Requirement For Further Surgery Research Articles

Endovascular and microsurgical management of blister aneurysms: a multi-centre review.

Blister aneurysms (BA) are high-risk cerebrovascular lesions accounting for 1% of intracranial aneurysms. The defective vessel wall and broad-based neck make this clinical entity difficult to treat, with high rates of re-rupture and mortality in patients presenting with acute subarachnoid haemorrhage. Blister aneurysms pose substantial challenges for both endovascular and microsurgical management. The objective of this study is to evaluate endovascular and microsurgical outcomes in intracranial blister aneurysm management across two tertiary hospitals. A review of two tertiary hospitals with a systematic imaging database search for term of "blister" in modalities from January 2010 to October 2022 was conducted. Operation reports were screened for the 5-year period since cerebral angiogram reports transitioned to surgical database. Identified reports were screened and reviewed for confirmed diagnosis by consultant neuroradiologist. A total of 21 cases of blister aneurysms managed at respective facilities were included. Sixteen cases (76%) were managed endovascularly. Four cases (19%) were managed surgically-2 with primary clipping, and 2 wrap and clipping. One case was managed conservatively (5%). Clinical outcomes were discharge disposition, aneurysm exclusion and post-operative complications. BAs have challenging considerations with high mortality and morbidity. Endovascular treatment offers a less invasive modality with lower rates of intraoperative rupture and morbidity. Mortality rates and patients discharged home were comparable. Commencement of dual anti-platelet therapy was safe in patients with flow diversion stents despite sub-arachnoid blood volume. Management of blister aneurysms is complex. Endovascular treatment shows promise for acute management but careful collaborative consideration of antithrombotic regime and requirement for further surgery should be considered.

Functional outcomes after Medial Patellofemoral Ligament Reconstruction show inverted J-shaped relation with Body Mass Index.

Medial patellofemoral ligament reconstruction (MPFL-R) is a recognised surgical procedure for the treatment of recurrent patellofemoral instability with excellent outcomes reported. The aim of this study is to determine if body mass index can influence these outcomes. This is a single-centre retrospective analysis of a longitudinal patellofemoral database. Patients with recurrent patellar instability, without patellar alta or severe trochlear dysplasia were treated using a MPFL-R between 2015 and 2019 at The Robert Jones & Agnes Hunt Orthopaedic Hospital. The clinical efficacy following surgery was assessed by Kujula, International Knee Documentation Committee Score (IKDC), and EuroQol-5 score (EQ-5D) at baseline and up to 26months post-operatively; their safety assessed by complication rate and requirement for further surgery. The effect of Body Mass Index (BMI) on clinical outcome was analysed using linear, curvilinear, and segmented models following propensity score weighting. A total of 97 patients (97 Knees, mean age 25y) were analysed. Of these, 61 patients had a BMI < 30kg/m2 (mean age 23y, mean BMI 24) of which 7 patients (12.3%) required additional surgery. A further 36 patients had a BMI > 30kg/m2 (mean age 27y, mean BMI 36) of which 2 patients (5.6%) required additional surgery. The re-dislocation rate was 0% in each BMI group. Both groups had a significantly improved mean outcome following surgery, with improvements in mean IKDC above the minimum clinical important differences (MCID) of 20.5. BMI had an inverted J-shaped association with functional outcome, showing peak outcomes at BMI of 20.5 (95% CI 18.5 to 22.4; IKDC and Kujala) or BMI of 28 (EQ-5D index). No evidence for an association between BMI and complication risk was found. BMI influences the functional outcomes in MPFL-R with an inverted J-shaped relation, without evidence it affected the complication or re-dislocation rate. In the absence of patella alta and severe trochlear dysplasia, an isolated MPFL reconstruction is a safe and effective procedure to treat patellar instability, with the best functional outcome in patients with a BMI around 20 to 21. Level III.

MP42-17 INCONTINENCE AFTER SUCCESSFUL ANATOMICAL CLOSURE OF VESICO-VAGINAL FISTULA; INCIDENCE AND MANAGEMENT

You have accessJournal of UrologyCME1 Apr 2023MP42-17 INCONTINENCE AFTER SUCCESSFUL ANATOMICAL CLOSURE OF VESICO-VAGINAL FISTULA; INCIDENCE AND MANAGEMENT Amaani Ahmad, Helena Gresty, Anthony Noah, Richard Nobrega, Mahreen Pakzad, Jeremy Ockrim, and Tamsin Greenwell Amaani AhmadAmaani Ahmad More articles by this author , Helena GrestyHelena Gresty More articles by this author , Anthony NoahAnthony Noah More articles by this author , Richard NobregaRichard Nobrega More articles by this author , Mahreen PakzadMahreen Pakzad More articles by this author , Jeremy OckrimJeremy Ockrim More articles by this author , and Tamsin GreenwellTamsin Greenwell More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Vesicovaginal fistula (VVF) is a rare condition in high resource settings. Significant urinary incontinence (UI) rates have been reported following VVF closure in low resource setting. We have reviewed our VVF series for anatomical closure and post closure UI rates. METHODS: Retrospective review of 132 patients having 1st surgical management of their VVF between 2004-2022. Median age was 51 (16-88) with a median follow-up of 14 months (2-150). Data was collated on demographics, fistula aetiology and characteristics, previous surgery, outcome in terms of anatomical closure and urinary continence, and any requirement for further surgery. Statistical analysis was carried out using chi-squared test, fisher test or students t-test as appropriate. RESULTS: Of the 132 patients identified, 127 (96.2%) had surgery to close their VVF whilst 5 (3.8%) had a primary ileal conduit. Successful anatomical closure was achieved in 118 (93.9%) at 1st attempt. Of the 9 failures, 6 had a 2nd VVF closure attempt, 2 had ileal conduit formation and 1 had recurrent carcinoma and did not proceed to further surgery. Vaginal closure was successful in 95% (97/102) after 1st attempt whilst abdominal closure was successful in 88% (22/25). Of the 6 failures having a 2nd attempt at VVF closure, 3 had an abdominal and 3 had a vaginal approach, with 100% successfully closed. Anatomical closure was confirmed in all patients by cystogram and/or cystoscopy. Of those with successful VVF closure 19 (15.2%) (16 vaginal and 3 abdominal approach) had bothersome post repair UI. This was pre-existing stress urinary incontinence (SUI) in 5 (4%), new onset SUI in 8 (6.4%), pre-existing urgency urinary incontinence (UUI) in 1 (0.8%), new onset UUI in 3 (2.4%) and new onset mixed urinary incontinence (MUI) in 2 (1.6%). 5 (26.3%) (4 with pre-existing SUI) required surgical intervention for management of their SUI (2 colposuspensions and 3 rectus fascial slings) whilst the patient with pre-existing UUI progressed to sacral neuromodulation, with resolution or significant improvement. The remaining 13 (68%) patients experienced resolution or significant improvement of their UI with conservative measures. CONCLUSIONS: Successful anatomical closure of VVF in high resource health care settings can be achieved in 92.9% after 1st repair and 100% after 2nd repair. Post closure bothersome urinary incontinence occurs in 15.2% and resolves with conservative measures in 68%. Surgical interventions for SUI or UUI post closure in 4.8%, with excellent results. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e574 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amaani Ahmad More articles by this author Helena Gresty More articles by this author Anthony Noah More articles by this author Richard Nobrega More articles by this author Mahreen Pakzad More articles by this author Jeremy Ockrim More articles by this author Tamsin Greenwell More articles by this author Expand All Advertisement PDF downloadLoading ...

Performance of contrast-enhanced ultrasound for lymph node metastasis in papillary thyroid carcinoma: a meta-analysis

Papillary thyroid carcinoma is the most common thyroid carcinoma worldwide. Papillary thyroid carcinoma metastasis to the cervical region increases the probability of local or regional recurrence and the requirement for further surgery. Contrast-enhanced ultrasound has been suggested as a possible adjunct diagnostic technique for evaluating papillary thyroid carcinoma metastatic lymph nodes in several studies. This meta-analysis aims to evaluate the diagnostic accuracy of contrast-enhanced ultrasound for cervical lymph nodes metastatic in papillary thyroid carcinoma patients. A search for studies evaluating the role of contrast-enhanced ultrasound for assessing cervical lymph nodes metastatic in papillary thyroid carcinoma patients from January 2000 to May 2022 was performed in PubMed, Embase, OVID, and Web of Science databases. The Quality Assessment of Diagnostic Accuracy Studies 2 evaluated the quality of the studies. All analyses were performed using Review Manager 5.3 and Stata 17.0. A total of seven articles were finally included in this study. Perfusion type, enhancement homogeneous, hilum absent, and perfusion defect were involved in the meta-analysis as the standard of contrast-enhanced ultrasound, among which, perfusion type showed the best diagnostic performance. The pooled estimated sensitivity, specificity, positive likelihood, negative likelihood ratio, and diagnostic odds ratio of perfusion type in contrast-enhanced ultrasound for detecting lymph node metastasis were 0.95 (0.91, 0.97), 0.87 (0.69, 0.96), 7.51 (2.80, 20.14), 0.06 (0.03, 0.10), and 124.17 (42.78, 360.46), respectively. Heterogeneity was moderate. The perfusion type in contrast-enhanced ultrasound has good diagnostic performance for cervical lymph nodes metastasis in papillary thyroid carcinoma patients.

The "COVID-19 Approach" to Distal Radius Fracture Management.

Background In response to the coronavirus pandemic the British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guidelines advised treating distal radius fractures (DRFs) non-operatively where possible. Questions/Purpose The aim of this study was to assess whether the coronavirus disease 2019 (COVID-19) pandemic lockdown within the United Kingdom did alter the management of DRFs and whether there was any subsequent change in patient outcome or complication rate. Patients and Methods A retrospective cohort study was performed at a single orthopaedic center within the United Kingdom. The cohort of patients presenting with DRFs during the first lockdown was identified through the virtual fracture clinic database. The cohort of patients from the previous year was also identified for comparison. Data was collected on patient demographics, radiological features of the fractures, management, patient outcome and subsequent complications. Comparisons were then made between the cohorts for each year. Results The pre-COVID cohort had a significantly higher number of patients reviewed in face-to-face clinic appointments ( p = 0.0044) and the mean number of clinic appointments for those patients was significantly higher ( p = 0.0149). There was no significant difference between the cohorts regarding patient complications or any need for return to theater with a minimum 10 month follow-up period. Conclusion Despite comparative numbers and patterns of DRFs as well as no significant difference in the number of injuries requiring orthopaedic intervention, the burden on fracture clinic services was significantly reduced during the COVID pandemic. Encouragingly, this reduction in follow-up has not translated into an increased prevalence of complications or requirement for further surgery. Level of Evidence The level of evidence of the study is level III.

Orthodontic Treatment of Patients With Clefts: Satisfaction and Psychological Aspects.

To assess parents’ satisfaction with cleft child's facial appearance and function; compare these findings with orthodontist (expert) satisfaction and evaluate influence of various factors on satisfaction. Cross-sectional study. Sixty-three parents of non-syndromic patients with clefts (ages 7-20 years), and an orthodontist, completed the Cleft Hearing, Appearance and Speech Questionnaire. Two scores were produced: cleft-associated, and non-cleft-associated features. Additional open questions were presented to the parents. Both parents and orthodontist gave high satisfaction scores (mean: 8.4 &amp; 8.2, respectively), significantly correlated, for the cleft-associated features ( P &lt; .001). Parents were least satisfied with appearance of teeth, then nose, then lips. Scores did not vary significantly with age and sex of patients. Higher parents’ satisfaction was found in the unilateral cleft lip + alveolus (UCL + alveolus) group, compared with the unilateral cleft lip and palate (UCLP), regarding cleft-associated features, and compared with cleft palate (CP), regarding non-cleft-associated features ( P &lt; .05). Greater parents and orthodontist satisfaction were found when parents’ education was &gt;12 years. Parents of Jewish ethnicity showed higher satisfaction, compared with parents of non-Jewish ethnicity. Patients requiring future surgery received lower scores. Parents satisfaction was directly correlated to socioeconomic status. The following factors appear to lower parents’ satisfaction: [1] cleft severity, [2] hearing or speech of CP/BCLP patients, [3] requirement for further surgery, and [4] low socioeconomic status. Severe cases may require additional explanation to parents in order to lower expectations. A more thorough explanation may be required in patients of lower socioeconomic status.

Surgical Outcomes of Trabeculectomy Alone versus Trabeculectomy with Manual Small Incision Cataract Surgery Following Acute Angle Closure Glaucoma: A Comparative Study

Introduction: Acute Angle Closure Glaucoma (AACG) is an ophthalmic emergency and is managed medically. Therapeutic options for the management of the post congestive phase are varied and no procedure has a documented therapeutic superiority over the other. Two established procedures were therefore chosen and compared to determine their therapeutic efficacy. Aim: To compare the surgical results of combined manual Small Incision Cataract Surgery (SICS) and trabeculectomy with standalone trabeculectomy in patients following an attack of AACG, with a final aim to decide which would be the better therapeutic approach in such a situation. Materials and Methods: This was a prospective observational study done in Bankura Sammilani Medical College located in West Bengal, India. Sixteen patients presenting with AACG in a 19 months study period from October 2019-April 2021 and having 50% or more synechial angle closure on indentation gonioscopy were selected for this study after obtaining necessary ethical clearance. Eight of them underwent trabeculectomy alone (Group A) and the rest underwent a combined procedure of trabeculectomy and SICS (Group B). They were followed-up for a six-months period and compared on the basis of Intraocular Pressure (IOP) control, Anterior Chamber (AC) depth and the requirement for further surgery. Results: Mean IOP following surgery at the end of six weeks in Group A was 15.98±1.56 mmHg whereas in Group B it was 12.01±1.18 mmHg. Results were compared by unpaired t-test, and the difference was statistically significant (p&lt;0.001). Three out of eight patients (37%) in Group A developed cataract which caused a reduction in visual acuity and needed cataract surgery within the six months follow-up period but none of the patients in Group B needed any additional surgery. One patient in Group A needed additional medications due to uncontrolled IOP after surgery but no such event was noted in Group B. Seventy five percent patients in Group A had Grade 2 angles whereas 87% patients in Group B had Grade 4 angles as estimated by Van Herrick’s method. Conclusion: Combined trabeculectomy and SICS offers a better level of postoperative IOP control than trabeculectomy alone, and perhaps offers a better therapeutic option following AACG. Also, the chances of postoperative cataract formation and associated visual debility are eliminated.

Surgical Strategies to Reduce Postoperative Recurrence of Crohn's Disease After Ileocolic Resection.

Postoperative recurrence after ileocaecal resection for fibrostenotic terminal ileal Crohn's disease is a significant issue for patients as it can result in symptom recurrence and requirement for further surgery. There are very few modifiable factors, aside from smoking cessation, that can reduce the risk of postoperative recurrence. Until relatively recently, the surgical technique used for resection and anastomosis had little or no impact on postoperative recurrence rates. Novel surgical techniques such as the Kono-S anastomosis and extended mesenteric excision have shown promise as ways to reduce postoperative recurrence rates. This manuscript will review and discuss the evidence regarding a range of surgical techniques and their potential role in reducing disease recurrence. Some of the techniques have been shown to be associated with significant benefits for patients and have already been integrated into the routine clinical practice of some surgeons, while other techniques remain under investigation. Current techniques such as resection of the mesentery close to the intestine and stapled side to side anastomosis are being challenged. It is looking more likely that surgeons will have a major role to play when it comes to reducing recurrence rates for patients undergoing ileocaecal resection for Crohn's disease.

Clinical validation of the Oswestry-Bristol Classification as part of a decision algorithm for trochlear dysplasia surgery.

The Oswestry-Bristol Classification (OBC) is an MRI-specific assessment tool to grade trochlear dysplasia. The aim of this study is to validate clinically the OBC by demonstrating its use in selecting treatments that are safe and effective. The OBC and the patellotrochlear index were used as part of the Oswestry Patellotrochlear Algorithm (OPTA) to guide the surgical treatment of patients with patellar instability. Patients were assigned to one of four treatment groups: medial patellofemoral ligament reconstruction (MPFLr); MPFLr + tibial tubercle distalization (TTD); trochleoplasty; or trochleoplasty + TTD. A prospective analysis of a longitudinal patellofemoral database was performed. Between 2012 and 2018, 202 patients (233 knees) with a mean age of 24.2 years (SD 8.1), with recurrent patellar instability were treated by two fellowship-trained consultant sports/knee surgeons at The Robert Jones and Agnes Hunt Orthopaedic Hospital. Clinical efficacy of each treatment group was assessed by Kujala, International Knee Documentation Committee (IKDC), and EuroQol five-dimension questionnaire (EQ-5D) scores at baseline, and up to 60 months postoperatively. Their safety was assessed by complication rate and requirement for further surgery. The pattern of clinical outcome over time was analyzed using mixed regression modelling. In all, 135 knees (mean age 24.9 years (SD 9.4)) were treated using a MPFLr. Ten knees (7.4%) required additional surgery. A total of 50 knees (mean age 24.4 years (SD 6.3)) were treated using MPFLr + TTD. Ten (20%) required additional surgery. A total of 20 knees (mean age 19.5 years (SD 3.0)) were treated using trochleoplasty + TTD. Three patients (15%) required additional surgery. In each treatment group, there was a significant improvement in Kujala, IKDC, and EQ-5D at one year postoperatively (p < 0.001) with a recognized level of overall complication rate. The OBC is a valid assessment tool to grade patients with trochlear dysplasia and, when used as part of the OPTA, helps to determine treatments that are safe and effective. This fulfils the requirements for its application in mainstream clinical practice. Cite this article: Bone Joint J2021;103-B(10):1586-1594.

Ozone therapy versus surgery for lumbar disc herniation: A randomized double-blind controlled trial

ObjectivesSurgery is the treatment of choice for symptomatic disc herniation after conservative management. Several studies have suggested the potential utility of intradiscal ozone infiltration in this pathology. The aim of this trial was to compare intradiscal ozone infiltration vs. oxygen infiltration vs. surgery. Design and interventionsThis was a randomized, double-blinded, and controlled trial in patients on a waiting list for herniated disc surgery. There were three treatment groups: surgery; intradiscal ozone infiltration (plus foraminal infiltration of ozone, steroids, and anesthetic); intradiscal oxygen infiltration (plus foraminal infiltration of oxygen, steroids, and anesthetic). Main outcome measuresThe requirements for surgery. ResultsFive years after the treatment of the last recruited patient (median follow-up: 78 months), the requirement for further surgery was 20 % for patients in the ozone group and 60 % for patients in the oxygen group. 11 % of patients initially treated with surgery also required a second surgery. Compared to the surgery group, the ozone group showed: 1) significantly lower number of inpatient days: median 3 days (interquartile range: 3–3.5 days) vs. 0 days (interquartile range: 0–1.5 days), p = 0.012; 2) significantly lower costs: median EUR 3702 (interquartile range: EUR 3283–7630) vs. EUR 364 (interquartile range: EUR 364–2536), p = 0.029. ConclusionsOur truncated trial showed that intradiscal ozone infiltrations decreased the requirements for conventional surgery, resulting in decreased hospitalization durations and associated costs. These findings and their magnitude are of interest to patients and health services providers. Further validation is ongoing.

Paediatric cataract in the uveitis setting.

Cataract formation is common in uveitis and is visually more threatening in the paediatric cohort due to the risk of amblyopia. In addition, paediatric uveitis can often be difficult to manage. We report our experience with IOL placement in cataract surgery in the setting of paediatric uveitis. This non-comparative, retrospective interventional case series examined our cases of paediatric cataract occurring in patients with uveitis from 2003 to 2016. Parameters examined included visual acuity (VA), underlying diagnosis, immunosuppression status, intra-operative complications and requirement for further surgery. In total, 10 eyes of seven patients were identified. The mean age at diagnosis of uveitis was 7.7 years (range 5.2-14 years) with onset of cataract at a mean of 29.3 months later (range 0-66 months). Three cases were bilateral and four cases were unilateral. Final visual outcomes were excellent with 80% showing improvement in VA achieving greater than 6/9.5 (p < 0.05). These patients had significant co-morbidities with concurrent glaucoma, band keratopathy and cystoid macular oedema. Uveitis was quiet for a minimum of 6 months in all cases prior to surgery with augmentation of immunosuppression pre-operatively as well as intra-operative local or intra-venous steroids. Tight post-operative care was necessary as 80% developed further flare-up of uveitis requiring increased immunosuppression and surgical interventions to manage their uveitis. Paediatric uveitis patients who develop cataract can have good visual outcomes with IOL insertion at the time of surgery when there is aggressive control of uveitis in the pre, peri and post-operative period.

Achieving margin clearance following oncoplastic breast surgery in comparison with simple wide local excision: a three-dimensional specimen assessment.

Pre-operative breast tumour radial dimensions often determine the choice between simple wide local excision (WLE) and oncoplastic breast surgery (OBS). We reviewed the three-dimensional interplay between tumour and surgical specimen dimensions in the two cohorts. Demographic, tumour and treatment data were collected for all patients undergoing OBS by a single surgeon and compared with a randomly selected cohort of WLE patients treated. The relationship between tumour and specimen medio-lateral, supero-inferior and antero-posterior dimensions were explored in both groups. Subgroup analyses were performed in the OBS cohort (parenchymal displacement versus replacement). We identified 60 OBS patients (63 breasts), comparing them with 60 WLE patients. Pre-operative tumour estimated size was significantly larger in the OBS cohort and concordant with macroscopic tumour radial dimensions and final microscopic tumour size. Surgical specimen weight was more than 3.5 times higher in the OBS group and its radial dimensions were almost double. No significant difference was observed for the antero-posterior dimensions. The rate of margin re-excisions and completion mastectomies were lower in the OBS cohort. WLE patients with positive margins had a lower tumour-to-specimen ratio, whereas, the requirement for further surgery in the OBS cohort was associated with larger tumour dimensions. Despite larger tumour dimensions, OBS is not inferior to WLE in providing clear surgical margins. Our analysis of the three-dimensional spatial relationship between cancer and surgical specimen, although not completely conclusive, can be helpful in the selection of the most appropriate surgical approach for every patient.

Duplex systems: Top-down or bottom-up approach?

Duplex systems can be complicated by reflux, ureterocele, obstruction (most commonly PUJ in a lower moiety) and wetting secondary to an ectopic ureteric insertion in girls. The decision making algorithm for selection of surgical approach is complex and there is no consensus. The authors described the outcomes following an upper urinary tract approach in 2011(1) and now compare these results in a similar group of patients managed using a lower approach. To assess whether a top-down or bottom-up approach results in different likelihoods for further surgery. A prospectively database was maintained for consecutive patients undergoing surgery for duplex systems by a single surgeon between 2003 and 2015. Patients were classified into 2 groups; Group 1 initial intention for upper urinary tract approach (heminephroureterectomy-HN) or Group 2 lower urinary tract approach (bladder reconstructive surgery-BRS). The requirement for further surgery was recorded-endoscopic incision (EI), bladder reconstructive surgery (BRS), endoscopic correction of reflux (ECR), heminephroureterectomy (HN). Indications for initial and subsequent surgery included urinary tract infection, VUJ obstruction and incontinence. Endoscopic incision was not performed for patients with an asymptomatic ureterocele. Statistical analysis consisted of Fisher's exact test with a 2 tail p value<0.05 being statistically significant. 79 patients underwent surgery for duplex systems. 39 patients had HN initially (Group 1) and 40 patients had BRS initially (Group 2). Further surgery was performed in 21% of patients from Group 1 (8 BRS) vs 5% of patients from Group 2 (1 redo BRS, 1 ECR). Significantly less additional surgical procedures were performed after BRS compared to HN (p=0.048). The presence of both reflux and ureterocele increases the chances of further surgery in those patients who had HN initially compared to BRS (p=0.01). No patients developed urinary retention or required intermittent catheterisation to improve bladder emptying. Bladder reconstructive surgery (BRS) reduces the requirement for further surgery compared to heminephroureterectomy (HN) in symptomatic patients with a duplex kidney and either dilating vesicoureteric reflux or ureterocele.

Metachronous colorectal cancer following segmental or extended colectomy in Lynch syndrome: a systematic review and meta-analysis

Around 5% of colorectal cancers are due to mutations within DNA mismatch repair genes, resulting in Lynch syndrome (LS). These mutations have a high penetrance with early onset of colorectal cancer at a mean age of 45 years. The mainstay of surgical management is either a segmental or extensive colectomy. Currently there is no unified agreement as to which management strategy is superior due to limited conclusive empirical evidence available. A systematic review and meta- analysis to evaluate the risk of metachronous colorectal cancer (MCC) and mortality in LS following segmental and extensive colectomy. A systematic review of the PubMed database was conducted. Studies were included/ excluded based on pre-specified criteria. To assess the risk of MCC and mortality attributed to segmental or extensive colectomies, relative risks (RR) were calculated and corresponding 95% confidence intervals (CI). Publication bias was investigated using funnel plots. Data about mortality, as well as patient ascertainment [Amsterdam criteria (AC), germline mutation (GM)] were also extracted. Statistical analysis was conducted using the R program (version 3.2.3). The literature search identified 85 studies. After further analysis ten studies were eligible for inclusion in data synthesis. Pooled data identified 1389 patients followed up for a mean of 100.7 months with a mean age of onset of 45.5 years of age. A total 1119 patients underwent segmental colectomies with an absolute risk of MCC in this group of 22.4% at the end of follow-up. The 270 patients who had extensive colectomies had a MCC absolute risk of 4.7% (0% in those with a panproctocolecomy). Segmental colectomy was significantly associated with an increased relative risk of MCC (RR = 5.12; 95% CI 2.88–9.11; Fig. 1), although no significant association with mortality was identified (RR = 1.65; 95% CI 0.90–3.02). There was no statistically significant difference in the risk of MCC between AC and GM cohorts (p = 0.5, Chi-squared test). In LS, segmental colectomy results in a significant increased risk of developing MCC. Despite the choice of segmental or extensive colectomies having no statistically significant impact on mortality, the choice of initial surgical management can impact a patient’s requirement for further surgery. An extensive colectomy can result in decreased need for further surgery; reduced hospital stays and associated costs. The significant difference in the risk of MCC, following segmental or extensive colectomies should be discussed with patients when deciding appropriate management. An individualised approach should be utilised, taking into account the patient’s age, co-morbidities and genotype. In order to determine likely germline-specific effects, or a difference in survival, larger and more comprehensive studies are required.

Early Results of the ARPE Arthroplasty Versus Trapeziectomy for the Treatment of Thumb Carpometacarpal Joint Osteoarthritis.

Thumb carpometacarpal joint arthroplasty for osteoarthritis may hold advantages over trapeziectomy by preserving range of motion, whilst providing stability and preventing thumb shortening. We compare functional and satisfaction outcomes scores, radiological shortening and complication rates between patients treated with trapeziectomy and those receiving the ARPE thumb CMCJ arthroplasty. Seventy-five trapeziectomies and one hundred and ten ARPE arthroplasties were performed over the study period. Both treatments resulted in significant improvements in functional scores. When matching patients according to pre-operative function, patients receiving the ARPE arthroplasty had better post-operative function (Quick DASH: trapeziectomy = 25.1, ARPE = 16.8). More patients receiving the ARPE arthroplasty were satisfied with their treatment (trapeziectomy = 7.8/10, ARPE = 8.7/10) and would have the same treatment again (trapeziectomy = 76%, ARPE = 89%). The ARPE also resulted in less thumb shortening. However the ARPE arthroplasty is associated with a higher complication rate, with 14% of patients requiring further surgery at a mean of 2 years follow up (95% implant survival). Both trapeziectomy and the ARPE CMCJ arthroplasty are effective treatment options for thumb CMCJ osteoarthritis. Arthroplasty may offer potential advantages in terms of post-operative function and patient satisfaction. However the risk of complications and requirement for further surgery is greater and must be carefully considered during patient selection and pre-operative counselling.

Short- and medium-term outcomes following primary ileocaecal resection for Crohn's disease in two specialist centres.

Despite improvements in medical therapy, the majority of patients with Crohn's disease still require surgery. The aim of this study was to report safety, and clinical and surgical recurrence rates, including predictors of recurrence, after ileocaecal resection for Crohn's disease. This was a cohort analysis of consecutive patients undergoing a first ileocaecal resection for Crohn's disease between 1998 and 2013 at one of two specialist centres. Anastomotic leak rate and associated risk factors were assessed. Kaplan-Meier estimates were used to describe long-term clinical and surgical recurrence. Univariable and multivariable regression analyses were performed to identify risk factors for both endpoints. In total, 538 patients underwent primary ileocaecal resection (40·0 per cent male; median age at surgery 31 (i.q.r. 24-42) years). Median follow-up was 6 (2-9) years. Fifteen of 507 patients (3·0 per cent) developed an anastomotic leak. An ASA fitness grade of III (odds ratio (OR) 4·34, 95 per cent c.i. 1·12 to 16·77; P = 0·033), preoperative antitumour necrosis factor therapy (OR 3·30, 1·09 to 9·99; P = 0·035) and length of resected bowel specimen (OR 1·06, 1·03 to 1·09; P < 0·001) were significant risk factors for anastomotic leak. Rates of clinical recurrence were 17·6, 45·4 and 55·0 per cent after 1, 5 and 10 years respectively. Corresponding rates of requirement for further surgery were 0·6, 6·5 and 19·1 per cent. Smoking (hazard ratio (HR) 1·67, 95 per cent c.i. 1·14 to 2·43; P = 0·008) and a positive microscopic resection margin (HR 2·16, 1·46 to 3·21; P < 0·001) were independent risk factors for clinical recurrence. Microscopic resection margin positivity was also a risk factor for further surgery (HR 2·99, 1·36 to 6·54; P = 0·006). Ileocaecal resection achieved durable medium-term remission, but smoking and resection margin positivity were risk factors for recurrence.

Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.

Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.

Factors Associated with Choice and Success of One- Versus Two-Stage Revision Arthroplasty for Infected Hip and Knee Prostheses.

Prosthetic joint infections (PJI) of hip and knee arthroplasties are becoming increasingly common with an aging population and an increasing demand for these procedures. Despite attempts at standardization, medical and surgical approaches vary widely among practitioners. We first sought to determine if there were specific factors associated with choice of one- versus two-stage revision. Then we investigated whether the type of revision approach influenced clinical treatment success. Finally, among two-stage revisions, we assessed if an antibiotic holiday prior to the second procedure affected clinical treatment success. We retrospectively reviewed patients who had revision surgery for infection of a hip or knee arthroplasty between January 1, 2000, and December 31, 2013, at the Sunnybrook Health Sciences Centre and the Holland Orthopedic and Arthritic Centre. PJI cases were identified using the Ontario Joint Replacement Registry. Infection was defined by gross intraoperative evidence of infection, positive intraoperative culture(s), and/or sinus tract prior to operation. The primary outcome was treatment failure at 1year after revision surgery based on requirement for further surgery, ongoing infection, and/or continuous suppressive antibiotics. Of 110 eligible patients identified, 35 patients had a one-stage and 75 patients had a two-stage revision. Choice of a one-stage approach was most influenced by particular surgeon preference and was more likely for hip revision versus knee revision (OR 3.39 (95%CI 1.85-6.23). There was no statistical difference in clinical treatment success rate between one-stage (33/35; 94.2% success) and two-stage revision (63/75; 84%; p=0.13). Enterococcus spp. (21 versus 3%; p=0.027) and Peptostreptococcus spp. (14 versus 1%; p=0.042) were more common among clinical treatment failures than successes, with a trend towards the same for Staphylococcus aureus (29 versus 9%; p=0.06). Additionally, treatment success was not influenced by whether the patient had an antibiotic holiday with a two-stage revision. Our findings confirm the uncertainty of surgical strategy for treatment of PJI in hip and knee arthroplasty. Superiority of one- versus two-stage revision and the value of antibiotic-free periods prior to definitive revision remain unclear. Large prospective studies or randomized controlled trials are needed to inform best practice for treatment of these complex clinical problems.

Masquelet technique: myth or reality? A systematic review and meta-analysis

IntroductionThe induced membrane technique (IMT) or Masquelet technique, is a two-step surgical procedure used to treat pseudoarthroses and bony defects. Many authors have introduced variants to the technique. This study aims to compare the surgical variants of IMT and to evaluate its efficacy in achieving infection eradication and bone union. MethodsA systematic review was carried out following the PRISMA guidelines. PubMed and other medical databases were explored using keywords “Masquelet technique” and “induced membrane technique”. Articles were included if written in English, French or Italian, dealing with IMT employed to long bones in adults, reporting at least 5 cases with a 12 months-mean follow-up. Patients’ clinical features, bone defect features, aetiologies, surgical data, complications, reinterventions, union rates and infection eradication rates were searched. Fischer's exact test, chi-square test and unpaired t-test were used for the statistical analysis on the individual patient's data. ResultsSeventeen papers met the inclusion criteria (427 patients). Among these, only 10 studies reported individual patient's data (137 cases). The union rate was 89.7% and the infections rectified in 91.1% of cases. The bone defect length ranged from 0.6 to 26 cm. The main complications were superficial (21; 4.9%) and deep surgical site infections (19; 4.4%), failure of one of the IMT steps (persistence of infections or non unions, 77, 18%), with subsequent requirement for further surgery. The surgical variants included the use of antibiotic-coated spacers, internal fixation during the first step, use of Reamer-Irrigator-Aspirator technique, iliac crest grafting, bone substitutes and growth factors. However, univariate analysis only showed a positive correlation of the need for reinterventions with poorer bone union rates (p = 0.005) and complications (p <0.001), while patients undergoing IMT because of bone infections had a higher risk of surgical complications (p <0.001). DiscussionIMT aims to achieve bone union and infection eradication, but persistence of infection or non-union was noted in 18% of cases necessitating re-interventions. This may be related to the different anatomical sites that the technique has been applied and different local and patient related conditions. We believe the choice of a surgical technique to achieve union should be tailored to the individual patient's needs. This systematic review was limited by the few studies meeting our inclusion criteria, and their high variability in data reporting, making it impossible to undertake a meta-analysis. ConclusionFurther studies are needed to demonstrate the role the patients’ clinical features and IMT variants have upon achieving bone union and infection eradication.

PWE-118 Metachronous Cancers Following Segmental or Extended Colectomy in Lynch Syndrome: A Systematic Review & Meta-Analysis

Introduction Around 5% of colorectal cancers are due to mutations within DNA mismatch repair genes, resulting in Lynch Syndrome (LS). These mutations have a high penetrance (85–90%), with early onset of colorectal cancer at an average age of 45 years. The main surgical management options are either a segmental or extensive colectomy. Currently there is no unified agreement as to which management strategy is superior due to the limited conclusive empirical evidence available. A systematic review and meta- analysis to evaluate the risk of metachronous colorectal cancer (MCC) and mortality in LS following segmental and extensive colectomy. Methods A systematic review of the Pubmed database was conducted. Studies were included/ excluded based on a pre-specified criteria. In order to assess the risk of MCC and mortality attributed to segmental or extensive colectomies, pooled odds ratios (OR) were calculated and corresponding 95% confidence intervals (CI). Publication bias was investigated using funnel plots. Statistical analysis was conducted using the R program (version 3.2.3). Results The literature search identified eighty-five studies. After further analysis nine studies were eligible for inclusion in this study. Pooled data identified 1429 patients followed up for a mean of 103.1 months with a mean age of onset of 43.3 years of age. 1135 patients underwent segmental colectomies with risk of MCC in this group of 22.0% at the end of follow-up. 294 patients had extensive colectomies with a MCC risk of 4.7% (0% in those with a panproctocolecomy). A segmental colectomy was significantly associated with an increased risk of MCC (OR = 4.47; 95% CI: 2.68–7.45; Figure 1), but no significant association with mortality was identified (OR = 1.65; 95% CI: 0.71–3.82). Conclusion In LS, segmental colectomy results in a significant increased risk of developing MCC. Despite the choice of segmental or extensive colectomies having no statistically significant impact on mortality, the choice of initial surgical management can impact a patient’s requirement for further surgery. An extensive colectomy can result in decreased need for further surgery; reduced hospital stays and reduced costs. The significant difference in the risk of MCC, following segmental or extensive colectomies should be discussed with patients when deciding appropriate management. Disclosure of Interest None Declared