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Recently, there has been a rapid shift from open shoulder surgery to arthroscopic shoulder procedures for treating several shoulder pathologies. This shift is mainly due to reduced postoperative complications and 30-day readmission. Although the 30-day readmission rate is low, the risk still exists. One way to minimize the risk factors is to analyze all the risk factors contributing to the 30-day readmission following shoulder arthroscopy. Electronic databases such as PubMed, Google Scholar, and Cochrane library were searched. Studies were selected based on predefined inclusion and exclusion criteria. Newcastle–Ottawa score was used for the quality assessment of individual studies. Two reviewers extracted data from the selected studies. Results were evaluated through narrative analysis and presented as an odds ratio with 95% confidence interval. A meta-analysis was not possible due to the heterogeneity in the available data. A total of 12 studies evaluating 494,038 patients were selected in our review. All the studies have a low risk of bias (median = 8). Significant factors predicting readmission included age, gender, COPD (chronic obstructive pulmonary disorder), steroid use, smoking, preoperative opioid use, higher American Society of Anesthesiologists (ASA) score (3 or higher), and general and regional anesthesia vs. regional anesthesia alone. Through our systematic review, we tried to identify risk factors that can predict 30-day readmission following shoulder arthroscopy. These include age > 65 years, COPD, steroid use, opioid use, and OR time > 90 mins. These high-risk patients could be triaged earlier by identifying these parameters, and effective pre and post-operative surveillance could minimize 30-day readmission risk following shoulder arthroscopy. [ABSTRACT FROM AUTHOR]

Analysing morbidity and using this to improve the quality of patient care is an important component of clinical governance. Several methods of data collection and clinical analysis have been suggested, but to date none have been widely adopted. All adult patients sustaining facial fractures were prospectively identified between 01 March 2019 and 28 February 2020, and matched to those who required a return to theatre for surgical complications. Morbidity resulting in a return to theatre was determined using the Clavien-Dindo classification and the Northwestern University error ascribing method. During this period, return to theatre occurred for 33/285 (11.6%) procedures and 23/173 (13.3%) of patients being treated for facial fractures. According to the 27 procedures discussed, Clavien-Dindo Grade IIIb was most commonly found (20/27). Error in judgement (13/35) and nature of disease (12/35) were ascribed as the most common causes of error. Presence of a consultant was associated with increased odds of a return to theatre (p = 0.014). Standardised national data collection of morbidity and error is required for comparisons of outcomes within a single institution or between institutions. To the best of our knowledge, this is the first paper to utilise these widely used methods of morbidity analysis for facial fracture surgery. We would recommend further development of an error analysis method that is more specific to complications from facial fracture surgery. [ABSTRACT FROM AUTHOR]

Limb graft occlusion (LGO) is a serious complication after endovascular aneurysm repair (EVAR) and while device development enables treatment of increasingly complex aortic anatomy, little is known about how endograft type affects the risk of occlusion. This observational study aimed to explore the incidence of LGO after EVAR for three major endograft systems. All patients with standard EVAR as the primary intervention for infrarenal abdominal aortic aneurysm (AAA), between January 2012 and December 2018, at five Swedish vascular surgery centres, were included in this multicentre retrospective cohort study. LGO was defined as a total limb occlusion regardless of symptoms, or a treated significant stenosis. A nested case control (NCC) design with incidence density sampling of 1:3 was used for analysis of potential per-operative and morphological risk factors. Conditional logistic regression was used to estimate multivariable odds ratios (OR) with 95% confidence intervals (CI) A total of 924 patients were included. The majority were male (84%), the mean age was 76 years (± 7.5 SD), and median AAA diameter was 59 mm (IQR 55, 67). Patients were treated with Zenith Alpha (n = 315, ZISL limbs), Excluder (n = 152, PLC/PXC limbs), and Endurant (n = 457, ETLW/ ETEW limbs). During median follow up of 37 months (IQR 21, 62), 55 occlusions occurred (5.9%); 39 with Zenith Alpha (12.4%), one with Excluder (0.7%), and 15 with Endurant (3.3%). In the NCC analysis, the Zenith Alpha device (OR 5.31, 95% CI 1.97 – 14.3), external iliac artery (EIA) landing (OR 5.91, 95% CI 1.30 – 26.7), and EIA diameter < 10 mm (OR 4.99, 95% CI 1.46 – 16.9) were associated with an increased risk of LGO. Endograft device type is an independent risk factor for LGO after EVAR. Specifically, the Zenith Alpha demonstrated an increased risk of LGO compared with the Endurant and Excluder devices. In addition, a narrow EIA and landing zone in EIA are also risk factors for LGO. [ABSTRACT FROM AUTHOR]

The decision to undertake a major lower limb amputation can be complex. This review evaluates the performance of risk prediction tools in estimating mortality, morbidity, and other outcomes following amputation. A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The MEDLINE, Embase, and Cochrane databases were searched to identify studies reporting on risk prediction tools that predict outcomes following amputation. Outcome measures included the accuracy of the risk tool in predicting a range of post-operative complications, including mortality (both short and long term), peri-operative morbidity, need for re-amputation, and ambulation success. A narrative synthesis was performed in accordance with the Guidance on the Conduct of Narrative Synthesis In Systematic Reviews. The search identified 518 database records. Twelve observational studies, evaluating 13 risk prediction tools in a total cohort of 61 099 amputations, were included. One study performed external validation of an existing risk prediction tool, while all other studies developed novel tools or modified pre-existing generic calculators. Two studies conducted external validation of the novel/modified tools. Nine tools provided risk estimations for mortality, two tools provided predictions for post-operative morbidity, two for likelihood of ambulation, and one for re-amputation to the same or higher level. Most mortality prediction tools demonstrated acceptable discrimination performance with C statistic values ranging from 0.65 to 0.81. Tools estimating the risk of post-operative complications (0.65 – 0.74) and necessity for re-amputation (0.72) also performed acceptably. The Blatchford Allman Russell tool demonstrated outstanding discrimination for predicting functional mobility outcomes post-amputation (0.94). Overall, most studies were at high risk of bias with poor external validity. This review identified several risk prediction tools that demonstrate acceptable to outstanding discrimination for objectively predicting an array of important post-operative outcomes. However, the methodological quality of some studies was poor, external validation studies are generally lacking, and there are no tools predicting other important outcomes, especially quality of life. [ABSTRACT FROM AUTHOR]

Summary Background/Objective Hepatectomy is the mainstay of curative treatment for intrahepatic cholangiocarcinoma (ICC). The relationship between postoperative complication and oncological outcome has not been defined. We aimed to elucidate the effect of postoperative complication on long-term survival of ICC patients after curative resection. Methods Data of consecutive patients who had curative resection for ICC at our hospital from 1991 to 2013 were reviewed. Patients with cholangiohepatocellular carcinoma, metastatic adenocarcinoma or Klaskin tumor were excluded. Clinicopathological data and postoperative events were extracted from database for survival analysis. Results There were 107 patients in our series. Their median age was 61 years. The median follow-up time was 24 months. The median tumor size was 6 cm. Major hepatectomy was required in 52.3% of them. The median operation time and blood loss was 439 minutes and 0.9L respectively. R0 resection was achieved in 88.8% of them. The median length of stay was 11 days. The 30-day and 90-day mortality was 2.5% and 6.8% respectively. Major complications were found in 20.6% of them. Patients with postoperative complications had significantly inferior survival than patients without (3-yr DFS 38% vs. 27%, P = 0.001; 3-yr overall: 51% vs. 27%, P < 0.001). Multivariable analysis showed that postoperative complication was an independent factor associated with disease-free survival (OR 1.9 95% C.I. 1.10–3.24, P = 0.021) and overall survival (OR 2.1, 95% C.I. 1.13–3.93, P = 0.018). Conclusion Postoperative complication has a significant impact on ICC patients' long-term survival. Extra measures such as adjuvant chemotherapy should be considered for patients who develop major complications after surgery. [ABSTRACT FROM AUTHOR]

Summary Autologous microsurgical flap reconstruction has become commonplace in most plastic surgery units, and the success rates of this procedure have markedly increased over recent years. However, the possibility of flap failure still needs to be considered. A review of the literature reveals that the critical period for flap-threatening complications is the first 24–48 post-operative hours; however, the window for the onset of these complications remains open for up to 7 days post-operatively. In this study, we focus on the timing of flap complications, aiming to elucidate the time period over which meticulous flap monitoring can positively contribute to flap salvage rates. The relevant literature on the study topic was collated and reviewed in conjunction with the senior author's case series, which consisted of a total of 335 free flaps used during a 2-year period for breast and head and neck reconstruction or limb trauma. Patients' series were then divided into groups according to the complications timing. The correlation between the timing of complications and the flap salvage rate was investigated among the groups. Overall analysis of both the literature and our own data on 335 free flaps showed a progressive reduction in flap salvage rate during post-operative days; the correlations between the times of complication onset and the flap salvage rates in all groups were significant up to the third post-operative day. The correlations between salvage rates and later complications were not significant. Our results suggest that hourly flap monitoring should be compulsory during the first 48 post-operative hours, but clinical monitoring four times daily should be sufficient thereafter. [ABSTRACT FROM AUTHOR]

Summary Introduction-Aim Anastomotic leakage (AL) is the most feared complication after colorectal surgery. Its prognosis is related to early recognition and post-operative management and should be based on the concept of “failure to rescue”. The aim of the present study was to validate the “DULK” diagnostic score for AL, developed in The Netherlands. Material and method From June 2012 to June 2013, 100 consecutive patients were included in a prospective study according to the post-operative care protocol developed by den Dulk et al. The score is based on several laboratory and clinical items recorded daily. Results Among the 100 patients, 12 developed a post-operative AL (12%) with a specific mortality rate of 16.6% (2 patients). A DULK-score > 3 was good criteria for early diagnosis of AL with a sensitivity of 91.7%, a specificity of 55.7%, a positive predictive value of 22%, a negative predictive value of 98%, and an area under the ROC curve of 0.83. If used routinely, the DULK-score would allow diagnosis of AL 3.5 days earlier than clinical judgment alone. The DULK-score was superior to common diagnostic criteria described in the literature such as the C-reactive protein or procalcitonin, in terms of both sensitivity and specificity. Conclusion The DULK-score is, at present, the most reliable instrument for early diagnosis of AL after colorectal surgery and should be integrated into risk management health policies aiming to improve the quality of care according to the “failure to rescue” concept. [ABSTRACT FROM AUTHOR]

Persistent gastrocutaneous fistula (GCF) is a common complication after removal of a gastrostomy tube. Many different techniques for GCF closure have been described. A novel technique involving a punch biopsy device was recently described, called the Punch Excision of Epithelialized Tract (PEET) procedure. This case report describes a serious complication of necrotizing soft tissue infection after utilizing the PEET procedure for a GCF closure. [ABSTRACT FROM AUTHOR]

Rigid fixation with either bicortical screws or miniplates is the current standard way to stabilise the mandibular segments after bilateral sagittal split osteotomy (BSSO). Both techniques are widely used and the superiority of one or other method is still debatable. One complication of rigid fixation is the need to remove the osteosynthesis material because of associated complaints. The main aim of this retrospective study was to analyse how often we needed to remove bicortical screws because they caused symptoms after BSSO in our clinic. Review of other published papers also enabled us to investigate the reported rates of removal of screws and miniplates at other centres. The mean (SD) duration of follow-up of 251 patients (502 sites) was 432 (172) days, and the number of bicortical screws removed in our clinic was 14/486 sites (3%). Other methods of fixation were used at 16 sites. We found no significant association between removal of bicortical screws and age, sex, presence of third molars, or bad splits. Published rates of removal of bicortical screws and miniplates are 3.1%–7.2% and 6.6%–22.2% per site, respectively. These findings show that fixation with bicortical screws after BSSO is associated with a low rate of removal of osteosynthesis material. Reported incidences imply a lower rate of removal for screws than for miniplates. [ABSTRACT FROM AUTHOR]

Abstract: Both total and unicompartmental knee arthroplasty are effective operations for the treatment of gonarthrosis. However, up to 20% of patients will return with pain and a suboptimal functional outcome. The investigation of such a patient is critical in determining an accurate diagnosis and establishing an effective management plan. Causes of pain can be broadly classified into extrinsic and intrinsic. The commonest intrinsic causes of pain are infection, component loosening, component mal-orientation and soft tissue impingement. Extrinsic causes, including hip and spinal pathology, may be responsible for the patient’s symptoms and must be considered. Accurate evaluation uses a four-step procedure involving a detailed history, thorough clinical examination and microbiological plus imaging analysis. This review article will focus on each of these key steps and highlight some of the latest modes of investigating the painful knee arthroplasty. [Copyright &y& Elsevier]

Summary: Aim: The aim of this study was to determine the feasibility of laparoscopy-assisted gastrectomy (LAG) with extraperigastric lymph node dissection for gastric cancer. Methods: The authors attempted LAG with extraperigastric lymph node dissection in 117 consecutive gastric cancer patients between May 1998 and January 2004. The clinico-pathologic characteristics, operative outcomes, post-operative morbidities and mortalities, and follow-up findings of patients with advanced gastric cancer were evaluated. Results: LAG with extraperigastric lymph node dissection were successfully performed in 114 of 117 patients (success rate, 97%). Of these 114 successful cases, 100 cases were early gastric cancers and 14 cases were advanced gastric cancers. The mean operation time for the 114 cases was 259 (range 150–415)min, and the mean number of retrieved lymph nodes was 23 (range 6–66). Operative mortality, hospital death, and overall post-operative complication rates were 0, 1.7 and 14.7%, respectively. Follow-up was available in 110 of the 112 patients (two post-operative hospital deaths were excluded from the 114). Follow-up ranged from 6 to 74 months (median: 19). 108 patients remain alive without recurrence or port-site metastasis. Conclusions: LAG with extraperigastric lymph node dissection is a technically feasible and acceptable method for the surgical treatment of gastric cancer. [Copyright &y& Elsevier]

Proximal hypospadias repair remains challenging. Our approach to the first stage of two-stage proximal hypospadias repairs has evolved from using Byars' flaps to preputial inlay grafts in anatomically suitable cases and pedicled preputial flaps in more complex repairs. We reviewed our outcomes, hypothesizing that inlay grafts and pedicled preputial flaps were associated with lower complication risks than Byars' flaps. A single institution, retrospective, cohort study of consecutive two-stage, primary, proximal hypospadias repairs performed from 2007 to 2017 was conducted. Patients with <6 months follow-up and incomplete operative reports were excluded. Risk of complications (fistula, dehiscence, diverticulum, meatal stenosis, stricture) were evaluated following urethroplasty and stratified by first-stage repair technique. As technique refinements have been made since 2012, comparisons between two temporal subgroups (those who underwent repair in 2007–2012 and in 2013–2017) were made. 78 of 127 patients met inclusion criteria. Overall complication rate was 47% (Summary Table). Median follow-up was 25.4 months (range 6.4–128.5 months) after urethroplasty. Pedicled preputial flaps (hazards ratio [HR] 0.30; 95% Confidence Interval [CI] 0.14–0.65) and inlay grafts (HR 0.32; 95% CI 0.11–0.95) were associated with lower complication risks compared to Byars' flaps (Summary Table). Median time to complication was significantly shorter for Byars' flaps (5.7 months) than for inlay grafts (40.6 months) and pedicled preputial flaps (79.2 months) by Kaplan Meier analysis. Temporal subgroup comparisons showed that overall complication rates decreased from 70% to 31% (p = 0.001), but differences in complication rates by first-stage technique were not statistically significant. In our cohort, repairs with Byars' flaps had the highest complication rate, which is consistent with our observations that urethras tubularized from Byars' flaps lack appropriate backing and are hypermobile and irregular. To overcome these shortcomings, modifications were made to our approach to two-stage proximal hypospadias repairs with the use of inlay grafts and pedicled preputial flaps quilted to the underlying corporal bodies to optimize the stability of the urethral plate. Our preliminary results are promising. Approach to the first stage of two-stage repairs affects outcomes. Pedicled preputial flaps and inlay grafts were associated with lower complication risks than Byars' flaps. Refinement of technique and patient selection may have resulted in fewer complications in the short term. However, long-term follow-up is needed. Summary Table. Overall Complications and Unadjusted Cox Proportional Hazards Model Comparing Complications by First-stage Repair Technique Overall Complications All (N = 78) Inlay Graft (N = 13) Pedicled Preputial Flap (N = 33) Byars' Flaps (N = 21) Combined (N = 11) Complications a 37 (47%) 4 (31%) 11 (33%) 17 (81%) 4 (36%) Median Number of Complications Per Patient 0 (0–2) 0 (0–2) 0 (0–2) 1 (0–2) 0 (0–1) Type of Complications (n, % of cohort) b Fistula 18 (23%) 2 (15%) 6 (18%) 8 (38%) 2 (18%) Glans/Partial dehiscence 10 (13%) 1 (8%) 0 6 (29%) 3 (30%) Stricture 6 (8%) 2 (15%) 1 (3%) 3 (14%) 0 Diverticulum 3 (4%) 0 1 (3%) 2 (10%) 0 Meatal Stenosis 3 (4%) 0 3 (9%) 0 0 Dehiscence 2 (2.5%) 0 1 (3%) 1 (5%) 0 Unadjusted Cox Proportional Hazards Model Comparing Complications by First-stage Repair Technique Repair Hazard Ratio 95% Confidence Intervals Inlay Graft versus Byars' Flaps 0.32 0.11–0.95 Pedicled Preputial Flap versus Byars' Flaps 0.30 0.14–0.65 Combined versus Byars' Flaps 0.48 0.18–1.31 a This notes the number of patients who developed complications. If a patient developed two complications, they were only counted once for this variable. b This notes the number of patients with each type of complication. [ABSTRACT FROM AUTHOR]

Stoma closure surgery (SCS; restoring intestinal continuity) in children is associated with high post-surgical complication rates with no established preventive strategies. Although many of these complications can be directly or indirectly attributable to bowel obstruction, no anatomical obstructive pathology is found in the majority. Intestinal dysmotility in children with no prior surgery is a well-known entity, which can lead to clinical features similar to anatomical obstruction. It is not known if a similar pathology could be the reason for SCS complications as well. We retrospectively reviewed five consecutive cases in our institution between 2016 and 2018, where scintigraphy was utilized to assess bowel motility prior to SCS. The radiotracer is administered via stoma or per anum, admixed with barium for anatomical assessment. Three children had failed prior attempts at SCS (underlying disease: spontaneous neonatal perforation, necrotizing enterocolitis, colonic atresia). A fourth patient, with gastroschisis, had ongoing obstruction despite multiple stricture resections. In all these patients, a dysmotile section of bowel was identified on scintigraphy in the distal small or large bowel and was resected. Three had excellent post-surgical follow up with no complications; one patient died in the immediate postoperative period likely from unrelated cause. A fifth child had a normal bowel motility study prior to SCS and had an uneventful follow up. Areas of segmental dysmotility in the distal gut may be the primary cause of post-SCS complications. Using a novel approach of assessing bowel motility using scintigraphy, such areas can be identified pre-operatively and resected, leading to reduced post-SCS complications. We recommend further investigation and validation in a larger prospective study. [ABSTRACT FROM AUTHOR]

Abstract: An unusual fracture of the mandible is reported that occurred 20 months after a bilateral split sagittal osteotomy. [Copyright &y& Elsevier]