De Novo Vesicoureteral Reflux Following Ureterocele Decompression in Children: A Systematic Review and Meta-Analysis Comparing Laser Puncture versus Electrosurgical Incision Techniques

Background: The available endoscopic techniques for ureterocele decompression include laser puncture (LP), electrosurgical incision (ES), and cold-knife incision. This systematic review was performed to compare the efficacy of LP versus ES techniques with special emphasis on de novo VUR. Methods: Four databases were systematically searched by the authors. The inclusion criteria were all comparative studies in which ureterocele decompression was performed by either LP or ES endoscopic techniques. Outcomes including the incidence of de novo VUR, the need for endoscopic retreatment of the ureterocele, and the need for secondary surgical procedures were studied. Risk ratios (RR) were calculated for all outcomes and the Mantel-Haenszel method was utilized for the estimation of pooled RR. The methodological quality was assessed by the Downs and Black scale. Results: Five studies were considered for systematic review, while four of them were included in the meta-analysis. Out of 202 children, 67 developed de novo VUR. Significantly lower rates of reflux were observed in the LP group vis-a-vis ES group (RR = 0.17, 95% CI 0.09 to 0.32, p < 0.00001). Endoscopic retreatment rates (n = 20) demonstrated no significant difference among the two patient groups (RR = 0.66, 95% CI 0.26–1.68, p = 0.38). A total of 46 secondary procedures were performed in 170 children, mostly ureteral re-implantations, with a significantly lower need of secondary surgeries following LP versus ES (RR = 0.26, 95% CI 0.13–0.49, p < 0.0001). The risk of bias in the included studies was low-to-moderate. Conclusions: When compared to the ES technique, the LP technique is associated with a significantly low incidence of de novo VUR and requirement for secondary surgeries (particularly anti-reflux surgeries). Endoscopic retreatment rates showed no significant difference between the two techniques. However, due to the moderate risk of bias in two out of four included studies, randomized controlled trials are needed in the future.

Fixation failure in patients with traumatic diastasis of pubic symphysis: impact of loss of reduction on early functional outcomes

Background Failure of fixation (FF) in pubic symphysis diastasis (SD) ranges between 12 and 75%, though whether it influences functional outcomes is still debated. The objective of this study is to evaluate the impact of anterior pelvic plate failure and loss of reduction on Majeed’s functional scores. Methods Single center retrospective review of consecutive patients with acute SD treated by means of anterior pubic plating. Thirty-seven patients with a mean age 45.7 ± 14.4 years were included. Demographics, AO classification, pelvic fixation and secondary procedures were recorded. Majeed’s functional scores at minimum 6 months follow-up were compared according to the presence of FF and loss of reduction. Results Fifteen patients presented FF. Eight presented an additional loss of symphyseal reduction. Mean Majeed´s score (MMS) in patients with and without FF was 64.4 ± 13.04 and 81.8 ± 15.65, respectively (p = 0.0012). Differences in MMS in patients without FF and those with FF and maintained or loss of anterior reduction were 11.3 [70.5 vs 81.8] (p = 0.092) and 22.7 [59.1 vs 81.8] (p = 0.001), respectively. Significant association of FF with AO classification was noted. (OR 12.6; p = 0.002). Conclusions Differences in MMS in the analyzed groups suggest that loss of reduction might be more relevant than failure of the anterior osteosynthesis in functional outcomes.

Race-Based Differences in the Utilization and Timing of Secondary Cleft Procedures in the United States

Objective: Secondary procedures optimize outcomes following cleft lip and palate (CL/P) repair. We analyzed the association between race and the utilization and timing of revisionary/secondary cleft surgeries in the United States. Primary CL/P repair, revisions, and secondary procedures—cleft rhinoplasty, speech surgery, and alveolar bone grafting (ABG)—performed from 2014–2018 were identified from the Pediatric National Surgical Quality Improvement Program (NSQIP) database. Utilization estimates were derived via univariable and multivariable logistic regression. A Kruskal-Wallis rank-sum test and multivariable linear regression were used to assess differences in timing for each procedure cohort. The primary outcome measures were the odds of a patient being a certain race/ethnicity, and the age at which patients of different race/ethnicity receive surgery. There were 23 780 procedures analyzed. After controlling for sex, diagnosis, and functional status, there were significant differences in utilization estimates across procedure groups. Primarily, utilization was lowest in patient who were Black for cleft rhinoplasty (OR = 0.70, P = .023), ABG (OR = 0.44, P < .001) and speech surgery (OR = 0.57, P = .012), and highest in patients who were Asian patients in all surgery cohorts (OR 2.05-4.43). Timing of surgery also varied by race, although differences were minimal. Conclusions Estimates of utilization and timing of secondary cleft procedures varied by race, particularly among patients who were Black (poor utilization) or Asian (high utilization). Further studies should identify the causes and implications of underutilized and/or delayed cleft care.

Brain–lung interactions and mechanical ventilation in patients with isolated brain injury

During the last decade, experimental and clinical studies have demonstrated that isolated acute brain injury (ABI) may cause severe dysfunction of peripheral extracranial organs and systems. Of all potential target organs and systems, the lung appears to be the most vulnerable to damage after brain injury (BI). The pathophysiology of these brain–lung interactions are complex and involve neurogenic pulmonary oedema, inflammation, neurodegeneration, neurotransmitters, immune suppression and dysfunction of the autonomic system. The systemic effects of inflammatory mediators in patients with BI create a systemic inflammatory environment that makes extracranial organs vulnerable to secondary procedures that enhance inflammation, such as mechanical ventilation (MV), surgery and infections. Indeed, previous studies have shown that in the presence of a systemic inflammatory environment, specific neurointensive care interventions—such as MV—may significantly contribute to the development of lung injury, regardless of the underlying mechanisms. Although current knowledge supports protective ventilation in patients with BI, it must be born in mind that ABI-related lung injury has distinct mechanisms that involve complex interactions between the brain and lungs. In this context, the role of extracerebral pathophysiology, especially in the lungs, has often been overlooked, as most physicians focus on intracranial injury and cerebral dysfunction. The present review aims to fill this gap by describing the pathophysiology of complications due to lung injuries in patients with a single ABI, and discusses the possible impact of MV in neurocritical care patients with normal lungs.

Management of a mutilated hand: the current trends

Mutilated upper limbs suffer loss of substance of various tissues with loss of prehension. The most important factor in salvage of a mutilated hand is involvement of a senior surgeon at the time of initial assessment and debridement. A regional block given on arrival helps through assessment and investigations in a pain-free state. Infection still remains the important negative determinant to outcome and is prevented by emergent radical debridement and early soft tissue cover. Radical debridement and secure skeletal stabilization must be achieved on day one in all situations. Dermal substitutes and negative pressure wound therapy are increasingly used but have not substituted regular soft tissue cover techniques. Ability to perform secondary procedures and the increased use of the reconstructed hand with time keeps reconstruction a better option than prosthesis fitting. Toe transfers and free functioning muscle transfers are the two major secondary procedures that have influenced outcomes.

TP5.2.2 Office based endovascular radiofrequency ablation (OBEVRFA) as a standalone procedure for varicose veins

Aims The aim of this study was to identify the number of patients that required a secondary procedure for persistence/ recurrence of symptoms within 3 years of the index (OBEVRFA) procedure. Method Retrospective analysis of data collected prospectively for patients booked to have OBEVRFA in the period January 2017- January 2018 was accessed from electronic patient records. Their clinic follow letters, scans and any secondary procedures done were documented on an excel sheet. Results A total of 303 patients, were booked for an OBEVRFA of which 17 (5.6%) patients did not attend the procedure. 39 (12.8%) patients were cancelled on the day of the procedure. 247 patients (M:F 1:1.5), underwent OBEVRFA. 53 patients (21.8%), had residual veins or were symptomatic & were followed up beyond their 3 month period. 24 patients had a duplex scan which showed complete recanalization in 4, a reflux in non-treated secondary vein (Like Anterior thigh vein or duplicated Long saphenous vein) and a new perforator incompetence in others. 40 (16.1%) patients eventually underwent secondary procedures, 8 underwent classical High flush ligation and stripping with multiple stab avulsions (MSA) , 7 had a redo OBEVRFA, 3 had a redo RFA with MSA under GA, others had MSA alone and 1 had successful sclerotherapy. 3 patients were not keen for a secondary procedure. Conclusion OBEVRFA alone provides complete symptomatic relief in over 80% of patients with only 16% needing a secondary procedure. For symptomatic varicose veins from truncal reflux OBEVRFA should be the first line treatment on NHS.

Fixation Failure in Patients With Traumatic Diastasis of Pubic Symphysis: Impact of Loss of Reduction on Early Functional Outcomes.

BackgroundFailure of fixation (FF) in pubic symphysis diastasis (SD) ranges between 12 to 75%, though whether it influences functional outcomes is still debated. The objective of this study is to evaluate the impact of anterior pelvic plate failure and loss of reduction on Majeed`s functional scores. MethodsSingle center retrospective review of consecutive patients with acute SD treated by means of anterior pubic plating. Thirty seven patients with a mean age 45.7+/-14.4 years, were included. Demographics, AO classification, pelvic fixation and secondary procedures were recorded. Majeed´s functional scores at minimum 6 months followup were compared according to the presence of FF and loss of reduction. ResultsFifteen patients presented FF. Eight presented an additional loss of symphyseal reduction. Mean Majeed´s score (MMS) in patients with and without FF was 64,4+/-13,04 and 81.8+/-15.65 respectively (p=0.0012). Differences in MMS in patients without FF and those with FF and maintained or loss of anterior reduction were 11,3 [70,5vs81,8] (p=0,092) and 22.7 [59,1vs81,8] (p=0,001) respectively. Significant association of FF with AO classification was noted. (OR 12.6; p=0.002).ConclusionsDifferences in MMS in the analysed groups suggest that loss of reduction might be more relevant than failure of the anterior osteosynthesis in functional outcomes.