Corneal epithelial defects following vitreoretinal surgery: incidence and outcomes from the DISCOVER study

AIM: To investigate the incidence, risk factors, clinical course, and outcomes of corneal epithelial defects (CED) following vitreoretinal surgery in a prospective study setting. METHODS: This was a post-hoc analysis of all participants in DISCOVER intraoperative optical coherence tomography study. Subjects with CED 1d after surgery without intraoperative corneal debridement was defined as the postoperative CED group. Subjects who underwent intraoperative debridement were defined as intraoperative debridement group. Eyes were matched 2:1 with controls (eyes without postoperative CED) for comparative assessment. The primary outcomes were the incidence of CED on postoperative day one and the incidence of required intraoperative debridement. Secondary outcomes included time to defect closure, delayed healing (>2wk), visual acuity (VA) and presence of scarring at one year and cornea consult. RESULTS: This study included 856 eyes that underwent vitreoretinal surgery. Intraoperative corneal debridement was performed to 61 (7.1%) subjects and postoperative CED developed spontaneously in 94 (11.0%) subjects. Significant factors associated with postoperative CED included prolonged surgical duration (P=0.003), diabetes mellitus (P=0.04), postoperative ocular hypotension (P<0.001). Prolonged surgical duration was associated with intraoperative debridement. Delayed defect closure time (>2wk) was associated with corneal scar formation at the end of the 1y in all epithelial defect subjects (P<0.001). The overall rate of corneal scarring for all eyes undergoing vitrectomy was 1.8%. CONCLUSION: Prolonged duration of surgery is the strongest factor associated with both intraoperative debridement and spontaneous postoperative CED. Delayed defect closure is associated with a greater risk of corneal scarring at one year. The overall rate of corneal scarring following vitrectomy is low at <2%.

Assessment of Functional Outcome of Bicolumnar Dual Plating for Bicondylar Fractures of Tibial Plateau

Introduction: Operative treatment of bicondylar fractures of tibial plateau is challenging and controversial. Aims: The aim of this study is to reveal the functional outcome of it by using bicolumnar dual plates and screws. Methods: This is a prospective hospital based interventional study carried out in the department of Orthopaedics of Nepalgunj Medical College Teaching Hospital. Thirty two Schatzker type V or AO (Association of Osteosynthesis) type 41 C1 & C2 fractures were treated between January 2016 and December 2019 with bicolumnar dual plating. The functional clinical outcomes were analyzed and evaluated using modified Rasmussen score. Results: Thirty two patients were included in the study. Out of which twenty four were male and eight were female. Average age was 32.21 years, eighteen were right sided and fourteen were left sided. Duration of surgery was 106 mins (range 90-120 mins) and the average duration of hospitalization was 7.81 days (range 4-14 days). Five patients of impending compartment syndrome and three patients with common peroneal nerve palsy were managed conservatively and also were included in the study. Two patients with superficial wound infection needed minimal debridement. One patient had varus angulation of 100 at third follow up after he fell from bed but surgical intervention were not needed. All fractures united. The average time for fracture healing was 21.5 weeks (range 16-32 weeks). At the Eighteen months follow up, the average knee range of motion was 1310(range 1100-1400). The functional outcome were evaluated using modified Rasmussen scoring system, which was 27.34 (range 22-30). Conclusion: Bicolumnar dual plating for bicondylar fractures of tibial plateau can provide excellent and stable fixation allowing early range of motion and gives excellent to good functional outcome.

The Incidence and Causes of Unplanned Reoperations as a Quality Indicator in Pediatric Surgery

Background: Unplanned return to the operating room (uROR) within the 30-day postoperative period can be used as a quality indicator in pediatric surgery. The aim of this study was to investigate and evaluate uROR as a quality indicator. Methods: The case records of pediatric patients who underwent reoperation within the 30-day period after primary surgery, from 1 January 2018 to 31 December 2020 were retrospectively reviewed. The primary outcome of the study was the rate of uROR as a quality indicator in pediatric surgery. Secondary outcomes were indications for primary and secondary surgery, types and management of complications, factors that led to uROR, length of hospital stay, duration of surgery and anesthesia, and starting time of surgery. Results: A total of 3982 surgical procedures, under general anesthesia, were performed during the three-year study period (2018, n = 1432; 2019, n = 1435; 2020, n = 1115). Elective and emergency surgeries were performed in 3032 (76.1%) and 950 (23.9%) patients, respectively. During the study period 19 (0.5%) pediatric patients, with the median age of 11 years (IQR 3, 16), underwent uROR within the 30-day postoperative period. The uROR incidence was 6 (0.4%), 6 (0.4%), and 7 (0.6%) for years 2018, 2019, and 2020, respectively (p = 0.697). The incidence of uROR was significantly higher in males (n = 14; 73.7%) than in females (n = 5; 26.3%) (p = 0.002). The share of unplanned reoperations in studied period was 4.5 times higher in primarily emergency surgeries compared to primarily elective surgeries (p < 0.001). The difference in incidence was 0.9% (95% CI, 0.4–1.4). Out of children that underwent uROR within the 30-day period after elective procedures, 50% had American Society of Anesthesiologists (ASA) score three or higher (p = 0.016). The most common procedure which led to uROR was appendectomy (n = 5, 26.3%) while the errors in surgical technique were the most common cause for uROR (n = 11, 57.9%). Conclusion: Unplanned reoperations within the 30-day period after the initial surgical procedure can be a good quality indicator in pediatric surgery. Risk factors associated with uROR are emergency surgery, male gender, and ASA score ≥3 in elective pediatric surgery.

Incidence and risk factors for surgical site infection post-gynecological operations in a tertiary hospital in Egypt: a retrospective study

Background: Surgical site infection (SSI) is the most common complication of surgical procedures in gynecology and it poses a significant burden for both patients and healthcare systems. Our objective was determining the incidence and risk factors for SSI post-gynecological operations during the period of five years.Methods: A matched case-control study at Minia maternity university, Egypt where A total of 18772 cases had undergone different gynecological procedures. The 876 cases were complicated with SSI (SSI cases group) and 2 matched controls per case were chosen from the rest of the cases and served as the control group (n=1752 cases).Results: The overall incidence of SSI post-gynecological operations was 4.67% and post-hysterectomy was 7.57%. SSI group had a significantly higher number of cases with diabetes, obesity, high parity (>4), increased blood loss and those had prolonged duration of surgery compared to the control group (all p<0.01).Conclusions: The identified risk factors are crucial for risk stratification of SSI and prioritizing interventions to improve the outcome. These results could give a picture for SSI post-gynecological operations in our country and identifying these risk factors is crucial for risk stratification of SSI and prioritizing interventions to improve the outcome.

Precision resection of pulmonary tuberculoma using Nd:YAG-laser

The objective of the study: a comparative study of immediate and long-term results of pulmonary tuberculoma precision resection with Nd:YAG-laser with a wavelength of 1,318 nm and atypical resection with suturing devices.Subjects and Methods. Two groups of 58 patients each were compared. The groups were comparable in terms of gender, age, the nature of the concomitant pathology and the main pathological process. In Group I, patients were operated on using precision 1,318-nm Nd:YAG-laser resection, and in Group II, the sublobar resection with suturing devices were used.Results. The mean duration of hospital stay in Groups I and II was 19.10 ± 6.02 and 19.20 ± 6.02 days respectively (p > 0.05), the duration of surgery made 65 [55; 75] and 55 [45; 60] minutes (p > 0.05), the mean volume of surgical blood loss was 50 [33; 70] and 70 [50; 165] ml (p > 0.05), and the mean duration of pleural cavity drainage after surgery was 4 [3; 5] and 4 [3; 6] days (p > 0.05). Statistically significant differences were noted in the mean volume of the resected part of the lung: 14.0 ± 7.4 mm3 in Group I versus 95.0 ± 9.7 mm3 in Group II (p ≤ 0.05). The complete clinical and radiological cure was achieved in 70% of patients in Group I and 82% in Group II. According to MSCT data, in 91.6% of cases, a thin linear scar is formed in the area of precision intervention.Conclusion: The surgical methods are comparable in terms of immediate and long-term results but precision laser resection minimizes the removal of intact tissue during the removal of tuberculomas.

Should Preoperative Computed Tomography Be Routine Examination For Cervicofacial Space Infections?

Background: Cervicofacial space infections are potentially life-threatening, which require accurate diagnosis, early incision, and adequate drainage. The utilization of computed tomography (CT) in cervicofacial space infections has significantly increased. However, the clinical value of preoperative CT imaging in cervicofacial space infections remains controversial. We, therefore, investigated whether CT examination should be used as a routine examination in the treatment of patients with cervicofacial space infections.Methods: A retrospective study of all patients affected by cervicofacial space infections that received incision and drainage surgery from Jan 2016 to Dec 2020 was performed. Patients were divided into 2 groups: the group with preoperative CT and the group without preoperative CT. Outcomes, including re-operation rate, missed diagnosis rate, days of symptom relief, length of stay, duration of surgery, and total cost of hospitalization, were analyzed.Results: Of 153 patients, 108 patients underwent surgery with preoperative CT and 45 patients without preoperative CT. The re-operation rate in the preoperative CT group (6/108, 5.6%) was significantly lower (P<0.05) than that in the group without preoperative CT (10/45, 22.2%). Significant reduction of missed diagnosis rate, days of symptom relief, length of stay, and duration of surgery (P<0.05) were detected in the preoperative CT group. Conclusions: Preoperative CT examination should be recommended as a routine examination in the treatment of cervicofacial space infections for its usefulness in reducing the missed diagnosis rate and repeated surgery complication.

Transanal endoscopic microsurgery in the treatment of patients with benign neoplasms and early rectal cancer

Introduction. Transanal endoscopic microsurgery (tem) is a method that allows the specialists to clearly visualize a tumor and bimanually remove the tumor using a set of special instruments. For a number of patients with a good tumor response to chemoradiation therapy (crt), tem is used as an advanced biopsy technique for tumor verification. The purpose of the study was to analyze the results of tem performed at a. Tsyb mrrc. Material and methods. Between 2015 and 2020, 64 patients (men – 42.2 % and women – 57.8 %) underwent tem. Forty patients had rectal cancer and 25 patients had benign rectal tumors. The indication for tem in patients with rectal cancer was the evidence of tis-t1 tumor by postoperative examination findings (mri and endosonography). Eleven patients with stage ii–iii rectal cancer received chemoradiation therapy. The indication for performing tem after rt in patients with rectal cancer was a good tumor response (mri trg1- 2). For statistical processing, commercial biomedical packages prism 3.1 and instat (graphpad software, inc., san diego, usa) were used. The significance of the differences between the indicators was assessed using the pearson χ2 test. Differences were considered significant if the p value was less than 0.05. Results. The median duration of surgery was 110 minutes (30–385). The volume of blood loss did not exceed 40 ml. Postoperative complications were observed in 15 cases (23.4 %). Grade 3 complications according to the clavien-dindo classification were observed in 5 (7.8 %) cases. Postoperative complications occurred more frequently in patients after crt (10.7 and 18.2 %; p=0.603), however, the differences were not statistically significant. At a median follow-up of 18 months (7–30), local relapses developed in 6 out of 26 (23 %) patients who underwent surgery alone. There were no signs of local recurrence in patients with adenocarcinomas after neoadjuvant chemotherapy and rectal adenomas. When comparing patients with the depth of tumor invasion tis-t1sm2 and t1sm3-t2, local relapses occurred in 1 of 21 (4.7 %) and 5 of 12 (41.6 %) cases, respectively (p=0.015). Conclusion. The analysis of the results of tem interventions in patients with rectal neoplasms allows us to conclude that this method of treatment is a priority for patients with benign rectal neoplasms and early rectal cancer. The method can also be used after rt or crt in patients with tumor invasion ≥t1sm3, provided a complete or almost complete tumor response to the treatment.

The Modified Procedure of Totally Tubeless PNL

Mini percutaneous nephrolithotomy (mPNL) is a standard treatment for kidney stones larger than 1.5 cm, with the placement of a nephrostomy drainage at the end of it, which is considered the standard procedure, but tubeless/ totally tubeless mPNL techniques reduce postoperative discomfort in patients and shorten hospital stays. The aim of article was to compare the efficacy and safety of our proposed modified method of totally tubeless mPNL with control of the parenchymal canal, with existing methods of tubeless/totally tubeless mPNL. Novelty of the study presented by modified method of totally tubeless mPNL. During the period from 2018 to 2020 we performed 486 mPNL were performed in our clinic in total, among which 63 (12.9%) patients underwent tubeless PNL. Patients whose surgeries ended with using tubeless techniques were divided into three groups: Group I – 22 patients who had tubeless mPNL (with ureteral stent), Group II (20 patients) – totally tubeless mPNL with a safety thread (the proposed procedure), Group III (21 patients) – totally tubeless mPNL. In all three groups, the access point was most often made through the lower group of renal calyces: Group I – 12 (54.5%), Group II – 14 (70.0%), Group III – 13 (61.9%); then through the middle calyx: Group I – 8 (36.4%), Group II – 6 (30.0%), Group III – 7 (33.3%); and the upper calyx: Group І – 2 (9.1%), Group ІІ – 0%, Group ІІІ – 1 (4.8%), no differences in the distribution of access points between groups were found (p=0.67). There were no differences in the distribution of tract sizes between the groups (p=0.95) with tract dilatation to 16.5/17.5 Fr was performed most often: Group I – 12 (54.5%), in Group II – 11 (55.0%) and Group III – 11 (52.4%). The mean duration of surgery in Group I was 83.0±22.9 min, in Group II – 74.9±13.6 min, in Group III – 72.6±12.0 min (p=0.47). This study confirms the high effectiveness of totally tubeless mPNL. The proposed modification to perform totally tubeless mPNL allows you to have permanent postoperative control over the parenchymal channel and in case of postoperative bleeding it enables you to immediately insert nephrostomy drainage through the safety thread. Study contributes to practical methods as an intermediate step for surgeons who are considering transition to a totally tubeless PCNL technique.

Pedicle flap reconstruction for treatment of infected median sternotomy wounds after cardiac surgery in overweight and obese patients: proposal of a management algorithm based on a case series analysis

Background A relationship between obesity and adverse outcomes in patients with post-sternotomy wounds undergoing pedicle flap reconstruction is not well-documented. In this study, we present a single-centre retrospective case series analysis of early postoperative outcomes of patients with infected post-sternotomy wounds undergoing pedicle flap reconstruction. We also propose a management algorithm for such patients, based on BMI and wound width. Methods We retrospectively analyzed all patients, who underwent pedicle flap reconstruction for major sternal wound infections after sternotomy for cardiac surgery in a tertiary hospital in Germany during a 5-year period. Exclusion criteria included patients younger than 18 years of age and patients with BMI < 18.5 kg/m2. Patients were divided into 2 groups according to BMI: normal-weight (NW; BMI < 25 kg/m2) and overweight/obese (OB/OW; BMI > 25 kg/m2). Both groups were compared in terms of preoperative parameters and early postoperative outcomes. Preoperative parameters included demographics, wound bacteria and comorbidities. Postoperative outcomes included duration of surgery time (from incision to skin closure), transfusion requirement (during surgery and entire hospital stay), onset of flap and donor-site complications, length of stay and 30-day mortality. We employed the two-tailed t-test to compare continuous variables and the two-sided Fischer’s exact test to compare categorical variables. Statistical significance was set at p < 0.05. Results The total sample consisted of 48 patients. Overall mean BMI was 28.4 (6.1) kg/m2. Mean age was 67 (12) years. The study group consisted of 28 patients with BMI > 25 kg/m2, who were compared with 20 normal-weight patients. There was a significant difference amongst both groups regarding duration of surgery (120 vs. 174 min, p < 0.05). Donor-site complications requiring intervention were observed in 30% of patients in both groups. Flap-related complications were recorded in 16 (57%) cases in the study group and 7 cases in the control group (35%, p = 0.15). Conclusions We conclude that wound width and BMI can aid the decision-making process for patients with infected sternal wounds after cardiac surgery requiring pedicle flap reconstruction. However, in our case series analysis, OB/OW patients were not found to be at statistically significantly increased risk for worse postoperative outcomes, but were associated with a longer duration of surgery.

The impact of operative time on the outcomes of necrotizing soft tissue infections: a multicenter cohort study

Background The primary aim of this study was to identify if there is an association between the operative time of the initial debridement for necrotizing soft tissue infections (NSTIs) and the mortality corrected for disease severity. Methods A retrospective multicenter study was conducted of all patients with NSTIs undergoing surgical debridement. The primary outcome was the 30-day mortality. The secondary outcomes were days until death, length of intensive care unit (ICU) stay, length of hospital stay, number of surgeries within first 30 days, amputations and days until definitive wound closure. Results A total of 160 patients underwent surgery for NSTIs and were eligible for inclusion. Twenty-two patients (14%) died within 30 days and 21 patients (13%) underwent an amputation. The median operative time of the initial debridement was 59 min (IQR 35–90). In a multivariable analyses, corrected for sepsis just prior to the initial surgery, estimated total body surface (TBSA) area affected and the American Society for Anesthesiologists (ASA) classification, a prolonged operative time (per 20 min) was associated with a prolonged ICU (β 1.43, 95% CI 0.46–2.40; p = 0.004) and hospital stay (β 3.25, 95% CI 0.23–6.27; p = 0.035), but not with 30-day mortality. Operative times were significantly prolonged in case of NSTIs of the trunk (p = 0.044), in case of greater estimated TBSA affected (p = 0.006) or if frozen sections and/or Gram stains were assessed intra-operatively (p < 0.001). Conclusions Prolonged initial surgery did not result in a higher mortality rate, possible because of a short duration of surgery in most studied patients. However, a prolonged operative time was associated with a prolonged ICU and hospital stay, regardless of the estimated TBSA affected, presence of sepsis prior to surgery and the ASA classification. As such, keeping operative times as limited as possible might be beneficial for NSTI patients.