Similar Recurrence Rates Research Articles

Failure rate of the pulmonary embolism rule-out criteria rule for adults 35 years or younger: Findings from the RIETE Registry.

The use of a computed tomography pulmonary angiogram to diagnose pulmonary embolism (PE) has increased, leading not only to higher PE diagnoses but also to overdiagnosis and unnecessary radiation exposure, even in young patients despite a lower PE incidence. The aim of this study was to assess the failure rate of the pulmonary embolism rule-out criteria 35 (PERC-35) rule developed to reduce unnecessary testing in individuals aged ≤35 years among patients included in the Registro Informatizado de la Enfermedad TromboEmbolica Venosa (RIETE) Registry. This retrospective cohort study used data from the RIETE Registry, an ongoing, international prospective registry of patients with objectively confirmed venous thromboembolism. The primary outcome was the missed PE rate using PERC-35 criteria. Secondary outcomes included the comparison of demographic and clinical characteristics, PE localization, treatment strategies, and outcomes between PERC-negative (PERC-35N) versus PERC-positive (PERC-35P) patients. Of 58,918 adult patients with acute PE, the PERC-35 rule demonstrated a low missed PE rate of 0.35% (n = 204), with an upper 95% confidence interval [CI] of 0.40%. The missed rate was 7.0% (95% CI 6.0%-7.9%) in the 18- to 35-year subgroup. Compared to PERC-35P patients, PERC-35N patients were younger (mean age 28.4 years), with a lower body mass index, and included a higher proportion of pregnant/postpartum women. PERC-35N patients had a significantly lower rate of chronic diseases and presented less frequently with dyspnea or syncope but more often with chest pain. They showed lower rates of positive D-dimer and troponin levels. PERC-35N patients experienced fewer major bleeding episodes, similar recurrence rates of PE/deep vein thrombosis, and no deaths during anticoagulation. The PERC-35 rule demonstrated a low failure rate to exclude PE in patients aged 18-35 years and could reduce imaging and radiation exposure in young patients with a low PE pretest probability if confirmed prospectively.

The necessity of thyroid-stimulating hormone suppression therapy for low-risk differentiated thyroid carcinoma following hemithyroidectomy: A systematic review and meta-analysis

Background and objectiveThyroidectomy, followed by postoperative thyroid-stimulating hormone (TSH) suppression therapy, is the established therapeutic approach for low-risk differentiated thyroid carcinoma (DTC). Recently, there has been a growing body of research dedicated to postoperative TSH suppression therapy in low-risk DTC. This study aims to conduct a comprehensive literature review concerning the necessity of TSH suppression therapy in DTC after hemithyroidectomy. MethodsA systematic search of publicly available literature on postoperative TSH suppression therapy in DTC was conducted by querying databases such as PubMed, Embase, Cochrane, and Web of Science. Patients were stratified into two groups: the experimental group (patients who received TSH suppression therapy) and the control group (patients who did not receive TSH suppression therapy). Concurrently, the five selected studies were categorized into two groups based on the average follow-up period (5–8.6 years). ResultsA total of five eligible studies, involving 2964 participants, were included in the analysis. The analysis of these five studies indicated low heterogeneity (I2 = 40 %). During the follow-up period, patients who received TSH suppression therapy had similar recurrence rate (P = 0.13) compared to those who did not. In both average follow-up period less than 6 years group (P = 0.85) and more than or equal to 6 years group (P = 0.07), postoperative TSH suppression therapy did not affect the recurrence of DTC after hemithyroidectomy. ConclusionThis study demonstrates that postoperative TSH suppression therapy does not reduce the recurrence rate of low-risk DTC patients after hemithyroidectomy.

Efficacy and safety of catheter ablation for paroxysmal atrial fibrillation as first-line therapy vs. after drug failure -analysis from Japan Nationwide Ablation (J-AB) Registry-

Abstract Background Catheter ablation is an effective rhythm control therapy for atrial fibrillation (AF). Recent advancements in technology have improved the efficacy and safety of this procedure. Current European Society of Cardiology and Japanese Circulation Society guidelines recommend that catheter ablation (CA) for patients with paroxysmal AF (PAF) after failure of drug therapy is classified as Class I, and CA as first-line therapy is categorized as Class IIa. However, there are limited clinical studies directly comparing these groups. Objective This study aimed to compare the efficacy and safety of CA as first-line therapy vs. those after failed drug therapy using data from the Japan Nationwide Ablation (J-AB) Registry led by the Japanese Heart Rhythm Society. Methods Detailed data of patients who underwent catheter ablation for PAF extracted from the J-AB registry were analyzed. Patients were divided into two groups: those who underwent CA as first-line therapy (First-line group) or those who underwent CA after failed drug therapy (Drug failure group). Patients’ characteristics, efficacy and safety of CA were compared between the two groups. Efficacy was assessed by evaluating the recurrence rate of any atrial arrhythmia within one year after the 90-day blanking period, and major safety outcomes were set as severe bleeding complication, stroke, and gastrointestinal disorders during the perioperative period. Result This analysis included 5,011 cases with a median age of 69 years (range 61-75) and 35% females. Comparing patient characteristics between the first-line therapy group (n = 3,447) and the drug failure group (n = 1,564), there are no statistically significant differences between the two groups except in left atrium diameter in echocardiogram (LAD) (38 [34-42] mm vs. 38 [34-43] mm, P <0.001), serum creatinine levels (0.8 [0.7-1.0] mg/dl vs. 0.9 [0.7-1.0] mg/dl, P <0.001), and beta-blocker usage (38.2% vs. 46.7%, P <0.01). A total of 501 recurrence events were observed in this analysis during a median follow-up of 365 [254-390] days. Recurrence rates did not statistically differ between the two groups (log-rank P=0.49). After adjusting for contributing factors with age, gender, body mass index, LAD, and left ventricular ejection fraction in echocardiogram using a multivariate Cox proportional hazards model, efficacy outcomes showed no significant difference between the two groups (adjusted hazard ratio; 1.06 95% confidence interval; 0.88-1.28, P = 0.55). Besides, the two groups had no significant difference in major safety outcomes. Conclusions Catheter ablation as the first-line therapy for paroxysmal atrial fibrillation showed a similar recurrence rate of atrial arrhythmias and adverse events compared to those who underwent catheter ablation after drug failure.

Does defect size matter in abdominal wall reconstruction with successful fascial closure?

BackgroundConflicting literature suggests that larger defects in abdominal wall reconstruction both increase the risk of recurrence and have no impact on recurrence. In our prior work, hernias with defect areas ≥100 cm2 were associated with increased discomfort, operative time, and length of stay but not recurrence or reoperation. Our goal was to determine if defect size, even in giant hernias, would impact recurrence after mesh repair with complete fascial closure. MethodsA prospectively maintained hernia database was reviewed for clean, abdominal wall reconstruction with fascial closure and synthetic mesh. Patients were grouped and compared by defect area: moderate hernias <200 cm2 (LT200) and giant hernias ≥200 cm2 (GT200). ResultsOf 984 patients, 607 LT200 (average area: 92.8 ± 60.8 cm2) were compared with 377 GT200 (average area: 363.2 ± 196.7 cm2). LT200 and GT200 had similar mean age, body mass index, and smoking rate, but GT200 had higher rates of diabetes (22.1% vs 27.9%; P = .040), recurrent hernias (52.7% vs 63.4%; P = .001), preoperative Botox (0.7% vs 8.8%; P < .001), component separation (23.4% vs 59.9%; P < .001), panniculectomy (8.7% vs 15.4%; P = .001), and negative-pressure incisional vacuum placement (5.9% vs 13.5%; P < .001). GT200 had increased mesh size (753.5 ± 367.1 vs 1168.2 ± 412.0 cm2; P < .001), operative time (147.8 ± 55.7 vs 205.3 ± 59.9 minutes; P < .001), and length of stay (5.1 ± 3.2 vs 6.9 ± 4.4 days; P < .001). GT200 had more wound complications (24.7% vs 36.1%; P < .001) and readmissions (9.1% vs 15.1%; P = .004) but similar recurrence rates (3.0% vs 3.7%; P = .520) over the mean follow-up of 30.1 ± 38.9 and 23.0 ± 33.6 months for LT200 and GT200, respectively. On multivariable regression, previous abdominal wall reconstruction, lightweight mesh, and wound complications independently predicted recurrence; component separation was protective, but defect size was not predictive of recurrence. ConclusionGT200 required more complex measures to achieve fascial closure and resulted in increased length of stay, wound complications, and readmissions; however, GT200 had the same recurrence rate as smaller defects when fascial closure was achieved.

Early Oral Step-Down Versus Continued Intravenous Antibiotic Treatment of Complicated Intra-Abdominal Infection.

Background: Complicated intra-abdominal infections (cIAIs) require a combined tactic, of source control and antimicrobial therapy. This study aimed to evaluate the safety and efficacy of oral step-down antimicrobial therapy in cIAIs after initial intravenous (IV) antimicrobial therapy. Methods: This retrospective cohort study included hospitalized adult patients diagnosed with a cIAI who received more than seven days of IV therapy from March 2017 to October 2021. Exclusion criteria included primary/peritoneal dialysis-related peritonitis, necrotizing pancreatitis, fistulizing inflammatory bowel disease, or upper gastrointestinal tract infection. Patients were assigned into two groups: IV-only or oral step-down therapy. The primary outcome was infection recurrence, defined as re-initiation of antimicrobial agents after a treatment-free period of more than or equal to three days. Secondary outcomes included treatment escalation, repeat source control procedure, treatment-related complications, and all-cause mortality. Results: The cohort consisted of 248 patients (199 IV-only and 49 oral step-down). Patients receiving IV-only therapy had a shorter median antimicrobial duration than the oral step-down group (13 vs. 23 d; p <0.0001). Infection recurrence occurred in 26 (13.1%) and 6 (12.2%) patients in the IV-only and oral step-down groups, respectively (p = 0.88). Treatment escalation, repeat source control, and 28-day mortality were similar between groups. Oral step-down therapy resulted in more adverse drug events (10.2% vs. 3.0%; p = 0.04). Discussion: Transition to oral step-down after initial IV therapy had a similar rate of infection recurrence as IV-only therapy but was associated with a longer duration of antimicrobial therapy and an increased rate of adverse drug reactions. Larger randomized non-inferiority studies are needed to confirm this approach.

Racial disparities in thyroid cancer outcomes: A systematic review

IntroductionRacial disparities in surgical outcomes are well described, but a paucity of literature exists examining trends in outcomes of thyroid cancer. We performed a systematic review of studies on thyroid cancer outcomes to better delineate the impact of race. MethodsA comprehensive search strategy was performed in several academic databases for articles on thyroid cancer and surgical outcomes in accordance with PRISMA guidelines. A total of 1771 abstracts were reviewed. Abstracts were screened by two independent reviewers with disagreements resolved by a third. Studies that were based in the United States, included single center, unique data, focused on outcomes of differentiated thyroid cancer, were performed on adults >18 years old, and reported race in their results were included. Chi square statistics with Yates correction were calculated on the compiled data. The protocol was registered on PROSPERO (CRD42022300021). ResultsTwelve studies met inclusion criteria with data on 7,221patients. Among the included studies, our study consists of 67 ​% White patients, 22 ​% Black patients, 7 ​% Hispanic patients, and 3 ​% Asian patients. Extrathyroidal extension was observed in 8.4 ​% (n ​= ​13) of White patients. In comparison to White patients, Black (18.4 ​%, n ​= ​21, p ​= ​0.024) and Hispanic patients (28.3 ​%, n ​= ​30, p ​< ​0.001) had a higher incidence of extrathyroidal extension, while a similar incidence was observed in Asian patients (14.0 ​%, n ​= ​8, p ​= ​0.336). Compared to White patients (22.2 ​%, n ​= ​34), Black (12.4 ​%, n ​= ​13, p ​= ​0.065), Hispanic (16.0 ​%, n ​= ​15, p ​= ​0.301), and Asian (18.4 ​%, n ​= ​9, p ​= ​0.709) patients had a similar incidence of T1a stage. White patients had 10.1 ​% (n ​= ​54) recurrence rates, and Black (13.5 ​%, n ​= ​7, p ​= ​0.595), Hispanic (10.5 ​%, n ​= ​2, p ​= ​1.000), and Asian (11.1 ​%, n ​= ​3, p ​= ​1.000) patients had similar recurrence rates. ConclusionsRace is seldom reported in outcomes on studies of thyroid cancer. From our analysis we conclude that non-White patients may have a higher risk of more advanced local disease at presentation. More data with granular detail on race is necessary to better understand racial disparities in thyroid cancer outcomes and how to alleviate them.

Novel cryoballoon technology for atrial fibrillation ablation: Impact of pulmonary vein variant anatomy, cooling characteristics, and 1-year outcome from the CHARISMA registry

BackgroundNo data have been reported on cooling characteristics and the impact of variant pulmonary vein (PV) anatomy on atrial fibrillation (AF) recurrences after POLARx cryoballoon (CB) ablation. ObjectiveThe purpose of this study was to analyze the impact of PV anatomy variants and cooling characteristics after CB ablation from a large multicenter prospective registry. MethodsThe primary end point was defined as 1-year absence of any atrial tachyarrhythmias (ATAs: AF/atrial flutter/atrial tachycardia). Correlation between ATA recurrences and anatomy variants/cooling characteristics were evaluated. The secondary outcome was the rate of major periprocedural complications. ResultsA total of 429 consecutive patients diagnosed with paroxysmal AF (83.4%) or persistent AF (peAF; 16.6%) were enrolled. Twenty-eight patients (6.6%) exhibited an anatomical variant (common ostium: 4.0%; adjunctive PV: 2.6%). Nadir temperature, thaw time, and total deflation time were different between standard PVs and PV variants. After the blanking period, over a mean of 431 ± 99 days of follow-up, 63 patients (14.7%) suffered an ATA recurrence. Patients with recurrences had both a shorter thaw time (18.5 ± 7 seconds vs 19.8 ± 7 seconds; P = .0012) and a shorter total deflation time, whereas time to isolation was longer (57.4 ± 42 seconds vs 49.1 ± 33 seconds; P = .04). Patients with anatomy variants showed a similar ATA recurrence rate (5 of 28 [17.9%]) to the standard PV anatomy group (58 of 401 [14.5%]) (P = .584), with a hazard ratio (HR) of 1.43 (95% confidence interval [CI] 0.49–4.13; log-rank, P = .4384). After adjusting for confounders, heart failure (HR 4.12; 95% CI 1.75–9.73; P = .0013) and peAF (HR 1.81; 95% CI 1.03–3.18; P = .0433) remained associated with ATA recurrence during follow-up. ConclusionThe POLARx CB system demonstrated long-term efficacy, along with a safe profile, in both patients with paroxysmal AF and those with peAF, regardless of the presence PV variants. Time to isolation was longer in patients with ATA recurrences during follow-up. Clinical Trial RegistrationCatheter Ablation of Arrhythmias with a High-Density Mapping System in Real-World Practice (CHARISMA). ClinicalTrials.gov identifier: NCT03793998. Registration date: January 4, 2019.

Comparison of Recurrence and Survival Between Patients With Pathological Stage I Epithelial Ovarian Cancer After Laparoscopic or Laparotomic Surgery: Retrospective Analysis of a Propensity-Matched Cohort

ObjectiveTo compare oncologic outcomes after laparoscopic or laparotomic surgery to treat epithelial ovarian carcinoma in FIGO Stage I. DesignRetrospective cohort study. SettingGynecological cancer ward in a tertiary hospital. ParticipantsA total of 85 patients with FIGO Stage I epithelial ovarian carcinoma who underwent laparoscopic staging surgery and 206 who underwent laparotomic staging surgery at West China Second Hospital, Sichuan University (Chengdu, China) between January 1, 2013 and December 31, 2019. InterventionsLaparoscopic surgery or laparotomic staging surgery. ResultsBefore propensity score-based matching, the laparotomy group showed higher prevalence of preoperative elevated CA125 level (48.5% vs 35.3%, p = .045) and tumors >15 cm (27.2% vs 5.9%, p <.001). Multivariate analysis associated higher body mass index with better overall survival (adjusted HR 0.83, 95% CI 0.70–0.99, p = .043). Among propensity score-matched patients (82 per group) who were matched to each other according to propensity scoring based on age, body mass index, CA125 level, largest tumor diameter, FIGO stage, history of abdominal surgery, and American Society of Anesthesiologists grade, the rate of progression-free survival at 5 years was similar between the laparoscopy group (87.1%, 95% CI 79.3–95.7%) and the laparotomy group (90.9%, 95% CI 84.7–97.6%, p = .524), as was the rate of overall survival at 5 years (93.9%, 95% CI 88.0–100.0% vs 94.7%, 95% CI 89.8–99.9%, p = .900). Regardless of whether patients were matched, the two groups showed similar rates of recurrence of 9–11% during follow-up lasting a median of 54.9 months. ConclusionsRates of recurrence and survival may be similar between laparoscopy or laparotomy to treat Stage I epithelial ovarian cancer. Since laparoscopy is associated with less bleeding and faster recovery, it may be a safe, effective alternative to laparotomy for appropriate patients.

Changes in Clinical Practice in Adherence to the 2014 American Thyroid Association Guidelines on Thyroid Cancer: A Retrospective Study from a Tertiary Referral Center.

Thyroidectomy, a pivotal treatment for various thyroid disorders, has seen its indications evolve, particularly with the 2014 American Thyroid Association (ATA) Guidelines advocating for conservative surgical approaches like lobectomy. This retrospective study analyzes thyroidectomy practices at a high-volume center from January 2014 to December 2023, focusing on patients potentially eligible for lobectomy per ATA guidelines. The inclusion criteria were tumors < 4 cm, indeterminate thyroid nodules, or differentiated thyroid carcinoma with clinically uninvolved lymph nodes (cN0). This study analyzed the proportion of patients undergoing lobectomy versus total thyroidectomy (TT) and the oncological outcomes. Of 357 patients, 243 underwent TT and 114 underwent lobectomy. The prevalence of lobectomies rose markedly, comprising 73.9% of surgeries in 2023. TT patients were predominantly female (83.5%) and had higher rates of autoimmune thyroiditis (67.5%) and malignancy (89.7%). Lobectomy patients had larger nodules and more indeterminate cytology. Among 301 malignant cases, TT was associated with higher lymph node metastasis, but similar recurrence rates, compared to lobectomy. This study underscores a shift towards lobectomy, reflecting adherence to ATA guidelines and suggesting conservative surgery is feasible without compromising outcomes. Further research on long-term outcomes and refined patient selection criteria is needed to optimize surgical approaches.

Oncoplastic Surgery Outcomes in the Older Breast Cancer Population: A Matched-Cohort Comparison Study.

Oncoplastic breast surgery (OBS) is a form of breast conservation surgery (BCS) that involves a partial mastectomy followed by immediate volume displacement or volume replacement surgical techniques. To date, there are few studies evaluating OBS in older patients. Therefore, we sought to determine if outcomes differed between patients 65 years and older versus younger patients who underwent oncoplastic surgical procedures. A retrospective chart review was performed for all oncoplastic breast operations within a single health system from 2015 to 2021. Patients were stratified by age, with patients 65 years and older (OBS65+) identified and then matched with younger patients (OBS <65) based on BMI. Primary outcomes were positive margin rates and overall complication rates; secondary outcomes were locoregional recurrence (LR), distant recurrence (DR), disease-free survival (DFS), overall survival (OS), and long-term breast asymmetry. A total of 217 patients underwent OBS over the 6-year period, with 22% being OBS65+. Preoperatively, older patients experienced higher American Anesthesia (ASA) scores, Charlson Co-morbidity index (CCI) scores, and higher rates of diabetes mellitus, hypertension, and grade 3 breast ptosis. Despite this, no significant differences were found between primary or secondary outcomes compared to younger patients undergoing the same procedures. Oncoplastic breast reconstruction is a safe option in patients 65 years and older, with overall similar recurrence rates, positive margin rates, and survival when compared to younger patients. Although the older cohort of patients had greater preoperative risk, there was no difference in overall surgical complication rates or outcomes. Supporting the argument that all oncoplastic breast reconstruction techniques should be offered to eligible patients, irrespective of age.

Tacker Fixation versus Suturing of Mesh in Laparoscopic Inguinal Hernia Repair

Abstract Background Laparoscopic hernia repair is more difficult technically than open surgery and there is evidence of learning curve in its performance and many complications which reported from laparoscopic procedure is due to learning curve lead to operative complications. Objective To compare the outcome results of the fixation of mesh by intracorporeal sutures and by tackers in TAPP hernia repair. Patients and Methods In our study, 30 patients were included divided on two groups, 15 for each. Group A; fixation mesh with tackers, Group B; fixation mesh with intracorporeal sutures. Both groups were compared in terms of operative technique, operative time, mesh device fixation cost, intra &amp; post operative complications, early post operative pain within two weeks and in first month, hospital stay, restriction of physical activity and incidence of recurrence and chronic pain. Results We found that using Intracorporeal sutures for fixation mesh is available, cheaper and more handle than using the Tackers which are expensive and less available so it makes a laparoscopic hernia more practical and decrease need for open surgery so we avoid the complication of open surgery. Both techniques are considered safe and effective with similar rates of recurrence and chronic pain although further wider scale studies are recommended. Conclusion TAPP hernia is considered safe as all perioperative complications are well tolerated by patients and mostly there was no need for a second operative intervention. Mesh fixation technique did not affect long-term persistent pain. A large number of patients reported persistent pain regardless of mesh fixation technique, which emphasizes the need for preoperative information. Preoperative pain was a risk factor for persistent pain. The optimal surgical approach must be selected individually for the patient, taking into account patient age, hernia size, unilateral or bilateral, primary or recurrent status, strangulation and type of anesthesia, occupation, and leisure activities. Both techniques are effective in the management of inguinal hernia and were associated with same recurrence rate. However, due to small sample size and short follow up duration, longer- term studies are also recommended.

Tunneled or Pocket Creation Method Versus Conventional Endoscopic Submucosal Dissection for Gastric Lesions: A Systematic Review and Meta-analysis

Tunneled endoscopic submucosal dissection (T-ESD) and pocket creation-method ESD (PCM-ESD) are considered to have technical advantages over conventional ESD (C-ESD). However, data comparing these techniques for ESD of gastric lesions are limited. PubMed and Cochrane databases were reviewed for relevant studies from their inceptions to October 31, 2023. Studies comparing T-ESD or PCM-ESD (T/PCM-ESD) with C-ESD for gastric lesions were included. The primary outcomes were dissection speed and en-bloc resection. Secondary outcomes were R0 resection, recurrence, perforation, and post-ESD bleeding. A random effects meta-analysis was conducted. Eight observational studies (359 patients with T/PCM-ESD, 670 patients with C-ESD) were included. T/PCM-ESD was associated with a significantly faster dissection speed (mean difference, 4.42mm2/min; 95% confidence interval [CI], 2.05-6.79; I2= 79%). There were no significant differences between the groups in terms of en-bloc resection (risk ratio [RR], 1.01; 95% CI, 1.00-1.03; I2= 0%), R0 resection (RR, 1.03; 95% CI, 0.99-1.07; I2= 0%), and recurrence (RR, 0.73; 95% CI, 0.14-3.84; I2= 0%). Although T/PCM-ESD was associated with a significantly lower risk of perforation (RR, 0.21; 95% CI, 0.06-0.80; I2= 0%), post-ESD bleeding rates were not significantly different. T/PCM-ESD facilitates faster and safer gastric ESD than C-ESD, with similar en-bloc resection, R0 resection, and recurrence rates. A future randomized controlled control trial is required.

Bilateral inguinal hernioplasty in emergency surgery: Is it feasible? Comparative retrospective study using “propensity score matching”

ABSTRACT INTRODUCTION: Hernias, particularly groin hernias, are prevalent surgical pathologies worldwide, often necessitating surgery in cases of complications. This study investigates the safety and efficacy of performing bilateral inguinal hernioplasty when one side faces complications, addressing the lack of consensus in emergency groin hernia treatment. MATERIALS AND METHODS: A retrospective, single-center study spanning a duration of 10 years was conducted, including adult patients who underwent emergency surgery for inguinal hernia. Propensity score matching was employed to create similar groups for comparative analysis of unilateral versus bilateral emergency groin hernioplasty. Surgical techniques, complications, mortality, and long-term outcomes were evaluated. RESULTS: This study included 341 patients. Data obtained from the study revealed high morbidity and 90-day mortality rates, consistent with the data of existing literature. Propensity score matching yielded two comparable groups. Short-term outcomes showed no significant differences in complication rates, mortality, surgical site infection, or hospital stay between unilateral and bilateral hernioplasty groups. Bilateral surgery takes approximately 15 min of the procedure time. Long-term outcomes exhibited similar recurrence rates between groups. CONCLUSION: This study supports the practice of bilateral inguinal hernioplasty in emergency scenarios when one side faces complications. It is a safe approach without any significant increase in morbidity or hospital stay, while reducing the need for a subsequent intervention and its associated risks and costs. Further prospective research is necessary to confirm these findings.

Needle aspiration versus tube thoracostomy in patients with symptomatic primary spontaneous pneumothorax: an updated meta-analysis of randomized controlled trials.

Primary spontaneous pneumothorax (PSP) is an important disease commonly seen in young males. While incidentally diagnosed cases can be managed conservatively, symptomatic patients often necessitate intervention. Chest tube placement (tube thoracostomy) is commonly used, at least in the USA as a primary treatment modality, which requires hospitalization. On the other hand, needle aspiration (NA) has been widely adopted due to simplicity and reported efficacy and safety. No consensus is reached regarding superiority and/or preferred modality, with a lack of guidelines agreement. Therefore, we conducted an updated meta-analysis of randomized controlled trials comparing NA to tube thoracostomy in patients with symptomatic PSP. Prespecified outcomes were immediate success rate, 12-month recurrence rate, post intervention complications rate, and hospital length of stay. We identified and pooled data from six randomized trials, with a total of 759 patients and a median follow up of 12 months. Our analysis showed that NA and tube thoracostomy have similar immediate success rate and 12-month recurrence rate. We also found that NA has less complication rate, need for surgical intervention, and less hospital stays. In conclusion, our review showed that in symptomatic patients with PSP, NA is as effective as tube thoracostomy regarding immediate success rate and 12-month recurrence rate, with the added benefit of less complications rate and need for surgical intervention.

Pediatric Cholesteatoma Follow-Up: Residual and Recurrence in 239 Cases with Over 5-Year Hindsight.

Pediatric cholesteatoma is an aggressive disease which requires long-term evaluation to assess management strategies. The objective was to determine optimal follow-up duration in pediatric cholesteatoma to detect residual and recurrent diseases. This cohort study was set in a tertiary referral center. All consecutive patients with a minimum 5-year follow-up were included. Medical history, initial extension, surgical procedures, and follow-up were collected. The main outcome measure were Kaplan-Meier survival curves of residual and recurrence cumulative incidence. Totally 239 ears with the first tympanoplasty between 2008 and 2014 were studied including 25% congenital. At first surgery (S1), mean age was 8.4 years and mean follow-up time 7.9 years. Mastoidectomy was performed in 69% and stapes was absent in 38% of cases. Notably, 83% (199 ears) had a second procedure (S2) of which 186 were planned. After S1, maximum cumulated incidence of residual was 45% [95%CI, 38%; 52%] at 74 months, with probability of residual of 39% at 3 years. After S2 (n = 199), maximum cumulated residual incidence was 21% [95%CI, 12%; 32%] at 62 months and 16% at 3 years. Concerning recurrence, maximum cumulated incidence after S1 (n = 239) was reached at 98 months with 21% [95%CI, 12%; 32%], 13% at 3 years and 16% at 5 years. Congenital disease had significantly less residuals after S1 (p = 0.02), but similar recurrence rate (p = 0.66) compared with acquired. We recommend MRI follow-up of at least 5 years after the last surgery for residual disease and clinical follow-up of at least 10 years to detect recurrence. 4 Laryngoscope, 134:4789-4798, 2024.

Comparative analysis of surgical techniques in the management of chronic subdural hematomas and risk factors for poor outcomes.

Chronic subdural hematomas (CSDH) are increasingly prevalent, especially among the elderly. Surgical intervention is essential in most cases. However, the choice of surgical technique, either craniotomy or burr-hole opening, remains a subject of debate. Additionally, the risk factors for poor long-term outcomes following surgical treatment remain poorly described. This article presents a 10-year retrospective cohort study conducted at a single center that aimed to compare the outcomes of two common surgical techniques for CSDH evacuation: burr hole opening and minicraniotomy. The study also identified risk factors associated with poor long-term outcome, which was defined as an mRS score ≥ 3 at 6 months. This study included 582 adult patients who were surgically treated for unilateral CSDH. Burr-hole opening was performed in 43% of the patients, while minicraniotomy was performed in 57%. Recurrence was observed in 10% of the cases and postoperative complications in 13%. The rates of recurrence, postoperative complications, death and poor long-term outcome did not differ significantly between the two surgical approaches. Multivariate analysis identified postoperative general complications, recurrence, and preoperative mRS score ≥ 3 as independent risk factors for poor outcomes at 6 months. Recurrence contribute to a poorer prognosis in CSDH. Nevertheless, use burr hole or minicraniotomy for the management of CSDH showed a similar recurrence rate and no significant differences in post-operative outcomes. This underlines the need for a thorough assessment of patients with CSHD and the importance of avoiding their occurrence, by promoting early mobilization of patients. Future research is necessary to mitigate the risk of recurrence, regardless of the surgical technique employed.

Intra-operative extracorporeal irradiation of tumour-invaded craniotomy bone flap in meningioma: a case series

BackgroundExtracorporeal irradiation of tumorous calvaria (EITC) can be performed to restore function and form of the skull after resection of bone-invasive meningioma. We sought to examine the rate of tumour recurrence and other selected outcomes in patients undergoing meningioma resection and EITC.MethodsRetrospective single-centre study of adult patients undergoing meningioma resection and EITC between January 2015 and November 2022 at a tertiary neurosurgical centre. Patient demographics, surgery data, tumour data, use of adjuvant therapy, surgical complications, and tumour recurrences were collected.ResultsEighteen patients with 11 (61%) CNS WHO grade 1, 6 (33%) grade 2, and 1 (6%) grade 3 meningiomas were included. Median follow-up was 42 months (range 3–88). Five (28%) patients had a recurrence, but none were associated with the bone flap. Two (11%) wound infections requiring explant surgery occurred. Six (33%) patients required a further operation. Two operations were for recurrences, one was for infection, one was a washout and wound exploration but no evidence of infection was found, one patient requested the removal of a small titanium implant, and one patient required a ventriculoperitoneal shunt for a persistent CSF collection. There were no cases of bone flap resorption and cosmetic outcome was not routinely recorded.ConclusionEITC is feasible and fast to perform with good outcomes and cost-effectiveness compared to other reconstructive methods. We observed similar recurrence rates and lower infection rates requiring explant compared to the largest series of cranioplasty in meningioma. Cosmetic outcome is universally under-reported and should be reported in future studies.

Randomized Controlled Trial of Awake Transnasal Laser-Assisted Surgery for Benign Laryngeal Lesions.

To compare functional and cost-effectiveness of awake transnasal laser assisted-surgery versus microlaryngeal surgery for benign laryngeal lesions. This was a prospective non-inferiority randomized controlled trial conducted from May 2021 to December 2022 at two tertiary referral hospitals in Hong Kong. Patients were block-randomized to receive either awake transnasal laser-assisted surgery or microlaryngeal surgery, with post-operative follow-up in a multidisciplinary voice clinic for 1-year. Primary outcome was Voice Handicap Index (VHI-30). Secondary outcomes included operation time, complications, length of stay, peri-operative discomfort, recurrence, and medical costs. Sixty-one patients were randomized to either awake transnasal laser-assisted surgery (n = 30) and microlaryngeal surgery (n = 31). Both groups had comparable demographics and laryngeal pathologies. Both groups showed significant improvement of VHI-30 score over time and had comparable post-operative VHI-30. Awake transnasal laser-assisted surgery group had a significantly shorter length of stay (0.5 vs. 1 day) and less throat discomfort (2 vs. 4) compared to microlaryngeal surgery group. Intraoperative complications were more common in microlaryngeal surgery group (14.3% vs. 0%). Otherwise, both groups had similar operative time and recurrence rate. Cost-analysis showed a significantly lower hospital cost for awake transnasal laser-assisted surgery (USD 3090) compared to microlaryngeal surgery group (USD 5120). Awake transnasal laser-assisted surgery was safe, functionally non-inferior, as measured by VHI-30, to microlaryngeal surgery in managing benign laryngeal lesions, while superior to microlaryngeal surgery in peri-operative discomfort and medical costs. 2 Laryngoscope, 134:3732-3740, 2024.

Pediatric Takotsubo cardiomyopathy: a review and insights from a national multicentric registry

Abstract Funding Acknowledgements None. Background Takotsubo syndrome (TTS) in the pediatric population is an infrequent but relevant cause of morbidity and mortality, with limited studies addressing its clinical course and prognosis. Objectives We aimed to analyze the clinical features and prognosis of pediatric TTS in a nation-wide multicenter registry and considering the published literature. Methods we included a total of 54 patients from 4 different hospitals in Spain, as well as pediatric TTS patients from the published literature. Comparisons between groups were performed in order to assess for statistically and clinically relevant prognostic differences between pediatric and adult population features. Results Comparison between the RETAKO general population is detailed in Table 1. Pediatric patients with TTS had a median age of 11 years (IQR = 4-14). When compared to the RETAKO general population, they were more often male (51.9% vs 23.3%, p&amp;lt;0.001), and displayed a higher prevalence of secondary forms (90.7% vs 35.6% in adults, p&amp;lt;0.001). Regarding race, 11 cases (20.4%) were from Asia and 42 (77.8%) were Caucasian; whereas in RETAKO 1420 (94.9%) were Caucasians, with under 5 cases (&amp;lt;0.1%) being Asian. Pediatric patients presented less commonly with angina (11.1% vs 64.1%, p&amp;lt;0.001) or dyspnea (30% vs 41.7%, p&amp;lt;0.001), compared to the general RETAKO cohort. Nevertheless, pediatric patients with TTS exhibited a higher Killip status on admission (Killip IV 74.1% vs 10.5%, p&amp;lt;0.001), and higher needs of vasoactive and mechanical ventilatory support during hospitalization. Regarding complementary exams, pediatric patients presented with lower LVEF on admission (30.5+10.4 vs 36.9+16.9, p = 0.014) together with greater prevalence of atypical (basal or midventricular) TTS patterns on echocardiography (30.2% vs 15.8%, p = 0.006). Additionally, there were significantly less ST-segment alterations in the pediatric population (either ST-segment elevation or depression), without differences on T wave inversion in the admission ECG. During follow-up, all-cause deaths (11.1% vs 12,5%, p = 0.761) and TTS recurrences (3.8% vs 3,8%, p = 0.863) were similar between groups. Conclusions TTS in the pediatric population presents a distinctive clinical profile, with higher prevalence of atypical symptoms and physical triggers; as well as higher rates of cardiogenic shock on admission and similar mortality and recurrence rates than those of the adult population. This study provides valuable insights into understanding pediatric TTS and underscored the necessity for further research in this age group.Table 1

Outcomes of posterior sheath supplementation with Vicryl mesh in TAR-a single-center study.

In the Transversus Abdominis Release (TAR) procedure, ideally, the posterior sheath is completely reapproximated to establish an interface isolating the polypropylene mesh from visceral contents. When primary closure of the posterior sheath is unachievable, Vicryl mesh is commonly used to supplement the posterior sheath closure and an uncoated polypropylene mesh is placed superficial to the Vicryl mesh. The long-term implications of utilizing Vicryl mesh as an antiadhesive barrier are poorly understood. In this study, we aimed to assess our outcomes when utilizing Vicryl mesh to supplement the posterior sheath defects when placed underneath polypropylene mesh in patients undergoing posterior component separation. Adult patients who underwent VHR with concurrent TAR procedure with a permanent synthetic mesh and posterior sheath supplementation with Vicryl mesh in the Cleveland Clinic Center for Abdominal Core Health between January 2014 and December 2022 were queried retrospectively from a prospectively collected database in the Abdominal Core Health Quality Collaborative. We evaluated 30-day wound morbidity, perioperative complications, long-term mesh-related complications, and pragmatic hernia recurrence. 53 patients who underwent TAR procedure with posterior sheath supplementation using Vicryl mesh and had a minimum 12-month follow-up were identified. Of the53 patients, 94.3% presented with recurrent hernias, 73.6% had a midline hernia, 7.5% had a flank hernia, and 18.9% had concurrent parastomal hernia. The mean hernia width was 24.9 cm (± 8.8 cm). No Vicryl mesh-related operative complications were identified in our study, with no instances of mesh erosion, fistulas, or interventions for small bowel obstruction. Skin necrosis requiring reoperations was observed in three patients (5.7%), leading to permanent mesh excision in two cases (3.8%) without intraabdominal visceral involvement. Throughout the 12-month follow-up, 23 incidences (43.4%) of surgical site occurrences (SSOs) and surgical site occurrences requiring procedural intervention (SSOPI) were documented. Our findings suggest that posterior sheath supplementation with Vicryl mesh is a feasible approach to achieve posterior sheath closure in challenging abdominal wall reconstruction cases. Given the absence of notable mesh-related complications and a similar hernia recurrence rate to cases without posterior sheath supplementation, Vicryl mesh can be used to safely achieve posterior sheath closure in complex reconstructions with insufficient native tissue.