In patients undergoing valve-sparing aortic root replacement, is reimplantation superior to remodelling?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients undergoing valve-sparing aortic root replacement, is reimplantation superior to remodelling? The purpose of this best evidence topic was to re-review the updated evidence that has become available in the near decade since the previous review published in 2011. Altogether more than 300 papers were found using the reported search, of which 8 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The included studies have significant limitations relating to low-level evidence study design, variable outcome collection and limited significance testing with direct comparison. Long-term outcomes such as survival, recurrence of aortic regurgitation and valve reintervention were largely equal between the two procedures across the studies. This review, updated from the previous best evidence topic, continues to suggest that there are no clear recommendations or even consensus to guide clinical decision-making when choosing between remodelling or reimplantation approaches to valve-sparing aortic root replacement. To date, no study provides strong clinical benefit to favour either procedure in terms of perioperative outcomes, medium-long term survival or reintervention of the aortic valve. As such, procedure selection should be based upon patient factors and valve evaluation, combined with surgeon preference and experience.

Finger Replantation Optimization Study (FRONT): Update on National Trends.

PURPOSE: Traumatic digit amputations have an adverse impact on patients' daily living. Despite experts advocating for digit replantation, studies have shown a continued decrease in rate of replantation. We performed a national-level investigation to examine the recent trend of practice for digital replantation. METHODS: We used the National Inpatient Sample database under the Healthcare Cost and Utilization Project to select adult patients with traumatic digit amputation from 2001 to 2014. We calculated the rate of attempted and rate of successful digit replantation per year, subcategorizing for digit type (thumb or finger) and for hospital type (rural, urban nonteaching, or urban teaching). We also analyzed the pattern of distribution of case volume to each hospital type per year. We used 2 multivariable logistic regression models to investigate patient demographic and hospital characteristics associated with the odds of replantation attempt and success. RESULTS: Among the 14,872 adult patients with a single digit amputation from 2001 to 2014, only 1,670 (11.2%) underwent replantation. The rate of replantation attempt trended down over the years for both thumb and finger injuries at all hospital types, despite increasing proportions of cases being sent to urban teaching hospitals where they were more than twice as likely to undergo replantation. The rate of successful replantation stayed stable for the thumb at 82.9% and increased for fingers from 76.1% to 82.4% over the years. Patients were more likely to undergo replantation if they had private insurance or a higher level of income. Neither hospital case volume nor hospital type was predictive of successful replantation. CONCLUSIONS: Although more single-digit amputations were treated by urban teaching hospitals with higher likelihood to replant, the downward trend in rate of attempt regardless of hospital type demonstrates that concentration of case volume is not the solution to reverse the declining trend. CLINICAL RELEVANCE: Financial aspects of digit replantation need to be considered from both the patients' and the surgeons' perspectives to improve delivery of care for digit replantation.

Disappearing Digits: Analysis of National Trends in Amputation and Replantation in the United States.

BACKGROUND: Significantly fewer replantations have been performed at the authors' institution in recent years, with similar trends observed across the United States. A study of three national databases was performed to evaluate this trend, its possible cause, and national health care implications. METHODS: The National Electronic Injury Surveillance System, Bureau of Labor Statistics, and National Inpatient Sample databases were queried for cases with a diagnosis of finger amputation over available years from 2000 to 2011. Data were weighted and analyzed to give appropriate national estimates of amputations, replantations, and related clinical variables. Trend analysis was performed using modified Poisson regression. RESULTS: Although workplace finger amputation rates decreased 40 percent from 2000 to 2010 (p < 0.0001), the overall finger amputation incidence did not change significantly (26,668 versus 24,215; p = 0.097). Compared with 930 replantations in 2001, only 445 were performed in 2011, more than a 50 percent decrease (p < 0.001). In all years, the majority of hospitals performing replantation performed only one (49.3 to 64.1 percent) each year, with a small minority (2.2 to 8.1 percent) performing more than 10 per year. In 2000, 120 hospitals (12.1 percent) performed at least one replantation, compared with only 80 hospitals (7.6 percent) in 2010, a 4.6 percent annual decline (p = 0.002). CONCLUSIONS: There has been a striking decline in digital replantations being performed, despite a relatively stable incidence of amputations. Apparently independent of declining work-related injuries, evolving clinical decision-making may be responsible for this trend. Decreasing replantation experience among hand surgeons lends credence to the development of specialized regional centers designed to treat these complex injuries.

From Autotransplantation to Allotransplantation: A Perspective on the Future of Reconstructive Microsurgery.

It has been half a century since Susumu Tamai reported on the first thumb replantation. The evolution of reconstructive microsurgery has continually added new applications of the operating microscope for reconstructive surgery and has had profound impact on countless patients. From the time of Harold Gillies until today, the reconstructive ladder has evolved to a reconstructive elevator with the "penthouse" floor being represented by vascularized composite allotransplantation.

Long-term outcome following upper extremity replantation after major traumatic amputation.

BACKGROUND: Amputations in general and amputations of upper extremities, in particular, have a major impact on patients' lives. There are only a few long-term follow-up reports of patients after macro-replantation. We present our findings in contrast with the existing literature. METHODS: Sixteen patients with traumatic macro-amputation of an upper extremity were eligible for inclusion in this study. Altogether, the patients underwent replantation in 3 institutions between 1983 and 2011. RESULTS: Twelve male and four female patients with an average age at injury of 40.6 years (range, 14-61 years) were included in this study. The mean follow-up period was 13.5 years (range, 4.4-32.6 years; SD, 5.7 years). The mean disabilities of the arm, shoulder and hand (DASH) outcome measure was 41 (range, 5.2-94.8; SD, 18.2), functional independence measurement (FIM) was 125 (range, 120-126; SD, 1.8). Chen I representing very good function was accounted in six, Chen II representing good function in eight, Chen III (fair) in one and Chen IV (bad function) in one patient. CONCLUSIONS: We found that while the majority of the included patients exhibited good or very good function of the extremity, none of the replanted appendages regained normal levels of functionality. In addition, all participants were very satisfied with their outcomes. Positive long-term results with high rates of subjective satisfaction are possible after replantation of upper extremities.

Use of Pediatric Open, Laparoscopic and Robot-Assisted Laparoscopic Ureteral Reimplantation in the United States: 2000 to 2012.

PURPOSE: We characterize the use of pediatric open, laparoscopic and robot-assisted laparoscopic ureteral reimplantation in the United States from 2000 to 2012. MATERIALS AND METHODS: We used the Kids' Inpatient Database to identify patients who underwent ureteral reimplantation for primary vesicoureteral reflux. Before 2009 laparoscopic ureteral reimplantion and robot-assisted laparoscopic ureteral reimplantation were referred to together as minimally invasive ureteral reimplantation. A detailed analysis of open vs robot-assisted laparoscopic ureteral reimplantation was performed for 2009 and 2012. RESULTS: A total of 14,581 ureteral reimplantations were performed. The number of ureteral reimplantations yearly decreased by 14.3%. However, the proportion of minimally invasive ureteral reimplantations increased from 0.3% to 6.3%. A total of 125 robot-assisted laparoscopic ureteral reimplantations were performed in 2012 (81.2% of minimally invasive ureteral reimplantations), representing 5.1% of all ureteral reimplantations, compared to 3.8% in 2009. In 2009 and 2012 mean ± SD patient age was 5.7 ± 3.6 years for robot-assisted laparoscopic ureteral reimplantation and 4.3 ± 3.3 years for open reimplantation (p <0.0001). Mean ± SD length of hospitalization was 1.6 ± 1.3 days for robot-assisted laparoscopic ureteral reimplantation and 2.4 ± 2.6 for open reimplantation (p <0.0001). Median charges were $22,703 for open and $32,409 for robot-assisted laparoscopic ureteral reimplantation (p <0.0001). These relationships maintained significance on multivariate analyses. On multivariate analysis robot-assisted laparoscopic ureteral reimplantation use was associated with public insurance status (p = 0.04) and geographic region outside of the southern United States (p = 0.02). Only 50 of 456 hospitals used both approaches (open and robotic), and only 6 hospitals reported 5 or more robot-assisted laparoscopic ureteral reimplantations during 2012. CONCLUSIONS: Treatment of primary vesicoureteral reflux with ureteral reimplantation is decreasing. Robot-assisted laparoscopic ureteral reimplantation is becoming more prevalent but remains relatively uncommon. Length of stay is shorter for the robotic approach but the costs are higher. Nationally robot-assisted laparoscopic ureteral reimplantation appears to still be in the early phase of adoption and is clustered at a small number of hospitals.

Restoration of ovarian activity and pregnancy after transplantation of cryopreserved ovarian tissue: a review of 60 cases of reimplantation.

Aggressive chemotherapy/radiotherapy and bone marrow transplantation can cure >90% of girls and young women affected by disorders requiring such treatment. However, the ovaries are very sensitive to cytotoxic drugs, especially to alkylating agents. Several options are currently available to preserve fertility in cancer patients. The present review reports the results of 60 orthotopic reimplantations of cryopreserved ovarian tissue performed by three teams, as well as 24 live births reported in the literature to date. Restoration of ovarian activity occurred in almost all cases in the three series. Among the 60 patients, eleven conceived and six of those had already delivered twelve healthy babies. In the future, we are looking to: 1) improve freezing techniques; and 2) enhance the "vascular bed" before reimplantation to increase pregnancy rates. On the other hand, cryopreservation of ovarian tissue may be combined with removal, via puncture, of small antral follicles, making it possible to freeze both ovarian tissue and isolated immature oocytes.

Current trends in surgery for renal hyperparathyroidism (RHPT)--an international survey.

PURPOSE: The indications and results of preoperative localization, surgical strategy, indication for thymectomy, the application of intraoperative parathyroid hormone (PTH) monitoring, cryopreservation, and replantation of cryopreserved parathyroid tissue are not well documented in renal hyperparathyroidism (RHPT). The current trends in surgery for RHPT are to be evaluated in an international online survey. METHODS: Thirty-three questions regarding preoperative localization, surgical management of RHPT, intraoperative PTH monitoring, immediate/delayed autotransplantation (AT), and parathyroid cryopreservation were sent to members of various societies of endocrine surgeons. RESULTS: The data from 86 responses were analyzed, 61.6 % reported more than 50 parathyroid surgeries per year, and 62.7 % operated on less than 16 patients with RHPT per year. Subtotal or total parathyroidectomy (with/without AT) was the standard procedure in 98.8 % of the cases. Immediate AT was performed in 40.7 % (72.7 % in the forearm). In most patients, the onset of graft function was documented later than 1 week after AT. Cryopreservation was routinely performed in 27.4 %. In 10.7 %, replantation was performed in more than five patients (hypo- or aparathyroidism: n = 41; fresh graft failure: n = 13; reoperations: n = 9). Intraoperative PTH monitoring (in RHPT) was routinely used in 46.2 %. Its influence on surgical strategy was confirmed in 40 %. CONCLUSIONS: The survey reflects the divergent strategies applied for AT, cryopreservation, and PTH monitoring in RHPT.

Reimplantación coclear en el mismo oído: hallazgos, peculiaridades de la técnica quirúrgica y complicaciones / Cochlear reimplantation in the same ear: Findings, peculiarities of the surgical technique and complications

Introducción: Los implantes cocleares son, por diversos motivos, dispositivos electrónicos perecederos y, en ocasiones, han de reemplazarse. La técnica quirúrgica de reimplantación coclear, si bien no difiere substancialmente de la implantación virgen, si tiene unas peculiaridades características. En este artículo se analizan estas peculiaridades, no solo desde el punto de vista técnico, si no también respecto a las complicaciones que genera y el rendimiento funcional auditivo que consigue. Objetivos: Descripción detallada de los hallazgos operatorios, las peculiaridades de la técnica quirúrgica y las complicaciones generadas en el proceso de reimplantación coclear. Evaluación del rendimiento auditivo funcional del paciente reimplantado. Material y método: Revisión descriptiva retrospectiva de 34 reimplantaciones en el mismo oído, realizadas en nuestro servicio durante el periodo entre 1993 y 2008 en 27 pacientes en un hospital terciario por el mismo equipo de cirujanos. Los implantes reemplazados fueron 2 Ineraid® (Smith & Nephew Richards), 23 Laura® (Philips Hearing Implants), 8 Nucleus 24K® (Cochlear Corp.) y un Clarion® (Advanced Bionics). Resultados: La tasa de reimplantación por paciente en el mismo oído fue del 18,5%. La causa más frecuente de reimplantación en nuestra serie fue el fallo interno del implante (14 casos). Otras causas fueron la substitución por actualización tecnológica (7 casos), malposición del haz de electrodos (8 casos), necrosis/infección del colgajo cutáneo con exposición del implante (3 casos) y por último traumatismos externos (2 casos). Los hallazgos operatorios más significativos fueron la reosificación parcial de la mastoidectomía, la ausencia de osificación de la timpanotomía posterior y la permeabilidad de la espira basal de la cóclea cuando esta alojaba el haz de electrodos. En 25 pacientes, se consiguió una reintroducción completa del haz de electrodos y en 2 pacientes una introducción parcial. La tasa de complicaciones generadas fueron, tanto cuantitativamente como cualitativamente, comparables a la tasa de implantación en el oído virgen, salvo cuando el implante original fue del tipo Ineraid. Conclusiones: La técnica quirúrgica de reimplantación y de multirreimplantación tiene peculiaridades específicas en cado uno de sus pasos, pero, en términos generales, tiene una complejidad parecida a la implantación de oídos vírgenes y se asocia a una tasa de complicaciones similar. La introducción del nuevo haz de electrodos es sencilla y completa en la inmensa mayoría de casos, dado que la cóclea permanece permeable, siempre y cuando aloje al haz de electrodos; en caso contrario, tiene tendencia a reosificarse. El rendimiento auditivo esperable del nuevo implante está en consonancia con sus prestaciones. Si son iguales a las del implante substituido, el rendimiento auditivo del implantado es similar, y si son mejores, también lo es su rendimiento, excepto en oídos con grandes periodos de deprivación auditiva (AU)

Introduction: Cochlear implants are, for many reasons, expirable electronic devices and occasionally may have to be replaced. The surgical cochlear reimplantation technique is not substantially different from the initial implantation but does have some peculiarities. These peculiarities are analyzed in this paper not only from the point of view of surgical technique but also with respect to the complications involved and the functional auditive outcome obtained. Objectives: An accurate description of the surgical findings, peculiarities of the surgical technique and complications found during the process of cochlear reimplantation. An evaluation of the audiometric functional outcome of the reimplantation. Material and method: A descriptive retrospective review of 34 reimplantations in the same ear, carried out at our department during the period between 1993 and 2008, in 27 patients in a tertiary hospital by the same team of seniors surgeons. The cochlear implants replaced were 2 Ineraid ® (Smith & Nephew Richards, TN), 23 Laura ® (Philips Hearing Implants), 8 nucleus 24K ® (Cochlear Corp., Englewood, CO), 1 Clarion r (Advanced Bionics, Sylmar, CA). Results: The rate of reimplantation in the same ear was 18.5% per patient. The most frequent reason in our series was internal failure of the device (14 cases). Other causes were substitution for a technological update (7 cases), misplacement of electrodes (8 cases), necrosis/infection of the skin flap with exposure of the implant (3 cases) and external injuries (2 cases). The most important surgical findings were partial mastoidectomy reossification, absence of ossification in the posterior tympanostomy and the permeability of the basal turn of the cochlea when it housed the electrodes. A complete reintroduction of the electrodes was achieved in 25 patients and a partial one in 2 patients. The rate of complications generated was similar in reimplantation and in virgin ear implantation, except for when the original implant was an Ineraid device. Conclusions: The surgical technique of reimplantation and multireimplantation technique has characteristic peculiarities at each step, but in general terms, its complexity is similar to that of implantation in virgin ears and the rate of complications is also similar. The introduction of the new electrodes is simple and complete in the immense majority of cases, given that the cochlea remains permeable, as long as it houses the electrodes; otherwise it tends to become reossified. The functional auditory outcome of the new implant is in relation with its capacities. If they are equal to those of the initial implant then the auditory outcome will be similar and if they are better, then so will the outcome be, with the exception of ears with long periods of auditive deprivation (AU)

Replantation: past, present, and future.

The reattachment of completely severed parts has only been a clinical reality for 40 years. During that time there has been a shift in focus from refining technical aspects and improving success rates to assessing functional outcomes and better defining the indications for replantation. Although replantations are most frequently performed in academic environments, all practitioners should understand the basic indications for replantation as well as the principles of preservation of tissue. The advances in microsurgery and replantation over the past four decades have revolutionized the way reconstructive surgeons restore form and function to the body, and have laid the groundwork for new advances in composite tissue allotransplantation and tissue engineering.

Interposición apendicular en uréter inferior derecho (ureteroapendiconeocistostomía) / Appendicular interposition in inferior right ureter (uretero-appendico-neocystostomy)

El tratamiento del cáncer de vejiga tiene como finalidad la curación, control local y preservación de la función sexual urinaria. Durante 30 años, la cistectomía radical es la terapia estándar para pacientes con cáncer de vejiga invasivo y, la creación de un reservorio continente, con reimplantación ureteral, ha permitido preservar la función urinaria. Sin embargo, este procedimiento presenta un 30 por ciento de complicaciones, principalmente infecciones urinarias, estenosis y reflujo urteral. La utero-apendico-neocistostomía no ha sido un procedimiento los suficientemente difundido para reunir una experiencia acerca de la morbilidad y el éxito del mismo. Presentamos un paciente de 63 años de edad con antecedentes de cistoprostatectomía radical y neovejiga ortotópica tipo Hautman por carcinoma de células transicionales de vejiga estadio I, con estenosis ureteral inferior derecha de 3 cm. Se reparó la estanosis ureteral con la interposición apendicular entre el uréter derecho y la neovejiga. La evolución fue satisfactoria, con un resultado posoperatorio funcional adecuado, con continuidad ureterovesical demostrada por radiología. La cistectomía, linfadenectomía pélvica y reconstrucción urinaria ortotópica es una de las mejores opciones para los pacientes con cáncer de vejiga invasivo, con una excelente tasa de sobrevida y funcionalidad. La estenosis ureteral es una posible complicación tardía de este procedimiento. La uretero-apéndice-neocistostomía es una opción valedera para la reparación quirúrgica de la estenosis, a pesar de no ser una técnica muy difundida

[Cryopreservation of human ovarian tissue. Method of freezing and therapeutic use]. / Kryopraeservering af humant ovarievaev. Metoder til nedfrysning og terapeutisk anvendelse.

The medical treatment of various cancers may, as long-term sequelae, cause infertility in girls and young women. In order to preserve the fertility of such women, techniques to cryopreserve ovarian tissue have gained considerable interest during recent years. The ovarian tissue is cryopreserved before cancer treatment is commenced, and first replaced when the woman has been cured. Based on the successful results from the use of this technique in test animals, where normal live young have been born, cryopreservation of human ovarian tissue has been initiated in a number of fertility clinics worldwide over the last few years. So far, only two women have experienced transplantation of cryopreserved ovarian tissue. Menstrual cycles and oestradiol production were restored in both women, but restoration of fertility have not yet been demonstrated. This review describes the technique and its present possibilities and limitations. The legal aspects in Denmark are presented and some ethical aspects described.

Laparoscopic extravesicular ureteral reimplantation for vesicoureteral reflux: recent technical advances.

Ureteral reimplantation is an effective treatment for primary vesicoureteral reflux. Recent efforts have been directed toward reducing the perioperative morbidity of open reimplantation. We have refined the technique of laparoscopic extravesical ureteral reimplantation with emphasis on minimal tissue dissection, achieving reliable detrusor closure, and downsizing ports and instruments. With our current technique, excellent results comparable to those of established open procedures are achieved, while postoperative discomfort and the recovery period are significantly reduced. The laparoscopic technique of ureteral reimplantation is described, with emphasis on key technical modifications crucial to the ease of performance and a successful outcome.

[Updated status of replantation services in Germany, Austria and Switzerland]. / Aktualisierter Stand des Replantationsservice in Deutschland, Osterreich sowie der Schweiz.

The revised survey involves the years 1991 and 1992 and includes 41 university and major civil hospitals. As in the years 1989 and 1990, replantation activity in the year 1991 still declined, whereas in 1992 we registered a sharp increase in replantations, especially in Germany. In numbers, 856 were reported for 1991 (72 macro- and 784 microreplantations), and 1091 in 1992 (85 macro- and 1006 microreplantations). A considerable number of amputation cases (617) were rejected mainly due to lack of operative manpower capacity.

[The status of replantation centers and services in the area served by the German Professional Society of Microsurgery of Peripheral Nerves and Blood Vessels (Commission for Replantation)]. / Zur Situation der Replantationszentren und -dienste im Einzugsgebiet der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefässe (Kommission für Replantationen).

This survey concerns the years 1989 and 1990. While the number of institutions performing replantations remained constant in Austria and Switzerland, there has been a noticeable trend in Germany from around-the-clock replantation centers to simple replantation services, offering emergency microsurgery by arrangement only. The total number of replantations performed decreased from 975 replanted parts (903 microreplantations and 72 macroreplantations) in 1989 to 875 in 1990, with a micro-/macroreplantation ratio of 12.8:1. Based on the results of questionaire received from 34 university and city hospitals in Austria, Switzerland and former West Germany, an analysis of clinical organization and management of replantation services is presented.

Microsurgery: directions for the 1990s.

Speculating on the possible advances of microsurgery in the 1990s has encompassed discussion of transplantation technique, biochemistry, monitoring, and nerve and motor reconstruction. This article, however, is by no means exhaustive, and many other discoveries and innovations may come from areas not discussed here. The only clearly incorrect possibility concerning microsurgery in the 1990s is that nothing exciting will happen.