Similar Rates Of Postoperative Complications Research Articles

Survival after esophagectomy for metastatic esophageal cancer: Should surgery’s role be reconsidered?

410 Background: Standard treatment for stage IV esophageal cancer (EC) is systemic therapy, with surgery considered contraindicated. The objective of this study is to assess the impact of surgical resection on outcomes for patients with metastatic EC. Methods: We reviewed our institution’s IRB-approved database of 1334 esophagectomies from 1994 to 2023 and identified 18 patients with distant disease (stage IV) by AJCC8 found prior to or during surgery. Chi-Square, ANOVA, and Kaplan-Meier survival analyses were used to compare demographics, clinical characteristics, and survival from time of surgery in those with metastatic versus non-metastatic EC. Results: Most metastatic patients were male (89%), Caucasian (83%), and had adenocarcinoma (89%). Compared to the non-metastatic cohort, stage IV EC cases were younger (57 vs 63; p=0.03), non-Caucasian (17% vs 6%; p=<0.001), and more likely to get chemotherapy (41% vs 8%; p=0.04) or immunotherapy (23.5% vs 0%; p=0.06), with no difference in gender (89% vs 83%) and receipt of chemoradiotherapy (94% vs 92%). While the difference in intra-operative complication rates was significant (13% vs 2%; p=0.001), both groups had similar rates of post-operative complications ( p=0.95). Non-regional nodal metastasis had the most favorable outcome (mOS NR; median follow-up=14m); while peritoneal/omental disease had the shortest survival (5.2m). Patients receiving surgery more than a year after stage IV diagnosis ( n=6) had better survival than those who either underwent resection within a year after diagnosis ( n=2) or had metastasis identified at time of surgery ( n=8) ( p=0.02). PDL-1 positive and HER2-neu positive tumors also had better outcomes, with neither group reaching median survival. Conclusions: Esophagectomy for highly selected patients with distant disease demonstrates similar post-operative complication rates to locally advanced EC. For stage IV patients, a short interval from diagnosis to surgery is associated with worse survival; however, prolonged diagnosis-to-surgery interval >12m and PDL-1 and HER2-neu positivity demonstrate better outcomes. Surgery’s role in treatment of stage IV EC preferably more than a year after diagnosis of metastasis should be further studied.

Perfusion Dynamics during Secondary Flap Debulking with Liposuction.

Lower extremity trauma often necessitates reconstruction with flap transfer. One of the reconstructive goals is a thin soft tissue coverage with appropriate contour. Therefore, a secondary debulking of the flap is usually performed. Debulking through conventional lipectomy is compared with liposuction followed by excision of the defatted flap excess. Demographic data, surgical details, and postoperative outcomes are compared and analyzed. The perfusion dynamics of the flaps undergoing liposuction debulking are studied by means of perioperative indocyanine green fluorescence angiography, as well as postoperative laser Doppler imaging. Patients undergoing lipectomy (n = 69; 57.5%) or liposuction (n = 51; 42.5%) debulking had a similar rate of postoperative complications. Partial necrosis was observed in 7.2% (lipectomy) versus 7.8% (liposuction) of flaps. Fluorescence angiography showed a substantial decrease in flap perfusion following the infiltration with an epinephrine-containing tumescent solution (74.3% ± 8.2% prior to infiltration versus 16.8% ± 7.1% after infiltration; p < 0.001), resulting in a dark flap appearance. Laser Doppler imaging confirmed the hypoperfusion on postoperative day 1. Secondary debulking of a lower extremity flap can be safely and efficiently performed through liposuction combined with peripheral excision of the defatted flap in a single stage. Perfusion studies may show a misleading hypoperfusion of the defatted flap, which does not accurately predict subsequent necrosis or complications.

Safety and efficacy of endovascular versus microsurgical treatment of unruptured wide-necked middle cerebral artery aneurysms: a propensity score-matched analysis of the NeuroVascular Quality Initiative Quality Outcomes Database Cerebral Aneurysm Registry.

Unruptured, wide-necked middle cerebral artery (WN-MCA) aneurysms have traditionally been considered ideal candidates for microsurgery (MS), although endovascular treatment (EVT) has dramatically increased in popularity with the advent of novel devices such as intrasaccular flow disruptors. The purpose of this study was to evaluate the safety and efficacy of MS versus EVT for unruptured WN-MCA aneurysms. The NeuroVascular Quality Initiative Quality Outcomes Database (NVQI-QOD) Cerebral Aneurysm Registry, a multiinstitutional, prospectively collected procedural database, was queried for cases of unruptured WN-MCA aneurysms treated with MS or EVT between 2015 and 2022. A wide neck was defined as an aneurysm neck ≥ 4 mm or a dome/neck ratio ≤ 2. Demographics and aneurysm characteristics were queried. Propensity score matching (PSM) was utilized to match aneurysm size, number of aneurysms treated, patient age, and aneurysm status. Safety outcomes were evaluated including intraoperative and postoperative complication rates. Aneurysm occlusion status and clinical outcomes using the modified Rankin Scale (mRS) score at discharge and the last follow-up were also assessed. Of 671 unruptured MCA aneurysms, 319 were wide necked. Thirty cases were excluded, as the aneurysm had been previously treated. Two hundred eighty-nine operations (203 EVT, 86 MS) in 282 patients satisfied inclusion criteria. After PSM, there were 86 operations in each group for analysis. The mean aneurysm width was 5.0 (EVT) versus 4.9 mm (MS; p = 0.285). Safety data showed similar intraoperative (7.0% EVT vs 3.5% MS, p = 0.496) and postoperative (4.7% vs 7%, p = 0.746) complication rates. The MS patients were more likely to have complete aneurysm occlusion at discharge (90.4% vs 58.8%, p < 0.001). In a limited subset of patients (52.9%) for whom outcome data were available, the EVT patients were more likely to have an mRS score 0 at discharge (50/59 [84.7%] vs 29/54 [53.7%], p < 0.0003] and at the last follow-up (36/55 [65.5%] vs 13/36 [36.1%], p = 0.006). This study describes a large, modern cohort of propensity score-matched patients who underwent treatment of unruptured WN-MCA aneurysms. Safety data on intraoperative and postoperative complication rates were similar in both treatment groups. MS was more likely to result in complete aneurysm occlusion at discharge. In a subset of patients with available outcome data, EVT was associated with better functional outcomes at discharge and the last follow-up. Given the lack of complete follow-up data and rates of retreatment, these results should be interpreted cautiously.

Musculoskeletal deformities after thoracoscopic versus conventional open repair for esophageal atresia

BackgroundThe superiority of thoracoscopic repair (TR) over conventional open repair (COR) for esophageal atresia, especially in terms of long-term outcomes, remains to be investigated. The aim of this study was to compare short- and long-term results between TR and COR group. MethodsPatients who underwent TR or COR for esophageal atresia without other predispositions to musculoskeletal deformities (2003–2016) and had been followed up for a minimum of 5 years were retrospectively reviewed. Musculoskeletal deformities (e.g., scoliosis, chest wall asymmetry, and rib deformities) were mainly evaluated based on the most recent chest radiographs. ResultsNine and eight patients were included in the TR and COR groups, respectively; the mean follow-up period was 8.7 and 11.5 years, respectively (p = 0.14). These groups had similar epidemiological characteristics and rates of postoperative complications. Musculoskeletal deformities developed significantly less frequently in the TR group versus the COR group (11 % vs. 88 %, p < 0.05; scoliosis: 0 % vs. 38 %, p = 0.08; chest wall asymmetry: 11 % vs. 50 %, p = 0.14; and rib deformities: 11 % vs. 88 %, p < 0.05, respectively). ConclusionTR was associated with a decreased incidence of musculoskeletal deformities and comparable complication rates versus COR for esophageal atresia repair. TR may achieve better long-term outcomes in this setting.

Minimally invasive versus conventional mitral valve surgery: A propensity score matching analysis

Background: This study aimed to compare the outcomes of minimally invasive mitral valve surgery and conventional surgery in terms of mortality and postoperative complications. Methods: A retrospective analysis was conducted on consecutive minimally invasive and conventional mitral valve surgeries performed between January 2019 and December 2022. Patients undergoing concomitant procedures were excluded from the study, and 293 patients (149 females, 144 males; mean age: 53.8±12.9 years; range, 18 to 82 years) were included in the study. Of these patients, 96 underwent minimally invasive surgery (MI group), and 197 underwent mitral valve surgery via conventional sternotomy (CS group). Propensity score matching was utilized to minimize the biases and confounding factors. After propensity score matching, 55 patients were included in each group. Results: There was no statistically significant difference in terms of mortality between the propensity score-matched groups (p=0.315), and no statistically significant difference in postoperative complications was observed between the groups. However, it was found that postoperative new-onset atrial fibrillation was lower in the minimally invasive group (p=0.022). Conclusion: This study demonstrates that minimally invasive mitral valve surgery is a safe alternative with similar mortality and postoperative complication rates compared to conventional surgery. Additionally, the study suggests an association between minimally invasive surgery and postoperative new onset atrial fibrillation.

First Results of the Primary Outcome of a Phase II Prospective Clinical Trial to Assess the Feasibility of Preoperative Radiation Boost in Breast Cancer Patients

A radiation boost targeted at the tumor bed is an important component of breast-conserving therapy (BCT) and has been shown to improve outcomes in patients with early-stage breast cancer. This is a prospective phase II study (NCT04871516) to assess the feasibility of delivering the radiation boost pre-operatively. This approach allows more accurate targeting of the high radiation dose at the tumor that may spare more normal breast tissue. We hypothesize wound complication rates to be comparable to standard treatment. The study design was a prospective phase II with a planned accrual of 55 patients. Women with non-metastatic node negative breast cancer or DCIS who were eligible for BCT were included. Patients were treated with pre-operative radiation boost of 1332 cGy in 4 fractions, followed by lumpectomy and adjuvant hypofractionated whole breast radiation to 3663 cGy in 11 fractions. The primary outcome of the study was to demonstrate that the incidence of grade 3 or more wound complications was not inferior to the current standard of care with conventional lumpectomy, postoperative whole breast radiation and a postoperative boost (6- 20%). Secondary outcomes included cosmetic outcome, local-regional control, and immunologic biomarkers induced by the preoperative radiation boost. We report here the results of the primary outcome of the study. Fifty-five women were enrolled between June 2021 and October 2022. Of those, 48 patients had at least 1 month follow up and were included in the analysis. Median age was 64 years-old, (range 40-77). Median follow up time was 2 months, (range 1-15). Forty-three patients (90%) had invasive cancers and 5 (10 %) had DCIS. Median clinical tumor size was 13 mm, (range 5-26). Median pathologic tumor size was 9 mm, (range 0-27). Margins were negative in 47 patients (98%). Two patients were found to have node positive disease on final pathology. Grade 3 wound dehiscence requiring surgical revision occurred in one patient (2%). There were no other grade 3 adverse side effects reported. Three patients (6%) had grade 2 wound infections requiring antibiotics. Cosmetic outcome at 1st follow up was available for 45 patients and was very good or excellent in 39 patients (87%). No patient had a poor cosmetic outcome. The use of a pre-operative radiation boost prior to lumpectomy followed by whole breast radiation as administered in this prospective trial resulted in an acceptable primary outcome with a similar rate of post-operative wound complications as the standard of care. We are currently enrolling patients on an expansion cohort to assess longer term cosmetic outcomes and performing a panel of immunologic markers to assess immune response to the preoperative boost.

Interim Analysis of Clinical Outcomes with Open versus Closed Conjunctival Implantation of the XEN45 Gel Stent

/Purpose: To examine the longitudinal postoperative outcomes of open versus closed conjunctiva implantation of the XEN45 gel stent. Retrospective multicenter study. 193 patients with glaucoma underwent XEN45 implantation via an open or closed conjunctiva approach. Patient demographics, diagnoses, preoperative and postoperative clinical data, outcome measures including intraocular pressure (IOP), use of glaucoma medications, visual acuity, and complications were collected. Statistical analyses were performed with P < 0.05 as significant. Failure was defined as less than 20% reduction of IOP from medicated baseline or IOP > 21 mmHg at 2 consecutive visits at postoperative month 1 and beyond, the need for subsequent operative intervention or additional glaucoma surgery, or a catastrophic event such as loss of light perception. Eyes that had not failed by these criteria and were not on glaucoma medications were considered complete successes. Overall success was defined as those who achieved success either with or without topical medications. Patients were followed for an average of 17 months. Complete success was achieved in 42.5% and 24.7% of the open and closed groups, respectively (P = 0.01). Overall success was achieved in 64.2% and 37.0% of the open and closed groups, respectively (P < 0.001) at the last follow up. Bleb needling was performed in 12.4% of eyes in the open group compared to 40% in the closed group. An IOP spike of 10 mmHg or greater was twice as likely to occur in the closed compared to the open group during the postoperative period (40% vs 18% P = 0.001). Implantation of the XEN45 with opening of the conjunctiva resulted in a lower IOP with greater success and lower needling rate compared with the closed conjunctiva technique. Similar rates of postoperative complications and vision loss were noted in each group. While both procedures provide substantial IOP reduction, the open technique appears to result in higher success rates and fewer postoperative interventions.

Goldilocks principle of minimally invasive surgery for gastric subepithelial tumors.

Minimally invasive surgery had been tailored to individual cases of gastric subepithelial tumors (SETs) after comparing the clinical outcomes of endoscopic resection (ER), laparoscopic resection (LR), and hybrid methods. To study the use of Goldilocks principle to determine the best form of minimally invasive surgery for gastric SETs. In this retrospective study, 194 patients of gastric SETs with high probability of surgical intervention were included. All patients underwent tumor resection in the operating theater between January 2013 and December 2021. The patients were divided into two groups, ER or LR, according to the tumor characteristics and the initial intent of intervention. Few patients in the ER group required further backup laparoscopic surgery after an incomplete ER. The patients who had converted open surgery were excluded. A logistic regression model was used to assess the associations between patient characteristics and the likelihood of a treatment strategy. The area under the curve was used to assess the discriminative ability of tumor size and Youden's index to determine the optimal cut-off tumor size. One-hundred ninety-four patients (100 in the ER group and 94 in the LR group) underwent tumor resection in the operating theater. In the ER group, 27 patients required backup laparoscopic surgery after an incomplete ER. The patients in the ER group had small tumor sizes and shorter procedure durations while the patients in the LR group had large tumor sizes, exophytic growth, malignancy, and tumors that were more often located in the middle or lower third of the stomach. Both groups had similar durations of hospital stays and a similar rate of major postoperative complications. The patients in the ER group who underwent backup surgery required longer procedures (56.4 min) and prolonged stays (2 d) compared to the patients in the LR group without the increased rate of major postoperative complications. The optimal cut-off point for the tumor size for laparoscopic surgery was 2.15 cm. Multidisciplinary teamwork leads to the adoption of different strategies to yield efficient clinical outcomes according to the tumor characteristics.

Trends and outcomes of outpatient total shoulder arthroplasty after its removal from CMS's inpatient-only list

In January 2021, the US Medicare program approved reimbursement of outpatient total shoulder arthroplasties (TSA), including anatomic and reverse TSAs. It remains unclear whether shifting TSAs from the inpatient to outpatient setting has affected clinical outcomes. Herein, we describe the rate of outpatient TSA growth and compare inpatient and outpatient TSA complications, readmissions, and mortality. Medicare fee-for-service claims for 2019-2022Q1 were analyzed to identify the trends in outpatient TSAs and to compare 90-day postoperative complications, all-cause hospital readmissions, and mortality between outpatients and inpatients. Outpatient cases were defined as those discharged on the same day of the surgery. To reduce the COVID-19 pandemic's impact and selection bias, we excluded 2020Q2-Q4 data and used propensity scores to match 2021-2022Q1 outpatients with inpatients from the same period (the primary analysis) and from 2019-2020Q1 (the secondary analysis), respectively. We performed both propensity score-matched and -weighted multivariate analyses to compare outcomes between the two groups. Covariates included sociodemographics, preoperative diagnosis, comorbid conditions, the Hierarchical Condition Category risk score, prior year hospital/skilled nursing home admissions, annual surgeon volume, and hospital characteristics. Nationally, the proportion of outpatient TSAs increased from 3% (619) in 2019Q1 to 22% (3456) in 2021Q1 and 38% (6778) in 2022Q1. A total of 55,166 cases were identified for the primary analysis (14,540 outpatients and 40,576 inpatients). Overall, glenohumeral osteoarthritis was the most common indication for surgery (70.8%), followed by rotator cuff pathology (14.6%). The unadjusted rates of complications (1.3 vs 2.4%, P<.001), readmissions (3.7 vs 6.1%, P<.001), and mortality (0.2 vs 0.4%, P=.024) were significantly lower among outpatient TSAs than inpatient TSAs. Using 1:1 nearest matching, 12,703 patient pairs were identified. Propensity score-matched multivariate analyses showed similar rates of postoperative complications, hospital readmissions, and mortality between outpatients and inpatients. Propensity score-weighted multivariate analyses resulted in similar conclusions. The secondary analysis showed a lower hospital readmission rate in outpatients (odds ratio: 0.8, P<.001). There has been accelerated growth in outpatient TSAs since 2019. Outpatient and inpatient TSAs have similar rates of postoperative complication, hospital readmission, and mortality.

Efficacy of Adding Acetaminophen to Preemptive Multimodal Analgesia in Total Knee Arthroplasty: A Double-blinded Randomized Study.

Preemptive multimodal analgesia is a frequently utilized method for controlling pain after total knee arthroplasty (TKA). So far, no studies have specifically examined the efficacy of adding acetaminophen to preemptive multimodal analgesia in TKA. The current work aimed to assess the efficacy of adding acetaminophen to preemptive multimodal analgesia for clinical pain management after TKA. This was a double-blinded randomized study including 80 cases randomized to the acetaminophen and control groups, respectively. The acetaminophen group was administered celecoxib at 400 mg, pregabalin at 150 mg, and acetaminophen at 300 mg 2 h before TKA. Control patients were administered celecoxib, pregabalin, and placebo. The primary outcome was postsurgical use of morphine hydrochloride for rescue analgesia. Secondary outcomes included the time to the initial rescue analgesia, postsurgical pain as determined by a visual analogue scale (VAS), functional recovery as reflected by the range of knee motion and ambulation distance, hospitalization duration, and complication rates. Continuous data with normal and skewed distributions were compared by the Student's t test and the Mann-Whitney U test, respectively. Categorical variables were compared by the Pearson's chi-squared test. The control and acetaminophen groups were comparable in postoperative 0-24 h morphine consumption (11.3 ± 6.5 mg vs 12.3 ± 7.7 mg, P = 0.445) and total morphine consumption (17.3 ± 10.1 mg vs 19.3 ± 9.4 mg, P = 0.242). Additionally, time to the initial rescue analgesia, postoperative VAS score at any time point, postoperative functional recovery of the knee, and hospitalization duration were similar in both groups. Both groups also had similar occurrence rates of postoperative complications. In this study, adding acetaminophen to preoperative preemptive multimodal analgesia did not decrease postoperative morphine use or ameliorate pain relief. The efficacy of adding acetaminophen to preemptive multimodal analgesia in TKA need to be further explored in future studies.

Endoaortic balloon occlusion versus transthoracic cross-clamp for totally endoscopic robotic mitral valve surgery: a retrospective cohort study.

Endoaortic balloon occlusion (EABO) and transthoracic cross-clamping have been shown to have comparable safety profiles for aortic occlusion in minimally invasive mitral valve surgery (MIMVS). However, few studies have focused exclusively on the totally endoscopic robotic approach. We sought to compare outcomes for patients undergoing totally endoscopic robotic mitral valve surgery with aortic occlusion via EABO and transthoracic clamping after a period where EABO was unavailable required us to use the transthoracic clamp. Retrospective review identified 113 patients who underwent robotic mitral valve surgery at our facility between 2019 and 2021 with EABO (n = 71) or transthoracic clamping (n = 42). Relevant data were extracted and compared. Preoperative characteristics were similar other than a higher rate of coronary artery disease [EABO: 69.0% (49/71) vs clamp: 45.2% (19/42), p = .02] and chronic lung disease [EABO: 38.0% (27/71) vs clamp: 9.5% (4/42), p < .01] in the EABO group. Median percutaneous cardiopulmonary bypass time, operative time, and cross-clamp time were comparable. Similar rates of postoperative bleeding complications were observed, and no aortic complications were observed. One patient in each group underwent conversion to an open approach. 30-day mortality and readmission rates were comparable. EABO and transthoracic clamp were associated with similar bleeding and aortic outcomes, and mortality and readmission rates were comparable at thirty days postoperatively. Our findings support the comparable safety of the two techniques, which is well documented in studies encompassing all MIMVS techniques, within the specific context of the totally endoscopic robotic approach.

Analysis of inpatient complications in HIV/AIDS patients undergoing total hip arthroplasty – A propensity matched cohort study

Patients with human immunodeficiency virus (HIV) are at higher risk for orthopedic related diseases due to dysregulation in bone metabolism and metabolic effects related to their medication regimen. Furthermore, the rate of hip arthroplasty in HIV patients is increasing. With the recent changes in THA methodologies and improvements in HIV treatment, there is a need for updated research analyzing hip arthroplasty outcomes in this high-risk patient population. In this study, we used a national database to evaluate postoperative outcomes in HIV patients undergoing THA compared to THA patients without HIV. We use a propensity algorithm to create a cohort of 493 HIV negative patients for matched analysis. Among the 367,894 THA patients included in this study, 367,390 patients were HIV negative and 504 were HIV positive. The HIV cohort had a lower mean age (53.34 vs 65.88, p < 0.001), lower proportion of females (44% vs 76.4%, p < 0.001), lower incidence of diabetes without complications (5% vs 11.1%, p < 0.001) and a lower incidence of obesity (0.544 vs 0.875, p = 0.002). In the unmatched analysis, the incidence of acute kidney injury (4.8% vs 2.5%, p = 0.004), pneumonia (1.2% vs 0.2%, p = 0.002), periprosthetic infection (3.6% vs 1%, p < 0.001), and wound dehiscence (0.6% vs 0.1%, p = 0.009) were higher in HIV cohort, most likely due to inherent demographic variances present in the HIV population. In the matched analysis, the rates of blood transfusion (5.0% vs 8.3%, p = 0.041) were lower in the HIV cohort. Other post-operative variables, such as rates of pneumonia, wound dehiscence, and surgical site infections were not statistically significant between the HIV positive population and HIV negative matched cohort. Our study found similar rates of postoperative complications in HIV positive and HIV negative patients. The rate of blood transfusions in HIV positive patients was also noted to be lower. Our data suggests that THA is a safe procedure in patients infected with HIV.

Single versus multiple hyperthermic intraperitoneal chemotherapy applications for T4 gastric cancer patients: Efficacy and safety profiles.

To explore the clinical safety and efficacy of single and multiple applications of lobaplatin-based hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with T4 gastric cancer and to evaluate the impact of HIPEC on peritoneal metastasis. We retrospectively reviewed prospectively collected data from T4 gastric cancer patients who underwent radical gastric resection plus HIPEC between March 2018 and August 2020 from the National Cancer Center and Huangxing Cancer Hospital. Patients who underwent radical surgery and HIPEC were divided into two groups: the single-HIPEC group (radical resection + a single application of intraoperative HIPEC with lobaplatin 50 mg/m2 at 43.0 ± 0.5°C for 60min), and a multi-HIPEC group (two more HIPEC applications were performed after radical surgery). A total of 78 patients were enrolled in this two-center study; among them, 40 patients were in the single-HIPEC group, and 38 patients were in the multi-HIPEC group. The baseline characteristics were well balanced between the two groups. There was no significant difference in the postoperative complication rates between the two groups (P > 0.05). Mild renal dysfunction, mild liver dysfunction, low platelet levels and low white blood cell levels were recorded in both groups, without significant differences between the two groups (P > 0.05). After a mean follow-up of 36.8 months, 3 (7.5%) patients in the single-HIPEC group and 2 (5.2%) patients in the multi-HIPEC group experienced peritoneal recurrence (P > 0.05). Both groups had comparable 3-year overall survival (OS) (51.3% vs. 54.5%, P = 0.558) and 3-year disease-free survival (DFS) rates (44.1% vs. 45.7%, P = 0.975). Multivariate analysis showed that an age > 60 years and low preoperative albumin levels were independent risk factors for postoperative complications. Single and multiple applications of HIPEC in patients with T4 gastric cancer were safe and feasible. Both groups had similar postoperative complication rates, 3-year OS rates and 3-year DFS rates. Special attention should be given to HIPEC for patients aged > 60 years and patients with low preoperative albumin levels.

The safety and cost-analysis of simultaneous versus staged bilateral total knee arthroplasty in a Taiwan population.

In patients with advanced osteoarthritis (OA) of the bilateral knees, uncertainty remains as to whether simultaneous bilateral total knee arthroplasty (SiTKA) or staged TKA (StTKA) is the treatment of choice. The purpose of this study was to investigate the safety and relative cost of SiTKA vs StTKA in Taiwan patients. Using the Big Data Center of Taipei Veterans General Hospital, we retrospectively reviewed all patients who underwent SiTKA or StTKA due to OA or spontaneous osteonecrosis of the knee from January 2011 to December 2016. We assessed length of stay, transfusion rate, early postoperative complications, 30- and 90-day readmission rate, 1-year reoperation rate, and the indication for reoperation. Furthermore, we analyzed the total cost of the two groups, including reimbursement from the national health insurance (NHI), cost of the procedures, and net income from each case. A total of 2016 patients (1565 SiTKA and 451 StTKA) were included in this study. The two groups had no significant differences in rates of complications, 30- and 90-day readmission, or 1-year reoperation. The length of stay was on average 5.0 days longer for StTKA ( p < 0.01). In terms of cost, all categories of medical costs were significantly lower for SiTKA, while the net hospital income was significantly higher for StTKA. SiTKA is a safe and cost-effective surgery. Both SiTKA and StTKA have similar rates of postoperative complications, readmission and reoperation, but SiTKA significantly reduces medical expenses for both the patient and the NHI.

Comparison of Aesthetic Outcomes of Epidermal Staples vs Sutures in Deep Epigastric Perforator Flap Breast Reconstruction

Abstract Background A secondary benefit of abdominally based autologous breast reconstruction may be improving the abdominal contour; however, poor scaring can lead to aesthetic dissatisfaction and complications. Although studies have demonstrated favorable aesthetic results and decreased operative time using dermal or subcuticular stapling (Insorb), no reports exist regarding epidermal stapling. Objectives The aim of this study is to compare the aesthetic abdominal scar outcomes, closure time, and postoperative complications of abdominally based breast reconstruction patients who have undergone suture closure vs epidermal staple closure. Methods A total of 217 patients who underwent abdominally based autologous breast reconstruction from 2011 to 2022 were included and retrospectively analyzed (staples = 41, suture = 176). Twenty-four patients’ postoperative abdominal scar photographs were randomly chosen (staples = 12, sutures = 12) and assessed by 3 board-certified plastic surgeons using a modified patient observer scar assessment scale (POSAS) and visual analog scale (VAS). Closure time (minutes per centimeter) using staples or sutures was also analyzed. Results The assessment of abdominal scars closed by epidermal staples revealed significant improvements in thickness (P = .033), relief (P = .033), surface area (P = .017), overall opinion (P = .033), POSAS score (P = .034), and VAS scar score (P = .023) in comparison with scars closed by sutures. Closing the abdominal wound with staples was significantly faster than closing with sutures (P &amp;lt; .0001). Staple and suture closure had similar postoperative complication rates. Conclusions Abdominal donor-site scar quality may be superior and faster using the epidermal staple compared to traditional suture closure. Level of Evidence: 2

The impact of the COVID-19 Pandemic on the delivery of lower limb arthroplasty

Hip and knee arthroplasty is an extremely successful and cost-effective procedure that is widely performed to restore function and alleviate pain. The arrival of the SARS-CoV-2 virus (COVID-19) brought significant disruptions to delivery of surgery worldwide, including lower limb arthroplasty. Three years on from the start of the pandemic the effects of the virus are still present. This literature review aims to explore current data published from our single specialty orthopaedic centre and data collected nationally and internationally, on the impact of the COVID-19 pandemic on lower limb arthroplasty. Elective hip and knee arthroplasty in the UK fell by approximately 40% and 50% respectively (2020 vs 2019) and by the end of 2021 the number of procedures completed still remained below pre-pandemic levels. As a result, elective waiting times are longer than ever before, with more patients suffering worse health states and a significant impact on quality of life. The UK National Hip Fracture Database showed an active COVID-19 infection was associated with a three-fold greater risk of 30-day mortality post lower limb arthroplasty. Several reports have also correlated peri-operative COVID-19 infection with increased risk of systemic complications with the virus such as pneumonia, deep vein thrombosis, pulmonary embolisms, acute kidney injury and myocardial infarction to name a few. NHS England provided guidelines for safe recommencement for elective operating. Upon adoption of these recommendations, several orthopaedic units found similar rates of post-operative complications and mortality to pre-pandemic levels, demonstrating that safe elective care can be delivered even during an emergency pandemic setting. The development of rapid testing, use of personal protective equipment and introduction of pre- and post-operative isolation protocols were effective measures to allow elective surgery to restart. For infected individuals awaiting surgery, delays of at least seven weeks are recommended to reduce complication rates. There is limited literature discussing the impact of the vaccine on post-operative complications and mortality. Early reports however have suggested vaccinated individuals benefit from a reduced mortality risk in emergency cases of hip fracture surgery, but this is an area which would benefit from further research.

Laparoscopic and robotic approaches for treatment of choledochal cysts in adults

Background: While well-described for hepatic and pancreatic resection, the minimally invasive (MIS) approach in the treatment of choledochal cysts (CC) has been under-reported. Due to the technical complexity and steeper learning curve of minimally invasive biliary reconstruction, the MIS approach has not been as widely adopted in biliary surgery. We herein review the use of laparoscopic and robotic-assisted surgery in the treatment of CC. Methods: A comprehensive review of the literature was performed on the use of laparoscopic and robotic-assisted surgery in the treatment of CC. Results: Similar morbidity and mortality rates were noted among patients undergoing laparoscopic choledochal cyst resection (LCCR) compared with previous data from patients in the literature who had undergone an open approach (OCCR, open choledochal cyst resection); however, LCCR was associated with longer operative times and high conversion rates, largely attributable to the learning curve given the technically challenging nature of the procedure. The robotic platform (RCCR, robotic choledochal cyst resection) has been shown to offer an advantage in the hepaticojejunostomy anastomosis portion of CC resection vs. laparoscopy while providing comparable short-term outcomes compared with the LCCR approach. Conclusion: A minimally invasive approach to CC likely has improved perioperative outcomes with shorter LOS, return to baseline function, as well as improved cosmesis vs. OCCR. Longer operative times with minimally invasive approaches to CC have been attributed to steep learning curves, which have improved over time as surgeons become more facile with this technique. Both LCCR and RCCR have demonstrated similar rates of long-term postoperative complications and overall survival when compared to OCCR.

Prior Acromioplasty Provides Similar Outcomes and Rate of Postoperative Complications Including Acromial Fracture After Reverse Total Shoulder Arthroplasty: A Retrospective Matched-Cohort Analysis

To compare outcomes of reverse total shoulder arthroplasty (RTSA) in patients with prior arthroscopic acromioplasty versus a control group of patients with no history of acromioplasty. We performed a retrospective matched-cohort study of patients from a single institution who underwent RTSA with a history of acromioplasty from 2009 to 2017 with a minimum 2-year follow-up period. Patients' clinical outcomes were evaluated using the American Shoulder and Elbow Surgeons shoulder score and Simple Shoulder Test, visual analog scale, and Single Assessment Numeric Evaluation surveys. Postoperative radiographs and patient charts were reviewed to determine whether patients sustained a postoperative acromial fracture. Charts were reviewed to determine range of motion and postoperative complications. Patients were matched on a 1:1 basis to a cohort of patients who underwent RTSA without a history of acromioplasty, and comparisons were performed using t and χ2 tests. Forty-five patients who underwent RTSA with a history of acromioplasty met the inclusion criteria and completed the outcome surveys. There were no significant differences between cases and controls in post-RTSA American Shoulder and Elbow Surgeons, visual analog scale, Simple Shoulder Test, or Single Assessment Numeric Evaluation outcome scores. There was no difference in the postoperative acromial fracture rate between cases and controls (P= .577). Overall, more complications occurred in the study group (n= 6, 13.3%) compared with the control group (n= 4, 8.9%); however, this difference was not statistically significant (P= .737). After RTSA, patients who have undergone a prior acromioplasty have similar functional outcomes without a significant difference in the rate of postoperative complications compared with patients with no history of acromioplasty. Furthermore, previous acromioplasty does not increase the risk of acromial fracture after RTSA. Level III, retrospective comparative study.

Comparison of Perioperative Outcomes in Patients Undergoing Short-Level Lumbar Fusion Surgery After Implementing Enhanced Recovery After Surgery: A Propensity Score Matching Analysis Focusing on Young-Old and Old-Old.

There were exponentially increased studies focused on revealing the satisfactory outcomes after implementing enhanced recovery after surgery (ERAS) in patients undergoing lumbar fusion surgery. However, little attention has been paid to the impact of chronologic age alone on perioperative outcomes. In the present study, patients were dichotomized into two groups: young-old (65-79 years), and old-old (80 years and older). Given the heterogeneity and age-related comorbidities in this population and the need to compare similar groups, we performed propensity score matching for gender, body mass index (BMI), operation time, American Society of Anesthesiologists (ASA) grade, Charlson Comorbidity Index (CCI), fusion levels and frail status. Perioperative outcomes were compared between two groups. In our study, we found there were significant discrepancies in length of stay (LOS) (7.17 ± 2.81 vs 8.11 ± 3.57 days, p = 0.031) and postoperative nausea and vomiting (3.7% vs 11.0%, p = 0.038); however, there were no significant differences in C-reactive protein (21.50 ± 26.52 vs 19.22 ± 22.04 mg/L, p = 0.490), overall complication rates (24.8% vs 33.0%, p = 0.179), ambulation time (2.89 ± 1.34 vs 2.55 ± 1.49 days, p = 0.078) or removal of urinary catheter time (2.47 ± 1.44 vs 2.32 ± 1.40 days, p = 0.446). There were few differences in perioperative outcomes between young-old and old-old groups. Despite similar postoperative complication rates, the old-old group might experience longer LOS when complications occur. More importantly, current outcomes suggested that chronologic age alone does not appear to have the capacity to reflect the tolerance of elderly patients to surgery.

Surgical considerations and outcomes of minimally invasive approaches for gastric cancer resection.

Despite high mortality rates from gastric cancer, surgical management remains critical for curative potential. Optimal outcomes of gastric cancer resection depend on a multitude of variables, including the extent of resection, scope of lymphadenectomy, method of reconstruction, and potential for a minimally invasive approach. Laparoscopic gastrectomy, compared with open gastrectomy, has been analyzed in numerous randomized control trials. Generally, those trials demonstrated statistically similar postoperative complication rates, mortality, and oncologic outcomes between the two approaches. Although laparoscopic gastrectomy requires longer operative times, significant improvements in estimated blood loss, postoperative length of stay, and return of bowel function have been noted in patients who undergo laparoscopic gastrectomy. These short-term benefits, along with equivalent oncologic results, have influenced national guidelines in both Eastern and Western countries to recommend laparoscopy, especially for early stage disease. Although robotic gastrectomy has not been as widely validated in effective trials, studies have reported equivalent oncologic outcomes and similar or improved postoperative complication and recovery rates after robotic gastrectomy compared with open gastrectomy. Comparing the two minimally invasive gastrectomy approaches, robotic surgery was associated with improved estimated blood loss, incidence of pancreatic sequela, and lymph node harvests in some studies, whereas laparoscopy resulted in lower operative times and hospital costs. Ultimately, when applying outcomes from the literature to clinical patient care decisions, it is imperative to recognize these studies' range of inclusion criteria, delineating between patients originating from Eastern or Western countries, the use of neoadjuvant chemotherapy, the volume of surgeon experience, and the extent of gastrectomy, among others.