Functional Outcomes and Quality of Life after Redo Anastomosis in Patients With Rectal Cancer: An International Multicenter Comparative Cohort Study.

BACKGROUND: Redo anastomosis can be considered in selected patients with persistent leakage, stenosis, or local recurrence. It is technically challenging, and little is known about the functional outcomes after this seldomly performed type of surgery. OBJECTIVE: The aim of this study was to compare functional outcomes and the quality of life between redo anastomosis and primary successful anastomosis following total mesorectal excision for rectal cancer. DESIGN: This study was designed as an international multicenter comparative cohort study. SETTINGS: The study was conducted in 3 tertiary referral centers in the Netherlands, Belgium, and France. PATIENTS: Patients undergoing redo anastomosis were compared with patients with a primary successful anastomosis after total mesorectal excision for rectal cancer. MAIN OUTCOME MEASURES: Low anterior resection syndrome score, European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30, and EORTC QLQ-CR29 questionnaires were used to assess outcomes. RESULTS: In total, 170 patients were included; 52 underwent redo anastomosis and 118 were controls. Major low anterior resection syndrome occurred in 73% after redo anastomosis compared with 68% following primary successful anastomosis (p = 0.52). The redo group had worse EORTC QLQ-CR29 mean scores for fecal incontinence (p = 0.03) and flatulence (p = 0.008). There were no differences in urinary (p = 0.48) or sexual dysfunction, either in men (p = 0.83) or in women (p = 0.76). Significantly worse scores in the redo group were found for global health (p = 0.002), role (p = 0.049) and social function (p = 0.006), body image (p = 0.03), and anxiety (p = 0.02). LIMITATIONS: This study is limited by the possible response bias. CONCLUSIONS: Redo anastomosis is associated with significantly worse quality of life compared with primary successful anastomosis. However, major low anterior resection syndrome was comparable between groups and should not be a reason to preclude restoration of bowel continuity in highly motivated patients. See Video Abstract at http://links.lww.com/DCR/B565. RESULTADOS FUNCIONALES Y DE CALIDAD DE VIDA POSTERIOR A LA RECONSTRUCCIN DE LA ANASTOMOSIS EN PACIENTES CON CNCER DE RECTO ESTUDIO INTERNACIONAL MULTICNTRICO DE COHORTE COMPARATIVO: ANTECEDENTES:Se puede considerar reconstruir la anastomosis en pacientes seleccionados con fuga persistente, estenosis o recidiva local. Esto es técnicamente desafiante y poco se sabe sobre los resultados funcionales después de este tipo de cirugía que rara vez se realiza.OBJETIVO:El objetivo de este estudio fue comparar resultados funcionales y la calidad de vida entre reconstrucción de la anastomosis y la anastomosis primaria exitosa posterior de la escisión total de mesorrecto (TME) por cáncer de recto.DISEÑO:Este estudio fue diseñado como un estudio internacional multicéntrico de cohorte comparativo.ENTORNO CLINICO:El estudio se llevó a cabo en tres centros de referencia terciarios en Holanda, Bélgica y Francia.PACIENTES:Los pacientes sometidos a reconstrucción de anastomosis fueron comparados con pacientes con anastomosis primaria exitosa después de TME por cáncer de recto.PRINCIPALES MEDIDAS DE VALORACION:Los cuestionarios; Escala de Síndrome de Resección Anterior Baja (LARS), EORTC QLQ-C30, y QLQ-CR29, fueron utilizados para evaluar los resultados.RESULTADOS:En total, se incluyeron 170 pacientes; 52 reconstrucción de anastomosis y 118 controles. LARS ocurrió en el 73% posterior a la reconstrucción de la anastomosis en comparación con el 68% posterior a la anastomosis primaria exitosa (p = 0,52). El grupo de reconstrucción tuvo peores puntuaciones medias de EORTC QLQ-CR29 para incontinencia fecal (p = 0,03) y flatulencia (p = 0,008). No hubo diferencias en disfunción urinaria (p = 0,48) o sexual, ni en hombres (p = 0,83) ni en mujeres (p = 0,76). Se encontraron puntuaciones significativamente peores en el grupo de reconstrucción para salud global (p = 0,002), desempeño (p = 0,049) y función social (p = 0,006), imagen corporal (p = 0,03) y ansiedad (p = 0,02).LIMITACIONES:La limitación de este estudio es el posible sesgo de respuesta.CONCLUSIONES:La reconstrucción de la anastomosis se asocia con una calidad de vida significativamente peor en comparación con los pacientes con anastomosis primaria exitosa. Sin embargo, LARS fue comparable entre los grupos y no debería ser una razón para impedir la restauración de la continuidad intestinal en pacientes muy motivados. Consulte Video Resumen en http://links.lww.com/DCR/B565.

The Association of Previous Prostate Biopsy Related Complications and the Type of Complication with Patient Compliance with Rebiopsy Scheme.

PURPOSE: Prostate biopsy complications have important consequences that may affect patient compliance with rebiopsy schemes. However, to our knowledge this has not been studied in earnest. Thus, we evaluated whether previous prostate biopsy related complications and the type of complication were associated with repeat prostate biopsy compliance in a clinical trial with study mandated systematic biopsies. MATERIALS AND METHODS: We retrospectively analyzed the records of 4,939 men 50 to 75 years old who underwent 2-year prostate biopsy and were recommended to undergo 4-year prostate rebiopsy in the REDUCE (Reduction by Dutasteride of Prostate Cancer Events) study. The analyzed biopsy complications were hematuria, urinary tract infection, acute urinary retention and hemospermia. RESULTS: A total of 260 men (5.3%) had a 2-year prostate biopsy related complication, including hematuria in 180 (3.6%), urinary tract infection in 36 (0.7%), acute urinary retention in 26 (0.5%) and hemospermia in 102 (2.1%). A total of 474 men (9.6%) were noncompliant with 4-year rebiopsy. On univariable analysis any previous complication (OR 1.56, 95% CI 1.08-2.24, p = 0.018), urinary tract infection (OR 2.72, 95% CI 1.23-6.00, p = 0.013), acute urinary retention (OR 4.24, 95% CI 1.83-9.81, p = 0.016) and hemospermia (OR 1.78, 95% CI 1.03-3.06, p = 0.037) were associated with rebiopsy noncompliance. Hematuria was not associated with rebiopsy noncompliance (OR 1.19, 95% CI 0.74-1.91, p = 0.483). Results were unchanged on multivariable analysis, including for any complication (OR 1.65, 95% CI 1.08-2.26, p = 0.018), for urinary tract infection (OR 2.62, 95% CI 1.07-3.21, p = 0.029), for acute urinary retention (OR 4.51, 95% CI 1.93-10.54, p = 0.001), for hemospermia (OR 1.85, 95% CI 1.07-3.21, p = 0.029) and for hematuria (OR 1.19, 95% CI 0.74-1.93, p = 0.472). CONCLUSIONS: In men who undergo repeat prostate biopsy a previous biopsy related complication and the type of complication were associated with lower compliance with rebiopsy schemes. Patients who experience biopsy related complications are ideal candidates to receive intervention regarding the importance of prostate rebiopsy to prevent noncompliance.

Concurrent midurethral sling excision or lysis at the time of repeat sling for treatment of recurrent or persistent stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Limited evidence guides operative technique in primary midurethral sling (MUS) lysis or excision at the time of repeat sling placement for persistent or recurrent stress urinary incontinence (SUI). Our objective is to compare subjective improvement in patients undergoing repeat MUS placement with and without concurrent primary sling lysis or removal. METHODS: This was a retrospective cohort study with a prospective survey of patients who underwent two MUS placements for SUI at a single institution from January 1996 to December 2015. After patient identification, the electronic record was queried for demographic and perioperative data. Subjects then completed the Urogenital Distress Index, (UDI-6), Incontinence Severity Index (ISI), and the Incontinence Impact Questionnaire (IIQ-7). Subjects were also asked if they would choose to undergo repeat MUS surgery again. RESULTS: Sixty-one patients were included. 17 out of 61 (28%) underwent concomitant primary sling lysis or excision, and 44 out of 61 (72%) did not. Fifty-seven percent (n = 35) completed the survey. Of the respondents, the median ISI score was 4 (1-8), with no difference between groups; 14 out of 35 (40%) reported the presence of bothersome urge incontinence, 11 out of 35 (31%) reported bothersome stress urinary incontinence, and 8 out of 35 (23%) reported symptoms of voiding dysfunction, with no difference between groups. 57% of patients (20 out of 35) would undergo repeat MUS placement again. CONCLUSIONS: In a small cohort, concurrent excision of the primary sling at the time of repeat MUS did not improve subjective outcomes. Many patients reported urinary urgency and voiding symptoms, and only about half of patients would choose to undergo the surgery again if given the choice.

Surgery for recurrent stress urinary incontinence: the views of surgeons and women.

INTRODUCTION AND HYPOTHESIS: The objectives were to explore the views of women with recurrent stress incontinence (SUI) with regard to treatment preferences and the acceptability of randomisation to a future trial, and to survey the views of UK specialists on treatment preferences and equipoise regarding different treatment alternatives. METHODS: An online survey of the British Society of Urogynaecology (BSUG) and British Society of Urological Surgeons (BAUS) was carried out. Qualitative semi-structured interviews with a purposive sample of surgeons and women suffering from recurrent SUI from three UK centres. RESULTS: Two hundred fifty-six survey replies were received (176 gynaecology; 80 urology). Comparing the treatments offered, urogynaecologists were more likely to offer pelvic floor exercises (p < 0.05), and repeat midurethral tape (MUT) (p < 0.001). From the Surgical Equipoise Scale (SES) responses, "no preference" was rarely the commonest response. Marked differences for several options existed; midurethral tape dominated responses whenever it appeared. Twenty-one clinicians were interviewed. Treatment preferences were complex, influenced by a range of factors (reason for failure, patient comorbidity, investigations, personal experience, training). A future trial was regarded as important. Eleven women were interviewed. Most had considered more than one option, but felt that decision-making was more a process of elimination rather than a positive process. Randomisation to a study was regarded as unacceptable by most. CONCLUSIONS: No consensus exists among surgeons about preferred treatment options for recurrent SUI, and personal experience and training dominate decision-making. For patients, choices were usually based on an elimination of options, including that of a repeat failed procedure. This contrasts with surgeons, who mostly preferred a repeat MUT above other options. Any future comparative study will be challenging.

Infection after knee replacement: a qualitative study of impact of periprosthetic knee infection.

BACKGROUND: Approximately 340,000 knee replacements are performed each year in the USA and UK. Around 1% of patients who have had knee replacement develop deep infection around the prosthesis: periprosthetic knee infection. Treatment often requires a combination of one or more major operations and antibiotic therapy. This study aimed to understand and characterise patients' experiences of periprosthetic knee infection. METHODS: Qualitative semi-structured interviews were conducted with 16 patients (9 men, 7 women; 59-80 years, mean age 72) who experienced periprosthetic knee infection and subsequent revision treatment in six National Health Service orthopaedic departments. Interviews were audio-recorded, transcribed, anonymised and analysed thematically. The concept of biographical disruption was used to frame our analysis, and four transcripts double-coded for rigour. Patients were interviewed between two and 10 months after surgical revision. RESULTS: Participant experiences can be characterised according to three aspects of biographical disruption which we have used to frame our analysis: onset and the problem of recognition; emerging disability and the problem of uncertainty, and chronic illness and the mobilisation of resources. Participants' experiences of infection and treatment varied, but everyone who took part reported that infection and revision treatment had devastating effects on them. Participants described use of social and healthcare support and a need for more support. Some participants thought that the symptoms that they had first presented with had not been taken seriously enough. CONCLUSIONS: Periprosthetic knee infection and its treatment can be life-changing for patients, and there is a need for greater support throughout treatment and lengthy recovery. Future work could look at preparedness for adverse outcomes, help-seeking in impactful situations, and information for healthcare professionals about early signs and care for periprosthetic infection.

Outcomes and early revision rate after medial unicompartmental knee arthroplasty: prospective results from a non-designer single surgeon.

BACKGROUND: This prospective study evaluates outcomes and reoperation rates for unicompartmental knee arthroplasty (UKA) from a single non-designer surgeon using relatively extended criteria of degenerative changes of grade 2 or above in either or both non-operated compartments. METHODS: 187 consecutive medial mobile bearing UKA implants were included after history, clinical assessment and radiological evaluation. 91 patients had extended clinical outcomes. Post-operative assessment included functional scoring with the Oxford Knee Score (OKS) and radiographic review. Survivorship curves were constructed using the life-table method, with 95% confidence intervals calculated using Rothman's equation. Separate endpoints were examined: revision for any reason and revision for confirmed loosening. RESULTS: The mean follow-up was 3.5 years. The pre-operative OKS improved from a mean of 21.2 to 38.9 (Mann-Whitney U Test, p = < 0.001). Twelve Patients required further operations including 9 revisions. No patients developed deep infection and no surviving implants were loose radiographically. Survivorship at 7 years with endpoints of re-operation, revision and aseptic loosening at surgery or radiographically was 88.4% (95% CI 79.6-93.7), 93.1% (95% CI 85.5-96.9) and 97.3% (95% CI 91.2-99.2) respectively. The presence of pre-operative mild contralateral tibiofemoral or any extent of patellofemoral joint degeneration was of no consequence. DISCUSSION: The indications for UKA are being expanded to include patients with greater deformity, more advanced disease in the patellofemoral joint and even certain features in the lateral compartment indicative of an anteromedial pattern of osteoarthritis (OA). However, much of the supporting literature remains available only from designer centres. This study represents a group of patients with what we believe to be wider indications, along with decisions to treat made on clinical grounds and radiographs alone. CONCLUSION: This study shows comparable clinical outcomes of UKA for extended indications from a high volume, high-usage non-designer unit.

Transperineal reanastomosis for treatment of highly recurrent anastomotic strictures after radical retropubic prostatectomy: extended follow-up.

OBJECTIVES: To re-evaluate safety and efficacy of transperineal reanastomosis (TPRA) as a viable therapeutic option in highly recurrent anastomotic strictures (AS) after radical retropubic prostatectomy (RRP). METHODS: Retrospective analysis by standardized questionnaire inquiring for recurrence of stricture, stress urinary incontinence (SUI), sexual function, satisfaction, and changes in quality of life (QoL) was performed in all patients undergoing TPRA. Validated questionnaires (ICIQ-UI, EQ-5D, and IPSS) were included. RESULTS: Median follow-up was 45.0 months. The average number of prior operations was 4.69. Success rate was 87% (20/23). Three recurrences were successfully treated via endoscopic means. All patients had urinary incontinence pre-op and post-op. Implantation of an artificial urinary sphincter (AUS) has been performed successfully in 73.9% (17/23). Rate of complications was low (8.7%; 2/23, Clavien-Dindo Grade II + III). EQ-5D-VAS showed a good general state of health (73.5/100). An improvement in QoL was noted in 63.6% (14/22) and patient satisfaction was high (72.7%; 16/22). CONCLUSIONS: This extended follow-up confirms the initial results for TPRA as an excellent treatment option for highly recurrent AS after RRP. Postoperative SUI as a consequence of transsphincteric urethral mobilization can be satisfactorily treated by the implantation of AUS. In case of AS recalcitrant to endoscopic treatment, the described procedure-even though technically challenging-represents a valuable treatment option.

Patients' experience of acute unplanned surgical reoperation.

BACKGROUND: Undergoing surgery always involves various risks of complications, often depending on the type of surgery. Because of complications, a second surgical intervention, a reoperation, must occasionally be done, which in turn often causes an extended hospital stay, a longer recovery phase, greater suffering for the patient, and higher health care costs. Even though complications after general surgery are relatively common, little is known regarding patient experience of a reoperation. Knowledge of this could impact on care models in the future. The aim of this study was to describe patients' experience of acute, unplanned reoperation during a planned hospital stay. MATERIALS AND METHODS: A purposive sampling strategy was used, and 16 patients were included, all who had undergone acute unplanned reoperation during a planned hospital stay. Semi-structured interviews were used to collect data, and a content analysis with an inductive approach was used for data analysis. RESULTS: The analysis resulted in two main themes: (1) health professionals' importance, having its foundation in categories trust and information, and (2) reaction, based on the categories anxiety and sadness. CONCLUSIONS: Unplanned reoperation caused psychological, social, and existential reactions. Health care professionals were perceived as important because good communication, accurate information, their presence, and creating feelings of confident and safe care were meaningful factors for the patients as they managed the situation.

Primary liver transplantation and liver retransplantation: comparison of health-related quality of life and mental status - a cross-sectional study.

BACKGROUND: Liver Retransplantation (Re-LT) procedures are associated with an increased risk of morbidity and mortality. Up to date, there is no knowledge on the health-related quality of life and the mental status of these patients. METHODS: Health-Related Quality of Life (HRQoL) was assessed by using the Short Form 36 (SF-36) Health Survey and Mental Status was assessed by using the Hospital Anxiety and Depression Scale (HADS). The patients were examined in different assessments: During regular check-up examinations in the LT outpatient department in 2011 (Survey 1) and in a postal survey in 2013 (Survey 2). Their medical data was collected by using an established database. RESULTS: We received eligible surveys of 383 patients (55.6%) with a history of LT, of which 15 (3.9%) had undergone Re-LT (Re-LT group). These patients were compared to a group of 60 patients who had undergone only one LT. With regard to their HRQoL, the Re-LT group had significantly lower scores on the scales of physical function (PF, p = 0.026), their role-physical (RP, p = 0.008), their vitality (VIT, p = 0.040), and their role-emotional (RE, p = 0.005). The scores for anxiety and depression did not differ significantly between the groups. In a multiple regression analysis, chronic kidney disease was found to be an independent risk factor for decreased scores of PF (p = 0.023). CONCLUSIONS: Patients who have to undergo Re-LT procedures are faceing impairments in physical aspects of a HRQoL. Together with clinical results from other studies, the findings of the present examination underline the need for an optimized organ distribution strategy since not all patients listed for Re-LT appear to benefit from it.

[Beauty complication unit]. / Beauty-Komplikationssprechstunde.

A growing market, high demand, and the increasing complexity of cosmetic interventions have led to greater challenges in aesthetic medicine. In the present paper, medical, psychological and sociocultural aspects of possible complications are presented. Difficult situations can occur before, during, or after aesthetic interventions and require specific medical measures. This makes it necessary to set up a special consultation unit for beauty complications that takes into account extended medical and emotional aspects.

Long-Term Health-Related Quality of Life Outcomes in Digital Replantation versus Revision Amputation.

Background Earlier, digit viability judged the success of digital replantation. Now, utility health-related quality of life (HRQOL) measures can better assess the impact of digital replantation. Methods Overall, 264 digital injury patients were sent a regimen of utility measures: Disabilities of the Arm, Shoulder and Hand (DASH) score, European Quality of Life 5 Dimensions, visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG). Overall, 51 patients responded completely to all of these-36 replantation patients and 15 revision amputation patients. The utility results of these patients were stratified between replantation versus revision amputation; dominant hand replantation versus nondominant hand replantation; and dominant hand revision amputation versus nondominant hand revision amputation. Results The mean VAS score of replant (0.84) and revision amputation (0.75) groups was significantly different (p = 0.05). The mean DASH score of dominant hand replantations (29.72) and nondominant hand replantations (17.97) was significantly different (p = 0.027). The dominant hand revision amputation had higher anxiety levels in comparison to nondominant hand revision amputation (p = 0.027). Patients with two or more digits replanted showed a significant decrease in VAS, TTO, and SG scores in comparison to patients who only had one digit replanted (p = 0.009, 0.001, and 0.001, respectively). Conclusions This study suggests that HRQOL can offer better indices for outcomes of digital replantation. This shows some specific replantation cohorts have a significantly better quality of life when compared with their specific correlating revision amputation cohort. These findings can be employed to further refine indications and contraindications to replantation and help predict the quality of life outcomes.

Long-term effects of parotidectomy.

The present study investigated the long-term complications of parotidectomy, the differences in these complications in regard to the pathological diagnosis and type of surgery. The patients were questioned regarding the presence of facial paresis-paralysis, pain, loss of sensation, scarring, collapse, and mouth dryness in the area of operation. Complaints of pain (p = 0.287), scarring (p = 0.456), and mouth dryness (p = 0.136) did not show statistically significant differences between the cases with benign or malignant pathological outcomes. However, complaints of loss of sensation (p < 0.001), collapse in the area of operation (p = 0.025), paresis-paralysis (p < 0.001), and fear of repeated surgery (p = 0.032) were present at significantly higher rates. Complaints of pain (p = 0.258), scarring (p = 0.665), mouth dryness (p = 0.113) and fear of repeated surgery (p = 0.053) did not show statistically significant differences between the cases who underwent superficial or total parotidectomy. However, complaints of loss of sensation (p = 0.002), paresis (p < 0.001), and collapse in the area of operation (p = 0.019) were present at significantly higher rates. The type of tumor and surgical approach significantly affect the quality of life; however, parotidectomy generally does not lead to serious long-term complications that would disturb the patients.

Patient expectations of primary and revision anterior cruciate ligament reconstruction.

PURPOSE: Unrealistic patient expectations have been shown to negatively influence patient-reported outcomes in orthopaedic surgery. Knowledge about patient expectations is important to associate preoperative expectations with the reasonable outcome of a specific procedure. The purpose of this study was to prospectively analyse and to compare patient expectations of primary and revision anterior cruciate ligament reconstruction (ACLR) and to assess the factors associated with patient expectations. METHODS: Preoperative expectations of 181 consecutive patients undergoing ACLR were assessed prospectively using a 5-item questionnaire. Primary ACLR (P-ACLR) was performed in 133 patients (73%), whereas 48 patients (27%) underwent revision ACLR (R-ACLR). The questionnaire assessed the expectation of the overall condition of the knee joint, return to sports, instability, pain, and risk of osteoarthritis. RESULTS: All patients expected a normal (38%) or nearly normal (62%) condition of the knee joint. Return to sports at the same level was expected by 91%. With regard to instability (pain), no instability (pain) independent of the activity level was expected by 77% (58%). No or only a slightly increased risk of the development of osteoarthritis was expected by 98%. The R-ACLR group showed a significantly lower expectation of the overall condition (p = 0.001), return to sports (p < 0.001), and pain (p = 0.002). No statistically significant difference was found between female and male patients (n.s.). In the P-ACLR group, patients with a history of previous knee surgery showed inferior expectations of return to sports (p = 0.015) and risk of osteoarthritis (p = 0.011). Age, number of previous knee surgeries, and pre-injury sports level significantly influenced patient expectations. CONCLUSIONS: Overall, patient expectations of ACL reconstruction are high. Patients undergoing revision ACL reconstruction have lower but still demanding expectations. Younger patients, patients without a history of knee surgery, and highly active patients have higher expectations. Explicit patient information about realistic goals of ACL reconstruction seems to be necessary in order to prevent postoperative dissatisfaction despite a successful operation in the surgeons' point of view. LEVEL OF EVIDENCE: Prospective case series, Level IV.

Striving for Normalcy after Lower Extremity Reconstruction with Free Tissue: The Role of Secondary Esthetic Refinements.

BACKGROUND: Many patients with successful lower extremity salvage have postoperative functional and esthetic concerns. Such concerns range from contour irregularity preventing proper shoe-fitting to esthetic concerns involving color, contour, and texture match. The purpose of this study is to determine the overall incidence as well as factors associated with an increased likelihood of undergoing secondary, esthetic refinements of lower extremity free flaps and to review current revision techniques. METHODS: All patients undergoing lower extremity soft tissue coverage for limb salvage procedures between January 2007 and June 2013 at a single institution were included in the analysis. Patients who underwent secondary refinements for lower extremity free flaps were compared with patients not undergoing secondary procedures. RESULTS: During the study period, 152 patients underwent reconstruction and were eligible for inclusion. Of these, 32 (21.1%) patients underwent secondary, esthetic revisions. Few differences in patient or case characteristics were noted, although revision patients trended toward being younger, having lower body mass index, with defects secondary to acute trauma located below the ankle. The most common revision was complex soft tissue rearrangement or surgical flap debulking/direct excision (87.5% of patients), followed by scar revision (12.5%), suction-assisted lipectomy (3.1%), laser scar revision (3.1%), and tissue expansion with local tissue rearrangement (3.1%). CONCLUSION: A significant portion of patients desire secondary revisions following the initial procedure. This is especially true of younger patients with below ankle reconstruction. In many patients, an esthetic consideration should not be of secondary concern, but should be part of the ultimate reconstructive algorithm for lower extremity limb salvage.

Do surgical expectations change depending on first time surgery or reoperation? A prospective cohort study in lumbar spine surgery.

PURPOSE: To assess whether patients undergoing lumbar spine surgery for the first time (Group 1) had different expectations from those undergoing lumbar spine surgery for a failed previous procedure (Group 2). METHODS: A prospective study that included 77 patients. A set of self-reported questionnaires was pre-operatively administered including VAS, Oswestry Disability Index (ODI), Zung Depression Scale and the NASS lumbar spine questionnaire (expectations scale). RESULTS: Fifty-six patients in Group 1 and 21 patients in Group 2. Both groups had high expectations with regard to the surgical procedure (n.s.). Depressed patients, despite being more disabled than non-depressed according to ODI (p 0.001), had similar expectations than non-depressed patients (n.s.). CONCLUSION: Patients' expectations remained very high despite having had a failed previous surgery for the same procedure.

Complications after surgery for colorectal cancer affect quality of life and surgeon-patient relationship.

AIM: This multicentric prospective study aimed to investigate how postoperative complications after surgery for colorectal cancer affect patients' quality of life and satisfaction with care. METHOD: One hundred and sixteen patients operated on for colorectal cancer were enrolled in this study. Patients answered three questionnaires about generic (EORTC QLQ-C30) and disease-specific (EORTC QLQ-CR29) quality of life and treatment satisfaction (EORTC IN-PATSAT32) at the time of admission and at 1 and 6 months after surgery. Non-parametric tests and linear multiple regression models were used for statistical analysis. RESULTS: Twelve patients had complications requiring further surgery (anastomotic leakage, abdominal bleeding, abdominal wall sepsis, wound infection). Patients with complications that required surgery reported a worse score of physical function, emotional function and anxiety than patients without such complications 1 month after surgery. These patients judged their general satisfaction with the quality of care and doctors' interpersonal skills, technical skills, information provision and availability to be worse than in patients without such complications. The presence of postoperative psychiatric complications and anastomotic leakage were independent predictors of quality of life (ß = -0.30, P = 0.004, and ß = -0.42, P < 0.001). CONCLUSION: In patients undergoing surgery for colorectal cancer, complications requiring any kind of surgical management significantly affected patients' perception of all doctor-related items suggesting an impairment of the entire surgeon-patient relationship. Convincing patients that 'zero risk' cannot be achieved in surgical practice is therefore a priority.

Are patients open to elective re-sampling of their glioblastoma? A new way of assessing treatment innovations.

BACKGROUND: This is a qualitative study designed to examine patient acceptability of re-sampling surgery for glioblastoma multiforme (GBM) electively post-therapy or at asymptomatic relapse. METHODS: Thirty patients were selected using the convenience sampling method and interviewed. Patients were presented with hypothetical scenarios including a scenario in which the surgery was offered to them routinely and a scenario in which the surgery was in a clinical trial. RESULTS: The results of the study suggest that about two thirds of the patients offered the surgery on a routine basis would be interested, and half of the patients would agree to the surgery as part of a clinical trial. Several overarching themes emerged, some of which include: patients expressed ethical concerns about offering financial incentives or compensation to the patients or surgeons involved in the study; patients were concerned about appropriate communication and full disclosure about the procedures involved, the legalities of tumor ownership and the use of the tumor post-surgery; patients may feel alone or vulnerable when they are approached about the surgery; patients and their families expressed immense trust in their surgeon and indicated that this trust is a major determinant of their agreeing to surgery. CONCLUSION: The overall positive response to re-sampling surgery suggests that this procedure, if designed with all the ethical concerns attended to, would be welcomed by most patients. This approach of asking patients beforehand if a treatment innovation is acceptable would appear to be more practical and ethically desirable than previous practice.

Psychosocial effects of repetitive surgeries in children with early-onset scoliosis: are we putting them at risk?

BACKGROUND: The use of growing instrumentation in children with early-onset scoliosis (EOS) has created interest in determining if these repetitive procedures are prompting the development of lasting psychosocial problems. Given the increasing role of this treatment modality in the management of EOS, this study aimed to assess the psychological status of this patient population and to determine factors associated with worse scores in various psychosocial domains. METHODS: A cross-sectional assessment of 34 EOS patients was performed utilizing 2 well-established, caregiver-completed psychiatric instruments: the Child Behavior Checklist (CBCL) and the Strength and Difficulties Questionnaire. Scores were calculated for 15 CBCL and 6 Strength and Difficulties Questionnaire domains and subdomains and grouped as "Normal" or "Abnormal" according to published normative values. The prevalence of abnormal scores was within each instrument subdomain and was compared with the national norms. Domain scores were also correlated with age at first scoliosis surgery, total number of operative procedures, and total number of growing instrumentation surgeries. RESULTS: A higher prevalence of Abnormal scores were found in multiple psychosocial domains in our cohort as compared with national normative data. Children with Abnormal CBCL "Total Problems" domain scores were younger at the time of first scoliosis surgery (2.50 vs. 5.52 y). Normal and Abnormal scoring groups showed significant differences in the number of (1) total surgeries; (2) total scoliosis surgeries; and (3) growing instrumentation surgeries in multiple domains on both instruments. Aggression, Rule-breaking, and Conduct were positively correlated with total number of surgeries. CONCLUSIONS: Our findings showed a higher prevalence of Abnormal psychosocial scores in multiple domains in multioperated EOS patients as compared with national norms. Our findings suggest that EOS patients with abnormal psychosocial scores were younger at the time of their initial scoliosis surgery. The number of repetitive surgeries also correlated positively with 3 behavioral problem scores. Although healthier scores were seen in 1 positive behavioral domain in more operated children suggesting the potential for "posttraumatic growth," the other findings of this study are concerning given the increasing use of this treatment modality and indicate a need for ongoing screening and mental health care in this high-risk population. LEVEL OF EVIDENCE: Level III--case-control.

The effect of a manufacturer recall on the threshold to revise a metal-on-metal hip.

PURPOSE: Management of the unexplained, painful large diameter metal-on-metal (MOM) hip replacement is difficult. Although there are guidelines for surgeons, there is no clear documented evidence describing the overall threshold for revision surgery. The 2010 product recall of the DePuy Articular Surface Replacement (ASR) and subsequent media coverage may have increased patient and surgeon apprehension, resulting in earlier intervention, i.e. at a greater Oxford hip score (OHS) than expected. Our aim was to investigate whether the threshold for revision using known parameters was affected by the ASR recall. These parameters include poor clinical results (persistent pain or mechanical symptoms), pseudotumour or other progressive soft tissue involvement, osteolysis and high or rising metal ion levels. METHODS: We used our national referral database of MOM hips, which were revised between 2008 and 2012. Once inclusion and exclusion criteria were applied, we identified 240 patients--71 patients in the pre-recall group and 169 patients in the post-recall group. RESULTS: The ASR product recall did not seem to affect the threshold for revision of a MOM hip, with no significant difference between the two groups in terms of the functional (median OHS = 17 pre-recall and 20 post-recall; p = 0.2109) and radiological (median inclination angle = 50 pre-recall and 48 post-recall; p = 0.3221) markers used to guide management. We did however discover that blood metal ion levels were higher in the post-recall group. CONCLUSION: Issue of a product recall did not change the hip function threshold for revision surgery. The decision to revise a metal-on-metal hip is complex and should follow published guidelines, encompassing metal ion measurement and cross-sectional imaging where appropriate.

Roux-en-Y reconstruction is superior to redo fundoplication in a subset of patients with failed antireflux surgery.

BACKGROUND: A subset of patients requires reoperative antireflux surgery (Re-ARS) after failed fundoplication. The aim of this study was to determine symptomatic outcomes beyond 1 year following Re-ARS and to assess the relative utility of two different surgical approaches. METHODS: After Institutional Review Board approval, patients who underwent Re-ARS were identified from a prospective database. Symptom severity was graded on a 0-3 scale. Patients with postoperative symptoms of grade ≥ 2 were considered to have a poor outcome. Patient satisfaction was graded using a 10-point visual analog scale. RESULTS: At least 1 year of follow-up was available for 130 patients. There were 94 redo fundoplications (RF) and 36 Roux-en-Y reconstructions (RNYR). Symptom risk factors (significant preoperative dysphagia, significant preoperative heartburn, esophageal dysmotility, short esophagus, delayed gastric emptying, multiple failed hiatal surgeries, reflux-related respiratory symptoms) were more prevalent in patients who underwent RNYR compared to RF (mean 3.0 vs. 2.2; p = 0.003). Postoperative leaks and major complications occurred in 4.5 % (5/110) versus 0% and 21.6 % versus 33.3 % of the RF and RNYR groups, respectively. Twenty-eight RF patients (29.8 %) and 9 RNYR patients (25.0 %) reported poor outcomes. Among patients with ≥ 4 risk factors, those who underwent RNYR had a lower incidence of poor outcome (7.7 % vs. 55 %, p = 0.018) and higher satisfaction scores (8.4 vs. 5.8, p = 0.001) compared to those who had RF. Overall, 85 % of patients were satisfied or highly satisfied with their results and the average satisfaction score was 8.2. CONCLUSION: Re-ARS provides good subjective outcomes when measured more than 1 year after surgery. Patients with more complex pathology benefit more from RNYR despite the higher postoperative complication rate. This is especially true for patients with decreased esophageal motility and short esophagus.