Risk Of Reoperation Research Articles

Mesh-related complications and recurrence after incisional hernia repair in patients with fistulizing versus non-fistulizing Crohn's disease.

Patients with Crohn's disease (CD) frequently undergo multiple abdominal operations, which increase the risk of incisional hernia repair (IHR) and associated mesh-related complications. Patients with intra-abdominal fistulizing CD (FCD) may be more susceptible to mesh-related complications than patients with non-fistulizing CD (non-FCD). The primary objective was to evaluate the risk of reoperation due to mesh-related complications after IHR in patients with FCD and non-FCD. Secondarily, the study evaluated the impact of isolated perianal fistulizing CD on mesh-related complications and the difference in hernia recurrence reoperation rates between FCD and non-FCD patients. This nationwide study followed patients from 30days after their first recorded IHR until reoperation due to mesh-related complications or hernia recurrence. Cumulative incidence proportion and Cox regression analysis were used to estimate the risk of these outcomes. A total of 334 patients with CD (FCD, n = 55; non-FCD, n = 279) underwent IHR between 2007 and 2016 with a follow-up rate of 100%. FCD patients had a significantly higher 5year risk of reoperation for mesh-related complications (HR 15.95, 95% CI 4.29-59.35) compared with non-FCD patients. None of the patients with isolated perianal fistulizing disease required a reoperation for mesh-related complications. The overall risk of reoperation for recurrence was 8.7%, and did not vary significantly between FCD and non-FCD patients (HR 1.06, 95% CI 0.44-2.58). FCD may be associated with higher rates of mesh-related complications compared with non-FCD, although larger studies are needed to confirm this finding. Conversely, isolated perianal fistulas do not appear to be associated with an increased risk of mesh-related complications. The benefits associated with mesh should be balanced with the risk of long-term mesh-related complications in patients with FCD.

Impact of Early Resumption of Oral Anticoagulation on Recurrence After Surgery for Chronic Subdural Hematoma in Patients With Atrial Fibrillation: A Target Trial Emulation.

Clinicians treating patients with atrial fibrillation (AF) on oral anticoagulants who undergo surgery for chronic subdural hematoma (CSDH) face a dilemma: while early postoperative resumption of anticoagulation is necessary to prevent embolism, it may increase the risk of CSDH recurrence. To date, however, no study has evaluated this question while adequately addressing common biases in observational studies. Here, we assessed this issue using target trial emulation framework. We identified patients undergoing initial CSDH surgery who had received anticoagulation for AF preoperatively from two hospital-based administrative databases (2014-2022). We compared two treatment strategies: resumption of anticoagulation within 14 days postoperatively versus no resumption during this period. Using a three-step method of cloning, censoring, and weighting, we estimated the risk of CSDH recurrence, along with the risk ratio and risk difference at postoperative day 90. 291 CSDH patients with AF were eligible, of whom 29 (10.0%) underwent CSDH reoperation. The weighted estimated 90-day reoperation risk was 11.7% (95% confidence interval [CI], 6.0 to 14.3) for resuming anticoagulation within 14 days postoperatively and 9.4% (95% CI, 4.1 to 12.8) for not resuming within 14 days, corresponding to a risk ratio of 1.20 (95% CI, 0.67 to 2.36) and risk difference of 1.9% (95% CI, -4.0 to 6.6). 90-day risk of CSDH recurrence may not differ between early and non-early resumption of anticoagulation, although early resumption could modestly accelerate recurrence. Allowing for the imprecision of the estimates, these findings provide important insights for clinical decision-making regarding anticoagulation resumption.

Adjunctive Middle Meningeal Artery Embolization for Subdural Hematoma

BackgroundSubacute and chronic subdural hematomas are common and frequently recur after surgical evacuation. The effect of adjunctive middle meningeal artery embolization on the risk of reoperation remains unclear.MethodsIn a prospective, multicenter, interventional, adaptive-design trial, we randomly assigned patients with symptomatic subacute or chronic subdural hematoma with an indication for surgical evacuation to undergo middle meningeal artery embolization plus surgery (treatment group) or surgery alone (control group). The primary end point was hematoma recurrence or progression that led to repeat surgery within 90 days after the index treatment. The clinical secondary end point was deterioration of neurologic function at 90 days, which was assessed with the modified Rankin scale in a noninferiority analysis (margin for risk difference, 15 percentage points).ResultsA total of 197 patients were randomly assigned to the treatment group and 203 to the control group. Surgery occurred before randomization in 136 of 400 patients (34.0%). Hematoma recurrence or progression leading to repeat surgery occurred in 8 patients (4.1%) in the treatment group, as compared with 23 patients (11.3%) in the control group (relative risk, 0.36; 95% confidence interval [CI], 0.11 to 0.80; P=0.008). Functional deterioration occurred in 11.9% of the patients in the treatment group and in 9.8% of those in the control group (risk difference, 2.1 percentage points; 95% CI, −4.8 to 8.9). Mortality at 90 days was 5.1% in the treatment group and 3.0% in the control group. By 30 days, serious adverse events related to the embolization procedure had occurred in 4 patients (2.0%) in the treatment group, including disabling stroke in 2 patients; no additional events had occurred by 180 days.ConclusionsAmong patients with symptomatic subacute or chronic subdural hematoma with an indication for surgical evacuation, middle meningeal artery embolization plus surgery was associated with a lower risk of hematoma recurrence or progression leading to reoperation than surgery alone. Further study is needed to evaluate the safety of middle meningeal artery embolization in the management of subdural hematoma. (Funded by Medtronic; EMBOLISE ClinicalTrials.gov number, NCT04402632.)

Clinical Outcomes of Revision Lumbar Fusion in the Aging Population

Study Design. Retrospective Cohort Objective. To examine the profile of older patients undergoing revision lumbar fusion and to evaluate the impact that advancing age may have on outcomes following revision lumbar fusion. Summary of Background Data. The proportion of older patients undergoing revision lumbar fusion is increasing, however, the benefit of revision lumbar fusion in an aging demographic is not well documented. Methods. Patients aged 55+ who underwent revision lumbar between 2011 and 2022 were included and were stratified into age groups: 55-64, 65-74, and 75+. Primary outcomes consisted of postoperative emergency department (ED) visits, 30- and 90-day readmissions, all-cause reoperations, and the need for secondary revisions. Secondary outcomes included patient-reported outcome measures (PROMs) obtained preoperatively, and at three months and one year postoperatively. Results. A total of 914 patients were included: 55-64 years (n=512, mean: 61.1 years), 65-74 years (n=296, mean:69.1 years), and 75+ (n=106, mean:78.9 years). Adjacent segment disease as a revision indication significantly increased with age(P=0.001). A circumferential approach was used most (N=200, 39.7%) in patients 55-64, while a posterior-only approach was used in 86.3% of patients 75+(P<0.001). Levels decompressed increased with age, from 1.67 in the youngest group to 2.04 in the oldest (P<0.001). The number of levels fused showed no significant difference (P=0.068). 90-day readmissions and the need for secondary revisions did not vary by age. Age groups were not independently associated with ΔPROMs at one year, but the oldest groups continued to experience improvement in PROMs in line with their younger counterparts. Conclusion. Patients 75 years and older derive similar benefits from revision lumbar fusion compared to their younger counterparts with no increased risk of ED visits, readmissions, or reoperations. Clinicians should be advised that there remains significant value in revising older patients when indicated. Level of Evidence. 3

Long-term outcomes comparison of Bentall-De Bono-versus valve-sparing aortic root replacement: An updated systematic review and reconstructed time-to-event meta-analysis

BackgroundFor patients with aortic root dilatation and a structurally normal aortic valve (AV) undergoing composite aortic valve-graft (Bentall-De Bono) versus valve-sparing aortic root replacement (VSARR) procedures there are conflicting data regarding early and long-term benefits. We undertook a study-level meta-analysis to compare the results of both procedures. MethodsThree databases were assessed, and both randomized trials and observational studies were considered eligible. Kaplan-Meier curves of long-term survival and reoperation risk were reconstructed and compared with Cox linear regression and incidence rate ratios (IRR) with 95 % confidence intervals (CI). Landmark analysis and time-varying hazard ratio (HR) were analyzed. Odds ratios (OR) were calculated for early mortality, postoperative stroke, and re-exploration for postoperative bleeding. A random effects model was used. Sensitivity analyses included leave-one-out-analysis, meta-regression and subgroups analysis. Results1456 articles were identified, including 39 observational studies, totaling 14,651 patients (Bentall-De Bono = 9557 and VSARR = 5094). Twelve studies were adjusted. The mean weighted follow-up was 5.05 ± 3.7 years. VSARR was associated with significantly greater survival (HR = 0.50; 95 % CI, 0.45–0.57; p < 0.0001) at 15-year follow-up. The reoperation risk was higher following VSARR (HR = 1.30; 95 % CI, 1.03–1.63; p = 0.02.), although time-varying HR model and landmark analysis reported an increased risk of reoperation within 5 years after VSARR (HR = 1.57; 95 % CI, 1.23–2.01; p < 0.001), after which the difference disappeared. Subgroups analysis of studies excluding aortic dissection showed a comparable rate of late reoperation. ConclusionsVSARR is associated with improved long-term survival compared to Bentall-De Bono. The risk of late reoperation is higher within 5 years following VSARR, after which the two procedures are comparable.

The missed diagnosis of femoral hernias in females undergoing inguinal hernia repair - A systematic review and proportional meta-analysis.

Given the 4-times higher prevalence of femoral hernias among females compared to males, this diagnosis may be missed during inguinal hernia repair (IHR), causing risk of reoperation for pseudo recurrence of femoral hernias (FH). Minimally invasive approaches are suggested as potential reducers of missed FH since they provide a posterior view of all defect areas, despite studies suggesting that women receive less MIS than men. We aim to assess the missed FH during IHR and after reoperation for recurrence following IHR in women. PubMED, Cochrane, and EMBASE databases were searched for studies assessing patients undergoing recurrent IHR, analyzing the incidence of reoperation for FH and occult femoral hernias during IHR. Statistical analysis was performed using R software. From 6,226 records, 10 retrospective observational studies were included, totaling 15,863 patients (20% females). We found that 19.56 per 100 women (95% CI 8.34, 39.37) who are reoperated for an inguinal hernia are found as having a FH during the new repair. Compared to men, women were at a significantly higher risk to be reoperated for FH after IHR (RR 8.97; 95% CI 7.35, 10.93; P < 0.001). Our analysis also showed that 20.7% of females received MIS approaches for groin hernia repair, while 79.3% received open procedures. Furthermore, our study found a pooled incidence of occult FH during the initial IHR of 6.85 per 100 patients for both genders (95% CI 2.78, 15.90), which increased to 21.42 per 100 patients when assessing females only (95% CI 15.46, 28.89). Females have a higher incidence of FH following reoperation for recurrence of inguinal hernia repair. Added to the high rate of occult FH encountered during inguinal procedures, this suggests a missed diagnosis of FH during IHR. The adoption of MIS IHR for women is fundamental to reduce the underdiagnosis of FH.

Reoperation after short-segment lumbar spinal fusion surgery in dialysis patients: A retrospective cohort study.

Patients with dialysis are at high risk of reoperation after lumbar spinal fusion surgery. However, the risk of reoperation after short-segment (≤2 fusion levels) lumbar spinal fusion surgery in this patient group has not been completely investigated. This study aimed to compare the risk of reoperation after short-segment lumbar spinal fusion surgery between patients with dialysis and matched controls without dialysis. We retrospectively evaluated 85 patients who underwent short-segment lumbar spinal fusion surgery at a single institution. Based on the current dialysis treatment, patients were divided into the non-dialysis and dialysis groups. We compared the patients' characteristics, surgical data, pre- and postoperative radiographic measurements, locomotive functional levels in activities of daily living (ADL), rate of whole reoperation, and cause-specific incidence of reoperation such as adjacent segmental disease (ASD) and implant failure between the non-dialysis and dialysis groups. Then, these variables were compared after adjusting for age, sex, and body mass index (BMI) via a propensity-score-matched analysis. In total, 68 patients in the non-dialysis group and 17 patients in the dialysis group were included in this study. The dialysis group was significantly younger and had a lower postoperative ADL status than the non-dialysis group. Moreover, the dialysis group had a significantly higher rate of whole reoperation (8.8% vs 41.2%, P = .003), reoperation due to ASD (4.4% vs 23.5%, P = .027), and reoperation due to implant failure (0.8% vs 11.8%, P = .038) than in the non-dialysis group. Based on a propensity-score-matched analysis, the dialysis group had a significantly higher rate reoperation rate after short-segment lumbar spinal fusion surgery than the non-dialysis group (0.0% vs 58.3%, P = .005). The current study firstly clarified that patients with dialysis are at significantly high risk of reoperation even after short-segment lumbar spinal fusion surgery.

INTERNAL LIMITING MEMBRANE PEELING IN CASE OF RHEGMATOGENOUS RETINAL DETACHMENT AS A PREVENTIVE MEASURE FOR EPIRETINAL MEMBRANE

Rhegmatogenous retinal detachment (RRD) is one of the general determinants of the primary sight disability. However, employable people represent the majority of patients with RRD.Over the past 50 years, retinal detachment surgery had rapid progress, and the rate of success surgery increased up to 90% and higher. However, reducing the risks of reoperations, improving functional outcomes and increasing postoperative visual acuity remain topical issues at present.The main reason for second surgical interventions is progression of the proliferative vitreoretinopathy, which can lead to epiretinal membrane, macular oedema, and to recurrence of the retinal detachment.We reviewed current literature studies that report the results of internal limiting membrane peeling in cases with RRD and other alternative techniques aimed at reducing the risk of mentioned above postoperative complications.

Abdominoplasty With Umbilical Hernia Repair: A Long-term Comparative Analysis of Clinical Outcomes.

The risks and benefits of performing small fat-containing ventral or umbilical hernia repair (HR) during cosmetic abdominoplasty remains a reconstructive and aesthetic challenge for plastic surgeons. This study aimed to compare clinical outcomes in patients undergoing abdominoplasty with concurrent HR and abdominoplasty alone. Retrospective review of patients undergoing abdominoplasty with and without a concurrent HR from January 2015- June 2022 was performed. Patients were stratified by concurrent HR. All hernia patients underwent primary fascial repair, without the use of mesh. Demographics, surgical site occurrences (SSO) and cosmetic complications, including delayed healing and necrosis were assessed. Multivariate analysis was used to compare association of umbilical hernia repair with clinical outcomes. One hundred and six patients underwent abdominoplasty, 68 (64%) had concurrent HR. No significant difference in demographics was identified between groups including mean BMI (HR=27.2 kg/m2 and No HR= 26.3 kg/m2, P=0.73), and number of previous open hernia repairs (P=0.09). After a mean follow-up of 1.5 years, hernia recurrence rate was 1.4% (n=1), with a time to hernia recurrence of 12.2 months. After controlling for confounders, there was no difference in risk of SSO (OR 1.02 [0.31-3.36] P=0.978), cosmetic complications (OR 0.80 [0.14-4.57] P=0.805), procedure length (-21.5 minutes [-46.92-22.93] P=0.501), readmissions (2.8% vs. 0%, P=0.336), or reoperations (8.8% vs. 10%, P=0.766), compared to patients who underwent abdominoplasty alone. Abdominoplasty with concurrent HR can be performed safely and effectively, with no increase in adverse outcomes or cosmetic complications. The benefit of performing mesh-free HR with abdominoplasty can achieve an enhanced aesthetic outcome and reduce long-term abdominal wall morbidity.

Risk Factors of Reoperation in Patients with Intestinal Behçet's Disease Treated by Initial Bowel Resection.

Background/Objectives: Intestinal Behçet's disease (iBD) often requires surgical intervention, with a significant proportion of patients needing reoperation. This study aimed to investigate the risk factors associated with reoperation in patients with iBD who underwent initial bowel resection and to evaluate the perioperative and long-term outcomes in these patients. Methods: This was a retrospective case-control study analyzing patients who underwent their initial bowel resection due to iBD between 2005-2021 at a tertiary referral hospital. Reoperation was considered a surgery due to postoperative complications (within 30 days of the initial surgery) or disease progression. Results: A total of 81 patients were included. The median follow-up duration was 107.1 months, during which 26 patients (32%) underwent reoperation. Multivariable analysis showed that the presence of hematological disorders (hazards ratio [HR], 9.13; 95% confidence interval [CI], 3.79-22.02, p < 0.001), higher c-reactive protein (CRP) levels before the initial surgery (HR, 1.01; 95% CI, 1.01-1.02, p < 0.001), and a shorter specimen resection length (HR, 0.96; 95% CI, 0.93-0.99, p = 0.011) were risk factors for reoperation. Patients who underwent reoperation had higher rates of postoperative complications (69.2% vs. 43.6%, p = 0.031), required longer antibiotic use (12 vs. 7 days, p = 0.012), and had extended hospital stays (18 vs. 9 days, p = 0.011). They also had worse 5-year survival rates than those who did not undergo reoperation (83.5% vs. 98.4%, p = 0.012). Conclusions: Concurrent hematological disorders, high preoperative CRP levels, and short specimen resection were associated with an increased risk of reoperation in patients with iBD who underwent their initial bowel resections. They also had worse perioperative and long-term outcomes.

Same-day discharge for pediatric Nuss procedure; an analysis of the NSQIP-pediatric database from 2017-2022.

Limited data exists evaluating same-day discharge for pediatric Nuss procedure; most being single-center studies. Our analysis, using the NSQIP-P registry, aimed to assess if same-day discharge for the Nuss procedure influenced post-operative outcomes. The NSQIP-P database (2017-2022) identified patients who underwent the Nuss procedure. Patients discharged same-day postoperatively (SDD) were compared to those discharged 1-7days postoperatively (non-SDD). Of 5486 patients identified, 91 (1.7%) were SDD. From 2018 to 2022, the annual SDD rate increased from 0.8% to 2.7%. There was no significant difference between SDD and non-SDD groups for 30-day readmission (1.1% vs 3.5%, p = 0.376), reoperation (0% vs 1.5%, p = 0.643), or other outcomes. Twenty-six patients required readmission or reoperation within 3-days; only one underwent SDD. The most common readmission was for pain (n = 4) and reoperation for chest-tube placement (n = 10). Asthma (OR 1.66, 95% CI 1.03-2.67, p = 0.038), and increased operative time (per 10min increment: OR 1.060, 95% CI 1.034-1.086, p < 0.001) each increased risk of readmission or reoperation. Same-day discharge for the Nuss procedure, although infrequent, has increased without significant differences in complications in the 91 patients who were discharged same-day in this analysis. Same-day discharge for Nuss procedure is reasonable for non-asthmatic patients with a satisfactory postoperative x-ray and meeting other goal-based discharge criteria, including adequate pain control. Level III.

Preoperative anemia is associated with increased length of stay in adult spinal deformity surgery: evaluation of a large single-center patient cohort and future suggestions for patient optimization.

This study aimed to investigate the relationship of preoperative hemoglobin levels as an independent prognostic factor for hospital and intensive care unit (ICU) length of stay (LOS) in patients undergoing surgery for adult spinal deformity (ASD), with the intent of determining whether there exists a correlation and enhancing patient preoperative optimization protocols. The authors reviewed consecutive patients who underwent elective thoracolumbosacral posterior spinal fusion (PSF) involving six or more vertebrae for ASD from January 1, 2013, to December 13, 2021, with a minimum follow-up period of two years. This study primarily investigated the association of preoperative hemoglobin levels with hospital and ICU LOS. To analyze the data, both unadjusted and adjusted generalized linear models (GLM), incorporating cubic splines for non-linear variables, were applied. A total of 598 patients were included. GLMs for hospital and ICU LOS demonstrated nonlinear relationships with preoperative hemoglobin levels. Specifically, hospital LOS decreased with increasing preoperative hemoglobin until a significance threshold of 13.5g/dl. Similarly, ICU LOS significantly decreased with increasing preoperative hemoglobin until 13.0g/dl. Lower preoperative hemoglobin was associated with more perioperative transfusions, less likely discharge to home, and greater risk of reoperation. Preoperative anemia is an independent non-linear risk factor that significantly affects LOS, disposition, and outcomes after surgery for ASD. These findings advocate for a systemic preoperative approach and highlight the need for future research to improve postoperative outcomes and reduce hospital resource utilization. IV.

Multicenter Randomized Clinical Trial of Highly Cross-Linked Polyethylene Versus Conventional Polyethylene in 518 Primary TKAs at 10 Years

Background: Second-generation highly cross-linked polyethylene (HXLPE) has revolutionized total hip arthroplasty. However, the long-term risks and benefits of HXLPE in primary total knee arthroplasty (TKA) remain unknown. This randomized clinical trial evaluated implant survivorship, complications, radiographic results, and clinical outcomes of HXLPE and conventional ultra-high molecular weight polyethylene (UHMWPE) inserts in primary TKAs. Methods: We enrolled 518 patients (518 knees) who underwent primary TKA in 3 centers within 1 tertiary referral network. The mean age was 67 years, the mean body mass index was 32 kg/m2, and 58% of the patients were women. All of the patients underwent primary TKA with a cemented posterior-stabilized tibial insert and patellar resurfacing. Randomization proceeded via stratified dynamic allocation. The patients were blinded to their study group allocation: those in the control group (254 knees) underwent TKA with an UHMWPE insert (N2Vac; Stryker); those in the treatment group (264 knees) received an HXLPE insert (X3; Stryker). Kaplan-Meier survivorship, radiographic results, and clinical outcomes were assessed. This trial was registered with ClinicalTrials.gov. The mean follow-up was 11 years. Results: The 10-year overall survivorship free from any revision and from any reoperation was 96% and 94%, respectively. There were no differences in the risk of revision or reoperation between the groups (p &gt; 0.05). There were a total of 19 revisions. Revision indications included periprosthetic joint infection (14 knees), instability (4 knees), and open reduction and internal fixation (ORIF) for a patellar fracture due to osteolysis around a UHMWPE insert (1 knee). There were no revisions due to polyethylene wear, osteolysis, or fracture of the post in the HXLPE group. The radiographic results and clinical outcomes were otherwise similar. Conclusions: Notably, no wear-related failures were identified in the HXLPE group, but there was 1 case of osteolysis in the UHMWPE group. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The association of bearing surface materials with the risk of revision following primary total hip replacement: A cohort analysis of 1,026,481 hip replacements from the National Joint Registry.

The risk of re-operation, otherwise known as revision, following primary hip replacement depends in part on the prosthesis implant materials used. Current performance evidences are based on a broad categorisation grouping together different materials with potentially varying revision risks. We investigated the revision rate of primary total hip replacement (THR) reported in the National Joint Registry by specific types of bearing surfaces used. We analysed THR procedures across all orthopaedic units in England and Wales. All patients who received a primary THR between 2003 and 2019 in the public and private sectors were included. We investigated the all-cause and indication-specific risks of revision using flexible parametric survival analyses to estimate adjusted hazard ratios (HRs). We identified primary THRs with heads and monobloc cups or modular acetabular component THRs with head and shell/liner combinations. A total of 1,026,481 primary THRs were analysed (Monobloc: n = 378,979 and Modular: n = 647,502) with 20,869 (2%) of these primary THRs subsequently undergoing a revision episode (Monobloc: n = 7,381 and Modular: n = 13,488). For monobloc implants, compared to implants with a cobalt chrome head and highly crosslinked polyethylene (HCLPE) cup, the all-cause risk of revision for monobloc acetabular implant was higher for patients with cobalt chrome (hazard rate at 10 years after surgery: 1.28 95% confidence intervals [1.10, 1.48]) or stainless steel head (1.18 [1.02, 1.36]) and non-HCLPE cup. The risk of revision was lower for patients with a delta ceramic head and HCLPE cup implant, at any postoperative period (1.18 [1.02, 1.36]). For modular implants, compared to patients with a cobalt chrome head and HCLPE liner primary THR, the all-cause risk of revision for modular acetabular implant varied non-constantly. THRs with a delta ceramic (0.79 [0.73, 0.85]) or oxidised zirconium (0.65 [0.55, 0.77]) head and HCLPE liner had a lower risk of revision throughout the entire postoperative period. Similar results were found when investigating the indication-specific risks of revision for both the monobloc and modular acetabular implants. While this large, nonselective analysis is the first to adjust for numerous characteristics collected in the registry, residual confounding cannot be rule out. Prosthesis revision is influenced by the prosthesis materials used in the primary procedure with the lowest risk for implants with delta ceramic or oxidised zirconium head and an HCLPE liner/cup. Further work is required to determine the association of implant bearing materials with the risk of rehospitalisation, re-operation other than revision, mortality, and the cost-effectiveness of these materials.

“Comparison of DIEP and PAP free flaps for breast reconstruction in the context of breast cancer: A retrospective study of 677 patients over 10 years”

BackgroundPAP (Profunda Artery Perforator) flap following cancer surgery has emerged as a relevant alternative for breast reconstruction but remains mainly used in cases where the DIEP (Deep Inferior Epigastric Perforator) flap cannot be performed. The aim of this work is to compare PAP and DIEP flaps’ surgical and aesthetics outcomes in breast reconstruction. MethodsWomen who underwent breast reconstruction by DIEP or PAP flap at the Plastic Surgery Department of Georges Pompidou European University Hospital, Paris, France, between January 2012 and December 2020 were included. Patient’s demographic characteristics were recorded as well as type, laterality and timing of reconstruction. Operative times, length of hospital stay, general and surgical complications were compared. The number of late surgical reoperations, their timing relative to the initial reconstructive procedure, and their purpose were also compared. ResultsA total of 677 patients were included, 559 of whom received a DIEP flap and 118 a PAP flap. PAP flap patients were significantly younger, thinner, and had a smaller initial bra cup size than those who received a DIEP (p<0.001) Operative time was similar for both groups (p=0.074). There was no difference in the number of early postoperative reoperations (p>0.554) or of late revisions (p>0.403) between DIEP or PAP. ConclusionProvided that the technical and human resources are available, PAP flap is a valid technique, with no increased risk of surgical complications and reoperations, nor lengthening of operative time. The PAP flap should be considered a primary therapeutic option and not only an alternative to the DIEP flap.

Long-Term Outcomes of Subcutaneous Versus Transvenous Implantable Cardioverter Defibrillator Use Among Patients on Maintenance Dialysis

Despite an elevated risk of sudden cardiac death among dialysis patients, implantable cardioverter defibrillators (ICDs) have not been shown to improve mortality and are associated with high complication rates. Subcutaneous (S-)ICDs may reduce the risk of complications for eligible dialysis patients, but safety and benefits versus transvenous (TV-)ICDs are unknown. To compare long-term outcomes between dialysis patients receiving S-ICD versus TV-ICDs. We performed a retrospective analysis of ICD implants among Fee-For-Service Medicare beneficiary dialysis patients in the National Cardiovascular Data Registry ICD Registry. Outcomes were ascertained from Medicare claims data. We compared survival outcomes, hospital admissions, and ICD- associated and dialysis vascular access-associated complications, between eligible S-ICD and single chamber TV-ICD recipients using stabilized inverse probability of treatment weighting. We identified 529 dialysis patients receiving S-ICDs and 842 receiving single chamber TV-ICDs who met the inclusion criteria. S-ICD recipients were younger, more often Black, and had a higher burden of cardiac disease and prior dialysis access interventions. After propensity weighting, there was no difference in the risk of death (HR 1.12, 95% CI 0.96-1.30), hospital admission (HR 1.01, 95% CI 0.88-1.16), bacteremia/sepsis (HR 1.01, 95% CI 0.80-1.26), device reoperation (HR 1.06, 95%CI 0.59-1.89) and subsequent dialysis access interventions (HR 1.12, 95% CI 0.86-1.46). In this representative longitudinal cohort study of dialysis patients, compared with TV-ICD, S-ICD was not associated with decreased risks of death, hospitalization, device complications, and dialysis access interventions.

Reverse Total Shoulder Arthroplasty for Acute Proximal Humerus Fractures: Is Delay Associated With an Increased Rate of Reoperation?

To compare reoperation rates of acute versus delayed reverse total shoulder arthroplasty (RTSA) following a period of nonoperative treatment for proximal humerus fractures (PHFs). We also aimed to identify an optimal time interval from PHF to RTSA before the risk of reoperation significantly increased. . Database review. Ontario, Canada. Adults aged 50 years and older who sustained a PHF (OTA/AO 11A-C) between 2004 and 2019 were included. Exclusion criteria included polytrauma, open fractures, non-Ontario residents, invalid health insurance, and any operative treatment before RTSA. The primary outcome measure was reoperation within 2 years following RTSA. A risk-adjusted, restricted cubic spline was used to model the probability of reoperation according to the time elapsed between PHF and RTSA to identify a time point at which the risk of reoperation significantly increased. A multivariate logistics regression was used to identify predictors. In total, 891 patients (685 acute, 206 delayed) underwent RTSA for PHF. The acute cohort had a significantly lower reoperation rate (3.9%) compared with the delayed cohort (8.3%) (P = 0.02). The odds of reoperation increased with a delay to RTSA greater than 28 days and continued to rise until 100 days after fracture. Patients who underwent RTSA 28 days after PHF were found to have a significantly higher odds of reoperation by 2 years (P = 0.03). Among patients undergoing RTSA for acute PHFs, a delay to surgery greater than 28 days is associated with a greater odds of reoperation and may be useful when counseling patients. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Spondylolisthesis in Young Patients in a Large National Cohort: Reoperation Rate Depends on Surgical Approach.

The current literature investigating surgical treatments for lumbar spondylolisthesis in adolescent patients is limited by small sample sizes. There are high reoperation rates, and posterior interbody fusion has not been reported to help. The current study aimed to utilize a nationwide database to investigate outcomes of spinal fusion for spondylolisthesis in young patients. The PearlDiver database was queried for patients <21 years old who had undergone lumbar spinal fusion for spondylolisthesis between 2010 and 2020. Patients were divided into 4 cohorts based on surgical approach: (1) posterior spinal fusion with posterior instrumentation (PSF), (2) posterior spinal fusion with posterior instrumentation plus interbody (PSF+I), (3) anterior spinal fusion without posterior instrumentation (ASF), and (4) anterior spinal fusion plus posterior instrumentation (A+PSF). Patients with <2 years of follow-up were excluded. The primary outcome was reoperation. Of 33,945 patients with spondylolisthesis, 578 (1.7%) underwent lumbar spinal fusion: 236 (40.8%) had PSF, 219 (37.9%) had PSF+I, 66 (11.4%) had ASF, and 57 (9.9%) had A+PSF. The mean age was 16.5 ± 1.1 years, and the mean follow-up was 5.4 ± 2.9 years. A higher percentage of girls underwent surgery compared with boys (2.0% versus 1.4%). Survival analysis using all-cause reoperation as the end point demonstrated an overall 5-year reoperation-free survival rate of 85.5% (95% confidence interval [CI]: 82.5% to 88.6%). The overall reoperation rate within 5 years was significantly different depending on the approach, with A+PSF being the lowest at 7.0% (PSF = 11.9%, PSF+I = 10.5%, and ASF = 31.8%). This is the largest reported series of spondylolisthesis surgery in young people. The lowest rate of revisions within 5 years was for a combined approach of A+PSF. The 5-year risk of reoperation of 31.8% for a stand-alone ASF appeared to be unacceptably high compared with other approaches, and was over 4 times higher than A+PSF (7.0%). Consistent with previous clinical series, the addition of an interbody fusion to a PSF did not decrease the reoperation rate and did not appear to offer any advantages to a PSF alone. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Postoperative complications in patients with Behçet’s disease

ObjectiveTo assess the proportion of postoperative complications of various surgeries in patients with Behçet’s disease (BD) and compare the risk of surgical complications between BD patients and controls.MethodsWe analyzed 389 BD patients who underwent surgeries at Seoul National University Hospital between January 2003 and December 2019. Controls were 1:1 matched with BD patients based on age at surgery, sex, and type of surgery. Generalized estimating equation analyses were performed to compare the postoperative complications between BD patients and controls.ResultsAmong 632 surgeries in BD patients, 36 (5.7%) surgical site complications, including wound dehiscence (38.9%), bleeding (13.9%), infections (8.3%), anastomotic dehiscence (22.2%), and stricture (5.6%), occurred after median 12 days (IQR 7.8–22.0). Surgical site complications developed frequently after cardiac (33.3%) and vascular (22.2%) surgeries and rarely occurred after ophthalmic (1.5%) surgeries. Seventeen (2.7%) cases required reoperation within median 15 days (IQR 7.0–43.0). Four patients died within median 21 days (IQR 8.3–41.3 days). After adjustment for confounders, BD patients exhibited a significantly higher risk of surgical site complications (OR 3.4, 95% CI 1.4–8.0) and reoperation (OR 5.2, 95% CI 1.2–22.8) after cardiovascular surgery than controls. However, the risks of surgical site complications and reoperation after other types of surgery were similar in both groups.ConclusionsThe risk of postoperative complications varies according to the type of surgeries among BD patients. While cardiovascular surgeries result in higher perioperative complications in BD patients, ophthalmic surgeries show a safety profile similar to those in non-BD patients.Key Points• Patients with Behçet’s disease exhibited an increased risk of surgical site complications and subsequent reoperations after cardiovascular surgery than controls.• The safety profile of ophthalmic surgery was comparable between patients with Behçet’s disease and controls.• In patients with Behçet’s disease, the risk of postoperative complications varies according to the type of surgery.

Reoperation Rates and Risk Factors after Spinal Cord Stimulation Revision Surgery

Introduction: Spinal cord stimulation (SCS) is an effective treatment for patients with refractory chronic pain. Despite its efficacy, rates of reoperation after initial implantation of SCS remain high. While revision rates after index SCS surgeries are well reported, less is known about rates and risk factors associated with repeat reoperations. We sought to evaluate patient, clinical, and surgical characteristics associated with repeat reoperation among patients who underwent an initial SCS revision procedure. Methods: We performed a retrospective review of patients who underwent SCS revision surgery performed at a single institution between 2008 and 2022. Patients were stratified by whether they underwent a single revision (SR) or multiple revision (MR) surgeries. Multivariate logistic regression was performed to determine risk factors associated with repeat SCS revision. Kaplan-Meier survival analysis was used to compare rates of devices requiring revision across groups. Results: A total of 54 patients underwent an initial SCS revision. Of these, 15 (28%) underwent a second revision. The most common indication for revision surgery was lead migration (65%). No significant differences were observed in age, body mass index, comorbidities, lead type, and revision indication among the SR and MR groups. On multivariate adjusted analysis, only cervical lead position was significantly associated with repeat reoperation (OR 7.10, 95% CI [1.14, 44.3], p = 0.036). Time to reoperation after a single and MR SCS surgeries did not differ. Conclusions: Among patients who undergo SCS reoperation, a substantial portion requires additional revisions. Cervical lead placement may be associated with a higher risk of repeat revision surgery compared to thoracic lead positioning. Consideration of lead positioning in the decision to perform and undergo reoperation may therefore result in lower revision rates and improved clinical outcomes among SCS patients with MRs.