[A Case of Intestinal Obstruction Due to an Internal Hernia in the Mesenteric Defect after Laparoscopic Resection of Transverse Colon].

72-year-old man who was diagnosed with transverse colon cancer cT3N1aM0, Stage Ⅲb, and underwent laparoscopic- assisted resection of the transverse colon. Postoperatively, the patient was discharged from the hospital after 24 days due to complications such as paralytic ileus and intra-abdominal abscess caused by prolonged intestinal congestion. On postoperative day 91, the patient developed abdominal pain and vomiting at home, and was rushed to our hospital on the same day. Abdominal CT showed that an internal hernia had formed in the mesenteric defect after resection of the transverse colon, which was suspected to have caused obstruction of the small intestine. After adequate preoperative decompression of the intestinal tract, a laparoscopic surgery was performed on the 9th day. The operative findings were that the jejunum(100- 160 cm from the Treitz ligament)had strayed into the mesenteric defect of the transverse colon, resulting in an internal hernia. After the internal hernia was repaired laparoscopically, the mesenteric defect was closed with a 3-0 V-Loc(non- absorbable). The patient had a good postoperative course and was discharged home 6 days after surgery.

Conversion of one anastomosis gastric bypass to distal Roux-en-Y gastric bypass due to recurrent weight gain and gastroesophageal reflux disease: A video case report.

One-anastomosis gastric bypass (OAGB) complications include inadequate weight loss, recurrent weight gain (RWG), and gastroesophageal reflux disease (GERD). Conversion to distal Roux-en-Y gastric bypass (D-RYGB) may be an effective conversional approach. A 38-year-old female underwent OAGB with a body mass index (BMI) of 53 kg/m2 and 43% initial total weight loss but had RWG to BMI of 44 kg/m2 over 5 years with refractory GERD symptoms. She underwent D-RYGB conversion, creating a 330 cm biliopancreatic limb, 75 cm Roux limb, and 400 cm total alimentary limb length to decrease the chance of malnutrition. At 2 weeks, GERD symptoms were resolved completely. By 12 months, 42% total weight loss was achieved with normal nutritional parameters. For RWG and refractory GERD after OAGB, conversion to D-RYGB can promote weight loss and GERD symptom control while preventing nutritional deficiencies.

Comparison of the clinical outcomes between proximal femoral nail anti-rotation with cement enhancement and hemiarthroplasty among elderly osteoporotic patients with intertrochanteric fracture.

BACKGROUND: The proximal femoral nail anti-rotation (PFNA) with cement enhancement enhances the anchorage ability of internal fixation in elderly with osteoporotic intertrochanteric fracture. However, whether it is superior to hemiarthroplasty is still controversial. The present study aimed to determine which treatment has better clinical outcomes among older patients. METHODS: We retrospectively analyzed 102 elderly patients with osteoporosis who developed intertrochanteric fractures and underwent PFNA combined with cement-enhanced internal fixation (n = 52, CE group), and hemiarthroplasty (n = 50, HA group) from September 2012 to October 2018. All the intertrochanteric fractures were classified according to the AO/OTA classification. Additionally, the operative time, intraoperative blood loss, intraoperative and postoperative blood transfusion rates, postoperative weight-bearing time, hospitalization time, Barthel Index of Activities Daily Living, Harris score of hip function, visual analog (VAS) pain score, and postoperative complications were compared between the two groups. RESULTS: The CE group had significantly shorter operative time, lesser intraoperative blood loss, lower blood transfusion rate, and longer postoperative weight-bearing time than the HA group. The CE group had lower Barthel's Index of Activities of Daily Living, lower Harris' score, and higher VAS scores in the first and third months after surgery than the HA group, but no difference was observed between the two groups from 6 months to 12 months. There was no significant difference in the total post-operative complications between the two groups. CONCLUSION: The use of PFNA combined with a cement-enhanced internal fixation technique led to shorter operative time and lesser intraoperative blood loss and trauma in elderly patients as compared to HA.

Comparing two vascular division techniques in laparoscopic varicocelectomy. A prospective study. / Comparación de dos técnicas de sección vascular en la varicocelectomía laparoscópica. Estudio prospectivo.

INTRODUCTION: Varicocele is the abnormal dilatation of the pampiniform plexus. It occurs in 15-20% of pre-adolescent/adult males. Varicocele diagnosis is important since it can induce testicular hypertrophy and fertility issues in adulthood. The objective of this study was to assess whether complications, including varicocele recurrence, depend on the vascular occlusion technique used -clipping + division vs. vascular sealer- in the laparoscopic Palomo technique used in our institution. MATERIALS AND METHODS: A longitudinal, prospective study was carried out from 2017 to 2021. Two therapeutic groups were created according to the vascular occlusion method used during laparoscopic varicocelectomy -clipping + division vs. vascular sealer. Patients were randomly allocated to the groups in a systematic alternating consecutive manner. Variables -age, varicocele grade according to the Dubin-Amelar classification, postoperative complications, follow-up, and varicocele recurrence- were analyzed according to the method employed. RESULTS: A total of 37 boys, with a mean age of 12 years (10-15 years) and a mean follow-up of 12 months, were studied. In 20 patients (54.1%), clipping + division was used, and in the remaining 17 (45.9%), the vascular sealer was employed. 24.3% had symptomatic Grade II varicocele and 75.7% had Grade III varicocele. 32.4% of the children had postoperative complications during follow-up. 29.7% of the patients had hydrocele following surgery -8 boys from the sealing group and 3 boys from the clipping group-, with 13.5% requiring re-intervention as a result of this. None of the patients had varicocele recurrence. CONCLUSIONS: The laparoscopic Palomo technique is safe and effective, with good results in pediatric patients and few postoperative complications, regardless of the vascular occlusion device used. In our study, no statistically significant differences regarding the use of clipping or vascular sealer in this laparoscopic technique were found. However, further studies with a larger sample size are required to find potential differences.

INTRODUCCION: El varicocele es la dilatación anormal del plexo pampiniforme. Puede afectar al 15-20% de los varones preadolescentes-adultos. La importancia de su diagnóstico radica en que puede inducir hipotrofia testicular y problemas de fertilidad en la etapa adulta. El objetivo de este estudio es evaluar si existe mayor índice de complicaciones, incluyendo la recurrencia del varicocele, dependiendo de la técnica de oclusión vascular utilizada: clip y sección o sellador vascular, en la técnica de Palomo laparoscópico en nuestro centro. MATERIAL Y METODOS: Estudio longitudinal prospectivo que se realiza de 2017 a 2021. Se crean dos grupos terapéuticos según el método de oclusión vascular utilizada durante la varicocelectomía laparoscópica: clip y sección o sellador vascular. Los pacientes son incluidos en un grupo mediante asignación sistemática consecutiva alternante. Se realiza el análisis de las variables: edad, grado de varicocele según la clasificación de Dubin-Amelar, complicaciones postquirúrgicas, seguimiento y recurrencia del varicocele, según el método empleado. RESULTADOS: Se intervinieron un total de 37 niños, con edad media de 12 años (10-15 años) y una media de seguimiento de 12 meses. En 20 pacientes (54,1%), se utilizó clip y sección, y en los 17 restantes (45,9%), sellador vascular. El 24,3% presentaba varicocele Grado II sintomático y el 75,7%, Grado III. El 32,4% de los niños presentó alguna complicación postquirúrgica durante el seguimiento. El 29,7% de los pacientes presentó hidrocele tras la intervención, perteneciendo 8 niños al grupo de sellado y 3 niños al de clipaje. El 13,5% de estos precisó reintervención por este motivo. Ningún paciente presentó recurrencia del varicocele. CONCLUSIONES: La técnica de Palomo laparoscópica es una técnica segura y efectiva que presenta buenos resultados en pacientes pediátricos, ya que presenta pocas complicaciones postquirúrgicas, independientemente del dispositivo de oclusión vascular que se utilice. En nuestro estudio, no se ha demostrado que existan diferencias estadísticamente significativas en cuanto al uso de clip o sellador vascular en esta técnica laparoscópica. No obstante, es preciso realizar más estudios con mayor tamaño muestral para hallar posibles diferencias.

Routine Upper Gastrointestinal Series Post-bariatric Surgery: Predictors, Usage, and Utility.

OBJECTIVE: To investigate usage and utility of routine upper gastrointestinal (UGI) series in the immediate post-operative period to evaluate for leak and other complications. METHODS: Single institution IRB-approved retrospective review of patients who underwent bariatric procedure between 01/08 and 12/12 with at least 6-month follow-up. RESULTS: Out of 135 patients (23%) who underwent routine UGI imaging, 32% of patients were post-gastric bypass (127) versus 4% of sleeve gastrectomy (8). In patients post-gastric bypass, 22 were found with delayed contrast passage, 3 possible obstruction, 4 possible leak, and only 1 definite leak. In patients post-sleeve gastrectomy, 2 had delayed passage of contrast without evidence of a leak. No leak was identified in 443 patients (77%) who did not undergo imaging. The sensitivity and specificity of UGI series for the detection of leak in gastric bypass patients were 100% and 97%, respectively, and the positive and negative predictive values were 20% and 100%, respectively. On univariate and multivariate analysis, sleeve gastrectomy patients (OR 0.4 sleeve vs bypass; P < 0.01) and male patients (OR 0.4 M vs F; P 0.02) were less likely to undergo routine UGI series (OR 0.4 M vs F; P 0.02). CONCLUSION: Routine UGI series may be of limited value for the detection of anastomotic leaks after gastric bypass or sleeve gastrectomy and patients should undergo routine imaging based on clinical parameters. Gastric bypass procedure and female gender were factors increasing the likelihood of routine post-operative UGI. Further larger scale analysis of this important topic is warranted.

Comparative Interrupted Time Series Analysis of Direct Medical Expense and Length of Stay in Elderly Patients with Femoral Neck Fractures Who Underwent Total Hip Arthroplasty and Hemiarthroplasty: A Real World Nationwide Database Study.

Background: The objective of our study was to analyze the postoperative direct medical expenses and hospital lengths of stay (LOS) of elderly patients who had undergone either hemiarthroplasty (HA) or total hip arthroplasty (THA) for femoral neck fractures and to determine the indication of THA by comparing those variables between the 2 groups by time. Methods: In this comparative large-sample cohort study, we analyzed data from the 2011 to 2018 Korean National Health Insurance Review and Assessment Service database. The included patients were defined as elderly individuals aged 60 years or older who underwent HA or THA for a femoral neck fracture. A 1:1 risk-set matching was performed on the propensity score, using a nearest-neighbor matching algorithm with a maximum caliper of 0.01 of the hazard components. In comparative interrupted time series analysis, time series were constructed using the time unit of one-quarter before and after 3 years from time zero. For the segmented regression analysis, we utilized a generalized linear model with a gamma distribution and logarithmic link function. Results: A total of 4,246 patients who received THA were matched and included with 4,246 control patients who underwent HA. Although there was no statistically significant difference in direct medical expense and hospital LOS for the first 6 months after surgery, direct medical expenses and hospital LOS in THA were relatively reduced compared to the HA up to 24 months after surgery (p < 0.05). In the subgroup analysis, the THA group's hospital LOS decreased significantly compared to that of the HA group during the 7 to 36 months postoperative period in the 65 ≤ age < 80 age group (p < 0.05). Direct medical expenses of the THA group significantly decreased compared to those of the HA group during the period from 7 to 24 months after surgery in the men group (p < 0.05). Conclusions: When performing THA in elderly patients with femoral neck fractures, the possibility of survival for at least 2 years should be considered from the perspective of medical expense and medical utilization. Additionally, in healthy and active male femoral neck fracture patients under the age of 80 years, THA may be more recommended than HA.

Laparoscopic-Assisted Transvaginal Cholecystectomy - the US Military Experience With Long-Term Follow Up.

Objectives: We present our initial clinical experience applying Natural Orifice Transluminal Endoscopic Surgical (NOTES) technique to perform cholecystectomy in ten patients at a military institution. Methods: A posterior colpotomy was created to accommodate a single site working port used to facilitate dissection and gallbladder mobilization under direct visualization via an infraumbilical port. The specimen was retrieved through the vagina and the colpotomy was closed with absorbable suture under direct visualization. Long-term follow up was performed over the phone to assess quality of life with 2 widely used health-related quality of life (HRQoL) surveys including RAND-36 Health Item Survey (Version 1.0),1 and the Female Sexual Function Index (FSFI).2. Results: Ten women underwent a laparoscopic-assisted transvaginal cholecystectomy (TVC) with 7 available for long-term follow-up. The average age was 28.9 years (20-37) and the indications for surgery included symptomatic cholelithiasis (9) and biliary dyskinesia (1). The mean operative time was 129 mins (95-180), and median blood loss was 34 ml (5-400). There were no conversions and the average length of stay was 9.98 hours (2.4-28.8). Pain (analogue scale 1-10) on postoperative day three was minimal (mean 2.3) and was limited to the infraumbilical incision. On average patients returned to work by postoperative day six and resumed normal daily activities at seven days. Immediate postoperative complications included one incident of postoperative urinary retention requiring bladder catheterization. One intra-operative cholangiogram was successfully performed due to elevated preoperative liver enzymes without significant findings. Long-term complications included one asymptomatic incisional hernia repair at the infraumbilical port site. The RAND-36 survey demonstrated an average physical and mental health summary score of 82.2 and 63.7 with an average general health score of 63.6. The average FSFI total score was 21.8. Conclusion: TVC is safe and effective. Implementation may improve operational readiness by returning service members to normal activities more expeditiously than conventional laparoscopy.

Early and late outcomes of congenital biliary dilatation in pediatric patients.

BACKGROUND: This study aimed to reveal the early and late postoperative complications and outcomes after surgery for congenital biliary dilatation (CBD) by reviewing cases over the past 40 years. METHODS: We retrospectively evaluated 59 patients with CBD who underwent radical surgery for complications and outcomes, based on medical records. Early complications were defined as those requiring treatment within 5 years of the initial operation. Late complications were defined as those treated more than 5 years later. RESULTS: The median age at the first surgery was 37 months. Regarding biliary reconstruction, 54 of the 59 patients (91.5%) underwent hepaticojejunostomy. Although three patients underwent cholecystoduodenostomy and one patient underwent hepaticoduodenostomy, all were converted to hepaticojejunostomy after a median of 12.5 years. One patient developed synchronous biliary carcinoma and underwent pancreaticoduodenectomy. Early complications occurred in seven patients with 10 events (surgical site infection, n = 3 bile leakage, n = 3; ileus, n = 3; bile duct obstruction, n = 1 and intussusception, n = 1). Late complications occurred in nine patients with 12 events (ileus, n = 3; anastomotic stricture, n = 3; hepatolithiasis, n = 3; asynchronous biliary carcinoma, n = 2; pancreatolithiasis, n = 1). Two of the three patients with hepatolithiasis underwent hepatectomy refractory to the endoscopic approach. Two patients developed asynchronous biliary carcinoma at 34 and 13 years after last operation; both ultimately died of the carcinoma. Only 35 patients (61.4%) underwent a follow-up examination. A total of 11 female patients (45.8%) eventually married, and all successfully gave birth. CONCLUSION: Although the long-term prognosis is excellent with complete cyst excision and hepaticojejunostomy, we emphasize the importance of long-term follow-up.

Efficacy and safety of robotic-assisted knee reconstruction: a systematic review and meta-analysis.

OBJECTIVE: Robotic-assisted surgery is increasingly being utilized in hip and knee reconstruction. However, the relative efficacy and safety of robotic-assisted total knee replacement (RATKR) compared to traditional surgery remained uncertain. This study aimed to systematically review the current literature comparing the outcomes of RATKR to traditional procedures. MATERIALS AND METHODS: Comprehensive literature searches were conducted in major databases to identify studies comparing RATKR with traditional surgeries. The primary outcomes were functional scores and post-operative complications. Pooled mean differences (MDs) with 95% confidence intervals (CIs) were calculated using a random effects model. RESULTS: A total of 12 studies were considered for inclusion. The pooled functional scores of The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Society Score (KSS), hospital for Special Surgery (HSS) score, visual analogue score (VAS) pain score showed no significant differences between the two groups (MD = -0.99, 95% CI -2.32 to 0.34, p-value = 0.14). The subgroup analysis for hip and knee reconstructions also revealed no significant difference in terms of functional scores. However, for post-operative complications, while there was no significant difference in terms of blood loss (MD = -1.62, 95% CI -4.42 to 1.17, p-value = 0.25), the readmission rates were significantly higher in the RATKR group (MD = 0.94, 95% CI 0.77 to 1.11, p-value < 0.00001). The overall heterogeneity was extremely high (I² = 93%), particularly in the analyses of post-operative complications. CONCLUSIONS: The findings suggested that robotic-assisted knee reconstruction did not significantly improve functional outcomes compared to traditional surgery. The safety profile was similar except for a higher readmission rate following RATKR. Given the high heterogeneity, further large-scale, well-designed, randomized controlled trials are needed to conclusively determine the efficacy and safety of robotic-assisted hip and knee reconstruction.

Impact of drainage retinotomy on surgical outcomes of retinal detachment: insights from the Japan-Retinal Detachment Registry.

We investigated the impact of drainage retinotomy on the outcome of pars plana vitrectomy for repair of rhegmatogenous retinal detachment (RRD). This study was a retrospective observational multicenter study. All patients were registered with the Japan-Retinal Detachment Registry. We analyzed 1887 eyes with RRD that had undergone vitrectomy and were observed for 6 months between February 2016 and March 2017. We compared the baseline characteristics and postoperative outcomes between eyes with and without drainage retinectomy. We then performed propensity score matching using preoperative findings as covariates to adjust for relevant confounders. Of 3446 eyes, 1887 met the inclusion criteria. Among them, 559 eyes underwent vitrectomy with drainage retinotomy, and 1328 eyes underwent vitrectomy without drainage retinotomy. After propensity score matching, each group comprised 544 eyes. There was no significant difference between the two groups in BCVA at 6 months after vitrectomy (0.181 vs. 0.166, P = 0.23), the primary anatomical success rate (6.3% vs. 4.4%, P = 0.22), or the rate of secondary surgery for ERM within 6 months (1.5% vs. 1.3%, P = 1.0). Drainage retinectomy does not increase the risk of decreased postoperative BCVA, surgical failure, or secondary surgery for ERM within six months outcomes.

Comparative Analysis of Ventral Hernia Repair and Transverse Abdominis Release With and Without Panniculectomy: A 4-Year Match-Pair Analysis.

INTRODUCTION: Amid rising obesity, concurrent ventral hernia repair and panniculectomy procedures are increasing. Long-term outcomes of transverse abdominis release (TAR) combined with panniculectomy remain understudied. This study compares clinical outcomes and quality of life (QoL) after TAR, with or without panniculectomy. METHODS: A single-center retrospective review from 2016 to 2022 evaluated patients undergoing TAR with and without panniculectomy. Propensity-scored matching was based on age, body mass index, ASA, and ventral hernia working group. Patients with parastomal hernias were excluded. Patient/operative characteristics, postoperative outcomes, and QoL were analyzed. RESULTS: Fifty subjects were identified (25 per group) with a median follow-up of 48.8 months (interquartile range, 43-69.7 months). The median age and body mass index were 57 years (47-64 years) and 31.8 kg/m2 (28-36 kg/m2), respectively. The average hernia defect size was 354.5 cm2 ± 188.5 cm2. There were no significant differences in hernia recurrence, emergency visits, readmissions, or reoperations between groups. However, ventral hernia repair with TAR and panniculectomy demonstrated a significant increase in delayed healing (44% vs 4%, P < 0.05) and seromas (24% vs 4%, P < 0.05). Postoperative QoL improved significantly in both groups (P < 0.005) across multiple domains, which continued throughout the 4-year follow-up period. There were no significant differences in QoL among ventral hernia working group, wound class, surgical site occurrences, or surgical site occurrences requiring intervention (P > 0.05). Patients with concurrent panniculectomy demonstrated a significantly greater percentage change in overall scores and appearance scores. CONCLUSIONS: Ventral hernia repair with TAR and panniculectomy can be performed safely with low recurrence and complication rates at long-term follow-up. Despite increased short-term postoperative complications, patients have a significantly greater improvement in disease specific QoL.

Complications Following Tissue Expander-Based Reconstruction in Pediatric Burn Injuries: A Retrospective Analysis.

BACKGROUND: Tissue expansion has been widely used to reconstruct soft tissue defects following burn injuries in pediatric patients, allowing for satisfactory cosmetic and functional outcomes. Factors impacting the success of tissue expander (TE)-based reconstruction in these patients are poorly understood. Herein, we aim to determine the risk factors for postoperative complications following TE-based reconstruction in pediatric burn patients. METHODS: A retrospective review of pediatric patients who underwent TE placement for burn reconstruction from 2006 to 2019 was performed. Primary outcomes were major complications (TE explantation, extrusion, replacement, flap necrosis, unplanned reoperation, readmission) and wound complications (surgical site infection and wound dehiscence). Descriptive statistics were calculated. The association between primary outcomes, patient demographics, burn characteristics, and TE characteristics was assessed using the chi-squared, Fisher's exact, and Mann-Whitney U tests. RESULTS: Of 28 patients included in the study, the median [interquartile range (IQR)] age was 6.5 (3.3-11.8) years, with a follow-up of 12 (7-32) months. The majority were males [n = 20 (71%)], Black patients [n = 11 (39%)], and experienced burns due to flames [n = 78 (29%)]. Eleven (39%) patients experienced major complications, most commonly TE premature explantation [n = 6 (21%)]. Patients who experienced major complications, compared to those who did not, had a significantly greater median (IQR) % total body surface area (TBSA) [38 (27-52), 10 (5-19), P = 0.002] and number of TEs inserted [2 (2-3), 1 (1-2), P = 0.01]. Ten (36%) patients experienced wound complications, most commonly surgical site infection following TE placement [n = 6 (21%)]. Patients who experienced wound complications, compared to those who did not, had a significantly greater median (IQR) %TBSA [35 (18-45), 19 (13-24), P = 0.02]. CONCLUSION: Pediatric burn injuries involving greater than 30% TBSA and necessitating an increasing number of TEs were associated with worse postoperative complications following TE-based reconstruction.

Assessing the perioperative outcomes of abdominal drain omission after robot-assisted partial nephrectomy.

The study aimed to evaluate the impact of abdominal drain placement (vs. omission) on perioperative outcomes of robot-assisted partial nephrectomy (RAPN), focusing on complications, time to canalization, deambulation, and pain management. A prospectively-maintained institutional database was queried to get data of patients who underwent RAPN for renal masses between January 2018 and May 2023 at our Institution. Baseline, surgical, and postoperative data were collected. Retrieved patients were stratified based upon placement of abdominal drain (Y/N). Descriptive analyses comparing the two groups were conducted as appropriate.77 After adjusting for potential confounders, a logistic regression analysis was conducted to evaluate significant predictors of any grade and "major" complications. 342 patients were included: 192 patients in the "drain group" versus 150 patients in the "no-drain" group. Renal masses were larger (p < 0.001) and at higher complexity (RENAL score, p = 0.01), in the drain group. Procedures in the drain group had statistically significantly longer operative time, ischemia time, and higher blood loss (all p-values < 0.001). The urinary collecting system was more likely involved compared to the no-drain group (p = 0.01). At multivariate analysis, abdominal drainage was not a significant predictor of any grade (OR 0.79, 95%CI 0.33-1.87) and major postoperative complications (OR 3.62, 95%CI 0.53-9.68). Patients in the drain group experienced a statistically significantly higher hemoglobin drop (p < 0.01). Moreover, they exhibited statistically significant higher paracetamol consumption (p < 0.001) and need for additional opioids (p = 0.02). In summary, the study results suggest the safety of omitting drain placement and remark on the need for personalized decision-making, which considers patient and procedural factors.

Clinical outcomes of perforator-based propeller flaps versus free flaps in soft tissue reconstruction for lower leg and foot trauma: a retrospective single-centre comparative study.

BACKGROUND: The efficacy and safety of perforator-based propeller flaps (PPF) versus free flaps (FF) in traumatic lower leg and foot reconstructions are debated. PPFs are perceived as simpler due to advantages like avoiding microsurgery, but concerns about complications, such as flap congestion and necrosis, persist. This study aimed to compare outcomes of PPF and FF in trauma-related distal lower extremity soft tissue reconstruction. METHODS: We retrospectively studied 38 flaps in 33 patients who underwent lower leg and foot soft tissue reconstruction due to trauma at our hospital from 2015 until 2022. Flap-related outcomes and complications were compared between the PPF group (18 flaps in 15 patients) and the FF group (20 flaps in 18 patients). These included complete and partial flap necrosis, venous congestion, delayed osteomyelitis, and the coverage failure rate, defined as the need for secondary flaps due to flap necrosis. RESULTS: The coverage failure rate was 22% in the PPF group and 5% in the FF group, with complete necrosis observed in 11% of the PPF group and 5% of the FF group, and partial necrosis in 39% of the PPF group and 10% of the FF group, indicating no significant difference between the two groups. However, venous congestion was significantly higher in 72% of the PPF group compared to 10% of the FF group. Four PPFs and one FF required FF reconstruction due to implant/fracture exposure from necrosis. Additionally, four PPFs developed delayed osteomyelitis post-healing, requiring reconstruction using free vascularized bone graft in three out of four cases. CONCLUSIONS: Flap necrosis in traumatic lower-leg defects can lead to reconstructive failure, exposing implants or fractures and potentially causing catastrophic outcomes like osteomyelitis, jeopardizing limb salvage. Surgeons should be cautious about deeming PPFs as straightforward and microsurgery-free procedures, given the increased complication rates compared to FFs in traumatic reconstruction. DATA ACCESS STATEMENT: The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Transforaminal endoscopic lumbar discectomy with two-segment foraminoplasty for the treatment of very highly migrated lumbar disc herniation: a retrospective analysis.

BACKGROUND: The surgical resection of very highly migrated lumbar disc herniation (VHM-LDH) is technically challenging owing to the absence of technical guidelines. Hence, in the present study, we introduced the transforaminal endoscopic lumbar discectomy (TELD) with two-segment foraminoplasty to manage VHM-LDH and evaluated its radiographic and midterm clinical outcomes. MATERIALS AND METHODS: The present study is a retrospective analysis of 33 consecutive patients with VHM-LDH who underwent TELD with two-segment foraminoplasty. The foraminoplasty was performed on two adjacent vertebrae on the basis of the migration direction of disc fragments to fully expose the disc fragments and completely decompress the impinged nerve root. The operation duration, blood loss, intra- and postoperative complications, and recurrences were recorded. Additionally, imageological observations were evaluated immediately after the procedure via magnetic resonance image and computerized tomography. Clinical outcomes were evaluated by calculating the visual analog scale (VAS) score and Oswestry Disability Index (ODI). The MacNab criterion was reviewed to assess the patients' opinions on treatment satisfaction. The resection rate of bony structures were quantitatively evaluated on postoperative image. The segmental stability was radiologically evaluated at least a year after the surgery. Additionally, surgery-related and postoperative complications were evaluated. RESULTS: The average age of the patients was 56.87 ± 7.77 years, with a mean follow-up of 20.95 ± 2.09 months. The pain was relieved in all patients immediately after the surgery. The VAS score and ODI decreased significantly at each postoperative follow-up compared with those observed before the surgery (P < 0.05). The mean operation duration, blood loss, and hospital stay were 56.17 ± 16.21 min, 10.57 ± 6.92 mL, and 3.12 ± 1.23 days, respectively. No residual disc fragments, iatrogenic pedicle fractures, and segmental instability were observed in the postoperative images. For both up- and down- migrated herniation in the upper lumbar region, the upper limit value of resection percentage for the cranial SAP, caudal SAP, and pedicle was 33%, 30%, and 34%, respectively; while those in the lower lumbar region was 42%, 36%, and 46%, respectively. At the last follow-up, the satisfaction rate of the patients regarding the surgery was 97%. Surgery-related complications including dural tear, nerve root injury, epidural hematoma, iatrogenic pedicle fractures, and segmental instability were not observed. One patient (3%) suffered from the recurrence of LDH 10 months after the initial surgery and underwent revision surgery. CONCLUSIONS: The TELD with two-segment foraminoplasty is safe and effective for VHM-LDH management. Proper patient selection and efficient endoscopic skills are required for applying this technique to obtain satisfactory outcomes.

The influence of postoperative outcomes on survival after esophageal cancer surgery: validation of a consensus-based updated textbook outcome parameter.

BACKGROUND: Esophagectomy in combination with perioperative multimodal therapy is the cornerstone of modern curative treatment for esophageal adenocarcinoma. The primary aim of this study was to assess the influence of textbook outcome (TO) as a composite quality performance indicator (QPI) and its perioperative parameters on survival in patients who underwent esophagectomy with curative intent. METHODS: Consecutive patients who underwent an esophagectomy between January 2014 and December 2022 at Christchurch Hospital were identified from a prospectively maintained hospital database. Univariable and multivariable analyses were performed to assess prognostic factors for each composite and individual postoperative outcome. Survival analysis was performed to evaluate the influence of these outcomes on overall survival. RESULTS: A total of 108 patients underwent an esophagectomy during the study period. The overall and Clavien-Dindo (CD) grade ≥ 3 postoperative complication rates were 62% and 26%, respectively. The anastomotic leak rate was 6.5% (n = 7). The TO rate, 30-day readmission rate, and 30-day mortality rate were 20%, 13%, and 1%, respectively. Resection margin and nodal disease were found to be independent prognostic factors for reduced survival. CONCLUSION: TO as originally defined and its postoperative parameters of 30-day postoperative complications and 30-day readmission are validated QPIs of esophageal cancer surgery. Updating the postoperative complication parameter to include CD grade ≥ 3 complications resulted in a positive association between achieving TO and increased survival. Our findings support the call to redefine TO based on an update to this parameter, making it a more precise QPI of esophageal cancer surgery.

The development of a risk assessment tool for patients with postoperative pneumonia after gastrectomy for gastric cancer.

BACKGROUND: Although frail patients are known to experience increased postoperative complications, this is unclear for postoperative pneumonia (POP). We investigated associations between frailty and POP in patients with gastric cancer (GC) undergoing gastrectomy. METHODS: In this prospective study conducted between August 2016 and December 2022, we preoperatively assessed frailty in 341 patients with GC undergoing gastrectomy using a frailty index (FI). Patients were divided into high FI vs low FI groups to examine frailty and pneumonia rates after gastrectomy for GC. RESULTS: Of 327 patients, 18 (5.5%) experienced POP after gastrectomy. Multivariate analyses showed that a high FI and total or proximal gastrectomy (TG/PG) were independent risk factors for POP (high FI: odds ratio [OR], 5.00; 95% CI, 1.77-15.54; TG/PG: OR, 3.07; 95% CI, 1.09-8.78). The proportion of patients with POP was 2.4% in those with nonhigh FI and non-TG/PG, 5.3% in those with nonhigh FI and TG/PG, 7.1% in those with high FI and non-TG/PG, and 28.0% in those with high FI and TG/PG (P < .001). The area under the receiver operating characteristic curve for this risk assessment for predicting POP was 0.740. CONCLUSION: In patients with GC undergoing gastrectomy, POP was independently associated with preoperatively high FI and TG/PG. Our simple POP risk assessment method, which combines these factors, may effectively predict and prepare patients for POP.

Textbook outcome in liver surgery: open vs minimally invasive hepatectomy among patients with hepatocellular carcinoma.

BACKGROUND: We sought to investigate whether minimally invasive hepatectomy (MIH) was superior to open hepatectomy (OH) in terms of achieving textbook outcome in liver surgery (TOLS) after resection of hepatocellular carcinoma (HCC). METHODS: Patients who underwent resection of HCC between 2000 and 2020 were identified from an international database. TOLS was defined by the absence of intraoperative grade ≥2 events, R1 resection margin, posthepatectomy liver failure, bile leakage, major complications, in-hospital mortality, and readmission. RESULTS: A total of 1039 patients who underwent HCC resection were included in the analysis. Although most patients underwent OH (n = 724 [69.7%]), 30.3% (n = 315) underwent MIH. Patients who underwent MIH had a lower tumor burden score (3.6 [IQR, 2.6-5.2] for MIH vs 6.1 [IQR, 3.9-10.1] for OH) and were more likely to undergo minor hepatectomy (84.1% [MIH] vs 53.6% [OH]) than patients who had an OH (both P < .001). After propensity score matching to control for baseline differences between the 2 cohorts, the incidence of TOLS was comparable among patients who had undergone MIH (56.6%) versus OH (64.8%) (P = .06). However, MIH was associated with a shorter length of hospital stay (6.0 days [IQR, 4.0-8.0] for MIH vs 9.0 days [IQR, 6.0-12.0] for OH). Among patients who had MIH, the odds ratio of achieving TOLS remained stable up to a tumor burden score of 4; after which the chance of TOLS with MIH markedly decreased. CONCLUSION: Patients with HCC who underwent resection with MIH versus OH had a comparable likelihood of TOLS, although MIH was associated with a short length of stay.

Independent external validation and comparison of existing pancreatic fistula risk scores after laparoscopic pancreaticoduodenectomy with Bing's pancreaticojejunostomy.

BACKGROUND: The fistula risk score (FRS) is the widely acknowledged prediction model for clinically relevant postoperative pancreatic fistula (CR-POPF). In addition, the alternative FRS (a-FRS) and updated alternative FRS (ua-FRS) have been developed. This study performed external validation and comparison of these 3 models in patients who underwent laparoscopic pancreaticoduodenectomy (LPD) with Bing's pancreaticojejunostomy. METHODS: The FRS total points and predictive probabilities of a-FRS and ua-FRS were retrospectively calculated using patient data from a completed randomized controlled trial. Postoperative pancreatic fistula (POPF) and CR-POPF were defined according to the 2016 International Study Group of Pancreatic Surgery criteria. The correlations of the 4 risk items of the FRS model with CR-POPF and POPF were analyzed and represented using the Cramer V coefficient. The performance of the 3 models was measured using the area under the curve (AUC) and calibration plot and compared using the DeLong test. RESULTS: This study enrolled 200 patients. Pancreatic texture and pathology had discrimination for CR-POPF (Cramer V coefficient: 0.180 vs 0.167, respectively). Pancreatic duct diameter, pancreatic texture, and pathology had discrimination for POPF (Cramer V coefficient: 0.357 vs 0.322 vs 0.257, respectively). Only the calibration of a-FRS predicting CR-POPF was good. The differences among the AUC values of the FRS, a-FRS, and ua-FRS were not statistically significant (CR-POPF: 0.687 vs 0.701 vs 0.710, respectively; POPF: 0.733 vs 0.741 vs 0.750, respectively). After recalibrating, the ua-FRS got sufficient calibration, and the AUC was 0.713 for predicting CR-POPF. CONCLUSION: For LPD cases with Bing's pancreaticojejunostomy, the 3 models predicted POPF with better discrimination than predicting CR-POPF. The recalibrated ua-FRS had sufficient discrimination and calibration for predicting CR-POPF.