Time Of Initial Surgery Research Articles

Impact of Intraoperative Branch Embolization for Type 2 Endoleak Prevention During Endovascular Abdominal Aortic Repair

Endovascular abdominal aortic repair (EVAR) has a significantly higher revision rate than open repair, primarily due to Type 2 Endoleak (2EL). Although 2ELs are considered benign, late open conversion (LOC) due to the expansion of the aneurysm diameter of the 2EL is a concern in the mid- and long-term. In this study, we investigated the impact of embolization of the inferior mesenteric artery (IMA) or lumbar artery (LA) at the time of the initial EVAR and its long-term outcomes. Between April 2008 and December 2021, 743 EVAR procedures for abdominal aortic aneurysms (AAAs) were performed at our institution. The patients were divided into two groups at the time of initial surgery, namely, 215 and 528 patients in the embolization (Group E) and non-embolization (Group N) groups, respectively. Branch embolization was performed in patients with an IMA diameter ≥3 mm and LA diameter ≥2 mm on preoperative computed tomography. Re-embolization with EL was performed in patients with a diameter enlargement ≥10 mm, and LOC was performed in patients with continued enlargement ≥15 mm after re-embolization. The mean follow-up period was 7.0 years. The mean number of branch embolizations was 2.3±1.1. Intraoperatively, the operative time, fluoroscopy time, irradiation dose, and contrast medium use were significantly higher in Group E than in Group N. There was a significant difference between the two groups regarding shrinkage (Groups E vs. N: 45.6% vs. 37.3%; p=0.03) and enlargement (Groups E vs. N: 9.3% vs. 19.5%; p<0.001) of the aneurysm diameter by >5 mm after EVAR. In the mid- and long-term, the avoidance rate of 2EL reintervention was significantly lower in Group E at 5 years (93.5% vs. 88.6%) and 10 years (87.5% vs. 76.4%; p=0.04). LOC prevention was 5 years; Group E: 100% vs. 96.9% for Group N, and 10 years; Group E: 98.8% vs. 92.5% for Group N, significantly lower in Group E (p=0.02). The impact of branch embolization at the time of the initial EVAR is believed to prevent enlargement of the aneurysmal sac and LOC. However, prolonged operation time, increased radiation exposure, and the use of contrast medium have been debated. To improve the long-term results of EVAR, embolisms of both the IMA and LA are required.

Expression of integrin αvβ3 in medullary thyroid carcinoma.

Aim: Tumor markers often remain elevated after intended curative resection of medullary thyroid carcinoma (MTC). The aim of this study was to determine the expression of αvβ3, a promising theranostics target, in MTC and its metastases.Materials & methods: Avβ3 expression was analyzed in 104 patients using a tissue microarray and correlated with clinicopathological variables and survival.Results: Cytoplasmic αvβ3 positivity was seen in 70 patients and was associated with lymph node metastases at time of initial surgery. Membranous positivity was considered positive in 30 patients and was associated with sporadic MTC.Conclusion: Avβ3 was expressed in the cytoplasm of 67% of MTC patients. Membranous expression, which is presumably most relevant for the theranostic use of αvβ3, was seen in 29%.

Remediation of Heavy Metal Pollution from Coal Mine Effluent Using Metal-Organic Frameworks (MOF): Impact of Water Media, Operational Factors and Metal Characteristics

The energy sector is the sector that generates the highest amount of environmental contamination, especially in water sources, mostly in the case of coal-based energy production. The aim of this study was to examine a significant contamination source, heavy metal contamination, in coal mining effluents. The current investigation introduces an MOF platform based on zirconium clusters and isophthalic acid with NH2-MIP-SO3H mixed amine and sulfonic acid functional groups in order to remove the most common heavy metal ions in coal mining effluents, including Hg, Cd, Pb, and Cu ions. The water matrix and the operational conditions were identified to be very influential in the removal process, such as the pH of water, the initial metal concentration and operating time. NH2-MIP-SO3H offers a great removal efficiency of metals starting from 745.83 mg/g for Cd, 673.67 mg/g for Cu, 589.85 mg/g for Hg, and 481.66 mg/g for Pb ions, with the Langmuir equation for equilibrium and pseudo-second-order equation for kinetics being the ideal models to express the equilibrium and kinetic data, respectively. A significant impact of water pH was found to occur, with the NH2-MIP-SO3H platform performing best at pH 6. Reuse of NH2-MIP-SO3H demonstrates excellent reusability, sustaining 90% of initial performance over eight regeneration cycles. The interaction of functional group-functional metal was the dominant mechanism in the removal process. The NH2-MIP-SO3H unique approach to heavy metal removal provides a very hopeful outlook for additional investigations in larger-scale studies.

Ectopic adrenocorticotropic hormone syndrome in patients with olfactory neuroblastoma.

Olfactory neuroblastomas rarely secrete adrenocorticotropic hormone, leading to ectopic adrenocorticotropic hormone syndrome. However, the prevalence, timing, and triggers of ectopic adrenocorticotropic hormone syndrome in patients with olfactory neuroblastomas remain unclear. This study aimed to investigate these factors and conduct a literature review. Fifteen patients with olfactory neuroblastomas who underwent surgery at our institution were included. The prevalence of ectopic adrenocorticotropic hormone syndrome development was assessed by evaluating adrenocorticotropic hormone expression using immunohistochemistry. Furthermore, 26 patients with olfactory neuroblastomas who developed ectopic adrenocorticotropic hormone syndrome from previous reports were reviewed. Among the 15 patients, three (20%) showed adrenocorticotropic hormone-positive tumor cells at the time of initial surgery, and two (13%) developed ectopic adrenocorticotropic hormone syndrome. The timing of developing ectopic adrenocorticotropic hormone syndrome was 2.5 and 10 years following the initial treatment of olfactory neuroblastoma. Based on the literature review, nine patients with recurrent and metastatic olfactory neuroblastoma developed ectopic adrenocorticotropic hormone syndrome after the initial surgery, of whom, three had confirmed disease after developing ectopic adrenocorticotropic hormone syndrome, three developed during disease progression, two developed after receiving chemotherapy, and one developed after undergoing a biopsy. The timing of ectopic adrenocorticotropic hormone syndrome was 2.5-15 years after initial treatment. Our study revealed that acknowledging olfactory neuroblastomas can manifest as ectopic adrenocorticotropic hormone syndrome with a certain low prevalence is crucial. Moreover, our study speculated that tumor stimulation, such as biopsy or chemotherapy, as well as disease progression, could trigger ectopic adrenocorticotropic hormone syndrome onset. Thus, olfactory neuroblastomas can develop into ectopic adrenocorticotropic hormone syndrome, even long after the initial treatment.

A case of pediatric Perthes’ disease with unexplained hyperlactatemia at the time of initial surgery and anesthetic management with remimazolam for the subsequent surgery

BackgroundThe causes of perioperative hyperlactatemia vary, but they are generally associated with hypoperfusion. Here, we report the case of a pediatric patient who developed unexplained hyperlactatemia during anesthesia with propofol and sevoflurane, which recurred during a second surgery under anesthesia with remimazolam.Case presentation.An 8-year-old boy with Perthes disease and no remarkable past or family history was scheduled for an osteotomy. Anesthesia was induced with propofol and rocuronium and then maintained with sevoflurane and remifentanil. The patient developed lactic acidosis without hemodynamic instability during anesthesia, with a normal lactate/pyruvate ratio after surgery, suggesting a lack of hypoperfusion. We used remimazolam instead of propofol during the second surgery 6 months later, considering the possibility of drug-induced lactic acidosis, including malignant hyperthermia and propofol infusion syndrome, where the unexplained hyperlactatemia recurred.ConclusionsDistinguishing the causes of hyperlactatemia, particularly in the absence of other symptoms, is challenging. The lactate/pyruvate ratio during episodes of hyperlactatemia can provide insights into the underlying pathology.

Clinical and pathological spectrum of aortitis in a Chinese cohort

BackgroundThis study aimed to explore the clinical and pathological features of aortitis in China, which is a rare disease that is often overlooked preoperatively. MethodsWe reviewed the records of 2950 patients who underwent aortic surgery at Wuhan Asia General Hospital from 2016 to 2023. Clinical and pathological data were collected and compared across different groups. ResultsOut of 2950 patients, 15 had healed aortitis, 2 were healed Takayasu aortitis (TAK), and 13 were not further classified. Forty-two had active aortitis, including clinically isolated aortitis ([CIA], 42.9%), infectious aortitis ([IA], 26.2%), TAK (16.7%), and Behçet's syndrome ([BS], 14.3%), half of these cases were not recognized preoperatively. All patients who developed perivalvular leakage during follow-up had concurrent non-infectious valvulitis with mixed inflammatory pattern at the time of initial surgery. Seventeen out of 18 patients with CIA survived without complications, as did 8 out of 11 patients with IA, 6 out of 7 patients with TAK, and 2 out of 6 patients with BS. ConclusionsHalf of the aortitis cases were initially diagnosed by pathologists. Noninfectious valvulitis with mixed inflammatory pattern is a risk factor for perivalvular leakage. BS is associated with a higher rate of complications. Patients with CIA have a good prognosis in China, which is different from the West.

Biomechanical Comparison of Impaction Techniques and Cross-Sectional Femoral Stem Shapes for Cementless Total Hip Arthroplasty.

Traditional mallet broaching and stem seating in cementless total hip arthroplasty (THA) can result in femoral stem misalignment, potentially reducing implant longevity. This study aimed to compare the pullout strength of cementless THA femoral stems with different cross-sectional designs achieved through the powered impactor method versus the traditional mallet method. The authors utilized 24 polyurethane foam femurs and two femoral bone preservation stems with different proximal cross-sectional shapes (double taper: ACTIS®, size 5; flat taper: TRI-LOCK®, size 5). A single orthopedic surgeon broached each femur from size 0 to size 5 using either the powered impactor or mallet impaction methods. Broaching time and component implantation times were recorded. A load-to-failure pullout strength test was conducted, and the ultimate pullout load was recorded. The broaching time for the TRI-LOCK® stem showed a statistically significant difference between the two impaction methods (powered: 37±7 seconds, mallet: 75±29 seconds, F[3, 20] = 4.56, p = 0.002), but no statistically significant difference was detected for the ACTIS® stem between the two impaction methods (powered: 47±22 seconds, mallet: 59±9 seconds, F[3, 20] = 4.56, p = 0.304). There was a statistically significant difference in pullout strength between the two impaction groups, and this strength was influenced by the implant cross-sectional shape (ACTIS®: 774±75N versus 679±22N, F(3,20) = 16.38, p = 0.018; TRI-LOCK®: 616±57N versus 859±85N, F(3, 20) = 16.38, p <0.001). The technique used for femoral bone preparation (powered impactor versus mallet) and the cross-sectional design of the cementless femoral stem are crucial factors that affect initial stem stability and operation time.

Abstract IA012: The role of the serine/threonine phosphatase PP2A in endometrial cancer development and progression: lessons learned from mutations and small molecules

Abstract Uterine cancer is the most common gynecologic malignancy in the United States with approximately 60,000 new diagnoses each year. While many cases of uterine endometrial carcinoma (EMCA) have favorable outcomes with recurrence-free long-term survival, outcomes for the high-grade, treatment-refractory histological subtypes, including uterine serous carcinoma (USC) and uterine carcinosarcoma (UCS), remain an important clinical problem. Uterine serous carcinomas and uterine carcinosarcomas tumors are the most aggressive subtypes of uterine cancer, displaying a high propensity to invade the peritoneal cavity and to metastasize to distant sites. Accordingly, 50-70% of high-grade tumors exhibit extrauterine spread at time of initial surgery and have limited treatment options. The inherent aggressiveness of these tumors suggests that they are intrinsically equipped to disseminate and propagate tumors at secondary sites. The molecular drivers of this phenotype, however, have yet to be completely characterized. A lack of established and validated molecular drivers of the high-grade subtypes, especially those that are responsible for the high rate of metastasis, has limited the use of targeted treatment strategies. However, we and other groups have shown that PPP2R1A, the scaffolding subunit of the tumor suppressor protein phosphatase 2A, is mutated in up to 40% of USC patients, and these recurrent mutations are found at both the primary and metastatic sites. These mutations are heterozygous, and two specific mutations: P179R and S256F, occur exclusively within these high-grade subtypes of uterine cancer (i.e., are not found in any other cancer type). PP2A, is a family of serine/threonine phosphatases, where the active heterotrimeric form of the enzyme is comprised of a catalytic (C) subunit, a scaffolding (A) subunit, and a substrate directing regulatory (B) subunit. In aggregate, PP2A is considered a tumor suppressor protein, but certain heterotrimers have tumor promoting roles. Here we present data related to the molecular and biological basis through which these recurrent pathogenic mutations drive endometrial cancer development and progression using disease relevant cellular and in vivo model systems. Additionally, building from previously published work from our group, we have developed a novel series of small molecule molecular glues (PMGs) that specifically correct the mutant heterotrimer driving tumor regressions in both cellular and patient derived xenograft models of high-grade endometrial cancer. Collectively, this data suggests that recurrent pathogenic mutations in the PPP2R1A gene drive endometrial cancer pathogenesis and these mutations can be therapeutically targeted using a series of pharmaceutically tractable small molecules. Citation Format: Goutham Narla. The role of the serine/threonine phosphatase PP2A in endometrial cancer development and progression: lessons learned from mutations and small molecules [abstract]. In: Proceedings of the AACR Special Conference on Endometrial Cancer: Transforming Care through Science; 2023 Nov 16-18; Boston, Massachusetts. Philadelphia (PA): AACR; Clin Cancer Res 2024;30(5_Suppl):Abstract nr IA012.

Predicting Contralateral Surgery for Trapeziometacarpal Arthrosis Within 5 Years

Symptomatic trapeziometacarpal (TMC) joint arthritis is a common cause of hand pain. It is unknown how many patients ultimately elect to have bilateral surgery for TMC arthritis. In this study, we assessed the frequency and predictive factors for contralateral TMC surgery in patients who underwent prior TMC surgery. We identified 712 patients who underwent primary surgery for TMC arthritis with a follow-up period of 5 years. We collected demographic, surgical, and follow-up data. Prediction models for contralateral surgery using a training and testing data set were created with multivariable logistic regression and random forest classifier algorithms. At the time of initial surgery, 230 patients had bilateral thumb pain (32%), but only 153 patients ultimately had an operation for TMC arthritis on the contralateral side within 5 years (21% of 712 total patients and 67% of 230 patients with bilateral pain). Common predictive factors between both models for contralateral surgery were younger age (odds ratio [OR]= 0.95; 95% confidence interval [CI], 0.93-0.98), bilateral thumb pain (OR= 3.76; 95% CI, 2.52-5.65), and anxiety disorders (OR= 1.84; 95% CI, 1.11-3.03). In our study, we found that the rate of contralateral surgery was 21% in patients who underwent prior TMC surgery. Predictive factors for future contralateral surgery included younger age, bilateral thumb pain, and anxiety disorder at the time of initial surgery. Prognostic II.

A modified triple tibial osteotomy for management of canine cranial cruciate ligament disease: retrospective assessment of 309 procedures (2017–2020)

ABSTRACTCase historyMedical records from a single referral hospital (Animal Referral Hospital, Sinnamon Park, Australia) of dogs treated with modified triple tibial osteotomy (TTO) for management of cranial cruciate ligament (CrCL) disease from June 2017 to June 2020 were reviewed. Modifications to the originally described TTO procedure included a modified wedge angle calculation and performing the tibial osteotomies without the use of pre-drilled guide holes.Clinical findingsA total of 253 dogs met the inclusion criteria. Two dogs were excluded, leaving 251 dogs that had undergone 309 procedures for assessment, and data from these, including complications, were reviewed. Complete, partial competent, and partial incompetent rupture of the cranial cruciate ligament was identified in 202/309 (65.4%), 79/309 (25.6%), and 28/309 (9.1%) stifles, respectively. Medial meniscal injury was identified in 207/309 (67.0%) stifles at the time of initial surgery.Treatment and outcomeFifty-eight dogs had bilateral procedures, including both single-session and staged surgeries, and 48 of these were available for analyses. The modifications to the TTO procedure described herein resulted in a median wedge angle of 21° and a median post-operative tibial plateau angle of 5.8°. Tibial compression testing following surgery indicated elimination of cranial tibial thrust in all stifles in this series. The most common intra-operative complication was tibial tuberosity fracture (15/309; 4.9%). Minor post-operative complications occurred in 37/309 (12.0%) procedures, with infection being the most common (27/309; 8.7%). Major post-operative complications occurred in 9/309 (2.9%) procedures. The intra- and post-operative complication rates for dogs undergoing bilateral single-session TTO were both 8.3% (2/24). The intra- and post-operative complication rates for dogs undergoing bilateral staged TTO were both 4.2% (1/24). The low number of complications for both the bilateral single-session and bilateral staged TTO groups precluded statistical analysis. All complications resolved uneventfully as determined by the attending surgeon.Clinical relevanceThe modified TTO technique described here was safe and effective for the management of canine CrCL disease in the dogs included in the case series. Findings of this study suggest that, with careful case selection, the modified TTO may be performed as a bilateral single-session procedure in dogs with concurrent bilateral cranial cruciate ligament disease. Future studies analysing the effects of these modifications on stifle biomechanics would be beneficial.AbbreviationsCrCL: Cranial cruciate ligament; SSI: Surgical site infection; TPA: Tibial plateau angle; TPLO: Tibial plateau levelling osteotomy; TTA: Tibial tuberosity advancement; TTO: Triple tibial osteotomy

Lower levels of Th1 and Th2 cytokines in cerebrospinal fluid (CSF) at the time of initial CSF shunt placement in children are associated with subsequent shunt revision surgeries

ObjectiveWe compare cytokine profiles at the time of initial CSF shunt placement between children who required no subsequent shunt revision surgeries and children requiring repeated CSF shunt revision surgeries for CSF shunt failure. We also describe the cytokine profiles across surgical episodes for children who undergo multiple subsequent revision surgeries. MethodsThis pilot study was nested within an ongoing prospective multicenter study collecting CSF samples and clinical data at the time of CSF shunt surgeries since August 2014. We selected cases where CSF was available for children who underwent an initial CSF shunt placement and had no subsequent shunt revision surgeries during >=24 months of follow-up (n = 7); as well as children who underwent an initial CSF shunt placement and then required repeated CSF shunt revision surgeries (n = 3). Levels of 92 human cytokines were measured using the Olink immunoassay and 41 human cytokines were measured using Luminex based bead array on CSF obtained at the time of each child’s initial CSF shunt placement and were displayed in heat maps. ResultsQualitatively similar profiles for the majority of cytokines were observed among the patients in each group in both Olink and Luminex assays. Lower levels of MCP-3, CASP-8, CD5, CXCL9, CXCL11, eotaxin, IFN-γ, IL-13, IP-10, and OSM at the time of initial surgery were noted in the children who went on to require multiple surgeries. Pro- and anti-inflammatory cytokines were selected a priori and shown across subsequent revision surgeries for the 3 patients. Cytokine patterns differed between patients, but within a given patient pro-inflammatory and anti-inflammatory cytokines acted in a parallel fashion, with the exception of IL-4. ConclusionsHeat maps of cytokine levels at the time of initial CSF shunt placement for each child undergoing only a single initial CSF shunt placement and for each child undergoing repeat CSF shunt revision surgeries demonstrated qualitatively similar profiles for the majority of cytokines. Lower levels of MCP-3, CASP-8, CD5, CXCL9, CXCL11, eotaxin, IFN-γ, IL-13, IP-10, and OSM at the time of initial surgery were noted in the children who went on to require multiple surgeries. Better stratification by patient age, etiology, and mechanism of failure is needed to develop a deeper understanding of the mechanism of inflammation in the development of hydrocephalus and response to shunting in children.

Bilateral Inferior Turbinate Flaps for Salvage Reconstruction after Proton Beam Radiotherapy for Clival Chordoma.

Clival chordoma is a rare, aggressive, notochord-derived tumor primarily managed with surgery via an endoscopic endonasal approach (EEA) and adjuvant proton beam radiotherapy. Reconstruction is commonly performed with a nasoseptal flap (NSF) at the time of initial surgery. While failures of the NSF are rare, they can occur following the initial surgery or in the setting of osteoradionecrosis. Salvage repair typically requires transfer of alternative vascularized tissues outside of the previously radiated field including regional scalp flaps such as pericranial or temporoparietal fascial flaps, or free vascularized tissue transfer. Here we describe the case of a 29-year-old woman with a history of clival chordoma with widespread skull base osteomyelitis secondary to NSF necrosis after proton beam radiotherapy. We describe successful skull base reconstruction with intranasal bilateral inferior turbinate flaps based on the sphenopalatine artery with lateral nasal wall extension, despite prior proton beam therapy and a failed prior vascularized intranasal reconstruction.

114. A Nationally Validated Novel Risk Assessment Score for Prediction of Unplanned Reoperations and Readmissions in Hand Surgery

PURPOSE: Risk predictors are an emerging tool as the need for granular, individualized risk estimation remains necessary for informed patient counseling and clinical decision making. Existing comorbidity-driven risk indices have had varied success in accurately predicting risk in hand surgery. This study provides a novel risk score for reliably predicting reoperations and readmissions in hand surgery. METHODS: Hand surgeries from the National Surgical Quality Improvement Program (NSQIP) 2012 to 2020 database were identified by Current Procedural Terminology (CPT) codes. Independent predictors of 30-day unplanned reoperation and readmission were identified using multivariable logistic regression with backward variable selection on the testing sample (2012-2019). Subsequently, the predictors were weighted according to β-coefficients to generate an integer-based Novel Risk Score (NRS) predictive of reoperation and readmission. The NRS was then validated on 1000 bootstrapped replications of the original sample, and again tested on NSQIP patients who had undergone hand surgery in 2020. The NRS was compared to the modified frailty index (mFI-5) and the modified Charlson Comorbidity Index (mCCI) with receiver operating characteristics (ROC) analysis. RESULTS: 83,409 hand surgeries were identified in the modeling cohort. Reoperations and readmissions occurred 1.1% and 1.3% of the time, respectively. Independent risk factors included male gender, inpatient status, smoking, dialysis dependence, transfusion within 72 hours of surgery, wound classification, ASA Class, diabetes mellitus, CHF, sepsis or septic shock, emergent case, and long initial operative time (all P < 0.05). ROC analysis of the testing (2020) cohort rendered an area under the curve of 0.730, which demonstrates the accuracy of this prediction model. The mFI-5 and mCCI rendered AUCs of 0.580 and 0.585, respectively. CONCLUSION: We present a validated risk stratification tool for unplanned reoperations and readmissions following hand surgery that outperforms the mFI-5 and mCCI. Future studies should determine if implementation of this NRS optimizes safety and reduces reoperation and readmission rates in hand surgery patients.

Extensor Mechanism Disruption Impacts Treatment of Dislocated and Multiligament Injured Knees: Treatment and Schenck Classification Recommendations Based on a Global Delphi Method.

Multiligament knee injury (MLKI) with associated extensor mechanism (EM) involvement is a rare injury, with limited evidence to guide optimal treatment. The purpose of this study was to identify areas of consensus among a group of international experts regarding the treatment of patients with MLKI and concomitant EM injury. Utilizing a classic Delphi technique, an international group of 46 surgeons from 6 continents with expertise in MLKI undertook 3 rounds of online surveys. Participants were presented with clinical scenarios involving EM disruption in association with MLKI, classified using the Schenck Knee-Dislocation (KD) Classification. Positive consensus was defined as ≥70% agreement with responses of either "strongly agree" or "agree," and negative consensus was defined as ≥70% agreement with "strongly disagree" or "disagree." There was a 100% response rate for rounds 1 and 2 and a 96% response rate for round 3. There was strong positive consensus (87%) that an EM injury in combination with MLKI significantly alters the treatment algorithm. For an EM injury in conjunction with a KD2, KD3M, or KD3L injury, there was positive consensus to repair the EM injury only and negative consensus regarding performing concurrent ligamentous reconstruction at the time of initial surgery. In the setting of bicruciate MLKI, there was overall agreement on the significant impact of EM injury on the treatment algorithm. We therefore recommend that the Schenck KD Classification be updated with the addition of the modifier suffix "-EM" to highlight this impact. Treatment of the EM injury was judged to have the highest priority, and there was consensus to treat the EM injury only. However, given the lack of clinical outcome data, treatment decisions need to be made on a case-by-case basis with consideration of the numerous clinical factors that are encountered. Little clinical evidence exists to guide the surgeon on the management of EM injury in the setting of a multiligament injured or dislocated knee. This survey highlights the impact that EM injury has on the treatment algorithm and provides some guidance for management until a further large case series or prospective studies are undertaken.

PC3. A Nationally Validated Risk Assessment Score for Predicting Unplanned Reoperations in Hand Surgery

PURPOSE: To present a validated model that reliably predicts unplanned reoperation after upper extremity/hand surgery. METHODS: A total of 83,409 hand surgery patients were identified using the 2012-2019 ACS-NSQIP databases. Thirty-day unplanned reoperation was defined as unexpected reoperation for a postoperative occurrence related to the principal hand surgery. Independent predictors of 30-day unplanned reoperation were identified using multivariable logistic regression with backward variable selection on the testing sample. Subsequently, the predictors were weighted according to β-coefficients to generate an integer-based Novel Risk Score (NRS) predictive of reoperation. The NRS was then validated 1000 bootstrapped replications of the original sample, and validated on NSQIP patients who had undergone hand surgery in 2020 (n = 15,247). The NRS was compared to two other widely used risk scores with receiver operating characteristics (ROC) analysis. RESULTS: The rate of 30-day unplanned reoperation in the 2020 cohort was 1.1%. Independent risk factors included male gender, inpatient status, smoking, dialysis dependence, transfusion within 72 hours of surgery, wound classification, ASA Class, diabetes mellitus, CHF, sepsis or septic shock, emergent case, and long initial operative time (all P < 0.05). ROC analysis of the testing (2020) cohort rendered an area under the curve of 0.730, which demonstrates the accuracy of this prediction model. The mFI-5 and mCCI rendered AUCs of 0.580 and 0.585, respectively. CONCLUSION: We present a validated risk stratification tool for unplanned reoperations following hand surgery. Future studies should determine if implementation of this NRS optimizes safety and reduces reoperation rates in hand surgery patients.

The Impact of Perioperative Morbidities, Lack of Discharge Aspirin, and Lack of Discharge Statin on Long Term Survival Following EVAR.

Adverse perioperative events and discharge medications both have the potential to impact survival following endovascular abdominal aortic aneurysm repair (EVAR). We hypothesize that variables such as blood loss, reoperation in the same hospital admission, and lack of discharge statin/aspirin have significant effect on long term survival following EVAR. Similarly, other perioperative morbidities, are hypothesized to affect long term mortality. Quantifying the mortality effect of perioperative events and treatment emphasizes to physicians the critical nature of preoperative optimization, case planning, operative execution and postoperative patient management. All EVAR in the Vascular Quality Initiative between 2003 and 2021 were queried. Exclusions were: ruptured/symptomatic aneurysm; concomitant renal artery or supra-renal intervention at the time of EVAR; conversion to open aneurysm repair at the time of initial operation; and undocumented mortality status at the 5 year mark postoperatively. 18,710 patients met inclusion criteria. Multivariable Cox regression time dependent analysis was performed to investigate the strength of mortality association of the exposure variables. Standard demographic variables and pre-existing major co-morbidities were included in the regression analysis to account for disproportionate, deleterious co-variables amongst those experiencing the various morbidities. Kaplan-Meier survival analysis was performed to provide survival curves for the key variables. Mean follow up was 5.99years and 5-year survival for included patients was 69.2%. Cox regression revealed increased long term mortality to be associated with the following perioperative events: reoperation during the index hospital admission (HR 1.21, P = .034), perioperative leg ischemia (HR 1.34, P = .014), perioperative acute renal insufficiency (HR 1.24, P = .013), perioperative myocardial infarction (HR 1.87, P < .001), perioperative intestinal ischemia (HR 2.13, P < .001), perioperative respiratory failure (HR 2.15, P < .001), lack of discharge aspirin (HR 1.26, P < .001), and lack of discharge statin (HR 1.26, P < .001). The following pre-existing co-morbidities correlated with increased long term mortality (P < .001 for all) : body mass index under 20kg/m2, hypertension, diabetes, coronary artery disease, reported history congestive heart failure, chronic obstructive pulmonary disease, peripheral artery disease, advancing age, baseline renal insufficiency and left ventricular ejection fraction less than 50%. Females were more likely to have EBL >300mL, reoperation, perioperative MI, limb ischemia and acute renal insufficiency than males (P < .01 for all). Female sex trended but was not associated with increased long term mortality risk (HR 1.06, 95% CI .995-1.14, P = .072). Survival after EVAR is improved with optimal operative planning to facilitate evading the need for reoperation and ensuring patients without contra-indication are discharged with aspirin and statin medications. Females and patients with pre-existing co-morbidity are at particularly higher risk for perioperative limb ischemia, renal insufficiency, intestinal ischemia and myocardial ischemia necessitating appropriate preparation and preventative measures.

Is damage control surgery useful in the treatment of colorectal perforation? A single-center case-control study.

From January 2013 to December 2019, 131 patients with colorectal perforation underwent emergency surgery at our hospital. Among these, 95 patients required postoperative intensive care unit management and were included in this study; of these patients, 29 (31%) underwent DCS, and 66 (69%) underwent primary abdominal closure (PC). Patients who underwent DCS had significantly higher Acute Physiology and Chronic Health Evaluation II (23.9 [19.5-29.5] vs. 17.6 [13.7-22]; P<0.0001) and Sequential Organ Failure Assessment (SOFA) (9 [7-11] vs. 6 [3-8]; P<0.0001) scores than did those who underwent PC. The initial operation time was significantly shorter for DCS than for PC (99 [68-112] vs. 146 [118-171]; P<0.0001). The 30-day mortality and colostomy rates were not significantly different between the two groups. The results suggest that DCS is useful in the management of acute generalized peritonitis caused by colorectal perforation.

Aesthetic Considerations in Extremity Salvage and Reconstruction.

After studying this article, the participant should be able to: 1. Have an in-depth understanding of the functional and aesthetic requirements of lower extremity reconstruction. 2. Describe the considerations for achieving an optimal aesthetic outcome in the primary reconstruction settings. 3. Describe modalities of secondary flap revision for achieving an optimal aesthetic outcome. Significant advancements have been made in the management of lower extremity reconstruction since Dr. Taylor's seminal case in 1973. Improvements in our understanding of vascular anatomy and evolution of microsurgical techniques have allowed for an ever-increasing array of free tissue transfer options for lower extremity reconstruction. The resulting expertise has engendered a paradigm shift toward the reconstructive elevator approach, with increased emphasis on cosmetic results. In the primary setting, aesthetic considerations play an important role in precoverage wound preparation, flap selection, and harvest technique, with the goal of achieving excellent like-with-like reconstruction at the time of initial surgery. Flap selection should be made to best match the three-dimensional architecture of the wound, and take into account the defect thickness, flap thickness, flap composition, and pedicle length. Primary flap thinning and harvest in the superficial fascial plane has been shown to be an effective modality to address excess adiposity and improve contour. Despite these efforts, secondary procedures are often required to optimize the limb's final appearance and functional outcomes, particularly in the foot and ankle region. These include debulking, liposuction, and staged excisions. As the field of limb salvage keeps evolving, aesthetics will continue to play an important role in extremity reconstruction planning and execution.

Treatment of surfactant wastewater by foam separation: Combining the RSM method and WOA-BP neural network to explore optimal process conditions

In the field of water treatment, the treatment of wastewater containing surfactants has been an important issue. The foam separation technique is often used to separate surfactants from water as a simple and efficient separation technique. We used a newly designed foam separation column to treat wastewater containing sodium dodecyl sulfonate (SDS) (0.5–2.0 mmol/L). The effects of initial SDS concentration (CSDS, i), operation time (t), foam height (H), gas velocity (V) and pH value (1−7) on the separation effect of SDS were investigated. The Box-Behnken design model was used to design the experimental group, and the process parameters of foam separation were optimized by combining response surface methodology (RSM) and WOA-BP neural network. The results showed that the prediction accuracy of the optimized BP neural network using the WOA algorithm was superior to that of the RSM model. The best operating parameters were: CSDS,i (0.88 mmol/L), t (28.13 min), H( 81.3 cm), V (1.03 L/min) and pH (3.5) and the recovery rate of SDS was up to 97.32%.

Subsequent Forearm Fractures Following Initial Surgical Fixation.

Forearm fractures are a common pediatric injury. Currently, there is no consensus on treatment for fractures that recur following initial surgical fixation. The objective of this study was to investigate the subsequent fracture rate and patterns and describe the treatment of these forearm fractures. We retrospectively identified patients who underwent surgical treatment for an initial forearm fracture at our institution between 2011 and 2019. Patients were included if they sustained a diaphyseal or metadiaphyseal forearm fracture that was initially treated surgically with a plate and screw construct (plate) or elastic stable intramedullary nail (ESIN), and if they subsequently sustained another fracture that was treated at our institution. A total of 349 forearm fractures were treated surgically with ESIN or a plate fixation. Of these, 24 sustained another fracture, yielding a subsequent fracture rate of 10.9% for the plate cohort and 5.1% for the ESIN cohort ( P =0.056). The majority of plate refractures (90%) occurred at the proximal or distal plate edge, while 79% of the fractures treated previously with ESINs occurred at the initial fracture site ( P <0.001). Ninety percent of plate refractures required revision surgery, with 50% underwent plate removal and conversion to ESIN, and 40% underwent revision plating. Within the ESIN cohort, 64% were treated nonsurgically, 21% underwent revision ESINs, and 14% underwent revision plating. Tourniquet time for revision surgeries were shorter for the ESIN cohort (46 vs. 92min; P =0.012). In both cohorts, all revision surgeries had no complications and healed with evidence of radiographic union. However, 9 patients (37.5%) underwent implant removal (3 plates and 6 ESINs) after subsequent fracture healing. This is the first study to characterize subsequent forearm fractures following both ESIN and plate fixation and to describe and compare treatment options. Consistent with the literature, refractures following surgical fixation of pediatric forearm fractures may occur at a rate ranging from 5% to 11%. ESINs are both less invasive at the time of initial surgery and can often be treated nonoperatively if there is a subsequent fracture, while plate refractures are more likely to be treated with a second surgery and have a longer average surgery time. Level IV-retrospective case series.