Kidney transplantation in prostate cancer patients after local therapy with curative intent: a systematic review.

PURPOSE: It is still unclear whether kidney transplantation can be safely performed in patients with prostate cancer after local therapy with curative intent. METHODS: The protocol was registered in PROSPERO. We systematically searched Google, MEDLINE, the Cochrane Library, and the ICTRP for studies, official standards, clinical practice guidelines and organ transplant laws. Two review authors independently examined the full-text reports and identified relevant studies and one review author extracted the data. We assessed the overall certainty of the evidence for each outcome according to the GRADE approach. RESULTS: We identified 1346 references through electronic database searching and finally included 6 references for official standards, clinical practice guidelines, and organ transplant laws, and 6 references for retrospective studies with very low certainty of evidence. We identified no prospective or ongoing studies and reported all results narratively. CONCLUSION: We recommend that decisions on kidney transplantation in patients with prostate cancer after local therapy with curative intent should be made on a case-by-case basis. It is indispensable to consult with health care professionals or specialists at transplant centers to obtain individualized information regarding the waiting time requirements for renal transplantation in prostate cancer patients after local therapy with curative intent. No recommendation can be made regarding the waiting times after prostate cancer therapy with curative intent.

Transperineal laser ablation (TPLA) of the prostate for benign prostatic obstruction: the first 100 patients cohort of a prospective, single-center study.

PURPOSE: Transperineal laser ablation (TPLA) is a new minimally-invasive surgical treatment for patients with benign prostatic obstruction (BPO). We report the perioperative and mid-term functional results of the first 100 consecutively patients undergoing TPLA at our institution. METHODS: Clinical data from consecutive patients undergoing TPLA at our institution from April 2021 to July 2023 were prospectively collected. Primary endpoints were the postoperative changes in IPSS, QoL and MSHQ 3-item questionnaires and in Qmax and post-void residual volume (PVR). RESULTS: Overall, 100 consecutive patients underwent the procedure. Median age and prostate volume were 66 (IQR 60-75) years and 50 (IQR 40-70) ml, respectively. In the cohort, 14 (14%) patients had an indwelling catheter and 81 (81%) were under oral BPO therapy at the time of TPLA. Baseline median Qmax (ml/s) and PVR (ml) were 9.1 (IQR 6.9-12) and 90 (IQR 50-150), respectively, while median IPSS and QoL were 18 (IQR 15-23) and 4 (IQR 3-4). At all the follow-up timepoints, the evaluated outcomes on both symptoms and functional parameters showed a statistically significant improvement (p < 0.001). Antegrade ejaculation was preserved in all sexually active patients. No postoperative Clavien-Dindo > 2 complications were recorded. CONCLUSIONS: TPLA represents a safe option for selected well-informed patients swith LUTS due to BPO. Our prospective study confirms the feasibility and favorable perioperative and functional outcomes in a real-world cohort with heterogenous prostate volumes and patient characteristics.

Improvements and challenges in intraperitoneal laparoscopic para-aortic lymphadenectomy: The novel "tent-pitching" antegrade approach and vascular anatomical variations in the para-aortic region.

INTRODUCTION: This study introduces and compares a new intraperitoneal laparoscopic para-aortic lymphadenectomy method to reach the level of the renal vein, the "tent-pitching" antegrade approach with the retrograde approach in gynecological malignancy surgeries in terms of success rate, complication incidence, and the number of lymph nodes removed. It focuses on the feasibility, safety, and effectiveness. Meanwhile, this article reports on the vascular anatomical variations discovered in the para-aortic region to enhance surgical safety. MATERIAL AND METHODS: This was a retrospective cohort study including patients undergone laparoscopic para-aortic lymphadenectomy at a single center from January 2020 to December 2023 for high-risk endometrial and early-stage ovarian cancer. Patient charts were reviewed for mode of operation, perioperative complications, operative details, and histopathology. The patients were divided into anterograde group and retrograde group according to the operation mode. The two groups were further compared based on the success rate of lymph node clearance at the renal vein level, perioperative complications, and the number of removed lymph nodes. Quantitative data were analyzed using the t-test, non-normally distributed data using the rank-sum test, and categorical data using Fisher's exact test and the chi-square test, with statistical significance defined as P < 0.05. RESULTS: Among 173 patients, the antegrade group showed higher surgery success (97.5% vs 68.82%), more lymph nodes removed (median 14 vs 7), and less median blood loss. The operation time was shorter in the antegrade group. Postoperative complications like lymphocele and venous thrombosis were lower in the antegrade group. Vascular abnormalities were found in 28.9% of patients, with accessory lumbar vein routing anomaly and accessory renal arteries being most common. CONCLUSIONS: The antegrade approach is feasible, safe, and effective, improving surgical exposure, reducing difficulty without additional instruments or puncture sites, and minimizing organ damage risk. It is effective in achieving better access to the renal vein and removing more para-aortic lymph nodes than the retrograde method. Recognizing and carefully managing the diverse vascular abnormalities in the para-aortic area, including variations in renal arteries, veins, and the inferior vena cava, is essential to reduce intraoperative bleeding and the likelihood of converting to open surgery.

Correlation between intraosseous thermal change and drilling impulse data during osteotomy within autonomous dental implant robotic system: An in vitro study.

OBJECTIVES: This study aims at examining the correlation of intraosseous temperature change with drilling impulse data during osteotomy and establishing real-time temperature prediction models. MATERIALS AND METHODS: A combination of in vitro bovine rib model and Autonomous Dental Implant Robotic System (ADIR) was set up, in which intraosseous temperature and drilling impulse data were measured using an infrared camera and a six-axis force/torque sensor respectively. A total of 800 drills with different parameters (e.g., drill diameter, drill wear, drilling speed, and thickness of cortical bone) were experimented, along with an independent test set of 200 drills. Pearson correlation analysis was done for linear relationship. Four machining learning (ML) algorithms (e.g., support vector regression [SVR], ridge regression [RR], extreme gradient boosting [XGboost], and artificial neural network [ANN]) were run for building prediction models. RESULTS: By incorporating different parameters, it was found that lower drilling speed, smaller drill diameter, more severe wear, and thicker cortical bone were associated with higher intraosseous temperature changes and longer time exposure and were accompanied with alterations in drilling impulse data. Pearson correlation analysis further identified highly linear correlation between drilling impulse data and thermal changes. Finally, four ML prediction models were established, among which XGboost model showed the best performance with the minimum error measurements in test set. CONCLUSION: The proof-of-concept study highlighted close correlation of drilling impulse data with intraosseous temperature change during osteotomy. The ML prediction models may inspire future improvement on prevention of thermal bone injury and intelligent design of robot-assisted implant surgery.

Opportunities for, and barriers to, uterus-preserving surgical techniques for placenta accreta spectrum.

INTRODUCTION: Placenta accreta spectrum (PAS) can lead to major peripartum morbidity. Appropriate management approaches depend on the clinical severity, each individual's preference, and the treating team's expertise. Peripartum hysterectomy is the most frequently used treatment option. However, it can impact psychological well-being and fertility. We investigated whether conservative treatment with focal resection or leaving the placenta in situ is associated with comparable or lower maternal morbidity than hysterectomy in centers of excellence within the International Society for placenta accreta spectrum (IS-PAS). Furthermore, a survey was conducted to explore potential barriers to conservative management in antenatal counseling and intraoperative decision-making. MATERIAL AND METHODS: Confirmed PAS cases in the prospective IS-PAS database from 22 registered centers between January 2020 and June 2022 were included in the analysis. A separate online survey with 21 questions was answered by the IS-PAS center experts about indications, diagnostic criteria, patient counseling, surgical practice, changes from the preoperative treatment plan, and why conservative management may not be offered. RESULTS: A total of 234 cases were included in the analysis: 186 women received hysterectomy and 38 women were treated by focal resection, and 10 by leaving the placenta in situ. Blood loss was lower in the focal resection group and in the placenta in situ group compared to the hysterectomy group (p = 0.04). 46.4% of the women initially planned for focal resection, and 35.7% of those initially planned for leaving the placenta in situ were ultimately treated by hysterectomy. Our survey showed that the IS-PAS centers preferred hysterectomy according to a woman's wishes (64%) and when they expected less blood loss and morbidity (41%). Eighteen percent of centers did not offer focal resection at all due to a lack of experience with this technique. Reasons for not offering to leave the placenta in situ were avoidance of unexpected reoperation (36%), puerperal infection (32%), or skepticism about the method (23%). CONCLUSIONS: Uterus-preserving treatment strategies such as focal resection appear to be safe alternatives to peripartum hysterectomy. However, less than half of the IS-PAS centers perform them. Acceptance of conservative treatments could be increased by standardized criteria for their implementation and by systematic training for PAS experts.

Randomized controlled trial on the efficacy of a custom-made, fully guided implant system for flapless crestal sinus floor elevation: Accuracy and patient-reported outcomes.

OBJECTIVE: To compare fully guided flapless implant surgery using a light-cured surgical guide (FG group) with partially guided open flap surgery (PG group) in the posterior maxilla when performing simultaneous sinus floor elevation in terms of the accuracy, time requirements, and patient/clinician-reported outcomes (PROMs and CROMs). MATERIALS AND METHODS: In this study, 56 tissue-level implants were placed with crestal sinus floor elevation in 56 patients at single-tooth sites, with 28 implants allocated to the PG group and 28 to the FG group. The deviations of the placed implants from the virtually planned positions were measured at the implant platform and apex and for the angular deviation. The presurgical preparation time and the duration of surgery were measured. PROMs and CROMs were made by administering questionnaires at multiple time points. RESULTS: Horizontal deviations at the platform and apex and the angular deviation were significantly smaller in the FG group than the PG group (p < .05). Presurgical preparation and surgery times were significantly shorter in the FG group (p < .001). Patient satisfaction and willingness to receive repeat treatment were significantly better in the FG group than in the PG group (p < .005 and .025, respectively). Clinicians were more satisfied in the FG group than the PG group (p < .05). CONCLUSION: When placing an implant with sinus floor elevation, the flapless approach using a fully guided surgical system can be more accurate, faster, and increase the satisfaction of both the clinician and patient compared to the partially guided surgery.

Morbidity following robot-assisted surgery in a gynecological oncology setting: A cohort study.

INTRODUCTION: The objective of the study was to provide a comprehensive description of perioperative morbidity associated with robot-assisted surgery (RAS) in a gynecological oncology setting in order to improve the preoperative counseling of women and support shared decision-making. MATERIAL AND METHODS: All women scheduled for intended RAS between January 2015 and December 2022 were prospectively included in an electronic morbidity database for the analyses of perioperative complications. RESULTS: In total, 2225 women were included. Sixty-four patients (2.9%) experienced an intraoperative complication. Intraoperative complications were associated with a higher rate of conversion to laparotomy (15.6% vs. 1.8%, p < 0.001), a higher rate of major postoperative morbidity (9.3% vs. 2.4%, p < 0.001), and a higher rate of reoperation (9.3% vs. 1.7%, p < 0.001), compared to cases without intraoperative complications. Thirty-day postoperative morbidity was evaluated according to the Memorial Sloan-Kettering Cancer Center Surgical Secondary Events Grading System. Grade 3-5 events were considered major. A total of 57 patients (2.6%) experienced a major event after surgery, postoperative rupture of the vaginal vault being the most common complication requiring surgical intervention. Conversion to laparotomy occurred in 49 cases (2.2%) and was associated with higher intraoperative blood loss (300 mL vs. 25 mL, p < 0.001), a higher rate of postoperative major events (20.4% vs. 2.2%, p < 0.001), and a higher rate of reoperation (11.8% vs. 1.6%, p < 0.001). CONCLUSIONS: Our study demonstrates low rates of major perioperative morbidity and conversion to laparotomy after RAS performed by trained high-volume surgeons in a gynecological oncology setting.

Evolving indications and surgical techniques for corneal transplantation at a tertiary eye care center in southern China.

BACKGROUND: This retrospective study aimed to analyze the evolution of primary indications and surgical techniques for corneal transplantation in Southern China from 2012 to 2021. METHODS: The medical charts of all patients who underwent keratoplasty between January 2012 and December 2021 at Zhongshan Ophthalmic Centre, Sun Yat-Sen University, Guangzhou, Southern China were reviewed. We collected and analyzed the primary indications for corneal transplantation and the surgical methods used in each keratoplasty. RESULTS: The total number of corneal transplantations was 7,286 during this decade, increasing from 210 cases in 2012 to 1054 cases in 2021. The primary indications for keratoplasty included acquired nontraumatic corneal diseases (56.2%), congenital corneal abnormalities (16.4%), acquired traumatic corneal diseases (14.0%), and regraft (13.4%). Infectious keratitis was the leading indication among all keratoplasties (18.5%), followed by regraft (13.4%). Over the decade, the proportion of infectious keratitis gradually decreased (P = 0.013), while the proportion of regraft increased (P = 0.019). The predominant surgical technique was penetrating keratoplasty (PKP), accounting for 56.7%. However, the number of deep anterior lamellar keratoplasty (DALK) and endothelial keratoplasty (EK) significantly increased from 2012 to 2021 (P = 0.007 and P = 0.002). CONCLUSIONS: The annual number of corneal transplants significantly increased from 2012 to 2021. In the past decade, infectious keratitis and regraft have become the leading primary indications for corneal transplantation. Although the use of customized lamellar techniques has dramatically increased, PKP remains the predominant surgical technique for keratoplasty.

Recurrent pelvic organ prolapse after hysterectomy; a 10-year national follow-up study.

PURPOSE: Hysterectomy may be a risk factor for pelvic organ prolapse (POP). We assessed the risk of recurrent POP (operations and visits) after hysterectomy among women with previous POP. We also studied patient and operation related risk factors for POP recurrence. METHODS: This retrospective cohort study included 1697 women having previous POP diagnosis or POP at the time of hysterectomy (FINHYST 2006 cohort). Follow-up was until the end of 2016. The data was derived from the Finnish National Care register linked to the cohort. Hysterectomy approaches and other demographics were compared to the risk of a prolapse diagnosis and/or surgery. Cox regression model was used to identify hazard ratios. RESULTS: Following hysterectomy, a total of 280 women (16.5%) had a POP reoperation and 359 (21.2%) had an outpatient visit due to POP. Vaginal vault prolapse repair was the most common POP reoperation (n = 181, 10.7%), followed by anterior wall repair (n = 120, 7.1%). Median time to POP reoperation was 3.7 years. Hysterectomy approach did not affect reoperations or visits. Previous cesarean section and anterior repair during hysterectomy were associated with decreased risk, whereas concomitant sacrospinous fixation and uterus prolapse as the main indication led to increased risk of anterior/vault prolapse reoperations. Concomitant posterior repair decreased posterior reoperations and visits, but uterus weight over 500 g caused a fivefold increased risk of posterior prolapse visit. Residential status was associated with elevated risk of any POP reoperations and visits. CONCLUSIONS: Approximately one out of five women suffering from POP ensue POP reoperation or visit after hysterectomy. These high rates are independent on hysterectomy approach, but probably indicate that hysterectomy may worsen previous pelvic floor dysfunction.

Audiological outcomes after revision stapes surgeries: a systematic review.

PURPOSE: Revision stapes surgery is a challenging procedure performed in relatively small numbers compared to other middle ear procedures. Despite numerous data on hearing results of different middle ear surgeries, the audiological standards for successful outcome of this procedure are still not clarified. On the basis of well-documented data, we wanted to determine what the expected audiological results and complications are after revision stapes surgery in order to set a realistic threshold for surgical success. METHODS: After the protocol registration in the PROSPERO database, a systematic review was performed in multiple databases (PubMed, Cochrane, Web of Science, Scopus, ScienceOpen, ClinicalTrials.gov, Google Scholar) according to PRISMA guidelines. Twelve articles were reviewed according to the inclusion criteria. A total of 1032 cases were obtained for evaluation. A modified version of Newcastle-Ottawa Scale (NOS) was used to assess publication quality. RESULTS: Average air-bone gap (ABG) gain was 17.3 dB, average air conduction (AC) gain was 17.5 dB. The average postoperative air-bone gap was 11.1 dB. The postoperative ABG distribution was the following 0-10 dB: 53.3%, > 10-20 dB: 28.2%, > 20 dB: 18.5%. SNHL as a surgical complication was described in a total of 17 cases (1.6%), no equilibrium disorder was reported. CONCLUSION: The pooled data suggest that revision stapes surgery is an effective solution after failure of previous stapes surgery. However, the results are clearly inferior to those of primary stapedotomies. Hence, we need to apply different expectations and use different standards in the indication and evaluation of this type of surgery.

Bridge plating is an effective adjunct treatment for complex elbow instability.

BACKGROUND: Managing persistent elbow instability and chronic dislocations presents challenges despite traditional treatments. Supplementary methods like immobilization and various fixations, though common, can carry high complication rates. This study assesses the efficacy of bridge plating in treating complex elbow instability through a retrospective review of patients. Data on characteristics, treatment duration, range of motion, complications, and evaluation scores were analyzed, providing insights into outcomes complications associated with bridge plating. RESULTS: Eleven patients were reviewed at a mean follow-up of 80 ± 68 weeks postoperatively. The mean age was 53 ± 14 years and there were 5 females and 6 males. The mean body mass index was 38. Bridge plating was used for a spectrum of complex elbow injuries. The mean time from injury to bridge plating in acute cases was 29 ± 19 days and 344 ± 381 days in chronic cases. The mean duration of bridge plating was 121 ± 72 days. At the time of plate removal, mean intraoperative elbow motion was extension 58° ± 12°, flexion 107° ± 14°, supination 66° ± 23° and pronation 60° ± 26°. At the latest follow-up visit, mean elbow motion was extension 37° ± 22°, flexion 127° ± 17°, supination 72° ± 15°, and pronation 63° ± 18°. There were 6 complications (55%): heterotopic ossification, ulnar neuropathy, wound failure over the plate in a thin patient, an ulnar shaft periprosthetic fracture due to a seizure-induced fall, and persistent elbow subluxation despite bridge plate fixation. Finally, 1 patient sustained a fracture of a 3.5-mm locking bridge plate. One patient required a contracture release for persistent stiffness. Four of these complications can be directly attributed to the use of the bridge plate (36%). At final follow-up, the mean patient-rated elbow evaluation score was 34, with 0 indicating no pain and disability. The mean Single Assessment Numeric Evaluation score was 66% for the 8 patients who had this available, with 100% being the best possible attainable score. CONCLUSION: Bridge plating effectively maintains joint reduction in selected complex elbow instability cases. However, patients with bridge plates often require a second surgery for removal and experience high rates of general complications because of the complexity of their condition.

Long stem revision versus short stem revision with plate osteosynthesis for Vancouver type B2 periprosthetic femoral fracture: a comparative study of eighty five cases.

PURPOSE: Periprosthetic femoral fractures (PPFs) around the hip are challenging complications in orthopaedic surgery, particularly Vancouver type B2 (VTB2) fractures. The surgical management of these fractures is crucial and depends on various factors. Cementless short taper stem with plate osteosynthesis is an alternative surgical technique. This study aims to compare the outcomes of this surgical technique with revision arthroplasty (RA) with long stem in the treatment of VTB2 PPFs. METHODS: This retrospective study was conducted in a single medical institute from February 2010 to May 2019. Patients who had received either total hip arthroplasty or bipolar hemiarthroplasty and subsequently developed a VTB2 PPF were included; patients who sustained intra-operative fractures or received a cemented stem previously were excluded from the analysis. The patients were divided into two groups: group I received RA with cementless long stem, while group II underwent RA with cementless short taper stem with plate osteosynthesis. Demographic data, radiographic and functional outcomes, and complications were analyzed between the two groups. RESULTS: A total of 85 patients diagnosed with VTB2 PPFs were included in the study. There were no significant differences between the two groups in terms of demographic data, including age, gender, mean follow-up times, estimated blood loss, and operative times. The radiographic results showed that there was no significant difference in the incidence of subsidence and implant stability between the two groups. However, group II tended to have less subsidence and periprosthetic osteolysis. Patients in group II had significantly better functional scores (mean Harris hip score: post-operative: 60.2 in group I and 66.7 in group ii; last follow-up: 77.4 in group 1 and 83.2 in group II (both p < 0.05)). There were no significant differences in the overall complication rate, including infection, dislocation, re-fracture, and revision surgery, between the two groups. CONCLUSIONS: Both surgical techniques, cementless long stem and cementless short taper stem with plate osteosynthesis, are effective in the treatment of Vancouver B2 PPFs, with no significant differences in outcomes or complications. However, patients in cementless short taper stem with plate osteosynthesis had better functional scores at both post-operative and the last follow-up.

Different Surgical Approaches to the Treatment of Cleft Palate Fistulae as Perceived by Cleft Surgeons.

OBJECTIVE: Palatal fistulas after palatoplasty could pose difficulties for both patients and surgeons. Numerous surgical approaches are available to treat palatal fistulas. In this manuscript, we investigate surgical treatment options for palatal fistula repair looking at the different anatomical locations, and we create a summary of surgical approaches to facilitate the decision-making process for palatal fistulae repair. DESIGN: In this cross-sectional survey, nine anonymized patient cases with palatal fistulae that differed in severity and anatomical location were presented to participants from the International Cleft Master Course in Amsterdam about "Palatal Fistulas". Participants were invited to participate in this survey. A total of 141 participants reported their preferred surgical treatment options for fistula repair at different anatomical locations. RESULTS: We created different options for fistula treatment, catalogued by fistula location. This overview gives the surgeon possible approaches for each location. If the soft palate is involved, this overview underscores the importance of including velopharyngeal insufficiency management into the fistula repair. For hard palate involvement, our overview lists techniques available for nasal lining repair and for oral lining repair in each region. CONCLUSIONS: We provide a comprehensive overview of potential surgical approaches to repair palatal fistulae. This inventory of techniques is grouped per location to support surgeons in their decision-making process when confronted with a palatal fistula.

Techniques for Penile Augmentation Surgery: A Systematic Review of Surgical Outcomes, Complications, and Quality of Life.

The increase in practices related to enhancing penile size can be attributed to the belief that an improved genital appearance contributes to a man's virility, coupled with an altered self-perception of his body. It is crucial to tailor interventions to meet the genuine needs of patients by thoroughly assessing their history, psychological state, and potential surgical benefits, all while considering the associated risks of complications. This systematic review aims to summarize the available evidence on outcomes, complications, and quality of life after penile augmentation surgery, examining both minimally invasive and more radical techniques. A search of the PubMed and Scopus databases, focusing on English-language papers published in the last 15 years, was performed in December 2023. Papers discussing surgery in animal models and case reports were excluded from the present study unless further evaluated in a follow-up case series. The primary outcomes were changes in penile dimensions, specifically in terms of length and girth, as well as the incidence of surgical complications and the impact on quality of life. A total of 1670 articles were retrieved from the search and 46 were included for analysis. Procedures for penile length perceived enhancements include lipoplasty, skin reconstruction plasty, V-Y and Z plasty, flap reconstruction, scrotoplasty, ventral phalloplasty, and suspensory ligament release; techniques for increasing corporal penile length include penile disassembly, total phalloplasty, and sliding elongation. Finally, penile girth enhancement may be performed using soft tissue fillers, grafting procedures, biodegradable scaffolds, and Penuma®. In conclusion, while penile augmentation surgeries offer potential solutions for individuals concerned about genital size, the risks and complexities need to be accounted for.

Visual Outcomes in Ectopia Lentis in Marfan Syndrome: A Study of Four Surgical Techniques in Children and Adults.

Background/Objectives: To evaluate how the surgical technique and type of implanted intraocular lens influence the postoperative visual acuity and complications in ectopia lentis associated to Marfan syndrome patients. Materials and Methods: The medical records and videos of ectopia lentis surgeries in patients (children and adults) with Marfan syndrome, were retrospectively reviewed and compared. The study included 33 eyes that underwent four different intraocular lens implantation (IOL) techniques: IOL in conjunction with a simple capsular tension ring, IOL in conjunction with a Cionni modified capsular tension ring (m-CTR), two-point scleral IOL fixation and IOL with one haptic in the bag and one haptic sutured to the sclera. Results: Vision significantly improved from a mean preoperative visual acuity of 0.1122 to a mean postoperative visual acuity of 0.4539 in both age groups (p < 0.0001), with no difference in the primary outcome between children and adults. The most common surgical technique used in both age groups was IOL in conjunction with an m-CTR. There was only one major postoperative complication requiring additional surgery. Conclusions: Zonular weakness mainly influenced by age was the most important selection criterion for the surgical approach. Regardless of the technique employed, the postoperative visual acuity was improved in both adults and children.

Enhanced recovery management in pediatric pyeloplasty: outcomes in a single institution and tips for improvement.

OBJECTIVE: We report the application of enhanced recovery after surgery (ERAS) regimens to pediatric patients undergoing laparoscopic pyeloplasty (LP), aiming to guide the practice of ERAS in pediatric LP. METHODS: From October 2018, we prospectively implemented a twenty-point ERAS regimen, including a modified LP procedure, for pediatric UPJO patients in a single institution. Data from 2018 to 2021 were collected and analyzed retrospectively. The variables gathered included: demographics, preoperative details and recovery elements. Outcomes were postoperative length of stay (POS), readmission rate, operation time and blood loss. RESULTS: A total of 75 pediatric patients (0-14 years) were included. The mean POS was 2.4 ± 1.4 days, shorter than that in recent studies in China (3.3 ± 1.4 days, 6 (3-16) days). None were redo, and six restenosis (8%) were improved after treatment with ureteral balloon dilatation. The mean operation time was 257.9 ± 54.4 min, and blood loss was 11.8 ± 10.0 ml. In the univariable analysis and multivariable analysis, no external drainage, sacral anesthesia, and withdrawal of the catheter on day one were independently associated with a POS of ≤ 2 d (p < 0.05). CONCLUSION: The implementation of this ERAS protocol for pediatric LP has resulted in a shorter length of stay without a higher readmission rate. Surgery techniques, drainage management and analgesia are the key to further improvement. ERAS for pediatric pyeloplasty should be encouraged.

An international survey exploring the management of pilonidal disease.

AIM: Pilonidal disease (PD) is a common debilitating condition frequently seen in surgical practice. Several available treatments carry different benefit/risk balances. The aim of this study was to snapshot the current management of PD across European countries. METHOD: Members affiliated to the European Society of Coloproctology were invited to join the survey. An invitation was extended to others via social media. The predictive power of respondents' and hospitals' demographics on the change of therapeutic approach was explored. RESULTS: Respondents (n = 452) were mostly men (77%), aged 26-60 years, practising in both academic and public hospitals and with fair distribution between colorectal (51%) and general (48%) surgeons. A total of 331 (73%) respondents recommended surgery at first presentation of the disease. Up to 80% of them recommended antibiotic therapy and 95% did not use any classification of PD. A primary closure technique was the preferred procedure (29%), followed by open technique (22%), flap creation (7%), sinusectomy (7%) and marsupialization (7%). Approximately 27% of subjects would choose the same surgical technique even after a failure. Almost half (46%) perform surgery as office based. A conservative approach was negatively associated with acutely presenting PD (p < 0.001). Respondents who were not considering tailored surgery based on patient presentation tended to change their approach in the case of a failed procedure. CONCLUSION: With the caveat of a heterogeneous number of respondents across countries, the results of our snapshot survey may inform the development of future guidelines.

Resolution and recurrence of anemia following repair of paraesophageal hernias.

BACKGROUND: Iron deficiency anemia is a common paraesophageal hernia (PEH) symptom and may improve after repair. When present, anemia has also been proposed to be associated with an increase in length of hospital stay, morbidity, and mortality after PEH repair. This study aimed to determine anemia-related factors in patients with PEH, the rate of anemia resolution after PEH repair, and the risk of anemia recurrence when repair failed. METHODS: We included patients who received a PEH repair between June 2019 and June 2020 and had 24 months of postoperative follow-up. Demographics and comorbidities were recorded. Anemia was defined as pre-operative hemoglobin values < 12.0 for females and < 13.0 for males, or if patients were receiving iron supplementation. Anemia resolution was determined at 6 months post-op. Length of hospital stay, morbidity, and mortality was recorded. Logistic regression and ANCOVA were used for binary and continuous outcomes respectively. RESULTS: Of 394 patients who underwent PEH repair during the study period, 101 (25.6%) had anemia before surgery. Patients with pre-operative anemia had larger hernia sizes (6.55 cm ± 2.77 vs. 4.34 cm ± 2.50; p < 0.001). Of 68 patients with available data by 6 months after surgery, anemia resolved in 36 (52.9%). Hernia recurred in 6 patients (16.7%), 4 of whom also had anemia recurrence (66.7%). Preoperative anemia was associated with a higher length of hospital stay (3.31 days ± 0.54 vs 2.33 days ± 0.19 p = 0.046) and an increased risk of post-operative all-cause mortality (OR 2.7 CI 1.08-6.57 p = 0.05). Fundoplication type (p = 0.166), gastropexy, or mesh was not associated with an increased likelihood of resolution (OR 0.855 CI 0.326-2.243; p = 0.05) (OR 0.440 CI 0.150-1.287; p = 0.05). CONCLUSIONS: Anemia occurs in 1 out of 4 patients with PEH and is more frequent in patients with larger hernias. Anemia is associated with a longer hospital stay and all-cause mortality after surgery. Anemia recurrence coincided with hernia recurrence in roughly two-thirds of patients.

Methods of quality assurance in multicenter trials in laparoscopic fundoplication for gastroesophageal reflux disease.

BACKGROUND: Operative performance may affect the internal and external validity of randomized trials. The aim of this study was to review the use of surgical quality assurance mechanisms of published trials on laparoscopic anti-reflux surgery, with the objective to appraise their internal (research quality) and external validity (applicability to the clinical setting). METHODS: Building upon a previous systematic review and network meta-analysis published by the authors, Medline, Embase, AMED, CINAHL, CENTRAL, and OpenGrey databases were searched for randomized control trials comparing different methods of laparoscopic anti-reflux surgery for the management of gastroesophageal disease. Quality assurance in individual studies was appraised using a specified framework addressing surgeon accreditation, procedure standardization, and performance monitoring. RESULTS: In total, 2276 articles were screened to obtain 43 publications reporting 29 randomized controlled trials. Twenty-five out of 43 (58.1%) articles reported the number of participating centers and surgeons involved. Additionally, only 21/43 (48.8%) of articles reported consistent use of a bougie, while 23/43 (53.5%) of articles reported consistent division of the short gastric arteries during fundoplication. Surgical experience and credentials were stated in half of the studies. Standardization of the technique was reported in almost 70% of cases, whereas operative notes or video was submitted in one fourth of the studies. Monitoring of the operative performance during the trial was not documented in most of the trials (62%). CONCLUSION: Surgical quality assurance in randomized trials on laparoscopic anti-reflux surgery is insufficient, which does not allow appraisal of the internal and external validity of this research. With improved reporting, trials assessing the use of laparoscopic anti-reflux surgery will enable surgeons to make informed treatment decisions to enhance patient care in the surgical management of GERD.

Leveraging access to technology and enhanced surgical technique (LATEST) in laparoscopic bile duct exploration (LBDE).

Single-stage management of choledocholithiasis with concomitant gallstones consists of performing either laparoscopic bile duct exploration (LBDE) or intra-operative endoscopic retrograde cholangiopancreatography at the same time as laparoscopic cholecystectomy. Transductal LBDE is associated with significantly higher post-operative morbidity, longer operative times and longer hospital stay when compared to transcystic LBDE. The aim of this study was to report the transcystic exploration rate and post-operative outcomes from LBDE before and after implementation of the LATEST (Leveraging Access to Technology and Enhanced Surgical Technique) principles. METHODS: A retrospective review of 481 consecutive patients between February 1998 and July 2021 was performed. Patients were assigned into two groups determined by whether they were operated before or after the implementation of LATEST. Data collected included pre-operative demographic information, medical co-morbidity, pre-operative investigations, and intra-operative findings (including transcystic exploration rate, negative choledochoscopy rate, use of holmium laser lithotripsy and operative time). Outcomes of this study were the transcystic exploration rate, stone clearance rate, conversion to open surgery, post-operative morbidity and mortality, and length of post-operative hospital stay. RESULTS: The pre-LATEST group contained 237 patients and the LATEST group comprised of 244 patients. Ultra-thin choledochoscopes and holmium laser lithotripsy were used more frequently in the LATEST group (41.4% and 18.4%, respectively). Enhanced surgical techniques (correction of the cystic duct-CBD junction and the trans-infundibular approach) were also performed more frequently in the LATEST group. More patients in the LATEST group received transcystic LBDE (86.1% vs 11.0%, p < 0.0001). The LATEST group had significantly higher stone clearance rates (98.8% vs 93.7%, p = 0.0034), reduced post-operative morbidity and shorter post-operative hospital stay (4 days vs 1 day, p < 0.0001). CONCLUSIONS: LATEST describes four key factors that can be used when performing LBDE. The adoption of LATEST in LBDE is associated with an increased stone clearance, a higher transcystic exploration rate and reduced post-operative morbidity.