only 3 patients were treated by compassionate care. Overall survival was affected by the size of true central pulmonary arteries on the first angiogram (P = 0.001) and whether repair was achieved (P < 0.0001). After successful repair, the survival rate was 93% at 1 year, 91% from the second year, and functional capacity as assessed by New York Heart Association (NYHA) I-II remained in 85% of patients alive at the end of follow-up. Palliated patients at 1, 5, 10 and 20 years of age had Kaplan-Meier estimated survival rates of 55, 42, 34 and 20%, respectively. Patients who underwent repair attempts but were left palliated with right ventricle (RV)-pulmonary artery connection and septal fenestration had better survival than the rest of the palliated patients (P = 0.001). Further, the McGoon index improved after implementation of a systemic-pulmonary artery shunt in the overall PA + VSD population (P < 0.0001). These findings show that achievement of repair and initial size of true central pulmonary arteries affect survival of patients with PA + VSD. Although the overall survival of patients with MAPCAs showed no difference compared with simple PA + VSD patients, they had a higher risk of remaining palliated. However, palliative surgery may have a role in treatment of PA + VSD because the size of pulmonary arteries increased after placement of systemic-pulmonary artery shunt. In addition, subtotal repair by a RV-pulmonary artery connection and septal fenestration improved survival over extracardiac palliation.