Terms Of Reoperation Research Articles

Endoscopic third ventriculostomy versus ventriculoperitoneal shunt in patients of hydrocephalus in eastern India: A prospective observational study

Background: Hydrocephalus is a disorder of cerebrospinal fluid (CSF) physiology, resulting in an abnormal enlargement of the ventricles due to excessive accumulation of CSF. Although neurosurgical treatment has evolved over time with ventriculoperitoneal shunt (VPS) as the standard of care, procedure-related complications and poor long-term cognitive and motor milestone outcomes are still considerable, justifying the need for safer alternatives. Endoscopic third ventriculostomy (ETV) has emerged as a promising prospect especially in non-communicating hydrocephalus (NCH). Aims and Objectives: To compare the beneficial effects of ETV versus ventriculoperitoneal shunt in patients of NCH. Materials and Methods: The present prospective study was conducted at the Department of Neurosurgery, Bangur Institute of Neurosciences, IPGMER and SSKM Hospital, Kolkata from July 2021 to December 2022 among 60 patients admitted with NCH. Out of 60 patients; 30 patients underwent ETV and the remaining 30 patients VP shunting. All included patients had their history taken and relevant clinical and radiological examination done pre-operatively. They were discharged on the third post-operative day or later depending on their clinical condition and recovery. Results: Aqueductal stenosis was the most common etiology for NCH in both the groups. Post-intervention, complications and reoperation rate were reported more in VP group as compared to ETV group. Overall 3 subjects died, out of which 2 belonged to VP group and 1 to ETV group. Success was found in 70% and 86.67% of the subjects in VP and ETV group respectively. Conclusion: In patients with non-communicating or obstructive hydrocephalus, ETV was reported to be superior to VPS in terms of reoperation and complication rate at 4th, 12th, and 24th weeks after the treatment.

Does Surgical Experience Affect the Outcomes During Percutaneous Release of the Trigger Finger?

Background Trigger finger is a condition characterized by clicking or locking during finger movement, sometimes resulting in the freezing of a finger in flexion or extension. The aim of our retrospective study was to determine the effect of the surgeon's learning curve on clinical outcomes in percutaneous release of the trigger finger. In addition, we evaluated the effects of diabetes and local steroid injections on clinical outcomes. Methodology A total of 954 trigger fingers in 678 patients were reviewed from 2012 to 2022. All percutaneous release procedures were performed by a single surgeon in our institute under local anesthesia. The main outcome measures were recurrence and patient satisfaction. In addition, all patients were evaluated in terms of re-operation and complications. The mean follow-up period was 54.87 months. Results There was complete relief of symptoms in 636 (93.81%) patients, and 22 (3.24%) patients had mild pain but were satisfied. We found that the success rateincreased over time. The success rate was 91.4% in the first three years and increased to 98.25% in the next seven years (p = 0.001). There was no statistically significant difference between the diabetic and non-diabetic groups in terms of recurrence, satisfaction rate, and complications (p > 0.05). There was no statistically significant difference in terms of recurrence, satisfaction rate, and complications between the groups that received and did not receive steroid injections (p > 0.05). Conclusions Percutaneous release is a safe and reliable procedure in the treatment of trigger fingers, and the success rate increases as the experience increases. Moreover, diabetes mellitus and steroid injections did not affect the clinical results.

CAN RECONSTRUCTION IN REVISION TOTAL HIP ARTHROPLASTY WITH MAJOR ACETABULAR BONE LOSS BE REPRODUCIBLE AND RELIABLE?

Contemporary acetabular reconstruction in major acetabular bone loss often involves the use of porous metal augments, a cup-cage construct or custom implant. The aims of this study were: To determine the reproducibility of a reconstruction algorithm in major acetabular bone loss. To determine the subsequent success of reconstruction performed in terms of re-operation, all-cause revision and Oxford Hip Score (OHS) and to further define the indications for custom implants in major acetabular bone loss.Consecutive series of Paprosky Type III defects treated according to a reconstruction algorithm. IIIA defects were planned to use a superior augment and hemispherical cup.IIIB defects were planned to receive either augment and cup, cup-cage or custom implant.105 procedures in cohort 100 patients (5 bilateral) with mean age 73 years (42–94).IIIA defects (50 cases) − 72.0% (95%CI 57.6–82.1) required a porous metal augment the remainder treated with a hemispherical cup alone. IIIB defects (55 cases) 71.7% (95%CI 57.6–82.1) required either augments or cup-cage. 20 patients required a hemispherical cup alone and 6 patients received a custom-made implant.Mean follow up of 7.6 years. 6 re-revisions were required (4 PJI, 2 peri-prosthetic fractures & 1 recurrent instability) with overall survivorship of 94.3% (95% CI 97.4–88.1) for all cause revision. Single event dislocations occurred in 3 other patients so overall dislocation rate 3.8%. Mean pre-op OHS 13.8 and mean follow-up OHS 29.8.Custom implants were used in: Mega-defects where AP diameter >80mm, complex discontinuity and massive bone loss in a small pelvis (i.e., unable to perform cup-cage)A reconstruction algorithm can >70% successfully predict revision construct which thereafter is durable with a low risk of re-operation. Jumbo cup utilized <1/3 of cases when morphology allowed. The use of custom implants has been well defined in this series and accounts for <5% of cases.

Eş zamanlı karotis endarterektomi ve koroner arter baypas greftleme operasyonu yapılan hastalarda otolog perikard alternatif bir karotis yama materyali olabilir.

Backround: Dacron, polytetrafluoroethylene, great saphenous vein, and bovine pericardium are the commonly used as patch materials. However, there is no study about autologous pericardial as a patch material in carotid endarterectomy surgery. We aimed to assess the results of the use of autologous pericardial patch in patients undergoing concomitant carotid endarterectomy and coronary artery by-pass graft surgery.
 Materials and Methods:: The study involved 30 patients who underwent concomitant carotid endarterectomy with patch angioplasty and coronary artery bypass grafting surgery from January 2016 to February 2020. Patchplasty is performed with autologous pericardium for 13 patients and dacron patch for 17 patients during carotid endarterectomy. 
 Results: No statistical difference was found between the groups in terms of reoperation, arterial occlusion, restenosis, operation time, and neurological events. In the postoperative follow-up, it was determined that the amount of drainage from the area on which the carotid surgery was applied was less in the those in whom autologous pericardium was used compared to those in whom Dacron patch was used. (p=0.001)
 Conclusion: We concluded that the use of autologous pericardium as a carotid artery patch is a safe, feasible, and effective method in patients undergoing combined carotid artery and coronary bypass surgery.

Surgical outcome of endoscopic third ventriculostomy compared to ventriculoperitoneal shunt in non-communicating or obstructive hydrocephalus

Objectives: To assess and compare the effectiveness of Endoscopic Third Ventriculostomy over Ventriculoperitoneal shunt in terms of rate of revision in non-communicating or obstructive hydrocephalus at a tertiary care centre in a low-middle-income country. Materials and methods: A Prospective Cohort Study was conducted from January 2019 to December 2020 at PIMS/SZABMU, Islamabad, Pakistan. A total of 104 patients of either gender under the age of 12 years diagnosed with non-communicating/obstructive hydrocephalus were enrolled in this study. They were allocated into two equal groups of 52 by the lottery method. One group underwent Ventriculoperitoneal Shunt (Group I) and another group underwent Endoscopic Third Ventriculostomy (Group II). They received routine treatment of one-week postoperative prophylactic broad-spectrum antibiotics. They were discharged on the third postoperative day and were instructed for follow-up on the 4th, 12th and 24th postoperative week. Clinically, successful outcomes were defined as no event occurring during or after the surgery that could result in reoperation or any significant postoperative complication. Results: There were 55.8% males and 44.2% females in group I while 50.0% males and 50.0% females were in group II. The mean age of Group I was 0.89 years ± 1.5 SD while 2.3 years ± 2.8 SD in group II. During the procedure, the overall complication rate was 0% in group I and 4.1% in group II. In the 4th postoperative week, the overall complication rate was 5.9% in group I and 4.1% in group II. At the 12th postoperative week, the overall complication rate was 17.6% in group I and 2.0% in group II. On the 24th postoperative week, the overall complication rate was 9.8% in group I and none in group II. During the procedure, reoperation was needed in 0% in group I and 4.1% in group II. In the 4th postoperative week, reoperation was needed in 5.9% of patients in group I and 2.0% in group II. In the 12th postoperative week, reoperation was needed in 17.6% of patients in group I and 2.0% in group II. At the 24th postoperative week, reoperation was needed in 9.8% of patients in group I and none in group II. The overall mortality rate was 5.9% in group I and 4.1% in group II. Conclusion: Endoscopic Third Ventriculostomy procedure was found to be better than the Ventriculoperitoneal shunt in terms of reoperation and complication rate at the 4th, 12th and 24th week after the procedure in infants and children with non-communicating/obstructive hydrocephalus.

The effectiveness of antibiotic cement-coated nails in post-traumatic femoral and tibial osteomyelitis - comparative analysis of custom-made versus commercially available nails.

Background: The first objective of this retrospective study was to assess infection control rates in patients with chronic post-traumatic osteomyelitis (CPTO) of the femur or tibia treated with antibiotic cement-coated nails. The second objective was to compare the efficacy of custom-made nails versus commercially available antibiotic-coated nails in terms of infection control and need for reoperation. Methods: We reviewed a consecutive series of CPTO patients treated with antibiotic-coated nails who had a minimum follow-up of 24 months. We recorded the characteristics of the initial injury, the type of nail used, cement–nail debonding, infecting microorganisms, operating time, infection control, need for reoperation, and failure rate. We performed a comparative analysis between nails manufactured in the operating room (i.e., custom-made) and those commercially available. Results: Thirty patients were included. The affected bones were the femur () and the tibia (). Twenty-one of the 30 initial injuries were open fractures. Staphylococcus aureus was the most frequently isolated microorganism (50 %). Sixteen patients were treated with custom-made nails and 14 with commercially available antibiotic-coated nails. At the time of extraction, four out of five custom-made antibiotic-coated nails experienced cement–bone debonding. Commercial nails were associated with shorter operating times (). The overall infection control rate was 96.66 %. Eight (26.66 %) patients needed reoperation. There was one failure (3.33 %) in the group treated with custom-made antibiotic-coated nails. We did not find significant differences between nail types in terms of reoperation, infection control, and failure rate. Conclusions: The use of antibiotic cement-coated nails proved useful in CPTO treatment. Commercially available nails had significantly shorter operating times and did not present cement–bone debonding during removal. Our results seem to indicate that both nail types are similar in terms of infection control and reoperation rates.

Applicability of contemporary quality indicators in vestibular surgery\u2014do they accurately measure tumor inherent postoperative complications of vestibular schwannomas?

BackgroundDue to rising costs in health care delivery, reimbursement decisions have progressively been based on quality measures. Such quality indicators have been developed for neurosurgical procedures, collectively. We aimed to evaluate their applicability in patients that underwent surgery for vestibular schwannoma and to identify potential new disease-specific quality indicators.MethodsOne hundred and three patients operated due to vestibular schwannoma were subject to analysis. The primary outcomes of interest were 30-day and 90-day reoperation, readmission, mortality, nosocomial infection and surgical site infection (SSI) rates, postoperative cerebral spinal fluid (CSF) leak, facial, and hearing function. The secondary aim was the identification of prognostic factors for the mentioned primary outcomes.ResultsThirty-day (90-days) outcomes in terms of reoperation were 10.7% (14.6%), readmission 9.7% (13.6%), mortality 1% (1%), nosocomial infection 5.8%, and SSI 1% (1%). A 30- versus 90-day outcome in terms of CSF leak were 6.8% vs. 10.7%, new facial nerve palsy 16.5% vs. 6.1%. Hearing impairment from serviceable to non-serviceable hearing was 6.8% at both 30- and 90-day outcome. The degree of tumor extension has a significant impact on reoperation (p < 0.001), infection (p = 0.015), postoperative hemorrhage (p < 0.001), and postoperative hearing loss (p = 0.026).ConclusionsOur data demonstrate the importance of entity-specific quality measurements being applied even after 30 days. We identified the occurrence of a CSF leak within 90 days postoperatively, new persistent facial nerve palsy still present 90 days postoperatively, and persisting postoperative hearing impairment to non-serviceable hearing as potential new quality measurement variables for patients undergoing surgery for vestibular schwannoma.

Results of large pulmonary homograft implantation for right ventricular outflow tract reconstruction.

To evaluate the long-term results of implantation of homogeneous large size of pulmonary homograft (PH) for reconstruction of the right ventricular outflow tract (RVOT). Between January 2000 and December 2017, 107 patients were implanted with PH for reconstruction of the RVOT. Data were collected retrospectively in this single-center study. PH failure was defined as a peak of gradient greater than 40 mmHg and/or as a pulmonary regurgitation greater than Grade 2. Primary endpoint was the reoperation of the RVOT during follow-up. Secondary endpoints were overall survival, occurrence of PH failure and the rate of reoperation for all cause. Mean age of the recipients was 26.1 ± 13.6 years. Median follow-up interval was 2.99 years (interquartile range [IQR]: 6.2). Mean size of PH was 24.9 ± 1.9 mm. Reoperation of the RVOT occurred in eight patients (7.8%). Time before reoperation was 2.74 years (IQR: 6.4). Freedom from reoperation for RVOT at 5 and 10 years was respectively 95.7% and 90.0%. Overall survival at 10 years was 95.2%. PH failure occurred in 13 patients (12.0%). Median time before PH failure was 6.7 years (IQR: 9.6). Freedom from PH failure at 10 years was 81.6%. Reoperation for PH failure occurred in four patients (3.9%). Concomitant tricuspid surgery (p = .01; 95% confidence interval [CI]: 1.9-319.6) and undersized PH (p = .01; 95% CI: 2.06-719.8) were independent risk factors of late reoperation. Implantation of large PH for RVOT reconstruction provides excellent midterm results in terms of reoperation.

Short- and midterm outcomes of aortic arch reconstruction: Beating heart versus cardiac arrest.

We aimed to compare the short- and midterm results of perfusion strategies used for arch reconstruction surgery. One hundred and seventy-three consecutive patients who underwent aortic arch reconstruction surgery for transverse arcus hypoplasia between January 2011 and February 2020 were retrospectively analyzed. The patients were divided into two groups, as beating heart (BH) group and cardiac arrest (CA) group. The CA group comprised 60 (35%) patients and the remaining 113 (65%) patients were in the BH group. The median age of the patients was 30 (interquartile range: 18-95) days. The incidences of acute renal failure (ARF) and delayed sternal closure were higher in the CA group (p = .05, <.001, respectively). Balloon angioplasty was performed in 5 (2%) patients and reoperation was performed in 11 (6%) patients due to restenosis. There were no statistically significant differences between the two groups in terms of reoperation or reintervention rates (p = .44 and.34, respectively). Both strategies were associated with satisfactory midterm prevention of reintervention and reoperation. Given the lower incidence of ARF and delayed sternal closure in the postoperative period and similar midterm outcomes, we believe that the BH strategy is preferable.

Total Hip Arthroplasty Versus Hemiarthroplasty for Displaced Femoral Neck Fracture

Hip fractures are a leading cause of disability worldwide, with displaced femoral neck fractures being of particular concern. A recent meta-analysis reported that total hip arthroplasty (THA) was superior to hemiarthroplasty (HA) in terms of reoperations, but inferior in terms of dislocations. However, publication of 4 additional randomized controlled trials that enrolled nearly 1,780 additional patients merits an updated meta-analysis. We conducted a literature search of 4 databases to identify randomized controlled trials comparing THA and HA in patients with displaced femoral neck fractures. For patient-reported outcomes, the minimally important difference informed calculation of risk differences. We performed a subgroup analysis to address the possible impact of risk of bias and performed meta-regression to assess the possible impact of duration of follow-up. Sixteen studies that enrolled 3,084 patients randomized to undergo THA (n = 1,521) or HA (n = 1,563) proved eligible. There were no significant differences between the 2 groups in terms of the revision rate at up to 5 years of follow-up or functional outcome at up to 3 years. Health-related quality of life was superior in the THA group (mean difference [MD] = 0.05, 95% confidence interval [CI] = 0.02 to 0.07, minimally important difference, 0.145). There was no significant difference between the groups in terms of dislocation or periprosthetic fracture incidence. Operative time was significantly shorter in the HA group (MD = 22 minutes, 95% CI = 9 to 35 minutes). Analyses addressing risk of bias and length of follow-up did not reveal subgroup differences. Certainty of evidence for all outcomes was rated as moderate. The best evidence showed, with moderate certainty, that HA and THA likely result in similar revision rate, function, mortality, periprosthetic fracture, and dislocation at up to 5 years, with a small, possibly unimportant benefit in health-related quality of life with THA. More specifically, the improvements are well below established cutoffs for clinical importance. Almost half of all patients were from a single large randomized controlled trial, although the results were consistent across the studies. In addition, HA likely results in a clinically unimportant reduction in operative time. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Utilidad del drenaje quirúrgico en la cirugía de Artroplastia Total de Rodilla

Introduction. The aim of this work is to study the effect of the use of surgical drains in Total Knee Arthroplasty surgery, regarding the appearance of associated complications, the need for reoperation, blood loss and the need for transfusion, as well as postoperative mobility. Material and methods. This is a retrospective, observational, descriptive study in which 112 patients operated on for Total Knee Arthroplasty are divided into 2 groups based on the use or not of drainage. In addition to demographic variables, the following were studied: Days of post-surgery stay, loss of Hemoglobin and Hematocrit, need for transfusion, complications, and reoperations. Results. Demographic characteristics were similar in the two study groups. In the variables hemoglobin loss and hematocrit loss, statistically significant differences (p &lt;0.05) were highlighted, with a greater decrease in the group of patients who used drainage. The demographic variables, radiological Ahlbäck classification and type of prosthesis, showed potential to be modifying factors for blood loss, showing a greater decrease in PS models and in high degrees of osteoarthritis. In the other variables, no relevant differences were found between two groups. Conclusions. This study shows the absence of benefit in the use of surgical drains in total knee arthroplasty surgery. The use of this surgical technique does not entail any postoperative improvement compared to patients who did not use it in terms of reoperation needs, the appearance of complications or limitations in mobility. In fact, the drains produce a greater blood loss characterized by a greater decrease in hemoglobin and hematocrit after surgery, despite the fact that said loss does not lead to an increased need for blood transfusion.

The efficacy of clinical pathway in gastric cancer surgery.

Clinical pathways are useful tools for surgical quality improvement and better peri-operative clinical outcomes for patients undergoing major surgery. This study aimed to evaluate the influence of clinical pathway on early postoperative outcomes for gastric cancer patients. The study was designed as a retrospective cohort observational study. Patients who had undergone curative gastrectomy for gastric cancer were evaluated by using the gastric cancer database, which was prospectively maintained. The patients were divided into two groups based on the date when the clinical pathway was first used: The control group (May 2015-May 2016) and the clinical pathway group (June 2016-December 2017). Early postoperative outcomes including the length of hospital stay, start of the day of diet, and 30-day complications including reoperation, and operative mortality were compared after propensity score matching. A total of 101 patients were analyzed, and the data of 70 patients (35 patients in each group) were compared after matching. Clinical pathway group demonstrated shorter hospital stay, earlier nasogastric tube removal, and start of earlier liquid/soft diet. Overall complication rate was lower in the clinical pathway group, while there was no statistically significant difference in major complication rates. No statistically significant difference was observed between the groups in terms of reoperation and operative mortality. Clinical pathway may shorten the postoperative length of hospital stay and reduce the overall complication rate without increasing major morbidity in patients undergoing elective gastric cancer surgery.

Outcomes of mitral valve repair compared with replacement for patients with rheumatic heart disease

ObjectiveWhether mitral valve repair is superior to replacement in the population with rheumatic heart disease has been debated. This study aims to compare outcomes of repair with replacement by the propensity score method. MethodsThis observational, prospective study enrolled patients with rheumatic heart disease who underwent mitral valve repair and replacement from January 2011 to April 2019. The propensity score method was used to select 2 groups with similar baseline characteristics. Baseline, clinical, and follow-up data were collected. Clinical outcomes included death from any cause, reoperation, and valve-related complications. ResultsThe overall population before matching (N = 1644) included 612 patients who underwent repair and 1032 patients who underwent replacement. The propensity score analysis generated matches for 1058 patients (529 pairs). The median follow-up time was 4.12 years. Early mortality and death from any cause during follow-up were significantly lower in the repair group compared with the replacement group (hazard ratio, 0.19; 95% confidence interval [CI], 0.05-0.64; P = .003; hazard ratio, 0.38; 95% CI, 0.19-0.74; P = .003, respectively). Patients in the repair group had a lower risk of valve-related complications compared with patients in the replacement group (subhazard ratio, 0.44; 95% CI, 0.21-0.90; P = .025). In terms of reoperation, no significant difference was observed between the repair and replacement groups (subhazard ratio, 2.54; 95% CI, 0.89-7.22; P = .081). ConclusionsThe results suggest that rheumatic mitral valve repair in select patients is superior to mitral valve replacement with regard to lower mortality and fewer valve-related complications; meanwhile, it has a comparable risk of reoperation compared with replacement.

Predictive Factors for Postoperative Outcome in Children with Jejunoileal Atresia.

Background Jejunoileal atresia is a relatively rare congenital gastrointestinal requiring surgery and long postoperative care. The postoperative outcome is affected by many factors and this study focuses on finding predictors for time to full enteral feeding, length of hospital stay (LOH), and postoperative complications. Methods This was a retrospective study of all children operated for isolated jejunoileal atresia between 2001 and 2017 at a tertiary center of pediatric surgery. Independent variables regarding demographical-, operative-, and postoperative data were abstracted. Primary outcome was time to full enteral feeding, LOH, and postoperative complications in terms of reoperation or central line complication. Any significant variables from the univariate analysis were further analyzed with logistic regression and presented as odds ratio with 95% confidence interval. Results After exclusion because of concomitant gastroschisis ( n = 1), and death before discharge ( n = 2), 47 patients were further analyzed (49% boys, 53% premature). No significant differences could be seen in the univariate analysis between children with short and long time (median > 17 days) to full enteral nutrition. Patients with longer LOH (median >32 days) had significantly lower birth weight compared with those with shorter LOH; median 2,550 g versus 2,980 g ( p = 0.04). Patients with a central line complication had significantly longer median time to full enteral feeding (median 27 vs. 12 days, p = 0.03), and significantly longer median LOH (median 43 vs. 21 days, p = 0.03), but these parameters were not significant in a multivariate analysis. No significant results were found regarding reoperation. Conclusion Low birth weight seems associated with an increased LOH in children operated on for jejunoileal atresia, and central line complications seem related to the duration with central line in this group. The small cohort may constitute a power problem in this study and further research regarding the included variables may reveal more potential predictors for the postoperative outcome.

Investigating rates of reoperation or postsurgical gastroparesis following fundoplication or paraesophageal hernia repair in New York State.

Little is known of the natural history of fundoplication or paraesophageal hernia (PEH) repair in terms of reoperation or the incidence treatment of postsurgical gastroparesis (PSG) in large series. Repeat fundoplications or PEH repairs, as well as pyloroplasty/pyloromyotomy operations, have proven to be effective in the context of PSG or recurrence. In this study, we analyzed the incidences of PSG and risk factors for these revisional surgeries following fundoplication and PEH repair procedures in the state of New York. The New York State Planning and Research Cooperative System (NY SPARCS) database was utilized to examine all adult patients who underwent fundoplication or PEH repair for the treatment of GERD between 2005 and 2010. The primary outcome was the incidence of each type of reoperation and the timing of the follow-up procedure/diagnosis of gastroparesis. Generalized linear mixed models were used to examine the risk factors for follow-up procedures/diagnosis. A total of 5656 patients were analyzed, as 3512 (62.1%) patients underwent a primary fundoplication procedure and 2144 (37.9%) patients underwent a primary PEH repair. The majority of subsequent procedures (n = 254, 65.5%) were revisional procedures (revisional fundoplication or PEH repair) following a primary fundoplication. A total of 134 (3.8%) patients who underwent a primary fundoplication later had a diagnosis of gastroparesis or a follow-up procedure to treat gastroparesis, while 95 (4.4%) patients who underwent a primary PEH repair were later diagnosed with gastroparesis or underwent surgical treatment of gastroparesis. The results revealed low reoperation rates following both fundoplication and PEH repairs, with no significant difference between the two groups. Additionally, PEH repair patients tended to be older and were more likely to have a comorbidity compared to fundoplication patients, particularly in the setting of hypertension, obesity, and fluid and electrolyte disorders. Further research is warranted to better understand these findings.

Outcomes of Surgical Repair of Complex D-Transposition of the Great Arteries.

D-transposition of the great arteries (TGA) or TGA-type double outlet right ventricle (DORV) with ventricular septal defect (VSD) and left ventricular outflow tract obstruction (LVOTO) may be treated with the arterial switch operation (ASO), Rastelli, Réparation à l'Etage Ventriculaire (REV), or Nikaidoh procedures. We evaluated midterm results of these techniques. We retrospectively reviewed 42 cases of anatomic repair from 2005 to 2014 at our institution for TGA (n = 29) or TGA-type DORV (n = 13) with VSD and LVOTO. We analyzed outcomes (mortality, reoperation, residual/recurrent LVOT peak gradient ≥20 mm Hg, right ventricular outflow tract [RVOT] peak gradient ≥40 mm Hg) and performed a risk analysis. Mean follow-up was 5.77 ± 3.08 years. Seventeen (40.5%) patients had an ASO with (n = 4) or without (n = 13) LVOTO resection. The Rastelli, REV, and Nikaidoh procedures were used in 14 (33%), 5 (12%), and 6 (14%) patients, respectively. There were no mortalities or moderate aortic insufficiency at last follow-up. Three (9%) patients developed LVOT gradient ≥20 mm Hg, while nine (21.4%) patients had RVOT obstruction. Reoperations included RVOT/pulmonary artery reoperation (n = 10; 23.8%) and LVOT reoperation (n = 1; 2.5%). Freedom from reoperation was 84% ± 6% and 75% ± 9% at one and three years, respectively, for the entire cohort with no differences between groups by type of operation (log-rank P = .64). The Nikaidoh procedure compared favorably to all other techniques in terms of reoperation (n = 0/6; 0% vs n = 13/36; 36%; P = .08). Midterm outcomes after anatomic repair for TGA or TGA-type DORV with LVOTO and VSD are excellent but vary by surgical technique. The Nikaidoh procedure seems to compare favorably to the other techniques.

Spinal Implants Can Be Inserted in Patients With Deep Spine Infection

A retrospective, cohort study of 84 patients with deep spine infection managed at a major tertiary hospital over 14 years with a minimum follow up of 2 years. To determine the role of instrumentation in spines with deep infection. It is often believed that implants should not be inserted in patients with deep spine infection because of the risk of persistent or recurrent infection. However, there are often concerns about spinal stability and a paucity of evidence to guide clinical practice in this field. We compared the mortality, reoperation, and reinfection rates in patients with spine infection treated with antibiotics alone, antibiotics with debridement, and antibiotics with debridement and instrumentation. Significant outcome predictors were determined using multivariable logistic regression model. Forty-nine males and 35 females with a mean age was 62.0 years had spine infection affecting the lumbar spine predominantly. The most common form of infection was osteomyelitis and spondylodiscitis (69.4%). Staphylococcus aureus was the most common causative organism (61.2%).There was no difference in terms of reoperation or relapse for patients treated with antibiotics alone, antibiotics with debridement, or antibiotics with debridement and instrumentation. However, compared with antibiotics alone, the crude inhospital mortality was lower for patients treated with instrumentation (odds ratio, OR, 0.82; P = 0.01), and antibiotics with debridement (OR 0.80; P = 0.02). Spinal instrumentation in an infected spine is safe and not associated with higher reoperation or relapse rates. Mortality is lower for patients treated with instrumentation. 3.

Centres that do not offer TLH as their primary method of hysterectomy should be considered outdated and not Fit for Purpose: AGAINST: To allow one their informed choice may mean others have no choice at all.

The delivery of a laparoscopic hysterectomy service presents many challenges, not all of which can be met by every centre. The availability of appropriately trained doctors is limited by access to Advanced Training Skills Modules (ATSMs) in Benign Gynaecology and Advanced Laparoscopy, which not all consultants have yet undertaken. In addition to the doctors, theatre personnel who know how to use and maintain the equipment are also essential. Affordability is another factor given that laparoscopic hysterectomies use more consumables and operative time. Training has a long learning curve and time taken to complete surgery can be many hours per case. Most health economic arguments that support this approach assume that all operators are equally skilled and take similar operative time, when we know that not to be true. Operative time is a finite and expensive resource, and targets from referral to definitive management currently drive the service more than quality-of-life outcomes. They also assume that all patients who have laparoscopic surgery only stay for 1 day. Remuneration is not the same across all institutions. Currently the tariff for laparoscopic hysterectomy is lower than for open hysterectomy. They also do not account for the cost of acquisition, amortisation, and maintenance, nor for the cost of higher complication rates, both in terms of re-operations and prolonged stays in hospital. As the surgical techniques are refined, the cases for which they are advocated increase in both number and complexity, with a commensurate increase in the equipment required delivering it. With time the cost of delivery can only rise. All these factors make affordability a major issue in most centres. The patient's anatomy, performance status, and pathology of the condition to be managed also have an influence. Treatments such as the intrauterine system (IUS), endometrial ablation, and hysteroscopic surgery means that hysterectomy is reserved for more challenging pathology, such as fibroids and endometriosis. Sometimes an open approach is intrinsically safer. It is no longer acceptable to reduce a fibroid in size in order to aid its removal because of the risk of disseminating previously unrecognised cancer. The US Food and Drug Administration (FDA) estimates this risk to be 1/350, and although this figure is debated, it would be a foolhardy surgeon that ignores it. Thus a fibroid that obstructs safe access to the uterine vessels, pelvic sidewall or cannot be removed intact is not suitable. Only surgeons trained in advanced laparoscopic techniques can manage rectosigmoid disease and dense adhesions safely. Advanced ovarian cancer will usually require an open approach. The needs and priorities of health care vary widely in resource-rich and resource-poor countries. The quality-of-life outcomes have little relevance when maternal and perinatal mortality is high. Training in these countries is quite appropriately focused on the improvement of maternity care. The supply of basics such as sutures, swabs, and an electrical supply are more pressing matters than the ability to deliver complex minimal-access surgery. In a state-provided service, the needs of the population supersede those of the individual. Thus an individual patient's ‘rights’ should be seen within the context of safety and affordability. To allow one their informed choice may mean others have no choice at all. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Risk factors and consequences of perioperative reoperation in patients undergoing pulmonary resection surgery

Perioperative reoperation is generally agreed to be necessary for the management of particular, severe complications. Understanding the incidence and predictors of perioperative reoperation enables surgeons to improve surgery quality. The objective of this study is to investigate the incidence, risk factors, and consequences of perioperative reoperation after pulmonary resection. Data from patients who underwent perioperative reoperation after pulmonary resection surgery over the past 6years in our department were reviewed retrospectively. A propensity score-matched analysis was performed to identify the association between reoperation and clinical outcomes. Univariate and multivariate analysis were used to analyze independent risk factors for the occurrence of reoperation. Overall, 19,304 patients with various lung diseases who underwent pulmonary resection surgeries were analyzed retrospectively, in which 195 patients (1.01%) required reoperation for severe perioperative complications. The leading cause for reoperation was hemorrhage in 143 (73.33%) patients, followed by bronchopleural fistula in 22 patients (11.28%). Further indications for reoperation were chyle leak, bronchial esophageal fistula, empyema, pulmonary congestion, air leak, and femoral artery embolism. The mortality of reoperation was 5.13% (10/195), with the highest (33.33%) among bronchial esophageal fistula and empyema. Patients undergoing reoperation had a higher mortality at hospital discharge, a longer duration of hospital stay, and a lesser incidence of postoperative transfusion (P<.05). Logistic regression indicated that patients with comorbidity, operative approach of open thoracotomy, and location of upper lobe were independent risk factors for the occurrence of early reoperation that performed within 24hours (P<.05); however, operative approach showed no significance in terms of reoperation that happened beyond 24hours (P=.087). The incidence of perioperative reoperation after pulmonary resection surgery is low and is mainly related to technical issues from the initial operation. The most common complication is hemorrhage, and the mortality of reoperation in bronchial esophageal fistula and empyema is higher than in others. Patients undergoing reoperation had a higher mortality at hospital discharge, a longer duration of hospital stay, and a lesser incidence of postoperative transfusion. Preoperative comorbidity, operative approach of open thoracotomy, and location of upper lobe were independent risk factors for the occurrence of early perioperative reoperation that was performed within 24hours; approach of surgery was not significant in terms of reoperation that happened beyond 24hours.

An improved dual approach to post bariatric contouring - Staged liposuction and modified medial thigh lift: A case series.

Objective:Following massive weight loss (MWL) medial contouring of the thigh is frequently requested to improve appearance and function. Thigh lifting can be associated with significant complications. We present a case series of post bariatric patients undergoing thigh lift using staged the liposuction, a modified T incision and a buried de-epithelialised dermal flap.Materials and Methods:From January to December 2012, 21 consecutive patients underwent a modified medial thigh lift. A retrospective review of the case notes was performed to assess complications that occurred.Results:There were no major post-operative complications in terms of reoperation, hematoma, thromboembolism and no seromas. Seven patients, all of which were smokers had minor superficial wound healing complications. Aesthetic outcomes were satisfactory for all patients at a minimum follow-up of 6 months.Conclusions:The modified ‘T’ incision with staged liposuction is described. We have found the technique to be useful for a variety of different thighs. It is a reproducible method for contouring the medial thigh in MWL patients. In this series, our overall complications were low, and no seromas occurred.