Second-stage Surgery Research Articles

Non-Hodgkin Lymphoma Mimics Infected Total Knee Arthroplasty: 非何傑金氏淋巴癌模仿全膝關節置換感染

Lymphoma associated with total knee arthroplasty is a rare condition. We report a case of non-Hodgkin lymphoma mimicking an infected total knee arthroplasty. A 73-year-old woman who received left total knee replacement presented with fever and a discharging sinus over her left knee 12 weeks after surgery. The diagnosis of prosthetic joint infection was made and a two-stage revision arthroplasty planned. After implant removal and insertion of an antibiotic spacer in the first-stage operation, culture results of all intraoperative specimens were negative but the pathology report showed diffuse large B-cell lymphoma. She then received chemotherapy and a second-stage reconstruction operation. The wound healed uneventfully and she regained independent mobility.

Microvessel Density Evaluation of the Effect of Enamel Matrix Derivative on Soft Tissue After Implant Placement: A Preliminary Study.

Enamel matrix derivative (EMD) is commonly used in periodontal therapy and has been used successfully for periodontal regeneration. In addition, this material has a possible angiogenic effect that has been associated with enhanced wound healing. The aim of this study was to evaluate the effect of EMD on microvessel density (angiogenesis) on the soft tissues surrounding newly placed implants after 14 days. Five patients were selected, each requiring at least one implant on each side of the maxilla, in a split-mouth experimental design. The implants were placed in a two-stage procedure. Each side was then randomized as test or control. On the test side, 0.1 mL of EMD was topically applied to the soft tissues surrounding the implants, while the control side did not receive any treatment. Second-stage surgery was performed after 14 days. A 6-mm punch biopsy was performed for each implant, with the samples subsequently prepared for histology and immunohistochemistry. Quantitative vascularization analysis was performed, which involved counting three areas or "hotspots" containing vessels strongly positive for CD34 and CD105, a pan-endothelial and new vessel marker, respectively. There was no significant difference between test and control groups when evaluating the formation of new blood vessels. The total number of blood vessels, however, was significantly higher in the group treated with EMD (test group). Within the limits of the present study, it can be concluded that topical application of EMD on the soft tissues surrounding newly placed implants resulted in an increased number of blood vessels at 14 days, suggesting that EMD may play a beneficial role in this aspect of wound healing.

Two-stage revision surgery for infected total knee replacements: reasonable function and high success rate with the use of primary knee replacement implants as temporary spacers.

Two-stage revision surgery for infected total knee replacements remains the gold standard treatment. Articulating spacers are preferred to static spacers for improved functional outcome. Articulating spacers made of cement can be prone to fracture, may not be suitable for full weight bearing, create abrasion debris and necessitate second-stage revision surgery. An alternative is the use of primary knee replacement implants as temporary spacers. With this technique, implants are loosely cemented into place at time of revision, allow the patient reasonable mobility and an ability to fully weight bear and can obviate the need for second-stage surgery. A retrospective review of all patients undergoing revision for infection over two years was conducted. Patients were clinically assigned to single- or two-stage revision. Patients who had a temporary knee replacement, that is, a primary knee replacement used as an articulating spacer, were identified and contacted to complete an Oxford Knee Score. Time to second stage and recurrence was identified from the notes 23 patients received temporary knee replacements. Of these, one patient died, 13 proceeded to a second-stage revision and nine remain in situ. Median time to second-stage revision was 19weeks [range 11-27]. No patients had re-infection. Median follow-up for ongoing temporary knee replacements was 43weeks [range 24-90]. Four temporary implants had survived for longer than 1year. Median Oxford Knee Score was 26 [23-32] and satisfaction score was 8 out of 10 [8-8]. These early results show that knee replacement implants used as spacers provide a good alternative to cement-based articulating spacers with low re-infection rates. Their additional cost when compared with cement spacers is offset by the fact that many patients achieve adequate function and frail patients can avoid a revision procedure. Level of evidence Case series, Level IV.

Invited Commentary

The National Paediatric Cardiology Quality Improvement Collaborative (NPC-QIC; http://npcqic.org) is a multicenter initiative led by Cincinatti Children’s Hospital and created with the mission of standardizing care and improving outcomes for infants with single-ventricle congenital heart disease. The group began in 2007 by implementing practice change among participating institutions. Since then, outcomes have been monitored and studied through a registry that now encompasses data from more than 2000 patients, and lessons learned from this research have driven further practice changes. Evans and colleagues [1Evans C.F. Sorkin J.D. Abraham D.S. et al.Interstage weight gain is associated with survival after first-stage single-ventricle palliation.Ann Thorac Surg. 2017; 104: 674-680Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar] interrogated the registry to answer the question: Is interstage weight gain after stage 1 palliation associated with improved survival? They identified 1358 patients undergoing non-hybrid stage 1 palliation operated over a 7-year period. An association between weight gain in the interstage period and survival (both overall and transplant-free) was shown in adjusted analysis that was not present in simple univariable analysis. The magnitude of this gain is small but significant and would not have been detected were it not for the quantity of longitudinal follow-up data within the registry. The major limitation of this dataset is that it captures only the fraction of patients who were discharged between stage 1 and stage 2, which is a select subgroup of patients. In addition, the data comes from a group of institutions for whom hypoplastic left heart syndrome is the predominant single ventricle morphology. Finally, the effect of weight gain on the hospital mortality after stage 2 could not be analyzed. These limitations notwithstanding, to our knowledge this is the first study to demonstrate an association between survival and weight gain between stages 1 and 2. Although optimizing weight gain is already a major focus of care in the interstage period, these data demonstrate that we need to do something more for patients who, for whatever reason, are not gaining weight. Aggressive reintervention for arch or shunt obstruction or, more controversially, earlier performance of the stage 2 operation may be beneficial in the subset of patients struggling to gain weight. Although data from the Pediatric Heart Network Infant Single Ventricle trial previously demonstrated higher procedural risk for those undergoing stage 2 at a younger age [2Cnota J.F. Allen K.R. Colan S. et al.Superior cavopulmonary anastomosis timing and outcomes in infants with single ventricle.J Thorac Cardiovasc Surg. 2013; 145: 1288-1296Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar], a recent report from the NPC-QIC registry suggests similar outcomes and less interstage attrition among centers performing the stage 2 operation earlier [3Hill G.D. Rudd N.A. Ghanayem N.S. Hehir D.A. Bartz P.J. Center variability in timing of stage 2 palliation and association with interstage mortality: a report from the National Pediatric Cardiology Quality Improvement Collaborative.Pediatr Cardiol. 2016; 37: 1516-1524Crossref PubMed Scopus (22) Google Scholar]. Interstage Weight Gain Is Associated With Survival After First-Stage Single-Ventricle PalliationThe Annals of Thoracic SurgeryVol. 104Issue 2PreviewLow birth and operative weight have been identified as risk factors for death after first-stage single-ventricle palliation. We hypothesize that weight gain after the first-stage operation is associated with transplant-free interstage survival to admission for the second-stage operation. Full-Text PDF

Perioperative Use of Vedolizumab is not Associated with Postoperative Infectious Complications in Patients with Ulcerative Colitis Undergoing Colectomy.

Preoperative use of vedolizumab has been associated with increased short-term postoperative infectious complications. We assessed this risk in a single-centre cohort of patients with ulcerative colitis undergoing colectomy. Chart review was performed for all colectomies between 2006 and 2016. Short-term postoperative [non]infectious complications were evaluated within 30 days after colectomy. The comprehensive complication index was calculated based on all reported events. We identified 170 eligible patients [46% female, median age 40 years]. Thirty-four patients [20%] received vedolizumab within 16 weeks, 60 [35%] received anti-tumour necrosis factor [TNF] within 8 weeks, 32 [19%] received a moderate-to-high dose of prednisone and 71 [42%] received other therapies at colectomy. Pouch construction was performed at first stage in 47 patients [28%], and less frequently in patients under vedolizumab, anti-TNF or steroids [all p < 0.01]. Sixty-two short-term infectious and 75 noninfectious complications were reported in, respectively, 49 [29%] and 64 [38%] patients. Only pouch construction at first stage of surgery was independently associated with short-term postoperative infectious (odds ratio 2.40 [95% confidence interval 1.18-4.90], p = 0.016), overall complications (3.11 [1.52-6.40], p = 0.002) and more severe complications (comprehensive complication index 20.9 [0.0-30.8] vs 0.0 [0.0-20.9], p = 0.001). Perioperative medical therapy [including vedolizumab] did not influence short-term outcome, either in the overall population or in the subpopulation of patients with pouch construction at a second stage. Perioperative use of vedolizumab was not associated with short-term postoperative [infectious] complications. However, postponing pouch construction to a second stage of surgery is advisable in patients under biological therapy or moderate-to-high doses of steroids.

Application of antibiotic cement-coated locking plates in induced membrane technique for treating post-traumatic tibial osteomyelitis

Objective To investigate the clinical outcome of post-traumatic tibial osteomyelitis treated by induced membrane technique combined with the antibiotic cement-coated locking plate. Methods A restrospective case series analysis was made on 71 cases of post-traumatic tibial osteomyelitis treated by induced membrane technique from September 2014 to September 2014. There were 55 males and 16 females, aged 18-60 years(mean, 37.4 years). Mean length of bone defect following debridement was 4.5 cm(range, 4-11 cm). Antibiotic cement-coated locking plates were used to provide the stability of the bone defects after one-stage debridement. Bone grafting and exchanging the plates with ntramedullary nails were done during the second-stage surgery. Parameters were monitored dynamically after operation to evaluate infection recurrence and bone healing, including C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), clinical features(sinus formation, redness and swelling, warmth and pain) and X-ray films of the involved limbs. Results All patients were followed up for 13-25 months (mean, 19.5 months). There was no sign of recurring infection and CRP and ESR were normal in all cases after the first stage surgery. However, four cases (6%) had recurrent infection with sinus exudates and their CRP and ESR were abnormal after the second stage surgery, and further treatments were carried out on these patients. Follow-up showed bony union in all patients within mean 5.5 months (range, 4-6 months). Conclusion Induced membrane technique with antibiotic cement-coated locking plates for treatment of post-traumatic tibial osteomyelitis can shorten bone healing time and decrease infection recurrent rate without obvious impact on osteogenic activity. Key words: Osteomyelitis; Fracture fixation, internal; Induced membrane technique

RESULTS OF STAGED SURGICAL TREATMENT OF PATIENTS WITH TANDEM STENOSIS OF THE CERVICAL AND LUMBOSACRAL SPINE

Objective. To conduct a retrospective analysis of staged surgery in patients with tandem stenosis of the cervical and lumbosacral spine, to identify causes of poor outcomes. Material and Methods . The study included 190 patients with tandem stenosis of the cervical and lumbosacral spine. Out of them 72 had symptomatic cervical and asymptomatic lumbosacral tandem stenosis (Group 1), 67 - symptomatic lumbar and asymptomatic cervical tandem stenosis (Group 2), and 51 - compression with neurological manifestations in both spine departments (Group 3). Patient’s anthropometric data, initial clinical symptoms, and duration of disease were analyzed. The intraoperative characteristics of surgical interventions and features of the postoperative period, clinical parameters and the existence of complications were evaluated. Results . Excellent and good postoperative outcomes were achieved in patients of Groups 1 and 2 with monosymptomatic tandem stenosis, in patients of Group 3 with symptomatic tandem stenosis, and in patients of all groups who underwent laminectomy and bilateral foraminotomy for bilateral symptomatic foraminal stenosis, and minimally invasive bilateral foraminotomy through unilateral approach in case of radiographic evidence of foraminal stenosis without symptoms. Conclusion . Symptomatic tandem stenosis of the cervical and lumbosacral spine is a severe nosological entity requiring meticulous removal of pathological substrate primarily in the cervical spine. The early implementation of the second stage of surgery significantly reduces neurological symptoms, relieves pain and improves quality of life in patients.

The use of medpor as a projection block for the elevation of the constructed auricle in total auricular reconstruction

The 2-stage methods of the total auricular reconstruction developed by Dr. Nagata have been widely used. In the second stage of ear reconstruction, the implanted auricle is separated from the underlying bed, and its posterior surface is covered with a skin graft or a flap. Many surgeons have used various projection blocks, such as banked cartilage or alloplastic materials, to provide the constructed auricle with adequate projection. Banked costal cartilage is most commonly used as a projection block, but it may not be possible to obtain banked cartilage in sufficient volume to ensure an acceptable projection. Previously, in this procedure, the author used a new fabricated cartilage block harvested from the fourth and fifth costal cartilages. Although this material is stable and yields acceptable results, an invasive and time-consuming procedure is necessary to obtain it. Therefore, the author considered the use of a Medpor (a high-density porous polyethylene, Stryker, USA) projection block as an alternative to the cartilage. Between January 2012 and May 2015, the author performed the second-stage operation by using a Medpor block in 51 patients. The follow-up period ranged from 1 year to 4 years. The use of a Medpor block for projection in the second stage is time-saving and less invasive. Delayed healing of the wound was noted in 2 cases, in which a deep temporal fascial flap, instead of a temporoparietal fascial flap, had been used for the coverage of the exposed framework. A hypertrophic scar was noted on the posteroinferior surface of the reconstructed ear in 1 case. However, no major complications such as infection or exposure occurred. The constructed ears showed a firm and stable projection.

Two-stage flap repair of severe hypospadias: Usefulness of the tubularized incised plate urethroplasty

The use of flaps in the two-stage repair of posterior hypospadias associated with severe chordee has been well established. Despite the almost certain guarantee of flap take, complications such as diverticuli are still relatively high. While different applications of the tubularized incised plate have been described, experience with the application of the technique to the two-stage flap repair is very limited. A previous local review of 15 cases performed at the present institution during the period 1998-2003, using the technique as described by Rekit, revealed fistulae and diverticulum rates of 20% and 27%, respectively. With the primary objective of improving surgical outcome, the midline incision was incorporated into the two-stage flap repair. Between 2004 and 2015, 35 boys (aged 2-15 years) with severe hypospadias that required excision of the urethral plate were operated using the two-stage flap technique. The first stage involved mobilization of preputeal or dorsal penile skin (if circumcised) to the ventral surface, as described by Retik. After a minimum interval of 6 months, the second-stage operation was performed in a way similar to the technique of tubularized incised plate urethroplasty, as popularized by Snodgrass, and involved a preliminary midline incision on the neo-urethral plate followed by tubularization and multilayered closure. All but one flap took successfully. The outcome was satisfactory in 80% of patients, and there was a fistula rate of 14% ( Summary Table). One patient had a complete breakdown of the flap and was successfully treated about 12 months later by repeating the second stage of the operation. No case of diverticulum or stricture was recorded. Even though there was a marginal improvement in the fistula rate, the most striking observation was the complete absence of diverticulum or stricture. With a reported incidence rate of 20-63%, different authors have reported diverticulum formation (despite the absence of distal obstruction) to be a major problem of the two-stage flap technique. Attempts by these authors at reducing the risk of diverticulum by reducing flap size have tended to increase the risk of strictures. This has been the main reason given by some authors for abandoning the technique. The main limitations of the present study included the wide age range of the patients and the small sample size. The inclusion of a midline incision in a two-stage flap urethroplasty for proximal hypospadias appears to prevent the development of diverticulum.

Modified loop myopexy technique for severe high myopic strabismus fixus.

This study introduces a modified loop myopexy technique for severe high myopic strabismus fixus. This study aims to evaluate the surgical results of loop myopexy with or without medial rectus recession for the treatment of patients with myopic strabismus fixus. This is a retrospective study in a Chinese teaching hospital. Data was collected from 25 myopic strabismus fixus patients (33 eyes) with restriction in both abduction and sursumduction. First, the loop myopexy technique was performed. Following the loop myopexy technique, a medial rectus recession was performed if esotropia remained. If esotropia and/or hypotropia still persisted, second-stage surgery of the contralateral eye was performed. The main outcome measures were ocular deviations, eye movements and the angles of dislocation of the globe. At the last follow-up, mean deviation of esotropia was significantly improved (10 vs. 92 PD; p=0.000), while mean deviation of hypotropia was improved (6 vs. 32 PD; p=0.008). Mean abduction limitation was improved (-2.7 vs. -5.0; p=0.000); mean elevation limitation improved (-3.2 vs. -5.0; p=0.000). The angle of dislocation of the globe was significantly decreased (103.0 vs. 235.3 D; p=0.002). Modified Yokoyama's surgery effectively corrected the restrictive esotropia and hypotropia, restored the dislocated globe back into the muscle cone and improved the eye movement in severe myopic strabismus fixus.

Comprehensive treatment of cholangiocarcinoma complicated with obstructive jaundice

The paper deals with the analyzed results of treatment of 45 patients with cholangiocarcinoma complicated with obstructive jaundice. It has been proved the effectiveness of percutaneous transhepatic endobiliary interventions as the first or the final stage of the surgical treatment of these patients, following by the aggressive surgical strategy that involves major hepatectomy combined with total caudal lobectomy, resection of the extrahepatic biliary tract and extensive lymph node dissection (D2–D3) as the second stage of surgery.

Hybrid Palliation for Interrupted Aortic Arch With Small Aortic Valve.

Open heart surgery for interrupted aortic arch in the neonatal period is still a high-risk procedure related in part to patient factors such as low birth weight, other morphologic anomalies, and, especially, small aortic valve size. Recently, we performed hybrid palliation with bilateral pulmonary artery banding and ductal stenting as the first-stage palliation for such cases. In this study, the outcomes of this procedure were examined. Six cases of interrupted aortic arch with a small aortic valve underwent the hybrid procedure in the neonatal period in our institute from 2010 to 2015 (mean age: 6.8 days, mean body weight: 3.2 kg, mean z score of the aortic valve annulus: -8.3). Their postoperative clinical courses and results of the second-stage surgery were evaluated. No mortality or severe morbidity was seen in association with initial hybrid palliation. Five of six patients were discharged from the hospital; the one exception had a significant urinary tract anomaly. None needed an additional catheter intervention or surgical procedure postoperatively. All surviving patients underwent second-stage surgery; three had biventricular repair by the conventional method or Damus-Kaye-Stansel anastomosis with the Rastelli procedure and the other three proceeded toward staged Fontan reconstruction. Growth of the aortic valve was seen in four patients, and increased indexed left ventricle volume was recognized in one after the palliation. Hybrid palliation could be useful not only to avoid high-risk neonatal surgery but also to allow for eventual selection of the second-stage surgery based on the observations of potential interval development of left ventricular structures.

Drainage à pression négative en préopératoire des traumatismes complexes ouverts de la main : à propos de 17 cas

BackgroundFew studies have been conducted to explore the use of the vacuum sealing drainage (VSD) technique in complex hand injuries. The aim of this study was to report outcomes in patients with complex hand injuries receiving VSD as a coadjuvant treatment prior to second-stage surgery. MethodsThis case series study retrospectively reviewed the patients who underwent VSD for treatment of hand injuries. Inclusion criteria for the study were: (1) traumatic soft tissue defects of the hand and wrist, accompanied by different degrees of injury and exposure of bone, tendon, or blood vessel; (2) the wound surface of hand and wrist was seriously contaminated and direct wound closure was not possible; and (3) the soft tissues of hand and wrist were seriously lacerated or avulsed, and showed necrosis or acute infection. After debridement, one-stage and/or two-stage repairs using healthy adjacent tissues were performed and the wound was covered by the VSD materials. The non-cytotoxic polyethylene alcohol hydration seaweed salt foam was applied during the VSD treatment for its good biocompatibility. The drainage tube was connected to the vacuum equipment and the negative pressures were set at –60kPa to –40kPa. The VSD device was left in place for 5 to 7 days before removal. Either free skin grafting or skin flap transplantation was used for wound closure and/or reconstructive surgery. The hand injury severity score was used to assess wound severity. The surgical results were scored using the total active motion classification. ResultsA total of 17 patients (13 and 4 patients had major and severe hand injuries), averaging 33.8years were included. During the study period, 6 patients with severe hand injuries were not treated with VSD for the following reasons: (1) hemodynamic instability (n=1); (2) impaired coagulation function (n=1); (3) uncontrollable hemorrhage on the wound surface (n=2); and (4) exposure of the main blood vessels after surgical repair (n=2). VSD treatment was performed for an average of 7.4days (range, 6–14days) and the duration of wound healing averaged 23days (range, 20–43days). Wound infection was not reported prior to second-stage surgery. Only one of 17 patients had superficial necrosis at the flap edge, for a success rate of 94%. Average follow-up was 8.7months (range, 4–13months). Twelve (71%) patients reported excellent or good, four (23%) reported fair, and one (6%) reported poor results. ConclusionThe VSD can effectively promote safe and rapid repair of local soft tissues with good prognosis.

A New Transalveolar Sinus Lift Procedure for Single Implant Placement: The Ebanist Technique. A Technical Description and Case Series.

Background:Nowadays, there are many techniques to compensate bone atrophies of the posterior maxilla in order to obtain an implant-supported rehabilitation.Objective:This case series describes the Ebanist technique: a sinus lift procedure to be used in case of extremely resorbed bone crests (≤3 mm) allowing simultaneous implant placement.Methods:With a dedicated cylindrical trephine bur, it is possible to harvest a cylinder of bone from a fresh mineralized frozen homologous bone block graft and to simultaneously create a trapdoor on the recipient site. The trapdoor cortical bone is detached from the sinus membrane and removed. Dental implant is placed into the graft before the grafting procedure since the cylindrical block, once inserted in the recipient area, is not able to oppose sufficient resistance to the torque needed for implant placement.Results:Second-stage surgery and following prosthetic rehabilitation were performed after 5 months. In all cases, implant stability was manually checked and no pathological symptoms or signs were recovered at any follow-up visit.Conclusion:This technique can be considered a valid procedure for implant therapy on atrophic posterior upper maxillae, when the residual bone crest is extremely resorbed.

Interstage Weight Gain Is Associated With Survival After First-Stage Single-Ventricle Palliation

Low birth and operative weight have been identified as risk factors for death after first-stage single-ventricle palliation. We hypothesize that weight gain after the first-stage operation is associated with transplant-free interstage survival to admission for the second-stage operation. We used historical data from the National Pediatric Cardiology Quality Improvement Collaborative database to conduct a longitudinal study to assess the association between weight gain and transplant-free interstage survival. The primary predictor was weight gain. The primary outcome was transplant-free survival. We constructed a repeated-measures logistic regression model using the general estimating equation method to examine the association between weight gain and transplant-free interstage survival. The study population included 1,501 infants who were discharged alive from the first-stage single-ventricle palliation between June 2008 and January 2015. Patients who underwent a hybrid operation (n= 132) or were lost to follow-up (n= 11) were excluded. Transplant-free interstage survival was 90% (1,228 of 1,358). The mean weight gain was 2.5 (SD, 1.0) kg. Adjusted for age at the time of each measurement, the number of measurements, age at discharge from the first-stage operation, sex, diagnosis, postoperative arrhythmia, postoperative complications, and discharge antibiotic therapy, each 100-g increase in weight was associated with an odds ratio of transplant-free interstage survival of 1.03 (95% confidence limit, 1.01, 1.05). After first-stage single-ventricle palliation, interstage weight gain is significantly associated with transplant-free interstage survival.

Vacuum sealing drainage as a pre-surgical adjunct in the treatment of complex (open) hand injuries: Report of 17 cases

BackgroundFew studies have been conducted to explore the use of the vacuum sealing drainage (VSD) technique in complex hand injuries. The aim of this study was to report outcomes in patients with complex hand injuries receiving VSD as a coadjuvant treatment prior to second-stage surgery. MethodsThis case series study retrospectively reviewed the patients who underwent VSD for treatment of hand injuries. Inclusion criteria for the study were: (1) traumatic soft tissue defects of the hand and wrist, accompanied by different degrees of injury and exposure of bone, tendon, or blood vessel; (2) the wound surface of hand and wrist was seriously contaminated and direct wound closure was not possible; and (3) the soft tissues of hand and wrist were seriously lacerated or avulsed, and showed necrosis or acute infection. After debridement, one-stage and/or two-stage repairs using healthy adjacent tissues were performed and the wound was covered by the VSD materials. The non-cytotoxic polyethylene alcohol hydration seaweed salt foam was applied during the VSD treatment for its good biocompatibility. The drainage tube was connected to the vacuum equipment and the negative pressures were set at –60kPa to –40kPa. The VSD device was left in place for 5 to 7 days before removal. Either free skin grafting or skin flap transplantation was used for wound closure and/or reconstructive surgery. The hand injury severity score was used to assess wound severity. The surgical results were scored using the total active motion classification. ResultsA total of 17 patients (13 and 4 patients had major and severe hand injuries), averaging 33.8 years were included. During the study period, 6 patients with severe hand injuries were not treated with VSD for the following reasons: (1) hemodynamic instability (n=1); (2) impaired coagulation function (n=1); (3) uncontrollable hemorrhage on the wound surface (n=2); and (4) exposure of the main blood vessels after surgical repair (n=2). VSD treatment was performed for an average of 7.4 days (range, 6–14 days) and the duration of wound healing averaged 23 days (range, 20–43 days). Wound infection was not reported prior to second-stage surgery. Only one of 17 patients had superficial necrosis at the flap edge, for a success rate of 94%. Average follow-up was 8.7 months (range, 4–13 months). Twelve (71%) patients reported excellent or good, four (23%) reported fair, and one (6%) reported poor results. ConclusionThe VSD can effectively promote safe and rapid repair of local soft tissues with good prognosis.

Graftless sinus augmentation and growth factors, clinical results and biological perspective

The compartment around implants under the sinus mucosal lining in the sinus floor can either be filled with various scaffolds or left to be filled with blood clot from surrounding bleeding after sinus lifting procedure. Two studies have been performed to evaluate bone formation the lifted maxillary sinus Schneiderian membrane (MSSM). The first study involves graftless sinus lifting procedure with simultaneous placement of dental implants while the second study involves sinus lifting but grafted with buccal fat pad (BFP) and concentrated growth factors (CGFs). In the first study, eighteen consecutive patients underwent 30 graftless sinus lifting procedures using the lateral window approach, with 72 dental implants. Clinical and radiological follow-up was conducted throughout six-month healing period. Biopsies of 30 cases were taken and analysed during the second-stage surgery. Fifteen biopsies were taken from the newly formed bone near the basal floor and the others from the newly formed bone near the elevated membrane. New bone consolidation in the maxillary sinus was radiologically and histologically apparent after six months of sinus augmentation, providing an average 6.14 ± 1.34 mm of bone-gain. Based on histological analysis and histomorphometric data, the consolidated bone in the augmented sinus utilising two-place biopsy samples have demonstrated 56.7% ± 11.9% to 59.9% ± 13.4% vital bone tissue. Out of the 72 implants placed, only 4 failed, indicating a 95% overall implant survival rate. In the second study, six consecutive patients underwent 10 sinus-lifting procedures, 24 dental implants. The compartment around the implants under the sinus mucosal lining in the sinus floor was filled with autologous adipose tissue from BFP and CGFs. Clinical and radiological follow up were conducted through healing period, all cases, samples were taken for biopsy during the second stage surgery. New bone consolidation in the maxillary sinus was radiologically and histologically observed within an average of 7.2 months after the sinus augmentation. According to the histomorphometric data, 62.8% ± 13.1% vital bone formation was observed. Out of the 24 implants placed, only 1 failed, indicating a 95% overall implant survival rate. These studies, based on their respective size of case series, strongly indicate that the autologous blood clot and the BFP/CGFs constitute osteogenic graft material to which osteoprogenitors can migrate, differentiate, and regenerate bone.

Two-stage hepatectomy for colorectal liver metastases: A multi-institutional retrospective review.

351 Background: A significant number of patients with colorectal liver metastases (CRLM) present with unresectable bilobar disease. Two-stage hepatectomy with portal vein embolization (PVE) have been described as a treatment for CRLM allowing for volume regeneration of a functional liver remnant. No large-scale multi-institutional studies exist. The aim of this project was to describe outcomes following two-stage hepatectomy, including overall survival (OS), recurrence-free survival (RFS), and complications. Methods: Patients completing two-stage hepatectomy for CRLM at five US institutions were identified and retrospectively analyzed (2000-2015). Overall survival and recurrence-free survival following second-stage surgery, short-term mortality, Clavien-Dindo complications, and readmission rates were examined. Results: A total of 209 patients were identified. Mean age was 52 (SD +/-11.4), 59.8% were male, and 87.0% had synchronous disease. A total of 65.1% of patients underwent PVE, and 27.3% underwent hepatic artery infusion pump placement. 88.3% of cases underwent neoadjuvant chemotherapy. Following the first stage, 30-day morbidity was 24.4%, with 4.8% major (Clavien-Dindo grade ≥3) complications, and 30-day readmission was 6.7%. Mean time between first and second stage was 4.1 months (S.D. +/-3.1), and 57.5% received systemic chemotherapy between the two resections. Following the second stage, overall complications were 47.4% with 23.9% major complications, and 30-day readmission was 9.7%. Mortality following second stage was 3.8% at 30 days, and 5.3% at 90-days. Following the second stage, RFS at 1-, 3-, and 5-years was 80%, 46%, and 29% respectively. OS at 1-, 3-, and 5-years was 87%, 64%, and 45% respectively. Conclusions: Two-stage hepatectomy for CRLM provides acceptable recurrence-free and overall survival in the context of advanced bilobar disease. Major complications and readmission following the first stage are rare. Following the second stage, short-term major morbidity, mortality, and readmissions are also acceptable. For well-selected patients, two-stage hepatectomy remains a safe and effective treatment for CRLM, with potential for more widespread adoption.

Modified ALPPS Procedures Avoiding Division of Portal Pedicles.

We describe a modified procedure associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) including portal pedicle preservation during parenchymal division, thus avoiding necrosis. Although ALPPS recently has been advocated for treating advanced liver tumors, sepsis originating from the ischemic area produced by parenchymal division increases mortality, accounting for one-third of postoperative deaths. Our procedure differs from the original ALPPS technique by sparing portal pedicles at the transection plane, thus maintaining blood supply. The preserved pedicles are segment 4 (S4) in right lobectomy plus right portal vein ligation (PVL), S1 in extended right hepatectomy (extended to S1) plus right PVL, lateral portal pedicles of the right paramedian sector (RPS) in extended right lateral sectoriectomy plus lateral PVL, and both portal pedicles of the lateral RPS and S1 in extended right lateral sectoriectomy with S1 resection plus lateral PVL. These procedures were performed in 5 patients. Morbidity rates at first- and second-stage operations were 0% and 80%, without mortality. Mean hypertrophy of the future liver remnant was 1.638 ± 0.384 a week after the first-stage procedure. Our technique stimulates rapid hypertrophy and may improve safety in ALPPS.

Single mandibular implant study - denture satisfaction in the elderly.

To investigate whether there are differences in patients' denture satisfaction when an implant placed in the midline of the edentulous mandible is loaded either immediately or three months later, after second-stage surgery. One hundred and fifty-eight edentulous patients received a single implant in the midline of the mandible. After randomisation, it was loaded either immediately after implant placement (N = 81, group A) or three months later, after a submerged healing phase and a second-stage surgery (N = 77, group B). Patients' denture satisfaction aspects were assessed, using visual analogue scales (VAS), before treatment, one month after implant placement during the submerged healing phase (only group B) and one and four months after implant loading. The statistical analysis was performed using the Wilcoxon signed-rank and rank-sum tests. One month after loading, a significant improvement in comfort, function and stability of the mandibular denture could be observed in both groups (P ≤ 0·05). A slight but not significant improvement was found between one and four months after loading. Patients with second-stage surgery and delayed loading rated the stability and fit of the mandibular denture as significantly better than patients who had immediate loading. A single implant in the edentulous mandible significantly increased patients' denture satisfaction. After four months, stability and fit of the mandibular denture were considered better when a delayed loading protocol had been followed. A single mandibular implant in the edentulous mandible significantly increases patients' denture satisfaction, regardless of the loading protocol.