Time Of Surgical Procedure Research Articles

The Evaluation, Management and Outcome about an Experience with Sharp Force Abdominal Injury

<p><strong>Background and Objective:</strong> Sharp force injuries (SFI), inflicted by cutting or stabbing, result in variable outcome depending upon the nature and site of the injury. This study evaluated the cases of SFIs and their outcome with reference to the time of presentation, demographic data, wounded organs, and surgical procedure performed.<br /><strong>Methods:</strong> This retrospective study analyzed the clinical data of 20 patients who presented with sharp force injury (knife stabbing and penetrating abdominal trauma) and were admitted between April 2015 and November 2016. The management and outcome of patients were recorded.<br /><strong>Results:</strong> All patients in this study were male and aged between 21 and 30 years. Knife stabbing was the only mechanism of injury in all cases. Colon (50%) was the commonest organ injured followed by intestine (40%) and liver (30%). Mortality rate was 10%. There were two cases with negative laparotomy (10%). Wound sepsis (10%) was the commonest complication.<br /><strong>Conclusions: </strong>SFI involving abdominal area are managed either conservatively or with primary repair and laparotomy to save internal organs. Early presentation and prompt management leads to reduced chances of complications and mortality.</p>

Pre-contoured reconstruction plate fabricated via three-dimensional printed bending support.

A mandibular continuity defect can be repaired using either a prosthetic device or autogenous bone. A titanium reconstruction plate can be used with a localized or vascularized flap over the defect of the mandible. Unfortunately, the plate may fail due to plate exposure, screw loosening, fracture, or infection, and will need to be removed. Plate exposure though the skin or mucosa is one of the main reasons for failure. In the present work, the authors introduced a lingually positioned reconstruction plate fabricated via three-dimensional printed bending support. This custom reconstruction plate can avoid plate re-exposure as well as reduce surgical errors and operation time.

Impact of Obesity on the Orthopedic Spine Surgical Procedural Time and Hospital Stay: King Saud University Hospital Experience

Impact of Obesity on the Orthopedic Spine Surgical Procedural Time and Hospital Stay: King Saud University Hospital Experience

Preoperative platelet transfusions: A retrospective review of pediatric patients with thrombocytopenia, 2011–2016

BackgroundThrombocytopenia is a common perioperative clinical problem and preoperative platelet transfusion prior to surgery is standard practice. Recent platelet trials and literature reviews have found no association between platelet count and bleeding incidence except when platelet count is extremely low. Our aim was to evaluate the bleeding risk and the overall platelet transfusion management among pediatric patients with severe thrombocytopenia based on whether they were preoperatively transfused versus transfused at time of incision. MethodsThis is a retrospective analysis of pediatric patients with a platelet count ≤50 × 109/L in the 12 h prior to surgery at a single tertiary pediatric hospital from 2011 to 2016. Eligible patients were ≤21 years old. Patients with necrotizing enterocolitis and neonates were excluded. The primary outcome was postoperative bleeding complications. Additional outcomes were preoperative platelet change and weight adjusted transfusion volumes. ResultsA total of 37 patients were included in this analysis of which 29 (78%) received preoperative platelet transfusions within 12 h prior to surgery. No postoperative bleeding complications occurred 30 days after operation, regardless of preoperative transfusion status. There was no significant difference in platelet change by preoperative transfusion status and preoperative transfusion volume was a poor predictor of change in preoperative platelet count (crude: r2=0.19, age/gender adjusted: r2=0.48). ConclusionPatients transfused at time of surgical procedure did not have an increased risk of bleeding over those preoperatively transfused. This finding is in agreement with previous studies in adult populations, supporting the safety of deferring platelet transfusions until the time of incision for thrombocytopenic pediatric surgical patients.Level of evidence: III

Comparison of Laparoscopic Myomectomy with and without Uterine Artery Occlusion in Treatment of Symptomatic Multiple Myomas

ObjectiveUterine artery occlusion (UAO) is a minimally invasive approach often used to treat symptomatic uterine myomas. This study aimed to compare the clinical effects of laparoscopic UAO (LUAO) in combination with laparoscopic myomectomy (LM) with LM alone to treat symptomatic multiple uterine myomas.MethodsThis was a prospective observational study. In total, 122 patients with symptomatic multiple uterine myomas underwent LUAO + LM or LM alone between April 2015 and October 2017. The surgical procedure time, blood loss, highest postoperative temperature, hospital length of stay, number of removed myomas, surgical complications, and recurrence rate of the two groups were compared.ResultsMean blood loss was significantly lower in the LUAO + LM group compared with the LM group (177.97 ± 104.09 mL vs 258.10 ± 119.55 mL, p < 0.05). No significant difference in surgical procedure time, hospital length of stay, highest postoperative temperature, and surgical complications was found between the LUAO + LM group and LM group. The number of removed myomas was considerably higher in the LUAO + LM group than in the LM group (4[4–7] vs 3[3–5], p < 0.05). The recurrence rate in the LUAO + LM group was considerably lower than that in the LM group (6.2% vs 25.9%).ConclusionLUAO in combination with LM was associated with higher surgical quality and lower recurrence of myomas compared with LM alone. LUAO in combination with LM is recommended for women with symptomatic multiple uterine myomas who wish to retain their uteruses.

A prospective study of functional outcome of comminuted metaphyseal distal femur fracture treated with lateral locking compression plate and medial augmentation with TENS

Background: Distal femur fractures are complex injuries producing long term disability and present considerable challenges in management. These fractures poses challenges to the treating surgeon because of thin cortex of the femoral condyles, wide medullary canal, relative osteopenia, short condylar fragment and comminution involving articular surface. Distal femur fracture disrupts normal knee joint functioning, hence needed anatomical reduction and stable internal fixation to prevent crippling disabilities and hardware failure. Objective: To evaluate the functional and radiological outcome of comminuted metaphyseal fracture of distal femur treated by Lateral locking compression plate and medial TENS nail using NEER’S score. Methods: In this study, 20 cases of comminuted metaphyseal fracture of distal femur were operated between November 2018 to April 2020 with distal femur lateral locking compression plate and medial augmentation with tens nail. Patients were selected based on inclusion and exclusion criteria and were followed up for 12 months. The results were analysed with NEER’S score. Results: Out of 20 patients with comminuted metaphseal distal femur fractures AO-Muller type A3 -subtypes 15 and C2 subtypes 5 patients were studied. Mean age of the patients was 45.5 years with age ranging from 20 years to 80 years. Right sided fractures were predominant. In 65% cases mode of injury was road traffic accident and rest were self-fall. 2 cases were operated under MIPPO technique and rest all were operated on with standard open lateral approach. Average surgical procedure timing was 119.5 minutes in our study. Average duration of radiological union was 18.6 weeks and average duration of weight bearing was 20.5 weeks. Complications such as superficial wound infection, knee pain and stiffness were observed in 9 patients. The NEER’S score was excellent in 45%, good-fair in 50% and 5% poor outcome. Conclusion: Comminuted distal femur fracture needs dual column fixation to achieve bone healing and restore function of the affected limb in shortest time without compromising stability. The advantage medial augmentation with TENS is active range of motion can be started earlier, stable internal fixation that does not allow varus collapse, mal-union and further implant failure.

Predicting Operation Time and Creating a Difficulty Scoring System in Donor Nephrectomy.

Background: To determine predictive formulas for operation time and surgical difficulty in laparoscopic living-donor kidney transplantation. Methods: We retrospectively analyzed data for 222 living donors aged >20 years and recorded factors affecting operation time from patients' CT images and medical records. We used the factors significantly affecting operation time to create a formula to predict operation time and designed a model to predict surgical difficulty based on the standardized partial regression coefficient, β. We also analyzed the relationship between surgical difficulty (high vs low) and operation time. Results: This study involved 111 pure retroperitoneoscopic donor nephrectomies (PRDN) and 111 hand-assisted laparoscopic donor nephrectomies (HALDN). Patients' mean age was 55.7 years, and 59.5% were women; 5.0% underwent right nephrectomy, and 77.0% vs 23.0% had single- vs multiple renal arteries. The average estimated kidney graft weight was 160.0 g, and actual average graft weight was 155.3 g. The following factors were significantly correlated with operation time in the regression analysis: number of renal arteries, Mayo adhesive probability score, estimated kidney graft weight, right nephrectomy, and operation type (PRDN). These five factors were used to create the operation time prediction equation and difficulty scoring system. The multiple r2 value was 0.40 for the operation time prediction equation. Receiver operating characteristic curve analysis of the difficulty scoring system revealed the following: sensitivity: 78.0%, specificity: 64.9%, and c-statistic: 0.76 (95% confidence interval: 0.70 to 0.83). Conclusions: The equation to predict operation time and the surgical difficulty prediction model created in this study are easy to calculate and are accurate. Both may help in selecting an appropriately skilled surgeon and in improving safety in living-donor kidney transplantation.

Trans-anal minimally invasive surgery (TAMIS) versus trans-anal endoscopic microsurgery (TEM): a comparative case-control matched-pairs analysis.

Since its introduction, transanal endoscopic microsurgery (TEM) has become the treatment of choice for rectal benign lesions not amenable to flexible endoscopic excision and for early rectal cancer. Disposable soft devices as the Trans-anal Minimally Invasive Surgery (TAMIS) are a valid alternative to non-disposable rigid trans-anal endoscopic microsurgery (TEM) platforms. The aim of the present study is to compare TEM and TAMIS in terms of incidence of R1 resection and lesion fragmentation which were combined in a composite outcome called quality resection. Perioperative complication and operative time were also investigated. A total of 132 patients were eligible for this study of whom 63 (47.7%) underwent TAMIS and 69 (52.3%) underwent TEM. Patients were extracted for froma prospective maintained database and groups resulted homogenous after matching using propensity score in terms of size of the lesion, height from the anal verge, position within the rectal lumen, preoperative histology, neoadjuvant treatment. A multivariate logistic and linear regression analysis was carried out using those variables that have significant independent relationship with the quality of surgical resection and operative time. The incidence of R0 resection and lesion fragmentation was similar between groups. No differences were found in terms of perioperative complication. TAMIS was associated with less setup time and less operative time compared with TEM. Variables influencing quality resection at the multivariate analysis were larger lesion (> 5cm) and ≥ T2 stage. Variables influencing operative time were surgical procedure (TEM vs TAMIS), height from the anal verge and size of the lesion. The present study shows that TEM and TAMIS are equally effective in terms of quality of local excision and perioperative complication. TAMIS resulted less operative time consuming compared to TEM.

Open versus arthroscopic release for lateral patellar compression syndrome: a randomized-controlled trial

IntroductionLateral patellar compression syndrome is one of the causes of anterior knee pain in young adults and resulted from tight lateral patellar retinaculum. The aim of our study is to compare between open and arthroscopic release of lateral patellar compression syndrome in relation of functional outcome, time of surgical procedure, length of hospital stays, intraoperative and postoperative complications as bleeding, infection, recurrence, and patellar instability with 2 years of follow-up.Materials and methods80 patients, age (21–49 years), were divided randomly into 2 groups (A and B). Group A (40 patients) were treated with open release. Group B (40 patients) were treated by arthroscopic release. All these patients are diagnosed as lateral patellar compression syndrome depending on clinical features and MRI. All patients were assessed by Lysholm knee scoring scale before surgery and at periods of 2, 6 weeks, 6, 12, and 24 months after surgery.ResultsThere is significant difference in functional outcome, measured by Lysholm knee scoring scale, between preoperative and postoperative assessment periods in both groups (P < 0.001). There is significantly better functional outcome at 2 years of follow-up with arthroscopic release (P = 0.018). There is no recurrence in both groups, but there were 4 patients develop medial patellar instability in the group of open release.ConclusionBoth open and arthroscopic lateral release for patients with isolated lateral patellar compression syndrome can be effective surgical procedures, but arthroscopic release can achieve better functional outcome.Trial registration: NCT, NCT04130412. Retrospectively registered on 3rd of June, 2020 at ClinicalTrials.gov.

Sutured Versus Mesh-augmented Hiatus Hernia Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

This meta-analysis systematically reviewed published randomized control trials comparing sutured versus mesh-augmented hiatus hernia (HH) repair. Our primary endpoint was HH recurrence at short- and long-term follow-up. Secondary endpoints were: surgical complications, operative times, dysphagia and quality of life. Repair of large HHs is increasingly being performed. However, there is no consensus for the optimal technique for hiatal closure between sutured versus mesh-augmented (absorbable or nonabsorbable) repair. A systematic review of Medline, Scopus (which encompassed Embase), Cochrane Central Register of Controlled Trials, Web of Science, and PubMed was performed to identify relevant studies comparing mesh-augmented versus sutured HH repair. Data were extracted and compared by meta-analysis, using odds ratio and mean differences with 95% confidence intervals. Seven randomized control trials were found which compared mesh-augmented (nonabsorbable mesh: n = 296; absorbable mesh: n = 92) with sutured repair (n = 347). There were no significant differences for short-term hernia recurrence (defined as 6-12 months, 10.1% mesh vs 15.5% sutured, P = 0.22), long-term hernia recurrence (defined as 3-5 years, 30.7% mesh vs 31.3% sutured, P = 0.69), functional outcomes and patient satisfaction. The only statistically significant difference was that the mesh repair required a longer operation time (P = 0.05, OR 2.33, 95% confidence interval 0.03-24.69). Mesh repair for HH does not offer any advantage over sutured hiatal closure. As both techniques deliver good and comparable clinical outcomes, a suture only technique is still an appropriate approach.

Complications of intrathecal drug delivery therapy (ITDD): A retrospective study of 231 implantations between 1999 and 2014

ObjectiveDetermination of types and frequencies of complications related to ITDD therapy, and assessment of possible risk factors for such complications. MethodsRetrospective study (1999–2014) including all ITDD-implantations at one regional center in Sweden. Descriptors comprised: sex; age; medical condition; body weight index; preoperative ASA-grade; presence of indwelling urinary catheters, feeding tubes, and/or daily urinary or anal incontinence; primary or re-implantation; type of pump and catheter; drug delivered; weekday of surgery; surgical procedure time; surgeon; experience of surgeon; surgical theater; and type of antibiotic prophylaxis. All deaths during the study period were assessed as regards possible relation to ITDD.Data were analyzed with SPSS 25, using Chi2 test for correlations between descriptors and complications. Results231 ITDD pump implantations/re-implantations occurred in 159 patients. Seventy-eight (34%) instances of complications were found: 33 catheter-associated; 6 pump-associated; and 29 infection-associated, where 16 were surgical site infections.A higher infection rate occurred in pump re-implantations, as compared to primary implantations (p = 0.002), and in patients with traumatic spinal cord injury (TSCI) as compared to other diagnoses (p = 0.02). Cloxacillin as antibiotic prophylaxis correlated with a higher infection risk (p = 0.005) relative to other antibiotic prophylaxis.Prolonged surgical procedure time in re-implantations correlated positively with increased catheter-associated complications (p = 0.006). ConclusionComplications in ITDD therapy were common, comprising catheter-, infection-, and pump-associated mishaps. A comprehensive system of care needs to be present for managing complications. Future studies may show less complications due to improved protocols and equipment.

Standardization of cerebrospinal fluid shunt valves in pediatric hydrocephalus: an analysis of cost, operative time, length of stay, and shunt failure.

CSF shunts are the most common procedures performed in the pediatric neurosurgical population. Despite attempts in multiple studies, a superior shunt valve has never been shown. Because of this, the authors aim was to examine the impact of shunt valve standardization at their institution to determine if there is a difference in surgical cost, operative time, or short-term postoperative shunt failure. A retrospective analysis at the authors' institution was performed for all new CSF diversion shunts, as well as shunt revisions requiring a new valve, or a new valve and at least a new proximal or distal catheter over a 1-year period (January 1, 2016, to December 31, 2016). After a period of transition, neurosurgeons were encouraged to use only one type of fixed-differential-pressure valve and one type of programmable valve when performing shunt surgeries. These patients who underwent "standardized" shunt surgery over a 1-year period (January 1, 2018, to December 31, 2018) were then compared to patients in the prestandardization epoch. All patients were followed for a 12-month period after surgery. Demographic information, surgical cost, operative time, and postoperative shunt failure data were collected in all patients in the study. The authors analyzed 87 shunt surgeries in patients prior to standardization and 94 shunt surgeries in patients after standardization. The rate of violation of the standardized shunt valve policy after implementation was 5.3% (5 of 94 procedures). When comparing the prestandardization group to those who received the standardized valve, operative costs were less ($1821.04 vs $1333.75, p = 0.0034). There was no difference in operative times between groups (78 minutes vs 81 minutes, p = 0.5501). There was no difference in total number of shunt failures between the two groups at 12 months after surgery (p = 0.0859). The rate of postoperative infection was consistent with the literature at 8%. In accordance with quality improvement principles, the reduction of unexplained clinical variance invariably leads to a decrease in cost and, more importantly, increased value. In this study, the implementation of a standardized shunt valve decreased operative cost. There were no differences in postoperative shunt failures at 12 months after surgery and no differences in length of surgery. Standardizing shunt valves in the treatment of pediatric hydrocephalus seems to be cost-effective and safe.

A standardized protocol to reduce preoperative hypothermia in pediatric spinal fusion surgery: a quality improvement initiative.

Hypothermia in adult surgical patients has been correlated with an increase in the occurrence of surgical site wound infections, increased bleeding, slower recovery from anesthetics, prolonged hospitalization, and increased healthcare costs. Pediatric surgical patients are at potentially increased risk for hypothermia because of their smaller body size, limited stores of subcutaneous fat, and less effective regulatory capacity. This risk is exacerbated during pediatric spinal surgery by lower preoperative temperature, increased surface exposure to cold during induction and positioning, and prolonged surgical procedure times. The purpose of this quality improvement initiative was to reduce the duration of hypothermia for pediatric patients undergoing spine surgery. Demographic and clinical data were collected on 162 patients who underwent spinal deformity surgery between October 1, 2017, and July 31, 2019. Data points included patient age, gender, diagnosis, surgical procedure, and temperature readings throughout different phases of perioperative care. Temperatures were obtained upon arrival to the day of surgery, upon presentation to the operating room, during prone positioning, at incision, and at the end of the procedure. Twelve patients were analyzed prior to implementation of a protocol, while 150 patients composed the post-protocol group. Using descriptive statistics, the authors found that the average body temperature at the time of incision was 34.0°C prior to the adoption of a preoperative warming protocol, and 35.3°C following a preoperative warming protocol (p = 0.001). There were no complications, such as burns, hyperthermia, or arrhythmias, related to preoperative warming of patients. The placement of a warming blanket on the bed prior to patient arrival and actively targeting normothermia reduced the incidence and duration of hypothermia in pediatric patients undergoing spine surgery with no adverse events.

Stereotactic depth electrode placement surgery in paediatric and adult patients with the Neuromate robotic device: Accuracy, complications and epileptological results

ObjectiveThe number of patients requiring depth electrode implantation for invasive video EEG diagnostics increases in most epilepsy centres. Here we report on our institutional experience with frameless robot-assisted stereotactic placement of intracerebral depth electrodes using the Neuromate® stereotactic robot-system. MethodsWe identified all patients who had undergone robot-assisted stereotactic placement of intracerebral depth electrodes for invasive extra-operative epilepsy monitoring between September 2013 and March 2020. We studied technical (placement) and diagnostic accuracy of the robot-assisted procedure, associated surgical complications and procedural time requirements. ResultsWe evaluated a total of 464 depth electrodes implanted in 74 patients (mean 6 per patient, range 1–12). There were 27 children and 47 adults (age range: 3.6–64.6 yrs.). The mean entry and target point errors were 1.82±1.15 and 1.98±1.05 mm. Target and entry point errors were significantly higher in paediatric vs. adult patients and for electrodes targeting the temporo-mesial region. There were no clinically relevant haemorrhages and no infectious complications. Mean time for the placement of one electrode was 37±14 min and surgery time per electrode decreased with the number of electrodes placed. 55 patients (74.3%) underwent definitive surgical treatment. 36/51 (70.1%) patients followed for >12 months or until seizure recurrence became seizure-free (ILAE I). ConclusionFrameless robot-guided stereotactic placement of depth electrodes with the Neuromate® stereotactic robot-system is safe and feasible even in very young children, with good in vivo accuracy and high diagnostic precision. The surgical workflow is time-efficient and further improves with increasing numbers of implanted electrodes.

Arthroscopic repair of massive rotator cuff tear. The role of the LHB distal tenotomy.

The aim of the study was to evaluate the results of an all arthroscopic technique for the treatment of massive rotator cuff tears using the long head of biceps as a graft to reconstruct the superior capsule and to reinforce the cuff. A retrospective review of a consecutive series of arthroscopic repair of massive rotator cuff tears using the long head of biceps tendon was conducted. Twenty-five patients underwent surgery, and none were lost at follow-up. Minimum follow-up period was more than 12months. Constant, UCLA and VAS scores as clinical outcome were analyzed. Time for surgical procedures was also registered. Two alternative procedures (transosseous or anchors) were employed to fix laterally the long head of biceps to the greater tuberosity and to reinforce the cuff. This choice was essentially determined by the bone quality of the greater tuberosity. All patients of both groups (Transosseous: 15 and Anchors: 10) showed a significant improvement of clinical and functional scores. Difference of the operative times between two procedures was statistically significant in favor of the anchor approach. No intraoperative complications were recorded. Postoperative shoulder stiffness was found in two male patients. In no case biceps tenodesis was performed: Popeye sign was easily detected in 16 patients but they did not complain any superior arm pain and weakness. This technique represents a valid solution for treatment of massive rotator cuff tears resulting safe, easier and cost saving in comparison with other published techniques.

Meta-analysis of laparoscopic mesh rectopexy versus posterior sutured rectopexy for management of complete rectal prolapse.

To evaluate comparative outcomes of laparoscopic mesh rectopexy (LMR) and laparoscopic posterior sutured rectopexy (LPSR) in patients with rectal prolapse. We conducted a systematic search of electronic databases and bibliographic reference lists with application of a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits. Recurrence, Cleveland Clinic Incontinence Score (CCIS), Cleveland Clinic Constipation Score (CCCS), surgical site infections, procedure time, and length of hospital stay were the evaluated outcome measures. We identified 5 comparative studies reporting a total of 307 patients evaluating outcomes of LMR (n=160) or LPSR (n=147) in patients with rectal prolapse. LMR was associated with significantly lower recurrence rate (OR: 0.28, P=0.009) but longer procedure time (MD: 23.93, P<0.0001) compared to LPSR. However, there was no significant difference in CCIS (MD: -1.02, P=0.50), CCCS (MD: -1.54, P=0.47), surgical site infection (OR: 1.48, P=0.71), and length of hospital stay (MD: -1.54, P=0.47) between two groups. No mesh erosion was reported in any of the included studies at maximum follow-up point. Sub-group analyses with respect to ventral mesh rectopexy, posterior mesh rectopexy, randomised studies, and adult patients were consistent with the main analysis. LMR seems to be associated with lower recurrence but longer procedure time compared to LPSR. Although no mesh-related complications have been reported by the included studies, no definitive conclusions can be made considering that the included studies were inadequately powered for such outcome. Future high-quality randomised studies with adequate sample size are required.

How Successful Is Surgical Sperm Retrieval in Klinefelter Syndrome?

Klinefelter Syndrome (KS) is characterized by the presence of an extra X chromosome. It was first diagnosed in 1942 in a group of azoospermic men. KS is the most common chromosomal abnormality encountered in infertile men and accounts for more than 10% of the causes of azoospermia. Men who are azoospermic may still father children via testicular sperm extraction followed by intracytoplasmic sperm injection (ICSI). This review article summarizes the success rates of the available techniques for surgical sperm retrieval (SSR) in KS including conventional testicular sperm extraction (cTESE) and micro testicular sperm extraction (mTESE), as well as the risks of these procedures for future fertility. The evidence indicates that the SSR rate is as successful in non-mosaic men with KS as those with normal karyotypes, with retrieval rates of up to 55% reported. The influence of different factors that affect the chances of a successful outcome are discussed. In particular, the impact of aneuploidy rate, physical characteristics, co-morbidities, reproductive endocrine balance and the use of different hormone management therapies are highlighted. Evidence is presented to suggest that the single most significant determinant for successful SSR is the age of the patient. The success of SSR is also influenced by surgical technique and operative time, as well as the skills of the surgeon and embryology team. Rescue mTESE may be used successfully following failed TESE in KS patients in combination with hormone stimulation.

Improving Outcomes in Carotid Body Tumors Treatment: The Impact of a Multidisciplinary Team Approach

The purpose of this study was to evaluate how a multidisciplinary approach, including patients and familiar genetic counseling, preoperative succinate-dehydrogenase (SDH) gene mutation analysis, preoperative adjunctive endovascular procedures (PAEPs) and postoperative rehabilitative team may affect the outcomes in patients who underwent surgery for carotid body tumors (CBTs). Fifty-seven consecutive CBT resections were performed from January 1995 to December 2019 in a single center institution. Two groups of patients were compared: group A (1995-2003; n = 10) and group B (2004-2019; n = 47), treated before and after the establishment of a multidisciplinary approach to CBTs. Group A and group B were evaluated retrospectively and prospectively for SDH mutations, respectively. PAEPs (external carotid artery stenting, percutaneous transfemoral embolization or direct percutaneous puncture of the tumor with simultaneous embolization) were performed only in patients of group B, when the size of the tumor exceeded the 45 mm. Primary endpoints were blood loss (BL) and cranial nerve injuries. Secondary endpoint was the number of new silent masses (NSMs) discovered after genetic evaluation. SDH mutations were found in 2 patients of group A and in 11 patients of group B. There were no significant differences in mass diameter between the groups. A significant difference regarding the surgical procedure time was observed in the 2 groups, with a higher time in the group A (Group A: 180 ± 77.3; Group B: 138 ± 54.5, P= 0.04). BL was significantly lower in group B (203 ± 69.5 mL vs. 356 ± 102 mL; P = 0.0001), as well as for patients underwent PAEPs vs. those underwent direct surgery (n = 15, 149 ± 53 mL vs. n = 42, 273 ± 88 mL; P = 0.0001). No differences between transient and persistent cranial nerve injuries were observed between the 2 groups. Carotid reconstruction was necessary for 2 patients of group A (n = 2 vs. n = 0; P = 0.02). Unilateral tumor recurrence was detected in 7 patients, with a significantly higher rate (P ≤ 0.002) in patients carrying SDH mutations compared to those without SDH mutation (wild-type). SDH mutations detected in the groups lead to discover 7 NSMs (group A n = 1 vs. group B n = 6; P = 1.00). The impact of the multidisciplinary team suggests that surgical resection still remains the gold standard for the treatment of CBTs, but the use of PAEPs in selected cases may reduce surgical procedure time, BL and the need for reconstructive carotid surgery. Genetic counseling and SDH gene analysis allow to diagnose NSMs in asymptomatic patients. Larger studies should be considered to evaluate the effectiveness of postoperative rehabilitative program.

The burden of waiting: wait times for pediatric surgical procedures in Quebec and compliance with national benchmarks.

BackgroundWait time information and compliance with national guidelines are limited to a few adult conditions in the province of Quebec. We aimed to assess compliance with Paediatric Canadian Access Targets for Surgery (P-CATS) guidelines and determine the burden incurred due to waiting for 3 common elective surgical conditions (inguinal hernia, cryptorchidism and hypospadias) in a pediatric population.MethodsWe carried out a population-based retrospective cohort study of randomly selected children residing in Quebec without complex chronic medical conditions, using administrative databases belonging to the Régie de l’assurance maladie du Québec for the period 2010–2013. Disability-adjusted life years (DALYs) were calculated to measure the burden due to waiting. Multivariate forward regression identified risk factors for compliance with national guidelines.ResultsSurgical wait time information was assessed for 1515 patients, and specialist referral wait time was assessed for 1389 patients. Compliance with P-CATS benchmarks was 76.6% for seeing a specialist and 60.7% for receiving surgery. Regression analysis identified older age (p < 0.0001) and referring physician specialty (p = 0.001) as risk factors affecting specialist referral wait time target compliance, whereas older age (p = 0.040), referring physician specialty (p = 0.043) and surgeon specialty (p = 0.002) were significant determinants in surgical wait time compliance. The total burden accrued due to waiting beyond benchmarks was 35 DALYs.ConclusionOur results show that provincial compliance rates with wait time benchmarks are still inadequate and need improvement. Patient age and physician specialty were both found to have significant effects on wait time target compliance.

Laparoscopic management of symptomatic congenital diaphragmatic hernia of Morgagni in the adult.

Currently, there is a relative paucity of literature regarding the management of symptomatic congenital diaphragmatic hernia of the foramen of Morgagni in the adult. This study aims to describe our unique surgical technique and outcomes in adult patients undergoing laparoscopic repair of symptomatic Morgagni hernia. This is a retrospective review of adult patients from 2003 to 2020 who underwent a laparoscopic Morgagni hernia repair at our institution. All patients underwent a similar laparoscopic approach, utilizing the surgical principles of reduction of intra-abdominal contents, complete resection of the hernia sac, followed by primary repair of the hernia defect and mesh reinforcement with permanent mesh if the primary repair was subjectively under tension. The study population consisted of 12 consecutive patients with a Morgagni hernia. Patients presented with a variety of symptoms attributed to the hernia, including pain 83% (n = 10), respiratory symptoms and shortness of breath 58% (7), and gastrointestinal obstruction 25% (3). Other complaints included: nausea 33% (4), reflux 50% (6), early satiety 8% (1), palpitations 16% (2), a gurgling sensation in the chest 8% (1), and weight loss 8% (1). Primary repair was possible in all patients following complete reduction of hernia contents including the hernia sac. Mesh reinforcement was used in 5 of 12 patients. Average surgical operative time was 93 (± 37) min. Median length of stay was 1.3days (range 0.5-5.5days). At a median follow-up of 10.9months (IQR 8.0-41.5months), all symptoms attributed to the hernia had resolved. No recurrences were identified. Adults with symptomatic Morgagni hernia should undergo surgical repair. A laparoscopic approach utilizing the surgical principles of reduction of intra-abdominal contents, complete resection of the hernia sac, followed by primary repair of the hernia defect (when possible), with or without mesh reinforcement can be performed safely and effectively.