Similar Rates Of Postoperative Complications Research Articles

Outcomes of Adolescent and Young Adults Receiving High Ligation and Mesh Repairs: A 16-Year Experience.

Interestingly, the pediatric and adult surgeons perform vastly different operations in similar patient populations. Little is known about long-term recurrence and quality of life (QOL) in adolescents and young adults undergoing inguinal hernia repair. We evaluated long-term patient-centered outcomes in this population to determine the optimal operative approach. The medical records of patients 12-25 years old at the time of a primary inguinal hernia repair at our institution from 2000 to 2016 were retrospectively reviewed. Patients then completed a phone survey of their postoperative courses and QOL. Outcomes of high ligation performed by pediatric surgeons were compared to those of mesh repairs by adult general surgeons. The primary outcome was recurrence. Secondary outcomes included time to recurrence, postoperative complications, and patient-centered outcomes. A Cox regression analysis was used to determine associations for recurrence. Of 213 patients identified, 143 (67.1%) were repaired by adult surgeons and 70 (32.9%) repaired by pediatric surgeons. Overall recurrence rate for the entire cohort was 5.7% with a median time to recurrence of 3.5 years (interquartile range 120-2155 days). High ligation and mesh repairs had similar rates of recurrence (6.3 versus 5.8, P = .57) and postoperative complications (17% versus 16%, P = .45). 101/213 (47%) patients completed the phone survey. Of those surveyed, 20% reported postoperative pain, 10% had residual numbness and tingling, and 10% of patients complained of intermittent bulging. Overall, a survey comparison showed no differences among subgroups. In adolescents and young adults, the long-term recurrence rate after inguinal hernia repair is ∼6% with time to recurrence approaching 4 years. Outcomes of high ligation and mesh repair are similar, highlighting the need for individualized approaches for this unique population.

Comparison of elliptical excision versus punch incision for the treatment of epidermal inclusion cysts: A prospective, randomized study

Comparison of elliptical excision versus punch incision for the treatment of epidermal inclusion cysts: A prospective, randomized study

Assessing the Different Oncologic Disease Distribution and Postoperative Complications of Octogenarian and Nonagenarian Head and Neck Oncology Patients

The admission rate of patients aged 80years or older (oldest-old) with head and neck (HN) oncologic disease is on the rise. Our goal was to study the demographic characteristics, reasons for admission, types of surgical procedures, and postoperative complications of the oldest-old patients with HN malignancy. We conducted a retrospective cohort study including all inpatients aged 80years or older who were admitted to the department of otolaryngology-head and neck surgery or department of oral and maxillofacial surgery because of HN oncologic disease between 2009 and 2013. The control group was composed of a matched number of randomly selected patients aged 60 to 79years. We compared the demographic characteristics, diagnoses, comorbidities, surgical interventions, and postoperative complications of the 2 age groups to characterize the oldest-old patients' admissions and determine whether age alone increases the risk of postoperative complications. The study included 109 oldest-old patients (median age, 83years) and 107 patients in the control group (median age, 68years). Although the oldest-old patients had significantly more underlying diseases (4.41 vs 2.86) and drugs prescribed (4.76 vs 3.21), similar rates of postoperative complications occurred in both groups. An important finding was that ischemic heart disease and chronic lung disease were the only significant risk factors for postoperative complications among the oldest-old patients (odds ratio on multivariate analysis of 5.5 and 4.5, respectively). Although comorbidities and prescribed drugs are more prevalent in the oldest-old patients, the rate of postoperative complications did not differ between the age groups, suggesting that age alone should not be a factor in the surgical treatment of HN malignancies.

Impact of body mass index on surgical outcomes, narcotics consumption, and hospital costs following anterior cervical discectomy and fusion.

OBJECTIVE Given the increasing prevalence of obesity, more patients with a high body mass index (BMI) will require surgical treatment for degenerative spinal disease. In previous investigations of lumbar spine pathology, obesity has been associated with worsened postoperative outcomes and increased costs. However, few studies have examined the association between BMI and postoperative outcomes following anterior cervical discectomy and fusion (ACDF) procedures. Thus, the purpose of this study was to compare surgical outcomes, postoperative narcotics consumption, complications, and hospital costs among BMI stratifications for patients who have undergone primary 1- to 2-level ACDF procedures. METHODS The authors retrospectively reviewed a prospectively maintained surgical database of patients who had undergone primary 1- to 2-level ACDF for degenerative spinal pathology between 2008 and 2015. Patients were stratified by BMI as follows: normal weight (< 25.0 kg/m2), overweight (25.0-29.9 kg/m2), obese I (30.0-34.9 kg/m2), or obese II-III (≥ 35.0 kg/m2). Differences in patient demographics and preoperative characteristics were compared across the BMI cohorts using 1-way ANOVA or chi-square analysis. Multivariate linear or Poisson regression with robust error variance was used to determine the presence of an association between BMI category and narcotics utilization, improvement in visual analog scale (VAS) scores, incidence of complications, arthrodesis rates, reoperation rates, and hospital costs. Regression analyses were controlled for preoperative demographic and procedural characteristics. RESULTS Two hundred seventy-seven patients were included in the analysis, of whom 20.9% (n = 58) were normal weight, 37.5% (n = 104) were overweight, 24.9% (n = 69) were obese I, and 16.6% (n = 46) were obese II-III. A higher BMI was associated with an older age (p = 0.049) and increased comorbidity burden (p = 0.001). No differences in sex, smoking status, insurance type, diagnosis, presence of neuropathy, or preoperative VAS pain scores were found among the BMI cohorts (p > 0.05). No significant differences were found among these cohorts as regards operative time, intraoperative blood loss, length of hospital stay, and number of operative levels (p > 0.05). Additionally, no significant differences in postoperative narcotics consumption, VAS score improvement, complication rates, arthrodesis rates, reoperation rates, or total direct costs existed across BMI stratifications (p > 0.05). CONCLUSIONS Patients with a higher BMI demonstrated surgical outcomes, narcotics consumption, and hospital costs comparable to those of patients with a lower BMI. Thus, ACDF procedures are both safe and effective for all patients across the entire BMI spectrum. Patients should be counseled to expect similar rates of postoperative complications and eventual clinical improvement regardless of their BMI.

Reduced Impact of Smoking Status on 30-Day Complication and Readmission Rates After Elective Spinal Fusion (≥3 Levels) for Adult Spine Deformity: A Single Institutional Study of 839 Patients.

Smoking status has been shown to affect postoperative outcomes after surgery. The aim of this study was to determine whether patients' smoking status impacts 30-day complication and readmission rates after elective complex spinal fusion (≥3 levels). The medical records of 839 adult spinal deformity patients undergoing elective complex spinal fusion (≥3 levels) at a major academic institution from 2005 to 2015 were reviewed. We identified 124 (14.8%) smokers and 715 (85.2%) nonsmokers. Patient demographics, comorbidities, intraoperative and postoperative complications, and 30-day readmission rates were collected for each patient. The primary outcome investigated in this study was the rate of 30-day postoperative complication and readmission rates. Patient demographics and comorbidities were similar between both groups, including age, sex, and body mass index. Median [interquartile] number of fusion levels and operative time were similar between the cohorts (smoker: 5 [4-7] vs. nonsmoker: 5 [4-8], P= 0.58) and (smoker: 309.6 ± 157.9 minutes vs. nonsmoker: 287.5 ± 131.7 minutes, P= 0.16), respectively. Both cohorts had similar postoperative complication rates and lengths of hospital stay. There was no significant difference in 30-day readmission between the cohorts (smoker: 12.9% vs. nonsmoker: 10.8%, P= 0.48). There were no observed differences in 30-day complication rates, including pain (P= 0.46), UTI (P= 0.54), hardware failure (P= 0.36), wound dehiscence (P= 0.29), and wound drainage (P=0.86). Smokers had greater rates of 30-day cellulitis (smoker: 1.6% vs. nonsmoker: 0.3%, P= 0.05) and DVT (smoker: 0.8% vs. nonsmoker: 0.0%, P= 0.02). Our study suggests that smoking does not significantly affect 30-day readmission rates after complex spinal surgery requiring ≥3 levels of fusion. Further studies are necessary to corroborate our findings.

Safety and Feasibility of Umbilical Diverting Loop Ileostomy for Patients with Rectal Tumor.

Fashioning an ileostomy in the umbilicus and combining the trauma from extraction of colorectum with that from ileostomy should be less invasive and lead to improved cosmetic outcomes. However, there are only a few reports regarding umbilical ileostomy. We retrospectively collected data for 121 consecutive patients with rectal tumor who underwent elective laparoscopic rectal resection with diverting loop ileostomy between 2010 and 2015 at Osaka University Hospital, Japan. The safety and feasibility of umbilical diverting loop ileostomy and its influence on stoma care were investigated. A total of 83 patients were included in this study; of these, 30 underwent umbilical diverting loop ileostomy and 53 underwent conventional diverting loop ileostomy, which was created in the right lower quadrant of the abdomen. The umbilical and conventional groups showed similar rates of postoperative and stoma-related complications (26.7 vs. 32.1%, p=0.804 and 3.3 vs. 3.8%, p=1.000, respectively). Level of parastomal dermatitis was evaluated by DET score at three time points (stoma self-management establishment, first outpatient review post-discharge, and just before stoma closure). DET scores at any time points did not differ significantly between the two groups. Umbilical diverting loop ileostomy is comparable to conventional ileostomy with regard to safety and feasibility. Our methods for umbilical ileostomy using the umbilical skin flap were less invasive and did not have a negative impact on stoma care and parastomal dermatitis. Umbilical ileostomy may be a promising alternative to conventional ileostomy in selected cases.

A systematic review of suture-button versus syndesmotic screw in the treatment of distal tibiofibular syndesmosis injury

BackgroundNow, using a suture-button device to treat distal tibiofibular syndesmotic injuries is overwhelming due to its advantages over screw fixation. Current systematic review was conducted to make a comparison between suture-button fixation and traditionally screw fixation in the treatment of syndesmotic injuries. The outcomes included functional outcomes, implant removal, implant failure, malreduction, post-operative complications (except implant failure and malreduction), and cost-effectiveness aspects.MethodA literature search in the electronic databases of Medline, Embase, the Cochrane Library, Web of Science was conducted to identify studies until March 2017. The references of the included articles were also checked for potentially relevant studies. Only English articles were included. We followed the Preferred Reporting Items for Systematics reviews and Meta-Analysis (PRISMA) guidelines in this review.ResultsFinally, 10 studies were identified, encompassing a total of 390 patients. The mean American Orthopaedic Foot and Ankle Society ankle score (AOFAS) score of 150 patients treated with the suture-button device was 91.06 points, with an average follow-up of 17.58 months, and the mean AOFAS score of 150 patients treated with syndesmotic screws was 87.78 points, with an average follow-up of 17.73 months. Implant removal was reported in 5 of 134 (3.7%) patients treated with the suture-button device, and in 54 of 134 (40.2%) patients treated with the syndesmotic screw. No patient in the suture-button fixation group had implant failure, however the rate of implant failure in the screw fixation group was 30.9%. Malreduction was reported in 1 of 93 (1.0%) patients treated with the suture-button device, and in 12 of 95 (12.6%) patients treated with the syndesmotic screw. The rate of post-operative complications in the suture-button fixation group was 12.0% and 16.4% in the screw fixation group. There was only one publication demonstrated about cost-effectiveness aspects, it showed that patients treated with the suture-button device spent on average $1482 less and had a higher quality of life by 0.058 quality-adjusted life-year compared with patients who received fixation with 2 syndesmotic screws in supination-external rotation type 4 injuries.ConclusionBased on our research, though the suture-button fixation group had similar functional outcome (measured on the AOFAS score) and post-operative complication rate compared with the syndesmotic screw fixation group, the suture-button device could lead to better objective range of motion (ROM) measurements and earlier return to work. Besides, the suture-button fixation group had lower rate of implant removal, implant failure, and malreduction. However, high-quality randomized controlled trials with more uniformity in outcome reporting are desirable to determine the long-term effects and cost-effectiveness of the suture-button device.

Long-term Outcomes of Single-Site Laparoscopic Colectomy With Complete Mesocolic Excision for Colon Cancer: Comparison With Conventional Multiport Laparoscopic Colectomy Using Propensity Score Matching.

Complete mesocolic excision has been suggested to improve oncological outcomes for patients with colon cancer. However, the long-term outcomes of single-site laparoscopic colectomy with complete mesocolic excision remain unclear. We evaluated the long-term outcomes of single-site laparoscopic colectomy with complete mesocolic excision compared with conventional multiport laparoscopic colectomy for colon cancer, as well as the short-term outcomes. This is a single-center, retrospective study. The study was conducted at Osaka University Hospital in Japan. A total of 971 consecutive patients who underwent laparoscopic surgery for colon cancer between 2008 and 2014 were included. Of these patients, 517 were analyzed using propensity score matching (231 with single-site laparoscopic colectomy and 286 with conventional multiport laparoscopic colectomy). Recurrence, survival, intraoperative morbidity, and postoperative complications were analyzed. Before propensity score matching, the single-site laparoscopic colectomy group had greater proportions of women and of patients with right-sided and early stage tumors compared with the conventional multiport laparoscopic colectomy group. After matching, the 2 groups each included 200 patients and did not significantly differ in any patient characteristics. The median follow-up period was 41.4 months. The 2 groups showed similar rates of intraoperative morbidity (p = 0.22) and postoperative complications (p = 0.87). Rates of 3-year disease-free and overall survival in single-site laparoscopic colectomy and conventional, multiport, laparoscopic colectomy groups were 95.5% and 91.3% (p = 0.44) and 100.0% and 98.7% (p = 0.24). The 3-year disease-free and overall survival rates in each stage did not significantly differ between the 2 groups. This study was limited by its retrospective nature. Single-site laparoscopic colectomy with complete mesocolic excision for colon cancer provided acceptable perioperative outcomes and oncological outcomes, similar to those achieved with conventional multiport laparoscopic colectomy. Evidence accumulation from randomized controlled trials will be necessary to promote the wide acceptance of single-site laparoscopic colectomy. See Video Abstract at http://links.lww.com/DCR/A326.

A comparison of left ventricular function in patients undergoing beating heart bypass surgery using mixed versus pure venous conduits

Background: The pathophysiology of coronary artery disease was established in 1876 by Adam Hammer when he postulated that angina is caused by interruption of coronary blood supply and that myocardial infarction occurred after the occlusion of at least one coronary artery. Aims of the study were to compare the left ventricular function in patients who have undergone beating heart bypass surgery using mixed (internal mammary artery and venous conduits) versus pure Venous conduits, and to compare the incidence of postoperative complications.Methods: It was an observational, analytical study. All patients admitted with triple vessel disease requiring CABG (n=50), with ejection fraction &gt;30%, were subjected to either left internal mammary artery and venous conduits (group A, n=25) or only venous conduits (group B, n=25). Patient who had undergone prior surgical myocardial revascularization, preexisting valvular disease, any evidence of raised pulmonary arterial pressure more than 40/15 mmHg, operated using cardiopulmonary bypass machine, pre-operative use of Intra-Aortic Balloon Pump, any history of neurological dysfunction/Transient ischemic attack, left atrium size more than 5.5 cm were excluded from the studyResults: Improvement in left ventricular function after coronary artery bypass grafting was objectively demonstrated in both the groups. There was a statistically significant increase in mean LVEF in group B (56.16±4.13) compared to group A (51.96±5.30) at 3 months of follow up (p=0.009). The most common complication in both the groups were atrial fibrillation group A=36% (n=9), group= B 16 % (n=4), renal failure group A=12% and group B=8% and sternal wound infection. The post-operative bleeding (Drain output) in first 24 hours was similar in both the groups, 295.56 ml in group A and 265.20ml in group B (p=) with similar hospital stay (group A=9days, group B=8.5days).Conclusions: Patients with venous conduits have better postoperative LVEF as compared to Mixed conduit with similar rate of post-operative complications.

Introduction of robot-assisted radical hysterectomy for early stage cervical cancer: impact on complications, costs and oncologic outcome.

The objective was to assess the impact of robot-assisted radical hysterectomy (RRH) on surgical and oncologic outcome and costs compared with open radical hysterectomy (ORH) at a tertiary referral center in Sweden. In this retrospective analysis all patients treated with radical hysterectomy and pelvic lymphadenectomy for early stage uterine cervical cancer during 2006-2015 were included (n = 304). The patients were divided into two groups, ORH (n = 155) and RRH (n = 149). Patient characteristics, FIGO stage, histology, adjuvant therapy, operation time, length of stay (LOS), lymph node yield, recurrence rate and survival were retrieved from medical records. Complications were graded according to the Clavien-Dindo classification. In addition, costs related to the surgical treatments were calculated. Blood loss, LOS and intraoperative complications were significantly lower as well as lymph node yield after RRH. No differences in postoperative complications or costs were observed between the two groups. Recurrence of disease was detected in 13.4 and 10.3% after RRH and ORH, respectively. Regression analysis demonstrated that histology, tumor size, positive lymph nodes and type of operation (RRH) were significantly associated with recurrence. The introduction of RRH was accompanied by similar postoperative complication rates and costs but lower LOS compared with ORH. An initial learning curve may account for the higher recurrence rate observed after RRH. These data reinforce the need for structured training and monitoring of outcomes when novel treatment modalities are introduced.

Perioperative opioid administration in children with and without developmental delay undergoing outpatient dental surgery

Study objectivePrior research has indicated that children with developmental delay (DD) experience qualitative and quantitative differences in health care (Boulet et al., 2009). In the perioperative setting, there is concern that children with DD may be more likely to experience postoperative complications including agitation and nausea/vomiting than typically developing patients (TDP). Differences in the administration and dosage of perioperative opioids may contribute to this, however, empirical investigations are lacking. The purpose of this research was to compare the experience of postoperative nausea/vomiting and agitation, as well as to examine perioperative opioid administration, among children with DD as compared to TDP. DesignRetrospective original research. SettingOperating room, postanesthesia care unit. Patients1145 patients (1–20.9years, ASA I-III, 23.9% with a history of DD) who had undergone outpatient dental surgery involving extraction/restorations under general anesthesia. MeasurementsData was obtained and analyzed from the medical records of both DD and TDP across a five-year period. Data included the experience of agitation, nausea/vomiting, as well as perioperative medication administration. Main resultsPostoperative agitation and nausea/vomiting did not differ significantly between the DD and TDP groups. Children with DD were significantly less likely to receive opioids during both the intra and postoperative period (χ2=10.02, p=0.001 and χ2=8.08, p=0.003, respectively). Further, higher dosage of intraoperative opioids was predictive of reduced administration of postoperative opioids among TDP; however, no significant association was observed between the dosage of intraoperative opioids and administration of postoperative opioids in the DD group. ConclusionsChildren with DD experience similar rates of postoperative complications including nausea/vomiting and agitation as TDP. DD children were less likely to receive both intra and postoperative opioids than TDP. Importantly, while the dosage of intraoperative opioids was predictive of administration of postoperative opioids in the TDP group, this was not the case for the DD group. Clinical implications are discussed.

Propensity-matched comparison of video-assisted thoracoscopic with thoracotomy lobectomy for locally advanced non–small cell lung cancer

ObjectiveWe evaluated whether video-assisted thoracoscopic lobectomy for locally advanced non–small cell lung cancer could be performed safely and with acceptable long-term outcomes by our improved technique and compared with standard thoracotomy lobectomy in a well-balanced population. MethodsPatients with clinical stage II and III A non–small cell lung cancers who received lobectomy were reviewed. Video-assisted thoracoscopic lobectomies were all performed with Wang's technique by the surgeons who had overcome the learning curve and achieved proficiency. By using propensity-matched analysis, perioperative outcomes and long-term survival were compared. ResultsMatching based on propensity scores produced 120 patients in each group. Conversion rate to thoracotomy was 11.7%. After thoracoscopic lobectomy, hospital length of stay was shorter compared with thoracotomy (9.2 vs 12 days; P = .014) despite similar rates of postoperative complications (30/125 [25%] vs 34/125 [28.3%]; P = .56). Disease-free survival (49.1% vs 42.2%; P = .40) and overall survival (55.0% vs 57.1%; P = .73) at 5 years were similar between groups. Although advanced pathologic stage (hazard ratio [HR], 2.018; 95% confidence interval [CI], 1.330-3.062) and no postoperative chemotherapy (HR, 1.880; 95% CI, 1.236-2.858) were independently associated with increased hazard of death in multivariable Cox regression at each time point in follow-up, thoracoscopic lobectomy was not (HR, 1.075; 95% CI, 0.714-1.620; P = .73). ConclusionsWith continued experience and optimized technique, video-assisted thoracoscopic lobectomy can be performed in the majority of cases without compromising perioperative outcomes and oncologic efficacy.

Acute Appendicitis During Pregnancy: Different from the Nonpregnant State?

Acute appendicitis is the most common nonobstetric indication for surgical intervention during pregnancy. However, the current literature is scarce and composed of relatively small case series. We aimed to compare the presentation, management, and surgical outcomes of presumed acute appendicitis between a contemporary cohort of pregnant women and nonpregnant women of reproductive age. The study group included 92 pregnant patients who underwent appendectomy for presumed acute appendicitis at a single tertiary medical center in 2000-2014. Preoperative, operative, and postoperative clinical data were derived from medical records and compared to data for 494 nonpregnant patients of reproductive age who underwent appendectomy in 2004-2007 at the same institution. Median age was 28years (range 25-33) in the study group and 26years (range 20-34) in the control group (P=0.1). There were no between-group differences in mean white blood cell count, patient interval, hospital interval, or operative time. Preoperative abdominal ultrasound was used in a significantly higher proportion of patients in the pregnant group than in the nonpregnant group (73 and 27%, respectively, P<0.001) and computed tomography, in a significantly lower proportion of patients (1 vs. 16%, respectively, P<0.001) . The two groups had similar rates of negative appendectomy (23 and 22%, P=0.9), complicated appendicitis (12 and 11%, P=0.9), and overall postoperative complications (15 and 12%, P=0.3). The clinical presentation and outcome of presumed acute appendicitis are similar in pregnant women and nonpregnant women of reproductive age. Therefore, similar perioperative management algorithms may be applied in both patient populations.

Donor BMI >30 Is Not a Contraindication for Live Liver Donation.

The increased prevalence of obesity worldwide threatens the pool of living liver donors. Although the negative effects of graft steatosis on liver donation and transplantation are well known, the impact of obesity in the absence of hepatic steatosis on outcome of living donor liver transplantation (LDLT) is unknown. Consequently, we compared the outcome of LDLT using donors with BMI <30 versus donors with BMI ≥30. Between April 2000 and May 2014, 105 patients received a right-lobe liver graft from donors with BMI ≥30, whereas 364 recipients were transplanted with grafts from donors with BMI <30. Liver steatosis >10% was excluded in all donors with BMI >30 by imaging and liver biopsies. None of the donors had any other comorbidity. Donors with BMI <30 versus ≥30had similar postoperative complication rates (Dindo-Clavien ≥3b: 2% vs. 3%; p=0.71) and lengths of hospital stay (6 vs. 6 days; p=0.13). Recipient graft function, assessed by posttransplant peak serum bilirubin and international normalized ratio was identical. Furthermore, no difference was observed in recipient complication rates (Dindo-Clavien ≥3b: 25% vs. 20%; p=0.3) or lengths of hospital stay between groups. We concluded that donors with BMI ≥30, in the absence of graft steatosis, are not contraindicated for LDLT.

Outcomes after endovascular aneurysm repair conversion and primary aortic repair for urgent and emergency indications in the Society for Vascular Surgery Vascular Quality Initiative

Open conversion after endovascular aortic aneurysm repair (EVAR-c) is performed nonelectively in up to 60% of cases. EVAR-c has been reported to have significantly greater risk of postoperative morbidity and mortality than primary aortic repair, but few data exist on outcomes for symptomatic or ruptured presentations. This study determined outcomes and identified predictors of postoperative major adverse cardiac events (MACEs) and mortality for patients undergoing nonelective EVAR-c compared with nonelective primary aortic repair (PAR) in the Vascular Quality Initiative (VQI). All VQI patients undergoing urgent/emergency EVAR-c or urgent/emergency PAR from 2002 to 2014 were reviewed. Urgent presentation was defined by repair ≤24hours of a nonelective admission, and emergency operations had clinical or radiographic evidence, or both, of rupture. End points included in-hospital MACE (myocardial infarction, dysrhythmia, congestive heart failure) and 30-day mortality. Possible covariates identified on univariate analysis (P< .2) were entered into a multivariable model, and stepwise elimination identified the best subset of predictors. Generalized estimating equations logistic regression analysis was used to determine the relative effect of EVAR-c compared with PAR on outcomes. During the study interval, we identified 277 EVAR-c, and 118 (43%) underwent urgent/emergency repair. nonelective PAR was performed in 1388 of 6152 total (23%). EVAR-c patients were older (75± 9 vs 71± 10years; P<.0001), more likely to be male (84% vs 74%; P= .02), and had a higher prevalence of hypertension (88% vs 79%; P= .02) and coronary artery disease (38% vs 27%; P= .01). No differences in MACE (EVAR-c, 31% [n= 34] vs PAR, 30% [n=398]) or any major postoperative complication (EVAR-c, 57% [n= 63] vs PAR, 55% [n= 740]; P= .8) were found; however, 30-day mortality was significantly greater in EVAR-c (37% [n= 41]) than in (PAR, 24% [n= 291]; P= .003), with an odds ratio (OR) of 2.2 (95% confidence interval [CI], 1.04-4.77; P= .04) for EVAR-c. Predictors of any MACE included age (OR,× 1.03 for each additional year; 95% CI, 1.01-1.03; P= .0002), male gender (OR, 1.3; 95% CI, 1.03-1.67; P= .03), body mass index ≤20kg/m2 (OR, 1.8; 95% CI, 1.13-2.87; P= .01), chronic obstructive pulmonary disease (OR, 1.2; 95% CI, 0.86-1.80; P= .25), congestive heart failure (OR, 1.5; 95% CI, 0.98-2.34; P= .06), preoperative chronic β-blocker use (OR, 1.3; 95% CI, 0.97-1.63; P= .09), and emergency presentation (OR, 2.3; 95% CI, 1.8-3.01; area under the curve, 0.70; P< .0001). Significant predictors for 30-day mortality were age (OR× 1.07 for each additional year; 95% CI, 1.05-1.09; P< .0001), female gender (OR, 1.6; 95% CI, 1.01-2.46; P= .04), preoperative creatinine >1.8mg/dL (OR, 1.6; 95% CI, 1.04-2.35; P= .03), an emergency presentation (OR, 4.8; 95% CI, 2.93-7.93; P< .0001), and renal/visceral ischemia (OR,× 1.1 for each unit increase log (time-minutes); 95% CI, 1.02-1.22; area under the curve, 0.84; P= .01). Nonelective EVAR-c patients are older and have higher prevalence of cardiovascular risk factors than PAR patients. Similar rates of postoperative complications occur; however, urgent/emergency EVAR-c has a significantly higher risk of 30-day mortality than nonelective PAR. Several variables are identified that predict outcomes after these repairs and may help risk stratify patients to further inform clinical decision making when patients present nonelectively with EVAR failure.

Centres that do not offer TLH as their primary method of hysterectomy should be considered outdated and not Fit for Purpose: FOR: It is a patient's right to be offered laparoscopic surgery as an informed choice.

In the UK, 56976 hysterectomies were performed in 2012; 62% total abdominal hysterectomy (TAH), 32% vaginal hysterectomy (VH) and 6% laparoscopic hysterectomy (LH) (www.hysterectomy-association.org.uk). Despite the increasing evidence of its clinical and financial merits, LH is yet to be routinely offered. Although patient informed choice and involvement in care plans is a routine practice in the UK, women seem to be denied this when it comes to selecting the route of hysterectomy. One of the key principles for valid consent is discussing all the alternative management strategies with the clinician (RCOG, Clinical governance advice 6, 2015). Certainly, the UK Supreme Court, in its ruling in 2015, did not give a choice for centres or clinicians to deny women their right to get enough information to enable them taking part in the decision (http://supremecourt.uk/decided-cases/index.shtml). A systematic review, including 47 randomised controlled trials (RCTs) with 5102 participants concluded that where VH is not possible LH has advantages over TAH in terms of shorter hospital stay, rapid recovery, and fewer febrile episodes and wound infection. There was no significant difference between VH and LH in terms of return to normal activities, satisfaction, quality of life and surgical complications. The finding of longer operating time and slightly more urinary tract injuries with LH than with TAH reflected the learning curve in the earlier studies, which has been offset by the improvement in skills and advances in technology in more recent years (Aarts et al. Cochrane Database Syst Rev 2015;8:CD003677). The safety assets of LH have also been confirmed in a large RCT (n = 2616) and a meta-analysis (n = 498) reporting a similar rate of intra-operative complications and fewer postoperative complications when compared with TAH. Furthermore, there is adequate evidence on the safety and efficacy of LH for endometrial cancer to support its use [NICE, Interventional procedure guidance (IPG356), 2010]. Many units do not routinely offer LH because of the alleged higher cost and/or the lack of skills. Nevertheless, there is evidence that the cost of consumables is counterbalanced by the shorter hospital stay [NICE, Interventional procedure guidance (IPG356), 2010]. The gynaecologists and stakeholders should learn from the experience of the general surgeons in cholecystectomy and own experience in ectopic pregnancy where the laparoscopic approach has become the norm in the past two decades. Every centre should invest in developing a team for LH of gynaecologists, anaesthetists and nurses, with arrangements in place for clinical governance to optimise outcomes and maximise safety [NICE, Interventional procedure guidance (IPG356), 2010]. The American Association of Gynecologic Laparoscopists (AAGL) stated in 2011 that ‘most hysterectomies for benign indications should be VH or LH and continued efforts should be taken to facilitate these approaches. Gynaecologists without the requisite training and skills should enlist the aid of colleagues who do or refer women to them’. Recent statistics showed rates of LH reaching 20–30% of all hysterectomies in Western Europe and USA with some centres exceeding 70%. This makes us wonder why the UK is lagging behind the developed world (Mäkinen et al. BMJ Open 2013;3:e003169). None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Comparação entre a utilização dos fios de sutura barbado e de poliglactina em cirurgia urológica laparoscópica – uma revisão sistemática

The intracorporeal suture is considered one of the most difficult and challenging procedures of the urologic laparoscopic surgery. The suture of the renal parenchyma during partial nephrectomy and the vesico‐urethral anastomosis in radical prostatectomy are critical and time consuming steps requiring a long learning curve. In an attempt to optimize these procedures, it was created on March 2009 a unidirectional self‐retaining bearded suture to maintain the tension in the suture lines even avoiding the need to run knots.After a brief experience using a barbed suture during the laparoscopic partial nephrectomy with a subjective feeling of having made the procedure simpler, faster and more effective, we decided to conduct a systematic literature review on the use of of the usual polyglactin vs. a barbed suture to ascertain the real benefit its use.Comparing to the usual polyglactin suture, the use of a barbed one appears to simplify the nephrorrhaphy technique during laparoscopic partial nephrectomy significantly reducing the warm ischemia time and possibly the perioperative complications. Its use in the laparoscopic radical prostatectomy allows performing the vesico‐urethral anastomosis safely and significantly faster with similar postoperative complication rates. There may be an overall cost reduction using this suture, although stronger global analyses are still needed.

Comparing Zero Ischemia Laparoscopic Radio Frequency Ablation Assisted Tumor Enucleation and Laparoscopic Partial Nephrectomy for Clinical T1a Renal Tumor: A Randomized Clinical Trial

We evaluated the functional outcome, safety and efficacy of zero ischemia laparoscopic radio frequency ablation assisted tumor enucleation compared with conventional laparoscopic partial nephrectomy. A prospective randomized controlled trial was conducted from April 2013 to March 2015 in patients with cT1a renal tumor scheduled for laparoscopic nephron sparing surgery. All patients were followed for at least 12 months. Patients in the laparoscopic radio frequency ablation assisted tumor enucleation group underwent tumor enucleation after radio frequency ablation without hilar clamping. The primary outcome was the change in glomerular filtration rate of the affected kidney by renal scintigraphy at 12months. Secondary outcomes included changes in estimated glomerular filtration rate, estimated blood loss, operative time, hospital stay, postoperative complications and oncologic outcomes. The Pearson chi-square or Fisher exact, Student t-test and Wilcoxon rank sum tests were used. The trial ultimately enrolled 89 patients, of whom 44 were randomized to the laparoscopic radio frequency ablation assisted tumor enucleation group and 45 to the laparoscopic partial nephrectomy group. In the laparoscopic partial nephrectomy group 1 case was converted to radical nephrectomy. Compared with the laparoscopic partial nephrectomy group, patients in the laparoscopic radio frequency ablation assisted tumor enucleation group had a smaller decrease in glomerular filtration rate of the affected kidney at 3 months (10.2% vs 20.5%, p=0.001) and 12 months (7.6% vs 16.2%, p=0.002). Patients in the laparoscopic radio frequency ablation assisted tumor enucleation group had a shorter operative time (p=0.002), lower estimated blood loss (p <0.001) and a shorter hospital stay (p=0.029) but similar postoperative complications (p=1.000). There were no positive margins or local recurrence in this study. Zero ischemia laparoscopic radio frequency ablation assisted tumor enucleation enables tumor excision with better renal function preservation compared to conventional laparoscopic partial nephrectomy. Less blood loss and a shorter operative time were achieved with similar postoperative complication rates.

A Retrospective Comparison of Primary Baerveldt Implantation versus Trabeculectomy with Mitomycin C

To compare the safety and efficacy of Baerveldt implantation (Abbott Medical Optics, Santa Ana, CA) and trabeculectomy with mitomycin C (MMC) in patients who have not undergone prior incisional ocular surgery. Retrospective, comparative case series. A total of 125 patients with low-risk glaucoma undergoing primary glaucoma surgery, including 55 patients who received a 350-mm(2) Baerveldt glaucoma implant and 70 patients who underwent trabeculectomy with MMC. Eligible patients were identified using Current Procedural Terminology codes, and their medical records were reviewed retrospectively. The primary outcome measure was surgical success (intraocular pressure [IOP] ≤21 mmHg and reduced ≥20% from baseline, IOP >5 mmHg, no reoperation for glaucoma, no loss of light-perception vision). Secondary outcome measures included visual acuity, IOP, number of glaucoma medications, and complications. The cumulative probability of success at 3 years with or without medical therapy was 87% in the Baerveldt group and 76% in the trabeculectomy group (P = 0.23). Postoperative complications occurred in 11 patients (20%) in the Baerveldt group and 20 patients (29%) in the trabeculectomy group (P = 0.27). Mean follow-up ± standard deviation was 27±19 months in the Baerveldt group and 34±20 months in the trabeculectomy group (P = 0.053). Similar rates of surgical success and postoperative complications were observed in patients undergoing trabeculectomy with MMC and in those undergoing Baerveldt implantation during 3 years of follow-up. Both are viable primary glaucoma procedures in patients who have not undergone prior ocular surgery.

Reducing Trismus After Surgery and Radiotherapy in Oral Cancer Patients: Results of Alternative Operation Versus Traditional Operation

In patients with oral cancer, trismus (maximum interincisal opening [MIO] <35mm) can develop as a result of surgery and radiotherapy. The aim of this study was to provide an alternative operation to both eradicate oral cancer and prevent postsurgical trismus. In our retrospective cohort study of oral cancer patients who underwent operations during 2010 to 2014, the predictor variable was the type of operation (alternative operation or traditional operation) and the outcome variable was MIO. All of the cases were allocated by 2 periods: the traditional operations were performed from 2010 to 2011, and the alternative operations were performed from 2011 to 2014. All patients received marginal mandibulectomy, anterolateral thigh free flap, and adjuvant radiotherapy or concurrent chemoradiotherapy. In addition to traditional marginal mandibulectomy, the alternative operation included ipsilateral coronoidectomy and myotomy of the temporalis muscle insertion, masseter muscle, and medial pterygoid muscle. MIO was measured at 10 time points. The adjusted variables included demographic data, diagnostic parameters, treatment, and response. Of the 36 male patients with oral cancer, 16 were placed in the alternative operation group (AOG; mean age, 53.5 ± 11.9years) and 20 were placed in the traditional operation group (TOG; mean age, 50.7 ± 7.1years). Regarding the outcome indicator of patient MIO, the preoperative MIO in the AOG was on average 7.5mm shorter than that in the TOG (P < .01), but it was consistently superior to the MIO in the TOG after the operation. Multivariate analysis of variance showed that patients in the AOG were more likely to have postoperative non-trismus. The alternative operation exhibited superior postoperative MIO values and similar postoperative complication rates. For the prevention of trismus, it is practical to perform the combined operation simultaneously, cutting all ipsilateral jaw closing muscles and the coronoid process and eradicating the tumor.