Standardized Surgical Protocol Research Articles

Associations among gene polymorphisms, crestal bone loss, and bone mineral density in patients receiving dental implants

ObjectivesInterleukin 1 (IL-1) and interleukin 6 (IL-6) gene polymorphisms have been suggested to be responsible for diminished bone mineral density (BMD) and high crestal bone loss (CBL) in some individuals. However, the effects of systemic BMD on variations in peri-implant CBL are unclear. Hence, this study was aimed at investigating the association of IL-1 and IL-6 gene polymorphisms with systemic BMD and CBL around dental implants. MethodsA total of 190 participants undergoing dental implantation in the mandibular posterior region were selected according to predetermined selection criteria and divided into a normal BMD group (NBD, 93 participants, T-score ≥ −1) and low BMD group (LBD, including both osteoporosis and osteopenia, 97 participants, T-score < −1 standard deviation) according to the BMD of the right femoral neck, measured with dual-energy X-ray absorptiometry. Dental implants were placed through the standard surgical protocol, and CBL was calculated after 6 months with cone beam computed tomography scans before second-stage surgery. Genotyping was performed on all participants for IL-1A-889 A/G, IL-1B-511G/A, IL-1B+3954, and IL-6-572 C/G gene polymorphisms. ResultsThe demographic and clinical characteristics of the participants in both groups were compared with t-test and chi-square test (χ2). The associations of NBD and LBD with the different genotypes and CBL was determined with odds ratios, and p < 0.05 was considered statistically significant. The frequency of IL-1B-511AA and IL-6-572 GG genotypes was significantly higher in LBD than in NBD (p < 0.05). In LBD, the IL-1B-511 AA (AA vs GA + GG; p ≤ 0.001) and IL-6-572 GG (GG vs CC + GC; p = 0.001) genotypes were significantly associated with higher peri-implant CBL. ConclusionsIndividuals with the IL-1B-511 AA or IL-6-572 GG genotype had elevated risk of osteoporosis/osteopenia and were more susceptible to CBL around dental implants.

Fitostimoline® in fibro-endoscopic and trans-nasal trans-speculum septoplasty as a beneficial tool to improve post-surgical outcome: Preliminary results of a case-control study

ObjectivesTopic treatment can be useful to improve short and long-term nasal outcomes after nasal surgery, reducing discomfort and risk of synechia. This study aimed at evaluating the effect on clinical outcomes of nasal packaging using Fitostimoline® gauze in FESS and septoplasty. MethodsA case-control study on hospitalized patients was performed in a tertiary referral center. The control group included 20 patients treated with the standard surgical protocol for septoplasty and standard nasal packaging; treatment group included 21 patients underwent same surgical procedure but in whom the nasal tampon was wrapped with a gauze containing Fitostimoline® before being placed into the nose. ResultsPatients in treatment group had better outcomes than control; nasal mucosa showed better healing - recovery of normal color- in those patients in whom we applied the Fitostimoline® gauze around tampons. Moreover, 100 % patients in the treatment group did not refer discomfort during at tampon removal versus 60 % subjects in the control group who referred pain, tension or tearing during the same action. ConclusionOur results, although preliminary because of the small cohort of subjects included, suggest that the apposition of a gauze with Fitostimoline® after nasal surgery might improve the mucosal healing with consequent reduction of patients discomfort during the post-surgical period.

Frequency and Risk Factors of Surgical Site Infection with and without Antibiotic Prophylaxis in Adults Undergoing Minor Trauma Surgery

Background: Trauma surgeons are more likely to experience surgical site infections (SSI). Preoperative antibiotic prophylaxis was a common strategy in trauma procedures. This research aimed to determine the frequency and risk factors of surgical site infection with and without antibiotic prophylaxis in adults undergoing minor trauma surgery. Methods: A descriptive cross-sectional investigation was carried out. The surgical emergency and trauma units at Jinnah Hospital and THQ Hospital DGK provided the data for this investigation. Data from 190 patients were gathered and divided into two groups. Before surgery (Group A) took antibiotic prophylaxis while Group B did not. Standard surgical protocols were followed during the surgical operation. Patients were checked for postoperative fever, surgical site infection, and discharge at the incision site. On the third, seventh, and twelfth postoperative days, the wound was checked. The chi-square test was used for analysis and P&lt;0.05 was considered significant. Results: Surgical site infections (SSI) occurred in 18 patients out of 190 patients, with 6 (6.3%) patients from group A and 12 (12.6%) from group B. Two (2.1%) of the patients in Group A who developed SSI were female, whereas no female patients in Group B experienced it. Contaminated wounds, diabetes, and improper surgical site cleaning were the three main risk factors for SSI in minor trauma cases. Conclusion: The study found that the use of prophylactic antibiotics in minor trauma cases performed in adult patients significantly decreases the incidence of SSI.

Operative Time Predicts Long-Term Abdominal Morbidity and Complication Requiring Treatment after DIEP Flap Breast Reconstruction.

The relationship between skin-to-skin operative time and long-term complications, as well as complications requiring treatment, after deep inferior epigastric perforator (DIEP) flap breast reconstructions has not been thoroughly investigated. The study objective was to evaluate if operative time would independently prognosticate the type and number of treated complications, as well as long-term abdominal morbidity. Patients who underwent bilateral DIEP flaps from 2010 to 2021 by two senior surgeons with standardized surgical and postoperative protocols were retrospectively reviewed. Inclusion required at least 1 year of postoperative follow-up. Extensive multivariable regression analyses were utilized to adjust for potential confounders, including measures of intraoperative complexity. Three hundred thirty-five patients were entered into multivariable analyses. After risk adjustment, there was a significant increase in the risk of all treated complications per hour. Each hour of operation increased risk of complications requiring extended hospital stay for treatment by 25%, flap-site complications requiring readmission treatment by 24%, and flap-site complications requiring extended hospital stay for treatment by 26% (all p < 0.0001). Long-term abdominal morbidity (abdominal bulge) increased by 25% per hour of operative time (p < 0.0001). The number of complications requiring treatment, abdominal donor-site complications, and complications requiring extended hospital stay for treatment had statistically significant linear relationships with the duration of surgery (all p < 0.05). Operative time predicts long-term abdominal morbidity and complications requiring treatment, especially impacting the odds of developing abdominal bulges and complications requiring extended hospital stay for treatment or readmission treatment. This study emphasizes the importance of reducing operative time to improve DIEP flap breast reconstruction outcomes.

The Unfortunate Triad of the Elbow: About 5 Cases and Review of the Literature

The unfortunate elbow triad is a severe trauma involving posterior elbow dislocation, fracture of the radial head and coronoid process. Its management is not codified in the literature. We report a retrospective series of 5 patients treated at the Traumato-Orthopedics department of the CHU Ibn Sina in Rabat, over a period of 7 months from May 2021 to December 2021, the objective being to carry out a diagnostic and therapeutic analysis. Both patients had a stable but nevertheless very painful elbow. The unfortunate elbow triad leads to bone and ligament damage threatening short- and long-term elbow stability, with a high rate of complications and random outcomes. Only the restoration of the integrity of the elbow by repairing all the structures, using a standardized surgical protocol allows good functional results.

Outcome following elective unilateral arytenoid lateralization performed in an outpatient manner is comparable to hospitalization for dogs with laryngeal paralysis.

To compare outcomes and short-term complications of dogs with laryngeal paralysis treated with unilateral arytenoid lateralization performed on an outpatient versus inpatient basis. 44 client-owned dogs. Medical records were retrospectively reviewed to identify dogs that underwent unilateral arytenoid lateralization for the treatment of laryngeal paralysis between 2018 and 2022. Signalment, surgical technique, anesthesia time, comorbidities, laryngeal examination, concurrent procedures, use of prokinetics and sedatives, episodes of vomiting, episodes of regurgitation, duration of hospitalization, postoperative complications, anxiety scores, and pain scores were recorded. Variables were compared between dogs and grouped by outpatient or inpatient management. The overall complication rate was 22.7% (10/44), with 35% (7/20) being in the inpatient group and 12.5% (3/24) being in the outpatient group. The overall mortality rate was 6.8% (3/44). The overall morbidity for hospitalized patients versus those undergoing and outpatient procedure was 5% (1/20) and 4.2% (1/24), respectively. There was no significant difference between overall rate of complications and mortality rates between the inpatient and outpatient groups. Results suggested that outpatient management of dogs with laryngeal paralysis treated with elective unilateral arytenoid lateralization is an appropriate method of postoperative management with no difference in complication or mortality rates. Further prospective studies with standardized surgical, sedative, and antiemetic protocols are warranted to evaluate more definitely.

Comparison of Long-Term Outcomes of DSEK and DMEK in Fuchs Endothelial Dystrophy.

This study aimed to compare the long-term endothelial cell loss, graft survival, and clinical outcomes in patients with Fuchs endothelial dystrophy (FED) after Descemet stripping endothelial keratoplasty (DSEK) and Descemet membrane endothelial keratoplasty (DMEK) using a standardized surgical protocol. Three hundred and six consecutive DSEK and DMEK grafts of 223 patients with FED performed by 8 surgeons between January 2006 and August 2022 were analyzed. The primary outcome measures were graft survival, endothelial cell loss, and best spectacle-corrected visual acuity. At 5 years, graft survival was 96% for both DSEK and DMEK eyes. The mean percentage of endothelial cell loss was 57.7 ± 17.1 in DSEK and 56.8 ± 15.2 in DMEK eyes ( P = 0.430). The mean best spectacle-corrected visual acuity was 0.13 ± 0.14 logMAR in DSEK and 0.01 ± 0.18 logMAR in DMEK grafts ( P <0.00001) at 5 years postoperatively. Rebubbling was performed in 7.8% DSEK and 2.1% DMEK grafts ( P = 0.441). Cox regression identified rejection episodes (HR 6.5; 95% CI: 1.70-24.8; P = 0.0062) as a significant contributing factor for graft failure. DMEK had superior visual acuity outcomes compared with DSEK in these patients up to 5 years after surgery. At 5 years, there was no significant difference in graft survival or endothelial cell loss between DSEK and DMEK eyes with FED. We propose that our standardized technique reduces the need for rebubbling.

Blended Suture-bridge Technique for Arthroscopic Rotator Cuff Repair

Techniques in rotator cuff repair are constantly evolving, with the main goal of a biologic, stable, and tension-free construct. Significant controversy exists between various methods, and there is no gold standard surgical protocol. We demonstrate an alternative arthroscopic rotator cuff repair technique with 2 key components. First, we performed a transosseous equivalent, suture bridge technique with a combination of triple-loaded medial anchors and knotless lateral anchors. Second, we incorporated 2-strand and 3-strand suture shuttling through the torn rotator cuff and selective medial knot-tying. A total of 6 passes through the tendon are made, comprising 1-2-3-3-2-1 strands each pass. This minimizes the number of passes through the tendon and the overall number of medial knots. Our technique retains the known biomechanical advantages akin to a double-row repair, including less gap formation and wider footprint coverage. In addition, using fewer medial knots with efficient suture passing may result to decreased cuff strangulation and favorable biologic environment for tendon healing. We theorize that this technique may yield lower retear rates while maintaining immediate stability, translating to improved clinical results.

Operative Time Is an Independent Predictor of Postoperative Outcomes in Bilateral DIEP Flap Breast Reconstruction: A Multivariate Analysis of 1000 Flaps

Introduction: Skin-to-skin operative time (OT) as a risk factor for adverse postoperative outcomes in microvascular breast reconstruction has not been thoroughly investigated. This study evaluates OT’s impact on length of stay (LOS), overall morbidity, individual complications, and unplanned reoperation (UR) in Deep Inferior Epigastric Artery Perforator (DIEP) flaps, with a primary objective of identifying a clinically relevant time of decreased odds. Materials and Methods: Patients who underwent bilateral DIEP flaps from 2010-2021 by two senior surgeons with standardized surgical and postoperative protocols were retrospectively reviewed. 1000 flaps (500 patients) were analyzed with extensive multivariate regression equations to adjust for potential confounders, including intraoperative complexity. The odds of postoperative complication, extended LOS (eLOS, defined as ≥5 days) were compared across OT per hour and OT intervals. Results: After risk-adjustment, each hour of OT increased morbidity by 19%, UR by 8.7%, and LOS by 6.5 hours (all p<0.001). For eLOS, procedures ≤5 hours had 9.5 times lower odds than ≥5 hours (p=0.050), 5-7 hours had comparable odds (p=0.540), and 7-9 hours had 5.5 times lower odds than procedures ≥ 9 hours (p<0.001). Lastly, a multivariate linear regression showed that LOS can be calculated from OT: LOS (days) =1.527 + 0.272 x OT (hours) (R2=0.308; p<0.001). Conclusion: Operative time (per hour) independently predicts morbidity, UR and LOS in DIEP flaps. Furthermore, 5 hours and 9 hours are critical cutoffs for eLOS. These findings emphasize the benefits of decreasing OT through efficiency models, such as process analysis, team-based intraoperative protocols, and co-surgery model.

A Standardized Operative Protocol for Fixation of Proximal Humeral Fractures Using a Locking Plate to Minimize Surgery-Related Complications.

The current literature suggests that up to 55% of complications after plate osteosynthesis treatment for patients with proximal humerus fractures are attributed to the surgical procedure. The hypothesis of this study was that a standardized surgical protocol would minimize surgery-related adverse events. This prospective cohort study included 50 patients with a mean age of 63.2 (range 28-92) years treated by one single surgeon using a previously published standardized surgical protocol. Clinical and radiological follow-up examinations were conducted for up to 24 months using Constant-Murley Score (CS), Subjective Shoulder Value (SSV) and radiographs in true anteroposterior, axial and y-view. Finally, CS was 73.9 (standard deviation [SD]: 14.0) points (89% compared to the uninjured shoulder), and SSV was 83.3% (SD: 16.7) at two years of follow-up. Postoperative radiologic evaluation revealed no primary surgical-related or soft-tissue-related complications (0%). The main complications were secondary, biological complications (20%), largely represented by avascular necrosis (8%). Eight patients underwent revision surgery, mainly for implant removal. In addition, a total of four patients were revised using a hemiarthroplasty (n = 2), reverse shoulder arthroplasty (n = 1) or re-osteosynthesis. The use of our standardized surgical technique on proximal humerus fractures improves fixation with regard to primary stability and prevents primary, surgical-technique-related complications. The subjective grading of a high level of difficulty surgery was associated with more complications.

Surgical Treatment of Monteggia-Like Lesions With a Modified Boyd Approach.

Monteggia-like lesions are rare injuries in adults that include a wide spectrum of complex fracture-dislocations of the proximal ulna and radius. In this retrospective study, we performed a modified Boyd approach and a standard surgical protocol for the treatment of these lesions. Our aim was to evaluate the results of the operative treatment for patients with Monteggia-like lesions, using a modified Boyd approach. We present a retrospective study of 14 patients who underwent surgical treatment for Monteggia-like lesions. Preoperative clinical and radiological evaluation was performed. In 5 cases radial head prosthesis was placed, and in 3 cases the radial fracture was stabilized with the use of interfragmental screws. Regarding the proximal ulnar fracture, ORIF-anatomical plate and ORIF-straight plate was used in 12 and 2 cases, respectively. Average clinical follow up was 16.9 months. Postoperatively, the mean Mayo Elbow Performance score was 83.4 points (range 70-100) and the mean visual analog scale was 1.7 (range 0-14). Mean flexion and loss of extension were 122.1° (range 80°-140°) and 21.4° (range 5°-40°), respectively. Mean supination of the forearm was 66.8° (range 50°-80°) and the mean pronation was 67.5° (range 60°-75°). Heterotopic ossification was observed in 3 patients (21.4%) and 1 patient developed stiffness (7.1%). The patient who developed stiffness underwent reoperation for plate removal and arthrolysis, with satisfactory results. The surgical treatment of Monteggia-like lesions in adults remains a challenge. In the present study, the use of a standard surgical protocol, with a modified Boyd approach, successfully restores the movement and stability of the elbow, with a low complication rate.

COMPLICATIONS AFTER PENIS ENHANCEMENT WITH HYALURONIC ACID: A LITERATURE REVIEW

Introduction. The penis is a symbol of the primal sense of male fertility and sexual activity, which affects the sense of male personality and the ability to satisfy a partner. Some patients experience discomfort, even if their penis is within the normal size range from an anatomical point of view. The reason for the spread of penis enlargement procedures is related to the feeling of masculinity that the appearance of the genitals can give a man, as well as a changed perception of his body. Penis enlargement procedures are becoming more and more common among men who seek to achieve a more desirable aesthetic of their male organ. In addition, penis enlargement methods remain a controversial issue, as they do not have clear indications and can cause complications. Materials and methods. This study reviewed the literature on complications after penile enhancement with hyaluronic acid (HA). To achieve this goal, we conducted a systematic search for scientific medical information in English-language databases such as MEDLINE, Embase, AMED (Allied and Complementary Medicine), and HMIC (Health Management Information Consortium). We analyzed all articles that met the specified search parameters. In addition, we manually searched for relevant references in the found texts. Results. The use of HA injections for penis enlargement in men shows a low rate of complications both in the early- and long-term period after the procedure. In a small percentage of patients, early and expected side effects included swelling, bruising, subcutaneous nodules, and infections. In this work, radical ways of their correction are proposed for all types of complications, which makes the use of HA safe and effective for penis enlargement. Conclusions. Nowadays, there is a lack of high-level evidence-based information on complications after HA injections. Due to the growing demand for these procedures, the issue of their safety is relevant. According to the available statistics, the overall incidence of complications after HA injections is spontaneous without further side effects. If complications are detected, the prognosis after treatment is satisfactory. As a result, there are no standardized surgical protocols and recommendations for penile enhancement with hyaluronic acid in the world.

Operative Time Predicts Postoperative Outcomes in Bilateral DIEP Flap Reconstruction: Multivariate 1000 Flap Analysis.

Patients who underwent bilateral DIEP flaps from 2010 to 2021 by two senior surgeons (N.T.H. and S.S.T.) with standardized surgical and postoperative protocols were retrospectively reviewed. One thousand flaps (500 patients) were analyzed with extensive multivariate regression equations to adjust for potential confounders, including intraoperative complexity. The odds of postoperative complication, extended LOS (eLOS, defined as ≥5 days) were compared across OT per hour and OT intervals. After risk-adjustment, each hour of OT increased morbidity by 19%, UR by 8.7%, and LOS by 6.5 hours (all P < 0.001). For eLOS, procedures ≤5 hours had 9.5 times lower odds than ≥5 hours (P = 0.050), 5-7 hours had comparable odds (P = 0.540), and 7-9 hours had 5.5 times lower odds than procedures ≥ 9 hours (P < 0.001). Last, a multivariate linear regression showed that LOS can be calculated from OT: LOS (days) =1.527 + 0.272 × OT (hours) (R2 = 0.308; P < 0.001). OT (per hour) independently predicts morbidity, UR and LOS in DIEP flaps. Furthermore, 5 and 9 hours are critical cutoffs for eLOS. These findings emphasize the benefits of decreasing OT through efficiency models, such as process analysis, team-based intraoperative protocols, and co-surgery model.

25-year Follow-up of Primary Tibial Periosteal Graft for Hard Palate Repair in Cleft Lip and Palate: Outcomes, Concerns and Controversies.

This study evaluates long-term outcomes in adults with Unilateral and Bilateral Cleft Lip and Palate (UCLP/BCLP) treated during the period 1992 to 1995 with tibial periosteal graft in primary repair. Retrospective study. Department of Plastic and Maxillofacial Surgery, Children's Hospital Bambino Gesù (Italy). The study included 52 patients with non-syndromic BCLP/UCLP who met the inclusion criteria. All patients underwent a standardized surgical protocol using a tibial periosteal graft as primary repair of the hard palate. Long-term outcomes on maxillary growth, residual oronasal fistula, and leg length discrepancy. About <2% of patients showed oral-nasal communication. Mean value of maxillary depth was 86° ± 4.5°. The lower value for maxillary retrusion was 76.8° in relation to the Frankfurt plane. At the x-ray control, 12.2% of patients showed leg discrepancy with a difference of always <2 cm. The rate of maxillary retrusion obtained was the same if compared to other techniques. Tibial periosteal graft reduces the risk of fistula and the need for reintervention after secondary bone graft. The study did not observe negative impacts on leg growth after 25 years.

EP-379 Day-case laparoscopic Nissen fundoplication. Experience from a tertiary center

Abstract Aim For day-case laparoscopic surgery to be successful, patient selection is of the utmost importance. This study aimed to assess the acceptability, feasibility, and results of day-case laparoscopic fundoplication for gastro-esophageal reflux disease (GERD) in a university tertiary care center. Methods A Day-case surgery for GERD was proposed routinely to all patients with proven asymptomatic, uncomplicated GERD. All of them were fulfilling predetermined inclusion criteria from January 2020 and December 2021. All patients underwent standard anesthetic, surgical, analgesic, and antiemetic protocols. Patient age, social circumstances, and other demographics were also recorded as well as any comorbidities and ASA score. The primary endpoint measured was the rate of readmission and complication rates. Results Of 23 patients undergoing laparoscopic fundoplication for GERD during the study period, 16 (69.56%) had day-case procedures. Most of them (81.6%) were discharged 6 to 8h after operation. Five patients were converted to in-patient hospitalization because of nausea (n=1), inadequate pain control (n=3), or anxiety (n=1). There were no complications and no re-admissions recorded. Conclusion Day-case laparoscopic Nissen fundoplication is a feasible, effective, and safe option for treating selected patients with gastroesophageal reflux disease (GERD) subject to careful patient selection and surgeon expertise.

Pharmacognosy and Phytochemistry of Tinospora cordifolia

Guduchi is a Sanskrit word that meaning "protector of the body." It's also known as amrta or nectar, and it's incredibly beneficial for boosting the body's immune system and balancing the activities of its numerous organs. As a result, attempts have been made in the current research activity to give a comprehensive study on Guduchi Satva, with its authentication and validation carried out in a variety of ways. Tinospora cordifolia Genuine and market samples were examined for pharmacognostic characterization, phytochemical screening, and antibacterial testing during standardization. According to studies, the market sample was tainted and could not be used as a safe and effective medicine. This identification was utilized to create multiple markers for guduchi satva standardization. These features can also be employed as key identifiers in Ayurvedic pharmacopoeia. As a result, these indicators may be employed scientifically to detect adulteration and maintain medicine purity. In this study, a single Guduchi formulation, Guduchi Satva, is prepared using three different sizes (diameters) of Guduchi stems in three different batches in order to determine the ideal size of Guduchi stem that should be used to obtain the highest yield. Throughout the investigation, standard surgical protocols are followed.

Evaluation of Immediately Loaded Parallel Conical Connection Implants with Platform Switch in the Maxillary Esthetic Zone: A Prospective Clinical Study

To assess immediately loaded parallel conical connection (Nobel Biocare) implants with platform switch design in the maxillary esthetic zone for soft and hard tissue changes. A total of 20 patients (n = 20) underwent prosthetic replacement of the missing maxillary anterior tooth, with an immediately loaded parallel conical connection implant (Noble Biocare, Sweden) having a platform switch design. The size of the implant was 3.75 mm in width and 13 mm in length for all patients and placement followed a standardized surgical protocol. Postoperatively, acrylic provisionalization was done within 48 hours followed by a definitive zirconia prosthesis in the 3rd month. Clinically and radiographically, the implants were evaluated for hard tissue (bone density, implant stability, crestal bone loss) and soft tissue changes (mucosal thickness-MT, sulcus probing depth-PD, bleeding on probing-BOP, width of keratinized gingiva-KG) at baseline till 36 months with follow-up intervals after loading. All patients showed uneventful healing. The difference in implant stability and density scores was significant (p <0.05*) from baseline to 36 months indicating bone formation and osseointegration of the implant. Bleeding on probing was not observed, and probing depth remained within the acceptable range (≤5 mm) at all time intervals after loading. The marginal bone loss was minimal (≤0.2 mm annually) with the absence of implant mobility and without any peri-implant radiolucency. The thickness of the gingiva (3.47 ± 0.34 mm) and width of keratinized gingiva (2.46 ± 0.39 mm) remained within reasonable limits at the 36th month with acceptable esthetic appearance. In the present study, immediate loading of Nobel parallel conical connection implant in the maxillary anterior region provided adequate primary stability, minimal marginal bone loss, and increased bone density indicating earlier osseointegration. Decreased probing depth, absence of bleeding on probing, and adequate tissue collar at the neck showed better soft tissue emergence in the esthetic zone. The platform switch design demonstrated promising results and therefore can be used as an alternative to the conventional method. The present study results suggest that parallel conical connection implants (Nobel Biocare) with TiUnite surface, built-in platform switch combined with conical connection interface, parallel walled body, tapered apex, and double threads from tip to platform are all designed to provide high primary stability and support immediate function protocol, hence can be used flexibly in different bone densities.

120. Operative Time is an Independent Predictor of Postoperative Outcomes in Bilateral DIEP Flap Breast Reconstruction: A Multivariate Analysis of 1000 Flaps

Purpose: The deep inferior epigastric perforator (DIEP) flap is the gold standard autologous breast reconstruction, with a rapid increase in regularity in recent years. Operative time (OT) as a risk factor for adverse postoperative outcomes in microvascular breast reconstruction has not been thoroughly investigated. This study evaluates the impact of OT on length of stay (LOS), overall morbidity, individual complications, and unplanned reoperation (UR) in DIEP flaps, with a primary objective of identifying a clinically relevant time of decreased risk. Methods: Patients treated with bilateral DIEP flaps from 2010-2021 by two senior surgeons (NTH, SST) with standardized surgical and postoperative protocols were retrospectively reviewed. 1000 flaps (500 patients) were analyzed with multivariate regressions to adjust for potential confounders, including microsurgeon experience, and isolate the impact of OT on postoperative outcomes. We rounded the 25%ile, 50%ile, and 75%ile of OT quartiles (I.e. 4.92, 6.60, and 8.87 hours) to the nearest hour (I.e. 5, 7, and 9 hours) for ease of use as an easy-to-follow guideline for OT intervals. To identify a cutoff, beyond which risk for postoperative complications, extended LOS (eLOS, defined as ≥5 days), and UR significantly increases, adverse outcomes were compared amongst OT intervals. Results: The occurrence of all adverse outcomes with more than one incidence was associated with longer operative times. Procedures with and without complications had an average of 8.05±3.29 and 6.33±2.51 hours (p<0.001) respectively. With risk-adjustment, each hour of OT increased morbidity by 22% (p<0.001) and LOS by 4.8 hours. Procedures >5 hours had 3.9, 4.8, and 2.6-fold increased risk of UR (p=0.029), eLOS (p=0.007), and overall complications, respectively. Breast fat necrosis, abdominal donor-site morbidity, and medical complications also had significantly higher risk after 5 hours. Lastly, a risk-adjusted linear regression showed that LOS can be calculated from OT: LOS (days) =1.702 + 0.201 x OT (hours) (p<0.001, R2=0.369). Conclusions: For the first time, operative time is shown as an independent predictor of morbidity, LOS, and UR in DIEP flaps, with significantly greater risk >5 hours. The findings emphasize the importance of decreasing OT through efficiency models, such as process analysis, team-based protocols, and co-surgery.

Arthroscopic Synovectomy of the Hip Joint: The Regional Surgical Technique

Synovial disease is a common reason for hip joint dysfunction. Although traditionally treated with open synovectomy, with the popularization and development of arthroscopic techniques, arthroscopic synovectomy has become the main surgical treatment for synovial diseases. Given the long soft tissue channel and learning curve, arthroscopic synovectomy of the hip joint has high surgical requirements for surgeons. However, there is currently no standardized surgical protocol for arthroscopic synovectomy of the hip joint to guide the surgeon to perform hip synovectomy in an orderly manner. During the past 3 years, we have employed a novel technique, wherein we divided the synovium of the hip into seven regions based on the anatomical structure and the operating range of the arthroscopic portals. With the assistance of flexion, extension, and traction of the hip joint, synovectomy was sequentially performed under arthroscopic guidance. This regional surgical technique can be popularized and likely has the potential to become a standardized arthroscopic synovectomy protocol of the hip joint.

Incidence and risk factors associated to Medication-Related Osteo Necrosis of the Jaw (MRONJ) in patients with osteoporosis after tooth extractions. A 12-months observational cohort study

ObjectiveTo evaluate the 12-months incidence of MRONJ after tooth extractions and possible related risk factors in patients with osteoporosis treated by means of oral bisphosphonates. Material and methodsForty-five records of osteoporotic patients on therapy with oral bisphosphonates and treated with at least one dental extraction at the Department of Oral Surgery of University of Naples Federico II were selected. All patients were treated using a standardized surgical extraction protocol. At baseline and after 12-months follow-up, the following variables were recorded: “mucosal healing”, “gender”, “type of drug”; “duration of therapy”; “drug holiday”. The collected data were analyzed and a linear regression analysis was performed to assess a possible correlation with onset MRONJ. ResultsA total of 159 tooth extraction in 43 females (95.6%) and in 2 males (4.4%) with a mean age of 67.5 ± 3 years were available for the analysis. The majority part of patients was on therapy with alendronate (23; 51.2%), 11 patients (24.4%) were treated with risedronate and 11 (24.4%) with ibandronate. Before oral surgery, 84% of the patients showed a low-medium risk of MRONJ, while in 16% of the patients a medium-high risk was recorded. After 12-months follow-up, osteonecrosis was observed in 1 patient, with an overall incidence of MRONJ of 0.6%. The linear regression showed a significant correlation with MRONJ onset only for “gender” variable, with a R2 of 0.489. ConclusionsWithin their limitations, the outcomes of the study indicate that the risk of MRONJ after tooth extraction in osteoporotic patients taking bisphosphonates for OS is very low. A prolonged and specific antibiotic and antiseptic therapy, in addition to a surgical procedure as little traumatic as possible, will allow to perform oral surgery safely.