Surgeon's Choice Research Articles

Engineering standards for trauma and orthopaedic implants worldwide: a systematic review protocol

IntroductionDespite multiple scandals in the medical implant sector, premarket testing has been the attention of little published research. Complications related to new devices, such as the DePuy Articular Surface Replacement...

Mitral valve repair versus replacement for patients with preserved left ventricular function without heart failure symptoms

ObjectiveThe purposes of this study are to compare outcomes of mitral valve repair (MV-repair) and mitral valve replacement for patients with severe mitral regurgitation with preserved ventricular function and no congestive heart failure (CHF) symptoms and to examine variations in surgeon choice of procedure and outcomes by surgeon volume. MethodsIn total, 2259 consecutive patients in 42 New York State hospitals with the characteristics mentioned previously who underwent mitral valve repair (1801, 79.7%) or replacement between January 1, 2008, and December 31, 2014, were identified from a mandatory statewide clinical registry. Propensity-matching was used to compare mortality and competing risk analyses were used to compare nonfatal outcomes. Median follow-up was 4.0 years. The use of mitral repair and risk-adjusted mortality for surgery were also examined as a function of individual surgeon mitral case volume. ResultsPropensity-matched patients who underwent MV-repair experienced a significantly lower mortality rate at 4 years (3.5% vs 12.1%, P < .001). Greater-volume surgeons were more likely to perform MV-repairs (92% vs 84%, 74%, and 69% in lower volume quartiles, respectively). No significant differences in mortality were observed among volume quartiles. ConclusionsPatients with chronic severe primary mitral valve regurgitation with preserved ventricular function and no CHF symptoms who underwent MV-repair experienced lower mortality and no different reoperation, CHF, or stroke readmission rates than patients who underwent replacement. Greater-volume surgeons were more likely than their lower volume counterparts to choose mitral repair. Repair should be considered as the surgical option for these patients whenever possible.

Harmonic Scalpel over Electrocautery, Evaluation of Peroperative Blood Loss in Selective Neck Dissection: A Comparative Study

Introduction: The use of Harmonic Scalpel (HS) over Electrocautery (EC) in neck dissection has become standard of care in recent years. However, both the devices are presently widely used in practice and still serve large number of patients globally according to surgeon's choice and cost effectiveness.Objective: To evaluate the amount of peroperative blood loss in cancer patient undergoing selective neck dissection (Levels I, II and III) with Harmonic Scalpel (HS) and Electrocautery (EC).Methodology: The study was performed in the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Biratnagar Hospital PVT LTD and Birat Medical College and Teaching Hospital, Nepal from June 2012 to February 2018. A total of 40 patients, 27 male and 13 female, aged 45 to 70 years diagnosed with oral cavity cancer were included in this prospective study. Two groups were formed, 20 patients in each group based on the surgical instrument used; Harmonic Scalpel (HS) and Electrocautery (EC). Data for age and sex of the patients were collected preoperatively. The surgery was performed under general anesthesia with endotracheal intubation and standard protocol was maintained during surgery. Amount of peroperative blood loss was measured and recorded. Data was processed and analyzed using SPSS and was compiled and test of significance was done using unpaired't' test.Results: The amount of peroperative blood loss was significantly lower in Harmonic Scalpel (HS) group then in Electrocautery (EC) group.Conclusion: Results from this study suggests that the Harmonic Scalpel (HS) is an effective device to reduce peroperative blood loss during selective neck dissection. BJHS 2018;3(2)6: 475-479

Hundred years development and future prospect of the material science for hernia

Inguinal hernia is a defect disease in the abdominal wall. Surgeons have tried various ways to repair the defect for more than 100 years. The traditional herniorrhaphy destroys the normal anatomical structure, and the recurrence rate is quite high. After that, surgeons began to repair the defects with prostheses, from the initial use of rough metal materials such as silver, tantalum, stainless steel, to nylon, fiberglass, silicone rubber and other non-metallic materials, and also from artificial synthetic polymer non-absorbable materials such as polypropylene, polyester, ePTFE, to synthetic absorbable materials such as polyglycolic acid and the acellular extracellular matrix derived from biological meshes. However, these prostheses still can not meet the diverse needs of patients. Thus, multifunctional composite prostheses consisting of two or more materials were born, and various types of composite prostheses, stem cell coating meshes, 3D meshes, microstructure meshes were developed. The repair method evolved from traditional hernia repair to tension-free hernia repair and laparoscopic hernia repair. Surgeons are dedicated to finding idealized meshes for the perfect repair of defects, while considering postoperative complications, patient's quality of life, long-term efficacy and other issues. In the face of a wide variety of repair materials, the choice of surgeons is blind, and there is no standard to determine which prostheses are suitable for patients. Therefore, we have combed the development of different types of prostheses, summarized the development process of hernia repair materials for the past 100 years, and put forward the prospects for future development of prostheses, in order to provide reference for the selection of prostheses.

Total Laparoscopic Hysterectomy versus Total Abdominal Hysterectomy in Uterine Tumors

Background: laparoscopic hysterectomy (LH) rates have increased but abdominal hysterectomy (AH) still high and often the first choice for many surgeons even with most of studies reported that the minimal access method offers significant patient benefit over open surgery. Aim of the Work: we aimed to compare the outcome of total laparoscopic hysterectomy as regard the result and safety compared to total open abdominal hysterectomy in cases of uterine tumors. Patients and Methods: this prospective randomized controlled study performed on 25 patients who underwent LH (group 1) compared to 25 patients who underwent AH (group 2). The mean age of the cases, body mass index (BMI), duration of operation, estimated blood loss (EBL), rate of complications, post-operative hospital stay and convalescence time were compared for two groups. Results: LH was associated with a significantly longer operating time (139.96±22.66 minutes vs. 106.54±21.8 minutes P 0.001). As regard intraoperative complications and estimated blood loss there was no difference in both groups. In LH group the pain score and analgesia requirements in post-operative period were significantly less with fewer requiring opioid analgesia. There was a highly significant difference between groups in postoperative wound infection which was higher in AH group. LH was also associated with a significantly shorter inpatient hospital stay (2.22 days vs. 5.52 days P= 0.022) and earlier returned to normal life (7.5 days vs. 20.6 days P<0.001). Conclusion: total laparoscopic hysterectomy is safe and feasible procedure in treatment of uterine tumors with accepted peri-operative morbidity and good improvement of quality of life post-operative.

Reducing the donor site morbidity in radial forearm free flaps by utilizing a narrow radial forearm free flap.

BackgroundThe radial forearm free flap (RFFF) has remained a leading choice of many plastic surgeons as a fasciocutaneous flap due to its versatility, pedicle length, and simple elevation technique. However, donor site morbidity has led many reconstructive surgeons to limit their use of the RFFF and to use other flaps instead. We propose that using a narrow RFFF (nRFFF) decreases the aesthetic and functional morbidity of the donor site.MethodsWe report our experiences with the nRFFF from April 2012 through May 2015 at the Department of Plastic, Reconstructive, and Hand Surgery at Liaquat National Hospital, Karachi. The donor defects were closed primarily. The Stony Brook Scar Evaluation Scale and comparison with the contralateral hand were used to assess aesthetic and functional outcomes, respectively.ResultsA total of 24 patients underwent nRFFF procedures during the study period. The donor arm showed excellent motor function in 22 cases (91.7%), and very good function in the remaining two cases (8.3%). The aesthetic outcomes were excellent in four patients (16.6%), very good in eight patients (33.3%), good in 10 patients (41.6%), and fair in two patients (8.3%) who developed a hypertrophic scar. All flaps were successful and there were no cases of partial or complete loss.ConclusionsFor small to medium-sized soft tissue defects, the nRFFF had acceptable outcomes due to its thinness, pliability, and major reduction in donor site aesthetic and functional morbidity.

Non-inferiority of open passive drains compared with closed suction drains in pancreatic surgery outcomes: A prospective observational study

BackgroundPolicies concerning the management of operatively placed drains after pancreatic surgery are still under debate. Open passive drains and closed-suction drains are both used currently in clinical practice worldwide, but there are no reliable data regarding potential differences in the postoperative outcomes associated with each drain type. The aim of the present study was to compare open passive drains and closed-suction drains with regard to postoperative contamination of the drainage fluid and overall morbidity and mortality. MethodsThis study was a prospective, observational analysis of 320 consecutive, standard, partial resections (pancreaticoduodenectomy and distal pancreatectomy at a single institution from April 2016 to April 2017. Either open passive drains (n = 189, 51%) or closed-suction drains (n = 131) were used according to the operating surgeon's choice. Postoperative outcomes, including samples of drainage fluid collected on postoperative day V and sent for microbiologic analysis, were registered. ResultsThe open passive drain and closed-suction drain cohorts did not differ in terms of their clinical features, use of neoadjuvant chemotherapy or preoperative biliary drainage, fistula risk zone, and type of operative procedure. The overall rate of postoperative day V drainage fluid contamination (27.5% vs. 20.6%, P = .1) was similar between the groups. The same results were obtained for each specific procedure. The postoperative outcomes, namely, overall 30-day morbidity, postoperative pancreatic fistula, intra-abdominal fluid collections, percutaneous drainage, wound infections, reintervention, mean duration of hospital stay, and mortality did not differ between the 2 groups. Qualitative microbiologic analysis revealed that after pancreaticoduodenectomy, 61.5% of the bacteria contaminating the drainage fluid were attributable to human gut flora, while after distal pancreatectomy, 84.8% of the bacteria belonged to skin and mucous flora (P < .01), however, the spectrum of bacterial contamination did not significantly differ between the open passive drain and closed-suction drain cohorts. ConclusionThe use of open passive drains and closed-suction drains for major pancreatic resection does not significantly impact the postoperative outcome. The spectrum of drain contamination depends on the specific operative procedure rather than on the type of drain used.

How do patients and surgeons decide on uterine preservation or hysterectomy in apical prolapse?

Increasingly, uterine preservation surgeries are being performed for treating apical prolapse. Several types of procedures and surgical approaches to correct apical prolapse have been described in the literature. Despite this, there remains inadequate information to provide evidence-based recommendations regarding the optimal treatment approach and materials to use, and trials are ongoing to identify the optimal techniques. In the future, our patients may be the strongest determining influence when it comes to choice of apical prolapse surgery, with factors such as autonomy, reproduction, intimacy and fear influencing their decision. It is our opinion that the two most powerful forces behind the choice of apical POP surgical technique are the woman's personal desire for uterine preservation or not and the surgeon's personal choice of procedure based on training received. Present management of apical prolapse involves understanding patient goals and acknowledging their treatment preferences and values.

Robotic-assisted Laparoscopic Repair of Scrotal Inguinal Hernias

Scrotal inguinal hernias represent a challenging surgical pathology. Although some advanced laparoscopists can repair these hernias through a minimally invasive approach, open repair is considered the technique of choice for most surgeons. The purpose of this study is to show our results of robotic-assisted laparoscopic repair of scrotal inguinal hernias. We reviewed the charts of 14 patients with inguinoscrotal hernias who underwent robotic-assisted transabdominal preperitoneal (TAPP) hernia repair. Mean follow-up was 7 months. The European Registry for Abdominal Wall Hernia Quality of Life score, a 90-point scale, was utilized to quantify patient reported outcomes. Robotic TAPP repair was successful in all 14 patients. Average case duration was 100 minutes (78 to 140 min) for unilateral hernias and 208 minutes (166 to 238 min) for bilateral hernias. Trainees were involved in 93% (13/14) of cases. There were no recurrences. Three patients developed postoperative seromas. The mean European Registry for Abdominal Wall Hernia Quality of Life score was 3.7 (0 to 10). Scrotal hernias can be safely repaired using robotic-assisted TAPP methods with low morbidity and favorable patient reported outcomes.

Robotic versus laparoscopic radical hysterectomy in early cervical cancer: A case matched control study

BackgroundThis study aims at evaluating the feasibility, surgical outcome and oncological results observed after robotic radical hysterectomy (RH) compared to laparoscopy for patients with early stage cervical cancer (ECC) patients. MethodsBetween January 2010 and October 2016, 210 patients underwent RH for treatment of ECC: 70 underwent robotic approach (Cases), and 140 underwent laparoscopic approach (Controls). ResultsThere was no statistically significant difference between the two approaches with regard to clinical patient characteristics and in terms of extent of RH and rate of pelvic and aortic lymphadenectomy. Operative time was significantly longer in the robotic versus laparoscopic group (median = 243 min, range 90–612 versus median = 210 min, range 80–660; p value = 0.008). Conversion to laparotomy was necessary in 4 patients (1.9%) in the whole series.No difference was found in terms of intraoperative and postoperative complications between the two groups. Overall, during the observation period, 34 (16.2%) patients experienced any grade postoperative complications, and 21 (10.0%) had >G2 complications.The 3-yr DFS was 88.0% versus 84.0% in robotic and laparoscopic group, respectively (p value = 0.866). Central and/or lateral pelvic disease represented the most common site of relapse. The 3-yr OS was 90.8% in patients underwent robotic RH versus 94.0% in patients underwent laparoscopic RH (p value = 0.924). ConclusionsThe present study shows the equivalence of robotic and laparoscopic approaches to radical surgery of ECC patients, in terms of perioperative and postoperative outcomes with equivalent survival figures, and thus the choice of approach can be tailored to the choice of patient and surgeon.

How do patients trade-off surgeon choice and waiting times for total joint replacement: a discrete choice experiment

Patients face significant waiting times for hip and knee total joint replacement (TJR) in publicly funded healthcare systems. We aimed to assess how surgeon selection and reputation affect patients' willingness to wait for TJR. We assessed patient preferences using a discrete choice experiment questionnaire with 12 choice scenarios administered to patients referred for TJR. Based on qualitative research, pre- and pilot-testing, we characterized each scenario by five attributes: surgeon reputation, surgeon selection, waiting time to surgeon visit (initial consultation), waiting time to surgery, and travel time to hospital. Preferences were assessed using hierarchical Bayes (HB) analysis and evaluated for goodness-of-fit. We conducted simulation analyses to understand how patients value surgeon reputation and surgeon selection in terms of willingness to wait for surgeon visit and surgery. Of 422 participants, 68% were referred for knee TJR. The most important attribute was surgeon reputation followed by waiting times, surgeon selection process and travel time. Patients appear willing to wait 10 months for a visit with an excellent reputation surgeon before switching to a good reputation surgeon. Patients in the highest pain category were willing to wait 7.3 months before accepting the next available surgeon, compared to 12 months for patients experiencing the least pain. Our findings confirm that patients value surgeon reputation in the context of wait times and surgeon selection. We suggest opportunities to reduce wait times by explicitly offering the next available surgeon to increase patient choice, and by reporting surgeon performance to reduce potential misinformation about reputation.

Arthroscopic Fixation of Tibial Eminence Fractures: A Biomechanical Comparative Study of Screw, Suture, and Suture Anchor

To compare biomechanical outcomes of 4 different arthroscopic techniques for fixation of tibial eminence fractures. Twenty-four skeletally mature, fresh-frozen cadaveric knees were divided into 4 comparison groups based on the fixation method: screw fixation (group A), traditional sutures fixation with 2 FiberWire sutures (group B), a modified suture technique with 2 FiberWire sutures that created neckwear knots to firmly trap the fracture fragment (group C), or suture anchors which was based on the suture bridge technique primarily used in the shoulder for repair of rotator cuff tears and greater tuberosity fractures (group D). A tibial eminence fracture was created in each knee for subsequent fixation. After fixation, each knee underwent cyclic loading of 100N to assess the displacement change after500 cycles of the fixation construct. Afterward, a single tensile failure test load was performed to assess the ultimate failure load, stiffness, and failure mode for each specimen. All specimens survived cyclic testing and were subsequently loaded to failure. Group C had the highest ultimate failure load (P < .05) and group D had the lowest displacement compared with the other 3 groups (P < .05). Different failure modes were found among the 4 groups. Suture fixation using the neckwear knots technique provides superior fixation with regard to higher ultimate failure load, and absorbable suture anchor fixation with the suture bridge technique provides less displacement under cyclic loading conditions. Both techniques exhibited superior biomechanical properties compared with traditional screw and suture fixation. The new techniques showed satisfactory biomechanical properties and provided more choice for surgeons in the treatment of tibial eminence fractures.

212 The Relationship Between Infection Severity, Microorganisms, and Surgical Intervention in Inflatable Penile Prosthesis Infections

Inflatable penile prosthesis (IPP) infection presents in many forms and results in myriad treatment choices for prosthetic urologic surgeons. We reviewed our multi-institution database of IPP infections to examine for patterns regarding organisms discovered at salvage or explant surgery and interventions deemed necessary by contributing surgeons based on severity of infection. This is a retrospective IRB-approved analysis of 213 patients at 25 institutions who underwent salvage procedure or device explant between 2001 and 2016. Patient data were compiled after extensive review of operative reports, nursing operative data, intraoperative wound cultures, perioperative antibiotics, inpatient notes, consult notes, and follow-up visits. Of 7 anaerobic infections, 5 devices underwent successful malleable implant salvage (71%). The other 2 devices were explanted. Only 1 of the patients had a previous implant surgery, the other six were primary implants. Of 62 Gram positive infections, 25 devices underwent successful malleable implant salvage (40%), 22 were explanted (35%), and 15 underwent classic Mulcahy salvage (24%). Forty-seven patients had previous implant surgery, the other 15 were primary implants. Of 14 fungal infections, 4 underwent malleable implant salvage (40%), 4 devices were explanted (40%), and 4 were salvaged in the classic Mulcahy technique (20%). Four patients had previous implant surgery, the other 10 were primary implants. Of 39 fungal infections, 10 underwent malleable implant salvage (26%), 16 devices were explanted (41%), and 13 were salvaged in the classic Mulcahy technique (33%). Twenty-four patients had previous implant surgery, the other 15 were primary implants. Three artificial urinary sphincters were implanted simultaneously with IPPs in this series and all 3 cases developed Gram negative infections.

Sutureless prosthesis for failed small Mitroflow valves: the Perceval-after-Mitroflow procedure.

Because of its favourable haemodynamic characteristics and easy implantability, Mitroflow aortic valve bioprosthesis has been the valve of choice for many surgeons in patients with small aortic annulus. Disappointingly, early structural valve deterioration and high transvalvular gradients have been reported mostly in older patients with small prostheses. Reimplanting a new stented prosthesis sutured in a narrow and damaged annulus is technically challenging and demanding mainly in high-risk patients. Valve-in-valve transcatheter aortic valve implantation has been proposed as a viable option; however, it presents significant limitations because of residual high transprosthetic pressure gradients and risk of coronary occlusion. We report a series of 8 patients, with medium-term follow-up, who underwent successful Perceval-S surgical sutureless aortic implant after the removal of a degenerated small Mitroflow valve. No early mortality occurred, but 1 patient died 4 months postoperatively due to gastrointestinal disease. No major complications occurred. Early and mid-term postoperative pressure gradients were low (mean gradients 13.1 ± 3.3 mmHg and 10.2 ± 3.8 mmHg, respectively). In operable patients with a degenerated Mitroflow valve, these favourable clinical and haemodynamic results suggest that the sutureless solution is a simple, valid and safer alternative to conventional redo valve replacement or to valve-in-valve transcatheter aortic valve implantation.

UNIFESP Info Plastica – An informative application covering the most frequently performed plastic surgeries worldwide

OBJECTIVES:The objective of this study was to develop a free smartphone application with reliable and useful information for the lay public on the most frequently performed plastic surgeries worldwide.METHODS:The five most frequently performed surgeries worldwide according to ISAPS (International Society of Aesthetic Plastic Surgery) were selected. Information from the websites of the American Society of Plastic Surgeons (ASPS), American Society for Aesthetic Plastic Surgery (ASAPS) and Brazilian Society of Plastic Surgery (SBCP) and from the Outpatient and Hospital Medicine Guide of the Plastic Surgery Division at the Federal University of São Paulo (UNIFESP) was used for content assembly. YouTube videos with patients’ postoperative testimonials were used for an improved understanding of their real concerns. Printed text was distributed to patients in Brazil’s Unified Health Service to improve comprehensibility. Content on each of the five surgeries was presented in the application with the following layout: What is the surgery?; Who are the candidates?; Preparations for surgery; Stages of surgery; Recovery after surgery; Complications; Choice of surgeon; Consultation; What is the cost? and Glossary. All material was delivered to an outsourced company to produce the application software.RESULTS:The result was the creation of an application with extensive content on the most frequently performed plastic surgeries.CONCLUSION:The UNIFESP Info Plastica application is an academically based, free and reliable source of information for the lay public interested in all aspects of the most frequently performed plastic surgeries worldwide.

Tubeless Pediatric Percutaneous Nephrolithotomy: Assessment of Feasibility and Safety.

Introduction:Tubeless pediatric percutaneous nephrolithotomy (TL-PCNL) is evolving and adult criteria are being safely applied to children. We examine the feasibility, safety, and outcomes of pediatric TL.Materials and Methods:A retrospective review of pediatric (≤18 years) PCNL patients at our institute was done. Patients eligible for TL but underwent tube (T) PCNL due to surgeon choice or protocol were compared with TL. Only children with 100% stone clearance were included, and those receiving nephrostomy for intraoperative complications were excluded from the study. Demographic, baseline, and stone characteristics were matched. Safety, outcome, and complications were assessed. Group T was classified into large bore (22F-LB) and small bore (16F-SB) based on nephrostomy size. Statistical analysis was done.Results:A total of 46 children were eligible - TL in 17 (37%) and T in 29 (63%). Among T, SB was performed in 6/29 (20.7%) and LB in 23/29 (79.3%). TL had fewer complications. Urinary leak developed in 2 (6.9%) patients in T. Eight (27.6%) patients in T and 3 (17.7%) patients in TL had supracostal access with complications similar to infracostal access. SB had significantly lesser and analgesic requirement than LB. SB and TL had similar LOH and analgesic requirement. Adult expanded criteria such as supracostal access, 2 punctures, prior renal surgery, and larger tract size were feasible.Conclusions:TL is safe, feasible, and less morbid alternative to T in uncomplicated pediatric nephrolithiasis. TL is feasible with supracostal access, 2 punctures, adult tract size (24F), and anomalous kidneys. SB nephrostomy is reasonable when tube is indicated.

Controversies in the management of ovarian tumours in prepubertal children — A BAPS and UK CCLG Surgeons Cancer Group National Survey

BackgroundNo clear treatment and follow-up protocols have been established for prepubertal patients with ovarian tumours. The lack of adequate prospective data in the literature includes all aspects of their management. A significant number of children with ovarian masses present out of hours as a surgical emergency and are initially managed by paediatric surgeons without special interest in surgical oncology. Clear guidance on the management of such tumours is therefore fundamental. We hypothesised that – owing to the lack of clear guidelines – the current approach to prepubertal ovarian tumours amongst paediatric surgeons is highly heterogenous. MethodsAn eleven-item multiple choice questionnaire was distributed amongst all BAPS consultant paediatric surgeons in the UK and simultaneously to all paediatric surgical oncology members of the UK Children's Cancer and Leukaemia Group in order to survey the management of ovarian masses in children. We aimed to compare the management approaches in both groups. Results63 consultants participated in the survey; 49% with a special interest in surgical oncology, 48% with different subspecialty interests. The majority of participants (56%) performed 1–5 operations on ovarian tumours per year. Preoperative imaging of choice for the oncology surgeons was US and MRI (77.3%) versus 41.4% in the group of surgeons with different special interests. Surgeons with different special interests were more likely to request Ca125 as a preoperative tumour marker (62.1% vs 32.3%). 19.3% of oncology surgeons, and 27.6% of surgeons with other special interest stated they would never remove an ovarian tumour via the laparoscopic approach. Follow-up practise was highly variable amongst survey participants in both surgeon groups regarding frequency, duration and further investigations during follow-up. Almost 50% of participants follow their patients up according to personal practice protocols. ConclusionThis first national survey on the management of prepubertal ovarian tumours demonstrates great heterogeneity in the current approach amongst UK paediatric surgeons. Better evidence is needed to formulate clear guidance for the management of such tumours. We propose instigation of a multicentre registry for ovarian tumours to generate prospective data and clarify guidance for the future. Level of evidence statementThis is a level II evidence study. In itself it is a retrospective study, with the literature review including one large, high-quality prospective cohort study, and further prospective cohort studies of ordinary quality.

Radiologic Parameters Can Affect the Preoperative Decision Making of Three-Column Spinal Osteotomies in the Treatment of Severe and Stiff Kyphoscoliosis.

Retrospective analysis. To evaluate whether radiologic parameters affect spine surgeon's osteotomy choice in patients with severe and stiff thoracic kyphoscoliosis. Three-column osteotomies were developed to address severe and stiff kyphoscoliosis. Current choice on osteotomies is based on the morphology of kyphosis, global balance, and locations of the main curvature; however, quantitative basis for decision making is still lacking. Sixty patients with severe and stiff thoracic kyphoscoliosis who underwent three-column osteotomy in the thoracic spine were classified into four groups according to the grade of osteotomy. The radiologic parameters including maximum scoliosis, maximum kyphosis, deformity angular ratio (DAR; maximum Cobb angle divided by number of vertebrae involved), apical vertebral translation, coronal balance, and sagittal balance were measured and compared. Correlation analysis between the radiologic parameters and the osteotomy grades was conducted. Perioperative and long-term complications were reviewed. The overall scoliosis was corrected from a mean preoperative Cobb angle of 129.1° (range, 90-174°) to 56.4° (range, 14-100°), and overall kyphosis was corrected from 124.3° (range, 64-180°) to 54.3° (range, 11-95°). As the osteotomy grades increased, the mean preoperative maximum kyphosis increased from 104.5° to 151.8° and the mean sagittal DAR (S-DAR) increased from 16.4 to 24.9. Statistically significant between-group differences were found for preoperative maximum kyphosis (P = 0.001), S-DAR (P = 0.045), and total DAR (P = 0.033). Significant correlations were observed between the preoperative maximum kyphosis and the osteotomy grade (r = 0.454, P < 0.001). The S-DAR significantly correlated with the osteotomy grade (r = 0.322, P = 0.012). The preoperative maximum kyphosis and the S-DAR may affect the surgeon's decision on the grade of osteotomies. This may enrich the theoretical basis on preoperative planning and help with patient counseling. 4.

Streptococcus anginosus is associated with postoperative intraabdominal collections in appendicitis

Aim of studyStreptococcus anginosus group (SA) (formerly Streptococcus milleri) are pathogens recognised to have a high risk of postoperative collection in appendicitis, although little data exist specifically in children. We performed a retrospective review of all microbiological data from appendicectomies to assess whether there was an association in children. MethodsA retrospective case note review of patients admitted to a paediatric tertiary centre coded for appendicitis from January 2015 to October 2016 was completed. Initial length of stay (LOS), cumulative hospital days, histology, microbiology, and radiology reports were recorded. The postoperative antibiotic regimen was based on surgeon's choice and not standardised. Main results231 children were identified, and 18 were excluded. In the remainder, 169 (78.9%) had positive microbiology cultures, and of these 45 were positive for SA (26.6%). There was no significant variation in monthly incidence (P=0.58). Patients with SA+ve cultures were associated with complicated appendicitis on histology (P=0.01), longer LOS and cumulative hospital days (P=0.001), and increased likelihood of developing postoperative collections (P=0.001). The relative risk of developing a postoperative collection with SA+ve cultures was 2.40. There was no difference in time to presentation, histology, or intervention between SA and non-SA patients who developed collections. All SA cultures were sensitive to penicillin and erythromycin. ConclusionSA cultured from intraoperative serial swabs is associated with an increased risk of developing postoperative collection (2.40). Using this information with standardisation of antimicrobial management may reduce the rate of postoperative complications in paediatric appendicitis. Level of evidenceLevel II prognosis study.

Outcomes of immediate versus delayed breast reconstruction: Results of a multicenter prospective study

BackgroundPrevious studies suggest that immediate reconstruction following mastectomy produces superior results over delayed procedures. However, for medical or oncological reasons, some patients may be poor candidates for immediate reconstruction. We compared complications and patient-reported outcomes between immediate and delayed breast reconstructions in a prospective, multicenter study. Methods1957 patients (1806 immediate, 151 delayed) met eligibility criteria. Demographic data, major complications, infections, and reconstructive failure rates were evaluated. Patient-reported outcomes were assessed with BREAST-Q, PROMIS, and EORTC QLQ-BR23 surveys, pre- and two years post-operatively. Subscale scores were compared across cohorts using mixed-effects regression models, controlling for patient characteristics and hospitals. FindingsComplete data were available in 1639 immediate and 147 delayed reconstruction patients. There were significant baseline differences between immediate and delayed cohorts in age, BMI, prevalence of diabetes, lymph node management, use of radiation, and chemotherapy. Controlling for clinical covariates, the delayed group had lower odds of any (OR 0.38, p < 0.001) and major (OR 0.52, p = 0.016) complications, compared with immediate patients. Furthermore, delayed reconstruction was associated with a significantly lower failure rates (6% vs. 1.3%, p = 0.032). However, multivariate analyses found no significant differences in patient satisfaction or in psychosocial, sexual, or physical well-being at two years. ConclusionsCompared with immediate techniques, delayed reconstruction following mastectomy was associated with lower rates of overall and major complication, while providing equivalent patient satisfaction and quality of life benefits. Although immediate reconstruction is still the preferred choice of most patients and surgeons, delaying reconstruction does not appear to compromise clinical or patient-reported outcomes.