Risk Of Additional Complications Research Articles

Overnight to Outpatient: A Single Institution's Experience With Mastectomy and Reconstruction Before and After the Start of the COVID-19 Pandemic.

Minimizing resource use while optimizing patient outcomes has become an ever-growing component in modern healthcare, especially in the era of COVID-19. One essential component of this is deciding whether patients need hospital admission following elective procedures. The aim of this study is to investigate operative factors and patient outcomes when mastectomies with or without reconstruction are performed as ambulatory procedures versus planned inpatient admissions. Patient charts for those undergoing mastectomy with or without reconstruction were retrospectively analyzed ranging from March 2019 until February 2021. Factors such as demographic information, operative type, operating room time, cancer stage, total stay time in the medical environment, and postoperative complications were assessed and compared between the 2 groups. A total of 89 patient charts were reviewed, 46 from before the COVID-19 pandemic and 43 from after the start of the pandemic. No differences were observed in demographic factors between the 2 groups. After surgical cases resumed a significant proportion, 79%, of mastectomies with or without reconstruction were performed in the ambulatory center, versus just 2% pre-COVID-19. Similarly, of all of these cases performed, only 19% resulted in hospital admission versus the previous rate of 100% (P < 0.00001). Together, these changes resulted in a significant reduction in length of stay of 39.77 ± 19.2 hours pre-COVID-19 versus 14.81 ± 18.4 hours afterward (P < 0.00001). Unfortunately, a higher number of patients who received surgery after the start of the pandemic elected to forego immediate reconstruction 49% versus 72% (P = 0.032). Most importantly, there were no observable differences found in 7-day readmission, reoperation, or emergency department visit between groups. There was also no difference in 30-day complication rate between groups. Mastectomy with or without reconstruction can be safely performed in the ambulatory setting without additional risk of complications or negative patient factors. This divergence from traditional the protocol of inpatient overnight admission may contribute positively toward patient comfort, minimize the use of healthcare costs and resources, and allow for increased scheduling flexibility for patient and provider alike.

A prospective observational study comparing outcomes application of low-frequency pulse electrical combined with target-oriented rehabilitation therapy in postoperative nerve function rehabilitation of patients with distal humeral fracture and radial nerve injury.

The aim of the present study was to compare the effect of low-frequency pulse electrical stimulation combined with target-oriented rehabilitation therapy and single low-frequency pulse electrical stimulation therapy on postoperative neurological improvement in patients with radial nerve injury and humeral condylar fracture. A total of 88 patients with humeral condyle fracture and radial nerve injury admitted to our hospital from April 2019 to January 2022 were randomly divided into a combined group and a control group, with 44 patients in each group. The patients in the combined group received low-frequency pulse electrical stimulation combined with target-oriented rehabilitation therapy, while those in the control group received low-frequency pulse electrical stimulation therapy. The recovery rate of radial nerve function, the recovery of finger extensor and wrist extensor muscle strength, and the occurrence of postoperative complications were evaluated in all patients. After treatment, the recovery rate in the combined group (77.27%) was higher than that in the control group (50.00%) (p < 0.05). There was no significant difference in finger extensor and wrist extensor muscle strength before treatment between the two groups (p > 0.05). After treatment, both groups showed improvement compared to before treatment (p < 0.05), and the recovery in the combined group was better than that in the control group (p < 0.05). There was no significant difference in MCV and amplitude before treatment between the two groups (p > 0.05). After treatment, both groups showed improvement compared to before treatment (p < 0.05), and the recovery in the combined group was better than that in the control group (p < 0.05). The fracture healing time in the combined group was shorter than that in the control group (p < 0.05). During the treatment period, there was one case of infection and one case of joint pain in the combined group, with a complication rate of 4.55%. In the control group, there was one case of infection and two cases of joint pain, with a complication rate of 6.82%. There was no significant difference in the complication rate between the two groups (p > 0.05). The DHI score in the combined group was better than that in the control group (p < 0.05). The ESCA score in the combined group was better than that in the control group (p < 0.05). Low-frequency pulse electrical stimulation combined with target-oriented rehabilitation therapy can promote muscle strength and functional recovery after radial nerve injury, accelerate fracture healing time, and no additional risk of complications. https://www.researchregistry.com/, researchregistry9461.

The impact of pre-transplantation nephrectomy on quality of life in patients with autosomal dominant polycystic kidney disease

PurposeIn selected ADPKD patients, a nephrectomy is required in the work-up for a kidney transplantation. Because the impact of this procedure is unknown, we investigated the effect of pre-transplantation nephrectomy on quality of life in this group.MethodsIn this retrospective cohort study all ADPKD patients, ≥ 18 years, who received a kidney transplantation in 2 ADPKD expertise centers between January 2000 and January 2016, were asked to participate. Quality of life was assessed using three validated questionnaires on three time points. Nephrectomy was performed in preparation for transplantation.ResultsTwo hundred seventy-six ADPKD patients (53 ± 9 years, 56.2% male) were included. 98 patients (35.5%) underwent native nephrectomy in preparation for transplantation, of which 43 underwent bilateral nephrectomy. Pre-transplantation, ADPKD-IS scores were worse in the nephrectomy group vs. no-nephrectomy group (physical: 2.9 vs. 2.3, p < 0.001; emotional: 2.0 vs. 1.8, p = 0.03; fatigue: 3.0 vs. 2.3, p = 0.01). Post-transplantation and post-nephrectomy, ADPKD-IS scores improved significantly in both groups, with a significantly higher improvement in the nephrectomy group. During follow-up, all scores were still better compared to pre-transplantation. Observed physical QoL (ADPKD-IS physical 1.3 vs. 1.7, p = 0.04; SF-36 physical 50.0 vs. 41.3, p = 0.03) was better post-transplantation after bilateral nephrectomy compared to unilateral nephrectomy. In retrospect, 19.7% of patients would have liked to undergo a nephrectomy, while the decision not to perform nephrectomy was made by the treating physician.ConclusionThis study shows that pre-transplantation nephrectomy improves quality of life in selected ADPKD patients. Bilateral nephrectomy may be preferred, although the risk of additional complications should be weighted.

Extreme Lateral Interbody Fusion (XLIF) with Lateral Modular Plate Fixation: Preliminary Report on Clinical and Radiological Outcomes.

The lateral transpsoas approach (extreme lateral interbody fusion, or XLIF) allows surgeons to use various lordotic cage sizes to help restore intervertebral disk height, correct sagittal alignment, and improve fusion rates. The use of standalone devices has consistently raised doubts due to the high risk of complications and inadequate functional recovery that a circumferential arthrodesis can support. The recent introduction of a novel XLIF cage with adapted lateral plate fixation (XLPF) may further enhance the structural rigidity, consolidating the cage and plate into a singular modular entity. Nine patients from our surgical centers underwent a procedure of 1-level XLIF with XLPF in selected cases. We observed that XLPF does not extend the intraoperative footprint and provides immediate rigidity to the anterior column without any additional risk of complications and with minimal increased time compared to the traditional cage implant procedure. Although it has been shown that the use of interbody fusion cages with supplemental posterior fixation improves stabilization in all directions, the technique of standalone lateral cages may also have a place in spine surgery in that the stability may be sufficient in selected cases, such as junctional syndrome and in some forms of degenerative scoliosis.

Does metaphyseal modularity in femoral revision stems have a role in treating bone defects less severe than IIIB? Clinical and radiological results of a series of 163 modular femoral stems

IntroductionRevision for loosening of femoral stems requires an extensive analysis of bone defects to determine the most appropriate course of action. The drawbacks of using modular stems are that they can break or corrode at their junction. They have rarely been evaluated based on the extent of bone loss and particularly in patients with less severe bone loss. This led us to carry out a retrospective study to analyze modular femoral stems as a function of the initial bone defect (stage IIIB versus less severe in the Paprosky classification): 1) implant survivorship, 2) osteointegration and subsidence of the stem, and 3) breakage of implant. HypothesisModular femoral stems can be used for all types of bone defects (not only IIIB) as the complication rate is identical. Patients and methodsBetween January 1, 1996, and December 31, 2016, 163 patients were included who had received a modular femoral revision stem. The minimum follow-up was 4 years; the mean was 6.7 years±3.3 [4-21]. One patient was lost to follow-up, 88 had died before the analysis date and 74 were still alive; however, 10 of them had the stem removed less than 4 years after implantation. Thus 64 patients were available for the clinical evaluation. There were 44% (72 patients) with Paprosky stage IIIB femoral bone loss and 56% (91 patients) with stage I, II or IIIA bone loss. The stem's bone integration was evaluated using the Engh and Massin score. All complications were documented. ResultsThe survivorship of the femoral stem was 93.75% (95% CI: 83.33–96.70) at 5 years with removal for any reason as the end point. There was no significant difference (p=0.0877) in survivorship relative to the severity of the initial bone loss: 89.84% (95% CI: 78.73–95.31) for stage IIIB; 95.23% (95% CI: 82.24–98.79) for stage IIIA; 97.06% (95% CI: 80.90–99.58) for stage II. Bone integration was considered as being achieved in 76% of stems based on available radiographs (119 of 156 patients) with the severity of bone loss having no effect. We found 18 instances of stem subsidence out of 156 stems with available data (11.5%). The mean subsidence was 14.7 mm ± 12.3 [5-40]. Among the 18 stems with postoperative subsidence, 13 had been implanted for stage IIIB defects, while 5 were for less severe defects (p=0.751). Two stem fractures occurred in patients with stage IIIB bone loss, thus 2/66 for stage IIIB and 0/86 in the less severe bone loss cases (p=0.188). ConclusionModularity provides similar results no matter the severity of initial bone loss, without the risk of additional complications. Level of evidenceIV, Retrospective study.

Organization of Post-Transplant Care and the 5-Year Outcomes of Kidney Transplantation.

The outcomes of kidney transplantation depend on numerous factors and vary between transplant centers. The aim of this study is to assess the relationship between selected organizational factors, comorbidities, and patient and graft survival. This is a retrospective analysis of 438 renal transplant recipients (RTR) followed for 5 years. Patient and graft survival were evaluated in relation to hospitalization length, distance from the patient’s residence to the transplant center, the frequency of outpatient transplant visits, and the number and type of comorbidities. Five-year patient and graft survival rates were 93% and 90%, respectively. We found significant associations of patient survival with the prevalence of pre-transplant diabetes, cardiovascular diseases, malignancies, the number of comorbidities, and the first post-transplant hospitalization length. The incidence of infections, cardiovascular diseases, and transplanted kidney diseases was 60%, 40%, and 33%, respectively. As many as 41% of RTR had unknown etiology of primary kidney disease. In conclusion, the organization of post-transplant care needs to be adapted to the multi-morbidity of contemporary RTR and include multi-specialist care, especially in the context of current problems related to the COVID-19pandemic. The high proportion of patients with undetermined etiology of their primary renal disease carry the risk for additional complications during their long-term follow-up.

Laparoscopic Umbilical Hernia repair in male patients with abdominal obesity.

Objective:Obesity is a global health problem, and obese patients are subject to developing abdominal wall hernias. There are few prospective studies comparing the laparoscopic method of umbilical hernia mesh repair between abdominal obesity patients and normal abdominal waist patients. The aim of this study was to evaluate the short-term outcomes (operative time, early complications and hospital stay) in the patients having laparoscopic hernia repair with abdominal obesity.Methods:This prospective cohort study was conducted at King Fahad Hospital Hofuf, Kingdom of Saudi Arabia from June 2014 to June 2021. Fifty four (54) adult male patients with umbilical hernia were included in this study. The patients were divided into two groups: Group-A: Patients with abdominal obesity (n=26), and Group-B: Patients without abdominal obesity (n=28). All the patients underwent laparoscopic repair of umbilical hernia. The patients with abdominal obesity were defined as those having an abdominal girth more than 102 centimeters.Results:No significant differences were observed as related to age, co-morbidity and risk factors between the two groups. The statistically significant difference between the two groups observed was related to the mean operative time and the mean hospital stay.Conclusion:Laparoscopic umbilical hernia repair can be safely performed in abdominal obesity in male patients without an additional risk of complications.

Pre-Planned Cranioplasty Using Computer-Assisted Designed Temporalis Muscle Augmentation in Patients With Decompressive Craniectomy Involving Resection of the Temporalis Muscle

Decompressive craniectomy (DC) is the last-resort surgical procedure to reduce intracranial pressure and prevent secondary brain injury. Additional resection of the temporalis muscle and fascia can achieve a higher extracranial herniation volume compared to the standard DC technique at the expense of cosmetic problems for the patients. Various methods have been used to augment temporal fossa hollowing. To improve the cosmetic outcome, the authors report a patient who had a skull defect restored using a precisely shaped implant engineered via a computer using the opposite temporalis muscle as a mirror image. Polyether-ether-ketone cranioplasty was performed for the 52-year-old man with temporal hollowing after DC with resection of the temporalis muscle and fascia, due to a ruptured cerebral arteriovenous fistula. The shape of the patient's surgical side was restored and not asymmetrical. The patient was very satisfied. In the case of cranioplasty (CP) in patients with DC with resection of the temporalis muscle, CP with implants that include the opposite muscle may increase patient satisfaction without the risk of additional complications.

A 15-Minute Incremental Increase in Operative Duration Is Associated With an Additional Risk of Complications Within 30 Days After Arthroscopic Rotator Cuff Repair.

Background:Operative time is a risk factor for short-term complications after orthopaedic procedures; however, it has yet to be investigated as an independent risk factor for postoperative complications after arthroscopic rotator cuff repair.Purpose:To determine whether operative time is an independent risk factor for complications, readmissions, and extended hospital stays within 30 days after arthroscopic rotator cuff repair.Study Design:Descriptive epidemiology study.Methods:The American College of Surgeons National Surgical Quality Improvement Program was queried for all hospital-based inpatient and outpatient arthroscopic rotator cuff repairs (Current Procedural Terminology code 29827) from 2005 to 2016. Concomitant procedures such as subacromial decompression, biceps tenodesis, superior labrum anterior and posterior (SLAP) repair, labral repair, and distal clavicle excision were also included, whereas patients undergoing arthroplasty were excluded from the study. Operative time was correlated with patient demographics, comorbidities, and concomitant procedures. All adverse events were correlated with operative time, while controlling for the above preoperative variables, using multivariate Poisson regression with a robust error variance.Results:A total of 27,524 procedures met inclusion and exclusion criteria. The mean age of patients was 58.4 ± 10.9 years, the mean operative time was 86.9 ± 37.4 minutes, and the mean body mass index was 30.4 ± 7.0 kg/m2. Concomitant biceps tenodesis, glenohumeral debridement, SLAP repair, labral repair, and distal clavicle excision significantly increased operative time (P < .001) but not the risk of adverse events (P > .05). The overall rate of adverse events was 0.88%. After adjusting for demographic and procedural characteristics, a 15-minute increase in operative duration was associated with an increased risk of anemia requiring transfusion (relative risk [RR], 1.27 [95% CI, 1.14-1.42]; P < .001), venous thromboembolism (RR, 1.17 [95% CI, 1.02-1.35]; P = .029), surgical site infection (RR, 1.13 [95% CI, 1.03-1.24]; P = .011), and extended length of hospital stay (RR, 1.07 [95% CI, 1.00-1.14]; P = .036).Conclusion:Although the rate of short-term complications after arthroscopic rotator cuff repair is low, incremental increases in operative time are associated with an increased risk of adverse events such as surgical site infection, pulmonary embolism, transfusion, and extended length of hospital stay. Efforts should be made to maximize surgical efficiency in the operating room through optimal coordination of the staff or increased preoperative planning.

27 Prescribing Patterns of Pharmacologic Sleep Agents Following the Implementation of a Sleep Protocol in Adult Burn Patients

Sleep disturbances in burn patients can prolong recovery, cause psychological and physiological stress, and put patients at risk for additional complications. A gap exists in the literature regarding optimal pharmacologic sleep agents in burn patients. In September 2014, a sleep protocol was introduced in our burn center to promote sleep-wake cycles through use of non-pharmacologic interventions and pharmacologic agents. Our study objective was to assess sleep protocol implementation and its effects on prescribing patterns of pharmacologic sleep agents in adult burn patients. This retrospective review evaluated outcomes of a sleep protocol in adult patients admitted for burn or inhalational injury between 10/1/16 and 8/31/17. Exclusion criteria were active psychological disorders, pregnancy, or incarceration. The primary outcome was the prescribing pattern of pharmacologic sleep agents (e.g., medication class, name, dose). Secondary outcomes included non-pharmacologic interventions and assessment/documentation of sleep. Of 242 patients admitted during the study period, 76 (31%) received first- or second-line sleep agents for pharmacologic intervention as defined by the protocol. Of those, 40 met inclusion criteria. Patient demographics are listed in Table 1. Of the included patients who received pharmacologic treatment, 34 (85%) received first-line medications according to the protocol (p<0.001). 78% received melatonin and 38% received trazodone vs. diphenhydramine (18%) or other agents (15%); p<0.001. Non-pharmacologic recommendations were provided in 3 (8%) patients and were documented as completed in 0 patients. Physicians (45%) and physical/occupational therapists (45%) provided documentation regarding sleep most commonly, while nurses reported in 15% of patients. Identified areas for improvement include: protocol adherence, non-pharmacologic interventions, medication dosing, and sleep documentation. A phase two study is underway to develop and validate a standardized tool to objectively assess sleep, educate regarding non-pharmacologic interventions and documentation, and evaluate the effect of these items on prescribing of pharmacologic agents for sleep. To our knowledge, no previously published literature exists evaluating prescribing patterns of pharmacologic sleep agents or a sleep protocol in adult burn patients. Patient Demographics Patient Demographics

Impact and Safety Associated with Accidental Dislodgement of Vascular Access Devices: A Survey of Professions, Settings, and Devices

BackgroundDislodgement rates with intravenous catheters are reported at 1.8%-24% events per year resulting in failed access, interrupted treatment, and greater resource consumption with catheter replacement. The purpose of this study was to quantitatively evaluate the perceptions of frequency, impact, contributing factors, and safety issues from accidental dislodgement affecting intravenous (IV) devices as reported by healthcare clinicians. MethodologyA cross-sectional descriptive survey was conducted via a voluntary online web-based survey of clinicians. Subjects were divided as those actively working in a clinical healthcare setting and those no longer active. Analysis of data was performed quantifying responses of clinicians on question of dislodgement. ResultsSurvey results indicate clinicians routinely observe a significant percentage of accidental dislodgement, with 68% of the 1561 respondents reporting often, daily, or multiple times daily occurrence and 96.5% identifying peripheral intravenous catheters as most common device experiencing accidental dislodgement. Respondents prioritized 10 contributing factors, with confused patient (80%), patient physically removes catheter (74%), and IV catheter tape or securement loose (65%) as the top 3 causes. Over 95% of respondents consider IV dislodgement a safety risk to patients. ConclusionsThis study reports perceptions and impact of accidental dislodgement with IV devices. Inconsistencies exist with use, application, and management of catheter securement and dressings for IV catheters. Risk of additional complications and complete device failure are increased when dislodgement occurs. Given possible complications, along with necessitating replacement of the IV device in many cases, IV catheter dislodgement was considered a safety risk to patients by nearly all respondents.

Tracheoesophageal Fistula: A Different Surgical Approach

SESSION TITLE: Cardiothoracic Surgery SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Acquired tracheoesophageal fistula (TEF) is a relatively uncommon—but often life-threatening—complication of mediastinal malignancy, occurring in 5%-15% of patients with mediastinal/esophageal malignancies.1 TEFs are mainly treated with esophageal stenting2 or single-stage primary repair of both the airway and an esophageal defect with tissue flap interposition.3 We present a patient whose TEF was repaired by surgical creation of a “pseudodiverticulum” with a remnant esophageal pouch after definitive chemoradiation. CASE PRESENTATION: This 66-year-old man with esophageal squamous cell cancer was found to have a mass in the mid-esophagus. Bronchoscopy showed no airway involvement of the tumor. The patient opted for definitive chemoradiation. After treatment, he noted coughing while eating. Workup showed a TEF (Fig. 1). Because he had not tolerated previous stenting, he decided to proceed with esophagectomy. The patient underwent a planned right thoracotomy with intercostal muscle flap, but intraoperatively, the TEF was larger than expected, and its surrounding tissue was fibrotic. Due to concern that the esophagus was fused to the airway (and attempts at dissection would result in a larger fistula or more severe tracheal defect), the esophagus was transected 1 cm above the TEF. The distal esophagus was dissected and staple transected just above the hiatus. A spit fistula was created. After recovery and improvement of nutrition, the patient was brought back to the OR for reconstruction with a substernal gastric interposition. Now 3 years out from his original diagnosis, the patient is able to tolerate oral intake and shows no evidence of recurrent disease. Recent upper endoscopy showed widely patent gastric anastomosis and a stable-appearing pseudodiverticulum, with a small esophageal remnant on the posterior side of the proximal left mainstem bronchus (Fig. 2). DISCUSSION: The benefits vs. risks of surgical intervention for treatment of acquired TEFs must be carefully considered. This patient refused stenting due to prior negative outcomes, but given his presentation and esophageal fusion to the airway, the risk of additional complications by dissecting the fistula was too great. Instead of traditional stenting or standard TEF takedown and repair, we resolved his TEF by leaving the esophagus attached to the airway, transecting the esophagus above and below the fistula, and leaving a small pseudodiverticulum at the level of the fistula. This ultimately allowed him to eat without recurrent aspiration. CONCLUSIONS: Acquired TEFs may be successfully managed using this technique when traditional methods are unavailable or in patients for whom the risk of complications is higher (e.g., those with dense fibrosis and adhesions after radiation). Reference #1: Marulli et al. Eur J Cardiothorac Surg 2013;43(6):e155-161 Reference #2: Silon B et al. Dig Dis Sci. 2017;62(2):424-431 Reference #3: Puma F et al. J Thorac Dis. 2017;9(2):278-286 DISCLOSURE: The following authors have nothing to disclose: Taylor Ipsen, Paul Banks, Ross Bremner, Jasmine Huang No Product/Research Disclosure Information

Preoperative Deep Vein Thrombosis following Acute Anterior Cruciate Ligament Tear: Report of Three Cases

ABSTRACTCase reportWe report 3 cases of preoperative deep vein thrombosis (DVT) following anterior cruciate ligament (ACL) injury in a 20-year-old female volleyball player (C1), a 22-year-old female snowboarder (C2), and a 36-year-old male recreational basketball player (C3). In all three cases, the patients presented with hypersensitivity in the injured knee and guarded significantly on physical examination. The patients were all placed on anticoagulation prior to operative intervention. C1 underwent repair 45 days after her injury and C2 delayed repair until completion of a 6 month course of warfarin. C3 did not undergo repair of the ACL; he developed significant stiffness and had diagnostic arthroscopy with lysis of adhesions and synovectomy 5 months following his injury.ConclusionData is limited regarding the risk of DVT after nonmajor orthopaedic injury, such as ACL injury. Recognition and immediate treatment of the DVT is essential in minimizing the risk of additional complications. Duration of anticoagulation and delay in surgical intervention should be determined based on individual patient goals and risk factors.Baumgartner RE, Jones MD, Hame SL, McAllister DR. Preoperative Deep Vein Thrombosis following Acute Anterior Cruciate Ligament Tear: Report of Three Cases. The Duke Orthop J 2017;7(1):30-33.

Re-operative urethroplasty after failed hypospadias repair: how prior surgery impacts risk for additional complications

The primary aim of this report was to compare urethroplasty complications for primary distal and proximal repairs with those after 1, 2, 3, and 4 or more re-operations. Prospectively collected data on consecutive hypospadias repairs (tubularized incised plate (TIP), inlay, two-stage graft) from 2000 to 2015 were reviewed. Isolated fistula closures were excluded. Extracted information included patient age, meatal location, repair type, primary vs. re-operative surgery, number of prior operations, any testosterone use, glans width, and urethroplasty complications. Pre-operative testosterone stimulation was used during the study period until 2012. Initially, it was given for a subjectively small-appearing glans, but from 2008 to 2012 use was determined by glans width <14mm. Patients initially managed elsewhere were queried for any testosterone treatment. The number of prior operations was determined by patient history and confirmed by review of records. Calibrations, dilations, cystoscopies, and/or isolated skin revisions were not considered as prior urethroplasty operations. Multiple logistic regression was performed for all patients, and for the subset of patients undergoing re-operation, using stepwise regression for the following potential risk factors: meatal location (distal vs. midshaft/proximal), number of prior surgeries (0, 1, 2, 3, ≥4), pre-operative testosterone use (yes/no), small glans (<14 vs. ≥14), surgery type (TIP, inlay and two-stage graft), and age (continuous in months), with P-values <0.05 considered statistically significant. In contrast to the 135/1085 (12%) complication rate in patients undergoing primary distal and proximal TIP repair, re-operative urethroplasty complications occurred in 61/191 (32%) TIP, 16/46 (35%) inlay, and 49/124 (40%) two-stage repairs, P<0.0001. Data regarding testosterone use was available for 1490 (96%) patients. A total of 139 received therapy, of which 65 (46%) had urethroplasty complications vs. 229 of 1351 (16%) without treatment, P=0.0001. Logistic regression in 1536 patients demonstrated that each prior surgery increased the odds of subsequent urethroplasty complications 1.5-fold (OR 1.51, 95% CI 1.25-1.83), along with small glans <14mm (OR 2.40, 95% CI 1.48-3.87), mid/proximal meatal location (OR 2.54, 95% CI 1.65-3.92), and use of pre-operative testosterone (OR 2.57, 95% CI 1.53-4.31); age and surgery type did not increase odds (AUC=0.739). Urethroplasty complications doubled in people undergoing a second hypospadias urethroplasty compared with those undergoing primary repair. This risk increased to 40% with three or more re-operations. Logistic regression demonstrates that each surgery increases the odds for additional complications 1.5-fold. Mid/proximal meatal location, small glans <14mm, and use of pre-operative testosterone also significantly increase odds for complications. These observations support the theory that previously operated tissues have less robust vascularity than assumed in a primary repair, and suggest additional adjunctive therapies are needed to improve wound healing in re-operations. The finding that even a single re-operative urethroplasty has twice the risk for additional complications vs. a primary repair emphasizes the need for hypospadias surgeons to 'get it right the first time'. The fact that 40% of the re-operative urethroplasties in this series followed distal repairs emphasizes that there is no 'minor' hypospadias. A single re-operative hypospadias urethroplasty has twice the risk for additional complications vs. the primary repair, which increases to 40% with three or more re-operations. These results support a theory that vascularity of penile tissues decreases with successive operations, and suggest the need for treatments to improve vascularity. The higher risk for complications during re-operative urethroplasties also emphasizes the need to get the initial repair correct.

Breast cancer-related lymphoedema and venepuncture: a review and evidence-based recommendations

Lymphoedema is a recognised complication of axillary surgery in women with early breast cancer. Such women are widely advised to avoid venepuncture on the ipsilateral side lest this cause complications including lymphoedema. This can lead to multiple failed venepuncture attempts causing distress to both patient and healthcare professional. We reviewed current guidelines and critically appraised the evidence relating the development of lymphoedema to venepuncture to educate healthcare professionals and develop evidence-based guidelines. A systematic search of bibliographic databases was performed and an Internet search undertaken to identify patient information leaflets from societies and support groups. Seven published articles were identified together with 15 published patient information leaflets. Only one small prospective study was identified (level of evidence 2), the remainder being case-control studies (level 3) or retrospective reviews (level 4). There is no good evidence that venepuncture can precipitate lymphoedema. New, patient-centred, evidence-based recommendations for venepuncture in women with breast cancer are proposed. Whenever possible, venepuncture should be performed on the contralateral arm. If this is not readily achieved, in the absence of lymphoedema it is preferable to consider venepuncture in the ipsilateral arm or insertion of a central venous device than to make further attempts in the contralateral arm or resort to sites such as veins in the foot. In the absence of lymphoedema, venesection in the ipsilateral arm carries little, if any, risk of additional complications. We offer evidence-based, patient-centred guidelines for venepuncture in patients with breast cancer following an axillary intervention.

Selective reduction in multiple gestations

The frequency of multiple gestations has increased dramatically. Twins and higher order multiple gestations have pregnancies with increased risks for almost every complication of pregnancy, especially preterm labour, preterm delivery, and congenital anomalies. Monochorionic twins, by virtue of the unique placental angioarchitecture, are at risk for additional complications, such as severe discordant malformations, twin reversed arterial perfusion sequence, twin-to-twin transfusion syndrome or severe selective intrauterine growth restriction. These complications create unique challenges to those who manage multiple pregnancies. Reduction of higher order multiple pregnancies is on option to reduce pregnancy related risks and improve overall outcomes. Selective termination in complex monochorionic pregnancies can be lifesaving for the co-twin by preventing intrauterine demise or extreme prematurity. It is critical, however, to determine chorionicity before considering any approach to selective reduction. Techniques applied to dichorionic twins cannot be directly translated to cases involving monochorionic twins.

V1233 A MODIFICATION FOR CONTROLLING THE DORSAL VASCULAR COMPLEX IN ENDOSCOPIC EXTRAPERITONEAL RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Oncology1 Apr 2012V1233 A MODIFICATION FOR CONTROLLING THE DORSAL VASCULAR COMPLEX IN ENDOSCOPIC EXTRAPERITONEAL RADICAL PROSTATECTOMY Rens Jacobs, Kevin L.J. Rademakers, Laurent M.C.L. Fossion, and Kevin De Laet Rens JacobsRens Jacobs Veldhoven, Netherlands More articles by this author , Kevin L.J. RademakersKevin L.J. Rademakers Veldhoven, Netherlands More articles by this author , Laurent M.C.L. FossionLaurent M.C.L. Fossion Veldhoven, Netherlands More articles by this author , and Kevin De LaetKevin De Laet Veldhoven, Netherlands More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1537AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Controlling the dorsal vascular complex (DVC) in endoscopic extraperitoneal radical prostatectomy (EERPE) by (selective) suture ligation remains a challenging step during apical dissection of the prostate. In this study we report our results of the first 212 cases in which ligation of the DVC was omitted. The aim was to evaluate the consequences of this sutureless transection in terms of blood loss and oncologic control. METHODS Between January 2006 and September 2011 212 patients underwent an EERPE for clinically localized or locally advanced prostate cancer in two different centers. All patients were operated by the same urologist. One hundred and forty-three patients (67.5%) simultaneously underwent an extended laparoscopic pelvic lymph node dissection (LPLND). EERPE was performed according an antegrade manner, as described by Stolzenburg. After complete dissection of the prostate the DVC was selectively divided using bipolar forceps and harmonic scalpel. Blood loss, transfusion need, operative time, pathological stage, margin status and complications were evaluated. RESULTS Mean age of all patients was 64 years (44-74) and mean PSA was 13.2 ng/ml (0.87-190). Mean follow up was 28 months. Mean Gleason score was 6.6. Pathological stage was pT2 in 146 patients (68,9%), pT3 in 63 patients (29,7%), pT4 in 1 patient (0,47%) and pTx in 2 patients (0,94%). Positive margin rates for pT2 and pT3 tumors were 25.3% and 61.9% respectively. Of all positive margins 53.2% was located apically. The mean operative time was 180 min (105-364) for EERPE and 254 min (120-430) for EERPE with LPLND. The median estimated blood loss was 500 ml (50-4000). Six patients (2.8%) had a blood loss more than 2000 ml. Nine patients (4.2%) had a blood transfusion with a mean number of packed cells of 2.9 (1-6). Only one patient needed an extra suture ligation after transection of the DVC. One open conversion was performed due to bleeding from the internal iliac vein during LPLND. CONCLUSIONS Sutureless transection of the DVC in EERPE is a feasible modification and is associated with an acceptable blood loss and oncologic control. It is not associated with a risk for additional complications. Because the 212 patients in this study were part of the surgeon's learning curve even better results are to be expected over time. Functional outcomes of this technique need to be evaluated. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e499 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rens Jacobs Veldhoven, Netherlands More articles by this author Kevin L.J. Rademakers Veldhoven, Netherlands More articles by this author Laurent M.C.L. Fossion Veldhoven, Netherlands More articles by this author Kevin De Laet Veldhoven, Netherlands More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Der nierenkranke Patient mit Typ 1-Diabetes mellitus - Nierentransplantation allein oder mit Insel- oder Pankreastransplantation?

Due to the recent changes in reimbursement politics in islet and pancreas transplantation in Switzerland, the question, which patients with type 1-diabetes mellitus get which form of beta-cell replacement, is of utmost importance for referring physicians. As of July 1, 2010 all forms of islet- or pancreas-transplantations are reimbursed by the Swiss health care system. The limited availability of donor organs and the necessity of transplantation of the islets of several pancreata in order to achieve insulin independence has led to a change in paradigms in Switzerland, where insulin independence by multiple islet transplantations is not the key goal in islet transplantation any longer. The primary goal is achieving a good blood glucose control and avoidance of severe hypoglycaemic episodes. This goal can be achieved in 80 - 90 % of all patients. Only if this goal cannot be achieved by a single islet transplantation, a second or third islet transplantation is performed. By adapting this strategy more patients can benefit from this new therapy. Unlike the North American centers, the Swiss centers in Zurich and Geneva concentrated their efforts on islet after kidney and simultaneous islet kidney transplantation. Due to the organ donor shortage in Switzerland, 50 % of kidney transplants are nowadays living-organ donations, therefore this option has to be included in the decision tree of a beta cell replacement. The choice between islet and pancreas transplantation depends on the existence of diabetes complications (because the perioperative risk is considerably higher in pancreas transplantation) and the potential benefit of a pancreas- or islet transplantation. The first question in the decision tree is, therefore, whether the patient with type 1-diabetes and severe renal failure is a potential candidate for simultaneous pancreas-islet transplantation. If the perioperative risk is considered to be too high, or if revascularisation procedures cannot be done before transplantation, the patient qualifies only for islet transplantation. If a living organ donation for the kidney is possible and the patient not yet on dialysis then the patient can be listed for simultaneous islet-kidney or pancreas-kidney-transplantation. If dialysis is imminent or already performed, a living-donor kidney should be transplanted with the option of a later islet- or pancreas after kidney transplantation. If the patient with type 1-diabetes mellitus is able to maintain a reasonable glycemic level, he would be a good candidate for islet transplantation. If the patient is willing to take the additional risk of complications associated with a pancreas transplant, was never able to maintain a good glycated haemoglobin, has an acceptable perioperative risk, and wishes to become insulin-independent, a simultaneous pancreas-kidney transplant would be recommended. If the kidney has already been transplanted previously, a pancreas- after kidney transplantation would be the procedure of choice. An islet or pancreas transplantation alone is reserved for the patient with type 1-diabetes with a good renal function and frequent life-threatening hypoglycemias, which have to be balanced against the risks of a life-long immunosuppression. In this review article the advantages, disadvantages, and current indications for both beta-cell replacement options in Switzerland are discussed in the light of the available evidence with the help of a new flow chart.

Face-Lift Incision Combined With Sternomastoid Muscular Flap in Parotidectomy

To improve the aesthetic outcome of a traditional parotidectomy, this study used a face-lift incision combined with a sternomastoid muscular (SCM) flap and compared the classical method with these techniques from the patient's perspective. Between 2005 and 2007, 38 patients with benign parotid disease underwent surgery. The patients were retrospectively assigned to two groups according to the surgical technique used. Parotidectomy was performed using a combined face-lift incision and SCM flap for 18 patients (modified group). Another 20 patients received classical parotidectomy (Blair incision without reconstruction) (classical group). The patients were followed up every 3months for 3years. During the follow-up period, the patients were specifically asked about their satisfaction with their postoperative appearance. During the follow-up period, all the patients in the group that had the face-lift incision and SCM flap were satisfied with the aesthetic outcome, and the depression deformity was considerably less. Nine patients in the classical group were not satisfied with the aesthetic outcome. The face-lift incision and SCM flap technique can be performed safely with satisfactory cosmetic and functional results. It results in improved patient satisfaction without additional risk of complications.

Perforator-Sparing Abdominoplasty Technique in the Presence of Bilateral Subcostal Scars after Gastric Bypass

The number of patients after gastric bypass being referred to plastic surgery units for secondary plastic surgery procedures is increasing. The characteristic abdominal deformity includes a draping apron of panniculus, occasionally associated with previous transverse surgical scars in the upper abdomen. Often a limited abdominoplasty of the low transverse type with limited undermining only up to the level of the umbilicus is performed in order not to compromise blood supply in the zone between the old transverse and the new transverse scar. We propose a new, modified and safe surgical technique to perform a complete abdominoplasty with wide undermining up to the xiphoid process in patients with preexisting transverse subcostal scars after gastric bypass surgery, by selectively dissecting and preserving one to three periumbilical abdominal wall perforator vessels to secure flap blood supply. Vessel tunnelling through the rectus sheath and muscle and ligation of the cephalad branch of the perforator provide sufficient flap mobility without perforator tension or traction. Flap undermining is performed around these perforator vessels. To match dissected flap perforators with blood-flow, we performed post-operative color-flow duplex scanning. We treated two patients according to this new technique. In both cases the postoperative course was uneventful and a good aesthetic result was achieved. We conclude from our experience that with this perforator-sparing abdominoplasty technique, safe and complete abdominoplasty can be performed with no additional risk of complications and that a good cosmetic result can be achieved in patients after open gastric bypass surgery.