Anastomotic Stricture in End-to-End Anastomosis—Risk Factors in a Series of 261 Patients with Esophageal Atresia

Aim To assess the risk factors for anastomotic stricture (AS) in end-to-end anastomosis (EEA) in patients with esophageal atresia (EA). Methods With ethical consent, hospital records of 341 EA patients from 1980 to 2020 were reviewed. Patients with less than 3 months survival (n = 30) with Gross type E EA (n = 24) and with primary reconstruction (n = 21) were excluded. Outcome measures were revisional surgery for anastomotic stricture (RSAS) and number of dilatations required for anastomotic patency without RSAS. The factors that were tested for risk of RSAS or dilatations were distal tracheoesophageal fistula (TEF) at the carina in C-type EA (congenital TEF [CTEF]), type A/B EA, antireflux surgery (ARS), anastomotic leakage, recurrent TEF, and Spitz group and congenital heart disease. Main Results A total of 266 patients, Gross type A (n = 17), B (n = 3), C (n = 237), or D (n = 9) underwent EEA (early n = 240, delayed n = 26). Early anastomotic breakdown required secondary reconstruction in five patients. Of the remaining 261 patients, 17 (6.1%) had RSAS, whereas 244 patients with intact end to end required a median of five (interquartile range: 2–8) dilatations for anastomotic patency. Main risk factors for RSAS or (> 8) dilatations were CTEF, type A/B, ARS, and anastomotic leakage that increased the risk of RSAS or dilatations from 4.6- to 11-fold. Conclusion The risk of severe AS is associated with long-gap EA, significant gastroesophageal reflux, and anastomotic leakage.

Primary Versus Staged Reconstruction and Risk of Surgical Failure in Patients With Ulcerative Colitis: a Nation-wide Cohort Study

Background Restorative surgery after colectomy due to ulcerative colitis (UC) may be performed simultaneously with colectomy (primary) or as a staged procedure. Risk factors for failure after restorative surgery are not fully explored. This study aimed to compare the risk of failure after primary and staged reconstruction. Methods This is a national register-based cohort study of all patients 15 to 69 years old in Sweden treated with colectomy due to UC and who received an ileorectal anastomosis (IRA) or ileal pouch-anal anastomosis (IPAA) between 1997 and 2017. Failure was defined as a reoperation with new ileostomy after restorative surgery or a remaining defunctioning ileostomy after 2 years. Risk of failure was calculated using the Kaplan-Meier method and Cox regression adjusted for sex, age, calendar period, primary sclerosing cholangitis, and duration of UC. Results Of 2172 included patients, 843 (38.8%) underwent primary reconstruction, and 1329 (61.2%) staged reconstruction. Staged reconstruction was associated with a decreased risk of failure compared with primary reconstruction (hazard ratio, 0.73; 95% CI, 0.58–0.91). The 10-year cumulative risk of failure was 15% vs 20% after staged and primary reconstruction, respectively. In all, 1141 patients (52.5%) received an IPAA and 1031 (47.5%) an IRA. In stratified multivariable models, staged reconstruction was more successful than primary reconstruction in both IRA (hazard ratio, 0.75; 95% CI, 0.54–1.04) and IPAA (hazard ratio, 0.73; 95% CI, 0.52–1.01), although risk estimates failed to attain statistical significance. Conclusions In UC patients undergoing colectomy, postponing restorative surgery may decrease the risk of failure.

Ten-Year (2010–2019) Activity Report of the Replantation Service for Hand and Finger Amputations in Poland

Replantation of amputated hands is now considered a routine procedure in countries representing high standards of medical care. However, organization of care for patients with hand amputations is not uniform and varies from country to country, even in the European Union. This article presents organization of the Replantation Service for hand amputations in Poland, and ten-year activity report of the Service. Data to this report were obtained by mailing questionnaires to seven participating departments.A total of 974 patients, 871 men (89 %) and 103 women (11 %) at a mean age of 40 years with total or subtotal amputations or other severe upper limb-threatening injuries were admitted to the seven units participating in the Service. The most common injury was multidigital amputation – 353 (36 %), followed by the thumb – 282 (29 %), the metacarpal and wrist – 231 (24 %) and the forearm and arm – 108 (11 %) amputations. The most common operation was replantation of totally amputated hands/fingers – 368 cases (38 %), followed by revascularization of subtotal amputated hands/fingers – 344 (35 %). Primary reconstruction of a complex injury to the hand was performed in 135 patients (14 %). The rate of survival of the replanted/revascularized hands/fingers was a mean of 80 %. The report is supported by literature review about replantation services in other countries.

SURGICAL MANAGEMENT OF ORAL CANCER WITH PRIMARY RECONSTRUCTION

Introduction: Primary tumours of oral cavity may be derived from the mucosa, salivary glands,bone or dental tissues. Over 90% of tumours of the oral cavity are squamous cell carcinomas.1,9 Reconstructive surgery following resection for oral cancer is considered when there is functional or aesthetic loss of structures in the oral cavity. Although primary closure can be achieved within oral cavity,the larger the defect,the more is the functional compromise.The majority of soft tissue repair within the oral cavity require three – dimensional reconstruction with soft pliable skin often without significant bulk. Aims : To study the proportion of oral cancer with surgical management with primary flap reconstruction.To analyse the different surgical modalities of treatment and its outcome.Materials And Methods: This study was carried out in a tertiary care hospital in Central India, from March 2020 to August 2021. Out of 136 patients diagnosed with oral cancer, 61 (44.85%) were found to be operable. 75 (55.15%) patients were inoperable, unfit or not willing for surgery.They were assessed,evaluated and managed accordingly. Results:Oral cancer was most commonly noted in fourth decade.The most involved site was alveobuccal complex.Flap reconstruction was required in 62.3% (38 out of 61) of the patients.Out of 38 patients,Pectoralis major musculocutaneous flap only was the most common flap reconstruction accounting for 19 out of 38 patients and in combination with Deltopectoral flap in 3 patients.Conclusion: Though free flap reconstruction has emerged as a good option in primary reconstruction with increased functional repair, strict post operative monitoring was needed as complications were more frequently encountered in those cases.

To Close, Observe, or Reconstruct: The Third Way of Managing Dialysis Fistula Aneurysms in Kidney Transplant Recipients

Background: The management of patent dialysis fistulas in patients after kidney transplantation (KTx) is controversial—the options that are usually considered are the fistula’s closure or observation. Many complications of dialysis fistulas occur in patients after KTx, and immunosuppression increases the risk of fistula aneurysms and hyperkinetic flow. This study aimed to evaluate the results of dialysis fistula aneurysm treatment in patients after KTx and to compare them to procedures performed in an end-stage renal disease (ESRD) dialyzed population. Methods: We enrolled 83 renal transplant recipients and 123 ESRD patients with dialysis fistula aneurysms qualified for surgical revision to this single-center, prospective study. The results of the surgical treatment of dialysis fistula aneurysms were analyzed, and the primary, assisted primary and secondary patency rate, percentage and type of complications were also assessed. Results: For the treatment of dialysis fistula aneurysms in transplant patients, we performed dialysis fistula excisions with fistula closure in 50 patients (60.2%), excision with primary fistula reconstruction (n = 10, 12.0%) or excision with PTFE bypasses (n = 23, 27.7%). Postoperative complications occurred in 11 patients (13.3%) during a follow-up (median follow-up, 36 months), mostly in distant periods (median time after correction procedure, 11.7 months). The most common complication was outflow stenosis, followed by hematoma, dialysis fistula thrombosis and the formation of a new aneurysm and postoperative bleeding, infection and lymphocele. The 12-month primary, primary assisted and secondary patency rates of fistulas corrected by aneurysm excision and primary reconstruction in the KTx group were all 100%; in the control ESRD group, the 12-month primary rate was 70%, and the primary assisted and secondary patency rates were 100%. The 12-month primary, primarily assisted and secondary patency rates after dialysis fistula aneurysm excision combined with PTFE bypass were better in the KTx group than in the control ESRD group (85% vs. 71.8%, 90% vs. 84.5% and 95% vs. 91.7%, respectively). Kaplan–Meier analysis showed a significant difference in primary patency (p = 0.018) and assisted primary (p = 0.018) rates and a strong tendency in secondary patency rates (p = 0.053) between the KTx and ESRD groups after dialysis fistula excisions combined with PTFE bypass. No statistically significant differences in patency rates between fistulas treated by primary reconstruction and reconstructed with PTFE bypass were observed in KTx patients. Conclusions: Reconstructions of dialysis fistula aneurysms give good long-term results, with a low risk of complications. The reconstruction of dialysis fistulas can be an effective treatment method. Thus, this is an attractive option in addition to fistula ligation or observation in patients after KTx. Reconstructions of dialysis fistula aneurysms enable the preservation of the dialysis fistula while reducing various complications.

Intraosseous Venous Malformation of the Zygomatic Bone: Comparison between Virtual Surgical Planning and Standard Surgery with Review of the Literature

Intraosseous venous malformations affecting the zygomatic bone are infrequent. Primary reconstruction is usually accomplished with calvarial grafts, although the use of virtual surgical planning, cutting guides and patient-specific implants (PSI) have had a major development in recent years. A retrospective study was designed and implemented in patients diagnosed with intraosseous venous malformation during 2006–2021, and a review of the scientific literature was also performed to clarify diagnostic terms. Eight patients were treated, differentiating two groups according to the technique: four patients were treated through standard surgery with resection and primary reconstruction of the defect with calvarial graft, and four patients underwent resection and primary reconstruction through virtual surgical planning (VSP), cutting guides, STL models developed with CAD-CAM technology and PSI (titanium or Polyether-ether-ketone). In the group treated with standard surgery, 75% of the patients developed sequelae or morbidity associated with this technique. The operation time ranged from 175 min to 210 min (average 188.7 min), the length of hospital ranged from 4 days to 6 days (average 4.75 days) and the postoperative CT scan showed a defect surface coverage of 79.75%. The aesthetic results were “excellent” in 25% of the patients, “good” in 50% and “poor” in 25%. In the VSP group, 25% presented sequelae associated with surgical treatment. The operation time ranged from 99 min to 143 min (average 121 min), the length of hospital stay ranged from 1 to 2 days (average of 1.75 days) and 75% of the patients reported “excellent” results. Postoperative CT scan showed 100% coverage of the defect surface in the VSP group. The multi-stage implementation of virtual surgical planning with cutting guides, STL models and patient-specific implants increases the reconstructive accuracy in the treatment of patients diagnosed with intraosseous venous malformation of the zygomatic bone, reducing sequelae, operation time and average hospital stay, providing a better cover of the defect, and improving the precision of the reconstruction and the aesthetic results compared to standard technique.

Brachial Plexus Injury Surgical Service in Time of Coronavirus Disease 2019 Pandemic Experience from a Single Tertiary Orthopaedic Hospital in Indonesia

BACKGROUND: Brachial plexus injury (BPI) is one of the most devastating nerve injuries to the extremities. BPI in adults is an increasingly common clinical problem due to road traffic accident. Injury patterns, the timing of surgery, priority on the recovery of function, and patient’s understanding about the expectations of the prognosis are things that are important to consider before deciding on surgical management. The coronavirus pandemic coronavirus disease 2019 (COVID-19) has significantly affected all sectors, one of which is a surgical practice both in terms of medical personnel and equipment, also patient perceptions of hospital services. AIM: This study will analyze epidemiological data on BPI patients who underwent surgery during the COVID-19 pandemic. METHODS: A retrospective descriptive study of BPI profile in Prof. Soeharso Orthopedic Hospital before (2019) and during (2020) the COVID-19 pandemic. Demographic data, the total number of surgery, type of surgical procedure, and patient origin were collected. We compared to the same period in 2019 before pandemic started. RESULTS: In the data obtained from patients treated or undergoing BPI surgery before pandemic (March 1, 2019 to December 31, 2019) and during the pandemic (March 1, 2020 to December 31, 2020), Indonesia first confirms case was on March 2, 2020, until today. There were 51 and 43 cases, respectively. Panplexal type before the pandemic there were 27 patients (52%), and during the pandemic were 20 patients (46%), the upper type before: during the pandemic was 24 (48%): 23 (54%), and lower type 0 cases. Primary reconstruction before: during the pandemic was 26 (55%): 27 (62%) case, and secondary reconstruction before: during the pandemic was 25 (49%): 16 (38%) case, respectively. CONCLUSION: COVID-19 pandemic has no significant effect in the term of the number of BPI surgery performed. Better outcome in BPI surgery is influenced by the timing of the operation, therefore primary reconstruction remains the main choice for BPI patients with safety concern or health protocols. Pre-operative screening applied in our hospital includes laboratory examination, chest radiograph, and polymerase chain reaction swab test. Surgical personnel using personal protective equipment such as protective suit, face shield, google, shoes and medical mask during the COVID-19 pandemic. Patients with significant axon loss and limited clinical recovery are considered “urgent”, as surgery should be performed within 6 months or sooner (depending upon the distance to recipient’s muscle) to avoid irreversible muscle atrophy and degradation of motor endplates.

Vascular graft infection in the aortoiliac territory – our view in the light of European Society for Vascular Surgery Guidelines − the retrospective observation study

Introduction: Vascular graft infection in the aortoiliac territory (abdominal VGI) is undoubtedly one of the most serious complications in vascular surgery. The treatment is burdened with high mortality and morbidity rates. In 2020, the Guidelines on the Management of Vascular Graft and Endograft Infections were published by the European Society for Vascular Surgery (ESVS). In the light of these guidelines, we decided to review retrospectively all patients who presented to our institution with abdominal VGI. Methods: Retrospective observational study of patients presented with abdominal VGI treated in our institution between 2011−2019 (9 years). The primary goal was to elucidate the rate of vascular graft infection in aortoiliac reconstructions performed between 2011−2019 and also the mortality rate in the patient cohort operated for this complication. The secondary goals were to evaluate the success rate and the complication rate in different types of reconstructions. Results: In the defined period between 2011−2019 we performed 363 open aortoiliac reconstructions. During the same period we treated altogether 15 patients with abdominal VGI, whose primary reconstruction was mostly performed before 2011 (11 patients). In our cohort of patients who underwent reconstruction between 2011−2019 we observed a graft infection only in 4 cases (1.1%). In the group of 15 patients with abdominal VGI, the male gender prevailed (14 patients). The mean age at the time of primary reconstruction was 61 years. Most of our reconstructions were performed for occlusive disease (14 cases). All infected grafts were aortobifemoral (1 unilateral aortofemoral). They were all late infections with an average presentation time of 61 months since the primary reconstruction (15−180 months). Early mortality rate was as high as 27% (4 patients) and overall mortality was 40%. The secondary reinfection rate after primary treatment was 33%. Conclusion: Treatment of abdominal VGI is still burdened with high mortality and morbidity rates. The current ESVS guidelines provide valuable guidance for the diagnosis and management of VGI. It nevertheless remains obvious that the treatment needs to be tailored individually in a multidisciplinary team environment.