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Pre-operative localization of non-palpable breast lesions with non-wired non-ionizing (NWNI) techniques may improve clinical outcomes as reoperation rate, cosmetic outcome and contribute to organizational aspects improvement in breast-conserving surgery (BCS). However only limited literature is available and clinical studies involving these forefront devices are often small and non-randomized. Furthermore, there is a lack of consensus on free margins and cosmetic outcomes definitions. The objective of the present meta-analysis was to determine the crude clinical outcomes reported for the NWNI techniques on BCS. A literature search was performed of PubMed, Embase and Scopus databases up to February 2021 in order to select all prospective or retrospective clinical trials on pre-operative breast lesion localization done with NWNI devices. All studies were assessed following the PRISMA recommendations. Continuous outcomes were described in averages corrected for sample size, while binomial outcomes were described using the weighted average proportion.Twenty-seven studies with a total of 2103 procedures were identified. The technique is consolidated, showing for both reflectors’ positioning and localization nearly the 100% rate of success. The re-excision and clear margins rates were 14% (95% CI, 11–17%) and 87% (80–92%), respectively. Overall, positive margins rates were 12% (8–17%). In studies that compared NWNI and wire localization techniques, positive margin rate is lower for the first techniques (12%, 6–22% vs 17%, 12–23%) and re-excision rate is slightly higher using the latter (13%, 9–19% vs 16%, 13–18%).Pre-operative NWNI techniques are effective in the localization of non-palpable breast lesions and are promising in obtaining clear (or negative) margins minimizing the need for re-excision and improving the cosmetic outcomes. Randomized trials are needed to confirm these findings.

Introduction: This is a retrospective audit of 187 cases of coronectomies of mandibular third molars (M3M) carried out at a two large teaching hospitals in London. Methods: We collected data from the electronic patient records on all mandibular third molar coronectomy procedures performed between April 2017 and November 2020. Data was collected on complications including dry socket, infection, re-operation and nerve injuries to the inferior dental and lingual nerves. Results: 187 coronectomies were performed on 153 patients during the study period. This represents approximately 3% of the total number of third molars managed surgically. Almost 80% of these cases had cone beam computed tomography imaging prior to surgery. The majority (64%) of cases performed under general anaesthetic. Seven consultants and their teams managed the patients. Over half of the patients were prescribed antibiotics post-operatively. Complications were as follows: dry socket 2.1%; infection 4%; re-operation 1.6%; lingual nerve injury 0.5%, inferior alveolar nerve injury 1%. Of these nerve injuries, only one (0.5%) was considered to be permanent after two years of follow up. One patient (0.5%) had roots removed 12 months after coronectomy. Conclusion: We found that coronectomy is a safe and effective modality for treating high risk mandibular third molars. Complication rates are similar to those seen from surgical removal of such teeth with a lower than expected incidence of nerve injuries.

Objective: Residual aortic dissection (AD) following DeBakey type I AD repair is associated with a high rate of adverse events that need additional intervention or surgery. This study aimed to identify clinical and early post-operative computed tomography angiography (CTA) imaging factors associated with adverse events in patients with type I AD after ascending aorta replacement., Methods: This single centre, retrospective cohort study included consecutive patients with type I AD who underwent ascending aorta replacement from January 2011 to December 2017 and post-operative CTA within three months. The primary outcome was AD related adverse events, defined as AD related death and re-operation due to aortic aneurysm or impending rupture. The location and size of the primary intimal tears, aortic diameter, and false lumen status were evaluated. Regression analyses were performed to identify factors associated with AD related adverse events. A decision tree model was used to classify patients as high or low risk., Results: Of 103 participants (55.43 ± 13.94 years; 49.5% male), 24 (23.3%) experienced AD related adverse events. In multivariable Cox regression analysis, connective tissue disease (hazard ratio [HR] 15.33; p < .001), maximum aortic diameter ≥ 40 mm (HR 4.90; p < .001), and multiple (three or more) intimal tears (HR 7.12; p < .001) were associated with AD related adverse events. The three year cumulative survival free from AD related events was lower in the high risk group with aortic diameter ≥ 40 mm and multiple intimal tears (41.7% vs. 90.9%; p < .001)., Conclusion: Early post-operative CTA findings indicating a maximum aortic diameter ≥ 40 mm and multiple intimal tears may predict a higher risk of adverse events. These findings suggest the need for careful monitoring and more vigilant management approaches in these cases., (Copyright © 2024 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

The vertical rectus abdominis myocutaneous (VRAM) flap is a versatile and well-established reconstructive technique for many defects created as a result of colorectal and gynecologic extirpation. However, major re-operation in the pelvis following a VRAM flap reconstruction several months later is uncommon, and the safety and integrity of the VRAM flap in this setting has not been described. This case examines VRAM flap preservation during repeat exploratory laparotomy, and a unique view of the VRAM flap during interval exploration. We demonstrate an intact flap after lysis of adhesions with an audible Doppler signal, and maintenance of flap integrity in the postoperative period. This further substantiates its use as a durable rotational flap for perineal tissue defects.

Objective: Although observational cohort studies report that interventions to achieve functionality are clinically successful in 85% of patients, the proportion of newly created autologous arteriovenous fistulas that result in functional vascular access typically is only 70 - 80%. To address this discrepancy, the selection and outcomes of interventions to achieve functionality in a multicentre prospective cohort study were analysed., Methods: The Shunt Simulation Study enrolled 222 patients who needed a first arteriovenous fistula in nine dialysis units in The Netherlands from 2015 to 2018 and followed these patients until one year after access creation. In this observational study, the technical and clinical success rates of interventions to achieve functionality based on lesion and intervention characteristics were analysed and the clinical outcomes of arteriovenous fistulas with assisted and unassisted functionality were compared., Results: For patients who were on dialysis treatment at the end of the study, unassisted fistula functionality was 54% and overall fistula functionality was 78%. Thirty-four per cent of arteriovenous fistulas required an intervention to achieve functionality, 68% of which eventually became functional. Seventy-five per cent of these interventions were percutaneous balloon angioplasties of vascular access stenoses. Patients with clinically successful interventions to achieve functionality had larger pre-operative vein diameters (2.8 ± 1.0 mm vs. 2.3 ± 0.6 mm, p = .036) and less often presented with thrombosed fistulas than patients with unsuccessful interventions (7% vs. 43%, p = .006). Arteriovenous fistulas with assisted functionality had similar secondary patency as fistulas with unassisted functionality (100% and 98% at six months, p = .44), although they required more interventions to maintain function (2.6 vs. 1.7 per year; rate ratio 1.52, 95% CI 1.04 - 2.18, p = .032)., Conclusion: Interventions to achieve functionality were needed in about a third of newly created arteriovenous fistulas. Most thrombosed fistulas were abandoned, and when selected for thrombectomy rarely reached clinical success. On the other hand, interventions to achieve functionality of patent fistulas had high clinical success rates and therefore can be done repeatedly until the fistula has become functional., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: Paddle leads for spinal cord stimulation (SCS) offer more efficient energy delivery and advantages in some patients. However, there is concern for how safely SCS paddles can be replaced once previously implanted because of scar tissue and the relative vulnerability of the thoracic cord. In this study, we share our experience on SCS paddle replacement., Materials and Methods: Participants who underwent SCS replacement at Albany Medical Center between 2011 and 2020 were identified. The medical records were reviewed for demographic data and information regarding initial complications, reason for removal or revision, subsequent complications of replacement surgery and its timing, and whether the implant was ultimately removed. Percutaneous lead replacement cases performed over the same period were used as a comparison group., Results: A total of 1265 patients were identified to have had an SCS-related procedure based on billing codes. Of these, 73 involved replacement of epidural leads (51 paddles, 22 percutaneous). Most paddles (48/51) were replaced at the time of removal. A total of 30 of the 51 paddle replacements required additional lamina removal. Re-operations that occurred more than one year after initial implant were significantly more likely to require additional bone removal (p < 0.001). Paddle re-operations lasted in general 1.7 ± 0.2 hours and had 35 ± 5 mL of blood loss, whereas percutaneous operations lasted 1.3 ± 0.2 hours and had 12.5 ± 2 mL of blood loss. Despite the invasive nature of paddle replacement, there was no difference in complications (p = 0.23) compared with that in percutaneous leads., Conclusions: This study characterizes the safety profile of SCS paddle replacement surgeries. Here, we demonstrate that the replacement of paddle leads at the time of removal, with additional lamina removal if needed because of scar, is associated with low rates of complications. This validates the feasibility and low-risk profile of replacing paddle leads when clinically indicated for experienced surgeons with specialization in SCS., (Copyright © 2022 International Neuromodulation Society. Published by Elsevier Inc. All rights reserved.)

Objectives: To create estimates for clinically meaningful changes and differences in pain and joint function for the Oxford Hip and Knee Scores (OHS/OKS) in primary and revision joint replacement., Study Design and Setting: 694,487 primary and revision joint replacement procedures were analyzed from the NHS PROMs dataset between 2012-2020. Minimal important changes (MIC) and differences (MID) were calculated using distribution and anchor-based methods (including receiver-operating characteristic (ROC) curve and predictive-modelling techniques)., Results: For comparison of two or more groups (such as in a clinic trial), MID estimates were ∼5 points. For cohort studies investigating changes over time in a single group of patients, MIC group estimates were 12.4 points (primary hip replacement), 8.6 points (revision hip replacement), 10.5 points (primary knee replacement) and 9.4 points (revision knee replacement). For studies investigating changes over time at the individual patient level, MIC adjusted estimates were ∼8 points, ∼6 points, ∼7 points and ∼6 points respectively., Conclusion: This study has calculated contemporary estimates of clinically important changes and differences for the OHS/OKS for primary and revision hip and knee replacement. These estimates can be used to inform sample size calculations and to interpret changes in joint function over time and differences between groups., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Introduction: Pituitary surgery has shifted in recent years from microscopic surgery(MS) to endoscopic endonasal surgery (EES). However, the comparative long-term outcome of these surgical approaches, including the need for subsequent re-operation has never been reported. We present our experience in a high-volume referral center experienced in both endoscopic and microscopic approaches to compare the need for re-operation after initial resection of non-functioning pituitary macroadenomas using these surgical approaches., Methods: 684 patients (398 with NF adenomas) underwent trans-sphenoidal pituitary surgery in our institution between 2006 and 2017. Complete follow-up (mean 72 months, minimum two years) was available in 87 newly diagnosed patients with non-functioning pituitary macroadenomas (NFPMA; 48-microscopic and 39-endoscopic). The EES approach has been used almost exclusively since 2012. The need for repeat operation for tumor resection during the follow-up period was assessed as the primary end-point of the study. Extracted data included various demographic and clinical parameters, radiographic findings as well as the extent of resection (EOR)., Results: The EOR was similar for both groups, with a trend towards better EOR in the EES group. The rate of surgical complications was also similar for both groups. There was a strong trend towards lower need for re-operation in the EES group compared to the MS group (12.8% vs. 29.2%, p = 0.056). In a multivariate analysis, only EOR and Knosp grade were independently associated with the need for re-operation surgery., Conclusion: Our data indicate that EES in NFPMA tends to be associated with a lower need for re-operation compared to the MS approach, with a similar rate of EOR and complications., Competing Interests: Declaration of competing interest None., (Copyright © 2021 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Objective: This study aimed to determine the incidence and risk factors associated with revision or removal of a sacral nerve stimulation device for treatment of lower urinary tract dysfunction or fecal incontinence., Materials and Methods: This is a single-center multidisciplinary retrospective cohort study conducted at a university hospital from January 2013 through October 2017. Subjects who underwent successful sacral neuromodulation were identified via procedural codes. Clinical and demographic data regarding device revision or removal were extracted from the medical record. When testing differences between groups, t-test or Mann-Whitney U test was used to compare continuous variables. Categorical variables were compared by Chi-square test. Risk factors with a p value <0.2 in univariate investigation were included in the multivariate analysis. Logistic regression modeling was used to compare associations between risk factors and re-operation rates., Results: Of the 219 subjects analyzed, 35 (16%) had revision or explantation of the sacral nerve stimulation device. Median time to re-operation was 164 days (interquartile range [IQR]: 29, 525). Subjects with device revised or explanted were younger, with a median age of 50 years vs. 62 years (p < 0.01) for those who did not undergo explantation. Patient demographics and co-morbidities were otherwise similar. Multivariate analysis identified age under 55 years (odds ratio [OR]: 2.51; 95% confidence interval [CI]: 1.18-5.33) as a significant risk factor. Our regression model showed that neither preimplantation diagnosis of chronic pain (OR: 0.60; 95% CI: 0.28-1.27) nor the specialty of the surgeon (OR 1.04; 95% CI 0.66-1.62) was associated with stimulation device revision or explantation., Conclusions: This study found a 16% incidence of revision or explantation. Age under 55 years was identified as a significant risk factor. Our analysis did not find further demographic characteristics, co-morbid disorders, or behavioral diagnoses that were associated with revision or removal. Identification of risk factors may aid in patient selection for sacral nerve stimulation device implantation., (© 2019 International Neuromodulation Society.)

Objective: To conduct a systematic review on the effect of posterior tilt on reoperations, patient reported outcome measures (PROM) and functional outcome following osteosynthesis of undisplaced FNFs (uFNF)., Material and Methods: A search string was developed with the aid of a scientific librarian and the search was performed in PubMed, CINAHL and Embase. The studies were screened independently by two authors using Covidence. Data were extracted by two authors and quality assessment was performed using Robins-I tool. The meta-analyses were performed in STATA IC 16 using Risk Ratio as the primary effect estimate., Results: In total, 617 studies were screened and ten studies were included with a total of 3,131 patients. The mean age ranged from 68.3 to 85.0 years and the prevalence of posterior tilt ≥20° in the studies ranged from 4.5% to 27.6%. There were 10.3% reoperations when posterior tilt was <20° whereas there were 24.5% when posterior tilt was ≥20° The meta-analysis therefore demonstrated an overall risk ratio of 0.11 (95% confidence interval; 0.04-0.18). Only one study investigated functional outcome, using ADL as measurement, but found no significant difference. No studies investigated PROM. In general, the studies were assessed to be of poor quality mainly due possible bias and confounding., Conclusion: A posterior tilt ≥20° leads to a higher risk of reoperations in uFNF. Even though the studies were of poor quality, the results suggest that we should include the measurement of posterior tilt in national guidelines., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Introduction: Approximately 2% of the population are anticoagulated and over 50% of over 65-year-olds are prescribed antiplatelet agents. Several systematic reviews have shown the safety of interrupting anticoagulation and antiplatelets for non-emergency surgery, although such reviews excluded upper limb procedures and represents the rationale for this review., Methods: The literature was systematically searched for studies concerning the outcomes of adult hand or wrist surgery on patients receiving anticoagulation or antiplatelet agents in direct comparison to controls (no anticoagulation or antiplatelet agents, or interruption of either). The primary outcome was reoperation for any complication related to postoperative bleeding, within 30 postoperative days., Results: Nine cohort studies (3628 individuals; 3863 operations) were included. Based on very low-quality evidence, anticoagulation did not affect the risk of reoperation for bleeding (RR 2.4 [95% CI 0.1, 57]; 3 studies, n=443) or bruising (RR 2.5 [95% CI 1.0, 6.3]; n=124; I 2 =0%). Based on low quality evidence, antiplatelet agents did not affect the risk of reoperation for bleeding (RR 0.8 [95% CI 0.3, 1.8]; 6 studies, n=1885; I 2 =0%) or bruising (RR 3.2 [95% CI 0.2, 44]; n=571; I 2 =66%). A sensitivity analysis showed that carpal tunnel decompression on patients receiving anticoagulants or antiplatelets appeared to be safe (RR 0.8 [95% CI 0.3, 1.8]; 6 studies, n=2077; I 2 =0%)., Conclusions: Given the sparsity of events (bleeding and bruising) and low-quality of the literature, no firm conclusions can be drawn. The decision to interrupt antiplatelets or anticoagulants should be made jointly with expert physicians and the patient. Registration: PROSPERO ID CRD42018087755., Competing Interests: Conflicts of Interest There are no conflicts of interest., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Repair of distal hypospadias is one of the most common pediatric urology procedures in the US. However, the risk of postsurgical complications has been reported primarily from single-institution and tertiary center studies, with short duration of patient follow-up., Objective: The aim of the study was to examine the incidence of re-operation and risk factors for re-operation following outpatient distal hypospadias repair in a large, representative sample of US children., Methods: A retrospective cohort study of patients aged 0-18 years undergoing single-stage distal hypospadias repair was conducted. Data were obtained from the State Ambulatory Surgery and Services Databases of 9 participating states. Patients who underwent outpatient surgery in 2008-2013 were identified using Current Procedural Terminology (CPT) codes. Patients with records suggesting prior surgery for hypospadias (CPT) were excluded, as were patients who underwent the initial repair <2 years before the end of state data availability. Return outpatient surgery visits across institutions within each of the 9 states were tracked to identify re-operations after the single-stage repair, using CPT codes for surgical treatment of hypospadias complications in 2008-2015. Time-to-event analyses were used to estimate the probability (risk) of re-operation over time and to examine whether patient and institutional characteristics were predictive of re-operation (age, race/ethnicity, health insurance, facility ownership, and institutional volume of hypospadias repair)., Results: A total of 4673 children treated across 148 institutions were included. The median follow-up time was 4.1 years (range: 2-7.9). Most patients were <1 year of age at the time of initial repair (53%). The risk of re-operation was 2.6% (95% confidence interval [CI]: 2.1-3.0%) at 1 year and 6.7% (95% CI: 6.0-7.5%) at 5 years after initial repair (Figure). Approximately 13% of re-operation patients had the re-operation at a different institution. None of the patient or institutional factors examined was a significant predictor of the risk of re-operation., Discussion: In this population-based cohort, the estimated 5-year risk of re-operation following single-stage distal hypospadias repair was 6.7% (95% CI: 6.0-7.5). Most re-operations occurred after the first year, informing long-term expectations about postoperative complications. This study was limited by a lack of data on severity of hypospadias and surgeon characteristics and the inability to track re-operations outside of the state in which the original repair was performed., Conclusion: Approximately 7% of children undergoing distal hypospadias repair undergo a re-operation within 5 years. None of the factors studied were predictive of re-operations., (Copyright © 2019 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Background and Purpose: The recommended treatment of displaced femoral neck fractures (FNF) in patients younger than 70 years of age is fracture reduction and internal fixation (IF). The incidence of re-operation due to nonunion (NU) or avascular necrosis (AVN) has been reported to be between 20-30%. Knowledge of possible predisposing factors needs to be elucidated. The primary aim of this study was to identify factors associated with a major re-operation due to NU or AVN in patients <70 years with a displaced FNF treated with IF., Patients and Methods: 128 patients, 20-69 years with a FNF treated with IF. Follow up included radiographic and clinical examination at 4, 12 and 24 months. Logistic regression analysis was used to identify factors associated with re-operation due to NU or AVN., Results: The re-operation rate due to NU or AVN was 6%, 16% and 28% at 4, 12 and 24 months respectively. Patients with low BMD was more likely to be re-operated than those with normal BMD, OR 5.5, CI (95%) 1.15-26.8, and those with a high alcohol consumption had 3.2 times higher odds to be re-operated due to NU or AVN, CI (95%) 1.16-8.76., Interpretation: In more than two thirds (83/120) of the patients the fracture healed after one operation. Moreover, a low BMD and high alcohol consumption were related to a major re-operation. These results suggest that only age as a sole variable for choosing the type of surgical treatment may not be rational., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: Because of the health care initiative on quality improvement projects in academic medicine, this study explores the impact of different postgraduate years (PGYs) on unexpected re-operation rates., Methods: Using the National Surgical Quality Improvement Program 2005-2014, adult neurosurgical cases were divided into subspecialties: spine, open vascular, cranial, and functional. Comparison groups were cases involving junior residents (PGY 1-PGY 3), mid-level residents (PGY 4 + PGY 5), and senior residents (PGY 6 + PGY 7). Comorbidity disease burden was measured by frailty index. The primary outcome measure was 30-day unintended return to the operating room., Results: Of the 9782 cases, re-operations were higher for those cases featuring a senior resident (5.6%) compared with mid-level resident (4.1%) and junior resident (3.8%) (P = 0.001). Although senior residents operated on patients with a statistically significantly higher neurologic disease burden, greater relative value units, longer operative times, and more 30-day postoperative adverse events, the level of resident training did not have an impact on revision surgery after multivariable logistical regression. The strongest predictors of return to the operating room included the frailty index (adjusted odds ratio [OR adj ] = 5.18, P < 0.001), functional subspecialty (OR adj  = 2.65, P < 0.001), and Wound Class 4 - dirty/infected wound (OR adj  = 2.33, P = 0.016)., Conclusions: Resident participation in neurosurgical cases does not affect 30-day unplanned re-operation rates, which were affected by frailty index, functional subspecialty, and wound class., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Implant infections in the setting of breast reconstruction present a significant setback for patients with breast cancer. Traditional management of implant infections is predicated on the operative removal of the implant and delayed replacement. Another option for implant infection management has emerged in which the soft tissue infection is neutralized, the implant is removed, the surgical site is washed out, and a new implant replaced immediately. In this study, we present our findings with the implementation of this technique and an algorithm for choosing which patients are the most appropriate candidates on the basis of a retrospective review., Methods: A retrospective chart review of patients who underwent operative removal of infected expanders from January 1, 2010 to December 31, 2015 was performed at the University of Michigan by the senior authors. The final reconstructive outcome, time to reconstruction, and infection recurrence were evaluated., Results: Twenty patients with clinical signs of implant infections were identified. Of them, 16 patients with clinical signs of implant infection underwent immediate implant exchange; 15 remained infection free, while 1 patient developed recurrent infection within a month, which was treated with device removal. The mean time to final reconstruction in the 15 infection free patients was 207 days, and the 4 patients who underwent removal without immediate replacement had a 75% rate of non-completion at over 500 days., Conclusions: Our findings demonstrate that immediate implant exchange safely offers patients the opportunity to remain on a path toward reconstruction. These findings offer support for a paradigm shift in our management of implant infections in breast reconstruction patients who already face challenges associated with breast cancer care., (Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: In hip fracture surgery, the exact choice of implant often remains somewhat unclear for the individual surgeon, but the growing literature consensus has enabled publication of evidence-based surgical treatment pathways. The aim of this article was to review author pathways and national guidelines for hip fracture surgery and discuss a method for future pathway/guideline implementation and evaluation., Methods: By a PubMed search in March 2015 six studies of surgical treatment pathways covering all types of proximal femoral fractures with publication after 1995 were identified. Also we searched the homepages of the national heath authorities and national orthopedic societies in West Europe and found 11 national or regional (in case of no national) guidelines including any type of proximal femoral fracture surgery., Results: Pathway consensus is outspread (internal fixation for un-displaced femoral neck fractures and prosthesis for displaced among the elderly; and sliding hip screw for stabile- and intramedullary nails for unstable- and sub-trochanteric fractures) but they are based on a variety of criteria and definitions - and often leave wide space for the individual surgeons' subjective judgement. Appearing neither exhaustive nor exclusive, most of the pathways seem difficult to evaluate scientifically, which might explain why only very few have been evaluated for compliance, reliability and complications after implementation in an actual clinical setting. We therefore introduce a model for step-wise pathway implementation including proper scientific evaluation., Conclusions: Surgical treatment pathways for proximal femoral fractures are available in literature and nationally with somewhat evidence based treatment consensus, but the scientific evaluation of the pathways them selves needs to be optimised., (Copyright © 2015. Published by Elsevier Ltd.)

Background: Extrahepatic cyst excision and Roux-en-Y hepaticojejunostomy is not satisfactory in many patients with complex Todani type IV-A choledochal cysts., Aims: To report the results of combined extrahepatic cyst excision, partial hepatectomy, and Roux-en-Y hepaticojejunostomy for type IV-A choledochal cysts., Methods: The records of patients who received extrahepatic cyst excision, partial hepatectomy, and Roux-en-Y hepaticojejunostomy for type IV-A choledochal cysts from January 2002 to December 2011 were retrospectively reviewed, and surgical outcomes analysed., Results: 59 patients (30.5% males; mean age, 43.2 ± 18.4 years) were included. Radical excision of cystically dilated bile ducts was achieved in 53 patients (89.8%). Bile leakage, delayed wound healing, and abdominal infection occurred in 5 (8.47%), 7 (11.86%), and 3 (5.08%) patients, respectively. Forty-nine patients (83.1%) were followed for an average of 42.6 ± 15.3 months. During the follow-up, 6 patients (12.2%) experienced recurrent cholangitis. Long-term biliary function was excellent in 33 (67.4%), good in 9 (18.4%), fair in 5 (10.2%), and poor in 2 (4.1%) patients., Conclusion: Combined extra-hepatic cyst excision, partial hepatectomy, and Roux-en-Y hepaticojejunostomy is effective for the treatment of complex Todani type IV-A choledochal cysts with substantial intrahepatic bile duct involvement and hilar bile duct stenosis., (Copyright © 2014. Published by Elsevier Ltd.)

Objective: To report a series of four cases of intradural disc herniation (IDH) with a review of the literature., Summary of Background Data: IDH is a rare type of disc herniation. Preoperative diagnosis is difficult and IDH is only confirmed during surgery in most cases. Here, we describe four cases of IDH, including three with lumbar hernia and one with thoracic hernia., Methods: A retrospective chart review, surgical database query, and review of radiology reports are presented for each case, along with a literature review of IDH., Results: Two of the four patients had a history of surgery at the same spinal level. Ring enhancement in gadolinium-enhanced MRI, an air image in computed tomography, and complete block in myelography were observed in the series. Surgery was performed with a transdural approach in all patients. One patient underwent transforaminal lumbar interbody fusion after postoperative recurrence. Three patients with lumbar involvement had nerve root symptoms preoperatively, but showed symptomatic improvement in the early postoperative period. In contrast, the patient with thoracic involvement had preoperative muscle weakness due to myelopathy symptoms, and had residual symptoms after surgery., Conclusions: IDH is a rare disease and characteristic imaging findings can be useful for diagnosis. Intraoperative findings lead to a definitive diagnosis in many cases and recognition of the pathological characteristics of IDH is important., (Copyright © 2014 Elsevier B.V. All rights reserved.)

The aim was to identify prognostic variables associated with survival in 301 breast cancer patients after surgical treatment of skeletal metastases. The study period was 1986-2012. The median age at surgery was 61 (interquartile-range [IQR] 52-70) years. The cumulative 1-, 2-, and 5-year survival after surgery was 45% (95% CI 39-51), 27% (22-32), and 8% (5-12), respectively. The median follow-up time was 1 (IQR 0.2-2) year. Age over 60 years (Hazard ratio [HR] 1.9) and hemoglobin levels <110 g/L (HR 2) increased the risk of death after surgery. Patients with impending fractures (HR 0.4) had a lower death rate. The overall neurological function in patients with spinal metastases improved after surgery (p < 0.001). The complication rate was 25%, including 14% re-operations. Survival data and analysis of complications of this large cohort of surgically treated breast cancer patients help to set appropriate expectations for the patients, families, and medical staff., (Copyright © 2014 Elsevier Ltd. All rights reserved.)