Surgical Options Research Articles

A RARE COMPLICATION OF MITRAL TEER PROCEDURE: CLIP LATE DETACHMENT AND EMBOLIZATION

Abstract Intraprocedural and late complications of MitraClip implantation have already been described. This report highlights the importance of conventional surgical options in the event of percutaneous treatment failure. An 85–year–old woman with a history of chronic anemia, and thalassemia Minor was referred to our clinic for severe mitral regurgitation (MR) due to a P2 flail with significant calcification of the posterior mitral annulus. During the Heart Team discussion, age and comorbidities led to consider the patient eligible for TEER with the MitraClip system (EuroSCORE II 9,34%; STS score 7,47%). TEER procedure was uneventful: one XTW was deployed at the level of the flail (A2–P2), a second XTW was then placed more lateral to treat a separate residual jet, and one NTW was finally placed between them. MR reduction was considered acceptable (moderate MR, mean grad 6 mmHg). After two months, symptoms worsened, and TTE showed severe MR (no device detachment) with increased sPAP and associated moderate TR. A couple of weeks later, the patient was hospitalized. Chest X–ray revealed clip embolization confirmed by coronary angiography that showed an XTW Clip embolized to the Right coronary sinus with partial occlusion of the ostium. Percutaneous clip retrieval is described in the literature, but the embolized device position and the presence of recurrent severe MR led us to prefer an urgent surgical intervention. Under CPB, the embolized XTW was easily retrieved through a small aortotomy; the intervention was completed by mitral valve replacement and tricuspid valve repair. The postoperative course was uneventful. Predischarge TTE showed normal mitral bioprosthesis function, mild AR, mild TR, and preserved LV function. DISCUSSION Clip embolization is a rare but potentially critical complication of TEER and can happen periprocedurally or on early follow–up. Single leaflet detachment is more common, but complete detachment and embolization can occur. Therapeutic options are represented by surgical or transcatheter approaches according to embolization sites and patient comorbidities. In our case, the risk of potential coronary obstruction or thrombosis and the concomitant need for MR treatment have led us to consider surgery as the first option. CONCLUSION TEER can be graved by acute or late complications. The best approach has to be tailored to each patient, and surgery can be an effective and safe option even for initially discarded high–risk patients.

SEVERE MITRAL REGURGITATION TREATED WITH TRANSCATHETER AORTIC VALVE IMPLANTATION IN MITRAL RING (TMVIR): A CASE REPORT

Abstract Introduction The increasing prevalence of mitral regurgitation (MR), combined with a growing population of elderly patients at risk of being unsuitable for surgical options, has led to a greater interest in the use of less invasive treatments such as transcatheter heart valve (THV) implantation. This case involves the use of transcatheter aortic valve implantation in a patient with a previous mitral annuloplasty (TMViR). Case Presentation A 77–year–old woman had previously undergone mitral annuloplasty (Physio Ring II 32 mm, Medtronic), Neocord implantation and closure of the posterior commissure for severe MR due to anterior leaflet prolapse. She presented to our attention with worsening dyspnea (NYHA Class III) and a sudden weight gain. Transesophageal echocardiogram (TEE) revealed findings indicative of a previous mitral annuloplasty failure, with residual severe MR along with severe tricuspid regurgitation (TR). The case was discussed in the Heart Team and given the elevated surgical risk and the patient‘s anatomical unsuitability for edge–to–edge therapy, it was decided to perform a TMViR implantation. Under echocardiographic guidance and general anesthesia, right common right femoral vein access was obtained. After transseptal puncture, predilation of the interatrial septum was performed with balloon (Evercross 12 mm, Medtronic). Subsequent access to the left ventricle was achieved with a 6F PigTail catheter, and a stiff exchange guide (Safari S, Boston Scientific) was used to advance the 16Fr Delivery system. With the assistance of TEE, aortic valve implantation on the mitral ring was performed (Sapien 29 mm, Edwards Lifesciences) with rapid pacing via transvenous temporary PM placed in right ventricle (Spikeflow, Fiab). At the end of the procedure, two closure systems (Proglide, Abbott) were used for right femoral vein access. Post–implantation TEE showed a trivial paravalvular leak external to the annulus and a mean transvalvular gradient of 5 mmHg. The postoperative course proceeded without complications, facilitating the patient‘s discharge on the third postoperative day. Currently no further hospitalization in the last 6 months. Conclusion Despite surgical intervention remaining the gold standard in treating severe MR in patients who have undergone a previous annuloplasty, in patients at high surgical risk for a re–operation, who are not eligible for other percutaneous options, TMViR could be a safe and effective option for treatment.

Laparoscopic Magnetic Sphincter Augmentation for Symptomatic Gastroesophageal Reflux After Roux-en-Y Gastric Bypass: Outcome in 13 Patients

Abstract Background Gastroesophageal reflux disease (GERD) represents a common burden after bariatric procedures, particularly after laparoscopic sleeve gastrectomy (LSG). While GERD after LSG is usually treated with conversion to Roux-en-Y gastric bypass (RYGB), there are limited surgical options to manage medically refractory GERD after RYGB due to the altered anatomy. The use of magnetic sphincter augmentation (MSA) is one option, but the literature on this topic remains scarce. Aims To present mid- to long-term outcome of patients treated with MSA for GERD after RYGB. Methods We performed a retrospective single-centre analysis of data from patients who underwent laparoscopic MSA for GERD between August 2015 and December 2023, and who had previously RYGB. Outcomes were persistence/recurrence of GERD symptoms, use of proton pump inhibitors (PPIs) and need for redo surgery related to MSA complications or recurrent GERD. Results Of the 312 MSA procedures performed for GERD, we identified 13 patients who underwent laparoscopic MSA after RYGB. There were 10 female patients (77%), with mean age of 42.6 ± 13.7 years and mean BMI of 27.2 ± 2.7 kg/m2. Seven patients (54%) had de novo GERD. All MSA procedures included hiatoplasty. Median follow-up was 40 months (range 7-72) and median time between RYGB and MSA placement was 42 months (range 8-242). One patient (8%) required endoscopic dilatation due to persistent postoperative dysphagia. Two patients (15%) needed redo surgery: 1 redo hiatoplasty with adhaesiolysis and 1 conversion to esophagojejunostomy with implant removal. There was no erosion or migration of the MSA implant. Overall satisfactory control of reflux with discontinuation or reduction of PPIs was achieved in 9 patients (69%). Conclusion The use of MSA to manage refractory GERD after RYGB is a safe option and was effective in 69% of patients but is limited to patients with intact oesophageal motility.

Perianal Fistulizing Crohn's Disease: Outcomes of Surgical Repairs and Current State of Stem Cell-Based Therapies

AbstractPerianal fistulizing Crohn's disease is one of the most disabling phenotypes of Crohn's disease, due to the severe impairment in quality of life including social and personal wellbeing. A multimodal approach with patient-tailored care is the key to optimal management of this condition. Medical therapy is needed to optimize the luminal disease, and surgical intervention is required to control any associated perianal sepsis and attempt palliative or definitive fistula repair. While several medical and surgical options are available, the majority of patients continue to have symptomatic disease. Fortunately, this continues to drive novel innovations which are revolutionizing the treatment and outcomes of perianal fistulizing Crohn's disease. However, there continues to be a need for randomized trials and consistent metrics utilized for classification and treatment outcomes in order to accurately describe optimal treatment outcomes.

Subchondral cystic lesions of distal phalanx in young and mature horses: A new surgical option

SummaryBackgroundThe outcome of conservative treatment for subchondral cystic lesions (SCLs) of the distal phalanx may be poor, and surgical approach through the hoof may be challenging.ObjectivesTo describe the use of an absorbable device to treat SCLs of the distal phalanx, regardless of cyst location, that eliminates lameness and stimulates bone healing in both young and mature horses.Study designClinical case series.MethodsFive young horses and five mature horses presented with an SCL of the distal phalanx causing lameness. Only rest and medical treatment were previously attempted. An absorbable screw was inserted in all horses after transcortical debridement of the SCL. Follow‐up data were obtained from the official electronic database.ResultsAll horses returned to athletic activity after surgical treatment. In two patients, surgical complication was recorded.Main limitationsThe low number of patients, the need for dedicated instruments and the lack of familiarity with the use of absorbable devices to perform surgical procedures.ConclusionsThe insertion of an absorbable device can be considered a valid surgical option for treating subchondral cystic lesions of the distal phalanx.

Treatment Effectiveness and Recurrence of Extracranial Arteriovenous Malformations Following Surgical Operations: A 15-Year Retrospective Cohort Study.

At present, there is no golden standard for treatment of extracranial arteriovenous malformations (AVMs) and recurrence remains a major challenge with limited available evidence on the associated factors. This study aimed to evaluate the effectiveness of surgical treatment options, in terms of size reduction, symptoms, and early recurrence in patients treated surgically for AVMs. A retrospective cohort study was conducted to evaluate patients with AVMs following surgical treatment in 2 centers from 2005 to 2020. Posttreatment lesion size and symptoms, as well as recurrence, were assessed. Multiple regression analysis was performed to identify factors associated with recurrence. Forty-four surgical treatment cases in 31 patients were assessed with a mean follow-up duration period of 67.9 ± 39.5 months. Treatment included total resection in 26 cases (59.1%) and partial resection 18 (40.9%), with free flap coverage used in 19 cases (43.2%). No acute exacerbation following treatment was observed in our cohort. Total resection significantly reduced posttreatment lesion size ( P < 0.001), symptoms ( P < 0.001), and recurrence (20.0%, P = 0.03). The recurrence rate was significantly higher after partial resection (73.7%, P = 0.03). Total resection was identified as an associated factor for significantly reduced AVM recurrence (odds ratio: 0.12; 95% confidence interval: 0.03, 0.52). However, the use of free flaps did not significantly reduce recurrence, post treatment size or improve AVM symptoms. Total resection is the optimal treatment for AVMs. Free flaps are useful in covering large defects but the regulative effect of free flap remains controversial.

Management of colorectal neoplasia in IBD patients: current practice and future perspectives.

Inflammatory bowel disease (IBD) patients are at increased risk of developing colorectal neoplasia (CRN). In this review, we aim to provide an up-to-date overview and future perspectives on CRN management in IBD. Advances in endoscopic surveillance and resection techniques have resulted in a shift towards endoscopic management of neoplastic lesions in place of surgery. Endoscopic treatment is recommended for all CRN if complete resection is feasible. Standard (cold snare) polypectomy, endoscopic mucosal resection and endoscopic submucosal dissection should be performed depending on lesion complexity (size, delineation, morphology, surface architecture, submucosal fibrosis/invasion) to maximize the likelihood of complete resection. If complete resection is not feasible, surgical treatment options should be discussed by a multidisciplinary team. While (sub)total and proctocolectomy play an important role in management of endoscopically unresectable CRN, partial colectomy may be considered in a subgroup of patients in endoscopic remission with limited disease extent without other CRN risk factors. High synchronous and metachronous CRN rates warrant careful mucosal visualization with shortened intervals for at least 5 years after treatment of CRN.

Mini-Craniotomy for Chronic Subdural Hematoma: A Reliable Surgical Option

Abstract Introduction Chronic subdural hematoma (SDH) is one of the most common conditions encountered in the neurosurgical practice. Surgical modalities like twist drill craniostomy, burr hole evacuation, mini-craniotomy, and craniotomy are practiced in the management of chronic SDH. Mini-craniotomy without excision of membranes may help to achieve best results with decreased complication rate. Materials and Methods Patients with chronic SDH operated from September 2013 to September 2022 were included in the study. Mini-craniotomy (40–60 mm) was done and cruciate incision was given over the dura. Dura was left wide open by reflecting and suturing the cut edges of the dural leaflets to the craniotomy edge allowing to evacuate subdural space under vision during surgery and to allow any residual collection to drain out freely in the postoperative period. A drain was placed between the inner membrane and the bone flap. Preoperative and postoperative clinical and radiological parameters were recorded. Complications, recurrence, and residual collections were noted. Results Seventy-seven patients were included in the study. Mean age was 57.32 years. Median Glasgow Coma Scale (GCS) at presentation was 13 while median GCS at discharge was 15. Two patients with preexisting comorbidities expired after surgery due to medical causes. No recurrences were noted. Fourteen patients had residual collections which resolved by 6 weeks. Two patients had wound infection. One of these patients later needed a bone flap removal due to osteomyelitis. Conclusion Mini-craniotomy without membranectomy is a good option for complete evacuation of chronic SDH under vision mainly avoiding the complication of membranectomy. It is not associated with increased complications rate. It needs fewer follow-ups as brain expansion can be established radiologically in a short period.

Clinical study on the efficacy and safety of glaucoma drainage implants in the treatment of different types of glaucoma

Objective: To evaluate the efficacy and safety of glaucoma drainage implants(XEN-45 Gel Stent) for glaucoma treatment. Methods: A prospective study was conducted to continuously collect the clinical data of patients who were diagnosed with glaucoma and underwent XEN-45 Gel Stent implantation in the Ophthalmology Department of Peking University People's Hospital from January 2022 to August 2023. The visual acuity, intraocular pressure, number of glaucoma medications, and success rate of the patients were analyzed before and after surgery at 1 day, 1 week, 1 month, 3 months, 6 months, 12 months, and 18 months. The differences in intraocular pressure and number of glaucoma medications among primary open-angle glaucoma, primary angle closure glaucoma, secondary glaucoma, and different implantation methods of XEN-45 Gel Stent among patients with primary open-angle glaucoma were compared. The intraoperative and postoperative complications were observed, and the risk factors for needling and surgical complete success were analyzed. Results: A total of 48 eyes from 48 patients were included in this study, comprising 27 males and 21 females, with a mean age of (54.4±18.0) years and the disease duration was 36.0(7.3, 81.0) months.There were 28 cases of primary open-angle glaucoma, 4 cases of primary angle closure glaucoma, and 16 cases of secondary glaucoma.The follow-up period was 8.0 (3.0, 12.0) months. At 12 months after surgery, the intraocular pressure decreased from 20.5 (17.0, 26.0) mmHg to (13.5±3.3) mmHg (P<0.05), and the number of glaucoma medications decreased from 3.0 (3.0, 4.0) to 0.0 (0.0, 0.0) (P<0.05). The complete success rate and qualified success rate were 73.9% (17/23) and 91.3% (21/23), respectively. The most common postoperative complications were shallow anterior chamber in 6 cases (12.5%), hypotony in 3 cases (6.3%), and blocked stent in 3 cases (6.3%). The most common postoperative treatment was needling in 27 cases (56.3%). There was no significant difference in intraocular pressure among different types of glaucoma. In the comparison of postoperative effects of different surgical implantation methods for primary open-angle glaucoma, there were no statistically significant differences in intraocular pressure and the number of glaucoma medications at other follow-up time points except 1 month after surgery (P<0.05). Univariate logistic regression analysis did not find any risk factors associated with needling and surgical complete success. Conclusions: XEN-45 Gel Stent implantation is an effective and safe surgical option for different types of glaucoma patients in China, which can significantly reduce intraocular pressure and the use of glaucoma medications and has a high success rate. However, some patients may need needling or other treatments after surgery.

Is endoscopic third ventriculostomy a viable treatment option for normal pressure hydrocephalus? A systematic review.

Endoscopic third ventriculostomy (ETV) is considered an alternative treatment for hydrocephalus and has become a standard of care for obstructive hydrocephalus. Recent studies have also explored its role in normal pressure hydrocephalus (NPH). We conducted a systematic review aiming to assess the outcomes of this minimally invasive endoscopic technique as a viable treatment option for NPH. A systematic literature search was performed using PubMed and Scopus databases, using iterations of search terms "Endoscopic third ventriculostomy," "Idiopathic normal pressure hydrocephalus," and "Normal pressure hydrocephalus." To be eligible for inclusion in the review, articles had to report the usage of ETV as a primary treatment modality for NPH, report its outcomes, and be published in the English language. Out of the 13 studies selected for qualitative synthesis, nine supported the use of ETV for NPH as an effective treatment option with improvement in the preoperative symptoms. Two studies favored shunt over ETV, stating that quality of life is better with VP shunt insertion. One study reported that ETV has higher perioperative mortality rates that outweigh its benefits. One study reported it to be an ineffective surgical option. The current review of evidence does not support the use of ETV for the treatment of NPH, except perhaps in a small subset of patients. These patients have a shorter duration of symptoms and a better preoperative neurological status. The lumbar infusion test and ventricular infusion test are modalities useful for selecting these candidates.

A PROSPECTIVE OBSERVATIONAL STUDY OF THUMB FUNCTION FOLLOWING FIRST CARPOMETACARPAL JOINT ARTHRODESIS

IntroductionDespite the rising popularity of 1st carpometacarpal joint (CMCJ) arthrodesis as one of the surgical options for basilar thumb arthritis, the available literature on this is poor. This study aims to investigate post-operative pinch and grip strength following 1st CMCJ arthrodesis, at a minimum of 1 year follow-up. Complication rates, range of motion and patient reported scores were also evaluated.MethodsA retrospective cohort (2012–2020) was used, which included patients who had arthrodesis performed by the Hands surgeons at Counties Manukau DHB. In a 15 minute visit, we took the measurements using our standard dynamometer and pinch gauge, and collected three questionnaires [QuickDASH, PRWHE, PEM]. For analysis, we compared our results to the preoperative measures, contralateral hand, and to a previous study on a similar cohort looking at thumb strength following trapeziectomy.Results42 arthrodesis were performed, and 24 were available for follow-up. The average follow-up time was 77 months and the average age was 51 years old. Overall, we found a statistically significant improvement in thumb strength following surgery. Mean preoperative grip strength was 21.4kg and 32.5kg postoperatively (= +11kg). Preoperative pinch strength was 5.5kg and 7kg postoperatively (= +1.5kg). These results were significantly higher compared to the trapeziectomy cohort. We also found an improvement in 1st CMCJ ROM post-operatively. 7 complications were reported (29.1%). 4 were metalware-related and 3 were non-union. QuickDASH score significantly improved from a median of 42.95 to 12.5 while PRWHE from 67.5 to 14.5. Overall patient satisfaction was 87.4%.Conclusion1st CMCJ arthrodesis leads to an improvement in thumb function, pain and range of movement and results in high patient satisfaction, and therefore should be recommended for younger patients who need a pain-free and strong thumb.

Metacarpal Fracture Fixation with Intramedullary Screws.

Background: Intramedullary screws (IMS) have become a viable option for metacarpal fracture fixation. To further appraise their utility, this study assessed clinical and patient-reported short- and medium-term outcomes of IMS fixation for extra-articular metacarpal fractures. Methods: A retrospective cohort study was performed in a series of 32 patients (with a total of 37 fractures) who underwent metacarpal fracture fixation over a 42-month period between January 2020 and July 2023. Results: Mean time for return to work was 39.8 days; mean time for return to full function was 88.4 days; total active motion was 250.7° (range: 204.9-270.9); Quick Disabilities of the Arm, Shoulder and Hand score was 2.3 (range: 0-22.7); mean visual analogue pain score was 0.9 out of 10 (range: 0-6) and a single complication was observed. Conclusions: The use of IMS in metacarpal fracture fixation is a practicable surgical option. IMS fixations yields a satisfactory duration for return to function, good postoperative range of movement, modest pain scores and low rates of complications. Level of Evidence: Level IV (Therapeutic).

Association between immigration status and total knee arthroplasty outcomes in Ontario, Canada: a population-based matched cohort study.

Immigrants and refugees face unique challenges navigating the health care system to manage severe arthritis, because of unfamiliarity, lack of awareness of surgical options, or access. The purpose of this study was to assess total knee arthroplasty (TKA) uptake, surgical outcomes, and hospital utilization among immigrants and refugees compared with Canadian-born patients. We included all adults undergoing primary TKA from January 2011 to December 2020 in Ontario. Cohorts were defined as Canadian-born or immigrants and refugees. We assessed change in yearly TKA utilization for trend. We compared differences in 1-year revision, infection rates, 30-day venous thromboembolism (VTE), presentation to emergency department, and hospital readmission between matched Canadian-born and immigrant and refugee groups. We included 158 031 TKA procedures. A total of 11 973 (7.6%) patients were in the immigrant and refugee group, and 146 058 (92.4%) patients were in the Canadian-born group. The proportion of TKAs in Ontario performed among immigrants and refugees nearly doubled over the 10-year study period (p < 0.001). After matching, immigrants were at relatively lower risk of 1-year revision (0.9% v. 1.6%, p < 0.001), infection (p < 0.001), death (p = 0.004), and surgical complications (p < 0.001). No differences were observed in rates of 30-day VTE or length of hospital stay. Immigrants were more likely to be discharged to rehabilitation (p < 0.001) and less likely to present to the emergency department (p < 0.001) than Canadian-born patients. Compared with Canadian-born patients, immigrants and refugees have favourable surgical outcomes and similar rates of resource utilization after TKA. We observed an underutilization of these procedures in Ontario relative to their proportion of the population. This may reflect differences in perceptions of chronic pain or barriers accessing arthroplasty.

Protocol for a systematic mapping review of surgical and pharmacological interventions for the treatment of trigeminal neuralgia.

Trigeminal neuralgia is a painful neuropathic disorder characterized by sudden electric shock-like pain that significantly impacts patients' quality of life. Multiple treatment alternatives are available, including medical and surgical options but establishing the optimal course of action can be challenging. To enhance clinical decision-making for trigeminal neuralgia treatment, it is imperative to organize, describe and map the available systematic reviews and randomized trials. This will help identify the best treatment alternatives supported by evidence and acknowledge potential knowledge gaps where future research is needed. This systematic mapping review aims to provide up-to-date evidence on the different surgical and pharmacological treatment alternatives used for trigeminal neuralgia. A search will be systematically conducted on the Epistemonikos database to identify potentially eligible systematic reviews. Additionally, a search will be made in PubMed, CENTRAL, and EBSCO to identify randomized controlled trials assessing pharmacological and surgical treatment interventions for trigeminal neuralgia. Two independent reviewers will screen and select the studies. Data on the different treatment alternatives and reported outcomes in the included studies will be extracted using standardized forms. Following extraction, descriptive statistical methods will be used to analyze the data. The final output of this study will include an evidence map that will illustrate the connections between different treatments and their respective outcomes, providing a clear depiction of the evidence landscape. This study expects to map, describe and assess the methodological quality of the available systematic reviews and trials on pharmacological interventions and neurosurgical procedures for treating trigeminal neuralgia. It will present the results in an evidence map that organizes the available evidence based on their different interventions and outcomes. This evidence map will serve as a visual tool to assist healthcare professionals and patients to understand evidence-based treatment options and their implications for managing this medical condition. La neuralgia del trigémino es un trastorno neuropático doloroso caracterizado por un dolor súbito y agudo, similar a una descarga eléctrica, que impacta significativamente en la calidad de vida. Dada la variedad de tratamientos disponibles, médicos y quirúrgicos, es crucial organizar y mapear la evidencia proveniente de revisiones sistemáticas y ensayos clínicos para orientar las decisiones clínicas. Esto permite identificar tratamientos respaldados por evidencia y señalar áreas de investigación futura. El propósito de esta revisión sistemática de mapeo es proporcionar una visión actualizada de la evidencia existente en relación con las diversas opciones de tratamiento quirúrgico y farmacológico empleadas en el manejo de la neuralgia del trigémino. Se realizará una búsqueda sistemática en la base de datos Epistemonikos para identificar potenciales revisiones sistemáticas. Adicionalmente, se buscará en PubMed, CENTRAL y EBSCO ensayos clínicos aleatorizados que evalúen intervenciones de tratamiento farmacológico y quirúrgico para la neuralgia del trigémino. Dos revisores independientes cribarán y seleccionarán los estudios. Se extraerán datos sobre las diferentes alternativas de tratamiento y los resultados reportados en los estudios incluidos utilizando formularios estandarizados. Tras la extracción, se utilizarán métodos estadísticos descriptivos para analizar los datos. El producto final de este estudio incluirá un mapa de evidencia que ilustrará las conexiones entre los diferentes tratamientos y sus respectivos resultados, proporcionando una representación clara del panorama de la evidencia. Los resultados que se extraerán de este mapeo sistemático incluyen identificar y describir las diferentes alternativas, tanto farmacológicas como quirúrgicas, que existen para el tratamiento de la neuralgia del trigémino. Además, se planea presentar un mapa de evidencia que se basará en los ensayos clínicos aleatorizados y revisiones sistemáticas, el cual mostrará la evidencia de manera organizada entre las diferentes intervenciones y sus desenlaces. Este mapa de evidencia servirá como una herramienta visual que ayudará a los profesionales de la salud y los pacientes a comprender mejor las opciones de tratamiento respaldadas por la evidencia y sus consecuencias en el manejo de esta condición médica.

Patellofemoral Instability Part II: Surgical Treatment

Treatment of patellofemoral instability in skeletally mature patients remains an important area of clinical and research interest. Both nonsurgical and surgical interventions are used to treat the underlying causes. Surgical management is the mainstay of treatment of recurrent PFI that fails nonsurgical treatment, and it is broadly classified into bony and soft-tissue procedures. Proximal bony procedures include femoral trochleoplasty, derotational osteotomies, and coronal alignment correction of the femur. Distal bony procedures include tibial tubercle transfer and derotational (supratubercle and infratubercle) osteotomies. Soft-tissue procedures consist of medial patellofemoral ligament repair or reconstruction and lateral lengthening procedures. This article is the second part of our two-article review on PFI, which focuses on surgical treatment options, their indications, outcomes, and potential complications.

Overall survival after mastectomy versus breast-conserving surgery with adjuvant radiotherapy for early-stage breast cancer: meta-analysis.

Breast-conserving surgery with adjuvant radiotherapy and mastectomy are currently offered as equivalent surgical options for early-stage breast cancer based on RCTs from the 1970s and 1980s. However, the treatment of breast cancer has evolved and recent observational studies suggest a survival advantage for breast-conserving surgery with adjuvant radiotherapy. A systematic review and meta-analysis was undertaken to summarize the contemporary evidence regarding survival after breast-conserving surgery with adjuvant radiotherapy versus mastectomy for women with early-stage breast cancer. A systematic search of MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL), and Embase that identified studies published between 1 January 2000 and 18 December 2023 comparing overall survival after breast-conserving surgery with adjuvant radiotherapy versus mastectomy for patients with unilateral stage 1-3 breast cancer was undertaken. The main exclusion criteria were studies evaluating neoadjuvant chemotherapy, rare breast cancer subtypes, and specific breast cancer populations. The ROBINS-I tool was used to assess risk of bias, with the overall certainty of evidence assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool. Studies without critical risk of bias were included in a quantitative meta-analysis. From 11 750 abstracts, 108 eligible articles were identified, with one article including two studies; 29 studies were excluded from the meta-analysis due to an overall critical risk of bias, 42 studies were excluded due to overlapping study populations, and three studies were excluded due to reporting incompatible results. A total of 35 observational studies reported survival outcomes for 909 077 patients (362 390 patients undergoing mastectomy and 546 687 patients undergoing breast-conserving surgery with adjuvant radiotherapy). The pooled HR was 0.72 (95% c.i. 0.68 to 0.75, P < 0.001), demonstrating improved overall survival for patients undergoing breast-conserving surgery with adjuvant radiotherapy. The overall certainty of the evidence was very low. This meta-analysis provides evidence suggesting a survival advantage for women undergoing breast-conserving surgery with adjuvant radiotherapy for early-stage breast cancer compared with mastectomy. Although these results should be interpreted with caution, they should be shared with patients to support informed surgical decision-making.

Outpatient mastectomy is a safe surgical option for patients treated in a rural Appalachian tertiary facility

IntroductionThe feasibility of the outpatient mastectomy in a rural setting is poorly characterized. The aim of this study is to analyze the efficacy and safety of an outpatient mastectomy program in our tertiary care facility treating rural Appalachian patients. MethodsWe performed a single-institution, retrospective review of all women with breast cancer older than 18 years of age treated with mastectomy with or without immediate alloplastic breast reconstruction at JW Ruby Memorial Hospital from 2019 to 2022. Our primary objective was to determine the 30, 60, and 90-day readmission rates and complications. Our secondary objective analyzed perioperative pain control variables that contribute to appropriate discharge. ResultsWe identified thirty-two women between 2019–2022 who underwent same-day mastectomy at JW Ruby Memorial Hospital in Morgantown, West Virginia. Overall readmission rates at 30- 60- and 90-days were 3.1% (n = 1), 9.4% (n = 3) and 9.4% (n = 3), respectively. Two patients were admitted for reasons unrelated to surgery. The patient in the 30-day readmission group required washout for hematoma due to perioperative apixaban making the overall surgical readmission rate 3.1% (n = 1). Preoperatively, 90.6% (n = 29) of women received a local anesthetic block by the anesthesia provider. The mean milligram morphine equivalents received for the duration of the hospital encounter was 15.9 (STD = 10.1). ConclusionOutpatient mastectomy is a safe and effective option for eligible patients in rural settings. Careful patient selection and a multidisciplinary team should assess the individual circumstances to determine if outpatient mastectomy is appropriate.

Pre-Operative Characteristics Helping to Avoid Gastrostomy Tube After Mandibular Distraction in Neonates With Pierre-Robin Sequence: A Institutional Case-Series and Review of the Literature.

to investigate the ability of mandibular distraction osteogenesis (MDO) to avoid gastrostomy tube (G-tube). PubMed, EBSCOhost, Cochrane, and Embase. We retrospectively reviewed the number of MDO cases performed at our institution for patients with Robin Sequence (RS) over the past 10 years. In our institutional review, patients were excluded if they had a G-tube already placed at the time of surgery. We also performed a systematic review of the literature. Articles were excluded if they did not detail feeding outcomes after MDO, or if MDO was performed on patients that did not have RS. In our systematic review, 12 articles were included that comprised a total of 209 neonates with RS that underwent MDO. A total of 174 (83.3%) patients avoided a G-tube once MDO was performed. A total of 14 patients met the inclusion criteria at our institution. Of the 14 RS patients, 9 (64%) avoided having a G-tube placed and all (14/14) avoided tracheostomy. The average birth weight of patients avoiding a G-tube was 3.11 kg compared to 2.25 kg (P = .045) in the group requiring a G-tube. In the group avoiding a G-tube, the average weight at time of operation was 3.46 kg compared to 2.83 kg (P = .037) in the group requiring a G-tube. MDO may be considered as a surgical option to prevent G-tube placement for neonates with non-syndromic RS who have difficulty with PO feeding but whose airway obstruction is not severe enough to require respiratory support. Based on our institutional experience, a minimum weight of 3.00 kg correlated with higher success rates of PO intake and avoiding a G-tube.

Gonioscopy-assisted transluminal trabeculotomy as a primary surgical option for glaucoma in Fuchs uveitis syndrome: A case series.

Fuchs uveitis syndrome (FUS) is a chronic intraocular inflammatory disease. It can lead to glaucoma which can be intractable to both medical and surgical treatment. In the present report, we describe our experience with GATT as a primary surgical option in the treatment of glaucoma secondary to FUS. Four consecutive patients with FUS-associated glaucoma underwent GATT in a single institution. Case 1 was a 28-year-old pseudophakic male with a preoperative intraocular pressure (IOP) of 43 mmHg had unsuccessful circumferential cannulation; his IOP remained high after GATT and received trabeculectomy followed by Ahmed glaucoma valve (AGV) implantation to control IOP. Although IOP was stable following AGV, he required descemet membrane endothelial keratoplasty due to persistent corneal decompansation. He had a stable IOP of 12 mmHg over 21 months. Case 2 was a 42-year-old male with preoperative IOP of 35 mmHg and posterior subcapsular cataract had 360-degree GATT combined with phacoemulsification; his IOP reduced to 14 mmHg over 18 months. Case 3 was an 52-year-old pseudophakic male with a preoperative IOP of 28 mmHg had 360-degree GATT; his IOP remained stable at 10 mmHg over 18 months. Case 4 was an 47-year-old pseudophakic female with a preoperative IOP of 39 mmHg had 360-degree GATT; her IOP remained stable at 14 mmHg over 12 months. GATT may be used as an initial approach in secondary glaucoma due to FUS. But, further evidence is still warranted to better ascertain the usefulness of GATT in this specific patient population.

Diverting Stoma-Related Evisceration: A Comprehensive Review of 28 Case Reports Published in the Medical Literature in English.

Evisceration is an exceptional complication of diverting a stoma (a common procedure, often considered a minor surgery) with peculiar, specific, features (distinct-to-usual incisional evisceration), due to the presence of a stoma. Available data are limited to a few case reports; some aspects are not fully documented. The results of 28 case reports (full-text articles published in the English literature) were analyzed using 14 variables: age and gender; pathology; surgical setting; index surgery and type of stoma; intended stoma creation; time from surgery to evisceration; type of evisceration; visceral content; cause of evisceration; specific predisposing/risk factors; surgical approach; resection of nonviable content; surgical stoma treatment; and short-term outcome. Urgent surgery resulted in 46.42% resection of nonviable eviscerated content and 7.14% mortality. All issues (some not discussed in previous reviews) were analyzed, to highlight their clinical relevance for surgical practice. The mechanisms (types of evisceration) are different in parastomal and transstomal/intrastomal evisceration; they should be considered as distinct entities. The real (underlying) etiology was identified in 26/28 case reports (92.85%): surgical failure, such as inadequate technique/tactics/strategy (12/26 case reports, 46.15%); trauma (7/26 case reports, 26.92%); and spontaneous necrosis (6/26 case reports, 21.42%). Parastomal hernia and/or prolapse (10/28 case reports, 35.71%) were specific predisposing factors; in such cases, early surgical treatment is recommended. Temporary stoma was a potential risk factor, both for early as well as for late evisceration (e.g., long-standing temporary stoma); in such cases, early take-down or conversion to definitive stoma is beneficial. A local surgical approach (avoiding median laparotomy) was used in 13/28 (46.42%) of case reports. Seven different surgical options were used for surgical stoma treatment, demonstrating versatility; the initial stoma site was preserved in 22/28 (78.57%) of case reports.