Simultaneous Bilateral Surgery Research Articles

Clinical outcomes of concurrent surgery with weight bearing after modified lasso-loop stitch arthroscopic ankle stabilization

To determine the effects of unilateral and bilateral ankle stabilization surgery with or without additional concurrent procedures for other pathologies on return to activity in patients who were allowed unrestricted weight bearing postoperatively. Ninety-three athletes underwent 120 ankle stabilization surgeries including 27 that underwent bilateral simultaneous surgery using the all-inside arthroscopy-modified lasso-loop technique and were divided into two groups: arthroscopic ligament repair alone without concurrent procedures (group A) and with simultaneous procedures for other pathologies (group B). Group A was further subdivided into unilateral (group A1) and simultaneous bilateral ankle surgery (group A2), and group B into ankle stabilization surgery with simultaneous procedures not requiring weight bearing postoperatively (Group B1) and with concurrent procedures allowing weight bearing (Group B2). Return to activity postoperatively was assessed by recording the time to walk without any support, jog, and return to full athletic activities. Clinical outcomes were assessed preoperatively and 12months postoperatively using a subjective clinical score. The average time between surgery and unsupported walk, jog, and return to full athletic activities was 1.6 ± 2.5, 16.9 ± 3.7, and 42.4 ± 19.3days in group A, 17.2 ± 19.6, 34.5 ± 20.8, and 60.9 ± 22.8days in group B, 1.7 ± 2.9, 16.1 ± 2.4, and 41.6 ± 18.2days in group A1, 1.3 ± 0.6, 18.9 ± 5.5, and 44.6 ± 22.5days in group A2, 25.3 ± 20.2, 43.3 ± 21.1, and 70.7 ± 23.1days in group B1, and 4.8 ± 11.7, 20.7 ± 11.7, and 45.0 ± 13.7days in group B2, respectively. These results indicate that the patients in group B2 showed a statistically significant faster time to return to activity than did those restricted from weight bearing. Differences in ankle stabilization alone between patients in groups A1 and A2 as well as groups B2 and A were not statistically significant. Clinical outcomes were similar for patients in groups B2 and A1 versus group A2. Time to return to activity and clinical outcomes after ankle stabilization surgery using the modified lasso-loop technique were negatively affected if simultaneous bilateral surgery or simultaneous concurrent procedures were added or if weight bearing was unrestricted. However, a delay in return to athletic activity was observed when ankle stabilization surgery was performed using the modified lasso-loop technique with concurrent procedures that require non-weight bearing postoperatively. Level III.

Simultaneous bilateral hallux valgus surgery: Percutaneous or conventional? Early results of a matched study from a tertiary institution

BackgroundHallux valgus is bilateral in up to 84 % of cases. In the setting of simultaneous bilateral correction, we aim to evaluate if minimally invasive percutaneous surgery (MIS) provides any advantage compared to conventional open surgery. Methods52 feet (26 patients) undergoing simultaneous bilateral MIS surgery were matched by severity of deformity to 52 feet (26 patients) undergoing simultaneous conventional open surgery. Patients were followed for a minimum of six months. Pre- and post-operative radiographs and clinical records were reviewed. ResultsThere were no significant differences in pre-operative function or pain between both groups. Post-operatively, the mean hallux valgus angle (HVA) was significantly lower in the MIS group. (HVA MIS – 8.6; Open – 11.8, P = 0.013). There were no significant differences in post-operative outcome and patient satisfaction between both groups. ConclusionThis study demonstrates that simultaneous bilateral MIS hallux valgus surgery can be considered for patients with bilateral symptomatic hallux valgus.

Day-Case Admission for External Dacryocystorhinostomy in Preschool Children.

Epistaxis during or after dacryocystorhinostomy may present a risk of circulatory compromise, particularly in young children. In view of this concern, we reviewed the outcome and complications of external dacryocystorhinostomy in preschool children, aged less than 4½ years. Retrospective noncomparative series. A case-note review for a series of preschool children undergoing external dacryocystorhinostomy as a day-case admission at Moorfields Eye Hospital between 1992 and 2018; all surgery was consultant-led. Details were taken of the type of surgery, any intraoperative or postoperative complications (surgical or anesthetic), any unplanned admissions after surgery, and the functional outcome. To assess the veracity of the medical records, the parents for a sample of 67 children were contacted to check whether there had been any unrecorded events or concerns. Anesthetic or surgical complications, unplanned admissions, and postoperative events. One-hundred and eighty-seven children (117 boys; 63%) underwent 228 external dacryocystorhinostomies during 201 admissions, the average admission age being 36.8 months (median, 37.5; range, 5.5-53.5 months). Forty-one children (20%) underwent bilateral dacryocystorhinostomy: the 27 having simultaneous bilateral surgery dacryocystorhinostomy were operated at a mean age of 38.2 months (median, 37.5; range, 15.5-53.5 months), this being significantly different from the average age at first operation in 14 children undergoing sequential admission for bilateral dacryocystorhinostomy (mean, 24.9 months; median, 27.0; range, 5.5-42.5) (p = 0.0023). No adverse anesthetic events were recorded, 2 children (2 dacryocystorhinostomies) required temporary nasal packing at the end of surgery for epistaxis, and one further child was admitted for overnight observation because of persistent mild epistaxis after bilateral dacryocystorhinostomy. Three children (3 dacryocystorhinostomies) had a mild, self-limiting secondary epistaxis, and there were no unplanned emergency admissions. The telephone survey did not reveal any disparity in the medical records. With experienced surgeons and anesthetists in a suitable specialist hospital, external dacryocystorhinostomy in preschool children would appear to be a safe and effective procedure, with few and minor complications. Although facilities for overnight observation should be available, the surgery can typically be planned as a day-case admission, and simultaneous bilateral surgery is also possible in this age-group.

Outcomes of bilateral simultaneous hallux MTPJ fusion

BackgroundArthrodesis of the first metatarsophalangeal joint (MTPJ) is a frequently performed surgical procedure. Many patients have bilateral hallux MTPJ pathology requiring bilateral arthrodesis. There are concerns that bilateral simultaneous hallux surgery, under one anaesthetic, results in the patient being severely incapacitated in the early post-operative period. We hypothesize that bilateral simultaneous hallux MTPJ fusions does not compromise outcomes or the patients’ post-operative comfort and rehabilitation and is cost and time effective. MethodsIn this retrospective study, 16 patients who underwent bilateral simultaneous first MTPJ arthrodesis were compared to 16 patients who had unilateral MTPJ arthrodesis with regards to outcome, tolerance, cost and time effectiveness. Outcome measures were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux score and the Self-Reported Foot and Ankle questionnaire (SEFAS). ResultsThere was a significant improvement in the AOFAS scores post surgery in the bilateral group and according to the SEFAS grading, 14 patients (87.5%) had good or excellent outcome scores with 13 (81.25%) of these patients having excellent scores. This was comparable to the outcome scores in the unilateral group. Two patients developed non-unions bilaterally compared to one in the unilateral group. There is also a notable general cost saving and less time off work when bilateral fusions are done at the same setting. ConclusionBilateral simultaneous hallux MTPJ arthrodesis is an effective, convenient and cost effective option for patients requiring MTPJ fusions for bilateral hallux pathology. Level of evidenceLevel 4

Single-center experience of simultaneous bilateral uni-portal video-assisted thoracoscopic surgery for multiple ground-glass opacities

BackgroundThere is an increasing incidence rate of ground-glass opacity (GGO), especially for multiple GGOs (≥2). Whether it is safe and feasible to have bilateral simultaneous surgical resection remains unknown. The purpose of this study is to summarize the experience of surgical resection of patients with multiple GGOs in our Hospital in recent years, and to discuss the above questions.MethodsClinical datas of patients who underwent one-stage bilateral uni-portal VATS resections of multiple pulmonary ground glass opacities and had routine pathological examination were collected from May 2016 to May 2019 in our hospital.ResultsA total of 34 patients underwent simultaneous bilateral surgical resection of multiple GGO lesions, 28 were women,6 were men, the average age of total patients was 57.9 ± 6.7 years. All patients underwent bilateral uni-portal video-assisted thoracoscopic surgery (Uni-portal VATS), the average intraoperative blood loss was 100.9 ± 67.7 ml, the average operation time was 140 ± 74.8 min, the average thoracic drainage time was 2.8 ± 3.1 days, and the average postoperative hospital stay was 4.2 ± 4.3 days. Postoperative complications including: 2 cases of infection, 3 cases of atrial fibrillation, and 5 cases of persistent air leakage for more than 3 days. All of them improved after treatment, and there were no serious complications and deaths in perioperative period. A total of 76 GGO lesions were resected, with a total malignancy rate of 81.6%, including 40 were pure GGO, of which 28 were malignant (70%), and the average diameter of them were 9.6 ± 3.8 mm; 36 were mixed GGO, of which 34 were malignant (94.4%), the average diameter of them were 15.6 ± 6.6 mm.Mean postoperative follow-up was 28.4 (range, 3–39) months. There was neither recurrence nor deaths at final follow-up.ConclusionThe malignancy rate of multiple GGOs is high. Therefore, when the lung function is allowed,one-stage bilateral uni-portal VATS can be considered. According to experience of main surgeon and the frozen biopsy, either sub-lobar resection or lobectomy was acceptable. The risk of postoperative complications and the prognosis were optimal.

Experience and outcome of simultaneous bilateral endoscopic surgery (SBES) for patients with bilateral upper tract urolithiasis

Introduction: 15% of Urolithiasis patients presents with bilateral renal stones. Management of patients with renal stones along with ureteric stones commonly requires staged approach. Simultaneous bilateral endoscopic surgery (SBES) has emerged as more efficient treatment option which allows management of renal and ureteric stone in a simultaneous manner. We report our experience with SBES for patients with bilateral Urolithiasis. Patients and Methods: From May 2018 to February 2020, 12 patients who would otherwise have been treated in staged or in consecutive manner were planned for Simultaneous Bilateral Endoscopic surgery. Procedures were performed in the FOSML position to achieve both antegrade and retrograde access. Management of renal stones by supine approach and retrograde uretroscopic lithotripsy for ureteric stones under general anesthesia. Results: A total of 12 patients underwent simultaneous bilateral endoscopic surgery. Among these 12 patients, 2 patients had contra lateral upper ureteric calculus, 4 had mid ureteric calculus and remaining 6 had lower ureteric calculus. 11 patients were discharged on second postoperative day and remaining 1 patient was discharged on 3rd postoperative day due to procedure related complication. Conclusion: Simultaneous bilateral endoscopic surgery can be performed in FOSML position and is safe and effective procedure with shorter operative time and anesthesia. Procedure is beneficial for patient, healthcare system and surgeon.

The Clinical Implications of Simultaneous Bilateral Chronic Ear Surgery for Patients with Asymmetric Hearing

Background and Objectives Surgery for bilateral chronic otitis media (COM) is usually performed sequentially, not simultaneously. The main reason is to prevent iatrogenic bilateral conductive hearing loss during recovery period. However, with asymmetric hearing loss, the difference in patient inconvenience between sequential and simultaneous surgery may be the same. This study evaluates the efficacy of simultaneous COM surgery in patients with asymmetric hearing.Subjects Materials and Method From 2012 to 2018, 9 patients underwent simultaneous bilateral COM surgery. The period of patients’ hospital stay, the success rate of tympanoplasty, tolerability for operation, and hearing thresholds were analyzed statistically.Results For the 8 same-day surgery patients, the mean hospital period was 4.4±0.7 days, which was much shorter than that of sequential surgery (8 days). Tympanoplasty was successful in all patients without complications. In the better side, the preoperative/postoperative mean air conduction thresholds (AC) were 62.97±12.89 dB/47.81±19.07 dB (p=0.017), the bone conduction thresholds (BC) were 46.72±10.31 dB/37.66±16.99 dB (p=0.161) and the air-bone gaps (ABG) were 16.25±8.81 dB/10.16±7.78 dB (p=0.176). In the worse side, the preoperative/ postoperative mean AC were 86.56±18.22 dB/72.18±29.43 dB (p=0.035), BC were 53.28± 11.10 dB/48.13±18.41 dB (p=0.173), and ABG were 33.28±11.22 dB/24.06±14.80 dB (p=0.500). In both ear, the postoperative AC and BC were better than or equivocal to those of the preoperative value, and the result was similar with each of the unilateral ear audiological results.Conclusion Despite the fact that there is no complete consensus to date, simultaneous bilateral COM surgery can be an option when patients have asymmetric hearing loss. Simultaneous bilateral COM surgery could save time, cost, and lead to similar results with sequential surgery, so it could be a considerable surgical option for patients with bilateral COM.

Staged upper and lower limb lengthening performing bilateral simultaneous surgery of the femur and tibia in achondroplastic patients.

Surgical lengthening and angular correction of the limbs are an option for treating the orthopedic clinical manifestations in patients with achondroplasia. This study assesses a staged limb lengthening protocol, performing simultaneous bilateral lengthening of the femur and tibia (stage I [S1]), and humeral lengthening (stage II [S2]). Twenty-one achondroplastic patients were included in this study, and 106 segments (34 femurs, 34 tibias and 38 humeri) were lengthened. Achondroplasia patients with a growth curve below the mean of the standard growth curves for achondroplasia were included in S1. The remaining patients were included directly in S2. Variables analyzed included anthropometric measurements, lengthening outcomes, difficulties, and functionality. Of the all patients included in the protocol, 15 patients completed S1 and S2, 4 only completed S2, and 2 only completed S1. Height and limb-trunk ratio before S1 were 107.65 ± 7.14cm and 1.89 ± 0.10 and after S1 were 126.50 ± 9.19cm and 1.64 ± 0.09, respectively. Limbs were lengthened 14.43 ± 1.41cm (femurs and tibias) for S1 and 9.95 ± 0.60cm for S2 (humeri), with a stage healing index of 18.23 ± 3.54 in S1 and 28.92 ± 4.42 in S2. Correction of lower angular deviations, functional improvement, and a controlled complications rate were achieved in all patients. The limb lengthening protocol proposed in this study is a suitable treatment for achondroplasia patients to achieve the agreed-upon objectives (limb-trunk ratio, improved functionality, and lower limb alignment). The reproducibility of the procedure and patient safety were upheld.

Simultaneous bilateral combined micro invasive glaucoma surgery (migs) with istent inject® and femtosecond laser-assisted cataract surgery with premium iols

Simultaneous bilateral combined micro invasive glaucoma surgery (migs) with istent inject® and femtosecond laser-assisted cataract surgery with premium iols

Frontiers of stone management.

The surgical tool-box for urinary stone disease is growing. In this review, we discuss recent developments in the surgical management of urolithiasis, with emphasis on tailoring the management to the individual patient, and attention to the quality of care. Shockwave lithotripsy remains a popular noninvasive treatment option for patients, with new data emerging on how to improve treatment outcomes as well as its limitations. Next-generation holmium lasers are expanding the role of dusting techniques for ureteroscopy but further studies are needed to assess safety and clinical outcomes. Advances in miniaturization and patient positioning are propelling percutaneous renal stone surgery toward endoscopic combined intrarenal and simultaneous bilateral surgery for patients with complex stone disease. Stone management will be increasingly personalized to the unique qualities of the patient, stone, desired outcome, and available expertise and technology. Future studies assessing the quality of stone surgery should incorporate objective metrics to better delineate the success and cost of the different techniques available.

Computer-Assisted Kinematic and Mechanical Axis Total Knee Arthroplasty: A Prospective Randomized Controlled Trial of Bilateral Simultaneous Surgery

BackgroundRandomized controlled trials of kinematic alignment (KA) and mechanical alignment (MA) in primary total knee arthroplasty (TKA) have to date demonstrated at least equivalence of KA in terms of clinical outcomes. No trial of bilateral TKA has been conducted so patient preference for one technique over the other is unknown. MethodsForty-one participants underwent computer-assisted bilateral TKA. The outcome measures were as follows: (1) joint range of motion and functional scores including the KOOS, the KOOS JR, Oxford Knee Score, and the Forgotten Joint Score at a minimum of 2 years; (2) preference and perception of limb symmetry; (3) intraoperative alignment data; (4) release and gap balance data; and (5) postoperative radiographic joint angles. ResultsThere were no significant differences with respect to flexion range (P = .970) or functional scores (mean KOOS, P = .941; KOOS JR, P = .685; Oxford Knee Score, P = .578; FJS, P = .542). Significantly more participants who favored one knee preferred their KA TKA (P = .03); however, half of the patients had no preference and the overall numbers were small. Only 3 participants perceived any limb asymmetry (P < .001). More releases were required in the MA group (P = .018). Standing hip-knee-ankle angle means and frequency distributions were similar (P = .097 and P = .097, respectively). ConclusionClinical outcomes were equivalent at 2 years. Significantly more participants preferred their KA joint. Fewer releases were required using a KA technique. Participants were visually insensitive to modest hip-knee-ankle angle asymmetry. Level of EvidenceLevel 1.

Development of a prediction model for allogenic blood transfusion in children undergoing surgery for developmental dysplasia of the hip.

Blood transfusion is a common practice, but it is not without cost and risk. A model that predicts the risk of blood transfusion could guide informed preoperative blood ordering and use of blood loss preventive measures. This study aimed to develop a prediction model of blood transfusion in children with developmental dysplasia of the hip (DDH) undergoing surgery. A retrospective cohort of DDH patients from 2008 to 2017. The included patients were between 1 to 9 years old, underwent anterior open reduction and/or acetabular osteotomy with and without femoral shortening. The unit of analysis was undergoing such an operation. The outcome was allogenic blood transfusion. Potential predictors were age, sex, body mass index (BMI), international hip dysplasia institute grade, type of surgery, intervention bilaterally during the same operative session, primary versus reoperation surgery, the addition of regional anaesthesia, preoperative haemoglobin and hematocrit. A total of 524 patients who met the inclusion criteria underwent 721 operative sessions. The median age (interquartile range) at operation was 23 (20-33) months. The blood transfusion rate was 11.8%. Independent predictors were lower preoperative haemoglobin, reduced BMI, simultaneous bilateral surgery and the extent of surgical treatment. The developed prognostic model allows prediction for blood transfusion in DDH patients undergoing surgery.

Pediatric Bilateral Cochlear Implantation: Simultaneous Versus Sequential Surgery.

To compare outcomes of bilateral cochlear implantation between simultaneous and sequential surgeries. Retrospective study of surgical outcome for 54 children who received bilateral cochlear implants (CIs) over a five-year period. Tertiary health care PATIENTS:: We analyze surgical outcomes for 54 children who received two CIs over a five-year period. Thirty-two of these children received these implants simultaneously and 22 of these children received their implants sequentially (76 CI operations and 108 CI). One hundred and eight CIs; Group A-bilateral simultaneous CI; Group B- bilateral sequential CI. Measurement of body temperature; recording drug administration measurement of the total length of hospital stay, surgery time, and total operating room utilization; recording complications. Simultaneous bilateral CI-implantation is associated with a significantly reduced cumulative surgical time and cumulative operating room time. It shortens the total in-patient stay for children in comparison to sequential implantations. There were no clinically significant, adverse consequences of simultaneous implant surgery. Further information include medical history including cochlear malformations as well as complications after the surgery, use of analgesic and antiemetic medication and length of hospital stay. Simultaneous bilateral surgery is a safe option of pediatric cochlear implantation.

ARE THERE SIDE-TO-SIDE DIFFERENCES IN KNEE MORPHOLOGY IN PATIENTS WITH BILATERAL PATELLAR INSTABILITY

Introduction It is not known if there are side-to-side differences in knee morphology in patients with bilateral patellar instability (BPI). Such knowledge would help to answer the question whether similar treatment and prognosis could be expected for both knees in patients with BPI. The purpose of our study was to evaluate and compare anatomic / morphologic risk factors between knees in patients with BPI. Materials and Methods Of 294 patients who underwent surgical stabilization for patellar instability (2008-2017), 32 patients were identified who underwent staged or simultaneous bilateral surgery. This formed the study cohort. Demographic data, mechanism of initial injury and first knee side to be symptomatic were recorded. Radiographs and MRI of these 64 knees were evaluated for trochlear dysplasia (trochlear depth), patellar height (Caton-Deschamps index, Insall-Salvati ratio), patellar tilt, TT-TG distance, sulcus angle (cartilaginous and bony) and trochlear bump (cartilaginous and bony). The number and percentage of knees with pathologic values for measured risk factors were analyzed. For each risk factor, 15% side-to-side differences were considered significant. Statistical correlation was calculated between the time of presentation (first symptomatic knee) and magnitude of risk factors. All measurements were repeated after a 3-week interval and ICC was calculated to determine intraobserver reliability. Results The mean age of 32 patients was 14.6 years. 17/32 patients were females. 29 patients had staged surgery with mean interval of 21 months between surgeries; 3 patients had simultaneous surgery on each knee. Patients with BPI had multiple risk factors. 22/32 patients (69%) had the same Dejour type of trochlear dysplasia. For each measured risk factor, the number and percentage of patients with 15% or more side-to-side differences is shown (Table 1). There were significant side-to-side differences in patellar height ratios, TT-TG distance, and trochlear bump. The timing of presentation did not correlate with increased risk factors, i.e, the knee that presented earlier did not have increased risk factors compared to contralateral knee. ICC showed excellent intraobserver reliability. Conclusion There were significant side-to-side differences between knees in patients with BPI. Treatment and prognosis should be based on anatomic risk factors for each knee in patients with BPI. [Table: see text]

V11 - Simultaneous bilateral endoscopic surgery (SBES): A new technique for the treatment of bilateral renal stones

V11 - Simultaneous bilateral endoscopic surgery (SBES): A new technique for the treatment of bilateral renal stones

Simultaneous and synchronous bilateral endoscopic treatment of urolithiasis: a multicentric study.

IntroductionThe general prevalence of bilateral urolithiasis has risen to 15% and bilateral non-simultaneous treatment has been reported to have good outcomes. The objective of this study was to evaluate the effectiveness and safety of simultaneous bilateral endoscopic surgery (SBES).Material and methodsAn international multicenter analysis was performed between May 2015 and December 2017. All patients with bilateral stone disease that underwent SBES were included. Patients were treated under general anesthesia in either the supine or lithotomy position. Demographic, clinical, intraoperative and postoperative data were analyzed.ResultsA total of 47 patients were included. Mean age was 53.8 years and 70% of the patients were males. The mean American Society of Anesthesiology (ASA) score was 2. The mean diameter of right- and left-sided stones was 29.43 mm (2–83 mm) and 31.15 (4–102 mm), respectively. Staghorn stones were treated in 18 cases (8 right-sided and 10 left-sided), four of them were defined as complete staghorn. The procedures performed were 42 cases of bilateral URS and PCNL and ureteroscopy. Additionally, 5 bilateral flexible ureteroscopy (fURS) cases were described. Intraoperative complications occurred in five patients: four of them were classified as Clavien-Dindo (CD) I and one as CD II. Postoperatively, there were two cases with CD I, 6 with CD II and one CD IIIa.The stone-free status was 70%. Residual stones (30%) were detected only on the side treated for high-volume (complete) staghorn calculi.ConclusionsSBES is a feasible, effective and safe procedure. It may potentially avoid repeated anesthetic sessions as needed for staged procedures and reduce the length of patients' hospital stay.

Socio-demographic factors impact time to discharge following total knee arthroplasty.

AIMTo determine social, logistical and demographic factors that influence time to discharge in a short stay pathway (SSP) by following total knee arthroplasty (TKA).METHODSThe study included primary TKA’s performed in a high-volume arthroplasty center from January 2016 through December 2016. Potential variables associated with increased hospital length of stay (LOS) were obtained from patient medical records. These included age, gender, race, zip code, body mass index (BMI), number of pre-operative medications used, number of narcotic medications used, number of patient reported allergies (PRA), simultaneous bilateral surgery, tobacco use, marital status, living arrangements, distance traveled for surgery, employment history, surgical day of the week, procedure end time and whether the surgery was performed during a major holiday week. Multivariate step-wise regression determined the impact of social, logistical and demographic factors on LOS.RESULTSEight hundred and six consecutive primary SSP TKA’s were included in this study. Patients were discharged at a median of 49 h (post-operative day two). The following factors increased LOS: Simultaneous bilateral TKA [46.1 h longer (P < 0.001)], female gender [4.3 h longer (P = 0.012)], age [3.5 h longer per ten-year increase in age (P < 0.001)], patient-reported allergies [1.1 h longer per allergy reported (P = 0.005)], later procedure end-times [0.8 h longer per hour increase in end-time (P = 0.004)] and Black or African American patients [6.1 h longer (P = 0.047)]. Decreased LOS was found in married patients [4.8 h shorter (P = 0.011)] and TKA’s performed during holiday weeks [9.4 h shorter (P = 0.011)]. Non-significant factors included: BMI, median income, patient’s living arrangement, smoking status, number of medications taken, use of pre-operative pain medications, distance traveled to hospital, and the day of surgery.CONCLUSIONThe cost of TKA is dependent upon LOS, which is affected by multiple factors. The clinical care team should acknowledge socio-demographic factors to optimize LOS.

Prone percutaneous nephrolithotomy: its advantages and our technique for puncture.

Percutaneous nephrolithotomy (PCNL) is considered the treatment of choice for large urinary calculi and staghorn lithiasis. The approach for this surgery may be either supine or prone, and different access techniques are described in the literature with the use of ultrasound, fluoroscopy, or both combined. We believe that prone PCNL offers to the urologist key advantages, such as the possibility of puncturing anatomically abnormal urinary tracts, to perform multiple percutaneous tracts in the same kidney, experiencing the vacuum cleaner effect, ease of exploring the upper calyx through the inferior calyx, possibility to perform endoscopic combined intrarenal surgery (ECIRS) and bilateral simultaneous surgery, and to performed over local anesthesia. An adequate training for the endourologist should include both the prone and supine techniques for PCNL and to know which patient can benefit the most from each one.

Clinical analysis of 56 cases of simultaneous bilateral video-assisted thoracoscopic surgery for bilateral synchronous multiple primary lung adenocarcinoma.

Bilateral synchronous multiple primary lung adenocarcinoma (BSMPLA) is a rapidly increasing disease for which timely and accurate treatment is required. We describe our experience which we hope to establish optimal therapeutic options for patients with BSMPLA. This study aimed to explore the feasibility and safety of simultaneous bilateral video-assisted thoracoscopic surgery (VATS) in 56 patients who received histological diagnoses of BSMPLA at our hospital between January 2016 and January 2018. In this retrospective analysis of clinical outcomes, we observed no serious postoperative complications or perioperative death. Four and 28 patients respectively underwent bilateral lobectomy and lobectomy with contralateral sublobar resection, whereas the remaining 24 patients underwent bilateral sublobar resection. Sublobar resection means anatomical segmentectomy or wedge resection. The mean postoperative hospital stay duration was 5.39±2.67 days. Postoperative complications comprising persistent air leakage for more than 5 days was observed in 8 (14.2%) of 56 patients. No severe postoperative complications or deaths occurred. Our results suggest that simultaneous bilateral VATS is feasible, safe, and reproducible. This therapeutic strategy appears to confer considerable benefits on patients with BSMPLA.

Effect of unilateral subthalamic deep brain stimulation in highly asymmetrical Parkinson's disease: 7-year follow-up.

For patients with highly asymmetrical Parkinson's disease (PD), unilateral subthalamic nucleus (STN) deep brain stimulation (DBS) has been suggested as a reasonable treatment. However, the results of a previous 2-year follow-up study involving patients with prominently asymmetrical PD who had unilateral STN DBS suggested that simultaneous bilateral surgery should be performed. In the present study, the authors analyze 7-year follow-up data from the same patient group to examine changes in motor benefit from unilateral STN DBS over time and the interval between initial unilateral surgery and a second (contralateral) STN DBS surgery. Eight patients with highly asymmetrical parkinsonism who underwent unilateral STN DBS were evaluated. The factors measured were scores on the motor part of the Unified Parkinson's Disease Rating Scale (UPDRS III), Hoehn and Yahr (HY) stage, and levodopa equivalent daily dose (LEDD). Evaluations occurred at 3, 6, and 12 months after the initial surgery and annually thereafter. The mean follow-up period was 91.5 months (range 36-105 months). Three years after the initial unilateral surgery, motor benefits on the contralateral side continued; however, an aggravation of the ipsilateral parkinsonism attenuated the improvement in total UPDRS III scores, which reverted to baseline. Axial motor score, LEDD, and HY stage did not differ from the baseline. Seven of 8 patients (87.5%) were considered candidates for a second surgery to offer additional motor benefits. Of the 7 candidates, 4 patients (50% of total patients) underwent the second surgery at 58.5 ± 11.6 (mean ± SD) months after the initial surgery. Three patients were not able to have the second surgery: one patient died of gastric cancer, one patient was severely immobilized by an accident, and one patient could not afford the second surgery. One patient remained content with the initial unilateral surgery throughout the follow-up period. Seven of 8 patients with unilateral STN DBS became candidates for second surgery before battery replacement surgery of the first implanted device. Baseline asymmetry alone may not predict appropriate candidates for unilateral STN DBS. This study provides further evidence that, from a long-term perspective, initial simultaneous bilateral STN DBS should be considered for PD patients with prominently asymmetrical motor symptoms.