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BACKGROUND AND AIMS: The number of procedures performed by internal medicine residents in the United States (US) is declining. An increasing proportion of residents do not feel confident performing essential invasive bedside procedures and, upon graduation, desire additional training. Several residency programs have utilized the medical procedure service (MPS) to address this issue. We aim to summarize the current state of evidence by systematically evaluating the effect of the MPS on resident education, comfort, and training, as well as patient safety and procedural outcomes in the US. METHODS: We conducted a systematic review of all studies reporting the use of an MPS with supervision from a board-certified physician in internal medicine residencies in the US. Database search was performed on PubMed, Embase, ERIC, and Cochrane Library from January 2000 to November 2020 for relevant studies. Quality of evidence assessment and random-effects proportion meta-analyses were performed. RESULTS: A total of nine studies reporting on 3879 procedures performed by MPS were identified. Procedures were safely performed, with a pooled complication rate of 2.1% (95% CI: 1.0–3.5) and generally successful, with a pooled success rate of 94.7% (95% CI: 90.8–97.7). The range of procedures performed by residents under MPS was 6.7–72.8 procedures per month (n = 9) compared to 4.3–64.4 procedures (n = 4) without MPS. MPS significantly increased confidence, comfort, and use of appropriate safety measures among residents. CONCLUSION: There are a limited number of published studies on MPS supervised by a board-certified physician in US internal medicine residencies. Procedures performed by MPS are generally successfully completed and safe. MPS benefits internal medicine residents training by improving competency, comfort, and confidence. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-020-06526-2.

Orbital floor fractures subsequently lead to consequences such as diplopia and enophthalmos. The graft materials used in orbital floor fractures varied from autografts to alloplastic grafts, which possess certain limitations. In the present study, a novel porcine bone matrix decellularized by supercritical CO2 (scCO2), ABCcolla® Collagen Bone Graft, was used for the reconstruction of the orbital framework. The study was approved by the institutional review board (IRB) of Kaohsiung Medical University Chung-Ho Memorial Hospital (KMUH). Ten cases underwent orbital floor reconstruction in KMUH in 2019. The orbital defects were fixed by the implantation of the ABCcolla® Collagen Bone Graft. Nine out of ten cases used 1 piece of customized ABCcolla® Collagen Bone Graft in each defect. The other case used 2 pieces of customized ABCcolla® Collagen Bone Graft in one defect area due to the curved outline of the defect. In the outpatient clinic, all 10 cases showed improvement of enophthalmos on CT (computerized tomography) at week 8 follow-up. No replacement of implants was needed during follow-ups. To conclude, ABCcolla® Collagen Bone Graft proved to be safe and effective in the reconstruction of the orbital floor with high accessibility, high stability, good biocompatibility, low infection rate and low complication rate.

Introduction CRT Survey II was initiated by the European Heart Rhythm Association and the Heart Failure Association, to explore everyday implantation practice of cardiac resynchronization therapy (CRT) devices in a broad spectrum of hospitals in European Society of Cardiology (ESC) member countries. Aim To compare Polish and European procedural practice. Material and methods Procedural details of Polish patients collected in 37 Polish centres (n = 1241 - Poland group) were compared to the patients enrolled throughout Europe (n = 9847 - CRT II Survey group). Results There were significant differences in: successful implantation (96.1% vs. 97.4%), type of device implanted (for CRT-D: 87% vs. 67.6%), implanting physician subspecialty (for electrophysiologist: 69.2% vs. 79.8%), type of location of procedure (for operating room: 19.4% vs. 8.9%), duration of procedure (117.8 ±44 vs. 97.5 ±46.1 min), left ventricle lead type (for multipolar lead: 50% vs. 57.9%), coronary sinus venogram with occlusion rate (41.4% vs. 47.9%) and peri-procedural complication rate (7.5% vs. 5.3%) between Poland and CRT II Survey groups, respectively. Conclusions This study provides important information describing current differences in Polish procedural routines in relation to ESC member countries. Heterogeneous CRT implantation practices across European countries still exist. However, it may be related to different clinical profile of patients qualified for CRT implantation in Poland as well as organization of care.

SUMMARY – The aim of the study was to reevaluate the safety and feasibility of discharge 24 h after elective uncomplicated laparoscopic cholecystectomy. Since the introduction of laparoscopic cholecystectomy in our hospital, the minimum postoperative stay was considered to be two days based on surgeons’ experience. The study included 337 operations performed by 21 surgeons during 2016 in the Sestre milosrdnice University Hospital Centre. Conversion to open technique and cases of acute cholecystitis were excluded, while 15 patients had insufficient postoperative data. The mean length of stay was 2.38 (range 1 to 6) postoperative days, median two postoperative days. Serious complications involving suspected drain bile leakage and postoperative hemorrhage occurred in two (0.59%) patients, both in the first 24 h following surgery. One patient required emergency laparotomy on the first postoperative day. Readmission rate was 1.2%. The postoperative minor complication rate was 42 of 337 (12.46%); these included wound infections, urinary tract infections, symptoms included in postcholecystectomy syndrome, etc. The onset of these complications was mostly after postoperative day 3. The data obtained suggest that discharge on the first postoperative day after elective uncomplicated laparoscopic cholecystectomy should be considered safe and can be practiced in our hospital.

Introduction In last three decades we have been observing development of minimally invasive walled-off pancreatic necrosis (WOPN) treatment techniques. The choice of access to the necrosis and technique of treatment depends not only on the position and spread of necrosis, but in the first place on the experience of the medical center. Aim To assess the effectiveness and safety of combined endoscopic and percutaneous drainage of WOPN. Material and methods We performed a retrospective analysis of 64 consecutive patients with symptomatic WOPN, who underwent endoscopic treatment in our department between 2011 and 2013. Results Additional percutaneous drainage was executed during endoscopic treatment in 20/64 (31.25%) patients. Complications of treatment occurred in 4/20 (20%) patients. Complications of treatment occurred in 4/20 (20%) patients. All these complications were related to endoscopic treatment. No complications related to percutaneous drainage were noted. There were no deaths. Therapeutic success was achieved in all 20 patients. No patients required surgery. The average time of endoscopic drainage was 41.4 (11-173) days. The mean number of endoscopic procedures was 4.2 (2-12). The average time of percutaneous drainage was 11.3 (5-20) days. The medium time of follow-up was 54 (48-64) months. During the observation the recurrence of WOPN was noted in 2/20 (10%) patients. Long-term success of combined drainage was achieved in 18/20 (90%) patients. Conclusions In selected patients with symptomatic WOPN combined endoscopic and percutaneous drainage enables a high success rate with a low procedure-related complication rate.

Objectives Chronic kidney disease (CKD) is associated with an increased complication rate after cardiac interventions. Although CKD has a high prevalence among atrial fibrillation patients, the impact of CKD on periprocedural complications and the outcome after an interventional left atrial appendage closure (LAAC) is unclear. The present study, therefore, aimed to investigate whether CKD influences the procedure’s effectiveness and safety. Methods LAARGE is a prospective, non-randomised registry. LAAC was conducted with different standard commercial devices, and the follow-up period was one year. CKD was defined by an eGFR 2, and subgroups were further analysed (i.e. eGFR 2, respectively). Results Two hundred ninety-nine of 623 patients (48.0%) revealed a CKD. The prevalence of cardiovascular comorbidity, CHA2DS2-VASc score (4.9 vs. 4.2), and HAS-BLED score (4.3 vs. 3.5) was significantly higher in CKD patients (each p p 2; p > 0.05 vs. eGFR 30–59 mL/min/1.73 m2). Non-fatal strokes were absolutely infrequent during follow-up (0 vs. 1.1%). Severe non-fatal bleedings were observed only among CKD patients (1.4 vs. 0%; p = 0.021). Conclusions Despite an increased cardiovascular risk profile of CKD patients, device implantation was safe, and LAAC was associated with effective stroke prevention across all CKD stages.

Introduction: Female stress urinary incontinence (SUI) is often treated surgically. Urethral bulking agents are a minimally invasive alternative, especially in patients suffering from intrinsic sphincter deficiency, but often with limited long-term efficacy. Urolastic® is a non-deformable, non-resorbable silicone elastomer that is used as an injectable. Its properties might result in a more durable response after injection. If this durability factor can be combined with a low complication rate, this can become a useful treatment option. We therefore assessed the subjective improvement and safety after treatment with Urolastic®. Materials and Methods: In 2 Dutch hospitals, 65 patients were treated with Urolastic®. The subjective improvement was assessed and the medical charts were reviewed for complications that appeared during the follow-up period. The complications were classified using the Clavien-Dindo classification. Results: We found that 76-88% of the patients showed subjective improvement at 12-25 months follow-up. The rate of improvement experienced was 50-70%. The rate of complications classified as Clavien-Dindo >II was 24-33%. The 12 patients with 75-100% subjective improvement after 2 months, showed 85% improvement after a median of 25 months. Conclusions: With careful patient selection, Urolastic® seems to be a safe, durable and effective treatment option for female SUI.

Introduction Single-port access laparoscopic lateral segmentectomy (LLS) has been developed as a novel minimally invasive surgery. We have experience with this LLS technique. Aim To report our technique and patients' postoperative course in a series of single-port access LLS performed in our department. We also examine the cosmetic outcome, safety, and utility of the procedure. Material and methods Between February 2010 and October 2016, 54 patients who underwent single- or multiple-port laparoscopic or open lateral segmentectomy (LS) were retrospectively analyzed with respect to cosmetic outcome, safety, and utility. Results In the single LLS group, the laparoscopic procedure was successfully completed for all 14 patients. The median operative time was significantly shorter in the single LLS group (123 min; range: 50-270 min) than in the other groups. Estimated blood loss was also significantly lower in the single LLS group (10 ml; range: 0-330 ml). During the first 7 postoperative days, the visual analog scale pain score and the use of additional analgesia were not significantly different between groups. The single LLS group had a 7.1% complication rate (Clavien-Dindo classification > IIIA); this was not significantly different between groups. Conclusions Single-port access LLS is a procedure with excellent cosmetic results, although, with regard to invasiveness, there are no major differences from conventional LLS.

Purpose Central venous access ports (CVAP) are widely used to provide long-term vascular access for the delivery of chemotherapeutic medications. The aim of this study was to evaluate the clinical outcomes and complications following CVAP implantation in the interventional radiology suite. Material and methods A retrospective analysis was conducted on 937 oncology patients who underwent CVAP implantation between January 2009 and June 2017. Information regarding patient characteristics, operative data, and procedural outcomes was collected and analysed. Results A total of 937 patients scheduled for CVAP were included in the final analysis. Initial success was achieved in 930 patients (99.3%), and overall completion was achieved in 933 patients (99.6%). There were 63 complications overall. Among these, 19 (2.0%) occurred during the intra- and perioperative period and 44 were late complications (4.7%). No CVAP-related mortalities were observed. Conclusions The analysis in the present study revealed that the CVAP is a safe and effective route for long-term administration of chemotherapy with an overall complication rate of 6.7% throughout the entire device duration. The CVAP implantation procedure carried out in the interventional radiology suite provides an advantage in the management of procedural, vascular and catheter-related complications.

Interval laparoscopic cholecystectomy was found to be safe and associated with a low rate of perioperative complications., Background and Objectives: Up to 19% of patients undergoing laparoscopic cholecystectomy (LC) have common bile duct stones and may require endoscopic retrograde cholangiography (ERCP) before LC. The risk of complications of LC after ERCP is higher, and the optimal interval between ERCP and LC is disputed. In our unit, LC is performed approximately 6 weeks after ERCP. This study aims to compare outcomes between subsets of patients undergoing LC with or without prior ERCP. Methods: All patients undergoing ERCP and elective laparoscopic cholecystectomy (ELC) over a 1-year period were included. Outcome measures included ERCP outcomes, duration of surgery, intraoperative findings, and postoperative outcomes. Two groups of patients were compared: LC after ERCP and ELC. Results: The study included 190 ELC patients and 43 patients with LC after ERCP (ERCP-LC) (December 2008 to December 2009). At ERCP, 25 patients (58%) had ductal stones. The post-ERCP complication rate was 5%. The median time to LC was 42 days, and 6 patients (14%) were readmitted before LC. There were more severe adhesions and longer median operating times in the ERCP-LC group (75 minutes for ELC vs 110 minutes for ERCP-LC, P = .013). We found no significant differences in rates of conversion to open surgery, postoperative complications, lengths of stay, and readmission rates. Conclusion: Interval LC after ERCP is a more technically challenging procedure but is associated with a low rate of complications. Although there is emerging evidence that early LC after ERCP is feasible, our study shows that our current practice of delaying LC by approximately 6 weeks is safe.

The results of this study suggest that there is a significant increase in intraoperative and postoperative complications for obese patients undergoing laparoscopic adrenalectomy compared with healthy weight individuals., Objectives: Laparoscopic adrenalectomy has become the standard of care for resection of adrenal masses, with extremely low morbidity and mortality. This study investigates the difference in outcomes in patients who underwent laparoscopic adrenalectomy, comparing obese with healthy weight patients. Methods: A retrospective chart review was performed on patients undergoing laparoscopic adrenalectomy between January 2000 and February 2010. Intraoperative and postoperative complications in the patients were compared. A patient with a body mass index >30kg/m2 was considered obese. Results: Eighty patients underwent laparoscopic adrenalectomy between January 2000 and February 2010. Forty-nine patients (61%) were considered obese based on the body mass index criteria. Operative time, estimated blood loss, and length of stay did not differ significantly between the 2 cohort groups. There was no 30-day mortality in the population. There were 9 complications in the obese population and no complications in the healthy weight population (P

Introduction: A number of different adjustable gastric bands are available for laparoscopic adjustable gastric banding (LAGB). Few attempts have been made to compare the influence of band design differences for efficiency and complication rate and conflicting results have emerged from comparative studies. Aim: To compare SAGB (Swedish Adjustable Gastric Band) and MiniMizer Extra adjustable gastric bands. Material and methods: One hundred and three patients were included in the prospective randomized study. All patients underwent LAGB. The SAGB was used in 49 and MiniMizer Extra in 54 patients. The primary endpoint was weight loss, and secondary endpoints were complication rate, correction of co-morbidities and improvement of quality of life. Results: There were no early complications. A significant difference in the proportion of patients who have reached good or excellent weight loss results (≥ 50% of initial excess body mass index loss) was found in favour of the MiniMizer Extra group (29.6% vs. 8.2%, p = 0.006). No difference was found in other weight loss parameters, resolution of co-morbidities and improvement of quality of life. One oesophageal dilatation and one leakage were diagnosed in the MiniMizer Extra group. Five band penetrations (9.3%) were diagnosed in the MiniMizer Extra group and no penetrations in the SAGB group (p = 0.069). Conclusions: No major significant differences were found between the compared bands. Further results need to be confirmed by longer follow-up.

The aim of this study was to compare the functional outcome, quality of restoration, and complication rate after open reduction and internal fixation (ORIF) of displaced or unstable 2-, 3- and 4-part humeral fractures using two different locking plates.The data used in this analysis was prospectively collected in two large multicentre studies in 15 European Level 1 trauma centres. A total of 318 patients with proximal humeral fractures were treated with ORIF using either the locking proximal humerus plate (LPHP) or proximal humeral internal locking system (PHILOS). Outcome measurements included Constant and Neer scores, evaluation of local pain at the fracture site and complications, and radiographic assessment at one year.At one year, the mean Constant scores (relative to the contralateral shoulder) improved significantly for both groups and were above 80% for 2-, 3-, and 4-part fractures. A significantly shorter surgical time, less pain at the fracture site, and better functional outcome was achieved by PHILOS-treated patients with 2-part fractures throughout the one-year follow-up month and with 3-part fractures at three months (p 0.05). There was no difference between the treatment outcomes for 4-part fractures, and no difference in the complication rates (p 0.05).PHILOS and LPHP can be considered as useful implants for ORIF of displaced and unstable proximal humeral fractures. There was a slight advantage of the PHILOS system with regard to operative time and functional outcome, especially for the treatment of 2- and 3-part fractures.

Recent attention in THA has focused on minimally invasive techniques and their short-term outcomes. Despite much debate over the outcomes and complications of the two-incision and the mini-lateral and mini-posterior approaches, complications arising from use of the anterior THA on a fracture table are not well documented.We determined the intraoperative and postoperative complications with the anterior approach to THA through an extended single-surgeon patient series.We reviewed 800 primary THAs performed anteriorly with the aid of a fracture table over 5 years and recorded all intraoperative and postoperative complications up to latest followup (average, 1.8 years; range, 0-5 years). Patients with severe acetabular deformity or severe flexion contractures were excluded and those surgeries were performed with a lateral approach during the time period of this study.Intraoperative complications included 19 trochanteric fractures, three femoral perforations, one femoral fracture, one acetabular fracture, one bleeding complication, and one case of cardiovascular collapse. There were no ankle fractures. Postoperative complications included seven patients with dislocations; seven with deep infections; one with delayed femur fracture; 37 with wound complications, among which 13 had reoperation for local débridement; 14 with deep venous thrombosis; and two with pulmonary embolism; and 31 other nonfatal medical complications.The main intraoperative complications of trochanteric fractures and perforations occurred mostly early in the series, while the main postoperative complications related to wound healing were prevalent throughout the entire series. Despite potential advantages of use of a fracture table, surgeons should be aware of the potential complications of trochanteric fractures, perforations, and wound-healing problems associated with this technique.Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Complications of open tibial fractures have been found to be very frequent after application of monotherapies (external fixator, plate, intramedullary nailing). The use of combined therapy has improved our results. We treated 658 patients for open tibial fractures over a course of 15 years. Plating was the method of treatment in the initial phase, and then external fixators and unreamed tibial nails (UTN) were used as a monotherapy. In the last ten years the option of a combined therapy was at our disposal, namely, changing the method of treatment. Monotherapy was performed in 352 cases, and 270 patients were treated in a combined manner. The rate of septic complications could be reduced with the combined therapy from 15.5% to 6.6%, the rate of bone healing disorders from 31.6% to 8.7%, and that of amputations from 4.9% to 0.7%. Elaboration of therapeutic tactics and their consistent application increases the healing potential of open tibial fractures. During this 15 year period, our therapeutic concepts have changed, whereby gradual, combined therapy models were initiated, increasing the advantages and decreasing the disadvantages of the different methods.

The optimum operative technique for lateral lumbar disc herniations (LLDH) remains unclear, and both interlaminar and extraspinal approaches are used.To compare outcome after LLDH removal either by a lateral transmuscular approach (LTM) or by a combined interlaminar and paraisthmic approach (CIP).28 patients underwent surgery using CIP and 20 using LTM. All patients were operated on by the same neurosurgeon. The clinical presentation of the two groups was comparable. Overall outcome was assessed after a mean follow up period of between 19 and 37 months using the Ebeling classification. In addition, the effect of surgery on radicular pain, low back pain, and sensory and motor deficits was defined.Excellent to good results were achieved in 95% of the LTM group and 57% of the CIP group. The outcome was satisfactory to poor in 5% of the LTM and 43% of the CIP group (p0.004). The percentage of sensorimotor deficit and of radicular pain improvement was higher in the LTM group. New low back pain was found exclusively in the CIP group (21%). The complication rate was 5% in the LTM group and 11% in the CIP group.The LTM approach achieves a better overall outcome and improvement in radiculopathy. The complication rate is lower with the transmuscular route and the risk of new low back pain is minimised. These results are likely to be attributable at least in part to the lesser invasiveness of the LTM approach.

To compare the ablation volume, local tumour progression rate and complication rate of radiofrequency ablation (RFA) for small hepatocellular carcinomas (HCCs) using 15-G and 17-G single electrodes.This retrospective study was approved by the institutional review board and informed consent was waived. We reviewed percutaneous RFA cases for HCCs using 15-G or 17-G electrodes without multiple overlapping ablations. A total of 36 pairs of HCCs matched according to tumour size and active tip length were included. We compared ablation volume and complication rate between the two electrode groups. Cumulative local tumour progression rates were estimated using the Kaplan–Meier method and compared using the log-rank test.Tumour size and ablation time were not significantly different between the 15-G and 17-G groups (p50.661 and p50.793, respectively). However, ablation volume in the 15-G electrode group was larger than that in the 17-G group (14.465.4cm3 vs 8.762.5cm3; p,0.001). No statistical difference in complication rates between the two electrode groups was found. The 10- and 20-month local tumour progression rates were not significantly different between the two groups (2.8% and 5.6% vs 11.1% and 19.3%; p50.166).Ablation volume by the 15-G electrode was larger than that by the 17-G electrode. However, local tumour progression rate and complication rate were not significantly different between the two electrode groups.RFA of HCC using a 15-G electrode is useful to create larger ablation volumes than a 17-G electrode.

A new technique for dividing the fibula when performing a high tibial osteotomy is described. The head of the fibula is enucleated and morselized. The technique is simple and safe with a low complication rate.

BACKGROUND: The technical advantages in utilizing human acellular dermal matrix (ADM) products as pectoral extenders in immediate breast reconstruction with tissue expanders or implants are well documented in the medical literature. In this study, the authors examine a commonly used biologic xenograft product that has not yet been described in the medical literature for use in immediate breast reconstruction to determine whether a lower overall complication rate is identified compared to published data on ADM products. METHODS: A retrospective multicenter medical record review of data on 54 subjects in 93 tissue expander/implant-based, consecutive, immediate breast reconstructions from three surgeons at different institutions was performed in which Veritas® bovine pericardium was used as the biologic graft material for the pectoral extender. RESULTS: Over a 24-month period with an average of 11-month follow-up, complication rates using Veritas® in breast reconstruction for seroma formation (7.5 %), marginal skin flap necrosis (5.4 %) infection (6.5 %), and capsular contracture (0 %) were found to compare equally or favorably with statistically significant lower overall complications relative to one comparison study and lower rates of marginal skin flap necrosis relative to two comparison studies based upon previously published data from multisurgeon studies using ADM products. CONCLUSIONS: Overall complications were found to be lower with Veritas® than ADM products in comparable multisurgeon studies, though this was found to be statistically significant in only one comparison study. Level of Evidence: Level II, theraputic study.

Objective—To determine the rate of late complications following first implantation or elective unit replacement of a permanent pacemaker system. Design—Analysis of pacemaker data and complications prospectively acquired on a computerised database. Complications were studied over an 11 year period from January 1984 to December 1994. Setting—Tertiary referral cardiothoracic centre. Patients—Records of 2621 patients were analysed retrospectively. Main outcome measures—Complications requiring repeat procedures occurring more than six weeks after pacemaker implantation or elective unit replacement. Results—The overall rate of late complications was significantly lower after first implantation of a permanent pacemaker (34 cases, complication rate 1.4%, 95% confidence interval 0.9% to 1.9%) than after elective unit replacement (16 cases, complication rate 6.5% (3.3% to 9.7%). There were 20 cases of erosion, 18 infections, five electrode problems, and seven miscellaneous problems. Complications were more common with inexperienced operators (18.9% (6.0% to 31.8%)) than with experienced operators (0.9% (0.3% to 1.5%)). Conclusions—The incidence of late complications following pacemaker implantation is low and compares favourably with early complication rates. The majority are caused by erosion and infection. Patients who have undergone elective unit replacement are at particular risk. Keywords: permanent pacemaker; elective unit replacement; late complications; arrhythmias

Objective Injuries of the hand often require free flap reconstruction. To minimize flap loss, evidence exists to surgically syndactylize digits when repairing multiple injuries, with delayed flap division, or desyndactylization. However, evidence suggests that division of the flap at the time of inset can be accomplished with minimal negative effect. The purpose of this study was to evaluate outcomes, following hand reconstruction with free flaps utilizing either acute or staged desyndactylization techniques.Methods A systematic review utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Articles that described the use of a free flap for surgically syndactylized digits or multilobed flaps for coverage of multiple digits were included.Results One hundred sixty-one articles were reviewed with 34 fulfilling inclusion criteria. One hundred seventeen patients underwent 145 free flap reconstructions. Traumatic avulsions (49%) were the most common injuries, followed by burns (11%). Twenty-one (62%) papers described surgical syndactylization of digits, which were later desyndactylized and five (15%) papers included reconstruction of more than one digit with multilobed free flaps. Eight papers (24%) described both techniques. Overall, 100% of included flaps survived. Total complication rate was 6%, with six complications (67%) occurring in flaps with primary syndactylization.Conclusion Hand defects often require free flaps for reconstruction. Although free flaps for the reconstruction of digital defects is technically demanding, they result in better outcomes. With available evidence indicating complications rates less than those of staged desyndactylization, multidigit reconstruction with multilobed free flaps may be a more desirable technique.

Background Hump recurrence is a commonly encountered problem following dorsal preservation (DP) rhinoplasty when surgeons are learning the procedure. Objectives The aim of this paper was to compare the different methods for the prevention and treatment of dorsal problems following DP surgery. Methods One hundred and fifty primary rhinoplasty patients were included in our study. Their noses were classified in terms of both hump shape (V- or S-shaped) and height. All patients had a DP rhinoplasty by either a push-down (PD) or a let-down (LD) technique. The PD method was used for humps 4 mm. Follow-up evaluations were made with physical examination and photographs at 1 week, 3 months, and 12 months. Results Mean follow-up was 12.68 [1.78] months. Seventy-eight humps were V-shaped and 72 were S-shaped. PD was used for 67 cases, LD for 83 cases. Eight patients (5.3%, 8/150) had a visible dorsal hump problem after DP surgery. Based on their preoperative hump shape, 3 cases were V-shaped and 5 were S-shaped. All recurrent cases had a preoperative hump deformity >4 mm. The revision procedures were as follows: 4 patients had a PD procedure, 3 had a LD procedure, and 1 patient was treated by classic open resection rhinoplasty. Conclusions There is a correlation between preoperative hump height and eventual hump recurrence. The complication rate can be decreased with additional technical maneuvers and proper patient selection. Level of Evidence: 4

The first trials of measles vaccines in the United Kingdom were reported in 1961 by Aldous et al., when three living attenuated vaccines derived from the Edmonston strain (Enders et al., 1960) were compared at the Fountain Hospital. In many cases vaccination reactions were too pronounced for the vaccines to be suitable for routine use. However, in view of the high complication rate of measles in young children (Miller, 1964), it was considered important to continue clinical trials of measles vaccine rendered less toxic by further attenuation. The present paper describes four subsequent trials of vaccines prepared from the Edmonston strain but which had undergone a further series of passages in chick-embryo or chick-cell tissue cultures. In some of the trials the vaccines were given alone, and in others concurrently with gamma-globulin.

Background: Leadless pacemakers (PMs) were recently introduced to address the complication rate of standard PMs with transvenous leads. Methods and Results: A 34-year old male with a history of intravenous substance abuse and a chronic type C hepatitis developed a complete atrioventricular block after cardiac surgery for infective endocarditis. Repeatedly, endo- and epi-cardially implanted PMs had to be explanted due to infection. A leadless MICRA pacemaker was successfully implanted with a dislocation into pulmonary artery several days after implantation. The PM was successfully retrieved using a single-loop retrieval snare guided by a steerable sheath. Subsequently, another Micra PM was successfully implanted with no further issues. Conclusion: In the case of a Micra leadless pacemaker dislocation, a conventional gooseneck snare in combination with a steerable sheath can be used to retrieve the device, improving the overall safety of leadless pacemakers.

Introduction: Malignant Pleural Mesothelioma (MPM) is characterized by an aggressive behavior and an inevitably fatal prognosis, whose treatment is still far from being standardized. The role of surgery is questionable since a radical resection is unattainable in most cases. Hyperthermic IntraTHOracic Chemotherapy (HITHOC) combines the advantages of antitumoral effects together with those of high temperature on the exposed tissues with the aim to improve surgical radicality. Material and Methods: this is a narrative review on the role of HITHOC in the management of MPM patients. To provide data on the beginnings and the historical evolution of this technique, we searched the available literature by selecting the more exhaustive papers on this topic. Results: from 1994 to date different authors experimented HITHOC following a cytoreductive surgery in MPM, obtaining in most cases a good local control and a better overall survival associated to very low complication rate. Conclusions: HITHOC may be considered as a safe, feasible and effective procedure although there is a high heterogeneity between different protocols adopted worldwide. More structured studies are needed to reach a unanimous consensus on this technique.

ObjectiveTo study short-term (DesignSystematic review.MethodsThe systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed and EMBASE were searched for relevant papers on 11 June 2019 and rerun on 27 May 2020. Studies reporting complications, reoperations, length of stay and mortality within 90 days were included. Studies were reviewed according to criteria from the Oxford Centre for Evidence-Based Medicine and the quality of evidence was assessed using the Newcastle–Ottawa Scale.ResultsThe search retrieved 1957 articles. Sixty-six articles were included. The quality of evidence was poor to good. Most studies were retrospective, and no randomised clinical trials were identified. Of included studies a median of 6 Martin criteria for reporting complications after surgery were fulfilled. The Clavien-Dindo classification for grading complications was most frequently used. The weighted overall complication rate after RC was 34.9% (range 28.8–68.8) for in-house complications, 39.0% (range 27.3–80.0) for 30-day complications and 58.5% (range 36.1–80.5) for 90-day complications. The most common types of complications reported were gastrointestinal (29.0%) and infectious (26.4%). The weighted mortality rate was 2.4% (range 0.9–4.7) for in-house mortality, 2.1% (0.0–3.7) for 30-day mortality and 4.7% (range 0.0–7.0) for 90-day mortality. Age and comorbidity were identified as the best predictors for complications following RC.ConclusionShort-term morbidity and mortality are high following RC. Reporting of complications is heterogeneous and the quality of evidence is generally low. There is a continuous need for randomised studies to address any intervention that can reduce morbidity and mortality following RC.PROSPERO registration number104937.

Termination of pregnancy and laparoscopic sterilization has been performed in 101 women in a one-year period. The complication rate was low and the average stay in hospital was short. With close supervision and co-operation between the gynaecologist and the patient's general practitioner it is suggested that this is a safe and economic procedure.

A prospective study of vacuum aspiration in 400 cases of therapeutic abortion is described showing that the procedure was quick, involving little blood loss in most cases, and that the complication rate was low. The routine use of this method in therapeutic abortion is recommended.

The majority of femoral fractures are surgically treated with intramedullary nails. Non-union rate is low but challenging and costly if it occurs. There have been encouraging results from the use of augmentative plating as a treatment for non-union of femoral fractures. We performed a systematic review of the literature to compare union rates, time to union and complications between exchange nailing and augmentative plating as a primary procedure following a diagnosis of femoral non-union following initial nailing. We found a total of 21 papers, which found the mean union rate of augmentative plating to be 99.8% compared to 74% (P = 2.05−12) found for exchange nailing. Times to union were comparable at 5.9 months for augmentative plating and 6.3 months for exchange nailing (P = 0.68916), and complication rate was 4% for augmentative plating compared to 20% for exchange nailing. From the evidence available, plate augmentation provides a more reliable union rate if used as the first operative intervention on a non-union of a femoral fracture compared to exchange nailing. Level of Evidence IV Systematic review of therapeutic studies.

The overall complication rate of Transurethral resection of prostate (TURP) is about 11.1%. Amongst all complications, ocular complications are one of the rarest. In this paper, we present a case of vision loss due to paradoxical embolism as a rare complication following TURP. Ocular complications are very rare in urological surgeries but can happen due to paradoxical embolism following patent foramen ovale. Therefore, we recommend the early diagnosis and treatment of PFO prior to this type of surgery.

Laparoscopic sleeve gastrectomy (LSG) is gaining popularity for the treatment of morbid obesity. It is regarded as a simple, low-cost procedure achieving significant weight loss within a short period of time. LSG is considered a safe procedure with a relatively low complication rate. The complications encountered nevertheless can result in significant morbidity and may even be lethal. The most significant complications are staple-line bleeding, stricture, and staple-line leak. The purpose of this paper is to present a case of a 31-year-old patient complicated by a 3.06 cm staple-line leak 10 days after LSG. Review of the current literature regarding this complication as well as outline of a strategy for the management of large post-LSG gastric leaks is suggested.

Introduccion La ruptura del biceps distal es una lesion infrecuente producida por la aplicacion de una carga excentrica sobre el codo flexionado. El objetivo de este trabajo es analizar nuestros resultados para la reinsercion del biceps distal mediante la tecnica de doble fijacion con boton de anclaje cortical y tornillo interferencial de biotenodesis a traves de una incision anterior unica, con una casuistica mayor a la presentada con anterioridad. Material y Metodo Entre agosto de 2008 y agosto de 2015, se intervino 24 casos de rotura del biceps distal tratados quirurgicamente por via anterior limitada. Los 22 ultimos casos consecutivos fueron tratados con doble fijacion utilizando boton extracortical y tornillo de biotenodesis, y son el grupo de estudio de este articulo. Todos eran hombres, con una mediana de edad de 39,5 anos (rango 22–59). Los pacientes fueron evaluados con el Cuestionario DASH y la valoracion Subjetiva/Objetiva de Andrews y Carson, la fuerza de flexion y supinacion se controlo con la escala del British Medical Research Council modificada por Mackinnon y Dellon (M0-M5). Resultados El valor promedio del cuestionario DASH fue de 1,7 (0 - 31,6) y el de Andrews y Carson, de 197,5 (135–200), con 20 resultados excelentes, 1 bueno y 1 regular. Todos consiguieron una fuerza M5 para la flexion y la supinacion de antebrazo. El tiempo promedio de seguimiento fue de 17,5 meses (10–38). En tres pacientes se registraron complicaciones, todos con una recuperacion total. Conclusion La tecnica descrita demostro ser segura y eficaz, con resultados satisfactorios y baja tasa de complicaciones. Nivel de Evidencia : IV. Serie de Casos. Purpose Distal biceps rupture is an unusual lesion produced after an eccentric load is applied to the bent elbow. The aim of this study is to analyze our results for the reinsertion of the distal biceps with a double fixation technique of cortical button and biotenodesis interference screw through a single anterior incision, with a larger number of cases cases than previously submitted. Methods Between August 2008 and August 2015, 24 cases of distal biceps rupture, surgically treated through an anterior limited procedure. The last 22 consecutive cases were treated with double fixation using an extracortical button and biotenodesis screw and are the group tudied in this paper. All patients were males with a mean age of 39,5 years (range 22–59). Patients were evaluated using the DASH questionnaire and the subjective/ objective scoring system of Andrews and Carson, flexion and supination strengths were assessed with the British Medical Research Council scale, modified by Mackinnon and Dellon (M0-M5). Results The mean DASH score was 1,7 (0–31,6), and the mean Andrews and Carson score was 197,5 (135–200), with 20 excellent, 1 good and 1 regular results. All patients achieved a M5 (level of) flexion and supination strenght of the forearm. The median follow-up period was 17,5 months (10–38). Complications were registered in three patients that recovered totally. Conclusion The described technique proved to be both reliable and effective, giving satisfactory results with a low complication rate. Level of Evidence IV. Case Series.

Background Capsular contracture is a common complication of breast augmentation surgery and many techniques to prevent and treat it have been suggested with inconsistent or variably effective results. Objectives The aim of this paper was to describe a protocol for treating established capsular contracture after breast augmentation with a low recurrence rate. Methods From January 2009 to December 2012, 79 previous bilateral breast augmentation patients presented for treatment of established capsular contracture. There were 135 breasts with capsular contracture: 56 were bilateral and 23 were unilateral. Ten patients opted for no treatment; 2 patients opted for implant removal. Twenty-four were treated with the ICES (implant exchange, capsulectomy, and possible exchange of site) protocol and 43 were treated with the SPICES (Strattice placement in the reconstructive position, implant exchange, capsulectomy, and possible exchange of site) protocol. Results The 24 patients treated with the ICES protocol had a recurrent capsular contracture rate of 15%. The 43 patients treated with the SPICES protocol had a 2.7% recurrent capsular contracture incidence and an 2.7% complication rate. Conclusions Capsular contracture after breast augmentation, whether primary or recurrent, can be successfully treated with the SPICES protocol. Level of Evidence: 4

Editor,—The paper by Walker and Brenchley1 highlights a crucial area of emergency medicine practice. The key issues are “How are skills maintained” and “What is an acceptable period of training”. The authors state in their conclusions that the majority of accident and emergency (A&E) consultants thought that rapid sequence induction (RSI) would be undertaken by A&E staff if an anaesthetist were unavailable. If the A&E staff are only performing this procedure rarely then they will become de-skilled and will have a higher complication rate than a colleague performing the procedure on a regular basis. Anaesthesia is defined as an essential secondment for training, why have this secondment if the skills are not going to be actively used. In order to be given the responsibility of “on call” the anaesthesia minimum requirement is three months of supervised training. I feel that it is no coincidence that this also is the length of our secondment. 1. ↵ Survey of the use of rapid sequence induction in the accident and emergency department. Walker A, Brenchley JJ. J Accid Emerg Med 200;17:95–7. # {#article-title-2} Editor,— As a doctor with a background in both anaesthesia and accident and emergency (A&E) medicine, and currently working in an emergency medicine environment, I read the paper by Walker and Brenchley with interest.1 I have been aware for some time now of the debate among emergency physicians, and anaesthetists, over their respective roles in emergency airway management. I suspect …

Background: Initial intraperitoneal access and first trocar entry are responsible for nearly half of all complications of laparoscopic surgery. The purpose of this article is to detail our method of initial intraperitoneal access with Veress needle and first trocar at the umbilicus used over the past 28 years. Patients and Methods: Since 1990, a single surgeon performed laparoscopic surgery in 7600 patients. From 1992 onward, 6975 patients underwent laparoscopic surgery. On assessment, 739 cases (10.6%) were found unsuitable for Veress needle entry at the umbilicus. The remaining, 6236, patients form the study group for this article. Every patient was operated in the identical, repetitive manner. Every detail was considered important. The method of the first trocar entry is modified to minimise complications of this manoeuvre. Results: The average time from cleaning umbilicus again to Veress needle tip in peritoneum was 1 min 40 s (25 s–7 min). Out of the 4228 patients in whom no adhesions were observed at first trocar entry (Group 1), the Veress needle insertion was successful at first attempt in 3829 (90.5%) patients, at second attempt in 322 (7.6%) and at third attempt in 30 (0.7%). In the 2008 patients with significant adhesions observed after first trocar entry (Group 2), successful insertion of the Veress needle was achieved at first attempt in 1700 (84.6%) patients, at second attempt in 182 (9%) and at third attempt in 19 (0.9%). In this group, there was one bowel injury (0.05%) and 3 (0.15%) minor vascular injuries. There was no mortality in either group. In the overall series, the Veress needle was successfully introduced in 6082 of the 6236 patients (97.5%) and 154 patients (2.4%) failed Veress needle entry. The incidence of bowel injury in the series was 0.016% and that of minor vascular injuries was 0.048%. Conclusions: Initial intraperitoneal access must be performed with utmost caution after adequate training and proctorship. This paper stresses with meticulous attention to every detail, this safe, method of initial intraperitoneal access leads to low complication rates.

Lobectomy can be done either via thoracotomy or via video-assisted thoracic surgery (VATS) (1-3). In the recent years, VATS approach is adopted increasingly worldwide due to its advantages of less pain, lower complication rate, shorter hospital stay, and equivalent long term survival rate, comparing with thoracotomy (4-7). However, VATS lobectomy is complicated, especially VATS left upper lobe resection (8,9). The aim of this paper is to introduce the detailed procedures which presented in the videos of singledirection thoracoscopic left upper lobectomy and left lower lobectomy.

Total Hip Arthroplasty (THA) is regarded as one of the most successful surgical procedures of modern times yet continues to be associated with a small but significant complication rate. Many early failures may be associated with poor component positioning with, in particular, acetabular component orientation dependent on the subjective judgement of the surgeon. In this paper, we compare the manufacturers’ instructions on acetabular cup orientation with the literature-based recommended safety zones, by transforming them onto a single, clinically-relevant framework in which the different reference systems, safety guidelines and current instrumentation surgical techniques can be evaluated. The observed limited consensus between reflects ongoing uncertainty regarding the optimum acetabular component positioning that is probably responsible for a significant number of hip dislocations and early revisions. Our analysis suggests a new safety zone - the Strathclyde Safety Zone, SSZ (30° - 55° inclination and 5° - 30° anteversion) - defined in the operative reference frame, that encompasses other safety zones and which, incidentally, holds the majority of manufacturers’ guideline positions.

Endoscopic retrograde cholangiopancreatography (ERCP) can fail in 3–10% of the cases even in experienced hands. Although percutaneous transhepatic cholangiography (PTC) and surgery are the traditional alternatives, there are morbidity and mortality associated with both. In this paper, we have discussed the efficacy and safety of endoscopic-ultrasound-guided cholangiopancreatography (EUS-CP) in decompression of biliary and pancreatic ducts. The overall technical and clinical success rates are around 90% for biliary and 70% for pancreatic duct drainage. The overall EUS-CP complication rate is around 15%. EUS-CP is, however, a technically challenging procedure and should be performed by an experienced endoscopist skilled in both EUS and ERCP. Same session EUS-CP as failed initial ERCP is practical and may result in avoidance of additional procedures. With increasing availability of endoscopists trained in both ERCP and EUS, the role of EUS-CP is likely to grow in clinical practice.

The technique of seromuscular bladder augmentation (SMBA), as first described experimentally by Shoemaker [1] and later popularized in human subjects by Dewan [2], continues to hold great interest among urologists as a means of providing an augmentation substrate that avoids incorporation of absorptive epithelium. Yet the widespread acceptance of this technique has remained elusive, due to lack of evidence that a significant decrease in complication rate exists that would warrant the increased technical challenges and length of the operative procedure. To this end, the authors of the present paper seek to document differences between augmentation with unaltered ileal and demucosalized colonic segments. While this report lends further support to SMBA being a safe and effective technique, the results presented show no advantage over standard enterocystoplasty. The small number of subjects in the SMBA group (n Z 10) does not provide sufficient power to demonstrate a statistically significant difference in the categories investigated. The authors point to more stones being formed in the ileocystoplasty group (8/30 or 27%) relative to the SMBA cohort. However, from the results section, one gleans that only five of the stones were of significant size to require surgical intervention. If only 5/30 (17%) patients had significant stones, the calculated P-value between the SMBA and ileocystoplasty groups would be PZ 0.17. Compared to the historical results of Jednak, et al, who found that 6% of his cohort of 32 SMBA patients developed calculi [3], the

Background The use of NVBG for mandibular defects seems to be gradually giving way for more advanced reconstructive techniques but it has the advantages of shorter operating time and lesser amount of blood loss. The aim of this study was to review the available data on the success and failure rates of use of NVBG and factors associated with failure. Method Studies published from 1978 to 2014 regarding the use of NVBG were searched. Most important information was graft success and failure outcomes. Information on graft success with particular focus on large defects was extracted and the quality of papers was rated. Defects > 6cm were considered long defects. Results Twenty publications were included in this review. The quality of the studies was low and there was high heterogeneity. All articles reported high graft success rates ranging from 67 to 100%. Success in defects > 6cm was considerable, the range was 72–100%. Three main factors were associated with failure; these were defect length, fixation method and infection. Infection contributed the highest complication rate which was 48.2%. Conclusion NVBG seems to be appropriate for mandible reconstruction when there is vascular recipient bed and sufficient soft tissue cover and mucosal lining are achievable.

Highlights • Closed abdominal traumatisms occurring at typical popular horse-riding festivals in our region constitute a high risk of pancreatic traumatism. • We describe our experience in the diagnosis and treatment of pancreatic lesion secondary to closed abdominal traumatism. • Facing a complete traumatic pancreatic section in the neck the most extended surgical procedure is the resection of pancreatic body, tail, and spleen. • A safer option may be the distal pancreatic preservation with pancreaticogastric anastomosis in grade III lesions with healthy pancreatic tissue., Introduction Pancreatic lesions are very infrequent after closed abdominal trauma (5% of cases) with a complication rate that affects 30–40% of patients, and a mortality rate that can reach 39%. In our experience, closed abdominal traumatisms occurring at typical popular horse-riding festivals in our region constitute a high risk of pancreatic trauma. The purpose of the present paper is to raise awareness about our experience in the diagnosis and treatment of pancreatic lesions secondary to closed abdominal traumatism. Presentation of case We present the clinical cases of two young patients who, after suffering blunt abdominal trauma secondary to the impact of a horse during the celebration of typical horse-riding festival, were diagnosed with pancreatic trauma type III. The treatment was surgical in both cases and consisted in performing a pancreaticogastric anastomosis with preservation of the distal pancreas and spleen. The postoperative period was uneventful and, at present, both patients are asymptomatic. Discussion Signs and symptoms caused by pancreatic lesion are unspecific and difficult to objectify. With some limitations CT is the imaging test of choice for diagnosis and staging in the acute phase. The Wirsung section is indication for surgical treatment. The most extended surgical procedure in these cases is the resection of pancreatic body, tail, and spleen. Conclusion The identification of a pancreatic injury after closed abdominal trauma requires a high suspicion based on the injury mechanism. A safer option may be the distal pancreatic preservation with pancreaticogastric anastomosis in grade III lesions with healthy pancreatic tissue.

Introduction ankle sprains are a common sports-related injury. A 20% of acute ankle sprains results in chronic ankle instability, requiring surgery. Aim of this paper is to report the results of a series of 38 patients treated for chronic lateral ankle instability with anatomic reconstruction. Materials and methods thirty-eight patients were enrolled in the study. Seventeen patients underwent a surgical repair using the Brostrom-modified technique, while the remaining underwent anatomic reconstruction with autologous or allogenic graft. Results at a mean follow-up of 5 years the AOFAS score improved from 66.1 ± 5.3 to 92.2 ± 5.6. Discussion the findings of this study confirm that anatomic reconstruction is an effective procedure with satisfactory subjective and objective results which persist at long-term follow-up along with a low complication rate. No differences, in term of clinical and functional outcomes, were observed between the Brostrom-modified repair and the anatomic reconstruction technique. Level of evidence level IV.

Vertebroplasty (VP) is a percutaneous mini-invasive technique developed in the late 1980s as antalgic and stabilizing treatment in patients affected by symptomatic vertebral fracture due to porotic disease, traumatic injury and primary or secondary vertebral spine tumors. The technique consists of a simple metameric injection of an inert cement (poly-methyl-methacrylate, PMMA), through a needle by trans-peduncular, parapeduncular or trans-somatic approach obtaining a vertebral augmentation and stabilization effect associated with pain relief. The technique is simple and fast, and should be performed under fluoroscopy or CT guidance in order to obtain a good result with low complication rate. The aim of this paper is to illustrate the utility of VP, the indications-contraindications criteria, how to technically perform the technique using imaging guidance, and the results and complications of this treatment in patients affected by symptomatic vertebral compression fracture.

A short cut review was carried out to establish whether the seldinger "over the wire" technique is better than other techniques of pneumothorax drainage. Altogether 28 papers were found using the reported search, of which three presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

Traumatic ruptures of Achilles tendon become more frequent in the last few decades because of the increased sport activities. This fact urges the orthopedics to search for more effective methods with lower patient morbidity and shorter period for recovery. The conclusions of the study prove very low complication rate, short period for recovery and patient satisfaction after any of the presented minimally invasive techniques. It makes percutaneous minimally invasive Achilles tendon suture preferable method in the daily traumatology practice.

A trial of nonescalated conformal versus conventional radiotherapy treatment of prostate cancer has been carried out at the Royal Marsden NHS Trust (RMH) and Institute of Cancer Research (ICR), demonstrating a significant reduction in the rate of rectal bleeding reported for patients treated using the conformal technique. The rate of bleeding has been shown to fall significantly as the extent of rectal wall receiving a planned dose-level in excess of 57 Gy is reduced. Dose-distributions delivered to the rectal wall over the course of radiotherapy treatment inevitably differ from planned distributions. In a previous paper estimates were obtained of the uncertainties in some planned rectal dose-distribution parameters generated by patient setup error, rectal wall movement and the variable degree of rectal wall distension. Here these uncertainties are combined to obtain estimates of the total planning uncertainties in rectal dose-distribution parameters thought likely, on the basis of mechanistic biological modeling, to correlate strongly with the complication rate. Working from these totaled uncertainty values, together with values of patient-to-patient and technique-to-technique differences in planned dose-distribution parameters, it can be inferred that the rectal dose-distribution uncertainties: (i) Have only a marginal impact on fits of a normal tissue complication probability (ntcp) model to RMH/ICR dose-distribution and grade 1, 2, 3 bleeding data (slightly flattening observed volume-response curves); (ii) only slightly reduce the power of a 2 x 100 patient trial of conformal versus conventional prostate radiotherapy to detect a significantly lower rate of grade 1,2,3 rectal bleeding amongst conformally treated patients; (iii) do not diminish the information content of individual planned patient dose-distribution data to the point where the fitting of technique-averaged data would provide as sensitive a test of the existence of a volume effect as the fitting of individual patient data.

The word tracheostomy derived from two greek words meaning ‘I cut the trachea’ has been known for about 3500 yrs. The process has evolved over the years and has undergone revolutionary changes in the methodology, instrumentation and indications. Although tracheostomy is now commonly used the complication rate remains high. In our series it was 48% which is comparable with other series. The purpose of this paper is to discuss the complications of tracheostomy with special attention to their management and prevention.

In the last years, propeller flaps have become an appealing option for coverage of a large range of defects. Besides having a more reliable vascular pedicle than traditional flap, propeller flaps allow for great freedom in design and for wide mobilization that extend the possibility of reconstructing difficult wounds with local tissues and minimal donor-site morbidity. They also allow one-stage reconstruction of defects that usually require multiple procedures. Harvesting of a propeller flap requires accurate patient selection, preoperative planning, and dissection technique. Complication rate can be kept low, provided that potential problems are prevented, promptly recognized, and adequately treated. This paper reviews current knowledge on propeller flaps. Definition, classification, and indications in the different body regions are discussed based on a review of the literature and on the authors’ experience. Details about surgical technique are provided, together with tips to avoid and manage complications.

Background: Laparoscopic cholecystectomy (LC) is taking the place of an effective and tested procedure in surgery, therefore it must not be inferior to the standard modality in any aspect. Some complications specific to the technique, however, are severe and complication rate seem to be higher than in standard open surgery.Methods: In this paper the authors report their guiding principles in applying LC and methods of treatment, and describe the bile duct injuries of 2500 LCs accomplished during the past 4.5 years.Results: Seventeen ductal injuries occurred in the whole series, which means an overall incidence rate of 0.68%. Data obtained in the last period, however, show a decrease down to 0.14%. Following ductal injuries six ductal strictures became clinically apparent. The various complications of these injuries caused the death of two patients.Conclusions: The great number of intraoperatively undetected injuries, many of them arising not due to technical difficulties, suggest the possibility of an injury caused by electric current. Depending on the type of injury direct suture, T-tube drainage or biliodigestive anastomosis can equally be effective. Long established practice and experience can help reduce the occurrence of complications to the level in standard open surgery.

The ilioinguinal approach (IIA) to the acetabulum has been used as a golden standard for fifty years to treat “anterior” acetabular fractures. Since its introduction by Hirvensalo and Cole, the anterior intrapelvic approach (AIPA) has been adopted by some surgeons, whilst others remain devoted to the IIA. IIA is routinely used in the Republic of Macedonia. The aim of this study is to present a review of literature for two different anterior approaches for the treatment of acetabular fractures used in modern day surgery, focussing on AIPA and its priorities and comparing it to IIA.We performed a search, mainly electronically, and retrospective analysis of existing literature. We have identified and selected two representative and well-systematized papers for IIA, and six for AIPA. We presented the advantages and disadvantages, priorities and weaknesses of both approaches separately, comparing complications, risks and results. Based on the facts presented regarding the advantages of AIPA with a focus on visualization, accessibility and biomechanical justification, the approach should be implemented in our everyday practice and we are comfortable in stating this preference, especially due to the fact that upon comparison of the complication rate there is no significant difference between the two approaches.