Linear Stapler versus Circular Stapler for Patients Undergoing Anastomosis for Laparoscopic Gastric Surgery: A Meta-Analysis.

BACKGROUND: Anastomotic devices, including linear staplers (LSs) and circular staplers (CSs), have been widely used after laparoscopic gastric surgery. However, it is controversial whether linear stapling is superior to circular stapling for anastomosis. Thus, we conducted a meta-analysis to compare the aspects of postoperative complications, particularly anastomotic stricture and anastomotic leakage, on the use of the two techniques to assist clinical decision-making. METHODS: We conducted a systematic search using Embase, PubMed, and Cochrane Library to evaluate studies that compared LSs and CSs after laparoscopic gastric surgery. RESULTS: Pooled analysis suggested that patients who received LSs had fewer postoperative complications (P = 0.019), and anastomotic complications (P < 0.001), stricture (P = 0.001), and bleeding (P = 0.005). The subgroup analyses showed that LSs caused fewer anastomotic complications (P < 0.001), anastomotic strictures (P < 0.001), and postoperative hemorrhage (P = 0.007) in patients with gastric cancer than CS. In addition, LSs caused fewer incidences of overall morbidity (P = 0.042), anastomotic strictures (P = 0.023), postoperative hemorrhage (P < 0.001), wound infection (P < 0.001), and shorter length of hospital stay (P = 0.048) in patients with obesity. Furthermore, the subgroup analyses showed that the use of LS resulted in lower overall morbidity (P = 0.042), anastomotic stricture (P = 0.023), wound infection (P < 0.001), length of hospital stay (P = 0.048), and postoperative hemorrhage (P < 0.001) when applied in gastrojejunostomy, while LSs resulted in fewer anastomotic complications (P < 0.001), anastomotic stricture (P = 0.016) than CS when applied in esophagojejunostomy. CONCLUSION: Compared with CSs, LSs yielded a lower incidence of overall morbidity, anastomotic complications, anastomotic stricture, bleeding, and wound infection, indicating that linear stapling is safer and more efficient than circular stapling when performing anastomosis after laparoscopic gastric surgery.

Comparison of effects of energy based devices on quality of life after sutureless thyroidectomy.

OBJECTIVE: In current literature, no studies evaluated effect of energy-based vessel-sealing-devices on quality of life after sutureless total thyroidectomies. This study aimed to identify any potential differences between two energy-based vessel-sealing-devices (Harmonic Focus, Ligasure LF1212) in patients with benign thyroid disorders who underwent sutureless total thyroidectomy. MATERIALS AND METHODS: Differences in quality of life of patients were evaluated using data obtained by Thy-PRO-39-Tr questionnaire prior to and four-week after surgery. Total and domain-based alterations in quality of life were compared between groups according to energy-based vessel-sealing-devices type (Group L, Group H). Additionally, data including demographics, height, weight, body mass index, neck circumference, sternomental distance were collected. RESULTS: Of 1032 patients, 200 were eligible for study, at the end 193 were analysed. There were no differences between groups in terms of age, sex, body mass index, tobacco use. Analysis did not reveal any differences in overall quality of life between groups (P = .42). However, in "eye symptoms" (P < .001) and "cognitive functions" (P = .002) domains, Harmonic provided statistically improved quality of life. Effect on cognitive function was greater in patients of advanced age. CONCLUSIONS: Especially in elderly patients with worsening eye conditions and cognitive functions, use of Harmonic may enhance patients' outcome by increasing quality of life in addition to optimizing surgical outcome when compared to Ligasure.

A new technique for emergency cerclage: Guard suture method.

Objective The aim of this study was to introduce a novel technique to treat midtrimester cervical insufficiency with prolapsed membranes. Material and methods This retrospective study included patients with singleton pregnancies between 16 and 28 gestational weeks that underwent emergency cervical cerclage in a tertiary center. Patients were divided into two groups as McDonald method and guard suture method group according to the procedure they underwent. The following variables were recorded and evaluated: gestational age at cerclage, cervical length between the suture and external cervical os measured by transvaginal ultrasound on postoperative 1st and 7th day, gestational age at delivery, time between the procedure and delivery, intraoperative complications, newborn intensive care unit (NICU) admission, Apgar scores of neonates, and discharged alive newborns. Results During the study period, 38 patients underwent emergency cerclage procedure. Twenty-three were included in the McDonald group and 15 were in the guard suture group. The mean gestational age at the time of cerclage was 22.1 (17 -27) weeks and the mean gestational age at delivery was 33.9 (26- 38) weeks. Prolongation time between cerclage and delivery was 80.42 (1 - 140) days. Significantly higher 1st and 5th minutes Apgar scores and significantly lower NICU admission was found in the guard suture group (p = 0.04, p = 0.01 and p = 0.02, respectively). Conclusion In cases with cervical insufficiency and prolapsed membranes, emergency cerclage may prevent premature birth by prolonging pregnancy. Guard suture method is safe, effective, and easily applicable and can help obstetricians achieve better fetal and neonatal outcomes.

Double-layered purse string uterine suture compared with single-layer continuous uterine suture: A randomized Controlled trial.

BACKGROUND: With the aim of preventing cesarean scar defects, we introduced a new technique involving a purse string uterine suture. To date, this uterine suture technique has not been formally evaluated. The objective of the study was to test the hypothesis that compared to single layer continuous uterine suture (SLCUS), a double layered purse string uterine suture (PSUS) significantly reduces cesarean scar defect (CSD) rates, without increasing the perioperative maternal morbidity. METHODS: A prospective randomized study. Primary outcome was the rate of CSD. 100 patients were enrolled in 2 groups according to the uterine suture technique. A hysterosonography was performed by the same senior obstetrician blinded to the uterine suture technique 6 months after surgery .Operative time and calculated blood loss (CBL) were used for the short time analysis. Uterine and CSD measurements were used for the mid time analysis. RESULTS: Despite a longer operative time with PSUS (7.17 ± 2.31 min Vs. 6.31 ± 3.04 min, p = 0.028; p <10‾³); there was no significant difference in terms of CBL (520 ± 58 with PSUS vs. 536 ± 50 ml, p = 0.724). There was a significant decrease in the rate of CSD with PSUS: 6.66% Vs.40% with SLUCS; p<0.001. Moreover, SLUCS was the leading risk factor for CSD: adjusted OR=6; 95% CI [0-1], p<10‾³). CONCLUSION: Compared to single layer continuous suture, double layered purse stringuterine suture significantly reduces cesarean scar defect rates, without increasing the perioperative maternal morbidity.

Sutured Versus Mesh-augmented Hiatus Hernia Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: This meta-analysis systematically reviewed published randomized control trials comparing sutured versus mesh-augmented hiatus hernia (HH) repair. Our primary endpoint was HH recurrence at short- and long-term follow-up. Secondary endpoints were: surgical complications, operative times, dysphagia and quality of life. SUMMARY BACKGROUND DATA: Repair of large HHs is increasingly being performed. However, there is no consensus for the optimal technique for hiatal closure between sutured versus mesh-augmented (absorbable or nonabsorbable) repair. METHODS: A systematic review of Medline, Scopus (which encompassed Embase), Cochrane Central Register of Controlled Trials, Web of Science, and PubMed was performed to identify relevant studies comparing mesh-augmented versus sutured HH repair. Data were extracted and compared by meta-analysis, using odds ratio and mean differences with 95% confidence intervals. RESULTS: Seven randomized control trials were found which compared mesh-augmented (nonabsorbable mesh: n = 296; absorbable mesh: n = 92) with sutured repair (n = 347). There were no significant differences for short-term hernia recurrence (defined as 6-12 months, 10.1% mesh vs 15.5% sutured, P = 0.22), long-term hernia recurrence (defined as 3-5 years, 30.7% mesh vs 31.3% sutured, P = 0.69), functional outcomes and patient satisfaction. The only statistically significant difference was that the mesh repair required a longer operation time (P = 0.05, OR 2.33, 95% confidence interval 0.03-24.69). CONCLUSIONS: Mesh repair for HH does not offer any advantage over sutured hiatal closure. As both techniques deliver good and comparable clinical outcomes, a suture only technique is still an appropriate approach.

Feasibility of endoscopic hand suturing on rectal anastomoses in ex vivo porcine models.

Prevention of postoperative anastomotic leakage in rectal surgery is still required. This study investigated the feasibility of endoscopic hand suturing (EHS) on rectal anastomosis ex vivo. By using isolated porcine colon, we prepared ten anastomoses 6-10 cm from the virtual anus. Then, we sutured anastomoses intraluminally by EHS, which involved a continuous suturing method in 5 cases and a nodule suturing method with extra corporeal ligation in 5 cases. Completeness of suturing, number of stitches, procedure time and presence of stenosis were investigated. Furthermore, the degree of stenosis was compared between the two suturing methods. In all cases, EHS were successfully completed. The median number of stitches and procedure time was 8 and 5.8 min, respectively. Stenosis was created in all continuous suturing cases whereas none was seen in nodule suturing cases. The shortening rate was significantly greater in the continuous suturing method than in the nodule suturing method. Intraluminal reinforcement of rectal anastomosis by EHS using nodule suturing with extra corporeal ligation is feasible without stenosis, which may be helpful as a countermeasure against possible postoperative anastomotic leakage in rectal surgery.

Smart surgical sutures using soft artificial muscles.

Wound closure with surgical sutures is a critical challenge for flexible endoscopic surgeries. Substantial efforts have been introduced to develop functional and smart surgical sutures to either monitor wound conditions or ease the complexity of knot tying. Although research interests in smart sutures by soft robotic technologies have emerged for years, it is challenging to develop a soft robotic structure that possesses a similar physical structure as conventional sutures while offering a self-tightening knot or anchor to close the wound. This paper introduces a new concept of smart sutures that can be programmed to achieve desired and uniform tension distribution while offering self-tightening knots or automatically deploying secured anchors. The core technology is a soft hydraulic artificial muscle that can be elongated and contracted under applied fluid pressure. Each suture is equipped with a pressure locking mechanism to hold its temporary elongated state and to induce self-shrinking ability. The puncturing and holding force for the smart sutures with anchors are examined. Ex-vivo experiments on fresh porcine stomach and colon demonstrate the usefulness of the new smart sutures. The new approaches are expected to pave the way for the further development of smart sutures that will benefit research, training, and commercialization in the surgical field.

Incisional Surgical Site Infections After Mass and Layered Closure of Upper Abdominal Transverse Incisions: First Results of a Randomized Controlled Trial.

OBJECTIVE: To compare the early results of mass and layered closure of upper abdominal transverse incisions. SUMMARY OF BACKGROUND DATA: Contrary to midline incisions, data on closure of transverse abdominal incisions are lacking. METHODS: This is the first analysis of a randomized controlled trial primarily designed to compare mass with layered closure of transverse incisions with respect to incisional hernias. Patients undergoing laparotomy through upper abdominal transverse incisions were randomized to either mass or layered closure with continuous sutures. Incisional surgical site infection (incisional-SSI) was the primary end-point. Secondary end-points comprised suture-to-wound length ratio (SWLR), closure duration, and fascial dehiscence (clinicatrials.gov NCT03561727). RESULTS: A total of 268 patients were randomized to either mass (n=134) or layered (n=134) closure. Incisional-SSIs occurred in 24 (17.9%) and 8 (6.0%) patients after mass and layered closure, respectively (P =0.004), with crude odds ratio (OR) of 0.29 [95% confidence interval (95% CI) 0.13-0.67; P =0.004]. Layered technique was independently associated with fewer incisional-SSIs (OR: 0.29; 95% CI 0.12-0.69; P =0.005). The number needed to treat, absolute, and relative risk reduction for layered technique in reducing incisional-SSIs were 8.4 patients, 11.9%, and 66.5%, respectively. Dehiscence occurred in one (0.8%) patient after layered closure and in two (1.5%) patients after mass closure (P >0.999). Median SWLR were 8.1 and 5.6 (P <0.001) with median closure times of 27.5 and 25.0 minutes (P =0.044) for layered and mass closures, respectively. CONCLUSIONS: Layered closure of upper abdominal transverse incisions should be preferred due to lower risk of incisional-SSIs and higher SWLR, despite clinically irrelevant longer duration.

Prophylactic subcutaneous retention sutures in the prevention of superficial wound separation of midline laparotomy.

OBJECTIVES: This prospective study aimed to determine the effectiveness of prophylactic subcutaneous retention sutures in the prevention of superficial wound separation in women with a confirmed or suspected cancer who had gynecological surgery by midline laparotomy. METHODS: This was a non-randomized, controlled intervention study including patients who underwent cancer surgery between May 2018 and August 2019. Patients who underwent midline laparotomy with confirmed or suspected cancer were included and patients who had an early post-operative complication or who underwent surgery again before the removal of stitches were excluded. The independent variables that might predict the superficial wound site dehiscence and prolongation of the hospitalization period were analyzed using logistical regression analysis. RESULTS: A total of 208 patients were included in the study. Age, presence of comorbid diseases, low pre-operative hemoglobin, low pre-operative albumin, higher weight, higher body mass index (BMI), pre- and post-operative blood transfusion, and absence of retention sutures were associated with higher risk of superficial wound separation. Low pre-operative albumin, weight, and BMI were associated with prolonged length of hospital stay. In a multivariate analysis, BMI (OR: 1.12; 95% CI: 1.09 to 1.28, p<0.001) and retention sutures (OR: 0.31; 95% CI: 0.11 to 0.83, p=0.019) retained an independent association with superficial wound separation. In addition, BMI (OR: 1.11; 95% CI: 1.03 to 1.25, p=0.010) and intra-operative complications (OR: 4.10; 95% CI: 1.08 to 15.60, p=0.038) were independent predictors increasing the length of hospital stay, and use of retention sutures (OR: 0.19; 95% CI: 0.05 to 0.66, p=0.009) was an independent predictor decreasing the length of hospital stay. CONCLUSIONS: Prophylactic subcutaneous retention sutures reduced superficial wound separation and shortened hospital stay. Prophylactic subcutaneous retention sutures may be considered in patients who undergo gynecological surgery using a midline laparotomy.

"Sleeve" Sinus of Valsalva Repair in Patients with Acute Type A Aortic Dissection.

PURPOSE: The optimal surgical strategy of aortic root in acute type A aortic dissection (ATAAD) is controversial. The aim of this study was to evaluate the feasibility and safety of "Sleeve" Sinus of Valsalva repair for AAD limited to the non-coronary sinus or partial left and right coronary sinus without involvement coronary artery ostia. METHODS: From September 2016 to March 2019, 20 patients with AAD involving non-coronary sinus or partial left and right coronary sinus Valsalva underwent "Sleeve" Sinus of Valsalva repair. A tailored Dacron patch was inserted into the dissected layers and two Dacron strips were placed inside and outside of the aorta, and the new five-layers root was sutured with 3/0 prolene continuous stitches. The artificial vessel was reversed about 1cm and anastomosed with the reconstructed root. Then, the reversed artificial vessel was pulled and anastomosed with the Dacron strip of the new proximal aorta. RESULTS: There was no early death in hospital and one death occurred during the 30-day postoperative period. Re-thoracotomy due to bleeding was necessary in only one patient and no bleeding was related to the proximal anastomosis. The postoperative drainage was 390.5 ± 229.3 mL. During follow up, the echocardiography showed the normal sinus of Valsalva and aortic valvular function. Computed tomography angiography showed normal aortic root without endovascular leak or dissection around the sinus of Valsalva. All patients were free from reoperation. CONCLUSIONS: "Sleeve" Sinus of Valsalva repair with Dacron patch for aortic dissection limited to the non-coronary sinus or partial left and right coronary sinus without involvement coronary artery ostia was technically feasible and safe.

Incidence of valvular regurgitation and leaflet perforation by using automated titanium fasteners (CORKNOT®) in heart valve repair or replacement: less usual than reported.

BACKGROUND: CORKNOT® facilitates a reduction in cardiopulmonary bypass (CPB) time, aortic cross clamp (ACC) time and operative time, but reported to be associated with other complications. We aim to quantify the incidence of valvular complications related to CORKNOT® and determine the feasibility of its use between different valvular surgeries. METHODS: Patients who underwent heart valve repair or replacement surgery via the use of automated titanium suture fasteners (CORKNOT®) in a tertiary care hospital were included in the study. This single-centre retrospective study was conducted on 132 patients between January 2016 and June 2018. RESULTS: In our study, the overall mean operative time was 320.0 ± 97.0 min, mean CPB time was 171.4 ± 76.0 min and the calculated mean ACC time was 105.9 ± 54.0 min. Fifty-eight patients (43.9%) underwent minimally invasive valve replacement or repair surgery and 66 patients (50.0%) underwent concomitant procedures. A total of 157 valves were operated on, with 112 (84.8%) single valve surgeries, 15 (11.4%) double valve surgeries and 5 (3.8%) triple valve surgeries. After reviewed by the cardiologist blinded towards the study, we report trivial and/or mild paravalvular leak (PVL) in immediate post-operative echocardiography was found in 1 (1.01%) patients. There were no reported cases of valvular thrombosis, leaflet perforation, device dislodgement or embolization, moderate and/or severe PVL during hospitalization and follow-up echocardiography within 1 year. Single mitral valve and aortic surgeries had comparable incidences of post surgical complications. CONCLUSION: We conclude the feasibility of CORKNOT® utilisation in mitral and aortic valve surgeries. Additionally, incidence of CORKNOT® related complications in heart valve repair or replacement surgery is less usual in our setting than previously reported. These results motivate the use of CORKNOT® as a valid alternative with complete commitment.

Comparison of Mini-DMEK versus predescemetal sutures as treatment of acute hydrops in keratoconus.

PURPOSE: To compare two surgical treatment options for acute corneal hydrops in keratoconus: Mini-DMEK versus predescemetal sutures. METHODS: Sixteen patients were treated by either Mini-Descemet membrane endothelial keratoplasty (Mini-DMEK) (n = 7, group 1) or predescemetal sutures (n = 9, group 2) early after onset of acute hydrops. Visual acuity, maximum corneal thickness (SD-OCT) in the affected oedematous area, complications and recurrence rates were retrospectively compared between both groups. Measurements were taken immediately preoperatively as well as 1 day, 1 week and 1 month postoperatively (Table 1). RESULTS: Both groups showed reductions in corneal thickness and increased visual acuity shortly after surgery. In group 1 (average age 33 years ± 7 years), the best corrected visual acuity (BCVA) increased from logMAR 1.65 ± 0.7 before Mini-DMEK to logMAR 0.93 ± 0.6 30 days after Mini-DMEK (p = 0.046). During that period, maximum corneal thickness decreased from 1159 ± 338 µm before surgery to 531 ± 75 µm after Mini-DMEK (p = 0.046). Patients from group 2 (average age 34 ± 10 years) had a BCVA of logMAR 1.59 ± 0.8 which increased to logMAR 0.97 ± 0.5 (p = 0.014) 30 days after surgery. At the same time, the preoperative maximum corneal thickness decreased from 1439 ± 272 µm to 476 ± 162 µm (p = 0.014). There was no difference in corneal thickness or BCVA one month after the surgical intervention between both groups (p = 0.394 and p = 0.871). CONCLUSIONS: Both techniques, Mini-DMEK and predescemetal sutures, are effective in the treatment of an acute hydrops in keratoconus. Mini-DMEK appears to be beneficial in large DM tears.

Utility of a Suture-Mediated Closure System for Large Bore Arterial Access During Challenging Liver Intra-Arterial Catheters Implantation.

PURPOSE: To describe and study the utility of vascular suture-mediated closure systems for large bore arterial access during challenging implantation of liver intra-arterial catheters taking as a reference the conventional procedure involving patients without challenging anatomy. MATERIALS AND METHODS: Between January 2017 and January 2019, 61 consecutive patients underwent 65 intra-arterial catheter IAC implantations for colorectal cancer. Twenty-three procedures (35%) considered by the operators with challenging coeliac trunk angulations were treated using a vascular suture technique where a 6-F introducer was used, the other patients were treated with a conventional 4F access technique. Clinical and radiological characteristics of patients, technical success (implantation of catheters allowing safe infusion of chemotherapy) and complications (Common Terminology Criteria for Adverse Events, CTCAE 5.0) were recorded. RESULTS: Mean coeliac trunk angulations were 36.3° (± 14.3) for the vascular closure group and 49.6° (± 17.1) for the conventional group. Technical success of the procedures was 100% for the vascular closure group and 80% in the conventional group (p < .05). Four patients with technical failure in the conventional group had a successful IAC implantation on the second attempt using the vascular closure technique. The use of a suture-mediated closure system for large bore arterial access allowed more frequent positioning of the distal tip into the gastro duodenal artery (GDA) (p = .01). No major complication occurred. CONCLUSION: The use of a large bore arterial access combined with a suture-mediated closure system may be useful for challenging IAC implantation without major complications.

Wound complications after primary and repeated midline, transverse and modified Makuuchi incision: A single-center experience in 696 patients.

ABSTRACT: There are 3 main types of incisions in major open, elective abdominal surgery: the midline incision (MI), the transverse incision (TI) and the modified Makuuchi incision (MMI). This study aimed to compare these approaches regarding wound complications and hernias, with a special focus on suture material and previous laparotomies.Patients who underwent elective abdominal surgery between 2015 and 2016 were retrospectively analyzed. Uni- and multivariate analyses were computed using stepwise binary and multifactorial regression models.In total, 696 patients (406 MI, 137 TI and 153 MMI) were included. No relevant differences were observed for patient characteristics (e.g., sex, age, body mass index [BMI], American Society of Anesthesiologists [ASA] score). Fewer wound complications (TI 22.6% vs MI 33.5% vs MMI 32.7%, P = .04) occurred in the TI group. However, regarding the endpoints surgical site infection (SSI), fascial dehiscence and incisional hernia, no risk factor after MI, TI, and MMI could be detected in statistical analysis. There was no difference regarding the occurrence of fascial dehiscence (P = .58) or incisional hernia (P = .97) between MI, TI, and MMI. In cases of relaparotomies, the incidence of fascial dehiscence (P = .2) or incisional hernia (P = .58) did not significantly differ between the MI, TI, or MMI as well as between primary and reincision of each type. On the other hand, the time to first appearance of a hernia after MMI is significantly shorter (P = .03) than after MI or TI, even after previous laparotomy (P = .003).In comparing the 3 most common types of abdominal incisions and ignoring the type of operative procedure performed, TI seems to be the least complicated approach. However, because the incidence of fascial dehiscence and incisional hernia is not relevantly increased, the stability of the abdominal wall is apparently not affected by relaparotomy, even by repeated MIs, TIs, and MMIs. Therefore, the type of laparotomy, especially a relaparotomy, can be chosen based on the surgeon's preference and planned procedure without worrying about increased wound complications.

Trabeculectomy: is releasable suture trabeculectomy a cause of better bleb?

Purpose: To compare the outcome of fixed suture trabeculectomy with releasable suture trabeculectomy in terms of IOP control, bleb morphology, complications and need of antiglaucoma medication post-surgery. Methods: This study enlisted 200 cases of open angle glaucoma, whose IOP was uncontrolled despite maximal medication. Trabeculectomy was performed using releasable suture in one group of 100 patients and fixed suture in another group of 100 with mitomycin 0.02% in both groups. The study was randomized, the method being the simple randomization. Fornix based trabeculectomy was done in both groups. Two 10-0 nylon releasable sutures were used at two corners of the rectangular flap and one fixed 10-0 vicryl suture was used in the center of the flap. Two mattress sutures (conjunctiva cornea) were also used. Essentially, all the sutures were removed postoperatively over a period of 2-4 weeks depending upon the level of IOP. Mitomycin c 0.02% was used in both groups. Results: The mean preoperative intraocular pressure was 33 ± 12 mmHg in the single suture group and 39 ± 13 mmHg in the releasable suture group (p). We observed a highly significant reduction of intraocular pressure at all times in both groups compared with the preoperative intraocular pressure (P, 0.0001). There was an obvious difference between the bleb morphology between conventional trabeculectomy and releasable suture trabeculectomy. Blebs in releasable suture trabeculectomy were more diffuse, low lying and presented a more ideal vascularity. Conclusion: Releasable suture trabeculectomy is a far much better technique than conventional trabeculectomy. Results are very good in terms of IOP control, post-operative complications, and bleb morphology. They may possibly have a role in wound modulation thereby achieving an ideal bleb, though more large sample studies need to be done.

Medial Patellofemoral Ligament Reconstruction Using Suture Tape for Patellofemoral Joint Instability.

OBJECTIVE: To describe a surgical technique using suture tape for reconstruction of the medial patellofemoral ligament (MPFL). This technique restores the stability of the reconstructed ligament and has excellent postoperative outcomes. METHOD: This is a retrospective analysis. From January 2016 to June 2018, 17 patients underwent MPFL reconstruction using high-strength suture (FiberTape; Arthrex) augmentation, with at least 12 months of follow up. There were 11 female and 6 male patients. The mean age at the time of MPFL reconstruction was 22.1 years (range 13-34 years). Clinical outcomes included pain level, knee range of motion, passive patellar hypermobility, and maltracking at follow-up. The lateral patellofemoral angles, congruence angles, and patellar tilt angles were measured in a skyline view by CT at 30° of knee flexion at 12 months. Functional outcomes were assessed using the Lysholm knee scoring scale, the SF-12 score, the Tegner score, and the Crosby and Insall grading system at yearly follow-up. RESULT: No patients were lost at the last follow up. One patient had recurrence of patellar dislocation and none of the others had serious complications. The success rate of MPFL repair for preventing recurrent dislocations was 94.1% (16 of 17 knees). Fifteen knees had full range of motion of more than 130°. At follow-up, 2 knees were judged to have mild hypermobility and none had severe hypermobility or maltracking. Using the Crosby and Insall grading system, 12 knees (70.6%) were graded as excellent, 4 knees (23.5%) as good, 1 knee (5.9%) as fair to poor, and none as worse at the last follow-up assessment. In all patients, the Lysholm knee score (55.12 ± 13.52 vs 79.88 ± 7.50, P < 0.01), the SF-12 score (47 ± 9.53 vs 65.24 ± 12.82, P < 0.01), and the Tegner score (2.76 ± 1.39 vs 6.53 ± 1.70, P < 0.01) had improved at their 12-month follow up. Compared with preoperative radiological findings, there was a significant improvement in lateral patellofemoral angle (-10.24 ± 7.10 vs 6 ± 5.43, P < 0.01), patellar tilt angle (26.53 ± 7.23 vs 9.88 ± 4.24, P < 0.01), and congruence angle (29.59 ± 11.95 vs -8.65 ± 4.86, P < 0.01). CONCLUSION: The use of FiberTape in MPFL reconstruction can improve the stability of the knee following surgery and has good midterm clinical results and low complication rates.

Postinfarction posterobasal ventricular septal defect closure with a triple-layer patch.

We present the case of a 65-year-old patient who developed a large posterobasal ventricular septal defect resulting from an extensive acute myocardial infarction involving the inferior and basal septum and wall. We repaired the interventricular lesion by verticalizing the cardiac apex to perform a left posterobasal ventriculotomy. We removed a great part of the residual infarcted tissue, leaving the residual scar in place. Our technique first involved creating a double-layer patch comprising heterologous pericardium and a non-collagen-impregnated Sauvage Dacron patch, fixed with single pledgeted U-stitches from the right side of the anterior septum; then we applied a third layer of heterologous pericardium on the left side of the septum in order to have only a pericardial surface in contact with blood on both ventricular sides. A running suture was used to complete the procedure from the middle to the posterior rim of the ventricular septal defect.  The final triple-layer patch allowed us to obtain a complete and durable closure of the defect. The subsequent closure of the left ventriculotomy was performed with a similar bilayer pericardium-Dacron patch (always leaving pericardium on the internal surface). This technique proved effective, guaranteeing resistance to suture stress, less risk of leakage, and reduced thrombogenicity.