Underwent Salvage Procedures Research Articles

Long-term Outcomes of Salvage Surgery Versus Induction Therapy Followed by Surgical Resection for Advanced NSCLC: A Propensity Score-matched Analysis.

The outcomes of lung cancer treatment have improved over time. However, in contrast to other treatments, the clinical outcomes of salvage surgery are seldom reported because the follow-up periods after salvage surgery are short. We conducted a comprehensive study involving consecutive patients who underwent salvage surgery at two different institutions. Our analysis encompassed the exploration of clinicopathological features, perioperative variables, and surgical outcomes. Additionally, we employed propensity score matching to compare the long-term survival of patients with non-small cell lung cancer (NSCLC) who underwent salvage surgery with those who received induction chemoradiotherapy prior to surgery. Twenty-five patients underwent salvage procedures, while 113 patients received induction chemotherapy followed by surgery during the same study period. When assessing the overall survival (OS) from the registration date to the initial treatment date, the five-year OS rates were 73.8% in the induction group and 70.5% in the salvage surgery group (p=0.674). No significant differences were identified between the two groups in a cohort of 48 patients with NSCLC who were matched using propensity scores. In patients who underwent salvage surgery, reasonable long-term survival was achieved with outcomes comparable to those of induction chemotherapy followed by surgical resection.

Evaluation of chronic perilunate dislocations: A comparative study of single-stage, two-stage ORIF, and salvage procedures

ObjectiveThis study aims to evaluate the outcomes of open reduction and internal fixation (ORIF) for chronic perilunate dislocations using single-stage, two-stage, and salvage procedures. The study also compares these approaches with each other and with results from existing literature. MethodsA total of 15 patients with chronic perilunate injuries from 2013 to 2019 were included in the study. Pre-operative and post-operative assessments were conducted using plain radiographs, with CT scans performed selectively for detailed morphology and fracture pattern analysis. Among the patients, 13 underwent ORIF, while 2 underwent salvage procedures. Among the ORIF cases, single-stage procedures were performed in 4 patients, and two-stage procedures in 9 patients. External fixators, including unilateral uniplanar external fixators (UUEF) and bilateral uniplanar external fixators (BUEF), were applied in 5 and 4 patients, respectively. Our methodology of treating chronic perilunate injuries has evolved over the years. We started with single stage ORIF then graduated to a two staged procedure initially using a external fixator as a carpal distractor applied only on the radial side and finally settling down with bilateral carpal distraction using external fixators both on the radial and ulnar sides. ResultsAmong the 15 patients, 3 were lost to follow-up. Of these, one underwent four-corner fusion, while the remaining two had UUEF. The mean time interval between injury and surgery was 3.60 months. The post-operative mean scapholunate angle measured 52.46°, with a negative radio-lunate angle (indicating flexion) observed in two patients, while others showed a positive angle (indicating extension). Two cases exhibited nonunion and avascular necrosis (AVN) of the scaphoid, while one case presented with lunate AVN. Mid-carpal and radio-carpal arthritis was observed in 4 and 2 patients, respectively. Functional outcomes were evaluated using Mayo's wrist score categorized as good for two-stage BUEF cases and satisfactory for UUEF and single-stage procedures. ConclusionStaged reduction utilizing the BUEF followed by open reduction has demonstrated superior outcomes when compared to UUEF, single-stage open reduction and salvage procedures. Level of evidence: 4

Allograft or Synthetic Mesh Extensor Mechanism Reconstruction After TKA Carries a High Risk of Infection, Revision, and Extensor Lag.

Extensor mechanism disruption is a devastating complication after TKA. Extensor mechanism reconstruction can be performed using an allograft or synthetic mesh. Recent studies have disagreed about the durability of these reconstructions. Evaluating a larger series of reconstructions that use current popular techniques and principles provides information to guide patient and surgeon expectations while bringing to light the potential fate of patients who experience an infection postoperatively. (1) What was the 5-year survival free of repeat revision surgery or persistent extensor lag of more than 30° after allograft or synthetic mesh reconstruction of extensor mechanism disruptions after TKA, and did this differ between techniques? (2) What was the 5-year survival free of infection after allograft or mesh reconstruction, and what proportion of those patients experienced a secondary severe complication (arthrodesis or amputation)? Between April 2008 and December 2020, 123 patients underwent extensor mechanism reconstruction after TKA at one center. Of those, 37% (45) were lost to follow-up before 2 years, had not been seen in the past 5 years, did not reach a study endpoint (repeat revision or extensor lag > 30°) before that time, or underwent primary repair and thus could not be analyzed, leaving 63% (78) for analysis here. During the study period, we considered extensor mechanism surgery when acute or chronic disruption of the patellar or quadriceps tendon was present or there was a fracture of the patella resulting in extensor lag. The decision to use either mesh or an allograft largely depended on surgeon experience and familiarity with either technique. We collected patient demographics, operative details (location of disruption and presence of a hinged prosthesis), subsequent periprosthetic joint infection (PJI), and postoperative SF-12 and Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, scores. We used Kaplan-Meier survivorship analysis, with endpoints of extensor lag more than 30° or revision of the reconstruction and PJI. The mean follow-up duration was 5.3 ± 3.2 years. Survivorship free from revision or recurrent extensor lag was 54% (95% CI 44% to 66%) at 5 years. There was no difference between those undergoing reconstruction with allografts and those with mesh in terms of survivorship free from those endpoints at that timepoint (52% [95% CI 40% to 68%] versus 57% [95 CI% 41 to 78%]; p = 0.99). Survivorship free from PJI was 81% (95% CI 73% to 90%) at 2 years. There was no difference between those with allografts and those with mesh in terms of survivorship free from PJI at that timepoint (79% [95% CI 69% to 92%] versus 83% [95% CI 71% to 98%]; p = 0.75). Of the 17 patients who experienced PJI, four ultimately underwent arthrodesis and three more underwent transfemoral amputation. Allograft and synthetic mesh reconstructions commonly left patients with persistent limb dysfunction, while several patients had PJI and some underwent salvage procedures. Although improvements have been made with regard to treating extensor mechanism disruptions, patients and surgeons should be well aware of the potential adverse outcomes when determining management and use these findings to conduct risk-benefit analyses. There is a need for future studies to identify protocols that improve the durability of reconstructions and to determine whether interventions such as prolonged prophylactic antibiotic therapy have a role in minimizing the risk of PJI. Level III, therapeutic study.

Deep inferior epigastric vessels for free scapular flap phalloplasty

We aimed to present our 20-year experience of using the deep inferior epigastric vessels as recipient vessels for free scapular flaps phalloplasty and evaluate the outcomes. Penile reconstruction was performed using a free scapular flap between 2000 and 2020 by the same surgical team. Deep inferior epigastric vessels were used in all the cases. The surgical techniques and outcomes were described. Overall, 73 patients used the deep inferior epigastric artery (DIEA) as the recipient artery. Regarding the recipient veins, 2 veins were anastomosed in 72 (98.6%) patients, 1 deep inferior epigastric vein (DIEV) was used in 1 patient, 2 DIEV in 14, 1 DIEV + superficial inferior epigastric vein (SIEV) in 13, 1 DIEV + superficial circumflex iliac vein (SCIV) in 38, great saphenous vein (GSV) + SCIV in 4, and GSV + SIEV in 3. The mean age and body mass index of the study cohort was 28 years and 24.3 kg/m2, respectively. The shortest follow-up time was 7 months. Eleven patients had flap-related complications. Three patients were readmitted to the operating room within 24 hours, and 2 of them underwent salvage procedures with venous revision. Two patients lost the entire flap. One patient with 3-cm distal portion necrosis required surgical intervention. Three patients experienced urethral necrosis. DIEA is a suitable receptor artery for inflow. The DIEV, SIEV, and SCIV are available options for venous drainage according to the patient anatomical characteristics. The GSV can be an excellent backup for outflow and salvage procedures.

The Medial Femoral Trochlea Osteochondral Flap for Scaphoid Reconstruction: A Systematic Review.

The medial femoral trochlea flap has been used to resurface scaphoids with recalcitrant proximal pole fractures or avascular necrosis, providing vascularized osteochondral tissue with similar morphological characteristics. This article aims to review the contemporary literature on its use for scaphoid reconstruction. A systematic review of Embase, PubMed, Cochrane Central Register of Controlled Trials, and MEDLINE assessed the use of medial femoral trochlea flaps in scaphoids. Eight studies were included, with 76 patients at a mean age of 26 years. Forty-three patients underwent clinical review, and 10 patients underwent radiographic evaluation, at a mean 23.3 months of follow-up. Flaps were generally performed for proximal pole fractures, avascular necrosis, nonunion, or failure of prior fixation; 94.4% of the flaps united. No marked change in sagittal plane motion was noted; reductions were seen in axial and coronal plane motion. The Disabilities of the Arm, Shoulder, and Hand scores improved from a mean of 25.2 to 11.5. Radiographic markers also improved. A total of 12.3% of patients had unplanned return to theater. Three patients required early revision for vascular thrombosis, and 1 patient suffered a volar carpal dislocation. Three patients underwent salvage procedures for ongoing pain. Although technically demanding, promising early-term to medium-term results are noted with the use of medial femoral trochlea flaps in the scaphoid.

Recanalization of thrombosed aneurysmal hemodialysis arterovenous fistulas using a hybrid technique based on data from a single center

ObjectiveTo explore the technical specifications and clinical outcomes of thrombosed aneurysmal haemodialysis arteriovenous fistula (AVF) treated with ultrasound-guided percutaneous transluminal angioplasty combined with minimal aneurysmotomy.MethodsThis case series study included 11 patients who had thrombosed aneurysmal AVF and underwent salvage procedures over a 13-month period. All procedures were performed under duplex guidance. Minimal aneurysmotomy was performed, along with manual thrombectomy and thrombolytic agent infusion, followed by angioplasty to macerate the thrombus and sufficiently dilate potential stenoses. A successful procedure was defined as immediate restoration of flow through the AVF.ResultsThe 11 patients (four males and seven females) had a mean age of 49.6 years ± 11.9 years. Six patients (54.5%) had two or more aneurysms. The mean aneurysm maximal diameter was 21.5 mm (standard deviation: ± 5.0 mm), and the mean thrombus length was 12.9 cm (8–22 cm). Ten (83.3%) of the 12 procedures were technically successful. The mean duration of operation was 150.9 minutes (standard deviation: ± 34.2 minutes), and mean postoperative AVF blood flow was 728.6 ml/min (standard deviation: ± 53.7 mi/min). The resumption of hemodialysis was successful in all 11 cases, with a clinical success rate of 100%. The primary patency rates were 90.0% and 75.0% at three and four months over a mean follow-up time of 6.3 months (3–12 months). The secondary patency rates were 90.4% at three and four months.ConclusionA hybrid approach combining ultrasound-guided percutaneous transluminal angioplasty and minimal aneurysmotomy might be a safe and effective method for thrombosed aneurysmal AVF salvage.

Outcomes after Bone-Ligament-Bone Intercarpal Ligament Reconstruction.

Numerous surgical reconstructive techniques have been described for chronic scapholunate and lunotriquetral interosseous ligament instability. The authors retrospectively reviewed 16 consecutive patients who underwent bone-ligament-bone reconstruction for scapholunate or lunotriquetral intraosseous ligament predynamic and dynamic instability at a single tertiary care institution from 2013 to 2019. Clinical and radiographic outcomes, and complications, were recorded. Eleven patients had bone-ligament-bone reconstruction for scapholunate ligament injuries and five for lunotriquetral instability. Fourteen patients (87.5 percent) underwent diagnostic arthroscopy before bone-ligament-bone reconstruction, with nine of 14 having grade 3 and four of 14 having grade 4 injury. Capitohamate bone-ligament-bone grafts were used in nine patients (56 percent) and the graft was taken from Lister tubercle in seven (44 percent). The average age at surgery was 37 years. The average follow-up was 60.6 weeks. There were no significant differences between preoperative and postoperative radiographic parameters. Median postoperative wrist flexion was 45 degrees, and mean postoperative wrist extension was 53 degrees, which were significantly less than contralateral flexion (85 degrees; p < 0.0001) and extension (78 degrees; p < 0.0001). Thirty-eight percent of patients complained of persistent pain at final follow-up, and two patients (13 percent) underwent salvage procedures, both at approximately 6.5 months after the index reconstruction. Short-term outcomes of bone-ligament-bone reconstruction for early-stage scapholunate and lunotriquetral ligament injuries reveal many patients with residual postoperative wrist pain and disability, and almost uniform limitations in flexion-extension motion. Therapeutic, IV.

The Fate of Periprosthetic Joint Infection Following Megaprosthesis Reconstruction.

Background:A megaprosthesis may be used for reconstruction in patients with massive bone loss or a periprosthetic fracture. Periprosthetic joint infection (PJI) may occur after a megaprosthesis reconstruction and may pose a major challenge. The outcomes of managing PJI in patients with a megaprosthesis is relatively unclear. The aim of this study was to investigate the clinical course and outcomes of PJI in patients with a megaprosthesis in place.Methods:From a total of 219 patients who underwent megaprosthesis replacement for non-oncologic conditions, 38 (17.4%) developed subsequent PJI. A retrospective review of the medical record was performed to ascertain the course of the PJI and treatment outcomes. Kaplan-Meier analysis was performed to evaluate the survival function, and the log-rank test was used to assess differences in outcome measures.Results:The surgical management of 33 patients with PJI included debridement, antibiotics, and implant retention (DAIR) (82%), consisting of DAIR with modular component exchange (19 patients) and DAIR without component exchange (8 patients); 2-stage exchange arthroplasty (9%); resection arthroplasty (6%); and a single-stage revision arthroplasty (3%). The Kaplan-Meier survivorship analysis demonstrated that the overall survival rate was 65.1% at 2 years. The mortality rate was 15%, with many patients undergoing salvage procedures including amputation (18%), arthrodesis (6%), and resection arthroplasty (6%).Conclusions:The rate of PJI after megaprosthesis reconstruction, 17% in this study, appears to be very high. The management of PJI in these patients is challenging, with 1 of 3 patients undergoing failed treatment. Despite the limited options available, DAIR seems to be an appropriate treatment strategy for some of these patients. Further data on a larger cohort are needed to assess the success of various surgical procedures and predictors of failure in this challenging patient population.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Abductor Deficiency-Induced Recurrent Instability After Total Hip Arthroplasty.

» Operative intervention for deficient hip abductor muscles may require muscle transfer or the use of synthetic materials, possibly with biologic augmentation, to help stabilize the hip joint and prevent further dislocation following total hip arthroplasty (THA). » Direct repair of the abductor mechanism onto the greater trochanter can be used in patients who present with instability <15 months following primary THA. » Augmentation of soft tissue with acellular dermal allografts can be considered for patients with abductor avulsion that requires posterior capsular reconstruction. » The Achilles tendon + calcaneal bone allograft is indicated for patients who have undergone multiple prior revision surgeries, who have experienced failure of nonoperative management, and have tissue inadequacy in the posterior wall of the hip joint. » The gluteus maximus tendon transfer is indicated in patients with chronic abductor tears, limited or loss of function in the gluteus medius and minimus, and a fully functioning gluteus maximus. » Vastus lateralis transfer may benefit patients with a history of multiple revision procedures, large separation between the gluteus medius tendon and the proximal part of the femur, and the ability to observe the postoperative protocol of splinting for 6 weeks. » The latissimus dorsi tendon transfer should be reserved as a reconstructive procedure for patients with acute abductor insufficiency, such as those who have undergone extensive tumor resection. » Synthetic mesh can be used to enable capsular reconstruction and prosthesis stabilization in patients undergoing salvage procedures for tumors of the hip and associated soft tissues. » Synthetic ligament prostheses can be used in patients with recurrent posterior dislocations in the setting of normal components. » The fascia lata plasty is indicated for patients with recurrent posterior instability without an identifiable cause. » Although the quality of literature is limited, surgical interventions utilizing techniques of soft-tissue augmentation have shown promising outcomes with regard to pain relief, limping, ambulation, and the reduction of instability following THA.

Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection: The Rate and Reason for the Attrition After the First Stage

BackgroundTwo-stage exchange arthroplasty remains a popular surgical treatment for patients with chronic periprosthetic joint infection (PJI). Patients who do not receive reimplantation were largely overlooked in the current literature. We aimed at investigating the clinical outcomes of these patients. MethodsOur institutional PJI database was retrospectively reviewed to identify 616 patients (237 hips, 379 knees) who were treated with an intended 2-stage exchange. Of them, 111 (18%) did not receive reimplantation within a minimum follow-up of 1 year. Chart review and targeted interviews were performed to elucidate the cause of attrition. Patients were considered to have failed treatment in the absence of reimplantation if they remained medically unfit for reimplantation, underwent a salvage procedure, or died during the study period. ResultsOf the 111 patients without reimplantation, 29 (26.1%) did well with their retained spacer and were unwilling to proceed with reimplantation, 23 (20.7%) underwent salvage procedures, and the remaining 59 (53.2%) were considered medically unfit for reimplantation, with 34 of them dying within 1 year of initial spacer insertion. The overall success rate for 2-stage exchange cohort at 2 years was 65.7% when treatment failure without reimplantation was taken into account. Several factors associated with increased risk of treatment failure without reimplantation were identified using a multivariate regression model. ConclusionAlmost 1 in 5 patients may never receive the intended reimplantation. Among many reasons for attrition, mortality appears to be a relatively common event. The current definition of treatment success does not take into account the attrition group and thus inflates the relative success of 2-stage exchange arthroplasty.

Outcomes of Salvage Arthrodesis and Arthroplasty for Failed Osteochondral Allograft Transplantation of the Ankle.

Osteochondral allograft (OCA) transplantation is a useful treatment for posttraumatic ankle arthritis in young patients, but failure rates are high and reoperations are not uncommon. The aim of this study was to evaluate the outcomes of failed ankle OCA transplantation converted to ankle arthrodesis (AA) or total ankle arthroplasty (TAA). We evaluated 24 patients who underwent salvage procedures (13 AA and 11 TAA) after primary failed ankle OCA transplantation. Reoperations were assessed. Failure of the salvage procedure was defined as an additional surgery that required a revision AA/TAA or amputation. Evaluation among nonfailing ankles included the American Academy of Orthopaedic Surgeons Foot and Ankle Module (AAOS-FAM), pain, and satisfaction. In the salvage AA cohort, 3 patients were classified as failures (2 revision AA and 1 amputation). The 10 nonfailing patients had a mean follow-up of 7.4 years. Eighty-eight percent were satisfied with the procedure, but 63% reported continued problems with their ankle (eg, pain, swelling, stiffness). Mean pain level was 1.9 and AAOS-FAM core score was 83±13. In the salvage TAA cohort, 2 patients were classified as failures (both revision TAA). The 9 nonfailing patients had a mean follow-up of 3.8 years. Fifty percent were satisfied with the procedure, but 40% reported continued problems with their ankle. The mean pain level was 1.3, and the median AAOS-FAM core score was 82±26. Revision and reoperation rates for salvage procedures following failed OCA transplantation of the ankle are higher compared to published data for primary AA and TAA procedures. However, we believe OCA transplantation can serve as an interim procedure for younger patients with advanced ankle joint disease who may not be ideal candidates for primary AA or TAA at the time of initial presentation. Level IV, case series.

ACS NSQIP risk calculator reliability in head and neck oncology: The effect of prior chemoradiation on NSQIP risk estimates following laryngectomy

PurposeTo determine whether inclusion of chemoradiation history increases estimated risk for complications following total laryngectomy using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator. Materials and methodsA retrospective review of 96 patients with laryngeal cancer, approximately half of who had received prior chemoradiation, who underwent laryngectomy between January 2010 and December 2014. NSQIP estimates were calculated and compared to actual event occurrence using receiver operating characteristic (ROC) curves, Brier scores, and risk estimates. ResultsPatients who had received prior chemoradiation were at significantly greater risk for complication postoperatively (OR=2.63, 95% CI=1.145–6.043). NSQIP Calculator discriminability and accuracy were generally poor for this sample. While NSQIP estimates significantly predicted risk for any postoperative complication, pneumonia, and discharge to nursing care for primary laryngectomy patients, predictive capability was lost among salvage laryngectomy patients. NSQIP adjustments to both Somewhat Higher and Significantly Higher Risk categories did not improve predictive capability. Of the risk factors considered by NSQIP, preoperative functional status (p=0.041), age at time of surgery (p<0.008), and inclusion of neck dissection (p=0.035) emerged as significant predictors of actual postoperative complications, though again estimates lost significance among salvage laryngectomy patients. ConclusionsThe NSQIP Calculator may be poorly calibrated to estimate postoperative complication risk for patients previously exposed to chemoradiation undergoing salvage laryngectomy. Caution should be used when estimating postoperative risk among patients undergoing salvage procedures, especially those of older age, poorer functional status, and those requiring neck dissection.

The Artificial Urinary Sphincter is Superior to a Secondary Transobturator Male Sling in Cases of a Primary Sling Failure

We compared continence outcomes in patients with post-prostatectomy stress urinary incontinence treated with a salvage artificial urinary sphincter vs a secondary transobturator sling. We retrospectively reviewed the records of patients undergoing salvage procedures after sling failure from 2006 to 2012. Postoperative success was defined as the use of 0 or 1 pad, a negative stress test and pad weight less than 8 gm per day. We performed the Wilcoxon test and used a Cox regression model and Kaplan-Meier survival analysis. A total of 61 men presenting with sling failure were included in study, of whom 32 went directly to an artificial urinary sphincter and 29 received a secondary sling. Of the artificial urinary sphincter cohort 47% underwent prior external beam radiation therapy vs 17% of the secondary sling cohort (p = 0.01). Average preoperative 24 hour pad weight and pad number were higher in the artificial urinary sphincter cohort. Median followup in artificial urinary sphincter and secondary sling cases was 4.5 (IQR 4-12) and 4 months (IQR 1-5), respectively. Overall treatment failure was seen in 55% of patients (16 of 29) with a secondary sling vs 6% (2 of 32) with an artificial urinary sphincter (unadjusted HR 7, 95% CI 2-32 and adjusted HR 6, 95% CI 1-31). In this cohort of patients with post-prostatectomy stress urinary incontinence and a failed primary sling those who underwent a secondary sling procedure were up to 6 times more likely to have persistent incontinence vs those who underwent artificial urinary sphincter placement. These data are useful for counseling patients and planning surgery. We currently recommend placement of an artificial urinary sphincter for patients in whom an initial sling has failed.

PD24-11 THE ARTIFICIAL URINARY SPHINCTER IS SUPERIOR TO A SECONDARY TRANSOBTURATOR MALE SLING IN CASES OF A PRIMARY SLING FAILURE

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence: Evaluation (Urodynamic Testing)1 Apr 2015PD24-11 THE ARTIFICIAL URINARY SPHINCTER IS SUPERIOR TO A SECONDARY TRANSOBTURATOR MALE SLING IN CASES OF A PRIMARY SLING FAILURE Divya Ajay, John Selph, Michael Belsante, Ngoc-Bich Le, Aaron Lentz, George Webster, and Andrew Peterson Divya AjayDivya Ajay More articles by this author , John SelphJohn Selph More articles by this author , Michael BelsanteMichael Belsante More articles by this author , Ngoc-Bich LeNgoc-Bich Le More articles by this author , Aaron LentzAaron Lentz More articles by this author , George WebsterGeorge Webster More articles by this author , and Andrew PetersonAndrew Peterson More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1466AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The male transobturator sling (TOS) is a minimally invasive treatment for postprostatectomy stress urinary incontinence (PPSUI). Reported success rates for the male transobturator sling (TOS) are 41-76%. In the case of a failed primary sling, many surgeons offer a secondary sling; however, there is no literature describing the success of a secondary TOS placement in these situations. Our objective was to assess the success of secondary TOS in comparison to AUS for PPSUI patients who failed a primary TOS. METHODS We retrospectively reviewed all patients undergoing salvage procedures after failure of TOS from 2006 to 2012 at our institution. Demographic and follow-up data were extracted by chart review. Post-operative success was defined as the use of 0 or 1 security pad, a negative stress test on exam, or pad weight of less than 8 g/day. Cox regression model and Kaplan-Meier survival analysis were performed. RESULTS 61 men were included. All had a TOS for PPSUI and presented with persistent incontinence after initial sling placement. 32 subsequently underwent placement of an AUS and 29 had a secondary TOS at a median of 10(IQR 6-29) and 14(IQR 7-19) months from primary TOS surgery, resp. The mean ages of the AUS and secondary TOS cohorts were not significantly different. 47% of the AUS cohort had received prior external beam radiation therapy versus 18.5% of the secondary TOS (p<0.01). Average pre-operative 24 hour pad weight was higher in the AUS cohort (517g) versus the TOS cohort (274g; p<0.01). The median follow-up for the AUS and TOS patients was 5 (IQR 4-16) and 4 (IQR1-5) months, resp. Treatment failure was seen in 55% (16/29) of secondary TOS versus 15% (5/32) of AUS patients with a hazard ratio of 2.9 (95%CI 1.1-8.3). 6 (21%) patients who failed a secondary TOS went on to receive an AUS. Figure 1 shows improved treatment success rates for TOS failures who received an AUS versus a secondary TOS (p=0.03). CONCLUSIONS In this cohort of patients with PPSUI who failed TOS, those who underwent a secondary TOS were 2.9 times as likely to have persistence incontinence in comparison to those who underwent AUS placement. This finding was noted despite the fact that there was a higher likelihood of radiation therapy in the AUS group. This data may be very useful in counseling patients and surgical planning. We currently recommend placement of an AUS for patients who have failed an initial TOS. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e490 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Divya Ajay More articles by this author John Selph More articles by this author Michael Belsante More articles by this author Ngoc-Bich Le More articles by this author Aaron Lentz More articles by this author George Webster More articles by this author Andrew Peterson More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Sa1505 Underwater EMR As a Salvage Technique for Recurrent Adenoma After Piecemeal EMR of Large Colorectal Adenomas

Sa1505 Underwater EMR As a Salvage Technique for Recurrent Adenoma After Piecemeal EMR of Large Colorectal Adenomas Hyun Gun Kim*, Nirav C. Thosani, Subhas Banerjee, Ann M. Chen, Shai Friedland Institute for Digestive Research, Soonchunhyang University College of Medicine, Seoul, Republic of Korea; Department of Gastroenterology, Stanford University School of Medicine, Palo Alto, CA; Department of Gastroenterology, VA Palo Alto Health Care System, Palo alto, CA Objectives: Piecemeal EMR of large colorectal polyps is associated with significant recurrence rates of 5-10%. Conventional endoscopic treatment of recurrences is technically difficult due to fibrosis, with low en-bloc resection rates, significant reliance on ablation due to inability to snare fibrotic residual, and frequent recurrence. Underwater EMR (UEMR) may facilitate resection of fibrotic lesions without exposing patients to excessively long procedure durations and the high risk of perforation associated with other advanced techniques such as endoscopic submucosal dissection. We investigated the usefulness and safety of underwater EMR (UEMR) as a salvage procedure for recurrent adenomas after prior piecemeal resection of large polyps. Methods: Retrospective cross-sectional study of patients who underwent salvage procedures (UEMR vs. EMR) for recurrent adenomas after piecemeal EMR of colorectal polypsO2cm. We compared the en-bloc resection rate, endoscopic complete removal rate and need for adjunctive ablation with argon plasma coagulation (APC) of visible residual between the two procedure groups. Also, we evaluated the associated factors for en-bloc resection and endoscopic complete removal by multivariate logistic regression. Results: Seventy three salvage procedures (29 UEMR vs. 44 EMR) were analyzed. Clinical aspects including sex, mean age, medication use, size of primary lesion, size of recurrent adenoma, location and histology were not significantly different between the two groups. En-bloc resection rate (58.6 % vs. 15.9%,p!0.001) and endoscopic complete removal rate (89.7% vs. 31.8%, p!0.001) were significantly higher in UEMR group than in the EMR group. APC ablation for residual tumor was lower in UEMR group than EMR group (10.3% vs. 65.9%, p!0.001). Two cases of delayed bleeding occurred in the EMR group; there were no complications in the UEMR group. UEMR (Odds 11.41, 95% confidence interval (CI) 2.41w54.17, pZ0.002) and smaller size of recurrent lesion (Odds 1.64, 95% CI 1.22w2.22, pZ0.001) were the independent predictive factors for successful en-bloc resection in the multivariate logistic regression analysis. UEMR (Odds 25.55, 95% confidence interval (CI) 5.09w128.22, p!0.001) and smaller size of recurrent lesion (Odds 1.09, 95% CI 1.02w1.16, pZ0.012) were the independent predictive factors for endoscopic complete removal. Conclusions: UEMR was associated with higher rates of en-bloc resection, and complete adenoma removal, and a lower need for APC ablation of residual lesion during salvage procedures. UEMR is a useful and safe technique for treatment of recurrent colorectal adenomas after prior piecemeal EMR. Table 1 Comparison between two salvage procedure groups for recurrent adenoma after primary procedure Table 2 Univariate and mult Analysis for en-bloc resection

Protocol for splenic salvage procedures in this era of non-operative management.

The increased prevalence of non-operative management of splenic injuries contributes to the infrequent use of salvage procedures. Nevertheless, salvage procedures are sometimes required. The study aimed to evaluate the safety and feasibility of our salvage procedure protocol for selected patients. This retrospective study included 27 splenic injury patients divided into two groups: those treated by salvage procedures (splenorrhaphy or partial resection) and those who underwent splenectomy. Our salvage procedure protocol was applied in the following situations: if hemodynamics were stable during laparotomy or bleeding was fully controlled by manual or incisional mobilization of the organ, when no more than two other organs required repair, and if no clinical coagulopathy existed. The splenic abbreviated injury scale, intraoperative bleeding, and transfusion requirements of packed red blood cells and fresh frozen plasma requirements in 24 h were significantly lower in the salvage procedure group. There was no difference in the injury severity score, initial amount of bleeding, length of intensive care unit stay, or morbidity and mortality rates between the groups. Patients who underwent salvage procedures were managed without major complication, except one pseudoaneurysm case. We confirmed the feasibility of our salvage procedure protocol for selected patients, particularly for those with simple or lower grade injuries.

Failure Rate and Cosmesis of Immediate Tissue Expander/Implant Breast Reconstruction After Postmastectomy Irradiation

BackgroundThis study reports the rate of breast reconstruction failure and cosmetic outcomes after postmastectomy radiation therapy (PMRT) with temporary tissue expanders (TEs) or implants in place. Patients and MethodsNinety-four patients underwent mastectomy (93 unilateral, 1 bilateral; 95 cases total) and immediate TE reconstruction followed by PMRT. Ninety TEs and 5 permanent implants were irradiated. All patients received a dose of 5400 cGy given in 180-cGy fractions to the reconstructed breast. Twenty-one patients (22%) received tangents alone and 74 patients (78%) were treated with tangents and a supraclavicular field using a monoisocentric technique. Bolus was used in 91 patients (96%). Eighty-eight patients (93%) received chemotherapy and 78 patients (82%) received endocrine therapy. ResultsWith a median follow-up of 24.1 months, 19 patients (20%) experienced failure of reconstruction. The 1-, 2-, and 3-year actuarial rate of reconstruction failure was 9.7%, 19.3%, and 25.5%, respectively. Infection was the most common cause of failure. Of the 19 failures, 8 patients underwent salvage procedures with flap reconstruction. Univariate analysis was performed examining age, chemotherapy use, hormone therapy use, use of a supraclavicular field, smoking status, diabetes, hypertension, and menopausal status. No risk factors were found to be associated with reconstruction failure. In patients who did not experience reconstruction failure, good/excellent cosmesis was observed in 75% of patients. ConclusionIn the current series of women with a high risk of locoregional recurrence, PMRT with a TE/implant in place provides good cosmesis in the majority of women, with an acceptable risk of expander or implant loss.

Which Implant Is Best After Failed Treatment for Pathologic Femur Fractures?

Successful treatment of pathologic femur fractures can preserve a patient's independence and quality of life. The choice of implant depends on several disease- and patient-specific variables; however, its durability must generally match the patient's estimated life expectancy. Failures do occur, however, it is unclear which implants are associated with greater risk of failure. We evaluated patients with femoral metastases in whom implants failed to determine (1) the rate of reoperation; (2) the timing of and most common causes for failure; and (3) incidence of perioperative complications and death. From a prospectively collected registry, we identified 93 patients operated on for failed treatment of femoral metastases from 1990 to 2010. We excluded five patients who subsequently underwent amputations leaving 88 who underwent salvage procedures. These included intramedullary nails (n = 11), endoprostheses (n = 61), and plate fixation (n = 16). The primary outcome was reoperation after salvage treatment. Seventeen of the 88 patients (19%) required subsequent reoperation a median of 10 months (interquartile range, 4-14) from the time of salvage surgery: 15 for material failure, one for local progression of tumor, and one for a combination of these. Five patients died within 4 weeks of surgery. Although perioperative complications were higher in the endoprosthesis group and dislocations occurred, overall treatment failures after salvage surgery were lower in the that group (four of 61) compared the group with plate fixation (eight of 16) and intramedullary nail groups (five of 11). Despite relatively common perioperative complications, salvage using endoprostheses may be associated with fewer treatment failures as compared with internal fixation. Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Long-Term Results of Scaphoid Nonunion Surgery

Untreated scaphoid nonunions are a hazard to the wrist, resulting in deteriorating function and radiologic degenerative changes with increasing time. Long-term results after surgery of scaphoid nonunion reporting clinical, radiologic, and subjective outcomes are scarce. Retrospective follow-up study. From 1990 to 1998, 53 patients were operated on for persistent scaphoid nonunion; three patients were excluded from the follow-up (one expelled foreigner, another died of an unrelated cause, one never appeared after surgery), leaving 50 patients eligible for follow-up. All patients were operated on with open reduction and internal fixation; the majority also received a bone graft. Radiology and computed tomography verified union, degenerative wrist changes, and final salvage treatment. Range of motion, grip strength, key pinch, and subjective outcome (QuickDASH, visual analog scale). Fifty patients were followed up after a mean of 12.2 years (standard deviation [SD], 3.0), 47 by clinical and radiologic examination; three were interviewed by telephone and completed QuickDASH and visual analog scale forms. Union was achieved in 45 of 50 scaphoids and an additional two after a second attempt. Five patients (one persistent and four healed nonunions) underwent salvage procedures. Grip strength (41 vs 45 kg, P = nonsignificant), key pinch (11.5 vs 12.4, P = nonsignificant), and active range of motion (186° vs 214°, P < 0.001) were slightly reduced compared with the uninjured side. The subjective outcome was good (mean visual analog scale = 7, mean QuickDASH = 9.1). Minor degenerative changes were seen in nine wrists at surgery and 22 at follow-up. Healing of a scaphoid nonunion provides long-term pain relief, excellent wrist function, and halts degenerative changes in the majority of patients. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Long-Term Results of Forearm Shortening and Volar Radiocarpal Capsulotomy for Wrist Flexion Deformity in Children With Amyoplasia

To perform a long-term review of results of forearm shortening osteotomies, tenotomy, and volar wrist capsulotomy for treatment of typical wrist flexion deformities in children with the amyoplasia form of arthrogryposis, a procedure originally reported and described as "most rewarding" by Lexington Shriners Hospital for Children in 1965. A retrospective review of operating room and clinic records was done. An attempt to contact all patients produced 1 current follow-up. Nine extremities in 6 patients had undergone the procedure. Of the 9 extremities, 3 subsequently underwent salvage procedures, 2 had salvage procedures recommended, and 1 had a distal forearm fracture angular malunion that compensated for the wrist flexion contracture. The charts for the patients with the 3 remaining extremities showed that at 3-year follow-up, the wrist flexion contractures had recurred. Long-term follow-up of the procedure shows that the initial improvement in wrist position is not maintained. This procedure is not recommended for correction of the wrist deformity in amyoplasia. Therapeutic IV.